Transradial approach for complex PCI in a high bleeding risk (HBR) patient - Webinar In The Lab

[Music] Hello, hello everybody. Hello. Good afternoon, and welcome to Toulouse for this PCi our webinar series. We have the slides up there, please gentlemen. So we're here at the clinic Pasteur in Toulouse. My name is Jim Nolan; my colleague here is Raphael Philipart; and the two operators in the cath lab today are John Frangie de and Bruno Farah.

I just want to take the opportunity here to remind you that this webinar today is part of a series. There are three separate webinars. The second one will be related to the management of our high bleeding risk patients with a bifurcation lesion; and the third session will be management of high bleeding risk patients with a focus on mastered afton. You will receive information relating to these in due course.

The objectives today are to discuss how complex angioplasty can be safely performed through radial access in patients who are at high risk of bleeding, and to review tips and tricks for successful radial procedures in these often complex and demanding patients.

I just want to start by reviewing some issues around the question of bleeding after angioplasty. Bleeding events in highly selective populations who have been enrolled in most of the randomised trials is relatively infrequent, in the range of 1 to 3 percent, often below 1 percent. But it is more frequent in the randomised trials that have reported recently, which have recruited specific high bleeding risk patients; and I refer there specifically to the LEADERS FREE, the ZEUS, and the SENIOR trials. And in these trials, bleeding is occurring in the range of 3 to 10 percent per annum. LEADERS FREE, in particular, has the is greater bleeding, and it does have patients who have a constellation of bleeding risk factors.

Now, there are multiple previous definitions of high bleeding risk, multiple scores, but these these have recently been pulled together by the ARC definition of high bleeding risk, which which defines high bleeding risk as a risk of a BARC 3 to 5 bleeding—so a major bleeding event greater than 4 percent, or the risk of an internal hemorrhage greater than 1 percent at 12 months. Patients are defined as having this high bleeding risk by the presence of one major or two minor criteria, which we'll discuss briefly before we go to the cath lab. Around 20 percent of angioplasty placements will meet this definition for high bleeding risks, so it is a common problem that faces us every week in our cath labs all around the world. This is the reference I refer to, defining high bleed and risk in patients undergoing PCI, published this year in Circulation, and I recommend that you read this if you haven't seen it yet.

Factors that are associated with a high bleeding risk are outlined on this visual graphic. Age is a factor, so age greater than 75 years is a minor criteria for high bleeding risk. Major comorbidities affecting the kidneys, the liver, or an active cancer are all major drivers of high bleeding risk. In terms of renal disease, a creatinine clearance of less than 30 defines major criteria for bleeding. Liver disease: it's cirrhosis with varices and active cancer (excluding non-melanoma skin cancers). Anemia with a hemoglobin of less than 11 is important. A platelet count of less than 100 is an important driver of a high bleeding risk. Having an intracranial event in the last 6 months, in the terminal, in the form of an ischemic stroke or a major intracranial hemorrhage is a major driver for bleeding. Having a known bleeding problem, a coagulation disorder, having had a bleeding event in the last six months needing a transfusion, and then finally, long-term requirement for oral anticoagulant treatment, or the need for chronic non-steroidal aa steroid therapy, or a requirement for planned surgery in the next six months after the PCI procedure are all major drivers for bleeding risks.

One of the problems with defining patients as having high bleeding risks is that 1/3 of patients in this analysis, recently published from our group, are using a large UK database, is that high bleeding risk factors often coexist with high ischemic risk factors; and so the very patients that we need to treat the cardiac catheterization procedures and intensive antithrombotic therapy are the patients who are most also at most risk of bleeding; and so those two factors play off against each other. These patients have a high risk of adverse events, and they often have a low rate of intervention or optimal medical therapy.

So I'm just gonna briefly present the details of the patient who's going to be treated today. The patient is a female of 80 years of age, and so she meets the criteria for increased bleeding risk as as as she is over 75 years of age. She has an active lifestyle, normal cognitive function, a height of 170 centimeters, weight of 77 kilograms, so a BMI of 26. She has a prior history of coronary disease with right coronary stenting in 1999, so quite a long time ago for our first coronary intervention, and at conventional set of risk factors of hyperlipidemia and hypertension. She has symptoms of spontaneous angina despite medical therapy. My H8 grade 2 ECG is unremarkable apart from the presence of first-degree heart block and some partial right bundle branch block, normal T waves. These are blood results. I'm not going to go through them in detail, but there is no adverse factors in any of the blood results. You can see that the GFR is well in the normal range; haemoglobin and platelet counts are normal; troponin is also normal. Her angiography was performed some weeks ago, and there was an initial finding of disease in the right coronary artery, the circumflex, and the LAD. The right coronary artery lesion you can see circled on the left picture there, and that's been treated with a single drug-eluting stent achieving a good angiographic result; and she's come back to the cath lab today for a staged procedure to deal with the disease in the LAD and the circumflex.

Now, can I ask you to comment, Raphael?

Yeah, the angiogram here of the left system, you have diffused lesion in LAD with quite totals and calcified lesion, and you have a bifurcation on a diagonal where you have a lesion quite deep just before the bifurcation. Okay, that CT, I don't know if we will treat treat it. And on the next, you can see the circ… yeah, it was always led lesion. What do you think? CoC of the diagonal… quite quite good. Yeah, so although it's a bifurcation lesion, yeah, you maybe will get away without having to treat that. There is some additional disease… no, no, me for myself, I will only treat the LAD. Yeah, but we will see what we want to choose. So the issues in the LAD, there are quite a lot of tortuosity, some possible calcification presentation, although it the the… you may would you use two wires there or a single one, or maybe two wires because it's it's very long. Lee, it's a quite good diagonal. Yeah, I don't want to lose it. Oh yeah, it's a large diagonal. Yeah, well, I have to admit I do that with a single wire because of the chance of the diagonal going down. Yeah, it's very less room, but you know you don't have any illusion, but be careful to to the that the pretty lady asian of your LAD lesion, don't switch the karim. Yeah, you can't be criticized for wiring the diagonal; that many people would do it, but… so can we go on to the next slide, please? Yeah. And on a circ, it's quite difficult to see, but you you we have a very diffused lesion on the bifurcation right now on the circumflex and the OM, and it's you are the quite like another and everything just after the lesion on the circ and up to the lesion… yeah, yeah. So what is a very torturous… yes. One of the big difficulties there is it is demonstrating that an geographically isn't it is opening it out so that you you know you have to be able to see what you're doing in order to treat it and get a good result. So yeah, you know I agree with you that there is aneurysm of dilatation of the proximal circumflex. The circumflex is always the most difficult artery to work in because it doesn't just run down; it runs away from you at the same time; and there's more conformational change in that vessel; and so the force vectors of advancing equipment down the circumflex are less favorable than they are down the LAD or often the right coronary artery. So I think the the circumflex is quite a challenging lesion to deal with. The OM, as you say, is a large vessel, and I don't think that one will prove to be particularly easy. So we we just tried to set the scene for you to talk a little bit about bleeding risk and some of the challenges of the case, so we're going to go over to the cath lab now to Jean and Bruno.

Oh guys, hello. Hello. So thank you, Jim, and thank you, Raphael, for this nice introduction. Maybe we can move up to the next slide just to summarize the case and what will be our strategy, and key hue may have the next line. So we have to deal with stenting in this octogenarian female with a three-vessel complex disease. We have already treated to start with the most complex lesion that is the left circumflex marginal lesion, John, and if you agree, and to start with with one and then after moving to the LAD lesion. So about the setup of this paper of this patient, a new router, okay. So we can show you the table now, and so we have already placed a sheath, so six French sheath, light she glides a slender on the right radial artery. This woman, a nice radial artery here. We have a six French XB 3.5 guiding catheter, and here we have already performed some views. Maybe we could see the the unjú the views here. We have the AP view with a caudal view, AP caudal, and you see that you have a code of 31, and we need quite yeah more than 30-degree caudal view in order to see the bifurcation of the see complex and OM. So I will show you in this view here, you could see the the the first to see convex artery, she complex, how to read a proximal circ at some, you know, like an aneurysm proximal to the bifurcation, and this is the first point. In other words, we have around the 3-millimeter vessel followed by a 3.5 enlargement of the the vessel, and then distal to this pseudoaneurysm shape we have the bifurcation, oh, and one OM two with the long lesion on the OM one which is really long and torturous. You could see here the the taught you city of the the vessel, and we could anticipate week some concern with the tractability of the device. And it's true that in this particular patient we have to pre-dilate. And second, we have on the other view the… here we can see again the distillate the the the bifurcation of LCX OM ii am is a very large vessel, more than 2.5, around 3-millimeter vessel, and 2.5 for the first OM. Here you could see on the top of the image the LAD with a significant lesion, chest at the origin of the mid-segment, just at the side, just distal to the origin of the first septal branch. On the next view here we have the, you know, the gain the lesion of the the circumflex OM OM one OM two, and here you have the LAD and the diagonal. It's a long diffuse LAD disease involving the origin of the the diagonal branch; and when you look on the next view, the diagonal itself, there is a quite a severe lesion quite wrong on this large or diagonal branch. So we know now we have seen the different views LCX OM1 OM2 now and LAD major diagonal. Yeah. So now we have to talk about what will be the threat alert strategy. So for sure for the left circumflex marginal we will put two wire, wire both branch. I think that here the two branches are diseased at the ostium, so we need to to wire. Then we will pre-dilate the first marginal branch because it's the long lesion. We will not pre-dilate the second modulus from the beginning. We decide not to appreciate the second marginal after fertilization of the first marginal. Then we will stent from left circumflex proximal edge the complex to the long lesion of the first marginal branch. Then we do a post on the proximal circumflex, and finally we will cross and probably put a second stent on the second marginal. This is the plan that we have addressed for the moment, okay. And father LAD, father LAD, I think that we will follow a little bit the same. We will, I think, wire the LAD and why are the diagonal bows. Yeah, personally I will not read the diagonal. I will try to keep medical. I will not touch the diagonal, even the second the second portion of the diagonal, but if we decide to treat it has to be done before treating the LAD. So we can treat the mid portion of the diagonal with a stent then, but personally I will not do it. So my strategy would be just to Twitter LAD, open the struts world tour dragon on and to be provisional. Okay, discussion. Yes, we have a question from the the audience. What do you think about the ostium of the Cirque? Do you want to treat until the osteoma or not? Because you can see the diameter of the asean of the Cirque. Yeah, that's that's a very good question. In other words, when you look at this view, which is an apical or view, the lesion of the Cirque are the proximal segment is not severely diseased, but when we move to the alario caudal and you will see and they on this view you see that the origin of the proximal circumflex artery proximally to the, you know, the owner is there is some disease. So certainly we will have to place the stand from the Rose the Ostrom of the circumflex to what River Hotel explained you to the OM one, and then after the post-dilatation we will recross and certainly place the second stent at the origin of or provisional, but certainly a second centered origin of OM two. But you're right, that's a goose question. Yeah, I mean, we from what we can see on the angiogram, there seems to be a fair amount of calcification in the basket of cherries as well, so that circumflex is not going to be particularly easy to navigate. Stands down with the tortuosity and the calcification be non-compliant. Um, can I just ask you, um, did you experience any difficulty with the radio puncture? Presumably you use the radial artery for the right coronary angioplasty? Yeah, no, there was no particular problem to do the to to do the puncture. Yeah, and the ys was good, was quite a large purse, and we used this in French sheath, and so now we have a good I think we think a good support with the XV 3.5 guiding. So no resistance that could indicate, for example, a media Cal cause or something like that. Yeah. Okay. So, and you wouldn't routinely do an arm angiogram; you'd reserve that for experience in any particular issues with tracking your equipment. Okay, that's a good point. In our in our usual experience, we are not doing systematic and geography when we do radial angioplasty, only if we have any resistance at this moment. If you experience any resistance when you advance the wire, when you advance the guiding, never force; do an angiography and understand what is the problem. Yeah, and we did have we have another question from the audience. Oh, now I'm not sure, Bruno, what your experiences is, but there was a question as to whether distal radial access could have been employed in this operations. Well, I don't have any experience with the distal radial access. Maybe you, Jim, have you already done some puncture of… yeah, we we we've done a limited number of distal radial procedures, and I have to admit that this is a challenging case, and it's not one that I would choose to do a distal radial procedure on. We're building up our experience, and at the moment, you know, we reserve it for a situation where the standard radial approach is not available, or there's a particular issue where the patient might need a dialysis fissure in the very near future. So I think it's technically feasible for sure, but I think I, you know, it's it's some because it's a challenging case. I would reserve a good solution for bleeding, high bleeding. Yeah, yeah. Okay, so we have already… please… it was not easy to place a wire in the in the second one branch, and now it we try to place the second one in the first one branch, so the wire is the runs through wire from… yeah, to run through wire and through wire, and so we will see. I hope that the problem is actually it's not too difficult navigation through this… yeah, high tatras angulation and so sometimes really difficult. So the quality of this run-through is, you know, they said ruefully coding this can facilitate the navigation in this kind of heavy torturous way vessel that we will see. So now we are advancing the second one genre… no… yes… a question for Mr. Salim. You want to know what… but do you have a cost respond about the the aneurism segment about the stenting talked about? Do you have advice or anything? I think we have to rely to what will be the normal size of this… okay, let's see where your… okay, what would be the normal side of the artery? And sometimes you have to to take a larger balloon just at the level of the artery. So effectively what when we dealer when we have to deal with the problem of such an arisen, we choose this to the diameter of a sense according to the diameter of the reference vessel, and we try to postulate with a non-compliant balloon at the level of the aneurysm in order to to be able to perfectly adaptable to the stent at the level of the and every shot quite shorter and companion balloon. Yeah, so difficulty to take the right… maybe I am in a small branch. Yeah, let's see. We will see in the different view angulation test. Not easy. Yeah, you see, you see, I'm not in the… maybe this one is better to separate. Yeah. And I think that Jim mentioned that at the beginning, what is really a problem here is that we have really difficulty by the angiography to see you see clearly the ceiling very well the lesion. It's always complex to treat it perfectly. Yeah, but that's a good message at angiography, so you need a very good and geography to understand the anatomy. You see, we are not in and and very difficult. Maybe I have to change the shape. So Jim, for this kind of anatomy, tortuosity anatomy, do you choose any one stent particularly or… well, I mean, the stands… yeah, the stent companies make claims about the deliverability of the different systems, and operators form opinions how much to science is behind that, and how much is perception and an emotional reaction rather than reality is hard to say. I'm not really convinced that any specific stent is more deliverable than any any other one at this point in time, given the current generation of systems. Many people will argue differently, and they will have their favorites, but I don't think that the actual stent difficult per manufacturer is a big driver deliverability. They're all very deliverable in my opinion. I mean, I started to do coronary stents with hand crimp only shot stents; those things were not very deliverable. You know, current generation of stents are entirely different. There is a question from the audience about using extra support wires considering the vast vessel tortuosity. I mean, I have to admit that although the extra support wires will help in some ways, they're not the easiest way to deliver in here, and I wouldn't be going for an extra support one. The other issue with them is that they will cause lots of wire artifact I suspect, and that may cause even more difficulty with we with an geographic appreciation what's going on, so I would go for standard like a wise crucial. What was the thing that we didn't explain but sharper flexi go in the second marginal, then pull back the wire, and when he pulled back the wire, I tried to enter the first marginal, and at this moment he was possible to achieve not seen… yeah, the dostala T of the wire is nothing. We could leave the wire at that point, so we try to have a better position, try to place the really the wire in the in the distal real distal segment, but you see that they're not easy, not easy because now we have lost, you know, the shape, the distal shape of the wire test here. Maybe sometimes you can advance a micro catheter and then you know do MIT. I think that here it's cool, it's okay to strain. Yeah, yeah. Sometimes you could be helped if you ask the patient to take a deep breath, but the problem here that the woman is sleeping on the table, and so what is Minerva cannot be used today, but this is could be a good night if not that we leave the wire here. What do you think? We know I think it's okay test. Yeah, I think it's okay. And if…

We have an adopter about stenting. It's January the first. When we leaked all the detour across to, but you see now anymore that they study the wire; it's difficult. So I'm turning slowly, you see, the talker clockwise, counterclockwise, and try to negotiate this curve slowly. Never push, never push. And we have to be patient. Did you change the band until the beginning or not? No, no, no. It's just the same band. But you see here now we have a community-like SunZia conflict, so that's it; it's very difficult to test, so with this patience, so now it's the most important point. We have a good position with the guiding catheter, good support. We have the distillate of the two-wire, the OPAC radio opacity of the tire in the distal vessel, and now we will follow the tell you. We laid the first marginal, so we use two five om one as a major vessel. Yeah, so this is no description, I think. Well, this—we'll look at all the difficulty to go through this. Okay, so this is when one we can—yes, the question if you you have some difficulties to pass the wire into the GOM, do you want, do you change your strategy and have a proven provisional stenting or not? You, you want to always try through that? If we have no—it was not possible to to place a wire into M1, that is tolerant one, we will try to open them to maybe and leave the way M1 with medical treatments. That's, I think that we have a plow, plow. Yeah, we have to adapt what happened during, according to the course of the procedure. Okay, so this one is a balloon to five, twenty millimeter long, one to five when I 20. Okay, we cross here; we have so we can go from the from the top here. Okay, that's just a little bit, just to see if we, what is the length? Twenty, twenty, twenty. So twenty plus twenty should be a long center. Yeah. Okay, we can discuss. Yeah, seems to use to say percent one small to five for the distal and one maybe a little bit. Yeah, let's see, because 38 could be okay. Here is good. Yeah, eight atmosphere. Noah. Okay.

And just to recap on your strategy: you're going to stent into that here, first marginal, fir as your first step, and then deal with the second margin ology second step. Yeah, yeah. Why? Because anatomically the three crossing the first, the one one stand will be easier with an, to do the opposite, because there you saw the the difficulty that we had place the wire. Okay, here you know you would anticipate it would be very difficult if you just entered into the second marginal to then place your second step into the forest on the resistance of the the stands and a potential for causing problems as you try to track through it would be very, but then if you do it in the sequence that you're honest with our parts, we have a much straighter run-through. Okay, so you see what to do, what we try to do is to place about to advance the balloon and to see if the balloon can be moved freely from this star to proxy mon proximal to distal. Okay, and I felt there is some resistance at that point, that the reason why we Bruno, we inflate one more time, and then I will again test the vessel. Here it's okay now with a 20 millimeter, we can appreciate the length, so we can do Baloo and okay, we need section, so we need to go from here, this is 20. Yeah, so it's at least 28 for the OM one, and we need at least plus we did a long one. Yeah, but maybe, maybe 2 1, because 38 could maybe two. My question now is to stand with a media 24 down to the bifurcation and then took a second stand before the bifurcation. What do you think? What we need is to avoid yeah, the overlap of the stand at the side; that's why I came down to the bifurcation. Yeah, let's see that the referee S&C. So I removed the balloon. Can you strategy because we have some question about the structure, who is the main and with the main branch, and can you resume the strategy of Bruno? And so I'm sure graphically the main circuit could be the second one. Yeah, but technically for the procedure we consider the main the first way, Matt the main course of the tour to city. It's a more complexly anatomy, so big if we consider the vessel with a more complex anatomy at the main vessel, it's quite equivalent, the diameter are quite comparable, so we take a 24, 24, 28 because we need 220 area ladies section 105 a distal body. Yeah, the same vintage in to 528 and we take another one okay, to do the proximal part of the circuit and we don't I 528, we will have the overlap distal to the back to the bifurcation, so it should be okay to thank to side 28 will team a certain size, so it's an ultimate certain say to 528. Let's see how it will Magnum it. We need you layer to see up to the curve because we have 28 should be okay.

And we have a couple of questions from the audience about the guiding catheter. It's a six French guide that you've chosen us Tallyho work multi stamp bifurcations through a six. I think most people are nowadays and the configuration you, you told us it was, it's a an extra backup type configuration, is that right? Yeah, right, extra backup 43.5. Yeah. And so if you're a radial operator, it's important not to understand that you need to get your guiding cuffs are optimally deployed and positioned at the beginning of the procedure. If you start, if you start the procedure with the polyresin tuning guide, it will certainly deteriorate during the course of the procedure because we have a difficulty to advance. Yeah, that's the next question I will ask if you have some difficulty to to go to to cross first the position of the wire. This is very important because for the moment I think that John is taking care of it, take care of the the wire, the two wires. This is the one they said the second wire, we have lose a little bit what we said before. Okay, we'll see. Okay, maybe we need to repeat the inflation, or what I'm doing is just pushing slowly, maintaining the push. The guiding is a little going to events. You have done some progress. Yeah, I would say replaced of the wire. Yeah, and then we will come back to an additional pushing maneuver of the catheter. So you put a catheter in and you push the stent. Yeah, but you see the guiding is a continuous pressure. Okay, the other possibility is to use a guide liner to advance the guyliner. Yeah, till the I try to place the guiding like that, you see at every mode at an occurring balloon here about an ankle. Yeah, I mean, I guess it looks very difficult to deliver that stent, and I would, I think I would try either with the guideline ER or with the shortest and to think there's a lot of resistance in the proximal circumflex vessel. He may be easier to deliver a shorter stands. Yeah, I may have to put two or three stents in, but yeah, so but an uncle we need, we need a place idea because a higher pressure. Yeah—yeah, yeah. So you could certainly do that because the guideline, you know, the guiding catheter isn't going to give enough support—yeah, to deliver us this long stent into that vessel. I think it's a combination of factors, the circumstances. So what we can do is to take an additional a balloon inflation. You think there is some, you know, city lack of support with the guiding, so there is different solution, and the first one is to go back with the balloon and to try to open a little bit largely the the proximal third oh of course, we know at the beginning that it should be difficult. I have a question for the audience at this step: who wants to use a liner? The moderate child Godzilla, you can, you can vote. There is always the possibility to push the second wire, but yeah, when we see the difficulty—that's the problem. Yeah, I mean, if you're going to do some other annotation, it could be an opportunity to deliver a guideline into a festival position, but you have to have the guideline er deployed before the balloon to do that. Yeah, so we will try with first a balloon inflation under the wire, and then we will see by maybe our pressure. So you will, you, you choose on here more aggressive or readily tension. Yes, is it the same value? Yeah, symbol driver two point five hundred atmosphere. Now you don't want to shoot a bigger balloon. What we will see, you see, so here is not too bad. Go on. You want to replace the Seneca client balloon to 520 atmosphere. Is going to be reasonably big, it's going to be a fun day to pond either something like that three anyways down. We try to advance a little bit of iMod stone. Yeah, if I tell the truth. Yeah, it's a good result with presentation. Yeah, I think the fact that you Denton would suggest to me that taking the shortest end, my actually doing, you know, the the calcification makes it rigid and non-compliant in the proximal vessel, and then you have tortuosity, so tracking things down there will always be challenging for anybody. I think for this kind of illusion the circuit, do you use if the left mainstem was quite short and Amplatz guiding cut to is perfect because you pull it back and point the tip down into the selectively into the circumflex, but this page this kind you, you think those main templates would offer a lot here because the left mainstem is not one, so I guess my next option here would be to go to the guideline. Yeah. Okay, now we do dance. We have a lot of guideline no proposition. I mean, there is a question why not pre dilate, a pre dilate with a bigger balloon, but I'm not sure about that. I think there's a section risk in doing that. You know, your balloons been up to nearly three millimeters in diameter already. I think the main problem is compliance and tortuosity, know calcification law. Yeah, no, now we have a better position, you know, of the of the wire in the first OM branch, the the vessel is trained by the wire and symbol, and now we will try again to advance the the the stand. So the next step would be to now because we advanced the wire more distally, we straighten a little bit. Yeah, but maybe we can be successful to advance the cent. We will not, we will use the guyliner, if not we use a guideline. So yeah, you have an excellent Y position there now, and you can see that it's not too bad, so yeah, we will see. So vessel conformation is quite different than it was at the beginning, maybe a second wire. So you see the accordion effect on the on the web, but how you hope that we could advance the stent. We don't have any is kim yeonji no. Okay, you see that pressure is good and jean briault. We have a couple of questions about using the guideline here when you have when you have two wires in deployed distally, or is it safe to use a guideline, our do you have any experience difficulties? You mean something that I have not faced for the moment, but I think that if you choose to put the the guyliner on the first marginal branch, normally you can advance it. Yeah, I will say that for me it's not a real an issue like this, but yeah, so I to be honest, I have no experience with that. Yeah, so I think it's it's perfectly safe and appropriate to use a guideline when you have two wires down there vessels in two separate launches, and you can load the guideline iran to either of those wires and it will work perfectly well. No, I think that we see once the same problem. Yeah, even with we have always the possibility to remove the second wire. Okay, in advance, you see. Yeah, you see, you see, matter of patience. Yeah, yeah. Are we advanced because rewrite it was the second. Yeah, there was a dissection, so I can eventually to be more distal test. Yes, we know we have to advance at the top of the like this technique. Oh, it's, you know, it's just a position, the difference is the position of the wire in the history. I think that we straighten going when they prom six. Yeah, so we are to the bifurcation six eight six, and we are down to the bifurcation which was eighty two point five two five. Yeah, he looks on. Yeah. And what stance is that? It's the same one before, the two 528 will tea master Tom sighs. Okay, okay. So what we draw at eight atmosphere nostril Otto in here. Yeah, I pull back a little bit. We are inside now. Maybe you can take a high pressure. Yeah, I am inside and go to idea in order to try to postulate correctly. Okay, good. And now we can place one more here proximal to the bifurcation to test relation. Yeah, maybe inflation of the one more. Okay, good. Yeah, very important to do that, I think Joan, because the next step we'll need to track into that area. Yeah, do the proximal tortuosity sir. You can also problem if you don't do that. Yeah, we did incredibly well to get that stent in there. I think the distal Y position was a big help to you and yeah, okay, we we are able to straighten a limit the loop and see what you think of, you know, it's not too bad, huh? Okay, okay. So now we have to advance, the problem will be the length, and maybe we can measure with the balloon wait like 20. We can take the 20 millimeter balloon. Yeah, 20 millimeter balloon maybe free zero, what do you say? Yeah, it's because when it was a two-five a little bit large. Yeah, I'm got the two five Willa 2 5 20 min ago 75, it's okay to 5:20 just to measure the length, then in November do is to place a balloon from the awesome of the circumflex close to the ocean to the end of the stage the proximal end of the stent placed into M1. So now we need to measure, I should be more than 20. Yeah, yeah, should be certainly 224. Let's see, maybe 28 by 24. Sure, we'd see where we are. Look, difficult to cross. This is 20, so take a picture and then we will see if we need 24 or shorter. Just 20 inches and office 1821 1821. I would say 283 too short, 18 will be more deliverable. Yeah, I would take 21. No way 21—no, no, no, no. Okay, on Pentagon feed on you. Okay, so we take an inflation here. We have a question from the audience here as to whether there's an intersection at the distal end of the stand or whether it's all accordion to me, it all looks like then we will, I think that we cannot, you know, address this problem in time. We cannot say. Okay, so two point seven five by 21, you want to, we can take a view. Yeah, to be okay then we could postulate with a free or maybe three five, which three should be no. Yeah, okay, it depends. So the challenge for this next part of the procedure will be navigating the tip of the second stent into the ostium of that stent there. Yeah. Okay, clearly fully agree with you and she said early sometimes uh asking the patient's to breathing will change the configuration of the vessels and facilitate passage of equipment. Okay, so we are slowly push slowly. No, it's okay. You are inside, inside, and now we have two two wires, one this one particularly don't lose, replace the guiding here. Okay, and now try again to advance a little bit. Ready, ready to test. Okay, test. Okay, sorry, I don't want to take your time, take your time. I was looking, it's not too bad. No, it's okay, it's okay, it's okay. You want to do another view for the whole show, and I think it's okay. Okay, we go. You want to, maybe we can Vic sure. Yeah, we are clearly inside. Yeah, yeah, go on six eight, so it's a two point five. Yeah, yeah, but you can go to twenty, sometimes you know we can do it's doing this look at the, it's okay, look at LED, we are just should be okay. So what we can do now is to advance the standard little beam the balloonist and Modi strong in order to take the overlap if I can, you know, it's a balloon of the stand, so what he was inflated one time once a twenty atmosphere, is difficult to adventure this story here, maybe it's better go on 20, take care of the wire. Yeah, definitely. Yeah, okay, here is good. So we have done, we can see the tour true city and this tip of the wire, I think this is yeah, so it was our current. Yeah, I think we'll see it. Okay, I guess we have told the time to be optimistic, can bet on our Korean defector II hope, but good. So now we have the went to wire jailed by the stent in proximal, now we remove the balloon of the stent, maybe we can take of you. Yeah, we know it's good, good. Yeah, you see now that the wire bring back we don't have this question now. What do you think? Take a 3-0 certainly Airport. Yeah, we have a 3-0 don't even went below in the tourism no computer for they all do is knock opium incomprehensible. So think that very well answers the audience's a request earlier question about the distal appearance. It was clearly an accordion effect because it's disappeared, and when you do the the pot in the proximal vasculature here you'll you'll leave the OM to Y still in situ. You have no concerns about pulling that wire after the pots in. No, well, it's a good point because for this particular patient we have some—a lot of tortuosity and it's maybe you know it could be a problem sometimes. What we can do is to pull back the part of the wire till the radiopaque for example part in order to limit the the the risk of resistance. We will pull back the button, but I think that it's in most of the time it's not an issue to the the balloon to the wire gel here is the pienso que concern any fear about this problem. You can pull back the wire till de radiopaque part you're the Ostrom the radio back spark started the austrian, and then you just have to pull the the end of the balloon, it's the end of the wires. Okay, so here we are now. We have a 3-0 at 24 22 in C balloon, so we can do up to you see 24 atmospheres. So we have one question from the audience about are you concerned about whether you have involved the LED ostium where the extent will project them. We have done, you know, a contrast injection with the balloon with the stent inflation, and we see that there was still passage of dye inside the LED, so normally this is an indication that the stent clearly not be in front or it just in front of the Austrian but not covering the 3D. So now the idea would now we need to recross recross. Yeah, so we have two options, take the web one wire and go to the—you know, say no, no way, but this could be done when we have a normal Anatomy easier to me in this particular case. No, no, we will use a third wire. Yeah, so we have the OM one here, OM two here, on the table OM one is here, and now we will use a second third wire to cross the stands threats and place this third wire in the OM to decision when the wire will be it's the same with the same wire and then when we we have I hope the wire in distal one two, we will remove the jail wire, the OM to jail wire and then advance certainly with 2.5 balloons through those threads open the threats do the kissing, and the question will be do we need to use a double strain strategy, maybe we need to do a you know a sort of tap because there was if you look at the baseline and her to me the baseline angel there was a critical lesion at the Ostrom of the of the web to. So now what we need is to go in the third conflict yes, so maybe we have to push which is good but is not the purpose now it's not the objective see it's not easy because or maybe to change a wire or everything that was a good point from the beginning to discussed, you know, the source of the shape of the guiding and the only and on Platts could be this is not to our ear they say we are just facing the stretch I'm not sure that we are not through the stretcher so it's okay so no yeah you try to go in the well we have to descend into and—. Okay, maybe are you sure that you

Are you know, so the do not feel you know this metallic feeling that you have when you have read? I do not feel it, but really honestly, I'm not sure. I mean, the advantage of using the the OM1 wire is that you know that you'll be within the stent architecture when you cross, but then you lose your wire position, the distal in the OM1. That's correct. Yeah. The other possibility is to place a short balloon, you know, and in the proximal Cirque under this wire and Betsy, very just you are in difficult, really. I could, you could believe that we are circumflex. The first there is wrongish navigate. There is another possibility is to move to the Lau view. Yeah, I'm not sure that because this particular not to me that we could see better the the vessel.

There is a question from the audience as to whether you are confident, you know, within the stent luminal or whether you concern that you may be outside the proximal struts of the stand. Yeah, that's so it's a matter of the feeling that we have between your fingers when you are animating the wire. If you feel some, you know, metallic resistant metallic feeling with you talk are your fingers, you are certainly through the the wire. If you do not feel this, you could be more optimistic to say that you are in testing, but not easy to look at that, and maybe we will have to if I cannot recross, we will leave that it like that. Yeah, that's another because the second marginal is open is difficult, so difficult. Well, you have to me three, you have to me three flow in that vessel. Absolutely, Monday to be to do exactly, and you know the wire is a little bit destroyed. Yeah, if you are able to go in there lady and change why.

Yeah, we have a same question in the audience, in the audience, what do you want to reconsider to have a like a whisper or filter wire? Yeah, why not change the band? Oh yeah, because it's the first threat of the of the stent. Woo, yeah, you see back maintain this is this shape and it's difficult, it's not easy. Yeah, the the whole confirmation of that proximal circumflex is quite different now that we've tried with another wire, the fielder FC. I like this wire for the verification lesion, so we will try with this one. Okay. Yeah, I'm gonna ask a question to the audience here, don't ask, ask them to vote on who who would be happy to leave the OM2 now with that appearance of a narrowing, its Austin but Tim III flow. So would you be happy to leave it, yes or would you be unhappy to leave it, no? We'll see what what. No, honestly, we will be happy to leave, but I think that's a good message. It's you have to adapt to the procedure, and clearly here it's a complex procedure since the beginning when we see the difficulty to advance the wire, the difficulty to advances and with the risk of, you know, of a migration of embolization of the CENTAC etcetera. Then we have already extend the circum proximal circumflex, the first marginal, we have a good quite result on this vessel, so we can consider that if the patient now has only this second marginal lesion could be okay. Yeah, so the balance of lis, yeah, the balance of the audience votes is two is that you you know they feel that you have to do something to the other one to you. I have to say I can't talk. I don't totally agree with that because I think there is an excellent flow and you know you don't it's not Monday to me to do anything. Why is this? It is now the the keys that can we cross the stretch, so do not ask me if it is the distal threat or Noxzema one, remove the wire. Yeah, so happy to.

What about the patient at the do you have any city modification? Honestly, she is sleeping on the table. Okay, now maybe it can you can change your strategies you if you have any sign of ischemia and the wire that I shown is that a field that you've come to fill your FC FC. Okay, FC wire, but the problem is that I take this small it's not the big branch it's that do you see this movie is a comedy style Cirque, so we try to come back and take the right one, but if you okay this is the right one. Okay, so this is the right one. Yeah, so now we have to avoid the mistaken. Yeah, this is the right one. This is the gel wire is up. This is the gel wire and I only remove okay. From here we can remove the gel wire here. You see there is no major engagement, so now we have the two wires in the right and so here we have it's easy because they don't have the same color, so now the the filter here and the fielder is here, it's a green one, so now on the whoop, okay, here we are, so on the fielder now we can take we can is a 2.5 balloon when you want to thank the same gas company on, so we we can advance the 2.5 on the distal and the second OEM open the threats and then after doing that advance the short stand using a tap technique, yeah, and finishing by the key scene and a final pot, so this is a gold and then the LED should be certainly easier because we will take care of the certainly the LED leaving the diagonal nothing. Yeah, I think so. And what we know at the beginning and maybe we have to consider to stage the second procedure because already we have spent a lot of energy on this first region, maybe we can use two two procedures. Let's see. Oh, it's yeah, I have to finish first and see what to do, focus to focusing to do under on the circumflex and use tomorrow although day after tomorrow do the okay. Always it's not easy. I hope that we have not outsider. Yeah, yeah, maybe could be could be, so we'll see how do we knew if you are normally, you know, normally if you with a two five you should cross. I will say the process we have, I will say if I see this kind of resistance this is an indication that probably the wire going around. I think so. So I think that would the blue truck on the other wire that will tell you on to the trucks on the other way, you know, you first why I must be outside. I mean, do to try on the other wire my ax. Yeah, this one is a right one. If you choose a smaller button, no, but I think that normally you should not have difficulty here. Mmm, this is not you know, if you the smaller balloon you can increase the problem. Yeah, I will not use a smaller balloon. Yeah, if I have difficulty to cross through the stress of the stands, maybe take a value of that at this stage. Now we are in front of the Ostrom of the circumflex. Yeah, I will not push now, so don't even want watch him get super. We will try now we take another filter. I leave this one because we know that this one is not in the good, yeah, not in the right channel for these. Now it's do you routinely have these patients quite sedated? Oh no, that's quite a widespread practice in France that you have Anani Thetis there and the patient. Yeah, yeah, and if you have any CT your stress, yeah, we can have a little bit more. We don't routinely use that. We don't routinely have an Anita test with us, so you know we would use midazolam and fentanyl as required in approach, good feeling, so the patient can answer and ask question, so it's not a very deep sedation. Well, you know, I think there's a lot there's a lot to be gained from sedating patients in certain circumstances and with a complex difficult and long case like this, you know, having a comfortable patient free of distress during the procedure is a useful thing. Look at the position of the guide wire. I think it's better on the osteon of the circ. Still difficult to pass through this strap, but difficult, huh. Here we are. Is it the fielder if FC? Yeah, I had the same one, see, but quite difficult. Asian is the key to take it. Okay, here we are, and now we have to take the second your angle Asian the same and why not we can take it here. What? Okay, here we are. Oh, so now on this one leaving the other. Yeah, you want to leave the other. Yeah, why not take to advance to the 2.5 balloon. Let's see if not a 2-0 balloon. Do you have a better feeling? You know, the other feeling was not bad, but that's a problem. I was surprised, but you know that's life. Okay, here we are, so it's a 2.5. Yes, we will see. We will try with the same balloon. If not we take a 2-0. I want to arrive if you need to take what is yours then it's not a good indication to stand there. Do you use either sometime for this kind of difficulties and well look an eye this would be great, but there's no way an Ibis probes going to get a balloon easily into it, so I think trying to pass an Ibis broke down there will be sure if you could get it down and try to assess the wire position in relation to the stench straw it's great, but I just don't think you deliver on. I've escaped. I have no expense to do use iris through the stands. Yeah, I mean it may help you in the proximal segment there to is to to determine precisely where that I just don't think a novice is gonna be deliverable is better. Now we have just difficulty to progress threat but we do the same place, so I think that fear here is good. It's okay. What is the size of the balloon? Two five five, but if we cannot I think another one we try I think the other one, but you want a smaller or new one. It's okay. We cross it. Okay. Yeah, go on. Six a ten to fourteen. Good. Maybe you can try to advance the balloon little bit more. Now we can we can. Okay, you see we can. Ok go. I care up the other one twelve. So you've clearly crossed it with the balloon Avenue. There was some question from the audience by using a smaller or shorter balloon, but I think the same one to five and how long is the blue? Fifteen fifteen. Okay, so now what we will do is to try to go up inside the the guiding and try again to cross it and you see it's not easy. Yeah, so we could anticipate that running time is too early to take the stand. Go on. Maybe we can do provision. Yeah, stent delivery into that vessel will be very very difficult to think because you know the additional friction of the stent balloon on the the wire bias will take the stent against they against they already deployed stents, so I would try very hard now not to not to not to make this a to stent procedure. Got here. Go 20. Yeah, but we are I try to, you know, advanced balloon several times. Yes, take a high pressure down in order to make a right channel. Yeah, and then we will try again to advance the balloon. If have no resistance, I will I will place a stand. If I have I think some difficulties here is not too bad, but I think that the crucial point is to cross the proximal third and it's true that I think that our guiding is a little bit too short and I think that a 375 could be the best option in this particular case, but now it's too late, so I advanced the other wire. Okay, here and I'll try again from the guiding, take the curve. It's not to worry. You don't have any resistance. No, no, no, but maybe it's time to understand. We will see. We have to control. Are you ready? So we control the the picture ready. Yeah, go on. Let's go down. Not so bad, huh? So for the size of the stand, - 5, yeah, by 15 or 18, what do you think? I will be short to 12. No, not to longer because there's a curve. They have it in you. What are you thoughts about really? Maybe except in an geographical - yes, let's let's see the result and the other of you. What do you think? There is a dissection. Yeah, we see it's only 12 of 15. 12 should be enough. 12. Okay, the sink the stang do them those we see on this view that there is yeah no sorry unfortunately I will say we see the stagnation of the contrast also. Okay, now it's another story. Let's see now. I think it was interesting cassette because definitely we need to do something for this woman's and we know we know what when do we select this patient that we will get a lot of difficulties. We know that but so I verify that this wire is OM1. You see the contrast hang up there quite clear. Yeah, yeah, contrast the dye is still present, so that's not a good news. I will say the wire is is this tall. It's okay. Oh, it's okay. No, are you just - we'll see that's the key point and okay let's see that's a problem with the guys the guiding is too short definitely and that's the difficulty. We will try but I'm not optimistic otherwise moving out. This is a good news. Maybe this one is will be now with less resistance on the curve. Let's seek like this maybe maybe like that. Let's see if you can take no care of it. Not now. So now we are it's my help help the the stent with the guiding. No Adamo Madame la Musa I'll a Papa sometimes if you ask you the patient to cuff this could help that you see sleeping now. This is clearly we see that at the site of the bifurcation see on the opposite wall. Yeah, that's that's why I try to push the guiding here like that. You see on the we will see if I can the risk is to have every everything moving out. I advance very very slowly. The guiding is going around. Yeah, maybe reconsider the berliner. There is the other option is to put a third wire but difficult difficult. The advantage of the guyliner is that you will maybe be able to put it in the first curve so what but i will do is to open with a large balloon take it was it all possible cancer. Yeah, i think if we open the threads with a large balloon maybe it should be easier. We would it was the whole kind of balloon that was it all come pre-owned possible cans. We will see so when fever stands on the table. First step is to open a little bit large. This is the first then you have the possibility to put a third wire in order to make the like body wire there at this moment the stem could slide on the other wire and avoid - but tube - abrupt on the opposite side of the stem and after you have the possibility of the guyliner. Let's see and is the patient still quite stable with pleasure at all. You see the pressure. Yeah, I took it. Okay, I open it. I opened the valve in order to advance the free zero balloon. There is no problem with the balloon. Yeah, absolutely no problem. Go on. We have a good idea from the audience using a non-korean value in the in the OM stent. That's a possibility. Yeah, I was thinking to that. So first I will use this balloon free zero just to open the threads. We will use this free zero to open the proximal end of the stand and then we try again with the stand if it doesn't work effectively. Okay, go on six eight and we will use the and anchoring the balloon technique. Okay, down the other passivity also she put a small 1 5 millimeter balloon on the first marginal branch to make also like a body wire but with the balloon a body balloon you've already value in the air one six one more time to reopen the sweater when you see that balloon track down quite easily Emily you should be able to get a guideline a close to the application point now is it new so good so now there's stent again yep and if not we play we do the anchorena if it doesn't work before the games you play vez para whoops so I verify the integrity of the stories go of this maneuver it's good and you can have stenography to track it we can use it so always important to check the stand there's no because you can lift the edge of the stent in the original attempts to deploy you sometimes say yes not sticking up but 90 degrees okay we go one more time you see the support with the guiding is not optimal and here we have attained a problem okay take care of the wire difficult tunnels and this one also difficult so I have to pull the remove the balloon try again with this so this is a distal one yeah and this one is the proximal one and I have now they did a lot of difficulty to move the proximal one that this is normally because we are everywhere so the other possibility may be is to place the look at that sorry for that but very difficult you know that's perfect yeah yeah a test just to see where we are with very difficult test good idea from the from the audience is to use a micro catheter in in the UM to wire on the wire and to change with the stick yeah I understand that but I don't think that will resolve the problem because there is a wire bias issue the wire is taking the stent loaded balloon against the stents struts and I don't think the stiffer why I won't resolve there I think the anchoring balloon is the value there result yeah so that's a problem so you need to reinvent it or I don't know what we need to do the OEM one wire isn't absolutely critical to the procedure at this point is it I mean it's at that point you know yeah the possibilities to use that so what we can do is to remove it yeah try again to advanced on this why the balloon if the this is not working then we can answer or we can advance a micro catheter use a stiff wire I I like the this idea and on the stiff wire advance the gain to stand in though I am too if this is not working maybe we will live like that are you concerned about using the guideline I mean there is a question from the audience about no no no the problem is you see I look at that it's a very difficult and I think that the problem is the support with the catheter which is not optimal and that that's why so what we can do it's two things a guideline er yeah or but I'm not sure that the guide lighter could be advanced not sure on the balloon air if we track again the balloon yeah yeah oh you see you see the problem okay I tell you that's so difficult so yeah do you want to change the guy exactly don't what so some case so sorry for that because it's 5:20 I'm sorry for that made one ransac get it one sank we get home thank digital channel copied on okay the catheter process on cancer of Yanam plots as a personality so with the with a 375 guide you may have more suppose yeah yeah the other option is also the left hand plots l2 l3 this is another option they really do pose but I would want to be too aggressive with the left-hander lads an al - I mean she's not a very tall lady is she and it will be a bigger I didn't capture to manipulate my eye or deep bruise oh yeah okay here we are regime so here's a question about the Amplatz we've dealt with that really yeah do you think if you have some difficulties to pass sustained in the balloon in the in the Ostia of Cirque do you think it's that we have a stretch Pro - protruded in the in the LM it's certainly possible but yeah but I don't think it's support it's the reason you we we have so some difficulty yeah due to past I mean the the still open the problem is the confirmation of your vessel you know same direction in relation to the tip of the kind that second marginal has Tim III flow the Bronner is the stagnation of dying yeah [Music] I think I Section D be distorted to the level of the curve because there was a curve so we retry with a you know a wire with a better support you see the D section the risk now is to take the audience asked about if there's a concern about LSD longitudinal stent definition with guide liners but I mean the answer to that is yes but it may be the may be something that you have to do any passage of any equipment through a previous era of deployed stent.

Can be associated with LSD event, so it doesn't have to be the guard aligner; you know, the stance, the balloons, they can all cause LSD events. Difficult to see; maybe we have to go in a different view to, in order to see where we are, because I could be in the dissection test. You see, I think it's not the right—why do you think this is the beginning? This one is the one, one, but maybe we can leave it in the Orion one, because there's needed to have a wire in the OM one.

Yeah, it's okay; we live here. Yeah, don't want Dejima under the NBN with well, has holes for one's home. Yeah, luckily it's okay, advance easily. You know, now there is no problem here, but the problem will be to cross and to place the second wire in, inside the, the, you know, and to avoid the dissection. That the difficulty—it's quite easy when you have a straight segment. In this kind of tortuosity, when you want, you have to ream, you know, to rotate the wire like drilling, to advance the wire through the tortuosity. It is very difficult to be sure that you avoid the dissected area; that, that's the difficulty here. Now anyway, we will try to talk here to advance the, the second wire. We're inside a—so difficult here. We are; a small branch is good. Now we want to take the, the first one, the larger. That's okay; that's correct here. Okay, okay. So now, now what's your next step?

We come back to the beginning. Yes, give me a balloon; the balloon. Yeah, 2.5, just to see if there is no bubble on the shank left after the second—just to see if there is no resistance. You see, did you use the same, the same sank? It's to run through its feelers. Now it—you have in fact in the first marginal in the OM one, it's a BMW wire, then you know a lot of, you know, good surprise that the advance right now, and the second one is a run through wire, and once again it seems to advance quite nicely. Maybe the support is different and mass difference. Yeah, I think that the change of the guiding cadet era is very important, because it was that the three five was definitely too short, and here we will see—here we have a still somewhere your resistance here due to the two wires I think, and the two wire are superimposed. We try one more time; the balloon is not a new one. Okay, here we are; no, are us a 1014; it's a two point five A. We can go up, down, so go on. Here 14, 18, 20. Okay, now what? Weeks down. Now what we can do is to—maybe we need a longer one. Yeah, what strategy? We can see the resection coupon, funny. Yes, yeah. Give me a 2.5 by 20; 14, 18 could be shorter; we have a 12. Oh, so you want to place—to—no, betrayed. See, here is something; let's see what is first if I—give me the 12 and end through this. No, no, no; we can try at 18; no problem, no problem; we can't repeat it. Well, I think that's a new one, maybe ever—so in your strategy you want to, you want to cover all the dissection. Oh yeah, I think we possible. Yeah, what we want is to avoid to come back twice, but—so I'm sorry, because it's 528 now, and we can, we can run, run on the broadcast. Anyway, Johnson, he is challenging, but fascinating, grace, and you know an example of great skill in being able to cross those lesions and get those wise into distal positions. I think that would be difficult for anybody. So try again. You see, my god, so difficult; its longest and non-current. I don't know; we can't do an anchoring, but again—no. I, when I feel the difficulty here, I will say that maybe, you know, is to, to use, try the guideline. Yeah, so you, if you put the balloon, yeah, where you've had it with you, can bring the guideline it down. Yes, that's the only way you'll get the guideline. It's—are there, and if it's, if it's close to the exit into the OM2, then you may understand. Yeah, yeah. So I have to try, try to try again with the wire, but I'm not sure that the wire is in the right channel now. It says this one. Yeah, some difficulties. Okay, here. Now I'm sure, test, but I don't want to have this section; this toy is it test? No, it's okay. Yeah, the first mode universal is in good shape. Yeah, yeah, yeah. That's again what we like to, to see it, so ever a wire really distal, because if I have not the Y and distal position, test should be difficult. So what we can do is to place a balloon. Yeah, what do you think? Yeah, I think it's the most—a balloon. We're on the same one, and if you want. Yeah, yeah. I will say you can use a two five millimeter balloon, 2.5 millimeter balloon in the OM one, and we will use this. Yeah, under anchoring. Okay, okay. You think yes. This one is OM one. Achieve. AHA. Dorner is stand up. I'm up here. Okay, we will try to do this song Corinne with the two five in UM one, yeah, and then advance on the side the 2.5 standing went to ready, ready, negative. Difficult, so difficult, because now we have inflate the balloon through the struts, and we have the difficulty now, of course we could anticipate this ramble on nephron Pascal, I'd this balloon was used previously. Don't even belong the dose tank. Neff named puff to kill me happy dose given to Changmin way. Okay, so we, which we try to place a new balloon, because this one was inflated several time before, and we have a lot of difficulty to advance it. Okay, so we try one more time on this one. Sorry for that; it's difficult lines, but such a very difficult, but this is its life, so, so we try with a new balloon. Negative. I hope that we could—you see the difference; new device is better. It's not perfect, but picker anyway, maybe stronger, you know, try to advance a little bit more distal the balloon. Difficult. Why do you think? Yeah, first I think you crossed by a test; if it is enough we can't place a balloon here. That's done necessary to go more distal. Yeah, it's okay. Good, go on. You want to advanced extent, and we inflate that there, because we, yeah, but I'm afraid to lose. Okay, you know the position. Look, look at the guiding again. Okay, okay, okay, okay. So I inflate now. Yeah, we can at 4 H is to, to, to, to proximal. Okay, you can leave it here. Okay, you can take high-pressure. Okay, now we inflate the stent on this one. You were trying to ascent on this one; this is the 80. Now we try; it's a very clear demonstration of the difference in performance of a previously used on a fresh balloon. Yeah, yeah. The difficulty, the wire, so we have to detergent leader the balloon. Yeah, cannot advance the other one, and look—oh my god, sorry; we cannot, you cannot advance the stains. No, no; it's clear this block at that point. You see, it's a curve, so probably with the curve and the wire twisted. Certainly, no; it's I don't know; I push a lot, and okay, it's so difficult. My god, you know—can I see it again? So difficult. Is—you deflate it? Yeah, do you still, do still have your stand on your balloon? Yeah, I don't know on the—or yes. Yeah, yeah. Save item. Yes, I think so. Yeah, are you see? Yeah, yeah; it's here we are; we have the stand on now, but so what do you think? Deflated, maybe the balloon; deflate the balloon. Let's deflate all ready. What we do? Remove the balloon. You remove the stent and leaving the wire in place. Yeah, but and then what to do? Now we have to take a decision to remove maybe this balloon. Okay, I—so difficult to see; I cannot remove the balloon from—oh my god, you see. Hmm, it's—you have a rupture of the balloon. Let's see. Yeah, if the blood is coming. Yeah, rupture the balloon of the stent. Okay, so you have to vacation when you lose. Okay, so what we can do is to remove from here to the combine wait. Okay, balloon is inflated. No, no, no, no, no, no, no; the balloon is not inflated, but we can with this balloon remove the stand. You see. Mm. Okay, here we are. Now on—I think so. Allah should be life for the materials here; this one is—you see the stent is going down. Yeah, but I cannot remove the burger. Okay, here before company la voie Serato difficile SE ela table. Okay, okay. Perfect. Thank you. Okay, good. I'll continue it. Okay. Allah, Allah, Allah power gay. I cannot see it. Huh. No steady here. Yeah. Okay. We can't, we continue here. The problem is the other balloon; very difficult; it may be does not remove the other one. You cannot remove these. No, that's a problem; I cannot remove the other one. So the tube, the two balloons must be interacting with each other, twist. Yeah. Okay, here we have the balloon inside the stand. Okay, no problem, but okay, here. Now we have to look if we can—we have to move the rock goose. Why you gotta feel? Okay, move the co. Yeah. Okay, okay. And now we will continue to see there. Okay, here. This one, you have to see where is the stand up; is that? Yeah, we see—you say you are in here. Okay, here. Okay. So now if we can remove the other one. I cannot; everything is going down. Yeah, so two possibility to open it, but it's not right now, because the balloon. No, no, no; it's not right way. We'll both balloons come back at the same time. Yeah, I can fool the two balloons at the same time here, like that, but I love style; I lost the stand. I think you see one more time the scent is in, is on, I think so. Yeah, you are in, and now we'll be inside the sheet with you, inside the tube. Okay, I continue to remove it, and I hope that we get in the connector where are the wire which I need the two wires. Okay, here. Okay, good. Now I pull back, open the valve which I sure love you know—know what power. Okay, we have it; I will show you. Excellent. Okay, okay. So then I'll put some traceable player zoom a civil pay. So la zoom a civil pay to like impress Asuma show a contrast Asuma para bread palaburn Camila said I can be hard and fast it will pay Sumeria kami hard and fast medium box. No, no. Well assist you. See people zoom a single plane zooming wrong. No way. Zoomy, zoomy a forum Cebu pay. You see the standing; we can see it; we destroyed, completely destroyed. Well, the good news is understand is on the now we can only remove the balloon. Now we can remove the both balloon, and so now we have to meet a good one to minimum. So now we take a view and—but I think it's 5:40, so maybe we know we will continue, but I don't know if we have the possibility to continue live if Allah met with us on that table. I don't know. Yeah, we can't carry—oh, I don't know; I don't know; it's uh—no, the wire is out, so no problem; we can remove the wire. So what I suggest we do for a little while here, John, is we will cut the broadcast to the lab while we do, we discuss some of the issues that have come up your case on there, and then we will come back to you and see what you've decided to do where you're—okay, we continue; we can continue live. So the good news is that everything is—we have a TV free floor boom. Yeah. Now what we need to do is to look at in LA Oh to see at the bifurcation how is it here; I mean, not it's not too bad. Yeah, I mean, what's—what we have to do is to replace a wire in the first row, am recross the second one, maybe first postulated in a second pot, and then advanced wire in the second OM and try to redo what we have done, but we can see things take time; this is the plan. So if we want to discuss, we can follow what we are doing on the screen. Yeah, it's after you BAM. So we will just give you 10 or 15 minutes to, to progress with that, and also we will, we'll chat about some of the issues that have come up during the case and some of the issues around bleeding risk management, and, and then we'll come back to you in a little while. We'll let me know when we're coming back. Okay. Can we have this, this lights back up there? So we have some questions here. How do you assess bleeding risk? Any score that you prefer? So there have been multiple bleeding risk scores in the literature, but my recommendation is to use the ARC bleeding risk score from the circulation paper. So if we go, if we have the slides up from the beginning, please, from the very first set, from the very first slide. Yeah. Okay. So here we'll just look at bleeding risk calculations. So yeah, so the, the bleeding risk score I would recommend is the ARC definition of bleeding risk, which is the—if you're, you are greater than four percent risk of a bleed or greater than 1% risk of intracranial hemorrhage, then you are at high risk, and they—and you calculate the score using the methods outlined in this circulation paper from 2019, and these are the factors that we discussed before the patient today. The major factor of increasing the bleeding risk was the age, so aged over 75 is a way to do it, and high bleeding risk patients are defined as patients who have one major criteria or two minor criteria, and so ages are minor criteria; advanced renal disease, major criteria; liver disease, all the things that we discussed before as a way of calculating bleeding risk. Do you want to comment on that about calculation of bleeding risks? And—no, it's, it's always quite—it terms are quite natural; it's daily practice, and we have to think about that in each angioplasty, in each procedure, and it's—we need scores, but we need those also clinical advice, and I mean just put a numerical value assessment to the patient to think, and the problem with the scores is that many of our patients are over 75, so the wrong by definition high bleeding risk. So look, you know, thinking about angioplasty in patients who are at increased bleeding risk, femoral access has an increased risk profile in these patients, so I think there's no doubt based on extensive randomized and observational data that radial access is the site of choice. One thing to bear in mind, and I think we've seen that today, is that older age is associated with radial access procedural complexity; particularly the incidence of anatomical variation in the radial artery rises with age, and the instance of subclavian tortuosity rises with age, but you have any comments about in, in that particular case? I don't think it's relax; I see you there was no issues. Yeah, it's a support. Yeah, but in this case you don't have more support in ephemeral excessively, no. So you know, sometimes people who are committed ephemeral operators will maintain that guiding caf2 performance is premised for radio cases, but it isn't; it's a matter of selecting the right guiding comforter, but I think there's no doubt that, you know, patients when a patient comes into my cath lab who is over 85, I always say stop, go to the left radio, okay, rather than the right radio, because anatomical variation in the forearm is less frequent in the left arm; some calcification of some problem—. Yeah, to—access to the—yeah, I totally agree with you. So you know, selective use of left radial access is an important way of managing an anatomical variation in the older patient group. Another thing to bear in mind is that, you know, small older ladies have small caliber vessels, and they may not tolerate large catheter guides, large caliber guides. So I'm downsizing your, your, your sheath with the glide sheath slender system, which in which a, a introducer sheath with a six French internal lumen has an external five French diameter. It seems strange that you can achieve that, but, but that is the reality, you know. Yeah. So it's, it's due to the thin wall of the glaad sheet slender. So we routinely use and ride—you can have six, seven, seven French with—yeah. So you know, using the, the downsized access sheets will increase the range of patients who is suitable for angioplasty via the radial artery, and with contemporary practice and techniques and equipment there shouldn't be any procedural limitations for the radial operator. Another thing about high bleeding risk patients is to use abbreviated double antiplatelet therapy, and in leaders zeus and senior abbreviated courses of double antiplatelet therapy of one to six months were shown to be safe and as, and as good as more prolonged ones, but with less bleeding risk. Anna, I have to admit however, you know, in a patient like the one today with very complex and ask me difficult procedure, multi vessels, I, I wouldn't be abbreviating the double antiplatelet therapy for this patient today. Yeah, it's—how many time do you use for this patient? Well, not for this patient; however, you know, if you had a person in their 80s, maybe if they had another major criteria for bleeding risk like a low platelet count, low hemoglobin, whatever it was, I, I would definitely try to—if it was a straightforward Angie parsley to do a monsterbowl antiplatelet therapy. Can you do radial access in all—I mean, in the institution here, would you know what the radial access penetration rate is for your cases? Yeah, what proportion of the cases that don't rate it? Depends, but most of the time I think maybe 80 percent, 85. Right; it depends if you are the diagnostic agnostic with very tortuosity, they're painful access and calcified and you need more support or more very good access. Yeah, I will prefer thermal access, quicker, yes, safer, and I will use at the end device. Yeah. Okay. So we, in our institution we have 11 operators, and 10 of the operators do 95% of the cases radially, and one operator is probably 50/50. Now this is my own personal data, so in the UK we have to submit details of every case to the interventional Society; it's collated centrally, and it's then published on an open access interventional society website, and you can see there that my own personal radial rate for that year was 100 percent. Now that, that is unusual; I'm sure I wouldn't expect that to be repeated, but certainly 95 percent swings. So we're gonna go back to the catheter lab and catch up with the case now. So Jean, were back with you, John. So we show you what, what we have done. We have done some—yeah, good. Yeah, it was—well, you know, when sometimes going to start with a new Wars, it's a, it's better. So finally we place—so—sorry, here this was the beginning. Yeah, we place the first wire inside the digital circumflex, then you pass a wire, a second wire easily, easily, and you see the place of second Y and M one, and you see the easily we could cross with the stand because you don't have any difficulties. Just suppose it's—so we place the second balloon; we opened—this was a test; we opened—this was to proximal here; we opened the understand, and they do—we did a kissing, and now we are that point here, so we will do the kissing balloon here. Yeah, yeah. You agree? We take one more time, six, six. Okay. Oh, we can go, and we can take—that's okay here. Maybe we'll have to prove that the balloon of the stent; I think it's a little be inside here. Born one more time, I would be more comfortable. Right. Cool. When you see the procedure so easily there, it does make it—yeah, maybe the original wires were persistence of very easily. Yeah, it's a matter of, you know, to take the water place the wire in the rice threats to—there is some dye contrast. Oh yeah, yeah. Let's see, because what you can do is you reveal, leave the wiser to wire in place, remove the two balloons, and see what's the ratio, and now take a view of that. Okay, is okay. And now what we need is to place a second stand, but maybe you have to replace your why, or the problem is that the wire in the small branch. Yeah, we will do it. Change em honey is 21 to possibility to take a second Y or to take this one, but anyway now the situation is better. Yeah, so I can't touch you only a Boojum pull back here like this or play here. We are maybe other than sink as well or something like this; you can take a view of that. Yeah, and then we advanced at twelve or fifteen millimeters, tenth in addition now Adam. Okay, no, don't any video possible plane boom also the price Coveney. Okay, okay. We

Did we do it? Does it, yeah? I think we need 12 or something. Twelve point five, twelve or fifteen. Not to you. Give me fifteen. The same cancer to thank you already. That om to distal to the stent looks better, doesn't it? Just from the yeah, it's splinted the dissection in change. Yeah, the angulation. I will show you one more time the result, but you see now the situation is better. Yeah, but again, what we had to do which to remove everything and start from the beginning again. Yeah.

In other words, please new guiding catheter 3.75, these two wires and then it was so easy to to advance. I mean, I'm not exactly sure what happened with the standard stripped from the balloon. He may have been the the wires were twisted or because it was very unusual situations you to answer that problem now. True, and I think it was twisted. You see or look at the stats very easy. Okay, maybe we can do is 10v. Yeah, we can do a send this just to be sure that we are care stand these. Can we do it? Okay, probably up a server set up a fan standees civil. Okay. Oh ple okay. Good. Maybe we can pull back. What do you think? No, it's okay. We are just at the edge, just at the edges. Okay, and you can deliver it. Okay, perfect. Good. A little bit more proximal in order to do the the junction of the two stands. Okay. Okay, take 18. I can take 20. Okay, very good. Down. Okay, and now I think it's okay. We have done already the kissing. We are down to the bifurcation. What we can do is to do to finish by the final part proximally with a short beam at a balloon. Yeah, because we have done a lot of inside this proximal stand and maybe it's a good view the ID to finish by your pots. Yeah, I think so. Was the oldest one really picture? Go on. Sorry. No, I mean no no no problem. Okay, during this time I will advance the wire. Okay. Okay, really. Okay. I think it's okay. Okay. Yeah. Good. Yeah, we are still some died come. It's okay because every sub charge of the stands. Okay. Good fix. I mean, I go spying on the layers of the dissection and is now trapped behind the stand so that's not gonna be the three zero and we don't lose we can't really step on. No, it's good. We can do the pot on this one on the lever on whatever I should be proximal to the bifurcation so it could be on this wire so this one will be a free zero ready to answer a question from the audience will be now will be online afterlife. No problem desta so it should be promised. Okay, it's okay here. Yeah. Okay, go on. No, it's okay after my vacation. Okay, here we can do user when 20 atmospheres. Excellent test if it is okay. I think we can remove everything. Yeah, first I think it's okay. Correct. So we remove everything nitro glycerine. Final nitro and then we will take a final music. Okay, ready. Okay, clean my face. Okay, go on. Okay, fantastic. So congratulations. Yes, you did incredibly well to to to do that. It was a very challenging case and I you know and the problems you are presented with with the guy comes to performance with the wire placement with the stent dislocation for some strange reason you overcome them all and you've you've got a fantastic looking result there. So congratulations and thanks from the studio here. Thank you. Thank you.

Okay, so we're going to close out here the cases there was still an LED lesion to treat but I don't think that's likely mention a few things overcoming challenges of radial access in high bleeding risk patients so you know as as came up early in the discussion distal radial can be an option optimize puncture technique so you have to be able to puncture these arteries downsize slender sheets are really important and I strongly recommend them they're in routine use in our lab I routinely use arm and geography wasn't necessary in this case I'm for very experienced operators I don't think it's necessary or what but if you're earlier in your learning curve shooting an arm angiogram will alert you to loops and tortuosity segments if you have any trouble that's yeah so you know if you further on I think it's entirely appropriate to not do an arm and you remember earlier on I would shoot it in everyone optimize drug therapy I don't know how you feel about that I mean we root I routinely give a vasodilator cocktail at the beginning with some rapper mill and GTN we use a okay for everybody for everybody okay so you know again some some operators will defer using that unless there's a problem with spasm or some difficulty with manipulating equipment but I recommend using a vasodilator cocktail at the beginning for everyone to minimize the risk of spasm yeah balloon assisted truckin and pigtail assisted trekking do you use balloon tracking very much no so if you have torch rusty or a small diameter loop you can deploy an angioplasty wire up the vessel you then inflate you then insert a balloon through your guide catheter you deploy it halfway out at the end of the vessel and inflate it and that smooths the transition from the wire into the guide and you can easily track around loops or through tortuous segments pigtail assisted tracking is a version of that if you have a no.35 wire that's in it's you in the proxy wall into the aorta and you're worried about tracking a six French guide if you put a five French pigtail inside it it will poke out the end of the guide and it will do the same thing it will smooth the transition sheath las' approach is a way of using larger diameter guides in small vessels I mean you have to really be familiar with the approach it's not something that I use frequently Mammoth's in our Center has done a lot of Sheila's cases but it is a little bit technically challenging and I wouldn't routinely recommend it and of course at the end you have to do the hemostasis properly with Peyton hemostasis use a monadic compression we we use a a different device we use the TR band in some cases and we also use a different device with a rotating bezel and our nurses all then use the oximeter and check for Payton hemostasis and I see very little radial artery occlusion these days with with those kind of approaches so there are many different technical issues to do to consider really so I will just bring your attention to the upcoming webinar in Massie on September the 17th and the one from Paris on December the 12th and we learned today with a thanks to Tarun Moe for the unrestricted educational grant I hope you found it an interesting and useful case thank you [Music] you