So, let me, let me start. So, this is a case that I did a few years ago. So, this is a 51-year-old man that had, that had a stent three years before presentation, because it's been three years, his doctor told him to stop taking Clopidogrel. Very early in the morning, he comes in with one or two hours of chest pain. The pre-hospital EKG shows ST elevation in the anterior lids. Patient receives in the ER at 6 a.m., treated with morphine, Ticagrelor 180, and transferred to the cath lab at 6.15. So, in this case, we were using an Ikari. It's not like, it's not my favorite guiding catheter, but, you know, I was testing the Ikari. So, Ikari IL-3.5 or Ikari IL-4, but it's a left coronary that allows you to engage of both vessels. So, I engage the right first, because it wasn't going to take much longer. It's only one view. So, then you flip the catheter to the other side, and you get the, a good view. So, my views for the, we didn't talk about that. I usually use an AP caudal and an AP cranial. That will give you a great view of what's happening with the circumflex and the LAD. Here's the LAD, and you can clearly see here that there's, the LAD is missing, and there's an empty stent, so stent thrombosis. So, we go here with a standard regular wire. So, it's a workhorse BMW wire. We obtain, we obtain, we are able to transverse the lesion. Then we went, we felt that there was enough thrombus to require that thrombectomy. We went with an export catheter, and this is the result after the export catheter. So, then we pre-dilated further with a 2-5 balloon, just to establish. Dr. Cohen, sorry. I'm going to just pause, because I'd like to actually, this is one of the key points of this case, and I didn't get a chance to stick a question in there, but I'd like to sort of ask, let's ask Dr. Barman. So, now you've got a STEMI with stent thrombosis and a bifurcation lesion, and you know, and a diagonal with some disease. How would you, you know, do you, do you protect the diagonal? Do you do provisional stenting? What are your thoughts here? I mean, I'm a minimalist for sure. I think certainly because it's a stent thrombosis and because it's a STEMI presentation, I would want to be avoiding stenting a side branch, or even interacting with the side branch. So, I would only do so if I was concerned that it would close. So, I think in this case, and you know, I've had the luxury of seeing the slides, I would probably have pre-treated it, you know, even though you have an unbelievable result with the thrombectomy, and I think it speaks to the fact that there are individual cases where there's value there. I still think there's probably a great deal of thrombus in that area. There's a 50% osteo lesion. I think it's a favorable angle. So, you know, not doing it is reasonable. I think you'd ultimately be able to cross, but I probably would have done either atherotomy as there's kind of a fibrotic ring there, or even just a PTCA prior to stenting across. Okay. So, okay. That's a good point. I mean, we felt here that the vessel is not that big anyway. It's two, two and a half, you know, enough to consider this a bifurcation, right? But given the TIMI 3 flow, so we predilated there with a 2-5, and then this is a result. So, at this point, the patient shows non-accelerated ediventricular rhythm. He's super stable. So, that's a sign of reperfusion here. Patient is happy, feels great. Patients fall asleep. He hasn't slept all night long. So, now, this is how do we approach the lesion. So, now, we have to finish it up. We have to stent it. So, the options are, do you just stent across? Do you do any of the dedicated techniques like TAP or DK Crush or provisional stenting? So, I don't know how would you approach this. You call the panelists and Jackie. Yeah. So, Dr. Barmengat has his input. Let's take one more comment. Dr. Young, what would you do here? I would still take a provisional approach, maybe put a wire in it, but just see how it goes and decide after if there's more flow. Yeah. I'd just like to comment that even though there is 50% lesion in the side branch, it's relatively focal. I think this is an excellent lesion for a provisional strategy. And as it was already brought up, we really get concerned about bifurcative stent strategies in a thrombotic milieu. It certainly increases the risk. So, I do agree with having a wire there. Even though the risk of acute complete closure is low, it does potentially maintain some flow and identify the vessel origin if that were to happen. Okay. Well, so, I heard all you said about the IVUs and this is a stent failure. So, I think you are kind of obligated to do IVUs before you treat these lesions so you understand the reason why the stent close could be underexpanded, could be a stent fracture, could be a dissection, could be so many things for stent failure. So, the stent was, I think, undersized. So, we decided to... I don't have the pictures of the IVUs, but the stent was clearly undersized and the vessel sized for a 4.0 stent. So, we decided to do an Onyx 4.0 stent, 4.0 by 15. So, this is our positioning there. So, we deploy the stent. I wish I have heard you about protecting this with a wire, but I felt that, well, this is probably unlikely to occlude, and then if it occludes, it's relatively a small branch and God has given us so many diagonals. So, I mean, that's the concept that many operators argue not to do anything with the diagonals. So, here we did some overlapping inflations and then we post-dilated this and now... So, then the patient wakes up. He's having chest pain again. The monitor shows ST elevation. So, what do we do now? All right. Let's ask Dr. Sandoval. Yeah. I mean, at this point, there's no going back. Of course, we lost the branch and now we have to figure out how to rescue. I think, I mean, you can bring a wire and try for a few seconds whether you can get in there, but I would also have a low bar to get like a dual lumen micro catheter, see whether I can park it right next to the origin and scratch at it and just escalate it. You might sometimes have to go to a little bit more polymer jacketed, see on black or something to get at it. But I do think it's a sizable branch and I think we always, always struggle in the cath lab. Do we wire? Do we not wire the side branch? At least in my view, it's almost never the wrong answer. Sometimes it's whether we want to do it or not. But of course, at this point, I think we have to rescue that with either quick wire escalation or dual lumen micro catheter as the next step. Okay. So, we went with... Here, I put a double bend on a pilot 200. So, I went looking and scratching the stand to see if anything was going to happen. So, I'm trying to point to where the... I have the roadmap on the side. I was trying to see where the branch would be. There was no signs then. I tried IVUS to see if the IVUS would allow me to identify the origin. I was not successful. So, trying, trying. So, finally, keep on trying and you can see that the branch sometimes will open up. You can maximize your anti-thrombotic strategy. Sometimes it will show, but here we're very unlucky. The patient is unstable with significant pain. We keep going, change views. A question, Mauricio, Dr. Cohen. When you did the IVUS, was the first stent distal to the diag? So, there's only one layer of stent or are there two layers now? So, they're in front of the diagonal and there's one layer. So, we can go back to the previous... No, we don't have to go back. I was just wondering because that also sometimes influences your... Right. That's from the old taxes. Remember the old taxes trials that shows that the side branches were occluding at the site of overlap. So, but I think, no, I think that the stent was right distal It looked it. I was just checking. But I mean, I think the fact that you intermittently see some flow is promising. And sometimes if you've tried for a while and it's not going to happen, just maybe putting a balloon pump or something for perfusion. And they often will reopen if you brought them back because there is a diminishing returns where the more and more aggressive you get, sometimes you can't get it open. But the strategies, dual lumen, polymer wires, different shapes are all things to do, for sure. So, finally, we got through somewhere. We felt it was a lesion. So, we tried a 2-O balloon, didn't go. We tried a 1-O balloon. And you can see that that thing is not even filling. So, then we try the 1-5 balloon. Then after we try the 1-5 balloon, inflate a little bit, this is what happens. Patients go into V-fib and then we have to shock the patient. So, once that happened, look where the wire went. So, now we lost the branch, but at least we have a little, we have a little bit of trickle of flow going to the diagonal. So, we were able to get in the diagonal again, balloon it with a 1-5 and then increase to a 2-O. You can see here that the Icari catheter is a catheter that it's called an active support. So, we have it very deep-seated. So, finally, we got, we re-established flow. And we have the Timmy III flow. So, we look again in the other view. We have, it's a huge LED that wraps around the apex. The diagonal stayed open. This is his convalescent EKG. You can see there are Q-waves across the anterior leads all the way until like before. This is his EKG the following day. He had a large, he had a large infarct with a large spill of enzymes. And this is his residual EKG. So, all these patients, you know, there's a toll for STEMIs and that's why we need to maximize our treatments. So, I don't have a conclusion slide, but I felt that we could we could work together on the conclusions of this case. Thank you, Dr. Cohen. What a wonderful presentation. I think it really highlights a number of key lessons and educational points from the document that apply for any intervention, practicing interventional cardiologist. The issue of imaging where you have a pre- or post-stent with stent thrombosis. The issue of trying or if able to do provisional PCI. And the issue of bifurcations. You know, again, this is an area that I don't know that we have any robust randomized data of bifurcation STEMI and what to do. So, this is where a document provides some information for the community to fit this, to fit in this area. So, again, I think we're over time. From what I can see, there's over 100 in the webinar. I see that in X there's over 300 people joining. So, thank you to everybody that took one hour to join us. And engage with us in the discussion. You know, we invite all of you to go to J-SCI and access the full manuscript that is now available. This webinar, the recording will be available shortly. And I'm sure at SCI we can continue the discussions in a number of exciting meetings. Thank you to all of you. Thank you so much, everybody. Have a great night.

stent thrombosis

STEMI

bifurcation lesion

angioplasty

coronary lesions