Further insight into the case. Decided to fix the LMS, LAD &diagonal during index admission. LMS, LAD provisional as no landing zone at the ostial LAD. LAD d1 mini crush. Lcx ostium was normal. Decided not to touch the lcx.

As RCA was the culprit. So we fixed it. Now what about the left system? Staged CABG. Staged PCI. Index procedure. Index admission. Or after 4 weeks.

What should I do? A 50-year-old diabetic female presented to the gastroenterology OPD with abdominal pain, Refer to our ER, having inf STEMI. LVEF 30%. Shifted to the cath lab for PPCI.

Decided to fix the LAD as well I'm same setting. Hybrid approach. Focal DES to proximal LAD and DCB to distal LAD. Lcx left on GDMT.

A case of #HDR regret. Proximal tortuosity and a blunt cap were the challenge for me. AR 2, MC PJW poor guide support. Switched to AL1. PJW was way away likely in a small RVB. Tip injection com HDR. Gaia 2nd with secondary band found its way. 3 stents. Good distal flow.

Diffusely diseased left system and RCA CTO. Cap looks ambiguous/blunt. How much should be done in this case? Pt was symptomatic on GDMT.

F/U After seeing in nasty thrombus. We decided to do further optimisation. 3.5 NC in lcx &4.0 in LAD. Sequential then KBI at higher pressures. Pt remained stable afterwards. Discharged after a couple of days on TAT. Will review at 4 weeks for the left system and staged RCA PCI.

We brought him back for relook after 60 h. 48h of gp2b 3a and then TAT. I was surprised to see ugly thrombus again at the same site. Lcx ostium. No what to do.

At this point, we stopped. Kept him on GP 2b 3a for the next 48h. Stabilized. Brought him back to the cath after almost 60h. Another surprise was waiting for us.🤔

As it was STEMI and the patient was having active chest pain. 7F, predil lcx. The thrombus shifted to the LAD. Minicrush. Everything was good till the pot. But when we recrossed towards LCX. Thrombus prolapse into the stent. RI closed. KBD 3.5 &4.0. Aspiration failed Now what.

A 70-year-old man with inferior STEMI. What's your take on the likely culprit vessel, and how would you manage this case?

What is your way to go with a deficient aortic rim? LUPV or RUPV.

Finally decided to fix the native OM as well.

FU angio after 72 hours of TAT therapy. Complete resolution of thrombus.

Marinated therapy. It was a huge thrombus. TPA wasn't available so I decided to use streptokinase as a marinated therapy with a distal blocking balloon with intermittent inflation and deflation. Half a dose of SK has been used with promising results.

There was much more to the case. What had happened here after stenting and what to do now.

Decided to start with SVG. Pre dil. 4.0 stent 5.0NC for post dil. LSD at the ostium of SVG. Correct with 5.0 NC at much higher pressures.

70y old male. CABG 2018. LIMA patent. SVG to RCA occluded. SVG to OM/RI ostial and proximal calcified stenosis. Suspected thrombus at mid-segment. Native 2nd OM severe diffuse disease. Native RCA long segment CTO. Now US/ACS.

TOE guided PMBV. Inoue looks beautiful.

Hybrid DES and DCB route. LAD /D1 nano crush. Mid distal LAD DCBs.