Hear Dr. Jimmy Kerrigan and Dr. Lorenzo Azzalini as they discuss the role of intravascular imaging in their practice and how the utility of routine IVUS can guide procedural planning and optimization of treatment. This program highlights the clinical utility and benefits of IVUS through a review of current clinical data, including the ULTIMATE trial, and through demonstration and discussion of IVUS in a variety of clinical scenarios.
We're glad you could join us this evening. Um We have a great program tonight with two great respected physicians talking about Ibis and we'll introduce them in a moment again. Uh This program will last for approximately an hour. There'll be some Q. And A. By using the ask a question feature in the bottom of your screen that you can use and ask questions and we'll find opportune moments to ask the doctors at that time. Uh Again, we'll also have some poll questions and we'll start right off with so without too much further do I'd like to introduce our faculty this evening. Starting us off tonight will be dr Lorenzo Angelini, who's the director of complex coronary interventions um at the VCU Health Polly Heart Center in Richmond Virginia. And also joining us tonight will be dr jimmy kerrigan interventional cardiologist, co director of the Advanced coronary therapeutics program at ascension ST thomas house thomas West Hospital in Nashville Tennessee. Uh so with that we'll start with a quick poll that Dr one of the doctors will ask us. So we'll ask this poll. There you go. So welcome everybody. Thanks David for the introduction. We're very excited to share this uh presentation on Ibis for Pc. I. So the first question is uh before the webinar actually starts, what is your comfort level And use of bibles to help implant a treatment strategy or optimize your stance. And you can click here on the four possible answer. And this is going to provide us with important information. So let me start sharing my screen. I hope you can see it just one second. Yeah, I think you guys can see it now. Yeah, I'll get a few more people answer this question and then we will show you the results. Yeah. It's not letting me answer. Well, yeah, there you go, Wow, that's awesome. Very comfortable. And use it often 78% somewhat comfortable and use it occasionally. 22%. So we are dealing here with with pros apparently. Which is good. At least we are all like minded and and it probably um already are embracing where our specialty is is directed in the next few years and actually is already directed now. So I'm gonna start on with the presentation why we should use Ibis and then jimmy is gonna teach you how to best use. I was for your D. C. I. So my part of the presentational and come past mainly the evidence based for able to use during D. C. I. So those are my disclosures so we know that standing is not devoid of risk and complications. And there are several different problems that we can face. Uh when we deploy a stent we can miss uh the exact plaque and have geographical miss or we can basically understand on a plaque. And this is called again geographical miss. We can have a problem uh, under expansion or in complete opposition of our stand. Or again we can also have edged by sections and all these problems can have repercussions on our stand outcomes. We know that angiography, which is what we use on a daily basis, um, is a bi dimensional technique that give you, give us a good but not optimal view of the vessel. So it's not able to tell us exactly what the plaque geometry in three dimensions because we can see a plaque that has some kind of Geometry on one projection. But sometimes we're not able to visualize it on a different projection. And you know, combining all this information would allow us to do a better job. Also operators in general, uh, some some of them are good at estimated vessel and stand size and stand expansion and others are not. So it requires significant experience. And even experienced operators at some point can make a mistake. Again the plaque is eccentric. And so we need to have a three dimensional technique to be able to evaluate um our our vessel and then our stand geometry. So we know that I was provides us with more information is a 3D technique that imaging technique that provides us with a lot of information on the diameter of the vessel, the lesion length, uh the plaque burden and also the composition of this plaque. If there is calcium Fabbro specific tissue, if it's a soft black, if there is from bas. And very importantly I was enables us to visualize our stance so we can evaluate all the problems that I mentioned before, sustained opposition and expansion uh plaque burden at the edge. And this stand at assessment to see if there is any edge dissection. So there are there are ample data in the literature establishing a strong role for uh I was guided the CI and we will review the main published paper in the field. So the first study that I want to share with you today um is a very important study called adapt. Yes, this is a very big study that included over 8000 patients. Is not a randomized trial is a multi center perspective and structure registry that was meant initially for the main objective to analyze the interaction between patient and lesion characteristics with platelet reactivity and one pre specified um study was the one evaluating I was versus angiography guided P. C. I. So about uh 35-40% of patients had guidance PC. I guided with ibis. And this is a study performed about 10 years ago. It was published in 2014. Um and two thirds of the patient were actually treated with second generation drug eluting stents. So at long term follow about two years follow up. We can see clearly that patients treated with I was guidance, enjoy way better outcomes that patients who were just treated with angiography guidance alone 4.9 versus 7.4% of maize defined as cardiac death and Target vessel and me and definite or probable strength thrombosis. So in other words, a 35% reduction in May's a two year follow up. So how was I was able to improve the patient outcomes in this in this patient population. So, first of all, to say that in three quarters of the patient I was usage was able to inform a change in procedural strategy to the operator. The operators were specifically asked to uh right down at the end of the procedure, How I was helped them. So in one third of patients they were able I was allowed the operators to choose a larger size of balloon or stand in about 20%. They went higher pressure. There was a significant smaller but significant proportion of patients where I will show the problems related to stand, expansion or opposition that led to pass validation. In a minority of patients, Additional standing was required in about 20%. Again, combination of all the aforementioned changing in procedural strategies were performed. Another trial is the ultimate trial that was recently published. Um And this is a randomized trial comparing ideas versus angiography guided PC. I in eight hospitals in china. It included over 1400 patients all comers undergoing PC. I. With last generation drug eluting stent Um lesion preparation and possible litigation was enforced with the good clinical practice with no compliant balloon inflated a high pressure more than 18 atmospheres. So uh in the arm there were essentially three criterias that when met the three of them, when the three of them were met, it defined optimal D. C. I. So first criteria was less than 50% plaque burden at the five millimeter proximal or distal to the stand edge. Second criterion was M. L. A. In the standard segment more than five millimeters square, or more than 90% of the distal reference. Uh M. L. A. And finally, the third criteria was um absence of edge extraction involving the media. There were longer than three. So at one year follow up patients in the eyeballs group enjoyed again, similar to the adoptee? S. study better clinical outcomes in this case target vessel failures. So cardiac theft, target vessel mayan target vessel revascularization compared to patients undergoing and geography guidance alone 5.4%. So approximately 50% reduction. And interestingly when we define optimal Pcs we just mentioned by procedure that met the three criteria, optimal Pc I was associated with extremely low rates of T. V. F. At one year 1.6% versus 4.4%. So almost a 34 reduction inpatient enjoying optimal PC. I versus those enjoying suboptimal. So this tells us that I was does not work as intention to treat you. Just not. You cannot just throw the I was on the table and say you have used it. You really need to understand what's going on and use the information derived from the iris for uh to improve your your stand outcomes. And this is extended follow up up to 36 months show again that the results were consistent on long term follow up, 6.6% in the iris group and 10.7% in the angiography guidance alone. And also incidents of stent thrombosis. Very importantly was quite lower, much lower, 1.1% in the Geographic Guidance vs just 0.1% in the Irish guys. And so here again this is a more complex uh slide that shows that how, on three years followed. Again, suboptimal pc. I. 9.2% of a T. V. F versus 4.2% with optimal D. C. I. So again the importance of achieving optimal results on Ivan's grounds is maintain up to three years Follow up. And so there was a process 56% reduction TDF rate three years in patient enjoying um sorry, enjoying um optimal PC is defined by ideas. Another study is the eyeballs XPS studies a randomized trial, 1400 patients, 700 others guided versus 700 geography guidance 20 centers. And so this again shows basically the same thing. So there was a reduction in maine straight long term follow up five years follow up with those guidance as opposed as compared with angiography guidance alone. And they also perform a landmark analysis. So they removed from the calculations, all The events that happened in the first year and just focus from on the events that happened between wine one Sorry and five years. And again, the results were still significant. So it's not only an advantage that we achieved with. I was the last for a few months is something that keeps on accruing over time. Up to five years of follow up. And this again, another sub analysis shows that patients who meet the criteria from optimal pc. I. So an M. S. A minimal stand area greater than the distal minimal Luminal area in the vessel. Those are the patients that enjoy improved outcomes and follow up exactly mirroring the ultimate trial analysis. Finally, a method analysis that shows again in almost 30,000 patients the benefit of ideas, guidance over angiography guidance and these uh, know. given the large amount of patient, we are able to see differences in all endpoints death and my target legion revascularization and also stand thrombosis. So very very strong evidence. And if you're wondering, you know these these uh these results come only from very experienced operators from randomized try it. This is not only the case also in real life clinical practice. This is an sub analysis recently published from the Medicare registry that shows over the course of eight years. Also in real life practice. I was is associated uh with lower tvR Microtel inn fortune and even mortality rates on long term follow up in a very logical heart, almost two million patients. So I'm gonna show you now some some cases from my experience, but you're more than welcome to interrupt me anytime with any questions you might have. And there are more polls, more questions for for you guys um to answer at some point. Um but I can start showing my my case is just a couple of cases um from my personal experience. So this is a man, 37 year old patient with end stage renal disease on dialysis. And see a ds he had in the past a Pc to the middle lady. So in my practice it's a peculiar because we have a very high number very high proportion of patients on dialysis. And we know that in this patient population the pcr result must be optimal because uh they have very challenging lesion or very often fiber calcified lesions that require adequate election preparations. So we didn't have the films of the initial um of the initial P. C. I. This patient presented with interior ischemia uh and the LVF 25%. And our nephrologist very often require left our cat in other patients in most of their patients undergoing renal transplant workups. And so in this case even more so because this patient had anterior ischemia on the N. P. I. So in this case we proceed with captain balloon dilatation with a three or wall marine And then we implant a 35 synergy stand. We passed away with 35 very high pressure 24 atmospheres. And this is the uh initial results that many operators. Well, we'll be satisfactory actually. It's nice. It's very big here and it tapers down however pull your sheath and be done. Looks great. Yeah, we could be done. Yeah. But In all my practice, especially for ISR. I am very adamant on pursuing image guided optimization. So we, despite the almost perfect and geographic results, we saw that actually this is the result we got after 35 mm and see past delectation here. So there is a lot of under expansion of the stand because the the stand is actually 3.5. So it's not that the stand itself is under expanding. It's just that the vessel is much much bigger. It's 5.2 more approximately 4.6 more mid to distal. So what we did is go there with a 45 millimeter and see balloon at 25 atmospheres. And we achieve increasing 25% of stand expansion. And we achieve beyond the, you know, the M. S. A. is that we're probably already satisfactory. With the prior result we achieve a much more expanded stent more than 25% increase. And you can see side by side. This is the actual final result with I've got a facilitation to see and you can say, Oh wow, this is big. But you would have said with angiography guidance alone that is most big too. So you might have been fooled and you might have condemned your patient again to another episode of instant risk stenosis. And you know, to later use our is uh is something is a different ball game. You cannot put a third layer, You might need laser, you might require very aggressive techniques to fix. So it's better to get destroyed from the first time you approach the patient And then one might be able to go back and say had the first person who put that lady stint in the first time I got it right, you might not have needed this procedure and ZF might not be 25. That's all speculative of course. But. Oh yeah, absolutely, absolutely. And it's also these they have so uh for the patient that you know has to go back and forth from the to the hospital. So These are all consideration that needs to be taken care of. So this is another case I want to share with you the 43 year old man obese several risk factors, smoker diabetes, um who had angina and the in step with normal LVF and non specifically wave changes. So in the first procedure and not gonna show here for the sake of time. Very boring procedure sir. Complex and om one were covered and extended but he still had some multi focal stenosis here. Proximal meat and distal in the R. C. A. So he comes back first stage R. C. A. P. C. I. Which is complete revascularization. So this is it this interrogation at baseline. So in these cases I encourage you to use eyeballs as base uh for baseline imaging in all your cases. But even more so in this case of diffuse disease because you really here you have no idea where you can end with the stance. You might be fooled in such a long uh stigmatic segment about the real vessel size and why not patient with a lot of respect. Er might have a severe calcification. This was not the case fortunately. But sometimes you you might have some some surprise and find some surprises and then you you might have issues with standard Malone expansion. So approximately about four million similar. And this It was three oh honestly without I was I would have never gone to pre delayed with a 40 and C balloon here and maybe I would have gone distantly with a to five or to 75 But I was allows us, you know, to get it right from the get go. So when we're 275 here in AsIA was more cautious because there was this cracks bifurcation 35 in the mid two distal Megan proximal. And then we put some stands, we put a three or 15 pistol possibly with 3035 23 overlapping with the previous one, possibly with a 35 and then approximately to meet, leaving about 50 millimeter gap between the 1st and 2nd and 3rd 10 with a forum 38 possibly with a 4 10 41 C balloon. So this is a an image. We, we thought we were done. We were ready to get a final I was down but there is this plaque. So you know if you don't have I booze, I already have seen it multiple times. What people will start doing here is to take elio shot, then aereo then coddle the media, leo cranial and then So you give another 25-30 million lit of contrast and you're back to the same situation you were before. So the first reaction was to give a massage with a 40 and C balloon. Because in the ultimate trial, they said if you have black burden at the edge, what you should do is to um, to do delectation gentle delectation to crush the plaque. And so we did. And then we interrogated with the I've us I'm gonna let it play at some point. You will see and I'm gonna stop it do time that there is uh residual black. So the plaque was not actually it's movement. It was actually just uh pushed away and then it came back. Yeah. He here let me see. I don't know. It always feels bad to balloon something and not stinted. Especially a vessel like that with an edge here. Yeah. Yeah. It's also true. Um that is another consideration. So according to the ultimate trial that we just reviewed um we had met two out of these three criteria. The 2nd and 3rd. But not as you will see the first one. You can see that here. The MSs five point told me to this is 8.3 and approximately is 8.5. But here where I showed you before With the I was you can see that the plaque burden is actually 67%. So it's more than 50% at the distant edge. And this is associated with rich the noses on farm. So this is the steel frame. My correspondence here. And so we put an understand for oh 15 populated with 40 N. C. And then the M. S. A. Uh in this tent is okay and there is no more uncovered black at the edges because we basically did okay a full metal jacket but we cover all that we needed to cover and this is an optimal levels result. That's great. And this is it. This is what I have to share for the moment but happy to answer your question and to talk more with jimmy about his cases. So there is another another question here currently in your practice. How often Uh do you use eyeballs or imaging to access the lesion vessel prior to standing more than 70% of the time? 50-75%. or less than 25%. So let's see what your practice. So. Well let me answer for some reason. But um you know what was interesting and the ultimate data is that The operators knew what their targets were with Iv's guidance. And still I think if I recall quickly it was 57% of the time they could not achieve all three criteria um due to inadequate vessel prep for not finding a clean spot in the vessel. So but as dr Uccellini said putting it down and getting the sizing isn't enough. You have to actually use the information to check your work and make sure that your appropriately sizing and we'll jump over. Lorenzo, if you want to stop your screen share, I can throw mine up, we can do a little bit of how to do it, how to use the information and then a couple of additional cases. So there we go. Alright, that one's a little bit more spread, wow, this is nice, lot of its originality. Right? So it would be interesting in an anonymous fashion. So I'm gonna switch the moderation over to dr Uccellini and he'll monitor the chat room and the Q. And I'm going to close it, so I'm not distracted. But you can do this anonymously. It would just be of interest to me for the people who are using it, less than 50, or even less than 25% of the time. Uh Why? Uh especially hold up, we have one more new question coming up. Sure. So this one. Uh So how often do you use I this post pc I to assess and optimize? We're not here to beat anybody up for your practice. Of course. We've made our decisions on how we practice, but just uh of interest as to what the reasoning would be for not using it pre and post. Thanks. All right. And we'll share these in just one second. Let a few more people get their votes in Lorenzo. Can you see my slides or Dave? Yeah. Yeah. Yeah. I'll just let a few more people answer this. You guys can see the results here in a moment. Few more. One more anybody else want to vote? They're all asleep, Dave. Which is my fault. I laid down. So here you go. Here you get your results. Perfect. So post pc I still a pretty big spread hopefully after tonight doctor gasoline and I can convince you that maybe that's the best strategy for treatment. But this is even more interesting because there is a lower. So the most common answer is between 25 and 50%. 38% of the answers. And the pre pc I they would use it more than to check the final results. So this is something interesting, you know, and I think that that might reflect real world practice going back to how I was using I've is even a couple of years ago, it was to go down and get the stent sizing, look for calcium, see if I needed a threat to me. And then I'd stand and say, hey, that looks good and geographically and then like the case you code that's not adequate. And in a place where 14% of our pcs are done for instant restenosis, I'm trying to be very cautious and think that you know as dr Uccellini show doing using I this pre and post and achieving good results matters and helps with these patients. Alright. My disclosure. They're so plan land and expand. Is kind of the phillips answer to M. L. D. Max with regards to a pneumonic that you can keep in mind with regards to how to use intravascular imaging in general. And we'll talk about I this specifically but this is applicable to other technologies as well. So use I this before you put the stent in to plan your procedure for me. The worst thing ever is to put in a 25 stent. Like in that right coronary that Lorenzo showed and then realize that's a 50 vessel. And I'm gonna have to either fracture the stent or stretch it beyond its postal limits and then maybe not be able to get a good result that way land. So make sure using precision techniques, we'll talk a little bit about sink vision, you know where your proximal and distal ends are. And use the information provided there and then expand. Make sure that you've achieved the M. L. A. Targets. Make sure that you don't have edge issues including dissection and a significant plaque, pardon? So here's some pictures. A couple of cases will go through with regards to optimization. So again with planning we want to figure out what's our proximal and distal reference in an area with less than 50% plaque garden. And we'll go through a live case example or two with how to actually calculate that. You want to look if you have access to either affinity which has built in length information or sink vision through intra site seven. That will also let you co register the information with your angiogram and figure out the length of the stent and then assess the lesion morphology so you don't want to put a stent in without making sure that you have adequately pre dilated a calcification or if I brought it plaque and we can go through some case examples of that another time. Because you know, I said the worst thing ever is to put a to five and a five oh. The worst thing ever is to put in a four oh the middle of it's a 20 And you can't dilate it. Hopefully less frequent now that we have access to intravascular little trip see. But then you're also worrying about fracturing polymer. And then So ideally as we talked about get it right the first time, reduce the chances of restenosis to less than 2%. And then our goal from the ultimate trial. Lorenzo went over this bears repeating because it's what you have to keep in mind as I want my edges to be clean. I don't want there to be more than 50% black within five millimeters of the proximal or distal edge. I don't want there to be a dissection that is significant. And I want the minimal stent area to be at least 90% of the distal reference luminous or five square millimeters, whichever is larger of the two. So for small vessels you're going to shoot for the five square millimeters for bigger vessels 90% so that you do a good job across the board. So here's a case example. This is a gentleman who was referred from another institution, had come in with an anterior AM I and had a failed intervention unfortunately. So it was sent for consideration of bypass on MRI. He had no viability in the anterior wall. So we did not proceed with that did not think it was going to modify his life expectancy or symptom metrology, but he did have a residual stenosis in his obtuse marginal for the complete trial. We know that treating severe stenosis improves outcomes for these patients. So he was brought back to the Cath lab for us to revascularization Sir complex at a whim. So again, how do you actually get this information? So this was done in a room with access to interest site. So the decision was to use the 20 megahertz Eagle Eye Co. Register that and use that information for us to figure out what we needed to do. So here's the live pullback, ignore the fact that my main branch wires and uh not the main branch I fixed that later. Uh, so then here's the pull back and this is what it looks like on the system. So then starting distantly, I'm trying to find a spot that has less than 50% black. So somewhere down here looks appropriate. And then as I pull back through here, you can see the white marker on the om moves with me. So I know where I am on the angiogram. Then as I get back to the side branch, it looks like I have a little cuff of vessel that Is relatively healthy, should have less than 50% plaque and we'll go through some calculations. There was also a bit of a calcium in the middle. There was so about 100 and 20 degrees there. So definitely. And I tend to use a 1 to 1 and see that my distal to make sure that's going to expand pretty routinely. With exceptions of van graphs and maybe fresh rhombus and a steamy but if there's any hint of calcium or really for most of my semi elective pcs, I'll go in with a 1 to 1 in C. So which I did. But yeah, good point there. So calcium there at You know 3 to seven o'clock and then never more than 1 80 or 2 70. So I wasn't thinking at the rectory upfront. Now if I put the N. C. Balloon in it doesn't expand, I've not burned any bridges. I don't have a stent in there. I can still go back in and perform a directory of some kind. Or use a cutting balloon or scoring balloon like an angio sculpt to make sure that this all expands appropriately but also jimmy this baby. It doesn't even cross your mind, but maybe does crosses somebody's mind. Maybe old school operators, it is not a legion for direct stenting. No, I would challenge that. There aren't many lesions for direct stand together outside again, a bank drafts or maybe a robotics to me. But we have better ways of dealing with rhombus nowadays. So in the real world, so you can see um turn my laser on. So in the distal aspect, this white markers where I am. So then I have traced out or this is actually the automated tracing, which is really good on the interest side. It's hit or miss on our core mobiles. So the outer vessel is blue, the inner vessel is green, the outer vessel, There's two ways to size and we'll talk about both. So the average diameter of the vessel itself is 3.15 mm. The average diameter of the luminous 2.8 mm. So if you're in an area with less than 50% plaque, these numbers should come out to be pretty close when you consider what sent to use. So the recommendation and this has been published I think. See Italy and others from Colombia. And now he's at ST. But you can take the average diameter of the lumen and add a quarter millimeter and that's your target. Or take the overall vessel size. Subtract a quarter millimeter and that's your target here. I was in the 275 to 30 Range as dr Uccellini did a little bit conservative especially with my N. C. I'd rather under than over because I can always post dilate. So I picked a 2.75 as my distal reference. Yeah, I would have done the same actually. Actually, you sound surprised and at my proximal reference. So now I've got a 38 millimeter vessel. I have 335 millimeter lumen. So about 36375 So I, you know, I think at this point I think about the notes in here, it was a 35 very high pressure 24 atmospheres, approximately two flare. That vessel there and then I was able to calculate that it was 22.2 millimeters in order to give myself some wiggle room. I took a 23 stent but ended up being a 275 23 and then post dilating distillery with the 275 at high pressure and then approximately with a 35 if I recall. And then that's the other part of the ultimate trial which we talked, is that all of these stents were post-dilated to at least 18 atmospheres in the trial, both in the and geographic guided arm and in the I was guided arm. So high pressure balloon dilation was the protocol in that trial. So go into my pre dilation. My N. C. Balloon expands 1 to 1. I'm not worried about any kind of calcification module that's preventing me. I check in a couple of different views, go ahead and put in my stent at this point a small puff of contrast which is optional. You know, we can talk about ultra low contrast P. C. I. Another time but as long as the patient's doing well, skip that, check the posts dilation uh images and make sure at that point. So at this point I'll have the staff read back to me. Okay you said the 275 distantly 35 approx. Well go in use the N. C. Balloons and get everything done. And at that point we go back in with the iris and make sure that we hit the ultimate criteria again. Bears repeating No edge with more than 50% 5 chord within 5 mm No edge dissection over three in length or an geographic significance. And that your minimal stent area is at least 90% of the distal reference or five sq mm. So then here's my pull back. I have put my wire back in the right vessel. My other wires have actually come back. So, the way that you do this practically is um you'll have your wires down, you put the ibis down and then you perform Flora Skopje and you pull back on Flora. It tracks the head of the iris. So you can see here. So I pulled the Ibis back, got my information and pulled my wires back to have both a completion angiogram, Uh and my co registration angiogram. So then I lost a little bit of the tortuous of the straightening of the vessel. It's more tortuous now because I pulled my wires back. So Flora Skopje back into the catheter in this instance. Because I thought I was close to being done and had concerns about re crossing. I pulled the wires back so I can check for just a wire per for an edge dissection at the end of the stent and then perform my completion angiogram. And this is the last picture I took in the case. So, I want to go distillery in the vessel and make sure that I am well opposed jimmy. You can also do without injecting contrast with the single lesion, right? You can just do the pull back. You can um and then either draw the dots and try to fool it. Or you can put down a law. So two wires and used. So I can pull back my wire that's in the A. V. Groove. And put it on the dark part, The soft part on the proximal end of my wire that's in the om. And then try to fool it that way and draw over there. Otherwise. Or you can just draw in the vessel. Uh It tends to be easier on my staff if I just spend the three CCs of contrast and get this picture because drawing the vessel is not completely ideal. So then you want to go to the C. I. A. Yeah. Without injecting. Yeah. But in this case was not needed. So sorry dr Garrigan. You can explain again. Why are you why did you choose to pull your wires back during the right after the pullback? Er I'm not clear on that. So what I do, how I do it. I've got my wires down. So imagine these wires or to the end of the vessel where we started my eye. This is down over my first stop to see marginal. I am pulling back my ideas on Flora Skopje. And then at the end of the procedure, I personally want to have my wires back, at least within the stent that's freshly placed so that I can see a distal edge dissection. I didn't appreciate one on the ibis, so, I didn't think it was gonna be there. If I had seen a flat, I would never have pulled my wire back because that's not a good day. Um And I want to make sure that I don't have a perforation out an end vessel from the wire. It's prolapsed out of side branch or something, which are also not good days. Um And then just to save a little bit of contrast, I think it's based on creating was around 1518 if I recall. So just trying to be a little bit conservative generally speaking. Um You know that's not completely standard practice. I will do the pull back, get the information with the wires down and then pull my wire back and perform a completion angiogram. Except in the cases Doctor Uccellini said where I want to get by with minimal contrast A to C. C. Final injection. There are ways that we can use to fool the system into giving us the full back. Um I got a case of that that we'll talk about I think next week. Um So then I did the information. Then I checked my work. So this is my M. S. A. Um So I achieved 6.1 square millimeters and if we go back to what my distal reference was, we were at six point oh square millimeters. So I'm at 100 plus percent of the distal reference and greater than five millimeters after having post dilated and pulled back. There's no edge dissection or no issues. The bifurcation is preserved. The standards landed right at the austin. Um There's some additional tools and techniques with phillips with live side branch monitoring and positioning that come with this as well outside the scope of this conversation. So I thought that I had achieved an ultimate like result for this patient and he was discharged, went home and is doing fine. So again plan land and expand using intravascular imaging before and after. Um is important in order to get those results that we know from the clinical trials. There are yet more clinical trials ongoing in the United States to hopefully gather additional information for the use of intravascular imaging and hopefully make it a class one indication one day. And it would be really nice if the government would reimburse hospitals for it. So that administrative questions from Yeah, we have a couple of questions. But before I I I ask the questions, I would like to say that. I mean This way of doing PCS really 21st century Uh it takes away the guessing the probably the, you know, the need for the experience having done thousands and thousands of PC. I it's a democracy Democratisation of PC. I everybody can get awesome results. If you do it 100 times with this technique, you're gonna get it right 99.9% of the time. Whereas maybe to do it right. Um in some settings you need without. I was you really need to have a lot of experience. But even then you might every now and then, you know, undersize your balloon. Underestimate classification or even perv the vessel. If you overestimate vessel size, you can have a big product and perforate the vessel. So this is really a way to get these uh, these optimal results in the hand of everybody. And so I'll count at that point if I may because going back to that, the es which We're expert and geographers even then 3/4 of the time they were wrong. Uh, so, you know, I I think this should The standard if it's available in the lab to use it for I use it for 99.5% of my interventions and the ones I don't know because I'm going down or re much, but just all right. And I can't actually physically won't reach at that point or it's too tortuous through lima. But anyway, just challenge you on that. And not an expert and geographer. Yeah, exactly. And even expert and geographer, you know, if we could check all the results with eyeballs, we will prove them wrong. As you just mentioned, the adoptee. S So the two questions are from eric Rosen. Can you talk about intramural hematoma? And I've us stand sizing and stand under expansion. So I'm going to reserve that for this next case. This was not a planted question because that is exactly what this next case looks at. Perfect. So we can answer the ask and answer the second question. So, When the expansion question from uh even Rendon from Columbia. So when the expansion is more than 90%, do you think the opposition doesn't matter? Opposition matters? I think what gets difficult is to situations one so late, incomplete stent opposition. So you put the stent in today and the vessel remodels and pulls away. Do you chase that? I've got some interesting cases and we can have a discussion about that. Um and then segments of positive remodeling. Uh So when we size, we size to the distal normal segment, we size to the proximal normal segment. You don't really have to worry much about negatively remodeled segments because that vessel will expand to accept appropriately sized balloons and stents, it's chasing the positive positively remodeled segments. That I worry about perforating the vessel because the wall of the vessel is already stretched with plaque. So I do aimed for complete stent opposition. In addition to getting 90% of the distal mlr, greater than five square millimeters, but not to the point that, you know, if it's a 35 vessel discipline for approximately, I'm not going to take a 55 and see to the mid portion of that step, I'm gonna try to make sure that it smoothly tapers up. And then hopefully with improved flow, the vessel will remodel back in the direction of the stand. I don't know. Lorenzo, if you have it. Yeah, I would like to add jimmy to answer advance question. So, uh, opposition. Uh, for example, achieving good opposition is very important at the inflow of the stand because if it's my opposed, then the next guy, uh, there's going to tackle this lesion maybe because a recent or new lesion diesel to your stand, it's gonna have a lot of trouble and it's gonna wire be the outside the stent. So if you reach opposition at the influence. Also, very important. Yes, absolutely. Kind of like the osteo stand hanging out. You don't want to make it harder. Hopefully nobody ever has to go back in and do this again. But we all know that even with optimal results, it's a 2% chance of incentives to notice a year. So the good messages that opposite positions not associated with central bosses. Unlike under expansion. Under expansion is the worst. Yeah, man, I had stenosis and thrombosis had a good complete case. I could have showed but not tonight. Another time of that two days later. So this is uh so to the first person's point, so here's an angiogram assuming it will play. There we go. So this is uh two o'clock in the morning interior. Am I? The guy is not hypertensive. He's not shocking, surprisingly. So, no mechanical circulatory support. Go in straight away with my guide and his lady is out great. Um So wire, it performed PTC a with a two a balloon to restore flow and get the clock to stop and then here's what we have. So relatively static proximal segment That tends to straighten out, seems to straighten out. And then there's a little bit of tortuous city in the mid 80s. So perform intravascular ultrasound again, plan land and expand. So planning. So this is the live run. I blanked out the date for hippo reasons I did not blink at the time because at 2 45 in the morning, I still did I this and I still did post Davis. So some calcium. They're coming back and I'll go through the measurements here in just a second into the left main. And this is one where I was a bit concerned because I had a really hard time finding something proximal that was less than 50% and I really didn't want to cross over stent into this guy's left main at 2:00 AM and surgery really wasn't really needed or an option. Then Otherwise looking at the Ibis, there's some calcification changes but nothing over 120°.. So I didn't think that I directed me, not that I would do as directed me outside of laser in a steamy. Um and at that point, so my measurements, this is my distal reference 42% black burden. The vessel itself in blue averaged out 2345 The lumen itself averaged out to 265 at a quarter to the lumen take a quarter from the vessel. Either way, I'm into this 30 Range. Uh So my distal reference was three oh uh 3 to 5 would be pretty aggressive, But then approximately in the ADM right at 50%. A little bit of concern about the ultimate criteria there. But again, I'm not going to stand his left main for this. Um and then there's a pretty big size mismatch given that there is a significant amount of plaque. So the vessel approximately by The vessel says I need a 465 if not a little bigger. So maybe a 475 Post dilation. 3.65. If you have a quarter to the limits in that situation, give me here. You got a problem because if the distant references 30 and approximate is more than 375. You know, this is a standard will break if you go high pressure, right you fracture. There was a good paper that I'm happy to share which showed some post stent dilation on the bench and I think we can push things. I know that the resolute onyx has recently had their labelling updated with new post dilation limits. I think we go a little higher than what the box says. So I feel comfortable with the three Oh this was a an abbot stand so I felt a little bit comfortable with the four approximately. But beyond that, no it's not not going to push it much bigger than that. I don't want to fracture it and then have restenosis because of that is the mechanism. So three or 33 cents. I did go through with a 30 N. C. Made made sure everything expanded before I put the stent in. I didn't say that. Hopefully nobody has epilepsy with that safe frame there for you. Um And then an angio. So the stent looks great. The distal edge there is a significant step down. Uh So I post dilated with a three oh. Distillate high pressure for approximately at 18. Didn't want to go too much higher than that proximal spine. But then the distal gave me pause notice that I don't have my wire back at this point. So I don't want to leave an edge dissection. I don't want to leave an area of concern without checking it out. I was going to visit anyway so back in with the ibis. Um And this is a trick when looking for dissection that I learned from one of my local reps. So you use a chroma flow on the way in as you go down gives you information and then as you come out switch over to duty so you don't have to go in and go out and go in and go out. So I'm going in with chroma flow as you can see the resolution. The temporal resolution is diminished because of that. And there was the issue there. So I'll come back. Mhm And thank you again to whoever asked the question about intramural hematoma. So at the distal stent edge, there's a hematoma doing cto, we see it all the time doing stem E P C. I a little bit less frequent. Now there's minimal flow into it. I think that maybe just artifact from what we're seeing there in those spots. So I thought it was a relatively contained rupture from that standpoint, but definitely not something that I want to pull my wires and call it a night. Can you use your minute to point that out back in that frame? That sure I'm actually. So here's the chroma. Then I'll show it on the 2D much more clearly and write about and every froze. That's perfect timing right here. Let me switch my laser on. So this space helmet shaped dark, it doesn't respect the vessel contours the stent. The vessel itself is up here and there's a line of so probably with some of my ballooning dissected the vessel. Some blood got into the wall. I sealed it with the stent that I placed approximately. Which happens when we do things like integrate dissection reentry, we re enter and some hematoma can propagate distal to that. We seal it with a stent but sometimes we have to go in and release it or continue our stent if it's human dynamically significant. So I said it's 2:00 AM. I'm not going to fr to see if it's significant. I'm not gonna be able to sleep at that point. If if if I just leave it. So this is my eye. This coming back. So there's my new distal reference. If I can find it, it's not easy to find it, but it's about the same. Although for me once shame on you. I went to 75 when I extended the stent and then here coming back. What did I put the wrong one in again? Yeah. No, don't. Never mind. That's a previous. I will fix that and send that out to whoever wants. But because there's a clear representation of the intramural hematoma, you can see your smiling at us. Hmm. So also the approximate stent was a little bit under expanded based on what my targets were. So I went in NC balloon approximately extended the stent a little bit distantly with a three year low lower pressure, then post dilated. The overlap. Uh left the dis allege alone because I didn't want to toothpaste anything down. And then and geographically Guy went home two days later doing doing fine. Um, So yeah, interesting case because the intramural hematoma that was there. Um, there has been no evidence that the use of intravascular imaging leads to over sizing or issues, but it allows us to recognize those issues before I pull the wire and then I get a call in three hours that he's having chest pain and his sts are back up so putting it all into practice. Um Dr Uccellini went through the reasons why we should be doing this. The equipment is out there. Um You have the expertise based on the initial slide, the initial poll question. And if you have additional questions or need additional training phillips of course. And I'm sure every imaging company will allow for that training and clinical support through clinical reps on site. Prospering virtual Procter and things like that. Um, yeah, so, and I'm sure you want to share your contact info as well. But there's my emails, my Twitter, my cellphone. It's been the same since I was 16. Feel free to call email tweet, hang out with us and watch baseball from a parking garage anytime we have time for any questions. Please, if anybody has any question to submit, this would be a great time to do that and ask a question feature more than having that. If we can also ask the final poll, which will help us understand it was helpful. All right. So uh overall question is did this help? Um did it give you anything that you didn't already know or give you any additional information that you're going to take back to practice? And again, either anonymously or via email to Dave or anyone else who's on the call. Feel free to give feedback as well for the presentation. So I will jump back to eric's question. So hematoma on either so you saw their intramural hematoma. We have examples from CTO as well. I'm sure Lorenzo could show that um on it's just a dark area outside with no flow outside of aluminum, the vessel and then if human dynamically significant, it needs to be released or treated in some fashion um, stead sizing. I think we talked about so take a quarter off the distal reference vessel at a quarter to the distal reference lumen. In an ideal world, that number comes out to be exactly the same. Be careful not to undersize the stent. So, as we talked about putting a three year stint in and trying to go to four or five, you're gonna go beyond the limits of the stent, potentially fracture the stent and then potentially uh increase the chances of restenosis in the future and then stand under expansion is terrible, especially if you're dealing with it with multiple layers of stent, thankfully with the use of laser a threat to me. It's been shown that you can get a larger stent area at that point. And the role of intravascular that the trips is being determined. Because currently off label for use instance, the labelling for C. Two with shockwave says that it is for use in de novo calcifications only. I know that it's been we've all seen plenty of cases on twitter and we've all probably participated in cases of intravascular lift the trips uh for uh stent under expansion, but otherwise you can go to very high pressure with angio sculpt with NC balloons if you're not in the United States O. P. N. Which I wish some company and phillips would bring to the United States. Um And then laser laser with contrast intravascular with the trip see um if it's an old stent potentially other threats. I mean there was a really good session at Sky on saturday with this discussion. So if you were in attendance, it should be on demand. If not, I think you can sign up and review that from the scientific sessions. Right. Thanks so much. Just great information and uh signifying the importance of of using. I've it's not only after but before and and how the ultimate trial is helpful. So there are no other questions. We so appreciate the time and expertise of uh of our faculty and doctors and the willingness. Um and it looks like everybody had a great uh session and we thank you for your time and everybody thank you this evening for joining us. Take care and have a wonderful safe evening you to do it. Yeah.