 Thank you so much for the invitation and the organized committee for having me here. It's really, really an honor for me to belong as a staff surgeon in this legendary institution. And overall, you know, having to work with such a remarkable profusion is that I make my work and the work of our team very, very easy and very, very proud of to belong to this group. So, the talk that I have today, the process and our kind of recent management, but I think, since it's a profusion conference, so I think I'm going to give it a profusion strategy. So how to manage this aneurysm send and pretty much there cover some certain basics and the reason why we do it and how we do it. So, just a lot to some basic definitions in case that you know sometimes when when we were in the middle of the night and and some of the students a what we're doing to do an aneurysm we're doing a dissection we're doing. You know, so it's kind of like that we got to go to the basics and say that the New York canary since you can go from some dilation of any portion of the order that extends from, you know, to the root all the torque of Domino New York to the dissection which the one of the catastrophic situations that we see overnight is just a tear separation and between the intimate advantage and the flow goes into, you know, and into the files of women and compromise everything downstream, you know, the great micro fusion and pseudo aneurysms. We also talk about many times about acute aortic syndromes they can happen in any part of the order, but we're focusing pretty much in in in what entails that the, you know, the proximal thoracic aorta can be a dissection it can be a penetrating also in the hematoma, all the situations that we see the require attention and usually surgery and in any any any time in a minute. The when it happens this stuff to the your that this problems they can either way treat medically you can be a treat with end of ask the therapist and most of the time sometimes require surgery to her next. All right, so just going back to remind everyone about the classification we use a basic classification and absolutely and and for the Stanford sometimes in a system for be medical management usually Stanford type A. You know, either way a type two or type one. Usually we, we treat the type ones and type tools in the in the war. And the important reasons that we treat these dissections is because we're trying to prevent that. I think, if you look at what are the reasons that people died of dissection is because one pretty kind of tamponade. Sometimes when you notice when we open the chest and we open the pericardium. Sometimes it's all you see a brody pericardium fusion but it's not because it's raptures because the kind of sweats around and you feel that pericardial pericardial space and that can cause this pericardial tamponade so that's one of the reasons that people died congestive heart failure you know it's dissection extends into the non-coronavirus sinus cause a you're thinking sufficiency or compromise of the corners stroke. And my cardinic function, you know if you dissect one of the corners. So usually people who has a section to the corner is usually they don't make it alive to the hospital so you know when they come and the corners I said that they usually very, very, very sick people that usually are not very good if it's not being treated properly. So dissection can happen and with my profusion in any in any basket, part of the vasculature but you know the important thing is that at least 20 to 75% people has my profusion in the renal also open and lower extremities and the less common is in the mesentery circulation corners or spinal cord. So thankfully because this is probably the most I'm stating in the heart failure or the paraplegia or not having a gut it's just pretty much a dead sentence. So, we have to remember that this is a lethal disease and 24% of these people they don't survive. Even if you treat an aortic dissection with surgery 19%, there will still be dead after surgery and not even mentioned that you decided to go medical management and mortality is 50 to almost 100%. So what we're trying to achieve when you know when we when we call you guys in the middle of the night to help us out with the cases is just to is expedite and do an urgent open aortic repair and the main the main the main the main goal is to exercise the the site of this here by your place that there with the graph replacement and reestablish the flow in the true woman. Sometimes, you know, according to the complexity of the case, either way you have to replace the root if it's dilated or or is a marathon patient is I said you have to replace the root replace the root or replace the arch if it's dilated or it has a big tear and fortunately, this is less common. And usually we've tried to get the patient alive out of the table and replace the hemorrhage and sending with the resuscitation of the valve so the patient can go back and and and and and you know we did with the consequences of complications after. So, usually the algorithm that we tried to do and it's just if your page has a microfusion corner is a little more profusion is going straight to the war. If and close minuses you know if there has a mess in theory is Kenya sometimes approach is taken first to the cat lab and do a quick fenestration of the rena so the mess of Terry Carter is and then go back and and perform a few hours later. According to the stability of the patient and do the ascending your kind of reason repair. So, but totally with the Arctic arch, you know, doing a total large. As you know, it's a big enterprise a team approach and fortunately, here with the city and our group and that prevents that we, we, we are very lucky to have this referral of that we do these cases in that. But it's not very common, you know, for people to start doing that total large surgery outside in the community as you can see, you know, also, all the arches they are not just I'm going to do an arch is usually include something else you include a your background with my territory corner bypass. So all these things add complexity to to what you're trying to achieve. This is some of the reconstructions that we do, you know, the classic image that we always call about himmy arch but in reality is approximate transverse actually construction there is no himmy arch but you know people know this total large replacement of what they once with the branch of circulation of the head vessels and beyond the arch preparing the patients for you know trying to do an elephant trunk frozen elephant with the stance and set him up for a second stage elephant trunk completion. So, you know, in order to achieve that, you know, just we have to come with some techniques to try to not to go into this route that this you know, the surgeon Russia they do 3000 patients or usually kids, they put these people in an ice and they just perfusion less. So, you know, imagine you got a kind of like cold patient and put ice and operate as fast as you can and you know that they realize that all these kids that after the operation even if they didn't have severe brain damage, they realize that those kids have some sort of, you know, development issues and cognitive issues and deficit attention disorder issues and, and, you know, they're always a brain damage so in order to not to have to go that route so that many many pioneers be before us they they they try to solve this problem is how we're going to pursue the brain. Well, so the goal is after this is minimize all injuries and the clinical effects after this. And the many is been talked about, what about the metabolic demands brain you know you you don't, you know, the most important piece of that you got to protect the brain but also you don't have to forget about the the rest of the body, you know the kidneys the gauze you know the legs, everything matters, but the brain is very egocentric organ, as you can see this is most important is just doesn't like to share blood with anything. And he likes to be in a constant aerobic glycolysis to use fresh ATP you put in an ana and anaerobic anaerobic situation so they like this increases and it's very toxic to the neurons. So uses as 50% of the total cardiac output and 25% of the total body glucose is what the brain is so important. This is probably a paper that everybody should quote and read this is a classic study by Dr. McCool, then the group of Mount Sinai New York, that actually they test how the test the limits of deep hypothermia group there is how far you can take a people down and as you can see in the website is that the metabolic demands of the brain they're never zero. They're always they're always even you could on the patient to five degrees sometimes physically possible, you still have some brain activity. But, you know, fortunately, you know, to do to do this repairs in the circuit or as they figured out that you need, you know, probably safe limit is around 40 minutes, 15 degrees so you still have some the body's demands so 16 so that's, don't forget about this number because that's why you know this 16% you kind of like a complimented with the integrates or retrograde cerebral profusion so I think this is what a lot of what we do is based on and everybody should read this paper once in a lifetime. What options do we have for circuit rest is either way we go straight to hypothermia secretaries, retrograde cerebral profusion or antiretrial profusion, which method disappear I think it can be at the date of, you know, every single meeting and organization is every single time you just prepare what is best. The one is what it works for the surgeon what it feels comfortable because there is no randomized clinical trials and one is better than the other but one thing we know is that probably is better not to go straight to deep hypothermia secretaries that just to complement with something else retrograde cerebral profusion antiretrial profusion yes to supplement that 16% that you are taking when you when based on the graphic that I mentioned in previous days. Dr prevents I've already mentioned this but you know around the community, many people are changing back to antiretrial profusion. Still deep hypothermia secretaries many people believe in still and doing it and it's not a bad thing but you know the perfusion is insurgents need to be comfortable doing this. RCP is effective, you know, it is good for my doctor, you're adding Cornell, you're going to train on Dr, so he said it back in the days used to do a lot of retrograde cerebral profusion. So he's taking that way and doing his cases in that way, but the important thing is that we know for the graphic that I've been saying before you know for the temporary drop that you have 40 minutes but what happened after 40 minutes if you complement with something you can extend the time when you serve you're literally longer and without pretty much neurological events you know permanent nautical deficit or transient nautical deficit. So, what about cognitive levels when you when you when you when you do a retrograde or integrate this study by doctors Benson. You know, in terms of clinical stroke, visual, neurological symptoms prefer twitching the lyrium seizure apparently the old same. The same thing again, this metanalysis and the great versus right to reserve profusion. I think these metanalysis favors they use either way where if you're comfortable ACP or RCP, but you know they kind of like a field less inclined to do to use the use that deep hypothermia or rest alone. And this story about the doctor said his group is the warmer temperature safe. Yeah, yeah, they they prove this. It is but probably view cool down the patient that the instance probably don't stay in the ventilator for for a day more or having more transfusions because you're called the only thing that this they're serious to this but you know it's just no difference. And, and going back to how, you know, how we could refuse these patients, you know, everybody's asking say what what are you going to do for you what what are you going to use. So pretty much any article it can be used as a source of inflow as soon as it's not dissected from both or or with past classifications. You can use a family you can use the axiom that they nominated karate, you can use the wreck that you're the kind of relation the Subtavian both sizes, transapical, and I don't know you guys are familiar right now but they're popularizing the right technique in dissections when you you don't have any, any source of inflow or the uses is just kind of directly but in order to do that is just you pretty much got to put a snare around the, the sending a your thing you have to drain the patient, and then then you stick the counter and then you start flowing and start calling so I think it's probably something that is, you know, some people want to venture and do this that they will start, you're going to stop her seeing this somewhere I type but the goal we don't need to forget about it is that having an inflow with it just dissected from both you can create more microfusion because then so that you're going to, you have a dissected denominator you have a dissected axillary, sometimes you can flow and that's what we always test the line and we know won't won't pump and you know it flows are okay and you know everything looks looks fine so you can keep flowing but sometimes, you know you have a high pressure high resistance you're not flowing fine, it means that you're flowing in in the file zoom and then you're creating more more profusion, and that's a problem so you have to do either way I don't know kind of outshed your or change your kind of relation strategy. So, not very common but you know when when when it's an emergency we use femoral artery and obviously this thing, you can see the CT scan and predict it in advance if it's a good vessels to candidate, so you can do that. So, when you expect a long cross clamp time and a long procedure so it's better to saw a graph that is going to, is going to allow you to keep profusely distal down the legs, and not include the femoral artery downstream and you finish at, you know, but 300 is the wrong case with no legs and you know fasciatomies and, and the patient can lose extremely just because of that so I encourage you know that you expecting a long come run in Houston and using a femoral cannulation is better to upfront so in a femoral cannula, the graph. So, what about the axillary cannulation. I think this is the workforce for many, many places is the right axillary, but again, it doesn't have to be dissected has to be calcified has to be, you know, accessible there are some people who are 500 400 pounds and just you know you spent an hour and I want to have to to get the axiaries are probably you know and the patients in extremis, this is not the world that you want to go so you got to you got to look for another source of influence. So, here, the important thing is that somebody asked me one time is like what are you guys did you put a cannula in it in the direct in the axillary well they did it before, and they felt miserable with a lot of problems with, you know, the access, you know, problems with dissections and neurovascular complications so that's why the group of people in a clinic specifically Dr. Savick popularize the song in a graph and since 1998, you can see it right now I think everybody uses a sort of graph. I think we tried guys to make you happy you know because you saw an eight and a big patient and just all the pressure the pressure is 300 everybody gets an arm. Now I think I'm happy with that we can flow but you know we want to accommodate the profusion, the profusion needs and usually depends on the BSA, you know we will choose a 10 millimeter graph and or a millimeter so I think at the end is as you can have a decent kind of results, it's fine, regardless of the pressure that you get in the aliens. So this is what we see you know, as you can see it's full of structures so you know that the regular plexus is right here. So, you, you, you have to, you know, be careful to respect that you can have some some neurovascular, you know, complications I mean in the patient I have some problems with strength in the hand and so on. A lot of people are concerned about hyper profusion of the arm and they tie these to this so they don't, they don't hyper flowed arm, you know, is, it's a complication we're described but usually we don't do it but you know it can happen and you know it's just according to the surgeon's preferences they want to put a tie or tie them around to try to avoid this complication is described. Again, it's the same video, you know, just stick the artery and saw in a graph. So, either way, you know, I think we talk about if you use a profusion, be axillary or inominate artery cannulation there is a fence, I think, you know, you've got to feel comfortable that doing axillary cannulation take a couple of cases just to feel comfortable doing this. They're both they're, they're, they're good that simplifies the delivery of antibodies about profusion and it's a good source of profusion. So the important thing here is that you know you're, you're in the nominate you're putting some partial the carotid so you have to be, you got to do, you know, expeditious way to saw in the graph, and keep the pressures by an efficient higher historic pressure 120 and obviously we do this with the nears and if we know that the nears they're coming down so either way, you will abandon the case or increase the profusion pressure but you know it's just as soon as a partial occluded I think you know 99% of the times you're going to be fine so in this profusion Canada. So there's a more advanced techniques that once you know you try to do the arch you can either way. Once you know the branch techniques first and then you just move the profusion according to what best curing plant is sequentially and the kind of nation of the medical apex also that this is being described you know when you don't have access you know you feel comfortable in a samurai or techniques, you know kind of the apex is always there was described by rubbish at the same guy who started closure with the weave around the sternum for for complication and chest closure. And it's provided the same thing is just as fast and the apex of the ventricle is right there and useful in cases that you know you don't have another another way to candidate this patient so there's a quick video here that said it facilitated me and you know he's putting this setting your technique in the kind of leading putting the wire up and just put your your kind of through the apex and you got to make sure that you cross the left ventricle of tracking and just start profusely through there. The direct that you're the kind of nation is also also that is also that is being done and you know it's just used to appear or the ultrasound try to kind of through looming with the cellular technique and, and either when you use the ultrasound on the table or the tea, and just kind of it and go on pump and then you have to adjust your, you know, your, your, your sequence or how do you want to refuse the brain once you, you know, stop the pump and, and the second tissue and then you get going to integrate or retroverser perfusion. So, there is no difference whatever you use I think that word that prevents this and whatever you use for for this and write accelerators to nominate. And what, you know, we use, you know, when I think of the cooling is the warmness as important as the cooling. And, you know, we also had tried to not to overwhelm the patient. And maintain a gradient and perforate and best in 10 degrees and stop rewarming once you're 36.5. Sometimes we, you know, recently we've done a warm up to 37 but you know we're watching carefully and we never, we never get to that is just to set it up that he the changer higher so you guys can can give us some time to just those patients you know they they drop the temporary free fast and you try to gain a couple minutes so you can correct the quality. So I worked on the surgical adhesives, you know, I think we is very common to use by blues and the implication for profusion is, you know, I think you have to either way when you the surgeon is going to apply some sort of by blue you got to you got to be aware of that and the way you got to stop the pump. And there is some time to, you know, to try it out because it's been cases and four cases that by blue just embolize into the brain and then you have to scoop those things later in the with the help of neuro interventional radiology patient will have a stroke, you know, and it's very important also the same thing when you apply by root to root is important to just stop the, you know, the sound that you have there. So, with this, I just conclude and I'm open for questions and thank you for the opportunity again take for the invitation.