Upfront Two-Stent Strategy, The DK Crush technique. Our experience in NHFH

Bifurcation lesions pose a significant challenge in percutaneous coronary intervention (PCI), occurring in 15-20% of all PCIs. The key strategic choice is between the default Provisional (1-Stent) strategy and the Upfront (2-Stent) strategy. The Upfront Two-Stent Strategy (U2SS) is indicated for complex true bifurcations (Medina 1,1,1), large myocardium at risk (especially distal Left Main), and for proactive Side Branch (SB) protection. The Double Kissing (DK) Crush technique is the most studied two-stent strategy, demonstrating superior outcomes over provisional stenting in complex Left Main bifurcations. The procedure's key differentiator is the first Kissing Balloon Inflation (KBI) immediately after SB stent crushing, which ensures easier and more reliable final SB re-wiring. Landmark evidence from the DKCRUSH-V trial showed that DK Crush significantly reduced Target Lesion Failure (TLF) and Stent Thrombosis (ST) compared to Provisional Stenting in Unprotected Left Main Bifurcation. The DKCRUSH X long-term analysis confirmed a durable benefit with a 29% relative reduction in TLF over a six-year period for complex true bifurcations (Hazard Ratio: 0.71). The DK Crush technique is associated with the lowest rate of Major Adverse Cardiac Events (MACE) compared to other techniques, making it the Gold Standard for superior long-term outcomes in complex bifurcation lesions. Results: A total of 1443 cases of upfront two-stent strategy was performed in NHFH over last 5  years of which 352(24.4%) were DK Crush technique. Among the DK Crush cases 91.20% were LM bifurcation lesions. Rotablation were used in 9% of DK Crush cases and IVUS and OCT in 63.10% of cases. 12.5% of these cases underwent symptoms driven check CAG which revealed an ISR rate of 5.4%. Total death were 9.4% with 1.4% in-hospital death. Among the total deaths 24.2% were of non-cardiac causes. Conclusion: Key Takeaways Provisional stenting remains the default strategy for *simple* bifurcations. For *complex, true bifurcations* (esp. Left Main, large SB, long lesion), an upfront two-stent strategy is superior. The DK Crush technique is a reliable and evidence-based strategy , demonstrating lower adverse events in these high-risk patients. Procedural success hinges on meticulous adherence to al steps, especially the "Double Kiss."