Stepwise bifurcation strategy in totally occluded spontaneous left main coronary artery (LMCA) dissection: Successful management with the culotte technique

Spontaneous coronary artery dissection (SCAD) is a rare, non-atherosclerotic cause of acute coronary syndrome, with left main coronary artery (LMCA) involvement being particularly uncommon and life-threatening. We report the case of a 39-year-old previously healthy female who presented with recurrent chest pain and syncope. Initial investigations were inconclusive, but she later developed hypotension and ischemic electrocardiography changes, prompting emergent coronary angiography. A dissection of the LMCA extending into the left anterior descending artery and first diagonal artery was identified, with likely circumflex artery occlusion. Given the patient's instability, immediate percutaneous coronary intervention was performed using a stepwise bifurcation stenting approach, culminating in the culotte technique. The patient made a full recovery with normalization of cardiac function and remained asymptomatic during long-term follow-up. This case highlights the clinical challenges of diagnosing and managing SCAD involving the LMCA and demonstrates that timely intervention with structured bifurcation strategies can result in excellent outcomes, even in high-risk scenarios.