Author + information
- Dhiman Banik1
Patient initials or identifier number
Relevant clinical history and physical exam
A 40 years old male, hypertensive, diabetic, smoker with a strong family history of IHD, complaints of chest pain CCS-III. There was no shortness of breath. On examination, a patient is not anemic. Pulse was 68/min and regular, Blood pressure-130/76 mmHg. Planned for a coronary angiogram.
Relevant test results prior to catheterization
ECG shows T in V1-V6. Echo reveals regional wall motion abnormality with LVEF -52%.CXR PA view- Normal. CBC- normal. S. Creatinine- 1.0 mg/dl.S. Electrolytes- Within normal range. HBsAg-Negative.
Relevant catheterization findings
LMCA-Distal LMCA 30-40% narrowing. LAD-Critical lesion-Ostio proximal LAD (90-95%), LCX- Shows mild tapering at its ostia (20-30%), Ramus small size vessel with 40-50% at its ostia. RCA – Free of significant disease. Syntax score-32.
EBU 3.5 7F guiding catheter taken. LAD & LCX were wired. LAD was predilated. Plaque shifted to ostial LCX. Vessel size mismatch in LM & LAD so single stent strategy was abandoned. 4.0 x 24 DES from LM to LCX deployed. Post dilatation did in LCX. Rewired LAD through the stent strut and dilated. 3.0 x 38 mm DES from LM to LAD deployed. Post dilatation done in LAD. Kissing balloon dilatation done. IVUS revels under an expansion of LAD proximal stent. POT done in LAD. Final kissing balloon dilatation done. Final, angiogram shows LMCA, LAD & LCX were well revascularized with TIMI-III flow.
The intervention of doing ostial LAD or ostial LCX are always challenging. This is more brainstorming if distal LMCA is involved- Then comes the question-What to Do. As there was a wide angle between the LM and LCX, rewiring would be difficult. Therefore, Cullote technique was performed. In this technique, we use two stents – that leads to full coverage of the bifurcation at the expense of an excess metal mass of the proximal end. Rewiring of both the branches through the stent struts is difficult and time consuming. The Cullote technique probably gives the best coverage of the carina. Final kissing is mandatory when treated bifurcation lesion with double stent strategy. IVUS is a very useful.