Scott Webb (Host): Welcome to Wise and Well, presented by Community Memorial Healthcare. I'm Scott Webb. And today, we're going to learn about thoracic branch endoprosthesis or TBE from cardiothoracic surgeon, Dr. Ryan Vela, and vascular surgeon, Dr. David Blitzer.

It's nice to have you both here today. We're going to talk about advanced aortic care, you know, close to home. So, Dr. Vela, I'm going to start with you and the basics. Like, what is the aorta exactly, and why can conditions affecting the portion in the chest become so serious?

Dr. Ryan Vela: The aorta is the major highway for blood to travel in the body. It connects directly to the heart. And so as every heartbeat occurs, you have a lot of force and a lot of pressure that gets transmitted all throughout the aorta, and that allows every red blood cell to go up the highway, to the brain, down to the kidneys, and all the way down to the little toe.

Problems with the aorta are not subtle. They generally come up as a dissection or a rupture, and that comes with ripping, tearing chest pain. That can be a surgical emergency. And luckily, for the people here in Ventura County, Dr. Blitzer and I are experts in these problems.

The other thing that can happen is something that's called an aneurysm. These are the silent killers, because there's not a really good way of knowing if you have an aneurysm or not unless somebody catches it with a CT scan, usually done for other reasons. Once these people are found, it's really good because Dr. Blitzer and I can watch them closely and kind of determine the time when a repair is going to be needed.

Dr. David Blitzer: Yeah. I think that Dr. Vela explained it beautifully. Aorta is really the major, as you said, the major highway in the body that's bringing blood everywhere. And so, as a heart surgeon in Dr. Vela's case, as a vascular surgeon in my case, we pay a lot of attention to it, what it's doing and when it becomes diseased.

So, being able to offer a variety of treatments when that happens for conditions that are life-threatening, becomes a major priority of ours, and especially how to use the best and most advanced technology to provide our patients here in the community access to safe and effective procedures.

Host: Right. Yeah. And as I sort of teased there at the beginning, you guys are close to home. You're specialists, you're experts. And I said the words out loud, you know, for TBE, thoracic branch endoprosthesis. And, Dr. Blitzer, maybe just in everyday language, when we think about TBE, like, what does the branched design allow you to do?

Dr. David Blitzer: That's a great question. It's a really interesting area in what we do in endovascular procedure, so minimally invasive procedures, rather than a big incision being able to repair this major highway, the aorta, via needle sticks in the groin and maybe in the wrist.

So generally, when we fix the aorta through something with a minimally invasive procedure, we put what's called a graft there. So essentially, stents or struts that are covered in fabric, in this case Gore-Tex, to cover up where the aneurysm is or where the dissection is. TBE is a special kind of that. So, imagine that you have a tube, and that's generally what we use in the chest. This TBE in this case is a tube that has a little cutout in it, so we could put another tube in there. So, all of these branches are connected. If we go into the chest, one of the artery, for example, that goes to the arm comes directly off the aorta in the chest.

And now, rather than doing partially an open surgery and partially an endovascular surgery, so doing a bypass and then covering up the aneurysm, we're able to do everything through a needle hole in the groin and a needle hole in the wrist, and that's what TBE does.

Host: Well, Dr. Blitzer, I certainly appreciate the everyday language. As I said, we're going to abbreviate TBE because that's a little easier to say. And Dr. Vela, when we think about TBE exactly, who may be considered, might be considered, and what anatomy, imaging, medical history, or overall health factors sort of guide your recommendation?

Dr. Ryan Vela: So in the past, a lot of these required a big open operation like Dr. Blitzer said. Those usually came with people that had dissections or ruptures. They're not subtle. Those were people we were easily able to find. Patients with aneurysms are a little difficult because people don't know that they have an aneurysm. It's usually found incidentally. These patients that would be a really good candidate for a TBE, would be patients that have isolated aneurysms, either of their, what we call, descending thoracic aorta or the aortic arch. These are two very special areas of the aorta that are amenable to having these specialized grafts placed in order to continue having blood flowing in the right direction.

The caveat to this, unfortunately, is there is a part of the aorta called the root and the ascending. Now, in very, very certain patients, we can sometimes consider a TBE in patients that have an ascending aneurysm. However, unfortunately, patients that have root aneurysms, those are patients that are generally going to have to see me for open heart surgery in order to repair that.

Host: Yeah, and that's not a small caveat, right, Dr. Blitzer? But, yeah, I'm going to capitalize that caveat, of course. But Dr. Blitzer, when you think about recommendations and what guides your recommendations, take us through that.

Dr. David Blitzer: The real beauty of modern technology and having specialists like Dr. Vela and myself that are able to collaboratively review anatomy is that we can offer even advanced treatments in our community. So whereas previously some of these wouldn't be available and would require much bigger surgeries or being sent out of town, maybe even down to Los Angeles or farther, now we're able to do everything right within our hospital here.

And, again, that's the real beauty of having a collaborative approach between Dr. Vela and myself. We cover every blood vessel in the body for the most part. So, that's the beauty of it. When we're thinking about which patients are best and how to approach it endovascularly, Dr. Vela and I, we review scans together. We look at the nuances of anatomy, not just whether or not there's an aneurysm and its location, but we look at very finite features, what the aorta itself looks like, what the surrounding vasculature looks like, what the highways leading up to the aorta look like to make sure we can deliver the devices.

There's all sorts of requirements at each level that we are able to evaluate and determine which type of treatment's going to be best. And sometimes in a lot of cases with what we have available, that's a minimally invasive treatment. And then, there's times when it's a hybrid, meaning we can do an incision that's going to be not as invasive and doesn't require the same recovery as a big incision, but still a small incision and an endovascular minimally invasive approach. And sometimes, like Dr. Vela said, the best treatment really is an open operation, which we are more than happy to offer as well.

Host: Right. And it does sound, Dr. Blitzer, like you guys really is a real team approach, right? You work closely together. You bring cardiothoracic and vascular surgery expertise in many of these same cases. So, how do your perspectives complement each other from evaluation and treatment planning through follow-up?

Dr. David Blitzer: Dr. Vela and I, we're guiding the train down the tracks, but we also have other specialists that are involved too, where we collaboratively discuss with folks such as cardiologists or neurosurgeons that may need to be required with their expertise in the procedures as well, including the postoperative management.

So, a lot of times, even though technically we're able to accomplish the surgery, we need other faculty, other buy-in within the hospital on the intensive care unit. So, it's even farther outside of Dr. Vela and I. Our two approaches though are interesting because we have different skill sets that are complementary. So, we're able to evaluate the aorta as a whole, pick up on the nuances. There's times when he says, "Yeah, but you know, what about this? What if we look at it this way?" And I can give him the opposite opinion. So, really hammering home the fact that a multidisciplinary approach is absolutely how Dr. Blitzer and I come together and evaluate every single patient specifically. There's no just sleeve blanket answer that we apply to anybody that comes and sees us.

Dr. Ryan Vela: Everybody, as they say, is unique, and everybody's anatomy is unique, which is why having a very multidisciplinary evaluation, Dr. Blitzer, myself, neurosurgery, cardiology, intensive care, the primary physicians taking care of the patient as well, all matters extremely, largely for these patients so that we can do the optimal therapy for them that gets them back moving and home with their loved ones as quickly and safely as possible

Host: Right. Yeah, and it's just amazing to me that it's all right there at the local hospital. It's all right there at Community Memorial. And I know, Dr. Vela, Community is the first and only hospital in Ventura County offering TBE. So, maybe you can explain, like, what can having this option, having it so close to home, like, what does that mean for patients, families, and maybe even especially continuity of care?

Dr. Ryan Vela: It's extremely exciting to have it here. Only even maybe three to four years ago, this operation wasn't offered except at very select tertiary centers. In LA County, UCLA just started doing this procedure. Otherwise, it was mostly USC and Cedars, and they were very, very critical on which patients they would offer this procedure or not to. Luckily for myself, while I was at UCLA, I did have the opportunity to learn, some skills outside of my regular cardiothoracic skillset to make me a good collaborator with Dr. Blitzer. One of the other fundamental beauties of this is just if something goes wrong on my end, Dave is there to help me out. And if anything happens on Dave's end, I'm there to help out so that we can take care of any problem that arises when the procedure is performed.

Nowadays, the procedure is being more readily available, but it's still difficult to come by. And so, patients here in Ventura County, if Dr. Blitzer and I weren't available to offer this procedure to them, they would honestly have to be considering going down to Los Angeles or even San Diego in order to receive the care that they need.

So, being a one-stop shop here in Ventura County for everybody that resides here at the Central Coast, it is extremely efficient to coordinate care, keep it all here, and everybody that takes care of that patient after their procedure knows Dr. Blitzer and I and knows that they'll have all the information regarding what happened. They won't go into a black hole into the LA metroplex and come back with, "I don't know. They did something to me. Hopefully, you'll get the records at some point."

Dr. David Blitzer: I don't think Dr. Vela gives himself enough credit as a cardiac surgeon. I know that one of the really exciting things when I found out that Dr. Vela was coming to town was to have a cardiac surgeon that's interested and has the skill set to pursue endovascular procedures.

So for me, coming from a vascular background, we take care of a lot of disease within the aorta itself. But to have someone like Dr. Vela, a trained cardiac surgeon who does a high volume of open procedures but is also interested in the minimally invasive world, that was super exciting. Because like you said, now there's no part of the aorta essentially, that we're not able to evaluate and treat or at least to decide what the best management is going to be.

And I think that, again, one of the really important facets of what Dr. Vela described, and I found this as well with our patients, is not only having access to the procedure itself or the types of procedures that we're able to offer, but it's the post-procedure care, it's the surveillance imaging. So, making sure that the repair holds up and there's not further degeneration of the aorta, which is not uncommon to see with this subset of the population. So, be able to say, "I can go down the street and now I know my two specialists that operated on me. I trust them. We've been seeing each other for months or years at this point." That's really, really important for this community.

Host: Yeah, it definitely is. And Dr. Blitzer, you sort of touched something there that made me think like, all right, so maybe not everyone's a candidate. Maybe people need to be evaluated to find out if they're a candidate for TBE. So, if someone has been diagnosed with a thoracic aortic condition or is concerned maybe about a family member, like, what's the next step for them to find out if in fact TBE will work for them, or if either or both of you can help them?

Dr. David Blitzer: We approach these cases collaboratively. A lot of these patients that both Dr. Vela and myself whoever will see them first, we communicate with each other. We both review the images. We'll both see the patient in clinic to gather both of our perspectives, and it's an ongoing discussion. A lot of times, patients are being referred over from their primary care physicians or another specialist within the community that recognizes there's complex pathology or even any sort of aortic pathology.

I think it's actually a really important point to harp on is that any sort of aortic pathology, I think, should be evaluated by a specialist. There's a lot of nuances. There's predictable models and things that we look at, even with something that may seem benign, to adequately evaluate it. And sometimes things that may jump out and seem scary on a radiological read, someone gets a CAT scan and the read says something that could be scary, it's worth being evaluated by both Dr. Vela and myself.

Dr. Ryan Vela: I agree wholeheartedly with Dr. Blitzer. There's been way too many times in my experience that a patient finds their way to my office and they look at the report that they got for a CT scan because a doctor thought they had pneumonia. And incidentally, it came with this very scary description of the aorta that says possible rupture, atherosclerotic penetrating ulcer. They're very scary words that not only do the patients not understand, but many of their primary care physicians don't see these things regularly.

And so, to Dr. Blitzer's point, I think it is absolutely critical that any abnormality seen in the aorta, it doesn't matter how trivial it may be, should be seen by a vascular and cardiothoracic surgeon. So in patients that have these reports and they say, "Doc, what does this mean?" And their primary care might be scratching their head. I think the first step for anybody is just an immediate referral over to Dr. Blitzer and myself so we can look at the images and in a fair amount of the time console the patient that, "Yes, this sounds scary.

However, this doesn't necessarily need surgery right now. We're looking okay." So, it not only gives them peace of mind, but it helps them understand what exactly is going on. And that disseminates to the primary care physicians too, so they get a better understanding.

Dr. David Blitzer: One of the really unique and important things about the collaboration that Dr. Vela and I have is that we're happy to see patients that even may have benign pathology or it's not really jumping out. The aneurysm doesn't meet particular size criteria. It's not huge yet. It's maybe developing or smaller. I think that the importance of having two specialists say, "Hey, we want to see all of the aortic pathology." We're happy to evaluate, happy to make sure that they're on the correct surveillance protocols, that medical management is optimized, that patients aren't falling between the cracks and developing pathology that can be prevented or treated before it becomes something very complex and life-threatening is important.

Host: Right. I just want to finish up. And obviously, without sharing any identifying details, Dr. Blitzer, can you walk us through a story of a patient who benefited from TBE? Maybe what made the procedure appropriate for them, how the two of you collaborated on their care and, most importantly, I guess, how the patient is doing now.

Dr. David Blitzer: Absolutely. We had a patient couple months back that presented to the hospital. And I believe Dr. Vela was the first call for this patient. They had chest pain that started over the left side of the chest and radiated or traveled to their back. It was excruciating. This is sort of the classic clinical buzzwords that we hear when we are thinking about aortic pathology. We evaluated them and there was indeed the aortic pathology right in the vicinity of the thoracic aorta, near where the artery in the left arm comes off the aortic arch. So, this is way up in the chest, exactly where they're describing the symptoms. Medically, their blood pressure was through the roof. Dr. Vela had initially evaluated the patient, clued me in right away. We both evaluated the images together. And we determined that this is a patient who's a little bit older. They had comorbid or other risk factors involved with them as well, and we can offer them a minimally invasive repair for a pathology that's potentially life-threatening and do so expeditiously. So, we looked at them on our advanced imaging platform to look at exactly the measurements of how big the aorta is and where these other vessels were in the vicinity of the pathology, and we're able to complete a repair expeditiously. Patient did very, very well afterwards, was able to be discharged from the hospital a couple of days later and continues to do well.

Dr. Ryan Vela: I recall this patient very well. They were a much older patient, someone that most other places would not consider doing an operative repair on just because of their advanced age. And the daunting task of doing a big, open, emergent surgery that would require the heart-lung machine kind of fills any patient with dread in a situation like that.

And luckily enough, we were able to look at the imaging, come up with a very tailored plan for this patient, and the TBE fit perfectly. And actually, when we were doing that procedure, we do other very special imaging during it that we actually found that the patient had ruptured her aorta. That is a death warrant in any patient that has that problem. And luckily, we were able to diagnose it and took care of it minimally invasively with two small pokes in the groin and one small poke in the wrist, and she went home after three to four days. I saw her as well. She's doing fantastic. She would've otherwise not been with her family anymore if any other hospital would've received her. And at her age, I would say, and Dr. Blitzer might agree with me, not many surgeons at all would have given her a chance. And we got her through this with a minimally invasive repair, and she went home very quickly.

Host: Yeah, it's amazing. And just to note, like, this is probably how you guys talk to patients and talk to their families, and it's very easy to understand. And then, you start wrapping in the multidisciplinary care, you know, individualized patient care, the two of you working so closely together. It's just down the street at Community Memorial. I mean, I don't know that anybody wants a TBE, right? I don't think we want to raise our hand for that, right? But it's just really good stuff. Heartwarming, big smile at the end. I loved all of it. So, thank you so much.

Dr. Ryan Vela: Absolutely.

Dr. David Blitzer: Oh, absolute pleasure. Thank you for having us on the podcast.

Host: And for more information, go to mycmh.org/tbe. 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.