The Retrograde Approach Dr Sam Farah and Dr Yogeesan Sivakumaran

In our first non technical episode we discuss changes in life from going from trainee surgeon, to surgeon.

In this episode, Yogi and Sam delve into discussing thoracic aortic stenting.
Podcast 26 - Thoracic Aortic Stenting

The first endovascular thoracic aneurysm repair was performed by Dale in 1994 - with the use of custom designed graft with a combination go Gianturco Z-stents and polyester fabric. It was not till 2005 that a commercially available thoracic graft became available

The introduction of TEVAR has added further dimensions to open surgery by creating treatment options not previously available in treating aortic dissection, thoracic and thoracoabdominal aneurysm and traumatic injury.
In elderly patients, TEVAR has replaced open surgery and medical management for problems confined to the descending thoracic aorta 

Indications
Aneurysmal disease (>5.5cm) - true degenerative aneurysms vs. post dissection aneurysms vs. mycotic vs. pseudo aneurysms (Zone 2)Complicated acute aortic syndromesBlunt thoracic aortic injury Evolving techniques - management of dissection aneurysms in Zone 0/1

Approved Devices 
Gore TAG Conformable Thoracic Stent GraftMedtronic Valiant Thoracic Stent Graft with Captivia Delivery System  Cook Zenith AlphaEndospan Nexus and BoltonTerumo Aortic Relay Device  

Pre-operative Considerations
How do we do it?
General consideration - vascular access, iliac vessel diametersFor suitable iliac and femoral access vessels are requiredSmall diameters 7mm in diameter to accommodate a 22Fr sheath and >8mm for a 24 Fr sheath Alternate options - iliac conduits or endo-paving Landing zone General role >20mm of normal appearing aorta for an adequate seal zone - proximal and distal Longer seal zones is considered adequate for most cases, longer seal zones are preferable in angulated aortic segments to decrease the occurrence of Type 1 end-leaks and device migrations Anatomical boundaries include the left subclavian artery and the coeliac artery should be considered aProximal and distal aortic diameters Ishimaru’s Classification of Landing Zone Coverage of the left subclavian artery is generally well tolerated because of a rich collateral network - however routine exclusion should be discouraged because experimental and clinical evidence suggest that not all patients tolerate the occlusion safely The left subclavian artery is vital for perfusion of both the spinal cord and the brain via the left vertebral artery through the internal management and anterior intercostal branches When left subclavian coverage is considered, pre-operative CTA imaging should assess latency of the right vertebral artery, connections to the Basilian artery and the COW in order to identify patients that may not tolerate left SCA occlusion As we approach Zone 0,1 or sometimes in 2 supra-aortic debranching may be necessary Open CTS vs. CCA-CCA-SCA, CCA- SCA, chimney stents ImagingCTA with fine slicesSizingOverzealous device sizing is associated with graft infolding, gutter formation and aortic neck degeneration due to excessive radial force \Aortic diameters are measured with orthogonal reconstructions...

In this episode, Yogi and Sam unpack and explore the highly anticipated Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia (Best CLI) publication. This study has sought to clarify questions that had been raised in regards to the optimal treatment of chronic limb threatening ischaemia in the era of modern endovascular treatment.
https://www.nejm.org/doi/full/10.1056/NEJMoa2207899

In this episode we discuss the recent sitting of the vascular surgery fellowship exam with Dr Vikram Iyer. He shares his experiences and reflections on getting through the final hurdle before becoming a fully qualified vascular surgeon.

In this episode of The Retrograde Approach, Sam and Yogi take an introductory look at peripheral arterial disease.

In this weeks episode, we are joined by Dr Leonard Shan. A vascular surgeon working at St Vincent's hospital in Melbourne. Dr Shan is currently completing a PhD through the University of Melbourne, and joins us to talk today about balancing his busy research career, with his professional career and his home life.
Dr Shan is an academic vascular surgeon and honorary senior fellow in the Department of Surgery at The University of Melbourne. He received his medical education at The University of Melbourne where he graduated with honours. Following vascular surgical training at multiple centres in Melbourne and Auckland, he joined the vascular staff at St. Vincent’s Hospital in 2020.
His academic interest is in outcomes research where he has helped to improve the understanding of patient- reported outcomes after intervention. He serves on the editorial board of the Annals of Vascular Surgery and is a regular reviewer for the European Journal of Vascular and Endovascular Surgery and the Journal of Vascular Surgery. Leonard is currently undertaking a PhD on the patient-reported outcomes and economic evaluation of arterial surgery with Professor Peter Choong at The University of Melbourne, where he is the recipient of an Australian Government Research Training Program scholarship.