Double kissing crush versus provisional stenting for left main distal bifurcation lesions: DKCRUSH-V randomized trial

Selected in the Journal of the American College of Cardiology by C. Cook

References

Authors

Chen SL, Zhang JJ, Han Y, Kan J, Chen L, Qiu C, Jiang T, Tao L, Zeng H, Li L, Xia Y, Gao C, Santoso T, Paiboon C, Wang Y, Kwan TW, Ye F, Tian N, Liu Z, Lin S, Lu C, Wen S, Hong L, Zhang Q, Sheiban I, Xu Y, Wang L, Rab TS, Li Z, Cheng G, Cui L, Leon MB, Stone GW

Reference

J Am Coll Cardiol. 2017 Nov 28;70(21):2605-2617

Published

November 2017

Link

Read the abstract

My Comment

Why this study – the rationale/objective?

Although provisional stenting (PS) is the most common technique for the treatment of distal left main (LM) bifurcation, the double kissing (DK) crush planned 2-stent technique has been shown to result in lower rates of TLR compared with PS in non-LM coronary bifurcation lesions. The investigators of the DKCRUSH-V trial sought to determine whether a planned DK crush 2-stent technique was superior to PS for patients with true distal LM bifurcation lesions.

How was it executed – the methodology?

This was a multicenter (26 centres), prospective, randomized clinical trial. Patients with Medina 1,1,1 or 0,1,1 distal LM bifurcation lesions were randomized in a 1:1 fashion to either a PS (n=242) or DK (n=240) approach. The primary endpoint was a 1-year composite rate of TLF (cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization). Routine angiographic follow-up was conducted at 13 months (i.e. after ascertainment of the primary endpoint).

What is the main result?

TLF within 1 year occurred in 26 patients (10.7%) in the PS group versus in 12 patients (5.0%) in the DK crush group (HR 0.42; 95% CI 0.21 to 0.85; p = 0.02). Furthermore, compared with PS, DK crush also resulted in lower rates of target vessel MI I (2.9% vs. 0.4%; p = 0.03) and definite or probable stent thrombosis (3.3% vs. 0.4%; p = 0.02). No significant difference in cardiac death was noted between the groups.

Critical reading and the relevance for clinical practice

The DKCRUSH-V trial provides a clear demonstration of the superiority of the double kissing crush planned 2-stent technique over the more common (and simpler) provisional stenting technique for distal left main bifurcation lesions. The trial provides important additive information on the optimal interventional approach to LM disease and builds on the insights gained from EXCEL and NOBLE (predominantly provisional stenting strategy LM trials).
The results of DKCRUSH-V trial have surprised some, who had hypothesized that the fewer stent layers associated with PS would be associated with less TLF. However, this preconception has been robustly refuted by the findings of the trial.

As a final point, in order to participate in the trial, primary operators were required to have performed >300 PCIs/year for 5 years, including at least 20 LM PCIs per year. In addition, each operator performed 3 to 5 DK crush cases, which were reviewed by the steering committee to ensure appropriate technique before randomization commenced. Therefore, the major challenge for translating the impressive results of DK CRUSH-V into everyday clinical practice is likely to be related to a comparative lack of operator experience.

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