Coronary Bifurcation Stenting: From Crush to Culotte. Avoiding Limerence and Meme Propagation?

The Wikipedia term “crush” refers to a short-lived and unrequited love or limerence (“to crush on”). The primary characteristics of limerence can be summarized as intrusive, perhaps obsessive thinking about the limerent object and acute longing for reciprocation. Limerent people can act as a reservoir of memetic ideas as expressed in Karl Popper’s Conjectures and Refutations (1963). From his point of view, theories that better survive the process of refutation are actually not more true, but rather, more “fit”.¹ The limerent attitude of interventional cardiologists to crush drug-eluting stents against the coronary wall is now spreading as a memetic infection. Its rationale fits the possibility to homogeneously cover the coronary carina to overcome the problem of restenosis. Unfortunately, to crush two layers of cytotoxic drug-eluting metal against the coronary wall with a drug-eluting stent represents, at the very least, a high-risk procedure possibly able to irreversibly jeopardize coronary endothelium. In 2003 Virmani et al. described 13 cases of late bare metal stent thrombosis (LST) with impaired intimal healing.² Taxol- or sirolimus-eluting stents can intrinsically compromise endothelial function, and caution has been suggested in overlapping, as differential response of delayed healing and persistent inflammation at sites of overlapping sirolimus- or paclitaxel-eluting stents has been shown.³ A recent study concludes that the cumulative incidence of stent thrombosis nine months after successful drug-eluting stent implantation in consecutive “real-world” patients is substantially higher than the rate reported in clinical trials. Premature antiplatelet therapy discontinuation, renal failure, bifurcation lesions, diabetes and low ejection fraction were identified as predictors of thrombotic events.⁴ Thus, evidence has arisen that to crush a drug-eluting stent is not safe, representing a memetic behavior with inherent contraindications. The “culotte stent technique” consists in creating a new coronary carina, stenting the more angulated branch first, and after balloon dilatation of the stent meshes, stenting the uncovered branch through the first stent and leaving the main vessel covered with two overlapped stents. A final kissing balloon dilatation creates a new carina. The results for this procedure have not been promising with BMS, however, some possible advantages in the era of DES must be taken into account, such as the possibility to stent provisionally, use lower French sizes and completely cover the coronary wall and the new carina with a single or double stent layer. Recently, new evidence is arising that this technique may have a rebirth, substituting the old memetic and limerent ideas.⁵ Apart from technical considerations, percutaneous therapy in coronary bifurcation remains challenging, especially in the era of drug-eluting stents, and every effort must be made to substitute unjustified memes with demonstration of efficacy.

1. Dawkins R. The Selfish Gene. Oxford University Press, 1976. 2. Farb A, Burke AP, Kolodgie FD, Virmani R. Pathological mechanisms of fatal late coronary stent thrombosis in humans. Circulation 2003;108:1701–1706. 3. Finn AV, Kolodgie FD, Harnek J, et al. Differential response of delayed healing and persistent inflammation at sites of overlapping sirolimus — Or paclitaxel-eluting stents. Circulation 2005;112:270–278. 4. Schmidt T, Bonizzoni E, Ge L, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 2005; 293:2126–2130. 5. Hoye A, van Mieghem CA, Ong AT, et al. Percutaneous therapy of bifurcation lesions with drug-eluting stent implantation: The Culotte technique revisited. Int J Cardiovasc Interv 2005;7:36–40.