Good afternoon. Thanks for your attention dr lee. That was a great talk. Uh I'm Robin Bonnie. I'm one of the best future surgeons at the V. A. And today I'll be presenting a talk called vein is king. I have nothing to disclose. Unfortunately you're gonna see a lot of the same data as you just saw. But we know that 1-2% of patients with peripheral arterial disease present to us with chronic limb threatening ischemia. This population is burdened with an advanced disease process leading to 20% major amputation rate And 25% mortality within one year of diagnosis. Although some patients may have CLT I due to inflow disease, the large majority of these will have significant information law, inclusive disease. So the mainstay of treatment for any patient who presents with subtlety is reestablishing pulsate tile in line blood flow to the foot. Of course this can be accomplished by either endovascular therapies or open surgical techniques. As a therapeutic options for endovascular therapy evolved the ongoing debate continues as to which option reigns supreme with either method. A myriad of factors are important including severity of disease, an atomic characteristics of the lesions, overall medical condition and availability of conduit. Currently there's a positive data in the form of randomized controlled trials basil One trial is one such study where 452 patients with Clt ay and infra inguinal disease were randomized to a lower extremity bypass first vs of balloon angioplasty. one treatment strategy. Although no major difference was shown at the end points at two years on the subject analysis. They found a significant increase in overall survival for those who lived more than two years in the surgical bypass first approach, there was also a non statistically significant trend towards an increase in amputation, free survival and the same cohort. So based on these studies, will use some of the cardiology recommendations. In 2000 and 11, they updated the A. C. C. F. And H. A. Task guidelines. So they made two new recommendations for patients with no exogenous fame And life expectancy of less than two years. A endovascular first approach was appropriate, but for those with life expectancy greater than two years and good vein performing an open surgical bypass first was a reliable initial treatment. So if there's no difference out to two years, then why not try and endovascular first approach. You don't burn any bridges and you can always perform a bypass after. Well, I would argue not so fast. The basil results showed that bypass first after failed endovascular therapy had significantly worse amputation. Free survival clark at all showed that in patients who failed an endovascular first approach, there was substantial degradation of the runoff vessels, which limited further attempts at rescue bypass because it all showed that in wifi stage four patients, open surgical revascularization first was associated with better limb salvage rates compared to endovascular therapy. Furthermore, No one at all found that in patients who underwent bypass first after failed prior bilateral DVT, There were significantly higher rates of graft occlusion and amputation rates went from 18 to 28% for graft occlusion And from 20 to 31% for amputation at one year's time. So it becomes critical to identify the patients that are high risk for endovascular failure. Numerous studies have shown that poor arterial runoff is associated with worse outcomes. Meltzer found that tissue loss, long lesion length, chronic total occlusion, heart failure and end stage renal disease, all to be predictors of early endovascular therapy failure. So, as we just discussed and the talk is named when factors like chronic total occlusion and long lesion length are taken into consideration, outcomes can be affected. Sing at all observed that task C. And D lesions were associated with lower peri procedural rate and pattinson and higher male and major imputation rates when compared to interventions on task A and B patients. So, in patients who endovascular options may not be ideal and who have good life expectancy. In my opinion, open surgical bypass remains the gold standard with consideration of conduit a single segment. Greater staff in spain is the ideal option for lower extremity bypass. A systemic review by Al Asiri found that the rate of amputation is the lowest for in for England and bypass with gsp when you compare it with all other conduits. The Pattinson and long term durability of such vain repairs has been well established with four year. Primary Pattinson rates of 62-68 and secondary rates of 76-81%,, Limb Salvage rates remain exceptionally high at four years as well, with greater than 80% of patients. The technique, however, for performing these bypass, whether that be in an insight to bypass versus a reverse staff in this vein bypass has been looked at, but no significant difference has been shown between these two techniques. So, if that pattern, see data is not enough pompous. Elie showed that in petal bypass, the discourse to the dorsal pedis artery At five years. Primary and secondary pattern see rates were 57% and 68%. So bypassing torpedo artery, if that is truly bringing pulse style blood flow to a foot. In conclusion, we have a limited high quality data to definitively declare one therapy superior to the other. Both open surgical revascularization and endovascular therapy are complementary and the best patient outcomes can be achieved by working together and individualizing care, adopting and always under vascular first approach can be problematic and is not without its own inherent risks. And those patients who have good ambulatory status, life expectancy greater than two years and a good caliber greater softness vein. There is a benefit to open surgical revascularization. First, I would like to thank you all for your attention and for the moderators for allowing me to speak today. Uh we can if there's any questions I'd be happy to answer them. And just obligatory pictures of my family.