Double Kissing Crush vs. Provisional Stenting for LMT Bifurcation Stenosis

Study Questions:

What is the difference in major adverse cardiac events (MACE) at 3 years after double-kissing (DK) crush versus culotte stenting for unprotected left main distal bifurcation lesions (LMDBLs)?


A total of 419 patients with LMDBLs who were randomly assigned to either the DK crush or culotte group in the DKCRUSH-III study were followed for 3 years. The primary endpoint was the occurrence of a MACE at 3 years. Stent thrombosis (ST) was the safety endpoint. Patients were classified by simple and complex LMDBLs according to the DEFINITION (Definition and Impact of Complex Bifurcation Lesions on Clinical Outcomes After Percutaneous Coronary Intervention Using Drug-Eluting Stents) study criteria.


At 3 years, MACE occurred in 49 patients in the culotte group and in 17 patients in the DK crush group (cumulative event rates of 23.7% and 8.2%, respectively; p < 0.001), mainly driven by increased myocardial infarction (8.2% vs. 3.4%, respectively; p = 0.037) and target-vessel revascularization (18.8% vs. 5.8%, respectively; p < 0.001) between groups. Definite ST rate was 3.4% in the culotte group and 0% in the DK crush group (p = 0.007). Complex LMDBLs were associated with a higher rate of MACE (35.3%) at 3 years compared with a rate of 8.1% in patients with simple LMDBLs (p < 0.001), with an extremely higher rate in the culotte group (51.5% vs. 15.1%, p < 0.001).


The authors concluded that culotte stenting for LMDBLs was associated with significantly increased rates of MACE and ST.


This randomized, multicenter study reports that compared with the DK crush technique, culotte stenting is associated with significantly increased MACE in patients with LMDBLs, especially in patients with complex lesions. Furthermore, the increased 3-year rate of definite and probable ST in the culotte group translated into more frequent cardiac death and myocardial infarction. Additional studies are necessary to compare DK crush with provisional T-stenting in patients with complex LMDBLs.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery

Keywords: Drug-Eluting Stents, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Stents, Thrombosis

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