As highlighted at TCT 2021, Dr. Ziad Ali and Dr. Allen Jeremias from St. Francis Hospital in Roslyn, NY, perform and describe the steps and strategies used for an ACS patient with tandem lesions in the RCA while using little or no contrast. The operators utilized the latest tools in their lab including imaging, physiology, and co-registration to deliver treatment to significant lesions while optimizing their results to help provide the patient with optimal results in the face of severe CKD.
Hello everyone. I'm Ziad ali I'm joined by Alan Jeremiah's we're gonna be doing a sink, vision guided zero contrast pc. I have the right coronary artery and a gentleman with multi vessel disease. And where we are so far is simply guide engagement. We tried the Jr it didn't really go. We think we're engaged with the A. R. Guide. We might not be. And one of the tricks to determine this is firstly to deliver sailing down the coronary artery. Look for E. K. G. Changes sometimes when the artery is very tight. Like in this situation there's a 90% lesion in the distal R. C. A. You might not get the E. K. G. Changes. And so in that situation what we can try to do is actually use the wire and see if it goes. So that's what we're gonna do now. So as a background this is a gentleman who actually presented to an outside hospital with a cardiac arrest. Um At the time he had a diagnostic angiogram done. His correct name was five. They didn't want to proceed with invasive procedures. And he has tandem lesions in the R. C. A. Mid to distal about a 90% stenosis and maybe 70% approximately and also significant left side of disease. And so the plan for today is um is to do a zero contrast pc. I. Of the R. C. A. And then bring him back for the for the left system. Okay so this worked pretty well. Right. The guy it looks like it was engaged. We got some minor changes on the E. K. G. But not classic which is why we we tried the wire but it worked well. So what's the first step of zero? I'm just trying to, yeah so sometimes what I try to do is to try to get a knuckle. One thing you have to be make sure of is that you're not in some distal vessel but I think that's that's a good sign that we're going in the right place. Which I'm trying to do that. Let me just face it downwards here in advance. That's going in some other branch. That's why I'm slightly concerned that we might be in the pd we're going a little bit too distal maybe do this. Um Come into the R. A. O. Make sure you're not an RV branch. Yeah we might be. So what I'm gonna do is I'm gonna pull back here trying to re advance. That's good. Now we're talking yeah now we're down the path. Okay perfect. So what we also did you guys can't see is that we actually printed the pictures from his last angio. Um And we taped it to the screen and so we have a map we have an outline of where to go. Great. Now the thing we don't have here is the angles. Do you see the angles? Yeah we didn't have them from the old angiogram I'm afraid. So what we're gonna do is we're gonna work in this view. What we're gonna do next is do a sync vision. Can we have the omni wire, please? So, there's two lesions here. There's approximately 10 in the distal lesion. And I think what the omni is gonna help us do is to determine which lesion were. We definitely need to treat. Um, clearly the distant one, we need to an approximate one. Really. What we're going to do is to do things two things. One is to demonstrate how to do a sink vision without zero with zero contrast and then second to see how much pressure is lost. There is an approximate vessel Just to play Devil's advocate for a second. I know this is how we normally do it when there's tandem lesions. And obviously it makes perfect sense. Um, that's how it was designed to find GPS as a as a clinical trial. But one thing that is important to know is that when there is a critical stenosis, 90% plus that overwhelms the system. And sometimes the pressure lost in that one lesion is so dramatic that you won't actually see step ups in the other lesions. So the caveat here is um, you know, we've got to be a little careful if there's no step up. It doesn't mean there won't be a step up once the critical lesion is taken care of. So what we'll do that. Right. So we'll repeat it. I think that's that's what that's my point. I think that's important. Right. And I think what we should do is to try to do a try registration. You know, let's put it in. Let's see what it is. Let's do a pull back, let's do a co reg and then maybe just re advance it in and then do a balloon angioplasty on the other wire and then we can see how it changes. I think that's a great idea. So um can we um set up the eagle eye as well please? So a couple of things if we go back one, you'll notice that we took a fair amount of time to make sure we are where we think we were. And second is we worked um you know, fairly diligently in order to make sure that we got a J at the end of the wire that's specifically valuable because now if we do any sort of pushing it's much safer and we can't get an end hole from the wire itself. So the wire, this is a completely new wire. Right? The reason that that they made this change is because you couldn't talk the wire before. Remember they had the cables were kind of eccentric. There was no core of the wire. So it was a terrible wire. It was completely redesigned the wire based on the BMW. So it has actually a court just like a BMW does and the electrical is kind of in the coding and the outer layer of the wire. And if you use a regular talker, you potentially can, can screw up the electrical connection if you will, that is running outside of the wire. This is a special torture that is has a soft basically. This is my talk has a soft touch. You want to you want to zero this for a second here. Just to make sure we're good and 00. It's not this step. You can skip in the volcano system, but it's nice to do. So this way you're it's a good it's a good habit and were normalized at zero. So now we can take the wire out. Can I introduce you please Rachel? So, this is also a good habit habit in a zero contrast is that we have the first wire to guide the placement of the omni. Now, this is the Omni is a game changer because of its handling characteristics. But previously, when we first started doing zero contrast pcs, we did them all with a service wire. Um because we like to measure the coronary flow, make sure that there was no slow flow. Using the index of micro circulate resistance. But now that's all kind of dissipated as we have the omni wire, which really has very favorable characteristics. And as Alan said, what we're planning to do is to see the change in the crosstalk based on a balloon angioplasty on the other wire. Okay, so we're gonna go in the first step is going to be for us to normalize. I'm gonna take the introducer out and then it's a good habit to just take a little record there, make sure that's good. It's a perfect way for him. You see the diagnostic notch so we're not too deeply engaged. Which is important normalized, please. Okay. Very good. Alright, and then we also record that just so we have it. Now let's see how it goes. That was maybe the little branch warren before, huh? Maybe a little committed. People know that actually there is a tight lesion without pictures. Nobody believes us. Okay, so now we're following the I'm just following the path of the other wire just to show everybody. I'm gonna pull it back a little bit. Take my introducer out. It's a skeptic. So the first thing we do is the spot I fr Yes, it's a systemic you can actually see nicely how you have a change in the waveform on the digital wire compared to the audio waveform. The electronic notches gone. It almost looks like it's ventricular ized. It's actually now lower. Look at this point for Okay, so it's a systemic were approved. We're going to treat not how we're going to treat. So now let's do the pull back. Yeah, so the important things with the pullback er is is really to not manipulate much. So now we can start, I we like to press floral and record the entire floral. So for sync vision it's mandatory. Right, right, you have to pull back slowly by hand. But under continuous Flora Skopje to be able to do a sync vision. This is one of the only things that an interventionist should do slowly. So no jump and and Okay, so that's probably ischemic. Yeah, but that was what I said before. When you have such a tight lesion, you really don't recognize a lot else. Okay, I'm back at the tip of the guide. Don't move anything. Okay now, so the way we do a sync vision with normally what you would do is now inject contrast to co register, right? Obviously they're not going to do that. So what we're trying to do is kind of create a silhouette of the vessel with the wires, which is probably good. Right here and we're going to step on dry ice in it for like two seconds. It's the longest. Right, Okay, good. And then let's try to see if we can co register this one when we were very nice. Now note also that at least based on the picture that we have, it's the all the dots are just a little bit more proximal to the actual lesion, which is a phenomenon called pressure recovery where you actually have to get through the lesion and then you kind of have the have the jump. So I think what we can do next is is balloon do try registration with IV's and then instant this and then, so that would be curious is this let's balloon this lesion, Let's put this wire down right as a second. Wireless balloon and let's have a 3015 or something. Mhm. And then let's re measure to see if in fact there will be another gradient approximately because I guarantee you once the ibises and you're gonna see a lot of plaque. So we have to make a decision what to treat and what we can leave. So at least based on the current sink vision, the plan would be to stent the distillation. Do nothing about the proximal of course we know there is crosstalk but I think the crosstalk is going to be minimal. Um at least based on the lesion. But let's let's maybe Alan's right. It really depends how how tight the lesion is. I think the other concern I have is I don't know if you see distal to the lesion. There is also another you see in that bend. Yeah. So what we can do is I think that's one of the advantages that eagle eye will advance it, make sure that there's nothing tight distantly. But to be honest I'm I'm very much inclined to follow the physiology on the sink vision and really just focus on that and we can do a final physiology and then obviously add more. Exactly. I'll have 3000 have been please. Um So the next step we're going to do is can have their getting us a balloon guys Maybe a 253. Okay. Sounds good. So a couple of other comments. Obviously this is the crux of the R. C. A. And so um what we don't want to do also and the reason we just don't do physiology guided stenting is this is an area of the artery that specifically prone to um just alleged dissection and intramural hematoma because there's no branches until we get distantly. So Right now as you can see the Sink Vision is showing 18.1 mm. And what we're gonna do is just make sure that that's correct based on Ibis as well as based on the physiology. So when you're doing the zero contrast there's there's no contrast in the guide. And so it's a good habit to just make sure that the um the guide is flushed and all of this is being done with saline. Mhm. We'll take the balloon. Great. So that's kind of neat to have a second wire where we can work on and then and then check the physiology at the same time with the omni. I wouldn't recommend jailing it with a stent to we have to remember to take it out before you want to. So I think based on the um sink vision. I think I'm good there. So let's go slow to see if we find the waste in the balloon. Yeah proximal. Right. Yeah go ahead and take that. Maybe you know the sink was actually right on and we just don't have the views lined up properly. 14 I think we got it. Maybe come back. I would just come back a little bit five. Okay. Yeah, I think I think that's good down. So now let's see, Let's see when we take our balloon out of the guy. A little bit of hyperthermia. Don't forget that when we actually inflate a balloon in the vessel or occluded vessel for some time. That is a hyper dynamic agent. And has been shown when you do a 32nd inclusion, that is just as potent as giving a tennessean. Okay, having said that. So that's this thing really works. Huh? Insomnia where really measures the balloon actually creates angioplasty. Alright, so I think what we're gonna do is come back with our omni wire. Now let's do another pullback. So let me just come back a little bit cause we don't need that length of pull back, but we can start from here. Alright, I for pullback please. So important to wait until the blue line which occurs now and then start pulling back and again. The whole thing is under Flora Skopje. And one of the other little tricks is that sometimes when we first touched the wire there was a jump. So you said Ziad. That is actually very nicely was completely flat. And the way he did it was that um we hold onto the wire before we go on. And so this way there is no movement of that. You can stop the so there is a second step up. Yeah. So let's see on the let's re advance re advance the wire a little bit and then we can do another sink. Now, having said that right, the wire is distal to the proximal lesion and it's .92.93. So it's going to be a small amount. It's not going to be a huge amount. Very small. So, this makes a lot of sense to me. The proximal has has changed a little bit by only .2 points. And so I think what we do is use our ivascyn resistant. And then we can do a final I fr Alright, so let's take this this wire out for now. We're gonna we're gonna reuse it. So, this is a this is not a rotational ibis, right? The 20 megahertz volcano. I this is a A steady state. It has 64 little ibis probes actually and it kind of, you know, activates someone one by one and look at this. There's an automatic ring down. Beautiful. It's supposed to take care of it. There's the lesion. So go all the way Distal. Okay. Yeah, that's what I was talking about. There's a little plaque. We can maybe leave that alone. I think I'm gonna plan to leave that alone. Right. So, well, you know, I think so, why don't why don't we start? It's it's it's not huge, but let's go down here. There's some plaque here and then I'm just gonna, I'm just doing a perusal. There's a tight lesion. And so the nice thing about this is you want to talk about the distance between the markers allen? Yes. So the imaging section is at the front of that little bulky um, ivy's scattered in the front and then the first dot is 15 millimeters and then each subsequent dot is 10 millimeters. So I'm tempted to just treat this whole segment. Just so let's do this before we do anything. Let's do a come off. Okay, let's do a recording. Right? And then let's see if we can sync it and then we'll decide it's the same here. Slow, manual pull back under continuous Flora Skopje and then we'll see if the sink is going to work in our experience. It works better for the I. F. R. Pullback than for the Ivies pull back. For whatever reason, A lot of black. I say we're about 50, 50 of our success. So this is a nice landing zone approximately. It's pretty much a normal vessel. I think there should be a little bit of atherosclerosis up here, approximately. Maybe the guide is in a little deep. There. It is. That's a that's a tight leash, it's surprising that it only has, you know, a few units of pressure drop. Now? Having said that, I'm willing to create let's do this, put this back in and let's see if we can sink. So let's go back in and then we'll do a scene. You got to go get it okay ready? Susan step on. Alright let's see if we can do it. This actually is very helpful if you can do it because this shows you exactly where where you are, where the plaque is. So that's kind of nice. Right? And you can Yeah, I think that worked. I think so. Go more distal go right to the distal edge if you could. Okay, good Mark that. Mark that as your distal reference. And then give us a size there. Okay, 2.6. Okay So too will put a 25 device. We're gonna scroll forward. You want to cover all of that and then process here you can leave it somewhere here. What about here? And this is 38. You can make it so we can make our 25 and 35. Good. So do you want to give us a length from the sink vision? I'm not going to touch that because I'm going to believe the physiology. I don't want to put a second stent this one. I'm okay by putting on a longer stent but I'm not going to put a second stint in. Okay. It's based on the physiology. If I do a post pc I then let's let's go down and mark. She's going to tell us here how long we need to be 28 or 30. Yeah. 33. Perfect. But let's go down and make sure. So can you go live virus for me please? Susan I'm in the lesion right here. Okay. Okay so that's gonna be a 33. This is basically 35. Right from the from the office to so why don't you do this just to be double safe? Come back and see if in fact that is what you want to land. It's come back more more more more more. No I was just gonna mark this. Mark this and here. Yeah that's perfect. I'm happy with that. You can have a 25 33 stent. And then can I have a 30. And a 35 N. C. Balloon please. So this is an interesting debate. Right? There's obviously a highly lipid IQ lesion in the proximal vessel. So prospect would say that's a high risk lesion. But physiology says don't touch it in the setting of um a CS. Right physiology was not predictive of future events. So my feeling is this yes there might not be a critical gradient based on physiology but the presentation of him was basically what cardiac arrest O. A. C. S. Right. And so in that case I think that you technically you're right trump's physiology in the clinical setting. Well I mean he had an A. C. S. There's no question he presented with acute chest pain and cardiac arrest is pretty. and and the complete study showed in stemming populations that complete revascularization is better. Let me ask you another question. Does this flowery Am I work when you're doing resting indices? Because maybe FFR doesn't work so well in that situation. Yes, that's that's you know, you have that's an important caveat and obviously we don't know, don't know the answer to that. So what I have up on my, okay, let me ask, let me ask you this. What is the downside of you put already extent you're going to put them on interpreted therapy. You already have incurred 90% of the risk. What is the additional risk of putting a second stand? It's a it's a fair question. Um, you have to come back. I'm happy with that. I'm happy with that. Let's take that. It's actually interesting to see how relatively accurate the ivies 35 mm in services, right? Compared to, yeah. Sorry. Mhm. Okay, I'll take the 30. N. C. Please. Yeah, I'll stay away from the edge because we landed in the normal tissue. Okay, mm hmm. Yeah. So you know, what about what about that? That arresting index might be better in that situation actually. To me it makes sense that it would it does to me too. So obviously, without having the data, you can make that argument, but at least theoretically it should be better. In fact, I would I would suggest that in most difficult. Can you turn on device detection? Thank you, arresting index might be superior. So this is another thing that we commonly do in zero contrast P. C. I. Is used device detection because it helps us to make sure that we stay within the confines of the stent especially when we're not using dye. So a little bit we're going to use the device detection. You get to sign up for this. Yeah. Yeah actually room. I'm gonna go in a little bit. That's nice. Okay. Susan we're gonna do that again. Yeah go up. I think this device detection is a really nice feature for these type of cases. So this would be actually maybe this is a good um topic of discussion. What are the circumstances when you would actually use a little bit of contrast in the plan zero contrast Bc. I let's take that one of which is you know chest pain I think an ischemic changes and so you know what I think what we'll do is you know there's some branches down there. I wouldn't be surprised if we might have pinched one of those off. What I'm gonna do is repeat the physiology here, repeat the ivies. And if that's good first before we let's repeat the IV's first make sure the status code and everything looks good and when we're happy with it then do the physiology. Yeah I like that idea. Alright okay you ready for pullback record please. It's actually pretty nice. Nice transition. Beautiful. Looks good. Alright, so far so good. This is the 35 section here. I think it's appropriate. There's always a positive, positive remodeling. But compared to the proximal landing, which we did well, by the way, it looks great. So now the question is the proximal lesion fix it or leave it so that I think we can at least get a physiology number and then pontificate a bit more good. So that's normalized again. Wait, wait one second actually leave it there. See that's what happened. What happened? This is an artifact where the sensor of the pressure wire is hitting the guide every time it does. That you get this little bounce. Obviously avoid that. There we go, advance it a tiny bit. There we go. That's better. It's very sensitive like you, it's very sense this is why, you know, I I bond with it now. This is such a great wire. Okay, that's okay. Yes, so let's see what it is. So this is pretty distant and it's 0.96. So it's it's hard to argue with that. And to be honest, it was three points in the proximal in two points in the mid. So let's do a pull back and do the same pool and hard to argue with fixing something that basically has no greater. Wait a minute in your trial. Isn't this a good number. 20.95 is what we're trying to get to as an optimal Pc I in GPS. So, absolutely, I would be thrilled to have that in GPS, frankly. No step up across the standard GPS is not an imaging trial. We expect about 15% of people having imaging as a routine practice, but most people won't have imaging. So there's no step up even across that lesion. Yes. And the only step up is approximately, and frankly it is what? Three points. Right, okay. So let's do it. Let's do one sink because I like that. But now it's just a philosophical debate. Do you want to seal the plaque because of a CS presentation or not? It's not a physiological diagnosis. I think that's pretty clear. I think that speaks for itself. Right. I think we're done. Okay, fair enough.