Mid LAD Bifurcation Lesion Treated by Culotte Technique

- Operator : Ian T. Meredith

Mid LAD Bifurcation Lesion Treated by Culotte Technique

- Operators: Ian T. Meredith, MD, Robaayah Zambahari, MD

Case Presentation

A 60-year-old gentleman was admitted with resting chest discomfort. His coronary risk factors were diabetes, hypertension, hyperlipidemia, and ex-smoker. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. Thallium SPECT showed reversible large sized perfusion defect at LAD territory, and treadmill test was positive at stage 3.

Baseline coronary angiography

1. The left coronary angiography revealed tight stenosis at mLAD bifurcation lesion with Medina classification (1,1,1). ( Movie 1) 2. The right coronary angiogram was normal.

Procedure

A 7 Fr XB 3.5 guiding catheter with side holes was engaged at the left coronary artery ostium. They checked mLAD FFR value using a pressure wire and mLAD FFR value was 0.72. Two 0.014 inch BMW wires were placed into the LAD and Di, respectively. A 0.014 inch BMW wire at Di was replaced by a pressure wire using 0.014 inch FINECROSS 1.8 Fr coronary micro-catheter. Di FFR value was 0.62. They performed balloon predilatation at Di and LAD with a Maverick balloon 2.5x20mm, sequentially (Figure 1, Figure 2). And then, they deployed a Promus Element 3.0x24mm stent at Di (Figure 3). A 0.014 inch BMW wire was placed into the LAD. They performed balloon predilatation with a Maverick balloon 2.0x15mm and deployed a Promus Element stent 3.0x16mm (Figure 4). Post-stenting adjunctive balloon dilatation was performed at Di with Maverick balloon 1.5x15mm and Elect balloon 2.5x15mm, sequentially. Kissing balloon inflation was performed with Dura Star balloon 3.0x20mm at LAD and Elect balloon 2.5x15mm at Di (Figure 5). Then they performed intravascular ultrasound evaluation at LAD. They performed second kissing balloon inflation with Dura Star balloon 3.25x20mm at LAD and Dura Star balloon 3.0x20mm at Di (Figure 6). After second kissing balloon inflation, dissection at pLAD was observed ( Movie 2). Therefore, they decided to deploy another Promus Element stent 3.5x12mm at pLAD (Figure 7). The final angiogram showed that procedure was successful ( Movie 3).