Case 155: Manual of PCI - Double DK crush

A patient presented with NSTEMI and was found to have severe 3-vessel CAD with significant lesions in the mid RCA, left main, proximal and mid LAD and proximal circumflex, some of which were in-stent restenotic lesions. He declined CABG and was referred for multivessel PCI. Hemodynamics were normal, hence no hemodynamic support was necessary. The RCA was predilated and successfully stented using IVUS guidance. There was a mid LAD/diagonal bifurcation and a distal left main bifurcation lesion. We elected to use the double DK crush technique: after lesion preparation (done with intravascular lithotripsy in the circumflex) the diagonal and circumflex were both stented with slight stent protrusion into the LAD and LM, respectively (initial steps of DK crush). The protruding portion of each stent was then crushed with a balloon in the LAD/LM, followed by rewiring and kissing balloon inflation in both lesions. A single stent was then deployed across the origins of both diagonal and circumflex, followed by rewiring both vessels and final kissing balloon inflations. Rewiring was challenging requiring use of a Sasuke dual lumen microcatheter.