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A planned hybrid culotte stenting procedure in the setting of an
Chitradeep De*1, Medhat Zaher1, Mayur Lakhani1, Joseph T McGinn Jr1,
Roberto Baglini2 and Duccio Baldari1
Address: 1Staten Island University Hospital, 475 Seaview Avenue, Staten Island, New York 10305, USA and 2University of Pittsburgh Medical
Center in Italy, Via Tricomi 1, 90127 Palermo, Italy
Email: Chitradeep De* - firstname.lastname@example.org; Medhat Zaher - email@example.com;
Mayur Lakhani - firstname.lastname@example.org; Joseph T McGinn - email@example.com; Roberto Baglini - firstname.lastname@example.org;
Duccio Baldari - email@example.com
* Corresponding author
Introduction: Bifurcation lesions have traditionally presented a unique problem for interventional
cardiologists because of their inherent anatomy and risk of closure of the side branch, after a
percutaneous intervention for the primary lesion of the main branch.
Case Presentation: We report the case of a 57-year-old man who presented with acute ST-
segment elevation myocardial infarction secondary to a 100% occlusion at the ostium of first
diagonal (D1) branch. Patient also had a 70% stenosis of the mid-segment of the left anterior
descending (LAD) coronary artery at the D1 branching point (1,1,1 Medina classification). A bare
metal stent (BMS) was deployed at the site of the culprit lesion in the D1, while a drug eluting stent
(DES) was placed in the LAD. We believe that the BMS at the culprit thrombotic, inflamed site in
D1 is more likely to re endothelialize than a DES and the DES in the LAD, is less likely to re-stenose
than a BMS.
Conclusion: This is the only reported case, where in the setting of an acute ST elevation
myocardial infarction, a hybrid Culotte technique was successfully performed with excellent long-
term results, thus achieving an acceptable balance of risks between restenosis (in the case of a BMS)
and stent thrombosis (in the case of a DES).
A 57-year-old Caucasian man presented to the emergency
room with severe precordial chest pressure radiating to
the left jaw and arm and associated with dyspnea and nau-
sea. The past medical history included gout and hypercho-
lesterolemia for which he was treated with atorvastatin
and allopurinol. He also was a chronic heavy smoker but
denied history of alcohol or drug abuse.
The patient was in mild distress. Initial physical examina-
tion revealed blood pressure of 180/115 mmHg and heart
rate of 96 beats/min with regular rhythm. Cardiac exami-
nation showed normal first and second heart sounds with
no audible murmurs, rubs or gallops. He was given sub-
lingual nitroglycerine with some relief of chest pain. A stat
electrocardiogram revealed ST-segment elevation in leads
V3-V6. He was given aspirin 325 mg orally, metoprolol 50
Published: 27 November 2009
Cases Journal 2009, 2:9104doi:10.1186/1757-1626-2-9104
Received: 26 October 2009
Accepted: 27 November 2009
This article is available from: http://www.casesjournal.com/content/2/1/9104
© 2009 De et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cases Journal 2009, 2:9104http://www.casesjournal.com/content/2/1/9104
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mg orally, clopidogrel 300 mg orally, atorvastatin 80 mg
orally, a bolus of heparin 5000 units intravenously as well
as nitroglycerine infusion at 25 mcg/min.
Emergent selective coronary angiography showed a 100%
occlusion with a filling defect suggestive of thrombosis at
the ostium of the first diagonal branch (D1) and a 70%
stenosis of the mid-segment of the left anterior descend-
ing coronary artery (LAD) at the D1 branching point
(1,1,1 Medina classification). Balloon angioplasty was
performed on the D1 lesion using Maverick 2 RX 2.0 × 12
balloon with maximum inflation pressure of 16 atm lead-
ing to reestablishment of blood flow through D1. Chest
pain improved significantly and ST-segment elevations
started to regress. Further dilation of the same lesion was
done using Maverick 2 RX 2.5 × 15 balloon with maxi-
mum inflation pressure of 6 atm. A Mini Vision 2.5 × 18
bare metal stent (BMS) was deployed in the D1 ostium
with maximum inflation pressure of 16 atm.
Using the Cullote technique, balloon angioplasty using
Maverick 2 RX 2.5 × 15 balloon with maximum inflation
pressure of 10 atm was performed on the 70% stenosis of
the mid LAD. Then a Paclitaxel eluding stent (Taxus) RX
3.0 × 20 was deployed in the LAD lesion with maximum
inflation pressure of 16 atm. Simultaneous kissing bal-
loons were inflated in the D1 and the mid LAD using Mav-
erick 2 RX 2.5 × 15 with maximum inflation pressure of 6
atms in the LAD and Maverick 2 RX 2.5 × 15 with maxi-
mum inflation pressure of 10 atms in D1. Following inter-
vention, there was excellent angiographic appearance
with 0% residual stenosis of both vessels. The patient was
transferred to the coronary care unit for overnight obser-
vation and was discharged home the following day with-
Three months later, staged percutaneous coronary inter-
vention of an 80% stenosis of the mid right coronary
artery was performed. Angiography revealed a 40% reste-
nosis of the BMS in the D1 and no restenosis in drug elut-
ing stent (DES) in the LAD. The patient continues to be
Interventional treatment of coronary artery bifurcation
lesions represents one of the most challenging techniques
in the field of coronary interventions. Bifurcation lesions
represent up to 16% of coronary targets for intervention
. When compared with non-bifurcation interventions,
bifurcation interventions have a lower rate of procedural
success, higher procedural costs, longer hospitalization,
and a higher rate of clinical and angiographic re-stenosis.
Plaque redistribution "plaque shift" across the carina of
the bifurcation may risk occlusion of the side branch or
even the parent vessel [2-5]. Eccentric stenosis at the bifur-
cation and ostial narrowing of the side branch further
increase this risk . The kissing balloon technique was
developed more than twenty years ago for side branch
protection . More recently, in the coronary artery stents
era, many techniques were described to stent bifurcation
lesions . However, it was shown that stenting both ves-
sels in a bifurcation lesion provides no advantage in terms
of procedural success and late outcome versus a simpler
strategy of stenting only the parent vessel if feasible ana-
tomically . In some cases, the bifurcation lesion anat-
omy places a major vessel or more at a very high risk of
occlusion dictating stenting both vessels. Chevalier et al
have first proposed the Culotte technique as a new option
for bifurcation lesion stenting in 50 patients and reported
an acceptable re-stenosis rate of 24% .
However, later reports on double stenting of bifurcation
lesions using BMS although provides better immediate
angiographic results is associated with higher (37.6%)
incidence of clinically driven repeat target lesion revascu-
larization with 2 stents as compared to 5.6% using 1 stent
at six months . On the other hand, bifurcation lesion
stenting using DES was shown to be associated with sig-
nificantly higher rates of stent thrombosis in multiple
studies [10-13]. In one study, DES was associated with a
significantly higher risk of stent thrombosis at 9 months
with a hazard ratio of 6.42 (95% CI, 2.93-14.07; P < .001)
In our particular case, the D1 had a true ostial occlusive
lesion and was associated with a 70% lesion in the mid
LAD, necessitating double stenting of the bifurcation to
salvage the large D1 and protect the diseased LAD.
Based on the previous data, we believe that stenting of
bifurcation lesions with two BMSs will significantly
increase the risk of restenosis and rate of target vessel
revascularization. On the other hand, using two DESs
instead will significantly impair re-endothelialization and
increase the risk of stent thrombosis. Consequently, we
chose to pursue a balanced approach using a hybrid tech-
nique of a BMS and a DES. We chose to deploy the BMS at
the site of the culprit lesion in the D1 and DES in the LAD.
We believe that the BMS at the culprit thrombotic,
inflamed site in D1 is more likely to re endothelialize than
a DES and the DES in the LAD, is less likely to re-stenose
than a BMS. Furthermore, using culotte technique, we
were able to completely cover all the coronary layers of the
bifurcation lesion, avoiding any excessive "crushing" of
displaced and distorted metal against the coronary wall.
Thus, in our opinion, we achieved a balance and accepta-
ble compromise between potential benefits and risks.
Although this hybrid technique still carries a risk in terms
of re-stenosis of the D1 stent and/or stent thrombosis of
the LAD stent, we feel this approach could be significantly
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Cases Journal 2009, 2:9104 http://www.casesjournal.com/content/2/1/9104
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useful, especially during the acute phase of STEMI where
a bifurcation lesion is involved.
In our opinion, the most suitable subsets of bifurcation
lesions for this approach should be Medina 0,1,1 and
1,1,1 with significant involvement of the main branch.
This is the only reported case to our knowledge, where in
the setting of an acute ST-segment elevation myocardial
infarction, a hybrid culotte technique was successfully
performed with excellent long-term results, achieving an
acceptable balance of risks between restenosis (in the case
of a BMS) and stent thrombosis (in the case of a DES).
This case could serve as a sentinel for further research
using our rationale in a larger number of patients.
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
DB, ML, MZ and CD analyzed and interpreted the patient
data regarding the unique presentation and the novel
intervention performed on the patient. CD, JM and DB
were instrumental in obtaining informed consent and
also in the preparation of the manuscript. All authors read
and approved the final manuscript.
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