<v ->Before we go to the audience question</v> your protrusion is pretty minimal. How do you define that versus the nano DK crush? Are we considering now we're trying to achieve a nano-crush, or is one to two millimeters? What is your approach? <v ->Yeah, actually, nano-crush</v> is a good stenting technique too but, personally, I think if the protrusion is too short, nobody can make sure the full coverage of ostial and flares. Certainly that, you know, we always recommend to revive from different cell. So if nano-crush you use is, for some case, it could be a transfer to classic crush. Thank you. <v ->Okay, great.</v> And I like the fact you're adding more steps to the 12-step DK crush. But I believe that optimization of the ostial circumflex is key, and one way to do it is adding that step with the NC balloon before the crush. But I do think, prior to stenting, making sure you have optimal plaque modification and good vessel prep is another way to assure your ostial circumflex is gonna have a good luminal diameter or area. I think that's something we underestimate and it is frequently underexpanded, so I like adding that extra step even if you have good vessel prep. <v ->Shao-Liang, one other question that was asked to me,</v> "The second time you recross, was it important to recross in the proximal or middle cells rather than any cell? Why you think the second time when you recross Why should it be proximal? Or maybe made, is it science behind that? Because we've already done that once before but the first proximal recross. But the second time around, is that essential?" <v ->Yes, thanks for your good question.</v> Actually, you know, for second rewiring, because we have performed a kissing balloon inflation, we can rewire even from tissue cell. But, you know, a different stent has different design. For example, if stent has very large cell, there is a risk to rewire if below the side stent. Also, I wanted to see, answer the question by Don Abbo. Actually, you know, even I have showed 12 stables, by a single forensic secure intervention cardio university, there are only five stables for DK crush. Very simple. <v ->(chuckles) Yes. You make it look simple for everybody.</v> Terrific. <v ->To Shao-Liang, about the angle of the bifurcation,</v> do you think that there are some angles where the DK crush is mandatory, let's say, they really can be the best technique, or do you think there are some other bifurcation angles where DK crush is not really the best and we should go for something else? <v ->Well, thank you very much.</v> Actually, for angularity bifurcation, I do believe the DK crush is the best stenting technique. Let me give you, through example, Why is from our DK crush V study? 'Cause, you know, we compare the DK crush with the provision of what is left in true bifurcation. But the reason for why, there is a high rate of stents on both results of prominent stenting technique. And that's because of the sudden, if I mention, because of very angulated dislodged stent, revised successful pulled or even stent could not be put into the side branch to get the dissection, something like that. So there's a first example from our definition two, starting with two. For that trial, we only include a complex coronary bifurcation, defined by definition criteria. Outpatient are really, really, have the complex bifurcation. So for some case, similarly we could not deliver this single stent into the side branch after provision. Thank you. <v ->Maybe one last thing.</v> Yiannis, with all your computational modeling what do you think that angle is, the optimal angle where, the narrow angle where you should go to something else, whether it's a DK-culotte or when should you avoid a T and protrusion or, you know, what angle's too narrow? <v ->Yeah.</v> <v ->Yeah.</v> <v ->That's a very good point.</v> And actually that was a question I tried to answer. When it's like T, the perfect 90 degrees, 80, 90 degrees, or even more than 90, I think the scenario of a T technique is probably the best. I'm not quite sure that the culotte will work well. Culotte is meant for bifurcations in the range of less than 60 degrees, like not T-like. And second condition for culotte, both the distal main vessel and the side branch should be equally sized, within a millimeter, to the proximal main vessel. So as long as we have a wide bifurcation with equalized branches to the main vessel, I think culotte becomes ideal. Anything out this, we can consider T and protrusion. Or if it's the ideal scenario of 90 degrees, then a T technique. For DK crush, obviously we have the pope of the technique here, but I'm not quite sure for a T-like bifurcation the DK crush would work very well because it requires lots of protrusion of the stent into the main vessel to crush it. I think, in a nutshell, when it's T-like, a T technique, when it's Y-like, culotte technique, and then T and protrusion essentially can play in between. <v ->And for your case that you presented,</v> because, you know, that's not a normal approach that we're doing every day, inverted versus non-inverted, how did you choose to stent the circ first? Is that based on the severity of disease or the angulation? <v ->Yeah, so the scenario</v> is that once you define the complexity based on the length of disease into the side branch, as we discussed, with 10 millimeters being the threshold, once you decide about the complex, then you decide about two-stent technique. Then the next question you have to answer is, "Which vessel I stent first, the side branch or the main vessel?" And the answer to this question comes from what is the likelihood of losing or jeopardizing the ability to rewire the side branch after I fix the main vessel. So if we feel that it's a very calcified, very angulated, very tough side branch takeoff, and we have high chances to lose a side branch or compromise it after we stent the main vessel, then the best approach is to stent the side branch first. In this case, either you stent with a DK crush or you stent with any inverted T, inverted TAP, inverted DK-culotte, which is inverted, means I stent the side branch first. And whether you do T, inverted T, or inverted TAP or inverted culotte, it's dependent on the angulation. If it's Y-like inverted DK-culotte will be perfect. If it's T-like, inverted T would be perfect. And again, inverted TAP is anything in between. <v ->Perfect, maybe we can move now</v> to some questions from the audience. We've got 10 minutes left, which is a good amount of time. <v ->Please show me what it says. Make a comment.</v> <v ->Oh, yes, yes.</v> <v ->I'm sorry, I have two more comments</v> about the DK-culotte and the T-stent technique. Basically, culotte-stent technique is similar to T-stent technique Secondly, I think because there is a high rate of recent losses at the ostial side branch. So for reverse T technique, I think the patient will be at high risk for ischemia during follow-up, because her ID was treated as a side branch. Third one, I'm also the founder of DK-culotte stenting technique. After that, I modified it to mini DK culotte stenting technique. But personally, I don't recommend culotte stenting technique for left main bifurcated stenting because from our DK crush Swiss study during three, two, five years of follow-up, there was a very high resistance on policies after culotte stenting technique. This is a typical drawback from culotte stenting technique. Thank you. <v ->All right, terrific.</v> We'll definitely need a debate another day on this topic. (laughs) But anyway, let's move to the questions. <v ->But we have a consensus to some extent here.</v> You know, I don't think for the angulation's left main which are usually 70 degrees plus DK-culotte is the best approach. <v ->Yeah.</v> <v ->For left main.</v> <v ->Terrific.</v> John, are you gonna bring some questions in from the audience? <v ->Yeah, I have a few, some of which are kind of recurring</v> from the last bifurcation club as well, so I'll put those out there again 'cause there's a lot of interest. And this is a practical question, I think. Dr. Chen, for your case, you showed two BMW wires throughout the case. What are, if ever, the panel's kind of standard algorithm of wire choices in terms of class of wires and then wire for side branch access after jailing it? <v ->Well, I can.</v> I use two workhorse wires, non-hydrophilic workhorse wires. Generally, I just choose two of different colors so I can tell them apart, so I may use something like a Runthrough and a MINAMO. But however, you can use the same one if you want. I don't tend to go to hydrophilic wires unless there's an issue crossing, either initially or afterwards. And I always, anything polymer-coated, I would remove as soon as I've accomplished the task at hand with that. I don't tend to work with them. And so it's amazing how infrequently you need to escalate to a more aggressive wire in these bifurcations. Most of the time, more cross is fine. Anyway, it's certainly an option. You can go to a hydrophilic non polymer-coated first and, if needed, a polymer-coated wire. I'd be interested to see what others are doing. <v ->Valeria, what do you do in Netherlands?</v> <v ->Yeah, I think what's important indeed,</v> I usually start with more cross. It's important to have a wire which can really keep a good shape of the tip. Because then you can, I mean, try multiple attempts to rewire the side branch and you will, anyhow, have the support of a good shape of the tip. That's, I think, my preference. <v ->Shao-Liang, are you still with the BMW</v> or do you change out? We talked many years ago, like a decade ago, with the BMW wires. I was so scared of doing it. But anyway, still using BMW or do you change? <v ->How about you, Tanveer? What are you doing?</v> <v ->Me, I use a Runthrough and a BMW like I want,</v> and also like... What you need to know is that if you do good proximal stent optimization side branch and do a good pot, your wire always go through, you know? That's what I've learned. Good PSO, good pot, there's no reason why a wire would not go back. <v ->Yeah, and I think if you're stuck on that point</v> which is the rewiring aspect then doing another pot, and the EBC has a really remarkable document. That's a troubleshooting document that will take you through the bifurcation algorithm and at any step you're getting stuck, it will tell you the possible reasons, you know, three or four reasons why and give you potential solutions. So that is a really important document to keep in mind because in general, again, you wanna just go back and make sure you've done the proximal optimization and then try to recross. <v ->So that is a recurring question we get on these chats</v> is if you've done proximal optimization, you're still struggling, what is some tips and tricks you could share with the attendees on how to rewire that difficult side branch? <v ->Yeah, I think other than reshaping your wires,</v> there are angled catheters like the SuperCross if you're talking about proximal bifurcation like the left main. Often dual lumen catheters like a Twin-Pass or a Sasuke will allow you to, you know, change where your wire is probing the osteo side branch. So those are some suggestions other than escalating to a polymer-jacketed wire or changing the curve is, you know, having some other supportive device like a microcatheter. I mean, Yiannis, you were working on that troubleshooting document. Do you have any other suggestions? <v ->Yeah, I think that to put in</v> some kind of like stepwise approach, one is you take your main vessel wire and try to go from this strut into the side branch, you cannot do it, then obviously you have to escalate wire at this point. and then if this does not work, you can consider using a dual lumen catheter. If this does not work, then I guess another pots, more aggressive pots to open up more the struts, and relocate the struts, and then repeat the same, again, from the beginning, try with a poly jacket wire and with a dual lumen catheter again or the Agilis catheter. I believe with a good wire, at the end of the day, with a good support from a dual lumen or Agilis catheter, it's very unlikely not to make it. It'll be a really, really rare case that you cannot rewire at all. <v ->Yeah, and the cases I've seen that happen,</v> it's people who've kind of had an extensive crush, like a very long overlap or that there was inadequate expansion of the osteo side branch such that, you know, there's risk of getting behind those struts. So I think again, if you optimize the side branch stent before it is crushed, you'll have less likely to have that issue. <v ->Yeah, I have more comment</v> about the kissing balloon inflation. I think the quality of kissing is very important. So like I always say, so all angio or two-stent, in the main vessel should be as shown as possible. It do have severe intrusive images study to conform. Showing them being is very, very important. Thank you. <v ->Wait, Shao-Liang, I have one question to ask you.</v> You know, now that Valeria and I have come out with this imaging of the side branch, do you think... And you did imaging DK study, do you think they'll increase or change the way we think about side branch in adding that to lesion complexity if imaging is now included? We didn't use that in your definition study. So what do you think now? Will you image more to include them in the trials? <v ->Yeah, very, very good question.</v> Intravascular imaging is critical for left main, also left main bifurcated lesion. You know, definition two trial, so I was only using 40% of the patient. But for left main, definitely 100% in my class lab. Now, one DK crush edge trial is I'm going to compare iso-cardio and angiocardio DK crushing technique. So far only 60% of patient enrolled. Many, many interesting findings from the iso-cardio group. Thank you. <v ->Terrific, well, maybe as we wrap up here,</v> we can just go down the panel for your last, final, you know, recommendation for getting an excellent outcome with left main bifurcation stenting. So maybe we'll start with Dr. Paradies. What's your recommendation? <v ->Well, my recommendation...</v> That was a terrific session, so a lot of take-home messages. But my recommendation is always to carefully plan the procedure upfront and be ready for anyhow, any dynamic changes of the bifurcation, and use imaging. <v ->Terrific. Yiannis?</v> <v ->Yes, so three words, planning, planning, planning.</v> And two more on top of those three, imaging and follow the steps religiously. I think this is the most high technical field. Once you are cheap and you try to bypass a step, you might end into a big trouble. So follow the steps religiously, meticulously. You need to be OCD. <v ->Okay. Shao-Liang.</v> <v ->I feel a few words cannot say everything.</v> I think a very carefully assessment of angiography and the pre-procedure in vascular imaging are very, very important. Certainly, I think the left main study is very important and also we need very, very wonderful skills. Thank you. <v ->Okay. Tanveer, any last words?</v> <v ->No, I think everybody said what I was on my mind.</v> But I think it's very important that, the no shortcuts, you know? And Shao-Liang taught me DK crush about 10 years ago, so imagine. I followed every step religiously, actually, and you'll get in trouble if you miss that one, guessing, or if you don't do proper pot. If you don't do things correctly, you'll get into mess. And the implication for the patient is that this is the left main. If it thrombosis or something bad happens, the patient's gonna die, you know? And, you know, you really have to do this very, very meticulously. <v ->Yeah.</v> Okay, so in conclusion, the stakes are high but I think certainly everyone here on the panel has confidence in those attending the webinar that this is certainly a lesion subset you can tackle with the right tools and experience, and we really appreciate you participating tonight to learn more about it. And thank Sky and thank Medtronic for hosting this webinar tonight. Hope you have a good evening. <v ->Thank you. Good night.</v> <v ->Thank you, everybody. Bye.</v> <v ->Thank you. Good morning.</v> <v ->Good morning.</v> <v ->Good morning, good evening, and good night.</v> <v Dr. Abbott>From all over the world,</v> in all different times. (uplifting music)

left main bifurcation stenting techniques

DK crush stenting technique

culotte stenting technique

proximal optimization

wire choice