In this program, Professor Sharp and Dr. Gallagher will review a case of an IVUS-guided PCI for a long, but relatively uncomplicated lesion. They will show the workflow and strategies for assessing the vessel before PCI, lesion preparation, stent positioning, sizing and optimization.
Thanks everybody. Welcome to cardiff. So we done to lecture based um sessions for you talking about the diagnostic aspect of virus in the first one and the second one was talking about the theory of stent optimization. So from now on in we go with recorded cases. So we've actually just recorded this case a couple of hours ago which was a pretty much ideal case as it turned out and I'm now going to show you it. Um So I'm going to share my screen now yep. Fantastic. Okay great. And I'm grateful to my colleague dr sean Gallagher who you'll see in a minute who's our director of cardiology? He does about 600 pcs a year himself which is the size of a moderate sized hospital, the volume that he does and we did it together and I'm very grateful to the patient and to the staff who allowed us to record this. These are my conflicts of interests which include being a consultant to phillips. Okay so just a reminder from the last session, what are we trying to do when we size and optimized stunts were trying to achieve the best minimum stent area that we can and in the ultimate study which was a randomized trial of all comers. So anyone who had P. C. I. 1448 of them were randomized to either receive p ci with angiography guidance or pc. I with IV's guidance. The goal was to get a minimum cross sectional area within the stent of either more than five or 90% or more of the digital reference lumen meaning that the healthy vessel just beyond where the stent lands. If it's eight millimeters squared, Your goal is to make sure the stent is no smaller than 90% of that value. Whatever that is. 7.2. You're also trying to find an area to start and stop your stent Where you have less than 50% blackbird, which might sound easy. But actually because of the way area works, a relatively thin crescent can produce 50% Blackbeard normal. And afterwards you're looking for hedge dissections when you do your final post stent optimization run with your office. So those are the goals of therapy and that's what we're going to show now. And why do we do that? Because what what ultimate showed is that if you just do and your guidance, you have about an 11% target vessel failure rate it three years. If you do have this guidance, it's about 6.5%. So about a 40% reduction in events. Which if it were a drug, I think we'd all be seen as medically negligent if we didn't use that drug If it had been demonstrated in a randomized trial to reduce events by 40 and yet we're not quite there yet with this. So I think part of that is we've got to get more people using it. Okay. So I've got a video here just on prepping the office and I'll talk over it while we start. So Uh they said we're going to use their affinity in this life case and it's a rotational device. It's a 45 MHz devices. Very low profile. It'll go very easily down to six french catheter and it goes over a while. It's very short monorail segment. So this is me receiving the device into the sterile sleeve and we want the sterile sleeve to run as far back as we can as long the length of sterile sleeve over the hub of the rotational ibis device to make sure that we can move this device up and down the table without the sterilizing it. Um We then start getting the hub of the device in shape so we take off the sticky thing. That over over lies the whole we put the whole of the device where we're going to put the IV's into back into the motorized sled and then we start prepping the iris device. So you can see here we've got a three way tap on an extension. So the three way tap goes onto the back of the extension And then we put a 10 mil syringe lulac which comes in the pack on one side as a filled syringe. And then we use our injector two mil syringe co actually with the piece of cable we fill the two mil syringe with the donors 10 mil syringe. And then with the two mil syringe. We flushed through. So we've got this prepped accordingly as we see here and that is going to then refill your prep syringe if you've used it already. But what we've got is a closed system now with a to nil strange having prepped all the way along that line. So all we've got is fluid now in that line, we got rid of air, air gets in the way of intravascular ultrasound. So we want rid of that. We then connect up. But before I do that I'm going to show you how we handle the sled. So you click onto manual and you bring the sled back. Now one really important thing is you have enough slack in the plastic bag that the hub can go all the way back. If you don't have enough slack then what happens is the motorized sled pulls back, It gets caught on the amount of plastic sleeves that you have and it will time out and say there's a machinery error but it's not a machinery era. It's just detecting resistance. So when you're prepping it, just make sure that in the cradle of the sled you have lots of slack in the plastic bag. Um My assistant here who has done one of our excellent scrub nurses, he starts flushing through and I can see that there's resistance. And I now realize why the reason is that the catheter sheath is forwards. And what you want to do when you're prepping is to have the ivy's back within the sheath. So there's about that much length outside of the sheath. And then when you flush with the two milk given a tap to make sure there's no air bubbles from the fill syringe, it becomes much easier to flush through. And then we get a good stream through you then re sheathed the ibis. So remember the rotational ibises within a plastic sheath and then there's a black dot which is on the base of the ivies catheter. And that goes in at the base of the arrow there. Which I'm going to show you in a second where my finger was. And then we rotate it round and it clicks in. Okay so that's the device now prepped. And it's taken me you know, two minutes um that you then slide the sheet within which the driver sits down into the cradle and you reset the length. And then you press image on and make sure that you're seeing something that looks like an inverse image of course you're outside of the body. So it won't look like a coronary artery. And after that you just put it over the wire put into the coronary and press pull back. So it's a pretty simple procedure to prep, as with all things simplicity comes from practice. Uh And it helps if you've got um if you're doing this on a regular basis so that you and your team are used to prepping the device. But you can see that that's real time. Although even I think it looks like I've sped it up artificially. I haven't that's what's doing it in real time. So I'm not gonna go into the case that we did today. So this is a 64 year old male. He's a type two diabetic and he's an HDTV driver. Um That's a heavy goods vehicle. That means they have to have very stringent health requirements including full revascularization. So if they have angina and coronary disease they have trouble getting their license in order to drive one of these vehicles until they've had revascularization have been proven to them passing ischemia test afterwards. He has angina onto anti angina so he has a conventional indication for Pc. I. But he also has this occupational reason that he wants to revascularization. And we're going to just come along here too five minutes where we'll start and then I'll keep my mouth shut and we will get on with watching the live case. So I'll just go to the start. Okay welcome to cardiff. I'm Andrew sharp. I'm one of the consultant cardiologists here and I'm here with Sean Gallagher, our director of interventional cardiology whose highest volume operator in cardiff and does a lot of our complex work. Hi Sean I'm here with Sarah at the table and we've got a skilled team here, we're going to hopefully explain to you how to use intravascular ultrasound. Um We've got an interesting case today. We've got a 64 year old chap who drives HTV a heavy goods vehicle Who has um Angina despite medical therapy on a background of type two diabetes and hypertension has been discussed at an M. D. T. By the referring team. And having had an angiogram showing some proximate led disease. And the team have come to a conclusion that he should have P. C. I. For that. We've now taken the setup shots. Uh So Rachel if you wouldn't mind just going through the angiogram here. So if you go forward for us Rachel. So sean you want to tell us what your setup shots are showing. So this is um A. R. E. O. Cranial looking at the led diagonal bifurcation. So I think what you can see here is quite significant disease after the diagonal bifurcation. That extends a reasonable distance. I think the real challenge in this case is where's normal. Where are we going to land our distal stent. And I suspect we're landing this in the mid to distal led where we'll find normal on either. And I think the important part of the history as you presented it was the diabetes. And I think if you're gonna stent over long length in a diabetic you have to achieve excellence and I don't think you can do that without either. So if we flick forward one further. So you see a long length of disease in the lady keep going forwards. I think the diagonal costume is spared. There's a wire in the diagnostic that you'll see in a moment that's really there to mark it and protect it. We're not planning to do anything. We're planning to send the lady isolation one further and you're seeing a pretty normal looking proximity lady. So I'm expecting to find the landing zone in approximately Lady. The one thing I look at with the angiogram is there's probably a little bit of calcium in this. We may be underestimating it, but I think this will have the answer. So strategy wise, I would start here with the divers looking for landing zones and to get an idea of plaque morphology. What are your thoughts? Andrew. Yeah, I agree. I mean it looks like the proximate reality is okay. Um and so hopefully we're not going to have to go back into the left main here. The distal landing zone is trickier so I'm not sure where that is. I mean you can see how the cranial view doesn't really appreciate the king king and the how in the mid led the vessel dives down frequently into the pericardium and then back out into the disability so that this the landing zone will be crucial here. This is a slightly longer lesion than I'd expected for this session in the ivies program. But it's an excellent case on the use of diverse and we'll get going. I think, yep agreed. Okay. So we'll start with upfront imaging. So this catheter is being prepped and I've just shown you how we prep the catheter already. So now we will get this. I understand. And that was some nitrates just to make sure we get a true representation of vessel diameters. So we're using the affinity catheter for this case. It's a 45 MHz Catheter. It's low profile and it's a motorized pull back so we can do length measurements. You can't call register with this. Um you can only do um cross sectional measurements where you are and co register by going onto the pedal on the underground at the time of the pullback, you need to use Eagle Eye for co registration but we'll come to your registration in later segments of this online series. Okay, great. So we're down at the distal septal, there may be a little further to go on. A touch more. Just take an angiogram. There was just a setup. So we know where we are. Okay, great. Okay, good. So we're going to turn the image on. We just got a little bit of artifact there. So we'll just sort that out and there we are. Okay, great. So we know where we are on the underground image. If you're doing a motorized pull back, you've got to register yourself. So we're gonna stay on the floor or during the pull back so we can work out where we are through and then we'll stop and sean and I will talk through what we find. Um It's this is set at half a millimeter a second. So it'll be quite a long pull back here. But we're probably looking at about you know, 30 40 seconds I think in the grand scheme of things for doing along approximately LED in a diabetic. You can afford that sort of detail and data. Okay, so what you're seeing at 12:00 there is the wire artifact. So if you're a single wire case, which we're not here, but we are where the catheter is within the led, you will always see a wire artifact with a rotational device with a solid state catheter like the eagle eye. You will not see that wire artifact unless you've got a second wire in place. So you can see a branch coming in there down at 5:60. And as we come up towards the proximity, the diagonal wire will come in eventually. It's actually a better vessel that they expected. Absolutely. So in real time you can always get an estimate. So there's more calcium there than I expected agreed. So that's the severe stenosis in between the 1st and 2nd. Septal. So we might need to prepare that You can see some nerd their non uniform rotational distortion at 3:00. That happens with rotational devices. It's just where the catheter is getting slightly restricted in its rotation within the ivory sheath ways to avoid that is to keep your roaring open, keep the catheter straight and avoid qingqing it during the prep. But sometimes it's unavoidable in a rotational device, you can post process it out. But um it isn't post process out with this software. And then we're coming back towards the diagonal now. So we're going to see a second wire coming any moment. Mm hmm. Yeah, we're seeing one. They're going towards 1:00. It's hidden by the Nerd. And then here's our proximity which was expected is a good landing zone. Pretty healthy looking vessel. We'll come back into left lane and maybe we've already crossed into left lane. We cross the left man. So and we see the water coming in there and then we're back in the garden. Okay, great. So let's take this out and we'll have a look at those images and decide what we're gonna do. I think this is very helpful there. I think actually the vessel is much better distantly than I expected and worse within the body of the lesions more calcium than I expected. So it's going to change the way we approach this completely or anything like that. So we have the interstate system here, which allows us to control it at the table side. So what I can do is drag the I this image back. Um And now if I drag down myself on the touch screen, we can see this pretty beyond where we're going to stand. We've got a very healthy architecture here. If I wanted to measure the disloyal lady, I can just do it with my finger on the touch pad and then you can correct any errors in the estimation of the computer. So it's 2.5 millimeters display, which I think we could have guessed from the angiogram. The more interesting thing is Sean and I were concerned about what happens in the middle lady. Now, there is a bit of disease here. So you can see here, we've got a 12 o'clock wire artifact going north and you can see how the wire causes drop out in a small arc at 12 o'clock on the image beyond the beyond the vessel here and here. Um Okay, so as we carry on coming back, we'll see that there's also a calcified area here. It's superficial calcium causing dropout behind it here to here. Now it's less than 90°. So this would be easily modifiable with a standard balloon. It's not really what we call a nodule. It's just calcified adenoma. It's not projecting out into the vessel. It's just this calcified plaque within which the superficial calcification causing dropout behind it in the areas that have marked there. Now we're coming more proximal and you can see this is certainly a bit of disease here. So we've got some fibrosis around here, but you can see behind it. So we're not getting much dropped out. So that's how we know the white material is fiber optic rather than calcified. We've again got our wire artifact coming up there. But on the whole we've seen a lot worse. We're coming back to here. There is the potential landings on there. So suddenly the vessel looks beautiful here. So let's imagine this was our landing zone. We haven't decided yet. We're going to select our media. So we're looking for the jet black circle inside the bright white advantage and it's huge at this point in the middle lady, it's 3.5. And I just wonder if that's that ecstatic segment shown in the middle of because it's palpably bigger on ivy's here than anywhere bit proximal to it and then we've got this. So I think it is that area. So this is the surprise. So what do you think? I mean, this is not what we expected to find? Well, I think we've got a tight lesion. There's a bit more calcium in this than I ever thought. But actually most of its internal calcification here in one quadrant, I think as you come further back, there's a bit more calcium. So we've got quite a lot of dropout, haven't we? So at this point here, so if I just show there this is a very good example of three quadrant calcifications. So we've got calcification from there And we see nothing around the arc from 2:00 all the way around To 10 o'clock now, we do get a little bit of penetration here. So it's quite thin calcium from 9:00 around to 11 because we are getting a little bit through into the advantage but we're losing a bit of resolution. The absolute calcification uh is more like that. So we're going from two o'clock around 29 o'clock. So we've got a two and a bit arcs of calcium at that point. And then we've got somethin fiber calcified disease from nine round 22 that's allowing some tissue penetration. So that's usually a signal that it will give with a balloon. So when you've got two arcs, what what's your thoughts Here? I mean I'm looking at this, I think this is going to go up with with a balloon. So I'm going to take a score flex balloon here and I've sized that to the distal vessel. So I've just asked for 3.5 scoring balloon and then we'll revive itself and see where we are. I think most of this is internal calcification. And I'm pretty hopeful that this will go up. And then in terms of sizing we've sized our distal references being 3.7 by 3.9 if I remember, well, a proximal to the lesion to get a signal that's right And we got three, it's a little oversized that. But it's about 3.5 there. So we're not going to go to extremely high pressure with this scoring balloon, But it's about 3.5 x four. And then as we come more approximately again, you've got this two quadrants of calcium. So here round two here. So from seven o'clock round to two o'clock, we've got complete dropout from official calcium. And then we've got a little bit of signal getting through on the other side. But that other sides fiber optic as well, it's a bright white signal. So that's going to be difficult to release. And that's another good candidate for a scoring balloon. So let's get going. Mm hmm. Yeah, I want. Mhm. Okay. So, so tell us about the score flexion. Uh for people who are watching, who don't use it. So, what we've got with the score flexes, we've got a semi compliant balloon with a very, very short monorail segment on the balloon. There is a scoring filament and the short monorail segment means that the wire sits outside the balloon. So, you have two areas, you have the filament outside the balloon and the wire where you achieve forced focused angioplasty. So the balloon is driving the wire into the wall of the vessel. Uh And we get more dilatation force there. So just going up on the balloon now And its approximate landing zones 4.1 x 4.8. Which fits with really a 45 will well, I'm not sure. We're quite far enough now. And I just want to see now, I just need to go on a little bit more just a little too far down the vessel. That's fine. That's fine. Just a 10. That's really nice. That would be lovely to see if that's cracked, wouldn't it? On the over. So should we do that? I think that's really good practice now when you're dealing with any kind of calcium ibis, I think when we started using it, was there too size stents. Look at morphology. But actually I use Ivers to guide every step of the procedure to do a lot less angiograms and a lot more either. Um Okay, great. So let's have that back. So I always just give it another little injection. Just tap make sure your bubbles are at the top. Whoops! That was unexpected. Okay, we're going to have to refill now if you don't mind, you got some coming out there. That's correct, correct. Thank you, cheers. Yeah, please please just follow me. Okay, mm hmm. On a touch more about there is where we're looking. Okay, so our images on. We're pretty distal there. We're quite as difficult as you think. We threw that ecstatic segment. What is alcoholic tactic? It's actually the normal vessel. That's where we are. Okay, great. So let's do the pull back. So this is the led after we've prepped it. You see there's still that small single lack of calcium there and there's that little aneurysm or segment that you see in the angiogram and then we come in pretty normal vessel. Just proximal to that. I'll bookmark that to measure. And then we're coming back into areas where we had quite tight almost napkin like disease albeit only two quadrants were calcium two quadrants of fibrosis. That looks pretty good. Now see how much more resolution we're getting out in the advantages and beyond because we've released all the segments that were obstructing the Ivies beam so the office is now able to get through and and beside the calcium because we've cracked it it's almost like there's nothing left no disease left. Well we have used drug eluting balloons before in this scenario a bit. There you go. You see there's a dissection down there at 12:00 at 6:00. And here we've got the prep segment you can see just how much more image we're getting from the full 360° view. And that's because we've created gaps in the calcium for the signal to get through. And then we're coming back towards proximal. It looks a completely different vessel which is the goal of prep. And then we're coming back drugs. LSD there's the two wires. A C. T. Is ready. You want to just get a C. T. Once we get this out Actually always it'll suck Aaron and then we're back into the left main. So in the interest of time will stop them. This has just got caught here. Okay just trying to untangle this. Thank you for a flush if you wouldn't mind. Can I have M. A. C. T. Syringe? Okay so I'll just have a look at this ibis from there there's our digital vessel again which had a single are calcium. Here is what we're calling an ecstatic segment but it's actually a healthy segment. And then we come back in and that was where we had that lesion. And you can see how much more we're seeing now it's nicely released. And then as we come back to this segment here which will be within the body of the stent. Ah Where at 3.25 there is an average and then as we come back this is a segment that's really had quite extensive preparation. There's maybe a bit of negative remodeling in this segment. uh so 3.25 again within this segment here and obviously we're gonna there is this debate by what you do within negative remodel segments of vessels. You know it used to be a bit bigger but now it's a little smaller than the distal reference. And so we're always a little cautious about how aggressive we are within negative remodeled segments And then it goes up to 3.5 in the body of the lesion more approximately. And then we're coming back here for our landing zone which should be 4.5 given that it was earlier and it's around that. Yeah. So what what in terms of length? What are you thinking? Yeah. So let's say we're starting here as our approximate reference and Our digital reference is about three the second round. We haven't gone far enough. That's how landing zone. That's about. Right. So, so, so yeah. 30. So our landing zone. Is there distantly? This is the ecstatic segment 3.5. Set his reference and then approximately. Uh, let's get rid of that. Um, Yeah, yeah. 3333. Okay. So we've got when we get our landing zones right, it's 36-38. So we'll take a three by 38 bearing in mind that within the body of the lesion, there's some negative remodeling. And the vessel is only 3.25 at that point, We could always make it three bigger. Exactly, exactly. And we're looking at four or five roughly an approximate vessel. And we can take this stamp platform 24548. So, I'm comfortable with it being three. I think if it was big approximately, I would do this in two stents and I would go through distantly 35 approximately and blow it up. I mean, this is a science, right? So it goes to 4.25 approximately on message. But you can make it bigger than that for kim. Okay, let's take that. Thank you. Mm hmm. Okay, just completely cordial for me please. So, I think this will go to that appearance of the Ecstatic segment one. So one of the difficulties, we have shown is how we popped the proximal segment because it's such a short segment of rocks led and we just Yeah, okay, good. We don't have to be true hostel. We've seen that. It's healthy. Cranial please. That whole segment of of proxy ladies healthy. So we don't have to land at the austin. Good. Just needs a millimeter forward. Do you think? I think actually, I think on the iris we were pretty sure that we have that area there where it was slightly ecstatic and actually had relatively normal vessel. A proximal. So I'm okay coming a touch more proximal. And the science is mid market, mid market. So we're looking at the distal mid marker. We've got that ecstatic segment. What's your what's your aim for the dis ledge of the stent relationship to that? But I think we're looking at the obvious. I'm not too worried about that topic segment because the office was telling us we had relatively normal vessel proximal to it. So I'm okay with that. I think it will look fine. Yes, there's going to be an ecstatic but there's nothing we can do about that. So okay, I'm happy there. So we're going to go up. Um going up And this is a three so we can afford to inflate. I would give it 18, 18. It's obviously with these semi compliance. 10 balloons they elongate. If we go too high. But It's good. You can actually see where it is there. That's 18. Can we have a 3-5 20 n. c. 3515 n. c. and then a 408. So I think it's reasonable to post delay on the basis of your previous. But you've always got to check afterwards. We might have to go back with bigger balloons because it could look different once we've released. Thank you sir and check your okay and we look fine as predicted. Yeah. Great. And then if we have a 3520 or 3515 something like that. And then a short for ideally in eight. So this is a long stand 48 38. So there's no question that um our digital reference is not the same, giving us the same information for the distal part of the stent is the proximate cause we're going across into a 4.254 point five millimeter vessel. So there's Yes please. Yeah. There's a couple of ways we can handle this. We can segment the stent into two and just treat them almost as two independent stents and try and get expansion more than 90% of the digital reference of each segment. Or we can segment it here which is slightly more logical into the two parts of the vessel. So you can see after the diagonal comes off the vessel steps down in size from about 4.5 down to 3.25 3.5. So we could segmented according to the proxy led reference where the diagonal comes off. So we'll have a look at that afterwards. I think that's really what we're doing now. Andrew aren't we? Were segmenting, distorted the diagonal into two. But then we're treating the vessel proximal to the diagonal separately. Good. Mm hmm. That's right. That's fine. Okay, it's 14. And we're just gonna go a bit harder. That 16 16 16 down from 16. Mhm. Okay. So what's your next plane? 3.5 3.5. Just distal to the clarification. Thank you. And there's your work. He said I would have thought it would have been longer than a 38. Just looking at the I agree. I agree. I said 48. Just because my brain was looking at the underground and thinking for longer. But well, it's not the syringe. I think it's interesting. But you know, I think we have this thought process that I've makes cases take longer. I think it's made it quicker. I think we have a thought process that makes us do more and actually it's making us do less. Indeed, we're happy with our landing zones. So up you go there 10 or 12 is probably 12 Down from 12. Now we're going to come back across the bifurcation. So you'll recall that in the distal severe lesion. We had negative remodeling in the vessel diameter was only 1616 down from 16. The media to media within the body of the severe section was only 3.25. Even though the distal landing zone was 3.5. So in those negative remodeled segments just be a little bit cautious about how far you push it. I released some data at the c. In 2009 showing that in cases that rupture after I've us they're more likely to be within remodeled segments like this negative remodel segments. In fact five out of the six where we found rupture after an office was in a negative remodeled segment. So remember our goal is to get an area of 90% or more of the distal reference. We don't have to get 100 or 100 and 10. Can we have the four? Oh please. So now we've got this challenge that it's a very short segment. So we want to avoid belittling the austin at the led where it's not centered but equally we got to be a little cautious about going beyond into the middle lady. Now the fact that there's a septal immediately after the diagonal gives us a bit of leeway because that confluence of a bifurcation is always more forgiving than smaller segment on its own forward. Again, thank you. Mhm. We had little test therefore. And do we want to checking coddle? Yeah. I think we should check in Kordell Kordell please. And then if you could kona mag on it. Just so we get a lot of resolution contract for us approximately. No you're you're good. Yeah so we're about to approximately. That's okay. Okay. I think we accept that it is what it is. That's fine. We're in the stand now going up so I'll be relatively cautious here. So hey, let me know how you want to go in 1212 And down and down. So down from 12 that's with the four. Okay. It's a little tough for me. Yeah lovely please. And then we'll revive us yep I'll give you that so you want some nitrate. This will make it look nice so you're happy. Your diagonals got timmy three flows so that's out. I mean it was a healthy costume so if we had if if this was a disease diagonal maybe we'd have this the diagonal as well. We saw on the flyby uh fine at the office so I was pretty comfortable and if we have the I. V. Catheter back now please. And that's the other thing about this is it can reduce contrast even if you're not trying to do a zero contrast procedure because you know why do you want to take four different views to see if there's a dissection at the exit when we're about to find out properly. If there's a problem at the exit. Yeah. Just a touch more so image on we're at half a millimeter second. Okay we've got nice landings on there. Do you just want to say that? Okay great so we're coming back now. There is a little bit of fiber optic disease. They're distantly but it's certainly not flow limiting. And then as we're coming back into this ledge of the stent, we're getting ready to press book mark So we can easily find, I will stand edge and just double check for any edge problems. But at the moment we've just got less than one arc of calcium and otherwise a pretty healthy looking vessel. There's that ecstatic segment that we aim to land our stent in and we've landed it perfectly. This is pretty well expanded. Maybe go a touch higher there. But we'll have to see what the area is before we decide on that. I'll look like that for luck later on. But all all in all it's looking okay so far. And of course when you start out with this, that's a little bit small less. So we might need to do something with that. So what we need is is that maybe the 3-5 at higher pressure, What do you think? three or 3-5 higher pressure. We'll measure it in a minute. 3- five. I'm happy with. So if you want to make an under expanding segment bigger, you don't need more diameter. You need more pressure. So, um, I've seen people reach for bigger balloons when they see an under expanded segment. What you need is bigger pressure and then we're coming back approximately. It's a little undercooked there. Only a little of the area is not bad. It's just a diagonal. And that was the septal and then the diagonal. And so here we are in the proximity there's a touch of opposition down there. 5:00 but nothing too bad. And then there's another little bit of 10:00 there. You can tell because you start to get this reverberation artifact behind the stent struts but all in all it's pretty good. It's pretty good. Landing zone is okay. So if we take the 3 to 5 back, can we have a 375 long N. C. And do we have a 456? Mhm. Mhm. And then a 4.5 x six please. So for putting that proximal stand on the wall, we don't need high pressure. We just need to in that case called more diameter because it's not an under expanded stent it in the sense that it's being restricted by the lesion. It's just that the balloon we've used isn't big enough to put the stent on the wall. Yes Please. So this is the 3.25 that we used earlier and we'll just use this just to try and inflate that small segment of under expansion there which I'll demonstrate in a second. Once we've got this down just go back a picture for me. Right. What? eight. Okay. We don't have a six anywhere. Yes please. Yeah. six would be better. So as I measure the area here, you can see it's not quite right there. Okay. So at the smallest bit of the stent, it was 2.5 x 2.9. So that's why we've taken the 3.25 back and we're going to higher pressure. What do you want now? 2022. So It's not that we need larger diameter. We've taken 3.25 above either of these measurements, it was 2.5 in one plane and 2.9 in the other. What we need is higher pressure to release it to the diameter of the balloon. So hopefully we've done that now, as mentioned, you do have to be a little cautious. 3.25 at 22 we'll go to about 3.43 point 45 millimeters. Which is a little beyond the media to media diameter. We measured at that point at the beginning. Now the digital reference will accommodate that. So hopefully this will and we have no choice. We've got to blow it up bigger because that that 5.9 area is not going to be 90% of the distal reference. Okay, that's lovely. Have we got the 375. Okay. Okay. Okay. So that is one of the And we want the 375 1st mm hmm, yep. Okay. Great turnout. Yeah. Okay forward. Thank you. I'm just going to get our landing zone area now. We've posted elated it. So our landing zone area, admittedly it's an ecstatic segment. So we've got to be a little skeptical of this Is here. And so the second rule from ultimate was get it more than five squared. So you can see here the vessel is eight with it within the standard segment distantly. And if I do another measurement within the stent so that this ledge of our stent is around, looks like I'm cheating there. But I am just a little bit underestimating their So 5.1 at the dis ledge of our stent. So we've met the second rule of ultimate for stent optimization has to be over five or 90% of the digital reference. So we are meeting that, yep, Just go over there, just go to 10 there, that's fine. And then let's have that 4.5. Mm hmm. Okay, then there's the 45. So we do have to be a little cautious here because the nose of this balloon is either going to be two proximal to the stent or it's going to be beyond the diagonal. But that's septal, that's, it's just beyond the diagonal. Will give us a bit of leeway here. I think that's a really important point. You've got a little bit more space than you think in the kind of confluence of the verification Alright, next for me. And so again, we want to avoid, I mean, although the austin melody was healthy balloon injury and relatively low pressure is not likely to do much harm. We want to stay within the body of the stent. We don't have a six millimeter length balloon in this diameter. So we've just got to make the best called judgment on whether we go slightly beyond the diagonal and accept that the septal is forgiving or whether we go a proximal to the stent risk polluting the led or we take a different so this is perfect. It's right back at the austin of the stent. We're not going to injure the proximal led before the stent And Sean is going to go to relatively low pressure 10. So I'm not sure our inflators know how to go. Only to 10. But in this case we are going to take quite a low pressure inflation and then you get the balloon into the catheter and just check you're okay. Just close your rings. Let's make sure we're okay. And we're okay. So I'll give you that. Okay, great. So I've us again and then hopefully we're done Mario cranial again. Please reach mm hmm. Mhm. A big plus for me him. Mhm Okay. That's a good flip through. So that tells you something, doesn't it? We got wide bias but we'll see. So I got the I was just got caught on the top edge of the stand in the way and it may just be that the why I was just up against the roof or it may be that there's a little bit of an opposition still at the roof so we'll see. So our exit is perfect and we've got a big extent I think we can appreciate that this is much better expanded and um we've got uniform expansion. It's a nice round stent because we've gone to higher pressures at the moment. I'm extremely pleased with this. There's that segment that didn't quite go up so we'll measure that in a minute. We need it more than five or more than 90%. So five is going to be our go to measure those are the parameters in ultimate. That showed a 40% event reduction with the routine you survivors here. It looks beautiful. Okay. And of course acute mala position is not a predictor of stent failure some very weak. Oh ct data, there's very little I I've this data, its expansion, that's the issue and we've got a very large, nicely expanded stent there and then we're coming back into proxy lady now And there was just to see at 5:00 there's just a little bit of Mala position there that might be where it got caught or not. But either way you can't make any, you can't make that much better and it's not a predicted extent failure or a problem. We're just coming back out, you know, there's just a little bit of something that again, Okay, I'll have a look at that in a minute but in terms of expansion we're looking pretty good apart from that one area where we took the 3.25-22. So we're gonna have a good look at that now. So I'll drag it to here. That's that's where it was. So it was Just about 5.1 And it's 7.3. So that was well worth taking that bigger balloon. There's one thing that caught my eye back in the proxy led. So as we came back, You know, you see the similar position at 9:00, but it's fine. It's very mild there as soon as I let go it. But this is no problem. This massive area. So we're looking always at our landing zones, make sure that there's not more than 50% plaque burden. So here's our distal landing zone Which is fine. There's not 50% black bird in there and then stink comes in. We look at the proximal edge, We're looking for black burden here and there's not 50% black bird in there. If I measured it, I'm sure I'll tell you. And then we're looking for dissections And there's no dissection there. What we're seeing up at the 10:00 is the minor Mala position I talked about. So I'll just draw that here right here. There's minor mala position. Now, the e a. P ci guidelines say if you've got more than 400 microns of Mala position, you might want to think about doing something to it, but Greater than .3 then um but in this case we're done, we just need to do an angiogram, make sure there's no wire mischief. But I'm pretty hopeful this is going to. So you can see, we've still got a little bit of eccentric plaque there. I think if we go to another view the please. Yeah. Mhm. Yeah. Just away from here. Touch definitely. Mhm. And so you can see there's a dictator, there's actually a tiny branch there. That's so the topic appearance is a block told small diagonal, isn't it? So that's the stump of the costume of diagonal. That makes it look like there's such an a tactic segment which explains why it looks so healthy at that apparently ecstatic segment, what we're seeing on the angiogram is the stump of the diagonal occlusion, which has been gone for a long time. Okay, Shawn, that's beautiful sum summing up from your point of view. I think it's a great step. But when I looked at the angiograms, I would have been looking to spend much further actually, we've kept our stent relatively short. Um I didn't expect to be quite as much calcium. It would have been very very easily very very easy to put a longer under expanded stent into this vessel that would lead to poor outcomes. So I think we've done the best job we can in a diabetic who is going to have a high step failure rates. We have to do the best job we can. And you see in this view how shortening the stent has made such a difference. We've avoided that kink where it goes down into the myocardial, it's a little hazy in the inter myocardial segment which we've seen with fiber optic disease on the ibis. So the chances this then lasting if it goes round that bend and into that much smaller segment or are lower. Um I think it's a great example. So how long have we been operating for? 35 minutes And we've done four IV's runs, whatever we've done. So this business of you've no time to do. I've, I think we've just demonstrated that that's not the case. Okay. Thanks everybody. We'll take questions once we stop this video. And this is the first of eight live cases that will do that will get progressively more complex. Thanks to everyone in the lab. Thanks everybody that we saw a lovely example. I think of a long lesion being um having the native vessel assessed. Um, we we then we thought we weren't gonna need anything sophisticated to prep the vessel. So we actually had an ordinary semi compliant balloon out on the trolley to five by 32 pre dilated. And when we saw in the previous that there was two arcs of calcium and on the opposite side was fiber optic material that we thought it might struggle to go up with an ordinary balloon. So we took a sculpting bloom and uh and released it with the blades of that with the with the wire of that. Um We then found our landing zone. And what was interesting is the landing zone look very healthy on the led ibis and yet the angiogram, it made it look like it was ecstatic and disease. And so we didn't really work that out until the end of the procedure as to why that was because there was insufficient flow down the led to see that this that there was a very small diagonal that had a chronic conclusion that we could now see backfilled up towards that stump. And so it was an act asia at all. It was a healthy segment with a little out patching from it that was representative of the stump of the cto of a two millimeter um third diagonal. Um we found our approximate landing zone. I think that would have been easy on an angio as well. I think I just didn't have that much there rather than give us the size which was 4.2-4.5 depending on where you cut it. Um we then uh once we had released it we checked that it was released and although sometimes even on high resolution ideas with 45 MHz and beyond sometimes it's difficult to actually see the cuts which you sometimes see with O. C. T. Um what you saw was a much greater field of view behind the vessel. And so we knew by seeing that that we'd created cracks in the calcified segments. Because we could see much more of the surrounding the vessel. And the only way that happens is if you crack the plates of the calcium, pushed it aside and then the Ivies beam can get through in between the cracks and you can see more of the peripheral field of view. Um We then took our stent. Now We are just a landing zone was 3.5-3.7 depending on where you measured it, approximate landing zone was 4.2-4.5. So ordinarily would have taken a 35 and we measured the length of 36. So we took a 38. So why did we take a three instead of a 3.5. It was because within the two tightest napkin segments, we measured the media at 3.2 at that point. And in 2009 when I was in Milan I looked at the database of about 40,000 cases and one of the whole points of using Iverson upfront is to make sure that you don't then rupture the vessel by taking balloons that are too big. And I found six ruptures. And of those 65 of them Had 3, 3 acts of calcium or more with negative remodeling. And what had happened was the operator its size, the balloons and the stents on the distal and proximate reference, which is what we tell you to do. But in the middle, in between that the vessel has shrunken down because it was heavily diseased with calcium and fibrosis. And so what happened was the rupture had occurred as we were trying to restore the old diameter of the vessel. Now remember that's incredibly rare that six cases out of 40,000. So that, you know, we're doing this all the time. If we look at an angiogram, what we're doing is we're visually estimating the reference approximately visual estimate. Honestly, we have no idea what's in between because it's diseased. Um So when we put stents in, we get away with this all the time. So so you shouldn't be terrified of negative remodel segments. But having seen that in two in two segments, we took a three, We were confident that it would go up to 4.25 from the engineers, which usually means it's 4.5 for the real world. And um we were able to use one single stent hostility with a 3.25 to 22 atmospheres Sicily, Which then sized the vessel for the distal landing zone at 3.5. And then we took 3.75 in the in the sort of middle proximal segment. And then we took a four, initially four millimeter balloon for the proximal edge. But actually it wasn't enough. We still had more opposition. And so we took a four or five you don't need high pressure in that situation need diameter for my opposition. You need high pressure for under expansion within a calcified segment. You need diameter from all opposition. And we just took a four or five up to relatively low pressure approximately in order to fully oppose the stent. Um and we'd used a provisional approach to the diagonal, which was healthy and it was fine. So we just removed that wire and didn't really cross. It was only a modest diagonal with excellent flow and non geographic Corinne will shift. So um that's a a relatively short lesion of 36 millimeters long. So the divers xbl trial showed that with a 28 millimeter or more long lesion. Ivers guidance can reduce the risk of events. And I'm hopeful that we've just demonstrated how that could be the case because we used exactly the right length of stent. We avoided excessive treatment of what, what what looks and geographically like a mid to disability that might be diseased. But actually it wasn't that bad. We've avoided going around a sharp bend in the led And we've got the biggest diameter of the stent that we can safely get. We were 5.1 when we thought we'd done enough. We? Re archivist so that we aren't big enough fixed it and we were above seven millimeters squared after that. So the chances of stem fairly drop off dramatically as your cross sectional area minimum gets above five. So I'm pretty hopeful for this chap. I think he's going to get a good result from that. Right. I wasn't able to read the chat while the video was on because he kept stopping the video. So sorry about that. I'll have a little look. So when a cutting balloon. So we did you we did use a scoring balloon, you know, cutting balloon, sculpting balloon. Um, so we would have been happy. I'd have been happy using any plaque modification technology there. Um, you could argue just take an NC balloon and blow it up. But you know, I think the key was we didn't just use a simple semi compliant balloon when we saw that there's two acts of calcium on one side and fiber optic disease on the other. We need something to modify it. Um, if there's any other questions, feel free to drop them in the chat. Thank you for the for the positive governments. And I'm sorry about the technical glitches. But we got there in the end, what I didn't tell you by the way, was that before that case we had uh, stem is in the morning. So we should have recorded that case about four or five hours earlier. And in fact, we finished it with about half an hour to spare because of the stem is and then as soon as we started the case, they called another step on the way and so we did that whole case with the stem me on the way. Um, so it wasn't, we were going a little bit quickly in the recording, but hopefully it was easy to follow. It's steamy day in south Wales. So, um, if the, if there's no more questions then what I'll do is I'll sign off given that we're a little bit over time already. Thank you very much for coming. Um, the next, we've got another seven of these sessions to come and will gradually build up a library. So I'd encourage you to, certainly with this one. Once we edited down and get rid of the glitches and then when you come back to the website, you'll be able to watch it once more and hopefully if you watch it a second time, you'll start to get into the rhythm of it and we'll gradually take you through how we handle all the different lesions here in cardiff over the course of this case series and once a month and will flag up when those dates are going to be in good time people on my twitter feed, if you want to know when the next one's going to be. All right. Thank you to everyone. Thanks to Philips for sponsoring and thanks to the organizers for, for getting us over the line. Uh, and um, I'll see you in about a month where we'll hopefully have another interesting case, Thanks everybody.