All right, so we'll show you a case of plastic culotte that I did recently. So this was a diabetic male in the 60s who really was essentially free of critical obstructive disease in the LAD system, and he had a non-dominant right. So this was, he came in with a seven-week history of chest discomfort, which culminated in non-STEMI, and this was his angiogram. And I'm not showing you the diagnostic studies, I'm just going to show you where we started off from the PCI procedure. So he really has a large circumflex marginal system, and you know, the congenation of the circumflex, it's subtotal, and so there's also a lesion of the osteomarginal large marginal branch. So I'm going to stop here, and Gabor, what do you think, is this a reasonable case to think about a two-stent strategy with a culotte technique? And anyone else can pitch in. So my view on the definition of the techniques is that, indeed, this case looks like a case which will probably, or most probably, end with two stents. But, and I will show you at the end of my slides the thinking algorithm, what I have in mind when I decide about the stenting technique, but actually only DK Crush is the single technique when you have to say right away which technique you're going to use during your procedure. Culotte and provisional, it starts with the same steps. So performing a provisional approach means that you give a chance that maybe you can finish with one stent, or you will end up with two stents, but you don't define it right away. So, but in general, I agree with this case that this case will most, most, most probably end with two stents, and as you said, I will just start with the steps of provisional, keeping open for finishing with two stents at the end. So Arasi, Prateek, or John, any comments? I'm not sure, I'm a big fan of provisional stenting, but in this case when there's disease both at the end of the, it's like a one, one, one Medina, right? So I would kind of aim for upfront to a stent strategy and, you know, Culotte or DK Crush depends on how the PDPL, PD branch looks after you've wired and ballooned it. That would be my approach. I agree with Arasi. I think just given the disease at both, you know, honesty of both branches, and I think a two stent strategy up front with Culotte is probably appropriate here. All right, so also notice the fact that the vessels are calcified even before I inject contrast. So what I did was I wired both the left circumflex and second marginal. The, I used a run-through which is about work hours tomorrow, which went in pretty easily in the second marginal, but I had real difficulty in crossing into the lower marginal. And in fact, it was a functional CTO, I crossed with a turnpike LP and a mongo wire. And after that, pre-dilated the continuation circumflex, the mid-portion with it, starting with a 1.5 balloon and a 2.0 semi-compliant balloon, and then perform pre-dilatation of the OM with a 2.0 semi-compliant balloon. After this, you know, there's a vase that you notice in the marginal, right, which is not yielding, and I couldn't pass it to a non-compliant balloon. And the post-PCI angiogram after I did balloon work is as shown in this movie here. So just keep on playing it. So I could not, I tried to get a 2.5 into the side branch, I could not. And I knew the branches were both calcified. And so what is the next step, guys, and what did you do for this calcified lesion? Are you going to think of some kind of arthritomy or other kind of plaque modification here now? Next? No, I'll go first. You know, if your 2.0 balloon still got a vase and you're unable to deliver a 2.5 balloon, the chances of delivering a shockwave balloon are very low. So I would either try to IVAS it to understand exactly what's happening, but more than likely IVAS also may not go. Switch out the wire for a rotafloppy and try to do arthritomy would be my next step. Okay. And I might do the CTO branch first before I tackle the other OM branch. So actually, I was able to deliver a shockwave, I was able to deliver a 2.5 by 12 shockwave into the mid-circ, 20 pulses were given, there was no vase, and I was able to push it to the stenosis and then beyond. This balloon sort of pulled back a little bit, but delivered 30 pulses with resolution of the vase. I had to use a guideliner over here, if you notice in the top, to be able to do it, and I had to pull back the wire for the continuation of the circumflex when I did the side branch. So after this, we removed the wire, but both diodized it with a 2.0 semi-compact balloon again, and I didn't think the vessel was very large, by the way, I was not able to deliver one of my IVAS systems to appropriately size it, but I was able to deliver and right beyond the curve where the stenosis was, beyond it, the stem was a 2.0 by 30 millimeter drug-loading stem, and I have not yet wired the continuation, but anyway, this is what I did, and then I, because the proximal circ was larger, I did a pot with 3.5 by 12, and also with a 4.0 NC balloon, sized it up a little bit. And then I was, no, sorry, I did a pot with 3.5 by 12, and I was not able to wire the continuation of circumflex, so I ended up with a pot with a 4.0 non-compliant balloon, then I was able to rewire it to the continuation of the circ, and then I did a balloon dilatation of the stem struts with 2.5 non-compliant balloon. After this, I delivered a 2.5 by 26 drug-loading stent from the proximal circ to beyond the stenosis. The stenosis was really a short stenosis over here, it didn't quite extend as far down, and then I did a pot, and then I was able to rewire the side branch, I don't have a picture of the pot, I rewired the second marginal, did the balloon dilatation, and then used a 2.5 by 12 balloon to do kissing balloon inflation, then the final pot with a 4.0 by 8 non-compliant balloon. And just to show the steps that Gabor just did, the first one was, of course, a stent after prep, side branch to the main vessel, the second thing was a pot, then after dilatation of the struts, push a stent through, then do a pot, then rewire both, and do the only kissing balloon inflation in this series, then do a pot again, and then your end of the result. And this was the result in this case, and I'll just play it through. That looks absolutely beautiful, Dr. Raab. So I'll take comments from Gabor, Pratik, or John, and we can move to chat questions. That's a nice result. One of the things that comes up is you pull your main branch wire, so if you're ballooning aggressively and you have a dissection when you're prepping the vessel, do you feel comfortable doing that here? Say, after ballooning both branches, you had a dissection in one of the branches, Dr. Raab. Yeah, you may have to think what a strategy change there, what you do next, you know? But I think, you know, if you've done an adequate dilatation, you take a chance and do it. And even if you're going to dissection plane, you can probably do a parallel wiring to get back into another plane, as you did in one of the cases of the LAD that you did, Pratik, the parallel wiring for some months ago. But I think I'm comfortable, I'm comfortable with it. Yeah, yeah, I mean, I think that's one of the things to consider when, you know, trying to use couloir technique for bifurcations, is to give up that main branch wire if you're concerned about a dissection. I think what this case demonstrated nicely, that a common comment on couloir technique is that people like to say that in case of smaller side branches, you have problems because of the side branch, main branch diameter mismatch. But as you have shown that actually most of our stands, but again, please check, everyone should check what kind of stand you have on your shelf in your cat lab. But there are nowadays, there are stands with amazing expansion capacitors. So even in this case where you have chosen relatively small stands fitting to the distal diameters, you were able to expand to quite large diameters for the proximal main branch where it was needed. And so I'm fully against this critique, which is used commonly against couloir technique, because I think nowadays with the stands what we have, this expansion capacity and diameter mismatch issue is less of a problem. Now the other thing is that, you know, this was a difficult side branch to deal with in terms of ballooning and plaque preparation. And so in this kind of strategy, side branch stenting first, and two branches of almost similar size favor couloir technique by preserving side branch access, okay? So that's why I chose this technique. So in the interest of time, John, is there any question before I ask Gabriel to go to DK Couloir to present his case? So there's not any questions in the chat, but I have a question for the entire panel. When you're doing the kissing balloon, do you do low pressure inflation, like eight atmospheres in both balloons, or do you all prefer 12 atmospheres in both balloons? I go high pressure in each branch, and then the simultaneous is a lower pressure. So I might go up to 16 in each branch, and then drop it to eight or 10 in the final kissing balloon inflation. I fully agree with you. This is also what I would do. I would go even for higher pressure. So note these were calcified lesions. Even if you prepared it with shockwave, these are still calcified lesions which you just stented. So for me, the kissing is on one hand, it's the optimization, the centralization of the carina, but it's also the post dilation of one or other stent. So what I normally do, I even go to 20 plus bars on one branch, then 20 plus bars on the other branch. And then just the real kissing, the simultaneous inflation should be around 12, 14 bars.

diabetic male

angiogram

two-stent strategy

stent placement

kissing balloon technique