Aortic Arch and its anatomy... and its Access

Brain Aneurysm Foundation Brain Aneurysm Resources
1

We hear/read on our med records...the Right and/or Left Groin... and its access to our brain...

The basics: the groin is at / access reaches...(left and Right)

Common Femoral Artery (main duty is to our legs) ...which extends to:

External iliac Artery (left and right) ..extends to

Common iliac artery (left and right) ... extends to

Abdominal portion of the Descending Aorta... a single large artery extends to:

NOTE: either the abdominal aorta bifurcates to the Lt/Rt common iliac

OR...the common iliacs join to form the aorta...(similar to the basilar?) .

Thoracic portion of the Descending Aorta... extends to:...

NOTE: chest/ cardio-pulm much more...

AROTIC ARCH: it has three branches off it...

Left subclavian artery

Left common carotid artery

Right Bracheocephalic artery (aka innominate artery) w/branching to/of

the right ommon carotid and right subclavian arteries...

More turns before reaching the brain..

ASCENDING AORTA...supplies our heart and branches to those related arteries

and possibly others... (skipping that here)

There are numerous resources w/two noted here: http://inside.ucumberlands.edu/academics/biology/faculty/kuss//courses/CirculatorySystem

This one brings up a page of the selections...by names...

http://biology.about.com/od/anatomy/ss/brachiocephalic_artery.htm

Later...the Aortic Arch access branches will be added...but they are easy to find anywhere online... including this second website... and, many more...

This is just an intro...to the arterial access to our brain...

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adding my own...(and of some others...) the importance of this data...is the relationship to Coronary Care and/or continued cardio/pulm and (later...GI issues)...whatever else...

Then, the Brain Stem is passed thru/by arteries...(likely/presumably no dissections---)...but the brain stem hosts the cranial nerves...for something like this, search online: brain stem anatomy and physiology...

The intent here...is for more research/learning...at least in opening the door of questions...when you are making a decision for which procedure(s)...

3

Adding to / correcting the websites... I must have been distracted...'cuz I cannot find the first I typed.. .

Best for any search: aortic arch anatomy and physiology

It always brings up numerous websites to glance thru... for whatever the words/names used...

The one I so appreciated was/is: http://www.innerbody.com as it also has rotational images

Regret the confusion I may have caused by the wrong (or mis-yped?) website...

Well and I thoguth I had done a good job... on the aortic arch...

Thee are some other sites similar to this one...to help us understand the anatomy of our brain and then the supplier arteries...

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AORTIC ARCH ... RIGHT SIDE..

Brachiocephalic trunk (artery)...quickly becomes:

the Right Subclavian... where

the Right Common Carotid Artery branches off it and

it bifurcates to the Right External Carotid Artery (to the face) to

the Right Internal Carotid Artery (R ICA) .. of which the

Right ophthalmic artery branches off @ ICA's oph segment

Rt Posterior Communicating Artery (R PCOM) branches off the

Rt Anterior Choroidal Artery to the...

Rt ICA bifurcation to the

Rt Middle Cerebral Artery (Rt MCA) and

Rt Anterior Cerebral Artery (Rt ACA)

The Right Vertebral Artery branches off the Rt subclavian (past the

Rt ICA branching) which joins the Lt VA to form the basilar artery...

known as the vertebrobasilar system...

Search any arteries by: artery name anatomy and physiology

A fabulous YouTube...search: Circle of Willis anatomy and Physiology

It is by AnatomyZone...there are many other sites following this..

Now...I have to study (over and over) how the walnut size limbic system

intertwines w/in the Circe of Willis area...

For close to a decade I could only "see" the 'circle of Willis' as the three

communicating arteries...ACOM and the R/L PCOM (pair)...

Next...I have to imagine our walnut size limbic system structures are

supplied by which arteries in the circle of Willis...

5

AORTIC ARCH - LEFT SIDE

Left Common Carotid Artery (direct connection to the aortic arch)

It has the only the one major turn off the aortic arch

for its access on up to the brain and it bifurcates to:

Left External Carotid Artery and the

Left Internal Carotid Artery of which it branches the

Left Ophthalmic Artery

Left Posteiror Communicating Artery

Left Anterior Choroidal Artery

To L ICA bifurcation to

Left Middle Cerebral Artery

Left Anterior Cerebral Artery to

Anterior Communicating Artery (ACOM) which

connects to the Right ACA

Left Subclavian Artery branches directly off the aortic arch...

Left Vertebral Artery branches off ...and joins the R VA

to form the Basilar Artery...

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ANATOMY of the AORTA and HEART ... search online by title...not a web address

Cedars Sinai has a great 'edu' apx 2 pages on the 7 sections (segments)...beginning at the heart...

All the data directed at the minimally invasive procedures...from the groin...to the brain...do not really address the aorta artery...especially the access off the aortic arch...to the brain...

Because some survivors have had cardio-pulm issues post-procedure(s)...there are more arterial connections to be researched...and, this initial article can/may be helpful...

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Wow, I found all of this very helpful. I've been diagnosed with a thoracic aneurysm. It is 4.1 cm proximal and distal ( I hope I spelled/said these terms correctly). I also have aortic valve insuffiency. I'm wondering if any of these issues caused my aneurysm? Is this the place I should ask questions concerning my heart issues? All of my ekg's are abnormal, I am taking 200mg of metoprolol. I've worn every type of holter monitor possible (except the inplanted one). I have lots n lots of pvc's but am under the 20% something or another, meaning no immediate harm but should be monitored. The dizzyness is unreal at times and the palpitation interfere with everyday life, however I don't feel them nearly as much as I did before increasing the metoprolol.

8

Mary...I hope those subjects I have added opens areas/items to ask your MDs..and/or research online before forming your questions to ask your neuro-docs..

Then, in search, use: name and anatomy and physiology: (sample) thoracic aorta anatomy and physiology

We often need to vary terms... for (some of) us to find/comprehend readily...or compare to other articles...artery branches or segment (name of #) of the branching and, often reviewing several websites qualified on our med records...a/w/a as what the doc said..

Did your NeuroMD id/explain the location of your aneurysm on the thoracic aorta re: near the aortic arch or lower in the thoracic as it enters/approaches the abdominal aorta portion?

My thoughts are wandering (far too often!!!) as I am currently searching terms of: cognitive impairment to dementia... and, I cannot yet (after a week of study) mentally arrange the comparisons...to even share my concerns/intent...

In searching 4.1 cm is equivalent to 1.6 inch ...thus, next question...what is the size of the neck if it is a berry aneurysm...or if it is fusiform aneurysm along oneportion of your thoracic artery?

The reason I ask this is because my berry aneurysm was on one record as 6mm ...and then 7mm X 5mm...so was/is 6mm an average of 5mm X 7mm of a "berry"? ..

CMs are 10 mm's...so a good question to ask your neuro-doc... on the size/shape ...and any suggested treatment? ...

A number of us have had the ekg's and have variations of our "symptoms"...I only notice mine if I turn in bed...sometimes to the point I awaken..and, I am lying on my side (seldom occurs) ...it is not typically to me during a day (at least of memory!)....when it does occur at night, I take on my Yoga deep breathing..

IF any answer of mine lacks clarity/sense....please do not hesitate to tell me/ask me what I meant...That is only how I/we may advance to help others...

Mary...prayers for your successes, and for your sharing-updating all of us...what to learn and to ask our neuro-docs...I have chapters yet to seek/share....

Warm Regards, patioplans

Mary Terrance said:

Wow, I found all of this very helpful. I've been diagnosed with a thoracic aneurysm. It is 4.1 cm proximal and distal ( I hope I spelled/said these terms correctly). I also have aortic valve insuffiency. I'm wondering if any of these issues caused my aneurysm? Is this the place I should ask questions concerning my heart issues? All of my ekg's are abnormal, I am taking 200mg of metoprolol. I've worn every type of holter monitor possible (except the inplanted one). I have lots n lots of pvc's but am under the 20% something or another, meaning no immediate harm but should be monitored. The dizzyness is unreal at times and the palpitation interfere with everyday life, however I don't feel them nearly as much as I did before increasing the metoprolol.

9

Hi Patioplans,

I tried to comprehend my results of my last echo in February 2015. I believe it is a fusiform aneurysm. Now, I have read all I can concerning these things listed below. It's like reading a whole different language. I got the gist of some of it, but for the most part. I understand no more than I have regurgitation of two heart valves and an aorta aneurysm. How serious is these findings? Should they be doing something about these results? What danger am I in if any at all?

I am oh so hoping for clarification and if you could help me solve this, I will be for ever grateful.

My Echo-2/2015

FINDINGS:

LEFT VENTRICLE
The left ventricle is mildly dilated.
There is moderate left ventricular hypertrophy.
Left ventricular systolic function is normal.
Baseline left ventricular diastolic function is normal.
Mitral annular lateral E/e': 12.5. Mitral annular septal E/e': 10.0.
Wall Motion:
All scored segments are normal.

RIGHT VENTRICLE
The right ventricle is normal in size.
Right ventricular systolic function is normal.
Estimated right ventricular systolic pressure is not reported due to an
insufficient tricuspid regurgitation signal.
MITRAL VALVE
There is trivial mitral valve regurgitation. There is mild systolic anterior
motion of the chordae. The pressure half time is 71 msec. The peak mitral E/A
ratio is 0.84. The average mitral E/e' ratio is 11.2. The mitral flow deceleration
time is 246 msec.

TRICUSPID VALVE
The tricuspid valve leaflets are structurally normal. There is no tricuspid valve
regurgitation.

AORTIC VALVE
There is mild (1+ - 2+) aortic valve regurgitation. The peak gradient is 17 mmHg
(peak velocity = 208.0 cm/s).

PULMONIC VALVE
The pulmonic valve was not seen or not interrogated. There is no pulmonic valve
regurgitation.

AORTA
The visualized aorta is dilated.
Measurements - Sinus 3.1 cm. Sinotubular junction 2.9 cm. Mid ascending aorta 4.1
cm. Distal ascending aorta 4.1 cm. Mid arch 3.2 cm.

CONCLUSIONS:

- Technically difficult exam due to body habitus.
- Exam indication: AI
- The left ventricle is mildly dilated. There is moderate left ventricular
hypertrophy. Left ventricular systolic function is normal. EF = 60 ± 5% (2D
biplane) Baseline left ventricular diastolic function is normal.
- The right ventricle is normal in size. Right ventricular systolic function is
normal.
- There is mild chordal SAM at rest with no LVOT obstruction at rest or with
valsalva.
- Dilated ascending aorta measuring 4.1 cm proximal and distal.
- Prior echocardiogram performed on 7/21/2014. No significant change.

10

Dear Much2Much...I can so understand that...I will answer/ refer/suggest as much as my little brain allows... First...know/remember...I have no expertise...am non-degreed/non-licensed..(in anything!!!)

I am doing tremendous research...from the "family" of arteries to those of lobes/structures supplied by each of the arteries/family branches. ...and which arteries (may/may have supplied them)...


What I will do...is note my responses /suggestions down by each one...by POP: (patioplans...) ... Well...one sample is noted as POP 1... I am messing up my attempt on continuing (hey, those are brain cells...aka "cognitive impairment"... for me..

Bear w/me as I try to figure it out (this is not uncommon...and, I have a tremendous techie who helps me figure out the "how" connections... bear with me if I am slow ...


Much2Much said:

Hi Patioplans,

I tried to comprehend my results of my last echo in February 2015. I believe it is a fusiform aneurysm. Now, I have read all I can concerning these things listed below. It's like reading a whole different language. I got the gist of some of it, but for the most part. I understand no more than I have regurgitation of two heart valves and an aorta aneurysm. How serious is these findings? Should they be doing something about these results? What danger am I in if any at all?

I am oh so hoping for clarification and if you could help me solve this, I will be for ever grateful.

My Echo-2/2015

FINDINGS:

LEFT VENTRICLE
The left ventricle is mildly dilated. POP1: in /around the heart or the brain?
There is moderate left ventricular hypertrophy.

Left ventricular systolic function is normal.
Baseline left ventricular diastolic function is normal.
Mitral annular lateral E/e': 12.5. Mitral annular septal E/e': 10.0.
Wall Motion:
All scored segments are normal.

RIGHT VENTRICLE
The right ventricle is normal in size.
Right ventricular systolic function is normal.
Estimated right ventricular systolic pressure is not reported due to an
insufficient tricuspid regurgitation signal.
MITRAL VALVE
There is trivial mitral valve regurgitation. There is mild systolic anterior
motion of the chordae. The pressure half time is 71 msec. The peak mitral E/A
ratio is 0.84. The average mitral E/e' ratio is 11.2. The mitral flow deceleration
time is 246 msec.

TRICUSPID VALVE
The tricuspid valve leaflets are structurally normal. There is no tricuspid valve
regurgitation.

AORTIC VALVE
There is mild (1+ - 2+) aortic valve regurgitation. The peak gradient is 17 mmHg
(peak velocity = 208.0 cm/s).

PULMONIC VALVE
The pulmonic valve was not seen or not interrogated. There is no pulmonic valve
regurgitation.

AORTA
The visualized aorta is dilated.
Measurements - Sinus 3.1 cm. Sinotubular junction 2.9 cm. Mid ascending aorta 4.1
cm. Distal ascending aorta 4.1 cm. Mid arch 3.2 cm.

CONCLUSIONS:

- Technically difficult exam due to body habitus.
- Exam indication: AI
- The left ventricle is mildly dilated. There is moderate left ventricular
hypertrophy. Left ventricular systolic function is normal. EF = 60 ± 5% (2D
biplane) Baseline left ventricular diastolic function is normal.
- The right ventricle is normal in size. Right ventricular systolic function is
normal.
- There is mild chordal SAM at rest with no LVOT obstruction at rest or with
valsalva.
- Dilated ascending aorta measuring 4.1 cm proximal and distal.
- Prior echocardiogram performed on 7/21/2014. No significant change.

11

***********************************************************************************

Thank you Patioplans,

I am so glad that you will try to the best of your ability help me understand this. I understand that you are no expert or anything, but at this moment you are to me because the so called "medical experts" are not patient enough to help me. When I see a "Pop" I will underline my response to it, okay? I have a hard time focusing and my eyes sometimes struggle to see things clearly. Things double up or overlap. I use bold, underline, or symbols (axstric) to help me un-jumble what i see.

POP1: in /around the heart or the brain? In my heart

*************************************************************************************

12

Cherish your patience...(not our patienthooding)

What should take 30-45 minutes to read/comprehend/remember...can readily take 4 hours...depending on complexity... some times it takes multiple repeats for the memory portion... (sometimes I cannot remember the "subject title" on my notes stored on my Word 10... (at least now you may understand why my techies (2 of 'em) have kept me from advancing my desktop programming to learn more...especially while I am learning new small parts (at a time) of my new tablet...)...

I have been so concentrating on the 'cognitive impairment'....to 'dementia' and, neither of those terms may be clearly defined/explained by the experts performing the neuropsych testing...

Changing subjects trips my brain cells (or skips over some)...so bear with me on my timing...I printed off your two pages...to read/re-read...easier than up/down on the screen (hey...my vision/memory issues)... I wanted to be sure of heart/ brain because there are named ventricles in both brain stem and the heart.. When I was fatigued last night...I just sort of blanked off...

Pat

**********************************************************************************

Thank you Patioplans,

I am so glad that you will try to the best of your ability help me understand this. I understand that you are no expert or anything, but at this moment you are to me because the so called "medical experts" are not patient enough to help me. When I see a "Pop" I will underline my response to it, okay? I have a hard time focusing and my eyes sometimes struggle to see things clearly. Things double up or overlap. I use bold, underline, or symbols (axstric) to help me un-jumble what i see.

POP1: in /around the heart or the brain? In my heart

*************************************************************************************

13

I think my problem is the same. I spend hours reading the same passages over and over with no understanding of what I have read. I print articles, results etc... I highlight words that I don't understand. I grasp the meaning momentarily only to return to what I have read and it appears like I have never read it before.

I appreciate your willingness to help me but feel guilty in having dumped this on you. I am withdrawing my request of you being mindful of the difficuties that you may experience trying to help me solve a jig-saw puzzle with many pieces missing.

Still, I am most grateful for the assistance you have provided thus far. Thank you again, have a wonderful week and a peaceful and joyous Thanksgiving.

Respectfully

Mary (Aka) Much2Much

14

Pat, thanks so much for this detailed explanation and links. The YouTube was great and helped explain why my new cardiologist was so excited with my Neurosurgeon’s notes! You rock!

15

Thanks much....I can only imagine how frustrating it is when our members do not know/understand the name/area of the artery(ies) where they have an aneurysm+ ...



Moltroub said:

Pat, thanks so much for this detailed explanation and links. The YouTube was great and helped explain why my new cardiologist was so excited with my Neurosurgeon's notes! You rock!
16

thank you Patioplans, after I pulled up the second site, I do better understand the dimensions of the heart aorta. I have not tied in where it plays a part in the brain. I rember being told by my first cardio doc that my brain aneurysm was likely caused by my heart. I wish I still had him as a doc, he would always explain and would answer my questions no matter how silly they sounded. I have a much better idea of what portion of the aorta I have the aneurysm. The dismal and proxismal portion is clear. I took your advice and googled based on what was in the echo result report and found a few things to help. I'll have to go back and read it again so that I can write questions to ask my doctor. Like since my aneurysm is of the ascending aorta, how close is it to the arch? Will/can it shrink?

17

Much2Much...I am so glad you've responded... your response to my initial is well under way...and, I will have to put a few more words together for it yet...again, a step at a time..

If I have ever had an addiction...it is my commitment to bring forward data that is not, has not been, provided to us as paying patients...Sunday-Monday were my (mentally) crash days, and, which can/may occur anytime I am studying a subject...it is like it "attaches" me...and I will not sleep...then I crash... for 10 hours and a f/u with another 2 or 10 hours...

Thus, I follow what my brain/body needs... and it is not to avoid an issue...it is to recapture...

As for shrinkage...I do not know that of the aortic arch yet...My med records note the (potential) 3 branches off it...by their names...not where they branched off... (the usual BS (biz standards))...can be so overwhelming...

I do have a specific shrinkage (documented) in brain tissue...for which I do not have a fully defined explanation... YET!!!...and, well, if I should live so long...I am driven to open up the brain issues from/by the varied treatments...to open the doors of the results of the procedures...including IF the procedure or IF the quality of the performer (aka provider... which opens more doors...)

Again, bear with me in my ability to respond...IF ever, I recognize/realize, I typed the wrong word, I will let you know...Your "will/can it shrink?"...Yes, shrinkage can occur in brain tissue for which I have initial and specific documentation...I will pull the records and note those for you /others...

My mind (I almost typed "window" vs "mind") so it is time for me to back off tonight...I am emotionally side-tracked...my PBS tonight has "Yearbook - 1960-1963" ..(so you may need to ask your mom/gramma).

Bear with me a day at a time...and, if anything slips by me this week...have a warm Thanksgiving...

patioplans...

18

Pat, as we age our brain naturally shrinks. Here’s a neat little paper on it. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2596698/

Remember, it’s importent for healthy diets, exercise and exercising the brain to keep them healthy.

19

Moltroub...thank you for your info...However, the measurements I have addressed on shrinkage were a decade + ago... the one (first med record noting it formally)...was 20 minutes post-abrupt angio stoppage which was two days after the initial abrupt angio (called the diagnostic) stoppage...

For this first two hours the MD-pathologist was involved who coded her billing under ICD9 of 799.9:

...Undiagnosed disease not specified as to site or system... or

...Unknown cause of morbidity or mortality

(all in the story formats and/or the CPT(current procedural terminology) for that billing)

FYI: the conversion to ICD 10 began in October 2015 and the conversion of ICD 9 799.9 are:

ICD 10: R69: illness unspecified ...or R99 ill-defined and unknown cause of mortality

One group I hope (plan) to put in this 'category' site is on CODES from ICD 9 to ICD 10; the HCPCS, CPT (billing) and Revenue codes (a state set-up w/minor variances) and some others (i.e. doc performance codes - a/w/a the facility procedure codes...)

My current research...is to clarify the types of the changes in our brain from "cognitive impairment" to various dementias... it is a bit complex for ??? by the anatomy/physiology our brain tissue... and, then adding the general arterial supplier to those areas...

And, also the neuropsych tests which are used to diagnose our brain levels...

Yes, our brain cells can shrink..in various ways/causes...and, there are specific neuropsych tests for one or all types...

In 2007, I was so excited about taking the Brain Fitness program of the PositScience group...I was telling (aphasic over my words/thoughts) some friends of mine (40 years)...and I could not understand what the hubby was telling me to "discover"...The wife then re-explained that Lee wanted me to get the March 2007 Discover magazine...for the article on Brain Fitness/PositScience and even told me the founder's name/MD status which I still forget)

Lee was 102 years old...advising me what to read...

Conversely, I know some who have lost their spouse to the renowned AD...and MS and PDD (Parkinson's disease dementia)...Slow learning what I am reading is tremendous...and over whelming to me until I type them into order/comparison...I did take 14 months of vision therapy to regain reading/comprehension...no surgeries - no pharmafia products...

RE: vision..I did not regain all the (blanking as I type) peripheral vision...

I hope none of this offends you/others...I call it opening another door...basics and resources... and, likely may post some of my images...I have hesitated on that, rather anticipating they will be blocked off and/or I will be blocked off...

RE: healthy diets...I have been a co-op member for decades...re: organic foods, etc...even including my red wine...which limits to almost zero sulfites...I was one of the original promoters in asking Costco when they would begin organics...and they began several years back w/some samples have added more and more...A recent Costco recall of chicken was not organics...

When the pituitary is hit (particularly w/the contrast dye)...the thyroid can be hit...and, the pineal (circadian rhythm - sleep) gland is in the roof of our 3rd ventricle... (near/around/by our brainstem of cranial nerves)...

Thank you, once again...for bringing in the data on shrinkage...later on, I will bring forth the data on my specific shrunken area...and, this time frame to extravasated contrast dye... (my first 72 hours hospitalized and the beginning of angios)

Back in 2012...one of our members posted an article: "iodine in Contrast Material Poses Thyroid Threat | Medpage Today:

http://www.medpagetoday.com/Cardiology/PCI/30837?pfc=101&spc=24


Moltroub said:

Pat, as we age our brain naturally shrinks. Here's a neat little paper on it. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2596698/

Remember, it's importent for healthy diets, exercise and exercising the brain to keep them healthy.
20



patioplans said:

Much2Much...I am so glad you've responded... your response to my initial is well under way...and, I will have to put a few more words together for it yet...again, a step at a time..

If I have ever had an addiction...it is my commitment to bring forward data that is not, has not been, provided to us as paying patients...Sunday-Monday were my (mentally) crash days, and, which can/may occur anytime I am studying a subject...it is like it "attaches" me...and I will not sleep...then I crash... for 10 hours and a f/u with another 2 or 10 hours...

Thus, I follow what my brain/body needs... and it is not to avoid an issue...it is to recapture...

As for shrinkage...I do not know that of the aortic arch yet...My med records note the (potential) 3 branches off it...by their names...not where they branched off... (the usual BS (biz standards))...can be so overwhelming...

I do have a specific shrinkage (documented) in brain tissue...for which I do not have a fully defined explanation... YET!!!...and, well, if I should live so long...I am driven to open up the brain issues from/by the varied treatments...to open the doors of the results of the procedures...including IF the procedure or IF the quality of the performer (aka provider... which opens more doors...)

Again, bear with me in my ability to respond...IF ever, I recognize/realize, I typed the wrong word, I will let you know...Your "will/can it shrink?"...Yes, shrinkage can occur in brain tissue for which I have initial and specific documentation...I will pull the records and note those for you /others...

My mind (I almost typed "window" vs "mind") so it is time for me to back off tonight...I am emotionally side-tracked...my PBS tonight has "Yearbook - 1960-1963" ..(so you may need to ask your mom/gramma).

Bear with me a day at a time...and, if anything slips by me this week...have a warm Thanksgiving...

patioplans...

My thought process is as such, that I spend too much time trying to comprehend only to end up frustrated and bewildered. I too take things is small doses and can be obssesed with trying to figure out what they so desperately deny telling me. Hours lasp and I find that I have not slept and wake to be totally unfunctional which those around me find unrealistic for they do not comprehend the depth of my inabilities to function as they do. I encounter this behavior daily at work. They refuse to think/believe that I am no longer the same quick witted, problems solving person I once was and that my mind continues to detoriate (I no longer spell words, I sound them out and spell as I see fit hoping to get the jist of the word across) daily. Nor do I hope to retain/regain the ability to do so for it is very exhausting. I will continue to read for there are days when the light bulb goes on and I lavish is the moment of understanding, but on the very next day to find that my cognitive sense of the input I so desperately try to hold on to has again disolved.

Thank you Patioplan for the warm Thanksgiving wishes and I extend the same to you and your family.

Have a Happy Thanksgiving!