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.
Q To help us better, where do you prefer Culotte?
A. Culotte stenting will be ideal for the bifurcation lesions where side branch is small to medium size and is angulated.
Q And mini crush?
A. 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.
Q What are the step wise differences between DK crush and mini crush?
A. 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.
Q Any cases where one should completely avoid Culotte?
A. Culotte stunting should be avoided in severely calcified lesions as 2 layers of stent in the proximal vessel may prevent full stent expansion.
Q What new technology will advance results and outcomes with Bifurcation lesions?
A. OCT use will certainly enhance our understanding of the full lesion coverage, stent expansion and any residual dissection.
Q So, no more inappropriate cases left in our verbiage?
A. Fortunately now we will be using the term Rarely necessary.
Q Do you agree with this change in nomenclature?
A. 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.
Q Are we not skirting around such an important issue that clearly guided us in performing PCI?
A. Overall the concept of Appropriate and not so Appropriate as a quality evaluation will continue to guide our interventional approach.
Q Is this good science or protecting our turf?
Q In today's procedure, for physicians not adept with Rotational Ablation, what would you recommend?
A. 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.
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!