The Retrograde Approach

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 StentingThe 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 availableThe 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 IndicationsAneurysmal 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 0/1Approved 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 ConsiderationsHow 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.

In this episode, we aim to give a basic overview to arteriovenous fistula's for dialysis access. Although, we could spend hours discussing AVFs - we have attempted to provide a general overview for those new to the concepts.

In this episode, Yogi and Sam provide an overview into foot disorders within diabetic patients.

In this episode we delve into the interesting world of carotid artery disease and discuss our management of patients who are asymptomatic. See Yogi's (amazing) crib notes below:Why do we care about asymptomatic carotid artery disease?About 10 to 15% of all first ever stroke patients will experience an unheralded ischaemic, carotid territory stroke following thromboembolism from a previously untreated asymptomatic significant carotid diseaseOxford Vascular StudyEnrolled 2354 consecutive patients including 207 with 50 to 99% carotid stenosisThe ipsilateral stroke rate at 5 years for the patients with 70% to 99% was 14.6% compared with 0% for 50 to < 70%For patients with 80 to 99% carotid stenosis, the ipsilateral stroke was significantly greater than that for those with 50% to 50%) and severe (>70%) stenoses in a population of 23,706 people (mean age of 61 years, 46% male) was 2.0% and 0.5% respectivelyModerate stenosis > 50% found in 4.8% of men and 2.2% of women younger than 70 yearsThe percentage increase to 12.5% in men and 6.9% in women if patients older than 70 years are consideredSevere asymptomatic stenosis (>70%) indicate that its prevalence ranges from 0% to 3.1% of general populationSeminal TrialsSeminal trials have demonstrated a marginal but definitive benefit for CEA in reducing the risk of stroke after 5 and 10 years when compared with “best medical therapy” alone. However, these studies conducted in the late 1980s and in the 1990s, and since their completion, progress in the medical management of cardiovascular diseases has led to a progressive decrease in the yearly risk of stroke in patients with asymptomatic carotid artery stenosis managed with medical treatment alone.Veterans Affairs Cooperative Study (VACS) [1983 and 1987]440 men with asymptomatic >50% carotid stenosis were randomised to CEA plus medical management versus medical management only CEA significantly reduced the combined incidence of ipsilateral neurologic events (stroke or TIA) compared to medical group (8.0% vs. 20.6% respectively)ACAS1662 patients with asymptomatic >60% carotid stenosis were randomised to medical therapy versus CEA plus medical therapyAcross the United States and CanadaThe study was stopped early, after a median follow up of 2.7 yearsPatients in the surgical arm had a 5.1% risk of ipsilateral stroke and preoperative stroke/death over 5 years versus 11.0% risk of ipsilateral stroke in the medical arm for a relative risk reduction of 53%; absolute risk reduction of 5.9%Recommended CEA for patients aged < 80 years as long as the expected combined stroke and mortality rate for the individual surgeon as not > 3% ACST-13120 patients with asymptomatic >60% carotid stenosis were randomised to either immediate CEA or deferred

In this exciting episode we are joined by Dr Gert Frahm-Jensen, who is an Australian trained Vascular and Endovascular Surgeon working in the Australian Capital Territory. After attaining his medical degree from the Australian National University he completed specialist training in vascular surgery throughout Victoria, Queensland and the ACT. He has a special interest in the management of thoracic outlet syndrome, and we are very appreciative of his expertise that he shares with us in this episode.

This episode of The Retrograde Approach is proudly supported by The Australian and New Zealand Society for Vascular Surgery (anzsvs.org). We are excited to welcome Dr Nedal Katib (http://www.specialistvascular.com.au/dr-nedal-Katib/). Dr Katib completed his Vascular Surgery Training through the Royal Australasian College of Surgeons, which took him to South Australia, New Zealand and New South Wales. He also completed a further fellowship in Belgium in advanced Endovascular and Minimally Invasive Surgery. Originally born in Melbourne, his career path has taken him all over the world including Dubai UAE and graduating from the Royal College of Surgeons in Dublin Ireland before returning to Australia to continue his surgical career. During his training he completed his masters in surgical anatomy at Sydney University and his United States Medical Licensing Exams (ECFMG licence). Dr Katib is also the chair of communications for the ANZSVS.

Absorbed dose, effective dose, equivalent dose, air kerma and Marie Curie. In this episode, we dive into radiation safety.

In this special episode, we are joined by Adelaide vascular surgeon Dr Edwards Travers to discuss the sometimes daunting and confusing area of hyperhidrosis management.

In this very special episode, we are joined by Professor Ramon Varcoe to discuss his updated meta-analysis on the mortality rates after paclitaxel coated device use in patients with occlusive femoropopliteal disease.Found in the Journal of Endovascular Therapy: https://pubmed.ncbi.nlm.nih.gov/34106028/

In this weeks episode we are joined by Dr Kalpa Perera, a final year vascular surgery trainee who recently successfully completed the Royal Australasian College of Surgeon Fellowship Examination in Vascular Surgery in Melbourne. He reflects on his time as a vascular surgery trainee, and shares insights and advice about the strategies he used to succeed in the exam.

In this episode of The Retrograde Approach, Yogi and Sam delve into the world of acute limb ischaemia.

In this weeks episode of The Retrograde Approach, we are joined by Mr Iman Bayat. Mr Bayat is the Head of vascular surgery at Northern Health and Head of complex venous disorders at Northern Health. In this episode he shares with us a wealth of knowledge when it comes to managing all things iliofemoral. Buckle up, this is a good one!

In this episode we discuss our decision making and thought processes when it comes to managing tibial vessel disease, including open reconstruction and endovascular procedures.

In this episode of The Retrograde Approach, we are joined by Dr Tom Lovelock, a first year vascular surgery trainee to talk about his strategy and approach for success in the selection process for vascular surgery training, and unpack his strategy to conquer the selection interview.

In this episode Yogi and Sam discuss their management, work up and assessment of ruptured abdominal aortic aneurysms. Link to Journal of Vascular Surgery articlehttps://www.jvascsurg.org/article/S0741-5214(20)32132-7/fulltext

In this episode of The Retrograde Approach, Yogi and Sam discuss open infrainguinal bypass and reconstruction.

In this episode Yogi and Sam discuss their approach to the assessment and management of patients presenting with popliteal artery aneurysms. Including both acute and elective presentations.

In this episode Dr Yogi Sivakumaran and Dr Sam Farah discuss how they prepare, plan and perform an endovascular aneurysm repair (EVAR).General PrinciplesQuality of the CT Scan1mm slicesIf initial scan – scan thoracic, abdomen and lower limbs; allows for exclusion of aneurysmal disease elsewhere as well as if baseline status of the aortia prior to interventionAlso allows planning if a fenestrated repair required Centerline – images are not cross-sectional and end up with cross-sectional diameters Narrow diameter of the elliptical cross-section more in keeping with the true diameter Draw a diagram and compare with the rep and consultant's plan – appreciation of the complexity of the caseDate of the index scanDocumentation calcification, dissection, thrombus and stenotic diseaseSite of the lowest renal arteryClock face of the renal arteries origin as well as the origin of the internal iliac arteries Angulation of the aortic neck Type of neckStraight, angulated (plan according to IFU), tapered (oversize on the basis of the diameter below the renal arteries), reverse tapered (careful to avoid oversizing), bulge and shortAccess vessels Diameters and lengths (which will be discussed)Grafts chosenTalk to the reps re: planning books Pre-operative considerationIn the era of an endovascular repair, a durable repair is desired Patient's age Patient's co-morbidities Renal function, cardiac and respiratory historyLife expectancyFitness for GA vs. LA and Sedation The patient better of with an open or endovascular management strategySuitability for endovascular Complex vs. Standard EVAR Imaging Renal artery positionLowest renal artery; accessory renal arteries DiametersInfrarenal aortic neck diameter (assess for infrarenal thrombus; aim < 25% of the circumference and 3mm

In this episode, Yogi and Sam discuss the management of blunt thoracic injury and discuss difficult and challenging operative decisions.

In our third and final part in our review of the vascular exam in vascular surgery we discuss the clinical decision making viva, as well as the long case and the short cases.

In our second episode, Yogi and Sam take a deeper look into the fellowship exam looking specifically at the operative and imaging vivas. They reflect on the strategies and approaches they used to successfully navigate these challenging aspects of the examination.

In our first episode of The Retrograde Approach, Dr Yogi Sivakumaran and Mr Sam Farah embark on part one of a three part series discussing their recent reflections on completing the fellowship exam in vascular surgery in a year like no other.