Culotte Stenting Favored for Coronary Bifurcation Lesions: BBK2

Patrice Wendling

September 07, 2016

ROME, ITALY — In experienced hands, culotte stenting is preferred over T-and-protrusion (TAP) stenting for the treatment of coronary bifurcation lesions requiring side branch stenting, according to the BBK2 trial[1].

Culotte stenting was associated with a very low angiographic restenosis rate and lower rate of target lesion revascularizations than TAP stenting, Dr Miroslaw Ferenc (University Heart Center Freiburg-Bad Krozingen, Germany) said in a hot-line session at the European Society of Cardiology (ESC) 2016 Congress.

There are no randomized trials comparing TAP stenting, where the side branch T-stent slightly protrudes into the main branch, with culotte stenting, where two stents in the side branch and in the distal main branch are overlapping in the proximal part of the main branch. In both techniques, final adaptation is achieved by a kissing-balloon maneuver.

Although patients benefit more from culotte stenting, the approach is "a bit more technically challenging" and requires more training, he observed.

Session cochair Dr Andreas Baumbach (University of Bristol, UK) picked up on this point, observing that final kissing-balloon dilation occurred in 100% of patients in both arms, "which I'm not aware of was achieved in any other study."

He added, "So don't go out and just practice culotte; train and learn. Your data show it's good, if it's done with excellent operators."

Ferenc sounded a similar note during a press briefing on the study. "If you are not able to do culotte stenting correctly, then I think it's still better to do TAP stenting. It's better to have good TAP stenting than bad culotte stenting," he said.

Discussant Dr Marie-Claude Morice (Cardiovascular European Research Center, Massy, France) said the results, published simultaneously in the European Heart Journal,"showed today that culotte is superior to TAP with an angiographic end point when two stents are needed."

She took issue, however, with the small patient numbers (n=300) and baseline differences between the two arms, including a longer side branch lesion length in the TAP group than in the culotte group (15.5 mm vs 13.8 mm; P=0.03).

The bifurcation angle was also significantly different pre-PCI (52˚ vs 58˚; P=0.03), and "this also affected the results," she said.

Morice observed that the difference between the two techniques was present only in the side branch, with culotte and TAP performing equally in the main branch.

At 9 months, the primary end point of maximal percent diameter stenosis at the bifurcation lesion was 21% after culotte stenting and 27% after TAP stenting (P=0.038; adjusted P=0.017).

The rate of binary in-stent restenosis >50% was 6.5% in the side branch after culotte stenting vs 16.5% after TAP stenting (P=0.029) but was similar in the main branch after culotte and TAP stenting (1.4% vs. 4.4%; P=0.434).

Still, there was a trend toward fewer target lesion revascularizations in the side branch at 1 year with culotte than with TAP stenting (4.7% vs 8.7%; P=0.16).

One-year rates of death, target vessel MI, stent thrombosis, and target lesion failure were similar in both groups, though BBK2 was not powered to examine clinical outcomes. Morice concluded by calling for larger trials with clinical end points.

Dr Steen Dalby Kristensen (Aarhus University Hospital, Skejby, Denmark), who was not involved in the study, told heartwire from Medscape that he's been using the culotte technique for years and that the BBK2 findings are transferrable to current practice. "I think it could be done by most operators and most centers if they have a reasonable number of patients that they treat every year."

The study was supported by an unrestricted grant from the University Heart Center Freiburg–Bad Krozingen. Ferenc reports speaker honoraria from Abbott Vascular, Medtronic, Biotronik, Biosensors, and Boston Scientific. Disclosures for the coauthors are listed in the article. Baumbach reports no relevant financial disclosures. Kristensen reports lecture fees from AstraZeneca and Aspen Pharmacare.

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