Randomized Study on Double Kissing Crush Technique Versus Provisional Stenting Technique for Coronary Artery Bifurcation Lesions - DKCRUSH-V

Contribution To Literature:

The DKCRUSH-V trial showed that a two-stent DK crush strategy is superior to provisional stenting for clinical outcomes at 12 months for unprotected distal LMT bifurcation PCI.

Description:

The goal of this trial was to compare the efficacy of double kissing (DK) crush stenting to provisional stenting for unprotected distal left main trunk (LMT) bifurcation percutaneous coronary intervention (PCI). 


Study Design

Patients with unprotected LMT stenosis were randomized in a 1:1 fashion to either PCI with a two-stent DK crush stenting (n = 242) or provisional stenting (n = 240). Complete revascularization of all ischemic territories was required with drug-eluting stents (DES). Intravascular ultrasound (IVUS) was strongly recommended. Final kissing balloon inflations and proximal optimization techniques were also strongly recommended.

  • Total number of enrollees: 482
  • Duration of follow-up: 12 months
  • Mean patient age: 64.5 years
  • Percentage female: 20%
  • Percentage with diabetes: 27%
  • Percentage with left ventricular ejection fraction: 60%

Inclusion criteria:

  • PCI intended in a true de novo distal LM bifurcation lesion (Medina 1,1,1 or 0,1,1), with >50% diameter stenosis (DS) of both the ostial left anterior descending (LAD) and left circumflex (LCX) arteries by visual estimation
  • Non-LM lesions in the LAD, LCX, or right coronary artery (RCA), if present, had to be treatable by no more than two additional stents
  • Primary operator volume ≥300 PCIs/year for 5 years, including ≥20 LMT PCIs annually

Exclusion criteria:

  • Cardiogenic shock
  • Severely calcified LM lesions requiring atherectomy
  • In-stent restenosis
  • Need for oral anticoagulation
  • Any clinical condition that would interfere with medication compliance or long-term follow-up

Other salient features:

  • Unstable angina: 72%, myocardial infarction (MI) (>24 hours): 12%
  • Baseline SYNTAX score: 31, low: 13%, intermediate: 43%
  • LMT bifurcation lesion Medina 1,1,1: 82%
  • Radial approach: 76%
  • Procedural IVUS use: 41%
  • Side branch stent necessary in provisional stenting arm: 47.1%

Principal Findings:

The primary outcome, target lesion failure (cardiac death, target vessel MI, target lesion revascularization [TLR]) at 12 months for provisional stenting of side branch vs. DK crush, was 10.7% vs. 5.0%, p = 0.02.

  • Cardiac death: 2.1% vs. 1.2%, p = 0.48
  • Target vessel MI: 2.9% vs. 0.4%, p = 0.03
  • TLR: 7.9% vs. 3.8%, p = 0.06

Secondary endpoints for provisional stenting vs. DK crush:

  • Stent thrombosis: 3.3% vs. 0.4%, p = 0.56; definite stent thrombosis: 0.8% vs. 0.4%, p = 0.50
  • Angina during follow-up: 9.3% vs. 4.5%
  • Contrast use: 190.9 vs. 226.7 cc, p < 0.001
  • Procedural time: 66.1 vs. 81.9 minutes, p < 0.001
  • Quantitative coronary angiography at follow-up (n = 317): in-stent restenosis in main branch stent: 5.7% vs. 1.9%, p = 0.09; in side-branch stent: 12.0% vs. 5.0%, p = 0.09

Interpretation:

The results of this trial indicate that a two-stent DK crush strategy is superior to provisional stenting (with a need for bailout stenting in nearly 50% of patients) for clinical outcomes at 12 months for unprotected distal LMT PCI, driven by a reduction in TLR and target vessel MI; stent thrombosis rates were also better with the DK crush strategy.

Bifurcation lesions remain a challenging subset of patients undergoing PCI. In general, particularly for non-LMT lesions, provisional stenting is thought to be superior to a two-stent approach, driven by a reduction in periprocedural MI mostly, but also a lack of benefit in clinical outcomes with the two-stent approach. Distal LMT lesions are thought to be different due to a larger myocardium at risk even of the “side-branch” (frequently the LCx). DK crush is a specific technique that does require some training and experience to develop expertise in (the side-branch has to be wired twice after stenting, for instance).

The same investigators showed that the DK crush technique was superior to Culotte stenting for these distal LMT lesions, suggesting that this might be an important technique to master for distal LMT PCI. Even among experienced operators as in this trial, the use of contrast was higher.

References:

Chen SL, Han Y, Zhang JJ, et al. Double Kissing Crush versus Provisional Stenting for Left Main Distal Bifurcation Lesions: The DKCRUSH-V Randomized Trial. J Am Coll Cardiol 2017;70:2605-17.

Editorial Comment: Brilakis ES, Burke MN, Banerjee S. DK-Crush Should Become Preferred Strategy for Treating Unprotected LM Bifurcation Lesions: No Pain, No Gain. J Am Coll Cardiol 2017;70:2618-20.

Presented by Dr. Shao-Liang Chen at the Transcatheter Cardiovascular Therapeutics meeting (TCT 2017), Denver, CO, October 30, 2017.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Aortic Surgery, Interventions and ACS, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Angiography, Angina, Unstable, Coronary Stenosis, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Stents, TCT17, Thrombosis, Transcatheter Cardiovascular Therapeutics, Ultrasonography


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