65 year old diabetic male presented with new onset class II angina and a stress echo revealed apical and mid inferior wall ischemia. A Cardiac Cath on August 2, 2016 revealed 3V CAD: 70% RCA-RPL1, 80% proximal-mid LAD, 80% D2 LAD bifurcation, 80% LCx-OM1 and 70% LCx-LPL with normal LVEF; SYNTAX Score of 25. Patient underwent Heart Team discussion and then opted for complex multi-vessel PCI. Patient continued on aggressive CAD risk factor modification and maximal medical therapy. Patient is now planned for LAD-D2 bifurcation lesion PCI using dedicated 2 stent technique.
I personally believe that mini-crush, DK-crush and Culotte are 3 most important dedicated 2 stent techniques of large bifurcation lesions with comparable acute and long term results and SAT rates. I will strongly advice the young Interventionalist to become good at one of these techniques; that make one of these as the work horse technique in their practice and keep doing the same in the majority of bifurcation lesions. Then they will become good at that preferred technique.
I am still concerned about the double layer of metal DES in the main vessel which potentially can create problem at the long run; neoatherosclerosis.
Most important technical tips about Culottes technique are adequate pre-dilatation of the side branch and final kissing balloon dilatation of the proximal MV with appropriate size NC balloons and in some cases even POT technique.
I agree that correctly done 2 stent technique for bifurcation lesions with large side branch (>2.75mm) is superior to conventional one stent technique without increasing the SAT rates.
Lesion modification in bifurcation lesion is usually not needed in ACS pts and when the lesion is moderate angiographically (50-70% diameter stenosis) of MV of SBr. Even 70-90% non calcified lesions of SBr ostium, should get cutting balloon pre-dilatation before stenting the MV or SBr.
All current 3rd-4th generation stents are good for bifurcation lesions with the exception of BVS and can provide the Strut opening of 3mm+.
BVS should be kept for the MV and if needed metal DES for the side branch with final final mini kissing balloon dilatation using undersized compliant balloon for the SBr.
Newer antiplatelet agents (Prasugrel or Ticagrelor) are preferred for the complex bifurcation lesions especially if 2 stent strategy was used. These agents will be associated with lower SAT rates in bifurcation lesions and should be continued for more then one year.
Final kissing balloon dilatation is a must in the 2 stent technique of bifurcation lesions. This has been proven by the RCT results where lack of final kissing balloon dilatation was associated with 5x higher MACE rates. In conventional one stent technique, kissing balloon dilatation should only be done if SBr was dilated via stent struts.
FFR of the SBr is usually indicated when SBr flow is good after MV stenting and patient has no chest or EKG changes but angiographically lesion appears 70-90% with or without minor dissection. FFR of <0.81 will convince us to open the SBr with PTCA or second stent if needed. Routine SBr evaluation with FFR has not shown to be of added benefit in the randomized DK-Crush VI trial.
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.