Culotte versus Crush Stenting in Coronary Bifurcation Lesions: A Multimodal Insight into Mechanical and Clinical Outcomes

Abstract

Background: Coronary bifurcation lesions remain a major challenge in percutaneous coronary intervention, particularly when a double-stent strategy is required. Among various techniques, Culotte and Crush are commonly used, yet their biomechanical implications and clinical outcomes are still debated.

Objective: This study aims to compare the mechanical performance and clinical implications of Culotte and Crush double-stent techniques for treating bifurcation lesions, using finite element analysis (FEA) and intravascular ultrasound (IVUS) validation.

Methods: A patient-specific 3D coronary bifurcation model was reconstructed from CTA data. FEA simulations of Culotte and Crush stent deployments were performed to evaluate stent malapposition, side branch (SB) ostial obstruction, minimum lumen area, and vessel wall stress. Post-procedural IVUS imaging and retrospective clinical data from 50 patients were used to validate the computational findings.

Results: The Culotte technique demonstrated superior biomechanical outcomes, including lower stent malapposition (0.57% vs. 1.26%), improved SB lumen area (2.83 mm²vs. 1.76 mm²), and reduced SB ostial obstruction (0.00% vs. 3.76%) compared to the Crush technique. Stress analysis revealed that Culotte produced more favorable distribution patterns with less concentration at critical vessel sites. Clinical data further supported these findings, with lower target lesion revascularization rates observed in the Culotte group (12.0% vs. 28.0%, p = 0.042).

Conclusions: Culotte stenting provides mechanical advantages over the Crush technique for coronary bifurcation lesions, as evidenced by both computational modeling and clinical validation. FEA serves as a promising tool for personalized strategy selection in complex coronary interventions.