DKCRUSH VIII

In patients with complex coronary bifurcation lesions treated predominantly with DK crush stenting, IVUS-guided PCI reduced 1-year target vessel failure compared with angiography-guided PCI, mainly through fewer target vessel MI and clinically driven target vessel revascularization events.

Study design

  • Randomized, open-label, multicenter, controlled superiority trial
  • 24 centers in China
  • 1:1 randomization
  • N = 555
  • Follow-up: 1 year
  • Complex bifurcation lesions defined by DEFINITION criteria
  • DK crush used in 96.8% of patients

Population

  • Clinical indication for PCI
  • Complex coronary bifurcation lesion
  • Side branch lesion length ≥10 mm
  • Left main bifurcation involved in 44.8% vs 43.9%
  • Median age 67 years
  • 78% men
  • Operators were experienced with DK crush PCI

Interventions

  • IVUS-guided PCI: 277
  • Angiography-guided PCI: 278
  • Both groups treated using a DK crush strategy when appropriate
  • IVUS arm targeted IVUS-defined optimization criteria
  • Number of treated vessels and lesions was similar between groups

Primary outcome

  • Target vessel failure at 1 year
  • Composite: cardiac death, target vessel MI, or clinically driven target vessel revascularization
  • 6.1% with IVUS-guided PCI vs 14.7% with angiography-guided PCI
  • HR 0.40; 95% CI 0.23-0.71
  • P = 0.002
  • Superiority met
IVUS-guided PCI vs Angiography-guided PCI
Primary endpoint: target vessel failure at 1 year
15% 11.25% 7.5% 3.75% 0%
6.1%
IVUS-guided PCI
14.7%
Angiography-guided PCI
6.1% vs 14.7% | HR 0.40
Primary endpoint: cardiac death, target vessel MI, or clinically driven target vessel revascularization at 1 year.

Secondary outcomes

  • Benefit was mainly driven by fewer target vessel MI and target vessel revascularization events
  • Target vessel failure excluding periprocedural MI: 3.6% vs 12.2%
  • Target vessel MI: 4.3% vs 9.4%
  • Spontaneous MI: 1.8% vs 6.1%
  • Clinically driven target vessel revascularization: 2.9% vs 7.6%
  • Benefit was consistent across prespecified subgroups

Safety

  • Fewer procedural complications occurred with IVUS guidance
  • No excess safety signal reported with IVUS-guided PCI
  • Trial was open-label, though clinical outcomes were adjudicated
  • Results reflect experienced DK crush operators and may not generalize to low-volume bifurcation PCI settings

Interpretation

  • DKCRUSH VIII supports IVUS guidance for complex bifurcation PCI treated with DK crush
  • The benefit appears tied to achieving IVUS-defined optimization targets, not just imaging for its own sake
  • The trial strengthens the case for routine intravascular imaging in complex bifurcation PCI
  • Best-fit population: true complex bifurcation lesions, especially long side branch disease and left main involvement
  • Generalizability depends on operator experience with both DK crush and IVUS-guided optimization
Gao, X., Kan, J., Chen, Y., et al. (2026). IVUS or angiography guidance for percutaneous coronary intervention in complex coronary bifurcation lesions: The DKCRUSH VIII randomized clinical trial. Journal of the American College of Cardiology, 87(16), 2080-2095. https://doi.org/10.1016/j.jacc.2026.01.081