Cases of Early, Aggressive In-Stent Restenosis in Left Main Double Kissing (DK) Crush Technique and Treatment Options

Abstract

Background/purposeWe present three recent cases at our institution that demonstrate early, aggressive in-stent restenosis (ISR) of double-kissing (DK) crush technique despite careful adherence to the technique and compliance of the patient. There are multiple percutaneous coronary intervention strategies for left main (LM) coronary artery bifurcation disease. The DK crush technique has gained popularity for the treatment of complex bifurcation lesions, including distal LM bifurcations. Methods/materialsWe reviewed clinical and procedural characteristics of three recent patients who presented at our tertiary center with non-ST-elevation myocardial infarction (NSTEMI) in the setting of early, aggressive ISR of DK crush. All patients underwent imaging-guided DK crush stenting with full adherence to all steps of the technique. ResultsThe median age was 65 years, median follow-up was 8 months from initial DK crush, and all three patients presented with NSTEMI. Patients had significant ISR in both limbs of the bifurcation involving aggressive tissue proliferation. These patients were treated differently: intracoronary brachytherapy, direct stenting, and coronary artery bypass grafting. ConclusionsDK crush for unprotected LM distal bifurcation can result in aggressive ISR with tissue proliferation and target vessel failure despite adhering to all steps of the technique. More research is warranted before DK crush is adopted as the default technique for bifurcation lesions.