thank you so much, Jeannie. That was terrific. Um I think in the interest of time and to get to uh some mock RPV I questions if if you have a question for our speakers run up here really quickly. Um If not I'm going to let our speakers go so they don't have to sit through our whole RPV eye exam. And I'm going to invite dr hearth up here and it looks like maybe Dr Boyko though has a question. I do as years go on in my practice with carotid disease and I'll ask any one of you. Um I'm feeling more confidence in transcranial Doppler and carotid duplex scans. CT scans at times. I just don't believe I just wanna get some opinion concerning making carotid artery or endarterectomy decisions on your belief in what you really feel is going on with the carrot a duplex scan versus a cat scan results that says 50 to 60% when you're you know, it's going to be higher than that. Um When I run into those situations, I look at trends. So when a trend of a crowded duplex scan from that point starts going up, don't repeat another C. T. A. I take the patient to surgery. So is California, are they still mainly making their decisions on transcranial Doppler and carotid duplex without further imaging. I believe they were doing that quite a number of years ago. I don't know if that's still the case or if they even are. Um But just your overall opinion well as a vascular surgeon. I have gone back and forth over the years I've tended recently to really only treat very severe still no season. And in those I don't think it's necessary to do a ct angiogram when you have a velocity in the internal And then diastolic of 180 and a ratio of nine. I'm not sure I've ever seen a ct that didn't corroborate that. Um In symptomatic patients, it's different because these patients have always had a cT angiogram. And the problem I get into there is that the patients got a classic symptom what looks like a high grade lesion on the C. T. A. And the duplex just doesn't look that bad and I end up operating on them and I'm frequently underwhelmed by the plaque. Um It's so complicated heather. Asymptomatic patients in general on top heather mentioned the this study that we did and I can tell you I was involved in the reading of the angiogram. So this is gold standard. There was no agreement. Some of the instagrams were terrible. Some of them are overlapping the two vessels. Some of them we literally were guessing at the degree of stenosis. Some of them we had to just throw out. Um So I'm not sure there's an easy answer. I think most vascular surgeons will operate based on a high grade lesion and an asymptomatic patients seen on duplex alone. Yeah. There's uh with technology and the as far as the equipment improvement, knowledge of actual real physics involved when you're talking about a crowded duplex scan to me. I mean I've seen cat scans that missed the total occlusion of the iliac artery when I know that there's 100% occlusion because there's no femoral pulse. Take the patient to surgery. Sure enough. There was a short lesion occlusion. So just it's weird. The more experience I get, the more baffled I am with this stuff dr Boyd. I think you raise an important point for the trainees is you can't just look at the reports for either duplex or C. T. A. Because there's been so many times where I've had patients where A C. T. A. Is read as normal or mild disease and you actually pull up the images and um maybe have slightly different perspectives. Same with duplex. I personally think duplex can map for endarterectomy but I think it needs to be a very detailed study and perhaps our surgeons can comment but you really need to see the distal vessel diameters. It's not just a snapshot. I see that I get the PSV. Of 2 60. I'm done. I mean it really requires a lot of detailed interrogation to be adequate to map for the O. R. I agree with you Jeff. What I would basically say is the reasons my partners may be very liberal with C. T. A. And I am personally not. I will get a C. T. A. If there seems to be some kind of discrepancy or something on the ultrasound. I can't with tandem lesions. Something in the common carotid. I would get a C. T. A. For that. If a tech tells me that they feel the bifurcation is high, I may look with a C. T. A. To actually be certain that I can still get there. But other than that I know my lab, I know my texts are very good and I will go exactly on what they say. I I agree. One more thing. So Doing ibis for May eight earners. Um a couple of things. So um patients who fit the criteria to invade their bodies with intravascular ultrasound, doing a venogram and looking at reflux within the inferior vena cava into the iliac veins. Um As far as a probable cause for lower extremity edema. And yet the cardiologists are saying everything's normal. So what is what is the what are the issues involved with significant reflux from the entry arena, Kaveh into the uh into the iliac veins? Where else do you turn? I mean as far as pulmonary status and cardiac status, everybody's telling me everything's normal. So where where else would you pursue information or an answer for that? Mhm. I don't know that. I certainly don't have a good answer for that question. Dr hart might and we might, I don't know I have a number of partners who do extensive venus work and they're not really usually looking at reflux in the iliac veins. As much as either chronic thrombosis or compression. And in those cases this is actually invaluable. And the study without I've this is probably inadequate. Um We've done many, many vina grams where the iliac vein looks normal, then you run the ibis probe through and you see that that vein is almost completely compressed. I understand that. But when you have a wide open, after looking with IV's and and going into the intervening cave and yet on your veena grams or I'm seeing significant reflux from the ibc into the iliac veins. So, um I just feel that this is creating chronic venous hypertension of the lower extremities leading to adama. So where else do we turn from here? As far as an answer. When cardiology is telling me, there's no right heart failure, there's no pulmonary hypertension. I'm just getting trying to get an idea of where else to how else to explain their lower extremity edema. Sounds like this might be a great topic for next year's vascular review.