How to perform the DK crush technique for bifurcation stenting

[@alirhayim]

Beautiful elegant presentation. I have watched this one many times.

[@svijaykumarreddy1242]

Excellent demonstration of DK CRUSH

[@SantanuDas-jt7jr]

Initial crush is not done with wire in side branch. All gears should be removed from side branch before sb stent crushing. This demonstration would send a wrong message.please note.

[@mohamedkishkt3667]

After my warm greeting to you professor... Thank you very much..

[@volskiv]

Dr Brilakis' book is extremely useful and now also having these videos is truly amazing

[@JohnB-2021]

What was the diameter of this diagonal ?

[@jandenkmann6791]

Thank you Dr. Brilakis. Do you perform a POT of the MV after MB stenting and before 2nd SB re-wiring? I don't see this step in the video, but it is listed in the word document. Thank you.

[@matheuscsmed]

Thank you, Matheus Silva

[@zemos777]

Thanks for the illustrative case. I have a couple of questions: 1) do we have to cross through the proximal strut during the 1st kiss for optimal SB scaffolding? And regarding the second kiss (after MB stenting) do we cross from the distal stent strut as usual in any Bifurcation or cross from the proximal strut again? 2) Regarding the jailed SB wire after the crush, is it better to remove it before crushing the stent to avoid entrapment, especially that I had never had a problem to rewire the SB after the crushing of it's stent? Thanks alot for ur videos and for ur CTO book..... Really helpful

[@manosbrilakis]

From the proximal strut on both occasions. This is different from the distal strut wiring used in most provisional stenting for kissing balloon inflation. Rewiring the SB from the distal MV stent cell could increase the possibility of the wire going between the stent and the vessel wall, which will leave a gap at the ostium after balloon crushing. For more information look at: Zhang J-J, Chen S-L. Classic crush and DK crush stenting techniques. EuroIntervention 2015;11:V102-V105.

[@heekong]

@@manosbrilakis Thank you Dr. Brilakis. Just wanted to confirm with you again regarding rewiring through proximal/distal stent struts. Your Manual of PCI says the first rewiring should be through the proximal stent strut (no question about this). For second rewiring, should not it through the distal stent strut? Which is similar to rewiring after any POTS? Your book says the second rewiring should be through distal stent strut. Thank you again.

[@zadigbalaban8359]

All Rewiring by all Crush Techniks should done from proximal Stent Struts, because you don't need to scaffolding the side branch, you have already in all Crush Techniks Stent over there in side branch.

[@tuanhoanh1198]

I used to hear that the outer layer of a polymer-jacket wire has the risk to be torn and gets stuck inside the vessel if we use it for jailing SB therefore we should avoid this kind of wire. But you prefer it. can you explain more?

[@manosbrilakis]

See the following paper that makes an argument in favor of polymer-jacketed wires: interventions.onlinejacc.org/content/jint/9/18/1917.full.pdf

[@konstantinschwarz1525]

Excellent video. However traditional DK crush technique teaching warns against jailing the SB wire, both at time of crushing the SB stent and at time of MV vessel stent deployment. Entrapment risk of wire between two layers of metal may not be insignificant.

[@manosbrilakis]

Excellent point: there is a risk of wire entrapment vs the risk of not being able to rewire the branch. One has to decide which risk is higher in each case. I personally jail the SB wire in nearly all cases. Thanks, Manos

[@manosbrilakis]

You are right that jailing a wire always carries a risk for entrapment. At the same time jailing a wire facilitates rewiring and can allow advancement of a balloon if the side branch becomes occluded after stenting the main branch. Also polymer-jacketed guidewires are less likely to be entrapped. Weighing the risks/benefits is key for making a decision whether to jail a wire or not in each case.

[@grjvlk]

Thank you for a detailed account of the technique. During kissing inflations is it necessary in Your opinion to use NC baloons? How can "braiding" of the guidewires be avoided during rewiring?

[@manosbrilakis]

NC balloons allow you to go to higher pressure - on the other hand compliant balloons are more deliverable. You can use either depending on the specifics of the case. One way to avoid "twisting" of the wires is to use a dual lumen microcatheter, such as the TwinPass. Alternatively one can try to minimize wire rotation during insertion.

[@grjvlk]

Manos Brilakis So, you believe it is OK to do a final kiss with semi-compliant baloons or should one always try to deliver 2 NC baloons for KD? Myself find it often a good enough result with a semi- compliant baloon in the side branch.

[@manosbrilakis]

Agree - compliant balloons can work pretty well in most cases.

[@ashwinigmc]

Thank you for this educational video. What do you think about risk of wire entrapment especially after deploying the main vessel stent? Did it ever happen to you during during DK crush?

[@manosbrilakis]

Thanks for a great question. It has not happened to me during DK crush but can certainly happen. I still jail the SB wire during bifurcation stenting, but do the following: (a) prefer jailing polymer-jacketed guidewires that may be less likely to get trapped; (b) if the wire does not come back easily I advance a microcatheter or balloon as far as possible and then attempt withdrawing again.

[@MinorityDoc]

@@manosbrilakis sir, why don't we remove the SB wire while deploying the MV stent? Is it just to make the wire act like a marker for the SB ostium?

[@AliAbbas-sb3gi]

Yes we had it once trapped and we withdrew with a balloon assistant.

[@drhmalhotra99]

EXCELLENT------------- DR HEMANT

[@cchung1098]

GOOD TEACHING

[@HoaBui-zc9ys]

Thank you for sharing this video. Can you help me: Why do we have to rewire side branch before the first kissing?

[@manosbrilakis]

Because otherwise you would just re-expand the stent you just placed! The goal is to "crush" the part of the stent protruding into the main vessel and expand the struts at the side branch ostium.

[@tuanhoanh1198]

is it deemed culotte is easier than DK Crush to perform? when will you prefer Culotte?

[@manosbrilakis]

I personally do not use culotte - I prefer DK crush given better supporting data, even though is is technically a little more complex.

[@tuanhoanh1198]

i usually find it tough to rewire after stenting SB when applying DK Crush, do we have any other way to overcome this along with filder FC wire and Twinpass?

[@manosbrilakis]

1. I leave jailed wire in place as marker of position of SB. 2. Polymer-jacketed and TwinPass as you suggested. 3. Angulated microcatheter, like Supercross 120 and Venture. 4. Blocking balloon technique (balloon inflated transiently in main branch to prevent wire from prolapsing into the main branch.

[@ahmedsabbar9049]

Please did you have Vedio for TAP technique, thank u very much .

[@manosbrilakis]

I am sorry, I very rarely do tap and do not have a video on it.

[@ahmedsabbar9049]

@@manosbrilakis Thank you Sir.

[@jomonvarghesejomon9220]

Good Result .

[@minhtrungtran8131]

Thank you

[@svijaykumarreddy1242]

DK CRUSH is superior to culotte DK CRUSH3 RESULTS Culotte needs vessels of similar diameter. Excellent demonstration of DK CRUSH BY BRILAKIS.

[@TheAshokari]

very useful

[@drmahbuborrahman1061]

Excellent demonstration of DK Crush technic