 Thank you, Patrick. It's really a great privilege to be here, and I would like to thank Deborah Adams and Kathy Kiebler for putting this excellent program together. Of course, I would like to congratulate Teri. Teri, after so many years, we made it. Who can believe it? When I first came here, somebody told me that you're not going to last more than a week. And that was about 14 years ago. So anyway, something to be said about this. It's really a great privilege to be again here. And after the feedback, when I was talking to Kathy and Deborah, we thought that we'll try to make this talk very practical. And I think this is very important because the way that they think about it is that whatever I have learned from Dr. Koseli for the last 14 years, it's really my job now to be able to teach you what I learned. Because the important point here is that if I'm the patient, I would like from you to be the perfusionist so you can have great results and great outcomes. So first of all, I would like to congratulate you for the 50th anniversary for the Texas Heart Institute School of Perfusion Technology. It is really a great milestone. And you have to be very proud for it. This is my disclosures. So the things that we're going to talk about is how we protect the visionals when we do thoracic abdominal aortic surgery and how we protect the brain. So they are open for abdominal operations, as most of you have actually encountered and have seen. It can be a very extensive operation and can carry significant morbidity and mortality. And the reason is because it is a distal aortic ischemia. And this distal aortic ischemia can manifest as complications of the kidneys as well as the visceral vessels and the visceral. Like bowel and, of course, the kidney and the legs. The instance for a post-op kidney injury can range from 12% to up to 50%. And up to 17% of the patients will need amodialysis, which may decrease, as we know, the long-term survival. The mesenteric ischemia in this kind of cases is about like 3%, so it's not a lot. But what happens is, even though it's not a lot, the mortality can be up to 60%. So let's see about the different agents, as well as the main things that we use for a thoracic abdominal aortic aneurysm repair. The first thing that we use is the left-hand bypass. That is the most common way that we deal with the thoracic abdominal repairs. The second thing is the cardiopulmonary bypass with a hypothermic circulatory arrest. And then the agents that we use, as I'm going to show you, is the cold renal perfusion, selective visceral perfusion. And then we're going to talk very briefly about how we manage surgically the renal and the visceral arteries. So let's talk about the cardiopulmonary bypass. This is most of the centers, actually quite a few of them in the United States. They do use cardiopulmonary bypass with a hypothermic circulatory arrest. Now, we don't use this quite often. The times that we use it is when we don't have a clump site here, and the aneurysm is very big, where we have to actually use a cell caress. Now, what is the easiest way to establish cell caress? This, of course, as you're very well known, is via a femoral artery and femoral vein. Sometimes we can actually use the IVC when we are open. But again, the whole idea here is to make things reproducible so quite a few people can use the same technique. So the easier way actually to use it is via the common femoral vein and common femoral artery. And then after place the patient with cardiopulmonary bypass, we drop the temperature down to 18 degrees or 20 degrees. And in addition, we can use a drainage via the left inferior pulmonary vein, where we can relate the edgier. Let's go on into the left her bypass. So the left her bypass, what it is, this is a closed secret, is a temporary bypass that goes from the left atrium into the descending thoracic f-mortiaorta. And the whole idea is to provide blood into the visceral kidneys and the distal f-mortiaorta. And what does the left her bypass does is that provides isothermic self-oxygenated blood to the distal aorta. And actually, this is being performed during the proximal f-mortia nostromosis. And especially, we use the left her bypass for 1, 2, and sometimes 3 type 3 repairs. And we can see here is that we have the inflow canula via the left inferior pulmonary vein. And then the outflow canula into the descending. This is a descending thoracic f-mortiaorta. And this is the cold crystalloid circuit. This is a completely different circuit, as you know. So now this is the left her bypass circuit. And the flow is said to be 1,500 to 3,500 ml per minute. So the left her bypass is on during the proximal anastomosis. And this is what we call the protective ischemic time. We have found from studies of the past that left her bypass can be protective for the spinal cord. So and this is one of the reasons we actually why we use it. Let's move into the cold renal perfusion. So the left her bypass is completed after the proximal anastomosis is completed. At that point, the rest of the orta is open and we proceed with the repair. Now how we diffuse and how we actually what we do for the kidneys and the visuals. With the kidneys, we use a cold crystalloid circuit. And this is a standalone roller hair pump circuit that goes direct into the left and the right kidney, as you can see here, with the French, with the French, with the nine French and with the Prue. Regarding the perfusion, we can use it. I've shown this in multiple studies of the past. We can use blood, cell in rigorous lactate, acetate, plasma light or custodial. Now, as you know, for the last approximately four years, maybe four year plus, we started using crystal or custodial. Before, we use a ringer lactate with a solar medulla as well as monitor. So in case that the custodial is not available, you can still use and have great protection by using the ringer lactate solar medulla monitor. How we do it, initially, we give a bolus at 300. And then we actually continue to give another like 200, 300, every 15 to 20 minutes via these emollient catheters. Regarding the visceral perfusion, so what we do with the visceral perfusion and the purpose is to actually mechanically perfuse the celiac axis as well as the superior mesenteric artery. And the whole idea is to minimize the hepatic ischemic time as well as mesenteric ischemic time. Now, how we do that is that after the left her bypass is off, we still have the circuit. And we have a Y branch, as you can see here. And this Y branch is off the rerouted left her bypass circuit. And this Y branch, we have two nine-flange fluids that goes into the left, that goes into the superior mesenteric artery as well as into the celiac and superior mesenteric artery. And we flow approximately 4 to 500 ml per minute. One of the advantages of the visceral perfusion is the potential reduction in the risk of postoperative coagulopathy and bacterial translocation. And there's no really any apparent additional or additional risk of doing it. And it's relatively easy to perform. Now, how we manage the inner visceral arteries. And this is a little beyond the scope of this talk, but just very briefly, we can do an endocrinectomy bypass graphs, or we can use balloon expandable stands direct into the vessels. How we do the operation, in case that we use individual branch crafts, we do the proximal anastomosis first, the distal anastomosis for perfused legs. And then we do this individual anastomosis after we have perfused and we have established flow distally into the legs. In case that we do a patch anastomosis and we don't do the individual crafts, then after we complete the proximal anastomosis during the left hip bypass, then we proceed with the intercostal anastomosis, intercostal artery patch anastomosis, then the visceral patch, and then final, you know, the legs. The most common configuration is actually the celiac SMA and the right renal together. When we do this anastomosis, then we perform the distal anastomosis, the legs, and then the final one is the left renal where we do this separate. So in summary, the way that we protect the renal and the mesentery circulations during the thoracic abdominal or the cannurism repair is with the left hip bypass or with the cardiopulmonary bypass with the hypothermic circulatory arrest with the cold renal perfusion, visceral perfusion. And of course then we decide regarding the surgical management and the expeditious repair. Again, this kind of procedure is a team approach. It is not really one person's operation. As you can see, you're all into the entire, during the entire procedure is extremely important. Let's switch gears now and let's see how we protect the brain during a proximal arch operation. So the primary goal here is to preserve the cerebral cognitive function. The brain tissue has a very high metabolic rate and is very sensitive to ischemia. These are the main cerebral perfusion strategies. One is a deep hypothermia. The other one is the integrates cerebral perfusion. And then the other one is the retrograde cerebral perfusion. Of course, as most likely know is that there is some debate about what is the optimum brain protection strategy during the arch surgery. Now, been here for the last 14 years, we haven't really used retrograde cerebral perfusion. But still there is a few parts in the country where retrograde cerebral perfusion has been used. Dr. Safi and Dr. Estrella at the University of Texas, they do use retrograde cerebral perfusion with excellent results. Dr. Giraldi in Cornell in New York is also using retrograde cerebral perfusion with excellent results as well. And how about the deep hypothermia? This has been used extensively from the Yale group. And the results that they have are actually excellent, especially when the circulatory arrest time is short. But we can see here these that when the circulatory arrest time is beyond the 15 minutes, you can see that the stroke actually goes up to 16% versus day 1.3 when the circulatory arrest time is actually short. The ways that we think about it is that if we have to do any advance or any extensive arch replacement and reconstruction, we want to provide the brain with what we call the metabolites and certain other agents in addition to the hypothermia. You can see here, this is the usual trans that was actually published from the Yale Equity Group in 2014, where you can see the trends in Europe as well as in the United States. Most of the people actually, they use, and we can see it, 45% anti-grade cerebral perfusion. But there is still a lot of centers where they use deep hypothermia or they use the deep hypothermia in combination with the retrograde cerebral perfusion or in combination with also anti-grade cerebral perfusion. And now, what is our strategy? Regarding the cannulation strategy is axillary or anominal cannulation we use as arterial inflow for a cardiopulmonary multi-bypass. And we have actually extensively published on that and how we think about how to cannulate. And this is when we have a primary repair, how we think if we're going to cannulate the anominal versus the axillary or in case that we have a redo operation where we have to think about the proximity of the structures into the sternum. And of course, which are the cases where we proceed with direct aortic cannulation. Now, let's go through certain simple steps. After we are on circulatory end-of-the-arrest, we snare down, this is where we have actually cannulated the anominate. So at that point when we snare down the tourniquet we give perfusion into the right side of the brain. And then we place a second cannula into the left common carotid artery. If the question is, why do we need to have bilateral anti-grazeria perfusion is because we have found again with other studies that we have done in the past that because of the sycophilis that can be incomplete we have actually better results especially when the ACP time is actually more extensive. Now by saying that there's other groups in the United States such as the Emory group where they have used the unilateral seroprefusion with actually very good results as well as some other groups in Germany. Regarding the temperature of multi-management, we like to go around like 24 degrees and with Celsius. We have actually multiple publications with regards to the temperature management. And when we talk about moderate hypothermia according to the concessions that were documented quite a few years ago, moderate hypothermia is actually 20.1 to 28 degrees. And for all the years we have actually classified that with different studies that we have done in the low moderate hypothermia or the high moderate hypothermia. But usually if it is something that is relatively simple we go down to 24, 25 or sometimes 26 degrees. I think it's something that we anticipate that is going to be a little more complicated. We like to be close to 23 or 24 degrees. And actually some of these studies like this one here or this one you can actually recognize one of your colleagues named the Erathina Ramu that she was actually very instrumental of helping actually putting some of this data together. So our preference is bilateral anti-gray cerebral perfusion with moderate hypothermia. And then of course after the anastomosis is completed we go back to our full flow. So in summary, the way that we prefer to do it again this is not necessarily the best way but it's just one way that work for us throughout the years. And what at least in my experience I have seen here for the last 14 years been participated in quite a few hundred actually of cases and would countless hours in the hour. We refuse the brain at the rate of eight to 12 cc per minute per kilo. And we maintain a perfusion pressure at 50 to 60 millimeter mercury. And regarding the temperature we keep it around to 23 to 24 degree of modic Celsius. Again, I would like to thank you for this opportunity is really a great privilege to be again here and talk to you every year. Actually I'm looking forward for this invitation and Deborah and Kathy, thank you so much for that. And thank the entire organizing committee for putting this excellent program together. I would like Terry, I would like also to thank you again and the whole school of perfusion is I consider most I can see a lot of familiar faces around and they consider you my colleagues. Thank you for your support for the last 14 years and it's really a privilege to be here.