Key Points
- The DKCRUSH VIII Trial conducted in China showed that in patients with complex coronary bifurcation lesions treated with the DK crush technique, IVUS-guided PCI significantly lowered 1‑year target vessel failure compared with angiography guidance (6.1% vs. 14.7%; HR 0.40; 95% CI, 0.23–0.71; p=0.002).
- Reductions were driven primarily by lower rates of target vessel myocardial infarction (4.3% vs. 9.4%; HR 0.46; 95% CI, 0.23–0.90) and clinically driven target vessel revascularization (2.9% vs. 7.6%; HR 0.37; 95% CI, 0.16–0.84).
- The benefit of IVUS guidance was largely confined to procedures meeting prespecified IVUS-defined optimization criteria; patients with suboptimal IVUS results experienced event rates comparable to the angiography-guided group.
Intravascular imaging has been increasingly recognized as a cornerstone of contemporary percutaneous coronary intervention, particularly for complex coronary anatomy. Complex bifurcation lesions represent one of the highest‑risk subsets, where the technical demands of two‑stent strategies, such as double kissing (DK) crush, raise the stakes for optimal procedural execution. The DKCRUSH VIII trial (NCT03770650), presented as a late‑breaking clinical trial at ACC.26 and simultaneously published in the Journal of the American College of Cardiology, evaluated whether systematic IVUS guidance could improve clinical outcomes over angiography‑guided PCI in patients with true complex bifurcation disease.
This multicenter, randomized, open‑label superiority trial enrolled 555 patients meeting DEFINITION criteria for complex bifurcation lesions across 24 centers in China. Patients were randomized 1:1 to IVUS-guided DK crush (n=277) or angiography-guided DK crush (n=278). Nearly half of all lesions involved the distal left main (44.8% vs. 43.9%), and DK crush was used in 96.8% of procedures. The prespecified primary endpoint was target vessel failure (TVF); a composite of cardiac death, target vessel MI, or clinically driven target vessel revascularization-at 12 months.
At one year, TVF occurred in 17 patients (6.1%) in the IVUS group compared with 41 patients (14.7%) in the angiography group (HR 0.40; 95% CI, 0.23–0.71; p=0.002). Excluding periprocedural MI, TVF remained significantly lower with IVUS (3.6% vs. 12.2%; HR 0.28; 95% CI, 0.14–0.57). Target vessel MI was reduced by more than half (4.3% vs. 9.4%), driven largely by a lower rate of spontaneous MI (1.8% vs. 6.1%). Clinically driven TVR also favored the IVUS-guided strategy (2.9% vs. 7.6%). All‑cause and cardiac mortality were infrequent and similar between groups.
IVUS revealed frequent procedural pitfalls that were unrecognized angiographically. Incomplete crushing was seen in 28.2% of cases following balloon crush and 12.7% after stent crush; distal rather than proximal rewiring occurred in 41.5% of patients during the first rewiring step. Despite these challenges, operators achieved IVUS-defined optimal PCI in 75.4% of cases. Patients meeting these criteria had a strikingly low 1‑year TVF rate of 2.6%, compared with 15.9% in those with suboptimal IVUS results-nearly identical to the angiography-guided cohort. Safety outcomes were similar across groups. Definite or probable stent thrombosis was rare (0.4% vs. 1.1%), and intraprocedural complications were infrequent, though TIMI flow <3 occurred more often with angiography guidance (4.7% vs. 0.7%). Contrast use and procedural time were modestly higher with IVUS, reflecting the multistep imaging protocol.
According to the trial’s lead investigator, Shaoliang Chen, MD, “the one-year TVF rate was 6.1% in the IVUS-guided group compared to 14.1% in the angiography-guided group, and this benefit was achieved largely through meeting IVUS-defined optimization targets rather than IVUS use alone.”
Together, these findings demonstrate that in real complex bifurcation lesions, nearly all treated with the DK crush technique, IVUS guidance meaningfully improves clinical outcomes, primarily by preventing spontaneous MI and reducing repeat revascularization. The magnitude of benefit, however, depends on achieving rigorous imaging‑based optimization, underlining the importance of meticulous technique in this challenging lesion subset.