Centered on Health 12-19-24 - Trans Carotid Artery Revascularization (TCAR) procedure with

Centered on Health 12-19-24 - Trans Carotid Artery Revascularization (TCAR) procedure with Dr. Noah Scherrer.

Episode Transcript

Speaker 1 (00:01):
It's now time for Centered on Health with Baptis's Health
on use Radio waight FORTYJS. Now here's doctor Jeff Tumbler.

Speaker 2 (00:10):
Good evening, everyone, and welcome to tonight's episode of Centered
on Health with Baptist Help Here on News Radio eight
forty whass.

Speaker 3 (00:19):
I'm your host, doctor Jeff Publin, and we're.

Speaker 2 (00:21):
Joined as always from our studio with our producer mister
Jim Sen. Tonight we're talking about vascular diseases, and just
by a way of introduction, I just want to let
people know that as boomers age, the burden of vascular
disease is increasing in our country and seventy six million
Americans will create a demand for increase.

Speaker 3 (00:40):
In vascular health.

Speaker 2 (00:42):
Virperal artery disease affects twelve million people in the United
States and two hundred thousand people a year suffer with
abdominal aortic aneurysms and stroke is still one of the
leading positive deaths in our country. So with that background
and massive undertaking in mind, I want to you to
tonight's guest, who is doctor Noah Sharer. Doctor Scherer comes

(01:06):
to us and specializes in general surgery and vascular surgery.
He is a graduate from the University of Louisville School
of Medicine. He did surgery at the University of Louisville
and vascular surgery at University of Kentucky, and he specializes
in extensive and has extensive experience in caroated end our
directomy for a world vascular disease and.

Speaker 3 (01:27):
Aortic aneurysm and dirotation disfection. And we're going to.

Speaker 2 (01:30):
Learn about what all of those things mean tonight. So
welcome to Centered On Hell, Doctor Terror.

Speaker 4 (01:36):
Great Jeff, thanks for having me.

Speaker 5 (01:39):
It's our pleasure.

Speaker 2 (01:39):
This is actually a topic we haven't covered in a
very long time. So we're thrilled to have you. We're
thrilled to have you as part of our community. But
maybe just start by telling us a little bit about
your path and your decision to become a vascular surgeon.

Speaker 1 (01:56):
So back in med school, I was always kind of
attracted to the surgical side of things. The hands on
nature of surgery was always intriguing to me. I also
had interest in radiology, just the computers the science of
radiology were always intriguing to me as well. And as

(02:18):
I kind of progressed through surgery training, I realized there
was kind of a mixture between radiology and surgery, and
that was vascular surgery, which is very technical in nature,
but that also relies heavily on technologies X ray, ct skins,
things like that.

Speaker 2 (02:34):
I'm sure we'll hear a lot about that, But tell
us what is a vascular surgeon?

Speaker 3 (02:39):
What kind of condition do you treat it? What are
the most common things that you treat? In your questions?

Speaker 1 (02:46):
A very good question, and my family asked that question
as I was getting involved with ascular surgery, and so
my initial response was, a bascular surgeon is a surgeon
who takes care of arteries and things, to which my
family would say, you mean like open heart surge, and
I'd have to correct them and say, no, open ur
surgery is done by open art surgeons, right. I said, okay, well,
what kind of conditions do you treat? And I would say, well,

(03:07):
a big, big group of conditions. We treat our aneurysms.
They say, like, like brain aneurysms, and I'd have to say, no,
the neurosurgstreet the brain aneurysm. So, after many failures in
trying to describe what a vascular surgeon is, I think
I've come down to. A vascular surgeon is someone who
takes care of the arteries in veins outside of the
heart and outside of the brain.

Speaker 2 (03:30):
That seems like a very understandable and something we can
all bite into to understand. So within that context, give
us a very small one oh one anatomy lesson of
the types of arteries or veins that we're going to
be talking about with some of these conditions tonight.

Speaker 1 (03:48):
Sure, and so a big part of what every vascular
surgeon takes care of is we would term it cervical
crowded artery disease, and so that would that means in
the neck, and so artery disease accounts for about a
third of all stroke is the cause of about a
third of all strokes. And so there's once again blockages

(04:09):
that occur within the neck, but then also.

Speaker 4 (04:14):
Within the brain.

Speaker 1 (04:15):
The neuro certains take care of the ones in the brain,
where we take care of the ones in the neck. Abdominally,
ortic aneurysm is a big part of what we treat.

Speaker 6 (04:25):
Uh.

Speaker 1 (04:25):
This is an andeurism or a dilation of the artery
in the abdomen, the main artery called the aorta peripheral
arterial disease is blockages out in the extremities, mainly in
the lower extremities.

Speaker 6 (04:39):
And then we do a lot of what we term dial.

Speaker 1 (04:41):
Dialysis access, and so patients who are on dialysis dialysis
need a means to receive that, and so we help
the neuprologists obtain access surgery normally in the upper extremities.

Speaker 2 (04:57):
And you just did a great job of sort of
road mapping some of the different conditions We're going to
try and talk a little bit about tonight, but in general,
what are some of the more common causes of disease?
Are we talking genetic here or are we talking things
in the environment that cause these problems? What do you
see as sort of the most common reasons people develop

(05:19):
diseases of sure.

Speaker 1 (05:22):
And so genetics hereditary is a big, a big part
of it. Smoking, diabetes, high blood pressure, high quest for
all or kind of the classic five main ideologies of
vascular disease.

Speaker 2 (05:38):
So it's certainly a big, a big problem in Kentucky.
With tobacco, I would imagine that.

Speaker 1 (05:45):
Yeah, tobacco and diabetes are big drivers on a regional
level for vascular disease.

Speaker 2 (05:53):
And so I think we're all you know, you mentioned
the brain and you mentioned the heart, and I think
we all kind of are able to sort of wrap
our head around, you know, a heart attack. We hear
about the plaque, and we hear about that causing the
heart attack. Is that kind of what we're talking about
with the vessels throughout the rest of the body. Are
these blockages or are these low flow states? What kind

(06:14):
of things are you do you see.

Speaker 1 (06:17):
Some of it that just depends on the location. So
like for lower extremity, for for our teer disease, normally
we're dealing with flow restrictions being the main problem. These
arteries of the legs get blocked off and there's just
not enough blood supply making it down to the legs.
Whereas the crowded arteri is a little bit different because
very rarely in the crowded are we dealing with the

(06:39):
flow restricting lease into the brain. Normally we're dealing with
the lesion. That is, as it gets more severe, if
becomes fragile, and parts of that blockage can kind of
break off and shower up to the brain causing strokes.

Speaker 4 (06:52):
So it's a little bit different, and it's just that
depends on.

Speaker 1 (06:55):
The location is to what's the main driver of the
symptom that's produced.

Speaker 2 (07:00):
And what are some of the sort of typical symptoms
that somebody might present with. If somebody's at home wondering
if they might have vascular disease, what what are some
of the presenting symptoms.

Speaker 1 (07:14):
Well, it just it somewhat depends on the location.

Speaker 6 (07:17):
And so for for crodded art.

Speaker 1 (07:19):
Disease, the kind of the scary thing there is usually
they're asymptomatic.

Speaker 4 (07:23):
Until they cause a stroke, and so.

Speaker 1 (07:27):
There's screening kind of recommendations out there, and then to
determine if someone has an asymptomatic blockage that might require
treatment for an abdominally or degangneurism, that's usually those are
asymptomatic until they cause pain and can potentially rupture.

Speaker 4 (07:45):
And so.

Speaker 1 (07:47):
Whereas the lower extremities of proffer arterial disease. Normally people
will complain about cramping in their legs. Usually they're caps
when they walk due to that flower restriction.

Speaker 5 (08:00):
And is that is that qudication?

Speaker 2 (08:03):
Is that what people describe as claudication when they read
in that term.

Speaker 1 (08:09):
Yeah, and so I would I would be a little
bit more specific and say that would do vascular qudication.
There's also a neurogenetic quadication out there. My professors in
college tell me that qudication is derived from the Latin
word to limp, and so there's many reasons, and so
the neurosurgeons talk about neurogenetic ludication, but persual Archer disease

(08:32):
would cause vascular genetic qudication.

Speaker 2 (08:35):
So it sounds like the type of symptoms that that
patients experience help you localize kind of where the problem
might be. That the symptoms may vary obviously depending on
which part of the vascular system is involved. Is this
something that the primary care normally picks up on and
sends to you?

Speaker 3 (08:54):
Or how do may get to you normally?

Speaker 1 (08:57):
Primary care doctors are a big a big group of
kind of referrals for US cardiologists because they're they're dealing
with athmoscrotic disease of the heart and they there's a
lot of overlap there or a big referral. And then
nephrologists are a big group that refer to us as well,

(09:19):
but usually a lot of vascular disease is kind of
identified incidentally, and so someone's getting a CT scan of
their abdomen for abdominal pain and they see a small aneurysm.
That's a big a big group of referrals or these
incidentally identified vascular abnormalities or diseases.

Speaker 2 (09:39):
Well, I think you have really set the stage for
us to jump into some of these diseases. So we're
going to take take a break, and I want to
let everyone know you're listening to center It on Health
with Baptist Health here on news.

Speaker 5 (09:50):
Radio eight forty w h as.

Speaker 2 (09:53):
We are talking tonight with doctor Noah Sharer vascular surgery
about different types of vascular diseases and and changes in
and surgery.

Speaker 5 (10:02):
We'll be right back.

Speaker 2 (10:15):
Welcome back to set it on Help with Baptist Help
here on news.

Speaker 5 (10:18):
Radio eight forty w h AS.

Speaker 2 (10:21):
I'm your host, doctor Jeph Publin, and tonight we are
talking with doctor Noah Sharer about provided arder disease, vascular disease,
abdominal aneurysm, lots of stuff to cover with him. We
just talked a little bit about some of the anatomy
and some of the symptoms that people might have with
these conditions. So welcome back, doctor Sharer, and I just

(10:43):
wanted to you mentioned something we talked a little bit
about stroke, and I know that that kind of spans
a little.

Speaker 3 (10:49):
Bit between vascular and neurovascular.

Speaker 2 (10:52):
But for the people listening, can you talk to us
about the difference between stroke and something we hear a
lot mentioned, which is c I A. Are those are
those the same thing?

Speaker 1 (11:04):
There's similar things, some would call them kind of on
a spectrum of disease, where strokes and more serious and
tias or are are less serious. But generally speaking, these
are generated from a lack of blood supply to the brain,
where traditionally strokes.

Speaker 6 (11:24):
Were a lack of blood supply.

Speaker 1 (11:26):
That would cause symptoms for greater than twenty four hours
or TIA's or less than twenty four hours. Most TIA
people have symptoms that are relatively quickly resolved, while stroke
people are more at risk for having a permanent disability
from it.

Speaker 2 (11:41):
Okay, caused by sort of similar risk factors and and
things like that.

Speaker 1 (11:47):
Yeah, there's there's two broad classes of strokes. There's a
schemic strokes and hemorrhagic strokes, and so a hemorrhagic stroke
would be from a brain bleed. As a vascular surgeon,
we don't really get too much involved in the hemorrhagic strokes.
We generally are are more focused on the schemic strokes
because that's that's where the blockage in the crowded artery

(12:08):
in the neck is really more common.

Speaker 2 (12:11):
The cause of that, now you mentioned in the first
segment and with your interest in doing this, the kind
of the combination between the vascular system and the radiology
part of things. So what radiology tests do you use
most to help with your diagnoses and for for.

Speaker 1 (12:33):
For vascular surgeons, it's it's a crowded ultrasound or a
crodi duplex, which is a non invasive study where an
ultrasnographer will ultrasound the crowded artery ct angiogram, which is
a cat scan that uses contrasts to image of the
arteries into a lesser extent. MRIs are helpful for us.

(12:57):
MRIs are very extremely help or to determine what's going
on in the brain itself, but for imaging the arteries,
the the CT scans much preferred.

Speaker 5 (13:09):
And you know, we would be remiss.

Speaker 2 (13:11):
You know, obviously we love having our vascular surgeons, but
even better would be if we did a good job
of keeping people out of your offices. So what you
mentioned some of the lifestyle things like the tobacco and diabetes.
Is this reversible if somebody were to be at risk
for this periphol vascular or prodid disease? Does lifestyle modifications

(13:32):
do they make a difference?

Speaker 1 (13:35):
I would absolutely they make a difference, and so as
well as medical therapy. And so I saw two or
three people today in my office that had moderate astyantumatic
crowda disease.

Speaker 6 (13:47):
And everyone wants to know, well, is my crowd.

Speaker 1 (13:49):
Disease improving with the medicines and with smoking cessation? And
I know, I'm tell them, listen, this this won't improve
on its own, but as long as it doesn't get
worse and it remains a symptomatic, and that's that's a
pretty stable place to be in. And so as a general,
some lifestyle modifications will prevent the progress or reduce the

(14:11):
risk of progression of disease, but it won't reverse the disease.

Speaker 2 (14:17):
And so how does a vascular surgeon such as yourself
then decide when is it time to operate?

Speaker 1 (14:26):
There's pretty good The Society of Rescue Surgery has some
pretty good guidelines and they're kind of pulling large amounts
of research and so current guidelines would suggest that anyone
who has a greater than seventy percent product blockage should
be evaluated for some sort of revascularization, and then people

(14:47):
who have over fifty percent blockages who've had a neurologic
event such as a stroker tia, should be evaluated for surgery.

Speaker 2 (14:57):
And I know we're to get into some the specifics
of some of the surgeries, but in general, is what
you do. Would it be considered invasive surgery or non
invasive surgery? I mean, I know all surgery is somewhat invasive,
but when we talk about non invasive type procedures, is
that what you're doing in your practice?

Speaker 4 (15:19):
I would say that.

Speaker 1 (15:20):
There's really three options for crodded revasterizations. There's it's called
the endar direct to me, which is a surgery that's
an incision on the neck. I mean, it's there's there's
no way to describe that other than surgery. There are
some options for for stenting that are less invasive, but
I would as a surgeon, I would always consider them

(15:41):
surgeent surgery.

Speaker 6 (15:42):
However, I do some people.

Speaker 4 (15:43):
Think that.

Speaker 1 (15:46):
One of the types of stinting would be considered mentally.

Speaker 2 (15:49):
Or less invasive less invasive, And before we hear about that,
let's get some clarity. We hear about stents a lot,
and I think people might be familiar with the idea
of a stent, you know, in the in the vessels
at the heart. Are we talking about the same kind
of scent? What what is a stent and how is
it placed in? What is it doing once it's being placed.

Speaker 1 (16:14):
A stent is essentially a metallic structure that that goes
into an artery that you can place it remotely, so
your access point to the artery system is different in
the place that the actual stent's being deployed. And then
there's there's different stent technologies and delivery systems that are
the cardiologists are using a different type of stent in

(16:36):
than we are in a lot of situations. But the
overall concept is you're entering the artery somewhere remote to
where the actual narrowing is and then deployed remotely.

Speaker 2 (16:48):
And do these things stay in forever? Do they get
changed out over time? What what's the long term?

Speaker 4 (16:55):
Generally they stay in forever.

Speaker 1 (16:56):
I mean, there's very few indications to go in and
actually remove a stent, and there are some, but they're
very kind of few and far between. Generally speaking, the
stand forever. Anytime anyone has a stent in the artery,
there's always some risk of some reen erring or resynosis
in the stent, but that's.

Speaker 6 (17:14):
Generally fairly rare in the crowdrid arteries.

Speaker 2 (17:18):
And I would be remiss as a GI doctor because
some of you keep us in business.

Speaker 3 (17:24):
Tell us a little bit about the need for blood
dinners with the stent.

Speaker 1 (17:29):
Yeah, and so we'll kind of speak to the crowded
stent because I think there's actually maybe some of the
best data we have for crouded stents. And so generally speaking,
you have to be on multiple blood ending medicines for
at least a month after a crowded stent.

Speaker 6 (17:48):
I generally prefer to have people on it.

Speaker 1 (17:49):
For three months after a stint, and then if subsequent
imaging shows that the stent is without any renarrowing, we
can drop to a single agency should ask for an
or plants. But yeah, that that's dealing with the arteries. Normally,
we're dealing with blood any medicines almost in everything that
I do.

Speaker 2 (18:11):
Yeah, and so from for a stent, though it's not
lifelong necessarily that they have to stay on bloodsinners.

Speaker 1 (18:19):
At least single agent.

Speaker 6 (18:20):
Yes, we'll need to be honest.

Speaker 2 (18:21):
At least a plant long term, Okay, And starting with
the karate end artectomy, you know, thinking about the karrotid artery,
you talked about symptoms being a little bit different based
on where the problem is. So if we stick for
now with the krotid artery, if there was a problem
with the artery other than a stroke, what are some

(18:43):
other symptoms people might experience that might alert them to a.

Speaker 3 (18:46):
Problem with that.

Speaker 1 (18:50):
That's one of the I want to say kind of
scary things about the crowded arteries a lot of times.
For most times, the first symptom someone has is a
tia or stroke, and so there's not a lot of.

Speaker 4 (19:02):
Symptoms that are other.

Speaker 1 (19:04):
I mean, every now and then, if someone has severe
quandity blockages on both sides, they can have dizziness or
white headedness, but that is extremely rare. The vast majority
of people are asymptomatic until they have a stroke, and
so there are some screening kind of protocols out there.
Most major hospitals who have kind of a vascular presence

(19:26):
will offer a screening evaluation for patients at pretty low
costs just to see if they have risk factors.

Speaker 4 (19:34):
They can get one of these screening tests.

Speaker 2 (19:38):
And when you're doing the exam in the office, do
you rely only on the ultrasound? Is there something when
you're examining a patient that you can tell that indicates severity?

Speaker 3 (19:49):
Like anything?

Speaker 6 (19:50):
Sure?

Speaker 1 (19:51):
Very good, very good question. You can osco take to
take a stethoscope to the neck and you can hear
a brew which is actually the abnormal kind of squish
over the blood through a severe and arrow wing. It's
a good test in the sense that if you hear it,
they probably have blockages. But it's not a great test
if you don't hear a brewerie. There's plenty of people

(20:12):
out there that have fairly severe crowdate blockages without any
brewerie on a uh with the stethoscope. And so really
the the I wouldn't feel comfortable at saying that someone
doesn't have a blockage.

Speaker 6 (20:23):
And we have a crown a duplex.

Speaker 2 (20:26):
We are talking tonight with doctor Noah Scherer, who is
a vascular surgeon who's telling us tonight about all different
types of vascular surgeries and improvements in the treatment.

Speaker 5 (20:37):
This is centate on Health with Factors Health.

Speaker 3 (20:39):
Here on news radio A forty w as.

Speaker 5 (20:42):
I'm the health doctor Zeth Peblin, and.

Speaker 3 (20:44):
We'll be right back after these plays.

Speaker 5 (20:57):
Welcome back to Senate on Health with baftor Hell here.

Speaker 3 (21:00):
On news radio eight forty whas.

Speaker 5 (21:03):
Sign your hosts doctor Jeff Publin, and tonight we're talking
with doctor.

Speaker 1 (21:07):
Noah's Share vascular surgery.

Speaker 2 (21:09):
So teaching us about signs and symptoms of vascular disease
and working it up and how to get.

Speaker 3 (21:14):
It taken care of.

Speaker 2 (21:15):
So, Doctor Schera, you have done a great job setting
the table of explaining all of this to us.

Speaker 3 (21:21):
But I think you know now we really want to
know what you do when.

Speaker 2 (21:26):
You find these problems and what you do when you
take us to your operating room. So starting with sort
of the caroated artery, which is spent a lot of
time talking about what are the different types of surgeries
you do on the karate.

Speaker 4 (21:43):
I would say there's there is a general statement.

Speaker 1 (21:45):
There's really three different ways to revascularize or croddit artery.
There's the kind of tried and true gold standard surgery
it's called a crowded and our directomy. There's the trans
semeral crowded stint, and then there's the trans crowded arterial
stent placement.

Speaker 4 (22:05):
The crowded end our directing.

Speaker 1 (22:08):
He is a surgery that's been done for roughly seventy
years in the United States. It has very well documented outcomes.
It's one of the more durable things that we do
in vascular surgery. It entails making an incision along the
side of the neck, overlying the crowded artery, dissecting down

(22:28):
to the artery itself, and then actually putting clamps above
and below the blockage, and we actually open up the
artery and shell out or core out the blockage itself
and then close the artery.

Speaker 2 (22:41):
So when you say that are you are you stopping
the actual blood flow through that vessel if you're plamping
it on both sides.

Speaker 1 (22:51):
Yeah, So we would never do a crowded end our
directing on both sides simultaneously, and so there's always blood
flow coming up to the other side.

Speaker 4 (23:01):
The way that I and a lot of.

Speaker 1 (23:03):
Surgeons do their crowded end our directmis is we can
actually insert a temporary tube that carries blood supply through
the crowded artery while we're working on it. It's something
we we call a shunt, and that allows us to
have plenty of time to clean out that artery and
know that the brain is getting adequate blood supply during
during that person to surgery.

Speaker 2 (23:23):
And so while you're in there, are you you're literally
just scraping out what's in there to open up the
loom there.

Speaker 1 (23:33):
Yeah, And so I think when when you when you
get inside of an artery, uh, it's better to not
to think of it as just a single walled structure.
The walls of the artery almost have kind of the
layers of an onion kind of phenomenon to it. And
so generally speaking, the apiscratic plaque is involving the inner
layers and it's say it spares the outer layer. And

(23:54):
so we can actually remove the inner layers of the
artery almost like we're peeling out the core of an onion,
and then close the outer layer back.

Speaker 2 (24:04):
And what's warming on the inside is this is this
made of cholesterol?

Speaker 5 (24:09):
Like what what?

Speaker 2 (24:10):
What is the disease process that typically you're dealing with
when you're generally it's.

Speaker 1 (24:16):
A it's a broad kind of class of it's called
aphis closis, and so it's it's all the risk factors
that we talked about before that lead to it, and
it's kind of a complex phenomenon, but it's a lot
of it's driven by mascular information in cholesterol and deposition
in the wall of the arteries.

Speaker 2 (24:36):
And the way you describe it, this sounds like on
the spectrum of things, a little bit more on the
like more invasive side of things. What how do the
other two things you mentioned compared to this process.

Speaker 4 (24:51):
Yeah, and so I'll talk about this.

Speaker 1 (24:54):
The other one, which is kind of a newer procedure,
is called the key car transcarded our tour rescuezation. In
that situation, we make a small incision at the base
of the neck. We actually insert a catheter or a
sheath into the artery itself below the blockage, and then
we can go up from that access point and use

(25:14):
a balloon and use a stent to open up that artery.

Speaker 2 (25:19):
And how do you see that affecting either the time
of the procedure or the recovery, Like, what what are
we seeing in terms.

Speaker 3 (25:29):
Of differences with these two different approaches.

Speaker 1 (25:33):
The timing of the actual inoperating room times roughly similar.

Speaker 6 (25:37):
The hospital time is roughly.

Speaker 4 (25:39):
Similar as well.

Speaker 1 (25:41):
Both these both those types of surgery require admission to
the hospital for close observation overnight, but most of the
people go home on post operator day.

Speaker 4 (25:51):
Number one.

Speaker 1 (25:54):
The benefit about the making the nec incision to put
the stent in versus making an access in the femoral
artery and the groin and put the stent in that way.
One of the fears about putting a stent in is
that while we're manipulating the stent across the blockage, that
parts of the blockage can break off and you go

(26:16):
through the brain and cause strokes. And so.

Speaker 6 (26:20):
The way we've.

Speaker 1 (26:21):
Kind of figured that out, if we're doing this from
the neck, we can actually through kind of a using
clamps in different external catherines, we can actually temporarily reverse
the blood supply in the brain.

Speaker 6 (26:35):
Thereby, if anything.

Speaker 1 (26:36):
Breaks off in the crowded artery while we're working on
getting a stent in there, that it'll come out of
the patient and go through a filtering device and then
we're able to give that blood back to them via
an IV basically, and that way it prevents that blockage
from breaking off and causing a stroke during the procedure.

Speaker 2 (26:53):
Wow, So how do you determine who's a good candidate
for WITCH or is this it's about what your comfort
level is as a surgeon, or what is the decision
process to who gets what type of procedures.

Speaker 1 (27:09):
Some of that becomes surgeon and patient preference, and so
there's always kind of a discussion and we talk about
this shared decision making with the patient about well, here's
the risk, here's the benefits of each type of procedure.
The outcomes are pretty similar when it comes to risk
or stroke during during the procedure. The incision is less

(27:31):
for the transcrided arterial stent versus the end our directomy.
I don't pride myself on being a plastic surgeon, so
people I don't try to minimize scars, but at the
same time, I'm not going to alter what I think
is going to be best for the patient based upon scars.
The one thing that I have found is there are

(27:53):
certain aspects of a person CT scan that make them
favorable an end our directimy versus the crime. It's ten
placement and I normally just figure out which which anatomy
the patient has and try to tailor the recommention to them.
If I think his stent is going to be easier,
lower risk. I think that's the way to go versus
an indoor direct tomy. And in one of the things

(28:15):
that we found is what makes an indoar direct to
me easy, makes a T car hard and kind of
vice versa.

Speaker 3 (28:21):
Oh that's interesting.

Speaker 5 (28:22):
Yeah.

Speaker 2 (28:23):
So having said that, so is the t CAR something
that at this point, you know, somebody's looking for a
baster or surgeon they need work done. Is everybody trained
in this at this point or is this still something
that certain people are doing and patients.

Speaker 3 (28:41):
Need to specifically ask if this is an option.

Speaker 4 (28:46):
I know in my.

Speaker 6 (28:47):
Group, so I work with seven other rescular.

Speaker 1 (28:49):
Surgeons, we are all doing key cars. I can't speak
for every everyone else. I would imagine that anyone coming
out of a training program and twenty twenty four will
be trained in t CAR. But this is a relatively
new procedure. It's I think that one of my partners
did the first one in Kentucky back in twenty seventeen, doctor.

Speaker 4 (29:10):
Thomas, and so it's a.

Speaker 1 (29:12):
Relatively new procedure, but it has gained traction pretty quickly.

Speaker 2 (29:19):
So with these procedures give us a little bit of
like an outlook afterwards. So somebody has this disease that
needs to be fixed in the crowded arry, they have
one of these procedures done, what's their long term outlook in.

Speaker 3 (29:35):
Terms of needing something to be redone down.

Speaker 2 (29:38):
The road or their quality of life afterwards? What can
they expect from their long term health?

Speaker 1 (29:45):
I think the real expectations should be to get them
back to their preoperative kind of quality of life. I mean,
most people do quite well with the cervical with the
that concision and to beyond, most people when they come
back and see me in two weeks and for follow up,
most these people are kind of, hey, can I start

(30:06):
driving again? Can I start doing the things that I
want to do again? And I kind of generally let
them go back to what they were doing preoperatively. There
is always risk of renarrowing occurring in either and end
our directing or extent, and so all these people become
kind of lifelong patients for me, where we'll be checking
ultrasounds at scheduled.

Speaker 4 (30:28):
Intervals for the rest of their life just to.

Speaker 1 (30:31):
Make sure that there's no blockage that redevelops.

Speaker 2 (30:35):
Fantastic, Well, we are gonna move from the carotit artery
to the aortic aorta when we get back. So you
are listening to Center on Health with Saptors Health here
on news radio eight forty whas.

Speaker 5 (30:48):
I'm your host, Doctor Jeff Calvin. We're talking tonight but doctor.

Speaker 3 (30:51):
Noah Sarah vascular Surgery.

Speaker 2 (30:53):
I want to remind everybody to download the iHeartRadio apps free.
It's easy to use, and to listen to tonight's show
any of our other shows.

Speaker 5 (31:01):
You'll be right back. Welcome back to Centered on Health with.

Speaker 2 (31:14):
Factor's Health here on news radio eight forty whas. I
am your host, Doctor Jeff Puelblin, and we're talking tonight
with doctor Noah Share vascular Surgery about different types of
vascular diseases and procedures. Remember to die download the iHeartRadio
app to re listen to this or any of our
previous segments, and to have access to all the other

(31:35):
features that the app has to offer. Well, Doctor Share,
we spent a good amount of time on the carotid artery,
and I think we're all understanding our options for that treatment.
One of the other big vessels that I know that
you deal with is the A order, and we talked
a little bit about that at the beginning, but tell.

Speaker 5 (31:53):
Us about why why the order.

Speaker 2 (31:57):
Is so important and the different parts of the A
order that you might see the disease.

Speaker 6 (32:02):
Sure, and so the order is.

Speaker 1 (32:04):
The main artery that comes out of a heart and
kind of is the distribution network for the entire body.
And so it starts in the heart and goes up uh.
Then it kind of almost makes a candy cane before
it goes back down through the chest into the abdomen
before listening to two main arguments to the legs.

Speaker 2 (32:24):
And so.

Speaker 1 (32:27):
The sections of the A order are kind of the
A sending A order. That's the one immediately adjacent and
above the heart.

Speaker 6 (32:34):
That's the one area that the cardiac.

Speaker 1 (32:37):
Surgeons are kind of fully in charge of. In the
mascular surgeons, we really don't get involved up at the
NBA sending A order. The arch as we turn as
turn as it kind of goes back down through the
chest into the abdomen, and at that point it's given
off the main orderies and are going up to the neck,
brain and arms. It goes down through the chest we

(33:01):
call the descending A order, uh, and then it ends
up entering the abdomen, where it gives off all.

Speaker 6 (33:06):
The arties that go to the kidneys and.

Speaker 1 (33:08):
Testined livers or liver and the poor. It's roughly the
level of the valley button into the two artis that
goes in the banks.

Speaker 2 (33:17):
So it sounds like depending on which part of that
a order might be disease would certainly have implications on
what organs or downstream effects one might experience. So we
all hear of the word triple a. You know what
what is an aneurysm? What is a triple a and

(33:38):
why is it so concerning.

Speaker 1 (33:41):
U triple A stands for an abdominal aorderic aneurysm, and
it's a ballooning out or a dilation of the portion
of the aorta called the abdominal aorder, which is obviously
down in the abdomen. We care about them greatly because
as they grow, they start running the risk of rupturing,

(34:02):
and the general from people who have ruptured aneurism.

Speaker 6 (34:07):
Do fairly poorly right from that process.

Speaker 2 (34:11):
Now, as a gastroenterlogist, and I'm sure everybody in other
fields would feel the same way, we order imaging tests
for our personal reasons all the time, and sometimes we
get a result that that someone has an aneurysm, but
we don't have to address them right away. What are
sort of the Is there a reason why not every

(34:34):
aortic aneurysm has to be operated on?

Speaker 5 (34:36):
And how do you follow them?

Speaker 3 (34:38):
And at what point does it become something that needs
to be addressed?

Speaker 1 (34:41):
Sure, on a personal level, I wish every aneurism needs to.

Speaker 6 (34:44):
Be operated on because it's one of my favorite.

Speaker 1 (34:46):
Operations, and so from a pure selfish reason, I wish every.

Speaker 4 (34:51):
Generally speaking, at.

Speaker 1 (34:52):
The size the risk of rupture is based upon the
size of the aneurism in so five or five and
a half centimeters inside kind of uh, is the point
in which we really need to start thinking about fixing them,
because the risk of rupture kind of starts.

Speaker 4 (35:06):
To really increase at that.

Speaker 2 (35:07):
Point, and before we get into some of the ways
that you repair these. Is it the similar risk factor
for what we talked about with the Karada in our
direct you and were talking like how important is cholesterol
and hypertension and those things? Can those things alone modify
the risks of the aneurysm? Or once you have the aneurysm,

(35:28):
it's a mechanical thing that this needs to be fixed.

Speaker 1 (35:31):
That's kind of both those both those statements are kind
of partially true. And so there's there's kind of degenerate
degenerative forces that kind of will will over time make an.

Speaker 4 (35:43):
Aneurysm get larger. Uh.

Speaker 1 (35:46):
One of the big risk factors for reducing that would
would be smoking cessation. But a lot of times we
see people who have controlled risk factors in their aneurysm
continues to grow. So there's more things that play than
just risk for modification.

Speaker 2 (36:02):
Well, one of the things I love about doing this show,
I mean, that's the statement I say, almost weakly, is
when we get to highlight something that is happening in
our community that really advances the leading edge of any
particular field. And I know that with you and your practice,
you're doing some work with aortic aneurysms that are fitting that.

(36:22):
Can you tell us a little bit about some of
those procedures and surgeries that you're doing.

Speaker 6 (36:27):
Yeah, and so traditionally, kind of twenty.

Speaker 1 (36:30):
Thirty years ago, the way these aneurysms were all fixed
was it was a very big operation where we would
make an incision, we would go down to the aneurysm itself,
we would put large clamps kind of above and below
the aneurysm, partially resect it and so a synthetic kind
of fabric graft in the place of it. These were

(36:51):
very large operations where people took three four months to
get over them, and then really a lot of them had,
I mean, it was a big ordeal. Over the last
twenty or thirty years, stent craft technology has improved where
we're now able to go pretty minimally invasive and make
small incisions in the growing and kind of go up

(37:12):
from inside the aneurysm and re line the andeurism with
a device called a stent craft. And so for the
last kind of twenty years we were really confined by
the patient's anatomy on who was a candidate for the
stent craft repair versus who would still require open surgery.
But as kind of technology advances, so to our abilities
to kind of treat people in you remain invasive. And

(37:33):
so there's two relatively new technologies where we can kind
of expand the anatomy that we can treat. These are devices.
One of them is called the TV or the thoracic
branch end or prosthesis, which allows us to treat more
complicated aneurysms in the chest that actually involved that involved

(37:54):
one of the arteries.

Speaker 6 (37:54):
Going to the arm.

Speaker 1 (37:56):
And then there's another device called a tambi which allows
us to treat more complicated aneurysms that involve the arteries
that are going to the intestines and kidneys.

Speaker 5 (38:09):
And how in general do those do you do?

Speaker 3 (38:12):
Those two things? Is there? You're not removing part of
the order with that.

Speaker 6 (38:18):
No, So the.

Speaker 1 (38:20):
Way I would kind of describe it as we're we're
re lining the artery so that an aneurysm is a ballooning
out of the artery. We're going in. We have stent crafts,
which are basically large stents, and so these are stints
that are the size of garden hoses.

Speaker 4 (38:35):
And these aren't these.

Speaker 6 (38:36):
Aren't open cell stent.

Speaker 1 (38:37):
These aren't just a metal stent or a metal stent
wrapped in fabric. And we're able to use those stents
to to seal to the normal artery above uh the
androism to the normal arteries below, and that kind of
takes the pressure, takes the blood supply, and takes the
risk of rupture away from that aneurysm.

Speaker 2 (38:58):
And so is it are those two are similar they're
just being done in different locations or are there other
differences between the TV and the T A M D
E Uh, they're different.

Speaker 7 (39:10):
The there These are stint crafts that have kind of
what we call them branch technologies, where for a long
time one of the limitations of stent crafts that we
really couldn't deal with vessels coming.

Speaker 1 (39:23):
Off of the aneurysm themselves. And so if an aneurysm
was and so the TV is the technology that allows
us to kind of push the stent further up into
the threat and the a order in the chest.

Speaker 4 (39:36):
Uh.

Speaker 1 (39:37):
The it's a very commonplace that people get an aneurysm
is just beyond the artery going to the left arm,
and so this TB allows us to cover that artery,
to expand our seal upward, but also keep put supply
to that artery going through the arm, because that's important
as well.

Speaker 5 (39:56):
Got it.

Speaker 2 (39:57):
And with these larger vessels and you putting these sort
of scent graphs in there, do they require the same
type of anti collaboration that the smaller scent like in
the throat of end ard recumee and scenting.

Speaker 1 (40:14):
I would say, as a general if someone We're way
less particular in about with regards to kind of post
operative and I play with medicines after these surgeries versus
a croaded surgery. Most these people need to just be
on an ask for in long term after afterwards.

Speaker 2 (40:32):
Well, doctor Shara, I can't thank you enough for sharing
all of this with us. We haven't haven't covered this
in a very long time, if at all. So I
love hearing about what you're doing for our community that's
going to do it. For another segment of centered on
Health with Doctor Health, I am your host, Doctor Jeff Publin.
I want to thank our guests, doctor Nolah Sharre, doctor
a surgeon, and I want to thank our producer, missus

(40:55):
j Fenn and you the listener.

Speaker 6 (40:56):
Join us every Thursday night.

Speaker 2 (40:58):
For another segment explained on Health, Have a Copy and
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(41:19):
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