Scott Webb (Host): Welcome to UK HealthCast, a podcast from UK HealthCare. I'm Scott Webb. And today, we're going to learn about a new FDA approved device and procedure called TAMBE which is being used to treat thoracoabdominal aneurysms, meaning aneurysms that span both the chest and abdominal cavities from Vascular Surgeon, Dr. Sam Tyagi.

 Doctor, it's so nice to have you here today. We're going to talk about the  TAMBE procedure for aortic aneurysms. And you're an expert and it's good to have you here because I got a whole bunch of questions for you. Before we get to that, just want to kind of start generally. What does a Vascular Surgeon do exactly, and what kinds of patients do you see?

Sam Tyagi, MD: Yeah, that's a great question. You know, it's a common joke amongst vascular surgeons that sometimes even our mothers can't describe exactly what we do. So essentially we are a specialty that treats diseases of the blood vessels, whether it's atherosclerosis or aneurysms or even trauma; all the blood vessels in the body, with the exception of those on the heart, the coronaries or those within the skull.

 So we have a lot of tools at our disposal. You know, we are trained as surgeons, so we repair with using open incisions and directly repair or bypass the arteries, as well as we're trained in endovascular techniques. So those are minimally invasive techniques, using wires and catheters and balloons and stents that don't require incisions.

So in addition to that, we do see our patients for life because many of the diseases in which we treat, are lifelong diseases. We do have a long standing relationship with our patients, whether we perform surgery on them or we're monitoring their conditions closely, you know, to see if they do need surgery.

Host: Yeah, so close relationships with patients, lots of tools in the toolbox, you know, kind of old school open procedures, and now as you say, more minimally invasive procedures. And let's do that. Let's talk about  TAMBE. I know it's a new procedure that UK Healthcare is offering. So what is the  TAMBE procedure?

Sam Tyagi, MD: Traditionally, I think most people understand what aneurysms are. So the blood vessels in the body are composed of many layers and so what can happen is there can be a weakness in the wall of the blood vessel, and then under the pressure of blood pressure, it can become larger and more dilated like a balloon.

And if it gets too large, they can rupture or sometimes clot can form into the aneurysms and clot can go to the blood flow downstream and cause problems. So, traditional treatment for aneurysms is through open surgery and in the abdomen and chest parts of the body, those open procedures are very large, major operations. Starting in the nineties and perfected more in the early 2000s, we've been able to treat aneurysms with stents. And in the beginning those were restricted mainly for higher risk patients because it was newer technology. But as the technology has come now to fifth, sixth generation devices, it's becoming more mainstream now, becoming the treatment of choice for straightforward abdominal and thoracic aneurysms.

Maybe 80 to 90% of cases now are treated with stent grafts as opposed to open surgery. The one area that has always been treated with open surgery though, is that area in between. So in between the abdomen and chest there are a lot of branched blood vessels and the stents have not been designed as well to treat these more complex aneurysms.

Until now. We have the  TAMBE device, which is the first FDA approved device for thoracoabdominal, which means chest and abdomen aneurysms. So aneurysms that span both body cavities and these have built-in branches that can help preserve the blood flow to the organs, such as the kidneys, the stomach, and the intestinal vessels.

So, this newer technology, this  TAMBE device has been something we've been waiting for, for many, many years. Had really good results in the clinical trial and is now FDA approved. UK was in the first group to be trained in implanting this device and performed it in the first month it was available, very successfully. That was mid-summer, 2024. And since then we've done 12 procedures. All have been technically very smooth and we're excited to offer this, the minimally invasive treatment for which there was no minimally invasive option on label before, now at UK.

Host: Yeah, it sounds like you're off, you know, off and running. Great success so far. So just want to get a sense of maybe which patients are the best candidates for  TAMBE. You've given us a sense of sort of where in the body that  TAMBE is ideal for. But who are the best candidates?

Sam Tyagi, MD: The fact that UK is a quaternary care center, we tend to see a lot of these patients referred to us from community vascular surgeons and our cardiology colleagues and cardiac surgery colleagues. The  TAMBE procedure has a very, very low risk of you know, mortality, which sounds fairly drastic, but when compared to an open surgery, which has anywhere reported from seven to 20% mortality, it's, it's much better. So patients who have very large aneurysms that involve the branched vessels, they go to the abdomen, such as the renal arteries. So those are the arteries who go to the kidney or the mesenteric arteries that go to the intestine. Those are the ones the  TAMBE is designed for. So those would be the best candidates for this procedure.

Host: Yeah, and in putting my notes together, I was looking up, you know, other procedures. So of course,  TAMBE seems to be on the cutting edge and perhaps it's already the gold standard or will become such soon, but what about TVAR? And when you're trying to compare and contrast and try to figure out how to best, you know, help and treat a patient, maybe you can take us through that. Maybe something a little more traditional versus  TAMBE.

Sam Tyagi, MD: Essentially what a  TAMBE is, is a next step of the TVAR platform. So the TVAR generally is designed only for the chest, and it's a large straight tube, and in the chest, there are not branched vessels beyond those that go to the brain. So those aneurysms tend to be from the arm and brain vessels straight down to the abdomen.

So that TVAR is a straight tube. What a  TAMBE is, is a TVAR that has built branches into it. So it's kind of, if you think of it modular based, that you have a TVAR to fix aneurysms in the chest. You have a  TAMBE to bridge the aorta from the chest to the abdomen, and then you have EVAR, which is the abdominal aortic aneurysm device to go from the abdominal aortic aneurysm down to the arteries that go to the legs. So it's kind of  TAMBE is the next step downstream from the TVAR device.

Host: Gotcha. Yeah, as you said earlier, you have lots of tools in the toolbox, which is great for patients and families, and obviously providers as well. And that's what I wanted to talk about next was sort of your multidisciplinary team. Tell us about the folks who are there performing  TAMBE with you.

Sam Tyagi, MD: Yeah. For a lot of our complex aortic cases that we have at UK, we do involve our structural heart colleagues and our CT surgeons. So we have a conference for our particularly challenging patients, and we all, the vascular surgeons, cardiac surgeons and cardiologists, we do meet and we present the imaging very similar to a tumor board style that cancer patients all have that type of evaluation. So we've kind of taken that model and applied that to aneurysmal disease, especially of the thoracic aorta and the thoracoabdominal aorta. And so, we go through the imaging. What are the options, the indications, the risks for the patient, their suitability for surgery, and then we offer that to the patient, and if they elect to undergo it, then they undergo it. In terms of implanting the TAMBE device, that is mainly done by the vascular surgeons.

Host: I, I'm sure there's a lot of collaboration, right, between radiologists, surgeons, anesthesiologists, you know, all those big words, but I'm sure there's a lot of collaboration, before, during, and after, right?

Sam Tyagi, MD: Correct. I mean, our radiologists, I think they particularly, they get to see all of the CAT scans before and after, so they often will call and we'll discuss specific things postoperatively in the scans of the patients. Because these are quite complex procedures just to describe, you know, what the anatomy is now and what we are seeing and we do need to follow one thing.

That we have to keep an eye on with all these procedures is because they're stents and they're very modular, just making sure there's no leaks anywhere and that the repair is durable. And the best way to do that is through serial imaging. There's a few of the radiologists at UK that are really dedicated specifically to cardiovascular.

So those are the ones we tend to communicate with the most. And we do meet with them as well periodically, and they call us often just to discuss these cases. Um, and we'll call them too if we're wondering like, I'm not sure if I see a leak here or not, what is your opinion? That sort of thing. So that's been great and it's fun to see how excited they are to look at the imaging as, as much as we are to do the procedures.

Host: Yeah, it does sound exciting, you know, even for a lay person like me, and you have such a great way of explaining it. You mentioned that it's only been recently FDA approved, that UK is sort of on the cutting edge. Just wondering about its availability  TAMBE that is, is it still pretty limited to kind of specialized centers?

Sam Tyagi, MD: Yes. In order to perform  TAMBE, you know, the institutions have to have sufficient experience with TVAR and EVAR and even there, there is some fenestrated devices, which is a kind a more complex version of EVAR. Addition to that, you have to go for training and you have to be proctored for several cases before you're doing them independently.

And so many places don't have the infrastructure or volume or support, you know, with the multidisciplinary team as we described earlier, to do that. So this is really reserved for high volume centers. In the state of Kentucky we have performed, I think there may have been one case done elsewhere, but other than that, 90% of them are done at UK.

Host: Right. Let's talk recovery. You know, I've, in speaking with a lot of experts, Doctor, I hear that the minimally invasive techniques, approaches, sometimes when robots are involved, you know, that the recovery is just better and faster for patients. So maybe you could take us through that, the  TAMBE procedure. What's the recovery look like?

Sam Tyagi, MD: Yeah, so the recovery is very similar to that of TVAR and EVAR, which is, you know, when done in a minimally invasive approach, patients don't have large incisions. We, they just have punctures at the femoral artery sites in the groins and occasionally in the upper extremity, in the upper arm. So there may be some minor discomfort and pain from the access sites, but other than that, there's very few restrictions afterwards, and most patients go home within one or two days of the procedure although sometimes the patients are doing so well, they'd love to leave earlier. We are involving a lot of blood vessels and a lot of the major organs, so we like to monitor to make sure that everything is fine for at least 24 hours before patients go home. But once they go home, you know, really everyone's different, but we don't have any significant restrictions on what the patients can do. They're limited by what they feel like doing.

Host: Yeah, it's really amazing. As you say, you know, they may want to go home a little earlier, but you try to hold them back at least, you know, 24 hours, and I'm sure it's just vastly different than the open surgery and the recovery from that right?

Sam Tyagi, MD: Correct. For an open thoracoabdominal repair, I would say the average length of stay for that would be anywhere from seven to 14 days, you know, and that's, everything going smoothly.

Host: That's everything going, yeah. Going to plan of course. Yeah. So lots of good reasons to love  TAMBE and to embrace that. Do you foresee it becoming, I mentioned earlier I said refer to it as the gold standard, but the standard of care. Do you foresee that, that's where, this is going in terms of, you know, treating these types of aneurysms, that  TAMBE's going to be the gold standard.

Sam Tyagi, MD: Well, I think for many aneurysms it will be. Minimally invasive technology and stent technology does have its limitations. You know, there are specifications for vessel size and anatomy that this is suited for, and some that makes it more challenging. So there will still always be a need for other technologies with different specifications and open surgery for those cases that, you know, stent grafts are not suitable for. For example, the stent has to go through the femoral arteries in order to get to the aorta. And if the femoral artery is not large enough to accommodate the undeployed or compressed stent, then we cannot do a stent graft procedure. So, perhaps further generations we'll give this a lower profile so it's not as large as it's being delivered, but there are still some constraints, but generally speaking, I think a patient who meets criteria for this repair, this will be the gold standard versus open repair.

Host: Yeah, as you say, for certain conditions, it just makes total sense again, even to a lay person like me to use  TAMBE. Just want to finish up today, and this has been really educational. I love having experts on from UK healthcare and learning from them. Just what would you most want patients, families, maybe other medical professionals to know about the  TAMBE procedure?

Sam Tyagi, MD: If you do have a complex aneurysm, you know, now there is, and there hadn't been in the past, but there is now a well-studied robust FDA approved device, you know, to treat this condition and that open surgery, although sometimes is an option, now we have an endovascular option for it as well.

So if, you do have a complex aneurysm, just ask about are there any minimally invasive options for this now. I heard there's a new, device out there that can treat a lot of these complex aneurysms.

Host: Yeah, well hopefully, you know, with any luck they've heard this podcast, and gotten a taste of this, gotten to benefit from your expertise and your time as I did so. Thank you so much.

Sam Tyagi, MD: Alright, well thank you Scott.

Host: And for more information, go to ukhealthcare.uky.edu. And that wraps up another episode of UK HealthCast from UK HealthCare. Please remember to subscribe, rate, and review this podcast and all the other UK HealthCare podcasts. I'm Scott Webb. Stay well.