Transcription
Uh, okay. So, welcome to uh, to Messi for this uh, special CTO session that will focus on the use of laser. We have selected the first case, which I think it will be very interesting. So, if I can see this first slide. So this is an 80-years-old patient who are the only one restrictor which is hypertension, and he uh, it was admitted for a three months before. And yeah, the chronangiogram we showed the severe Legion of the Zurich and the chronic occlusion of the right. So we have treated the Circ, and we have done the MRI which shows a large ischemia at least four segments in the inferior territory. UKG is normal, the echo is normal, the creatine clearance is very good, and we have estimated the difficulty we're using the gc2 score which is a score one, so it's relatively easy case. So you can see the the angiogram with a tight lesion of the circle and some collaterals from the sock to the right uh, coming from the septal branches and also the digital Circ. So this is a right coronary angiogram; it's a dominant right. You can see some distal disease and then the occlusion which looks relatively short. And what is interesting to know is that when we have treated the Circ, we had to use a very high pressure; we went up to 26 atmosphere just to be able to open the this lesion. So that's why we decide that we will go with a laser as a first intention treatment in this case. Okay. So now we are, so I'm working with Peter O'Kane, who is very experienced with laser. I think you are the guy who had used the most in Europe at least, and uh, we uh, we have done some cases in the past together, and uh, we we are very happy to solve the problems with the help of the laser. So I will show you the first angiogram. So we'll start with the rights. So we have used a non-platz catheter from the femoral approach for the CTU, and we have a contrainateral catheteria diagnostic five French. So it's just to show you uh, the lesion. You can see that there is a collateral which is coming from the occlusion, and we have already in place a fine cross. Okay. So maybe I will go back a little bit more. Okay. So now we can do a biator injection. So we start by injecting the left Z. Okay, and now I'm injecting the right. Okay. So you see the equation is not very long. Okay. So the the first step is to start with the filter XT, and then we'll see uh, what we're able to do. If we are able to cross with Fredo XT, then we will move to the laser directly, exactly without predilatation. Okay. So very short tip, so very important to start with a good support when you do a CTO; that's why we have non-platz. So I think the difficulty will be that we will go systematically in this small branch, maybe or not. Okay. So this is going in the right direction, I think. Makes injection from the left. Okay. Looks good. [Music] Foreign. Different view. Difficult to know, isn't I mean difficult? Yeah, it's difficult to see because it's very small, very small, but I had no difficulty to push this way on very easily. I mean, I guess the, so I will continue to push, and we will see uh, we'll inject nitrates in the left corner system and check. So we'll check it again. Yeah. So we are in the side branch. Okay. Perfect. So maybe a few uh, agree. We uh, we use the Razia now, I think. So I think so. Yeah, yeah, I think it's a good indication. So you can see that the wires right. So the glasses are to protect everyone's eyes, which is very important. Um, there are two two laser beams within the catheter. There's an infrared beam that we can see uh, just the guiding catheter. Then there's the ultraviolet laser itself, and it's the ultraviolet laser which is dangerous, and that's why we wear these uh, eye protection to make sure that we don't damage anyone's eyes. Could break, and therefore everyone will be exposed. So it's important to wear throughout the case. The Machine's already been calibrated; that's the first thing to do before opening up a laser catheter because it's important to make sure the machine is working. What we're going to do now is take out the catheter has been opened up, and we're going to plug it in to the machine via this coupler, probably uh, take it out carefully because it's quite uh, so the proximal coupler will plug into the laser machine, and then we will first of all calibrate this particular catheter. Yeah, and Cherry will calibrate the catheter by pointing it at the receiving plate which is on the machine, the gray gray round circle, and he will point that and then activate the laser via a foot pedal which is uh, hopefully he's got easy access. So very important to know that this this is not laser, it's red, but it's not going to infrared gliding BMX. Don't look at it. Yeah. Perfect. So if there's any fault with the catheter, it will come up now. Is that okay, the captain? You're happy? Yeah, yeah. So we should think about the settings we're going to use. So there are two numbers, I think, if you want to focus on the machine itself. There are two numbers that you see on the machine: the first is the is the fluence or the effective power, okay, and the second number is the repetition rate or the frequency that you're delivering those pulses. Now 4525 is very good uh, settings if you're dealing with thrombus or atrogenic type material, but it's probably not very good for calcification. Yeah, I agree. So I think we should at least start with 60 40. Okay. Um, on this in terms of settings generally for the kind of non-crossable lesions, we generally use 8080 which is the maximum power. Yeah, I don't mind whether we could start slightly lower, and we could build up because I mean it may cross at low power here because okay, the wire has gone very easily. So in the early laser use, there was always the concern about sections and perforations, and generally that was because uh, the laser cafter had slightly deeper penetration and wasn't protected by a saline. When we inject saline into the milieu around the laser catheter in the lesion, it negates any of that kind of uh, macromolecule formation and allows the old provided light to give very shallow penetration without causing dissection. In CTOs, it's a bit more challenging because often the blood will not be going down there, so how effective is saline injection is difficult to say, but if you we can show afterwards once we've done this case what it looks like in, or what do you want to show now? We have a water now. So this is uh, saline saline. Yes. Yeah. So I will show the laser. Okay. So this is laser in the saline saline. Now we'll use the contrast media. Okay. So we do the same now with contrast. Okay. So you hear the noise is different, and you saw these micro bubbles. Exactly. So a big difference. Yeah. So sometimes some people are using it. I think we increase the power. Yeah, I think for under expanded stents we've had success when we've done that. Oh, okay. Yeah, that's about the only indication I would use it for. Okay. Okay. So now we are ready to uh, to laser. [Music] So it's a monorail catheter, so very useful. Okay. So you start uh, the weather. So you just push the line. Yeah, about half a milliseconds, very very slowly. Yeah. Okay. Okay. So we are moving. It's okay. Stop slowly. So yeah, I mean, when you're in resistant lesions, you can move it only as fast as you get 10 seconds of lazing time and then five seconds off, and it automatically resets. Okay. Okay. So you see it's moving, and it looks like it's moving very nicely. Yeah. So we continue to inject the saline. Okay. So now we have cross Collision, come straight through. You've done very very nice, very nice. So now I'm pushing the fine cross. I see that it's very easy to cross, no difficulty. Yeah. Okay. Good. And now I will put the BMW wire in order to have good support and to decrease the risk of digital performance. Yeah, absolutely. So now we I think we can use the two balloons for pediatrician. We'll go directly with the two balloon; I think it will be okay. So we go to 14 again. Okay. So we I think we have already cracked the the layer, yeah, and we are at five atmosphere, so very low, very difficult not to have a too much engagement of Bloods. Okay. So we have a good integrate flow. Notification is open, a lot of disease. Yeah. Okay. So I will uh, three day late with air pressure. So now we'll prepare the region and put the stands. So with the 2-0, I think the distally The Stance is no more than two five. What do you think? Yeah, I think it's pretty small vessel. Yeah, and okay. So I you think it's okay? I think it looks good. I think yeah. So go to low pressure and mm-hmm. So we have a waste, but I will put back the balloon a little bit on the good wire pressure. Okay. So we're making a the right slowly. Okay. Exactly. Yeah, on the screen. Well, if you use a 16 just to be sure that we cover everything, says okay. So we go to 16. [Music] Very nice. Okay. Okay. Very nice. Okay. I will put daily just at this level, low pressure. So we go to 20, but it will be too small, I think. Okay. So we'll uh, just post dilate the aneurysm segments with the sweep on five non-compliant balloon just to be sure that the stand is opposed to the wall. Okay. So we go to 16 of. Okay. Brilliant result. Fantastic. So now we have a good characterial from uh, yeah, yeah, the River Circle. Okay. Good. It's very good. So thank you very much. I think this case was uh, very interesting. We're able to cross the lesion uh, with the laser very easily with a lower energy energy, yeah, and then it was really easy to pre-dilate to put the stand Etc. Um, so I think it's uh, it made the case very quick. Yeah, exactly. So Leicester city is uh, 319, so it's uh, it's okay. Okay. So you can see that with the multi-plate we have checked the sensitivity to aspirin and Plavix, and the sensibility is good for both but not too good. So this is also very important because you can check that okay, it's working, but sometimes it's too much. So we decrease the dose in some patients. Okay. So how much contrast, 150, and how much Gray? Okay. So the last command is about x-ray exposure; it's very important when you do CTOs to be careful with this. So you can see that the duration of extra Exposition was 0.25, so 24 minutes, and the total dose is 1.5 gray, so it's very acceptable. We start to be anxious when we have more than three, and five is really not good, and in the US they have to stop at 10. So if they have 10 Grays, they stop whatever the situation of the patient. Okay. So thank you very much. Thank you for your help. Thank you very, thank you, and I think we'll move to the next case. Thank you. Brilliant. Thank you.