How to do culotte bifurcation stenting

Step-by-step description of the culotte technique for coronary bifurcation stenting.
The culotte technique is performed for coronary bifurcations when:
a. the side branch (SB) is important and needs to be preserved, and
b. there is high likelihood of SB occlusion after main vessel (MV) stenting, and
c. the angle of the bifurcation is less than 70 degrees.
DK crush is another technique that can be used for such bifurcation lesions and is preferred by many due to more supportive clinical data and maintenance of guidewire position in the main vessel throughout the case, in contrast to culotte in which the MV needs to be rewired after SB stenting.
The 11 steps of the culotte technique are as follows:
1. Wire both MV and SB
2. Predilate both MV and SB
3. Deliver + deploy first stent in most angulated branch
4. Remove stent balloon
5. POT
6. Rewire non-stented vessel + remove jailed wire
7. Dilate struts into non-stented branch
8. Deliver + deploy 2nd stent
9. POT
10. Rewire initially stented branch + remove jailed wire
11. Kissing balloon inflation

[@georgetouma5430]

Culotte is best performed as a double provisional technique. It’s the easiest way to remember steps. POT must be performed after each stent placement as the stent is sized for the distal vessel and will be mallaposed proximally. This prevents wire passage understruts which may go undetected without routine imaging.
Always stent the branch that supplies the largest territory. Angulation no longer matters in current generation DES.
Lastly it is vital to wire as close to the carina as possible to optimise side branch opening to prevent creation of a long neocarina.

[@micger]

I was taught not to jail the SB wire with the MB stent creating a metal on metal jailing which makes it hard to pull the SB wire out.

[@manosbrilakis]

You should do whatever you feel comfortable with. I have jailed several wires metal on metal and have not had issues in the past. If you get resistance when trying to withdraw the guidewire you should NOT pull hard - instead advance a balloon or microcatheter over the jailed wire as distal as possible and then pull.

[@micger]

@@manosbrilakis Thanks for the tip!

[@JCT75]

Thanks Sir

[@shooterpcb]

Teleport works great to help withdraw jailed wire or a 1.0mm Sapphire balloon.

[@MinorityDoc]

Thanks for the excellent depiction Sir. really inspired by your CTO videos as well.

[@Torsade101]

Great.
Should finish with a final POT however

[@tuanhoanh1198]

Should we minimize the 2nd stent to protrude into the proximal main vessel in order to avoid overlapping long metal?

[@farukakturk5388]

Thank you for this educational video. May i consult a case?

[@drdeepakonkar]

After deploying first stent should we pull back side branch wire and put it in main vessel, this will definitely avoid wire going behind struts of first stent. We can do POT over this wire and re wire side branch again

[@huseyinuguryazc7196]

GREAT PRESENTATİON. YOU SHOULD HAVE ADDED THE FİNAL POT.

[@mythoughts8080]

great work sir

[@rajak76]

Between steps 7 and 8 is there any advantage or disadvantage to performing a kissing balloon inflation?

[@VaibhavYawalkar]

Sir at 3:50 you said you have maintained wire position in main branch but I am not able to see the wire there in main branch. Also how the wire was un-jailed was not shown. I assume that wire was simply un-jailed by pulling and then recrossed through a strut of first stent.

[@JCT75]

I think that wire has to be kept. In the workshop they must have removed it to avoid using an extra wire.

[@DrKASATKIN]

Hello. Thank you for great manual. I have a question. What size of the ballon on finale kissing?

[@yassernaceri9106]

Thank you

[@775maas]

thank u sir for this illustrative video ..
I have two question :
which is better for distal LM stenting ? DK crush or the culotte technique ?
and if the jailed wire broken during pulling it back after POT .. is there any hazards?

[@unique4u718]

Hello sir what about the size of stent protrusion ??

[@tuanhoanh1198]

Would you choose jailed balloon technique for a STEMI case with Culotte-suitable lesion or Culotte in terms of DES thrombosis?

[@BarrieLouis]

great!

[@fereydoonnaraghipour8822]

Great

[@micger]

Do you need to first POT? Wouldn't the second POT dilate both stents and optimise apposition of both stents?

[@manosbrilakis]

You need first POT, otherwise when you rewire the jailed vessel the wire may be under the struts of the initially implanted stent.

[@micger]

@@manosbrilakis Thanks for the tip. What I normally do is after deploying the first stent is that I pull the stent balloon back to the MB and then pull SB wire back to the carina (without pulling past the proximal edge of stent) and then forward into the MB through the first stent struts. And then push down the same stent balloon down the MB and dilate the struts + MB part of the first stent - that would avoid the issue of rewiring under the struts of the first stent?

[@JohnWick-wh8sn]

@@micger Hi that's a great idea. Usually, do you do kissing balloon with NC balloon? or it doesn't matter, and whats your inflating pressure for that? :-)

[@JCT75]

micger thats a great tip

[@josehar9474]

❤

[@yasserelsayed632]

Good jop

[@trooperrex9972]

Culotte is allways risky...bcause you leave the MV unprotected. MV allways before SB. Therefore for me allways T...TAP...DK

[@mehmetdemir2369]

After kissing balloon , isn't final POT ( instead of second POT) necessary?

[@manosbrilakis]

Another POT should be done if the kissing balloons did not come back enough into the MV. If kissing balloon are back enough in the MV and the MV is well expanded it may not necessary.

[@georgetouma5430]

Manos Brilakis the opposite is true. If the kissing balloons are in the polygon of confluence (which is elliptical anyway) ie minimal overlap in main vessel POT is not needed. If the kissing balloons come back a long way into the main vessel then a POT is definitely needed to correct elliptical deformation.
Great videos. Thanks