A 33 year old male complained of worsening chest pain and fatigue with light activities such as walking 100 meter, giving a long speech in the last 3 months. He had 3 vessels and critical left main (LM) disease with in-stent restenosis (ISR) at proximal Left Anterior Descending (LAD) artery. On March 2024 at Regional Hospital, he underwent balloon angioplasty for ISR and had 1 stent implanted overlapped distal to the previous one. His Body Mass Index was 31.8 kg/m² other findings were unremarkable.
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The Electrocardiogram showed Sinus Rhythm with poor R wave progression in V1-V5. Echocardiography revealed good ejection fraction (LVEF 57%), global normokinetic at rest and mild to moderate Aortic Regurgitation. 

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Cannulation of Left Coronary Artery (LCA) was challenging due to pressure damping. With the side-hole EBU 3.5/6F (Medtronic) positioned just in front of the ostium, the angiography revealed progression of the lesion, i.e. subtotal occlusion of ostial-distal LM, subtotal occlusion of ostial LAD and Left Circumflex (LCX) artery with appearance of underflow to proximal-distal LAD and LCX (Medina 1,1,1). 

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Double wiring with workhorse wire to LCX served as anchor while the other wire crossed the lesion to LM-LAD.Semi-compliant (SC) balloon 2.0 x 15 mm was used to predilate LM ostial-proximal LAD and ostial-proximal LCX while Non-compliant (NC) balloon 3.5 x 15 mm treated the LAD ISR and predilate ostial-proximal LCX. Angiographic evaluation showed TIMI flow 3, residual stenosis at LAD and LCX and type B dissection at proximal LCX. The intravascular ultrasound (IVUS) showed  < 90^o calcium arc fibrocalcific plaque, calcium nodule at proximal LCX and some lipid plaque at mid LAD. The LAD ISR was caused by undersized and under expansion with minimal neointimal hyperplasia. Based on the angiography and IVUS data, Mini Culotte Double Kissing Technique was planned. Stent DES 3.0 x 38 mm was implanted at ostial-proximal LCX with protrusion to distal LM then POT with NC 4.0 x 10 mm balloon. Balloon SC 2.0 x 15 mm was used to open strut to LAD. The jailed wire was retracted after rewiring with workhorse wire to LAD. Simultaneous kissing balloon inflation was done with NC 3.5 x 20 mm balloon to LM-LAD and NC 3.0 x 20 mm to LM-LCX.After DES 3.5 x 18 mm stent was implanted in ostial LM-proximal LAD, the POT, opening strut to LCX, rewiring and retracting jailed wire from LCX and the final kissing balloon inflation was done with the same devices and procedures as the previous. The final angiography demonstrated TIMI 3 flow from LM to distal LAD and LCX, no dissection, perforation or residual stenosis.

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Complex bifurcation lesion remains a challenge in PCI. Choosing the most appropriate strategy is crucial. The Double Kissing Mini-Culotte technique is reliable to treat the suitable complex bifurcation lesion. As a modification of classical culotte technique, it offers significant advantages including relatively easier and safer to perform, enhanced immediate procedural success in regards to morphological characteristics, and good clinical outcome.