'DK crush not gold standard for complex left main bifurcation lesions'

David Hildick-Smith, MD presents debate on provisional- vs. dual-stenting at TCTAP 2022

  • Both provisional stenting and systematic dual stenting techniques (DK crush) are equally acceptable for complex left main bifurcation lesions, an expert said.
  • Strategy uptake may depend on region as European cardiologists are more accustomed to PS and Chinese experts to DK crush, indicating that guidelines should not advocate a particular strategy.

Provisional stenting (PS) is equally applicable as the upfront two-stent DK crush technique in complex left main (LM) bifurcation lesions, an expert said, despite the “plaudits” and guideline endorsements heaped on the latter.

David Hildick-Smith, MD (Sussex Cardiac Centre, Brighton, UK) sided with the provisional approach over upfront dual-stenting during a debate at the 27th TCTAP 2022 on April 27.

“Both provisional and systematic dual techniques are applicable for complex LM stem bifurcation,” Smith said. “Operators must learn and apply their preferred strategy carefully and rigorously since application is more important than technique.”

True LM bifurcation lesions involving the main branch (MB) and side branch (SB) are technically challenging and suboptimal results can lead to restenosis, thrombosis and poor outcomes.

Currently, various strategies for percutaneous coronary intervention (PCI)help treat LM bifurcation. Among available strategies, the provisional stenting and upfront two-stent techniques are the most utilized.

  • Provisional stenting: treats bifurcation lesions in a “stepwise” manner by starting with one stent and adding more when needed rather than starting with two stents.
  • Upfront 2-stenting (dual-stenting): starts and ends with two stents by incorporating multiple steps and includes the T-stenting, Culotte, DK crush and Kissing techniques.

Although provisional stenting was the most popular strategy for complex LM, mounting data on dual stenting from Chinese operators had displaced the approach in major guidelines. The DK crush technique, championed by Shao-liang Chen, MD, PhD (Nanjing Medical University, Nanjing, China) and colleagues, particularly rose to prominence with several studies reporting positive outcomes.

Despite the larger body of data for DK crush, Smith advised against its wide application in LM bifurcation, citing drawbacks such as forceful, upfront commitment to two stents, multiple steps required for completion, and a discrepancy between immediate and long-term results.

Smith also referred to results from last year’s EBC Main study that directly opposed findings from the DKCRUSH-V study. Findings from EBC Main showed that provisional stenting was more effective for lowering risk of adverse events, including major adverse cardiac events (MACE).

“Internationally, cardiologists feel obliged to perform DK crush because guidelines endorse it based on the DKCRUSH studies,” Smith said. “But baseline characteristics of European and American populations generally differ from the highly complex lesions of Chinese patients that were studied in DKCRUSH-V.”

“The long lesions of DKCRUSH-V are unusual in the US and Europe,” he said. “These anatomies require a stent in their own right, so it’s no surprise that two-stenting is de rigueur in that population.”

“Guidelines should not promote a specific technique, considering there are no clinical differences between an optimally done mini-culotte and equally well done mini-DK crush,” Smith added. “Recommending a specific technique in the guidelines is a significant error that can mislead cardiologists to try techniques beyond their scope of expertise.”

Smith stressed that the PS strategy, unlike dual-stenting, offers additional leeway by giving operators the opportunity to assess for next steps after the first stent and then stop or add more:

“Each step in the provisional approach requires rigorous decision-making that offers an option to do less, not more. It’s possible to stop earlier than expected - which is great since less in left main often means less subsequent restenosis.”

Despite the differences between the two techniques, Smith noted their complementary nature by comparing the characteristics of the patients enrolled in their respective studies.

Analysis showed that EBC-Main and DKCRUSH-V had patients with different baseline characteristics such as lesion length (7 mm vs. 16 mm) and SYNTAX score (22 vs. 31), indicating that patients with certain anatomical features would benefit from either provisional stenting or DK crush.


Edited by

Kyusup Lee
Kyusup Lee, MD

Daejeon St. Mary's Hospital, Korea (Republic of)

Written by

YoonJee Marian Chu
YoonJee Marian Chu, Medical Journalist
Read Biography
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