Cacvs 2015 Abstracts book by divine [id]

Chairman Jean-Pierre Becquemin French Scientific Committee Jean-Luc GĂŠrard Yves S. Alimi Eric Allaire Pierre Bourquelot Pascal Desgranges Hicham Kobeiter Jean Marzelle

www.cacvs.org

International Scientific Committee Piergiorgio Cao Nicholas Cheshire Hans-Henning Eckstein Christos D. Liapis Martin Malina Armando Mansilha

Table of contents

CONTROVERSIES & UPDATES IN VASCULAR SURGERY THURSDAY JANUARY 22 Aortic dissection: what’s new . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Distal arch pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Chairman Pr Jean-Pierre Becquemin

MD, Professor of Vascular Surgery Créteil, France

cientific Committee S Pr Yves S. Alimi

MD, PhD, Professor of Vascular Surgery, Marseille, France

Dr Jean-Luc Gérard MD, Paris, France

Pr Eric Allaire

MD, PhD, Professor of Vascular Surgery, Créteil, France

Dr Pierre Bourquelot MD, Paris, France

Pr Pascal Desgranges

MD, PhD, Professor of Vascular Surgery, Créteil, France

Pr Hicham Kobeiter

MD, PhD, Professor of Vascular Radiology, Créteil, France

Dr Jean Marzelle MD, Créteil, France

International Scientific Committee Pr Piergiorgio Cao

MD, PhD, Professor of Vascular Surgery, Perugia, Italy

Pr Nicholas Cheshire

Professor of Vascular Surgery, London, United Kingdom

Pr Hans-Henning Eckstein MD, PhD, Vascular surgeon, Munich, Germany

Pr Christos D. Liapis

Professor of Vascular Surgery, Chaidari, Greece

Dr Martin Malina

MD, PhD, Vascular surgeon, Malmo, Sweden

Pr Armando Mansilha

Professor of Vascular Surgery, Porto, Portugal

FRIDAY JANUARY 23 Main session Infection in vascular surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . EVAR and infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aortic infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Crazy guys or pioneers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Progress in EVAR treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reducing complications after EVAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Type 2 endoleaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Carotid remaining questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14 15 16 17 22 26 28 30

Parallel session CONTROVERSY: Basilic vein transposition, the eternal debate . . . . . . . . . . . . . . . . . 38 CONTROVERSY: Which preoperative vein imaging? . . . . . . . . . . . . . . . . . . . . . . . . . 39 CONTROVERSY: Forearm fistula for everbody? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 CONTROVERSY: A nastomotic techniques reduce… . . . . . . . . . . . . . . . . . . . . . . . . . . 49 CONTROVERSY: What’s next when upper limb access sites are exhausted? . . . . . . 50 CONTROVERSY: Stents and stent grafts in AV access . . . . . . . . . . . . . . . . . . . . . . . . . 58 LECTURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40, 45, 51

SATURDAY JANUARY 24 CONTROVERSY. Imaging: do we really need these costly machines? . . . . . . . . . . . . CONTROVERSY: Ruptured aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethics: you said ethics? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONTROVERSY: Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Improve your peripheral techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lower limbs solved and unsolved questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONTROVERSY: Which stent for the aorta? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

64 65 67 68 70 75 77

CONTROVERSIES & UPDATES IN VARICOSE DISEASE DEEP VEIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOME DEBATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SCLEROTHERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . THERMAL TECHNIQUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80 84 86 89

EPOSTERS AORTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SUPRA AORTIC TRUNKS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VISCERAL ARTERIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CASE REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PAOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VEINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

96 112 118 121 144 156 173

Faculty authors MAIN PROGRAM

VENOUS PROGRAM

Hiroshi BANNO, Nagoya, Japan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

François-André ALLAERT, Dijon, France . . . . . . . . . . . . . . . . . . . . . 84

Younes BENSAID, Souissi Rabat, Morocco . . . . . . . . . . . . . . . . . . . . 64

Piotr CIOSTEK, Warszawa, Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Pierre BOURQUELOT, Paris, France . . . . . . . . . . . . . . . . . . . . . . 45, 51

Alessandro FRULLINI, Figline Valdarno-Florence, Italy . . . . . . . . . . 86

Eric BRESSON, Caluire-Et-Cuire, France . . . . . . . . . . . . . . . . . . . . . . . 44

George GEROULAKOS, London, United Kingdom . . . . . . . . . . . . . 88

Piergiorgio CAO, Perugia, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Milka GREINER, Paris, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Piotr CIOSTEK, Warszawa, Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Lowell S. KABNICK, New York, United States . . . . . . . . . . . . . 85, 89

Raphael COSCAS, Boulogne Billancourt, France . . . . . . . . . . . . . . . 70

Philippe LEMASLE, Le Chesnay, France . . . . . . . . . . . . . . . . . . . . . . 80

Michael DAKE, Stanford, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Michel PERRIN, Chassieu, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Patrick FEUGIER, Lyon, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Attila SZABO, Budapest, Hungary . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Gilbert FRANCO, Paris, France . . . . . . . . . . . . . . . . . . . . . . . . . . . 39, 49

Lars RASMUSSEN, Copenhagen, Denmark . . . . . . . . . . . . . . . . . . . . 90

Krassi IVANCEV, London, United Kingdom . . . . . . . . . . . . . . . . . . . . 20 Sarah JOLIVET, Créteil, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Stavros KAKKOS, Patras, Greece . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Lamisse KARAM, Beyrouth, Lebanon . . . . . . . . . . . . . . . . . . . . . 41, 60 Miltos LAZARIDES, Alexandroupolis, Greece . . . . . . . . . . . . . . . . . 50 Christos D. LIAPIS, Chaidari, Greece . . . . . . . . . . . . . . . . . . . . . 15, 28 Ian LOFTUS, London, United Kingdom . . . . . . . . . . . . . . . . . . 6, 22, 67 Mohamed MORSY, London, United Kingdom . . . . . . . . . . . . . . . . . 54 Marek RAWA, Meknes, Morocco . . . . . . . . . . . . . . . . . . . . . . . . . 40, 59 Hermann RENNER, Nuremberg, Germany . . . . . . . . . . . . . . . . . . . . 17 Peter SCHNEIDER, Honolulu, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Julien SFEIR, Beirut, Lebanon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Matthew THOMPSON, London, United Kingdom . . . . . . . . . . . . . 10 Jan TORDOIR, Maastricht, The Netherlands . . . . . . . . . . . . . . . . . . . 47 Scott TREROTOLA, Philadelphia, USA . . . . . . . . . . . . . . . . . . . . 57, 58 Ramesh TRIPATHI, Bangalore, India . . . . . . . . . . . . . . . . . . . . . . . . . 16 Marc VAN SAMBEEK, Eindhoven, The Netherlands . . . . . . . . . 27, 75 Frank J. VEITH, Riverdale, USA . . . . . . . . . . . . . . . . . . . . . 30, 31, 65, 68 Jason WAGNER, Pittsburgh, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Thursday January 22 - Main program -

ortic dissection: what’s new A When is the best timing for TEVAR in acute Type B Dissection

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Ian Loftus, Patterson Ben

St Georges, London, United Kingdom INTRODUCTION Aortic dissection is often defined as being “acute” after initial presentation, before becoming a more clinically benign “chronic” dissection two weeks after onset of symptoms, as most major adverse events will have occurred during this timeframe1. A sub-acute phase between 2 weeks and up to 3 months before a dissection becomes chronic has increasingly been referred to in the published literature2,3. Acute dissections can be further classified as complicated or uncomplicated, with the former defined as the presence of malperfusion, rupture of the false lumen, the presence of rapid expansion, a large false lumen size or any other factor constituting a risk of imminent rupture4. The presence of any one of these features mandates urgent surgical treatment. Other factors that may prompt consideration for intervention are refractory hypertension or pain during the acute phase of presentation5. In the non-acute phase the main indication for treatment is chronic expansion of the false lumen. Non-surgical treatment has been the standard of care for non-complicated acute type B aortic dissection and appears to be effective in preventing aortic death and is associated with less early morbidity than traditional surgical treatment6. ANATOMICAL CLASSIFICATION The anatomical classification of an aortic dissection is dependent on morphology within the aortic arch, distal extent and the relation of the entry tear to the origin of the great vessels. As imaging technology improves, and the range of available treatments expand, the classifications according to DeBakey and Stanford based on conventional open surgical techniques may no longer be as applicable. Dake et al have revised the anatomical and clinical classification in line with advanced imaging techniques and endovascular management options based on the mnemonic DISSECT (duration, size, segmental extent, clinical complications of the dissection and thrombus within the aortic false lumen)3. This classification system includes information regarding the location of the primary entry tear and the segmental extent of aortic involvement (proximal to distal boundaries) as well as the size of the aorta based on the center line measurements at all levels of the dissected segment. It describes both clinical presentations and temporal manifestation. Finally it describes the false lumen patency with regards to anatomical landmarks and thrombosis including location of the thrombosis. AIMS OF MANAGEMENT The primary goal of the treatment of acute complicated type B aortic dissection is to prevent progression of the disease process by attempting to re-expand the true lumen and decompress the false lumen, or to treat specific aortic branch vessels that are occluded or threatened. The secondary aim is to avoid subsequent aortic dilation that may later lead to aortic related death. Minimally invasive endovascular management of type-B aortic dissection has lead to a reduction in the peri-operative mortality rate, but the risks associated with repair remain not insignificant due to the pathophysiological process itself and lethal peri-operative complications such as retrograde type-A dissection7,8. Despite this, the aorta may be more likely to remodel if treated in the early phase, and may avoid a more difficult procedure in the future as the disease progresses9,10. Approximately 15% of the patients will develop aneurysmal enlargement of the aorta during the chronic phase of the dissection which may eventually require intervention11. A challenge for vascular specialists is to determine the appropriateness and optimum timing of the treatment of acute aortic dissection, especially in those patients with indistinct indications for intervention or uncomplicated disease. EARLY INTERVENTION Despite the suggestion that endovascular treatment may be the best first line treatment for complicated dissection, there are few good quality prospective studies, and most describe the results of endovascular treatment alone with no comparator. The VIRTUE registry recruited 100 patients with a diagnosis of com6

LATE RESULTS OF INTERVENTION The INSTEAD trial randomised 140 patients with a diagnosis of uncomplicated type B dissection to be treated either by insertion of a TalentTM endovascular stent graft with best medical therapy (72 patients) or by best medical therapy alone (68 patients)14. In the intervention group, the peri-procedural mortality and morbidity was low, with two deaths, two serious intra-procedural technical complications and three serious neurological complications. Although the risk of mid-term all-cause death was similar in both groups (11.1% vs. 19.3%), aortic specific mortality was lower (6.9% vs. 19.3%) and disease progression was less frequent (27% vs. 46.1%) and there was a 90.6% rate of false lumen thrombosis in the interventional group. The Medtronic Outcomes of THoracic Endovascular Repair (MOTHER) registry contained 114 patients who were treated for acute complicated aortic dissection with endovascular therapy8. The earl mortality was 11%, and those who survived had a mean documented follow-up of 2.2 years. The aortic related death rate for those who had not died or been censored at 90 days and onwards was 0.6 per 100 patients years, suggesting that treating aortic dissection in the acute phase protects against aortic related death in the mid-term. The rate of aortic re-intervention was high in this group however, and the rate per 100 patient years was 6.7, three times that observed in the thoracic aortic aneurysm group. This suggested that for some patients the price for protection against aortic related death is an increased risk of aortic re-intervention. Favourable aortic remodeling is often seen in patients undergoing TEVAR for acute aortic dissection in the form of significant reduction in false lumen diameter (or volume) and increase in true diameter (or volume)15. This has been seen to commence immediately following surgery and continue for many years in some. Remodeling such as this is associated with a lower incidence of endoleak/distal reperfusion and resultant re-intervention16. The explanation for the variable rate of aortic remodeling observed in some dissection patients may be due to variable peri-operative practices over time. For example a short length of aortic coverage has been shown to be less likely to result in favourable aortic remodeling after three years of follow-up17. A shorter length of coverage has also been associated with a risk of the distal end of the stent damaging the aorta due to movement with the cardiac cycle18. It is intuitive that a longer length of coverage physically expands the true lumen, and minor fenestrations are likely to be 7

Thursday January 22

plicated type B dissection who underwent placement of a Valiant aortic stent-graft (Medtronic, Santa-Rosa, CA, USA)2. 50 patients with acute, 24 sub-acute and 26 with chronic dissection were recruited in total. The indication for treatment in the acute group was rupture in (22%), limb or visceral ischaemia (16%), persisting pain (64%) and uncontrolled hypertension (16%). The in-hospital mortality amongst these patients was 12%, with a serious neurological complication rate of 10%. The indications for treatment amongst the sub-acute group were a diameter over 4 cm (37.5%), expansion to over 5.5cm (12.5%), persistent pain (20.8%), malperfusion (33%) and rupture (4.2%). No serious complications were recorded in this group during the peri-operative period. The STABLE trial studied the use of the Cook Zenith Dissection Endovascular System in the setting of complicated type B dissection in 40 patients12. As with the VIRTUE study, a high rate of complications was reported in the acute dissection group, with a 25% rate of renal failure, a 20% risk of stroke and a 10% rate of retrograde aortic dissection. The rate of complications in the sub-acute group was considerably lower with no recorded deaths at follow-up. The ADSORB study aims to compare the interventional treatment and medical management of uncomplicated aortic dissection, using aortic remodelling as the primary end-point13. Recruitment is ongoing. Initial reports suggest that patients undergoing interventional treatment in addition to best medical therapy achieve the best results in terms of aortic remodelling. Of the 1007 patients enrolled in the IRAD-registry, 384 (38%) patients presented with a type B aortic dissection. About 73% of the patients were initially managed medically. In-hospital mortality was 13% and the majority of patients (85%) died within one week1.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

covered in addition to the main entry tear. Extensive dissections which extend below the visceral aorta were less likely to remodel, potentially because treating the segment of aorta above the diaphragm will often not address the main re-entry tear19. The timing of treatment has been seen to have an influence on morphological changes post-operatively. The INSTEAD trial intervention arm recruited patients at a median of 3.5 weeks and a mean of 7.5 weeks after the diagnosis was made, and the rate of total false lumen thrombosis at one year was 92.6%. In comparison a study which treated patients at a mean of 100 weeks post diagnosis achieved false lumen thrombosis in only 39% of patients at three years. The proportion of patients with thoracoabdominal extension of the dissection was similar in both groups, but the total false lumen thrombosis rate was only 13% with a deferred treatment strategy20. Conversely a high rate of false thrombosis was achieved in the INSTEAD cohort despite the fact that a single (short) stent graft was used in 83% of patients. Studies reporting morphological changes in patients with untreated dissections of the aorta are few, but a recent study from the IRAD database has demonstrated that aortic expansion can be expected to occur in 59% of patients with acute uncomplicated dissection managed medically at 1-2 years. Paradoxically those with a smaller aortic diameter initially exhibited the biggest expansion, whereas female gender, intra-mural haematoma and the use of calcium channel blockers were protective. Defining the natural history of aortic dissection and the factors that influence this in the different subgroups of patients is key to choosing the correct treatment options for individuals, as it is likely that remodeling of the aorta could have been achieved in many of these patients with appropriately timed surgery intervention21. A literature review that examined the same question found a variety of factors that may predict aortic growth in patients with uncomplicated dissection. These included connective tissue disease, eliptical false lumen configuration, saccular false lumen, false lumen orginating in the lesser curve of the aortic arch, large entry tear and multiple entry tears, although no quantitive analysis of the relative importance of each was performed22. A study which described the likelihood of requiring surgical intervention based on the status of the false lumen in patients with acute uncomplicated type B dissection reported that in those with a completely thrombosed false lumen, none needed treatment as an inpatient23. Conversely, 16% with a partially thrombsed false lumen and 26% with a patent false lumen required treatment. Of interest, mortality at long-term follow-up did not differ, but by four years follow-up almost 60% of those with a patent false lumen had undergone intervention compared with approximately 20% in the complete and partially thrombosed false lumen groups. SUMMARY It would appear that the outcome of immediate endovascular treatment of acute type-B aortic dissection is consistently worse than for patients intervened on in the sub-acute phase, but in the presence of immediately life threatening complications treatment clearly cannot be delayed. There is a subgroup of patients who do not have an absolute indication for intervention that may benefit from delayed treatment. In selected cases, those with labile blood pressure, persistent pain or a large but stable false lumen volume may be stabilised physiologically by a suitable interval of observation and maximal medical therapy. At present there is no systematic way to determine which patients with uncomplicated acute dissection will go on to require treatment. It is possible that some of these individuals may benefit in the long-term from treatment in the sub-acute phase or acute phase, which is the subject of the on-going ADSORB trial. New methods of classification, such as the â&#x20AC;&#x153;DISSECTâ&#x20AC;? system, can aid in the description of the clinically pertinent morphological features of the dissected aorta and may help to stratify patients on the basis of who will require surgery in a more objective fashion.

Thursday January 22

REFERENCES 1. Suzuki T, Mehta RH, Ince H et al, International Registry of Aortic Dissection. Clinical profiles and outcomes of acute type B aortic dissection in the current era: lessons from the International Registry of Aortic Dissection (IRAD). Circulation. 2003;108 Suppl 1:II312–7. 2. VIRTUE Investigators. The VIRTUE Registry of type B thoracic dissections--study design and early results. Eur J Vasc Endovasc Surg. 2011;41:159–166. 3. Dake MD, Thompson M, van Sambeek M, Vermassen F, Morales JP, Investigators TD. DISSECT: A New Mnemonic-based Approach to the Categorization of Aortic Dissection. European Journal of Vascular & Endovascular Surgery. 2013;:1–16. 4. Thrumurthy SG, Karthikesalingam A, Patterson BO, Holt PJE, Thompson MM. The diagnosis and management of aortic dissection. BMJ. 2012;344:d8290. 5. Trimarchi S, Eagle KA, Nienaber CA et al, International Registry of Acute Aortic Dissection (IRAD) Investigators. Importance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2010;122:1283–1289. 6. Tefera G, Acher CW, Hoch JR, Mell M, Turnipseed WD. Effectiveness of intensive medical therapy in type B aortic dissection: a single-center experience. J Vasc Surg. 2007;45:1114–8– discussion 1118–9. 7. Canaud L, Ozdemir BA, Patterson BO, Holt PJE, Loftus IM, Thompson MM. Retrograde Aortic Dissection After Thoracic Endovascular Aortic Repair. Annals of Surgery. 2014; 8. Patterson B, Holt P, Nienaber C, Cambria R, Fairman R, Thompson M. Aortic Pathology Determines Midterm Outcome After Endovascular Repair of the Thoracic Aorta: Report From the Medtronic Thoracic Endovascular Registry (MOTHER) Database. Circulation. 2013;127:24–32. 9. Sayer D, Bratby M, Brooks M, Loftus I, Morgan R, Thompson M. Aortic Morphology Following Endovascular Repair of Acute and Chronic Type B Aortic Dissection: Implications for Management. European Journal of Vascular & Endovascular Surgery. 2008;36:522–529. 10. Pujara AC, Roselli EE, Hernandez AV et al. Open repair of chronic distal aortic dissection in the endovascular era: Implications for disease management. The Journal of Thoracic and Cardiovascular Surgery. 2012;:1–9. 11. Winnerkvist A, Lockowandt U, Rasmussen E, Rådegran K. A prospective study of medically treated acute type B aortic dissection. European Journal of Vascular & Endovascular Surgery. 2006;32:349–355. 12. Lombardi JV, Cambria RP, Nienaber CA et al. Prospective multicenter clinical trial (STABLE) on the endovascular treatment of complicated type B aortic dissection using a composite device design. J Vasc Surg. 2012;55:629–640.e2. 13. Brunkwall J, Lammer J, Verhoeven E, Taylor P. ADSORB: A Study on the Efficacy of Endovascular Grafting in Uncomplicated Acute Dissection of the Descending Aorta. European Journal of Vascular & Endovascular Surgery. 2012;44:31–36. 14. Nienaber CA, Kische S, Rousseau H et al: INSTEAD-XL trial. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv. 2013;6:407–416. 15. Patterson BO, Cobb RJ, Karthikesalingam A et al. A Systematic Review of Aortic Remodeling After Endovascular Repair of Type B Aortic Dissection: Methods and Outcomes. The Annals of Thoracic Surgery. 2013; 16. Kim KM, Donayre CE, Reynolds TS et al. Aortic remodeling, volumetric analysis, and clinical outcomes of endoluminal exclusion of acute complicated type B thoracic aortic dissections. J Vasc Surg. 2011;54:316–325. 17. Qing K, Yiu W, Cheng SWK. A morphologic study of chronic type B aortic dissections and aneurysms after thoracic endovascular stent grafting. J Vasc Surg. 2012;55:1268–1276. 18. Manning BJ, Dias N, Manno M et al. Endovascular treatment of acute complicated type B dissection: morphological changes at midterm follow-up. J Endovasc Ther. 2009;16:466–474. 19. Andacheh ID, Donayre C, Othman F, Walot I, Kopchok G, White R. Patient outcomes and thoracic aortic volume and morphologic changes following thoracic endovascular aortic repair in patients with complicated chronic type B aortic dissection. J Vasc Surg. 2012;56:644–50. 20. Kang WC, Greenberg RK, Mastracci TM et al. Endovascular repair of complicated chronic distal aortic dissections: Intermediate outcomes and complications. The Journal of Thoracic and Cardiovascular Surgery. 2011;142:1074–1083. 21. Jonker FHW, Trimarchi S, Rampoldi V et al. Aortic Expansion After Acute Type B Aortic Dissection. ATS. 2012;94:1223–1229. 22. van Bogerijen GHW, Tolenaar JL, Rampoldi V et al. Predictors of aortic growth in uncomplicated type B aortic dissection. J Vasc Surg. 2014;59:1134–1143. 23. Tanaka A, Sakakibara M, Ishii H et al. Infuence of the false lumen status on short- and long-term clinical outcomes in patients with acute type B aortic dissection. J Vasc Surg. 2013;:1–6.

istal arch pathology D How to manage the LSA: when to revascularize, when not?

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Matthew Thompson

St Georges Vascular Institute, London, United Kingdom INTRODUCTION Thoracic endovascular aortic repair (TEVR) has been associated with peri-interventional neurological complication rates of up to 15%. The objective of this analysis was to determine the influence of the management of the left subclavian artery (LSA) on neurological complications , and to define subgroups who might benefit from LSA revascularisation. METHODS The MOTHER registry consists of five sponsored trials and a single institutional series, incorporating 1010 patients undergoing TEVAR from 2002-2010. Peri-operative stroke and spinal cord injury (SCI) rates were described according to the management of the LSA and presenting pathology. Survival-analyses were performed for freedom from mid-term events. RESULTS Of 1002 patients included in the analysis, 48 (4.8%) had a stroke and 42 (4.2%) developed acute SCI within 30 days of surgery. The stroke rate in patients with no coverage of the LSA was 2.2% versus 9.1% with coverage alone and 5.1% in patients who underwent LSA revascularisation after coverage (p<0.001). This relationship was strongest in the aneurysm group. Coverage of the LSA without revascularisation was independently associated with stroke (OR 3.5; 95% CI 1.7-7.1), specifically in the posterior territory (OR 11.7; 95% CI 2.5-54.6), while a covered LSA was not associated with increased risk of SCI. Management of the LSA did not influence the incidence of neurological events in the mid-term. CONCLUSIONS Coverage of the LSA without revascularisation is an important modifiable risk factor for stroke in patients undergoing TEVAR for thoracic aortic aneurysm. Prior revascularisation appears to protect against posterior circulation territory stroke.

istal arch pathology D Finally: when endo, when open? Piergiorgio Cao

Division of Vascular Surgery - Hospital San Camillo Forlanini, Rome, Italy In the last decades open repair of aortic arch has been advantaged by progressive improvements and adjuncts that conferred the achievement of safer outcomes and reduced mortality.1 At the same time, hybrid or total endovascular repair have been increasingly used as an alternative in patients previously denied surgery because of relevant comorbidities.2-3 Nevertheless, hybrid arch procedures, despite the reduced invasiveness and the progressive evolution in the last years, present unclear benefits in the outcome, and total endovascular repair is still in its early days.4-6 Particularly for diseases involving total arch and requiring stentgraft implantation in the ascending aorta as proximal landing zone, perioperative mortality and stroke risks are less than satisfying.7-10 The requirement of anatomical feasibility is an additional constraint that does not always allow the implementation of these new approaches. Still, any type of repair of aortic arch requiring supra-aortic vessels revascularization remains demanding and exposes to not negligible mortality and stroke risks. REFERENCES 1. Ouzounian M, LeMaire SA, Coselli JS. Open aortic arch repair: state-of-the-art and future perspectives. SeminThoracCardiovasc Surg. 2013;25:107-15. 2. Kotelis D, Geisbüsch P, Attigah N, Hinz U, Hyhlik-Dürr A, Böckler D. Total vs hemi-aortic arch transposition for hybrid aortic arch repair. J Vasc Surg. 2011;54:1182-1186. 3. Cao P, De Rango P, Czerny M, Evangelista A, Fattori R, Nienaber C, Rousseau H, Schepens M. Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections and other arch diseases. J ThoracCardiovasc Surg. 2012;144:1286-300. 4. Haulon S, Greenberg RK, Spear R, Eagleton M, Abraham C, Lioupis C, Verhoeven E, Ivancev K, Kölbel T, Stanley B, Resch T, Desgranges P, Maurel B, Roeder B, Chuter T, Mastracci T. Global experience with an inner branched arch endograft. J ThoracCardiovasc Surg. 2014 Feb 28. [Epub ahead of print] 5. Moulakakis KG, Mylonas SN, Dalainas I, Sfyroeras GS, Markatis F, Kotsis T, Kakisis J, Liapis CD. The chimney-graft technique for preserving supra-aortic branches: a review. Ann Cardiothorac Surg. 2013;2:339-46. 6. Vallejo N, Rodriguez-Lopez JA, Heidari P, Wheatley G, Caparrelli D, Ramaiah V, Diethrich EB. Hybrid repair of thoracic aortic lesions for zone 0 and 1 in high-risk patients. J Vasc Surg. 2012;55:318-25. 7. De Rango P, Cao P, Ferrer C, Simonte G, Coscarella C, Cieri E, Pogany G, Verzini F. Aortic arch debranching and thoracic endovascular repair. J Vasc Surg. 2014;59:107-14 8. Sood V, Patel HJ, Williams DM, Dasika NL, Yang B, Deeb GM. Open and endovascular repair of the nontraumatic isolated aortic arch aneurysm. J Vasc Surg. 2014 Mar 19; .Epub 2014 Mar 19. 9. Milewski RK, Szeto WY, Pochettino A, Moser GW, Moeller P, Bavaria JE. Have hybrid procedures replaced open aortic arch reconstruction in high-risk patients? A comparative study of elective open arch debranching with endovascular stent graft placement and conventional elective open total and distal aortic arch reconstruction. J ThoracCardiovasc Surg. 2010 ;140:590-7. 10. Murashita T, Matsuda H, Domae K, Iba Y, Tanaka H, Sasaki H, Ogino H. Less invasive surgical treatment for aortic arch aneurysms in high-risk patients: a comparative study of hybrid thoracic endovascular aortic repair and conventional total arch replacement. J ThoracCardiovasc Surg. 2012; 143:1007-13.

Thursday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Friday January 23 - Main program -

I nfection in vascular surgery Vascular infection: current spectrum and new challenges

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Sarah Jolivet

APHP, Créteil, France Endovascular grafting for endovascular aortic aneurysm repair (EVAR) have become well-accepted alternatives to traditional open surgery because of the diminished perioperative complications and mortality. Infection after vascular procedures occurs with low frequency but can be associated with extensive morbidity and mortality. The incidence of infection ranges from 0.5% to 4.5%. Endograft infection is associated with a substantial mortality rate, highly dependent of the location of the vascular graft. Risk factors include patient-related, surgery-related and postoperative risk factor. Appropriate peri-operative systemic antibiotic prophylaxis may be the most important method for preventing infections after procedures that involve implantation of prosthetic material, together with strict adherence to infection control measures before (skin prep, etc..) and during surgery. Antibiotic-impregnated sponges have not been shown to prevent surgical site infections. Other approaches include antibiotic-impregnated grafts; however, there are no controlled study demonstrating their efficacy. Infection may occur early, i.e. within the first four months of endograft implantation, or after more than 12 months. Early infections involve mostly Staphylococcus spp, streptococci and Enterobacteriaceae. There are three modes of presentation for infected EVAR: approximately one third of patients present with evidence of an aorto-enteric fistula, one third present with non specific signs of low grade sepsis and the remainder with evidence of severe systemic sepsis. There is no consensus on diagnostic criteria, the diagnosis is usually based on a combination of clinical symptoms, imaging studies and microbial cultures whenever possible. Standard procedure for treatment includes removal of the infected endograft and reconstruction associated with aggressive and prolonged antimicrobial therapy. Reconstruction can be performed by the interposition of an autologous vein, a cryopreserved allograft or a rifampicin soaked Dacron graft. Recently, endograft preservation with percutaneous drainage can be offered to patients who refuse surgery or as a palliative option or bridging procedure for severely ill patients. In patients who cannot undergo repeated surgery, the only option may be the so-called “suppressive” antimicrobial therapy, but one which has not been adequately evaluated.

VAR and infection E Infected EVAR: what about the â&#x20AC;&#x153;laisser faireâ&#x20AC;? option? C. Liapis1, S. Mylonas, C. Antonopoulos

Professor of Vascular Surgery, Chaidari, Greece Endovascular treatment of aortic abdominal aneurysm (EVAR) has evidenced better short-term outcomes, compared to open surgical repair. However, in the long run, a relatively high number of re-interventions is necessary to maintain the efficacy of EVAR, which may outweigh its early benefits 1. Since EVAR is still gaining popularity, it is expected that a growing number of patients will present with some form of delayed complications 1. Among them, endograft infection, is estimated to be less than 1%, ranging from 0.3% to 0.7% in most series, and it usually represents a fatal complication. Since this complication is scarcely reported in the literature, there are no guidelines concerning the management of patients with an infected endograft. Therefore, the treatment is still being applied on a caseby-case basis 2. The gold standard of treatment for endograft infections still remains the traditional total endograft explantation with debridement of infected tissue and arterial reconstruction, either in situ using biological conduit, or extra-anatomically using prosthetic graft. However, it is a demanding operation with reported mortality rates ranging from 20% to 30% 3. Preservation of the endograft followed by appropriate antibiotic therapy and percutaneous or surgical debridement has been reported as an alternative treatment in selected high risk patients who are unfit for open repair 2. In a recently published systematic review, the authors 2 identified seventeen studies with a total of 29 patients on treatment of endograft infection with preservation of the stent-graft. In 7% of the cases, endograft infection was diagnosed within 30 days of the initial procedure, in 14% within 3 months and in 76%, within 12 months. Among the study cases, 24.1% of the patients presented with a secondary aorto-enteric fistula. A total of 41.4% of the patients received only antibiotic therapy, while the remaining had an additional procedure including drainage, surgical debridement, sac irrigation, and/or omentoplasty. In-hospital mortality for the case series was 20.7%. Interestingly, overall mortality reached 45% after a mean follow-up period of 11 months, whereas none of the patients with secondary aorto-enteric fistula finally survived. Mortality among the patients who received only antibiotic therapy was 50%, whereas mortality among patients who underwent an additional procedure, was 41%. On the contrary, the opponents of the conservative treatment, namely the surgically treated group, reported also considerably high (28%) mortality rates 3. More specifically, graft excision followed by aortic ligation and extra-anatomic bypass or in situ reconstruction are presented with mortality rates of 30.9% and 22.2%, respectively. As a result, the quest for the optimal treatment of endograft infection is still out there. In a study 4 evaluated eleven patients of infected EVAR treated with percutaneous drainage and 12 patients treated with surgery, no periprocedural deaths occurred in the percutaneous drainage group, whereas six patients in the surgical group died in the perioperative period (p = .02). Endograft preservation with lifelong antibiotic administration accompanied by surgical debridement or CT-guided percutaneous drainage is not a largely advocated strategy for endograft infection management. However, it seems that can be reserved as a treatment option in severely ill patients with comorbidities who are poor candidates for major aortic reconstructive surgery. Larger studies are needed in order to examine the efficacy of this approach comparing to surgical conversion with endograft excision and in situ reconstruction or extra-anatomical bypass. REFERENCES 1. Becquemin JP, Allaire E, Desgranges P, Kobeiter H. Delayed complications following EVAR. Techniques in vascular and interventional radiology. 2005 Mar;8(1):30-40. 2. Moulakakis KG, Sfyroeras GS, Mylonas SN, Mantas G, Papapetrou A, Antonopoulos CN, Liapis CD. Outcome after preservation of infected abdominal aortic endografts. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists. 2014 Jun;21(3):448-55. 3. Setacci C, De Donato G, Setacci F, Chisci E, Perulli A, Galzerano G, et al. Management of abdominal endograft infection. The Journal of cardiovascular surgery. 2010 Feb;51(1):33-41. 4. Belair M, Soulez G, Oliva VL, Laperriere J, Gianfelice D, Blair JF, et al. Aortic graft infection: the value of percutaneous drainage. AJR American journal of roentgenology. 1998 Jul;171(1):119-24. 15

Friday January 23

Aortic infection Superficial femoral vein to replace aortic infection

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Ramesh K. Tripathi

Narayana Institute of Vascular Sciences, Bangalore, India AIM To report a single surgeon experience of using femoral vein to reconstruct a “neo-aorta” for infective aortic pathology. MATERIAL & METHODS Between 2001 and 2014, thirty-one patients were operated for infected infra-renal aortic pathology (23 mycotic AAA, 4 aorto-enteric fistula, 3 infected aortic dacron grafts and 1 infected endograft). “Femoral vein Neo- Aorta” was used for aortic reconstruction in 16 patients in a “pantaloon” configuration. In scenarios of high surgical risk, florid infection or poor quality of veins on duplex, alternative options for revascularization were utilized (7 axillo-femoral bypass, 7 silver Dacron graft, and 1 cryo aorta). All patients underwent a minimum of 6 months antibiotics and were followed up by CT scans at 3 and 6 months. If there was no sign of infection at 6 months patients were followed with serial abdominal ultrasound. RESULTS Of the 16 patients who underwent femoral vein “neo-aorta” reconstruction, 14 patients (85.7%) had a full recovery with freedom from infection and morbidity of up to 2 years. There was 1 death (6.25%). This patient developed blow out at aortic anastomotic end and was treated with an emergency aortic stent graft. He died 6 month later due to re-rupture. 30-day major morbidity included Deep Vein Thrombosis involving the left popliteal vein in 1 patient, who at 2 years also presented with post thrombotic syndrome with a non-healing venous ulcer and underwent a Sapheno-femoral bypass with eventual ulcer healing. Mean length of hospital stay was 11 days (range 7-21 days). CONCLUSION Femoral veins can be harvested and used effectively to reconstruct a “neo-aorta” for infected aortic fields with very low morbidity and mortality. A video demonstration of femoral vein harvest and neo-aorta creation will accompany this talk.

razy guys or pioneers? C The Role of Fenestrated/Branched aortic stent-grafts in chronic dissection Eric Verhoeven1, Hermann Renner1, Kyriakos Oikonomou1, Athanasios Katsargyris1, Wolfgang Ritter2

1. Department of Vascular and Endovascular Surgery, Paracelsus Medical University Nuernberg, Germany 2. Department of Radiology, Paracelsus Medical University Nuernberg, Germany INTRODUCTION Type B dissections are usually classified into acute and chronic (more than 2 weeks from the onset of symptoms). For complicated acute Type B dissections, urgent treatment is indicated. Acute complications include rupture, abdominal end-organ ischemia, lower limb ischemia, and although rare also spinal ischemia. Pleural effusion as a precursor to rupture and persistent thoracic pain are more and more also considered an indication for treatment. Uncomplicated type B dissections are nowadays more often also treated with early stent-grafting, in order to promote thrombosis of the false lumen, and subsequent remodelling of the aorta.1-4 A randomized controlled trial (ADSORB) has addressed whether acute uncomplicated type B dissections would benefit from preventive endovascular treatment. One-year results seem to support the benefits of early stent-grafting, although the trial was clearly underpowered to warrant definite conclusions.5 Whatever treatment option is chosen in acute Type B dissection, a significant number of surviving patients will develop post-dissection aneurysmal degeneration of the thoraco-abdominal aorta. Endovascular repair of aneurysms has proved to be a viable alternative to open surgery.6,7 Evolution towards fenestrated and branched stent-grafts soon made it possible to treat all types of aneurysms involving the visceral arteries. Results are consistent, and durability of both fenestrated grafts for complex abdominal aortic aneurysms, and fenestrated/branched grafts for thoraco-abdominal aortic aneurysms (TAAA) have been demonstrated.8-13 Post-dissection aneurysms were long regarded unsuitable due to the peculiar anatomy, but with initial positive reports, nowadays there is a serious interest to treat this complex pathology with fenestrated/branched grafts.14 TREATMENT INDICATION FOR CHRONIC TYPE B DISSECTION The main and probably only indication to treat a “chronic” Type B dissection is aneurysmal degeneration. This aneurysmal enlargement usually occurs over years and not within a couple of weeks. All other potential indications for treatment after the initial acute Type B dissection are extremely rare (late malperfusion, persistent pain). This report therefore discusses the late complications of acute type B dissection rather than the early complications that can occur later than two weeks from onset. A definition including sub-acute Type B dissection would help to fill the gap between the acute dissection and the late chronic dissection. If one accepts that treating a chronic Type B dissection is treating a post-dissection aneurysm, it logically means that the treatment should aim at excluding the aneurysm, either by open or by endovascular techniques. Most post-dissection aneurysms do not have a suitable distal neck above the celiac trunk, and are therefore thoraco-abdominal aneurysms. This makes the use of fenestrated/branched grafts mandatory in order to achieve exclusion of the aneurysm with preservation of the visceral branches of the aorta. Technical difficulties in the treatment of chronic type B dissections with fenestrated or branched grafts Fenestrated grafts including fenestrations only are used for complex abdominal aortic aneurysms, i.e., short-necked, juxtarenal, and suprarenal aneurysms. The fenestrations should ideally be positioned close to the aortic wall and the ostium of the target vessel, and the graft needs to be repositioned to allow for catheterization of each target vessel. The longer the distance between the fenestration and the ostium of the target vessel, the more unstable the connection becomes between the bridging covered stent and the nitinol-reinforced fenestration. In contrast, branched grafts are grafts with incorporated branches and are used in thoraco-abdominal aneurysms, where the distance between graft and target vessel is too long to use a fenestration. Branches provide a better fixation and sealing with the bridging covered stents. Downwards facing branches are obviously very suited in combination with visceral arteries pointing downwards at their origin (e.g., the celiac artery). It is accepted that branches need some “space”, as they should not 17

Friday January 23

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

be squashed against the aortic wall. One way to achieve some extra room for the branches is to taper down the diameter of the main graft. In chronic dissections, the four visceral branches of the aorta are usually involved. One specific feature in this pathology is the narrow true lumen. Due to this narrow true lumen, a fenestrated graft seems more suitable than a branched graft. Downwards facing branches, as mentioned above, can be needed when the take-off angle of the visceral artery makes it necessary to catheterize the vessel from above. Extra room, besides tapering down the main graft to the maximum, can be achieved by using a tube graft first with a distal landing zone a few cm above the visceral branches of the aorta. This should carefully widen the true lumen and allow for the branched graft to open completely. Experience has shown that only a small channel is needed for catheterization, and that the bridging graft can open the true lumen further. Another second specific feature in chronic Type B dissections is that the aortic visceral branches do not always originate from the same lumen. Especially the left renal artery is often originating from the false lumen with the other three vessels arising from the true lumen. Using a fenestrated graft then means using a technique to perforate the dissection flap in order to switch from one lumen to the other. This can be achieved by puncturing the dissection flap with a needle (e.g., TIPPS needle) or the stiffer back side of a wire. Guiding sheaths can be used for more support. After ballooning, the channel can be used to insert and deploy a bridging covered stent. Experience however has shown that switching from one lumen to the other is far more easy than initially expected, which probably underlines the need for complete exclusion, and that TEVAR only would not suffice to seal the expanding lumen of the aneurysm. PERSONAL EXPERIENCE Our initial experience in six cases was published earlier.15 A paper including 31 patients from two institutions, Regensburg and Nuernberg, is currently in press.16 Experience worldwide is growing quickly, with now over 100 cases having been performed. The Nuernberg experience now includes 26 patients. The grafts used usually include both fenestrations and downwards facing branches. In a number of cases, the celiac artery did not need attention, as it was already occluded, or highly stenosed. This allowed using a triple fenestration graft with three fenestrations for the superior mesenteric artery and the two renal arteries. This design obviously only needs a double femoral approach, and no upper approach. In our 26 patients, the technique was successful. Noteworthy is that 21 patients had previous surgery of any kind, either open for acute Type A dissection, or endovascular for acute Type B dissection. Mortality was two (7.7%) patients, due to multiple organ failure in one patient, and a myocardial infarct in another patient. During follow-up, there were no ruptures, and only two target vessels occluded, including one celiac artery, and one renal artery originating from the false lumen towards a smaller kidney (both occlusions asymptomatic). Endoleaks were seen frequently, either because there was still some flow in the false lumen, or because the bridging stent-graft in the target vessel did not seal well. Whether a type II endoleak in the false lumen of a chronic dissection aneurysm is persistent and requires additional treatment in the future remains to be determined. The type II endoleak may even contribute to the collateral flow of the spine and prevent paraplegia at an early stage. In our experience, most of the Type II endoleaks with flow in the false lumen regressed and even disappeared. The Type Ib endoleaks in target vessels were all (n=3) treated by graft extension in the target vessel, with success. The lesson learned was that one should probably stent somewhat deeper in the target vessel in dissection patients, to achieve long-term sealing. CONCLUSION Fenestrated and branched stent-grafts are a realistic option to treat chronic post-dissection aneurysms, especially in this high surgical risk patient group. CONFLICT OF INTEREST: Eric Verhoeven is consultant for Cook Medical, W.L. Gore & Associates, Atrium, and Siemens.

Friday January 23

REFERENCES 1. Estrera AL, Miller CC, Goodrick J, et al. Update on outcomes of acute Type B aortic dissection. Ann Thorac Surg 2007;83: S842-5. 2. Winnerkvist A, Lockowandt U, Rasmussen E, et al. A prospective study of medically treated acute type B aortic dissection. Eur J Vasc Endovasc Surg 2006;32: 349-55. 3. Sueyoshi E, Sakamoto I, Hayashi K, et al. Growth rate of aortic diameter in patients with type B Aortic Dissection during the chronic phase. Circulation 2004;110(11 Suppl 1): II256-61. 4. Song JM, KimSD, KimJH, et al. Long-term predictors of descending aorta aneurysmal change in patients with aortic dissection. J Am Coll Cardiol 2007;50:799-804. 5. Brunkwall J, Kasprzak P, Verhoeven E, Heijmen R, Taylor P, ADSORB Trialists. Endovascular repair of acute uncomplicated aortic Type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial. Eur J Vasc Endovasc Surg 2014;48(3):285-91. 6. Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004; 364(9437): 843-848 7. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351: 1607-1618. 8. Verhoeven EL, Vourliotakis G, Bos WT, et al. Fenestrated Stent Grafting for Short-necked and Juxtarenal Abdominal Aortic Aneurysm: An 8-year Single-centre Experience, Eur J Vasc Endovasc Surg 2010;39(5):529-536. 9. Amiot S, Haulon S, Becquemin JP, et al. Fenestrated Endovascular Grafting: The French Multicenter Experience, Eur J Vasc Endovasc Surg 2010;39(5):537-44. 10. Muhs BE, Verhoeven EL, Zeebregts CJ, Tielliu IF, Prins TR, Verhagen HJ, et al. Mid-term results of endovascular aneurysm repair with branched and fenestrated endografts. J Vasc Surg 2006; 44(1):9-15 11. Greenberg RK, Lytle B. Endovascular repair of thoracoabdominal aneurysms. Circulation. 2008;117:2288-2296. 12. Verhoeven EL, Tielliu IF, Bos WT, et al. Present and future of branched stent grafts in thoraco-abdominal aortic aneurysm repair: a single-centre experience. Eur J Vasc Endovasc Surg. 2009;38:155-161. 13. Haulon S, Dâ&#x20AC;&#x2122;Elia P, Oâ&#x20AC;&#x2122;Brien N, Sobocinski J, Perrot C, Lerussi G et al. Endovascular repair of thoracoabdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2010;39:171-8. 14. Trimarchi S, Righini P, Grassi V, Lomazzi C, Segreti S, Rampoldi V, Verhoeven EL. Do Branched and Fenestrated Devices have a role in Chronic Type B aortic Dissection? J Cardiovasc Surg. 2011; 52:529-538. 15. Verhoeven EL, Paraskevas KI, Oikonomou K, Yazar O, Ritter W, Pfister K, Kasprzak P. Fenestrated and branched stent-grafts to treat post-dissection chronic aortic aneurysms after initial treatment in the acute setting. J Endovasc Ther 2012;19(3):343-9. 16. Oikonomou K, Kopp R, Katsargyris A, Pfister K, Verhoeven EL, Kasprzak P. Outcomes of Fenestrated/Branched Endografting in Post-Dissection Thoraco-abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2014. doi: 10.1016/j.ejvs.2014.07.005.

razy guys or pioneers? C How to prevent SCI in TAAA endo repair

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Krassi Ivancev, Hamish Hamilton, Jason Constantinou

The Royal Free Hospital NHS Trust, London, United Kingdom Endovascular repair of thoracoabdominal aneurysms necessitates coverage of longer segments of the thoracic and abdominal aorta than open surgical grafting to obtain secure proximal and distal sealing zones for the endograft. This has implications on limitation of perfusion from the collaterals that feed the arterial blood supply to the spinal cord from above, via branches of the left subclavian artery, and below from collateral from the internal iliac arteries.1 A further major difference between open and endovascular techniques, which affects the potential for postoperative spinal cord ischaemia, is that with endovascular repair, unlike open repair, there is no potential to directly revascularise the intercostal arteries that supply the spinal cord, at the time of operation. To mitigate this, various strategies have been used to reduce the potential for spinal cord ischaemia. Another capability of open thoracoabdominal repair that is not precisely controlled in endovascular repair is the use of hypothermia as this is shown to preserve spinal cord function2. The experimental and clinical evidence that the spinal cord and paraspinal muscles have an inter connecting segmental arterial supply that can be developed with time, has also lead to changes in the endovascular management of thoracoabdominal aneurysms3 as regards using this arterial network to maintain perfusion when aortic segments have the segmental intercostal arteries covered. The basic effect of spinal cord ischaemia is that the injury results in spinal cord oedema, and to reduce pressure on the spinal cord the gradient between the mean arterial pressure and the cerebrospinal fluid pressure requires optimization. This can be done by maintaining the mean arterial pressure and cardiac stability, which maximizes oxygen delivery given, and by preventing hypoxemia and anaemia. Similarly, the cerebrospinal fluid pressure can be lowered in the short term with controlled spinal fluid drainage. Both these strategies maximize spinal cord perfusion pressure.4 Temporary postoperative spinal cord arterial perfusion can be achieved by sealing the aneurysm proximally and distally with the endograft and then connecting its visceral branches, but having a customised deliberate open perfusion branch made for the endograft. This temporarily perfuses the aortic sac and intercostal branches to the spinal cord, and then it is closed after an interval5. Another strategy is to avoid immediate connection of a visceral branch6, or leave the distal seal or create a lack of seal in between two thoracic endograft (type 3 endoleak). These all maintain intercostal perfusion, but at the risk of not initially treating the aneurysm completely. Sequential planning is useful in the prevention of spinal cord ischaemia, because by staging or separating the coverage of the aorta into smaller procedures, several objectives are reached. Firstly, the use of an extra-anatomic debranching procedure is used to maintain perfusion to a significant arterial branch, which will be covered by the endograft to obtain a sealing zone. For example, left subclavian artery malperfusion is avoided by staged carotid subclavian bypass. Its branches are recognized as a source of spinal cord perfusion. Secondly, if only part of the aorta is covered by the endograft, collaterals to the spinal cord develop and the critical threshold of intercostal coverage that promotes ischaemia is not reached at one operation7. Thirdly, the operations are shorter, with less blood loss and physiologically better tolerated. The use of perioperative MEPâ&#x20AC;&#x2122;s in endovascular grafting8 may be helpful in deciding whether to stage the procedure, leave a perfusion branch or provide adjunctive blood pressure elevation9.

REFERENCES 1. Eagleton MJ, Shah S, Petkosevek D, Mastracci TM, Greenberg RK. Hypogastric and subclavian artery patency affects onset and recovery of spinal cord ischemia associated with aortic endografting. Journal of Vascular Surgery.59(1):89-95. 2. Luehr M, Etz CD. Moderate-to-mild hypothermia may not be sufficient to protect the spinal cord during aortic arch surgery. European Journal of Cardio-Thoracic Surgery. 2014;45(4):767. 3. Etz CD, Kari FA, Mueller CS, Silovitz D, Brenner RM, Lin H-M, et al. The collateral network concept: A reassessment of the anatomy of spinal cord perfusion. The Journal of thoracic and cardiovascular surgery.141(4):1020-8. 4. Ullery BW, Cheung AT, Fairman RM, Jackson BM, Woo EY, Bavaria J, et al. Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair. Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. 2011;54(3):677-84. 5. Harrison SC, Agu O, Harris PL, Ivancev K. Elective sac perfusion to reduce the risk of neurologic events following endovascular repair of thoracoabdominal aneurysms. Journal of Vascular Surgery.55(4):1202-5. 6. Kasprzak PM, Gallis K, Cucuruz B, Pfister K, Janotta M, Kopp R. Editor’s Choice – Temporary Aneurysm Sac Perfusion as an Adjunct for Prevention of Spinal Cord Ischemia After Branched Endovascular Repair of Thoracoabdominal Aneurysms. European Journal of Vascular and Endovascular Surgery.48(3):258-65. 7. O’Callaghan A, Mastracci TM, Eagleton MJ. Staged endovascular repair of thoracoabdominal aortic aneurysms limits incidence and severity of spinal cord ischemia. Journal of Vascular Surgery. 8. Schurink GW, De Haan MW, Peppelenbosch AG, Mess W, Jacobs MJ. Spinal cord function monitoring during endovascular treatment of thoracoabdominal aneurysms: implications for staged procedures. The Journal of cardiovascular surgery. 2013;54(1 Suppl 1):117-24. 9. Schurink GW, Nijenhuis RJ, Backes WH, Mess W, de Haan MW, Mochtar B, et al. Assessment of spinal cord circulation and function in endovascular treatment of thoracic aortic aneurysms. Ann Thorac Surg. 2007;83(2):S877-81; discussion S90-2.

Friday January 23

In summary, the prevention of spinal cord ischaemia in the endovascular treatment of thoracoabdominal aneurysms now involves several strategies based on an evolving knowledge of spinal cord anatomy and physiology, but despite endovascular operations being less invasive the risks are as high as with open repair, as different reasons for spinal perfusion limitation are present.

rogress in EVAR treatment P Closure devices: which are the best?

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Ian loftus

St Georges, London, United Kingdom INTRODUCTION Local groin wound complications following endovascular aortic interventions, as a result of exposure of the common femoral arteries, are not insignificant. This has led some surgeons to develop alternative access techniques. Larzon described a minimal access suture technique of the cribriform fascia (fascial closure). However, complication rates are significant and the technique has not been widely adopted1, 2. Early attempts with a wholly P-EVAR approach proved disappointing3. However, advances in percutaneous arterial closure device technology and a reduction of stent-graft delivery profile have led to a resurgence in the interest for P-EVAR. The Perclose Prostar XL (Abbott) is the only device with formal approval for use in EVAR, though the Proglide system (Abbott) is widely used off-label4, 5. There are a number of fundamental differences between these devices, which will be demonstrated during the presentation. The percutaneous closure device is usually deployed prior to sheath placement in the “Preclose Technique”. Briefly, a small stab through the skin is made caudal to the common femoral artery. Some authors advocate blunt dissection when using Prostar, to facilitate sheath passage. Ultrasound is recommended to confirm correct puncture site. The initial sheath is replaced with the percutaneous closure device over a wire. The needles are deployed and sutures secured to avoid slippage and entanglement. Some centres use two Prostar devices for the main delivery system. The endovascular procedure is performed as usual. At the end of the procedure, the sheath is removed slowly while a knot is tied with the aid of a knot pusher. The skin is closed by a single suture or adhesive tape. Local variations in the techniques exist6, 7. This review analyses the evidence to support the use of P-EVAR over standard aortic stent-graft delivery through open arterial exposure in the groin. METHODS A systematic review of P-EVAR was performed from January 1991 – July 2009 using Ovid MEDLINE in-process and other non indexed citations and Ovid MEDLINE and EMBASE. Primary outcome was success rate of percutaneous closure. Secondary outcomes assessed were operative duration, hospital stay, time to ambulation, blood loss, cost and late locoregional complications. Study outcome heterogeneity was analysed by means of the Chi-squared test. Means were weighted and data pooled after significant study outcome heterogeneity was excluded and confidence intervals were provided if enough data was provided. Data on success rate and complication rates were analysed using Fisher’s exact test. A p- value less than 0 .05 was considered as significant. RESULTS The initial systematic search retrieved (311 articles, 258 for EMBASE). Limits were applied to work in English and involving humans (252 articles). 219 titles remained after excluding review articles and case reports. Manual review of the retrieved titles and abstracts after exclusion of duplicate and irrelevant publications resulted in a total of 22 titles. These included a randomised trial (n=1); prospective nonrandomised studies (n=8) and retrospective studies (n=13). One study (Lee 2007) 8 was excluded from pooling as it appeared that a later study 4 potentially shared a proportion of the patient population. Success rate of percutaneous closure The 22 retrieved papers reported on the success rate of percutaneous closure. The overall reported success rate of percutaneous closure (SR) was 91% (89.7-92.3, 95% CI). The rate of totally percutaneous closure (Where percutaneous closure was attempted and successful without open dissection in either groin) was reported in 13 studies as 79% (74.9-83.1, 95% CI). Factors potentially influencing Success rate Patient and device selection One study randomised patients suitable for EVAR into standard open femoral access versus percutaneous closure9. P-EVAR was offered to a series of consecutive patients in 13 studies3, 4, 6, 8, 10-17. Patient selection was not clear in 8 studies7, 18-22. Patients with thoracic aortic pathology were included in eight studies. Seven studies excluded heavy femoral artery calcification11-13, 17, 22. The 22

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next most common exclusion criterion was scarred groins in five studies10, 11, 13, 17, 22. Patients with femoral artery aneurysms were excluded in three studies9, 14, 22. There was no statistically significant difference in the percutaneous closure success rate in the studies that considered all comers 4, 6, 9, 15, 16 and the studies that excluded patients with femoral artery calcification and groin scarring 11, 13, 14, 17, 22. (94%, 92.3-95.7, 95% CI versus 91%, 88.2-93.8, 95% CI, p> 0.5) The majority of studies (n=19) used the Prostar XL. Three studies from two groups dealt with Proglide. The success rate in the Proglide group, 93.7% (91.5-95.9, 95% CI) was better than in the Prostar group 90% (88.4- 91.6, 95% CI) P=0.02. The complication rates in the Proglide group were 1.9% (1.5-4.3% ,95% CI) versus 4.8% (3.3-6/3%, 95% CI) for the Prostar group P= 0.03. Sheath size Details on percutaneous closure success rate according to sheath size was available in 10 studies. There was a tendency of success rate to decrease with increasing sheath size. Three studies reported a statistically significant difference in success rate with increasing sheath size 8, 14, 23. Sheath size was considered a reason for failure in 6 studies 3, 5, 9, 13, 14, 23, 24, and a cause of complications in three studies 8, 9, 13. Scarred groins Previous groin surgery was a reason for P-EVAR exclusion in four studies 10, 11, 13, 22. Despite attempting to exclude patients with scarred groins, failure was attributed to patients with scarred groins in one study22. Another study involving a significant proportion of patients with previous catheterisation and scarring found no correlation with failure21. Obesity Obesity was associated with P-EVAR failure in five studies 8, 9, 14 17, 22. However, in only one was this relationship statistically significant 17. One study found no correlation of failure with obesity 21. Access related complication rate The overall access-related complication in reviewed studies of P-EVAR was 4.4%. (3.5- 5.3, 95% CI). Seven papers compared data on access related complications with a control cohort of patients undergoing standard open groin arterial exposure 8-11, 15, 19, 21. Study heterogeneity was not significant and pooled data suggested P-EVAR was associated with less access-related complications, relative risk 0.47 (0.28-0.78, 95% CI), p= 0.004. Three studies associated an increase in access related complication rate in P-EVAR with sheath size 8, 9, 14. One showed a significant association of complications with large sheath size and obesity 14. Hospital Stay Hospital stay was reported in seven studies 10-12, 14-16, 25, 26. Mean hospital stay was 2.07 days. The difference in hospital stay between PEVAR and EVAR was assessed in three studies. In all three studies, hospital stay was shorter in patients undergoing P-EVAR group. P-EVAR was associated with a shorter hospital stay (2.7 vs. 3.5 days weighted mean) 10, 11, 15. One study reported a significant difference 11. Operative time Seven studies reviewed operative time 3, 8, 9, 11, 15, 16, 21, 24. P-EVAR was associated with less operative time compared to open groin exposure (106 vs. 145 minutes, weighted mean). Operative time was reported as significantly shorter in five out of the seven studies 3, 9, 15, 16, 21. Compared to EVAR, a significant proportion of PEVAR procedures was performed under local anaesthesia as reported in two studies 11, 15. Blood loss One study reported significantly loss blood loss in P-EVAR compared to O-EVAR 16. Although blood loss in P-EVAR and O-EVAR was similar, failed P-EVAR resulted in more blood loss 15, 24. The randomised controlled study reported similar blood loss in all three groups (P-EVAR, O-EVAR and failed P-EVAR) 9. Time to ambulation and cost Ambulation time was reported in three studies. One study reported ambulation in 81% of patients 4-6hrs following P-EVAR 7. Ambulation time was shorter for P-EVAR in comparison with O-EVAR 9, 15. One study reported less cost associated with P-EVAR, but this was statistically non significant 11. P-EVAR average procedure cost was â&#x201A;Ź99 more than O-EVAR group in the randomised study 7. Another study reported an overall increase in procedural cost despite a shorter operative time due to the cost of closure devices (US $295 per closure device) 8. Neither study explored the effect of reduced hospital stay on overall cost. Discussion The result of this systematic review of the evidence on percutaneous endovascular aneurysm repair was based on the available, published studies. Mostly, retrospective or prospective non randomised studies, with only one randomised controlled trial. This should be considered when interpreting results. Interestingly, the review results are close in many respects to the RCT9. Issues of selection bias should be considered, however it was possible to perform P-EVAR with good result in randomised and non selective patients (calcified arteries, scarred groins and obesity). In this systematic review, P-EVAR was shown to be both, a feasible and safe alternative to open femoral access. The overall success rate was high even in an unselected population 9 .Several studies included ruptured aneurysms, which may be a particularly attractive indication due to the feasibility to perform under local anaesthesia in unstable patients 19, 27. Vessel calcification, obesity and scarred groins were considered a contributory factor in failure in several studies. This should not be a deterrent to P-EVAR in this group of patients as it is these patients that would benefit the most from a whol-

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ly percutaneous approach. Despite this, there is a need to identify more clearly patients that are at risk of developing complications. Other outcomes measured were also in favour of P-EVAR. The overall access related complication rate in the all the included titles was low and comparable to the best results in O-EVAR series. The incidence of access related complication rate was significantly higher in O-EVAR in the cohort that reported complications in both P-EVAR and O-EVAR groups in the same study 8-11, 15, 19, 21. The two widely available percutaneous closure devices are the Perclose ProstarXL and the Perclose Proglide (Abbott). Three studies from two research groups used the Proglide 4, 8, 12 with the remaining studies reporting on the ProstarXL. Authors experienced with the Proglide report ease of manipulation and knot tying attributed to device design and the use of monofilament sutures in contrast to the braided sutures in the ProsrarXL 4, 12. In coronary interventions the braided sutures have been more prone to infection 28. The overall rate of infection remains low in P-EVAR. Difficulties in suture manipulation were initially reported as a reason for failure and conversion were more commonly seen with the Prostar device 3, 5, 13. The review results indicate a higher complication rate using the ProstarXL. However, these results should be interpreted with caution because of the off-label use in two centres with an enthusiasm for this device, which should be used with caution as it still lacks formal approval for use in EVAR. Several authors reported on device malfunction and faulty puncture as a cause of failure and complications particularly early in the experience (learning curve) 11, 13. High puncture site is usually associated with haemorrhage on mobilisation due to incorporating fibres of the inguinal ligament into the suture, and a low puncture can lead to ischaemia from vessel damage and occlusion. Preporocedural angiography through micropuncture sets can be used to confirm correct puncture site 14. More recently, intraoperative ultrasound guided puncture was found to significantly improve the success rate and reduce P-EVAR access related complications 6 and would be recommended as routine in all cases. Adoption of such adjuncts should be routine practice but more so in the initial learning curve where failures and complications were reported by several authors 3, 17. Femoral compression devices have been used following percutaneous closure, but evidence is lacking to whether this offers added benifit 24. The additional cost of percutaneous closure devices is still considered an obstacle preventing these devices from widespread use. As our results show, that P-EVAR was associated with an overall shorter operative time and hospital stay. This difference was reported as significant in several studies. It appears that this will shift the cost effectiveness ratio to P-EVAR particularly when a larger number of patients are treated with this modality. CONCLUSION P-EVAR appears safe and effective in selected patients. Local access related complications were comparable to the best O-EVAR series. More work is required to identify the most suitable candidates and there is little to guide which individual device is best. REFERENCES 1. Larzon T, Geijer H, Gruber G, Popek R, Norgren L. Fascia suturing of large access sites after endovascular treatment of aortic aneurysms and dissections. J Endovasc Ther 2006;13(2): 152-157. 2. Diethrich EB. What do we need to know to achieve durable endoluminal abdominal aortic aneurysm repair? Tex Heart Inst J 1997;24(3): 179-184. 3. Traul DK, Clair DG, Gray B, O’Hara PJ, Ouriel K. Percutaneous endovascular repair of infrarenal abdominal aortic aneurysms: a feasibility study. Journal of Vascular Surgery 2000;32(4): 770-776. 4. Lee WA, Brown MP, Nelson PR, Huber TS, Seeger JM. Midterm outcomes of femoral arteries after percutaneous endovascular aortic repair using the Preclose technique. J Vasc Surg 2008;47(5): 919-923. 5. Dosluoglu HH, Cherr GS, Harris LM, Dryjski ML. Total percutaneous endovascular repair of abdominal aortic aneurysms using Perclose ProGlide closure devices. Journal of Endovascular Therapy: Official Journal of the International Society of Endovascular Specialists 2007;14(2): 184-188. 6. Arthurs ZM, Starnes BW, Sohn VY, Singh N, Andersen CA. Ultrasound-guided access improves rate of access-related complications for totally percutaneous aortic aneurysm repair. Ann Vasc Surg 2008;22(6): 736-741. 7. Quinn SF, Kim J. Percutaneous femoral closure following stent-graft placement: use of the Perclose device. Cardiovasc Intervent Radiol 2004;27(3): 231-236. 8. Lee WA, Brown MP, Nelson PR, Huber TS. Total percutaneous access for endovascular aortic aneurysm repair (“Preclose” technique). J Vasc Surg 2007;45(6): 1095-1101.

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9. Torsello GB, Kasprzak B, Klenk E, Tessarek J, Osada N, Torsello GF. Endovascular suture versus cutdown for endovascular aneurysm repair: a prospective randomized pilot study. Journal of Vascular Surgery 2003;38(1): 78-82. 10. McDonnell CO, Forlee MV, Dowdall JF, Colgan MP, Madhavan P, Shanik GD, Moore DJ. Percutaneous endovascular abdominal aortic aneurysm repair leads to a reduction in wound complications. Irish Journal of Medical Science 2008;177(1): 49-52. 11. Jean-Baptiste E, Hassen-Khodja R, Haudebourg P, Bouillanne PJ, Declemy S, Batt M. Percutaneous closure devices for endovascular repair of infrarenal abdominal aortic aneurysms: a prospective, non-randomized comparative study. European Journal of Vascular & Endovascular Surgery 2008;35(4): 422-428. 12. Dosluoglu HH, Cherr GS, Harris LM, Dryjski ML, Dosluoglu HH, Cherr GS, Harris LM, Dryjski ML. Total percutaneous endovascular repair of abdominal aortic aneurysms using Perclose ProGlide closure devices. Journal of Endovascular Therapy: Official Journal of the International Society of Endovascular Specialists 2007;14(2): 184-188. 13. Watelet J, Gallot JC, Thomas P, Douvrin F, Plissonnier D. Percutaneous repair of aortic aneurysms: a prospective study of suture-mediated closure devices. European Journal of Vascular & Endovascular Surgery 2006;32(3): 261-265. 14. Starnes BW, Andersen CA, Ronsivalle JA, Stockmaster NR, Mullenix PS, Statler JD. Totally percutaneous aortic aneurysm repair: experience and prudence. J Vasc Surg 2006;43(2): 270-276. 15. Morasch MD, Kibbe MR, Evans ME, Meadows WS, Eskandari MK, Matsumura JS, Pearce WH. Percutaneous repair of abdominal aortic aneurysm. Journal of Vascular Surgery 2004;40(1): 12-16. 16. Howell M, Doughtery K, Strickman N, Krajcer Z. Percutaneous repair of abdominal aortic aneurysms using the AneuRx stent graft and the percutaneous vascular surgery device.[see comment]. Catheterization & Cardiovascular Interventions 2002;55(3): 281287. 17. Howell M, Villareal R, Krajcer Z. Percutaneous access and closure of femoral artery access sites associated with endoluminal repair of abdominal aortic aneurysms. Journal of Endovascular Therapy: Official Journal of the International Society of Endovascular Specialists 2001;8(1): 68-74. 18. Heyer KS, Resnick SA, Matsumura JS, Amaranto D, Eskandari MK, Heyer KS, Resnick SA, Matsumura JS, Amaranto D, Eskandari MK. Percutaneous Zenith endografting for abdominal aortic aneurysms. Annals of Vascular Surgery 2009;23(2): 167-171. 19. Najjar SF, Mueller KH, Ujiki MB, Morasch MD, Matsumura JS, Eskandari MK. Percutaneous endovascular repair of ruptured abdominal aortic aneurysms. Arch Surg 2007;142(11): 1049-1052. 20. Peterson BG, Matsumura JS, Morasch MD, West MA, Eskandari MK. Percutaneous endovascular repair of blunt thoracic aortic transection. J Trauma 2005;59(5): 1062-1065. 21. Rachel ES, Bergamini TM, Kinney EV, Jung MT, Kaebnick HW, Mitchell RA. Percutaneous endovascular abdominal aortic aneurysm repair. Ann Vasc Surg 2002;16(1): 43-49. 22. Teh LG, Sieunarine K, van Schie G, Goodman MA, Lawrence-Brown M, Prendergast FJ, Hartley D. Use of the percutaneous vascular surgery device for closure of femoral access sites during endovascular aneurysm repair: lessons from our experience. Eur J Vasc Endovasc Surg 2001;22(5): 418-423. 23. Rachel ES, Bergamini TM, Kinney EV, Jung MT, Kaebnick HW, Mitchell RA. Percutaneous endovascular abdominal aortic aneurysm repair. Annals of Vascular Surgery 2002;16(1): 43-49. 24. Borner G, Ivancev K, Sonesson B, Lindblad B, Griffin D, Malina M. Percutaneous AAA repair: is it safe? Journal of Endovascular Therapy: Official Journal of the International Society of Endovascular Specialists 2004;11(6): 621-626. 25. Quinn SF, Duke DJ, Baldwin SS, Bascom TH, Ruff SJ, Swangard RJ, DeHaas DR, Padgett RC, Bergin PJ, Lau S. Percutaneous placement of a low-profile stent-graft device for aortic dissections. J Vasc Interv Radiol 2002;13(8): 791-798. 26. Heyer KS, Resnick SA, Matsumura JS, Amaranto D, Eskandari MK. Percutaneous Zenith endografting for abdominal aortic aneurysms. Annals of Vascular Surgery 2009;23(2): 167-171. 27. Borner G, Ivancev K, Sonesson B, Lindblad B, Griffin D, Malina M, Borner G, Ivancev K, Sonesson B, Lindblad B, Griffin D, Malina M. Percutaneous AAA repair: is it safe? Journal of Endovascular Therapy: Official Journal of the International Society of Endovascular Specialists 2004;11(6): 621-626. 28. Johanning JM, Franklin DP, Elmore JR, Han DC. Femoral artery infections associated with percutaneous arterial closure devices. J Vasc Surg 2001;34(6): 983-985.

educing complications after EVAR R How to prevent renal injury after EVAR

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Hiroshi Banno, Kimihiro Komori

Nagoya University, Nagoya, Japan INTRODUCTION Acute kidney injury (AKI) after any type of intervention is associated with a high mortality rate, as well as with morbidity and prolonged hospitalizationn, and perhaps worsens long-term survival. In the case of endovascular aneurysm repair (EVAR), the incidence of AKI ranges from 1% to 19% for elective repair and has been similar or even less than open repair. The pathophysiology of AKI in EVAR is complex: contrast-induced nephropathy, renal microembolization, and acute tubular necrosis are all implicated. Prevention strategies include hydration, reduction of contrast volume, ischemic preconditioning, regional anesthesia, and pharmacological agents. In this study, we evaluate the perioperative estimated glomerular filtration rate (eGFR) using the most contemporary formula of patients in elderly and chronic kidney disease (CKD), and examine the predictive factors of AKI. METHODS 364 consecutive patients who underwent EVAR from June 2007 to September 2013 were retrospectively examined. The patients were divided into five groups based on CKD classification (G1, 2, 3a, 3b and4). AKI was defined as a decrease in eGFR>25% of baseline. RESULTS Mean age was 77.9 Âą 6.4 years. AKI occurred in 28 patients (7.7%) who were labeled the AKI group. The median dose of contrast agent (113ml for the AKI group versus 100ml for the non-AKI group; p=0.04) and the procedure time (196min for the AKI group versus 141min for the non-AKI group; p<0.0001) were significantly different between two groups. AKI occurred 0% in G1, 6.7% in G2, 11.1% in G3a, 8.7% in G3b, and 0% in G4. CONCLUSION The incidence of AKI after EVAR in patients with CKD is similar to that in patients with normal renal function. Longer procedure and large amount of contrast were predictors of AKI after EVAR. We also introduce our methods to reduce the volume of contrast during EVAR.

ew generation devices N Are new generation devices really better than previous ones? Marc RHM van Sambeek, Pieter Broos, Philuippe W Cuypers, Joep AW Teijink Department of Vascular surgery, Catharina Hospital, Eindhoven, The Netherlands

Since the introduction of endovascular aortic aneurysm repair (EVAR) in 1991, there have been substantial changes in the treatment of abdominal aortic aneurysms (AAAs). The success of EVAR, in terms of exclusion of the aneurysm and absence of perioperative and postoperative complications, is closely dependent on an AAA’s morphology and dimensions. Severe infrarenal aortic neck angulation and short infrarenal aortic necks are likely to cause more intraoperative and postoperative complications, such as graft migration and endoleakage, especially Type I endoleaks. With practitioners becoming more experienced with endovascular therapy and improving stent graft technology, an increasing number of patients with unfavorable aortic anatomy are treated with standard endograft devices. In this we want to compare the differences in perioperative and postoperative outcomes after endovascular repair of AAAs treated with a new generation endograft with results from randomized trials and registries with ‘older’ generation endografts For this analysis, we want to use data from 1263 patients prospectively enrolled in the ENGAGE registry. We will compare these data with results from DREAM Trial, EVAR I Trial, ACE Trial, OVER Trial and EuroSTAR Registry. RESULTS Comparison with the randomised trials is cumbersome due to differences in analysed outcome. Comparison with EuroSTAR Registry showed a significant reduction in conversion to open surgery, migration, endoleak Type I and III and secondary interventions CONCLUSION EVAR is getting better due to improve insight in the pathophysiology and due to new generation endografts.

Friday January 23

T ype 2 endoleaks Surgical ligation. How I do it, what are the results

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

C. Liapis, C. Antonopoulos

Chaidari, Greece

Endovascular aneurysm repair (EVAR) is currently used for the treatment of infrarenal abdominal aortic aneurysm repair for patients with suitable anatomical characteristics 1. However, endoleaks account for almost 60% of complications after EVAR and are responsible for more than 45% of all re-interventions 2. Among them, a high prevalence (10% - 30%) of type II endoleaks has been reported after EVAR. Furthermore, an increasing number of studies investigating the clinical relevance, natural history and evolution of type II endoleaks have been recently published, raising awareness concerning their benign course 3. A single optimal threshold for intervention or the best treatment strategy for patients with type II endoleak has not been strongly evidenced so far 1. Not all type II endoleaks seem to equivalent in terms of natural history and treatment. It has been proposed that persistent type II endoleaks may lead to aneurysm sac expansion or rupture, although this was not clearly confirmed by the European Collaborators on Stent Graft Techniques for Abdominal Aortic Aneurysm Repair (EUROSTAR) registry 2. Some studies suggest the safety of a conservative approach, even in cases of increasing aneurysm diameter, whereas others propose an intervention when the aneurysmal sac enlarges, or if the endolek does not resolve within 6 months of operation 2. Despite the debate on the indications of treatment of type II endoleaks, elective delayed open conversion with ligation of feeding arteries and preservation of the endograft has been reported with good results 4. A transperitoneal approach is used in most of the cases, whereas a few sporadic retroperitoneal cases have also been reported. A clamp is usually placed, but not closed below the renal arteries for potential control purpose. However, clamping of the infrarenal aorta that contains a stent graft can theoretically be cumbersome, resulting in stent graft damage or incomplete proximal control. As a result, the surgeon should be ready to proceed to suprarenal clamping, in cases of not completely hemostatic initial infrarenal clamping 5. After opening of the aneurysmal sac, a selective ligation of the culprit arteries causing a type II endoleak; lumbar artery, inferior mesenteric artery, or middle sacral artery is performed. Closure of the sac only after complete hemostasis and no back-bleeding and closure of the abdomen follow. Results of the technique, although reported by small case series, seem rather good. In a recent series of 10 cases, a zero 30-day mortality was recorded 5. However, special attention should be paid during maneuvers for culprit artery ligation, because it may lead to stent graft dislodgement. In the previous case series, 30% of the patients needed cut and removal under infrarenal clamping of the distal part of the stent graft and a tube graft placement. The surgeon should be aware that complete removal of the stent graft may have catastrophic consequence, as it may cause uncontrolled denudation/laceration of the juxtarenal aorta. It seems that open conversion for persistent type II endoleak can be safely performed without aortic cross-clamping. It seems to be a â&#x20AC;&#x153;minimally invasiveâ&#x20AC;? strategy, with short operative times and no hemodynamic consequences, eligible even for high-risk patients. REFERENCES 1. Avgerinos ED, Chaer RA, Makaroun MS. Type II endoleaks. Journal of vascular surgery. 2014 Aug 28. 2. El Batti S, Cochennec F, Roudot-Thoraval F, Becquemin JP. Type II endoleaks after endovascular repair of abdominal aortic aneurysm are not always a benign condition. Journal of vascular surgery. 2013 May;57(5):1291-7. 3. Cieri E, De Rango P, Isernia G, Simonte G, Ciucci A, Parlani G, et al. Type II endoleak is an enigmatic and unpredictable marker of worse outcome after endovascular aneurysm repair. Journal of vascular surgery. 2014 Apr;59(4):930-7. 4. Chaar CI, Eid R, Park T, Rhee RY, Abu-Hamad G, Tzeng E, et al. Delayed open conversions after endovascular abdominal aortic aneurysm repair. Journal of vascular surgery. 2012 Jun;55(6):1562-9 e1. 5. Klonaris C, Lioudaki S, Katsargyris A, Psathas E, Kouvelos G, Doulaptsis M, et al. Late open conversion after failed endovascular aortic aneurysm repair. Journal of vascular surgery. 2014 Feb;59(2):291-7. 28

Friday January 23

Figure. A lumbar artery (blue/white arrow) causing a type II endoleak. The black arrow indicates the arterial jet

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

arotid remaining questions C Should we stop investigating asymptomatic carotid stenoses: no we should not, CEA & CAS may be justified in some cases

Frank J. Veith

F rom New York University Langone Medical Center, New York, NY and The Cleveland Clinic, Cleveland, Ohio, USA The basis for invasive treatment of all carotid stenosis patients are the so-called Landmark trials comparing carotid endarterectomy (CEA) with best medical treatment vintage 1990 to 1995. These trials which include NASCET, ESCT, ACAS, ACST and others involved both symptomatic and asymptomatic patients. The benefits for symptomatic patients undergoing CEA were highly significant and quite dramatic in patients with >70% stenotic lesions. The benefits were less dramatic in symptomatic patients with 50-69% stenoses and in all patients with asymptomatic lesions. In such asymptomatic patients, all studies showed a reduction of stroke rates from about 2% per year to about 1% per year by CEA, and that it takes about 6 years for this benefit to outweigh the morbidity of the operation. Even then about 16 CEAs must be performed to prevent one stroke. Moreover, since completion of these Landmark trials, best medical treatment has improved markedly with the introduction and widespread use of statins, beta blockers, improved antiplatelet agents, ACE inhibitors and better control of diabetes and hypertension. Many of these treatments have been clearly shown to decrease stroke and death rates. It is therefore likely that current best medical treatment will be as effective as CEA in preventing strokes, particularly in asymptomatic patients. However, this remains to be shown in appropriate trials comparing CEA with current (vintage 2015) best medical treatment. Moreover, since no convincing Level I evidence yet exists to show that carotid angioplasty and stenting (CAS) is as effective and safe as CEA, there is also a pressing need not only to show this equivalence, but also to compare CAS with current (vintage 2015) best medical treatment. Since all studies have shown that both CEA and CAS have known complications, a small mortality rate and are costly, one can make a case that most patients with asymptomatic carotid stenosis should be treated by best medical therapy until such time as CAS and CEA can be shown to produce better outcomes. In addition to the need for appropriate studies to demonstrate such superior outcomes for interventional treatments, there is a need to develop better methods to determine which asymptomatic carotid stenosis are at a high risk of having a stroke so that invasive treatments can be used more selectively to reduce this risk. Many such methods show promise and are on the horizon, but further studies and trials to prove their value are needed.

arotid remaining questions C The future for carotid stenting is bright

Frank J. Veith

New York University Medical Center and the Cleveland Clinic, USA

Carotid artery stenting or CAS has undergone its ups and downs since it was first introduced in the late 1980s. In its early years CAS was greeted with skepticism, particularly by vascular surgeons. Despite this, CAS was increasingly embraced by interventional cardiologists as an extension of their technical skills with coronary stenting procedures. The demonstration that CAS usually produced showers of embolic particles lead to the introduction of a variety of cerebral protection devices to capture most of this debris. These and other technical advances lead to improved results which in turn were followed by widespread usage of CAS to treat asymptomatic as well as symptomatic carotid stenosis. Again interventional cardiologists were foremost in this enhanced usage. Nevertheless, because carotid endarterectomy (CEA), the alternative procedure for treating these lesions could be performed with good results and low morbidity and mortality, CAS remained highly controversial. This lead to several prospective randomized trials comparing the two procedures. The earlier of these trials, conducted in Europe, demonstrated lower periprocedural stroke rates for CEA in symptomatic patients, but were criticized for not employing state of the art CAS technology. A major multicenter US trial, CREST, had its 4 year results published in 2010. Symptomatic and asymptomatic patients were included. With up to 4 years follow-up, there was no difference in total adverse event rates between the two procedures. However, stroke rates were significantly higher in the CAS treated patients, while myocardial infarction rates were higher in the CEA treated patients. These data were interpreted in different ways by different specialists who were clearly influenced by their interventional or open surgical orientation and their bias. In addition, multiple Society guidelines, all based on data from the same trials, also differed in their main conclusions, again based on specialty orientation and bias. Nevetheless, at present, CAS usage is declining and CEA, because of its lower stroke rate, appears to be generally considered the procedure of choice for most patients around the world with symptomatic carotid stenosis. Exceptions in which CAS is chosen include some centers of excellence and some patients with unusual anatomy or surgical contraindications. This decline in CAS usage is furthered by the increasingly widespread opinion that most asymptomatic carotid stenosis patients are best treated by modern statin based medical therapy and require neither CAS nor CEA. Increasing numbers of experts have even opined that with current medical therapy no patient with asymptomatic carotid stenosis should undergo invasive treatment because the annual stroke rate is so low (<1% per year). According to this opinion, most asymptomatic patients who have undergone CAS derive no benefit, and up to 90% of reported CAS patients have been asymptomatic. Despite this dire status for CAS, I believe its future is bright for several reasons. All the level 1 evidence indicating that CAS carries a higher stroke rate than CEA were obtained from trials using CAS technology which is now obsolete. Improvements in CAS technology now on the horizon will likely decrease its periprocedural stroke rates. These improvements include better embolic protection systems featuring cessation or reversal of flow during the stenting and ballooning phases of CAS, parts of the procedure that are most productive of embolic debris. There is already some evidence that such protection is more effective than the commonly used distal filters, particularly with high risk and symptomatic lesions. In addition, avoiding transit of CAS devices through the aortic arch by using cervical access to the common carotid arteries reduces embolization from manipulation in diseased or tortuous aortic arches or proximal

Friday January 23

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

great vessels. Such complex arches are particularly common in elderly symptomatic patients who make up the bulk of candidates likely to benefit most from CAS. The recent introduction of a proprietary system to facilitate both cervical access and reversal of flow protection seems to be a particularly attractive way to improve CAS results, although such improvement with this Michi System from Silk Road Medical remains to be conclusively demonstrated. The current iteration of this system requires open exposure of the common carotid artery, but percutaneous modifications are on the drawing board. It is well known that many strokes with CAS become apparent several hours or days after the procedure is completed and the embolic protection device has been removed. It is thought that these strokes are the result of debris trapped in stent interstices, and such debris has been observed in bench top models of stented carotid lesions. When flow is restored, the trapped debris is freed as cerebral emboli, resulting in â&#x20AC;&#x153;delayed strokesâ&#x20AC;? after CAS. To obviate this problem, three companies are evaluating membrane or mesh covered carotid stents with much smaller interstices to prevent delayed embolization. Finally, evidence is accumulating that we are on the threshold of having methods available to select those few asymptomatic carotid stenosis patients that are at a high risk of having a stroke from their lesion. These methods involve detection of cerebral microemboli by transcranial doppler, techniques to evaluate various characteristics of carotid plaque morphology with duplex, MRI or CT imaging and detection of silent cerebral infarcts by CT or MR. Although none of these techniques is ready for widespread use, the likelihood is that one or more of them soon will be. If asymptomatic patients with such high risk lesions could be identified, it would become justified to treat them either by CEA or CAS, thereby adding to the patient group needing CAS treatment. CAS has been slow to gain widespread approval as a method to treat carotid bifurcation stenosis. Controversy and bias have been connected to the procedure and the interpretation of its results. Registry and trial findings have generated more heat than light. The new technology advances described herein give promise that CAS will emerge as an effective and justifiable mainstream treatment which has a bright future and will benefit many patients. Further studies to document that promise are in order.

arotid remaining questions C Can we operate a carotid stenosis based on duplex scanning only? Stavros K. Kakkos, Ioannis A. Tsolakis

Department of Vascular Surgery, University of Patras, Greece Duplex scanning has an established role as the initial diagnostic modality of choice in the assessment of carotid artery stenosis. Being a non-invasive test, Duplex has long time ago replaced diagnostic digital subtraction angiography (DSA) in order to eliminate its complications, including periprocedural stroke, which occurred in 1.3% in the ACAS trial. Over 30 years ago it was realized that in certain cases Duplex provided sufficient enough information, compared to the gold standard DSA, to allow carotid endarterectomy (CEA) to be performed without the use of DSA, a traditional prerequisite for arterial surgery. DSA indeed provides a detailed demonstration of the carotid artery anatomy including critical information on the extension of carotid atherosclerosis in relation to the carotid vascular bed and other anatomic information, all essential for proper patient selection and uneventful CEA.1 In the majority of patients with carotid stenosis, Duplex provides the anatomical information required to proceed to CEA; on the other hand it is evident that in some cases Duplex results are not interpretable and provide insufficient information to plan a CEA, and therefore a DSA is required.2, 3 During the last 10-15 years carotid artery diagnostic DSA has been mostly replaced by the non-invasive magnetic resonance angiography (MRA) and computed tomography angiography (CTA).4 Complete or near occlusion of the carotid artery on Duplex should be confirmed by CTA, because Duplex can misdiagnose a near occlusion for complete occlusion and vice versa, despite technological advances of ultrasound technology. The implications of the above are obvious, while near occlusion in symptomatic patients can be managed with best medical treatment according to the symptomatic carotid surgery trials, especially if there is string sign distal to the stenosis on CTA. An additional indication to perform carotid angiography is the presence of extensive acoustic shadowing or vessel tortuosity on Duplex scanning that precludes an accurate assessment of the severity of stenosis. Proximal and distal extension of the carotid plaque outside the field of the ultrasound or a high carotid bifurcation - above the angle of the mandible - should also prompt further investigation before any intervention is planned. Therefore the presence of technical limitations on Duplex in surgical candidates should be followed by further evaluation with angiography and as expected operative planning can be modified as demonstrated by an MRA study.5 The same recommendation applies for Duplex scans from vascular laboratories of unknown accreditation or validation. Others extend the indication for angiography to all patients with a symptomatic carotid stenosis, especially in cases where the stenosis itself cannot explain the symptoms reported by the patient. In the presence of a technically acceptable Duplex scan from an accredited laboratory it seems that further evaluation with angiography before CEA is not necessary, as demonstrated by a pilot study comparing CEA performed with Duplex scanning alone and CEA performed with mandatory preoperative DSA;6 however the small difference of perioperative stroke in favor of the DSA group might be the result of a type II error, rendering the study underpowered. In the absence of other randomized studies the recommendation to perform CEA with Duplex alone is based on level B evidence, additionally derived from case series and case-controlled studies.7, 8 Nevertheless, operating with Duplex alone (feasible in the majority of patients with carotid stenosis) is considered to be a cost saving policy. On the other hand others prefer to use routinely a second non-invasive test (CTA or MRA) before CEA, in order to increase specificity, by grading carotid artery stenosis more accurately and avoiding overtreatment in cases Duplex has overestimated the degree of stenosis or is erroneous.4, 9 An additional argument for routine preoperative angiography is the detection of more proximal CCA stenoses that should be also treated, however these are usually suspected on physical examination and Duplex scanning.10 A similar debate exists for distal tandem lesions. 33

Friday January 23

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

In summary, CEA can be safely performed based on Duplex scanning alone provided that certain safeguarding findings are present and the test is performed by an experienced and validated operator who reports that the examination has no technical limitations. In all other cases, or as a routine preoperative requirement, the liberal use of complementary angiography (CTA or MRA) is necessary. REFERENCES 1. Bain DJ, Fergie N, Quin RO, Greene M. Role of arteriography in the selection of patients for carotid endarterectomy. Br J Surg. 1998;85(6): 768-770. 2. Collins P, McKay I, Rajagoplan S, Bachoo P, Robb O, Brittenden J. Is carotid duplex scanning sufficient as the sole investigation prior to carotid endarterectomy? Br J Radiol. 2005;78(935): 1034-1037. 3. Loftus IM, McCarthy MJ, Pau H, Hartshorne T, Bell PR, London NJ, Naylor AR. Carotid endarterectomy without angiography does not compromise operative outcome. Eur J Vasc Endovasc Surg. 1998;16(6): 489-493. 4. Jaff MR, Goldmakher GV, Lev MH, Romero JM. Imaging of the carotid arteries: the role of duplex ultrasonography, magnetic resonance arteriography, and computerized tomographic arteriography. Vasc Med. 2008;13(4): 281-292. 5. Back MR, Rogers GA, Wilson JS, Johnson BL, Shames ML, Bandyk DF. Magnetic resonance angiography minimizes need for arteriography after inadequate carotid duplex ultrasound scanning. J Vasc Surg. 2003;38(3): 422-430; discussion 431. 6. Deriu GP, Milite D, Damiani N, Mercurio D, Bonvicini C, Lepidi S, Grego F. Carotid endarterectomy without angiography: a prospective randomised pilot study. Eur J Vasc Endovasc Surg. 2000;20(3): 250-253. 7. Logason K, Karacagil S, Hardemark HG, Bostrom A, Hellberg A, Ljungman C. Carotid artery endarterectomy solely based on duplex scan findings. Vasc Endovascular Surg. 2002;36(1): 9-15. 8. Thusay MM, Khoury M, Greene K. Carotid endarterectomy based on duplex ultrasound in patients with and without hemispheric symptoms. Am Surg. 2001;67(1): 1-6. 9. Nicholas GG, Osborne MA, Jaffe JW, Reed JFI, . Carotid artery stenosis: preoperative noninvasive evaluation in a community hospital. J Vasc Surg. 1995;22(1): 9-16. 10. McLaren JT, Donaghue CC, Drezner AD. Accuracy of carotid duplex examination to predict proximal and intrathoracic lesions. Am J Surg. 1996;172(2): 149-150.

Friday January 23

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Friday January 23 - Vascular access -

ONTROVERSY: Basilic vein transposition, the eternal debate C One stage

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Julien Sfeir, Carlos Saadeh

Lebanese University Hospital, Beirut, Lebanon Single Stage Brachio Basilic Arteriovenous Fistulas. BACKGROUND In the absence of a suitable cephalic vein or in patients with failed proximal arteriovenous fistulas (AVF), brachiobasilic transposition or superficialization is a preferred option over prosthetic grafts for creation of AV access. However there is still an ongoing debate as to which approach is better: the one-stage or twostage procedure. The objective of this study is to determine the clinical outcomes and complication rates of the one-stage brachiobasilic AVF. METHODS 106 brachiobasilic AVFs were created over a 7-year period. All procedures were performed using the superficialization technique: after mobilizing the basilic vein up to its junction with the brachial vein by ligating its branches, the arteriovenous anastomosis is completed with 5-0 polypropilene running sutures, followed by a careful anterolateral displacement of the basilic vein over the arm fascia. Duplex ultrasound was used preoperatively as well as postoperatively when deemed necessary. The primary outcome was patency at 1 and 2 years. Secondary outcomes consisted of time to maturation, functional patency, the incidence of AVF-related complications and the need for re-intervention. RESULTS 41% of all patients had diabetes mellitus while 70% were hypertensive. Mean age was 51 years. An ipsilateral central vein catheter was present during or just prior to the AVF creation in 17% of the patients. Mean time to use the fistula was 42 days. Edema of the arm was present in various degrees in almost all patients. Primary patency at 1 and 2 years was 90.5% and 84% respectively. Endovascular procedures for central vein stenosis were carried out in 12% of patients within 2 years of follow up. Secondary patency reached 89% at 1 year and 84% at 2 years. Wound complications included hematoma in 7.5% and infection in 3.7% of the fistulas. A moderate steal syndrome was detected in 4.7% of the patients, but none needed surgical repair. 1 patient (0.9%) suffered severe neuropathy which resolved 6 months later. No access-related deaths were observed. CONCLUSION The single stage AVF offers several advantages, including an early fistula use and high maturation rates. Compared with the 2-stage AVF results reported in the current literature, primary and secondary patency at 1 and 2 years are similar. When a brachiobasilic AVF is needed, we recommend the 1-stage approach to reduce the time intervals before hemodialysis.

ONTROVERSY: Which preoperative vein imaging? C Duplex ultrasound Gilbert Franco

Clinique Arago, Paris, France Arteriovenous fistula (AVF) at wrist is the primary and best option for vascular access in patients who need long-term intermittent haemodialysis. A large number of AVF (28 to 53%) never mature enough to allow dialysis. Routine preoperative duplex scanning ultrasound (US) cannot only increase the utilisation of native AVF for dialysis access, but also allow proper selection of a target vessel with adequate luminal diameter to improve outcome.Physical examination alone may be inadequate and although phlebography is known as gold standard to assess veins patency, preoperative ultrasound scanning, less invasive and less expensive, is routinely preferred. Beside vessels assessment, B mode ultrasound gives informations about texture of the soft tissue and depth of the vessels suggesting in some cases transposition in a more superficial position. The aim is to check patency of the deep venous system and to draw a complete mapping of the superficial veins. When normal, these vessels have an hypoechoic or anechoic lumen, sharply echogenic walls, and characteristic Doppler flow patterns that vary with changes in intrathoracic pressure. A suitable vein appears thin-walled, easily compressible and dilatable by means of a tourniquet. Normal valve leaflets appear thin and free within the lumen. Only US can provide such informations. Some limitations such as bone interposition prevent direct explorations of central veins but even if venography is more accurate in identifying a mild central vein stenosis, it cannot predict how it will evolve after angioaccess creation, as the flow patterns will be completely different .US screening is a highly valuable, cost effectivene, tool, especially in elderly patients, in diabetic patients and in patients with a history of previous AVF.

Friday January 23 - VASCULAR ACCESS

LECTURES The snuffbox arterio-venous fistula

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Marek Rawa

Polyclinique «Zerhoune » ex Polyclinique « Cornette de Saint Cyr», Meknès, Morocco The first AV fistula has to be established as distally as possible, giving a long segment of arterialized vein for repeated venipuncture and permitting creation of a further fistula proximally in the case of complication 2. The Snuffbox Fistula was described by Rassat JP on 1969 1. Between January 2011 end December 2012, 617 radio-cephalic AVF were created including 105 snuffbox fistulas. The procedure was performed under plexic anaesthesia and preventive hemostasis 3. A longitudinal 1-3 cm skin incision over the anatomical snuffbox was used. An side-to-end fistula was created between the cephalic vein and the radial artery, using continuous polypropylene sutures (8/0 Prolene, 9/0 Ethilone) with the aid of operative microscope. One patient thrombosed his fistula at the end of surgery, 9 patients were lost of survey, 5 were re-operated for non-maturation (new more proximal arterio-venous anastomosis), et 7 were re-operated for late failure (new more proximal arterio-venous anastomosis). One patient died with a functioning fistula. 82 patients were dialyzed by fistula at the date of the 31.03.2013 with observation period between 3 to 27 months. CONCLUSION The snuffbox fistula is the most distal site for AV fistula and therefore gives a long segment of vein for dialysis. The close proximity between the radial artery and the cephalic vein in the anatomical snuffbox allows easy anastomosis without mobilization and transposition of the vein. 1. Rassat JP, Moscovtchenko JF, Perrin J, Traeger J, La fistule artério veineuse dans la tabatière anatomique,Journal d’urologie et de néphrologie 1969, 75(suppl 12): 482 2. L. Wolowczyk1, A. J. Williams2, K. L. Donovan2 and C. P. Gibbons1; The Snuffbox Arteriovenous Fistula for Vascular Access Departments of 1 Vascular Surgery and 2 Nephrology, Morriston Hospital, Swansea, U.K.; Eur J Vasc Endovasc Surg 19, 70–76 (2000) 3. Bourquelot P; Preventive haemostasis with an inflatable tourniquet for microsurgical arteriovenous fistulas for haemodialysis; Microsurgery 1993; 14 (7) : 462-3

LECTURES Brachial vein transposition

1. Department of Vascular Surgery, Saint Joseph Hospital, Beirut, Lebanon 2. Department of Vascular Surgery, Polyclinique Cornette de St Cyr, Meknes, Morocco 3. Department of angiology, Clinique Arago, Paris, France 4. Department of interventional radiology, CMC Ambroise Paré, Neuilly Sur Seine, France 5. Department of interventional radiology, Clinique Alleray-Labrouste, Paris, France 6. Department of Vascular Surgery, Clinique Jouvenet, Paris, France

OBJECTIVES Brachio-brachial arteriovenous fistula (AVF) with vein superficialization in 2-stages is being increasingly reported 1, 2 for creation of an ultimate autogenous arteriovenous access in the upper limb. We hereby report our experience retrospectively. PATIENTS Over the last 25 years, 65 patients were considered for a two stage brachial artery-brachial vein autogenous fistula. M/F ratio was 34/31 and mean age was 53 years (11-84). Mean duration of previous treatment was 7 years (SD 17.2, range 0-34). Preoperative imaging included duplex scan in 48 patients and venography in 41 patients. TECHNIQUES Surgery (Figure 1) was achieved in 2 stages in all patients. The second-stage superficialization proved impossible in 35% of patients (23/65). It was carried out in 42 patients. RESULTS Success was defined as the ability to obtain a functional angioaccess. It was achieved in 38/42 (90%) patients. The delay between creation of the vascular access and its ﬁrst successful use was reported as 4.5 months (range=1.6-14). Access failure was noted in 4 patients: 2 were immediately lost to follow-up and 2 presented early complications which were neglected (one thrombosis, one low-flow). After the second stage (mean= 508 days), the mean flow was 1142 mL/min (SD 285, range 540-2200). Mean follow up was 2.2 years (SD 1.4, range 0.1 -11.8). At the end of the follow-up period, 21 accesses (50%) were functional, 2 patients had received a kidney transplantation, 5 patients were dead, 8 were lost to follow-up, and 4 accesses had had neglected thrombosis. Complications. (Table 1) Thrombosis and stenosis were the most frequent complications (N=15) and were treated percutaneously. Patency rates. (Table 2 and Figure 2) Primary patency rates (life-table method) at 1, 2 and 3 years were 80% ± 7%, 65% ± 9%, and 57% ± 12%, respectively. Secondary patency rates at 1, 2 and 3 years were 95% ± 4%, 81% ± 7%, and 71% ± 9%, respectively. CONCLUSION 2-stages brachio-brachial fistula appears as a plausible option in absence of any other possible native fistula in the upper extremity. However rigorous selection is mandatory and preoperative clinical and imaging criteria still need to be defined to avoid first stage failure.

Friday January 23 - VASCULAR ACCESS

Lamisse Karam1, Marek Rawa2, Gilbert Franco3, Bernard Beyssen4, Alain Raynaud5, Pierre Bourquelot6

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Figures

Operative view: starting dissection of the lateral brachial vein

Kaplan-Meier analysis of primary and secondary access patency

TABLES N째 Patients 10 5 1 2 3 2 3 1 1 1

Treatment Percutaneous transluminal angioplasty (PTA) Thromboaspiration + PTA Radial artery transposition (ref 2) Open surgery reduction Open surgery removal Wound infection: Drainage + Antibiotics Limberg skin flap Associated axillary vein superficialisation Occlusion with vascular plug 2 brachial veins arterialized, coils in one

Table 1. Complications Patency Primary Secondary

Year 1 2 3 1 2 3

Cumulative patency rate 80% 65% 57% 95% 81% 71%

Standard error 7% 9% 12% 4% 7% 9%

Table 2. Life table patency REFERENCES 1. Transposition of the brachial vein: A new source for autologous arteriovenous fistulas. Bazan HA and Harry Schanzer H. J Vasc Surg 2004; 40: 185-86. 2. Greenberg TI, May S, Suliman A, Angle N. The brachial artery-brachial vein fistula: expanding the possibilities for autogenous fistulae. J Vasc Surg 2008; 48:1245-50.

Friday January 23 - VASCULAR ACCESS

Complication Stenosis Thrombosis (5 occurrences for 1 patient in 11 years) High flow Vein aneurysm Pseudo aneurysm Infection Abscess at puncture site: AVF ligation + antibiotics Necrosis at puncture site Too short vein superficialisation Low-flow non matured AVF Distal ischemia

ONTROVERSY: Forearm fistula for everybody? C Yes, the radiologist will finish the job

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Eric Bresson

Infirmerie Protestante, Caluire, France Forearm fistula is definitely the best vascular access with the less complication rate and the longest secondary patency. Ageing population, increasing diabetes incidence and cardiovascular risk factors lead to create anastomosis with vessels in bad condition, like small and highly calcified arteries, fibrous or stenosed veins. Because of these poor anatomic conditions, frequent non-maturing fistulas are observed, needing close monitoring and early management. Surgical repairs may be technically difficult or ineffective. Endovascular approach, performed from the sixth week after anastomosis creation, can correct anatomic defects like one or several focal arterial or venous stenosis, underdeveloped calcified arteries or extensive venous fibrosis. The best results are obtained for arterial dysfunctions, the poorest for thrombotic non-matured forearm fistulas. Early color-doppler ultrasound between the forth and the sixth week explores the maturation failure, showing always an underlying cause such as stenosis or an inadequate enlargement of the artery, and helps to choose the best endovascular approach. These procedures can even be performed on non-dialyzed patients, with less than 5cc of iodine, diluted up to 90% without worsening residual renal function. Repeated procedures will often be required during the first year to provide more than 80% of patency at one year, without compromising a proximal anastomosis. Stenting need is unusual, mainly designed for managing angioplasty complications like vessel rupture wich can be avoided by using appropriate sized balloons and often corrected by low pressure balloon inflation alone. Endovascular procedures efficiency for non-maturing forearm vascular accesses should encourage the creation of forearm natives fistulas, even with poor condition vessels.

LECTURES Bleeding necrosis at puncture site: a simple stitch is enough? Pierre Bourquelot1, Laura Pettorini2, Jacopo Scrivano2, Paolo Menè2, Lamisse Karam1, Nicola Pirozzi2

1. Clinique Ambroise Paré, Neuilly sur Seine, France 2. Department of Clinical and Molecular Medicine, Sapienza University, Roma, Italy INTRODUCTION A local skin flap may be appropriate for treatment of skin necrosis complicating a haemodialysis angioaccess that is associated with bleeding a potentially lethal complication. Two recent series reported a total of 188 deaths by exsanguination 1-2. However, there is only one recent report of the various therapeutic options to be used in such cases 3-4. We therefore reviewed our series of end-stage renal disease patients who were treated by performing a locally rotated Limberg skin flap for angioaccess ulceration and bleeding 5-7 (Figure 1). OBJECTIVE To assess the efficacy of a Limberg skin flap to treat non-infected necrosis and bleeding at angioaccess puncture sites. METHODS Retrospective analysis of 40 selected (no infection, necrosis <20 mm diameter) patients (25 arteriovenous fistulae [AVF], 15 grafts) treated between 1998 and 2012 by rhomboid excision, vessel repair, and a locally rotated full-thickness Limberg skin flap 8-9 (Figure 2, Figure 3) together with early postoperative percutaneous transluminal angioplasty (PTA; n = 23/40). Preventive haemostasis was used whenever possible 10. Success was defined as wound healing and angioaccess patency without complications. RESULTS Success rates at 1 and 6 months were 96% (24/25) and 76% (19/25), respectively, for AVF, and 80% (12/15) and 40% (6/15) for arteriovenous grafts. Complications included flap necrosis (n = 2), graft thrombosis (n = 4), minor sepsis (n = 1), death (n = 2), and new puncture site necrosis (n = 3). Four patients were lost to follow-up. CONCLUSIONS Vessel or graft repair, PTA for distal stenoses and local debridement followed by a Limberg skin flap for tissue defects prevented further bleeding and maintained vascular access patency after 6 months in 25/40 (62%) patients. Keywords: angioaccess, arteriovenous, bleeding, cannulation, haemodialysis, Limberg, necrosis, skin flap. REFERENCES 1. Byard RW, James RA. Forensic issues in cases of fatal hemorrhage from arteriovenous dialysis access sites. Forensic Sci Med Pathol 2007;3:128-32. 2. Ellingson KD, Palekar RS, Lucero CA, Kurkjian KM, Chai SJ, Schlossberg DS, et al. Vascular access hemorrhages contribute to deaths among hemodialysis patients. Kidney Int 2012;82: 686-92. 3. Jaffers GJ, Fasola CG. Experience with ulcerated, bleeding autologous dialysis fistulas. J Vasc Access 2012;13:55-60. 4. Gill JR, Storck K, Kelly S. Fatal exsanguination from hemodialysis vascular access sites. Forensic Sci Med Pathol 2012;8:259-62. 5. Moosa HH, Peitzman AB, Thompson BR, Webster MW, Steed DL. Salvage of exposed arteriovenous hemodialysis fistulas. J Vasc Surg 1985;2:610-2. 6. Tellis VA, Weiss P, Matas AJ, Veith FJ. Skin-flap coverage of polytetrafluoroethylene vascular access graft exposed by previous infection. Surgery 1988;103:118-21. 7. Pirozzi N, Pettorini L, Scrivano J, Menè P, Karam L, Bourquelot P. Limberg skin flap for treatment of necrosis and bleeding at haemodialysis arteriovenous angioaccess puncture sites. Eur J Vasc Endovasc Surg. 2013 Sep;46(3):383-7. 8. Germann G. Principles of flap design for surgery of the hand. In: Levin LS, Germann G, editors. Atlas of hand clinic, local flap coverage about the hand. Philadelphia, PA: W.B. Saunders; 1998. 45

Friday January 23 - VASCULAR ACCESS

9. Lister GD, Gibson T. Closure of rhomboid skin defects: the flap of Limberg and Dufourmentel. Br J Plast Surg 1972;25:300-14. 10. Pirozzi N, Scrivano J, Pettorini L, Baldinelli M, Punzo G, MenĂ¨ P. Preventive hemostasis for haemodialysis vascular access surgical reinterventions. J Vasc Access 2013; 14(2): 193 â&#x20AC;&#x201C; 195.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Figures

Figure 1: Necrosis and bleeding at puncture sites a) before necrosis removal b) before tourniquet inflation

Figure 2: Limberg flap - operative view

Figure 3: Limberg flap - operating diagram

LECTURES A computational model for surgical planning of vascular access Jan Tordoir1, A. Caroli, S. Manini, L. Antiga, K. Passera, B. Ene-Iordache, S. Rota, A. Bode, F. van de Vosse, M. Malovrh, W. Huberts, R. Vanholder, A. Remuzzi 1. MUMC, Maastricht, The Netherlands

Computational approaches have been proposed for the simulation of hemodynamics and vascular wall dynamics in complex vascular networks, which can be used to predict blood flow volumes (BFV) (maturation) after vascular access (VA) creation. A pulse-wave propagation model has been developed to accurately predict preoperative and postoperative BFV in different AVF types and locations. These models estimate changes in BFV only immediately after surgery, but also simulation of vessel wall remodeling and consequent hemodynamic changes that are responsible for the so-called access maturation. A multicenter longitudinal clinical prospective study was conducted in patients with end-stage renal disease awaiting VA creation for HD treatment in the context of the EU-FP7 research project ARCH. In the study, on the basis of preoperative ultrasound (US) measurements, patient-specific potential changes in BFV that take place immediately after VA surgery and during the subsequent 6-week period (VA maturation) were determined. The predicted postoperative results were compared with real time patient. A total of 93 consecutive patients (mean age 62± 16 (19–85) years, 31% women, 33% diabetic) were enrolled in four European HD centers: Maastricht University Medical Center, The Netherlands ; Universzitetni Klinikni Center Ljubljana, Slovenia ; Ospedali Riuniti di Bergamo, Italy ; and Ghent University Hospital, Belgium. All patients underwent clinical and vascular US examinations preoperatively, and they were systematically followed up after VA surgery through clinical and US examinations for a period of 2 years. During each US examination, brachial, radial, and ulnar artery BFV and size of major arm vessel diameters were assessed. BFV measured in brachial artery after VA surgery was lower in distal AVFs as compared with proximal AVFs. Among RC AVFs, E-E anastomosis resulted in higher BFV than S-E (Figure 2). Preoperative vessel dimension and arterial BFV measured during US investigations were used as input parameters to predict postoperative diameters and BFVs at different time points after surgery. Predicted results were compared with measurements obtained by US examination at 1 day and 40 days after surgery. BFV prediction was more accurate at 40 days than immediately after surgery, regardless of AVF configuration. A good agreement was observed between measured and predicted brachial artery BFV in individual patients 40 days after surgery, for both proximal and distal AVF and for both AVF configurations, and this for the entire range of brachial artery BFV, fromo 300 ml/min to 4 2 l/min. Regression analysis between predicted and measured values of brachial artery BFV showed a high and statistically significant correlation for each of the four AVF configurations (R2 ranging from 0.77 to 0.96; Figure 3) AVF function in12 patients with fistula failure or nonfunction at 40 days after surgery were also modeled. Mean predicted brachial artery BFV averaged 635± 298 (range 415–1293) ml/min in patients with early AVF thrombosis (n. 8) and 292± 77 (range 183–355) ml/min in four patients with AVF nonmaturation.In these patients, predicted brachial artery BFV was below the threshold of 400 ml/min to perform HD. The availability of patient-specific prediction of BFV increase after VA surgery, based on different AVF configurations, would allow more efficient planning of AVF surgery and may increase the chance of achieving adequate increases in BFV at the end of VA maturation. For instance, predicting whether a distal anastomosis will result in adequate BFV or not would provide a suggestion to the surgeon for the use of more proximal location for the AVF, potentially reducing the rate of VA nonmaturation and avoiding the need for reoperation. The computational model can reliably predict, on the basis of the preoperative work-up of patients awaiting AVF creation, the resulting effect of a given VA surgery procedure in terms of vascular remodeling and changes in VA BFV.

Friday January 23 - VASCULAR ACCESS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Figure 1 The pressure and flow waveforms calculated by the model in the brachial artery and distal radial artery before surgery (solid), after the creation of a lower arm AVF (dashed) and after creation of an upper arm AVF (dotted). The anastomosis angle was set at 45 degrees.

Figure 2 B lood flow volume (BFV) adaptation following vascular Figure 3 Correlation between measured and predicted brachial access (VA) surgery in a subgroup of 52 patients with artery blood flow volume at 40 days after AVF surgery radiocephalic (RC) end to end (E-E) and side to end (S-E). in the group of 63 individual patients. (Empty circle: radiocephalic (RC) end to end (E-E); full circle: RC side to end (S-E); full triangle: brachiocephalic (BC) S-E; empty triangle: brachiobasilic (BB) S-E.) REFERENCES Huberts W, Bode AS, Kroon W et al. A pulse wave propagation model to support decision-making in vascular access planning in the clinic. Med Eng Phys 2012; 34: 233–248. Manini S, Passera K, Huberts W, Botti L, Antiga L, Remuzzi A. Computational model for simulation of vascular adaptation following vascular access surgery in haemodialysis patients. Comput Methods Biomech Biomed Engin. 2014;17(12):1358-67. Bode AS, Caroli A, Huberts W et al. Clinical study protocol for the ARCH project—computational modeling for improvement of outcome after vascular access creation. J Vasc Access 2011; 12: 369–376. Caroli A, Manini S, Antiga L, Passera K, Ene-Iordache B, Rota S, Remuzzi G, Bode A, Leermakers J, van de Vosse FN, Vanholder R, Malovrh M, Tordoir J, Remuzzi A; ARCH project Consortium. Validation of a patient-specific hemodynamic computational model for surgical planning of vascular access in hemodialysis patients. Kidney Int. 2013 Dec;84(6):1237-45. 48

ONTROVERSY: Anastomotic techniques reduce C 1/ Juxta-anastomotic stenosis 2/ High flow? Not sure Gilbert Franco

Clinique Arago, Paris Reminder: side to side (STS) short anastomosis 3 to 5 mm at wrist was the model chosen by Brescia and Cimino and Appel fifty years ago achieving 86% patency rate!!!! So what have we learned during this period? Mechanical stress activates adhesion molecules after arterio venous fistula (AVF) creation but intense response is limited to the first 1 to 4 cm. AVF creation results in 3 fold increase in wall shear stress (WSS) that results in nitric oxide production (NO) and 3-fold increase in luminal venous calibre. Unlike healthy veins, with potential for successful remodelling and maturation, renal insufficiency induces vasculopathy and intimal hyperplasia leading to non-maturation. If intimal hyperplasia (IH) outbalances outward remodelling, stenosis and fistula failure occur. Juxta-anastomotic stenosis is the predominant lesion, independent of fistula type, involving mainly the swing point. Is it caused by anastomotic technique, inadequate sizing of the anastomosis, mobilization of the vein, or others additional factors as underestimated pre-existing wall lesions, injury of valves by torsion or only by uncontrolled IH? Is anastomotic technique the main factor? Computational fluid dynamic evaluation of the AVF anastomosis brings theoretical arguments about impact of anastomosis type, size and angle that we can summarize as: - STS and 90° end to side (ETS) anastomosis had the lowest pressure drops - 45° ETS anastomosis configuration had the highest pressure drop - STS anastomosis may have desirable characteristics in terms of flow and prevention of HI. - Pressure drop decreases with increasing anastomosis cross-sectional area. - End-to-side anastomosis induces three-dimensional movement of the vein and “torsional stress zone” even more important if the vein artery-distance is longer. But computational fluid dynamic evaluation have many important limits: as evaluation of dissection, vessel tension, twisting, compliance, patient blood pressure, cardiac output, size, shape, and compliance could not be modelled, vessel compliance are considered the same for arteries and veins etc… The situation of angle shape and size of AVF anastomosis are in continuous remodelling. Flow reduction is an important issue, that, unfortunately, a theoretical approach based on Poiseuille’s law fails to solve. According to this law, a 50% reduction in radius should increase resistance 16-fold (1500% increase). In fact total resistance increases only by 16%, because microcirculation comprises about 70% of the total resistances, and large artery resistance is only about 1% of the total resistances. A critical stenosis is typically thought of in terms of a 75% reduction in the diameter leading to flow reduction. This is why banding fails to reduce high flow.

Friday January 23 - VASCULAR ACCESS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ONTROVERSY: What’s next when upper limb access sites are C exhausted? Lower limb femoral vein transposition is the best choice Miltos Lazarides

Democritus University, Alexandroupolis, Greece The existing DOQI guidelines provide no clear algorithm for patients who have exhausted all conventional upper extremity access options; most such patients are presented with intractable arm edema due to central vein obstruction not amenable to angioplasty or stenting. The guidelines suggest chest wall or “necklace” prosthetic grafts or lower extremity fistulas or grafts not stating any order of preference. Long-term catheters should be avoided because lower patency was recorded and infection-free survival was far worse for catheters than for thigh grafts.1 Regarding the choice between all other existing options femoral vein transposition is theoretically superior as is the only autologous procedure with optimal long-term patency and unimportant infection rate. In a recent study reporting the results of the hybrid procedure HeRo (Hemodialysis Reliable Outflow) device compared with lower extremity AV grafts, the primary patency of the lower extremity grafts was significantly superior.2 One may assume that comparison with the autologous femoral vein transposition would have been even better in favor of the latter procedure. The femoral vein transposition autogenous or composite,3 represents an attractive reliable tertiary option compared to the totally prosthetic various chest-wall access procedures or the HeRo device. However, femoral vein transposition is contraindicated for obese or patients with peripheral arteriopathy as may be complicated in these subgroups with severe healing problems or limb threatening steal. The following Figure depicts the suggested algorithm when all upper extremity options are exhausted.4

Algorithm of available accesses when all upper extremity options are exhausted REFERENCES 1. Song Ong et al Long-term outcomes of arteriovenous thigh grafts in hemodialysis patients: A comparison with tunneled dialysis catheters Clin J Am Soc Nephrol 8: 804–809, 2013 2. Steerman SN, Wagner J, Higgins JA, et al. Outcomes comparison of HeRO and lower extremity arteriovenous grafts in patients with long-standing renal failure. J Vasc Surg. 2013;57:776-783 3. Georgakarakos EI, Georgiadis GS, Schoretsanitis NG, Kapoulas KC, Lazarides MK. Composite PTFE-transposed superficial femoral vein for lower limb arteriovenous access.J Vasc Access. 2011;12:253-257 4 Lazarides MK et al Extra- and intrathoracic access. J Vasc Access 2014; 15(suppl 7) 125-129

LECTURES Femoral vein superficialisation

Department of Vascular Surgery: 1. Clinique Jouvenet, Paris, France. 2. Polyclinique Cornette de St Cyr, Meknes, Morocco. 3. CMC Ambroise Paré, Neuilly sur Seine, France. 4. Department of angiology: Clinique Arago, Paris, France.

INTRODUCTION When all autogenous access options in the upper limb have been exhausted, an autogenous access in lower limb is a valuable alternative 1,2,3,4 to arteriovenous grafts. We report our experience of the femoral vein transposition (FVT). METHODS Seventy patients underwent 72 FVs in two centers (Paris and Meknes) with the same techniques (Figures 1-2). All patients had exhausted upper arm veins or had central vein obstructions. Patients were followed by serial duplex scanning. All complications were recorded and statistical analysis of patency was performed according to intention to treat using the life-table and Kaplan-Meïer methods. RESULTS The mean interval between initiation of dialysis and creation of the FVT was 10 years. The sex ratio was even (one female/one male). Mean age was 48 years (range, 1-84 years), and there were no postoperative infections. Duplex measurements in 33 patients indicated high-flow: mean = 1529 ± 429 mL/min; range, 700-3000 mL/min. Two immediate failures were observed and four patients were lost to follow-up soon after the access creation. Ten patients (14%) experienced minor complications (hematoma, five; lymphocele, one; delayed wound healing, two; distal edema, two) and 30 patients (42%) experienced mild complications (femoral vein and outflow stenosis, 16 [treated by percutaneous transluminal angioplasty (Figure 3 a-b), 13, or polytetrafluoroethylene patch, three]; puncture site complications, three [ischemia, two; infection, one]; reversible thrombosis, three [two surgical and one percutaneous thrombectomy]; abandoned thrombosis, eight [11%] after a mean patency of 8.1 years). Thirteen patients (18%) experienced major complications necessitating fistula ligation (ischemic complications, five diabetic patients with peripheral arterial occlusive disease [one major amputation included]; lower leg compartment syndrome, one; acute venous hypertension, two; secondary major edema, two; high-output cardiac failure, one; bleeding, two). All the patent accesses (59/72) were utilized for dialysis after a mean interval of 2 ± 1 months (range, 1-7 months) resulting in an 82% success rate. According to life-table analysis, the primary patency rates at 1 and 9 years were 91% ± 4% and 45% ± 11%, respectively. The secondary patency rates at 1 and 9 years were 84% ± 5% and 56% ± 9%, respectively (Figure 4). CONCLUSION Femoral vein transposition in the lower limb is a valuable alternative to arteriovenous grafts in terms of infection and long-term patency. Secondary venous percutaneous angioplasties may be necessary. High flow rates are frequently observed and patient selection is essential to avoid ischemic complications. REFERENCES 1. Gradman WS, Cohen W, Haji-Aghaii M. Arteriovenous fistula construction in the thigh with transposed superficial femoral vein: our initial experience. J Vase Surg 2001;33:968-75. 2. Tüzüner A, Hazinedaroglu SM, Ayli D, Demirer S, Duman N, and Yerdel V. Femoral vein transposition versus femoral loop grafts for hemodialysis: a prospective evaluation. Transplantation Proceedings, 36, 000 (2004) 3. Gradman WS, Laub J, Cohen W. Femoral vein transposition for arteriovenous hemodialysis access: improved patient selection and intraoperative measures reduce postoperative ischemia. J Vasc Surg 2005;41:279-84. 4. Bourquelot P, Rawa M, Van Laere 0, Franco G. Long-term results of femoral vein transposition for autogenous arteriovenous hemodialysis access. J Vase Surg 2012;56:440-5. 51

Friday January 23 - VASCULAR ACCESS

Pierre Bourquelot1, Marek Rawa2, Olivier Van Laere3, Gilbert Franco4

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

LEGENDS

Figure 1. Operative view: femoral artery-femoral vein side-to-end anastomosis.

Figure 2. Femoral vein is tunneled distally.

Figure 3. Secondary stenosis of outflow iliac veins, before (A) and after (B) percutaneous transluminal angioplasty.

Figure 4. Primary (solid line) and secondary (dashed line) patency rates after transposition of the femoral vein (n=72) according to the Kaplan Me誰er method. 52

LECTURES Outcomes comparison of HeRO and lower extremity arteriovenous grafts

Jason Wagner

Pittsburgh, USA OBJECTIVE The Hemodialysis Reliable Outflow (HeRO) graft is becoming a recognized alternative to lower extremity arteriovenous grafts (LEAVGs) as an option for patients who have exhausted traditional upper extremity access; however, which should be applied preferentially is unclear. METHODS A retrospective review of LEAVG and HeRO implants from January 2004 to August 2010 was performed. Patient demographics, medical history, procedural data, and outcomes were evaluated. RESULTS Within the time periods, 60 HeROs were placed in 59 patients and 22 LEAVGs were placed in 21 patients. Demographics were similar between the two groups for many factors; however, the patients who underwent HeRO placement had significantly higher body mass index compared with the LEAVG group. Mean follow-up was 13.9 months for the HeRO group and 11.9 months for the LEAVG group. The HeRO patients underwent a mean of 6.3 previous tunneled dialysis catheter insertions and 3.1 previous AVG/ arteriovenous fistula placements. The LEAVG patients underwent placement of a mean of 4.1 previous tunneled dialysis catheters and 2.6 previous AVG/arteriovenous fistulas. The principal difference was the number of interventions to maintain patency, which was 2.21 per year in the HeRO group and 1.17 per year in the AVG group (P [ .003) Secondary patency at 6 months was 77% for the HeRO patients and 83% for the LEAVG patients (P [ .14). The HeRO and LEAVG groups had no difference in infection rate per 1000 days (0.61 vs 0.71; P [ .77) or mortality rate (22% vs 19% respectively; P [.22) at 6 months. CONCLUSIONS In access challenged patients, LEAVG and HeRO offer similar rates of secondary patency, infection, and allcause mortality. The LEAVG required fewer interventions to maintain patency, and the HeRO maintains the benefit of utilizing the upper extremity site of venous drainage.

Friday January 23 - VASCULAR ACCESS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

L ECTURES Treatment of aneurysmal angioaccess: What is better to keep a functioning haemodialysis access? Mohamed Morsy

Renal and Transplantation Unit, St Georgeâ&#x20AC;&#x2122;s Hospital, London, United Kingdom INTRODUCTION Angioaccess aneurysms are not uncommon. They include true degenerative and false aneurysms. True aneurysms affect mainly the autogenous or biological angioaccess and evolve over long time, while false aneurysms affect both autogenous and prosthetic angioaccess following needling trauma. The incidence of aneurysmal formation varies between 6%-43%1,2. True aneurysms are located juxtaanastomotic/ anastomotic, mid-access or further upstream, either localised post-stenotic, pre-stenotic or at the site of frequent needling or diffuse aneurysmal dilatation affecting the whole vein2 in patients on steroids or unused angioaccess (Figures 1-5). DIAGNOSIS AND MANAGEMENT OF ANEURYSMAL ANGIOACCESS Aneurysmal angioaccess is exposed to a wide range of complications including complete/partial thrombosis, being unsuitable for needling, shortening of needling segment, unhealthy skin cover or signs of impending rupture including shininess/thinning, infection or redness of the covering skin and rapid expansion. These changes might be associated with inefficient dialysis, venous hypertension, prolonged bleeding after needling or aspiration of clots2,3. Duplex scan and fistulogram are required looking for pre or post aneurysmal stenosis, thrombosis, velocity, flow and central veins. Surveillance is required in a regular basis if intervention is not indicated. The majority does not need intervention. The indications for intervention include stenosis, rapid expansion, involvement of arteriovenous anastomosis, unhealthy overlying skin or skin infection, shortness of needling area, thrombosis or risk of rupture and all false aneurysms (DOQI)4. The rescue modality depends on local expertise and feasibility. However, the most important determinant is the timing of intervention. Surgical rescue1,5-7, endovascular rescue (angioplasty/stenting)8,9 or hybrid approaches10 are advocated options. Depending on presentation, location, skin condition, thrombosis or stenosis, surgical rescue include end to end repair (resection of aneurysmal segment and repair), New anastomosis (complete removal of juxta anastomotic aneurysmal dilatation and high implantation), Aneurysmorraphy (partial wall resection/plication or stapling and repair), Repair using synthetic graft (interposition graft after resection of aneurismal segment or exclusion and bypass), Endovascular thrombectomy and dilatation, Thrombin injection in false aneurysm, Hybrid approach Endovascular/surgical (surgical repair/PTA/stent graft). The use of endografts to exclude aneurysm and treat stenotic segments8-11 is suggested to be a useful option. However, a range of complications with stents including haemorrhage, migration, erosion, fracture, and rupture at the site of the stent grafts were reported11,12. LOCAL EXPERIENCE Over the last 2 years, 11 aneurysmal angioaccess required rescue in our centre, including 7 braciocephalic (BC) (6 true and one false), 3 radiocephalic (RC) (true) and one bravhioaxillary prosthetic angioaccess (false). The indications for intervention were thrombosis in 4 (3 BC and one RC), rapidly expanding with unhealthy skin in 2 BC, one false BC and one false prosthetic aneurysms and 3 (2 RC and one BC) presented with declining flow and partial thrombosis. Postenotic aneurysms were noted in 6 cases (4 BC and 2 RC), 4 of these were associated with frequent needling sites. Three (2BC, one RC) were associated with pre-aneurysmal stenosis. Surgical rescue included end to end repair after resection of the aneurysmal segment in 2, aneurothmoraphy, declotting and dilatation in 5, exclusion and bypass graft in 2 and simple repair and thrombin injection in 2 false aneurysms. All rescued angioaccess were used within 24 hours post-rescue except in 2 cases used after one week.

REFERENCES 1. Woo K, Cook PR, Garg J, Hye RJ, Canty TG. Midterm results of a novel technique to salvage autogenous dialysis access in aneurysmal arteriovenous fistulas. J Vasc Surg. 2010 Apr;51(4):921-5, 925.e1. doi: 10.1016/j.jvs.2009.10.122. 2. Valenti D, Mistry H, Stephenson M. A Novel Classification System for Autogenous Arteriovenous Fistula Aneurysms in Renal Access Patients. Vasc Endovascular Surg. 2014 Dec 8. pii: 1538574414561229. [Epub ahead of print] 3. Padberg FT Jr, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: recognition and management. J Vasc Surg. 2008 Nov;48(5 Suppl):55S-80S. 4. DOQI http://www2.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/va_guide5.htm 5. Hossny A. Partial aneurysmectomy for salvage of autogenous arteriovenous fistula with complicated venous aneurysms. J Vasc Surg. 2014 Apr;59(4):1073-7. 6. Georgiadis GS, Lazarides MK, Panagoutsos SA, Kantartzi KM, Lambidis CD,Staramos DN, Vargemezis VA. Surgical revision of complicated false and true vascular access-related aneurysms. J Vasc Surg. 2008 Jun;47(6):1284-1291. 7. Furukawa H. Surgical management of vascular access related aneurysms tosalvage dialysis access: case report and a systematic review of the literature. J Vasc Access. 2014 Nov 17;0(0):0.[Epub ahead of print] 8. Shemesh D, Goldin I, Zaghal I, Berelowitz D, Verstandig AG, Olsha O. Stent graft treatment for hemodialysis access aneurysms. J Vasc Surg. 2011 Oct;54(4):1088-94. 9. Shah AS, Valdes J, Charlton-Ouw KM, Chen Z, Coogan SM, Amer HM, Estrera AL, Safi HJ, Azizzadeh A. Endovascular treatment of hemodialysis access pseudoaneurysms. J Vasc Surg. 2012 Apr;55(4):1058-62. 10. Georgiadis GS, Nikolopoulos E, Papanas N, Mourvati E, Panagoutsos S, Lazarides MK. A hybrid approach to salvage a failing long-standing autogenous aneurysmal fistula in a hemodialysis patient. Int J Artif Organs. 2010 Nov;33(11):819-23. 11. Peden EK. Role of stent grafts for the treatment of failing hemodialysis accesses. Semin Vasc Surg. 2011 Jun;24(2):119-27. 12. Zink JN, Netzley R, Erzurum V, Wright D. Complications of endovascular grafts in the treatment of pseudoaneurysms and stenoses in arteriovenous access. J Vasc Surg. 2013 Jan;57(1):144-8.

Friday January 23 - VASCULAR ACCESS

CONCLUSION Presentation of aneurysmal angioaccess varies. The majority does not need intervention. Various rescue procedures can be used individually or in combination including endovascular intervention. However, surgical intervention is the preferred and recommended rescue modality.

Figures

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Figure 1. Duplex Ultrasound scan showing false aneurysms Figure 2. Aneurysmal Brachiocephalic angioaccess (a) Prosthetic and (b) Brachiocephalic Angioaccess. (needling sites with skin changes)

Figure 3. Aneurysmal Radiocephalic angioaccess (Juxtaanastomotic)

Figure 4. Aneurysmal Radiocephalic angioaccess (post-stenotic)

Figure 5. Aneurysmal Brachiocephalic angioaccess (complex: diffuse/needling sites)

LECTURES Rethinking central vein stenosis

Scott Trerotola

Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA Central venous stenosis (CVS) in hemodialysis patients is considered by many a problem uniquely associated with catheter use and which always needs treatment. Many believe that CVS is less prevalent in those with fistulae compared to those with grafts, and that symptoms from CVS do not relate to access location. A large proportion of interventionalists of all types treat CVS regardless of symptoms; many do so because they believe it improves access function. Most would not use pressure measurements in CVS to guide therapy. Several recent publications regarding CVS have challenged each of these notions or built on existing literature in that regard. A French study 1 has reinforced the concept of not treating asymptomatic CVS 2, and very importantly has demonstrated that CVS is not at all limited to those with prior catheterization-63% of the patients in that study never had a catheter! Our group has codified the relationship between access location and symptomatic CVS, showing that regardless of access type, upper arm access is more likely to be symptomatic, and that fistulae are less likely to be symptomatic with CVS regardless of location. Further, in that study CVS was equally distributed between those with fistulae and those with grafts 3. Another study from our group has demonstrated that there is little if any relationship between access flow (related to function) and CVS, with patients who had symptomatic CVS responding clinically to PTA regardless of flow changes 4. Regarding decision making, a recent study used pressure measurements during CVS PTA, applying a 5 mm Hg cutoff and comparing this to percent residual stenosis post PTA 5. Using 12 month postintervention primary patency, these authors found that while percent residual stenosis did not predict patency, pullback pressures did, but only if the residual stenosis was >30%. Applying this simple and inexpensive problem solving tool will help to curb the continued explosion of stent and stent-graft use. In summary, evolving literature has caused us to rethink CVS. REFERENCES 1. Renaud CJ, Francois M, Nony A, Fodil-Cherif M, Turmel-Rodrigues L, Comparative outcomes of treated symptomatic versus nontreated asymptomatic high-grade central vein stenoses in the outflow of predominantly dialysisfistulas. Nephrol Dial Transplant 2012;27:1631-1638. 2. Levit RD, Cohen RM, Kwak A, Asymptomatic central venous stenosis in hemodialysis patients. Radiology 2007;238:1051-105 3. Kothari S and Trerotola SO. Central venous stenosis is more often symptomatic in hemodialysis patients with grafts compared to fistulae (abstract). JVIR 2014;25:S 181-182. 4. Yan Y, Sudheendra D, Dagli M, et al, Effect of central venous angioplasty on hemodialysis access circuit flow (abstract). JVIR 2014;25:S19-20. 5. Lin Y, Yang C, Chu C, et al, The role of postintervention pullback pressure gradient in percutaneous transluminal angioplasty for central vein stenosis in hemodialysis patients. Cardiovasc Intervent Radiol 2013;36:1296-1305.

Friday January 23 - VASCULAR ACCESS

ONTROVERSY: Stents and stent grafts in AV access C Stent-grafts are better

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Scott Trerotola

Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA Evidence-based practitioners rely on level 1 evidence to guide interventions whenever it is available. Fortunately, such evidence in now available to guide decisions regarding stent and stent graft use in AV access, at least in certain areas. After a series of 1990s randomized trials (RCT) showing PTA and bare metal stents (BMS) to be comparable at best, several trials of stent grafts (SG) have shown them to be superior to PTA. That said, it must be kept in mind that the only evidence supporting such devices over PTA is at the veingraft anastomosis in grafts (AVG) and in treating in-stent restenosis in BMS. There are as yet no randomized data supporting these devices over PTA as primary treatment in fistulae (AVF). The Flair trial showed roughly a doubling of patency when a SG was used at the venous anastomosis 1. These results were replicated in the RENOVA study at 12 months 2. In the REVISE trial (ViaBahn), comparable improvements were seen in access circuit primary patency (ACPP) and target lesion primary patency at 6 months 3. The latter study included clotted grafts, and benefit was shown in that group as well. The RESCUE RCT of SG in BMS restenosis showed superior patency of Fluency over PTA at 6 months, although ACPP was poor in both groups (3% vs 16.7%, P<0.001) 4. To date there is but one trial comparing BMS to SG; a small RCT comparing S to SG in the terminal arch of the cephalic vein showed fairly convincing evidence of superiority of the covered device in this location 5. However, since no RCT of SG or S versus PTA in this location has been performed, there is no evidence that either is preferable to PTA. In summary, balloon angioplasty remains the mainstay of therapy for most lesions in hemodialysis access. When a stent device is used, it should be a stent-graft based on available evidence. REFERENCES 1. Haskal ZJ, Trerotola S, Dolmatch B, et al. Stent graft versus balloon angioplasty for failing dialysis-access grafts. N Engl J Med 2010; 362:494-503. 2. Haskal Z, Twelve month results of the RENOVA trial: a prospective multicenter randomized, concurrently-controlled comparison of the Flair endovascular stent graft vs. balloon angioplasty in dialysis access grafts. JVIR 2013;24:S5 (abstract) 3. Vesely T, Rodriguez A, Summary of the Gore REVISE Clinical Study. Endovascular Today June 2014 (supplement), 22-26. 4. Falk A, Maya I, Yevzlin A, Six-month results of the RESCUE trial: FLUENCY PLUS endovascular stent graft versus PTA for in-stent restenosis. JVIR 2014;25;661 (abstract) 5. Shemesh D, Goldin I, Zaghal I, Berlowitz D, Raveh D, Olsha O. Angioplasty with stent graft versus bare stent for recurrent cephalic arch stenosis in autogenous arteriovenous access for hemodialysis: a prospective randomized clinical trial. J Vasc Surg 2008; 48:1524-1531, 1531 e1521-1522.

LECTURES Treatement of stenosis and thrombosis in Morocco without interventional radiology Marek Rawa

Polyclinique Zerhoune formerly Polyclinique Cornette de Saint Cyr, Meknes, Morocco In Morocco, interventional radiology is uncommon, and the surgeon is frequently the one who needs to address complications of arterio-venous fistulae (AVFs). Stenosis is most common complication of AVFâ&#x20AC;&#x2122;s. Untreated stenosis often leads to thrombosis. Stenosis should be treated as soon as the low rate of flow prevents effective dialysis. If the flow rate falls below 400 ml/ min, thrombosis is imminent. Thrombosis should be treated as soon as possible to be able to continue dialysis without having to place a catheter. The goal of surgical intervention is to immediately reestablish AVF functionality while also preserving as much of the length of the arterialized vein as possible. Post-anastomotic stenosis is treated by creating a new or latero-terminal or latero-lateral anastomosis depending on the position of the vessels. Stenosis at the distal and middle third of the forearm is treated by a new latero-lateral anastomosis, which also allows the preservation of existing points of punctures. Stenosis in the proximal third of the forearm is treated by latero-lateral or latero-terminal anastomosis. Post anastomotic stenosis of the cephalic vein is treated using a short graft of polytetrafluoroethylene (PTFE) even though not a lasting fix. It does however allow for another AVF without needing to place a catheter. Stenosis of the distal segment of the basilic vein is treated with a new anastomosis given the veinâ&#x20AC;&#x2122;s proximity to the artery. In 2013 I operated 427 patients for vascular access including 375 for AVFs or for AVF complications, 310 of these patients were operated for radio-cephalic fistulae, 84 patients (diagnosed with stenosis or thrombosis of the arterial vein) were considered. In 11 patients the AVF was abandoned because it was determined to be unrecoverable. 73 patients were operated â&#x20AC;&#x201C; and of these, 69 were able to resume dialysis via the AVF. In four patients the intervention was unsuccessful on account of either early thrombosis or low flow. In conclusion, there are many advantages to interventional radiology in treating AVF complications. However, in absence of this technology, surgeons can save many fistulas through surgical intervention. Last year, 69 of 73 patients diagnosed with stenosis or thrombosis of the arterial vein were able to resume AVF dialysis following surgery.

Friday January 23 - VASCULAR ACCESS

LECTURES Plug for angioaccess occlusion or flow reduction

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Karam L.1, Beyssen B.2, Raynaud A.2, Bourquelot P.3

1. Department of vascular surgery, Saint Joseph Hospital, Beirut, Lebanon. 2. Department of Interventional Radiology, Clinique Alleray-Labrouste, Paris, France. 3. Department of Angioaccess Surgery, Clinique Jouvenet, Paris, France. BACKGROUND Use of the Amplatzer vascular plug (AVP; St. Jude Medical Inc, St. Paul, Minn) for minimally invasive occlusion of an angioaccess is an emerging practice 1,2,3. Only a few reports have been published. We hereby report a multidisciplinary experience of this technique not only for angioaccess occlusion but also for flow reduction in selected patients. METHODS Amplatzer vascular plugs (Figure 1) are self-expandable nitinol mesh occlusion devices used for performing transcatheter embolization. They have the ability to be recaptured and repositioned, if necessary. AVP deployment was through a 4F to 8F sheath (Figure 2), with oversizing from 30% to 50% to reduce the risk of migration. This preliminary study includes a series of 21 plugs of different types (I, II, and IV) and diameters (4 to 16mm) used in 20 hemodialysed patient treated between February 2010 and December 2012. Mean age was 58Âą33 years (range 13 to 87). Mean age of fistulas was 3.5 years (range 0.06 to 14). All fistulas were autologous angioaccess fistulas located in the elbow except 4. Angioaccess occlusion (n=14), by placing the AVP in the vein at its origin, was performed for central vein occlusion after unsuccessful percutaneous recanalization (n=4), high flow (n=2), hand ischemia (n=3), successful kidney transplant (n=1), and brachio-basilic or brachialbrachial fistula second-stage superficialization technical failure (n=4). Vein/ polytetrafluoroethylene grafts were not removed. Angioaccess flow reduction (n=6), by placing the AVP in the radial artery (Figure 3 A B C), was performed for well-tolerated high flow (n=3) or high flow associated with distal ischemia (n=3). All patients underwent a postoperative evaluation at 6-month intervals that included a clinical examination and duplex scan. RESULTS AVA occlusion or flow reduction was successfully achieved in all patients. Ischemia persisted in one patient and a revascularization with a distal bypass was necessary. The patient with brachial artery pseudoaneurysm required a secondary open surgery. Mean follow-up was 1.2Âą0.8 years (range 2 months to 2.9 years). No plug migration, access revascularization, or other complications were observed. Conclusion: Surgical ligation of an arteriovenous fistula is sometimes technically challenging, especially at the elbow level. Multiple coils delivery in large and high flow vessels is associated with a high risk of migration. The results of this short preliminary study suggest that plug insertion for angioaccess occlusion or flow reduction constitutes a reasonable alternative to coil insertion or to open surgery in selected patients.

Figure 1. Amplatzer vascular plug.

Figure 2. Technique of percutaneous plug occlusion of a hemodialysis arteriovenous fistula.

Figure 3. Percutaneous plug flow reduction of a hemodialysis arteriovenous fistula (AVF) in a 5-year-old child with a preoperative flow in the fistula of 1.5 L/min. A: Angiography during the procedure showing an early bifurcation of the brachial artery and the upper arm radial-basilic fistula. B: Plug delivery in the radial artery proximal to the fistula. C: Complete vascular occlusion with reduction of the postoperative flow to 0.95 L/min. REFERENCES 1. Powell S, Narlawar R, Odetoyinbo T, Littler P, Oweis D, Sharma A, Bakran A. Early experience with the Amplatzer Vascular Plug II for occlusive purposes in arteriovenous hemodialysis access. Cardiovasc Intervent Radiol. 2010 Feb;33(1):150-6. 2. Gumus B. Percutaneous embolization of hemodialysis fistulas byAmplatzer vascular plug with midterm follow-up. J Vasc Interv Radiol 2011;22: 1581-5. 3. Bourquelot P, Karam L, Raynaud A, Beyssen B, Ricco JB. Amplatzer vascular plug for occlusion or flow reduction of hemodialysis arteriovenous access. J Vasc Surg. 2014 ;59:260-3. 61

Friday January 23 - VASCULAR ACCESS

LEGENDS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Saturday January 24 - Main program -

I maging: do we really need these costly machines? Behcet disease: a nightmare for the vascular surgeon?

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Younes Bensaid

Souissi Rabat, Morocco INTRODUCTION The vasculitis of Behçet’s disease (BD) is distinctive because of involvement of both arteries and veins of all sizes. While venous manifestations are frequent and have been reported in many publications, data regarding arteriel lesions in patients with BD are rare and often isolated. 55 patients with artey involvement secondary to Behçet’s Disease were followed in the department of vascular surgery at the Avicenne Hospital in Rabat (Morocco). We retrospectively studied their cases and their outcome after vascular surgery. METHODS The main locations of arterial lesions were the femoral and iliac arteries (n=29), the aorta (n=22). Other arterial lesions involved carotid arteries (n=5), popliteal artery (n=4), infrapopliteal artery (n=4), superior mesenteric artery (n=1) and upper limb artery (n=3). Behçet was diagnosed on the basis of the behçet’s disease international study group criteria. All patients underwent surgical intervention. The graft interposition with PTFE (n=19) or saphenous vein (n=11) was most commonly employed to vascularize the limbs, but also ligation (n=3), patch (n=2) and stent (n=1) were used. We performed for the aorta, aortic tube graft interposition (n=12), aorto bifemoral bypass (n=4), aorto biiliac bypass (n=2) and patch graft (n=4), with associated procedure: renal artery (n=2) and visceral artery (n=2) revascularization. Excision and reconstruction by interposition graft (n=2), excision and end to end anastomosis (n=1), endarterectomy (n=1) and ascending aorta-carotid artery bypass (n=1) were performed in carotid artery. Excision and revascularization of superior mesenteric artery were used in one case. 54% of patients received immunosuppression with cyclophosphamide and corticosteroids before the operation. All of them received that medication in the postoperative period. RESULTS 2 patients with AAA and another with iliac involvement died during the postoperative period (1 lackage, 2 systemic decompensated BD), 2 others presented totally regressive paraparesis. Concerning limbs, 7 cases of grafts thrombosis were observed. One of ilio-caval phlebitis with renal failure was reported. About carotid involvement, one ischemic stroke was observed. The mean follow up was 10 years, while 16 patients were lost to follow up. 6 patients presented intermittent claudicating and 5 cases of anastomosis aneurysm were observed. 5 cases of secondary locations, were observed. One patient presented a prosthesis infection and another an aorto enteric fistula. CONCLUSION Behçet’s disease gives rise to a nosologic problem. The surgical indications is still difficult. The excessive rate of post-operative thrombosis must reduce the surgical indications in presence of arterial stenosis, however aneurysms are a surgical emergency as their rupture is a rule. The course has tendancy to thrombosis and blindness reduces naturally the walking distance. In addition, there are several technical problems : Dissection too difficult to be performed (Periarterial fibrosis), thrombo-endarterectomy impossible to be carried out (parietal thickening), young subject requiring non prothetic material ( but vena can be attained).

uptured aneurysms R EVAR vs Open Repair for ruptured AAAs: the recent randomized trials do not help

Frank J. Veith

New York University Medical Center and the Cleveland Clinic, USA Although some vascular surgeons are convinced that EVAR is superior to open repair for the treatment of ruptured abdominal aortic aneurysms (RAAAs), the issue remains controversial. The nay-sayers for the superiority of EVAR in this setting claim that all data showing superior outcomes for EVAR are flawed by patient selection, and they demand level 1 evidence from randomized comparisons of EVAR and open repair. Three such randomized controlled trials (RCTs) have recently published or presented their results: the AJAX or Amsterdam (Dutch) trial1, the ECAR or French trial2 and the IMPROVE or UK trial3. All three trials concluded that 30-day mortality outcomes after EVAR are no better than those after open repair. However, in these three trials this conclusion is rendered unjustified or misleading because of serious flaws or misinterpretation of the trial data. Let us examine the specifics. The AJAX and ECAR trials randomized small numbers (116,107) of patients and had the serious flaw of excluding hypotensive or unstable RAAA patients. Such high risk patients are precisely the ones who are most likely to have better outcomes with EVAR than with open repair. Therefore, exclusion of these high risk patients precludes these trials from demonstrating the advantage EVAR might have in the overall population of patients with RAAAs. In addition, both these trials may have used, in a suboptimal fashion, 3 adjuncts generally believed to improve EVAR outcomes. Better usage of fluid restriction (hypotensive hemostasis), supra-aortic balloon control and open abdomen treatment of abdominal compartment syndrome might have further improved the EVAR outcomes in both trials. In contrast to these two smaller RCTs, the larger UK IMPROVE trial was conducted in 30 high volume centers. Although 652 possible RAAA patients were excluded for various reasons, the trialists did randomize 613 patients with a diagnosis of RAAA to either an ENDOVASCULAR STRATEGY (316 patients) or OPEN REPAIR (297 patients). Patients were randomized before CT scans were performed. The 30-day mortality in the Endovascular Strategy group was 35%; in the Open Repair group it was 37%. Obviously there was no significant difference, and a primary conclusion of the main IMPROVE trial article3 was “A strategy of endovascular repair was not associated with significant reduction in 30-day mortality”. This was paraphrased in various news report headlines as, “NO DIFFERENCE BETWEEN ENDOVASCULAR & OPEN REPAIR”. However, the detailed data from the IMPROVE trial must be examined closely to see why these conclusions are misleading. Of the patients randomized to the Endovascular Strategy group, only 154 (about half) actually underwent EVAR; 112 had an open repair and 17 had no treatment. The 30-day mortality in this group was 27% for those treated by EVAR, and 38% for those treated by open repair. Of the patients randomized to the Open Repair group, 36 actually had EVAR, 220 had open repair and 19 had no treatment. The 30-day mortality in this Open Repair group was 22% for those undergoing EVAR and 37% for those undergoing open repair. Overall in the two randomized groups, taken together, the 30-day mortality for RAAA patients actually treated by EVAR was 25% and for those actually treated by Open Repair, it was 38%. Clearly the conclusion of the IMPROVE trial should have been, in patients with a RAAA, if they can be treated by EVAR, their 30-day survival will be superior. If one adds to this the fact that patients undergoing EVAR are less likely to receive no treatment, the conclusion is inescapable: EVAR is superior to Open Repair for the treatment of patients with RAAAs.

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Thus, those treating RAAA patients must learn how to do EVAR in this setting, including acquiring expertise in all the adjuncts and strategies that can improve EVAR outcomes in such patients. We do not need further RCTs to confuse the issue any more. 1. Reimerink JJ, et al. Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial. Ann Surg 2013;258:248-56. 2. Desgranges P, Kobeiter H, and the ECAR Investigators. Results of the ECAR RCT comparing EVAR and open repair for Ruptured AAAs. Presented at the 2013 VEITHsymposium. www.veithondemand.com/2013 3. IMPROVE trial Investigtors, Powell JT, et al. Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial. BMJ 2014;348:f7661.

thics: you said ethics? E Mortality Rates in the Newspapers: the Fatal Mistakes of the Brits Ian Loftus

In response to a number of healthcare ‘scandals’ in the UK, the National Health Service (NHS) launched an agenda called ‘Everyone Counts’. In theory this is to put the patient at the heart of the planning and structure of healthcare. The fundamental themes include greater patient choice, more transparency, more information available to the public, better quality of data especially relating to outcomes, all leading to higher standards of care. As part of this agenda, the NHS decided to publish individual surgeon level outcomes for 10 specialist societies including vascular surgery, from 2013. These were to be determined from a National Vascular Database (NVD) which had been run by the Vascular Society of Great Britain and Ireland for a number of years, as an audit and research tool. Data submission until 2013 had been non-mandatory, though data ascertainment levels had increased year on year. The data have been used in previous years to drive quality improvement programmes in aneurysm and carotid surgery, which have dramatically improved outcomes. Following publication of the surgeon level outcomes on aneurysm and carotid surgery, some surgeons were subjected to gross misinterpretation of data by local and national media, despite press briefings by the Council of the Vascular Society and the Royal College of Surgeons of England. Concerns about possible misinterpretation of individualized outcomes data had been expressed to the NHS by a number of the surgical societies, and appeals made that Unit level data would be a more appropriate tool for guiding patient choice. Many of the problems related to relatively low volumes of procedures, especially aneurysm repair. A small number of deaths within a very low caseload volume was, in many cases, incorrectly determined to be an unacceptably high mortality rate, despite being within what could occur within normal statistical “chance”. Indeed throughout the process, there were no surgeons with mortality rates outside of an acceptable range. We have repeatedly recommended that individualized outcomes should be interpreted alongside unit level data and steps taken to prevent data being interpreted as a form of “league table”. However, a further round of surgeon level data has been mandated by HQIP during 2014 and we can assume this will continue on a yearly basis. A number of fundamental changes have been made to the way in which data will be displayed which will be demonstrated during the presentation. However many problems remain with the analysis and interpretation of the data, including dealing with missing data, inaccurate data, and appropriate risk adjustment. The latest round of reports will show that, as a group, we continue to make dramatic improvements to our carotid and aneurysm services, with a continued decline in perioperative mortality for aneurysm surgery, and decline in time from symptom to surgery for symptomatic patients with carotid disease without increasing perioperative stroke risk. Despite this, misinterpretation of data and close public scrutiny has raised significant concerns within the profession of risk aversion and increased case selection. In preparation for the continued desire at a political level for individual surgeon level outcomes, the NVD has been abolished and replaced by a National Vascular Registry (NVR). This is funded using Government money (through an organization called the Healthcare Quality Improvement Partnership, or HQIP) and has been designed to be fit for purpose. We have dramatically reduced the number of data fields required and attempted to collect data to allow for meaningful risk adjustment. Data ascertainment is now mandatory for surgeons to undergo revalidation and continue in practice, and for vascular units to be commissioned by fundholders to provide a vascular service. The prime objective of the NVR, from the perspective of HQIP, is to monitor the quality of care for patients who undergo vascular surgery in NHS hospitals. The NVR forms part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). NCAPOP is a closely linked set of centrally-funded national clinical audits that collect data on compliance with evidence based standards, and provide local hospitals with benchmarked reports on the compliance and performance. The data are therefore no longer controlled by the Vascular Society, though we work closely with HQIP who are the data controllers, through an NVR Project Board. This includes representation from the British Society of Interventional Radiology and patient groups. 67

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St Georges, London, United Kingdom Professor of Surgery, St Georges London, United Kingdom Chair, Audit and Quality Improvement Committee, Vascular Society of Great Britain and Ireland

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ONTROVERSY: Conflicts of interest C Why the on-going initiative to separate physicians from industry is bad for patients and society

Frank J. Veith

New York University Medical Center and the Cleveland Clinic, USA Because of some flagrant abuses and excessive hidden financial rewards to MDs, a recent initiative to completely sever the relationship between industry and MDs has gained traction. This initiative has been supported by several states (MA, VT) and universities (Harvard, Stanford, Massachusetts, Michigan) which have enacted draconian laws or policies designed to separate MDs and industry and to interrupt any relationships between them. Obamacare or the Affordable Care Act does just that in its draconian Sunshine Provision which mandate declaration of all financial relationships between industry and physicians – even very minor ones. Some states have enacted similar laws. Perhaps our federal and state elected officials, who are so eager to prevent even the appearance of financial conflict of interest between MDs and industry, should apply the same standards to their own relationships with their financial supporters. It is also interesting that many individual MDs have sanctimoniously jumped on the band wagon by writing articles or op ed pieces attacking the evils of any relationship between industry and MDs and suggesting the severance of any such relationships. Surprisingly, professional and specialty societies have bowed to these attacks and have remained surprisingly mute in defense of the benefits of such relationships. The initiative to separate industry from physicians has taken on the trappings of a witch hunt. Let’s examine this initiative more closely. Yes, there have been abuses in these relationships and bad things have happened. But does that mean that all such relationships are intrinsically bad and should be interrupted? I submit that it does not. Some husbands beat their wives, but we should not prevent relationships between men and women or outlaw marriage. Similarly, we have numerous road accidents, many of them fatal. That does not mean we should outlaw cars and trucks or driving. We should enact rules and measures to minimize accidents and take measures to make our highways safer. So too with relationships between MDs and industry. We should establish rules to prevent or minimize the abuses, but we should not totally interrupt all MD – industry relationships. To do so is wrong-headed and would eliminate the many beneficial effects that accrue to medical care and society from these relationships. It would be throwing the baby out with the bath water. What are some of these benefits? First, relationships between MDs and industry foster innovation and development. Nowhere is this more apparent than in vascular device development. Physicians have ideas to improve the treatment of patients, and industry has the engineering expertise and money to develop these ideas into useable devices, which must in turn be evaluated by MDs. Second, physicians also have the expertise to assist in the development and evaluation of effective drugs and assays. This advantage is exemplified by a recent front page lead article in the New York Times, headlined “Rare Sharing of Data Led to Results on Alzheimer’s Disease: Collaboration Between Science and Industry Seen as Model for Parkinson Studies” – NY Times August 13, 2010. Third, industry sponsored medical education helps to keep MDs informed about new developments, new devices and how they should be used most safely and effectively. Sure there is opportunity for the introduction of bias, but this can be minimized by appropriate safeguards, as it currently is under ACCME guidelines. Moreover, some bias is a part of most marketing and advertising efforts in every other part of our society. Without industry support, meetings and many other forms of continuing medical education would be largely eliminated, and MDs would be forced to get all their continuing education from textbooks and journal articles which are notoriously out of date and in some cases heavily biased. Fourth, without industry representatives to enlighten vascular specialists in the use and pitfalls of individual devices, our learning process would be more difficult and dangerous to patients. Some of these industry representatives who are in attendance at device insertions on a daily basis have far more familiarity with their devices than MD specialists who are using them initially or sporadically. The result is that patients are cared for better and more safely. Fifth, industry sponsored courses on these devices help MDs 68

These are just some of the ways industry-MD relationships are beneficial to patients and society. The positive parts of these relationships must be preserved, just as the positive part of relationships between lobbyists and congress, between lawyers and judges, between producers and merchants should be preserved. To eliminate industry-MD relationships will do far more harm than good. Universities and states that enact strict measures to separate MDs from industry will be blighted and suffer competitive disadvantages. Their leaders should recognize this and resist the temptation to join the separation witch hunt and preserve the positive aspects of these relationships. More importantly, our medical and specialty societies, while supporting the elimination of abuses, should speak up and take official positions strongly in support of preserving the positive aspects of the natural relationships between MDs and industry.

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learn to use them better and more safely, and industry sponsored support of training for vascular residents almost always has positive effects for patients and trainees.

I mprove your peripheral techniques Radial artery access for peripheral angioplasty

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Raphael Coscas, Isabelle Javerliat, Olivier Goeau-Brissonniere, Marc Coggia

Hopital Universitaire Ambroise Paré, AP-HP, Boulogne-Billancourt, France

OBJECTIVE The radial approach is currently gaining popularity in the setting of coronary percutaneous transluminal angioplasty (PTA) since it decreases the incidence of vascular complications. Aim of this study was to report our initial results with radial access for peripheral PTA. METHODS Between November 2011 and January 2014, we performed peripheral transluminal angioplasty in 526 patients. In total, 24 (4.6%) ambulatory patients presenting with TASC A or B lesions on preoperative computed tomography angiography scan underwent a PTA through left radial access (LRA). Materials included: 1. a 110-cm length introducer, 2. a 0.018’’ 400-cm length wire, 3. 150-cm-long angiography catheters 4. 180-cm-long shafts balloons and stents. Data was prospectively collected. Results are presented as median with ranges. RESULTS There were 22 males (92%). Median age was 65 years (range, 45-88) and 38 target lesions were treated. Indication for revascularization was disabling claudication and critical ischemia in 22 (92%) and 2 (8%) cases, respectively. Indication for choosing the radial approach was bilateral hostile groins, bilateral infrainguinal lesions, need for a contralateral femoral approach in the setting of kissing iliac stents or bifurcated surgical aortic grafts, and elective in 12 (50%), 4 (17%), 3 (13%) and 5 (21%) patients, respectively. In one case (4%), radial puncture failed and PTA was performed through brachial access. Technical success was 91% (20/22 patients). Thirty-seven stents were implanted. Total procedure duration was 45 minutes (range, 30-120). Fluoroscopy time was 9 minutes (range, 5-35) and 40 cc (range, 20-90) of contrast product were necessary. In two patients (8%), radial artery rupture secondary to spasm was noted at the end of the procedure. All patients could ambulate 2 hours after the procedure. No patient died. Median follow-up was 8 months (range 1-23). Three (13%) radial arteries were found to be occluded at last follow-up. At 6 months, freedom from target lesion revascularization and target vessel revascularization were 91% and 91%, respectively, for iliac lesions and 93% and 86%, respectively, for infrainguinal lesions. CONCLUSION These results demonstrate the feasibility of radial access for peripheral PTA. The radial access could represent an alternative to the brachial access for peripheral and visceral interventions. Although complication rates of the present series are concerning, larger studies are needed to determine the role of transradial PTA once the learning curve is overcome. A wider diffusion of the technique mandates: 1. smaller diameter sheaths, 2. longer shaft devices, and 3. the development of specifically designed rescue devices, such as covered stents and thrombo-aspiration catheters.

I mprove your peripheral techniques Can we predict the reentry site in totally occluded SFA P. Feugier, N. Della Schiava, M. Arsicot, T. Boudjelit, J. Herail, A. Million, P. Lermusiaux

Department of Vascular Surgery, University E Herriot Hospital, Claude Bernard Lyon 1 University, Hospices Civils de Lyon - France

The site of reentry depends of course on the recanalization technique used. For IL PTA, the area of reentry must match at the end of thrombosis. On the other side, if a SI PTA is done, then the site of reentry may be located downstream of the end of thrombosis. It usually corresponds to a healthy parietal transition arterial zone where the atheromateous plaque is petered out 1, 7. Very few studies have focused on the location of reentry 7. We retrospectively analyzed the procedures in 37 patients undergoing femoropopliteal endovascular recanalization for symptomatic chronic de novo above-knee thrombosis. Failure crossing the lesion was noted in 3 cases (8%). No reentry system was used. The crossing of the lesion was carried out in intra-luminal in 10 cases (29%), in sub-intimal in 16 cases (47%). It was not possible to confirm the type of recanalization in 8 cases (23%). The site of reentry could be predicted from the preoperative exams (targeted duplex-scan, CT angiography, MR angiography) in 73% of cases (25/34). It was confirmed in 100% of cases (10/10) for IL PTA, in 56% (9/16) for SI PTA and in 75% of cases (6/8) when there is doubt in terms of type of recanalization. External extension of parietal calcifications, a circumferential calcified atheromatous lesion extending beyond femoropopliteal thrombosis were failure criteria of immediately reentry. The existence of a collateral branch on the way of the guide wire seems rather to promote it. These criteria can be analyzed pre-operatively from the duplex-scan and especially the CT angiography data. Just as the analysis of the puncture site, the study of the arterial wall downstream of the thrombosis seems to be to us important. It can predict the reentry area and thus better planning endovascular treatment strategy, particularly regarding the use of reentry systems. REFERENCES 1. Markose G, Miller FN, Bolia A. Subintimal angioplasty for femoro-popliteal occlusive disease. J Vasc Surg. 2010 Nov;52(5):1410-6. 2. Loftus IM, Hayes PD, Bell PR. Subintimal angioplasty in lower limb ischaemia. J Cardiovasc Surg (Torino). 2004 Jun;45(3):217-29. 3. Lipsitz EC, Veith FJ, Ohki T. The value of subintimal angioplasty in the management of critical lower extremity ischemia: failure is not always associated with a rethreatened limb. J Cardiovasc Surg (Torino). 2004 Jun;45(3):231-7. 4. Ihnat DM, Mills JL Sr. Current assessment of endovascular therapy for infrainguinal arterial occlusive disease in patients with diabetes. J Vasc Surg. 2010 Sep;52(3 Suppl):92S-95S. 5. Mwipatayi BP, Hockings A, Hofmann M and All. Balloon angioplasty compared with stenting for treatment of femoropopliteal occlusive disease: a meta-analysis. J Vasc Surg. 2008 Feb;47(2):461-9. 6. Chang ZH, Liu ZY. Subintimal angioplasty for chronic lower limb arterial occlusion. Cochrane Database Syst Rev. 2013 Mar 28;3. 7. Schneider PA, Caps MT, Nelken N. Re-entry into the true lumen from the subintimal space. J Vasc Surg. 2013 Aug;58(2):529-34.

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The success of femoropopliteal arterial recanalization must go with the crossing the occlusive lesion by the guide-wire. This essential step can be done either through the thrombosis (intraluminal recanalization, IL PTA) or through an external parietal way (sub-intimal recanalization, SI PTA) 1-4. If some tools (angled rigid guide wire, reentry catheter, reentry systems ...) or certain endovascular techniques (SAFARI technique ...) help to achieve recanalization, predict the area of intra-luminal reentry, also seems fundamental in the mastery of the procedure 5, 6.

I mprove your peripheral techniques Popliteal Artery Lesions: Atherectomy, Stenting or Bypass?

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Peter A. Schneider

MD Kaiser Foundation Hospital, Honolulu, Hawaii INTRODUCTION Each of the arterial segments of the infrainguinal vasculature presents its own unique challenges. The popliteal artery gives origin to the important pergenicular collaterals. These are typically numerous and can be responsible for maintaining a limb that may have extensive proximal or distal occlusions. When a popliteal occlusion extends into the tibial vessels, it can present a particular challenge since re-entry at the tibial level can be difficult and can also exclude other tibial arteries in the process. The popliteal artery is short but is located in a highly flexible segment at the knee joint. It can be the site of highly calcified eccentric lesions. The popliteal artery is also considered somewhat hostile to stents. In this abstract, we will discuss the options and review the data for popliteal artery repair. ANATOMY AND SPECIAL CHALLENGES The popliteal artery is divided into 3 segments. The P1 segment extends from the adductor canal to the superior aspect of the patella. The P2 segment of the popliteal artery is located between the superior aspect of the patella and the knee joint. The P3 segment included the below-the-knee popliteal artery and is from the knee joint to the origin of the anterior tibial artery. The artery typically tapers as it proceeds distally. Less than 5% of the population will have an anomalous tibial artery origin, either the anterior tibial or posterior tibial artery that arises from the retrogeniculate popliteal artery. Popliteal artery disease may be focal, involving one segment or several segments of the popliteal artery. Popliteal disease may also be diffuse and may be combined with contiguous superficial femoral artery disease or tibial artery disease, or both. The popliteal artery conformation is dynamic and responds to flexion/extension at the knee joint by changes in length averaging of 3.2cm, , twisting of 61 degrees, and the formation of more than 2 flexion points of 15 degrees or more.1 Among patients with femoral-popliteal occlusive disease and more heavily calcified popliteal arteries, there is more curvature overall, since the diseased segments are less flexible and the majority if the bending requirements are shifted to the less diseased segments of the artery.2 When popliteal arteries were evaluated at 90 degrees flexion of the knee and hip, stented popliteal arteries demonstrated 11% longitudinal compression, versus 14% for native-non-stented popliteal arteries.3 This suggests that stent placement diminishes the capacity of the popliteal artery to respond to changes of leg position that is associated with common behavior. The artery is somewhat fixed proximally due to the adductor canal and in its mid-segment due to the perigenicular collaterals. Stent fracture in the femoral-popliteal arteries have been associated with positioning in the adductor canal and the popliteal artery.4,5,6 In the TASC II classification of lower extremity occlusive disease, the length of popliteal artery lesions is not considered as it is so significantly for the superficial femoral artery. A TASC B lesion is defined as <15cm, but not involving the below-the-knee popliteal artery. The presence of popliteal artery stenosis, length not specified, automatically qualifies as TASC B. TASC D lesions include popliteal artery occlusion that extends into the tibial vessels and also an SFA lesion that is >20cm that also extends into the popliteal artery. There is an implication in the TASC II guidelines that a popliteal artery lesion substantially increases the challenge of repair. DATA ON POPLITEAL ARTERY REPAIR Studies performed for approval of devices intended for femoral-popliteal repair have typically included the SFA and the proximal popliteal artery (P1). This is the case for the Durabilty, Stroll, Zilver PTX, and Superb stent trials and the IN.PACT SFA drug coated balloon trial. The Resilient Trial (Lifestent, Bard) included both the P1 and P2 segments and the Levant 2 Trial included P1, P2 and a portion of P3 (Moxy drug coated balloon, Bard). The ETAP Trial specifically evaluated PTA (with bailout stent) versus primary stent for popliteal artery lesions using the Bard Lifestent.7 The P1 and P2 segments were involved in 47%, the P2 and P3 segments 72

TREATMENT RECOMMENDATIONS PTA and selective stent is a viable option for isolated popliteal artery lesions and for lesions associated with SFA or tibial disease. If SFA disease is being treated, whatever stent is required for the SFA disease can be extended into the popliteal artery. I like to avoid a stent when possible so that all treatment options are preserved for later usage if needed. Modified balloons, such as scoring balloons may be helpful to assist in stent avoidance. If a stent I required for a popliteal artery lesion, especially if it is heavily calcified, I favor a Supera stent, although this requires more preparation of the vessel than other stent types. Atherectomy is a good option for focal, highly calcified lesions, especially if eccentric. It is possible that DCB may help to make atherectomy a more successful long-term option. Bypass with good autologous vein remains an option with reasonable results but there is a well-documented decrement in patency at one year of 15-20% when the vein graft crosses the knee joint. We have typically used bypass for patients with early endovascular failure, multiple endovascular failures and for some patients in whom a complete popliteal occlusion is present (P1,2,3), especially when associated with an extensive occlusion proximal or distal to the popliteal occlusion. CONCLUSION There are multiple tools for use in the repair of popliteal artery lesions, none of which may be used exclusively. Bypass remains an option when endovascular does not work or is a poor choice. There is some direct competition between PTA with selective stenting, primary stenting, and atherectomy. The availability of the Supera stent and drug coated balloons may also change the balance of these treatment choices in the near future.

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were affected in 47% of patients and about 7% had involvement of P1, 2 and 3. The patency at 12 months was 67.4% for primary stent placement and 44.9% for PTA. Selective stent placement was categorized as a TLR. Freedom from TLR, amputation, death and MI was significantly better in the primary stent group than in the PTA group (p<0.0001). When primary stent was compared with PTA/selective stent (as treated) there was no significant difference in MAE. This suggests that routine stent placement confers no significant advantage over selective stent placement. In another study of an alternative stent design, the Supera Popliteal Registry, the lesion length was 58mm and the stented length was 84mm.8 Primary patency at 12 months was 87.7%. Popliteal artery stents have also been evaluated in the setting of critical limb ischemia (CLI).9 Forty patients with CLI and lesions of P1 and P2 were treated; 88% were occlusions and lesion length was 74mm. The primary patency was 68%. Atherectomy is also a tool which may have some use on the popliteal artery. The potential of atherectomy is to avoid prosthetic implants in the popliteal artery, to preserve collaterals, and to manage highly calcified lesions, especially when they are eccentric. There is some risk of distal embolization with this technique and the potential for need of a bailout stent. Atherectomy has been reported in 4 studies, comprised by of a total of 295 patients.10-13 The lesion lengths in the studies varied from 34mm to 100mm (mean) and the percentage of occlusions included in the study varied from to 30% to 100%. The primary patency at 12 months ranged from 55% to 73%. In summary, the one-year patency for PTA and selective stent was 65%, for atherectomy was 55% to 69%, and for primary stent was 67% to 87%.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

REFERENCES 1. Klein et al.Catheter Cardiovasc Interv 2009;74:799 2. Gokgol et al. J Endovasc Ther 2013;20:828 3. Nikanarov et al. J Vasc Surg 2008;48:435. 4. Iida et al. Am J Cardiol 2006;98:272. 5.Sirocco J Endovasc Ther 2006;13:701. 6.Scheinert et al. JACC 2005;45. 7.Zeller et al. LINC 2014. 8. Scheinert et al. JACC Interv 2013;6:65 9. Goltz et al. J Endovasc Ther 2012;19:450 10. Semaan et al. Vasc Endovasc Surg 2010;44:25 11. McKinsey et al. Ann Surg 2008 12. Gallagher et al. J Endovasc Ther 2011;18:624 13. Siracuse et al. J Vasc Surg 2014 March 17.

L ower limbs solved and unsolved questions Disposable radiation-absorbing surgical drapes results in significant dose reduction Marc RHM van Sambeek, Carla Kloeze, Elisabeth G. Klompenhouwer, Peter Brands, Joep AW Teijink, Philippe W Cuypers Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands

OBJECTIVES Due to the increasing number of interventional endovascular procedures with fluoroscopy and the corresponding high annual dose for interventionalists, additional dose protecting measures are desirable. The purpose of this study was to evaluate the effect of disposable radiation absorbing surgical drapes in reducing scatter radiation exposure for interventionalists and supporting staff during an endovascular aneurysm repair (EVAR) procedure. DESIGN A randomised control trial in which 36 EVAR procedures were randomised between execution with and without disposable radiation absorbing surgical drapes (Radpad: Worldwide Innovations & Technologies, Inc., Kansas City, US, type 5511A). MATERIALS AND METHODS Dosimetric measurements were performed on the endovascular surgeon and theatre nurse. In the Radpad cohort two Radpad shield were positioned on the lower body of the patient. RESULTS Use of disposable radiation absorbing surgical drapes (Radpad) resulted in dose reductions of 49%, 55% and 48% respectively, measured on the hand of the surgeon, the chest of the interventionalist and the chest of the theatre nurse. CONCLUSION The use of disposable radiation absorbing surgical drapes (Radpad) significantly reduces scatter radiation exposure for both interventionalist as well as supporting staff during EVAR procedures. REFERENCE Eur J Vasc Endovasc Surg. 2014;47:268-72

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L ower limbs solved and unsolved questions Are drug-eluting stents keeping their promises in the long term?

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Michael D. Dake

Stanford, USA

PURPOSE The Zilver PTX multinational, prospective, randomized trial compared the safety and effectiveness of the Zilver PTX stent to balloon angioplasty (PTA) and bare metal stenting (BMS) in the superficial femoral artery (SFA). METHODS Patients with de novo or restenotic SFA lesions were randomized to Zilver PTX stent placement or PTA. PTA patients experiencing acute failure (e.g., â&#x2030;Ľ30% residual stenosis) underwent secondary randomization to provisional stenting with Zilver BMS or Zilver PTX. Follow-up included event-free survival (EFS) and primary patency by duplex ultrasound core laboratory analysis. RESULTS As previously reported, 479 patients were enrolled in the United States, Japan, and Germany, and 5-year follow-up is complete. The 5-year freedom from TLR (target lesion revascularization) rate is significantly higher for the Zilver PTX group compared to the standard care group, which includes optimal PTA and provisional BMS (83.1% vs. 67.6%, p<0.01). This represents a 48% reduction in reinterventions through 5 years. Regarding effectiveness, the 5 year patency rate for the Zilver PTX group is superior to the standard care group (66.4% vs. 43.4%, p<0.01), which represents a 41% reduction in restenosis through 5 years. Provisional stenting with Zilver PTX versus Zilver BMS continues to demonstrate significant benefit of the paclitaxel coating through 5 years, with patency rates of 72.4% and 53.0%, respectively (p=0.03), which represents a 41% reduction in restenosis through 5 years due to the drug. CONCLUSIONS The 5-year results show sustained safety and effectiveness with the Zilver PTX drug-eluting stent, which may represent a new gold standard for the treatment of SFA disease.

ONTROVERSY: Which stent for the aorta? C Aortic stenting: why a covered stent is better. Piotr Ciostek

When discussing â&#x20AC;&#x153;witch stent is better for aorta: bare or covered?â&#x20AC;?, first we have to specify what lesions shall be treated. For stenosis, dissections or endoleak type 1 in aorta we have choice between bare and covered stents. For repair of aortic occlusion typical for PAD (peripheral arterial disease) use of stent-grafts is the only sensible solution because of the risk of aortic rupture and/or releasing distal emboli during the procedure. According to TASC II recommendations from 2007, type D lesions at aorto-iliac level including high infrarenal total occlusion of aorta and iliac arteries have to be operated by means of open surgery. Nowadays this recommendation seems to be no more valid. For more than two years, encouraged by success obtained with a patient absolutely unfit to open aortic surgery, we started to treat juxtarenal aorto-iliac occlusions in patients with high perioperative risk by realizing regular implantations of long peripheral stent grafts in aortic position toward femoral or iliac arteries. During the years 2012-2014, we performed 14 of the above mentioned endovascular procedures: two unilateral, and twelve bilateral. In all the cases we used long stent-grafts restoring flow in aorta from the level of renal arteries to common femoral arteries. In three patients we have landed distally in common iliac arteries. The follow up in now going on for three years (18,2 months on the average). Results: Technical success - 100%; graft permeability - 100%, lack of major surgical complications, one cardiac death D1 post op (MCI). Conclusion: Covered stents are the best and unavoidable technical solution in restoring blood flow through occluded aorta and iliac arteries.

Saturday January 24

1st Chair and Clinic of General and Vascular Surgery, 2nd Faculty of Medicine, Medical University of Warsaw, Poland

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Saturday January 24 - Varicose disease -

DEEP VEIN Compression of the left renal vein: an algorithm for diagnosis by duplex Philippe Lemasle

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Cabinet Nouvelle France, Le Chesnay, France The nutcracker syndrom (NCS) is defined by the permanent stenotic compression of the ending of the left renal vein (LRV), usually between the abdominal aorta and the superior mesenteric artery, heads of a pressure gradient â&#x2030;Ľ 3 mmHg The phlebographic diagnosis of NCS is well codified and based on three criteria: - compression and narrowing of the VRG ending - increase of the gradient of renocava pressure: â&#x2030;Ľ 3 mmHg - visualization of collateral pathways The ultrasound diagnosis of NCS is less well defined. In our practice, we use the following algorithm: Step 1: look for the VRG in the mesenteric artery entrapment Step 2: assess the aorta-mesenteric space, quantitatively or qualitatively (measured in mm from the aorto-mesenteric space and/or aorta-mesenteric angle) - either the space is large and the anatomical compression of the LRV is not possible - or it is narrow, and the compression is possible Step 3: If the compression is possible, look for direct signs, anatomical and especially haemodynamic of stenosis LRV, in the entrapment: - decrease in the caliber - ratio of diameters - aliasing, increased speed - ratio speeds - no flow Step 4: If there is hemodynamic compression of the LRV, look for indirect signs, anatomical and especially hemodynamic, upstream of the entrapment. They are in favor of a stenosis with haemodynamic impact. - expansion of the LRV upstream - flow to slow speeds, not modulated by respiration in the LRV upstream - permanent reflux, not modulated by respiration, in the left gonadial vein - visualization of abnormal collateral pathways - abnormal flow at high speeds, in theses collateral pathways This approach provides guidance of: - the differential diagnosis between nutcracker phenomenon and nutcracker syndrom - the management of pelvic varicose

DEEP VEIN Treatment of the nutcracker syndrome: the interventional radiologist’s point of view Milka Greiner

Hôpital Américain de Paris, Neuilly Sur Seine, France Le nutcracker syndrome (NCS) se définit comme une compression sténosante de la veine rénale gauche responsable d’une réduction du flux direct réno-cave et d’une hyperpression veineuse d’amont. Il en existe plusieurs formes dont la plus connue est la compression dans le dièdre aorto-mésentérique (NCS antérieur). L’hyper pression veineuse en amont de la compression est à l’origine d’une souffrance rénale et/ou d’un syndrome de congestion pelvienne avec présence de varices pelviennes secondaires à une circulation à contre-courant de la veine ovarienne gauche et/ou de varices des membres inférieurs. Il peut s’y associer des manifestations d’hyperpression veineuse médullaire. Le NCS est à différencier des compressions relatives de la veine rénale gauche qui sont fréquentes et des faux nutcracker syndromes par drainage préférentiel du sang veineux rénal gauche dans la veine ovarienne gauche (syndrome de vol ovarien). Le but du traitement d’un NCS est de lever la compression veineuse rénale gauche pour traiter les symptômes sans générer de conséquences néfastes à long terme. L’abstention thérapeutique, les indications d’embolisation isolée de la veine ovarienne gauche (principale voie de dérivation) sont analysées. La pose d’une endoprothèse dans la veine rénale est discutée et les publications la concernant sont commentées. La place de la chirurgie veineuse rénale, le traitement d’un syndrome de May-Thurner-Cockett associé sont développés. CONCLUSION Le traitement d’un NCS doit s’envisager sur des critères précis incluant symptomatologie invalidante, analyse tomodensitométrique et phlébographique, retentissement rénal et étude du rapport bénéfices/risques.

Saturday January 24

EEP VEIN D Is medical compression by stockings the panacea to prevent post thrombotic syndrome after proximal DVT

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Michel Perrin

Unité de pathologie vasculaire Jean Kunlin, Chassieu, France INTRODUCTION There are so many patterns of postthrombotic syndrome (PTS) in terms of clinical severity, anatomical anomalies, physiopathological abnormalities that a global answer looks impossible to formulate. METHODS Randomized control trials (RCTs) on compression versus no compression or placebo compression to prevent PTS after proximal deep venous thrombosis (DVT) - have been researched through the English and French literature RESULTS Finally 3 RCTs fully exploitable were selected and analyzed Brandjes. Lancet 1997 - Knee length compression for 2-Y vs. no compression - DVT location Iliac. No Femoral 5%. There is no information on the precise location: Common femoral vein or femoral vein. - Type of assessment: Brandjes scoring not validated - Adherence to treatment: Excellent in 76%, Poor 3% Conclusion: Compression prevents PTS. P < 0.001 Prandoni. Annals of Internal medicine. 2004 - Knee length compression for 2-Y vs. no compression - DVT location Iliac. No Femoral 20%. There is no information on the precise location: Common femoral vein or femoral vein. - Type of assessment: Villalta scoring, validated - Adherence to treatment: Excellent in 93% Conclusion: Compression prevents PTS. P=0.011 Kahn. Lancet 2013 - Elastic compression stockings (ECS) for 2-Y vs. placebo compression - DVT location Iliac. 11.5% Common femoral vein 27%. - Type of assessment: Ginsberg and Villalta criteria or scoring. - Adherence to treatment: was considered adherent to treatment patient wearing compression 3 or more days per week/10-11hr day - Adherence to treatment was variable according to Follow-up duration: 1month 86.4%. 24 months 55.6% Conclusion: The cumulative incidence of PTS was 14.2% in active ECS versus 12.7% in placebo ECS (hazard ratio adjusted for centre 1.13, 95% CI 0.73–1.76; p=0.58). Interpretation .ECS did not prevent PTS after a first proximal DVT, hence our findings do not support routine wearing of ECS after DVT. Comment on the 3 RCTs. DVT localization is poorly documented in the Brandjes and Prandoni’s studies and results according to this information are not provided. In Kahn’s study the location of initial DVT is detailed. 82

DISCUSSION - Presently classification of DVT in proximal and distal is nonsense particularly for proximal localization. Obviously you cannot put in the same basket a DVT affecting the popliteal or/and femoral vein to the one interesting the ilio-femoral axis in terms of possible future after effect. It is the same for a PTS, an isolated femoral vein obstruction cannot be compared to ilio-femoral occlusion. In other words proximal DVT definition must be modified and segmented - To answer the question is medical compression by stockings the panacea to prevent post-thrombotic syndrome after proximal DVT several survey and studies must be undertaken i) In patients presenting ilio-femoral DVT with or without distal extension below inguinal ligament does thrombolysis or pharmacomechanical ablation gives better results than traditional treatment. If the answer is in favor of operative treatment does combined compression improve the outcome or not. If compression is useful how long and on which criteria compression should be maintained. ii) In patients presenting femoro popliteal +/- distal thrombosis is compression beneficial. If the answer is yes on which criteria (clinical, instrumental investigations) compression continuation should be decided and for how long. iii) Very few data are available on adherence to compression after acute DVT. We only know that long-term compression compliance is poor for various reasons. The effectiveness of compression to minimize PTS must be realistic and take in account this crucial problem.

Saturday January 24

Iliac vein+ Common femoral vein 38.5% The compression proponents have expressed many criticism on the methodology used in Kahnâ&#x20AC;&#x2122;s article more or less relevant, but according to available data it looks that considering adherent patients as defined in this study is realistic. Raju. Ann Vasc Surg 2007 Conversely Prandoni and Brandjes are not.

OME DEBATES S Les différents questionnaires de qualité de vie et les scores dans la maladie veineuse sont-ils utiles et pertinents ?

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Francois-André Allaert

Chaire d’évaluation des allégations de santé Dijon, France

Depuis de nombreuses années différents scores d’évaluation de la sévérité de la maladie veineuse et de l’altération de la qualité de vie qu’elle provoque ont été proposés. Certains ont été élaborés selon des méthodologies rigoureuses permettant de connaître ce que l’on appelle leurs propriétés psychométriques c’est-à-dire la quantification statistique de leur cohérence interne, de leur reproductibilité, de leur validité externe et de leur sensibilité au changement, d’autres au contraire ne sont issus tout au mieux que de consensus d’experts et n’ont guère fait l’objet d’évaluation. Certains ont bénéficié de traductions transculturelles, d’autres non. Certains sont spécifiques de la maladie veineuse, d’autres sont des questionnaires généralistes. D’autres encore, souvent présentés comme des scores n’en sont pas comme l’erreur est souvent commise pour la classification CEAP. Certains sont pertinents dans le cadre de la recherche clinique mais leur durée et leur complexité les rendent inutilisables dans la pratique quotidienne. Par ailleurs certains domaines n’ont fait encore l’objet d’aucune élaboration rigoureuse de score pour les évaluer comme par exemple l’observance de la compression élastique. Un exemple de méthodologie applicable à ce domaine sera présenté pour appréhender ce que requiert l’élaboration d’un score utile et pertinent. Une liste de quelques outils considérés comme les plus pertinents et les plus utiles pour la pratique sera présentée et discutée. La grande lacune aujourd’hui de tous ces scores est peut-être qu’ils négligent pour la plupart une dimension essentielle : la satisfaction des patients et leur appropriation des traitements de leur maladie veineuse.

OME DEBATES S CONTROVERSY: Duplex exam after GSV ablation is not necessary! Lowell Kabnick

NYU Vein Center at NYU Langone Medical Center, New York, USA In 1999, radiofrequency ablation of the saphenous vein was introduced and approved by the FDA in the USA as a new and minimally invasive modality for the treatment of superficial venous insufficiency. In 2002, the approval of radiofrequency ablation was followed by endovenous laser ablation. These minimally invasive procedures have revolutionized the treatment of superficial venous insufficiency and have caused a dramatic shift from highly invasive and morbid inpatient procedures to minimally invasive and ambulatory office procedures. Soon after the introduction of these two innovative modalities, Endothermal Heat-Induced Thrombosis (EHIT) was identified as a new clinical entity. This terminology, a classification system, and treatment strategies were introduced by Kabnick in 2005. Subsequently, advances in technique, along with the discovery of associated risk factors and a better understanding of the pathophysiologic process of endothermal coagulum formation, have reduced the current incidence of EHIT classes 2-4 to between 1 - 2%. Still, a lack of data exists regarding the true incidence of clinically significant pulmonary embolism secondary to EHIT. I believe that the rate is less than 0.01%. Furthermore, successful thermal saphenous ablation efficacy in the perioperative period approaches 99%. Despite these excellent numbers, the standard of care is to obtain a duplex ultrasound to evaluate for the presence of EHIT within the first 1-2 weeks post endovenous thermal ablation. Given this information, I believe that performing duplex ultrasound in the perioperative period is wasteful and an inefficacious use of limited healthcare resources. I advocate against routine duplex ultrasound to evaluate for treatment efficacy and EHIT presence during the perioperative period in asymptomatic patients.

Saturday January 24

CLEROTHERAPY S Prevention of visual and neurologic disturbances after sclerotherapy with antiendothelin prophylaxis

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Alessandro Frullini

Studio flebologico, Figline Valdarno, Italy A possible cause of sclerotherapy complications could be the release of Endothelin 1 (ET 1). We have studied in vivo and in vitro the anti-ET1 action of Aminaftone (AMNA). Moreover a multicentric retrospective study was performed analyzing the effect of AMNA in the prevention of neurological and visual disturbances after sclerotherapy (Procomet study). We studied 3 groups of rats treated with polidocanol (POL) sclerotherapy: the group C, control, and the groups G1 and G2, that received respectively a 30mg/kg/die or a 150mg/kg/die of AMNA for 15 days before sclerotherapy. In vitro studies were performed on HUVEC cells: cells survival was analyzed in presence of AMNA and POL at different concentrations, and ET 1 level measurement was performed through an immunoenzymatic assay. Rats in group C showed an early mortality of 40%. This value was only 13,3 % and 20 % in group G1 and G2. The treatment with AMNA 6Âľg/ml did not affect HUVEC viability. After POL 0,05% and 0,5% treatments, HUVEC were viable in 44,36 % and 2,25% respectively. After AMNA pre-treatment and POL treatment, ET 1 cellular release was significantly lower after 6 (p<0.01) and 12 hours (p<0.05) in respect to control without AMNA. The Procomet study was performed on 540 patient for a total number of 1642 sclerotherapy session. Significant reduction of side effects was demonstrated in patients treated for teleangectasias and in those with a migraine history. This study confirms ET 1 release after sclerotherapy and lower in vivo mortality in G1 and G2 groups gives us a clue of ET-1 possible role in generating side effects. Aminaftone has been proven to be effective in inhibition of ET 1 release from endothelial cells after sclerotherapy and in migraine patients or after treatment of teleangectasias.

CLEROTHERAPY S Phlebogriff: a new device. Short term follow-up results Piotr Ciostek, Marcin Kowalski, Witold Wozniak Medical University of Warsaw, Warszawa, Poland

The model pathological mechanism of classical varicose veins sclerotherapy is vein shrinking and fibrosis due to the inflammatory process being the consequence of chemical damage of the endothelium initialized by needle puncture of the vessel wall. The aim of the study is to present the technique and results of mechano-chemical sclerotherapy with the new device. Phlebogriffe is a simple endovenous catheter equipped with the steel retractable claws intended to scratch the endothelium during catheter movement, while simultaneously delivering the sclerosant agent. The procedure is similar to standard long catheter sclerotherapy of saphenous veins under US control. No anesthesia (except in place of skin puncture), no sophisticated equipment and no hospital stay are required. From the second half of 2010 to the end of 2013, 40 patients with varicose veins (CVD;C2-C6) were treated with the Phlebogriffe catheter. Thirty GSV and 10 SSV were excluded due to mechano-chemical sclerotherapy. As sclerosant, we have used Polidocanol (2%) as foam. Two similar (C2-C6) control groups were build: one of 40 patients treated with long catheter foam sclerotherapy, the second of 40 patients treated with foam sclerotherapy with direct injections. The follow up for all patients was 12 months. The results of Phlebogriffe sclerotherapy are gratifying: a technical success and an efficacy meaning a 100% immediate saphenous veins exclusion; 97,4% after one month and 89,7% after 6 and 12 months. When compared with control groups, obliteration with Phlebogriffe was complete on the whole length of the vein; there was very little early recanalization, particularly segmental recanalization of the initially occluded veins. This was not the case in the two control groups. CONCLUSIONS The mechano-chemical sclerotherapy with Phlebogriffe catheter is easy to perform, save and more effective then classic technique of chemical sclerotherapy.

Phlegogriffe catheter

Saturday January 24

CLEROTHERAPY S Laser vs foam for GSV: the results of a RCT

George Geroulakos, C.Lattimer, E.Kalodiki, M.Azzam

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Josef Pflug Vascular Laboratory, Ealing Hopsital and Imperial College, London, United Kingdom Laser with phlebectomies compared to foam sclerotherapy in superficial venous insufficiency. Early and interim results of a randomised controlled trial. The early results of a randomised clinical trial comparing endovenous laser ablation (EVLA) with concurrent phlebectomies (n=50) versus ultrasound guided foam sclerotherapy (UGFS) into the great saphenous vein (n=50) revealed that laser was more expensive but at 3 months the results on the abolition of reflux were similar. UGFS significantly outperformed EVLA in treatment duration, pain, analgesia requirements and recovery time. The interim results at 15 months showed that the occlusion of the great saphenous vein was more effective with EVLA at 42/44 (95.5%) versus 31/46(67.4%) for UGFS. The venous clinical severity score and the Aberdeen varicose vein questionnaire remained unchanged between 3-15 months. Overall adjuvant foam was given 4.7 times more frequently in the UGFS patients. EVLA and UGFS are equally effective at abolishing global venous reflux with overall success of 41% and 43% respectively. As the high global reflux rate was not related to deterioration in quality of life, this reflux was largely asymptomatic. To achieve this result, a higher number of adjuvant foam treatments were necessary in the UGFS group.

HERMAL TECHNIQUES T Introduction to new and exciting venous interventions: new laser wavelength and a vessel occluder Lowell Kabnick

NYU Vein Center at NYU Langone Medical Center, New York, USA Secure vessel occlusion is critical to the success of all surgical and interventional procedures. This study tested, both in vitro and in vivo, the Vessel Occluder (Amsel Medical Corporation, Cambridge MA), a novel occlusion clip device for secure blood vessel closure in minimally invasive and percutaneous treatments. The Vessel Occluder, delivered through a fine hypodermic needle, transfixes the targeted vessel and delivers expandable proximal and distal elements on either side of the vessel wall which lock together for secure vessel occlusion. In vitro device testing was conducted on 5mm silicon tubing. Standard corrosion analysis, material biocompatibility, and cytotoxicity were performed on the implantable elements. In vivo studies on 9 swine compared safety and efficacy of the Vessel Occluder with the medium/large Ligaclip® (J & J) for 1 week and 30 days. The targeted vessels between 2mm - 7mm in diameter included the carotid, brachial, and femoral arteries and the jugular, brachial, and femoral veins. Successful application was confirmed by division of the targeted vessel between 2 Vessel Occluders or 2 Ligaclips®. In vitro testing (N=11) confirmed a holding pressure of 450mmHg (11/11), excellent clip closure repeatability (11/11), and release mechanism function (11/11). Once applied, the Vessel Occluder was secure and could not be dislodged (0/11). The Ligaclip® was easily dislodged (11/11). No corrosion was observed, and material biocompatibility and cytotoxicity (N=12) were within accepted ranges. In vivo studies (18 arteries; 18 veins) confirmed easy Vessel Occluder application and superiority in security. The Vessel Occluder showed no post-operative bleeding (Vessel Occluder=0/18), while one Ligaclip® dislodged resulting in a fatal hemorrhage 16 hours post-surgery (Ligaclip® 1/18). Sacrifice at 7 and 30 days confirmed complete occlusion in all occluded vessels with similar tissue incorporation, inflammatory response (histopathological examination), and healing between the Vessel Occluder and Ligaclip®. The Vessel Occluder is simple to deploy and securely maintains occlusion by transfixing the targeted vessel, unlike the widely used, non-transfixing Ligaclip® that has a tendency to dislodge. As such, the Vessel Occluder opens up numerous treatment opportunities in both the venous and arterial systems to minimize open, laparoscopic, robotic surgical and interventional procedures, and reduce patient morbidity.

Saturday January 24

T HERMAL TECHNIQUES 5 year follow-up after different techniques: RCT comparing surgery, chemical and thermal ablation

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Lars Rasmussen

Copenhagen, Denmark INTRODUCTION This study compares the outcome 5 years after treatment of varicose veins by endovenous laser ablation (EVLA), radiofrequency ablation (RFA, ClosureFast (CLF)), ultrasound guided foam sclerotherapy (UGFS) or surgery by assessing recurrence, venous clinical severity score (VCSS) and quality of life (QOL). METHODS A total of 500 patients (580 legs) were randomized to one of the 3 endovenous treatments or high ligation and stripping of the great saphenous vein (GSV). Follow-up included clinical and duplex ultrasound examinations, VCSS and quality of life questionnaires. RESULTS At 5 years, 7 (KM estimate 5.8 %), 8 (KM estimate 6.8 %), 36 (KM estimate 31.5 %) and 8 (KM estimate 6.3 %) of GSVs recanalized or had a failed stripping procedure (more than 10 cm open refluxing part of the treated GSV) (CLF, EVLA, UGFS and stripping) (P<.01). Twenty-two (KM estimate 18.7 %), 43 (KM estimate 38.6 %), 29 (KM estimate 31.7 %) and 38 (KM estimate 34.6 %) legs developed recurrent varicose veins (P<0.05). The pattern of reflux and location of recurrent varicose veins were not different between the groups. Within 5 years after treatment, 19 (KM estimate 17 %), 19 (KM estimate 18.7 %), 43 (KM estimate 37.7 %) and 25 (KM estimate 23.4 %) legs were re-treated in the CLF, EVLA, UGFS and stripping groups (P < .01). VCSS, SF-36 and Aberdeen QOL scores improved significantly in all the groups with no difference between the groups. CONCLUSION All treatment modalities were efficacious and resulted in a similar improvement in VCSS and QOL. However, more technical failures and reoperations were seen after UGFS.

HERMAL TECHNIQUES T Treating veins with monopolar radiofrequency - experience and results of the EVRF system Attila Szabo

VP-Med Health and Education Center, Budapest, Hungary OBJECTIVE EVRF is a monopolar radiofrequency system for the endothermal treatment of small, midsize and large veins. We evaluated the effectiveness of EVRF treatment and analyzed the early and middle-term results using the EVRF device for the endovenous ablation of GSV and/or SSV and summarized the results of EVRF spider veins treatments. METHODS AND RESULT FOR SAPHENOUS VEINS From July 2011 to October 2014 we treated 632 patients (48 years of average age) with saphenous reflux and varicosity using EVRF. The output power was 25 Watts, the catheter removal rate was 6 sec/cm at the beginning 2 cm back from the sapheno-femoral (sapheno-popliteal) junction. In every case we used tumescent local anesthesia with some superficial sedation in the present of an anesthesiologist. Patientsâ&#x20AC;&#x2122; clinical data, the data of the pre- and postoperative ultrasound examinations, the total power emitted and the diameters and flow of the treated veins measured by ultrasound have been recorded. Photo documentation was prepared in each case. Clinical evaluation was performed one day, one week and one to two months after surgery using a scale of postoperative pain, patient satisfaction and outcome ultrasound procedure. The procedures were performed on 632 limbs - 538 GSV, 72 SSV, 22 GSV+SSV; 601 patients belonged to CEAP 2,3, 31 patients to CEAP 4,5; 579 primary cases, 53 recurrent varicosity. Crossectomy was performed in 7 cases due to the GSV larger than 20 mm at the junction. Tributaries were treated in the same session in 76% of the cases. The mean diameter of the GSV was 6,9 and of the SSV 5,2 cm consequently. The length of the treated vein segment ranged from 15 cm to 82 cm, using an amount of 7200 Joules total energy emitted on average. Complete occlusion was found in 99 % at the one month ultrasound control, 1 year ultrasound control showed 97,2 % occlusion rate. Postoperative pain reported by the patients on a visual analogue scale was under 2/10, VCSS scores showed significant improvement of the QOL of the patients after 1 and 12 months. There were no cases of deep vein thrombosis, skin burns, neuritis or bleeding, we found minimal bruising at the treatment site of the tributaries in some cases, 4 patient had mild inflammation, treatable conservatively. METHODS AND RESULT FOR SPIDER VEINS For small veins we did 3000 treatment sessions for teleangiectasias and spider veins (smaller than 1 mm) with K3i needles on face (43 cases) and K6i needles on the lower limbs. 99% of the treated patients were females with a mean age of 36 years. We used RF treatment or combined the treatment with liquid sclerotherapy (polidocanol 0,5% or 1% 30-33 G needle)- in those cases sclerotherapy was initiated for the treatment of larger veins and feeding veins, RF treatment at the end for the rest of the small veins. On the face we used the K3i needles with 6-7 Watts and 2 pulses, on the legs the K6i needles with 9-11 Watts and 3 pulses. Recovery rate on the face was 100 % (3 patients - 15% needed a second treatment). On the lower limb we achieved an 82 % average recovery rate, 24 % needed several treatments. In case of combined sclerotherapy cases the recovery rate was 95 % after the first treatment session. The treatments were well tolerated, the pain level always depends on the patientsâ&#x20AC;&#x2122; current psychic status. The crusts following the treatments disappeared after 1-2 weeks in average, in some cases just after 2 months. 50 % of our patients felt an itching sensation on the treated area, which disappeared in 10-15 minutes. Patient satisfaction rate was high.

Saturday January 24

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

CONCLUSION The EVRF saphenous ablation is a safe, painless procedure for the treatment of the GSV and/or SSV - high patient acceptance and minimal postoperative discomfort allows the quick return to work and normal life. The procedure under local tumescent anesthesia is simple, the disposable devices are easy to use. In our practice the EVRF treatment with CR45i catheter was superior to conventional varicectomy or to laser ablation using a 2nd generation device with bare laser fiber. The EVRF handpiece with K3i and K6i needles proved to be useful in teleangiectasia treatment, with excellent results. This RF procedure is good for combination with liquid or foam sclerotherapy.

Saturday January 24

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ePosters

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

orta A Endovascular treatment of descending thoracic aortic dissection: a 2011-2014 review Konstantinos Roditis1,2, Anna Paspala1,2, Christos Klonaris3, Ioannis Kakisis4, Christos Liapis4

1. 3rd Department of Surgery and Vascular Unit, “Attikon” University General Hospital, National Kapodistrian University of Athens, Athens, Greece 2. Junior Doctors’ Network - Hellas, Athens, Greece 3. 1st Department of Surgery, “LAIKO” General Hospital, National Kapodistrian University of Athens, Athens, Greece 4. Department of Vascular Surgery, “ATTIKON” University General Hospital, National Kapodistrian University of Athens, Athens, Greece

PREAMBLE “The tragedies of life are largely arterial” -Sir William Osler. The year was 1760, and George II, King of England, had sustained fatal cardiac tamponade caused by an acute type A aortic dissection (AD), which had ruptured into the pericardium.Frank Nicholls, his personal physician, opened and embalmed the royal body, thus uncovering and meticulously documenting some of the most interesting findings. His description constituted the very first clear account of the disease that we nowadays name AD. INTRODUCTION AD is the most common and deadly manifestation of the acute aortic syndromes (AAS). Its incidence reaches no less than 30 cases per million people per year. Without treatment, acute type A AD has a mortality of about 1% per hour, with half of the patients expected to die within 72 hours, and around 80% by the end of the second week. Mortality is still significant, however lower, in acute type B AD: 10% at 30 days, and around 80% in the highest-risk individuals. The management of AD remains a therapeutic challenge. The traditional surgical approach to acute type B (descending thoracic) aortic pathology is unsatisfactory with high morbidity and mortality. Endovascular aortic stent grafts now represent an alternative minimally invasive approach in these patients who are often poor surgical candidates. PURPOSE Purpose of the present study was a retrospective review of the existing literature from the last 10 years (2004-2014) on management of descending thoracic AD as well as a review of the newest patient series published in the literature since the most recently published meta-analysis (after January 2011). Materials and methods: 2 multi-disciplinary consensus papers, 2 randomized controlled trials, 2 historical articles, 5 meta-analyses, 31 clinical trials and 50 review papers published in English between 2004-2014 and 11 patient series published from January 2011 until today were identified in Medline. Publications in Chinese, Spanish, Russian or other languages than English were excluded. RESULTS 3437 patients (71,6% men, average age 62,6 years) in 11 available publications were found. 2516 had type B AD (73,2%). TEVAR was performed in 1909 patients (75,9%). 30-day mortality was 7,0%. Type I-II (and in some cases III) endoleaks (11,5%), stroke (5,9%) and paraplegia or paraparesis (3%) were reported as complications. Need for re-intervention was approximately 6%. Finally, mean follow-up time was 24,7 (±15,8) months. CONCLUSION This review provides an insight into the technical success, potential advantages and complications, as well as survival rate for patients treated with TEVAR for type B AD. It should, nevertheless, be viewed in the light of its limitations, exactly like all other reviews published before. Studies published so far show endovascular repair to be technically feasible with fewer complications. Long term results are awaited to assess its true efficacy. 96

Figures

EPOSTERS

Detailed overview over the analyzed patient series

Detailed overview over the analyzed patient series (cont.)

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

REFERENCES 1. Criado FJ. Aortic dissection: a 250-year perspective. Tex Heart Inst J 2011;38(6):694-700. 2. Zahn R, Erbel R, Nienaber CA, Neumann FJ, Nef H, Eggebrecht H, Senges J. Endovascular aortic repair of thoracic aortic disease: early and 1-year results from a German multicenter registry. J Endovasc Ther 2013;20(3):265-72. 3. Steuer J, BjĂśrck M, Mayer D, Wanhainen A, Pfammatter T, Lachat M. Distinction between acute and chronic type B aortic dissection: is there a sub-acute phase? Eur J Vasc Endovasc Surg 2013;45(6):627-31. 4. Wilkinson DA, Patel HJ, Williams DM, Dasika NL, Deeb GM. Early open and endovascular thoracic aortic repair for complicated type B aortic dissection. Ann Thorac Surg 2013;96(1):23-30; discussion 230. 5. Qin YL, Deng G, Li TX, Wang W, Teng GJ. Treatment of acute type-B aortic dissection: thoracic endovascular aortic repair or medical management alone? JACC Cardiovasc Interv 2013;6(2):185-91. 6. Jia X, Guo W, Li TX, Guan S, Yang RM, Liu XP, et al. The results of stent graft versus medication therapy for chronic type B dissection. J Vasc Surg 2013;57(2):406-14. 7. Li Y, Yang N, Duan W, Liu S, Yu S, Yi D. Acute aortic dissection in China. Am J Cardiol 2012;110(7):1056-61. 8. Heijmen RH, Thompson MM, Fattori R, Goktay Y, Teebken OE, Orend KH. Valiant thoracic stent-graft deployed with the new captivia delivery system: procedural and 30-day results of the Valiant Captivia registry. J Endovasc Ther 2012;19(2):213-25. 9. Ehrlich MP, Rousseau H, Heijmen R, Piquet P, Beregi JP, Nienaber CA, et al. Midterm results after endovascular treatment of acute, complicated type B aortic dissection: the Talent Thoracic Registry. J Thorac Cardiovasc Surg 2013;145(1):159-65. 10. Lombardi JV, Cambria RP, Nienaber CA, Chiesa R, Teebken O, Lee A, et al.; STABLE investigators. Prospective multicenter clinical trial (STABLE) on the endovascular treatment of complicated type B aortic dissection using a composite device design. J Vasc Surg 2012;55(3):629-640.e2. 11. Zipfel B, Czerny M, Funovics M, Coppi G, Ferro C, Rousseau H, et al; RESTORE Investigators. Endovascular treatment of patients with types A and B thoracic aortic dissection using Relay thoracic stent-grafts: results from the RESTORE Patient Registry. J Endovasc Ther 2011;18(2):131-43. 12. Heijmen R, Fattori R, Thompson M, Eggebrecht H, Degriecke I, Nienaber C, et al.; The Virtue Registry Investigators. The VIRTUE Registry of type B thoracic dissections--study design and early results. Eur J Vasc Endovasc Surg 2011;41(2):159-66. 13. Eggebrecht H, Nienaber CA, NeuhĂ¤user M, Baumgart D, Kische S, Schmermund A, Herold U, Rehders TC, Jakob HG, Erbel R. Endovascular stent-graft placement in aortic dissection: a meta-analysis. Eur Heart J 2006;27(4):489-98. 14. Zhang H, Wang ZW, Zhou Z, Hu XP, Wu HB, Guo Y. Endovascular stent-graft placement or open surgery for the treatment of acute type B aortic dissection: a meta-analysis. Ann Vasc Surg 2012;26(4):454-461. 15. Xiong J, Jiang B, Guo W, Wang SM, Tong XY. Endovascular stent graft placement in patients with type B aortic dissection: a meta-analysis in China. J Thorac Cardiovasc Surg 2009;138(4):865-872.

orta A Obliterating endo-aneurysmorrhaphies with stent-graft preservation for treatment of type II progressive endoleaks Pierre Maitrias1, Adrien Kaladji2, Nathalie David3, Didier Plissonnier3, Jean Sabatier4, Sébastien Amiot5, Jean-Luc Magne6, Marc Coggia7, Thierry Reix1 1. University hospital, Amiens, France 2. University hospital, Rennes, France 3. University hospital, Rouen, France 4. Clinique de l’Europe, Rouen, France 5. Hospital, Valenciennes, France 6. University hospital, Grenoble, France 7. University hospital, Boulogne-Billancourt, France

INTRODUCTION Persistent type II endoleak (EL II) with sac enlargement after endovascular repair of abdominal aortic aneurysm requires treatment to prevent rupture. Transarterial embolization, the preferred treatment for many years, is not always effective. Conversion to open repair with stent-graft (SG) explantation is associated with high perioperative morbidity and mortality. The aim of our study was to evaluate an alternative technique combining sacotomy, ligation of patent back-bleeding vessels and SG preservation for type II or unspecified endoleaks repair. MATERIALS AND METHODS In this multicentric French study, 25 patients with a mean age of 77 years were included in 7 different centers. The ASA median score was 3. Nineteen patients (76%) had a bifurcated SG (including 2 fenestrated SG) and six patients (24%) had an aorto-uni-iliac SG including 2 deployed in emergency for ruptured aneurysm. The mean initial aneurismal diameter was 61±15mm. Five patients (20%) presented sac enlargement without any leak visible on CT. The origin of the endoleak remained unspecified in 4 cases (16%). Embolization by selective catheterization was carried out in 10 patients (40%), when the origin of the leak was well identified on CT (lumbar or inferior mesenteric artery), without success. The aneurismal sac reached an average diameter of 79±20 mm after a median duration of 35 months (range, 8-82), that means an increase of 30% in diameter. RESULTS A retroperitoneal approach was used in 18 cases (72%) and a transperitoneal approach in 7 cases (28%). An intra-aortic occlusion balloon was inserted for endoclamping in 7 patients and inflated temporarily in only 3 cases. A celiac aortic cross-clamping was performed in 5 patients. An EL II was identified in 23 patients, associated with a type I distal endoleak in one case, a type III endoleak in 2 cases and a type IV in one case. Two patients presented endotension without retrograde perfusion of the sac. All endoleaks were successfully treated. The mean operative time was 132±43 minutes and the mean blood loss was 470 milliliters. One SG was explanted after 12 days because of an early infection. The median length of hospital stay was 12 days (range, 8-20). One patient died after 26 months during SG explantation for aortoduodenal fistula. With a median follow-up of 15 months (range, 6-85), control CT-scan showed shrinkage of the aneurysm sac with stable diameters in every case. No EL II recurrence and no SG migration or disjunction was observed. CONCLUSION This study showed the feasibility and the good results of obliterating endo-aneurysmorrhaphy with SG conservation. Our technique can be considered to be a valid alternative to SG removal in the case of persistent EL II with aneurysm sac enlargement after embolization failure. By avoiding extensive dissection for surgical aortic cross-clamping, minimizing hemodynamic changes, reducing blood loss and operating time, this procedure can be performed even in patients initially considered unfit for surgery. 99

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Aorta Endovascular treatment of aortic arch using relay branched stent grafts Pr. H. Rousseau 1, Dr. M. Alonso 2, Dr. J.M. Alsac 3, Dr. Camparini 4, Prof. Cao 5, Dr. C. Forssell 6, Dr. M. Hamady 7, Dr. Kuratani 8, Pr. F. Moll 9

1. CHU de Rangueil, Toulouse, France 2. Hospital UCA de Oviedo, Oviedo, Spain 3. Hôpital George Pompidou, Paris, France 4. Ospedale G. Brotzu, Roma, Italy 5. Ospedale San Camillo Forlanini, Roma, Italy 6. Linköping University Hospital, Linköping, Sweden 7. St. Mary’s Hospital - London, London, United Kingdom 8. Osaka University Hospital, Osaka, Japan 9. UMC Utrecht, Utrecht, Netherlands

INTRODUCTION Several methods have been proposed to reduce the morbidity of aortic arch aneurysm repair. Endovascular treatment of aortic arch aneurysms using branched stent grafts provides an attractive alternative. METHODS Branched Stent graft used In this study, the branched stent grafts used are a custom-made version of RELAY NBS Plus platform Planning of the procedure was done with a 3D workstation after computed tomography angiography (CTA). Placement of the device The stent graft was implanted through the common femoral artery. Once the aortic stent graft has been deployed, the two branched grafts were implanted from the common carotids. RESULTS 34 patients consecutively, were treated between 02/2011 and 07/2014 with branched stent grafts and were reviewed from a prospectively maintained database. All were deemed high risk for conventional surgery. Full informed consent was obtained in all cases. 8 patients had a single branch (2 women) and 26 (8 women) had a double branched stent grafts. 24 had arch aneurysms, 5 parietal aortic ulcer and 5 patients had a chronic dissection. The median proximal diameter of the graft was 41 mm (range, 36–44mm), the median distal diameter was 35mm (range, 26–44mm) and the median length of the branched device was 250mm (range, 210–270mm). In 2 patients, a distal thoracic part was used. 29 patients had uneventful placement of the prostheses, with successful exclusion of their aneurysms. One patient developed a graft migration that was managed successfully. One patient presented a post procedural stroke. One presented a per-procedure right ventricule perforation. In one case a right subclavian exclusion was observed and one patient presented a LCCA dissection. As a whole, aneurysm exclusion without endoleak was therefore achieved in all patients. Of the 60 target vessels, all were successfully cannulated and preserved. The pre-discharge CTA findings showed in all cases the patency of the different part of the stent-grafts without endoleak. 8 patients died during the follow up, 6 before discharge and 2 patients after 4 months. DISCUSSION Branched stent-grafts introduced transfemorally is appealing for the aortic arch. The theoretical, but inherent, risk of disassembly of modular devices is diminished by the integrated long tunnel inside the branched endografts. Moreover, one of the main advantages of this device is the large fenestration, allowing easier catheterization of the two branches. Nevertheless, with aortic branched stent-grafts, absolute accuracy in the design and placement is necessary. The importance of using a 3-dimensional workstation for planning and a state of the art modern angiosuite for placement of the device cannot be underestimated. However, the long-term durability of the branched stent-grafts in the aortic arch is unknown. Endografts placed in 100

the ascending aorta and the aortic arch is subject to high pulsatile forces that could affect the integrity of their structure. Remodeling of the aortic arch over time could also affect their stability, and the long-term patency of the branches is another concern. CONCLUSIONS We have demonstrated the technical feasibility of a new modular trans femoral branched stent graft for treatment of aortic arch aneurysms. The method is relatively safe based on initial experience, and we currently recommend it to high-risk patients with aneurysms involving the aortic arch and suitable anatomy. Safety and efficacy will be better defined with longer follow-up and increased worldwide experience.

Thoracic Branched Endograft The thoracic stent graft is constructed with a large fenestration for supra aortic branches, with two side-branches of 12 mm, allowing branch extension into the IA and LCCA.

Ct scan Follow up at 3 months showing the patency of the 2 branches for the innominate artery and LCCA, as well as the LCCA-LSA bypass and the exclusion of the aneurysm.

REFERENCES 1. Yang J, Xiong J, Liu X, Jia X, Zhu Y, Guo W: Endovascular chimney technique of aortic arch pathologies: a systematic review. Ann Vasc Surg 2012; 26(7): 1014-21. 2. Andersen ND, Williams JB, Hanna JM, Shah AA, McCann RL, Hughes GC: Results with an algorithmic approach to hybrid repair of the aortic arch. J Vasc Surg 2013; 57(3): 655-67; discussion 666-7. 3. Antoniou GA, El Sakka K, Hamady M, Wolfe JH: Hybrid treatment of complex aortic arch disease with supra-aortic debranching and endovascular stent graft repair. Eur J Vasc Endovasc Surg 2010; 39(6): 683-90. 4. Hongo N, Miyamoto S, Shuto R, et al.: Endovascular aortic arch reconstruction using in situ stent-graft fenestration in the brachiocephalic artery. J Vasc Interv Radiol 2011; 22(8): 1144-8. 5. Numan F, Arbatli H, Bruszewski W, Cikirikcioglu M: Total endovascular aortic arch reconstruction via fenestration in situ with cerebral circulatory support: an acute experimental study. Interact Cardiovasc Thorac Surg 2008; 7(4): 535-8. 6. McWilliams RG, Murphy M, Hartley D, Lawrence-Brown MM, Harris PL: In situ stent-graft fenestration to preserve the left subclavian artery. J Endovasc Ther 2004; 11(2): 170-4. 7. Sonesson B, Resch T, Allers M, Malina M: Endovascular total aortic arch replacement by in situ stent graft fenestration technique. J Vasc Surg 2009; 49(6): 1589-91. 8. Manning BJ, Ivancev K, Harris PL: In situ fenestration in the aortic arch. J Vasc Surg 2010; 52(2): 491-4. 9. Preventza O, Cervera R, Cooley DA, et al.: Acute type I aortic dissection: Traditional versus hybrid repair with antegrade stent delivery to the descending thoracic aorta. J Thorac Cardiovasc Surg 2013. 10. Cochennec F, Tresson P, Cross J, Desgranges P, Allaire E, Becquemin JP: Hybrid repair of aortic arch dissections. J Vasc Surg 2013; 57(6): 1560-7. 11. Sugiura K, Sonesson B, Akesson M, Bjorses K, Holst J, Malina M: The applicability of chimney grafts in the aortic arch. J Cardiovasc Surg (Torino) 2009; 50(4): 475-81. 12. Inoue K, Hosokawa H, Iwase T, et al.: Aortic arch reconstruction by transluminally placed endovascular branched stent graft. Circulation 1999; 100(19 Suppl): II316-21. 13. Chuter TA, Schneider DB: Endovascular repair of the aortic arch. Perspect Vasc Surg Endovasc Ther 2007; 19(2): 188-92. 14. Lioupis C, Abraham CZ: Results and challenges for the endovascular repair of aortic arch aneurysms. Perspect Vasc Surg Endovasc Ther 2011; 23(3): 202-13. 101

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orta A Bi- and three-dimensional preoperative morphological features as predictors of reintervention and death after EVAR Laura Capoccia, Pasqualino Sirignano, Danilo Menna, Nunzio Montelione, Wassim Mansour, Anna Rita Rizzo, Enrico Sbarigia, Francesco Speziale

Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, Roma, Italy INTRODUCTION Maximum aortic diameter (AD) and the percentage of the lumen occupied by the clot (CA) are recognized as determinants of outcome after elective endovascular repair (EVAR). However, these data do not reflect the complexity of the aorta in its three-dimensional structure. Aim of the study was to evaluate the impact of bi-dimensional and three-dimensional preoperative morphological features on outcome. MATERIALS AND METHODS Preoperative CT-Angios in DICOM format were available in 191 out of 425 patients treated between January 2008 and December 2013. These cases were reviewed searching for AD, CA and aneurysm (AV) and clot volumes (CV). AD and CA (expressed as %) were assessed in one single axial projection. AV and CV (%) were calculated from the lowest renal artery to the aortic bifurcation. Study’s endpoints were reintervention rate and all cause mortality during follow-up. RESULTS Mean age was 73.7±7years; 87.9% of patients were male. Mean AD was 56mm (35.2-93.5), CA 49,6% (0-89.1), AV 119,36cm3 (43.9-491.1) and CV 43% (0-77.4). Technical success, using standard devices, was 100% (suprarenal fixation:53.4%) without perioperative mortality. At a mean follow-up of 32 months, reintervention rate was 8.9% and mortality rate was 9.4%. No aneurysm-related death was observed. Greater CA and CV were strong predictors for reintervention (p=0.005 and 0.0034). Increases in AD and in AV were related to higher reintervention rate, without statistical significance (p=0.62 and 0.12). AV was an independent predictor of any adverse event after EVAR (p<0.03). CONCLUSION Our experience seems to show that CA and three-dimensional morphological data could be more reliable in predicting clinical outcome after EVAR, than AD alone.

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Aorta Retrograde type B aortic dissection (rtbad):they are too bad! Laura Capoccia, Pasqualino Sirignano, Chiara Pranteda, Danilo Menna, Wassim Mansour, Nunzio Montelione, Enrico Sbarigia, Francesco Speziale

Endovascular repair (EVAR) for abdominal aortic aneurysms (AAA) is becoming the standard of practice in the majority of vascular centres, even if some concerns remain about the occurrence of early and longterm failure and reintervention. A rare but potential catastrophic event is represented by retrograde Type B aortic dissection (RTBAD). We report two cases of RTBAD after 425 standard EVARs performed in our Institution. Both patients were treated for AAA without perioperative complication and in both patients the presence of a pre-existing disease of the thoracic aortic wall (ulcerated plaque in one case and aortic ectasia in the other one) may have played an important role in the rapid evolution towards an early onset of the dissection. Only few cases of type B dissection after EVAR have been reported in literature and the aetiology of this complication remains uncertain. For the first time, our experience highlights the possible etiologic role of pre-existing lesions of the thoracic aorta. In these cases, the only possible strategy may be to carefully study the entire aorta before an EVAR procedure, eventually switching the indication to an open surgical repair or carrying out a more aggressive management, treating the defects of the thoracic aorta.

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Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, Roma, Italy

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

orta A Long-term cost-effectiveness of three different management strategies for type II endoleak Ahmed Aber, David Sidloff, Matt Bown, Robert Sayers

Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom AIM The long-term cost effectiveness of active intervention and conservative management of Type II endoleak following endovascular repair (EVAR) of aortic aneurysm remains unclear. We sought to estimate the cost effectiveness of two types of active identification and intervention strategies and a conservative management strategy for patients with type II endoleak. METHODS A Markov model was generated from the United Kingdom National Health Service (NHS) perspective using a 1-year cycle and a 25-year time horizon. The base-case patient was a 70-year-old patient with type II endoleak immediately diagnosed following EVAR. Three treatment strategies were analysed: active identification and treatment using trans-lumbar radiological intervention, active identification and treatment using trans-arterial intervention and a conservative management approach with long term annual follow up for all the patients in all three arms of this model. The model parameters were selected using the results of a recent systematic review about the clinical evidence, a systematic review of the utility data and NHS reference costs using the sterling value for the year 2012-2013. The main outcome measure was the incremental cost-effectiveness ratio (cost per quality-adjusted life-year gained). RESULTS In the base case analysis, the cost of the management using trans-lumbar radiological intervention was £ 3469.2 and quality adjusted life years (QALYs) gained were 16.29, the cost of management using trans-arterial radiological intervention was £3923.2 and the QALYs gained were 16.27. The cost of conservative management over 25 years was £1399.22 and the QALYs gained were 16.83. Comparing the trans-arterial approach to conservative management the ICER was £3249.2. Comparing the trans-arterial management to the conservative management the ICER was £3370.2. The conservative management dominated both intervention strategies. CONCLUSION The health benefits from the two active intervention strategies are undermined by the dis-utility caused by the morbidity and high failure rates of these active management approaches. Conservative management is a cost-effective approach based on the current available evidence in the literature.

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REFERENCES Drummond MF, Sculpher MJ, Torrence GW et al., Methods of Economic evaluation of health care programs (2005). Third ed: Oxford University Press. Harris, P. L. , J. Buth , and C. Mialhe . et al. The need for clinical trials of endovascular stent-graft techniques for abdominal aortic aneurysm repair: the EUROSTAR project.J Endovasc Surg 1997. 4:72–77. Gelfand DV, White GH, Wilson SE. Clinical significance of type II endoleak after endovascular repair of abdominal aortic aneurysm. Ann Vasc Surg 2006; 20: 69–74. Harris PL, Vallabhaneni S, Deagranges P, Becquemin JP, van Marrewijk C, Laheij RJ, for the EUROSTAR collaborators. Incidence and risk factors of late rupture, conversion and death after endovascular repair of infrarenal aortic aneurysms. The EUROSTAR experience. J Vasc Surg, 32 (4) (2000), pp. 739–749 Karthikesalingam A, Thrumurthy SG, Jackson D, Sayers R, Loftus IM, et al. Current evidence is insufficient to define an optimal threshold for intervention in isolated type II endoleak after endovascular aneurysm repair. J Endovasc Ther, 19 (2012), pp. 200–208 Laukontaus SJ, Pettila V, Kantonen I, et al. Utility of surgery for ruptured abdominal aortic aneurysm. Ann Vasc Surg. 2006;20:42–48. Perkins JM, Magee TR, Hands LJ, Morris PJ. Prospective evaluation of quality of life after conventional abdominal aortic aneurysm surgery. Eur J Vasc Endovasc Surg, 16 (1998): 203–207 Sidloff DA, Stather PW, Choke E, Bown MJ, Sayers RD.Type II endoleak after endovascular aneurysm repair. Br J Surg. 2013 Sep;100(10):1262-70. Van Marrewijk C, Buth J, Harris PL, Norgren L, Nevelsteen A, Wyatt AG. Significance of endoleaks after endovascular repair of abdominal aortic aneurysms: the EUROSTAR experience. J Vasc Surg, 35 (3) (2002), pp. 461–473

Aorta Treatment of type II endoleak with Onyx gel embolization: is it effective?

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Mohammad Elsayed, Manuel Garcia-Toca

Department of Vascular Surgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA INTRODUCTION Type II Endoleak (T2E) is the most common complication after Endovascular Aneurysm Repair (EVAR). Treatment of T2E using gel embolization is poorly understood. This study examines outcomes of gel embolization using Onyx ethylene vinyl copolymer. METHODS A literature search was conducted on PubMed and Google Scholar using terms related to Onyx and T2E. Studies directly examining the effectiveness of Onyx in treating T2E were included. Patient demographics, follow-up time, and clinical and technical success rates were analyzed. RESULTS Five studies with a total of 150 patients with T2E treated with Onyx embolization were identified.1-5 The mean age of patients receiving treatment was 76.6 years (range= 37-93). Available data showed a mean follow up time of 58.9 months from two studies and median follow-up of 15 weeks from a third. Technical success, defined by elimination or reduction of the endoleak at the time of surgery, was encountered in 89.5% of 133 patients. Clinical success, defined by the reduction or maintenance of aneurysm sac size on follow-up was encountered in 77.90% of 95 patients. Endoleak persisted in 34.3% of 73 patients after Onyx embolization. Four new endoleaks and zero ruptures were recorded after treatment. CONCLUSION Technical and clinical success was achieved in a majority of patients treated for T2E with Onyx polymer. However, there is a considerable rate of failure and persistent endoleak. Such findings indicate that more studies are necessary to understand optimal surgical candidates and appropriate clinical scenarios for reintervention using gel embolization. Given the low rate of rupture with T2E, surgeons should consider conservative therapy in the long-term.

Figure

Success Rate of Type II Endoleak Treatment with Onyx Polymer Columns represent outcomes of technical success, clinical success, and endoleak resolution. Areas shaded blue represent desired outcome. Areas shaded red represent treatment failure. 106

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REFERENCES 1. Abularrage CJ, Patel VI, Conrad MF, Schneider EB, Cambria RP, Kwolek CJ. Improved results using Onyx glue for the treatment of persistent type 2 endoleak after endovascular aneurysm repair. J Vasc Surg. 2012 Sep;56(3):630-6. 2. Khaja MS, Park AW, Swee W, Evans AJ, Fritz Angle J, Turba UC, et al. Treatment of type II endoleak using Onyx with long-term imaging follow-up. Cardiovasc Intervent Radiol. 2014 Jun;37(3):613-22. 3. Massis K, Carson WG, 3rd, Rozas A, Patel V, Zwiebel B. Treatment of type II endoleaks with ethylene-vinyl-alcohol copolymer (Onyx). Vasc Endovascular Surg. 2012 Apr;46(3):251-7. 4. Muller-Wille R, Wohlgemuth WA, Heiss P, Wiggermann P, Guntner O, Schreyer AG, et al. Transarterial embolization of type II endoleaks after EVAR: the role of ethylene vinyl alcohol copolymer (Onyx). Cardiovasc Intervent Radiol. 2013 Oct;36(5):1288-95. 5. Nevala T, Biancari F, Manninen H, Aho PS, Matsi P, Makinen K, et al. Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization. Cardiovasc Intervent Radiol. 2010 Apr;33(2):278-84.

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Aorta Management of Behçet’s aortitis a tunisian-single-center experience Majdi Gueldich1, Imed Frikha1, Aiman Damak1, Malek Fourati1, Héla Ben Jemâa1, Houda Tayari2, Sayda Masmoudi1

1. Cardiothoracic surgery department, Habib Bourguiba Hospital, Sfax, Tunisia 2. Radiology department, Habib Bourguiba Hospital, Sfax, Tunisia

Aortic involvement during Behçet’s disease is uncommon and linked to a poor prognosis. Our series includes six patients, 5 men and a woman. The mean age was 44.16 years (range, 27 to 54 years). Pseudo aneurysm is the most common lesion. Three patients underwent surgical treatment. Resection of aortic aneurysm and prosthetic interposition was achieved in 2 patients. Aneurysm flattening with closure patch was performed in one case. Three patients had an endovascular treatment with encouraging results in the medium term. A complementary therapy with immunosuppressive and / or corticosteroids was introduced before intervention and continued postoperatively in order to prevent recurrences. Actually, endovascular treatment is more and more recommended for the management of inflammatory aortitis in Behçet’s disease and saves patients from complications related to the surgical approach. Figures

Figure 1. Pseudo aneurysm of the supra celiac aorta.

Figure 2. Complete exclusion of the pseudo aneurysm formation by endoluminal stent-grafting.

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Aorta Single-centre experience with tevar: initial and 2-years outcomes Marina Dias-Neto, Paulo Gonçalves Dias, José Fernando Ramos, Augusto Rocha e Silva, Sérgio Sampaio, José Fernando Teixeira Department of Angiology and Vascular Surgery, São João Hospital Centre, Porto, Portugal

OBJECTIVES To assess the initial and 2-years outcome of endovascular treatment of thoracic aortic diseases in a centre of angiology and vascular surgery. METHODS This unicentric and retrospective study included all patients submitted to TEVAR until the end of 2013. Thirty-two patients were considered at high risk for open surgery because of major comorbidity and received endovascular treatment: 18 degenerative aneurysms or pseudo-aneurysms (11 asymptomatic), 1 non-ruptured thoracoabdominal aneurysm, 5 aortobronchial/aortoesophageal fistulas, 3 complicated dissections, 3 atherosclerotic penetrating ulcers/intramural hematomas, 1 traumatic laceration and 1 embolic atherosclerotic plaque. Nineteen (59%) were urgent/emergent procedures. RESULTS Mean age was 65 years and 29 patients were men (91%). Aortic arch revascularization was undertaken in two cases of zone 0 and zone 1 anchoring and there was 1 case of superior mesenteric artery debranching. Primary technical success was achieved in all but one patient (97%). Mean follow up was 32 months ranging from 0 to 122 months. All cause mortality at 30 days and at 24 months were, respectively, 3% (6% for emergent/urgent cases and 0% for elective cases) and 15%. Aortic-related mortality was identical (Figure 1). One patient developed permanent paraplegia and two had stroke (without functional impairment). Six patients had endoleaks (5 type I and 1 type III/IV) and 3 underwent a second procedure for successful repair. There was 1 stent migration and 1 stent infection. Survival free from aortic sac expansion (aneurysm, pseudoaneurysm or dissection, n=20) was 83% at 12 months. Survival free from aortic reintervention was 93% at 30 days and 82% at 24 months (Figure 2). CONCLUSION These results favour the current trend to consider TEVAR has a first line solution for several diseases of thoracic aorta. Figures

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Aorta First results with the Jotec E-iliac side branch prosthesis- a multicentre report S. Brunkwall1, W. Ahmad1, D. Gray1, S. Seifert2, J. Sch辰fer3, F. Vahl4, M. Yussef 4, J. Heckenkamp5, R端menapf 6, H. Schelzig7, A. Oberhuber7, B. Zipfel8, J. Brunkwall1 1. Department of Vascular Surgery, University Clinics University of Cologne 2. Chemnitz 3. Kiel 4. Mainz 5. Osnabr端ck 6. Speyer 7. D端sseldorf 8. Berlin

ABSTRACT Iliac involvment in AAA is seen in 20% of the cases. In some there is no landing zone in the common iliac artery. Extension of the landing zone into the external iliac artery requires occlusion of the internal iliac artery, which in turn leads to claudication in 50% of the cases and persistence in the majority. An iliac side branch does not sacrifice the internal iliac artery and thus does not lead to claudication. The aim of the present study was to present the first results of the Jotec iliac side branch captured retrospectively in eight German vascular centres. PATIENTS AND METHODS During August 2011 and September 2014 Fifty-one patients (44 males, 3 females) with 55 iliac side branches were treated. In 28 cases the right side was treated with iliac side branch and in 27 cases the left side). Median age was 73 years. Aortic size was 42mm in mean (23patients had the iliac aneurysm as indication for EVAR) and the iliacs 31mm. Follow up was with CT after 3,6 and 12 months and then yearly thereafter. RESULTS One patient died within 30-days (mortality 2%). All side branches were technically well placed. In one case there was a type 1 endoleak and in eight a type II endoleak. At follow up after 6 months, no type 1 endoleaks were present in but two a type 2 endoleak. Two cases of occlusion of the 55 branches (3.6%) were seen after 2 and 4 months. CONCLUSION This retrospective study indicates the Jotec iliac sidebranch with patency rates of 96% is comparable to the Cook IBD prosthesis. Long term and a prospective studies are warranted.

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upra Aortic Trunks S Safety of carotid intervention following thrombolysis in acute ischaemic stroke

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Rishi Mandavia, Mahim Qureshi, Brahman Dharmarajah, Karen Head, Alun Davies

Academic Section of Vascular Surgery, Imperial College London, London, United Kingdom OBJECTIVES Thrombolysis is effective in improving clinical outcome in the treatment of acute ischaemic stroke. However, thrombolysis results in low recanalisation rates, particularly in the event of carotid occlusion. Carotid intervention is indicated in stroke resulting from significant carotid atherosclerosis, but intervention soon after thrombolysis may be associated with increased risks. This study aims to assess the safety of carotid intervention post-thrombolysis for acute ischaemic stroke. MATERIALS AND METHODS Medline and Embase databases were searched on May 29, 2014, Inclusion criteria were (1) intra-arterial or intravenous thrombolysis for acute ischaemic stroke; (2) carotid intervention within 14 days of thrombolysis; (3) derivable primary outcome. The primary outcome was 30-day stroke or death. A meta-analysis of incidence was completed for the 30-day stroke or death rates using Freeman-Tukey arcsine transformations and assuming random effects. Point estimates with confidence intervals (CI) were generated and heterogeneity was assessed. Strength of recommendations and quality of underlying evidence were assessed using the American College of Chest Physicians (ACCP) grading system. RESULTS Nine included publications recorded 114 carotid endarterectomy (CEA) and 4 angioplasty interventions. The point estimate of 30 day stroke or death for CEA was 4.93% (95% CI = 1.83%, 9.44%), representing 4 cases in 114. Strength of recommendation and quality of underlying evidence for CEA as per the ACCP grading system was determined as 1C. There were no cases of stroke or death in patients undergoing angioplasty post-thrombolysis (0/4). CONCLUSIONS Early CEA post-thrombolysis appears safe with stroke or death rates similar to that of the operation without thrombolysis. However, the wide confidence interval obtained highlights the uncertainty of this result. Further, we emphasise that this recommendation is supported by low-quality evidence. Additional data are required to confirm the safety of surgery and early endovascular therapy post-thrombolysis.

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upra Aortic Trunks S Pre-CABG carotid intervention: just donâ&#x20AC;&#x2122;t do it Mohammed Ashrafi, Stephen Ball, Abid Ali, Iraj Zeynali, Vittorio Perricone

Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom INTRODUCTIONS Stroke remains a major cause of morbidity and mortality after CABG. The risk of stroke post CABG is 2%. Extra-cranial carotid disease has been implicated in the aetiology of post CABG stroke. CEA is a proven treatment for symptomatic and asymptomatic carotid disease. The aim of the study was to evaluate and compare the mortality and morbidity in patients with significant carotid disease either undergoing CEA prior to CABG or undergoing CABG alone in a tertiary referral centre. METHODS A retrospective case note review was conducted. Data over a 5 year period were collected and analysed. RESULTS 5924 open heart procedures were performed over the 5 year period. 2842 patients considered for open heart surgery had carotid duplex scan pre-operatively. 210/2842 (7.39%) of patients scanned had significant carotid disease. 29/210 (13.81%) had pre CABG CEA. 6/29 (20.69%) patients had significant adverse outcome post CEA. 95/181 (52.49%) who had significant carotid disease went on to have CABG without pre procedure carotid intervention. Overall stroke rate post CABG was 1.47%. Stroke rate post CEA pre CABG was 10.34%. Stroke rate post CEA and post CABG was 10%. Stoke rate post CABG in patients with significant carotid disease who had no carotid intervention was 3.16%. CONCLUSIONS Carotid disease does increase the risk of stroke post CABG. Carotid intervention pre CABG cannot be justified. Increased risk of stroke post CABG in patients with significant carotid disease needs to be accepted, as risk of stroke during carotid intervention pre CABG is significantly higher.

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upra Aortic Trunks S Is the brain of patients affected by carotid stenosis and contralateral occlusion at increased risk for after-cea neurological complications? Laura Capoccia, Enrico Sbarigia, Anna Rita Rizzo, Chiara Pranteda, Danilo Menna, Pasqualino Sirignano, Wassim Mansour, Nunzio Montelione, Francesco Speziale

Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, Roma, Italy

BACKGROUND AND PURPOSE We retrospectively reviewed a prospectively-collected single-center database to report on the incidence of neurological complications following CEA in patients affected by carotid stenosis with contralateral occlusion (CO), to analyze factors associated with neurological complications in this group of patients, and to compare perioperative results between those patients and the whole group of patients submitted to CEA at our Vascular Division. METHODS from January 1997 to December 2012 one-thousand-six-hundred-thirty-nine patients were consecutively submitted to CEA. 136 presented a CO contralateral to the carotid stenosis. Perioperative (30-day) outcomes considered for analysis were neurological death rates, major and minor stroke rates. Statistical significance was set at p≤0.05. RESULTS CO patients were more frequently male, smokers, younger, and symptomatic (p<0.001), presented more frequently with a preoperative brain infarct and associated peripheral arterial disease (p<0.0001), and presented with higher major neurological complications rates than patients without CO (4.4% vs 1.2% respectively, p=0.009). Perioperative complications analysis disclosed no significant difference in minor stroke and death rates between the two groups (p=0.76 and p=0.28 respectively), while major stroke rate was significantly higher in CO patients (4.4% in CO vs 1.2% in control group, p=0.009). Factors associated to the highest risk in CO patients were age>74 years and presence of preoperative brain infarct (p=0.03). The association of CO, age>74ys and contralateral or bilateral preoperative brain infarct significantly increased postoperative neurological complication rates in CEA patients (OR 40.9; 95% CI 5.6-298, p<0.0001; and OR 19.9; 95%CI 1.7-224, p=0.0006 respectively). CONCLUSIONS CO patients presented with a heavier burden of diffuse atherosclerotic disease when compared to control population. They were at higher risk for postoperative neurological complications because of a higher brain fragility mainly encountered in a small subset of patients presenting association of advanced age i.e.>74 years and preoperative brain infarction.

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upra Aortic Trunks S Percutaneous endovascular treatment of supra-aortic trunk stenosis – indications and procedures Marina Dias-Neto, Mário Vieira, João Neves, José Fernando Ramos, José Fernando Teixeira Serviço de Angiologia e Cirurgia Vascular, Hospital de São João, Porto, Portugal

Significant atherosclerotic involvement of proximal common carotid artery (CCA) or brachiocephalic trunk (BT) are rare findings1. These lesions may cause ischemic stroke due to embolism or hemodynamic compromise. BT disease may also comprise upper right limb ischemia or even coronary-subclavian steal syndrome (CSSS) in patients submitted to coronary artery bypass grafting (CABG) with right internal mammary artery (RIMA). Because there are currently no guidelines available from European Society for Vascular Surgery or Society for Vascular Surgery regarding the management of these lesions2, decisions follow individual clinical and anatomical features. Two patients are presented with high-grade supra-aortic trunk stenosis successfully revascularized with stenting to give an sight into indications and procedures in this field. A 53-years-old man presented a new stroke in the territory of the left medial cerebral artery numbering the third neurologic event in the left hemisphere within 16 months. Besides generalized cervical and intracranial atherosclerotic disease, doppler findings included a high-grade left CCA stenosis (75-80%) in the middle third of the artery with attenuated distal flux. The patient recovered from his deficits and underwent endovascular treatment through femoral approach and over the wire of a distal embolic protection device placed in internal carotid artery. A balloon-expandable stent was successfully deployed. After 5 months, he remains neurologically asymptomatic. A 79-yeas-old man proposed to CABG presented great aortic calcificaton and left subclavian artery oclusion which precluded RIMA as the best conduct. In order to prevent CSSS, endovascular treatment of an hight-grade BT stenosis was undertaken. A femoral approach was attempted over the wire of a distal embolic protection device, but intended stent positioning was not achieved. A bailout retrograde access (through right brachial artery) was then successfully conducted. The distal embolic protection device was removed uneventfully. Patient was submitted to CABG one week later without complications. Successful cases like this support balloon angioplasty and stenting as primary treatment of atherosclerotic lesions of the supra-aortic trunks in selected cases.

REFERENCES 1. Akers DL, Markowitz IA, Kerstein MD. The value of aortic arch study in the evaluation of cerebrovascular insufficiency. Am J Surg 1987;154: 230-2. 2. Liapis CD, Bell PR, Mikhailidis D, Sivenius J, Nicolaides A, Fernades e Fernandes J, et al. ESVS guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg 2009;37:S1e19. 115

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upra Aortic Trunks S Intervention in thoracic outlet syndrome: a diverse clinical entity with regard to a series of cases Ricardo Gouveia, Pedro Brandão, Pedro Sousa, Jacinta Campos, Andreia Coelho, José Meira, Alexandra Canedo

Centro Hospitalar Vila Nova de Gaia/ Espinho, Department of Angiology and Vascular Surgery, Vila Nova de Gaia, Portugal INTRODUCTION Thoracic Outlet Syndrome (TOS) is a rare clinical entity, although it is though to be underestimated. Occurs more frequently in women and its most observed form is Neurogenic (nTOS). Its etiology is multiple, usually envolving muscular, skeletal or fibrotic changes to which trauma mechanisms can be associated. CASE REPORTS We present a series of five cases of TOS. Three cases envolving both Arterial (aTOS) and nTOS forms, one only aTOS and one only Venous (vTOS). Three patients were female. Ages ranged from 19 to 51 years-old. Diagnosis was stablished based on elements of clinical, imaging and electromyographic order. Interventional treatment was adapted to etiology at hand: a patient with an acute upper limb ischemia due to thrombosis of a subclavian aneurysm underwent subclavian-braquial interposition graft with great safenous vein, aneurysmectomy in conjunction with cervical rib resection; a patient with posttraumatic venous thrombosis underwent catheter thrombolysis and anticoagulation in conjunction with resection of cervical rib and venous angioplasty of the subclavian vein and subsequently venous stenting for residual stenosis; in the remaining cases the patients were submitted to a combination of cervical rib, first rib or costiform process resection or fibrous ligament lysis and anterior scalenectomy and brachial plexus neurolysis. Interventional treatment was complemented by a functional rehabilitation program. DISCUTION AND CONCLUSIONS TOS may appear through multiple and sometimes dificult to identify clinical forms. Since it is very rare and has several differential diagnosis it may remain undiagnosed. It also represents a challenge in treatment which needs to be oriented to the etiology at hand. We report particularly rare cases of isolated aTOS and vTOS (less then 1% of the cases) and a case that presented at 19 years-old (less then 5% of the cases appear at an age bellow 20). Therefore, we report a series of unusuall cases that highlight the diversity in both clinical presentation and treatment forms of TOS. REFERENCES 1. Gillard J, Pérez-Cousin M, Hachulla E, Remy J, Hurtevent JF, Vinckier L, et al. Diagnosing thoracic outlet syndrome: contribution of provocative tests, ultrasonography, electrophysiology, and helical computed tomography in 48 patients. Jt Bone Spine Rev Rhum. 2001 Oct;68(5):416–24. 2. Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome part 1: clinical manifestations, differentiation and treatment pathways. Man Ther. 2009 Dec;14(6):586–95. 3. Ferrante MA. The thoracic outlet syndromes. Muscle Nerve. 2012 Jun 1;45(6):780–95. 4. Sanders RJ, Hammond SL, Rao NM. Thoracic outlet syndrome: a review. The neurologist. 2008 Nov;14(6):365–73. 5. Nichols AW. Diagnosis and management of thoracic outlet syndrome. Curr Sports Med Rep. 2009 Oct;8(5):240–9. 6. Thompson RW. Challenges in the Treatment of Thoracic Outlet Syndrome. Tex Heart Inst J. 2012;39(6):842–3. 7. Christo PJ, McGreevy K. Updated perspectives on neurogenic thoracic outlet syndrome. Curr Pain Headache Rep. 2011 Feb;15(1):14–21. 8. Laulan J, Fouquet B, Rodaix C, Jauffret P, Roquelaure Y, Descatha A. Thoracic outlet syndrome: definition, aetiological factors, diagnosis, management and occupational impact. J Occup Rehabil. 2011 Sep;21(3):366–73.

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upra Aortic Trunks S Subclavian steal syndrome and cerebral hypoperfusion during hemodialysis: a case report Sérgio Teixeira, Ivone Silva, Pedro Sá Pinto, Paulo Almeida, Luís Loureiro, Tiago Loureiro, Duarte Rego, João Gonçalves, Rui Almeida Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal

Subclavian steal syndrome is caused by retrograde vertebral artery flow “stealing” vertebrobasilar perfusion. Here we present the clinical case of a 53 year-old dialysis dependent woman with several cardiovascular risk factors, who had episodes of vertebrobasilar insufficiency and resting pain of the left superior limb, during hemodialysis sessions by a left arm brachiobasilic arteriovenous fistula. Noninvasive studies demonstrated a preoclusive stenosis at the origin of left subclavian artery, a stenosis on the left internal carotid artery greater than 70% and reversion of flow in the left vertebral artery. The patient underwent endarterectomy and Dacron patch angioplasty of the left internal carotid and carotid-subclavian ePTFE bypass, with total resolution of the previously described clinical presentation.

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Left posterior volume-rendered image from CT Angiography

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Visceral arteries The rationale in the treatement of visceral artery aneurysms

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Roberto Gattuso, Alessandra Giglio, Alban Malaj, Ombretta Martinelli, Luigi Irace

University â&#x20AC;&#x153;La Sapienzaâ&#x20AC;?, Rome, Italy

INTRODUCTION Visceral artery aneurysms (VAA), although rare, represent a pathological condition with high mortality rates, because of their high frequency of rupture and consequent fatal bleeding (22% - 70%). The increased incidental detection, is related to the increased use of advanced imaging technology; the vascular surgeon must choose when to treat them more frequently and with what approach: endovascular techniques or open traditional surgical treatment. MATERIALS AND METHODS From 1992 to 2014, 121 visceral aneurysms were treated: 51/121 (42.1%) with endovascular techniques (24 embolizations, 27 covered stents); 69/121 (57.1%) with open traditional surgical treatment (24 resections and 45 reconstructions). In one case, the endovascular treatment failed. In 20 cases (29%), surgery was performed in emergency conditions. The mean age of patients was 65 years. During follow-up ( 60 months) controls were performed with Doppler ultrasound and / or CT angiography. RESULTS In the endovascular group, the intra and post-operative mortality was nil. In this group, major complications were intestinal ischemia for superior mesenteric artery dissection and a massive splenic hematoma. In the surgical group, 8 patients, treated in emergency, died (40% mortality). CONCLUSIONS There is no standardized consensus regarding the indications for treatment of VAA. These should always be treated if: symptomatic, larger than 2 cm in a good-risk surgical candidate, with a rapid growth of more than 0.5 cm/year, when present in a pregnant women or those of childbearing age, or in patients undergoing an orthotopic liver transplantation. In the emergent setting, the endovascular approach may be considered as first choice, in spite of the high mortality of open surgical treatment. In the elective setting, it should consider the affected artery and its morphology to choose the right treatment.

Angio-CT reconstruction Splenic artery aneurysm

Angiography Splenic artery aneurysm

Stenting Splenic artery aneurysm

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isceral arteries V Our experience in the treatment of visceral artery aneurysm during the last 12 years. Introduction of endovasculars techniques Julio César Sepúlveda Grisales, Cristina Pantoja Peralta, Bahaa Arefai, Benet Gómez Moya, Vicente Martin Paredero University Hospital of Tarragona Joan XXIII, Tarragona, Spain

OBJECTIVE The aim of our study is to analyze our experience in the management of visceral artery aneurysm (VAAs) and review our protocols and techniques regarding the endovascular procedures. MATERIAL AND METHODS Between 2001 and 2013, 32 patients (17 males; mean age: 62.4 [range: 38-77] years) with visceral artery aneurysms (VAAs) were admitted into our center. The site of aneurysmal disease was: splenic artery (13), hepatic artery (4), superior mesenteric artery (3), pancreaticoduodenal artery (1), gastroduodenal artery (2), celiac axis (2), gastric artery (1), and renal artery (13) . Two patients (6.25%) presented with an aneurysm rupture. We analyze these patients to assess the type of procedure and its success. The follow-up period ranged between 12 and 60 months. RESULTS Sixteen cases received an endovascular treatment. Primary technical success was achieved in fourteen patients. Endovascular failures included one case of endoleak after stenting, one incomplete embolization. In 7 cases, the surgical treatment was performed successfully. The total survival rate was 96.8% . CONCLUSION The potential risk of rupture is the principle reason for the treatment of VAAs.In most cases, an endovascular approach permits in most cases a less aggressive treatment and a shorter hospital admission. Although not all VAAs are tributary of endovascular treatment, we consider that a trained endovascular surgeon could solve most of the cases. Benefits are the conservation of organ perfusion, fewer complications and next day hospital discharge. An economic study is still needed to verify the efficiency of these procedures.

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isceral arteries V Endovascular treatment of distal renal artery aneurysm: technique for stenting with preservation of segmental branches Ricardo Gouveia, Pedro Brand達o, Miguel Lobo, Pedro Sousa, Jacinta Campos, Andreia Coelho, Alexandra Canedo

Centro Hospitalar Vila Nova de Gaia/ Espinho, Department of Angiology and Vascular Surgery, Vila Nova de Gaia, Portugal INTRODUCTION True renal aneurysms are very uncommon and even vascular specialist referral centers do not have very large numbers to report. The treatment of this type of aneurysm has been moving toward endovascular repair, although surgical treatment can be done with good long-term results. Although endovascular repair can be attractive not only for patients unfit for open repair, it can, sometimes, be technically challenging, especially when renal artery bifurcations are involved and the segmental arteries have tortuous paths. CASE REPORT We report the case of a 63 year-old patient with a left segmental renal artery aneurysm of 25mm with sacular configuration and with complaints of abdominal pain. He has a past history of smoking and chronic obstructive pulmonary disease and therefore was offered an endovascular approach. The diagnostic angiogram showed a very tortuous segmental renal artery from which the aneurysm formed. It was not possible to find the correct angle to reveal the two segmental branches from the bifurcation so we could release the stent safely without occluding one of them. After crossing the aneurysm with a Terumo 0,035 guide wire and achieving good anchoring with a 6F reinforced Cook Sheath we chose to inflate a slightly undersized 4mm balloon to occlude the segmental branch from which the aneurysm formed. By moving back the balloon progressively and inflating it a few times until we achieved occlusion of the other segmental branch, and by using the opaque marking from the balloon as reference, we were able to detect accurately the proximal limit for the covered stent (Viabahn 6x50mm), and release it safely. The control angiogram showed good patency from both segmental branches and perfusion of the kidney. DISCUSSION AND CONCLUSIONS In a time where technical challenges can limit the applicability of endovascular treatment in renal aneurysms we report a simple technique to achieve go positioning of stents when segmental arteries near the bifurcation are involved.

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ase report C Seat belt aorta, an underdiagnosed cause of young adult aortic thrombosis. Case report José Tiago, Viviana Manuel, Sónia Ribeiro, Carlos Martins, Luis Pedro, José Fernandes e Fernandes Vascular Surgery Department, Hospital Santa Maria, Lisboa, Portugal

Safety belts were created to protect lives in accidents, however every year thousands of lives are lost in car crashes. Different modalities of blunt trauma may occur during accidents and steering wheel and seat belt injuries are common. Although seat belts are known to cause injuries to the abdominal viscera, they rarely produce aortic trauma, and when occurs mainly involves the thoracic aorta while the abdominal aorta is frequently spared. Seat belt aortic thrombosis results from direct compression of the aorta between the horizontal part of the seat belt and the vertebrae, resulting in intimal dissection. It is an infrequent event and represents only 0.04% of all blunt abdominal trauma. We report a 23 year old female that was admitted to our department 2 years after a major car crash accident with complaints of critical limb ischemia. The physical examination shows no palpable pulses in the limbs and CT scan revealed an infra-renal aortic partial occlusion. The patient was treated percutaneously with Advanta V12 stent graft deployed in the infrarenal aorta. One year after the procedure, she is performing well with all palpable pulses and no complaints. CT scan reveals a well deployed graft with no signs of aortic thrombosis. Seat belt aorta is a rare potential lethal lesion, can be asymptomatic in the initial phase and may evolute to chronicity causing critical limb ischaemia. Understanding the mechanisms of safety belt compression over the infrarenal aorta and being alert for clinical signs allow for prompt recognition even in the chronic phase. Nowadays endovascular treatment with stents or stent grafts is feasible percutaneously and can be the first option of treatment in the acute or chronic phase.

Left foot, ischaemic toe

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Preoperative angiography

Postoperative angiography

Preoperative Angio-CT

Postoperative angio-CT

REFERENCES 1. Roth SM, Wheeler JR, Gregory RT, et al: Blunt injury of the abdominal aorta: a review. J Trauma 1997;42:748-755 2. Vernhet H, Marty-Ane CH, Lesnik A, et al: Dissection of the abdominal aorta in blunt trauma: management by percutaneous stent placement. Card Intervent Rad 1997;20:473-476 3. Azizzadeh A, Keyhani K, Miller CC 3rd, Coogan SM, Safi HJ, Estrera AL. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg 2009;49:1403-8. 4. Starnes BW, Lundgren RS, Gunn M, Quade S, Hatsukami TS, Tran NT, et al. A new classification scheme for treating blunt aortic injury. J Vasc Surg 2011 [Epub ahead of print] doi:10.1016/j.jvs.2011.07.073. 5. Gunn M, Campbell M, Hoffer EK. Traumatic abdominal aortic injury treated by endovascular stent placement. Emerg Radiol 2007; 13:329-31. Seat belt injuries of the abdominal aorta in adults--case report and literature review. 6. Freni L, Barbetta I, Mazzaccaro D, Settembrini AM, Dallatana R, Tassinari L, Settembrini PG. Vasc Endovascular Surg. 2013 Feb;47(2):138-47 7. Shalhub S, Starnes BW, Tran NT, Hatsukami TS, Lundgren RS, Davis CW, Quade S, Gunn M. Blunt abdominal aortic injury. J Vasc Surg. 2012 May;55(5):1277-85

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ase report C Vascular complications associated with percutaneous ecls implementation – one centre experience Andreas Borowski, Hannan Dalyanoglu, Erhard Godehardt

Clinic of Cardiovascular Surgery, Univ. of Düsseldorf, Düsseldorf, Germany OBJECTIVES Percutaneous implementation of extracorporeal life support (ECLS) is associated with considerable risk for acute vascular sequelae at the cannulation site. The purpose of this study is to report on our experience with venoarterial (VA) – ECLS implanted in in-house and out-of-house setting, with focus on vascular complications requiring surgery. METHODS The investigation is based on a single-centre, retrospective study on 85 consecutive patients who required VA-ECLS for cardiogenic shock. RESULTS Between 09/2011 and 03/2014, a total number of 85 adult patients (age 18-80, 23 females) received percutaneous VA-ECLS via femoral access; of them 64 patients while on CPR. Perfusion cannula for lower limb was inserted in 52 patients, in most cases at the second occasion. In 24/85 patients (28%) vascular complications requiring surgery occurred, in 18 patients associated with lower limb ischemia. A total number of 64 surgeries were necessary (for bleeding control, hematoma-25, vascular reconstructions-9, thrombectomy-10, fasciotomy-14, femoro-popliteal bypass-1, change to axillary perfusion site-4, upper limb amputation-1). 56/85 patients (66%) died. The vascular complication rate in survivors was considerably lower to non-survivors (13% vs. 32%). CONCLUSION In patients with percutaneous ECLS (femoral access), the risk for lower limb ischemia is high. In case of suspected ischemia immediate and safe insertion of perfusion cannula is crucial to prevent further vascular sequelae.

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ase report C Transcarotid balloon occlusion of the brachiocephalic artery to control bleeding due to sharp injuries of the right subclavian artery Denis Skrypnik, Roman Vinogradov, Victoria Magamet, Kovalenko Alexey

Budget Institution of Public Health Department Regional Clinical Hospitalâ&#x201E;&#x2013;1 after prof. S.V.Ochapovsky, Krasnodar, Russia INTRODUCTION Military or civilian subclavian artery injuries are frequently life-threatening entities that are accompanied by high morbidity and mortality. Syntopic peculiarities can result in huge losses of blood and difficulty in the control of bleeding. Here, we present a new manoeuvre involving transcarotid balloon occlusion of the brachiocephalic artery to control bleeding due to sharp injuries of the right subclavian artery. SURGICAL TECHNIQUE A 25 year-old male was admitted to a general surgery hospital 40 minutes after suffering knife trauma to the right supraclavicular region and profuse bleeding from a linear wound above the middle third of the clavicle. The patient was in severe haemorrhagic shock, unconsciousness, and without a pulse in the right arm; however, he did not exhibit X-ray signs of haemothorax. He was immediately intubated and transported to an operation room. To control the bleeding, we employed a temporary transcarotid balloon occlusion of the brachiocephalic artery. The CCA, ICA, and ECA were exposed using standard techniques, and tourniquets were applied. After a 2500 EU bolus of heparin was delivered, a transverse ECA transverse arteriotomy was made, and a 6.0 Fogarty balloon catheter was introduced retrogradely into the aorta, inflated and pulled back (Figure 1). Next, the wound compression was removed, and the deep narrow wound canal was revised to reveal the full right subclavian artery transection in the interscalene zone. Transected fragments were selectively clamped, and the balloon in the brachiocephalic artery was deflated. The occlusion time was 4 minutes, which was sufficient to reach and selectively cross-clamp the artery fragments. The right subclavian artery was restored in an end-to-end fashion with a 6.0 Prolene suture, and the ECA arteriotomy was closed with a 6.0 Prolene suture using standard techniques. Postoperatively, the patient exhibited no central neurological deficits, but signs of right-sided plexitis due to the prolonged compression of the supraclavicular region were present. This plexitis completely resolved within 3 weeks. The patient was discharged on the 14th day. DISCUSSION Sharp subclavian artery injuries are associated with high mortality and morbidity rates 1, 2. The complex syntopy of this type of injury makes the control of bleeding with simple would compression difficult. Balloon-assisted endovascular bleeding control and endovascular repair 1, 2, 3 are a well-known techniques, but this techniques may be impossible to apply in military circumstances, in unspecialised general surgery hospitals or in situations in which an endovascular specialist is not immediately available. The use of Foley catheters for the control of bleeding 4 is commonly problematic; on the one hand, there is no concrete channel or cavity after tissue interposition, and on the other hand, the Foley balloon itself can be an obstacle to wound revision. Despite these limitations, endovascular control of bleeding is preferable because all compression materials must be removed from the wound prior to revision, which consequently leads to repeated bleeding and patient deterioration in the absence of a proximal control. The anatomy of the right subclavian artery, which arises from the brachiocephalic artery in 74% of patients 5, allows for the use of the ECA as a relatively safe access point for balloon occlusion of the brachiocephalic artery. As discussed above, transcarotid balloon occlusion of the brachiocephalic artery can be quickly implemented, can be performed even by general surgeons without X-ray control and, importantly, this manoeuvre allows the control of bleeding to be achieved during wound revision. Additionally, as demonstrated in the present case, intraoperative stroke can be avoided in patients in haemorrhagic shock. Further reports are needed, but we believe that the simple, relatively safe manoeuvre of transcarotid balloon occlusion of the brachiocephalic artery, which can be performed under ultrasound control in some circumstances, is capable of 124

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decreasing the morbidity and mortality rates of patients with sharp injuries to the right subclavian artery.

Insertion of the Fogarty catheter

Control of the bleeding 125

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Site of the damage

Final result REFERENCES 1. Chatt A. Johnson, M.D ., F.A.C.S. Endovascular Management of Peripheral Vascular Trauma. Semin Intervent Radiol 2010;27:38–43 2. Jack L. Cronenwett and K. Wayne Johnston. Rutherford’s Vascular Surgery 7th edition 2010; Vol. 2: 2327-2329 3. Chakraverty S., Flood K., Kassel D. et al. CIRSE Guidelines: Quality Improvement Guidelines for Endovascular Treatment of Traumatic Hemorrhage. Cardiovasc Intervent Radiol 2012; 35:427-482 4. Navsaria P, Thoma M, Nicol A. Foley catheter balloon tamponade for life-threatening hemorrhage in penetrating neck trauma. World J Surg. 2006 Jul;30(7):1265-8 5. G.C. Jakanany, W. Adair. Frequency of variations in aortic arch anatomy depicted on multidetector CT. Clinical Radiology 65 (2010) 481-487

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ase report C Vascular trauma secondary to a pit bull attack Diego Fernando Ruiz Chiriboga, Ana Apodaka Diez, Maria Azucena Ayala Strub, Maria Soledad Manzano Grossi, Octavio Daniel De La Torre Scherak, Luis Manuel Reparaz Asensio Hospital General Universitario Gregorio Marañón, Madrid, Spain

We present the case of a forty-one-year-old man with an anterior tibial artery and external popliteal sciatic nerve injury with tibioperoneal arterial trunk contusion due to multiple dog bite injuries after being attacked by one aggressive pit bull. The patient was unstable with a heart rate of 130x´ and had important bleeding in the anterior-lateral compartment of the right leg (RL) and multiple penetrating wounds in the front and back of leg. He also had weakness and numbness of the ankle and toes. We were unable to feel popliteal and distal pulses and the foot had signs of acute ischemia The patient underwent intra-operative angiography doing a open approach of the first portion of the popliteal artery. The angiography revealed the complete occlusion of the anterior tibial artery and a contused tibioperoneal trunk We decided to ligate the anterior tibial artery and vein because there was an important avulsion of the muscle and tissue around the lesion, and repair the tibioperoneal trunk doing a vein patch with good angiography result and outflow. The nerve and muscle injuries were evaluated together with orthopedics with primary suture. The wounds were washed and cured with rifampicin daily and saline solution, until they ere able to place a skin graft. The patient was discharge at 15 days of hospitalization. Actually in the 4 months follow up the patient had the skin graft by plastic surgery, the wound didn’t have more complications and continues in rehabilitation. Vascular injuries are uncommon in dog bites but it´s important to identify the type of injury because it can have devastating consequences reflected in acute arterial, vein and nerve lesions. All these injuries should be consider severe and need extensive follow up for further complications. REFERENCES A. George Akingba, MD, PhD,a,b Eric A. Robinson, BS,b Andrea L. Jester, MD,a Brian M. Rapp, MD,a Anthony Tsai, MD,a Raghu L. Motaganahalli, MD,a Michael C. Dalsing, MD,a and Michael P. Murphy, MD,a Indianapolis, Ind. Management of vascular trauma from dog bites, JOURNAL OF VASCULAR SURGERY, Volume 58, Number 5, 2012

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Pit-bull bite

AFTER THE SURGERY

Vein patch and final angiogram

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ase report C An adult case of idiopatic internal carotid – internal jugular vein arteriovenous fistula Aniello Enrico Puca, Francesco Pignatelli

Vascular Surgery Unit Ospedale dei Pellegrini, Napoli, Italy Carotid-jugular fistula is an abnormal connection between the carotid artery and/or its branches and jugular vein. It can develop either because of trauma or spontaneous causes. Traumatic fistula may occur after head injuries , and can range from minor falls to severe penetrating wounds. Traumatic fistula may also results from endovascular therapy, however these fistulas may be congenital arteriovenous connections that open spontaneously in the setting of collagen vascular disease, atherosclerotic disease, hypertension, or childbirth. Spontaneous fistulas between internal carotid artery and internal jugular vein are very exceptional diseases therefore this case is presented for its rare incidence in literature. A 59 years old woman with dizziness and headache came to our observation in november 2013 to undergo duplex scanning of supra aortic trunk. During the exam it was detected dilated right internal jugular vein with arterial flow inside and high peak of systolic velocity with turbulence at color doppler in absence of stenosis of carotid artery. The patient had no history of neck trauma or surgical interventions or biopsy of the neck, she had headache and dizziness since a year and she had undergone to eye surgery several years ago for bilateral degeneration of the cornea. She suffered of arterial hypertension and gait disturbance for a decreased vision due to a degenerative disease of the retina. Upon hospital admission , the patient’s clinical findings included headache and dizziness, there wasn’t no cardiac failure or other cardiopathy, no peripheral edema and the serum biochemical levels were all found to be within normal limits. There was no visible or palpable swelling at neck esamination and the right side of the neck was warm with a continuous thrill. Angio-MR imaging revealed venous congestion, a dilated right internal jugular vein and the presence of a fistula between the internal carotid artery and internal jugular vein. There was no sign of cerebral ischemia at MR. The patient was undergone to surgical repair of the arteriovenous communication with standard approach like carotid surgery for stenosis, in general anesthesia, but there wasn’t need vessels clamping and arterial reconstruction. The fistula was closed using hemostatic single points with 6/0 polypropylene monofilament. The patient was discharged 3 days after surgical repair and returned for follow up after 1 month. Duplex scanning performed after 1 month showed normal size of right internal jugular vein with low flow and absence of turbulence at color doppler. The patient reported complete resolution of headache and dizziness. Spontaneous carotid–jugular fistulae are uncommon. A high index of suspicion is necessary for the diagnosis. Unlike arteriovenous fistulae in the limbs, carotid– jugular fistulae are particularly prone to complications such as intractable high-output cardiac failure, atrial fibrillation, and embolization. The development of high cardiac output and heart failure depends on the proximity of the fistula to the heart and the degree of left-to-right shunting. The latter is determined by the diameter of the fistula and the number of fistulae present, when possible, the degree of shunting and the number of fistulae should be ascertained before surgery to assist in planning the procedure. Noninvasive color-flow echo Doppler scanning is highly sensitive for these fistulae when it is performed by an experienced physician. Other diagnostic methods, such as chest radiography and 2-dimensional echocardiography, may be needed in order to detect cardiomegaly and also to rule out the possibility of an intracardiac foreign body. For long-standing cases, atrial fibrillation and bundle branch block may be revealed by electrocardiography. Surgery for carotid–jugular fistulae involves adequate exposure, vascular control, heparinization, and direct vascular procedures. The ideal treatment is to divide the fistula and maintain the vascular continuity of both vessels. These goals can be achieved by direct lateral suturing, as we did. When direct suturing is not possible, patch arterioplasty and venoplasty or interposition graft placement may be necessary. In conclusion early treatment of carotid–jugular fistulae is necessary in order to avoid associated complications.

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Angio-RM REFERENCES 1. Kawakami K, Takahashi A, Sugawara T, Nakamura N, Yoshimoto T, Suzuki J. Spontaneous arteriovenous fistula of external carotid artery treated by detachable balloon: a case report. Neurol Surg 1986;15:549–553 2. Willinsky R, Terbrugge K, Montanera W, Mikulis D, Wallace C. Venous congestion: MR findings in dural arteriovenous malformations with cortical venous drainage. AJNR Am J Neuroradiol 1994;15:1501–1507 3. Prevot J, Babut JM. Congenital cervical jugulo-carotid fistula. J Pediatr Surg 1970;5:431–436 4. Gobin YP, de la Fuente AG, Herbreteau D, Houdart E, Merland JJ. Endovascular treatment of external carotid-jugular fistula in the parotid region. Neurosurgery 1993;33:812–816 5. Masahiro Horiuchi, Tsutomu Kamo, Hiroshi Sugihara, Koshiro Fujisawa, Yoichi Takahashi, Ritsuko Ikeda, Hiroyuki Morishima, and Yoshitaro Yamaguchi An Adult Case of Congenital External Carotid–Jugular Arteriovenous Fistula with Reversible Circulatory Insufficiency in the Cerebellum and Lower Brain Stem AJNR Am J Neuroradiol 22:273–276, February 2001

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ase report C Primary aorto-enteric fistula in a 79-years-old man: report of a case successfully treated by an endovascular repair Sara Gallinucci1, Luigi Iazzolino1, Matteo Azzarone1, Simone Bosi2, Federica Persi1, Bilal Nabulsi1, Alessandro De Troia1, Tiziano Tecchio1, PierFranco Salcuni1 1. Vascular Surgery Dipartment-Ospedale Maggiore , Parma, Italy 2. Gastroenterology- Ospedale Maggiore, Parma, Italy

INTRODUCTION Primary aorto-enteric fistula (PAEF) is a communication between the aorta and the bowels, not due to previous surgery. It is a rare but serious condition with an incidence rate of 0.04-0.07%, associated with a high mortality, whose diagnosis and management are discussed. 1-2 Surgical treatment is considered the gold standard, consisting in extra-anatomic axillo-bifemoral bypass and aortic ligation. 2-3 Endovascular treatment should be an alternative approach. 4-7 CASE PRESENTATION A 79-years-old male with epigastric pain, proctorrhagia and secondary syncope came to our observation from Emergency Department. An episode of self-limited proctorrhagia had been reported 15 days before. At the admission, the patient was hypotensive, with pulse rate of 105/min and anemia. No remarkable abdominal pain was reveled . The rectal exploration showed the presence of bright red blood mixed to clots. Esophagogastroduodenoscopy (EGDS) was negative for bleeding or erosion. Abdomen CT-Scan revealed a communication between the third part of the duodenum and the unknown abdominal aortic aneurysm, suspected of PAEF (Figure 1). An emergent endovascular placement of Endurant II right aorto-uni-iliac stent-graft (Medtronic-Santa Rosa-CA) was performed, completed with the placement of a controlateral common iliac artery occluder (Talent-Occluder-Medtronic-Santa Rosa-CA) and femoro-femoral PTFE bypass. The post-operative course was uneventful. Subsequent CT-Scan showed the aorto-uniliac stent-graft and the femoro-femoral bypass patency without finding suggested infection. The patient was discharged with antibiotic therapy (linezolid 1,2 g /die and levofloxacin 500mg /die) to be continued for two months. An EGDS performed three months later showed the closed fistulous orifice without any further perilesional sign of inflammation (Figure 2). At 12 monthsâ&#x20AC;&#x2122; follow up, the patient was healthy. CONCLUSIONS We report a rare case of a PAEF successfully treated with an endovascular approach. Endovascular repair of PAEF should be a valid alternative to open surgery, especially in high risk patients; long lasting antibiotic therapy is mandatory to reduce infective complications. 4-7

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Abdomen CT-Scan: communication between the third part of the duodenum and the AAA

Post-operative EGDS: closed fistulous orifice without sign of inflammation REFERENCES 1. Ferguson MJ, Arden MJ. Gastrointestinal hemorrhage secondary to rupture of aorta. A review of four duodenal and three esophageal cases. Arch Intern Med. 1967;117(1):133-140. 2. GenovĂ¨s-Gasco B, Torres-Blanco A, Plaza-Martinez A, et al. Primary aortoduodenal fistula in a patient with pararenal abdominal aortic aneurysm. Ann Vasc Surg 2012; 26: 731-735. 3. Montgomery RS, Wilson SE. Surgical management of aortoenteric fistulas. Surg Clin North Am 1996; 76:1147-1157. 4. Grabs AJ, Irvine CD, Lusby RJ. Stent-graft treatment for bleeding from presumed aorto-enteric fistula. J Endovasc Ther 2000; 7: 236-239. 5. Deshpande A, Lovelock M, Massap P, et al. Endovascular repair of an aortoenteric fistula in a hight risk patient. J Endovasc Surg 1999; 6: 379-384. 6. Burks JA, Faries PL, Gravereaux EC, et al. Endovascular repair of bleeding aortoenteric fistulas: A 5-years experience. J Vasc Surg 2001; 34: 1055-1059. 7. Jayarajan S, Napolitano LM, Rectenwald JE, et al. Primary Aortoenteric Fistula and Endovascular Repair. Vasc Endovasc Surg 2009 43: 592-596

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ase report C Novel therapeutic strategies for endovascular treatment of chronic type b aortic dissections Diletta Loschi Perugia, Italy

Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment for chronic type B aortic dissection (CTBAD) at our institution. TEVAR in aortic intends to depressurize and thrombose the false lumen, and promote aortic remodeling in a majority of patients with acute aortic dissection 1,2. Response to this treatment strategy is limited in patients with chronic dissections with a reduced capacity for aortic remodeling due to the fibrotic degenerated intimal flap 3,4. In chronic aortic dissection there is continued pressurization from persistent retrograde false-lumen flow to intercostal and bronchial arteries from downstream entry-tears . Retrograde filling and pressurization leads to late aortic expansion in 35% of patients treated by TEVAR for chronic type B aortic dissection 5,6. Post-dissection aneurysms involve the thoracoabdominal aorta, however, additional technical challenges arise .The fenestrated/branched stent-grafts to achieve complete aneurysm exclusion is used, that allow covering an even longer segment of the aorta and to occlude more distal entries thus increasing the risk of paraplegia 5,6. Simple endovascular coverage of primary entry tear in chronic Type B Aortic Dissection (CTBAD) is often unsuccessful in promoting false lumen (FL) thrombosis and aortic remodeling. Aim of this case report is to illustrate technical solutions for effective endovascular treatment of residual CTBAD following Acute Type A Dissection. METHODS A 61-year-old man with was admitted emergently for type A dissection, and received ascending and hemiarch open repair. Sixteen months later, his CT control showed a type B dissection with thoracic aneurysm 7.5 cm in diameter; the left subclavian artery presented chronic dissection involving the dominant vertebral artery. He was treated by carotido-subclavian by pass plus vertebral artery re-implantation, followed by TEVAR. After nine months a CTA showed distal type I endoleak associated with expansion of aortic diameter. To obtain complete sealing of FL, distal backflow was interrupted by deploying in the distal thoracic aorta an oversized, tapered stent-graft. Controlled rupture of the dissection membrane, the so called Knickerbocker technique, was performed with graft ballooning at its mid-section. RESULTS The â&#x20AC;&#x153;Knickerbocker techniqueâ&#x20AC;? was used to successfully occlude flow in the false lumen of the thoracic aorta Follow up CTA at 3 months showed complete thrombosis of the proximal false lumen; duplex at 10 months is showing persistent false lumen thrombosis. CONCLUSION Multiple therapeutic options are available today for treatment of CTBAD. A pre-planned standardised approach with staged open and endovascular procedures seems to be effective in excluding FL. Thoracic endografitng and controlled flap rupture in CTBAD may ensure distal sealing and false lumen thrombosis in patients with suitable anatomy.

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CT AFTER TEVAR DISTAL TYPE I ENDOLEAK

30-DAY CONTROL CT COMPLETE THROMBOSIS OF THE PROXIMAL FALS LUMEN REFERENCES 1. Chavan A, Rosenthal H, Luthe L, et al. Percutaneous interventions for treating ischemic complications of aortic dissection. Eur Radiol. 2009;19(2):488-94. 2. Sayer D, Bratby M, Brooks M, et al. Aortic morphology following endovascular repair of acute and chronic type B aortic dissection: implications for management. Eur J Vasc Endovasc Surg. 2008;36(5):522-9. 3. Kusagawa H, Shimono T, Ishida M, et al. Changes in false lumen after transluminal stent-graft placement in aortic dissections: six years’ experience. Circulation. 2005;111(22):2951-7. 5. Kölbel T, Diener H, Larena-Avellaneda A, et al.. Advanced endovascular techniques for thoracic and abdominal aortic dissections. The Journal of cardiovascular surgery. 2013;54(1 Suppl 1):81-90. 6. Scali ST, Feezor RJ, Chang CK, et al. Efficacy of thoracic endovascular stent repair for chronic type B aortic dissection with aneurysmal degeneration. J Vasc Surg. 2013;58(1):10-7 e1. 7. Simring D, Raja J, Morgan-Rowe L, Hague J, Harris PL, Ivancev K. Placement of a branched stent graft into the false lumen of a chronic type B aortic dissection. J Vasc Surg. 2011;54(6):1784-7. 8. Verhoeven EL, Paraskevas KI, Oikonomou K, et al. Fenestrated and branched stent-grafts to treat post-dissection chronic aortic aneurysms after initial treatment in the acute setting. J Endovasc Ther. 2012;19(3):343-9

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ase report C Simultaneous presentation of a carotid body tumour and extra-cranial internal carotid artery aneurysm: too rare to be coincidental? Ashrafi M., Al-Jarrah Q., Oldbury J., Rogers S., Baguneid M., Wolowczyk L. University Hospital of South Manchester, Manchester, United Kingdom

INTRODUCTION Carotid body tumours (CBTs) are the most common parangangliomas identified within the head and neck. They remain rare neoplasms arising from the carotid body and present technical difficulties in excision with high complication rates. There have been no reported cases of simultaneous CBTs and extra-cranial internal carotid artery (ICA) aneurysms. We report, to our knowledge, the first and subsequent management of such a case. CASE PRESENTATION A 76-year-old female presented with a sudden onset left-sided facial weakness and sialorrhoea. On clinical examination she had a palpable firm pulsatile mass in the right carotid triangle. Duplex scan revealed an echogenic well-vascularised mass with splaying of the carotid bifurcation, consistent with a CBT (Figureâ&#x20AC;Ż1). Magnetic resonance imaging identified a distal cervical segment ICA aneurysm (Figure 2). The patient initially underwent catheter angiography in view of stenting the aneurysm; however, this was abandoned due to the tortuosity of the ICA (Figure 3). The patient later returned and underwent open ICA aneurysm repair and CBT excision (Figure 4). The patient had no complications immediately post operatively. DISCUSSION This is the first report on the management of concurrent CBT and extra-cranial ICA aneurysm. The morbidity and mortality associated with open surgical excision of CBTs is well-documented. However, in this case, the management is complicated by the presence of an ICA aneurysm. It remains unknown whether there is an association between the CBT and ICA aneurysm. CBT-induced hypertensive crises could be the causal link between the two conditions in this case 1. CONCLUSION This is the first reported case of simultaneous CBT and extra-cranial ICA aneurysm. Although unique, it seems highly unlikely that this was a coincidental finding and therefore an aetiological link must exist. REFERENCE 1. Inci S and Bertan V. Catecholamine-secreting carotid body tumor and intracranial aneurysm: coincidence? Surg Neurol. 2000 May;53(5):488-92

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3D Duplex Image Tomographic US reconstruction of extra-cranial carotid arteries

3D MR angiogram reconstruction

Digital Subtraction Angiography

Intra-operative image of CBT and ICA aneurysm Arrow: ICA Aneurysm 136

ase report C Pulmonary embolectomy without heart - lung - machine through thoracotomy Hartmut Rimpler

Thoracic and Vascular Surgery Vivantesklinikum Friedrichshain, Berlin, Germany Surgical treatment of pulmonary embolism is commonly performed in connection with a cardiopulmonary machine. We report a surgical method in which approach of the pars interlobaris of the arteria pulmonalis via a thoracotomy does not require a cardiopulmonary machine. The surgical objective is to remove endoluminal occlusion of the arteria pulmonalis and to relieve pulmonary hypertension to the heart (right chambers). From 2002 to 2014, 16 patients with pulmonary embolism where operated, among which 5 Patients were operated in both sides: 11 patients survives, and 5 patients died. Complications are bleeding after lysis (1x), bleeding from bronchial system (2x) and intraoperative deaths (2x, one with bleeding from bronchus after lysis). Even in the presence of severe lung adhesions this intervention is of medium technical difficulty and can be recommended to every hospital, with experienced surgeons in the field of vascular and thoracic surgery. This procedure without sternotomy is a new option in the operative treatment of lung embolism.

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ase report C Infrapopliteal ruptured mycotic aneurysm: case report and literature review

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Ana Ferreira, Emílio Silva, Alfredo Cerqueira, José Teixeira, Roberto Roncon de Albuquerque

Centro Hospitalar S. João, Porto, Portugal

Popliteal artery aneuryms are the most common peripheral arterial aneurysms and a significantly related cause to morbidity, mortality and limb loss. Complications include distal embolisation, thrombosis, and rarely rupture. Infrapopliteal ruptured mycotic aneurysm is extremely rare with only 2 cases reported in the literature. We present a case of ruptured popliteal mycotic aneurysm in the context of Streptococcus mitis and Streptococcus oralis mitral endocarditis. Diagnosis was based on history and physical examination. Ultrasound confirmed the rupture. The patient was treated by open surgery with an infrapopliteal- tibioperoneal trunk bypass and aneurysm excision. He was discharged 10 days after with palpable pedal, tibial posterior and peroneal pulses, mild edema of lower leg and normal ultrasound control. The literature of infected popliteal aneurysms is also discussed. REFERENCES 1. Lawrence PF, Lorenzo-Rivero S, Lyon JL: The incidence of iliac, femoral, and popliteal artery aneurysms in hospitalized patients. J Vasc Surg 1995; 22:409-415. 2. Osler W: The Gulstonian lectures on malignant endocarditis. BMJ 1885; 1:467. 3. Lewis D, Schrager J: Embolomycotic aneurysms. JAMA 1909; 63:1808. 4. Khasnis A, Chick D, Havlichek D Jr.: Mycotic aneurysm of the tibioperoneal trunk as a complication of aortic valve endocarditis due to lactobacillus casei infection: Case report and review of literature. Infect Dis Clin Pract 2006;14:185– 187. 5. Akers DL Jr, Fowl RJ, Kempczinski RF: Mycotic aneurysm of the tibioperoneal trunk: Case report and review of the literature. J Vasc Surg 1992;16:71–74. 6. McKnee MA, Ballard JL: Mycotic aneurysms of the tibioperoneal arteries. Ann Vasc Surg 1999;13:188–190. 7. Murashita T, Yasuda K, Takigami T: Mycotic aneurysm of the bilateral tibioperoneal trunks associated with bacterial endocarditis: A case report. Int Angiol1997;16:176–179. 8. Larena-Avellaneda A, Debus ES, Daum H: Mycotic aneurysms affecting both lower legs of a patient with Candida endocarditis— endovascular therapy and open vascular surgery. Ann Vasc Surg 2004;18:130–133. 9. Albayrak R, Saglan H, Emmiler M: Large mycotic aneurysm of the peroneal artery. J Clin Ultrasound 2007;35:344–346. 10. Menanteau B, Gausser NDF, Ladam-Marcus V: Mycotic aneurysm of the posterior tibial artery and pseudo-phlebitis: Contribution of color Doppler ultrasonography. J Radiol 1995;76:205–208. 11. Kreid R, Hatem J: Mycotic aneurysm of the tibioperoneal trunk. An extremely rare localization with pseudo-phlebitis clinical presentation. J MedLiban 2006;54:50–53 12. Blanesã JI, Crespoã I, Gãmezã F, Martã¬nezã I, VerdejoÂ R, OrtizÂ E. Ruptured popliteal artery aneurysm. Angiologia. 1999;5:219-222 13. DeromÂ A. Ruptured pseudo-aneurysm of the popliteal artery after percutaneous transluminal angioplasty. Acta Chir Belg. 2003;103(1):102-104 14. Belmir H, Azghari, A. Mechchat A., Benzirar A., Idrissi R., Lekehel B., Sefiani Y., El Mesnaoui A., Ammar F., Bensaid Y. Rupture of a popliteal artery pseudo-aneurysm revealing a tibial osteochondroma: Case report and review of the literature. Journal des Maladies Vasculaires.2011 ;36(1)50-55. 15. Ysa A., Bustabad M.R., Arruabarrena A., Perez E., Lopez-Vidaur I, Garcıa-Alonso J.A. Rupture of an Infected Popliteal Aneurysm. Case Report and Review of the Literature. EJVES. 2007. 14: 39-44 .

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ase report C Dacron patch infection following carotid endarterectomy, a clinical case Ricardo Castro-Ferreira, João Neves, José Teixeira Hospital São João, Porto, Portugal

INTRODUCTION Although extremely rare, infection following carotid endarterectomy can have devastating consequences1. CLINICAL CASE Female, 70 years old, with history of diabetes mellitus type 2, hypertension and cerebrovascular disease. The patient was submitted to carotid endarterectomy (CEA) following a transient ischemic attack in early 2011. The post-operative carotid duplex ultrasound in 2011 and 2012 are both normal and the patient is discharged from hospital follow up. In late 2013, 30 months after CEA, the patient returns to hospital due to a cutaneous drainage in the site of the previous surgery (Figure 1). Neck magnetic resonance confirms the diagnoses of carotid patch infection. The patient is submitted to block excision of the patch and surrounding common, internal and external carotid arteries (Figures 2 to 4), with complete reconstruction with saphenous vein graft (Figure 5). The patient remains asymptomatic, with a normal duplex scan, one year after the procedure. DISCUSSION A recent systematic review identified 123 patients with prosthetic patch infection in the world literature1. Most patients present with pseudoaneurysm formation, neck swelling or a draining local sinus and are infected with either Staphylococcus epidermidis or Staphylococcus aureus2. The majority of the patients develop signs/symptoms during the 1st year after surgery 1. Complete excision of all infected material and arterial reconstruction with a vein patch or graft remains the ‘gold standard’ treatment2.

Figure 1 Cinical presentation - cutaneous fistulization

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Figure 2. Carotid surgical dissection

Figure 3 Dacron patch in the base of the cutaneous fistulization

Figure 4 Block excision of the patch and affected arteries

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REFERENCES 1. Mann CD, McCarthy M, Nasim A, et al. Management and outcome of prosthetic patch infection after carotid endarterectomy: a single-centre series and systematic review of the literature. Eur J Vasc Endovasc Surg 2012;44:20-6. 2. Knight BC, Tait WF. Dacron patch infection following carotid endarterectomy: a systematic review of the literature. Eur J Vasc Endovasc Surg 2009;37:140-8.

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Figure 5 Complete reconstruction with saphenous vein

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ase report C Thoracic endovascular aortic repair (TEVAR) for uncomplicated chronic type B aortic dissection (AD): a case study and systemic review of literature Rayya Saadiq, Peter Gloviczki, Gustavo Oderich

Mayo Clinic, Rochester, USA

BACKGROUND Treatment of uncomplicated chronic type B AD remains controversial. CASE 66-year-old male presented with 3 months history of type B AD, managed with antihypertensives. Dissection extended from 2.7 cm distal to left subclavian artery (LSA) into the infrarenal aorta, without visceral or renal malperfusion. There was interval increase in aortic diameter (4.2 cm to 5.4 cm, Figure 1) Transposition of LSA was followed by TEVAR, without complications. At 6 months the stent-graft is widely patent, there is no endoleak, aneurysm sac has decreased and distal dissection is stable. (Figure 2) SYSTEMIC REVIEW Systemic search of all studies from databases (OVID MEDLINE, PUBMED, EMBASE) and a hand-search of their bibliographies were conducted per PRISMA guidelines. Studies involving traumatic or complicated dissections, and papers with insufficient data were excluded. Five studies were included; 318 TEVARs with optimal medical therapy (OMT) and 163 patients with OMT alone. Thirty day mortality was 0.6% with similar rate of conversion to open repair. Peri-procedural complications occurred in 5.7% (retrograde dissection 0.95%, stroke 0.3%, myocardial infarction 0.9%, brachial artery pseudoaneurysm 1.9% and paraplegia/ paraparesis 1.3%). 30 day mortality and complication in the OMT group was zero. Follow up ranged from 1 to 96 months. The risk of all-cause mortality and aortic diameter was significantly lower after TEVAR than after OMT. In one RCT TEVAR induced false lumen thrombosis was seen in 90.6% of those with improved survival and less progression. Greater aortic remodeling was seen in the TEVAR group in 3 studies. CONCLUSION TEVAR with OMT decreases long term all-cause mortality, aortic diameter and increases false lumen thrombosis. More RCTâ&#x20AC;&#x2122;s are needed but current evidence suggests it is more effective treatment of chronic Type B AD than OMT alone.

Figure 1. CT angiogram prior to surgery

Figure 2. CT angiogram post TEVAR - 6 month follow-up 142

ase report C Acute limb ischemia following anti-cellulite leg massage: an uncommon case report Ricardo Castro-Ferreira, Paulo Gonçalves-dias, José Teixeira Hospital São João, Porto, Portugal

INTRODUCTION Acute limb ischemia (ALI) is a condition with a potentially devastating outcome. We describe an unusual case of ALI that no other cause was found beyond iatrogenic caused by anti-cellulite massage. To the best of our knowledge, there is no description in the literature of this uncommon cause of ALI. CASE REPORT A 41 years-old female patient presented to the family doctor regarding her inability to perform the daily morning jogging due to left leg pain and weakness. She had no prior medical condition, no chronic medication, no history of drug abuse, and had a regular jogging practise for the last 10 years. She related an acute onset of leg and foot pain, associated with decreased leg strength, following an anti-cellulite leg massage session in a beauty clinic. The clinical history was interpreted as a muscular rupture and the patient was medicated with NSAID and recommended to rest. The symptoms worsened and she developed intermittent nocturnal rest pain. After more than one month from the onset of the symptoms she was finally referred to our vascular surgery department. The affected limb was pulseless with an ankle brachial index (ABI) of 0.5 (distal pressure of 50 mmHg in posterior tibial and 60 mmHg in anterior tibial arteries). The arteriography demonstrated occlusion of the femoral at the Hunter level with repermeabilization of the tibial-peroneal trunk. She had normal ECG and Holter, no morphological anomalies in echocardiography, no aortic disease at the angio-CT and no signs of popliteal entrapment at the MR. The initial treatment was with anticoagulation and she became free of rest pain, developing claudication. She was not submitted to intervention because of the chronicity of the symptoms, the good response to anticoagulation, and also because of her age and her esthetical concerns. After discharge she had regular and daily walk programme, statin, anticoagulation and platelet anti-aggregation. After one-year follow-up, she has only intermittent claudication for long distances (>1000m), with 0.7 ABI. DISCUSSION The absence of any predisposing condition to the acute ischemia and the clear association of the massage and the symptoms onset by the patient, highly suggest an arterial thrombosis induced by a vigorous massage. Acute thrombolysis was not an option due to the long duration of the symptoms. Due to the patient´s young age and also for esthetical concerns, an arterial intervention was reserved only if the best medical therapy failed to improve her condition. To our knowledge this is the first description of a massage induced acute arterial thrombosis.

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Research The role of cost-effectiveness for service provision within vascular surgery

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Rishi Mandavia, Brahman Dharmarajah, Mahim Qureshi, Alun Davies

Academic Section of Vascular Surgery, Imperial College London, London, United Kingdom OBJECTIVE The cost of healthcare is increasingly becoming an international issue with many healthcare systems requiring evaluation of cost when agreeing to fund healthcare. In the UK for example, the National Institute for Health and Care Excellence (NICE) highlights the importance of utilising cost-effectiveness analyses to facilitate the effective use of resources. This study evaluates the use of cost-effectiveness analyses and the provision of vascular surgery. METHODS A systematic review of published literature was performed. UK-based studies assessing cost-effectiveness or cost-utility of superficial venous interventions, abdominal aortic aneurysm (AAA) repair and carotid endarterectomy (CEA) were included. All included studies were quality assessed to determine the overall strength of UK economic evidence for each intervention. RESULTS Five superficial venous, six AAA and two CEA studies met the inclusion criteria. Following quality assessment, the UK evidence supporting the cost-effectiveness of superficial venous intervention was graded as strong. The economic evidence for asymptomatic and symptomatic CEA was graded limited and insufficient respectively owing to a paucity of UK literature in this field. There was strong UK economic evidence affirming that Endovascular Aneurysm Repair (EVAR) is unlikely to be a cost-effective alternative to open repair. CONCLUSIONS There is strong economic evidence for symptomatic superficial venous intervention. However, funding for varicose vein treatments remains controversial. Future economic analyses are required for symptomatic and asymptomatic CEA to better advise national policy. Despite strong economic evidence, current UK guidance is for EVAR over open repair in the elective setting, with the majority of elective AAA repairs being EVAR. Existing cost-effective analyses do not appear to be a major factor when decisions are made on vascular surgical services in the UK. This may be analogous to other healthcare systems outside the United Kingdom, necessitating further research in this field and questioning the purpose of health economic analyses if recommendations are not implemented.

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esearch R Simulation of a complete stent-graft deployment in a patient-specific abdominal aortic aneurysm David Roy1, Claude Kauffmann1, Sophie Lerouge2, Rosaire Mongrain3, Gilles Soulez1 1. University of Montreal, Montreal, Canada 2. Ecole superieure de technologie, Montreal, Canada 3. McGill University, Montreal, Canada

The endovascular repair of abdominal aortic aneurysms (AAA) still implicates potential complications such as endoleaks, occlusion, migration and kinking. In order to address these issues, a simulation of stent-graft (SG) deployment was developed. A first experimental validation of the mechanical behavior of numerical SG was conducted, by submitting some typical commercial specimens to load cases such as three-point bending and axial, transversal and radial compressions. Also, the virtual reconstruction of a patient-specific AAA from a CT-scan was performed. The accuracy of the simulated SG was 5.93% in terms of large displacements, and the stresses observed in the pressurized AAA model departed from 4.41% with regard to published and well recognized values. Finally, a plug-in application was written to make the developed workflow of simulation as automatic as possible. This interface allows clinicians to select commercial SG in a menu, and prescribe the desired landing position along the centerlines of the vessel. The pre-deformed AAA geometry due to catheter insertion was accounted for. This first encouraging result still needs to be validated experimentally, and an improved version including the intraluminal thrombus is presently under analysis. Figures

Experimental validation of numerical stent-grafts

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AAA reconstruction and pre-deformation due to catheters

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esearch R Abdominal aortic aneurysm follow-up after endovascular repair in a canine model with non-invasive vascular elastography Elie Salloum 1,3,4,5, Antony Bertrand-Grenier 1,3,4,5, Sophie Lerouge 1,2, Claude Kauffman 1,3,4, Hélène Héon 1, Eric Therasse 1,4,6, Marie Hélène Roy Cardinal 1,5, Guy Cloutier 1,5,6, Gilles Soulez 1,3,4,6

1. Centre de recherche de l’Université de Montréal (CRCHUM), Montreal, Canada 2. Department of mechanical engineering, École de technologie supérieure, Montreal, Quebec, Canada 3. Clinical Image Processing Laboratory (LCTI), Centre de recherche de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada 4. Department of Radiology, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec, Canada 5. Laboratory of Biorheology and Medical Ultrasonics, Centre de recherche de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada 6. Department of Radiology, Radio-Oncology and Nuclear Medicine, and Institute of Biomedical Engineering, Université de Montréal, Montreal, Quebec, Canada PURPOSE To assess the ability of non-invasive vascular elastography (NIVE) to characterize endoleaks and thrombus organization in a canine model of abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR) with stent-graft (SGs). METHODS AND MATERIALS SGs were implanted in a group of 18 dogs with an aneurysm created in the abdominal aorta. Type I endoleak was created in 4 aneurysms, type II in 13 aneurysms and no endoleak in 1 aneurysm. Doppler ultrasound (DUS) and NIVE examinations were performed at baseline, 1-week, 1-month, 3-month and 6-month follow-up. Angiography, CT-scan and macroscopic tissue slides were performed at sacrifice. Strain values were computed using the Lagrangian Speckle Model Estimator (LSME). Areas of endoleak, solid organized thrombus and fresh thrombus were identified and segmented by comparing the results of CT scan and macroscopic tissue slides. Strain values in areas with endoleak, organized and fresh thrombi were compared. RESULTS Maximal axial strains over consecutive heart cycles in endoleak, organized and fresh thrombus areas were respectively 0.78 ± 0.22, 0.23 ± 0.02, 0.10 ± 0.04 %. Strain values were significantly different between endoleak and organized or fresh thrombus areas (p = 5,136E-09) and between organized and fresh thrombus areas (p = 0.00063). All endoleaks were clearly depicted on elastography examinations. No correlation was found between strain values and type of endoleak, sac pressure, endoleak size and aneurysm size. CONCLUSION NIVE can characterize endoleak and thrombus organization regardless of the size, pressure and the type of endoleak.

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Figures

The red arrow on each image indicates the endoleak region for the same proximal axial acquisition of the first dog. (a) Duplex US, (b) CT-scan, (c) Cumulated axial shear strain NIVE, (d) Macroscopic section.

148

esearch R MicroRNA deregulation in symptomatic carotid plaque: a pilot study Pierre Maitrias1,2, ValĂŠrie Metzinger-Le Meuth2, Ziad Massy2,4, Thierry Reix1, Thierry Caus1, Laurent Metzinger2,3 1. Amiens University Hospital, Amiens, France 2. INSERM U-1088, Amiens, France 3. Centre de biologie humaine, Amiens, France 4. Ambroise ParĂŠ Hospital, Boulogne-Billancourt, France

INTRODUCTION Stroke is a leading cause of death and a major source of handicap in developed countries. Embolization of carotid stenotic plaques is the direct cause in nearly 20% of cases. Genetic mechanisms and especially the roles played by microRNAs in the regulation of plaque destabilization and rupture are mostly unknown. MicroRNAs represent potential biomarkers to target high-risk groups of carotid-related stroke among patients with carotid stenosis. The aim of this pilot study was to compare the expression of 7 microRNAs allegedly involved in plaque growth and instability (miR-100, 125a, 127, 133a, 145, 155, 221), between symptomatic and asymptomatic human carotid plaques. MATERIALS AND METHODS Thirty patients undergoing carotid endarterectomy in our department were prospectively included in the study. Carotid plaques were subdivided in symptomatic (n=15) and asymptomatic (n=15) according to the presence or absence of stroke. After isolation of total RNA from atherosclerotic plaques, microRNAs were quantified by real-time polymerase chain reactions. Levels of miRNAs were normalized to an exogenous C. elegans miRNA control, spiked-in during RNA extraction step. RESULTS The 2 groups of patients were comparable in terms of age, gender, risk factors of cerebral ischemia, medication and stenosis severity. All 7 microRNAs were quantified in extracted carotid plaques. miR-100, miR125a, miR-127, miR-133a, miR-145 and miR-221 were significantly overexpressed in symptomatic versus asymptomatic plaques. Multivariate analysis showed that the difference in miRNA expression levels between the 2 groups was not related to any potential confounding factors but only to the presence of symptomatic plaques. Levels of miR-155 were not different between the 2 groups. miR-125a expression was significantly inversely correlated with the circulating level of LDL-cholesterol in the symptomatic group. CONCLUSION This pilot study demonstrated the feasibility of miRNAs detection in human carotid plaques and suggests a potential regulatory role for miRNAs in evolution of the plaque towards growth, instability and rupture. Further studies involving microRNAs modulators will need to confirm the exact role of microRNAs in carotid disease.

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Figure

Expression of microRNAs in symptomatic and asymptomatic carotid plaques. Figure 1. Expression of microRNAs in symptomatic and asymptomatic atherosclerotic plaques. Mean value ± SEM. (* p<0.05) TABLE miR-100 miR-125a miR-127 miR-133a, miR-145 miR-155 miR-221

modulation of vascular inflammation and angiogenesis (Grundmann et al, 2011) modulates capture of oxLDL by macrophages (Chen et al, 2009) modulation of vascular inflammation and oxidative stress (Santovito et al, 2012) regulation of vascular remodeling and inflammation by controlling VSMC proliferation and differentiation (Torella et al, 2011 ; Cordes et al, 2009) modulation of endothelial dysfunction, macrophages differentiation and lipid uptake in oxLDL (Huang et al, 2010) promotes re-endothelisation and neo-angiogenesis (Davis et al, 2009)

CL1lmirna-table-1.doc - Table 1. MicroRNAs described roles in atherosclerosis

REFERENCES 1. van Rooij E, Olson EN. MicroRNAs: powerful new regulators of heart disease and provocative therapeutic targets. J Clin Invest. 2007 Sep;117(9):2369-76. 2. Fichtlscherer S, De Rosa S, Fox H, Schwietz T, Fischer A, Liebetrau C, Weber M, Hamm CW, Röxe T, Müller-Ardogan M, Bonauer A, Zeiher AM, Dimmeler S. Circulating microRNAs in patients with coronary artery disease. Circ Res. 2010 Sep 3;107(5):677-84. 3. Ji RR, Cheng YH, Yue JM. MicroRNA expression signature and antisense-mediated depletion reveal an essential role of microRNA in vascular neointimal lesion formation. Circ Res. 2007 Jun 8;100(11):1579-88. 4. Cipollone F, Felicioni L, Sarzani R, Ucchino S, Spigonardo F, Mandolini C, Malatesta S, Bucci M, Mammarella C, Santovito D, de Lutiis F, Marchetti A, Mezzetti A, Buttitta F. A unique microRNA signature associated with plaque instability in humans. Stroke. 2011 Sep;42(9):2556-63. 5. Grundmann S1, Hans FP, Kinniry S, Heinke J, Helbing T, Bluhm F, Sluijter JP, Hoefer I, Pasterkamp G, Bode C, Moser M. MicroRNA-100 regulates neovascularization by suppression of mammalian target of rapamycin in endothelial and vascular smooth muscle cells. Circulation. 2011 Mar 8;123(9):999-1009. 6. Santovito D, Mezzetti A, Cipollone F. MicroRNAs and atherosclerosis: new actors for an old movie. Nutr Metab Cardiovasc Dis. 2012 Nov;22(11):937-43. 7. Chen T, Huang Z, Wang L, Wang Y, Wu F, Meng S, Wang C. MicroRNA-125a-5p partly regulates the inflammatory response, lipid uptake, and ORP9 expression in oxLDL-stimulated monocyte/macrophages. Cardiovasc Res, 2009;1;83(1):131-9. 8. Torella D, Iaconetti C, Catalucci D, Ellison GM, Leone A, Waring CD, Bochicchio A, Vicinanza C, Aquila I, Curcio A, Condorelli G, Indolfi C. MicroRNA-133 controls vascular smooth muscle cell phenotypic switch in vitro and vascular remodeling in vivo. Circ Res. 2011 Sep 30;109(8):880-93. 9. Cordes KR, Sheehy NT, White MP, Berry EC, Morton SU, Muth AN, Lee TH, Miano JM, Ivey KN, Srivastava D. miR-145 and miR-143 regulate smooth muscle cell fate and plasticity. Nature. 2009 Aug 6;460(7256):705-10. 10. Davis BN, Hilyard AC, Nguyen PH, Lagna G, Hata A. Induction of microRNA-221 by platelet-derived growth factor signaling is critical for modulation of vascular smooth muscle phenotype. J Biol Chem. 2009 Feb 6;284(6):3728-38. 11. Roberts TC, Coenen-Stass AM, Wood MJ. Assessment of RT-qPCR normalization strategies for accurate quantification of extracellular microRNAs in murine serum. PLoS One. 2014 Feb 19;9(2):e89237.

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12. Fichtlscherer S1, De Rosa S, Fox H, Schwietz T, Fischer A, Liebetrau C, Weber M, Hamm CW, Röxe T, Müller-Ardogan M, Bonauer A, Zeiher AM, Dimmeler S. Circulating microRNAs in patients with coronary artery disease. Circ Res. 2010 Sep 3;107(5):67784. 13. Huang RS, Hu GQ, Lin B, Lin ZY, Sun CC. MicroRNA-155 silencing enhances inflammatory response and lipid uptake in oxidized low-density lipoprotein-stimulated human THP-1 macrophages. J Investig Med. 2010 Dec;58(8):961-7. 14. Derksen WJ1, Peeters W, van Lammeren GW, Tersteeg C, de Vries JP, de Kleijn DP, Moll FL, van der Wal AC, Pasterkamp G, Vink A. Different stages of intraplaque hemorrhage are associated with different plaque phenotypes: a large histopathological study in 794 carotid and 276 femoral endarterectomy specimens. Atherosclerosis. 2011 Oct;218(2):369-77. 15. Raman G, Moorthy D, Hadar N, Dahabreh IJ, O’Donnell TF, Thaler DE, Feldmann E, Lau J, Kitsios GD. Management strategies for asymptomatic carotid stenosis: a systematic review and meta-analysis. Ann Intern Med. 2013 May7;158(9) :676-85.

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esearch R Endoleak and thrombus characterization with dynamic elastography after endoleak embolization following aneurysm endovascular repair Antony Bertrand-Grenier1,2,3,4,5, Fatemeh Zehtabi1,6,7, Claude Kauffmann1,2,3, Guy Cloutier1,2,4, Sophie Lerouge1,6,7, Gilles Soulez1,2,3,4,8

1. Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, Canada 2. Département de Radiologie, Radio-oncologie et Médecine Nucléaire, et Institut d’Ingénierie Biomédicale de l’Université de Montréal, Montréal, Canada 3. Laboratoire Clinique du Traitement de l’Image, CRCHUM (LCTI), Montréal, Canada 4. Laboratoire de Biorhéologie et d’Ultrasonographie médicale, CRCHUM (LBUM), Montréal, Canada 5. Département de physique de l’Université de Montréal, Montréal, Canada 6. Laboratoire de Biomatériaux EndoVasculaires, Montréal, Canada 7. École de Technologies Supérieures (ETS), Montréal, Canada 8. Département de Radiologie du Centre Hospitalier de l’Université de Montréal, Montréal, Canada

PURPOSE Supersonic Shear Wave Imaging (SSWI) measure the tissue elasticity in real-time.1 Our goal is to characterize the mechanical properties of abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR) in a canine model (endoleaks, thrombus, walls) and correlate results with CT-Scan, Doppler Ultrasound (DUS) and pathologic findings.2-6 METHODS AND MATERIALS EVAR was done with creation of type I endoleak in eighteen aneurysms created in nine dogs (common iliacs arteries).7-9 Two embolization gels (Chitosan (Chi) or Chitosan-Sodium-Tetradecyl-Sulfate (Chi-STS)) were injected in the sac to seal the endoleak and promote healing.10 SSI and Doppler Ultrasound were performed at baseline (implantation, 1-week, 1-month, 3-months) whereas angiography and CT-scan were performed at sacrifice. Macroscopic and histopathological analyses were processed to identify and segment five different regions of interest (ROIs) (endoleak, fresh or organized thrombus, Chi or Chi-STS). Elasticity modulus values were compared in these ROIs. RESULTS At sacrifice, ten aneurysms had endoleaks, nine had fresh thrombus, fifteen had organized thrombus and three were completely sealed. At 3 months, elasticity modulus (in kPa) of 0.1±0.2, 9.2±3.5, 47.3±25.7, 55.9±21.7 and 69.6±29.0 were respectively found in endoleak, fresh and organized thrombus, Chi and Chi-STS regions. Elasticity values of endoleak and fresh thrombus areas were significantly lower than organized thrombus, Chi and Chi-STS areas (p<0.001). Elasticity values of fresh thrombus ranged between 3 and 19 kPa (8.7±3.6 kPa) at 1-week and 30.2±13.8 kPa at 3-months indicating that SSI can evaluate thrombus maturation. Aneurysm with fresh thrombus did not shrink as fast as aneurysm with only organized thrombus. CONCLUSION The results show that SSWI is able to detect endoleaks and characterize thrombus organization. The next objective is to evaluate in a phase II clinical study the feasibility and efficacy this approach.11 CLINICAL RELEVANCE/APPLICATION, NEW OR BREAKTHROUGH WORK TO BE PRESENTED Supersonic Shear Wave Imaging has the potential to characterize thrombus organization within the aneurysm sac and in particular fresh thrombus which is associated with endoleak and endotension.12, 13 The SSI was able to distinguish fresh thrombus that cannot be detected on CT-scan (actual gold-standard). 152

Supersonic ShearWave Imaging (SSI) was able to detect endoleak in real-time.The SSI can be complement conventional DUS in post-EVAR surveillance since the same machine can be used for both examinations. It could reduce the cost, the exposition to ionizing radiation and nephrotoxic contrast agents of surveillance CT-Scan follow up of AAA after EVAR.

Images from an AAA with endoleak, fresh thrombus and organized thrombus.

Images from an AAA without endoleak and with massive fresh thrombus

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Figures

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TABLES ROIs Endoleak Fresh Thrombus Organized Thrombus Chitosan Chitosan STS

Min 0.0 4.0 11.0 19.2 24.9

1st Quart 0.0 5.9 29.6 47.7 45.0

Median 0.0 9.6 40.9 51.5 78.3

3rd Quart 0.2 11.9 63.3 65.7 84.5

Max 0.7 15.9 122.4 111.7 139.3

Mechanicals Properties of ROIs at 3 Months (kPa) Comparison Endoleak ; Fresh Thrombus Endoleak ; Organized Thrombus Fresh Thrombus ; Organized Thrombus Organized Thrombus ; Chitosan Organized Thrombus ; Chitosan STS Chitosan ; Chitosan STS

Mean ± StD (in kPa) 0.1 ± 0.2 ; 9.2 ± 3.5 0.1 ± 0.2 ; 47.3 ± 25.7 9.2 ± 3.5 ; 47.3 ± 25.7 47.3 ± 25.7 ; 55.9 ± 21.7 47.3 ± 25.7 ; 69.6 ± 29.0 55.9 ± 21.7 ; 69.6 ± 29.0

P Value < 0.001 < 0.001 < 0.001 0.18 0.008 0.12

Statistical Significance of Mechanicals Properties of ROIs at 3 Months REFERENCES 1. Sarvazyan AP, Rudenko OV, Swanson SD, Fowlkes JB, Emelianov SY. Shear wave elasticity imaging: A new ultrasonic technology of medical diagnostics. Ultrasound Med Biol. 1998;24:1419-1435. 2. Eliason JL, Upchurch GR Jr. Endovascular treatment of aortic aneurysms: state of the art. Curr Treat Options Cardiovasc Med. 2009 Apr;11(2):136-45. PubMed PMID: 19289026. 3. White GH, Yu W, May J, et al. Endoleaks as a complication of endoluminal grafting of abdominal aortic aneurysms: classification, incidence, diagnosis, and management. J Endovasc Surg 1997;4:152-68. 4. Brown LC, Brown EA, Greenhalgh RM, Powell JT, Thompson SG; UK EVAR Trial Participants. Renal function and abdominal aortic aneurysm (AAA): the impact of different management strategies on long-term renal function in the UK EndoVascular Aneurysm Repair (EVAR) Trials. Ann Surg. 2010 May;251(5):966-75. 5. Kato N, Shimono T, Hirano T, Mizumoto T, Suzuki T, Ishida M, et al. Aneurysm expansion after stent-graft placement in the absence of endoleak. J Vasc Interv Radiol 2002;13:321-6. 6. Koole D, Moll FL, Buth J, Hobo R, Zandvoort HJ, Bots ML, et al. Annual rupture risk of abdominal aortic aneurysm enlargement without detectable endoleak after endovascular abdominal aortic repair. J Vasc Surg 2011;54:1614-22. 7. Soulez G, Lerouge S, Salazkin I, Darsaut T, Oliva VL, Raymond J. Type I and collateral flow in experimental aneurysm models treated with stentgrafts. J Vasc Interv Radiol 2007; 18:265–272. 8. Soulez G, Lerouge S, Darsaut T, Salazkin I, Oliva VL, Raymond R. Role of the endothelial lining in endoleak formation and persistence after endovascular repair of aneurysm. J Vasc Interv Radiol 2008;19:1070–8. 9. Lerouge S, Raymond J, Salazkin I, Qin Z, Gaboury L, Cloutier G, et al. Endovascular aortic aneurysm repair with stent-grafts: experimental models can reproduce endoleaks. J Vasc Interv Radiol 2004;15:971–9. 10. Fatimi A, Chabrot P, Berrahmoune S, Coutu JM, Soulez G, Lerouge S. A new injectable radiopaque chitosan-based sclerosing embolizing hydrogel for endovascular therapies. Acta Biomater. 2012 Jul;8(7):2712-21. 11. (CHUM), C.h.d.l.U.d.M. Abdominal Aortic Aneurysm Follow-up After Endovascular Repair by Non-invasive Vascular Elastography 2013; Available from: http://clinicaltrials.gov/ct2/show/NCT01907386?term=abdominal+aortic+aneurysm&recr=Not+yet+recruiting&rslt=Without&type=Intr&titles=abdominal+aortic+aneurysm+follow-up+after+endovascular+repair+by+non-invasive+vascular+elastography&cntry1=NA%3ACA&state1=NA%3ACA%3AQC&locn=Montreal&rank=1 12. White GH. What are the causes of endotension? J Endovasc Ther 2001;8:454-6. 13. Castrucci M, Mellone R, Vanzulli A, De Gaspari A, Castellano R, Astore D, et al. Mural thrombi in abdominal aortic aneurysms: MR imaging characterization– useful before endovascular treatment? Radiology 1995;197:135-9.

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esearch R CCL5-dependent mediation of transplant-induced atherosclerotic lesion formation in the aorta Zuzanna Rowinska 1,2, E. Liehn2, N. Gerdes3, C. Weber3, A. Zernecke4

1. Department of Vascular and Endovascular Surgery, D端sseldorf University Hospital 2. Institute of Molecular Cardiovascular Research, University Hospital, RWTH Aachen University 3. Institute for Cardiovascular Prevention, Hospital of the University of Munich 4. Institute of Clinical Biochemistry and Pathobiochemistry, W端rzburg University Hospital

METHODS We have orthotopically transplanted infrarenal abdominal CCL5-/- Apoe-/- aortic segments into Apoe-/mice and Apoe-/- aortas in CCL5-/- Apoe-/- mice (n = 4-6 mice) (anastomosis time 22 min). After 4 weeks, the intimal plaque size in the region of the transplanted aorta was analyzed in serial sections, and the plaque macrophage assessed by immunohistochemical staining. RESULTS Deficiency of CCL5 in vascular cells of the transplanted segment (transplantation of CCL5 Apoe-/- aortas into Apoe-/- mice) entailed a reduction in the formation of atherosclerotic plaques and the accumulation of macrophages, compared to the deficiency of CCL5 in circulating cells (transplantation of Apoe-/- aortas into CCL5-/- Apoe-/- mice). SUMMARY These results indicate that CCL5 expressed in cells of the vascular wall plays an important role in the recruitment of monocytes / macrophages to transplanted vessels and may thereby contribute to the development of atherosclerotic lesions after aortic transplantation.

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INTRODUCTION The CCL5 chemokine plays an active role in the initiation of inflammation, and by recruiting monocytes to sites of atherosclerotic lesion growth is critically involved in atherosclerosis. A function of CCL5 in circulating cells versus resident vessel wall cells in atherosclerosis within transplanted aortic segments has not yet been examined.

AOD P Contralateral femoral approach… Is a guiding catheter a must?

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Ahmad Naga

Alexandria University, Alexandria, Egypt Contralateral femoral approach has been a common place in angioplasty for femoro-popliteal disease. This approach allows proper evaluation and treatment of concomitant iliac disease and allows for a greater freedom to use devices that may require larger French sizes. The contralateral approach is also the approach of choice for a flush occlusion of the superficial femoral artery from its origin from the common femoral artery. However, this approach may not be successful in patients with acute angle aortic bifurcation or in patients with prior aortobifemoral bypass. Additionally, it may be more difficult to generate sufficient torque and forward force on distal lesions from a contralateral approach. 1,2 Some enthusiastic interventionists have been trying to pass guide wires, balloons and stents through a contra lateral approach without using a long flexible guiding catheter to cross the aortic bifurcation. Their excuse is to cut down on cost and time. Also they refrain from introducing large 7 F sheaths into diseased arteries for fear of intimal damage. However, we think this technique should not be a common practice especially for junior trainees. In this work we are demonstrating few of the complications that might rise during this maneuver and their possible solutions. The first case is a bare stent that has slipped over its balloon when tried to cross the aortic bifurcation without a guiding catheter. The second case is a balloon that was kinked at the aortic bifurcation when passed without a guiding catheter rendering its lumen blocked against any wire or even dye to pass through. Another case is a foot trash that resulted from doing this maneuver inside a shaggy aorta. Figure

Stent on Aortic Bifurcation REFERENCES 1. Geronemus A, Peña C. Semin Intervent Radiol. Dec 2009; 26(4): 303–314. 2. Narins C. Access strategies for peripheral arterial intervention. Cardio J 2009;16 (1): 88–97.

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AOD P Clinical and haemodynamic assessment of percutaneous transluminal angioplasty in femoro-popliteal atherosclerotic disease Ahmad Naga

Alexandria University, Alexandria, Egypt BACKGROUND While aggressive endoluminal therapy for femoro-popliteal occlusive disease is commonplace, the implication of ABI, runoff and peak systolic velocities on short term outcomes of these interventions in patients with TASC II A and B lesions is unclear. The aim of this study is to evaluate by non invasive techniques the clinical and haemodynnamic outcome of TASC II A and B femoro-popliteal lesions treated by Percutaneous transluminal angioplasty (PTA). METHODS A prospective study of patients undergoing endovascular treatment of superficial femoral artery (SFA) and popliteal artery was designed. Patients with Fountain classification 2,3&4 were included. Patients with TASC II A and B femoro-popliteal lesions and having at least 1 patent tibial artery runoff were selected. Those with haemodynamically significant aorto-iliac disease or extensive foot necrosis necessitating amputation were excluded. RESULTS 33 patients were studied (76% males, mean age 57 years) underwent PTA for chronic SFA and popliteal lesions. Technical success was 94% after 3 months. The mean ABI (+SD) before and 3 months after intervention was 0.48(+0.19) and 0.81 (+0.23) respectively. The mean PSV (+SD) increased from 43 + 9 cm/sec before intervention to 71 + 21 cm/sec 3 month after intervention. CONCLUSIONS Ankle Brachial Index (ABI) calculation before PTA is a good indicator for results. Those patients with ABI > 0.58 are less likely to end up with a major amputation. Distal tibial runoff has a great implication over PTA outcome. The more the number of patent tibial arteries are there, the more successful interventions and limb salvage are likely to occur. Colour duplex ultrasound is safe and non-invasive investigation that gives clues about the femoro-popliteal lesions, but no clinical or statistical significance could be found between PSV and patency rates. Figures

Figure: Box plot showing the results of ABI measurement at different follow up periods

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Successful intervension with limb salvage Limb salvage with toe amputation Limb salvage with trans-metatarsal amputation Below knee amputation Above knee amputation Occluded without amputation Total

Patient complaint Rest Trophic changes Trophic changes pain (ulcer) (gangrene dry/wet) 2(7%) 1(3%) 2(7%) 0 0 3(10%) 1(3%) 0 6(19%)

15(48%) 3(10%) 7(23%)

0 0 0 3(10%)

3(10%) 2(6%) 1(3%) 31(100%)

Intermittent claudication 10(32%) 0 0 0 0 1(3%) 11(36%)

Table: Relationship between patientsâ&#x20AC;&#x2122; complaints and fate of limb

158

0 1(3%) 0 2(7%)

3(10%) 1(3%) 0 15(48%)

Total

AOD P Which is currently the best strategy for treatment of sfa in-stent restenosis? Maxime Elens

Imelda, Bonheiden, Bruxelles (Woluwe-Saint-Lambert), Belgium Stents have been created to prevent vessel recoil after percutaneous transluminal angioplasty (PTA). Despite the evolution in stent design, intimal hyperplasia and stent fractures and the resulting in-stent restenosis (ISR) still occur. Different strategies to treat ISR have been described with variable results in patency rates in the short and the long-term. PTA only in the treatment of ISR showed high procedural success, but the mid and long-term patency rates were very disappointing. Atherectomy devices have showed same insufficient results. If stent fracture is the cause of the ISR, the fracture has to be overstent. The best two options are covered stents and drug eluting stents (DES). Drug eluting devices like DES and drug eluting balloons (DEBs) showed promising results, with patency rates up to over 90% after one year. DEBs have the advantage of leaving nothing behind. Combined treatment of ISR with atherectomy and DEB has a similar good result. Endovascular brachytherapy showed high patency rates after one year but this technique is limited due to the time-consuming nature of the procedure, complex radiation safety measurements, and staffing requirements. Overall drug-eluting devices are emerging as the best treatment of SFA ISR with patency rates over 90% after 2 years. REFERENCES 1. Payne MM. Charles Theodore Dotter. The father of intervention. Tex Heart Inst J. 2001;28(1):28-38. 2. Bosiers M, Deloose K, Callaert J, Maene L, Keirse K, Verbist J, Peeters P. Refining stent technologies for femoral interventions. J Cardiovasc Surg (Torino). 2012 Aug;53(4):465-73. Review. 3. Soga Y, Iida O, Hirano K, Suzuki K, Yokoi H, Nobuyoshi M. Restenosis after stent implantation for superficial femoral artery disease in patients treated with cilostazol. Catheter Cardiovasc Interv. 2012 Mar 1;79(4):541-8. doi: 10.1002/ccd.23304. Epub 2011 Aug 9. 4. Ikushima I, Yonenaga K, Iwakiri H, Nagoshi H, Kumagai H, Yamashita Y. A better effect of cilostazol for reducing in-stent restenosis after femoropopliteal artery stent placement in comparison with ticlopidine. Med Devices (Auckl). 2011;4:83-9. doi: 10.2147/ MDER.S21629. Epub 2011 Jun 24 5. Hoffmann R, Mintz GS, Dussaillant GR, Popma JJ, Pichard AD, Satler LF, Kent KM, Griffin J, Leon MB. Patterns and mechanisms of in-stent restenosis. A serial intravascular ultrasound study. Circulation. 1996 Sep 15;94(6):1247-54. 6. Scheinert D, Scheinert S, Sax J, Piorkowski C, Bräunlich S, Ulrich M, Biamino G, Schmidt A. Prevalence and clinical impact of stent fractures after femoropopliteal stenting. J Am Coll Cardiol. 2005 Jan 18;45(2):312-5. 7. Bosiers M, Torsello G, Gissler HM, Ruef J, Müller-Hülsbeck S, Jahnke T, Peeters P, Daenens K, Lammer J, Schroë H, Mathias K, Koppensteiner R, Vermassen F, Scheinert D. Nitinol stent implantation in long superficial femoral artery lesions: 12-month results of the DURABILITY I study. J Endovasc Ther. 2009 Jun;16(3):261-9. doi: 10.1583/08-2676.1. 8. Soga Y, Iida O, Hirano K, Suzuki K, Yokoi H, Nobuyoshi M. Restenosis after stent implantation for superficial femoral artery disease in patients treated with cilostazol. Catheter Cardiovasc Interv. 2012 Mar 1;79(4):541-8. doi: 10.1002/ccd.23304. Epub 2011 Aug 9 9. Katzen B. The Resilient Trial 12-Month Analysis. Transcatheter Cardiovascular Therapeutics 2007. Washington Conference Center, Washington DC; Oct 23, 2007; J Vasc Interv Radiol. 2005 Mar;16(3):331-8. 10. Matsumura JS, Yamanouchi D, Goldstein JA, Pollock CW, Bosiers M, Schultz GA, Scheinert D, Rocha-Singh KJ. The United States StuDy for EvalUating EndovasculaR TreAtments of Lesions in the Superficial Femoral Artery and Proximal Popliteal By usIng the Protégé EverfLex NitInol STent SYstem II(DURABILITY II). J Vasc Surg. 2013 Jul;58(1):73-83.e1. doi: 10.1016/j.jvs.2012.12.066. Epub 2013 May 2. 11. Duda SH, Bosiers M, Lammer J, Scheinert D, Zeller T, Tielbeek A, Anderson J, Wiesinger B, Tepe G, Lansky A, Mudde C, Tielemans H, Bérégi JP. Sirolimus-eluting versus bare nitinol stent for obstructive superficial femoral artery disease: the SIROCCO II trial. J Vasc Interv Radiol. 2005 Mar;16(3):331-8. 12. Liistro F, Grotti S, Porto I, Angioli P, Ricci L, Ducci K, Falsini G, Ventoruzzo G, Turini F, Bellandi G, Bolognese L. Drug-eluting balloon in peripheral intervention for the superficial femoral artery: the DEBATE-SFA randomized trial (drug eluting balloon in peripheral intervention for the superficial femoral artery). JACC Cardiovasc Interv. 2013 Dec;6(12):1295-302. doi: 10.1016/j. jcin.2013.07.010. Epub 2013 Nov 13. 13. Dick P, Sabeti S, Mlekusch W, Schlager O, Amighi J, Haumer M, Cejna M, Minar E, Schillinger M. Conventional balloon angioplasty versus peripheral cutting balloon angioplasty for treatment of femoropopliteal artery in-stent restenosis: initial experience. Radiology. 2008 Jul;248(1):297-302. doi: 10.1148/radiol.2481071159. 14. Tosaka A, Soga Y, Iida O, Ishihara T, Hirano K, Suzuki K, Yokoi H, Nanto S, Nobuyoshi M. Classification and clinical impact of restenosis after femoropopliteal stenting. J Am Coll Cardiol. 2012 Jan 3;59(1):16-23. doi: 10.1016/j.jacc.2011.09.036. 15. Zeller T, Rastan A, Sixt S, Schwarzwälder U, Schwarz T, Frank U, Bürgelin K, Müller C, Rothenpieler U, Flügel PC, Tepe G, Neumann FJ. Long-term results after directional atherectomy of femoro-popliteal lesions. J Am Coll Cardiol. 2006 Oct 17;48(8):1573-8. Epub 2006 Sep 26. 159

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

AOD P Above knee stump ischemia – the value of internal iliac artery Duarte Rego, Luís Loureiro, Paulo Almeida, Tiago Loureiro, Diogo Silveira, Sérgio Teixeira, João Gonçalves, Vitor Ferreira, Gabriela Teixeira, Rui Almeida

Centro Hospitalar do Porto, Porto, Portugal

BACKGROUND Lower limb critical ischemia’s treatment represents a growing challenge to the vascular surgeon due to the increasing number of patients with multiple comorbidities and revascularization procedures. Therefore, to achieve limb preservation and improved quality of life creative (but effective) surgical solutions are often required. Above knee (AK) stump ischemia is a relatively rare complication1 that is associated with severe impact on patient’s quality of life2. Internal iliac artery (IIA) revascularization is usually applied to the treatment of gluteal claudication3,4, vasculogenic impotence5 and in the prevention of medullary and pelvic ischemia in patients treated to bilateral iliac aneurysms6. The collateral pathways between IIA and deep femoral artery are of great significance in cases of external iliac artery occlusion with extensive disease of the femoral bifurcation7,8. RESULTS We present a case of IIA stenting in a patient with a left AK stump ischemia. The patient had severe comorbidities (diabetes, stage 5 CKD and congestive heart failure) and several previous surgical revascularization procedures. He underwent endovascular treatment of a critical stenosis in the origin of the left IIA with stent placement. There was significant and fast improvement of stump’s ischemic lesions with near total healing two months later. DISCUSSION Usually performed with different clinical purposes, IIA revascularization can be a useful therapeutic resource when classical revascularization procedures aren’t possible. The possibility to apply endovascular techniques allows the treatment of patients unfit to open surgical procedures. Figures

Before IIA Stenting Ischemic AK stump before IIA revascularization 160

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After IIA Stenting AK stump three months after IIA revascularization

Left IIA Osteal stenosis of the left Internal Iliac Artery

Post-stenting left IIA Left Internal Iliac Artery after PTA and stenting

REFERENCES 1. Manouguian S.: Revascularization of the profunda femoris artery in ischemia of the stump after above knee amputation. Zentralbl Chir 2001; 126: pp. 157-160 2. DĂŠnes Z., Till A.: Rehabilitation of patients after hip disarticulation. Arch Orthop Trauma Surg 1997; 116: pp. 498-499 3. Seagraves A, Rutherford RB. Isolated hypogastric artery revascularization after previous bypass for aortoiliac occlusive disease. J Vasc Surg 1987;5:472-4 4. Donas KP, Schwindt A, Pitoulias GA, Schonefeld T, Basnera C, Torsello G. Endovascular treatment of internal iliac artery obstructive disease. J Vasc Surg 2009;49: 1447-1451 5. Flanigan DP, Sobinsky KR, Schuler JJ, Buchbinder D, Borozan PG, Meyer JP. Internal iliac artery revascularization in the treatment of vasculogenic impotence. Arch Surg 1985;120:271-4 6. Utikal P, Kocher M, Bachleda P, Drac P, Cerna M, Buriankova E, et al. Femoral-internal iliac bypass in aortoiliac aneurysms endovascular repair. Biomed PapMed Fac Univ Palacky Olomouc Czech Repub 2004;148:91-93 7. Iliopoulos JI, Howanitz PE, Pierce GE, Kueshkerian SM, Thomas JH, Hermreck AS. The critical hypogastric circulation. Am J Surg 1987;154:671-675 8. Iliopoulos JI, Hermreck AS, Thomas JH, Pierce GE. Hemodynamics of the hypogastric arterial circulation. J Vasc Surg 1989;9:637642

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AOD P Open conversion as the only solution for stent graft thrombosis after endovascular popliteal aneurysm repair Gladiol Zenunaj1, Luca Traina2, Pierfilippo Acciarri1, Francesco Mascoli2

1. University of Ferrara- Bologna, Ferrara, Italy 2. University of Ferrara, Ferrara, Italy

OBJECTIVES Endovascular repair of popliteal artery aneurysm (PAA) has emerged as a less invasive alternative to the open repair.1,2 Stent-graft thrombosis is the most frequently complication reported and its management is a challenging problem.3,4 In this study we report the effectiveness of different approaches used for the treatment of stent-graft thrombosis as clinical follow-up, thrombolysis and open conversion. MATERIAL AND METHODS A retrospective review to identify PAAs treated endovascularly at our institute between January 2011 and June 2014 was performed. RESULTS We identified 17 PAAs (mean size 4,7cm, range 2,6 to 6,5cm; 3 symptomatic, 1 bilateral) that underwent endovascular exclusion with covered stent-graft. Median follow-up was 20 months (range 10-34 months). Stent-graft thrombosis occurred in 6 cases. 1 patients presented advanced acute limb ischemia and underwent to major amputation after unsuccessful open repair. Further 3 patients presented acute limb ischemia and underwent thrombolytic therapy as first approach. It revealed useful in 2 patients and balloon angioplasty of stenosis at the distal landing zone was performed in 1 patients while in the other one mild stent bending was detected so he underwent clinical and duplex scan follow-up. In the last one stent-patency was not achieved so he underwent to open conversion. The 2 remaining patients presented claudication and stent bending was demonstrated at instrumental evaluation. The physical rehabilitation revealed insufficient to improve walking capacity and open conversion was necessary. Recurrent thrombosis occurred in the patients with stent bending under follow up. Figure 1 He underwent to open repair after unsuccessful thrombolysis. Figure 2 The stent-graft thrombosis group had a median follow-up of 10 months and the limb salvage was 83%, stent bending rate 50%, conversion rate 83% and survival rate 83%, reinterventions 17%. CONCLUSIONS Thrombolysis with endovascular treatment of the underlying defect is certainly a less invasive alternative but often it may results ineffective. Open conversion seems to be the only solution in cases with stent bending and ineffective thrombolysis.

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Figure 1 Stent bending and incomplete graft patency restored after thrombolysis

Figure 2 Explantation of the stent graft after posterior open repair

REFERENCES 1. Gerasimidis T, Sfyroeras G, Papazoglou K, Trellopoulos G, Ntinas A, Karamanos D. Endovascular treatment of popliteal artery aneurysms. Eur J Vasc Endovasc Surg 2003;26:506-11. 2. Antoniou GA, Schiro A, Smyth JV, Murray D, Farquharson F, Serracino-Inglott F. Multilayer stent in the treatment of popliteal artery aneurysms. Vasa. 2012 Sep;41(5):383-7. 3. Tielliu IF, Zeebregts CJ, Vourliotakis G, Bekkema F, van den Dungen JJ, Prins TR et al. Stent fractures in the Hemobahn/Viabahn stent graft after endovascular popliteal aneurysm repair.. J Vasc Surg. 2010 Jun;51(6):1413-8 4. Pulli R, Dorigo W, Troisi N, Innocenti AA, Pratesi G, Azas L, et al. Surgical management of popliteal artery aneurysms: which factors affect outcomes? J Vasc Surg 2006;43:481-7. 163

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Figures

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

AOD P Endovascular treatment of atherosclerotic iliac stenosis: local and systemic complications of the humeral access Bahaa Nasr, Bénédicte Albert, Pedro Marques Da Fonseca, Ali Badra, Jacques Braesco, Pierre Gouny

CHU Cavale Blanche, Brest, France

OBJECTIVE The femoral access is the most used method for iliac angioplasty. Data from the literature concerning the brachial and radial access is still limited. This paper evaluates the feasibility and the risk factors for complications of the brachial access. METHOD Between January 2012 and December 2013, 54 patients underwent 57 brachial approaches during interventional procedures on iliac axes. The indications for brachial access were: hostile scarpa (68%), bilateral iliac lesions (29%), and in 3% of the cases it was the surgeon’s choice. The primary endpoint was the safety of the humeral access in the endovascular treatment of iliac occlusive lesions. RESULTS The mean age was of 66 ±9 years old. 77% of the patients (41) were male. The brachial access was done with open surgery in all patients. In 42% of the patients, a local anaesthesia with sedation was performed. The procedure was considered successful in 92% of the cases. However, there were 4 cases of failure: 2 of them due to a difficulty in crossing the lesion, one due to the patient movement and one due to a very short material. Mortality at 1 month was of 6%. The actuarial survival at 24 months was 90%, and the 24 months survival without amputation was 85%. The mean hospitalization duration was 3.5 days. One patient was disorientated and presented a dysarthria without the presence of a stroke on the scanner. Three haematomas needed to be reoperated; these 3 patients were on dialysis. No ischemia or nervous complication was found in the upper limb. No clinical signs of cholesterol emboli or creatinine increase were found. The only significant risk factor of failure was the thrombosis of the iliac axis (Odds Ratio (OR) 23.3, 95% CI: 2.5 - 264.6, p=0.003). The risk for brachial access complication is not correlated with the stage of the occlusive arterial disease, neither with the use of anticoagulants, neither with the diameter or length of the introducer sheath. CONCLUSION The femoral access remains the recommended method for angioplasty; nevertheless the brachial access is useful for complex and/or redux endovascular procedures. The risk of complications related to intra-aortic catheterization is low (1.7%), which allows the safe use of this access in most patients. Figures

Humeral access complications humeral access complications 164

Survival curve survival curve and amputation free survival curve TABLES Mean ± SD 85±42 2,5±1,7 630±299 43,3±33

Percentage

47 10 4 53 8

53 82,5% 17,5% 7% 10%

45 36 49

79% 63% 86%

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Procedure time, min Irradiation dose, mGy/m2 Irradiation time, sec Contrast volume, ml Introducer sheath: Diameter 6F 7F Length 65 90 Recanalization Angioplasty : Balloon Stent Drainage

5jxvdonnees-per-op-2.doc - intraoperative data N Male Arterial hypertension Coronary disease Smoking history Diabetes Dyslipidemia Obesity Renal failure COPD Anticoagulant Double antiplatelet Rutherford classification type 4 Iliac Thrombosis

44 47 23 51 13 42 27 8 22 6 9 15 11

Complications N0 (%) 4 7 3 6 1 5 3 3 2 1 2 3 3

OR (IC 95%)

0,23 (0,03-1,49) 1,56 (0,16-78,7) 0,87 (0,12-5,08) 0,27 (0,03-3,65) 0,37 (0,04-3,3) 0 ,55 (0,09-4,04) 0,62 (0,13-2,9) 5,05 (0,6-37,5) 0,49 (0,04-3,1) 1,25 (0,02-14,01) 1,97 (0,16-14,45) 1,8 (0,25-11,1) 2,9 (0,38-19,5)

0,07 1 1 0,19 0,66 0,42 0,7 0,07 0,46 1 0,59 0,42 0,17

Relationship between preoperative variables and incidence of complications N Introducer sheath diameter (7F) Introducer sheath length (90) Recanalization Stenting Balloon diameter (≥7) Drainage

6 48 6 36 35 49

Complications N0 (%) 2 7 1 3 5 7

OR (IC 95%)

3,3 (0,5-22,9) 0,5 (0,05-5,6) 1,3 (0,13-12,4) 0,3 (0,06-1,4) 0,7 (0,12-4,5) 0,9 (0,09-8,1)

0,22 0,5 1 0,12 1 1

Relationship between intraoperative variables and incidence of complications 165

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N Male Arterial hypertension Coronary disease Smoking history Diabetes obesity Double antiplatelet Iliac Thrombosis

44 47 23 51 13 27 9 11

Complications N0 (%) 3 5 1 4 1 2 2 4

OR (IC 95%)

0,4 (0,06-2,7) 2,7 (0,1-53,1) 0,3 (0,007-3,8) 0,4 (0,04-4,63) 0,8 (0,08-8,1) 0,7 (0,1-4,6) 4,1 (0,6-30,4) 23,3 (2,5-264,6)

0,32 0,28 0,64 0,44 1 1 0,17 0,003

Relationship between preoperative variables and incidence of procedure failure REFERENCES 1. Norgren L. [New international consensus document on peripheral arterial disease. TASC II for improved care]. Lakartidningen. 2007 May;104(19):1474–5. 2. Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC). J. Vasc. Surg. 2000. pp. S1–S296. 3. Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J. Am. Coll. Cardiol. 1997 May;29(6):1269–75. 4. Ernst S, Fischbach R, Brochhagen H-G, Heindel W, Landwehr P. Transbrachial Thrombolysis, PTA and Stenting in the Lower Extremities. CVIR. 2003 Nov 21;26(6). 5. Criado FJ, Wilson EP, Abul-Khoudoud O, Barker C, Carpenter J, Fairman R. Brachial artery catheterization to facilitate endovascular grafting of abdominal aortic aneurysm: safety and rationale. YMVA. 2000 Dec;32(6):1137–41. 6. Alvarez-Tostado JA, Moise MA, Bena JF, Pavkov ML, Greenberg RK, Clair DG, et al. The brachial artery: A critical access for endovascular procedures. YMVA. Elsevier Inc; 2009 Feb 1;49(2):378–85. 7. Pelliccia F, Trani C, Biondi-Zoccai GGL, Nazzaro M, Berni A, Patti G, et al. Comparison of the Feasibility and Effectiveness of Transradial Coronary Angiography Via Right Versus Left Radial Artery Approaches (from the PREVAIL Study). AJC. Elsevier Inc; 2012 Sep 15;110(6):771–5. 8. Brueck M, Bandorski D, Kramer W, Wieczorek M, Höltgen R, Tillmanns H. A Randomized Comparison of Transradial Versus Transfemoral Approach for Coronary Angiography and Angioplasty. JCIN. Elsevier Inc; 2009 Nov 1;2(11):1047–54. 9. Belenky A, Aranovich D, Greif F, Bachar G, Bartal G, Atar E. Use of a Collagen-Based Device for Closure of Low Brachial Artery Punctures. CVIR. 2006 Dec 13;30(2):273–5. 10. Lupattelli T, Clerissi J, Clerici G, Minnella DP, Casini A, Losa S, et al. The efficacy and safety of closure of brachial access using the AngioSeal closure device: Experience with 161 interventions in diabetic patients with critical limb ischemia. Journal of Vascular Surgery. 2008 Apr;47(4):782–8. 11. Louvard Y, Benamer H, Garot P, Hildick-Smith D, Loubeyre C, Rigattieri S, et al. Comparison of transradial and transfemoral approaches for coronary angiography and angioplasty in octogenarians (the OCTOPLUS study). AJC. 2004 Nov 1;94(9):1177–80. 12. Gan HW, Yip HK, Wu CJ. Brachial approach for coronary angiography and intervention: totally obsolete, or a feasible alternative when radial access is not possible? Ann. Acad. Med. Singap. 2010 May;39(5):368–73. 13. Klocker J, Gratl A, Chemelli A, Moes N, Goebel G, Fraedrich G. Influence of use of a vascular closure device on incidence and surgical management of access site complications after percutaneous interventions. Eur J Vasc Endovasc Surg. 2011 Aug;42(2):230–5. 14. Basche S, Eger C, Aschenbach R. The brachial artery as approach for catheter interventions--indications, results, complications. VASA. 2004 Nov;33(4):235–8. 15. Chatziioannou A, Ladopoulos C, Mourikis D, Katsenis K, Spanomihos G, Vlachos L. Complications of lower-extremity outpatient arteriography via low brachial artery. CVIR. 2004 Jan;27(1):31–4.

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AOD P Laparoscopic aortobifemoral bypass - 10 year results Frederik Lecot, Toon Sabbe, Sabrina Houthoofd, Kim Daenens, Inge Fourneau Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium

INTRODUCTION The TASC II recommendations conclude that aortobifemoral bypass (AFG) is still the mainstay of treatment for severe diffuse aortoiliac occlusive disease, with better overall patency rates than endovascular treatment, albeit at a higher surgical risk. Laparoscopic AFG has been performed at Leuven University Hospitals since 2003. Good short-term results have been published. We present the long-term results in our center. GOALS AND OBJECTIVES To estimate the long-term primary, primary assisted and secundary patency of laparoscopic AFG for occlusive disease, recurrence of symptoms and long-term complications.Materials and Methods Between 2003 and 2014 130 patients with aortoiliac occlusive disease TASC C and D underwent laparoscopic AFG using a transperitoneal retrorenal or retrocolic approach. From these patient files demographic data, operative data, postoperative morbidity and mortality data, patency, long term complications and reinterventions were extracted. RESULTS AND CONCLUSION Based on interim results, laparoscopic AFG has similar long-term patency rates when compared to open AFG. These results, combined with a shorter postoperative recovery time, lower postoperative pain and a faster return to normal activity warrants a wider adoption of the laparoscopic technique. N.B. Study in progress. Will be finished for sure by December 2014.

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AOD P Use of drugcoated balloon angioplasty as first line treatment for all SFA lesions

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Koen Keirse 1, Bart Joos 1, J端rgen Verbist 2, Patrick Peeters 2

1. H.Hart hospital, Tienen, Belgium 2. Imelda Hospital, Bonheiden, Belgium

BACKGROUND The use of drugcoated balloons (DEB) in the SFA is currently still under investigation in Trials. Although there are clear indications of the benefits in case of restenosis or in-stent restenosis, scientific evidence to support the title of abstract is still lacking today. We have used DEB treatment for 116 consecutive limbs to challenge the title. METHODS Patient cohort is a subgroup of the prospective controlled trial IN.PACT Global conducted at our institution. Between Oct 2012 and Sep 2014, 92 patients (116 limbs treated) were enrolled. The efficacy endpoint of the trial is freedom from clinically driven TLR and primary patency within 12 months. Safety endpoint includes freedom from MAE through 30 days, freedom from target limb amputation and freedom from TLR within 12 months. RESULTS Of the 92 patients enrolled, 88% had intermittent claudication and 12% presented with critical limb ischemia. For lesion treatment, only 30% received a bail-out stenting for residual stenosis or flow-limiting dissections and these were considered as treatment failure. The overall mean lesion length was 149.6 mm. Early results show a freedom from TLR at 12 months of 72% and a primary patency at 12 months of 74%. CONCLUSION Treatment of all real-world SFA disease with DEB seems safe and feasible, shows promising primary patency rates and appears to have lower bail-out stenting rates as compared to POBA in other SFA trials. As these 12-month data show promising results, preliminar 24-month data will be presented at the congress.

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AOD P OffRoad™ Re-entry Catheter System for Subintimal Recanalization of Chronic Total Occlusions in Femoropopliteal Arteries: Primary Safety and Efficacy Results of the Re-ROUTE Trial Koen Keirse1, Andrej Schmidt2, Andrej Schmidt3, Thomas Zeller4 1. Regional Hospital Heilig Hart Tienen, Tienen, Belgium 2. Leipzig, Germany Erwin Blessing, Heidelberg, Germany 3. Berlin, Germany 4. Bad Krozingen, Germany

METHODS AND RESULTS A total of 92 patients (mean lesion length 175.1 ± 85.4 mm) were enrolled in this prospective, single-arm, multicenter, post-market study conducted at 12 centers in Europe. To be eligible for the study, patients were required to have claudication or critical limb ischemia and a de novo or re-occluded CTO lesion in a native femoropopliteal artery. Target lesion length ≥ 1 cm and ≤ 30 cm and a minimum reference vessel diameter of 4 mm by visual assessment were required. Eighty seven patients were evaluable for the primary 30-day safety endpoint. The composite rate of device-related major adverse events was 3.4% (3/87). All 3 events were clinically significant peripheral embolisms and the event rate was lower than the prespecified acceptable threshold. Effectiveness was based on device technical success, defined as placement of a guidewire in the true lumen distal to a CTO as confirmed by an angiography core lab. The core lab-confirmed success rate was 92.1% (70/76), however, the core lab was unable to evaluate all cases due to lack of proper post-operative images. Site-reported technical success was 84.8% (78/92). Technical success rates exceeded the prespecified performance goal. CONCLUSION RE-ROUTE trial results demonstrate acceptable performance of the OffRoad system in terms of safety and technical success.

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PURPOSE The objective of the Re-ROUTE Clinical Study (NCT01500031) is to provide additional clinical data regarding the safety and technical success of the OffRoad Re-Entry Catheter System for subintimal recanalization of chronic total occlusion (CTO) in the femoropopliteal arteries.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

AOD P Management of critical limb ischemia patients with complex femoro-popliteal lesions: bypass or angioplasty stenting? Aurélia Bianchini, Damien Labbe, Céline Perot - Millet, Hovan Chenorhokian, David Massouille

Vascular Surgery, Lille, France

PURPOSE To compare outcomes between femoro-popliteal (FP) bypass and angioplasty stenting (ST) in patients with critical limb ischemia (CLI). METHODES Between 2009 and 2013, in a single centre, patients treated with FP bypass (BP) or FP stenting (ST) for CLI with TASC C and D lesions were retrospectively analysed. Main point was primary patency rate. Secondary end points were secondary patency rates, primary and secondary sustained clinical improvement and limb salvage rate. Survival rates were estimated with Kaplan-Meier method. Cox proportional hazard model was used to determine primary patency influencing factors. RESULTS 50 patients were treated by FP stenting and 63 with FP bypass. Median follow-up time was 13,1 months (0,1 – 55,1) in ST group versus 21,1 months (0,1 – 57,4) in BP group. There were no significant differences in TASC D lesions or reinterventions rates between groups (p > 0,005). There was no significant difference in one-year primary patency rate between groups (64% for BP versus 68,5% for ST, p = 0,975 ; Figure 1). One-year secondary patency rate was 74,5% in BP group versus 76,5% in ST group (p = 0,794 ). Body mass index higher than 24 kg/m2 (RR = 3,839 ; p = 0,003) and poor runoff (RR = 4,890 ; p = 0,003) significantly affected primary patency (Table 1). One-year primary sustained clinical improvement was 59,4% in BP group versus 49,7% in ST group (p = 0,172) Secondary clinical improvement was no significantly different between groups at 12 months (74,6% versus 63%, p = 0,111). One year limb salvage rate was 85% in BP group versus 83,2% in ST group (p = 0,568). CONCLUSION No significant difference was depicted between ST and BP regarding one year primary and secondary patency rates ; FP stenting appears a good option in treatment of patients with critical limb ischemia. Several studies, dedicated to CLI patients, are required in order to confirm this tendency.

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Kaplan Meier analysis of primary patency for the bypass group and the stenting group (p = 0,896) TABLE Risk Factor Poor runoff BMI > 24kg/m2

Hazard Ratio 3,839 4,890

95% confidence interval 1,601 – 9,205 1,730 – 13,818

Poor runoff : less than 3 patent leg arteries BMI = Body Mass Index

171

p 0,003 0,003

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Figure

AOD P Best practice care tariff’ for lower limb amputation. Is this a viable model?

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Jason Lewis1, Shiva Dindyal2, Ahmed Abidia3, Jonathan Refson3

1. The Royal London Hospital, London, United Kingdom 2. St Mary’s Hospital, London, United Kingdom 3. The Princess Alexandra Hospital, Harlow, United Kingdom

BACKGROUND Peripheral vascular disease is the principle cause of lower limb amputation in the Western world. It is associated with a significant economic burden and a high mortality rate. The ‘Pre- Amputation Care Pathway’ implements recommendations outlined by the National Service Framework for older people and the National Confidential Enquiry into Patient Outcome and Death report, “An Age Old Problem”. The pathway facilitates the management of critical limb ischemia with the aim of reducing morbidity and mortality. AIMS To introduce a novel “Pre- Amputation Care Pathway” that can be implemented by acute National Health Service trust’s to facilitate the care of patients undergoing lower limb amputation.To evaluate whether the pathway has reduced the morbidity and mortality rate of amputees. METHODS All patients undergoing lower limb amputation 1st January 2013- 31st December 2013 were prospectively identified and admitted to the study.Patient data was recorded retrospectively by analysing discharge summaries, patient records and charts before statistical analysis was performed. RESULTS Demographics: 10 patients underwent lower limb amputation. 2 patients underwent bilateral limb amputations (12 amputated limbs). Amputees were elderly (mean age 69 years) and had significant co-morbidities (mean ASA= 3.36). Referral and Diagnostic Assessment: Following presentation, the mean time for Vascular Surgeon review was 12 hours. Only 10% of patients had computer topographical angiography on the same day as presentation, with 40% receiving a scan the following day. Surgery: 4 patients underwent primary lower limb amputation and 6 patients underwent secondary limb amputation. 40% of patients underwent SFA angioplasty and 20% underwent bypass surgery prior to amputation. 6 above knee amputations and 6 below knee amputations were performed. 66.6% of amputations were performed by a consultant grade. The mean time from presentation to amputation was 16.83 days, inclusive of those patients who underwent failed attempts at limb salvage. Post-operative Care: 80% of patients were admitted to Critical Care post operatively. 1 patient was deemed inappropriate for Critical Care following surgery. 1 patient was discharged to a general surgical ward postoperatively following a prolonged stay in recovery. The mean time spent in Critical Care postoperatively was 2.62 days. Following step down, 90% of patients were admitted to a Health Care of the Elderly and rehabilitation ward. These patients received daily ward- round reviews by a Health Care of the Elderly consultant physician and the Vascular Surgery team. Morbidity and Mortality: 66% of patient’s experienced at least one complication in the recovery period. 1 patient died <30 days of surgery, representing a 10% 30-day mortality rate. A further 2 patient’s died >30 days following surgery. 80% of patients who had an amputation within 10 days of presentation survived to discharge. In contrast, only 25% of patient’s who had an amputation after day 11 following admission survived to discharge (p= 0.0384). CONCLUSION The “Pre-amputation Care Pathway” has reduced mortality at this centre from 40% in 2011 to 10% in 2013.A multidisciplinary team approach of managing this patient group optimizes outcome. 172

Veins Varicose veins surgery of lower limbs - Can we preserve great saphenous vein? Pereira Alves C., Neves J., Moniz L., Toscano F., Figueiredo J., Matias R., Marques A., Manso Neves R.

CHLC – Hospital dos Capuchos – Surgical Department, Hospital da Ordem Terceira - Vein Clinic Lisboa, Portugal

OBJECTIVE Clinical and DUS follow-up study of patients with segmental pattern of reflux operated on with preservation of GSV. METHODOLOGY 54 lower limbs have been studied considering: sex – age - CEAP clinical class, clinical results and pre and post operative DUS findings. Clinical history and examination and surgical procedures done by the same surgical consultant. Pre and postoperative DUS according to UIP guide lines. Clinical follow-up done by surgical team and considering two items : worthwhile surgery and recurrence of varicose veins. DUS follow-up considering: no reflux, maintenance of previous reflux or progression of previous reflux ResultsSex: 42 females vs. 12 males. Age: from 27 to 77 years. Mean age 52, 7 years. CEAP clinical class: C2 - 37; C3 12; C4 - 5. Patterns of segmental reflux: just varicose collateral branches – 8 limbs, collateral branches plus great saphenous segments – 14 limbs, thigh collaterals plus saphenofemoral junction reflux – 32 limbs. Worthwhile surgery –95, 5%. Clinical recurrence 1 patient after 11 months. DUS postoperative findings: no reflux of GSV - 32 (58 %), maintenance of previous GSV reflux segments without progression: 21 (40%), progression of reflux- 1 (2%). Follow-up: Min – 1 month, Max – 3 years , Mean – 12,1 months.

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INTRODUCTION Duplex ultrasound (DUS) study of varicose veins allow characterization of two main patterns of reflux of great saphenous vein (GSV): the axial reflux that is a continuous reflux from inguinal region to the malleolus mostly with varicose collaterals and the segmental reflux that involve just venous segments without continuity, according to 2009 The VEIN-TERM consensus. Regarding our experience this segmental type of reflux could be limited to collaterals, saphenous or non-saphenous, collaterals plus saphenous segments or thigh collaterals, anterior saphenous vein or the anterolateral or anteromedial collaterals, plus the saphenofemoral junction. It is easily accepted that if only superficial branches are varicose and refluxive simple avulsion is enough and great saphenous vein preserved. Preservation of great saphenous vein with refluxive segments is debatable, although previous clinical works have shown no progression or even regression in around 2/3 of cases.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

CONCLUSIONS Treat varicose veins with segmental reflux patterns with preservation of great saphenous vein has shown in our patients good and maintained results. The answer to our question “Can we preserve the great saphenous vein?“ is a positive “Yes we can“. Follow-up time is short as smaller the number of limbs and we need long term follow-up and bigger number of cases to translate the suggestion of preservation of the great saphenous vein with segmental pattern of reflux into a recommendation. The duplex ultrasound findings favour the concept of varicose veins as a local and multifocal process that could start in any vein segment with up or down and in-out or out-in progression and not a progressive up-down reflux of great saphenous vein starting at saphenofemoral junction. REFERENCES Bo Eklof, Michel Perrin, Konstantinos, T Delis, Robert B Rutherford and Peter Gloviczki. Update terminology of chronic venous disorders: The VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg 2009;Vol 49,N 2, 498-01. Pittaluga P, Chastenet S, Rea B, Barbe R. Midterm results of surgical treatment of varices by phlebectomy with conservation of a refluxing saphenous vein .J Vasc Surg 2009; 50(1) 107-18. Creton D. Diameter reduction of the proximal long saphenous vein after ablation of a distal incompetent tributary. Dermatol Surg 1999;May: 25 (5) 349. Labropoulos N, Giannoukas A.D, Delis K. et al. Where does venous reflux start? J Vasc Surg 1997; 26: 736-42.

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eins V The additional benefit of graduated compression stockings to pharmacological thromboprophylaxis in the prevention of venous thromboembolism in surgical inpatients Rishi Mandavia, Joseph Shalhoub, Karen Head, Alun Davies

Academic Section of Vascular Surgery, Imperial College London, United Kingdom OBJECTIVE The evidence base supporting the use of graduated compression stockings (GCS) for venous thromboembolism (VTE) prevention has been challenged and there appears to be a lack of evidence for the additional benefit of GCS to pharmacological thromboprophylaxis. This study aims to summarise and quality assess the existing evidence concerning whether GCS offer a significant benefit in addition to pharmacological thromboprophylaxis in surgical inpatients. METHODS A systematic review of published literature was performed. Inclusion criteria were: (1) randomised controlled trials (RCTs), (2) surgical inpatients, (3) study arms examining prophylactic dose pharmacological thromboprophylaxis alone, or in conjunction with GCS, (4) outcome of VTE. RESULTS 1025 articles were screened of which 27 RCTs were included. Six RCT study arms included patients with GCS in conjunction with pharmacological thromboprophylaxis, whilst 22 RCT study arms included patients treated with pharmacological thromboprophylaxis alone. One RCT had both itsâ&#x20AC;&#x2122; study arms included in the systematic review. The total number of patients that received pharmacological thromboprophylaxis alone was 12,481. Of these patients, 1,292 (10.4%) suffered VTE. The total number of patients that received GCS in conjunction with pharmacological thromboprophylaxis was 1,283. Of these patients, 75 had VTE (5.8%). Heterogeneity analysis demonstrated that the results of included study arms were significantly heterogeneous, precluding a valid summation analysis. CONCLUSIONS The additional benefit of GCS to pharmacological thromboprophylaxis in surgical inpatients is not clear based on existing data. Further clinical trials directly evaluating this clinical question are recommended.

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eins V Mid to long term results of endovenous laser ablation versus conventional surgery in patients with great saphenous varicose veins in a tertiary referral centre Nader Hamada

UCHG, Galway, Ireland

BACKGROUND Many randomised controlled trials were carried out in the last decade to study the short term outcome of endovenous laser ablation (EVLA), conventional surgery (CS) and other modalities of treatment. There are very few studies took into consideration the mid to long term outcome of these procedures. OBJECTIVE To compare the clinical & radiological success rate, patient satisfaction & complication rate of EVLA versus CS (high ligation & short stripping to knee level) after 5 years follow up. METHODS A total of 130 limbs were treated either with EVLA or CS from April 2004 till June 2006. We were able to reassess 104 limbs out of these 130 limbs after 5 years of treatment. Primary endpoint was recurrence defined by non-obliteration or re-formation of the treated vein segment in ultrasound examination.Secondary endpoints were complication rate & change of Venous Clinical Severity Score (VCSS) RESULTS More than 88% of the cohort of our patients was classified as C2 or C3 venous disease. Their VCSS was of average of 3.6 in EVLA group & 4.3 in CS group.We have followed our patients for 5.3 years in average (range from 3.42 to 8.75 years)The recurrence rate by duplex was 54.76% in EVLA group while it was 32.26% in CS group (P value of 0.027)Early â&#x20AC;&#x201C;within 90 days of treatment- minor complications rate -excluding pain- in EVLA group was 21.43% while it was 12.9% in CS group (P value of 0.287). Both groups showed a significant improvement of VCSS with a higher improvement in CS group. CONCLUSION After 5 years of follow up, EVLA is associated with higher long term recurrence of the treated great saphenous vein segment in ultrasound duplex in comparison to CS. Both modalities are effective in improving VCSS.

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Veins Not just another picc provoked DVT Rayya Saadiq, Michael McKusick Mayo Clinic, Rochester, USA

76-year-old male treated for AML arising from CMML, status post induction chemotherapy was admitted recently with right-sided venous thrombosis extending into the superior vena cava (SVC) and incidental finding of pulmonary emboli. He had a PICC line in the right arm placed 30 days ago with duplex documentation of thrombus involving right innominate, subclavian, and axillary veins. CT angiogram demonstrated occlusive thrombus in the right lower lobe subsegmental pulmonary artery without any pulmonary infarctions or right ventricular strain. Of note, a chest x-ray (CXR) done a month ago demonstrated the line terminating in the superior vena cava and a repeat CXR at admission showed the line terminating in the right ventricle (Figure 1). Attempt was made at bedside to remove the PICC line but was unsuccessful. He was started on heparin and intervention radiology consulted for removal of the PICC line. Next day immediately following the removal of the catheter he became tachycardic, dyspneic and desaturated to 85% oxygen. On supplemental oxygen at 10 liters/minute his saturations improved to 97% but he continued to be tachycardic at 120-130 BPM. Bed side echocardiogram showed right heart strain. Believing this was most likely due to migration of the SVC clot to the pulmonary arteries, decision was made to treat with tPA. Patient tolerated the systemic dose of tPA and noted improvement in tachycardia and dyspnea within the next few hours. He was discharged 48hrs later, when hemodynamically stable and not requiring any supplement oxygen. This case highlights that not all PICC induced DVTs are benign and questions such as when to pull the PICC line and how long we should anticoagulate prior to removal, needs to be studied. Figures

PICC line pulled into right ventricle due to the clot. A= CXR done 1 month prior to event. B= CXR done at time of admission. Arrow = Tip of the PICC line

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Veins IVC filter insertion and removal â&#x20AC;&#x201C; the dangers of unregulated practice

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Su-Min Lee, Vikas Pandey, Marina Kafeza, Fateha Chowdhury, David Greenstein

Northwick Park Hospital, London, United Kingdom

INTRODUCTION In 2010, the Food and Drug Administration (FDA, United States of America) issued communications advising on adverse events associated with IVC filters. No regulatory attempts have been made in the United Kingdom. The study aims were to analyse management of IVC filters within a single centre. METHODS In total, 155 consecutive patients underwent IVC filter insertion between January 2007 and March 2014. Referral source, indications, removal date, complications and follow-up were assessed. RESULTS Non-vascular referrals accounted for 82.6% including Elderly Care (18.1%), Gastroenterology (15.5%), General Surgery (12.9%), General Medicine (7.7%), others (25.2%) and referral undocumented (3.2%). 64 (41.3%) temporary and 91 (58.7%) permanent filters were inserted via trans-jugular (18.1%) or trans-femoral (78.7%) routes (3.2%-unknown); 58.7% were inserted for absolute indications including recurrent PE (6.5%), contraindication to anticoagulation (16.8%), anticoagulation complications (9.0%), inability to anticoagulate (26.5%). 36.8% of filters were for relative indications including iliocaval DVT (11.0%), DVT+thrombolysis (12.3%), prophylactic indications (3.9%; Surgery (3.2%) and trauma (0.6%) with high VTE risk. Retrieval was attempted in 44 patients (28.3%) and was successful in 40 (25.8%; 15/91 permanent filters, 29/64 temporary filters.) These filters remained in-situ: median 42 days (range 5-201 days). Two patients required 2 and 4 attempts, respectively, before successful retrieval. Filters were left in-situ in 3 patients after failed retrieval. Retrieval snare damage occurred in 1 patient. Follow-up data was available for 126 patients. 62 patients (49.2%) had no recorded follow-up. Follow-up was not required in 39 patients (filter removed or patients receiving palliative care). The remaining 25 patients (19.8%) were followed up by haematology or vascular surgery. CONCLUSIONS With no clear national protocols, the practice of IVC filter insertion is unregulated and unstandardized. As a consequence of this haphazard practice, some patients may be put at risk.

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eins V Thrombosis of the inferior vena cava in a young patient with hyperhomocysteinemia Sérgio Teixeira, Joana Martins, Pedro Sá Pinto, Diogo Silveira, Lisa Borges, Vitor Ferreira, Gabriela Teixeira, Rui Almeida Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal

Deep venous thrombosis (DVT) is a relatively uncommon condition in patients below 30 years old and its global lifelong incidence in the general population is 0.1%. Venous thrombosis of the inferior vena cava is an even rarer clinical condition, which shares common etiological causes with DVT. Hyperhomocysteinemia is a well-known risk factor for DVT. In this work we present the clinical case of a 24-year-old male patient, with past history of vitiligo and hyperthyroidism, who was referred from a peripheral hospital due to a suspected DVT of the left inferior limb while hospitalized to treat a community acquired pneumonia. Upon admission to the ER, a venous ecodoppler scan of the inferior limbs was perfomed, which revealed a biiliac/bifemoral DVT (totally occlusive in the left side). To further study the thrombus extension, patient realized a thoracic-abdominal-pelvic angio-CT scan which showed a partially occlusive thrombosis of the inferior vena cava with extension to the right cardiac atrium, areas of pulmonary infarction and acute pulmonary thromboembolism. The patient remained hospitalized and a therapeutic dosage of unfractionated heparin was used for hypocoagulation. During hospitalization increased serum levels of homocystein were detected, in the presence of normal serum levels of vitamin B12 and folic acid. Eight months after the initial episode, the patient is under oral hypocoagulation with acenocumarol (INR 2-3) and we registered a progressive mild clinical recovery. The imaging studies recently performed show persistence of the venous thrombosis with partial dissolution of the thrombus, with extension until the intra-hepatic portion of the inferior vena cava. Figures

Angio-CT scan

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Transthoracic Echocardiogram Thrombus protruding into the right auricula (arrow)

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ORGANIZATION divine [id] 17, rue Venture 13001 Marseille - France Tel. +33 (0) 491 57 19 60 Fax. +33 (0) 491 57 19 61 info@divine-id.com www.divine-id.com