Excellent. Thank you very much. That was great. No surprise. So, where will we get to? You showed us that Dimitri showed a 10 times increase in transradial access until 2011, and then over the last 10 years, it's been increased by five times, about 53%. Is that sufficient? Are we leveling off? Yeah, so it's a great question, JP. I'm not sure that we're leveling off. NCDR no longer reports the proportion of radial procedures in their reports, which is unfortunate because that was a nice way to keep track of things. There's a really interesting paper that was published a few years ago by Amit Vora when he was a fellow at Duke looking at NCDR. It was in Jack Interventions, and he asked the question, what proportion of your cases need to be done with bleeding avoidance strategies, mostly radial access in this study, in order to affect your hospital level metrics of bleeding? And it turns out that that threshold is about 85%. So, if you've got 85% radial access, that's where your hospital level metrics of bleeding tend to improve. Now, why is that? It's probably because you have this radial first approach, and that risk treatment paradox that we see so often goes away. In other words, the highest risk patients in those hospitals that have a very high adoption rate of radial access continue to get radial access, like those in patients with shock, maybe even patients with certain kinds of CTOs where a biradial approach may be beneficial. Now, we're probably never going to get to 100% because there are certainly patients who require femoral access. Some very, very complex CTOs, for example, may need very large-bore access that's more feasible via femoral approach. Great. Thank you very much. I also found it very interesting how the guidelines, in terms of for STEMI and for shock, has really demonstrated the evolution of it. You know, 10 years ago, probably the mantra would have been never do non-culprit PCI for STEMI and always do complete revascularization. And this looks like a complete flip now. Jackie, do you want to make some more comments? Yeah, Roxanna and I were part of the 2015 update where we changed that. So it was a three 10 years ago in the 2013 STEMI guidelines. And it ended up being a 2B at the time because I think that there was a lot of apprehension about making it more than a 2B because, you know, it was certainly a decrease in MACE and there was no signal for harm. But the MACE was really largely driven by a reduction in revascularization and not really any strong, hard endpoints. So that's sort of why the PCI, the time of primary PCI has stayed the same. But, you know, with newer studies and particularly complete, I think the new move is to do the stage PCI. And I think the complete OCT sub-study sort of provided us with a mechanism to understand why there might be a benefit because we do see that in other non-infarctory vessels, there's a large proportion, I think close to 40 or 50, or 50%, I forget the number, Roxanna might know better, of a lot of thin cap fibroathromas. So, you know, fibroathromas that are at risk for rupture, and that might be the reason why in these patients, the non-infarctory would benefit from PCI. Great. Thanks very much. Um, Creighton, do you have any other more comments you had about, uh, uh, physiologically guiding the intervention for those patients who, uh, do you use, uh, FFR more to, just to prove the vessels are significant that you think you should be treating or vice versa to demonstrate the patients who you suspect you really should be deferring? I think both are true. And I think, you know, where radial was 10 years ago, that's where FFR is now, right? It's only implemented in about 10% of patients, despite the fact we know that it's probably superior to a purely andrographic driven, uh, PCI approach. So I think it's something that we need to implement more and we need to have more, um, uh, recognition of its benefit in cases. I do want to make one comment. You know, it is interesting that in the ACS study, that the FFR guided PCI wasn't beneficial compared to andrographic guided PCI. You can speculate on a number of reasons for that. I mean, FFR is obviously validated in stable patients who don't have, and the filling pressures aren't in shock. Uh, you know, we know there's a lot of myocardioedema with, uh, uh, ACS presentation. So that may affect the validity of FFR in that situation. And it may also be that, you know, FFR, what it helps to do is identify the right population. So in your ACS patients, why does complete revascularization benefit patients for incomplete when it didn't seem to do it so much in encourage and other studies. And maybe it's a, it's a better patient population that's suited toward that. And maybe what FFR is doing is taking your stable population, identifying the ones that patients are going to respond. Um, so I think that that might be a speculation why there's a difference in those studies, but I think it's, there's still some questions out there. I think as, uh, Celine mentioned, you know, adding something to your receiver because of time, people often don't want to do it, but I do think the data is fairly convincing that if you don't have clear evidence for ischemia in a territory, you really should be identifying it. I mean, the coronary flow reserve to stenosis rate is almost a scatterplot in some patients. Great. Selena, when you have, uh, IVSN OCT available, uh, you know, the images in OCT are, are beautiful. The data is not quite there. Do you, do you have a preference of choosing one versus the other? You know, I think that there are certain scenarios where one might make more sense than the other, uh, for example, especially in osteoporosis, obviously I have this, but also occasionally we're doing these procedures where we're aggressively decreasing our contrast use because of kidney disease. And in those cases, maybe we might prefer IVS in, in a lot of the procedures we're looking for things like stent, uh, apposition expansion, uh, and, and we're going to see great efficacy in both options. Um, I think if we're looking at reasons for stent failure, uh, then potentially we might get more information from OCT. So I think there is definitely utility for both depending on the circumstance. Yeah. I think you probably end up going with probably what you're more comfortable with, with the exception of what Lexelina said, if you're doing it for stent failure, you really want to see an edge dissection or something specifically that OCT maybe would show you better like plaque erosion or something then, you know, then, then I think the OCT would be better, but I would imagine you're going to do what you're more most comfortable with. I think the bottom line is that whether it's IVS or OCT, we're under utilizing the power of imaging in our procedures, especially as the procedures are becoming more complex. And I really think that we're really missing out in not imaging. Most of the procedures will go unimaged. And a lot of us are seeing failures of stents because of the fact that the stents are poorly opposed, undersized, you know, I, I was hearing somebody say, well, you know, you know, what are you going to do when you have a 2.75 proximal LAD and then your left main and you're doing a left main intervention and your, your your, your proximal LAD is 2.75. And then you have to put a 4.0 stent in the, in the left main. And I'm like, which who's proximal LAD is 2.75. If they have a 4.0, you really need to image this. And sure enough you know, by imaging this was during a live case by imaging, it was a 3.5 vessel. So we are underestimating by just looking at angiography pretty much all the time. So I can tell you that it is a pretty important tool that we have both imaging and physiology, and we really can enhance our outcomes. And I think we're at a two-way indication for IBIS-guided, but there's more data coming out continuously showing better outcomes when you're using meticulous imaging. And I'm not saying you need it in every procedure, but certainly in the complex lesions, bifurcations, calcific lesions, et cetera. And then the other thing that we underutilize is, is preparation of the plaque for especially calcific plaque. And I think that's another thing, you know, using multiple balloons going really high pressure instead of kind of just passing either rotoblader or, or other plaque modification to enhance stent expansion and to help get a better final stent, minimal stent area by IBIS. And I think those are the kinds of things we should be focusing on if we really want to, especially in high bleeding risk patients, I think it's really important because you're going to peel off dual antiplatelet therapies earlier in those patients, and hopefully you lose less stents if you do physiology and IBIS. So, I mean, I think we have to be really thinking about that, whichever one it is, you should use it. One of them that you're comfortable with, that you feel best with, and you can interpret the images and do the best possible result for your patient. Yeah, I know. I completely agree. One of the reasons you routinely image is that it gets incorporated into your workflow and becomes part of your routine. And so I think that's one of the reasons to just try to do it in every case. Again, you may not need it in every case, but if it gets integrated into your workflow, then it becomes part of what you do. Yeah, I know. I completely agree with that. I think the, my philosophy is that you need to find a reason not to IBIS or not to image rather than the other way around. And if you have that, I mean, you know, you will see that all it does is add five more minutes to your procedure. I mean, it becomes part of it. You do it very quickly and that becomes a standard of care. And the reason not to IBIS, in my opinion, is if it is a two distal lesion, the patient is fidgety, jumping off the table, et cetera. And of course, if it is a type A lesion. So, but you know, more and more we realize those are extremely small subgroup of patients. So in other words, most of the patients would need some kind of imaging. So let me, let me ask here, Tom. So you heard about, you're a CCU doctor mostly, right, Tom? Yeah, man, exactly. You're a CCU doctor. You've heard Sripal's talk. So what's the bottom line for devices? You prefer one over the other. What's your experience with the CCU? Because, you know, it's easy for us to put it in, but then you have to deal with these devices. Is it really worth it? Is it too much complication? What's your point of view? Yeah. The 20,000 foot view for me as an ICU doctor is that you have to balance the risk of support with the risk of not support. So if you have a patient who's actively under supported from a primary cardiogenic dysfunction, you know, you really need to support them because if you wait for multi-system organ dysfunction to set in, the kidneys go, the liver go, those patients are very hard to rescue. And if you do support, you have to do it early because again, if you wait till later in the course, they've developed vasodilatory shock and multi-system organ failure, the work is out of the barn. The second point is that, you know, the support devices are just devices to address the primary problem. They're not going to treat the ischemia. They're not going to alleviate the coronary lesion. And so Sripal's point was that revascularization early, so that the support will keep them alive while you're getting them revascularized, hopefully as early as possible. So, and then the final thing is that I think we're all awaiting data on these devices. We have a paucity of randomized data. And as Dr. Bangalore pointed out, we'll hopefully have more. So we're operating in a data-free zone, but to a first approximation, if they need support, support them early. I think we run up against our time. I want to thank all of our speakers. It was fantastic, better than we expected. You presented it as well as you wrote the guidelines. So thank all of you very much. Thank you to all the SCI staff for putting this together. And of course, thank you to everybody for attending and your attention. Have a great night.

interventional cardiology procedures

transradial access

improved outcomes

complete revascularization

imaging tools