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And here's the in jail total total inclusion to keep thrombosis here. Um pretty aggressive measures were used inflate or should they expand the stent with balloons at the 30 atmospheres which was successful in restoring flow but uh still left residual under expansion. So we know that post intervention limit the amateur and rumour gain is direct correlative outcomes. Under expanded under put stents carry a high risk of restenosis thrombosis. High rates of target lesion revascularization. And as they accumulate more stents for treatment of their under expanded stent. Restenosis it kind of leads to a vicious cycle. And the reason for senator expansion is often uh calcium related. Both perry stunt calcium and interesting near varada calcium. Um Which as we all know can be a big challenge But now we're left with an under extended sent in calcium. So there's no um there's no way to go back and modify the calcium before placing the initial steps so we have to deal with that. We have so we took him back to the lab. We were able to drive us into the proximal portion of the stent. The most severe aspects lesion. We weren't able to get out of this catholic across the novo but you can see Pretty much circumferential calcium with an under extended stent. So the scent itself was 2-5 which is not not expanded to here. So we used a laser here inside of this uh you know to stent calcified area initially with saline and then after that without adequate expansion at 80 80. With contrast utilizing um as matt mentioned, there's multiple um this multiple modifying effects of laser but in this case specifically photo mechanical effects Um functionally relying on this rapidly expanding interacting vapor bubble generates pressure up to 100 atmospheres. Now we're able to get an adequate balloon expansion the sense well uh well opposed afterward. And the under expanded segment is uh a lot better. So you know that's that's a that's an example of the ramifications of not dealing with upfront calcium thankfully that was able to be dealt with adequately but it certainly is a real problem. So I'm the case number two we have a 56 year old gentleman. He's got a history of several corner of disease. Risk factors came in with some chest pressure but really primary complaints of distant exertion, lower extremity edema. He was in a heart failure when he came in echo showed and you have 22%. He was started on the miller known in LASIK Strip before he came over. He had a diagnostic cath before transferred on our hospital. And these are three images from that. So we can see in the initial on the left hand side of cranial view with um totally included. And you can calcified lady with some collaterals from the left and then our legal coddle shot shows that it's really uh included at the osmium. Uh The R. C. A. Gives some collateral is predominantly a large uh medium sized epic cardio vessel with some reptiles as well that faintly fill in the distal lady. He had an MRI which demonstrated viability. There was a lot of discussion with the surgery. It was felt that he was uh unsuitable risk for surgical revascularization. So it was elected to go ahead with our cutaneous intervention. We utilize single access technique for our anti grade catheter. We have a retrograde catheter in as well. We're able to wire first the search for protection and then eventually navigate a guide wire into the lady Truman position confirmed by a contra lateral injection through the day. Um So after initial balloon inflation with necessarily larger noncompliant balloons, we still weren't really achieving the expansion that we like. You can see the ghosting of calcium in there. Um Some barrier to expansion there. So we were able to I visit which did demonstrate dense calcification of anarchy exceeding 207°. And elected to employ ibl Here's our into basketball trips balloon and on the right is uh is there an geographic result after with the trips before putting in a stent? So much better. Much better, expanded and suitable for stent placement. And here that placing the stent, this is the second of two overlapping sense. You can see distal to that balloon. On the left is the initial stent and approximate position of the left main and then kissing balloons into a large diagonal branch. And our final result here, he had a good led. He was weaned off piano tropes um, and his repeat echo several weeks later, uh, near for how we visit a correction to 45% nice outcome there. Published Created by Related Presenters Paul Lavigne, M.D. Sentara Cardiology Specialists View full profile
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