Novel Stenting Technique Shows Promise for ‘True’ Bifurcation Lesions

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For patients with bifurcation lesions, the new dual-stent modified “flower petal” technique offers several advantages over available stenting options, including complete coverage of the side branch ostium, according to a small single-center study published in the May 2013 issue of JACC: Cardiovascular Interventions. The novel strategy has also shown good procedural and early clinical outcomes.

Researchers led by Murat Çaylı, MD, of Adana Numune Education and Research Hospital (Adana, Turkey), and colleagues selected 30 patients with “true” bifurcation lesions (Medina type 1.1.1, or > 50% stenosis of the proximal and distal main branch as well as the side branch) for implantation with DES using the modified flower petal technique.

High Procedural Success, Low Event Rates

The main vessel was predilated in 17 patients (56.7%) and the side branch was predilated in 21 patients (70%). Final kissing balloon inflation could be performed in all patients; procedural success (defined as successful implantation of 2 stents in the main vessel and side branch, yielding a final residual stenosis of 30% or less) was also seen in all patients.

There were no in-hospital instances of MACE (cardiac death, acute MI, or TLR), but in 4 patients (13.4%) the balloon system could not be advanced to the lesion location because the wires were twisted together.

At 9 months, there were no cases of death, MI, or subacute or late stent thrombosis. However, 1 patient reported in-stent restenosis at the side branch ostium requiring reintervention as well as exertional angina.

Several Advantages

Dr. Çaylı and colleagues write that the new technique holds several advantages over available techniques for bifurcation lesions in that it:

  • Is easier
  • Offers complete coverage of the side branch ostium
  • Lowers metallic burden at carina
  • Has a high success rate of the final kissing balloon inflation
  • Shows excellent immediate and midterm clinical outcome

“The modified flower petal technique appears to be a feasible and safe novel technique in treating Medina type 1.1.1 bifurcation lesions,” they write. However, “[a] multicenter prospective randomized study comparing our technique with other techniques would be necessary to confirm the initial very promising results obtained in this single-center study.”

Simply a ‘Niche Interest’

In a telephone interview with TCTMD, Jeffrey W. Moses, MD, of Columbia University Medical Center/Weill Cornell Medical Center (New York, NY), said that although the new technique is “creative handiwork,” it will most likely not change practice.

“With bare metal stents, we did a lot of physical manipulation of the stents, but . . . there are always some concerns about manipulating the stent edges,” he observed. “If you can’t cross with the stent in this configuration, which is entirely possible, how do you get the stent out of the guide?” he asked rhetorically. “With a bent strut there actually may be a risk of stripping the stent off.”

With available techniques like T-stenting, culotte, and crush, Dr. Moses said that he does not see why DES need to be manipulated. Perhaps “it would be more interesting to design a platform that incorporates this in a more commercialized version—something that was pre-made this way, so you know you have the security of the stent and you could place it in the vessel or extract it from the vessel with confidence,” he suggested. “We have some pretty refined techniques in terms of 2-stent strategies, which are frankly a minority of our cases now. Most of these cases are dealt with with crossover technique and there’s also an emerging array of dedicated bifurcation stents.”

David Hildick-Smith, MD, of Royal Sussex County Hospital (Brighton, United Kingdom), told TCTMD in an e-mail communication that he is “not particularly surprised by the results as there are all manner of ingenious approaches to bifurcation lesions which will give good results in small cohorts undertaken by enthusiastic and capable interventionists.”

But the cohort is “much too small” to draw any clinical conclusions, he added, especially because the authors “start with the premise that you need 2 stents for 1.1.1 lesions, which is not the convention. Complicated processes such as partial stent pre-inflation, wiring of the final stent strut and recrimping by hand are never going to catch on. They also potentially destabilize and deform the stent architecture and would result in less stable adherence to the balloon in calcified or tortuous anatomy.”

“These kinds of elaborate and ingenious techniques have been around for a while, and this is an interesting further development, but I don’t see it being anything other than a niche interest,” Dr. Hildick-Smith concluded.

Study Details

The mean age of patients was 55.6 years, and just over one-half (56.7%) were male. The most common PCI indication was stable angina (86.7%), and 14 (46.7%) patients had diabetes. All procedures were performed by using ZES (Endeavor, Medtronic, Minneapolis, MN), PES (Coraxel, Alvi Medica, Istanbul, Turkey), and SES (Coracto, Alvi Medica).

All patients were pretreated with aspirin 300 mg and clopidogrel 300 mg followed by clopidogrel 75 mg daily.

The modified flower petal technique starts with wiring both branches and predilating all significantly stenosed branches. The plastic stent cover is pulled back slightly to expose the final proximal stent strut and the stent delivery system balloon is inflated and then deflated to expand the final proximal stent strut. The main vessel wire is then passed through the now expanded, final proximal stent strut. The stent cover is removed and another, compliant balloon is loaded on the main vessel wire and centered on the last proximal stent strut. The prepared side branch stent–main vessel balloon system is advanced through the guiding catheter to the lesion location until the main vessel balloon stops the advancement of the side branch stent. The first kissing balloon is then performed by simultaneously inflating the side branch and the main vessel balloons. Both balloons and the side branch wire are withdrawn and another stent is positioned in the main vessel.


Çaylı M, Şahin DY, Elbasan Z, et al. Modified flower petal technique: A new technique for the treatment of Medina type 1.1.1 coronary bifurcation lesions. J Am Coll Cardiol Intv. 2013;6:516-522.



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  • The paper contains no statement on conflict of interest for Dr. Çaylı.
  • Dr. Moses reports serving as a consultant for Boston Scientific.
  • Dr. Hildick-Smith reports no relevant conflicts of interest.