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(Circulation. 2009;119:71-78.)
© 2009 American Heart Association, Inc.

Interventional Cardiology

Randomized Study of the Crush Technique Versus Provisional Side-Branch Stenting in True Coronary Bifurcations

The CACTUS (Coronary Bifurcations: Application of the Crushing Technique Using Sirolimus-Eluting Stents) Study

Antonio Colombo, MD; Ezio Bramucci, MD; Salvatore Saccà, MD; Roberto Violini, MD; Corrado Lettieri, MD; Roberto Zanini, MD; Imad Sheiban, MD; Leonardo Paloscia, MD; Eberhard Grube, MD; Joachim Schofer, MD; Leonardo Bolognese, MD; Mario Orlandi, MD; Giampaolo Niccoli, MD; Azeem Latib, MD; Flavio Airoldi, MD

From the Interventional Cardiology Unit, San Raffaele Scientific Institute (A.C., A.L., F.A.), Milan, Italy; Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus (A.C.), Milan, Italy; Department of Cardiology, Policlinico S. Matteo (E.B), Pavia, Italy; Department of Cardiology, P.O. di Mirano (S.S.), Mirano, Italy; Department of Cardiology, Ospedale S. Camillo (R.V.), Rome, Italy; Department of Cardiology, A.O. Carlo Poma (C.L., R.Z.), Mantova, Italy; Department of Cardiology, A.O. Molinette (I.S.), Torino, Italy; Department of Cardiology, Ospedale Santo Spirito (L.P), Pescara, Italy; Interventional Cardiology Unit, Helios Heart Center (E.G.), Siegburg, Germany; Interventional Cardiology Unit, Hamburg University Cardiovascular Center (J.S.), Hamburg, Germany; Azienda USL 8 (L.B.), Arezzo, Italy; Department of Cardiology, Azienda Ospedaliera di Lodi (M.O.), Lodi, Italy; Department of Cardiology, Policlinico A. Gemelli (G.N.), Rome, Italy; and Interventional Cardiology Unit, Multimedica IRCCS (F.A.), S.S. Giovanni, Milan, Italy.

Correspondence to Antonio Colombo, EMO-GVM Centro Cuore Columbus Hospital, Via Buonarroti, 48-20145, Milan, Italy. E-mail info{at}emocolumbus.it

Received July 18, 2008; accepted October 22, 2008.

Background— Sirolimus-eluting stents have been reported to be effective in the treatment of coronary bifurcations. Still, it has not been fully clarified which strategy would provide the best results with true bifurcation lesions.

Methods and Results— The CACTUS trial (Coronary bifurcations: Application of the Crushing Technique Using Sirolimus-eluting stents) is a prospective, randomized, multicenter study comparing 2 different techniques of stenting, with mandatory final kissing-balloon inflation, in true bifurcations: (1) elective "crush" stenting and (2) stenting of only the main branch, with provisional side-branch T-stenting. From August 2004 to June 2007, 350 patients were enrolled in 12 European centers. The primary angiographic end point was the in-segment restenosis rate, and the primary clinical end point was the occurrence of major adverse cardiac events (cardiac death, myocardial infarction, or target-vessel revascularization) at 6 months. At 6 months, angiographic restenosis rates were not different between the crush group (4.6% and 13.2% in the main branch and side branch, respectively) and the provisional stenting group (6.7% and 14.7% in the main branch and side branch, respectively; P=NS). Additional stenting on the side branch in the provisional stenting group was required in 31% of lesions. Rates of major adverse cardiac events were also similar in the 2 groups (15.8% in the crush group versus 15% in the provisional stenting group, P=NS).

Conclusions— In most bifurcations with a significant stenosis in both branches, a provisional strategy of stenting the main branch only is effective, with the need to implant a second stent on the side branch occurring in approximately one third of cases. The implantation of 2 stents does not appear to be associated with a higher incidence of adverse events at 6 months.

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