Editorial Comment

Following a Crush and a Kiss:Why Is It Lonely Out There?

Ashok Seth, MBBS, FRCP (London), FRCP (Edinburgh),FRCP (Ireland), FACC, FSCAI, DScMax Heart and Vascular Institute,New Delhi, India

The bifurcation lesion has remained one of the mostexciting challenges for the interventional cardiologistsince the advent of angioplasty. It has tested ourskills, innovation, and creativity and, despite best strat-egies and execution, has given uncertain outcomes.With increased realization that CPK rises related toside-branch occlusion could adversely impact out-comes, achieving a full patency of the side branch(SB) at the end of the procedure became important inthe short and long term. To achieve this, numerousbifurcation techniques were developed in the baremetal stent (BMS) era, almost all of them involvingplacement of two stents: one in the main vessel andthe other in the side branch (T-stenting, modified T-stenting, culotte, Y- and V-stenting, and provisional T-stenting). However, as time went on, it became clearthat one stent had better outcomes than two stents,provided the side-branch patency could be maintainedby balloon dilatation alone [1]. With the drug-elutingstents (DES) being the magic bullet for all complexlesions, the enthusiasm for two-stent strategy resur-faced, only to be dampened by the results of random-ized trials of sirolimus-eluting stents in bifurcationlesions. The multicenter trial demonstrated that whilethe 6-month outcomes were better than historical con-trols of the BMS era, the restenosis rate in the side-branch stent was unacceptably high when two stentswere implanted [2]. One of the limitations of the studywas a nearly 50% rate of crossover from a single-stentstrategy to two-stent strategy, thus contaminating thegroup and subsequent clinical outcomes. It was alsofelt that the high restenosis rate in the side branch wasrelated to the lack of complete coverage of SB ostium.Keeping in mind the high crossover rate, it was alsofelt that a definitive technique using two stents andachieving good SB ostial coverage was needed. Toaddress the crossover issue, Pan et al. [3] performeda randomized study of single stent vs. two stentsin which crossover was prevented unless there was a

severe persistent stenosis or flow-limiting dissection ofSB (only 1 out of 47 crossed over), thus keeping thetwo groups pure. They still showed that single-stentstrategy with SB balloon dilatation was equivalent totwo-stent strategy as regards clinical outcomes andobviously simpler and more cost-effective.While for most, the pendulum swung back to single-

stent strategy with provisional SB stenting; for others,innovations in two-stent strategy continued. This led todescription of the crush technique, which was simplerto perform but surprisingly did not achieve the desiredclinical outcomes [4].We must compliment John Ormiston and his col-

leagues for developing a bench-top model to test outbifurcation strategies, the importance of which has in-creased in the DES era. Despite the obvious limitationsof a plexiglass tube bifurcation model versus humancoronary arteries, Ormiston et al. [5] had earlier pro-vided basic insights into the optimization of the crushtechnique. In this issue, Ormiston et al. [6] have meticu-lously studied a variety of commonly used stenting andpostballoon dilatation strategies with a variety of com-monly used DES platforms and provide some mostinteresting insights. For me, this study is a landmark inbifurcation treatment strategies in the DES era.The important and unexpected observations from

their present study are as follows.(a) The culotte technique followed by a final kissing

balloon inflation provides good stent expansion andapposition in the main vessel and excellent scaffoldingof the SB ostium, but is limited by the size of the holecreated in the stent, especially for the main vessel,which for Bx Velocity platform (Cypher stent; Cordis)was only 2.5 3 3.0 mm despite using a 3.5 mm bal-loon at 20 atm. The technique could find favor withthe Express and Liberte platforms (Taxus stent; BostonScientific), in which the cells can be stretched to createnearly a 3.5 mm opening.(b) The following internal (reversed) crush with tubu-

lar stents, the crushed SB stent is well flattened againstthe main-vessel stent and still the SB ostium remainsfully covered. This is in contradiction to the externalcrush, where following the crush the SB ostium getsuncovered and requires a final kissing balloon dilata-

DOI 10.1002/ccd.20563

Published online 15 December 2005 in Wiley InterScience (www.

interscience.wiley.com).

' 2005 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 67:56–57 (2006)

tion to achieve complete apposition at the ostium [5].Surprisingly, kissing balloon dilatation following inter-nal crush distorts the main-vessel stent, though it mayhelp improve access to the SB and may improve stentapposition at the ostium further. So, the proceduremust finish with a lone final balloon inflation withan appropriately sized balloon in the main vessel toachieve optimal results.Do these observations influence my strategy as I

approach bifurcation lesions? Yes, they do.For one, it strengthens my confidence in approach-

ing the bifurcation lesion with a single-stent strategywith provisional stenting of side branch. If I need tostent the side branch, the internal crush seems to pro-vide optimal coverage of SB ostium. So for all practi-cal purposes, I could finish the procedure as soon as Ihave crushed the SB stent. I could recross and dilatethe side-branch stent further; this would improve sub-sequent access to the SB and may improve stent appo-sition at ostium further. I should then finish with alone final balloon inflation in the main vessel. Recross-ing into SB could be easier than in external crush asthere is only one layer of stent to cross. However, ifrecrossing fails, I should not be so concerned.Do I have concerns regarding this simple strategy?

Yes, I do.I cannot understand why we do not see uncovering

of SB ostium following internal crush in the samemanner as is seen in external crush [5]. I am con-cerned that the observations in a plexiglass bifurcationmodel may not translate to human coronary arteries.Even if they do, will these bench-top observationsalone impact the short- and long-term outcomes givennumerous other variables? For instance, the drug deliv-ery at the ostium of SB is also affected by the size ofstent cells, the nature of lesion, differential pathophy-

siological response of cellular proliferation, and the listcould go on.The internal crush technique needs to be meticu-

lously and prospectively studied for its short- andlong-term clinical outcomes both as a provisional andas a definitive strategy. For the moment, though, itappears that for the bifurcation lesion, single-stentstrategy with provisional SB stenting using internalcrush followed by lone balloon inflation could be asimple, cost-effective, and optimal strategy.Moving away after crush and a kiss. Suddenly, it’s

lonely out there!

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Following a Crush and a Kiss 57