Dan Memmini

@TWilsonMD @BaoGTran @realarainmd @DrJayMohan @KPujdak @DrRajeshG1 @SrihariNaiduMD @MichaelMegalyMD @djc795 @jl35wilsonMD @rational_doc I have been looking at angios since 1987 and have never seen this before. Very cool.

@realarainmd @DrJayMohan @KPujdak @DrRajeshG1 @SrihariNaiduMD @MichaelMegalyMD @djc795 @jl35wilsonMD @rational_doc how many times have you seen this variant? 1,0,0 LAD-RCA lesion!

@realarainmd I have often found short CTOs to be some of the most frustrating and time consuming cases. They trick you into into thinking they are one thing when actually they are something else entirely. Great job going through your algorithm to get success for this pt.

Beware of the Short CTO! 78 M with new onset angina for 8 mths. PET showed a large area of ischemia in the lat. wall. The CTO here is VERY short. Seemingly favorable for any strategy. It was also soft - we crossed the cap with a Sion. But it took us almost an hour to cross!

@evandrofilhobr Wonderful job. As usual.

LAD CTO PCI, calcified CTO body and tortuous micro-channel. Good case of wire escalation and negotiation.

@msjluu Rather be lucky than good.

We didn’t even deserve to win

@realarainmd A less gracious person would say “I told you so”. I will just say congrats!!

Do you remember when you joined X? I do! #MyXAnniversary Here is a fun fact: I joined X exactly one year ago while waiting to hand out Halloween candy! 🤩 Little did I know how much it would become a part of my (almost) daily life.😳😂

@realarainmd @jedicath @evandrofilhobr @mornei2011 @DrBIqbal @crfheart I agree. When you first shared this technique with me, I have to admit, I thought there’s no way this is a good idea. I was so wrong.

It’s definitely energizing! 😅 I was honored to share the podium with people I admire, and who have taught me. The visceral reaction is understandable. But, some of the things that annoy us at first, become indispensable later in life. Dare I say wasabi and sushi for me?! 🍣 🍱 😋

#HDR polarizing in the CTO community -We need to learn to interpret the stains -this a skill that can be learnt -some operators have a visceral reaction to it @realarainmd @evandrofilhobr @mornei2011 @DrBIqbal #TCT2025 @crfheart

@jedicath @realarainmd @AnjaKsnes @evandrofilhobr @mornei2011 Very interesting concept. It would certainly reduce case time, radiation dose, contrast, and possibly equipment. Can’t wait to see how this plays out.

@realarainmd @AnjaKsnes @evandrofilhobr @mornei2011 It is a continuous workflow. I will present a case of HDR X 2 followed by STAR and investment, poor distal vessel. Relook at 5 weeks showed larger distal vessel and a great result. Important patient was now free of symptoms.

Investment for higher returns. #TCT2025 @AnjaKsnes @evandrofilhobr @mornei2011 @realarainmd #CTO

@aspergian1 Congrats!!

Congrats

@evandrofilhobr 2) Careful planning is very important. I also agree there is nothing like seeing a pt who has suffered for years, regain their lifestyle after the successful procedure. Keep up the great work!!

Sometimes we must take calculated risks to achieve good outcome — as long as every step is carefully planned. 🔹 Proximal LAD CTO opened retrogradely through patent LIMA. 🔹 Distal LAD collaterals used for RCA CTO retrograde recanalization. When there’s no easy way, build one!

@evandrofilhobr 1) Evandro, as always you have demonstrated the how and the why of CTO-PCI. A wonderful case and I loved how you “tested” the pt’s tolerance of having their LIMA partially occluded.

I cancelled my dashpass as well.

If you would like to keep waiting we’ll issue a $10 credit. What a joke. Customer service is dead. I am taking my business (several orders a week) to Uber Eats.

Door Dash sucks!!! @DoorDash I was a loyal customer for over 5 years. That ended tonight. I placed an order and delivery time kept getting pushed back. After 2 hours I canceled the order. Door Dash’s response: Sorry. This is not our normal level of service.

@msjluu You’re right. That’s exactly the same thing!!

Me, to my husband, about my engagement ring #newyearnewring

@realarainmd Outstanding tutorial as always! I get asked about you and #hdr every week. Keep up the good work.

4/ There is a lot more to say. But I will end by suggesting that the MC tip injection is an invaluable maneuver for the #CTOPCI operator! I inject early and I inject often! 🤩 We now have at least 4 types of intra CTO injections: #HDR injection, contemporary Carlino, passive Carlino, and the pullback MC injection. How many of these are you familiar with? Hope you enjoyed the case and I look forward to your comments! 🙏🏼

A Hard Nut To Crack - A #CTOPCI Saga! Here is the #HDR case from last week - as promised. Our pt. is a 70 y/o woman with an LAD CTO, sig. DOE despite OMT, + AW ischemia. There are several tips, tricks, and hacks here - for all operators. Happy viewing!

@realarainmd @stefan_harb I think that is an excellent idea. It gives you a chance to try #HDR without cutting off any other options.

The First Touch #contrast1st Approach The use of contrast for #CTOPCI has learning curve → successful #HDR requires several unique skills: 👉🏼 Optimal cap puncture 👉🏼 A gentle (or ‘shy’) microinjection - as @stefan_harb says 👉🏼 Stain analysis 👉🏼 Mindful and deliberate wiring Experienced operators often perform several injections per crossing - but that may not be everyone’s style. The staining of the vessel can be disconcerting! 👉🏼 I believe a ‘1st touch #contrast1st’ approach may be suitable for new users of the technique. 👉🏼 This means one injection followed by standard wire based approaches - including retro. What do you think? How did you become comfortable with #HDR and #CASE?

@realarainmd @JuradoRomanAl @JMonteroMD @RevEspCardiol @CtoEuro @Hemodin_LaPaz @shci_sec @secardiologia @MLCTOAcademy @JovenesSec Very well stated.

Interesting perspective Alfonso - which I obtained with the assistance of ChatGPT’s translation abilities. 😀🙏🏼 CTO trials have been difficult to conduct (and interpret) for several different reasons. IMHO, the three biggest hurdles have been: 1) inconsistent use of reliable, objective measures of ischemic burden associated with any CTO 2) exclusion of exertional dyspnea (by far the most prevalent symptom) as an indication for #CTOPCI, and 3) emphasis on ‘hard’ clinical outcomes (MI and death) alone in many studies. These factors have led to unrealistic definitions (and expectations) of the clinical value of #CTOPCI. In my practice, I offer #CTOPCI for a very simple reason - alleviate symptomatic ischemia as much as possible. I don’t do it to treat a stress test, relieve a particular symptom, improve the EF, or prolong life. Yes, all of these are welcome benefits of #CTOPCI, but often not guaranteed 👉🏼 which is why the outcomes, as currently measured in most studies, can be so disappointing.

Prognostic benefit of percutaneous revascularization for chronic total coronary occlusions. Paradoxes and contradictions in an endless debate. 🧐🧐 @JMonteroMD @RevEspCardiol @CtoEuro @Hemodin_LaPaz @shci_sec @secardiologia @MLCTOAcademy @JovenesSec #CTO kwnsfk27.r.eu-west-1.awstrack.me/L0/https:%2F%2…

@realarainmd @aspergian1 @TWilsonMD @jedicath @kerrigjl @kevinjamescroce @jl35wilsonMD @jbspadoni @mornei2011 @Hragy @slingsnack @EM_RESUS @DrIHHashmi1 @DrBIqbal I’ve seen that work many times. It’s a good option when you have limited choices.

Actually that is a great option! You won’t be able to get the struts circumferentially - only along the outer rim, but it is all about ‘cracking the ring’ and then stretching it out. An unproven (and perhaps fantastical) advantage of laser + contrast in my mind is that it heats the metal making it more ‘mallelable’(?) in a way that IVL cannot. Thoughts from the ad hoc Stent Ablation Panel? 😀

@jedicath @kerrigjl @kevinjamescroce @jl35wilsonMD @jbspadoni @mornei2011 @Hragy @aspergian1 @slingsnack @EM_RESUS @DrIHHashmi1 @DrBIqbal @realarainmd 60s M, STEMI 🚨 from OSH. “LAD STEMI” per ER doc, severe CP on Nitro. EKG reviewed on arrival. Mechanism of ISR? Treatment?

@aspergian1 @TWilsonMD @jedicath @kerrigjl @kevinjamescroce @jl35wilsonMD @jbspadoni @mornei2011 @Hragy @slingsnack @EM_RESUS @DrIHHashmi1 @DrBIqbal @realarainmd I was wondering about that myself. Given what has already happened, and the relatively poor prognosis, would a LIMA be the best strategy?

@TWilsonMD @jedicath @kerrigjl @kevinjamescroce @jl35wilsonMD @jbspadoni @mornei2011 @Hragy @slingsnack @EM_RESUS @DrIHHashmi1 @DrBIqbal @realarainmd Nice case! Imaging will diagnose it. Treatment is difficult! It looks like possibly 2 layers of stents. Can't/shouldn't/won't put a third in. If stent fracture, restenosis will be very high w or w/o DEB. Consider LIMA➡️LAD. If not fxr, IVUS optimize PTCA & finish w DEB?

@MichaelMegalyMD @TWilsonMD @jbspadoni @UICcardfellows @AdhirShroff @mividovich @spiritus_bah @KhalilIbrahimMD @evandrofilhobr @realarainmd @SarojNeupaneMD @Babar_Basir @Laserrman @LAzzaliniMD @Aspe @stefan_harb Agreed.

@DMemmini @TWilsonMD @jbspadoni @UICcardfellows @AdhirShroff @mividovich @spiritus_bah @KhalilIbrahimMD @evandrofilhobr @realarainmd @SarojNeupaneMD @Babar_Basir @Laserrman @LAzzaliniMD @Aspe @stefan_harb CTA should be done in an experienced center and honestly should be interpreted by the operator not any reader. We gain tons of info from CTA in our program

In the spirit of #CTOConnect2025, how would you approach this ambiguous Lcx? @UICcardfellows @AdhirShroff @mividovich @spiritus_bah @KhalilIbrahimMD @evandrofilhobr @realarainmd @TWilsonMD @SarojNeupaneMD @Babar_Basir @Laserrman @LAzzaliniMD @aspe @MichaelMegalyMD @stefan_harb