![Page 1: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/1.jpg)
PCI for Bifurcations: Which is the best strategy
DK Crush,Culotte,SKS,T or TAP
Subhash Chandra, MD,DM,FACC
Chairman,Cardiac Sciences BLK Super Speciality Hospital,
Pusa Road, New Delhi
CSI 2018
![Page 2: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/2.jpg)
Selection of Technique
![Page 3: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/3.jpg)
DEFINITION Criteria of LM bifurcation
• Simple: SB <70% stenosis,Length <10 mm
• Complex: If 2 of 6 minor criteria present
1. Calcification
2.Angle >70
3.MB diameter >2.5 mm
4.Multiple lesions
5.Thrombus
6.MB lesion length >25mm
![Page 4: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/4.jpg)
Factors Influencing 2-Stent Approaches
• Size of SB @ to MB
Important discrepancy: Avoid Culotte
• T-Stenting
• Crush/DK-Crush
• Bifurcation Angle
>70°: T-stent, or T and Protrusion (TAP)
<70°: Culotte, Crush, DK Crush
(Secures the precious,most angulated SB as first stent)
![Page 5: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/5.jpg)
T-Stent: Step-by-Step
• Wiring of MV and SB
• MV and/or SB dilatation (recommended but optional).
• Stenting MV with wire in place in SB (alternatively SB may be stented first).
• Rewiring SB and removal of jailed wire.
• Dilatation of SB though MV stent.
• Stenting SB though MV stent with no stent protrusion in MV (or placement of the MV stent if the SB was stented first).
• Final kissing balloon inflation.
Good if angle is --- 90 degree
![Page 6: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/6.jpg)
T-Stent Technique Advantages and Limitations
• Simple
• High rate of ostial restenosis of the SB due to suboptimal stent coverage in the bifurcation area, particularly the ostium
Not true if TAP technique used (similar to a “mini-mini” crush)
![Page 7: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/7.jpg)
Culotte Technique: Step-by-Step
• Wiring of both MV and SB.
• Predilatation of MV and/or SB (optional but recommended).
• Stenting of the MV.
• Rewiring SB through MV stent and removal of jailed wire in SB.
• Dilatation of SB through MV stent.
• Stenting proximal MV and SB through MV stent.
• Rewiring MV through SB stent.
• Final kissing balloon inflation.
Typically, the first stent should be placed in the
branch with the most angulated entry, whether
the MB or SB Should not be used if a large difference (≥1.5
mm) in vessel diameter between the MV and SB
exists
![Page 8: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/8.jpg)
Culotte: Stent MB & POT before re-wiring
![Page 9: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/9.jpg)
Culotte: Balloon SB after rewiring SB in most distal strut
![Page 10: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/10.jpg)
Culotte: Stenting SB Remove wire from main branch
![Page 11: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/11.jpg)
Culotte: Stenting SB & second POT
![Page 12: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/12.jpg)
Culotte: Final Kissing After rewiring MB (Ideally also a final POT?)
![Page 13: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/13.jpg)
Culotte Techique Advantages and limitations
• Full coverage of the bifurcation area
(especially the carina and SB ostium),
• 2 layers of metal in the proximal MV
• Multiples steps with necessity of re-wiring SBs twice
![Page 14: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/14.jpg)
NORDIC Bifurcation Study: Crush vs. Culotte
![Page 15: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/15.jpg)
DKCRUSH-3
![Page 16: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/16.jpg)
Crush Technique
• Wiring of both MV and SB.
• Predilatation of MV and/or SB (optional but recommended).
• Stenting of the SB first, with an un-inflated stent (or balloon) positioned in the MV. The proximal end of the SB stent should be several mm in the MV, but the proximal edge of the un-inflated MV stent (or balloon) must be proximal to the proximal edge of the SB stent.
• SB wire and stent balloon are removed.
• Crushing the SB stent with MV stent or balloon inflation (followed by MV stent).
• Rewiring the SB through MV stent.
• High-pressure inflation of SB (optional).
• Final kissing balloon inflation (mandatory).
![Page 17: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/17.jpg)
Crush: 2 stents in place; SB stent deployed first :
Pre-dilation
![Page 18: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/18.jpg)
Crush Technique: MB stent then inflated crushing SB stent previously
deployed; SB wire removed
![Page 19: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/19.jpg)
Crush Technique: Final kissing
![Page 20: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/20.jpg)
Crush Technique Advantages and limitations
• Difficulty in SB rewiring for final kissing inflation (less with DK-Crush; hydrophilic wire can help)
• Presence of multiple layers of crumpled stent at the SB ostium, substantially increasing the rate of SB ostial ISR
![Page 21: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/21.jpg)
DK-Crush Technique: Baseline
![Page 22: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/22.jpg)
DK-Crush Technique: Stent LCx+ Deflated Balloon LAD
![Page 23: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/23.jpg)
DK-Crush Technique: Crush of the LCx Stent with LM-LAD Balloon
![Page 24: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/24.jpg)
DK-Crush Technique: Pre-dilatation ostium LCx (facilitate passage)
![Page 25: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/25.jpg)
DK-Crush Technique: First Kissing
![Page 26: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/26.jpg)
DK-Crush Technique: LM-LAD stent
![Page 27: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/27.jpg)
DK-Crush Technique: POT
![Page 28: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/28.jpg)
DK-Crush Technique: Second-Final kiss
![Page 29: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/29.jpg)
DK-Crush Technique: Final
![Page 30: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/30.jpg)
DK crush vs Classical crush
![Page 31: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/31.jpg)
DKCRUSH-4 Trial(LM) Simple vs. Complex Strategy
Chen et al,JACC 2017
![Page 32: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/32.jpg)
DEFINITION-2 Trial
• Prospective,Multicentre,Randomized controlled, superiority clinical trial at 45 sites world wide
• 660 Pts
• Provisional Vs.Two –stent approach in complex coronary bifurcation lesions
![Page 33: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/33.jpg)
• Surprisingly DK crush has not gained desired acceptance.
• FKBI in classical crush technique is not always possible
• High adverse events in Crush tech. such as ST and ISR.
• Uniformly positive data from the DK crush trials.
• DK Crush is straightforward, reliable, safe and effective for complex LM bifurcation lesions and with all bifurcation angles.
• V stenting, SKS, Mini crush, Culotte may not be suitable in wide angled (≥70°) bifurcations.
Why DK Crush advantageous
![Page 34: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/34.jpg)
![Page 35: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/35.jpg)
![Page 36: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/36.jpg)
![Page 37: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/37.jpg)
![Page 38: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/38.jpg)
![Page 39: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/39.jpg)
![Page 40: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/40.jpg)
![Page 41: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/41.jpg)
![Page 42: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/42.jpg)
![Page 43: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/43.jpg)
![Page 44: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/44.jpg)
![Page 45: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/45.jpg)
![Page 46: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/46.jpg)
Simultaneous Kissing Stent (SKS)
![Page 47: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/47.jpg)
• Wiring of MV and SB
• Predilatation of MV and SB
• Placement of stents in both branches with minimal proximal protrusion in MV.
• Placement of balloons in both branches and simultaneous (or sequential) deployment of stents.
• Final kissing balloon inflation.
-Creation of a Neo Carina
-Management of ISR extremely complex…
-Really Challenging if proximal dissection
occurred…
Simultaneous Kissing Stent (SKS)
![Page 48: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/48.jpg)
• Several limitations…Double Barrel
• The most “primitive”, “un-sophisticated”, and anti-physiological technique!
• Used in cased of real life-threatening situation
Simultaneous Kissing Stent (SKS) Advantages and limitations
![Page 49: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/49.jpg)
Tips to remember • Importance of balloon sizing for post dilation
If too large distally, risk of carina shift
Proximal MB: know the maximal stent expansion capacity
• Importance of Final Kissing
• Importance of POT and Final POT
• Importance of IVUS guided PCI
• Choose the technique you are the most comfortable with…and avoid SKS as a first choice!
• DK Crush is going to supplant other stenting techniques and become sine-qua-non in LM bifurc.
![Page 50: PCI for Bifurcations: Which is the best strategy DK Crush ... · Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018](https://reader035.vdocuments.us/reader035/viewer/2022070800/5f0216de7e708231d4028476/html5/thumbnails/50.jpg)
Thanks for kind attention [email protected]