<v ->Great, we are not (indistinct).</v> So let's go on with the presentation from Francesco on provisional stenting in the interest of time. We have time at the end, John will again ask questions. So let's let Francesco get started. Thank you. <v ->Okay, do you see my presentation?</v> <v ->Yes.</v> <v ->Yes we do.</v> <v ->Yes.</v> <v ->So,</v> honestly I want to explain why we are in favor of using a provisional approach. I think that it is important to see that all the first generation trials when, especially when you look at long-term outcome, add strong signal in favor of the fact that in unselected lesions, provisional is better in terms of safety as compared to two stents systematical approach. This is meta analysis recently performed. We know that when there is disease in the side branch, if you do not have extensive diseases, we have two randomized trial by showing that there is no difference in unselected bifurcation. Again with the Medina one, one, however, a disease, two bifurcations, and the EBC MAIN that has been recently also named by Azeem. So all of this is in favor of using, considering valuable the provisional approach. But honestly what is outside the trials and is a signal death, I mean a little bit hinder over the trials is the fact that if you look at the very long clinical outcomes in the the clinical practice, you may have signals in favor of better safety for single stenting techniques. This is the syntax trial in which you may see that up to five years there is no significant difference in terms of mortality for patients with bifurcation treated receiving one or two stents, but thereafter there is the splitting of the survival curves in the second part. So, especially if we are taking care about the long term outcome of the patients, there is a signal that deserves attention and may provide reason for trying to spare the systematic implantation of a second stent. For sure, provisional according to the EBC approach, is not single stent, it means trying to perform PCI in a bifurcation implanting one stent and in the case of need effectively implanting the second stent and I'm quite sure that if they will convince you about the possibility to implant the second stent. So the case is this to be summarized, if you have two bifurcations like that, completely different in terms of complexity, and you want to fix it with a single stent like that, it is anticipated that you have higher risk of complication, higher complexity with the provisional. So this means that you should know about the tricks to improve the safety of provisional in the case you want to take on this complex lesion with the provisional. Anyway, if you are able doing this, you might be surprised to have fantastic results in these two cases with a single stent, like the one achieved in these two completely different cases. And this is the beauty and the potential of provisional. So the case I wanna share with you is a young male with classic risk factors presenting with inferior inducible ischemia documented on top of a fourth angina, so good indication. Left system was okay and this was the lesion into the distal, into the distal right coronary artery. So, short stop point with the panelist, how to treat. <v ->Okay, Yves Louvard, you have a crack at it?</v> <v ->What I will do here, is consider the PLE as a male vessel</v> for many, for several reasons, especially the distance to make the previsions longer, And I would use provisional strategy of course and exchange the wire and treat lesion but not by questing the bifurcation. And in case of absolute necessity put the stent in the (indistinct). <v ->Azeem?</v> <v ->Yeah, I agree with Yves.</v> I think you know, two wires, the question is really which is your main branch, which is your side branch, and the decision I think for me is often based on the importance of each branch, the territory of distribution as well, not just the amount of disease. So yeah, I mean I always think PDAs are really important because they will supply the inferior wall. So Yves, I don't like disagreeing with you. Maybe I would go stent towards the PDA and be provisional on the PL, but I think, you know, I would probably decide after a little bit of predation, see how the vessel responds, give some nitro and then decide which is the larger territory. <v ->Alright, let's see, what do you do?</v> <v ->Okay, so we go on.</v> I think that what is highlighted is the fact that in this case there are multiple choices in terms of options to start this procedure and in what is recommended for complex bifurcations. And I try to apply with OCT imaging in that in my practice is OCT and you may see how tight is the lesion, this is the bifurcation showing that really there is a lot of plaque inside the two branches and definitely this is the true Medina 1,1 lesions in which the risk of problems seem to the side branch does exist. So I think that for people that is afraid about losing the side branch both angiography and invasive imaging confirmed that there is risk of occlusion of the side branch in the case of crossover stenting in both branches because you see that the plaque is in both areas. What we did was to use radial approach, JR 4, 6 French and two BMW universal. Then what we did was to put two non compliant balloon inside the two branches, and we expanded the two balloons in a sequential way in order to be sure that this huge amount of plaque was appropriately dilated. We don't want (indistinct) that do not expand. So first inflation towards the PTA but with the other balloon ready, then the balloon for the PL with the the PDA balloon ready, and then low pressure questing inflation. This is something that, I mean we sometimes do but this is the kind of situations where we consider doing. As Azeem said the predation phase is important when you are complexity. And with this technique, the aim is to try to scaffold as much as possible the polygonal conference in order to reduce the risk of Karina shift during our interventions. And this is the preexisting technique. So, and this is the situation after. <v ->That's beautiful.</v> <v ->I think that</v> the risk of occlusion of this side branch in any of the two direction is completely different now, I think you may now agree about the fact that provisional is more and more safe in this condition to be considered. And what we applied was OCT showing that there was for sure some dissection, but look how much space you have in this area how much space you have here, and look at this Karina, how is it kept into the middle without having jeopardize any of them of the two areas. So on top of this we did the what is recommended, if we implanted the stent, regular stent toward, from the right toward the PDA, we expanded at nominal pressures. This was the result. There was some Karina shift expected at the basis of this OCT, but no conclusion. So, then we performed semi-compliant expansions 3.5 according to the proximal in vessel. We had all the sizes now well known according to intravascular imaging. Then we performed rewinding with a third wire using the pullback technique. You see here the wire that is pointing toward the PL and now it is jumping. As soon as Karina comes, you see this jump inside, and then the questing is applied with two non-compliant balloon appropriately sized. Then another stent has been implanted here proximal. And the same balloon has been of the stent has been used to further perform a POT that according to the the possibility to have this result. This is angiography, this is angiography in another view, and this is OCT showing, I mean not only absence of any kind of malposition but wonderful expansion of the stent. And I want you to emphasize how we change the geometry of this (indistinct) stent, having this prolonged scaffolding toward the PL. That really may explain why the result on geographically was so good. We should remember that if we perform all the manipulations we described we are able to change the (indistinct) stent platforms in order to have this fantastic adaptation to the geology. And this explains why provisional may be suitable for Medina one, one lesion, and is also at the vista stage very easy in the case of dissection or suboptimal result to add another stent into the site branch without having I mean a long prolapse inside the side branch. So the patient had uncomplicated post PCI course, DAPT was interrupted after six months, and the patient is now asymptomatic after three years. Thank you for your attention.

provisional stenting

bifurcation lesions

coronary arteries

safety outcomes

case study