Radisson BLU Hotel Nice, France MEET 2014 Course Directors Max Amor Patrice Bergeron Piergiorgio Cao Nicholas Cheshire Eric Ducasse Nicola Mangialardi
Scientific Committee Hakim Benamer Benjamin Faurie Mario Lachat Richard McWilliams RenĂŠ Milleret Claudio Rabbia Sonia Ronchey Peter Schneider Gunnar Tepe Isabelle Van Herzeele
Founding Directors Max Amor Patrice Bergeron Honorary Directors Luigi Inglese Thomas Ischinger Klaus Mathias Dieter Raithel
7th Annual Joint Meeting of ISES & MEET
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| MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
COURSE DIRECTORS 2014 Max AMOR, Essey-les-Nancy, France Patrice BERGERON, Marseille, France Piergiorgio CAO, Rome, Italy Nicholas CHESHIRE, London, United Kingdom Eric DUCASSE, Bordeaux, France Nicola MANGIALARDI, Rome, Italy SCIENTIFIC COMMITTEE 2014 Hakim BENAMER, Aubervilliers, France Benjamin FAURIE, Grenoble, France Mario LACHAT, Zurich, Switzerland Richard MCWILLIAMS, Liverpool, United Kingdom René MILLERET, Montpellier, France Claudio RABBIA, Torino, Italy Sonia RONCHEY, Rome, Italy Peter SCHNEIDER, Honolulu, USA Gunnar TEPE, Rosenheim, Germany Isabelle VAN HERZEELE, Gent, Belgium FACULTY 2014 Flavio AIROLDI, Milan, Italy Vladimir ALEXANDRESCU, Marche-En-Famenne, Belgium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Jean-Marc ALSAC, Paris, France Max AMOR, Essey-Les-Nancy, France Takashi AZUMA, Tokyo, Japan . . . . . . . . . . . . . . . . . . . 13 Hakim BENAMER, Aubervilliers, France Patrice BERGERON, Marseille, France . . . . . . . . . . 11, 18 Jérôme BRUNET, Avignon, France Clifford J. BUCKLEY, Temple, USA . . . . . . . . . . . . . . . . . 17 Jacques BUSQUET, Saint-Cloud, France Sante CAMILLI, Rome, Italy . . . . . . . . . . . . . . . . . . . . . . 9 Sylvain CHASTANET, Nice, France Laurent CHICHE, Paris, France . . . . . . . . . . . . . . . . . . . 22 Philippe COMMEAU, Ollioules, France Gioachino COPPI, Modena, Italy . . . . . . . . . . . . . . . . 26 Jean-Paul DE VRIES, Nieuwegein, The Netherlands Koen R. DELOOSE, Dendermonde, Belgium Edward DIETHRICH, Phoenix, USA Eric DUCASSE, Bordeaux, France Mark A. FARBER, Chapel Hill, USA Benjamin FAURIE, Grenoble, France Roberto FERRARESI, Milan, Italy Ciro FERRER, Rome, Italy . . . . . . . . . . . . . . . . . . . . . 12, 20 Jean-Luc GÉRARD, Créteil, France Jean-Luc GILLET, Bourgoin-Jallieu, France . . . . . . . . . . 5 Yann GOUËFFIC, Nantes, France . . . . . . . . . . . . . . . . . 29
Alison W. HALLIDAY, London, United Kingdom . . . . . 16 Olivier HARTUNG, Marseille, France . . . . . . . . . . . . . . 10 Réda HASSEN-KHODJA, Nice, France L. Nelson HOPKINS, Suite Buffalo, USA . . . . . . . . . . . . 15 Emmanuel HOUDART, Paris, France Luigi INGLESE, San Donato Milanese, Italy . . . . . . . . . 27 Elixène JEAN-BAPTISTE, Nice, France Xiongjing JIANG, Beijing, China Kiriaki KALLIGIANNI, Athens, Greece Piotr KASPRZAK, Regensburg, Germany Zvonimir KRAJCER, Houston, USA . . . . . . . . . . . . . . . . 28 Julien LEMOINE, Essey-les-Nancy, France Nicola MANGIALARDI, Rome, Italy Armando MANSILHA, Porto, Portugal Klaus MATHIAS, Hamburg, Germany Richard McWILLIAMS, Liverpool, United Kingdom Claude MIALHE, Monaco René MILLERET, Pezenas, France Piero MONTORSI, Milan, Italy Stefan MÜLLER-HÜLSBECK, Flensburg, Germany Furuzan NUMAN, Istanbul, Turkey Fausto PASSARIELLO, Naples, Italy . . . . . . . . . . . . . . . . . 6 Atul PATHAK, Toulouse, France Michel PERRIN, Chassieu, France Ivo PETROV, Sofia, Bulgaria Paul PITTALUGA, Nice, France Bernard PRATE, Cannes, France Thomas PROEBSTLE, Mainz, Germany Enrique PURAS MALLAGRAY, Madrid, Spain Claudio RABBIA, Torino, Italy Zoran RANCIC, Zurich, Switzerland Donald B. REID, Wishaw, Scotland, United Kingdom Timothy RESCH, Malmö, Sweden Sonia RONCHEY, Rome, Italy Natzi SAKALIHASAN, Liège, Belgium Antoine SAUGUET, Toulouse, France Peter SCHNEIDER, Honolulu, USA Francesco SETACCI, Rome, Italy . . . . . . . . . . . . . . . . . 21 Gunnar TEPE, Rosenheim, Germany Jörg TESSAREK, Münster, Germany Matthew THOMPSON, London, United Kingdom . . . . 19 Giovanni TORSELLO, Münster, Germany Jos VAN DEN BERG, Lugano, Switzerland Isabelle VAN HERZEELE, Gent, Belgium Fabio VERZINI, Perugia, Italy David WRIGHT, London, United Kingdom
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VENOUS SESSION. Tumescent less saphenous ablation Lafoss: laser and foam J-L. Gillet Vascular Medicine and Phlebology, Bourgpoin-Jallieu, France
Laser assisted foam sclerotherapy: the Lafoss technique Foam sclerotherapy is an effective treatment of saphenous varicose veins. However, controversial data are present in literature for veins with a diameter of the saphenous trunk exceeding 8 to 10 mm; poor outcome is expected. The recent European Guidelines for sclerotherapy recommend limiting the injected volume of foam, with a maximum of 10mL of foam per session in routine cases. Indication: The LAFOS technique is a new approach in the treatment of large (saphenous trunk > 0.8 cm) incompetent great (GVS) and small (SSV) saphenous veins. METHOD The Sclerolux Holmium laser Ho:HAG 2100nm is the only laser able to reduce the diameter of the vein with no damage to the endothelium, before performing foam sclerotherapy. The Holmium laser leads to an immediate and significant reduction of the vein diameter (1st step) transforming the large vessel in a smaller one that can be treated with better chance of success with a limited volume of sclerosing foam (2sd step). This technique is an in-office procedure. No tumescent anesthesia is required. Description of the procedure (echo-guided): 1. Access vein with a short catheter (17 Ăą 18G). 2. Insert optical fiber into the vein through the catheter. 3. Carefully check the position of the fiber inside the vein. 4. Perform shrinkage of the vein by delivering light energy with a pulsed Ho:HAG holmium laser (5 W max average power with max 500mJ per pulse). There is shrinkage of the collagen fibers of the media with no damage of the intima. 5- Remove the fiber from the catheter. 6. Inject a relatively small volume of sclerosing foam through the same catheter. On average: GVS : 5-6 mL of polidocanol 3% foam SSV: 2-3 mL of polidocanol 2% foam 7. Patient can walk immediately after the procedure, wearing compression stocking. Preliminary results (Frullini A et al, PhlĂŠbologie (French) 2013; 66: 51-54) 50 patients were enrolled in a pilot study to assess feasibility and tolerance of this new procedure. A complete occlusion was observed in all patients at one-month follow-up. No complication was reported. Personal experience At 6 months and 1 year, the clinical results remained excellent. We observed no complication. In some patients a small recanalization (2-3 mm) was observed and was easily treated with a direct injection of sclerosing foam (closed needle technique).
CONCLUSION The immediate reduction of the vein caliber makes possible treatment of large veins with low volume of sclerosing foam. The LAFOS technique could represent a true enhance of foam sclerotherapy of very large veins, allowing better immediate occlusion rate and possibly better late outcome.
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Figure 1: Holmium laser Ho:HAG
Figure 2: 10-day follow-up
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VENOUS SESSION. Preservation of saphenous trunks Office Based Chiva F. Passariello Centro Diagnostico Aquarius, Napoli, Italy
INTRODUCTION The cure ìConservatrice HÈmodynamique de líInsuffisance Veineuse en Ambulatoireî (CHIVA) can be office based. The Office Based CHIVA (OB CHIVA) is aimed at transferring CHIVA procedures to specialists rooms. OB CHIVA is a systematic organization of the working environment, in order to reduce to a minimum the required resources without any change† in security1. The use of less invasive methods will be a chance for non-surgical phlebologists to choose endovenous conservative procedures other than ablative ones.
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THE CROSSOTOMY In contraposition to the traditional crossectomy, CHIVA crossotomy is a flush ligation of the SFJ respecting all the tributary of the arch. OB CHIVA uses instead the Riobamba Draining Crossotomy (RDC), where Riobamba is the town in Ecuador where the RDC was firstly performed. The RDC respects one or more tributaries of the arch, using them as washing vessels of the sapheno-femoral junction (SFJ). A limited treatment of the arch is performed and tailored in length using an endovenous procedure till the confluence or one or more draining tributaries of the trunk. Draining vessels have the aim of preserving the GSV trunk. (Fig 1) 2 THE DIAGNOSTIC ALGORITHM A simplified diagnostic procedure allows an essential ultrasound examination of the venous net following a schematic and easily readable algorithm which guides the therapeutic choices. (Fig 2) 2 The overall diagnostic procedure generally takes a few minutes and requires a quick answer to three simple questions: 1. Is the terminal valve competent/incompetent ? 2. Is the reflux confined to the GSV or deviated instead towards an incompetent GSV tributary ? 3. In the latter case, is the GSV reflux abolished by the simple digit compression of the tributary (Reflux elimination test or RET)? These are the only items required to plan an OB CHIVA therapy. The same applies also to CHIVA, though of course CHIVA diagnosis is more complex. The algorithm catches essentially and in a simple way the shunts I, I+ II and III and the subsequent therapy. However, the user is not required to know anything about shunts classification. Additional quick information are needed to allow a thorough treatment of the arch: - the number and the maximum calibre of the washing and draining vessels - the distance between the last wash and the first drain - the GSV mid-thigh calibre.
| MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
THE RDC TACTICS The Riobamba draining crossotomy (RDC) tactic is composed of a set of OB procedures. While some of them are actually applied, others instead are at the moment only proposals. Devices generally used in ablative procedures such as LASER, radio frequency, steam, mechanical devices and glue are used in this context to serve as conservative interventions for CHIVA. New techniques have also been proposed for devalvulation and tributary disconnection. THE EXPERIMENTAL DESIGN The study checks the feasibility of OB-CHIVA and gathers also data pertaining to recurrence, giving the opportunity to investigate the SFJ stump evolution, the role of the washing vessels and the arch re-canalization rate. In addition, the effect of the length of the treated saphenous vein could be also analysed. The target of the therapy is considered the SFJ closure preserving at least one washing vessel, a condition which is described in the X-Paste terminology by the 0,1 decimal code 3. However, several different results can be observed, as reported in the PASTE literature 4. In rare cases a floating thrombus occurs, peripherally or centrally directed, though it has generally no consequences 3. Performing a more complex analysis of the patient venous network, the veno-venous shunts can be detected. The SFJ RDC treatment interrupts only some of these shunts, though the comprehension of this analysis requires a greater knowledge of venous hemodynamics. A frequent follow-up is suggested in order to determine the effects of therapy and the possible evolution of the venous disease. INDICATIONS AND CONTRA-INDICATIONS The indications to the OB CHIVA procedures are the relative contra-indications to the surgical crossotomy. Local conditions like extreme obesity and general conditions too (coagulation diseases, epatopathies, cardiopathies, ...), where office based procedures are useful also to reduce the time of the intervention. There is no real contra-indication, though some difficulties could be experimented treating mainly the isolated ShIII when the devalvulation is difficult to perform, owing to a very hypoplasic peripheral GSV trunk. INTERVENTIONS Actually only a limited and anecdotal experience is available. 13 cases were treated. 6M 7F, aged 47.9 +/- 15.2 yo (32-78yo), 10RT 3LT limbs. Clinical class was mainly C2 (C1 0, C2 10, C3 0, C4 2, C5 0, C6 1). The height of the groin was 74.5 +/- 6.1 cm. The† height of the first re-entry perforator 36.3 +/- 14.2 cm. The mid-thigh GSV calibre 7.4 +/- 3.2 mm. The number of washing vessels 2.5 +/- 1.1. Maximum washing
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calibre 3.3 +/- 1.7 mm. Number of draining vessels 1.9 +/- 0.7. Maximum draining calibre 2.1 +/- 0.5 mm. As to procedures, LASER was mainly used, 12 808nm power 14w LEED 140 J/cm and 1 1470nm power 6w LEED 60 J/cm. The used pullback speed was always 0,1 cm/s. Phlebectomies were associated in 8 cases, while foam ultrasound guided sclerotherapy (FUGS) in 5 cases. The planned strategy did not match often the effected treatment. GSV length to be treated was 7.7 +/- 3.6 cm, while the effectively treated GSV length was 6.8 +/- 5.3 cm. This difference is due to errors in the pre-treatment measures, which should also take into account the difference between linear echo measures and LASER fibre length. The fibre generally follows the curve of the vein and can adhere to the venous wall, also changing the side, thus it is often not positioned in the centre of the vein. FOLLOW-UP IMMEDIATE FOLLOW-UP The immediate follow-up (1-3 days) is available in all cases and shows good clinical results in the 100% (13/13) of cases, while washing and draining were satisfying in 92% (12/13) of cases. Reflux was present in 3/13 (23%) of cases, but complete incompetence only in 8% (1/13) of cases. Reflux was ascribed to an insufficient administered energy in 2 cases, while in 1 case it was a very light reflux due to the mild incompetence of an arch tributary, used as a washing vessel. One additional case (14 cases in total) was treated with a FUGS RDC of the shorter saphenous vein (SSV) with good clinical and hemodynamic (closure) immediate result. LONG TERM FOLLOW-UP Though only an anecdotal experience is at the moment available, observed cases provide some useful suggestions. Only 4 patients, including the FUGS SSV treatment had a long term observation. In all examined cases (4/4, 100%) clinical conditions were functionally satisfying, while only 2/4 complained about aesthetical results. One of them complained for matting after FUGS at 1y, 3y and 4y, while the other one for residual tributary varicosities with aesthetic impairment at 5y. No change at 1y was recorded in the case of complete re-canalization at 3d, but in an unexplainable way clinical conditions markedly improved from C6 to C5 at 1y (complete healing of 2 ulcers and ankle circumference decrease of 1 cm). As already remarked, since the beginning, it appeared clear that due to technical problems the administered LASER energy was insufficient. The SSV FUGS case had also a symptomatic pelvic shunt which was not treated at all. After 1y,3y and 4y she still complained for the persistence of the pelvic symptoms, while only a partial refluxing re-canalization was detected by Doppler at 4y with no important hemodynamic impairment. The last case is a GSV Riobamba LASER draining crossotomy (RLDC), planned to be performed with 4 washing vessels and observed with a follow-up at 5y, showing the
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complete closure of the GSV arch below a small 3rd tributary. The closure can be described in X-Paste terminology by the 0,001107 decimal code3. The 3rd tributary however is lightly incompetent and jumps the GSV closure, transmitting below a low intensity reflux and feeding only some aesthetical tributary veins in the leg, as it was already reported before. GSV is totally occluded for 9.5 cm and a partial closure is present distally for a total of 15 cm, GSV being therefore patent for a great part of its length. Apart from the peripheral light reflux jump, this case represents then a good example of long term closure. DISCUSSION Though data are very fragmentary and incomplete, some preliminary conclusions can be drawn. Re-canalization is of course an undesirable surgical result. However, a light re-canalization in LASER and FUGS is not considered absolutely a failure, especially when the refluxing volume is negligible. With this idea in mind and limiting this remark to re-canalization, OB CHIVA endovenous procedures should be compared to corresponding ablative ones and not to surgical methods. Data are not sufficient for a reliable analysis, but it could be concluded that the greater the number of the washing vessels, the greater the probability of having a jumping and refluxing parallel channel. As the strategy isnĂt still well known, it could be useful to reduce the procedure to a planned minimum, delaying phlebectomies and FUGS to a second moment. The evolution of the intervention can exhibit unexplainable improvements, which could otherwise be masked associating several procedures. In procedure reports the preference should be given to measured parameters instead of the computed ones, as these could be unreliable depending on unregistered variations of procedure details. The X-Paste terminology should be used as much as possible in order to increase our knowledge of the GSV/SSV stump evolution. In the same way, X-PASTE can describe also the distal behaviour. Finally, it could be interesting to record the length of the patent GSV, i.e. not involved in the saphenous closure, in order to measure the re-usability of the trunk for any useful future use. THE OB CHIVA PROTOCOL A clinical protocol was designed in order to simplify diagnostic and therapeutic procedures 2. An OB CHIVA register is actually available to gather cases performed by other groups and, apart of privacy protected data, it is freely accessible to everyone on a specialized website 5. CONCLUSIONS Though the OB CHIVA experience is at the moment preliminary and anecdotal, OB CHIVA seems a promising strategy and a simplified organization of CHIVA therapy in a more friendly environment.
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The Riobamba LASER draining crossotomy (RLDC) is a LASER example of RDC. (see JVD. Volume 2013:1 Pages 13 単 20.)
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This flow chart allows a quick assessment of the venous system of the lower limbs. (see JVD. Volume 2013:1 Pages 13 単 20.)
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References
1. Passariello F. Office Based Chiva (OB Chiva). Acta Phlebol. 2011;12:26単27. 2. Passariello F, Ermini S, Cappelli M, Delfrate R, Franceschi C. The Office Based Chiva. Journal of Vascular Diagnostics. Volume 2013:1 Pages 13 単 20. DOI: http://dx.doi.org/10.2147/JVD.S49637 3. Passariello F. X-PASTE: A ready-made model for thrombosis evolution in the human. Presented at the Hemodyn 2013 Meeting, Napoli, Oct 2013. 4. Passariello F. Post Ablation Superficial Thrombus Extension (PASTE) as a consequence of endovenous ablation. An up-to-date review. Reviews in Vascular Medicine. DOI: http://dx.doi.org/10.1016/j. rvm.2014.01.003 5. T he Office Based CHIVA website, available at the address http://www.vasculab.it/obchiva/obchiva.xml at the date of May 24th,2014.
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VENOUS SESSION. Preservation of saphenous trunks External Valvuloplasty S. Camilli, D. Camilli Private Practice, Rome, Italy
INTRODUCTION The strategy for the treatment of varicose veins (VVs) of the lower limbs is mainly based on the ablation of the greater saphenous vein (GSV) by stripping or intravenous thermal ablative techniques. Recent RCTs show that any ablative technique involves a remarcable varicose recurrences at 5 years f-u 1-2. Some other RCTs considered the conservative strategy (CHIVA) Vs. the ablative ones; at more than 5 years f-u,†the CHIVA series showed results of about 50% better than ablative in terms of relapsing veins 3-4. Since a weak point of the CHIVA strategy is the sapheno-femoral junction (SFJ) ligation/disconnection, a technique that allows the SFJ viability should further reduce the VVs recurrence after GSV sparing procedures. The report shows the technique and results of the SFJ stretching valvuloplasty (SV) combined with GSV sparing procedures. MATERIAL AND METHOD A cumulative personal experience of 45 operations of SFJ stretching valvuloplasty (SV) is presented. In case of incompetent SFJ with US-visible valve and floating cusps, an oval shaped external support (OSES) was placed about the valve to be repaired and was sutured to the apex of the opposite commissures [Figure 1]. Being elastic and properly oversized against the actual valve diameter, the device exerts a gentle stretching action onto the opposite inter-commissural walls. In so doing it stretches the inter-commissural diameter and consequently reduces the loosening of the valve cusps and finally it restores the SFJ competence thus regaining the valve function 5-6. 42 SV operations have been performed using OSES device (SV-OSES) for primary VVs (pVVs) and 3 operations for secondary VVs (sVVs) onto the SFJ. In all cases the incompetent tributaries were also treated by hemodynamic selective disconnection (CHIVA strategy) or stab avulsion (M¸ller technique) or US-guided foam sclerotherapy. RESULTS At 5 years f-u on 21 out of 42 cases with pVVs, the Duplex scanning showed the SFJ full competence in 16, while moderate reflux in 3 and failure in 2 cases were shown. 12 pts had a repeated foam sclerosis or VVs stab avulsion. On the 3 cases with sVVs, all resulted in a regained SFJ competence at 20th, 16th and 3rd month f-u, respectively. None of 24 cases had GSV ablation until now; all patients declared a QoL improvement and CEAP class lowering.
CONCLUSIONS The SV-OSES operation is a GSV sparing technique in primary and secondary VVs. The strategy combining SFJ valvuloplasty with GSVís trunk preservation procedures promises to slow down and to decrease the recurrencies, both in pVVs and sVVs, and finally to give better results than ablative ones at late f-u. A wider and multicentre clinical experience on SV-OSES is needed and a more conservative culture in VVs treatment is suggested.
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References
1. Disselhoff BCVM, der Kinderen DJ, Kelder JC, Moll FL. Five-year results of a randomized clinical trial of endovenous laser ablation of the great saphenous vein with and without ligation of the saphenofemoral junction. Eur J Vasc Endovasc Surg 2011;41:685-90. 2. Rasmussen L, Lawaetz M, Bjoern L, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation and stripping of the great saphenous vein with clinical and duplex outcome after 5 years. J Vasc Surg 2013;58:421-26. 3. Carandina S, Mari C, De Palma M, et al. Varicose vein stripping vs haemodynamic correction (CHIVA): a long term randomised trial. Eur J Vasc Endovasc Surg 2008;35:230-37. 4. ParÈs JO, Juan J, Tellez R, et al. Varicose vein surgery: stripping versus the CHIVA Method: a randomized controlled trial. Ann Surg 2010;251:624-31. 5. Camilli D, Camilli S. The external stretching valvuloplasty: a new technique for venous valve repair. J Vasc Endovasc Surg 2012;19:37-40. 6. Camilli S, Camilli D. The sapheno-femoral junction valvuloplasty in the post-thrombotic syndrome: a proposal with the use of a new device. Veins and Lymphatics 2014 (in press).
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VENOUS SESSION. New trends Iliac vein’s stenting in pelvic congestion syndromes O. Hartung Service de Chirurgie Vasculaire, CHU Nord, Marseille, France
Pelvic congestion syndrome (PCS) is mainly due to reflux into ovarian veins or branches of the internal iliac veins. Ilio-caval obstructive disease can also cause PCS and we herein report our experience with stenting in women presenting PCS. MATERIAL AND METHODS All patients admitted in our department for the treatment of chronic obstructive lesions of the iliac veins had clinical examination looking for PCS symptoms. Duplex-scan and CT or MRV were performed in all patients. In case of suspected nutcracker syndrome (NCS) or left ovarian vein (LOV) incompetence, a phlebography was performed with evaluation of the reno-caval gradient.The procedure was performed through percutaneous approach under local anesthesia plus sedation to deploy self-expanding stents.
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RESULT 83 patients were suffering from PCS but 14 which had an associated NCS were excluded. 69 women (median age 42 years) were included in the study. All were suffering from PCS. Lower limbs symptoms were present in 59 cases. The etiology of the obstructive lesion was primary in 59 cases and secondary in 10 cases. 15 patients had associated LOV reflux. Technical success rate was 100%. Left ovarian vein embolization was performed during the same procedure in 15 cases. No periprocedural complications occurred and the median postoperative length of stay was 1 day (range 1-4). Median follow-up was 32 months (range 1-150). 3 restenosis occurred at 2, 4 and 8 months; one was treated by in-stent balloon angioplasty and 2 by additional stenting. Primary and assisted primary patency rates were respectively 95% and 100% at 5 and 10 years. Three patients needed subsequent embolization that improved them.All patients but 5 were significantly improved (31 were asymptomatic regarding PCS). CONCLUSION Pelvic congestion syndrome is rarely due to ilio-caval obstructive disease. It can be treated by venous stenting safely and with good clinical results.
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Thoracic branch stent grafts complications How does EVAR affects the treatment and outcome of type A dissection P. Bergeron1, T. Abdulamit, JC. Trastour 1. Marseille, France
Type A dissection is a typical example of surgical emergency, nevertheless some high risk patients are still excluded. Indications of EVAR are the following: - In acute type A (<48h) EVAR is not advised due to the risk of rupture. - For subacute type A (D3-D15) EVAR must be discussed for octogenarian or HRP who survived the disease. - For evolving chronic dissection EVAR can be of great help in the following: residual post surgical dissection, chronic dissections arch dissecting aneurysm and visceral malperfusions. The anatomic requirements are sustained to the site and size of the tear on the ascending aorta whatever the extension of the dissection is and to the proximal and distal landing zones. To make safer the procedure it is advised to place a Guide Wire from the humeral artery in the IA for a bailout (periscope or cheminey). A Carotido carotid bypass from right to left can also increase the length of the ascending aorta. Devices with proximal tip-capture make the placement of the Stent graft easier with the adjunct of rapid pacing and/ or adenosine administration. Anticipating these complications is possible thanks to the adjunct of IA bypass to standard repair. No doubt that outcome can benefit from endovascular repair.
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Example of Subacute Type A dissection of an HR octogenarian favorable to EVAR
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Thoracic branch stent grafts complications Hybrid repair C. Ferrer Vascular Surgery, San Camillo Forlanini Hospital, Rome, Italy
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Open repair of thoracoabdominal aortic aneurysms is associated with significant morbidity and mortality. The need of a hybrid approach is based on the reduced operative stress approaching only the abdominal cavity, which may reduce complications and improve outcome. Hybrid approach allows, by surgical visceral debranching, the distal fixation for endovascular stentgraft. When thoracic endovascular aneurysm repair became available in 2005, there was much enthusiasm for this hybrid technique in order to extend the repair also for high risk patients with TAAA1. Even if hybrid approach to TAAA may be advantageous in selected population of patients who are considered at high risk for open TAAA repair, most series report similar perioperative morbidity and mortality if compared to open series. Furthermore, with the continuous improvement of branched and fenestrated stentgraft technology, the hybrid approach might be considered outdated. In addition, the safety, effectiveness, and long-term performance cannot yet be established, and lifelong follow-up must be taken into account to assess the ongoing patency of the grafts2.
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References
1. Yamaguchi D, Jordan WD jr. Hybrid Thoracoabdominal Aortic Aneurysm Repair: Current Perspectives. Semin Vasc Surg 2012;25:203207. 2. Moulakakis KG, Mylonas SN, Avgerinos ED, Kakisis JD, Brunkwall J, Liapis CD. Hybrid Open Endovascular Technique for Aortic Thoracoabdominal Pathologies. Circulation 2011;124:2670-2680.
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Thoracic branch stent grafts complications Fenestrated devices (custom and homemade) T. Azuma Tokyo Women’s Medical University, Tokyo, Japan
OBJECTIVE Short- and mid-term data regarding the use of pre-curved, fenestrated endografts have shown that the devices are both safe and effective in carefully selected patients. The first generation of the product was limited to patients with proximal landing zones of more than 20 mm. The next generation of these endografts has been refined to enable treatment of patients with shorter proximal seal zones (<20 mm), using smaller fenestrations and a greater diversity of skeletons. We reviewed the clinical studies involving the next-generation product and analysed the morphological characteristics of aortic arch aneurysms that were successfully treated. METHODS Next-generation endografts were used to treat 393 patients with aortic arch aneurysms, at 35 medical institutions during 2010 and 2011. There were 371 (94%) patients with sealing zones <20 mm, and 244 (62%) patients with sealing zones <15 mm. The proximal sealing length was 2ñ35 mm (14.2 ± 5.1 mm).
RESULTS Technical success was achieved in 390 patients (99.2%). Of the treated patient population, 6 patients died, 7 experienced strokes, and 17 were subsequently identified to have type I endoleaks. In cases with proximal landing zones <15 mm, the aneurysm was more likely to develop an endoleak. The proximal sealing zones (11 ± 12 mm vs. 9 ± 13 mm) were not significantly associated with the development of endoleaks, but the proximal aortic diameters were (34.0 ± 13.3 mm vs. 36.6 ± 6.3 mm; P < 0.01), in the univariate analysis. In the discriminant analysis, the maximum length of the aneurysm was the only factor that was predictive of type I endoleaks (73 ± 55 mm vs. 97 ± 59 mm; P < 0.001). CONCLUSION The next generation of pre-curved, fenestrated endografts show promise as devices for aortic arch aneurysms with less than a 15-mm proximal sealing zone. These devices have a significant advantage in cases where the landing zone has a short neck. However, more refinement is necessary to prevent type I endoleaks, so that these devices can be used with aortic vessels with large proximal diameters and large aneurysms.
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New developments in carotid stenting Taped Live CAS with Direct Carotid Approach using Silk Road Flow Reversal N. Hopkins Suite Buffalo, USA
CASE REPORTS AND VIDEOS WITH MCQ 73-year old male with multiple comorbidities: CAD, CABG, DM II. Work up for syncope revealed asymptomatic 85% right ICA stenosis. Poor candidate for CEA due an endomorphic body habitus and a lesion that extends well up into C2 and Poor candidate for transfemoral CAS due to tortuous access
with Type II aortic arch and CCA tortuosity. The Direct Carotid (Silk Road) approach with flow reversal employs a small surgical exposure of the Common Carotid Artery above the clavicle, insertion of short sheath and flow arrest and reversal through a filter into the femoral vein during stent placement.
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New developments in carotid stenting CAS 2014: Where are we for asymptomatic patients? A. Halliday University of Oxford, Oxford, United Kingdom
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ACST-2 is one of the largest trials ever conducted to compare carotid artery stenting (CAS) with carotid endarterectomy (CEA). †By April 2014 over 1,450 patients had been recruited from 100 mostly European centres. †Patients with severe asymptomatic carotid stenosis requiring revascularization are entered into ACST-2 when CEA & CAS are both possible, but where there is uncertainty as to which is procedure is more appropriate.†In April 2014, verified data was available on 1,330 randomised patients (912 men, 418 women) whose median age was 72 years (SD +/- 8.1). 31% patients were diabetic, most (96%) had ipsilateral stenosis of 70-99% (median 80%) with a contralateral stenosis of 50-99% in 30% patients and contralateral occlusion in 8%.†Patients were on appropriate medical treatment at randomisation and at 1-month follow-up (86% anti-hypertensive, 84% lipid lowering, 96% anti-thrombotic) though, as expected patients having CAS were more likely to take dual anti-platelet therapy for at least a month after the procedure. The mean time from randomisation until procedure was 24 days and patients had a
| MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
mean follow-up of 1.6 person years. At follow-up, 2% patients had crossed over to the non-allocated procedure. Annual yearly follow-ups show that patients continue to take good medical treatment with detailed recording of numbers and types of medication. †At the Trialís Data Monitoring Committee Meeting in April 2014, blinded combined interim results for 30-day mortality and major morbidity were reported. For 1,045 patients undergoing intervention with at least 1 month follow-up and Rankin Scoring at 6 months for any stroke, the overall serious cardiovascular event rate of peri-procedural (within 30 days) disabling stroke, fatal myocardial infarction and death was 1.0%.This compares favourably with results from ACST-1, with a peri-operative risk of 1.7%. †ACST-2 plans to recruit several thousand patients, with follow-up for a minimum of 5 years, enabling us to determine any important differences between the procedures and, for some† subgroups, information on those who may particularly benefit from one procedure or the other.
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New developments in carotid stenting Asymptomatic carotid stenoses should be treated C. Buckley Baylor Scott & White Health Care and Central Texas Veterans Health Care System, Temple, United States
Should asymptomatic carotid stenosis be treated? The answer, from a conservative vascular surgeon, is “yes”. The real questions should be: what are the indications for treatment; when do you treat; and what treatment methods are available ñ best medical therapy, endarterectomy or angioplasty and stent. Current practice management for carotid stenosis is based on 30+ year old clinical trials comparing available medical management to carotid endarterectomy (CEA). Two of the more widely quoted trials are NACET ñ a randomized trial from 1981 – 1994 looking at symptomatic (70% - 99%) carotid stenosis and ACAS - 1983 - 2003 - enrolling subjects in a randomized asymptomatic (50% - 99%) trial. Historically, medical management for carotid disease included risk factor modification plus aspirin; no statin or current antiplatelet therapies and no modern agents for managing comorbidities. Results of this form of therapy showed a 3% per year preven-
tion benefit from CEA and a 6% stroke / death risk at 30 days in the symptomatic group. In the asymptomatic group, there was a 0.5% - 1% per year benefit from CEA and a 3% stroke / death risk at 30 days. In today’s practice, medical management of co-morbidities and risk factors has dramatically improved with the incidence of stroke progressively declining to 0.5% per year. In the CREST Trial, CEA outcomes improved the stroke and/ or death rate to 4.7% in the symptomatic group and 2.7% or less in the asymptomatic group. Carotid stenting (CAS) outcomes showed the stroke and/or death rate in the symptomatic group as 6.4% and 4.5% in the asymptomatic group. There is no benefit or level I or II evidence to support screening risk stratified populations with Duplex Carotid Imaging. The best overall therapy, in patients with asymptomatic carotid disease, is aggressive medical management with statins, antiplatelet agents, and optimal risk factor control and treatment of comorbidities.
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New developments in carotid stenting Case reports and videos with MCQ A safe cervical access for CAS using US guidance and closing device P. Bergeron Marseille, France
PURPOSE To describe a safe approach for direct percutaneous carotid access for carotid angioplasty and stenting (CAS) in order to reduce the risk of stroke from debris embolization that can occur during catheter manipulation in the aortic arch during femoral access. TECHNIQUE An ultrasound-guided, direct micropuncture of the common carotid artery (CCA) is performed for CAS and followed by the use of a closing device to avoid bleeding complications.
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CONCLUSION This approach has a low rate of neurologic and access site complications. Our experience suggests that, with percutaneous direct carotid access, the indications for CAS could be expanded to include difficult anatomies and high-risk patients, and certain emergent situations that warrant easy and rapid access to the common carotid artery.
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EVAR challenges: follow-up, endoleaks and complications Debate If you donâ&#x20AC;&#x2122;t have an effective follow-up program, donâ&#x20AC;&#x2122;t do EVAR M. Thompson St Georges, London, United Kingdom
EVAR is associated with a specific range of late endograft-related complications. Surveillance is considered mandatory because if these complications are not identified and managed appropriately, aneurysm reperfusion can result in late rupture and mortality. A significant minority of patients require re-intervention after EVAR. All patients should continue to undergo surveillance after EVAR but that the frequency of surveillance should be greatest in those predicted to be at highest risk of endograft complications. The need for surveillance after EVAR is determined by the incidence of endograft complications, which has been previously summarized in a systematic review of the literature. The re-intervention rate at 5 years was demonstrated to be 18.5 percent. The study also demonstrated that the requirement for secondary interventions after EVAR continued through the lifetime of the graft. Combined re-intervention-free survival estimates were found to demonstrate a linear progression with 89.9 percent, 86.9
percent and 81.5 percent of grafts requiring no secondary intervention at two, three and five years respectively. Overall, almost one in five patients will require re-intervention within five years of EVAR, highlighting the essential role of surveillance in some form. The risk of developing endograft complications after EVAR may not be homogenous, and evidence suggests that individual patients may have predictably greater or lesser risk of long-term endograft failure. The ability to characterize a subgroup of patients at high risk of endograft complications might allow surveillance to be targeted. Evidence has increasingly suggested that endograft complications are related to aortic morphology rather than physiology or comorbidity. To conclude, there is no system at present which allows stratification of patients that require no surveillance, which therefore remains mandatory.
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EVAR challenges: follow-up, endoleaks and complications Enlargement of the proximal neck C. Ferrer Vascular Surgery, San Camillo Forlanini Hospital, Rome, Italy
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Endovascular repair of abdominal aortic aneurysm (EVAR) has shown significant advantages if compared with open repair (OR), especially in perioperative period1,2, but specific complications such as endoleak and migration, may negatively affect the long-term durability of endovascular approach3. Aortic neck dilatation (AND) was identified in published literature as a predictor of migration, type I endoleak and reintervention4,5. The continuous dilatation of the infrarenal aortic segments is observed in healthy people as consequence of ageing6, as well as in surveilled population with small AAA7 or in patients undergoing OR8-12 or EVAR4,13,14 for AAA. Several authors investigated proximal neck modifications after abdominal aortic intervention. What we learned from literature is that AND is common after OR and EVAR with an incidence rate from 19% to 43%8,15 and 13% to 59%16,4 respectively. On the other hand, the heterogeneity of studies about AND in terms of number of patients, duration of follow-up and neck measurement, makes data interpretation difficult. Several hypotheses have been advanced regarding the pathogenesis of AND after EVAR as well as the presence of any predicting factors. The structural reaction of the aortic wall to the stentgraft is unclear, and the role of oversizing or suprarenal fixation in AND pathogenesis has never been confirmed17-20. All these data support the hypothesis that continuous AND is rather a perpetuation of the aneurysmal disease process than related to specific interactions of different types of stentgraft with the aortic wall. References
1. Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG. Comparison of endovascular aneurysm repair with open repair in pa- tients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004;364:843-8. 2. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, et al. A randomized trial comparing conventional and endovas- cular repair of abdominal aortic aneurysms. N Engl J Med 2004;351: 1607-18. 3. Le Bas JF. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 2005;365:2179-86. 4. Cao P, Verzini F, Parlani G, Rango PD, Parente B, Giordano G, et al. Predictive factors and clinical consequences of proximal aortic neck dilatation in 230 patients undergoing abdominal aorta aneurysm repair with self-expandable stent-grafts. J Vasc Surg 2003;37:1200-5.
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5. Dillavou ED, Muluk S, Makaroun MS. Is neck dilatation after endovascular aneurysm repair graft dependent? Results of 4 US Phase II trials. Vasc Endovasc Surg 2005;39:47-54. 6. Sonesson B, Lanne T, Hansen F, Sandgren T. Infrarenal aortic diameter in the healthy person. Eur J Vasc Surg 1994;8:89-95. 7. Yau FS, Rosero EB, Clagett GP, Valentine RJ, Modrall GJ, Arko FR, et al. Surveillance of small aortic aneurysms does not alter anatomic suitability for endovascular repair. J Vasc Surg 2007;45:96-100. 8. Lipski DA, Ernst CB. Natural history of the residual infrarenal aorta after infrarenal abdominal aortic aneurysm repair. J Vasc Surg 1998;27:805-11. 9. FalkensammerJ,OldenburgWA,BieblM,HuglB,HakaimAG,Crook JE, et al. Abdominal aortic aneurysm neck remodeling after open aneurysm repair. J Vasc Surg 2007;45:900-5. 10. Liapis C, Kakisis J, Kaperonis E, Papavassiliou V, Karousos D, Tzonou A, et al. Changes of the infrarenal aortic segment after conventional abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2000;19:643-7. 11. Sonesson B, Resch T, Lanne T, Ivancev K. The fate of the infrarenal aortic neck after open aneurysm surgery. J Vasc Surg 1998;28:889-94. 12. Illig KA, Green RM, Ouriel K, Riggs P, Bartos S, DeWeese JA. Fate of the proximal aortic cuff: implications for endovascular aneurysm repair. J Vasc Surg 1997;26:492-9; discussion 499-501. 13. Napoli V, Sardella SG, Bargellini I, Petruzzi P, Cioni R, Vignali C, et al. Evaluation of the proximal aortic neck enlargement following endovas- cular repair of abdominal aortic aneurysm: 3-years experience. Eur Radiol 2003;13:1962-71. 14. Sampaio SM, Panneton JM, Mozes G, Andrews JC, Noel AA, Kalra M, et al. AneuRx device migration: incidence, risk factors, and conse- quences. Ann Vasc Surg 2005;19:178-85. 15. Oberhuber A, Buecken M, Hoffmann M, MD, Orend KH, MD, M_ hling BM. Comparison of aortic neck dilatation after open and endovascular repair of abdominal aortic aneurysm. J Vasc Surg 2012;55:929-34. 16. Makaroun MS, Deaton DH. Is proximal aortic neck dilatation after endovascular aneurysm exclusion a cause for concern? J Vasc Surg 2001;33:S39-45. 17. Sampaio SM, Panneton JM, Mozes G, Andrews JC, Noel AA, Kalra M, et al. Aortic neck dilation after endovascular abdominal aortic aneurysm repair: should oversizing be blamed? Ann Vasc Surg 2006;20:338-45. 18. Wever JJ, de Nie AJ, Blankensteijn JD, Broeders IA, Mali WP, Eikelboom BC. Dilatation of the proximal neck of infrarenal aortic aneu- rysms after endovascular AAA repair. Eur J Vasc Endovasc Surg 2000; 19:197-201. 19. Badran MF, Gould DA, Raza I, McWilliams RG, Brown O, Harris PL, et al. Aneurysm neck diameter after endovascular repair of abdominal aortic aneurysms. J Vasc Interv Radiol 2002;13:887-92. 20. Leurs LJ, Stultiens G, Kievit J, Buth J. Adverse events at the aneurysmal neck identified at follow-up after endovascular abdominal aortic aneu- rysm repair: how do they correlate? Vascular 2005;13:261-7.
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EVAR challenges: follow-up, endoleaks and complications Rescue EVAR for ruptured AAA: clinical success doesn’t meen technical success F. Setacci 1, L. di Marzo 1, C. Setacci 2 1. «Sapienza» University of Rome, Roma, Italy 2. University of Siena, Siena, Italy
We reported two cases of RAAA treated with emergent EVAR: 82-years old men was admitted to our ER for severe hypotension and the emergent CTA showed a RAAA with short and angulated proximal aortic neck. so an endovascular approach was planned. Under local anaesthesia we deployed an Endurant I stent-graft and bilateral iliac extension was required with good angiographic result. The post-operative course. The 1-month CTA showed a huge type Ia endoleak due to a stent-graft dislocation and so a proximal aortic extension Endurant II was required. The angiographic result showed sill the presence of the endoleak and so a new ballooning of the proximal sealing zone was performed protecting the left renal artery with a 0.035 guidewire. Then we decided to fix the endograft to the aortic wall using the EliFX endoanchors to avoid further dislocations with a nice angiographic result. However the 3-months
CTA control showed a huge type III endoleak due to a left limb dislocation. So an endovascular relining was successfully performed. No endoleaks was detected at 12-months CTA.80-year old men was admitted to our ER for hypovolemic shock due to a RAAA detected at emergent CTA. EVAR was planned with Endurant stent-graft with a nice angiographic result. The post-operative course was uneventful. One month CTA showed a small type II endoleak and so we decide to follow the patient. However the 3 months CTA showed an expansion of the sac and so a coil embolization was planned with a satisfactory result. The followed CTA control showed the persistence of the type II endoleak associated with a type Ib endoleak due to a proximal migration of the right limb. A new coil embolization with a right limb extension was performed with a nice angiographic result. No endoleaks was detected at the next CTA.
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EVAR challenges: follow-up, endoleaks and complications Infected stent-grafts Conservative, endovascular relining or conversion L. Chiche, J. Gaudric, C. Jouhannet, T. Khalife, C. Goulfier, F. Koskas CHU Pitié-Salpétrière, Paris, France
As the indications and use of EVAR expand, the number of patients presenting with an infected stent-graft increases. Although rare, this potentially devastating complication may be under-recognized. Stent-graft infection should be suspected in patients who present with clinical signs of acute or chronic infection or with radiological signs such as fluid or aeric collection surrounding the stent-graft. Sac expansion without evidence of endoleak is also possible. The management of aortic stent-graft infection depends on the patient’s clinical status, the presence of sepsis, the patient’s comorbidities and the microorganisms involved. Theoretically, eradication of infection implies complete explan-
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tation of the prosthetic graft and in situ or extra-anatomic revascularization. Endovascular relining might only be used as a bridge therapy in case of life-threatening aortoiliac rupture. Poor-risk patients, who probably represent up to 60% of cases, might benefit from conservative treatment, which variably associates systemic or local antibiotherapy sometimes combined with percutaneous or surgical drainage of infected collections and tissues. Indications, technical modalities and specific outcomes of these three options will be discussed based on the author’s experience and on literature findings.
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BTK and CLI: how to succeed? Developing concepts what do we really know about pedal angiosomes? When is the collateral circulation adequate to heal the foot through indirect revascularization and how do we know when we have done enough? V-A. Alexandrescu Princess Paola Hospital, Marche-en-Famenne, Belgium
Since its first anatomical description made by Taylor in 1987, 1 the Angiosome model gradually acquired new therapeutic perspectives in several surgical disciplines. For contemporary revascularization techniques, this theory adds new insights in evaluating and restoring arterial blood flow in specific «wound-oriented» limb areas. 2, 3 The main six angiosomes of the lower leg were previously detailed and will not be listed in this synopsis. Recent clinical observation in CLI refines Pedal Angiosomes utilization by studying both, their morphological and physiological implications in revascularization and wound recovery, in a dynamic perspective. 2-5 From a structural point of view, the inferior limb arteries were divided in several ranks of macro- and microcirculatory sequences. 5-7 In this categorization, the main angiosomes arteries and their appended large collaterals (around 1mm diameter, including the foot arches and the metatarsal perforators) could be assimilated into the same rank (the 3rd), separately from the medium-sized and small collaterals (<0.5 mm, the 4th level) and apart from the arterioles (the 5th) and the capillaries (the 6th stage), respectively. 5 From a physiological perspective, the same 3D Angiosomes (gathering the skin and underlying tissue) are subject to several flow redistribution phases. These stages can be designated as initiatory (minutes), early (hours) and retarded (days to weeks) steps of collateral reperfusion. 4, 8, 9 How can we evaluate the genuine capacities of each collateral pattern as to effectively assist indirect revascularization? What threshold of perfusion could be recognized as to predict correct wound healing? Our interventional group shares the presumption that, only a group of complementary exams may appropriately explore the whole of the macro and the microcirculatory collateral perfusion in a dynamic evaluation. 2, 5 Considering the perioperative evaluation (the early redistribution period): a) The macrocirculation assessment: By using «on table» angiography (that allows maximal spatial resolution and detection of > 500 micrometers-diameter collaterals), coupled to the «Indocyanine green» angiography (ICGA), useful information on each wound-related «large» to «small» collateral patterns could be acquired. 3, 10 b) Concerning the microcirculation: Real time skin perfusion pressure (SPP), 11 coupled to the tissue oxygen saturation
foot-mapping (StO2) and/or the postoperative transcutaneous oxygen pressure (TcpO2), may complete skin perfusion evaluation around the ischemic ulcer. 2, 5, 11 Focusing the delayed reperfusion period (the arteriogenesis and angiogenesis processes in specific angiosomes), the utilization of (99mTc) Scintigraphy, the PET and the SPECT scan assessment were equally described. 12 In conclusion, despite soaring technologies conceived for tissue perfusion evaluation, no method alone has proven so far enough reliability as to predict regular tissue healing following indirect revascularization. References
1. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental studies and clinical applications. Br J Plast Surg. 1987; 40(2): 113-141. 2. Alexandrescu V, Hubermont G, Philips Y, et al. Selective angioplasty following an angiosome model of reperfusion in the treatment of Wagner 1-4 diabetic foot lesions: practice in a multidisciplinary diabetic limb service. J Endovasc Ther. 2008; 15: 580-593. 3. Neville RF, Attinger CE, Bulan EJ, et al. Revascularization of a specific angiosome for limb salvage: does the target artery matter? Ann Vasc Surg. 2009;23(3):367-73. 4. Schaper W. Collateral circulation, past and present. Basic Res Cardiol 2009;104(1): 5-21. 5. Alexandrescu V. The angiosome concept: anatomical background and physiopathological landmarks in CLI, in: “Angiosomes applications in Critical Limb Ischemia: in search for relevance.” Ed. Minerva Medica Publ. 2012; 1-30 and 71-88. 6. Williams PL, Warwick R, Dyson M, et al. Angiology, blood vessels. in “Grayís anatomy.” 1996 Ed. Churchill Livingstone; 682-694. 7. Bouchet A, Cuilleret J. Topographic anatomy of the inferior limb. 3rd Ed. Simep Publ. Masson, 1995. 8. Ziegler MA, Distasi MR, Bills RG, Miller SJ, Alloosh M, Murphy MP, et al. Marvels, mysteries and misconceptions of vascular compensation to peripheral artery occlusion. Microcirculation 2010;17(1): 3-20. 9. Cai W, Schaper W. Mechanisms of arteriogenesis. Acta Biochim Biophys Sin. 2008; (1): 681-692. 10. Yamamoto M, Orihashi K, Nishimori H, et al. Indocyanine green angiography for intra-operative assessment in vascular surgery. Eur J Vasc Endovasc Surg. 2012; 43: 426-432. 11. Kawarada O, Yokoi Y, Higashimori A, et al. Assessment of macro- and microcirculation in contemporary critical limb ischemia. Catheter Cardiovasc Interv. 2011; 10: 1-8. 12. Orbay H, Hong H, Zhang Y, et al. PET/SPECT imaging of hindlimb ischemia: focusing on angiogenesis and blood flow. Angiogenesis 2013; 16(2): 279-287.
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BTK and CLI: how to succeed? New tools Bifurcated BTK stents: when and how to do it G. Coppi, R. Silingardi, A.Lauricella Department of Vascular Surgery, Nuovo Ospedale Civile Santâ&#x20AC;&#x2122;Agostino - Estense Baggiovara, University of Modena and Reggio Emilia, Italy
The results associated with percutaneous transluminal angioplasty (PTA) of the tibial arteries have by now matured. PTA/ stenting is beginning to obtain consensus in selected cases. However, in ostial lesions of the popliteal and tibio-peroneal bifurcations the use of PTA with or without stenting risk to jeopardise at least one of the treated arterial zones while the concept of angiosome tells us that at least in the extended lesions of feet the recovery could by inprouved by a recanalistion of two vessels. On the other and, like at the level of coronary arteries the possible evolution of arterisoclerosis in the long term in one vessel can by compensate with the maintenance of sufficient perfusion of the secon vessel. For this purpose we have used the bifurcated stent Nile Croco (Minvasys, Genevilliers,
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France) proposed first for the coronary arteries. The advandage is the easy use and the tapered shape of the balloon of the send branch and the possibilty to place the first stent and after the adjunctive stents in the distal vessell only if needed. The approach can be obtained with a 5 F. introducer and 0.14 duoble guide wire without real risck of troublesome problems. We have treated with Nile Croco 23 cases from 2006 to 2009 obtained satisfatory results and the succes was confirmed in the subsequent period. And to day this is the usual procedure in case of lesions at the artery biforcation of below the knee arteries.
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Choosing covered stents History of covered stents for small and medium size vessels L. Inglese San Donato Milanese, Italy
The practice of coronary and peripheral interventions has been plagued by risk of vessel rupture requiring in most cases an urgent surgical repair. With the advent of bare metal stents the risk was persisting. Moreover with BMS the presence of discrete aneurysm lesions and the protrusion through stents struts of soft plaque or thrombus could not be overcome. To address all of these problems, homemade attempts in rescuing a vessel rupture, either iatrogenic or post traumatic were conducted sewing a PTFE or Dacron tissue on a BMS (Palmaz Stent). in the early 90â&#x20AC;&#x2122; a Swedish Company, Jomed from Helsingfors developed for coronary and peripheral use a sandwich covered stent: the Jomed stent graft that after
deployment and histological studies in pigs was first implanted in 1992 in a saphenous vein graft aneurysm. In the same years an 8 mm stent graft was implanted in an ICA for a soft plaque critical stenosis. Control at 8 yrs. showed persistent good patency. All these stent grafts were balloon expandable covered stents. At the same time Gore (Flagstaff, USA) developed a self-expanding stent for medium size vessels with a nitinol skeleton embedded in a PTFE fabric called Hemoban. Release of the stent was obtained by a pull off mechanism with automatic self-expansion, thanks to the nitinol frame. In the beginning some caused problems, overcome later in the amelioration of the product.
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Choosing covered stents World clinical experience with TriVascular a Ovation system Z.R Krajcer Texas Heart Institute, Houston, United States
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The Ovation Prime system is FDA-approved to treat the widest range of anatomies with an innovative, less invasive, clinically proven solution for endovascular abdominal aortic aneurysm repair (EVAR). At 14F, the ultra-low profile system enables smooth access to the aneurysm. Low permeability PTFE enables effective aneurysm exclusion and device patency. Staged deployment of suprarenal stent allows simple and precise placement. Polymer-filled sealing ring creates a custom seal and protects the aortic neck. Conformable, kink resistant iliac limbs are designed to reduce risk of occlusion. The Ovation Global Pivotal Study was carried on in Chile, Germany, and USA in 161 patients (pts). The technical success, freedom from rupture, freedom from open repair, freedom from type I&III endoleak, and freedom from migration was 100% at 2 years of follow-up. Freedom from aneurysm enlargement was 96%. The 3-year results from the EU cohort in 30 pts revealed that freedom from rupture, freedom from open repair, freedom from type I&III endoleak, and freedom from migration was 100%. Freedom from aneurysm enlargement was reported to be 86%. A multicenter, prospective,
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post-market study of the Ovation and Ovation Prime is also available in 501 pts enrolled at 30 sites across Europe. Technical success was 99.6%. Freedom from rupture and conversion to open surgery was 100%. Freedom from type I&III endoleak, freedom from migration and freedom from iliac limb occlusion was also 100% at 2 years of follow-up. Freedom of aneurysm enlargement at one year was 99.1%. As of July 31, 2013, almost 2,000 patients had been treated with the Ovation and Ovation Prime worldwide with similar results as reported in the pivotal trial and post-market registry. Over 3000 patients worldwide have been treated with Ovation and Ovation Prime, with 25% of the experience in a tightly controlled study or registry (161 patients in the Ovation Global Pivotal Study, 77 patients in the Ovation Continued Access Study, 501 patients in the OVATION Post Market Registry). Patient demographics, anatomical characteristics, and procedural characteristics indicate a challenging patient cohort. Worldwide commercial experience mirrors the excellent clinical results achieved to date.
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CTO management Long stenting for CTO management Y. GouĂŤffic Department of vascular surgery, institut du thorax, CHU de Nantes, Nantes, France
Recent advances in endovascular techniques have led to widespread applicability of endovascular repair for more severe femoropopliteal lesions. Even though lesions are more distal and longer, the technical success does not seem to be altered. Successful recanalisation of TASC C and D lesions exceeds 80%.In addition, the use of new techniques and devices such as retrograde approach and re-entry catheters improves the technical success rates following failed initial procedure. According to some authors, failure of endovascular repair does not preclude the possibility of infrainguinal bypass. Thus, the use of primary stenting to treat femoropopliteal occlusive lesions has shown the most promising outcomes. However, primary stenting for longer femoropopliteal lesions is controversial because of the high risk of stent
fracture. Newer generations of longer nitinol self-expanding stents could allow endovascular treatment of longer femoropopliteal lesions thanks to their resistance to compression and fracture in this tortuous physical environment. In few studies, primary stenting of TASC C and D lesions appears to be safe and efficient given the high-sustained clinical improvement and the low rate of ISR. Endovascular treatment of such long and severe lesions exposes to high rate of stent fractures, which should not be a concern given their low clinical impact. Early narrow clinical and duplex scan follow-up of long stents is mandatory to detect potential thrombosis and ISR events. Primary stenting of TASC C and D lesions needs ongoing surveillance and longer follow-up, given the high rate of CLI.
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a p e e r F
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s r pe
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Endovascular treatment of internal carotid artery aneurysm under protection Rumas Aslam
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| FREE PAPERS 2014 | TUESDAY JUNE 10
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| ORAL PRESENTATIONS |
Perioperative aortic dissection rupture after endovascular stent graft placement for treatment of type B dissection Jian-fang Luo Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, China
BACKGROUND The perioperative aortic dissection (AD) rupture is a severe event after endovascular stent graft placement for treatment of type B AD. However, this life-threatening complication has not undergone systematic investigation. METHODS The medical record data of 563 Stanford type B AD patients who received thoracic endovascular repair from 2004 to December 2011 at our institution were collected and analyzed. Double entry and consistency checking were performed with Epidata software.
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RESULTS Twelve patients died during the perioperation after thoracic endovascular repair, with an incidence of 2.1%, 66.6% were caused by aortic rupture and half of the aortic rupture deaths were caused by retrograde type A AD. In our study, 74% of the non-rupture surviving patients had the free-flow bare spring proximal stent implanted, compared with 100% of the aortic rupture patients (74% vs. 100%, P=0.213). The aortic rupture patients are more likely to have ascending aortic diameters â&#x2030;Ľ4 cm (62.5% vs. 9%, P=0.032), involvement the aortic arch concavity (62% vs. 27%, P=0.041) and have had multiple stents placed (P=0.039).
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CONCLUSION Thoracic AD endovascular repair is a safe and effective treatment option for AD with relative low in-hospital mortality. AD rupture may be more common in arch stent-graft patients with an ascending aortic diameter â&#x2030;Ľ4 cm and with severe dissection that needs multi-stent placement. Attention should be paid to a proximal bare spring stent that has a higher probability of inducing an AD rupture. Post balloon dilation should be performed with serious caution, particularly for the migration during dilation.
Keywords: aortic dissection; aortic rupture; stent; graft
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The application of various devices and technique in aortic endovascular repair Xiaodong Li Cardiovascular Surgery, General Hospital, Ning Xia Medical University, Yin Chuan, Ning Xia 750004, China
OBJECTIVE To discuss the clinical outcomes of various devices and technique used in endovascular aortic repair(EVAR). METHOD 1. Use the occluder for treating congenital heart disease patent ductus arteriosus (PDA) to occlude the branch vessels and resolve type III endoleak in EVAR. Also the occluder can extend the proximal landing zone effectively and therefore prevent type I endoleak in EVAR 2. Use the coils to resolve type I and type II endoleak 3. Apply the chimney technique to extend the proximal landing zone in patients with short neck. 4. Place the restrictive distal stent to prevent the stent graft induced distal dissection post EVAR and to resolve the issue of the excessive oversize of stent grafts in treating teenagersâ&#x20AC;&#x2122; acute aortic injury
RESULTS All cases achieved procedural success without any serious complication. The 6-12 months follow-up indicated good clinical outcome without any serious adverse events such as endoleak, critical limb ischemia, and stent graft fracture and migration. CONCLUSIONS The application of various devices and technique can effectively expand the indication for endovascular aortic repair. The safety and efficacy of those devices and technique have been preliminarily demonstrated.
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| FREE PAPERS 2014 | TUESDAY JUNE 10
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| ORAL PRESENTATIONS |
Compliance with surveillance protocols, following elective endovascular aneurysm repair Godfrey AD, Morbi AHM, Albayati M, Shearman CP, Nordon IM Department of Vascular Surgery, Cardiac, Vascular and Thoracic Surgery (CV&T) Unit, University Hospital Southampton NHS Foundation Trust, UK
OBJECTIVES Integral to maintaining excellent outcomes post-endovascular aneurysm repair (EVAR) is a robust surveillance protocol and timely re-intervention. A significant proportion of patients fail to comply with surveillance, exposing themselves to complications of endoleak and graft migration. We examine EVAR surveillance in Wessex, exploring factors that may predict poor compliance.
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MATERIALS AND METHODS Data was retrospectively collated and cross-referenced for all patients who underwent EVAR between October 2008 and March 2013. Surveillance was conducted centrally (at the tertiary-referral trauma centre) and at 4 spoke-units. Surveillance compliance (attendance at imaging appointments) at varying time intervals and predictors of non-compliance, to include age, gender, co-morbid status and distance from surveillance site, were analysed for univariate significance.
| MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
RESULTS 179 consecutive elective EVAR cases were assessed. 50 patients (27.9%) were non-compliant with the surveillance protocol, with 12 (6.7%) having no imaging post-EVAR. At oneyear, 56.1% (of 123 patients) were compliant. At years two and three, 41.5% and 41.2% (of 65 and 34 patients respectively) were compliant. There were no statistically significant differences in age (p=0.77), gender (p=0.74) or co-morbid status (p=0.77) between the compliant and non-compliant groups. Distance to central unit was non-significant (p=0.67), irrespective of island or mainland residence. There was a trend towards compliance in upper-middle class socioeconomic groups (ABC1 v C1C2D), but overall predictive value was not significant (p=0.82). CONCLUSIONS While patients are willing to travel to the central unit for treatment, compliance with surveillance post-EVAR is poor (irrespective of imaging modality or surveillance-site). No independent predictor of non-compliance has been confirmed but socioeconomic status appears relevant. This study highlights an important issue, which needs to be addressed urgently, if we are to ensure the continued success of endovascular therapy.
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Technical success with a balloon-positioned subintimal crossing device: subgroup analysis from the Re-ROUTE trial K. Keirse 1, A. Schmidt 2, E. Blessing 3, J. Diaz-Cartelle 4, on behalf of the Re-ROUTE Investigators 1. Regional Hospital Heilig Hart Tienen, Tienen, Belgium 2. Park-Hospital Leipzig, Center for Vascular Medicine, Leipzig, Germany 3. University of Heidelberg, Heidelberg, Germany 4. Boston Scientific, Natick, MA, USA
AIM The Re-ROUTE Clinical Study was conducted to assess the safety and effectiveness of a balloon-positioned re-entry catheter system for subintimal recanalization of chronic total occlusion (CTO) of the femoropopliteal arteries. Secondary analyses included technical success rates in subgroups of patients based on demographic and clinical characteristics. METHODS A total of 92 patients were enrolled in this prospective, single-arm study conducted at 12 European centers. Patients were required to have claudication or critical limb ischemia and a de novo or re-occluded CTO lesion in a native femoropopliteal artery. The primary effectiveness measure (device technical success defined as placement of a guidewire in the true lumen distal to a CTO) was assessed in descriptive analyses of subgroups based on sex, diabetes, lesion calcification and lesion length.
RESULTS Mean lesion length was 175.1 Âą 85.4 mm, and 48% of lesions had moderate calcification. Site-reported technical success was 89% (25/28) for women, 83% (53/64) for men, 81% (38/47) for diabetic patients, and 89% (40/45) for patients without diabetes. Technical success was 86% (6/7) for the subgroup with lesions â&#x2030;¤50 mm and 89% (16/18) for those with lesions >250 mm. Mean device use time ranged from 8 to 15 min across lesion length subgroups. Lumen re-entry was successful in 93% (40/43) and 80% (35/44) of patients with none/mild calcification or moderate calcification, respectively. No device-related perforations requiring intervention, device-related dissections (grade C or greater), nor target lesion revascularizations due to complications were identified through 30 days post-procedure. CONCLUSION Although these descriptive analyses are not powered for statistical comparisons, they suggest that effectiveness of the balloon-positioned re-entry system was similar between both sexes, between patients with or without diabetes, across subgroups with increasing lesion length, and between none/ mild and moderate calcification subgroups.
| FREE PAPERS 2014 | TUESDAY JUNE 10
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| ORAL PRESENTATIONS |
Silent cerebral infarction following thoracic endovascular aortic repair AH Perera, N Rudarakanchana, CD Bicknell, L Monzon, M Hamady, O Kirmi, RG Gibbs Imperial College, London Department of Vascular Surgery, Cardiac, Vascular and Thoracic Surgery (CV&T) Unit, University Hospital Southampton NHS Foundation Trust, UK
INTRODUCTION Overt clinical stroke occurs in 2-8% of patients undergoing thoracic endovascular aortic repair (TEVAR), primarily due to embolic events. Silent cerebral infarction (SCI) is a brain injury detected incidentally on imaging. It is now recognised that SCI contributes to cognitive decline and is a predictor of future stroke, dementia and depression. AIM This study investigates cerebral embolisation and SCI in patients undergoing TEVAR.
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METHODS Two independent observers conducted blinded evaluation of pre-operative CT Aortograms for the presence of aortic atheroma, graded as 1-5 using a validated scoring system. Intra-operative Transcranial Doppler of bilateral middle cerebral arteries was performed, and microembolic events were identified by two blinded observers in an offline analysis. A sub-group of patients also underwent pre- and post-operative cerebral MRI to identify SCI.
| MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
RESULTS Twenty-eight patients (median age 63 years, interquartile range (IQR) 45-77) underwent 17 TEVAR, 4 TEVAR + carotid-subclavian bypass and 7 arch/visceral hybrid procedures. Microemboli were detected during all cases, and more frequently (i) in patients with greater aortic atheroma (atheroma grade 4-5: median emboli 151, IQR 95-210 vs. atheroma grade 1-3: median 48, IQR 34-85, p=0.02); (ii) in the left MCA territory compared to the right (median 83, IQR 28-146 vs. 41, 19-66, p=0.003); and (iii) during the treatment phase (stentgraft manipulation and deployment) compared to the diagnostic phase (wire and catheter passage) (median 55, IQR 20-160 vs. 24, 15-41, p=0.001). There were three post-operative strokes (11%) and SCI was found in 10/15 patients who underwent MRI. CONCLUSIONS Two-thirds of patients who underwent MRI had evidence of SCI; this is a previously unrecognised burden and implies the risk of cerebral injury following TEVAR is higher than currently acknowledged. This study has identified high-risk patients and procedural phases, which will inform future strategies to minimise risk of cerebral injury.
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s r ste
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| MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
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PV patency and integrity problem percutaneal management by stenting, endoluminal RFA&angioplasty or endoluminal RFA&stenting M. Mizandari, N. Habib, K. Kuntelia
PURPOSE Novel technique of PV patency and integrity percutaneous restoration is presented. MATERIAL AND METHODS Total 15 patients with portal hypertension due to PV patency problem; among them 14 underwent percutaneous recanalization using a novel endovascular bipolar radiofrequency device. RFA was followed by balloon angioplasty (7 cases; 6 - HCC, 1-retroperitoneal sarcoma) or vascular stent placement (7 cases; 6 - HCC, 1 - liver cirrhosis). in 1 case (choledocholithiasis and pancreatitis induced PV stricture and porto-biliary fistula) PV stenting was performed. The PV tributary was percutaneously accessed under US guidance and 5G guide catheter was manipulated through the block using guidewire technique under DSA guidance. In case of stenting the procedure was completed by stent placement; for RFA processing the endoluminal radiofrequency device was inserted into the thrombus; procedure was completed by immediate balloon angioplasty or stenting.
RESULTS The technical success rate was 80.0%; in 3 cases (20.0%) wire conduction through the organized thrombus was impossible. Posprocedure portography documented significantly improved portal vein blood flow in all patients, to whom the procedure was completed. Porto-biliary fistula was successfully managed by percutaneous stenting. Patients tolerated the procedure easily; no intra- or postprocedural complications were detected CONCLUSIONS The percutaneous management of PV patency and integrity problems by percutaneous stenting and endoluminal RFA is safe and effective technique; it should be suggested as a treatment option for otherwise incurable patients and might be used as a bridge for further treatment. However, a larger study is needed to assess its usefulness and long-term impact on patient outcome.
| E-POSTERS 2014 | MONDAY JUNE 9
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Innominate artery and right internal carotid artery PTA and stenting via right radial artery C. Moncalvo, V. Puma, A. Laurenza, G. Carosio, P. Ciuffi Clinica Città di Alessandria - Policlinico di Monza – Alessandria - Italy
CLINICAL CASE L. B.: 78 y.o., male. Symptoms: vertebro-basilar insufficiency, previous PTA failed via femoral approach. Risk factors: hypertension, dislipidemia. Comorbidity: cronic renal failure, COPD, HCV with esophageal varices. The angiographyc examination showed a subocclusion of the innominate artery (previous failed attempt of PTA of the innominate artery via femoral approach).
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TREATMENT Right radial approach with 8F sheath. The stenosis was crossed directly with the sheath and a 0,035” guidewire, then we carried the stent to the lesion site, keeping it running into the sheath. After having checked the correct locations of the stent, the sheath was withdrawn and the stent was released. In this case we choose a stent graft. The final angiographyc result was good. Follow-up: six years later the patient experienced a transient ischemic attac. The angiography showed a fracture of the stent graft on the innominate artery but the patency of this stent was maintained and no pressure gradient was detected. The same angiography showed a critical stenosis of the right internal carotid artery.
| MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
TREATMENT Right radial approach with a 6F introducer-90 cm, after having placed a distal filter protection, a predilatation of the stenosis was performed (balloon 3 mm in diameter and 30 mm in lenght inflated to 12 atm), then a stent was released (7-10 mm, length 3 cm). The stent was postdilated with a balloon 5 x 15 mm dilated to 12 atm. RESULT Good final angiographic result showing good patency of stent. No complications. Follow-up: The patient remained asymptomatic and EcoDoppler controls confirmed the maintenance of the good angiographyc result.
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EVAR for a Streptococcus Group A infected aneurysm of the abdominal aorta Karaca Saziye¹, Rager Olivier², Murith Nicolas¹, Kalangos Afksendyios¹ 1. Service of Cardiovascular Surgery, University Hospital of Geneva, Switzerland. 2. Service of Nuclear Medicine, University Hospital of Geneva, Switzerland
A CASE REPORT An infected aneurysm of the abdominal aorta due to a microorganism is an unusual finding, which can be associated with high morbidity and mortality. The classic treatment recommendation is antibiotic therapy and open-abdominal surgery. Alternative treatments including endovascular exclusion of the AAA are also recommended. In this case report, we document an 85-year-old woman with a streptococcus group A (S. pyogenes) infected abdominal aortic aneurysm [Fig.:1], who undergoes successful treatment with an endoprosthesis [Fig.:2] and antibiotherapy. Her clinical and radiological follow-up was uneventful and antibiotic therapy was continued. INTRODUCTION Mycotic aneurysms are uncommon and account for only 1%1.8% of aortic aneurysms. A mycotic aneurysm is a destruction of the vessel wall leading to dilation of an artery caused by infection due to a microorganism. Gram-positive bacteria such as the Staphylococcal species, Enterococcus species, and Streptococcus pneumonia, are the most common, and are responsible for 60% of these infections. Gram-negative bacilli is Salmonella are the majority of the cases. Streptococcus group A causing mycotic aneurysm is extremely rare, with only a few cases reported. Group A Streptococcus (S. pyogenes), a virulent gram-positive organism, causes a wide spectrum of diseases, including pharyngitis, skin and soft tissue infections, bloodstream infections, and streptococcal toxic shock syndrome. The mechanism of mycotic AAA includes hematogenous spread from an infection with concurrent bacteremia. Endovascular aortic stent grafting has significant advantages over open aneurysm repair of infected aneurysm, because it can avoid a large skin incision, aortic cross-clamping, blood transfusion, immobilisation and prolonged hospital stays. Long-term results of EVAR for infected AAA have not been reported, but the short and midterm outcomes of this treatment modality have been promising good results. We demonstrate that the use of endovascular aneurysm repair (EVAR) for mycotic aortic aneurysms simplifies the procedure and provides a good alternative in combination with pre-and postintervention antimicrobial therapy in a high-risk patient.
Figure 1: Sagittal reconstruction of the contrast-enhanced initial computed tomography (CT) scan showing typical appearance of a mycotic aneurysm: eccentric saccular (arrowheads) of the abdominal aorta with inflammation and infiltration (hematoma?) of the periaortic soft tissue.
Figure 2: Postinterventional a coronal reconstruction of the contrast-enhanced initial contrast-enhanced initial computed tomography (CT) scan showing the anatomic location of the aortic stent graft.
| E-POSTERS 2014 | MONDAY JUNE 9
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Feasibility and safety of laparoscopic aortobifemoral bypass using a clampless and sutureless aortic anastomotic technique Bernard Segers 1, David Horn 1, Jean Lemaitre 1, Alain Roman 2, Etienne Stevens 2, Vanessa Van Den Broeck 3, Pascale Hizette 1, Thierry Bosschaerts 1 1. Department of Vascular and Thoracic Surgery 2. Intensive Care Unit 3. Departement of Anesthesiology Hôpital Universitaire St Pierre, Brussels Belgium - Université Libre de Bruxelles (ULB)
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OBJECTIVES This study describes the feasibility and safety of a clampless and sutureless aortic anastomotic technique during retroperitoneal laparoscopic aortobifemoral bypass. Materials and methods From february 2012 to march 2013, 12 patients underwent a clampless and sutureless laparoscopic bypass for TASC D aortoiliac occlusive lesions using the EndoVascular REtroperitoneoScopic Technique (EVREST). The patients were placed in a 30° right lateral decubitus position. The dissection of the retroperitoneal space was performed laparoscopically and the infrarenal aorta was exposed. A bifurcated graft was inserted into the retroperitoneal space. Under videoscopic control the prosthetic limbs were brought to the groins. The graft was connected on the left side of the aorta by an intra and extra aortic covered stent-graft. This connection was performed 12 patients without suture. An aortic clamp was used temporarily on 4 patients. The femoral anastomoses were performed classically.
| MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
RESULTS Median follow-up was 9.3 months. The retroperitoneal laparoscopic approach to the aorta was always feasible. Median operative time was 265 minutes. Median duration of aorto-prosthetic connection was 60 seconds. Median hospital stay was 6.2 days. The thirty-day postoperative mortality was 0%. No major postoperative complications were observed. All grafts were patent at the end of the follow-up with no early or late disruption of the proximal assembly. The ankle brachial pressure index was improved in all cases. One patient died at 6 months from acute respiratory failure. CONCLUSION EVREST greatly facilitates the laparoscopic aortic surgery in occlusive disease with no need of suture nor clamping. The aorto-prosthetic anastomosis is then avoided, which is the most attractive feature. It offers the advantages of laparoscopy and those of endovascular surgery. This approach could make the laparoscopic aortic surgery more accessible. Early experience supports procedural and initial postprocedural safety and demonstrates proof of concept for EndoVascular REtroperitoneoScopic Technique.
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Asymptomatic aneurysm of the left gastric artery Pixner D., Franzen J., Granderath F.A. Department of General and Visceral Surgery, Center for Minimally Invasive Surgery, Hospital ‘‘Maria v. d. Aposteln’’ Neuwerk, Moenchengladbach, Germany.
This case report describes the incidental finding of an asymptomatic aneurysm of the left gastric artery by computed tomography scan in a mutlimorbid patient after laparoscopic cholecystectomy with postoperative complications. There are only few publications on results of surgical or endovascular treatment, thus most information is obtained from reviews. INTRODUCTION Aneurysms of the intestinal arteries are relatively rare, with a reported incidence of 1% (3). Their appearance is estimated to be in appro-ximately 1% of the population (3). Gastric artery aneurysms account for less than 4% of visceral artery may be congenital or acquired in origin and are potentially lethal lesions. They most frequently develop due to an adjacent inflammatory process (5). Other causes include Medial degeneration, arteriosclerosis, trauma, arteritis, fibromuscular dysplasia, and connectivetissue disorders (3,4). Gastric artery aneurysms are solitary and acquired, affecting men aged over 59 years three times more often Than women (3). Approximately 90% of gastric artery aneurysms are expected to result in rupture (1,8) either into the peritoneum or into the stomach (9), and complication-associated mortality reaches 70% (3).Due to an increase in quantity and quality of abdominal imaging by computed tomography scan (CT), These aneurysms are now more frequently detected incidentally. Visceral aneurysms are usually asymptomatic and of small size to be identified by physical examination. Two types of complications may arise: ischemia due to thrombosis or distal embolization and rupture. (10) If rupture occurs in the peritoneal cavity the patient may present with signs of hypovolemic schock and emergency laparotomy is the treatment of choice. Open operation and ligation, with or without vascular surgical reconstruction, is the golden standard of therapy. However, delayed surgical intervention in case of acute rupture may result in irreversible shock. Nevertheless, early identification of this pathology allows for elective treatment in terms of placement of an interposition graft. Furthermore, endovascular moda-Lities have emerged as alternative treatment options in high risk patients. (12) In the near future, selective angiography and embolization may become standard methods of evaluation and treatment (6).
CASE REPORT An 85 year old female was admitted to our hospital from a special care home with high fever (39.0°C), acute epigastric pain and localized peritonism in the right upper abdomen. Ultrasonographic examination demonstrated a gallbladder empyema. Laboratory examination showed elevated inflammation parameters (CRP 16 mg/dl and leukocyte count 19.400/µl). The patient’s history included recurrent pulmonary embo-lisms after surgery for femur fracture and over the past 3 months consecutive tracheostoma with long term artificial ventilation due to respi-ratory distress syndrome was necessary. A thoracic X-ray demonstrated an upside-down stomach (Fig. 3). Further anamnesis showed recurrent gastric bleeding due to gastric ulcer and a chronic anemia. The patient also suffered from a chronic renal insufficiency. Diagnostic laparoscopy and subsequently laparoscopic cholecystectomy were performed. A perforated gangrenous acute cholecystitis with gallbladder empyema (Fig.4) was confirmed intraoperatively. The post-operative course was complicated by a perihepatic abscess, confor-med by CT scan of the abdomen. Furthermore, an aneurysm of the left gastric artery was demonstrated as an incidental finding, with a size of (Fig. 3-5) 3,4 x 3,7 cm (Fig. 1 and 2) and thrombotic material in the aneurismal sac. A CT-guided drain of the abscess was obtained by the interventional radiologists 2 days after surgery. Definite operative treatment in terms of open reconstruction was denied by the patient and the relatives. Furthermore, in view of her chronic renal insufficiency, an exposure to high doses of contrast agent precluded endovascular treatment. After laparoscopic abdominal lavage 2 days after drain application, the physical recovery was uneventful and the patient was transferred in good conditions back to the special-care home. DISCUSSION The decision for intervention in case of an incidental finding of a anreurysma of the left gastric artery has to take into account the size and the natural history of the lesion, the risk of rupture and the relative risk of surgical or radiological intervention. For most asymptomatic aneurysms, observant treatment is indicated. Despite their rarity, they represent a serious vascular condition, since about 25% will rupture; if they do, mortality varies from 25% to 70% (1,3). Mortality after surgical intervention is low, and if the correct right measures are taken, then it is much lower than the 20-30% of mortality associated with rupture of these visceral aneurysms.Laparoscopic surgery appears useful for elective surgery of an aneurysm in the left gastric artery. (11)
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Figures
Fig 1: CT-Scan Abdomen with upside down stomach and incidental aneurysm of the left gastric artery intrathoracal
Fig. 3: thoracic X-ray p.a.
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Fig. 4: CT-Scan Abdomen sag. with gallbladder empyema Fig. 2: CT-Scan Abdomen diameter of aneurysm
References
1. S. Chandran, A. Parvaiz, A. Karim*, I. Ghafoor, B. Steadman, N.W. Pearce, and J.N. Primrose Department of Surgery, Southampton University Hospital, Southampton, U.K. Ruptured Left Gastric Artery Aneurysm Successfully Treated by Thrombin Injection: Case Report and Literature Review 2. Geelkerker RH, Van Bockel JH, De Roos WK, Hermans J (1990) Surgical treatment of intestinal artery aneursyms. Eur J Vasc Surg 4:563-567 3. Busuttil RW, Brin BJ. The diagnosis and management of visceral artery aneurysms. Surgery 1980;88:619–624 4. Kojima A, Shindo S, Kubota K, et al. Successful surgical treatment of a patient with multiple visceral artery aneurysms due to fibromuscular dysplasia. Cardiovasc Surg 2002;10:157–160 5. Rohatgi A, Cherian T. Spontaneous rupture of a left gastroepiploic artery aneurysm. J Postgrad Med 2002;48:288–289 6. Lookstein RA, Guller J. Embolization of complex vascular lesions. Mt Sinai J Med 2004;71:17–28 7. Y P Panaylotopoulos MD PhD P R Taylor MA MChir FRCS Senior Registrar Consultant Surgeon Raffi Assadourian MB BS Senior House Officer in Surgery Department of Surgery, Guy’s Hospital, London. Aneurysms of the visceral and renal arteries 8. Salam TA, Lumsden AB, Martin LG, Smith RB 3rd. Nonoperative management of visceral aneurysms and pseudoaneurysms. Am JSurg 1992;164:215-19. 9. Langlois NE, Miller ID. Intramural gastric haematoma from an atherosclerotic aneurysm of a gastric artery. Am J Gastroenterol 1993; 88: 613-14. 10. C.D. Liapis, K. Balzer, F. Benedetti-Valentini, J. Fernandes e Fernandes. Vascular surgery European manual of medicine 411-415 11. Sasaki A, Bandoh T, Shiraishi N, Adachi Y, Kitano S, Kaketani K. Department of Surgery I, Oita Medical University, Japan. Laparoscopic ligation of an aneurysm of the left gastric artery. Surg Laparosc Endosc Percutan Tech 2001 Jun;11(3):225-7 12. Murata S, Tajima H, Abe Y, Watari J, Uchiyama F, Niggemann P, Kumazaki T. Successful embolization of the left gastric artery aneurysm obtained in preoperative diagnosis: a report of 2 cases. Department of Radiology, Center for Advanced Medical Technology, Nippon Medical School, Tokyo, Japan. | MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
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Transbrachial angioplasty of Chronic Total Occlusion in iliac and femoral arteries: a safe and durable option Mosaad Soliman Vascular Surgery Unit, Mansoura University Hospital, Mansoura, Egypt
BACKGROUND Aortofemoral bypass has traditionally been the intervention of choice for chronic total occlusions (CTO) of iliac arteries. However, it is associated with significant mortality and morbidity making this procedure prohibitive in high risk patients. This option becomes even impossible if it is associated with long SFA occlusion. In order to make it feasible to revascularize iliac and femoral arteries, transbrachial angioplasty (TBA) for ilio-femoral CTO has been utilized. METHODS A consecutive series of 55 patients with long (> 5 cm) iliac and femoral artery CTO were treated by TBA. According to TASC II classification, there were 8 patients in type B, 19 patients in type C and 28 patients in type D. Recanalization of the occluded lesions was attempted with the left brachial access..
RESULTS 55 patients underwent TBA of an iliac and long femoral CTO, with a success rate of 72% (40/55). Technical failure was due to the inability to re-enter the lumen in all cases. 18 (32%) of these patients were considered to be non-surgical candidates. Indications for TBA were severe claudication, (64%), and critical limb ischemia, (36%). In the unsuccessful 15 patients, TBA and hybrid procedure were done. In 20 patients, a more distal lumen re-entry was achieved into the superficial femoral artery (16) or the popliteal artery (4). In 71% patients, stents were deployed with an average of 1.1 (range:0-3) stents utilized. True lumen re-entry was achieved with an assist device in 3% of patients. Mean pre-operative ABI was 0.52 (range:0.12-0.95). Mean post-procedural ABI was 0.76 (range:0.36-1.30). Mean ABI at last follow-up was 0.80 (range:0.36-1.20). Claudication improvement was documented in 72%. Primary patency was 80% and 69% at 1 and 2 years respectively. Secondary patency was 92% and 86% at 1 and 2 years respectively. Limb salvage was 99% and 97% at 1 and 2 years respectively. After TBA, 9 out of 12 patients with ulcers healed. Procedural 30-day mortality rate was 1.8% (1/55). Survival rate was 93% and 65% at 1 and 4 years respectively, reflecting the poor health status of this cohort. CONCLUSION TBA of iliac and femoral CTOs is feasible and can be performed safely and effectively, even in high-risk patients. Excellent patency and limb salvage rates can be achieved.
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In stent restenosis of superficial femoral artery: an off - label, but long-lasting, treatment C. Moncalvo, V. Puma, A. Laurenza, G. Carosio, P. Cioffi Clinica Città di Alessandria - Policlinico di Monza - Alessandria - Italy
CLINICAL CASE B. M. R., female, 55 years old. Risk factors: diabetes, dislipidemia, hypertension, smoking. Periphe-ral artery disease: previous multiple angioplasty and stent implantation on both superficial femoral arteries. 2009: instent restenosis on both superficial femoral arteries treated with multiple angiopla-sty. July 2010: left lower limb claudication. Doppler examination: instent restenosis on left superfi-cial femoral artery. The angiographyc examination confirmed a critical instent restenosis on left superficial femoral ar-tery.
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TREATMENT Right femoral artery approach with 7F sheath. Cross over into left common femoral artery. The ste-nosis was crossed with a 0,014” guidewire, then we performed atherectomy followed by post dila-tation with a drug eluting balloon. The final angiographyc result was good. Follow-up: september 2012 right lower limb claudication. Doppler examination: instent restenosis on right superficial femoral artery. The angiography confirmed the good angiographyc result on left superficial femoral artery after 18 months and a critical instent restenosis on right superficial femo-ral artery was detected.
| MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
TREATMENT Left femoral artery approach with 7F sheath. Cross over into right common femoral artery. The ste-nosis was crossed with a 0,014” guidewire, then atherectomy followed by angioplasty. No compli-cations. Follow-up: Patient is still symptoms-free. Eco-Doppler after 27 months showed the maintenance of the good result on right femoral artery. Eco-Doppler after 3 years and 6 months confirmed the maintenance of the good result on left superficial femoral artery.
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Percutaneous pulmonary artery stenting for extrinsic malignant compression: case report A. Kerzmann1,2, G. Swennen 3, S. Dassy 3, M. Miribung 4, T.N. Dang 5, E. Passelecq1,2, J.O. Defraigne 1 Hospital: 1. Dept. of Cardiovascular and Thoracic Surgery, CHU Sart-Tilman, Liège, Belgium 2. Dept. of Vascular and Thoracic Surgery, Sankt Nikolaus Hospital, Eupen, Belgium 3. Dept. of Oncology, Sankt Nikolaus Hospital, Eupen, Belgium 4. Dept. of Anaesthesiology, Sankt Nikolaus Hospital, Eupen, Belgium 5. Dept. of Radiology, Sankt Nikolaus Hospital, Eupen, Belgium
INTRODUCTION Pulmonary artery stenting is usually performed for congenital heart diseases. It can also be used for fibrosis, strictures after lung transplantation and malignant stenosis. We report one case of left pulmonary artery stenting for stenosis due to extrinsic compression by non-small cell lung carcinoma.
DISCUSSION Extrinsic compression of pulmonary artery by non-small cell lung carcinoma is rare. Percutaneous pulmonary artery stenting for that indication is minimal invasive, feasible and safe. It is a palliative treatment but it can strong improve patientâ&#x20AC;&#x2122;s quality of life.
CASE REPORT A 61-year-old man was treated by radiation and chemotherapy for pT3N1M0 squamous cell carcinoma in the hilum of the left lung. Since some months he complained of short windedness class III of the New York Heart Association classification. His general state was good. Pulmonary scintigraphy showed absence of perfusion in the left lung. Chest CT scan revealed severe stenosis of the left pulmonary artery due to extrinsic compression by the cancer. Under general anaesthesia, percutaneous dilatation followed by stenting with self expandable nitinol stent of the left pulmonary artery was realized. There was no peroperative complication. The symptoms decreased immediately. After 3 months follow up, the patient has dyspnea class II of the New York Heart Association classification.
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| E-POSTERS 2014 | MONDAY JUNE 9
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Use of drugcoated balloon angioplasty as first line treatment for all SFA lesions Koen Keirse 1, Bart Joos 1, J端rgen Verbist 2, Patrick Peeters 2, Marc Bosiers 3, Koen Deloose 3, Joren Callaert 3 1. H.Hart hospital, Tienen, Belgium 2. Imelda Hospital, Bonheiden, Belgium 3. A.Z. Sint-Blasius, Dendermonde, Belgium
BACKGROUND Drugcoated balloons have been proven efficient in BTK and is still under investigation in Trials for their use in the SFA. The use of drugcoated balloons (DEB), can reduce the number and length of stenting in the SFA. Although there are clear indications of the benefits in case of restenosis or instent restenosis, scientific evidence to support this title is still lacking today. We have treated 99 limbs consecutively with SFA disease (including TASC C and D lesions, restenoses and in-stent restenosis) in a subcohort of patients included in the IN.PACT Global trial to investigate the mid-term results (up to 36 months) in patients presenting with intermittent claudication or critical limb ischemia by use of DEB systems.
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METHODS Patient cohort is a subgroup of the prospective, non-randomized, multi-center, multi-national, controlled trial IN.PACT Global conducted in 1 site in Belgium. Between Nov 2012 and Dec 2013, 77 patients (99 limbs treated) were enrolled. The efficacy endpoint of the trial is freedom from clinically driven TLR within 12 months and primary patency within 12 months, defined as freedom from >50% restenosis at 12 months as indicated by an independently verified duplex ultrasound peak systolic velocity ratio (PSVR) <2.4 in the target vessel with no reintervention. Safety endpoint includes freedom from device-related and procedure-related mortality through 30 days, freedom from major target limb amputation and freedom from TLR within 12 months.
| MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
RESULTS Of the 77 patients enrolled, 68.33% were men and the mean age was 69.9 years. 88% had intermittent claudication and 12% presented with critical limb ischemia. For lesion treatment, only 30% received a bail-out stenting for residual stenosis of more 50% or flow-limiting dissections and these were considered as treatment failure. The overall mean lesion length was 149.6 mm. Preliminary results show a freedom from TLR at 6 months of 76% and a primary patency at 6 months of 74%. CONCLUSION Treatment of all real-world SFA disease with DEB seems safe and feasible, shows promising primary patency rates and freedom from TLR and appears to have lower bail-out stenting rates as compared to POBA and acceptable. As these preliminary 6-month data show promising results, full 6-month data and preliminary 12-month data will be presented at the congress.
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Cystic adventitial disease of the popliteal artery StĂŠphanie Donohue
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| E-POSTERS 2014 | MONDAY JUNE 9
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Are stent grafts the solution for In-Stent Restenosis after SFA stenting Koen Keirse 2, JĂźrgen Verbist 2, Patrick Peeters 2, Marc Bosiers 1, Koen Deloose 1, Joren Callaert 1 1. Department of Vascular Surgery, A.Z. Sint-Blasius, Dendermonde, Belgium 2. Department of Cardiovascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
BACKGROUND Tackling in-stent restenosis (ISR) in the superficial femoral artery (SFA) has some challenges. To date literature review reveals only very limited data on ISR in peripheral arteries. Current available treatments do not yield satisfactory results, demonstrating the need of a treatment with a better outcome. The Viabahn endoprosthesis with a heparin bioactive surface offers high flexibility when deployed in the SFA and the coating provides an enhanced haemocompatibility.
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METHODS The RELINE trial is a prospective, randomized, multi-center, international, controlled trial (RCT) in which enrollment was allowed to continue until 80 patients meet the eligibility criteria. Between June 2010 and February 2012, 100 patients were enrolled. The first primary endpoint is primary patency at 12 months, defined as no evidence of restenosis or occlusion within the originally treated lesion based on color-flow duplex ultrasound (CFDU) measuring a peak systolic velocity ratio â&#x2030;¤2.5 and without target lesion revascularization (TLR) within 12 months. The second primary endpoint is the proportion of subjects who experience serious device-related adverse events within 30 days post-procedure.
RESULTS The primary analysis is based on the intention-to-treat (ITT) total of 100 patients. 47 (47.0%) patients were randomized to the VIABAHN ISR group and 53 (53.0%) patients were randomized to the POBA group. The demographic data was comparable in both treatment groups. In the VIABAHN ISR group there were 34 (72.3%) men and the mean age was 67.34 (49-86) years. In the POBA group, 35 (66.0%) patients were male and the mean age was 69.26 (48-87) years. Per-protocol and as-treated subanalysis has been conducted for the same tests used with ITT-analysis and showed no significant difference concerning demographic data. In the Per Protocol analysis (illustrated on the slides) a total of 83 patients are selected from the ITT group (17 patients excluded based on protocol requirements). As-treated refers to the treatment the subject received, regardless of the originally intended treatment and regardless of the amount of follow-up and consists of 75 patients (excluding 8 patients that received bail-out stenting in the POBA group). The survival analysis in Per-Protocol analysis shows a primary patency rate at 12 months of 74.8% for the VIABAHN ISR group and 30.5% for the POBA group (p<0.001). Freedom from TLR at 12 months is 79.9% in the VIABAHN ISR group and 44.7% in the POBA group (p<0.001). CONCLUSION Reline is only the second RCT on ISR treatment published to date. The 12 months data shows that viabahn endoprosthesis is significant superior to POBA for ISR. The 24 months data are analyzed for the moment and are able to show a similar trend in patency outcome.
| MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
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Fusiform aneurysm of the occipital artery Mike Bogoyevac, M.D., Vanessa Ho, M.D. Eisenhower Medical Center â&#x20AC;&#x201D; Rancho Mirage, California USA
Occipital artery aneurysms are a rare finding. In fact, they are the rarest aneurysms involving the terminal branches of the external carotid artery. When they are discovered, they are usually sequelae of head trauma and tend to form saccular, pseudo-aneurysms. There are approximately 10 cases of both psuedo and true OAAs reported in English medical literature with an average of 1.2 cases per year since 2005. Here, we present a case of a 50-year-old male who came to the clinic for folliculitis of the scalp. Through physical examination, an incidental, painless, pulsatile mass was discovered on the right occiput. There was no history of head trauma. CT angiography confirmed the diagnosis of a true, fusiform occipital artery aneurysm. To the best of our knowledge, this will be the third case of a true, fusiform aneurysm of the occipital artery to be reported. Typically the treatment of occipital artery aneurysms is through invasive surgical resection. However, in this case, a minimally invasive approach was employed. Treatment via endovascular transcatheter embolization with a liquid embolic agent proved to be a successful alternative therapy.
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| E-POSTERS 2014 | MONDAY JUNE 9
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Use Of 4 French systems for treating Fem-Pop lesions: advantages and disadvantages: lessons from the 4EVER trial using Astron Pulsar stents and no closure devices Koen Keirse 2, JĂźrgen Verbist 2, Patrick Peeters 2, Marc Bosiers 1, Koen Deloose 1, Joren Callaert 1 1. Department of Vascular Surgery, A.Z. Sint-Blasius, Dendermonde, Belgium 2. Department of Cardiovascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
BACKGROUND One of the more recent treatment options for femoro-popliteal, atherosclerotic lesions, is the application of self-expanding nitinol stents. The use of 4 French systems, can reduce access site related complications. Although there are clear indications of the benefits of 4F devices for peripheral applications, scientific evidence to support this thesis are still lacking today. The 4EVER trial attempts to investigate the long-term results in patients presenting with intermittent claudication or critical limb ischemia by use of 4 French systems.
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METHODS The 4EVER trial is a prospective, non-randomized, multi-center, multi-national, controlled trial conducted in 5 sites in Belgium and Germany. Between June 2010 and May 2011, 120 patients were enrolled. The primary endpoint was primary patency at 12 months, defined as freedom from >50% restenosis at 12 months as indicated by an independently verified duplex ultrasound peak systolic velocity ratio (PSVR) <2.5 in the target vessel with no reintervention. RESULTS Of the 120 patients enrolled, 82 (68.33%) were men and the mean age was 71 (47-90; Âą9.70) years. 83.3% had intermittent claudication and 16.7% presented with critical limb ischemia. For lesion treatment, 70 (58.3%) patients received an Astron Pulsar stent, 46 (38.3%) were treated with Pulsar-18 stent placement and 4 (3.3%) received mixed stent use. The mean lesion length was 43.5mm in the Astron Pulsar group, 105.4mm in the Pulsar-18 group and 145.0mm in the mixed stent group. The overall mean lesion length was 72.4 mm. Kaplan Meier estimation reported a 12-month primary patency rate of 81.4% and a 12-month freedom of target lesion revascularization of 89.3%. Recent analyzed 24 months data shows a primary patency rate of 72.3% and freedom of target lesion revascularization of 82.7%. Subanalyses with stratification severe calcified lesions showed sustained primary patency as compared to less calcified lesions. For 103 patients, compression time was recorded with a mean compression time of 8.12 (2.00-15.00) minutes. The data on stent fracture
| MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
rate at 24 months are currently analyzed. CONCLUSION The FOREVER Trial indicates the benefits of treatment with 4 French systems. The results demonstrate that the use of 4 French systems is feasible for the majority of endovascular treatments, with equal technical success rate, primary patency and freedom from TLR as 6F devices over 2 years, even in calcified lesions. The need for less manual compression time showed less access complications and hence no need for expensive closure devices. The full 24-month data will be presented at the congress.
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Endovascular repair of below knee para-anastomotic pseudoaneurysm following multiple vascular procedures J. Jenkner, I.Sharaf, G.Rothenbacher, M.Storck Department for vascular and thoracic surgery,Karlsruhe City Hospital,Karlsruhe, Germany
PURPOSE We describe a technique of endoluminal graft exclusion of a distal para-anastomotic pseudoaneurysm following below-knee graft interposition for popliteal aneurysm.
CONCLUSION Minimally invasive strategies utilizing endovascular approaches are appealing even when anatomicallydifficult. Additional local thrombolytic therapy (LTLT) can effectively improve run-off.
METHOD A 83-year-old male patient with history of multiple transpopliteal thrombectomies and secondary healing in the lower leg presented 6 months after below-knee femoro-popliteal interposition graft implantation with pulsatile swelling in the lower leg. Via transfemoral approach angiography of the distal anastomosis was performed showing contrast filling of the pseudoaneurysm and multiple stenosis of the peroneal artery (PA) with occlusion of the anterior tibial artery (ATA) 4cm distal to the origin. A 9Ă&#x2014;50mm stentgraft (Viabahn, GoreR) was deployed via 7F sheath extending from the below knee popliteal artery reaching to distal part of the interponate. The peroneal artery was also dilated with a 3x80mm ballon. One month later the patient presented with rest pain in the left leg. Duplex ultrasound showed occlusion of the endograft. An ipsilateral common femoral artery puncture was performed, allowing placement of a 4F sheath. The popliteal artery was catheterized with 12cm thrombolysis-catheter. Local thrombolytic therapy (LTLT) was performed with urokinase bolus, then 50.000 IE/h and heparin 1.000 IE/h for 24h. Completion arteriography before removal of the wires showed complete recanalisation of both interposition graft and popliteal artery and surprisingly two run-off vessels (peroneal artery and anterior tibial artery).
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| E-POSTERS 2014 | MONDAY JUNE 9
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| EPOSTERS |
Endovascular cure of giant false popliteal aneurysm (90 mm) with a good longterm patency and fonctional result De Bast Y. 1 M.D., Barchiche R.M.D. 2 1 Department of Vascular Surgery CHIREC site Saint Anne Saint Remigius Brussels. 2 Department of Vascular Surgery CHIREC site Leopold Park Brussels, and C.H.U. Moliere Iris South, Brussels.
CASE In December 2006, a 84 years old man who lived in instutional home came to emergency for falling down with right hip and knee pain, radiography doesn’t show any fracture. Twenty days later, he came back with a painfull swelling behind the right knee and cutaneous suffering of the skin. Echodupplex sonography showed a popliteal aneurysma of 90 mm. Angioscanner wasn’t possible because an impossibility to extended his leg (photo 1)
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METHODS We abords first the superficial femoral artery at the upper popliteal access just above the knee and the low popliteal artery at the lower popliteal artery access below the knee to control the aneurysma above and below. We decide at this time to do an arteriography and puncture the superficial femoral artery (photo 2). We catheterized at the first attempt with a angle terumo 0.35 the lesion. An endoprosthesis
| MEET 2014 | MULTIDISCIPLINARY EUROPEAN ENDOVASCULAR THERAPY |
type Viaban® from Gore-Tex® of 6mm diameter and 50mm of long was implanted with total exclusion of the aneurysm (photo 3). An flattening of the aneurysma was realized to evacuate clots (photo 4) and decrease the pression in the leg and over the skin. The cause of aneurysma was visualized it was a posterior wall rupture of the popliteal artery (photo 5). Drainage of the space was realized and wounds were closed classically (photo 6). RESULTS At 7 years of follow up, the patient is still alive at 91 years olds the patency of endoprosthesis is complete with a good functional result (photo 7). CONCLUSION Endovascular techniques can have good result in the treatment for popliteal aneurysm .
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