Originally broadcast December 1st, 2020
A coronary artery perforation is one of the most feared complications in PCI. Drs. Kevin Croce, Duane Pinto and Jason Wollmuth discuss advanced perforation management techniques.
Faculty
Kevin J. Croce, MD, PhD
Interventional Cardiologist
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Duane Pinto, MD, MPH
Chief, Interventional Cardiology
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Jason R. Wollmuth, MD
Interventional Cardiologist
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welcome everybody we're excited to share time with this evening. My name's Kevin Crows, an interventional cardiologists from Boston. And I'm gonna be here tonight with colleagues Dwayne Pinto and Jason Wilmoth discussing case braced approaches to preparation management, you know, complications or something that, particularly in the case of perforations, occur relatively rarely. I think you know, having an idea of what to do in these dreaded complications occur is important. And with colleagues tonight, we're gonna walk through some case examples algorithms so that we're prepared when we see these entities in our practice will be well suited to treat patients that actually are coming to us and and stuff for these complications. So without a lot of twin and Jason chance to say hi and we'll get started the program in a couple minutes. Well, Kevin, thank you. I'm glad to be joined with a couple of my buddies. You and Jason. I think it's gonna be a good evening talking about crazy cases and things that happened infrequently but also have some tools in your, uh, on your belt Thio to deal with some of these uncommon complications. So I look forward Thio also interacting with you as you send in questions on the chat. Yeah, good to be with you guys. Obviously, always great to be with my friends and colleagues because every time I'm on a call with Kevin or for Dwayne, I always learn something new. And so hopefully we can impart some wisdom Thio to the audience. And, you know, like Kevin said, this is something that doesn't happen very often, but it's certainly scary when it does, particularly if you're not prepared and hopefully giving it will be able to give you some quick algorithms that you can keep in your back pocket. So you so you do know the few things that need to be done urgently. Uh, Thio stabilize the situation. So then you can kind of, uh, then take some time to think and do the best thing for the patient. So looking forward to it, looking forward to learn something new from my two friends. Awesome, great eso The agenda for this evening is that I'm gonna get over large vessel perforations. Jason's gonna cover distal vessel collateral vessel, and Dwayne has the difficult topic of covering post cabbage perforations and left main perforations which are some of the more terrifying because we can deal with ironically. So with that in mind, I'll get my slides up here and we'll get started. Awesome. So we're gonna talk about large vessel perforation. Thes my disclosures. Quicker review is really what your immediate reaction to a corneal perforation should be. Algorithmic management of large vessel perforations. As I said, colleagues will cover some of the other entities in the space. And then I'm gonna go through a case based discussion and perfect preparation treatment, either with prolonged balloon inflation or with covered stance using single and dual guy techniques so as we know, corny perforations or hazardous. Or there's some of them or dire things that we end up treating the cath lab and you can see over time patients with perforations. Birth patients without perforations have much higher 30 day mortality. The grading system for perforations. I think everybody is well aware of the ones that are really difficult to treat. Obviously, type three perforations, especially when there's significant perforation and spilling of blood into an an atomic cavity such as the pericardium or the media festival spaces. Duane will show us when he talks about post cabbage of preparations. The first steps whenever preparation is obviously, don't panic. Try to get some help in the room because things need to move quickly for this problem. Don't lose the wire That actually is oftentimes a lifeline to stabilize the patient. Assess the patient team of dynamic. You get those stabilize. You know fluid is a really good way to treat tampon on when you initially recognize it. And first thing you do is when you see it, you put the balloon up, hopefully stop flow, and it stopped the bleeding. Call for help getting an echo. Get a tap kit in the room and have an algorithm for treatment and the algorithms important. We'll talk a lot about this having thought about how to deal with these problems, which your uncommon. Having a pre rehearsed idea in your mind in terms of what you do for various types of perforations, I think allows it to be a little less nerve wracking and allows you to have an organized approach, which can lessen some of the stress of dealing with these problems. This is a perforation algorithm, one of many. It's a little bit busy. I'm gonna focus for my talk on the process of getting severe. Perforations dealt with with coverage, stents and Jason and Dwayne. They're gonna cover Mawr display vessel cabbage and collateral perforations with Spock's book. About the first thing to know is whether the wires across, if it is, you wanna do balloon. Tampa Not if it's a severe preparation. We're gonna move into moving on with coverage stance. If it's not severe, you can often deal with balloon tampon on. And then we'll talk a little bit about DS for PMS, and then Jason's gonna cover coil stats, microspheres and everything distal on his part. So there's two types of covered stent on the market. This is the older one, that Joe stent from Abbott and one of the things about the Joe sentence it tends to in sizes in four or five and eight actually used large need larger guides. And so this is a double sandwich, which has a relatively large profile, and it can be delivered difficult to deliver a few smaller front systems. As you're aware, the papyrus covered stent is a smaller. It's a single sandwich. It's covered and actually is able to be delivered in some sizes. through five friends or through six front systems. So with this modern tool, it's actually revolutionized to some degree the way we can deal with these processes, and we'll talk a little about the differences between the two in a few seconds. One of those things about the pirates is shown in this matrix here is that the smaller sizes are five French compatible, and that has some benefits through delivering them through guidelines, guidelines and other smaller, smaller French size system that we'll talk about It has been demonstrated this little clinical study. You're actually able to get them in quicker in a clinical problem where time is of the essence. So with regard to single guide technique for dealing with perforations, when you have a perforation, as we talk about, the first thing to do is to put a balloon up. If you have a larger French system, you can often put a second guide wire in and then put the coverage stent next to it. This typically requires the seven front system or greater, which we often well using complex PCB. But it may not always be possible if you have a six front system, depending upon what size matrix of balloon and or papyrus you're trying to fit in. It really can vary in terms of whether they'll fit. And certainly this is difficult to do with Joe Met, which has a much higher profile once you get the coverage. Stenton obviously want to make sure the human Stasis is achieving and stabilize the patient. Human dynamics that we talked about. The dual guy technique is often used when there's severe perforations. You don't have time to be shoveling gear in and out of the artery. The first thing you do after you put the after you recognize the perforation is to put a balloon up. You confirm that the bleeding has stopped and then you move. A second. Guiding catheter is demonstrated here, often the larger one in a ping pong fashion into the corner, and to be able to slip a wire down, let the balloon now quickly put it back up, let it down again. Deliver the stent until Hema Stasis is achieved. So these are the two main techniques for dealing with large vessel appropriations, and I'll show you a case which has a version that's using a guideline, that so this is a perforation case. I did actually, about two or three months ago. 78 year old gentleman referred to us for three layers of instant restenosis in his lab has led is pretty much function, including, especially with wire cross. You can see that this was balloon expandable and then certainly the three layers were under expanded quite prominently, has seen even on the fluoroscope e. So once we were able to balloon this even the high pressure we did O c t. I won't belabor the city run too much except to say you could see the waste right here. You can certainly tell how tight the lesion is. The minimal stent diameter of the inner layer of the third layer of the stent that was placed with only 1.1 millimeters. So it's quite severe stent under expansion. We have a pretty set algorithm for dealing with this. We use laser out correctly laser non contrast extensively. It was still un expandable at that point. We move on to stent ablation. We used the 1 to 5 and a 15 road uber to trying to Blake stents Trust to facilitate expansion. When you do this it's important to use higher burst feeds. You don't get the bird trapped. And after we actually did the 15 road, we still have the stent which was unable to be dilated. We escalated further. If you see here even after 15 rotational atthe erecting high pressure building, there still is a significant waste here. We went to 175 road, which admittedly was a little bit big in this artery and still had difficulty expanding. And so we took RNC balloon up the ultra high pressure and had an Ellis Type two perforation with the advantage still standing after the bullet ruptured. And so, luckily, this isn't a very serious perforation. It looked pretty stable. We manage this with three minutes of balloon inflation, and you could see that actually quelled down with quite nicely quiet. And so we put breaky therapy because the last thing we wanted to do in this moderately well expand extent now was to put another stent in. And after treating great with breaking therapy to try to minimize the chances of new animal formation, this is the final result. And so it's an example. I think of what you probably should do to prep vessels better on the front end. And if the stents aren't expanded well, please don't put a 2nd 3rd, Larry, this is a pretty difficult problem to treat that makes this case illustrates. So this is a final stent expands to post. It was much better. It certainly doesn't make the metric in this area. Of the 80 or 90% expanding we want relative to the different reference segment was much better compared to what we started with in the pre case. And so this is actually the first perforation I treated in practice. I was probably in practice about a year and a half. I did this on a Saturday when I was alone and really understanding algorithms for perforations ahead of time and knowing what to do. This case was really emblematic for me in my line because I was lucky enough to be the beneficiary, having gone Sky Fellows course where someone taught me the steps to deal with the big perf. And I think you know Louis Pasteur is quote the chance favors. The prepared mind was certainly a resident in this, you know, the patient was referred for a rotational directory of this hostile RCs stenosis. The wire was pretty much inclusive once we got across and then did several runs of rotational atthe erect me about six passes of it with a 15 bird. The patient complained of chest pain had inferior elevations. Bradycardia. And then this is my next picture. You can see here that there's a pretty severe great ls three perforation. And so first thing we did is we put the balloon backup took a picture to make sure it was a collusive. We've got a balloon very quickly on. Then we went ahead and got ready for a ping Pong guy. This is back in the job better or that was the only technology which we have available. So we got left federal access eight French guide, let this down, parallel, wired and then had profound hypertension. Not surprisingly, we needed to do pure Kardashian thesis. We got 400 ccs of blood out, started to leave a fed drip urging in communication, and I made a mistake here. I actually didn't know any better during the case. In the middle of it, I reversed with protein, which is a bad idea. I'll show you because we developed later, some promising the r c a Once we got a wire down through the pink pom, we put a 35 16 graft master through this eight French system, we post dilated at the four millimeters and still had a perforation with Frank spilling into the pericardial space. And you can see here because of the perforation in the injections were actually starting to unzip er the aorta patient type attention returned our pericardial drain cloud. Probably in some part related thio the fact that we had given protein into reverse and the aspirated then another 400 ccs of blood. So we then put a five over by 12 graph Master in and then you see we're able to fill toe actually stopped the bleeding in this particular case. And so the graph master was a little bit oversized, but it didn't do the job and actually still the rent and prevented us from getting further extra visitation into the aorta. Down to the disk Garcia, you see oclock form. We had to do distal Arcia aspiration from back to me. After removing that, patients stabilized further. This is the final angiogram. We actually did the order, Graham, to make sure that we didn't have any extension into the order. And also, when you have a dissection like that where I want to make sure there wasn't a problem with the right coronary, cussed and deception induced the organs efficiency. And so it looked fine. She estimated 24 hours later with discharging hospital day five. And so I think you know, the fact that, as a fellow somebody prepared me for how to deal with this case really gave me a benefit of knowledge that would have seen when I bumped in this for the first time alone on the weekend With this particular case, this is the case I did about six months ago. Uh, 61 year old female standard risk factors actually had sink API and fell and broke her neck and had a cervical decompression infusion with partial amon ectomy and postoperative day to she had a cardiac arrest on one of our surgical floors were referred to as urgently on call about 11 o'clock at night with these e k G changes. And so this is her diagnostic angiogram, right? Coronary artery looks relatively find this abnormality in the aria calling the Led. And then this is your led, which had a severe calcified region which we thought was culprit for the fact that she hadn't arrest and had the skin icky kg changes we put in NC balloon in It was constricted in Angie Sculptor would not cross. We did five runs of orbital atthe direct me had no difficulty the post orbital angio. So it's mild by section but no evidence of perforation. And then we went back down with an N C balloon, which was slightly constricted. We went to about 14 15 atmospheres. It finally released. And then this was the next picture. Significant illustrate. Three perforation. And so in this particular case, it was a six French system. But I was lucky because the guide, as you could see with a little bit short and we didn't have great guide supports. You already had a guideline in place, and in the night this happened, actually sent a picture, this middle picture to Jason, and he sent me back in Texas like said, Put the guideline er right back down. And I show this case because it's a good example that is a derivative from CEO work when we're trying to minimize inflow into things like subdermal hematoma is when we're doing anti grade that section entry. Ah, lot of times we bring a guideline er down into the space to stop flowing, so I put the balloon right back up. This also. So it's important when you're dealing with calcified arteries to do a scouting NGO before you take the balloon out. Because the last thing you wanna do shuttle this out of the body, you find out that you're now in Tampa and not knowing how to significant preparation. So I brought the guideline er down to the balloon. And by doing that, I purposely wanted it to be inclusive in this relatively small led. The next thing I did with the balloon up, I confirmed again, it wasn't bleeding. We got the papyrus open prepped and ready. We took the balloon out very quickly and then shoveled the papyrus and place. You could see there's a little diagonal that they were trying not to box with that. And so we tried to position this perfectly so we could actually seal the whole and not nail the diagonal. Knock it off the papyrus is deployed. Luckily, we got into place. We're able to seal the hole in the tiny diagonal was there the diagonal was lost. It would have been the end of the world that it would have been nicely elegant, potentially not losing possible. We ended up placing. We post dilated the papyrus. To start, we placed a proximal three millimeter de es post dilated that extensively in did O. C. T. You could see the papyrus quite nicely here you can actually see as the O. C. T. Runs through. It is a nice coverage step because it continues to have a relatively low profile way. Had about 88% expansion on the post final O C. T. In this case. And so I joked from friends. A goal for these is to get the 90% expanded A Don't judge me. I was happy to get this with Seo Holden. Relatively nothing. The whole sealed in relatively good expansion have a small effusion, did not need to have pericardial synthesis, and we put protein in after the gear is out in this case, something I've learned over the years not to do when they're still gear and she was human, amicably stable and actually went to one of our step down units. So take home points is that Korean preparations are associated with significant morbidity mortality. Early recognition management A careful post procedure care is key. Rely on these algorithms to systematically management. If you know what you could do, have time. It makes it easier when you bump into these dreaded complications thes prolonging balloon inflations or single or dual guide techniques to deliver covered stents and just put a plug in for please adequately prepared lesions. Protestant placement. We shouldn't see patients or three layers of understanding stent like I did in the case. I showed so that might have happened. Taken comments if there are any from attendees on any discussion from my colleagues and around Thank you very much. Kevin. That was great. A couple of things. You showed that one perforation where it happened after a balloon ruptured. High pressure. Andi. And you know, I've had that happen, you know, a handful of times myself, and it seems like those almost always respond to just a balloon inflation or a stent in the main vessel, and very, very rarely need to get Thio. Ah, covered stent. What's your What's your thought on that? Yeah. The only time I've had to put a coverage stent is when I both released and at the same time ruptured multi layer I S r. And there was a pretty big perforation, I think related Thio Mawr. The fact that the balloon ruptured and the stent released it the same time. And so I agree with you. Those advantage still stands from balloon pinholes tend to respond very well to serve a three minute inflation. I've I've never for a simple one like that ever had to put a covered stent in this case. And so I think it's a nice example. When you see those, they're potentially less clinically dangerous and a little more, you know, probably patients with balloon inflation tends to have them quiet down pretty quickly. Are they comment on the pair? Cardio synthesis. Part of things. It's gonna come up a couple of times tonight, But, uh, I think Kevin, you know, you show nicely. What we've learned over time is to not reverse the anti coagulation, even though you're worried that they're bleeding, you know, you can deal with that. But If you're dealing with bleeding and from boasts the same time, then you're in a lot of trouble. In the worst, there's a free flowing perf and the pericardium from boats, and you can't get the blood out. I mean, that becomes a surgical problem free flowing. But blood around the heart is a better problem than from boast throwing both blood. So it's a good point, you know, in the CTO space where we're kind of doing things that are a little bit more perforation problem. We give programming a lot before concerned that wires or gear maybe where they're supposed to be at some point in the case. But we always do that once the sheets the shoulder on the way out. So the timing of that is an important thing to consider. Yeah, but this happens when you go into the E. P lab and one and they ask you to drain somebody or you have your own pericardial effusion is you want to drain them dry and have the catheter in place before you administer the protein. Because, as Kevin said, if you have the jelly in their, uh, then you're not getting it out so drain them dry and even have somebody keeping sucking negative. Almost have the pair your into the, uh, to the heart while you're, you know, dealing with the rest of the stuff when they're dry and you're keeping them dry, then you can try Thio reverse the anti coagulation. Yeah, there's any question if they're still bleeding, Jason probably cover this. But inter coronary intravenous injection of definately echoed Contrast. If you see swirling bubbles, pericard even know you still have a problem and you got to probably get over that one question relative to you. This particular talk with someone said, Please explain ping pong technique that really is just the process of putting two guides up into the same artery. So while your balloon, including presumably with your six French system, as I was in that r c a perf I showed you, then bring a another guide up next to it, which allows you some expediency. You can drop that balloon quickly. Put a wire down. You could actually put the balloon back up. I've actually done this with micro catheters. If I have a ping Pong system and I have a balloon up in the artery I'll put a turnpike down past, pin it with the balloon, so I'm no longer bleeding that I could take my time wiring the rest of the artery. And so ping pong just means having to guides in the artery in the vicinity. Artists be able Thio to manage the perforation with more expediency. And so someone did ask about profusion, balloons and some of the new thoughts, and Dwayne is gonna go over there some detail in his talk. Thanks, guys. That was awesome. Kevin, Um, alright, we'll go ahead and switch to my talk. Kevin obviously talked about probably, um, or common thing, which is the large vessel perforation. And obviously the treatment of that is a bit different than what I'm gonna be talking about. So my talk really is focusing on small vessel perforations of distal vessel preparations. And in that we're gonna include collateral preparations for those in the audience who are our CTO operators. And so here are my disclosures. S O R. Outline for this talk is we're gonna talk about distance small vessel preparation that causes the management and probably the most important thing is prevention to we'll also talk about collateral perforations, both septal collaterals as well as EPA cardio collaterals on. Then we're gonna review a couple algorithms. One is what I consider ah, universal perforation algorithm, thes air. The things that I think of when? Whenever I have any type of perforation on, then specifically talk about the things to think of the approach to small vessel preparation. And so I'm going to start with a case I did about a year ago. This is a guy who came in with a non s television m. I had some anterior wall hypo kinesis and E k G changes on was sent to me for a cath. I did the diagnostic from his arm with a six French radio system could not engage the left coronary system. So eventually went to a guide catheter on the guide catheter that I picked wasn't wasn't great. Didn't give me good support. So even to get a good diagnostic picture, have a wire down the lady with a guide extender in Andi. I kind of was setting myself up at the beginning of this case for failure, and you could see there's a high grade proximal lady lesion right at the take off of that diagonal branch on the diagonal branch also had a lesion in it. So it was a Madonna 111 on DSO. We went toe to go about fixing it. I decided, because of the high grade lesion in the diagonal branch, in the slow flow in it, that we were going to go ahead and start with a two stents strategy. So I started by putting a stent in the in the side branch, doing a double kiss crushed technique on After I put the stent up and then crushed it, I struggled for a long time just getting back through, and I was ableto wire it relatively easily, but could not get any micro catheter balloon to go back through to do my initial kiss. But after adding a guide extender and bringing it all the way down basically onto the mouth of the diagonal, branch was able to pass a 15 balloon and on and then open it up and do my initial kiss. Then I put the stent in the main vessel on. After I did that, the patient started having some chest pain and e k G changes took a picture and you could see I don't have good flow down my diagonal branch again Struggled for a long time rewiring back through on eventually did and was able to spend a micro catheter through which you can see on the right hand side of the screen on eventually got in and we were able to do our second kiss. Got a picture. We got improved flow into the dying on a branch Pain went away E k g changes resolved. Ended up doing intravascular ultrasound, which showed that the stents were actually pretty well expanded, opposed in size. But we did have some thrombosis at the origin of the diagonal branch, probably because of dropping his, uh, a C t but eventually did a little bit additional ballooning and then opened up my my my frame took my wires out, took my final picture. You can see what I've got there. I've got a perf down at the distal portion of that diagonal branch, and again I struggled getting back through. Aunt had to use jacketed wires on. Then I really struggled getting any gear across the wire on and all that manipulation, uh, you know, probably put one of those jacketed wires out the distal vessel, and so the causes of just a wire perforation or distal vessel preparations are almost always are from distal wire perforations, and almost always those are from a jacketed wire. Or if somebody is using a penetrating wire in the wrong instance, you really don't want to go into small vessels with those. Occasionally ballooning in a small distal vessel can cause a small vessel preparation, and occasionally you can see this. If if you're passing gear over wiring, inadvertently pass it to the end of your wire on create a perforation That way. This is a case I did uh, many years ago is a cto of melody. Did anti great dissection reentry Got a nice looking results, sent the lady to the floor Two hours later, I got called because she was having plastic chest pain, and she had a moderate sized Tampa nod from a tiny little distal vessel perforation. And so when I have a perforation and again, this is any perforation, not just distal vessel. These are the five things that go that I have imprinted in my brain that I do immediately, and the important part of this is that it? It stabilizes the situation and it buys me time. So then I can start thinking about some of the finer points of how to manage it. But the first thing that you do is you inflate a balloon to include the vessel. Obviously, Kevin showed that with his large vessel perforation. But this is also important for distal vessel perforations, where you want to put a balloon up proximal to the vessel perforation. And again, it just gives you time to think and get things organized. I always immediately have my nurse start mixing up and having pressers available and opening I V fluids. You generally don't have any. Oftentimes don't need to use them, but have them available. You don't wanna need them. And then the nurses spending five minutes mixing up the medication. I always call for an echo because it usually takes in our institution that takes, you know, 10 to 15 minutes to get an echo there. Sometimes you don't need it, but you call early and get them there. We always open the para cardio sentry thio pieces, Trey, whether we need it or we don't And then I call for help and usually that for me it involves calling either AH colleague, untraditional cardiologists or even calling a surgeon if I feel like we need may need to drain it toe more quickly. And I think it's just a matter of getting help in the room because more minds kind of help you think through these things when you're kind of in a stressful situation. And so when it comes to a distal vessel perforation, there's kind of a multi pronged approach. Obviously, you want to treat the perforation on doing that. You block the inflow, deliver a micro catheter into the distal vessel and then deliver a huma static agent to that distal vessel. You want to try to make sure that you're maintaining human dynamics ability by giving I V fluids vase oppressors, if needed, draining the pericardium if needed on in worst case, even mechanical support on, then after all of that, then you consider reversing an eighth robotic therapy, and so to treat a distal vessel perforation. The first thing that you want to do again is to block the inflow by putting up a proximal occlusion balloon. What I like to do is have a balloon uh, in front of the main vessel where the side branch or the distal branches is perforated, and then wire into that distal branch with a wire and then a micro catheter as well on DSO. Once you get that micro catheter distal, you can inflate the balloon and then put negative suction on the micro catheter. If it's kind of buried distantly in the vessel and that negative suction sometimes will kind of create a non artery that kind of collapses on itself. And sometimes you don't even need to do anything after that. Uh, and But if you do, we kind of have this technique called block and deliver where you're blocking the inflow. So it's not bleeding a whole lot, and then you've got your micro catheter distantly, and then you can deliver coils or thrumming or whatever. You're gonna use Thio to seal the perforation. And so when we when we're talking about including the flow in the vessel, there's a handful of things that can be used. You probably don't need to know all of these, but you should probably know a couple of them. And in my in my lab, the easiest thing for us is coils and fat fat because it's on the table on coils because we have them in our perforation kit. Thrombin, oftentimes, is, uh, can be useful. But again, it requires somebody thio, find the thrombin and mix it, which sometimes takes time on then microspheres. We don't generally use myself, but But if you haven't ir specialist, that's really good with those that is helping you out. It's something that that's certainly on the table. The other thing is, you can always use thrombosis. If there's a little bit of thrombosis on your table, you could drop some of that into, ah, micro Catholic to a clue. And so usually what I use is coils, uh, in the coils that I typically use R 014 compatible coils. Most of these cases I have a micro catheter that's an 01 for micro catheter on the table. And so it's nice to use one for micro micro catheter compatible coils and the two that we have in our lab or the axioms and the target Nano's on. Those deliver very, very easily through through micro catheters. Owen eight Coils air Certainly nice and certainly helpful for bigger vessel perforations, where that you're going to coil. And the nice thing about them is that they have. You could get coils that are either have a bio active substance like Zork oils that we use or a fiber coil like the concertos that we also have. And the nice thing about those is that they help aid and creating a thrombosis and stealing the vessel a little bit quicker with the 014 coils, there are no bio active or fiber 14 coils, and so those oftentimes will block the flow. But then they're dependent on that vessel through on boasting off. And so you need to deliver the coils, make sure you've got almost complete resolution and then reverse the anti coagulation. And so, in this case, we're able to deliver our micro catheter distantly. We pulled negative on it to see if we were exclusive, but we weren't inclusive. You can still see some leaking out the around the side of the micro catheter. So we delivered a couple of, uh 014 coils to seal the distal vessel. He still actually had fairly good flow in that vessel, so I wasn't too worried about losing the diagonal branch down the road and so other things to include the inflow. You can use thrum, and this comes in a small vial of powder that's reconstituted with normal sailing on. Generally, you inject like a half or less of ml down the micro catheter. But the thing about thrombin is you don't really have a lot of control over it. So you want to make sure that after you deliver it, that you don't rewire the micro catheter because that will lead to additional spilling of from and And you wanna have negative suction on your micro catheter when you remove it, Uh, and so that the care you have to take care with the from and to, because this can enter the pericardial space and can from both your effusion. And so oftentimes, you if there is an infusion, if you think it needs to be drained, you want to drain it first or use something other than, uh than from it. Uh, including the inflow with fat is a common thing that's used in the CTO realm. This is a really nice technique because, uh, because like I said, fat is on your table. Generally, what you do is you take a pair of calipers Kelly's and and pull a little fat from your art Erie Autumn E site. You mix it with a little bit of contrast on. Then you put it in the back end of the micro catheter holding the micro catheter vertical on the fat, then kind of floats up to the top of the micro catheter mouth, and then you're able to push it in with a wire and the reason you want to mix a little contrast with it. Is that what you can see it when it comes out? The micro catheter. This is a case. Ah, colleague of mine did had a proximal om occlusion that he was able to wire with integrated wire escalation to real nice job, ballooned it up, put some stents in, got a fairly nice result. After he pulled his wire back, though, he could see that there was some disease still with the outflow. And he thought he was just gonna do a little more ballooning down there. So I struggled getting a wire back through, but eventually did and ballooned it with 15 balloon, and you could see, he opened up a little hole on in this case. He actually just had his micro catheter in, delivered a little fat distantly on. Got a fairly good seal just with that alone patient didn't need to have a pericardial drain put in. But I was able to reverse the that the heparin after this and had it seal on its own. And so to prevent distant wire preparations, you want to be very careful when you're using jacketed wire wires in the distal vascular bed. You want to be very careful and removing an advanced advancing gear over a jacket and wire like I was doing on that. On my first case, I showed you always want to make sure that once you've, uh, cross with a jacket and wire that you pass a micro catheter balloon over that, uh, over that and switch it out for a workhorse wire. And you always want to try to work over workhorse wires and then obviously simple things like passing gear with care into the distal vessel and avoiding oversized balloons and very small vessels. So collateral perforations, we're gonna kind of switch gears here. The majority of collateral perforations are obviously done during C t o P. C i and the majority of these air caused by wire perforations. But occasionally micro catheters can perforate. Oftentimes when you're trying to do a tip injection through a micro catheter to kind of help to find the course of the collateral that can lead to a rupture and then occasionally more commonly with epic cardio collaterals, you can actually volts the vessel if you're pushing or pulling the micro catheter across the collateral to aggressively three important thing about collateral perforations is that these bleed from both sides and so you need to make sure that you treat both sides of the bleed. Treating one side alone oftentimes is insufficient. Oftentimes, when you're when you're crossing with the retrograde micro catheter, it actually includes the perforation. And so oftentimes these aren't discovered until after you remove the micro catheter. And so what? What I've gone to doing is any retrograde case that I use a collateral with other than having graph, I leave a wire in both the anti great and retrograde channels before I take my final pictures. That way I maintain wire position that if there is any perforation then it's It's real quick to drop a micro catheter over both wires. Remove the wires and then maybe drop a coil or some fat thio seal it off. So septal collaterals perforations usually are small and secondary wire preparations. Uh, they're much higher risk of this happening. Jason, just one quick question. Do you leave the uncovered wired and retro system? Uh, when you take that picture, or is it just in the collateral like you don't leave it in the septal. You don't leave it all the way across. So this is after you pulled your externalized eso you rewire a re pass your micro catheter retrograde pulled the the externalization wire out, and then then we'll spend the micro catheter back through the the collateral. But before you come across the collateral dropped just a work force wire down and then remove the collateral and then take the picture. So yes, again. Not because you don't wanna pull a bare wire across. Ah, collateral eso septal collaterals rarely have athletic erotic disease, and perforations usually are contained on. Oftentimes they will just bleed into the LV or RV, but occasionally these can lead to compressive hematoma. Zvi STS on ventricular arrhythmias. But but in my experience, the most common issue really is just pain. These air fairly uncomfortable. Eso septal hematoma management. You need to seal both sides of the settles. You could do this either by putting a covered stent over each side of the septal or dropping coils in. Observation is usually all that's needed, though, in the majority of these cases. But if there are signs that it's being compressive, then you want to try to drain the hematoma. And this could be either done by passing a Mike Weir and then micro catheter into the hematoma on draining it with negative suction. Uh, there's case reports of it being done per Catania slee from the RV, where you basically take a micro catheter on a stiff penetrating wire and penetrate into the septum from the R V from the from the right side, the Venus system on, Then pass a micro catheter through on. Then once you're in the right place, oftentimes just ballooning it up in creating a channel so that then that drains into the right ventricle on. Occasionally, surgery is even needed, but that's obviously a very high risk of procedure. So prevention of central collateral perforations obviously don't force wires. Keep the tip moving. If you're gonna do balloon inflations, make sure they're done with very small balloons and low pressure. Inflation's. You wanna slowly remove and advance the micro catheter and switch to a smaller micro catheter if it's not advancing epic cardio collaterals. Obviously compared to settle collaterals, there's quite a bit of difference. These are more tortuous. They oftentimes they're more difficult to navigate both with the wire and the micro catheter, and they're more likely to have in elastic disease that can lead to perforation of rupture on these oftentimes lead to much more rapid Tampa nod on patient instability and usually will require para cardio synthesis. This is a case done, uh, several years ago where we gotta write CTO. We initially tried to do anti grade dissection reentry, but had some difficulty finding the distal vessel, and we weren't sure where we were relative to the distal vessel. We seem to be moving with the vessel, but we're quite a ways away from a good reentry area. So he had this nice little septal collateral or give me epic arial uh, collateral off of, uh, I think it was a distal a diagonal branch. Uh, on it looked like it was gonna be fairly easy tow wire, but obviously had difficulty wiring and eventually have a perforation. And so, uh, epic cardio collateral preparations are obviously, uh, high risk procedures. And so I generally try to avoid using epic cardio collaterals now attend to look for other options, if at all possible. We don't do use any jacketed wires when we're using these way are oftentimes very, very careful If we need to do tip injections now, we use smaller micro catheters, careful advancement and removal of micro catheters on then Never obviously dilated epic cardio collateral like we often times do except ALS. And I think from a prevention standpoint, it's really probably the biggest thing is just selective use of epic cardio collaterals, thes air to epic cardio collaterals that I I have used, uh, recently this thing, this one obviously, is a huge, uh, epic cardio off of the A pickle L A D. Which was very simple to use on a relatively low risk. The one on the right as a dia cirque two diagonal, uh, collateral that you probably can't even see it. But, you know, you really only want to use those when you have a lot of experience using collaterals, uh, EPA cardio, collaterals and and, more importantly, complication management of collaterals. And so if the CTO is fixed, you got to remember that you need to treat both the donor vessel and the recipient vessel on. Then the same options that we used for small vessel perforations can be used here again, coils from and fat from this from microspheres on. Then once gear is removed, I think it's very reasonable at that time, as long as you don't have a large fusion that needs to be drained that it's reasonable to consider reversing with pro to me. Now, if the CTO is not fixed on, you can't get a wire into the distal vessel. You want to include the donor vessel on, then drain the pericardium and put the drain on suction. And hopefully you hoped, basically, that that creates some negative section on the pericardium that will tampon on and off. And then after that, you probably want to reverse anti coagulation. But if the bleeding continues, those are the ones that oftentimes you need to have a surgeon go in and and deal with for you on. It's important to note that the the the donor vessel just give me the recipient vessel oftentimes will still bleed. But that's a low pressure system. And so these oftentimes bleed very slowly and so Tampa nod sometimes come developed hours, hours later. So you wanna obviously keep a real close eye on these folks. So back to this case, we had some difficulty. Obviously, with the perforation, we did some balloon inflations to kind of prevent further bleeding from the inflow, but eventually did need to drain it on. At that point, we decided to go back and too great to see if we could do integrate dissection reentry, get into the vessel so we could, uh, treat the the recipient vessel. We eventually were able to do that. Dropping coils into both the donor and the recipient vessels on ended up with a reasonable seal of that, uh, that lesion. So in summary again, the five big things that are on my list when a perforation happens again, regardless of the type of preparation, is a balloon up to Tampa nod, Ask for fluids to get started and start asking the nurse to mix up pressers. Get a pair of cardio synthesis, get open, get an echo on the way and get get help from your friends. And then with this, the vessel perforations. You obviously want to treat the inflow like we showed on. Do the things that you need to do to maintain human dynamic stability on. Then Onley reverse the anti throw Matics. Once the gear eyes out. That's that's what I got That's great chasing really nice to be appreciated. Someone asked a really good question. How do you size the coils? And maybe you could talk about the importance of packing them and just not leaving them with long strings. Yeah, and that's the nice thing about the 2014 coils that we have in our lab is they are, uh, there. They have a release mechanism that comes with the coils, and so you put it in and you pack it down. And if you don't like how it looks, you can always do another picture and see if it's still leaking. If you don't like how it looks, you can always retracted back into the micro catheter. Uh, either move the mic catheter forward or backward and try to get it into, ah, place where it'll pack better. Often times you will have a little bit of a tail hanging off of it, but I don't really worry about that too much a zoo long as I've got a good seal on the the the vessel and a Sfar, a sizing goes. So the accidents and the target Nano's like I don't remember no all the size matrix matrices on it, but they're usually, like one millimeter or two millimeters by anywhere from 1 to 4 centimeters in length. And so again, it kind of depends on the size of the vessel that you're trying to treat. In our case, I think I started with, like a one by three centimeter. It wasn't enough toe fully coil it, so I dropped a second one in. That was, I think, a two by three Andi. Usually that is enough to do it, Uh, and again it's sometimes it's Sometimes you could get it with one, but it's not uncommon to need to, and I don't think there's anything wrong with starting with a a smaller coil and seeing how it looks and adding a second coil, unpacking it behind it. And it's important to know, though, that that these 14 coils you want them to be inclusive on the vessel. But oftentimes, though, there's still some blood in contrast, that will seep kind of through the little cracks that are left in it. So so that's really where you know, kind of, long as you've got a fairly good seal and you don't see much blood going past. But even if there is a trivial amount, oftentimes those will respond. Just thio reversing the anti coagulation. At that point, Do you wanna go through your section next? Yeah. So you know where I'm gonna go through a couple of cases that we're gonna illustrate many of the lessons that Kevin and Jason gave you, and then also we're gonna focus on the post cabbage left main patients. These are my disclosures. So let's start with the 63 year old woman who left outside hospital and after being evaluated for chest pain. Normally, CG if you return with a non stemming and then went to the cath lab for this, and I think you can see what has happened with the diagnostic catheter. Is the left circum flecked? Certainly. But also in this case, the left main His has been dissected who? And at this point, she complained of worsening chest pain. Became human dynamically unstable. Uh, the operator asked for some help and we placed an impeller catheter. And you see, a wire has been placed in the l A. D. And there's a micro catheter in the circum flex on. I think, you know, maybe Jason and Captain has more experience CTO operators. Maybe you can kind of comment on this kind of picture here of wiring dissection planes On what? You know, What did you do? Is faras injections and feel. And what type of wire do you think? The first thing you said injections. The first thing is to stop injecting Every time you inject, you make that dissection plane bigger and more full of blood in contrast and makes it harder to wire on. Then you know what? I'm trying to wire a dissected vessel. Obviously these air, these air panic situations And so the biggest thing is that you did in this case is is you've got a wire down the lady on, so you've got the left main protected, and obviously that's huge. But in this case, then I usually would go up with a A wire, and usually I use a workhorse wire because that will tell you real quickly if you're in the true looming or the false women. But I also have a micro catheter with it. That way I can quickly switch out for my different wire. Different wire shapes. Uh, Thio kind of quickly get in. And now Thio, find the Lumen, and there are occasions where you just can't get into the true Lumen. And so these the types of cases where you know if you have a dissection reentry techniques like a stingray, you could use that. But if that doesn't work, you can always take a jacketed wire and make and knuckle with it. In this case, I would probably use a mongo or a fielder X T wire, put a knuckle on that wire and just push it and eventually will pop into the vessel downstream. And you can kind of balloon it all up, and it will look terrible, But you'll have flow. Don't stent it because you'll lose all the side branches. But oftentimes that's enough. Thio Thio, get flow into the vessel and kind of preserve Preserve the patient. Yeah, those are all really good points. I think you saw the angio here with now the vessel the wires in the vessel. You know, you wonder if the vessels are in distantly, but you see profound dissection, Uh, approximately in the left, main and circum flex and led. And I think, um, at least the person is starting to stabilize him a dynamically of a little more time. But I think there's a lot of worry are in the true Lumen or not. And, uh, I think your point about stenting, uh was, uh is a good one. If if you're not sure whether you're in the true Lumen or not, you're gonna close off all the side branches. So, uh, here's some balloon work that was done. Also, you see the office catheter in the theme the, uh, sir complex. And then, uh, we did a 30 Wolverine balloon inflation because there were slow flow in the lady with the idea of fenice trading the animal flap in order to, uh, improve flown to be done. Um, but we developed hypertension and suction alarms on the A paella with no flow out of the, um, paella. And, you know, uh, Tampa nod is a diastolic filling problems, so the left ventricle doesn't fill, and that is manifest with the M. C s device as a suction alarm. Left ventricle can be not filling because the right ventricle is bad, or most often because the patient is under filled or bleeding. But in this case, it was because the person was in Tampa non on its because she had a L S three perforation of which, uh, Kevin showed you what These are what they look like. We didn't actually save that picture. But here's the balloon inflated approximately. The pericardial synthesis was performed and her human dynamics improved. So at this point, we pursued the Ping Pong Guide technique that Kevin described where you get a second access, Uh, in this case, I believe we used a single access technique through the, uh in Pella. And and then so the other access was on the contra lateral side. And you see two guides in place to wires. Three initial guide has the balloon that we were including with. And now you see, in this case, a graft master, uh, in in place using the second system. So here's a version of the algorithm that Kevin showed earlier being flayed to bluh the balloon to include the vessel stat echo. If there's not persistent X Travis station, you monitor the patient. Uh, if there is, uh, you wanna treat the cause As we talked about just a wire perforations, Jason spoke about that large vessel perforation again. We talked about contra lateral access covered stent continue to extract ization reverse. But I'm going to show you now the I vis here, maybe Kevin and Jason when things come through, maybe you describe what to do, I think, uh, image ing here to know whether you're in the true loom in or not. It is helpful to know whether the stent and in cases like this, sometimes the wire will actually penetrate back through. So, you know, you've had some where we've been, you know, true, false, true again. So knowing where that is and what branch is gonna potentially be knocked off is important, but you don't want to stay until you have some sense of that. So I think the I This is helpful. But I think you can see the looming of the vessel has passed us by. But I think that is it. Yep. Yeah. So this is all a giant human told me, even though it looked relatively good from the angiogram. Uh, this is all you know, fall for women. So mercifully, when we took a pot, there wasn't any more bleeding. So just with balloon inflation, things had stopped. And so we did not deploy the covered stent and way also, did I This on the circum flexed. I'm gonna skip that in the interest of time we just speak with cardiac surgeon and both of us decided not to do bypass surgery. Really is challenging for the surgeons. Thio identify what is true and false Luminant in the operating room s So it really isn't a good fix. Try to put a Lima or graft on this. She was managed conservatively. It only in Pella support For about two days. Device was removed uneventfully. She had no evidence for recurrent ischemia. Rieff was 30% when answer and a pickle. Severe hypoxia nexus and be peaked at 1 43 Hospitalization complicated by a vap uh, discharge. After three weeks in the hospital, this was follow up. See, thi NGO, which was this was the area of the perforation where there was a small pseudo aneurysm. Evidence of the dissection flaps were seeing in cross section. This was nine months. Follow up. That pseudo aneurysm had resolved in 18 month Follow up. She's asymptomatic. Yes. Now greater than 50% with mild, inferior wall. Uh, psychokinesis, uh, 65 year old man status posed bypass has an abnormal stress test for accelerating angina. This is Lima and the other graphs were open apart from were closed. Apart from this graft here where you'll see a stenosis which I guess is not playing in this one. Do that lesion there, uh, in the graft to the right. And that's what the operator embarked upon with a guideline er in place. This will protection using a spider device in the balloon inflation. That's after pre dilation. Now, uh, you see, after a balloon inflation, there is a free flowing preparation into the media. Steinem. So maybe hear from Kevin and Jason. Um, what are some practical issues now dealing with this perforation. Uh, you know, we hear all the time that you know, perforations with, uh, post bypass. You can't get Tampa nod. What do you think about that? And then with the spider device in place, there's a special consideration. Yeah, I know. I think you know, the post cabbage perforations are the ones which terrifying the most because they're difficult to tap. And so I think they deserve a healthy amount of respect, which is potentially underappreciated. We we had a discussion about this that are Catholic conference a couple weeks ago. Like as post cabbage. Not a big deal. And so, well, the CTO space That's actually the ones that can burn you unexpectedly. And so, like you, depending upon where they are. Especially if they're near the red. A tumor, right ventricle. They could be a problem. That could be small. They could be populated to be hard to get to us, I'm sure gonna go over. Yeah. And there's also one practical concern with the spider device in place. When you use a ping Pong guide technique, you can't put the coverage stent in place without removing the spider device. Otherwise, you're gonna trap it there. Eso post cabbage perforations. Uh, over the last decade of n c d. R. Around 0.4% of all pursed around 1/5 of them are in post cabbage patients. Female gender, A lot of long lesion length type C lesions pos Uh, the maces substantial. A 23% 50% less likely to have made from the perf, but it's not 0% open. CTO had 7.1% preparation rate. Post cabbage patients, uh, eight of 26 of these, or 30% were associate with in hospital death. So exactly as uh, Kevin mentioned, you know, this is not a benign scenario, especially in the CTO patients. All the deaths in the open CTO were due to perforations and close cabbage patients. Eso What's the issue? Azaz was already mentioned. Inter pericardial minority of them. It still happens, by the way, Uh, sub EPA cardio Ah, fifth, uh, intramural eso within the muscle or extra cardiac. 9%. Uh, you get lock elated pockets in the pericardium, and they could be anatomically difficult to diagnose. And treat is kevin said on Do they have a typical consequences? Uh, from what we're usually used to. You'll not always have a pulse. Is not. You might have accuse malls sign, and you might not always have equalization of pressures. Um, 25 to 40% of all purpose and post cabbage patients had normal tts and human dynamics in the cath lab. So we still have to be vigilant about these patients and monitor them. He's probably aren't great patients for same day discharge. Eso uh, here is a picture after the 1st 40 by 26 papyrus stent goes in and they're still continued bleeding. You see, Also collection of die and contrast here. We've removed, uh, the, uh, distal protection device. And in fact, here it iss it had interacted with the other guide and had led to everything snagging. And so we had toe actually remove it. Recross quickly deploy this covered stent. And we were going to deal with, uh, the Disa protection device and retrieving it later. But what? You're mixing all these complications, You know, you're not doing a single complication. You like, get 2 to 3 complications from every case. Yeah, I'm really talented creating complications. Uh, so do you know what happens if it still bleeds after you put the 1st 1st covered stent in. So you could probably address that here because that's exactly the problem you have. That's exactly right. So the first step is always to post dilate to nominal, at least because you may not have you made of asymptomatic asymmetrically deployed and then post dilate with, uh, half a size bigger. And then this case way, What we did is we deployed another coverage stent e. I think you can appreciate two things here. One Here's the spider from the left radio still in place that we retrieved that later. Uh, the graft is being compressed here by this hematoma. Remember? It was nice and big without disease and the control angiogram. I did this spin for Kevin and Jason's benefit a t end of the case knowing that we would be showing this together. But that's the hematoma. We also did a right heart Cath and the person had abruptly developed purplish discoloration in his face plethora, and we diagnosed him with acute spc syndrome. Here is the proximal SBC. Uh, I j pressure at 35. Uh, this is the wedge at 10. This is the RV pressure at 25 with an R v e D p of five. So there's a grading of approximately 30 millimeters across, uh, the S E c R a. You can see this collection of blood here on his CAT scan and compression of the SBC into the r A. Uh, this is the echo showing the same. This is the mass. This is color showing the pancake R c a. And he had a very interesting phenomenon in the lab that he had multiple episodes of knowledge and vomiting for what you wanted to sit up. And every time he sat up and vomited thereby Val Salva, you would pass out many would fall backwards, regained consciousness when he was supine on that freaked everybody else out. Obviously, uh, but what we did is we had to maintain a supine position. Hey, had no further episodes of this sort slowly improved and was discharged on hospital day six. Um, so a final case in the last few minutes here, 69 year old man with a history of lung cancer, hypertension low e f has this disease involving the left main and sir complex. He was turned down for surgery We did a right heart, Kathy. At normal filling pressures, we differed. Mechanical assist. For that reason, here's repair of the circum flex wiring the circum flex micro catheter guideline er, to deal with that tortuous ity, we decided to perform a sleeve technique in this case, Uh, I didn't want to give up the wire in, uh, either the lady or the circum flex. So we used in a French guide. And instead of using ping Pong guides, as was described earlier by Kevin with a guideline er in this example in that l a d to protect from the a threat to me device mangling the wire use two guides we elected to produce this with the micro catheter instead. Technique that Kevin showed me, uh, where you have a micro catheter in the l a d a wire in the circum flex. You perform at the rectum e of the plaque, and you may abrade the fine cross, but you won't, uh, Catch three the, uh, wire. So here's an example of the orbital wire. Fine cross. And, uh, in this case, impel also, uh, So here's us wiring the lady. You see the fine cross in place here in the circum flex and the orbital after ectomy device, uh, is also being used. See it advancing in here. And this is after after rectum e we then perform a tap technique was it was gonna be a provisional approach to the esteem of the circum flex. We didn't like how the distal led, uh, appeared. I see that lesion there in the mid for action. So we elected Thio Treat that it required some, uh, some work with the guideline er down into the artery and anchor balloon technique on We delivered the stents. This is what it looks like after stenting then performed I vis on the left main And, uh and, uh l A D. And I won't bore you with the whole run. But what we found was, of course, we knew that it was heavily calcified, but measured the post dilation to be somewhere around five millimeters. And this is where I made a mistake and had the balloon sticking out too far into the l A. D. When I dilated and we're left with this left main perforation left main proximal, lad, perforation that you can see is an L is great, too. So when it comes to perforations in the left main, this is very tricky plates to deal with. Mostly, you can't do all of the things that we've shown. Uh, you know, you can't coil the areas you can't use thrombin beads or fat, fat, fat injections. Uh, and we're left with are covered stent. And when it comes to this covered stent, though, we have an important side branch in many cases either the l A d or he circum flex. Uh, this is a flow chart for managing perforations That really recapitulates what's been spoken about through the evening tonight. But when it comes to the left main, really, we don't have available to us most of these thes things. So ah, profusion balloon has been mentioned thes air balloons that back in the day we're available. But this is an investigational device. Uh, that will allow us to perform uh uh, profusion, balloon inflations, eso inflating and, uh, preventing bleeding while at the same time allowing for blood flow. So, you know, hopefully we'll get this device, uh, soon. Um, and it's called the ringer. Now, this is a video that Kevin put together of feminist rating a papyrus in order to deal with the left main circum flex, obviously on off label usage. But, Kevin, you want to describe what you were doing here? Yes, effectively. You know, there are some case reports from colleagues you've dealt with left made preparations in terms of putting a covered stent across one of the branches and then going back and finished rating. And so we've I've not had to do this in the case. Thank God this is a fairly harrowing problem. But, you know, the papyrus is being placed in this case in this model across what would be we'll call the sir complex. The wire is jailed purposely because you lose flow after you put up the covered stent. So it gives you a marker to know where to point to. So in this case, we then go in with a supercross. 1 20 is an angled micro catheter. And I'm taking a hornet 14, which is a penetrating wire. We using CTO and you could see having a little bit of trouble getting in. They're the wires entered to distance. You could see that tried advantage. It's somewhat difficulty. And so we pull it back, and then we'll stick mawr approximately in this next segment, we might wire through the graph Matt through the papyrus fabric, and then we get a wire in, and then you're able then to advance the micro catheter, which point you would definitely switch out for your course wire and think about ballooning. You could even do bifurcation stent with a regular sent you needed to, so luckily, have not needed to do that maneuver. But there are ways to do it to the one to give the team an example that so they could sort of talk through it and teach people how that's possible. So, uh, you know, just to show you what we did, uh, balloon inflation and that sealed the perforation. I will, uh, will say parenthetically as we're talking about off label stuff. The covered stent, Specifically the graph masters and papyrus stents are part of HD human device exemption. So that means that you have to have an i r b toe. Have, uh, these stents on the shelf there. Onley approved for coronary perforations. And you need Thio report on the case afterwards. So you know it's come up. Oh, you know, Let's use this for an aneurysm or let's do it for this or the vascular Surgeons want to do it for that. Uh, that can't be done. But, uh, if you wanna, uh, use thes stents is important to know the process and how to apply for an HD to your IRB. I'm sure the bio electronic folks can help you. This is a standard process in, uh, in all hospitals. This is what the vessel look like after balloon inflations. We've gone through a lot here. So a to this point, I elected Thio not finish off the tap with this Aussie, um of the circum flex. We had normal flow. We decided that we could fight this later. He was discharged two days later without any complication. Click will follow up in 10 months. He's had no events and has no further angina. So we actually haven't brought him in to treat that circum flex it all. With that, I'll stop and start for running a bit over. It's a great series of cases. Guys appreciate it. Jimmy Kerrigan has pointed out that a ringer profusion balloon showed eventually, once you get that up for a case like you're off led left Naper. That'll be nice, because you could potentially Lau some flow at least to the lady and allow it to seal off potentially, especially if it's not that that a perf like the one you showed the other thing, which, you know, I think, with mentioned by one of the attendees is eventually you might be able to rewire through that center of Lumen. Put the coverage stent distill left the profusion balloon down, pull the step back and deploy it so that technology, when it comes out, will certainly help us to be able to deal with these. There's probably some other uses for in C T o p. C I won't talk about, but the critical thing is, you know, when you're able Thio, it's nice to be able to not have to place the coverage stent across side branches. And hopefully that new tech will be able to help us, um, post cabbage perforations doing, you know, patients that have r v r. A compression. That's a pretty significant problem. I've not yet had to do it, Not would, but we've talked about, you know, right side of human dynamic support and someone like the patient you showed, by the way, those right heart cath tracing were impressing. That's a great case. Did you guys consider sort of an RP device to help him get floors? The human and the stable, where it wasn't even? Yeah, when he wasn't vomiting And like Val solving, he was, like, totally, like stable. And it was really interesting that, you know, he had no SBC flow and had, like, spc syndrome. And I was mostly worried about that, you know, like a cute sec syndrome. And then, you know, when he compromised I v c flow by vomiting. Uh, that's when, like, things about you know, what we were really actually thinking about really definitively dealing with the problem, which is the human toma that was either gonna be surgical or some maybe SETI guided per Catania's drainage. So that's what we have been talking about in the moment, I think practically, you know, getting things around through the heart and stuff. We're gonna be bothering me a bit. And I was worried about re instrument ing him on compromising that obviously flow a t least even temporarily or messing around with things. Yeah, there's case reports of endoscopic guidance of push cabbage perf something, knowing your cross sectional, interventional radiology colleagues and having to help in these cases and then sometimes surgeries, and you didn't. So they're sort of panoply of things that happened. But I think you know, your is a nice example that, you know, sometimes just to take your time, they settle down. So that's great. Well, you know, when talking with the surgeons, he was prepared for a right thoracotomy approach. So we had planned that off of the cat scan. Uh, because he didn't he you know, obviously a prior stra Nana. Me he didn't want after Russia in there on, he thought he could get it. You know that e think this case kind of highlights the value of having colleagues that have different backgrounds and experiences. And so, you know, obviously having a surgical colleague that can go in and definitively deal with the hematoma is helpful. But but don't forget your IR colleagues. They have a lot of tips and tricks and tools. You can really learn a lot from them. And, you know, there's there's things that I used very rarely in the in the coronary world that you know, such as coils or solitary devices or things like that that that iron docks really have a great tool kit. And oftentimes could be very, very creative and dealing with these These some of these complex, uh, complications, e frankly, I could envision these guys, you know, we're in the cat scanner. He's like advancing a needle cracking jokes. You know, they do stuff like that, you know, coming back. Yeah, I'm in advance a little bit more and then, like being in the hematoma and then just draining it. You know, that's a couple more things. Just about post cabbage purpose. You know, obviously the CTO world Those were things that were very afraid of the times where they really bite you and get you into trouble is when the perforations obviously you showed one of the vein graft. But the times where the really most complicated or when they're in the a V group Arcia in the a V group, sir complex, because those are the ones that tend to bleed and create a hematoma that then compresses either the left atrium of the right atrium. Oftentimes, you know. Wait, I talked a little bit about epic cardio, uh, collateral perforations. And, you know, the one epic cardio collaterals that I tend to like to use our epic cardio collaterals that are on the L V and a post cabbage patient. Because those oftentimes, even if you put a little hole in our clinically insignificant and so, uh, perforations on the on the LV, like from a pistol om or ah, diagonal branch, those oftentimes do just fine. It's really the ones that are closer to the atria that gets you into trouble. That's great. Well, there may be a few more comments, but I just wanted Thio Thank Jen Mats in the team from Bio Tronic for sponsoring this tonight. I think having a chance to share these cases and work through some of the difficulties and and have a chance to kind of go through algorithms before we see these problems is transformative in terms of preparation and potentially getting, you know, better outcomes for patients that have this. And so it's always nice to get together with the TV and share cases we appreciate by Trump. Keep forgiveness venue to do that. And I think you know, some of the complication courses that you know we're part of. Its faculty and colleagues like Bill Lombardi run nationally, go through scenarios like purpose and other uncommon things. And I think there's some of the best learning we have in interventional cardiology because they prepare you for uncommon events, which can be dire nature. And so, having algorithms and thinking through how to deal the problem before you see it at a time certainly lessen stress and potential improved outcomes for patients. So great job tonight, gentlemen, I appreciate the awesome cases brought. Some of them are new, especially yours doing you've never seen before. So, uh, I'd like to say, keep up the good work, but I think probably less less less. Father, we have processes like this, probably better for everybody. And I might have a little less great here if I don't see these as much. Yeah, well, thanks for everyone's time. We appreciate the audience for tuning in and for their great questions. And, uh, Jennifer is going to send around requests for other topics which might be covered by faculty like us or colleagues as part of the Siri's. So thanks very much you appreciate. I hope everyone has a great night. Take care. So everybody
