It looks like we've been joined by Dr. Zhang, who's going to present our third presentation, and it's going to be a case presentation of IVAS-guided left main bifurcation stenting. Dr. Zhang? Okay, thank you very much for inviting me. So this is a challenger case, complex PCI with distal FM bifurcation lesions, treated with DK-PARSH with IVAS-guided. This is a 50-year-old gentleman presented with exertional chest pain and the shortness of breath for one mouth. Laboratory examination, so elevated BMP, and also you can see ECG, there were Q-weaver in anterior wall, echocardiographic hypokinesis in anterior wall, and with reduced LVEF only 32%. Clinical diagnosis is unstable angina, old anterior MI, and half-life. Next please. So this is a baseline angiogram. Please clip the left panel. Yeah, you can see this is the RCA angiogram, there is a diffused lesion from the proximal to the distal, and also with a severe classification. Next. This is the left corner, you can see it's a typical distal FM bifurcation lesions involved with distal FM, extended to diffused severe classified LED lesion, and also you can see including the circumflex, very diffused. Next. Next, yeah. This is AP cranial view, previous one, yeah. Please go back one Rebecca, go back one. Just play both, you can go into it. Thank you. So you can see from the AP cranial and the IO cranial view, you can see also very diffused LED with severe classified lesions. Involved the second, actually it's a large diagonal. Next please. So according to the baseline angiogram, the SYNTAX score is quite high, 61, and also SYNTAX score also show the high mortality for PCI compared with CABH. In terms of the distal FM bifurcation lesions, according to the definition criteria, it's a complex FM bifurcation, and in terms of LED diagonal too, it's a simple bifurcation. So next. So of course we will do the hot team discussion. Unfortunately the patient and his family were reluctant to receive CABH for this defaulter or treatment approach for this particular case. So finally the decision was made to perform stage PCI for this case. So first stage we will perform RCA with IVP, then second stage PCI for left coronary, we will use ECMO with IVP, with treated the complex left marrow and the simple LED bifurcation lesions. In term, actually this case is quite a severe classification involving either RCA and the left coronary low tabulation, and actually if needed from the intra-coronary imaging, IVL may be needed. Next. So this is the first PCI, so considering it's a low LVEF case, we use IVP support with a 7-french guiding passage. After 2-O balloon pre-dilation, we inserted the ivers. Ivers show actually there is a kerosene arc was only 118 degrees. So the decision was to use the next slides, cutting balloon to treat these RCA calcification lesions. So we use a sequentially use 2.5 cutting, then followed by 2.75 and the 3-O NC balloon before standing to get optimal lesion prepare. Next slides. So after good lesion prepare, with the support of the extension gazelle cassette, we insert three DES fully cover from the distal RCA to the optimal RCA. Next. So this is the final result. You can see from the end zone, it's optimal. Of course, we will check the ivers. So after ivers check, the minimum stand area for the RCA standing was 5.2 millimeter square, larger than five millimeter square. It's according to the automated criteria, it's optimal result. So next. Next. So three days later, so second stage PCI for the left corner lesions. Still considering it's a low LVF for a high risk patient and also complex PCI, it's a typical chip case. So we decided to use ECMOPARS IVP to support. So we from the right read approach to use a seven branch EBU 3.5 guiding cassette to engage the left man. So from the baseline NGO, you can see it's a typical distal complex left man bifurcation. In terms of the second diagonal, it's a very short lesions. So it's a simple LAD diagonal bifurcation. Next. So according to the definition criteria proposed by Professor Shaoliang Chen, it's a typical left man complex bifurcation. Decision was made to treat it with DKCRUSH for the LAD diagonal two bifurcation. It's a simple. So decision was made to perform provenial standing with a gelder wire or gelder balloon protected the second diagonal. Of course, for all these complex lesions. So intra-coronary imaging guidance was mandatory. So we decided to still use IVAS guidance. In terms of the severe classification, low tabulation or further IVR may be needed according to the intra-coronary imaging guidance. Next. Next, so with IBP and ECMO support, we use a small balloon predilation, the Pistolepman, LAD, and the circumflex. Then we inserted the iveris cassette to get to the baseline intraponemengine modality. So this is the baseline iveris imengine of the LAD. You can see the Pistolepman vessel diameter was 2.25. And the minimum lumen LAD was only 1.45. And also you can see in the proximal LAD, there is a 360-degree superficial calcification. In terms of Pistolepman, very tight lesions, MA only 3.94. And also you can see the EM is quite large, a diameter more than 5 millimeters. Next. We also go back from the circumflex, got the circumflex information. The Pistolepman you can see is 2.8. And also the ostimo circumflex was only 216 millimeters squared. Actually, in the middle OM, there is a negative remodeling. The vessel size is only 2.45. We should be cautious when selecting the stem size. The total circumflex length is 32 millimeters. Next. Next. So after the intrapolar imagine, according to the IBIS imagines, there is a very superficial and 300-degree calcification. We perform low tabulation with a 1.5 bar, 26 virus 3 rounds. Fully do the low tabulation, low astereotomy for the proximal LAD to the middle LAD. Next. Then following low tabulation, we check the IBIS again. As you can see, the middle LAD, there is a reverberation phenomena after low tabulation, which means we have cracked the superficial calcification. But still in the proximal LAD, you can see still there is a nearly 300-degree calcification. Maybe for this site, we may need further region preparation with IVL, with a sugar balloon. Next. So for the middle LAD, after low tabulation, we followed with a 2.5 NC balloon for further predilation before stemming. Next. Then with a jade wire and the jade balloon, protect the second diagonal with a provisional stemming. The first stem is 2.25, just to put in the distal ND. The second stem 2.75 by 30 millimeters, just to cross over the optimum of the second diagonal with a 1.5 jade balloon to protect the diagonal. Next. So after we treated the middle and the distal LAD, we check the IBIS again. You can see the distal LAD is good, plug burden less than 50%. And also still show there is a 270-acre calcification at the proximal LAD. So division was made to perform the IVL treatment with a sugar balloon. Next. So according to the IVL imaging, so 3.5 sugar balloon was used to treat the proximal LAD calcification lesions. So after IVL treatment, we check the IBIS again, and show there is a crack after the IVL treatment. So which means it's a good lesion prepare. Then we will switch to treat the distal FM by patient lesions. Next slide. So for the distal FM complex calcification, so decay crash was mandatory. So lesion prepare with 2.25 NC scoring balloon for the treatment of the osteomole circumflex. Next. Then followed by 2.538 DES. There is a minimal protruding 2mm into left main. After side branch standing, 2.75 NC balloon was used to post-stylation the osteomole circumflex, make a stem fully expansion. Okay, then the next step is the first crush. We first use a 3.5Nc balloon from the distillatement to proximal ending. Then further crush with a 4-0 balloon because according to the Iversene engine, left main is quite large. The EM is a 5-0. We use a 4-0 balloon to crush again. Get a fully crush. Next. So then we further rewind to the second blacks from the process here. They're followed with the first casing, 3.5 by with a 2.75 NC balloon, first casing. Next. Then main metal standing is followed, 3.5 by 26 DES, fully cover from the Austin black man to the proximal LED. Follow the main metal standing where you still use a 4-0 balloon to do the report. Make the stand fully expansion. Next. Then secondary winding and the secondary casing still with a 3.5 and a 2.75 NC balloon. And finish with a 4-0 balloon report. Next. So this is the final angiogram. You can see from angiogram, it's quite a good result. Next. Then we will still check the Ivers. You can see we got the LED wrong and the second blacks wrong. So this LED landing to plot burden less than 30%. The minimum stand area of the middle LED was larger than a 5-0. Proximal larger than 8. And also this to left man, we got more than 10 millimeter square. And also the proximal circumflex is a larger than a 6 millimeter square. Next. So ladies and gentlemen, let's take inclusion. For complex lesions, Iver guidance is a mandatory to reduce the risk of cardio deaths and the maze. The definition criteria can distinguish complex from simple bifurcation lesions. Definition to try to confirm that the two standing technique, especially DK-CRUSH was associated with a superior result compared with a provisional standing technique for the treatment of complex bifurcation lesions at three years follow up. In true bifurcation left man lesions, DK-CRUSH could be performed over provisional T-standing. For this kind of a cheap case, especially with a low LVEF ECMO with a IBP supporter where maintain the hemodynamics stable during the PCI. Thanks for your attention. Wow. That's, I mean, that is a master class in complex PCI. Amazing. I've never seen a syntax score of 61. You really beautiful result and a very meticulous technique. And the fact that even after all of that work, you took time to image the final result to make sure that it was a durable result. Congratulations on that fantastic case. I'll ask Dr. Penilla to maybe make a comment or two. Yeah, I wanna, these cases were amazing with this. The complexity was quite high. With imaging, we see more than what we want to see when we are doing these bifurcation. So we see more complex plaque morphology. We probably see our wire going through this track that we were not aiming to get like parts that are not as optimal as we were expecting. So, and interesting to hear from the speakers, how often and how systematic they are with the wire recrossing. I was impressed by Dr. Marazato presentation. We say first attempt, second attempt, third attempt. So how often do we keep re-imaging to make sure we are across the extended strap we are aiming to do depending on the bifurcation technique we decided. Thank you very much. It's quite a very important point for the two-stand technique. So wire recross. In term of DKCRUSH, first and second rewiring should be from the proximal set. So of course, OCT, that is the fly model, we can see the online. But for the Iverse imaging, we can also use Iverse guided wire access. Actually, this is a live demonstration. This case is from, I think it's three months ago. So Professor Chen and us performed this case. It's from the 320 medical stream live case. Actually during the live case, we, after rewiring to the circumflex, we still inserted Iverse. Auto pullback from the LED to distal left main. So there is some tips. So we can define the optimal point, LED point and the distal left main point. Then there is maybe, we can calculate the total slides we have. Then if we check the wiring from the circumflex to the LED is just at the proximal part of the Iverse image slides, which is defined as the proximal access. Otherwise, there will be decided distal access. So through this method, we can precisely define the proximal access with the DKCRUSH. Not only from Andrew, but also from the Iverse image. Perfect. Thank you for sharing that. And Richard, I have a question for you. Now with the OCT and the question whether we are gonna use more contrast or not, how often, I find when we use no pure contrast for OCT, sometimes we don't have perfect images, but now we are using other contrast media as Dr. Marazato shared with us. So how often do you use those media no pure contrast and you use a pre-PCI, post-PCI? I find quite challenging getting a post-PCI no pure contrast OCT image. Richard, you're muted. So a couple of comments. Dr. Marazato, one exciting thing I wanna tell you, I didn't show it, but in the Ultron 2.0, we have three-dimensional. We have amazing three-dimensional. So you don't have to use the old system at all. You can spin it, you could do everything with it. You could zoom it, you have carina view, you have osteal view. Next time I'll show it to you. I didn't bring it up on this case, but you do have three-dimensional imaging on the Ultron 2.0. And to answer your question, Natalia, instead of dextrose, what I use routinely is saline. And in the RCA and circumflex, I get pristine runs with saline. And if I don't, I can redo it because it's saline. And the LAD, I just do a mid and proximal run and I get saline. So we do a lot of no contrast angioplasty or super low contrast angioplasty at St. Francis where we use saline or high-definition IVs. But I use OCT with saline for all my renal cases and I can do as many runs as I want. One quick question for Dr. Marazato. I was fascinated by your wiring techniques as Natalia was. My question is, do you leave one wire in if you've imaged and you're in the wrong cell just to help direct you? And do you just keep putting wires in until you get to the right spot? Because I'm not as expert as you in that area and I'm going to try doing it, but as a technique, you leave the wire down and then keep going until you get the next one? Yes, if we mistake the ultron wiring, we keep the sub-ultron wire in the side branch and we use double-man catheter. So double-man catheter inserted to the sub-ultron wire and the next wire aiming to the more distant side. So if we achieve ultron wiring, double-man catheter lock like this. Sub-ultron wiring and ultron wiring, double-man catheter lock, stop the cranial area. So we can achieve the ultron wiring. In such technique, we achieve the ultron wiring. So you usually use a double-man catheter when you do your side branch routinely? Yes. No, routinely. However, firstly, we use the pull-back wire advancing. However, if we fail the ultron wiring, identify the solidity, we use a double-man catheter. Okay, great. Really interesting. I think one of the things that I kept coming back to in the presentations by Professor Morisato, by Dr. Schlofmitz, by Dr. Zhang is the fact that the imaging was done initially to help plan the procedure. There's a plan that is then executed based on the imaging and then the imaging is done afterward. And I think one of the issues around bifurcation stenting is to make sure that you have that plan and you continue to work that plan. You can't be in a hurry. You have to be very meticulous because I think as noted at the beginning of this webinar, bifurcations are still, and CTOs are really the final frontier for PCI. And in order for us to be able to get outcomes as good as bypass surgery, it's very, very important to make sure that you're doing things in a methodical way. So Richard, maybe I'll ask you a little bit. I mean, you're someone who has adopted imaging sort of wholesale in your practice, which I think, just talking with you personally has been a relatively recent phenomenon over the last five to seven years or so. Can you talk a little bit about how you came to that decision and why you've continued to use imaging in your complex cases? I'm getting older, Sunil. It's around 10 years now. I've been in practice 38 years. And for the first 27 years, I thought I was a really good angiographer. I didn't realize how mediocre I was until I came upon imaging. And it wasn't easy. It took me two years to really transform it to 95%. And then there's a moment when you look at it and you say to yourself, oh, that's a 275 LED, and you measure and it's a 4.0, and you hold your breath when you put the 4.0 in there, and it changes your life forever professionally. And it really is about a comfort zone. You know, we're comfortable with angiography, so we think we know what we're looking at. But once you start imaging, you realize how impotent angiography is. And it's sort of, I felt like I was on a mission now. And my whole professional career is I'm so excited about how it changed my life. That's what I want to do for everybody else. So it's when you see how imaging, there is no such thing as a type A lesion until you image, in my opinion. Because I think Professor brought up something like, gee, unrecognizable things. So many times on a three-dimensional, you're focusing on the mid-circ, and then it's an osteocerc lesion that you would have missed. So many times when you say, oh, a stress thalum test was a false alarm, or a CT edge was a false alarm, the false alarm is not imaging. Yeah, that's fantastic. Well, I want to thank everyone for attending this fantastic Sky webinar. I'm going to turn it over to Dr. Raab for final thoughts and maybe a summary. So thank you very much for participating. The important message is a complex PCI cannot be done without imaging. And certainly a modification PCI is so important to use imaging, otherwise you'll have, patients will have fatal consequences if you don't do it right, particularly if you do a two-extent technique like DK Crush. So I think both imaging modalities are great. It's certainly OCT as demonstrated, and also IVAS has to be maximized. And you do get to be very good at it, to be able to do this procedure. But without imaging, I think the modification is incomplete. So I want to thank all our guests, but again, our guests from overseas who are in a different time zone right now. And thank you for presenting your excellent cases and I hope all our guests enjoyed it.

IVAS-guided stenting

left main bifurcation

unstable angina

drug-eluting stents

imaging techniques

PCI procedure