It's an honor to be here. Thank you for your attention. Iliac artery ivus is super important. If there's a section in the arterial ivus world that requires almost 100 percent, especially if there's no pre-procedural imaging like CT and MRI, is ivus. From a medical legal standpoint, it's very hard to defend the case that went wrong if imaging has not been done and only on angiography. Basically, the analogy that I make for Iliac arterial ivus is you take an engineer, you ask them to work on a tunnel through a mountain, and you tell them you can get into the tunnel and look inside when you're doing your measurements, or another engineer looking from the tunnel from the outside and making the same decision. Which one would you pick? So basically, I'm going to present a complex case here that involves also coronary interventions. This is a gentleman who presented in 21 for non-STEMI, and the operator could not palpate a right femoral pulse, went to the left, barely palpated the femoral pulse on the left side, and found this monster sitting in the Iliac here. So bailed, went left radial, and the culprit was the saphenous vein to a right posterior descending artery, which was fixed. Then in May of 2022, the patient came back for another non-STEMI, unfortunately. He continued to smoke, unfortunately, and the vein to the right posterior descending artery re-stenosed and had another PCI. This was done from the right femoral axis, and obviously you see the right common Iliac artery stenosis. This was not taken care of intra-procedurally because the patient was relatively asymptomatic, not too active. But we went on to actually fix that right Iliac for the purposes of a complex intervention of the left circumflex artery. The right external Iliac artery looked okay. The right common Iliac artery was treated with intravascular lithotripsy that allowed us to pass a 7x45 sheath to the aorta and fix the left circumflex artery, and the complex 2-cent PCI went well. Then because he started rehab, he could not really finish up even the earliest stages of the treadmill or the bike, so we decided to fix his right Iliac. So planned the right common Iliac first and then staging the left common Iliac. As you can see, there's a pretty difference between the right and the left, and that's why we wanted to stage the left because it's a much bigger project. So we decided to place an 8x58 covered balloon expandable stent, which was post dilated to 9 millimeters, and that was the angiographic result afterwards. And you can see a stent edge dissection. Obviously, we pull our IVUS, which was done beforehand, and now it's being done right after the stent was placed. And you can see the different sections here very easily identify the distal edge dissection, and I represented that on the longitudinal aspect. And of course here, the challenge is the internal Iliac is severely diseased. It was also severely diseased on the contralateral side. We don't want to lose that internal Iliac. You'll be surprised how many people would have buttock claudication after that. So we really wanted to preserve that. So we picked a non-covered balloon expandable stent, an 8x27, and tried to land it literally at the takeoff of the internal Iliac, knowing that with plaque shift, we can probably salvage it if possible. And one of the technical tips during the procedure, very important to move the sheath upwards within the covered stent before you advance the other stent to overlap. You make sure this is the sheath tip. This is the overlap, probably half to one centimeter in the arterial space. And then the internal Iliac on roadmap, we had it really well identified in order to position the stent. And you basically unsheath, and you deploy your stent, and thankfully that internal Iliac remained patent. Of course, we were not going to intervene on it. But then in April of 23, this is the time when we really needed to get to work on this gentleman on the left side. He was clearly symptomatic. The first part of the procedure is obviously making sure that your sheath goes through the stents under fluoroscopic imaging, and make sure that you fluorosave that because you can sometimes damage stents, and you can find out about it at the end of the procedure just from your sheath. And this is the initial angiogram. So we decided to go with intravascular lithotripsy. Thankfully, we had this available on trunk stock since it's so new. The 10 millimeter by 30 L6 was used at two atmospheres, and an eight French sheath was placed on the left, seven French on the right, eight French on the left because of the expected very large diameter stent that we're going to be having. You can see here only the other aspect of IVUS that has not been talked about, not only the axial images, but the longitudinal fluoroscopic image of the IVUS gives you a very clear idea about the length of the lesion and gives you a very nice opportunity to size your stents from a length standpoint. So I represented that here. What you see is the largest diameter is 24 by 25. Obviously it's an aneurysmal calcified, so we have three challenges. The first challenge is the aneurysm. How are you going to oppose a stent in the aneurysm? Second challenge is there's tons of calcium in there, so the risk of perforation is substantial if we are not careful. And thirdly, that internal iliac is also severely diseased, and we didn't want to cover it with a covered stent, especially that the contralateral internal iliac was also diseased. So in terms of stenting strategy, we studied unconventionally to start distal to proximal, and we took kind of the analogy of the venous space where we anchor in the least aneurysmal segment. We decided with the external iliac artery with a balloon expandable non-covered stent in order to basically jail the internal iliac, hoping not to occlude it, and then after that, place a covered stent within that with a long overlap, a 2-centimeter overlap balloon expandable, and then dilate the transition in a funneled fashion so that we can try to mimic the anatomy as much as possible. So here's the actual procedure. So our sheath is sitting distal to the external iliac proximal segment. We deployed an 8x59 non-covered balloon expandable stent, and then after that, the sheath is being advanced, as you see here, through the lesion. It's very important to advance the sheaths through the stent. And then a 10x38 covered balloon expandable stent was deployed in the proximal comma iliac with an 8x40 balloon protecting the contralateral iliac, which was barely protruding into the aorta, but not too much. And basically, we, of course, kissed, and then this transition, the 2-centimeter overlap, was post-dilated with this 10-millimeter stent balloon at kind of lower atmospheres to make it like a 9-millimeter stent. And the internal iliac remained patent, thankfully. And then this is the final post-dilation of the external iliac, which was negatively remodeled. Of course, you can imagine with the chronic stenosis, we decided to use a 7-millimeter balloon in the external iliac instead of an 8, just because we have a non-covered stent there, and we don't want to be too aggressive. And this was the final angiogram of this patient, who obviously had his symptoms relieved after the procedure. And thank you very much. I appreciate the opportunity to present. Thank you. I'm just going to go down the line. Out of all your procedures, what proportion of your procedures are performed with intravascular imaging? It doesn't matter, coronary or peripheral. Kate, you're coronary. Well, I'll say I'm only doing anything in the periphery because I made a boo-boo, so I'll exclude that. But I think from the coronary side, we've seen that effectively 99 percent of our successful PCI cases are with that, and the rare cases are someone who's very elderly, kind of decompensating for other means, and, you know, you basically see a law of diminishing returns there. But I think it should be really the exception. I'll go down the coronary. Yeah, coronary. We do…almost all of our PCIs or physiology are both guided. And then for peripheral, I'm using it for probably about 75 to 80 percent of my cases. It's compulsory for venous and below the knee, and it's used in almost every case for asthma and disease. So coronary, probably above 90 percent, peripheral, venous, 100 percent, arterial, depends. Very close, about 90-95 in the coronaries, 100 percent venous, no question, and in arterial about 60 percent, but for the iliacs, 100 percent. Yeah, I think this is a pretty common theme. So I'm over 90 percent for the coronaries, 100 percent for venous, and I would just add that on the arterial side, I also do some OCT work. So between OCT and AVIS, I'm probably around 90 percent. Right. Wonderful. Head-to-toe intravascular imaging is an important part of our inovascular procedures. Thank you, everyone, for staying tuned. Thank you to the coronary operators for looking at feet with us. And oh, we got one question. Maybe we'll just have you come up and ask the panel so we can get to the next session. Thank you.

intravascular ultrasound

IVUS

iliac artery stenosis

restenosis

intravascular imaging