Thank you again for everyone for joining us tonight, evening. I know this is after or during your dinner time, but really we are excited to have our third session for Michigan Sky First. This is a totally program geared towards fellows presenting challenging cases or techniques to other fellows and moderated by experts in the field. The program is again geared towards fellows interventional as well as general with an interventional interest from Michigan, Ohio, and Indiana. Thanks for the presenters for submitting the cases, for putting the slides together, and also for their time, as well as to your time to attendees for being here with us. Sky has been phenomenal launching this program even before COVID pandemic. I think in 2018, that was in person and then went virtual, but now came in Michigan, and this is we're really privileged to have the third session. As you know, Sky is the kind of the mothership for all interventionists. Make sure your membership is up to date, and also mark your calendar for the annual meeting in Phoenix in May of 2023. I would like to thank the sponsor for this program, Zoll, as a founding program. Betsy and Ivan has been really a profound supporter of this program, Boston Scientific, CSI, CAYESI, and Medtronic. I'm really privileged to be with my co-moderator, Dr. Amir Khaki, who is the director of the High-Risk Intervention and Mechanical Circumstance Support at Ascension. Together we have been coming to you with this program, and also with other guest moderators, Dr. Jane Mohan and Jackson Trebaks, as well as Dr. Dan Manese, and also Dean Bobolas. Thank you, everybody, for being with us. This is the agenda for today. I don't want to take too much of your time, but we're going to present three cases. During the case or after each case, we'll discuss few teaching or educational items for the fellows, and also we'll close at around 8 o'clock p.m. Eastern time. With that, I will stop. I will ask Dr. Rao, please share your screen. All right, so today I'm going to be presenting Not Your Average Problem, Approaches to Managing a Kinked and Entrapped Coronary Catheter. My name is Lakshmi Rao. I'm a first-year cardiology fellow at McCleary Macomb, Oakland. And so today we have a 57-year-old male who presented to the hospital status post-motor vehicle crash. He was found to be acutely hypoxic and requiring increasing amounts of oxygen supplementation, up to 15 liters. Notable cardiac past medical history for essential hypertension, poorly controlled diabetes mellitus. He had no prior cardiac surgeries, prior heart casts, or stents placed. In regards to his social history, he had current tobacco dependence with a 90-pack year history. He denied any regular ETOH or illicit drug use. And in regards to the family history, he had no reports of premature coronary artery disease. For a cardiac evaluation, initial EKG showed sinus tachycardia with interventricular conduction delay and nonspecific STT wave abnormalities. He had a marginally elevated high sensitivity troponin. Echocardiogram performed on mission showed a new cardiomyopathy with an EF of 35%, along with new wall motion abnormalities. The apex appeared to be aconetic, along with mid to distal inferior and anterior wall hypokinesis with a possible apical thrombus. At that time, decision to proceed with right and left heart catheterization along with coronary angiography was made. So then we took him to the cath lab and we initially got right radial access and we inserted a six French glide sheath. So we placed that into the right radial artery, utilizing a modified Seldinger technique. Antispasmodics were given, interarterial cartosome and nitroglycerin, and we gave our standard heparimbolus. A five French TIG 4.0 diagnostic catheter was flushed and advanced over the guide wire. We initially tried to engage the right and left coronary arteries, but we were met with some difficulties and successful cannulation. So at that time, we noticed as well a dampened waveform and reduced ability to torques. We lost torque ability at the time we were concerned for a possible catheter kink. So reflexively, unfortunately, we started pulling the catheter slowly back while panning the length of the catheter. And at that time, that's when we noticed a kink in our TIG catheter. So in regards to how we attempted to unwind the kink, we initially tried to reverse the rotation of our catheter that we did to unwind the kink. That was unsuccessful. Fortunately, because we made the mistake of pulling back the diagnostic catheter, we were able to advance it slowly with the glide wire advantage. However, that did not help with unwinding the kink. We next tried a super core wire, and again, unsuccessful. That was followed by an ankle tip glide wire, and as you can see, that was unsuccessful as well. And finally, we tried a Lunderquist wire, which for those who may have never used it, it's a very stiff wire. So even with that, we were unable to successfully unwind the kink. So that's when Dr. Mohan came to the rescue. So we requested assistance from interventional cardiology to help our rookie move of a first year kinking the catheter. We reattempted to advance the glide advantage wire through, and that was unsuccessful. We did try to put pressure on the axillary region, so to try to provide some compression to the catheter in situ. We even tried an indeflator technique, but that was unsuccessful as well. So at that time, we decided to attain right femoral access. So we used ultrasound guidance, a micropuncture technique, and we placed a six French glide sheath, or six French sheath, into the right common femoral artery. So because all of our other maneuvers were unsuccessful, we then proceeded to use an AMPLAT's Gooseneck 20 millimeter snare, and that was advanced to the ascending aorta. The TIG diagnostic catheter was then also repositioned as well, as you can see. And the snare technique was utilized, and successful capture of the diagnostic catheter was made by proper alignment. Oh, sorry. And after we snared it, sorry, this went forward. So using the snare technique, like I said, we're able to unwind it, as you can see. The diagnostic catheter was able to be successfully unkinked, and we were able to remove the TIG through the right radial access site. So what we did was pull gentle traction and keep resistance on the femoral access site end where the snare was, while we slowly unkinked it, as you can see, and we were able to remove it. So this was awesome because we were able to then proceed with our diagnostic cath, and we didn't have to forego performing our coronary angiography, because as you can see, our patient did have multivessel disease and does need a staged PCI with Dr. Mohan in the very near future. And so going over our case on what we did, we suspected a catheter kink due to our loss of torque along with the dampened waveform. We made the mistake of reflexively pulling the catheter back, but we were luckily able to advance it slowly forward based off of review of prior cases in the past in literature. Sometimes you aren't that lucky, and that would be times when maybe a surgical intervention would be required. But here, luckily, like I said, we were able to advance it forward, attempting to untwist it with countermaneuvers. So if we were rotating in one direction, going in the opposite direction of the torque, trying different wires like we did, attempting to pass a guide wire, changing out wires for different tip strings, different tip strength, and then finally using an advanced method for retrieval. We used a snare technique. Our facility, we had a limited supply of what we can use, so that's why we went with the AMPLATS Gooseneck Snare. There were also ensnared catheters that we could have used. And lastly, on the right, we had another issue with a kinked catheter, a 5 French TIG, but this was an additional method that I thought was pertinent to this case because it was pretty similar, but this actually had a double kink. And instead of using a snare technique, consideration of using retrograde wiring and balloon traction to unkink a double kink in the diagnostic catheter. And that was just more of a zoomed up view of the case that I had just talked about, the additional technique of retrograde wiring and balloon traction. And so a few take-home points is that entrapment of a kinked catheter is a rare but a known complication, especially when we're going through a radial approach and if you're a first-year fellow and we're just getting used to manipulating the catheters, keeping in mind not going beyond 180 degrees or you should be watching for one-to-one movement, knowing the predisposing factors that can cause a catheter to kink, looking at tortuosity of the patient's vessels, especially in our older patients as they age with the likely increased tortuosity of their vessels, having strategies to prevent a catheter kink, maybe even considering a longer sheath if there is a tortuous vessel. And then if the catheter does become kinked, utilizing some of the maneuvers to attempt to unkink the catheter and prevent having to take the patient to have a surgical intervention. That was very good. I got a couple of questions for you, Lakshmi. Yeah. So I didn't understand the wire escalation strategy that you mentioned. It's counterintuitive. Did you guys consider, first of all, did you ever consider like an 014 or 018 wire? Because the Lunderquist is very stiff, as you pointed out, that's not going to work. So my recommendation, if you're going to try the wires, you can start with the 014, 018, and then try hydrophilic wires. So I would avoid those very stiff wires. You could potentially, you know, do more harm. And the other thing is that we don't talk about much, but it actually works really well, is you mentioned it briefly in passing, blowing up the blood pressure cuff. Did you do that? And if so, did you do it properly? Could you tell us where you put the cuff? Was it proximal or was it distal? What pressures do you recommend that we do it on? I believe we applied manual pressure. So in terms of blowing up the blood pressure cuff, I'm not quite sure if we actually did blow it up to a certain point. Okay. Okay. I'll let the... I do know what you're talking about, Dr. Kaki, and I believe, but I'm not 100% certain that we could place the blood pressure. Oh, sorry. Can you hear me? Yeah, I can hear you. No, I think that's a good technique. We don't talk about it enough, but it's very, very effective. The 014, 018 wire escalation works as well. And the two other things I noticed in your case, number one is whoever was torquing the catheter, you never will kink the catheter without, you know, there's always a signal, you're going to lose pressure before it kinks. So once you see the pressure dampening, you quit doing that. So I always tell the fellows that early in their experience. And the second thing is if you do get a kink, the wrong thing to do is to pull the catheter back because it's much easier to work with that kink in a bigger vessel. So in the subclavian or in the aorta there. So the mistake we often make is pull it and then you pull it back. You guys got lucky. I saw you were able to push it back with the glided hand and you had the expertise of Dr. Mohan, who looks like the standard. So those are my comments. I'd like to hear from the other moderators if you guys have tips and tricks, but I think that the cuff is underutilized. It works pretty well. Yeah. So we did try, we tried to feel their XT choice PT. Unfortunately, the kink was just so severe. These cases are nightmares to me because when I was a first year fellow, I actually kinked the catheter as a general fellow. And the attending at the time actually pulled the catheter back into the brachial and we were stuck. And unfortunately, one thing definitely do not do, and Dr. Khaki kind of mentioned, kind of alluding to this, is you take like a stiff end of the wire and try to poke it through. And what actually happened during my case, when I was a fellow, that happened and the wire just pierced through the catheter and made a new hole. And then you're hosed at that point. So that patient for me actually had to go to surgery. So I've taken a lot of time to learn how to deal with these things. It's actually one of the reasons I don't use a TIG ever for my own cases. I like Jutkins because I don't like that over buildup of torque. One of the things you always look at is the pressure. My eyes are always there when I'm over-torquing a catheter. So one thing you can also do to avoid that is you can put a 75 centimeter radial sheath. Trumo makes one. Really with the right radial, you get a lot of brachiocephalic tortuosity. That works well. And then also if you use a co-pilot or a TUI and then put a stiff wire through that and help you torque it while you're doing that too, that also is a nice technique to use. But I do like that. I mentioned to Lakshmi to show that straw technique at the end where you could use a balloon to actually help retrieve the catheter. So if you ever pull your catheter back by accident into the axillary and you can't get a snare there, you could take a guide, put it in the brachiocephalic, wire your kinked catheter and inflate a non-compliant balloon within the kinked catheter and pull from the femoral and radial. That also works pretty well. Do you think going left radial, if on a stay radial, you could have got it as well or this is not advised? Are you saying to snare? We could, I guess that that was an option. I think at that point I was just, you know, I was... I would have done the femoral. I think you guys did the right thing. The femoral gives you a lot more options if you have to escalate to a bigger sheath, you know, bigger sheath and pull it in. So I wouldn't mess around with the contralateral radial in a case like this. I think you did the best thing is go femoral, gives you more options. So we got Dan and Justin, they've been doing radials probably longer than all of us. What do you guys think? What do you guys do when the fellow or... You know, it's interesting, about 10, 12 years ago, when you converted a radial, we had way too many of these from attendings to fellows. And so everybody did kink. And I think the key that you said is you never, you always advanced it. You always want to go to a bigger vessel. So as a fellow, you know, for the fellows, just remember that don't pull back and try to straighten it out. You always advance to get more room. And I agree, smaller wires to try to... Desmond Howard. Smaller wires to get through for sure. And try to see if you can snake it through. I will tell you one trick that we actually had to resort to because we thought the patient was going to end up going to surgery. We tried everything. I think that everybody mentioned here was, got femoral access. This was one of my partners. I thought it was pretty slick and it worked. And that surgery was there. We avoided occasional surgeries. Actually get a snare, could not wind it. And so she size was upside from the femoral, snared it, cut the catheter from the radial, pulled it in all the way through the large bore sheath and came right out. I saw that maybe about 10 years ago for the first time and it actually worked. But we had about probably four or five people in there trying to brainstorm. So that's just kind of a last resort thing. But I think these other tricks you've mentioned should usually do the trick. But yeah, it can be problematic. And we've leaned towards that destination sheath that you mentioned, the guiding sheath from Terumo when the break is felt and the arch is tortuous. I think that can help as well. And maybe even torque if you're trying to get the right with your wire before pulling it out and hooking up to your either a cyst or your manifold or whatever you're using. Yeah, I think you touched on a lot. It's a lot about recognition, right? I mean, prevention is probably the best key. And it's hard for the first few foes, I'm sure what the right amount of torque is. I mean, that's the thing that is usually hard. And usually you can figure it out if you can just figure out what they're trying to do. And if they were overclocking it, a lot of times you can just figure out just go the opposite way. But when it gets kinked like that and a double kink, you can be in a real bind. But it's mostly recognition and prevention, I think. I think, as I mentioned, really great things. The only other thing I've seen is actually just being able to wire and straighten out the vessel. But I think the key is to not, as everyone said, try not to pull, resist that urge, which always happens in the cath lab when you're doing something unexpected. And just trying to find different locations. Obviously, mostly, especially from the radial, if you're going forward, you get bigger artery. But sometimes just finding a different location in a different vest, which you're ideally pushing forward and not traumatizing the vessel coming back, that a lot of times will help you out as well. And it'll take some of the acute angle of that kink out, even if you can almost make it more of a rounded edge by pushing forward. A lot of times pushing forward on your wire as you're doing that, a lot of times you can get that on kinks as well. But that was a great case. Thanks. Thank you. Yeah, that was very good. Very practical case. Thank you Lakshmi for sharing that for you and Jay. We all learned a lot there. Thank you. We have any other more comments from the panelists or moderators or do you guys want to move forward to the next case? Okay, sounds like we're going to the next case. Hi everyone, my name is Mishita Goel and I'm one of the first year cardiology fellows at Wayne State University Detroit Medical Center. And then my presentation today is on approach and bailout strategies for calcified lesions. So this case is about a 76 year old male with past medical history of hypertension, hyperlipidemia, type 2 diabetes mellitus, CAD, and he had a RCA stent some years ago, end stage renal disease on hemodialysis who presented to ER with chest pain. EKG showed normal sinus rhythm with T wave inversions and lateral leads. His initial high sensitivity troponin levels were 650 nanograms per liter. He was already on medications, aspirin, atorvastatin, Coreg, and nifedipine 60 mg. So given his presentation for NSTEMI, he was taken to a cath lab. And here we first engaged the RCA and the RCA showed patent stent and there were only mild luminal irregularities. And then we engaged the left coronary system. And as you can see here, there is like severely calcified LED vessel, which we suspected to be the culprit vessel given the EKG findings. So then we wired the lesion with workhorse wire and then we wanted to pass the iowas catheter to assess the morphology of the plaque. However, as you can see here, we were unable to pass our iowas catheter. So we next opted for debulking and the lesion modification with CSI orbital atherectomy system. And for that, we, as you can see, advanced the viper flex tip wire here. And then with using the micro catheter for support, we did the orbital atherectomy. We did two runs of the system at 80,000 RPM at a slow speed of one mm per second. And then after that, the next thing we see is that there is a TIMI zero flow post atherectomy. So I want to take a pause here and ask my CardioCurious residents who I see have joined here and my co-fellows as to what you guys think happened here. So as you can see here, like with the TIMI zero flow, you would expect that either there could be an air injection or we caused a micro dissection or there are thrombus that was created or a micro vascular occlusion that occurred due to athero emboli, which we call a no reflow phenomenon. And the next thing, like our patients started also complaining of chest pain. And we also saw these changes on the monitor where you see the ST elevations as can be seen here. So in this case, like I said, those were our top differentials. So at this point, our ACT we knew was 275 seconds. So we knew our patient was well anticoagulated. But with the no reflow phenomenon, because we know that it's like platelet and fibrin plugging is an important contributor to pathophysiology of this phenomenon, we did give the patient Tirofiban, which is GP2B3A inhibitor. And then we also injected, there was distal micro catheter injection of nipride 300 micrograms, which is a coronary vasodilator. And then we also did mechanical power aspiration using Penumbra. After that, as you can see the results here, there is a restoration of blood flow in the LAD. So after that, we deployed our stents using a 3 by 32 mm and 3.5 by 32 drug eluting stents, followed by post dilatation with 3.5 by 20 mm and 4 by 20 mm NC balloon. And this is our final result. So with this case, we want to highlight the importance of utilizing imaging and appropriate calcium and plaque modification techniques to prevent a stent under expansion and malapposition, which can further lead to instant stenosis and stent thrombosis. Our case was also complicated by no reflow post atherectomy, which by itself has been shown to independently correlate with mortality. And then to mention treatment with intracoronary vasodilators, which decreases the incidence of no reflow. We also want to highlight the adjunctive use of mechanical aspiration thrombectomy for the same. And then for, again, my colleagues, here are the therapies that we can use for no reflow during PCI. We can use adenosine and the recommended dose is 24 microgram or greater. We can also use nitroprusside, 50 to 300 microgram is the recommended dose that we use for our patient. We can also do diltiazum, 200 microgram or nicardipine, 200 to 300 microgram. And that is my presentation. Thank you, everyone. And I can take any questions. That was very good, Rashida, very nice presentation. I'm sorry, I missed it. Did you use orbital or rotational for the atherectomy? Orbital atherectomy. Yeah, that's interesting because it's interesting to see what the others think. I use a lot of orbital and I see a lot less no reflow than rotational. And I'm pretty much a default orbital. Does any of the panelists have a lot of experience with rotational and orbital comparing the two? I am preferentially rotational, so I'm probably opposite. But I guess my question would be, you know, I think it's preference. I'm not sure any of us here could probably tell you one better than the other. I guess my question is, what about the use of mechanical atherectomy in a non-STEMI? And I'm just curious what people's thoughts. And if you have something like IVL, would that be a preferred first choice in a situation like this? I think that's a really good point, Dan. I think I don't know when this case was done. I could tell you I have privilege of the DMC and that they don't readily have lithotripsy available. So you have to you can't use the ad hoc. So that might be a challenge downtown at the other hospitals I go to. We readily have IVL. And I agree. Your point is well taken, Dan. In a setting of ACS, if you think that's the culprit, should IVL, you know, be our default for calcium? And then disrupt CAD data, they obviously none of those were ACS patients. But this was not observed. I don't know if there's a lot of published data on the utilization of IVL in ACS. But I take your point. I agree with you. Probably a preferred strategy. What do you think, Justin? Yeah, so these cases will happen. And it doesn't matter how good you are with anticoagulation or dual antiplatelet therapy or, you know, vessel preparation, whatever it may be. So these will happen. And I think that's actually one of the reasons why atherectomy has a relative contraindication with reduced ejection fraction. Simply because if you shut another vessel down and you get no flow scenario, you can get into a lot of trouble. So what I think it's important to do for the fellows here is that when you see that, you identify it. Make sure you start, you know, with the checkboxes. So what is my ACT and my therapeutic? What's my antiplatelet regimen? The other thing is I know you tried passing an IVUS. Maybe we need to reconsider doing it now. And then you start going down the pathway. And like Dan was saying, you know, could this have been thrombosis or was it all calcium? Is it embolization of something else? Do you have a dissection? I think that's a huge consideration here. And if you look back at your case, you kind of treated everything at that point, right? You made sure you were therapeutic. You did a penumbra. You did, you know, prolonged balloon inflations, it looked like, or maybe just balloon inflations. And then, you know, you're you give a bunch of drugs. So it's important not to get too uncomfortable. You always have mechanical support if you need it. Sometimes you do, especially in a proximal LAD like that. But I think you go through the checkboxes and you get the patient to the other end of the procedure. So I agree with you, Justin, especially this is a stressful situation. You see the hemodynamic changes of the patient or start moving around because of chest pain. So you have to keep it together and work an algorithm step by step and ask for your equipment right away. And be familiar with the doses of these vasodilators who come. Sometimes the nurse has to pre-mix or arrange for them, which takes a few minutes sometimes. Yeah. The other thing that I noticed, Mashida, that you did that should be applauded is in a no-reflow scenario like this, is oftentimes people will deliver the therapeutic medications through the guiding catheter. And the key is you'll notice that there's a big difference. So use a micro catheter, go as distal as possible and give your therapy through the micro catheter. So I've learned that over the years. It's very effective. I saw that you guys did that. So I think I agree with Justin. You guys are very commendable. You treated everything. You were very thoughtful in your approach. And I agree with Dan. Probably in the future, if you encounter an ACS case with heavy calcium, consider IVL if you have it available. I'd like to thank Dr. Al-Rais because he was the rescuer in the case. So thank you. Yeah, I would say they're very well done. The first thing I would have thought would have been dissection for me, at least in my head when I saw that. I probably would have reflexively probably went with the stent first. So I applaud. Usually what I'll do is I'll have the nurses mix up the no-reflow while I get the stent ready. So that's great. And I think Kaki brought up a really good point. I've seen a lot of better outcomes with no-reflow with delivering the medicine to the distal bed. So in this situation, I'd be a little bit worried to pull my wire with using a micro catheter over the wire balloon. In case there is a dissection, I would consider something like a twin pass or even like what you guys did with export. You can actually deliver it with keeping your monorail wire still in. So that's another good thing to keep in mind. Thank you, everyone. One other thing that I played around with was I didn't want to open up a penumbra. And so I did use a regular balloon that I had on my table. And I think I saw this online or on Twitter or something. But I actually just made about 10 different holes with a small needle in the balloon. I emptied out my indeflator. I put my medication in the indeflator, got the balloon down, and I went up on the balloon slowly just so that the medication was kind of showering the distal bed there through a balloon. And the balloon was so small that I think I got quite distal and it worked great. That's great. So like I used a douche for the distal artery. There used to be a balloon that Atrium made. I can't remember the name of it right now. I think it was Clearway, wasn't it? Yeah. It was good, actually, so that you wouldn't have to do it at, you know, you wouldn't have to MacGyver it, Trevax. It came pre-made, but it was, yeah, the Clearway. We used to use it to deliver medication locally. And I think it was a cost prohibitive and it's kind of gone away. But your point is well taken. So we're doing good on time, guys. Both of those cases were great by the fellows noticing that, you know, the women in cardiology in Michigan is going strong. So Cindy would be very, Cindy would be right now. So the Roxanna Maran. Yeah, pretty soon we're going to be having mixed men in cardiology. We're going to be outnumbered. So we'll get started with the next case. My name is Brian Beller. Nice to meet you. I'm one of the first year fellows at McLaren Macomb, a Michigan State program with Dr. Jay Mohan as well. Today, we'll be talking about beyond the guidelines, tailoring treatment for acute STEMI with CABG indications. So without further ado, appreciate your time. So case presentation. Fifty seven year old male presents with past medical history, just hypertension, hyperlipidemia. State started having chest pain after playing around a golf. After about 15 minutes of constant substernal pain without radiation, patient did call EMS after he was hesitant upon EMS arrival. The patient was sitting in a chair. He's diaphoretic, pale to EMS per the run sheet. The patient's wife actually, of all things, gave him six, 81 milligrams of aspirin, and she gave him six prior to EMS getting there. Like I said, medical history, only hypertension, hyperlipidemia. Meds were only Lipitor and Lisinopril. Really insignificant past surgical history. Right, you know, right hip surgery. So nothing cardiac in nature. Denies alcohol, denies tobacco or drug use. Family history, did have an M.I. in his brother who was older than him. Allergies, no known drug allergies. So now timeline. So EMS got there at 1750. They were they were actually contacted, first responded. They got their EMS later, 1758. Initial EKG in the field, which is shown here, conducted at 1800, demonstrating what you can see is an inferior stemmy pattern with reciprocal lateral and anterior changes. Vitals when they were there, stable, alert and oriented, blood pressure, heart rate, everything stable. So at this point it was sent over to McLaren Macomb and a semi-activation was had. In the meantime, while they were in route. So now this is 17 minutes later into the drive before they get to our hospital. This was in the field, like I said, shows resolution now of those inferior ST segments with residual T-wave inversions. Now, within two minutes of the patient actually coming to our hospital, this EKG is the one that it's attained, which I do apologize. It doesn't transcribe that well, but it does show normal sinus rhythm. The inferior segments, again, show resolution of that original ST elevations with the continual T-wave abnormalities. And then the anterior and lateral reciprocal changes that were prior seen on that original 1800 EKG is also no longer present. So basically, at this point, though, because the patient was still at this point, he also what I want to say, I want to stay with the case, is he just painted miraculously once he got into the ER. It is painted like complete, almost completely resolved. We went from like a 10 out of 10 to about a three to four out of 10. But based on the original EKG changes and his classic story, the cath lab was activated, like I said, he was brought to the cath lab and proceeded with the case. So I'd like to show. So here's the first clip. So it was a six French JL-35 diagnostic catheter selectively engaging, which which demonstrates here a left main that is small or a large caliber, but very short, but no obvious disease. LAD also demonstrates a moderate caliber vessel. The osteo of the LAD showing a 99% stenosis was giving rise to the first diagonal branch, which is 80% osteostenosis. Mid LAD here is having a mild bridging like we're kind of seeing some other. We'll see some other films here in just a second. And then looking at the proximal left circumflex here, moderate caliber vessel looking at this, a non-dominant vessel. If you see there's a very small first OM branch, very small diffusive disease. That second OM branch you see is large, has an 80% proximal stenosis. And then that third OM branch is likely small, but likely due to underfilling because you have a subtotal occlusion at the proximal aspect of the vessel. So, again, now if we go to some more shots of the same thing, if there we go again, these are just different angles that we're taking and again, demonstrating the same kind of disease pattern that we had. So at this point, we now know we have two vessel disease in this patient. Again, not a history of diabetic, no prior cardiac history in this gentleman. Inferior STL ovations originally, non-dominant left. So after this, we proceed. The catheter is exchanged for a six French GR4 diagnostic, you know, catheter. And at this point, he was engaged in selective engagement to right. He demonstrates here that the vessel is obviously has disease into it. Hold on, we got a mess. This is a mess up here. Hold on a second. As you can see here on the left video, the RCA is is engaged, like I said, the GR catheter is engaged. RCA was a large caliber vessel, dominant in nature by the PLV and PDA. Filling defect that's seeing the mid portion of the vessel is got that hazy appearance, which is consistent with plaque rupture and thrombus formation. There was there is some it was called it. There was one picture that was unfortunately not captured here, but there was distal to that lesion, believe it to me to flow at this time. At this point, talking to the patient, he is still having that mild chest discomfort rating in about a three to four out of ten at this point. So this proceeds now forward. But to show you at this point, again, this is kind of just highlighting. So now you're sitting in a situation where you have a clear STEMI situation showing anatomy that's amendable to CABID surgery. He does have good targets that you would look at. You do have osteal disease of your LAD, you know, your CERT and your RCA. So this is discussions I like, I'll kind of push this till the end, but these are things that we're now thinking, what are the best management modalities we'd like to go with this case? Multiple things that we can kind of discuss after, but, you know, guidelines are guidelines. If we have these, we know that the, you know, the CABID equivalents that we all are well aware of. However, in this situation, what is the best plan? Because everything we do is, you know, has a consequence to timing for everything else. So without further ado, what was decided is based on the patient's age and cardiovascular surgery was actually consulted and discussed looking at these images during this whole catheterization. The plan was to proceed with POBA or PTCA of this lesion because he was still having that pain. And again, SC segments are still are flat at this point. Also had the TIMI 2 flow distally prior. And our goal obviously is to restore our TIMI 3 flow in this setting. The idea was it will see if we can get a resolution of his pain and improvement of his distal TIMI flow. And if that is the case, we will stop therapy at that point and be able to get him to a CABID intervention urgently versus making him delayed. So at this here, you can see it was wired through the lesion. And then the right before the shot prior, which was not saved, unfortunately, this is a pro water over a O1 4, what's the O1 4 wire is 180 centimeter in length there. But there was a better picture of the TIMI 2 flow distally prior to this. So balloon inflation, which is done in 1906. Go ahead and play this. Demonstrating again, this here now was a 2.5 by 15 non-compliant Trex balloon. It was advanced over there. It was inflated for eight atmospheres for 10 seconds. And then again, another five seconds later, which is not, Sydney wasn't saved, but there was a further, that 2.5 was then pulled out and we didn't, weren't happy with the sizing. So a 3.0 by 15, so same length balloon compliant was advanced the same lesion, 12 atmospheres, 10 seconds in length at the same thing. Right video again, demonstrating subsequent angiogram that was performed afterwards, revealing a decrease in the severity of the observed lesions. Nonetheless, the persistent concerns remained with regard to the patient's presence of thrombus within this lesion. So again, this is, would you stop here? This is also the talking points. You say, I have my TIMI 3 flow, he's feeling better. We will, you know, based on what cardiothoracic said, we can probably get him to an urgent, we can get him urgently into treatment. Do you treat him medically and do not even touch and even proceed with potentially embolizing any of this plaque by basically doing POBA. Another modality thought because of the concern for that ruptured plaque was that we, as we go to the next slide here, we'll see, we proceeded with a arthrectomy catheter that was an aspiration thrombectomy catheter was advanced down to the lesion, trying to get as much out as possible. About 20 milliliters in total was able to be removed. It wasn't significant. And then the right video again, where it's demonstrating post angiographically after the aspiration arthrectomy with demonstrating some improvement. And again, now this patient's feeling, he's got TIMI3 flow, vitals are stable with ANO3 and he's completely asymptomatic now. He has no chest pain whatsoever. So at that point there was open communication established already with the patient interventional cardiology and cardiothoracic surgery. Patient's pain, like I said, was a zero. So after careful consideration by interventional and cardiothoracic surgery, I was agreed that an urgent CABG would be most beneficial for him, especially if he's only 57 years old. And consequently a mutual decision was taken not to proceed with any further DES placement in this setting and get him off the table. There's again, first objective is do no harm. So finally angiographic after the pro water was removed, did demonstrate a reduction in the initial 99% stenosis at mid RCA. It did have a little residual, less than 20% stenosis, which was acceptable in this setting as the patient was known to be going to an urgent CABG. Hopefully the next day ended up taking more than just the next day. It took about two or three days, I believe later, but you do have successful restored TIMI 3 flow distally. All right. Then a six French pigtail catheter was advanced over to get our ventricular gram here. So as you can see here, we did able to get our hemodynamic numbers. LVEDP here was a 24. Systolic pressures were 150s. No, on pull there was no AS. But demonstrates in this here, we do have a down EF in this 57 year old estimated about 45%. There is basal to mid anterior and inferior lateral hypokinesis noted here, which does make sense based on the anatomy that we're aware of. So at that point, patient was coming off the table. Was like I said, he was having drip his aspirin, his Lipitor. It was started on his metoprol, which was now on before. I did forgot to mention prior to the original pro water that was being placed. He did get an agrostat bolus and then the drip was ordered by pharmacy. We were in it for eight hours after, which was started right after he got off the table by the time pharmacy got it up here. And then like the three was three days later, underwent successful three vessel cabbage. He did get a REMA to his PDA, SVG to OM2 and a LEMA to his LAD. So I would say thank you for listening to that. I was just curious to any other experience in this setting when, because basically we have these guidelines. They do serve a purpose. The act is our roadmap, which we know, but ultimately you are the driver. So I'm just curious to anyone's thoughts. Thank you. That was really good, Brian. It's interesting. We had a case like this at our hospital about six months ago, and the operators did the same thing and they weren't as lucky as you. And while waiting for surgery, the patient's right coronary artery thrombo. So it's severe three vessel disease and they wanted to do POBO to the right to buy him time and stop the infarct, which was reasonable. So, but our patient ended up infarcting thrombosing and then we ended up putting him on support and fixed everything percutaneously. So the lessons I learned from doing this, now several of these cases is abrupt closure and thrombosis is real. So the question is, I'd like to hear from the panelists and some of the fellows that you guys have seen is the modern four generation drug code is sent. And if you look at them, we have good data that at 30 days, they're endothelialized. And so you gotta ask yourself the left side disease, although it's severe, probably didn't have it overnight, happened over a long time. And is it safer if the surgeons are gonna delay to do it all percutaneously? Is it safer to actually send the guy and have an elective surgery? Is it safer to, if you're gonna use your approach, put a balloon pump in? The other thing to take into consideration is this experiment has been tried and there was a good study in the Pacific Northwest when I was a fellow, looking at taking these patients to surgery in the setting of acute infarcts, non-STEMIs. And they actually don't do as well as you think. So the surgeons, when they sit there and buy a lot of time, it's for a reason, we get frustrated and irritated with them, but it's for a reason. Cause the longer that they could wait, the better their patient does. The problem is, is that waiting time for us, sometimes it's a ticking time bomb. So I'm not sure what the right answer is and in your particular case, you guys were very thoughtful. You did the right thing and it worked out for the patients, but for all of everyone else listening, sometimes we think this through and it doesn't work out as planned. So consider all the options. So I would have done, probably stented that coronary artery and had the patient come back for elective surgery. I would also consider putting a balloon pump in if that was a strategy that you guys were doing to increase coronary perfusion to the left. But there's a lot of ways that you could skin this cat. What do you guys think, Dan at Michigan? I do want to just interject one second. I appreciate that. Just for time, I didn't want to, I mean, I have a decent time, but ultimately a balloon pump was put in prior to him undergoing CABG for left-sided support. Yeah, so the balloon pump in this scenario is not a hemodynamic support device. It's actually kind of a bridge to try to reduce the angina and increase coronary perfusion as they're waiting for surgery. That is one of the utilities of balloon pump that I still think is valuable in patients like this awaiting surgery. It's not a very robust mechanical support device, but in your case, you didn't need it. You had good hemodynamics at the end. Yeah, for the better diastolic flow, yeah. So I would have done what you said, Amir. I would have just stented the right. I think with today's current generation of stents, I mean, it was nice to see that it got a remit of that right, but if your surgeons are going to put a vein graft on that lesion, I would have much rather just give him a DES and probably give him a better long-term patency anyway. I agree with you. The less set of disease, what's the rush to rush him off to surgery? It's chronic. It was a Timmy III flow. The nice thing here is there's a STEMI. You know, when I look at a STEMI, it's like a trauma. Take care of that aspect, get that dealt with. And as you pointed out, I think a lot of times, you know, you don't know, a lot of it obviously depends on where you're at and what your surgeons want to do and what the practice is. So you have to tailor, you know, I think everybody's experience is different. Our surgeons would probably have, you know, slow played this as well. And while they're doing that, you're exactly right. I mean, you just kind of struggle with, is that going to thrombose? And, you know, POVA work, but POVA can work if you're going to continue antiplatelet therapy. You know, you can't put them on Plavix. You're not going to have that antiplatelet therapy. So yeah, I think he kind of got lucky on this one. I would, Ron, I think it would have been, from my experience, I probably would have stented that. Give him, you know, four weeks of DAPT and then let him have surgery, you know, electively. Dan, I agree completely. A few things to add to that is that you can really kind of pick whatever scenario you want it to be and go with it. So from my perspective, when I was looking at the initial angiogram of the right, I know there was TIMI 2 flow, but I think the flow into that distal bed was probably adequate. If you did nothing, didn't wire it, didn't do anything, just put them on a heparin and balloon pump, I think the outcomes probably would have been the same as if we do POBA, number one. And number two, as we've mentioned here a few times now, is that, you know, there is some risk associated with doing a POBA. You can really shut that vessel down. Now you're stuck because you've got no reserve on the left side. The final thing just to mention here is that if you have a surgeon who comes in to the cath lab, oh gosh, there is just severe multivessel disease. This patient needs a bypass. Look at, there's OM2, OM1 has a trickle of flow, the ball, the diags, this patient needs bypass. You have to remember exactly what are they going to do that you are not going to do? Are they gonna bypass all the small little vessels, OM2 and diag2 and, you know, the PL, and they're not going to. So sometimes, as Amir was saying, if you put in two or three drug-eluting stents on the left system, you're gonna achieve exactly what they would achieve. So just keep that in mind. Then one other, I think, practical point, Brian, is that another drug I think that's underutilized in this scenario is Kangalore is a very friendly drug as a bridge to surgery, because you could kind of turn it on and turn it off, and it protects our patients. The surgeons are tolerable of the medication. It's not like dapt and that, you know, you have to wait. And that's the biggest excuse I get from surgeons is presumably this patient got some type of antiplatelet and they want to wait five to seven days. And that's when the ticking time bomb goes off. So I think that I agree with Dan's comments that I think you guys got lucky, but it's sometimes better lucky than to be good. But next time, if you do this long enough and you adopt this strategy, you'll see that sometimes it doesn't work out as well as it did for you. But that was very good. And I really appreciate, you know, the thoughtfulness of you and your team. You guys were very thoughtful. And just a couple of points. One is that's a great case because you have to really think about what to do. And I think that's harder than deciding how to fix a lesion with Roto or CSI. You know, all the cases were amazing. I will tell you, I agree. I would extend to that acute vessel closure. If you talk to the gray hairs before stents were out is real and it's a big problem. And the other thing you got to realize is Plavix is a worst drug. It really is. It inhibits 30 to 50% of your platelets at most. You know, when I was at Vanderbilt, we had the first hybrid OR, which we loaded everybody with Plavix. Chronic Plavix gave a Lima and stented in the same setting. There was no difference in bleeding, no difference in chest tube drainage, no difference in dropping hemoglobins. And it really comes down to your surgeon feeling comfortable or knowing the data. And I would say that you just, you know, you have to have these discussions with your surgeons and maybe in your combined conferences. And that's what we've done and really discuss the data and review it. And it may actually, you may notice that, you know, some of these patients are going to surgery post stent and we have a handful of surgeons who will operate on Plavix. Some won't, but we definitely do. And I think the other good point that was mentioned was that post ACS like this, if the lesions are stable, you can wait. But if it's a 99.9 left main, your hand, you know, you may be forced to do the surgery, but you're right, there's nothing wrong with waiting, but, you know, just going back to the DAPT, you can operate on DAPT and that needs to be discussed with your surgeons and that should be reviewed in your combined conferences if you have them, the data. I wish I could have called all of you when I did this case, but I was, it was early career, you know, first one of the first STEMI's. So it's kind of like you want to make the right decision. And I think a lot of surgeons, it depends on the surgeon that you talk to. So I think that day that particular surgeon was very adamant that this patient should go to bypass. And he told me that he was going to do a Lima Rima. And so in my mind, I was, I thought, okay, that what's going to give the patient the best outcome long-term. But as you guys talk and as I've done this longer, I realized, you know, if the patient had acutely occluded while waiting, it would have been a disaster. So, yeah, you fix the disaster first and then you can still send the patient for surgery. You're not doing them a disservice. So just like Amir said in the beginning, so fortunately we live in a day and age where drug looting stunts don't just, you know, that doesn't take the surgical option away completely like it used to, so. I don't think I did anything wrong. I think actually I commend you for thinking about it and calling surgery, having them there, having discussion about the best plan. I mean, hindsight's always 20-20. I would, you know, second guess. I just think that, you know, we tend to maybe folks on this panel just tend to stand in those situations, but. No, I actually agree. I think, Jay, at the end of the day, your patient, you know, got two mammary, so they can't do, we can't do better than that in the cath lab. But I think also, you know, these meetings are important because now you have the collective experience of a lot more people so that it increases our volume when, you know, theoretically when this patient comes in next time, people who haven't been doing this long enough will think of this case. And so just to be honest with you, I've done this many times and I got burnt, Jay. And so now I just put the stent in. So I love my- I was going to say, Jay, we've all been there. I'm telling you what I've done now, but I'm not telling you what I would have done 10 years ago when I started. Yeah, it's completely different. And it has, every case is different and your surgeons are different. Yeah, surgeries would be a variable. I will tell you, we have one surgeon who will operate on Berlinta, which, you know, I mean, no one else will in our group, but when push comes to shove and it's an emergency, you know, it's happened a couple of times and the patients have been fine. It's like, yeah, if I need a transfuse, I transfuse. It's not a routine thing. I'm not saying to go advocate for that, but I'm saying everything's possible. You just got to take individual, like each case. Yeah. Well, we are eight o'clock now. Thank you so much. Really, it's been a great, a lot of teaching points, the fellows, as well as for us to learn from really all of you. Thank you so much for the presenters for really having the courage to submit, the interest to present and putting things together. And for our attendees, we really had 51 attendees throughout the webinar. Thank you so much for your time. I know it's eight time today. And I'd like to thank Amir Kayaki, my co-moderator. Again, always entertaining with a great and thoughtful comments. And our guest moderator, always bring new things to the table. Your experience is tremendous and your input is very valuable. I'd like to put a plug for the upcoming Sky First. It's going to be in person this time. It's going to be in April 26th. So please make sure you mark your calendar and also prepare your cases for the April. We have at least three months. It's going to be in Syldam Standard in Detroit. The capacity, I think almost 20 to 25 or 30 people. So would love to see you there. We're going to be live events. It's going to be phenomenal. They can see people face-to-face. So for the fellows out there, please make sure you get your case ready as well for submission. The theme this time is going to be STEMI and cargogenic shock. Plenty of us came across. So I think it's going to be an easy one to put it together. Thanks again for all the sponsors, all for the founding support and Boston Scientific, CSI, KUZ, and Medtronic. Again, this is not a CME activity, but it's really valuable education activity. Last but not least, thanks to the panel who put it really together. Rebecca from Sky, Ivan from, and Mitzi from Zoll for really your support for making this happen. And any final thoughts? No, I thought the cases were fantastic and the fellows did an awesome job. And for those of you who are in April, I could just tell you, I'm a foodie and Selden Standard is my favorite restaurant. So even if you don't learn anything, you're going to get a wonderful meal. So hopefully everyone will get to make it out there. So thank you guys. And it's been a wonderful evening. I learned a lot from the fellows and I hope everybody took some pearls home. ♪♪

cardiology fellows

case presentations

challenging anatomy

blocked coronary artery

snare technique

kinked coronary catheter

acute ST-elevation myocardial infarction

coronary artery bypass graft

percutaneous transluminal coronary angioplasty