Bifurcation Stenting
Provisional single-stent treatment remains the default strategy for most coronary bifurcation lesions. Planned two-stent techniques may be appropriate for selected complex bifurcations, particularly those involving a large, significantly diseased side branch.
Double-Kissing Crush¶
Double-kissing crush (DK-crush) is a planned two-stent technique incorporating:
- Side-branch stent deployment
- Side-branch stent crushing
- First kissing-balloon inflation
- Main-vessel stent deployment
- Proximal optimization
- Side-branch rewiring
- Final kissing-balloon inflation
- Repeat proximal optimization
Successful DK-crush requires careful lesion preparation, accurate stent positioning, appropriate proximal optimization, and successful performance of both kissing-balloon inflations.
Evidence¶
DKCRUSH-II¶
DKCRUSH-II compared DK-crush with provisional stenting for true coronary bifurcation lesions.
At 5 years:
| Outcome | DK-crush | Provisional |
|---|---|---|
| MACE | 15.7% | 23.8% |
| Cardiac death | 2.2% | 3.2% |
| Target-lesion revascularization | 8.6% | 16.2% |
| Definite or probable stent thrombosis | 2.7% | 2.7% |
DK-crush significantly reduced target-lesion revascularization. The difference in MACE narrowly missed conventional statistical significance (p = 0.051).
EVOLUTE-CRUSH Registry¶
The EVOLUTE-CRUSH registry compared DK-crush with mini-crush in 269 patients with complex bifurcation lesions.
Target-lesion failure was similar between DK-crush and mini-crush:
- DK-crush: 12%
- Mini-crush: 14%
p = 0.453
DK-crush required more balloons, guidewires, fluoroscopy time, and total procedural time.
Practical Interpretation¶
- Use provisional stenting for most bifurcation lesions.
- Consider an upfront two-stent strategy when the side branch is large, important, and extensively diseased.
- DK-crush has the strongest randomized evidence among planned two-stent techniques, particularly for complex distal left-main bifurcations.
- Its benefits depend on meticulous execution and may not generalize to inexperienced operators.
- Intravascular imaging should be strongly considered during complex bifurcation and left-main PCI.
- DK-crush should not be interpreted as superior for every bifurcation lesion.