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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Long-Term Outcomes After Stenting of Bifurcation Lesions With the "Crush" Technique

Predictors of an Adverse Outcome

Angela Hoye, MB ChB, PhD^_*, Ioannis Iakovou, MD, Lei Ge, MD, Carlos A.G. van Mieghem, MD^_*, Andrew T.L. Ong, MD^_*, John Cosgrave, MD, Giuseppe M. Sangiorgi, MD, Flavio Airoldi, MD, Matteo Montorfano, MD, Iassen Michev, MD, Alaide Chieffo, MD, Mauro Carlino, MD, Nicola Corvaja, MD, Jiro Aoki, MD^_*, Gaston A. Rodriguez Granillo, MD^_*, Marco Valgimigli, MD^_*, Georgios Sianos, MD, PhD^_*, Willem J. van der Giessen, MD, PhD^_*, Pim J. de Feyter, MD, PhD^_*, Ron T. van Domburg, PhD^_*, Patrick W. Serruys, MD, PhD^_*,_* and Antonio Colombo, MD

^_* Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
EMO Centro Cuore Columbus and San Raffaele Hospital, Milan, Italy.

Manuscript received August 28, 2005; revised manuscript received November 23, 2005, accepted November 28, 2005.

^_* Reprint requests and correspondence: Prof. Patrick W. Serruys, Thoraxcenter, Bd 406, Erasmus Medical Center, Dr Molewaterplein 40, 3015 GD Rotterdam, the Netherlands. (Email: p.w.j.c.serruys{at}erasmusmc.nl).

OBJECTIVES: The purpose of this study was to evaluate predictors of an adverse outcome after "crush" bifurcation stenting.

BACKGROUND: The "crush" technique is a recently introduced strategy with limited data regarding long-term outcomes.

METHODS: We identified 231 consecutive patients treated with drug-eluting stent implantation with the "crush" technique for 241 de novo bifurcation lesions. Clinical follow-up was obtained in 99.6%.

RESULTS: The in-hospital major adverse cardiac event (MACE) rate was 5.2%. At 9 months, 10 (4.3%) patients had an event consistent with possible post-procedural stent thrombosis. Survival free of target lesion revascularization (TLR) was 90.3%; the only independent predictor of TLR was left main stem (LMS) therapy (odds ratio [OR] 4.97; 95% confidence interval [CI] 2.00 to 12.37, p = 0.001). Survival free of MACE was 83.5% and independent predictors of MACE were LMS therapy (OR 3.79; 95% CI 1.76 to 8.14, p = 0.001) and treatment of patients with multivessel disease (OR 4.21; 95% CI 0.95 to 18.56, p = 0.058). Angiographic follow-up was obtained in 77% of lesions at 8.3 ± 3.7months. The mean late loss of the main vessel and side branch were 0.30 ± 0.64 mm and 0.41 ± 0.67 mm, respectively, with binary restenosis rates of 9.1% and 25.3%. Kissing balloon post-dilation significantly reduced the side branch late lumen loss (0.24 ± 0.50 mm vs. 0.58 ± 0.77 mm, p < 0.001).

CONCLUSIONS: The crush technique of bifurcation stenting with drug-eluting stents is associated with favorable outcomes for most lesions; however, efficacy appears significantly reduced in LMS bifurcations, and further research is needed before the technique can be routinely recommended in this group. Furthermore, the incidence of possible stent thrombosis is of concern and requires further investigation. Kissing balloon post-dilatation is mandatory to reduce side branch restenosis.

Abbreviations and Acronyms   AMI = acute myocardial infarction   BMS = bare-metal stent   CABG = coronary artery bypass graft   CI = confidence interval   DES = drug-eluting stent   LMS = left main stem   MACE = major adverse cardiac event   MLD = minimal lumen diameter   OR = odds ratio   PES = paclitaxel-eluting stent   SES = sirolimus-eluting stent   TLR = target lesion revascularization   TVR = target vessel revascularization

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