The Pakistan Society of Interventional Cardiology (PSIC) envisions itself as a leading force in the global interventional cardiology arena, recognized for its commitment to education, innovation, and professional excellence. As a premier professional body, PSIC aims to elevate the standards of cardiovascular care in Pakistan by fostering cutting-edge research, advanced training, and collaborative partnerships with international cardiology societies.

From April 24 to 27, 2025, the annual Pakistan Live conference was hosted by PSIC. The cardiovascular team from Nanjing First Hospital, led by Professor Shaoliang Chen, was invited to present a live demonstration of a percutaneous coronary intervention (PCI) for a complex left main coronary bifurcation lesion.

Patient information

The patient was admitted with unstable angina. Coronary angiography revealed triple-vessel disease. The patient and family declined open-heart coronary artery bypass grafting (CABG). After heart team evaluation, the right coronary artery (RCA) was identified as the culprit vessel. The RCA lesion was successfully treated with PCI a week ago. This procedure was planned for the left coronary artery.

According to the MEDINA classification, the left anterior descending artery (LAD)–diagonal branch 2 (D2) bifurcation lesion was classified as a true bifurcation (1.1.1), and the LAD–diagonal branch 1 (D1) bifurcation lesion as a true bifurcation (0.1.1). Under the DEFINITION criteria proposed by Professor Chen, the LAD–D2 lesion was a complex bifurcation, while the LAD–D1 lesion was a simple bifurcation. For complex bifurcations, a planned two-stent strategy is recommended, whereas a provisional stenting strategy is advised for simple bifurcations. Based on the DKCRUSH series of trials, the DK-Crush technique is the most evidence-based two-stent method for complex bifurcations; therefore, LAD–D2 was selected for treatment with DK-Crush.

The ULTIMATE and IVUS-ACS studies, led by Professor Chen’s team, influenced the 2024 European and 2025 American guidelines to recommend intravascular ultrasound (IVUS) guidance for complex PCI as a Class I, Level A indication. This intervention was therefore planned under IVUS guidance. The operative plan proposed by Director Zhen Ge received full agreement from participating experts.

Intraoperative Details

The LAD was predilated with a 2.0 mm balloon. Under IVUS guidance, two drug-eluting stents (DES) were implanted in the mid-to-distal LAD. The LAD–D2 bifurcation lesion was then treated using the DK-Crush technique under continued IVUS guidance.

A proximal optimization technique (POT) balloon, developed by Professor Chen, was used for full crushing and precise rewiring, ensuring smooth access to the side branch. Discussions among the assembled experts focused on optimization of the side branch ostium, completeness of the crush, rewiring positions and methods, double POT maneuvers, and double kissing balloon inflations.

International colleagues expressed interest in the POT balloon’s short, rounded shoulder design, which enables precise positioning and expansion, optimal POT results, and improved rewiring into the side branch. Director Zhen Ge demonstrated its application during the live case.

Clinical Outcome

Coronary angiography after DES implantation showed less than 10% residual stenosis in the LAD and D2, with no dissection at stent edges. The D1 branch was unaffected, and Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow was achieved. IVUS confirmed complete coverage of the LAD ostium by the DES, a minimal stent area (MSA) in the LAD–D2 bifurcation exceeding the “6-5-5” benchmark, and plaque burden <50% at the distal stent edges in both LAD and D2, with no dissection—meeting the ULTIMATE criteria.

Expert Commentary

Complex coronary bifurcation lesions present significant technical and prognostic challenges. Professor Chen’s team has conducted the DKCRUSH, DEFINITION, ULTIMATE, and IVUS-ACS & ULTIMATE-DAPT clinical trial series, influencing both European and American guidelines. These studies provide strong evidence that IVUS-guided DK-Crush stenting in complex bifurcation lesions can significantly improve long-term outcomes. This live demonstration illustrated the practical advantages of applying the DK-Crush technique in this setting.