Comparison of Double Kissing Crush Versus Culotte Stenting for Unprotected Distal Left Main Bifurcation Lesions: Results From a Multicenter, Randomized, Prospective DKCRUSH-III Study

Study Questions:

What is the difference in major adverse cardiac events (MACE) at 1 year after double kissing (DK) crush versus Culotte stenting for unprotected left main coronary artery (ULMCA) distal bifurcation lesions?


A total of 419 patients with ULMCA bifurcation lesions were randomly assigned to DK (n = 210) or Culotte (n = 209) treatment. The primary endpoint was the occurrence of a MACE at 1 year, including cardiac death, myocardial infarction, and target vessel revascularization (TVR). In-stent restenosis (ISR) at 8 months was the secondary endpoint, and stent thrombosis (ST) served as a safety endpoint. Patients were stratified by SYNTAX and NERS scores. Survival rate free from events was generated by Kaplan-Meier analysis, and was compared using the log-rank test.


Patients in the Culotte group had a significantly higher 1-year MACE rate (16.3%), mainly driven by increased TVR (11.0%), compared to the DK group (6.2% and 4.3%, all p < 0.05). ISR rate in side branch (SB) was 12.6% in the Culotte group and 6.8% in the DK group (p = 0.037). Definite ST rate was 1.0% in the Culotte group and 0% in the DK group (p = 0.248). Among patients with bifurcation angle ≥700, NERS score ≥20, and SYNTAX score ≥23, the 1-year MACE rate in the DK group (3.8%, 9.2%, and 7.1%) was significantly different to those in the Culotte group (16.5%, 20.4%, and 18.9%, all p < 0.05, respectively).


The authors concluded that Culotte stenting for ULMCA bifurcation lesions was associated with significantly increased MACE, mainly due to the increased TVR.


The primary finding of this study is that Culotte stenting for ULMCA distal bifurcation lesions was associated with significantly increased 1-year composite MACE rate, mainly because of the higher TVR rate. It is possible that both DK crush and Culotte stenting techniques are safe for distal ULMCA bifurcation lesions, and that optimizing the expansion of the SB stent, as did DK crush technique, would put patients at lower risk of ST. While additional studies are needed to determine optimal PCI technique for ULMCA distal bifurcation lesions, it should be noted that coronary artery bypass grafting remains the preferred revascularization modality for these patients at this point.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Aortic Surgery, Cardiac Surgery and SIHD, Chronic Angina

Keywords: Myocardial Infarction, Receptors, Endothelin, omega-Chloroacetophenone, Coronary Stenosis, Coronary Restenosis, Thrombosis, Survival Rate, Cardiology, Receptor, Endothelin B, Coronary Artery Bypass, Angioplasty, Balloon, Coronary, Stents

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