Intracoronary imaging guidance has become an established recommended strategy in complex coronary lesions. In the specific setting of complex bifurcations, uncertainty remained regarding the incremental benefit over an angiography-guided approach alone. This question is particularly relevant in the DK crush technique, which involves multiple steps in which procedural optimization—especially the rewiring step—may be critical to the effectiveness of the technique.
The aim of the DKCRUSH VIII study was to investigate the effect of an IVUS-guided PCI strategy compared with an angiography-guided PCI in patients with true complex coronary bifurcation lesions.
A randomized study was conducted across 24 centers in China, enrolling 556 patients, with 278 assigned to IVUS-guided DK crush and 278 to angiography-guided DK crush. Patients older than 18 years with truly complex bifurcations were included, defined—among other criteria—by a side branch lesion ≥10 mm, side branch ostial stenosis of 70% to 90%, plus two minor criteria, and MV-QFR ≤0.8.
The primary endpoint (PFP) was target vessel failure (TVF) at 12 months, defined as a composite of cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularization.
The mean age was 67 years, and 77.3% of patients were male. Most patients presented with unstable angina, and approximately 18% with STEMI. From an anatomical and procedural standpoint, nearly half involved distal left main bifurcations; radial access was predominant, and the DK crush technique was used in 96.8% of both groups.
Read also: ACC 2026 | OPTIMAL: IVUS Guidance in PCI of the Unprotected Left Main Coronary Artery.
At 1-year follow-up, the primary endpoint occurred in 6.1% of the IVUS group and 14.7% of the angiography-guided group (HR 0.40; 95% CI 0.23–0.71; p=0.0016). Reductions were also observed in several clinical components: target vessel MI in 4.3% vs 9.4% (HR 0.46; p=0.02), spontaneous MI in 1.8% vs 6.1% (HR 0.29; p=0.01), and TVR in 2.9% vs 7.6% (HR 0.37; p=0.02). There were no significant differences in all-cause mortality (1.4% vs 1.1%; p=0.70), cardiac death (0.7% vs 1.1%; p=0.66), or definite/probable stent thrombosis (0.4% vs 1.1%; p=0.38).
Systematic IVUS evaluation identified relevant procedural findings, including incomplete crushing in 28.2%, distal rewiring after the first rewiring in 41.5%, and suboptimal diameter after final POT in 61.0% of evaluated patients.
An additional exploratory analysis showed that when IVUS-defined optimization criteria were achieved, the TVF rate was 2.6%, compared with 15.9% in suboptimal PCI and 14.7% in the angiography-guided arm.
Conclusions: IVUS significantly reduces target vessel failure in complex coronary bifurcations treated with DK crush
In this randomized study, IVUS-guided DK crush was associated with a lower rate of TVF at one year compared with angiography-guided PCI in complex coronary bifurcations. This benefit was primarily driven by achieving IVUS-defined optimization targets rather than by the mere use of IVUS.
Presented by Shao-Liang Chen at the Late-Breaking Clinical Trials, ACC.26, March 28–30, New Orleans, USA.
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