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A 50 year-old ex-army man presented with worsening chest pain with reduced effort tolerance for 1 week. He has Diabetes, Hypertension and had CABG with 4 grafts in 2011 after a myocardial infarction.  His heart rate was 105 bpm and blood pressure of 110/70mmHg. Clinical examination is unremarkable. 

ECG showed Sinus tachycardia, T wave inversion V5-V6, Troponin T not raised. He was treated for Unstable Angina.  ECHO showed reduced ejection fraction of 34% with multiple hypokinesia segments.                  
                     

Coronary angiogram showed severely diseased Left main (LM) with chronic total occlusion Left anterior descending (LAD) and severe stenosis at the ostial & proximal segments of an angulated Left circumflex (LCx) with calcification & also the ostium of the Obtuse marginal (OM) (Medina 1,1,1). Right coronary artery (RCA) had chronic total occlusion from proximal with side branch collaterals. Graft study revealed only a patent LIMA-LAD graft.

Percutaneous Intervention to LM/LCx & OM using an EBU 3.5/6Fr guiding catheter via Right femoral with 6Fr sheath. We first predilated the proximal &Ostial OM till the LM (MB)with RYUREI 2.0/15mm up to 14atm then with SCOREFLEX NC 2.25/15mm up to 14atmafter crossing it with Run through floppy workhorse wire. This was done to facilitate the wiring of both OM (MB) & the angulated LCx (SB). By using FIELDER XT, we were able to cross the ostial LCx lesion and predilated it with SCOREFLEX NC 2.25/15mm up to LM with 20atm.  FIELDER XT was exchanged to SION BLUE then to Grandslam for better support using the FINECROSS microcatheter. Further predilation with SCOREFLEX NC 2.25/15mm up to 22atm again before stented LM-LCx with BIOFREEDOM ULTRA 2.25/14mm followed by postdilation with APOLLO NC 2.5/10mm up to 22atm. OM was rewired first with SION BLUE before postdilation 1st stent with APOLLO NC 2.25/10mm 14atm followed by Kissing balloon inflation using APOLLO NC 2.25/10mm 14atm at OM and APOLLO NC 2.25/8mm 14atm at LCx. After Kissing balloon inflation, we overlap stent LM-OM with BIOFREEDOM ULTRA 2.25/24mm and postdilated with APOLLO NC 2.75/12mm up to 20atm.1^st stent at LCx was recrossed with Run through floppy before final Kissing balloon inflation done with APOLLO NC 2.25/8mm at 14atm LCx and APOLLO NC2.25/10mm 14atm at OM. Procedure ended with postdilation (POT) of LM with APOLLO NC 2.75/12mm upto 22atm. Right femoral access was closed with Angioseal device. 

Coronary bifurcation stenting remains a complex procedure with high risk of stent thrombosis and restenosis even with contemporary techniques. Culotte stenting technique was used in this patient with similar vessel size of OM & LCx. His calcified vessels and angulated LCx was a challenge to us in wiring and deploying the stent, however we were able to do so with adequate vessel preparation and different coronary guide wires. Vessel diameter between the branches and the concept of plaque shift and carina shift is important in determining the strategy in bifurcation stenting, also the training experience of the operator.