Thank you for having me here for this webinar. As just mentioned during the interaction, let's start from the traditional way of culotte. So, when we are talking about different bifurcation techniques, and as you just said, there's every month, every week, there's a new technique that we need to talk about, but I think there are some main principles that we have to keep in mind when we try to compare different techniques. And there are some advantages and disadvantages that we have to keep in mind. When we talk about the actual traditional techniques, the provisional, the tap, the culotte, and the decay crush, what we have to consider, how is the side branch osteal coverage with one or the other technique? We have to understand that in the provisional technique, of course, we have a poor osteal coverage for the side branch, while for the double stand techniques, the coverage is good or better. Second important question, neocarina, we know that neocarina is, let's say, it's a bad thing. Neocarina, if you perform it properly, that with single stand technique, there is no neocarina. With any two stand techniques, there are different magnitude of neocarina, and depending on how well you master the technique, you can optimize this aspect. Multiple layers, of course, if you have single stand, then there is no multiple layers. If you have more stand, there are different spots of multiple layers. With culotte, in the proximal main branch, you have the double layer, depending on the extent of the overlap of the two stand. It can be a lot or it can be just a few millimeters, while in decay crush, you have actually even a triple layer at a certain length. Potential hotspots for malaposition. Again, when we are discussing all the new techniques, hotspots of malaposition are practically the summary of the previous two points, the neocarina and the multiple layer parts. These are the hotspots of malaposition. The neocarina is, let's say, a floating strut level, and at every level where you have double layers, these are potentially hotspots for malapositions. And the technical complexity, of course, the more you master the technique, the less complex it sounds for you, but still, we have to admit there are easier and more complex techniques on the range from PN protrusion to decay crush. When we talk about traditional culotte, actually, the following steps, what we have to keep in mind, with traditional culotte, we start to stand one of the two branches. Normally, we start to stand the side branch in this case, with a certain couple of millimeters of protrusion to the main branch. And the next most important step here is to perform the proximal optimization. Why? Because, of course, especially in case of side branch stenting, it results in massive malaposition in the proximal main branch. But we have to correct before we will rewire the distal branch. Here you can see that for proximal optimization, you take a balloon which fits to the size of the proximal main branch. And this is why I think it's probably obvious for everyone in the audience that due to the diameter mismatch between the daughter branches and proximal main branch, there is the mismatch in the stent, mismatch between the stent size and the proximal main branch size. And this is what we have to correct in order that the stent is well opposed and in order that during rewiring, we are certainly inside the stent and not somewhere behind picking up struts. An important thing to understand with proximal optimization is the type of balloon what we use. This is something what we are not much talking about, but there are different balloons of the market and you have to check what you have on your shelf in your cat lab. Because when we say that normally in bifurcation club, people say that, OK, for proximal optimization, put the marker to the level of the carina. We have to understand that there is this conical shaped tip of the balloon, which extends beyond the marker and this is potentially oversized for the distal branches, while in some other dedicated devices, the shoulder of the balloon is much shorter. So you have to understand what kind of balloon you have in your cat lab and this might define how to position the balloon when you perform proximal optimization. So after this step, you rewire the, let's say, the jail branch and after predilation, you put the stent again fitted to the size of the distal branch. And accordingly, the next step is just as before, performing a proximal optimization. An important difference, while the first stent needs to only protrude a couple of millimeters into the main branch, the second stent has to be just as long enough to fitting you to your proximal optimization balloon, meaning that the balloon, your shortest balloon, the stent length in the proximal main branch should be at least as long as your shorter balloon in order you can perform an appropriate proximal optimization. After that, again, you perform rewiring and you perform the kissing and eventually a final proximal optimization resulting in this trouser-like result of the culotte showing that it's one stent toward the side branch, one stent toward the main branch with a certain double layer in the proximal main branch. So, these were the key steps of culotte and I hand it over to Reb to show a case fitting to this technique.

bifurcation stenting

traditional techniques

culotte technique

proximal optimization

case presentation