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Long-term outcomes following double kissing crush or mini-culotte stenting for complex coronary bifurcation lesions: the EVOLUTE-CRUSH IV study

Langzeitergebnisse nach Double-Kissing-Crush- oder Mini-Culotte-Stenteinlage bei komplexen Koronarbifurkationsläsionen: die EVOLUTE-CRUSH-IV-Studie

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Abstract

Background

This study aimed to evaluate the long-term outcomes of double kissing crush stenting (DKC) and mini-culotte technique (MCT) in patients with complex bifurcation lesions.

Methods

This retrospective study enrolled 236 patients who underwent percutaneous coronary intervention (PCI) for complex coronary bifurcation disease between January 2014 and November 2022. The primary endpoint was target lesion failure (TLF), defined as the combination of cardiac death, myocardial infarction (MI), or clinically driven target lesion revascularization (TLR). The secondary endpoint was major cardiovascular and cerebral events (MACCE) including all-cause death, MI, TLR, stroke, or stent thrombosis. The regression models were adjusted by applying the inverse probability weighted (IPW) approach to reduce treatment selection bias.

Results

The initial management strategy was DKC in 154 (65.3%) patients and MCT in 82 (34.7%) patients (male: 194 [82.2%], mean age: 60.85 ± 10.86 years). The SYNTAX scores were similar in both groups. The rates of long-term TLF and MACCE rates were 17.4% and 20%, respectively. The rate of TLF (26.8% vs. 12.3%, p = 0.005) was higher in patients treated with MCT than those treated with the DKC technique, mainly driven by more frequent TLR (15.9% vs. 7.1%, p = 0.035). The long-term TLF and MACCE rates were notably lower in the DKC group compared to the others: adjusted hazard ratio (HR; IPW): 0.407, p = 0.009 for TLF, and adjusted HR(IPW): 0.391 [95% CI: 0.209–0.730], p = 0.003 for MACCE.

Conclusion

At long-term follow-up, the rates of TLF and MACCE were 17.4% and 20%, respectively. However, long-term TLF was significantly higher in patients treated with MCT than those treated with the DKC technique, primarily due to a more frequent occurrence of clinically driven TLR.

Zusammenfassung

Hintergrund

Ziel der vorliegenden Studie war es, die Langzeitergebnisse der Double-Kissing-Crush-Stenteinlage (DKC) oder der Mini-Culotte-Technik (MCT) bei Patienten mit komplexen Koronarbifurkationsläsionen zu untersuchen.

Methoden

In diese retrospektive Studie wurden 236 Patienten einbezogen, bei denen eine perkutane Koronarintervention (PCI) wegen einer komplexen Koronarbifurkationsläsion zwischen Januar 2014 und November 2022 erfolgte. Primärer Endpunkt war das Zielläsionsversagen („target lesion failure“, TLF), definiert als Kombination aus Herztod, Myokardinfarkt (MI) und klinisch gesteuerter Zielläsionsrevaskularisierung („target lesion revascularization“, TLR). Sekundärer Endpunkt waren schwerwiegende kardiovaskuläre und zerebrale Ereignisse („major cardiovascular and cerebral events“, MACCE) einschließlich Tod aus sämtlichen Ursachen, MI, TLR, Schlaganfall oder Stentthrombose. Die Regressionsmodelle wurden durch Anwendung des Ansatzes der inversen Wahrscheinlichkeitsgewichtung („inverse probability weighted“, IPW) zur Verminderung eines Therapieselektionsbias angepasst.

Ergebnisse

Der initiale Behandlungsansatz bestand aus DKC bei 154 (65,3%) Patienten und MCT bei 82 (34,7%) Patienten (Männer: 194 [82,2%], Durchschnittsalter: 60,85 ± 10,86 Jahre). Die SYNTAX-Scores waren in beiden Gruppen ähnlich. Die Rate für Langzeit-TLF und MACCE betrug 17,4% bzw. 20%. Bei mit MCT behandelten Patienten war die TLF-Rate (26,8 vs. 12,3%; p = 0,005) höher als bei mittels DKC-Technik versorgten Patienten, was hauptsächlich an einem häufigeren TLR lag (15,9 vs. 7,1%; p = 0,035). In der DKC-Gruppe waren die Langzeit-TLF- und MACCE-Raten deutlich niedriger als bei den anderen: adjustierte Hazard Ratio (HR; IPW): 0,407; p = 0,009 für TLF und adjustierte HR (IPW): 0,391 (95%-Konfidenzintervall, 95%-KI: 0,209–0,730); p = 0,003 für MACCE.

Schlussfolgerung

Beim Langzeit-Follow-up betrug die Rate für TLF 17,4% bzw. für MACCE 20%. Jedoch war die Rate für ein Langzeit-TLF bei Patienten, die mit MCT behandelt worden waren, signifikant höher als bei Patienten, die mit der DKC-Technik therapiert worden waren, in erster Linie aufgrund häufigeren Auftretens eines klinischen TLR

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Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

The culotte technique was introduced in the literature by Chevalier et al. [1]. However, the culotte technique has some limitations, among which the double layers of metal struts are reported to be related to the occurrence of high rates of combined ischemic consequences, in-stent restenosis, and stent thrombosis [2,3,4]. Hence, the conventional culotte technique is not widely used in the treatment of coronary bifurcation lesions. In 2009, Wen et al. reported on the “mini-culotte” technique (MCT), with several modifications of the classic culotte technique [5]. Today, the MCT has become one of the most commonly used systematic two-stent techniques [6, 7]. The MCT offers several advantages, including fewer overlapping struts, higher final kissing balloon inflation (KBI) success, and better cardiovascular results, as reported in Nordic studies comparing MCT with crush stentings [8, 9].

The first double kissing crush (DKC) technique for coronary bifurcation lesions was reported by Chen et al. in 2005 [10]. Several randomized controlled trials (RCTs) previously showed that the DKC technique was a safe and effective technique for the treatment of complex coronary bifurcation lesions compared to stepwise provisional stenting and other two-stent techniques [4, 10,11,12,13]. Additionally, a recent meta-analysis and registry indicated that the DKC technique provides a significant reduction in major cardiovascular events (MACE) compared to provisional stenting, crush, and culotte, while it has comparable MACE rates to mini-crush [13, 14]. To date, there is a paucity of data comparing the long-term outcomes of DKC and MCT in patients with complex coronary bifurcation lesions. Hence, this study sought to determine the clinical outcomes of DKC and MCT under long-term follow-up.

Abbreviations

DKC:

Double kissing crush

MACCE:

Major cardiovascular and cerebral events

MCT:

Mini-culotte technique

SB:

Side branch

TLF:

Target lesion failure

TLR:

Target lesion revascularization

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Authors and Affiliations

  1. Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey

    Mustafa Yıldız MD, Ahmet Güner MD, Gökhan Demirci MD, Ahmet Yaşar Çizgeci MD, Serkan Kahraman MD, Fatih Uzun MD, Cemalettin Akman MD, Emre Aydın MD, Abdullah Doğan MD, İrem Türkmen MD, Muhammed Mustafa Yıldız MD & Mehmet Ertürk MD

  2. Department of Cardiology, Istanbul University-Cerrahpasa Cardiology Institute, Org. Abdurrahman Nafiz Gürman street. No: 24, 34098, Fatih, Istanbul, Turkey

    Hasan Ali Barman MD

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Conflict of interest

M. Yıldız, A. Güner, G. Demirci, A.Y. Çizgeci, S. Kahraman, H.A. Barman, F. Uzun, C. Akman, E. Aydın, A. Doğan, İ. Türkmen, M.M. Yıldız and M. Ertürk declare that they have no competing interests.

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Yıldız, M., Güner, A., Demirci, G. et al. Long-term outcomes following double kissing crush or mini-culotte stenting for complex coronary bifurcation lesions: the EVOLUTE-CRUSH IV study. Herz (2024). https://doi.org/10.1007/s00059-024-05244-3

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