Why is this study important?

Coronary bifurcation lesions represent a significant proportion of percutaneous coronary interventions (PCI) and are among the most technically challenging subsets, associated with higher risks of restenosis, stent thrombosis, and repeat revascularization. While the double kissing (DK) crush technique has emerged as the preferred strategy for complex bifurcation lesions, procedural success and long-term outcomes remain highly dependent on optimal stent deployment.

Traditional angiography-guided PCI has inherent limitations in accurately assessing vessel size, plaque burden, and stent expansion due to vessel overlap and poor visualization of the carina. Intravascular ultrasound (IVUS), by contrast, provides detailed intraluminal and vessel wall imaging, enabling more precise lesion assessment and optimization. Although prior studies have suggested improved outcomes with IVUS-guided PCI, robust randomized data specifically in complex bifurcation lesions treated with contemporary DK crush technique have been lacking.

What question was this study supposed to answer?

The DKCRUSH VIII trial sought to determine whether IVUS-guided PCI is superior to angiography-guided PCI in patients with complex coronary bifurcation lesions undergoing treatment with the DK crush technique.

Specifically, the study aimed to evaluate whether IVUS guidance reduces the incidence of target vessel failure (TVF)—a composite endpoint including cardiac death, target vessel myocardial infarction (MI), and clinically driven target vessel revascularization—at 1 year.

What did the study show?

In this multicenter randomized trial involving 556 patients, IVUS-guided PCI demonstrated a significant reduction in adverse clinical outcomes compared with angiography guidance.

• The primary endpoint (TVF at 1 year) occurred in 6.1% of IVUS-guided patients vs 14.7% in angiography-guided patients (HR 0.40, p =0.002), representing a ~60% relative risk reduction.
• This benefit was primarily driven by reductions in target vessel myocardial infarction and clinically driven revascularization.
• IVUS guidance also reduced spontaneous MI and improved procedural outcomes.
• Patients achieving IVUS-defined optimal stent deployment had markedly lower event rates.
• No significant differences were observed in all-cause mortality or stent thrombosis.

Additionally, IVUS-guided procedures resulted in larger stent dimensions and better lumen gain, albeit with longer procedure time and slightly higher contrast use.

Clinical Perspective

The DKCRUSH VIII trial provides compelling evidence that IVUS-guided PCI should be considered standard of care for complex bifurcation lesions, particularly when a two-stent strategy such as DK crush is employed.

The key clinical insight is that imaging-guided optimization—not just imaging use—drives improved outcomes. IVUS enables precise vessel sizing, identification of inadequate stent expansion, and correction of issues such as malapposition or edge dissection.

From a practical standpoint, the findings support routine IVUS use in left main and complex bifurcation PCI, long or diffuse lesions, and cases requiring two-stent techniques.

Although IVUS increases procedural time and resource utilization, the substantial reduction in MI and repeat revascularization suggests a favorable risk-benefit profile. Overall, this study reinforces a paradigm shift toward precision PCI.