So I thank you, Dr. Rab and Alex for having me. Obviously we know the theme and I was asked to speak about a patient who had a bifurcation and acute cardiogenic shock as well as hostile PAD. So this is an 84 year old female. She's an artist by profession. She had an exhibition planned on the weekend that she presented to the emergency room. She came in at middle of the night on a Friday, I think around 3 a.m. and complaining of epigastric discomfort radiating to her substernal area. And she was supposed to exhibit her art, I think that Saturday afternoon. She has a past medical history, just really notable for hypertension and remotely used to smoke. At presentation, she was hemodynamically stable. I'll share with you her EKG, which was concerning. Her metabolic profile, CBC were normal and her biomarker troponin was elevated at 5.6. Here's her EKG and you can take a look at it for a minute. There's some ST depression in the lateral leads. There was some questionable ST elevation in V1 and V2. And you can see she had some reciprocal depressions in the inferior leads. Because of that tracing and her presentation, she was taken to the catheterization lab about 3 a.m. And you can see she has a large dominant right corner artery. She has a co-dominant CERC and she has a critical disease at the left main proximal circumflex and the LAD. And you can see the TEMI flow in the LAD is I would describe it as TEMI 2. And you can see her left ventricular function there on the V-gram. So I guess I would just ask you guys in a case like this, can anyone qualify the lesion characteristics just based on the angiogram? Is that thrombus or is that calcium given her presentation? Can you make that distinction or do you not know until you do imaging? What do you think, Dr. Rab? I think it's, you know, the way it's circumscribed is probably calcium, okay? Thrombus has a bit of irregularity to it. And certainly just to left main, thrombus looks very different from this. It's a big film deflex if it's a thrombotic lesion. But it's probably calcified just to left main and calcified nodule with proximality. Okay, I think that's a very, very astute points. I agree. I was concerned if you, I don't know, do you guys agree that the flow in the LAD is to me too? Yes, to me it's an X. Okay, the operator did an angiogram and femoral angiogram. Do you remember the EDP in this case? EDP was 30 at that time. And they did this angiogram anticipating to put the patient on mechanical circulatory support. The operator was a mature operator, probably practicing for about eight to 10 years. And after this iliofemoral angiogram, patient felt that the patient was prohibited based on the tortuosity for large bore mechanical circulatory support. So we could have that conversation. This is the echocardiogram, which was done Saturday morning. This was about four hours later. And you can see that with the contrast, you can see it more that there is some hypokinesis of the anterior wall in the septal. And it was quantified at 35%. So with that, what were the treatment considerations? So she was 84, it happened at 3 a.m. At this point, what would you guys do? And I'll tell you what the operator did. Do you want, what would you do, Alex Truesdell? I don't know if this patient was in your institution. Yeah, you know, so first of all, 84, I think not just my institution, I think most institutions, the person's not gonna go for bypass surgery. So that's already in my mind, no matter how, as I say, I know everyone's a healthy 84, car with 400,000 miles works until you pop the hood and you see squirrels in there. And so it's that, you know, this is not someone who's gonna go to surgery. I, you know, I think the decision about whether you act immediately or whether you stop, get some additional data and act in a rapid fashion is reasonable. What I sometimes worry about and I see is somebody says, well, we're gonna decide. And then this person goes through the ICU. And I think if you're gonna wait more than an hour or two hours, or you're gonna make, or at least take longer to make a decision, you've already made a decision. So if you're gonna push this to the next day and just wait until the patient's in multi-organ failure, you have made a passive decision instead of an active decision to do nothing. And so, you know, if this patient's crashing, I'm going, you know, right in with a percutaneous coronary intervention, probably with a support of some sort. If there's some other complexities and they're stable enough, I think I can stop, pull in colleagues, but really feel like a decision has to be made within, you know, an hour, two hours, three hours at most. Otherwise, I don't think you're gonna have a decision to be made personally. Okay. Yeah, I mean, there's, oh, not just in the LAD, but also the circumflex. This entire, you know, LCA circulation has got slow flow, not Timmy III flow. Yes. So I agree with those comments. And this is what, this is exactly what happened as the strategies that were considered that night. Medical therapy was considered coronary bypass surgery, which was, we discussed, I'll tell you what the surgeons decided, our institution. High-risk PCI with a balloon pump, given the ileothermal tortuosity. High-risk PCI with Impella on standby. That's something that, you know, I personally don't think it's a good idea, but it does occur. And high-risk PCI with upfront mechanical support with an Impella using alternative access. So medical therapy, we decided was not reasonable or the team did because she was highly functional and we felt that she still had a life expectancy that was reasonable. Surgery was consulted in the middle of the night. They did come to their credit early Saturday morning. And as Alex alluded to, they felt that her surgical risk was prohibitive. So she was turned down. High-risk PCI with a balloon pump. You just saw that Bobber effectively did a case with that. It's not an unreasonable approach. We talked about high-risk PCI with Impella on standby. Like to hear the panel's opinion on this. I personally think that's a bad idea. If you look at the CVAD registry, obviously it is confounded by the patient's, you know, selection bias. But in patients who were undergoing high-risk PCI who got Impella as crash and burn Impella in that setting, not upfront, they had a high mortality as high as 50%. Obviously a lot of confounders in that population. And then high-risk PCI with upfront Impella using an alternative access. That's what was all considered. So what would you guys do given the consideration? So Benita, what would you guys do in New York out of those options that we offered? Yeah, I mean, we would have started off with a right heart cath just to get a sense of the numbers. I think balloon pump is reasonable, but I also don't think that that tortuosity is prohibitive towards an Impella upfront through a transfemoral access approach. So I would be thinking either a balloon pump first or just an Impella upfront through a transfemoral approach. I think once you get into alternative access and an 84-year-old you're, I mean, as long as you do everything meticulously, it's great. I just, I feel like we do tavers in this type of tortuosity, so we should be able to turn them. That's very reasonable. So I'll tell you what happened in the case. Surgeons were consulted. The patient was deemed prohibitive risk due to advanced age and limited ability to rehabilitate. We planned to do a high-risk PCI with Impella. We were gonna stage it. We wanted to use her axillary. We felt the, I think Benita brings up a good point. Could we have gotten away with stiff wires and straightened the iliofemorals out? I think you could have. Our institution, we have a couple operators that feel very comfortable with axillary, and so they've been able to do that successfully, and the threshold is probably lower than most. And then we would do, obviously, I have this guy, I did DK crush to that left main and modify based on the plaque morphology. Use a right heart cath to wean, and that was what our plan was. What happened to this patient is, despite our planning, the patient became hypotensive despite her balloon pump, and we decided to go to the cath lab sooner than planned. So the balloon pump did not ameliorate her symptoms long enough. The right heart cath shows she had an index of 1.4, CPO of 0.6, a mixed venous of 39. So based on that, those hemodynamics that were deteriorating, we thought it was best to do her urgently. So the decision was to go up front with an alternative access, and this is an axillary impella. I won't go into the details on the axillary because it's not the purpose of the presentation, but you could see here, we have from the femoral artery, where we're gonna do the PCI, we leverage that, and we have a catheter there. That catheter gives us angiographic guidance of the second segment of the axillary artery. Raj Tyal and James McCabe are really kind of pioneered this technique, and they do it a little differently than we do in Detroit. They like to use ultrasound, and if you're fast on with ultrasound, that's a good way to do it. We use angiographic guidance, and you could definitely hit the second part of the axillary artery without a lot of difficulty. The only meaningful things that you should know about this angiogram is this vessel that goes north here, supplies the humeral head, and in the event that we don't get successful hemostasis, and you have to use a covered stent, you can potentially cause avascular necrosis of the humeral head. So for that reason, we like to be away from it, more proximal. The other thing that's important on the access point is you don't wanna invade the chest, and you can see we're far away. In this particular case, the patient had a long runway of the second segment of the axillary artery. Also here, the third segment where you see the branch, the circumflex humeral going up, this is where you can see the, you can't see that, but this is where the brachial cords are, or the brachial plexus. They're superficial at this segment of the axillary artery, and as you get proximal, they actually dive down deep. So superficially here, when you get access in the vessel, it's devoid of the cord. So also that's another reason you wanna stick there. So we were able to successfully get access here in the second segment where we wanted to, and we put a sheath in there, and then ended up getting the impella in with really without much difficulty. So we went on to the PCI, and the PCI we did, I have the IVs, I should put the IVs first, but circumferential calcium, as Dr. Rab alluded to, of the both lesions and the LAD, that's the left magnet and circumflex. I'll show you those IVs, and a result of that, we decided to do orbital atherectomy, particularly to the LAD. We did not, this was done maybe two and a half years ago. We did not have shockwave at the time, so we modified the circumflex with non-compliant balloon. If you look at the angle of that circumflex, at least in my humble opinion and experience, I felt that angle was prohibitive for overall atherectomy. I know we have a lot of people here on the panel that use rotoblader much more than I do. I use mostly orbital. I'd like to get their opinion. Do you guys ever take angle or tortuosity into consideration when you're choosing rotational versus orbital versus neither? In my opinion, I tend to avoid atherectomy and acute angles and in tortuous vessels because perforations often end up to be catastrophic and difficult to deal with in those situations. Now that we have shockwave, it really makes that decision much easier. Do you guys, I know Bob and Alex, you guys use rotoblader more than I do. Would you guys rotoblade this circ or is that angle prohibitive? Would you use shockwave these days or orbital? What's your atherectomy or debulking strategy in these cases? I think both are appropriate. I think, you know, I wouldn't have much hesitation with this angle doing rota. I think when you get multiple, you know, angles together and there's a lot of tortuosity, it can be higher risk. What's interesting is, is that there's risks on both ends. With rota, the risk is getting stuck, which is really scary. But with orbital, there's actually a risk of dislodgement of the burr itself. And so that's something that we've actually reported on where it actually broke due to the tortuosity despite being only used on low speed. So those are my thoughts. Okay. Yeah, I also worry about the circumflex in particular. I feel like that angle is always more acute than it sometimes looks angiographically and you always start recognizing that as you're trying to deliver more bulky equipment. So I do get a little bit more worried with that direct to me on those, on the circumflex. Yeah, one of the things is, you know, remember the issue of wire bias, you know, you may be cutting into adventitia and not really black at an acute angle, but I think this angle is not that terrible to allow 1.5 burr to advance really slowly into that segment. And you're maybe at a lower speed of 160 rather than 180, 200 and see how it reacts to you. But I think this is dual. The other thing is we have not commented about the nodularity of the lesion. You know, calcified nodule is big in our interventional world right now. So what is the best strategy? Is it rotational? Is it orbital? Is it shockwave? Or a mixture of both? So I think that's something we need to address between calcified eccentric left main nodules and nodules in the LED because there is a malignant kind of eruptive nodule that may go through the stem struts. So what is the best strategy to shave it off is also something that we need to think about. I'm also not willing to give up my LED wire if I needed to do something that required me to move wires around. Yeah. In the circumflex. I think those are all excellent points. So we did aphorectomy to the circumflex and then we'd use a non-compliant balloon to the, excuse me, aphorectomy to the LED and a non-compliant balloon to the circumflex. And I don't know if these are gonna run here. Looks like these are still, but they're not gonna run. But you could see here, this patient had more circumferential calcium. This arc was about 180 degrees. And after we did the debulking, we decided to use a decay crush strategy for this left main. And here you could see, these are all still images, but we went through the steps of decay crush on support. I think this is where I think mechanical support really helps and bifurcation, particularly in ACS patients. If you're gonna do a decay crush on these patients, it does take a little bit more time. It does take some more patience and steps. You are occlusive to the whole left coronary system, dependent on a right coronary system. But in a setting of a patient who presents with ACS, patients often are not tolerant. And unfortunately, I didn't bring the hemodynamics from the Impella console, but all of you have seen how these patients respond. They lose pulsatility to become hemodynamically dependent on the device. And this oftentimes, particularly if they have really bad LV function, you could have uncoupling, which Bobber has really described in the early use of Impella in these types of patients. So we did the decay crush and the stepwise approach that we all know, that we learned here with bifurcation club. And I'll show you what happened here. This is how we started, and this is how it ended. And so we had a nice result. So I was just looking at that IVUS, actually, I thought it was three years ago, but it was actually four years ago in June of 2019. And this lady was in the newspaper today, actually celebrating her art. So there was a spot there, she's in the gross point newspaper in Detroit. So she's alive and still doing well. The cardiologist who I helped do this case actually incidentally sent me that earlier this afternoon. So happy report, she's doing well. So some of the technical challenges that we had in this case, we were able to wire the LAD, that tight lesion in the mid. However, our micro catheter of choice for this case was a Caravelle. For those of you guys that use it, it's a very low profile. Micro catheter probably has the best crossing profile and it wouldn't cross. And so when it doesn't cross these lesions, but the wire crosses, there's a few things that you could do. We were fortunate that we advanced it as far as we could and use the Viper wire to free wire it that allowed us to do the atherectomy. We chose to spend only the LAD as we discussed and deferred spinning the CERC because of the angle. We did IVAS guided decay crush. The patient was taken off Compella the next day on post-procedure day number two. Axillary access for mechanical CERC for support and cardiogenic shock. We published this in 2019. This was based on a series of cases that we did at the DMC at the time. Over the course of one year, we had 17 patients who came in in shock and ileofemoral disease that was felt to be hostile. And we published our experience. And you can see from our experience, I think the notable things are important is that the time to Impella activation as it relates to minutes was 14.8 minutes, which means that you could actually put an Impella in the axillary artery in a relatively quick time, probably not as fast as the femoral obviously, but 15 minutes is not bad. All these patients had CP, so really robust devices. Most of them we put in the right. I think that's just because it was technically easier in the room setup. What's interesting is that if you look at the survival of these patients, on our 17 patients, only five of them survived. And if you look at the five that survived, how were we able to close one of them, really with pre-close that worked, two of them with prolonged inflation with balloon tamponade, two of the survivors required a covered stent. But you could see that, you know, you talk about bifurcation left main in the setting of shock and PAD, portends a very poor prognosis. Five out of 17 have survived with this approach based on our experience.

84-year-old female artist

emergency room

epigastric discomfort

catheterization

high-risk PCI

Impella mechanical support