06 Jan 2025

Bifurcation lesion Imaging – Coronary

Complicated subendothelial dissection during left anterior descending coronary artery – first diagonal branch bifurcation treatment with Culotte technique

Supported by the EuroIntervention Journal

Learn more about troubleshooting and tailor-made treatment combining 2D and 3D OCT thanks to this image in cardiology!

Authors

Michele Schincariol^1*, Jiayue Huang^2,3*, Harald Rittger¹, Stylianos A. Pyxaras¹, Shengxian Tu²

^{*Both authors contributed equally to the manuscript.}

Case summary

An 84-year-old female patient with severe left anterior descending (LAD) – first diagonal (D1) bifurcation lesion (Medina classification 1,1,1) (Figure 1, Panel A) was electively treated with percutaneous coronary intervention (PCI) using the conventional Culotte technique (two-stent strategy), implanting the first stent into the most angulated branch (D1)^1-3.

The LAD stent was a 2.5/28 mm drug eluting stent (DES) and it was extended longer into the proximal segment of the main vessel, whereas the D1 stent was a 2.5/22 mm DES.

Angiography performed after stent implantation revealed a filling-defect of the D1 stented segment (Figure 1, Panel A).

Multiple balloon dilatations, as well as thrombus aspiration, did not improve the angiographic phenotype.

Optical coherence tomography (OCT) with three-dimensional (3D) reconstruction using a dedicated software (OctPlus software, Pulse Medical, Shanghai, China) revealed a distal edge-stent dissection of D1 and, proximally, a partially crushed stent within the sub-intimal space (Figure 1, Panel A and Video 1).

Video 1: Dynamic 3D reconstruction of a 2D OCT run, showing the crushed D1 stent within the subintimal space. Reconstruction was performed using OctPlus software, Pulse Medical, Shanghai, China.

The presumed mechanism of stent crush might have been abluminal wiring of the previously implanted stent in D1 due to the omission of proximal optimization technique (POT). Guidance with OCT during the first procedure could have prevented this complication, as suggested by the results of the OCTOBER trial⁴.

Based upon the OCT-findings, a second stent (in-stent) was implanted in D1, connecting the proximal main-branch (MB) true-lumen to the D1 true lumen in a culotte-fashion (Figure 1, Panel B).

Good stent expansion and exclusion of the dissection plane were confirmed with both 2D and 3D-OCT (Figure 1, Panel B, and Video 2).

Video 2: Dynamic 3D reconstruction of a 2D OCT run, showing the result after implanting a second stent, to exclude the dissection plane in D1. Reconstruction was performed using OctPlus software, Pulse Medical, Shanghai, China.

In this procedure, 3D-OCT-reconstruction was instrumental to allow precise diagnostic assessment of the stent-failure mode and, subsequently, tailor percutaneous coronary intervention.

Supplementary material

Suppl. Video 3: OCT pullback from D1 to the proximal LAD, highlighting the situation before 3rd stent implantation.

Suppl. Video 4: OCT pullback from D1 to the proximal LAD, highlighting the situation after 3rd stent implantation.

Suppl. Video 5: Dynamic 3D reconstruction at the level of the LAD/D1 bifurcation, highlighting the metallic neocarina, before 3rd stent implantation.

Suppl. Video 6: Dynamic 3D reconstruction at the level of the LAD/D1 bifurcation, highlighting the metallic neocarina, after 3rd stent implantation.

References

Erglis A, Lassen JF, Di Mario C. Technical aspects of the culotte technique. EuroIntervention. 2015;11 Suppl V:V99-101.
Chang CF, Chang KH, Lai CH, Lin TH, Liu TJ, Lee WL, Su CS. Clinical outcomes of coronary artery bifurcation disease patients underwent Culotte two-stent technique: a single center experience. BMC Cardiovasc Disord. 2019 Sep 2;19(1):208. doi: 10.1186/s12872-019-1192-2. PMID: 31477022; PMCID: PMC6719358.
Lassen JF, Albiero R, Johnson TW, Burzotta F, Lefèvre T, Iles TL, Pan M, Banning AP, Chatzizisis YS, Ferenc M, Dzavik V, Milasinovic D, Darremont O, Hildick-Smith D, Louvard Y, Stankovic G. Treatment of coronary bifurcation lesions, part II: implanting two stents. The 16th expert consensus document of the European Bifurcation Club. EuroIntervention. 2022 Aug 19;18(6):457-470. doi: 10.4244/EIJ-D-22-00166. PMID: 35570753; PMCID: PMC11064682.
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Affiliations

Medizinische Klinik I, Klinikum Fürth, Academic Teaching Hospital of the Friedrich-Alexander-University Erlangen- Nürnberg, Fürth, Germany
Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland.

Conflicts of interest

Prof. Tu is the cofounder of, has received research grants from, and been a consultant for Pulse Medical.
Prof. Rittger reports consulting fees for Siemens and Speaker´s fees for Novartis, Pfizer, Astra and Boehringer.
Dr. Pyxaras reports proctorship and consultancy fees from Asahi Intecc, Biotronik and Boston Scientific.
Dr. Schincariol and Dr. Huang have no conflicts of interest to disclose.