Double kissing crush bifurcation stenting: step-by-step troubleshooting

Abstract

The double kissing crush (DK crush) is the most studied two-stent coronary bifurcation stenting strategy. While published data support its use, DK crush can be challenging to perform. In this review we provide a detailed step-by-step description and troubleshooting for each stage of the DK crush technique.

Figure 1

Angiographic case example of a bifurcation lesion treated successfully with the double kissing crush technique. A) Medina 1,1,1 bifurcation lesion (yellow circle) with significant disease involving the mid left anterior descending (LAD) artery and the bifurcating second diagonal branch. The bifurcation angle is <70°. The side branch supplies a large myocardial segment. B) Wires (yellow arrows) are placed in both the LAD (main vessel) and the diagonal branch (side branch). A balloon (white bracket) is placed in the diagonal branch for predilation. C) A balloon (white bracket) is placed in the LAD for predilation. D) A stent (yellow arrow) is positioned in the diagonal branch. A balloon (white bracket) is pre-positioned in the LAD prior to deploying the diagonal stent to allow subsequent crushing of the diagonal branch stent. E) The diagonal branch stent is deployed (yellow arrow). The angiographic result in the diagonal is optimised (for example to correct stent underexpansion indicated by arrowhead) prior to crushing the side branch stent. F) The LAD balloon (white bracket) is inflated, crushing the diagonal stent. G) A new wire (yellow arrow) is used to re-wire the crushed diagonal branch stent and the original diagonal wire is removed. H) The first simultaneous kissing balloon inflation (white bracket) is performed in the LAD and diagonal branch. I) The LAD stent is positioned (white bracket); the diagonal wire (yellow arrow) is not removed. J) The LAD stent (white bracket) is deployed, followed by proximal optimisation technique (POT) of the main vessel stent (not imaged). K) Due to difficulty re-wiring the diagonal branch, a Twin-Pass™ Torque (Teleflex) dual-lumen microcatheter (white bracket) is used, with successful advancement of a new wire (yellow arrow) through the over-the-wire port of the device. L) The jailed diagonal wire (yellow arrow) is removed. M) The second simultaneous kissing balloon inflation (white bracket) is performed. A wire (yellow arrow) was placed in a more proximal first diagonal to maintain access to the vessel. N) Repeat POT is performed, with balloon inflation (yellow arrow) within the proximal main branch (LAD) stent up to the carina. O) Excellent final angiographic result.

Figure 2

The steps of the double kissing crush bifurcation stenting technique. The numbers to the left of each image correspond to the step number and affiliated troubleshooting information provided for each step within the body of the text.

Figure 3

Algorithm for approaching a side branch which is difficult to wire. *atherectomy only if no new stents yet placed. MC: microcatheter

Figure 4

Examples of wire tip shapes that can be formed to facilitate difficult side branch wiring.

Figure 5

The "hairpin" wire technique. A) Illustration of how to form a “hairpin” on a coronary wire. B) A hairpin shape on a wire is used to enter an acute marginal branch. The hairpin is advanced past the branch and is then withdrawn, unfolding and entering the branch. Reproduced with permission from: Brilakis ES. Manual of Coronary Chronic Total Occlusion Interventions. A Step-By-Step Approach. 2nd edition. Amsterdam, the Netherlands: Elsevier; 2017.

Figure 6

A microcatheter (yellow arrow) is used to direct a wire into an obtuse marginal branch.

Figure 7

Algorithmic approach in case of failure to advance a balloon or stent into the main branch or side branch of a coronary bifurcation. *atherectomy only if no new stents yet placed. LM: left main; MC: microcatheter; MV: main vessel; SB: side branch

Figure 8

Use of an anchor balloon in a side branch to increase support for advancement of equipment in the main branch in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). This technique can be adapted for use when equipment is difficult to advance into the main branch or even side branch, when performing double kissing crush bifurcation stenting.

Figure 9

The “independent hand” technique, that allows careful and precise placing of a stent at the side branch ostium with slight protrusion in the main vessel. It is also a useful technique for difficult angioplasty equipment delivery in general. The white arrow on the left shows how the operator’s left fingers are used to hold and, as needed, adjust the guide position. The white arrow on the right shows that the coronary guidewire is held between the 4th and 5th digits of the right hand. The operator’s right index finger and thumb are used to pinch and advance or retract the balloon or microcatheter, while the 3rd and 4th digits of the right hand are used to grasp the circumference of the Tuohy.

Figure 10

Drawback of too distal SB re-crossing in the classic crush technique. A) Position of MV and SB stents. B) SB stent deployment. C) MV stent deployment to crush the SB stent. D) Gap formation near the carina. E) Distal SB re-crossing, wire going between the SB stent and vessel wall. F) Final kissing balloon inflation. G) & H) Leaving a significant gap near the carina. MV: main vessel; SB: side branch Reprinted from Zhang JJ and Chen SL. Classic crush and DK crush stenting techniques. EuroIntervention. 2015;11:V102-V105. With permission from Europa Digital & Publishing.