DKCRUSH-V: Left Main, Not Just Another Bifurcation

Cardiac Artery Bypass Graft Surgery has been shown more effective than percutaneous coronary intervention (basically because it renders lower revascularization rate) in patients with severe left main  bifurcation lesions receiving 1st generation drug eluting stents. This is why the 2014 American guidelines recommend CABG for most patients.

But the EXCEL and the NOBLE trials brought back hope to interventional cardiologists and reinstalled the question about what technique to use on bifurcations, since approximately 80% of lesions involve the distal segment.

Read also: “DKCRUSH-V: What Is Simple Is Not Always Best for the Left Main Coronary Artery”.

Both the EXCEL and the NOBLE favored provisional stenting to treat left main bifurcations. 

The planned DK crush 2-stent technique has improved results in other bifurcations. Specifically, in left main bifurcations, this technique has been shown superior to culotte stenting. However, it had never been tested against provisional stenting.

482 patients from 26 centers and 5 countries with left main bifurcation lesions (Medina 1,1,1 or 0,1,1) were randomized to provisional stenting (n=242) vs. DK crush technique (n=240). Primary end point was a composite of cardiac death, vessel related infarction or clinically driven revascularization. There was routine angiographic follow up at 13 months.

Read also: “Ischemic and Bleeding Risk After Primary Angioplasty”.

Primary end point at one year occurred in 26 patients undergoing provisional stenting (10.7%) and in 12 patients (5%) of patients undergoing DK crush (HR: 0.42, CI 95%: 0.21 to 0.85; p=0.02).

In addition, DK crush resulted in lower rates of target vessel MI (2.9% vs. 0.4%; p=0.03) and definite/probable thrombosis (3.3% vs. 0.4%; p=0.02).

Clinically driven revascularization (7.9% vs. 3.8%; p=0.06) and angiographic restenosis (14.6% vs. 7.1%; p=0.10) were also lower with the DK crush technique, compared to provisional stenting.

Read also: “Angioplasty Complexity May Define the Duration of Dual Antiplatelet Therapy”.

Cardiac mortality was similar in both groups.

Conclusion

Distal left main bifurcation using planned DK crush 2-stent technique resulted in a lower rate of the composite of death, target vessel infarction and target vessel revascularization, vs. the traditional provisional stenting.

Editorial Comment

The group randomized to provisional stenting required a second bailout stent 47% of the time. This percentage is relatively high, and speaks of bifurcation lesions.

DK crush V is the first study to assess clinical and angiographic results of left main bifurcations with this technique vs. provisional stenting. Prior to this study, the DK crush III had been tested against culotte stenting.

Possible explanations for the difference between these outcomes and those of the rest of studies that had deemed provisional stenting superior, could be that left main caliber is always bigger, bifurcation angle is in general more open and trifurcations are rare at left main level.

Original title: Double Kissing Crush Versus Provisional Stenting for Left Main Distal Bifurcation Lesions. DKCRUSH-V Randomized Trial.

Reference: Shao-Liang Chen et al. J Am Coll Cardiol 2017, article in press.

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