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We use the MB wire for final POT. You may review a video animation of the TAP steps I have under Bifurcation LM part 1: ruclips.net/video/IU43KJYIvu8/видео.html

@@eliashanna8248 Thank you Sir

Exactly!!!

Thank you! And great question. We use the same bolus dose that would be used intravenously, which is what was used in all trials of IC GPI. I administer each bolus via a 10 ml syringe, sometimes 2 syringes mixed with blood. For eptifibatide, we use the standard 2 boluses of 180 mcg/kg/bolus, given 10 min apart (or 1 dose if GFR<50); and for tirofiban, we use the standard one dose. This is followed by the standard IV infusion for up to 24 hrs. Eptifibatide solution is acidic, and there is a hypothetical concern about microvascular injury using it directly in the coronary; so, if possible, try to buffer the bolus by mixing a bit of blood in the syringe (blood aspirated via the guide/Tuohy). One study has buffered 10 ml of Eptifibatide with 2 ml of bicarb 8.4%, but that is somewhat less practical.

Thank you. You are correct. There is a concern about vacuum suctioning when connecting Penumbra suction to Tuohy/Guideliner, which creates air and air embolism. That is why, after this maneuver, it is important to remove the Guideliner from the body while on negative suction, then back bleed the Tuohy vigorously (passively initially, to get potential air out).

Thank you! IT is likely that one of the 4 essential techniques will work, especially the local tpa. IF none worked and marinating the pt did not work either, consider laser if you have it. Another technique that is somewhat similar and more widely available than stent retriever is to deploy a Filter or Spider wire distal to the clot. Then pull the Filter wire and try to trap the clot and pull it in the guide. There is, however, a concern about clot dislodgement and aortic/cerebral embolization doing this; stent retriever is safer in that regard, as it integrates into the thrombus.

Thank you! I will give you the same reply as below: The idea of direct stenting does not apply to heavy thrombus. As I describe, you do not want to stent in the midst of very heavy thrombus, as you have a high risk of macro and micro embolization from cheese crater effect (rather than trapping the thrombus, you squeezed it through the stent cells; remember the stent has open cells). Also, significant risk of stent thrombosis, esp if you aggravate distal flow. The cerebral stent retriever concept is different: it is s a slow self-expanding stent (no balloon) that is pulled out. In milder thrombus burden (thrombus <2 vessel diameters, esp <1/2 vessel diamters), direct stenting may have some merit via reducing the overall manipulations and potentially reducing distal emboli and improving reperfusion, based on 5 small trials (A meta-analysis of randomized controlled trials of conventional stenting versus direct stenting in patients with acute myocardial infarction.J Invasive Cardiol 2015;27:405). However, direct stenting necessitates that the artery is not totally occluded and has flow, whether at baseline or after wiring; if it is totally occluded, you have to get some flow before direct stenting, via thrombectomy (which is not recommended if thrombus burden not high, class III) or lesion dottering with deflated balloon. Overall, I do not believe it has a major role, and a more modern meta-analysis did not show a benefit (European Heart Journal 2018: 39: 2472-2479). It has risks in some subsets and several limitations. This was more relevant in the early 2010s, when thrombectomy was routine and when we could do thrombectomy followed by stenting. But TOTAL trial showed the hazard of routine thrombectomy and it is now class III in the guidelines. As an extension of those ideas, post-stenting is what should be limited in STEMI to reduce embolization and cheese crater effect.

Thank you for the valuable inputs......

You may use a standard microcatheter, but you would have to pull out the wire to inject the drugs. A dual lumen catheter allows you to maintain distal wire access and also has the advantage of being monorail system. It is a Monorail system that allows you to maintain distal wire access, while you inject the drugs via the OTW port

Thank you! The idea of direct stenting does not apply to heavy thrombus. As I describe, you do not want to stent in the midst of very heavy thrombus, as you have a high risk of macro and micro embolization from cheese crater effect (rather than trapping the thrombus, you squeeze it through the stent cells; remember the stent has open cells). Also, significant risk of stent thrombosis, esp if you aggravate distal flow. The cerebral stent retriever concept is different: it is s a slow self-expanding stent (no balloon) that is pulled out. In milder thrombus burden (thrombus <2 vessel diameters, esp <1/2 vessel diamters), direct stenting may have some merit via reducing the overall manipulations and potentially reducing distal emboli and improving reperfusion, based on 5 small trials (A meta-analysis of randomized controlled trials of conventional stenting versus direct stenting in patients with acute myocardial infarction.J Invasive Cardiol 2015;27:405). However, direct stenting necessitates that the artery is not totally occluded and has flow, whether at baseline or after wiring; if it is totally occluded, you have to get some flow before direct stenting, via thrombectomy (which is not recommended if thrombus burden not high, class III) or lesion dottering with deflated balloon. Overall, I do not believe it has a major role, and a more modern meta-analysis did not show a benefit (European Heart Journal 2018: 39: 2472-2479). It has risks in some subsets and several limitations. This was more relevant in the early 2010s, when thrombectomy was routine and when we could do thrombectomy followed by stenting. But TOTAL trial showed the hazard of routine thrombectomy and it is now class III in the guidelines. As an extension of those ideas, post-stenting is what should be limited in STEMI to reduce embolization and cheese crater effect.

@@eliashanna8248thank you for the detailed answer. I am glad to have your book and be able to hear your voice and communicate with you on youtube. Greetings from Germany. ❤

Ahmed, the best interventional fellow ever :). We all miss you!!