CX 2019 Digest by BIBA Publishing

Vascular & Endovascular

Challenges Update 15–18 APRIL 2019 MONDAY–THURSDAY OLYMPIA LONDON • UNITED KINGDOM

Aortic Challenges

Peripheral Arterial Challenges

Venous & Lymphatic Challenges

Acute Stroke Challenges

Vascular Access Challenges

CX 2019 DIGEST

EDUCATION

INNOVATION EVIDENCE

2019

CX Digest

CX Executive Board

Vascular Access

Aortic

Nicholas Inston

Frank Vermassen

Consultant Surgeon and Clinical Lead for Renal

rofessor in Vascular and Thoracic Surgery P Department of Vascular Surgery at Ghent University Hospital, Ghent, Belgium

Domenico Valenti

Janet Powell

onsultant Vascular Surgeon and Honorary Senior C Lecturer at King’s College London, London, UK

rofessor of Vascular Biology and Medicine, Imperial P College London, London, UK

Krassi Ivancev

epartment of Vascular Medicine, University D Hospital Hamburg-Eppendorf, Hamburg, Germany; Honorary Professor, Division of Surgery

Dittmar Böckler

rofessor of Vascular Surgery at University of P Heidelberg and Head of Department of Vascular Surgery and Endovascular Surgery at University Hospital Heidelberg, Heidelberg, Germany

Stéphan Haulon

rofessor of Vascular Surgery, Université Paris Sud, P Hôpital Marie Lannelongue, Le Plessis Robinson, France

Tilo Kölbel

rofessor of Vascular Surgery, University of P Hamburg, and Vascular Surgeon at the University Heart Center Hamburg, Hamburg, Germany

Surgery and Transplantation at Queen Elizabeth Hospital Birmingham, Birmingham, UK

Fiona Rohlffs Department of Vascular Medicine, University

Hospital Hamburg-Eppendorf, Hamburg, Germany & Interventional Sciences, Faculty of Medical Sciences, University College London, London, UK

Peripheral Arterial

Eric Verhoeven

hief, University Department of Vascular and C Endovascular Surgery, Paracelsus Medical University, General Hospital Nuremberg, Nuremberg, Germany

Venous & Lymphatic

Alun Davies

rofessor of Vascular Surgery, Head of Section P of Vascular Surgery, Imperial College London and Consultant Surgeon at Imperial College NHS Trust, Charing Cross Hospital and St Mary’s Hospital, London, UK

Andrew Holden

iWounds

ssociate Professor of Radiology at Auckland A University School of Medicine and Director of Interventional Services at Auckland City Hospital, Auckland, New Zealand

Michael Edmonds

Gerard O’Sullivan

rofessor of Diabetic Foot Medicine and Consultant P Diabetologist at King’s College Hospital, London, UK

onsultant Interventional Radiologist, Galway C University Hospitals, Galway, Ireland

Keith Harding

rofessor of Wound Healing Research, School of P Medicine, Cardiff University, Cardiff, UK

Claudine Hamel-Desnos

Una Adderley

irector, National Wound Care Strategy Programme D (NHS England), Academic Health Science Network and University of Leeds, Leeds, UK

Gunnar Tepe

ead of Diagnostic and Interventional Radiology, H RoMed Clinic, Rosenheim, Germany

Thomas Zeller

rofessor of Angiology at Albert-Ludwigs University P of Freiburg and Head of Department of Angiology at Universitäts – Herzzentrum Freiburg, Bad Krozingen, Germany

Venous & Lymphatic

Stephen Black

onsultant Vascular Surgeon at Guy’s and St C Thomas’ Hospital, and Reader in Venous Surgery at Kings College London, both London, UK

Manj Gohel

onsultant Vascular & Endovascular Surgeon, C Addenbrooke’s Hospital, Cambridge, UK, and Honorary Senior Lecturer, Department of Surgery and Cancer, Imperial College London, London, UK

CX Advisory Board

rofessor of Dermatological Medicine, Consultant P Dermatologist, St George’s, University of London, London, UK

Acute Stroke

Ross Naylor

rofessor of Vascular Surgery at University Medical P Center Utrecht, Utrecht, Netherlands

onorary Professor of Vascular Surgery at University H of Leicester and Consultant Vascular Surgeon at Leicester Royal Infirmary, Leicester, UK

Peripheral Arterial

Cliff Shearman

meritus Professor of Vascular Surgery, University E of Southampton and Non-Executive Director, Royal Bournemouth and Christchurch NHS Foundation Trust, Southampton, UK

Hugh Markus

Giovanni Torsello

rofessor of Stroke Medicine, Honorary Consultant P Neurologist, University of Cambridge, Cambridge, UK

Professor, Chief

ssociate Professor of Surgery, Medical University A Innsbruck, Deputy Director, Department of Vascular Surgery, University Hospital Innsbruck, Innsbruck, Austria

Peter Mortimer

Barbara Rantner

Frans Moll (Chairman)

ascular Physician, Hôpital Privé Saint-Martin, Caen, V France, and President of the French Society of Phlebology

Acute Stroke

of the Department of Vascular Surgery at Franziskus Hospital, Münster, Germany

Trevor Cleveland

onsultant Vascular Radiologist and Honorary C Senior Lecturer at Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK

Robert Hinchliffe

rofessor of Vascular Surgery at University of Bristol P and Vascular Surgeon at North Bristol NHS Trust, Bristol, UK

Recruitment to Vascular Management

Armando Mansilha

rofessor of Angiology and Vascular Surgery, Faculty P of Medicine at the University of Porto, Porto, Portugal, and Secretary General, UEMS Section and Board of Vascular Surgery

Sophie Renton

onsultant Vascular Surgeon at Northwick Park C Hospital, Honorary Senior Lecturer for Imperial College London, London, UK, and Honorary Secretary, The Vascular Society for Great Britain and Ireland

CX Abstract Board Meryl Davis (Chair) Daryll Baker

Marcus Brooks

Paul Moxey

Rachel Bell

Robert

Anna Prent

Colin Bicknell

Hinchliffe

Celia Riga

2019

Participants discuss their highlights of CX 2019 It brings all of the world’s experience to one place.

Switzerland Brazil China Poland Spain Turkey Greece Portugal Egypt Sweden Belgium Ireland Australia Russia Saudi Arabia Austria Denmark Japan Czech Republic Finland Israel India Singapore Canada Argentina Slovenia South Africa Hungary Mexico Thailand Romania Serbia South Korea New Zealand Norway Slovakia United Arab Emirates Kuwait Taiwan Bulgaria Croatia Lebanon Sri Lanka Ukraine Costa Rica Iraq Jordan Other

CX Digest

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68% Western Europe 10% North America 8% Asia 6% Eastern Europe 4% Latin America & Caribbean 2% Africa 1% Middle East 1% Australasia

I was completely blown away with the quality of the innovations being reviewed in the programme. I was able to network with colleagues and receive information to enhance patient care. Lots of time for discussion after the presentations!

Everything is here for you—the opportunity to network with vascular surgeons; see new approaches; and gain hands-on experience of certain suture techniques as well as discuss how to improve those techniques!

The meeting offered many perspectives and workshops that highlighted the current state of vascular surgery. The direct communication and contact with experts in the field was one of the best things about the symposium.

CME feedback Of the CME delegates surveyed, 91% rate the CX 2019 programme as “excellent” or “good” .

91% Excellent or Good 8% Fair 1% Poor

2019

CX Digest

Acute Stroke

Acute Stroke programme

he Acute Stroke Challenges programme—with Barbara Rantner (Innsbruck, Austria) and Hugh Markus (Cambridge, UK) as the CX Executive Board members—focused on three areas: Hot carotid challenges, Acute stroke challenges, and Stroke after cardiac surgery.

In the first of five debates (most of which occurred during Hot carotid challenges), Sofia Strömberg (Gothenburg, Sweden) went up against Clement Darling III (Albany, USA) in a CX debate about the optimal timing of carotid endarterectomy after a minor stroke. She successfully persuaded the audience that “urgent” endarterectomy (within the first 48 hours) was not a reasonable option (73% vs. 27% supporting Darling’s motion that it was a reasonable option). The second debate of the programme saw Ross Naylor (Leicester, UK) win support for his view that the “majority of patients with asymptomatic carotid disease do not benefit from carotid interventions”: 76% of the audience vs. 24% of the audience supporting Alun Davies (London, UK) arguing against the motion. According to Naylor, the “vast majority” of patients with asymptomatic carotid disease “will never benefit from a one-size-fits-all approach to treatment”. He urged that “we [physicians] need to be more selective, and identify the high risk for stroke patients, and then offer surgery or stenting”. In his counter argument, Davies stated that carotid endarterectomy decreases the risk of stroke, and that its “results are improving with time”.

Barbara Rantner One highlight of the Acute Stroke Challenges programme was the debate on whether intracranial thrombectomy should be limited to neurointervenionists (see main text). Also, a presentation about the impact of virtual reality on the quality of thrombectomy training by Thomas Liebig (Munich, Germany) added some relevant information to this discussion.

Davies had better luck in the third debate, in which 64% of the audience agreed with him that carotid revascularisation (with surgery or stenting) was not safe to be performed early after thrombolysis. Maarit Venermo (Helsinki, Finland), who was supporting the motion that it was safe, said that the optimal timing is between two and seven days following thrombolysis and cautioned against delays because of the potential for strokes to occur. “I do not think it is wise, because we never know what happens to these patients while we are waiting,” she explained. Davies stated that he would wait for a minimum of 72 hours. In the fourth debate, 75% of the CX audience voted against the motion that newer technologies and innovations have made carotid artery stenting as safe as carotid endarterectomy in the first 14 days after a transient ischaemic attack or stroke. Peter Schneider (Honolulu, USA) argued for the motion and Naylor argued against the motion. However, the closest vote of the day was the one in which Jan Kovac (Leicester, UK) and Andrew Clifton (London, UK) discussed whether intracranial thrombectomy should be limited to neurointerventionists. Kovac (a cardiologist), whose proposition was that it should not be limited to neurointerventionists, won the debate with 57% of the vote, but a substantial minority (43%) supported Andrew Clifton’s

arguments that the procedure should be limited to neurointerventionists. While Clifton argued that experience and proper training leads to “appropriate patient selection [and] faster, safer procedures with fewer complications”, Kovac said that, given the magnitude of the potential clinical and economic benefits of mechanical thrombectomy, a “collaboration of various interventional specialists is desirable to deliver this therapy to a wider population”. As well as the debates, during the Acute Stroke Challenges programme, there were talks on the choice of intracranial stent technologies, the frequency of stroke after cardiac surgery, and the clinical impact of carotid stenosis in patients undergoing transcatheter aortic valve implantation (TAVI). Additionally, David Hargroves (Kent, UK) reviewed what thrombectomy trials “really tell us”, and how the findings can be implemented into routine clinical practice. In the light of DAWN and DIFFUSE-3, he said that there is a strong evidence basis for thrombectomy and that this treatment should be available to all patients. Additionally, Hargroves posited that regional and countrywide networks are required to deliver and achieve its 10% potential reach. However, he said, caution is needed when reorganising stroke services, so as not to destabilise the “core” business and therapeutic benefit of organised care, closest to home.

2019

CX Digest

Voting results

CX Debate: Intracranial thrombectomy should be limited to neurointerventionists.

27% For the motion: Clement Darling III* 73% Against the motion: Sofia Strömberg* Comments by Roger Greenhalgh (RG), Chairman of the CX Executive Board: An overwhelming defeat of this motion suggests that the CX audience is not at all convinced that they should operate within the first 48 hours.

43% For the motion: Andrew Clifton* 57% Against the motion: Jan Kovac* RG: “Against the motion” is carried but not as big as in earlier debates. Perhaps the sentiment here is that someone who is not a neurointerventionist, nevertheless, should be trained to the same level as a neuronterventionist.

CX Debate: The majority of patients with asymptomatic carotid disease do not benefit from carotid interventions. 76% For the motion: Ross Naylor* 24% Against the motion: Alun Davies* RG: The motion was carried hugely, suggesting that indeed the majority of asymptomatic carotid disease patients do not benefit from carotid interventions in the view of the CX 2019 audience.

CX Debate: Carotid revascularisation (surgery or stenting) is safe to be performed early after stroke thrombolysis. 36% For the motion: Maarit Venermo* 64% Against the motion: Alun Davies RG: “Oh no it is not!”, says the CX 2019 audience.

CX Debate: Newer technologies and innovations now make carotid artery stenting as safe as carotid endarterectomy in the first 14 days after onset of transient ischaemic attack/stroke. 25% For the motion: Peter Schneider* 75% Against the motion: Ross Naylor RG: “Oh no it does not!”, again says the CX 2019 audience.

* Affiliations: Clement Darling III (Albany, USA); Sofia Strömberg (Gothenberg, Sweden); Ross Naylor (Leicester, UK); Alun Davies (London, UK); Maarit Venermo (Helsinki, Finland); Peter Schneider (Honolulu, USA); Andrew Clifton (London, UK); Jan Kovac (Leicester, UK)

Acute Stroke

CX Debate: It is reasonable to offer urgent carotid endarterectomy (within the first 48 hours) in patients suffering a minor stroke.

2019

CX Digest

Peripheral Arterial programme

Peripheral Arterial

levels of circulating paclitaxel following the use of a paclitaxel device to manage peripheral arterial disease and 67% did not agree that these levels were “potentially dangerous”. Furthermore, 85% supported the view that “no danger has been demonstrated in any organ of the body that is attributable to circulating paclitaxel”.

Other peripheral arterial disease issues Peripheral Proximal Arterial Ischaemia Challenges

n a special “CX 2019 Highlight” session, CX sought to have “The last word” on paclitaxel. This was in response to the Katsanos et al meta-analysis, published last year, and the subsequent debate that followed it. The meta-analysis raised questions about the safety of paclitaxelcoated devices (balloons and stents) for the management of peripheral arterial disease. Since the meta-analysis was published, several companies have published their own patient-level data (showing no link between paclitaxel and increased mortality) and the US Food and Drug Administration (FDA)— following its own preliminary analysis of the long-term data—has advised against the use of paclitaxel devices unless a patient has a high risk of restenosis.

At CX, speakers and delegates together reviewed the “potential problem”, scrutinised the statistics behind the longterm results, and discussed the current ways that paclitaxel is being used. In particular, vascular pathologist Elena Ladich (Hollywood, USA) presented insights from a new analysis on the effects of paclitaxel in the body. She explained that a proportion of the drug and excipient coating of paclitaxel-coated devices are known to embolise distally, adding it was important to ask whether or not we should be concerned with “the potential shower of

drug into the end organ”. According to Ladich, there have been “rare case reports” of aneurysms, localised hypersensitivity, downstream vasculitis and panniculitis following drug-coated balloon treatment. However, she noted that “to date” no reports of autopsy findings or specific organ toxicity in humans treated with drug-coated balloons have been published. Additionally, she commented no causal links or mechanisms explained the suggested association between paclitaxel and increased mortality. But, she observed: “This does not mean a potential damaging effect to organs does not exist.” The lack of mechanistic signal was a major criticism levelled at the Katsanos et al metaanalysis. Defending his methodology and conclusions, at CX, Konstantinos Katsanos (Patras, Greece) said his and his colleagues’ findings were consistent and significant across multiple statistical analyses. He said: “We are mathematically 99% certain of this significance”, adding that a trial was “only as good as its methodology”. “The key message here is not a smoking gun—it is the consistency of the findings. You see here the consistency of the mortality signal, and this I would say is the main take-home message,” Katsanos commented. Overall, the CX delegates seemed to still be in favour of paclitaxel. Nearly 70% (68%) voted against there being “substantial”

As well as the paclitaxel session, the Peripheral Proximal Arterial Ischaemia Challenges programme also had sessions on peripheral arterial disease issues, interventional techniques, and open bypass. Delegates also had opportunities to watch edited cases. Speaking about office-based lower extremity arterial interventions, Enrico Ascher (Brooklyn, USA) presented data that “challenges” the dogma that high-risk patients should not be offered officebased endovascular infrainguinal arterial procedures. He cited studies that showed patient satisfaction levels with outpatient care of 99%, and listed its other advantages as improved physician efficiency, due to multitasking, better reimbursement levels, and increased independence for practitioners because hospital administrators are “cut out of the equation”. During the imaging session, Steven Rogers (Manchester, UK) spoke about the use of contrast-enhanced 3D ultrasound imaging for peripheral arterial disease. He commented that surgeons at his centre “certainly prefer the 3D vein map to a 2D vein map”, adding that tomographic 3D ultrasound imaging was “minimally invasive”. “You can do it with relatively little experience, it is fast, it is inexpensive, it can be reimbursed, and potentially it is becoming more clinically valuable; perhaps it is the way forward,” he told CX delegates.

2019

CX Digest

Voting results

Do you agree with BASIL 3 and SWEDEPAD to recommend to stop using paclitaxel products at this moment?

Do you recommend ambulatory treatment for your patients with peripheral arterial disease? 63% Yes

52% Yes 48% No RG: A small victory in favour of this decision, but the CX 2019 audience was very split.

37% No RG: The majority do recommend ambulatory treatment of some sort. Of course this does not go on to define the type of ambulatory treatment. It does not say that it is “supervised exercise” or “Nordic pole walking” but simply “ambulatory treatment”, so the CX audience accepts that this is a good idea in general.

56% Yes 44% No RG: This is quite a striking finding and here supervised exercise is specified and more than half are in favour of it. Here the big problem is to get funding for it, but it seems that people are absolutely convinced that it should be adopted wherever there is funding for it.

Does IVUS tend to catch on as it has in the United States? 14% Yes

53% Yes 47% No RG: Again, a split opinion amongst the CX audience 2019, but 53% finding it to be correct certainly raises that it is an important issue to take a view on this.

Peripheral Arterial

Do you provide supervised exercise advice for your patients?

Do you suspect that the finding of Dr Katsanos is correct?

Is there statistical evidence at this moment indicating a real increased mortality from the use of paclitaxel on a balance of probabilities? 57% Yes 43% No RG: There was a difference of opinion between statisticians of almost everyone who spoke. The issue that came up was whether there is an association of increased mortality with the use of paclitaxel. Of the audience, 57% thought that there could be.

86% No RG: For sure, IVUS is popular in the USA and certainly has not had the same degree of uptake at this side of the Atlantic. Cost for individual case or value achieved from it could be a major factor there. If the specific indication is specified, such as suspected transection of the aorta, it is by far the most reliable investigation tool to decide whether this diagnosis is correct or not. I would expect a massive uptake for specific indications.

CX Debate: DCB alone is enough for the popliteal segment. 41% For the motion: Marc Bosiers* 59% Against the motion: Theodosios Bisdas* RG: Drug-coated balloon (DCB) alone does not win this debate.

Are the regulatory authorities reacting appropriately? 68% Yes 33% No RG: The FDA and MHRA are acting appropriately in the opinion of a two-third majority of the CX 2019 audience.

Do you think that those who used paclitaxel in the early days were quite aware that paclitaxel kills cells? 85% Yes 15% No RG: There can be no doubt whatsoever in the CX audience mind that it was always known that the use of paclitaxel involved cell death. It was clearly used by the pioneers in an attempt to knock out the restenosis process.

* Affiliations: Marc Bosiers (Dendermonde, Belgium); Theodosios Bisdas (Athens, Greece)

2019

CX Digest If you accept that the pioneers knew that paclitaxel would kills cells, do you think that they always aimed to have a balance between achieving less restenosis in the patient’s interest without increasing mortality?

Peripheral Critical Ischaemia Challenges Interdisciplinary Leg Initiative

72% Yes 28% No RG: A resounding “yes” with 72% in agreement clarified this position substantially.

Peripheral Arterial

Have we established that there are substantial levels of paclitaxel circulating arteries used for reducing restenosis? 32% Yes 68% No RG: Sixty-eight per cent said “No”. This is quite a firm finding. No, this has not been established and is in doubt.

Are these levels potentially dangerous? 33% Yes 67% No RG: Again, 67% said “no”, not even potentially dangerous, whereas 33% thought that they could be potentially dangerous.

Has any danger been demonstrated in any organ of the body attributed to circulating paclitaxel? 15% Yes 85% No RG: A resounding 85% of the CX audience were of the view that the organs of the body had not been shown to be damaged by circulating paclitaxel. Therefore, the CX audience could not attribute any mortality of a patient to circulating paclitaxel.

CX Debate: In the absence of suitable venous graft material, prosthetic bypass is the answer. 67% For the motion: Clement Darling III* 33% Against the motion: Andrew Holden* RG: Sixty-seven per cent of the CX audience are in agreement with this.

* Affiliations: Clement Darling III (Albany, USA); Andrew Holden (Auckland, New Zealand)

he Peripheral Critical Ischaemia Challenges programme, which incorporates the Interdisciplinary Leg Initiative (iLegx) and the Critical Limb Ischemia (CLI) Global Society, was comprehensive— focusing on topics ranging from guidelines to drug therapy. Additionally, the programme had two mini symposiums: “Arterial disease below the ankle” and “The ischaemic renal foot and Charcot foot”.

In one of the first talks of the programme, Michael Conte (San Francisco, USA) looked at whether the term “critical limb ischaemia” was an outdated concept. He argued that the term was outdated because it “fails to encompass the full spectrum of patients who are evaluated and treated for limb-threatening ischaemia in modern practice”. He added that the term “chronic limb-threatening ischaemia” should be used instead to include “a broader and more heterogeneous group of patients with varying degrees of ischaemia that can often delay wound healing and increase amputation risk”. Another one of the first talks in the programme was Marianne Brodmann’s (Graz, Austria) presentation on managing the geriatric patient in “the age of modern endovascular treatment options”. Brodmann stated that data show that “endovascular revascularisation is cost-effective compared with conservative treatment for critical limb ischemia patients older than 70 years”. Therefore, she noted, physicians should consider individual circumstances that can alter the outcome of the intervention. Brodmann also discussed, in a separate presentation, the COMPASS and VOYAGER PAD trials and examined how they are trying to address questions surrounding the use of secondary prophylactic treatment in patients with peripheral arterial disease. After Brodmann spoke about the COMPASS and VOYAGER PAD trials, Peter Schneider (Honolulu, USA) looked at the use of drug-

2019

CX Digest “Try to understand what is, more or less, functioning, and do not touch it!”

During the mini symposium on arterial disease below the ankle, Roberto Ferraresi (Milan, Italy) gave the talk “Indications and techniques for below-the-knee angioplasty”. He talked about the importance of recognising foot anatomy, concluding:

Exceptional skills are required for retrograde tibiopedal angioplasty. It is not a technique for everyone to do. 94% Agree 6% Disagree RG: Special skills are needed.

Given all the recent focus on suggested increased mortality risk in one meta-analysis, do you accept that drug-coated balloons and stents improve treatment of patients with critical limb ischaemia? 57% Yes 43% No RG: Fifty-seven per cent of the CX audience said “yes”.

If drug-coated balloons and drug-eluting stents are discontinued, do you expect greater restenosis and amputation rate? 38% Yes 62% No RG: Sixty-two per cent is a remarkable figure saying “no” to this suggestion.

Peripheral Arterial Podium 1st session

en peripheral Podium 1st talks were presented in a dedicated, CX 2019 Highlight session. The studies discussed in the session included the MUST trial (Kak Khee Yeung, Amsterdam, The Netherlands), ZILVERPASS (Marc Bosiers, Dendermonde, Belgium), and REPLACE (Yann Gouëffic, Nantes, France).

Additionally, Timothy Sullivan (Minnesota, USA) presented the two-year findings from the MIMICS-2 trial, which showed that the BioMimics 3D stent (Veryan)—designed to mimic natural vascular curvature—remains safe and effective for patients with symptomatic atherosclerotic disease of the femoropopliteal arteries two years after implantation. “We know that swirling flow creates increased wall stress in the arterial wall, which is atheroprotective, and this is especially important in the superficial femoral artery where, under normal circumstances, shear stress is quite low. The use of a helical stent produces swirling flow and increased wall shear stress,” he noted.

Peripheral Arterial

coated balloons and stents for the management of below-the-knee lesions. He observed that the devices did have the potential to “significantly impact” the treatment of these lesions but added it was “just the beginning”. He noted that he was optimistic about below-the-knee drug delivery, but commented “we must safely reduce major amputation and the need for repeat revascularisation to achieve wound healing”.

In the final talk of the day, Graeme Ambler (Bristol, UK) presented results from the PLACEMENT (Perineural local anaesthetic catheter after major lower limb amputation trial). The aim of the study, he said, was to establish the efficacy of perineural local anaesthetic catheters to help manage pain after lower limb amputation. He explained that the catheters were “easily placed at the time of amputation” but added there were “little data on their direct effect on pain”. In the study, patients were randomised to undergo “usual care” or usual care with the addition of a perineural catheter. The outcomes included the proportion of patients recruited and the proportion of patients providing at least nine pain scores over five days. Ambler concluded that recruitment of patients to assess the efficacy of routine use of perineural catheters is feasible and that a full efficacy trial was practical. However, he added that assessment of chronic/phantom pain at follow-up is difficult.

Voting results

2019

CX Digest CX Peripheral Workshop

T Peripheral Arterial

he CX Peripheral Workshop, now in its second year, ran over two days (Tuesday and Wednesday of the Symposium). It provided delegates with opportunities to try out innovative peripheral technologies such as the minimally invasive excimer laser system Dabra (Destruction of arteriosclerotic blockages by laser radiation ablation; Ra Medical Systems) that was showcased for the first time at CX.

Georg Bach (Bulach, Switzerland) demonstrated the Pulsar-18 T3 stent (Biotronik) at the Workshop. He noted: “We have samples here and we let [the delegates] deploy the stent themselves to show them how accurate it is.” Other stations at the Workshop included “Jaguar self-expanding nitinol stent”, “Indigo system and large volume coils”, “See clearly: The value of peripheral arterial IVUS in decision making”, and “Vessel preparation with JetStream Atherectomy system and Ranger DCB”.

CX Peripheral Techniques & Technologies

or the first time, as part of the peripheral live & edited cases session, the CX audience were able to experience an array of “virtual reality” live cases. The virtual reality involved live streaming of a 360-degree video—allowing the audience to see all aspects of the case that was being performed.

Thomas Zeller (Bad Krozingen, Germany), live from Bad Krozingen, performed the first virtual reality case, which used a drug-coated balloon plus directional atherectomy for the management of a lesion in the common femoral artery. The patient in the case was a 64-yearold male with claudication (Rutherford 3) in the right leg. Targeting the right common femoral artery, Zeller carried out directional atherectomy with HawkOne (Medtronic). Subsequently, the IN.PACT Admiral drugcoated balloon (Medtronic) was used. Arne Schwidt (Münster, Germany) performed the second virtual reality live case. In his case, he used a balloon-expandable endoprosthesis for the management of iliac lesions. Throughout the day, there were also edited case presentations from Andrew Holden (Auckland, New Zealand), Trevor Cleveland (Sheffield, UK), and Luis Mariano Palena (Abano Terme, Italy) among others. As well as the CX Peripheral Techniques & Technologies (live & edited cases) session, the LINC@CX session (held on the Wednesday of CX) also provided an opportunity for delegates to see edited cases. Moderated by Giancarlo Biamino (Mercogliano, Italy) and Dierk Scheinert (Leipzig, Germany), the session focused on pioneering techniques for below-the-knee revascularisation in critical limb ischaemia.

However, the aim of the Workshop was not just to highlight peripheral technologies as it also sought to raise awareness of important initiatives. For example, at the Workshop, Medi was discussing their campaign to encourage the early detection and management of peripheral arterial disease. As part of this campaign, they handed out small red hourglasses to demonstrate how blood flow can be restricted in arteries. A Medi representative said: “We are trying to encourage vascular surgeons to endorse the campaign, in order to make it stronger, as well as to encourage the screening of ankle brachial pressure index in primary care. Everyone in the high-risk group should get screened for ankle brachial index, to check the state of their arteries. If this can be implemented, we would avoid the [current] massive number of amputations.”

2019

CX Digest

Venous and Lymphatic programme Venous and Lymphatic Challenges

his year’s CX plenary Venous and Lymphatic programme looked at superficial veins, advanced venous disease, lymphoedema, venous ulceration, pelvic venous disease, and deep venous disease. The sessions reviewed the latest data, new treatments, and debated hot topics in the management of venous conditions.

Manj Gohel At a time where venous specialists have a plethora of superficial and deep venous interventions at their disposal, the CX 2019 Venous and Lymphatic programme focused on the real-world challenges of optimal patient selection and pathways of care. For superficial venous disease, although non-thermal modalities show real potential, case selection and optimal procedural technique remain important determinants of outcome. The management of acute iliofemoral deep vein thrombosis remains controversial after recent trials, but early thrombus removal has a role in the right patients. For patients with venous ulceration, optimal venous assessment and treatment through better pathways of care and improved links with primary care remain the key to better healing rates.

patients—and, importantly, for patients living in warmer climates—a reduced need for compression stocking therapy post-procedure. Isaac Nyamekye (Worcester, UK) also presented data during the Venous and Lymphatic Challenges programme. He reported that he and his colleagues found that compared with the Venefit and radiofrequency induced thermotherapy (RFITT) systems, endovascular radiofrequency ablation (EVRF) provided inferior truncal ablation at six months. He added this result indicated that operators should be more cautious about adopting “new, unproven, endovascular techniques into clinical practice”. In his talk, Alun Davies (London, UK) looked at maximising implementation of the EVRA (Early venous reflux ablation) Ulcer trial. EVRA, presented (by Davies) at CX last year, found that patients with superficial venous reflux who

underwent early ablation had faster healing than those who underwent ablation at a later date. According to Davies, despite the results of EVRA and guidelines recommending that patients with a venous leg ulcer should be referred to a vascular specialist within two weeks, patients are not being seen when they should be. He said: “Urgent action is required to improve referral pathways between primary and secondary care for patients with venous ulceration.” However, Davies acknowledged that there were certain barriers preventing the optimal implementation of this intervention, including a lack of education, system failure, inadequate facilities, and the perception of cost. He added that these barriers have led the UK Venous Forum to issue a guidance information leaflet that has, so far, been distributed to healthcare funding bodies and parliament. The leaflet details a strategy of

Venous

In a Podium 1st presentation, Nick Morrison (Scottsdale, USA) presented 60-month data for the VenaSeal closure system (Medtronic). These data show that, at five years, the system is not inferior to radiofrequency ablation for closure of diseased vein segments. Both treatments, Morrison commented, demonstrated “sustained improvement in disease-specific, generic quality of life and functional outcomes”. He added that “no serious adverse events, pulmonary embolism, deep vein thrombosis or treatment limb related adverse events were reported between 36- and 60-month visits”. According to Morrison, the “main advantage” of VenaSeal is rapid recovery period for

2019

CX Digest Voting results

Do you accept that the evolution of superficial venous management has moved away from thermal techniques substantially? 46% Yes 54% No RG: The CX 2019 audience does not all accept this suggestion by any means. Perhaps it is quite difficult to interpret the meaning of the question. To have 46% say “yes” and 54% say “no”, it is clear that there has been movement away from thermal techniques and the discussion is about the extent of that movement.

Venous

early referral, and the early assessment of patients with a venous leg ulcer. “From diagnosis to treatment, we should be able to do it within two weeks. We can certainly do it with cancer and other diseases, so why shouldn’t we be able to do this with leg ulceration?” he commented. In the first of two debates, Gerard O’Sullivan (Galway, Ireland) won the motion “The dangers of stenting for Nutcracker syndrome far outweigh any benefits”: 82% vs. 18% against the motion (argued by Olivier Hartung, Marseille, France). The poll at the end of the second debate was much closer, with 51% of the audience voting against the motion “Aggressive thrombus removal of iliofemoral DVT is overutilised as most patients do not develop PTS”. Speaking for the motion was Manj Gohel (Cambridge, UK) and speaking against it was Michael Lichtenberg (Arnsberg, Germany).

CX Debate: The dangers of stenting for Nutcracker syndrome far outweigh any benefits. 82% For the motion: G O’Sullivan* 18% Against the motion: O Hartung* RG: Very much agreed.

CX Debate: Aggressive thrombus removal for iliofemoral DVT is overutilised as most patients do not develop significant post-thrombotic syndrome. 49% For the motion: Manj Gohel 51% Against the motion: Michael Litchenberg RG: This is as close to a “break-even” vote as one can get and certainly thrombus removal for the iliofemoral DVT is now used much more than it used to be.

Do you think we need another RCT to look at iliofemoral DVT? 75% Yes 25% No RG: I feel that another trial will begin!

* Affiliations: Gerard O’Sullivan (Galway, Ireland); Olivier Hartung (Mareseille, France); Manj Gohel (Cambridge, UK); Michael Litchenberg (Arnsberg, Germany)

2019

CX Digest

CX Venous Workshop

he CX Venous Workshop, held on the Wednesday and Thursday of CX, was designed to showcase innovative technology and offer delegates the chance to get hands-on experience with the latest devices in the field. It brought delegates and demonstrators from all over the world to experience and discuss the latest developments.

Individual stations covered practical handson skills, diagnostic venous ultrasound, thermal and non-thermal ablation techniques, tributary treatment, aesthetic phlebology, sclerotherapy, plethysmography, lymphoedema, and compression techniques amongst other, additional stations. Berna Özata, a representative of Invamed (who had several stands at the Workshop), said there was a “good atmosphere” at the Workshop. “I have met lots of new people and the feedback that we have been getting has been great,” she commented.

Other stations at the Workshop included “Air plethysmography”, “Novel compression device”, “Surgical procedures for lymphoedema”, “Treatment of perforator veins”, “Saphenous sparing treatment”, and “Decision making for pelvic vein disease”.

CX Venous Techniques & Technologies

n each day of the Venous Workshop, prior to the start and during lunch breaks, edited cases were presented. On Wednesday morning, CX Executive Board member (Venous & Lymphatic) Manj Gohel (Cambridge, UK) presented a case on customised superficial therapy in advanced venous disease. Following this, Kathleen Gibson (Bellevue, USA) discussed a case using VenaSeal and then Johann Christof Ragg (Berlin, Germany) looked at ultrasound valve diagnostics. In the lunchtime edited case session, Gohel and fellow CX Executive Board member Stephen Black (London, UK) oversaw interactive case vignettes.

On Thursday, in the morning session, the cases included “Mechanical thrombectomy in the treatment of acute venous occlusion”, “ABRE venous stenting“, and “Venous obstruction management”. “JETi in a typical ilifemoral thrombosis” was one of the cases of the lunchtime session.

Venous

Speaking on the first day of the two-day event, Gurdeep Jandu (Bolton, USA)—a demonstrator for the PIUR tomographic ultrasound stand—reported that the Workshop was busy throughout the day.

He said: “Footfall has been great. Even before Venous City opened this morning, we had other demonstrators showing interest in our stand; so, the atmosphere has been really good and we have had some really good interactions with both clients and delegates.”

2019

CX Digest

Aortic programme Aortic Podium 1st session

rior to the start of the Abdominal Aortic Challenges programme, a dedicated “Aortic Podium 1st session” gave CX delegates the opportunities to listen to results for new and emerging aortic technologies.

Fabio Verzini (Turin, Italy), for example, reported that endovascular aneurysm repair (EVAR) with an iliac branch endoprothesis (Gore) is safe and effective. He added that the procedure was associated with improved quality of life in the short term and walking capacity was preserved. Hence Verhagen (Rotterdam, The Netherlands) also presented a study on EVAR, looking at the role of proximal neck sealing. He stated: “We know that the most common failure mode of EVAR is loss of proximal seal. This is especially seen in implants in attachment zones that are aneurysmal. So basically, a wide neck is a durability issue for EVAR.” He added that repair using proximal polymer sealing did not seem to induce neck dilatation like other endografts. Moreover, in contrast to self-expanding EVAR devices, patients treated with the largest size of Ovation (Endologix) do not experience more complications than those treated with standard diameter devices. Frank Arko (Charlotte, USA) spoke about Heli-FX Endoanchors (Medtronic), reporting that two-year data from the ANCHOR global registry show that using Endoanchors to fix

and seal endovascular aortic grafts is safe and effective for short-neck abdominal aortic aneurysm patients. He said: “At two-years’ follow-up, we have excellent clinical outcomes from a complex, short neck cohort, with no type Ia endoleaks, 65% sac regression, and only one proximal neck-related secondary procedure through two years. It should be added to the armamentarium of any vascular surgeon treating this type of patient’s condition. There probably needs to be in this hostile neck anatomy a variety of different therapies offered to the patient.”

Abdominal Aortic Challenges The first session—a CX 2019 Highlight session—of the Abdominal Aortic Challenges programme looked at the durability of EVAR in the context of the draft UK National Institute for Health and Care Excellence (NICE) aortic guidelines. The draft guidelines advise that EVAR is not a cost-effective treatment option for patients with abdominal aortic aneurysms; therefore, if finalised, these guidelines could lead to a major change in the way that aneurysms are managed given EVAR is a common treatment in the UK. A point raised during the session was that post-EVAR surveillance in terms of follow-up protocol had fallen short. Roger Greenhalgh (London, UK) commented: “In EVAR 1, patients failed to turn up for their follow-up appointments and this is the main reason why reintervention was not performed.”

Stéphan Haulon

Aortic

For the Durability of EVAR and the NICE guidelines session, I had the opportunity to show the audience—through a live “virtual reality” case from Paris (France)—how EVAR can be (and in my view should be!) performed with the support of 3D imaging. I demonstrated how to select the appropriate patient according to the instructions for use, design the endograft (3D workstation), guide the intervention (with fusion imaging), and how to check the technical success of the procedure (with cone-beam computed tomography). This up-todate workflow is associated with a high rate of technical success and a reduced risk of early and late complications; thus, for the patient, this means a reduced hospital stay and reduced need for secondary procedures. While performing the case, I enjoyed listening to the talk by Tara Mastracci (London, UK) in which she nicely summarised how EVAR has evolved from enrolment in EVAR 1 to the present day.

The failure of follow-up ultimately led to the “inevitable outcome” that EVAR was not costeffective based on the protocol and practices of 1999–2004 data. A panel (including Greenhalgh) reviewed how to optimise surveillance and reintervention strategies after EVAR. They worked on the assumption that sac diameter could be monitored at home, by the patient, in the community; therefore, dispensing of the need for an in-hospital annual computed tomography (CT) scan. Greenhalgh showed the audience a hand-held device that could perform this task: a mobile, lightweight device that could perform a Doppler ultrasound scan (via a smartphone). This, Greenhalgh said, was a technology that could come to “revolutionise” aneurysm care. Later on in the Abdominal Aortic Challenges programme, Vincenzo Brizzi (Bordeaux, France) reported the 10-year results for late rupture after EVAR at his centre (Groupe Hospitalier Pellegrin, Bordeaux, France). These showed that late rupture was a rare event—accounting for 15% of all ruptured aneurysms cases during the 10-year period— but indicated that there had been a slow increase in incidence to the extent that it had reached 28% by 2018. Summarising the findings, he said: “Late rupture after EVAR is a rare but an increasing complication. Respect of instructions for use at the time of index EVAR and lifelong tailored surveillance seems to be essential for long-term success.” He added that “tailored” surveillance was important because the first CT scan after EVAR could be used to identify those at high risk of rupture (<10mm proximal or distal sealing and/or endoleak) and should receive more frequent surveillance. Thus those at lower risk for rupture could receive less frequent surveillance, reducing costs and the risks of complications related to radiation/ contrast exposure.

2019

CX Digest

Voting results Are you inclined to support the use of Endoanchors as a primary intention for short proximal necks based on these data? 54% Yes 46% No RG: After the data given at CX, 54% of the audience were in favour of the use of Endoanchors in this situation.

Do you favour polymer sealing for neck-related adverse events? 38% Yes 62% No RG: Sixty-two per cent of the audience said “no”; they do not favour polymer sealing.

Do you welcome the draft NICE aortic guidelines? 38% Yes 62% No RG: A resounding 62% were against this proposal.

Do you favour estimation of long-term aortic risk as described? 82% Yes 18% No RG: Eighty-two per cent were in favour of this.

Do you think that, by tracking sac growth after EVAR, EVAR will be more clinically effective and at lower cost than occurred in the EVAR trials? 81% Yes RG: A resounding 81% was of this view. This is a very significant vote because if the EVAR trials themselves were taken literally as how the follow-up would be performed, endovascular repair would not be cost-effective; the NICE aortic guidelines committee would then be right to find this under their terms of reference. However, within a very short period of time and with use of a simple probe attached

In my daily practice, I prefer to use a reliable, trusted and proven BX covered stent over a new technology stent without mid-term clinical outcomes. 14% Always 64% Most of the time 21% Rarely 0% Never RG: It is popular.

Do you agree that these high volume centres are associated with improved results? 79% Yes 21% No RG: Seventy-nine per cent of the CX audience were of this view. This is a very clear majority.

Is the innovative 3D navigation system likely to be of substantial benefit? 95% Yes 5% No RG: Ninety-five per cent were quite sure that this would be a great benefit. This is a huge step forward.

CX Debate: Hostile necks should be treated with standard EVAR devices. 8% For the motion 92% Against the motion RG: “No they should not” says 92% of the CX 2019 audience. This implies that much more thought needs to be used for hostile necks and alternative methods used for these patients. In this debate, Hence Verhagen (Rotterdam, The Netherlands) was speaking for the motion and Giovanni Torsello (Mϋnster, Germany) was speaking against the motion.

Aortic

19% No

to a smartphone, it will be possible to assess annual sac diameter in the community and it is very likely that this will lead to those whose sacs grow over 12 months being referred for hospital investigation for endoleaks. Those who have no sac growth will not be referred to the vascular centre. It will give rise to a huge saving and a huge increase of patient satisfaction potentially as well as a great reduction in radiation exposure from annual CT scans.

2019

CX Digest CX Debate: The vast majority of failed EVARs can be treated endovascularly. 43% For the motion: Jean-Pierre Becquemin* 57% Against the motion: Michel Makaroun* RG: Fifty-eight per cent of the CX audience felt that they could not. Indeed, this underlines that perhaps these known and well-described endovascular

corrections or rupture preventing reinterventions are only known by less than half of the CX audience. In other words, a much greater effort is required to be made for more to understand how to perform life-saving rupture, preventing reinterventions by the endovascular method. At CX 2018, five different methods were described. * Affiliations: Jean-Pierre Becquemi (Champigny-sur-Marne, France); Michel Makaroun (Pittsburg, USA)

Thoracic Aortic Challenges

Aortic

The Thoracic Aortic Challenges programme began with a session on Stroke from Thoracic Endovascular Procedures (STEP), which featured a “virtual reality” live case. The virtual reality case—a new feature of CX this year— allowed delegates a “360-degree” view of the case as it was being performed. In the case, a 77-year-old female patient with American Stroke Association (ASA) class III and multiple aortic aneurysm disease successfully underwent thoracic endovascular aortic repair (TEVAR). The 360-degree camera allowed session moderator Tilo Kölbel (Hamburg, Germany) to control the angle and direction of the camera from CX, showing the audience each corner of the operating room in real time. Giuseppe Panuccio (Hamburg, Germany) and his fellow operators performed the TEVAR procedure at the German Aortic Center (of which, Kölbel is the head). They reported that: “In the aortic arch [in the patient], the thoracic aortic aneurysm is approximately 5cm, and the additional abdominal aortic aneurysm is approximately 4cm.” The team planned the technical procedure to use a two-component Valiant Navion (Medtronic) endograft, covering 286mm of aortic arch. “We have a difficult access, because the access vessels are compressed on both sides, so we decided to get our main access on the right side due to the patient’s urostomy and femoral distal bypass on the left side,” they explained, adding that the patient had high-grade stenosis of the right internal iliac artery. As operators had determined the patient was at

the system before devices are put into the patient—as that itself can be the cause of stroke by air blockage.” Stéphan Haulon (Le Plessis Robinson, France)—who was moderating the session alongside Kölbel, Hugh Markus (Cambridge, UK), and Heinz Jakob (Essen, Germany)— noted the importance of having large overlaps between multiple devices in this type of procedure (as was seen in the case). He said: “This is routine now but a bit different to what we were doing 10 or 15 years ago.” Kölbel explained that we now know that, in aneurysmal disease, the diseased aorta will not only grow in diameter but also grow in length as well. “So, you need some additional length in order to avoid device separation: when we can, we plan at least three stents’ overlap,” he observed.

New data from STEP

high risk for spinal cord ischaemia, they used cerebrospinal fluid drainage prior to the procedure. The operators flushed the device with CO2 for two minutes and then followed this with standard saline flushing. The STEP study collaborators have identified this technique as a preventative measure to reduce the risk of stroke from air embolisation during TEVAR procedures. Roger Greenhalgh (London, UK), commented: “It is important to note that every effort is now being made to exclude air from

During the STEP session, STEP collaborators provided new data for use of diffusion weighted (DW)-MRI after TEVAR procedures, involving zone 0, 1, 2 and 3 of the aortic arch. The total series of 37 cases combined results from three centres, which Greenhalgh noted

Dittmar Böckler Highlights of the Aortic programme were, from my perspective, the sessions on abdominal aortic aneurysms and dissections.

2019

CX Digest Discussing the data presented at CX 2019, Kölbel commented: “The biggest difference to what is already known is that these cases include a large number of very proximal landings—with a significant zone 0 and zone 1 percentage. It is important that MRI is done within a certain post-procedural timeframe, and we were able to keep to the range of two to eight days, with the exception of only one patient.”

gives the “largest global experience” to date. The data presented at CX 2019 focused on the ability of DW-MRI to recognise whether a cerebral lesion identified during follow-up imaging was associated with the TEVAR procedure itself and also ability of DW-MRI to provide a means to monitor outcomes [of the lesion] in the long term.

However, Haulon noted that an unanticipated result was the key finding was that while new lesions were seen on DW-MRI in 80% of zone 0 cases, “63% of zone 3 patients were found to have new lesions on DW-MRI”. These new lesions were seen despite the investigators use of preventative measures, including carotid clamping and, notably, CO2 flushing of the device systems before the standard saline flush.

Voting results Are you convinced that DW-MRI in the postoperative period should be performed in every case, open or endovascular, involving reconstruction of the ascending and arch of the aorta? 32% Yes 68% No RG: Sixty-eight per cent are not convinced of this.

Concluding the session, Greenhalgh commented: “DW-MRI should be a standard of care—by which I mean that whether open or endovascular, we should press upon the funding bodies of our hospitals and institutions, that the procedures should include funded DW-MRI.”

Other Thoracic Aortic sessions As well as the STEP session, the Thoracic Aortic Challenges programme also had sessions on chosen access for aortic reconstruction, thoracoabdominal aortic aneurysms, radiation, descending aorta, and spinal cord ischaemia. The session concluded with a presentation looking at juxtarenal aneurysms, complex endovascular aneurysm repair (EVAR), and “challenging neck”.

Is it justifiable to operate outside Instructions For Use for TEVAR procedures if the alternative is considered less satisfactory? 69% Yes 31% No RG: “Yes” says 69%. This is a key issue because while it is accepted that operating outside Instructions For Use has greater risks and less success, the alternative to that—i.e. using a different technique—may be even worse. This, therefore, is a statement on the extent of disease and how to manage it.

Is it helpful to know a variety of access possibilities? 86% Yes 14% No RG: Eighty-six per cent were in favour.

Aortic

Can we be sure that we are now taking enough care with radiation during these procedures compared with five years ago? 12% Yes 88% No RG: “No” says 88% of the CX audience.

2019

CX Digest CX Aortic Techniques & Technologies

are going to perform two or three procedures in order to completely exclude the false lumen.” Indeed, “this is not a one-stage procedure”, he said. “These patients had the acute type A open repair and then had an evolution of their false lumen at arch level.”

ow in its fourth year, the aim of CX Aortic Techniques & Technologies is to give delegates the opportunity to explore the application of different techniques in complex situations.

This year, the session began with the Best of Aortic Live and Paris Endovascular Aortic Course. Stéphan Haulon (Le Plessis Robinson, France) began proceedings by describing a total endovascular repair in a chronic aortic arch dissection. He described a procedure that was performed at the Centre de l’Aorte, Hôpital Marie Lannelongue, Université Paris Sud, France, as part of the Paris Endovascular Course. Haulon began with an overview of an inner branched arch endograft following ascending open repair with Cook’s A-branch device before showing an edited video of the case. He mentioned that he chose to focus on a case performed in chronic dissection as these patients are the “perfect match” for this new technology because they present with an ideal landing zone. Haulon went on to discuss a recent paper in which he and his colleagues describe findings from 70 patients, all of whom had previously undergone acute type A open repair. The in-hospital combined mortality and stroke rate was 4% (n=3), which included one minor stroke, one major stroke causing death, and one death following multi-organ failure. The technical success rate was 97%. After a mean follow-up of 301 days, 20 patients

(29%) underwent secondary interventions, including nine for endoleak correction, and 110 had a distal extension to the thoracic or thoracoabdominal aorta. He concluded: “Patient selection is key, and those patients with a prior open ascending repair are probably a niche of patients that will highly benefit from this technology.” Additionally, he noted: “You have to inform patients that you

Later in the session, Tilo Kölbel (Hamburg, Germany) presented an edited live fenestrated arch repair in a type B aortic dissection case from 2018. He noted that the procedure was carried out in a 73-year-old female who had undergone a lobectomy for lung cancer in 2017, and a transverse colectomy in 1998. She had previously had a type II thoracoabdominal aortic aneurysm (53mm) and her treatment plan was fenestrated endovascular aneurysm repair (EVAR). Other topics featured in the session included new devices, hybrid procedures, and juxtarenal aneurysms.

Tilo Kölbel This year´s Aortic Techniques & Technologies (edited cases) focused on challenges in thoracic and thoracoabdominal repair. The key message of the session was the continued need for open surgery—particularly for patients with endovascular failure, genetic aortic syndromes and graft infection. Overall, from the Aortic programme, we saw that new and improved devices offer wider applicability for challenging aortic segments such as the aortic arch. Furthermore, we learned that aortic dissection is very much the focus and requires a disease specific approach, techniques and devices. Audience participation revealed that prevention of stroke and spinal cord ischaemia is in the clinical focus of many operators and results of newer treatment strategies such as pre-emptive segmental artery coil embolisation are urgently awaited.

Aortic

CX Aortic Workshop

he CX Aortic Workshop ran across two days (Tuesday and Wednesday) and gave delegates opportunities to try out different aortic technologies. On the first day of the Workshop, Vikki Galgerud (Vienna, Austria) was demonstrating the PIUR tomographic ultrasound imaging system. She stated that having this technology available “in the flesh” helped to facilitate discussion

surrounding the important challenges reviewed at CX 2019. At another station at the Workshop, Gustavo Oderich (Rochester, USA) shared his experience of a fusion imaging system; he looked at how to simplify fenestrated endovascular aneurysm repair procedures using EVAR ASSIST 2.

Like the other Workshops at CX 2019

(including peripheral and venous), the CX Aortic Workshop facilitated peer-to-peer interactions between a world-class faculty and delegates from all over the world. As well as the aforementioned imaging stations, there were stations on fenestrated endovascular aneurysm repair (EVAR), complex thoracic aortic abdominal aneurysms, and arteriovenous malformations.

2019

CX Digest

Additional Sessions

CX Vascular Access

he CX Vascular Access programme had a new element this year—CX Vascular Access Techniques & Technologies (edited cases), which was held just prior to the CX Vascular Access Workshop. The CX Vascular Access Workshop itself was held on the Thursday of CX from 10am to 4pm. It had a variety of different stations on topics ranging from “Assessment of vascular access” to “Dialysis made simple”.

As well as the Techniques & Technologies and Workshop session, the CX Vascular Access programme also had a Masterclass and abstract/poster presentations. During the Masterclass, as part of the “Can we prevent thrombosis?” session, Colin Deane (London, UK) looked at the role of surveillance. After giving a brief overview of some “exciting” new technology in this field, he concluded: “This is going to be best where people are interested in it, trained and understand the clinical problem.” Another session in the CX Vascular Access Masterclass reviewed the use of drug-coated balloons in vascular access, specifically examining the potential impact of current

concerns regarding paclitaxel. Following presentations and a panel discussion, Vascular Access CX Executive Board member Nicholas Inston (Birmingham, UK) asked the audience if they would continue to use drug-coated technology in their practice and if they believed more data were needed. While the audience was undecided

about their continued used of drug-coated balloons, they did reach a consensus that more data were needed to determine the place of drug-coated balloons in vascular access treatment. Other sessions of the Masterclass reviewed maintaining and optimising dialysis access and innovations in vascular access.

Nicholas Inston The CX Vascular Access programme, which started with an afternoon of abstract presentations, was another success. The quality of abstracts improves year-on-year—as does the number of submissions. This year there were many contenders but the winning paper was from Singapore by Fui Jin Chong for his paper “Systematic review and meta-analysis of randomised-controlled trials comparing drug-coated balloon angioplasty vs. plain balloon angioplasty in arteriovenous salvage”. The Masterclass this year focused on the important topic of maintaining vascular access and included case-based presentations, state-of-the-art evidence and novel techniques and innovations. Following an update on the current trials, a panel of assembled experts debated the risk of paclitaxel devices in vascular access with heated discussion from the audience and panellists! As always, CX aims to bring the best evidence of clinically relevant innovations along with what is on the horizon. In vascular access, this includes pharmacological studies, pre-access optimisation and the important topic of patient-related outcomes and experience measures. Additionally—for the first time—experts in interventional nephrology were invited and debated the role for interventional nephrology in the vascular access pathway. On the final day of the programme, we had a heavily attended Vascular Access Workshop. The Workshop gave delegates the opportunity to learn about—via “hands-on” one-to-one tutorials—a vast range of new devices. It spanned all aspects of dialysis patient care from how a dialysis machine works to how to manage end-stage vascular access. Although all surgical techniques for the creation of vascular access were covered in the Workshop, the excitement of delegates regarding endovascular percutaneous techniques was obvious. We had excellent simulations and demonstrators walking delegates through the technique. Overall, vascular access continues to grow at CX and the interest of delegates and expansion of industry into the field of dialysis is clear. This can only be a good thing for improving the lives of patients requiring renal replacement.

2019

Additional Sessions

CX Digest

NEW to CX 2019:

aunched this year, iWounds seeks to encourage the early diagnosis of the underlying conditions of leg/foot tissue loss. It works across three workstreams: interdisciplinary & interprofessional education; early referral; and implementation. This year’s programme consisted of a plenary programme and a hands-on Workshop. Additionally, both the Venous and Lymphatic programme and the Peripheral Critical Ischaemia programme had dedicated iWounds sessions.

The programme had sessions on wound care challenges and innovations in wound care. Speaking during the programme, iWounds CX Executive Board member Una Adderley (Leeds, UK) said an “accurate diagnosis is the foundation of any treatment decision”. The ankle brachial pressure index is, she argued, a “relatively accurate” test for arterial insufficiency, noting that it is “more valid and reliable than pedal pulse palpation”. The Workshop ran across two days, with stations ranging from complex lower limb compression to footwear technology for

patients with diabetic foot ulcers. William Ennis (Chicago, USA), a facilitator at the Workshop, said there was potential for showcasing technologies on wound imaging to measure healing pre- and post-bypass, and video live cases based on wound anatomy that could help physicians to decide on revascularisation strategies. He said: “The concept of iWounds is novel and different. You are only taking

care of one component of the problem if you focus on the vessel, whether it is the artery or the vein. Twenty-something per cent of those people are going to have some kind of soft tissue injury, and then you have no solution for them, or you just refer them on. It does not mean that [vascular surgeons] are going to physically do [wound care], per se, but it is increasing their knowledge of it.”

iWounds CX Executive Board share their highlights of the programme Michael Edmonds As part of the iWounds programme, a wide array of techniques for diagnosis and treatment of wounds of various different aetiologies were discussed. This included diabetic ulcers, venous ulcers and arterial ulcers. In particular, the Workshop showcased recent innovations in state-of-the-art diagnostic and wound healing technologies and also demonstrated the latest in wound care dressings, debridement, and footwear provision. In summary, iWounds—through both its formal sessions and Workshop—promoted interdisciplinary care between vascular specialists

and other wound healing disciplines. Too many legs are being amputated at present and it is anticipated that such an interdisciplinary collaboration as iWounds will reduce the number of major amputations. Keith Harding The inclusion of the exciting and novel wound stream in CX has provided vascular surgeons with new insights in this aspect of clinical practice. It has also aided those of us interested in this subject by creating opportunities for exchange of ideas and start to develop new collaborations to even further enhance the value of this meeting and improve the

standards of care patients with wounds receive. Una Adderley The iWounds session brought together clinicians and academics from a number of different clinical professions and countries. Together, the group identified the need for relevant, well-designed research to answer certain aspects of care but also recognised that there is an even more pressing need for greater focus on implementation of existing evidence-based guidance. More interdisciplinary working that achieves genuine collaboration between all those who provide care is needed to deliver better outcomes for patients.

2019

CX Digest

Additional Sessions

CX Vascular Malformations

he CX Vascular Malformations programme reviewed low-flow malformations, imaging, and the complimentary role of surgery in vascular malformations among other topics. Additionally, it ran a special session—“Case presentations: Help I am stuck!”—that provided delegates with the chance to get help with cases that they needed advice on or to review how they had managed a complication.

Fiona Rohlffs This year, the CX Vascular Malformations programme offered an interesting scientific programme. The presentations included new data for intraosseous and capillary venous malformations, as well as a review of radiation exposure during endovascular treatment of vascular malformations. The faculty consisted of world-leading experts in the field of vascular malformations—all of whom gave an insight into their practice. The attendance was very good and the programme was greatly appreciated by those who participated in it.

CEC@CX

EC@CX—chaired by Wei Guo (Beijing, China), Daqiao Guo (Beijing China), Sheng Wang (Beijing, China), and Frans Moll (Utrecht, The Netherlands)—reviewed endovascular aneurysm repair (EVAR), new results from the China AcoArt study, and new techniques for managing dialysis access-associated steal syndrome.

Speaking about the importance of an exchange of knowledge between CEC and CX, Guo said: “We need communication between eastern and western vascular surgeons because of different experiences, evidence, techniques and devices. We need deeper cooperation in order to exchange

experiences, which will be helpful not only for doctors but also for patients.” This is the second year of the CEC@CX programme and, according to Guo, it is “even better than last year”. He noted that this year there are “more young doctors who have enough experience and who can speak English well, which means there are now very few barriers to communication.”

CX Meets Latin America

his year’s CX Meets Latin America, as in previous years, was an extremely popular and well attended programme. It brought together practitioners from across Latin America—providing a forum for lively debate in a spirit of camaraderie and good humour; it was chaired by a diverse panel of opinion leaders from Argentina, Mexico, and Brazil.

Co-chair Luis Mariano Ferreira (Buenos Aires, Argentina) commented: “CX is one of the only meetings that gives this opportunity to Latin America. It provides us with a great platform to share our experiences with all Latin American surgeons. It is important for us, and, therefore, important for our patients.” Álvaro Razuk (Sâo Paulo, Brazil), one of the moderators of the programme, commented that CX Latin America has some “very good sessions”. He said: “We have been talking about some challenging cases, looking at innovation.”

2019

Additional Sessions

CX Digest

Programmes for young practitioners

2019 had two different programmes for those at the beginning of their medical career: “An Introduction to Vascular Surgery” and “European Vascular Surgeons in Training—Prize Session”. The first of these, run in conjunction with the Vascular Society of Great Britain and the Rouleaux Club, was aimed at those considering a career in vascular surgery.

The second provided trainees and young vascular surgeons from all over Europe with the opportunity to present their scientific work. Andreia Coelho (Porto, Portugal) won the first prize for her abstract “Prediction of survival following repair of a ruptured abdominal aortic aneurysm—multicentric study for external validation of a new prediction score for 30-day mortality”. Second prize went

to Pavel Kuryanov (St Petersburg, Russia) for “Distal hybrids for long chronic total occlusions of superficial femoral artery with severely compromised runoff” and third prize went to Thomas Aherne (Dublin, Ireland) for “Novel non-thermal vs. thermal endovenous ablation in superficial venous incompetence: A systematic review and meta-analysis of comparative studies”.

CX Innovation Showcase

he first session of the CX Innovation Showcase focused on “innovation challenges”; this included the presentation “Confessions of a mad inventor” by Lindsay Machan (Vancouver, Canada) in which he talked about the lessons he had learned from being a founder of Angiotech (developer of the paclitaxelcoated stent). According to Machan, one of the hardest lessons to learn was accepting that “large companies do not care about your timetable”. “The deal Boston Scientific and Cook Medical made with Angiotech only happened after a cash offer from a competitor. That was almost two years after doing the dance with these companies,” Machan observed.

Following this session, the second session reviewed the growing use of artificial intelligence in vascular medicine. Tom Carrell (Barrington, UK), the CEO of Cydar Medical (which has an artificial intelligence system), said: “We think it is cloud, data, and artificial intelligence—the combination of the three; the trinity—that leads to better patient outcomes.” Additionally, there were sessions focused on aortic innovation, peripheral innovation, venous innovation and vascular access innovation. In the paclitaxel innovation session, Peter Gaines (Sheffield, UK) spoke about sirolimus as an alternative to paclitaxel and noted that it has “the potential to improve patient outcomes”. However, York Hsiang (Vancouver, Canada) proposed using “microelectronics” and

presented a “smart” stent that could be used to monitor blood flow and detect restenosis. He noted that in an animal model, the custom device demonstrated real-time wireless tracking of local blood pressure over 100mmHg change.

Dragons' Den This year, Petra Apell (Gothenburg, Sweden) won the £1,000 prize for her and her colleague’s work on the “HeadPeace radiation protection textile”. Her colleague is Fredrik Gellerstedt (Gothenburg, Sweden). The Dragons' Den expert panel consisted of Andrew Holden (Auckland, New Zealand), Frans Moll (Utrecht, The Netherlands), Bob Mitchell (Irvine, USA), Peter Philips (Didcot, UK), Chas Taylor (Horsham, UK), Jeffrey Jump (Mont-sur-Rolle, Switzerland), and Alan Edwards (Ruthin, UK). The other innovators were: Hans Henkes (Stuttgart, Germany)— Phenox hydrophilic coating for reduced

thrombogenicity of stents. Sean Morris (Missouri City, USA)—Nanoscale medical devices: A new frontier in the treatment of critical limb ischaemia. Colette Cook (Ellesmere Port, UK)— Community portable infrared thermography: Improving outcomes in patients with diabetic foot disease. Cees Wittens (Maastricht, The Netherlands)— Second-generation venous stent. John Martin (Annapolis, USA)—Butterfly iQ pocket-sized ultrasound. Paolo Spada (Buccinasco, Italy)— EVARPlanning’s platform. Cecile Feracci (France)—4EVAR adjunctive technology. Dai Yamanouchi (Madison, USA)—Single nanometer oxygen nanobubble. Claude Mialhe (Monaco)—New cap for endovascular.

2019

CX Digest

verall, at CX 2019, there were more than 300 abstract presentations in 25 sessions; the abstracts covered the five core topics of CX: Acute Stroke, Aortic (both Abdominal Aortic and Thoracic Aortic), Peripheral Arterial, Venous, and Vascular Access.

Of 300 abstracts presented, 138 were categorised as “Global Stars and Rising Stars”. Introduced last year, the Global Stars and Rising Stars category recognises the large number of high-quality abstracts that are submitted to CX each year. Global Stars and Rising Stars presenters are given CX Faculty status. Additionally, there were 164 e-posters on display in the exhibition hall—42 of these were presented during lunch hours of Tuesday, Wednesday, and Thursday in five poster presentation sessions (again covering the five core topics of CX).

CX 2019 Abstract Prize winners Trainee: Maciej Juszczak (Birmingham, UK) Abdominal Aortic: The role of sarcopenia in survival of patients with abdominal aortic aneurysm: A prognostic factor review and meta-analysis of time-to-event Senior: Jens Eldrup-Jorgensen (Portland, USA) Abdominal Aortic: Redefining the volume outcome relationship for endovascular repair

Vascular Access Abstract Prize winner Fui Jin Chong (Singapore) Systematic review and meta-analysis of randomised-controlled trials comparing drugcoated balloons angioplasty vs. plain balloon angioplasty in arteriovenous fistulae salvage

CX 2019 Certificate of Merit winners Trainee clinicians

Acute Stroke Umar Sadat (Cambridge, UK): Ferumoxytol-

enhanced magnetic resonance imaging study of patients with symptomatic and asymptomatic carotid artery disease—an exploratory study

Thoracic Aortic Marco Franchin (Varese, Italy): Kidney autotransplant for treatment of complex aneurysms of the renal artery

Senior clinicians

Acute Stroke Steven Rogers (Manchester, UK): Carotid plaque volume measured by 3D tomographic ultrasound

Thoracic Aortic

Reinhard Kopp (Zurich, Switzerland): Modular branched stent grafts for redo aneurysm and urgent interventions to treat pararenal and thoracoabdominal aortic aneurysms

Ahmed Eleshra (Hamburg, Germany): Feasibility and early results of a new-generation Candy Plug II for endovascular false lumen occlusion with TEVAR in chronic aortic dissection

Hailei Li (Shenzhen, China): Methods and clinical outcomes of in situ fenestration for aortic arch revascularisation during thoracic endovascular aortic repair

Drosos Kotelis (Aachen, Germany): Outcomes after one-stage vs. two-stage open repair of type II thoracoabdominal aortic aneurysms

Kenneth Tran (California, USA): Renal stent complications following standard fenestrated endovascular aneurysm repair

Abdominal Aortic Simon Glasgow (London, UK): Are NHS vascular surgeons adequately prepared to meet the demands of the newly proposed NICE guidelines on AAA management? Kane Treadwell (Kent, UK): A comparison of survival after endovascular and open repairs of unruptured elective infrarenal abdominal aortic aneurysms in octogenarians

Abdominal Aortic Baris Ata Ozdemir (Bristol, UK): Early outcomes of native and graft related abdominal aortic infection managed with orthotopic xenopericardiaI grafts Konstantinos Donas (Münster, Germany): Long-term results of the chimney technique by use of a standardised combination of devices in the treatment of 211 patients with pararenal pathologies Simone Hofer (Chur, Switzerland): Analysis of aortic neck dilatation after endovascular aortic repair

Peripheral Arterial

Irene Ng (Singapore): Implementation of a multidisciplinary team approach in lower extremity amputation prevention programme for diabetic foot ulcers referral from primary healthcare to a tertiary centre vascular surgery clinic: Initial experience in an Asian population

Marianne Brodmann (Graz, Austria): Safety and feasibility of intravascular lithotripsy for treatment of common femoral artery stenosis

Venous Roshan Bootun (London, UK): Randomised controlled trial of compression following endothermal ablation (COMETA trial) Vimalin Samuel (Vellore, India): Ascending venogram in patients with active ulcer to predict wound healing: A single-centre experience

Syed Hussain (Peoria, USA): Prospective evaluation of the CELT arterial closure device in an outpatient based catheterisation laboratory Pavel Kuryanov (St Petersburg, Russia): Distal hybrids for long chronic total occlusion of superficial femoral artery with severely compromised runoff

Venous Johann Christof Ragg (Berlin, Germany): Six stages of acquired vein valve one insufficiency

Additional Sessions

CX 2019 Abstract and Poster programmes

2019

CX Digest 4000

2019 Statistics

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4,020 participants attended CX 2019, 2000 which took place in Olympia London (London, UK).

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Of those who attended, 69% were 1000 vascular and endovascular surgeons. But, reflective of CXâ&#x20AC;&#x2122;s expansive multidisciplinary approach to the management of vascular disease, a substantial number of interventionalists and other cardiovascular specialists were also at the Symposium; both among the Faculty and the audience.

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69% Vascular & Endovascular surgeons 10% Interventionalists

9% Vascular scientists and nurses Clinician versus 3000

Industry attendance

10% Other cardiovascular specialists Clinicians

2% Other clinicians

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69% Vascular & Endovascular surgeons 10% Interventionalists

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69% Vascular & Endovascular surgeons 10% Interventionalists 9% Vascular scientists and nurses 10% Other cardiovascular specialists

9% Vascular scientists and nurses

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2% Other clinicians

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United Kingdom United States Germany Italy

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2019

Overall attendance was similar to all previous years in Olympia London. The clinician attendance was higher than last year while industry attendance decreased.

Singapore Canada Argentina Slovenia South Africa Hungary Mexico Thailand Romania Serbia South Korea New Zealand Norway Slovakia United Arab Emirates Kuwait Taiwan Bulgaria Croatia Lebanon Sri Lanka Ukraine Costa Rica Iraq Jordan Other

2019

CX Digest 69% Vascular & Endovascular surgeons 10% Interventionalists 9% Vascular scientists and nurses

At CX 2019, we had participants from more than 80 countries. Although most came from Western Europe, a sizeable 10% Other cardiovascular specialists amount came from other areas of the globeâ&#x20AC;&#x201D;including 10% from North America, 8% from Asia, and 2% from Africa. 2% Other clinicians

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United Kingdom United States Germany Italy Netherlands France Switzerland Brazil China Poland Spain Turkey Greece Portugal Egypt Sweden Belgium Ireland Australia Russia Saudi Arabia Austria Denmark Japan Czech Republic Finland Israel India Singapore Canada Argentina Slovenia South Africa Hungary Mexico Thailand Romania Serbia South Korea New Zealand Norway Slovakia United Arab Emirates Kuwait Taiwan Bulgaria Croatia Lebanon Sri Lanka Ukraine Costa Rica Iraq Jordan Other

68% Western Europe 10% North America 8% Asia 6% Eastern Europe 4% Latin America & Caribbean 2% Africa 1% Middle East 1% Australasia

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68% Western Europe 10% North America 8% Asia

2019

CX Digest

The Charing Cross Symposium would like to thank all the Pavilion Sponsors and Major Sponsors.

Pavilion Sponsors

Major Sponsors

2019

CX through the lens

CX Digest

CONTROVERSIES

CHALLENGES

CONSENSUS

Vascular & Endovascular

Consensus Update 21–24 APRIL 2020 T U E S D AY – F R I D AY OLYMPIA LONDON • UNITED KINGDOM

Aortic Consensus

Peripheral Arterial Consensus

Venous & Lymphatic Consensus

Acute Stroke Consensus

Vascular Access Consensus

See you next year! WWW.CXSYMPOSIUM.COM

EDUCATION

INNOVATION EVIDENCE