Optimal management of high bleeding risk patient with multivessel disease - EuroPCR 2025

Good morning, everyone. My name is Jean Fad, and uh, we will, uh, with Toma, will share this uh symposium with a live case from Toulouse. We will focus today on the optimal management of high-bleeding-risk patients with multivessel disease. Uh, here we are on the podium, very happy to have uh Chima, Valeria, Davidid, and uh, and uh, sorry, uh, Russia. Okay.

The objectives of the session are the following: First, to discuss the optimal management of high-bleeding-risk patients with multivessel disease; and second, more practically, to analyze how intracoronary imaging first and physiology could optimize procedural outcome in this uh type of patient.

Next, I think we will get uh the all the session team today. So Russia will be our procedure analyst. Our discussion panel includes Davidid, Ross, and Valeria in Toulouse. In the cath lab, the two operators will be Benjamin and Bruno Farah. Our cath lab medical coordinator is Clemens, and onstage medical coordinator, Julia. Next.

So, important uh, because every year we have a lot, lot of questions or comments. So you have two possibilities to ask questions or to give your comment: first, using the mobile application; or second, you can use the aisle-standing microphone. So tomorrow we present you the clinical history of this patient, and then we could discuss before taking the line to uh uh to Toulouse uh about the particularity of the clinical and angiography particularity of this patient.

Yeah, thank you, Jean. Dear colleague, indeed, we'll share with you the case selected by the team in Toulouse. And before going live, we'll have time to discuss the case, about the strategy. So, really, please uh send us your comments, questions, and contributions either by the microphone in the room or in the app.

So, it's, as you can see, it's a regular elderly and high-risk patient; it's a male of 85 years, uh, coming with a stable angina and on the non-invasive testing, namely myocardial scintigraphy, this patient had significant ischemia in the inferoapical part with some degree of ejection fraction decline after the stress. And accordingly, because of symptoms and ischemia, this patient was scheduled for invasive coronary angiography. He has significant prior medical history; the patient had a pacemaker, paroxysmal atrial fibrillation, and 15 years ago, he has been already treated by a drug-eluting stent on the LAD.

If you have the patient details, just showing mainly that we are dealing with a very active patient still, and significant cardiovascular risk factors with diabetes, hypertension, and dyslipidemia as the medical therapy. This patient received a low-dose rivaroxaban for atrial fibrillation, associated with a single antiplatelet therapy with aspirin, and he has also some medication both to tackle the risk factors that we've just described, but also some degree of anti-ischemic drugs, and and mainly low dose of beta blockers. On the laboratory investigation, the patient had normal hemoglobin, uh no significant troponin release, but as you can see, a slight degree of renal dysfunction in this 85-year-old patient.

So now let's move to the coronary, uh, invasive coronary angiography, and you can already see, even before the contrast, that there is a diffuse disease with some degree of calcification, and we we can see already a significant lesion on the LAD that we will see much better on the cranial view. And interestingly, just remember that the patient had already PCI of the LAD. It will be interesting to discuss whether we have a de novo lesion, an in-stent restenosis, or probably the two types of lesion. Again, on this view, we can see that there is also an intermediate and significantly calcified lesion on the left main that will need to be discussed and probably assessed. And on this view, we can see a bifurcation lesion on the circumflex with the first marginal branch on quite a small vessel, but still probably a 111 lesion. And again, on the right, there is, in the mid part of the right coronary artery, what we can call at least a significant, if not critical, lesion of the mid RCA that we can see nicely also on this view.

It is so just uh to summarize the patient presentation and the risk assessment as well. So we are dealing with an elderly patient, 85 years old, trivessel disease, mildly reduced ejection fraction, in a diabetic patient. And according to this, let's say global presentation of the patient, the decision of the team was uh to go for percutaneous revascularization with a staged PCI. And accordingly, the team in Toulouse decided to treat first, probably the most critical but also not the most complex lesion, which was the tight lesion in the mid right coronary artery, and implant an Ultimaster Nagami 2.75 by 8 mm, and as you can see on the right part of the of the slide, with a good angiographic result.

So just to summarize and to open the case for for discussion: We have an elderly patient with oral anticoagulation, coming for both angina and identified ischemia on the non-invasive test, trivessel disease with already recent PCI of the LAD, and still significant and calcification on the LAD and the circumflex, with what we can call, on the angiogram, an intermediate lesion in the left main. I think the case can be opened for discussion with the with the panel and of course with the with the audience.

Now it's true that uh uh the difficulty here in this patient, which was octogenarian, diabetic, normal renal function, and uh this problem of hybrid risk, the problem, if for me, it's the left main, but there's no doubt on the trivessel disease. Mid-right was critical and already treated; LAD really severe; and we have this lesion at the bifurcation circumflex. But when you look at the angiography, before you know the injection of contrast media from the guiding catheter, we have a really a zone taking all the length of the left main and the distality of the left main which is calcified. And so the difficulty with the to appreciate exactly uh the uh amount of calcium on this left main and if we need or not to revascularize this.

Yes, maybe Jean, we we are dealing with an elderly, challenging patient, multivessel disease, and the first question for you, Valeria. We learned for for many years the concept of complete revascularization for the best prognosis of the patient. What is your your practice in such frail elderly patients with high bleeding risk?

Thanks, Tom. That's a great point. Indeed, complete revascularization, but we're facing now uh a stable patient. So we're not talking about an acute coronary syndrome, first of all. And then when we look at this patient with a really high bleeding risk and also high ischemic risk from an anatomical point of view—left main, bifurcation, anatomically, from a procedural point of view, multivessel disease—and also patient-related CKD and diabetes, I mean, this patient is really complex. So I would aim for relief of symptoms and reduce ischemic burden. Okay, so it's not complete revascularization is not absolutely an absolute role in this kind of patient.

We can ask David. When you look at the clinical presentation of the patient, this is octogenarian, symptomatic, and evidence of ischemia in inferior and apical wall, and and with a light left ventricular dysfunction. So when we have this kind of uh, you know, ischemia already uh shown by the non-invasive test, is there a place for intracoronary physiology testing?

Okay, so let's say, of course, a trivessel disease, left main. I think particularly in an in-stent lesion patient, we need to simplify the procedure as much as possible to avoid placing too many stents, otherwise we become reliant on the antiplatelet medication for a longer period, and this may be an issue with this patient. So using uh IFR or FFR in this case can help us to rule out some lesions that look like tight and they are not functionally significant. I'm thinking of the circumflex in particular because the scintigraphy tells us that the anterior wall and the inferior wall are involved. So the left main system and the right coronary artery, we don't know about the circumflex, but because this is already a very complex patient, I would recommend not to study this circumflex because the scintigraphy was negative on the lateral wall. So this is a situation where I would try to avoid looking for troubles because we have already many troubles to address.

Okay, thank you, David. Maybe speaking about the left main, so it's nice that the comment from David is aligned with what Valeria said already about the complete revascularization. This left main, on the angiogram, it's what we call intermediate. And in our words, I mean, intermediate means I don't really know what it means. How you will assess the left main then to decide in this in this specific anatomy?

Yes, Thomas, I think the left main is going to be a bystander here because the culprit lesions are clearly LAD, which is pretty severe, and maybe, sir, I don't know, the right was also treated. There was ischemia in the scintigraphy. For assessment of the left main, you see geographically an ambiguous lesion. We have physiology, but physiology, we have the problem with the downstream lesions. You have lesions in LAD and circumflex, and you cannot make the evaluation properly. Imaging is better because you have the possibility not only on assessing the lumen, but also the calcification, the plaque distribution, the compromise of the ostium, observing lesion, in order to plan the treatment of the left main. You are going to treat it, and we have a cut-off. What cut-off? We use a cut-off that comes from all the studies we conducted, which is to use six square millimeters with IVUS. If you are the federal criteria, you have more than six, you can leave alone. If you have less than six, you should treat definitely. It is less than 4.5 or five is significant. Between five and six square millimeters is the gray zone that sometimes we do physiology. But uh, keep in mind that for doing physiology here, you need to treat first LAD in order to have the flow. Then in my view, imaging is better for this left main. Uh, IVUS, uh, you have the the advantage of not having the problem of the blood in contaminating the lumen of the main, and the contrast is a kidney disease, and also we had the cut-off. OCT could be used as well; uh, the cut-off is not so clear, it's not validated, it's uh should be around 5.5, not six for OCT, but uh definitely I would use imaging uh on this complex left main to see the lumen with this cut-offs in mind and also the distribution of the plaque and classification. So it's usually difficult because of the older lesions, so probably imaging and six cut-off for IVUS and 5.5.

So I have another question. When you look at the angiography, it's really calcified main and proximal lesion, uh, so, Valeria, when you see this angiographic feature, uh, do you see that there is room for plaque preparation, plaque modification, and uh, when you see this angiography, do you use, you do decide to use a plaque modification device just on angiography or do we need intracoronary imaging?

A great question, indeed. Um, from angiography, you see that there it looks like a very severe, severe uh calcium in the left main, but we need to see more, understand the calcium distribution. If this calcium is uh only uh in the vessel wall or is the superficial calcium also affecting the lumen. So we understand, we need to understand that better. I think intravascular imaging can really guide us, and at that point, I would choose for one device or the other um depending on the presence, for example, of calcific nodule, you might expect the ostial LAD or bifurcation. Presence of calcified nodule, we want to understand better what's going on in that stent in the proximal LAD, for eventually consider IVL treatment. But long lesion and discrepancy between calibers in the left main and LAD may also open, for example, the the way for orbital atherectomy.

And Valeria, speaking about dedicated devices for calcium, the fact that this patient had a stent 15 years ago, do you see it as an issue or not to use, for example, you know, the different type of atherectomy?

Yeah, that's also a very good point. I mean, we don't have data about the use of orbital when when you treat uh a lesion, a stent implanted 15 years ago. We have more reassuring data for what concerns the treatment of IVL. Uh, but indeed, the stent was placed 15 years ago. I think it's more important now to understand what's the mechanism of of this stent failure. So stent many years ago, not a big issue for dedicated devices. Yeah, probably we can now have more in-depth analysis of the of the angiogram thanks to Rasha. Please, Rasha.

Thank you, Toma. Um, so we just have to keep in mind that the images we have are limited because of contrast and the patient has CKD, but we can gain a lot from what we have so far. So this is the cranial view, and you can appreciate, obviously, it's very clear the lesion right here. So I don't think anybody can argue with that. The question is where exactly within the stent is this? So the stent technically ends around here, at least based on angiography. So there is a possibility that this lesion is beyond the stent. Now moving on to another important aspect is we don't really know the extent of the bifurcation up into the uh diagonal right here. So another cranial view would open up, and there seems to be also another diagonal lesion there. And one more important thing that we we uh talked about already this morning is earlier today is that you also have this short left main, and you get the sense that there is actually tubular disease. So if you look at the caliber of the left main here, it's actually similar to the caliber of the LAD. So it gives you a sense there might be actually more significant disease here than we think uh right before the injection. And it's really important to pay attention and do a cine with a few seconds before contrast. And you can clearly see the amount of calcium here extending from the left main all the way down to the LAD. So what we don't know yet, and I think imaging will definitely help a role here, is that one is we need to know how much, what's the minimal luminal area in the left main and if we need to treat or not. Two is we want to see the extent of the ISR, the mechanism of ISR, and the extent of disease beyond the uh this the stent or not. And the third thing is that also to look at the calcium distribution and whether any calcium uh modification technique that we need, we need to or if we need to use, and what kind of what kind to use as well. Um, and then one last thing on this slide is that if the left main is significant um and if the operator needs a stent beyond the initial stent, it would be nice to have a platform that covers all the way from distal to proximal with a long stent. And most importantly, it has the capability of oversizing in the proximal segment. So we know that they did a 3.5 around here. So 3.5 can expand to 6.25 in some platforms. Uh, now moving on to the second slide, which is uh on the caudal image. Um, and before we move on to the circumflex, just one more point on the LAD lesion. If the left main is not significant, they do have a good landing zone, at least angiographically, which we'll see on imaging. You just need to make sure that it's proximal enough to the um diagonal for a good pot. Now moving on to the last lesion here. We do have a circumflex lesion. Um, it's more of an OM2, but it's also bifurcating OM. Um, it is a 111, but we have to keep in mind the size is around 2.5. The ostium of the side branch is actually less than 5 mm in this in terms of length. So if the operator decides to treat, especially with the clinical scenario of high bleeding risk, a provisional strategy might work in this scenario.

Thank you, Jean.

Thank you, Asha. Thank you, Russia. So now uh now tomorrow you can uh uh summarize the the situation and uh look at the strategy. Before that, we have one question coming from the audience. Explain and you will explain the risk and the benefit of staging the procedure, ah, to stage.

Yeah. Before starting. Yeah. It's it's always a difficult discussion because we have elderly patients which sometimes have very challenging vascular access. So it's true that sometimes we want to we want to do all in one if the vascular access is difficult, but on the other side, we have patients with impaired renal function in which we want to save some contrast also, and sometimes to split the procedure, especially when we know and we we have the feeling that the second one will be more complex with left main, LAD, and maybe the circumflex as well. So I think there are pros and cons, as always, but probably if we don't have very challenging vascular access, I will also go for staged for several reasons.

Second question coming from the audience. It's a patient, octogenarian, I think it's 85 years old. When you look at a lesion of the left main which is calcified, in one view, cranial view, is it looks angiographically 50%; in the apicocordal view is less than 30%. In other words, in this intermediate lesion, the age of the patient is a major impact on the uh the decision of angioplasty. In other words, the same lesion in a 50-year-old patient, we change the strategy or not compared to 85?

Thank you, Jean. It's a very challenging question. I think that's my role to give you the, as we discussed. I think for the circumflex, 85 or 45, it's another story, but still, the left main is the left main. So I will, I think I will keep the same way assessing the left main as we discussed, either physiology which might be challenging here because of the downstream lesion. So probably by imaging, and after, we just have to decide. I think in very frail elderly patients, sometimes you can decide medical treatment, but still, I think it's the left main, and we need to assess it properly. I think so.

Just before going to to Toulouse and join Benjamin and Bruno for the management of this case, we would like to to share with you what the team in Toulouse decided to to propose to this uh to this patient. And accordingly, just to review the objectives we'll try to achieve together with this uh live case, it's of course, as we already started to discuss, management of complex multivessel disease, to illustrate the role of intracoronary imaging in complex PCI, and probably more to the end of the session to also review the possible DES strategies for such high-risk patients with complex multivessel disease. And the procedure decided in Toulouse again was to do a staged procedure because PCI of the right has been done in the first setting with a right transradial access, using glide sheath, slender, and seven French extra backup guiding catheter, to use a high-quality OCT acquisition for many objectives. The first is to assess the lesion of the LAD, and as we discussed, the degree of calcification, but also to to know more about the in-stent restenosis mechanism in the LAD, and of course uh to assess the left main lesion which is still ambiguous on the angiography. And based on that, we will do a, they will do a clarity-guided uh treatment of the LAD and maybe the left main, and they will take a final decision for the circumflex strategy.

So Jean, that's the that's the plan of the team in Toulouse. So I think we can join Benjamin and Bruno into Toulouse in the cath lab.

Hello. Hello. I don't know. Hello. Do you hear us?

Yes. Yes. Perfect. Hello to Hello Jean. Nice to see you. We have already heard all the the comments of the experts, and we we we have uh we we we have we we agree fully what was been done. Uh, we have already advanced in the case and uh you know we have done the OCT, the intracoronary imaging, in order to clarify some points, the points of discussion to to treat this patient as good as possible, and I think that now we are ready and with Benjamin's OCT. So Benjamin, you have done the OCT, there are many points to discuss. The first point is the mechanism of the in-stent restenosis in the LAD. What's what's the point?

Absolutely. And first of all, I want to show you uh the OCT that we use because we use a new catheter which is a Viscet, which has 1.8 eight French uh compatible, and you can see how it's easily cross the in-stent restenosis without predilation. So this new catheter has axial resolution of 12 micron and a depth of 16 mm. So it could be very useful to analyze the left main because you rate the issue of the left main which was the main issue that we have to face with Bruno. Do we have to treat this left main? And if you go on the OCT, we dive directly on the pullback of the OCT. We will go first on morphology, and morphology at the level of the in-stent restenosis. You can appreciate that uh the MSA is at 0.8 mm square. So very tight, and we know it from the however, we have information on the mechanism, and you can nicely appreciate that there is a lipid plaque. It's

Neatercerosis with the lipid plaque. If we go a little bit higher, you will see that the osteomos diagonal is involved on the stent. It's covered by the precious stance. You can see my guide wire at 5:00, which goes through the struts. And this is something that we have to take into account because if we have to treat with a new stent, which will be probably the case with neoatoscerosis, we will have to be careful not to lose this jagon albuno because of two layers of struts. That's the other point.

The other point is you can see at 10:00 and 11:00 there is also calcification in neoateroscerosis. So neoaterosperosis is the main, uh, is the main mechanism of instant stenosis, lipid and calcified, and interestingly because we, uh, know the history of this patient and we know that it's a 3.5 stent which has been implanted many years before, and you can see on the, you can appreciate that the diameter is nearly 3 mm. So there is a little bit underexpanded stent, which is a mechanism underlying the instant stinosis. So to summarize, we have neoasteroscllerosis for instant mechanism led, and we have the diagonal which is covered. Absolutely.

So now we move to the left main, the left main, and you can appreciate and we heard about the black box under 6 mm square, and we are nearly, we are nearly in the left main, nearly 7.5 to 7.8 a minimum square in OC, and so far I think the main point for this patient, this old patient Ashbear, is safety, and we have MLA on the left main nearly 7.5 to 8 mm, which is not normal, but this is not critical, and so with Bruno and all the team we decide to treat it medically and to avoid a strategy of plasty in this old patient on the left main. So to summarize, we will just treat LED instant stenosis, taking care of the diagonal, but we will not treat the left main with the result of the intracoronary imaging. Absolutely. Absolutely. But this is, this point is very important, but Valeria says we need a proper landing zone.

So if you go on the distal landing zone, there is a lipid plaque at the edge of the stance. Uh, you can see it from, um, from 6 to 11, there is an important lipid plaque. So we will try to avoid a burden plaque burden at the distal edge of the stent. But if we go also on the proximal part, on the proximal LED, we also face from, uh, a lipid plaque on the proximal LED. So the strategy will be to only treat the instant stenosis, try to stay on the L, but keeping in mind that there is a high burden of lipid in the distal and proximal edge. Okay. So I think that we can move now to the treatment. So what's the strategy to preate or to prepare due to the in, due to the mechanism of the instant stenosis, and what, what we choose is we, we should not lose this diagonal. Okay, this diagonal is important, and so we first going to treat by a kissing to be sure that the strut from the first stent will be enough open to avoid a coverage with two layers of struts of this diagonal. Does it make sense for the panel, or any comment on the OCT or the strategy?

No, I think it makes sense Bajama, and as we said also the timing of restenosis was also a good argument to think that it might be neatosclerosis and consecutively as you say that will be probably a good indication to put a new stent while we earlier earlier rest stenosis we could have considered other options, but clearly not in this case. I think that also the rational to treat the diagonal first and to do a kissing set, we don't have the information about a possible kissing during the first intervention. So I think in this kind of situation, probably the doing a kissing is, is a good option, and you see there is some difficulty to cross. So it's a, it means that probably there was no kissing during the first procedure, and you know which type of wire do you use for both? It's okay. I think for the LED it's, it's a run-through wire, and Banjama likes to use the filer X in order to cross the struts of the stent. FC, FC. I like this guide wire to recross the straight. I think it's a perfect, of course we have to be for the younger in dimensional you have to be careful with the tip of this wire, but for recrossing it's a perfect wire. Yeah, David, you and now we advance the, the balloon in the, in the diagonal is a small one, but it's just to open, and we want to avoid to have a dection in the diagonal and to complicate a little bit after the, the procedure. So, it's a two. It's a little bit on the side, but it's just to really to open the struts of the stent before putting a new stent. And for the, uh, uh the LED, it's a three. It's a two non-compliant balloon in order to, to stay on the safe part and not to go to, to very high diameter.

Yeah. But we know we have a question from, we have a question from David. Now let me just underscore sometimes in elderly patients we're hesitant to use OCT because we are afraid of the contrast, etc. But in this case, it shows how it simplifies the procedure more than making it more complex because there is less metal in the end as a decision, and we discovered the two mechanisms that are likely the reason for this PCI failure, neottheroscerosis and underexpansion. So because the OCT is on the table, I guess that we will also see the result and optimize. You're right. It's contritive. Sometimes using imaging makes your procedure simpler. So that's, that's a very important point. Just a question Bruno concerning the length of the balloon of the diagonal. Uh, the question is it's a long one. It's a 20 mm. Yeah. And the question is why 20 mm? It could be, it could be a short, why it was the preference of Benjamin, to be but I think that the shorter will be, will be very accurate. Yeah, the pilot is deciding. Yeah, I, I like to use a 20 mm balloon for the side branch. I think it's very stable, more than the 12. So, but again, it's a, it's a personal, uh, preference. Yeah, I want to make a comment in the OC was clear that there was no side branch opening, was a full jailing of the side branch. This, this is remarkable because this illustrates how important it is to, to do the procedures properly for thinking in the future because if you have a restinosis in the LEDs 10 and you don't have a side branch opening, maybe you have a compromise of the side branch and this may also become occluded then, uh, I think it's always important when the diagonal or the side branch it's, is large like this to finish with side branch opening and kissing, something thinking in what's going on in the future. Yeah. And it's going a little bit against what we used to do. Okay. Probably I will do another inflation down to the, this is not, not enough for the distality of the stance. So we will, we will take, but we don't need to do kissing, just the three. Absolutely.

And Bruno, know the distal part of the lesion is outside the stent. It's proliferative the restenosis or it's just within the stent. Uh, we have some disease beyond the stent, we, as mentioned Banjama, there was some disease and all, there is no landing free landing zone without any alter, so it's complex to say that here to have a free landing zone without any disease, it's a quite diffused disease, uh, for this patient like for also the bifurcation when you look at the bifurcation of the cell complex, it's a quite long and diffused disease now. As, as, as Bruno says, there is a lot of, uh, you can see it's not enough prepared because the 3 mm balloon non-component that we use first has some difficulty to cross, uh, this legion, so maybe I will, I will need to take another one. Okay, just a matter of, okay, you remove it a little bit, I test please, okay, this, okay, okay. Another point is you've seen that left main is disease is not critically but it's a disease. So I have to avoid to, to make injury with my guiding catheter, and there is a lot of friction in the guiding catheter to, uh, to take, maybe I will do a higher inflation just here. Yeah, Uno. Okay. Here. Okay. I like to have the, the balloon nicely inflated like this. And Bruno, as you say when we have a question that, sorry please, no please, please, tomorrow I think, no, I think it's good that when we have stent failure we have to look for mechanical also explanation, and you nicely show that there was some degree of stent under expansion and then you optimize it before placing just another stent. Yeah, absolutely. And the question on this mix neoeroscerosis which is a lipid and calcifications, does we need a specific plaque preparation and do we need other tools than non-compliant, and for that purpose we propose with Bruno to, uh, to make a run of OCT to be sure that we have enough prepare our instant stenosis before going to another stent because the risk is on this under expansion, underexpended stent is to go for another under expansion of the stance. So I think we are pretty concerned about the kidney disease of the patient, but I think we, we, we will need another run of OCT to be sure that we have perfectly prepared this lesion. Maybe we will do an to see what we have done. Just a question, uh, from the audience. In this, uh, case of instant trait on the LED, do we prefer to use semicompliant balloon low pressure or NC balloon high pressure? I definitely when I'm facing stentis I prefer to go with the NC balloon in order also to have a high pressure and to be sure that the stent is better expanded. Thank you. Okay. So and graphic is much better. We can see that on the distal of the stent there is some again some narrowing, but we keeping in mind that at the OCT there is an important plaque burden lipid plaque burden at the edge of the stent. So if you agree Tomar and John, we will go for the OCT to control that the preparation in the stent is enough. Yeah, and probably we will also have to answer another question because after this predilation I have the feeling that maybe there is a proximal dection but we will control it. They will change our strategy. It will change and there's no dissection of the Austral, we'll see and you know sometimes the angography also is useful, but the beauty of OCT that you can have both the NGO the acquisition and then the imaging just after. Yeah, exactly. And just Bruno for this specific run you, you speak about, you know, to assess whether plaque modification has been optimal or not. What you will look at for this specific intraulary imaging run to decide.

Yeah, I will, I will especially see the MSR, the MSR after preparation if we have enough. Um, we will, we will not seek for fracture of the calcium or or specific things, only the MSI in the stent which will be probably appropriate to, to put another stent and crossability of the device looks really nice. I think one of the key points here at this stage is really the length of the stent as well because of this, uh, shoulders of the balloon that may have impacted on the landing zones. So if we have dissections we will go for the longer stance otherwise a shorter one could be longer. Okay. Okay. Always in this view the, the trunk the left main is, is worse than the other one, but we have to trust in the OCT for the left main. Uh, but of course when you see the angio, so maybe we can share the OCT, uh, on the screen. Okay. Okay. So would you be kind to make the stop on the interesting point please? So this is again this is a new city. This is not a core, a true core, core registration that you are on the right. This is will be on the second, on the second generation. Uh, however, you can nicely appropriate in this see understand that we have improved for sure 1 more than 4.5 mm square. There is blood swirl which, uh, we are still inside the stent. Yeah. And we are still inside. So we are still inside the stent, and if you can go Germany on the oium of the LED please go back a little bit left me here. Yeah, Johnny, if you can go on the, on the oium of the diagonal that we see, you can see the wire at 7:00 up. So the straits are well open, so that's a good point. So now I think we are pretty convinced all that MSI is enough to go for a treatment in this stent. However, we will focus on what you see on angiography and go on the proximal le to be sure that there is no dissection. But I'm pretty convinced like Jean and Bruno that the oium of L there is a dissection and you can see nicely at 11:00 the experience and, uh, if we go on the nearly the bifocation with the left main, do we have enough place to treat and yeah, but change our strategy, what do you think we know, what do you think in the panel for, for my position I think we will not have the choice to, to, to not treat the, the left main because we don't have a proper proximal lending zone. What do you, what do you feel?

Yeah. Well, you are more experienced than me for the evaluation of the intraornary emerging but effectively here it will be interesting to know if they have the space or not to put a stent, uh, before the left main and if we don't have this space we have to, to treat the left main. Yeah. J, can you go just at the bifurcation of the left main, the distation again frame one, so this here, okay, so what do you think, do you think that this is proximal landing zone is enough, is enough safe to go for only strategy LED strategy stent? I'm not sure of that, will provide a variable opinion, well I think it was challenging from the beginning finding a healthy landing zone in this proximal LED and we also saw from OCD clarified very well that indeed there was a high lipidic burden the proximal stent edge. So what happens when you dilate with a, with a non-compliant balloon, with a balloon in general, sometimes you have slippage of the balloon, uh, also especially in this neoccllerotic calcified lesion. So it may happen indeed that the balloon, um, slip, uh, proximally or distally and may create a dissection and that a risk you take. I don't see an healthy landing zone here. So I would proceed for the left main. Okay. Yeah. Agree. And can we reassess the left main on this run? Uh, yes please go ahead. Jo, could you be kind to go upper on the left main? It's not to have a, this time not to have second. We have to take a decision about the second wire because we have the wire in the diagonal and probably we have to decide to, do we leave it in the diagonal or do we put it in the circumflex because now we have to treat the left main right, it's about the same, we are still above six but it's borderline, it's that without learning zone in the o led I think makes sense to cover the left main tending the o of the led in presence of plaque in the led main in the dist main the mother distension is always a bit complicated. In that case is you take it you cross over the led main and you use the led as a landing and you treat the plaque, it's not treating something the decision is made more, and Bruno would you consider to do predilation of the left main and very proximal le if finally we'll take a long stent covering the left main or you think just the predilation of the let's say the culprit lesion we identify was enough? Yeah, I'm pretty convinced map because in the we have seen that it's more lipidic in the oium of the LED. So I think it will be enough to tackle it. If you agree I will, uh, just remove my diagonal wire and try to place it in, in the circumflex to protect, but there is an important angulation on the circumflex. Go. So now you, you, you put the second wire which was in the diagonal to put it in the, in the circumflex because the territory is larger. Uh, we have, we are in six French and we are, we are not in seven French because, because we are not sure to treat the left main and we feel that if the war have a very diseased left main probably to put a seven French could be an issue with the dump, dumping of the, of the pressure. Okay. So interesting real life case and this is real life, this is complex decision. So now the, the stent that we put, what's, what size and what length. So this is important coming from the OCT and we have a distal zone, we are pretty convinced that on dist we are on 3 mm stent, if we go it's 2.66 in luminal we cannot appreciate the eel diameter because it's too diseased, so on the lumen is 2.66. So you have to increase by 25%. So we will go on, on a 3 mm diameter stent. And if we have to, to tackle all the lengths, so Juani can you make a measurement from the middle to the, the oium of the, of the left m will be more on 40 mm and we will need a long stent. Uh, let's see the, the technical point is the, is the 3 mm stent enough in diameter for the left main because we'll have to expand after this 3 mm stent in the left main and what is the size of the diameter of the left main, we know that the 30 can reach 4.5 but it is over 4.5 maybe we have to consider to put two stents, what do you think? I, I think we can nicely, this is an interest of the ultim masteraster, can we have a full measurement? Yes, please, count 40, 44. Yeah, 44, 44 mm, mm. So we have a, a platform that can be deformed. If you talk about the platform of 3 mm, we can nicely deform it to 44.5 to 5 mm the master nagumi. So I will razor one, take only one stent, Buo, because there is also instant stinosis. So try to avoid multiple layers of struts and to increase according to the OCT the diameter of the Nagumi stent from 3 to five according to the OCT. So to be clear, not all the stent or not all, not all the 30 mm diamond stent can, can reach 4.5. Oh, that's the strength I think on the of the Nagumi. And what is the size on the OC of the left main Bruno? You say it's, what's the, the diameter of the left main? What's, can you refresh for us the diameter of the left main, please? At least 4.5. Yeah. Between 4.5 and five at least. Yeah. So would be suitable over expansion of the negomi. That's, and as you say it's, it's not the case for many tree hosts and okay, yeah, okay, so you can nicely see that it's crossing quite easily, so now we will, it's a 44 mm, yeah 44, so we will check in this if we are in the LT zone that we want to reach, so please Ela make a test, we know, okay, up, so for the distal. It's okay. And now we have to go in order to separate the extending. Yeah. Maybe just to explain you go in cranial because it's usually the best of the, of the left main. Yes. You see here we can see the separation between the aorta and probably maybe will, that's okay. Yeah. I think, uh, it's okay because the stent, the stent is inside the margin. So know if you agree. I think the position is good. Okay. So let's go. Nominal pressure is 12. So I go with 12 or 11. Yeah. So there's nice expansion of this tent and a nice bubble inside the balloon. What is, what is the pressure? Okay. 12. 12. It's 12. I, I don't want to go, uh, to too high pressure because I don't want to have a distal dection. So I go nominal at 12. Probably we, we will go back with a 35 maybe for a proximal before the diagonal and with a 50 for the left main. First we have to check the, the patency of the different side branch that is the circumflex the main one and then to look at the diagonal and do the pot and, and of course we have to be very careful, try to avoid a stent failure with the guiding catheter, we, you see Benjama is doing very gently, he's not removing very fast the balloon, is taking especially when we have to do that with a long balloon where there is more friction, more tendency of attraction of the guiding catheter. So you

Have to take time and here the balloon is inside. Sometimes you deflate. You see he's doing that very gently. He pulls back his guiding catheter in order to avoid any damage of the proximal tip of the stent. Oh, that's an important, uh, beautiful demonstration. An important moment.

Yeah. You have to be very careful not to be attracted by the Jung wire, 5 by 8 please, for the pot on the stand because of some degree of calcification and stain filler as well. Would you also consider what we can call the dot that sometimes we do, also, is to optimize the distal part, you know, of the stent with a higher pressure?

Yeah, probably. Yeah, you are right. Okay, tomorrow we will do it. We have to do multiple optimizations here again.

Yes, absolutely. Again, but the first one is the pot in order to be sure that after there is no difficulty to recross toward the left. Maybe we can do an angiogram to see the patency of the circumflex, but it's true that, uh, for the people in the room, when you have done this, we know definitely that, uh, in the left main, the stent is undersized and not well opposed. So the first thing to do is to do the pot with a 4.5 mm balloon in the left main, and then we will be sure to have a good opposition, and then we could work on the side branches on the distal part of the stent. So we have seen on the diagonal is patent and also the circumflex is patent.

Okay. So now you will advance the non-compliant balloon. Okay. Okay, five 50. Okay. Yeah, 5. We will check it to be sure that we are not too distal. Okay. I think I can advance it a little bit. Yeah. Of course, I'm not perfecting the Okay, please go ahead. Straight forward there. It's great. So we try to be just at maybe you see he pulls back a little bit. Yeah, definition. So you can appreciate that. Uh, okay. So now we have opened the, optimize, sorry, the left main, probably because we are okay, go ahead again. I hope it will not it's like a okay, it's better. Probably we can go back with a 35 because it's maybe too big for this, and now we will do the same, that is to remove the balloon and to be cautious with the tip of the stent.

Okay, perfect. So I think that we can go with a 35 at least 12 mm non-compliant balloon. We will recross the stretch of the circumflex first. So can I have another filter? Oh, you don't want to optimize the proximal LED? No, we will do it. Um, we will discuss it after. Just I want to get out this jail. So, filter FC please. So, maybe we can do an angiogram. Okay. Okay. But this circumflex is correct. Absolutely. We don't have any problem. And sometimes I think the diagonal is patent for the pot. Do you feel that sometimes, you know, the system of stent enhancement, stents, or stent boots can also be useful? Sometimes I think in this case you have beautiful views to position the pot balloon, but it's true that sometimes it can be useful. Yeah, correct, that's perfect. Here the we will, you will try to, we cross toward the D, to the circumflex, sorry. So the tip is to go inside the LED if possible with a loop to be sure that we are not under the struts of the left main stent and then to pull back the wire and to jump in the circumflex. So as you can see, so here is the aorta. So the difficulty is to be coaxial with the guiding catheter because there is a jail wire, but the circumflex is perfectly patent. You have to be very gently. So what's important, it's of course important because we have a jail wire in there, complex that we could not intubate the left main with the guiding catheter because of the jail wire and, uh, so this increases the difficulty to place the wire, the third wire in the left main. Okay, now it's done and, um, as you did for the diagonal and you use a filter again to recross the strut if I'm not wrong. It's still a filter. It's the Yeah, it's a filter FC. Yeah. When you have such a difficult, it's a challenging case, but you can see that there is a you can see the angle of my guiding catheter which is attracted by the circumflex guide wire, and as Bruno says, the circumflex is patent and maybe I will remove the no because you, when you say that you cross, you see maybe maybe you cross. You just support yourself a bit. Yeah. But effectively as the circumflex is patent, you have the possibility to remove the wire. For sure it helps you to recross because it shows the pathway, but sometimes it's also a limitation and you can just work with one wire and to recross thereafter and then to improve your intubation.

Okay. So we are now in a better position and we'll try to make a better angle. Okay. Let's see. So immediately you see that the guiding catheter now can be pushed inside the left main and to have a coaxial access of the guiding, the distal of the guiding, honestly, the maybe we have to look really nice. Yeah. Yeah. Absolutely. And there is no destabilization of this ostium, keeping in mind the key term that we use at the beginning of the case is safety. So, okay, the realization of a kissing could be discussed or not. That was exactly my point, Bruno, but to say that well what maybe what we can do is to optimize with a 35 non-compliant balloon and then do the OCT, but in this, during this time, you I think that you can have a lecture and so you have time to do the optimization of the proximal LED and then we do the OCT and we come back to you with the OCT recording to see if we have to do some work more on the left main or on the left. Yeah. And before the lecture we can ask to all the members of the panel what we do for the ostium of the circumflex balloon, or nothing.

Okay. Perfect. Okay. We have, you have time to think of I would ensure that there are no struts in front of the circumflex, it's too much an important side branch. So I would balloon it. Okay. Honestly, I almost always do kissing for the left main, but for this one, looking at the injury in this specific patient, maybe I would stop. Maria agrees with Toma, indeed. I mean, opening the struts towards the circumflex is really to allow further intervention. Do we really want to go for further intervention? This I always do say branch opening, I want to leave the door open behind for the future, and you have a bifurcation in the circumflex which is diseased, yeah, but we decided to leave it alone. So I think if we don't treat the distal maybe in the future, in a few months, it's 90% with symptoms and you have to go to the cath lab to treat it, then I prefer to do branch opening in the that's why we so maybe because I am the oldest guy here in the panel, but I will leave the conflict like that, but you know it's interesting to discuss. Nobody knows. So maybe Jean, while they are optimizing proximal LED and doing the OCT run, we can ask Valeria because they're already exactly nicely mentioned this, the Ultimaster Nagomi stent they use and the mechanical overexpansion capability. So probably it's a good moment that for Valeria to update all of us about this specific stent platform. An update on Ultimaster studies and, uh, this is the most recent technology by Terumo, indeed, the Nagomi drug-eluting stent with an inherited technology, open-cell to link design from the previous Ultimaster, but also shortened struts and beds widths which increase flexibility. We have three platforms with increased expansion capacity and also a broader lineup of ultim, um, the new hydrophilic coating for enhanced deliverability and we talk about expansion capacity. We have to bear in mind that the platforms from three and a half to four and a half allows an expansion of the stent diameter up to six mm, 25, and that's particularly important in the setting of bifurcation cases and re particularly relevant in the setting of left main and also the 10 crowns in the these platforms. So the largest platform improves expansion in large vessels in the centering of left main, um, not only provides better opposition but also a more uniform vessel coverage, what we call scaffolding, and um, Nagomi DS has been the objective of an important registry dedicated to complex lesions which just completed its enrollment. 3,000s of complex PCI patients were recruited in it. As you see here, complexity goes from anatomical complexity to procedural complexity. But there was also an interest focus, a specific focus on subgroups of high bleeding risk patients. And these results have been just presented one hour ago about HBR patients which were represented in 45% of the population enrolled. As you see here, stent length and multi-vessel PCI as left main stenting were well represented in this population as we saw indeed in the case from Tolu. We have to acknowledge that these HBR patients have a less favorable profile, more diabetic, hypertension, more atrial fibrillation, prior revascularization. So these patients are complex from an high bleeding risk perspective and ischemic risk. But we have been reassured that also in this complex subgroup of patients we have excellent short-term clinical outcomes with a 30-day TLF rate of 1.4% and stent thrombosis rate of 0.3%. And we will, we are expecting the primoint results in 2026. But these HBI patients are particularly relevant because as we saw in the Nagomi complex, they represent indeed 45% of all the population, all the patients that we treat all over the world and if we look at the trials dedicated trials to HBR patients, we have to make also some consideration on the top. We see all the trials which compare different DES platforms, uh, in the setting of using the same DAPT regimens. These trials are not really informative about the safety of DAPT of shortened DAPT, more about the choice of the DES platform. On the bottom, we see all the trials instead which compare different DAPT regimens with the same DES platform. And when we exclude the trials which enrolled a historical cohort or an objective performance goal, we see that the only trial which completed results was the MASTER DAPT. And they did, um, this trial showed that in more than 4,000 HPR patients, 50% presenting with ACS and abbreviated DAPT proved to be non-inferior in terms of MACE and superior in terms of major or clinically relevant bleeding as compared to non-abbreviated DAPT with or without anti-coagulation. But how about complex procedures? Even in the MASTER DAPT, we have a sub-analysis about patients with high ischemic risk so undergoing complex PCI and these results were confirmed. There have been multiple publications from the MASTER DAPT focusing on different subgroups, but what's more important is that the results of MASTER DAPT actually serves as evidence for the guidelines recommendation. There was only MASTER DAPT, the reference to allow the guidelines lines on acute coronary syndrome in 2022 to say that we can go in HBR patients for one month of DAPT. It may be considered with a class 2B recommendation and later the chronic syndrome 2024 allowing a shortened DAPT, so one to three months, class 1A recommendation in HPR. Thank you.

Thank you, Valeria. So probably before going back to Tolu, we can ask Rusha to have an analysis of the angiography that we've seen during this first part of the live case. Thank you so much, Tama. So, uh, very interesting case and it kind of highlights how imaging really changes your strategy throughout the procedure. So if you look at the first image that they got of the left main and the whole idea is to get the MLA, it was 7.8 8 and decisions not to treat. And one probably theory why we're seeing it worse in the cranial view is probably we're looking at it from one of these angles. It's an elliptical shaped, as if you're looking at it from the caudal might be from this angle. Now moving on to the ISR segment. You can clearly see that the stent is overall, I know they mentioned a little bit of underexpansion, but overall it's 2.95 in terms of diameter. And here's where the stent is, but clearly there's neoatherosclerosis. And this particular view looked like neointimal hyperplasia as if somewhat more uniform. But then if you look at other segments, it was clearly neoatherosclerosis with mixed plaque and a segment mixed plaque here and also a segment of calcium right here. Uh, they did point out that they, this is where the ostium of the diagonal and they wanted to make sure to not overlap with the stent with the initial strategy which changed. Now moving on to the next image and this is where imaging was extremely crucial. So after they did the ballooning, uh, they did an OCT run and you can clearly see the dissection, um, right in the proximal LED and it did not end here in terms of imaging changing your practice changing your strategy, the decision when to treat. They also looked for a good landing zone and in this case there wasn't a good landing zone at the proximal LED, uh, which I'll show you in a second. So this was the proximal LED and you clearly see how diseased that segment is. Um, and the lumen is also small. So it was a right decision to take the stent all the way to the left main and we'll see the final results in a second.

Thank you, Asha. Thank you. We can come back to the cath lab, Bruno. Yes, you're on live. Do you? Yes. Yes. Okay. So, we will explain what you have done. Yeah. So, uh, we heard about the dot and the optimization with 3.5 mm balloon that you can see there. We are and, uh, and we go this study also and we go this study of course to optimize in the stent and we perform zoo. So please can you share the OCT and first of all, you know that when you perform OCT on post PCI you have to first check the distality and Germany, if you come back some frames just below you can see that it's distal part of the stent and there is no dissection, no dection, no edge dection, so that's the first point and if you come back slowly in the mid part of the stent you can nicely appreciate that we have a lumen which is much more than 4.5 mm square, we have nearly 6.8 to 7.2 in the stent. So for the purpose of the treatment of the in-stent restenosis, I think the job is done. Okay. If we go also interestingly on the ostium of the LED and we see here the two layers absolutely the OCT on the LA diagonals, sorry, Germany, the diagonal, you can see that, uh, I think we did the first good choice to open the previous strut and you can see that there is only one crown just in front of this diagonal and so far we will not go for another kissing in these cases and now if we go on the zone of interest on, uh, left main on the left main on the stent you can appreciate that there is one crown of, so of strut just in front of the circumflex that you can see at 12:00 and when we go back again in the left main trunk and you can see that there is a perfect opposition and MACE nearly 10 mm square, so we jump from 6.4 to 10 mm square with a good opposition and good expansion of the stent. Just to refresh me because for the LED, what is the target MSA that you want to reach because you say 6.4 is okay, but what was, what will be your level of decision? What is your threshold of treatment? Yeah, we say six mm square and it's a black box, you know, and sometimes we have to combine physiology and anatomy. But in this case, I think the main choice of treatment of the left main was the ostium of the LED which was imperfect for a proper stenting of the LED.

Okay. Okay. So now we have done this OCT. So we know that we don't have to go back to the LED stent. We don't have to go back to the left main stent. And so the decision is, do we need to do a kissing? Yes or no? That's the final question. Do you want to do an angiogram in this view? Maybe. Okay. Ready. I'm sorry, I'm not properly in the left main. So in terms of it's not so bad. We know because when you look at the proximal LED there is also some just at the ostium there is also some disease. So I'm afraid that doing a kissing could destabilize this plaque. Let's see. It's an open discussion and because yeah, we have the privilege to have a lot of experts. So we will follow you because we don't know. Bruno, we discussed that within the panel and probably we have also from the room and honestly we had different views on that and one of the points from CHMA was to say that there is distal lesion in the marginal, so probably for the, you know, for the future it could be safe to do to do the kissing and to keep the door open in case the patient is coming back in a few weeks, a few months, hopefully not, but then to make the life of your friends easier. That's okay. Absolutely. And I think it's a very important point. Uh, maybe we can do a kind kissing. Maybe we can slightly undersize the balloon on the circumflex. So maybe we will use a 3.5 for the LED and a 2.5 for the circumflex just to open the crown. Okay. And to be sure that we can go on the circumflex if needed in the future. Do you agree with that? Yeah, it sounds like a very good compromise. I don't know what you think. Yeah, maybe you have to replace your wire. Personally, I agree. If you take a 2.5 balloon just to open the strut, why not? If you use a balloon in order to have a perfect opening of the on the vessel, I think you will put a stent. You could transform this single stent implantation in a T-stent technique. You know, that's a this again in an octogenarian patient, it's a high price to pay. That's exactly what we want. If you want to do it, my advice will be to take a very small balloon in order to just open the struts and for this, this could be discussed to continue on this discussion and to come we this octogenarian under oral anticoagulation if we can stay with only one stent it's always maybe better in order to stop the DAPT a little bit earlier. What you mentioned John is what exactly we do in the side branch opening, it is just to use a balloon that is 0.5 mm less than the balloon you could use to treat the ostium in case of being diseased because you only want to open the strut but not to injure the vessel because the injury have dissection, maybe you need an extension or maybe you elicit the restenosis process. Is with the imaging you can calculate the balloon that is just for side branch opening very gently and smoothly. Yeah, the concept of undersizing. Which one, which balloon do we are here? So I, I, we don't want to push too much the operator, but Bruno, we know we work more than 50 years together. He knows perfectly what I will do in this situation. Yes, I know. No, but I think they found it's a good compromise between aggressive kissing and not to do it. Huh. You see he tried to cross with a non-compliant balloon. That's explained maybe his difficulty. So I will maybe switch for a semi-compliant balloon. Is it a new one or the one you already used? That's No, no, it's we already used it. Yeah, that's why maybe I think in this case after challenging PCI, usually I just take a new one. That's Yeah, we could 2.5 by 10. 10 is enough. No, would you want longer? No, a longer one, 15, 15, 15, the stents up and especially you have to be very gently and not try to force to cross the strut because if not you can undergo stent failure. So and if it's not, I will change the strut of free crossing, if that's another solution. Yeah, that's the difference with John's strategy. With John's strategy, we have finished the case. But we try to follow the rules of the open bifurcation club to try to do the kissing with a non-compliant balloon. So let's go a little bit. It doesn't cross. Huh? Isn't interesting.

So, maybe I will have to change the cells, the cell of crossing the strategy. Yeah. Yeah. I will not force, because it's 25 semi-compliant and probably be very gently. Yeah. So, we will try another thing. Give me a short, a smaller balloon of 2 mm, just to see if the two cross, and we will go after um, and if it's not, I will change my cells of crossing. And would you consider just semi-compliant in this case? We know that the profile sometime it's easier, or you will change the cell as proposed by Baraba, which happened well, honestly at this point there was a two and a half, I mean it should have gone quite easily uh towards the circumflex. So, I would consider indeed changing the [Music] let's see if not, we will change. What do you have now? A 2 mm balloon semi-compliant, just to make the path, and if not, we I will change the crossing cells. Yeah, you see, still a difficulty. So, it's not normal. No. So, if you agree, I will change the cell of crossing.

Okay. So, at this moment when you want to change the cell of crossing, do you put to still stay stay with you take a third wire or do you? No, I will take the same one. The same one. Yeah. So, so you remove this one and you will try to replace it. Correct? Absolutely. Okay. So, I will. So, any advice? No, the advice was to recross to another position, another cell. Yeah. Now, would you consider to ch also to change the wire in case you know this one recrossing another strut doesn't work, but another way it's so yeah, sorry, we are changing the strut, but is it shameful to change the strategy at all and go to Jean's idea that if it fails we stop like that? Because I think it depends on how much difficult it is. In this patient, we made jeopardize yes, more contrast, more. No, no, of course. Of course. When you are hesitating between kissing and not kissing, sometimes the case decide for you. So, exactly. That's my point. Yeah, it's a sign now. So, you will cross. We hope it's not the same cells. We will see. If not, maybe let's come back. We heard your advice and to be wise, huh? And maybe uh not to search for, but I'm sure you follow the discussion and a significant number of the panelists were in favor of not doing kissing in this. So, it's both options I think are really valid in this case. I think there is no absolute truth. Yeah, absolutely. And what I really want to avoid, do and all the panel is to have a stent failure on the left main course just to cross this strut. Okay, because it would be a pity to have a longitudinal compression or a crush, a crush of the left main stent to open on this circumflex. And you see I got the same issue. Interesting. I'm sure that I am in the lumen. I'm not under the strut. That's not possible because I cross with a knuckle on the left main, and you know there is some and the stent, the balloon is inside the left main. So, really it's at the level of the bifurcation, but there is very difficult B that we've seen on the spider; there is almost and maybe some calcification also. Support provided by the catheter is poor; it is continuously going back. Yes, maybe. Yeah. Yeah, that's correct. So, I think sometimes we should be wise. Okay. But what I will do before is to go back with the 50 because we have do some and to be sure that the stent is really well at the left.

Absolutely. That's a good point because we have done some manipulation with the balloon. Sret no, sret no, so we will finish with another pot in order to be sure that the left main stent has not been a little bit damaged by all our maneuver. As mentioned Benjamin, what is important is the stent and deployment at the level of the left main. As Chimma mentioned, we don't have an ideal support probably with the guiding, so in this case probably it's wise to stop, but in case we really need to do it, what we can do is also to anchor the guiding with a small balloon in the proximal LED, which will give more support to cross through the circ, but I don't think we have to use Dutch complex tips here in this case. Yeah, that's a good trick when you have this kind of problem. You place a balloon in proximal LED, you use this as an anchor, then you can push, but again otogeneration benefit, I will not change my no my strategy, single stent, and then the most important in the auditorium is the safety of the patient. Yeah. Okay. Just a tips to be used was left main LED, we have done. The result is perfect. The rest is, you know, accessory. Now the tip, safety first of anchoring drone probably to be used when you have really side branch loss or really you need to have access. That's a good tip. But in this case, probably geographically, it's too complex. I think I agree. And for our young colleague, I will say it's possible to cross with a balloon, but not with a stent. Don't do it to cross with the stent. Yeah, you can imagine if you have this section. Yeah. Beautiful. Okay. Yeah. I think it's good. Yeah, it's good. We don't want to change our mind. We talk about safety. Okay. I can insist to cross. Yes, it's technically feasible. We have multiple tools to try to cross. Oh, as you say Tomar, but do we have to do it? I'm not, I'm sorry, not convinced. Uh, so if you agree, I will check on the cranial incidence, and if the results on the LED is good, I will stop the procedure at this time on this old patient. What do you think? All the panel and the and even the I'm sure the room is fully aligned with what you suggest Bjamar. I think it's to keep it safe. The left main LED job is done. Result is ideal. And I think that's more than enough for this 85-year-old gentleman. I think of you.

Okay. Perfect. Perfect. Just perfect. So, there is no issue on the left main. The left main is treated. The circumflex is patent. We have probably we have well opposed the stent on the left main. I think on the LED the result is good. The instant wrist loses is treated. Okay, let's keep. I think it's a wise take-home message to, and we started, I think it was the first question to Valeria on the do we need to have a full revascularization or not. This is a perfect demonstration that we did the right coronary artery with good result. You did the left main LED good result, and for the bifurcation of the circumflex there is room for medical treatment. For me it's clear. Yeah, I'm sure the patient will be free of symptoms now, and that's exactly what we want to. And when you look at the circumflex, it's a quite diffused disease because the osium is not perfect, and then you have a long disease toward the first marginal and then to the second marginal, 85-year-old patient, so uh yeah, I think it's a good message to say that technically we can do, but do we have to do it? We are not convinced. It's impressive and geographically the size of the left main when you compare to the size of the andrography left main at the beginning, we have this on the left side, look at the difference, so this is really a great result, but that has been achieved by imaging because if you rely on the angio probably the stent would have been a bit smaller expanded in the left main, so that's so bravo. Thank you. Thank you. Congratulation. Great job. Great job. Thank you. Thank you. Thanks to all of you. I think we've seen a beautiful example of a challenging PCI in HBR patient, and also because it's nice to show what we can do, but it's also very important especially for our younger colleagues to see when to stop and when to be wise in this kind of frail HBL daily patient. So, again, thanks a lot and thanks to Timu who supported this session. It was a pleasure to prepare all that together, and I wish you a nice day and a beautiful meeting here in Paris. Thank you. Thank you.