In this program, Professor Sharp and Dr. Gallagher will present a case of an IVUS-guided PCI of bifurcation lesion. They will discuss and demonstrate the various strategies available for this LAD/Diag bifurcation lesion and how IVUS plays a significant role in the planning, treatment and optimization of this PCI.
Okay, welcome everybody. Thanks for joining on a friday morning or afternoon depending on which side of the world you're on? This is the fourth session in our training series. I'm Andrew sharp. I'm a consultant cardiologist from cardiff in the United Kingdom. It's a lovely day in cardiff today. Hopefully joined by Sean Gallagher who's my colleague from cardiff who did the case with me and he's going to do all the life cases with me. This is four out of 10. We're going to take you through different types of cases and try and show you how we use in our Cath lab to optimize our stent deployments. If you're with us on session one, we went through the basics of image interpretation, Session two. We talked through stent optimization. Session three, we did a case in a box, looking at a long lesion that we optimized in approximately Lady lesion. We've got a very nice result using us now. Today is a is a very interesting case and I think it will create a fair amount of debate at the end. So you have a chat function or you can put questions in and we will try and answer those questions at the end. But right now, what I'm gonna do is I'm going to share my screen. So welcome back to cardiff for the second live case or live in a box. I'm joined by Sean Gallagher who's our director of interventional cardiology and our team here in cardiff. We're going to tackle a bifurcation today and hopefully demonstrate this optimization of bifurcation stenting Sean, what do, why don't you introduce the case? Tell us a bit about the anatomy. Okay, So if we can take us through to the first picture, please john if we run forward one. So this is a 45 year old man who presented with an inferior stem E three or four days ago and had pcs with Sir Complex. And he's come back now for stage procedure to the led diagonal bifurcation. So we roll on one more picture. So what we're seeing here is in the L. A. D diagonal bifurcation, quite significant aroma. And then at the led at the bifurcation itself a 111 bifurcation lesion with a good sized diagonal. So that's the target for the intervention today, Sir. Complex looks nice. So he's recovered well from his stem. E I guess this is the old complete story, isn't it? Is should we do anything about this lesion? It's pretty tight. It's got a high risk of instability based on anatomy and we need to fix this. Why not just a provisional sean. We've we've got lots of data. The provisional stenting is frequently the right option. I think I think I think that's the age old question isn't. Andrew which side do you intervene on and which ones do you leave alone? And I think the data is very difficult to interpret because a lot of the bifurcation trials take a lot of patients without proper side branch disease. So this patient clearly has side branch disease. And what drives me towards two stents strategy here is firstly the disease does extend at least five millimeters away from the bifurcation and it's a large vessel. I think this is going to give us a lot of insights here into the degree of plaque burden in that diagonal. But when I look at it initially I am thinking two stents here. Yeah, I mean the drug eluting balloon has opened a few doors for us. I mean it's not available in America. So for something like this, I might consider just pre dilatation of both limbs. And then if it looks good on the iris, maybe single stent. And then drug eluting balloon. But but I agree with you. I think this is an important territory. Um you know, it's it's not that much smaller than the led. We've got some act asia running into it. It's maybe some positive remodeling approximately. Or it may be that at that septal there is more disease than we can appreciate on the underground. But maybe we're gonna have some size issues and my position here. So this is important for uh elucidating that what God have you got and why have you chosen it? So we've got a seven french voter left 35. The voters shape is my go to shape from the arm. I think it just gives you slightly more support than most of the kind of EU type shapes. Just a secondary curve on it. And then seven french. Think seven french just makes things easier in a bifurcation and we're radial. Of course. Yeah. So. Okay, great. So we're going to get on now and just wire both these vessels. We'll just start prepping the ivys if we may please. So we're going to use the affinity ivies today via the inter site system and we're going to need to pre dilate both these limbs. I guess the question is do we pre dilated then? I this or just go straight with the with the ibis? Actually, yeah, I think we'll probably see what we need to see. P. A cranial please. So there are certainly some lesions where you can't get the IV's through. And I think it's best to relate with a small balloon before you try and get through. Um I don't think there's any anything to be concerned about with that strategy. You're in the diagonal. There. We could see the roadmap of the diagonal. Please give it back into P. A cordial please. And let's have the second wire. There you go. And I'll be there affinity Ibis please center please. And of course he's having just had a stem E. We do have a jeopardy situation here that we certainly can't afford to be losing big side branches. So that's another thing to consider is going to tolerate loss of the diagonal less. Well having just had a ser complex in fact, if he was a stable outpatient of course we never want to lose a branch like this. But again it's into the thinking and these are sound blue wave, So quite terrible. We just Gotta watch when we go above 22 atmospheres. We don't get any balloon lock, lovely. Just need that helpful loop. Now I think that will do test there for me. Happy enough down there to pull that back out. Okay, great. Okay, we're ready for that office when you are done. You know, I was awake. So we used the infinity last time. It's a 45 megahertz rotational iris. So it's a single ibis probes spinning at high velocity to produce a 45 megahertz frequency image. Um When you're using the affinity, you'll always see a wire on the screen, The wire that you've used for the iris. Um It is occasionally subject to nerd non uniform rotational distortion which is an artifact that will probably be able to demonstrate on this case. It's not such a big issue. You can minimize that by avoiding qingqing it and avoiding trapping the ivies probe within your catch. Okay, so it's a sled pull back. You can't do without sled. Unlike the eagle eye where you can do it by hand, the sled of course automates the speed at which it pulls back which is either half a millimeter per second or a millimeter per second. And I think if if you want a lot of precision, then obviously the half a millimeter is helpful. But to be honest, for pragmatic purposes, we tend to have it on one millimeter a second because we're going to do a few runs. So as you can see, we're default here almost as a core age. You got relatively normal looking vessel here. Good landings on. Yeah, agreed. Just grab that for as well. And what we're gonna do is we're gonna start an automated pull back now on our side panel and keep an eye on that screen. So you'll see that there's some nerd at 9, 10 o'clock. That's a little bit of distortion. Just try and keep the catheter straight as we can to minimize that. We're coming back into some fiber optic disease now, back towards the bifurcation. If you could stay on floor or sean, that'd be great. And then there's that severe fiber optic disease, there's some calcification from one o'clock around five o'clock there, but it's more fiber optic than calcified. I don't think this is something that's gonna need modification but we'll have a look at it in a second in terms of calcium modification. I mean that fibrosis will need to attend to and then we're coming back to work through this ecstatic segment now. Well, you can see that there is some disease at the site of that settle. So that's going to give us a decision as to how far back we go and then we're back into the left main. Okay, so we're pulling back from the diagonal now so you can see there's some nerd at nine o'clock and a wire artifact going up towards 12 o'clock. We're coming back into some quite fiber optic disease, very extensive plaque burden. Quite a bit of dropout. So I think we we do have some attention required. The austin of the diagonal and we're back into proxy lady. That's the middle of that what we call the static but it's actually a healthy segment. And then as we come back towards the septal there was a septal coming in. There's some plaque at that point. Not severe but certainly enough for us to be careful about where we land our proximal stents. And then we're coming back into left main shortly and back towards the guiding catheter left me is not too bad. There's a bit of plaque on the floor there and then we're into the guiding catheter. Okay great. So let's stop that pole back. We'll take that out and I'll give you this done. So do you want to go through both of the angiograms? Do some measurements. Tell us what you think. Okay great. So let's go back to the case menu. We'll just have a look at the first run open that. So this is the L. E. D. And let's just tell it that it's the led. So it's the led. Pre and we're starting distantly here. Very healthy looking vessel. So first of all we want to find our distal landing zone and about there is pretty good. So we make some measurements and we can do that by hand here and it's three by 3.5. So that's pretty good. So we'll tag that as L. E. D. Pre reference distal. Okay. And then we'll save that frame and that will go into our pack system. I'll get that out of the way. Uh And now we scroll back. We can see here there's a bit of negative remodeling at this point. So the vessel is bigger here than it is in here. So we'll just be a little cautious about that. Some eccentric plaque there with a lot of leopard 3520 scoped this .3.1 x 3.4. And then as we come back towards the real meat of the lesion here, you can see how the vessel is remodeled in an adverse way. So if we do a diameter here and this just goes to show when you're measuring, just make sure you don't measure on a long axis and ignore the short axis. So you can see it's it's actually only at the led just after the bifurcation. An average of 3.1 for the vessel and fairly extensive extensive plaque there. And then here it's really quite fiber optic with quite a lot of dropout. So it definitely needs a good bit of remodeling list isn't it? In terms of what we're going to do to it and then our landing zone just before the bifurcation. Yeah. If we take it on media to media is 4.6 x five. So let's label that led proximal reference and save that frame. And then in terms of measurements we can do length now from there to there. And one potential landing zone is roughly at 23 stent. Uh But let's just see if we've got any other potential landing zones because we've got this plaque at the septal, it looks like we don't need to get involved in that show. And what do you think I would try and land in that normal segment? Just proximal to the bifurcation and leave all of the disease around the scepter. Yeah, I think I agree with you. There is some remodeling going on in this proximity lady. You know, it's it's huge here. If we do an amateur there, That's just before the bifurcation, it's 4.9 if we do a diameter here, just around the point of the septal in this arc, It's 3.9. So I think there is some positive remodeling going on and I think we want to stay where we're safe. And I agree with you. I think this is our landing zone here. Uh And I think we want to be sizing on but We're looking at 23 and then distantly we can probably go two or 35 once we've agreed Dilated this, remember there's a tight stenosis at the point of the bifurcation. So as soon as we've released that the distal vessel, we'll probably fatten up. So what are we taking here for modification? So I was going to do, we wanna have a quick look at the diagonal. Um So my thoughts are a three angle sculpt into the diagonal and then a 35 cutting balloon in the L. A. D. Simply because we don't have a 35 and sculpt. Um Okay so let's just open the diagonal. So the diagonal is clearly the smaller vessel. So if we just go where we we started and uh then 2.4 x 2.8. So this is the uh we'll call it the led even though it's actually a brunch and it's a reference and it is distal. So 2.5, there. But if we come more approximately, yeah, we're straight into disease. And then that Osti um is very heavily abnormal. So we've got quite a lot of artifact there but we've got extensive fiber optic plaque from four o'clock around to seven o'clock. But what worries me a little is we've got a lot of dropout around the actual osteo. Um So I think we'll disrupt that with an endoscope and then we'll see what we get and then we'll take the wolverine thereafter for the lady. Yeah, I'll take both cheers. So tell us about the angie sculpture. So the angle scoped is a semi compliant balloon and it sits within within a night and old cage and there are three times on the night and old cage. The idea being it's really forced focused angioplasty. A little bit like a stiletto heel that as the balloon goes up the times of the um, I think quite effective in this fiber optic osteo disease. I like a cutting balloon or a scoring balloon in an Austrian. I'm happy to help you. Let's just give a 10 or so. Okay, 10 good and down she's gonna take that forward a little bit more. It's 10. So we're we're three here which is on the big side on the big side but I think it's all going to grow a little low pressure. Quite happy with that nicely. Okay, time. So we're down from 10 little test for me actually. We're okay before we come out very nicely. And then if we have the cutting balloon. Next please. So I think we got a 3.25 by relatively short wolverine cutting balloon. It's just a conventional cutting balloon. It's the next iteration of the cutting balloon. So from the flex home much much more deliverable than the flex tone. Um any reason we didn't just use reuse and I think this is a little bit bigger than that. I think 35 approximately to the bifurcation where most of the plaque burden is. Okay. This comes very nicely. Yeah. Yeah, I'm happy that going on. So we're at 10. Good and again. 12. Thank you. Just go 12. Yeah. 12 good and came down from 12. Okay. So I wasn't quite sure that fully released nor was I. So let's have a 3.5 by 20 N. C. Balloon. Just prep that with neat contrast please. So if this was a purely fiber optic plaque and I think we are stuck with these bladed technologies. It's not gonna be a one for road ablation of C. S. I. Or. Thank you. So slightly slow flow down the diagonal. Now it's interesting isn't it? Yeah I'll fix it once you've put the new contrast. A little bit of type I suspect. I mean it's it's certainly released the diagonal. Better than the L. A. D. I think I'd like to see the lady come up with a balloon with neat contrast in it. And what we didn't see on the iris was extensive. 3 60 calcification. We did see some drop out uh and some fiber optic material but we didn't see, you know, napkin ring here. So we're expecting not to have to use road ablation C. S. I. Or shockwave here. Bladed technology should do the trick. They've released this up quite nicely and now we'll just double check that that led has gone up. We're just a bit cognizant that the the Iv's before we established a bit more flow in the vessel. Uh was only 3.2 on average. So we will just be a bit cognizant of that. We don't want to go too high with the 35 I think all we're looking to see is whether it's going to release fully. Thank you. Yeah it's just a bit of slow flow in that diagonal. Just as we And we're at 10 12 12. I'm happy with that. Let's just go oreo cranial. Stay up for me. R. E. O. Cranial And we can repeat the ibis and make sure I'm pretty happy with that. Okay we're down from 12. We'll go back into the P. A. crane. Good thanks. Have an A. C. T. Then please. So there's a lot of chat about Hepburn at the moment. The large doses were needing in order to get therapeutic calculation if we could center up a bit. Okay looking all a little bit better. Let's have the iris back. I think we just need to use the L. A. D. I'm pretty happy with the way everything is released in the diagonal. Okay so we're in the L. A. D. Now I can see the vessel has fattened up a bit and we're coming back into the bifurcation now you see that fiber optic material, it's really extensively fiber optic. We get a much better view of the vessel now and it's released nicely. Okay great. I think that's plenty. Let's get so as you can see here distantly. The vessel has fattened up just at the exit a little. We haven't given any nitro yet. We probably should about to do that. So it's three distantly not that much bigger. And then what we can see here is fiber optic material. So if I draw some dots here fibrosis from three o'clock round to six o'clock you can see there's a bright white material with an absence of drop out behind it. And then we've got a little bit of nerd down here. So Coming into the lesion itself, its fibers calcification can see this drop out from 6:00 ground to nine and that looks like deep oil calcium. It's not superficial But the vessel has expanded a bit. We've got this healthy segment, there's a bifurcation coming in at 11 o'clock and I think that's what we're seeing on the angiogram. Andrew when the balloon doesn't fully go up. We've got the calcium on the contra actual walls of the bifurcation. It's really difficult to modify that because the balloons will always deflect into the bifurcation itself. And that's what we were seeing. I mean it's not perfect from 12 round 25 is it because of that fiber optic restriction. But I think we saw that the balloon went up pretty nicely. Okay, what are your thoughts? I think this for me raises a question about whether we need to do anything to that side branch. I quite like the idea of a drug eluting balloon in a single stent now. Yeah. I mean do you want to revive us? The diagonal? Just make sure there's no dissection and then if there's no dissection, I'm quite warm to that idea because we've got pretty good loom. So again pretty healthy looking vessel here if you just floor or just so you record where we are. We're coming back into the disease segment now and its fiber optic and not dissected. So uh as we come back through, I don't see any dissections. There's two wires there, one that's on the iris and the other one in the L. A. D. And it looks pretty healthy in the L. A. D. They just have a good look at that. But it looks to me like it's not dissected. It does look like there's still quite a lot of plaque burden at the osmium of the diagonal. And I suspect we're going to be in a position where we send the L. A. D. It's going to be crossover and balloon through to get a nice result. But I think that's okay. Right okay. So let's have a look at this. So our landing zone is still pretty healthy. So let's see what it's it's fattened up to. So if we bring that in It's still only 2.75-3 in the long axis. And then as we come back in here. That's the critical point, isn't it? So the Nerd at 7:00 is not helping. But as we come back through certainly not extensive dissection there. And so uh you know quite a bit of recoil. So as we look at our lumen It's gonna be pretty small. 3.5 Let's send the led and see what it looks like after that. Because I'm looking at that luminaria there. I wonder whether we'll get to five with just balloon technology. But let's see. We got 3.5 by 20 for synergy please. So I think one thing about this is it does change the management. I mean we saw in the adoptee s trial 75% of cases I've is change management. And I think one of the key things about being on an I. V. S. Learning curve is accepting the information that it gives you. It's very easy to just get stuck on the path and keep going. Um Here we don't see dissection so we'll probably be all right to go with the drug eluting balloon strategy from the point of view of acute safety but we've got a pretty modest austral Luminal area in the diagonal. And so I'm sort of 50 50 now and whether we're going to need a stent because once we entered LED is going to modify the carina across and make that look worse. So I wouldn't be surprised if the area of the austin the diagonal doesn't look so good after the led stent but you know I agree entirely. And that's my concern is that we're gonna push the carina across here. I'm pretty sure we're going to end up really re crossing and kissing but I think we'll get a good result. We might end up even having to complete the colony into the diagonal possibly oh half off and his sisters come down nicely. So even though he had that slow flow in the diagonal, everything's alright now. Yeah. Thanks. So this is adding on. Maybe if it's my relative on the table, I want those decisions to be right rather than two or three minutes quicker. So I think the argument about time when you're talking about an L. A. D bifurcation. I don't think it comes into play here. Gotta get the decision right. And a little test there for me, sonny angiogram just when we get in the right place mentioned guys properly. Yeah, testing in. Okay, that's fine, that's fine. Yeah. The guy just needs to be in a touch. That's that. Still not there we go. Maybe forward. She's going forward a touch more. That's it. Yeah, like that. Yeah, I'm happy that that looks good. Up we go. So up to 10 initially we'll just get a look at this diameter 12 12. I don't need to go mad here, we can optimize that proximal segment nicely. This has gone up nicely down from 12. So can I have a 3.5 by 15 N. C. Balloon and the shortest 45 N. C. That we have please. Yeah, we're okay though. If you then what? eight plus 8 here, I can't just it looks nice but as expected the costume of the side branch looks disrupted and unhappy. We knew that was coming didn't we? From the office? If we just go back to the led free and open it we can work out something neat here. So there was our landing zone and then where's the settle? There's the settle. So if we now want to measure length we are gonna be just and then we go down to the city of room for an eight millimeter post annotation balloon here without committing. 3.5. This is 3.5.5. We have a stem based there please. Yes, you're just Just to # one on the switcher. You can see we're fine. I hope you got that. It's 12:14 actually a little bit and I'll come back. Okay. 1414. Save that. Please jump Go there. 1618. That worry of the guy dragging in 18 and just acquire that. Just so we can just demonstrate that the balloon is going up. There's still a touch of restriction in the end. It's pretty good inside. So remember we saw on the opposite side to the diagonal on the ibis that the fibrosis was on the opposite side and that's what we see now is just a little dent from that 12 round to five o'clock segment of fibrosis? I showed you earlier. The 45 now in the end if you keep pushing that you're just gonna push in the other direction. The balloon will just go towards the diagonal. You're not gonna modify that much. Now we've given it a wolverine to modify it at that point and so hopefully we'll end up with a nice area at the end. Okay, so we're now gonna do the pot. Have you got the prep syringe there? Please don't cheers. Practice. It might help you a little. Okay, john can we redo the stamp please, yep. Happy with that to see what the enhancement is. Let's go to 10 Yeah. 10. Just acquire that good and down. Good there. Yes please. Again, you just gotta watch these big balloons as you're bringing them out. They don't drag your guide in. So you're not just going back to cast out there while he was pulling cheers. She has some natural to see what that austin looks like. That's 200 nitro. Okay, have a fresh sign? Blue wire please. Okay, so now we've put the proximal stent on the wall, we can now rewire through into the diagonal and we can have a look. Nice little Hello from Yeah, everything. Yeah, so I think it would be useful now to reverse things. So what I'd like to know is I like to know that a proximal stent struts are up against the wall and there's no way of inadvertently wiring behind the proximal stent on the re cross if I've got any concerns about that lumen catheter down. But the iris can answer that question. I'll just give you that and I'll just again flush through, make sure there's no air in the system, make sure there's no blood from the prior run. Yeah. So can we switch to feed two rather than three? Feed two rather than three. Yeah. Nice one. Okay. Okay great. So let's go image on and we're pulling back so we're in the L. E. D. Now just flew up. Please sean just show everybody where we are and there's this thing coming in. Okay, stent looks nice at this point. You'd expect that A little bit of restriction there from six round to 9:00 but it's the area that matters. So we want an area over five or 90% of the distal reference. So we'll check that in a moment and then we're back proximal to the bifurcation. We're about there's the bifurcation with the septal and the inflow look nice. It looks fine. Okay, great, good. And I'm happy that we're up against the wall with no mala post stents cuts. So that's great touch on the small side there. So if I stop this so there's our distal reference and we'll just check the area. So our area is 8.3 so 90% of that's gonna be 7.4. So we want to ideally a minimum stent? Area 7.4 as we come back here, it's a little on the small side and there's that fiber optic restriction that now we're seeing. So 5.8. So we've met one of the ultimate criteria which is to get your minimum stent area over five. We don't have any exit problem. We don't have any inflow problem. But the stent is a little small at this point because of this arc of fibrosis that in this view runs from 3:00 right around 12:00. And at the moment it's 2.5 by 2.9 despite has taken a 35. So what we might need there is higher pressure, not bigger diameter. And when we kiss we can deal with that, we can do a step kiss. So we'll just rewire into the diagonal first and kiss that and see where we end up. But our distal reference is good, can I please? So this is to do a little bit more work in the L. A. D. Distal. If I can have a two point A two by 12 balloon, please just to open the struts uh no semi compliant almost. So we're not too worried about the exit of the stent. The exit extends find. So we don't have to run right up to that edge agreed. No dissection there. I'm just off the edge now. So we're gonna come back a little just come back off the edge and you're good to go to high pressure there. So we've got to be a bit cautious of candy wrapping which are 18. I mean that area looks good. So if it if it comes down now it's recoil recoil. So we're down to 18. So back across the verification and one of the reasons for taking the synergy was radio strength here. Uh we go up there 20 22, That looks great down from 22. Good. So when you're happy cross pretty easily cross easily optimist. The stent before we try and re cross and again, it's a synergy. Wide open, wide open cells across and down. So the agent is a paclitaxel balloon. Yeah, 62nd inflation. Just to release all of the uh well, most of the pact attacks, about 80% of it goes on the first inflation. Clearly, if we dissected here or we've got a very poor area and putting paclitaxel on, it is not going to save the vessel. So we want a good final area but we might get it. We've prepared the lesion reasonably well. So I know this isn't available to some people watching in the United States, you've got peripheral balloons but these drug eluting balloons are coming. They do give you an option to avoid some of the less positive outcomes associated with bifurcation stenting when you use distance. So up we go. So going up on the agent just give a 10, 10 I think it's gone up very well. It's not bad. Shall we see another view? Just come to Mario cranial cranial 12. Just step back for Us Leon Please. So you can actually see how it's deforming the LED stent. The importance of the final kiss. You can see the stent has come off the back wall. Absolutely and if we go to okay so we might get a good area if there's no recoil. But that's the question. So we're at 35 seconds now, 60 seconds. A long time in interventional cardiology. Nice view with the circle extent on the skyline. So I'll go back to the diagonal um area and I'll just work out 35-15 balloons. So our reference to the diagonal was 5.3. So we now want yeah, I'm just gonna bring it back now into the guide. You ready for a little picture there. Okay that's pretty good actually I'm pretty happy with that. We've got a lot of spasm in the disability agreed agreed. You can see how the led stent is deformed now. So kissing inflations and we might get away with just the D. B. Tuck that back in there. There's obviously a little bit of interaction between the balloons. That's okay. I'm happy to just have a little look just document where we are actually. We come back a little but we can do it twice. 22466 and 88 10 10. Pretty happy with. That's not bad. Okay, 321 down. So we're gonna report here because we've oversized the proximal stent. So rather than I've us and demonstrate that we're just going to repeat the pot. There is about as far as I'm happy to go. Just go there. Just go to 10. I think it's enough. Good. That's fine. And I don't know whether the audience can actually see the stem boost and the way the stents opened out nicely scaffolding for us, john back to the screen please feed to Okay, so there's our landing zone which looks beautiful and larger. Just flew in that just has defaulted there. What I'll do is I'll just create a bit more slang, put this back in and I will put this further forward or to it. And if we're ready to pull back. Okay, great. So there's our stent edge. We've got no dissections, stent looks massive at the distal edge and then as we come in here, it's a touch smaller. I think we expected that. I think we're clearly over five, but we'll measure in a minute. We'll come back to our bifurcation looks fantastic and then we're into proxy lady. There's no gross smell opposition. It's more than 50.3 millimeters. We would try and optimize, get that stand back on the wall. The inflow has no dissection. Let's just come all the way back to the left main. Just make sure that guide hasn't caused any mischief and then we'll check the diagonal side branch and when we do the diagonal run we'll just disengage the guide and just make sure we we're seeing the full length of left main back to their so there's left main now very healthy. And what I'll do is I'll also change the field of view for the left main when we come back from the diagonal so we can stop on this. But I'm pretty happy with that. Do you want to have a look at it? There was anything else you want to see but I thought that looked great. You want to go into the diagonal wire? I'll just give you a little flush and I'll just have a look at this. Okay, so first thing you're checking is what is the area of your distal landing song? So it looks a bit bigger than before. Now we've given it some welly and just try and get it right And so there's just a reference is up to nine now, so we're looking for 8.2, ideally. So first of all check for exit dissection, there's no exit dissection, there's the stent and it looks beautiful and then the smallest bit of the stent, we just got to visually assess that at the moment. Probably here. This is just in the limb. Uh just as the bifurcation is coming in and our minimum stent area was 9.6. That's excellent. So as we come further down, I'm really quite pleased with that. Probably about there. We have a little look there where it's a bit over there are software coming to automate this. But for now I think we'll live with that. Are you happy above the bifurcation that we've got no mail opposition. Yeah, I'll just go through that. So we're coming back through. There's our disability. You can see our diagonal coming in here. There's the stent scaffolding the austin of the diagonal. Remember we haven't put a stent in the diagonal and yet you can see struts in the Austrian and then as we come back approximately, it looks great. Very happy. So we're looking at the inflow, there's no evidence of dissection. Their stent is nicely expanded. Normal opposition. Everything looks great. So we're in diagonal now. And as we pull back, see our wire artifact there. It's looking nice. We've still got some heavy fiber optic plaque. There's a very small dissection there at the on the floor of the Austrian is the diagonal, but it looked definitely not more than three in length. And then we get another look. You want to disengage the guy just make sure we can see the Austrian and the left mains. Okay. And as we come back up, we're into rocks led. We're coming back towards the left main. Okay, so now we've got some measurements to do in that diagonal. And we just want to have a close look at that costume. It looked to me like there was a very small lip of dissection in the floor of the Austrian. You don't have to stand all dissections. So we've got so we've got a small dissection at the Austin as the diagonal. We've got an area of 4.4, Ideally it would be five or more uh 59% of our digital reference would be around 5.25.3. Can I give you those? Let's have a look and see what it looks like. It's disruptive. I think you can see the dissection at the Austrian but we've got timmy three flow. Yeah, I'm okay with this. So this is where drug eluting ballooning changes what we've done for many years. So when we started off with Pogba because they didn't have stents and then when stones came we probably went a bit far extended everything. And now the drug eluting balloons are back. We're accepting these small dissections. It did actually involve the media at the austin. It probably runs for about two rather than three. And So you know, there's probably a 1-2% chance of vessel closure with this but We've got Timmy three flow. Our area is 4.4. Yeah, I think the angiogram is completely consistent with the ibis with a dissection just at the Austrian. But I would let this, he'll bring it back in a few weeks time and have another angiogram is what it looks like. We can always completely then I think the chances of acute closure pretty small here. Um And I think the likelihood is that this will heal up and look better with time. And that's the thing is you're spending a lot of time to C. T. O. S. And leaving dissected vessels and we're always assuming they're gonna block but they hardly ever do. And similarly the drug eluting balloon experience. We have a colleague as you know in the United Kingdom who's doing 60 70% of his pc. I with drug eluting balloons alone and only using stents for potentially inclusive dissection. But I think here we've got a very nice result within the standard segment. We've got an acceptable result in any special pharmacology or not. Well he's post Emmy, so he's already aspirin and proceed gross. He's already on a potent anti platelet, which I think is the right thing. If I've been doing this in the elective setting, I would have given him a potent anti platelet to go home on rather than clopidogrel. I think you've also got to weigh this up against putting a stent into the cyber ranch where we know we've got fiber optic disease and we know we've got a stent that potentially may not fully expand. I think this is a reasonable place to stop. Just get another. Yeah, our Ukrainian face. I think it's worth just just demonstrating that the angiogram is just a two dimensional structure and again we see the dissection, good flow. I'm still happy. Okay, so any final comments on the kitchen? I think I this has changed the way that we've really approached this right from the start looking at this and geographically I kind of had my views. I thought we were going to end up with two stents. I think with this understanding the morphology of the plaque, picking our tools appropriately. So scoring balloons and then cutting balloons. How well the difference it looks like after it's been ballooned. A little bit of a dilator has taken this to a one stent strategy. So I this has completely changed our approach to the way that we are managing the bifurcation. We thought we came here to use us to optimize a lot. And actually we've used divers to change our strategy and I think this has moved in the way that we are um, undertaking procedures. Um, it's not just for stent sizing. If we use it, we look at it, we understand it, it will change our strategy mid case. And I think any comments for any less experienced operators, I mean here we've we've used to identify a dissection, we can see it on this, we can see it on angiography and we've left it, which for many people looking will be very uncomfortable indeed because they don't have that drug eluting balloon experience. We've had for five or six years. Um, any any tips and tricks on that. I mean it's it's a risk benefit isn't it? I think it is. I think it is and I think as you say I do a lot of C. T. O. C. T. O. You leave vessels looking really unhappy with lots of the sections flow tends to keep them open and with time vessels hell and putting a metal scaffolding that's there forever and we can come back another day. I think the likelihood is that I would bet that this artery will be fine. The flow so good. I really don't see acute occlusion here. Um Well maybe we'll be wrong but hopefully not. And I think down the line I would much rather leave a small dissection plane than put a stent in and come back another day. You can come back in six weeks, have another angiogram. We can re evaluate all of this and think about competing at that stage. I mean remember the last case we did where we competed a lot. 10 years down the line. Yeah we've got time. Yeah. Okay great. Well this is an interesting case and this is we've recorded this a few days before it goes out. So we'll update you at the end of this recording on how this chap's done and thanks very much for watching. We'll now do some questions live online and hear what you think, cheers. Thanks. Thanks everybody. Right so thanks for watching that video. I mean it's interesting. It's not what we expected at all. We expected to do a follow up procedure and do a two step strategy and then optimize the stents focusing on the Austrian side branch. But in fact there was pretty good response to basic ballooning. Once we've done a provisional crossover and once we've done drug eluting balloon side branch, we had initially a stent like result. And so we decided to change strategy and we're doing this a lot more. And what you'll find is that when you come back and look at that osteo diagonal, it'll have healed and it will exhibit positive remodeling and expansive cell properties and you'll probably find that the area is well above five. If you brought it back and reversed it, which we're going to do in about six weeks time. So the patient is absolutely fine. He's no problem at all. He went home and he's doing great. And you know, to stem verifications, there's some debate about whether the second stent can cause an increase in complexity, increasing complications or whether it can improve outcomes. Um, I think the trials are pretty mixed on that. But given that fiber optic Osti um, of the diagonal, it's likely that the second step would only have had an area of 3.5 4, no matter what we did to it. And so that second step would have been a high risk for having subsequent restenosis. So I think it was a reasonable strategy to do what we do. We're doing it more and more now. And this is something that needs a randomized trial to test, which is single staying crossover recross kiss. If you get a good result in side branch and kiss with a drug eluting balloon. And we're then seeing that in the longer term, the vessel actually gets bigger over time. I mean, this was the promise of scaffolds. This is what, by resolvable scaffolds were meant to do. It was meant to be that once the cage had disappeared, then you started to recover visa motion and get positive remodeling of the vessel subsequently in the area that's been and plastic. And we're finding that that's happening as well. Longer term follow up with uh, with the drug eluting balloons. So there's a question. Um, so yeah, there was a lot of note in this case. So I think what happened is the catheter was maybe a little bit king because it was coming out. Maybe we should have taken another catheter. That's the non uniform gestational distortion that showed about 10% of the ark was always a bit distorted. So you don't get nerd on a digital ibis, we will be using the digital lives for the next case properly. So you'll be able to see the difference. So that with the digital, you get 20 megahertz. So it's very good for the size of vessels we were operating on on this video today. Um it's less good in the really small vessels where the, you know, you saw the exit of the diagonal step there when you had a 2.7 millimeter vessel and crispy images one. But you you are at risk of nerd with a rotational device which you don't get with the digital device. So we'll show you that on the next case that we do and you'll be able to compare and contrast the two technologies and the strengths and weaknesses of each one. Um, in terms of optimal ivy's criteria for drug coated balloon, I try and get to the same as I would do for a stent. So greater than five millimeters squared for your smallest area. Then you've got a very small likelihood of subsequently going on to develop restenosis and needing target lesion revascularization in that segment. However, if I can't get it that big, I'm not so Draconian with the 90% of distal reference. And the reason is that because they are going to potentially go on and exhibit positive remodeling once you've completed the angioplasty without the cage of the stent. And I find that if I leave it at four when I bring it back after six months, it may actually be a bit bigger than that. And so I'll aim for the same thing greater than five millimeters squared as our smallest bit of the angioplasty area or more than 90% of the distal reference area. But if I'm slightly down like we were here here, we were about 4.4 and we'd like to have been 55.2. I would not be surprised at all if when we come back that flow and healing means that we have an Austrian there, that's around 555.2. So that's the advantage of not caging the vessel and that's the advantage of not converting to a two stent. Is that? Yes, you might get recoil but the drug is going to inhibit the restenosis in the way that largely a drug eluting statements. Not quite as good as some of the drug. Eluting stents at doing that. But the positive expanse, our action that takes place after you've used a drug eluting glue gives us a bit of hope that that this will get better all the time rather than worse. And we'll see, you know, we're going to bring him back and do a another underground menu in due course just to see how the early healing is taking place. And then we will update you on that probably two months down the line for those of you who are able to come back for some of the future ones. So we've got coming up, Iverson cto Iverson stem e Iverson severe calcium and Iverson recent losses. We've got a whole number of different types of case coming up. Um and I think it's useful, what we never see in live cases is operators actually doing the case, We tend to see very very rushed or very clipped cases where you don't see the workflow, how they're using the equipment, how much time in reality it doesn't. So we've just done a bifurcation stent with 89 ivers runs, we've done kissing inflation's re crossed and we finished the case there in under an hour and I think that that serves to emphasize that Yes, you had a potentially a little bit of time on with nine runs a virus but if you're not quite sure what the result is and you're leaving people with what we had originally which was an led stent with a minimum area of 5.5 and then we got it up to a minimum area of eight after Iris I think we've done that patient a favor, especially given that he was quite a young guy and it's the led. So if nobody else has got any questions and then what we'll do is we'll close this session. This will be edited down a little and put onto the Philips website along with all the other sessions in due course. So I hope you've enjoyed this. Thank you for coming on a on a friday which I realized for some parts of the world it's friday night, which is quite quite extraordinary. You're here on an I. V. Session on friday night and and I realize it's it's working day in the States and in europe. So thanks so much for your interest and keep an eye on my twitter feed, which is Doctor Andrew Sharp, and you'll be able to get advanced notice of when we're going to do the next session. Alright? Thanks everybody.
