SA

75 years old female, had no significant medical and surgical history. One evening ,the patient shifted from one hospital to our tertiary care center with the complaint of severe chest pain of 2 hours duration. Her physical examination at the time of admission showed stable vital signs with HR-75/min, BP -130/80mmHg, R.R 15cycle/minute, RBS-115 mg/dl, heart sounds normal, lungs-clear.

Investigations revealed ECG-NSR with ST elevations in I, avL and posterior chest leads; creatinine-1.0mg/dl, troponin T positive, CPK-MB-48mg/dl; 2D echocardiogram- regional wall motion abnormalities of lateral& posterior wall with good LV function, EF –50% with mild mitral incompetence.

Left main coronary artery: osteal 90% stenosis and trifurcating to LAD LCX and Ramus. LAD: 90% narrowing involving its ostium and 80% lesion involving its proximal segment.LCX is a small non-dominant vessel with proximal segment subtotal occlusionRamus branch showed proximal subtotal lesion.Her right coronary showed no significant lesion.
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Prior to insertion, the XB 3.5 guide catheter was preloaded with 2 BMW wires. The first wire (vessel wire) was shaped using standard technique according to the LAD curvature. An exaggerated, large loop was formed to use as a floating wire. The vessel wire was easily advanced into the LAD; and the catheter was then carefully withdrawn to disengage the LM, while constantly maintaining distal wire position. Next, the floating wire was advanced into the aortic root to protect against guiding catheter deep intubation. Then a third wire was introduced into the Ramus branch.The LAD lesion stenosis was predilated with 1.5 x 12 mm balloon. A roadmap cineangiogram was then performed then a 3 x 38 mm DES stent was advanced into the left main- LAD lesion and deployed.POT of the left main was done by a 4.5 x 12 mm NC balloon. Meticulous distal rewiring was done followed by kissing technique with a 3 x 12mm balloon in the LAD and 3 x 12 mm balloon in the Ramus.Another DES stent 2.75 x 38 mm was advanced and deployed into the left main- Ramus with minimal protrusion into LM intending for mini Culotte technique. 2^nd POT was done with 4.5 x 12 mm NC balloon followed by another distal rewiring and 2nd kissing balloon using the same 2 balloons 3 x 12 mm each. Final POT using 4.5 x 12mm NC balloon was done with an excellent final result.

In patient with acute coronary syndrome the final TIMI flow together with the residual lesions will shape the long term outcome in such patients, in spite of being debatable, two stent technique in acute settings may be practiced provided the good preparation and the whole team experience with such procedures and techniques.When choosing a two-stent technique in acute setting ,techniques with minimal stent overlap and metal layers may be preferable such as the TAP but in our patient with such an acute angle between both branches, mini Culotte with the minimal overlap may be a viable option.