Complex coronary cases
Staged PCI of Calcified Prox LAD and Angulated Diagonal Bifurcation using Rotational Atherectomy, Venture Catheter and 2-Stent Technique – Jan 2017

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.


To help us better, where do you prefer Culotte?

Culotte stenting will be ideal for the bifurcation lesions where side branch is small to medium size and is angulated.

And mini crush?

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.

What are the step wise differences between DK crush and mini crush?

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.

Any cases where one should completely avoid Culotte?

Culotte stunting should be avoided in severely calcified lesions as 2 layers of stent in the proximal vessel may prevent full stent expansion.

What new technology will advance results and outcomes with Bifurcation lesions?

OCT use will certainly enhance our understanding of the full lesion coverage, stent expansion and any residual dissection.

So, no more inappropriate cases left in our verbiage?

Fortunately now we will be using the term Rarely necessary.

Do you agree with this change in nomenclature?

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.

Are we not skirting around such an important issue that clearly guided us in performing PCI?

Overall the concept of Appropriate and not so Appropriate as a quality evaluation will continue to guide our interventional approach.

Is this good science or protecting our turf?


In today's procedure, for physicians not adept with Rotational Ablation, what would you recommend?

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.


Join the Discussion

One thought on “Staged PCI of Calcified Prox LAD and Angulated Diagonal Bifurcation using Rotational Atherectomy, Venture Catheter and 2-Stent Technique – Jan 2017”

  1. Riccardo Sartor, MD says:

    Good job, especially about difficult wiring of the diagonal! However, after crush stenting one should be perform POT.
    Furthermore, after stenting it would have been interesting measure FFR for the residual stenosis of mid LAD.
    Thank you for sharing your cases!

Leave a Reply

Your email address will not be published. Required fields are marked *

By submitting this form, you are consenting to receive marketing emails from: Mount Sinai Hospital, One Gustave L. Levy Place, Box, New York, NY, 10029, You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact

Complex PCI of Tortuous Calcified RCA using Rotational Atherectomy with Guide Extension Catheter – April 2021
Views 492

Case and Plan 43-year-old morbidly obese male with ESRD on HD presented with new onset Class IV angina and NSTEMI (pTnI 2:1U). A Cardiac Cath on February 26, 2021 revealed 2 V CAD: multiple calcified 80-99% lesions in extremely tortuous RCA, 90% mid LAD, LVEF = 55% and SYNTAX Score of 27. Patient underwent successful […]

IVUS Guided PCI of LAD-D1 Bifurcation using Rotational Atherectomy and 2-Stent Mini-crush Technique – March 2021
Views 537

Case & Plan: 47-year-old female with ESRD on HD, presented with CCS Class I angina and a markedly positive SPECT MPI for anterior and lateral wall ischemia. A Cardiac Cath on February 23, 2021 revealed severely calcified 1 V CAD: 90% proximal LAD and diagonal bifurcation (Medina 1,1,1), 80% mid LAD and SYNTAX Score of […]

Complex prox RCA CTO Recanalization via Retrograde Approach – February 2021
Views 518

56-year-old male presented with Class III unstable angina and positive stress MPI for significant inferior ischemia. A Cardiac Cath on November 20, 2020 at outside hospital revealed 2 V VAD: 85% mid LAD, 70% D1 and CTO proximal RCA with distal vessel fills retrogradely via septal collaterals (J-CTO Score 3), LVEF = 50% and Syntax […]

High-Risk Complex PCI of Diffuse Multivessel CAD – January 2021
Views 744

  Case and Plan: 45-year-old male with multiple CAD risk factors presented to OSH on November 6, 2020 with unstable angina and positive ETT. A Cardiac Cath on November 9, 2020 revealed extensive 3V CAD: 100% mid LAD, 90% D2, 70% proximal LCx, 100% LCx-OM1, 100% mid RCA with LVEF = 60% and SYNTAX Score […]