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Crush technique for bifurcation lesions appears effective
Stents placed in side branch and main vessel simultaneously; balloon in main branch inflated, crushed against side branch stent.
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To ensure full stent coverage of bifurcation lesions, interventional cardiologists have developed a crush technique that appears to be effective.
Stephane Carlier, MD, assistant professor of medicine at Columbia University, participated in a study published in the Journal of the American College of Cardiology that observed the crush technique in 40 patients treated with sirolimus-eluting stents (Cypher, Cordis).
Carlier said the crush technique was developed to ensure that no lesion was left without stent struts. Interventionists place stents in the side branch and the main vessel simultaneously, and then inflate the balloon in the side branch. The side branch balloon is then deflated while the balloon in the main branch is inflated and “crushed” against the side branch stent.
“Most of the time the lumen on the side branch of the stent is still very small and that does not leave a lot of room for any progression of disease, neointimal hyperplasia or restenosis,” Carlier told Cardiology Today.
Before the crush technique, Carlier said most interventionists would place a stent in the main branch first and then try to insert a stent in the side branch. “However, this approach is not much better than when you put only one stent in,” Carlier said.
IVUS findings
For Carlier’s study, researchers performed IVUS on both branches in 25 lesions, and only the main vessel in 15 lesions, in five distinct locations: main vessel proximal stent, crush area, distal stent, side branch ostium and side branch distal stent.
Overall the main vessel minimum stent area was larger than the side branch minimum stent area (6.7 mm2 vs. 4.4 mm2).
When only the main vessel was considered, the minimum stent area was found in the crush area rather than the proximal or main vessel distal stent in 56% of the IVUS readings. The main vessel minimum stent area was <4 mm2 in 8% of lesions and <5 mm2 in 20%.
When both the main vessel and the side branch were considered, the minimum stent area was found at the side branch ostium in 68%. Researchers said this might contribute to a higher rate of restenosis at this location.
“This was an acute study where we looked just mechanistically at what is happening in the region where there is a crush,” Carlier said.
Kissing balloon
In a separate study, researchers explored whether using the final kissing balloon technique post-dilation would improve outcomes in patients treated with the crush technique using drug-eluting stents.
“When we use the crush technique it is very important to always perform a final kissing balloon inflation,” Antonio Colombo, MD, director of the cardiac catheterization lab at the EMO Centro Cuore Columbus in Italy, told Cardiology Today.
Colombo said the kissing balloon technique is performed by advancing a balloon into the side branch following stent deployment, advancing another balloon in the main branch and then inflating both sides together.
“For bifurcation lesions, two stents are probably needed about 30% of the time. In such cases, the kissing balloon technique is almost mandatory,” Colombo said.
Colombo was a corresponding author on a study of 181 consecutive patients who were treated with the crush technique; 116 of these patients had received a final kissing balloon while 65 had not.
Restenosis in the side branch was lower in the kissing balloon group at 11.1% vs. 37.9% in the non-kissing balloon group. The lack of kissing balloon was also a predictor of target lesion revascularization (HR=4.17). – by Jeremy Moore
For more information:
- Costa RA, Mintz GS, Carlier SG, et al. Bifurcation coronary lesions treated with the “crush” technique. J Am Coll Cardiol. 2005;46:599-605.
- Ge L, Airoldi F, Iakovou I, et al. Clinical and angiographic outcome after implantation of drug-eluting stents in bifurcation lesions with the crush stent technique: importance of final kissing balloon post-dilation. J Am Coll Cardiol. 2005:46:613-20.