Class #3: Mini-culotte

We discussed the following case:

Case Summary: a 60-year-old man presented with inferior STEMI. Right radial access was obtained and a 6-Fr Heartrail Ikari Left 3.5 guiding catheter was used to engage the RCA , which showed an occluded mid-RCA. A Sion Black wire was passed down the RCA and aspiration thrombectomy was performed using 6F Thrombuster II followed by balloon dilatation establishing RCA patency, however the RV marginal was lost and the patient developed hypotension and bradycardia.  A Sion wire was used to wire the RV marginal followed by balloon dilatation of the ostium of the RV marginal and mid RCA restoring flow to the RCA/RV marginal system. The ostium of the RV marginal was stented with a  2.5×18 DES (Xience Alpine) ensuring  a single stent strut protruded into the RCA (main branch). The stent balloon was then removed and a “mini-culotte” was performed by retracting RV marginal wire back into the proximal RCA and wiring through a single stent strut towards the distal RCA which was then dilated with a 3.0mm balloon. A 3.5×38 DES (Xience Alpine) was then passed through this strut, inflated and post-dilated with a 4.0mm NC balloon. The RV marginal was then rewired and kissing dilatation was performed (3.5mm NC in RCA and 2.75mm NC in RV marginal) followed by a final POT using a 4.0mm NC balloon.

Challenges Encountered: Medina 1-1-1 mid RCA lesion involving the RV marginal and haemodynamic collapse with transient loss of the RV marginal after aspiration thrombectomy and initial balloon dilatation

Devices: Heartrail 6F Ikari Left 3.5 guiding catheter, 6F Thrombuster II

Wires: x2 Sion Black wires

Learning Points:

  • The mini-culotte technique uses two stents and leads to full coverage of the bifurcation without the expense of an excess of metal covering of the proximal end (cf. original culotte technique) because main branch stent is delivered through a single side branch stent strut
  • The main disadvantage of the technique is that rewiring the single stent strut of the side branch stent can be difficult

 

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