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great. I'm so following George's talk. We have Ms Manchester, a guest who is a vascular trading s. So she's going to give a specialty talk on vascular surgery s so I'll hand it over to her. Okay. Hi. Thanks. Emily. Introduction. So I'm Francesca Guest. I, um, an ST six in vascular surgery. I'm just gonna give you a little talk. About what? About what is vascular surgery and why I chose to do it. So a said I'm nasty. Six. Fasting is registrar. My journey through so far is that I was a foundation training in the Southwest on the cool trainee in the Southwest. Do MRI and straight through, right foundation of not, you know, I want to do surgery. A tall thought. I wanted to be a psychiatrist when I was in university. So it's very possible that if you are just started, you might end up doing something completely different to what you always thought you're going to be on. You might love it s o n Foundation year. I realized I did a like job, didn't love it, did some surgical jobs and fell in love. So that's why I decided to call surgical training off that point, I Once again, the thing I knew least about was probably Vascular. Remember our training? I think I had one week and vascular maybe didn't attend one of the days because I was too hung over or something irresponsible on. Actually, I didn't know much about it. As one of the others. You spend much more time general surgery or 12 in orthopedics or something that, you see, the general hair is much more on the specialist areas. Less so. I thought I had written off my head. I don't really want to do basketball. Went round core training on actually really fell in love with vascular surgery. On things that I love about vascular surgery is they operate everywhere in the body, away from head to the toes, all the limbs and within a body cavities, um, rather than to say, for example, general surgery tends to be just in the in the abdomen. There are lots of different types of Texan techniques. You so you've got thing operations, like taking off limits, which are, although there's very much an art to them, they're a bit more hacky slash the operating than a carotid endarterectomy was really fine, delicate, careful dissection on beautiful anatomy in the neck and careful and aspirated on. Then there's a third type of operating, which is the endovascular side of things, which isn't something you ever really got to do. Before we were a register. I don't get to see very much of that type of thing, but is the percutaneously? And then why is going through into the arteries or veins there twiddled about outside the body and you're watching your honor on an X ray screen. And so it's very much almost like playing a video games, a similar sort of thing. It's fun to do yourself on really frustrating to watch anybody else do. But it's another reason to love vascular surgery. Eso I'll get onto that a bit more just more about my pathway of gone through South made vascular on, but I went to taunt a night it colorectal placement on then extra my ft five and I just back to South made and rest a lot for my chest x six. So if you like me haven't had as much experience in vascular surgery, how do you know what it is we actually cover So, first of all, it's all of the arteries and veins outside of the heart and brain on. But we are just people plumbers. So if there is a block in the pipe, then we either unblock it or bypass the block. And then sometimes it's a swollen pipe in an aneurysm. And if that first we we want to ideally repair it before it bursts, or when it best with quickly trying to repair the blockage. But there's a lot more stuff to deal with. So the box pipes of the is the occlusive disease, with peripheral artery disease critical limb threatening a skinnier on, then on more acute side of the acute ischemia. And also diabetic foot has something to do with a close it disease, but very much in the small arteries and foot bother van. Typically the large central arteries. There's an original disease. As we mentioned that selected versus emergency, a dissection where the internal flap is separated from the media and the other antiseizure in an artery, and blood is forced between the layers and then venous disease. Um, so when you get in varicose veins, venous insufficiency before you're getting chronic venous changes ulceration, bleeding or recovering from both phlebitis. Because of those veins, you contribute them with old fashioned way. Would you seduced dripping? But Andre pull the vein out. That was problem. Actually, Now we don't tend to do that. A smudge When we use minimally invasive therapies like end of Venus, laser therapy or radiofrequency ablation, I have this just one small cup on. Then there's trauma, but obviously anybody that falls off a motorbike and breaks their arm or leg all of their major arteries and veins tend to run pretty closely. And major bones cause there, then protective on on a central pathway to work wherever they need to get so often. If bones broken, you can get veins and arteries that are broken a swell on that could mean that you've got to keep them ischemia. So trauma were involved. A lot in all penetrating chest roll over and some of the, uh, larger centers you know you'll be involved in that, well, vascular access. So diabetics anybody that's got in stage renal failure on day or so it's really fairly because of diabetes or otherwise might need. Fistula is made and looked after, um, and so we do that thoracic outlet, something people don't often think about. But if you have either an extra rib or a just an anatomical abnormality, that means you have compression of the arteries. If you lift your hands up above your head, you can get to every ischemic limbs when you're holding your hands up. Or sometimes when people sleeping or doing repetitive motions, just drawing their hair or brushing the hair or something above their head. Uh, so going up under the high in the armpit and into the super include in for a perfectly spaces to do with, that is is another thing that we can do. And that's something that I completely did not understand that more of a full breath of things that the vascular surgeon would be involved in when I first started. I don't like those about was Smelly Feet don't really want to do it on There is very faint, So these are examples of a peripheral problem. You've got these toes, these necrotic toes. There's going to be a blockage in the artery, so here's some pictures of what we've done. The blockage in the artery have taken a vein so that marking is the vein. Take a vein turned upside down. Plug it in above the blockage on below the blockage on. Then you end up, uh, getting blood down to the problem area, or you can do it properly. So if you put a catheter in and a wire going in and you can insert a stent into a blockage, push the stent open so that there's the blockages pushed out to the side on. That's an example here of a lesion being recanalization with an angioplasty balloon on D further up. More approximately is another example. So, up in the main I Act vessels here we're getting passed on initially on the picture on the left, you consider long occlusion. Then you can see two balloons being put up and inflated next to each other, and then you can see that there's there is blood flow getting down on that patients left hand side where there previously wasn't on that will take the picture of those toes from the picture on the leftovers, the pitch from the right, with them healing because they've got enough blood getting down in an acute situation. Everything happens very quickly, and that could tend to be more of an embolic event or acute from biotic event within a previous narrowing rather than this long term flaring up of the arteries. And if that's an acute and blessing a clot, then we can do a thromboembolic me. And that is basically just sticking a wire done on the artery with balloon on the end. So you stick it down with the balloon, deflated to get away, passed that lot, inflate the balloon and then pull it back up to to wherever it is that you are on. That pulls out this really satisfying long worm of clot. Make sure there's none left in there, so it up, uh, flush it through soda on. Then you can see if it's our turn pink again before your eyes. It's quite doesn't always go so well, and sometimes we need to remove legs. It is an example living above from below knee operation, um, of Bologna amputation Operation on. Then there's the aortic procedure, so you get things right up in the arch for thoracic or in the abdomen, and we can need to do something before it's wrapped. It's which is preventive and elective or after it ruptures, and that's emergency and reactive. See, this is I think it was a 10 or 12 centimeter. Um, there is, um they were all the bases. So looking from inside the abdomen with but the retroperitoneum still covering the aneurysm on D, we will then open that up and do a repair. There's a CT showing a ruptured abdominal aortic aneurysm so you can see in the center. There is the aneurysm. You can just about make a ring around there, and then there's this great contrast. There's leaks out into the afternoon. On that is the blood. So looking back again, head down into an abdomen. You've got somebody that has and attached done anastomosis and attached a graft. Adapt ground graft in this case onto the aorta at the top, on down at the bottom, and that will bypass the swollen aspect. This is a more complex aneurysm repair. That's a thoracoabdominal aneurysm. So that's is encompassing everything off the top to the bottom so you can see the Iraq vessels of the bottom. On in the middle, there's this section where you've got you see Axiron a lotteries s n a on the arms were down there was well, so you have to replace the whole thing on because they vary in in complexity. The other way in which you can fix and risen's is to do it with a stent. So with that in devicescape Nick that we used before just with slightly bigger graphs and, um, on bigger wholes, you've got a pair of trousers that basically squash down into a tiny on tiny sheath on. Then you open up paratransit got one long leg, one short leg on. Then you push a catheter up from the other side on, try and wiggle a tiny wire into the short leg of the trousers on. Then extend with another graphs that you've got a unequal pair of France's that goes down into both of your back arteries on, not just bypasses and excludes the swollen bit on. So the blood that's in there will just thrombose off on that thief. Lowing blood will go through your stent on down towards your legs, but without causing any ongoing risk from the sac expansion on so percutaneously or, you know, just through the skin into the arteries that could be done through holes. Biggest this so you can do an entire abdominal aortic aneurysm. Repair through holes is bigger than this on. That's sort of a three D reconstruction of what? It what it could look like afterwards. That's a fenestrated and the vascular repair. So we've repaired all the way up from the arch when you can see you've got little stents heading towards the kidneys and things like that. Uh, this is what? It's quite difficult to figure out what this is here, but this is what it looks like from the inside. So here we have a clamp of the very top, which is on the aorta. On do the we are looking inside the sac on backwards. What you can see, that you can see a bit of ligamentum flavum so that the ligaments that are on top of the spine not flying and they have ruptured out backwards. And so all of the blood was being pushed back that way. And that's just a big, gaping hole where the aorta would normally say, and we then need to repair that as previously my personal favorite, that crowded operation Cross it endarterectomy we do is before is risk reduction. It's not before his risk reduction surgery. So somebody has a stroke and they have thrown off some clot from their artery. They're internal carotid artery up to the brain, and that's causing embolic stroke. Uh, if appropriate, weaken. Do an operation on the artery to reduce the risk of a future strike, buy it, reducing the likelihood that that will happen again. Most interesting things about best that people often confused by as it's not the narrowing in the neck, meaning that blood is restricted. Blood flows restricted up to the top of the brain. And then you have in a scheme extract. That's not the problem. What happens is you have a plaque, a cholesterol plaque in the internal carotid artery. The plaque ruptures. You get thrombus formation on top of the plaque on, then the high speed flow that is going past the narrowing throws that clot off into the brain and the clock get stuck in the small, smaller arteries in the brain, and that causes this game extract. Uh, so in this picture you've got over by the white sleep, you've got the common carotid it by one of the red sleeps. You've got the internal carotid on do we can tell that the internal has new branches on the way up to the brain on the external carotid you've got at the superior thyroid artery coming off pointing forward to towards the thyroid on the external carotid has eight branches, which we all learn in our anatomy lessons. Okay, so these air, what looks like when you patch a carotid artery and this is just the examples of the other things. So vascular access here on here's a list of all the other things that we do deal with as we mentioned a little bit the beginning. Our patients are very complex and interesting. So all of our vascular patients used to be smokers, so they've got terrible lungs. Diabetics have vascular disease, or they're complex to marry, manage on they have heart disease. Because if you've got vascular disease in your arms and legs have gotten around your heart and your brain as well, um, assay these the reasons that I love vascular surgery in particular, um very happy to move on to some questions. Um, just highlighting that if you are interested any more questions, you can contact me personally. All the vascular society on Bruno Club, which I remember on. We'll be very happy to answer any of your questions. Awesome. Thank you, Francesca. And so I've just had to look on the chart. I can't see any source specific vascular questions at the moment. But, you know, obviously, as you said, if you're happy for them to contact you directly or through the Twitter, tweaked to recover. So yeah, so we got the Ruler Club specifically, we're always available in order to help us questions on. Then I'm very happy people to email me that Francesca doctor guests at gmail dot com, which we can put in the chat on. I'll get around to you on despond. Very happy to lovely. And just to clarify, um, I can't say it. So is it route Ruler Club? So it is. They, um it's the training training representative group. So we are a group off trainees presenting the views of trainings and trying to make training better for vascular trainees. They're also thinks people aren't yet vascular trainees, and we have always excited to have people aren't muscular trainings with us on. Do we put events on the training there? Is there a free learning materials on the Rudo website as long as you are a member of the ruler club which it is free to join. If you are interested in joining the real oh club, you can just head to the website or if you would like to run for any of our roles that were up for up for office as it were in December early December, we'll be having a a changing of the guard so you can have a look at the website. See, the roles were up for up for grabs on day supply, should you see wish nice And I've seen yet the name of a lot around for research and everything, so I think quite big sort of research. Collaborative wise. Yes, they always involved in the the Vascular Collaborative. So you have the massacre, vascular, an endovascular research, and it works well. Verne, on some other things that way, talked to you well, collaborative research is definitely the the way to go fluid that. Okay, thank you so much. Francesca. That was that was really useful. And yeah, thanks for talking about vascular. There's often it's quite confusing, You know, whether it's demo surgeries, it branch or, you know, I just I just didn't know anything about it until I got into it. So I think I've tried Teo, give a little bit more information about the types of things that we do. So I just found that I have no idea. Until I saw it, I had no idea that I would fall in love with it. Um, because I clearly have any vascular surgeon, so Yeah, thank you so much.