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Volume 11 – Number 3 – October 2025

Double-kissing crush versus provisional stenting in patients with true coronary artery bifurcation lesions: a pooled individual patient-level analysis of randomised trials (DKCRUSH X trial)

AsiaIntervention 2025;11:178-188 | 10.4244/AIJ-D-25-00021

Shao-Liang Chen1, MD; Jing Kan1, MD; Teguh Santoso2, MD; Tak W. Kwan3, MD; Imad Sheiban4, MD; Tanveer S. Rab5, MD; Muhammad Munawar6, MD; Wei-Hsian Yin7, MD; Fei Ye1, MD; Lianglong Chen8, MD; Junjie Zhang1, MD; Kwan Seung Lee9, MD; on behalf of the provisional stenting versus systematic two-stent (DKCRUSH X) collaborator group

1. Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China; 2. Department of Cardiology, Medistra Hospital, Jakarta, Indonesia and University of Indonesia Medical School, Jakarta, Indonesia; 3. Department of Cardiology, Lenox Hill Hospital, New York, NY, USA; 4. Department of Cardiology, Pederzoli Hospital, Peschiera del Garda, Italy; 5. Division of Cardiology, Emory University Hospital, Atlanta, GA, USA; 6. Division of Cardiology, Binawaluya Cardiac Center, Jakarta, Indonesia; 7. Division of Cardiology, Cheng Hsin General Hospital, Taipei, Republic of China; 8. Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China; 9. Department of Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA

Abstract

Background: Provisional stenting is the standard treatment for patients with coronary artery bifurcation lesions.

Aims: This pooled individual patient data (IPD) analysis aims to evaluate the long-term (six-year) outcomes of provisional stenting versus upfront two-stent techniques in patients with true coronary bifurcation lesions treated with drug-eluting stents.

Methods: A systematic review and IPD analysis of randomised trials with centrally adjudicated endpoints was conducted to assess the efficacy and safety of provisional stenting versus upfront two-stent approaches in patients with true coronary bifurcation lesions undergoing percutaneous coronary intervention with drug-eluting stents. All patients were prospectively followed, with their intervention having been completed at least six years earlier. The primary endpoint, re-evaluated by an independent clinical event committee, was target lesion failure (TLF) – a composite of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularisation − assessed at the final follow-up on 8 November 2024.

Results: A total of 6,225 citations were screened, and four randomised trials met the inclusion criteria. Among 1,573 patients in the intention-to-treat population, TLF at six years occurred in 144 patients (Kaplan-Meier estimate 18.2%) in the upfront two-stent group and 193 (Kaplan-Meier estimate 24.7%) in the provisional stenting group (hazard ratio [HR] 0.71, 95% confidence interval [CI]: 0.57-0.89; p=0.0022, τ²=0.00, I2=0%). These results were consistent across both unadjusted and per-protocol analyses. In patients with complex coronary bifurcation lesions, TLF occurred in 88 patients (Kaplan-Meier estimate 19.6%) in the two-stent group and 115 (Kaplan-Meier estimate 27.6%) in the provisional stenting group (HR 0.68, 95% CI: 0.52-0.90; p=0.0066).

Conclusions: This IPD analysis provides robust long-term evidence that upfront two-stent techniques, particularly double-kissing crush stenting, significantly reduce TLF over a six-year follow-up period compared with provisional stenting, especially in patients with complex bifurcations.

Abbreviations

  • DAPT: dual antiplatelet therapy
  • DK: crush double-kissing crush
  • IPD: individual patient data
  • TLF: target lesion failure

The prevalence of coronary bifurcation lesions varies between 15% and 40% of all percutaneous coronary interventions (PCI), depending on the definitions applied12. Stenting coronary bifurcation lesions presents a technical challenge compared to non-bifurcations and is associated with worse clinical outcomes, including higher rates of revascularisation and stent thrombosis, particularly when systematic two-stent approaches are used1234. Consequently, the 2018 European Society of Cardiology (ESC) guidelines on myocardial revascularisation recommend provisional stenting (main vessel stenting with provisional side branch stenting, if necessary) for the majority of bifurcation lesions5. Despite this, controversy persists regarding the clinical outcomes of different stenting approaches. Due to the small sample sizes, varied follow-up duration, and inconsistent endpoint definitions in randomised clinical trials, multiple meta-analyses34678910111213 have been conducted to compare provisional stenting with upfront two-stent approaches. However, these meta-analyses − limited by study-level data, significant heterogeneity3467891011, inclusion of different types (false or true bifurcations) and locations (distal left main and non-left main) of bifurcation lesions, and a paucity of long-term (greater than five years) clinical outcomes − have yielded inconclusive results. Moreover, the lack of stratification based on lesion complexity34789101112 has hindered the understanding of how lesion complexity influences the comparative efficacy of stenting techniques. Although study-level meta-analyses have suggested that double-kissing crush (DK crush) stenting is associated with fewer adverse clinical events, its long-term (six-year) benefits remain unclear. This individual patient data (IPD) analysis based on randomised clinical trials with reduced heterogeneity aims to assess the long-term advantages of systematic two-stent techniques (particularly DK crush) over provisional stenting for true coronary bifurcation lesions.

Methods

This systematic review and IPD-level analysis of randomised trials with centrally adjudicated endpoints were conducted to evaluate the comparative effectiveness and safety of systematic two-stent techniques versus provisional stenting in patients with true coronary bifurcation lesions treated with a drug-eluting stent. All patients were followed prospectively and had interventions occurring at least six years earlier. Trials comparing different two-stent techniques or involving intravascular imagining guidance versus angiography guidance were excluded. No additional restrictions were applied for trial selection. This IPD analysis follows the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines (www.prisma-statement.org), and the study protocol was prospectively registered with PROSPERO (DKCRUSH X Study, www.crd.york.ac.uk/prospero: CRD42024580040).

Search strategy

Two investigators (J. Kan, K.S. Lee) independently determined trial eligibility, with a third investigator (S.-L. Chen) resolving any disagreement. We searched Ovid Medline, PubMed, and Embase on 28 August 2024, to identify randomised controlled trials. Reference lists of identified articles were manually reviewed to locate additional studies. No language restrictions were applied. Studies were included based on the following criteria: (1) randomised controlled clinical trial comparing systematic two-stent versus provisional stenting; (2) true bifurcation lesions (Medina 1,1,1/1,0,1/0,1,1); (3) side branch lesion length ≥10 mm; (4) ≥6 years follow-up; and (5) use of drug-eluting stents. Eligible trials were predominantly identified from the DKCRUSH/DEFINITION consortium to ensure technical consistency in two-stent approaches. Studies outside this consortium were excluded due to heterogeneity in procedural techniques or endpoint definitions.

Study outcomes

The primary endpoint was target lesion failure (TLF), defined as a composite of cardiac death, target vessel myocardial infarction (MI; both periprocedural and spontaneous), or clinically driven target lesion revascularisation at six years. Only centrally adjudicated events by an independent clinical events committee were included in the analysis. Secondary endpoints included TLF without periprocedural MI, all-cause death, cardiac death, periprocedural and spontaneous MI, target lesion and target vessel revascularisation, and stent thrombosis (definite and probable). For patients lost to follow-up, the last known follow-up was used as the final result.

Data extraction and quality assessment

The principal investigators of eligible trials provided anonymised IPD in an electronic dataset for analysis. In case of missing data or inconsistencies, the principal investigators of the trials were contacted and asked to provide source documents, which were reviewed by a newly established clinical event committee. Two investigators (J. Kan, K.S. Lee) independently assessed the risk of bias using the revised Cochrane risk-of-bias tool (RoB 2). Disagreements were resolved through discussion or arbitration by a third author (S.-L. Chen). Only full-text, peer-reviewed studies (with a mean lesion length in the side branch at least of 10 mm) were included, and reference lists of retrieved articles were manually screened for additional studies not captured in the initial search. Each trial was approved by the local medical ethics committee, and all patients provided written informed consent.

Statistical analysis

A one-step approach was used to model patient-level data from all included trials simultaneously, employing a mixed-effect Cox regression model with baseline hazards stratified by trial and a random slope to account for variation between trials in treatment effects. Treatment effects were expressed as a hazard ratio (HR) and 95% confidence interval (CI). The heterogeneity of the treatment effect between trials was quantified using the variance of the random slope (τ²). Sensitivity analyses employed a two-step approach using the Paule-Mandel estimator to combine trial-level estimates, with heterogeneity measured by I2. We first assessed the difference in the primary endpoint between the systematic two-stent approach and provisional stenting in the intention-to-treat population, adjusted by sex, initial presentations at admission (chronic coronary syndrome, unstable angina, and myocardial infarction), diabetes, and participating sites (China, other Asian countries, and Europe/America). The intention-to-treat population included all randomised patients according to their random allocation. The per-protocol population excluded patients who were ineligible due to protocol violations or who did not receive the assigned treatment strategy. Lesions were also stratified by lesion complexity using the DEFINITION criteria14. Primary and secondary endpoints were compared between provisional stenting and upfront two-stent groups for patients with simple or complex bifurcations. Prespecified subgroup analyses included age (>65 vs ≤65 years), sex, diabetes status, renal dysfunction (defined as estimated glomerular filtration rate <60 vs ≥60 mL/min/1.73 m²), heart failure, initial presentations at admission (chronic coronary syndrome vs unstable angina vs MI), hypertension, hyperlipidaemia, single- versus multivessel disease, complete versus incomplete revascularisation, and use of intravascular imaging guidance. The analyses were performed using R, version 4.3.1 (R Foundation for Statistical Computing). The Review Manager (RevMan) version 5.4 (The Cochrane Collaboration) was used to calculate the pooled effect sizes. Significant heterogeneity was defined as I2 >50% or a p-value for heterogeneity <0.05. Publication bias was assessed using funnel plots. For all analyses, a two-sided p-value and 95% confidence interval were reported.

Results

A total of 6,225 citations were screened. Of those, 610 records were considered potentially eligible during the screening of titles and abstracts, and four trials were deemed eligible and provided IPD (Figure 1): the DKCRUSH-II15, DKCRUSH-IV16, DKCRUSH-V17, and DEFINITION II18 trials. The characteristics, main inclusion or exclusion criteria, and definition of primary endpoints of the trials were the same across the four trials. The risk of bias assessment revealed no major concerns. All four trials were sponsored by non-profit academic organisations. The final patient enrolment in the DEFINITION II trial occurred on 8 November 2018, establishing the scheduled clinical follow-up for this IPD analysis to be completed on 8 November 2024. In total, 1,573 patients were included in the intention-to-treat analysis (Central illustration), with 791 (50.3%) patients assigned to the systematic two-stent approach and 782 (49.7%) to the provisional stenting group. Baseline clinical characteristics were balanced between the groups (Table 1). The median age was 65.0 years, and 349 (22.2%) participants were female. A total of 457 (29.1%) patients had a history of diabetes, and 246 (15.6%) had renal dysfunction. Additionally, 228 (14.5%) had a history of heart failure, including 81 (5.1%) with a left ventricular ejection fraction of less than 40%. A history of MI, PCI, or coronary artery bypass graft surgery was present in 248 (15.8%), 282 (17.9%), and 7 (0.4%) patients, respectively. At presentation, 345 (10.9%) patients had chronic coronary syndrome, 943 (59.9%) had unstable angina, 122 (7.8%) had ST-segment elevation MI (STEMI), and 162 (10.3%) had non-STEMI. A total of 736 (46.8%) patients had distal left main bifurcation lesions, and 1,085 (69.0%) had multivessel disease. Thrombus-containing lesions were identified in 112 (7.2%) patients, and Medina 1,1,1 bifurcation lesions were present in 1,199 (76.2%) patients. A total of 956 (60.8%) patients had a SYNTAX score >22. A total of 866 (55.1%) lesions were classified as complex according to the DEFINITION criteria14. The transradial approach was used in 1,118 (71.1%) patients, and an intravascular imaging-guided procedure was performed in 705 (44.8%) patients, with intravascular ultrasound being the most common guidance (37.8%). Predilation for the side branch was performed in 314 (40.2%) patients in the provisional stenting group, compared to 53.8% in the two-stent group. The median stent length was 38 mm in the main vessel and 20 mm in the side branch, which corresponded to the mean lesion lengths (31.9 mm and 17.1 mm, respectively). Two-stent techniques were ultimately used in the provisional stenting group in 258 (33.0%) patients. In the two-stent group, provisional stenting was used in 35 (4.4%) patients, while the remaining 756 (95.6%) received two stents, with DK crush used in 652 (86.2%). Final kissing balloon inflation was performed in 94.6% (two-stent group) versus 65.7% (provisional stenting group). Use of the proximal optimisation technique was significantly higher in the two-stent group (43.2%) than in the provisional stenting group (26.9%; p<0.001). Thrombolysis in Myocardial Infarction grade 3 flow in both the main vessel and side branch was achieved in 1,533 (97.5%) patients post-procedure. The median contrast volume and procedural time were significantly greater in the two-stent group (200 [interquartile range [IQR] 150, 260] mL and 66 [IQR 42, 90] min) than in the provisional stenting group (180 [IQR 120, 240] mL; p<0.001; and 56 [IQR 34, 81] min; p<0.001). Dual antiplatelet therapy (DAPT) was prescribed to 1,542 (98.0%) patients at discharge, 1,394 (88.6%) at one year, 713 (45.3%) at three years, and 480 (30.5%) at six years. At a median of 365 days, 920 (58.5%) patients underwent angiographic follow-up, and restenosis in the side branch was found to have occurred in 107 (24.0%) patients in the provisional group and 70 (15.2%) in the two-stent group (p=0.0005). At six years, TLF had occurred in 144 (18.2%) patients in the two-stent group, compared with 193 (24.7%) in the provisional stenting group (HR 0.71, 95% CI: 0.57-0.89; τ²=0.00; I²=0%; p=0.0022) (Table 2, Figure 2). Subgroup analyses showed no significant interactions (Figure 3). Target lesion revascularisation and target vessel myocardial infarction rates were lower in the two-stent group (88 [11.1%] and 30 [3.8%], respectively) compared to the provisional stenting group (118 [15.1%], HR 0.73, 95% CI: 0.55-0.96; p=0.0258, and 67 [8.6%], HR 0.44, 95% CI: 0.29-0.68; p=0.0002, respectively) (Table 2). TLF excluding periprocedural myocardial infarction was 17.3% in the two-stent group and 21.9% in the provisional stenting group (HR 0.78, 95% CI: 0.62-0.97; p=0.0275). These results were consistent with unadjusted analyses. A total of 63 (4.0%) participants (35 in the two-stent group and 28 in the provisional stenting group) were excluded from the per-protocol analysis due to non-compliance with the allocated treatment strategy. In the per-protocol analysis, the composite of cardiac death, target vessel myocardial infarction, and clinically driven target lesion revascularisation were lower in the systematic two-stent group (n=136, 18.0%) than in the provisional stenting group (n=189, 25.1%; p=0.0012). Cardiac death and stent thrombosis rates (Table 2) were similar between the two groups across all analyses. According to the DEFINITION criteria, patients with complex bifurcation lesions exhibited higher rates of hyperlipidaemia, diabetes, smoking, stroke, and MI at initial presentation. The rate of target lesion failure was similar between the provisional stenting and two-stent groups in patients with simple bifurcations. However, the two-stent approach resulted in a lower incidence of target vessel myocardial infarction (2.3%) compared to 6.0% in the provisional stenting group (p=0.0241) among patients with simple bifurcations, without significant differences in target lesion revascularisation. Among patients with complex coronary bifurcation lesions, TLF occurred in 88 (19.6%) patients in the two-stent group versus 115 (27.6%) in the provisional stenting group (HR 0.68, 95% CI: 0.52-0.90; p=0.0066). This reduction was primarily driven by lower rates of target lesion revascularisation (10.5% [n=47] in the two-stent group vs 16.1% [n=67] in the provisional stenting group, HR 0.64, 95% CI: 0.44-0.93; p=0.0199) and target vessel myocardial infarction (4.9% [n=22] vs 10.8% [n=45], HR 0.46, 95% CI: 0.27-0.76; p=0.0027). Among patients with simple coronary bifurcation lesions, periprocedural MI occurred in 2 (0.6%) patients in the two-stent group versus 5 (1.4%) in the provisional stenting group (HR 0.43, 95% CI: 0.08-2.20; p=0.308), while acute side branch occlusion was comparable between the two-stent and provisional stenting groups (1.2% vs 1.6%; p=0.892).

Figure 1. DKCRUSH X study flowchart. Of a total of 1,580 screened patients, 1,573 were included in the intention-to-treat analysis. DKCRUSH-II: a randomised clinical study comparing DK crush with provisional stenting for treatment of coronary bifurcation lesions: results from the DKCRUSH-II (Double Kissing Crush versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions) trial; DKCRUSH-IV: haemodynamic changes of fractional flow reserve after double kissing crush and provisional stenting technique for true bifurcation lesions; DKCRUSH-V: Double Kissing Crush Versus Provisional Stenting for Left Main Distal Bifurcation Lesions: DKCRUSH-V Randomised Trial; DEFINITION II: multicentre, randomised comparison of two-stent and provisional stenting techniques in patients with complex coronary bifurcation lesions: the DEFINITION II trial. DK crush: double-kissing crush; FFR: fractional flow reserve

Central illustration. Long-term outcomes of DK crush vs provisional stenting for bifurcations. Of 2,630 patients with true coronary artery bifurcation lesions, 1,573 patients were studied. At six-year follow-up, target lesion failure occurred in 24.7% of patients in the provisional group and 18.2% in the upfront two-stent group. CI: confidence interval; HR: hazard ratio; ITT: intention-to-treat; PS: provisional stenting; TLF: target lesion failure

Table 1. Baseline clinical characteristics.

Overall population (n=1,573) Two-stent group (n=791) Provisional stenting group (n=782) p-value
Included studies
DKCRUSH-II1526 370 (23.5) 185 (23.4) 185 (23.7)
DKCRUSH-IV16 68 (4.3) 38 (4.8) 30 (3.8)
DKCRUSH-V17 482 (30.6) 240 (30.3) 242 (30.9)
DEFINITION II18 653 (41.5) 328 (41.5) 325 (41.6)
Geographical region
China 924 (58.7) 469 (59.3) 455 (58.2) 0.655
Other Asian countries 284 (18.0) 134 (16.9) 150 (19.2) 0.248
Europe and America 365 (23.3) 188 (23.8) 177 (22.6) 0.595
Age, years 65 (57, 72) 65 (57, 72) 65 (57, 72) 0.985
Female sex 349 (22.2) 168 (21.2) 181 (23.1) 0.363
Height, cm 168 (162, 172) 168 (162, 172) 168 (162, 172) 0.394
Weight, kg 70 (62, 75) 70 (62, 75) 70 (62, 75) 0.497
Body mass index, kg/m2 24.57 (22.84, 26.67) 24.57 (22.86, 26.67) 24.57 (22.84, 26.67) 0.647
Hypertension 1,070 (68.0) 560 (70.8) 510 (65.2) 0.018
Hyperlipidaemia 783 (49.8) 380 (48.0) 403 (51.5) 0.166
Renal dysfunction* 246 (15.6) 123 (15.5) 123 (15.7) 0.922
Diabetes 457 (29.1) 225 (28.4) 232 (29.7) 0.593
On insulin treatment 128 (28.0) 63 (28.0) 65 (28.0) 0.997
Current smoker† 431 (27.4) 232 (29.3) 199 (25.4) 0.084
Previous PCI 282 (17.9) 145 (18.3) 137 (17.5) 0.675
Previous CABG 7 (0.4) 2 (0.3) 5 (0.6) 0.285
Previous MI 248 (15.8) 128 (16.2) 120 (15.3) 0.649
GI bleeding 30 (1.9) 18 (2.3) 12 (1.5) 0.283
Stroke 108 (6.9) 44 (5.6) 64 (8.2) 0.04
Peripheral artery disease 115 (7.3) 57 (7.2) 58 (7.4) 0.872
Heart failure 228 (14.5) 110 (13.9) 118 (15.1) 0.505
LVEF, %  62.0 (55.0, 66.0) (n=1,244) 62.0 (55.0, 65.5) (n=619) 62.0 (56.0, 66.0) (n=625) 0.208
 LVEF <40% 81 (5.1) 42 (5.3) 39 (5.0) 0.772
Red blood cells, 109/L 4.43 (4.06, 4.78) 4.41 (4.04, 4.75) 4.45 (4.08, 4.82) 0.147
White blood cells, 109/L 6.66 (5.50, 8.00) 6.60 (5.53, 8.00) 6.70 (5.47, 8.07) 0.826
Total cholesterol, mg/dL 159 (131, 189) 159 (128, 189) 159 (131, 189) 0.52
Low-density lipid cholesterol, mg/dL 93 (72, 120) 92 (70, 120) 94 (73, 120) 0.24
Fasting blood glucose, mg/dL 97 (88, 121) 95 (87, 115) 99 (88, 124) 0.126
Serum creatinine, mg/dL 0.90 (0.76, 1.07) 0.91 (0.77, 1.07) 0.90 (0.76, 1.07) 0.347
Presentation on admission
Silent ischaemia 73 (4.6) 33 (4.2) 40 (5.1) 0.374
Stable angina 272 (17.3) 145 (18.3) 127 (16.2) 0.273
Unstable angina 943 (59.9) 466 (58.9) 477 (61.0) 0.399
STEMI 122 (7.8) 67 (8.5) 55 (7.0) 0.287
NSTEMI 162 (10.3) 79 (10.0) 83 (10.6) 0.683
Medications on admission
Statin 1,146 (72.9) 571 (72.2) 575 (73.5) 0.643
ß-blocker 293 (18.6) 137 (17.3) 156 (19.9) 0.401
ACEi/ARB 337 (21.4) 177 (22.4) 160 (20.5) 0.058
Calcium channel blocker 233 (14.8) 106 (13.4) 127 (16.2) 0.242
Data are n (%) or median (interquartile range). *Defined as eGFR <60 mL/min/1.73 m2. †Defined as those who had smoked ≥100 lifetime cigarettes and were still smoking at the time of enrolment; other tobacco products were not included. ACEi: angiotensin-converting enzyme inhibitor; ARB: angiotensin II receptor blocker; CABG: coronary artery bypass graft; eGFR: estimated glomerular filtration rate; GI: gastrointestinal; LVEF: left ventricular ejection fraction; MI: myocardial infarction; NSTEMI: non-ST-segment elevation myocardial infarction; PCI: percutaneous coronary intervention; STEMI: ST-segment elevation myocardial infarction

Table 2. Clinical outcomes in the intention-to-treat population.

Two-stent group (n=791) Provisional stenting group (n=782) Hazard ratio* (95% CI) p-value
Primary outcome
Target lesion failure, a composite of cardiac death, target vessel myocardial infarction, and clinically driven target lesion revascularisation 144 (18.2) 193 (24.7) 0.71 (0.57 to 0.89) 0.0022
Secondary outcomes
Target lesion failure without periprocedural myocardial infarction 137 (17.3) 171 (21.9) 0.78 (0.62 to 0.97) 0.0275
Cardiac death 53 (6.7) 55 (7.0) 0.96 (0.66 to 1.39) 0.815
All-cause death 101 (12.8) 107 (13.7) 0.93 (0.71 to 1.22) 0.605
Target vessel myocardial infarction 30 (3.8) 67 (8.6) 0.44 (0.29 to 0.68) 0.0002
Periprocedural myocardial infarction 10 (1.3) 27 (3.5) –2.2%
(–3.8% to –0.7%)
0.0042
Spontaneous myocardial infarction 20 (2.5) 40 (5.1) 0.49 (0.28 to 0.83) 0.0086
Clinically driven target lesion revascularisation 88 (11.1) 118 (15.1) 0.73 (0.55 to 0.96) 0.0258
Clinically driven target vessel revascularisation 93 (11.8) 123 (15.7) 0.74 (0.57 to 0.97) 0.0286
Stent thrombosis 36 (4.6) 45 (5.8) 0.79 (0.51 to 1.22) 0.282
Definite stent thrombosis 16 (2.0) 14 (1.8) 1.13 (0.55 to 2.31) 0.742
Probable stent thrombosis 20 (2.5) 31 (4.0) 0.63 (0.36 to 1.11) 0.111
Data are n (%). *Adjusted by sex, initial presentations at admission (chronic coronary syndrome, unstable angina, and myocardial infarction), diabetes, and participating sites (China, other Asian countries, and Europe/America). CI: confidence interval

Figure 2. Target lesion failure. A) The rate of target lesion failure at six years after a stenting procedure was 18.2% in the upfront two-stent group and 24.7% in the provisional stenting group (p=0.0022). B) Target lesion failure stratified by trial; the heterogeneity of trials is shown (Tau2=0.00; chi2=0.49, df=3 [p=0.92]; I2=0%; test for overall effect: Z=2.86 [p=0.004]). CI: confidence interval; HR: hazard ratio

Figure 3. Subgroup analysis on the intention-to-treat population. In the 10 subgroup analyses, no interaction was detected. CI: confidence interval

Discussion

This IPD analysis comprehensively assessed the evidence from randomised clinical trials comparing provisional stenting and systematic two-stent techniques, particularly the DK crush approach, in patients with true coronary artery bifurcation lesions treated with drug-eluting stents. Our findings indicate a significant superiority of the systematic two-stent approach over provisional stenting in reducing the composite endpoint of TLF over a six-year follow-up period. Specifically, two-stent techniques demonstrated considerable reductions in both target vessel myocardial infarction and target lesion revascularisation. Notably, a 28.9% reduction in the risk of six-year TLF was observed in patients with complex bifurcation lesions undergoing two-stent intervention, while no significant benefit was noted for those with simple lesions. Coronary artery bifurcation lesions present a unique challenging lesion subset1234, influenced by various anatomical factors that impact stenting strategies and clinical outcomes514. Existing randomised clinical trials have compared the efficacy of provisional stenting versus systematic two-stent techniques15171819202122, or they have compared different two-stent techniques232425. Yet, discrepancies in study design, lesion complexity, disease burden, amount of myocardium at risk, patient population, operator experience, and technical approaches have hindered the extrapolation of results across trials. To this end, numerous meta-analyses34678910111213 have attempted to address this heterogeneity; however, their reliance on study-level data and varied methodologies has yielded inconclusive results. For instance, the degree of heterogeneity (I2) in prior clinical trials ranged widely (from 0% to 86%)34678910111213; patients with distal left main bifurcation lesions were the only participants in the DKCRUSH-III23, DKCRUSH-V17, and EBC MAIN trials22, but they were excluded in other trials; periprocedural MI was not reported in some trials. Such differences indicate significant variability in treatment effects. The importance of conducting an IPD analysis is underscored by these limitations, particularly as we established an independent clinical event committee to ensure precise adjudication of clinical events, especially regarding periprocedural MI. Prior studies have not consistently demonstrated the superiority of two-stent techniques over the provisional approach, and the latter is often favoured because of concerns regarding prolonged procedure time, greater metal burden, increased contrast use, and heightened radiation exposure202125. Currently, the provisional approach, encapsulated by the philosophy of “keep it simple and safe”, remains the standard approach for most simple bifurcated lesions15. However, our analysis revealed a sustained reduction in TLF over six years for patients in the upfront two-stent group, predominantly due to reductions in target vessel myocardial infarction and target lesion revascularisation. There were no significant differences in cardiac or all-cause mortality between the two groups. Provisional stenting is a stepwise strategy where 33% of cases required bailout two-stenting, reflecting real-world adaptability but also indicating that lesion complexity may dictate strategy selection. This dynamic aspect was inherent in the included trials. The debate regarding different treatment effects among various two-stent approaches has persisted since the era of bare metal stents134111213. Most previous study-level meta-analyses indicating a reduction in clinical events associated with two-stent techniques111213 were primarily driven by trials incorporating the DK crush technique. This technique has been linked to lower rates of restenosis in the side branch due to the introduction of a first kissing balloon inflation, which mitigates complications such as carina and/or plaque shifting1517 and side branch recoiling1415171823, which are commonly associated with provisional stenting. This rationale informed our criteria for including trials where a minimum of 50% of patients underwent DK crush stenting. Importantly, the risk reduction in the primary endpoint associated with the two-stent approach was consistent throughout the six-year follow-up, aligning with the five-year results of the DKCRUSH-II trial26 and the three-year outcomes of the DEFINITION II27 trial. In cases of significant side branch disease (e.g., >50% diameter stenosis or fractional flow reserve ≤0.80) extending over 5 mm, an upfront two-stent strategy is warranted128. However, the lack of universally accepted criteria for defining the complexity of coronary bifurcation lesions complicates clinical decision-making. The DEFINITION criteria14 provide a novel framework for differentiating simple from complex bifurcations, with key components such as a side branch lesion length ≥10 mm. Study-level meta-analyses61329 have corroborated these findings, indicating that longer side branch lesions correlate with greater benefits from two-stent strategies. Our IPD analysis further substantiates that the reduction in TLF associated with two-stent approaches is significant only in complex bifurcations, primarily driven by substantial decreases in target vessel myocardial infarction and target lesion revascularisation. Interestingly, we also observed a 61.7% reduction in target vessel myocardial infarction risk for patients with simple bifurcation lesions undergoing two-stent approaches, a finding not previously reported, though its clinical relevance warrants further investigation in larger cohorts.

Limitations

This IPD analysis has limitations. First, the majority of investigators involved in the four DKCRUSH trials were experienced in both provisional and DK crush stenting techniques1718, potentially limiting the generalisability of our findings to operators with less experience in DK crush stenting. Second, the mean lesion length ≥10 mm in the side branch was a key inclusion criterion to ensure that more complex bifurcation lesions were represented in this IPD analysis consisting of four trials in which DK crush was used in over 50% of patients. Consequently, the higher event rates associated with the other two-stent techniques may have been diluted by the inclusion of DK crush stenting. Future clinical trials comparing DK crush with other two-stent strategies for complex bifurcation lesions are therefore warranted. Third, routine repeat angiography was not performed at six years; however, the clinically driven nature of revascularisation mitigates potential biases associated with visual assessments. Fourth, intravascular imaging guidance was utilised in less than 50% of patients, yet this was consistent across both groups, allowing us to exclude its influence on treatment outcomes. While optical coherence tomography-guided PCI was associated with fewer major adverse cardiac events for coronary bifurcation lesions – most of which were simple, as indicated by a side branch lesion length of 8.9±6.1 mm30 – future randomised trials comparing angiography-guided versus intravascular imaging-guided bifurcation stenting are warranted31. Fifth, the low rate of DAPT at six years in both groups may have impacted stent thrombosis rates, although current guidelines do not advocate for prolonged DAPT after bifurcation stenting32. Sixth, we did not differentiate between DK crush and other two-stent techniques within the upfront two-stent group, as DK crush was employed in the majority of cases. Previous trials have indicated that DK crush yields lower clinical event rates compared to classical crush33 or culotte stenting23 for distal left main bifurcation lesions. Seventh, while we did not compare the outcomes of one-stent versus two-stent strategies in the provisional group, the transition (36.2%) from one to two stents often reflects lesion complexity, necessitating a larger sample size for direct comparisons. Eighth, trials like EBC MAIN and EBC TWO (ClinicalTrials.gov: NCT01560455) were excluded as they did not meet the inclusion criteria (e.g., lack of long-term follow-up or mixed lesion types). This may limit generalisability to all true bifurcations. Ninth, bleeding events were not systematically adjudicated across trials, precluding safety analysis of prolonged DAPT. Finally, the clinical significance of periprocedural MI remains underexplored. However, the lower rate of TLF observed in the two-stent group, even in the absence of periprocedural MI, compared to the provisional stenting group, underscores the net benefits of the upfront two-stent approach, particularly DK crush stenting. This finding suggests that the advantages of the two-stent strategy extend beyond procedural success and highlight its potential for long-term clinical benefits.

Conclusions

In complex true bifurcations defined by the DEFINITION criteria, upfront DK crush significantly reduces TLF compared to provisional stenting.

Impact on daily practice

This individual patient data analysis highlights a significant reduction in target lesion failure associated with the upfront two-stent strategy compared to provisional stenting. The clinical advantages of double-kissing crush stenting are particularly pronounced in true bifurcation lesions with a long lesion in the side branch (>10 mm).

Guest Editor

This paper was guest edited by Davide Capodanno, MD, PhD; A.O.U. Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy.

Acknowledgements

We appreciate all staff participating in data collection and remote monitoring. We thank Professor Feng Chen for leading the statistical team that performed the statistical analysis. S.-L. Chen made substantial contributions to the initial conception and design of the whole study, data management, statistical expertise, and wrote the first draft. J. Kan, J. Zhang, T. Santoso, T.W. Kwan, I. Sheiban, T.S. Rab, M. Munawar, W.-H. Yin, Y. Ye, L. Chen, and K.S. Lee provided comments and suggestions in critical revision of the article. All authors approved the final version of the article. All authors had unrestricted access to the data and vouch for the accuracy and completeness of the data and for the fidelity of the trial to the protocol and had final responsibility for the decision to submit for publication.

Funding

This pooled IPD analysis was funded by The National Key Research and Development Plan (2022YFC2503503), the Chinese Society of Cardiology (grant number CSCF 2019-A0003), and the Jiangsu Provincial & Nanjing Municipal Clinical Trial Project (grant number BE 2019615).

Conflict of interest statement

S.-L. Chen reports speaker fees from MicroPort, Boston Scientific, Medtronic, Sanofi, Amgen, Pulnovo Medical, and BrosMed; received grants from the National Scientific Foundation of China; and is the faculty of the Key Laboratory of Cooperative Innovational and Translational Center at Nanjing Medical University. J. Zhang received grants from the National Scientific Foundation of China. The other authors have no conflicts of interest to declare. The Guest Editor reports receiving fees from Terumo.

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References

  • Pan M, Lassen JF, Burzotta F, Ojeda S, Albiero R, Lefèvre T, Hildick-Smith D, Johnson TW, Chieffo A, Banning AP, Ferenc M, Darremont O, Chatzizisis YS, Louvard Y, Stankovic G. The 17th expert consensus document of the European Bifurcation Club – techniques to preserve access to the side branch during stepwise provisional stenting. EuroIntervention 2023;19:26-36
  • Elwany M, Palma GD, Cortese B. Treatment of coronary bifurcation lesions: current knowledge and future perspectives. Future Cardiol 2018;14:165-79
  • Abdelfattah OM, Radwan A, Sayed A, Elbadawi A, Derbas LA, Saleh Y, Ahmad Y, ElJack A, Masoumi A, Karmpaliotis D, Elgendy IY, Alfonso F. Meta-Analysis of Provisional Versus Systematic Double-Stenting Strategy for Left Main Bifurcation Lesions. Cardiovasc Revasc Med 2022;45:53-62
  • Nairooz R, Saad M, Elgendy IY, Mahmoud AN, Habash F, Sardar P, Anderson D, Shavelle DM, Abbott JD. Long-term outcomes of provisional stenting compared with a two-stent strategy for bifurcation lesions: a meta-analysis of randomised trials. Heart 2017;103:1427-34
  • Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferović PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. EuroIntervention 2019;14:1435-534
  • Bujak K, Verardi FM, Arevalos V, Gabani R, Spione F, Rajwa P, Milasinovic D, Stankovic G, Gasior M, Sabaté M, Brugaletta S. Clinical outcomes following different stenting techniques for coronary bifurcation lesions: a systematic review and network meta-analysis of randomised controlled trials. EuroIntervention 2023;19:664-75
  • Chiabrando JG, Lombardi M, Vescovo GM, Wohlford GF, Koenig RA, Abbate A, Guzmán LA, Berrocal DH, Biondi-Zoccai G. Stenting techniques for coronary bifurcation lesions: Evidence from a network meta-analysis of randomized clinical trials. Catheter Cardiovasc Interv 2021;97:E306-18
  • Bhogal S, Zhang C, Aladin AI, Mintz GS, Waksman R. Provisional Versus Dual Stenting of Left Main Coronary Artery Bifurcation Lesions (from a Comprehensive Meta-Analysis). Am J Cardiol 2022;185:10-7
  • Zhang Q, Huan H, Han Y, Liu H, Sun S, Wang B, Wei S. Clinical Outcomes Following Simple or Complex Stenting for Coronary Bifurcation Lesions: A Meta-Analysis. Clin Med Insights Cardiol 2022;16:11795468221116842
  • Elbadawi A, Shnoda M, Dang A, Gad M, Abdelazeem M, Saad M, Salama A, Sharma A, Gilani S, Latib A, Rab T, Elgendy IY, Abbott JD. Meta-Analysis Comparing Outcomes With Bifurcation Percutaneous Coronary Intervention Techniques. Am J Cardiol 2022;165:37-45
  • Park DY, An S, Jolly N, Attanasio S, Yadav N, Rao S, Vij A. Systematic Review and Network Meta-Analysis Comparing Bifurcation Techniques for Percutaneous Coronary Intervention. J Am Heart Assoc 2022;11:e025394
  • Fujisaki T, Kuno T, Numasawa Y, Takagi H, Briasoulis A, Kwan T, Latib A, Tamis-Holland J, Bangalore S. Provisional or 2-Stent Technique for Bifurcation Lesions in the Second-Generation Drug-Eluting Stent Era. J Soc Cardiovasc Angiogr Interv 2022;1:100410
  • Di Gioia G, Sonck J, Ferenc M, Chen SL, Colaiori I, Gallinoro E, Mizukami T, Kodeboina M, Nagumo S, Franco D, Bartunek J, Vanderheyden M, Wyffels E, De Bruyne B, Lassen JF, Bennett J, Vassilev D, Serruys PW, Stankovic G, Louvard Y, Barbato E, Collet C. Clinical Outcomes Following Coronary Bifurcation PCI Techniques: A Systematic Review and Network Meta-Analysis Comprising 5,711 Patients. JACC Cardiovasc Interv 2020;13:1432-44
  • Chen SL, Sheiban I, Xu B, Jepson N, Paiboon C, Zhang JJ, Ye F, Sansoto T, Kwan TW, Lee M, Han YL, Lv SZ, Wen SY, Zhang Q, Wang HC, Jiang TM, Wang Y, Chen LL, Tian NL, Cao F, Qiu CG, Zhang YJ, Leon MB. Impact of the complexity of bifurcation lesions treated with drug-eluting stents: the DEFINITION study (Definitions and impact of complEx biFurcation lesIons on clinical outcomes after percutaNeous coronary IntervenTIOn using drug-eluting steNts). JACC Cardiovasc Interv 2014;7:1266-76
  • Chen SL, Santoso T, Zhang JJ, Ye F, Xu YW, Fu Q, Kan J, Paiboon C, Zhou Y, Ding SQ, Kwan TW. A randomized clinical study comparing double kissing crush with provisional stenting for treatment of coronary bifurcation lesions: results from the DKCRUSH-II (Double Kissing Crush versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions) trial. J Am Coll Cardiol 2011;57:914-20
  • Ye F, Chen SL, Zhang JJ, Zhu ZS, Kan J, Tian NL, Lin S, Liu ZZ, You W, Xu HM, Xu J. Hemodynamic changes of fractional flow reserve after double kissing crush and provisional stenting technique for true bifurcation lesions. Chin Med J (Engl) 2012;125:2658-62
  • Chen SL, Zhang JJ, Han Y, Kan J, Chen L, Qiu C, Jiang T, Tao L, Zeng H, Li L, Xia Y, Gao C, Santoso T, Paiboon C, Wang Y, Kwan TW, Ye F, Tian N, Liu Z, Lin S, Lu C, Wen S, Hong L, Zhang Q, Sheiban I, Xu Y, Wang L, Rab TS, Li Z, Cheng G, Cui L, Leon MB, Stone GW. Double Kissing Crush Versus Provisional Stenting for Left Main Distal Bifurcation Lesions: DKCRUSH-V Randomized Trial. J Am Coll Cardiol 2017;70:2605-17
  • Zhang JJ, Ye F, Xu K, Kan J, Tao L, Santoso T, Munawar M, Tresukosol D, Li L, Sheiban I, Li F, Tian NL, Rodriguez AE, Paiboon C, Lavarra F, Lu S, Vichairuangthum K, Zeng H, Chen L, Zhang R, Ding S, Gao F, Jin Z, Hong L, Ma L, Wen S, Wu X, Yang S, Yin WH, Zhang J, Wang Y, Zheng Y, Zhou L, Zhou L, Zhu Y, Xu T, Wang X, Qu H, Tian Y, Lin S, Liu L, Lu Q, Li Q, Li B, Jiang Q, Han L, Gan G, Yu M, Pan D, Shang Z, Zhao Y, Liu Z, Yuan Y, Chen C, Stone GW, Han Y, Chen SL. Multicentre, randomized comparison of two-stent and provisional stenting techniques in patients with complex coronary bifurcation lesions: the DEFINITION II trial. Eur Heart J 2020;41:2523-36
  • Steigen TK, Maeng M, Wiseth R, Erglis A, Kumsars I, Narbute I, Gunnes P, Mannsverk J, Meyerdierks O, Rotevatn S, Niemela M, Kervinen K, Jensen JS, Galloe A, Nikus K, Vikman S, Ravkilde J, James S, Aaroe J, Ylitalo A, Helqvist S, Sjogren I, Thayssen P, Virtanen K, Puhakka M, Airaksinen J, Lassen JF, Thuesen L; Nordic PCI Study Group. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation 2006;114:1955-61
  • Colombo A, Bramucci E, Sacca S, Violini R, Lettieri C, Zanini R, Sheiban I, Paloscia L, Grube E, Schofer J, Bolognese L, Orlandi M, Niccoli G, Latib A, Airoldi F. Randomized study of the crush technique versus provisional sidebranch stenting in true coronary bifurcations: the CACTUS (Coronary Bifurcations: Application of the Crushing Technique Using Sirolimus-Eluting Stents) Study. Circulation 2009;119:71-8
  • Hildick-Smith D, de Belder AJ, Cooter N, Curzen NP, Clayton TC, Oldroyd KG, Bennett L, Holmberg S, Cotton JM, Glennon PE, Thomas MR, Maccarthy PA, Baumbach A, Mulvihill NT, Henderson RA, Redwood SR, Starkey IR, Stables RH. Randomized trial of simple versus complex drugeluting stenting for bifurcation lesions: the British Bifurcation Coronary Study: old, new, and evolving strategies. Circulation 2010;121:1235-43
  • Hildick-Smith D, Egred M, Banning A, Brunel P, Ferenc M, Hovasse T, Wlodarczak A, Pan M, Schmitz T, Silvestri M, Erglis A, Kretov E, Lassen JF, Chieffo A, Lefèvre T, Burzotta F, Cockburn J, Darremont O, Stankovic G, Morice MC, Louvard Y. The European bifurcation club Left Main Coronary Stent study: a randomized comparison of stepwise provisional vs. systematic dual stenting strategies (EBC MAIN). Eur Heart J 2021;42:3829-39
  • Chen SL, Xu B, Han YL, Sheiban I, Zhang JJ, Ye F, Kwan TW, Paiboon C, Zhou YJ, Lv SZ, Dangas GD, Xu YW, Wen SY, Hong L, Zhang RY, Wang HC, Jiang TM, Wang Y, Chen F, Yuan ZY, Li WM, Leon MB. Comparison of double kissing crush versus Culotte stenting for unprotected distal left main bifurcation lesions: results from a multicenter, randomized, prospective DKCRUSH-III study. J Am Coll Cardiol 2013;61:1482-8
  • Ferenc M, Gick M, Comberg T, Rothe J, Valina C, Toma A, Löffelhardt N, Hochholzer W, Riede F, Kienzle RP, Achtari A, Neumann FJ. Culotte stenting vs. TAP stenting for treatment of de-novo coronary bifurcation lesions with the need for side-branch stenting: the Bifurcations Bad Krozingen (BBK) II angiographic trial. Eur Heart J 2016;37:3399-405
  • Ferenc M, Gick M, Kienzle RP, Bestehorn HP, Werner KD, Comberg T, Kuebler P, Büttner HJ, Neumann FJ. Randomized trial on routine vs. provisional T-stenting in the treatment of de novo coronary bifurcation lesions. Eur Heart J 2008;29:2859-67
  • Chen SL, Santoso T, Zhang JJ, Ye F, Xu YW, Fu Q, Kan J, Zhang FF, Zhou Y, Xie DJ, Kwan TW. Clinical Outcome of Double Kissing Crush Versus Provisional Stenting of Coronary Artery Bifurcation Lesions: The 5-Year Follow-Up Results From a Randomized and Multicenter DKCRUSH-II Study (Randomized Study on Double Kissing Crush Technique Versus Provisional Stenting Technique for Coronary Artery Bifurcation Lesions). Circ Cardiovasc Interv 2017;10:e004497
  • Kan J, Zhang JJ, Sheiban I, Santoso T, Munawar M, Tresukosol D, Xu K, Stone GW, Chen SL; DEFINITION II Investigators. 3-Year Outcomes After 2-Stent With Provisional Stenting for Complex Bifurcation Lesions Defined by DEFINITION Criteria. JACC Cardiovasc Interv 2022;15:1310-20
  • Chen SL, Ye F, Zhang JJ, Xu T, Tian NL, Liu ZZ, Lin S, Shan SJ, Ge Z, You W, Liu YQ, Qian XS, Li F, Yang S, Kwan TW, Xu B, Stone GW. Randomized Comparison of FFR-Guided and Angiography-Guided Provisional Stenting of True Coronary Bifurcation Lesions: The DKCRUSH-VI Trial (Double Kissing Crush Versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions VI). JACC Cardiovasc Interv 2015;8:536-46
  • Lavarra F. Medina Classification Modification Proposal. It’s Time for a Step Ahead: the Side Branch Lesion Length Matters More (and Changes our Interventions). Cardiol Res Cardiovasc Med 2024;9:237
  • Holm NR, Andreasen LN, Neghabat O, Laanmets P, Kumsars I, Bennett J, Olsen NT, Odenstedt J, Hoffmann P, Dens J, Chowdhary S, O’Kane P, Bülow Rasmussen SH, Heigert M, Havndrup O, Van Kuijk JP, Biscaglia S, Mogensen LJH, Henareh L, Burzotta F, H Eek C, Mylotte D, Llinas MS, Koltowski L, Knaapen P, Calic S, Witt N, Santos-Pardo I, Watkins S, Lønborg J, Kristensen AT, Jensen LO, Calais F, Cockburn J, McNeice A, Kajander OA, Heestermans T, Kische S, Eftekhari A, Spratt JC, Christiansen EH; OCTOBER Trial Group. OCT or Angiography Guidance for PCI in Complex Bifurcation Lesions. N Engl J Med 2023;389:1477-87
  • Ge Z, Kan J, Gao XF, Kong XQ, Zuo GF, Ye F, Tian NL, Lin S, Liu ZZ, Sun ZQ, He PC, Wei L, Yang W, He YQ, Xue YZ, Wang LM, Miao LF, Pu J, Sun YW, Nie SP, Tao JH, Wen SY, Yang Q, Su X, Yao QC, Huang YJ, Xia Y, Shen FR, Qiu CG, Mao YL, Liu Q, Hu XQ, Du ZM, Nie RQ, Han YL, Zhang JJ, Chen SL. Comparison of intravascular ultrasound-guided with angiography-guided double kissing crush stenting for patients with complex coronary bifurcation lesions: Rationale and design of a prospective, randomized, and multicenter DKCRUSH VIII trial. Am Heart J 2021;234:101-10
  • Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Jüni P, Kastrati A, Kolh P, Mauri L, Montalescot G, Neumann FJ, Petricevic M, Roffi M, Steg PG, Windecker S, Zamorano JL, Levine GN; ESC Scientific Document Group; ESC Committee for Practice Guidelines (CPG); ESC National Cardiac Societies. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018;39:213-60
  • Chen SL, Zhang JJ, Ye F, Chen YD, Patel T, Kawajiri K, Lee M, Kwan TW, Mintz G, Tan HC. Study comparing the double kissing (DK) crush with classical crush for the treatment of coronary bifurcation lesions: the DKCRUSH-1 Bifurcation Study with drug-eluting stents. Eur J Clin Invest 2008;38:361-71

Volume 11 - Number 3

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Keywords
  • coronary artery bifurcation lesions
  • double-kissing stenting
  • provisional stenting
  • target lesion failure
  • upfront two-stent
Authors
  • Fei Ye
  • Imad Sheiban
  • Jing Kan
  • Junjie Zhang
  • Kwan Seung Lee
  • Lianglong Chen
  • Muhammad Munawar
  • on behalf of the provisional stenting versus systematic two-stent (DKCRUSH X) collaborator group
  • Shao-Liang Chen
  • Tak W. Kwan
  • Tanveer S. Rab
  • Teguh Santoso
  • Wei Hsian Yin
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