Systematic Two-Stent Culotte Strategy Studied in Large-Caliber Side Branch Bifurcations

September 27, 2016—David Hildick-Smith, MD, et al published findings from the EBC TWO study online ahead of print in Circulation: Cardiovascular Interventions.

The investigators explained that the background of the study is that for the treatment of coronary bifurcation lesions, a provisional strategy is superior to systematic two-stent techniques for the most bifurcation lesions. However, complex anatomies with large side branches (SBs) with significant ostial disease length are considered by expert consensus to warrant a two-stent technique upfront. This consensus view has not been scientifically assessed, advised the EBC TWO investigators.

In EBC TWO, 200 symptomatic patients (ages 64 ± 10 years; 82% men) with large-caliber true bifurcation lesions (SB diameter ≥ 2.5 mm) and significant ostial disease length (≥ 5 mm) were enrolled at 20 European centers. The patients were randomized to either a provisional T-stent strategy or a dual-stent culotte technique. The clinical presentations were stable coronary disease (69%) and acute coronary syndromes (31%). SB stent diameter (2.67 ± 0.27 mm) and length (20.30 ± 5.89 mm) confirmed the extent of SB disease.

As summarized in Circulation: Cardiovascular Interventions, procedural success (provisional 97%, culotte 94%) and kissing-balloon inflation (provisional 95%, culotte 98%) were high. Sixteen percent of patients in the provisional group underwent T-stenting.

The investigators found that the primary endpoint (a composite of death, myocardial infarction, and target vessel revascularization at 12 months) occurred in 7.7% of the provisional T-stent group versus 10.3% of the culotte group (hazard ratio, 1.02; 95% confidence interval, 0.78–1.34; P = .53). Procedure time, x-ray dose, and cost all favored the simpler procedure.

When treating complex coronary bifurcation lesions with large stenosed SBs, there is no difference between a provisional T-stent strategy and a systematic two-stent culotte strategy in a composite endpoint of death, myocardial infarction, and target vessel revascularization at 12 months, concluded the EBC TWO investigators.