Double Kissing Crush Research Articles

Abstract 4141481: Outcomes of the upfront two stent strategies for bifurcation percutaneous coronary interventions: Insights from PROGRESS-BIFURCATION registry

Background: Upfront two-stent techniques are often used in bifurcation percutaneous coronary interventions (PCI), but there is controversy about optimal strategy selection. Methods: We examined the clinical, angiographic characteristics, and long-term outcomes of 206 bifurcation PCIs using the double kissing (DK) crush or the culotte techniques in 192 patients between 2014-2023 from the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (NCT05100992). For the long-term outcomes adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were calculated using the mixed effects Cox proportional hazards model. Results: DK crush was more commonly used (70.4%). Patients in the culotte group had similar baseline characteristics with the DK crush group. Lesions treated with culotte were more likely to be in the left anterior descending (54.1% vs. 35.9%, p<0.001) and circumflex arteries (21.3% vs. 9.0%, p<0.001), had smaller proximal (3.50 [3.00, 3.75] vs. 3.50 [3.30, 4.00] mm, p=0.032) and distal (3.00 [2.75, 3.00] vs. 3.00 [3.00, 3.50] mm, p=0.047) main vessel diameters, and were less likely to have severe calcification (6.6% vs. 32.4%, p<0.001). Technical success (96.7% vs. 98.6%, p=0.583), procedural success (93.1% vs. 93.9%, p=0.758), and in-hospital major adverse cardiovascular events (MACE) (3.4% vs. 6.1%, p=0.726) were similar in both groups. During a mean follow-up of 38-month, 32 (28.3%) patients experienced MACE. On multivariable analysis, culotte was associated with similar MACE (aHR 1.19; 95%CI 0.78-1.80; p=0.680), mortality (aHR 1.11; 95%CI 0.68-1.79; p=0.810), and target vessel PCI revascularization (aHR 0.58; 95%CI 0.30-1.13; p=0.460) compared with DK crush (Figure). Conclusions: Bifurcation PCI with DK crush and culotte had similarly high technical and procedural success, low in-hospital MACE, and long-term outcomes.

Abstract 4140163: Initial Experience with Mini-Crush Versus Double Kissing Crush in Bifurcation Percutaneous Coronary Intervention: Insights from PROGRESS-BIFURCATION registry

Background: There is limited data on use of the mini-crush technique in two-stent bifurcation percutaneous coronary intervention (PCI). Methods: This retrospective, observational, cohort study was performed across 6 centers in the United States, Russia, and Turkey between 2013-2024, as part of the Prospective Global Registry of Percutaneous Coronary Intervention in Bifurcation Lesions (PROGRESS-BIFURCATION, NCT05100992). We evaluated procedural characteristics of patients who underwent bifurcation stenting using the mini-crush technique and compared it with those who were treated with double kissing (DK) crush. Results: Of 1,138 PCIs involving 1,499 lesions, 46 (4.04%) were performed using the mini-crush technique and 147 lesions (12.91%) using the DK crush technique. Baseline characteristics of the patients were similar in both groups. There was no difference between mini-crush versus DK-crush in technical success (100.0% versus 98.6%; p=0.99), procedural success (95.1% versus 97.1%, p=0.62), procedural complications (10.9% versus 14.7%, p=0.51), or in-hospital major adverse cardiovascular events (MACE) (6.5% versus 5.7%, p=0.73). In contrast, mini-crush technique was associated with shorter procedure time (79.00 vs 116.50 minutes; p<0.001; Figure 1A), fluoroscopy time (23.50 vs 30.35 minutes, p=0.002; Figure 1A), and lower contrast volume (150 versus 109 milliliters; p<0.001; Figure 1B), and air kerma radiation dose (1.11 vs 1.71 gray; p=0.024; Figure 1C). Conclusion: In patients undergoing PCI for bifurcation lesions, the mini-crush technique had similar rates of procedural complications and in-hospital MACE as compared with the DK crush technique but required less contrast volume, fluoroscopy time, radiation dose, and procedural time.

Clinical Outcomes of Double-Kissing Crush or Double-Kissing Culotte in Nonleft Main Bifurcation Lesions: The ROUTE Trial.

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.

The Balloon-Assisted Double-Kissing T-Stenting Technique: Concept, In Vitro Model, and Case Examples

BackgroundIn complex bifurcation percutaneous coronary intervention, 2-stent strategies are often required. Commonly used 2-stent techniques can lead to suboptimal results due to their complexity. We developed the balloon-assisted double-kissing T-stenting (DKT) technique, which uses balloons to optimize stent placement, delivery, and final architecture. MethodsWith the balloon-assisted DKT technique, a balloon is inflated into the main branch (MB) to identify the best position of the side-branch (SB) stent instead of relying on angiography. DKT aims at supporting the SB ostium with stent crowns instead of distorted open cell(s), by achieving a longitudinal deformation with minimal crush of the SB stent upon implantation of the MB stent. This hypothesis was tested on a bench model. We report how the technique was performed in 2 cases and provide intracoronary imaging of the results. ResultsAs hypothesized, DKT resulted in a longitudinal accordion-like deformation and minimal crush effect on bench. The SB ostium was supported by stent crowns. The SB wall opposed to the carina was well covered with crowns from the MB stent after proximal optimization technique and final kissing. The technique was successfully used in 2 complex left main cases with perfect coverage of the SB ostium as assessed with intracoronary imaging. ConclusionsThe balloon-assisted DKT is a simple technique that combines strengths of double-kissing crush and culotte techniques, results in appropriate SB ostium coverage, and deserves further investigation.

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.

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.

The role of calcification in cardiovascular outcome after left main bifurcation revascularization: a single centre experience

Abstract Introduction Left main bifurcation (LMB) disease represents a high-risk subset of advanced coronary artery disease, often associated with severe calcification. Different stenting techniques have been evaluated to overcome challenges of the LMB anatomy, but the role of the calcific burden on cardiovascular (CV) outcome after LMB revascularization is unclear. Purpose We sought to evaluate the CV hospitalization predictors during follow-up of patients who underwent LMB revascularization (LMBR) in a high-volume center in Italy. Methods We performed a retrospective analysis of LMBR patients between 2018 and 2021. Patients were treated with different techniques in the acute or chronic settings and followed-up by telephone or outpatient visit. Coronary calcification (CC) was visually judged as absent, mild, moderate or severe. Predictors of CV hospitalizations were assessed. Results The median follow-up was 511 days. Among 129 patients who underwent LMBR during the study period, 32 (24.8%) were female, with a mean age of 72 (±10.6) years. 105 (81.4%) patients were hypertensive and 49 (38%) diabetics. The mean eGFR value was 66.3 (± 21.8) ml/min/m2. The majority of patients had three vessel disease (79, 61.3%), while only a small minority had one vessel disease (5, 3.9%). The mean SYNTAX score I was 27.1 (± 8.6), with most patients at intermediate risk (65, 50.4%) followed by patients at low (37, 28.7%) and high (27, 20.9%) risk. A provisional technique was used in most cases (79, 61.2%), followed by double-kissing crush (37, 28.7%) and T-stent/T-and-protrusion (13, 10.1%). Intravascular imaging was used in 84 (65.1%) cases. Most patients had no angiographic demonstration of CC (73, 57.9%), while when present, they were mild in 14 (11.1%), moderate in 29 (23%) and severe in 10 (7.9%) patients. Preparation of the CC was performed only with non-compliant (NC) balloons in mild CC (10, 71.4%) and with NC balloons (14, 48.3%) or intravascular lithotripsy (IVL) (13, 44.8%) in case of moderate CC. In the presence of severe CC, lesion preparation was carried out with IVL (4, 40%) or NC balloons (6, 60%). CC were associated with a more unfavorable outcome and, when present in a severe grade, resulted in a statistically significant risk of CV hospitalizations (HR 1.652; 95% CI 1.723–15.793; p=0.003) (Figure 1). After univariate and multivariate Cox regression analysis (Figure 2), only the presence of severe CC was associated with an increased risk of CV hospitalizations (HR 1.9; 95% CI 1.76–19.63; p=0.002), whereas aspirin therapy was a protective factor (HR −1.34; CI 0.07–0.86; p=0.02). Conclusions The presence of severe calcification is associated with a higher risk of CV hospitalizations, despite preparation of calcific lesions was always performed and intravascular imaging use was extensive. There were no differences in outcomes regardless to clinical presentation at admission, different stenting techniques and SYNTAX score I. Funding Acknowledgement Type of funding sources: None.

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.

Why double-kissing crush should be preferred over culotte for two-stent bifurcation stenting.

Key Points The thrombogenicity of the double‐kissing (DK) crush and culotte bifurcation stenting techniques was assessed with three different stent types using optical coherence tomography in a porcine arteriovenous shunt model. Culotte had malapposition in the proximal main vessel, which was not observed in DK crush. Culotte also had more thrombus in the bifurcation area compared with DK crush. DK crush may be preferable to culotte when performing bifurcation stenting using an upfront two‐stent strategy.

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.

Practice Patterns in the Interventional Treatment of Coronary Bifurcation Lesions: A Global Survey.

The study aim was to assess current procedural strategies and perceptions for percutaneous coronary intervention (PCI) involving bifurcations. We distributed an online survey via email (8050 invitations) and social media. Among 440 responders, median annual PCI volumes were 15 cases (interquartile range [IQR], 10-29 cases) for left main (LM) and 50 cases (IQR, 27-73 cases) for non-LM (nLM) bifurcation lesions. Radial access use was reported in 51% of LM and 82% of nLM cases. An upfront 2-stent strategy, most commonly double-kissing (DK) crush, was reported in 49% of LM and 29% of nLM lesions. Bailout stenting during provisional stenting was reported in 26% of LM-PCIs, usually using the T and protrusion technique. In provisional stenting cases, most operators (<35%) did not report predilating the side branch, but routinely postdilated after successful provisional stenting (>85%), most often using both kissing-balloon inflation and the proximal optimization technique. Intravascular imaging was used in 80% of LM and 46% of nLM cases. Among the survey responders, the DK crush technique was the most frequently used 2-stent strategy for bifurcation PCIs. For LM lesions, bailout stenting was performed after provisional strategy in approximately 25% of cases. For nLM lesions, use of intravascular imaging and coronary physiology was lower than for LM lesions.

Stenting techniques for coronary bifurcation disease: a systematic review and network meta-analysis demonstrates superiority of double-kissing crush in complex 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

Implante de stent em lesão de bifurcação do tronco da coronária esquerda usando técnica double-kissing culotte modificada

Left main coronary artery bifurcation represents one of the most challenging settings for the interventional cardiologists. The conventional stents are designed and shaped to restore tubular geometry, while the left main coronary artery bifurcation is far more complex with different diameters and non-tubular cross-sections. In relevant patients, two stent strategy is preferred over provisional T-stenting. The double-kissing crush has been the preferred double stent technique. We present a case in which the double-kissing approach was used in left main coronary artery bifurcation stenting with the culotte technique, which resulted in good angiographic outcome and no malapposition. Patient was stable even at 4 months follow-up.

Comparison of intravascular ultrasound-guided with angiography-guided double kissing crush stenting for patients with complex coronary bifurcation lesions: Rationale and design of a prospective, randomized, and multicenter DKCRUSH VIII trial

Double kissing (DK) crush approach for patients with coronary bifurcation lesions, particularly localized at distal left main or lesions with increased complexity, is associated with significant reduction in clinical events when compared with provisional stenting. Recently, randomized clinical trial has demonstrated the net clinical benefits by intravascular ultrasound (IVUS)-guided implantation of drug-eluting stent in all-comers. However, the improvement in clinical outcome after DK crush treatment guided by IVUS over angiography guidance for patients with complex bifurcation lesions have never been studied in a randomized fashion. DKCRUSH VIII study is a prospective, multicenter, randomized controlled trial designed to assess superiority of IVUS-guided vs angiography-guided DK crush stenting in patients with complex bifurcation lesions according to DEFINITION criteria. A total of 556 patients with complex bifurcation lesions will be randomly (1:1 of ratio) assigned to IVUS-guided or angiography-guided DK crush stenting group. The primary end point is the rate of 12-month target vessel failure, including cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularization. The secondary end points consist of the individual component of primary end point, all-cause death, myocardial infarction, and in-stent restenosis. The safety end point is the incidence of definite or probable stent thrombosis. An angiographic follow-up will be performed for all patients at 13 months and clinical follow-up will be continued annually until 3 years after the index procedure. DKCRUSH VIII trial is the first study designed to evaluate the differences in efficacy and safety between IVUS-guided and angiography-guided DK crush stenting in patients with complex true bifurcation lesions. This study will also provide IVUS-derived criteria to define optimal DK crush stenting for bifurcation lesions at higher complexity.

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.

Stenting techniques for coronary bifurcation lesions: Evidence from a network meta-analysis of randomized clinical trials.

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.

Multicentre, randomized comparison of two-stent and provisional stenting techniques in patients with complex coronary bifurcation lesions: the DEFINITION II trial.

The present study aimed to assess the benefits of two-stent techniques for patients with DEFINITION criteria-defined complex coronary bifurcation lesions. In total, 653 patients with complex bifurcation lesions at 49 international centres were randomly assigned to undergo the systematic two-stent technique (two-stent group) or provisional stenting (provisional group). The primary endpoint was the composite of target lesion failure (TLF) at the 1-year follow-up, including cardiac death, target vessel myocardial infarction (TVMI), and clinically driven target lesion revascularization (TLR). The safety endpoint was definite or probable stent thrombosis. At the 1-year follow-up, TLF occurred in 37 (11.4%) and 20 (6.1%) patients in the provisional and two-stent groups, respectively [77.8%: double-kissing crush; hazard ratio (HR) 0.52, 95% confidence interval (CI) 0.30-0.90; P = 0.019], largely driven by increased TVMI (7.1%, HR 0.43, 95% CI 0.20-0.90; P = 0.025) and clinically driven TLR (5.5%, HR 0.43, 95% CI 0.19-1.00; P = 0.049) in the provisional group. At the 1 year after indexed procedures, the incidence of cardiac death was 2.5% in the provisional group, non-significant to 2.1% in the two-stent group (HR 0.86, 95% CI 0.31-2.37; P = 0.772). For DEFINITION criteria-defined complex coronary bifurcation lesions, the systematic two-stent approach was associated with a significant improvement in clinical outcomes compared with the provisional stenting approach. Further study is urgently warranted to identify the mechanisms contributing to the increased rate of TVMI after provisional stenting. http://www.clinicaltrials.com; Identifier: NCT02284750.

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.

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.