 I'm Zvonmyr Krazier, I'm clinical professor of medicine and cardiology at Baylor College of Medicine and also interventional cardiologists at Texas Heart Institute in Houston, Texas. I'm also immediate past president of the International Society of Endovascular Specialists. The topic of this presentation is the latest advances in imaging for endovascular interventions. Here are my disclosures, none of them are pertinent to the current presentation. As far as advances related in imaging concerning developments in the last decade or so, there are significant technological advances that have offered us reduction in the radiation dose, also integration of imaging modalities and improvement in image processing. And all of those have offered us better, faster, safer, and more effective care for our patients. Now let's discuss a little bit advances in pre-procedural imaging and there are many of them and I'm showing you some of the examples that are very important and pertinent. Rotational and geography for 3D imaging and Dynacity has offered us a great opportunity to treat our patients more effectively. The automatic reconstruction with a five-second rotational angiogram offers fewer images as far as duration to achieve the imaging is concerned and reduces the patient radiation dose. Also overlay of 3D volumes and contours or points of interest on the live floor images are now available. This all offers us better definition of the anatomy in patients that are those sensitive to radiation. Another example is the introduction of artificial intelligence as far as imaging is concerned and here is one of the examples of guided cardiac MRI imaging as the data is acquired from the MRI scanner. It is transmitted in the form of images that are reconstructed in a real time and then they are analyzed using custom artificial intelligence algorithms and then implemented and used to update the scanner settings as we can see in this particular scenario. So this is what we call one-click MRI. How effective this technology is, it reduces scan time from 90 minutes to 15 minutes which is absolutely amazing. Another progress that has been achieved is the use of CTA in coronary imaging and measurement of fractional flow reserve which is a non-invasive assessment of severity of coronary artery disease. Here we have two examples patient A and patient B. On the CT images we can see there is stenosis of the left anterior descending in the mid-segment that is estimated to be roughly 70%. When we actually use FFR we can see that there is a difference between two patients as far as FFR is concerned. The patient A has significantly better FFR values while patient B has worse FFR values. And this tells us that FFR in a non-invasive way is a more reliable tool than just plain CTA. Now when this patient under one coronary angiography, patient A we can see the lesion that was seen on the CT is not critical and correlates to good FFR as far as measurements are concerned invasively during angiography. In patient B we can see that the FFR shows a different number than we anticipated from the previous just plain CTA of this patient B. Now how reliable and how sensitive is this particular technology by hard flow in measuring non-invasively FFR? We can see the top blue line shows the use of FFR with hard flow and we can see on the right hand side excellent diagnostic accuracy in two separate clinical trials that fairs better than the use of a coronary CTA or even PET or SPECT imaging in assessing the severity of coronary artery disease. Another very interesting pre-procedural development is the use of elusive vascular cap CTA for in vivo tissue characterization. This is in vivo technology. We can see here images of the carotid angiogram and then we can see the pathological analysis comparing the findings that we can see that on the right hand side the plaque shows a composition of a lot of cholesterol liquid laden and a vulnerable plaque and severe and significant stenosis that correlates well in the mid-segment with pathological analysis. Now similar technology can be applied for treatment decision using this particular technology in patients with coronary artery disease. Here we have a patient with expected coronary artery disease and the CTA showed some calcium and no evidence of critical disease. Now using a vascular cap technology we can see the calcification that's relatively mild and the green is a lipid rich necrotic core or vulnerable plaque that can lead to a myocardial infarction. So the application of this technology is obviously non-invasive method of analyzing and detecting a vulnerable plaque. It offers a quantification of severity of disease and also therapeutic responses that might be needed or change in therapy to improve this particular patient outcome. We can also plan for PCI knowing the severity of disease and location of the vulnerable plaque. Again looking at outcomes and predictability of this approach and MACE outcomes in particular we can see in a brown curve that this particular technology offers superior results in comparison with several other technologies including a plain CTA and in this particular retrospective study with a 24-month follow-up looking at the vulnerable plaque the vascular cap was definitely more sensitive than some of the other technologies where this particular technique was compared with. Now what about advances in procedural imaging is concerned? We know that road mapping is very useful and accurate mode of evaluation and imaging to accurately assess stent deployment and also to decrease the operative radiation during the access or during the procedure and therefore also reduce the contrast load. More recent advances in dynamic road mapping has offered us something that the stationary road mapping is not able to offer us as we rotate the C-arm or II we still have good quality imaging as shown in this particular image on the right lower panel. Another advances that have greatly helped us in procedural management of complex anatomy is fusion imaging and this particular case is the use of fusion imaging during EVAR. We can use a preoperative CTA for pre-procedural planning and for parallax correction but we can also use this particular fusion imaging for C-arm positioning to assess the vessel origin such as the origin of the renal arteries or the origin of the iliac arteries as shown in a panel on the right hand side that offer us the accurate deployment of the stem graft during EVAR procedure. One of the latest and the most exciting advances as far as images is concerned is fiber optic real shape imaging during EVAR or FORCE that is being investigated by Philips and here we can see that fiber optic catheter and wire is being advanced through a very complex and tortuous iliac artery anatomy during EVAR procedure. We can see then the catheter position that has offered us a great benefit in cannulating the contralateral gait and also for positioning of the stem graft in perfect position just below the origin of the renal arteries that's marked with a green ring and then we can see on the right hand side a final image or the angiogram showing a accurate placement of the stem graft in desired location and here on the final angiogram we can see excellent result at the completion of the procedure. Now one area that's extremely exciting as far as the future of endovascular intervention is concerned is the use of holographic imaging as showing here. This particular technology offers us the opportunity to look at the images right in front of the operator we can move our controls as we need to changing positions from one side of the patient to another side and this particular opportunity gives us the option to perform procedures in a simpler way and more efficient way. Now in conclusion we can say that the progress achieved in imaging has facilitated us for better and more effective care at the lowest possible radiation dose which is important for our patients and the operator. Some of the currently performed procedures would be unthinkable without all the advances that have been achieved in the last decade as far as imaging is concerned. What's important is before proceeding with angiography one should consider the most appropriate exercise, choice of equipment and contrast type and amount. The next frontier will be the integration of robotics and imaging technologies for endovascular interventions. Thank you very much for your attention.