Jack Hall

@TWilsonMD @realarainmd @DrJayMohan @KPujdak @DrRajeshG1 @SrihariNaiduMD @MichaelMegalyMD @djc795 @jl35wilsonMD @rational_doc 1st

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

Well said Mike!

@jtsaxon Sealed

@mirvatalasnag @TCTConference @TCTMD @djc795 @tavrkapadia @GilbertTangMD @MarwanSaadMD @kimskeldingmd @nickaram This discussion has been excellent, @mirvatalasnag ! I have had multiple conversations with operators about this case. The initial strategy depends on crossability. Can IVUS, NC 🎈, CB 🎈, IVL cross? Build a strong foundation i.e. coaxial guide and supportive wire. Rota will go

IC community: how would u treat this heavily calcified LAD lesion in this octogenarian? What’s the current evidence for periprocedural coronary revasc in patients planned for TAVI? @TCTConference @TCTMD @djc795 @tavrkapadia @GilbertTangMD @MarwanSaadMD @kimskeldingmd @nickaram

Alright kids, brush your teeth! Time to get ready for bed! But it’s still daylight outside. :( I know, but it’s bed time. What’s the point of having more daylight if we can’t even stay up to enjoy it? Sorry, you’ve got to go bed so we can all wake up in the dark tomorrow.

Great thread Mike, thanks for sharing these insights. A few additional thoughts from my experience: 1️⃣ Epicardial collaterals are often rich in small invisible side branches. As you mentioned, careful selective injection and meticulous observation of the main channel trajectory are critical before attempting to cross. 2️⃣ Larger epicardial channels that are very tortuous can sometimes be crossed using the “J-wire” technique, which may help the wire follow the “main” lumen of the collateral rather than diving into small branches. 3️⃣ I am personally a big Sion Black fan. In Brazil we do not have access to the Suoh 03, so I ended up developing most of my epicardial skills using Sion Black. 4️⃣ There is also a Chinese wire (APT Anyreach P/C 0.3 g – polymeric or coil, neon-polymeric version) that I have used a few times. It seems to have slightly more body/support than the Suoh 03, which can be helpful in some situations. 5️⃣ In terms of microcatheters, sometimes the Finecross performs better than the Caravel and vice versa, so having both available can be very helpful depending on the channel characteristics. 6️⃣ From personal experience, in very high-risk epicardial channels, I sometimes consider pre-emptive coiling. More than once I have encountered collateral injury only during the final check after successful CTO recanalization. I completely agree with your technique of leaving microcatheters on both sides and removing the wire before checking. I even had an anecdotal case of delayed bleeding from an epicardial collateral despite completing the procedure retrogradely through that channel with a seemingly normal final angiographic check. Congratulations again Mike for this excellent review!

(10) Finally, epicardial channels are risky and their use has rightfuly derceased over the years with the safer investment techniques and intentional 2-stage procedures. However, mastering the options in the toolbox is important for the complete experience we provide to our patients.

@mirvatalasnag @TCTConference @TCTMD @djc795 @tavrkapadia @GilbertTangMD @MarwanSaadMD @kimskeldingmd @nickaram RotaShock followed by DES LM-LAD with POT. IVUS of course.

@TWilsonMD @drrkhyd @Hragy Distal edge dissection in diffuse disease segment just proximal to a stented ostial branch. Tough call how to treat. Even with short stent there is going to be a lot of overlap and will somehow engage the bifurcation. Sadly I think I drop a longer stent, jail the branch, & POT

@drrkhyd @Hragy Distal Edge dissection in diseased segment. Probably less than 2-3mm in length but encroaching on ostial SB. Normal I would leave it. But w SB involved would probably cover/stent it hopefully finding a healthy LZ.

Can you read this ivus finding ? What will u do ?

@nadig_cardio @ShariqShamimMD Leave it, IMO. This is a data free zone. Anecdotally, this is successful without increased risk of SAT. Perhaps, with good image guided PTCA followed by DCB will be a successful strategy. It is unknown which is better for the patient short and long term

@aspergian1 @ShariqShamimMD So if there s malapposition fo nearly 3 mm at the aneurysm we just leave it?

These kind of lesions always bother me Tight stenosis filled by ecatsia Ivus in non ecatsia segment 3.3 mm In aneurysm segment 6.3 How would I treat such lesions #cardiotwitter #cardioX 1 - 2 stents of different dm ( like 3 prox and 5 distal) 2 - single des with pot in ecatsia zone 3 DCB 4 stent graft (Will share my results later )

Salman, a superb discussion. I certainly agree.

@BarberoUmberto @ElixirMed @skat_ct @AgostoniPF I would like to see pre & post Lithix IVUS. Obviously a head to head with imaging of Lithix vs IVL will be needed

Severely tortuous, heavily calcified RCA successfully managed with a 🎈-based strategy with the @ElixirMed Lithix balloon allowed safe, efficient PCI with optimal expansion and final result. Nice case made reality together with Delio Tedeschi and @skat_ct live at #CTOhighlights

@ShariqShamimMD @nadig_cardio Ditto, Shariq!

@nadig_cardio One DES from OM to OM. Reference size of normal vessel. No POT in between.

Hey look! @nejm moved my writing to a new spot. Here's the first post, a rant about a particularly annoying requirement for those of us in work in hospitals (link below) 1/3

A new study shows one antigen, CD70, is expressed on 100% of cancer cells in some solid tumors but at such low levels it can't normally be detected. Researchers have created Immune cells that detect extremely low levels of the target antigen & have eliminated kidney, ovarian and pancreatic tumors in mice which has been near impossible using conventional CAR-T immunotherapies. Unlike blood cancers, solid tumors are hard to treat using CAR T cells because the tumors are dense, difficult to access and lack a common antigen target on every cell. Nature summary nature.com/articles/d4158… Original article science.org/doi/10.1126/sc…

👆🏼 Poll question above! @rajivxgulati @aymanka @agtruesdell @stefan_harb @SripalBangalore @RinfretStephane @rickytiago @evandrofilhobr @Hragy @DocSavageTJU @djc795 @mirvatalasnag @SanjogKalra @mmamas1973 @jedicath @SarahFairley7 @saraceciliamtz @ShariqShamimMD @DrDarshanDoshi @NishithChandra @aspergian1 @SaidAshrafMD @MichaelMegalyMD @mornei2011 @DrIHHashmi1 @TariqShafiDr @abadkhan2002 @gbiondizoccai @TWilsonMD @jl35wilsonMD

Fielder XT

HDR

Recent HDR CTO PCI of LAD. This how you like your wire in this case a Fielder XT with God's bend, traverse the CTO after HDR