Scott Webb (Host): Thoracoabdominal branch endo-prosthesis or TAMBE is a revolutionary procedure that's used to repair complex and life-threatening thoracoabdominal aneurysms. And vascular surgeon Dr. David Blitzer is here today to tell us about the first successful use of TAMBE at Community Memorial Hospital and why this is a game-changer for aneurysm patients in Ventura County.

 Welcome to Wise and Well, presented by Community Memorial Healthcare. I'm Scott Webb. Doctor, it's nice to have you here today. We're going to talk about the first TAMBE procedure in Ventura County. And you know and I know that TAMBE stands for thoracoabdominal branch endo-prosthesis, but we'll probably abbreviate as TAMBE today because it's just easier to say. Before we get there though, I want to have you introduce yourself, briefly describe your respective roles in the successful performance of this first TAMBE procedure in Ventura County.

Dr. David Blitzer: So, my name is Dr. David Blitzer. I'm a vascular surgeon in the community with Pacific Cardiovascular and Vein Institute. TAMBE procedure is really interesting. This is a newer device that has come through the FDA over the last several years.

To put it very briefly, it's for a very complicated aneurysms that extend up. So, they extend not just in the belly, but they start moving towards the chest and including other blood vessels that supply major organs, including the kidneys, the bowels, stomach, liver, spleen, they include all of those blood vessels as well. And previously, this type of pathology would require a big surgery, a surgery that would enter the chest and the belly. So as you can imagine, it's not just the complicated surgery that we worry about, but the recovery for something like that is huge. This procedure allows us to do that type of repair, but with a very small couple centimeter incision in the arm and a needle hole in the groin. And so once we identified that one of our patients was a candidate because of his very challenging pathology, this is how it came about to plan and execute the first TAMBE in Ventura County and at Community Memorial Hospital.

Host: Yeah. It's really amazing. And I am just a lay person trying to keep up with you here as maybe listeners are as well. But I was doing a little bit of research and I was thinking like the huge, you know, open surgeries, old school, if you will, and to have done now this first TAMBE procedure is pretty amazing. And I just want to ask like about these types of aneurysms, what makes the condition so particularly challenging and, most importantly, life-threatening?

Dr. David Blitzer: With aneurysms in general, as you can imagine with a blood vessel, they're essentially muscle tubes. As they get bigger, aneurysm, it just means that there's a very specific spot that's starting to balloon out. And just like with the balloon, as it gets bigger, that wall gets thinner and eventually puts you at-risk for rupturing or bursting open. It has a high incidence of causing catastrophic bleeding. And we measure them. We measure them to see when the sizes that puts you at-risk for that catastrophic bleeding. And when that risk becomes high enough, we offer repair.

In general, for most people, this happens below right around where the belly button is, below the kidney arteries. And the repair is endovascular, meaning we just do it through needle holes in the groins, and it's relatively straightforward. But with TAMBE in particular, now it's encompassing these other blood vessels. And if you were to do the same kind of repair, trying to cover up where the aneurysm is, then you would eventually take out these blood vessels or you'd block them off from perfusing those important organs.

What TAMBE does is it gives us these portals that would be deployed. So, imagine that there's little doorways or gates that are deployed above where those other blood vessels are, and we snake in other stent grafts or other coverings, so we could still profuse those organs and cover up the aneurysm.

Host: Yeah. And I'm just trying to get a sense, I'm assuming, unlike the rest of us, Doctor, you didn't watch just like a YouTube video or TikToks, right, to learn--

Dr. David Blitzer: A little more than that.

Host: Yeah. To learn how to do TAMBE, right? So, just give us sense, you know, as best you can in audio form, if you will, like what makes the device and the procedure just such a significant leap forward in vascular surgery? Because it just sounds kind of mind-blowing. But tell us more about it and how'd you learn to do it.

Dr. David Blitzer: My training was at the University of Maryland, which is one of the busiest places for complex aortic pathology or diseases of the aorta, the main blood vessel in the body. And so, we were on trial for TAMBE actually. So when this was going through the big clinical trials to look at the safety and the efficacy of it, we were some of the first surgeons that were putting them in for folks. And so, I trained under some very talented surgeons, taught us how to do it. And it's not only doing the procedure, but it's also understanding the complexities and the nuances of it. So as you can imagine that before this procedure, before it was available, it would require a big incision to the chest, going between the ribs, taking the diaphragm with the muscle that helps you breathe off of the ribs, and then going into the belly. And sometimes even putting a patient on cardiac bypass to do this type of procedure because of how extensive these aneurysms can be. And then, finding and trying to fix all the blood vessels in a very precise but quick manner because they can't lack blood flow for too long.

Now, what the procedure is we were able to do this through, as I told you, that little incision in the arm and then one in the groin. We put that graft up or that covering up into the chest where it has our gateways, and then we go from the arm to snake into those other blood vessels and fix that aneurysm. So, the whole surgery takes about two to three hours on average. It could take longer than that, obviously, for more complexities. But it allows us to deal with just a few incisions and have a patient undergo a much safer, much quicker recovery. So for patients that wouldn't even be candidates for it, patients that are older, they have other comorbidities, other medical problems, they would not be candidates for a big open surgery. They wouldn't be able to recover from it. This allows us to reach a greater percentage of the population.

Host: Yeah. It all is just kind of mind-blowing. And then, I'm just trying to keep up with you here, but I want to get a sense of the key risks, or you mentioned recovery there, the differences for a patient, you know, undergoing traditional old school open surgery versus the minimally invasive TAMBE procedure.

Dr. David Blitzer: The biggest risks that we look at is, number one, bleeding. We're entering blood vessels. And any way you round it, whether it's percutaneous and through needle holes, or it's through a big open surgery whenever you're on blood vessels, we're worried about bleeding we're worried about infection.

Specific to this procedure, I worry about spinal cord perfusion. The aorta, the big blood vessel in the body gives off the perfusion of the blood flow to the spine as well. And the more we cover up of those little blood vessels, the higher a patient is at risk for spinal cord ischemia. And that can cause weakness or even paralysis.

So, it's one of the things I'm very cognizant of and we look at it closely, the imaging beforehand, what kind of blood vessels are we covering up different types of precautions that we take during the procedure and after the procedure, regarding blood pressure, regarding drainage of some of that spinal cord fluid to keep that pressure down in some areas. So, we take those precautions. And then, obviously, with those vessels that we're snaking into that feed the bowel that feed the kidneys, we have to be very precise with how we measure and how we deploy these coverings, these stents in there to make sure that they're adequately giving those organs blood flow, but we're not damaging the arteries that are already pressing.

Scott Webb: Right. Yeah. And I'm just picturing, Doctor, I am assuming anyway, that you're not doing this by yourself, right? That you're in there with a team of docs, nurses, whomever, and I just wanted to have you just sort of explain like your specific expertise and your role, maybe the roles of some of the other folks that are there together, you know, executing the TAMBE procedure. And you know why that's so critical? Because this first case you had was so complex and, generally speaking, you know, that's what TAMBE's for.

Dr. David Blitzer: Absolutely. And you hit the nail on the head that this is absolutely 100% a team procedure, that it's not just a surgeon there calling all the shots. That it was actually my partner and I Dr. Lishang Kong. He was with me, so I was working from the arm. He was working from the groin and we were working together. And just as critically, we were with the Community Memorial Cath Lab. And this is a team of head to toe-- each individual is highly, highly trained. These guys and women are doing catheter procedures all day with vascular surgeons with cardiologists, doing some of the most complex procedures.

So when it came to dealing with the complexities and the different wires, catheters, nuances of the procedure that are really, really challenging, they're all right on it. They're able to, you know, put something in your hand before you're even ready for it, and that's the correct device to use to figure out how to safely do this procedure. So, this is 100% a team procedure.

Host: Yeah. Multidisciplinary team, you, Dr. Kong, the folks from the cath lab, you know, everybody working together, pulling on the same end, so to speak. And, you know, one of the reasons we're doing this, obviously, Doctor, is to get the word out, right, that this procedure is now available in Ventura County, and that they can have it done there at Community Memorial Hospital.

So, what does it mean, I guess, for patients in the county to have access to such a cutting-edge procedure, this TAMBE procedure, and really that it's available so close to home.

Dr. David Blitzer: That's one of the things we're most excited about, that there was a significant amount of patients that we were able to identify that would either have to go into Los Angeles to have this procedure done or they just wouldn't seek care at all, because it's so challenging to find spots that are able to do this procedure, that have the capability, have the team, and have the support from a hospital system to perform it.

So, this is a way that we view that we can really serve the community and provide care that was otherwise inaccessible or really challenging to obtain. And then, from the back end of things or the the aftercare sort of things, having family that's able to see you in the hospital that's down the street is very different than driving an hour and a half down the 101 going into Los Angeles. So, just having that support available as well, I think, is a real advantage to keeping this in the community.

Host: Yeah. I just want to get a sense from you, Doctor, as we wrap up here and that we could speak forever for hours about this--

Dr. David Blitzer: Oh, I can nerd out about this for hours, absolutely.

Scott Webb: Yeah, I'm right there with you. I don't know about the listeners, but I'm right here with you. So, I'm assuming that this first patient is doing great, hopefully, fingers crossed. But ultimately, how do you decide which patients are the right candidates for the TAMBE procedure? You mentioned that, You know, open surgery, the old school way wouldn't be appropriate, especially for a lot of older patients. So, how do you pick and choose moving forward, you know, make sure it's the right candidate, the right procedure, all of that.

Dr. David Blitzer: First and foremost, the patient that we did this procedure for is doing great. He's doing very well, recovered well, you know, got his strength back pretty quickly after the surgery, which was remarkable. And I drew out for him what we ended up doing. And he was sort of mind-blown, like, "That's inside of me now?"

Host: "That happened in my body?"

Dr. David Blitzer: Exactly his reaction. When I'm having scans that come across in patients that are referred over, there's a few indications for the procedure. So, a thoracoabdominal aneurysm, basically an aneurysm that involves those other blood vessels. And then, what we're seeing even more commonly are patients that have previously had an aneurysm that was fixed usually through an endovascular or that stent graft within the belly, right around the belly button. And now, the aorta has started to degenerate or get bigger above that previous repair, and it's leaking into the aneurysm again.

Again, before, this would be a big surgery to take out the old stent and to now do a big open surgery that you didn't want to do to begin with. So, that's probably the more common referral that we're getting are for patients that are leaking around a previous repair. And in my mind, unless there's a real compelling factor, which means something like connective tissue disease or a really young and healthy patient, then an endovascular minimally invasive approach is going to be the better repair for most patients.

Host: Right. Yeah. As you say, it may not be appropriate for every patient. But for most patients, it's available there at Community Memorial Hospital. The first patient, patient number one, if you will, is doing great. I know. So, it's fun to learn about this. It's fun to get the word out. Thank you so much.

Dr. David Blitzer: Absolutely. I really appreciate you having me. This has been exciting to discuss.

Host: And that's vascular surgeon, Dr. David Blitzer. For more information, go to my cmh.org. And if you found this podcast helpful, please share it on your social channels and check out the entire podcast library for additional topics of interest. I'm Scott Webb. Thanks for listening. This is Wise and Well, presented by Community Memorial Healthcare.