HDR is a new to concept to many of us. HDR in some ways challenges how we have been taught and currently practice CTO PCI. The use of contrast modulation is not new, but what is new is the move to using contrast first as “a first approach” for a CTO. There are my initial comments on this: 1.  The strategies we currently use are AWE/ADR and RWE/RDR. The question is where HDR fits into the algorithm. But then HDR is not for every CTO. But that’s fine, as we know that no one strategy works for every CTO, and we often switch strategies as per the hybrid algorithm. 2.  In post-CABG heavily calcified CTOs, where I have used a contrast injection to disrupt tough proximal cap, has a provided a natural means of testing this. HDR does not work for these CTO subsets in my experience. I think with time we will indeed learn more about this technique and the anatomies where it is likely to work. 3.  The key question in most minds is : Should HDR always be the “first approach”? In most lesions where this may work, are the soft CTOs, which one may argue may be easily addressed with AWE. So the question is shouldn’t one try AWE first, before considering HDR. Although HDR may show the way for AWE, there is also a chance that HDR may disrupt the vessel unfavourably as such to reduce the likelihood of subsequent AWE, and then the need to switch to other strategies like ADR, which could have otherwise be avoided. 4.  It is always important to try and learn new strategies and techniques. After all that’s how we grow and get better. There are no hard and fast rules. I am always welcome to trying new techniques.💪🙌

Another successful #CTOPCI using Crossboss and wire escalation for #ADR topped off with #IVL for a calcified blunt cap with excellent results. #PennsyInterventions @jcgeorgemd @GPAngioClub @ACVCPhila @PennCardiology @PennCVFellows @BSCCardiology @ShockwaveIVL