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00:00:09Música
00:00:35Música
00:00:39Música
00:00:41Música
00:00:44Música
00:00:46Música
00:00:48Música
00:00:51Música
00:00:59Because I forgot to introduce her this morning
00:01:01And it's going to be like hell
00:01:03For the rest of the year
00:01:05So stay with me
00:01:07Stay with me with us this morning
00:01:08So we're going to introduce her
00:01:09Do you have the picture? No?
00:01:11Alright, we have Eric, we have Ricardo
00:01:13We have Miss Santa
00:01:13Música
00:01:15Sampalero
00:01:15And Anesthesia
00:01:16So do you have a picture?
00:01:18so that's that's amy yay all right so we have a great case for you guys go ahead
00:01:26alex produce lights we have another rca uh over here from puerto rico next
00:01:33so she's a 64 year old female usual risk factors and she has a relevant history of
00:01:39lung cancer and chest radiation um those are her cardiac mark her markers um so she had
00:01:47new onset chest pain um last year and she underwent a coronary angiogram um at another institution
00:01:54in october she was said like there was nothing important to fix and to continue medical therapy
00:01:59and so at that point she she went for a second opinion with a colleague of ours and he did
00:02:05a
00:02:06an angiogram and and she found you know three basically three vessel disease we're gonna see
00:02:10the films but calcified um mid 60 um led with an rfr that they did was very positive 0.69
00:02:18um a small diag with 80 90 stenosis a circumflex that's the main om like a subtotal basically
00:02:26and then a proximal rca um severely calcified cto with normal ef so she was referred for surgery
00:02:33at that point um and she was a surgical turndown um mainly because of the issue of the chest radiation
00:02:41yeah so and she was referred to us back in january for for rca cto pci and she had the
00:02:47guideline direct medical therapy on board she was still symptomatic um at that point of course no
00:02:52dual injections were available and we talked to her and we scattered her for cto pci and then
00:02:57multivessel um pci next films again and hole catheter don't do that for the lv um so normal lv systolic
00:03:08function on the left the right side you can see the om which i think is subtotal and severe calcified
00:03:16of course you can see the rca already it's a big rca you can see a lot of calcium um
00:03:21next
00:03:24then cranial shots you can see we have a lot of collaterals to the to the rca you see the
00:03:30calcification
00:03:30and disease in the mid segment of the of the led and of course the wire there and the the
00:03:36rfr was a
00:03:370.69 next and so this is her rca and again we don't have dual injections but you see a
00:03:47proximal
00:03:48very severely calcified cto i don't i mean it can't uh it's not ambiguous really you see the calcium you
00:03:54know where you're going but there's a couple side branches there that you have to take you know
00:03:57consideration and then alex if you can play on the right side again just go over with the mouse and
00:04:02just play because it's stopping for some reason um but you can see all the way the landing zone of
00:04:07the uh
00:04:08of the rca it's not playing okay i'll show them here
00:04:16it's not playing all right next i'll show him now so we don't have i mean we did the ccta
00:04:23for this
00:04:23patient but it was um due to quality for some reason i don't know if it's the classification or
00:04:29something it was not uh analyzable and we couldn't get the information and so that's all that we have
00:04:35i don't know if you want to see the films go next the dual injections from today let's see if
00:04:40this
00:04:40place actually yeah cool you can see it down down below so we have a couple discussion points there
00:04:47but i want to leave it to the panel to discuss it so i think there's a couple of things
00:04:52here one this
00:04:53is a diabetic patient with a prior history of lung cancer treated with radiation has triple vessel
00:04:58disease has led disease that is mostly ischemic has a subtotal of the surface and then now has this
00:05:05right cornered cto surgical turndown the question is how would you go about approaching it would you do
00:05:10the cto first would you do anything else first and so we'll turn it to the panel for the discussion
00:05:17so
00:05:46we have a
00:05:47like don't worry we have a we have a flight to catch
00:05:49thank you
00:06:30there
00:06:32there
00:06:34there
00:06:35there
00:06:49there
00:06:50there
00:06:50there
00:06:50there
00:06:57there
00:07:01there
00:07:02there
00:07:03there
00:07:03there
00:07:04there
00:07:34Gracias por ver el video.
00:08:03Gracias por ver el video.
00:08:10Gracias por ver el video.
00:08:48Gracias por ver el video.
00:09:07Gracias por ver el video.
00:10:04Gracias.
00:13:06And so we stopped right there and actually advanced the microcatheter a little bit because we know we're in the
00:13:12vessel architecture and actually we stopped right there and that's where we are.
00:13:16Because I think if I keep pushing this is going to just go intraplaque and just cross.
00:13:21So I wanted to ask the panel what do you guys want to do just push the knuckle switch for
00:13:25straight gladius with a gut bend or do anything else.
00:13:35Okay.
00:13:50Okay.
00:13:52Okay.
00:13:53I'm just pushing this I'm pushing I'm pushing this right there.
00:14:03Yeah.
00:14:04So one of the things we were thinking was whether or not right there's a hub channel right here.
00:14:09But there's an ipsilateral collateral that goes to the mid RCA as well.
00:14:14And so the question is is there some contrast in the middle?
00:14:16Is it more subtotal than anything?
00:14:18Yeah.
00:14:18The films from the outside certainly.
00:14:23Yeah.
00:14:25Yeah.
00:14:25Interplaque.
00:14:25Correct.
00:14:29Yep.
00:14:30Can I have a fresh Gladius?
00:14:33Gladius.
00:14:35Sure.
00:14:38Sure.
00:14:39Sure.
00:14:40Sure.
00:14:40Sure.
00:14:40I'm going to.
00:14:44Yeah.
00:14:44Yeah.
00:14:44MG.
00:14:45Get this out.
00:14:46You got it?
00:14:46Yeah.
00:14:47Ready?
00:14:48You have it?
00:14:49Yep.
00:14:50Go ahead.
00:14:51Go.
00:14:55Eh.
00:14:56Not that much.
00:14:57Go.
00:14:58Alright.
00:14:58Coming out with this.
00:14:59What's up?
00:15:05Good.
00:15:05Good.
00:15:06Good.
00:15:06Good.
00:15:06Good.
00:15:07Good.
00:15:07Good.
00:15:07Good.
00:15:07Good.
00:15:22Good.
00:15:23Good.
00:15:25Good.
00:15:34Yes.
00:15:35Alright, so this is a Gladius, so yeah, here we go, alright, back across, go retrograde.
00:15:45Yeah, we'll just take a retrograde injection to ensure we are where we are.
00:15:48Go.
00:15:50Yeah, it's just a branch.
00:15:54Yeah, here we go.
00:16:01Yeah.
00:16:06Yeah.
00:16:11Yeah, thank you, sir.
00:16:13Okay.
00:16:15Just have to cross the bike.
00:16:17Yeah.
00:16:19Alright, can I switch for workless?
00:16:21Wait.
00:16:23Workless.
00:16:26I'm making a flight playboard.
00:16:31You made it.
00:16:33Se supone que estamos off the…
00:16:35El mute.
00:16:37El mute.
00:16:37¿Tienen en la caneta el mute?
00:17:00¿Tienen en la caneta el mute?
00:17:06Gracias.
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00:28:40Gracias por ver el video.
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00:55:02This is super, super distal close to the bifurcation.
00:55:07And so now I think I'm going to get this just for so here you see this is kind of
00:55:15distally
00:55:17past the midpoint where we were like at talking about doing ADR or something.
00:55:21This is our close to healthy then a little bit of a calcium fibrotic plaque there.
00:55:29And then when we get to the really, really calcified stuff, this is just distal to the distal cap and
00:55:35then here is all the CTO segment.
00:55:38You see the calcium was not 360 degree per se except like probably right there.
00:55:49Yeah.
00:55:54Yup.
00:55:57Yup.
00:55:57I agree.
00:56:04And then here you see this, yup.
00:56:09And all that all the way to the proximal cap here.
00:56:13So we decided to go just with a, yeah, so then after that, I mean, what would you guys do
00:56:19and I will tell you.
00:56:20Yeah.
00:56:21Yeah.
00:56:23Yeah.
00:56:23Yeah.
00:56:31Agreed.
00:56:34Agreed.
00:56:50Yeah.
00:56:53Yeah.
00:56:54Yeah.
00:56:57Yeah.
00:56:59Yeah.
00:57:16yeah so afterwards uh we got three five and this is the expansion with the uh with the three five
00:57:25nc um and this is what happens when we went to 16 was it so it burst there you see
00:57:34we we went down
00:57:36rupture yeah so we went down really quickly everything was okay um we probably have a
00:57:43little bit of hematoma you can see it there and you'll see it on iris so there's a new one
00:57:48right
00:57:48there a new three five we went all the way up to 1618 um it expanded fairly well um and
00:57:55then of
00:57:56course we re-ivis and you can see the ibis now um yeah yep
00:58:11i can see here
00:58:17correct so colin what would you do do you think there was a role for lithotripsy here or some
00:58:23other advanced calcium modification yeah so
00:58:37cool so this is the ibis after the three five and you see um right when we get here to
00:58:45you see more
00:58:46breaks in the calcium you can see it there um more yeah and then we get to this point where
00:58:54colin is talking about like there's probably nothing here maybe here and i don't know if
00:58:59this is the shadow of the wire but there's nothing here yeah yeah agreed when we uh
00:59:09away from this correct
00:59:14yep
00:59:17we agree
00:59:21yeah so
00:59:24correct
00:59:26so based on that we decided to just do lithotripsy um and this is a 4-0-12 um shockwave
00:59:35and so we did the whole thing um like 100 pulses probably and you see there all the way and
00:59:44then
00:59:44uh we went all the way to the ostium um gave a fairly amount of shocks in the area where
00:59:50we
00:59:50were talking about where it was not expanding and then we did ibis after that to see
00:59:59and of course here we go um looks a little bit better right
01:00:03more breaks more breaks more breaks but then
01:00:06i think this is the yeah
01:00:09exactly
01:00:10yep
01:00:13and and here we are and
01:00:16all the way
01:00:19back
01:00:20yeah
01:00:21no
01:00:29yeah
01:00:30yeah the risk of that it's just pushing against that calcium you just probably run the risk
01:00:34of uh of rupturing the vessel or you know the risk of perforation just increases
01:00:40yeah
01:00:51it looks
01:00:53yeah
01:00:54i'm gonna
01:00:55we
01:01:01yeah so this is how it looks
01:01:03it looks with a 3.5 this is a 3.5 so this is how it looks i think it
01:01:09looks it looks okay
01:01:11um and we deliver
01:01:14yeah
01:01:16so we delivered the distal stent and we're right now uh we have the the proximal stent we have it
01:01:23in right there we're trying to maneuver how to because now we have the dissection right the
01:01:29hematoma um so we kind of want to go back to the ostium but it's very challenging to we're not
01:01:36externalized so it's very challenging to get this guide system out because of the al and the
01:01:41positioning and whatnot so that's what we're working on right now you see that moving back and
01:01:46trying to save this um make sure if you look at the hemodynamics yeah turquoise is the tracing for
01:01:54the al so you see that you're still yeah so i don't know i'm trying to pull this and be
01:02:01very careful
01:02:01about it but in the end i think uh we probably you're going to send it at some point and
01:02:09just
01:02:10deal with uh trying to get it afterwards i don't know
01:02:17not this silly you know you see there it's out
01:02:24yeah perfect perfect man take care of this we'll post that later and i'll come back to you
01:02:29thank you sir all right
01:02:50thank you
01:03:13Gracias.
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01:20:41I'll go live for you guys.
01:20:43Yeah.
01:20:43We were at the...
01:20:48Yep.
01:20:49Yeah.
01:20:51We'll go there.
01:20:52We did one run run where the gist will look fine.
01:20:54Yeah.
01:20:54There we go.
01:20:55Okay.
01:20:57There we go.
01:21:03That's a run and we were concerned about that area of under expansion.
01:21:08You're going to see probably coming soon.
01:21:11Yeah.
01:21:14That's the area.
01:21:15Yeah.
01:21:16Yup.
01:21:20That's it.
01:21:21Okay.
01:21:25I'm going to show it to you.
01:21:30You can see it in the lung axis too.
01:21:34Right there.
01:21:37Yeah.
01:21:38So the question for the panel is what to do here.
01:21:49Sure.
01:21:50Yup.
01:21:52No.
01:21:54It's probably bigger.
01:21:55Yeah.
01:22:07Yeah.
01:22:09Yeah.
01:22:10Yeah.
01:22:14Yeah.
01:22:23Yeah.
01:22:35Okay.
01:22:51Okay.
01:22:52So what you're saying is that we are happy with you?
01:23:20Okay.
01:23:21Ok.
01:23:53Yeah, so we hit it
01:23:55with a 4-5
01:23:56at 18 atmospheres
01:23:59and we wanted to showcase what
01:24:00Calm was talking about on the session
01:24:02about the shaft of the balloon
01:24:05and then the, you know, we're pushing
01:24:07against that
01:24:08against the calcium, so really
01:24:10stretching that atlanticia, so
01:24:12yeah, I think we're going to be happy with that
01:24:15and then
01:24:16you know, deal with it
01:24:20Oh, Cheryl
01:24:22Yeah, correct
01:24:30Agreed
01:24:34Yeah
01:24:35Oh, yeah, for sure
01:24:48Go
01:24:49Go
01:24:50Go
01:24:53Yeah, so what I'm doing is
01:24:56Hello
01:24:57Down
01:25:12Yeah, so what I'm doing is
01:25:21I'm doing
01:25:24Yeah
01:25:28I absolutely agree, Alex.
01:25:52Ok, we're going to take a picture too.
01:25:58Yup, alright, this is great, alright, so of course there's a little bit of disease
01:26:08distally which we're going to leave for now and we'll tackle that in a future
01:26:12session. For now we have a plane to catch, so I think we're gonna sign off, we're
01:26:19gonna sign off from Puerto Rico. Come to the people I want to thank my and my staff.
01:26:24Come here guys. And so, yeah, let's play. Thank you for having us and I hope you guys
01:26:34have a, you guys have a great conference and we'll see you, we'll see you there. Alright.
01:26:42Y
01:26:58Ustedes están... que activos de verdad.
01:27:01Jajaja.
01:27:02Aplausos.
01:27:04Aplausos.
01:27:05Aplausos.
01:27:06Aplausos.
01:27:08Aplausos.
01:27:08Adiós.
01:27:38Adiós.
01:28:35Adiós.
01:28:40Pioneros.
01:28:41Trayéndote ciencia.
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