Yes, so I'm – welcome, everybody. My talk is intracoronary imaging and arthrectomy, so it's big, big topics, but I've included a lot of slides for everybody's use, okay? So I'm going to jump over some of the theoretical aspects, and then I'm going to focus on the case. So, you know, everybody's familiar with this, so I'm going to jump over this. This is very important. I really think that we need to understand that side branch occlusion compromise is still important, and 85 percent of them are due to coronal shift. Most people think that it's all plaque shifting. It's really not. Eighty-five percent of them is coronal shift. Plaque shifting, if you have proximal main vessel disease, is a strong – and also, if it's a very, very wide angle. So those are the two scenarios where plaque shifting becomes very, very important. So a very narrow angle and a very wide angle are also a problem. This is what I was talking about. This is the algorithm that Yanis showed, which is similar to what we did, and if your risk of side branch occlusion is higher, especially if you have calcium, you angle, and you have what we call a sharp carina, an eyebrow sign that you see there, the side branch occlusion rate is much, much higher, 26 percent versus 3.9. Those are the ones in provisional that we then recommend trapping a balloon to offset all those things rather than just the wire. So this is what Yanis showed, but I'll tell you, the reason I'm showing this is every step, we have all this complaint, oh, we can't wire, we can't do this, we can't do this. Make your life simple. Every step has OCT or IVUS in there, and it helps in every step in bifurcations. Okay, so imaging is crucial in bifurcation lesions. It really is. No, I don't know, but this imaging is not that crucial. What happened there, George? Shut me down. It's imaging, imaging. It's all about imaging. It's all about imaging. That's a proof why it's all about imaging. We can't see. So there is data. A lot of these trials are sort of prospective registries or retrospective registries. We published our paper with 400 patients, also IVUS versus angioguided, and there is a huge difference, really. Not really we have lack of randomized data, but huge difference in all these registries. This was our trial, 449 patients, and you can see IVUS-guided versus non-IVUS-guided. There is a huge difference in death, MI, stent thrombosis, TVR, and TLR. And so now, not only with imaging, but then we have what we call SyncVision coregistration, and then what happens is if you have a Medina callicification, it's all angio, and we know in bifurcation, especially left veins, it's really very limited angiogram. So we can actually use coregistration techniques and pull back and see exactly what the plaque morphology, plaque distribution is, then you actually can modify the corona, and here, we can actually change the Medina scope by doing coregistration. OCT has very, very similar data, similar to IVUS, and then OCT coregistration is also very, very important here, and this really changes the way complex cases are done also, so very, very important. And this is what somebody asked a question about, you know, how do you know which stent strut to cross and all those things. 3D reconstruction of OCT actually shows you exactly what stent strut you're crossing. IVUS SyncVision has this thing called device detection. It actually will tell you exactly which side branch, which strut you are crossing. Okay, so those are the two tools we can use to make it easy for us, rather than guessing, to cross the distal side branch, and it's important, really. When you do side branches, when you do imaging, you have to usually do…with IVUS, you do both. You have to do both, because you really do not…you really overestimate the significance of the side branch and plaque distribution on IVUS. With OCT reconstruction, actually, you can just do the main branch, and it actually correlates very, very nicely, and it tells you what the ostium is, so it takes one step less. But with IVUS, you know, you have to do both, actually. So here, you have to plan, land, plan size, and optimize, which is very important with OCT, and this is what we were talking about. So when you cross the proximal stent strut, Johannes, remember we were talking about that you really pull the stents. You see how you deform the stents when you do proximal stent, and then you cause a sharper carina where the endothelial shear stress is much more. So this is why it's very, very important to cross the distal stent strut and not the proximal stent strut, okay? Very important. And post-procedure is important. Same thing we talked about with IVUS plan, land, and expand, no guessing. All these steps become really simple if we stop guessing. We plan ahead of time, whether we need artherectomy or no, what size, you know, Yannis showed that you have to size the distal side branch, then you do POT. We guess all those things on angiogram. You don't want to guess, because if you use imaging, it makes your bifurcation pretty simple and predictable. So bifurcation, PCI, obviously, wiring, then main branch, side branch preparation is important. And you really want to make sure that you prepare. Like we said, a lot of side branches, if they're calcified, they don't really expand. So you want to make sure that stenotic lesions, very, very angulated, very calcified lesions, very, very important to have preparation. So calcium modifications are important, obviously, with your calcium volume index is higher, your arc is much larger, and calcium is one. Imagine, when you do coronal shift with calcium, that's the time you'll never get in the side branch. Calcium is your enemy. So those are the things you either protect with gel balloon, or you adequately, you have to adequately prepare this. It's very, very important, okay? So this is what, you know, we talked about the calcium modification and artherectomy. So in osteolesians, usually rotational or lithotripsy works pretty well. Low ejection fraction, because the way the orbit is still orbital, it still has some circulation. We find that it's really well-tolerated in people who have low ejection fraction. Bifurcation, obviously, laser with two wires, you don't want to give up the wire. So again, laser artherectomy works pretty well also, and obviously, if you can cross with lithotripsy. So I'll show you this case here, 77-year-old female with previous ejection fraction of 40%, CKD, AFib, anemia, she came in shortness of breath, and chest heaviness, she had non-STEMI, and outside hospital ejection fraction has decreased now to 20%. This is what her artery looks like. So you can see a little filling defect in the distal left main, which you will see more, and the LED is diffusely calcified and is very, very tight. Ejection fraction is 20%, and her legs are terrible, and there's just no real protection happening here. So you can see pretty bad bifurcation lesion, obviously, very, very calcified. That coronary artery is moderate size. So refuse, obviously, same story, refuse cabbage, there's a thing, and you know, so they send it to us, right? So we did access, you know, this was the only leg that was good, so we micropunctured ultrasound, safe access, and then we have a seven French guide. So we actually wired primarily with a Vipaflex wire, which I usually use now to wire. It actually wires very, very nicely. So I use primarily with that, and you'll see left main was not that difficult, really, but it was very difficult to cross the mid-LED lesion with the CSI device. So looks like decent luminal gain. We angioplasty this area, and then we iris. So you see, this is what we are doing. We are marking where we are really, the image is, let me see if I can go back here. So that's the marking of the, not only sizing, but where to land and what to do. And so here, this is what I was saying, is when you pull from the circumflex to the LED, you really overestimate that area where, so you have to do both, actually. So this is what our after-arthrectomy showed, that you had significant amount of fracture, and you'll see there, there was a little bit of nodule in the left main also, but a very, so nodule, and then concentric thick 360 degrees of calcium extending in there. So what we did, we wired the circumflex after that, and we did shockwave, because it was very, very calcified initially, iris would not go into the circumflex, so we did shockwave of that area, and then we marked. So this is what happened. So you'll see the catheter, where the imaging happens is not at the tip or not back. It actually happens where the black part becomes less black. That's the two-thirds of the way. That's exactly where the imaging happens. So we marked the ostium in this, and you can do it, if contrast was not an issue, you can do IVS co-registration also. So we did that, we marked it, and then we IVS from the circumflex, you can see how bad it is, but it's broken up, broken up, but you can see it's pretty tight, and the IVS catheter will not stay there, it usually jumps, like everybody experiences. So we stented a long stent. You can see the expansion is very, very nice, because after post-arthrectomy, and then this is the technique that I think, it is like DK Crush, but four steps less, okay? So what we do here is we put the two stents, or you could use a balloon size of the left main into LED also, if you wanted to. We have seven friends, so we put a stent into the ostium of the circumflex and the left main LED, and then what we do is, you'll see it'll play, we stent the ostium where we marked it by IVS, and we stent it at high pressure, 20 atmospheres, and then you pull the stent balloon back and leave it there, okay? Because then when you crush from left main into LED, you're actually crushing the one millimeter or so, whatever side actually is coming back, okay? So you're crushing it. So what do you do then, after you've done that, you deflate the balloon in the LED left main, then you re-inflate high pressure to correct the deformation that you've done, okay? So we tested that. You see at the bottom here, that's the visible heart lab in Minneapolis, and this is what looks like a dedicated bifurcation stent. So where you already corrected it, then you deform the LED stent, right? So what do you do is you re-inflate the stent balloon at high pressure, and you take it out. And then I'll show you something here. So this is stented crush, and there's decay crush, but then this is this technique here. So then you look at it, we part, obviously, we don't want to follow Yanis. Yanis always told us this, so we want to make sure that we do a nice part. And we know the size, we're not guessing, right? 4.5? We do 4.5. So then that's your ivors. The stent looks beautiful. It always will look beautiful if you image, I'm just telling you. See this is what it is. That's why they go to him, you know, to surgery. So then we re-cross the distal stent, and then remember we talked about it. So this is how you do it. That's the device dissection, and the OCT you can do very, very similar. So we cross the distal stent strut, and look at the non-compliant 3-5 balloon after you've corrected it. Non-compliant, it goes like butter, because you've already corrected it. So what do you do? Sequential high pressure, low pressure kiss. Low pressure kiss, the reason you do high pressure, high pressure, and then low pressure is you create an ellipse, and you can see bottleneck if you don't have a short overlap. You always should have short overlap, and you can create a bottleneck. So then you have to re-pot. But in general, if you do that, and you ivors, and if it doesn't change into a bottleneck, you really don't need to do re-pot, but imaging actually guides you through that. But most people recommend a re-pot. So we re-potted it because we actually had deformed it, and this is your result. This is like a dedicated bifurcation stent. It looks beautiful. And you're done. Particularly because you magnified the view now. No, no, no, no. I always do 70-inch afterwards, yeah. Anyway, so that's your final ivors. You always do final ivors, and you can see, despite that thick of a calcium, you really had very, very good stent expansion, and you should be familiar with the imaging of rule of 5, 6, 7, and 8 in this left main. Bigger patients, you can add .5 to it to make sure that at least you get 8.5 in the main left main point of confluence in an LAD and CERC. And so this is every step, as I said, imaging really changes it. Your wiring, your difficulty with wiring, your wire going in the vessel, but then you are under the stent strut, no pot, and all those things. Every step is a guessing step, and you don't want to guess. You just imaging either OCT or ivors really helps you. So there is OCT randomized trial, October trial that's actually bifurcation angio versus OCT guided, and then obviously Illumion 4 has bifurcation, significant amount of bifurcation patients, and the improved trial, which we are part of also. This is the ivors randomized trial in complex BCI also has bifurcation, and in class, and data from these two trials will really enlighten us as to where we go with bifurcation stenting. So thank you very much. Great. Thank you. Well, I hope the studies allow dedicated bifurcation secondary analysis just to reveal the data on the bifurcation. Right. That would be definitely a great paper for these cases. Dr. Magdi, please get a microphone. So many people in the room, we want to hear you. Anyone on the panel also, please, any question to just go ahead. So you still like the agreement that complex bifurcation needs two stents from the beginning, complex. And if this case was simple, then single stent would be better. This is one thing. The other thing is at least now 15 to 20% of our patients, they have actually trifurcation. And so what will you do with your maneuvers in such cases? So trifurcation, again, what I do is you simplify any complex BCI you do. And the only way we do is we image them. And you see the plaque distribution. So and then we treat mainly, make sure you lesion prep, whatever you need to prep. And then usually you treat them as bifurcations, and then salvage the other branch that you do. So you cannot really put three stents and all those things, make it too complex. So just understand where the plaque distribution is, prep the lesion, and then you take the bigger branches and do that, and then you go through the side branch and you can actually salvage them. That's what I usually do in trifurcations. Any other questions? Anybody? Now everybody's going to image, huh?

intracoronary imaging

bifurcation lesion management

side branch occlusion compromise

intravascular ultrasound (IVUS)

optical coherence tomography (OCT)