Vascular News 92 – November 2021

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November 2021 | Issue 92

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CX Aortic Vienna: Highlights

Joseph Bavaria Type A dissection enters a new revolution

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Next generation of vascular surgeons need open and endovascular skills Building and maintaining expertise in both open and endovascular surgical techniques will play an important role in training the next generation of surgeons in order to optimise outcomes in patients with vascular disease. This is among the key messages to have emerged on the final day of CX Aortic Vienna 2021 (5–7 October, broadcast), when speakers discussed training in aortic procedures, and at other meetings this Autumn. In addition, the need for multidisciplinary working was advocated, and the place of centralised, specialised centres for vascular conditions scrutinised.

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choing polling results and discussion from day one of CX Aortic Vienna in which there was agreement over the importance of offering a choice between open and endovascular approaches for aortic conditions, speakers including Society of Thoracic Surgeons (STS) past president Joseph Bavaria (University of Pennsylvania, Philadelphia, USA), stressed the need to have multiple options open to patients with aortic disease. Bavaria’s presentation zeroed-in on the importance of having a multidisciplinary thoracic aortic team, including collaboration across the boundaries of both vascular and cardiovascular surgery. The goal of this type of collaboration is to move towards an aortic centre, Bavaria said, describing this as the multidisciplinary “holy grail”. During discussion, he remarked: “The way this is going to end up, certainly in the large centres, is that we are going to be going to the aortic centre concept. That concept is a way of bringing everyone together to wrap around the aorta in a 360-degree fashion with a multidisciplinary approach, with people with different skillsets.” Also speaking during the session, Eric Roselli (Cleveland Clinic, Cleveland, USA) presented a view on the future of training for surgeons who will specialise in the aorta. He commented that aortic disease “knows no boundaries” and offered the opinion that there is a need to “think smarter about how we offer care for this complex disease”. Both open and endovascular approaches can be complementary, he added, and said that the focus has to be on what the patients’ needs are, based around the details of aortic disease and the interplay of comorbidities. Roselli added that aortic care requires a mixed skillset, combining both cognitive and technical attributes, and said that overlapping training programmes involving specialists from cardiology, vascular surgery, and cardiothoracic

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surgery are important components in the future landscape for aortic surgery training. Following the two opening presentations, the audience was asked to vote upon whether there is a desire to see multidisciplinary aortic teams. There was total support in favour of the multidisciplinary philosophy, with a 100% vote for the motion. Later in the session Maani Hakimi (Luzerner Kantonsspital Luzern, Switzerland) offered a view on treatment of abdominal aortic aneurysm (AAA) from the perspective of a training centre for vascular and endovascular surgery. One of Hakimi’s key themes was the development of training over time, commenting that teaching has shifted from a mentoring-based system, more towards a centralised curriculum.

“There was total support in favour of the multidisciplinary philosophy, with a 100% vote for the motion”

“Bypass is not disappearing”

At Paris Vascular Insights, Peter Schneider (University of California San Francisco, San Francisco, USA) also spoke on training, and specifically the need to remain skilled in femorotibial/pedal bypass, echoing the discussion at CX Aortic Vienna on the need for trainees to learn both open and endovascular skills. Schneider recalled that an “extremely important question” when he was a trainee was ‘how will we learn endovascular?’. A couple of decades later, “the shoe is completely on the other foot,” he said, noting that the question now is ‘how will the trainees learn femorotibial bypass or pedal bypass and/or how will we maintain those skills?’ “Bypass is not disappearing,” the presenter declared, referring to a graph showing a downward trend but then a stabilisation, at least of cases in the USA. Instead, bypass is evolving, Schneider stated. “We are going to more distal

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Head-to-head trial shows superiority of FemoSeal over ProGlide for peripheral interventions Results of the randomised, prospective, multicentre STEP trial show that the FemoSeal vascular closure system (Terumo) is superior to the Perclose ProGlide suturemediated closure system (Abbott) in peripheral arterial disease (PAD) patients in terms of technical success using a retrograde femoral puncture. Bahaa Nasr (Brest University Hospital, Best, France) presented the late-breaking data at Paris Vascular Insights (PVI) 2021 (21–23 October, Paris, France), concluding that FemoSeal should be used in PAD patients undergoing lower limb arterial endovascular treatment, especially if they are discharged on the same day as their surgery. ACCORDING TO NASR, MANY studies have compared vascular closure devices (VCDs) for the coronary arteries, while none have compared them for PAD. “We all know that the efficacy of a VCD is different for PAD patients because of the plaque nature in the common femoral artery,” he remarked. In order to assess this gap in the literature, Nasr and colleagues initiated the STEP trial. “The aim of the study was to perform a direct, head-to-head comparison between ProGlide and FemoSeal,” he relayed, explaining that the FemoSeal is a double polymer resorbable disc, while the ProGlide involves a direct suture in the artery. He noted that the primary endpoint was VCD technical success, assessed five hours post-procedure, and defined as either haemostasis without the need for either an additional VCD or manual compression, or a drop in haemoglobin. Patients were included in the study if they had received endovascular treatment for PAD with the use of 5–7Fr sheath, Nasr informed the PVI audience. He added that patients who had undergone previous ipsilateral open repair of the common femoral artery, previous stenting at the puncture site, or had either Continued on page 6

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