Double Kissing Crush Technique Research Articles

Exploring the best strategy for true bifurcation coronary diseases to avoid a "fall between two stools".

Key points The double kissing crush technique is a promising strategy for true bifurcation coronary diseases, although it is yet to be recognized as a “gold standard” because of its complexity. A “one strategy fits all” approach is not applicable to bifurcation percutaneous coronary intervention (PCI) because of diversity. New technologies may overcome this issue with diversity and support tailored PCI for true bifurcation coronary diseases.

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

ObjectiveDespite the development of dedicated, two-stent strategies, including the double kissing (DK) crush technique, the ideal technique for coronary artery bifurcation stenting has not been identified. We aimed to compare and determine the absolute risk difference (ARD) of the DK crush technique alone versus provisional stenting approaches for coronary bifurcation lesions, using the Bayesian technique. MethodWe queried PubMed/MEDLINE to identify randomized controlled trials (RCTs) that compared DK crush technique with provisional stenting for bifurcation lesions, published till January 2023. We used Bayesian methods to calculate the ARD and 95% credible interval (CrI). ResultsWe included three RCTs, with 916 patients, in the final analysis. The ARD of cardiac death was centered at −0.01 (95% CrI: −0.04 to 0.02; Tau: 0.02, 85% probability of ARD of DK crush vs. provisional stenting <0). ARD for myocardial infarction was centered at −0.03 (95%CrI: −0.9 to 0.03; Tau: 0.05, 87% probability of ARD of DK crush vs. provisional stenting <0). ARD for stent thrombosis was centered at 0.00 (95% CrI: −0.04 to 0.03, Tau: 0.03, 51% probability of ARD for DK crush vs. provisional stenting <0). Finally, ARD for target lesion revascularization was centered at −0.05 (95% CrI: −0.08 to −0.03, Tau: 0.02, 99.97% probability of ARD for DK crush vs. provisional stenting <0). ConclusionsBayesian analysis demonstrated a lower probability of cardiac death, myocardial infarction and target lesion revascularization, with DK crush compared with provisional stenting techniques, and a minimal probability of difference in stent thrombosis.

Optical Coherence Tomography Predictors of SIde Branch REstenosis after unprotected Left Main bifurcation angioplasty using double kissing crush technique (OP-SIBRE LM Study).

Among the two stent strategies, contemporary evidence favors double kissing crush technique (DKC) for complex unprotected distal left main bifurcation (UdLMB) lesions. However one of the major challenges to these lesions is side branch (SB) restenosis. Our aim was to identify optical coherence tomographic (OCT) characteristics that may predict SB restenosis (SBR) after UdLMB angioplasty using DKC technique. This was a single-center, retrospective study that included 60 patients with complex UdLMB disease, who underwent OCT-guided angioplasty using DKC technique. Angiographic follow-up was performed in all patients at 1 year to identify patients with SBR. Patients with SBR groupwere compared with patients without SBR(NSBR group) for OCT parameters during index procedure. Twelve (20%) patients developed SBRat 1-year follow-up. The SBR group had longer SB lesion (18.8 ± 3.2 vs. 15.3 ± 3.7 mm, p = 0.004) and neo-metallic carinal length (2.1vs. 0.1 mm, p < 0.001) when compared to the NSBR group. Longer neo-metallic carinal length was associated with the absence of the dumbbell sign, presence of hanging stent struts across the SB ostium on OCT of final MB pullback. On multivariate regression analysis, SB distal reference diameter (DRD) and SB stent expansion were identified as independent predictors of SBRwith SB-DRD of ≤2.8 mm (area under curve-0.73, sensitivity-83.3%, and specificity-62.5%) and SB stent expansion of ≤89% (area under curve-0.88, sensitivity-83.3%, andspecificity- 81.2%) as the best cut off values to predict SBR. SB DRD and SB stent expansion are the OCT predictors of future SBRafter UdLMB angioplasty using DKC technique.

Cardiovascular Outcomes After Mini-Crush or Double Kissing Crush Stenting Techniques for Complex Bifurcation Lesions: The EVOLUTE-CRUSH Registry

Comparison of clinical outcomes of double kissing crush (DKC) and mini-crush (MC) techniques in patients with complex coronary bifurcation lesions is lacking. This study sought to determine the clinical results of DKC and MC stenting techniques in mid-term follow-up. This retrospective study included a total of 269 consecutive patients with complex bifurcation lesions who underwent percutaneous coronary intervention; 132 (49%) of them were treated with MC technique, whereas 137 (51%) treated with DKC technique. The primary end point was target lesion failure (TLF), defined as the combination of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. This is the first study to compare the cardiovascular outcomes of DKC and MC stenting techniques in patients with complex bifurcation lesions. The SYNTAX scores were similar in both groups (23 [20 to 30] vs 23 [19 to 28], p=0.631)]. The number of balloons (6.31 ± 1.80 vs 4.42 ± 0.87, p <0.001) and guidewires (3.55 ± 0.83 vs 2.86 ± 0.74, p <0.001) used, fluoroscopy time (21.55 ± 7.05 vs 16.66 ± 4.19minutes, p <0.001), and procedure time (80.42 ± 27.95 vs 69.61 ± 18.97minutes, p <0.001) were significantly higher in the DKC group. The rate of composite TLF was similar in complex bifurcation patients treated with MC than those treated with the DKC technique (14% vs 12%, p=0.453). Moreover, both groups had similar rates in terms of cardiac death or all-cause death, target vessel-related myocardial infarction, clinically driven target lesion revascularization, and stent thrombosis. In conclusion, the present study showed that both techniques of bifurcation treatment met high angiographic success with low complication and similar TLF rates.

Current Evidence and Future Perspective for Coronary Bifurcation Stenting.

Coronary bifurcation lesions account for 15%-20% of all percutaneous coronary interven tions and are associated with greater procedural complexity and consequently at higher risk for cardiac adverse events. Early clinical trials in the interventional approach to bifurcation lesions supported provisional stenting. However, the most recent randomized studies have indicated potentially superior results using a double-kissing crush technique, particularly for unprotected distal left main bifurcation lesions. Moreover, many operators recently favor double-kissing mini-culotte, nanocrush, and double-kissing nanocrush stenting techniques for bifurcation lesions. In this review, we describe the traditional and novel bifurcation stenting techniques and the current evidence for each and review general principles for bifurcation percutaneous coronary intervention.

Treatment Strategies for Coronary Bifurcation Lesions: Complexity and Risk

Treatment Strategies for Coronary Bifurcation Lesions: Complexity and Risk

Provisional or 2-Stent Technique for Bifurcation Lesions in the Second-Generation Drug-Eluting Stent Era

<h2>Abstract</h2><h3>Background</h3> For bifurcating coronary lesions, a provisional stent technique is recommended compared with a routine 2-stent strategy. However, much of these data are from trials involving first-generation drug-eluting stents (DES) or bare-metal stents where the risk of restenosis with the 2-stent technique is higher. We investigated the efficacy of various 2-stent techniques versus a provisional stent technique for bifurcation lesions with newer-generation DES. <h3>Methods</h3> PubMed and Embase were searched through May 2022 for randomized control trials investigating bifurcation percutaneous coronary intervention techniques using newer-generation DES, and a meta-analysis was conducted. The primary end point was major adverse cardiovascular events (MACE) at the longest reported follow-up time. <h3>Results</h3> Our study identified 13 randomized control trials including 4041 patients. Compared with the provisional technique, 2-stent techniques significantly decreased MACE (hazard ratio [HR], 0.76; 95% CI, 0.59-0.97; <i>P</i> = .03), target vessel myocardial infarction (HR, 0.38; 95% CI, 0.20-0.71; <i>P</i> = .002), and target vessel revascularization (HR, 0.66; 95% CI, 0.47-0.93; <i>P</i> = .02). There were no significant differences in all-cause mortality (HR, 0.94; 95% CI, 0.62-1.45; <i>P</i> = .79), cardiovascular mortality (HR, 0.82; 95% CI, 0.49-1.38; <i>P</i> = .45), myocardial infarction (HR, 1.00; 95% CI, 0.73-1.37; <i>P</i> = .99), and stent thrombosis (HR, 0.86; 95% CI, 0.52-1.44; <i>P</i> = .58). Of the 2-stent techniques, the double kissing crush technique significantly decreased MACE and target lesion revascularization than other 2-stent techniques. <h3>Conclusions</h3> In this era of newer-generation DES, a 2-stent approach, especially the double kissing crush technique, is superior to a provisional stenting technique for a bifurcation lesion, with a significant reduction in MACE, target vessel myocardial infarction, and revascularization.

A Review of Double Kissing Crush Stenting in Coronary Bifurcation Lesions

Double kissing (DK) crush stenting for coronary bifurcation lesions has gain popularity worldwide because of its superior randomized studies data and excellent clinical outcomes. This review evaluates all DK crush clinical trials and studies. It also reveals the contemporary technique steps by steps as well as the trouble shooting with illustrated clinical scenarios. Among all the available evidence, the DK crush technique is superior when compared to the provisional stenting technique for complex bifurcation lesion. DK crush stenting provides the best evidence-based approach to complex bifurcation lesions especially the left main coronary artery bifurcation lesions. Future direction of how to make this DK crush technique better is also proposed.

Optical coherence tomography assessment of acute thrombogenicity at bifurcation sites using different stenting techniques: A porcine arteriovenous shunt study.

We aimed to compare bare-metal stents (BMS), durable-polymer everolimus-eluting stents (DP-EES), and abluminal biodegradable-polymer sirolimus-eluting stents (ABP-SES) in the bifurcation model setup. The mechanism of thrombogenicity, which differs among second-generation stents implanted using double-kissing (DK) crushor culotte stenting techniques, remains unclear. We have shown previously that setting up a porcine arteriovenous shunt model is feasible and useful to assess thrombogenicity at vessel bifurcation points. Six porcine shunt models were prepared for the comparison between DK crushand culotte stenting techniques using BMS, DP-EES, and ABP-SES. Intracoronary imaging with high-resolution optical coherence tomography (OCT) was performed to evaluate the thrombogenicity in different stent types in the bifurcation stenting model and was evaluated by a core lab. Culotte stenting demonstrated more thrombogenicity at the proximal main branch (MB) with DP-EES, side branch (SB) with BMS, and the bifurcation site irrespective of the stent type, while DK crush technique exhibited thrombogenicity only at SB with BMS and ABP-SES. OCT analysis revealed malapposition of DP-EES in the proximal MB with culotte stenting. Stent expansion was generally larger in ABP-SES than BMS and DP-EES. The study provides hypothesis-generating findings in distinct thrombogenicity of bifurcation stenting with DP- or ABP-coated drug-eluting stents.

Fundamentals of percutaneous coronary bifurcation interventions.

Coronary bifurcation lesions (CBLs) account for 15%-20% of all percutaneous coronary interventions. The complex nature of these lesions is responsible for poorer procedural, early and late outcomes. This complex lesion subset has received great attention in the interventional cardiac community, and multiple stenting techniques have been developed. Of these, the provisional stenting technique is most often the default strategy; however, the elective double stenting (EDS) technique is preferred in certain subsets of complex CBLs. The double kissing crush technique may be the preferred EDS technique because of its efficacy and safety in comparative trials; however, this technique consists of many steps and requires training. Many new methods have recently been added to the EDS techniques to provide better stent scaffolding and to reduce early and late adverse outcomes. Intravascular imaging is necessary to determine the interventional strategy and postinterventional results. This review discusses the basic concepts, contemporary percutaneous interventional technical approaches, new methods, and controversial treatment issues of CBLs.

Successful Orbital Atherectomy of Left Main Bifurcation Lesion Using Microcatheter Protection of Nonatherectomy Wire

-Optimal PCI may be challenging with calcified left main bifurcation lesions-Orbital atherectomy is a common strategy for lesion optimization-Side branch occlusion is a feared complication of orbital atherectomy-Utilizing microcatheter wire protection can minimize occlusion risk with orbital atherectomy Corrigendum to “Successful Orbital Atherectomy of Left Main Bifurcation Lesion Using Microcatheter Protection of Nonatherectomy Wire”Journal of the Society for Cardiovascular Angiography & InterventionsVol. 1Issue 3100030PreviewFollowing publication, it was noted that several panels of Figure 1 included contouring in the IVUS images. The figure has been replaced in the original article. The revised image is shown below. Full-Text PDF Open Access Atherectomy is a tool for calcium modification, but there is an increased risk of losing the side branch in left main (LM) bifurcation lesions. Protected atherectomy using dual-1Medda M. Casilli F. Bande M. Tespili M. Protected rotational atherectomy with double-guiding catheter technique for unprotected distal left main.JACC Cardiovasc Interv. 2019; 12: e27-e29Crossref PubMed Scopus (4) Google Scholar and single-guide catheter technique2Panchal H.B. Nagabandi A. Kirtane A.J. Beohar N. Microcatheter-protected orbital atherectomy for severely calcified bifurcation coronary artery disease with single-guiding catheter technique.JACC Cardiovasc Interv. 2020; 13: e1-e3Crossref PubMed Scopus (0) Google Scholar with mechanical support has been described as a strategy to minimize side branch closure and wire damage to nontarget vessel during bifurcation atherectomy. However, single-guide catheter technique has not been reported without the use of mechanical circulatory support. We present a case of a 79-year-old man with severe, heavily calcified distal LM, proximal left anterior descending (LAD), and left circumflex artery (LCx) lesions (Fig. 1A, Supplemental Video 1) who was referred for complex percutaneous coronary intervention in the setting of reduced ejection fraction (40%), daily anginal symptoms, and viable myocardium on cardiac magnetic resonance imaging. Peripheral angiography revealed severe peripheral vascular disease prohibitive for mechanical support devices. An 8-F sheath was placed in the left femoral artery, and an 8-F XB 4.0 guide catheter was used. Intravascular ultrasound (IVUS) confirmed severe calcified stenoses in LM, LAD, and LCx (Fig. 1B, C, Supplemental Videos 2 and 3). After placement of ViperWire Advance with Flex Tip (Cardiovascular Systems Inc) in the LM-LCx for orbital atherectomy, a Runthrough wire (Terumo Interventional Systems) was placed in the LAD “protected” with a Turnpike LP microcatheter (Teleflex). Orbital atherectomy (2 runs) of the distal LM and proximal circumflex arteries was performed at low speed (Fig. 1D). The microcatheter was advanced after each pass to minimize damage. During wire exchange between the LAD and LCx, the microcatheter was removed, flushed, and checked for any damage. It was then used to “protect” the LM-LCx wire during 4 total atherectomy passes from LM into the LAD at both high and low speeds (Fig. 1E, Supplemental Video 4). After atherectomy of each vessel, the microcatheter was examined, and minor abrasions similar to those reported by Panchal et al. were noted on the catheter without any significant catheter injury.2Panchal H.B. Nagabandi A. Kirtane A.J. Beohar N. Microcatheter-protected orbital atherectomy for severely calcified bifurcation coronary artery disease with single-guiding catheter technique.JACC Cardiovasc Interv. 2020; 13: e1-e3Crossref PubMed Scopus (0) Google Scholar Therefore, the same microcatheter was used during atherectomy of both the LAD and LCx. IVUS-guided percutaneous coronary intervention using double kissing crush technique was performed with the placement of a 3.5 ​× ​18-mm drug-eluting stent in the LCx-LM and a 4.0 ​× ​18-mm drug-eluting stent in the LM-LAD with postdilation of the LM using a 5.0-mm noncompliant balloon. Final angiography and IVUS showed excellent expansion and apposition (Fig. 1F, G, Supplemental Video 5). At 3-month follow-up, the patient was doing well with resolution of anginal symptoms and normalization of left ventricular ejection fraction. Microcatheter-“protected” orbital atherectomy of LM bifurcation lesions can be successfully performed using a single 8-F guide without the need for mechanical circulatory support in patients with prohibitive comorbidities and peripheral arterial disease. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. https://www.jscai.org/cms/asset/7b35004e-dfa0-4f91-b28b-cee49b008a06/mmc1.mp4Loading ... Download .mp4 (1.04 MB) Help with .mp4 files Supplemental Video 1https://www.jscai.org/cms/asset/ffdddfda-c460-4b09-a272-55333f079168/mmc2.mp4Loading ... Download .mp4 (6.67 MB) Help with .mp4 files Supplemental Video 2https://www.jscai.org/cms/asset/ec8a523b-adc5-4933-a970-e3a33f5cfab0/mmc3.mp4Loading ... Download .mp4 (6.43 MB) Help with .mp4 files Supplemental Video 3https://www.jscai.org/cms/asset/17b83443-8235-4f23-97f7-53dfaf1a6be6/mmc4.mp4Loading ... Download .mp4 (0.95 MB) Help with .mp4 files Supplemental Video 4https://www.jscai.org/cms/asset/85d13be4-0e1e-4fb8-80db-427769cd4524/mmc5.mp4Loading ... Download .mp4 (4.2 MB) Help with .mp4 files Supplemental Video 5

Meta-Analysis Comparing Outcomes With Bifurcation Percutaneous Coronary Intervention Techniques

There have been mixed results regarding the efficacy and safety of various percutaneous coronary intervention bifurcation techniques. An electronic search of Medline, Scopus, and Cochrane databases was performed for randomized controlled trials that compared the outcomes of any bifurcation techniques. We conducted a pairwise meta-analysis comparing the 1-stent versus 2-stent bifurcation approach, and a network meta-analysis comparing the different bifurcation techniques. The primary outcome was major adverse cardiac events (MACEs). The analysis included 22 randomized trials with 6,359 patients. At a weighted follow-up of 25.9months, there was no difference in MACE between 1-stent versus 2-stent approaches (risk ratio [RR] 1.20, 95% confidence interval [CI] 0.92 to 1.56). Exploratory analysis suggested a higher risk of MACE with a 1-stent approach in studies using second-generation drug-eluting stents, if side branch lesion length ≥10mm, and when final kissing balloon was used. There was no difference between 1-stent versus 2-stent approaches in all-cause mortality (RR 0.95, 95% CI 0.69 to 1.30), cardiovascular mortality (RR 1.07, 95% CI 0.68 to 1.68), target vessel revascularization (TVR) (RR 1.22, 95% CI 0.90 to 1.65), myocardial infarction (MI) (RR 1.04, 95% CI 0.69 to 1.56) or stent thrombosis (RR 1.10, 95% CI 0.68 to 1.78). Network meta-analysis demonstrated that double kissing crush technique was associated with lower MACE, MI, TVR, and target lesion revascularization, whereas culotte technique was associated with higher rates of stent thrombosis. In this meta-analysis of randomized trials, we found no difference between 1-stent versus 2-stent bifurcation percutaneous coronary intervention approaches in the risk of MACE during long-term follow-up. Among the various bifurcation techniques, double kissing crush technique was associated with lower rates of MACE, target lesion revascularization, TVR, and MI.

Double kissing – crush technique to treat coronary bifurcation lesions: analysis of success rate, procedural times and device usage

Abstract Background The Double Kissing Crush (“DK Crush”) technique is one of the recommended planned 2-stent techniques to treat true coronary bifurcation lesions (Medina 1–1-1, Medina 0–1-1). While some trials demonstrated superiority to other techniques, DK Crush requires a sequence of specific and potentially technically challenging steps. No data exists on the procedural difficulty of the various steps required for DK Crush. We therefore analyzed procedural times and device usage in a systematic fashion. Methods and results 54 patients (42 male, mean age 67±12 years) intended for treatment with DK Crush were enrolled. Detailed procedural characteristics including exact times and device usage for each step of DK Crush were prospectively measured and analyzed. DK Crush was successful in 48/54 patients (89%). In two patients stenting technique was changed to T- or TAP-stenting due to anatomical reasons at the moment of positioning of the SB stent. In one patient no balloon could cross the lesion and in another the procedure had to be modified due to coronary perforation directly after pre-dilatation. True failure of DK Crush was observed in two cases: In one case, the first rewiring of the SB, in the other, placement of a balloon for first kissing balloon (KB) maneuver in the SB was not possible. These 6 patients were excluded from further analysis. Median times for each step were: 1:21min (IQR 0:52min-1:50min) for wiring SB, 1:18min (IQR 0:47min-1:42min) for wiring MV, 1:30min (IQR 0:54min-2:15min) for stent placement in the SB, 0:40min (IQR 0:29min-1:21min) for balloon placement in the MV. First rewiring of the SB after SB stent crush required 1:30min (IQR 0:37min-2:05min), 1st KB placement in the SB took 1:42min (IQR 1:00min-3:13min) and 1st KB placement in the MV required 0:45min (IQR 0:27min-1:19min). Stent placement in the MV required 1:34min (IQR 1:09min-2:40min) and 2nd rewiring of the SB 1:21min (IQR 0:55min-2:04min), 2nd KB placement of the SB 2:08min (IQR 1:01min-3:36min) and 2nd KB placement of the MV 0:50min (IQR 0:34min-1:01min). Final POT was performed in all cases. Median total procedure time was 52:35 min (IQR 00:42:54h-1:01:37h). Additional devices were needed in 10% (3x1, 2x2 balloons) for stent placement in the SB; in 46% (20x1, 1x4 wires) for the first rewiring of the SB and in 49% (20x1, 3x2 balloons) for 1st KB placement in the SB. The 2nd rewiring of the SB required additional wires in 32% (13x1, 2x2 wires) and 54% of the patients required additional balloons for the 2nd KB placement in the SB (20x1, 2x2, 1x3, 2x5 balloons). Final TIMI flow was III in 97.9%. Complications occurred in 6% (n=3), each showing coronary dissection with TIMI III flow in 2 patients and TIMI I flow in 1 patient after placement of additional stents. Conclusion DKMC has a high success rate but is a time-consuming and material-intensive technique. The placement of the 2nd KB in the SB requires most of the procedural time and resources. Funding Acknowledgement Type of funding sources: None.

Abstract 15552: Learning and Innovation Among Interventional Cardiologists, Insights From an International Survey

Introduction: The willingness of interventional cardiologists to adopt innovation and implement changes in day-to-day practice has received limited study. Methods: Online-based survey on learning and innovation involving 38 questions distributed via email list to interventional cardiologists. Results: The survey was distributed to 8,110 e-mails and completed by 621 (7.6% , 92% men, 60% in the 35 to 54-year-old age group). Of the respondents who perform coronary interventions, 45% perform &gt;100 cases of non-complex percutaneous coronary interventions per year and of the respondents who perform structural interventions, 15% perform more than &gt;100 transcatheter aortic valve replacements per year. Most respondents (86%) are highly likely/likely to introduce recently approved equipment in everyday practice and 48% have tried a new coronary guidewire in the past six months ( Figure ). Regarding specific techniques, most (69%) use the double kissing crush technique when treating coronary bifurcations with a 2-stent strategy, followed by T -stenting (60%). Radial access in STEMI cases is always used by 43% of the respondents and 54% always use radial access for coronary angiography. Of those who use femoral access, 32% always use ultrasound guidance and 91% have used a closure device in the last six months. The majority read journals to keep up with current practice and believe that the most effective way to learn is through attendance of workshops/short courses (79%), followed by proctorship (61%). Most of the respondents (69%) are involved in research. Conclusions: Interventional cardiologists who participated in the survey are highly likely to adopt innovation in daily clinical practice.

T and Small Protrusion (TAP) vs Double-Kissing Crush Technique: Insights From In Vitro Models

BackgroundPercutaneous coronary interventions on complex bifurcation lesions may require implantation of two stents to appropriately treat diffuse side-branch (SB) disease. Comparisons among different bifurcation stenting techniques are continuously attempted by various study designs (bench tests, computer simulations, clinical studies). Among different techniques, double kissing crush (DKC) represents the last evolution for “crushing” while T and small Protrusion (TAP) represents the evolution of “T stenting”. Both techniques are actually gaining popularity, but head-to-head comparisons are lacking. Methods and resultsTwo last generation drug-eluting stents (Synergy™, Boston Scientific, MA, USA and Ultimaster™,Terumo Corp., Japan) were implanted in left main bifurcation bench models using TAP (n = 6 sets) and DKC (n = 6 sets) techniques. A peristaltic pump with fresh porcine blood was used to perfuse the blood through the silicone model at a flow rate of 200 ml/min for 4 min. Optical coherence tomography (OCT) was used to assess stent struts geometry and thrombus formation. SB cross sectional area as well as SB obstruction did not significantly differ between the two techniques. Numerical (but not statistically significant) differences were found in terms of malapposed struts (fewer with TAP) and floating struts (fewer with DKC). Thrombus formation after blood perfusion was similar between TAP and DKC technique (1.53 ± 1.12 vs. 1.20 ± 1.01 mm2, p = 0.6). ConclusionThe result of the present in-vitro study shows the absence of significant difference between TAP and DKC in terms of stent struts apposition and acute thrombus formation potential. Despite the completely different technical steps required, both techniques have similar performance according to such articulated pre-clinical evaluation. What is already known about this subject?Due to its limited complexity, T and Protrusion (TAP) technique is considered the to-go technique for bifurcation lesions with good long-term results. Recently, double kissing crush (DKC) technique has been gaining popularity and demonstrated promising results in randomized clinical trials. What does this study add?This in-vitro bench test study provides a unique detailed OCT comparison and local hemodynamic environment analysis of the two techniques. How might this impact on clinical practice?New insights of acute thrombogenicity and computational flow model simulation may guide percutaneous therapeutic strategies of bifurcation lesions.

Percutaneous management of coronary bifurcation lesions: current perspective.

Coronary artery disease affecting bifurcations poses a challenge for percutaneous intervention. Several techniques and strategies for percutaneous management of bifurcation lesions have been described in the literature with variable data available for outcomes. In this review, we provide an overview of the strategies and techniques used for percutaneous intervention of bifurcation lesions with an update of recent technical developments and clinical evidence. The coronary bifurcation lesions of both left main and other coronary segments are best treated with a provisional stenting strategy where main branch is treated with a stent placement and side branch intervention reserved for angiographically or physiologically determined hemodynamically significant residual stenosis despite application of a proximal stent optimization technique. When a provisional stent strategy is not likely to be successful due to anatomic or morphologic lesion characteristics and a large side branch or distal left main bifurcation is involved, an upfront bifurcation stenting strategy with double kissing crush technique may provide the optimum results. Coronary imaging and fractional flow determination may guide lesion specific management, facilitate device selection and improve clinical outcomes for percutaneous therapy for bifurcation lesions. Despite advances in technology and procedural techniques, percutaneous intervention of coronary bifurcation lesions remains challenging and associated with higher adverse outcomes compared to non bifurcation lesions. Among the several bifurcation strategies, a provisional stenting approach is preferred for technical simplicity and better long term outcomes. Double kissing crush technique provides superior clinical results and should be preferred when a two stent strategy is indicated. Use of coronary imaging and physiology assessment should be incorporated in the algorithm of bifurcation interventions for greater technical and clinical success.

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.

Percutaneous Coronary Intervention for Coronary Bifurcation Lesions: Latest Evidence.

This paper provides a synopsis of the best evidence to guide bifurcation percutaneous coronary intervention (PCI), with a focus on recent studies. This is with the aim of guiding the interventional cardiologist in choosing the best, evidence-based technique, to treat commonly encountered coronary bifurcations. Current evidence supports the use of provisional stenting for most anatomically suitable bifurcation lesions. Newer techniques for side branch protection in provisional stenting have been developed. When a two-stent strategy is required, use of a double-kissing crush technique is favoured, particularly in left main bifurcations. For bifurcation PCI, as in all complex procedures, intravascular imaging plays a key adjunctive role in improving procedural success. PCI for coronary bifurcation lesions is an ever-growing field with significant advancements in techniques and technology.

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

Abstract Background The optimal PCI technique for bifurcation lesions remains a matter of debate. Several RCT have compared different bifurcation PCI techniques. Provisional stenting has been recommended as the default technique for most bifurcation lesions. However, emerging data suggests that double-kissing crush technique can be considered in true left main bifurcation lesions and has been endorsed by the European Society of Cardiology Guidelines. Purpose To compare the clinical outcome between different bifurcation PCI techniques. Methods We searched MEDLINE for randomized clinical trials (RCT) comparing PCI bifurcation techniques for coronary bifurcation lesions. Outcomes of interest were major adverse cardiovascular events (MACE) defined as the composite of cardiac death, myocardial infarction (MI) and target vessel or lesion revascularization (TVR/TLR), and the individual components of MACE. Stent thrombosis was assessed as defined by the ARC. Stratification based on left-main or distal bifurcations was performed. We evaluated the studies' risk of bias in accordance to the Cochrane Handbook for Systematic Reviews of Interventions, and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We estimated summary odds ratios (ORs) using pairwise and Bayesian network meta-analysis. Results We identified 263 studies and of these included 19 RCT including 5572 patients treated with 5 bifurcation PCI techniques namely provisional stenting, systematic T-stenting, crush, culotte and double-kissing crush. Median follow-up was 12 months (IQR 8 to 36). When all bifurcation lesions were combined, double-kissing crush technique reduced the occurrence of MACE (OR 0.42; CrI 0.28 to 0.61) compared to provisional stenting. This difference was driven by a reduction in TVR/TLR (OR 0.39; CrI 0.25 to 0.65). No differences were found in cardiac death, MI or stent thrombosis among analyzed PCI techniques. No differences in MACE were observed between provisional stenting, systematic T-stenting, crush. In distal bifurcations (n=17 studies, 4634 patients), double-kissing crush also showed to reduce MACE (OR 0.48; CrI 0.29 to 0.67 vs. Provisional). In left-main bifurcations (n=3 studies, 938 patients) no differences in MACE were found between PCI techniques. Conclusions In this network meta-analysis, PCI bifurcation techniques were similar with respect to the occurrence of cardiac death, myocardial infarction and stent thrombosis. When all coronary bifurcations were combined, an advantage of double-kissing crush was observed in terms of MACE driven by lower rate of repeated revascularization. Further studies are required to define the best PCI bifurcation technique for left main coronary artery disease.

TCTAP C-008 Double Kissing Crush Technique of Critical Left Main Stenosis in Acute Coronary Syndrome

### Patient Initials or Identifier Number HBTB ### Relevant Clinical History and Physical Exam A 69-year-old Malay female was referred to our hospital because of NSTEMI. Past medical history included DM (10 years), hypertension (10 years) and End stage renal failure (5 years) on hemodialysis. She