Stent malapposition caused by improper rewiring during left main intervention: the role of intravascular ultrasound in avoidance and management--a case report.

The optimal technique for bifurcation stenting of distal Left main (LM) lesions remains unestablished and controversial. Some techniques with superior stent apposition, such as culotte technique were supposed to be associated with lower rate of stent thrombosis. However, with culotte technique, the double-stent layer at the carina and in the proximal part of the bifurcation, may lead to difficult or improper rewiring of the side branch before final kissing balloon postdilatation (KBP). We describe a case of distal LM disease associated with distal left circumflex (LCX) and posterior descending artery stenosis. During LM stenting using culotte technique, improper rewiring of LCX before final KBP caused malapposition of the inner sent layer at the mid part of LM. Despite the optimal angiographic result, intravascular ultrasound (IVUS) was able to detect stent malapposition and guided further management to achieve complete stent apposition. The present case indicates that IVUS is an essential tool for LM stenting particularly when applying double stent strategy requiring final rewiring before KBP. Moreover, we suggest that some tools, such as Crusade and Venture catheters, can be used to ensure proper rewiring and hence, prevent subsequent stent malapposition, which may lead to catastrophic complications such as early and late LM stent thrombosis.