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Smart Cathlabs: Achieving more in complex cases

Oct 23 | 2:00 PM

To successfully perform routine procedures in a Cath lab, precise control over catheter tip placement is required. The use of technology was incorporated as a solution to improve the treatment of cardiovascular disease by enhancing physicians' movements through increased precision. Join us as these essential procedures are demonstrated in a Smart Cath lab.

[Music] uh good evening everyone i am dr naveda from netflix and on behalf of team netflix i welcome you all to today's session for this session uh we have dr joshua who's a senior interventional cardiologist consultant at hcg hospital amsabad and we have with us dr anushka who is also a senior interventional cardiologist with hcg hospital and star hospital amphipath so good evening all uh respected viewers and at the outside i would like to thank dr nivedita dr rohan desai and the team netflix for giving us this type of platform which is in a very very unique platform where we can go from didactic talks to extempore talks as well so just as a part of continuation of our engagement with netflix we are starting one series uh which will contain a different topics in the field of cardiology and to start with our topic we are starting with a very uh i would say upcoming a way of dealing with the complex cardiac disease or complex cardiac cases presentation or the cases which is known as smart cath labs why do we call it smart catholic because uh cath lab they are being invented and they are there since last 20 years in especially in ahmedabad and different catholics are there with different technology here i am going to discuss about the catholic which is not only going to give you the better outcome but at the same time by using certain technology how can we improvise on the overall cardiovascular outcome for that patient by giving them survival benefit by reducing the radiation by decreasing the length of stay in the cardiac catheter and by using certain specific softwares which are available in the cath lab which can give you even with a lesser amount of chemical which is being utilized for doing the different cadet procedures mainly coronary angiography corollary angioplasty uh and different uh you know methodology how can you give a minimum possible i would say you know adverse or side effects sort of things because of this chemical and because of the radiation which is going to be there because of this cath lab activity so uh with accordance to with that particular thing let me start with a different software which are going to be there in the cath lab nowadays we are using multipara monitors hemodynamic monitors which will give you the idea about the blood pressure pulse and along with that there are two very important software which we are installing in our cat slab and they are known as dynamic coronary range and stent boost now these are the two important software why it is important stand boost means you are able to see the stand after deploying angioplast after deploying stand in a case of angioplasty what exactly is the geometry of the stand which are the connectors and how the connectors are being attached within the stand and whether the stand has produced a proper position and a position in the vessel wall that can be seen on a on a monitor of a cath lab and that is known as stand boost important second software it is known as dynamic coronary range now this software is something where we are using that dye or a chemical by which we are doing an angiography you just deploy like you just give a one push of die and that die on that film will give you a road map in a simpler manner or a simplistic language if i wanted to tell you that if you take a first angiographic picture and that angiographic picture will remain as a reference so that without the use of the dye or a chemical you can pass on the wire and balloon and stand and then just do a check angiography by doing that the amount of chemical which is being utilized is tremendously reduced and that is why the kidney damage is going to get prevented so that is the importance of the uses of the smart catheter by using this software normal angioplasty requires almost around 70 to 80 ml of dye or a chemical but in this type of software including angiography in angioplasty you can finish it off the whole procedure in around 25 to 30 ml of diet so not only you are decreasing the amount of chemical which is being utilized at the same time you are preventing the high risk patient to develop any kidney damage because of that chemical so with that there are two three other important things which we are going to discuss and one of them is called ios that is intravascular ultrasound what exactly do we mean by that what is ios it in nutshell like in a normal layman language it is known as sonography of the hard arteries so you just go inside the artery by putting the small catheter and that catheter is having a camera and that camera will give you the idea about the inner part of the artery and that is known as ios what exactly is the ios means it's basically an ultrasound but we do it in a regular routine you know sonography it exactly works on that basis it produces echo and that echo is reflected by different sound waves and that waves will be reflected as the image and that image will give you the exact idea about the presence of the underlying condition and why this is required by because when we do an angiography that angiography will be given you the idea about the presence of a two dimensional image of the artery but by using this ios you will be getting a three three-dimensional idea of the artery now look at the panel a what do you see you see that there is a big container and there is some rabbit which is going to be like rabbit which is lying within the within the within the container but if you do the introspection you will be able to see that it is nothing but a bowl of fruits which is having two banana which will be looking like a rabbit ear and this is where the role of ios comes the amount of clarity which you require while doing an angioplasty is going to get multiple away multifold beneficial by using just a ios which is providing more than just the shadow of information so that is what i wanted to highlight now look at the the importance of this particular uh picture how can we justify the role of ios because there are certain limitations of coronary angiography in panel a you will be seeing that the artery it has been cut in a cross section area area and you will be seeing the deposition of the cholesterol within the coronary artery now if you take an angiography of this particular vessel it is on angiography on the panel b that is a gray panel you will be seeing that it is a 75 blockage that means there are two are the artery and the middle part of the artery is getting narrowed because of the blockage and that is looking at this 75 percent the same artery if you just turn it upside down from horizontal make it in the vertical plane you will be seeing that the same blockage which was looking at around 75 percent on angiography it is now has become 25 percent so are we justified in putting a stand or treating the lesion if the lesion is having 25 percent as well as 75 scenario to improvise on that thing let us take another example now the panel a which is a red panel which is showing a blockage or a cholesterol deposition within the artery and that is how it is being seen on an angiography as 50 in the similar way if you took the take the second picture the the the panel is showing a diffuse narrowing and still the patient is having the angiographic picture is having around 50 blockage so in that particular scenario if you are seeing the artery from inside you will be able to not only quantify the diameter stenosis but you are justified in putting the stand or not putting or not requiring the the intervention so both the things can be achieved with the help of this particular technology how does it work here there is a cartoon which is showing that the mouth of the person is exactly inside the coronary artery and that is how the detection of the blockages are being seen the detection device receives the sound waves and it will be it will give you the idea about the internal picture of the artery i will not go into the detail of the very basic uh things but there is a transducer here you can see that in the in the small picture there is a transducer on the tip of the catheter which is seen as a yellow line which emits high frequency sound waves through the conductive tissue that is blurred and this transducer it will it is a basic device which will run and produce a camera-like picture and give you the idea about converting electrical energy into sound energy and sound energy into electrical energy and give you the the image which is being seen in the right corner and this system it will create a cross-sectional image on the intensity of the return waves and you will see the picture of the artery as a gray black uh you know the image the gray black image now this image is being seen like this that the first panel which is showing the uh you know the the coronary artery or the artery which is having a yellowish deposition of the blockage when you do this particular procedure the inside of the artery is looking like this and it will produce a narrowing of the lumen you can see that that middle part of the black uh transluce uh the e collusion shadow is nothing but the reduction in the luma the actual artery is very big which is seen as a white round or a white shadow similarly if you look at the inside part it is looking very very narrow and that is the blockage and why is it important look at the coronary angiography of one of my patient this patient is having a blockage which is being seen inside the the main artery you can see that the artery is big in between that is having a very narrow structure or a narrow a part which is lying as a bifurcation and that part is being seen on an angiographic picture like this now this is a angiographic picture but now if you look at the artery from inside you will be able to see this type of stenosis of the blockage how much is the disease now if you cut section if you do the cut section in some of the angle you will be seeing 20 percent in some angle you see 40 percent in some angle you see 60 percent but each angle is showing or giving you the different parameter of the underlying condition by looking at the ivers you are seeing the artery like this in a gray scale where there is a small tiny black circular structure which is nothing but the muscle of the artery here you can compare it in that diagram that schematic picture where the pinkish part is coinciding with the inner part of the the white shadow the outer part which is looking white is coinciding with the black strip likes uh you know slit like rounded structure which will give the idea about the inner part of the coronary artery now different coronary artery is having a different picture this panel a in the panel a1 which is showing a normal coronary artery but on the second panel in the mid part where the arrow is being there in the center is showing a very wide refractile tissue inside the coronary artery which is nothing but the calcium you always hearing about the presence of calcium within the blockage presence of cholesterol within the blockage presence of fatty tissue within the blockage the presence of fibrous tissue within the blockage all these things are getting completely clear on an ios picture and this is how the blockage in the artery is getting further progressed the normal vessel having blockage or the starting of the blockage with a mild disease followed by the moderate disease there is a compensatory expansion of the coronary artery and this compensation overcome by reducing the size of the lumen and that is the reason the mid part which is being seen as a small hole that is the part where the blood flow is going to get uh flowing and the rest of the artery is getting narrow so whenever the patient is doing any exertion there'll be a reduction in the blood flow and it will produce angina or a cardiac pain or a chest pain this is the way you will be able to see in an ios the progression of the coronary artery disease you can see that the panel a is absolutely normal panel b is having a crescent shape blockage panel c is having christian shape blockage along with the calcium there is a the white dot and panel c the lumen becomes very narrow and the whole you can you can compare it with the with the you know the doojka chan you know the e chan you can see that exactly similar way in a christian shape similarly in panel a a you will be seeing a very small crescent shape uh you know a moon like half moon like scenario which is nothing but a blockage which is lying at the proximal part of the artery and in panel b it is the vessel wall that the wall which is containing all the layers of the artery and the similarly this uh uh this red shadow is showing the lumen the the lumen which is showing the blood flow the blood pattern which is being seen within the coronary artery now this lumen and the rest of the coronary artery is having a yellow and red scenario now this yellow and red is panel a which is showing the blockage and panel b which is showing the normal segment where the lumen is large the yellow part is less whenever the yellow part is small that means the blockage is more red part is small that means the lumen is narrow so that is the difference between angiography and ios angiography will give you the shade of the lumen but ios will give you the exact visualization of the lumen what will be the shape and the location of the plaque in angiography the inner side of the artery is not being imaged or visualized while in ios you will be seeing all the layers of the coronary artery angiography will definitely underestimate the extent of the disease the progression of the disease while ivers will give you the idea about the morphology of the plaque the morphology of the blockage whether it is having a fat fibrous tissue muscle calcium or any other different modality of the fat tissue is being seen on an ios catheter angiography which will give you the idea about the large dissection that means cut within the coronary arteries while in iowa's even a small cut can easily be visualized with the help of this technology now i am going into the detail of the normal ios image this is the normal ios image which is coinciding with the panel one which is uh adventitia panel two or rather number two which is a middle part it is the muscle and panel three it is the inner inner side of the vessel wall or the lumen which is known as intima and image interpretation will require adventitia then there is a equilibrium layer which is a smooth muscle cell or a media then three which is the intima four is lumen fifth is the ring or the hello which is a hello of a guiding catheter l of the catheter and six is the dead space which is showing the lumen of the catheter six is not the lumen of the artery three or four is the lumen of the artery which we'll be seeing the blood speckles in a gray form this is the normal artery how can we identify some of the important side effects of that or rather the artifacts of the diverse that is a ring down effect then there is a non-uniform rotational distortion this is a little highly you know technical thing so i am not going to the detail of all these things but you will be able to appreciate the actual 12 o'clock artifact which is being seen as now visualization of the wire shadow which will be seen as a reverberation on an uh on an ios image which is seen as a multiple reverberation as a as a part of lumen which is being seen as a wire shadow and an inadequate production that means you might have to place a injectable uh you know dye which will give you the earlier clear more clear picture and that can be prevented by giving a proper justification by preventing the band in the catheter and by doing a proper justification of the ios procedure now i am just going to the detail of pathological images what is normal what is disease panel a is normal panel b is diseased which is showing the blockage within the artery panel a is showing a blockage which is in a concentric fashion that means the whole artery is having a black deposition of the cholesterol deposition while in panel b which is showing an eccentric or a christianity blockage which is seen on the arterial circumference the whole circumference so one is having a semicircular layer and the other one is having a complete circular layer of the blockage how can you see the soft blockage on panel a you will be seeing the blockage which is having a multiple gray and black shadow which is seen as a soft block that means there's a presence of a fatty tissue within the blockage and fibroid that means it will be looking like a little more firm tissue it is more whitish and not on the grayish black side it is more on the white side so that is a fibrotic and the most white side it is being seen as a calcium and the black part which is being lying and being seen as an arrow that is the the part which is being seen or not seeing because of the calcium present it is a acoustic shadow and that can be seen on an ios like this now whenever there is a heart attack this blockage or the fat is getting ruptured that means there is a tab in the blockage and this stair will lead to release of that mud or the material into the wall and that will completely occlude the vessel wall which will create a heart attack and that is the reason it is very important to identify the whether the plaque is being broken or not that can be done with the help of ivers if there are multiple cuts within the within the artery that can also be visualized on an ios catheter whenever there is a presence of a clot or a blockage with with the presence of a blood inside which will be seen as a small circular filling defect on an iverse and that can easily be picked up on uh intravascular ultrasound catheter then comes hematoma that means collection of blood within the vessel wall that can also be picked up on an engine on an angiography and on an ios but on an angiography it will be looking like just a blockage but actually it is not a blockage actually it is a hematoma that means collection of blood within the vessel wall which will be seen as a separation between the media and the adventitia and there's a complete pocket full of blood which is being seen here in a yellow shape or yellow part which is being seen as a hematoma how does the stent look on an ios stand is being seen as a very like multiple dotted things and whenever you look at the stand the stand is being seen as a multiple white small small dots inside the vessel wall and this whitish dots are nothing but a strand this is the way you see the stand there are dots which are being seen from two o'clock to almost 11 o'clock position multiple whitish dots are being seen and the stand window will be looking like this that inside this this black hole is a whole of the ios and this whitish multiple shadows are the stent design or the stent markers and the stent is being seen in different uh you know condition in a different way like bifurcation stand is being crushed or not stand is being properly placed or not whether the stand is having interest and wrist noses or the places of blockage within the stand that can also be seen on an ios catheter now one of the most important complication of angioplasty is stent thrombosis which is not very common it is being seen in point five to two percent of the cases of angioplasty say for example if you are doing hundred angioplasty 2 out of 100 angioplasty can have such type of complication which shows the presence of blockage or the clot formation within the stand wall because that will give you the acute mi or a heart attack sort of situation and that can be treated as a very life-threatening situation and you have to do a life-saving procedure to combat or to survive or to make the survival of the patient and the last slide aneurysm that means abnormal wall structure on an ios which will be seen as a abnormal dilatation of the coronary artery and that will be seen as a damage to the internal part of the artery which will form a abnormal stack abnormal direction and that is known as aneurysm so this is where i wanted to end my talk and i am just giving you the idea about the basis of such type of technology by which you can further improve eyes on the favorable outcome of all your patients thank you very much for the kind support thank you uh thank you so much for the presentation it was very informative for our residents and for our uh consultants uh would you want to take the questions now or at the end of the session either ways it is okay to [Music] should we take in applying stems in diabetics okay very important and a very good question in a diabetic individual whenever we apply strength you need to see three important things one diabetes ideally should be under well control second diabetic patients are having multiple blockages in multiple arteries or there is a widespread diffuse blockages so you need to choose a stand which will take care of the whole blockage in some of the scenario in diabetic individual if you use a stand which is being properly expanded properly opposed properly deployed then the results are very superior you can prevent complication of that particular procedure or any side effect of the procedure because in diabetic patients when you put a stand the re-blockages chances are little more as compared to those are non-diabetics and even the stand related complications are also little more in diabetics as compared to non-diabetics another important point is that in diabetic patient i think it is always better to put a drug looting stand that means medicated stem you cannot put a bare metal stain otherwise the chances of re blockages are very high in the proportion of around 22 to 25 percent but in case of drug lifting extent the similar percentage is being reduced by only four to five percent so that is where you can give a little better quality of life and better survival for the diabetic patients thank you so much for that sir can you explain about biodegradable skin okay very good question from dr heman ah biodegradable stent it is the the polymer which is being applied on the stand platform the stents are made up of multiple uh metals from stainless steel to cobalt chromium to magnesium alloy all these are the underlying formulation of the stand there are platinum based stand also now whenever there is a stand placement the inside part is the metal inside the metal there will be a the polymer or the biodegradable polymer which is being applied which will help in establishing the inner part of the stent to the vessel wall and then there is a spray of the drug which is a drug in a serolimus analog fashion this is the drug which will help in preventing the re blockages within the stented part so that is called drug drug polymer and the stent material or the underlying metal jacket or the metal platform that is where the biodegradable polymer will act now what does the biodegradable polymer x when you deploy a stand from inside the stand the first thing which is getting eluted or released is a drug which is being sprayed inside the stand so the drug is getting released it will be embedded within the vessel wall and it will be preventing the further blockages within the standard area number one then after the drug is getting released completely in a span of around 21 days the polymer which is being there on the top of the stand wall is also getting degraded so that is also getting vanished from the strained wall and then there is a next layer of skin which is getting deposited on the top of the stent wall which is of the metal and there will be a new skin formation inside the vessel wall on top of the stem so you just assume that you have some cut on the on the skin and then gradually you are getting a new skin on that particular scar similarly in heart whenever there is some damage to the vessel wall and you put a strand due to this drug and the polymer once it is getting absorbed or biodegraded then the new layer that is known as neo intimacy is getting deposited and form a neo-endothelial that means the newer inner side of the arctic is getting re-endothelized and that will prevent further re-blockages so that is how the whole stent and the mechanism of stand will work in our case of angioplasty you sir uh we have one more question uh when could we suspect a stent thrombosis post ptca and uh what are the absolute indications for checking cage okay now there are definite like there are multiple reasons uh by which we can suspect a stand uh you know thrombosis first and foremost is if the patient is diabetic number one if the patient is having uncontrolled diabetes if the the vessel wall or the vessel size is involving blockage in the proximal part of the artery if you are putting a stand which is in a long length or long diffuse blockage if the stand is being deployed and it is being properly not properly i would say post dilated or if there is a presence of any uh discontinuation of the drug say for example after putting a stand if the patient has discontinued the therapy then the chances that is the most common reason followed by diabetes followed by rest of the other like proximal led if the patient is having acute coronary syndrome situation that means if the patient is having ongoing attack or ongoing heart related issue then also the chances of strength thrombosis are high to combat that we require or rather we need to in a case of say for example out of 100 cases if two cases are developing stand hormones sometimes the the artery related factors are there stand related factors are there patient related factors are there if the patient is not complying with the therapy then also this tent thrombosis can occur you need to give the best possible drug available to prevent the stent thrombosis and that is known as antiplatelet drug because when you put a stand the most important thing which which can create stand thrombosis is platelet so you need to prevent that formation by giving the best possible available antiplatelet therapy and you need to make sure that the patient takes that therapy regularly so that is where i think the role of stand will come then there are certain uh you know the i would say drug compliance issue then the patient if uh is not following the advice from the doctor or if they are not you know continuing with the smoking dab like any other drugs say for example if the patient is taking painkillers then the chances of strength related failures are high thank you so much for that sir uh there's i guess one more question a little brief about stent collapse tent pull ups uh cannot be there if you have properly expanded the stand because whenever we put a stand we always make sure that on an angiography that it should be required to be properly opposed and to be very friendly the the ios which we have talked is not a routinely being done across the globe it is required only in five to ten percent of the cases even in usa where the technology is so advanced the amount of uses of this technology is hardly limited to 15 of the cases or 10 to 15 percent of the cases so every angioplasty does not require this thing just in a case of if you are facing any stem related problem then it is the indication to use this technology by which you can give the best possible outcome for that patient you can increase the longevity of the patient you can give a proper justification for your treatment to that patient because every patient behaves in a different manner every coronary artery behaves in a different manner in a in a case of acute coronary syndemara in a case of ongoing hearted heart related issues the arteries are getting narrower or the arteries are in the spasm spasm means there is a complete uh you know narrowing of the coronary artery when you deploy the stand the art is getting properly inflated or getting properly opposed now in some of the situation there's a terminology called positive remodeling that means the artery is getting its uh you know original shape in a different manner after few days so that is the nature of the disease of that particular patient so it varies with a different patient in different uh you know subset of the scenario if the patient is old age the patient's having high blood pressure high cholesterol level high diabetes these are the patients they are having more chances of development of remodeling related issue and that so whenever there is a stent related issues it is always better to check the best possible available modality by which we can prevent the further you know the further uh i would say adverse reaction to that particular condition thank you so much sir for that um we can start with the second half of the presentation if thank you so much for the quite listening and thank you so much all the audience for your pride list thank you so much for the second half we have dr anand shukla who is also a senior interventional cardiologist uh with uh hcg hospitals and uh star hospital and so my topic will be the practical aspect of what dr jai has explained how we can use the intravascular ultrasound in coronary angioplasty in the best way which is the patient is patient substrate require the intravascular ultrasound so in my subsequent slide i will show the practical aspect of intravascular ultrasound i have keep this picture of arjun matsuya to know that it is rooting practice then we may want to take the sword we look at the target directly but in this picture in masjid arjun has to see the reflected image of the fish which he has to see look the concentrate on the water and an opposite way he has to target the fish similar way angiography and angioplasty is considered as a usage of contrast media without uses of contrast media we cannot do angiography or and geoplastic but angioplasty or angioplastygraphy the usage of contrast has their disadvantage it can lead to kidney failure that is a renal impairment and patient may require the dialysis if patient having the multiple risk factor for the renal failure suppose we always do blood investigation in form of serum creatinine before posting any patient for the angiography or angioplasty to know that how much renal function either normal or abnormal if patient is having abnormal regional parameter the chances of kidney damage will be the higher in the magnitude of 10 to 20 percent and the chances of requirement of dialysis will be the higher so in the other way though the angiography angioplasty [Music] are the good diagnostic and therapeutic mode but usage of contrast carries its own the advantage and this one is advantage and disadvantage is mainly the kidney failure so i will show you the one case there is a 46 year female her serum creatine remains between 9 to 10 milligram per deciliter normally the serum creatine of patient will remain less than 1.5 surprisingly patient never required the dialysis patient not on dialysis she is able to pass the 1.5 liter of urine per day so she is in the observation watch list of the nephrologists whenever the kidney deteriorate and urine output decrease she may require the dialysis now she had heart attack inferior volumi she has been managed by thrombolytic therapy at the local center and further she has been referred for the further angiography and the further treatment now situation is catch-22 why because she is having the renal impairment and whenever we cannot do the angiography without the die now if suppose any blockage of treatment required further amount of dye she will be see maybe we expose it for the amount of dye and chassis of renal failure will be the much more higher so please show me the video first so i'll just stop your presentation to play your video yeah yeah so i will show you green angiography this is the bracket static this totally occluded and myocardial infarction please go next yes so important thing in this next place if at all any blockage require the treatment we have to inject the die next video please so how we can use the technology to overcome this herder or limb these are all the left sides today system which were normal next please so there are certain words of dye by using next intravascular ultrasound which doctor sj has elaborated in detail next so we have taken help of the intra task an amount of diet so further kidney [Music] yes so here here we try to pass the wire in the totally uploaded 100 percent block the vehicle i will give without instruction so vessel has been post procedure after angioplasty even we have repair damage now this requires ultrasound catheter catheter has been passed so is between five so what we did we complete the procedure under the guidance of intravascular ultrasound without using the any dye during the whole procedure and once we deploy the stain ex dilated the stent as per the standard diameter of vessels and then we also check again with the intravascular ultrasound and finally only one angiography suit required to fin confirm the procedure so only hardly three to five ml of die has been used by whole proceed though the procedure lasted for the 45 minutes but only the 5 ml of contrast media has been used the important importance of the ios in such case is very much we have to emphasize that if we are not able to complete the procedure with minimum die amount then she may require the dialysis exact early post procedure but due to technology the smart technology in form of intravascular imaging and the dedicated team effort be able to carry out the procedure without contrast load so the patient will discharge after two days of procedure without further worsening of the serum creatinine as well as worsening of urine output the aim we want to do that has been achieved successfully by the help of intravascular ultrasound so now in my presentation i keep the photo of the arjuna and krishna the ear is the krishna is just like the guiding the one i was good interpreter so you require the good colleague for yourself to image interpretation as well as sizing and the length and deployment of 10 precisely without die so by using the technology we can helpful to the patient in very much way though the technology can have their 70 000 maybe the add-on but against that we have saved the dialysis in current status she may require the dialysis in any time in future but the angioplasty is not the reason for the beginning of the dialysis so the my take home message for this for this is we can combine the technology and apply clinically aptly to helpful this patient and for long term better outcome though we know that the contrast is the ampulla agent for the kidney patient but by using the ios we can prevent the contrast induced nephropathy or requirement dialysis by the ios thank you very nice thank you so much for that presentation uh i think there was a question that i missed earlier um indications of doing ibis the indication every technology has caused benefit ratio because technologies are all there but they all always carry along with their cost then we medically analyze this cost benefits ratio with applying additional cost we are getting the result or not benefit or not so ios is theoretical touch all the indication particularly when the particle in strain failure and patient who are in kidney disease these are the broad spectrum there are two current indications for usage of ios but in japan they do the all majority plasti when the image guidance but the budget is if the budget is not issued and the technology is available one should use it but not all case we require the ios bit because it also carries the cost for the technology so broadly in or indication to patient with kidney disease and stand filler thank you for that so i think there's one more question that i missed how do we how do we follow our post uh ptca was ptca we give the blood thinner agent standard dual anti-platelet aspirin along with either kloppy dagger or ticagrail or plaza as per the patient led statins equation these are the mush truck and the beta blocker and ac inhibitor as per the indication control of the respecter for the oscillosclerosis these are the standard guidelines for the ptca follow thank you sir um i think we've covered all the questions um thank you so much uh sir dr ajesha and dr anand shukla for coming up on to netflix and we hope to see you again in the future on this platform thank you thank you thank you so much thank you so much

BEING ATTENDED BY

Dr. Sasikanth Reddy & 506 others

SPEAKERS

dr. Jay Shah

Dr. Jay Shah

Interventional Cardiologist | Consultant - HCG hospital, Ahmedabad

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dr. Anand Shukla

Dr. Anand Shukla

Interventional Cardiologist | HCG hospital & Star Hospital, Ahmedabad

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dr. Utsav Unadkat

Dr. Utsav Unadkat

Interventional Cardiologist | Star Hospital, Ahmedabad

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dr. Jay Shah

Dr. Jay Shah

Interventional Cardiologist | Consultant - HC...

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dr. Anand Shukla

Dr. Anand Shukla

Interventional Cardiologist | HCG hospital & ...

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dr. Utsav Unadkat

Dr. Utsav Unadkat

Interventional Cardiologist | Star Hospital, ...

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