Study Supports Double Kissing Crush Stent Technique for Treating Bifurcation Lesions

March 10, 2013—The American College of Cardiology (ACC) announced that results from the DKCRUSH-III study, the first head-to-head comparison of double kissing (DK) crush and culotte stent techniques in coronary artery disease, were presented at the ACC's 62nd annual scientific session in San Francisco.

The study focused on bifurcation lesions, which are typically linked with poor prognosis. In DKCRUSH-III, patients fared significantly better when treated with DK crush stenting than with culotte stenting.

As explained in the ACC press release, the DK crush technique extends a small piece of the branch stent into the main artery, where it is squeezed against the main artery's wall. This approach introduces two points where the balloons used in stenting inflate in the artery and connect for a “double kiss.” The culotte technique places stents in the main artery and the side branch, overlapping them in the main vessel before the branch forks.

The ACC noted that bifurcation lesions account for approximately 15% of lesions treated with coronary stents and are associated with higher rates of restenosis and lower rates of long-term favorable outcome. High morbidity and mortality are connected with a subset of these lesions: unprotected left main coronary artery (ULMCA) disease. Approximately two-thirds of significant ULMCA disease involves distal bifurcations; the best treatment for this lesion type has been debated.

According to the ACC press release, the multicenter study randomly assigned patients with ULMCA distal bifurcation lesions to treatment with DK crush (210 patients) or culotte (209 patients) stenting. At 1 year, major adverse cardiac events occurred in 16.3% of the culotte patients and 6.2% of the DK crush patients. The culotte approach had markedly higher rates of repeat intervention at the target lesion (6.7% vs 2.4%) and the target vessel (10.5% vs 4.3%). Clotting at the stent site was low in both groups.

“Angiographic follow-up at 8 months found 12 cases of instent restenosis in the side branch with DK crush and 22 with culotte (6.8% vs 12.6%),” commented Jun-Jie Zhang, MD, in the ACC announcement. “Thus, we have to say that DK crush is superior to culotte stenting.” Dr. Zhang, who is an interventional cardiologist in the cardiovascular department of Nanjing First Hospital at Nanjing Medical University in China, added, “Although this trial did not include a bypass surgery group to contrast with the stenting techniques, the promising results achieved by DK crush were comparable with those after coronary artery bypass.”

The study will extend clinical follow-up for participating patients to 5 years, and further research through the DKCRUSH-V study is ongoing, advised the ACC.