Venkat Kalapatapu, MD, Chief of Vascular Surgery at Penn Presbyterian Medical Center of Penn Medicine discusses the latest techniques and advancements in the treatment of carotid disease. He elaborates on indications for surgery, medical management, surgical treatments, endovascular treatments, and more.
@PennMDForum See Dr. Kalapatau’s physician profile Thank you, Wilson. Thank you, Linda. Thank you, Michelle, for, um, inviting you to speak today. It's truly an honor and privilege to be talking to all of you. And I'm going to move on from this slide. Mhm. So the topic that was assigned to me to talk today, um, it was about corroded stenosis and cardiac surgery. Um, I'm going to spend more time just talking What crowded stenosis in itself. Because I'm sure that is basically what is off interest. All of us. The application in cardiac surgeries is pretty 11 to all our patients in dietary practice. And we'll talk about cardiac surgery in particular, Um, for a few minutes. So what I'm gonna do today is, uh, we'll go through introduction to corroborate stenosis. We'll talk a little bit about that. Oh, physiology and diagnosis. And the bulk of the talk is gonna be about management options, which is off interest, all of us. So there is medical management. The surgery, which is a traditional gold standard treatment for patients who need who need intervention and then the evolution off endovascular treatment over time is very interesting and exciting. We will talk about evidence for management, Um, in all of these options, and then we'll talk again. Probably the most exciting thing that's going on right now in the field of karate diseases, new endovascular technique called teak are transported out revascularization, and we'll turn and we'll see how that fits into the overall management. Do you? So, as you all are very well aware, Stroke is one of the leading causes of death in United States, and many American study have a stroke and even those who survive of significant disability with permanent cognitive and motor and sensory impairments. So again, karate discloses itself accounts for anywhere between 20 to 25% off all patients with strokes. Again, The petro physiology is, uh, starts office atherosclerosis, like anywhere else in the body with narrowing of the Lumen from a sclerotic black. But what is unique about can order artery stenosis is it is not really decreased flow from this diagnosis. As much as it is embolism from the ulcerated plaque where you have pledged aggregation and embolization into the internal carotid artery and into the anterior and middle cerebral arteries, I think this part is very important to understand. Um explains why patients have certain symptoms. It explains why certain symptoms and not related with sorted out of disease. And it also is important in light of the fact that there is a lot off debate and controversy in treatment. Medical management off crowded out restenosis in patients with asymptomatic character outfits. Hypnosis Again, when patients of symptoms is pretty straightforward, they you know they have crowded out Christian also over at least 50%. They need treatment. The challenge is being with patients are asymptomatic. And so there is a lot off research going on right now, both in terms off predominantly in aging techniques, um, to identify black, which is vulnerable even in patients or asymptomatic and and identify them as high risk patients who need intervention despite the fact that is symptomatic. So this slide is critical in understanding the physiology clinical features. Again, patients can be there. Asymptomatic or symptomatic is symptomatic patients again, maybe clinically asymptomatic and a right that specifically because some of these patients with really bad plaque on ultrasound or Marie or seedy image ing they have some political in forks in the brain and those patients are basically, in my opinion, high risks to developing symptomatic event like a transient ischemic attack, which is basically symptom ideology that results completely within 24 hours. Having said that usually results within a few hours. Whether it is, it's a lateral monopoly. Her blindness, loss of vision in the same I on the same side or contra lateral, um, extremity weakness. And if that persists beyond 24 hours, that is when we generally call it a stroke. So again, diagnosis is based on history. We've all gone through this in medical school, and we've talked about what a transient ischemic attack is. It is important to understand that there are symptoms which are not related to carry out terrorist Moses like global symptoms like headaches, confusion, business, single bill attacks unrelated to carry out a lot restenosis. If you go back and think about the pathology, that's M bothers them. So none of the symptoms would be related to embolism from a chaotic plaque and then obviously a full blood stroke. Besides a good neurologic exam from a vascular exam standpoint, three only thing that may signal the presence of corroded artery stenosis is a karate broody. But it's important to remember that just because someone has a brutal does not mean to have significant character at restenosis. The same token, if someone has classic clinical symptoms off transient ischemic attack and they did not have a groovy it does not mean that they don't have a terrorist analysis of pollution. So when I talk to medical students, I told them Brew is a 50 50 sensitivity specificity, so I would not put too much weight in it. And if you hear a brewery, obviously it's important. But if you don't hear a brewing and you have a classic clinical scenario, that's still important to continue to imagine, do whatever is necessary to diagnosed the disease. So when it comes to getting studies, they're broadly either a crowded duplex, as you all know or image ing with City or M R. Erotic duplex has Bean pretty much easy noninvasive study to obtain. It's being a gold standard for a few decades now, and what we're looking in the Karada duplexes, increasing velocity of blood flow as it passes through an area of stenosis and creates turbulence, and this is reflected in the degree off. The velocity is related to the degree of stenosis, so we have a chart where higher the velocity fire, the greater the degree of stenosis. And there's a phenomenon called spectral broadening where you see broad ing off the diastolic flow. Here. You know, multiple. It is Doppler shift, and that's significant. First, serial killer stenosis. So duplex scanning is definitely the initial study of choice, and patients were both asymptomatic and symptomatic. You can study the velocities. You can study the characteristics of the plaque, Um, and in an experienced ask for a lot, the duplex may be the only study, UH, majority of patients. And this is what we did for a long time is operating on patients just based on duplicates before advanced techniques were available, such as CT scan. And here you can see a three D reconstruction off severe left crowd and internal crowded out restenosis just beyond the gratification. And the city is incredibly helpful and not only assisting the degree of stenosis in the extracting and corroded artery, but it can also identifies gnosis approximately in the arch or approximately crowded or distantly in the intracranial portion of the corroded artery. And that may become very important in decision making in these patients also city is very good and identifying crumbles and calcium burden. Um, in the black. Unfortunately, not a huge fan off m R. But as we all know, Marie of the brain is very helpful in diagnosing stroke. And a lot of times patients get in memory of the neck as well at the same time. On this can be very helpful in diagnosing crowded stenosis. Uh, the reason. I'm not too excited about getting an Emory as the initial study over the city's because American over called the degree of stenosis and that can be confusing for in decision making, corroded angiogram before the advent off City and, um are back in the day with the Carter duplex. In equivocal patients, we got a counter angiogram which here you can see beautiful defines the area of stenosis. So turning to management of crowded stenosis is why what you're interested in talking about so broadly this medical management, the surgical management, which is the traditional character endarterectomy. And then there is the endovascular management, which traditionally has been the transfer Middle cannot extend, um which is being around for at least 2025 years, transported real exploration, which we're gonna talk about quite a bit in the stock is the new, exciting way off treating karate stenosis, and then I'm not going to spend much time talking about this. But you should be aware that there is another technique any other way off accessing or getting to the corroded arteries. Trans radio. So medical management again is a standard medical management of all patients with atherosclerosis, regardless of where it is anti platelet therapy, management of Hyperloop anemia. And when I say interpreter therapy, typically we keep patients on a low dose. Aspirin, Um, stat on antihypertensive therapy again keep the blood pressure below on 40 and 80. Strict diabetes control smoking cessation and one of the most important parts of medical management is really follow up. Serious studies to assist the progression of the sea, especially in patients, are asymptomatic or in patients after an intervention. Whether it is an art director, me or a stand, um, we have to mention that the first chronic surgery stroke was done by Michael DeBakey in the 19 fifties and, um, obviously cardiac surgery, grand rounds. It would be important to show his picture here. He was obviously pioneer in heart surgery as, uh, many off, you know? So what is? Qwilleran directed me. Black room. All drink crowded surgery. And I don't know how maney, uh, it in these on the webinar have seen a karate and direct to me, but I have a short video of that in a second. So the indications for character endarterectomy this was this was based on a very famous trial back in the early 19 nineties called the NASA trial, where they looked at patients having 70 to 99% character stenosis and also patients with 50 to 69% Paris Genesis, the group with the hard groups Gino six stenosis had a significant stroke election stroke from 26% with aspirin alone down to 9%. In fact, they had toe stop the drug prematurely. 18 months, uh, in order, uh, Thio prevent home to a patient with medical management. And even in patients who had 50 to 69% stenosis, there waas significant benefit. Not as much as 17 99 in asymptomatic patients. The s trial back again a few years after the NASA trial. Shorter in patients with greater than 60% stenosis, the five year stroke reintroduction was 11 to 5%. Again, the numbers needed to treat these patients is really high. Um, and for that reason, we generally wait until the genesis of the world 80% or greater in asymptomatic patients, Um, especially with better medical management now than back in the nineties. So again, for those of you who have not had the unfortunate not been lucky to see a character and daughter to me during your medical school rotation, this is a short video basically showing. So the had the brains in that direction, and the surgeon here is opening the get out of the ordinary. This is the common corroded artery down here to the left and the internal lists up there to the right, and you could see the yellow plaque in the and that's the area off stenosis. Imagine blood going through that law, um, opening. And when we do endarterectomy, the black easily peels off within the media off the wall of the artery. And this is the part being puller the external carotid artery. So again, here you can see the plague that was removed with the synoptic segments. So it's a really neat operation really satisfying. Um, okay, so but, you know, Dennis Asia, uh, anesthetic approach is really good in this issue. Options. They're really good for the character. In order to me, it can be done, look, And a patient. Um, but regardless of whether patients are done a big or asleep, um, most of the patients go home the following day, so switching gears to endovascular treatment off Roaders stenosis. So why not? Extending initially was, uh, started, uh, angioplasty alone with outstanding started in the early 80 s. And, um, as you can imagine, the early encounter in the vascular period 1917 1919 95. There's an incredibly high stroke rate because the end organ is sensitive and is not forgiving, I think they quickly learned that they needed some kind of suitable protection. So to say, the modern cannot in the vascular period started from the mid 19 nineties again, this is a short video off transfer. Meral crowded stenting with the first step again. This is internal category. The first step is crossing the lesion with the filter device which is placed DeSisto or beyond the lesion. And then angioplasties performed any concern this animation, few pieces of debris going off, getting caught in the filter. Then its strength is brought up and deployed across the lesion, and sometimes and a place to this tent is needed. Thio, open it up and then the last step is taking the filter out. So obviously, this involves lot off, um, maneuvers in the arts, which we'll talk about in a second. But all these patients, after a stent, are placed on jewel anti platelet therapy for a month, followed by aspirin indefinitely. And all these patients, just like I cannot in Dr Communication was followed with a duplex ultrasound every six months. So filter, um, are basically several protection devices so they can be filters is they can be inclusion, and they could be flow reversal again. There are different kinds of filters out there in the market that could be used to order a balloon to prevent debris from going to the brain and causing a stroke on the stents come in different designs, um, this open cell and close So, and the fundamental reason why they're two different designs is there's in patients who have a lot of calcification in the vestal um, the closer, closer design works better in terms off. Find radial force with the open cell design is better for tortuous Brussels, where you can see this There's less connections is gaps in the mesh. So the stand actually conforms. Better the open, sir. Designs are by far more popular. Um, there is. There are some studies that have shown lower event rage with open cell design. Again, I'm not gonna going toe to much of the details off the actual, um, standing through transfer Meral. We've seen the video. But the important point to note here is that for transformers standing, we go through the femoral artery and you know, obviously need to have good femoral arteries, good iliac arteries. You gotta make your way all the way from the groin to the neck. And one of the biggest problems with two issues with transformers standing is besides, access is navigating through the arch. And as you can imagine, these patients may have a lot of black burden in the arch. So as the wires and sheets are going across the ARJ, there is a risk off embolization into the brain. And the second point of concern is the first step as you saw in the video is passing this filter protection device across the region, and that process itself can cause embolization before the filter is deployed. And for that, for those two reasons, the stroke rates have always bean on the higher side, with transformative standing as compared to concurrent artwork to me again, the other challenges with the arch or how steep the arch angle is, As you can imagine, the arch and the very right side is what we call it. Type three Arch. Very difficult to navigate again. There are clinical factors were crowded understanding, transforming stand maybe good, like severe cardiopulmonary disease or contra lateral literal Angela Palacio, where you don't want to do it out and attacked me. Severe obesity. On the same token, all the patients don't do too well, the transformative standing. And obviously, if patients cannot tolerate duel interpreter therapy, transforming standing would not be a wise decision and renal function. Precluding use of contrast would be a problem again. Anatomy good an enemy on the right is previous neck radiation. Basically, these are situations we're doing. Surgery would be risky. Previous radical next surgery tracheostomy referenced diagnosis from previous quarter endarterectomy lesions that there are too high for clattered endarterectomy or contract recorded occlusion. So this the right column is good for standing. Where's the left? Column? From anatomy standpoint is not good for transformative standing if your area is deceased, heavy calcification or you have access problems in the iliac artery or this fresh crumbles and unstable park. So these are situations where patients are typically symptomatic. And that's why we see most of the trials when symptomatic patients are randomized. Uh, they don't do too well with Transformed outstanding. Again, um, crowded transformer, crowded standing can have complications, and there are management options with each other, complication like with any surgery or any procedure. So the initial data on counteract Resistance came through registries, and these are a list of industries. Were they had. This is a composite, my stroke and death waves, and subsequently they were in the early randomized trials that looked at karate, Rotary standing wishes, endarterectomy and generally had a little higher stroke rate compared thio significantly higher. So on studies compared to endarterectomy and as the technology improved, um, there were a couple other prospective registries that came out exact and captured, too, which showed that the results from Kanata notwithstanding in high surgical respirations started to get better and a lot of data here. I'm not gonna go through all of this. But they had reasonable stroke Ridge. A major stroke off less than 2%. But remember, these were prospected registries, um, again exact and captured. Two showing decent results with Roger Order extending, of course. Now, then, you know they had to do it. Animals trial to figure out. Okay, let's try and figure out whether and directly me is better or transformative. Get out. Extent is better. So with 2500 patients were randomized in the what we call the Crest Royal, where they looked at standing watches endarterectomy for in patients with both isn't American symptomatic groups and what the phone was collateral tree standing was better in patients with four younger, less than 70 and our documents better for older patients. Having said that, the biggest take away from this try a was the stroke raid. They struggled with transformer. Crowded stenting was 4.1% which is in direct me was 2.3 and this is very procedure. So 30 days am I on the other hand, was slightly higher in character and are actively patients 2.3 versus 1.1 with transformers standing. But when they looked at four years and down a 10 years, there was nada. There is not a significant difference the composite important stroke in mind debt between the two interventions and also when they looked at quality off life among these two subset of patients with stroke and, um, I they found that patients who had, um I did really well in terms of quality off life, although they had a greater 10 year mortality. On the other hand, patients who had a stroke they had poor quality off life, as you can imagine. Um, long term. So again, there's a lot of data on Crest or the lot off articles theme. From a symptom standpoint, it was clearly evident that patients with transforming standing did not do well, and women did not do well with grants. Family standing and again like we talked about, all the patients did better with director me So again, when you look at long term 10 year data on character arteries standing over 10 years, the lions begin to march this is not a significant difference. But in general, uh, endarterectomy results were better in terms off stroke prevention especially, um, for very procedural, our time frame. So there are several trials or their animals controlled trials comparing character and directing me and transforming standing This the i. C. S s crest a city lot off. Most of the trials were leaning towards endarterectomy, especially in patients with symptomatic disease. And these two trials were in Europe evil. Three years in space. These were symptomatic patients and significantly higher instruments off. Very procedural stroke in bed, transformers standing. And they were not able to return mine. Non inferiority off corroded artery stenting in patients were symptomatic. Oh, so there are ongoing studies looking at the the larger group of patients with asymptomatic disease, which is some of the bulk off patients who we end up treating, whether or not whether it's endarterectomy or standing. Um, and so there is a lot off interesting, um, studies going on because the best medical therapy has improved significantly, as all of you know, from the 19 nineties to two thousands to now with better starting therapy and and decorator therapies. So there are these are the stories going on right now and, uh, the CSD. Actually, I was checking on the on their website. It's, uh, anticipated completion December of this year. So the next year or two, we should be having a lot of information about what's best for patients. Were asymptomatic in terms off endarterectomy or transforming standing or just leave them alone with medical management. So what about character endarterectomy and transformers? Correct. Standing with coronary bypass surgery. I'm not going to spend a whole lot of time on this, but I'm sure Wilson will agree and he can comment at the end. But back when I was a fellow early two thousands, um, we did a lot off caradhras and direct amis in cabbages. Combined writing over the last 2015 years, there's been a lot of data that showed that, uh, it's not, uh, any significant benefit off doing these procedures. Uh, in most of these patients, that left the best left alone, especially the asymptomatic, another disease. And this is one of those studies publishing stroke in for three years ago that showed that patients who had simultaneous uh, Crawford director Min Cabbage, was his isolated cabbage there was no added benefit and you can see here. Time of survival free from stroke Isolated cabbage is actually slightly better so, but again, there's a five year follow up is to ongoing, and the same is with crowd extending private corner artery bypass surgery. This is a study that was again published three years ago that showed that there was no significant benefit between staged are same day. Get our arteries standing still with all that in the background, we just we Just When we thought that we figured everything out in terms off treatment options, new technology came about. So again, uh, character endarterectomy is probably, you know, 80% off what we do in terms of interventions for character stenosis. Again, three problems are local training. Low injuries, um, low risk off other local problems, but a little higher. And my rate, as we noted in the press trial, lower 30 days structures compared to transformers Standing, which has higher stroke rig and as we talked about challenges air crossing the arch lesion and crossing the actual lesion, the carotid artery before the filter is deployed. So the technique off transported artery rev escalation or de cartas we call it is based on partly how character and directing is done in terms of clamping the proximal common carotid artery and allowing toe blood the blood to come backwards through the circle of villas while the intervention is being performed so nothing goes upstream into the brain. Whatever degree is generated from the intervention is sent is brought back into the ephemeral Wayne. And so this is the layout, as you can see, a small incisions made in neck up here, she displaced the artery's clamped below the sheet so blood is not flowing backwards and it comes out of the body through the site part of the sheet. And there's a filter that furthers all the debris, and the tubing is connected to a federal Venus sheet, and the blood goes back in there. So during this reversal of flow is when the angioplasty and stenting is performed, and once a stand is done, shit is remote, and this is closed on the sheet from the dryness world. So this is definitely a shift in the way we started thinking off treating the crowded artery again. As we all know, the brain is very unforgiving in terms off any mobilization, and that's being the sort off the pain off transformers standing despite use off filter devices and unlike, and not recommit avoids any damage to the criminals. Watch the early cards and, uh, so basically, take all the combination off using surgical principles and the vascular technology. And this is the filter in the desert's bare those required to the procedure. There are certain an atomic requirements, which most patients do satisfy in terms of having good working length of the common crowded out rate in order to place that she didn't provide and performed the procedure. The patients who qualify for this procedure are basically the same. Patients will qualify for the transformative stand, which is a high risk patients. Um, on the restenosis in the contract. Basic the list here. I think Linda is going to pass the slides to everybody, and you have these slides to call. The list of patients will qualify for transport spending, and this is a video I'm gonna try toe go through this thing you have but and minutes left and, you know, trying fast forward. There's a little bit. So these are supplies, so our question is done to mark the, um, character artery in the neck. And this is access to the formal Venus. Usually we go on the opposite side just for these off placement off the filter on the body. And once Venus axes obtained, an incision is made in the, uh, just about the clavicle. The muscle will split this genital mass start. They cut out the arteries isolated, and a small posturing switcher is applied to the cloud artery here. And then we access the artery like we would access any other artery for performing and vascular procedures. You know, try to fast forward to some of this she displaced is this An angiogram is performed and thesis switched to a larger sheet in order to place the performing angioplasty and standing once the large she displaced. Then the next step is to establish the reversal of flow that we talked about. Well, the so this is the flow reversal to being that's connected. And then the blood is allowed to come back from the common corrupted artery that's connected to the femoral venous sheet now. So now established a circuit where the blood is flowing back into the body through the filter. Once that's established, then you know, obviously the patient's fully have glanced at this point, and then angiogram is performed to identify the lesion. And once the lesion is identified and the wider is loaded and enter, plastic relations performed. I'm just going through this faster. Just off times here you can see the wire crossing. And so, while this is happening, blood is flowing backwards. So any manipulation off the lesion with the while the balloon understand all the debris comes backwards instead of going up into the brain again after angioplasty, this is ah, stamping passed up. You can see the stamping deployed between the two darks. Here on completion, angiogram is done once that's done, and then basically, uh, ch'tis pulled the flu is returned back to integrate flow to the brain. And, uh, so the important thing about doing this procedure, obviously is maintaining good reversal of flow, and the time for the reversal of flow is really 5 to 10 minutes. And during that time, we maintain the main arterial pressure hired to keep the flow coming through the circle of Willis. And it's faster. Most of the time we do this in the jury anesthesia, but again, they can be completely done under sedation. Um, requires an arterial line. So the data, the data from translator artery stenting is very good. It's very robust. So there's the road Roadster retrial in the We'll talk about that in a second. This is just a couple of cases that we did at Presby. Um, with the T car radiated next symptomatic patients. But the so the data is, uh, right, very good. Very robust from T car. The roster trial showed significantly lower stroke rage compared to all the previous cannot stand data from transfer Meral access, which again is not surprising because you're not crossing the lesion when the blood is going into grade. And even in high risk patients, the stroke rate is lower. Then Crowder nor directed me done in standard surgical patients. So, um, and patients across the board, whether they were older or female, all of them they're significantly better with T car and then roasted to was basically a real world usage of the stand. And so far, the struggle. It is very low, so very encouraging and very, um, uh, interesting data and not surprisingly, the based off transported artery standing has taken off and across around the world, about 20 to 30,000 procedures have already been performed, and there could be a role patients with cardiac surgery Picard has been done. You already have a stern Artemis with cabbage, the left common carotid artery, the dominant artery with things already exposed. Or you can extend edition of the negative necessary place a sheet and duty car, Um, and the same thing with towers. It's been done, whether again, this has to be again. Very selected in patients who really needed the data again is you know, not for all patients undergoing or having this is in both areas of the body, but patients who have high risk out of legions. So, in summary, symptomatic standard risk patients, um, character on Earth and attractiveness to the gold standard. Patients who are high risk and symptomatic character artery stenting. Whether it's transfer Meral or the car, uh, it's intimate. Extended risk patients are still get character and not reckoning. But the key here is to identify high risk patients or high risk stroke. Rather isn't very high surgical risk patients. If they're younger, they can get crowded out restricting in a clinical trial setting with older patients are probably better off with medical management. So the emphasis in asymptomatic group is really the high risk. So toe identify patients who are actually high risk based on image ing. Or, you know, having some political informs our, uh, certain characteristics of the plaque that make them high risk their ongoing trials. It well, we all are looking forward to figuring out the role of best medical management in comparison to the interventions and in symptomatic disease we know from the recent trials that are, rectum is better than standing. But again, remember all the stories you've done with transformative standing uh, endarterectomy should be done earlier in patients Recent stroke and I didn't touch upon that. But that Z another standard is to do it within a week. Teak or is an exciting new investor option is very encouraging data, And both isn't American symptomatic groups. Currently again, it's only for high risk groups, and there is a need, uh, randomized control trial, setting Thio assess it, or compared with other interventions and best medical therapy, thank you for your attention, and that's my cell phone. You can call me any time again, this place will be passed on to you and then supposed to leave this on. Thank you again for your attention. And I'm happy to take any questions. Van Cott, this is Wilson again. Fantastic. Thank you for great summary. Um um, that was wonderful. I have a few questions, but I'm going to start with the audience question and chat. I understand. I see that there was a chat question from Dr Patel. How are you? I don't know. If you can hear, May um, the question from Doctor More Europe Hotel, which you alluded to a little bit earlier on dykan comment as well. After I hear from you, the question is, if patients going for corn bypass grafting which should be done first. Kurata Incorrecta me or a cabbage. I suspect this is assuming or on the on the assumption that there is an indication Do a combined procedure is you and I, as you had said before and I would echoed is completely I think the indication for a combined procedure is becoming mawr and mall mawr narrowing and smaller. Um, can you briefly, just in a very granular way again reiterate who gets a combined procedure. And the timing? Sure so in patients who have symptomatic coronary artery disease, you know whether they have unstable engineer there going for a nucular mind. They'll follow. Have asymptomatic, severe rotted snows is the answer is very easy. You have toe get the community of escalation done. First, uh, they can order can wait. So eso which of it is symptomatic goes first. So if someone has symptomatic in order disease with the TIA and they've found to have, uh, coronary disease, there's asymptomatic. I would say those patients needed the character intervention done. First. It's very rare for both to be symptomatic. Um, it's probably that it's a very small group of patients have asymptomatic water disease and, you know, minimalist symptomatic coronary disease. Even in those patients, I would lean towards treating the communities first unless the crowded disease is high risk, like contra lateral crowd occlusion or severe bilateral stenosis. Or there are the plaque characteristics on the image ing. Look, what is, um, for the disease? Yes, I would echo echo that I think the quote unquote hot patient with both symptomatic charity and corner disease is not that common um, I think you're right. It comes down to careful patient selection, and I think it speaks to the importance of ah of, ah, of a car team. Where involves cardiac surgery, cardiology and vascular surgery to really talk about this as a team. Yeah. I would echo that second question from one of our cardiologists here. Samir Condor. Uh, should all patients have a screening Carotid Doppler before cardiac surgery. And number two, Which patients warrant treatment before cardiac surgery? I think you just touch on that second question. But should all patients have how the screening Carol adopted before cardiac surgeon? What do the guidelines say about that? Yeah, if you go on Bob made there are studies out there that that exact question. Are we wasting time doing screening for Crowded? This is before coronary interventions is basically the question they're trying to ask because if the data is showing that there is no value or we're not going to intervene on is symptomatic karate. This is no matter what they do, click shows. Then why even bother getting these? Yeah. Study done. So I don't know if I would, you know, go to that extreme. I think they should still be screened because you may identify a small group of patients who are at high risk of stroke. As you know, Wilson, uh, urologic events after Connery surgery are multi factorial. Um, and the crowded. This is probably a a small part of it in terms off ideology. I would still screen just because off the, um, concomitant presents off perforated disease and crowded at risk gnosis and patients with, um, coronary disease and vice versa. So I think we should always scream for a truss Sclerosis in other territories. I have a question for you. Uh, van cott. And this is along the lines of tea car. You're not talked about this. I think t car is Aziz. You mentioned an absolute game changer. Um, it has lots of applications, including some of the work that we're gonna be doing together with arch stent grafting and branch stent grafting of the arch. This whole concept of flow modulation or full reversal is very interesting to me. So a few questions here, um um is an intact circle Willis an absolute requirement for tea car. So that's my first question. Yes. So and and that's a great question. So for that reason, when you duty car, we always want to see the base of the brain on the city image ing so initially have to be ahead of next city A. But even the next city, as long as they visualized that shows the circle of villas, um, to prove that. So, for example, there are certain situations where you may have what we call a peek out posterior inferior cerebral artery, which does not communicate. So the posterior circulation does not communicate with the anterior circulation. So there are certain anomalies in the circle of villages that have to be identified on if they're present, then they're not good candidates for floor oversell. Um So yes, they need to have on in tech circles village, but doesn't have to be the classics circle of a list, which is there, which is present only in about a third of the patients. There can be some incompleteness, but certain things are known to be play a major role in Florida oversell Second question, Um, I actually do see a potential expansion of Indication application, as you mentioned, would concomitant t car and cardiac surgery to me? Obviously more data needs to come. But I think this may potentially swing the pendulum back the other way, where we're mawr aggressive with common procedure. Because as you showed in your pictures, you're gonna have all the access you need. You're gonna have access to the left and right charity or nominate and left charity. And you can have access to the right. Right atrium. Right. Um, I cannot think of mawr aim or anatomically friendly scenario for T car. Yeah. Do you think you know, obviously more data is needed. Do you think that potentially can shift the paradigm towards Mork uncommon procedures? Yeah. No, absolutely. I think only the only thing that we think in terms off access to do the procedure onda the florid verse in the decrease the risk of neurologic events being low is certainly very exciting for that. The only thing I would say we need thio keep an eye on is the 40 cars. Just like transforming standing. You need toe patients need to go and jewel interpreter therapy. Prior Another few papers that have come out with concomitant procedures. They were not loaded with Plavix prior to the procedure they were after the cabbage was done. They started Plavix, so that's a little bit off the risk. Um, but I think that's ah, something that we can, you know, look at individual patients and make a decision. But this, uh, patients have been doing well for the ones that have been reported. I mean, I I'm just extremely impressed. And again, I was stressed the early data, But, you know, the tea cart data is very impressive. I think it has the potential to change court karate intervention, much like tavern has for aortic sentences. I see a potential. And again, I might be being overly enthusiastic. No, I don't. I don't see why this cannot replace Kurata. Interact me as the gold standard, even in low risk patients, even in low risk patients. Yeah, and I think the fact that the vascular surgery world in the community um, everybody is very excited about the car and that speaks volume toe that because as the vascular surgeons were ruled reluctant to take on transforming stenting, Um, but the fact that surgeons are beginning to get excited about this, uh, itself speaks Thio the about entity of the data. I have a question from Alan asking, Ace, I'll read it out to you. I don't know if you can see it and got, um, current guidelines recommend carotid screening prior to cabbage Onley in patients that are older than 65 with the presence of a brew we and a history of either a cva or TIA. This will reduce screening burned by 40% but miss less than 2% of patients greater than 70% cross tenacity. Do you have any comments about that? No, I don't mean it's really That's something that you know, I don't obviously control. Um, it Zuno. It's one of those things that, you know when I see patients with significant peripheral arterial disease. You know, a lot of those patients in symptomatic from corner disease, but in my mind, I'm always worrying. I mean, I didn't show a little a band diagram, you know, with coronary disease, karate disease and p 80 kind of intersecting in their percentage is gonna showing the kind of, uh, synchronous disease, uh, in other birds. So, you know, I'm not I'm not worried about and I agree with Ellen in terms off the screening guidelines. Having said that when I see when I follow patients, you know, serially for P. D. I'm always on the lookout for, you know, either canary symptoms or encourage them to see a cardiologist to, you know, make sure that you know the EKGs okay, or they don't have any underlying silent corner disease there, especially in patients with diabetes. So it's one of those things. I think you just have to look at individual patient, like Ellen pointed out. Yeah, and I would agree. I mean, we probably mean we I can tell we meaning we hear a pen. Um, we're probably on the aggressive side of the screening. I think we pretty much get a carotid ultrasound. Almost everybody on your right. There is a cost in the burdens of the system. Um, it has essentially no morbidity to the patient. It's an ultrasound. Right. But you're right. Um I mean, this is something that Alan, this is something that maybe we could look at as a group. Whether we're overly screening all our patients undergoing cabbage, essentially, all of them get a crowd ultrasound. So we can certainly talk about that up to as a group. Yeah. And the fact that we don't really intervene. And most of those patients, anyway. And what ends up happening is those patients followed with the cardiologists in the office down the road just to get in a serial. Duplexes once a year follow the karate disease. So I think, which is a good thing for the patient. Um, so, yeah, I think we can look at it. Okay. Any other question from the group? Whether you can type it in by chatter Q and A. Or if you want a new and speak, that's fine. Um, any other questions from the group? Well, um, van Card Again. Thank you very much for your time. I thought this is a very exciting, um, new area and a great talk. Thanks for being the inaugural virtual grand round speakers for us for cardiac surgery. Presbyterian. Thank you. Everybody on the line or on the phone. Joining us very much. Appreciate your support again. The event code is 66871 hopes I Here. I see that we have another question here. Right. Let me see if I can get that for you. Uh um, Another question from Alan. Great. Alan, um, I'll read it. to Vanguard stroke rate in ongoing crest two side by side registry Patients who refused medical therapy or C e a and then undergoes C A s crowded stenting was reported in December in 2019 to be 1.4%. What are your thoughts? Do you even need to re read that question to you? No, no, no, no. I got the question. So I think I need to look at that data in terms off. How many of those patients are symptomatic and asymptomatic? Um, I would think that most of those patients very symptomatic. I don't know the subgroup analysis off that, but the bigger question moving forward, really? Ellen is gonna be, um, patients with asymptomatic disease. And what the best treatment for them is eso that's going to be exciting, um, information, Because again, the bulk of patients that we treat our asymptomatic whether we're doing doctor ectomy or transformers standing or t car So and we know the long term data for sure between endarterectomy and standing in the restaurant was not any significantly different in terms of composite in poems. Okay? Allen says 1.4% for asymptomatic, 2.8% for symptomatic. Yeah, that makes sense. Yeah. All right. Um, thank you. Everybody again? Very. Thank you very much to everyone. Very much for the support of this inaugural event. For us. Um, event code again is 66871 on the screen are the three methods, uh, to obtain. You're seeing me again. Thank you for spending your Thursday morning with us and hope to see you next time. Thank you very much. Thanks for listening. Thank you. Van got appreciate it.