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Q2. Please check the sentence that begins with “The percutaneous coronary intervention (PCI) has been...” for clarity
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 Interventional Medicine & Applied Science, Vol. 9 (4), pp. 1–7 (2017) CASE REPORT

1
Double-kiss culotte bifurcation stenting with
2 long stents in non-left main lesions in acute
3
coronary syndrome setting

4 MOHAMMAD ALI SOWDAGAR*

5 Gowri Gopal Hospital, Kurnool, India

6 *Corresponding address: Dr. Mohammad Ali Sowdagar, MD, DM; Gowri Gopal Hospital, Budhawara Peta, Kurnool, Andhra Pradesh 518002,
Q1 7 India; Phone: +91 8518 255499; Mobile: +91 9866114593; E-mail: mdali49@gmail.com

8 (Received: April 26, 2017; Revised manuscript received: July 6, 2017; Second revised manuscript received: August 10, 2017;
9 Accepted: August 22, 2017)

11 Abstract: Although various strategies are available, the treatment of true bifurcation lesions has been challenging and controversial. Stenting only
12 the main branch, i.e., single-stent technique, or applying two-stent technique remains the matter of debate. Here, we present three cases with non-
13 left main bifurcation lesions in the setting of acute coronary syndrome. All these patients had significant side branch lesions, which necessitated
14 preserving the side branches. Thus, all were treated with double-kiss culotte technique, and resulted with favorable procedural and post-procedural
15 outcomes with an uneventful 12-month follow-up. However, the prudence in case selection and operator experience is important for successful
16 intervention.

17 Keywords: acute coronary syndrome, complex lesions, coronary bifurcation, drug-eluting stent, percutaneous coronary intervention

18 Introduction of lesion, and the technique implemented would affect 38

the final PCI outcomes [4]. 39
19 The percutaneous coronary intervention (PCI) has been More often, in a two-stent approach, main branch is 40
20 transpiring as the preferred approach for treatment of stented first followed by the side branch stenting. But side 41
21 coronary artery disease since the advent of drug-eluting branch stenting is occasionally performed first when side 42
Q2 22 stents. However, coronary bifurcation lesions, accounting branch is difficult to access, has dissections, possess high 43
23 about 15%–20% of total PCIs, are technically challenging risk of closure, or necessitates implantation of more than 44
24 even in this era of drug-eluting stents [1]. The type of one stent in the distal side branch [5]. After implement- 45
25 strategy to be applied for treatment of bifurcation lesions ing two-stent strategy, final kissing balloon inflation 46
26 remains under dilemma, i.e., to opt for single-stent strat- (FKBI) leads to reconstruction of carina resulting into 47
27 egy or two-stent strategy. The European Bifurcation oval-shaped distortion of the proximal part of the stents 48
28 Club recommends using main branch stenting with a [5], thus decreasing risk of restenosis and stent throm- 49
29 proximal optimization technique (POT) and provisional bosis following bifurcation stenting. 50
30 side branch stenting as a preferred approach [1]. Never- Previous studies state that the culotte technique for 51
31 theless, a two-stent strategy is preferred in lesions, which bifurcation stenting renders nearly perfect coverage of 52
32 pose difficulty in wiring or if side branch has large carina and side branch ostium with good immediate 53
33 diameter with extensive lesion of >5–10 mm beyond the angiographic results [6]. Furthermore, although under- 54
34 bifurcation [2]. Literature states that selection of patients represented, culotte technique exhibits advantage of bet- 55
35 for two-stent strategy requires appropriate assessment of ter scaffolding of the distal vessel ostium as well as 56
36 lesion severity, distribution, extension, and presence of minimizes the number of unopposed struts at the bifur- 57
37 concomitant disease [3]. Also, the anatomy of vessel, type cation [7]. Here, we report a series of three cases of 58

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
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DOI: 10.1556/1646.9.2017.35 1 ISSN 2061-1617 © 2017 The Author(s)

 Sowdagar

59 implementing double-kiss inverse culotte stenting (as per Case 2 111

60 MADS classification of techniques [8]) in acute coronary
61 syndrome (ACS) setting, with planned two-stent strategy A 44-year-old male presented with inferoposterolateral 112
62 using long stents. myocardial infarction and severe MR, post-thrombolysis 113
at a peripheral center, was referred for rescue PCI for 114
ongoing angina (CCS class III–IV) and recurrent pul- 115
63 Case Presentation monary edema (Killip class III). The ECG revealed 116
Q waves, ST elevation (II > III), and T inversions in 117
64 Case 1 leads II, III, aVF; ST elevations in I, aVL and tall R, ST 118
depressions and tall T waves in V1-3. Echo showed 119
65 A 50-year-old male, who presented with extensive inferoposterolateral wall hypokinesia, moderate LV 120
66 anterior wall myocardial infarction (AWMI) and Killip dysfunction (LVEF: 44%) with posteromedial papillary 121
67 class III [electrocardiography (ECG): ST elevations in muscle dysfunction and severe MR. Patient had signifi- 122
68 V2-V6 and T inversions in lead I, aVL], post-thrombolysis cant rest angina and orthopnea (functional NYHA 123
69 with streptokinase, was referred for rescue PCI, for class IV). The CAG revealed a (Medina class: 1,0,1) 124
70 ongoing frequent angina [Canadian Cardiovascular bifurcation lesion in dominant left circumflex artery (LCX) 125
71 Society (CCS) class IV]. Echo revealed regional wall and a big OM1 (about 2.75 mm vessel). Both the vessels 126
72 motion abnormality in left anterior descending artery were wired with 0.014″ guidewires (Pilot 50 in LCX and 127
73 (LAD) territory, moderate left ventricular (LV) dysfunc- BMW in OM1) through right femoral route using EBU 128
74 tion [left ventricular ejection fraction (LVEF): 40%], 7-Fr guiding catheter in a 7-Fr sheath. Initial strategy was 129
75 and moderate eccentric mitral regurgitation (MR). Cor- to get off with provisional stenting of proximal LCX to 130
76 onary angiography (CAG) revealed true LAD/D1 OM1. Proximal LCX and the ostium of OM1 were 131
77 bifurcation lesion (Medina class: 1,1,1). D1 was a sig- predilated with 2.0 × 12 mm Trek balloon. A 3.0 × 132
78 nificant 2.5-mm vessel with dual LAD physiology, with 32 mm Tetrilimus (Sahajanand Medical Technologies Pvt. 133
79 other diagonal branches arising from D1 rather than Ltd., Surat, India) stent was deployed from proximal LCX 134
80 LAD. Both the vessels were wired with 0.014″ Pilot 50 to OM1 covering the osteo-proximal region of the OM1 135
81 (Abbott Vascular, Santa Clara, CA, USA) in D1 and and was postdilated with the 3.0 × 12 mm NC Trek 136
82 BMW (Abbott Vascular) in LAD through right femoral balloon. However, the distal LCX that was dominant was 137
83 route using EBU 7F guiding catheter (Launcher, Med- severely stenosed. Hence, a change over to a bifurcation 138
84 tronic Inc., Minneapolis, MN, USA) in a 7-Fr sheath. strategy with two stents was considered. The LCX was 139
85 Patient developed angina and slow flow post-wiring, rewired through the struts of the first stent and predilated 140
86 which mandated a bifurcation strategy with two stents. with 2.5 × 12 mm Trek balloon. First kissing balloon 141
87 Both the vessels were predilated with 2.5 × 12 mm inflation was performed with 3.0 × 12 mm NC Trek 142
88 (LAD) and 2.0 × 12 mm (D1) Trek (Abbott Vascular) balloons in LCX and OM1. A 3.0 × 20 mm Tetrilimus 143
89 balloons and kissing inflation was performed with the stent was deployed in the LCX across the ostium of OM1. 144
90 same balloons at 10–12 atm. A 2.75 × 28 mm Xience After rewiring the OM1, final kissing inflation was per- 145
91 Pro (Abbott Vascular) stent was deployed in D1 to formed with 3.0 × 12 mm NC Trek balloons in LCX and 146
92 proximal LAD and postdilated. After rewiring LAD, OM1. The POT was performed with 3.5 × 12 mm NC 147
93 first kissing inflation was performed with 3.0 × 12 mm Trek balloon subsequently without complications to 148
94 NC Trek (Abbott Vascular) balloon in LAD and D1 at achieve good result with TIMI III flow. Representative 149
95 10–12 atm for 15 s. A 3.0 × 28 mm Xience Pro was images of this case are detailed in Fig. 2. Immediate 150
96 deployed in distal to proximal LAD through the struts of postoperative period, patient was relieved of angina and 151
97 D1 stent and postdilated. D1 was rewired and final orthopnea (NYHA class II). At 1-month follow-up, LV 152
98 kissing inflation was performed with 3.0 × 12 mm NC function improved significantly (LVEF: 55%) and only 153
99 Trek (Abbott Vascular) balloon in LAD and D1 at 10– mild MR. The patient is asymptomatic at 1-year follow- 154 Q3
100 12 atm for 15 s. POT was performed with 3.5 × 12 mm up (NYHA class I). 155
101 NC Trek balloon at 10 atm for 12 s. Good result with
102 TIMI III flow was achieved. Figure 1 shows representa-
103 tive images of this case. Post-percutaneous transluminal Case 3 156
104 coronary angioplasty, the patient had complete relief of
105 angina, without the need of anti-anginals as well as A 45-year-old male with extensive AWMI, post- 157
106 inotropes. Postoperative 1-month follow-up revealed thrombolysis with streptokinase (Killip class III), devel- 158
107 mild LV dysfunction (ejection fraction: 48%) and only oped recurrent post-infarct angina, and was referred 159
108 mild MR on echo and QS complexes in V1-3. The for a rescue PCI. The ECG showed ST elevations and 160
109 patient is asymptomatic at 1-year follow-up [functional T inversions in V1-6, I, aVL, and reciprocal ST depres- 161
110 New York Heart Association (NYHA) class I]. sions in inferior leads. On echo, he had LAD territory 162

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 Double-kiss culotte stenting

Fig. 1. Representative images of case 1: (A) 1, 1, 1 lesion involving LAD/D1, (B) diffused lesion in proximal LAD and distal LAD, (C) initial
kissing predilation 2.5 × 12 mm (LAD) and 2.0 × 12 mm (D1) Trek balloon, (D) 2.75 × 28 mm Xience Pro in D1 to proximal LAD,
(E) first kissing inflation 3.0 × 12 mm NC Trek, (F) 3.0 × 28 mm Xience Pro in distal to proximal LAD, (G) post-deployment of both
stents, (H) final kissing inflation with 3.0 × 12 mm NC Trek and POT 3.5 × 12 mm NC Trek, (I) final angiogram

163 hypokinesia, moderate LV dysfunction (LVEF: 39%), and 2.5 × 12 mm NC Trek balloon, a significantly large D1 175
164 moderate eccentric MR. He had recurrent angina on was noted, supplying the entire lateral wall of LV that 176
165 minimal activity (CCS class III). CAG revealed a true mandated its preservation. A 3.0 × 40 mm Nostrum 177
166 LAD/D1 bifurcation lesion (Medina class: 1,1,1) with (Envision Scientific Pvt. Ltd., Surat, India) stent was 178
167 subtotal occlusion of LAD and significant disease extend- deployed in D1 and postdilated with 3.5 × 10 mm NC 179
168 ing on either side of the major diagonal (2.5- to 2.75-mm Trek balloon. After rewiring LAD, first kissing inflation 180
169 vessel and dual LAD anatomy) and a dominant LCX. was performed with 3.5 × 10 mm NC Trek balloon in 181
170 Again, a bifurcation strategy with planned two stents was LAD and 3.0 × 10 mm NC Trek balloon in D1. A 3.5 × 182
171 opted. Both the vessels were wired with 0.014″ guide- 40 mm Nostrum stent was deployed in LAD and post- 183
172 wires (Pilot 50 in LAD and BMW in D1) through right dilated with 3.5 × 10 mm NC Trek balloon. D1 was 184
173 femoral route using EBU 7-Fr guiding catheter in a 7-Fr rewired and final kissing inflation was performed with 185
174 sheath. After sequential predilation of both vessels with 3.5 × 10 mm NC Trek balloon in LAD and 3.0 × 12 mm 186

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 Sowdagar

Fig. 2. Representative images of case 2: (A) 1, 0, 1 lesion involving LCX/OM1, (B) 3.0 × 32 mm Tetrilimus in OM1 to proximal LCX after
predilation, (C) severe pinching of distal LCX, (D) first kissing balloon inflation with 3.0 × 12 mm NC Trek, (E) 3.0 × 20 mm Tetrilimus
EES from distal to proximal LCX, (F) postdilation of stent in LCX, (G) final kissing inflation with 3.0 × 12 mm NC Trek balloons,
(H) POT 3.5 × 12 mm NC Trek, (I) final angiogram

187 NC Trek balloon in D1. The POT was performed with followed by a final POT with the guidance of stent boost 197
188 3.75 × 12 mm NC Trek balloon subsequently without (Philips Medical Systems, Eindhoven, The Netherlands) 198
189 any complications and favorable result was achieved with was performed. The first kissing inflation was performed 199
190 TIMI III flow. This case has been outlined in Fig. 3. after the deployment of the first stent in the more 200
191 Postoperatively, patient was angina-free (CCS class I) and angulated branch and the final kissing inflation was per- 201
192 at 1-month follow-up, his LV function improved (LVEF: formed after the second stent deployment. The TIMI III 202
193 48%) with mild to moderate MR. The patient was flow was achieved in all three cases, without any compli- 203
194 asymptomatic at 1-year follow-up (NYHA class I). cations. Although only three representative cases are 204
195 In all the above complex bifurcation lesions (as per presented, it is in the author’s experience that the first 205
196 DEFINITION criteria [9]), double-kiss culotte stenting, kiss facilitated easy recrossing of the stent struts and final 206

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 Double-kiss culotte stenting

Fig. 3. Representative images of case 3: (A) 1, 1, 1 lesion involving LAD/D1, (B) subtotal occlusion of LAD, D1, and dominant LCX, (C) D1
after sequential predilation of vessels, (D) 3.0 × 40 mm Nostrum in D1, (E) first kissing inflation with 3.5 × 10 mm in LAD and 3.0 ×
10 mm NC Trek, (F) 3.5 × 40 mm Nostrum in LAD, (G) final kissing inflation with 3.5 × 10 mm in LAD and 3.0 × 12 mm NC Trek in
D1, (H) POT 3.75 × 12 mm NC Trek in proximal LAD, (I) final angiogram

207 kiss ensured optimal final angiographic result and un- side branch mandated its preservation. As per patients’ 215
208 eventful post-procedural stay. condition and vessel anatomy, we decided to utilize the 216
culotte technique in these patients, instead of the well- 217
known crush or T-stenting approaches. In accordance 218
209 Discussion with these cases, Zheng et al. [10] and Kaplan et al. [11] 219
have previously stated favorability of culotte over crush 220
210 In the present cases, the double-kiss inverse culotte and T-stenting, respectively. Moreover, various trials have 221
211 stenting in true bifurcation lesions located in non-left also proved the efficacy of culotte stenting [1]. 222
212 main vessels has shown favorable procedural and post- The application of double-kiss balloon inflation in all 223
213 procedural outcomes. In all, the side branch was inter- three patients provided easy access to the other branch, 224
214 vened first as the significant disease with long lesions in proper expansion and better apposition of stents. 225

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226 Correspondingly, literature also states various boons of mellitus and impaired glucose tolerance, abdominal obe- 282
227 double-kissing inflation. The first kissing inflation repairs sity, and dyslipidemia (high triglycerides and low high- 283
228 the distorted geometry, fully dilates the side branch stent, density lipoprotein). 284
229 and prevents ostial side branch stent deformation Yet, only to a minority of patients receive the recom- 285
230 [12, 13]. While the FKBI amends stent distortion and mended reperfusion therapy with fibrinolysis and PCI 286
231 expansion [14], it also decreases late loss and restenosis [<60% and <10% of ST-segment elevation myocardial 287
232 [15]. Studies have recommended FKBI after bifurcation infarction (STEMI) patients, respectively] owing to the 288
233 stenting as it optimizes the clinical outcomes [16, 17] and “gap in care” arising from financial barriers, limited 289
234 provides better results when compared with two-stent health-care infrastructure, poor knowledge, and 290
235 technique without FKBI [18]. accessibility of acute medical services for a majority of 291
236 Previously in a study, Hu et al. [19] had compared its population [24]. 292
237 outcomes after classic culotte and double-kiss culotte The proposed “hub and spoke” model of STEMI care 293
238 stenting, and reported that double-kiss culotte stenting in India [25], where in STEMI patients residing in 294
239 was allied with high procedural success, improved out- villages and small towns, constituting about 80% 295
240 comes and lower major adverse cardiac events up to (non-PCI capable center/spoke hospitals) are thrombo- 296
241 12-month follow-up (22.18% vs. 4.71%; p = 0.001). lysed and shifted to a PCI capable center (hub hospital) 297
242 Comparator studies of double-kiss crush with culotte and in the cities/district headquarters within 3–24 h for 298
243 other techniques have been available [2, 20–22]. Theo- invasive evaluation and management, is both challenging 299
244 retically, crush technique is more likely to cause abnormal and discrepant due to economic and geographic 300
245 change in shear stress compared with culotte, owing to diversities along with infrastructural deficits. About only 301
246 the asymmetrical three-layered crushed metal on the side 20% of the population can afford proper medical care with 302
247 of side branch in the proximal main branch as compared either government-sponsored schemes or private 303
248 with the symmetrical circumferential two-layered metal insurance. 304
249 jacket in the proximal main vessel in culotte stenting.
250 Also, when the bifurcation angle is relatively small, the
251 double-kiss crush presents several limitations, like unsat- Conclusions 305
252 isfied kissing, partial stent coverage in distal side of the
253 side branch and close to the carina, complicated wiring or True, complex bifurcation lesions in non-left main vessel 306
254 rewiring technique, profound stent deformation, or acute can be successfully treated with double-kiss culotte stent- 307
255 stent destruction. ing in patients with ACS. However, the finesse in case 308
256 Double kiss in double-kiss culotte offers the same selection and operator experience is important for suc- 309
257 advantage as double-kiss crush over classical crush. How- cessful intervention. 310
258 ever, a direct comparison study between double-kiss
259 culotte and double-kiss crush in the treatment of true *** 311
260 bifurcation lesions is being conducted, the DK-CULOTTE
Funding sources: No financial support was received for this study. 312
261 I trial (ClinicalTrials.gov Identifier: NCT01735656). The
262 results of this study would further enhance the understand- Authors’ contribution: MAS was responsible for interventional proce- 313
263 ing about the treatment of true and complex bifurcation dure, literature review, drafting of the manuscript, and final approval of 314
264 lesions with two-stent strategy [13]. the version to be published. The author had full access to all the data in 315
265 To the best of our knowledge, no cases of double-kiss the study and takes responsibility for the integrity of the data and the 316
accuracy of the data analysis. 317
266 inverse culotte stenting in non-left main vessel have been
267 reported yet in the setting of ACS. However, any tech- Conflict of interest: The author declares no conflict of interest. 318
268 nique for bifurcation stenting is not without a downside.
269 The choice of culotte stenting requires proper matching
270 of the size of proximal main branch and side branch, and References 319
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