Good evening, good morning, and ladies and gentlemen, I'm pleased to here introduce my case. This case is decay crush technique for left-man compressed bifurcation neurons. I have nothing to disclose. This case presentation is a 68-year-old male because of recurrent chest pain two years and was in two months admitted to our hospital. The patient has hypertension and diabetes. After admission, the patient gets a lab examination, shows cardiac biomarker negative and EGF-19A2, and the UCG shows no abnormal wall bulging, and left ventricle eject fraction 58% is normal. The clinical diagnosis is unstable angina and hypertension and diabetes. Angiogram shows left-man bifurcation neurons with middle ICA, and we already treated the middle ICA with two drug-induced stents. This is left-man coronary angiogram. We can show this is left-man bifurcation within 1-1-1. And based on the definition criteria, and the definition criteria is like this one major criteria and plus two minor criteria. And that's mentioned in the preface of Principal Zhang before. I don't want to talk about that. And here is a complex bifurcation region. We should do that and use the decay correction technique with the IFC guidance. Before the procedure, we use the IFC to check the cavity and the second place. And here we can see the IFC imaging. And we use the IFC to find the distal 90 zoom. And we can also see the plaque characteristics and also find the proximal 90 zoom. Here we can use the IFC to check the length of the lesion. And we plan to the whole lung or size of the stent here. This is the complex IFC imaging. We can see this is the distal 90 zoom. Here probably we use this IFC to check the plaque burden. Probably less than 55%. And also we can use IFC measures the length of the lesion. Here is 26. Also we need to plus the 2 or 3 millimeters because we want to do the decay correction. Decay correction is the same as the stent. We protrude the main vessel 2 or 3 millimeters. So probably we need to add 26 millimeters stent. So this is the decay correction procedure. Decay correction consists of 7 steps. The first step is the sign branch stenting. We put the 3.5 mm, 29 mm stent in the circumflex. Also we put the 3.5 mm non-compliant balloon in the AID embedded. Here is the bench test imaging. This procedure is clearly. And then we deploy the sign branches stent and NGO. If we didn't find any complication, we remove the sign branch balloon. And then we do the second step. And we use the AOD non-compliant balloon to crush the circumflex stent. Because the left main vessel is huge. So we use the 4.5 mm non-compliant balloon to crush the stent completely. Here after the crush, we do the first rewind. Here we make sure the rewind from the proximal sail. Also we know the wire from the proximal problem. We use the eye to check it. We put back the eye from the distal to the left main problem. But we can use this eye imaging to make sure the wire from the proximal stent strut to cross. Here is the wire here. It's proximal. And this is the distal. And the wire crosses the stent strut. And then we can find this carina. This means the wire crosses from the proximal stent strut. After that, we need to do the first case implosion foundation. And we use the 3.5 mm circumflex and the 3.5 mm non-compliant balloon in the AOD to do the first case implosion foundation. After that, we do the left main to the LED stenting. 3.5 x 33 mm stent into the LED and to the left main OSTM. Here, deploy the stent. After that, we need to do the port technique. Here, we use the 4.5 mm non-compliant balloon to the port in the left main to make sure the stent is in position. And then to do the second rewire. This time, we should do the rewire also from the proximal seal. And we can check the IFC to make sure the wire crosses the proximal stent seal. And the method is the same as before. And we use the 3.5 mm circumflex and the 3.5 mm AOD to do the final case implosion foundation. Here is the final case implosion foundation. And then we do the report. Use the 4.5 mm non-compliant balloon to do the report. After that, we check the IFC from the AOD to the left main and circumflex. And here is the TKA trial. We precise the IFC criteria. Here is the 4.5 mm non-compliant balloon. This is the stent expansion to show the MSA 6, 7, 10. This is the circumflex AOD and left main. This is the MSA. We check the IFC from the AOD. Here we can see this osteo AOD is MSA greater than 8. And to the proximal, the left main is greater than 14. That means it's an optimization. Here we all can see this plug button of the edge of this stent is 25. It's less than 55. And also we can see the stent expansion is greater than 1. And the stem index is greater than 8. Here is the circumflex IFC. We can show this at the edge of the plug button 24. And the osteo AOD is MSA greater than 10. And the left main is greater than 14. This all meets the IFC optimization criteria. So this is the final result. We can see stent expansion very well. And the low tax section, TV flow is 3. Also the patient gets the 3 years of follow-up. Here we can see the left main, circumflex, and AOD Stent low, significant restentosis. Also we check the RCA is angel and restentosis. Ladies and gentlemen, this is the home message. JK Crush consists of seven steps, stent inside branch, main vessel, balloon crushing, and the first casing, and stent in main vessel port, and the final casing in the rear port. Complete crushing is very important. And use the non-compliant balloon based on the main vessel size. And the proximal vessel is one-to-one. And typically, for the rewind stent branch, and then rewind always using the proximal sail stent. And we use the IFC to check it to make sure the wire from the proximal sail. Always sequential post dilation with a non-compliant balloon before casing balloon inflammation. And two times in the port is mandatory. And I've defined the criteria for optimization. JK Crush probably gives the more clinical benefits. Thank you for your attention. I wonder if you could go into a little bit more detail about the rationale for the, you know, where you're re-crossing for JK Crush, because I think that's one thing I do see some variation in practice. And in particular, the second re-cross for the side branch about how proximal, because if you're too proximal, sometimes people have kind of an error gone abluminal around the stent, perhaps in the left main, for example. But I think just understanding those differences in the rationale is key. And again, I think you guys have done a great job. It's a fantastic case. So could you talk a little bit more about the rationale and what you're looking for there? Yes, yeah. It's about the rewiring from the first rewiring or second rewiring. We use the IVs or intravascular imaging to make sure the wire is in the accurate position, probably get the more benefit and get the good result. If we don't use this intravascular imaging properly, we make sure the wire is difficult. Probably we use an NGO to make sure the wire is away from the carina. That's not correct. So I think we use the intravascular imaging to make sure the wire positions precisely. So even if we use the second rewiring, we usually ask Professor Chen to tell us if it's proximal. Or sometimes we use the needle to do the case implementation. Maybe this gives us a very, very good result. One question I have, you know, I know you like using radial 6 French in China, but if you use a 7 French guide, do you use the Boston system? You know, certainly have a high-definition IVs available now where you can sit in the vessel continuously and you can see how you're wiring. Do you ever have an IV scatter there to see whether you're wiring the right cell or not? For example, from the catheter of the LED back to the left main, do you have the IV scatter sitting there to see if you're wiring the circumflex properly or not? Yeah. Yeah, usually with this, for this test application, we recommend to use the 7 French guide, the catheter probably to do the case implementation or using the IVs to check the wire position. That makes your procedure smoothly. So, for the test application, so you use the intravascular imaging, probably we need to use the 7 French. Also, we can check the wire position. Gage or Brian, any comments? No, it was a fantastic case. I think you went over the rationale and steps very well for everybody to understand. I appreciate it. Zhenji, do you ever keep a live IV scatter there while you're wiring? Actually, we can, yeah. Simultaneously put the IV catheter as a proximal of a POT and the rewiring guidance. Actually, we can, yeah. With the Boston system and the others, high-definition IVs, you can see things really quite well. In OCT, you have to go back and forth, back and forth, but I think your catheter is sitting there. I mean, I do that quite a bit if I want to be correct in a wire position, and I'm not sure. I leave the catheter sitting there in the confluence to see if I can wire the stem struts correctly. Yeah, I fully agree it's your option, yeah. In our catheter library, we use Boston HD IVs with 16 megabit hertz. Actually, we can go to the very, I think, equal quality compared with OCD guidance rewired side branch, yeah. So this protocol also, in our DK-CRUSH eight tries, use IVs guided wire position. After first CRUSH, first rewiring the side branch, and the final rewiring the side branch, use IVs guidance. Confirm it's from the proximal to middle cell for DK-CRUSH. In Nanjing, I remember using six-fringe radial most of the time. So do you go back to the groin to do these cases, or are you using six-fringe to radial approach? Sure. For DK-CRUSH, actually, six-fringe guided catheter can accommodate one balloon and one stem. Routinely, actually, from the radial approach, we will use a six-fringe guided catheter with a small branch inside the femur, yeah. Oh, go ahead. Oh, sorry. One thing to keep in mind for radial, most patients can accommodate a seven-fringe slender with a seven-fringe guide unless they're a small person, and the other is the OCAF, the sheathless guides. They come in very handy because the inner diameter is 7-7, and it's very good for left main and larger kissing balloons, and you can stay radial. Yes. We do have one question from the chat on if there was a preference or type of drug-eluting stent that was preferred or used in the DK-CRUSH study, or if the make or model of the stent matters when performing that technique. I think for DK-CRUSH, all the second-generation drug-eluting stents is okay. No demand for this. I think most current-generation drug-eluting stents have defined expansion profiles and side cell profiles, which are quite large, but I think the important thing to keep in mind is if there's a large size discrepancy between your distal main vessel and your proximal main vessel or left main that you understand the expansion capability, so you may have to oversize. There's certainly a push to maybe oversize the main vessel stent so that you can appropriately size the left main, so you just want to make sure you're not putting too small of a stent that you can't post-dilate it adequately in the proximal main vessel, so just having charts of those expansion profiles and side branch expansion profiles is very helpful. Yeah. That's great. And I'll just add one thing that I particularly liked in your presentation is I hadn't seen the longitudinal view of the IVUS used to actually understand your crossing location before, and I think that's actually a really useful tip or trick to use in the future to try to understand exactly whether it was a proximal or distal crossing, that longitudinal view on the IVUS, you hadn't really showed it nicely. Yeah, the Boston Avigo system really gives a good view to do that, I think. It's very helpful. Shaoling, do you have any final comments? I don't know. Yeah, I don't have more comments. Just one point. You know, for the D-CAG Part A study, so the secondary generation, I think secondary generation DES has very thin strut thickness. I think that's very important to minimize the stress on both sides. Changwei, I think we are closing two times, so can you summarize the whole session? Thank you very much to our friends at Nanjing for participating, and to Kate and Don and Brian for participating as well.

unstable angina

decay crush technique

intravascular ultrasound

drug-eluting stents

angiogram