Double-Kissing Stenting Bests Culotte Method

A new study demonstrates that the stenting technique called double-kissing (DK) is superior to the culotte method in tricky bifurcated lesions in patients with high-risk left main coronary disease.

Researchers at Nanjing Medical University (China;) conducted a study involving 419 patients with unprotected left main coronary artery (UPLMCA) bifurcation lesions who were randomly assigned to DK or culotte stenting treatment. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) at one year, including cardiac death, myocardial infarction (MI), and target vessel revascularization (TVR). In-stent restenosis (ISR) at 8 months was the secondary endpoint, while stent thrombosis (ST) served as a safety endpoint.

The results showed that patients in the culotte group had significant higher one-year MACE rate (16.3%), mainly driven by increased TVR (11.0%), compared with the DK group (6.2% and 4.3%, respectively). ISR rate in side branch was 12.6% in the culotte group and 6.8% in the DK group. Definite ST rate was 1% in the culotte group and 0% in the DK group. Among patients with a bifurcation angle of over 70°, New Risk Stratification (NER) score over 20, and Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score of over 23, the one-year MACE rate in the DK group was significantly different to those in the culotte group. The study was published early online on March 13, 2013, in the Journal of the American College of Cardiology (JACC).

“Significantly high rates of target vessel revascularization with the culotte technique were the main drivers of the high MACE rate,” concluded lead author Shao-Liang Chen, MD, and colleagues. “In a subgroup of challenging patients with a distal bifurcation angle higher than 70 degrees, high risk and SYNTAX scores, or diabetes, the odds of not having an event significantly favored the DK crush group.”

The treatment of angulated distal bifurcation lesions are more challenging and often require two stents. The DK crush technique allows the tip of the side branch stent to extend into the main branch proximally. The main branch stent squeezes the tip of the side branch stent against the arterial wall, resulting in both stent tips lying side-by-side. The simultaneous balloon inflation of both stents is the "double kiss”. In the culotte technique, the main branch stent overlaps the protruding tip of the side branch proximally, resembling how pant legs meet at the waist.

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Nanjing Medical University