Single versusDouble kissing Crush Techniques for the Left

Single versus-Double kissing Crush Techniques for the Left Main Coronary Artery Stenting : Serial IVUS Comparisons of Above Techniques Massoud Leesar, MD University of Alabama, Birmingham

Massoud Leesar, MD I Massoud Leesar, MD have no relevant financial relationships

Background • The Crush Technique was developed to cover the SB ostium to reduce SB restenosis • Final kissing balloon inflation (FKBI) is mandatory after the Crush or Culotte techniques to reduce stent thrombosis or restenosis

Background (Cont’d) • The Crush or Culotte technique results in a multi-layer struts covering the SB ostium, which reduces the success of final kissing balloon inflation (FKBI) • The Double kissing crush technique (DKCRUSH) significantly increased the success of FKBI and improved outcomes vs. Crush or Culotte techniques, but it is technically demanding • The single kissing crush technique (SKCRUSH) technique would simplify the procedure and facilitate FKBI, but the IVUS assessment of the procedure has not been investigated

multi-layered struts

Culotte Technique SB stenting multi-layered struts POT Final POT MV wiring

Single-layered struts DKCRUSH Technique SB stenting SB stent crushing SB rewiring MV stenting POT Re-POT SB rewiring KBI FKBI

Singlelayered struts Single Kissing Crush (Modified Balloon Crush) Technique “A simplified DKCRUSH Technique” SB stenting SB stent crush Roh et al. Medicine 2018; 97: 42 MV stenting FKBI SB dilation

DKCRUSH vs. Conventional Crush Techniques FKBI=100% FKBI=76% Chen et al. J Clin Invest 2008; 38 (6): 361– 371

Single vs. Double Kissing Crush Techniques for Left Main Coronary Stenting: Step-by-Step Comparisons of the above techniques by Serial High- Definition Intravascular Ultrasound Examinations

A 1 Baseline angiogram A 2 Crush the SB stent A 3 1 B MV balloon SB stenting B 1 1 C A 4 Opening SB stent Struts B 2 1 D 1 E 1 E 1 st KBI B 3 1 G 1 F LAD B 4 L main Fig. 1 1 H

MV stenting A 1 ST POT B FKBI C LMCA Fig. 2 2 nd POT D

Conclusions • Eliminating the first KBI with SKCRUSH technique would lead to the partially crushed LCX stent in the left main, which could hinder advancing the stent to the LAD • Eliminating the first POT before FKBI with SKCRUSH technique could lead to advancing the guidewire inadvertently under the malapposed LAD stent in the left main during the LCX rewiring. This would lead to crushing the LAD stent during FKBI • Eliminating Re-POT with SKCRUSH technique would lead to asymmetric stent expansion in the left main and increase restenosis • Shortcut is not always good! DKCRUSH is a complex technique, but is worthy of performing an elaborate technique to improve outcomes