A 77-year-old man who had acute coronary syndrome with reported chest pain was transported to the emergency department on a weekend night. He had received hemodialysis for more than 10 years and, on admission, had acute heart failure. An electrocardiogram showed ST-segment elevation in the augmented Vector Right (aVR) lead and ST-depression in the V4-6 leads. Left ventricular ejection fraction was 40% with anterior hypokinesis. Mechanical ventilation was performed because of hypoxemia and disturbance of consciousness. Then we performed emergent coronary angiography, which revealed left main true bifurcation lesion (LMTBL) (Medina classification 1-1-1) and severe stenosis in the mid-left anterior descending artery (LAD) with severe calcification (Figure 1A). Thrombolysis In Myocardial Infarction (TIMI) grade 2 flow of left coronary artery system was improved to TIMI grade 3 with support from an intra-aortic balloon pump. The right coronary artery had intermediate stenosis with calcification in the vessel wall (Figure 2). An intravascular ultrasound (IVUS) catheter could not pass the distal left main trunk lesion. Rotational atherectomy (RA) (Rotablator; Boston Scientific, Boston, Massachusetts, USA; burr size 1.5 mm) was performed in both the LAD and the left circumflex artery (LCx), and an additional RA (burr size 2.0 mm) was performed in the left main trunk and proximal LAD with high and low speeds. The procedure was successfully finished with TIMI grade 3 flow using verapamil, nicorandil, and nitroprusside (Figure 1B). Endovascular intervention for arterial access was also performed because of severe stenosis in the left common iliac artery before the initial PCI (Figure 3). Heart failure was controlled by the initial PCI with only RA. SYNTAX score was 47, and SYNTAX-II score was 71.0 for PCI and 59.7 for CABG after initial PCI. We discussed coronary revascularization options (CABG or PCI) in the dialysis setting with the heart team, including the surgeons; however, the patient and his family chose PCI because of the serious expected complications from long-term hemodialysis. We performed the second RA (burr size 1.75 mm) to the mid LAD and proximal LCx with high and low speeds and culotte stenting (LAD: Resolute Integrity 3.0 x 15 mm (Medtronic, Santa Rosa, California, USA); LCx: Resolute Integrity 3.0 x 18 mm, kissing balloon inflation, post-dilatation and proximal optimized dilatation with 4.0-mm non-compliant balloon catheter) with IVUS guidance (Figure 1C). IVUS study showed that the minimum stent areas were 11.87 mm2 in the left main trunk, 8.91 mm2 in the LAD, and 6.62 mm2 in the LCx (Figure 4A-C), and no malapposition of the drug-eluting stent (DES). There was no elevation in creatine kinase-MB after either PCI. Aspirin and clopidogrel were selected as dual antiplatelet therapy.
One year after undergoing culotte stenting, the patient developed dyspnea on exercise without heart failure. Follow-up angiographic surveillance was performed and showed in-stent restenosis in the proximal LAD, which had functional significance with fractional flow reserve value 0.72 (Figure 1D). We discussed this with the heart team again, and minimally invasive direct coronary artery bypass (left internal mammary artery to LAD) was performed by the cardiac surgeons. The patient, however, died a few days later in an intensive care unit because of non-occlusive mesenteric ischemia (NOMI), which was found by lactate acidosis on arterial blood gas evaluation and contrast-enhanced computed tomography (Figure 5A-C).