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all right tino go hey good morning hey jim here with uh sean samuels carrie campbell carrie is going to start with a vignette good morning today we have an 83 year old male with chf and hypertension here are disclosures next slide please its a 83 year old male with two weeks of worsening shortness of breath he presents to the er in pulmonary edema with a history of ischemic cardiomyopathy and refractory hypertension we were initially consulted for a 4.5 centimeter taa and a 4.4 cm aaa we also discovered renal artery stenosis suspected on cta during evaluation next slide past medical history includes hyperlipidemia hypert hypertension requiring three medications for over two years ischemic cardiomyopathy with an ef of 40 in 2008 he subsequently had two drug-eluting stents placed at that time medications include four antihypertensives aspirin and a statin next slide physical exam reveals elevated blood pressure lab elevated bnp next slide we have a 3d mip showing diffuse atherosclerosi