Double kissing crush stenting: No pain, no gain?

Optimal strategy and technique of percutaneous coronary intervention (PCI) for bifurcation lesions remain a subject of debate. Although provisional stenting (PS) is the preferred approach in most bifurcation lesions, a dedicated two‐stent approach might be preferable in selected patients with true left main (LM) bifurcation (Medina 1,1,1 or 0,1,1) or “complex” bifurcations. Double kissing (DK) crush technique has demonstrated superior results when compared with PS in both LM and non‐LM lesions. However, the DK crush technique involves many steps: side branch (SB) stenting, balloon crush, SB rewiring and first kissing balloon inflation (KBI), main vessel (MV) stenting, proximal optimization technique (POT), final KBI, and final POT. As such, procedural complexity and associated technical challenges limit the widespread clinical adoption of DK crush stenting in the United States. In this regard, the present study by Simsek et al. provide important insights into the procedural characteristics and outcomes of patients who underwent DK crush stenting (n = 48) from a single‐ center registry (PROGRESS‐BIFURCATION) of 435 patients. Authors report high technical (100%) and procedural success (96%) with a low rate of adverse events. Other important aspects include more frequent use of DK crush stenting in Medina 1,1,1 bifurcations and lesions involving LM‐proximal left anterior descending (LAD) artery in comparison with other bifurcation strategies (79% vs. 40% and 70% vs. 50%, respectively). Furthermore, intracoronary imaging was used in 55% of cases undergoing DK crush stenting. The highlight of this article is the in‐depth review of technical challenges encountered during bifurcation PCIs, specifically, the higher frequency encountered with DK crush when compared with other strategies (54% vs. 30%; p = 0.010). During DK crush stenting, these challenges were reported as (1) difficulty in SB wiring (38%), (2) inability to deliver a balloon to an SB for the first kiss (54%), (3) difficulty in SB second rewiring (19%), (4) difficult SB (4%) or MV (4%) stent delivery, and (5) SB dissection. Importantly, the authors also describe the steps undertaken to troubleshoot and overcome the different challenges (e.g., use of different guidewire, microcatheter, smaller balloon, etc.). Overall, the findings of Simsek et al. are promising with respect to the high technical success and low complication rates of DK crush stenting albeit in a relatively small sample. The study was conducted at a high‐volume tertiary center with experienced operators and thus. reinforces the message that operator experience is pivotal to the high efficacy and safety of complex bifurcation techniques. Keeping in mind that PS was performed in approximately 75% of bifurcation lesions in this study, this article may also highlight the principle of “KISS” (Keep it simple and safe) from the European bifurcation club consensus document. Further, its highly important that imaging‐ guided POT with proper balloon sizing (1:1 according to proximal MV) and placement (distal marker at the carina) is performed. Recently, an EBC MAIN study encouraging high use of KBI and POT during step‐wise PS found no significant differences in outcomes when compared with a planned two‐stent technique (predominantly culotte or T/TAP) in true LM bifurcations. Since the DK crush technique was pioneered by interventional cardiologists in China who also conducted the DK crush trials, perhaps a larger multicenter study in the United States comparing technical challenges and outcomes of DK crush with PS or other two‐stent techniques will provide more clarity. An obvious limitation of this study is the lack of longer‐term follow‐up particularly relevant in patients who had challenges during DK crush stenting. The results also illustrate some of the concerns arising from technical challenges that could rather be frequently encountered during the multiple steps of SB rewiring and KBIs. Indeed, procedural time, radiation dosage, and contrast volume were all higher with DK crush compared to other stenting techniques in this study. As such, it remains unknown if potentially missing a step during DK crush (for e.g., first KBI) still leads to superior long‐term