Double Kissing Crush Versus Culotte for Bifurcation Percutaneous Coronary Interventions: Insights From the PROGRESS-BIFURCATION Registry
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J INVASIVE CARDIOL 2025. doi:10.25270/jic/24.00350. Epub January 10, 2025.
Abstract
Background. Upfront 2-stent techniques are often used in bifurcation percutaneous coronary interventions (PCI), but there is controversy about optimal strategy selection.
Methods. The authors examined the clinical and angiographic characteristics and long-term outcomes of 232 bifurcation PCIs that were performed using the double kissing (DK) crush or culotte technique in 216 patients between 2014 and 2023 using data from the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (NCT05100992). The inverse probability of treatment weighted (IPTW) Cox proportional hazards model was used to assess long-term outcomes.
Results. DK crush was more commonly used (69.0%). Patients in the DK-crush group had similar baseline characteristics to those in the culotte group. Lesions treated with DK crush were more likely to be in the left main coronary artery (42.9% vs 15.5%, P < .001), had larger proximal (3.50 [3.50-4.00] vs 3.50 [3.21-3.79] mm, P = .027) and distal (3.00 [3.00-3.50] vs 3.00 [2.75-3.25] mm, P = .047) main vessel diameter, and were more likely to have severe calcification (29.8% vs 5.6%, P < .001). Technical (98.8% vs 97.2%, P = .588), procedural success (96.5% vs 95.1%, P = .698), and in-hospital major adverse cardiovascular events (MACE) (6.1% vs 3.0%, P = .509) were similar in both groups. During a median follow-up of 43 months, 60 (33.9%) patients experienced MACE. On IPTW adjusted Cox analysis, DK crush was associated with lower follow-up MACE (hazard ratio 0.28; 95% CI, 0.13-0.60; P = .001) compared with culotte driven by lower target vessel revascularization (TVR) (14.3% vs 29.3%, P = .029).
Conclusions. Compared with culotte, DK crush is associated with similar periprocedural outcomes but lower TVR and MACE during follow-up.
Introduction
Upfront 2-stent techniques are often used in bifurcation percutaneous coronary intervention (PCI), especially in lesions involving a large and diseased side branch (SB).1,2 There are several 2-stent techniques such as classic, mini, double kissing (DK) crush techniques, T-stenting, culotte, and T and protrusion (TAP), and there is controversy about optimal strategy selection.2 DK crush has been shown to be superior to both classical crush3 and provisional techniques4 in mainly non-left main true bifurcation lesions. In left main (LMCA) bifurcation lesions, DK crush has shown better outcomes than culotte, mainly driven by target vessel revascularization in the Double Kissing Crush Versus Culotte Stenting for the Treatment of Unprotected Distal Left Main Bifurcation Lesions (DKCRUSH)-III study.5 However, there is limited real-world comparative data of various 2-stent bifurcation techniques. In this study, we examined the clinical and angiographic characteristics and long-term outcomes of bifurcation PCI using DK crush vs culotte.
Methods
Patient population
We analyzed the procedural characteristics and outcomes of DK crush vs culotte bifurcation PCI performed between 2014 and 2022 at 6 centers participating in the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (PROGRESS-BIFURCATION, Clinicaltrials.gov Identifier: NCT05100992) registry (Figure 1). The PROGRESS-BIFURCATION registry collects patient-level baseline characteristics, procedural/angiographic characteristics, treatment strategies, and in-hospital and long-term outcomes in patients undergoing bifurcation PCI. The Research Electronic Data Capture (REDCap) web-based application was used to capture anonymized data.6 The study was approved by the institutional review board of all participating sites.
Definitions
Bifurcation stenoses were defined according to the Bifurcation Academic Research Consortium (ARC) recommendations as a coronary artery narrowing occurring adjacent to and/or involving the origin of an SB with a diameter greater than 2.0 mm.7 The Medina classification was used to assess bifurcation lesions, as outlined by Medina et al.8 Technical success was defined as Thrombolysis in Myocardial Infarction (TIMI)-3 flow and a residual stenosis of less than 30% in both the main vessel (MV) and SB (when SB stenting was attempted) or as TIMI-3 flow and a residual stenosis of less than 30% in the main vessel with TIMI-3 flow and either a residual stenosis of less than or equal to the initial stenosis or a residual stenosis of less than 50% or normal physiology in the SB (when SB stenting was not attempted).7
In-hospital major adverse cardiovascular events (MACE) were defined as the composite of death, myocardial infarction (MI), stroke, urgent repeat revascularization, or major bleeding.7 Major bleeding was defined according to the Bleeding ARC Classification as class 3 or higher.9 Procedural success was defined as technical success without in-hospital MACE. The Fourth Universal Definition of MI (type 4a MI) was used to define MI.10 Follow-up MACE was defined as the composite of death, MI, stroke, repeat revascularization with PCI, or coronary artery bypass graft surgery (CABG).
Statistical analysis
Categorical variables were presented as percentages and compared using Pearson’s chi-square test or Fisher’s exact test, as appropriate. Continuous variables were presented as mean ± SD or median (IQR) and compared using the independent-samples t-test for normally distributed variables and the Mann-Whitney U test for non-parametric variables, as appropriate. The normality of distribution was assessed using the Shapiro-Wilk test and Q-Q plots. The risk of MACE was evaluated with time-to-event analysis using Kaplan-Meier and Cox proportional hazards methods.
Multiple imputation was used to create and analyze 5 multiply imputed datasets. Missing data were imputed under fully conditional specification, using the default settings of the “mice” 3.16.0 package for R (R Foundation for Statistical Computing).11 The percentage of missing data was 2.1%.
Inverse probability of treatment weighting (IPTW) and robust sandwich-type variance estimation approaches were performed to decrease bias and to balance covariate distribution for estimating the average treatment effect.12,13 The following variables were selected as covariates for propensity score adjustment with IPTW to assess the DK crush treatment effect based on the prior research and expert knowledge:5,14 intravascular imaging, LMCA target PCI vessel, thrombus containing lesion, main vessel moderate/severe calcification, acute coronary syndrome, bifurcation angle, and true bifurcation.
The distribution of propensity scores within each treatment group was visually examined with a kernel density plot. Baseline and IPTW adjustment balance between covariates were assessed by absolute standardized mean differences (SMD). SMDs before and after covariate balancing were demonstrated to have a good balance (Figure 2).
The probabilities derived from the initial model were used to compute the stabilized IPTW. The weights were applied for adjustment to a Cox proportional hazard model to assess long-term MACE. After Cox proportional hazards model was performed in each of the imputed datasets, the results were pooled using the “pool ()” function of the “mice” package. All statistical analyses were performed using R Statistical Software, version 4.4.1 with “MatchThem”, “ggplot”, “mice”, “cobalt”, “rms”, and “survival” packages. All tests were 2-tailed, with a P-value of less than 0.05 indicating statistical significance.
Results
Clinical characteristics
During the study period, 232 bifurcation PCIs were performed using DK crush (149 patients, 69%) or culotte (67 patients, 31.0%) (Figure 1). The baseline characteristics of the study population are shown in Table 1. The mean age was 67.1 ± 10.5 years and 74% of the patients were men, with high prevalence of hypertension and dyslipidemia. The baseline characteristics of the DK crush patients were similar to the culotte patients. The most common presentation was stable angina (34.0%) in DK crush patients, and non-ST segment elevation MI in culotte patients (39.4%).
Angiographic and procedural characteristics
The most common proximal main vessel was the left anterior descending artery (LAD) (42.7%), followed by the LMCA (34.5%) and the left circumflex artery (13.4%). DK crush was more likely to be used in the LMCA (42.9% vs 15.5%, P < .001), in aorto-ostial lesions (14.2% vs 4.3%, P = .029), in larger proximal (3.50 [3.50-4.00] vs 3.50 [3.21-3.79] mm, P = .027) and distal main vessels (3.00 [3.00-3.50] vs 3.00 [2.75-3.25] mm, P = .047), and in severely calcified lesions (29.8% vs 5.6%, P < .001) (Table 2).
Intravascular imaging was more commonly performed in DK crush patients (43.0% vs 8.5%, P < .001) and calcification was more commonly detected (28.6% vs. 4.2%, P < .001) in DK crush patients. The most commonly used intravascular imaging modality was intravascular ultrasound (40.5%) (Table 2).
Procedural outcomes
DK crush patients had longer procedure (113 [79-174] vs 70 [51-102] minutes; P < .001) and fluoroscopy times (30 [22-44] vs 24 [16-36] minutes; P = .004) compared with culotte patients, but similar air kerma radiation doses (1.7 [1.0-2.7] vs 1.6 [1.1-2.0] Gray, P = .423) and contrast volumes (190 [140-260] vs 200 [132-230] mL; P = .178). Technical (98.8% vs 97.2%, P = .588), and procedural (96.5% vs 95.1%, P = .698) success and in-hospital MACE (6.1% vs 3.0%, P = .509) were similar in both groups (Table 3).
Long-term outcomes
Follow-up data was available in 177 (82%) cases. During a median follow-up of 43 (IQR 14-69) months, MACE occurred in 34 (28.6%) DK crush patients and in 26 (44.8%) culotte patients (Table 4). In the non-weighted Cox model, DK crush was independently associated with a lower risk of MACE (hazard ratio [HR] 0.31; 95% CI, 0.15-0.65; P = .002). In the IPTW adjusted Cox model, the association remained significant (adjusted HR [aHR] 0.28; 95% CI, 0.13-0.60; P = .001) (Figure 3), driven by higher target vessel revascularization (TVR) (14.3% vs 29.3%, P = .029). In the non-weighted model, age (per 10 years), diabetes, chronic kidney disease, greater than 70-degree bifurcation angle, and LMCA bifurcation PCI were independently associated with MACE. In the IPTW adjusted Cox’s model, the association remained significant for age (per 10 years) (aHR 1.52; 95% CI, 1.1-2.08; P = .009), diabetes mellitus (aHR 1.93; 95% CI, 1.09-3.43; P = .025), greater than 70-degree bifurcation angle (aHR 2.00; 95% CI, 1.00-3.97; P = .045), and LMCA bifurcation PCI (aHR 2.19; 95% CI, 1.05-4.57; P = .037) (Table 5).
Discussion
The major findings of our study are that (1) DK crush was used more frequently than culotte; compared with culotte patients, DK crush patients had (2) similar comorbidity burden, (3) higher procedural complexity, ( 4) longer procedure and fluoroscopy durations, (5) lower TVR, and (6) lower long-term MACE in both non-weighted and IPTW models; and (7) a bifurcation lesion with a greater than 70-degree angle was independently associated with higher risk of long-term MACE.
Current guidelines suggest provisional stenting as a preferred strategy for most bifurcation PCIs.15,16 However, in complex lesions, upfront 2-stent bifurcation techniques are often needed in patients with a large SB (> 2 mm in diameter) and high likelihood of SB occlusion.15-19 The likelihood of SB occlusion depends on the location and morphology of the MV and SB lesions and the bifurcation angulation.20
DK crush and culotte are the most widely used 2-stent techniques, however, the optimal strategy selection is still under debate.5,21,22 As observed in our study, DK crush has been associated with better outcomes than several other techniques in true bifurcation lesions.3,4,23 In the DKCRUSH-III study, at a 36-month follow-up, DK crush had lower MACE than culotte (8.2% vs 23.7%), primarily driven by lower TVR in the left main lesions (5.8% vs 18.8%).5 The incidence of MACE and TLR was higher in our study, likely due to higher prevalence of comorbidities, including older age, diabetes mellitus, heart failure, prior MI, and more complex lesions with higher prevalence of calcification.
In the COBIS (Coronary Bifurcation Stenting) III registry, 454 patients had a similar incidence of the composite of cardiac death, MI, or target lesion revascularization (TLR) with various 2-stent techniques including T-stenting, TAP, culotte, classical crush, DK crush, and V-stenting. However, DK crush and culotte were performed in only 14.3% and 6.8% of the study patients, respectively.24
Consistent with our findings, in a network meta-analysis of 26 randomized controlled studies, DK crush was superior to other 2-stent techniques, including culotte, for the composite of cardiac death, target vessel MI, stent thrombosis, and TLR or TVR (relative risk 0.62; 95% CI, 0.42-0.92).25
DK crush involves more steps than culotte and can be challenging to perform, as suggested by the longer procedure time. However, contrast volume and radiation dose were not significantly higher. Meticulous attention to the various procedural steps can streamline the procedure and minimize delays.
Bifurcation angle has been associated with worse outcomes of complex bifurcation lesions, particularly in cases with extremely narrow or wide angulations.26,27 In the DEFINITION study (Definitions and impact of complex bifurcation lesions on clinical outcomes after percutaneous coronary intervention using drug-eluting stents), a less than 45-degree angle was independently associated with higher 1-year MACE (HR 14.1; 95% CI, 9.2-18.0; P = .004) and was added to the DEFINITION criteria as a minor criterion.26 This criterion was developed to assess the complexity of the bifurcation lesions. In the DEFINITION II trial, an upfront 2-stent strategy (DK crush used in 78%, culotte used in 18%) had a lower risk of target lesion failure than a provisional strategy in the complex bifurcation lesions based on the DEFINITION criteria (HR 0.52; 95% CI, 0.30-0.90; P = .019).20 A possible explanation for the association between a narrow angle with increased MACE is the potential risk of side branch occlusion, which can originate from dissection, plaque and carina shift, or, in rare cases, perforation.20,28
In the DKCRUSH-III study, a bifurcation angle of greater than 70 degrees was linked to higher MACE risk, and the DK crush technique outperformed the culotte technique for these cases (odds ratio 0.2; 95% CI, 0.1-0.5).5 One possible explanation is that having a wider angle can increase the likelihood of developing neoatherosclerosis.29 In a study assessing the effect of bifurcation angle on blood flow with computational dynamics, as the bifurcation angle widened, low wall shear stress and gradients were detected, which have been associated with higher risk of developing atherosclerosis at bifurcation.30 Another explanation may be the potential risk of difficulty recrossing the crushed stent. Simsek et al reported that rewiring difficulty was the second most common challenge for the DK crush technique in a multicenter bifurcation PCI registry.14 Putting a secondary bend to the guidewire, using a polymer-jacketed guidewire, or using an angulated or dual lumen microcatheter can facilitate SB rewiring.31 The third potential explanation is the potential risk of stent fracture, especially in extreme angles, due to excessive mechanical stress on the stent from extrinsic compression of the vessel.32
Limitations
This study has limitations. The PROGRESS-Bifurcation is an observational bifurcation PCI registry with all inherent limitations. There was no independent adjudication of clinical events or core laboratory analysis of the study angiograms. The included procedures were performed at centers with experienced bifurcation PCI operators, which may limit the generalizability of our results to centers with less experience.
Conclusions
As compared with bifurcation PCI with culotte, DK crush is associated with similar periprocedural outcomes but lower TVR and MACE during long-term follow-up. Additionally, a bifurcation angle of greater than 70 degrees was independently associated with higher risk of long-term MACE.
Affiliations and Disclosures
Deniz Mutlu, MD1; Dimitrios Strepkos, MD1; Pedro E. Carvalho, MD1; Michaella Alexandrou, MD1; Ozgur Selim Ser, MD1; Barkin Kultursay, MD2; Ali Karagoz, MD2; Oleg Krestyaninov, MD3; Dmitrii Khelimskii, MD3; Mahmut Uluganyan, MD4; Korhan Soylu, MD5; Ufuk Yildirim, MD5; Seda Tanyeri Uzel, MD2; Olga Mastrodemos, BA1; Bavana V. Rangan, BDS, MPH1; Sandeep Jalli, MD1; Konstantinos Voudris, MD1; Yader Sandoval, MD1; M. Nicholas Burke, MD1; Emmanouil S. Brilakis, MD, PhD1
From the 1Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota; 2Kartal Kosuyolu Postgraduate Training and Research Hospital, Istanbul, Turkey; 3Meshalkin National Research Institute, Novosibirsk, Russian Federation; 4Bezmialem Vakif University, Istanbul, Turkey; 5Ondokuz Mayis University, Samsun, Turkey.
Acknowledgments
The authors are grateful for the philanthropic support of generous anonymous donors (2), and the philanthropic support of Drs Mary Ann and Donald A. Sens; Mrs Diane and Dr Cline Hickok; Mrs Wilma and Mr Dale Johnson; the Mrs Charlotte and Mr Jerry Golinvaux Family Fund; the Roehl Family Foundation; the Joseph Durda Foundation; Ms Marilyn and Mr William Ryerse; and Mr Greg and Mrs Rhoda Olsen. The generous gifts of these donors to the Minneapolis Heart Institute Foundation’s Science Center for Coronary Artery Disease (CCAD) helped support this research project.
Disclosures: Dr Sandoval is a consultant for and serves on the advisory board of Abbott and GE Healthcare; is a consultant for, serves on the advisory board of, and is a speaker for Roche Diagnostics and Philips; serves on the advisory board of Zoll; is a consultant for CathWorks; is a speaker for HeartFlow; ais a speaker for and receives research grants from Cleerly; is an associate editor for JACC Advances; and holds patent 20210401347. Dr Burke receives consulting fees and has received speaker honoraria from Abbott Vascular and Boston Scientific. Dr. Brilakis receives consulting/speaker honoraria from Abbott Vascular, the American Heart Association (associate editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medicure, Medtronic, Siemens, and Teleflex; receives research support from Boston Scientific and GE Healthcare; is the owner of Hippocrates LLC; and is a shareholder in MHI Ventures, Cleerly Health, and Stallion Medical. The remaining authors report no financial relationships or conflicts of interest regarding the content herein.
Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis, MN 55407. Email: esbrilakis@gmail.com; X: @dnzmtlu, @CCAD_MHIF, @yadersandoval, @esbrilakis
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