My Worst PCI Complications of the Past Year

Hello everyone and welcome to our webinar tonight. Uh, this is Manos Prapas, and it's my great pleasure to introduce you to the webinar entitled "My Word: PCI Complications of the Past Year."

Um, we are privileged to have uh two outstanding faculty to present with a goal to show you what really happens in the cath lab. Both of them are extremely experienced and know how to keep their cool and their calm during the storm. And this is, if you go to the next slide, this is uh CME accredited, so you can claim CME at the end of the webinar by going to the link which will show you. And there are no fees for doing that.

Once again, it's my great pleasure to introduce Dr. Wissam Jaber, who is the cath lab director from Emory University, a great city operator for many years. And also Dr. Jason Woolworth, the director of complex coronary interventions from the Providence Heart Institute in Oregon. Also a tremendous operator with many, many years of experience that we have shared many cases over the years.

I would like to thank some of the sponsors for this webinar, which is Abbott and StrokeV. And then also remind everyone that uh, in just a little over a month, we are going to have the full CPCI meeting. And this is a link for the webinar which is on the CPCI website, which uh this year is going to happen in Austin, Texas on July 20th to 22nd. So if you want to see more complications and exciting items, please join us in Austin.

And then uh, to finish up, there are also a lot of other pre-recorded uh recorded material that you're welcome to see on the CPCI website. So without further ado, Wissam and Jason, welcome. And Jason, I think um, you are the first one to share your cases. Thank you both for coming tonight. I'm super excited to discuss with you how we can prepare for these complications.

Thanks Manos. Uh, it's great to to join you and uh Wissam. And uh, unfortunately, we get to show some of our disasters. And I always hate it when I get invited to do complications because I, I uh, it means I'm an expert in them and maybe maybe I cause a few too many. But um, uh, this actually, I decided to show a couple cases of hemodynamic collapse in the cath lab. This idea kind of came up because I had a case about three weeks ago uh where this happened, and I thought, oh boy, this might be an interesting topic to review because it's not something that we generally review as much. We we tend to review the the specific things that cause uh hemodynamic collapse, but not kind of an overall view of hemodynamic collapse in the cath lab.

So the first case, I'm going to show two quick cases. One from a few weeks ago and then one from uh about a year and a half ago. Uh, they kind of had a hemodynamic collapse for different reasons in in one, and they were managed differently. Um, and and so maybe we can have some discussion about uh what we could have potentially done better.

So the first case is a gentleman that uh presented with about six weeks of gradually progressive exertional angina. Ended up having a stress test ordered by his primary where he only went two minutes and had inferior and anterior ST segment depression about three millimeters with a high Duke treadmill score. He was referred to one of my general cardiology colleagues and was referred for angiogram. But but the day before he was supposed to have his angiogram, he got admitted to an outside hospital with uh severe upper abdominal pain and chest pain. His his cardiac workup was unremarkable, but a CT scan showed some mesenteric stranding and an ultrasound showed uh evidence of cholecystitis. So he's actually admitted there and was seen by general surgery, but they didn't think he obviously was a great surgical candidate because of this recent high-risk stress test. So they decided to treat him conservatively and they put him on antibiotics. But during that hospitalization, he kind of got worse and worse. He was having more and more abdominal pain, larger amounts of narcotic requirements, and his uh white blood cell count was climbing and he was persistently febrile.

So eventually, it was transferred to our institution, had a a cholecystostomy placed, and did get somewhat better after this. And he was discharged a few days later on antibiotics. So he was referred to see me uh uh uh for an angiogram about six days later. And at that time, he just complained he was feeling lousy. He was having angina just simply ambulating around his house. He was having a lot of pain from the cholecystostomy tube and difficulty with deep breathing because of uh of the of the tube as well.

You can see here on his angiogram, this is the right coronary. I already had a kind of serial high-grade lesions with uh really TIMI two flow into the distal vessel. Uh uh. So then here it says left coronary system. You can see he's got uh a fairly uh at least co-dominant circumflex system uh with a high-grade left main stenosis that was involving the origin of the LAD and the circumflex. Again, you can see it here in the other view as well.

After we got these angiograms, I I uh had my surgeon come by um and and reviewed the case with him. Um, my surgical colleague says, you know, we can't do anything with this guy. Just go ahead and fix his coronaries right now with PCI. He he uh put a note in the chart, fortunately, before we did the procedure, saying that, you know, surgical open heart surgery is a terrible idea. I like how blunt our surgeons can be sometimes. I actually did call the general surgeon as well before I proceeded with uh doing his intervention. And and he recommended just going ahead and fixing him, and that they could operate on Plavix down the road if they needed to.

To here's kind of a picture just showing his the remainder of his LAD and distal vessels. Actually looked pretty uh pretty uh unremarkable. So really felt like it was a pretty so maybe this one's just as good. We sell actually because because I never had a case like this in the setting of cholecystitis that's uh that's used to me. I don't know what do you think? Your surgeons have said the same or is this maybe not uh I I don't know. I don't know guys that like dancer or not. But what do you think about yourself? You know, this could be uh this could be also a place specific and some surgeons are it risk adverse when it comes to that. There's going to be complications, they always wear that external wound infection and sepsis and things like that. So I would not be surprised that that surgeons in many places would actually say no to cases like this. And it also depends on how comfortable they are with the interventionists. So so they work with Jason and they know that he could fix something that that is as complex as it gets. So I think they it's very dark that they send them to him. But at the same time, right? I mean, the patient may need an open surgery and even with Plavix on board, if you have a surgery within the first week, especially after you have stents, I mean, the risk of phantom bosses is even with the U.S. It's probably on the high side. So anyway, it's it's fascinating, fascinating casual multiple friends. Yeah, it's one of the reasons why I wanted to touch base with the general surgeon before I got into this because, you know, I've had these issues before where where, you know, you don't kind of communicate with them and then they're kind of shocked by what you did. And so I wanted to make sure that we had a plan uh going forward. And he he actually felt pretty confident that he wasn't going to need any urgent uh cholecystectomy. He thought he could get by after draining him with the antibiotics that that he was probably going to be okay. And he was obviously way more concerned about his his cardiovascular uh uh risk. And and he said, and even if he did get into trouble, he he felt comfortable operating on a dual anti-platelet therapy because they've they've done that before. So uh I I felt good that we at least had that conversation before we jumped into this. But um, yeah, I think my surgical colleague's main concern just was the the infectious risk and the risks of potentially becoming septic. And, you know, he obviously had an indwelling drain as well. And so, you know, he looked at the angiogram, I looked at the angiogram, I felt pretty comfortable about fixing it. His LV function was normal, so I thought it was going to be a fairly straightforward uh, you know, intervention. I actually thought his right coronary artery was likely the more uh symptomatic vessel, even though it's a relatively small vessel, but but certainly the left main was was significant and they wouldn't they wouldn't have moved forward if we had just fixed the right. So we just decided to go ahead and do it all. Actually discussed it with the patient as well, said told him what what the plan was, and he was all for it because I think he had enough of being poked and prodded and was not interested in having a major open heart surgery followed by a cholecystectomy. So said I thought I think we can get just take care of this right here. So we actually didn't even take him off the table, which I don't do a whole lot. Um, um, you know, with with left main disease unless somebody's really uh, you know, symptomatic. But again, this guy was getting worse and worse and really having symptoms just walking around his house. So felt like it was it was reasonable to just proceed. So we uh, oh, that Jason, maybe taking a different track, maybe of fixing his left main and his his RCA seems to be pretty diffuse the disease distantly and kind of it's the more important vessel has left main. Good. Yeah, I think prognostically, certainly is more important. But I also thought that that the uh, the the right was potentially causing more of the unstable symptoms because it really had slow flow. Um, and it actually plumped up. It was a pretty good sized vessel once we got some flow down there. Uh, you kind of see here on the right. Uh, you know, we we put uh, I think three stents in, you know, kind of from the crux all the way back up to the proximal vessel and and got a good result. Tolerated it just fine. Um, you can take the argument too, Jason, that's actually fixing the right makes the left main safer, right? Because you're starting to look main and you have a severe release on the right, but then if you're getting ischemic domain, your backup is less. Yeah, yeah. And and well, quite quite honestly, with what happened, uh, uh, when we started on the left main, you'll uh, I I was glad I had the right to taken care of.

So, you know, the first thing we did obviously, we we do intracoronary imaging on all our uh interventions nowadays and and so we did Ivis of the left main and, you know, you could see that this really was a Medina 111 lesion. And so my plan was to do just a DK crush of the left main. You know, the the question oftentimes comes up, you know, hey, it's a left main and it's a not a dominant circumflex, but at least a co-dominant circumflex. You know, should you use hemodynamic support? And I had measured as LVDP before we started, it was nine. Um, he had normal LV function. He had an echo a week prior which showed his EF was 60%. So hemodynamically, it didn't seem like it was going to be necessary. And and anatomically, you know, although it is a Medina 111, there wasn't a lot of, you know, calcium. We weren't going to need to do pro, you know, atherectomy with prolonged ischemia or anything else that would make me feel like I needed hemodynamic support. So so we we went ahead and just uh fixed him without it. We upsized our radial sheath to a seven French. And I started by ballooning, you know, the left main uh into the circumflex and then I ballooned the left main into the LAD. And and as soon as I I deflated the balloon on the left main uh into LAD, he immediately started complaining of chest pain and getting real fidgety on the table and he had massive ST segment elevation. And so uh uh uh and and also his his blood pressure dropped into the 70s just almost immediately. So I gave him some phenylephrine. Had him get some Levo effect started. You can see I took a quick picture there, which showed uh sluggish flow down the circumflex system, not filling most of the OMs completely. And then you can see there's no flow down the LAD. Shortly after this, he arrested. Went right into VF. We ended up uh shocking him, got him right back. He was not very happy at this point. And uh had ended up having to give him some epinephrine to get his blood pressure up eventually. And after that, we had a, you know, reasonable blood pressure. We did some uh further ballooning of the uh left main into LAD and we restored flow. I didn't actually floor save a picture of it, but at that point, you know, kind of had a moment to like take a breath and we decided to get access uh femorally. I quickly got a femoral CPN. It took about three minutes from uh the time we stuck the the artery to the time we had him on support. But despite this, he remained hypotensive. Ended up, you know, again, my plan initially was to do a DK crush, but at this point, I felt like I needed to, you know, save flow down that LAD. So we stented the left main into the LAD. Left over. Well, maybe maybe I cannot squeeze some tradition. What do you think? Or maybe let's do something. What do you think caused this? What do you think causes? I mean, this is clearly, you know, crazy decrease in flow. I mean, even the OM looks even like embolic phenomenon. So I wonder if there was some culprit in the main, maybe some thrombus that embolized. I mean, I don't know with so many any thoughts? Yeah, it's interesting. I mean, it looks like there's some calcification in the lesion. Didn't look like an acute angry lesion to expect no reflow. It's very, very uncommon to have no reflow with left main intervention. My suspicion is is dissection at the distal left main and maybe the flow that we saw that slow in the in the circumflex was from arrest and hypotension. You see that frequently, but clearly the pathology was no flow in the in the LAD. And I have a question for Jason here. What kind of what size balloon did you use there? Do you size it one to one to the LAD or or and the other question is, yeah, go ahead. It was a four millimeter. Four by twelve millimeter balloon. By Ivis, his LAD and proximal circumflex were both four point five. His left main was five and a half to six. So it was it was aggressively sized, but not oversized. Yeah. And the other thing is, when when you're doing a case like this where you're worried about about this, do you have your size already with an Ivis? Do you have this? Do you have your stents called out and like ready on the table for a situation like this? Because I'm thinking in my mind, you balloon the left main and and the guy didn't do well. The first thing that comes to my mind is just place a stent very quickly from left main to LAD and make it long, just to cover whatever the dissection you created. Yeah, I had his circumflex stent on the table. I think I had a four by twelve circumflex stent that I was going to put in the circumflex and crush. I I was going to leave the the balloon in the LAD distally and then I'll drop my circumflex stent in, deploy that and then crush it. So that was that was what I had on the table. I did not have a left main to LAD stent in. And so, you know, the first thing I did when I got that first picture, I thought, I I kind of thought like Manos said, I was like, is that thrombus or what's going on? Because again, you pretty rare in a vessel that big to have a dissection that shuts everything down. And and with the sluggish flow, I thought maybe there's some thrombus there. But then after I ballooned it, I did another test injection and and at that point, it looked like it was a dissection. But at that point, I had flow everywhere and I had a pressure. So I thought, let's just get him on some support real quick. And again, this was a decision-making thing. And I think in retrospect, I would have done what you said, Wissam, which is just get a stent in the left main to LAD. But in the back of my mind, I'm thinking, I've got a dissection. I don't know if it goes down the circumflex. The last thing I want to do is put a stent in his left main into LAD and then, you know, a dissection flap, you know, affects flow in the circumflex. And so I thought, um, I I still was thinking when I was putting the Impella that I was going to keep going with my my original strategy of the DK crush. But after I got the uh Impella and got him on support, he was still high hypotensive. And so that's when we decided to just get that LAD taken care of. So we started the left main and the LAD was persistently hypotensive and and really had minimal pulsatility at this time. It gave him multiple doses of phenylephrine and epinephrine. And then and then also started him on some Levo. Unfortunately, at this point, he kept having VF. So this was actually just after stenting the left main into the LAD. You can see we've got really good flow down all the vessels, but I just can't keep the guy out of VF. And can see at the apical LAD here, there's there's a little bit of a cutoff of the vessel. I ended up running a thrombectomy device down there and ended up restoring flow to to that part of the LAD. But but despite us, you know, giving him amiodarone and eventually lidocaine, he he kept having the I think we shocked him five or six times and got him back. But then he went into refractory VF and and we tried to defibrillate him like five times and then before we finally got him back to a normal rhythm, did CPR. And then at this point, we got uh access for ECMO. You know, we had anesthesia there at this point. We got him intubated. And and after by the time our ECMO team got there, it took us about nine minutes before we had him on ECMO. At that point, um, this is kind of where we were at. I had stented the left main into the LAD. I'd actually proximally optimized the left main portion of it. And and then this was actually the TEE that we had, you know, during the procedure. So you can see it's just hardly got any myocardial contraction happening. So we ended up uh uh going and once we got him on the ECMO, he he stabilized out quite a bit. He didn't have much pulsatility, but we had a good arterial mean arterial pressure. So we went back and and kind of finished uh uh by doing a T and protrusion, again, not what I typically would do on a left main, but in a situation like this, it's what we had to do. And and got the circumflex opened and then finished with a kiss and had a nice angiographic result. After this, though, he still was hypotensive. He was on a little bit of Levo. He was on dobutamine. We ended up sending him down to the ICU on ECMO with the Impella CP. Actually turned the CP down to to I think P4 because we were getting a bit of suction. But but even when he got downstairs, we repeated a transthoracic and he had really almost no cardiac activity. He had no pulsatility for for much of that afternoon. But by the time I left in the evening around seven, he'd started to regain a reasonable amount of pulsatility. The next day, um, he uh, we put a PA catheter in. You could see his numbers there. And and again, had didn't have any pulsatility. The next day, he he uh, he was better. By the morning, he was off Levo. He was on only two mics of dobutamine. And then post-op day two, he was extubated and he was decannulated from the ECMO. We tend to try to initiate medical therapy early up and usually before the Impella is removed. So they actually started him on Captopril on post-op day two. And and here's his echo the the next day. You can see he's starting to regain some function, not normal, but but getting better. And then on post-op day three, his Impella was removed and his PA catheter was removed. And you could see his cardiac index was almost four by the time his catheter was removed. And then here's the the kind of post-op day two function was about 40 or so. And then post-op day four, he was pretty much back to normal function and was ended up being discharged on post-op day six.

So, um, this was kind of a weird case because again, you know, we we uh this was obviously an unexpected hemodynamic collapse and and likely, you know, because of the dissection and the left main ischemia. But the thing that was was a bit different about this case compared to to a lot of times when things like this happen is usually once you fix the vessel and you have flow, everything kind of, you know, levels out. But this guy just was so stunned. And then yeah, and then because of that, I think that's what was causing the the persistent VF. And then, you know, his heart was just at a standstill basically. And so it was really a case where, um, he he fell apart and fell apart fast. And then we just couldn't get him back. And, you know, fortunately, we were able to get him on ECMO relatively quickly and that kind of helped, you know, at least buy us some time for us for his heart to recover. And, you know, I've had this happen uh, I think two or three times in the cath lab where, you know, we've had uh, you know, a hemodynamic collapse and then they just have this stunned LV that doesn't work. And, you know, my surgical colleagues kind of liken it to what they've what they describe as that stone heart syndrome in bypass patients where, you know, it's almost like a reperfusion injury that where the myocardium just just gets locked and and doesn't work. And so, um, this was kind of an eye-opening case. Fortunately, he he recovered and did it uh relatively well.

So, um, I want to make is that, you know, that's the importance of ECMO, right? You do complex PCI, you know, having ECMO, I mean, imagine this patient didn't have any more available. I mean, it can be literally life-saving many of those days. And so I think it's it's a great thing. And of course, the experienced team like, you know, yourself, Jason, and Ethan and the whole group, be able to get him on ECMO very quickly and save him. We saw many comments at all. Yeah, I mean, this is an amazing case. I just want to draw people's attention. We think about no reflow also and the setting of of acute cases. I've definitely seen no reflow in non-acute cases when you have kind of very uh the plaques that are that are voluminous and and your patient can really can really not do well in these in these cases. We never know who's going to have more stunning than others. So I'm glad that that you saved this case. An amazing case, Jason. Yeah. One more question that came from the audience. Uh, Jason, is about the RCA. People are saying when you have the scanning, sometimes you meet from worship right coronary artery. Might you take any picture after this? Or I guess you didn't didn't take any picture of the right after the code? Yeah, no, I didn't go back and take another look. It's not a bad, it's not a bad thought, but but I did not, I did not look at it. Sure. Okay. Amazing save. I'm a phenomenal award. Yeah, thank you.

So this this next case is actually a case from about a year and a half ago, and it it didn't have a great outcome, but it's it's certainly something that's changed my practice and that I learned a lot from. And I I know we've got other great cases from Wissam, so I want to try to get through this relatively quickly. But this was a gentleman that was referred to me for high-risk PCI. Had uh typical cardiac risk factors. He's actually from China and was here visiting his family. He was diagnosed with coronary disease about 10 years prior where he had was having exertional chest pain and an angiogram was recommended at that time, but he never had it done. And he'd had basically chronic stable angina up until about 18 months prior to us getting involved with him in 2020. He had a two-week admission in China with heart failure and he was diuresed. Still didn't have an angiogram. And he was endorsing nightly PND, orthopnea, and shortness of breath with any activity and was using two to three nitroglycerin a day. He was actually seen by one of my general cardiology colleagues in clinic on New Year's Eve 2021, and he was so dyspneic just talking there and was having angina in the office. She sent him directly to the emergency room and he was admitted for decompensated heart failure in the ER. He was to Kipnick, so they actually put him on BiPAP. He had an echo that showed an EF of 10, LV was dilated, moderate to severe MR, had RV dysfunction and had pulmonary hypertension. Was diuresed for several days, was a bit hypotensive at one point, so they placed him on some dobutamine and eventually our advanced heart failure team was consulted. And about five days after he was admitted, he got referred for angiography in a right heart cath. One of my colleagues at that time, you could see his pulmonary pressures were quite high, his filling pressures were very high with an LEDP and a wedge of 30, and he had one of the lower CI's I've seen, 1.0 cardiac index with a very low CVP and low PA sats. Coronary angiography revealed his right was a CTO. His left coronary system showed a high-grade calcified lesion at the ostium of the LAD and a flush occluded circumflex as well with really not many collaterals or I think there was a small OM that you could see filling in faintly, kind of late, but um, so he actually got admitted from the cath lab to the ICU. But down in the ICU, he kind of decompensated relatively quickly, got tachycardic into Kipnick, couldn't lie flat. They put him on Nitro and Lasix, but he was still having some ongoing shortness of breath and chest pain. And this was in the middle of the night, so they decided to eventually to put him on a balloon pump and he seemed to stabilize at that point. Obviously, it was turned down for surgical revascularization given his shock and his very low EF and and the patient really wasn't uh interested in in pursuing a transplant course. And so they initially just treated him medically. And they ended up getting a PET scan on him a couple days later that actually showed a considerable amount of viability with only the inferolateral wall being infarct. So he was referred to me for high-risk PCI.

And so, you know, at this point, my plan was to to do a right heart cath. I removed his Swan for some reason at that point. I was going to remove the balloon pump and place the CP, and then I was going to fix his RCA CTO and then stent his left main into the uh into the LAD. We brought him upstairs. We did his right heart cath. You can see his numbers still looked pretty bad, but not not as uh bad as uh as uh his initial right heart cath. But the thing that was notable is when they were wheeling him into the room, I I heard the monitor beeping and it's like, boy, that that is a really fast heart rate. And turn around, sure enough, his heart rate is in the one teens. Um, his blood pressure is somewhat borderline, and that should have been my first clue that I should have stopped and and taken a different course. But, you know, I I plowed ahead with my original plan. And we got dual access. And again, we were going to fix the right first. Here's kind of our just our setup shots. We ended up, you know, getting the right dissected relatively quickly. And then he had some really nice septal collaterals. We were able to go into the septal. But as soon as I put the microcatheter into the septal, he lost pulsatility. And so I pulled the microcatheter back and then just did a balloon inflation of that distal left main into the LAD. And then I went back in with my microcatheter and at that point, he seemed to be tolerating it okay. I was able to get retrograde relatively quickly. And then set up for reverse card. But as soon as I like dissected his right and was trying to get into my antegrade guide extension, he started getting some drop in his pressure, losing some pulsatility. And then I got my wire externalized. And I think at this point, he's getting really restless and she eventually got anesthesia there and got him intubated and sedated. But at this point, he's very hypotensive and we lost all pulsatility. And ended up having to give him some phenylephrine and some epinephrine and briefly did a CPR. This is probably the fastest reverse card I've ever done because I knew that this guy was not going to tolerate this for very long. But I also didn't want to give up what my wire position. I I'm kind of stubborn, I guess. And so did a quick tip in just to get all of our retrograde gear out. And then ended up getting a wiggle wire into the distal vessel. And then, you know, obviously because of what happened, we checked his left system just to make sure we hadn't created any more damage over there. And then that looked okay. And then we were able to kind of quickly fix the right. Got a nice result on the right. Throughout the time we were working on the right, though, he continued to have a narrow pulse pressure, if not fully lacking pulsatility, and running on the Impella. We ended up putting him on dobutamine and some Levo fed, but we weren't getting great Impella flows. And it was we're quite sure what was going on because we weren't getting suction alarms. Initially, we thought I thought it was because of his right heart failure, maybe. But usually you'll get suction alarms. But I ended up calling my advanced heart failure team and they they thought, well, let's his PA pressures had climbed. So he put him on some inhaled nitric oxide in the lab. But the thought was that, you know, he's just his LV's big and dilated and maybe he's not getting suction alarms because he just hasn't we we just haven't fully unloaded his ventricle. And maybe he just needs some more right-sided support because his RV function was pretty bad. So we actually decided to put in an RP before we fixed the left coronary system because we knew I I knew how he reacted when I ballooned open his his LAD. Didn't tolerate that real well. So we ended up doing that. Did Rotablator and stenting of the left main and the LAD. Got a nice result there. And after this, he did relatively well. Got down to the ICU and was hypotensive though, was on a bit of Levo and was was fairly acidotic with a pH of seven and his lactate was elevated. But he responded relatively quickly to some bicarb. Overnight, he had some hemolysis. We were able to wean him off Levo fed and and was just on dobutamine by the next day. And his echo actually looked better. But but he was having some ongoing hemolysis. Here in output was still okay. But then things started to turn south. Yeah, we he ended up getting his RP out on post-op day two. But then he started becoming febrile and then a few days after that, his vasopressor requirements started climbing. And then he ended up getting blood cultures that were positive for gram-negative rods and starting to have abdominal pain. And then after that, they the family decided to move them to comfort care and so he he actually expired. And what I think happened is we, you know, we this is a guy obviously was a probably a long-standing vascular path who was very tenuous to begin with. And we gave him a pretty good hemodynamic insult with what we did. And and I the the thought was, even though we've got him through the procedure and we got some some improvement from a cardiac standpoint, that that hemodynamic insult probably led to some bowel ischemia and and maybe even some which was probably the source of his his infection and sepsis. And so this was a case that I really learned a lot on. And and I think the the big thing that I learned from it is that, you know, really get better hemodynamic support up front in this case. And this has really changed how we approach these patients. And I have a much lower threshold to putting in a surgical five five up front. And that's kind of how we'll do it in these patients now. There's a lot of reasons for it. We tend to have much less hemolysis than we do with the CP. They they can stay in. We have a place in the axillary artery. They could stay in for, you know, weeks at a time. The patients can ambulate with them. They just do much better. And it buys us a lot more time. And and even in the case like this, I would even consider, you know, putting an Impella five five in and then sitting on them for a few days before we get them up to the lab. And so we we've taken that approach with with some of these patients who who have really borderline hemodynamics and very, very poor LV function to to going with a surgical five five. And it just buys us a lot of time. We tend to to go into the procedure a little slower. We tend to come off a little slower. And they tend to to do much better. And so this was a case where I really think I made a mistake just by not recognizing the gravity of his hemodynamic derangements up front and and really did not do the guy this service by by jumping in and and and not having the right amount of hemodynamic support.

Well, I think first of all, thanks for sharing because that's a phenomenal case. I think it's a very learning for everyone. And these are the cases we want to see because they give you a lot of learning. So thanks so much for for sharing this. Uh, there was one comment on the on the on the comments. It's actually I think maybe relevant. They were asking whether losing the acute marginals might have played a role. Now, I think the RCA was very diminutive. I'm not sure this was the key thing, but sometimes in these very tenuous patients, if you lose an acute marginal or a big one, that might create more RV failure than before. Again, just a thought. Yeah, no, it's always a good thought. And I, I mean, you know, a lot of times we kind of blow off RV marginal branches. We kind of treat them like, you know, small diagonals or whatever. But, you know, until you know, the first time you have one patient fall apart because they lose a one millimeter RV marginal branch, you you have a whole new respect for RV marginal branches. But his right was occluded proximally and was occluded all the way through the AV groove. And so, um, I don't think that was a huge issue in this particular case. And and really his hemodynamic insult started when we crossed his LAD because, you know, obviously everything was hanging on that LAD ostial lesion. And so when he got ischemic from that, that's when I think we got into trouble more from that than the the RV marginal branches. But it's certainly a good question because that that obviously is in the differential of things that can can impact cause somebody to fall apart quickly. Yeah, I was gonna say that Jason, you're being harsh on on yourself. I think I mean, this this guy, you did kind of a great job in terms of interventional outcome in terms of in stenting of both vessels. But I think his ventricle was kind of way far down in terms of how sick this patient and she came in. He came in too sick. Probably weren't going to be able to salvage him even with hemodynamic support. Sometimes we try to do things. But well, these are the type of people that we cannot say, especially when they don't come acute. It looks like things have been building up for a while in his case, and he came with end-stage heart failure. Yeah, yeah. You know, we've had a few few folks like this since then. I I I I feel like I've done more cases on Impella 5.5 this year, this last year, than I have with Impella CP, you know, who have really, really low EF. And and I think that the support for the 5.5, I think there's two things. One is it has to be put in by a surgeon. In our institution, our surgeons put them in. And part of it is is they get it one day, and then by the time they get to the lab with me, it's two, three, four days later. Oftentimes, these patients are in a much, much better hemodynamic state and they tend to tolerate the the insults of the the intervention a little bit better. I'm not saying that this would have necessarily changed his outcome, but I feel like we would have given him a much, much better shot. Um, uh, had we had I taken a step back and said, hey, let's let's rethink our our support strategy. And I I don't know. It's always hard to know for sure. You can always to look back and and question how you do things. But it certainly has impacted me and how I approach these patients. And I have a much, um, a lower threshold to consider a higher level of hemodynamic support in these patients who are so tenuous. Yeah, absolutely. And there's some some comments coming through the chat. Some people are saying, you know, maybe fixing the LAD first might have prevented that. I guess having, um, the issue that would again, obviously respectively, it's easier to say or potentially staging the LAD with another option. But obviously the patient was taken, you want to get more flow to the other vessels. So it is one of those, as you said, these people are very, very challenging. Having strong support is important. And and, you know, sometimes the 5.5 may work, but, you know, it's people with heart failure, especially in such advanced heart failure, who have complex coronary disease are the talent for everyone. So thanks again, Jason. I think that was, uh, both cases were phenomenal and a lot of learning points, both in terms of hemodynamic decompensation, but also what can happen in people who have underlying heart failure and in the undergo a complex percutaneous coronary intervention. Sure. Thank you.

And maybe then we will switch to uh tuition. All right. Thanks Manos again. Um, and uh, we will switch gear here from from cath lab sick patients, complication with hypertension to actual technical complications, which I'm not very proud of. But if you're in the business of doing complex coronary intervention, you will be seeing these things. And the key is to try to identify him and do something to try to mitigate it and and take the patient. The first one is a perforation, which everybody's scared of. Um, a 74-year-old man with unstable angina underwent bypass with SVG to right PDA, SVG to OM, and for some technical reasons, the surgeon did not get a good result on the LIMA. So he took that LIMA down and put it on the SVG to the OM and was down to the distal LAD. But the patient was not very stable afterwards. He was having ST elevations and hypotension. So we took him to the cath lab several hours later. And long story short, all the bypasses are down. When the SVG is down to the OM, the LIMA is down with it. And you can see the problem here is the distal LAD, which used to be patent and is totally occluded. The ostium of the LAD here was the problem. The reason the patient was stented. You need to do the patient was sent to bypass and and this was patent. And if I have an email to this artery here, this happens. I'm sure all of us have seen that before. And if I have a LIMA that's still in place, I try first to go through the LIMA, see if I can salvage something. And occasionally you go through the net of the track to open it up. In this case, there's no going through the LIMA. It was going through an SVG that was totally gone and thrown from the from the ostium. So I went down here with the wire. And this is interesting because, um, a lot here. This is a Whisper wire that went down. You could see a balloon behind it. And and it took a little working, but it wasn't that hard. And the wire flew down. I was confident that wire was in the distal LAD. And we we can do that a lot when we cross CTOs. I know I don't see the largest CTO, but then daughter it down with the balloon. And this is a mistake here because I always tell my fellows, which is something we you should never follow any any gear on a wire where you're not 100% sure what it is. And it was somehow 99% sure where the wire was. Well, then a picture here showed this. And what happened is that it was it was the site of the LIMA insertion that that bled. And and the mistake is that should have double and triple checked that the distal wires and a true lumen. And I still don't know here with the bleeding at that specific time, what the bleeding was from and whether the wire is in the true LAD distal or not. So can you balloon that area? No, that was just going down with the balloon just to doctor it to see what's going on because I thought maybe there's a clot at this side of the ostium where the wire is. I don't want to balloon if the LAD isn't like taking a small distal than a diagonal or something like that. But and at that point, I didn't know anybody why it was was in a small branch. It wasn't a it looks like an LAD going around. He had a trap around the LAD. So the step here that people should do, I had a balloon already that kind of advanced the balloon to the place or just before the place and balloon it to to block the flow down in the vessel. And the solutions here. So you have the perforation and the solutions are prolonged balloon inflation, which which may not be a big option here because we don't know where that distal wire is. Place cover stent also does not work here unless I'm sure that my wire isn't distal. Which could still be, but if it is not, I would have created a big channel into the pericardium. And coil. I would do that if if we perfect a small distal vessel or the branch of an OM or a diagonal. But I would not do that yet for the distal LAD. Would be my very last thing that I would try here if everything else failed. Maybe you can ask Jason.

Jason, what would you do in the situation where you don't know where your wire is, but you do have a preparation that looks fairly sizable like this one? Yeah, I I think, you know, certainly the the wire looks like it's in a typical course of the LED. The problem with with this one is it's not unlike other CTOs. Usually, you have distal vessel visualization, promote, you know, a retrograde, uh, collateral or something. And, you know, because this is an acute occlusion, you don't have that luxury. And so this would be one case where I actually considered leaving my wire where it's at, dropping a Suzuki catheter down over the wire, and then doing a little test injection, uh, down downstream. You know, you could be be out of the pericardium, but I'd rather I'd rather deal with a a hole from a Suzuki than a hole from a two or two and a half millimeter balloon. And so that'd be the one time, you know, we don't generally do a lot of distal vessel injections where we don't know where our wire is, but that may be something to consider in this case. And then if if I felt like I was in a good position and my wire was at least in the architecture, the the the of the LED, then I do, uh, you know, a balloon tamponade, um, and and get get everything ready to to put a covered stent in.

So if you have a perforation and you have recent cabbage, are there some CIS tubes or something that can drain the blood? Are you going to get them or not? I mean, I don't know the answer to this. I don't know. This guy did not have tamponade. So so I've seen it go either way. Um, um, this guy, this thing was most likely going through his, uh, chest tubes. You could still see there are some tubes connected to the pericardium. So he did not end up with tamponade. At the spot, I mean, if you see this in somebody who who is not post-cab, this is for sure like an immediate big tamponade. That's a huge perforation. But this guy did not. But still, it's a big bleeding that you need to close it because he's gonna exsanguinate from that if you're just like working slowly and you leave the blood to go out through the chest tubes.

So so to Jason's point, um, at this point, I wanted to kind of like know where the distal wire is because that's the key in this case is knowing where the distal wire is to solve the case. And and at some point, I I didn't show that, but moving the wire around and moving the camera around, I got convinced that the wire is not in a true lumen. In this CTO, it's not it's not under that focus problem in the pericardium because I went back and forth on this one as the balloon was there closing the hole. And then I realized that the wire was was was too free to be in a in a true vessel. And I don't know how it fooled me before that. That's that I'm not proud of that. So so the key here is to get access into the true LED, which is very difficult when you have an exit point like that that's already been ballooned because I tried to block the flow into a slight bend. So now I had a I had a bigger hole than what I started with by just dotting this. So I tried here with multiple wires. That brought a wire down and I tried to to deflate the balloon just temporarily to see if it would go down somewhere. I would try to add also with the balloon inflated to try to close that kind of block that that hole that I created to see if the wire finds its way into the distal LED. But I was not successful, especially that I could not tell whether it's still LED. Is that I remember not seeing any collaterals going down to the distal vessel.

But then I went back and shot the RTA and stayed long on it. And if you focus hard, you're going to see that there's a little thing coming down here. You guys see it? Yeah, yeah. So that's a very distal kind of that wrap around the LED. Looks small and and it's probably underfilled and might be kind of thrown boost on top. So I thought, well, I see where the wire, where the vessel is now, and I tried again to get a wire here to see if I can get down into the LED. And I, you had an occluded vein graft, right? So worse comes to worse, could you have just gone through the occluded vein graft that was going to the LED and maybe just put a wire there just to mark the indication of the true lumen and distally? Very good point. I, the problem, you know what? I removed that slide. This this vein graft is fresh. So you should be able to get in. It looked like as if it's flush occluded and it had a Lima that takes off of primer. So at that time, I was not thinking about that just because of the complexity of the case. But but you're totally right. Um, the SVG would have led me though to the obtuse marginal, not to the because the Lima was connected to the side and there's no way I could have told where the side of the LED was connecting to the SVG.

So here I decided that that my second best choice is to try to get an epicardial collateral and get to that distal LED because this is the only connection that I see to the distal LED. I have to solve it somehow if I don't want to coil this this LED. So I send the microcatheter down this RB module. You see here, injection into the, uh, collateral and it looks straight enough for me to try to to ride up on an epicardial collateral. And this is a steerable. You see it's making the usual kind of taking the wrong branches back and forth and and, uh, eventually it finds its way down to where I think the artery should be. The steerable is nice. You can let it just slide and it finds its way and eventually it traveled off the LED and let it play here. Wow, wow. This is amazing. You know, a little great. I know the circumstances. I mean, that's, uh, especially through this tiny epicardial. I mean, that's an accomplishment as well with some amazing. Yeah, yeah. I mean, it's you you kind of think that that the exit point of your of your antegrade gear is is going to be more up towards the top of the balloon where it's making that turn, but it actually is kind of down near the end of the balloon. Um, so there's a real, there's a really funny tortuous segment. My guess is that graft that's sewn in there created some some, you know, some some kinking maybe of the vessel that that made it, uh, harder to wire antegrade. Very good point, Jason. You see it. We see it in CTOs, right? We see how the entry gets kinked with Lima when he's trying to open up these. It's really a hard area to cross when you have an angle or put a stent. And it always looks looks funny and and V-shaped. So yeah, you're right. Retrograde, though, that's not that's not that's not an easy epicardial to wire. Yeah.

Well, I'm always lucky here. So so that's good. And and so so you see here the wire. I tried to get the microcatheter down, very small epicardial. It wasn't traveling easy. So I thought, let me try something else. I have here the wire as a marker. Let me try to see if I could just, uh, now that I know where the arch is, I can like go down and see if I can get in it. And I did. So you see here the injected wire go down, finding exactly where the arch is. And now I flew down in the LED and I've got an antegrade. So from that on, the case is straight. Now you have a perforation, which is still not a good thing, but at least I had a wire in the lumen, which is which is key here. Um, and obviously, as I'm leaving that the collateral here injected with a microcatheter, notice that I kind of like redirected the balloon down into the new wire, now the distal LED and the new area. There's no perforations. And then switch the the guide from the right since I had two guides anyway, I might as well use it from the right up to the left and putting a new wire down at the LED. Which which is funny. Once you balloon that, now the wires fly all very easily down in the LED and not through the hole. But I'll tell you, I I kept that balloon up for some time. And you don't expect that hole to see to heal right just from balloon inflation because I've already ballooned that hole. So for sure it's gonna need a covered stent. It needed a lot of ballooning with NC balloons. The area needed a lot of preparation, but eventually the tire stents went went down and and, uh, and I could deploy it and seal that perforation. And from then on, I just sent the ostium of the LED, which was the patient needed in the first place, instead of all the spotlight surgery and looked good. And, uh, and he did fine afterwards.

So lessons from this, and I think we discussed everything. I'm just going to go for the benefit of time quickly over them. I would not advance catheters obviously unless 100% sure where the distal wire is. That's a lesson we always kind of like teach and and we we should not be 100 we should not be like overconfident over time. Plus fresh cabbage and a stenosis side can bleed. I mean, I didn't really try a lot for that wire to actually exit that side. So it's good for us to recognize that. And if there's a perforation, first control the bleed obviously. And in this case, you should not lose access to the area of bleeding and don't lose a wire in the main branch. In this case, I had to wire the main artery anyway. Any other thoughts before I move on to the next case? Yeah, that was a really wonderful job kind of, uh, you know, thinking through it and, you know, taking a moment while your balloon's, uh, you know, you then you have some time to think. You have time to get another access. You have a time to go find that collateral because finding that collateral and that that apical portion of the LED really, really changed the case for you. I think because it it opened up the option of least going retrograde to define the the course of the vessel. And then, you know, it was a phenomenal, uh, job fixing that problem. That was great. No, completely agree with him. That was an amazing save. Another thought, another thought. You could get done. So this was retrograde salad. But some sometimes what people can do is dissect just structural perforation, go knuckle, go down and re-enter, and then use the flap to assume the perforation again. In this situation, with a guy bleeding, I mean, obviously that's a high stake situation. So there's nothing to do but that's another option if you didn't have any other any retrograde options. That might be one way to do it. Yeah. The final thing is to just say, I'm just going to get rid of that distal LED. I'm just going to coil that area. Everything else fails. If you're there for a long time and still bleeding, and then just take the ostium of the LED. The guy will have a big typical enforcement. It is what it is. All right, so I'm going to move to the worst, the to the worst case, I guess now. Wow, we're excited.

So when when Manus, when you asked me to present cases of my worst complications in the last year, I was kind of from I'm not I'm not proud of of these. And this this case did not end well. This this guy, this guy expired. And I'm going to put that there. But I hope there are some teaching points that we can come out of that, which is when you have complications, you go back and look at where what are the things that you did different from usual? What are the things that you did wrong that you you could have done better? And this this is I do a lot of complex cases. And I've made this is the left main intervention. And this I haven't had this complication before that, uh, we'll we'll go over it and hope that never happens to anybody. So this is a 63-year-old man with hypertension. He has some chronic unit insufficiency. His EF is 20. And he will stand for worsening angina and now he has the best pain and some unstable symptoms. So I cast him and and this is what I had. Not a not a very complex disease, I would say. The only problem with this is arteries is that you could see the diffuse atherosclerosis. So you see left main here that starts that, but it's not normal distally. It doesn't look super tight, but it's not very normal. Then osteum of the LED is not normal either. In the LED here, in the mid segment gets absolutely occluded, which is probably what what's bringing his unstable symptoms right now. You see it feel faintly there. It doesn't have a lot of collateral. The RCA was fine, just similar vessel with some diffuse disease. The Circ has diffuse disease. Your distal OM, and I stopped there. Obviously, I'm not going to attack. Well, I don't do ad hoc. This is this is and this is not a super complex case, but but it's still diffuse case. We need to discuss with the patient. I would just jump in and start putting stents. I stopped talking to the patient about about the potential of all these ostium LED display. I am doing, but the surgery, he was adamant. He did not want surgery. He just wants to kind of get fixed and go home. And I personally thought it was reasonable to do that because this LED here at the top, total, you could put a stent and then I'll interrogate the left main LED both with Ibis and at the fall and see if it needs further treatment. Then we'll just extend it. And my my goal was to just put a stent if this treatment for the stent across the circumflex and just get out. And this is what I did. So I crossed that LED. Wasn't that hard to cross and distended. Did Ibis and everything? And after the Ibis, which showed the ostium of the LED, distal left main not to be great. I fought that and the FFR was not normal. I did. I thought it was not normal. So I decided to just keep going with stenting all the way back to the left main. And you see him steamy kind of like ballooned it and then sized it with the balloon to see the length. And I had a wire on the circumflex. And like I said, it was my goal was to for provisional stenting. And the couple things here that I did that are different from what I usually do is when I'm treating left main with stents that go all the way proximally, I do a couple of things now. Number one is is I'm always worried that my guide is going to deform these stents. So you always need to be worried about that when this when the when you're placing stents. Also, remember that you have a wire that's jailed. So in provisional stenting, heavy wire that's jailed in, that's very complex. And if you want to remove it, you have to be careful that your guide is not being sucked in, that you're not pushing the guide and deforming the stent proximally. So what I do typically is I put it down, which is usually my my plotting balloon in the in the left main internet pot before I do anything to this city to make sure that that stent looks nice. And before the even if laid that video, and I'll take a quick puff and make sure if the circumflex is painted, I'll just take the wire out and inflate that part. And the reason I do that is that if the guy dives in and deforms distally proximally, I already had a balloon there that would reform the stent when this happens. So on this guy, I didn't do that. I didn't take the wire out because his if his Xeno is sufficiency, I wanted to do things with minimal contrast. So so and this is one of the first kind of like things that I made that is different from my usual that that contributed to the complication. So I ballooned here, I potted, and then I took a picture. And this is where my second mistake is. I should have been very happy with this picture and walked out because that that was my plan to do provisional stenting. This 50 Oslo Circ. But I said, well, I have the pressure wire on the table that I'm doing, um, I'm I'm not sending this guy to surgery. I want to give him the best result. I want to make sure the stent, the ostium of the circumflex is not ischemic. So I plus placed a a I attempted to place a the the, uh, FFR wire that I had on the table already while it's open. Let's just put it in. So actually, I put it in. I put the pressure wire down and it went down, but it started kind of sticking down here. And then as I pulled it back, it wouldn't come back. So I don't have these saved, but I'll show you what happened afterwards. So the pressure wire, which I believe probably went back because I had the jailed wire in the back, and I did not want to puff to see where the Circ is. So I wanted to use the wire that's jailed to use it as a marker. It probably proximal strut, and it got caught on the strut on the way back. And has tried to pull and pull and it wouldn't come back. And I'm trying to pull my guide. Eventually, just pulling on this on this wire that's stuck, deformed the stent. And eventually according the stent. And that's what you see here. So when you have an issue pulling your wire, the next thing that you need to do is is obviously before you start pulling very hard on it, is put in a microcatheter, which is what I'm doing here. Or if you don't have a microcatheter, you put a balloon all the way down to where the wire is and start pulling on the wire by itself or fixing the microcatheter because that prevents the guide from diving in and and and makes kind of like the force go down to where the wire is done because I'm pulling the law. And and this is these these cities here are after kind of like multiple tries. It's like 10 minutes of trying to get the wire out. And and you see how the stent is already deformed. And that has contributed to the wire being further and further stuck. So so you guys can see that the stent is here, accordion and totally deformed. And that's that's where things are bad. And and then eventually I pulled very hard and I knew it was going to snap. And I snapped the pressure wire. So now I had the pressure wire sitting here, which which is just a tip distal free, uh, centimeters of the wire, which is which is not a big deal. I was going to just, uh, salvage the case and and rewire the circumflex and balloon and everything. Now, when this happens, you really need to be careful that now we have a jumbled, uh, metal inside the left main. So there's a high likelihood of clotting there. And I took a quick picture and and clearly something doesn't look great here. And it's kind of starting to look hazy. You know, another great flow down here. Put them immediately on on glycoprotein to B3A because he's going to clot. Make sure the ACT is high enough. And tried quickly to balloon the LED, but the balloon would not pass because now that wire is also is also caught in all this all this mess. And and Edward would not a balloon would not go at all. Try the one five, the cooler balloon would not cross. Microcatheter would not cross. At this time, the patient started blood pressure started sagging a little bit. His ST started changing. And and and if you look here, what what happened, um, is is the flow goes down. So flows goes down everywhere. And I know the guy is not going to do well. What you see next is before he crashed completely, I put him on ECMO. Yeah, I called for the ECMO team and came in. And you see here the venous cannula placed on ECMO because I knew we're going to have problem. And I'm having hard time riding and not wiring, but ballooning the LED as well. So I thought, let me just control the situation, which is great. Put them on ECMO initially. Pressure went up. Now I have time. So I had time to pull the LED wire out. I rewired the LED and placed balloons and to to for the sake of time, I'm going to go fast here. So put wires and balloons and the bifurcation balloon bifurcation stenting. Clearly, I'm like jailing here. Everything, the the wire that's stuck, but I was happy with it. Everything looked good and the flow looked good at the end. But the perfusionist is telling me that the patient is not doing well at all. And and, uh, this flow is not good in in the ECMO cannula. So so looking down and the outflow is not good. We're unable to establish good good pressure. Notice that there's disease in the in the, this is the ECMO return cannula. There's disease in the iliacs. And if you look at the picture here, something is funny in this in this, uh, ascending area. That's the question. Wow. Did we dissect that ascending aorta? Is that a problem? Suctioning? Put an impeller at some point? Did not work well. Still the patient is not doing very well. And then after all that, took a picture of the aorta. And, uh, I hope nobody ever sees this picture. Well, that's what you see. So, um, what's happening here is that the ECMO return cannula was in diseased iliacs and and the blood was returned all the way into a dissection flap that traveled all the way up, engulfed all the branches of his arteries, all the way down into the ventricle. You can see how the whole myocardium is hematoma. And it's not a quality diffusion because the vessels here, each all the border of the heart. When when you see this, if it ever happens, it's like there's nothing we can do. The patient is is gone at this time. And this case is horrible. And, uh, made me not able to sleep for for several months. So this is the case. And I have several lessons that I think I kind of like mentioned along the way, but I'll leave it up to you guys to comment and see what you think.

Well, which on this is, uh, I've ever seen before. I think most importantly, not everyone in the webinar, he has never seen before. And and the learnings are tremendous here. And I must have been actually guilty of the setting. I actually quite often I will try to put a pressure wire on the side branch. And, you know, I guess I was lucky. I haven't had this get stuck the same way it happened here because end of the day, right, that was the turning point when the pressure wire got stuck, then you pulled on it and then but the guy did accordingly. That's where triggered the whole situation. But I guess the lesson is that maybe we should be extremely careful of doing that because of the potential complications. I never realized you can do something like that. And then, um, in terms of, I guess, when I've had cases where the wire breaks and sometimes I don't know if that's the case here or not. Sometimes it's a wire unravel. In the other, it's not the wire fragment per se, it's actually the fine particles, whatever of the wire that's not make make it thrombogenic. So otherwise, that was the iteration here. But, um, again, very humbling case. And again, thank you so much for showing to us. I think this can really help in the future prevent similar things. Yeah, I mean, there are a few things that I changed here, um, since then, which I don't know if that helped or no. I mean, I'm I've always been careful with the I've done a lot of left mains, haven't had this complication, but you should. It only takes one case to kind of like make you even become more careful. And I keep guys away. I also do not use thin strut stents because they can deform easily in these cases when you're treating from the LED to the left main. And I stopped doing FFRs of of, uh, bifurcations going through stent struts. And like I said, the first thing I do is put static proximals when I take the side wire out. I, since that case, I don't need that wire any longer than what I need to just whenever I'm done, I'm just taking it out quickly. Yeah.

Wow. Yeah. It's, it's interesting because I, I routinely drop pressure wires through stent struts into the circumflex or into the LED if I've done a, you know, a provisional approach. And I've never, never had an issue at all without it. But boy, it makes me, I'm going to have to really want to know that information because that's that's just scary. Um, is there anything in particular about the, like the crossing, with that, uh, with the pressure wire that was difficult or challenging or, I mean, or was what what wire did you use? I mean, I've just never heard that happen. I don't believe maybe the pusher wire. But if you, if you think about it, I think it, it's called a proximal strut, right? Because you have a stent that goes all the way to the ostium of the left main. And you work across a proximal. We, we don't think a lot about it, right? I mean, we kind of put a lot in. And if you feel that it's gone behind a proximal strut, it's not in the middle of his stent, not a big deal. Usually, you take it back and you do what you kind of like redirect. It happens to us a lot. But in this case, it went through this back strut. And I realized that when I pulled it back, it wouldn't come back. It just locked on it. And it's partly because the stent that I was using here, maybe was a thin strut stent and and it kind of much easier to deform than the other stents that we typically now use in the in the left main. Yeah, I guess I guess if in that situation, once the wire, you're getting resistance on the wire and it's feeling stuck, you know, maybe the first thing before you do your hard pull, which, and I know every time we get something stuck, and I, I do this myself, the the natural reaction is just to pull. You know, and and sometimes it's hard to stop yourself from doing that and think. But in in this case, maybe, you know, maybe putting a a balloon distally in that LAD, you know, that way when you pull, you know, if you do deform it or you do break it in a funny way or do to form a stent, then at least you got a balloon distal and you can pull it back and at least get that LAD open. Still may, you know, mess up the mouth of that circumflex, but but at least you would have the left main and the LAD stabilized. But exactly, that's such a good point to Jason. I think I think this is why I'm what I mentioned here at this point is anytime I'm pulling anything from the side, I always never been one of that main addition, uh, in the main because his problems that I could not get a balloon left mainly due to deform the stent, deformed one of the problems. The other thing that I want people, I I wanted to show this because you won't see this, but I want people to to be aware of it if they use ECMO, is that is that whenever you have problem with the return cannula and the and and you're unable to kind of get any pressures into the patient, think about that as a complication. You have to stop the ECMO and re-evaluate for dissection in the iliac. Yeah, yeah.

I never heard of this. So essentially, you're saying this is dissection all the way from the femoral on the iliac, I guess, all the way up around the arch, right? Exactly. If you think about it, you have your your you have your all the blood that you're taking, sucking from the right part, returning all of it into that dissection flap. It's going to go somewhere. So I mean, it took it took the time that I was working to fix that left main for all that to walk itself backwards and to fill the whole extravascular space, extra, uh, it's a subintimal space and all the aorta and the branches. You see here with with this view, you cannot see even the main vessel. You see the AO, the carotids are all the carotid, the subplating and everything is dissected. Geez. And the thing is, you cannot do nothing. You said you don't know nothing about this, right? I mean, if you put an ECMO in emergency, which this was an emergency, you don't do an iliac angiogram because you just write it. A matter of you have to get them on support. So again, I'm not sure what you can do to prevent it, but, um, I guess, you know, just have to be aware of it that isn't a possibility. Yeah. So I don't think there's anything we could have done different here like in terms of this. Right. This happened. It could have happened to anyone anytime. Just probably it's just the nearly a collision probably close to the cannula. And that's where the dissection happened. And there's nothing to be done about it. When we talk about like support and things, I mean, we can say about support and maybe if we if this was planned, would not have happened. If you put him on support initially, but but when we talk about support, there's always complications that can. I mean, this is a platform application, but things can happen. So we talk about also five or auxiliary. I mean, all these things that the complications you have to factor that and play in in mind when you try to treat these these complex patients. Thank you. Thanks again. And thank you so much, Jason. These were amazing cases. I mean, truly did show us the worst complications. And, you know, I mean, myself, I had a death last month. So I know how hard it is to go through this and how hard it is to share them. But I think nothing everyone, including myself, are very appreciative because learning is huge. You learn the most by seeing serious complications like this. And both to prevent them and know what to do if this happens. So thank you both so much. Thanks everyone for being part of this webinar.