Live-in-a-box bifurcation stenting with culotte technique

LIVE-IN-A-BOX 
BIFURCATION STENTING WITH CULOTTE TECHNIQUE 
LE THANH BINH, MD 
VIETNAM NATIONAL HEART INSTITUTE 
BACH MAI HOSPITAL 
CASE STUDY 
58’s y.o. male 
Angina Pectoris (CCS class III) 
Stent in LCx 1 year ago 
Coronary Risk Factor: Smoking 
ECG: normal 
Echo: EF: 69% 
Stent in distal LCx is patent 
Proximal LAD lesion & Ostial LCx lesion, True Bifurcation Lesion: 0.1.1, α ≈ 75° 
SYNTAX Score: 21 
Trans right femoral artery 
7-Fr EBU guiding catheter 
Placement of 3 wires (LAD, 
LCx, Dig1) 
Predilatation in LM-proximal 
LAD (2.5x20mm baloon) 
Predilatation in the ostial LCx (2.5x20 baloon) 
Stent the LM-LCx leaving 2 wires in the LAD & Dig1 
Stent (3.5x23 mm) in the LM-LCx is deployed at 12 atm 
(leaving 2 wires in the LAD & Dig1) 
Remove the wire from the stented LCx & crossing into the LAD 
 (Rewiring at the distal strut of the stent) 
Rewiring at the distal strut of the stent 
Crossing with a baloon into LAD & dilate (2.5x20 mm at 12atm) 
Advance second stent into the LAD, but  
And remove the stent system (broken stent system) 
Use 2 NC baloons to capture the broken stent system 
Crossing with a new baloon into LAD & dilate (2.75x15 mm at 12atm) 
Advance stent into the LAD, remove the jailed wire in LAD & wire in LCx, deploy 
the stent in LAD 
Cross with a wire into the LCx stent 
(Rewiring at the distal strut of the stent) 
Crossing with a baloon into LCx & dilate 
Perform final kising baloon inflation (2 NC baloons) 
Final result 
Conclusions 
The culotte technique uses 2 stents & leads to full coverage of the 
bifurcation, probably gives the best coverage of the carina. 
This technique is suitable for all angles of bifurcations & provides near-
perfect coverage of the SB ostium. 
The culotte technique leads to a high concentration of metal with a double-
stent layer at the carina & in the proximal part of the bifurcation. 
Other disadvantages of the technique include rewiring both branches 
through the stent strut, placement a second stent into the unstented 
branch, which can be difficult and time consuming. 
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