Title
-
Left Main Bifurcation PCI using Mini Culotte String technique with IVUS guidance in a setting of Acute Coronary Syndrome
Introduction
-
There are various techniques of handling a left main bifurcation, DK Crush being most widely followed by operators all around the globe. However, it has a few limitations like a triple layer of stent at one edge of the carina, inability to achieve perfect apposition at the neo-carina and risk of side branch stent deformation. DK Culotte may be considered more "physiologic" and has no triple layer, as compared to DK-crush, has minimal neo-carina, as compared to T-and-protrusion whilst maintaining the tubular architecture of stents except for fractal deformation, that also can be taken care to some extent with a final POT.
Clinical Case
-
68 year old male, hypertensive, morbidly obese, dyslipidemic presented with chest pain & syncope. ECG revealed ST depression in anterior precordial leads. Echo revealed lateral wall hypokinesia with a LVEF of 40%. Coronary angiogram showed critical disease at ostial LAD & another tandem discrete critical lesion in proximal LAD. Ostioproximal LCx also had moderate stenosis angiographically with haziness suggestive of thrombus. An IVUS run revealed possible culprit plaque in proximal LAD with a superficially attenuated plaque and small MLA at ostial LAD of 3.3 mm
2. Distal LM also had a superficially attenuated plaque. The plaque was contiguous with plaque in ostial LCx. FFR to LCx was 0.76. A dedicated two-stent strategy was contemplated. A DES was deployed in ostial LAD with approximately 2-3 mm of stent hanging from LAD into left main. The wire was crossed through the hanging struts towards LCx, and dilating through these struts hence facilitating the "cross-stent" or "string-culotte" technique. This mini-culotte was first aided with first kiss with stent in LAD & balloon in LCx. Thereafter, LM to LCx stent was deployed. Wire was recrossed towards LAD through the stent struts of LM to LCx stent, followed by second kissing. The fractal deformation in LM area was corrected by a final POT.
Discussion
-
String Culotte, especially if coupled with a double kiss strategy is an excellent way of handling bifurcation PCI. Especially with IVUS guidance, we can be sure of the crossing of the wire strategically through the stent struts hence, avoiding a "crush" at every stage of bifurcation PCI. Newer generation stents that do have excellent post dilating capacity as well as ability to dilate inter-strut areas to higher volumes without risk of recoil has helped us overcome the limitation of "napkin-effect". This technique with modern generation stents & better hardware may give competitive results as compared to DK Crush technique.