1. 30 th Annual Meeting of The Egyptian Society of Cardiology

2. Layth A. Mimish The Cardiovascular Consultants Group Jeddah K.S.A. Debulking Before Stenting Is it Really Necessary?

3. Inadequate initial stent expansion

27. Guiding Catheter Standard C curve insertion technique Avoid deep osteal intubation Avoid overtorquing Coaxial alignment Supportive guidewire

28. DCA Complications Perforation Misdirected cuts Oversized device Spasm Wire fracture Severe angulation Extensive dissection CK Elevation Vasospasm Slow / No Reflow Procedural Bleeding

29. Debulking Technically more demanding and time consuming Higher CK rise Potential increased risk of vascular complications Limited access in tortous and calcified vessels

30. Successful DCA Angiographic results Post DCA stenosis =15% Post PTCA or stent =0% Smooth borders Good distal flow Absence of dissection Good tissue yield

38. Residual Plaque Burden Post Stenting & Intimal Hyperplasia

39. How Aggressive?

40. Left Main Disease

41. Flexicut

42. Instent Restenosis

43. HSRA for Instent Restenosis

48. Direct stenting / Drug eluting Stent <10 minutes floroscopy 50ml angiographic dye 3000 Dollars IVUS  HSRA 3Burrs  IV NTG, Isoptin or Adenosine  IABP  Reopro  Stent  IVUS >60 minute floroscopy >300-500 ml dye >10,000 DOLLARS

49. Is money an issue??

51. GOOD OLD BALLOON IS STILL A VALUABLE TOOL

52. Late Stent Malapposition Baseline Follow up

53. Conclusion