Figure 2. Baseline coronary angiography image. Medina (1,1,1) bifurcation lesion
with severe stenosis involving the distal Left Main Coronary Artery (LMCA),
proximal Left Anterior Descending (LAD), and proximal Circumflex (LCx) arteries.
SS–23 Successful Percutaneous Revascularization with Culotte Technique and Management of Acute Complications in Left Main Coronary Bifurcation Lesion
Yakup Han Yılmaz, Fatih Enes Durmaz, Bektaş Murat
Department of Cardiology, Eskişehir State Hospital, Eskişehir, Türkiye
Keywords: Left main coronary artery, bifurcation, culotte technique, cardiogenic shock, coronary dissection.
Abstract
Introduction and Aim: Percutaneous coronary intervention (PCI) of left main coronary artery (LMCA) bifurcation lesions requires high technical expertise and immediate management of potential hemodynamic and rhythm complications. In this case, we present the successful application of the Culotte stenting strategy for an LMCA-LAD-LCx bifurcation lesion in an 86-year-old female patient presenting with acute coronary syndrome and cardiogenic shock, along with the prompt management of intraprocedural ventricular fibrillation (VF) and coronary dissection complications. LMCA bifurcation lesions represent some of the most complex coronary interventions due to the large territory of myocardium at risk. The Culotte technique, a two-stent strategy, ensures complete ostial coverage of both branches; however, potential side-branch occlusion or severe arrhythmias during the procedure require rapid intervention.
Case Report: An 86-year-old female patient was admitted to our catheterization laboratory with a preliminary diagnosis of acute coronary syndrome. Upon arrival at the catheterization suite, the patient was in cardiogenic shock. The electrocardiogram revealed prominent ST-segment elevation in lead aVR with widespread ST-segment depressions in other leads (Fig. 1). Coronary angiography demonstrated a severe bifurcation lesion involving the distal LMCA, proximal LAD, and proximal LCx segments (Fig. 2). Given the clinical presentation of cardiogenic shock, immediate stenting was pursued. The procedure was initiated by engaging the LMCA ostium with an EBU 3.5 guiding catheter. The LAD and LCx arteries were crossed using soft workhorse wires. Predilatation was performed on the LCx and LAD lesions using a 2.0x20 mm balloon. A 3.5x24 mm drug-eluting stent (DES) was deployed along the LMCA-LCx axis. Proximal optimization technique (POT) was performed at the LMCA level using a 4.5x8 mm non-compliant (NC) balloon. Subsequently, a 3.5x21 mm DES was implanted along the LAD-LMCA axis. After rewiring the LAD and LCx, stent struts were dilated with a 2.0x15 mm balloon. Kissing PTCA was executed using 3.0x12 mm and 3.5x12 mm NC balloons in the LCx and LAD branches, respectively (Fig. 3). During the procedure, the patient developed VF, which was rapidly converted back to sinus rhythm with immediate electrical defibrillation. Following defibrillation, a decrease in LAD forward flow was noted; thus, an overlapping 2.5x34 mm DES was implanted into the LAD. Final POT was performed at the LMCA using a 4.5x12 mm NC balloon. Upon identifying a dissection at the LCx ostium, a 2.5x21 mm DES was deployed into the LCx. Following the two-vessel Culotte stenting, complete resolution of stenosis and TIMI-3 flow were successfully restored in all branches (Fig. 4). Post-procedure, a half-dose tirofiban (Aggrastat) infusion was initiated.
Conclusion: The Culotte technique provides high procedural success in LMCA bifurcation interventions when the vessel anatomy is favorable. Prompt response with immediate defibrillation to malignant arrhythmias such as VF, alongside bail-out stenting for flow-limiting dissections, are key determinants of clinical success in this high-risk patient population.
