71 year old male presented with new onset CCS Class III angina and positive ETT with significant ST-segment depression in multiple leads. A Cardiac Cath on November 29, 2016 revealed 3 V CAD: 80% calcified prox and mid RCA, 90% calcified proximal LAD and angulated 80% diagonal bifurcation and small sized 80% LCx-LPL1 with SYNTAX Score of 24 and normal LV systolic function. Patient underwent successful intervention of proximal and mid RCA using rotational atherectomy and two Promus Premiere DES. Patient is now planned for staged PCI of calcified proximal LAD and angulated diagonal bifurcation lesion using rotational atherectomy, venture catheter and dedicated two-stent strategy.
Culotte stenting will be ideal for the bifurcation lesions where side branch is small to medium size and is angulated.
Most of the bifurcation lesions of LM and non LM can safely and effectively be done by mini crush technique with excellent results, low ST and low TLR.
DK crush has extra step of dilating the SBr stent followed by first KBI before stenting the MV. This way SBr stent ostium can be fully expanded before stenting the MV. In mini crush this step is not done.
Culotte stunting should be avoided in severely calcified lesions as 2 layers of stent in the proximal vessel may prevent full stent expansion.
OCT use will certainly enhance our understanding of the full lesion coverage, stent expansion and any residual dissection.
Fortunately now we will be using the term Rarely necessary.
Yes as earlier word, Inappropriate had very negative connotations and non logical as many of those so called inappropriate cases were medically necessary and clinically indicated.
Overall the concept of Appropriate and not so Appropriate as a quality evaluation will continue to guide our interventional approach.
Today's case should not be done without rotational or Orbital atherectomy. Hence if atherectomy could not be done, then patient should either be referred to the center expert in atherectomy or even for CABG.
86 year old female with chronic stable angina CCS Class II and positive MPI for two years being managed on medication.
62 year old male presented with CCS Class II angina and positive SPECT MPI for basal inferior and inferolateral moderate size area of ischemia and infarction.
53 year old male with CKD on HD, known extensive inoperable severe calcific CAD and s/p SAVR in Nov 2017.
74 year old male with CKD Stage III presented with CCS Class II angina and positive stress MPI for moderate inferoapical ischemia.