of Skyshark leadership for giving me this opportunity. It's a great meeting, and I will try my best to tell in seven minutes what are your toolbox for complex PCI. I do not have any disclosures. So first of all, how we define a complex PCI, I think that's the first question. And I think you have seen enough case by now seeing left main bifurcation, patient with CTO, anybody with bypass graft, thrombus, calcifications, multivesel disease, small diffuse disease, they all constitute as a complex anatomy to undergo PCI. Then we have hemodynamics. We have shown last two cases, patient's presence, they have low EF, less than 30%, high filling pressure, elevated EDP, low cardiac index, that adds on to the complexity of the case. And then you have comorbidities, patient with cancer, prior bypass, MI, heart failure, add on it a kidney disease, creatinine is four, do a PCI, lung disease, COPD, all these comorbidities all together make your PCI worse and more complicated with higher risk of mortality. And this has been well documented. This is a definition from Briggs Registry showing that all these criterias have been taken into account. Higher the number of factors, including these patient factors, which are noted over here, the seven of them, and the procedural factors all together makes your chances of having a worse outcome in PCI higher. So what are the skills? Well, the way I learned in the cath lab is your wiring skill is very important. You need to know your guide, you need to know your guideliners, and you need to know what are you going to do with those when you're crossing lesions. Well, those are very important part and tools which you should know, but those are the enough tools. I'm going to tell you the most important tool for any complex PCI is planning. Knowing from pre-planning of what you're going to do, how you're going to do, having a plan A and plan B makes the most important part of the PCI, which includes starting from access sites, recognizing when to put a hemodynamic support, as we have seen in the first case by Haider, safe access techniques, physiology, imaging, and lesion modification. They all contribute to a high-risk complex PCI. So access site, well, we are well known by now that radial access is what we all love, and radial access improves outcome. But is radial access something we can use in patient with complex PCI? Because we know we have to cross some really complicated lesions. Some of the last cases we see, we had to go femoral because of the calcification. We need to put on mechanical devices. But there has been a study done. It was a randomized control study of about 400 patients showing that trans-radial access seven fringe sheath actually did better than the trans-femoral seven fringe sheath in terms of bleeding. And they were very limited crossovers. And they were good procedural success from the trans-radial access as well. So you can do trans-radial access in complex PCI using a seven fringe sheath if you have a good radial artery to begin with. Then the next question arise, do we need to use hemodynamic support to do complex PCIs? And this is again has been shown from the European data where they have shown the people who underwent complex PCI using mechanical circulatory support devices. And this data had multiple different devices. They found that the results were better. There were less mortalities. Overall survival was better over even a longer term period. Many of these lesions underwent more complete revascularization. And more atheroectomies procedures were done in the patients which were protected. And this is the most recent data coming fresh out of press by Dr. Basir regarding the information from PLEC-3 data where they looked at the impella data from all the patients who underwent PCI. And they noticed that about half of the patients had drop in their pulse pressures which was noted in the impella arm as well. That impella, there was a drop in the pressures. And it was shown that people who dropped this during a left main PCI when they go up with the balloon and the pulse pressure drops, they actually had worse outcome. And you could see this was true in patients whose blood pressure drops. And it was even true in patients whose blood pressures were normal. So the drop in pulse pressure during the PCIs of left main is not something which we should not consider into account because they do have worse outcome with that. And that's one thing I think an impella can help you. Then come out with the same vascular access side because all these large bore access, you require a large bore sheet in it which increases the risk of bleeding, especially when you're giving multiple anti-platelets and anti-coagulation. And we have already discussed all through our conference since yesterday that safe access techniques involve ultrasound, making sure we use micropuncture needles. If patient has a peripheral artery disease, you try to modify them or use an alternate access such as transaxle or transcaval. But I think one closure technique, pro-close before doing the access is very helpful and it does decrease his bleeding. And now we are well aware that with the impella device, we can actually do the entire PCI using a single access technique, which I think is helpful and useful to decrease the bleeding risk when we are performing complex PCI in these patients. And this again was shown when we compared the data from PROTECT-3 versus PROTECT-2. As we have evolved and modified our techniques, the improvement in mortality was significant in PROTECT-3 patients in comparison to PROTECT-2. So as we're improving our techniques of access and bleeding complications are getting better and better. Now we have multiple mechanical devices. We use balloon pump, we have ECMO, Stendham Heart and impella CPs. But I'm going to demonstrate one quick two slides on a patient I did recently with an impella 5.5 and I think it was a great idea to do that. This patient had a cervical cancer, needed a cervical surgery done. She was very obese, had some peripheral artery disease. And you can look at the vessel. She has triple vessel disease and I knew I will never be able to finish the entire PCI in one setting. I will need to admit this patient, she was in anemone and I will have to go to multiple settings. Her cardiac index was 1.4, so I decided we are going to do it with 5.5. And during the first setting, we fixed the LAD and we dissected it pretty bad. But we were comfortable. You know, we went the patient to the ICU. We let him chill out on the impella 5.5 a little bit for two, three days. Brought her back, finished the entire PCI of the LAD again with as well as the left circ and left main. And you can see the final results in there. So I think impella 5.5 is something also to be considered in these patients when we are performing complex PCI and we know they may need multiple settings during the same admissions. Then comes the physiology. It's a class one indication to use physiology in PCI. We have enough data to show the outcomes. There are multiple trials which have done and shown that. And we have better techniques now. We are using pullback techniques and coregistration which is very, very helpful in performing a complex PCI. And there's an ongoing defined GPS study to show those whether a complex PCI performed using physiology study can be helpful or not. And again, I will demonstrate quickly about this. As you can see in this patient, we clearly see a left main lesion. But you see some haziness in the LAD as well. Well, whether that LAD needs to fix or not, should I just go fix the left main and leave the LAD and decrease my overall procedure time is a question here. Now, so we had decided to do a physiology and you can clearly see that there is a step up and that LAD is pretty significant. The RFR is .54. If you treat that, it becomes to about .80 and you treat the left main, it becomes better. So then we decided and we treated both lesions. And that's something I think is important to utilize physiology for that. And then we have IFR coregistration where now we can decrease the amount of contrast we are using by using coregistration technique, which is specifically helpful in patient with chronic kidney disease. This is a long lesion. To decide what to treat or not, what we do it in this Philips IFR is that we basically pull back and each dot shows how much of disease the patient has. And you can clearly see the prox to mid LADs has a lot more dots. And those are the things and those are the targets that we are going to try to fix. And we leave the distal lesions as it is. The defined GPS study is actually looking into this. And the goal with these defined GPS study will be to leave less than five dots. And if possible, if you leave less than five dots, the previous studies have shown that they do better. So this clinical trial is ongoing, as I've already talked of utilizing physiology in complex PCIs. They will be doing physiology pre and post. The goal is to enroll 2,200 patients and we are very excited to look at the results of this study. Then the next thing is imaging. We have already discussed in previous talks. I'm not going to go into detail of it, but it has been well documented. This is a data from New York PCI Registry of 44,000 lesions showing that patients who underwent PCI with IVAS had not only a better short term mortality, but even a longer term mortality. But guess what? Out of these 44,000 lesions, less than 20% lesion in New York Registry, which includes a lot of big centers in New York, actually underwent imaging. So that's something to think about as of us as operators, that imaging is something we need to utilize to improve outcomes in these patients. It is very helpful, as we have seen in our first case, to identify calcified lesions and have strategies. Both IVAS and OCTs can help you in doing that. And there are multiple tool boxes for you to modify those calcified lesions, including shockwave intravascular atherosclerosis, orbital atherectomy, rotational atherectomy, and laser. What device to use? It all depends upon what you're dealing. The way I have used this, this is a very nice algorithm, which was published in JAG by Dr. DeMaria, is basically you see whether the balloon is crossable or not. If you can cross the balloon, predial it, do the imaging. And if the imaging shows it's a deep calcium, then you can consider, if it's concentric, doing a shockwave. It's something which is a big nodule, you can consider rotational atherectomy or orbital atherectomy, and then do your one-to-one balloon to see it's expanding enough. However, if it's an uncrossable lesion, then if it's a small vessel, try rotational atherectomy. If it's a bigger vessel, you can go with orbital atherectomy. Iota osteolesians, you can go with rotational or orbital atherectomy, and they are good techniques to help you modify your lesions and get a full-stent expansion. So to summarize, planning is crucial with complex PCI. There is a cognitive approach to deal with these PCI, and it takes a long time, and there's a learning period to start doing these cases. Access is an important part of any complex PCI, and save large-bore access skillset is very important if you're planning to do these PCIs using hemodynamic support. Crucial but underutilized tools includes imaging, physiology, and atherectomy, and we should critically think about utilizing more and more of these tools in our complex PCI for better outcomes. Thank you.

complex percutaneous coronary interventions

radial access

hemodynamic support

intravascular ultrasound

atherectomy devices