Yeah, is it possible that maybe you can use a drug balloon for the side branch and then extend the main and then you don't need to do all these steps or what do you think? Yeah, that's a really interesting idea. I'm doing Pinto. I don't know if he's actually here at this meeting had brought this up in a conversation recently as well that for managing these side branch issues if one, if you're stenting it and we crush it, but the main branches pristine and especially no dissection, you know, imaging looks fine, would we, would it, would there be utility to treating that with DCB? I mean, I think obviously an unknown, but it might make us feel more confident about that. But I think for the smaller branches like a sub two, Oh, you know, the small stents in these scenarios really don't have good long-term outcomes either. So I think that's where it's, it's really favorable. I know some of our colleagues, including those here who've used DCB more, especially for side branch management in these bifurcation cases, I think are more comfortable than us in leaving some small dissections alone that now, if you've got good flow and you're on DAPT, a lot of those actually heal really well. I think in these multivessel disease patients where you stage something and you have the opportunity to come back and check your provisional status, I'm always surprised how much better that looks. So I think especially in small vessel disease, that's a really, it's a really good idea. And I think some people have already been using that. Yeah. Katie, great case. Two things. One, for crash, as we said, we do two crashes essentially. One is with a balloon size to the distant main vessel, but that's incomplete crash. So this has to be followed by a more complete crash with another bigger balloon size to the proximal main vessel. So two crashes before you rewire the side branch into the first case. So two crashes. And then the other thing, again, when we have an issue with a side branch like here, decay crash is a great option, but it's not the only option. We can do any inverted T, TAP, or CULOT. Start from the side branch first, essentially, which is dissected, and then move the second stent to the main vessel. In this particular case, we could nicely do an inverted CULOT or an inverted TAP, for example. Of course, decay crash, as shown, is excellent and works very well. Yeah. And if the stent is, if the side branch is too small, cannot put a stent, can perhaps use a DCB, or you can put a liquid stent. Can use a lot of antiplatelet, and hopefully that will keep up a little bit as well. That's a good, that's a good term. Yeah. Or we definitely limit the CKMB elevation the next day. I think the point about the two crashes is valid. So in this particular case, there's a lot of size mismatch at that diag takeoff, which, and that's more likely if it's a branch you love enough to stent anyway, right? So there it was, like, 2.7 barely in the distal vessel, and it's 4.0 approximately. So choosing that crash balloon was challenging. So we started with a 3.0 and didn't like it, so then took a 4.0 and kind of snuggled that in. And it's, the combo usually does work, but I think it's good to try to limit your imaging to basically two runs per vessel so that you can stay efficient in these cases. But those are times where sometimes just, if you're at all worried that there's something going on, it's going to be easier to manage than before you get your stent in. I've actually started using a variation of the two balloon crush, which is I use right from the beginning a balloon size for the main vessel, and I just do gentle inflation into the main branch, and then a full pot at the crina. So that saves me a step, basically. Saves me maneuvering two stents. And that seems to work well. I've done that a number of cases now. The initial concern that I have with the case is if the side branch is small and has a lot of disease, sometimes you cannot get a good expansion at the ostium of the small branch, and then that may be very difficult to get a wire through and doing the final kissing stuff. So point is, you have to make sure that the ostium of that small branch is very well expanded, and sometimes have to use high pressures before doing the crushing, keeping the vessel very open and the ostium. Amazingly important point. Almost now, always deploying that stent in the side branch, you have the opportunity then to pull it back and go higher pressure. That is not enough. Go back with an NC before you crush it. I mean, before you crush it, because once it's crushed, the opportunity to expand that area is particularly difficult, and this is magnified when you're in the left main. That's my standard approach now, to always deploy the stent, pull back, high pressure. Yeah, to Vlad's point, you know, doing the side branch and then leaving the balloon, and I'll show a technique with my case a little bit later on. Leave the stent balloon in the side branch after you've done high pressure. Leave it there. And then when you crush it, you are really not only crushing it longitudinally, but you are actually, you are pushing it where it's supposed to be, OK? So then you already have your balloon in there, so you inflate that balloon, high pressure, that pre-existing stent balloon, you haven't taken it out, you automatically take several steps out. Then recrossing, all of those things really do not make a difference. So I'll show you a case that actually is another trick to use, because it makes it very, very simple. Well, obviously, Dr. Singh can't wait to start his talk on intracoronary imaging and antherectomy, bifurcation, PCI. Jas, thanks so much for joining us again. Dr. Singh, Director of the ARTS Consortium, Section Chief of Interventional Structural Cardiology at Washington University Barnes-Jewish Hospital. Dr. Kearney already joined us in the panel as well, that's great.

side branch management

bifurcation cases

drug-coated balloon

stenting techniques

small branch stenting