Dr. Mathews is a practicing Interventional Cardiologist at Manatee Memorial Hospital in Bradenton, FL specializing in complex coronary and peripheral, structural heart as well as endovascular treatments. Dr. Mathews has participated in several clinical trials and is a leader in the use of physiologic assessment. He was one of the 1st US physicians to use the new OmniWire by Philips.
In this program, participants will hear Dr. Mathews discuss and review his experience using the newest pressure wire OmniWire. The presentation will not only cover the clinical utility, durability and improved steerability of the wire but also the importance of physiologic assessment in a variety of patient and lesion scenarios. So I have the pleasure talking about the Omni wire system to which is a pretty big advance. Uh, when it comes thio pressure our technology on my history with with Phillips goes back many years, even to back when I was a fellow at Washington University when we were dealing with the original prime wire by volcano and we helped develop the prime or technology at that time. And for those of you remember that wire? Uh, no, that that eventually became the Varada wire, which many of you may have had a love hate relationship with, you know, considering where we came from, it was a significant Vance at the time. But this omni wire, I'm proud to say, is a quantum leap improvement over what we've had before in the marketplace. And if we look at advancing physiology, Phillips has been doing some pretty amazing things going from just your traditional fr technology developing. I fr in 2014 the scout system in 2015 and then co registration, which I'll talk briefly about as well to in 2017 which is now part of our regular armament material. And then, you know I'm new. I represent a really new paradigm when it comes to doing multi vessel physiology and combining this especially with the code registration technology. That's a really comprehensive physiology assessment. So I just wanna get everybody up to speed on I a far This is gonna be pretty brief because most of you obviously know this technology and algorithm quite well on. Obviously, most of you understand the limitations of angiography. You know, back when we were taught that, you know, intermediate severity was actually much a small arrange that we once thought. But the reality is that between 20 and 80% stenosis, there's a wide variation of, of, of significant. So if you have less than 20% blockage, you're probably good to go to leave it alone greater than 80%. You're good to intervene, but anything in between all bets are off. And, uh, obviously that has to do with your image in planes and and flow dynamics. Not all lesions or necessarily significant, and vice versa. So just basic pressure flow correlation. This is what we were trying to do originally with that far, however, resistance can impact this pressure flow relationship. So, uh, if you're able Thio keep resistance constant eliminated from the equation. Pressure and flow will be related, which is ultimately what we want to see by using a pressure wire. And this comes from obviously the simplified Bernoulli equation. So there is a period of the cardiac cycle which represents the way free period where both pressure and flow are essentially constant and relate to each other. So this is where resistance is minimized and can essentially be eliminated from the equation. And by a proprietary algorithm, you're able to develop this If our measuring and this was validated over 4500 patients from my far sweetheart defined flare, both New England General papers were published simultaneously. Huge post back to randomized control trials, big data validating the cut point of 0.0.89 and showing that really it correlated very well with using the traditional FFR cut point as well, too. So we're able to now use 0.0.89 as the standard for for these patients, uh, as opposed to using something like pointed off with far so uh, moving on, we've now found that fr potentially can have advantages even over FFR and this sub study. Aziz well by sen you know, show that especially for led lesions, I fr was actually superior and predicting, uh, major adverse cardiac events over FFR. So this is an interesting, provocative paradigm shift potentially where I fr maybe the preferred modality. So all of this comes down Thio how you use it and what does it mean and defined? PC I really, I think, upended some of the conventional thinking with just traditional physiology in and of itself with the concept that, uh, how do we evaluate physiology after intervention? And this was blinded Physiologic assessment Post P. C. I. And there's a lot of different reasons why you have residual ischemia that could be diffused disease, geographic, miss under expanded undersized stents, Which is kind of one of the more common things we think about, but also serial stenosis, especially finite ones. And, uh, these patients were essentially randomized to ah, blinded physiologic assessment post post intervention. So what they found was that 24% of the patients had significant residual ischemia. Post P c I on, uh, that's pretty shocking on. The operators were allowed to use I vis on the study on Lee. 10% did so, but what they found that, uh, that in many of these cases, uh, over 80% were just focal stenosis in various locations that were missed by, uh, by the interventional. So it's not that, and geographically, they couldn't see it Z that some of these lesions were visible by IBIs. Or even sometimes when you did the pullback, you could actually see the lesion. And what was deemed not significant was, in fact, physiologically significant. So Onley in about 18% of cases where it was, was it diffused. And so if you look at the breakdown, it's kind of a third, a 3rd and 3rd on Lee. A third was instant dude under expansion. But there were legions, both proximal and distal, to the stent itself, which were missed. And so this presents Ah, very interesting, uh, concept that we know with post physiology, you could reduce that residual ischemia from from 24 or 25% down only 5%. So that's Ah, that's a really big change. Uh, maybe potentially explain some of these patients that we have who get readmitted despite post despite having been intervened upon. Some of these patients comes despite intervention, and so there. There's an opportunity better. But for those of us that were doing physiology, post intervention found that it was difficult to do with their existing pressure wire technology because many times the wire would kink. It was difficult. Thio go back down and re use a lot of times you have a workhorse wire down and now try to bring down the pressure where again to is cumbersome. So there's many reasons why people did not or do not want to do post intervention assessment. Sometimes they don't even want to know the answer, but we want to see if we could do better. And this is where I'm to our presents an opportunity to use a pressure wire not only for your physiologic assessment, but also for, um, uh, your intervention, and also for post physiology assessments as well, all without messing up the wire. So this is that current technical challenge. How do you fit all of those sensors into a wire without making the wire very difficult to use or or torque or transmit? So, uh, this is where Anwar addresses the challenges of typical Hypo tube type pressure wires, and it's a completely different wire design from the tip of the wire all the way to the tail end of it. And you can see that they've come up with a solid proximal core which allows for improved kink, resistance and torque. Uh, the proximal sensor housing is eyes protected, and the distal course night all based. So this works more like your typical solid core, uh, solid workhorse wires, and with having the electron ICS on the outside on, not on the inside allows for good torque response and usability of the wires and resistance Thio, qingqing and deformation and then back in connectors. Also a lot easier to use now as well, too. So that's easy to disconnected to do your intervention and put it back on again to check pressure assessments. Post intervention. So this is what it looks like in schematic form eso There's the flexible portion of the front end, which is the flexible very, uh, tor Kable, uh, front end and then, uh, Nightingale distal court, which allows for that recovery, uh, resistance of deformation that you'd see with some of the other pressure wires, even the burrata wire for that, for that example on, then, of course, the solid proximal court as well, too. Where these, uh, high street cobalt alloy, which allows for force from the back end to be transmitted to the front end largely to transmit that torque and again, also avoids Qingqing as well. These conductive bands on the back end, or what? Hooking to the connector on the back. So let's compare with the traditional pressure wire with solid core wired so you could see Look at the differences so you've got in the original Varada wire thes electrical leads and that the offset center core, which creates issues when you when you try to torque the catheter, then by the fact that it's a hollow hype YouTube kinks and if you, you you encounter tortuous city calcification. Sometimes you'll get all these bends in there, and if you're trying to do an intervention over that, it could be difficult to deliver your balloons and stents over that very same wire. So that's why a lot of people traditionally have been, uh, removing the pressure wire and putting down a regular world course wire. But look at the comparison between the Omni Wire with a solid core design versus a traditional workforce guide wire. You got your polymer jacket, which is the same thing on both wires. You've got the large intercourse solid core, disciplined approximately. But what they've done is within that Palmer layer. They've embedded those conductor ribbons, which is how that information from that central housing gets transmitted to the back end. So you have a wire that looks just like a workhorse wire. But it does have some electron ICS in it which allow you to use the pressure wire features. So, uh, what about fiber optic wires? There's a lot of talk about fiber optic based technologies. Uh, but, uh, you know, especially that they have very little drift and what not to. But the reality is that you still have the problems with the hippo, too, because it is a hippo to, by definition, the torque and the push really come from the front end of it. But you don't really get to transmit from the back end a zoo much so in terms of wire performance, the under wire does seem to be significantly better than the fiber optic pressure wires that are out there. In addition, with regards to the criticisms on drift, the reality is with the new connections on the back end. There's a lot less drift that we see clinically on. But it's really kind of ah, more of an issue in the past. I believe so. I think, uh, most people who use on you are very, very pleased with its clinical performance, not only from a wire standpoint, but also from the drift aspect as well. On then, of course, the back end. I mean, if you're gonna be putting wires, you're feeling dance or balloons over this, Uh, this bad is very kink resistant. And it will, uh, last multiple exchanges before you decide to hook it back on again to the unique connector. So this is a example of just what you are looks like with regards Thio Tork transmission compared to the BMW Universal to which is a good world course wire, both have very similar Tork transmission. So, you know, with the average rotation is very, very similar to the workhorse wire. And then if you look at things like tip load, it's got a fairly soft a traumatic tip load similar to your world course wires like the BMW that shine blue. Uh, yeah, blue And then if you compare it thio this different wires. Obviously, it's, uh, obviously a lot softer. So, uh, to orginal strength, eso multiple terms before failure. Really a significantly better than that of Varada you could see. And also the kink radius is eyes so much better. So really did not king at that at that fulcrum point at the sensor around those small bands. That was always a concern with the varada wire because you could see where that sensor was, and sometimes the wire would bend right. At that point, you don't really see that with Omni Wire anymore. So putting this all together, this design allows you to one go through complex anatomy, deliver your IBIs catheters, balloons on stents over the wire. You could reuse it. Multiple vessels. You know, we've been routinely, uh, doing three vessel, uh, interrogation with on the wire now, And it's it's great to not have Thio worry that it's gonna take up a lot of time to do that. You could do it very quickly. I mean, I f r is already a fast thing to do. You don't want your wire to slow you down. So the fact that the wire keeps up with the physiologic assessment is amazing thing and the fact that we don't have to pull additional equipment, you know, if we're happy with it, we want to deliver a sense over that wire. We're not unnecessarily a limited. If we wanted to do physiologic assessment another vessel afterwards. Eso It gives us a lot of flexibility And it really does a good job when it comes to doing cool registration and showing good reproduce ability and reliability with regards those physiologic assessments. So all in all, a single wire if you decided to do it this way So what other quality features they have? They added this Ah, few silver on the back end. So now it's a continuous piece. You know, those of you gonna have nightmares about the back end of the Varada. You know, it starts to do this, Qingqing, which I believe would sometimes create to catheter faults and what not to And you have to replace the wire. So I don't know why I really eliminated that Teoh by Korean. That continuous piece with no joints and then the locking piece on the back end is really nice because we'll show this to you real quickly. Uh, this is what the spring loaded connector looks like in the back end. One thing you have to know is that you can't use your traditional, uh, tortures on this wire. And the reason why is most tortures have a metal collecting the inside that could damage the electrical connections in the polymer jacket. So we don't want to use that theon new artwork devices plastic, so it protects the wire is not gonna short it out. They also include a second one if you need. If you lose the first one, I find the torture to be fine. I don't. You know, a lot of people don't even use the torque at all nowadays. But if you do need to use a talker, historical works great and is included on the wire with the next one if needed. And then if we look at this spring loaded back connector, all you have to do is squeeze it open, and I just kind of drag it into the the the teeth that are there. And then, uh, the wire can freely rotate within. So there's no resistance if you're trying to Twerk the wire. You don't have to disconnect that back in connector in orderto wire through your vessel or do whatever you need to dio when it comes to the set up to the packaging is significantly improved. After you do your initial flush on, then do your connection. Thio zero the wire within the package housing you're able to just slide it directly out. This, uh, plastic piece just opens up, but a single him swing and then you're able to slide that wire all the way out smoothly. No, Qingqing on. Then the torture follows with you. So this actually, uh, makes a huge difference in comparison to the previous packaging, as you guys all remember. So the nice thing about onto our two is that's compatible with the interest site system. On there's this new, uh, connector, which you guys can see here, too. For those of you that have the connector near your contrast, sometimes you remember that trust will drip down getting into the previous connector. This is a much more solid connection that prevents fluids were getting on the inside as well too. They're also they also have the ability to use the old Varada sistemas well, too, with a different connector. Eso it is flexible. We want to talk a little bit about code registration is well, too. And I'll show an example of this during my cases on you can see here. This is what sink vision looks like with, you know, combining the Omni War physiology data with co registration. And these dots all represent essentially a point of, uh, uh, drop off from the distal measurement and you can see here the I f R estimate with these two areas uh, put together is around 20.95 so it's actually not significant. So all of these dots represent, uh, the total drop off from 1.0, and you can see it schematically drawn here is well, too, on this curve. But you could see the various, uh, points of pressure drop off the areas where there's where there's some flat, uh, drop out there. That is not necessarily an area that you would have to intervene upon. So the nice thing is that you could use this co registration, essentially identify exactly where stents would be needed, what would be needed and also what measurements you would need. So a 23 million stent or perhaps a, uh, 20 more were sent down here, you know would work quite well on instead of one long Giants center, multiple stents. So let's let's talk about some cases on then. Obviously, we will go ahead and go into some questions as well, too. S o, this is the This is the first case. This is an 80 year old gentleman who presented with significant chest pain. Eso most of you wouldn't do physiology on this type of case. Why? Because you could see a very discreet lesion there too. But, you know, we were doing the limit Mark released for on the wire. And I really wanted to push this wire, see what it could do. So I really didn't know. Uh, I had my doubts. Uh, but, you know, theoretically, it should be able to cross us without too much difficulty. But you can see this is a pretty tight tights analysis, not something that you would do. Physiology. So here's the Omni wire on again. You know, forgive me for the wiring job here, but that's because we were just getting to know the wire itself to But you could see how easy that thing twirls around the fact it was finding all the branches. So ultimately, I just prolapse the wire and took that down. Now, most of the time, if you prolapse the wire like that too, it actually will recover really nicely. But obviously, if you just keep collapsing the wire over and over again, that front end can retain that prolapse shape many times. Your ableto fix that out of the body with your introducer and then use it in other vessels if necessary. So, as expected, the I far was 0.5 to this obviously is a highly significant lesion. And then we did pull back across this, which I don't have here. And yes, we did that for for fun, mostly. But it demonstrated, of course, that that legion was, in fact significant. But, you know, e knew that this was calcified. And so, uh, I wanted to really put this wire through its paces. And I used the 0.9 Alfa laser and laser over the physiology wire at 60. 60 60 slash 80 and 80 slash 80 fluids frequency. And we had done I vis right before this, and I couldn't get my eye this past that inclusion, as expected because of the circumferential calcium that was there. So after laser and through this, we went ahead and did multiple NC inflation's which unfortunate didn't do a whole lot. So I had taken a cutting blue. You know, it's very possible that rotational after rectum e would have also done a good job of this for orbital A threat to me as well. So ultimately I chose used the cutting balloon, as I had already lasered, and that actually worked really well. The cutting blue just yielded this quite nicely. And afterwards we used at 30 18 drug extent, a too high atmospheres and post elated the stent after I vis, uh, thio appropriate size. Um and, uh, you know, approximately It was a around 35 53. 0, and then I did another pullback. I far in the distal portion of the vessel was 0.91 which is non significant if we pull back up here, As you can see, right to the midsection is 0.94 uh, near the stent edge. So again, I was pretty happy with this result on, uh, there was No, he was a MP Significant stenosis after we were done, so uh was impressive as, uh, I managed to perform a threat to me over this physiology wire and not disrupt the after the electron ICS at all multiple and see balloons cutting balloon angioplasty. And despite all of that, including this poor chew Osti, the physiology wire was still able to give me an accurate assessment and in fact, just double check this. I went down twice because I always check for drift, just to be sure. That's just the force of habit that I have. So I almost always end up doing, uh, Thio assessments And they were consistent, There was no drift, and the results were the same both times, So I was very happy with that. So this is another interesting case that I want to do before we finish up here and open up for some questions. This is a 78 year old woman who had an abnormal CTF afar. And for those of you who are familiar with c t FFR, it's a noninvasive modality for us to do physiologic assessment in patients. Now, I'm not a huge user of this. I think there's some utility and patients you think have maybe a low or intermediate predictive probability for having corn or disease. The reality is, if you find a C A d and then you're gonna have to potentially do a half anyway, So I tend to doom or invasive physiology. But there is a role for noninvasive physiology outside of stress testing. Uh, this this does provide some additional an atomic information. The problem is that you know, when we did our own validation for CTF fr, we found that oftentimes unless the CFR was highly significant, there was not great correlation with a farm and C t FFR was validated against FFR. But what we found in our own experiences that the fr correlation is not that great. So anytime I get an abnormal CTF fr I end up doing physiology of these cases unless it's blatantly obvious to go after these reasons and testament thoroughly. So this particular patient, she had an abnormal CTF fr both the led and also the sir complex. And if you look at this angiogram, you'd say, Well, the led is probably, you know, at most 50% 2 notes in the proximal segment, you could see forest optically that there's calcium on the outside going all the way down. And that was what the SETI also suggested. The CTF afar, for both of these vessels was less than a 3.75 On the surface, you can see what looks like a high grade lesion, perhaps 70 80% severity may be even higher. Maybe 80 90% severity on. Uh, the severity of the CTF follow was worse within the circum plex territory over that of the led, Which is kind of what I would expect it based off of this, Angela. So I decided to go ahead and perform physiology of everything. Um, first things first is you know, I'll note that the right was not significant, so we were not dealing with a cabbage situation or anything like that. So I went ahead and, uh, took some additional pictures here. And then here I am, wiring with the on the wire, and you could see how easily this wire is tracking down through the led. And then you can see here in another view of that hears me coming down after I changed my camera angle and easily twisting and talking the wire all the way down through this led without difficulty at all. So this is very impressive to me. I think this would have been more challenging with the previous broader wire. But this thing glides down like any regular workhorse flyer that you might use. So we went ahead and did pull back, and you could see that the I a far distant was pointing for most of the greedy. It was across this, uh, kind of mid area. Uh, there's a distal step up in a proximal step up. Uh, what? I want you to kind of take a look at this curve and make note of it, because it does impact what happened later on your case. So, you know, we had given nitroglycerin. We have gotten three i apart assessment, and we did what we thought would work. Well here. You can see that by going from a one state strategy here and extending out a little bit further on this curve here, Thio to set strategy. Uh, there wasn't a huge, uh, improvement, I think, in terms of the far assessment. So I decided initially that I would try for once that single cent strategy just of that middle lesion and kind of skipped the proximal lesion moving on here, too. We went ahead and pre dilated and then extended with a 338 doubling stent anti atmospheres and then went ahead and I'm pissed and post highlighted this. But despite doing that, I still had a positive by far, uh, 29 you know, And so I thought it was interesting because the pullback ingredient that was predicted was to be better than what we got. Now there's multiple reasons why this could happen. One is that sometimes the predicted I far is not 100% accurate. But in this situation, I think the reason why was because I didn't allow the nitroglycerin to fully take effect and that there was some delayed, uh, spasm that didn't resolve as the vessel got bigger. So I think that's the reason why the approximate brain became much more apparent. And so when we did itis of this, uh, you know, you'll notice a few things that additional edge of the stent. There's this little hazy lesion that was not significant on high fr pull back and also by IBIs It was only in one quadrant, uh, eccentric calcium. It was not significant on I decided leave alone. I didn't need to spend the distal edge. There was no dissection. And the flow there was fine. Approximately. There was definitely ingredient. And that's where that moderate stenosis that we that we had seen previously, both by itis and also on the pullback, which I mentioned before, showed that in fact, the two cents strategy was probably the right way to go here. So I went ahead and I ended up spending that with a 35 household post, Tyler that with IV's and checked it. And then after that, now we've got a knife, our 0.97 which is much closer to the predicted I fr that we got the first go around, which was 0.96 so I probably should have just done that right off the bat. But you could see that the flow is much better. The vessel is quite large again. That distal edge. You see it there, but it really is not an issue. And it looks okay. So they're now what about this? Uh, this lesion here in the sir complex. You know you just called all of you and geographically looked hazy. It looks severe. Didn't like the way it looked. Um, also at the Austin there was at least a moderate stenosis as well, too. So we went ahead. And here I am, crossing with the Omni wire through this tortuous sir complex. And this is actually kind of fun putting it through its paces. Kind of interrogated, wiring this thing down. You could see its finding all the branches, and I'm able to talk this thing through very easily without a lot of difficulties. Now, you have to be careful sometimes with severe torture. Rossi, especially this was seen with the varada wires. Well, to where the vessel would tend to straighten it out and then create, uh, pseudo cyanosis. But I've seen a lot less of that, too, with the Omni wires. Well, because it seems to take this tortuous Osti quite well, and it doesn't seem Thio king the vessel itself. So that's a good thing. And then what was interesting? So, after we had just done an initial assessment, we got a positive result, Appointee. Nine. I was like, Okay, but, you know, I was still waiting for the nitro fully take effect. Then all of a sudden I got a knife are of 0.92 So that was interesting and kind of unexpected. I thought that this was gonna be significant. Pretty much everyone else. Everyone else was watching on as well. To says, you need to step this thing. It's a hazy looking lesion. So I went down with IBIs and IBIs shows a soft kind of hazy plaque in there, too. But, you know, it was only about 62% so moderate in nature, and it was eccentric at the Austin, so there was one of the slit like orifice, So that area was not significant at all either. So not left with a situation where what do I do? So, you know, the CTF afar was positive. Leisure looks hazy and geographically, but both I f r and itis suggests that it's non significant. So, uh, you know, I don't know what the right answer is here. You're treating the patient, Not necessarily the numbers, but it's also a question, you know, that could be argued. And by the way, I ended up intervening upon this and end up stenting with a trio by 15 b s post elated. And afterwards, you know, it looks really nice. Uh, on, uh, this is a This is a final results here, but I went ahead and went back down with the on the wire. High far was unchanged at 0.92 So that's exactly what was what was free. And it was the same post. So did I really help this patient out? Did I just treat the interventionist? Um, I could tell you the referring doctor was quite happy I did it. However, again, I'm not sure I change this patient's outcome by fixing this leash. So I think you could argue in either way, uh, with this. But what's interesting is that the physiology gave me all the information that I needed, and I made a clinical call based off of this thing results. And I think that's what happens in the real world with these observations, especially the great. She felt wonderful afterwards, and I think there she's gonna do well in the future with intervention. So, Matthew, just one quick thing. We have a question coming in. I think you can hear the answer. Just a question do you routinely used Nitro Appoint doing physiology assessment. You have to use nitro on Duh. It's you know, the guys from Imperial College in the U K. Harp on this quite a bit too. The reason why is that? You need thio eliminate spasms much as possible. You will get erroneous I f r readings if you don't do nitro at some point. So a lot of times, some people do it in the diagnostic portion of the procedure Eso Then by the time they get to do the I four assessments already kicked in, uh, if you're not gonna do that, you're gonna go with the guide catheter. So right after you normalize the wire on, then you go into the vessel. You'll, uh, go ahead and give some nitro. But if you do it at that point as well to just realize you have to wait a minimum of 30 seconds or longer, the nitro fully kick in. And sometimes I've given multiple rounds of active listener, just to be sure. Just remember when you're doing that, you have to wait because there is some transient hyperthermia that happens with any substance that goes down the coronary So whether it be sailing or nitro or contrast that you get the transit hyperthermia, you'll get a really low I far number. Then I'll come back up again, so that's important. Sometimes you'll think lesions are ischemic when they're not in vice versa. So I think that's why it's important, obviously, a natural history before you do your assessment and give it enough time to fully kick in. So just really kind of wrapping things up here, too, is way. Talk about this. You know, there's this system is pretty amazing, you know, obviously navigating torture Rosset e delivering devices Doing post PC I measurement eyes is a huge advance. I would argue that there was a lot more challenging with the broadest system before, to a lot of people were also using a workhorse wire and trying toe avoided doing much over there, uh, varada wires or other physiology wires because they're afraid of thinking it. So now with this system, you're able to do that, treat the vessel and then check it afterwards and then co registration obviously gives you a lot of options when it comes Thio pre planning your procedure on also with, uh, really delivering your stents to precise locations that are causing scheme. And rather than just sending everything so it allows for targeted, uh, intervention strategy. So with that, I'm gonna go ahead and open it up to some questions from from the audience. Hopefully, you appreciate the program. You have any questions? I don't see any hands or raise a with such a great presentation. He answered all your questions. Um, yes, we do have a question. Um, any issue so far that you know of jailing this wires, for example, using a bifurcation? Yeah, probably. It's good. Good to hear from you. So, you know, it's funny. Uh, Jimmy Kerrigan has this exact same question as well. To when jazz and I were doing a presentation. And it's interesting. Uh, yes, you could do this on. I think it's totally fine because it's a polymer jacketed, uh, system. However, uh, I don't advise it. I mean, I don't think you should routinely jail. It's like in a bifurcation stenting strategy. I don't think routinely jailing the wires is a good plan. There obviously electron ICS in there, too. I don't think many of us have done it. Um, I've put it behind a stent before, too. But I knew that I had plenty of room there and I wasn't fully expanded. But you know, there is a theoretical risk of stripping theme the jacket with the electron ICS and then bunking up the wire the process. I don't think you're gonna fragment the wire. There is, of course, that sensor housing as well to that theoretically could get caught behind the struts, Um, again, all theoretical issues. I think it's probably find to do, but probably not routinely recommended. What I will say, however, is that it can easily cross through ST stress after doing a bifurcation standing strategy. So if you're wondering whether or not you need to convert from provisional Thio, you know ah, true bifurcation intervention strategy. The wire crosses really easily through those side branches, and then you could do your intervention just like you normally would. So, uh, multiple operators have reported the great results with that. I've done that myself. I've got a new young partner, just came out of clean Clinic who tried on the wire for the first time, and the first thing that he did was to take it through the side strip, and he was amazed how easily it went so that that really is no problem. But again, jailing wire. Yes, you can theoretically do it, but I don't recommend great, great, great answer. So thanks any other questions again? It was a great presentation. I think it really showed some good case presentations and challenging cases of what you may get counted out there. So with that, we really appreciate all of you coming on and and listening. And again, you have any questions? Reach out to your wraps, or you can reach out to the education Department. We could help steer your still the right resource is to you, but again to everybody out there. We appreciate it. Stay safe out there. And Dr Matthews really way. Have a question? Yeah. Yeah. So yeah, Janet, you know, so are we really appreciate the time you put into this and for helping us and supporting us with the wires. So Thanks, guys. Take care, Everybody. Alright, Stay safe. Thanks so much. Mhm.