 Είναι μου ευχαριστή μου να συμβαίνω και να συμβαίνω αυτό το δρόμος για το 2021 Πρεφουζιοντο-κομφερντ. Είμαι ανοίγησης για αυτή τη θεωρία, γιατί αυτό το Πρεφουζιοντο-κομφερντ είναι ο δρόμος που διδομείται τα οικονομικά παρακολουθούς της κράτης. Τα τελευταία εγώ είχα πολύ προβλημότητα να also participate and honor Terry Crane as well as a perfusion school at the Texas Heart Institute. So the talk this year is for strategies for brain protection during proximal aortic surgery as well as visceral protection during the thoracobdominal aortic surgery. And I hope that you'll be able to find this educational as well as very helpful into your everyday practice. This is my disclosures. So starting with the renal and visceral protection after thoracobdominal aortic surgery. The thoracobdominal aortic surgery can have significant perioperative mortality and morbidity. And this mortality and morbidity is large due to the aortic ischemia distilled to the aortic crossclamp. And this ischemia may manifest as complications of the kidneys as well as the viscera. And the kidney dysfunction as we can see here can actually arrange from 12 to 50 percent with up to 17 percent of patients needed hemodialysis which actually may decrease the long term survival. Mesenteric ischemia even though it's not common the mortality if it happens the mortality can be quite significant up to 60 percent. These are the various surgical techniques and conjuncts during the thoracobdominal aortic aneurysm repair. Via which really we protect the renal and the visceral aortic vessels as well as the organs as well as the spinal cord. So the first aortic technique and adjunct is the cardiopulmonary bypass with hypothermia. This is a mechanically oxygenated aortic blood. We use this technique when we are not be able to apply safely a proximal aortic clump along venous cannula is placed into the right atrium via the femoral and with the vein. And drainage is assisted via cannulation of the left atrium through the left inferior pulmonary vein. In addition as an arterial cannula we use a 20 or a 22 French straight cannula which is placed in the femoral and with the vein and then of course we cool down to a deep hypothermia 18 or 20 degrees. As I mentioned this technique is used only at least in our practice when we are not be able to proximally say place with the aneurysm and with the clump. Most of the time the technique that we use is left the cardiopulmonary bypass. Via the left bypass we provide isothermic self oxygenated blood into the distal aorta while the proximal anastomosis. What you see here is been performed and usually the left bypass is applied to extend one and two HMD repairs occasionally to extend HMD 3 repairs. And this is a closed circuit in centrifugal pump technology and this bypass as we see the circuit is from the left atrium into the distal descending thoracic aorta into the visceral as well as the kidneys during the proximal HMD anastomosis. And this is another way that we protect the kidneys and the viscera. And we can see here the cannula in the inferior pulmonary vein on the top right hand side image and then the arterial cannula in the distal descending thoracic aorta. So during the proximal anastomosis the left bypass is on and provides the blood into the visceral as we said into the kidneys into the distal HMD anastomosis. And then when the proximal anastomosis is completed the left bypass is off. At that point the protection to the kidneys and to the visceral is as follows. We use a standalone roller head pump where we provide called crystalloid solution into the left renal and to the right renal as we actually see in this HMD picture. This called perfusion is actually especially beneficial in patients with preoperative renal insufficiency. Different perfusion solutions used and in other practices is blood selling ringers lactate or ringers acetate as well as custodial solution. In our own practice we have used for many years the ringers lactate with mannitol and solumedrol but over the last few years we have switched into a custodial solution. Now the way that we infuse it is as an initial bolus approximately 300cc and then we use it intermittently every 15 minutes until the arterial flow is established. And this is one of the ways to protect the kidneys. Now with regards to the viscera the way that the perfusion is established this is via a Y connector into the left of the left heart bypass circuit. And this is what we do with the viscera perfusion is we mechanically perfuse the celiac and the superior mesentery artery to minimize the total mesentery as well as hepatic ischemic time. And you can see here the Y branch of the rerouted left heart bypass circuit. And this is a continuous flow to approximately 400 ml per minute. And again we provide with this way we provide isothermic self oxygenated and with the blood when actually when we perfuse the viscera this is usually in the more complicated secondary pairs usually for the extent to repairs. And especially when we use tetrafurcated multi branch graft. Now what we have found is and the reason behind this viscera perfusion is to potentially reduction in the risk of the post-op coagulopathy and bacterial translocation from the bowel. And it is easy to perform it does not really add more risk into it. So another way to protect the kidneys and the viscera is by the way that we perform dynastomosis we're using with the bypass graft or sometimes also we place balloon expandable stents into the superior mesentery artery or into the renal artery. As well as the celiac artery. And again the way that we manage it can be with individual branch grafts as we see in this image or actually as dynastomosis is performed as an island with regards to the viscera and the renal the island usually contains the superior mesentery artery, celiac artery and right renal artery. With the left renal artery done as a separate anastomosis. So in summary the way that we protect the kidneys as well as the mesentery the viscera organ is via left herb is a combination of left herb bypass called renal perfusion, viscera perfusion surgical management regarding the reattachment techniques as well as an expedition. The most important is to have of course a great equity team now switching gears how we protect the brain during equity arts equity surgery. Again the primary goal here is to preserve the cerebral equity function and the brain as we know is extremely sensitive to ischemia. So what we like to do is to suppress the cerebral metabolism with the use of the hypothermia as well as to provide the metabolites by the means of the anterior of the integrate or retrograde cerebral perfusion. So the three main cerebral strategies as you know one is the deep hypothermia and the other two is the integrates cerebral perfusion with hypothermic circulatory arrest or the retrograde cerebral perfusion with during the period of hypothermic circulatory arrest. One of the things that you know very well is that there is debate regarding the optimum brain protection strategy during our surgery and as we see here is some of the groups in the country especially the Yale group is very a big advocate of the deep hypothermia and in their hands they found that up to 50 minutes of deep hypothermia can be considered safe and we can see how the stroke is 1.3% with less than 50 minutes and goes up to 16% or more when the deep when the circulatory arrest extends to more than 50 minutes. So this is why really for extensive arch reconstruction adding an integrate or even retrograde cerebral perfusion it's recommended. We can see here this is the trends in the US as well as in Europe. This is a few years ago but the trend actually remains quite similar. Most commonly what is used around in the various orthographic centers is the integrates cerebral perfusion during hypothermic circulatory arrest. The way in our own practice we have traditionally used ephmoty axillary at least for the last ephmoty more than 13 years that I'm at Baylor College of Medicine in Texas Hart and in for the last more than decade we switched to a nominate ephmoty cannulation. This is our own ephmoty strategy. We published this a few years ago in the Journal of Thoracic and Cardiovascular Ephmoty Surgery. What is our cannulation strategy to provide the integrates cerebral perfusion for brain ephmoty protection during primary repairs of the orthocards but also during ephmoty redo ephmoty repairs and also in certain cases ephmoty emergency ephmoty cases. And so how we start we proceed with the cannulation axillary ephmoty or ephmoty a nominate via which we will be able to provide unilateral cerebral perfusion. The temperature is we decrease the temperature to approximately 24 degrees Celsius. This is considered to be moderate hypothermia. The range of the moderate is between 20 to 28 degrees and is our preference to go approximately 24 degrees and with the Celsius. And then we start the period of the protected circulatory arrest with the integrates cerebral perfusion. Now at that point we add a second cannula into the left carotid ephmoty artery in such a way that we provide bilateral integrates cerebral perfusion during the artery. The advantage of the integrate and the still there is debate between unilateral versus bilateral cerebral perfusion for brain protection is to is to is for the cases where the circle of willies is not complete. And when we finish ephmoty the period of circulatory arrest and when we complete the distal ephmoty anastomosis then we go back into a full flow. One thing to mention is that during the circulatory arrest usually the flows are down to 10 to 15 ml ephmoty per kilo per minute. So in summary the way that we protect the brain during the arch reconstruction is via metabolized with the integrate provided with the integrate cerebral perfusion. And if possible we provide bilateral integrates cerebral perfusion. We perfuse the brain at the rate of 8 to 10 or 8 to 12 ml per minute per kilo. The perfusion pressure we try to maintain it 50 to 60 mm ephmoty of mercury and the temperature range between 23 to 28 with our preference to be close to 24 degrees ephmoty Celsius. So you can see here that the protection of the brain during ephmoty arch surgery is actually multiple ephmoty modalities that we use to protect the brain similar with the various modalities that we use to protect ephmoty the visual also during ephmoty thoracobdominal ephmoty surgery. This is multiple papers that I was very honored to participate and author with your help as well as with anesthesia and what he helps over the last few years. Again I would like to thank you for this tremendous opportunity. I would like to congratulate the organizers for this amazing conference and the amazing speakers and I'm really touched by this invitation especially because this year the conference is actually honoring women. Again I would like to thank you. It's a great privilege to be here and I would like also at the end of this talk to entertain any questions. Thank you so much.