Navigating the Left Main Bifurcation: Which Stenting Strategy Best Minimises Major Adverse Cardiac Events and Target Lesion Revascularisation? A Network Meta-analysis.

3-Year Outcomes of the DKCRUSH-V Trial Comparing DK Crush With Provisional Stenting for Left Main Bifurcation Lesions

Design and rationale for the treatment effects of provisional side branch stenting and DK crush stenting techniques in patients with unprotected distal left main coronary artery bifurcation lesions (DKCRUSH V) Trial

The long-term comparative effectiveness of the Double Kissing (DK) Crush and Culotte stenting techniques for left main bifurcation lesions (LMBLs) remains a subject of clinical debate. This meta-analysis aimed to evaluate and compare the one-year and three-year clinical outcomes of the DK Crush and Culotte techniques in patients with LMBLs. A systematic search was performed in PubMed, MEDLINE, Cochrane, ScienceDirect, and Google Scholar databases up to June 2025. Three randomized controlled trials (RCTs) comprising 1,188 patients with LMBLs were included. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel fixed-effects model to assess one- and three-year outcomes, including target vessel revascularization (TVR), major adverse cardiac events (MACE), myocardial infarction (MI), cardiac death (CD), and coronary artery bypass grafting (CABG). Across all studies, DK Crush demonstrated significantly improved outcomes compared with the Culotte technique for several endpoints. At the one-year follow-up, DK Crush was associated with a significantly lower rate of target vessel revascularization (RR = 0.42, 95% CI: 0.24-0.75, p=0.003) and major adverse cardiac events (RR = 0.45, 95% CI: 0.29-0.71, p=0.0006). There were no significant differences between the two techniques in cardiac death (RR = 0.83, 95% CI: 0.32-2.12, p=0.70), myocardial infarction (RR = 0.60, 95% CI: 0.26-1.39, p=0.24), or coronary artery bypass grafting (RR = 2.42, 95% CI: 0.43-13.69, p=0.32). At the three-year follow-up, DK Crush maintained its superiority, showing significantly reduced rates of TVR (RR = 0.37, 95% CI: 0.24-0.58, p<0.0001), MACE (RR = 0.47, 95% CI: 0.34-0.65, p<0.0001), and MI (RR = 0.43, 95% CI: 0.21-0.89, p=0.02). However, no statistically significant differences were observed in cardiac death (RR = 0.81, 95% CI: 0.45-1.46, p=0.47) or CABG (RR = 2.25, 95% CI: 0.46-11.03, p=0.32). The DK Crush technique demonstrated superior clinical efficacy compared with the Culotte technique, with significantly lower rates of TVR, MACE, and MI at both one and three years. Although no significant differences were observed in cardiac death or CABG, DK Crush appeared to provide more favorable long-term vessel patency and reduced risk of repeat revascularization. Further large-scale randomized trials are warranted to validate these findings and strengthen the evidence supporting DK Crush as the preferred strategy for complex left main bifurcation lesions.

Double Kissing Crush Versus Provisional Stenting for Left Main Distal Bifurcation Lesions: DKCRUSH-V Randomized Trial

279Clinical outcome after coronary bifurcation stenting: a systematic review and network meta-Analysis of PCI bifurcation techniques comprising 5572 patients

We conducted a systematic review and network meta-analysis of available randomized clinical trials (RCTs) to compare cardiovascular outcomes involving stenting techniques in coronary bifurcation lesions. Although provisional stenting of the main branch and balloon angioplasty of the side branch is considered the standard approach, the use of two stents is often pursued with a wide variety of bifurcation stenting techniques available. We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and Clinicaltrials.gov from inception to December 2018. We performed a frequentist network meta-analysis to estimate relative risks (RR) of death, major adverse cardiovascular events (MACE), target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis (ST) among different two stent bifurcation techniques. We identified 14 studies, yielding data on 4,285 patients. Double Kissing (DK) Crush and Mini-crush were associated with significant reductions in MACE, TVR, and TLR when compared with the Provisional stenting (RR 0.31-0.55 [all p < .01] and RR 0.42-0.45 [all p < .02], respectively) and with the remaining bifurcation techniques (RR 0.44-0.55 [all p < .05] for DK Crush and RR 0.37-0.45 [all p < .05] for Mini-crush). In addition, Culotte and Crush were associated with an increased risk for ST compared to Provisional stenting (RR 3.25-4.27 [both p < .05]) and to DK crush (RR 3.02-3.99 [both p < .05]). DK crush and mini-crush were found to be associated with fewer events and complications compared to the other techniques reviewed, including the Provisional approach. Further, Culotte and Crush were associated with an increased risk of stent thrombosis when compared to the Provisional approach.

A Bayesian meta-analysis of double kissing (DK) crush or provisional stenting for coronary artery bifurcation lesions

ObjectiveThis study was aimed to compare different stenting techniques for coronary bifurcation disease (CBD).BackgroundPercutaneous coronary intervention (PCI) remains controversial for CBD; over the years, several stent techniques for bifurcation lesions have been used. Current guidelines recommend a provisional single-stent strategy as the preferred method for coronary artery bifurcation lesions. However, several randomized controlled trials (RCT) indicated that two-stent techniques showed better clinical outcomes.MethodsWe systematically searched Embase, PubMed, and Web of Science to include RCTs. The primary endpoint was the major adverse cardiovascular event (MACE). Secondary outcomes were cardiac death, myocardial infarction (MI), target-lesion or target-vessel revascularization (TLR or TVR), and definite or probable stent thrombosis (ST). Finally, we used 26 RCTs and a total of 7257 individuals were randomly assigned to one of the 6 stent techniques and included in this network meta-analysis.ResultsIn our network meta-analysis, double-kissing (DK) crush was significantly more superior to other 5 stent techniques in MACEs: OR vs. provisional 0.40 (95% CI 0.28–0.55); vs. culotte 0.40 (95% CI 0.26–0.60). DK crush ranked the most effective treatment for MACE (100%), MI (75%), ST (83%), and TLR (100%) in the rank probabilities analysis. In patients with complex bifurcation lesion defined by DEFINITION criteria, DK crush was notably more efficacious than provisional, culotte, and T-stenting/T-stenting and protrusion (TAP) in MACEs (OR vs. provisional 0.26, 95% CI 0.13–0.52) and TLR (OR vs. provisional 0.24, 95% CI 0.10–0.58).ConclusionCompared with other stenting techniques, DK crush had a lower incidence of MACEs in CBD. DK crush was significantly associated with a lower rate of MACEs in patients with complex bifurcation lesions defined by the DEFINITION criterion.Graphical abstract

Clinical Outcome After DK Crush Versus Culotte Stenting of Distal Left Main Bifurcation Lesions: The 3-Year Follow-Up Results of the DKCRUSH-III Study.

BackgroundClassical crush has a lower rate of final kissing balloon inflation (FKBI) immediately after percutaneous coronary intervention (PCI). The double kissing (DK) crush technique has the potential to increase the FKBI rate, and no prospective studies on the comparison of classical with DK crush techniques have been reported.Materials and methodsThree hundred and eleven patients with true bifurcation lesions were randomly divided into classical (n = 156) and DK crush (n = 155) groups. Clinical and angiographic details at follow-up at 8 months were indexed. The primary end point was major adverse cardiac events (MACE) including myocardial infarction, cardiac death and target lesion revascularization (TLR) at 8 months.ResultsFKBI was 76% in the classical crush group and 100% in the DK group (P < 0·001). The incidence of stent thrombosis was 3·2% in the classical crush group (5·1% in without- and 1·7% in with-FKBI) and 1·3% in the DK crush group. Cumulative 8 month MACE was 24·4% in the classical crush group and 11·4% in the DK crush group (P = 0·02). The TLR-free survival rate was 75·4% in the classical crush group and 89·5% in the DK crush group (P = 0·002).ConclusionsDK crush technique has the potential of increasing FKBI rate and reducing stent thrombosis, with a further reduction of TLR and cumulative MACE rate at 8 months.Eur J Clin Invest 2008; 38 (6): 361–371

IntroductionPercutaneous coronary intervention (PCI) of a left main coronary artery (LMCA) bifurcation lesion is a challenging topic among interventional cardiologists. The optimal stenting modality for patients requiring a 2-stent strategy is still debated.AimTo compare the clinical outcomes of double kissing (DK) crush and DK culotte techniques in distal LMCA bifurcation lesions.Material and methodsPatients with unprotected distal LMCA bifurcation lesions undergoing PCI with DK crush or DK culotte technique were enrolled in 9 heart centers. The primary endpoint of the study was target lesion failure (TLF) as a composite endpoint of target lesion revascularization (TLR), target vessel myocardial infarction (TVMI), and cardiac death.ResultsA total of 245 patients with unprotected distal LMCA bifurcation lesions treated with DK culotte (121 patients) or DK crush (124 patients) technique were followed up for 3 years. The incidence of 3-year TLF was lower in the DK culotte group than the DK crush group (5.0% vs. 11.3%, HR = 0.557, 95% CI: 0.211–1.471; p = 0.06). There was also no difference in 3-year TLR (5.0% vs. 7.3%, HR = 0.907, 95% CI: 0.310–2.651; p = 0.42), TVMI (2.5% vs. 3.2%, HR = 0.762, 95% CI: 0.160–3.627; p = 0.71), or cardiac death (0.8% vs. 2.4%, HR = 0.733, 95% CI: 0.063–8.550; p = 0.32) between groups.ConclusionsIn the present multicenter study, the DK culotte group had a lower TLF ratio than the DK crush group, without a statistically significant difference in distal true left main bifurcation lesions.

The present study aimed to compare the long-term (five-year) safety and efficacy between the one-stent, two-stent and double-kissing (DK) crush strategies, utilising drug-eluting stents, for unprotected left main coronary artery (ULMCA) bifurcation lesions. Between March 2004 and April 2007, 633 consecutive patients with ULMCA bifurcation lesions (232 in the one-stent group and 401 in the two-stent group) were prospectively enrolled. The primary endpoint was the occurrence of major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction (MI), and target vessel revascularisation (TVR), at five-year follow-up. Patients in the the two-stent group were classified as DK crush (n=155) and other two-stent techniques (culotte, T-stenting, kissing stenting and classical crush, n=246). Forty-seven (16.8%) patients in the one-stent group crossed over to the two-stent group. The one-stent group was associated with an increased incidence of MI compared to the two-stent approach (10.5% vs. 5.5%, p=0.025). The crude rate of MACE at five years was 28.0% in the one-stent group and 28.4% in the two-stent group (p=0.927). DK crush was associated with a significantly decreased five-year MACE compared to the other two-stent approaches or the one-stent approach (DK crush: 14.8% vs. other two-stent approaches: 37.0%, one-stent approach: 28.0%, p<0.001). The main benefit of DK crush primarily appeared to be secondary to a reduction in TVR (7.7% vs. 30.5% vs. 18.1%, p<0.001). By Cox regression analyses, the non-DK crush two-stent technique, a high SYNTAX Score (≥33) or New Risk Stratification (NERS) score (>20), and incomplete revascularisation were shown to be independent predictors of MACE at five-year follow-up. With distal left main true bifurcations, the two-stent technique (excluding DK crush) is an independent predictor of long-term MACE. DK crush is associated with more favourable long-term clinical outcomes. Confirmation of these findings is required from randomised controlled trials.

Double-kissing (DK) crush and DK culotte are the recommended 2-stent strategies in true coronary bifurcation lesions. However, it is a matter of curiosity about which of the DK crush and DK culotte stenting techniques will have superior results. We aimed to compare the clinical outcomes of DK crush and DK culotte stenting in nonleft main coronary artery bifurcation. Consecutive patients who received DK crush or DK culotte technique for de novo true nonleft main coronary artery bifurcation lesion were categorized according to which treatment they received. The primary end point of the study was target lesion failure as a composite end point of target lesion revascularization, target vessel myocardial infarction, and cardiac death. Secondary end points were all-cause death and definite stent thrombosis. A total of 202 patients were categorized as DK crush (101 patients) or DK culotte (101 patients) techniques. The target lesion failure had occurred frequently in the DK crush (10.9%) compared with the DK culotte (3.0%; P=0.028) that was mainly driven by increased target lesion revascularization (9.9% in the DK crush versus 3.0% in the DK culotte; P=0.045). The number of patients with target vessel myocardial infarction (3.0% in the DK crush versus 2.0% in the DK culotte; P=0.651) and cardiac death (1.0% in the DK crush versus 0.0% in the DK culotte; P=0.315) was higher in the DK crush. There were no differences in terms of definite stent thrombosis and all-cause death between groups. In the present analysis, DK culotte was associated with lower 1-year target lesion failure rates compared with DK crush in true nonleft main coronary artery bifurcations. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04789161.

Comparative Efficacy of Bifurcation Stenting Techniques for Left Main Disease: A Network Meta-analysis With Reconstructed Time-to-Event Data

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