Dr. Jimmy Kerrigan, St. Thomas Heart Hospital Nashville, demonstrates his workflow for a bifurcation PCI in which he uses Philips IVUS and SynVision Co-registration to help plan and guide the stent treatment. He also takes into account the most recent stent optimization criteria from the landmark ULITMATE trial while imaging to optimize the stent and provide the most durable and successful outcome for his patient.
So this is a gentleman who came in as a stemming. So when it comes to mind to another facility, uh, they ballooned open led, which was the park related artery. And he was transferred because there was concern that he would need open heart surgery. Unfortunately, his ejection fraction his heart function was quite depressed After all of this, we did an MRI that showed that that part of his heart, where the heart attack was, had died during the heart attack and was now unlikely to recover. So instead of going to bypass surgery for his lady and diagonals and also to an obtuse marginal show you the angiogram, the decision was made to, uh, step the obtuse marginal. So the complete trial from late last year told us that within four weeks for patients who have an acute M I, uh, anything that is an geographically severe or physiologically significant should be fixed in order to improve mortality. So this was a patient in whom we treated for the complete trial, left the in populated artery the lady alone because it wasn't alive and then treated that obtuse marginal, which was ugly and ulcerated, and some totally included. So as usual, but a couple of old horse wires down, I thought that the and geographic stenosis was greater than 70% so I didn't perform physiology in this setting. It wouldn't have changed my management in this kind of a patient where I think that even if it's greater than 70% but the bar were to be normal, I would likely still treat especially knowing that this part of the heart is viable. So Eagle eyes down, distill the vessel. I have a workhorse wire in the age group to protect it, just in case, because I thought that the black would come back all the way to the osmium. So here on sink, as we pull back, there's not a great landing zone distantly, um, so which is common? And, as I said, only about half of patients in the clinical trial who had I was gonna PC. I were able to meet all of the criteria I think we did at this point. So starting this building is crawling through That's relatively decent. It's gonna end up being less than 50% Blackburn, but only just. And then as we move forward, there's some speculative calcium at 12 o'clock there some software black and now a relatively dense segment of calcium from 9 to 12 and then about 100 and 80 degrees on this side. So this is a case where I would definitely take high pressure balloon and make sure that it expands 100% prior to putting an extent. The last thing I want to do is put an extent, have a dog bone and then not have much to do with it. Other than high pressure, ballooning laser, whatever I have to do to get a good result approximately thought there was a good cup of the landing zone. You can see the workhorse wire in body of the sir complex coming back there. So I thought that I had a spot where I could blame and do so relatively successful. So approximately approximately, uh, my reference. So this is an area with 23% black garden and again percent sizing, approximately which I use for post dilation, not for picking the stent. It was a 3.8 millimeter luminous aluminum or excuse me, media the media reference. So take a quarter millimeter off of that 355 would be my target for post dilution approximately and then distill e. It's a bit bigger than I would have expected. On the angiogram, I found a spot with 24% 5 hard right At the very beginning of the run. This was a 315 vessels, so 2.9 would be the reference. So in this instance, I put in a 2.7 by 23 millimeter drug eluting stent with plans to post dilated approximately so that it matched so 22.2. So I gave myself 0.8 millimeters uh, error on either side just to challenge myself again. The less metal in the body likely, the better so put in the stent post dilated. Repeat the intravascular ultrasound. Don't pay any attention to the tip of the wire, which looks like it's horribly mangled. Um, and then here is my full background, so the distal stent edge is in a decent spot. I'm still getting hung up a little bit on the calcium there, then pulls back through. Let's see if I can go back and manipulate that video just a bit so distantly. Here's what I'm looking at is. Where's my distal spent edge? And how much of the Lumen doesn't fill up? Am I going to be leaving more than 50% residual plaque? And I thought I was relatively good, and I'll show you the measurements on that, then, as I'm pulling back on to make sure that extent is well expanded. Ideally circular. But sometimes you can't achieve that because of expensive calcification. So you'll see hastily. That spot where there was 180 degrees of calcium did provide a little bit of compression, but went through and found the smallest area on the stent Ensure that there was no dissection. Approximately fiscally, I didn't end up coming back into the main body of the Sir complex again, a couple of examples of, uh, trying to avoid stenting into the main vessel so as to improve outcomes. Bifurcation outcomes are a little bit worse than single sniffing. Try to avoid it when we can. So my m s A at this point was 6.1 square millimeter, so definitely greater than five. And as you can recall from before, it's still bigger than the fiscal reference looming. Before we began the procedure So then on angiogram Women a gram again. It looks good. Um, but that's really not what I'm here for at this point. I'm taking the angiogram to look for any complications and perforations that I'm not going to be able to see on this guidance. We do do zero contrast PC. I, uh and that's a risk that I council patients on that if I can't take this final shot, I may miss a preparation that might be clinically meaningful.