In this short case example from St. Francis Hospital (Roslyn, NY), see Drs. Ziad Ali and Evan Shlofmitz utilize a variety of techniques and technologies to perform a PCI with an ultra-low contrast approach. They focus on the use of several simple techniques and then use iFR pullback to localize the ischemia and the rotational IVUS to plan their treatment as well as confirm their results.
Hey guys I'm at ST Francis. We're gonna do a zero contrast pc. I I'm here with Evan developments and uh Evan's gonna tell you a little bit about this case today. We have a 69 year old female with history of hypertension. Um C. K. D. With less grand. And a 3.1. She came in for diagnostic angiogram for evaluation of progressively worsening angina symptoms. A couple of weeks ago we found multi vessel disease and she now returns to us for plan P. C. I. Which is going to be zero contrast Pc. I. The plan for today is to treat her Circo M. And mid led lesion. She does have some small vessel diffuse R. C. A. Disease which we're going to medically manage. So um you know I think you've seen us do an I. F. R. Co registration sink vision system but we're gonna do something slightly different today for all those people who don't have that in all their rooms. So today we're planning to actually do a affinity zero contrast pc. I guided by I. F. R. But without sink vision instead using I. F. R. Scout. So um the way we start all of our zero contrast cases is by checking the diastolic pressure. And so what we're gonna do here where you can see we're six french radio. We um haven't hyper analyzed yet because we always hyper guys once we get over the shoulder and our diagnostic went smoothly through the radio so we shouldn't have a problem. Um uh doing this case through the wrist. So um again this this step can't be uh underestimated to actually you know get the end diastolic pressure is very very important because we otherwise won't really know how much hydration or how much room we have. Sometimes these patients have really low E. G. P. S. And sometimes they're just you know extremely high so that's rather unpredictable. And this is also a good time to remember to give the Hepburn. So what we're gonna do here is just flush. We're not gonna plan to use any contrast but we are connected to visit peak in case we need, yep we're checking and this is the end diastolic pressure. So can you show the human dynamics please? Okay so the end diastolic pressure is being recorded as eight so actually we can go ahead and give it to 50 bullets please. Alright so we're gonna do our catheter pull back here, we're gonna go ahead and give our Hepburn can have happen please. Alright so let's go on up. All right and so what we'll do is we'll teach you we'll show you some of the tricks to make sure that you're actually engaged. Now you know when you're going with a guide. One of the things you can do is of course you can use a workhorse wire. But um what we're gonna do here instead is show you what it looks like when you get saline. So we're up against the wall there. Okay just flushing back. Okay that might be pretty good. So this is where we're not really sure what there we go. Okay so what we're gonna do is just keep the wire in for a second, take a little bit of blood back to make sure there's no air. And then what we're gonna do is just focus on the E. K. G. For a second while we inject the saline and you can see that there's quite significant s T. Segment changes and that's actually how we know that we're actually engaged in the coronary artery. Now you don't need to give a huge bolts of these. But I think giving a a modest amount to show some E. K. G. Changes can actually be very helpful. Okay so we usually start these cases um with a regular workhorse wire as our protection wire. We have our views from previously. So if you guys want to go ahead and give me either the run through the BMW wire that'd be great. And so you know I think especially with the omni wire f don't you think that using um sort of doing a post pc i physiology is is so easy that there isn't a lot of excuse not to do it. I mean I think when you have the the other wires it was it was hard it was actually a bit of a pain in the butt wasn't it? But and I mean it really handles like a workhorse it makes a difference. Okay so um, we're already flushed with saline. So, but I'll just do that again just in case that's a good standard practice. It's also good standard practice to give a little nitroglycerin. So why don't we go ahead and do that? And the purpose of the nitroglycerin really is to get rid of any sort of epic Ardell spasm that you might be engaged into. So we're just gonna go ahead and give about 100 and 50 of nitro here. So you always want to flush, make sure all the contrast is out if you've used obviously in this case we haven't, you want to make sure that introduce ear's been removed prior to equalizing. If you don't get a good value at baseline for the equalization and really what you want to see on the aortic tracing is the dye chronic notch, which we can see. And so we are out. So I'm gonna go ahead and we're gonna go ahead and normalize. So if you can see on the interest site, Evans just gonna reach over and click the normalized button and uh there we go. And so that's one of the nice things we can do everything from the interest site really do this bedside. Okay, So now Evan's gonna go, we're gonna go live and then what I'm gonna do is I'm gonna do a pull back, wait for the blue line and I'm gonna start pulling back, what we do expect is to see a big pressure change, yep. So very focal lesion and you can see we're already at one. So that's a nice little, you know, idea of where we need to stand. So we don't need to do tons of stenting here. Okay, so our drift is acceptable, especially for the circum flex. You know, because of a .02 difference in equalization is acceptable because the circum flex is actually on the back of the heart. And so what I'm gonna do is go ahead and take this out now given how tight this is, what do you think about pre dilation versus just going ahead and and uh and direct stenting it. What do you think? I think there's no harm with rehabilitation um particularly just this way could allow us to facilitate intravascular imaging. Yeah. Sure. Okay. So why don't we um by angiography? I'd say this is like a 25. You wanna guys wanna give us like a 25 15 compliant balloon please? Well, I think you know what, while while they get us, let's try, let's talk a little bit about affinity and see, look at the deliver ability. So we can just you know, I don't think there's a lot of harm in it. Yeah, let's do that. Okay, so my BMW is in the let's leave that BMW in there. So we're working on the run through right of using the that's it if we can make sure that there isn't calcium. obviously in any patient with CKD you're always concerned with with coronary calcium. We don't want to let me come down a little just lift it up. Okay great. Alright so we're able to cross the lesion here. Okay good. And so Evan is gonna go I got this out, you go ahead and click start imaging. Okay so we're zeroed here and so what we can what I'm gonna do here is actually just on um go ahead. And I'm just gonna manually pull back to see when we until we get into a lesion. So this is all diseased. Okay and then I'm gonna re advance until I get into a sort of normal segment here. That's all diseased because you want to make sure you're at least in a good landing zone. And I think this is really good. I really like this. Okay. So what I'm gonna do is Cindy that that's my co registration segment. And what Evan is going to do here is just gonna start pulling back and so this again is one of the advantages is that we're going to be able to get the length here. And honestly this is not particularly calcified. We can talk about the rules for calcified nodules and or super calcium that would require a lesion preparation. Um For not as bad as I expected. Here's a good, very nice landing zone approximately. You see this is concordant with what the F are pull back show that it's very focal lesion large complex. Yeah. And I think there's some you know we we understand there's some diffuse disease but of course on the I. F. R. Pull back, we didn't see any pressure grading here. So this is where it's really we need to hesitate at doing the temptation to put in very very long stance based on the imaging when there's no pressure grading at all. And that's the synergy between imaging physiology. They both have a role. The physiology is telling us when to treat where to treat that. This is showing us how best to treat. It's giving us our strategy for direct stenting versus if lesion preparation was necessary. And we're gonna be able to determine from the office the exact size that we want to use as well. Okay. Okay. So he's gonna go to the last frame, right the last frame so go go back a little bit more. Just go to the first frame because that's where we co registered. Yeah. Okay, perfect. And so he's gonna do go ahead and do a diameter measurement for me there. Good 3.3. So now one thing to notice here is this four approximately. So it's quite a bit bigger and so we just need to be able to accommodate for that. So what Evan's gonna do now is scroll into to see where the bifurcation is. And make sure that we have at least eight millimeters to pot. Actually there's no real bifurcation, isn't it? Pretty small. Okay, so we'll just post daily approximately. All right. And so you want to give me a length from uh i from bookmark bookmark? Great. Okay, so uh so we're at 26.8 I think that's pretty good for a 28. So um can you get us a 30 by 28 stent, please? So in the meantime, what we're gonna do is you want to just scroll through and talk about the calcium and then and then talk a little bit about the calcium here. Okay, so the new calcium rules for when we should do advanced lesion preparation for calcium are remembered by the pneumonic calcium laden. So circumferential calcium gives you one point a length of calcium of five millimeters, which we can measure here with an arc of greater than 2 70. So I can show you if we have that or not, A diameter adjacent to the calcium of three, less than 3.5 and a calcified nodule. So to be honest, according to this, we really don't have any of those. And as a result of which, which is to be honest, why I think we're pretty comfortable direct stenting. So our screen setup is actually really important. So now what I have is that the the reference frame and the active frame immediately next to each other. And so that's gonna really help us make sure that we land in the in the right position and so about the sky point is the expansion in that's how dynamic that is. And particularly for vessels like this with the tapering it allows you to be able to expand to account for both the discrepancy in the proximal and distal vessel diameter. So you know I think the affinity had some real advantage here. Um I think we were the length measurement for zero contrast pcs particularly valuable I think. Okay so we're able to deliver this nicely I think you know I'm actually very happy with where we're landing right here Evan. So why don't you go ahead and go up? The imaging allowed us going up. I like to err on the side. I'm at 10:12 14. You see it nicely starting to expand there. So we've got a little bit of tapering down there which will Evans is gonna go a little bit higher. There we go. And it popped so at 18 and down. And so and the nice thing is we've got both I. F. R. And we've got um I've is to make sure that we don't have any edge problems. So you can go ahead and give us the N. C. Balloon please. And so you can see you know these cases are very smooth. The staff is comfortable with them. They're generally just imaging, guided and physiology guided P. C. I. S. And the only real difference is that we don't take any pictures. Um I also think you know having the interest site by the bedside is actually really very helpful? Um You know because we can do this case really as the operators making you know somewhat difficult decisions I would say. Especially for a zero case. That's right. Yeah I think back a little bit more. Right Let's go there. Have, yeah. Okay good. And so you know this is where we wish we had sink vision. Let's go 1820 good. Okay. And we'll come back here to get that approximate part that we missed before. Yeah 20 there you can see actually as that expanded where the pot was perfect in town. And so next we'll take the army wire back please. So this is kind of typical for us. We'll put the omni wire back in. It's only gonna take us a second and then we'll measure to see if there's a gradient will pay particularly close attention as we do the pull back around the edges of the stent. Because sometimes it can actually pick up a sort of a cult. Um uh an occult to dissection or something like that. But um and then we'll finish off with the obviously go to the led. So this is one of the other things I really like about the omni wire is you know it's it's a lot more durable than the previous wire. So you can actually kinda use it. Is it called up? Yeah the newer wires, what's nice is it's much more reliable. So you're much less likely to have drift even at the end of the procedure you can use it multiple times definite advantage. Let's see if it held at zero. Let's go back to up on our mag. Okay. So we're right at one. A good example of how Omni doesn't lose its uh its ability to hold pressure. I'm just gonna take that and not re equalize. I think it's a testament. I always like to go at least 10 distal to where you were treating. All right. So we're um we're in the non ischemic zone. So Evan is just gonna do an I. F. R. Spot ideally we'd be like to be greater than 0.95. We're at 0.94. I'm okay with that. Especially since we started at 1.1 or 1.99. So good. That's good for spot. And like let's do a pull back. You wait for the blue line to come up And then you're looking for any step up. But then we're also looking to make sure that we come back to 1.0 and that it's a reliable pressure. So you see there's a little step up at the distal edge. So that's a, you know, a potential sign for us to look for an edge of this section which is why we're gonna go back with this. Okay good. So uh what our team is we're just quickly gonna look and see the show that there's no drift. Which there isn't. And we'll take the office, please. So that's a little kink at the top. So just try to keep it straight, please. All right. We'll take the affinity. Now. According to the GPS, we should be going for 0.95. And to be honest, I'm not comfortable doing that without the co registration because we'd end up. We've already ballooned with a maximal size balloon and there's a little bit of diffuse disease approximately and distantly and, you know, going back to either post or put another stent um to get sort of, can you lift that up for me please? Right. Unless the other shows an area where there's significant under expansion, you have to balance potential gains versus I mean, sort of disadvantage, you know, I gotta say I really like doing these cases with the affinity, I think, you know, there isn't. We gotta just reset this. Let's take it back in the guide and reset it. Image quality is great with can you lift it up heaven please? Okay, very smooth, very easy to deliver. Okay, just go distal to the stent there. So Evan's gonna go ahead and click start imaging on the inter site. Okay. And then, well, let's go ahead and pull back great. This alleged day section so far. Everything's well expanded. Significant male opposition is the bifurcation looks good approximately. looks good, too. Okay, Innovation and you phillips.