DK Crush Technique Research Articles

A retrospective study on real world, 2-stent left main bifurcation PCI using DK crush technique with IVUS guidance - a single center experience

Abstract Objectives The aim of this study is to investigate clinical outcome of the IVUS guided 2-stent bifurcation strategy using DK crush technique performed in a complex Left Main (LM) bifurcation lesions defined according to DEFINITION study in our local setting. We seek to assess the composite endpoint of target vessel failure (TVF) at 9-12 months. Methods All patients underwent IVUS guided 2-stent Bifurcation PCI with DK crush technique for complex LM bifurcation lesions defined by the DEFINITION criteria performed in a heart institute from 1.1.2019 to 31.7.2023 were included..Patient baseline characteristics, post-procedural and 12-months follow-up outcomes including cardiac death,myocardial infarction (MI),rate of target vessel failure (TVF),rate of stent thrombosis (ST) and major adverse coronary event (MACE) were analysed.Exclusion criteria are patients age <18 years and previous stenting in the target vessel Results A total of 50 patients were included in this analysis. Mean age was 64.3±9.1 years with predominant males (n= 38, 76%).Majority were hypertensive (n=37, 74%) and diabetes mellitus accounted for 32 (64%) cases.Patients with pre-existing coronary artery disease were 39 (78%) cases. 40% presented with history of recent myocardial infarction (MI), 12% had new onset angina and 6% had heart failure. Pre-existing chronic renal failure (18%) and history of CVA (2%). Among chronic renal failure cases, 50% had eGFR <50 during index procedure.Additionally, previous PCI was performed in 22 cases (44%) and 2 previous CABG cases included (4%).Majority of the cases were performed as staged elective procedure ( n=45, 90%) and others were indicated for ACS ( n=5, 10%). Radial approach was predominantly preferred with 25 cases (50%), where additional 5 cases (10%) were converted to femoral approach due to severe radial spasm. Among these 50 cases, 1 case required additional PCI to CTO LAD and mid LCX, while 7 cases (14%) had calcified lesions requiring scoring / cutting balloons and atherectomy device utilization for adequate lesion preparation prior to bifurcation stenting.All 50 patients received combination of both aspirin and a P2Y12 inhibitors for 12 months. Follow up done at at 30-day, 60-days and 1 year after the index procedure.Clinical follow-up were available in 46 (92%) patients only.4 cases were lost to follow up due to logistic reasons. At 1 year follow-up, cardiac death occurred in 5 (10.9%) patients, out of which 3 (6.5%) cases were cardiac related and 2 (4.4%) are non-cardiac. Major adverse cardiac events (MACE) and target vessel failure (TVF) occurred in total 4 (8.7%) cases, where 3 (6.5%) cases resulted in cardiac death and 1 (2.2%) case had MI and clinically driven target lesion revascularization. Conclusion Our experience demonstrates that IVUS guided, upfront 2-stent Bifurcation PCI using DK crush technique for complex bifurcation lesions is effective and safe with a low MACE and TLR rate at 1 year follow-up.

The impact of the bifurcation angle for the Nano-Crush two-stent coronary bifurcation technique on long-term outcomes in a real-world clinical population

AimThis study aims to assess the direct impact of bifurcation angle (BA) on immediate procedural outcomes and patient prognosis post-Nano-Crush stenting for coronary bifurcation lesions. MethodsA retrospective analysis was conducted for all consecutive patients treated with the Nano-Crush technique across two high-volume interventional centers from January 2020 to October 2022. Primary endpoint: comparison of target lesion failure rate in two cohorts based on bifurcation angle (<70° vs. ≥70°), with secondary endpoints including side branch ostium coverage, rate of successful final kissing balloon inflation (FKBI), need for conversion to another technique, and procedure length. ResultsBaseline demographics included 71 patients in the BA<70° group and 49 in the BA≥70° group, with well-balanced characteristics. Angiographic characteristics revealed similar trends, including anatomic and morphological lesion characteristics (referencing Syntax score, Medina classification, and presence of calcifications). Both groups predominantly had complex coronary disease, with a baseline mean Syntax score of 24.18 ± 8.19 in the BA<70° group and 23.91 ± 7.29 in the BA≥70° group, respectively. A dedicated debulking device for lesion preparation was used in 25.35 % of patients in the first group and in 28.57 % of patients in the second group.The primary endpoint occurred in 5.63 % of patients in the BA<70° group and in 4.08 % of patients in the BA≥70° group (P = 0.7014) after ≥ 2 years of clinical follow-up. Angiographic success was achieved in 100 % of both groups, with procedural time averaging 74.99 ± 25.55 min in the BA≥70° and 76.94 ± 27.81 min in the BA<70° (P = 0.6922). The rate of successful final kissing balloon inflation was 98.59 % in the BA<70° group and 95.91 % in the BA≥70° group (P = 0.3566). The mean contrast volume was 189.54 ± 73.74 ml in BA<70° and 168.9 ± 62.77 ml in BA≥70° (P = 0.1126). Clinical follow-ups at 30 days and 2 years revealed similar outcomes and complications for each group, as summarized in Table 3. ConclusionsOur results demonstrate that the bifurcation angle does not significantly impact long-term clinical outcomes or procedural parameters, such as side branch ostium coverage, conversion to a modified DK Crush technique, FKBI success rate, and procedure length. These findings suggest that the Nano-Crush technique can be a viable option for bifurcation lesions, irrespective of the bifurcation angle, achieving optimal side branch ostium coverage while preventing excessive protrusion into the main vessel.

Comparison of long-term outcomes of double kissing crush versus T and minimal protrusion techniques in complex bifurcation lesions: The EVOLUTE-CRUSH II registry.

Double kissing (DK)-crush and T-stenting and small protrusion (TAP) techniques are gaining popularity, but the comparison for both techniques is still lacking. This study sought to retrospectively evaluate the long-term outcomes of DK-crush and TAP techniques in patients with complex bifurcation lesions. A total of 255 (male: 205 [80.3%], mean age: 59.56 ± 10.13 years) patients who underwent coronary bifurcation intervention at a single-center between January 2014 and May 2021 were included. Angiographic features, procedure details, and in-hospital or long-term outcomes were assessed. The primary endpoint was target lesion failure (TLF), defined as the combination of cardiac death, target vessel myocardial infarction, or clinically driven-target lesion revascularization (TLR). The regression models were adjusted applying by the inverse probability weighted (IPW) approach to reduce treatment selection bias. The initial management strategy was DK-crush in 152 (59.6%) patients and TAP in 103 (40.4%) cases. The SYNTAX scores (24.58 ± 7.4 vs. 24.26 ± 6.39, p = 0.846) were similar in both groups. The number of balloon (6.32 ± 1.82 vs. 3.92 ± 1.19, p < 0.001) usage was significantly higher in the DK-crush group than in the TAP group. The rates of TLF (11.8 vs. 22.3%, p = 0.025) and clinically driven TLR (6.6 vs. 15.5%, p = 0.020) were significantly lower in the DK-crush group compared to the TAP group. The long-term TLF was significantly higher in the TAP group compared to the DK-crush group (unadjusted HR: 1.974, [95% CI: 1.044-3.732], p = 0.035 and adjusted HR [IPW]: 2.498 [95% CI: 1.232-5.061], p = 0.011). The present study showed that the DK-crush technique of bifurcation treatment was associated with lower long-term TLF and TLR rates compared to the TAP technique.

Abstract 11910: Contemporary In-Hospital Outcomes of Bifurcation Percutaneous Coronary Interventions: Update From the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (PROGRESS-BIFURCATION)

Introduction: Bifurcation percutaneous coronary intervention (PCI) techniques are rapidly evolving and can be challenging to perform. Methods: We examined the angiographic, procedural characteristics, and outcomes of 472 bifurcation PCIs in Prospective Global Registry for the Study of Bifurcation Lesion Interventions (PROGRESS-BIFURCATION, NCT05100992). Results: A total of 472 bifurcation PCIs were included. Mean age was 67±12 years, 74% were men with a high prevalence of comorbidities: hypertension (81%), diabetes mellitus (36%), dyslipidemia (90%). Overall technical success was 95%. The incidence of in-hospital major adverse cardiovascular events (MACE) was 5.1%. The most common stenting strategy was provisional (71%), double-kissing (DK) crush (12%), mini-crush wish 2 stents (3%), culotte (3%), T-and protrusion (4%), and T-stenting (1.5%). Patients treated with the DK-crush had more severe stenosis of the left main (35%±38 vs. 19%±30, p&lt;0.001), proximal left anterior descending (68%±29, vs. 52%±35, p=0.001), and side branch lesion (82%±15, 51%±36, p&lt;0.001). Medina classification was more often 1,1,1 (79% vs. 39%, p&lt;0.001), with higher use of intravascular ultrasound/optical coherence tomography (57% vs. 31%, p&lt;0.001) compared to non-DK crush. The DK-crush required use of more contrast and took longer to perform (Table). Conclusions: Despite high patient comorbidity, bifurcation PCI can be performed with high technical success and low in-hospital MACE rates. DK-crush technique was more commonly preferred in bifurcation lesions with more severe/proximal vessel involvement.

Successful endovascular treatment of left main bifurcation lesion using the DK-CRUSH technique with intracoronary imaging using optical coherence tomography: A case report

We report the successful endovascular treatment of true left main bifurcation lesion in a patient with chronic coronary syndrome using the DK-CRUSH technique. We describe technical aspects of bifurcation stenting with intracoronary imaging using optical coherence tomography. Here, we review the current state of the problem of choosing the optimal technique for endovascular treatment of patients with true left main true bifurcation lesion.

TCTAP C-029 Balloon Embedded DK Crush Technique

TCTAP C-029 Balloon Embedded DK Crush Technique

Research Progress of Percutaneous Interventional Therapy For Bifurcation Lesions of Coronary Heart Disease

Compared with non-bifurcation lesions, even if the new generation of percutaneous coronary intervention (PCI) technology is used to treat coronary bifurcation lesions, the incidence of adverse cardiovascular events is still higher. The evaluation of related clinical data and computer virtual modeling before surgery can guide the implementation of bifurcation PCI in a more precise manner. The new understanding of bifurcation PCI may further improve the clinical prognosis and outcome of patients with bifurcation disease. This review aims to summarize the assessment methods of PCI for coronary heart disease non-left main bifurcation disease and the treatment plan supported by clinical evidence. The treatment plan depends on three parameters: the diameter of the three parts of the bifurcation lesion; the length of the lesion and plaque distribution; and the angle of the bifurcation. To this day, the best technique for PCI for bifurcation lesions is still controversial, and a personalized approach using temporary collateral stent implantation schemes seems to be suitable for 75% to 95% of patients. For more complex bifurcation lesions, it may be necessary to use two stents at the same time. More and more evidence supports the practicability of the DK-crush technique.

TCT-341 OCT Predictors of Side Branch Restenosis During LM Bifurcation Angioplasty Using DK Crush Technique

TCT-341 OCT Predictors of Side Branch Restenosis During LM Bifurcation Angioplasty Using DK Crush Technique

Double kissing crush bifurcation stenting: step-by-step troubleshooting.

The double kissing crush (DK crush) is the most studied two-stent coronary bifurcation stenting strategy. While published data support its use, DK crush can be challenging to perform. In this review we provide a detailed step-by-step description and troubleshooting for each stage of the DK crush technique.

PVAD-assisted left main DK-Crush Bifurcation PCI Post-ViV TAVR

We describe successful percutaneous coronary intervention (PCI) of significantly diseased ostial left main (LM) and distal LM bifurcation (Medina 1,1,1) in a patient with a reduced left ventricular ejection fraction and a recent valve-in-valve balloon-expandable TAVR using the DK-Crush technique with the support of a percutaneous left ventricular assist device.

Antegrade and retrograde in‐stent tibial artery chronic total occlusion recanalization with double kiss crush (DK crush) stenting of previous stent

Below the knee (BTK) peripheral arterial disease often presents with critical limb ischemia (CLI) clinically with involvement of more than one tibial vessels. Drug eluting stent (DES) technology for treatment of BTK disease has shown promising long-term durable results; however, currently only coronary DESs are available for application in the United States. Although coronary bifurcation stenting techniques are backed by extensive data in literature, there is a scarcity of data for the treatment of tibial bifurcation disease. Bifurcation angles in the tibials are similar to those in the coronaries and therefore the same two stent bifurcation technique can be applied in BTK disease. Double Kiss crush (DK crush) stenting has superior outcomes when compared to provisional or culotte stenting in randomized coronary trials (based on Medina classification). We present a case of BTK CLI with tibial bifurcation chronic total occlusion treated with two stent DK crush technique using coronary DES.

Clinical Outcomes Following Coronary Bifurcation PCI Techniques: A Systematic Review and Network Meta-Analysis Comprising 5,711 Patients

ObjectivesThe aim of this study was to compare clinical outcomes of different bifurcation percutaneous coronary intervention (PCI) techniques. BackgroundDespite several randomized trials, the optimal PCI technique for bifurcation lesions remains a matter of debate. Provisional stenting has been recommended as the default technique for most bifurcation lesions. Emerging data support double-kissing crush (DK-crush) as a 2-stent technique. MethodsPubMed and Scopus were searched for randomized controlled trials comparing PCI bifurcation techniques for coronary bifurcation lesions. Outcomes of interest were major adverse cardiovascular events (MACE). Secondary outcomes of interest were cardiac death, myocardial infarction, target vessel or lesion revascularization, and stent thrombosis. Summary odds ratios (ORs) were estimated using Bayesian network meta-analysis. ResultsTwenty-one randomized controlled trials including 5,711 patients treated using 5 bifurcation PCI techniques were included. Investigated techniques were provisional stenting, T stenting/T and protrusion, crush, culotte, and DK-crush. Median follow-up duration was 12 months (interquartile range: 9 to 36 months). When all techniques were considered, patients treated using the DK-crush technique had less occurrence of MACE (OR: 0.39; 95% credible interval: 0.26 to 0.55) compared with those treated using provisional stenting, driven by a reduction in target lesion revascularization (OR: 0.36; 95% credible interval: 0.22 to 0.57). No differences were found in cardiac death, myocardial infarction, or stent thrombosis among analyzed PCI techniques. No differences in MACE were observed among provisional stenting, culotte, T stenting/T and protrusion, and crush. In non–left main bifurcations, DK-crush reduced MACE (OR: 0.42; 95% credible interval: 0.24 to 0.66). ConclusionsIn this network meta-analysis, DK-crush was associated with fewer MACE, driven by lower rates of repeat revascularization, whereas no significant differences among techniques were observed for cardiac death, myocardial infarction, and stent thrombosis. A clinical benefit of 2-stent techniques was observed over provisional stenting in bifurcation with side branch lesion length ≥10 mm.

Proximal Side Optimization: A Modification of the Double Kissing Crush Technique

Coronary bifurcations with significant lesions &gt;10 mm in the side branch (SB) are likely to require two-stent treatment techniques. To date, double kissing Crush (DK-Crush) stenting has demonstrated higher rates of final kissing balloon inflation and better clinical outcomes. The technical iterations that lead to optimal clinical outcomes have been attributed to the first kissing balloon that repairs the distorted proximal segment and fully expands the orifice of the side stent. One potential caution, which relates to all Crush techniques, is the possibility of the guidewire crossing in an inappropriate position toward the Crushed SB stent. When this occurs, the SB stent may be further Crushed, leaving the ostium uncovered, which potentially negates the benefit of the Crush technique. In our experience, proximal side optimization (PSO) during DK-Crush stenting ensures stent size ‘accommodation’ to the larger vessel diameter in the proximal segment and better strut apposition to the wall, which is particularly important in the ostial segment. The benefits of this additional modification of the established DK-Crush technique are reduction or elimination of the risk of SB stent distortion, increase of the space of optimal wiring, and avoidance of guidewire advancement under the stent struts, even in unfavorable anatomies with extreme angulation. The author describes a step-by-step approach of a proposed PSO technique, which is easy to perform without any additional procedural time or costs.

P970DK-crush is the best treatment strategy to reduce stent oriented clinical outcome, results from a network meta-analysis of twenty-six randomized clinical trials comparing different stent techniques

Abstract Background Coronary bifurcation disease (CBD) accounts for approximately 20% of all and is associated with worse short- and long- term clinical outcomes. Provisional stenting (PS) is the preferred choice, however, this approach may not be suitable in all CBD anatomies, therefore several elective two-stents techniques have been described, however there is lack of randomized evidence to guide interventionalist across different stent techniques. Objectives. To identify the best percutaneous coronary interventions (PCI) technique for CBD. Methods We systematically review randomized clinical (RCTs) of patients receiving CBD PCI with either PS or six type of elective two-stent techniques (DK-crush, TAP, culotte, dedicated bifurcation stents, crushing, T-stenting) and compare device oriented clinical events (DOCE) in a network meta-analysis. DOCE was defined as composite of cardiac death, target-vessel myocardial infarction, stent thrombosis, target lesion revascularization OR target vessel revascularisation. Results We included 26 RCTs leading to a pooled population of 10339 patients-years with 1229 DOCE. Compared to PS, the DK-crush technique had a lower DOCE with RR=0.62, [0.42–0.92]. Figure. DK-crush had the highest likelihood (model likelihood=90.2%, SUCRA=98.0%) of being the best treatment to reduce DOCE. Figure 1 Conclusions In the management CBD, when a two-stent technique is required as upfront strategy, the DK- Crush technique should be privileged as it showed to reduce stent-related clinical outcomes (DOCE) when compared to other bifurcation techniques.

TCTAP C-051 Post-CABG Optimum Revascularization: PCI to Native Vessels Including Bifurcation Stenting by DK Crush Technique

### Patient Initials or Identifier Number MHMH ### Relevant Clinical History and Physical Exam A 65-year-old Bangladeshi male presented with CCS Class III-IV angina for 2 weeks, on optimum GDMT. He was hypertensive and a smoker, with a family history of coronary artery disease. Initial

TCTAP C-050 Left main Bifurcation Intervention Combined with Reverse Guidewire Technique and Modify DK-CRUSH Technique

### Patient Initials or Identifier Number PSL ### Relevant Clinical History and Physical Exam A 60-year male for chest discomfort ongoing 50 meters, could be relieved by rest or sublingual nitroglycerin for 3-5 minutes. The coronary risk factor was hypertension, hyperlipidemia current smoking.PE

ASSA13-15-25 Single Balloon Expansion Also Enhance the Rate of Final Kissing Expansion After the Branch Stent with CRUSH Technology

<h3>Objective</h3> A retrospective analysis on the use of DK crush and SBSK crush technology to deal with bifurcation lesions and to investigate the reliability and efficacy of the SBSK (single balloon single kissing) crush technology. <h3>Methods</h3> 56 cases of hospitalised patients undergoing percutaneous coronary intervention (PCI) were admitted in the Second Hospital of Shanxi Medical University from June 2005 to September 2012, including 40 cases of male and 16 cases of, age 63 ± 11 There were 26 patients in which DK crush technique was used to complete the double bifurcation lesion stenting (DK Group), of which, lesions of 18 cases were the left anterior descending (LAD) + D1, 6 cases were circumflex artery + OM, 2 cases were right coronary artery + obtuse marginal branch.. There were 30 patients in which SBSK crush technique was used to complete the double bifurcation lesion stenting group (SBSK Group). Of the 30 patients, including 22 males and 10 females, age 43 to 78, there were 12 cases with acute myocardial infarction in the recovery period and 18 cases with unstable angina. Lesions: These 30 patients with coronary disease are true bifurcation lesions in line with the Lefevre taxonomy branch vessel diameter &gt; 2.0mm. in which, lesions of 22 cases were the left anterior descending (LAD) + D1, 6 cases were circumflex artery +OM, 2 cases were right coronary artery + obtuse marginal branch. <h3>Results</h3> 2 patients did not complete the final kiss expansion. In the DK group; the completion rate was 92.3%. 2 patients did not complete the final kiss expansion in SBSK group; the completion rate was 93.3%. The difference between the two groups was not statisticallysignificant. The mean time of guide wire through the stent mesh into the branch was 6 ± 4.6min after stenting main branch in SBSK group. The mean PCI total time was 38 ± 19 min. The mean total contrast agent volume was 90 ± 60ml. In DK group, due to the earlier completion without making related statistics. <h3>Conclusions</h3> SBSK crush and DK crush technology can obtain a high and eventually kissing expansion rate. SBSK crush is easier to operate, it is possible to further shorten the time of PCI and reduce the use of contrast agents.

DK Crush Technique Compared to Other Two-stent Strategies for Treatment of Heavily Calcified True Left Main Bifurcation Stenosis

PCI of heavily calcified true left main bifurcation stenosis (TLMBS) usually requires more complex procedures with two-stent strategy (2SS) and has higher risk of dissection, perforation, stent thrombosis and restenosis. We compared the results of PCI with DK crush technique (DK) and different types of 2SS in patients (pts) with or without heavy calcification.

A Randomized Clinical Study Comparing Double Kissing Crush With Provisional Stenting for Treatment of Coronary Bifurcation Lesions: Results From the DKCRUSH-II (Double Kissing Crush versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions) Trial

The present study aimed to investigate the difference in major adverse cardiac events (MACE) at 12 months in patients with coronary bifurcation lesions after double kissing double crush (DK crush) or provisional stenting (PS) techniques. Provisional side branch (SB) stenting is preferable to DK crush because it has been associated with fewer complications. It is unknown which strategy would provide the best results. From April 2007 to June 2009, 370 unselected patients with coronary bifurcation lesions from 7 Asian centers were randomly assigned to either the DK or the PS group. Additional SB stenting in PS was required if final results were suboptimal. The primary end point was the occurrence of MACE at 12 months, including cardiac death, myocardial infarction, or target vessel revascularization (TVR). Secondary end point was the angiographic restenosis at 8 months. There were 3 procedural occlusions of SB in the PS group. At 8 months, angiographic restenosis rates in the main vessel and SB were significantly different between the DK (3.8% and 4.9%) and the PS groups (9.7% and 22.2%, p = 0.036 and p < 0.001, respectively). Additional SB stenting in the PS group was required in 28.6% of lesions. TVR was 6.5% in the DK group, occurring significantly less often than in the PS group (14.6%, p = 0.017). There were nonsignificant differences in MACE and definite stent thrombosis between the DK (10.3% and 2.2%) and PS groups (17.3%, and 0.5%, p = 0.070 and p = 0.372, respectively). DK crush was associated with a significant reduction of TLR and TVR in this unselected patient population. However, there was no significant difference in MACE between DK and the PS groups. (Randomized Study on DK Crush Technique Versus Provisional Stenting Technique for Coronary Artery Bifurcation Lesions; ChicTR-TRC-00000015).

Interventional therapy of coronary artery disease in China: retrospective and perspective

Interventional therapy of coronary artery disease in China: retrospective and perspective