DK-Crush or Mini-Crush Stenting for Complex Left Main Bifurcation Lesions: The Multicenter EVOLUTE-CRUSH LM Registry

Abstract

Background: The comparison of outcomes of mini-crush (MCT) versus double kissing crush (DKC) techniques for complex left main bifurcation (LMB) lesions is still lacking. This investigation aimed to assess the long-term outcomes of patients who underwent MCT or DKC for LMB disease.

Methods: From 2014 to 2024, patients who underwent percutaneous coronary intervention for complex LMB lesions were retrospectively collected. The primary end point was major adverse cardiac events as the combination of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization during follow-up. The secondary end point was measured as major adverse cardiovascular and cerebral events including all-cause death, target vessel revascularization, target vessel myocardial infarction, stent thrombosis, and stroke.

Results: This large-scale multicenter (n=13) observational study included a total of 531 consecutive patients (men: 405 [76.3%], mean age: 63.16±11.26 years) with complex LMB lesions who underwent percutaneous coronary intervention. The initial revascularization strategy was MCT in 313 (59%) patients and DKC in 218 (41%) patients. The number of balloons used (5.91±1.53 versus 6.72±1.70, P<0.001) and procedure time (66.60±24.20 versus 72.97±19.97 minutes, P<0.001) were notably lower in the MCT group. In the overall population, the long-term major adverse cardiac events (hazard ratio [HR], 0.704; P=0.169) and major adverse cardiovascular and cerebral events (HR, 0.660; P=0.079) did not differ in individuals with complex LMB lesions treated with MCT and DKC. Other end points were also comparable between the 2 groups.

Conclusions: In complex LMB lesions, risk-adjusted major adverse cardiac events and major adverse cardiovascular and cerebral events rates were comparable between both techniques, with a nonsignificant trend favoring DKC at long-term follow-up.

Registration: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT06546748.

Keywords: double kissing‐crush; left main bifurcation; major adverse cardiac events; mini‐crush.

Figure 1. Technical steps of MCT via transfemoral access.

A, Bifurcation localization in the distal LM and LAD‐Chronic total occlusion (CTO) lesion. B, Wiring and predilatation of LAD and stenting proximal‐mid LAD lesion. C, Predilatation of the LCx. D, LM‐LAD and LCx stents positioning and placement. E, Proximal side‐branch optimization with LCx stent balloon. F, Positioning and placement of the LM‐LAD stent. G, Checking LM‐LAD‐LCx stenting before POT. H, POT with NCB. I, Final KBI with NCBs. J, Final POT with NCB. K and L, Final result. DES indicates drug‐eluting stent; KBI, kissing balloon inflation; LAD, left anterior descending artery; LCx, left circumflex artery; LM, left main coronary artery; MCT, mini‐crush technique; NCB, noncompliant balloon; and POT, proximal optimization technique.

Figure 2. Step‐by‐step DKC via transfemoral approach.

A, Bifurcation localization in the distal LM. B, Wiring and predilatation of LCx‐OM1. C, Predilatation of LAD, an uninflated NCB in the distal LM, and LCx‐OM1 stent positioning. D, LCx‐OM1 stent placement and proximal side‐branch optimization with stent balloon. E, Balloon crushing of the LCx‐OM1 stent and first POT. F, First KBI with the NCBs. G, Positioning and placement of the LM‐LAD stent after removing the stent balloon from the LCx‐OM1. H, Second POT with NCB. I, Final KBI with NCBs. J, Third POT with the NCB. K and L, Final result. AP indicates anteroposterior view; DES, drug‐eluting stent; DKC, double kissing crush technique; KBI, kissing balloon inflation; LAD, left anterior descending artery; LAO, left anterior oblique view; LCx, left circumflex artery; LM, left main coronary artery; MV, main vessel; NCB, noncompliant balloon; OM1, first obtus maginal artery; POT, proximal optimization technique; and SB, side branch.

Figure 3. Kaplan‐Meier curves for the primary end point (MACE) according to the treatment of DKC (blue) or MCT (yellow).

DKC indicates double kissing crush technique; HR, hazard ratio; MACE, major adverse cardiovascular events; MCT, mini‐crush technique; and N, number.

Figure 4. Kaplan‐Meier curves for the secondary end point (MACCE) according to the treatment of DKC (blue) or MCT (yellow).

DKC indicates double kissing crush technique; HR, hazard ratio; MACCE, major adverse cardiovascular and cerebral events; MCT, mini‐crush technique; and N, number.

Figure 5. An overview of the study design and clinical outcomes.

DK indicates double kissing; MACCE, major adverse cardiovascular and cerebral events; MACE, major adverse cardiac events; ST, stent thrombosis; TLR, target lesion revascularization; TVMI, target vessel myocardial infarction; and TVR, target vessel revascularization.