Transcription
You know the case already. Have you seen the slides? Yes, we have seen the slide. Okay, okay. So I would just start from the beginning. All right. So this is cact uh so at the beginning, so at the beginning uh because it's a very long CTO, uh I decided to need to use retrograde probably. So the very often in my practice is I start off with a RAO Coral shot of the left side to look for channels. Because previously this case had okay septo channels, but then he had the cir stented. After the cir stented, there's now a dominant disto c channel, and so now the septo channel is all disappeared. You see no more septo channel? Yeah. So this is always a problem with doing a circumflex C when you have C Act is that you risk swapping septo channels for atal channels. Now I know Paul loves his atrial channels, so it's okay for him, but for the rest of us we struggle with atro channel, so we prefer to do septo channel. So I take this shot first.
The next shot I took was the AP cranial shot. Here you can see there's still a hint of a septo channel in the disc door. Now I have studied the angiogram from before many times, and so I know in the disto septo channel, that Big septo in the distal part of the LAD, the branches that go towards the Apex are very tortous; the branch that go proximal are much straighter. So I want to do that kind of Channel, but first, of course this is a long CTO. I want, if possible, to keep both antegrade and retrograde wire in the intermost space; then the reverse card is easy. But also because it's very long, the chance of that is very low. If I can't keep both wires in the inter plug space, it is better for both of them to be in the subintimal space. So with that idea, I wanted to start off with anr preparation and try to get an anr wire down in the intermost space as far as possible.
So next is the great. The Guiding is a al75 and it's damping already, and then I tried to wire with the um XTA, but the XTA cannot wire down into the stump; it keeps going around the side branch, and there was a lot of damping. So at this point I decided to go retrograde first. I I don't know if you all agree with this strategy, this plan. Uh Eugene, this is Paul, hi by the way. You look very sharp on the screen. Um so do you, may I ask you, uh you said that you are probably going for the septo and after circumflex stting the the dominant Channel shift from zto to the a Groove, but from here the AV Grove looks very straight and big. So in this circumstances, you still go for receptor struggling, do some tip injection or just go directly for the heavy Grue? Uh the septo, because I in my experience this is uh only a few months, so in my experience if it's within six months of the opening of the circumflex Channel, you can usually serf an invisible septo. So I show you, I show you. So uh unfortunately we did not, I don't know how to do Flor save on here, but this is the septo I chose and this is the tip injection; no connection at all. And uh this is the sepor wiring already done. Okay, so so little bit of pushing, which wire is this? Huh, which this a little bit of pushing and we can get the O and do tip injection.
Now the next problem is there's a lot of ambiguity, and it seems you see there's this channel that goes out, but the calcium seems to go down. So next I've done some wiring, but uh oops, you haven't seen anything. I'll show you now uh down. So wiring is here, but it's not very clear. You see, I have a lot of ambiguity. Do you still think I'm still in the vessel? This wire, probably. So what wire are you using now? XTA. I think I think this is where the right corner artery is the most variable in its course. Yes, at the junction of segment two and three where you have RV Branch coming out. So yes, in this particular portion the the r Corner are can take any shape. You can go smoothly upwards, downward and upwards, or even making a loop here. So if you cannot be sure that you are intimal, I would suggest that you start knocking from this point. Yes, yes, yes. I agree. Usually include that amazing to to. Yes, and uh please uh go back to the channel channel selection issue and usually and if we use the good quality Channel and we have to think about ising uh but yes, that's another problem. But in this case it's another issue because uh now the dominant is higher uh but if we use the AV group, even though we use the AV group, I believe that septo channel will open up, open at the time. Okay, yeah. So so in fact the patient had the insurance, so it's a double system yeah because the colle already Beau. So you can see we are not as Paul suggested. And one of the tips of knuckling is to get the B up. Now some people like to reduce the size of the knuckle when they get the cair up; uh I don't really bother because I think the size of the knuckle, the stiff part of the knuckle is here, so I would just keep going with the knuckle. But at this point, do you have any concern about the wire tricks in here? Yes. So at the moment it's one big knuckle, so I don't think it's terrible, but I think at this point if I go up again with the cor, now if I can go up with the cor now I would reduce the knuckle size. So question, when we use initiate anti y uh I think in this case I'm going to knuckle almost to us the why doesn't want to come back uh sometimes this is the problem with a big knuckle and also the XTA or XTR there is a junction point, so if you not go beyond that Junction point something but now it better. Yeah, so maybe a pilot is a better know enough of us in this instance. I think you are doing a great job here already. It seems that now you are already very I mean you are very close to the possible C Marine right uh and we're still about 18 mm. Well this is a good timing when you shift your projection angle uh to maybe Aro Cranium. Yes, let's go to Aro CR. You see the wire is not quite strong enough for me to knuckle. Yeah, I think you are hitting against the most calcified portion of this RC yes, and uh and you are attacking from the uh opposite direction, so well maybe we can start thinking about anra. Yes, I think so going but now because I'm worried about the integrate guiding damping I've actually switched down to uh jr4, yeah4, but I think there there is a proximal uh wrench that you canor. Okay, maybe we will see. So go back to Lao and if you hit the calcium and it's both slly that they yes I think I'm happy with this. I think we're not outside the vessel. You you are in good position. Yeah, but now there's another option here. Since we cannot knuckle, we can also switch out for a wire that intentionally tracks the sub interal space, something like a uv3, make more progress towards the proximal camp, but uh I think we try andyr first. Yeah, the the proximal stump is very Central and uh I think with that uh anchoring Branch you can you can make progress for sure. So the SE on Blue. So let's see the last shot and we open this.
I have one question and for the C, well I think damping itself is not a big problem because the vessel is uded anyway, but uh the damping will affect some of the aspect of the procedure. First uh if the pressure is always damping, you don't know whether you have a thrombus in the guide or not. That's first. Secondly, if it's in the damping position, then you are very cautious, you should be very cautious if you want to do any R injection because you can create dissection with contact. So I think damping itself is not a problem for the patient; it's it's not a problem, but then for the operator it's something that you should be careful. Yeah, so here not a very big, maybe a 15 balloon is okay. How about a 15 uh 15 balloon? I think you can use one five or two. This is a COR, yeah2 is okay. I want to ask you your experience if this is a sa uh I mean sa no arter uh auding it, how how many times you will expect uh cardia. Very Corners is usually same, but what about Sao artery and if if a patient uh developed the r card how do you deal with it? Yeah, not actually not so much, actually not so much and but uh and if this cor Branch be quite B one and so I have explain twice and and the depression and in this time and maybe there are very similar with the the canalization. Well um I think is ano artery causing body cardia is not sometimes situation and sometimes you need that anchor. So of course you can do intermittent inflation inflation; that is one uh trick, but the other trick is to do a a trans wire pacing for you. You can use that anchor wire with the balloon right, and then outside you connect to a generator pacemaker generator and you can paast okay on that wire, so you don't have any problem. Did you learn this trick from doing TV? Yes, and there another op using Theus oh and the new one. So for anr I think uh last I I tried an XTA a little bit with a very strong guiding support and it didn't go anywhere. So now I think we're going to go for a step up of in terms of puncture power of the wire and so we're going for gu second, but I want to check the cibil of The Guiding first, even with the anchor to make sure that I am ah you see the problem is my guiding is behind my left guy situation be different. The TRU gu yeah, but it's okay. And in this situation how about the side ofo? You want to use the side ofo side hole? Yeah uh side hole yes uh side hole is useful, but side hole is not that useful because side hole only tells you that you've got side hole, you got pressure; it doesn't tell you that you're not forming fromers and you are not causing dissection. And then sometimes the piure The Guiding. Yes Eugene, how often do you go an uh I tried to overcome most of the ambiguity through retro grade knuckle. The reason is the uh the it's easier to do reverse cut if the retrograde is something inal, the antegrade is true, but in this case I'm not too Keen to keep antegrade in the plumen because the retrograde is definitely in the sub interal. So if anything I want to get into the sub interal space and that's why I'm using a Gaia. Gia is very good for sub interal wiring. And you Eugene you you have to remember demonstrating us the ebw not possible in this case already because there's some precondition for the ebw, one of which is both wires needed to be in the intermost Spas, but now already both wires are not in the intermost base and so it's very difficult. Now here is interesting because unfortunately this Sky wire has kept inside the Intero space; it's not some inal, it's in PL. You can see it's hugging this calcium. Now here I'm going to try to get out into the inter some interal space if possible, but it looks like it's still intimal. So in this situation sometimes you can do traditional card, but I don't want to do that of course. I I don't think I don't think you need that. You just take a relatively larger balloon and crack the plock and then the retrade Y will coming. By the way the EB EB uh I'm sorry ebw technique, please explain this. Yeah yeah uh it's uh in balloon wiring meaning that uh your retrograde wire is intra PL and you use the antira balloon as your marker and then wire puncture. So it's a it's a kind of reverse car technique, but ebw stands also for Eugene [Laughter] your name will take me. So it looks like we are lucky today and we can get here. You say complete. Okay, so now we we have this and actually the wire is in the same space right I but still I would still try to get uh why to come out. So now the question is where to do reverse cut uh I should check this if possible, check. Okay AR. So obviously both wires are interal in the midsection of the right corner because that's where we knuckle and that would be the best place of course to do reverse cut. You don't even need to do reverse cut; you just put a guideliner there, you'll be home and drive. So for so I think guideliner reverse card would be the best solution in this case. When both are in the subintimal space, this is a very quick way of finishing the case. If you want to spend a long time doing reverse card, you can of course uh but if you want to finish the case quickly, this is a good method, but then at the cost of uh one extra device. I pull the wrong wire. Oops, I was supposed to pull the other wire. Ah, you see people make mistakes like luckily very easy to rewire at least until here. Well uh actually the Japanese approach is can can be finished in very quick, not not just as the uh not just as the uh most American menion and they think that the hybrid approach the ADR would be finish in very short time and actually uh the Japanese can then can be nicely. I think for this case ADR is not an option; you have to not you have to re-enter probably at Beyond. So now you are using guy, will you please tell us how to deliver the guy safy? Okay, so there's disease in the proximal, so you must pre-dilate the proximal before you can deliver the guideline. So I did a pre-dilation with the balloon to 12 atmospheres in the proximal first and then now with the guideliner in I'm hoping that I'll be able to support the balloon to go further like so I PL to 12. Now unfortunately there's a little Gap here between my guideliner tip and this, so I need to come back off and I need to also the Gap because there's all disease here. Would you would you change your retr wire because this is all broken? XT of course, of course, off for this yeah so benefici who get the get outan this. So now is the time to get rid of the r wire or at least get the r wi back uh and now I don't want to get the guideliner involved in so e on black. So we don't need puncture here because it's already connected. We want to wire that can move well. I think C on black is a wire that can move quite well. Eugene, you are moving too fast. We will ask you to do another case. No, no, no, no, no, too fast. Yeah, you're supposed to do this case in the whole session huh right since is going to do a case, don't worry. Okay, so don't worry, there's another case. Yeah, there's a great case. I think Sensei has a very difficult one this morning, not like my easy case. Actually this case is not easy at all. No, it's noty um it's very difficult. It's a very long CTO and a lot of ambiguity, but you make it looks very easy. No, no, no, very difficult. Okay, so here we need toer now. So we tried to wire the guideliner now luckily the two overlap wires when I was looking at overlap I tried to find where they're nearest because that's what is where they'll be nearest in the sub intermost space, but you can see that it's difficult because the sub interal space is very big here and you see the wire chip has no control. You turn it and it flips; it's very difficult. Am I in? I don't think we're in. It's very difficult. Are you working in a lowdose uh setting? I don't know. I don't think I'm in. I'm still out. So the way to do it is to go 360, no go out. What's what's the size of this Gilla? It's uh seven. I think seven. Is it a seven Gilla? It's a six gu Zilla. Oh, so always use a seven gu Zilla with a seven guide otherwise you're making your life difficult for yourself. Okay, so Gilla come back a little bit maybe because there's more space up here. So actually you don't want where the the space is very big; you want where the space is small. You do this. So you want to wire the Godzilla to a space where it's smaller. So do you seeing a bigger curve at the tip up the wire could be helpful? Maybe that's helpful, but I think another way is to go AR because sometimes you have front and back because on the Lao it looks good, are it's not so bad huh? Ario is not so bad. This to this part it's in the in way much better for the part. So not enough curve, you're right, and make more curve. So Jin, do you also think this is one of advantage of laco wire, although it can cost the CTO body uh very fast, it can cross very fast uh but you got to remember one thing, once you knuckle your retrograde is going to be in the sub intermost space, and this of course has implications for reverse carard. So I always try to think about reverse car before I go around to tackling the CTO because if you are in the CTO and you begin to think about reverse card then you may be in trouble because by the time you come to reverse card you may end up with a very difficult reverse car. So sometimes you want to think about reverse car earlier. No, let's go outside. No, maybe inside, outside. This is holding the edge. Okay, why you? So we can help with the balloon of course this doesn't work although okay this doesn't work. Oh, so we use the balloon to help us coming out, coming out, coming out. Here's the balloon. Come back, come back, come back. Now this is not good because this is on the bend; don't want to be on the B. So after the balloon, balloon in 12, off balloon off, balloon balloon inl off plate balloon, balloon. What do you think the program is here? It's because there is no connection between the inte guiner, there's connection okay but I think there's uh a lot of flaps and a lot of uh a lot of flaps and a lot of so I can use a ga of course puncture. Sometimes you need to do see well just for curiosity it would be very interesting to look at iers right now to understand of course I'm using C on black which is not very aggressive why for this purpose. You can see it's just stuck at the OST, so I think the is carrying the guideline is kind of carrying the flows right into hisha, so maybe guia second is a better choice. Okay, g second is on this side. Oh, then G third. Eugene, by choosing G you I mean unconsciously thinks that there is no connection, so you need something to puncture through right there's flat some tissue in between yeah tissue but I wor about yes that is also what I so I think it would be very interesting because yeah at the tip of the uh guy Godzilla probably yeah much better for the dist part and connection. So are you making another curve for so no I haven't made another curve uh we see how it goes this I'm going to try to do it on the straight path yeah but if you think there is already a big there do you think the guy the GU can get enough support for Ping? I think so, I think so. No sub sign outside. I think this is an old problem that the wire is keeping going out to the outside of the vessel. Not easy. Okay, so gu ler come back. So this is quite a old sort of uh the American trick which is to move the base of operations. I think it's no problem since you have L of ch move up and down and doesn't want to go in the guideliner. So bigger balloon or IIs or pick or maybe just take the take the guideliner out, maybe the wild will go into the guide itself. Yes, I think here I always feel that there's some resistance at the tip of the GU lineer. Okay, not a bad suggestion. We just do traditional reverse cut right of the proximal part of the vessel with the balloon, the balloon. Okay, but I want to get the coret up a bit; the wi control is a bit better. Okay, no, no, no, keep up, keep up, sorry. Okay, ebw, what's the uh what's the okay off balloon ew
Now, it's difficult because we need to guide the balloon. Oops, I shouldn't have pulled back the balloon just one. Once you pull back the balloon, you lose the straightness of the curve. Balloon is better. Okay, so in this situation, what should we do? Uh, so I'm going to do something that I usually do. Can you rotate your guide? You can use a balloon dist to pull your guide in more in alignment. Of course, the last resort can be snare, but okay, look up, look up, look yes. So we uh do this, and then we do an S like this. Okay, and then inflate the balloon. Yes, yes, please. Uh, what? What's Act uh 215? Oh, 213 uh 4, 5,000 please. I think you can inflate the balloon. Yeah, I want to inflate the balloon. Yes. Trap the wire. Okay. Off balloon one. Ah, but the the um the C doesn't want to go here. Usually is the problem. Heavy calcif. Yes, but I think it's yeah, it's high enough. Okay, here is good, I think. Yeah, see on black back. Okay, come out 5,000 and check in 10 minutes. Act. This is not on blank, not see on. Yeah, this is from or something. So I think in this situation, the deep engage of The Guiding is much better for insertion to the yes, yes. That's very important. The Guiding position. Don't move the wire, move the guiding and using the guiding. So the problem now is that the both sides is affecting the guiding, so I want to turn the guiding forward as much as possible, and I want it up because usually the wire goes up. Oh, I've got in the same branch. Oh, think branch. What you think? Not maybe? Maybe AR would be a better working. Okay, AR crani. Ah, you see the problem. The Guiding is nowhere near clocked enough, but it doesn't want to clock enough. You see, because of the um yeah, if you rotate the guide clockwise, but it doesn't move the clock because uh of the breathing. No, up, right, top, more. So sometimes you need help. Can you CL The Guiding for me? So the fellow needs to come and help you clockwise. Okay, hold on, hold on. Watch the wire. Not enough. B. Okay, good. Congratulations. Round of applause. Thank you. So this is now uh 25, is it? Yes. Okay, so we can use this to anchor. Well, uh, we going to move to another. Okay, thank you very much. Thank you. We back. Thank you for your good advice. Thank you. Ah, okay. So now Eugene, can you hear us now? Eugene? Hi, hi, hi. Yeah, you're back. Hello, hello. So let me show you what I've done. So let me see. You were with us when we crossed the channel, and we knuckled, and we couldn't do the guideliner, and I did this, and we pushed through, and we used the. Did you see the Seon black trying to wire in? You did? Yeah. So the Seon black we wired in, and then we trapped. Uh, so this is a little bit tricky. You have the Godzilla and the balloon and the trapping. So this is trapping, and you can see now the cor has gone into the guiding. So next I push forward [Music] the I push forward the balloon, so you will see this run. I record for you. I push forward the balloon. You see, to trap the forair. Yeah, to make it more stable and to stop bleeding. So then I tra the Corsair, and I externalize. Now another important thing for externalization, you got to make sure that the retrograde wire goes into the Godzilla and not outside around it because this is six and seven. So maybe that happen. So I check very carefully. You see the wire coming in, and so after I'm sure that we've gone in, we externalized. Now this very important too. We pull back the retrograde guide so that we can pull back the retrograde course there, not for left B dissection. So that's what we did. After that, we ballooned and we did IIs. So maybe we can show you the IIs. So you balloon first before IIs? Yes, two two balloon. I see. So and I mark the distal point. Okay. So you're not afraid of you're not afraid of losing the pla? No, not at all. Because the previous retrograde shot shows a very good connection. Good, and I can also rescue you through the AIL channel. Yes. Yeah. So show the IIs. Uh, not this one. First one. First one. So this is the distal. It's a very small vessel, and there's disease right in the PE, and you can see, I record for you, this is the Disco on the angel, but I can record for you this is where we enter subintimal, and that's where the cine is. You can see the cine too. And it's all subintimal. The vessel is around four, but in these subintimal phases, I don't like to put a big stent. Now this is where it enters into true, and I record for you on S. This is where it comes back into true. So uh I decided to put a 25 stent in the distal like that. 2538, 3038 here, 3538 up here to the ostium. We did check a little bit here, right to the ostium, and then was dilated with a three balloon and then another IIs, mix IIs. So this distal, still this distal, and you can see the stent just completely opposed, but the vessel is quite big, so we did further post dilation here to but still only a three. I don't like to post dilate this inmost space too aggressively, but I took the 30 again to where there was a little indent. I took it up to 26, and luckily I did not rupture The Vessel. Uh, this is the distal, this is the proximal, no rupture. So this is the final result. This is the cranial view. So now, now if you will bear with me, I will demonstrate I will demonstrate the uh removal. So I already drill up the Corsair. I already drew up the Corsair, and I already removed the retrograde wire. Now or guid guid. So we're trying to find the radio opaque part in The Guiding here, just in the AA. See, you can see that. Yes. And so now with this, we can back out the cor there, but again, we need to first remove the retrograde guiding so that you don't dissect. So now you can see it's actually very resistant because this is a very long channel. I need more, and even just now actually coming back with the Corsair was tricky, but why your Corsair is so high up in the stent? Oh, because I want to protect the stent. Actually, you don't have to because stent usually is not a problem, but I like protecting if possible. You can use, I mean, you can leave your stent balloon in this and then pull out the yes. That also. Okay, that's also okay. So now we mirror. So we can keep the guiding again. Go to R. So very important also to uh check channel, check channel. Channel looks okay. Check channel from other side. Channel looks okay from other side. So we do what the Sensei says, which is to go back through with the there. When we are into the PD, we pull back the wire, and now wire together with forair back like so and check again the channel. This is fine, and check again on this side and it's fine. So channel is perfect, and the LED looks fine. AP cranial check the final LED before we remove the wire. Okay, check the Led. Led looks fine. Okay, so we remove this, and we stay here to check the RCA. RCA, RCA. Okay, very nice, beautiful. So I'm finished. Thank you very much. Thank you. Thank you.