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Acute Type B Aortic Dissection
1 Plays3 months ago
In this episode of Critical Matters, Dr. Sergio Zanotti discusses the management of acute type B aortic dissection. He is joined by Dr. Firas Mussa, a vascular surgeon and professor at McGovern Medical School at UTHealth Houston. Dr. Mussa also holds a joint appointment with Imperial College in London.
Additional resources:
Management of Acute Type B Aortic Dissection. FF Mussa and P Kougias. N Engl J of Med 2025: https://pubmed.ncbi.nlm.nih.gov/40902163/
2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. EM Isselbacher, et al. Circulation 2022: https://pubmed.ncbi.nlm.nih.gov/36322642/
Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) Reporting Standards for Type B Aortic Dissections. JV Lombardi, et al. J Vasc Surg 2020: https://pubmed.ncbi.nlm.nih.gov/32001058/
Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. INSTEAD-XL Trial. CA Nienaber, et al. Circ Cardiovasc Inter 2013: https://pubmed.ncbi.nlm.nih.gov/23922146/
Books mentioned in this episode:
A Dangerous Liaison: A Revelatory New Biography of Simon de Beauvoir and Jean-Paul Satre. By Carole Seymour-Jones: https://bit.ly/3L0pIov
A Time For All Things: The Life of Michael E. DeBakey. By Craig Miller, et al.: https://bit.ly/44B2uMw
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
Understanding Acute Type B Aortic Dissection
00:00:34
Speaker
In today's podcast episode, we will discuss the management of acute type B aortic dissection.
00:00:39
Speaker
Our guest is Dr. Firas Musa, a vascular surgeon and professor of vascular surgery at McGovern Medical School at UT Health Houston.
00:00:47
Speaker
Dr. Musa also holds a joint appointment with Imperial College in London.
00:00:50
Speaker
A renowned surgeon, investigator, and educator, his clinical interests include open and complex endovascular repair of thoracic and abdominal aortic aneurysms, type B aortic dissections,
00:01:01
Speaker
carotid stenosis, lower extremity, and mesenteric ischemia, among others.
00:01:05
Speaker
It is a great honor and a privilege to have him as our guest today.
00:01:08
Speaker
Firas, welcome to Critical Matters.
00:01:11
Speaker
Thank you so much, Sergio.
00:01:12
Speaker
It's a great honor to be with you today.
00:01:15
Speaker
I'd like to start with a question of perspective.
00:01:19
Speaker
Why should intensivists care about type B dissections?
00:01:24
Speaker
Yeah, I think if you asked me five years ago, I would have to scratch my head a little bit more.
00:01:32
Speaker
But now I'm more and more convinced that aortic dissection or aortic disease in general is a multidisciplinary team approach.
00:01:43
Speaker
And for aortic dissection in particular or any acute aortic event,
00:01:48
Speaker
intensivist is almost as important as a surgeon.
00:01:53
Speaker
In aortic dissection in particular, half the people are treated medically and this medical treatment is done in the ICU under the supervision and auspices of a team of an intensivist with his or her team.
Acute Aortic Syndromes Explained
00:02:09
Speaker
And that is really being aware of what the medications are
00:02:17
Speaker
But the goals of blood pressure and heart rate and how to adjust that and be up to date on what are the best agents to use.
00:02:26
Speaker
It's really within the realm of both surgeons and intensivists.
00:02:30
Speaker
And I would argue intensivists play a big role in making sure the patient do well.
00:02:36
Speaker
Perfect.
00:02:37
Speaker
And you talked about acute aortic disease.
00:02:40
Speaker
So a good follow-up would be maybe defining some of these acute events.
00:02:45
Speaker
Acute aortic dissection, intramural hematoma, penetrating aortic also seem to be all bundled in a cluster that we have to differentiate.
00:02:54
Speaker
Could you tell us a little bit more about that?
00:02:57
Speaker
Yeah, sure.
00:02:59
Speaker
So these are what you call what you just listed are what's called acute aortic syndromes.
00:03:05
Speaker
So the section intramural hematoma and penetrating aortic ulcer lumped up, summed up in one.
00:03:12
Speaker
However, they're distinctly different pathologically and even their risk factors, honestly.
00:03:21
Speaker
But
00:03:22
Speaker
For acute aortic section, it's commonly known, it's a tear in the innermost layer of the aorta, which is the intima, and then the blood goes into and separate between the intima and the media, and you have what's called a true and false lumen.
00:03:36
Speaker
That is the classic description and the most common of the three.
00:03:42
Speaker
Less common, equally important, and could be argued as a
00:03:47
Speaker
as a pre-pathology to dissection is intramural hematoma.
00:03:53
Speaker
And that usually gives me a pause because pathologically, it's a bleeding in the vasovasorum of the media.
00:04:03
Speaker
And that leads to a plot.
00:04:05
Speaker
It's like, you know, ecchymosis, if you will.
00:04:09
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If when you hit your skin, if you hit your head,
00:04:12
Speaker
or armed, let's say, against a pole or something or get hit or
00:04:19
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you end up with a bruise and ecchymosis, and that blood is in the subcutaneous tissue, and you can see it on the skin.
00:04:25
Speaker
Similarly here, intramural hematoma, blood is in the media and then spreads throughout the aorta and form an intramural hematoma.
00:04:37
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However, there is no distinct tear that you can see then flow into
00:04:43
Speaker
two lumens, so then they're distinctly different, and many of them disappear or go away or heal
00:04:53
Speaker
over time, just like an ecchymosis heal over time, and that time is variable.
00:04:58
Speaker
And some of them do convert to a frank aortic dissection and get treated just like an aortic dissection.
00:05:04
Speaker
So thankfully, it's less common, less headache to deal with.
00:05:08
Speaker
Same treatment strategy as aortic dissection.
00:05:11
Speaker
Distinctly different is penetrating aortic ulcer, which is atherosclerotic in nature.
00:05:18
Speaker
Most of the time, patients who have
00:05:20
Speaker
who has smoked all their life and so on.
00:05:24
Speaker
It looks like a peptic ulcer, if you will, but it's an atherosclerotic.
00:05:31
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It's an outpouching.
00:05:32
Speaker
It could be also described at some point as a secular aneurysm.
00:05:37
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The pathology is atherosclerosis, and then the treatment would be variable,
00:05:47
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depending on size, symptoms, presence of symptoms, and definitely size and depth, how far into the, how big into outside the lumen of the aorta, and how wide is the mouth, if you will, of that penetrating aortic ulcer.
00:06:05
Speaker
So these are three different symptoms.
00:06:07
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and presentation of an acute aortic syndrome.
00:06:10
Speaker
By far, the most common and most studied is acute aortic section.
Risk Factors of Aortic Dissection
00:06:16
Speaker
In terms of the epidemiology of acute auric dissection, could you comment on the incidence and main risk factors?
00:06:25
Speaker
Right.
00:06:26
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So, incidence classically described as anywhere from 2 to 6.
00:06:32
Speaker
And as I'm finding out more and more in the trial, to be honest, it's more around 2 to 3 per 100,000 patients.
00:06:41
Speaker
Or, you know, you can argue three to four depend on the season per 100,000.
00:06:46
Speaker
So in a country like the United States would be with, let's say, 300 million, you'll find like three to 4,000 cases per year of acute aortic dissection.
00:06:58
Speaker
And that includes both type A and B. Slightly more A, probably, if you...
00:07:04
Speaker
count, if you try to be slightly generous, we'll end up around that number to 5,000 new cases per year for a country like the United States.
00:07:15
Speaker
That's in terms of men and women tend to be
00:07:19
Speaker
This tend to be, like most aortic diseases, underdiagnosed in women, but the incidents tend to be similar, slight predominance in men.
00:07:30
Speaker
But as they age, probably they're both similar incidents in men and women.
00:07:37
Speaker
Less known in other minorities, like African Americans and Asians, it's definitely, it's a,
00:07:46
Speaker
well-known described entity in Japan and China and Korea and treated the aorta dissected at different diameters.
00:07:57
Speaker
Now, risk factors are universal around the world.
00:08:01
Speaker
I like to tell patients and tell even providers that it's
00:08:07
Speaker
Aortic dissection is not a disease of technology or, you know, which devices and whatnot.
00:08:13
Speaker
It's primarily a disease related to hypertension in 9 out of 10 cases.
00:08:20
Speaker
It is uncontrolled hypertension is the number one cause or risk factor.
00:08:25
Speaker
The one that's less common but also important is connective tissue disorders like Marf and Louise Dietz, Vazcarina Helios-Enlows, that is, and many other genetic aortic erotopathy.
00:08:42
Speaker
And then important, and there are pockets in the country that,
00:08:50
Speaker
That's more than others, but it's everywhere, prevalent everywhere, is the use of illicit drugs, most importantly, cocaine and meth.
00:09:00
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Wherever you see cocaine and meth use, especially in younger folks, this spikes blood pressure at a very high level, and this spikes lead to an aortic section.
00:09:12
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We've seen that.
00:09:13
Speaker
throughout the country.
00:09:15
Speaker
And these are the three most common risk factors, but by far it is hypertension, just like smoking and peripheral disease.
00:09:26
Speaker
Classification of aortic dissections has important implications for therapy and understanding the disease and making sense of the anatomy.
00:09:36
Speaker
Could you tell us what are the current systems that are relevant and how they should be viewed by non-surgeons?
Classification Systems for Aortic Dissections
00:09:47
Speaker
Right.
00:09:47
Speaker
So that's, I agree.
00:09:49
Speaker
It's an important topic.
00:09:50
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So just to give you a little bit of a historic background, King George II died in 1760 of presumed type A aortic dissection.
00:09:56
Speaker
Okay.
00:09:57
Speaker
So that's 1760.
00:09:58
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Nothing happened till 1760.
00:10:13
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till the year of 1954 when DeBakey and the Dream Team here in Houston actually described the disease as type 1 and 2 and 3 and 3 was divided in 3A and 3B according to DeBakey classification.
00:10:31
Speaker
And then 20 years later, in 1970, Shumway and Daly came up with the Stanford classification.
00:10:38
Speaker
So today,
00:10:40
Speaker
DeBakey and more commonly Stanford classification is probably still the most commonly used is Stanford.
00:10:47
Speaker
You hear people talking about Stanford A and B. And that's really refers to Stanford A, refers to a dissection or a tear that involves the ascending aorta.
00:11:02
Speaker
And the ascending aorta definition, if you read it in the
00:11:06
Speaker
in our paper in the New England Journal, it is really delineated by the medial border or around the medial border of the innominate artery.
00:11:17
Speaker
So anything below that between the valve and the innominate artery is considered type A.
00:11:25
Speaker
Anything between the middle or kind of the lateral border of the nominate or is considered after that to be type B aortic section.
00:11:36
Speaker
And that's, I think, is slowly giving way to the newer classification that came up by the site of astral surgery, site of thoracic surgery, which is so the SVS STS zone one to 12, which I think,
00:11:54
Speaker
To their credit, I think it's more descriptive because if you're on the other end, like you're the intensivist, you're on the phone, and you're talking to the surgeon on the other end, if I tell you there's a type B, this could be anywhere.
00:12:10
Speaker
It doesn't tell you the, maybe tells you where the tear is, but doesn't tell you the extent.
00:12:16
Speaker
Here it tells you the tear and the extent goes from zone one to zone six or zone five or six or eight or nine.
00:12:24
Speaker
So if you have the table in front of you, it makes it easier for the person on the receiving end.
00:12:31
Speaker
Imagine it's two in the morning and I'm describing this to you.
00:12:34
Speaker
It wouldn't make sense unless you have really a visual.
00:12:39
Speaker
but zone 1 to 6.
00:12:40
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Now, this, in terms of making communication easier, and also has implications on therapy because, obviously, type A is treated differently than type B. And if you have a zone 1 or zone 2, zone 0, 1, 2, the treatment is different than what it is in zone 3, 4, and 5, and 6, 7 would involve 5, 6, and 7 would involve the viscera.
00:13:07
Speaker
So you're kind of...
00:13:10
Speaker
thought process would differ in terms of what you need in terms of stingraft or hybrid repair and so on.
00:13:15
Speaker
So these are the implications on
00:13:19
Speaker
There are new classifications that is less commonly used, especially in this country, but most parts, Stanford and the new SVS-SCS probably are more commonly used these days.
00:13:34
Speaker
Don't say that to the group at the Baytee Heart Center.
00:13:37
Speaker
For sure.
00:13:38
Speaker
But like you mentioned, we're both in Houston, so the historical context is always very important, right?
00:13:43
Speaker
Of course.
00:13:44
Speaker
We're pioneers in understanding history.
00:13:47
Speaker
and creating interventions for acute aortic disease.
00:13:51
Speaker
So Stanford, like you mentioned, is also what I believe most intensivists are familiar with.
00:13:57
Speaker
And from a very simplistic perspective, type A, you think, okay, we need surgery immediately.
00:14:04
Speaker
Type B, I need to talk with surgery, but we have a time to figure out what to do.
00:14:08
Speaker
Now, the SVS, STS that you mentioned in your wonderful review paper recently published in the journal that we will link in the show notes is probably something we should be aware of in terms of providing more precision in our communication.
00:14:23
Speaker
Right.
00:14:24
Speaker
Right.
00:14:25
Speaker
So like you mentioned, if I call you with a consult in the middle of the night or whatever, and I can tell you what SVS, STS zone model is affected, it gives you a much better perspective of what's going on and what are probably the next steps to take.
00:14:43
Speaker
So I would equate it for our intensivist listeners to talking with a neurointerventional person and giving them an NIH stroke scale.
00:14:52
Speaker
Yeah.
00:14:53
Speaker
It adds precision.
00:14:55
Speaker
And we can all speak the same language of what's really, really happening.
00:14:59
Speaker
Now, that would be amazing.
00:15:01
Speaker
Yeah, correct.
00:15:02
Speaker
So that would be phenomenal.
00:15:03
Speaker
We will work on that.
00:15:04
Speaker
I'm sure that it's still not the common pattern.
00:15:09
Speaker
But have you experienced a pickup in radiologist reporting SVS, STS, or they don't really go into that?
00:15:16
Speaker
No, not really.
00:15:18
Speaker
I mean, and it does pick up among trainees in surgery.
00:15:26
Speaker
So now is a resident calling me and telling me this is on one to five or something like that, which is,
00:15:33
Speaker
Which is helpful.
00:15:33
Speaker
But as you said, I think it's exactly like the NIH score.
00:15:38
Speaker
If you could, it would be incredible.
00:15:42
Speaker
As I said, I think the intensivists play a key role in understanding the anatomy for the intensivists, which I think their role is just as important as the surgeon.
00:15:52
Speaker
in a multidisciplinary team, we all should be speaking the same language and be on the same page.
00:15:58
Speaker
That would be ideal.
00:16:00
Speaker
Yeah, I agree.
00:16:02
Speaker
And the last classification, which I want you to comment on briefly, we're going to dive in in more detail to talk about management.
00:16:11
Speaker
But I also believe extremely important for type B, specifically dissection, is complicated versus uncomplicated.
00:16:21
Speaker
Right.
00:16:22
Speaker
So, um, the, the, um, in specific in type B, um, so type actually before the type A would be, would be the most of the time it's a fatal disease or, or, you know, it needs this urgent therapy because of either severe AI or a cardiology of fusion or secondary rupture or, um, you know, or malperfusion.
Managing Type B Dissections
00:16:46
Speaker
Most of the time it's associated with type A or a coronary event, which is a malperfusion.
00:16:53
Speaker
In type B, luckily most of the time it is, there is none of that.
00:16:59
Speaker
There is no rupture and there is no malperfusion and that is called uncomplicated.
00:17:04
Speaker
So,
00:17:04
Speaker
In other words, uncomplicated type B aortic section is any dissection without evidence of rupture or malperfusion.
00:17:15
Speaker
And malperfusion can happen to the cerebral, but more commonly into the mesenteric, so SMA, celiac, or the renal, or the leg.
00:17:26
Speaker
Okay, so the iliac goes out, one of the kidney arteries go out, or both.
00:17:30
Speaker
Celiac or the SMA, most importantly, will go out.
00:17:35
Speaker
These, in the absence of rupture or malperfusion, this would be considered uncomplicated.
00:17:43
Speaker
If they present with any of those signs of malperfusion,
00:17:47
Speaker
then it is complicated type B dissection.
00:17:49
Speaker
And this is really what the FDA defines, complicated aortic dissection.
00:17:54
Speaker
This was what led to the approval of Stengraft.
00:17:59
Speaker
It is that showed that Stengraft work, and we'll touch base on that.
00:18:03
Speaker
Maybe what showed that Stengraft work is because in the incidence of, or in the presence of rupture and malperfusion, Stengraft will probably be life-saving.
00:18:16
Speaker
So because it will redirect flow or patch, patch a rupture or redirect flow and resolve malperfusion.
00:18:26
Speaker
And again, we're emphasizing the classification and the vocabulary so that communication can be efficient and effective.
00:18:34
Speaker
Right.
00:18:35
Speaker
I always tell people when you call a colleague from another specialty, if you know the right words to use, you will always get their attention.
00:18:44
Speaker
Right.
00:18:44
Speaker
Right.
00:18:45
Speaker
Yeah, so I mean, if you call me for an aortic section and say, hey, Moosa, this is a type B aortic section zone 1 to 5 or type B aortic section with evidence the guy is hypotensive and blood pressure is 80 over 60, which is obviously in type A, B aortic section, the cause of their blood.
00:19:08
Speaker
of their dissection is usually hypertension.
00:19:10
Speaker
So if they are hypotensive, that means they are in a shock, and that is really what would be a complicated type B. Similarly, hey, Musa, this is a type B aortic section came in just now, and his leg is cold, and it cannot move it, and has no pulse in it.
00:19:32
Speaker
So that is malperfusion.
00:19:34
Speaker
And that is really get me out of bed right away and start driving towards you.
00:19:40
Speaker
Excellent.
00:19:40
Speaker
I actually, when you mentioned that second case, I recall a case that came through the ED with a cold leg after taking cocaine and everybody was focused on the cold leg and it was a type B dissection.
00:19:53
Speaker
Once you do the proper workup, it's much more extensive.
00:19:57
Speaker
Yeah.
00:19:57
Speaker
Yeah.
00:19:59
Speaker
It could be missed anywhere in the world, to be honest.
00:20:03
Speaker
It's crazy.
00:20:05
Speaker
So in terms of initial clinical management of acute type B dissection, could we start with diagnosis, clinical presentation, and from your perspective, what's the gold standard for imaging?
00:20:17
Speaker
And are there any other tests that we should be considering initially?
00:20:20
Speaker
Right.
00:20:21
Speaker
I think this is a very important topic because, as we mentioned in the paper, it gets missed many times, and that led to a huge worldwide Think Aorta campaign in this country and Europe and everywhere.
00:20:38
Speaker
that you think of aortic section or an aortic event, acute aortic syndrome, when patient presents.
00:20:46
Speaker
So initially, the classic presentation of a tearing chest pain, it is real.
00:20:52
Speaker
It does happen.
00:20:53
Speaker
Especially, you know, it happens suddenly.
00:20:58
Speaker
It's not like it's been going on.
00:20:59
Speaker
So a patient comes in with really a few hours, not a few days history of severe
00:21:06
Speaker
chest pain.
00:21:07
Speaker
This pain will bring you in that same day, okay?
00:21:12
Speaker
That's first hint.
00:21:14
Speaker
And the second hint, so mostly is the pain, you know, and then the second thing or the sign is the hypertension.
00:21:25
Speaker
So pain and severe hypertension, we're talking anywhere from 160 to 180, 200 diastolic over
00:21:35
Speaker
So, you know, 110 diastolic in a person may or may not be taking their blood pressure pills or not known to be hypertensive.
00:21:45
Speaker
This should alert you to an aortic dissection.
00:21:50
Speaker
So pain and hypertension should equal.
00:21:59
Speaker
section to the top of the differential in anyone's mind, in the ED, in the ICU, and so on.
00:22:07
Speaker
So the gold standard nowadays in 2025 is CTA of the chest, abdomen, and pelvis.
00:22:17
Speaker
Chest, abdomen, pelvis, not enough.
00:22:20
Speaker
Even if the patient has renal insufficiency and so on, CT scan without contrast is useless for this diagnosis.
00:22:29
Speaker
Cannot tell me anything, as you can imagine.
00:22:32
Speaker
It can't tell if there's malperfusion, if there's a rupture.
00:22:35
Speaker
So it becomes, I would be...
00:22:39
Speaker
I can't remember how many times I've told this to the intensivist or the, actually, it's usually the ED when it's like, you can't tell me it's patient has an aortic section on a non-con CT scan.
00:22:53
Speaker
So CTA, chest, abdomen, pelvis, should be the first immediate procedure.
00:23:00
Speaker
test for, obviously, at the same time, you would have done cardiac enzymes and EKG by the time they come and get the patient to do the CTA.
00:23:11
Speaker
It's 10
00:23:18
Speaker
Usually if it's positive, just like PE, it is more indicative of an acute aortic event.
00:23:26
Speaker
If it's negative, it does not rule it out.
00:23:29
Speaker
But definitely, this is a presentation and CTA from the initial presentation.
00:23:40
Speaker
Is there a role for echocardiography emergently or that's more for… Right.
00:23:48
Speaker
So, ECHO used to be, when I was growing up, ECHO used to be the gold standard, if you will, before the 64 slice, and it tells you how old I am, before the 64 slice and now 128 and God knows 230, or the presence of CT scan in the emergency department, ECHO.
00:24:09
Speaker
Now, ECHO could miss some areas in the heart.
00:24:13
Speaker
ECHO's still key in type A more than type B.
00:24:18
Speaker
aortic section.
00:24:21
Speaker
But I think for the general immediate diagnosis, it is kind of taking a back seat.
00:24:30
Speaker
I think it's important in the operating room to have an echo for many reasons for diagnosis and also to treat to guide therapy as well, just like an intravascular ultrasound.
00:24:43
Speaker
But definitely taking a back seat to CTA.
00:24:48
Speaker
Any other tests that you would recommend?
00:24:50
Speaker
I guess these days we get a bunch of tests in the ED anyways, but obviously creatinine would be helpful as a potential sign of hyperperfusion.
00:24:59
Speaker
Anything else?
00:25:02
Speaker
No, I think you hit it right.
00:25:04
Speaker
I mean, I think kidney function and full cell labs, I mean, the usual tests that come in, it depends on the scenario of patients hypotensive and anemic.
00:25:17
Speaker
And you have, that will explain the CT scan with a bloody pleural fusion, if you will.
00:25:26
Speaker
So there is nothing particular if you're asking.
00:25:30
Speaker
There is nothing except that, as I said, the markers of D-dimer.
00:25:34
Speaker
There are a bunch of other tests, other markers have been tested, but it's really hasn't been that widely used.
00:25:43
Speaker
But only probably D-dimer has been circulated as potentially, you know.
00:25:50
Speaker
But as I said, if it's negative, that does not rule it out.
00:25:54
Speaker
That's it.
00:25:55
Speaker
Just full set of CBC and chemistry should be helpful to guide therapy and also guide diagnosis and therapy.
00:26:04
Speaker
In terms of, and usually these patients, it comes through the ED, they're diagnosed in the ED, and immediately, obviously, vascular surgery and CT surgery, depending on the type of dissection, will be alerted.
00:26:15
Speaker
They usually are, I mean, they should be admitted to the ICU, as we mentioned earlier.
00:26:20
Speaker
What are the initial considerations for medical management of a type B aortic dissection?
ICU Management Strategies
00:26:28
Speaker
So I think this is the initial management is so important for type B. And that is where I think intensivist, I mean, you could, you can slice, it's like vascular surgeons.
00:26:42
Speaker
There are general vascular surgeons, there are aortic vascular surgeons, and there are carotid vascular surgeons and so on.
00:26:50
Speaker
There's dialysis and peripheral vascular disease.
00:26:53
Speaker
Here you could, same thing with it.
00:26:56
Speaker
There's
00:26:57
Speaker
CV anesthesia and so on.
00:26:59
Speaker
Here you can have a similarly dedicated ICU team led by an intensivist who is well-versed in aortic disease.
00:27:10
Speaker
So let's, let's, I'm going to spend a minute here on ICU management because I think
00:27:17
Speaker
if I learned anything so far from the trial that currently I'm running, is the ICU management could definitely change the course of the patient in the hospital and therefore even post-discharge.
00:27:34
Speaker
And here's how.
00:27:36
Speaker
We usually treat those patients with, still is, we still do, with a drip of what's called anti-impulse.
00:27:45
Speaker
meaning you treat the blood pressure to guideline therapy, blood pressure of a game of aim of a systolic of 120 and a heart rate below 120 and below and a heart rate below 80.
00:27:59
Speaker
And the same time, strict eyes and nose, make sure they're not really over hydrated, concentrate drips, make sure their urine output is monitored.
00:28:09
Speaker
You put a
00:28:10
Speaker
A-line and a Foley and, you know, make sure they use their incentives parameter and so on.
00:28:17
Speaker
And however, the drips, we used to use Esmolol, which is still in most, even in probably in our place, we use Esmolol.
00:28:26
Speaker
And I'm finding more and more that probably non-selective blockers like Levitolol,
00:28:34
Speaker
and we're investigating labetalol instead of esmolol, for instance, as an initial therapy, and also add oral medication at the time of presentation, would probably be worth switching to, if you will.
00:28:50
Speaker
Now, this is not a recommendation for everyone to adopt everywhere and start to boost aceto.
00:28:57
Speaker
It is an important...
00:29:01
Speaker
topic to evaluate per ICU.
00:29:05
Speaker
And I've seen it's now published in, I think the group in Wisconsin have published a good paper on their medical management of type B aortic section.
00:29:17
Speaker
So esmolol instead of, labirinol instead of esmolol has been linked to shorter ICU stay, shorter hospital stay,
00:29:28
Speaker
and better blood pressure control when they go home.
00:29:32
Speaker
There's a whole protocol for that.
00:29:35
Speaker
So as blood vitilose is first line IV therapy,
00:29:40
Speaker
plus amlodipine PO, then you switch to teltiazem, then, excuse me, you switch to cardine drip, then another calcium channel blocker, and then you add on oral and IV if you need a second line.
00:29:58
Speaker
Second line oral would be Losartan, for instance.
00:30:01
Speaker
So my point is, there is evolving
00:30:06
Speaker
change or evolving medical therapy in the ICU.
00:30:11
Speaker
And this medical therapy in the ICU will dictate the course in the hospital.
00:30:17
Speaker
And if they did not have a complication in the hospital, they're not likely to have a complication when they go home.
00:30:25
Speaker
And that is really important.
00:30:27
Speaker
And, you know, and that starts in the ICU initial management, if you will.
00:30:33
Speaker
And that is what I wanted to get people to know and understand that ICU team, like next time you see an aortic dissection, you're not going to just wait for your vascular surgeon to tell you.
00:30:47
Speaker
You're going to have a discussion with the vascular surgeon about the evolving therapy and how you can actually improve the outcome all around.
00:30:58
Speaker
And you mentioned the cardiac impulse, right?
00:31:01
Speaker
And I think it's worth kind of emphasizing physiology.
00:31:06
Speaker
I recall reading some years ago, the original animal studies in the, I don't know, 60s or 70s that looked at this.
00:31:13
Speaker
And many, many internist-based or many intensivists think about reflex tachycardia being a problem.
00:31:19
Speaker
But really what you're trying to modulate here is
00:31:22
Speaker
is the wave of propagation in the aortic artery, right?
00:31:26
Speaker
So it's that impulse, that delta.
00:31:29
Speaker
That's why it's so important to not only keep the blood pressure below 120, but also normalize the heart rate because the product of both of those determines the cardiac impulse.
00:31:41
Speaker
And I believe that, I mean, a lot of intensivists have to observe what you've described, which is that Esmolol does a better job with heart rate than with blood pressure.
00:31:50
Speaker
So sometimes you need a little bit more in terms of making sure that you're hitting both of those targets.
00:31:56
Speaker
But very, very important in terms of preventing further damage.
00:32:00
Speaker
And like you said, what we do initially has tremendous implications down the road for how those patients will fare once they leave the hospital.
00:32:11
Speaker
Honestly, they have a tremendous, everything you said is a 100%, and I'm glad that you stated it much better than I did.
00:32:20
Speaker
And then, but not only honestly on the down the road, I think if the patient's
00:32:26
Speaker
the hospital course well without without a without a glitch if you will mean a glitch meaning patients may have you know severe pain and require stent and stent leads to you know all sorts of complication or rupture and so on so the key initial management could prevent all that and have a kind of a smoother
00:32:52
Speaker
hospital course and definitely down the line will be a smoother.
00:32:57
Speaker
And that's really what we're observing even in the trial, it's currently ongoing.
00:33:01
Speaker
If you have a smoother course in the hospital, you're likely to be able to be monitored for a longer period of time without an issue.
00:33:10
Speaker
Perfect.
00:33:11
Speaker
What are some issues that you would encourage intensivists to monitor and some early warning signs that perhaps your type B dissection is becoming complicated?
00:33:21
Speaker
Right.
00:33:22
Speaker
So I think I intend to this, starting with the faculty and the staff and the APPs or the residents, is to have a low threshold
00:33:39
Speaker
of re-imaging, okay?
00:33:41
Speaker
There are certain centers that re-image in 24 to 48 hours to repeat the same CT scan to make sure everything is fine.
00:33:49
Speaker
But in terms of symptoms and signs, any severe pain that is despite adequate blood pressure control and the patient is still in severe pain, despite escalating doses of narcotics and the blood pressure is 110,
00:34:05
Speaker
So that's an issue that requires attention and proper action.
00:34:14
Speaker
You know, changes in the feeling of the leg and the arm and acting weird and funny.
00:34:19
Speaker
It's like an MI.
00:34:20
Speaker
I mean, if you're watching an MI and, you know, post-MI and the patient might or might not have gotten a PCI,
00:34:31
Speaker
and something goes wrong, patients have severe chest pain or enzyme leak or...
00:34:38
Speaker
or acting funny.
00:34:40
Speaker
I mean, funny is defined in many ways, but here in dissection, it really could be richer.
00:34:50
Speaker
You could think of retrograde aortic dissection.
00:34:53
Speaker
Patient comes in with a type B and now has a type A. So all of a sudden, their blood pressure is not staying up.
00:35:01
Speaker
For instance, they're hypotensive.
00:35:04
Speaker
That's a worrisome sign.
00:35:07
Speaker
Patient cannot lift their leg.
00:35:09
Speaker
That's a worrisome sign.
00:35:11
Speaker
Can a patient develop a stroke from a, let's say, carotid malperfusion from a retrograde aortic section or tear extension?
00:35:21
Speaker
So these are the things that you keep in mind that the disease is a fluid situation, that a disease itself could cause, could extend, despite your best effort.
00:35:33
Speaker
or your treatment could cause a problem despite your expertise and meticulous effort.
00:35:40
Speaker
So these are the two things.
00:35:41
Speaker
The disease itself could get worse proximally or distally or rupture.
00:35:48
Speaker
Or definitely if you treat it and put a sten graft in the patient or repair or, you know, has an open repair, they may not come back normal.
Role of T-VAR in Complicated Dissections
00:36:03
Speaker
I would like to dive into the treatment strategies and the current evidence for more definitive treatment, which obviously is your not only area of expertise, but I'm sure of passion.
00:36:15
Speaker
And this has really evolved over, I'm sure, over your career significantly.
00:36:21
Speaker
And like you mentioned, there's still a lot of research going on.
00:36:24
Speaker
But perhaps we could start, for us, with talking about the complicated type B aortic dissection.
00:36:31
Speaker
How do we approach that in terms of intervention?
00:36:35
Speaker
So just to redefine, complicated is something that patient present with a type B tear and around the aortic arch and down, and where they use mostly Stanford classification.
00:36:50
Speaker
And patient has evidence of hypotension.
00:36:54
Speaker
or malperfusion to the gut, severe abdominal pain, and you take a CT scan and it shows that the SMA is out, or a cold leg where the iliac is out, or, you know, renal failure where the creatinine is up and the kidney is out.
00:37:10
Speaker
So these are complicated aortic section.
00:37:13
Speaker
And I can say since 2000, yes, it is an area of passion.
00:37:19
Speaker
And it's incredible that throughout my career, actually, in vascular surgery, I saw that change drastically.
00:37:28
Speaker
So back in the day, patient presented with any of those that...
00:37:34
Speaker
that I just mentioned had almost 90% mortality because either you treat them and treating them, meaning take them to the upper room and do a laparotomy or do a thoracotomy and you cut that septum, and that aorta could never be put back together because it's tissue paper.
00:37:55
Speaker
Now, that by itself had a, you know, that plus the disease had next to 90% mortality.
00:38:03
Speaker
And that changed since the approval of Sengraft, first Sengraft 2003, and then 2013.
00:38:09
Speaker
In 2003, I was a fellow here in Houston.
00:38:17
Speaker
In 2013, I was faculty already, where 2013 Stengraft were approved for aortic section, but obviously we've been using Stengraft for aortic section way before that.
00:38:30
Speaker
So Stengraft essentially avoided this whole open...
00:38:35
Speaker
cut the septum out because you put that meticulously in the true lumen and kind of realign the aorta or push the septum back to where it belongs and seal that entry tear and the blood all of a sudden it's magic if you will all of a sudden the blood will redirect into the true lumen and the malperfusion gets resolved
00:39:00
Speaker
And that mortality went down from 90% to 10% in a couple of trials that were done, the stable one and stable two, which is drastically that you could think of a disease that kind of cut the mortality from 90%, 10% in our lifetime, not that many.
00:39:22
Speaker
So that was the – it's currently non-controversial,
00:39:30
Speaker
kind of first-line therapy gold standard if you will for complicated aortic section to get a thoracic endovascular repair or tvar from the start and that is that is really um considered you know this should be considered standard of care and it is it is the center of care and and in a complicated aortic dissection like this the tvar is emergent
00:39:56
Speaker
Yeah, T-Vor should be done within, it's like a stroke.
00:40:00
Speaker
It's like an MI and STEMI and PCI.
00:40:04
Speaker
Same thing, trauma and scoop and run.
00:40:07
Speaker
Same thing should be done right away, immediately.
00:40:11
Speaker
Time is, you know, kidney or brain or, you know, gut.
00:40:16
Speaker
Time is gut.
00:40:17
Speaker
I mean, you lose more gut by every hour.
00:40:21
Speaker
So it's really T-VAR should be done.
00:40:23
Speaker
And here I could argue T-VAR should be done expert hand because putting a stem graft may be technically not that complicated, even though it's operation for a complicated aortic section is not easy.
00:40:37
Speaker
It takes time, effort, and all that.
00:40:39
Speaker
But really the post-care, as I mentioned, you've got to put this patient in ICU that should be, this ICU should be really
00:40:50
Speaker
tuned in to what just transpired in the operating room.
00:40:54
Speaker
So that's really where the open communication and the knowledge of both teams or all the teams are important.
00:41:01
Speaker
Perfect.
00:41:04
Speaker
So like you mentioned, the evidence supports it, the dramatic improvement in outcomes.
00:41:11
Speaker
Are there cases where you're forced to do a surgical open approach?
00:41:17
Speaker
Well, if the anatomy is unfit, meaning in stent graft you've got to put a covered stent across some blood vessels and so on.
00:41:28
Speaker
And the limitation on that is getting less and less as technology and our skills are improving, that's not becoming an issue.
00:41:39
Speaker
There are one site in the U.S. that I know that does open repair anatomically unsuitable with reasonable results.
00:41:51
Speaker
I think for practical reasons, most, let's say here in Houston, there is...
00:41:59
Speaker
there's tremendous experience in open aortic repair that spans, as you said, from decades under DeBakey and Gouldy and on and on to today.
00:42:13
Speaker
So even in Houston, there would be hesitation to do an open repair if we can extend our T-VAR expertise in one way or the other.
00:42:27
Speaker
Definitely.
00:42:28
Speaker
Perfect.
00:42:29
Speaker
I shouldn't exclude it, but I definitely, I don't see much, much out there in terms of open repair for thoracic oortic dissection.
00:42:39
Speaker
Okay, perfect.
00:42:41
Speaker
Type B. What about type B uncomplicated oortic dissection?
Research on Uncomplicated Dissections
00:42:46
Speaker
Right.
00:42:46
Speaker
And maybe the caveat there is high risk uncomplicated.
00:42:50
Speaker
Right.
00:42:50
Speaker
Right.
00:42:52
Speaker
So here you're talking about this is really the area of my expertise, and I spent a good decade of my life.
00:43:01
Speaker
I still do spend most of my waking hours thinking about it and talking about it.
00:43:07
Speaker
It's...
00:43:11
Speaker
This is currently being tested in a randomized control trial that's funded by the government, by the NIH.
00:43:22
Speaker
It's called the IMPROVE-AD trial, where I serve as the principal investigator along with two colleagues of mine and a team from Duke and downstate and involves 60 sites in the US and Canada.
00:43:39
Speaker
So this is really an ongoing research question of what we do with patients with uncomplicated tibia aortic section.
00:43:49
Speaker
Now, you mentioned high-risk features.
00:43:52
Speaker
And high-risk features, in my mind, is same as no high-risk features.
00:43:57
Speaker
These high-risk features, let's say, there's a list in 2020, a group of vascular surgeons came up with a list.
00:44:07
Speaker
based on a very thin amount of data that said in the presence of those, let's say a size of 40 millimeter or an aortic tear that is of 10 centimeter or malperfusion only, imaging only malperfusion, a few features that are based on a single study here and there that they said, okay, we
00:44:32
Speaker
put a StenGraft in those.
00:44:34
Speaker
It wasn't really well thought out at the time and still isn't.
00:44:38
Speaker
And most recently, the European Society of Vascular Surgery repealed all those in favor of being randomized in the trial.
00:44:47
Speaker
So for the New England Journal paper, actually, I initially did not mention it to one of the reviewers who wanted to have it in there, which I think is valid.
00:44:57
Speaker
in the sense that, okay, we have those features, we will include all those features in the trial, and then we can then validate them prospectively in a thousand patients.
00:45:11
Speaker
How about that for a good scientific project?
00:45:16
Speaker
And I think that is where we are now.
00:45:19
Speaker
Uncomplicated type B aortic section, they're not all equal, I give you that.
00:45:27
Speaker
But there are
00:45:30
Speaker
They're, how shall I say, the best treatment forward, if I show up today in your hospital, okay, and in the emergency department with uncomplicated type B aortic section and say aortic diameter of 40, I'm going to ask your vascular surgeon, who I know very well and I have tremendous amount of respect to,
00:45:59
Speaker
for is to randomize me.
00:46:01
Speaker
So that's essentially how it tells you how much I do not know what is the best treatment.
00:46:06
Speaker
And the randomization is simple.
00:46:08
Speaker
You either get upfront Stengraft, which like many are suggesting, meaning you show up, you get a Stengraft based on the presence of high-risk creatures or not,
00:46:20
Speaker
Or you get placed in the ICU and get treated the way that you usually treat the type B aortic section.
00:46:28
Speaker
Treat them with blood pressure medications and pills, transition to pills, and then you go home and you follow them for the rest of their lives.
00:46:37
Speaker
Which is better?
00:46:38
Speaker
I don't know, but it's definitely currently is a debate.
00:46:42
Speaker
Your intensivist ought to know there is a debate on that.
00:46:46
Speaker
And the question has not settled.
00:46:49
Speaker
And your team ought to be part of that investigative team that want to know the answer to it.
00:46:55
Speaker
to that question.
00:46:56
Speaker
So true equipoise and we're trying to figure out that's the focus.
00:47:00
Speaker
And you're part of it.
00:47:01
Speaker
You're part of it.
00:47:02
Speaker
Honestly, you're intensive.
00:47:03
Speaker
That's why I mentioned, I stressed the fact that ICU management will make the trial go smoothly because if your ICU management, the blood pressure is 180 every six hours in a day, then most likely this patient's
00:47:21
Speaker
going to have an extension of the dissection and end up with a sten graft.
00:47:25
Speaker
So clearly, the ICU team play a big role in making sure the patient do well.
00:47:33
Speaker
And getting a sten graft in the hospital is not the worst of things, obviously, but it's not necessarily the best of things.
00:47:40
Speaker
There's been other areas of uncertainty historically that refer to special populations.
00:47:48
Speaker
Could you comment on the genetically triggered thoracic ortic disease?
00:47:51
Speaker
You mentioned it initially as part of the epidemiology, Marfan, Ender-Danlos, and others.
00:47:58
Speaker
And the second population I wanted to have your opinion on was pregnancy.
00:48:03
Speaker
Right.
00:48:04
Speaker
So I'll start with the genetically triggered aortopathy.
00:48:08
Speaker
So they are currently, if you look up the Marfan Society website, Stengraft in the elective setting is considered to be not malpractice, but it's contraindicated.
00:48:21
Speaker
So meaning patients with any of the known genetic disorder, known, that's like a list of 20 or 30, 20 known, the most notable is FB1, FBN1 mutation or Marfan, and then obviously Lewis Dietz, and then Vascular, Helostanlose, and so on.
00:48:48
Speaker
These are, if they present with an emergency today, if it's a known or unknown diagnosis of a patient with Marfan, and again, being in Houston, you're blessed with the fact that we have the world's largest registry of Marfan syndrome at the Med Center, then it's
00:49:10
Speaker
If they present with an emergency, they get treated just like anyone else to save their life.
00:49:15
Speaker
But here's considered to be a bridge.
00:49:19
Speaker
So you seal the entry tear, you stop the malperfusion, you stop the rupture, and patient survives.
00:49:29
Speaker
you know, survive even till discharge, but you bring them back to repair or take the sten graft out and repair that segment of the aorta on the elective setting.
00:49:39
Speaker
That is what's considered to be the standard therapy for patients with connective tissue disorder in the acute setting.
00:49:50
Speaker
In the chronic setting,
00:49:51
Speaker
These patients are not necessarily treated with Stengraft to treat their aneurysms.
00:50:05
Speaker
Special caveat exists.
00:50:07
Speaker
I don't want to delve into it.
00:50:10
Speaker
It becomes a little technical.
00:50:12
Speaker
But, I mean, in acute setting, definitely Stengraft are life-saving.
00:50:18
Speaker
and you bring them back at a later date to kind of take the stem graft out and repair that aorta.
00:50:27
Speaker
Now, that's any of the known genetic disorder.
00:50:30
Speaker
You say they're a lot
00:50:35
Speaker
You save the life of the, you're obviously there to save the life of the patient, that is the pregnant lady.
00:50:46
Speaker
And if you can save the life of the fetus as well, depends on the time of presentation, when is the time presentation.
00:50:57
Speaker
And that could be done with endovascular means.
00:51:00
Speaker
There is no limitation.
00:51:02
Speaker
Usually for pregnancy, it's the end of the first trimester, beginning of the second trimester, where the baby is most influenced by radiation.
00:51:15
Speaker
But if you're doing this for an acute rupture,
00:51:21
Speaker
you are there to save the life of the women, of the pregnant mother.
00:51:28
Speaker
Now, pregnancy itself is an area where it's really women present 30-week type B aortic section.
00:51:44
Speaker
What do you do here?
00:51:46
Speaker
37 is easy, but 30 weeks, 28 weeks pregnant and now has a type B aortic section.
00:51:52
Speaker
And that is really the area where I don't, I definitely think there is a very little amount of data out there or even a consensus of what to do for those patients.
00:52:06
Speaker
And that's why it's an area of uncertainty because it's treated very individually and duly so because we don't have that much data.
00:52:17
Speaker
And again, I hope it's clear.
00:52:19
Speaker
Yeah, and pregnancy also, the challenges of studying that patient population are well documented.
00:52:26
Speaker
So you don't have data, and it's likely that's the way it will remain for some time.
00:52:32
Speaker
Yeah, yeah, yeah.
00:52:33
Speaker
I mean, again, I sit on a document oversight committee for the Society of Vascular Surgery, and we were debating what are the important topics to bring as the guidelines.
00:52:44
Speaker
And then very pressing and important is actually a treatment of a pregnant woman with an acute aortic event.
00:52:53
Speaker
We have no, any vascular surgeon trying to look for this topic, you find nothing, you hit a wall.
00:53:02
Speaker
In terms of long-term management of T-VAR and complications, what's the recommended follow-up for patients who are discharged after a T-VAR?
Post-Treatment Follow-up Guidelines
00:53:13
Speaker
Right.
00:53:13
Speaker
So the guidelines say you see them at one month and you see them in your repeat imaging.
00:53:19
Speaker
So you see them at one month, six months, 12 months, and then yearly thereafter with a CT scan.
00:53:27
Speaker
At each visit, you document blood pressure.
00:53:31
Speaker
You ask them to have a most blood pressure, most hypertensive patients have a blood pressure.
00:53:38
Speaker
Many hypertensive patients have a diary or a table of their blood pressure control.
00:53:44
Speaker
So you obviously try to go over that with them and highlight any areas where the blood pressure could be improved.
00:53:57
Speaker
So that is the regimen and that is where a partnership with a cardiologist that also has an interest in aortic disease is important and important.
00:54:13
Speaker
you know, you follow them as a vascular surgery, you follow them for aneurysmal growth, essentially, that's the most important thing.
00:54:21
Speaker
And when they reach threshold, given over a period of time of repair, you then take them for a repair of their aortic aneurysm.
00:54:32
Speaker
And that varies from, it depends on age and presentation and so on.
00:54:39
Speaker
So that
00:54:40
Speaker
We were talking before we started recording that a common transfer reason is somebody presents to an ED and they have pain or other symptoms.
00:54:52
Speaker
They get a CTA and these are patients who already had a T-VAR and they see things that are interpreted as abnormal and they get transferred to a vascular referral center.
00:55:03
Speaker
What are the true emergencies post-T-VAR that we should be aware of?
00:55:08
Speaker
So...
00:55:10
Speaker
uh that's so i can feel your uh it's funny when you get when you when you get a call all patient has a t-var call and ask a surgeon and this fast surgeon looks at it is like okay well send the patient back but which is nine out of ten times probably the case however
00:55:30
Speaker
There are definitely emergencies post-TVAR, post-immediate implantation or years even, years later.
00:55:40
Speaker
You can think of the, and it depends also on the age of the patient and the risk factors and whether hypertension or not plays a role.
00:55:49
Speaker
Now, you can think of the StenGraft as a rigid implant.
00:55:54
Speaker
rigid material sitting in the aorta that is moving.
00:56:00
Speaker
So you can imagine the forces, and it depends on if you put it top of the candy cane or in the straight portion of the candy cane or in the curve of that candy cane, these forces are going to hit the stingraft and cause all kinds of issues.
00:56:18
Speaker
Now, the issues can happen,
00:56:20
Speaker
In the true emergencies, that jet of blood with the systolic blood pressure hit the proximal part in that candy cane portion of the aorta and lead to a new dissection that goes in a retrograde fashion into the heart.
00:56:40
Speaker
So retrograde aortic dissection is directly related to the size of the stingraft and the fact that
00:56:49
Speaker
uncontrolled hypertension, you'll end up with a real disaster here by retrograde aortic section and causing a patient to have a type A. So, all of a sudden, patient has no cardiac output if it's in the operating room or, you know, could come a later date with a new chest pain or so on.
00:57:09
Speaker
So, similarly, could happen in the distal portion of the aorta and cause
00:57:14
Speaker
what's called a distal single new entry tear or D or SINE and stent induced a new entry S-I-N-E and that could cause
00:57:30
Speaker
a new type B aortic section could be with malperfusion.
00:57:35
Speaker
You put a sten graft in and you're high-fiving and you're good and the patient two days later has no flow and lactate goes up to 10 in the ICU.
00:57:45
Speaker
And that is because your sten graft actually caused a new tear that led to malperfusion.
00:57:55
Speaker
So immediately you could have a new dissection, proximally or distally,
00:58:00
Speaker
And that, or could, you know, these are the immediate complication that are true emergencies.
00:58:09
Speaker
I think that was your question.
00:58:11
Speaker
Yes.
00:58:11
Speaker
True emergencies.
00:58:13
Speaker
Over a long period of time, I mean, Stencratt could migrate, the aorta could dilate, and still have an aneurysm.
00:58:21
Speaker
But these are more chronic elective repairs that could be addressed on follow-up.
00:58:28
Speaker
But true.
00:58:29
Speaker
true emergencies really could happen in the ICU.
00:58:31
Speaker
I'm talking retrograde dissection or new entry tear is definitely on the top of the list.
00:58:40
Speaker
Perfect.
00:58:42
Speaker
As we close for us, what would you as a vascular surgeon want your ICU colleagues to know and to do?
00:58:48
Speaker
And we mentioned a lot of it throughout the conversation, but in terms of kind of a wrap up and summary.
00:58:54
Speaker
Yeah.
00:58:55
Speaker
Right.
00:58:56
Speaker
Everything I mentioned, but honestly, I would love it if ICU team develop into, if anyone, if you can have a dedicated aortic disease.
00:59:11
Speaker
team, and that includes the ICU team, to understand that aortic dissection is, I want them to know that aortic dissection is changing in terms of therapy.
00:59:24
Speaker
Blood pressure control in the ICU is of blood pressure and heart rate control is so important for the patient outcome.
00:59:33
Speaker
Open communication and taking ownership of the patient as much as the surgeon is key.
00:59:41
Speaker
And then low thresholds really for re-imaging.
00:59:45
Speaker
I mean, of course, you're talking to your surgeon or surgical team and so on.
00:59:50
Speaker
But recognizing, you know, these changes in patient labs or presentations and so on are important to trigger, you know, re-imaging or direct communication with the surgeon to consider...
01:00:13
Speaker
something new happened.
01:00:16
Speaker
That's really important in terms of, but if I want to give something to the intensivist and the nurses and the APPs and so on, is to, I cannot overemphasize the critical role of initial blood pressure management with the appropriate agents.
01:00:35
Speaker
Yeah.
01:00:36
Speaker
Perfect.
01:00:37
Speaker
Ross, we'd like to close the podcast with a couple of questions that are unrelated to the clinical topic.
01:00:42
Speaker
Would that be okay?
01:00:45
Speaker
I mean, I'll try.
01:00:46
Speaker
I don't know anything outside of the orientation, but yeah.
01:00:49
Speaker
We'll give it a shot.
01:00:50
Speaker
Perfect.
01:00:52
Speaker
Is there a book or are there any books that have influenced you significantly or a book that you have gifted often to other people?
01:01:00
Speaker
So I gifted something else with the books that I read many years ago.
01:01:08
Speaker
There's a book that my wife handed to me, and I think that was a beautiful read.
01:01:16
Speaker
We still remember it many years later.
01:01:18
Speaker
It's called A Dangerous Liaison.
01:01:20
Speaker
It's by Carol Seymour Jones.
01:01:23
Speaker
It's about the story...
01:01:25
Speaker
are the lives of Jean-Paul Sartre and Simone de Beauvoir.
01:01:29
Speaker
They're the two existentialist philosophers that lived for the 20th century in France.
01:01:36
Speaker
And it's a beautiful read for...
01:01:46
Speaker
I think for me, it resonated so much in terms of depth of living and so on.
01:01:52
Speaker
And then, you know, it's from a beautiful era in Paris.
01:01:58
Speaker
So why wouldn't you love that?
01:02:00
Speaker
It was a very, a book influenced me.
01:02:02
Speaker
You know, I do like history books as well, but that's probably dear to my heart.
01:02:10
Speaker
A book I gift more than others is,
01:02:15
Speaker
Very relevant to what I do and what we just discussed is A Time for All Things by Greg Walker.
01:02:23
Speaker
It's a book about the history of Baylor College of Medicine and Michael DeBakey and all that, which I think, given that all my friends are vascular cardiac surgeons or cardiologists or intensives, they find it helpful or useful, whether they're in it or not.
01:02:41
Speaker
These are the two books.
01:02:43
Speaker
Perfect.
01:02:44
Speaker
Could you share with us something you changed your mind about over the last few years?
01:02:51
Speaker
So I worked in, I had the privilege of working at the Imperial College in 2021-22.
01:02:59
Speaker
Still, as you mentioned, I'm part of the faculty and working in the NHS in England,
01:03:11
Speaker
It was an outstanding, amazing experience.
01:03:15
Speaker
Because many people tell you, so which is better, right?
01:03:20
Speaker
Because as if it's like, I'm going to put a number on it.
01:03:23
Speaker
And it's honestly, I'll give you an example.
01:03:26
Speaker
shows up in the emergency department with a diabetic foot ulcer and in the US we spend you know we we take the patient the next day we do a bypass and so on and the patient may lose their leg right very possible within within but within 10 days a patient would have had a would have had a problem solved one way or the other in England this patient will spend a good month in the hospital may or may not you know
01:03:56
Speaker
Actually, in the U.S., we would save their leg, but 10 days in the hospital, gets a bypass, goes home, but end up with a bill of $5,000, for instance, let's say.
01:04:07
Speaker
In England, they may spend a month in the hospital, and they may lose their leg.
01:04:11
Speaker
There's a good chance, and they end up with a BKA, but guess what?
01:04:15
Speaker
It's free, right?
01:04:17
Speaker
So a patient, you ask as a patient, one is stuck with a $5,000 bill, and one is free, right?
01:04:25
Speaker
So which is happier?
01:04:26
Speaker
Because maybe you and I could pay a $5,000 bill, but not average, not most patients cannot, right?
01:04:34
Speaker
Right.
01:04:35
Speaker
So, so that led me to think is like, you cannot say which is better and you lost a leg guaranteed.
01:04:43
Speaker
And this guy that had a bypass may lose their leg eventually, but it changed my life in the sense of like, there's so much the things that we take, what we do and we think, you know, in our daily life that, that is totally different from, you go to a different country or even different hospital or different state.
01:05:02
Speaker
So that's my cynical way of actually how I change my views in medicine in general, to be honest.
01:05:11
Speaker
And I think different experiences provide different perspectives, but also at the end of the day, it's also why there's so much difference ideologically today in the United States is not because the other side of what you think or people feel different are wrong.
01:05:28
Speaker
It's just that they value different things.
01:05:30
Speaker
Yeah, totally.
01:05:31
Speaker
Totally.
01:05:32
Speaker
What you value and what you choose to solve for because you can't solve for everything, right, determines a lot of those impacts.
01:05:39
Speaker
But I do believe that I agree and it makes a lot of sense.
01:05:43
Speaker
And the final question is, what would you want every listener to know could be a departing thought, even a quote that you want to share with us?
01:05:53
Speaker
Well, that's a good one because I actually struggle to come up with –
01:06:02
Speaker
over the years, maybe as I get older, you become more and more cynical of everything around you or just me.
01:06:11
Speaker
I think a code or a fact, I think it's hardly no one knows.
01:06:17
Speaker
I mean, I guess you could say...
01:06:21
Speaker
no one cares to know the truth kind of thing because, I mean, the truth could be a lot of things that you may or may not want to know.
01:06:30
Speaker
So that's it.
01:06:32
Speaker
And for us, I want to thank you for your generosity with your expertise and your time.
01:06:38
Speaker
We'd definitely love to have you back for another conversation on vascular emergencies.
01:06:43
Speaker
We'll keep track of the ongoing trial with the uncomplicated patients.
01:06:47
Speaker
type B dissections and see when that comes out.
01:06:50
Speaker
But again, thank you.
01:06:51
Speaker
Thank you very much for being on with us.
01:06:54
Speaker
Thank you.
01:06:55
Speaker
Thank you, Sergio.
01:06:55
Speaker
It's a great honor.
01:06:56
Speaker
Thank you.
01:06:57
Speaker
It's a great day.
01:06:58
Speaker
Thank you.
01:07:00
Speaker
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01:07:04
Speaker
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01:07:10
Speaker
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01:07:14
Speaker
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