One-year versus three-year outcomes of DK-Crush versus Culotte for left main bifurcation lesions: A systematic review and meta-analysis of RCTs

Abstract

Background: The long-term comparative effectiveness of the Double Kissing (DK) Crush and Culotte stenting techniques for left main bifurcation lesions (LMBLs) remains a subject of clinical debate. This meta-analysis aimed to evaluate and compare the one-year and three-year clinical outcomes of the DK Crush and Culotte techniques in patients with LMBLs.

Methods: A systematic search was performed in PubMed, MEDLINE, Cochrane, ScienceDirect, and Google Scholar databases up to June 2025. Three randomized controlled trials (RCTs) comprising 1,188 patients with LMBLs were included. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using the Mantel–Haenszel fixed-effects model to assess one- and three-year outcomes, including target vessel revascularization (TVR), major adverse cardiac events (MACE), myocardial infarction (MI), cardiac death (CD), and coronary artery bypass grafting (CABG).

Results: Across all studies, DK Crush demonstrated significantly improved outcomes compared with the Culotte technique for several endpoints. At the one-year follow-up, DK Crush was associated with a significantly lower rate of target vessel revascularization (RR = 0.42, 95% CI: 0.24–0.75, p = 0.003) and major adverse cardiac events (RR = 0.45, 95% CI: 0.29–0.71, p = 0.0006). There were no significant differences between the two techniques in cardiac death (RR = 0.83, 95% CI: 0.32–2.12, p = 0.70), myocardial infarction (RR = 0.60, 95% CI: 0.26–1.39, p = 0.24), or coronary artery bypass grafting (RR = 2.42, 95% CI: 0.43–13.69, p = 0.32). At the three-year follow-up, DK Crush maintained its superiority, showing significantly reduced rates of TVR (RR = 0.37, 95% CI: 0.24–0.58, p < 0.0001), MACE (RR = 0.47, 95% CI: 0.34–0.65, p < 0.0001), and MI (RR = 0.43, 95% CI: 0.21–0.89, p = 0.02). However, no statistically significant differences were observed in cardiac death (RR = 0.81, 95% CI: 0.45–1.46, p = 0.47) or CABG (RR = 2.25, 95% CI: 0.46–11.03, p = 0.32).

Conclusion: The DK Crush technique demonstrated superior clinical efficacy compared with the Culotte technique, with significantly lower rates of TVR, MACE, and MI at both one and three years. Although no significant differences were observed in cardiac death or CABG, DK Crush appeared to provide more favorable long-term vessel patency and reduced risk of repeat revascularization. Further large-scale randomized trials are warranted to validate these findings and strengthen the evidence supporting DK Crush as the preferred strategy for complex left main bifurcation lesions.