<v ->Now we'll move on to the first case</v> and then we can pause for a few questions. <v ->Hello everybody.</v> Let me see how this can be applied to specific case. I'm gonna focus on the tips and tricks and steps of left main bifurcation with dedicated upfront two stent technique with a team protrusion approach. Brief history, a 74 year old man with multiple factors worsening stable angina on optimal therapy, refractory preserved EF, left main disease and mid LAD by angiography referred to bypass surgery. He declined surgery. And then the ball back to us. This is the baseline angiography. We talk about a true distal left main bifurcation with features that look like a complex left main bifurcation. According to what we just discussed earlier very briefly, here we have a complex bifurcation upfront two stent technique. The question is always do we stent the side branch first or the main vessel when we have fear that we might lose the side branch it's better to start from the side branch, circumflex in particular, here. And the best approach is given that this is not a pure T bifurcation, clots could be a possibility. But we elected to go with inverted TAP because we felt that the angulation is more favorable for TAP. DK Crush of course is always a consideration. So I'm gonna show you very briefly an animation of what we did and then I'll show you what we actually did. That animation is based on the work paper parts by the EBC couple of years back and it's available in this link. So they inverted T and small protrusion because inverted means that we start from the site branch first because we have fear of losing this. So we position the stent there according, always sized according to the side branch. Then we deploy the stent, always have some room in the proximal main vessel for an adequate POT at the end at least six eight millimeters in the main vessel. Then what we do, we do a nice POT with a short NC balloon in high atmospheres to open the struts to the main vessel nicely here. And then obviously the balloon marker of the carina and then we rewire with a wire exchange technique or other approaches or maybe a dual catheter. We rewire from distal struts to the main vessel. Then we do kissing, we're gonna do sequential and then simultaneous I'll show you. Then we deploy the main vessel stent, which as you see here has protruded by a couple of millimeters, couple of struts, couple of crowns, essentially into the main vessel. And always we keep an uninflated balloon into the side branch. We pull back the stent balloon and we optimize the ostium of the main vessel. And then we do the kissing balloon inflation with the stent balloon pulled back and then the uninflated balloon of the side branch in both inflated in low atmospheres. And finally POT, and keep in mind for TAP we don't need to go deep in locating the balloon because we have to respect the metallic neo-carina. So the POT balloon should be always meant just to optimize the proximal main vessel and avoid the deep dilatation which might distort the new carina. And that's essentially from what we would expect to see. That's a patient specific simulation of the TAP technique inverted TAP technique. That's from the inside. You see the neo-carina here nicely protruding the capital (indistinct) of the main vessel. Now, let me now show you what we did in this actual case. That's, as we said, the complex left main distal bifurcation. We started with the second flex pre dilatation with a compliant balloon. This is the IVUS pullback from the LAD to the left main LAD remains a designated main vessel but we start from the side branch here because of the complexity of disease. You see here that as we pull back there's some disease in the mid LAD which we fixed. And then here proximal AD fibro calcific stenosis right here the junction with the circumflex here. So we talk about complex fibro calcific disease, no more than half a circle of calcium into the ostium of LAD. And then you get to see here the IVUS from the circumflex to the left main right after the pre-dilatation. And as you see here, again, fiber calcific plaque on this side, more than 180 degrees as we enter now with other wire into the LAD. So what we do first we start, as we said, with a stent to the circumflex, the side branch, designated side branch in that case. Of course it's this side branch because it's circumflex So the 3.0 48 DES a long stent we position this all the way to the ostium of the left main to have enough space for a good POT. And the technique is crossover, covering the ostium of LAD. You see here the stent inflation always the standard size to the distal main vessel. Then we do the first POT. Keep in mind that the, as shown here, the mark the distal mark of the balloon should be at the carina. The left main carina will go with a non-compliant balloon 4.0 12. We always inflate in high pressures to oppose nicely the stent into the proximal main vessel, which in particular this particular case is called left main. Then what we do is we exchange the wires. We take the LAD wire and put it down into the circumflex and then we pull back the jailed circumflex wire out into the aorta. And then again we rewire with a loop preferably to secure that within within the struts within the stent. So with a loop, we rewire essentially down into the LAD. That's a wire exchange technique. And then what we do, we do kissing balloon and the specific technique here lately we like to have the sequential kiss and then the simultaneous. So what is sequential? We get two short NC balloons 3.0 12 both sides to the distal main vessel distal LAD and distal side branch distal circumflex. And then we position both with the centers at the carina of the left main. And then we inflate first on high pressures the one balloon and then the other balloon. And usually we prefer to inflate first the balloon with the stent. And then finally we do the simultaneous kissing balloon in which case we use exactly the same balloons but now we inflate them both simultaneously in low pressures. In the sequential we do high pressure inflations. In the simultaneous we do low pressure just to restore the carina in the middle. So both inflated at 10 atmospheres and then deflated simultaneously. These are the, this is essentially the technique, the tip and trick of a nice kissing balloon inflation sequential and simultaneous. And then what's next? Time now for the main vessel stent with a small protrusion by a couple of millimeters as shown here into the left main. And then keep the uninflated balloon into the side branch into the stented circumflex. As we deploy the stent, we then pull the stent balloon back into the left main and we do another inflation to optimize better the ostium of the LAD. And then finally, we inflate both balloons the balloon that was stationed to the circumflex and the one that is the stent balloon to the LAD on low pressure, 10 atmospheres, just to make sure that we restore the metallic neo-carina in the middle. And then we deflate simultaneously both balloons. We take them out, we do the final POT. Again, important not to have deep intubation of this balloon to avoid distorting the neo-carina. Just keep it out into the proximal main vessel. Here, bit of the balloon is out into the aorta. It's a 4.0 big short, big in diameter, NC balloon, inflate this in high atmospheres to optimize the result. And then that's the final result angiographically Here, pretty decent. And this picture here, without contrast. Good TIMI 3 flow, well expanded and apposed stent angiographically, no dissection perforation. And the results were also confirmed by IVUS. That's the circumflex pulled back to the left main. Here you go. We have the stent of the circumflex. As we pull back, you're gonna see the stent very distant, coming in. Right here, right here. That's the LAD coming in. Left main, two wires, and then all the way small protrusion to the aorta. And then finally that's a pullback of the LAD to the left main. We expect to see the metallic neo-carina here, as we pull back. That's still in LAD, proximal AD. And you get to see here the neo-carina coming. Here you go. Exactly. So that's essentially the neo-carina here. That's the metallic neo-carina, the part of the LAD stent that is protruding into the left main. And this part here is the circumflex stent. And they both come into the left main. And don't forget the rule of 8-7-6-5 which is coming from East Asian data. Maybe in the Western society, it's even bigger areas. And with that, I would like to thank you for your attention.

stable angina

left main disease

bypass surgery

two-stent technique

left anterior descending artery