Maximilian Will

6/ A Very Modern PCI, Or When The LIMA Is Not An Option! 70 M with a dual LAD system and multiple CTOs. Full case in the thread above. @agtruesdell @DocSavageTJU @rajivxgulati @ziadalinyc @nyalborgesmd @richardbogle @swissCTO @SripalBangalore @azeemlatib @jedicath @RinfretStephane @KambisMashayek1 @evandrofilhobr @Hragy @aymanka @JosipABorovac @maxFwill @Laserrman @mmamas1973 @mirvatalasnag @SarahFairley7 @stefan_harb @aspergian1 @saraceciliamtz @DrIHHashmi1 @TariqShafiDr @abadkhan2002 @ihtanboga @MichaelMegalyMD @drrashid05 @PurumittalDr @NishithChandra @AnkurKalraMD @SaidAshrafMD

Here is my algorithm: 1) Vasodilator therapy (if hemodynamic allow and pull) 2) Pull Rotawire. This works very effectively, 90% of times. It is frequently overlooked. The 0.014 tip works as a great way to bring back the stuck burr. Make sure wire is free with brake off for maximal efficiency. Pulling the driveshaft is less effective, as it is made of 3 coiled wires which gives some elasticity to the driveshaft. 3) If burr is free beyond lesion, can use short dynaglide runs and then pull. Prinicple is that dynamic friction is lower. Don’t overdo this and also with skipping rope technique, there is risk of driveshaft breakage and burr loss due to torsional forces with a fix s immobile burr! 4) Cut driveshaft and remove teflon sheath 5) Deliver GE over driveshaft to the burr and pull. 6) Intimal/subintimal wire and ballooning to dislodge burr and pull. 7) Re-deliver GE over driveshaft and pull. 8) Obtain second access and adding a ping-pong guide. Remember a ping-pong guide is not required in most cases. Once Teflon sheath is removed, a 6F guide can accommodate: Driveshaft + coronary wire, Driveshaft + Caravel microcatheter, Driveshaft + Corsair/Turnpike LP microcatheters, Driveshaft + 2.5-4mm balloons 9) Combine subintimal ballooning and GE over driveshaft and pull. Only these maneuvers requires ping-pong guides. 10) Call surgeons.

@realarainmd @swissCTO Having a GEC in Place offers several advantages: support, (partial) sealing of the perforation, the ability to inchworm, precise identification of the exit point, and avoidance of prolonged ischemia from balloon occlusion.

Why RIP works. And why you should try this at home today! Here are 3 slides by @swissCTO, and one video from our lab. You don’t need to be a CTO operator to try this. It works bec. once the shaft is disrupted, contrast leaves the balloon slowly maintaining tamponade. After the GEC is loaded, the wire introducer tool becomes the new hub of the 🎈shaft!

@realarainmd This is an excellent indication for the RIP technique! mdpi.com/2077-0383/15/8…