SS–02 IVUS-guided DK-miniculotte Technique in a Short LMCA

Abstract

Introduction and Aim: Left main coronary artery (LMCA) bifurcation lesions are among the most complex lesions encountered in percutaneous coronary intervention. Particularly in patients with a short LMCA anatomy, selection of an appropriate stenting technique becomes more challenging, and intravascular imaging plays a crucial role in determining the optimal bifurcation strategy and achieving procedural success. We present a case of successful percutaneous coronary intervention using an intravascular ultrasound (IVUS)-guided DK-miniCulotte technique in a patient with a critically diseased LMCA bifurcation and a short LMCA measuring approximately 4 mm, who declined surgical revascularization.

Case Report: An 80-year-old woman with a history of hypertension presented with progressively worsening exertional chest pain over the preceding 15 days. Coronary angiography performed at an outside center revealed critical stenoses at the ostium and distal segment of the LMCA, proximal left anterior descending artery (LAD), and ostium of the circumflex artery (Cx). Coronary artery bypass grafting (CABG) was recommended; however, the patient declined surgical treatment and was therefore referred to our center for percutaneous coronary intervention. During the procedure, severe angina and hypotension developed upon catheter engagement because of the critical LMCA ostial stenosis. To achieve hemodynamic stabilization, predilatation from the LMCA toward the Cx was performed using a 3.0×15 mm non-compliant (NC) balloon. IVUS examination was performed through both the Cx and LAD to determine the optimal treatment strategy. IVUS demonstrated an LMCA length of approximately 4 mm and severe calcific critical stenosis at the ostium. Considering the short LMCA anatomy and complex bifurcation morphology, a DK-miniCulotte strategy was selected. First, a 4.5×24 mm Synergy™ stent was implanted from the Cx into the LMCA. Because of inadequate stent expansion at the LMCA ostium, postdilatation was performed using 4.0×8 mm and 5.0×8 mm NC balloons. The LAD was then rewired through the distal stent struts, and the first kissing balloon inflation was performed using two 3.0×15 mm NC balloons (Fig. 1). Subsequently, a 3.5×26 mm Medtronic stent was implanted from the LMCA into the LAD in accordance with the DK-miniCulotte technique, followed by postdilatation with a 5.0×8 mm NC balloon. The Cx was then rewired, and final kissing balloon inflation was performed using two 3.0×15 mm NC balloons, followed by re-Proximal Optimization Technique (re-POT) with a 5.0×8 mm NC balloon. Final IVUS assessment demonstrated adequate stent expansion and apposition, with no significant residual stenosis, and TIMI 3 flow was achieved (Fig. 2).

Conclusion: In complex bifurcation lesions with a short LMCA anatomy, the IVUS-guided DK-miniCulotte technique may facilitate accurate assessment of anatomical characteristics and selection of an appropriate interventional strategy. This intravascular imaging-guided approach, together with meticulous procedural optimization, may enable safe and effective percutaneous revascularization.