Thank you so much for Skye and Manos and Yadir and Carlo's group, excellent talks, I always learn so much when I come to these sessions. Anyway, in my case, because I'm the last person, I'll go a little faster, a 64-year-old white male had dyspnea on exertion, he had a CT scan in December 2022 in a different hospital, he had a known RCA-CTO, I mean, RCA-CTO was diagnosed and CT-FFR was positive for circumflex, so which led to a PCR of the CERC, but he had ongoing angina, so as you can see, you can see the CERC stents, a mild disease, mild to moderate disease in the NAD per se, but and then here's the RCA-CTO. And for me, it almost looked like a functional CTO, you can kind of see some contrast flow and there's a big dominant or marginal branch, but I'm like, is it really a functional CTO if it actually existed for almost two years? But nevertheless, I could see some fluoroscopic calcium, I thought this is going to be a quick and easy process, not a big deal, anyway, brought him to the cath lab for a CT or PCI, but in general, you know, when you have a side branch at that level of occlusion, and I know this has been for two years, I go with all the guide support I need, so I call it TruDoc, and I don't know why my slides are going automatically behind, but which is basically a micro catheter and a micro catheter, a guide catheter and my guide catheter, and then in wire escalation was attempted, but the wire escalation, the wire would go into planes where I really could not understand where the wire was, so then I came in with a dual lumen catheter, and I could follow the calcium more than I could follow the vessel, so I was able to escalate the Gaia 3, deescalate with the Pilot 200, and there I am. So balloon, this is a 240 balloon, went easily, and I got extension catheters right there. But I go back to this slide, this picture, between this picture, after this picture, I tried to iris, okay, and the iris would not cross, and that was very surprising to me because a 240 balloon went in so easily, why is the iris not crossing? The iris wouldn't cross, and then I tried to bring the guide extension over the balloon so that I could deliver the iris, but the guide extension would also not cross beyond this point, which, you know, I was like, I really don't understand what's going on. So I said, okay, let me get a 25 balloon and pull back the guide extension, and that's when I saw this little undilatable lesion, and this is a 25 balloon, and it is just not giving at all. So right now, multiple, you know, the carnosis slide of different things going inside your head is what is going on, should I get a cutting balloon, should I rota it, should I shockwave it, or should I just serially balloon dilate, etc. But then, since I attended the Minneapolis Heart Institute CT, PCI course, I went back to the old CT scan from 2022, and you can see the calcium in the left main LAD, here's the RCA coming in, and you can see this dense, dense calcium and calcific nodule, calcium going in the native RCA all the way down. And this is the curved multiplanar reconstruction, and you can see the dense calcium right around the CTO segment with lack of flow here. So this CT actually changed my perception or my planning of what to do. I decided to rota burr it with a 1-5 burr, and as you can see, the burr just did not flight, it's getting stuck, and like several pecking attempts had to be done to get the burr across eventually. So after the burr across, I was able to iris, no problem, and here is the iris imaging itself, and you can see some negative remodeling, lots of tissue, then some specks of calcium in the vessel itself, and then here comes the burr calcific segment, and very soon you'll see a very protruding calcific nodule, which was ablated a little bit by a rotational atherectomy, but, you know, and you can see the cuts there, but there was still residual nodule. So at this time, I decided I'm going to take a shock wave and traverse it with a TRIPSY balloon. So this is my first balloon. Funnily enough, the shock wave balloon was watermelon seeding, so it took several attempts to do it, and this was the second shock wave. I had done 10 further down, another 10 further down, then I got the first one against the lesion, then you can see the little bit of dog boning still there, and then when I tried to do it again, the balloon ruptured. I was like, wow, this is interesting, because I really did not expect to have such intense calcium just based on what I saw in angiogram. So then we got another shock wave balloon, and kind of, this time I went a little higher, 4.0 instead of 3.5, and we were able to do the PCI, post-dilated it with some clear stent things to make sure we were good, and this is the final angiographic result. And I want you to bring your attention to this little outpouching here. I was like, what is going on? And this is my post-dent ivis, and you can see a little bit of outpouching there. I'm wondering whether I caused a small hematoma with the balloon ruptured in the vessel, but nevertheless, the patient was absolutely stable, and this is my final angiographic result. So, in general, when it comes to coronary calcium, you cannot be married to one strategy, and you have to have the skill set to utilize all the different strategies and all the tools in your toolkit. For example, a CT scan, which was done two years ago, was extremely effective, and I could have beaten this lesion to death with serial balloon dilatations, etc., but none of that. It would have just increased my overall case time, and instead, just going back, utilizing all my tools, I was able to move through my decision tree much more efficiently and get the result I wanted. Never underestimate coronary calcium. It's always more than you can see, and one nodule, if it goes the wrong way, you are going to say they're going to have a massive perforation and deal with perforations and more and more things, so it's better to learn all the tools and not be just stuck to one. With that, I will stop for sure. Wonderful. Thank you. Thanks, Harash, again. A phenomenal case, and as you said, it highlights the importance of taking all the data into account, and that CT, as you saw, was very useful showing the circumferential dense calcium that required quite aggressive modification to get it expanded. Before we discuss about this, maybe we'll answer a couple of questions that came online. The first question from Dr. Hirst is about the delay in getting a coronary CT, so I guess his question was, is it a problem if you have to wait for a CT? And that's one question. The second question from Dr. Manu is about the reimbursement. Are there any issues with reimbursement, which I know that it was also discussed in the document, but maybe, Jadre, you want to share your thoughts about those questions? Yeah, and I guess there's two aspects, just for the audience and everybody listening. So the CT, again, just for people that may have not embraced this, it's increasingly being recommended for diagnostic purposes. It has been long recommended in the UK, in the NICE guidelines, it's recommended in AHAs, you see. So for diagnostic purposes, these patients are getting a CT as part of their routine timeline of care, whether they have angina or shortness of breath or some symptom to lead to the CT. So technically speaking, there's no delay in care, because what we are suggesting here is that these patients already had a CT, and they might have already been on the basis of an abnormal CT being referred to the cath lab. So quote, unquote, there's no delay. We're just asking, indicating, let's look at that information and interact with that data. So there should be no delay. We're just looking at the existent information, information that we have long ignored. Now, separate from that, there are specific scenarios. One of those is the one that many of you are here experts on the call, which is CTOs, for example. Now, it's a patient that has a CTO that has a prior angiogram. Would you arrange for a CT just for CT-guided planning? My answer would be we're sitting in a randomized controlled trial for CTO on two trials for patients with prior bypass. So yeah, I think as long as there's a good clinical indication, rationale, will resolve ambiguity, lesion length, inferred classification, and whatnot, and there's documentation. At least in my experience, I've had no issues. Modest, I know you do a lot of CT for CTO planning. I mean, maybe you can speak to that as well and others. Yeah, no, I completely agree to we do CTO a lot of patients who had already diagnostic angiogram. Now, having said that, many of them are previous failures in other centers. So there is an extra reason. And as you said, there is a randomized trial showing the benefit for CTO. But I have not had personally many. There's been a couple times where the insurance had some issues with getting the CT. Otherwise, it's actually been not an issue getting reimbursement for getting this done. And as you said, in terms of the first question about the delay and everything, I was at our ASC today, and three out of the four cases I did had the coronary CT as the gateway to come to the cath lab. And actually, this was why they came to the ASC, because the CT is so not significant calcium or other high-risk features. So to your point, quite often, I think the way this is going, stress tests were probably going to be decreasing. Coronary CT will be increasing. So people will be coming to the cath lab with the CT more and more often. But the other question that is coming up is about, Arash, your case and about the use in calcium. Are there any characteristics on the CT? And I know it's a tough question and still under discussion, but how do you decide about, you know, atherectomy versus IVL versus plaque modification balloons? Is there an algorithm you're using? Is it a Gestalt? Is it case-by-case? How do you think about this question? Because I know many people have this question on their heads as well. Absolutely. I think Farouk talked about it, and I think Carlos also talked briefly about it. It's the density of the calcium, the thickness of the calcium, and the length of the calcium. These are the criteria. And in my case, it was extremely circumferential, and the density was quite, quite intense, and it was not speckled calcium. One thing the CT angiogram still hasn't come out with, it does not show us nodular calcium, like how we see an iris of obvious nodule protruding in. It doesn't show us that. But I think it is all putting it together. You see dense calcium on the CT scan, which is long and which is thick also, and your iris is not going. So the decision tree comes, are you going to do balloon-based strategy, and are you going to have enough balloon power to cause cracks without causing a spiral dissection, or if you're missing a nodule, are you going to perforate the nodule, trying to balloon dilate? And that's why I truly, Zeyad keeps saying that, you know, he says, shave and shatter, and I actually like that little analogy he uses. Shave off the nodular tip and then shatter it with intravascular dithotripsy or other technologies to make it safe for the patient. Wonderful. Any final thoughts? I know it's going to pass the hour, so any final thoughts before we conclude? I think, you know, from what you've heard from everybody here, you know, with folks with a lot of expertise in complex PCI and calcium and whatnot, I think there's, you know, many opportunities to use these tools to plan our procedures and understand what strategies to use and how to prepare for, you know, lesion modification, etc. I think we're at a stage where we need, you know, still more data, and it's exciting to hear from Dr. Collette and the trial, but also we need to be familiar with the botanology now and how to do all these assessments, and so I would invite the audience and listeners to engage with the cardiac imagers. I can tell you that in our practice, our success was to engage in those conversations with the imagers, learning how do they do things, and vice versa, they heard from us. So I think that's actually something that for those of you that do structural disease, this has been happening all along, but for those of you that have been doing just coronary interventions, I think this is a great opportunity to interact with our coronary imagers, and then just jump in, jump into the software. Wonderful. Well, again, I would like to thank all of you, all the panelists, as well as Sky and Shockwave for sponsoring the session. Lots of learning. I think many people are more and more excited, and thanks, everyone.

cardiology

coronary artery disease

calcified lesions

interventional procedures

multidisciplinary collaboration