we're running behind but I want to take a couple of questions from the audience. So if you have questions come on up to the microphones, maybe I'll start with a quick question for the aortic center leaders, when should we be referring patients who are stable to the aortic center? Is there an aortic diameter that's too small? Any type B dissection? When is when should we be getting you all involved? And how do we do? So is it working? So in terms of size? Um you know, we know and we are we've been discussing this because the answer is simple that we know across our life the order is always growing. But we know that at any certain point in life, regardless. How big is your body habitats or your body surface area Any or about four cm. It's it's it's beyond limits. So that doesn't mean that we need to do something. No, but we need to put that patient on surveillance Now, what we try to do. And that's the thing that we're working with an amateur list, try to categorize these patients, especially those that they have known characterized by authorities because we know about Martha and Lois this and all those, we know what to do with them. We don't know really what to do with those patients that you know, they present with 4, 4.5 because we also know that, you know, we have dissection and complications in patients with the order that they're smaller than we think during risk. So we're trying to identify those risk factors. And we are working hard on trying to get the, you know the proper answer for that. So genetic is going to be something what's coming now. We know with all these um um calcium score ct scans that we're getting. So we have a huge population with dilated aorta. So we need to identify what are those that are at risk now. So size and the other is is the rate of growth. Right? So we might not get the the you know the five or 5.5 by anybody who you know rated growing this is more than .5 or something in a certain amount of like six months or a year. That's also you know, it's a red flag in terms of should we be more aggressive on doing something and please, if you have a question, come on up. The only thing that I would add is that I agree with everything christians said. But 11 thing that I would like to bring to everybody's attention is the need to follow these patients who had erected sections. Even those who have prior repair, type A repair, they can have a residual Type B dissection after type of repair, they can continue to grow and it is quite alarming that a lot of these patients, great majority of these patients are not followed or surveilled. So if you were seeing patients with the previous Type B dissection even type A dissection patient who underwent repair. Please remember to follow them with routine surveillance who are referred to cardiac. You know every every center for for us to follow. Thank you. And just really quickly how do we get a patient into the aortic center at U. H. You can there is a actually if you go to the um the EMR there's an option to choose able to center console in order. Council the nordic center. Okay thank you very much. Dr jenny wong hi jenny Wong vascular surgery. I'm gonna ask dr cummins a very direct question. So once we do have several generations of vascular and interventional fellows trained in doing any type of protestant. Ng I mean preferably take are of course do you feel at some point that that will supplant crowded endarterectomy as the principal treatment for patients with carotid disease? The first and go to procedure The really challenging question to answer. Because the patients that were treated with teak are all of these trials were highly selected. They had to have specific anatomy. They did none of them had atrial fibrillation in the trial. None of them had intracranial disease. Um There are lesions were of a certain length, not too calcified. You can't have dense circumferential calcification. So in the absence of all of those factors, if they were in an atomic candidate, I think the car will rival ce A in outcome. Although it's a lot more expensive. But we did our own trial where we looked at a number of of CT scans of patients undergoing intervention and not everybody's a candidate or or any of the therapies. You know, there's there's a significant number of patients who are not candidates for C. E. A. A lot of them who aren't candidates for stenting some who are not candidates for the car. And so not everybody is going to qualify for all of these. So it sounds like this technology will end up being something similar to the way we use endovascular treatment for a lot of different problems in that. It adds another tool to the toolbox and it requires specialists who know how to utilize both in order to determine what's best for the patient. Thanks last question. Please introduce yourself. I'm imaging research, fellow doctors. I mean and my question is the doctor baez and dr cho first of all, thank you so much for presenting your impressive work. And my question is, was the contemporary measures you're utilizing your practice to prevent or to reduce spinal cord ischemia and arterial spinal syndrome. And how you see this, if you see it all. Well, that's a great question and it's a topic of a tremendous controversy nowadays. Ah The way we we are utilizing the way we prevent or mitigate the risk of paraplegia is to use a spinal cord drainage. Uh and my my practice is that if I know that the audit coverage is more than 20 cm, I would like to put a spinal drainage but in addition to the intra operatively, I have everybody on Narcan trip at one of my particular per hour and we will continue that at least for 24 to 48 hours, 24 hours if it's a T. Bar 48 hours is open surgery. And we drained in the operating room To 10 cm of water and we keep it at 10 cm of water. The patient develops a neurologic deficit and we drained it down to 5cm of water. Or sometimes I just put it to the floor and just let it drain irrespective of the total output. Other things people have done in the actually a friend of mine who does is to give a citizen of my Inter operatively and for 48 hours post op we have not done that here. But that is something that you can do. But we haven't done it. Another method of monitoring spinal cord profusion in the operating room is to use nearest monitoring system near infrared blood flow which is a surrogate marker of the spinal cord blood flow by measuring blood flow in the paris spinal muscles. When we have 22 electrodes in the upper thorax and two in the lower thorax. And we measure the Uh profusion if there's a more than 20% drop that we try to elevate blood pressure intra operatively. So those are the main areas that that are used. But again you have to be careful because the complications of spinal drainage such as hematoma formation or bleeding can be devastating to alright, for the sake of time. Unless you have a very quick comment dr bai isn't very quickly. Yes, very quick. I think that the spinal cord ischemia is such a devastating complication. You don't want to have one of those because you have one of those that say you're always going to watch that guy's face, it's not gonna be able to work so do as much as you can. And I was just going to repeat this. I regretted more the times that I did not use the drainage of what I did. So it's it's a big it's a big topic and I think that for us, the masters you do to prevent it. You you got to do a story as much as you can do. I want to thank all of our speakers for a terrific first session
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