Originally Broadcast: Tuesday, September 17, 2024 7 - 8 pm ET
Event Summary
Catch the recording of an exclusive webinar featuring renowned experts Dr. Tom C. Nguyen and Dr. Mehrdad Ghoreishi as they explore the future of aortic surgery. Learn about innovative techniques, groundbreaking research, and the latest advancements from the Center for Aortic Care at Baptist Health Miami Cardiac & Vascular Institute.
This insightful session covers cutting-edge procedures, recent developments, and emerging trends in minimally invasive aortic surgery. It's a valuable resource for referring physicians and healthcare professionals looking to stay ahead in the rapidly evolving field of aortic care.
Meet the Experts
Tom C. Nguyen, M.D., FACS, FACC
Mehrdad Ghoreishi, M.D.
To refer a patient, call 786-596-1240 or visit BaptistHealth.net/AorticCare
VIEW RELATED NEWS - NEW CENTER FOR AORTIC CARE >>
Good evening, everyone. And thank you for joining this exclusive Baptist Health webinar on the future of aortic surgery. I'm joined tonight by esteemed experts, Dr Tom Wynn and Dr Murda Qureshi. Um They'll be leading this uh panel on discussing cutting edge techniques and research. Doctor Wynn over to you. Thank you so much, Scott. I want to thank you all for joining us this evening uh to talk about something that we think is really important uh which is aortic disease and we're trying to transform aortic disease um for, for uh really the Miami and the state of Florida and for the country as well. Uh I'm the chief medical executive at Miami Cardiac Ambassador Institute and I'm privileged to be joined by Doctor Mead Qureshi, who's a professor of surgery and the co-director of the aortic program here at Baptist Health. As a cardiac surgeon, we recognize that treating the aorta is probably one of the hardest operations and procedures that we do. Uh The exciting thing around the horizon is that there are a lot of new and emerging technologies that allow us to treat the aorta in less, less invasive ways or less invasive ways without a lot of the potential morbidity, mortality that we've seen in the past. Uh someone that has been spearheading a lot of the, the research and the innovation in this space is Dr Mead Qureshi. And these can provide a summary of some of the new things in the pipeline about treating uh the aorta both the accenting and the descending aorta. As a summary of the format of the webinar. Uh Doctor Greci will, will give a brief um review uh of uh of his experiences. Uh We encourage you all to put questions in the chat box. And at the very end, uh we'll try to address and answer those questions uh and uh and have just a conversation about um about treatment of your disease. So, without further ado Doctor Greci, uh thank you for joining us and thank you all for joining us uh in this webinar. Doctor Greci. Uh Thank you very much, Tom. It's uh i it's really a great honor uh and privilege for me to uh to present some of the uh new uh treatment for uh modalities that are now available for patients uh with aortic disease. Uh And uh and, and so I'm, I'm gonna start uh with this uh uh with the uh slide presentations here, see if I can share them. And uh uh so the title that uh as you mentioned, it's about the future of aortic surgery, the cutting edge techniques and, and research that uh is is in the field and, and the aorta is now an individualized or organ based on the AC cah A guidelines. And it has 11 segments. Uh this, this huge organ, every part of it can, can become uh uh uh uh uh uh it can, can have disease in it and require some uh some uh intervention uh and treatment and from, from the get go from the aortic root attached to the heart. Uh and a patient can tolerate open operation is standard of care for, for these patients. Valve is very a root or uh aortic root replacement. Now, it's it's a standard technique with very good outcomes for these patients. If they are open surgical candidate, ascending aortic replacement is extremely safe operation when the aorist aneurysmal or dissection or any part of this require any intervention with great outcomes. And then aortic arch procedure uh again, if required uh for aneurysm or pseudoaneurysm or any other disease. Uh Now, the technology has really helped us to, to provide uh good outcomes for these patients and and then uh for the descending aorta and abdominal aorta if the patient requires intervention and good open uh candidate, uh we respect all of this and, and put a graft on it. And then the beauty of the aorta. Now is that uh we can also uh do uh less invasive and endovascular procedures for every segment of this aorta as well. And uh uh from R which is this part of the aorta segment nine and 10 and 11 from Toro abdomen which is segment 5678 and, and nine. and then uh for the, the descending aorta which is zone 345 and then aortic card uh and then ascending and then finally a recruit all of these part, we can also fix them uh endovascularly and, and turn this to aorta uh completely to a like a um uh lego. Uh and, and we build it up from inside or uh inside the aorta. Uh So, but before uh we John just wanted to address this, that the uh recent guidelines has changed for the aortic intervention from 5.5 to 5 is the number that we just have to remember uh f for patients with the aneurysm. And uh and time of the intervention has changed from that uh to, to five centimeter. And, and of course, if the aorta is growing faster than uh we like uh more than a half a centimeter in one year or more than uh uh 0.3 centimeter uh per year in two consecutive years, that's also require intervention. And then finally, if the patient is, is a good candidate for uh young and uh has an aortic root aneurysm, the valve is very root is recommended and the patient has severe A I uh and uh and and again, a young, you know, 50 year old or less aortic valve repair is recommended for these patients. The Ross procedure is something that again is coming back to the, to the game is for patients with uh uh CV, ras or for patients with severe A I that not repairable uh and uh or uh repair can or what uh can uh can fail and, and, and it's not, uh it's not durable based on some of the data that we know at the end of the procedure. So, Ross procedure is, is not coming back. Uh And it, it's in the guidelines. Uh uh Now, although it's a little less uh based on um based on the um level of evidence, if the patient is less than 50 year old and has severe A I or has severe A S the guidelines recommend mechanical aortic valve as a level two A and still the, the uh Ross procedure is a level two B. Uh But uh and, and we are still waiting to see how the data looks in, in uh overall uh AAA and then recommend that uh the valve is very rude now is, is, is uh level one for patients with aortic root dilation and aortic repair with level two B uh for patients with severe A I. These are some of the guidelines that now exist. Although for Raw's procedure, the uh uh the Canadian and the Canadian Ame uh guidelines are a little more aggressive. Uh And they recommend that uh uh Raw's procedure in young patients with uh uh level uh one evidence for these patients. Uh as I mentioned, the Ross procedure really because it felt uh in that previous uh version of the Ross procedure, it, it, it uh the number of Ross procedure in increased over time. But after that decline, because of the high failure rate. But the new uh technical uh version of this procedure, which is basically um put a graft on the uh the uh Agra uh uh it, it prevents the dilation. It showed that over uh for the last from 2017 to 2021. It's growth for 400%. Grow in ROSS procedure in the United States uh for, for patients with severe A I or, or severe A S and, and yawn. Uh and, and, and, and why is that? It's because the ro procedure in that, that we use the auto pulmonary valve and put it as the aortic valve and, and wrap it with the graphs around and make sure we enforce it. So it doesn't do it over time. It's uh it doesn't require anticoagulation at very low risk for endocarditis and superior hemodynamic versus uh when we replace this valve, it requires uh either anticoagulation or, or very uh the hemodynamic would be challenging for these patients because of the bi parasitic valve. So probably in the next uh uh uh uh probably 5, 10 years, we will see more ad uh evidence advocating for us procedure for these patients. And a as as I mentioned, the all patients, all patients right now for aortic valve disease uh should be assessed for valve repair or o procedure at a comprehensive uh valve center Aortic center. Uh to see how we can salvage these patients uh valve or no uh prevent them uh to get a mechanical valve uh or a tissue valve in a young age. The valve is very rude as I mentioned, for patients with aortic route aneurysm. It's a complex procedure, but now it's, it's uh it's a standard of care for these patients to salvage the valve when they are young when they are a 4045 year old or even a 50 year old. Some centers that are even more aggressive and, and, and do valves very root for 60 or even 65 year old patients with aortic root aneurysm. Uh uh um and uh and, and, and so here, uh we, we uh there's no guidelines uh with regard to the age. Uh And uh we go based on every case assessment. Every root replacement is a safe operation. As I mentioned, it's a national database is through create 1% mortality, 2% and be a bi a parasitic valve or a mechanical valve for those patients with uh uh root uh uh operation. And again, the extension of this operations, if the patient is only for aneurysm, it's require it it, it, it shows that it's uh it, it can uh provide a low mortality rate and lowest stroke rate for patients that require ascending or root a he arch which resect the arch all the way to the head vessels and then total arch replacement that in traditional way had a high, relatively high mortality rate and a stroke rate compared to the uh um less extensive uh operation. And for tautology placement, that huge amount of uh data and research being done still going on. What's the, how we can help these patients to have a lower stroke rate of mortality rate? And as you can see, uh multiple techniques uh from, from like 2030 years ago has been developed and multiple uh brain cerebral perfusion strategy being introduced island technique, the branching technique and uh traditional elephant trunk then switch to a little bit less aggressive zone to tot placement is is is is replacement just to the left Sola and then come back and, and put a stent graft here uh or for less healthier patients with comorbidities, hybrid arch, which is the branching of the head vessel and coming and put a tr which showed that it can provide uh i it can cause a typhoon, a endo uh leak uh around this graft. So that's almost uh uh it's, it's out of the picture for these patients that um that uh uh consider for this. We we, we almost don't do this anymore. Because of the high rate of uh stroke and high rate of endo league. And then after that is now total large frozen from trunk uh with the Toro places which is now FDA approved uh for the total placement is has been introduced. So you can see how many uh uh how many version of this total large been been uh introduced to the world. The open toro abdomen repair for descending urea is uh uh it's uh it's now established for those who can target open operation. Depends on the extension. Of course, the the complications can, can be higher and it requires a very major operation when we are resecting this whole descending aorta. And and therefore, the endovascular for uh toro abdominal and descending aorta has really evolved. The treatment of these patients made it easier for both patient and surgeon. Uh And uh and, and this is the only FDA approved right now. It's called Tambi tho adominal multi branch endoprosthesis. Tambi just got approved uh about two or three months ago. Uh That is for patients with the tho adominal aneurysm. And as you can see, it has 44 channels inside this graft. Uh two for kidney arteries and one for S ma and one for celiac artery is pre uh wired here. Uh The device gets deployed in the descending aorta uh wire level about uh 2 to 4 centimeter uh above the cilio Corti. So we can uh access each gate uh preemptively uh before complete deployment of this device uh wire and, and cattery in each of these branches. Uh And, and usually this is from right auxiliary um access uh on t great fashion and, and each of these gates that we can see them on angiography gets, gets access, gets uh sent into them. And then at the end, we just completely deploy the sting graft. Um So this is the only uh device uh right now approved FDA for aneurysm of the tr abdomen. Uh Of course, not that not that many patients can, can, can get this device. It's not approved for dissection yet and an access site, uh some of the variables if the, if the peripheral arteries are dissected, usually they get excluded for these. So not that many patients with th abdominal aneurysm uh or disease. Uh they, they can, they can get this device. However, uh you know, it's, it's not out there and, and we can use it for uh patients with toach adominal uh aneurysm. These are the steps that how, how this devi uh this device gets sustained for that. And if, if we can't use this device for variety of reasons that I mentioned, then we have to think about OK, how, how we can do uh um endovascular for these patients? And P A uh physician modified endograft has been introduced for a long time and, and, and we do this. Uh now is we we make the graf based on preoperative CT A scan. We, we exactly know where the CIO branches A kid B is can be uh pick up the graph that we want based on the size, make the penetrations uh make some uh branches or no, no branches and, and resheet this device again. Um And, and, and, and, and go from the pre axis and exactly deploy them where, where exactly we want uh and, and extend them from inside in each of these penetrations holes that we made for on the graph. For this. Uh This is an 81 year old that came with the uh near ruptured abdominal uh uh and uh with severe pain and, and so we, with this horrible access, you can see how, how the AIS looks. Basically she doesn't have any access. Uh but we use a very low profile device and, and, and, and then uh we made this graft for these patients. It's a very low profile stem graft and uh and, and, and then uh we uh we deployed that uh uh for this stroke abdomen and we fix all of her aneurysm and she went home uh post of day one after endo abdomen. So that's I can say that's impressive uh uh with this technology and the outcomes, this is just published in circulation in July about the ver uh the P A results. Uh and uh and over 1200 patients in 19 centers with the technical success of 94% 30 day mortality. 5.8%. Of course, the mortality rate was higher in rupture. The adverse event in 25% and freedom from reintervention was uh was 50% in five years. Gain. The reintervention, we can say 50%. But usually most of the time the reintervention is endovascularly manageable and, and survival in five years. 55%. These are uh these are the centers that they do pec penetrated drug abdomen, almost about 203 100 cases a year. Uh So, uh um these are excellent outcomes for, for a very uh a very challenging part of the e dissection uh can happen when the uh aortic aneurysm uh exists or or no in patients with aortic aneurysm with connective tissue disorder. This dissection can happen and the center for dissection patients need to have rapid transportation and resuscitation. We have to have a hybrid or room available for these patients and called AORTA team cardio surgery, vascular surgery, interventional radiologist and dedicated to our nurses for very uh uh sick patients. The first thing is to have uh make sure CT A is, is the recommended way to diagnose acute emergencies. That's, that's the key thing. And then anti impulse therapy with uh monitoring blood pressure. Uh And uh and we just have to make sure that we keep the blood pressure low or less than 120 heart rate low, uh less than 60 to 80 with the beta blocker and uh and cardine or nitrate uh stay away from hydrolyzing for these patients. The outcomes of type A is worse in the United States. It's very high mortality rate, 17, very high stroke rate. Uh and we still don't know why uh uh uh why, why all of this completely changed versus the aneurysm that I just showed with one or 2% mortality, one or 2% stroke rate. So, and I think the reason is OK, these patients who are secure head vessels are usually dissected and, and uh and, and, and so based on the extension of this, all of these outcomes are even worse mortality. When we do, all of these procedures are even higher, 25% versus the stroke rate, 20%. So, uh I can say we, we actually look in the whole United States, we saw that extremely high mortality and stroke rate uh in, in the United States. So we, you know, we uh uh almost every surgeon aortic sur surgeon look to see how we, how we can help these patients to have a lower stroke rate and lower mortality rate. And one technique that came actually from Cleve 19, Eric Rossilli and III I like that technique. I started doing that from 2018 was the be safer technique which is uh you know, simplified as tot place. And for this acute type, a putting a stent and Debra make fest administration in the stent for the left of Lavia. And uh but I quickly changed that because uh still for that procedure for, to be safer that I mentioned, we still have to cool the patient uh being on pump for a long time to cool and then be warm. And, and one of the main reason we found that patients uh mortality is high in acute type A is being on pal for, for, for a long time, cooling and warming and being on cardio bypass in every literature uh is associated with a higher stroke rate. When we look at coronary bypass, when we look at aortic body replacement, every procedure in cardiac surgery, one of the reason of the heart attributed to stroke is longer cardio bypass time. So uh uh one technique that I, I uh started doing that and uh uh around this area was using this toro flex stent graft that I mentioned that before and without cooling. And it's called no, the total ar and uh a and, and the technique is uh going, going around these head vessels and, and put this stent graft inside story perfusion, the body and uh and we cooling the head vessels already are, are are connected to the pump by the branching. Uh This is the video uh that shows this technique. Uh And uh I can say we have done the uh largest number of patients in the United States. So for 35 patients. This technique we are presenting that next month in Eu in European Association of Quadri thoracic surgery. But that's one technique. Uh uh uh this 11 K 77 year old with seven centimeter ascending five centimeter arch uh and um on the V to placement and cabbage time two. So the first thing we have, we do is we uh deran the head vessels. Uh uh let me we deran the head vessels. 1st, 1st 1 is the inno tree we connected to a trip for cat grat while the left crowd is getting perfusion by the pump. Uh we deran the um uh in ate artery uh by the Stratford cat graph. And, and then when it's done uh this in nominated three, we, we just connect that to the palm through this uh side arm of the strike for cat graft. Now, the enno or three gets perfusion. We the air graft here and, and connect this to the arterial uh limb uh o of the of the cardio bypass. The o the other limb is is in the central aorta perfusing, the left clotted brain and, and the body. And now we connect this one, this branch uh to the to the left crowd while the anin tree is perfusing. So we ligate the base of the left crowd and, and connect this uh the other branch to the anomic. So, and this is while the heart and body is perfusing we don't cool. We stay warm 35 34.5. Uh And the reason we don't cool here is the whole time, uh The head is getting perfusion and the s the, the bodies only take about four or five minutes uh for us to, to do the total replacement. So here we uh connect the left crowded part of this branch uh to the, to the left crowded and when I skip this, um, so the left crowded now it's done. It's perfusing with the air. It now both of the head vessels are perfusing in nominate and left prodded. We locate the base of the left. So Laan, uh we, we, right now we uh uh just leave it alone. And at the end of the surgery, we come off pump and bypass the left of Clavia because that's, that's reachable. That's right there. And we don't have to uh do anything right now about that. Now, we basically we do is seek arrest the patient. Sikh harassment, stopped the perfusion to the, to the and body and we resected aneurysm or dissected uh AORTA. And this is the Toro FFL device that now is FDA approved. Uh, and it's, it's a frozen elephant trunk, total large device and we deployed that it goes in the descending order. It comes and it has this cough that uh is wrapping it on the graft. And we just saw that it takes about 34 minutes to sew that uh to this cough and this, uh but that's, that's the dishonest stenosis that we just perform it. This, the beauty of this device is the whole pressure is in the descending aorta. It's not on this dishonest stenosis. And again, the whole time, the head is getting perfusion by the strive for cat graft. And at the end of this procedure, we do, uh we reconnect that trip for cat graph the sending aorta to the pros moos and two as a bypass on this guy that, that shows the two as a bypass tot placement. A 77 year old uh C time was six minutes. We stayed at 32 degree cor point bypass on was 160 minutes and he got discharged possibly four. It didn't require any blood transfusion. The other device that just got introduced still on a trial. And uh and working to get the FDA approved is called AM DS. And, and why is that? Is that uh I'll show that how it works when a Q type A section that the reason for this device got invented was the uh ACU type a section. Uh uh The general adult cardio surgeons uh still not comfortable when the patient has some m perfusion or dissected head vessels uh or di dis I'm sorry, dissected, uh descending aorta. And if you just do he placement, usually the Tulu men doesn't expand completely and, and, and it can cause a map perfusion distally. So uh in, in the AM DS uh graft, uh this shows if we just do hemi why uh we, we have a tear in the distal aura, it's called dane or distal Neer tear. You can see the suture completely toward the intima. But in this uh and you can see the true lumen still not expanded, false is still flowing to that. And this device has been uh introduced. Uh and uh uh in the trial um that uh it, it's like that the perimeter stents and then felt in the proximal part of this uh perimeter stent. Uh it gets uh the step of it. Uh It's exactly like a he arch. You have to cool the patient and a a and do this uh operation, leave some in no part and then put this stent inside and then this cuff here, you have to have another f outside and suture it first and then connect your aying graph to this. Uh I, I could never, I was part of this. We were part of this trial. I could never enter any patient into that because II I do to, I recommend to placement for even type a dissection uh and uh uh uh without cooling uh uh a a and so uh I could not uh put any patients into this trial, but this is uh this is a very good device for adult cardiac surgeons that face uh a typo dissection and they are not comfortable doing a tot placement. Um At least this will prevent a dane distal anastomosis, new entry tear and let the true lo be expanded and, and the false movement uh gets collapsed a little bit more. So, again, what is important is uh the patient selections for patients with a you type a dissection. If, if we take the patient sick to the operating room, we will uh come out of the operating room sick and patients with a Q type A, they can have a malperfusion going in or any other reason. And we found out that if they have a malperfusion, liver, kidney uh or gout is better to do some other intervention including descending tr or fest administration and not taking these patients to the or directly. Um and, and let the central repair happen later after when the patient is more stable. Uh and lactate comes down, creatinine gets better. Liver function gets better. But if the patient is ready to go to the or and is healthy and they can tolerate open operation, 85 year old can be a uh came with a chest pain and CV ras and, and, and this is her CV ras and this is her acute typo section, not fail noma perfusion. And this is uh this is her uh she got discharged post of day six and this is her strong and can tolerate open operation. However, we can have another patient 78 year old come with uh uh come with uh tearing her aortic uh ascending aorta and also rupture the ascending aorta. This patient cannot tolerate open operation. It's ruptured uh Coumadin iron or 4.7 liver and renal marker fusion. So, what we suggest is to do a sending a stent and descending a stent for these patients. So, uh exactly like that, the only FDF device right now for the aortic arch is only for uh zone two area. It's, it's for patients with aneurysm around the left ion and, and it's called TV E thoracic branch end graft. And, and that's how it works. It's, it's a very simple device. It has a gate, a channel for the left subclavian, it's prewired and the device goes up and, and, and has a branch for the left subclavian has a channel gate inside. Uh You can see that right now here, the fir the device deploys first and then this one deploys uh second for the arch, there's no FDA approved device. And uh and uh we have multiple uh devices coming single branch, dual branch and penetrated device, single branch devices like this, as I mentioned, uh the dual branch devices like this. Uh and then the frate devices, all of these devices right now are on a trial. Uh We are actually getting this hopefully uh the next trial uh and uh and start working on that. But all of these devices are in in Europe. But in the United States, we are just working for the trial to source for patients with aortic arch aneurysm. And, and these patients with the nexus arch device that I mentioned is this one uh that uh uh uh that is uh we hopefully we can get on the trial for this uh next Du O and that's how it works. The uh patients with the aortic uh Ar Aury here involves a zone, zone one, zone two and zone three. So just one simple T TB E will not work on this. And this is a Nexus device, how it works. It goes inside in the en no tree, it has a branch on it, it gets deployed. Uh This patient, these patients may have to do extra anatomy bypass, Kro carotid pro soan or for Nexus Duo, we only need to do left karate, left Soan bypass uh because uh because it has a branch for the left subclavian. And so that's how the Nexus uh device. This is the, the, the single stage or single branch. Nexus thero has been finished uh with the great outcomes, 3% through create uh excellent outcomes. One of the best uh outcomes with regard to the neurology function uh with the, with the R and devices. Uh And now Nexus Duo is starting, which has a branch for the left subclan. So we don't need to do KRO kro carotid subclan bypass. We only need to do left carotid left subclavian. So we do the uh art stint first and then we deploy the a sending stint uh component of this, of this device. So that's, that's the ascending uh ascend part of this device. But if now, if the patient comes, we don't have any FDA approved device and maybe these devices are right now. Uh uh it will take time for the, get the FDA approved. We have to come up with the P ME and that's what we do is to do physician modified in the graft exactly as toro abdomen. We can do one vessel anest administration. We can do uh multiple vessel penetration, two vessel with Karla and three vessel with uh all of these. We make them on the back table and deploy them like this patient that came with the aortic arch rupture. And we, we did Kroy Sola and bone vessel pic. Uh This patient came with the uh chronic dation and uh and, and two as a anest administration, this patient came with rupture of his descending a with the three vessel penetration. Again, in all of this, we have to make the graft on the back table, make three holes in it and and resheet them and exactly go and deploy it where we want. And then from inside the stent anticipation of mind that came with a dishonor thesis rupture. And we did a uh we did a total endovascular or hardship here like this or uh this is another patient came with uh an aneurysm and dissection of his head vessels. And uh and, and I'm gonna advance this. You can see dissection uh dissection here, huge ays preco effusion. And again, what we did was uh was uh uh mm mm uh we uh did a TB E at zone zero and then Laser Fest administration and uh and this is his uh post op CT a completely healed aora A sending a stent is another uh uh so um device that is on horizon still no a FDA approved device for this. We just using the uh the stent graphs that are available for these patients. And, and so as you can see this, this patient with a sending uh dissection fail not to not be able to tolerate open operation. And what we did was uh a sending stent for these. You can see this, that rupture the order and that the sending stent cover this rupture, the order, ascending keyword in the trial. Uh uh And right now, a couple of centers in the United States have this trial. Uh And uh it's active control is a sending uh sten graft. It's a seven centimeter uh sten graft it, active control. So we can exactly um um um give it bent where, where to land. Uh But when, again, when we get these patients here, uh we can either use the uh T or descending order or no for these patients. When they have a six centimeter ascending order. What we do is we use a text to cook graft, uh open it up, trim it from 15 centimeter, cut it down to six or five centimeters exactly what we want and then put it back inside the sheet and deploy that for patients. So, uh again, a lot of, a lot of new technologies for physician modified in the graft for those who are not or basically, we don't have the FDA approved devices for them. And then finally, when we come to the OIC root, uh you know, it comes endo for that, the concept of the disease is a tower valve attached to a stain craft with either branch or penetration. And uh we did that uh a year ago, the first two cases for end of vile repair and, and basically what it is is a trans catheter valve, uh self expanding that we sew it to the T board and with two holes in it that we make and then deploy it exactly like a self expanding valve concept and, and then extend from inside and, and again, so this is a self expanding valve. We, we on the back table, we opened the tower bath, we put it inside the TVO graft, we sew it with the four of one switcher all around. So the tower inside the TVO graft and, and, and then, and then make two. So that's how it looks from inside. They make two holes, one for the left coronary, one for the right coronary and wiring for them. So we can see them on the NGO. Uh we have to trim the uh nose going because it's very long and it can rupture the left and tle so we, we make it a small, then assemble the device on the tar delivery system exactly like this. They have those bars. So we, we put those bars goes inside the valve and this is the final device that it looks trim nose cone short device ready for the uh for the endo vent. And that's this is like one case that got it endo arch. And now this is how it deploys. You can see that Picton in non coronary costs and market in the non coronary of the valve that we actually put it ourselves on the back table. And we deploy this the right Coronary fest administration left coronary fest administration, left coronary fr is always lower than right. You can see it's like here, then we access the left coronary fence, right corner fence station from the apex, we access them, it's easier and then extent them and then left corner again from the apex. Uh it's uh a suitable sheet access them and extent them. Um and, and this is like a uh uh angiography for these patients. You can see the neur is is, is covered with this and, and this is like an 85 year old came with this hoong aorta, tearing the aortic arch, tearing the aortic root again. Uh The endo arch, endo vil is the is the option for this patient. So we, we proceeded with that. At first stage was Endo arch as I explained. And then second stage in the bal and this is her one year ct A which showed completely heal aorta all covered and, and that's the final angiography. Uh So, uh so this is the device that right now currently uh we are uh we are using it or making it for patients. So finally, I can say for all of these segments of the or 11 segments, we have open option, we have endovascular option when it's become an Aysal or disease. And, and so this is, this is what Alan Lamson in into a book that he wrote uh in 2007. And in fact, he showed this picture and said, say elderly patient severe a yes and a aneurysm short neck. And he in 2007 said, uh he will see the future. Uh He couldn't say that when, but he said, I'm sure he will see the future that the treatment for that would be endo V. He didn't have solution for that, but he said he will see it. Coronary stents, ac sending graft neuroprotection devices, uh a arch stent devices, descending stent devices and, and, and that's actually this is it like 2007 and now 2024 we have all of these uh for for these patients. So in summary, the management of aortic disease has evolved significantly with all of the, all of the stents, all of the devices, open endo perfusion techniques, cerebral protection techniques uh went to intervene for patients with type A or type P sections um or, or with taped sessions. Uh And then of course, the collaborative team uh is important for every aortic center, cardiac surgery, vascular surgery, interventional radiology. Uh And then all of these patients require a very meticulous preoperative planning, either open or end or a lot of thought needs to go through every patients. What's the best option for these patients? Uh Thank you very much. Thanks for your time. Thank you, Doctor Greci for, for incredible presentation. Um And I want to thank the audience for, for again attending the webinar. Uh Please feel free to submit your chat questions uh into your questions at the chat box and we'll do our best to answer them. Uh Doctor question. It looks like we have a list of questions already and I'll go through a couple of them and maybe you can answer them for us. The first question um is for referring physicians. What, what are some signs that should prompt an early referral to a neuro surgeon? And how can we uh best optimize preoperative care? Right? I I think the early signs are uh the uh the risk factors, uh the, and, and on the uh guidelines, uh the risk factors f positive family history, smoking history, high cholesterol, high uh and, and risk factor related to that. And, uh, and, and uh, and, and men, these are, these are the risk factors but the strongest one in the family history, uh high cholesterol and uh of course, history of aortic aneurysm somewhere else and brain aneurysm io aneurysm, all of these uh they are risk factors for to have aneurysm somewhere else. The uh guidelines right now for screening is very poor with regards to the ascending and descending aorta. The only thing right now we have is abdominal ultrasound for uh to rule out as a screening tool. I mean, we we do a screening for lung cancer but for aorta that is very, it is a common problem. The only screening tool we have is the ultrasound of the abdomen. Uh when the patient has risk uh or smoking when they are 55 or 50 year old based on men and female. So hopefully with uh uh in near future, we will have a more robust screening tools for, for pay for to rule out aortic aneurysm, ascending and BC sending for these patients. But right now, the only screening tool is OK, 5055 year old uh uh men and female. So uh doing abdominal trason gray to make sure if they are smoking. If, if they have a uh AAA. Uh, but I would, I would go right now, uh, just based on the family history, smoking, history and high cholesterol. Uh, the, uh, to, to get the abdominal ultrasonography, that's what they go along, said. And, uh, and if they have a family history of aurea sudden death, uh, well, I, I can say CT a of the chest and abdomen is something to think about and in a, in a more daily patients, more than 5055 year old. Uh the I'm sorry, go ahead, I'm sorry, go ahead. The procedure procedures you described look pretty complicated. Can you, can you elaborate a little bit on, on why uh in patients with aortic pathology, going to New York Center is important versus going to a place that does cardiac surgery. You know, we, we do a lot of cardiac surgery, bypass surgery, valve surgery. But, but what makes the New York Center different than just a, a regular place that does cardiac surgery? Uh So that's also, and that's why it comes to the guidelines. It's so important that no guidelines recommend all all of this in a, in, in, in the a center. And the reason is they saw better outcomes with regard to. Ok. Some of these uh procedures, of course, patient selection starts with the patient selection. Uh We look at, we look at patients and we see, oh, ok, the aorta is very calcified. Yes, patient is very healthy looking, but when we look, we look at the aorta is very calcified, not only in the area that we want to operate, but the area, other part IOC arteries descending aorta. And, and so that, that gives us some information how healthy this patient is inside. And, and what does this patient do in the IC U post op. So with regards to the patient selection, sharing decision uh uh with the patient and the pa and the and the aortic uh surgeon's team and also sharing decision with the multidisciplinary approach for each patient. We get an 80 year old, 75 year old patient is is not open surgical candidate. So we can think about some endovascular option for these patients with all of these uh all, all of these uh uh technologies that I mentioned and and and then screening and follow follow up is actually more important. So we don't lose these patients, make sure they follow up about 60% of the patients when they have intervention in one part of the order. Within five years, they require intervention in other parts of the order. And so uh we just have to make sure we follow these patients regularly. Guidelines recommend one month, three months, six months and every year ct A for these patients uh to, to see how the aorta evolves over time. So, Aortic center with the nurse practitioner and can follow these patients very closely. Genetic is another one guidelines recommend genetic testing if the patient, less than 50 year old uh is le less than 50 year old. They recommend genetic involvement, consulting to see if they have any uh genetic problems with aortic aneurysm or IZATION. If they have, if they are less than 50 year old, they require genetic. So, uh all of this, I think it would be easier. Uh And of course, if it comes to a very more challenging part, aortic root valve is very a total arch through abdominal and these are open. And when it comes to the endovascular, a very uh multidisciplinary collaborative team, none of these endovascular procedures that I mentioned is a one man job. It's not, it shouldn't be, nobody should be proud that hey, I alone did something in, in any of these areas. It's extremely dangerous if only one surgeon decides to do any of these alone, because it, it's a lot of things at stake and a lot of things can go wrong. And, and so it, it requires multi D team involved in every of these endovascular procedures. Can you collaborate on that multi discipline team a little bit? So, in the Cath lab or hybrid room who, who are in there and maybe describe some of the, the preoperative planning that takes place um what you do beforehand to make sure the operation goes well. And eventually, when you're actually in the hybrid room, Cath Lab, who's physically in there with, with the the patient So it, it depends on what part of the aorta we are. Uh uh uh we are tackling endovascularly. The A and again, some of these procedures require some extra anatomy bypass. If, if you are doing endovascular aortic arch and patient requires chic chic cortico or chrois Sola while somebody is making the graft, a vascular surgeon get do the bypass. And if interventional radiologist uh in the team can get the access. Can the wire up get the is intravascular tonography, assess the aorta wall, you know, uh cardiac surgeons may you know, modifying the graft or why. So the other way uh the other team is making the graft, somebody is doing the bypass, that's where the arch for the tr abdomen. The same. We are, somebody is Prew accessing. The other team is making the graft, modifying the graft and, and and so forth tr abdomen for endo arch for ENDO bol that we are performing. We, we actually uh the interventional cardiologist uh is, is uh from, from the skin to skin is is is there. Uh and, and, and uh from the modifying the graft. So again, interventional radiologist, vascular surgeon, um and cardiac surgery and interventional cardiology in endo like last case. And so like four teams for, for these. So that again, every case, every area of the aorta, um multiple teams around and, and everyone is doing something uh so that we can accelerate the the timing of the process in the operative room and, and usually most of the time we do a um a pre uh pre operative uh uh meeting multiple meeting to go over the planning for these patients. What stem graft? What size, what length uh with multiple session? The rep of all of these devices are uh part they participate in these meetings uh because they also can, can elaborate and, and put input, we uh we uh appreciate their input as well that we value them because they also have seen a lot of these cases across the country. So uh all of these um require multiple uh team member be involved, actively. Got you. One of the uh the audience members asked, what's the timing between an endo arch and a endo VT? Uh So uh the depends on the uh if it's acute or chronic setting, if the patient comes with acute uh acute type A and there's a tear in the aortic root and there's a tear in the aortic arch like uh like uh like we did a patient endo and in the route that patient can be to retrograde Taipei from his previous T one in the descending aorta. And we can't just go and do a endo ascending because there is a tear in the aortic arch and it can uh shut down the floor if you just fix the ascending, if the patient has a tear in the arch. So we have to do endo arch and ascending and endo vile, same stage. But if the patient has a chronic figure in that tear in the arch, so, uh we can give it time why? Because the, the true woman would not get collapsed. Uh uh And false women and expanded in the arch because they have a thick septum. So again, it depends on if it's acute setting or chronic setting uh at the same stage. Uh or, or no, at the, you know, multi stage, we'd rather do it multistage because it's a uh both of them are very complex procedures. But if the, if the team is there and if the patient needs it in an acute setting, then we have to do it at the same time. Recommend do it multis ST and one day, two days, three days a week later, it depends on how, how, how the acute or how the nature of the uh septum, the tear looks like. Uh someone else asked what advances advancements in New York surgery techniques have had the biggest impact on patient outcomes in recent years. Well, the tr uh let me, let me uh I think the tr uh and I I is, has been uh one of the innovations that, that really help a lot of patients. Just the descending tr uh we used to do a big incision, open, descending aorta uh in chronic setting in acute setting. But a simple tr or R let me uh that was introduced in 1980 was the biggest impact in, in the uh in the, in the patients uh with the aortic disease. Uh And, and, and this is with regard to the endovascular. Um And, and I'm sure, you know, endo was something that was the last frontier in aortic disease. And I think that really will help a lot of patients as well. But, but the simple RT R uh let me put it this way was the biggest uh game changer and was introduced uh in, in uh in nineties, the bit open procedure uh I can say uh the uh cerebral perfusion, Angra, cerebral perfusion uh by around the grape and, and retrial cerebral perfusion. All of that really changed the dynamic of the aortic arch operation. And uh uh that also revolutionized the uh the aortic surgery. Thank you, Doctor Greci. We're, we're almost at time and, and I wanted to, to wrap up and, and summarize what you presented. Um We started off with just the concept that the heart surgery can be tough, but operating in the aorta can be particularly hard and very complex as you alluded to. And you uh point out some really amazing technologies that allow us to, to replace part of the a a sending arch descending anor uh abdominal aorta in, in endo v ways that have uh really kind of transform uh the field. Uh So we appreciate your, your very high level summary uh and really kind of pushing um uh medicine forward. Um We do want to say that uh uh if uh the audience or if anyone has a patient with aortic disease in the next slide, uh there will be a website link and a phone number for you all to uh to access if you have someone that um that has aortic uh problems again. Thank you, Doctor Greci for your time. I think uh the audience for joining us on this evening to learn about aortic disease. Thank you.
