Optimization of a Double-Kissing Culotte Stenting Using Three-Dimensional Optical Frequency Domain Imaging for Left...

Percutaneous coronary intervention (PCI) for left main bifurcation lesions remains technically challenging, particularly when using two-stent techniques such as double-kissing (DK) culotte stenting. Achieving optimal rewiring and complete stent apposition is essential for procedural success but can be difficult under angiographic guidance alone. Moreover, differences in stent design, including the maximum expansion diameter, may affect stent deformation and apposition in the large-caliber left main bifurcation segment.

This study aimed to evaluate whether three-dimensional optical frequency domain imaging (3D-OFDI) guidance and the use of stents with a larger maximum expansion diameter could improve rewiring precision and stent apposition, thereby optimizing DK-culotte stenting for left main bifurcation lesions.

Two bench model experiments were conducted using a 3D-printed left main bifurcation model. In Experiment 1, DK-culotte stenting using the same stent (Ultimaster Tansei) was compared between angiography-guided (n = 6) and 3D-OFDI-guided (n = 6) groups. In Experiment 2, two stents (Tansei vs. Nagomi) were compared under 3D-OFDI guidance (n = 6 each). Endpoints included the rate of optimal rewiring and the incidence of incomplete stent apposition (ISA) at both the side branch and the opposite side of the bifurcation.

Compared to angiography guidance, 3D-OFDI guidance significantly improved the rate of optimal rewiring and reduced ISA at the side branch side. Among 3D-OFDI-guided cases, the Nagomi stent, which has a larger maximum expansion capacity than Tansei, showed a lower incidence of ISA at the opposite side, with no cases of sparse distribution of struts at the left anterior descending coronary artery ostium.

3D-OFDI guidance and the use of stents with sufficient maximum expansion capacity each contribute to improved procedural outcomes by enhancing rewiring accuracy and stent apposition, supporting the optimization of culotte stenting in left main bifurcation lesions.