Produced in partnership with Arterisphere, this multimedia presentation from Dr. George Adams featuring Dr. Robert Mendes, utilizes case examples and recorded content to demonstrate practice tips on the utilization of IVUS to personalize care, vessel prep for in-stent restenosis with focal force balloons, laser atherectomy, and drug coated balloon therapy.
with that, I'd like to introduce Dr Adams and Dr Mendez, who are both joining us together there in in Raleigh, North Carolina. U N C. Rex Hospital, where Dr Adams is an international cardiologist. Dr. Mendez. Bastard surgeon. Um, and we're honored to have them and walk through this content and get their dialogue and their feedback. I think we're on said Thanks, Devon. It's a pleasure to be here tonight, and we look forward to going through the program. Um, absolutely. Once again, this is our I guess our third third, uh, talk here in the last few weeks. And, uh, we've learned a lot in the last few weeks, and so it's enjoyable to be here. And thank you guys so much for putting these things on. Yeah, thanks. Thanks, Kevin. Thanks to Phillips. Absolutely. Well, thank you. Well, without any further ado, we can go ahead and launch into the first video. So I guess we'll tell you before we hit play. So, you know, kind of just the quick outline. So there's gonna be a video on IBIs went on prepping the vessel, and we'll talk a little bit about, um prepping the vessel with focal force balloons, then into a threat to me, Um, and then finally with drug coated balloons or biologic. So, um, that's the plan for the evening and we'll get started, um, with the video. And, uh, we'll take questions from there. So now we put ourselves in a position to treat. So how do we personalize care to effectively treat a patient to give us the best outcome? The first thing we gotta recognizes that and geographically, that's a two dimensional view in a three dimensional world. So how do we get this three dimensional view? Intravascular ultrasound. So intravascular ultrasound is key in several ways. It helps us determine the plaque morphology. It helps us determine the size of the vessel. And thirdly, if we aren't exactly sure what's going on so say, If there was a complication, for example, we can put intravascular ultrasound in, and it gives us eyes inside the vessel so we can actually diagnose the issue. So when we talk about plant morphology again, it's on a spectrum. So on the left side of the spectrum, there's homogeneous plaque, and you can see this intravascular ultrasound. It's a soft type of plaque on The other end of the spectrum is this hard calcification plaque, As you can see here by intravascular ultrasound in the Middle East is heterogeneous plaque, which has speckle calcification, uh, debris, as you can see. And then, lastly, is this re cinematic plaque. It's almost like a rubbery type of plaque. They all give you different views by intravascular ultrasound and ultimately help us choose what type of device we're gonna use to effectively treat the plaque. The goal in treating different plant compositions If you If you remember homogeneous to calcification homogeneous, we try to decrease the risk of in July, increase the size of the Lumen and prevent this cheese grating because it's very soft. Plaque. As you can see by this symbolic protection device, there's a lot of debris that was shed distantly because of this soft plaque on the other end of the spectrum. The calcification. We try to reduce elastic recall. We tried to increase the size of the Lumen, prevent our section, reduce stent fracture and optimize stent opposition and expansion. We do this by effectively prepping the vessel, which will be the next section, but we got to pick the right tool depending on the plant. Morphology in the middle of heterogeneous plaque and much like calcification plaques. We want to reduce the last recall, increase the size of the Lumen prevent complications such as dissection. And if we have to put a scaffold that we have good at position expansion of the stent. So let's actually look at a video. Or actually, let's watch your case, uh, to see how intravascular ultrasound is utilized. Welcome to Rex Hospital. Um, it's a pleasure to have you here. My name is George Adamson with interventional cardiologist here. We have a wonderful case for you today we have a 70 year old gentleman with the history of hypertension, high cholesterol and coronary artery disease he comes to with with Claude Education, and it's a little bit atypical in the sense that the classification is his left buttocks. So the thought was when we saw him in clinic is this could be secondary to a iliac obstruction. So we got an abdominal ultrasound as well as bilateral lower. It should be duplexes. And what it showed us was is that there was a possible significant left iliac obstruction, which could be the culprit that's causing uh, this buttock pain. So our plan today is to do an abdominal aorta agreement runoff to further define his anatomy. And if there is an obstruction to hopefully treat it so let's get started. Right there. Right there. Uh, that's it. That's it. Alright. Still run off, see what we got. All right. So what we've seen by the angiogram is that their looks as if there may be a significant left common iliac artery stenosis. The rest of the vascular on the bilateral lower extremities look very good. There's no significant obstructions from the external iliac all the way to the Tibbles in the bilateral lower extremities. So this is the most likely culprit to his buttock paying. So what we've done is we're going to place a seven French short sheath and the left common femoral artery. We'll leave our omni flush in the right common femoral. Uh, actually leave it at the level to display water through the right common femoral such that we can visualize. Our plan is to use a run through wire, which is another one for wire places, level the aorta and inform intravascular ultrasound, especially. We can see exactly what's going on at the level of common iliac and to see exactly what the obstruction is. So as you can see, we've got the volcano Peripheral IV's that level of the distillery order. We're going to slowly pull it back. As you can see approximately, we have a significant obstruction. Yeah, it's about a 1234 five vessel at the common iliac. A significant heterogeneous type of plaque. Almost two lumens. Then it opens up into one limit, as you can see here. And this is the distal aspect of the reference vessel. Yeah, all right. That's good stuff. Is that Yeah. Yeah. Wow. So what we did is we selected a nine by 27 millimeter balloon expandable stent. And the reason we selected it was that the intravascular ultrasound showed us that the approximate vessel size was nine millimeters. So we place this at the level of left common iliac through the seven France. She's going through the left growing accurately placed it by being able to visualize from the right groin, having nominee flush at the level of the aorta. We inflated it to Max atmospheres, which was approximately 9.27 millimeters. As you can see post, uh, intervention or post stent placement for an interesting ultrasound. We've got great expansion in that position of the stent, with the great flow going through the iliac axe again. Uh, this is a great case with multiple learning points. The first is is the actual presentation the patient with buttock pain. Remember that the common iliac, uh, which provides buffalo to the internal iliac, which provides buffalo to the buttocks, can be compromised if there's an iliac, a common iliac obstruction. The FBI are the aortic ultrasound, Uh, with a B s and duplexes confirmed this and then an geographically, we were able to identify and correctly sized the vessel using intravascular ultrasound considering the leash, and almost went exactly to the bifurcation of the common iliac. At the level of this way water, we decided to use a balloon expandable set for accurate placement. Um, considering we knew exactly what size to select by Avis, there was no guessing. And we had a great sign geographic result. We're gonna reminder folks can type in Q and A um but I was like watching Doctor Mendoza Dr Adams kind of their their banter back and forth and I wonder what your any any comments or feedback as folks are chiming in with their questions. I think you know, I was just kind of chime in really quickly here. The you know, IBIs has become a very important tool for me and my arterial procedures. Probably about 56 years ago, I wasn't using ivascyn my arterial procedures whatsoever, um, started using, you know, using it a lot. And venus disease, but really didn't take to the arterial disease. And then probably about 34 years ago, I really started to use it. And then once I did, it became almost like a crutch. Because the value that I get from being able to see the lesion in its entirety without, you know, just not just one, you know, the two dimensional view of an angiogram. But rather than having to do multiple views of my lesion, uh, whether it be at zero and then, you know, direct AP, followed by R. A l and L. A. Oh, views. Now I just passed my IBIs, and I'm able to not only get a very accurate evaluation of the stenosis, but the true diameter of the vessel which is probably the most accurate way to measure the diameter of your vessel. And because of that, a lot of my therapies have changed my stencil a lot more accurate and sizing. Um, my balloon angioplasties are a lot more accurate to size, have fewer distractions, and I have much more success for my procedures. Um, and not only that, I think that a lot of the and this is my personal opinion in Georgia. I love to hear what you think, but, you know, stents do it really well. I think stents do a great job of treating lesions. Um, and I think that the stent quality that we have is quite high. And when you see a stent that can last in the S f A, for example, and shows Patton see rates of, you know, primary patents, you have 90% of one year. It makes you wonder if the reason why that's failing, you know, 56 or 7% of that 10 that's left on. You know, that failed. Was it because we covered the whole lesion or did we not? Did we miss something because we didn't use? I've It's none of those trials were done with Avis. All of them were done were just simple, straightforward angiograms. And I have a strange feeling that a lot of those failures in those trials were because we didn't fully cover the lesion because it was a posterior anterior plaque that was missed from the AP view. That's just my opinion. But tell me what you think. I think you're probably right. You know, you learn a lot by intravascular ultrasound. You know, a three dimensional image in a two dimensional world, right? So it's nice to not only use it up front so you can actually accurately pick your device. But as Bobby said to evaluate the work that you've done, you know, we commonly do it in the coronaries because we know how important it is to get a position, an expansion of a stent, especially in small vessels like the coronaries. But I think regardless of where you are in the vascular system, intravascular ultrasound offers the opportunity, um, to give you the best result. It also answers the unanswered right. There's a lot of times that we utilize this device to try to figure out why things happen, Um, or why we aren't getting the result that we were hoping to get. Um, and it actually uncovers things that we wouldn't have recognized, but just plain old angiography. So again, a very powerful tool. And again, just like Bobby, I I use it a lot as well. None that have come in yet. So I think we can We can roll into the to the next video. But what I do like on that one, I always noticing how quickly how quickly you were able to kind of use those blue little graphic fuels on IVs and just say, approximate your your looming. You're just like up there it is and just how quick that was. But the nice thing is that you don't even have to guess. I mean, you can write accurate, accurate. Yeah, All right, we'll go to the next video we'll take to and from there. So now we know the size of the vessel when we know the type of flag. Now we want to prep the vessel such that we get the best outcome using devices such as scoring devices or focal force balloons at threat to me or intravascular little trip. See help us to effectively prep the vessel. Prepping the vessel allows us to form control cracks in the plaque such that we don't get elastic recall. We don't get dissection and hopefully decrease the risk of embolization. Additionally, as we've stated before is that if we have to place the scaffold as well, we get good opposition of the stent and a good expansion of the stent. So now let's watch a video on prepping the vessel, prepping the vessel. There are multitude of devices to help us prep the vessel that would include balloon angioplasty, vocal force balloons, a threat to me. And then, with these devices, you always have to consider throwing back the throne back to me, especially in homogeneous flags as well as symbolic protection with homogeneous flags. So what is the thought process when trying to select the device for the anatomy of the patient? What I mean by that is personalization of care. So, understanding each one of these devices, how do we personalize care depending on the plant morphology in the location of the lesion? So we put together a simple diagram on the X axis we have above the knee and below the knee on the Y axis. We have the characteristic of the plaque. Homogeneous, heterogeneous calcification and rest in Arctic plaque. Remember that chronic total occlusion spanned several of these spectrums, including homogeneous, heterogeneous and calcification, so you can have a array of plant morphology is in one type of plaque lesions such as a chronic total occlusion saying that which device do we use in each one of these boxes? So for plain old balloon angioplasty and focal force balloons, the span, the entire graph so you can use each one of these in each one of these buckets. But when we're thinking about personalization of care with a threat to me and throw em back to me and symbolic protection, well, let's look at the first column Homo genius plaque above the knee. Okay, so what we would use in terms of a threat to me that would fit this is laser. A threat to me would be one, and the second would be the jet stream device. Specifically rotational affected me because it hasn't thrown back to me component. You could also use thrown back to me in this bucket because it's soft plaque that you're worried about sending downstream as well as possibly placing anabolic protection for the below the knee bucket. Again, we would use laser a threat to me as well as thrown back to me and possibly an anabolic protection, depending on how large the below the knee vessel was the second row to consider his recent Arctic Klag. Remember, this sometimes has some homogeneous plaque in it. The only FDA approved at threatening the device for recent audit flag is laser a threat to me both above and below the knee. Also, considering that it may have some homogeneous plaque from Beck to me is important both above and below the knee as well as possibly anabolic protection. The next row to consider is calcification lag in terms of a threat to me, device devices used above the knee with calcification plaque you would consider directional a threat to me with the calcium cutter laser, a threat to me with the turbo power and overall that threat to me below the knee. For a calcification plaque, you would consider again directional a threat to me with the calcium cutter and orbital a threat to me as well as rotational a threat to me with the road a bladder. The last row to consider is heterogeneous flag, and the majority of devices work in this type of plant morphology. So if we look at above the knee, we would consider for a threat to me directional a threat to me rotational a threat to me with the jet stream device Orbital atk right to me laser a threat to me as well as the Phoenix device which is in our committee Screw below the knee. We would consider again a multitude of isis which it would include directional, a threat to me laser a threat to me orbital that threat to me rotational a threat to me specifically with the rotor blade er and lastly, the Phoenix device, Which again is that our committee screw So in terms of personalization, of care for location of the lesion, whether it be above the near below the knee and characteristics of the plaque, there is some rhyme to the reason of how we pick certain devices, whether it be balloon angioplasty. The focal force balloons at threat to me, throwing back to me and symbolic protection in terms of providing the best outcome for each one of the patients, depending on where the lesion is located and the type of lesion that they have. So a ton of information there that you shared and broke down with that matrix of what device you would you would use Where, um so you know, as we're as we're getting questions to queue in here, Um, obviously, you know, a lot of it's going to be just your comfort level with some of those devices, especially that heterogeneous black. So you know your ability to to know exactly what how something's going to perform plays a big part until which which device you would choose at any given moment. I'm assuming I'm assuming the answer is yes, there had not aiming. Yeah, that's that's great. And I got a question. So, Bobby, in your opinion, how many after ectomy devices should you be an expert at? I mean I mean I mean, you're an expert at most of them, of course, but in turn, you know, for the general population, Yeah, but you know, for the general population that you know, do you do you need to be an expert, all of them, or do you need to be comfortable with a certain number. So I mean, I don't I don't know if that's, uh I don't know if I could give you an exact answer to that. Um, but I do like the ability to have access to a couple of tools. Two or three of those a threat to me devices where I feel comfortable using them. Where I, you know, you get Obviously, one tool is not going to take care of all those vessels from above the need to below the knee. Uh, you have to have a little bit inside of your toolbox to be able to deal with different lesions in different times. Um, but, you know, I think with two or three devices, you can get very proficient with them. And the more that you use them is, the better you get to use them, and the better you are at using them and your success goes up. So, um, I'm kind of cautious, you know, when I first started out a long time ago, any device that came out, I wanted to get to be professional at it, and I'd used a lot and, you know, I'd have four or five or six or seven of these things that were being used in different areas. And then I started recognizing that, you know, if I just focused and use two or three of them frequently, my outcomes improved. Um, so that's kind of what I did. I mean, so I love the laser for below the knee. I love it for below the knee. I love some of the orbital threat to me, whether it be the rotor blade er or the jet stream. Uh, and then last but not least, directionally correct me on occasion. Uh, works well for me. Uh, so those are the three primary that I use the laser, some type of an orbital, whether it be the phoenix, whether it be jet stream for the FAA and then, of course, direction. So I kind of choose between two and three devices on a routine day. How about you? Yeah, just like the way you you set it up, you know, so ultimately Bobby more or less was saying it was personalized. So the initial the first thing he brought up is breaking the anatomy up and above the knee and below the knee, because certainly a threat to me devices. There are options that work better, either above the knee and below the knee. And then the other thing he brought up was the type of plaque. So it is personalized in terms of if it's going to be a soft plaque or if it's gonna be a really hard plaque or if it's a recent Arctic plaque. For example, um, so understanding that first of all, um, the algorithm per se, that understanding where you are and what type of plaque you have is very important and then having a tool that can adequately treat that that type of plaque in that location. So I think Bob is probably right having uh, an ex being an expert at two or three at the rectory, devices that you can personalize your care to treat all plant morphology is wherever they are in the vascular system. I think it's important. And several attractions devices are good at treating, you know, different types of plaques in different locations. It's just that you need to be proficient at, you know, one device, say, uh so you can treat it and then you get get a similar result. But right and so you know the other thing? This this section was really titled up as vessel prepping. Um, do you use a threat to me for only for vessel prepping or do you use it actually to treat allegiance? So there's obviously two different types of concepts here. First thing is preparing your vessel to be able to handle a stent. So of course, you have these big, chunky, you know, huge boulders of calcium. Your stent is not going to sit nicely in that area. And you want to kind of break that up a little bit with some type of an A threat to me device that you're going to choose, Um, and then you're gonna break it down, and then you're gonna have your stent lay more against the wall, have better opposition and have less risk for thrombosis. We know that, right? So that is one where we're doing vessel prepping, uh, in order to be able to handle the stent. But do you ever use what I mean? What are the real reasons why you use attractive prepping is one, But what else is the other reasons that you might use it? Yeah, and the other, the other thing, just to mention what Bobby just said is, um is almost all at freshman devices are used with a junked it balloon. Angioplasty. So ultimately, when I say prepping the vessel, that could be for balloon angioplasty. It could be for a stent like Bobby was talking about. Or it could be, um, uh, drug eluting, Yes, some sort of drug on a device. I gotta be careful because some people are critical about using the word biologic, But, um, but any type of therapy that's located on a device, um, it helps you get it to the advent issue of the vessel, uh, to say so you can get the best, uh, mechanistic action and result from it. So we use these things. Obviously, when this is the most important thing to understand, the more you use, it is the more familiar you get with it, the more comfortable you are with it. And you're gonna start doing things that are that are, you know, not necessarily always run of the mill run of the mill. Yeah, that's the best way to say But other things that I think are well described, and it's in the literature is that, you know, for like, for example, under expanded stents you can actually use to laser in certain ways to expand the stent. Um, I'm trying to think what? And also treatment. I mean, so thrombin Arctic plaques. You're actually treating the vessels, not just prepping it. You're treating it by taking care of that soft plaque. So the other things I use for vessel prepping is not just a threat to me devices, but I also use the and a scalpel. And so you know, when our goal is just to simply re modify or have the plaque be, you know, uh, well modified to modify a plaque, there are several ways we could do it. Of course, a threat to me is one of the most common things that people think of. Um, and of course, it has its own building category. But then you you talk about, you know, different types of balloons such as an angio sculpt balloon. And I've used that frequently in the superficial femoral artery to remold and re modify to modify my plaque so that I can do either some type of drug dilution technology or some type of stent laying so that it doesn't have, you know, the It has the appropriate wall at position, and it's not just taking the shape of the plaque itself. Um, So there there are other ways, of course, to vessel prep. Not just with a threat to me devices. And are you covering that later in this, or did I steal? No. No, I think I think so. So folk force balloons are very important. Plano balloon angioplasty, a threat to me devices whole host devices to prep the vessel, per se. But we have a question. Um, we don't have this set up as a polling question. All that this would be a great polling question, and we can see if we can address during the next section. But, um, it says how what percent are using, um, ask direct me only for treatments, Document. As you know, you asked this question, but what percent are only using a threat to me for treatment? Are you not adding any further treatment such as A D c B or instead? So, um, do you see that? You know, do you do do it? You see it since we can't pull the audience, it is me in my in my case population. It is very unusual where I use a threat to me as a standalone therapy. I am frequently using it as George mentioned earlier as an adjunctive therapy where I am removing plaque modifying the plaque, um, or, you know, removing. You know, some of the heterogeneous thrombosis component that needs to come out. Otherwise it just I don't know, if you remember, is looking at that picture earlier on where that cheese grater kind of appearance when you actually get that disease coming through the stent just gets to be a problem. When you do the A threat to me or the laser before that, you really reduce that type of embolization material and you are safer with your therapy. So, um, for me, it is very rare that I use a threat to me as a standalone procedure. George. Yeah, I would agree. It's It's probably 2% of the time you may see me. May you just use that threat to me as a standalone. It's almost always with the junk to blend angioplasty with a scaffold or with some sort of anti aristocratic therapy. Now where I have done it, and I've been able to treated only without threat to me. Only is instance stenosis using a laser, Uh, and being able to use the turbo laser where I'm actually directing towards the lesion doing my IV's before doing my I've us after and realizing after I've done an appropriate and threatening with my laser that there was nothing left to do. Angioplasty balloon. And I did my subsequent angiogram and didn't see any significant stenosis confirmed with two different technologies, I've ascended with an angiogram. Um, sometimes you can avoid an angioplasty. So that's it. Once again, very small numbers less than for me. Less than 1% of them. Yeah, Another question that was just received before we move on. So in this last segment, you talked the last two segments, you talked a lot about the homogeneous plaque and the type of device that you would use and when you would use a symbolic protection device. But I wonder if you could give a more, like a specific example because they're asking while using a threat to me, you know, what are your recommendations of involved? Yeah, So I'll take this one so and this is what I always tell our European colleagues who don't have as much experience with that threat to me if you're concerned about it and you know how to put down an M Bolic protection device and put it down. Um, if you want me to give you some specific criteria, so if you're doing chronic total occlusion, I would consider it if you have calcification plaque that are the popcorn type lesion, the coral calcium per se. I put it down because typically it's on a stalk and you break it. It will roll down stream. The third is those lesions that are longer okay, depending on the links, the we typically say greater than 60 millimeters or six centimetres. Um, you would consider it. I typically go a little bit longer than that, but that would be a good number for the for the novice or someone just getting into a threat to me. I think one of the big one of the largest challenges is is not only do operators not understand or don't have as much experience using that threat to me, but they have even less experienced putting down in public protection. So you have to be proficient at placing symbolic protection. And typically I'll put down a free floating filter so I don't lose wire access rather than a fixed yeah, rather than a fixed filter. So I'll add two different scenarios that I think that it's very important to put an embargo symbolic protection to buy ice down. I think when you're now using an A threat to me device for the first few times, it is very wise to use anabolic protection device until you're familiar with the device and you're comfortable using it. Um, that's the first one. The second one is if I only have single vessel runoff. If I only have one tibial vessel that's open and I'm treating an s if a lesion, um, and I don't want to take that chance of losing that one runoff vessel, that's when I make sure to have an M Bolic protection device. And and Bobby, I think you mentioned something really, really sharp is you know people can throw data at you and say, You know, this never happens. You know that's not true. There's two words we know we don't use, and the one is never and one is always. And if someone starts saying Always endeavor to you, you need to turn your head the other way. So again, if you're concerned about it and you're trying to hedge your bets like Bobby said, for the safety of the patient and your concern, just put it down. Yeah, I'm just gonna say I always agree with George. He's never wrong. No. Yeah, you're not muted. While the video is playing, I can feel you like elbowing him under the table and, you know differences. Opinions already. Well, let's go into the next one. We've got a great case lined up over the next couple of videos. Um, big into George Adams Rex Hospital. Remember, Ante angiography is a two dimensional look at the vessel. It's actually a three dimensional world. To get this three dimensional aspect, you have to use imaging. It's some sort of imaging, whether the intravascular ultrasound O. C. T. For example, here we use intravascular ultrasound, and as you can see, typically most people would have said that the black it just maybe 50% max stenosis. Within the instant. As you can see here, it's at least 70% by intravascular ultrasound, saying that, um it's gonna be very important, especially when you're dealing with healing a wound. It's not just getting blood flow to the to the wound, but it's improving Profusion, pressure, uh, such that the wound will heal. We're going to do that in two ways. The first is we're going to address that osteo anterior tibial. The way we're going to address the osteo anterior tibial is more or less, um, with a scoring type of element or a focal force balloon. We're gonna use something called an Angie sculpt. This vessel approximately is about four millimeters. So we're going to use an Angie sculpt. This is a balloon that actually had wires. They cross over it. And the thought here is is that with this heterogeneous plaque, we can actually score the heterogeneous plaque such that two things happen. Number one, we don't get recall. And number two, we don't get a dissection. The second thing we're gonna do is we're going to focus on this incident. Restenosis. It's so important to prep the vessel, you can prep the vessel in one or two ways. One way is with balloon angioplasty. And remember, there was a gentleman by the name of Mullins, who was an engineer who worked on rubber and what he what he showed us was that you can affect rubber uh, the elasticity. A rubber into ways Number one. You can start low with pressure, some sort of pressure. Say it's a balloon and press against the rubber. You can start slow and slowly read this balloon up, uh, such that it becomes the rubber will become elastic such that it doesn't recoil or doesn't break. The second way is that if you get hold pressure on this rubber that you would want to hold it for a period of time because it will take the bonds of the rubber such that again. It doesn't rupture, and it doesn't recoil. The same thing is true for a vessel. So if we're focusing on prepping a vessel, um, for with a balloon, we do two things. Either we start low and work our way up, okay? Or use a focal force balloon, some sort of either cutter, some sort of wires around the blood in the river. There's several types of local force balloons. There's one called a basket track, which is a wire beside the balloon. Uh, that you can actually score the vessel with that wire number two the Angie scope, which had wires that wrapped the balloon. But again, when you go up with the balloon, it gives you this, uh, patterns such that you can form this focal force against these wires, uh, to cause concentrated breaks in the black number three, a cutting balloon which has four micro surgical blades on it so that when you go up with it, it actually scores the plaque, and then the last one is a chocolate balloon. Remember, this is more or less a cage or a stint on the outside of the balloon that's attached to it, that you go up with the balloon. You actually, uh, cause focal force against the plaque, ultimately causing the scores in the plaque such that it doesn't recoil. The second way, aside from balloons, uh, in terms of, uh, modifying plaque is with is with the threat to me. Remember, there are several types of a threat to me that we can use here for instant restenosis. There's only one athlete committee device that is approved for instant restenosis and a suspect. Genetic slaves are a threat to me. We will plan on prepping the vessel with laser hysterectomy using a 2.3, uh, fiber, um, to hopefully, our goal would be to remove any soft black and hopefully break the blondes and heterogeneous fact followed by balloon angioplasty. A plain old balloon, Uh, much like Molin showed with rubber and ultimately holding pressure on that balloon such that it doesn't recall and doesn't dissect after doing this since since there has he has shown us that he can reach the nose, we'll use biologic therapy or goal would be not to place another stint. So we would most likely focus on using a drug coated balloon. Once we've done this will go back into the different types of biologic technologies. So let's begin with the anterior tibial. All right, So, um, I need an engine scope. So this is an inches scope balloon again. Owned by spectrum attics. This is a four by 40 inches. Go balloon. I think you can appreciate the wires that actually, um, uh, surround this balloon that will be used as the focal force to affect this heterogeneous flag. I want to 50 rooms for two atmospheres. What? You wanna do is go nice and slow with these balloons, making sure it has the actual vessel has time to expand. Where? Four atmospheres. We have six atmospheres getting a nice expansion. Her headaches CRA Nano for Yeah, and I'm gonna let it sit on this, um, again using Bolan's Molins type of concept. We're gonna sit on this for two minutes. Hopefully getting a good expansion of what we'll see is is I'm at eight atmospheres. As you can see here over that two minute span, the atmosphere's will tend to want to go down as the vessel becomes more elastic. So my job is to keep it on eight atmospheres. We're gonna do it one more time. Going up? Yeah. We used to four about 40 inches. Sculptor. We've had an excellent results. We took the 90% anterior tibial cyanosis, and now it's less than 10%. We have strongly improve blood flow. This sort of where we had that for a balloon. It looks like there's a slight stenosis is most likely spasm to expect that to clean up by the end of the cast. Yeah, all right. We haven't received any questions yet. We do have that pole. If we wanted to ask the users how, What percentage of the time they're using a threat to me without further treatment, we can ask that. Okay. Yeah. So, um, while everybody's answering those questions, George, you made a very important statement during the process. When your angioplasty using a cutting balloon or scoring balloon or an Andrew sculpt or whatever chocolate doesn't matter what you're using. Um, you said that you and your plastic very slowly you inflate slowly. Um, what's the importance of that? Really? I mean, we're doing a slow inflation to be able to allow for the tears, the injuries. But what What is the whole concept behind that? So, ultimately what we're doing is we're causing control breaks in the flag, right? It's sort of like your your carport, right? Your your driveway. When you're coming in, you've got seems in the driveway and that concrete and the reason you have seems is just when it gets hot or cold, your concrete can expand and constrict without just breaking across the concrete. Very similar, um, ideology of why we're using focal forest balloons is that we get control breaks in this plaque And if you can think about it, you're going slow for a couple of reasons. Number one, you feel the pressure on your insightful later. Um, so you know that your your meeting contact and you want to go slow, so you just don't shatter the vessel. You just don't want to rip the vessel. Um, number one number two is is you give an opportunity for your focal force elements to work, right? So just as Mullins showed us, you know, as you go up slowly, you know, you start off small. Typically, you go up slowly and you let the bonds break on the on the plaque that you're addressing. It gives it time to work effectively because otherwise you know, and again Bobby, we're trying to do is two things. Number one prevent the spiral dissections. And number two, this recoil. So again, I think you go up slow, you feel the pressure, and then you slowly increase it right. And then you also said that you maintain your angioplasty year. You hold it at nominal pressure for about two minutes and I've heard different variations. I mean in the old days, and I should be careful about saying that because I mean, I used to do this way back when, But we used to blow the balloon up and hold it for 5 to 10 minutes, the angioplasty for 5 to 10 minutes because that reduced the risk of dissections. And it allowed time for the actual morphology of the plaque to re modify or to modify it. So I shouldn't say re modify. But to modify and to to kind of change. It's, uh, you know, it's it's dimension or path of physiologic display, or however you want to call it at that point. But you're trying to make sure that you're changing the the outcome of your plaque by actually holding it for an extended period of time to reduce the sections. And it's interesting you say that, you know, data supported. Look at the drug coated balloon trials. Right? Our balloon plain old balloon, angioplasty arm. They did the best that we've ever seen. It was unexpected. Why is that? Probably because Yeah, because you held it up for three minutes. You're comparing it to a drug coated balloon being held for three minutes. And so that again when we talk about, um the right way to do balloon angioplasty. That's probably the right way. Um, you know, there was an accidental finding, you know, Do you remember the cryo balloon a little while ago? Uh, so that trial balloon, they also had a trial where they were comparing the angioplasty, the cryo bloom, which was held up for a very short, per brief period of time. And they were complaining it an angioplasty. And in their trial, they actually found that when bloom was inflated for longer than two minutes, the risk of dissection was less than 7%. If it was less than two minutes, Sorry. Less than 30 seconds, 30 seconds or less, the dissection rate was around 43%. So I mean, even way back when. And it wasn't designed to determine about the sections with with with plain old balloons. But we break agonized even then that the longer you inflate, your balloon is less the section rates that you have, So it's very important. Yeah, I got one question, uh, patient enough to be able to do that. That's the next question. Yeah, that is actually one of the questions that we got so obviously longer is better. Um, but how long? I mean slower. So you mentioned that as well. So, you know, slow and gradual. But then how long? It depends on who you ask. If you ask the Europeans, they'll say two minutes. If you ask someone, like renew Vermont and you're looking at delivery of a agent, you know, like paclitaxel. For example, the longer you leave the balloon up, the more drug you get delivered to the Advent. Isha. So she recommends at least three minutes, so I think it depends on what you're trying to accomplish. Um, I think what Bobby's point was is at least 30 seconds. I think if you stayed up two minutes, it helps with that recall. It helps with tacking up those dissections. Um, but if you're delivering a biologic agent, Alright. Delivering an agent to the Edmund. Tisha, Um, you may want to leave it up longer. So how long do you do? Three minutes. You have three minutes on a plain old balloon. No, no, no, no. Not playing a balloon with a drug coated balloon. How about a plain old blue 1.5 to 2 minutes? Okay, so I'm three minutes for all my balloon angioplasty. Um, I just figured it's easier just to standardize my practice and just to kind of do everything like that. And I've gotten some good results with that. So I haven't gone back since those trials. Great. Thank you. That should give. That should give a clear answer to that question. There was a question to that. It was more just of a comment while you guys were speaking that it's the concept of plastic deformation. It was a question. Kind of a question. Comment, plastic deformation. I don't know. Fantastic. Mm. I don't know. Sorry. They're probably smarter than me. You ever asked that question? What does that word mean? Yeah, I felt like I'm talking about fifth grader. I'm sorry we took that ball, but I think, honestly, we bias the results before we even got it back by saying that, uh, that you both you polluted or you are extend a drug drug could have alone after after actively so and 0 to 10% where all the responses. So we'll move on into the next video, which is a continuation. I believe it's the same great good understanding that laser at threat to me. Can you be used above the knee and below the knee as well as in all plaque, More apologies, homogeneous, heterogeneous calcification and re cinematic plaque. Let's actually watch a video on how its utilized. We always open up the the outflow before the inflows such that if the inflow has any degrees, that goes, uh, downward that the outflow can take care of it. So we've opened up the outflow. Now we're gonna open up or focus on the inflow. Our strategy here is to use to 2.3 laser, uh, in this appear, self expanding stent that has instant restenosis, which starts behind the eight Dr Canal and extends down into the P two segment of the population. So let's begin. So what I have in my hand is a new 2.3 turbo power laser. The nice thing about this laser is that number one is directional. As you can see by the handle, I can actually turn the catheter as you can see, and it rotates 360 degrees, depending on how you turn it. The second thing is that the fibers on the Inter actually s centric it gives more penetrating, uh, forces photochemical This photo mechanical ablation that occurs with laser at threat to me is more efficient using this 2.3, in fact, especially in the superficial femoral artery. Anecdotally, I've been able to penetrate calcium using this 2.3 fiber. So to begin with, we're going to calibrate the 2.35 and the way we do this is we hold it in the front, we press calibrate Can we hold it for a period of time? And now it's this calibration. Okay, as you can see and we're ready to go before we start, I want to do a little experiment. Now regarding this, we have to, uh, bowls. One is filled with normal saline and the other is filled with contrast. Now, as you can see, when we go in with this 2.35 or my technician does two things and when they hold the wire and then they slowly inject saline. Now, we always flush the catheter before going in with laser attracted me. The reason we do that is this as you can see that again, this is the saline, all right. And I have it in this 2.3, Uh, this laser in the sailing and this is what happens. It's like there's no heat, just general light. Now, if there was die in the system, our contrast and that's what we have here. Okay? This is what would happen if there was contrast. It's more or less a jackhammer type of that now. We never say always are never in the field of medicine, but in terms of this is strongly recommended that you try to clear your catheter with saline. Uh, such as the contrast is clear such that this jackhammer effect doesn't happen. All right, so now we've done this, We're going to clean our catheter, and we're gonna go in with this 2.3 catheter and perform laser hysterectomy of this sf instant restenosis. All right, so we've got the 2.3 laser fiber at approximately aspect of this disappearance. Uh, appearance, self expanding stent. As you can see here, um, Dr Ganesh has his hand on the manifold. Just slowly inject sailing as well as holding the wire. I'm gonna hold the catheter in my left hand. Is I slowly advanced. And then in my right hand. I'm gonna control the motion. The secret to laser that needs to go slow. Let the laser photo chemically in the photo. Mechanically. Oblate this instant Restenosis. We've got the laser said at 50 40 that's a 50 fluency in a rate of 40. Uh, and we'll go slow. Yeah. As I go through the plaque, I'm slowly rotating back and forth. That said I can get the entire length of the stem. Are the tire diameter nice And Floyd, you can see the catheter moving. You see the wire moving under it. It's another one for a wire. As I go through this thing, I'm going back. He's gonna flush the catheter with this sailing, right? Okay. We're gonna go to 60 60 a 60 year rate and a 60 influence. As you can hear, it's a higher pit and again the same manner going nice and slow rotating the Lezin that began to slowly injecting sailing as he holds the wire. Alright, Samba. We're done with laser threat to me. Once we get out with the laser, we're gonna get some nitro glycerin and then take an and geographic view Will also perform intravascular ultrasound So you get a good inside. Look exactly what the laser has done. So, post angiography. As you can see, we've got a very nice result in terms of laser effectively used in the 2.35 Now, we're gonna do intravascular ultrasound and actually see from a three dimensional view what has actually occurred with inside the vessel. So, as you can see, we place the volcano Purple Vascular IV's catheter back in distillate. As you can see, the plaque has been disrupted. It almost looks as if they're small dissections through this plaque again modifying the plaque such that we can go in with balloon angioplasty host and then hopefully deliver a biologic. Yeah, very nice limit is definitely bigger. Host laser effectiveness. Mhm. Mhm. Yeah. Those 2 80% stenosis aren't as a payment. Okay, we're outside the stent. You can stop. So, Dr Adams, question for you. Um, with the laser settings, I know that you presented, um, it link in in 2020. Um, you know, early results of a pilot study that you started looking at. You know how to guide your settings for influence and rate based off the type of plant morphology. I wonder if you could kind of give a little overview of that information that you presented. So actually, Bobby and I were just discussing that, um, you know, if you query Devon, um, interventionists are into vascular specialists across the country and even across the world. They use laser a threat to me and asked him what settings? In terms of fluency and rate do you use? You get a host of different answers, Um, and not to say ones right or one is wrong. It's just there's never been guidance, um, to tell us what works best. Um, in the past, the reason I I started with 50 40 and 60 60. The reason why is because the Japanese used and they had the most experience in the coronary arteries. So I figured they knew what they were doing. Um, and I'd say they didn't. It's just that there was nothing proven. So that set the premise for a study that we actually, uh, evaluated a low setting, a medium setting and a high setting to see the effect on Luminal gain in different types of plaque mythologies. And what we found was is there there was, You know, when you were dealing with account specific plaque, Uh, say compared to a homogeneous plaque, um, you would you They were different. So for a homogeneous, for example, you'd start with a low setting, right? Um, you say low setting, low influence or low rate, um, low influence. And then, um, a low. Both of both of those. So we went 40 60 60 60 60 80. It's what we did in terms of fluency and rate, um, and stepped it up, and we saw what we did is we did intravascular ultrasound before delivering therapy, classified the lesion. And then what we did is we deliver therapy at a low setting did into fast ultrasound afterward. We did a medium setting, did in fast ultrasound afterward and then did a high setting did in fast ultrasound such that you could tell what happened to liminal gain after each therapy. And you knew what type of plaque you were dealing with. And we used a core lab, um, to to classify the plaques and the actual looming gain that was attained. Um, and what we saw was there are a couple of things you could group them um, depending on low, medium and high. Um, and in the two that went together, I'm remembering was specific and, um hetero, actually, cal specific and rest in attic. And then the heterogeneous and the soft went together in terms of Luminal gain. But I'm not going to go too far in the details because we're putting the data together, finishing it so we can publish it. Um, but we were definitely seeing differences in the, uh, type the the level of fluency and rate on different plant morphology. So it supports the idea that it is personalized, right? And so after I read that paper, when you bring it out, we're going to have a much better idea of, well, influence And what rate to set our machine, too, when we're dealing with certain lesions. Yep. And my hope is is that in the future and the other the other reason for doing a study like this, You know, you can pick all types of numbers for fluency and rate, right. Um and you know, when you think about fluency and raise the size of the bubble and the reverberation that the laser gives simplistically, So if you could just have a low, medium and high setting without thinking of fluency and rate. I think it just makes it easier across the board. Um, and there's several thoughts devices that have it. Not only doing that, but you're also going to have to tell you I have to tell us why in the paper why using? Why not just go big every single time? I mean, they're obviously going to be some downsides to going high when you didn't need to use it. Um or is there I mean, so that's that's some of the questions and some of the answers I'm looking forward to seeing in your paper. So the other the other thing that I'm gonna, um, kind of bring forward here is, um I hope I don't Oh, yes, plastic deformation. We had a chance to kind of look that help when when the little break occurred there for us. Um, so it's definitely a physics term that was done to determine that you're actually changing the solid shape of something. In other words, you have a solid entity, and you're going to change the shape of it to permanently change the shape. And I don't know if we can truly classify what we're doing inside of the artery as plastic deformations. That's probably why we've never at least that I know of never used that term when we're dealing with angioplasty of a vessel. Main reason is because it's usually not a permanent deformation that's occurring. Um, there's gonna be some elastic recoil. There is some elastic recoil, no matter what type of balloon we're using or how much pressure we're putting it within the balloon. It's not like we're blowing a balloon up inside of clay. It doesn't just take the shape of the blue, and when we let it down, it's just going to stay like that. Uh, there's still the chance and the opportunity for D sections for flaps to occur, Uh, for perforations to occur. All of these kind of things this physiology, the changes in that physiology is what prevents us from having a true plastic deformation of the vessel. Although that's our goal. We definitely are striving towards that, but it's just never really truly attained, and I should never use the word never. Yeah, but you're always right. That that's right. Right? Okay, so one question and then we can move into our final chapter here, since I know we're pushing our our time jump up on you. Um, but we got a question on distal embolization with laser being less than other at the rectory devices. So, um, but I guess you know if we're not to compared to heavily head to head. But I guess if you could speak to just distal embolization, um, of laser, in your experience, I'll take some of that. I think the the laser catheter in the hands of a beginner versus any other atthe wrecked me device in the hands of a beginner. I think the laser a threat to me has a lower risk of embolization across the board. You take somebody who's highly experienced, you can get them to wear very few organizations occur with any device that they're using. Um, but I think that if you take the expert at laser and an expert at any other device, I think the head to head laser has less embolization, uh, documented or case reports, uh, than any other type of a threat to me device that it's out there. I guess that's the best way to say it. What do you think? Yeah, the thing is, is that any device can cause imbalance. Right? So, um, whether it be laser and I've had it happen with me with laser, I've had it happen with any threat to me. Device. You push things too fast. You're too aggressive too early on and you have a chance for mobilisation. I don't care what tool you're using, but you can use a balloon, right? He's a liar. I mean, you can use anything and cause embolization the question I think it's more important is, is how do you hedge your bets and say, You know what? I think we're pretty confident we're going to get away without throwing emboli using laser a threat to me in this case. But, uh, on the other hand, this is a long lesion that's got a lot of soft plaque in there. Regardless of what I use, There's a strong chance something's gonna go downstream, and I'm gonna use it. So do I put filters down with the laser? Yes. Um, I never say never. If I have a person that's got one vessel runoff critical m ischemia. Um, I'm not gonna I'm not gonna bet. Yeah, Why take a chance? Absolutely. Well, thank you. Well, let's go into our our last video here, Um, with our the drug coated balloons that neo prohibitive, um, technology, which I know you've. You've done a lot of research and and and talks into, So, uh, we'll start that and we'll have some more questions. The Achilles heel of profitable disease intervention has been restenosis. Now let's discuss biological therapies. So once we prep the vessel, how do you deliver biologic therapy to the advent? Isha? So there's a couple of devices that warrant mentioning The first is a drug coated balloons. The second is drug eluting stents. The third is bathing the vessel, uh, with drug by having two balloons on either side, including flow and the last is direct drug delivery specifically through the bullfrog indicator device. So let's take drug coated balloons. Currently, in the United States, you have three approved drug coated balloons. The first is the guard Lou Tonics balloon. The second is the Medtronic impact balloon, and the third is spectrum ethics slash Philips Stellar X balloon. Now, in terms of drug coated balloons, what are the components? The first is the balloon. The second is the exit viant and the third is the anti near proliferated. Now the importance of the X IPI intent is to help carry the biologic. The anti near proliferated. I've to the vessel all once it gets to the vessel wall, then the drug or the anti near proliferated. And typically on these three drug coated balloons, they are all paclitaxel. It helps them attached to the vessel wall and then hopefully go through the intimacy through the media to the Advent issue to prevent some muscle cell proliferation. Okay, the second group of devices is the drug eluting stent. The first is the silver PT X. The second is the Boston Alu via drug eluting stent. The two components of drug eluting stents include for those over P t X, the actual stent and the actual anti near proliferated. I've the second drug looting, said the Alu Via has three components. It actually has the stent scaffold. It has an exit viant, and it has the anti media, anti near proliferated paclitaxel. The exit viant helps the drugs stay in the vessel for a longer period of time. The third way to deliver biologic to the vessel is through, Uh, two balloons that actually include float is the tapas balloon. And you actually watch the vessel in between with an anti media proliferated, such as paclitaxel. Mm. The fourth way to deliver drug is through direct drug delivery. This is through the Mercator device, which is a micro needle between two balloons, such that when you blow the balloon up, the micro needle pops out and goes into the advent issue such that you can give direct biologic therapy. Currently being studied is decks and methadone. In the future, alignments drug will be used, followed by a combination of the two, followed by stem cells. So these are the four ways to deliver drug currently to the vessel wall to prevent restenosis or neo internal proliferation. Have any questions on on D. C. B. S are on troubleshooting troubleshooting technology and again chime in. But, um, we're a few minutes over where we said we would end. So, um, but I'd like to get your you know, any comments, um, to that segment, Um, if we have a need to add Yeah, I've got a question for Bobby, actually. Um, Bobby, in your opinion, when you look at these, um, technologies, these anti neo prolific of agents that Devon was just mentioning. What do you where do you see the future? I mean, do you think it's what Dakota balloons? You think it's with some sort of scaffold? I mean, what what does the future give us? Can you give us any insight? I mean, what do you think? You know, uh, money plays a large role in all of this. Unfortunately, you know, um, a great example. And I and I'm not trying to to detour your question, but drug eluting technology, um, put us, I mean tremendous environment for endovascular care. And over the course of the last four years, 34 years, we've been enjoying success with endovascular procedures that we have not had not been able to obtain for the years before that. And and that allowed us to now start doing more and more minimally invasive procedures. And all of a sudden, somebody comes out with a study saying that this drug eluting technology is actually killing people potentially. Um, and then the whole world goes on halt. And you know, the hardest part about that was the frustration behind now trying to take care of patients, knowing that you can provide the kind of care that you know that they can potentially have. And it really set back our endovascular, our corporal, interventional world by year's by doing that and, you know, everybody thinks so. You just start right back up and you keep going. But it doesn't work like that. Um, I think that it would be ideal to be able to have in this mythical world. And I think that people are getting closer and closer to it is to have some sort of, uh, stent. That itself has some sort of a drug eluting technology that's placed into the artery and over time will buy Absorb, uh, and that type of technology is very fascinating, because that is probably as close as we're gonna get to plastic deformation where you actually are able to put a scaffolding in place. That's going to be a structure that's going to hold the vessel to its shape for a month, two months, three months at a time. Allowing for the drug to get in, to allow for the actual molecules, to change their confirmation, to be able to maintain aluminum. Um, I think that that is some type of a thing that's going to be available to us in the future. Um, but I don't think it's gonna be a standalone procedure. I think there's going to be vessel prepping. That's gonna be very necessary. That's why I still believe today it's very important to understand how to and and how to safely deliver and a threat to me device and to perform vessel prepping in the appropriate way. But I do believe that that's the type of technology we're moving to. And that's the next wave that I think we're gonna see. Yeah, great, great, great response. So I think it's an exciting time. Um, granted, even with Cassano's, his papers that Bobby had alluded to in terms of, um, the Taxol is causing an increased mortality and the signals he showed, you know, its debate on on the realism behind it. Um, but I think what it's done is it's made us more aware our data is more clean. Um, it's also made us pivot. You know, I think there's gonna be other agents that are gonna be coming to the market, one of which is Sarah LIMAs, which is commonly used in the coronaries, will be on drug, drug coated balloons as well as drug eluting stents, Um, and other agents of that sort and you mentioned a great, uh, another technology via miserable scaffolds. Currently, three companies, maybe 43 in the US I know. But another couple outside of the U s that are going to be coming to the market if we just look at the below the knee data. You know, if we look at plain old balloon angioplasty, um, you know, as as the Comparator or if you look at, um uh, stents, stents, uh, you know, plain old bare metal stents below than he did no better than plain old balloon angioplasty. Drug coated balloons didn't know better than playing a balloon angioplasty. The only thing that ever showed benefit was a drug on a scaffold in shorter lesions with drug eluting stents such as Paradise is one of these studies, and I think that's where the promise of these scaffolds with with a drug on it may show benefit, especially below the knee. But I think it's gonna be exciting times in terms of where we go with these agents. Yeah, I guess there's a couple ways to look at it. You know, when When the first paper came out about the possibility of increasing death or mortality with drug leading technology, You know, a lot of us were very angry that they were taking away an opportunity. But it may like you said, You know, the world pivots very quickly and that that definitely made us more careful with our trials with how we collect data, how we present data, how we do different things. And at the end of the day, it's probably better for us. It just We always hate to take a couple steps backwards, but sometimes I guess it's important. I agree. So one question, um, you know, with the information that is available in those those randomized control trials How, like, how much does the drug dosage of paclitaxel weigh into your decision making, um, for drug coated balloons? So it is. It's a great question. Um, I don't know if we know the answer to that. So if you look at, um, the doses of I feel like I feel like somebody set me up here, So if you look at the question. Yeah. You look at doses of drug. The most dose on a drug on a drug on a drug coated balloon is with the impact. Okay, so that's that's first. The second thing is, is if you increase the length of the balloon regardless of what technology use, you're gonna get more drug, okay? And this pack the taxable. I'm sorry. The drug there is a significant amount that goes downstream that is left on the balloon that is left in the sheath. Okay, there is a smaller percentage that is actually goes to the advent Ishan. So the question is, what are the downstream effects? What are the systemic effects of a drug in the system? And that's where the signals of, especially with critical in ischemic patients. That poor vessel for poor wound healing, especially below the knee increased amputation rates. There were signals, um, with inferior on deep. Um uh, in terms of their trials. So So again, I think, you know, is it deleterious to have more drugs if it doesn't get to the event issue? Possibly so with drug eluting stents. We didn't see this with drug coated balloons. We did? Yeah. And then This one says quick question. Other options. Well, I think you've covered this. This is other options that exist instead of the paclitaxel drug. And I think that you've already covered so real quick other options, like famous anti inflammatories such as Dexter methadone, a mixture of agents combining limits combining anti inflammatories. There's also anti rest in Arctic drugs. Um, and I can't pronounce the agent. I can send it to you and then the other things that I think the future holds our stem cells dexamethasone doesn't also working. Covid. Yep. So, sending anti inflammatory. Yep. So remember, if you can solve the inventory, the inflammatory response, every pathology is revolved around the inflammatory response. Yep. Yeah, great. Well, with that, you know, our our last video that we that we pre prepared is a closing video. That just recaps what we covered in the last, um, three sessions. So we can we can play that quick minute and then, uh, to wrap up here. Okay. Yeah. We've learned a lot in this symposium. Just to recap. We've discussed the PhD epidemic, and now I think you have a sense of the morbidity and mortality that it portends we've discussed the anatomy of the lower extremity, the rhyme of how we think in terms of the Angie's own concept, opening up certain vessels that supply certain distributions of the lower extremity, uh, such that we can tailor therapy to heal winds. We discussed the recipe for success. Remember, a carpenter is only as good as his his tools. Time is of the essence. You have to put time into each one of these procedures to get the best care and then also the knowledge or skill of a physician from access to crossing to treatment. We've discussed the ability to personalize care through intravascular ultrasound. We've done a dot taking a deeper look at laser a threat to me because it's affected both above and below the knee and all plant morphology ease. And then, lastly, we've discussed biologic therapies to hopefully help us deter the Achilles heel of preferential disease intervention. Restenosis. Thank you for attending this symposium symposium. And we greatly appreciate Philips support, right? Yeah. Devon, that was great. Thank you for thank you for allowing us to be part of this. You know what was really enjoyable? And it's, uh what what you guys are doing. And you guys meeting Phillips and these kind of courses really is helping us at a time of need. So, thank you guys so much for everything. You're doing well again. Thank you for for taking the time to to sit here and educate and take time out of busy days and provide all this information because we're clearly leaning heavily on your expertise and sharing that with the attendees here. So very appreciative of your time and your effort that went into this. Thanks. Thank you, Ray. Stay safe. Thank you.