So, again, where we were, we were here. You know, there was kind of mobile thrombus inside this morose stent. We started calling for things, all simultaneously, as Jay was saying. You know, worried about imminent collapse, wanting to do thrombectomy. We do a lot of cataracts, penumbra thrombectomy. We got it in the room. We called for Impella, as well as called for balloon pump. We can talk about that a little bit with thoughts about coronary perfusion. This is a lab where we don't have the ability to start IV cangular in the lab. So we called for 2B3A, and the thought was, well, this guy's 80. I don't particularly want to give this, but if we have to give it, we're going to give it. And we just wanted to start doing things. Also, there was the same concept of how much distal intracoronary vasodilator are we going to give right now with a blood pressure of 150 versus what a blood pressure will do. My goal is when things go bad to start doing stuff that might do something. So we threw that cataracts penumbra catheter down. We actually gave just an intracoronary nitro because it was right there, and they were getting nitride for us. And so we gave that, and it kind of maybe a little bit, but then there's the international sign for my chest hurts. So all of a sudden, his hand is on his chest, and all of a sudden, his blood pressure's starting to go down, and we've got a little bit more flow, but we certainly don't have great flow. And so we did some more cataracts. We dove that back down. We're still having chest pain. We've got a little better flow. We also still have this kind of not dilated to size proximal stent, and on IV, it's just ratty disease all the way back to the ostia. And so we had some flow, but we had chest pain, we had a lowering blood pressure, and we had kind of untreated disease. So we post-dilated it again. So we post-dilated it up to our planned size, and so what happens? It goes away again. So now all of a sudden, we have nothing again. We've got a blood pressure. Dr. Justin Marchegiani We've got your marginal back. Dr. Andrew Hill I got our marginal back, which is very exciting. So we threw our IVs catheter down just to see if we were missing anything. On our IVs catheter, you can see there's thrombus kind of extruding through the stent, matches up with what we saw, kind of that mobile thing dancing around within the stent, so at least that kind of confirms for us that's some of what we're dealing with. And so we threw up a number of cataracts, catheter back down. At this point, we're given 2b3a, we have a levophed drip that was starting, we treated the proximal thing. And this is kind of an interesting part in the pathway where you're saying, you know, every time we do something to this artery, it's gonna get bad again. So at some point, you just gotta finish treating the artery and then deal with the complications of the treatment. So with a big 05518 Zion Sky Point, we post-dilated the stink out of it. Chest pain's terrible, blood pressure's terrible, levophed's on, called for a balloon pump, more thrombectomy, integral embolism, we're just trying to get stuff done. Balloon pump went in. With a balloon pump, his chest pain starts getting a little better, his blood pressure starts getting a little bit better, we start getting a little more flow. His chest pain, we actually IVs down and we saw a little flap distally, which we didn't see before. And then it was like, okay, did that flap with that edge stent dissection or did I do that? Diving up a number about 15 times through someone's kind of ectatic artery. For a minute, we were super happy that we're gonna tack this up and everything was gonna look great. We're gonna go on with our day. We tacked it up. We've now got three stents and we still got no flow. So it certainly wasn't that kind of mobile flap. But at this point, with the balloon pump in, we actually came off our levophed, interestingly enough. So we're only on levophed for about five minutes. The chest pain was improving and we said, okay, we're chest pain-free, we've got a blood pressure that's stable off hemodynamics. We started 2b3a, let's get a PO antiplatelet in him. We actually put him on ticagrelor. And then we left him sitting in the cath lab with us for a little bit with the balloon pump in as his chest pain continued to resolve. And he did okay. Now, he's gonna have a big infarct, right? So for a period of time, but the question is how that will evolve. His chest pain went away with the pump in, the levophed was off before he left the lab. We put him on a nitro drip, we loaded him with ticagrelor. The next day he was chest pain-free, we got the balloon pump out. So three days later, he went home. But this was one of those nightmare stories which aren't uncommon. So I'd asked the question before about the operations of getting ticagrelor started in the lab. It's a huge deal because, you know, if you see that high-risk artery, even if you're not using routine every case, I think these are the times you really start to put it into your algorithm.

thrombus

stent

thrombectomy

Impella

balloon pump