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DKCRUSH-II Trial

370 patients with bifurcation lesions were included in DKCRUSH-II (Double Kissing Crush versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions) trial (1). The patients were divided in two groups after being randomized to either the ‘Provisional’ side branch stenting or ‘double kissing crush’ stenting strategies. Both groups were implanted with soluble polymer-based sirolimus-eluting EXCEL stent. 

The main coronary was stented in the patients with ‘provisional’ side branch stenting and optionally (>50% stenosis at the side branch, type >B dissection, TIMI flow < 3) ‘kissing’ balloon was applied.  In the case of poor response with the kissing’ balloon, T-stenting was applied and the procedure was completed with the ‘kissing’ balloon.

In ‘double kissing crush’ stenting technique, predilatation is performed by inserting guide wire to both branches (Figure 1) (2). The stent to be implanted to the side branch is retracted 3-5 mm into the main branch. The stent in the side branch is deployed after placing a balloon, in a manner covering bifurcation to the main branch. The balloon of the side branch stent is removed and the side branch is checked for adequate result. In case an adequate result is obtained, the balloon on the side branch is inflated after the side branch guide wire is withdrawn and then the side branch stent is crushed. After the side branch stent is crushed, the guide wire is reinserted to the side branch and the side branch is dilated under high pressure (preferably at ≥ 16 atm with non-compliant balloon). The side branch balloon and wire are withdrawn following the ‘kissing’ balloon procedure to the bifurcation. After the stent is inserted to the main branch, the side branch is dilated following its passage from the struts of the main branch stent. The procedure is completed with ‘kissing’ balloon dilatation.

Figure 1. Bifurcation lesion. A. The stent to be implanted to the side branch is retracted 3-5 mm into the main branch. The stent in the side branch is deployed after placing a balloon, in a manner covering bifurcation to the main branch. B. The balloon on the main branch is inflated after the side branch balloon and guide wire are withdrawn and then the side branch stent is crushed. C. After the side branch stent is crushed, the guide wire is reinserted to the side branch and the side branch is dilated under high pressure (preferably at ≥ 16 atm with non-compliant balloon). D. Following high-pressure dilatation to the side branch, ‘kissing’ balloon procedure is applied to the bifurcation. E. After the side branch balloon and wire are withdrawn, stent is inserted to the main branch. F. The side branch is dilated following its passage from the struts of the main branch stent. E. The procedure is completed with ‘kissing’ balloon dilatation.
No difference is found between the two groups in terms of major cardiac events (cardiac death, MI, target vessel revascularization) on month 12, taken as the primary end-point. Main branch and side branch restenosis rates and the target vessel and lesion revascularization rates, taken as the secondary end-points, were found significantly lower in the patients with ‘double kissing crush’ stenting technique. No difference was found between the two groups in terms of stent thrombosis.

While incidence of restenosis both in the main and side branches was found lower with ‘double kissing crush’ stenting when compared to ‘provisional’ side branch stenting, target vessel and lesion revascularization was also found lower. The results of this trial are very important given that complex stenting strategy (stent implantation on both branches) has for the first time found to be superior to the simple stenting (stenting to the main branch/stenting to the side branch, if necessary) strategy among the randomized trials conducted on bifurcation lesions.

  1. Chen SL, et al. A randomized clinical study comparing double kissing crush with provisional stenting for treatment of coronary bifurcation lesions. J Am Coll Cardiol 2011;57:914-20.
  2. Jim MH, Ho HH, Chan AO, Chow WH. Stenting of coronary bifurcation lesions by using modified crush technique with double kissing balloon inflation (sleeve technique): immediate procedure result and short-term clinical outcomes. Catheter Cardiovasc Interv. 2007 ;69:969-75

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