Intermitent CP for 12 hours, LED Vein| Bypass, Lesions,Balloon | 78 | STEMI wake up!
Intermitent CP for 12 hours, LED Vein| Bypass, Lesions,Balloon | 78 | STEMI wake up!
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Alright so this is an old slide actually this is the patient that was not part of the... no actually this patient was in the past couple of months... so a different type of

patient seventy-year-old with intermittent chest pain for 12 hours. So the intermittency of chest pain... remember we saw that initial kind of animation actually was not an animation... I'll tell you how they did that's pretty cool. So

what they did is they took an artery and they actually sectioned it all the way up. It's the same patient so one artery...on autopsy obviously...and they sectioned the artery all the way up and they went from a normal segment to an abnormal

segment. That's actually how they got that picture. Those were like fifty hundred micron segments. So kind of cool how they got that picture. Pretty bad cause it's autopsy but that's the way it is to get great pictures. In this particular

patient we see some changes perhaps one in aVL. Very subtle. Right so this considered a lateral infarct. What's probably what would draw your eye to any EKG like this is that the depressions are greater magnitude than the lateral wall

the lateral EKG changes. And actually that is a pretty pathognomonic of a circumflex lesion. So in this patient left main. The LAD is actually a grafted vessel. This patient had bypass and the lesion's in the circumflex. So this

job was in the left AV groove. So therefore the marginals are the ones of the on the side of the heart the rounded side of the heart the left ventricle. And the changes will be in the lateral wall and that's why just changes are

seen in 1 and aVL. So kind of pretty typical for what we do this patient had a balloon and the final that was pretty. I gotta say so for myself. So pre and then the post. Even a grafted patient oftentimes has ungrafted

distributions and that's typically where see it. Vein graft occlusions interestingly enough are really complicated because they get competing flow. But in a native artery typically the changes are abrupt and

obvious. Ok so we look at targets... how far am I timewise...7 minutes...okay good. So this is the...actually I love that commercial where they're sending out the know the glasses and the

two deer in the woods. You guys don't know what I'm talking about right. Ok I love that commercial I'm trying to get a slide of that actually... and they kept saying those guys are dumb and its the two deer wearing the mask ok...

Anyway I want to go over some STEMI

I think carotid stenting is here to stay maybe not in the same iteration that we talked about 4 or 5 years ago where everything was's the only way we could do it. But I think it is here to stay and it's an exciting time

to be in the field. So thank you very much for the invitation and I'm happy to answer any questions. Thanks. Leading question. And sure the answer is yes. It will be different so i think it's

not just the arch though I think once you get past that and get into your carotid clearly you've got a lot of other steps but you know Magellan and the catheters are going to allow us maybe to use proximal protection.

Which i think is a big piece of it not just getting there but if you believe that proximal protection you've protected the brain before you cross the lesion is also a big piece of it. So we'll still need to if you're going to

use a filter you're still gonna have to go through that lesion. So. Yeah. Great great question. And so and out of all of these patients we've not had a stenosis at the access site. And you know

it's still in the common carotid so we can see it with duplex. So yeah. And then all of the stents and everything are the same so that data is out there and those stents are performing well. Alright. Thank you.

next three hours we would probably just go over all these trials if that's okay. So

obviously a lot of time and effort has and a lot of money has been spent by industry to actually look at this. And so the question is why are we still talking about this and what happened to carotid stenting. So if we

can take a lesion that looks like this which I would venture to say that most surgeons would not be anxious to approach this lesion because it goes for a very long distance high up in the internal carotid. And if you can make it

look like this why are we still talking about carotid stenting and what happened. So here's the reason. Because this is what these things look like from the inside and all surgeons know this and it

makes us nervous to put a wire and a balloon and a stent through this. And so embolic protection is the holy grail for carotid stending. And it's why we're still talking about it why is not completely replaced endarterectomy. So

current treatments really for carotid stenting... this is kind of what you all see. There's a little basket here a filter and here's a stent coming to treat this lesion. So there is a less invasive alternative. It's

patient-friendly and durable as proven... I'm sorry i keep getting wrong button... as proven in the CREST trial. But there is clearly still excess procedural stroke risk. So when you look at endarterectomy vs stenting even though

the overall risk when you add MI into the picture is equivalent. The stroke risk is clearly higher with stenting. So because the procedure itself can create thromboembolism and we're going to talk about that.

What causes peri-procedural stroke which is the real issue. Well traditional carotid stenting from a transfemoral approach requires several steps that can create and embolic risk. So you have to advance the

catheter from that femoral artery through the arch and if you follow me this catheter now potentially scraped off plaque from this arch disease into the left subclavian and the left vertebral so there's the first brain

artery at risk. When you're trying to treat a right carotid so left vert it then went by the left carotid so there's a second artery it went into the innominate which could theoretically then embolize the subclavian and the

right vert so there's a third one and here's your target lesion. So all four vertebral... all four cerebral arteries are at risk when you do a trans-femoral stents. And that's been proven in the trial so navigating and then the

last is you actually have to get through this lesion with your protection device before you have protection. So embolic

a big intervention. Ok different EKG. 48 year old with new onset chest and jaw pain. Anybody see any abnormalities. Yes we got some ST segment elevation

1 and aVL a little bit in v2 and v3 maybe a little bit in v4. The difference here of course is you see it in a lot of leads. And that's that sometimes confusing but it's the greatest magnitude that matters. So

indeed it's the lateral leads that we're seeing those changes in mostly. A little bit in the anterior not so much in these lateral leads. So what vessel. Actually it is also the LAD but it includes a very large diagonal. So we see

the lesion here. Left main circumflex LAD this is a septal perforator. And we see a very tight stenosis. It is not occlusive. And so we take a long wire long balloon. And we make that look like that. And fortunately we've got some... this is a really

small vessel. It's a really funky little little vessel. Very typical of a diabetic. Seventy-eight year-old female presents with

treated with TCAR and is that where carotid stenting has gone. I'm not sure that's the right answer but clearly in many patients it is because with transfemoral CAS

you've got arch manipulation leading to new DW lesions and are some of those strokes. Well clearly if you see them on MRI they're a stroke even though they're asymptomatic but is neuro cognitive decline a real issue and I

would tell you that it is. So there are more and more papers coming out that say these essentially asymptomatic hits are not good for the brain. So here's the a little data on TCAR. The ROADSTER trial was the U.S. IDE trial looking at at TCAR.

So it's a prospective single-arm multicenter trial 14 sites were in the US and obviously we were one of them. Using the transcarotid neuro protection system. Pivotal trial enrolled a 140 patients... sorry

18 sites..Some they were symptomatic and asymptomatic patients. This was a high surgical risk trial so not acceptable risk only high surgical risk is defined by CMS for all of the other chronic stent trials. And then we looked at

30-day stroke death MI. And again to cut to the chase the numbers are very very low so these are the best numbers that have been seen in really any carotid stent trial. So this is the intention-to-treat group

which 141 there was 5 patients that really fell out per protocol. So if you look at those the numbers are even better. But even if you focus on the entire group that was treated stroke and death was 2.8% and

that's lower than any other stent trial carotid stent trial out there at this point. So is this the new bar for carotid stenting and is this were we now are. So here are the high-risk patients seen for endarterectomy and carotid stenting

in the SVS data or the Society for Cascular Surgery database. So carotid endarterectomy is somewhere around 3.6% carotid stenting is almost 5%. Here's the trials on standard surgical risk were still

higher than our ROADSTER data of 1.4% for stroke. 12-month outcomes in patients who we think are even higher risk. So if you look at age 75 there were no strokes no deaths

excuse me no minor strokes death here so stroke and death rate of 3%. So quite a bit lower than the high-risk group seen for SVS and the other trials. And then the symptomatic patients who we all think have these lesions that are

probably at higher risk were even low. Octogenarian. So the patients who have those bad arches clearly have increased neurological events and more DWI lesions seen in these older patients as documented in the number of trials. And

here's why. So we get and we get more elongated arches with more calcium and increased risk of embolic events. And as you see as we get older look what happens to the type of arch. So the nice flat arch that we all want to

see for transfemoral stenting just keeps getting less and less and more and more of these type 3 elongated arches that are more difficult. But again TCAR data for octogenarians and symptomatic patients was actually quite good. So

again here's the question what's happened. Should all patients with carotid lesions be treated with TCAR. And I would tell you that all of these femoral stent trials as the technology has gotten better we've gotten better

at all of these things. So even from the groin I think carotid stenting is not a bad procedure at this point but I would venture to say that TCAR is probably a little bit safer. Again not going through all of these data but if

you look at the numbers TCAR the early data with ROADSTER you know this is right in the realm of better or at least equivalent to some of the of the transfemoral stents. And I would say that ACT 1 is probably the

important one to correlate this with. But remember ACT 1 are acceptable risk patients and these are all high-risk patients. So to have the equivalent numbers I think is impressive.

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