Thank you. This is a great opportunity to go through this joint session between SKY and CBS. Our Corner Rebuffering Summit will start next week, from November 29. I think this is a very important time for us to organize this webinar session. So, it's my honor to invite my colleague, Dr. Junjie Zhang, to present the IVI guidance in standing bifurcation leadership. Please, Junjie. Thank you, Prof. Chen. Thank you, my dear colleague from SKY, Tavir Raab, for having me to participate in this very important Corner Rebuffering Summit. Today, my topic is about intracoronary imaging guidance in bifurcation standing. I have nothing to disclose. First is about the evidence of IVI-guided PCI in bifurcation regions. The corner angiogram is used to diagnose CAD. However, compared with IVI, angiography is somehow underestimated the lesion severity. You can see this is a typical case. Actually, from the angiograms, I see only minor disease. However, after evaluating with IVI, you can see from the distal to proximal, there are actually diffuse lesions with a severe plaque burden at the middle part of the RCA segment. Also, you can notice under the panel, the plaque burden is 73%. Medina classification is the most used classification to define the lesion location at the bifurcation summit. However, there is some shortage of Medina classification. They only provide the location of the lesion at the bifurcation summit. They cannot supply something very important to the anatomic feature like the distal bifurcation angle and the lesion length at the bifurcation site, especially the lesion length at the ostomy site branch and also the plaque feature of the bifurcation summit. Definition criteria is the first anatomic criteria to define the complexity of the bifurcation lesions, which was proposed by Professor Xiaoliang Chen. The definition register shows, actually, according to the definition criteria, to find the complex bifurcation lesions compared with simple bifurcation lesions was associated with a high rate of MACE, including cardio-diastolic myocardial infarction and TBR. Actually, these criteria include two parts. One is the major part, including two major criteria. Another second criteria, including six minor criteria, according to the angiogram. In the subgroup analysis from the definition criteria, we do the post-talk analysis comparing IVAS-guided versus angio-guided bifurcation lesions. Totally, we included 81 IVAS-guided PCI and 620 patient angio-guided bifurcation PCI. The median follow-up time is seven years. As you can see, after seven years of follow-up, the IVAS-guided complex PCI was associated with a lower rate of cardio-diastolic myocardial infarction and MI. This is the largest register from the Sweden countries. As you can see, for IVAS-guided versus angio-guided, IVAS-guided was superior to angio-guided in left-man standing. After five years of follow-up, IVAS-guided was associated with a lower rate of mortality. Also, you can notice that IVAS-guided was associated with the largest stem diameter. This is also a bigger register from the British society. After one year of follow-up, totally, British cardiovascular society included more than 10,000 left-man standing. And after propensity score matched, you can also notice that IVAS-guided left-man standing was associated with a lower rate of mortality compared with angio-guided left-man standing. This is, so far, the largest simple center from China FuWai Hospital's left-man CAD PCI. Actually, you can notice the PCI technique advance, including post-dilation, second-generation DSUs, final casing, and also IVAS-guided. You also can notice all these new technologies and new devices were associated with improved clinical outcome in patients underwent left-man PCI. Artificial Immunity trial is organized by Professor Shaolian Chen. I presented in TCT28. It's a randomized study comparing IVAS versus angio-guided in a common CAD case underwent DES implementation. After one-year and three-year clinical follow-up, IVAS-guided PCI was associated with a lower rate of TBF. And also, in the pre-specific sub-analysis, show all the complex subset, including left-man, including bifurcation lesions, show the benefit of IVAS-guided. Recently, I think the most important interclinical imaging-guided bifurcation standing is October trial. This is a RCT study, totally included 1,020 patients, two bifurcation lesions. And also, you can notice that the side branch diameter is at least 2.5, one-to-one randomized either to OCT or angio-guided. So after two-year follow-up, 24-month follow-up, OCT-guided bifurcation standing was associated with a lower rate of MACE, 10% versus 40%. IVAS-ACCS study is another important randomized study. So far, I think the sample size is the largest. Professor Shaolian Chen presented in this year's ACC in Atlanta. Totally, this trial included 3,500 patients with recent ACS, randomized either to IVAS versus angio-guided. After one-year follow-up, IVAS MACE ratio only 4%, significantly lower than the angio-guided, 7.3%. Also, you can see the two bifurcation lesions account for 50%. And the Occupy trial is also a very important study from the Korea Society. Totally included 1,600 PCI cases compared with OCT versus angio-guided. You also noticed after one-year follow-up, OCT-guided was resulting significantly lower rate of MACE, including cardiovascular, myocardial infarction, and TBR. And in the OCT-guided subgroup, you also noticed at the right-side panel, they should get optimal OCT guidance. Otherwise, if you only do OCT without treating the optimum result, the one-year MACE rate is still very high. So recently, in 2022, Chinese Cardiovascular Society proposed the Chinese guideline for PCI inpatient with left-of-hand standing. The correspondent also is Professor Shao Liangchen. This guideline recommended the IVAS assessment prior, during, and post-PTI with one class and the level evidence is B. Also, OCT guidance in left-of-hand standing also, recommendation is a 2A, the level is a B. And recently, in this year, 2020, for ESC guidelines, according to previous randomized study and the big sample size register, recommended intraparty imaging guidance by IVAS OCT is strongly recommended for performing PCI on anatomic and complex lesions. In particular, left-man, true bifurcation, and the lung lesions. So next part is how to do the IVAS or OCT guided PCI. Actually, the intraparty imaging guided bifurcation standing actually should not only the final result, but also pre the procedure and during the procedure, and of course, which can be used to detect stem failure during the follow-up. This is the joint census on the use of OCT economy bifurcation lesions by European or Japanese bifurcation clubs. Also, you can notice this consensus input. During the stem implantation, the guidance of position of the wire toward the side branch is also a very important recommendation. So there are some predictor of the side conclusion by the OCT imaging, including high lipid content of the main muscle and the lipid block contralateral to the side branch and also a narrow carotid tip angle less than 50 degree and a short length between the proximal branch point to the carotid tip, which less than 1.7 millimeter, and also the calcified block in the main muscle. In terms of bifurcation, left-brain bifurcation is a very, very important subset. So far, we have several criteria after left-brain bifurcation PCI. We learned from our Korean colleagues. They proposed the 5, 6, 7, 8 criteria at the early days. Now, after Excel and the Nobel trials, the criteria was improved at least for osteomorph side branch, 6 osteomorph LAD, 8 millimeter square, and for left-brain, distal left-brain should be at least 10 millimeter square after left-brain stentings. However, that is the OCT optimal criteria for left-brain bifurcation currently. DK-CRUSH trial is an ongoing trial, which was proposed by Professor So Liangcheng. It's a randomized study. This trial were totally included 556 patients with complex bifurcation lesions. According to the definition criteria, randomized is a 1-to-1-to-ibis-guided DK-CRUSH versus angioguided DK-CRUSH. The prior point was 1-year TBS. Also, you can see in DK-CRUSH 8 trial, we proposed the optimal criteria for DK-CRUSH in ibis group. For left-brain, after DK-CRUSH technique, should be at least 6, 7, and 10 millimeter square. For left-brain complex bifurcation treated with DK-CRUSH with ibis guidance, the minimum standard area should be at least 6, 5, 5. So let me show you one case. You can see it's a typical chip case presented with non-STEMI with poor LEF. The angiogram shows it's a typical left-brain and ARID diagonal complex bifurcation lesions according to the definition criteria. Long lesion and significant narrowing at the side branch. So before procedure, we evaluate with ibis imaging and to decide the lesion prepare method and the stem diameter and the stem length. So this is an angiogram after DK-CRUSH guided with ibis. So then we switch to deal with distal left-brain. Also, we check with ibis before stemming. So you can see the left-brain is a huge left-brain. Diameter is 5.0. Circumflex is 3.5. So according to the ibis imaging, we also perform DK-CRUSH. For the distal left-brain, this is the final angiogram. Looks perfect. And of course, we will check with ibis. For beta-ARID, at least 6.8 millimeter and the OSTIMO diagonal 5, OSTIMO ARID 8.8, OSTIMO circumflex 6.6, and distal left-brain 15. It's an optimal result according to DK-CRUSH 8 criteria. So optimal ibis guided result after the one-year angio follow-up, there is no instant re-synopsis, and the patient was active with no symptoms. So October trial is a very important OCT-guided bifurcation study. Actually, it's included the big side branch and the complex bifurcation regions. OCT-guided strategy, there were three aims, including adequate traversal and stem expansion. Secondly, is a full-step partition. And thirdly, is optimal region coverage. Actually, there is a detailed protocol according to the OCT trials, including the pre-standing after predilation OCT guidance. Very important. After memeso standing, OCT-aware to check the wire partition. It's very important. And also, after standing, finally, we will check the OCT to detect if this achieves the optimal result. So let me show you the OCT case. Actually, it's a typical simple bifurcation left-brain standing. After memeso standing, there is a pinch at the optimal side branch. So we check the OCT. Actually, there is no significant lesions, only two layers of stem structure at the optimal side branch. Then we rewire the circumflex. And we check the OCT. You can see the wire is just protruding through the circumflex at the middle cell. I think for OCT, it's the right cell. And do the casing. And this is the final edurogram. And also check the OCT. Actually, you can see there is no any stem structure covered optimal. And the stem structure position is quite good. So finally, I would like to introduce the Chinese guideline for PCI in left-brain standing. For any true bifurcation, left-brain bifurcation, I think according to the definition criteria, if the complex bifurcation lesions, according to the Dickey-Crusher theory, RC studies, Dickey-Crusher is mandatory. For forced bifurcation, or definition criteria defined a simple bifurcation, provenance standing is a default choice. And after main vessel standing, do the port. If the side branch compromised, do the casing. All the procedure should be guided with intracoronary imaging, including IVERS or OCT guidance. So finally, ladies and gentlemen, summary. Intracoronary imaging guided bifurcation standing is mandatory, according to the guideline. In order to achieve the optimal long-term clinical outcome, provenance standing is always preferred. For definition, I defined the simple bifurcation lesions. Dickey-Crusher technique is a preferred two-step technique in complex left-brain or non-left-brain bifurcation lesions, based on the evidence from the Dickey-Crusher theory, RCT studies. Dickey-Crusher trial is comparing IVERS versus angio-guided Dickey-Crusher for the treatment of complex bifurcation lesions, which is undergoing. I think by the end of this year, we will totally enroll all the patients. By the end of next year, we will get to the one-year clinical outcome of the follow-up. Thanks for your attention. So the panelists, Dawn and Kate, any questions? Brian, did you have any questions in the chat for you? I just have one question about Occupy and also your thoughts on the optimization using the intravascular imaging. Because I believe in those studies, only about 50% of patients achieved optimal criteria for imaging. Do you have a sense of, is it that some lesions, there's just an inability to achieve the optimal results? Or do you think it's the way that operators are using the information? Yeah, actually, I think in Occupy studies, the sub-analysis of OCT, I think the optimal result in OCT group is up to 80%. So actually, it's a high rate compared with our early study, Artemeter and IVR, only 6%. The main reason is calcification. It's early studies. At that time, we don't have shockwave weapons. Nowadays, I think we have all the lesions prepared, especially for calcified lesions. Another important thing is we should do the IVR-OCT guidance before standings. At that time, we can do the prepared lesion prepare. And then finally, I think we can get to the optimal result. Thank you. Yeah, thank you. Thanks for such a great talk. I just want to take this opportunity to highlight, you showed a very nice example of demonstrating where you rewired through the stent strut using OCT. You are far more advanced, I think, at using that information and actually guiding the strategy than I think we are. So I just wonder if you could comment on how you do that and if you're able to ever see that on IVS or really that OCT stent platform is what you're using and what are you looking for that would cause you to actually remove the wire and choose another strut? Yeah, I think the beauty of OCT guidance actually is it can precisely guide the wire position during the procedure. Actually, according to the October protocol, actually in our daily practice, we also do like this. In addition to OCT, IVS also can guide the wire position during the procedure. Actually, we use a longitudinal view of the IVS guidance. And the IVS cassette was put at the distal membrane and auto-pull back. And also we can precisely detect the wire position. From the proximal cell, which should be mandatory for the provisional stenting or curate. But for decay crush, it should be at the middle cell, something like that. If the wire is not at the right position, we will rewire again and recheck the imaging again. Actually, this is also mandatory according to our decay crush protocol.

intracoronary imaging

bifurcation stenting

intravascular ultrasound

optical coherence tomography

major adverse cardiac events

DK-CRUSH technique