First randomized trial compares stenting techniques for coronary bifurcation

August 30, 2016

Rome, Italy - 30 August, 2016: Coronary bifurcations - a type of coronary artery narrowing - are best treated with a technique known as culotte stenting, as opposed to T-and-protrusion (TAP) stenting, when there is need for a side-branch stent according to results of the BBK II (Bifurcations Bad Krozingen) trial.

The findings, presented at ESC Congress 2016, with simultaneous publication the European Heart Journal, are the first randomized results directly comparing these two commonly used techniques.

Coronary bifurcations lesions have to be treated in about 20% of all percutaneous coronary interventions, and so far several different technical approaches have been recommended, explained investigator Miroslaw Ferenc, MD, PhD from the University Heart Center Freiburg, in Bad Krozingen, Germany.

"Treatment is often challenging and requires a high level of interventional qualification. This is the first head to head comparison of the two most commonly used techniques in patients needing side branch stenting and having suitable anatomy for both techniques, and it not only provides angiographic follow-up but also demonstrated a clear signal with respect to clinical outcome.

"There was a statistically significant difference in the primary study endpoint favouring culotte stenting. The lower angiographic restenosis rate in the bifurcation lesion after culotte stenting as compared with TAP stenting was also associated with lower rate of target lesion revascularisation (TLR) in the first year after PCI."

The study included 300 patients with stable or unstable angina and/or a positive stress test who were undergoing percutaneous coronary intervention and side-branch stenting of a coronary bifurcation lesion.

During the procedure, if a side branch stent was needed and the lesion was deemed amenable for both stenting techniques, patients were randomized to either TAP stenting (n=150) or culotte stenting (N=150).

The primary endpoint was maximal in-stent percent diameter stenosis of the bifurcation lesion assessed by follow-up quantitative coronary angiography at 9 months.

This showed a significant advantage to culotte stenting which resulted in a mean maximal percent diameter stenosis of 21% versus 27% in the TAP stenting group (P=0.038), said Dr. Ferenc.

This difference in the primary endpoint was driven almost entirely by differences in the side branch, where the mean percent diameter stenosis was 16% in the culotte arm versus 22% in the TAP (P=0.029). In contrast, there were no differences between techniques in the percent diameter stenosis in the main branch.

There were other important differences in favour of culotte stenting, added Dr. Ferenc.

These included a highly significant difference in binary in-stent restenosis at the bifurcation lesion (6.5% after culotte vs 17% TAP; P=0.006) as well as a 6% vs 12% target bifurcation lesion revascularization rate at 1 year (which just missed reaching statistical significance: P= 0.069). Again, both of these outcomes were driven by differences in the side, as opposed to the main branch, he said.

Death, target vessel myocardial infarction, and stent thrombosis were infrequent at 1 year, and did not differ significantly between the two study groups.

"Given the clear results of this trial together with the same trend for hard clinical endpoints, culotte stenting has now to be seen as the preferred approach for coronary bifurcations, when stenting of the site branch is needed," said Dr. Ferenc.

"Interventional cardiologists can use now culotte stenting with more confidence knowing that this technique is associated with a very low angiographic restenosis rate and lower rate of TLR as compared with TAP stenting - even though it is slightly more challenging and requires appropriate training."
Notes to editors

Sources of funding: This trial was exclusively supported by an unrestricted grant from the University Heart Center Freiburg - Bad Krozingen.

Disclosures: Dr. Ferenc receives speaker honoraria from Boston Scientific, Biotronik, Abbott, and Medtronic.

ESC Press Office

For background information, please contact the ESC Press Office at

For press enquiries, please contact, the Media & Press Coordinator, Jacques Olivier Costa: +393427028575

For independent comment on site, please contact the ESC Spokesperson coordinator, Celine Colas: +393402405148

To access all the scientific resources from the sessions during the congress, visit ESC Congress 365.

About the European Society of Cardiology

The European Society of Cardiology brings together health care professionals from more than 120 countries, working to advance cardiovascular medicine and help people lead longer, healthier lives.

About ESC Congress 2016

ESC Congress is the world's largest gathering of cardiovascular professionals contributing to global awareness of the latest clinical trials and breakthrough discoveries. ESC Congress 2016 takes place 27 to 31 August at the Fiera di Roma in Rome, Italy. The scientific programme is here. More information is available from the ESC Press Office at

This press release accompanies both a presentation and an ESC press conference at the ESC Congress 2016. Edited by the ESC from material supplied by the investigators themselves, this press release does not necessarily reflect the opinion of the European Society of Cardiology. The content of the press release has been approved by the presenter.

European Society of Cardiology

Related Stenting Articles from Brightsurf:

Randomization of provisional vs two-stent techniques in complex bifurcation lesions
Aim: The present study aimed to assess the benefits of two-stent techniques for patients with DEFINITION criteria-defined complex coronary bifurcation lesions.

10-year data show cardiac stenting equal to CABG in preventing events
In a study with the longest follow-up to date of patients with a high-risk form of heart disease known as left main coronary artery disease (LMCAD), researchers found no significant differences in rates of death, heart attack or stroke between patients who were treated with a stent and those who underwent heart bypass surgery.

Additional heart artery stenting reduces risk of future heart attacks
Research has shown that patients who have had emergency heart attack treatment with heart artery stenting -- and have significant narrowings in their other untreated arteries -- can benefit from additional stenting to help prevent future heart attacks.

'Smart' molecules that selectively target abnormal cell growth in blood vessels may reduce reoccurring blockage after stenting
Artificial 'smart' molecules that selectively target certain blood-vessel cells and prevent abnormal growth, appear to reduce reoccurring blockages in blood vessels previously opened by stents, while sparing healthy endothelial cells lining the blood vessel.

RUDN medics suggested modifications to coronary artery stenting
When coronary arteries are damaged, atherosclerotic plaques can reduce the blood supply of the heard.

Long-term antiplatelet monotherapy after stenting is safe but does not improve outcomes
Munich, Germany -- Aug. 27, 2018: Long-term antiplatelet monotherapy after stenting is safe but does not reduce the risk of death or heart attack compared to standard dual antiplatelet therapy, according to late breaking results from the GLOBAL LEADERS trial presented today in a Hot Line Session at ESC Congress 2018 and published in The Lancet.

Stenting system shown to benefit certain stroke patients
A specialized stenting system used to open blocked arteries in the brain resulted in a low complication rate among a specific group of patients with stroke histories, a study led by Cedars-Sinai researchers has found.

Results from the DKCRUSH-V trial reported at TCT 2017 and simultaneously published in JACC
A large-scale randomized trial examining the double kissing (DK) crush two-stent technique compared with provisional stenting (PS) in the treatment of true distal bifurcation lesions of the left main artery, found that the DK crush technique was associated with a lower rate of target lesion failure at one year.

First randomized trial compares stenting techniques for coronary bifurcation
Coronary bifurcations -- a type of coronary artery narrowing -- are best treated with a technique known as culotte stenting, as opposed to T-and-protrusion stenting, when there is need for a side-branch stent according to results of the BBK II (Bifurcations Bad Krozingen) trial.

Intravascular imaging identifies some heart attack patients who can forgo stenting
More than one-quarter of heart attack patients who are normally treated with stents to reopen their blocked arteries might be able to forgo this procedure and receive anti-thrombotic medications only, according to results of a pilot study.

Read More: Stenting News and Stenting Current Events is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to