All right, well, welcome, everybody. Welcome to the Sky First webinar, where we're going to be talking about PCI decisions in uniquely challenging lesions. We have two fantastic cases being presented both by UCI fellows here today and have some great faculty, Dr. Pranav Patel, as well as Dr. Mort Kern are here for interactive. Hopefully, we want to make this as interactive as possible. So please feel free to chime in via the chat, as well as if you need to speak up, just put your hand up and we'll get to you. Mort, you're free to speak whenever you want, as you know. So before we get started, though, I do want to thank some of our sponsors. So Zoll has been the founding sponsor of this case series. In addition to that, Abbott, Boston Scientific, CSI, as well as Kiasi and Medtronic are also sponsors of this great event. And I want to encourage all the fellows to join Sky if you're not already members, because this is your society. This is the society that goes to bat for you for things like reimbursement, battling CMS. This is the society that got our designation as our own subspecialty within cardiology. So certainly a society that's advocated for all of us and will continue to do so, as well as bring forth all of our scientific endeavors. So with that, I'm going to turn it over to Dr. Pranav Patel, who's going to introduce the first case or the first speaker, excuse me. Thanks, Vittal. And again, thanks to our sponsors and Sky. Again, really, look, this is a conversation, very interactive, the things we'll learn. So please just sort of come in and join us. Inaugural Sky First California, we hope to have more. The first case is presented by Dr. Fahad Gul. And I think the sponsor is Dr. Morton Kern, so he'll help along. So Fahad, let's get going with your case. Thank you, Dr. Patel. OK, so let me go ahead and share my screen. Can everyone see my screen? Yes. Yes. OK, great. Yeah. So as Dr. Patel said, my name is Fahad. I'm one of the second year cardiology fellows at University of California, Irvine. And I'm going to present one of the good case that we did over a week ago where we did a bifurcation lesion and used physiology to help guide our intervention. So we have a 38-year-old male of Asian ancestry who had an anterior STEMI May of this year. He essentially had a proximal LAD lesion and was treated with two drug-eluting stents overlapping in that region and essentially discharged home with medical therapy. In terms of his risk factors, he has hypertension. When he was admitted to this outside hospital, he had an LDL over 200. His father had a history of MI at the age of 52. He also had a 40-pack year history of smoking tobacco products. So the Calc report at the hospital showed that he had residual mid-left circumflex disease, 80 percent. He had an osteo-OM about 90 percent, a distal RCA 70 percent, and a mid-RPDA about 70 percent. He was discharged from medical therapy, but has had disabling angina despite being on medical therapy. He said that he was at the football game at SoFi Stadium. He didn't want to go up to the seats because he was so disabled by his angina, and nitroglycerin was helping with the symptoms as well. So on November 1st, he presented for a stage PCI for his residual CAD. Sorry. These are his medications. So he has aspirin, 81 milligrams daily. He was on Ticagrelor, 90 milligrams BID. And for blood pressure, he was on Norvast, 2.5 milligrams daily, metropolol succinate, 50 milligrams. And then for his lipid control, he was on Elirosumab and also Zetia, 10 milligrams daily. So these are his angiograms that we did on November 1st. So here we have our LAO caudal view. See the left main looks good. No significant stenosis. Hard to see anything beyond in the proximal segment, the stent of the LAD. The CERC, there's some stenosis there, about 70, 80 percent. Looking at the OM, there also appears to be an osteolesian as well. Not quite 90 percent. That was in the CAP report. All right, in the next view, we have the LAO cranial. So you can see that the LAD, the stent looks widely patent. There appears to be a healthy portion. And then there is a stenosis in the mid portion of that LAD, about 50 to 60 percent. Moving on to the RAO caudal views, so you can see that the left main looks nice and healthy, just some mild luminal irregularities. The CERC has that lesion there in the mid portion. The osteolesian of that OM doesn't look as tight as described in that CAP report. Maybe like 50, 60 percent. And then the LAD, about 60 percent, 60 to 70 percent in that mid portion. And then we have the RAO cranial view, see the LAD coming down. Right there, lesion looks very tight in this view, maybe about 70, 80 percent here. And then we take a look at the RCA. So the RCA, dominant RCA system, see this diffuse disease all along the RCA, especially in this mid portion. And then the osteo RPDA is like 95 to 99 percent. And then there's another sequential mid lesion, about 80 to 90 percent as well. And then the osteo PL also looks like it has some disease there. And so we're very nervous, not nervous, but we wanted to make sure that we treated that with dilation of the balloon prior to intervening on the PDA. And then here's a RAO view of RCA, you can see the tandem lesions there. And a diffusely diseased RCA in that mid portion. And then so... Before... Yeah. Did we want to have discussion in the middle before we take, show what we did, or do you want to just go through the whole thing? No, I think that's a good idea. I think it's a good idea to discuss what people would do here. Yeah, so two comments. One, we're never nervous, we are concerned. And two is, I think that this is a very interesting multivessel case in a very young guy, post STEMI in the anterior lesion. So where are our colleagues? Who is up? Mattel? Yeah, so this is a great case. I think, you know, obviously you don't have any stress testing in the interims to maybe perhaps guide you, but I agree. I think you take this patient immediately to the cath lab, knowing what he went through six months ago, and the symptoms that he's having are fairly classic. But now you have a bit of a conundrum because you've got multivessel disease, not really sure what the culprit is. If you're going to even attack just one of these three vessels where there's lesions, let's say this right coronary, you don't even know which of these is physiologically significant. So I think this is a fantastic case for discussion. And also, do you have any information about his original STEMI? What size stent was put in? Was it IVAS guided, et cetera? Because it looks like a stent edge issue in that LAD territory. I don't think we have much detail. Sorry. Go ahead. There was a three millimeter stent they put in that prox LED. I'm not sure if it was done with IVAS imaging or not. I guess it's probably not. So let me ask a question here. The RCA looks obviously pretty significant. And I saw a wire down the RCA. And the initial cath report suggested significant CERC OM disease. The LAD, you know, you guys called it intermediate. But to me, the right looks significant. The question would be how bad is the LAD and how bad is the CERC territory? And if it is significant three vessel disease, do you really go ahead and fix that RCA? Was that question ever answered, especially when we think about physiology here? Bahad, do you want to comment? Yeah, you know, I think if you wire that LAD and you see that it's significant and you know definitely that this RCA is angiographically very significant, then you can make a case that, you know, if you threw a pressure wire down that LAD and it was positive that you could potentially refer this young patient for coronary artery bypass surgery. So let me just add to that. So here's the guy. It's 38 years old. I'd like to postpone his surgery for 10 years if I can get it. Just on the nature of graft longevity. Agreed. 30 years if you can get it, really. If you can get it. So the issue that we're discussing, which is really irrelevant, is how severe are these lesions? You're looking at the angiograms and you can't tell. I can't tell. So this is the perfect case where you have to make an informed decision. We can't use stress tests. We don't have ischemia testing and any other thing. We don't have EKG changes. We got a typical angina and a critically tight right and other lesions which are potentially important. We're going to stand everything we can because these are relatively straightforward type A lesions, I think. In the LAD, CERC, this right is complex, but I think we can use physiology to sort it out. Yeah. And also, would you guys, can anyone comment, would you guys, if you saw this anatomy when he had his LAD STEMI, based on recent trial data, would you have just proceeded with complete revascularization? Well, I mean, my view is that complete is a relative term. At the one setting, probably not. In a sequential setting, stage setting, yes, definitely. And this is, there's a long time between his stages, but this is a staged PCI. And I would guide it with the physiology as well. Absolutely. So I'm assuming that you, at this moment in time, angiographically looking at the CERC and the LAD and saying it's not significant. So let's go ahead, fix the RCA. You're going to use physiology in some respects here as well. And then I assume, see how he does, unless you go back and look at the other vessels as well. That's totally- I'm surprised. But we didn't say that the LAD and CERC are not significant. We just said we're going to do the most significant one now and proceed in a logical fashion. So what happened, Fahad? Yeah, so angiographically, this looked the most significant to us and most likely to be the culprit behind the symptoms. So we decided to throw a pressure wire down the, let me just keep moving along. So we put a pressure wire down the PDA. Oh. OK, hold on. So before we do that, we need to explain something. This is a bifurcation lesion. And before we went and just threw a pressure wire down, we went and put two wires to approach this in a bifurcation fashion, right? So then we can talk about, do you want to do culotte kissing, T-stand provisional? And I'm a fan of provisional. Now, we happen to have an excellent wire called the opsense wire, nitinol fiber optic, which we use as our workhorse wire. It gives us a bonus. We don't need physiology for this branch. We may not need physiology for the other branch, but we have it. I like it. We're going to use it for assessment of the other lesions. So we pulled it out first. It's not that we thought this needed physiology because I don't think this lesion does. Pranav, I know you questioned that, but. No, you know, there's nothing wrong with physiology. It looks pretty significant angiographically and. Oh, no doubt. You know, and I know suddenly you have all the tools, you know, when it comes to non-hyperemic pressure ratios. You just answered my question. I was curious as to why you used DPR here and, you know, not IFR and RFR and things like that. I think you like this wire, right? Yep, I like the wire. And this does not need physiology, this lesion. And maybe the bifurcation doesn't, but we're going to show you something that's quite interesting. Now, whether I use DPR, IFR, RFR, whatever resting ratio makes no difference. They're all the same. Thresholds and outcomes. So Fahad, what happened? Yeah, so pressure wire down the PDA. And then we have an appeal. We have a workhorse wire. And then so we did a DPR on the RPDA across both those tendon lesions. And you can see that there is severely reduced flow in the RPDA with the DPR 0.29 and a repeat of 0.34. And the cutoff value for DPR is going to be 0.89, just like RFR and IFR. And you can see, go ahead. Sorry, Dr. Kern. No, no, no. You go ahead. Yeah, so you can see that during systole there's a very, very large gradient. And during diastole, there's also a very, very large gradient of flow between the aorta and also the distal RPDA. And you can also see that the waveforms doesn't look like your typical aortic waveform. It looks more ventricularized, which also signifies that there's significant disease and disturbance of flow in this coronary artery. So just to make a long story shorter, this is the most severe hemodynamics across the stenosis you see beyond total occlusion. This is a subtotal occlusion. And you can use this to tell you about the potential of collateral, which there's very little. The waveform, the separation in systole and diastole indicate a hypercritical lesion. And in fact, we knew that in about 10 minutes because he started to get angina after we crossed with the wire. So I'm pretty sure this was a culprit vessel. Okay, what happened next? All right, so then we did some predilation. So we knew that this was the vessel that we were gonna target. So we did the predilation of the mid-RPDA, did the osteo-RPDA, and then we also did a predilation of the PLB branch because there was some disease. And so we predilated to see if that can avert some provisional stenting. So next we did a post-dilation RPDA-DPR, and you can see that there is significant improvement that the waveform no longer has ventricularized, but there's still a very, very large diastolic pressure gradient. So just to mention, this is bonus information. Since we have a pressure wire, we're working on it, all we do is connect it, reconnect it. Oh, look, the balloon improved the gradient. Okay, let's keep working. So we're making no decisions with this at the moment, but it would be nice to see, as we will, what comes of our work as we go. Yep, so we felt like we got adequate predilation, so we decided to place a stent. It was a 33-millimeter stent, 2.75 by 33 millimeters. We placed it across that osteo and mid-RPDA lesion. It was extending into the RCA a bit. And then it's just a video of that, a sitting of that. And then this is the result of that stent. And so you can see that the PLB branch now looks more significant in terms of the stenosis. So it looks a little tighter. And so we're thinking, all right, let's throw our pressure wire down to PLB and see if it's significant, if there's a significant reduction in flow to see if we need to do some provisional stenting here. So before we do that, we do an RPDA-DPR post-PCI, and you can see that it's significantly improved. It's 0.85, and we started from 0.32, so a massive change with our stent. So keep going, because we're going to, this is not a real acceptable result, but it is the result we got. And we're going to gauge the result in the other branch before we go back. Was this obtained after higher pressure dilatations? I've forgotten. Yes, it was. Okay. So this is our post high pressure DPR pressure ratio across the PDA, right? Yes. And we're going to eventually pull this back to see if we're missing something in the stented segment. And I don't think we did, but go ahead. Yeah, on pullback, there was no change in pressure. So we feel like we've got a good result across the stent. And then, so we decided to now put our absence wire into the PLB branch to see if there was a significant drop in pressure that would indicate that we would need to do some provisional stenting. And so here, our absence wire is now in the PL branch across that lesion, and we measured DPR, and we got a value of 0.83. So I'm going to open up to discussion in terms of what people would do here. So, what do you think? Well, probably I think 0.83, it's a small branch. It'd be great to leave it alone. Like Dr. Kern, I'm also a fan of provisional stenting. I think the less metal is better. And also the additional information you derive from this is that the rest of that ratty-looking right coronary is also okay and can be left alone based on your DPR within your stented segment. Right. And the way to- Yeah, go ahead. The numbers are so much better, but you would have to do a pullback to really see what's going on. There is, you know, just proximal to that stent, there is some haziness and where is the step up? So I think a pullback would help. Right. Pranav, you have the key point for this whole assessment problem in hand. So we did exactly that. What happened next, Fahad? So we did a pullback. So our pullback, oh, sorry, you can't see my mouse. I'm gonna just get back out. Okay, so we did a pullback. We started at 0.81, 0.83. And as we're pulling back, you can see that there's stepwise incremental increase in the pressure. And so by the time we get back, it's about 0.89, 0.88. There was significant drift, but you can see that there was stepwise increase all along the RCA indicating that it's diffusely diseased and that we had a good outcome for our initial stent. And because there was no pressure differential across the PDA and PLB, we didn't need to do any provisional stenting. So because we didn't see any change in pressure across the stented segment, and we did see gradual pressure recovery as we moved it throughout the right back to the ostium, we attributed the residual down there at 0.83 due to diffuse disease along the course of the right. And that further treatment of that branch is not gonna make the DPR go higher. And so this is the role of diffuse disease. Now, it portends a worse outcome long-term, but it's certainly much better than it was. And I think it avoids an unnecessary stent, which would also not be in his best interest in the future. Pranav, what do you think? Yeah, I think most people would argue that less is more here. To start stenting areas which don't require a stent, I think it's probably the wrong thing for him. So angiographically, this guy would have gotten two stents, maybe three. Angiographically, yeah, you may have gone, someone may have gone and tried to set that PL branch, maybe that distal RCA. I mean, you do think twice, like you had a DPR of 0.83, which I don't think, compared to 0.36, it's pretty good. Right, it's still abnormal. So I think the right decision was made to just leave it alone after this and see how he does. Agree. What about those other lesions? Should we bring him back another day? Well, let's see how he does. He clearly has classic angina when he has flow-limiting lesions. And I don't know if he was at SoFi watching the Chargers or the Rams, but either of them are gonna give him angina this year. So you know we can't leave this guy alone until we know the LED is okay, right? And we know we don't wanna leave a CERC because we just keep bringing this guy back. So we have that wire, it's ready to go. We're gonna go from the right and just quickly assess the CERC and the LED. It's very easy. And tell you the truth, if they're positive, I'm gonna stent them. Because you're right, I'm not sure the right was the only source of angina. I mean, he certainly demonstrated it was, but I'd like to not leave him with positive ischemic residual disease if I can help it. So Fahad, what happened next? So next we did a left CERC DPR with a value of 0.96, a repeat of 0.95 across this mid lesion here. So not significant. So we left that alone. So not only not significant, this is normal, near normal. And anything we do to this artery mechanically would be a crime, maybe a felony. I'm not sure, but it would be bad. What'd you get for the LED? So moving on to the LED. So LED, we got a DPR 0.93 on repeat measurements. So not significant as well. So we decided to leave it alone, but it did look a bit clamped down. So we decided spastic. So we decided to do some nitro. So flow also wasn't that great through the vessel, looked like 2-me-2 flow. And so we did some nitro and it did pump up the vessel a little more. Stenosis wasn't as significant then. So, you know, I think we often forget to give nitroglycerin during diagnostic studies. And Paul Tierstein just wrote me a note the other day that he did that. And after he gave nitro, the FFR angio changed. So you can see the flow imagery changes. I don't know if the absolute flow changes a lot. The Timmy count changes, but that's not the same as a direct flow measurement. However, I think we should always give nitro to get the best lumen we can get, to get the best answer we can get. So this is a question out there to the audience and to you, Mark. Let's assume that the LAD had a DPR of, let's say 0.89, 0.90. And it's an important vessel. And this is borderline. Would you go to FFR? I might, I might. I mean, I'm still trusting that IFR or the DPR number pretty much. I'm trying to not, I'm trying to find a reason not to really get involved with a recently stented artery like this. Remember this myocardial bed might still be problematic. And that's why we have a little bit of sluggish flow. I wouldn't, I don't think I might go to FFR. There'd be no harm in it. We had everything ready to go. We just ran out of gas after working in that bifurcation lesion. Are you using FFR? We are. Would you use it as a gold standard when you were confused? Yes. If I have to go to FFR, that's the final decision point. Because then you're always confronted with who do you trust, right? Am I going to trust my IVAS, my angio, my stress test, my FFR, my DPR? I mean, you got to have, believe in something. So I believe in FFR. Do you, and I'm sort of hogging the question so anyone else can sort of come in. What about the, if you have a LAD slash left main versus RCA, some of the initial trials, when we looked at non-hyperemic pressure ratios, there was a discordance in terms of FFR and these non-hyperemic ratios when it came to left main and LAD compared to RCA. I think a little discordance of about 12%. Do you pay attention to that or you just, it doesn't matter, you'll just- Well, I mean, if the IFRs are high and near normal, I don't get too excited. If they're borderline in the left main, then I'm going to do FFR in the left main. But unless that's the scenario, I'm not going to worry. Like in this case, I would never get excited about 0.93 and go to FFR just to prove it. Now, he may fool us all because there's still a CERC marginal branch or PL branch and still have some discomfort, but not to the degree that he should, that he had before. So to answer your question for left main, you got to use all the information, get your hands on. Yeah, and I'll just kind of echo those points. If it's borderline and I have a symptomatic patient, I move to FFR. Just, I feel like it's the gold standard for hemodynamic assessment. And so that's, and to actually perform the PCI, I use the FFR wire on deciding whether to do it or not or the pressure wire deciding whether to do it or not. And then I typically use imaging to decide how to do it. And so if you had to do this LAD because the DPR was, let's say 0.83 or something like that, and decided to do it, I would definitely image it because there could be an issue inside that recently implanted stent that led to edge. The good news was right now, it doesn't, even if there is an issue, it's not obstructing flow to any degree. So I think that this helped us a great deal. It was a good case. I think we have to move on to the second case where there's a little bit of imaging there, which is important. So Mittal, do you want to introduce the next thing? Thank you Fahad, good job. Thank you everyone. Thanks Fahad. All right. Dr. Perry Wu, also from UC Irvine, is going to present our next case. So Perry, you want to get your slides up? All right, Perry, the floor is yours, my friend. All right, can everyone hear me? Yes, we can. Okay, great. So thanks for having me, everyone. I'm gonna go over case number two. This is a case that I was able to do at Long Beach Memorial with Dr. Todd Zinda. Unfortunately, he's on call, I think, tonight, so he wasn't able to make it to this to moderate, but would appreciate any feedback. No disclosures to give. So for this case, we have a 75-year-old female presenting with a history of CAD, which I'll go over in detail in the next slide. She has paroxysmal AFib, frequent PBCs, hypertension, ESRD, on dialysis through a permacath, and morbid obesity with a BMI of 43. She's presenting to clinic with worsening exertional dyspnea. She says that after walking maybe five to 10 steps, she just gets so short of breath she can't move anymore, so she's been mostly homebound because of that. She has a very complex CAD history. So she had a prior NSTEMI in 2016 when she initially came to medical attention. At that time, she had a stent to her mid-LAD, and then staged stent two months later to her prox RCA, which had a CTO at that time. She also had another NSTEMI in 2018, and ended up getting a mid-distal LAD stent. Finally, in 2019, she presented yet again with chest pain with NSTEMI, and ended up getting a three-vessel CABG for left main disease. So after that CABG, unfortunately, there was a severe complication where the LEMA to her first STIAG was dissected and closed up. Her SVG to her OM also closed up. So the only open lesion, the only open graft was the SVG to her LAD. So with this acute graft closure, she ended up suffering from cardiogenic shock and cardiac arrest, and ended up going to an outside hospital for emergent PCI to her left main CERC. So her left main into her CERC was stented with a Synergy 3.0 by 16 millimeter stent, which was under right axillary impella 5.0 support. So her chest x-ray around the time when she was in clinic shows that there is a left neck tunnel dialysis catheter. You can see she had a enlarged cardiac silhouette with a left atroclip, and a actual left axillary vascular stent if you look carefully. There are some median sternotomy wires, but of note, she does have some focal consolidation and not, sorry, some bilateral costophrenic angle blunting there. So probably some small portal fusion there. So she did undergo some more aggressive diuresis with dialysis with a renal, but unfortunately still was feeling just about the same with her shortness of breath. She had a EKG showing ventricular trigeminy, had a sinus rate in the 80s, poor ROA progression, and no other ischemic changes. So all in all, she was referred for an outpatient elective coronary angiogram for multiple indications in this case. She had exertional dyspnea with minimal activity. She actually had an echo done around the same time as her clinic visit showing a EF that was newly reduced to 35 to 40%. And then had a nuclear stress test just to find where this could be. And that ended up having a high ischemic burden of 16% on the SDS score. She had a medium-sized lateral wall defect and a small to medium anterior wall reversible defect. So we proceeded with the angiogram. This is just showing she has a little mild disease in the femoral artery on the right side. And on the next slide here, on her diagnostic cath, we can see on the RAO caudal view, there's about a proximal 40% disease in the LAD. You can see an outline of a prior stent in the mid-LAD and her mid-distal LAD, as well as when it appears, some retrograde flow into her SVG that touches down in between the two prior stents there. But unfortunately, because all this hardware and the atrial clip, it's kind of hard to see the left main very well. So we put it into AP caudal view and you can see there, there is a little bit of a narrowing, which when we go to the LAO caudal view is even more obvious. There's maybe like a 90% blockage. And when we go up to this final, more cranny view, we see that the osteocerc has 95% instant recinosis, and there is the stent going from the left main into the cerc. And this is like right at the bifurcation and it's a pretty acute take-off, 99 degree take-off there. Then we were able to get the RCA of note here. The RCA is a anomalous take-off in anterior, and we were able to engage it with the AL1. And you can see in the prox mid RCA, there is a stent there that is patent, but maybe has a little bit of instant recinosis. Distal RCA kind of leads to a small RPDA that does have severe disease, but it's not amenable to PCI. And finally, we found the SVGOM stump here that we knew from before. And as you recall, the Lima LAD was known to have a prior dissection and was a tratic. So we didn't think it was clinically significant in contributing to this picture. So we didn't try to risk that in this case, but we were able to use an AR1 to engage the SVG to LAD. Here you can see on the LAO view and on the right side, you can see on the RAO view, the SVG to LAD, which looks great with good flow into the native vessel. So in summary here, we have right dominant natives with the distal left main into osteoleft CERC with 95% instant recinosis. The LAD does have some proximal 40% disease, but the prior stents are open. The CERC has that osteo lesion, as we mentioned, and the RCA has a mild instant recinosis and some small severe RPDA disease. The graphs as a review, there's only that one graph SVG to LAD that is currently open. So in this case, I think it's pretty straightforward. You know, this patient is symptomatic. They have a severe instant recinosis. So the choice was to me to try to work on that. So before you get into that, just a couple of comments, completely agree. I think everyone on this panel will agree that the thing to do is fix the left main into the circumflex. But, you know, I realized that a lot of this work was done at other institutions, other hospitals, et cetera, but it makes you wonder why they didn't put the LEMA on the LAD unless they dissected it first and there was a complication and then decided to use the vein graft to the LAD. Also surprising that that vein graft is open because the stents in the LAD are open. So it's been battling competitive flow for quite some time and has done a good job of maintaining patency, which is actually surprising, especially given that the other graphs have gone down since. And then finally, you know, there aren't too many humans in this world that have a 3-0 left main. So I don't think it's super surprising that there's some issues in that stent. I mean, maybe they post dilated it, but most 3-0 scaffolds do not go to above four. So, you know, except for the 3-0, I think Boston has a synergy stent that will go to 4-2-5. And so, you know, I think that most of us are probably not surprised that there's issues with that left main to circumflex stent. What do you guys think? I think that's exactly right. The stent might be a little small. Imaging probably wasn't done. End result was probably questioned. And, you know, you might question it, but she was pretty sick. So maybe they took what they could get and get out. I don't want to cast a- No, absolutely not. And I think, yeah, you're absolutely right. I think, you know, imaging, I love it. Most people have adopted it now as kind of standard of care. Whether you have or not and what your beliefs are, I think for left mains, unless you're in a setting like Dr. Kern is suggesting, a setting of shock, which is what she was in, and you just need to get her out of there safely. But in those cases, you may want to bring them back and restudy them just as a surveillance angiogram. Good point, I agree. Left main imaging is required. Yeah. So I did fail to mention, there was a angiogram done about two years ago as a surveillance. And at that time, everything was actually nice. The left main two-circ was wide open at that time. So there's just something that started in the last two years. You know if they imaged the stent or just an angiogram? That's not clear. And I also don't know how big they post-dilated things. They did use that Synergy stent. So it's a 3-0. So they could have post-dilated it up to a 4-2-5. Yeah. Go ahead, Perry. What happened next? Yeah, so we decided to do this intervention with the six-inch EBU 3-5 here. You can see a run-through wire down the circ. And we had to switch over to a AP cranial view to help navigate past that 90-degree angle actually, but I didn't show it here. Then we put the first balloon down. It's a Trek 2-5 by 12 millimeter. And that we were able to dilate up to about 2-6-7 millimeters. And we did an angio after. That kind of looks like it's still pretty tight, but it looks like it was a little better than before. So we attempted to pass an IVAS balloon. So as you can see here, the IVAS balloon is kind of stuck right at where you would expect it to turn up into the circ. But we can see on the IVAS imaging in the distal F main at least, that it is quite small. The stent does seem well opposed, but there is suspicion that it's underexpanded. And around the stent, it seems to be possibly a lot of calcium as the cause for underexpansion. The MLA was calculated to be only 4.6 millimeters squared here. So we saw this and we decided to do a little bit more modification of the lesion. So next we took a slightly bigger balloon, a 2-7-5 by 15 balloon, and we're able to get it up to about a 3-0 millimeter size with inflation up to 18 atmospheres. And then we tried the IVAS again and still could not pass it. Then we tried a BMW buddy wire. Here you can see with that buddy wire, we still, it's having some trouble. Sorry, give me one second. I'm glad you tried the IVAS again, but the other individuals in this meeting, is there any thoughts of using an OCT? Yeah, I think the Philips IVAS is, you know, that eagle eye is just tough. It's great because the imaging is at the distal end, but this is a chronic problem with that particular device, unfortunately. So yeah, OCT, or if you have access to any other IVAS catheters, I'd certainly try it. I mean, the other thing is if you believe and look into every calcium management algorithm that's out there, if you can't get the imaging probe across, the next step is calcium modification. And so you have some options here for calcium modification now. We've got lithotripsy, you have orbital arthrectomy, you have rotational arthrectomy. I think it really depends on what you have available in your lab and what you're comfortable with, but this is gonna require some more extensive modification, no matter what. Don't forget shockwave, but. So there is a, I think OCT is a smaller, more flexible imaging device. There's an even smaller one coming soon to the market, down from two point something French to 1.8, with a very rapid pullback of one second for 50, 60 millimeters of distance. So you could, it's possible to switch. And there's another option, which I'm sure you're gonna tell us about, Perry. Yeah, so I actually have a cute couple of discussion slides on how we could have done this a little better in retrospect. But just here, even with a buddy wire, we could have passed it. And in retrospect, we could have possibly used a guy liner, which I'll go over in a little bit. But in this next slide, as we had talked about, we thought about doing a little more calcium modification. So we use the Wolverine cutting balloon here. It's a 275 by 10. We're able to get up to 12 atmospheres for about a minute. And then we reattempted IVAS again, actually. This was a very noble attempt multiple times, still couldn't get anything done. So we thought, this is pretty serious. So we tried to NC balloon that was 30 by 15, got up to about 3.11 millimeters. It looked better, but because we suspected there was under expansion and difficulties to pass the IVAS, we thought we would try shockwave. So we went ahead and put a 30 by 12 shockwave balloon. It was inflated to four atmospheres in between. So in between the treatments, and then we did four treatments in the distal part of the stent and the four treatments in the proximal part of the stent. Let me just make a comment on the methods. First of all, I think orbital or rotational atherosclerosis, not impossible, and can be done with instant restenosis, but you want to try to remodel that plaque. And the problem with IVAS here, apart from the fact that it's a stiffer, less flexible catheter, is that the metal will sort of hide some of that calcium. Because of the artifact that you would get. I think OCT would be useful because you want to see the depth of that calcium. You can have really deep calcium involved in that media, and then that's when it's useful to use lithotripsy or laser or something like that. So there are no guidelines or no set algorithms as yet for lithotripsy, but I think imaging is going to be extremely important for that, so, yeah. Yeah, that's a great point. The location of the calcium makes a huge difference or is a big branching point in terms of your next step in modification. And it's great that you got the shockwave balloon in there. I think after, you'll at least modify the calcium. Now what's left to figure out is whether you have a stent that's never going to be expanded to the size of the vessel, in which case maybe something like laser arthrectomy might be useful, but your next imaging step can help you guide that. Yeah, the one thing is we didn't have OCT actually at the facility where this was done. So we were kind of limited in that option, but yeah, we also considered like laser or even like something like rotashock as an option too, but I think we had decided just to try the shockwave and it did work pretty well. We were able to pass the stent across the lesion actually, which is what this next slide shows after the shockwave. So we did put a Resolute Onyx 3.0 by 18 stent across this lesion. And you can see it was post-dilated as well with a 3.0 by 15 non-compliant balloon up to 18 atmospheres. And not shown here is after all this, after the new stent, after it looked good, we tried the IVUS again and still could not pass it across this angle to look for post-stent modification. But this is the final shot here. You see maybe there's like still about 20% stenosis left there, but at least the flow is looking much improved or the flow is looking good and the blockage from before is looking much improved. So in summary, we did cutting balloon to shockwave, put in a new stent that was post-dilated up to only 3.1 millimeters. The IVUS did show this MLA of 4.6 pre-stent, but couldn't be passed further. And we thought it may be due to the acute angle of the CERC takeoff. The patient was follow-up in cardiac rehab and looking at those notes, it seems like she does report significant improvement in her exercise capacity, at least for now. So just a few discussion points. I think all of these were brought up already, but how to troubleshoot these issues where you can't really pass an IVUS catheter at an acute angle. So one thing that had been suggested when we asked some people was a guyliner assisted balloon tracking to try that. There are other types of IVUS catheters, especially long tips, tapered ones that may be helpful. And then OCT, of course. One thing I did wanna kind of talk a little bit about also is just whether or not the stent choice here was okay. Because we know previously there was a Synergy stent, it was 3.0. We had an MLA that was pretty small, it was like 4.6. Was it okay to use another 3.0 stent? And a Resolute stent, which we could only post-dilate up to like 3.75. And even that, we didn't dilate it that much. We only dilate up to 3.1 in there. And I also wanted to address a little bit of the utility of IFR and VFFR in assessing these kind of lesions that have bypass grafts. And then also what else could we have done in this case, which kind of discussed already, a rotoshock, orbital, or a laser or brachytherapy even. So just going over JBT, which I just heard about recently. I'm sure a lot of people know about this already, but it's where we can use a compliant balloon inflated to a nominal about halfway out of the guideliner. And then with that protruding, we can use that to help navigate this torturous segment. So this is something we could have attempted, or at least tried a guideliner to help with delivery first. And then just mentioning some of these dilation limits. I think this was mentioned by Dr. Mittal-Patel already, where the Synergy System can go up to 4.25. Whereas when we use the Resolute 3.0, it can only go up to 3.75 here. And then just had to shout out one of Dr. Kern's publications here on CathLab Digest, just showing that the blood flow that you do look at in the myocardium using FFR in these post-cabbage patients, their actual FFR assessment is relying on the potential for competing flow between the native and the conduit vessels. It also depends on the collaterals that are giving flow to the longstanding native occlusion. And then you also have to consider potential microvascular abnormalities from fibrosis or scarring as a result of the ischemia. And then in these cases, it may be helpful to think of those things, but you can still do FFR in these situations. So when you were measuring these, the pressure system should just be placed beyond the nastymosis in the native vessel. In this case, we could have tried that, and then we could have seen whether or not after that stent was placed, if the FFR reflect a still significant lesion or not. There are studies that show after a stent is placed, if the FFR is greater than 0.95, that there are fewer adverse cardiac events, but I don't think there's been too many studies looking at engrafted patients, whether or not doing post-stent FFR in new lesions will actually help determine outcomes or not. So that's just something that I don't know if anyone else has some input on as well. But just a couple of small points, technical. One, the cutting balloon is good because it stabilized the balloon when you deliver the pressure. It really doesn't cut anything. It just pushes everything in place. Because remember, you're inside a stent, it may adhere to the... Well, so I think it's a good dilatation balloon if nothing else will hold still. The switching to the OCT, the use of a guideliner, I think imaging would have been helpful both at the beginning and at the end, because you're still a little bit in doubt. I'm not sure physiology will give you much except to say there's not much of a gradient, and that would be reinforcing in terms of a positive outcome. But there are few studies, if any, in post-PCI physiology in this patient subset. So you'll have to extrapolate from what we know about this information. Rotoblader is useful if you can't deliver the shockwave balloon. But if you can deliver the shockwave balloon, you don't need rotoblader, at least that's my understanding. It fractures all the calcium and does a good job of it generally. So that's my take on this one. I think it's a good study. She may come back, and you have to do it right the first time. If you can't, I don't, again, not knowing what condition she was in when they put the first stent, she's back with us now. Yeah, so Mort, the technology obviously is changing. This new technology, I think, lets us know that imaging is gonna be so essential to future PCIs. I mean, this lady, we don't know what caused the incident re-stenosis, but was it under expansion? Imaging there would have helped. Imaging here would help. Orbital and rotational atherectomy will not get the whole of the calcium. It's usually just channels. Lithotripsy will cause fractures throughout. So it's a different way of sort of treating these lesions. So for the fellows out there, as you go into training, as you go into practice, imaging, whether it be IVUS or OCT, or hopefully both is gonna be essential as you start stenting these coronary vessels. And to tell you the truth, and I have to say that I'm pretty bad about this. I should be doing this for every coronary stent I put in, IVUS or OCT before and after to make sure that I get the optimal results. So I don't know if both of you guys are doing that, but this is what we should be doing. Pranav, welcome to the do as I say, not what I do club. And I'm part of that club too. Yeah, I mean, I think all of us are super happy about the development in drug doing stents and the decrease in instant restenosis. And as our friend and colleague Bill Lombardi pointed out at CTO Plus last year, if you had a new stent that cut those MACE rates in half, wouldn't you use it? And that's what an imaging catheter does, right? It cuts your MACE rates in half. Here, obviously, you tried your best and I definitely commend you Perry and your faculty member of trying to get that dang eagle eye in there. The enemy for all of us, we have two big enemies in interventional cardiology, it's tortuosity and calcium. And you were dealing with both of those. And on top of it, you had previous metal there. So that triple threat is just tough sometimes with our imaging catheters. I think an OCT catheter, as Dr. Kern mentioned, would have probably gone and would have been very helpful in terms of your next step. And in switching to a Resolute, you accomplished at least one thing, you changed the drug. So maybe she's a Zoterolemous responder, who knows? And you also increased, so the Resolute strut thickness and width is a little bit larger than the Synergy. So perhaps you gained some radial strength, but I probably would have put in a bit larger scaffold just to be able to come back. And the other thing is, I don't know, would you guys have opened up the struts to the LAD knowing this lady may need that in the future? I mean, that vein graft looks really good right now, but we all know the history of vein grafts. Yeah, I mean, she's gonna have problems. You know what I mean? It's just, even the IVs wouldn't go in that second time. Oh, and by the way, I thought of a good reason to put the vein graft on rather than the Lima to the LAD. She might, she has a left, oh, she has a left neck tunnel catheter. She doesn't have a fistula or anything, right? Because we have a lot of patients that end up getting a Lima and they have a left upper extremity fistula. And I think that's just a bad idea because you get a lot of steel and a lot of ischemia from that. Every time they're on dialysis, they have chest pain and drop the pressures. That's a great point. I think that the opening up the struts into the LAD would be quite considerate of your future interventional problem. But I'm not sure, you know, you don't want to create a problem now for something in the future. I probably would have left well enough alone, not going in there, but in the future, somebody's going to have to go in there and they'll open up the struts and they'll do the best they can. I worry that in a few years, the vein graft might degenerate too. But it is put between two stents, which is kind of interesting that a surgeon could pinpoint the location to put that graft. Or maybe the stents came in after the graft, I don't know, but- The stents probably came after. Yeah, because that's pretty targeted surgery. For Sky First California, this is really good. We looked at physiology. We looked at imaging. These are things that interventional fellows and interventionalists should master. When it comes to imaging, I think we're going to use more and more of it. And, you know, I was taught something, you know, I learned in a conference, which is a rule of five for the fellows to keep in mind, is that when you look inside a vessel, and usually probably OCT will help a little bit more than IBIS for this, is that if the depth of the calcium is more than 0.5 millimeters, if the angulation of calcium is more than 50%, so you have like about 180 degrees of calcium or more, so more than 50%, or the length of the lesion is more than five millimeters, you got to start thinking about lithotripsy or laser or something like that, because these are the lesions you won't get stent expansion. And this is where you'll have problems. So I suppose we're coming to an end here. Thank you Fahad and Perry for some amazing cases. Thank you Mort and Mitchell for your comments, everyone who sort of came to the conference. Thank you Sky and our sponsors. We hope to have a few more of these. These are very interesting cases. I hope you guys enjoy your evening as we sign off. I enjoyed it very much. Thank you everybody. Thank you all so much. Thanks to our sponsors. Thanks. Have a good night. Thank you guys. Bye-bye. Thanks.

percutaneous coronary intervention

challenging lesions

angiogram

physiology measurements

stent placement

CAD

bypass surgery

acute graft closure

exercise capacity