Yeah, I think that, you know, these are incredibly challenging cases, and the one thing I might add is sometimes pausing to allow the pharmacotherapy and the endogenous fibrinolysis to occur before proceeding with the next is not an unreasonable thing to do, and obviously none of us have the crystal ball, but I think, you know, the mechanism here was expansion into the nasty crud behind the struts, and it needed some time to baste before, you know, cutting into it again, and so the question always is, is how long do you wait and how long do you rush? And sometimes you don't know the answer until the event transpires, but it's, the alternative would be to, you know, pause a little bit in between and give the flow a chance to improve and hope that the clot doesn't continue to propagate before the next insult. Agree completely, and you know, it's, I'm the program director for interventional fellowship and it was myself and my fellow, and we got that flow back before post-dilating up top and I literally was like, this is going to go down again, you know, and so the question is do you baste it and drug with kind of undersized proximally and then bring them back and fix the top, or what would you guys do on the panel? I agree with that strategy mentioned by Joaquin, that what I think is necessary, although there's so much variability in how the patients actually respond, so it's a lot of this out of your hands, but when you have some flow going through there, then ideally the endogenous TPA is at least getting there, and then obviously my strategy would be highly aggressive on the meds, so the 2b3a plus the P2Y12 both on as emergently as possible, then ACT over 250. I throw the book at all, granted it only happens a few times a year, but I throw it all at all of them immediately, and then I wait, and sometimes we actually sat in the lab with a similar patient a week and a half ago for an hour and a half afterwards, and literally just sat there, watched, kept doing repeat angiograms in case you normalize, but there still wasn't great flow. We just kept waiting and waiting and waiting, and then finally it starts to get better, but you got to strap in, it was Friday night, two Fridays ago, so all right, Friday night dinner's over. And would you then treat the ostea, Jay? I would not personally, but that's not a criticism because I don't know that I'm correct, but I think that if I'm able to get out of dodge, I'll do that, and then now the patient's going to be on dual antiplatelet, I think it's totally reasonable to consider, I know we rarely do this these days, but a 48-hour relook, and then the patient's in a different position at that point. I would certainly, though, expand the stents because you don't want to leave the lab with massive, you know, under-expanded stents there. I agree. I like to give the 2B, if I'm giving a 2B3A, there's only one trial, it's limited data, but to suggest putting down a manual aspiration catheter, maintain wire position, and give the 2B3A, you know, intralegally as much as possible to kind of get that, I think it was a clear AMI trial, it was a two-by-two factorial design, and the one with the intracoronary right near the lesion sort of had somewhat better surrogate outcomes. And then the other thing is, when I've been in cases like this, and during COVID, gosh, there were so many of these, the only thing that would let me have that patience to let it baste, as Joaquin was mentioning, I'd put the drug down in the coronary, and then after that I'd put in whatever I needed to put in, in terms of balloon pump or impella, and that gave me the time and the patience to hold off and let the drug do its thing before I asked. Yeah, because there's lots of things you have to do at the same time, so getting the hemodynamics, that gives you 30 seconds, you know, and you can then go back and look to see if things are getting better. They don't have to be normal, but they can just be getting better, then you can just wait a little bit longer. Good, we don't do anything with our hands. I know. Maybe just these two questions, then I think we're going to have to close the session. I think you were first here. Yeah. Sometimes, like, when I see that the stent is not undersized and expanded, I don't do too much post-dilatation in a situation like this to avoid the cheese grater effect, like, you know, and with a plan to bring the patient back in a few weeks and optimize the stent rather than optimizing there and causing more reflow and close the artery three times or not get a right effect, but I don't know if that's the right thing to do. Well, this is, you know, this is a good case of you use the IVUS, so maybe you just go one-to-one straight up with the stent and, you know, so that if you can't post-dilate or for whatever reason, it's not the end of the world. I think it also depends on how much underexpanded it is, if it's the circumferential or 270 degrees. It's the difference between underexpanded and undersized, right? Right. It looked like the stents were fully expanded, but then small, and then the question becomes what's the risk if you have apposition with an undersized stent? And when you get up to MLAs over 10, it would seem that that risk is strongly small. That would be the argument for walking away. Sounds like you're in the liquid stent for these kinds of situations. The what? The liquid stent. You need to walk back. Right. Thanks for the explanation. One last question. Yeah. You know, in my experience, I've used long balloons, in this case, not a bigger balloon, but a longer balloon to prevent that watermelon seed effect. And for me, it always works. So if I see this thrombus or acute occlusion, I'll put a long, but up for the one-to-one size balloon, or even smaller, just to leave it there for a minute, and then you'll predict it's a good flow. That's a great point. I think when I've been doing that more and more, Sahil Parikh, who many of you will meet here, is talking about that. So it's washing the thrombus a little bit. Yeah. It's like he said, it creates a flow channel. So I've been using some of the purple balloons. So, like, a 100-millimeter balloon I had in an RCA, and I had beautiful flow after. And the question is, I took that picture and I ran. I don't know how long the flow stayed. How big? How small is that compared to the main? So how small was that balloon, though, in comparison to the luminal size of the vessel? It was like a 4-0 vessel. I took a 3-5, but I took a 3-500 millimeter, and it basically, you know, they were ischemic for a minute, as long as they tolerated it, ST started to go up, and that's when I came down and then it was beautiful. But I've used it, I think, five or six times now. Yeah. Let's just blow up the whole thing for a little bit and come back tomorrow. Yeah. But it's gotten me to my Friday night dinner, so. Yeah. Yeah. All right. Yeah. Yeah. That was the next question. Thank you for bringing that up, buddy. Yeah. That's a good question. Yeah. So I did use a fair amount of it during COVID, particularly in the first couple of weeks in New York. And I don't know if the dosing in the non-COVID setting versus the COVID setting is similar, but you know, they usually say you're supposed to...the one trial, I think, used 20 milligrams of...I'm sorry if I got my units all off, but like 20 was the dose, and I ended up using like half the bolus. But that was another thing where you just sort of...I would give it, again, this is just my experience, I would give it intralesionally through a manual aspiration catheter so I can maintain wire position, let it sit there for about five minutes, and try to not take a look. And before I would do anything else, I just then...at that point, I'd take the mechanical aspiration catheter down, aspirate, and then I would do angiography, just, you know, in that setting, there was just so much thrombus that I was even afraid of just getting contrast down was going to sort of shower the emboli. But I did...in those cases, I would end up giving half the...whatever the bolus was supposed to be would be half of that intracoronary right in the lesion, sit there for five minutes, don't take a picture after five minutes, aspirate with a mechanical aspiration catheter, and then see what...and in those cases, they cleared up very nicely. Again, whether or not you need that high of a dose, in the trials, they used a much lower dose, 15 to 20, in the non-COVID era, so... One of the strategies that's used...and you distinguish between a no-reflow situation and a situation where you have thrombus...a heavy thrombus burden with reflow. So in the latter situation, where you don't have no reflow, there's a strategy that J. Aaron Grantham has actually written about, right, where it's like they...some people call it jagged marination after him, where you throw in...you guys have seen it, right, where you throw the second...you throw a balloon down distally, blow it up, and you get a catheter in proximally, blow that up, and then you infuse the lytic, and when I've done that in the high thrombus brink, it's without the no-reflow, I'll use a 5-milligram bowl, so I guess I'm using a little less. I order 10 milligrams from the pharmacy, it takes 15 to 20 minutes to get there, so you're stuck anyway. It always takes at least 15 to 20 minutes for them to mix it, and then I give 5, then I give another 5, usually through that catheter. The reason why it's different, I think, when you have the no-reflow situation is you're not accomplishing everything you want. You actually want that lytic to get in the microcirculation, so you don't wanna block that up if you've gotten a no-reflow, and in those cases, my strategy is I use a dual and microcatheter, same thing, 5 milligrams, then I give 5 milligrams. I mean, this is everything I did two Fridays ago, patient got everything, so...

thrombus burden

reflow complications

interventional procedures

aggressive medication strategies

IVUS visualization