Interventional treatment of coronary artery bifurcation lesions represents one of the most challenging techniques in the field of coronary interventions. Bifurcation lesions represent up to 16% of coronary targets for intervention [1
]. When compared with non-bifurcation interventions, bifurcation interventions have a lower rate of procedural success, higher procedural costs, longer hospitalization, and a higher rate of clinical and angiographic re-stenosis. Plaque redistribution "plaque shift" across the carina of the bifurcation may risk occlusion of the side branch or even the parent vessel [2
]. Eccentric stenosis at the bifurcation and ostial narrowing of the side branch further increase this risk [4
]. The kissing balloon technique was developed more than twenty years ago for side branch protection [6
]. More recently, in the coronary artery stents era, many techniques were described to stent bifurcation lesions [7
]. However, it was shown that stenting both vessels in a bifurcation lesion provides no advantage in terms of procedural success and late outcome versus a simpler strategy of stenting only the parent vessel if feasible anatomically [8
]. In some cases, the bifurcation lesion anatomy places a major vessel or more at a very high risk of occlusion dictating stenting both vessels. Chevalier et al have first proposed the Culotte technique as a new option for bifurcation lesion stenting in 50 patients and reported an acceptable re-stenosis rate of 24% [9
However, later reports on double stenting of bifurcation lesions using BMS although provides better immediate angiographic results is associated with higher (37.6%) incidence of clinically driven repeat target lesion revascularization with 2 stents as compared to 5.6% using 1 stent at six months [1
]. On the other hand, bifurcation lesion stenting using DES was shown to be associated with significantly higher rates of stent thrombosis in multiple studies [10
]. In one study, DES was associated with a significantly higher risk of stent thrombosis at 9 months with a hazard ratio of 6.42 (95% CI, 2.93-14.07; P
< .001) [11
In our particular case, the D1 had a true ostial occlusive lesion and was associated with a 70% lesion in the mid LAD, necessitating double stenting of the bifurcation to salvage the large D1 and protect the diseased LAD.
Based on the previous data, we believe that stenting of bifurcation lesions with two BMSs will significantly increase the risk of restenosis and rate of target vessel revascularization. On the other hand, using two DESs instead will significantly impair re-endothelialization and increase the risk of stent thrombosis. Consequently, we chose to pursue a balanced approach using a hybrid technique of a BMS and a DES. We chose to deploy the BMS at the site of the culprit lesion in the D1 and DES in the LAD. We believe that the BMS at the culprit thrombotic, inflamed site in D1 is more likely to re endothelialize than a DES and the DES in the LAD, is less likely to re-stenose than a BMS. Furthermore, using culotte technique, we were able to completely cover all the coronary layers of the bifurcation lesion, avoiding any excessive "crushing" of displaced and distorted metal against the coronary wall. Thus, in our opinion, we achieved a balance and acceptable compromise between potential benefits and risks. Although this hybrid technique still carries a risk in terms of re-stenosis of the D1 stent and/or stent thrombosis of the LAD stent, we feel this approach could be significantly useful, especially during the acute phase of STEMI where a bifurcation lesion is involved.
In our opinion, the most suitable subsets of bifurcation lesions for this approach should be Medina 0,1,1 and 1,1,1 with significant involvement of the main branch.