JUNE 2 - 3, 2016 ≈ NICE, FRANCE
ABSTRACT BOOK ORGANIZING COMMITTEE Koen Deloose, Eric Ducasse, Yann Gouëffic
COURSE DIRECTORS
Nicholas Cheshire, Koen Deloose, Eric Ducasse, Yann Gouëffic, Mario Lachat, Julien Lemoine Nicola Mangialardi, Richard McWilliams, Peter Schneider, Isabelle Van Herzeele
VENOUS DIRECTORS Paul Pittaluga, Sylvain Chastanet
WEBINAR DIRECTOR Max Amor
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THURSDAY JUNE 2
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Practical approach to BTK-disease, based on state of the art data Lecture. Scaffolding with or without drugs BTK? Martin Werner Hanusch Krankenhaus, Wien, Austria
The optimal treatment of BTK disease is not known. Ballon angioplasty with or without drugs is limited due to a high restenosis rate. This presentation reviews the current evidence on stents in the infrapopliteal segment, focussing on the randomized trials on drug eluting stents
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| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
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Practical approach to BTK-disease, based on state of the art data Case. Atherectomy in the Btk arteries Martin Werner Hanusch Krankenhaus, Wien, Austria
Case presentation of a patient with critical limb ischemia and occlusion of all 3 BTK arteries. Patient was treated with the Diamondback 360 Orbital Atherectomy Sytem and Drug Coated Ballon. Step-by-Step explanation of this case and discussion of this new approach in BTK treatment.
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| SCIENTIFIC PROGRAM 2016 | THURSDAY JUNE 2
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Practical approach to BTK-disease, based on state of the art data Lecture. Final judgement about angiosome theory: myth or fact? Vlad-Adrian Alexandescu, François Triffaux Princess Paola Hospital, Marche-en-Famenne, Belgium
INTRODUCTION
RESULTS
Since its first anatomical description made by Taylor in 1987, the Angiosome theory (AT) gradually provided new therapeutic perspectives and related controversies, particularly focusing on critical limb ischemia (CLI) interventional treatment.
a) Available literature on AT applications in CLI gathers rather heterogeneous groups analysis data, with little prospective structured evidence. b) While a majority of surgical and endovascular CLI series examine DR throughout specific angiosomal foot arterial branches, other researchers rate “Wound Directed Revascularization” via complete/incomplete foot arches, or throughout large arterial-arterial remnant collaterals. c) The choice for suitable angiosome-targeted revascularization relies on synergic macro- and microcirculation assessment (owing specific techniques for each evaluation). No method alone has proven so far entire eligibility for solitary DR guiding. d) It appears that specific CLI categories of patients (ie, diabetic and renal presentations) exhibiting notable foot collateral destruction may particularly avail from AT applications.
OBJECTIVE
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As clinical knowledge about angiosome applications in limb salvage continually expands, several new challenges rise for practitioners in daily CLI practice: a) What is the real meaning of “Direct Revascularization” (DR)? b) How can we effectively identify the “right” angiosome(s) to target? c) What is the best method to assess DR in each patient? d) How can we validate genuine usefulness of the AT considering the three phases of post-ischemic reperfusion and among documented five stages for wound healing?
CONCLUSION MATERIALS AND METHODS.
This analysis encompasses a review over contemporary angiosomes applications in CLI, evincing eventual morphological and physiological implications in revascularization and wound recovery.
| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
Angiosome-targeted revascularization appears to enhance encouraging wound healing results, whenever feasible, particularly in CLI collateral deprived patients. For appropriate judgment, AT needs complementary clinical data issued from unitary diagnostic, and homogeneous inclusion and follow-up CLI series.
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AAA Hot Topics. Best practice in fEVAR in 2016 Barend Mees, Geert Willem Schurink Maastricht University Medical Center, Maastricht, The Netherlands
fEVAR has become an increasingly popular alternative treatment for pararenal aortic aneurysms. fEVAR is a technically challenging operation. The duration, blood loss, risk of limb ischaemia, contrast-induced nephropathy and reperfusion injury are higher than after standard endovascular aneurysm repair (EVAR). However, fEVAR has demonstrated good early clinical results with technical success rates of > 95% and 30-day mortality of < 5%, and late survival and target vessel patency are satisfactory. This presentation focuses on the current commercially available devices, ranging from custom-made to off-the-shelf to surgeon-modified in-situ fenestrated endografts, on planning and design, on intra-operative techniques and current limitations of fEVAR.
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| SCIENTIFIC PROGRAM 2016 | THURSDAY JUNE 2
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AAA Hot Topics. EVAS and chEVAS will replace EVAR and chEVAR Francesco Torella Liverpool Vascular & Endovascular Service, Liverpool, United Kingdom
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Although EVAR is now an established treatment for infrarenal aortic aneurysms, it is still marred by a discrete failure rate. The EVAR I trial results suggest that, at 15 years, patients treated with EVAR have greater all-cause mortality, aneurysm related mortality and cancer incidence than those treated by open repair1. Late aneurysm rupture still occurs, and is largely caused by stent failure (type IIIb endoleaks) or failure of seal/fixation (type I endoleaks)2. Life expectancy has increased by six years in the past ten3 so these data cannot be easily dismissed, particularly now that screening programmes result in early detection of aneurysms in many countries. EVAR was first used twenty-five years ago. Despite incremental marginal gains, largely due to improved stent design, until recently, the principles of endovascular aortic repair have remained the same of those described by Palmaz, Barone and Parodi in 19914. Now, however, EVAS can treat aneurysms by different means: unlike EVAR, EVAS obliterates the aortic lumen completely, potentially preventing the late causes of aneurysm rupture seen after EVAR. EVAS can be performed more expeditiously and with less radiation than EVAR5. It can be extended to the suprarenal segment using visceral chimneys (chEVAS)6 as an alternative to FEVAR, which, despite widespread adoption, remains a complicated procedure, particularly when four fenestrations are needed7. Despite these promises, however, it is far too early to conclude that EVAS can compete with, or even complement, EVAR, thus any supposition that it will replace EVAR is presently based on faith in the concept rather than concrete evidence. Are clinicians ready to place bets on EVAS and chEVAS?
| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
References
1. Patel R, Sweeting M, Powell J, Epstein D. Fifteen-year Follow-up of the EVAR Trials. Personal Communication. Charing Cross International Symposium, 27th April 2017 2. Office of National Statistics. National Life Tables â&#x20AC;&#x201C; UK. www.ons.gov.uk/ons/rel/ lifetables/national-life-tables/2012-2014/index.html (accessed 19th May 2016). 3. Antoniou GA, Georgiadis GS, Antoniou SA, Neequaye S, Brennan JA, Torella F, Vallabhaneni SR. Late Rupture of Abdominal Aortic Aneurysm After Previous Endovascular Repair: A Systematic Review and Meta-analysis. J Endovasc Ther 2015;22:734-44. 4. Parodi JC, Palmaz JC, Barone HD. Transfemoral Intraluminal Graft Implantation for Abdominal Aortic Aneurysms. Ann Vasc Surg 1991;5:491-9. 5. Antoniou GA, Senior Y, Iazzolino L, England A, McWilliams RG, Fisher RK, Torella F. Endovascular Aneurysm Sealing Is Associated With Reduced Radiation Exposure and Procedure Time Compared With Standard Endovascular Aneurysm Repair. J Endovasc Ther 2016;23:285-9. 6. T orella F, Chan TY, Shaikh U, England A, Fisher RK, McWilliams RG. ChEVAS: Combining Suprarenal EVAS with Chimney Technique. Cardiovasc Intervent Radiol 2015;38:1294-8. 7. Li Y, Hu Z, Bai C, Liu J, Zhang T, Ge Y, Luan S, Guo W. Fenestrated and Chimney Technique for Juxtarenal Aortic Aneurysm: A Systematic Review and Pooled Data Analysis. Sci Rep 2016;12;6:20497. doi: 10.1038/srep20497.
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AAA Tips and Tricks. Double barrel graft-assisted coiling in chronic aortic dissection Lorenzo Moramarco, Stefano Pirrelli, Ilaria Fiorina, Mario Torresi, Riccardo Corti, Pietro Quaretti Fondazione IRCCS Policlinico San Matteo, Pavia, Italy We report a case of a 55-year-old male, who had a previous aortic valvular substitution and thoracoabdominal endoprotesis placement for aortic dissection in another center, presented after 5 years in our Department with an angio-CT evidence of type 1 endoleak. Open-surgery treatment wasnâ&#x20AC;&#x2122;t possible because of many comorbidities, so we decide to perform an endovascular treatment through surgical access. Through a femoral access the false lumen was selectivated and in this place was releasead an endoprothesis. The endoleak embolization was then performed through a caval filter into the endoprothesis and several large volume macro-coils catched into the filter. We released 829 cm of coilsâ&#x20AC;&#x2122; total length in only 60 minutes of procedure. The patient was dismissed after few days, without any complications. At the 3 months follow-up angio-TC the endoleak was excluded and the true lumen obtained a restored vascularization.
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| SCIENTIFIC PROGRAM 2016 | THURSDAY JUNE 2
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Venous & thrombectomy What might bring a new wavelength for endovenous laser? Lowell kabnick New York, USA
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What might bring a new wavelength to the market for endovenous saphenous laser ablation is an easy question to answer. Most importantly, we would want to achieve a painless intraoperative and postoperative patient experience. However, would we find the â&#x20AC;&#x153;holy grailâ&#x20AC;? with a new wavelength, fiber, or combination of the two? A new wavelength range of 1920-1950, whose chromophore is water, would need to be entered into clinical trials. Since water absorbs energy more efficiently than hemoglobin, one could postulate that less energy output would be needed to have the same result as the already-existing wavelengths. In addition, in comparison to 1470nm, this new range of laser wavelength lies at higher peak of water absorption; thus theoretically, it reduces the needed energy output to achieve the same effect. Both in vitro and in vivo studies are underway. During this presentation, in addition to the new wavelength, I will shed some light on fiber importance. The final question that remains is: Is it the wavelength or is it the fiber that is more important for endolaser saphenous ablation?
| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
References
Fiber type as compared to wavelength may contribute more to improving postoperative recovery following endovenous laser ablation. Kabnick, L and Sadek, M. JVSV2015.12.004 Endovenous laser ablation of the great saphenous vein comparing 1920-nm and 1470-nm diode laser.Mendes-Pinto D1, Bastianetto P, Cavalcanti Braga Lyra L, Kikuchi R, Kabnick L. Int Angio.2015Sep29.
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Venous & thrombectomy Should we really treat varicose tributaries? Sarah Onida Imperial College London, London, United Kingdom
Varicose veins affect up to 40% of the population1, are associated with a significant clinical burden, negative effects on quality of life2, and represent an important expenditure, equating to up to 2% of the national health budget. Although evidence for the treatment of truncal vein reflux has increased over the last ten years, particularly with the development of minimally invasive techniques such as radiofrequency ablation and endovenous laser ablation, the treatment of varicose tributaries is still a matter of debate.
References
1. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous insufficiency and varicose veins. Annals of Epidemiology 2005;15(3): 175-84. 2. Sritharan K, Lane TR, Davies AH. The burden of depression in patients with symptomatic varicose veins. European Journal of Vascular and Endovascular Surgery 2012;43(4): 480-4. 3. Monahan DL. Can phlebectomy be deferred in the treatment of varicose veins? Journal of Vascular Surgery 2005;42(6): 1145-9. 4. Lane TR, Kelleher D, Shepherd AC, Franklin IJ, Davies AH. Ambulatory varicosity avulsion later or synchronized (AVULS): a randomized clinical trial. Annals of Surgery 2015;261(4): 654-61. 5. Onida S, Lane TR, Davies AH. Phlebectomies: to delay or not to delay? Phlebology 2012;27(3): 103-4.
Treating varicosities as a single sitting combined with truncal ablation reduces the need to perform further procedures and reduces the varicose reservoir. However, with evidence suggesting that a significant proportion of patients do not require secondary procedures following truncal ablation3, are we over treating patients with the former approach? Should delayed varicosity treatment be performed instead, reducing procedure time? Combined treatment is associated with improved clinical and quality of life improvements4, however, is this at the expense of an increased risk of venous thromboembolic events5?
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In this talk the literature will be appraised to gain a comprehensive understanding, evidence permitting, of what is the optimal approach for varicose tributary treatment is.
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Venous & thrombectomy Hemodynamics of development of the varicose disease: do we really have a new knowledge? Sarah Onida Imperial College London, London, United Kingdom
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The beauty of chronic venous disease is that it is so much more than valve failure. Important haemodynamic principles underlie not only the development of reflux patterns but also of signs and symptoms of chronic venous disease, including varicose veins. However, there is a paucity of evidence concentrating on haemodynamic concepts, despite their importance in the assessment and management of individuals with this condition1. This is reflected by numerous guidelines favouring imaging techniques such as duplex ultrasound2, 3 which, though providing information on venous anatomy and patterns of reflux, do not provide data to fully appreciate the physiological basis of disease, particularly with respect to flow, pressure, compliance and resistance of the venous system. Haemodynamic assessments, such as plethysmography and volumetry, are considered as adjuncts to venous duplex ultrasound in the investigation of the patient with CVD3, 4. Haemodynamic surgery, as represented by CHIVA, is also the remit of physicians expert in the technique, and not a routine management strategy endorsed by international clinical practice guidelines3, 4. Recently, the importance of the role haemodynamics in CVD has been recognised by a consensus statement of the Union Intérnationale de Phlébologie (UIP)1. Exposing known haemodynamic principles, data regarding the correlation between the severity of signs and symptoms of chronic venous disease and haemodynamic measurements, as well as opportunities for further research in this field, this document brings haemodynamics at the forefront of the CVD debate.
| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
In this presentation, the evidence regarding haemodynamics in CVD development, assessment and management will be reviewed in light of the latest evidence.
References
1. Lee BB, Nicolaides AN, Myers K, Meissner M, Kalodiki E, Allegra C, et al. Venous hemodynamic changes in lower limb venous disease: the UIP consensus according to scientific evidence. International Angiology 2016;35(3): 236-352. 2. National Clnical Guideline Centre. Varicose veins in the legs. The diagnosis and management of varicose veins. ; 2013 July 2013. 3. Wittens C, Davies AH, Baekgaard N, Broholm R, Cavezzi A, Chastanet S, et al. Editor’s Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). European Journal of Vascular and Endovascular Surgery 2015;49(6): 678-737. 4. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. Journal of Vascular Surgery 2011;53(5 Suppl): 2S-48S.
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Venous & thrombectomy Envovascular treatment of extended iliac vein occlusion: what are the limits? Alun Davies Imperial College London, London, United Kingdom
Iliofemoral deep venous thrombosis (DVT) accounts for 20% of all lower limb DVTs, with significant sequelae, including the development of pulmonary embolism (PE) and post thrombotic syndrome (PTS); this affects up to 90% of patients1, with development of disability and significant reduction in quality of life2. The management of acute DVT centres, initially, around anticoagulation. This prevents thrombus propagation and recurrent thrombosis, but is not able to dissolve the existing thrombus or reduce venous outflow obstruction. Alternative measures include thrombectomy and thrombolytic therapy. However, these techniques have a limited role in chronic occlusions.
References
1. Mussa FF, Peden EK, Zhou W, Lin PH, Lumsden AB, Bush RL. Iliac vein stenting for chronic venous insufficiency. Texas Heart Institute Journal 2007;34(1): 60-6. 2. Kahn SR, Shbaklo H, Lamping DL, Holcroft CA, Shrier I, Miron MJ, et al. Determinants of health-related quality of life during the 2 years following deep vein thrombosis. Journal of thrombosis and haemostasis 2008;6: 1105 - 12. 3. Wittens C, Davies AH, Baekgaard N, Broholm R, Cavezzi A, Chastanet S, et al. Editorâ&#x20AC;&#x2122;s Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). European Journal of Vascular and Endovascular Surgery 2015;49(6): 678-737. 4. Seager MJ, Busuttil A, Dharmarajah B, Davies AH. Editorâ&#x20AC;&#x2122;s Choice-- A Systematic Review of Endovenous Stenting in Chronic Venous Disease Secondary to Iliac Vein Obstruction. European Journal of Vascular and Endovascular Surgery 2016;51(1): 100-20.
Percutaneous transluminal angioplasty (PTA) and self-expandable stent deployment are now the recommended treatment combination to consider in chronic ilio-caval or ilio-femoral DVT3. Modern imaging techniques, such as intravenous ultrasound (IVUS), can help determine more reliably the extent of stenosis and obstruction in an iliac vein segment. PTA and stent deployment provide symptom relief and clinical improvement, with acceptable patency rates (up to 80% at 1 year) and reduced morbidity when compared with surgical bypass. However, long term data is not widely available; furthermore, the quality of the evidence supporting deep venous stenting to treat obstructive chronic venous disease has been classified as weak in a recent systematic review4.
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With the advent of new technology, the role of endovascular treatment is set to continue increasing in this patient population. However, long term data is necessary to obtain a complete picture regarding the efficacy of this intervention. In this talk, I will review the evidence supporting endovascular therapy in iliac vein occlusion, exploring the current limitations and directions for future research.
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Venous & thrombectomy Management strategies for patients with varicose veins (C2-C6): results of a worldwide survey Alun Davies Imperial College London, London, United Kingdom Internationally, both the clinical background of healthcare providers in chronic venous disease (CVD), and the delivery of services to CVD patients can be extremely heterogeneous. This has been recognised at a European level, with the establishment of the European College of Phlebology1 to help develop an international, multidisciplinary, standardised approach to the care of the venous patient.
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Worldwide, chronic venous disease is the remit of vascular surgeons, angiologists, phlebologists, dermatologists and physicians, including nursing staff when it comes to venous ulceration (C6 disease). These individuals may have differential approaches to the assessment and management of patients with CVD depending on their own professional experience and formation, leading to differences in service provision. Furthermore, the development of new technologies over the last 15 years has led to a plethora of techniques available to healthcare providers. The result is that management strategies may be very diverse for patients depending on the clinical background of the individual caring for them and their experience of novel technology. Finally, the availability of resources, as well as health care policies in different countries, further contribute to management heterogeneity. The Worldwide Survey performed by van der Velden and colleagues2 evaluated how patient characteristics and duplex ultrasound factors influence the management of individuals with chronic venous disease by practitioners from 43 different countries and from diverse training backgrounds, highlighting that, despite the presence of numerous international clinical practice guidelines3-5, the management of the patient with CVD is still very heterogeneous and significantly influenced by local factors.
| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
References
1. Onida S, Shalhoub J, Davies AH. Position of the European college of phlebology. Phlebology 2015;30(1 Suppl): 111-5. 2. van der Velden SK, Pichot O, van den Bos RR, Nijsten TE, De Maeseneer MG. Management strategies for patients with varicose veins (C2-C6): results of a worldwide survey. European Journal of Vascular and Endovascular Surgery 2015;49(2): 213-20. 3. National Clnical Guideline Centre. Varicose veins in the legs. The diagnosis and management of varicose veins. ; 2013 July 2013. 4. Wittens C, Davies AH, Baekgaard N, Broholm R, Cavezzi A, Chastanet S, et al. Editorâ&#x20AC;&#x2122;s Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). European Journal of Vascular and Endovascular Surgery 2015;49(6): 678-737. 5. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. Journal of Vascular Surgery 2011;53(5 Suppl): 2S-48S.
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FRIDAY JUNE 3
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Modern approach of carotid artery disease Standard operating protocol in stroke management at my hospital â&#x20AC;&#x201C; a multidisciplinary approach is mandatory Alison Halliday University of Oxford, Oxford, United Kingdom Stroke care has evolved rapidly in the last 10 years. It now includes intravenous and intraarterial thrombolysis, intracranial thrombectomy, carotid endarterectomy and stenting, as well as secondary care and prevention of reoccurrence of stroke. This presentation will outline the SOP in Oxford, UK where stroke care is provided by three types of physicians and two neuroradiology services as well as vascular surgery.
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Venous & thrombectomy The glue for the treatment of varicose veins? Lowell kabnick New York, USA
There is a paucity of long-term data regarding cyanoacrylate and its use for saphenous ablation. There are two different polymers of cyanoacrylate on the market and, with the altered set-up times for the cyanoacrylate, there are two different procedures. The VenaSeal procedure uses a segmental application, while the Variseal procedure dictates continuous pull-back application. Both chemical adhesives have entered pivotal trials using radiofrequency or laser as the comparator. The trial results have been excellent and ripe with data regarding efficacy, complication rate, and quality of life indicators. Venaseal, a multicenter, prospective randomized trial, VeClose, just reported 24 month results.1 Of note, these results demonstrated continued non-inferiority to RFA with regards to efficacy and quality of life. Variclose, in a 12 month single center randomized pivotal trial, published equal efficacy and quality of life outcomes with comparison to 1470nm laser ablation2.
References
1. Charing Cross, London, 2016 2. Bozkurt A and Yilmaz, M. Phlebology 2016Mar,31(1 Suppl):106-113.
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Venous & thrombectomy Post-operative compression after varicose vein treatments: yes or no? Roshan Bootun Imperial College London, Fulham Palace Road, United Kingdom
Application of compression post-treatment is an area of great contention in the management of varicose vein disease. The belief is that compression reduces post-operative swelling, haematoma formation and pain following surgery for varicose veins. No irrefutable evidence, however, exists so far1. In a survey of the members of the Vascular Society of Great Britain and Ireland, Edwards et al. (2009) found that three-quarters of them used bandages post-operatively, with a similar percentage changing to compression stockings afterwards2.
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Two randomised controlled trials (RCTs) looking at compression following endovenous laser ablation (EVLA) appeared to demonstrate a benefit of compression therapy in the short-term, but are limited by considerable drop-outs in both studies1, 3. RCTs investigating compression following foam sclerotherapy, for their part, did not demonstrate any significant differences, although compliance was an issue4, 5. Extensive heterogeneity noted in these studies was highlighted in a recent systematic review which found that the evidence available is insufficient to produce guidelines6. The main limitations found were insufficient number of patients, different compression regimens and variable duration of compression application6. The 2013 National Institute for Health and Clinical Excellence (NICE) Guidelines on varicose veins are unable to provide any clearer guidance either, other than stating a limit on the number of days compression bandaging, or hosiery, is prescribed for, when offered7. Elucidating the role of compression after varicose vein treatment would enable us to improve our current management even further and, hopefully, well-conducted and adequately powered randomised controlled studies will be able to provide an answer8, 9.
| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
References
1. Elderman JH, Krasznai AG, Voogd AC, HulsewĂŠ KWE and Sikkink CJJM. Role of compression stockings after endovenous laser therapy for primary varicosis. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2014; 2: 289-96. 2. Edwards AG, Baynham S, Lees T and Mitchell DC. Management of varicose veins: a survey of current practice by members of the Vascular Society of Great Britain and Ireland. Annals of the Royal College of Surgeons of England. 2009; 91: 77-80. 3. Bakker NA, Schieven LW, Bruins RM, van den Berg M and Hissink RJ. Compression stockings after endovenous laser ablation of the great saphenous vein: a prospective randomized controlled trial. European Journal of Vascular and Endovascular Surgery: the Official Journal of the European Society for Vascular Surgery. 2013; 46: 588-92. 4. Hamel-Desnos CM, Guias BJ, Desnos PR and Mesgard A. Foam sclerotherapy of the saphenous veins: randomised controlled trial with or without compression. European Journal of Vascular and Endovascular Surgery: the Official Journal of the European Society for Vascular Surgery. 2010; 39: 500-7. 5. Oâ&#x20AC;&#x2122;Hare JL, Stephens J, Parkin D and Earnshaw JJ. Randomized clinical trial of different bandage regimens after foam sclerotherapy for varicose veins. The British Journal of Surgery. 2010; 97: 650-6. 6. El-Sheikha J, Carradice D, Nandhra S, et al. Systematic review of compression following treatment for varicose veins. The British Journal of Surgery. 2015; 102: 719-25. 7. National Institute of Clinical Excellence. NICE Clinical Guideline Centre. Varicose veins in the legs - the diagnosis and management of varicose veins (Clinical guideline 168). NICE, 2013. 8. Bootun R, Lane TRA and Davies AH. Compression Therapy Following Endothermal Ablation. 2015 (https://clinicaltrials.gov/show/NCT02522845). 9. Onwudike M. Is leg compression needed after heat treatment of varicose veins? 2015 (https://dx.doi.org/10.1186/ISRCTN18119345).
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Venous & thrombectomy Treatment of acute venous femoro-iliac thrombosis: change the paradigme? Roshan Bootun Imperial College London, Fulham Palace Road, United Kingdom
Venous thromboembolism (VTE) is estimated to occur annually at a rate of 114 new cases per 100,0001 and is fast being recognised as an important medical ailment. For extended periods, the management of the condition, including with involvement of the ilio-femoral segment, has been limited to using anticoagulation with vitamin K antagonists (VKA) and compression therapy2.
The management of iliofemoral DVT has undoubtedly undergone substantial developments over the recent past. These new techniques appear to be potentially beneficial in improving the morbidity, mortality as well as associated healthcare costs. Longer-term studies are awaited to confirm these findings.
Over the past few years, however, newer methods have become increasingly available to enhance the diagnosis and treatment of patients, especially those with ilio-femoral deep vein thrombosis (DVT). Newer anticoagulants (oral non-vitamin K antagonists), such as Rivaroxaban, are increasingly being used and offer the advantage of reduced need for monitoring. So far, they appear to be at least equivalent to the more conventional treatment in the management and prevention of thrombus recurrence. Thrombosed veins can recanalise following initiation of anticoagulation therapy, but it is believed even better clinical outcomes, such as prevention of post-thrombotic syndrome, could be achieved by artificially removing the clots. Catheter-directed thrombolysis (CDT), one such method to restore venous flow, shows promise and could be further aided by using adjuncts to accelerate the lytic process and reduce the duration of treatment. Stenting of the iliac segments, combined with the novel anticoagulants, may additionally restore and maintain the vein patency for longer. Furthermore, advances made in imaging modalities allow identification of thrombi most susceptible to thrombolytic therapy.
References
1. Spencer FA, Emery C, Joffe SW, et al. Incidence rates, clinical profile, and outcomes of patients with venous thromboembolism. The Worcester VTE study. J Thromb Thrombolysis. 2009; 28: 401-9. 2. Lang KJ, Saha P, Roberts LN and Arya R. Changing paradigms in the management of deep vein thrombosis. British journal of haematology. 2015; 170: 162-74.
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Venous & thrombectomy Endovenous thermal ablations: consensus and polemics Lowell kabnick New York, USA
Regarding Endovenous thermal ablation procedural methods, there is generally more agreement than polemic. The procedures are standardized, but with modifications amongst interventionalists. However, the RFA procedure is better scripted than the EVLA procedure, which allows for less variation when it is administered. Most physicians are in agreement to treat C3-C6 with corresponding and appropriate reflux. Where there is dissention, it is within the C2s category. Postoperative care varies amongst clinics and ranges from exercise to compression. In addition, there is considerable variation in the field with regard to treating endothermal heat induced thrombosis, when to perform adjuvant therapy, and whether sclerotherapy or phlebectomy is superior to endovenous thermal ablation procedures.
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| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
References
Consensus for the Treatment of Varicose Vein with Radiofrequency Ablation. Jin Hyun Joh,1 Woo-Shik Kim,2 In Mok Jung,3 Ki-Hyuk Park,4 Taeseung Lee,5 Jin Mo Kang,6 and Consensus Working Group Vasc Specialist Int. 2014 Dec; 30(4): 105â&#x20AC;&#x201C;112. Multi-society Consensus Quality Improvement Guidelines for the Treatment of Lower-extremity Superficial Venous Insufficiency with Endovenous Thermal Ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology, and Canadian Interventional Radiology Association. Neil M. Khilnani, MD, et al for the Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology, and Society of Interventional Radiology Standards of Practice Committees J Vasc Interv Radiol 2010; 21:14â&#x20AC;&#x201C;31
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| SCIENTIFIC PROGRAM 2016 | FRIDAY JUNE 3
| SESSION PARAMÉDICALE | PERSPECTIVES SOIGNANTES Une équipe hybride pour une salle hybride Valérie Doussin1, Erwan Gouiffes2 1. Cadre de Santé IBODE 2. Cadre Santé MERME, CHU Nantes L’évolution des techniques radio-interventionnelles notamment la création de salles hybrides au sein des blocs opératoires conduisent au développement du travail en équipe interprofessionnelle entre manipulateurs en électroradiologie et infirmiers de bloc opératoire. Le contexte médico-économique nous amène à une réflexion sur les niveaux de complémentarité et de coopération entre les métiers soignants sur les plateaux techniques médico-chirurgical.
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| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
| VENDREDI 3 JUIN |
| VENDREDI 3 JUIN |
| SESSION PARAMÉDICALE |
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| SCIENTIFIC PROGRAM 2016 | FRIDAY JUNE 3
ORAL PRESENTATION
WWW.MEETCONGRESS.COM
*The Interactivity MEETing
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| ORAL PRESENTATIONS |
Iliac branched devices outcomes and surveillance modality Iain Roy, Vallabhaneni Srinivasa, Richard McWilliams, Robert Fisher Liverpool Vascular & Endovascular Service, Liverpool, United Kingdom
BACKGROUND
Sealing in ectatic iliac arteries is associated with poor durability after EVAR. Internal iliac (IIA) embolization with external iliac extension is an alternative but carries risks of gluteal claudication, impotence and colonic ischemia. Iliac branched Devices (IBDs) offer a solution by excluding aneurysmal iliacs while preserving IIA perfusion. METHODS
The first 33 IBDs used in our institution were reviewed. Discharge letters, post-operative clinic letters and surveillance imaging reports were reviewed to ascertain clinical details and subsequent symptomology. Surveillance results were obtained from our prospectively maintained clinical EVAR database. RESULTS 28
Between 2010-2016 33 IBDs (24 Cook, 9 Gore) were implanted in 32 patients, in combination with 1 bEVAR, 4 fEVAR and 24 EVAR stent-grafts. 2 iliac devices failed to achieve intra-operative success; 1 mal-deployement with occlusion of IIA, and one failed IIA cannulation.
| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
These were the only 2 IIA occlusions (6%) recorded throughout median follow-up of 22 months (IQR 16-33). 5 (16%) patients underwent 5 re-interventions for their IBDâ&#x20AC;&#x2122;s during follow-up. 2 patients died during follow-up, not aneurysm related. Patients underwent surveillance based on their proximal device type. All included at least CTA and duplex ultrasound (DUS) at 1 month and DUS and abdominal xray annually thereafter, with a compliance of 98% with surveillance visits. CTA visualised the IIA adequately on all occasions. DUS visualised IIA on 46% of occasions, overtly failed on 17% and IIA was un-reported on 37% of occasions. Iliac aneurysm size was recorded and graft related endoleaks excluded on 100% DUS. CONCLUSIONS
IBDs are a safe and successful method of preserving IIA blood supply with durable short term outcomes. Surveillance may be limited by the imaging modality with CTA as the gold standard. DUS reliably identifies common iliac diameter and presence of endoleak but may not confirm internal iliac flow in nearly half of cases. Specific DUS protocols may improve the visualisation rate.
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Endovascular treatment of aortic arch using relay branched stent grafts Bertrand Saint-Lèbes Rangueil University Hospital, Toulouse, France
INTRODUCTION
Figures
Endovascular treatment of aortic arch aneurysms using branched stent graft provide attractive alternativ for elderly patients. METHODS
The branched stent grafts used are a custom-made version of RELAY NBS. A large access in the graft, with one or two internal tunnels proximally oriented, allow the extension to the supra aortic branches. RESULTS
34 patients, were treated between 2010 and 2015 with branched stent grafts and were reviewed from a prospective database. All were deemed high risk for conventional surgery. 8 patients had a single branch (1woman) and 26 (5 women) had a double branched stent grafts. 29 had arch aneurysms and 5 patients had a chronic dissection. 30 patients out of 34 had uneventful placement of the prostheses, with successful exclusion of their aneurysms. Aneurysm exclusion without endoleak was achieved in all patients. Of the target vessels, all were successfully cannulated and preserved. The pre-discharge CTA findings showed in all cases the patency of the different part of the stent-grafts without endoleak. 8 patients died during the follow up, 5 before discharge and 3 patients after 4 months.
29 Sizing, anatomical limitation Subject must have a proximal landing neck with: Diameter of 42 mm or less and a healthy proximal neck length of 40mm (measurement 1 and 2) Minimum required distance between the sinotubular junction and the innominate artery of 60mm (measurement 4)
CONCLUSIONS
We have demonstrated the technical feasibility of a new modular trans femoral branched stent graft for treatment of aortic arch aneurysms. The method is relatively safe based on initial experience, and we currently recommend it to high-risk patients with aneurysms involving the aortic arch and suitable anatomy. Safety and efficacy will be better defined with longer follow-up and increased worldwide experience.
Single branched cases statistical analysis
Double branched CT scan at D7
Double branched cases statistical analysis | FREE PAPERS 2016 | FRIDAY JUNE 3
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Profile of secondary interventions after EVAR: how are they triggered and what are the implications for surveillance? Iain Roy, Srinivasa Vallabhaneni Liverpool Vascular & Endovascular Service, Liverpool, United Kingdom BACKGROUND
Despite improvements in device performance and changing views about indications for secondary intervention, all EVAR patients still require surveillance to trigger secondary interventions that prevent late failure. METHODS
We examined secondary interventions, indications and imaging modality that triggered interventions in relation to stent-grafts implanted after 2008 in one center. A total of 638 patients underwent standard EVAR between 2008 and 2015. Bi-planar radiography (AXR) and duplex ultrasound (DUS) was performed at 1 month and annually thereafter. CTA was routinely performed at one month. RESULTS
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553 patients undertook surveillance locally, median follow-up was 34 months (IQR 16-50 m). 1,382 completed patient-years of surveillance were analysed. Secondary interventions performed during this period were reviewed.
| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
79 (14%) patients underwent 110 secondary interventions in this period. Interventions were planned procedures on 95 occasions of which 8 were triggered by symptomatic presentation while the remaining 87 were triggered by surveillance imaging (9 of whom did have symptoms on direct questioning but failed to self-present). The remaining 15 interventions were emergencies or treating complications of other interventions. The primary modality of surveillance imaging that triggered intervention was AXR in 8 (9%), CTA in 24(28%) and DUS in 65 (75%). In 10 (11%) patients the relevant complication was detected on two modalities during the same surveillance visit. CONCLUSION
Surveillance remains as important as ever despite a change in the profile of complications and interventions. The value of Plain X-rays is evident from this analysis. Surveillance based on DUS and AXR, (promting CTA when required) continues to be effective in detecting the need for intervention.
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Giant Abdominal Aortic Aneurysms: clinical significance and surgical management Calì Filippo1, Salvina Diliberti1, Michele Savaia1, Ernesto Doffria1, Ginevra Fernando1, Salvatore Dell’Aira2, Nicola Reina1 1. Vascular Surgery Unit P.O. «S. Elia» Caltanissetta, Caltanissetta, Italy, Italy 2. Vascular Interventional Radiology Unit P.O. S. Elia, Caltanissetta, Italy
BACKGROUND
RESULTS
With increasing age of the general population, a higher awareness of the disease, better screening methods and the option of less invasive therapeutical strategies, the incidence of abdominal aortic aneurysms (AAA) is rising steadily. Giant (≥8 cm) abdominal aortic aneurysm (GAAAs) is nowdays a rare event . The authors report about 25 patients with GAAAs.
Seven patients died during intensive care after emergency surgical procedure, four of these died of multi-organ failure and three of myocardial infarction. eighteen patients had good postoperative outcome. In our experience procedure-related outcomes showed significant differences in operative blood loss and length of hospital stay compared with AAA < 8 cm patients, both in elective surgery The mean follow-up period was 26 months (1-72); three patient died on cardiological disease respectly after two, six and eight months from surgical intervention, and one patient died after 1 year of vascular cerebral disease.
MATHERIAL AND METHOD
From October 2012 to Marchr 2016, 25 individuals underwent AAA open surgery, 3 women and 22 men with giant AAA including 14 emergency operations. Demographic and aneurysm-specific data, comorbidities, operative morbidity, mortality, and late outcome were analyzed. Social, cultural and economic factors were associated with GAAS patients and a great familial predisposition (9 patients/25), a high incidence of current smokers and a high incidence of chronic obstructive pulmonary disease were observed. All patients were successfully operated in 4 cases using an aortoiliac Y-graft bypass technique, in 20 using an aorto-aortic graft and in 1 case using a aorto-bifemoral bypass. In all cases a Cell saver technique was used during the surgical procedure.
CONCLUSIONS
The midterm outcome of large aneurysms after EVAR was associated with increased rates of aneurysm-related death, unrelated death, and rupture. Surgical open treatment of Giant AAAs has showed that it can be performed safely and effectively. Anyway Aneurysms with greater diameter are related to a higher risk of perioperative death after surgical emergency operation, a shorter life expectancy, a higher risk of rupture and aneurysm-related death.
| FREE PAPERS 2016 | FRIDAY JUNE 3
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Compliance with surveillance following endovascular aortic aneurysm repair Iain Roy, Srinivasa Vallabhaneni Liverpool Vascular & Endovascular Service, Liverpool, United Kingdom
BACKGROUND
RESULTS
Surveillance is considered essential after EVAR, but difficulties in achieving compliance have been commented upon as a significant barrier. In our institution one whole-time-equivalent administrator manages the EVAR programme and surveillance. The administrator organises all appointments, coordinated for the same day whenever possible and contacts patients that fail to attend. Surveillance is transferred if they relocate and discontinued if they become too frail to have a secondary intervention. EVAR co-ordinator also ensures that significant findings are reviewed.
Of the 553 patients enrolled into surveillance, 130 (24%) died while on surveillance and 21(4%) were discharged due to frailty or relocation. The remaining continue to be invited for surveillance and have completed a total of 1382 patient surveillance-years with a median follow-up of 34 months (IQR 16-50 months). A total of 1930 surveillance visits were indicated during the period, of which 1795 were taken up representing a compliance with 93% of appointments. Only 34 (6%) patients were lost to follow-up, defined as missing their last two surveillance visits. Utilisation of plain film radiography was better than DUS or CTA, which were additionally affected by patient suitability (BMI & renal function).
METHODS
We performed a retrospective service review of compliance with surveillance following standard EVAR. All EVAR patients enrolled into our local surveillance programme after EVAR between 2008 and 2015 were included. 32
| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
CONCLUSION
Excellent compliance with EVAR surveillance is achievable within a large volume institution with dedicated administrative support. Poor compliance with surveillance, if noted, is a remediable problem.
| ORAL PRESENTATIONS |
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Fenestrated and branched thoracic endografts for complex arch pathology Robert Ma, Ming Yii Monash Medical Centre, Melbourne , Australia
Aortic arch pathology presents the surgeon with a complex challenge. The advent of thoracic stenting for aneurysmal disease has added to the armamentarium, in often comorbidly burdened patients, however to date, treatment has often required major debranching or bypass procedures to ensure an adequate landing zone. The development of scalloped, fenestrated and/or branched thoracic endografts may help in providing a solution to some of these more complex cases. We present five consecutive thoracic fenestrated and or branched endograft cases, and discuss key features of case planning, procedural tips, and the outcome in a cohort which included 2 patients with Kommerelâ&#x20AC;&#x2122;s diverticulum. Our cases demonstrate that thoracic fenestrated/branched endografts can provide a safe solution for complex thoracic anatomy without the requirement for simultaneous or staged debranching procedures.
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| FREE PAPERS 2016 | FRIDAY JUNE 3
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Comparing the efficacy of an angiosome-directed versus an indirect approach to arterial revascularisation in optimising wound healing outcomes for patients with diabetes and critical limb ischaemia: a literature review Benedictine, Y.C. Khor1, Pamela Price1 Glasgow Caledonian University, Glasgow, United Kingdom BACKGROUND
CONCLUSION
Ischaemic ulcerations have been reported to persist and/or deteriorate despite technically successful revascularisations; a higher incidence of which affects patients with diabetes and critical limb ischaemia. Specifically in the context of wound healing, it is unclear if applications of the angiosome concept (Taylor & Palmer, 1987; Attinger et al., 2006) in lower-limb vascular surgery in ‘direct revascularisation’ would be able to improve local perfusion to the site of ulceration better than the current “best vessel” or ‘indirect revascularisation’ strategy (Forsythe et al., 2015).
Within the limits of technical feasibility, it appears that re-calibrating the revascularisation strategy to incorporate the angiosome concept may be more efficacious than an indirect approach to revascularisations in achieving wound healing for patients with coexisting diabetes and CLI.
METHODOLOGY
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A literature search was conducted in eight electronic databases, specifically AMED, CINAHL, MEDLINE, ProQuest Health & Medicine Complete, ProQuest Nursing & Allied Health Source, The Cochrane Library, TRIP database and ScienceDirect. Articles were screened against a pre-established inclusion and exclusion criteria to determine eligibility, and the Newcastle-Ottawa Scale was used to appraise the methodological quality of included studies. FINDINGS
Four retrospective studies (Fossaceca et al., 2013; Söderström et al., 2013; Acín et al., 2014; Lejay et al., 2014) of varying methodological quality were eligible for inclusion in this review. Focusing on studies of higher methodological quality, giving a representative sample of 280 subjects, direct revascularisations was found to be superior than indirect revascularisations (p-values 0.04 and <0.001), and appear to result in a nearly twofold increased probability (HR, 1.97; 95% CI, 1.34-2.90) for subjects undergoing direct revascularisations to achieve wound healing in 12 months. As the current evidence-base is limited, further research is required to substantiate the safety and viability of pursuing a direct over an indirect revascularisation strategy in the diabetic population.
| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
References
Acín, F. et al., 2014. Results of infrapopliteal endovascular procedures performed in diabetic patients with critical limb ischemia and tissue loss from the perspective of an angiosome-oriented revascularization strategy. International Journal of Vascular Medicine [online]. 2014(2014), pp. 1-13. [viewed 04 January 2016]. Available from: http://dx.doi.org/10.1155/2014/270539 ATTINGER, C.E. et al., 2006. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plastic and Reconstructive Surgery [online]. 117(Suppl 7), pp. 261S-293S. [viewed 02 January 2016]. Available from: http://dx.doi.org/10.1097/01.prs.0000222582.84385.54 FORSYTHE, R.O., BROWNRIGG, J. & HINCHLIFFE, R.J., 2015. Peripheral arterial disease and revascularization of the diabetic foot. Diabetes, Obesity and Metabolism [online]. 17(5), pp. 435-444. [viewed 29 October 2015]. Available from: http://dx. doi.org/10.1111/dom.12422 Fossaceca, R. et al., 2013. Endovascular treatment of diabetic foot in a selected population of patients with below-the-knee disease: is the angiosome model effective?. CardioVascular and Interventional Radiology [online]. 36(3), pp. 637-644. [viewed 04 January 2016]. Available from: http://dx.doi.org/10.1007/s00270-012-0544-4 Lejay, A. et al., 2014. Long-term outcomes of direct and indirect below-the-knee open revascularization based on the angiosome concept in diabetic patients with critical limb ischemia. Annals of Vascular Surgery [online]. 28(4), pp. 983-989. [viewed 02 January 2016]. Available from: http://dx.doi.org/10.1016/j.avsg.2013.08.026 Söderström, M. et al., 2013. Angiosome-targeted infrapopliteal endovascular revascularization for treatment of diabetic foot ulcers. Journal of Vascular Surgery [online]. 57(2), pp. 427-435. [viewed 02 January 2016]. Available from: http://dx.doi. org/10.1016/j.jvs.2012.07.057 TAYLOR, G.I. & PALMER, J.H., 1987. The vascular territories (angiosomes) of the body: experimental study and clinical applications. British Journal of Plastic Surgery [online]. 40(2), pp. 113-141. [viewed 02 January 2016]. Available from: http://dx. doi.org/10.1016/0007-1226(87)90185-8
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Percutaneous mechanical rotational thrombectom in complex bypass occlusions Bruno Migliara Casa di Cura Pederzoli, Peschiera del Garda, Italy INTRODUCTION
CONCLUSIONS
By-pass occlusion in patients with critical limb ischemia (CLI) is a very challenging and dramatic situation related to a high risk of death and amputation. The risk of limb lose is from 20 to 50% in literature 1, 2. The treatment of this condition could be: surgery, thrombolysis, thromboaspiration or mechanical thrombectomy 3-5.
Percutaneous rotational mechanical thrombectomy is an effective and safe treatment in patients with CLI and bypass occlusion, with a high rate of limb salvage, with a very rapid blood flow restoration, without major complications and with only minor complications, all treated during the same procedure.
MATERIAL AND METHOD
From April 2014 to February 2016 (22 months), we performed 29 (23 male / 6 female; median age = 71,3 y) percutaneous rotational mechanical thrombectomies in patients with CLI (5 Rutherford 4; 21 Rutherford 5 and 3 Rutherford 6) and occluded bypass. The bypasses were: 12 femoro-popliteal above the knee; 17 femoro-popliteal below the knee or femoro-tibial. In 7 cases we used a double access: antegrade from the common femoral artery and retrograde from the tibial vessels (5 cases) or retrograde directly from the occluded bypass (2 cases). The average time to obtain complete restoration of distal flow was 11,4 minutes. RESULTS
References
1. Smeets L, Ho GH, Tangelder MJD, Algra A et al. Outcome after occlusion of infrainguinal bypasses in the Dutch BOA Study: comparison of amputation rate in venous and prosthetic grafts. Eur J Vasc Endovasc Surg 2005; 30: 604-9 2. Brumberg RS, Back MR, Armstrong PA, et al. The relative importance of graft surveillance and warfarin therapy in infrainguinal prosthetic bypass failure. J Vasc Surg 2007; 46: 1160-6 3. Lichtenberg M, Kaunike M, Hailer B. Percutaneous mechanical thrombectomy for treatment of acute femoropopliteal bypass occlusion. Vasc Health Risk Manag 2012; 8: 283-9 4. Wissgott C, Kamusella P, Andresen R. Recanalization of acute and subacute venous and synthetic bypass-graft occlusions with a mechanical rotational catheter. Cardiovasc Intervent Radiol 2013; 36: 936-42 5. AbuRahma AF, Hopkins ES, Wulu JT, et al. Lysis/balloon angioplasty versus thrombectomy/open patch angioplasty of failed femoropopliteal polytetrafluoroethylene bypass grafts. J Vasc Surg 2002; 35: 307-15
The immediate success rate was 100%; with 6 occlusions (20,7%) during follow-up, that were treated: 1 with percutaneous mechanical thrombectomy; 2 with redo bypass surgery; 3 with major amputation. Amputation free survival is 89,7%. We have had no major complications related to the procedure: death, cerebral haemorrhage or haemorrhage with transfusion. We only have had 5 minor complications: 1 distal native artery dissection; 1 vein bypass perforation; 1 distal anterior tibial artery perforation; 2 distal embolizations. All of these  were resolved during the same procedure.
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Exclusive endovascular treatment of severe tasc C and D external iliac artery occlusive disease with a new dual component stent Bertrand Saint-Lebes Rangueil University Hospital, Toulouse, France PURPOSE
Figures
External iliac artery occlusive lesions are difficult to treat. Especially when the disease is close to common femoral artery, such as in TASC C and D lesions. In this type of severe lesions, surgery remains the first line treatment. Endovascular treatment is less invasive, however it seems to offer a lower long-term patency. We present our results of external iliac artery TASC C and D lesions stenting through this prospective, multicenter study. MATERIAL AND METHODS
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All patients with severe occlusive external iliac artery disease were treated by endovascular way in 3 vascular surgery unit. We perform through groin, a percutaneous ponction of the ipsilateral or controlateral common femoral artery with a 6 French sheat. We performed a systematic angioplasty and stenting. All stenting were performed with a new generation self-expanding stent to adapt to the biodynamic constraints of the external iliac artery. The stent naturally conforms and allows vessel movement, especially when desease is close to femoral artery.
Patency
RESULTS
From 09/2012 to 11/2015, we treated 104 limbs in 96 patients (74 men, sex ratio 77%). The mean age was 66 years (range 4692). Majority of them were Rutherford III (60 patients, 61%) and Rutherford IV (14 patients, 14%). They presents severe occlusive disease of the external iliac artery, classified TASC C in 58% (57 cases), and TASC D in 42% (42 cases). All procedures were completed with a 100% succes rate. More frequents risk factors was tabacco (95%), dyslipidemia (61%), obesity (47%). Our Follow up was 13 months (1 to 37 months). 1 patients died at 1 months during an aortic procedure (peri operative mortality rate : 0,9%). One thrombosis occured (0,9%) and 4 stenoses (3,8%) were treated during FU. Our limb salvage was 100% without any major amputation. The late survival rate was 98% at 24 months and the primary patency was 94% at 12 and 24 months and 88% at 36 months. The assisted patency was 98% at 36 months. All patients become asymptomatic after treatment (< Rutherford II), with 83% Rutherford II and 17% Rutherford I. CONCLUSION
The new generation stents offer a mechanical design allowing greater conformability for high flexibility areas such as the external iliac artery. Our results are promising in patients with high selected TASC. A randomized study with long term follow up will assess the safety and accuracy of this indication.
| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
Rutherford improvment
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| ORAL PRESENTATIONS |
The impact of angiosome-targeted distal endovascular procedure on healing rate and outcome in critical lower limb ischemia Alec Duinslaeger1, Timothy Versyck, Alexander Croo, Caren Randon, Frank Vermassen 1. Ugent, Hamme, Belgium
INTRODUCTION
RESULTS
3-10% of the worldwide population is suffering from peripheral arterial disease and 1-3% will ultimately develop critical limb ischemia (CLI). One of the options to avoid major amputation and secure a better quality of life is an endovascular revascularization. The angiosome-concept divides the foot into six anatomic regions (angiosomes) fed by distinct source arteries arising from the posterior tibial, anterior tibial and peroneal arteries. This study investigates whether an endovascular procedure to the artery directly feeding the ischemic angiosome has an impact on wound healing, major amputation and mortality rate.
DR feeding the ulcer area was achieved in 88 legs (67%) compared with IR in 43 legs (33%). Revascularization was performed to the anterior tibial artery (49%), posterior tibial artery (26%) and peroneal artery (29%). There were no differences in comorbidities and wound characteristics except for ulcer localization and the treated vessel between the two groups. DR was not able to accomplish a higher healing rate, lower amputation rate or lower mortality rate compared to IR (p= .258, p= .828, p=.775). Wound healing (P = .007) reduces the risk of mortality. Wound infection (p= .038), high CRP (p= .007), renal insufficiency (p= .024) and a history of major amputation (p= 0.043) decreases wound healing rate. Patients who need a re-operation have a higher risk for minor amputation (p=.004).
MATERIALS/METHODS
Retrospective analysis with prospective follow-up was performed at Ghent University Hospital of 131 non-healing ischemic wounds requiring endovascular revascularization in 109 patients. For every patient the site of the ulcer, the treated artery and the outcome were identified. Based on this information the legs were divided into direct revascularization (DR) and indirect revascularization (IR).
CONCLUSION
Revascularization plays a crucial role in the treatment of ischemic lower extremity wounds. Similar results were obtained with regard to healing rates, limb salvage and mortality after DR compared to IR. Therefore revascularization should not be denied to patients in whom only indirect revascularization is possible.
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| CASE REPORT |
| ORAL PRESENTATIONS |
Endovascular treatment of an axillary arterial injury following a traumatic shoulder dislocation Roger Rodrigues, Ricardo Pereira, Alfredo Gil Agostinho, Óscar Gonçalves, Antonio Albuquerque Matos Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal Shoulder dislocation is a very common shoulder injury that may result from a fall, sports or trauma. Multiple complications have been reported, most commonly, recurrent dislocation, axillary nerve injury and bon defects .Axillary artery injury secondary to an shoulder dislocation without bone fracture is extremely rare. Less than 1% of axillary artery injuries are caused by this type of mechanism The nature of the injury might range from complete transection of the axillary artery to intimal tears, branch avulsion, or pseudoaneurysm formation. Association with a severe brachial plexus lesion is common in such injuries
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Concomitant orthopedic and vascular injuries are associated with a high rate of limb loss with reports ranging from 18% to 38%. The best intervention to restore blood flow or to stop hemorrhage is not always clear. Open surgery is the classical treatment of such lesions, consisting of direct suture at the site of the rupture or arterial reconstruction with a patch or a bypass.
2004;35:1128-32. 8. Karkos CD, Thomson GJ. Combined subclavian artery and brachial plexus injury following blunt trauma to the shoulder. Injury 1998;29:395-6.
Figures
Shoulder dislocation shoulder X-ray anterior dislocation without fractures
Axillary artery occlusion A selective catheterization of the right subclavian artery showed an abrupt occlusion of the axillary artery without contrast extravasation
Self-expanding stent graft contrast extravasation after the placement of the stent
Angioplasty ballon In an attempt to control the bleeding an 7 mm x 60 mm angioplasty balloon was introduced unsuccessfully
Minimally invasive percutaneous endovascular therapies offer an attractive treatment alternative. We report a case of a 74-years-old man who suffered a vascular and neurological injury after a recurrent glenohumeral joint dislocation and treated with a covered stent implant. In this case the option for the endovascular treatment was due to changes in hemostasis caused by anticoagulant therapy and because the risk of adverse events in an open surgical revascularization were considerable. After procedure radial and ulnar pulses were palpable and hand temperature increased. An electromyography was subsequently performed that showed severe damage of the brachial plexus. References
1. Sparks SR, DeLa Rosa J, Bergan JJ,et al. Arterial injury in uncomplicated upper extremity dislocation. Ann Vasc Surg 2000;14:110e3. 2. Gates JD, Knox JB. Axillary artery injuries secondary to anterior dislocation of the shoulder. J Trauma 1995 ; 39 :581-583. 3. Rozycki GS, Tremblay LN, Feliciano D,et al. Blunt vascular trauma in the extremity: diagnosis, management, and outcome. J Trauma. 2003;55:814-824. 4. Fass G, Barchiche MR, Lemaitre J, , et al. Endovascular treatment of axillary artery dissection following anterior shoulder dislocation. Acta Chir Belg 2008;108:11921. 5. Allie B, Kilroy DA, Riding G, Summers C. Rupture of axillary artery and neuropraxis as complications of recurrent traumatic shoulder dislocation: case report. Eur. J. Emerg. Med. 2005; 12:121–3. 6. Milton GW: The circumflex nerve and dislocation of the shoulder. Br J Phys Med 17:136, 1954 7. Kelleya SP, Hinsche AF, Hossain JFM. Axillary artery transection following anterior shoulder dislocation: classical presentation and current concepts. Injury | i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
Covered stent An 7 mm x 38 mm Control angiogram control angiogram balloon expandable covered stent was revealed patency of distal arteries placed controlling successfully the bleeding and maintaining the patency of the artery
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Chimney CERAB: an alternative new technique for extensive or Iuxtarenal aortoiliac occlusive disease Kim Taeymans1, Peter Goverde1, Martijn Dijkstra2, Michel Reijnen2, Andrew Holden3, Andreij Schmidt4 1. Vascular Clinic ZNA, ZNA Stuivenberg, Antwerp, Belgium 2. Dept Vascular Surgery ,Rijnstate Hospital, Arnhem, The Netherlands 3. Dept Interventional Radiology, Auckland City Hospital, Auckland, New Zealand 4. Dept Angeology, Leipzig University Hospital, Leipzig, Germany AIMS
Figures
Based on the promising results of the Covered Endovascular Reconstruction of the Aortic Bifurcation or CERAB, we wanted to see if this configuration can be used to treat iuxtarenal and extensive aortoiliac occlusive disease in combination of chimney stents to preserve visceral and renal arteries. METHODS
Patients were treated with the Chimney - CERAB technique. Endovascular bifemoral & brachial access; recanalisation of the both aortoiliac axes and predilatation. For preservation of mesenteric and/or renal vessels placement of: first, an ePTFE encapsulated covered balloon expandable stainless steel stent in the visceral artery (from brachial) and the placement of a 12 mm ePTFE encapsulated covered balloon expandable stainless steel stent in the distal aorta (9 Fr femoral). Simultaneous inflation. If needed postdilatation of the proximal part of the already expanded large diameter stent with a large balloon and extension of the aortic stent distally. Two iliac covered stents are then placed in this distal segment, in a “kissing-stent” configuration and inflated. Both stents are now making a very tight combination, simulating a new bifurcation.
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RESULTS
Multi-centre, non-randomised, follow-up study. We treated now around 15 patients (January 2013 – december 2014) with aortoiliac occlusive disease. Technical success rate up till now was 100 %. Follow-up: 3 to 24 months. No 30-days mortality or SAE were observed. All reconstructions are still patent.
End result of the procedure : new aortic bifurcation with the hemodynamic aspect of an aortobifemoral prosthesis , combined with secured visceral blood flow by the chimney grafts
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Multistep endovascular treatment of a complex pathology af the thoracoabdominal aorta in a patient with high surgical risk Manuela Cherchi1, Stefano Camparini2 1. University of Cagliari, Cagliari, Italy 2. AO Brotzu Cagliari, Cagliari, Italy AIM
Figures
Complex lesions of the thoraco-abdominal aorta are a challenging disease to treat both with open and endovascular surgery. Furthermore, morbidity and mortality are strictly related to the preoperative status of the patient. The aim of our paper is to report a case of multistep endovascular treatment in a patient with high surgical risk. CASE REPORT
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A 74-year-old male was admitted to our Vascular Surgery Unit with 2 PAUs in the aortic arch (respectively 12 and 27 mm) and one 28mm-PAU of the descending thoracic aorta plus a 6cm-pseudoaneurysm of the abdominal aorta and a right common iliac artery aneurysm in the contest of a small type 2 thoracoabdominal aortic aneurysm. He was affected by several comorbidities, such as ischaemic cardiopathy and severe heart failure (EF 18%), arterial hypertension, hypercolesterolemia, COPD and a lung solitary mass under follow-up. Step 1: The patient underwent left carotid-subsclavian artery bypass in PTFE 7mm plus TEVAR for the exclusion of the PAUs in the thoracic aorta. The subclavian artery was embolized through the release of an Amplatzer plug II. Step 2: After that, he underwent EVAS to exclude the pseudoanerysm of the abdominal aorta and the right common iliac aneurysm. The renal and hypogastric arteries were preserved patent.
Aortic anatomy 2 PAUs in the aortic arch (respectively 12 and 27 mm) and one 28mm-PAU of the descending thoracic aorta plus a 6cmpseudoaneurysm of the abdominal aorta and a right common iliac artery aneurysm in the contest of a small type 2 thoracoabdominal aortic aneurysm
Step 1:left carotid-subclavian bypass + TEVAR The patient underwent left carotid-subsclavian artery bypass in PTFE 7mm plus TEVAR for the exclusion of the PAUs in the thoracic aorta. The subclavian artery was embolized through the release of an Amplatzer plug II
RESULTS
The patient was dismissed asymptomatic after both the procedures with total exclusion of the PAUs, the abdominal pseudoaneurysm and the right common iliac artery aneurysm. At a 6months follow-up, there is no evidence of endoleaks. No complications occurred during the operations. CONCLUSIONS
A multistep endovascular treatment of complex lesions of the thoraco-abdominal aorta revealed to be a valuable solution in a patient with multiple comorbidities and high cardiovascular risk.
Step 1:left carotid-subclavian bypass + Abdominal aortic pseudoaneurysm TEVAR final result The patient underwent 6cm-pseudoaneurysm of the abdominal left carotid-subsclavian artery bypass in aorta PTFE 7mm plus TEVAR for the exclusion of the PAUs in the thoracic aorta. The subclavian artery was embolized through the release of an Amplatzer plug II
Pre-EVAS angiogram 6cm-pseudoaneu- Step 2: EVAS. Final control The patient unrysm of the abdominal aorta and a right derwent EVAS to exclude the pseudoancommon iliac artery aneurysm erysm of the abdominal aorta and the right common iliac aneurysm. The renal and hypogastric arteries were preserved patent. | i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
| CASE REPORT |
| ORAL PRESENTATIONS |
Progressive proximal anastomosis aneurysm of an aortobifemoral prosthesis including a dominant accessory renal artery Kim Taeymans, Peter Goverde, Katrien Lauwers, Paul Verbruggen ZNA Stuivenberg, Antwerp, Belgium
INTRODUCTION
CONCLUSION
Male patient 62-y-old with a medical history of aortobifemoral prosthesis presents with a progressive proximal anastomosis aneurysm including a dominant accessory left renal artery. (Figure 1)
This case shows that the CERAB (Covered Endovascular Reconstruction of the Aortic Bifurcation) technique can be used safely for the endovascular treatment of difficult proximal anastomotic pseudoaneurysms of aortobifemoral grafts and can be a valuable alternative for a possible EVAR solution.
METHODS & MATERIAL
We performed a hybrid procedure under general anesthesia. We gained access from a bifemoral and left brachial open approach and placed three 7Fr sheats. A guidewire was introduced in an antegrade manner and with a pigtail and DSA we visualised the aneurysm and the left accessory renal artery. After catheterisation of this left renal artery we performed a PTA of the narrow renal ostium. We tried to place an ePTFE encapsulated covered balloon expandable stainless steel stent but this was impossible due to the very sharp angle between renal artery and aorta. Then we placed an ePTFE encapsulated covered self expandable nitinol stent and pushed it upwards with a retrograde introduced snare kit. After this step we were able to place the 5x59mm ePTFE encapsulated covered balloon expandable stainless steel stent from the brachial approach in the earlier placed nitinol stent to secure the stent in this position. Placement of a 12x61mm ePTFE encapsulated covered balloon expandable stainless steel stent and postdilatation with a 16x20mm balloon at about 15 mm above the distal stent margin. In the distal conic segment we placed two ePTFE encapsulated covered balloon expandable stainless steel iliac stents in a kissing stent configuration and they were inflated simultaneously.
Figures
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Proximal anastomosis aneurysm of an aortobifemoral prosthesis including a left dominant accessory renal artery (arrow)
RESULTS
Angiographic control showed an exclusion of the aneurysm with optimal flow in aorta, iliac arteries and in the renal chimney graft.
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Efficacy of relining previous endovascular aortic grafts using endovascular aneurysmal sealing (EVAS) Maria Karouki1, Adheeb Rehman1, Francesco Torella1, Richard McWilliams2, Andrew England3, Robert K Fisher4 1. Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, United Kingdom 2. Department of Radiology, Royal Liverpool University Hospital, Liverpool, United Kingdom 3. Directorate of Radiography, University of Salford, Salford, United Kingdom INTRODUCTION
CONCLUSION
EVAS is a novel technique for treating abdominal aortic aneuryms, but relining of previous EVAR to treat type 1a/b and 3b endoleaks remains unproven.
EVAS can safely and effectively reline previous EVAR stent grafts and may successfully treat type Ia and IIIb endoleaks. Chimney techniques may prove useful adjuncts however, type IIIb endoleak diagnosis remains challenging.
METHODS
Retrospective single centre observational study performed between December 2013- 2015 included patients in whom previous EVAR had been relined with EVAS. Data collection included demographics, indications, operative details and clinical outcomes. Follow up included duplex and CTA at 30 days, 6, and 12 a months. Primary outcomes were successful deployment and resolution of endoleak. Secondary outcomes included peri-operative complications and secondary interventions. 44
RESULTS
Seven patients, (6 males, mean age 82.5 years) underwent EVAS relining of previous EVAR for three suspected and 1 proven type IIIb endoleaks, and 3 confirmed type Ia endoleaks. In total 13 Nellix devices were successfully deployed (1 aorto-uni-iliac). All 3 type Ia endoleaks were eradicated using proximal extension through chimney EVAS (5 renal and 2 SMA vessels) with no target vessel loss. There were no peri-operative deaths. Four patients had complications including UTI, AKI, stroke (recovered) and groin AVF requiring surgical intervention. Early post–operative surveillance indicated all type Ia endoleaks remained treated (1-10 months); the proven type IIIb had a stable sac dimension at 1 year; but, of the 3 suspected type IIIb cases, 2 had continued sac expansion (10-12mm) and one remained static.
| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
References
1. Cook Zenith Flex AAA Endovascular Graft Instructions for Use. https://www.cookmedical.com/data/IFU_PDF/T_ZAAAF_REV4.PDF 2. Medtronic Endurant II Stent Graft System Instructions for Use. http://www. medtronic.com/for-healthcare-professionals/products-therapies/cardiovascular/ aortic-stent-grafts/endurantII/indications-safety-warnings/#1 3. Management of Endoleaks following Endovascular Aneurysm Repair. Sarah B. White, M.D and S. William Stavropoulos, M.D. Semin Intervent Radiol. 2009 Mar; 26(1): 33–38. doi: 10.1055/s-0029-1208381 4. Endovascular treatment of delayed type 1 and 3 endoleaks. Naughton PA1, Garcia-Toca M, Rodriguez HE, Keeling AN, Resnick SA, Morasch MD, Eskandari MK. Cardiovasc Intervent Radiol. 2011 Aug;34(4):751-7. doi: 10.1007/s00270-0100020-y. Epub 2010 Nov 25. 5. Donayre CE, Zarins CK, Krievins DK, Holden A, Hill A, Calderas C, Velez J, White RA. Initial clinical experience with a sac-anchoring endoprosthesis for aortic aneurysm repair. 1. J Vasc Surg 2011;53:574-82 doi: 10.1016/j.jvs.2010.09.009. PMID: 21211931. 6. Böckler D, Peters AS, Pfeiffer S, et al. Nellix® endovascular aneurysm sealing (EVAS)—a new technology for endovascular management of infrarenal aortic aneurysms [in German]. Zentralbl Chir. 2014;139:562–568. 7. McWilliams RG, Fisher RK, England A, Torella F. Observations on surveillance imaging after endovascular sealing of abdominal aortic aneurysms with the Nellix® system. J Endovasc Ther 2015;22(3):303-6.
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Clinical outcome after endovascular aneurysm sealing of Abdominal Aortic Aneurysms (EVAS): a retrospective cohort study Maria Karouki4, Charles Swaelens4, Luigi Iazzolino4, Richard McWilliams2, Robert K Fisher4, Andrew England3, Francesco Torella4 1. Royal Liverpool University Hospital Vascular Surgery department, Liverpool, United Kingdom 2. Department of Radiology Royal Liverpool University Hospital, Liverpool, United Kingdom 3. Directorate of Radiography, University of Salford, United Kingdom 4. Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK , Liverpool, United Kingdom PURPOSE
Figures
To present the clinical outcome of endovascular sealing of abdominal aortic aneurysms (EVAS) with the Nellix endoprosthesis in patients with abdominal aortic aneurysms treated in our institution. METHODS
This was a retrospective, single centre, observational cohort study. A departmental database was interrogated in order to extract demographics, clinical information and outcome of all patients treated with EVAS between December 2013 and December 2015. Outcome measures included technical success (successful device deployment and absence of any endoleak at completion angiography), mortality, major complications, incidence of endoleaks, aneurysm rupture and reintervention. RESULTS
Sixty-four patients (48 men) with a mean (SD) age of 78 (6.9) years were successfully treated with EVAS, with no 30-day mortality. The cohort included one patient with ruptured aneurysm, seven patients with late complications of previous aorto-iliac repairs (two open, five endovascular) and three patients who required a total of six visceral chimneys for juxta-renal aneurysms. Four patients (6%) suffered major post-operative complications and three required intervention. There were no early or late endoleaks or aneurysm ruptures. After a median (range) follow-up of 12 (0-24) months, there was no aneurysm related mortality; two patients (3%) required aneurysm-related late interventions.
Postoperative lateral plain abdominal film after relining of Endurant endograft (Medtronic, Dublin, Ireland) with two Nellix stents extending into the visceral aortic segment and two chimneys for the left renal and superior mesenteric arteries for type Ia endoleak. The seal was extended by >5 cm.
Pre-discharge contrast enhanced CT angiography post EVAS for symptomatic saccular aortic aneurysm, showing no concerning features (a). The patient returned to hospital three days later with thrombosis of the right stent extending into the common, external and internal iliac arteries (b).
CONCLUSIONS
EVAS can be performed with good early and medium term results. Longer follow-up on larger cohorts is needed to prove the efficacy of this technique.
Keywords
endovascular aneurysm sealing, abdominal aortic aneurysm, computed tomography, endovascular repair, Nellix速
Operative aortogram of patient underA short aortic neck. Although technically going right aortouniiliac EVAS for acute outside the IFU for the Nellix device, on chronic ischaemia of the left leg. this patient with ruptured aneurysm Note the presence of three pairs of large underwent successful EVAS with sealing lumbar arteries arising from the infrawithin the secondary neck. renal segment, and occlusion of the left internal iliac artery. The patient developed postoperative paraparesis.
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Tables
References
Table 1. Comorbidity and smoking habits Ischemic heart disease Respiratory Diabetes Renal impairment Hypertension History of tobacco use Malignant disease Atrial fibrillation/flutter
N. (%) 32 (50) 18 (28) 8 (12.5) 14 (22.4) 55 (86) 48 (75) 8 (12.5) 9 (14)
Table 2. Anatomical measurements 46
| EPOSTERS |
Aneurysm maximum diameter (mm) Aortic neck length (mm) Infrarenal neck angulation (degrees) Maximum neck diameter (mm)2 Maximum left common iliac artery diameter (mm) Maximum right common iliac artery diameter (mm) Aortic lumen volume (ml)
59 (46-118) 26 (14.9)1 30 (0-78) 28 (5.1)1 16 (4.9)1 16 (4.9)1 41 (15.6)1
Table 3. Treatment outside IFU N. Large aortic lumen1 1 Occlusive iliac disease 4 Short neck (<10 mm) 6 Large neck (>32 mm) 1 Previous aortic intervention 8 Aortic rupture 1 Neck angulation 1 Narrow aortic bifurcation (<18 mm) 3
| i-MEET 2016 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
1. Karthikesalingam A, de Bruin JL, Patel SR, Azhar B, Rossi L, Morgan RA, Holt PJ, Loftus IM, Thompson MM. Appearance of the Nellix endovascular aneurysm sealing system on computed tomography: implications for postoperative imaging surveillance. J Endovasc Ther. 2015 Jun;22(3):297-302. 2. Donayre CE, Zarins CK, Krievins DK, Holden A, Hill A, Calderas C, Velez J, White RA. Initial clinical experience with a sac-anchoring endoprosthesis for aortic aneurysm repair. J Vasc Surg. 2011 Mar;53(3):574-82. 3. Krievins DK, Holden A, Savlovskis J, et al. EVAR using the Nellix sac-anchoring endoprosthesis: treatment of favourable and adverse anatomy. Eur J Vasc Endovasc Surg.2011;42:38–46. 4. Ķīsis K, Krieviņš D, Naškoviča K, Gediņš M, Šavlovskis J, Ezīte N, Lietuvietis E, Zariņš K. Quality of life after endovascular abdominal aortic aneurysm repair: nellix sac-anchoring endoprosthesis versus open surgery. Medicina (Kaunas). 2012;48(6):286-91. 5. Böckler D, Peters AS, Pfeiffer S, Kovacs B, Geisbüsch P, Bischoff MS, Müller-Eschner M, Hakimi M. Nellix® endovascular aneurysm sealing (EVAS) - a new technology for endovascular management of infrarenal aortic aneurysms. Zentralbl Chir. 2014 Oct;139(5):562-8. 6. Brownrigg JR, de Bruin JL, Rossi L, Karthikesalingam A, Patterson B, Holt PJ, Hinchliffe RH, Morgan R, Loftus IM, Thompson MM. Endovascular aneurysm sealing for infrarenal abdominal aortic aneurysms: 30-day outcomes of 105 patients in a single centre. Eur J Vasc Endovasc Surg. 2015 Aug;50(2):157-64 7. Bockler D, Holden A, Thompson M, Hayes P, Krievins D, de Vries JP et al. Multicenter Nellix Endovascular Aneurysm Sealing system experience in aneurysm sac sealing. J Vasc Surg. 2015 Aug;62(2):290-8. 8. Zerwes S, Nurzai Z, Leissner G, Kroencke T, Bruijnen HK, Jakob R, Woelfle K. Early experience with the new endovascular aneurysm sealing system Nellix: First clinical results after 50 implantations. Vascular. 2015 Oct 19. pii: 1708538115605430. 9. Carpenter JP, Cuff R, Buckley C, Healey C, Hussain S, Reijnen MM, Trani J, Böckler D; Nellix Investigators. Thirty-day results of the Nellix system investigational device exemption pivotal trial for endovascular aneurysm sealing. J Vasc Surg. 2015 Oct 16. pii: S0741-5214(15)01749-8. doi: 10.1016/j.jvs.2015.07.096. 10. Gossetti B, Malaj A, Alunno A, Martinelli O. Early and mid-term outcomes of a novel Endovascular Aneurysm Sealing (EVAS) system in patients with infrarenal Abdominal Aortic Aneurysms. J Cardiovasc Surg (Torino). 2015 (in press). 11. Reijnen MM, de Bruin JL, Mathijssen EG, Zimmermann E, Holden A, Hayes P, Krievins D, Böckler D, de Vries JP, Thompson MM. Global Experience With the Nellix Endosystem for Ruptured and Symptomatic Abdominal Aortic Aneurysms. J Endovasc Ther. 2015 (in press). 12. Antoniou GA, Senior Y, England A, McWilliams RG, Iazzolino L, Fisher RK, Torella F. Endovascular Aneurysm Sealing is Associated with Reduced Radiation Exposure and Procedure Time Compared to Standard Endovascular Aneurysm Repair. J Endovasc Ther 2015 (in press). 13. McWilliams RG, Fisher RK, England A, et al. Observations on surveillance imaging after endovascular sealing of abdominal aortic aneurysms. J Endovasc Ther. 2015;22:303–306 14. Shaikh U, Chan TY, Oshin O, McWilliams RG, Fisher RK, England A, Torella F. Changes in Aortic Volumes Following Endovascular Sealing of Abdominal Aortic Aneurysms With the Nellix Endoprosthesis. J Endovasc Ther. 2015 Dec;22(6):881-5 15. Endologix Inc. Nellix instructions for use - 2015.
| CASE REPORT |
| EPOSTERS |
Thoracic outlet syndrome complicated by double subclavian artery aneurysms – an hybrid approach Ricardo Castro-Ferreira, Paulo Gonçalves Dias, Sérgio Moreira Sampaio, Dalila Rolim, José Fernando Teixeira Hospital de São João, Porto, Portugal
INTRODUCTION
DISCUSSION
Subclavian artery aneurysm (SAA) can be an extremely rare complication of thoracic outlet syndrome (TOS)1. The arterial dilation usually occurs distal to the stenosis site causing TOS2. We describe a rare case of a in a patient with neurological TOS with two voluminous SAA proximal and distal to interscalene triangle.
The term thoracic outlet syndrome was originally used in 1956 by RM Peet to designate compression of the neurovascular bundle at the thoracic outlet3. Since its original description, a multitude of clinical entities was associated with TOS1. SAA is a rare but potential dangerous complication of TOS2. Whereas historically SAA have been managed by open surgery, the novel endovascular methods offer an elegant and safer approach to this condition. Although first rib resection is emerging as the regular method of thoracic outlet decompression4, this particular case imaging was highly suggestive of scalenus muscle compression. This case exemplifies how endovascular and open approaches can elegantly work together with remarkable results. To the best of our knowledge, this is the first description of a double subclavian artery aneurysm in the context of TOS.
CASE REPORT
A 55 years-old female patient, with no prior medical conditions, was referred to vascular surgery clinic with symptoms of neurological TOS. The radial pulses were absent but the patient had no arterial complains. In the work-up angio-CT two consecutive SAA (39 and 42mm) divided by anterior scalenus muscle were diagnosed. The aneurysms were excluded by covered stent angioplasty after circle of Willis flow assessment by transcranial Doppler. Subsequently the patient was submitted to anterior scalenectomy in operating theatre. The symptoms completely reversed and the patient was discharged two days after surgery. Follow-up angio-CT confirmed SAA exclusion. Patient remains asymptomatic 6 months after the treatment.
References
1. Grunebach H, Arnold MW, Lum YW. Thoracic outlet syndrome. Vascular medicine 2015;20:493-5. 2. Gruss JD, Geissler C. [Aneurysms of the subclavian artery in thoracic outlet syndrome]. Zentralblatt fur Chirurgie 1997;122:730-4. 3. Peet RM, Henriksen JD, Anderson TP, Martin GM. Thoracic-outlet syndrome: evaluation of a therapeutic exercise program. Proceedings of the staff meetings Mayo Clinic 1956;31:281-7. 4. Rochlin DH, Orlando MS, Likes KC, Jacobs C, Freischlag JA. Bilateral first rib resection and scalenectomy is effective for treatment of thoracic outlet syndrome. J Vasc Surg 2014;60:185-90.
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| CASE REPORT |
| EPOSTERS |
Percutaneous treatment of stenosis and aneurysmatic dilatation of the common carotid artery and left internal carotid artery with self-expandable novel mesh covered stent in patient submitted to thromboendoarterectomy previously Cinzia Moncalvo, Vincenzo Puma, Angelo Laurenza, Giuseppe Carosio, Paolo Cioffi ZNA Stuivenberg, Antwerp, Belgium HISTORY
CONCLUSIONS
P.A.B., man, 72 y.o. suffering from rom hypertension, dyslipidemia, polyneuropathy, partial gastrectomy, anemia. Doppler ultrasound: critical stenosis of the left internal carotid artery, confirmed by the angiography (01.22.2015) because of it the patient was submitted to thromboendoarterectomy. 04/15/2015: Doppler ultrasound detected a critical restenosis at distal edge of the patch on the distal portion of the common carotid artery and at the bifurcation with the left internal carotid artery Angiography: aneurysmatic dilation of the patch on the distal portion of the common carotid artery and at the bifurcation with the internal carotid artery.
The stent C-Guard can be considered the stent of choice in presence of aneurysm of the carotid artery because: the PET mesh that covers it reduces the risk of embolization immediately upon release and during the postdilatation, once released the stent exerts a radial force directed outward on the vessel walls, re-establishing the patency of the vessel, it prevents plaque prolapse and late embolic events, it allows to exclusion of the aneurysm providing a more physiological laminar flow into the lumen.
TREATMENT 48
Right femoral arterial access with 8 F sheath, guiding catheter AL 0.75 8 F, a distal embolic protection filter is positioned and two self-expandable stents covered with a novel PET mesh (C-Guard 8 x 40 mm x 40 mm 9 distal and proximal) are implanted and partially overlapped. Post-dilatation with 5.0 x 20 mm balloon inflated at 10 atm. Good final result. No complications. Angiographic control after two months: maintaining of the good angiographic result, complete exclusion of the aneurysm, no evidence of endoleaks or restenosis.
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