So, my case is this patient, 68-year-old patient with a CTO of the right and this left main proximal adelaide, proximal circumflex disease. The patient was refused for surgery and I would like to talk here about the bifurcation, not much about the CTO. So, when we describe this anatomy, we understand that it starts from the distal membrane, extends long in the LAD and in the circumflex and therefore it qualifies, as you said, potentially for two-stand technique and which starts with nothing else but the steps of provisional. After lesion preparation and proper predilation, you put the first stand across the bifurcation, fitting the diameter to the distal membrane. Then you perform the proximal optimization with a balloon fitted to the left main and this is a very critical in case of left mains because, I just go one back, just a second. So, after this, it's a tricky step because one wire is just jailed behind the stand, so in case the guide would dive in, it can potentially crush the freshly implanted stand. So, then we perform the proximal optimization. For proximal optimization, I normally remove the wire from… May I interrupt you for a second? Yes. Why did you choose to stem towards the LAD first and not the CERC, where CERC looked like a more difficult branch in this case? Yeah, it's a matter of discussion what one prefers to start with in this case. I was not afraid of the issue that I will have difficulties with rewiring the CERC and FLEX afterwards, but most of the collaterals to the right CTO were coming from the LAD, so we wanted to be sure that we will not have any issue with the LAD, but to treat LAD left main first and then the CERC and FLEX. But you are fully right that in case of culotte, the decision maker might be which is the more difficult to treat and this is the branch what you start with. Thank you. Again, the same story that I mentioned that for the proximal optimization, you have to know what kind of balloon you have. Why? We like to say that for proper proximal optimization, position the marker to the carina, but still in case of such large diameter mismatch, like in this case where we did the pot, if I remember well with the 5.5 balloon, there is a certain shoulder of the balloon which might be oversized for the distal branch and potentially pinching the side branch. So in this case, you might position it a bit more proximal, again, depending on the type of balloon that you have. So after that, the rewiring where I said it's very important to perform the most distal rewiring in order to avoid relevant neocarina. And this is the step which is for me followed normally by imaging towards, in this case the LAD, imaging towards the LAD to confirm that my CERC and FLEX wire is positioned properly. Dr. Toth, if I can interrupt you, we do have some questions there from the chat is that you had mentioned you had some tips to reliably cross through the distal-most strut. And then one of the participants is asking, do you ever use one of the fluoroscopic stent optimization systems like ClearStent or StentBoost? So would you mind sharing your technique in a little more detail there? Yeah. So to be honest with StentBoost or StentViz, I'm not sure that you can confirm that you are distal because with StentViz you see the stent struts, but you still don't see the vessel there. And so that one I'm not using for confirming distal rewiring. It might be interesting for the positioning of the second stent in relation to the first stent. What I normally do that for rewiring, I choose, I shape my wire with the band larger than the distal main branch diameter in this case. So with a relatively large band going distal, pulling back, facing towards the side branch. And because the tip of the wire is larger than the diameter, there is a certain tension in the tip. So as I'm pulling back the wire, as soon as the wire can release this tension, it will jump and the first spot where it can release this tension will be the most distal cell and there it will be jumping to the side branch. Thank you. And are you just using a workhorse wire to rewire that side branch or any specific wire characteristics? Normally I'm using a normal workhorse wire. What I also like is the Whisper X to support wire, which is floppy enough to get through the struts and gives also sufficient support afterwards to support the kissing and delivery of the second stent. Thank you. So then again, as I said, these are just nothing else but the steps of the provisional stenting. We perform the kissing. The kissing is sized according to side branch diameter and the previously implanted main branch diameter. Again, this dilation will be the lesion preparation for the side branch as well and the post dilation of the main branch as well. Therefore, fitting to the previous question, I use high pressures for individual inflations and then moderate pressure for the definite kissing. After that, the second stent can be delivered. Again, stent size fitted to the size of, in this case, the circumflex. Very important, it's the overlap between the two stents, in this case, in the left main. It's a short left main, so it's not a good demonstration for that, but the overlap of the two stents doesn't need to be much. It can be minimalistic, as we will hear later this evening, but otherwise, two, three millimeters is more than enough to have an overlap. There is no need to have a double layer in the full extent of the proximal main branch. Since the stent is positioned, and same story as before, it's very important to disengage the guiding in order to avoid crushing of the freshly implanted stent because the other wire is still jailed. This is followed by a proximal optimization. After proximal optimization, you perform, again, rewiring. Again, nothing else, just the steps of the provisional stenting. You perform a distal rewiring, and this is normally very easy. Why? Because with the first kissing, you fully prepared this first stent already, so there is no burden anymore to get there, and therefore, normally, you don't need to prepare the entry of the jailed branch, but you can go on right away with the properly sized kissing balloons and complete it with a final proximal optimization, and this is the result. When do we need the imaging? I think baseline for sizing, and after each rewiring to confirm that the wire is in a proper position and over behind the struts, and ideally, distal rewire the side branch. This is how we started, and this is the final result on the left main, and as I said, what we did is nothing else, provisional to the LED and steps of the provisional to the circumflex, two times exactly the same steps to one direction and to the other one. In this case, it was followed by a second procedure, and we did the right as well. So same aspects as discussed, advantages and disadvantages of different two-stent techniques. Where the stenting technique will come in the future, the important question is granted access to the non-treated branch. This is what you just mentioned before the previous case, DK Crush provides this. In DK Cullot, you have to give up the access to one untreated branch at a certain step of the procedure, but otherwise, side branch or steel coverage is excellent with DK Cullot. In Neocorina, you can optimize it, and then it's minimal, multiple layers, it just depends on you how much double layer you make in the proximal main branch, and therefore, you can also minimize malposition. Technical feasibility, actually, it's as I said, it's nothing else but the steps of provisional, but two times, and final side branch, main branch access is performed properly and properly sized, and it's excellent. The way I'm thinking about bifurcations, everything starts with the question whether it's a true bifurcation or not. If it's not a true bifurcation, then it's just main branch stenting first, and finishing with provisional, and completing to second stent in case no good result achieved in the side branch. In case the side branch is at risk based on a true bifurcation lesion, then you might start with the side branch first approach. This is the same story if after predilation, you notice that the side branch gets compromised. If side branch first, then you can go on with inverted culotte, and actually, only in case you think that if I treat the side branch first, I lose the main branch, if I treat the main branch first, I lose the side branch. If either or, you can compromise and potentially lose both branches, this is my way for DK Crush S-choice.

chronic total occlusion

bifurcation technique

provisional stenting technique

lesion preparation

two-stent techniques