Double-Kissing Crush Better than Culotte Technique for Left Main Bifurcation Stenting

SAN FRANCISCO, CA—In a trial comparing 2 stenting techniques for treating left main bifurcation lesions, the double-kissing (DK) crush procedure produced fewer major adverse cardiac events (MACE) and repeat procedures than the culotte technique. Results of the DKCRUSH-III study were presented March 10, 2013, at the American College of Cardiology/i2 Scientific Session and were published simultaneously in the Journal of the American College of Cardiology.

For DKCRUSH-III, researchers including Shaoliang Chen, MD, of Nanjing Medical University (Nanjing, China), and Bo Xu, MBBS, of Beijing Fuwai Cardiovascular Hospital (Beijing, China), randomized 419 patients with unprotected left main coronary artery bifurcations to receive either DK crush (n = 210) or culotte (n = 209) stenting. The culotte technique involves placing stents in the main artery and the side branch, overlapping them in the main vessel. DK crush involves side stenting and 2 kissing balloon inflations.

At 8 months, the secondary endpoint of in-stent restenosis in the side branch was lower with DK crush stenting, as was diameter stenosis and in-stent late loss (table 1).

Table 1. QCA of Side Branch at 8 Months



DK Crush
(n = 176)

(n = 174)

P Value

In-stent Restenosis




Diameter Stenosis

16.39 ± 7.45%

25.50 ± 7.36%


In-stent Late Loss, mm

0.20 ± 0.30

0.39 ± 0.36


At 1 year, the primary endpoint of MACE (cardiac death, MI, and TVR) was more than halved in the DK crush group, driven mainly by a reduction in TVR. TLR was also decreased in the DK crush group (table 2).

Table 2. One-year Outcomes



DK Crush
(n = 210)

(n = 209)

P Value





Cardiac Death
















Stent thrombosis rates were low and similar at 0.5% with DK crush stenting and 1.0% with culotte stenting (P = 0.623), including no cases of definite stent thrombosis in the DK crush group and a rate of 1.0% in the culotte group (P = 0.248).

In patients at intermediate and high risk, defined as New Risk Stratification (NERS) score ≥ 20, Syntax score ≥ 23, and bifurcation angle ≥ 70º, DK crush stenting was associated with reduced 1-year risk of MACE compared with culotte stenting:

  • NERS score ≥ 20: 9.2% vs. 20.4% (OR 0.40; 95% CI 0.20-0.79)
  • Syntax score ≥ 23: 7.1% vs. 18.9% (OR 0.36; 95% CI 0.17-0.76)
  • Bifurcation angle ≥ 70º: 3.8% vs. 16.5% (OR 0.20; 95% CI 0.08-0.49)

Routine Angiography Raises Questions

A number of panelists suggested that the TLR events may have been driven by routine angiographic follow-up. “In other words, if you had no routine angiographic follow-up, would there have been a difference in the clinical outcomes?” asked session co-chair Gregg W. Stone, MD, of Columbia University Medical Center (New York, NY).

Dr. Chen assured, though, that ischemia-driven TLR would not have changed the results.

Panel member Cindy L. Grines, MD, of Detroit Medical Center (Detroit, MI), was impressed with the clinical results. “You had 1% mortality and very excellent clinical outcomes,” she said. “That in and of itself should encourage us to do more of these cases.”

She noted, though, that “I’m not a big fan of the crush technique,” adding that, “My practice seems to do more single vessel stenting and leave the side branch alone or perhaps rescue the side branch.”

Working the Angles

Meanwhile, Dr. Stone commented on the 81.6% of patients with a bifurcation angle ≥ 70º. “Most people would not do a culotte or a crush [for these patients], but if they have to stent, would do a [different] technique,” he said. “There are other, easier techniques than DK crush for a wide angle distal bifurcation.”

“This is a limitation because culotte stenting [or DK crush] is maybe not suitable [for this group],” Dr. Chen acknowledged.

Jeffrey J. Popma, MD, of Beth Israel Deaconess Medical Center (Boston, MA), asked the discussion’s most provocative question: “Do we need a dedicated bifurcation stent rather than all the techniques that we do? Do we need a stent that has 2 pants to it and a central waist?”

Dr. Chen replied that in China “we have a dedicated bifurcation stent especially for this kind of scenario.”

Study Details

The majority of the patients (79% to 83%) had unstable angina and 3-vessel disease (70% to 71%). Firebird-2 stents (MicroPort, Shanghai, China) and Xience V stents (Boston Scientific, Abbott Vascular) were used in roughly one-third and two-thirds of patients, respectively.

Note: Dr. Stone and several co-authors of the study are faculty members of the Cardiovascular Research Foundation, which owns and operates TCTMD.



Chen SL, Xu B, Han YL, Sheiban I, et al. Comparison of DK crush versus culotte stenting for unprotected distal left main bifurcation lesions: A multicenter, randomized, prospective DKCRUSH-III study. J Am Coll Cardiol. 2013;Epub ahead of print.



  • The study was funded by the Jiangsu Provincial Outstanding Medical Program
  • Dr. Chen reports no relevant conflicts of interest.


Related Story:

We Recommend