for having these great webinars. Okay, so this is a rather challenging case. This is a 75-year-old gentleman who have been complaining of three hours of intense chest pain with transient ST elevation in pericardial leads. And as a past medical history, he has a strong history of alcoholism, child cystic cirrhosis, hepatorenal syndrome, bleeding through the esophagus, also have PAD, peripheral arterial disease, and a physical examination. The patient was with borderline blood pressure with tachycardia and vasopressors prescribed in the ER. So this patient was taken to the ER, to the cath lab, and this is the diagnostic baseline NGOs and as you can see, it's a pretty tight left lesion. It's a trifurcation. The LADs also have two lesions in the proximal third. The circuit's also compromised and it has two flows in the LAD. As you can see, it has also two more lesions in the proximal third of the LAD. On the right, it's also compromised, has a co-dominant artery who has also a disease in the PAD artery and the medial third of the RCA. So this is the first question that I would like to ask you, to all of you. How will you proceed in this case? CABG, PCI, or medical treatment? I know this is a very difficult case. So how would you treat this patient, maybe? Well, Ana, what do you think in this situation? I would start with number three, quite frankly. What's happening here? There's a lot of contraindications to everything. Let's go back to the film for a minute. Let's go back to the film. Yeah, sure. Yeah, let's stay here for a minute. Not so much for the RCA, but really for the left side. It's a trifurcation, actually. It's a huge burden of disease. Hmm. Yeah, definitely the reduced flow in the LAD after the middle is maybe a two, I don't know, maybe it's 1.5, this LAD. Ribos is not small, but obviously it's not as big as a CERC or the LAD. And can you show us quickly how big the right is? Because while working in this complex left vein, the right is gonna be the only vessel supporting this patient. Thankfully, it is large. It doesn't look like there's that much calcification on the angiogram, but it might be worth knowing on intravascular imaging, just to be sure. Or with a test and trial of a balloon inflation to see if it opens, if we choose to do PCI. But it needs to cross your mind about whether or not you'll be able to expand this kind of ring-like lesion. Carlos, you might've mentioned this. What is the ejection fraction? Sorry, I might've missed that. No, we didn't have the echo done in this case. We just, the patient went from the ER to a cath lab. So- Okay, and the- 20 something percent. But before this, the patient was taken from the ER to a cath lab. Got it. And the patient presented with a chest pain syndrome? Yeah. Okay. What was- With a transient HDL elevation. What was the comorbidities of this patient, Carlos? Yeah, Professor, this patient has cirrhosis, alcoholism, and bleeding. Patient had a history of esophageal bleeding because of this cirrhosis. So it's a very difficult case for Kavash, you know, and the surgeon refused to operate on him. Because if the patient don't have comorbidities or less comorbidities, I think this case is for surgery. The LAD, George, have a low flow, but I think the size of the LAD is not small vessel. No. No. It's a good size vessel, but with very low flow. I think this patient is for CABG, clearly. However, if the surgeons refuse to treat this patient, it's a very complex case for PCI. Because the LAD, the left main is very complex, a lot of calcium. That's for sure. Yeah, well, quite frankly, the bleeding story is hurting also the PCI, because how are you gonna allow, you know, complex stenting over there? You know, so that's a situation. So I have to say that looks like the case is an acute case. Looks like we don't know much about the patient. We don't have a reservation about the patient ability to tolerate antiplatelet therapy without bleeding. So I would like to primarily focus on the patient and on the lesions. And I would utilize a more simplistic view in order to finish with a one stent. And I would go with provisional 48 or 60 millimeter stent in order to go all the way from the middle LAD, whatever that lesion is, all the way, and whatever else, try to do some ballooning. And, you know, I don't know this patient is good to put complex bifurcation stenting and then have it bleeding on us. So I'm very nervous about the patient, and not so the lesion. But what about option six, drug eluding balloon with a short dapt? Yeah. This problem is less pain. That could be a good option, but not for less pain. Yeah. Number four is not candidate because the size of the left main, for instance, the size of the left main of the shirt are quite, are completely different. I go provisional with this patient, like George say. Yeah, let me encourage, by the way, all the audience, please send any questions to the chat. We're monitoring it, and I'm gonna ask your own questions as well as we go. So let's go ahead, Carlos. I think we got deliberated on the various possibilities to see what happened in order to also stay on time. By the way, what is the platelet count here? Does anyone talk to the platelet count? Say it again. The platelet count, what is the platelet count? The platelet count? No, I don't have it, professor. We don't have it at that time. I mean, I'm not sure the platelet count, but the patient has a strong history of esophageal bleeding, unfortunately. Okay, so we decided to treat the RCA first, you know, with the idea of having more reserve when we get going with the left circulation. We started with the RCA. Oops, oops, excuse me. And this is the result of the RCA. Then we moved to the left circulation, and we decided to go with the TAP, with T-S10 and the malt protrusion, because the angulation is near 90 degrees, so TAP is also very forgiving in this 90 degrees bifurcation. Also, it's a trifurcation, so for DK-CRUSH, it could be troublesome for trying to recross to the ramus intermedia. So DK-CRUSH, we didn't like it for that reason. And also, there's no impending acute side branch or seclosure after the stent implantation, so we decided to go with the TAP, with a provisional and a TAP stent. So we decided to go with a ramus first, okay? Then LAD, but the LAD was very challenging, actually, to trying to wire the TAP. To trying to wire, so we have to do a parallel wire technique. As you can see, I partially dissected the vessel, and finally, with parallel wire technique, we managed to advance the wire distally and do the predilation. And then start to dilate and start to extend the LAD. Yeah. The LAD is good, but... Yeah. Yeah, so... What concerns us the most is the low flow in the LAD, you know? We were very concerned about it, and we didn't have impella, we didn't have ECMO, so we have, you know, trying to rush, trying to have a good flow through the LAD, you know? So we started to stent the LAD and put the stent from the LAD to the left main. Yeah. Then going with a putt. Then after the putt, you can see that the carina shifted all the way through the circ, so we have to rescue the circ with a T-stent and a malprotrusion technique. So we start to open the struts, then position the stents through the circ, then do the tap, as you can see there. Then doing a kissing balloon, sequential inflation and kissing balloon at high pressure. This is the high pressure sequential ballooning, which is a crucial step in these cases. And then kissing balloon and then final putt, and this is the final result. When you have case like this, three, four cases, you always treat the three vessels or you select two? Yeah, what we see is that the Ramos had a bit of a space, so you can treat it in the first term as we did, you know? It's not, you know, the compromise of the trifurcation was not so proximal, so we thought that maybe doing first the Ramos, it should be the way to go, which in this case happens to be a good choice. So this is the final result, Ibus, and as you can see, we managed to pursue all of the MLA criterias, minimal leg criteria, and far exceeded the criterias in the circ. Great. Post, yeah, the LAD, Osteo, polygon of confluence, which is the number that you see here, and 19 for the proximal third. So this was my case. Great, terrific. I'd like to pass the opportunity to present all of you this book that we just published. We have a huge group of friends from Latin America and from the U.S., 99 authors here working collaboratively in this book, along with the Solaci Society. So thank you very much. Very good. That was great, Carlos, and particularly as it ended with this collaborative textbook of Solaci. Let's go to Brazil. Ricardo Costa is a leader in Brazilian interventional cardiology, and very recently, most recently, the president of the Brazilian Society of Hyperdynamics and Interventional Cardiology, and a major, I would say, collaborator of Sky, and we thank him for that. And go ahead, Ricardo, go ahead, and share your slides and start up your presentation.

complex medical case

severe heart conditions

PCI procedure

TAP stenting

high risk bleeding