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Okay, So just a reminder about the social media for the six PM Siris on Instagram, Facebook and Twitter for us to follow to keep up to date with the upcoming presentations. And often they have some questions on there and then a shot out to the sponsor of the six PM Siris MG year. So I'll be discussing a bit about vascular surgery, and stuff is just the start of practice off specialty. Then I'll go through overview off. About four conditions will start with a bit of a question to introduce the condition. And then we'll go through how they present some features on examination, how to investigate these patients and then some off the roles of the management. So it it's not What is it? What is vascular surgery? Vascular surgery is focused on the diagnosis, and management of disease is affecting all parts of the vascular system arteries, veins and lymphatics scope of practice. Excuse the Caries and intracranial baskets trailer that's managed by cardiothoracic and neurosurgeons. Respect me. Um, yeah. So for our first case, um, started the question Which of the following is the most common and important risk factor for an aortic dissection? a bicuspid aortic valve. Be connective tissue disorder. See system a systemic hypertension D Turner syndrome and he aortic surgery. We'll give a minute for the question. Okay, so, yeah, I think most of you got to write. Quit around. Answer that. The most important is the stomach hypertension. Uh, all of these are actually risk factors for aortic dissection. Bicuspid aortic valve is associated with a dilated A standing order so you can get a dissection. They're connected. Tissue disorders obviously can involve the intimate of the aorta so you can get that sections there, too. In a syndrome as well, there's an association in the aortic surgery can cause. And it's more flat, which again can lead to a section. But out of all of these, the most common and most important to manage is systemic hypertension. So an aortic dissection is a life threatening emergency and defined by turning a tear off the inner layer of the aorta. The Tunica intimate. So you can see here on this picture. Basically, you've got your normal, healthy vessel, and then the first the beginnings of a death section is a small tear in the interim, which then allows blood to enter into the clinic a media, and it causes this definition of the vessel, which then eventually you can rupture. Uh, say you've got three sort of causes off a dissection, the atherosclerosis also leading to insult tears. I mentioned you can get disruption of the very severe sore, um, which causes an intramural chemo timer, which again will lead to a bit of a distortion of the intimate and further damage. And then there's also your in your path, like you to know the insult cares. So for exams. In terms of erotic a section, the most important thing to know is the last. If it cations for an aortic dissection, there's two main classifications, your Stanford and the baking classifications. So ah, staph. It is quite simple. You've got a which is your proximal or your face in the water. And then B is you're descending aorta. If you've got one that involves a setting and descending them that falls under a, then your debate a classification. You've got a tough one, which makes up the most common that involves both. He's sending out the seven daughter Type two, which is just your body sending and then tap through, which is you're descending. And then I found that a little pneumonic bad helps you just remember this. So be is but a cyst. Any anti is descending for 12 and three. So as I'm already mentioned, the most common and important respect a systemic hypertension, a severe, severe and sudden increase in blood pressure poses the greatest risk for development off a a lot in that section. So things like weight lifting or energy drinks or cocaine, things that cause that sudden increase in blood pressure. The classic presentation that the patient will describe is a tearing or ripping pain in the chest. On your examination, you may find pulse deficits between the limbs, depending on where that that section actually is. Uh, then also, if you're dissection, extends to your aortic root, it's characterized by an aortic regurgitation happens. So imagine these patients on the chest X ray. You'll see some widening off the mediastinum humor thorax if there's a rupture. Ah, CT. With contrast, is the definitive test, and it's usually only in stable patients that we performed this investigation. MRI is the most sensitive method for diagnosing aortic dissection. The specificity is similar to that of CT, though this wouldn't really only be if you've got a small that section or you're not really sure if we need to further work up in a acute setting where patient presents with a severe tearing sensation and unstable this is a ruptured. You're not gonna have time to perform tomorrow, then echocardiography can also be useful. You've got to transesophageal, which is more accurate than transthoracic. Uh, but transthoracic is more useful for visualized in the he sending dissection. As with ultrasound, it's very operated dependent. And yeah, obviously different people can see different things. So this is a just a X ray off the oven aortic dissection. So here we can see the widened mediastinum with deviation off the trickier as well as the actual entire cardiac shin. And then the only the only other side sign, Um, a ck. Obviously, if there's a rupture, you'll see a human thorax and 11 of the sides. So your management you start with your A B. C's for the patients, especially if they're stable. They need to be appropriately resuscitated. The first line management for aortic dissection is to try and get that BP down to prevent any further dissection. So you use IV maybe two blocks for this in Taipei and B and then following this their surgery for Type A, which is your debate he wanted to. Surgical management is selectively chosen for complicated types. Three dissections That really depends on the surgeon. Your pain management in this is okay. It should be your first line of choice, Uh, and then surgical treatments. What happens is the area with tears, usually resected, and that it's higher section is replaced with synthetic rock. But currently there are some intervascular techniques which are emerging is the preferred treatment for especially for descending aortic dissection when it involves the A. Sending on the actions becomes a lot more complicated because you've obviously got your vessels emergent off the arch of the aorta. See here on the left will see an A sending graft, which doesn't involve any of the branch in those vessels. So that's simply that the section has been cut out. The graft has been put in. Then, on the next picture, we see where the thieves als I involved. So usually a portion of the vessel that branches off is also replaced with the graft, so we move on to your case, too. In 85 89 year old man presents with hypertension collapse, and he's found by the stuff from the toilet of his care he has more around and hey, unable to give a clear history. He had suffered a cardiac arrest in the ambulance, but it's since been resuscitated, and that has a BP with a 95 systolic. He hasn't abbvie asleep. Probable Triple A. What is the best course of action? Is patients so immediate? CT scanning immediate laparotomy. Immediate in the vascular aortic aneurysm repair or palliation or not, I'll give another minute or so for this question. Sorry about that. It wasn't getting Yes, sir, I think this may be surprising because I see there's some mixed opinions. They basically for the patient. Palliation would be the best management. So because this is a frail elderly patient, obviously with limited, you know, mobility and probably quite a bit of comorbidities a swell. He suffered a cardiac arrest already, which means the the immense amount of pressure that surgeon will put on this patient is probably going to fail. That's the functional outcomes would be very poor palliation is best option. And if you've decided for palliation, then there's not really any need. Teo. So the patient, any forms of imaging, so yeah, we'll discuss, um, aneurysm. So basically, you can get aneurysms in any vegetable body in terms of your aorta keeping your thoracic or abdominal aneurisms cerebral aneurysms in your back. Femoral and popliteal scan will have aneurysms begins mesenteric artery aneurysms, splenic artery aneurysms. And then you also get pseudo aneurysm, which forms that sort of injury. That was all of these aneurysms will present with a slightly different presentations, obviously if depending on the organ that they ultimately effect. So here's your types of aneurysms. This is a healthy vest on the left. Then you've got your two true aneurysms, which are secular and future form. So you're secular, the most common in several aneurysms Where you get from like the berry aneurysms on the infusion form obviously involves both both sides of the same of the vessel, causing a symmetrical widening. Then your dissection aneurysm, which we've already discussed with blood flowing through that infected insulin into the media. And then you've got a false aneurysm where the layer of the aneurysm is made up exclusively off adventitia, whilst a true aneurysm has all three layers which make up the wall of values. So this picture is a treatment pseudoaneurysm. Um, like I said, pseudoaneurysms format areas off injury. This is basically a patient that had multiple, um, blood gas sampling from the radio artery, which has led to a pseudoaneurysm forming asymptomatic patients with these small pseudoaneurysms can be managed conservatively if they become symptomatic, or it's a very large aneurysm like this one. You may consider thrombin injection under ultrasound guidance, and then, if they're very large, you may proceed to open or intervascular a pen. Like I said, that depends on the size of location of that, then Triple A your abdominal aortic aneurysm. Eso your normal abdominal aorta is, but is it considered less than three centimeters? Anything more than that is considered a triple A eso. There is obviously a a way up between surveying these and doing surgeries. Basically, you need to decide on a risk off wrapped job. Triple A, because of the surgery, imposes quite a big shock on the body like we were really mentioned, so you need to be sure that This is a patient that may rupture within the next few months, so we need to do surgery, and they would have to accept the risk. It's basically a balance between the skin benefits. So in the you came in, undergo screening from 65 years old on there is a 1 to 5.4% prevalence. A small tablet is considered anything from 3 to 4.4 centimeters. These patients, once they're diagnosed, undergo annual surveillance on, and they're advised to modify their life. So then medium Triple A's are anything for pain factor 5.4 centimeters. They then undergo three months. The surveillance, Um, and they also advised to modify the lifestyle and then a large Triple A is more than 5.5 centimeters. Is that the highest risk of rupture? And they are referred to vascular surgeon for surgery planning. Uh, the current surveillance method is a CT scanning CT Angie gram, but there is a moving out Teo do ultrasound scan for your patients, obviously, to reduce the contrast into the body as well as the radiation dose of the patients are getting, especially when they're under three months in surveillance. That ends up being four scans a year. So your risk factors for Triple A male patients old age smoking, obesity, hypertension, diabetes, currently heart disease and a family history in terms of your lifetime. On lifestyle modifications, you tell patients to lose weight, starts and exercise and then obviously stop smoking in your medical management. Our patients that are gonna be under surveillance will need to be controlling the comorbidities that make up their risk factors and then managing these patients surgically. Your options are either evil, which is endovascular aneurysm repair or open repair. So the picture on the left toes and repaired the patient is undergoes a midline laparotomy. The aorta is access, he aneurysm is dissected open, and then a synthetic craft is in place. Ivar, which basically goes through the vessels in the femoral arteries, both sides that involves no open surgery since obviously has a less taxing on the patient. A stent is deployed inside of the artery under imaging guys, so you have even the new of the two procedures, and it uses an and a graft. As I mentioned, it's the less traumatic procedure, and you access if I it's normal heart trees so obviously the sounds like a great procedure, but there are some contraindications, and some patients aren't able to get this procedure. So for a even you need approximately neck, which is basically the distance between your renal arteries and the beginning of the aneurysm. You need more than 15 minutes is there to perform? Even so, if you're approximately less than 15 minutes is this patient will need an open repair if you're infrarenal, aortic diameter is more than 26 millimeters. So quite a big aneurysm already. Then that was need open. Um, let's see if this aneurysm extends all the way to the for X, that's gonna need to prepare. Then you want to need to accept a special excellent relax internal and external, because these are your except points, and also you've got these two limbs that extend into them, which holds the graft. In place of prevents. It's slipping, so you need to make sure that these areas are two disease. Sometimes there is a concurrence, and your is, um, one of the attacks, but so long as it's not too big, then that's fine. Obviously, it can't be too stenosis, cause you need to put quite a lot of instrumentation. Three there. Uh, if the patient already has in a graft in the grinds, they will need an open repair. And if there's an evidence of Retroperitoneal Neek on CD, so basically that patients have been already ruptured Triple A, then you'll need to do an open repair. Then there are some relative contraindications. So if your vessels are quite tortuous, then some surgeons they are to not do investing repaired because you do risk perforating that I like vessel on possible neck and elation. That's basically just the neck that the aneurysm, if there's more any more angulations becomes more difficult to put that graft in place. If you've got bilateral common and internal like aneurysms against something depend on the overall still nicest off the artery and how much access you do have yeah, patients undergoing even have a shorter hospital stay, which is great and lower perioperative mortality. In the long term, though, the survival advantage balances out between open and evil, and most of the reintervention rates are it occurs in give our replacements of you. This is because graft slip or the ends up becoming occlusion of the renal arteries later on. It they they need of his, he reintervention. Because there's a graft already in place. That's reintervention has to be an open procedure, so open repair is more suitable for men under the age of 70. This is because, obviously, they're probably have better reserve to stand surgery, but also because this they have a longer life expectancy afterwards. Safety worried about graft, slippage and things. The longer the patient lives, the more chance this has happened. So really, with evil, we do it in patients holder than 70 because we hope that the graft will exceed their life. Expectancy on 2025 are makes up two thirds off aneurysm repairs in the UK So this is just a shows you the sciences and the growth rates so you can see that each sort of group has a rate of growth per year. Um, and then associated rapturous so 3 to 3.9 that's a small aneurysm is no rupture risk, and it's got quite a small growth rate. Then when we get up to above five towards six, you've got 3 to 15 10 to 20%. That's where it starts becoming ah much bigger risk, so it's better to undertake the risk of actually operating on the patient. Okay, so this is a slight actually presented under the emergencies or presented on Wednesday. But this just shows a ruptured Triple A on the NGO. Under CT angio there can see the Coast Guard walls of the aneurysm. Basically, approximately 50% of patients with reputable age reached the hospital alive and off those for me to the hospital and 50% it's survive. So you have a 25% survival rate. And that's what five A rate is only to survive for procedure itself and not all the comb abilities and problems that may have perceived the intervention. Occasionally, we get patients that come in with some abdominal pain and the CT scan, and you found a Triple A. The patient may be stable, but you still have to manage that patient exactly the same and take them for emergency manager. Just take a quick pause here, and I'll have a look at the question. See if there's any. Okay, So if patients have a 2.9 cents need to triple pain, will they be screened again in May 2 years Um, yes. So 2.9 centimeters is not a triple A, so they don't get any routine screening. Um, I'm not sure about the obviously routinely screening people later on at 65 years. Although if you're gonna have a an aneurysm, you probably have already have some daily allocation. So I think obviously that will go down a zone or Mel's aorta, Ms. Patient. But if they develop abdominal pain or some sort of symptoms later on, then obviously some reintervention reinvestigation would be done. But there would be no routine scanning in these patients. Cool. Okay, so third case, a 45 year old man undergoes surgical excision of a carotid body cream. Histological analysis is most likely to demonstrate which of the following in this patient a paraganglioma be fibromatosis collie. See each one. I'm I deal a poem or in your, uh, give him in into this question, Yes, we're going to be crossed that most of the cancer is a which is paraganglion. Remember, that's the correct answer. So carotid body tumors are the commonest type of head and neck here again on that we see. So it's just some background across the body is a chemo receptor, and it's located specifically in the adventitia at the bifurcate, one of the common carotid artery I was into internal and external carotid arteries. On the function of the carotid body is to monitor blood pH PCO to period, too, and that there are modulates cardiovascular respiratory function and does this basically by changing the sympathetic tone of the vessels, and it's able to then adjust BP. So, uh, uh, body is a rainy a plasm, but it makes up 50 to 60% off, hitting her again your numbers. As I said, it's most common on, and they developed within the adventitia at the medial aspect of the cross. Perfect cation. They're three subtypes of carotid body tumor got sporadic familial and hard plastic. So sporadic is the most common scene in 85% of cases. Then, obviously next common, you're familiar. It's more common in younger patients. If you get a younger patient, this is more likely to be here in a heritage condition, so they inherited in and what is only dominant fashion. They're associated with M. E N. Two. And to be your fibromatosis one cheaper sclerosis from hip elinda disease and Connie try it on then. Lastly, your hyperplastic carotid body treatment is usually common in patients with chronic hypoxic. So these are patients with a long standing COPD, or cyanotic heart disease or patients at a high altitude usually develop. This happened so these patients present with a slow growing around neck mass at the level of the higher dose on anterior to understand how to masturbate on history. Besides the mass, these patients may be completely since asymptomatic, if they do develop any symptoms there normally of nerve compression. So you gets cranial nerves 9, 10, 11 and 12 involved because they passed very close or within the crowded chief, then your spinal accessory and recurrent laryngeal nerves cannot be involved. Patients may have symptoms off excess catacholamines because the's carotid body treatment sometimes, especially with those in the entire Juma's. They secrete catacholamines. So these patients were paroxysmal have attentions that have attention that comes in episodes of very hard. They may have palpitations and diet frees, and then the main symptoms of mass effect of the actual Sure, so that may present with pain or police is the tone would just fade. You, uh, very rarely the trees get big enough to actually include on the airway, and because of the cartilage is the area will be protected. Before you start getting something back to stage on examination, you may hear a bruit over the the the mass. These masses typically are able to move horizontally, but they're unable to move vertically because of that attack. From that defecation on, then obviously, you may examine for them for signs of the nerve involvement. As I mentioned, So the work up for the patients on one C. We'll do your routine bloods specific test for this is your urine test means, uh, which may be raised. We'll do a Doppler ultrasound to look at, float through the karate. It's bilaterally, and then compare on CT. You may see a half a vascular tree in here, Mariah, you got is your gold standard investigation and you get something called the Salt and Pepper appearance, which I think you can see a little bit of this image that's basically just that's flattering of black and white dots like in the mass biopsy of these messages not indicated on, we only do. Finally, the aspiration. If imaging becomes inconclusive, and history. Everything been, it's certain. So here's some more imaging off cross body treatments. This is a CT image with their A three D reconstruction with changing the mass that the bifurcate a shin, um And then on the right side, there's this the top image there. It's called a liar. A y R E. It's an old Greek instrument, but basically the sign that you see on angiography is called the Liar sign. So you sort of just get a replication of this instrument in terms of image. So the surgery for this you you dissect over the mess that set all the way down. You always have to be cut the very careful of the vessels. You then isolate your common, um corrupted as well as the internal and external. And you put these slings around the vessels. So you you're able to lift up without causing any damage on the vessel, and then you slowly that sick to the adventitia and try and get through the vessel. This is I'm going to see a very delicate surgery because you don't a encroach into the medial since most of it causing damage or bleeding. And then the classifications are practically two. News is that shambling classifications so it categorizes into for your top one is a human less than four centimeters that doesn't entirely surround the vessels on day excision cares really quite easy talked to our larger four centimeter treatments. Which part of the surrounding bone completely certain other of the two branches. These are obviously a little bit more difficult. Then it to a is you get infiltration off the a corrected vessel. Um, with the mass morning four centimeters in size and then three b is where you've got actually infiltration off the sit around vessels with basically, you need to resect a part of the vessel and then you put it in her office. Thinks least a very true consider to do. I can move onto the last case. This is a 78 year old man who presents with left sided rest pain in his leg and a non healing arterials on the same leg. Imaging shows normal right leg vessels. On the left side, there is a long infusion of external iliac artery that is unseats. He has a significant cardiac history. What is the most appropriate treatment option? Femoral distal bypassed angioplasty embolectomy, Femara, femoral cross over the graft or an amputation. Okay, so I think what a mixed extends to that once is the correct ones, for there is a federal federal cross over growth. I see a lot of answers were for family distal back because that's wouldn't the indicates in this patient, because I just think his I lack is affected so you can't get blood from above too supply below. Um, and your last e in this patient is completely infusions. There something work in May? Let me. The patient doesn't have an ambulance, so it's not relevant on an amputation. You maybe later on. But that's a bit of a rush. Digital. So you have Femara femoral process. The graphs are options with Aaliyah conclusion with significant core mobilities and a healthy contralateral vessel. Um, so obviously you can do things like I was a low femoral, but that's a much more intense surgery. So patients with co morbidities the less invasion you can do the better. This patient had a healthy right inside, so it's easy to just take flow in the right femoral and attach it to the left. Usually the patients really present with a completely healthy vessel on one side with such severe disease on the other is usually sums disease on the one side, and you have to careful that you're not damaging the one side to to be able to supply the other because you'll end up, uh, running blood supply to both legs and, obviously, patients going to end up with bilateral amputation. So for peripheral vascular disease, just some history that you get from the patients may get the risk factors. So hypertension, diabetes happen lipidemia obesity and in a smoking history. So there's a thing called burgers disease, which is young patients who present with quite a significant smoking history and perfect vascular disease s. Obviously, these patients are too young to have developed such severe atherosclerosis, so it's usually smoking. History is landline core, and if you stop smoking is really the main treatment for this, and you can actually reverse disease by substance. Uh, then the patient may present with some incidents of medication, which made progress to rest pain on. Then they may get parasthesia. On examination, you're just gonna look for your six p, so you've got paying out of keeping with the presentation of paralysis of women Pulseless nous got your personally cold over your portal. A thermy a This power of the limb and then is also parasthesia. He's all quite late science. If you if you have a patient presented with you know all six of these signs, it's it becomes quite urgent to get that patient reperfus, she states patients with peripheral vascular disease. We use one of two classifications. You've got to rather fit. Or Fontaine uh, they followed very similar descriptions, so we'll just go with Fontaine from now. Eso Fontaine One is a patient that's completely asymptomatic, but obviously some imaging or whole Doppler ultrasound has proven some disease to a is mild chronic a shins, the able to walk a fair distance. But you know, after a specific event distance, they start getting symptoms to be my record of medications. That distance becomes less and then to be severe claudications, so they're not able to walk much without having to stop for rest on. Then three. That pain at rest your patients was plantain for start having ischemic forces of the digits of the foot with just small amount of tissue last and then when you start getting things like ulcers or large doses or gangrene, then that for the time for because that I mean yeah, well, that's also for Unfun Tane. That's a four be. But then, in rather, for better that's separate. Has separate group on it. So so indications to take these patients to surgery. If you revascularized, they're lower limbs. Obviously, if you've got intimate and cloudy, try dication as long as it's, you know, creating quite a lot of problems in the life. Then you take him to surgery. If it's not disabling, then you would consider maybe this is not really an indication, but it in perspective or their everything else that you may decide to take them. Patient's critical sq me a. So you, those sixty's patients that present with ulceration or gangrene they have to go. Uh, obviously, when once we progress to things like angry we made, um, not revascularized these patients, we may consider amputation instead, clinically assessing these patients, you'll do your full examination. You look at all your perform pulses and obviously evaluate them. You're gonna do your ankle, break your pressure index measurements, and then you'll do duplex, ultrasound and then, um, angiography. Standard is not really done. It's usually CT or MRI, and it's only performed if intervention is being considered. If you decide that does make it gonna be amputated. You don't really do this imaging. Or if this is a patient that has had a doctor that showed asymptomatic disease, then you're not gonna go as far as doing these imaging modalities. So just to cover angioplasty, the artery must be accessible. The lesion needs to be relatively short, and they need to be reasonable distal vessel runoff. Do you need to know that they're the rest vessel distal to the conclusion is healthy and can accept blood Once you, you do angioplasty. So if you've got a longer lesions, they may obviously are not amenable to angioplasty. But you can't do a thing called some intimal angioplasty. So that's this picture below. Basically, you use a a wire to access the sub in small space, and you you create almost your own back section down below the vessel, and then you re enter the vessel below the occlusion and this allowed blood to flow goes to bypass the occlusion. So then surgery you would move on to this when the the angio or angio has failed or it's not suitable in your patient on my part. Surgery involves bypassing the effective segment by using a graft run through above the disease to below that sees on. The ideal scenario would use pain. You would use either one of the veins around the area or you would use the long Stephanus. Made importantly, though, if you use long Stephanus pain, you have to. Once you've accepted at your your vein, you reverse it. And this is because of the valves that are present long. Stephanus makes you need to go against the flow so they obviously don't create a cruise in themselves. Uh, not all patients are able to have a vein graft. Prosthetic material sometimes use this. Has they recommend five year patients your rates? Obviously, they may include later on on. Then some surgeons would say, Use the, um, use the graft, the synthetic graft over a vein so that you can spare it that the vein for other procedures in the future, especially if the patient has shown multiple areas of disease and I've got a good, healthy events, then you may consider using your synthetic graph eso the year, then in terms of distal graphs, This these are craft, you know, much further down the legs. So be under a popliteal area. You would. There vein is definitely superior of a prosthetic material. The prospect of material used is called PTFE, which is probably tetraferon mean. Um, yes. So your veins a lot more superior because you do get occlusion much quicker off prosthetic material with distal segment grounds. When you gonna do bark cost with the vein, you start with vein mapping to see if your veins are suitable. So you don't just That's like the blind leading you pick which vessel you use your identify it so that you know exactly where you're going when you do surgery. Um, like I said to get some insulin, have a pleasure, Really? When you use the synthetic crawford distal intestinal, so it leads to early graft, a fusion and failure. If there is insufficient vein for the entire country, it in a distal bypass. What you can do is use is sort of a 50 50. So you use your synthetic right for the proximal aspect of the graft, and then you use your vein for the most distal part in this is called a vein Boots on. It's associated with better pizza stearate. Then just using the synthetic after. Yep. So, like I said, the more distal the arterial messed most is the lower. That success rate is for Rebif using Ritalin in terms of the procedure itself. The artery you dot sectary thing you've got set down to them with the last artery. Once you've done that to give IV heparin 3000 units and then you cross clamp the vessel that is basically in a name to prevent it from from forming, forming in that vessel while there's no flow through it, you didn't do a longitudinal cut through the vessel and you create a slip. So then you cut your side, your graft the size and you suture. You basically sutra it to me artery on both proximal and distant sites, we use protein suitors, which is a nonabsorbable sutra. So it just stays there for the life of the graft. Uh, and then in early diabetic patients with poor run off, you may just go with a primary amputation. It may be a safer and more effective option we wouldn't go to the effort of putting in a complicated bypassed for patients that has, you know, severe diabetes. Or they may be a really wheelchair out. You may just up to go straight for the amputation. There's a little mobility and there's lot less postoperative recovery because these are patients that ultimately need amputations in the long run. Anyway, So you just putting them 32 procedures unnecessary. Okay, so, yeah, this just shows the tops of graft, especially if you've got on my like attrition. So this bottom one shows your early across of breath. The femoral femoral one that we discussed earlier is very similar system. See it just because it down with a family and our femoral artery. Sorry on then, this graft you obviously dissect down on both sides. And you, Tuttle this under the muscular track that keeping synthesis then you've got a lot of my family is that we've got bilateral disease affecting both sides. Usually this is yeah, called a saddle blockage, where you've got blockages to both sides, both our necks. And then the one I mentioned before Xeloda by formal. So that's where you're taking from one of the axilla really arteries down. That's what you've got quite extensive. Distal aortic disease. This patient was It used to be fairly healthy. Besides this disease. No of the credibility because it's it's gotten extensive procedure that requires a lot of recovery time case. That's what I've got for today. There's my feet back QR code on there at and said I think we'll also just posted into the chat Just if you could just give me some feedback on how you found presentation today. And then there is a cure code for Instagram page where I think every couple days, some institution posted, as well as updates on when the next weapon on what? What will be. Thanks. Everyone will have a quick look, See if it's any more questions. Okay, so we'll stop it. I don't think is a little question. So Okay, so for a saddle blockage, you obviously have quiet. Let me just go back to the picture. So I mean, I said the settle blockage also with the aorta, my femoral, you can do that. So that's you need the most distal part of the aorta before the application to be patient, you don't do graft from the middle of aorta because then it started affecting things like the superior mesenteric artery. And you start, you know, take from a risk to bowel and everything. All the other organs perfused from that area. So if you've got a patient, just lay auto. You able to do that one? Obviously, if there's extensive disease leading up, then you'll do you. Excellent. Okay, stop it there. Thank you.