#  @realarainmd Salman Arain Salman Arain posts on X about lcx, hdr, lima, in the the most. They currently have [-----] followers and [---] posts still getting attention that total [-----] engagements in the last [--] hours. ### Engagements: [-----] [#](/creator/twitter::1852142895010086912/interactions)  - [--] Week [------] +11,934% - [--] Month [------] -51% - [--] Months [-------] +194% - [--] Year [-------] +70% ### Mentions: [--] [#](/creator/twitter::1852142895010086912/posts_active)  - [--] Month [--] -33% - [--] Months [---] +126% - [--] Year [---] +217% ### Followers: [-----] [#](/creator/twitter::1852142895010086912/followers)  - [--] Week [-----] +0.94% - [--] Month [-----] +2.90% - [--] Months [-----] +33% - [--] Year [-----] +108% ### CreatorRank: [-------] [#](/creator/twitter::1852142895010086912/influencer_rank)  ### Social Influence **Social category influence** [cryptocurrencies](/list/cryptocurrencies) [travel destinations](/list/travel-destinations) [finance](/list/finance) [stocks](/list/stocks) [technology brands](/list/technology-brands) [currencies](/list/currencies) [social networks](/list/social-networks) [countries](/list/countries) [fashion brands](/list/fashion-brands) [musicians](/list/musicians) **Social topic influence** [lcx](/topic/lcx) #23, [hdr](/topic/hdr), [lima](/topic/lima), [in the](/topic/in-the), [cto](/topic/cto), [injection](/topic/injection), [flow](/topic/flow), [yo](/topic/yo), [retro](/topic/retro), [prep](/topic/prep) **Top accounts mentioned or mentioned by** [@evandrofilhobr](/creator/undefined) [@hragy](/creator/undefined) [@laserrman](/creator/undefined) [@mmamas1973](/creator/undefined) [@jedicath](/creator/undefined) [@sripalbangalore](/creator/undefined) [@mirvatalasnag](/creator/undefined) [@drbiqbal](/creator/undefined) [@aspergian1](/creator/undefined) [@abadkhan2002](/creator/undefined) [@michaelmegalymd](/creator/undefined) [@shariqshamimmd](/creator/undefined) [@lazzalinimd](/creator/undefined) [@stefanharb](/creator/undefined) [@drihhashmi1](/creator/undefined) [@agtruesdell](/creator/undefined) [@jbspadoni](/creator/undefined) [@twilsonmd](/creator/undefined) [@mornei2011](/creator/undefined) [@jl35wilsonmd](/creator/undefined) **Top assets mentioned** [LCX (LCX)](/topic/lcx) [Calcium (CAL)](/topic/calcium) [Medtronic PLC (MDT)](/topic/medtronic) ### Top Social Posts Top posts by engagements in the last [--] hours "There are several other ways to resolve plaque ambiguity - I have found this to be the quickest one. Another advantage is that I am using this exercise to train myself for 3D wiring. Its a win-win End of lesson 🙏🏼 #IVUS #CTOPCI #ADR #AWE #TDADR #HDR #BSCI" [X Link](https://x.com/realarainmd/status/1852591156632170705) 2024-11-02T05:58Z [--] followers, [---] engagements "A Stain Is Not (Just) A Stain #HDR #contrast1st #HDRanalysis #HDRFAQs #CTOPCI Here what we look for in a contrast microinjection stain: - CTO penetration distance - Width ( = or than ref. vessel) - Intensity - Leading edge (sharp or fuzzy) - Side branches (the best sign) - Persistence - Growth with wire insertion into the MC This is the alphabet of the language of contrast (as Dr. Carlino calls it) Lets learn to speak this new language together" [X Link](https://x.com/realarainmd/status/1857071543118897346) 2024-11-14T14:42Z [---] followers, [---] engagements "How many #HDR interventions does it take to become a successful #contrast1st operator 🧐 Just one 💧🙌🏼 It is all about the journey not the destination. Many CTO and CHIP operators have already been there without knowing it #HDR #contrast1st #CTOPCI #mindfulPCI" [X Link](https://x.com/realarainmd/status/1858508153169830097) 2024-11-18T13:50Z [---] followers, [---] engagements "I may be the outlier here but the immediate issue is deranged hemodynamics. So a RHC is essential followed by viability. I opted for LHC just because it gives me the opportunity to measure hemodynamics. Haha. Sure info about the cors too. Re: nuclear stress in someone with an EF of 15% not likely to be helpful" [X Link](https://x.com/realarainmd/status/1858588207392149550) 2024-11-18T19:08Z [---] followers, [---] engagements "Great case Bilal Great use of your epic surfing skills. Presence of collaterals implies high grade stenosis at culprit lesion (pre-MI) = probable viability Cant speak to #TDADR but we use MC injections for old thrombus +/- micro (IP) tortuosities #HDR works for clot too BTW I love this picture Need this software in every lab. 😂" [X Link](https://x.com/realarainmd/status/1858727818336608378) 2024-11-19T04:23Z [---] followers, [---] engagements "💧#HDRanalysis 🧐 Case [---] Here is a blast from the past - a case from 10/2022 before #HDR was a thing. Lets call it an #HDR Classic 📽 First the clip then the analysis #HDR #contrast1st #CTOPCI #HDRFAQs" [X Link](https://x.com/realarainmd/status/1858753925790175248) 2024-11-19T06:07Z [---] followers, [----] engagements "This is an LAD CTO in a patient with a low EF. There is a nice cap a relatively straight course a diseased target and IP calcium. This was my #HDR exploratory phase - we probe the cap with an XT" [X Link](https://x.com/realarainmd/status/1858753927623151725) 2024-11-19T06:07Z [---] followers, [--] engagements "Knuckles are safe contrast (delivered appropriately) is SAFER Here is beautiful video of a traveling knuckle✈👊🏼 courtesy of @AIU_Medical Note the wire track - and the behavior of the knuckle. Now compare that to the plaque disruption by contrast injection. See what I mean At #VIVA2024 CROSSLEAD showcased its precise maneuverability for navigating tortuous CLI vessels to reduce radiation & contrast media. Interested Sign up for a hands-on demo & wire training here: https://t.co/FBCsvkDVKP #PeripheralVascularCare #vasctwitter #Irad https://t.co/PUqeLCUPHr At #VIVA2024 CROSSLEAD showcased its" [X Link](https://x.com/realarainmd/status/1858753939866304680) 2024-11-19T06:07Z [----] followers, [---] engagements "Mid ✈ Musings Tip injections are an integral part of #HDR. They are also useful in non-CTO #PCI Here is recent case (sorry stills only) What wire + tip shape do you start with A tip injection reveals the anatomy🧐 👉🏼 XT + Culotte for the win🙌🏼" [X Link](https://x.com/realarainmd/status/1858965528964198767) 2024-11-19T20:08Z [---] followers, [----] engagements "#HDR is happening💧🙌🏼 The response to #HDR has been nothing less than spectacular. Here is a partial list of places where #HDR is changing #CTOPCI Milan (birthplace of #HDR) Houston (#HDR 🌎 capital) 😀 Minneapolis Karachi Lahore Islamabad Sapporo (2nd city of #HDR) New Delhi Oradea Romania Maceio Brazil Chicago Coming soon to a cath lab near you 🤩" [X Link](https://x.com/realarainmd/status/1859106393363505618) 2024-11-20T05:27Z [---] followers, [----] engagements "If you are new to #HDR you can catch up by searching for the hashtags #HDR - cases discussions tips #contrast1st - more #HDR talk and cases #HDRanalysis - analysis of #HDR cases from around the 🌎 #HDRFAQs - answers to your questions Happy #HDR hunting💧🧐" [X Link](https://x.com/realarainmd/status/1859185112308461842) 2024-11-20T10:40Z [---] followers, [---] engagements "@Cryptoneday HydroDynamic contrast Recanalization (HDR): Description of a new crossing technique for coronary chronic total occlusions - PubMed https://pubmed.ncbi.nlm.nih.gov/39327837/ https://pubmed.ncbi.nlm.nih.gov/39327837/" [X Link](https://x.com/realarainmd/status/1859405723567894922) 2024-11-21T01:17Z [---] followers, [--] engagements "You can use #HDR for any CTO as long as you can puncture the proximal cap and park an MC. The key is to LEAD with contrast = #contrast1st. The injection should be within [--] mm of the angiographic PC - EVEN if the wire is moving freely within the CTO 👉🏼 Rationale: 1) Wires (e.g. Gaia family) can breach the IP/EP boundary without much tactile feedback. 2) A wire track cannot be undone 🔑 #HDR only works if the contrast is delivered IP AND has the ability to penetrate the plaque" [X Link](https://x.com/realarainmd/status/1859409579106537857) 2024-11-21T01:32Z [---] followers, [---] engagements "Best cases to start include a combination of the following factors: - Well defined PC - Short length - Relatively straight - Minimal calcium - In-stent occlusion - Good retro bailout options Try #HDR if you find a CTO with [--] or more of the features noted above. #HDRFAQs #contrast1st #HDR" [X Link](https://x.com/realarainmd/status/1859410743080227254) 2024-11-21T01:37Z [---] followers, [---] engagements "Stuck Between A Rock A Rock A Rock And A Hard Place (Prelude to a nice hack) 🧵 #CTOPCI tools/skills translate nicely to non-CTO PCI. Here is a sticky situation from earlier today [--] y/o 👨 with failed SVG to PDA. Failed PCI at OSH. You can see where the title comes from" [X Link](https://x.com/anyuser/status/1859489944328147220) 2024-11-21T06:52Z [----] followers, 12.1K engagements "@evandrofilhobr @SyedYNaqvi1 @Laserrman @MauroCarlino3 @mornei2011 @DrBillLombardi @agtruesdell @KambisMashayek1 @stefan_harb @RinfretStephane @LAzzaliniMD Exactly Which is why the no tip XT is the 🔑 here If the tip catches - IP micro tortuosity or EP architecture If it crosses WITHOUT bending - your are IP Like an secret service mission Throw the contrast first send in your scouts (i.e. XT) then the rest of the team 🫡😀" [X Link](https://x.com/realarainmd/status/1859927617669107745) 2024-11-22T11:51Z [---] followers, [---] engagements "Mid ✈ Musings This is a post I have been trying to write for [--] years The TIP IN Technique - why it works almost EVERY time 🤔 Lets start by looking at a recent still frame. You see a familiar friend the NO TIP XT. You also see two MCs in the guide" [X Link](https://x.com/anyuser/status/1860426999447289987) 2024-11-23T20:55Z [----] followers, 12.2K engagements "Looking at this we can predict where the wire will enter the MC.👉🏼👈🏼 Theoretically it is the SAME point regardless of which direction the wire is coming from (green dot) - as long as the inner curves are smooth. You can change this by pushing or pulling on the guide 😲" [X Link](https://x.com/realarainmd/status/1860427021949845821) 2024-11-23T20:55Z [---] followers, [---] engagements "💧#HDRanalysis 🧐 Case [---] Once you recognize an #HDR stain you start to notice other subtleties This case highlights that an more. [--] year 👴 with CCS III angina - improved but not resolved with 💊 Baseline is [--] m ago. This is an evolving CTO Intervention to follow 🧵" [X Link](https://x.com/realarainmd/status/1861168045798142093) 2024-11-25T22:00Z [---] followers, [----] engagements "This is a common problem with RCA CTOs in the elderly 👉🏼 Widened root 👉🏼 Ostial disease 👉🏼 Low + anterior take off We get some clues about the CTO - calcium + thrombus + ISR. A spicy gumbo 🦐" [X Link](https://x.com/realarainmd/status/1861168101368438823) 2024-11-25T22:00Z [---] followers, [---] engagements "This is the 🌟moment - the #HDR There is so much going on I have analyzed it in two images. But the 🔑 message here is this: #HDR can offer a solution for POOR guide support 👉🏼 Wires can push guides back (and out) - contrast can NOT 🤔" [X Link](https://x.com/realarainmd/status/1861168156632637884) 2024-11-25T22:00Z [---] followers, [---] engagements "Notice there is contrast OUT side the stent - the asterisk. 👉🏼 Contrast tells you the stent is UNDER sized before even crossing 😲 The crossing itself is the closest #CTOPCI is nothing short of poetry in motion 😍 No guide pushback - at ALL" [X Link](https://x.com/realarainmd/status/1861168212546855177) 2024-11-25T22:00Z [---] followers, [---] engagements "Here is the IVUS run. So many findings that we could have predicted [--]. Recanalized thrombus (explains change in baseline RCA) [--]. Calcium [--]. Remodeled vessel (note the wide stain) [--]. Undersized stent [--]. Possible nodule at prox stent edge (based on #HDR + wire movement)" [X Link](https://x.com/realarainmd/status/1861168283665473757) 2024-11-25T22:01Z [---] followers, [---] engagements "Seen at the MUJI Ginza store in Tokyo earlier today It is untitled (and I am not the artist) but I Dream Of Contrast seems to be an appropriate title. Happy Thanksgiving #HDR #contrast1st #CTOPCI #MUJI" [X Link](https://x.com/realarainmd/status/1862396018723307637) 2024-11-29T07:19Z [---] followers, [--] engagements "Seen at the MUJI Ginza store in Tokyo earlier today It is untitled (and I am not the artist) but I Dream Of Contrast Modulation seems to be an appropriate title. Happy Thanksgiving #HDR #contrast1st #CTOPCI #MUJI" [X Link](https://x.com/realarainmd/status/1862400478480650243) 2024-11-29T07:37Z [---] followers, [---] engagements "💧 #HDRanalysis 🧐 Case [---] - Return To Work Edition This is a case from today. A colleague with history of LAD PCI (2005 2011) with unstable angina. The case is presented Sapporo style. 🧵 TPLP+G2 for cap puncture #HDR XT crosses into TL IVL JSBT for D2 protection #HDR #HDRanalysis #contrast1st #CTOPCI #singleaccess #JSBT" [X Link](https://x.com/anyuser/status/1863833942660419658) 2024-12-03T06:33Z [----] followers, [----] engagements "Nice What is your approach to nodular calcium I have settled on a divide and conquer strategy - rota followed by IVL or aggressive cutting 🎈PTA. Images: baseline post rota post CBA (18 atm) post DES I ❤ to see luminal gain (MSA) as well as resolution of the lumen eccentricity. What is your style @evandrofilhobr @Laserrman @jbspadoni @ziadalinyc @calcbreaker @rotamonster @DrBIqbal @jbspadoni @rickytiago @agtruesdell @TWilsonMD @mirvatalasnag @mmamas1973 @rajivxgulati @DMemmini @AgostoniPF @stefan_harb" [X Link](https://x.com/realarainmd/status/1864313087362310637) 2024-12-04T14:17Z [---] followers, [---] engagements "That is the worst kknd of calcium - malignant The stent breaker Ca. I think rota makes IVL more effective in nodular calcium. The extra $ and time is worth it. My rota technique has landed on FFS (pun unintended 😂: fast fast slow. [---] [---] [---] IVL" [X Link](https://x.com/realarainmd/status/1864317988628816217) 2024-12-04T14:37Z [---] followers, [---] engagements "@rotamonster @EuroInterventio @Laserrman I see. This explains why IVL performs better after rota - in my experience. Of course this may be recall bias. But you can see it in my images too (though we used cutting balloons not IVL). Pre and post rota (before any other device)" [X Link](https://x.com/realarainmd/status/1864844520665297321) 2024-12-06T01:29Z [---] followers, [---] engagements "💧 #HDRanalysis 🧐 Case [---]. - The Persistence of Stains This one of my all time favorite cases - in part because we have a complex stain pattern [--] y/o 👨 with CABG in [----] and failed SVG to RI. 🎯 is LM. TPLP+G2 puncture #HDR complex stain no tip XT blocking 🎈assisted wiring Culotte final The entire case" [X Link](https://x.com/anyuser/status/1864942695916949605) 2024-12-06T07:59Z [----] followers, [----] engagements "The conventional #CTOPCI approach would have been: dual angio AWE entry into branch #2 or #3 🤞🏼 IVUS guided wiring of other branch. ADR would have been tricky given short LM trifurcation at distal cap and angulation of RI and LCX There are several retrograde options" [X Link](https://x.com/realarainmd/status/1864942698580312517) 2024-12-06T07:59Z [---] followers, [---] engagements "And now the magic of the no tip XT - one of my first uses of the wire. The wire seems to hesitate at the trifurcation sniff out the correct path 🐕 and take off in the correct direction Haha Blocking balloon for the win" [X Link](https://x.com/realarainmd/status/1864942831263007135) 2024-12-06T07:59Z [---] followers, [---] engagements "Good question That stain forms 1st. It is in the EP space of the LAD. The wire goes deep after cap puncture - that directs contrast towards the LAD first. However contrast also tracks towards the RI/LCX via #HDR. Once it breaks through the pressure on the LAD side is relieved and the EP stain stops growing" [X Link](https://x.com/realarainmd/status/1865023782416494638) 2024-12-06T13:21Z [---] followers, [--] engagements "Good question That stain forms 1st. It is in the EP space of the LAD. The wire goes deep after cap puncture - that directs contrast towards the LAD first. However contrast also tracks towards the RI/LCX via #HDR. Once it breaks through the pressure on the LAD side is relieved and the EP stain stops growing" [X Link](https://x.com/realarainmd/status/1865024279571533843) 2024-12-06T13:23Z [---] followers, [---] engagements "💧 #HDRanalysis 🧐 Case [---] - When is #HDR not #HDR Edition This is a case of a failed #HDR sent by Dr. Hashmi - an early adopter of the method. I decided to do a full analysis because it highlight important aspects of wire behavior during #HDR. Case here discussion to follow. @realarainmd The case for HDR analysis. https://t.co/Q8h5Vs01CN @realarainmd The case for HDR analysis. https://t.co/Q8h5Vs01CN" [X Link](https://x.com/anyuser/status/1865286202963657025) 2024-12-07T06:44Z [----] followers, [----] engagements "To me this is possibly a functional CTO vs. a long subtotal occlusion. Lets start by looking as the wire. The no tip PJW is in a septal - the only way a soft straight wire can end up in this position is by navigating a thin straight channel. Thus the wire likely marks the TRUE lumen" [X Link](https://x.com/realarainmd/status/1865286208630263940) 2024-12-07T06:44Z [---] followers, [---] engagements "The principle of #HDR is contrast modulation of plaque - i.e. the injection must be INTRA plaque. Here the injection with the MC seems to be intraluminal - which is good news because the distal TL lights up So we need to decide where is the connection" [X Link](https://x.com/realarainmd/status/1865286214036730270) 2024-12-07T06:44Z [---] followers, [---] engagements "Congratulations Mauro On another successful LIVE #HDR case. We have seen [--] live #HDR cases this year (Pakistan Germany and Hungary). That is [--] more than we would have had expected in January Hopefully we will see more in [----] I would love to see the 🌎 #CTOPCI community kick the tires of #HDR 😀" [X Link](https://x.com/realarainmd/status/1865557795606843572) 2024-12-08T00:43Z [---] followers, [---] engagements "@HeartOTXHeartMD @_radikalek @DocSavageTJU @SandeepNathanMD @Radial_ICG @djc795 @nolanjimradial @SVRaoMD @mmamas1973 @EricSecemskyMD @Hragy @willsuh76 @DrSaririan @MGtberg @aspergian1 @DrWhyWho @fischman_david @aymanka @moiz_hafiz @iamritu @sarahkmels @ecgrhythms @cardiojaydoc02 @angioplastyorg @X I am amazed by the number of pretty young women who like the highly technical content on my account. Haha. And the crypto peddlers. CTO PCI is much more popular than I would have imagined. 😍" [X Link](https://x.com/realarainmd/status/1865857280232829129) 2024-12-08T20:33Z [---] followers, [---] engagements "@jbspadoni Thats a great result 👏🏼 Did the G2 go all the way across the stent And did you try #HDR at any point. This is good result - you saved several branches. Also by uncoupling the LAD and LCX the LCX should already be perfusing better. 👌🏼" [X Link](https://x.com/realarainmd/status/1866706865444331981) 2024-12-11T04:49Z [---] followers, [---] engagements "💧 #HDRanalysis 🧐 Case [---] - What is YOUR stain threshold A 🧵 Today we treated an LAD CTO with an ambiguous cap and a failing LIMA graft. There were few retro options. Ambiguous caps are always tough to treat but this was one of the top [--] toughest cases of this year 😯" [X Link](https://x.com/anyuser/status/1866724570348097601) 2024-12-11T05:59Z [----] followers, [----] engagements "⚠: The images that follow may be disturbing to some operators 😯 We used contrast modulation - several times. The protocol is simple: puncture inject pass wire repeat. The evolving stain was very helpful in redirecting our wires around it. 👉🏼 We even got the diagonal once (I didnt like the entry point)" [X Link](https://x.com/realarainmd/status/1866724778603843816) 2024-12-11T06:00Z [---] followers, [---] engagements "We finally punctured the true cap using an innovative technique: We blocked the septal with a [---] mm balloon + blocked the EP entry with the MC then used Sasuke + G3 for precision puncture into the TL. 🙌🏼 Far from being a hinderance the stain gave us a ref point 🧭" [X Link](https://x.com/realarainmd/status/1866724870253580357) 2024-12-11T06:01Z [---] followers, [---] engagements "This was an unusual CTO several reasons. 1) An unusual cap. Most caps are close to a branch - so the true cap is distal to where it initially appears to be 2) The CTO morphology is unusual - several tight twists and lucencies 3) It was a re-do - we eont know the circumstances" [X Link](https://x.com/realarainmd/status/1867129198466220532) 2024-12-12T08:47Z [---] followers, [--] engagements "The CTO body has a unique appearance. Here it is side-by-side with an LCX we fixed today. 👉🏼 The CTO has a cork screw look in places and a moth bitten appearance. 🔑 To me this implies recanalized thrombus This has implications on the crossing and #HDR as we see" [X Link](https://x.com/realarainmd/status/1867129207769137272) 2024-12-12T08:47Z [---] followers, [---] engagements "George I dont see the circumflex ostium that well. As the general rule look for the region at which the competitive flows converge. Generally the lesion is at that location. If there is no lesion then the flow is equal in both RCA and LCX and your injection is transiently reversing it" [X Link](https://x.com/realarainmd/status/1867219047193956754) 2024-12-12T14:44Z [---] followers, [---] engagements "@Laserrman @DaitaroK @calcbreaker @SKuramitsu0511 @tadano98 @rotamonster @OpolskiMP @jcspratt @KambisMashayek1 Yes just different flavors of contrast modulation. Some combinations of #contrast1st (start end inj 👉🏼 meaning) IP IP or TL 👉🏼 #HDR IP EP 👉🏼 contrast mod EP entry EP IP 👉🏼 #HDR (you see SBs) EP TL 👉🏼 contrast guided (micro) STAR EP EP 👉🏼 contrast mod EP tracking" [X Link](https://x.com/realarainmd/status/1867460289538699281) 2024-12-13T06:43Z [---] followers, [---] engagements "A very good case - this time involving a trifurcation. #HDR makes it look easy (But we know it takes skill). 👏🏼 #HDR [--] showed you the lower SB - the OM2. I may have taken that and then re-punctured to the LCX. The reason is that PTCA inside the stent can displace NIH and occlude the SB ostium (which is already behind NIH + metal). (This happened in a case I showed here - where we lost an SB. Not from #HDR but post dilation)" [X Link](https://x.com/realarainmd/status/1867795797602943348) 2024-12-14T04:56Z [---] followers, [---] engagements "💧 #HDRanalysis 🧐 Case [---] Not the bees knees but still sweeter than honey Edition A 🧵 on #HDR in tough ISOs #HDR is ideal for ISOs - indeed many of the cases discussed here have involved stents. BUT these lesions can be tough for #HDR too Case here analysis after the jump" [X Link](https://x.com/anyuser/status/1867866209707872302) 2024-12-14T09:36Z [----] followers, [----] engagements "This was another tough proposition: hard calcium ISO longish lesion blunt cap and challenging retro options Here is the sequence: TP + multiple wire for puncture (MGG2G3Hornet) #HDR no tip XT CBA + DES The MC barely crosses the prox. cap - even with support" [X Link](https://x.com/realarainmd/status/1867866293254365645) 2024-12-14T09:36Z [---] followers, [---] engagements "Lets look at the HDR. Again you see a sequence of events - stain at the MC tip (type 1) reflux into a septal EP infiltration and peri adventitial streaming My hypothesis 👉🏼 in a CTO all layers are fused thus contrast penetrates the outer layers - this is NOT a perf" [X Link](https://x.com/realarainmd/status/1867866375978467555) 2024-12-14T09:37Z [---] followers, [---] engagements "💧 #HDRanalysis 🧐 Case 022: The Dreaded Ambiguous Cap And A Simple Way To Resolve It Here is an early X-mas treat for all #HDR and #CTOPCI aficionados. The case involves a tough CTO type - the mid LAD with an ambiguous cap. The entire case is here discussion to follow" [X Link](https://x.com/anyuser/status/1869431243596804313) 2024-12-18T17:15Z [----] followers, [----] engagements "Great question - short answer it varies. Several of the non-HDR cases discussed here have involved calcium. My case in the [--] year old for example. Also @SripalBangalores stellar #HDR facilitated rota case from yesterday. Angiography cannot tell us about the Ca distribution - but CTA might. However #HDR will typically find/create a path is there is soft (modifiable) plaque. 👉🏼 My advice start with #HDR even in calcified cases. There is no downside - but you may succeed and that will save time (and perhaps side branches)" [X Link](https://x.com/realarainmd/status/1869639666908938393) 2024-12-19T07:03Z [---] followers, [--] engagements "@evandrofilhobr @AntoniousAttall Interesting. I have never actually tried that but now I am intrigued. There is a technique where folks run cutting balloons in a similar fashion but for a different purpose. From what I recall it is meant for CTO investment" [X Link](https://x.com/realarainmd/status/1869814828002627803) 2024-12-19T18:39Z [---] followers, [---] engagements "Here is a mini tutorial on how to prep the MC for contrast injection for #HDR. Remember: the injection is SLOW and GENTLE. Thank you @jaygirimd for the question and @aspergian1 for the 100% accurate answer #HDR #HDRFAQs #contrast1st @aspergian1 @jedicath @DrBIqbal Thanks for step by step. Can you just expand a bit on the wire withdrawal partJust have a little contrast flowing out into the hub while wire is still in the lumen taking up space Wouldnt this still leave some potential space in MC that would cause initial air injection @aspergian1 @jedicath @DrBIqbal Thanks for step by step. Can" [X Link](https://x.com/anyuser/status/1869964182415720718) 2024-12-20T04:32Z [----] followers, 11.1K engagements "@jedicath @jaygirimd @SripalBangalore @LAzzaliniMD As such the #HDR did not fail. This is what #HDR in organized thrombus behaves. 🔑 #HDR works over very SHORT distances. 🔑 This CTO likely has hard Ca at the edges and a spongiform core - this locks in the contrast 🔑 It also explains the behaviors of the wires" [X Link](https://x.com/realarainmd/status/1870334180053209214) 2024-12-21T05:03Z [---] followers, [---] engagements "Sequence [--] A Rotawire ES os advanced into prox. LAD atherectomy TP LP across CTO final after CB PTCA and DES x2" [X Link](https://x.com/realarainmd/status/1870366441381486889) 2024-12-21T07:11Z [---] followers, [---] engagements "Final Thoughts This was a complicated #CTOPCI 😯 Challenges included: Failed prior attempt Flush ostial LM CTO - blunt Heavy() calcium Post CABG patient Distal cap at trifurcation Old SVG as retro option A combination of #contrast1st and BIDIRECTIONAL #HDR helped us resolve the challenge Long length" [X Link](https://x.com/realarainmd/status/1870366509114982495) 2024-12-21T07:11Z [---] followers, [---] engagements "Aptly summarized Stefan. I have come to believe that most CTOs have hidden potential channels. Mauro Carlinos gift to us is the use of IP contrast delivery to uncover these pathways. My use of the no tip XT evolved over time - as I experimented with different PJWs. The tip slowly disappeared into nothing Like the Cheshire Cat in Alice in Wonderland Haha. @MauroCarlino3 @esbrilakis @Laserrman" [X Link](https://x.com/realarainmd/status/1870460391140249946) 2024-12-21T13:24Z [---] followers, [---] engagements "Sripal are you talking about reverse (hairpin) wires or wires for SB in general A Suoh reverse wire would be impressive by virtue of the fact that it loses its unique features when bent. It is so soft. But then again you have mad skills. Re: tapered tip PJW for RWT I like them because I can knuckle them once across the ostium of the retroflexed SB" [X Link](https://x.com/realarainmd/status/1870516255251423395) 2024-12-21T17:06Z [---] followers, [---] engagements "@SripalBangalore @Laserrman @ShariqShamimMD @aspergian1 @evandrofilhobr @willsuh76 @jl35wilsonMD @SVRaoMD I think I get it 🤔 Yes in a diseased distal main branch the wire tip catches and the knuckles unravels. Interestingly the way I have dealt with that is to twist the wire - doing so makes the knuckle tighter then I just untwist it when the wire tip is near the SB ostium" [X Link](https://x.com/realarainmd/status/1870522178602664372) 2024-12-21T17:30Z [---] followers, [---] engagements "@drAliyor #HDR is the embodiment of mindful PCI. No rush and no drama but no less excitement. And its efficient. Thats why I like it so much 👌🏼" [X Link](https://x.com/realarainmd/status/1870525961315422643) 2024-12-21T17:45Z [---] followers, [--] engagements "@arnavkumar @Houston @pranav_loyalka @DLBHATTMD @YChatzizisis Congratulations Arnav on your #my1stHDR 👏🏼 Great job - it was interesting because you went against the typical #HDR - INTO the stent vs. out of it. (From a Eastern philosophy perspective there is no inside or outside. Haha. But that is a debate for another time) Well done" [X Link](https://x.com/realarainmd/status/1872106348718289235) 2024-12-26T02:25Z [---] followers, [---] engagements "@MarekRadomski71 @Hragy @TWilsonMD @DMemmini @jl35wilsonMD @ShariqShamimMD @jbspadoni @Laserrman I use the example of hip surgery - but I like yours better It is very gratifying to see these patients who can get back to enjoying life - unencumbered by dyspnea and/or fatigue 🤩" [X Link](https://x.com/realarainmd/status/1872885259278426580) 2024-12-28T06:00Z [---] followers, [--] engagements "💧#HDRanalysis 🧐 - Case [---] An CTO Intervention Unlike Any You Have Seen 🧵 Here is an unusual CTO for most. The patient is a [--] year old woman with systemic sclerosis (SSc) Raynauds and non-healing ulcer of the left 3rd digit. Here is the patients hand. More👇🏼" [X Link](https://x.com/anyuser/status/1872901056075841543) 2024-12-28T07:03Z [----] followers, 29.8K engagements "2/ The hand is typical for SSc with digital ischemia - something I have been treating since [----]. Note the swollen digits effacement of the skin folds (digits #1-3) and the non-healing ulcer The angiogram explains why" [X Link](https://x.com/realarainmd/status/1872901119065924066) 2024-12-28T07:03Z [---] followers, [----] engagements "3/ The patient has occlusions of BOTH the radial and the ulnar at the wrist 🔑 Ulnar occlusion is found in 85% of such patients 🔑 Etiology is complex and involves vasculitic vascular wall thickening + spasm + thrombosis 🔑 Refractory ischemia is rxd (usu. unsuccessfully) with sympathectomy - note scar" [X Link](https://x.com/realarainmd/status/1872901126342770727) 2024-12-28T07:03Z [---] followers, [----] engagements "6/ This is not entirely new. We reported this strategy (sans #HDR) in [----] Total Percutaneous Revascularization of the Hand to Treat Refractory Digital Ischemia in Advanced Systemic Sclerosis JACC: Case Reports https://www.jacc.org/doi/10.1016/j.jaccas.2021.12.006 https://www.jacc.org/doi/10.1016/j.jaccas.2021.12.006" [X Link](https://x.com/realarainmd/status/1872901310514909364) 2024-12-28T07:04Z [---] followers, [----] engagements "7/ Lets do the #HDRanalysis These lesions are usually very fibrotic and the CTO architecture is different from coronaries However #HDR still works - ll the way down to the digital arteries There is some EP infiltration but the crossing is quick Months to years of occlusion crossed in the blink of an eye" [X Link](https://x.com/realarainmd/status/1872901389006872693) 2024-12-28T07:04Z [---] followers, [----] engagements "8/ We dont know the optimal revasc. strategy - I typically use balloons. 👉🏼 These vessels are too small for stents 👉🏼 Recurrence rates high BUT 👉🏼 Healing rates are much higher - which is the goal as with LE CLI 🔑 We usually admit the patients for 3-5 days of Flolan" [X Link](https://x.com/realarainmd/status/1872901451162521999) 2024-12-28T07:04Z [---] followers, [----] engagements "9/ For many patients the relief in pain and hand stiffness is immediate. 😍 Note the flexed fingers and improved color of the entire hand - before Flolan" [X Link](https://x.com/realarainmd/status/1872901459530182780) 2024-12-28T07:04Z [---] followers, [----] engagements "10/ This patient did well. This is the hand prior to discharge. The fingertip already shows signs of wound healing - but there is underlying calcinosis (a known complication of SSc). The patient underwent a limited digital amputation - but the healing was quick and we saved the other digits" [X Link](https://x.com/realarainmd/status/1872901468472107216) 2024-12-28T07:04Z [---] followers, [----] engagements "11/ Hand ischemia is more common than we imagine - with poor treatment options Many vasculitides are associated with digital ischemia and there few options for medically refractory cases. Many patients have occlusions at or below the wrist. We like to treat these percutaneously if possible. (This explains my profile picture 🤩 I have countless pictures like this one. Some examples)" [X Link](https://x.com/realarainmd/status/1872901481193500883) 2024-12-28T07:04Z [---] followers, [----] engagements "12/ Anyway coming back to #HDR the principle is the same - contrast can go where wires wont at least not easily. This is the last detailed #HDRanalysis for the [----] I wanted it to be a special one. 🤩 Hope you are enjoying talking about #HDR as much as I am. I look forward to keeping the conversation going 🙏🏼" [X Link](https://x.com/realarainmd/status/1872901485228442044) 2024-12-28T07:04Z [---] followers, [----] engagements "@MauroCarlino3 @Laserrman @MdM_Ochiai @esbrilakis @LAzzaliniMD @DrBIqbal @ziadalinyc @RinfretStephane @KambisMashayek1 @AgostoniPF @stefan_harb @Texan2007 @KovacicMihajlo @OpolskiMP @swissCTO @BongKiLee3 @dautov_MD @DMemmini @evandrofilhobr @rickytiago @Hragy @TWilsonMD @jl35wilsonMD @grantham_aaron @SanjogKalra @BElbarouni @mirvatalasnag @kalazizimd @SripalBangalore @realjaimehudson @tadano98 @CurtAltmann @MitchellJi40220" [X Link](https://x.com/realarainmd/status/1872901487837208886) 2024-12-28T07:04Z [---] followers, [----] engagements "@DorBen @DrBillLombardi @joe_nolatx @RhianEDavies1 @jbspadoni @CtoEuro @sapporohunt @PCRonline @MLCTOAcademy @OptimaCTO @SCAI @skat_ct @CCAD_MHIF @agtruesdell @yassersadeknhi @MichaelMegalyMD @dautov_MD @DrIHHashmi1 @abadkhan2002 @aspergian1 @A_B_Hall @jedicath @jaygirimd @RajanPatelMD @SandeepNathanMD @SanjogKalra @mornei2011 @timir_paul @dandu_n @melsharabasssy @ShariqShamimMD @Pooh_Velagapudi @tomkaier @arnavkumar" [X Link](https://x.com/realarainmd/status/1872901490421149781) 2024-12-28T07:04Z [---] followers, [----] engagements "That is food for thought - though my personal experience suggests otherwise. When the MC exits an OPEN vessel (prox. or distal TL SB or collateral) you create a stable route for blood escape 👉🏼 perf. by default. When it exits the CTO body (plaque to pericardium) the pressure head is too low and transient to sustain the channel. It never gets to the point of blood loss. There is a subtle but real difference" [X Link](https://x.com/realarainmd/status/1873071986978500849) 2024-12-28T18:22Z [---] followers, [---] engagements "Using The #HDR Contrast Stain To Guide Wiring in #CTOPCI As promised here is a case that shows how the stain from a failed #HDR attempt can be used to guide cap re-puncture and wiring. The target 👉🏼 a heavily remodeled LCX/OM2 with an amb. cap. #HDR #contrast1st #CTOPCI" [X Link](https://x.com/realarainmd/status/1873722515148746833) 2024-12-30T13:27Z [---] followers, [----] engagements "@abadkhan2002 You pick one and go from there He had a sub-total LAD and ramus too. The plan was to fix the ramus + LAD +/- LCX and stage the RCA. This is only part of the intervention. The ramus is done and then the LCX (shown) followed by the LAD. Complete results below" [X Link](https://x.com/realarainmd/status/1873739308131393635) 2024-12-30T14:33Z [---] followers, [---] engagements "Now the analysis Calcified blunt caps are always tough. Specially when the vessel has a large size. ⚠ Here the issue is that the G3 is too deep before the #HDR. 👉🏼 Beware of the hi-tip load wire that easily glides across the CTO - it is usually EP. 🔑 The way we published the technique the G2 should not penetrate more than 3-4 mm" [X Link](https://x.com/realarainmd/status/1874529974029615478) 2025-01-01T18:55Z [---] followers, [---] engagements "Something doesnt add up here. If the patient has only had progressive angina for [--] weeks (and stable angina for a year) - there must be a LM. Or a better stump. This patient needs (in order): aggressive medical therapy coronary CTA dual injection angiography. PCI may be an option depending what the CT and angio reveal. I dont see a good LIMA target but the LM may be underfilled" [X Link](https://x.com/realarainmd/status/1875563672266785146) 2025-01-04T15:23Z [---] followers, [---] engagements "In my last comment I meant that the LAD may be underfilled. The usual scenario of a missing LM turns out to be either an anomalous take off or dual ostia (separate for LAD and LCX). If the patient has a single coronary then the left system arises proximally and typically has an intra septal course. Let us know how it goes" [X Link](https://x.com/realarainmd/status/1875571729936085040) 2025-01-04T15:55Z [---] followers, [---] engagements "@MichaelMegalyMD Very nice Michael 👏🏼 Thank you for sharing this. #HDR failure may be the first step to ADR success. Can you share just the #HDR clip Perhaps one with the MC in place The nice thing is that uou created a linear channel along side the TL. An ideal Stingray setup. 👌🏼" [X Link](https://x.com/realarainmd/status/1875941224273850773) 2025-01-05T16:23Z [---] followers, [---] engagements "@MichaelMegalyMD nicely shows how #HDR failure does NOT equal #CTOPCI failure. 🤔 On the contrary #contrast1st is a (quick) first step if you decide to use ADR. 👌🏼 IF Michael had come retro the #HDR would have set him up for re-entry. What @DrBIqbal calls Carlino CART Though H-CART may be a more contemporary term Haha. Here is what I did Cap puncture with Gaia III then tried HDR but ended up subintimal distal anyway Thought a lot to try ADR in a s diseased vessel and risk a lot of hematoma or go right away to this usable epicardial that would make the procedure fast. Decided to do one trial" [X Link](https://x.com/realarainmd/status/1875944398242116027) 2025-01-05T16:36Z [---] followers, [---] engagements "@MichaelMegalyMD Nothing to sell Michael - youve already bought it Haha. It is yours to keep. 😀" [X Link](https://x.com/realarainmd/status/1875945054394875973) 2025-01-05T16:38Z [---] followers, [---] engagements "@MichaelMegalyMD Also I saw it but the miniature clip doesnt allow analysis. It is tiny on my phone - and it goes by too fast. 😢 or maybe I need glasses Haha" [X Link](https://x.com/realarainmd/status/1875945587801292934) 2025-01-05T16:40Z [---] followers, [--] engagements "@Laserrman Here is something I wrote a few days after I made the account. I feel even more confident about my proclamation today than I did back then 😀 https://x.com/realarainmd/status/1853184373962502302s=46 THREE of the most exciting things in CTO PCI right now: 1) Up front contrast modulation 🩼💧 2) Knuckles 🤛 3) Tip detection wiring/puncture 🔍🎯 Here is a case that highlights #1 and #3. Also an intro to the Contrast Modulation 1st philosophy #HDR #contrast1st #CTOPCI https://x.com/realarainmd/status/1853184373962502302s=46 THREE of the most exciting things in CTO PCI right now: 1) Up" [X Link](https://x.com/realarainmd/status/1876428801082839217) 2025-01-07T00:41Z [---] followers, [---] engagements "@drAliyor Nice case Aliyor. How old was the LAD stent Also did you use IVL in the LM at all Great result. Stent landed nicely at the LM ostium. And the LCX is hanging in there" [X Link](https://x.com/realarainmd/status/1876615440115400785) 2025-01-07T13:02Z [---] followers, [---] engagements "#HDRanalysis - Happy New Year Edition 🧵 The first #HDRanalysis of [----] The case was posted earlier by @evandrofilhobr - a man who needs no introduction here. There were three #HDR injections - with three() different patterns. Case below my analysis to follow #CTO101 #HDR #CTOPCI Interesting RCA CTO PCI @realarainmd maybe I get honor to get your inputs in this case. Still don't know how to name the crossing technique lol 😅 (I'm sure the patient don't care) https://t.co/m7E8IDCXAw #CTO101 #HDR #CTOPCI Interesting RCA CTO PCI @realarainmd maybe I get honor to get your inputs in this case." [X Link](https://x.com/anyuser/status/1876879839644270691) 2025-01-08T06:33Z [----] followers, 10.3K engagements "An additional comment 👉🏼 The XT was likely IP it was the retro G3 that took you EP. An XT has a soft tip and it doesnt take much to deflect it. So there are two aspects to the wires movement - tip deflection and resistance. [--]. No deflection no resistance - likely IP rarely EP [--]. No deflection with resistance - very likely IP [--]. Deflection no resistance - likely EP rarely IP in small TL (safety knuckle) [--]. Deflection with resistance - definitely EP pre-knuckle 👆🏼 My rationale is admittedly conjecture this point but you do enough of these and you get some idea of wire behavior" [X Link](https://x.com/realarainmd/status/1877757470581379360) 2025-01-10T16:40Z [---] followers, [----] engagements "@jedicath @Obisht @hectortamezmd @skat_ct @DrBIqbal @aspergian1 @yassersadeknhi @kalazizimd @abadkhan2002 @agtruesdell @LAzzaliniMD Nice result Waqar. What microcatheter do you prefer to use Is that a FineCross Also Ive come to a point in life where I always inject through the MC. Its a win win 👉🏼 you either get a tip injection or an IP microinjection (#HDR hopefully). 🤩" [X Link](https://x.com/realarainmd/status/1878140873856237742) 2025-01-11T18:04Z [---] followers, [---] engagements "A Twisted Tale 😯 (Or We Took The Scenic Route Around The Mountain 🏔) [--] year old woman with RLE claudication. US showed occlusion of the CFA. I will let the angiogram speak for itself" [X Link](https://x.com/anyuser/status/1878346668908638274) 2025-01-12T07:41Z [----] followers, 12.9K engagements "3/ The crossing tools are simple - a TurnPike LP and a Sion Black. Rather several Sion Black wires. The TurnPike LP is unique because of a double nitinol coil in addition to a PTFE + braided inner tube and an outer polymer casing" [X Link](https://x.com/realarainmd/status/1878346921426772100) 2025-01-12T07:42Z [----] followers, [---] engagements "4/ This allows the TurnPike LP to build up torque and move forward whichever way you torque it. This is similar to the Corsair Pro XS (with one coil) and the Mamba Flex (several coils from hub to tip). Each catheter has its unique properties and advantages" [X Link](https://x.com/realarainmd/status/1878346928657723783) 2025-01-12T07:43Z [----] followers, [---] engagements "Haha. We have a running joke in our Cath Lab. Its something I have said for as long as Ive been teaching. It is a list of the enemies of the week. Thrombus is always number one Calcium is up there but it rarely displaces thrombus. Other top contenders include guide induced dissection perforation. and no flow. 😂" [X Link](https://x.com/realarainmd/status/1879720223386869839) 2025-01-16T02:39Z [---] followers, [---] engagements "@StevenMathern @stefan_harb @aspergian1 @evandrofilhobr @Laserrman @TWilsonMD @simonjwilson1 @dr_oss @hwcc0314 @VRejeki28 @jianshanzhiyi1 @MauroCarlino3 @GLGasparini @prof_aaa1 @cghanratty @AEslamiDO @CatalinPToma @BrianLi_MD @Pardhu6627 @abadkhan2002 @kevinjamescroce @prajith3668 @dautov_MD @jbspadoni @MdM_Ochiai @BakhshiHooman @tadano98 I think @stefan_harb was sharing his concept of an ideal device - we were all dreaming of conquering calcium" [X Link](https://x.com/realarainmd/status/1880076091551019311) 2025-01-17T02:14Z [---] followers, [--] engagements "@Laserrman @SripalBangalore @aspergian1 @evandrofilhobr @TWilsonMD @simonjwilson1 @dr_oss @hwcc0314 @VRejeki28 @jianshanzhiyi1 @MauroCarlino3 @GLGasparini @prof_aaa1 @cghanratty @AEslamiDO @CatalinPToma @BrianLi_MD @Pardhu6627 @abadkhan2002 @kevinjamescroce @prajith3668 @dautov_MD @jbspadoni @MdM_Ochiai @BakhshiHooman @tadano98 @ikki1127 What happens in the red zone Deep cuts Also disruption of softer tissue Also what if any is the recommended speed for stent ablation (BTW the screams of the burr against metal are unnerving enough to give a person nightmares 😳)" [X Link](https://x.com/realarainmd/status/1880077849136361531) 2025-01-17T02:21Z [---] followers, [---] engagements "3/ I believe there is no bifurcation strategy (1- or 2-stent) that cannot be enhanced by the Jailed Semi Inflated Balloon Technique (aka #JSBT). I use it almost daily 🤩 Here is the sequence for our patient" [X Link](https://x.com/realarainmd/status/1880092264086794654) 2025-01-17T03:18Z [----] followers, [----] engagements "4/ Here is our sequence: SB balloon in place KBI if needed (SB no greater than 4) MB stent in place SB up @ [--] MB stent up @ nominal + [--] MB down THEN SB down SB out and MB back up at supra nominal MB out DOT if needed POT Final KBI if needed Here is the post" [X Link](https://x.com/realarainmd/status/1880092295237939245) 2025-01-17T03:18Z [----] followers, [----] engagements "7/ BTW this video is from the excellent Bifurcation Exploration website by Univ. of MN and @Medtronic. After POT the stent is much better apposed to the wall. 🔑 ALL stents benefit from post-dilation. Whether it is done or not or how its done is up to the operator. We prefer NC balloons. https://www.medtronicacademy.com/en-us/content/bifurcation-pci https://www.medtronicacademy.com/en-us/content/bifurcation-pci https://www.medtronicacademy.com/en-us/content/bifurcation-pci https://www.medtronicacademy.com/en-us/content/bifurcation-pci" [X Link](https://x.com/realarainmd/status/1880853867765600585) 2025-01-19T05:44Z [----] followers, [----] engagements "@Laserrman Yes that is why I like to do a tip injection whenever I am in doubt. Here I think we were in and out of the honeycomb structure - I thought I saw a thrombosed channel. So IP all the way but not TL" [X Link](https://x.com/realarainmd/status/1881517382046544255) 2025-01-21T01:41Z [----] followers, [---] engagements "A More Typical CTO PCI - for those who know #HDR *(Its ok if you dont You will soon. 😀) [--] year old man CABG [--] years ago now with angina and severe AW ischemia. LIMA and SVG to OM - 100%. Dual injection shows short CTO blunt cap 3+ Ca distal cap trifurcation. Other info. EF 35% SVG to D2 patent high grade stenosis at D2 origin" [X Link](https://x.com/anyuser/status/1881579443808092654) 2025-01-21T05:47Z [----] followers, [----] engagements "2/ Is there a microchannel Perhaps. But a Gladius MG stops after penetrating the angiographic cap. Here is the crossing sequence: MC across cap #HDR no tip XT into ramus angled XT into LCX CTO Dottered with MC angled XT into LAD MC has difficulty crossing" [X Link](https://x.com/realarainmd/status/1881579627245903961) 2025-01-21T05:48Z [----] followers, [---] engagements "3/ Note the LM trifurcation. It is heavily diseased but it would be nice to salvage all [--] branches. We treated the LM as follows: 👉🏼 LAD: rota + IVL + CBA. 👉🏼 LCX: CBA 👉🏼 LM: rota + IVL + CBA Culotte (using IVUS) (Only the rota and subsequent wiring is shown)" [X Link](https://x.com/realarainmd/status/1881579750126502083) 2025-01-21T05:49Z [----] followers, [---] engagements "4/ Here is the final angio Look at the trifurcation All the branches are there. 🙌🏼 🔑 This is the beauty of #HDR - preservation of branches AND IP crossing No other technique (other than retro wire escalation perhaps) can handle a distal trifurcation this cleanly. 🤔" [X Link](https://x.com/realarainmd/status/1881579834914250934) 2025-01-21T05:49Z [----] followers, [---] engagements "HDR vs. the Carlino Injection - What is the difference I made this video with @MauroCarlino3 at TCT. It is Carlino certified Haha. Mauro is as good at teaching #HDR through PowerPoint as he is performing it live 👏🏼🤩 5/ If you know #HDR you can skip this part. If you are new here #HDR is hydrodynamic contrast recanalization - a novel CTO crossing method. It is latest iteration of the Carlino method - but so much more than that. Mauro Carlino honestly his technique and gave it this name https://t.co/SjWhHwEM8B 5/ If you know #HDR you can skip this part. If you are new here #HDR is" [X Link](https://x.com/anyuser/status/1881742948423061756) 2025-01-21T16:37Z [----] followers, [----] engagements "Interesting case. No doubt challenging but you got it done 👏🏼 This case highlights the different ways on which a CTO can be approached. It will interesting to see what other folks would have done. I may have started with dual inj. angiography - or switched early because the CTO is not that long and can guide repuncture. (With your #TDADR skills you dont need to so this but for the rest of us this is one way to deal with cap puncture failure) More" [X Link](https://x.com/realarainmd/status/1882285447520403875) 2025-01-23T04:33Z [----] followers, [---] engagements "2/ Some other things we may have tried: a) Leave the wire in the RV br. then re-puncture at the RV br. take off either with a DLMC (Houston style) or TD CP (Sapporo style). b) Block the RV br. and use a knuckle redirect followed by ADR (Seattle/NYC/Atlanta style) or STAR (Milano style) c) Retrograde epicardial (Tokyo/Lahr/Vancouver Island style) Many many good options" [X Link](https://x.com/realarainmd/status/1882287905495719985) 2025-01-23T04:43Z [----] followers, [---] engagements "Understandable This comment was meant more for students of the technique and practitioners of other #CTOPCI philosophies 😀 🔑 #HDR facilitates single access but doesnt require or mandate it. I would encourage people learning the technique to use dual injections. @MauroCarlino3 would concur" [X Link](https://x.com/realarainmd/status/1882291609942790203) 2025-01-23T04:57Z [----] followers, [---] engagements "@Laserrman @cto_chip_japan @DaitaroK @calcbreaker @SKuramitsu0511 @tadano98 You are the enlightened antegradist Many of us are still on the journey. 😀 Plus some good friends like @MdM_Ochiai and @DrBIqbal really enjoy going retrograde I want to keep them close. 😉" [X Link](https://x.com/realarainmd/status/1882292967920304476) 2025-01-23T05:03Z [----] followers, [----] engagements "We are neither treating (nor creating) these percutaneously 😯 There is a very high risk of infection with any Rx modality (papyrus or coiling) given the size of the PSA and proximity to the skin surface. From my experience treating AV fistulae (past life) these UE PSAs would all be sent for surgery. I have used covered stents (twice) when rupture was imminent - but just to buy time to get the patient to the OR. The artery is too small for a cover" [X Link](https://x.com/realarainmd/status/1883012853260529855) 2025-01-25T04:43Z [----] followers, [---] engagements "@DrPrimeroNg @sudhirtho @DrBillLombardi @KateKearney4 @LAzzaliniMD @cardiofrizz @crfheart Nice way to preserve the bifurcation when coming retrograde Also works well during LM #CTOPCI when the wire crosses from the LCX into the LAD (or vice versa). Its interesting that I learnt this technique from @DrBillLombardi while visiting UW several years ago 🤩" [X Link](https://x.com/realarainmd/status/1883034742754607340) 2025-01-25T06:10Z [----] followers, [---] engagements "Jump Start Or Taking A Road Less Traveled An unusual CTO PCI brought to mind by a post from @MichaelMegalyMD [--] year old man with failed SVG to OM2 and [--] 👉🏼 s/p LCX CTO PCI 👉🏼 recurrent OM2 occlusion with TWO prior stents Third attempt - #HDR reveals patent jump graft from OM3 to OM2. Successful OM3 +jump graft PCI 👉🏼 patient symptom free for [--] years 🙌🏼 *PS - Case is from before DCBs were approved in the US" [X Link](https://x.com/realarainmd/status/1884470540582133896) 2025-01-29T05:16Z [----] followers, [----] engagements "Another day in the lab another opportunity to go #contrast1st [--] year old woman s/p NSTEMI and LAD PCI in 01/2024 👉🏼 Persistent dyspnea with exertion - large area of lateral wall ischemia Not a true CTO but a functional one - no forward flow and sparse collaterals What wire would you start with And would you use an MC" [X Link](https://x.com/anyuser/status/1887370623946781038) 2025-02-06T05:19Z [----] followers, [----] engagements "I find a #contrast1st strategy to be very helpful - it is an excellent way to refine the diagnostic angiogram Method - engage lesion with MC (Corsair here) + WH wire tip inj. PJW based on findings Simple but effective. 🤩 Crossing took our fellow @MaxBourdillon under a minute (if that)" [X Link](https://x.com/realarainmd/status/1887370696994812321) 2025-02-06T05:20Z [----] followers, [----] engagements "@Laserrman @drAliyor @esbrilakis @evandrofilhobr @Sher_Intervent @dautov_MD Agreed. We have had a (ahem) similar situation in the periphery. The Astato [--] (and lesser wires) didnt work - largely because the balloon surface is smooth and usually the wire keeps slipping I did not realize the GCE shaft was that sharp. 🤔 Interesting" [X Link](https://x.com/realarainmd/status/1887581607587987915) 2025-02-06T19:18Z [----] followers, [---] engagements "Difficult to see where the ischemia is coming from - or rather where is the recent episode came from. You probably need to piece this coronary system back together. CTOs are a good place to start bec. you stress out the LV as much as - except during dual inj. Also beware of the failing SVG 😳 I would clean up the proximal LAD see if you can get into the LCX and/or LAD. Then tackle the SVG to OM (if LCX PCI unsuccessful) followed by the distal LAD via the LIMA. Finally the RCA via the LAD if viable #HDR early and often. 😀🤞🏼" [X Link](https://x.com/realarainmd/status/1887716900651577634) 2025-02-07T04:15Z [----] followers, [---] engagements "Yasser the EF has improved but the targets have not The mechanism of stent failure is interesting - and determines the subsequent PCI strategy. I see both stent fracture (LAD) and geographic miss (LCX). (What stent brand does she have) Option #1: IVUS LAD and if you see a good landing zone offer CABG. Option #2: Treat the LM more completely - DK Crush to minimize metal in the LM. Also consider changing the drug in the LM-LAD" [X Link](https://x.com/realarainmd/status/1887739834585743432) 2025-02-07T05:47Z [----] followers, [---] engagements "@doctor_dru_ Brilliant. 🤩 Here is the Southern US I use the aisles at Walmart scale after a patient used it to describe her ambulatory capacity. It is (dare I say) a very reliable and usable metric Also very patient centric. 👌🏼" [X Link](https://x.com/realarainmd/status/1888819650722468109) 2025-02-10T05:17Z [----] followers, [----] engagements "@evandrofilhobr correctly noted that there was air in the injection - hence the bubble #HDR. This is air that gets entrained during wire exchanges. But this happy accident has given me new insight as to how CTOs form - particularly at the distal cap" [X Link](https://x.com/realarainmd/status/1888831190179676243) 2025-02-10T06:03Z [----] followers, [---] engagements "In anticipation of #CTO2025 And inspired by @jbspadoni here is an LCX CTO PCI. I tried to case match but I couldnt find a flush ostial LCX occlusion with bifurcation at the distal cap. Nevertheless this case highlights the use of #contrast1st and #HDR in such cases" [X Link](https://x.com/anyuser/status/1894245290326065287) 2025-02-25T04:37Z [----] followers, [----] engagements "The low EF IVL for such a calcified LM would have required multiple treatments in the same location - and that may have exhausted the LV despite the Impella. By fixing the LCX first we gave the LV a little bit more reserve. It also allowed us to move the base of operations to the LAD proper where IVL may have been better tolerated. Re: Rodin Cut I like it very much but it does not keep me from using IVL if I need to. For example sometimes (rarely) the calcium does not respond to the combination of Rota and IVL. Thank you for the comment" [X Link](https://x.com/realarainmd/status/1895250457557074275) 2025-02-27T23:11Z [----] followers, [--] engagements "@ABaliMD @BifurcationClub Lately I have been trying out the Runthrough NS and the Minamo - as recommended by @Hragy and @MichaelMegalyMD respectively. 👉🏼 Both are very good workhorse wires. I am not as familiar with the RT Izanai - but it appears to have excellent torque reaponse" [X Link](https://x.com/realarainmd/status/1896764306253074738) 2025-03-04T03:27Z [----] followers, [---] engagements "Its important to know because it allows you choose the appropriate crossing strategy + wires. 👉🏼 When you are IP then the focus is on using contrast and/or wires to navigate through the CTO bosy. This is the philosophy behind #HDR #DRaW parallel wiring etc . 👉🏼 On the other hand when you are EP then the objective is to move towards the TL (relatively) quickly and re-enter using one of several different techniques. The wire selection for this is completely different" [X Link](https://x.com/realarainmd/status/1897796535733141929) 2025-03-06T23:48Z [----] followers, [--] engagements "What were some of YOUR favorite publications on LM PCI over the past [--] months Lesser discussed studies that may have impacted how you perform LM PCI - or not 🤔 See you at #CRT2025 @agtruesdell @DrBIqbal @LAzzaliniMD @Laserrman @MauroCarlino3 @evandrofilhobr @jbspadoni @mmamas1973 @mirvatalasnag @Hragy @aspergian1 @djc795 @DocSavageTJU @SmithElliotjs @stefan_harb @GoranEBC @RinfretStephane @SanjogKalra @TWilsonMD @jl35wilsonMD @WahajAmanMD @kalazizimd @SripalBangalore @ziadalinyc @MichaelMegalyMD" [X Link](https://x.com/realarainmd/status/1898000806294458550) 2025-03-07T13:20Z [----] followers, [----] engagements "@NabilYahya_MD @SripalBangalore @MaeharaAkiko @DrAnkushG The rationale is discussed in the editorial. It comes from ADAPT DES. The paper is really well written and the reasoning is sound" [X Link](https://x.com/realarainmd/status/1899823947551498622) 2025-03-12T14:05Z [----] followers, [--] engagements "Thank you Hady Your experience is relatable. We have all been shaped by our work for better or for worse. Sometimes very dramatically. The challenge (both in and out of the lab) is to live in the present moment. Without regrets of the past or fear of the future. 👉🏼 That is a tough balancing act that I often find myself trying to perform in my difficult cases" [X Link](https://x.com/realarainmd/status/1902553285288194357) 2025-03-20T02:50Z [----] followers, [--] engagements "Nice #HDR Mahesh 👏🏼 Here is what I have learned - in most cases the degree of collateralization is a good marker of the age of the CTO (not the underlying lesion). 👉🏼 Which means that when there is no visualization of the target AND the tissue is viable then the CTO is likely thrombus laden and less calcified (as a general rule) 👉🏼 Such lesions are great for #HDR more so if you have a tapered cap or a lead in segment like here" [X Link](https://x.com/realarainmd/status/1902577153591611663) 2025-03-20T04:25Z [----] followers, [---] engagements "Puncture Probe and Pass An #HDRanalysis case - #HDR meets #DRaW 🧵 [--] year old man with anomalous RCA CTO 👉🏼 Mod. JL4 guide + GEX cap puncture with G2 #HDR no. [--] first pass no-tip XT MC advanced #HDR no. [--] MG crosses IVUS DES placement 🙌🏼 #contrast1st" [X Link](https://x.com/anyuser/status/1902940460576116739) 2025-03-21T04:28Z [----] followers, 10.2K engagements "2/ Here is the IVUS - lots of chronic organized thrombus calcium and modulated plaque. You can see plaque with a starry sky pattern close to the proximal cap. Note how CTO length by IVUS is MUCH shorter than the length by angio - #HDR resolves the discrepancy" [X Link](https://x.com/realarainmd/status/1902940561042293216) 2025-03-21T04:29Z [----] followers, [---] engagements "@nolanjimradial @Hragy Great thought Jim. That would fit #2 or #3 in my scheme - acute reperfusion 👉🏼 BJR 👉🏼 slow HR +/- slow flow" [X Link](https://x.com/realarainmd/status/1907419585093271767) 2025-04-02T13:07Z [----] followers, [--] engagements "My first 3D OCT image - from [----] Not as pretty as the images shared by @mornei2011 but this is a 3D reconstruction from a post rota run. The image was constructed using 3rd party software. 🔑 I kept this image because it shows the engraved path of the rota burr along the lumen of the LM 🔑 The patient had ESRD and severely calcified arteries - our target was the LCX ostium" [X Link](https://x.com/realarainmd/status/1908403273683366282) 2025-04-05T06:16Z [----] followers, [----] engagements "Ex Vivo Grenadoplasty ( Or what pressure does it take to rupture an NC balloon) 👉🏼 We used an OPN indeflator to see how we could go on a [--] mm BSC NC balloon. Note the point of rupture The NC 🎈remains intact 🤔 But the hypotube is completely mangled. The video speaks for itself. Best viewed with the volume up" [X Link](https://x.com/anyuser/status/1913127846463037723) 2025-04-18T07:09Z [----] followers, 11.2K engagements "A common scenario with re: to the disease distribution - except many times it a moderately stenosed valve that becomes the sticking point. The fact that you had plaque rupture in the RCA suggests the moderate to severe LAD and LCX are at risk for progression and/or MI. As the patient is on no meds you could optimize the medical therapy and re-evaluate in [--] months. That will give you valuable info vis a vis: 1) CAD progression rate 2) Aortic root dilation rate 3) Medication compliance BUT it may be equally reasonable to do a baseline functional assessment with FFR - and offer PCI if needed." [X Link](https://x.com/realarainmd/status/1914182790851022886) 2025-04-21T05:01Z [----] followers, [---] engagements "@drdharmarajk @SripalBangalore @MauroCarlino3 @Laserrman @KambisMashayek1 @SKuramitsu0511 @rotamonster Another possibilities is that there is a potential channel there (the last remaining TL) full of organized thrombus and the contrast found to be the path of least resistance. 🤔" [X Link](https://x.com/realarainmd/status/1917559109739765805) 2025-04-30T12:38Z [----] followers, [--] engagements "A Hard Nut To Crack - A #CTOPCI Saga Here is the #HDR case from last week - as promised. Our pt. is a [--] 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" [X Link](https://x.com/anyuser/status/1919604780625723603) 2025-05-06T04:06Z [----] followers, [----] engagements "Great result Krzysztof Remarkable really.👌🏼 Do you have images from the original intervention 👉🏼 Whenever the follow up angio looks good (hardly this good though 😀) I like to go back and look at the index procedure - to see what I can learn from it. 👉🏼 All of the branches are preserved was confirmed that you had IP crossing and that it was a short CTO. We have only just started using DCBs for (very) select cases. They are expensive and only approved for ISR in the US - so our usage is audited" [X Link](https://x.com/realarainmd/status/1920227378170900610) 2025-05-07T21:20Z [----] followers, [---] engagements "Good case and excellent result. This patient needs aggressive lipid lowering and OMT - that is their best chance of making this a routine procedure. Re: the DCB your technique is 👌🏼. Pre and post IVUS CBA SB protection appropriate DCB sizing - you checked all the boxes. The LAD may need a LIMA in the future - but it is not the best target. You can see trouble brewing at the left main both by angio and IVUS. Lately we have been discussing the relative merits of DCB over DES. Here in the US we would have stented - because of the costs involved. Great final result. I hope the patient feels" [X Link](https://x.com/realarainmd/status/1921979954427752504) 2025-05-12T17:25Z [----] followers, [---] engagements "@DrWhyWho @jl35wilsonMD @TWilsonMD This is a great result 👌🏼 Glad the rota worked out - it is the best 1st strategy for calcified nodules IMHO. Rota NC Rota Cut and Rota Shock are all excellent choices. Do you have a cine of the rota run It would be intersting to see how the burr behaves over the bends. 🤔" [X Link](https://x.com/realarainmd/status/1922437260831522979) 2025-05-13T23:42Z [----] followers, [--] engagements "Case 281: Manual of CTO PCI - HDR [---] via @YouTube 👆🏼 A brilliant case by @esbrilakis showcasing the potential of #HDR in a wire uncrossable in-stent occlusion (ISO) The presentation is crisp and the explanation is on point 👌🏼 https://youtu.be/VAoqyZk4fQ4si=jX6X64Y9D7SN79H4 https://youtu.be/VAoqyZk4fQ4si=jX6X64Y9D7SN79H4" [X Link](https://x.com/anyuser/status/1923578722646434176) 2025-05-17T03:18Z [----] followers, [----] engagements "I can see why the first option is popular. I suspect this question is more likely to be answered by the dissatisfied practitioner. For e.g. I am sure healthcare administrators will have a different opinion all together. What has changed is how we practice medicine. There is less autonomy for the practitioner and more regulations. And yes patients are less forgiving but I dont sense a betrayal on either the side of medicine or the MDs/RNs. Our dissatisfaction with how we practice medicine makes us ask such questions. (My personal gripe is the excessive and redundant documentation. But what you" [X Link](https://x.com/realarainmd/status/1923744051255185436) 2025-05-17T14:14Z [----] followers, [--] engagements "The #HDR LIfe Last week we treated several peripheral CTOs - unusual only bec. of the vessels involved: subclavian vein SFA with prior stents and superficial palmar arch + common digital artery Here is what #HDR in the periphery looks like 😀 (We also had a couple of 'crazy' coronary CTOs - but that is for another time)" [X Link](https://x.com/anyuser/status/1923876474261504076) 2025-05-17T23:01Z [----] followers, [----] engagements "A key point is that ostial stent placment (even if it miraculously naila the ostium) shifts the carina into the SB (LCX) ostium. Particularly if the carina has bulky plaque. Crossover stenting (facilitated by JSBT if possible) is less likely to do so. Of course the true challenge is to POT after crossover PCI in a way that does not pinch the carina from the other side" [X Link](https://x.com/realarainmd/status/1929695471418704199) 2025-06-03T00:23Z [----] followers, [---] engagements "A key point is that ostial stent placment (even if it miraculously naila the ostium) shifts the carina into the SB (LCX) ostium. Particularly if the carina has bulky plaque. Crossover stenting (facilitated by JSBT if possible) is less likely to do so. Of course the true challenge is to POT after crossover PCI in a way that does not pinch the carina from the other side" [X Link](https://x.com/realarainmd/status/1929695575785496600) 2025-06-03T00:24Z [----] followers, [---] engagements "2/ Why did the MCs fail One could argue they all did what they were supposed to do - push forward when torqued. The ways in which the tips have been compromised gives us information about the catheters construction. The lesion was severe Only one wire could pass at a time" [X Link](https://x.com/realarainmd/status/1935603146123821149) 2025-06-19T07:38Z [----] followers, [---] engagements "3/ Here is a clip of the Corsair Pro trying to cross (after PTCA and grenadoplasty at the PDA ostium). Note the anchor balloon the direction of the MC tip and the configuration of the shaft When we tried to remove the MC it was stuck to the wire 😳" [X Link](https://x.com/realarainmd/status/1935603273186083243) 2025-06-19T07:39Z [----] followers, [---] engagements "4/ Over Torque MC Injury This is not a real injury per se but a series of inconvenient annoying and occasionally dangerous MC failure modes. Here the soft tip of the MC has been twisted onto the coronary wire. This occurred in 10% of reported failures. Images from the excellent review by @MichaelMegalyMD in @EuroInterventio" [X Link](https://x.com/realarainmd/status/1935603279347490826) 2025-06-19T07:39Z [----] followers, [---] engagements "5/ Why does this happen Not sure but my hypothesis in that the catheter tip gets crimped onto the wire. Interestingly the Mamba tip behaved differently here 🤔 The tip looks frayed without stretching out like the TurnPike and the Corsair Also note the stent strut induced lacerations on the latter" [X Link](https://x.com/realarainmd/status/1935603287358669061) 2025-06-19T07:39Z [----] followers, [---] engagements "7/ So how did we treat the patient Well we saw the writing on the (vascular) wall after sacrificing [--] MCs and several balloons. Interestingly the patient developed ST elevation() with every MC engagement. His angina is life style limiting but not debilitating. We have upped his ranolazine and are going to enroll him in the COSIRA [--] trial (I know two persons who would agree 😀 @GreggWStone @HenrytTimothy) 🙏🏼" [X Link](https://x.com/realarainmd/status/1935603296267374827) 2025-06-19T07:39Z [----] followers, [---] engagements "@SripalBangalore I think here the issue is the stent cage. Also the think the Gold works when you have a lead-in channel. (Though personally I havent had much luck with it.) Rather I can usually get across with either a Turnpike LP or Corsair XS - and oodles of support 😀" [X Link](https://x.com/realarainmd/status/1935711527195046052) 2025-06-19T14:49Z [----] followers, [--] engagements "Yes we did - [--] different brands Also a Sapphire [---] mm. We also purposely ruptured the balloons (BAM = Balloon Aided Microdissection aka grenadoplasty). In fact that is what allowed the Corsair to go deeper than the other micro catheters. Had I been more thrilled about the target I would have made it work - stent strut ablation +/- laser +/- deep seated guide. (I used the different MCs here to teach my quasi-CHIP fellows about the difference in performance and properties)" [X Link](https://x.com/realarainmd/status/1935718753150345231) 2025-06-19T15:18Z [----] followers, [---] engagements "The balloon tips crossed. Difficult to tell with the [--] mm balloons because the marker is farther away from the tip. But the mid marker of the [--] mm balloon was at the struts. Which is why we attempted BAM. Re: the stents I doubt if the shock waves would have any effect on strut malleability. My experience (n=2) using Javelin in small vessels - [---] mm or less - has been underwhelming. It works great when there is a lumen large enough to accommodate the nose cone" [X Link](https://x.com/realarainmd/status/1935875034947387539) 2025-06-20T01:39Z [----] followers, [--] engagements "@AntoniousAttall @Laserrman @cto_chip_japan @DaitaroK @calcbreaker @UmihikoKaneko Good pickup. I wonder if that is remnant hematoma in the the EP space - where the Sion Balck was parked. Difficult to say without IVUS but the blood/contrast used to be on the outside of a calcium ring" [X Link](https://x.com/realarainmd/status/1935914902302212277) 2025-06-20T04:17Z [----] followers, [---] engagements "Jay this reminds me of a case I was once referred in New Orleans - the patient had stents (with multiple overlaps) from the common iliac to the anterior tibial 😳 I showed it at a national conference as a demo of a) inappropriate use of stents in the peripherals and b) a heroic case of limb salvage. One of the surgeons in the panel got very upset that I did not send her for a surgical opinion before dripping tPA and using JetStream 😂 (@shishem was leading the panel and came to my rescue. He still remembers)" [X Link](https://x.com/realarainmd/status/1936053274731249925) 2025-06-20T13:27Z [----] followers, [--] engagements "Sripal we have been using [--] Fr guides the [--] Fr IVUS and the TurnPike LP for our TD cap punctures. It gets a little snug in there. [--] Fr is better but I gave up on [--] Fr some years ago. Here is the best sequence (that works best for me) [--]. Place two workhorse wires first. [--]. Park MC in straight portion of guide. [--]. Slip the IVUS past the MC and get it beyond the ROI in the vessel. [--]. Get MC beyond ROI and switch one wire for the puncture wire (needle). [--]. Retract MC proximal to ROI. [--]. Retract IVUS to just beyond the ROI. [--]. Survey the ROI using IVUS and identify the target. [--]. Retract the" [X Link](https://x.com/realarainmd/status/1936055064713379898) 2025-06-20T13:34Z [----] followers, [---] engagements "Nothing went wrong my friend You successfully treated an occluded RCA 👏🏼🤩 Re: the #HDR it seems you uncovered a latent microchannel through a calcified CTO. These can be tough to cross with an XT alone. Here are some things I do: 1/ Always use an XT with a straight tip. I gently torque the wire as it exits the MC. 2/ If the wire buckles I stop and advance the MC then repeat the microinjection - the so-called Ice Breaker method. 3/ Usually I will do the 2nd #HDR in two views - to understand the CTO in 3D. 4/ If thay doesnt work I typically switch to a Mongo (aka MG). 5/ if that doesnt work" [X Link](https://x.com/realarainmd/status/1936258853378707929) 2025-06-21T03:04Z [----] followers, [----] engagements "Mahesh I missed the leak. Now the post HDR leak is itself a fascinating phenomenon. And I am still learning. Here are the types of flow (leak) I have seen: [--]. Flow into true channel (MB or SB) - wispy and brisk smoke like [--]. Flow into adventitial pathways - often reticular [--]. Flow into an adjoining vein - like a fistula [--]. True perforation (rare often preceded by wire knuckle or exit) - brisk putt at the end of a branch 🔑 True bleeds from the mid CTO body are impossible without: a) significant trauma to the EP/IP interface and b) connection of the rent to the proximal TL" [X Link](https://x.com/realarainmd/status/1936460480790380605) 2025-06-21T16:25Z [----] followers, [---] engagements "@SaidAshrafMD @jedicath Quite the quandry IMHO the culprit is an elevated LVedp +/- high double product and maybe the LCX. Curious to see how you resolved this" [X Link](https://x.com/realarainmd/status/1936463406690861369) 2025-06-21T16:37Z [----] followers, [---] engagements "Solid strategy - I wouldve done the same except maybe use the MCS sooner. I do think that unloading the LV prior to PCI has a benefit at the tissue level. Re: the LCX - I am glad you quickly determined it wasnt the immediate culprit. It was the LVedp and abnormal micro perfusion (Not to say that the CAD is not the real long term etiology)" [X Link](https://x.com/realarainmd/status/1936482046517313717) 2025-06-21T17:51Z [----] followers, [---] engagements "@mahesh_maidsh @SCAI @TCTMD @cvinnovations Great result on that LCX 👌🏼 And the RCA too. Did you use OA for the LCX Also what size stent did you end up using It turned out larger than it first appeared to be. Which is often the case" [X Link](https://x.com/realarainmd/status/1936940917761491217) 2025-06-23T00:14Z [----] followers, [---] engagements "I agree 👏🏼🤩 Cap puncture #HDR or #CASE knuckle wire to distal RCA IVUS in PDA via SVG IVUS guided re-entry I only say that because contrast alone cannot puncture through the anastomosis. It rides over it. I have not been successful yet (n=3). IVUS guided repuncture works great here (after #contrast1st). 👌🏼" [X Link](https://x.com/realarainmd/status/1937686175558344970) 2025-06-25T01:35Z [----] followers, [--] engagements "@jedicath @Hragy @jl35wilsonMD @TWilsonMD @AntoniousAttall @aymanka @mmamas1973 @mirvatalasnag @SarahFairley7 @Allison_Dupont Waqar what brand of stent is it also since you have IVUS images from now and before is this chronic stent recoil Also what did the run off look like after the first PCI" [X Link](https://x.com/realarainmd/status/1937858954455040120) 2025-06-25T13:02Z [----] followers, [---] engagements "@Hragy Agreed Hany - though EECP is still very popular in some practices. But the options we have now are a) less drastic and/or b) actually effective. More than just placebo. So better options now (perhaps)" [X Link](https://x.com/realarainmd/status/1937879262343709032) 2025-06-25T14:23Z [----] followers, [---] engagements "@evandrofilhobr Great result @evandrofilhobr. Did you go EP at all If you were IP then rota may have been a good option before the IVL. Difficult to say what that small dent in the mid RCA means for long term patency as long as the MSA is decent" [X Link](https://x.com/realarainmd/status/1939328928138559845) 2025-06-29T14:23Z [----] followers, [---] engagements "😳 Thank you for pointing this out. I have always prescribed the [---] mg dose. But this is not new - Wellbutrin vs. Zyban for example. Questions: 1) How often is Lodoco prescribed By anyone. 2) Would the research costs have been significantly lower if colchicine [---] mg had been used for the trials. 3) Given the large expense(s) involved with conducting drug trials what incentive (if any) is there for manufacturers to investigate generic and/or low cost indications for new trials 🤔" [X Link](https://x.com/realarainmd/status/1939471892022436156) 2025-06-29T23:51Z [----] followers, [---] engagements "Nice Kambis 👌🏼 I think ROTA-SHOCK was the way to go here. Other vessel prep combinations just dont give results this good - by angio or IVUS. The use of a DCB at this location is interesting and thought-provoking. 🤔 We typically use DES for aorto-ostial lesions in the US - partly bec. DCBs are costly (and have a different indication) and partly bec. of concerns about recoil. What has your experience been Do DCBs work well in this location" [X Link](https://x.com/realarainmd/status/1940206406445212148) 2025-07-02T00:30Z [----] followers, [---] engagements "@KambisMashayek1 @Boston @Shockwave @Medtronic Hahaha Touch my friend. So now we wait for someone somewhere to do the trial 🧐🤞🏼" [X Link](https://x.com/realarainmd/status/1940273883241963981) 2025-07-02T04:58Z [----] followers, [---] engagements "Here is a recent Lazarus CTO in a young diabetic with diffuse small vessel CAD and refractory angina. We tried to enroll her in COSIRA [--] but she is legally blind and cannot walk on the treadmill. The PCI was done as a last resort. We used #HDR to cross multiple angioplasties and a DCB. The range of balloon sizes was [--] - [---] mm Look at all the AW blush 6+ months of angina taken care of. 👌🏼" [X Link](https://x.com/realarainmd/status/1941704595170001261) 2025-07-06T03:43Z [----] followers, [---] engagements "Nice angio I will leave the discussion of CABG up to you guys (😂). From a technical standpoint IF PCI were the choice then IVUS first then provisional. I have treated this type of LM in every conceivable way incl. LM to LCX stent using JSBT to protect the LAD. Personally for low SYNTAX score patients a trial of PCI is not an unreasonable choice as long as a patient is aware that they may develop re-stenosis later. 👆🏼This assumes the patient takes medications and the operator uses best practices (incl. IVUS)" [X Link](https://x.com/realarainmd/status/1942613656476475841) 2025-07-08T15:56Z [----] followers, [---] engagements "I dont think so. Difficult to say with certainty but the distribution of calcium is such that the LCX ostium is more constrained here than the LAD ostium. Ibt may be difficult to keep open with a DCB alone. It all comes down to the geometry of the LM bif. + branch ostia ones ability to modify it favorably + and ability of the stent to withstand the physical forces exerted on it. Argument for DES: Greater patency now with risk of re-stenosis later Argument for DCB: No risk of stent failure with unknown risk of re-stenosis" [X Link](https://x.com/realarainmd/status/1942733189438382329) 2025-07-08T23:51Z [----] followers, [--] engagements "Sripal I see a LM bifurcation encased in calcium - much more bulky along the lower edge (towards the LCX). In my experience circumferential Ca constrains expansion more than plaque. 🤔 Thus in any [--] stent strategy one of branch ostia usually. ends up deformed - ovoid or D-shaped +/- area [--] mm2. 👉🏼 I hardly ever use the baseline MLA or PB to determine stent strategy (in any bifurcation). The Ca distribution 3D geometry of the bifurcation myocardium at risk and the intended Ca mod. strategy are more likely to influence me. (A recent post by @KambisMashayek1 has me intrigued about the use of" [X Link](https://x.com/realarainmd/status/1942800384579276857) 2025-07-09T04:18Z [----] followers, [---] engagements "@SripalBangalore @TWilsonMD @ShariqShamimMD @jl35wilsonMD @drAliyor @DrIHHashmi1 @DrWhyWho @DavidLBrownMD @aspergian1 @dukwoo_park Yes perhaps rota first for the LCX if the entire rim is calcified Rota Cut and Rota Shock both work great for nodules - usually better than either therapy alone" [X Link](https://x.com/realarainmd/status/1942931366225777147) 2025-07-09T12:58Z [----] followers, [--] engagements "The Left Mains Of Harris County Texas My favorite vessel to treat is the left main. It used to be the carotid but thats when I was a young(er) man. 😂 Here are [--] of 6() left mains that I encountered over my long weekend call. Three more after the jump" [X Link](https://x.com/anyuser/status/1943568429991997793) 2025-07-11T07:09Z [----] followers, 10.7K engagements "We also had to fix the RCA both prox. and distal. She has a small LCX and a large RCA distribution. (You can see that on the very last clip.) Her EF is surprisingly normal. So we decided to stage the LAD if needed. She is currently scheduled for a follow up PET scan. BTW the patient was turned down for poor targets by three surgeons. She is also taking sirolimus for cancer - which poses challenges for sternal wound healing" [X Link](https://x.com/realarainmd/status/1943649296034705549) 2025-07-11T12:31Z [----] followers, [--] engagements "@BagaiJayant Good question that came up with one of @agtruesdells ad hoc LM PCI cases. My point 👉🏼 ad hoc does NOT equal impromptu. Both are unforeseen by definition but ad hoc = purposeful (by design) and impromptu = unrehearsed. So ad hoc is acceptable good even. Impromptu is not" [X Link](https://x.com/realarainmd/status/1943923941384347897) 2025-07-12T06:42Z [----] followers, [---] engagements "Sachin I have been waiting to do a case like this From a purely technical point of view the anatomy is deliciously complicated. The key is to identify the origin of the aneurysm. It is from the LM proper the carina or one of the branches CTA and IVUS are both key. Re: the fix the you have poor support and putting coils in may be frustrating. But not impossible. (You can stabilize the guide by jailing a wire behind a stent). Or you could use an anchor in a SB. A novel option may be to wire both branches cover the aneurysm with a Papyrus then use the jailed wire as a guide to puncture the" [X Link](https://x.com/realarainmd/status/1944086744732692855) 2025-07-12T17:29Z [----] followers, [---] engagements "The Dastardly Nodule 😈 Case from pre-DCB era 👉🏼Recurrent ISR at RCA ostium. Note CN trapped bet. stent layers Pt. prev. recd Taxus Promus and Orsiro 😬 CN tamed with IVL and Resolute Pt. left w/ mild stable angina 🙌🏼 Bonus: Unique OCT image - Strut Snow Storm 😳🙏🏼" [X Link](https://x.com/anyuser/status/1947185832084865295) 2025-07-21T06:44Z [----] followers, [----] engagements "It is very similar to AI Hany - but even better Let me explain. AI systems are large language models (LLM) that understand and generate human language. Your mind is a LEM - large experience model that uses your lifes experiences to create an output - your thoughts. The human mind processes more info constantly than it is aware of - and our decisions are made quicker than we often realize. What we are aware of at any moment is just the tip of the cognitive iceberg" [X Link](https://x.com/realarainmd/status/1947216459911884826) 2025-07-21T08:45Z [----] followers, [---] engagements "@evandrofilhobr Great result Evandro👏🏼 Tom and Jeff are correct. This pt would be referred for CABG in many (not all) US centers. Few surgeons would turn this pt. down - focal CAD and 👌🏼 targets. BUT that makes her an ideal PCI candidate too 😍 That is the equipoise IMHO" [X Link](https://x.com/realarainmd/status/1947794724242313585) 2025-07-22T23:03Z [----] followers, [---] engagements "@evandrofilhobr is incredibly skilled - the kind of operator I would send my family to. 🤩 But many patients dont have the luxury of knowing their cardiologists skillsets. If this patient called you with these diagnostic images + asked your opinion what would recommend 🤔 70F retired nurse. IVUS guided distal ULM PCI. LM-LAD Provisional approach. DCB to LCx & 1st Diag. https://t.co/2apiNbTZ44 70F retired nurse. IVUS guided distal ULM PCI. LM-LAD Provisional approach. DCB to LCx & 1st Diag. https://t.co/2apiNbTZ44" [X Link](https://x.com/realarainmd/status/1947796402794308006) 2025-07-22T23:10Z [----] followers, [----] engagements "@akbarul @jedicath @mmamas1973 @ShariqShamimMD @abadkhan2002 @toreyj01 @aspergian1 @angna_86 @DrBIqbal @nadig_cardio @DrIHHashmi1 @JoySanyal74 Very nice To my eye this is a func. CTO caused by a Ca nodule in series with a tubular stenosis. I would use a soft PJW (Fielder FC SB Pilot 50) to engage/cross prox. RCA tip injection vs. #HDR finish crossing Rota CUT IVUS + DES *Use MC not OTW 🎈if you can" [X Link](https://x.com/realarainmd/status/1947888853450141960) 2025-07-23T05:17Z [----] followers, [---] engagements "We have a couple of very good surgeons at our place and I would probably have a discussion about CABG at least. Not the best LAD target but a decent one. The big issue with CABG is morbidity incl. worsening CKD. Re: PCI - this can be done with very low contrast. Probably [--] ml" [X Link](https://x.com/realarainmd/status/1947905970476142881) 2025-07-23T06:25Z [----] followers, [--] engagements "@NishithChandra @akbarul @jedicath @mmamas1973 @ShariqShamimMD @abadkhan2002 @toreyj01 @aspergian1 @angna_86 @DrBIqbal @nadig_cardio @DrIHHashmi1 @JoySanyal74 The key here is the LIMA Not just fixing the LAD w/ PCI. Why🤔 I believe a LIMA is generally better than a DES for THREE reasons: 👉🏼 It add a new source of blood to the cor tree (DES do not) 👉🏼 Has proven longevity (req. good 🎯) 👉🏼 Can usu. be done without compromising SBs" [X Link](https://x.com/realarainmd/status/1947927444591133118) 2025-07-23T07:51Z [----] followers, [---] engagements "Thoughts About The LIMA The case below has generated an interesting discussion about the virtues of CABG vs. PCI - the age old debate. Clinical evidence aside there are good physiologic reasons for choosing a LIMA. My thoughts (as a repost) to follow https://x.com/akbarul/status/1947850584721064423s=46 [--] yr old with dyspnoeaLvef-35creatinine [--] due to stable ckd.What would be your approach#CardioTwitter @jedicath @mmamas1973 @ShariqShamimMD @realarainmd @abadkhan2002 @toreyj01 @aspergian1 @angna_86 @DrBIqbal @nadig_cardio @DrIHHashmi1 @JoySanyal74 https://t.co/zHGfOO7Spz" [X Link](https://x.com/realarainmd/status/1947934788670611617) 2025-07-23T08:20Z [----] followers, [----] engagements "2/ The 🔑 here is the LIMA Not just fixing the LAD w/ PCI. Why🤔 I believe a LIMA is generally better than a DES for THREE reasons: 👉🏼 It add a new source of blood to the cor tree (DES do not) 👉🏼 Has proven longevity (req. good 🎯) 👉🏼 Can usu. be done without compromising SBs" [X Link](https://x.com/realarainmd/status/1947934991293280413) 2025-07-23T08:21Z [----] followers, [---] engagements "5/ Which makes the CKD a moot point in the face of a EF which has declined recently. No matter the etiology of the cardiomyopathy the clock is ticking. And further decline will definitely impact the kidney. Which is why I dont understand when folks wait on Rx in CKD" [X Link](https://x.com/realarainmd/status/1947938581525283286) 2025-07-23T08:35Z [----] followers, [---] engagements "6/ To conclude here are my LIMA conjectures: Visibility Conj.: A pt. is not a good CABG candidate if the LAD is not seen on angio Viability Conj.: Or if viability of the AW cannot be demonstrated Availability Conj.: Or if there is lack of availability of a 🎯 or conduit" [X Link](https://x.com/realarainmd/status/1947940404030017732) 2025-07-23T08:42Z [----] followers, [---] engagements "@murshid_eyad2 @akbarul @jedicath @mmamas1973 @ShariqShamimMD @abadkhan2002 @toreyj01 @aspergian1 @angna_86 @DrBIqbal @nadig_cardio @DrIHHashmi1 @JoySanyal74 From what I have read coronary endarterectomy is to the CV surgeon as CTO PCI is to interventionalists Not everyones skillset. The coronary here is very calcified - so CorEA may not be a good option. Hybrid - LIMA + RCA PCI is likely better 🤔" [X Link](https://x.com/realarainmd/status/1947943757229474134) 2025-07-23T08:55Z [----] followers, [--] engagements "@GopalKkoduru @akbarul @jedicath @mmamas1973 @ShariqShamimMD @abadkhan2002 @toreyj01 @aspergian1 @angna_86 @DrBIqbal @nadig_cardio @DrIHHashmi1 @JoySanyal74 Re: MSA again the answer is nuanced because a focal MSA alone is unlikely to account for variations in diffuse disease. MSA as a predictor of TLR works well but not so much for clinical events. Also flow across a stent DECREASES with time (ISR) but goes up thru a LIMA" [X Link](https://x.com/realarainmd/status/1948279250533925207) 2025-07-24T07:09Z [----] followers, [---] engagements "Final thoughts Yes DES is comparable to LIMA for focal proximal disease. But perhaps not so much when the disease is diffuse. Also the Berman paper is from [----]. It is likely that we contemporary 💊 Rx the ischemic thresholds to show mortality benefit with revasc. are higher. 🤔" [X Link](https://x.com/realarainmd/status/1948279869374149113) 2025-07-24T07:11Z [----] followers, [---] engagements "2/ The accepted threshold by SPECT is 10% from Dan Bermans classic paper in Circulation. We use Coronary Flow Capacity by PET which incorporates CFR + MBF and Lance Gould (the father of 🫀PET) reported a threshold of 10-15%. 12% splits the difference" [X Link](https://x.com/realarainmd/status/1948283895327195455) 2025-07-24T07:27Z [----] followers, [---] engagements "3/ Re: MSA the answer is nuanced because a focal MSA alone is unlikely to account for variations in diffuse downstream dis. MSA as a predictor of TLR works well but not so much for clinical events. Also flow across a stent DECREASES with time (ISR) but goes up thru a LIMA" [X Link](https://x.com/realarainmd/status/1948284189196898772) 2025-07-24T07:28Z [----] followers, [---] engagements "4/ Yes a DES is comparable to LIMA for focal prox. disease. But perhaps not so much when the disease is diffuse. Also the Berman paper is from [----]. It is likely that w/ contemporary 💊 Rx the ischemic thresholds to show mortality benefit w/ revasc. are higher. 🤔" [X Link](https://x.com/realarainmd/status/1948284819617571058) 2025-07-24T07:31Z [----] followers, [---] engagements "7/ So how do I treat diffuse small vessel CAD 👉🏼 If no prior stress use FFR for diffuse +/- moderate dis. (80%) 👉🏼 Use pullback to determine the step ups - mark any stentable ones. 👉🏼 Use IVI to Rx sig. prox. dis. + use JSBT to protect SBs [---] mm 👉🏼 End with strong 💊" [X Link](https://x.com/realarainmd/status/1948436067473870929) 2025-07-24T17:32Z [----] followers, [---] engagements "8/ Here is a recent example. These are still frames only. Small CAD with large AW ischemia by ☢. We are treating the LCx medically for now. No FFr bec. CAD is visually severe. The patients angina has improved and hes in cardiac rehab. follow up PET planned for [--] days 🙏🏼" [X Link](https://x.com/realarainmd/status/1948440255448629648) 2025-07-24T17:48Z [----] followers, [---] engagements "To Bypass Or Not To Bypass - Question Of The Day Here are all the LIMA conjectures combined into one 🔑 CABG should be preferred over PCI only if ALL [--] criteria are met 👉🏼 visible LAD target 👉🏼 viable AW 👉🏼 healthy LIMA 👉🏼 stable patient 👉🏼 appropriate surgical resources" [X Link](https://x.com/anyuser/status/1948660479942873189) 2025-07-25T08:23Z [----] followers, [----] engagements "@evandrofilhobr Can you send me more info. I am intrigued" [X Link](https://x.com/realarainmd/status/1948668124254896274) 2025-07-25T08:54Z [----] followers, [---] engagements "@AAbbot52838 Interesting question 👉🏼 Fixing the IRA lowers SYNTAX immediately so decision hinges on left-sided CAD/PCI complexity. For focal CAD or simple bif I would PCI first; failure will declare itself in [--] mo. For complex CAD Id consider a LIMA but wait [--] wks to hold DAPT" [X Link](https://x.com/realarainmd/status/1948755119345934560) 2025-07-25T14:40Z [----] followers, [--] engagements "@GopalKkoduru I see your point. But in fairness CABG hasnt changed bec. it is still the gold standard. We have been working on PCI to match CABG with all of its assoc. morbidities. But Im sure that surgical techniques have evolved in ways we are unaware of" [X Link](https://x.com/realarainmd/status/1948776129466147123) 2025-07-25T16:03Z [----] followers, [---] engagements "@RSohnMD Beautiful IVUS images 👌🏼 What wire did you use for the STAR I ask because most wire knuckles dont have the penetrating power to go into and out of the media - except perhaps the tight Mongo knuckle. (There is a valuable lesson here I am trying to figure it out. 🧐😅)" [X Link](https://x.com/realarainmd/status/1951183531218010447) 2025-08-01T07:29Z [----] followers, [---] engagements Limited data mode. Full metrics available with subscription: lunarcrush.com/pricing
@realarainmd Salman Arain
Salman Arain posts on X about lcx, hdr, lima, in the the most. They currently have [-----] followers and [---] posts still getting attention that total [-----] engagements in the last [--] hours.
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Social Influence
Social category influence cryptocurrencies travel destinations finance stocks technology brands currencies social networks countries fashion brands musicians
Social topic influence lcx #23, hdr, lima, in the, cto, injection, flow, yo, retro, prep
Top accounts mentioned or mentioned by @evandrofilhobr @hragy @laserrman @mmamas1973 @jedicath @sripalbangalore @mirvatalasnag @drbiqbal @aspergian1 @abadkhan2002 @michaelmegalymd @shariqshamimmd @lazzalinimd @stefanharb @drihhashmi1 @agtruesdell @jbspadoni @twilsonmd @mornei2011 @jl35wilsonmd
Top assets mentioned LCX (LCX) Calcium (CAL) Medtronic PLC (MDT)
Top Social Posts
Top posts by engagements in the last [--] hours
"There are several other ways to resolve plaque ambiguity - I have found this to be the quickest one. Another advantage is that I am using this exercise to train myself for 3D wiring. Its a win-win End of lesson 🙏🏼 #IVUS #CTOPCI #ADR #AWE #TDADR #HDR #BSCI"
X Link 2024-11-02T05:58Z [--] followers, [---] engagements
"A Stain Is Not (Just) A Stain #HDR #contrast1st #HDRanalysis #HDRFAQs #CTOPCI Here what we look for in a contrast microinjection stain: - CTO penetration distance - Width ( = or than ref. vessel) - Intensity - Leading edge (sharp or fuzzy) - Side branches (the best sign) - Persistence - Growth with wire insertion into the MC This is the alphabet of the language of contrast (as Dr. Carlino calls it) Lets learn to speak this new language together"
X Link 2024-11-14T14:42Z [---] followers, [---] engagements
"How many #HDR interventions does it take to become a successful #contrast1st operator 🧐 Just one 💧🙌🏼 It is all about the journey not the destination. Many CTO and CHIP operators have already been there without knowing it #HDR #contrast1st #CTOPCI #mindfulPCI"
X Link 2024-11-18T13:50Z [---] followers, [---] engagements
"I may be the outlier here but the immediate issue is deranged hemodynamics. So a RHC is essential followed by viability. I opted for LHC just because it gives me the opportunity to measure hemodynamics. Haha. Sure info about the cors too. Re: nuclear stress in someone with an EF of 15% not likely to be helpful"
X Link 2024-11-18T19:08Z [---] followers, [---] engagements
"Great case Bilal Great use of your epic surfing skills. Presence of collaterals implies high grade stenosis at culprit lesion (pre-MI) = probable viability Cant speak to #TDADR but we use MC injections for old thrombus +/- micro (IP) tortuosities #HDR works for clot too BTW I love this picture Need this software in every lab. 😂"
X Link 2024-11-19T04:23Z [---] followers, [---] engagements
"💧#HDRanalysis 🧐 Case [---] Here is a blast from the past - a case from 10/2022 before #HDR was a thing. Lets call it an #HDR Classic 📽 First the clip then the analysis #HDR #contrast1st #CTOPCI #HDRFAQs"
X Link 2024-11-19T06:07Z [---] followers, [----] engagements
"This is an LAD CTO in a patient with a low EF. There is a nice cap a relatively straight course a diseased target and IP calcium. This was my #HDR exploratory phase - we probe the cap with an XT"
X Link 2024-11-19T06:07Z [---] followers, [--] engagements
"Knuckles are safe contrast (delivered appropriately) is SAFER Here is beautiful video of a traveling knuckle✈👊🏼 courtesy of @AIU_Medical Note the wire track - and the behavior of the knuckle. Now compare that to the plaque disruption by contrast injection. See what I mean At #VIVA2024 CROSSLEAD showcased its precise maneuverability for navigating tortuous CLI vessels to reduce radiation & contrast media. Interested Sign up for a hands-on demo & wire training here: https://t.co/FBCsvkDVKP #PeripheralVascularCare #vasctwitter #Irad https://t.co/PUqeLCUPHr At #VIVA2024 CROSSLEAD showcased its"
X Link 2024-11-19T06:07Z [----] followers, [---] engagements
"Mid ✈ Musings Tip injections are an integral part of #HDR. They are also useful in non-CTO #PCI Here is recent case (sorry stills only) What wire + tip shape do you start with A tip injection reveals the anatomy🧐 👉🏼 XT + Culotte for the win🙌🏼"
X Link 2024-11-19T20:08Z [---] followers, [----] engagements
"#HDR is happening💧🙌🏼 The response to #HDR has been nothing less than spectacular. Here is a partial list of places where #HDR is changing #CTOPCI Milan (birthplace of #HDR) Houston (#HDR 🌎 capital) 😀 Minneapolis Karachi Lahore Islamabad Sapporo (2nd city of #HDR) New Delhi Oradea Romania Maceio Brazil Chicago Coming soon to a cath lab near you 🤩"
X Link 2024-11-20T05:27Z [---] followers, [----] engagements
"If you are new to #HDR you can catch up by searching for the hashtags #HDR - cases discussions tips #contrast1st - more #HDR talk and cases #HDRanalysis - analysis of #HDR cases from around the 🌎 #HDRFAQs - answers to your questions Happy #HDR hunting💧🧐"
X Link 2024-11-20T10:40Z [---] followers, [---] engagements
"@Cryptoneday HydroDynamic contrast Recanalization (HDR): Description of a new crossing technique for coronary chronic total occlusions - PubMed https://pubmed.ncbi.nlm.nih.gov/39327837/ https://pubmed.ncbi.nlm.nih.gov/39327837/"
X Link 2024-11-21T01:17Z [---] followers, [--] engagements
"You can use #HDR for any CTO as long as you can puncture the proximal cap and park an MC. The key is to LEAD with contrast = #contrast1st. The injection should be within [--] mm of the angiographic PC - EVEN if the wire is moving freely within the CTO 👉🏼 Rationale: 1) Wires (e.g. Gaia family) can breach the IP/EP boundary without much tactile feedback. 2) A wire track cannot be undone 🔑 #HDR only works if the contrast is delivered IP AND has the ability to penetrate the plaque"
X Link 2024-11-21T01:32Z [---] followers, [---] engagements
"Best cases to start include a combination of the following factors: - Well defined PC - Short length - Relatively straight - Minimal calcium - In-stent occlusion - Good retro bailout options Try #HDR if you find a CTO with [--] or more of the features noted above. #HDRFAQs #contrast1st #HDR"
X Link 2024-11-21T01:37Z [---] followers, [---] engagements
"Stuck Between A Rock A Rock A Rock And A Hard Place (Prelude to a nice hack) 🧵 #CTOPCI tools/skills translate nicely to non-CTO PCI. Here is a sticky situation from earlier today [--] y/o 👨 with failed SVG to PDA. Failed PCI at OSH. You can see where the title comes from"
X Link 2024-11-21T06:52Z [----] followers, 12.1K engagements
"@evandrofilhobr @SyedYNaqvi1 @Laserrman @MauroCarlino3 @mornei2011 @DrBillLombardi @agtruesdell @KambisMashayek1 @stefan_harb @RinfretStephane @LAzzaliniMD Exactly Which is why the no tip XT is the 🔑 here If the tip catches - IP micro tortuosity or EP architecture If it crosses WITHOUT bending - your are IP Like an secret service mission Throw the contrast first send in your scouts (i.e. XT) then the rest of the team 🫡😀"
X Link 2024-11-22T11:51Z [---] followers, [---] engagements
"Mid ✈ Musings This is a post I have been trying to write for [--] years The TIP IN Technique - why it works almost EVERY time 🤔 Lets start by looking at a recent still frame. You see a familiar friend the NO TIP XT. You also see two MCs in the guide"
X Link 2024-11-23T20:55Z [----] followers, 12.2K engagements
"Looking at this we can predict where the wire will enter the MC.👉🏼👈🏼 Theoretically it is the SAME point regardless of which direction the wire is coming from (green dot) - as long as the inner curves are smooth. You can change this by pushing or pulling on the guide 😲"
X Link 2024-11-23T20:55Z [---] followers, [---] engagements
"💧#HDRanalysis 🧐 Case [---] Once you recognize an #HDR stain you start to notice other subtleties This case highlights that an more. [--] year 👴 with CCS III angina - improved but not resolved with 💊 Baseline is [--] m ago. This is an evolving CTO Intervention to follow 🧵"
X Link 2024-11-25T22:00Z [---] followers, [----] engagements
"This is a common problem with RCA CTOs in the elderly 👉🏼 Widened root 👉🏼 Ostial disease 👉🏼 Low + anterior take off We get some clues about the CTO - calcium + thrombus + ISR. A spicy gumbo 🦐"
X Link 2024-11-25T22:00Z [---] followers, [---] engagements
"This is the 🌟moment - the #HDR There is so much going on I have analyzed it in two images. But the 🔑 message here is this: #HDR can offer a solution for POOR guide support 👉🏼 Wires can push guides back (and out) - contrast can NOT 🤔"
X Link 2024-11-25T22:00Z [---] followers, [---] engagements
"Notice there is contrast OUT side the stent - the asterisk. 👉🏼 Contrast tells you the stent is UNDER sized before even crossing 😲 The crossing itself is the closest #CTOPCI is nothing short of poetry in motion 😍 No guide pushback - at ALL"
X Link 2024-11-25T22:00Z [---] followers, [---] engagements
"Here is the IVUS run. So many findings that we could have predicted [--]. Recanalized thrombus (explains change in baseline RCA) [--]. Calcium [--]. Remodeled vessel (note the wide stain) [--]. Undersized stent [--]. Possible nodule at prox stent edge (based on #HDR + wire movement)"
X Link 2024-11-25T22:01Z [---] followers, [---] engagements
"Seen at the MUJI Ginza store in Tokyo earlier today It is untitled (and I am not the artist) but I Dream Of Contrast seems to be an appropriate title. Happy Thanksgiving #HDR #contrast1st #CTOPCI #MUJI"
X Link 2024-11-29T07:19Z [---] followers, [--] engagements
"Seen at the MUJI Ginza store in Tokyo earlier today It is untitled (and I am not the artist) but I Dream Of Contrast Modulation seems to be an appropriate title. Happy Thanksgiving #HDR #contrast1st #CTOPCI #MUJI"
X Link 2024-11-29T07:37Z [---] followers, [---] engagements
"💧 #HDRanalysis 🧐 Case [---] - Return To Work Edition This is a case from today. A colleague with history of LAD PCI (2005 2011) with unstable angina. The case is presented Sapporo style. 🧵 TPLP+G2 for cap puncture #HDR XT crosses into TL IVL JSBT for D2 protection #HDR #HDRanalysis #contrast1st #CTOPCI #singleaccess #JSBT"
X Link 2024-12-03T06:33Z [----] followers, [----] engagements
"Nice What is your approach to nodular calcium I have settled on a divide and conquer strategy - rota followed by IVL or aggressive cutting 🎈PTA. Images: baseline post rota post CBA (18 atm) post DES I ❤ to see luminal gain (MSA) as well as resolution of the lumen eccentricity. What is your style @evandrofilhobr @Laserrman @jbspadoni @ziadalinyc @calcbreaker @rotamonster @DrBIqbal @jbspadoni @rickytiago @agtruesdell @TWilsonMD @mirvatalasnag @mmamas1973 @rajivxgulati @DMemmini @AgostoniPF @stefan_harb"
X Link 2024-12-04T14:17Z [---] followers, [---] engagements
"That is the worst kknd of calcium - malignant The stent breaker Ca. I think rota makes IVL more effective in nodular calcium. The extra $ and time is worth it. My rota technique has landed on FFS (pun unintended 😂: fast fast slow. [---] [---] [---] IVL"
X Link 2024-12-04T14:37Z [---] followers, [---] engagements
"@rotamonster @EuroInterventio @Laserrman I see. This explains why IVL performs better after rota - in my experience. Of course this may be recall bias. But you can see it in my images too (though we used cutting balloons not IVL). Pre and post rota (before any other device)"
X Link 2024-12-06T01:29Z [---] followers, [---] engagements
"💧 #HDRanalysis 🧐 Case [---]. - The Persistence of Stains This one of my all time favorite cases - in part because we have a complex stain pattern [--] y/o 👨 with CABG in [----] and failed SVG to RI. 🎯 is LM. TPLP+G2 puncture #HDR complex stain no tip XT blocking 🎈assisted wiring Culotte final The entire case"
X Link 2024-12-06T07:59Z [----] followers, [----] engagements
"The conventional #CTOPCI approach would have been: dual angio AWE entry into branch #2 or #3 🤞🏼 IVUS guided wiring of other branch. ADR would have been tricky given short LM trifurcation at distal cap and angulation of RI and LCX There are several retrograde options"
X Link 2024-12-06T07:59Z [---] followers, [---] engagements
"And now the magic of the no tip XT - one of my first uses of the wire. The wire seems to hesitate at the trifurcation sniff out the correct path 🐕 and take off in the correct direction Haha Blocking balloon for the win"
X Link 2024-12-06T07:59Z [---] followers, [---] engagements
"Good question That stain forms 1st. It is in the EP space of the LAD. The wire goes deep after cap puncture - that directs contrast towards the LAD first. However contrast also tracks towards the RI/LCX via #HDR. Once it breaks through the pressure on the LAD side is relieved and the EP stain stops growing"
X Link 2024-12-06T13:21Z [---] followers, [--] engagements
"Good question That stain forms 1st. It is in the EP space of the LAD. The wire goes deep after cap puncture - that directs contrast towards the LAD first. However contrast also tracks towards the RI/LCX via #HDR. Once it breaks through the pressure on the LAD side is relieved and the EP stain stops growing"
X Link 2024-12-06T13:23Z [---] followers, [---] engagements
"💧 #HDRanalysis 🧐 Case [---] - When is #HDR not #HDR Edition This is a case of a failed #HDR sent by Dr. Hashmi - an early adopter of the method. I decided to do a full analysis because it highlight important aspects of wire behavior during #HDR. Case here discussion to follow. @realarainmd The case for HDR analysis. https://t.co/Q8h5Vs01CN @realarainmd The case for HDR analysis. https://t.co/Q8h5Vs01CN"
X Link 2024-12-07T06:44Z [----] followers, [----] engagements
"To me this is possibly a functional CTO vs. a long subtotal occlusion. Lets start by looking as the wire. The no tip PJW is in a septal - the only way a soft straight wire can end up in this position is by navigating a thin straight channel. Thus the wire likely marks the TRUE lumen"
X Link 2024-12-07T06:44Z [---] followers, [---] engagements
"The principle of #HDR is contrast modulation of plaque - i.e. the injection must be INTRA plaque. Here the injection with the MC seems to be intraluminal - which is good news because the distal TL lights up So we need to decide where is the connection"
X Link 2024-12-07T06:44Z [---] followers, [---] engagements
"Congratulations Mauro On another successful LIVE #HDR case. We have seen [--] live #HDR cases this year (Pakistan Germany and Hungary). That is [--] more than we would have had expected in January Hopefully we will see more in [----] I would love to see the 🌎 #CTOPCI community kick the tires of #HDR 😀"
X Link 2024-12-08T00:43Z [---] followers, [---] engagements
"@HeartOTXHeartMD @_radikalek @DocSavageTJU @SandeepNathanMD @Radial_ICG @djc795 @nolanjimradial @SVRaoMD @mmamas1973 @EricSecemskyMD @Hragy @willsuh76 @DrSaririan @MGtberg @aspergian1 @DrWhyWho @fischman_david @aymanka @moiz_hafiz @iamritu @sarahkmels @ecgrhythms @cardiojaydoc02 @angioplastyorg @X I am amazed by the number of pretty young women who like the highly technical content on my account. Haha. And the crypto peddlers. CTO PCI is much more popular than I would have imagined. 😍"
X Link 2024-12-08T20:33Z [---] followers, [---] engagements
"@jbspadoni Thats a great result 👏🏼 Did the G2 go all the way across the stent And did you try #HDR at any point. This is good result - you saved several branches. Also by uncoupling the LAD and LCX the LCX should already be perfusing better. 👌🏼"
X Link 2024-12-11T04:49Z [---] followers, [---] engagements
"💧 #HDRanalysis 🧐 Case [---] - What is YOUR stain threshold A 🧵 Today we treated an LAD CTO with an ambiguous cap and a failing LIMA graft. There were few retro options. Ambiguous caps are always tough to treat but this was one of the top [--] toughest cases of this year 😯"
X Link 2024-12-11T05:59Z [----] followers, [----] engagements
"⚠: The images that follow may be disturbing to some operators 😯 We used contrast modulation - several times. The protocol is simple: puncture inject pass wire repeat. The evolving stain was very helpful in redirecting our wires around it. 👉🏼 We even got the diagonal once (I didnt like the entry point)"
X Link 2024-12-11T06:00Z [---] followers, [---] engagements
"We finally punctured the true cap using an innovative technique: We blocked the septal with a [---] mm balloon + blocked the EP entry with the MC then used Sasuke + G3 for precision puncture into the TL. 🙌🏼 Far from being a hinderance the stain gave us a ref point 🧭"
X Link 2024-12-11T06:01Z [---] followers, [---] engagements
"This was an unusual CTO several reasons. 1) An unusual cap. Most caps are close to a branch - so the true cap is distal to where it initially appears to be 2) The CTO morphology is unusual - several tight twists and lucencies 3) It was a re-do - we eont know the circumstances"
X Link 2024-12-12T08:47Z [---] followers, [--] engagements
"The CTO body has a unique appearance. Here it is side-by-side with an LCX we fixed today. 👉🏼 The CTO has a cork screw look in places and a moth bitten appearance. 🔑 To me this implies recanalized thrombus This has implications on the crossing and #HDR as we see"
X Link 2024-12-12T08:47Z [---] followers, [---] engagements
"George I dont see the circumflex ostium that well. As the general rule look for the region at which the competitive flows converge. Generally the lesion is at that location. If there is no lesion then the flow is equal in both RCA and LCX and your injection is transiently reversing it"
X Link 2024-12-12T14:44Z [---] followers, [---] engagements
"@Laserrman @DaitaroK @calcbreaker @SKuramitsu0511 @tadano98 @rotamonster @OpolskiMP @jcspratt @KambisMashayek1 Yes just different flavors of contrast modulation. Some combinations of #contrast1st (start end inj 👉🏼 meaning) IP IP or TL 👉🏼 #HDR IP EP 👉🏼 contrast mod EP entry EP IP 👉🏼 #HDR (you see SBs) EP TL 👉🏼 contrast guided (micro) STAR EP EP 👉🏼 contrast mod EP tracking"
X Link 2024-12-13T06:43Z [---] followers, [---] engagements
"A very good case - this time involving a trifurcation. #HDR makes it look easy (But we know it takes skill). 👏🏼 #HDR [--] showed you the lower SB - the OM2. I may have taken that and then re-punctured to the LCX. The reason is that PTCA inside the stent can displace NIH and occlude the SB ostium (which is already behind NIH + metal). (This happened in a case I showed here - where we lost an SB. Not from #HDR but post dilation)"
X Link 2024-12-14T04:56Z [---] followers, [---] engagements
"💧 #HDRanalysis 🧐 Case [---] Not the bees knees but still sweeter than honey Edition A 🧵 on #HDR in tough ISOs #HDR is ideal for ISOs - indeed many of the cases discussed here have involved stents. BUT these lesions can be tough for #HDR too Case here analysis after the jump"
X Link 2024-12-14T09:36Z [----] followers, [----] engagements
"This was another tough proposition: hard calcium ISO longish lesion blunt cap and challenging retro options Here is the sequence: TP + multiple wire for puncture (MGG2G3Hornet) #HDR no tip XT CBA + DES The MC barely crosses the prox. cap - even with support"
X Link 2024-12-14T09:36Z [---] followers, [---] engagements
"Lets look at the HDR. Again you see a sequence of events - stain at the MC tip (type 1) reflux into a septal EP infiltration and peri adventitial streaming My hypothesis 👉🏼 in a CTO all layers are fused thus contrast penetrates the outer layers - this is NOT a perf"
X Link 2024-12-14T09:37Z [---] followers, [---] engagements
"💧 #HDRanalysis 🧐 Case 022: The Dreaded Ambiguous Cap And A Simple Way To Resolve It Here is an early X-mas treat for all #HDR and #CTOPCI aficionados. The case involves a tough CTO type - the mid LAD with an ambiguous cap. The entire case is here discussion to follow"
X Link 2024-12-18T17:15Z [----] followers, [----] engagements
"Great question - short answer it varies. Several of the non-HDR cases discussed here have involved calcium. My case in the [--] year old for example. Also @SripalBangalores stellar #HDR facilitated rota case from yesterday. Angiography cannot tell us about the Ca distribution - but CTA might. However #HDR will typically find/create a path is there is soft (modifiable) plaque. 👉🏼 My advice start with #HDR even in calcified cases. There is no downside - but you may succeed and that will save time (and perhaps side branches)"
X Link 2024-12-19T07:03Z [---] followers, [--] engagements
"@evandrofilhobr @AntoniousAttall Interesting. I have never actually tried that but now I am intrigued. There is a technique where folks run cutting balloons in a similar fashion but for a different purpose. From what I recall it is meant for CTO investment"
X Link 2024-12-19T18:39Z [---] followers, [---] engagements
"Here is a mini tutorial on how to prep the MC for contrast injection for #HDR. Remember: the injection is SLOW and GENTLE. Thank you @jaygirimd for the question and @aspergian1 for the 100% accurate answer #HDR #HDRFAQs #contrast1st @aspergian1 @jedicath @DrBIqbal Thanks for step by step. Can you just expand a bit on the wire withdrawal partJust have a little contrast flowing out into the hub while wire is still in the lumen taking up space Wouldnt this still leave some potential space in MC that would cause initial air injection @aspergian1 @jedicath @DrBIqbal Thanks for step by step. Can"
X Link 2024-12-20T04:32Z [----] followers, 11.1K engagements
"@jedicath @jaygirimd @SripalBangalore @LAzzaliniMD As such the #HDR did not fail. This is what #HDR in organized thrombus behaves. 🔑 #HDR works over very SHORT distances. 🔑 This CTO likely has hard Ca at the edges and a spongiform core - this locks in the contrast 🔑 It also explains the behaviors of the wires"
X Link 2024-12-21T05:03Z [---] followers, [---] engagements
"Sequence [--] A Rotawire ES os advanced into prox. LAD atherectomy TP LP across CTO final after CB PTCA and DES x2"
X Link 2024-12-21T07:11Z [---] followers, [---] engagements
"Final Thoughts This was a complicated #CTOPCI 😯 Challenges included: Failed prior attempt Flush ostial LM CTO - blunt Heavy() calcium Post CABG patient Distal cap at trifurcation Old SVG as retro option A combination of #contrast1st and BIDIRECTIONAL #HDR helped us resolve the challenge Long length"
X Link 2024-12-21T07:11Z [---] followers, [---] engagements
"Aptly summarized Stefan. I have come to believe that most CTOs have hidden potential channels. Mauro Carlinos gift to us is the use of IP contrast delivery to uncover these pathways. My use of the no tip XT evolved over time - as I experimented with different PJWs. The tip slowly disappeared into nothing Like the Cheshire Cat in Alice in Wonderland Haha. @MauroCarlino3 @esbrilakis @Laserrman"
X Link 2024-12-21T13:24Z [---] followers, [---] engagements
"Sripal are you talking about reverse (hairpin) wires or wires for SB in general A Suoh reverse wire would be impressive by virtue of the fact that it loses its unique features when bent. It is so soft. But then again you have mad skills. Re: tapered tip PJW for RWT I like them because I can knuckle them once across the ostium of the retroflexed SB"
X Link 2024-12-21T17:06Z [---] followers, [---] engagements
"@SripalBangalore @Laserrman @ShariqShamimMD @aspergian1 @evandrofilhobr @willsuh76 @jl35wilsonMD @SVRaoMD I think I get it 🤔 Yes in a diseased distal main branch the wire tip catches and the knuckles unravels. Interestingly the way I have dealt with that is to twist the wire - doing so makes the knuckle tighter then I just untwist it when the wire tip is near the SB ostium"
X Link 2024-12-21T17:30Z [---] followers, [---] engagements
"@drAliyor #HDR is the embodiment of mindful PCI. No rush and no drama but no less excitement. And its efficient. Thats why I like it so much 👌🏼"
X Link 2024-12-21T17:45Z [---] followers, [--] engagements
"@arnavkumar @Houston @pranav_loyalka @DLBHATTMD @YChatzizisis Congratulations Arnav on your #my1stHDR 👏🏼 Great job - it was interesting because you went against the typical #HDR - INTO the stent vs. out of it. (From a Eastern philosophy perspective there is no inside or outside. Haha. But that is a debate for another time) Well done"
X Link 2024-12-26T02:25Z [---] followers, [---] engagements
"@MarekRadomski71 @Hragy @TWilsonMD @DMemmini @jl35wilsonMD @ShariqShamimMD @jbspadoni @Laserrman I use the example of hip surgery - but I like yours better It is very gratifying to see these patients who can get back to enjoying life - unencumbered by dyspnea and/or fatigue 🤩"
X Link 2024-12-28T06:00Z [---] followers, [--] engagements
"💧#HDRanalysis 🧐 - Case [---] An CTO Intervention Unlike Any You Have Seen 🧵 Here is an unusual CTO for most. The patient is a [--] year old woman with systemic sclerosis (SSc) Raynauds and non-healing ulcer of the left 3rd digit. Here is the patients hand. More👇🏼"
X Link 2024-12-28T07:03Z [----] followers, 29.8K engagements
"2/ The hand is typical for SSc with digital ischemia - something I have been treating since [----]. Note the swollen digits effacement of the skin folds (digits #1-3) and the non-healing ulcer The angiogram explains why"
X Link 2024-12-28T07:03Z [---] followers, [----] engagements
"3/ The patient has occlusions of BOTH the radial and the ulnar at the wrist 🔑 Ulnar occlusion is found in 85% of such patients 🔑 Etiology is complex and involves vasculitic vascular wall thickening + spasm + thrombosis 🔑 Refractory ischemia is rxd (usu. unsuccessfully) with sympathectomy - note scar"
X Link 2024-12-28T07:03Z [---] followers, [----] engagements
"6/ This is not entirely new. We reported this strategy (sans #HDR) in [----] Total Percutaneous Revascularization of the Hand to Treat Refractory Digital Ischemia in Advanced Systemic Sclerosis JACC: Case Reports https://www.jacc.org/doi/10.1016/j.jaccas.2021.12.006 https://www.jacc.org/doi/10.1016/j.jaccas.2021.12.006"
X Link 2024-12-28T07:04Z [---] followers, [----] engagements
"7/ Lets do the #HDRanalysis These lesions are usually very fibrotic and the CTO architecture is different from coronaries However #HDR still works - ll the way down to the digital arteries There is some EP infiltration but the crossing is quick Months to years of occlusion crossed in the blink of an eye"
X Link 2024-12-28T07:04Z [---] followers, [----] engagements
"8/ We dont know the optimal revasc. strategy - I typically use balloons. 👉🏼 These vessels are too small for stents 👉🏼 Recurrence rates high BUT 👉🏼 Healing rates are much higher - which is the goal as with LE CLI 🔑 We usually admit the patients for 3-5 days of Flolan"
X Link 2024-12-28T07:04Z [---] followers, [----] engagements
"9/ For many patients the relief in pain and hand stiffness is immediate. 😍 Note the flexed fingers and improved color of the entire hand - before Flolan"
X Link 2024-12-28T07:04Z [---] followers, [----] engagements
"10/ This patient did well. This is the hand prior to discharge. The fingertip already shows signs of wound healing - but there is underlying calcinosis (a known complication of SSc). The patient underwent a limited digital amputation - but the healing was quick and we saved the other digits"
X Link 2024-12-28T07:04Z [---] followers, [----] engagements
"11/ Hand ischemia is more common than we imagine - with poor treatment options Many vasculitides are associated with digital ischemia and there few options for medically refractory cases. Many patients have occlusions at or below the wrist. We like to treat these percutaneously if possible. (This explains my profile picture 🤩 I have countless pictures like this one. Some examples)"
X Link 2024-12-28T07:04Z [---] followers, [----] engagements
"12/ Anyway coming back to #HDR the principle is the same - contrast can go where wires wont at least not easily. This is the last detailed #HDRanalysis for the [----] I wanted it to be a special one. 🤩 Hope you are enjoying talking about #HDR as much as I am. I look forward to keeping the conversation going 🙏🏼"
X Link 2024-12-28T07:04Z [---] followers, [----] engagements
"@MauroCarlino3 @Laserrman @MdM_Ochiai @esbrilakis @LAzzaliniMD @DrBIqbal @ziadalinyc @RinfretStephane @KambisMashayek1 @AgostoniPF @stefan_harb @Texan2007 @KovacicMihajlo @OpolskiMP @swissCTO @BongKiLee3 @dautov_MD @DMemmini @evandrofilhobr @rickytiago @Hragy @TWilsonMD @jl35wilsonMD @grantham_aaron @SanjogKalra @BElbarouni @mirvatalasnag @kalazizimd @SripalBangalore @realjaimehudson @tadano98 @CurtAltmann @MitchellJi40220"
X Link 2024-12-28T07:04Z [---] followers, [----] engagements
"@DorBen @DrBillLombardi @joe_nolatx @RhianEDavies1 @jbspadoni @CtoEuro @sapporohunt @PCRonline @MLCTOAcademy @OptimaCTO @SCAI @skat_ct @CCAD_MHIF @agtruesdell @yassersadeknhi @MichaelMegalyMD @dautov_MD @DrIHHashmi1 @abadkhan2002 @aspergian1 @A_B_Hall @jedicath @jaygirimd @RajanPatelMD @SandeepNathanMD @SanjogKalra @mornei2011 @timir_paul @dandu_n @melsharabasssy @ShariqShamimMD @Pooh_Velagapudi @tomkaier @arnavkumar"
X Link 2024-12-28T07:04Z [---] followers, [----] engagements
"That is food for thought - though my personal experience suggests otherwise. When the MC exits an OPEN vessel (prox. or distal TL SB or collateral) you create a stable route for blood escape 👉🏼 perf. by default. When it exits the CTO body (plaque to pericardium) the pressure head is too low and transient to sustain the channel. It never gets to the point of blood loss. There is a subtle but real difference"
X Link 2024-12-28T18:22Z [---] followers, [---] engagements
"Using The #HDR Contrast Stain To Guide Wiring in #CTOPCI As promised here is a case that shows how the stain from a failed #HDR attempt can be used to guide cap re-puncture and wiring. The target 👉🏼 a heavily remodeled LCX/OM2 with an amb. cap. #HDR #contrast1st #CTOPCI"
X Link 2024-12-30T13:27Z [---] followers, [----] engagements
"@abadkhan2002 You pick one and go from there He had a sub-total LAD and ramus too. The plan was to fix the ramus + LAD +/- LCX and stage the RCA. This is only part of the intervention. The ramus is done and then the LCX (shown) followed by the LAD. Complete results below"
X Link 2024-12-30T14:33Z [---] followers, [---] engagements
"Now the analysis Calcified blunt caps are always tough. Specially when the vessel has a large size. ⚠ Here the issue is that the G3 is too deep before the #HDR. 👉🏼 Beware of the hi-tip load wire that easily glides across the CTO - it is usually EP. 🔑 The way we published the technique the G2 should not penetrate more than 3-4 mm"
X Link 2025-01-01T18:55Z [---] followers, [---] engagements
"Something doesnt add up here. If the patient has only had progressive angina for [--] weeks (and stable angina for a year) - there must be a LM. Or a better stump. This patient needs (in order): aggressive medical therapy coronary CTA dual injection angiography. PCI may be an option depending what the CT and angio reveal. I dont see a good LIMA target but the LM may be underfilled"
X Link 2025-01-04T15:23Z [---] followers, [---] engagements
"In my last comment I meant that the LAD may be underfilled. The usual scenario of a missing LM turns out to be either an anomalous take off or dual ostia (separate for LAD and LCX). If the patient has a single coronary then the left system arises proximally and typically has an intra septal course. Let us know how it goes"
X Link 2025-01-04T15:55Z [---] followers, [---] engagements
"@MichaelMegalyMD Very nice Michael 👏🏼 Thank you for sharing this. #HDR failure may be the first step to ADR success. Can you share just the #HDR clip Perhaps one with the MC in place The nice thing is that uou created a linear channel along side the TL. An ideal Stingray setup. 👌🏼"
X Link 2025-01-05T16:23Z [---] followers, [---] engagements
"@MichaelMegalyMD nicely shows how #HDR failure does NOT equal #CTOPCI failure. 🤔 On the contrary #contrast1st is a (quick) first step if you decide to use ADR. 👌🏼 IF Michael had come retro the #HDR would have set him up for re-entry. What @DrBIqbal calls Carlino CART Though H-CART may be a more contemporary term Haha. Here is what I did Cap puncture with Gaia III then tried HDR but ended up subintimal distal anyway Thought a lot to try ADR in a s diseased vessel and risk a lot of hematoma or go right away to this usable epicardial that would make the procedure fast. Decided to do one trial"
X Link 2025-01-05T16:36Z [---] followers, [---] engagements
"@MichaelMegalyMD Nothing to sell Michael - youve already bought it Haha. It is yours to keep. 😀"
X Link 2025-01-05T16:38Z [---] followers, [---] engagements
"@MichaelMegalyMD Also I saw it but the miniature clip doesnt allow analysis. It is tiny on my phone - and it goes by too fast. 😢 or maybe I need glasses Haha"
X Link 2025-01-05T16:40Z [---] followers, [--] engagements
"@Laserrman Here is something I wrote a few days after I made the account. I feel even more confident about my proclamation today than I did back then 😀 https://x.com/realarainmd/status/1853184373962502302s=46 THREE of the most exciting things in CTO PCI right now: 1) Up front contrast modulation 🩼💧 2) Knuckles 🤛 3) Tip detection wiring/puncture 🔍🎯 Here is a case that highlights #1 and #3. Also an intro to the Contrast Modulation 1st philosophy #HDR #contrast1st #CTOPCI https://x.com/realarainmd/status/1853184373962502302s=46 THREE of the most exciting things in CTO PCI right now: 1) Up"
X Link 2025-01-07T00:41Z [---] followers, [---] engagements
"@drAliyor Nice case Aliyor. How old was the LAD stent Also did you use IVL in the LM at all Great result. Stent landed nicely at the LM ostium. And the LCX is hanging in there"
X Link 2025-01-07T13:02Z [---] followers, [---] engagements
"#HDRanalysis - Happy New Year Edition 🧵 The first #HDRanalysis of [----] The case was posted earlier by @evandrofilhobr - a man who needs no introduction here. There were three #HDR injections - with three() different patterns. Case below my analysis to follow #CTO101 #HDR #CTOPCI Interesting RCA CTO PCI @realarainmd maybe I get honor to get your inputs in this case. Still don't know how to name the crossing technique lol 😅 (I'm sure the patient don't care) https://t.co/m7E8IDCXAw #CTO101 #HDR #CTOPCI Interesting RCA CTO PCI @realarainmd maybe I get honor to get your inputs in this case."
X Link 2025-01-08T06:33Z [----] followers, 10.3K engagements
"An additional comment 👉🏼 The XT was likely IP it was the retro G3 that took you EP. An XT has a soft tip and it doesnt take much to deflect it. So there are two aspects to the wires movement - tip deflection and resistance. [--]. No deflection no resistance - likely IP rarely EP [--]. No deflection with resistance - very likely IP [--]. Deflection no resistance - likely EP rarely IP in small TL (safety knuckle) [--]. Deflection with resistance - definitely EP pre-knuckle 👆🏼 My rationale is admittedly conjecture this point but you do enough of these and you get some idea of wire behavior"
X Link 2025-01-10T16:40Z [---] followers, [----] engagements
"@jedicath @Obisht @hectortamezmd @skat_ct @DrBIqbal @aspergian1 @yassersadeknhi @kalazizimd @abadkhan2002 @agtruesdell @LAzzaliniMD Nice result Waqar. What microcatheter do you prefer to use Is that a FineCross Also Ive come to a point in life where I always inject through the MC. Its a win win 👉🏼 you either get a tip injection or an IP microinjection (#HDR hopefully). 🤩"
X Link 2025-01-11T18:04Z [---] followers, [---] engagements
"A Twisted Tale 😯 (Or We Took The Scenic Route Around The Mountain 🏔) [--] year old woman with RLE claudication. US showed occlusion of the CFA. I will let the angiogram speak for itself"
X Link 2025-01-12T07:41Z [----] followers, 12.9K engagements
"3/ The crossing tools are simple - a TurnPike LP and a Sion Black. Rather several Sion Black wires. The TurnPike LP is unique because of a double nitinol coil in addition to a PTFE + braided inner tube and an outer polymer casing"
X Link 2025-01-12T07:42Z [----] followers, [---] engagements
"4/ This allows the TurnPike LP to build up torque and move forward whichever way you torque it. This is similar to the Corsair Pro XS (with one coil) and the Mamba Flex (several coils from hub to tip). Each catheter has its unique properties and advantages"
X Link 2025-01-12T07:43Z [----] followers, [---] engagements
"Haha. We have a running joke in our Cath Lab. Its something I have said for as long as Ive been teaching. It is a list of the enemies of the week. Thrombus is always number one Calcium is up there but it rarely displaces thrombus. Other top contenders include guide induced dissection perforation. and no flow. 😂"
X Link 2025-01-16T02:39Z [---] followers, [---] engagements
"@StevenMathern @stefan_harb @aspergian1 @evandrofilhobr @Laserrman @TWilsonMD @simonjwilson1 @dr_oss @hwcc0314 @VRejeki28 @jianshanzhiyi1 @MauroCarlino3 @GLGasparini @prof_aaa1 @cghanratty @AEslamiDO @CatalinPToma @BrianLi_MD @Pardhu6627 @abadkhan2002 @kevinjamescroce @prajith3668 @dautov_MD @jbspadoni @MdM_Ochiai @BakhshiHooman @tadano98 I think @stefan_harb was sharing his concept of an ideal device - we were all dreaming of conquering calcium"
X Link 2025-01-17T02:14Z [---] followers, [--] engagements
"@Laserrman @SripalBangalore @aspergian1 @evandrofilhobr @TWilsonMD @simonjwilson1 @dr_oss @hwcc0314 @VRejeki28 @jianshanzhiyi1 @MauroCarlino3 @GLGasparini @prof_aaa1 @cghanratty @AEslamiDO @CatalinPToma @BrianLi_MD @Pardhu6627 @abadkhan2002 @kevinjamescroce @prajith3668 @dautov_MD @jbspadoni @MdM_Ochiai @BakhshiHooman @tadano98 @ikki1127 What happens in the red zone Deep cuts Also disruption of softer tissue Also what if any is the recommended speed for stent ablation (BTW the screams of the burr against metal are unnerving enough to give a person nightmares 😳)"
X Link 2025-01-17T02:21Z [---] followers, [---] engagements
"3/ I believe there is no bifurcation strategy (1- or 2-stent) that cannot be enhanced by the Jailed Semi Inflated Balloon Technique (aka #JSBT). I use it almost daily 🤩 Here is the sequence for our patient"
X Link 2025-01-17T03:18Z [----] followers, [----] engagements
"4/ Here is our sequence: SB balloon in place KBI if needed (SB no greater than 4) MB stent in place SB up @ [--] MB stent up @ nominal + [--] MB down THEN SB down SB out and MB back up at supra nominal MB out DOT if needed POT Final KBI if needed Here is the post"
X Link 2025-01-17T03:18Z [----] followers, [----] engagements
"7/ BTW this video is from the excellent Bifurcation Exploration website by Univ. of MN and @Medtronic. After POT the stent is much better apposed to the wall. 🔑 ALL stents benefit from post-dilation. Whether it is done or not or how its done is up to the operator. We prefer NC balloons. https://www.medtronicacademy.com/en-us/content/bifurcation-pci https://www.medtronicacademy.com/en-us/content/bifurcation-pci https://www.medtronicacademy.com/en-us/content/bifurcation-pci https://www.medtronicacademy.com/en-us/content/bifurcation-pci"
X Link 2025-01-19T05:44Z [----] followers, [----] engagements
"@Laserrman Yes that is why I like to do a tip injection whenever I am in doubt. Here I think we were in and out of the honeycomb structure - I thought I saw a thrombosed channel. So IP all the way but not TL"
X Link 2025-01-21T01:41Z [----] followers, [---] engagements
"A More Typical CTO PCI - for those who know #HDR *(Its ok if you dont You will soon. 😀) [--] year old man CABG [--] years ago now with angina and severe AW ischemia. LIMA and SVG to OM - 100%. Dual injection shows short CTO blunt cap 3+ Ca distal cap trifurcation. Other info. EF 35% SVG to D2 patent high grade stenosis at D2 origin"
X Link 2025-01-21T05:47Z [----] followers, [----] engagements
"2/ Is there a microchannel Perhaps. But a Gladius MG stops after penetrating the angiographic cap. Here is the crossing sequence: MC across cap #HDR no tip XT into ramus angled XT into LCX CTO Dottered with MC angled XT into LAD MC has difficulty crossing"
X Link 2025-01-21T05:48Z [----] followers, [---] engagements
"3/ Note the LM trifurcation. It is heavily diseased but it would be nice to salvage all [--] branches. We treated the LM as follows: 👉🏼 LAD: rota + IVL + CBA. 👉🏼 LCX: CBA 👉🏼 LM: rota + IVL + CBA Culotte (using IVUS) (Only the rota and subsequent wiring is shown)"
X Link 2025-01-21T05:49Z [----] followers, [---] engagements
"4/ Here is the final angio Look at the trifurcation All the branches are there. 🙌🏼 🔑 This is the beauty of #HDR - preservation of branches AND IP crossing No other technique (other than retro wire escalation perhaps) can handle a distal trifurcation this cleanly. 🤔"
X Link 2025-01-21T05:49Z [----] followers, [---] engagements
"HDR vs. the Carlino Injection - What is the difference I made this video with @MauroCarlino3 at TCT. It is Carlino certified Haha. Mauro is as good at teaching #HDR through PowerPoint as he is performing it live 👏🏼🤩 5/ If you know #HDR you can skip this part. If you are new here #HDR is hydrodynamic contrast recanalization - a novel CTO crossing method. It is latest iteration of the Carlino method - but so much more than that. Mauro Carlino honestly his technique and gave it this name https://t.co/SjWhHwEM8B 5/ If you know #HDR you can skip this part. If you are new here #HDR is"
X Link 2025-01-21T16:37Z [----] followers, [----] engagements
"Interesting case. No doubt challenging but you got it done 👏🏼 This case highlights the different ways on which a CTO can be approached. It will interesting to see what other folks would have done. I may have started with dual inj. angiography - or switched early because the CTO is not that long and can guide repuncture. (With your #TDADR skills you dont need to so this but for the rest of us this is one way to deal with cap puncture failure) More"
X Link 2025-01-23T04:33Z [----] followers, [---] engagements
"2/ Some other things we may have tried: a) Leave the wire in the RV br. then re-puncture at the RV br. take off either with a DLMC (Houston style) or TD CP (Sapporo style). b) Block the RV br. and use a knuckle redirect followed by ADR (Seattle/NYC/Atlanta style) or STAR (Milano style) c) Retrograde epicardial (Tokyo/Lahr/Vancouver Island style) Many many good options"
X Link 2025-01-23T04:43Z [----] followers, [---] engagements
"Understandable This comment was meant more for students of the technique and practitioners of other #CTOPCI philosophies 😀 🔑 #HDR facilitates single access but doesnt require or mandate it. I would encourage people learning the technique to use dual injections. @MauroCarlino3 would concur"
X Link 2025-01-23T04:57Z [----] followers, [---] engagements
"@Laserrman @cto_chip_japan @DaitaroK @calcbreaker @SKuramitsu0511 @tadano98 You are the enlightened antegradist Many of us are still on the journey. 😀 Plus some good friends like @MdM_Ochiai and @DrBIqbal really enjoy going retrograde I want to keep them close. 😉"
X Link 2025-01-23T05:03Z [----] followers, [----] engagements
"We are neither treating (nor creating) these percutaneously 😯 There is a very high risk of infection with any Rx modality (papyrus or coiling) given the size of the PSA and proximity to the skin surface. From my experience treating AV fistulae (past life) these UE PSAs would all be sent for surgery. I have used covered stents (twice) when rupture was imminent - but just to buy time to get the patient to the OR. The artery is too small for a cover"
X Link 2025-01-25T04:43Z [----] followers, [---] engagements
"@DrPrimeroNg @sudhirtho @DrBillLombardi @KateKearney4 @LAzzaliniMD @cardiofrizz @crfheart Nice way to preserve the bifurcation when coming retrograde Also works well during LM #CTOPCI when the wire crosses from the LCX into the LAD (or vice versa). Its interesting that I learnt this technique from @DrBillLombardi while visiting UW several years ago 🤩"
X Link 2025-01-25T06:10Z [----] followers, [---] engagements
"Jump Start Or Taking A Road Less Traveled An unusual CTO PCI brought to mind by a post from @MichaelMegalyMD [--] year old man with failed SVG to OM2 and [--] 👉🏼 s/p LCX CTO PCI 👉🏼 recurrent OM2 occlusion with TWO prior stents Third attempt - #HDR reveals patent jump graft from OM3 to OM2. Successful OM3 +jump graft PCI 👉🏼 patient symptom free for [--] years 🙌🏼 *PS - Case is from before DCBs were approved in the US"
X Link 2025-01-29T05:16Z [----] followers, [----] engagements
"Another day in the lab another opportunity to go #contrast1st [--] year old woman s/p NSTEMI and LAD PCI in 01/2024 👉🏼 Persistent dyspnea with exertion - large area of lateral wall ischemia Not a true CTO but a functional one - no forward flow and sparse collaterals What wire would you start with And would you use an MC"
X Link 2025-02-06T05:19Z [----] followers, [----] engagements
"I find a #contrast1st strategy to be very helpful - it is an excellent way to refine the diagnostic angiogram Method - engage lesion with MC (Corsair here) + WH wire tip inj. PJW based on findings Simple but effective. 🤩 Crossing took our fellow @MaxBourdillon under a minute (if that)"
X Link 2025-02-06T05:20Z [----] followers, [----] engagements
"@Laserrman @drAliyor @esbrilakis @evandrofilhobr @Sher_Intervent @dautov_MD Agreed. We have had a (ahem) similar situation in the periphery. The Astato [--] (and lesser wires) didnt work - largely because the balloon surface is smooth and usually the wire keeps slipping I did not realize the GCE shaft was that sharp. 🤔 Interesting"
X Link 2025-02-06T19:18Z [----] followers, [---] engagements
"Difficult to see where the ischemia is coming from - or rather where is the recent episode came from. You probably need to piece this coronary system back together. CTOs are a good place to start bec. you stress out the LV as much as - except during dual inj. Also beware of the failing SVG 😳 I would clean up the proximal LAD see if you can get into the LCX and/or LAD. Then tackle the SVG to OM (if LCX PCI unsuccessful) followed by the distal LAD via the LIMA. Finally the RCA via the LAD if viable #HDR early and often. 😀🤞🏼"
X Link 2025-02-07T04:15Z [----] followers, [---] engagements
"Yasser the EF has improved but the targets have not The mechanism of stent failure is interesting - and determines the subsequent PCI strategy. I see both stent fracture (LAD) and geographic miss (LCX). (What stent brand does she have) Option #1: IVUS LAD and if you see a good landing zone offer CABG. Option #2: Treat the LM more completely - DK Crush to minimize metal in the LM. Also consider changing the drug in the LM-LAD"
X Link 2025-02-07T05:47Z [----] followers, [---] engagements
"@doctor_dru_ Brilliant. 🤩 Here is the Southern US I use the aisles at Walmart scale after a patient used it to describe her ambulatory capacity. It is (dare I say) a very reliable and usable metric Also very patient centric. 👌🏼"
X Link 2025-02-10T05:17Z [----] followers, [----] engagements
"@evandrofilhobr correctly noted that there was air in the injection - hence the bubble #HDR. This is air that gets entrained during wire exchanges. But this happy accident has given me new insight as to how CTOs form - particularly at the distal cap"
X Link 2025-02-10T06:03Z [----] followers, [---] engagements
"In anticipation of #CTO2025 And inspired by @jbspadoni here is an LCX CTO PCI. I tried to case match but I couldnt find a flush ostial LCX occlusion with bifurcation at the distal cap. Nevertheless this case highlights the use of #contrast1st and #HDR in such cases"
X Link 2025-02-25T04:37Z [----] followers, [----] engagements
"The low EF IVL for such a calcified LM would have required multiple treatments in the same location - and that may have exhausted the LV despite the Impella. By fixing the LCX first we gave the LV a little bit more reserve. It also allowed us to move the base of operations to the LAD proper where IVL may have been better tolerated. Re: Rodin Cut I like it very much but it does not keep me from using IVL if I need to. For example sometimes (rarely) the calcium does not respond to the combination of Rota and IVL. Thank you for the comment"
X Link 2025-02-27T23:11Z [----] followers, [--] engagements
"@ABaliMD @BifurcationClub Lately I have been trying out the Runthrough NS and the Minamo - as recommended by @Hragy and @MichaelMegalyMD respectively. 👉🏼 Both are very good workhorse wires. I am not as familiar with the RT Izanai - but it appears to have excellent torque reaponse"
X Link 2025-03-04T03:27Z [----] followers, [---] engagements
"Its important to know because it allows you choose the appropriate crossing strategy + wires. 👉🏼 When you are IP then the focus is on using contrast and/or wires to navigate through the CTO bosy. This is the philosophy behind #HDR #DRaW parallel wiring etc . 👉🏼 On the other hand when you are EP then the objective is to move towards the TL (relatively) quickly and re-enter using one of several different techniques. The wire selection for this is completely different"
X Link 2025-03-06T23:48Z [----] followers, [--] engagements
"What were some of YOUR favorite publications on LM PCI over the past [--] months Lesser discussed studies that may have impacted how you perform LM PCI - or not 🤔 See you at #CRT2025 @agtruesdell @DrBIqbal @LAzzaliniMD @Laserrman @MauroCarlino3 @evandrofilhobr @jbspadoni @mmamas1973 @mirvatalasnag @Hragy @aspergian1 @djc795 @DocSavageTJU @SmithElliotjs @stefan_harb @GoranEBC @RinfretStephane @SanjogKalra @TWilsonMD @jl35wilsonMD @WahajAmanMD @kalazizimd @SripalBangalore @ziadalinyc @MichaelMegalyMD"
X Link 2025-03-07T13:20Z [----] followers, [----] engagements
"@NabilYahya_MD @SripalBangalore @MaeharaAkiko @DrAnkushG The rationale is discussed in the editorial. It comes from ADAPT DES. The paper is really well written and the reasoning is sound"
X Link 2025-03-12T14:05Z [----] followers, [--] engagements
"Thank you Hady Your experience is relatable. We have all been shaped by our work for better or for worse. Sometimes very dramatically. The challenge (both in and out of the lab) is to live in the present moment. Without regrets of the past or fear of the future. 👉🏼 That is a tough balancing act that I often find myself trying to perform in my difficult cases"
X Link 2025-03-20T02:50Z [----] followers, [--] engagements
"Nice #HDR Mahesh 👏🏼 Here is what I have learned - in most cases the degree of collateralization is a good marker of the age of the CTO (not the underlying lesion). 👉🏼 Which means that when there is no visualization of the target AND the tissue is viable then the CTO is likely thrombus laden and less calcified (as a general rule) 👉🏼 Such lesions are great for #HDR more so if you have a tapered cap or a lead in segment like here"
X Link 2025-03-20T04:25Z [----] followers, [---] engagements
"Puncture Probe and Pass An #HDRanalysis case - #HDR meets #DRaW 🧵 [--] year old man with anomalous RCA CTO 👉🏼 Mod. JL4 guide + GEX cap puncture with G2 #HDR no. [--] first pass no-tip XT MC advanced #HDR no. [--] MG crosses IVUS DES placement 🙌🏼 #contrast1st"
X Link 2025-03-21T04:28Z [----] followers, 10.2K engagements
"2/ Here is the IVUS - lots of chronic organized thrombus calcium and modulated plaque. You can see plaque with a starry sky pattern close to the proximal cap. Note how CTO length by IVUS is MUCH shorter than the length by angio - #HDR resolves the discrepancy"
X Link 2025-03-21T04:29Z [----] followers, [---] engagements
"@nolanjimradial @Hragy Great thought Jim. That would fit #2 or #3 in my scheme - acute reperfusion 👉🏼 BJR 👉🏼 slow HR +/- slow flow"
X Link 2025-04-02T13:07Z [----] followers, [--] engagements
"My first 3D OCT image - from [----] Not as pretty as the images shared by @mornei2011 but this is a 3D reconstruction from a post rota run. The image was constructed using 3rd party software. 🔑 I kept this image because it shows the engraved path of the rota burr along the lumen of the LM 🔑 The patient had ESRD and severely calcified arteries - our target was the LCX ostium"
X Link 2025-04-05T06:16Z [----] followers, [----] engagements
"Ex Vivo Grenadoplasty ( Or what pressure does it take to rupture an NC balloon) 👉🏼 We used an OPN indeflator to see how we could go on a [--] mm BSC NC balloon. Note the point of rupture The NC 🎈remains intact 🤔 But the hypotube is completely mangled. The video speaks for itself. Best viewed with the volume up"
X Link 2025-04-18T07:09Z [----] followers, 11.2K engagements
"A common scenario with re: to the disease distribution - except many times it a moderately stenosed valve that becomes the sticking point. The fact that you had plaque rupture in the RCA suggests the moderate to severe LAD and LCX are at risk for progression and/or MI. As the patient is on no meds you could optimize the medical therapy and re-evaluate in [--] months. That will give you valuable info vis a vis: 1) CAD progression rate 2) Aortic root dilation rate 3) Medication compliance BUT it may be equally reasonable to do a baseline functional assessment with FFR - and offer PCI if needed."
X Link 2025-04-21T05:01Z [----] followers, [---] engagements
"@drdharmarajk @SripalBangalore @MauroCarlino3 @Laserrman @KambisMashayek1 @SKuramitsu0511 @rotamonster Another possibilities is that there is a potential channel there (the last remaining TL) full of organized thrombus and the contrast found to be the path of least resistance. 🤔"
X Link 2025-04-30T12:38Z [----] followers, [--] engagements
"A Hard Nut To Crack - A #CTOPCI Saga Here is the #HDR case from last week - as promised. Our pt. is a [--] 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"
X Link 2025-05-06T04:06Z [----] followers, [----] engagements
"Great result Krzysztof Remarkable really.👌🏼 Do you have images from the original intervention 👉🏼 Whenever the follow up angio looks good (hardly this good though 😀) I like to go back and look at the index procedure - to see what I can learn from it. 👉🏼 All of the branches are preserved was confirmed that you had IP crossing and that it was a short CTO. We have only just started using DCBs for (very) select cases. They are expensive and only approved for ISR in the US - so our usage is audited"
X Link 2025-05-07T21:20Z [----] followers, [---] engagements
"Good case and excellent result. This patient needs aggressive lipid lowering and OMT - that is their best chance of making this a routine procedure. Re: the DCB your technique is 👌🏼. Pre and post IVUS CBA SB protection appropriate DCB sizing - you checked all the boxes. The LAD may need a LIMA in the future - but it is not the best target. You can see trouble brewing at the left main both by angio and IVUS. Lately we have been discussing the relative merits of DCB over DES. Here in the US we would have stented - because of the costs involved. Great final result. I hope the patient feels"
X Link 2025-05-12T17:25Z [----] followers, [---] engagements
"@DrWhyWho @jl35wilsonMD @TWilsonMD This is a great result 👌🏼 Glad the rota worked out - it is the best 1st strategy for calcified nodules IMHO. Rota NC Rota Cut and Rota Shock are all excellent choices. Do you have a cine of the rota run It would be intersting to see how the burr behaves over the bends. 🤔"
X Link 2025-05-13T23:42Z [----] followers, [--] engagements
"Case 281: Manual of CTO PCI - HDR [---] via @YouTube 👆🏼 A brilliant case by @esbrilakis showcasing the potential of #HDR in a wire uncrossable in-stent occlusion (ISO) The presentation is crisp and the explanation is on point 👌🏼 https://youtu.be/VAoqyZk4fQ4si=jX6X64Y9D7SN79H4 https://youtu.be/VAoqyZk4fQ4si=jX6X64Y9D7SN79H4"
X Link 2025-05-17T03:18Z [----] followers, [----] engagements
"I can see why the first option is popular. I suspect this question is more likely to be answered by the dissatisfied practitioner. For e.g. I am sure healthcare administrators will have a different opinion all together. What has changed is how we practice medicine. There is less autonomy for the practitioner and more regulations. And yes patients are less forgiving but I dont sense a betrayal on either the side of medicine or the MDs/RNs. Our dissatisfaction with how we practice medicine makes us ask such questions. (My personal gripe is the excessive and redundant documentation. But what you"
X Link 2025-05-17T14:14Z [----] followers, [--] engagements
"The #HDR LIfe Last week we treated several peripheral CTOs - unusual only bec. of the vessels involved: subclavian vein SFA with prior stents and superficial palmar arch + common digital artery Here is what #HDR in the periphery looks like 😀 (We also had a couple of 'crazy' coronary CTOs - but that is for another time)"
X Link 2025-05-17T23:01Z [----] followers, [----] engagements
"A key point is that ostial stent placment (even if it miraculously naila the ostium) shifts the carina into the SB (LCX) ostium. Particularly if the carina has bulky plaque. Crossover stenting (facilitated by JSBT if possible) is less likely to do so. Of course the true challenge is to POT after crossover PCI in a way that does not pinch the carina from the other side"
X Link 2025-06-03T00:23Z [----] followers, [---] engagements
"A key point is that ostial stent placment (even if it miraculously naila the ostium) shifts the carina into the SB (LCX) ostium. Particularly if the carina has bulky plaque. Crossover stenting (facilitated by JSBT if possible) is less likely to do so. Of course the true challenge is to POT after crossover PCI in a way that does not pinch the carina from the other side"
X Link 2025-06-03T00:24Z [----] followers, [---] engagements
"2/ Why did the MCs fail One could argue they all did what they were supposed to do - push forward when torqued. The ways in which the tips have been compromised gives us information about the catheters construction. The lesion was severe Only one wire could pass at a time"
X Link 2025-06-19T07:38Z [----] followers, [---] engagements
"3/ Here is a clip of the Corsair Pro trying to cross (after PTCA and grenadoplasty at the PDA ostium). Note the anchor balloon the direction of the MC tip and the configuration of the shaft When we tried to remove the MC it was stuck to the wire 😳"
X Link 2025-06-19T07:39Z [----] followers, [---] engagements
"4/ Over Torque MC Injury This is not a real injury per se but a series of inconvenient annoying and occasionally dangerous MC failure modes. Here the soft tip of the MC has been twisted onto the coronary wire. This occurred in 10% of reported failures. Images from the excellent review by @MichaelMegalyMD in @EuroInterventio"
X Link 2025-06-19T07:39Z [----] followers, [---] engagements
"5/ Why does this happen Not sure but my hypothesis in that the catheter tip gets crimped onto the wire. Interestingly the Mamba tip behaved differently here 🤔 The tip looks frayed without stretching out like the TurnPike and the Corsair Also note the stent strut induced lacerations on the latter"
X Link 2025-06-19T07:39Z [----] followers, [---] engagements
"7/ So how did we treat the patient Well we saw the writing on the (vascular) wall after sacrificing [--] MCs and several balloons. Interestingly the patient developed ST elevation() with every MC engagement. His angina is life style limiting but not debilitating. We have upped his ranolazine and are going to enroll him in the COSIRA [--] trial (I know two persons who would agree 😀 @GreggWStone @HenrytTimothy) 🙏🏼"
X Link 2025-06-19T07:39Z [----] followers, [---] engagements
"@SripalBangalore I think here the issue is the stent cage. Also the think the Gold works when you have a lead-in channel. (Though personally I havent had much luck with it.) Rather I can usually get across with either a Turnpike LP or Corsair XS - and oodles of support 😀"
X Link 2025-06-19T14:49Z [----] followers, [--] engagements
"Yes we did - [--] different brands Also a Sapphire [---] mm. We also purposely ruptured the balloons (BAM = Balloon Aided Microdissection aka grenadoplasty). In fact that is what allowed the Corsair to go deeper than the other micro catheters. Had I been more thrilled about the target I would have made it work - stent strut ablation +/- laser +/- deep seated guide. (I used the different MCs here to teach my quasi-CHIP fellows about the difference in performance and properties)"
X Link 2025-06-19T15:18Z [----] followers, [---] engagements
"The balloon tips crossed. Difficult to tell with the [--] mm balloons because the marker is farther away from the tip. But the mid marker of the [--] mm balloon was at the struts. Which is why we attempted BAM. Re: the stents I doubt if the shock waves would have any effect on strut malleability. My experience (n=2) using Javelin in small vessels - [---] mm or less - has been underwhelming. It works great when there is a lumen large enough to accommodate the nose cone"
X Link 2025-06-20T01:39Z [----] followers, [--] engagements
"@AntoniousAttall @Laserrman @cto_chip_japan @DaitaroK @calcbreaker @UmihikoKaneko Good pickup. I wonder if that is remnant hematoma in the the EP space - where the Sion Balck was parked. Difficult to say without IVUS but the blood/contrast used to be on the outside of a calcium ring"
X Link 2025-06-20T04:17Z [----] followers, [---] engagements
"Jay this reminds me of a case I was once referred in New Orleans - the patient had stents (with multiple overlaps) from the common iliac to the anterior tibial 😳 I showed it at a national conference as a demo of a) inappropriate use of stents in the peripherals and b) a heroic case of limb salvage. One of the surgeons in the panel got very upset that I did not send her for a surgical opinion before dripping tPA and using JetStream 😂 (@shishem was leading the panel and came to my rescue. He still remembers)"
X Link 2025-06-20T13:27Z [----] followers, [--] engagements
"Sripal we have been using [--] Fr guides the [--] Fr IVUS and the TurnPike LP for our TD cap punctures. It gets a little snug in there. [--] Fr is better but I gave up on [--] Fr some years ago. Here is the best sequence (that works best for me) [--]. Place two workhorse wires first. [--]. Park MC in straight portion of guide. [--]. Slip the IVUS past the MC and get it beyond the ROI in the vessel. [--]. Get MC beyond ROI and switch one wire for the puncture wire (needle). [--]. Retract MC proximal to ROI. [--]. Retract IVUS to just beyond the ROI. [--]. Survey the ROI using IVUS and identify the target. [--]. Retract the"
X Link 2025-06-20T13:34Z [----] followers, [---] engagements
"Nothing went wrong my friend You successfully treated an occluded RCA 👏🏼🤩 Re: the #HDR it seems you uncovered a latent microchannel through a calcified CTO. These can be tough to cross with an XT alone. Here are some things I do: 1/ Always use an XT with a straight tip. I gently torque the wire as it exits the MC. 2/ If the wire buckles I stop and advance the MC then repeat the microinjection - the so-called Ice Breaker method. 3/ Usually I will do the 2nd #HDR in two views - to understand the CTO in 3D. 4/ If thay doesnt work I typically switch to a Mongo (aka MG). 5/ if that doesnt work"
X Link 2025-06-21T03:04Z [----] followers, [----] engagements
"Mahesh I missed the leak. Now the post HDR leak is itself a fascinating phenomenon. And I am still learning. Here are the types of flow (leak) I have seen: [--]. Flow into true channel (MB or SB) - wispy and brisk smoke like [--]. Flow into adventitial pathways - often reticular [--]. Flow into an adjoining vein - like a fistula [--]. True perforation (rare often preceded by wire knuckle or exit) - brisk putt at the end of a branch 🔑 True bleeds from the mid CTO body are impossible without: a) significant trauma to the EP/IP interface and b) connection of the rent to the proximal TL"
X Link 2025-06-21T16:25Z [----] followers, [---] engagements
"@SaidAshrafMD @jedicath Quite the quandry IMHO the culprit is an elevated LVedp +/- high double product and maybe the LCX. Curious to see how you resolved this"
X Link 2025-06-21T16:37Z [----] followers, [---] engagements
"Solid strategy - I wouldve done the same except maybe use the MCS sooner. I do think that unloading the LV prior to PCI has a benefit at the tissue level. Re: the LCX - I am glad you quickly determined it wasnt the immediate culprit. It was the LVedp and abnormal micro perfusion (Not to say that the CAD is not the real long term etiology)"
X Link 2025-06-21T17:51Z [----] followers, [---] engagements
"@mahesh_maidsh @SCAI @TCTMD @cvinnovations Great result on that LCX 👌🏼 And the RCA too. Did you use OA for the LCX Also what size stent did you end up using It turned out larger than it first appeared to be. Which is often the case"
X Link 2025-06-23T00:14Z [----] followers, [---] engagements
"I agree 👏🏼🤩 Cap puncture #HDR or #CASE knuckle wire to distal RCA IVUS in PDA via SVG IVUS guided re-entry I only say that because contrast alone cannot puncture through the anastomosis. It rides over it. I have not been successful yet (n=3). IVUS guided repuncture works great here (after #contrast1st). 👌🏼"
X Link 2025-06-25T01:35Z [----] followers, [--] engagements
"@jedicath @Hragy @jl35wilsonMD @TWilsonMD @AntoniousAttall @aymanka @mmamas1973 @mirvatalasnag @SarahFairley7 @Allison_Dupont Waqar what brand of stent is it also since you have IVUS images from now and before is this chronic stent recoil Also what did the run off look like after the first PCI"
X Link 2025-06-25T13:02Z [----] followers, [---] engagements
"@Hragy Agreed Hany - though EECP is still very popular in some practices. But the options we have now are a) less drastic and/or b) actually effective. More than just placebo. So better options now (perhaps)"
X Link 2025-06-25T14:23Z [----] followers, [---] engagements
"@evandrofilhobr Great result @evandrofilhobr. Did you go EP at all If you were IP then rota may have been a good option before the IVL. Difficult to say what that small dent in the mid RCA means for long term patency as long as the MSA is decent"
X Link 2025-06-29T14:23Z [----] followers, [---] engagements
"😳 Thank you for pointing this out. I have always prescribed the [---] mg dose. But this is not new - Wellbutrin vs. Zyban for example. Questions: 1) How often is Lodoco prescribed By anyone. 2) Would the research costs have been significantly lower if colchicine [---] mg had been used for the trials. 3) Given the large expense(s) involved with conducting drug trials what incentive (if any) is there for manufacturers to investigate generic and/or low cost indications for new trials 🤔"
X Link 2025-06-29T23:51Z [----] followers, [---] engagements
"Nice Kambis 👌🏼 I think ROTA-SHOCK was the way to go here. Other vessel prep combinations just dont give results this good - by angio or IVUS. The use of a DCB at this location is interesting and thought-provoking. 🤔 We typically use DES for aorto-ostial lesions in the US - partly bec. DCBs are costly (and have a different indication) and partly bec. of concerns about recoil. What has your experience been Do DCBs work well in this location"
X Link 2025-07-02T00:30Z [----] followers, [---] engagements
"@KambisMashayek1 @Boston @Shockwave @Medtronic Hahaha Touch my friend. So now we wait for someone somewhere to do the trial 🧐🤞🏼"
X Link 2025-07-02T04:58Z [----] followers, [---] engagements
"Here is a recent Lazarus CTO in a young diabetic with diffuse small vessel CAD and refractory angina. We tried to enroll her in COSIRA [--] but she is legally blind and cannot walk on the treadmill. The PCI was done as a last resort. We used #HDR to cross multiple angioplasties and a DCB. The range of balloon sizes was [--] - [---] mm Look at all the AW blush 6+ months of angina taken care of. 👌🏼"
X Link 2025-07-06T03:43Z [----] followers, [---] engagements
"Nice angio I will leave the discussion of CABG up to you guys (😂). From a technical standpoint IF PCI were the choice then IVUS first then provisional. I have treated this type of LM in every conceivable way incl. LM to LCX stent using JSBT to protect the LAD. Personally for low SYNTAX score patients a trial of PCI is not an unreasonable choice as long as a patient is aware that they may develop re-stenosis later. 👆🏼This assumes the patient takes medications and the operator uses best practices (incl. IVUS)"
X Link 2025-07-08T15:56Z [----] followers, [---] engagements
"I dont think so. Difficult to say with certainty but the distribution of calcium is such that the LCX ostium is more constrained here than the LAD ostium. Ibt may be difficult to keep open with a DCB alone. It all comes down to the geometry of the LM bif. + branch ostia ones ability to modify it favorably + and ability of the stent to withstand the physical forces exerted on it. Argument for DES: Greater patency now with risk of re-stenosis later Argument for DCB: No risk of stent failure with unknown risk of re-stenosis"
X Link 2025-07-08T23:51Z [----] followers, [--] engagements
"Sripal I see a LM bifurcation encased in calcium - much more bulky along the lower edge (towards the LCX). In my experience circumferential Ca constrains expansion more than plaque. 🤔 Thus in any [--] stent strategy one of branch ostia usually. ends up deformed - ovoid or D-shaped +/- area [--] mm2. 👉🏼 I hardly ever use the baseline MLA or PB to determine stent strategy (in any bifurcation). The Ca distribution 3D geometry of the bifurcation myocardium at risk and the intended Ca mod. strategy are more likely to influence me. (A recent post by @KambisMashayek1 has me intrigued about the use of"
X Link 2025-07-09T04:18Z [----] followers, [---] engagements
"@SripalBangalore @TWilsonMD @ShariqShamimMD @jl35wilsonMD @drAliyor @DrIHHashmi1 @DrWhyWho @DavidLBrownMD @aspergian1 @dukwoo_park Yes perhaps rota first for the LCX if the entire rim is calcified Rota Cut and Rota Shock both work great for nodules - usually better than either therapy alone"
X Link 2025-07-09T12:58Z [----] followers, [--] engagements
"The Left Mains Of Harris County Texas My favorite vessel to treat is the left main. It used to be the carotid but thats when I was a young(er) man. 😂 Here are [--] of 6() left mains that I encountered over my long weekend call. Three more after the jump"
X Link 2025-07-11T07:09Z [----] followers, 10.7K engagements
"We also had to fix the RCA both prox. and distal. She has a small LCX and a large RCA distribution. (You can see that on the very last clip.) Her EF is surprisingly normal. So we decided to stage the LAD if needed. She is currently scheduled for a follow up PET scan. BTW the patient was turned down for poor targets by three surgeons. She is also taking sirolimus for cancer - which poses challenges for sternal wound healing"
X Link 2025-07-11T12:31Z [----] followers, [--] engagements
"@BagaiJayant Good question that came up with one of @agtruesdells ad hoc LM PCI cases. My point 👉🏼 ad hoc does NOT equal impromptu. Both are unforeseen by definition but ad hoc = purposeful (by design) and impromptu = unrehearsed. So ad hoc is acceptable good even. Impromptu is not"
X Link 2025-07-12T06:42Z [----] followers, [---] engagements
"Sachin I have been waiting to do a case like this From a purely technical point of view the anatomy is deliciously complicated. The key is to identify the origin of the aneurysm. It is from the LM proper the carina or one of the branches CTA and IVUS are both key. Re: the fix the you have poor support and putting coils in may be frustrating. But not impossible. (You can stabilize the guide by jailing a wire behind a stent). Or you could use an anchor in a SB. A novel option may be to wire both branches cover the aneurysm with a Papyrus then use the jailed wire as a guide to puncture the"
X Link 2025-07-12T17:29Z [----] followers, [---] engagements
"The Dastardly Nodule 😈 Case from pre-DCB era 👉🏼Recurrent ISR at RCA ostium. Note CN trapped bet. stent layers Pt. prev. recd Taxus Promus and Orsiro 😬 CN tamed with IVL and Resolute Pt. left w/ mild stable angina 🙌🏼 Bonus: Unique OCT image - Strut Snow Storm 😳🙏🏼"
X Link 2025-07-21T06:44Z [----] followers, [----] engagements
"It is very similar to AI Hany - but even better Let me explain. AI systems are large language models (LLM) that understand and generate human language. Your mind is a LEM - large experience model that uses your lifes experiences to create an output - your thoughts. The human mind processes more info constantly than it is aware of - and our decisions are made quicker than we often realize. What we are aware of at any moment is just the tip of the cognitive iceberg"
X Link 2025-07-21T08:45Z [----] followers, [---] engagements
"@evandrofilhobr Great result Evandro👏🏼 Tom and Jeff are correct. This pt would be referred for CABG in many (not all) US centers. Few surgeons would turn this pt. down - focal CAD and 👌🏼 targets. BUT that makes her an ideal PCI candidate too 😍 That is the equipoise IMHO"
X Link 2025-07-22T23:03Z [----] followers, [---] engagements
"@evandrofilhobr is incredibly skilled - the kind of operator I would send my family to. 🤩 But many patients dont have the luxury of knowing their cardiologists skillsets. If this patient called you with these diagnostic images + asked your opinion what would recommend 🤔 70F retired nurse. IVUS guided distal ULM PCI. LM-LAD Provisional approach. DCB to LCx & 1st Diag. https://t.co/2apiNbTZ44 70F retired nurse. IVUS guided distal ULM PCI. LM-LAD Provisional approach. DCB to LCx & 1st Diag. https://t.co/2apiNbTZ44"
X Link 2025-07-22T23:10Z [----] followers, [----] engagements
"@akbarul @jedicath @mmamas1973 @ShariqShamimMD @abadkhan2002 @toreyj01 @aspergian1 @angna_86 @DrBIqbal @nadig_cardio @DrIHHashmi1 @JoySanyal74 Very nice To my eye this is a func. CTO caused by a Ca nodule in series with a tubular stenosis. I would use a soft PJW (Fielder FC SB Pilot 50) to engage/cross prox. RCA tip injection vs. #HDR finish crossing Rota CUT IVUS + DES *Use MC not OTW 🎈if you can"
X Link 2025-07-23T05:17Z [----] followers, [---] engagements
"We have a couple of very good surgeons at our place and I would probably have a discussion about CABG at least. Not the best LAD target but a decent one. The big issue with CABG is morbidity incl. worsening CKD. Re: PCI - this can be done with very low contrast. Probably [--] ml"
X Link 2025-07-23T06:25Z [----] followers, [--] engagements
"@NishithChandra @akbarul @jedicath @mmamas1973 @ShariqShamimMD @abadkhan2002 @toreyj01 @aspergian1 @angna_86 @DrBIqbal @nadig_cardio @DrIHHashmi1 @JoySanyal74 The key here is the LIMA Not just fixing the LAD w/ PCI. Why🤔 I believe a LIMA is generally better than a DES for THREE reasons: 👉🏼 It add a new source of blood to the cor tree (DES do not) 👉🏼 Has proven longevity (req. good 🎯) 👉🏼 Can usu. be done without compromising SBs"
X Link 2025-07-23T07:51Z [----] followers, [---] engagements
"Thoughts About The LIMA The case below has generated an interesting discussion about the virtues of CABG vs. PCI - the age old debate. Clinical evidence aside there are good physiologic reasons for choosing a LIMA. My thoughts (as a repost) to follow https://x.com/akbarul/status/1947850584721064423s=46 [--] yr old with dyspnoeaLvef-35creatinine [--] due to stable ckd.What would be your approach#CardioTwitter @jedicath @mmamas1973 @ShariqShamimMD @realarainmd @abadkhan2002 @toreyj01 @aspergian1 @angna_86 @DrBIqbal @nadig_cardio @DrIHHashmi1 @JoySanyal74 https://t.co/zHGfOO7Spz"
X Link 2025-07-23T08:20Z [----] followers, [----] engagements
"2/ The 🔑 here is the LIMA Not just fixing the LAD w/ PCI. Why🤔 I believe a LIMA is generally better than a DES for THREE reasons: 👉🏼 It add a new source of blood to the cor tree (DES do not) 👉🏼 Has proven longevity (req. good 🎯) 👉🏼 Can usu. be done without compromising SBs"
X Link 2025-07-23T08:21Z [----] followers, [---] engagements
"5/ Which makes the CKD a moot point in the face of a EF which has declined recently. No matter the etiology of the cardiomyopathy the clock is ticking. And further decline will definitely impact the kidney. Which is why I dont understand when folks wait on Rx in CKD"
X Link 2025-07-23T08:35Z [----] followers, [---] engagements
"6/ To conclude here are my LIMA conjectures: Visibility Conj.: A pt. is not a good CABG candidate if the LAD is not seen on angio Viability Conj.: Or if viability of the AW cannot be demonstrated Availability Conj.: Or if there is lack of availability of a 🎯 or conduit"
X Link 2025-07-23T08:42Z [----] followers, [---] engagements
"@murshid_eyad2 @akbarul @jedicath @mmamas1973 @ShariqShamimMD @abadkhan2002 @toreyj01 @aspergian1 @angna_86 @DrBIqbal @nadig_cardio @DrIHHashmi1 @JoySanyal74 From what I have read coronary endarterectomy is to the CV surgeon as CTO PCI is to interventionalists Not everyones skillset. The coronary here is very calcified - so CorEA may not be a good option. Hybrid - LIMA + RCA PCI is likely better 🤔"
X Link 2025-07-23T08:55Z [----] followers, [--] engagements
"@GopalKkoduru @akbarul @jedicath @mmamas1973 @ShariqShamimMD @abadkhan2002 @toreyj01 @aspergian1 @angna_86 @DrBIqbal @nadig_cardio @DrIHHashmi1 @JoySanyal74 Re: MSA again the answer is nuanced because a focal MSA alone is unlikely to account for variations in diffuse disease. MSA as a predictor of TLR works well but not so much for clinical events. Also flow across a stent DECREASES with time (ISR) but goes up thru a LIMA"
X Link 2025-07-24T07:09Z [----] followers, [---] engagements
"Final thoughts Yes DES is comparable to LIMA for focal proximal disease. But perhaps not so much when the disease is diffuse. Also the Berman paper is from [----]. It is likely that we contemporary 💊 Rx the ischemic thresholds to show mortality benefit with revasc. are higher. 🤔"
X Link 2025-07-24T07:11Z [----] followers, [---] engagements
"2/ The accepted threshold by SPECT is 10% from Dan Bermans classic paper in Circulation. We use Coronary Flow Capacity by PET which incorporates CFR + MBF and Lance Gould (the father of 🫀PET) reported a threshold of 10-15%. 12% splits the difference"
X Link 2025-07-24T07:27Z [----] followers, [---] engagements
"3/ Re: MSA the answer is nuanced because a focal MSA alone is unlikely to account for variations in diffuse downstream dis. MSA as a predictor of TLR works well but not so much for clinical events. Also flow across a stent DECREASES with time (ISR) but goes up thru a LIMA"
X Link 2025-07-24T07:28Z [----] followers, [---] engagements
"4/ Yes a DES is comparable to LIMA for focal prox. disease. But perhaps not so much when the disease is diffuse. Also the Berman paper is from [----]. It is likely that w/ contemporary 💊 Rx the ischemic thresholds to show mortality benefit w/ revasc. are higher. 🤔"
X Link 2025-07-24T07:31Z [----] followers, [---] engagements
"7/ So how do I treat diffuse small vessel CAD 👉🏼 If no prior stress use FFR for diffuse +/- moderate dis. (80%) 👉🏼 Use pullback to determine the step ups - mark any stentable ones. 👉🏼 Use IVI to Rx sig. prox. dis. + use JSBT to protect SBs [---] mm 👉🏼 End with strong 💊"
X Link 2025-07-24T17:32Z [----] followers, [---] engagements
"8/ Here is a recent example. These are still frames only. Small CAD with large AW ischemia by ☢. We are treating the LCx medically for now. No FFr bec. CAD is visually severe. The patients angina has improved and hes in cardiac rehab. follow up PET planned for [--] days 🙏🏼"
X Link 2025-07-24T17:48Z [----] followers, [---] engagements
"To Bypass Or Not To Bypass - Question Of The Day Here are all the LIMA conjectures combined into one 🔑 CABG should be preferred over PCI only if ALL [--] criteria are met 👉🏼 visible LAD target 👉🏼 viable AW 👉🏼 healthy LIMA 👉🏼 stable patient 👉🏼 appropriate surgical resources"
X Link 2025-07-25T08:23Z [----] followers, [----] engagements
"@evandrofilhobr Can you send me more info. I am intrigued"
X Link 2025-07-25T08:54Z [----] followers, [---] engagements
"@AAbbot52838 Interesting question 👉🏼 Fixing the IRA lowers SYNTAX immediately so decision hinges on left-sided CAD/PCI complexity. For focal CAD or simple bif I would PCI first; failure will declare itself in [--] mo. For complex CAD Id consider a LIMA but wait [--] wks to hold DAPT"
X Link 2025-07-25T14:40Z [----] followers, [--] engagements
"@GopalKkoduru I see your point. But in fairness CABG hasnt changed bec. it is still the gold standard. We have been working on PCI to match CABG with all of its assoc. morbidities. But Im sure that surgical techniques have evolved in ways we are unaware of"
X Link 2025-07-25T16:03Z [----] followers, [---] engagements
"@RSohnMD Beautiful IVUS images 👌🏼 What wire did you use for the STAR I ask because most wire knuckles dont have the penetrating power to go into and out of the media - except perhaps the tight Mongo knuckle. (There is a valuable lesson here I am trying to figure it out. 🧐😅)"
X Link 2025-08-01T07:29Z [----] followers, [---] engagements
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