CACVS 2016 Abstract book by divine [id]

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

International Scientific Committee Piergiorgio Cao Eric Chemla Nicholas Cheshire Hans-Henning Eckstein Christos D. Liapis Ian Loftus Martin Malina Armando Mansilha Fabio Verzini

www.cacvs.org

Table of contents

CONTROVERSIES & UPDATES IN VASCULAR SURGERY THURSDAY JANUARY 21 Thoracic and Thoraco Abdominal Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

FRIDAY JANUARY 22 Chairman Pr Jean-Pierre Becquemin

MD, Professor of Vascular Surgery Créteil, France

Main session

Dr Jean-Luc Gérard

Lower Limb Occlusive Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Challenges in Lower Limb Endovascular Repair: How to Break the Limits . . . . . . . . Aortic Occlusive Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Carotid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Flash News. The Latest of EVAR Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rupture AAA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How Can We Improve the Results of EVAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pr Eric Allaire

Vascular access

Scientific Committee Pr Yves S. Alimi

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

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

Vascular Access News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tricks of the Trade for a Safe Cannulation Technique . . . . . . . . . . . . . . . . . . . . . . . . . Debate. Vascular Access in the Elderly: Native or Prosthetic? . . . . . . . . . . . . . . . . . . . News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Debate. The Native Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14 16 19 21 29 31 33

42 45 47 50 52

SATURDAY JANUARY 23

MD, Créteil, France

I nternational Scientific Committee Committee Pr Piergiorgio Cao

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

Dr Eric Chemla

MD, Vascular surgeon, London, United Kingdom

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

Peripheral and Visceral Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypogastric Arteries during EVAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How and When Embolize the Sac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unusual Features of Endoleaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Juxta / Supra Renal Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

56 58 59 60 62 65

CONTROVERSIES & UPDATES IN VARICOSE DISEASE Deep vein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Some debates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sclerotherapy & Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thermal or glue techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

68 71 79 92

Pr Ian Loftus

Professor of Vascular Surgery, London, United Kingdom

EPOSTERS

MD, PhD, Vascular surgeon, Malmö, Sweden

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

Dr Martin Malina

Pr Armando Mansilha

Professor of Vascular Surgery, Porto, Portugal

Pr Fabio Verzini

Professor of Vascular Surgery, Perugia, Italy

102 131 134 136 167 173 193

Faculty authors VASCULAR PROGRAM

VENOUS PROGRAM

Jean-Noël ALBERTINI, St Etienne, France . . . . . . . . . . . . . . . . 34 Richard AMERLING, New York, USA . . . . . . . . . . . . . . . . . . . 52 Selcuk BAKTIROGLU, Istanbul, Turkey . . . . . . . . . . . . . . . . . . 47 Michel BARTOLI, Marseille, France . . . . . . . . . . . . . . . . . . 30, 37 Colin BICKNELL, London, United Kingdom . . . . . . . . . . . . . . . 20 Mourad BOUFI, Marseille, France . . . . . . . . . . . . . . . . . . . . . . . 7 Pierre BOURQUELOT, Paris, France . . . . . . . . . . . . . . . . . . . . 45 Piergiorgio CAO, Perugia, Italy . . . . . . . . . . . . . . . . . . . . . . . 11 Raphael COSCAS, Boulogne billancourt, France . . . . . . . . . . . . 51 Philippe CUYPERS, Oud-Turnhout, Belgium . . . . . . . . . . . . . . 58 Michael DAKE, Stanford, USA . . . . . . . . . . . . . . . . . . . . . 15, 65 Ronald DALMAN, Palo Alto, USA . . . . . . . . . . . . . . . . . . . . . 62 Alison HALLIDAY, London, United Kingdom . . . . . . . . . . . . . . 24 Réda HASSEN-KHODJA, Nice, France . . . . . . . . . . . . . . . . . . 23 Stavros KAKKOS, Patras, Greece . . . . . . . . . . . . . . . . . . . . . . 21 Koen KEIRSE, Elsene, Belgium . . . . . . . . . . . . . . . . . . . . . . . . 14 Patrick KELLY, Sioux Falls, USA . . . . . . . . . . . . . . . . . . . . . . . . 10 Asmaa KHALED, Créteil, France . . . . . . . . . . . . . . . . . . . . . . . 35 Adel KHAYATI, Tunis, Tunisia . . . . . . . . . . . . . . . . . . . . . . . . . 32 Kimihiro KOMORI, Nagoya, Japan . . . . . . . . . . . . . . . . . . . . 38 Christine JAHN, Strasbourg, France . . . . . . . . . . . . . . . . . . . . 50 Thomas LARZON, Orebro, Sweden . . . . . . . . . . . . . . . . . . . . 36 Christos D. LIAPIS, Chaidari, Greece . . . . . . . . . . . . . . . . . . . . 27 Ian LOFTUS, London, United Kingdom . . . . . . . . . . . . . . . 33, 64 Anne LONG, Lyon, France . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Serguei MALIKOV, Vandoeuvre les Nancy, France . . . . . . . . . . 19 Richard McWILLIAMS, Liverpool, United Kingdom . . . . . . . . . 60 Wesley MOORE, Los Angeles, USA . . . . . . . . . . . . . . . . . . . . . 25 George PAPANDREOU, New Hope, USA . . . . . . . . . . . . . . . . 14 Janet POWELL, London, United Kingdom . . . . . . . . . . . . . . . . 31 Hervé ROUSSEAU, Toulouse, France . . . . . . . . . . . . . . . . . 8, 59 Nirvana SADAGHIANLOO, Nice, France . . . . . . . . . . . . . . . . 42 Peter SCHNEIDER, Honolulu, USA . . . . . . . . . . . . . . . 16, 17, 26 Carlo SETACCI, Siena, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Julien SFEIR, Beirut, Lebanon . . . . . . . . . . . . . . . . . . . . . . . . . 18 David SHEMESH, Jerusalem, Israel . . . . . . . . . . . . . . . . . . . . . 49 Matt THOMPSON, London, United Kingdom . . . . . . . . . . . . . . 6 Marc VAN SAMBEEK, Eindhoven, The Netherlands . . . . . . . . . 29

François-André ALLAERT, Dijon, France . . . . . . . . . . . . . . . . 88 Denis CRETON, Nancy, France . . . . . . . . . . . . . . . . . . . . . . . . 74 Huw DAVIES, United Kingdom . . . . . . . . . . . . . . . . . . . . . . . . 81 Philippe DESNOS, Caen, France . . . . . . . . . . . . . . . . . . . . . . . 82 Bo EKLÖF, Helsingborg, Sweden . . . . . . . . . . . . . . . . . . . . . . . 89 Gilbert FRANCO, Paris, France . . . . . . . . . . . . . . . . . . . . . . . . 75 Alessandro FRULLINI, Figline Valdarno-Florence, Italy . . . . . . . 85 Jean-Luc GÉRARD, Paris, France . . . . . . . . . . . . . . . . . . . . . . 71 George GEROULAKOS, Chaidari, Greece . . . . . . . . . . . . . . . . 91 Peter GLOVICZKI, Rochester, USA . . . . . . . . . . . . . . . . . . . . . 69 Claudine HAMEL DESNOS, Caen, France . . . . . . . . . 76, 79, 83 Lowell KABNICK, New York, USA . . . . . . . . . . . . . . . . . . 68, 98 James LAWSON, Amsterdam, The Netherlands . . . . . . . . . . . . 93 Wendy MALSKAT, Rotterdam, The Netherlands . . . . . . . . . . . . 94 Patrizia PAVEI, Padova, Italy . . . . . . . . . . . . . . . . . . . . . . . . . 97 Michel PERRIN, Chassieu, France . . . . . . . . . . . . . . . . . . . . . . 86 Thomas PROEBSTLE, Mainz, Germany . . . . . . . . . . . . . . . 78, 95 Inga VANHANDENHOVE, Deurne Antwerpen, Belgium . . . . . 92

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Thursday January 21 - Main program -

Thoracic and Thoraco Abdominal Aneurysms Expansion, risk of rupture: are our current guidelines still valid?

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Matt Thompson

St Georges Vascular Institute, London, United Kingdom BACKGROUND Surveillance is mandatory for all patients with a small thoracic aortic aneurysm (TAA). The frequency of surveillance imaging however is not evidence based as few data exist on TAA growth rates. This study aimed to determine the rate of TAA expansion and to inform optimal surveillance intervals for individuals based on TAA diameter. METHODS The cohort comprised 995 patients with small TAA for whom morphological data were available from serial CT scans. Each patient had a minimum of 2 sequential and dated CT scans prior to undergoing repair of the TAA. Annualised growth rates based on diameter at presentation and time taken to reach a theoretical intervention threshold of 55m was calculated. The number of patients that would have achieved the threshold undetected was determined based on simulated imaging intervals of 6 months, 1, 2 and 3 years. RESULTS Scans from 995 patients were analysed. The mean aortic expansion rate was 2.76mm / year for all patients, with an exponential increase in expansion rate at sizes above 45mm. By one-year post-presentation, 36% of those with a starting diameter of 50-54mm and 25% of those with a starting diameter of 45-49mm had expanded to beyond the 55mm treatment threshold. Conversely, no patients with a diameter at presentation of 30-39mm and only 5% of those with a TAA diameter at presentation of 40-44mm achieved threshold size within 2 years. DISCUSSION Based on a threshold of 55mm for intervention, most patients with a maximal aortic diameter of <40mm could safely undergo surveillance at 2 yearly intervals. Those with a diameter of >50mm should be optimised for repair if this is clinically appropriate due to the subsequent rapid expansion observed.

Thoracic and Thoraco Abdominal Aneurysms Proximal issues. Should we choose specific stent-graft for a specific anatomy? Mourad Boufi

Marseille, France INTRODUCTION AND OBJECTIVES Extension of thoracic endovascular aortic repair (TEVAR) indication to different pathologies and landing zones raises the question relating the extent to which stent-grafts can be compatible with different anatomies. The association between morphology and complications after TEVAR seems evident. However, there are no clear recommandations defining morphological criteria which influence outcomes. The present study aims to analyse the different factors favoring the occurrence of two types of complications – endoleak and mispositioning – and in particular, the relationship between these phenomena and aortic anatomy. MATERIALS AND METHODS Between 2007 and 2014 patients admitted for TEVAR, with a proximal landing zone located in the aortic arch, were retrospectively reviewed. The study involved 73 patients (58 men, 54 ± 21 years) treated for traumatic aortic rupture (n=28), type B aortic dissection (n=24), penetrating aortic ulcer (n=4), intramural hematoma (n=2) and thoracic aortic aneurysm (n=15). Pre and postoperative computed tomographic angiography were examined to analyse the presence of endoleak and quantify mispositioning (discrepancy between the planned and the achieved landing zone). Different anatomical factors were calculated by means of Matlab script: aortic angulation within a 30 mm range at the proximal deployment zone, landing zone angle, aortic tortuosity index, curvature radius and arch width. RESULTS Primary type I endoleaks were noted in 5 cases (7%). Over a mean follow-up of 35 months (range 3- 95 months), secondary endoleaks were detected in 2 patients (3%) and stent-graft migration in 3 patients (4%). Mispositioning varied from 2 to 15 mm. A cut-off value of 11 mm was identified to be at risk of adverse clinical events. Multivariable analysis identified the following anatomic criteria as independant risk factors of complications: landing zone angle for the risk of type I endoleak (HR =1.38, 95% CI 1.02- 1.88, p=0.03) with a cutoff value of 160° and tortuosity index for the occurrence of mispositioning (OR=241.4, 95% CI=1- 6149, p=0.05) with a cut-off value of 1.68 CONCLUSION The present study clearly reveals the impact of anatomy on the occurrence of complications at the proximal deployment zone and argue for the limits of the stent-grafts currently available. Specific devices should be required for these complex anatomies.

Thursday January 21

Thoracic and Thoraco Abdominal Aneurysms Proximal issues. Left subclavian branch: technique and preliminary results

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Hervé Rousseau, Bertrand St Lebes

CHU Rangueil, Toulouse, France

Aneurysms that involve the aortic arch extend more commonly to the ascending and/or descending thoracic aorta, while isolated aortic arch aneurysms represent only 4% of all the aortic aneurysms. The endovascular treatment of arch aneurysms using branched stent grafts that can be introduced transfemorally is appealing for many reasons. This method is minimally invasive and avoids the need for creating a carotid– LSA bypass. The theoretical but inherent risk of disassembly of modular devices is also diminished with the integrated design of the Branched TEVAR. In this study, we used a branched stent-graft with a unibody design (Valiant® Mona LSA™ thoracic stent graft system), the branched limbs and the main stent-graft are fixed together inside a tunnel and thus the risks of component separation and type III endoleak are theoretically much lower than with modular stentgrafts. The Valiant® Mona LSA™ thoracic stent graft system is intended for the endovascular repair of aneurysms and penetrating ulcers of the descending thoracic aorta (DTA) in patients presenting with the appropriate anatomy and who would require coverage of the left subclavian artery (LSA). When placed within the target lesion, the stent graft provides an alternative conduit for blood flow to the LSA with an exclusion of the lesion from aortic pressure. DEVICE DESCRIPTION Each procedure requires implantation of at least 2 systems: 1 main stent graft (MSG) used in the thoracic aorta and 1 branch stent graft (BSG) implanted into the LSA. The thoracic and the branched graft are composed of a self-expanding, metallic spring scaffold made from nitinol wire sewn to a fabric graft with non-resorbable sutures. Radiopaque markers are sewn onto each component of the stent graft to aid in visualization and to facilitate accurate placement. At the proximal end of the Main Stent Graft (MSG), an 8-peak bare stent (FreeFlo) extends past the covered stent graft to provide additional fixation while maintaining transvessel flow. Between the first and second covered stents on the proximal end, there is a conical-shaped cuff that provides access for a secondary device to deploy the BSG. The cuff comprises the following components: • A mobile external connector (MEC) stent that imparts an inward radial force to provide a functional seal when the Branched Stent Graft (BSG) is deployed inside the cuff • Radiopaque coils on the proximal and distal end to assist with visualization during deployment and enhance deployment accuracy. The BSG is deployed in the cuff of the MSG. The proximal end of the BSG will overlap with the cuff, and the distal end will provide blood flow in the LSA. The MSG is available in diameters ranging from 30 mm to 46 mm and a length from 150 mm to 172 mm. The proximal and distal end diameters are constant throughout the covered length of the device. The BSG is available in 10, 12, and 14 mm diameters and a length of 40 mm. DEVICE SELECTION Planning of the procedure is done with a 3D workstation after computed tomography angiography including the aorta from the level of the aortic annulus to the femoral arteries. The analysis must include: orientation of the supra-aortic trunk vessels and identification of sufficient sealing zones within the “normal“ aorta, each of supra-aortic target artery and the descending thoracic aorta. Careful examination of the access site (brachial and femorals) is also done.

CLINICAL EXPERIENCE A prospective, multicenter, single-arm, non-randomized pre-market clinical study is in progress. The preliminary experience on 10 patients, have demonstrated the technical feasibility of the endovascular treatment of aortic arch aneurysms with a LSA branched stent graft. With aortic-branched stent grafts, absolute accuracy in design and placement is necessary. The importance of using a 3-D workstation for planning and a state-ofâ&#x20AC;&#x201C;the-art modern angiosuite for placement of the device cannot be underestimated. Moreover, the theoretical risk of stroke in these patients remains high, as complex arch anatomy may necessitate extensive instrumentation within the arch during positioning of the stent graft or during cannulation of branches. A minimum of devices manipulation in the arch is crucial to avoid embolic migration and stroke. Therefore, hostile anatomy together with excessive arch calcification should be considered contraindications for the endovascular approach. Increased case volume and longer follow-up will better characterize this feared complication.

Thursday January 21

PLACEMENT OF THE DEVICE Briefly, a transversal arteriotomy of the common femoral artery is performed and the stent graft delivery system is inserted up to the thoracic aorta through a 25 French sheath and supported by a 0.035-inch stiff wire (Back Up Meyer (Boston Medical) or Lunderquist SuperStiff wire (Cook Medical, Bloomington, IN), under general anesthesia. Contra-lateral femoral artery puncture is performed to introduce a pigtail catheter and positioned to the aortic arch for angiography. A 6-Fr sheath is placed at the origin of the LSA from a left percutaneous brachial approach. Intravenous heparin is administered to maintain an activated clotting time (ACT) time >250 s. The graft is advanced over the stiff wire up to the descending aorta. By the brachial access, a snare catheter is introduced to the proximal descending aorta. With the tapered tip of the MDS positioned in the DTA, the BSG guide wire (Jagwire DT 4.5m, Boston Medical) is snared, and pull through the brachial access site. It is crucial to do not torque the branch wire as it may result in wire wrap. If necessary, wire wrap could be removed by rotating main delivery system in descending thoracic aorta. After confirmation of the correct position of the proximal main body, with its proximal edge of fabric lying distal to the left carotid ostia and the distal markers of the LSA branch lying proximal to the LSA ostia, the first part of the aortic stent graft is implanted. In order to a correct orientation of the branch window, a 45Â° left anterior oblique view is needed. Tension to the LSA branch guidewire is used to aid the alignment of the cuff into the ostium of the LSA. Once the aortic stent graft has been deployed, the branched graft is implanted from the femoral artery. No remodeling is performed after the complete deployment of the thoracic stent graft, but remodeling of the LSA branch is performed with a 12 mm balloon. A distal thoracic graft extension is implanted when the landing zone is further distal in the descending thoracic aorta.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Thoracic and Thoraco Abdominal Aneurysms New stent grafts for the thoracic and thoraco abdo segment. Complete Endovascular Debranching: design considerations Patrick Kelly

Sanford Health, Sioux Falls, USA BACKGROUND Endovascular repair of thoracoabdominal aneurysms has provided an alternative for patients who are not candidates for open surgical repair. No branch devices are yet approved in the US for commercial use. OBJECTIVE To demonstrate a novel endovascular technique for repairing all types of TAAAs and to present the initial outcomes obtained with a physician-modified TAAA device. MATERIAL AND METHODS The procedures involved a physician-modified thoracic stent graft and infrarenal stent graft. Twenty three patients, 14 male and 9 female, were treated between March of 2012 and July 2014. Baseline, Index, 6 month, and 1-year single-center outcomes were collected retrospectively. Twenty two were followed to 1 month, 18 patients were followed to 6 months, and 14 patients were followed to 1 year. Twelve of the 23 would meet the patient selection criteria of our current physician-sponsored IDE. There were 2 Crawford type 1s, 4 type 2s, 6 type 3s, 5 type 4s, and 6 type 5s. RESULTS Average procedure time was 297 minutes with an average fluoro time of 96 minutes and 103 mL of contrast used. Eighty four of 85 target vessels were successfully stented and 83 of the 84 target vessels remained patent throughout the follow-up. In the group meeting IDE patient selection criteria, there was an average length of stay of 7 days with no in hospital or 30 day death, no cases of paraplegia, and one case of renal failure which resolved. There was one death at 11 months from a CVA. In the group not meeting IDE patient selection criteria, there was an average length of stay of 9.5 days, with no in hospital or 30 day death, two cases of paraplegia, and six cases of temporary or permanent renal failure. There were 8 deaths in the 1 year follow-up with no aneurysm-related death. Of the patients that donâ&#x20AC;&#x2122;t meet the IDE selection criteria, four of the patients were emergent ruptures, three were chronic type B dissections, and the remaining four either had suprarenal fixated stents or an occluded renal. CONCLUSIONS Early results show that a TAAA device can be implanted safely. The repair appears to be durable with excellent branch vessel patency, with some patients being more than three years from the index procedure. More experience with the device is needed and will be obtained in our newly granted PS-IDE (G140207) and with an industry manufactured device, namely the Valiant Thoracoabdominal Stent Graft System which was recently approved for human use.

Thoracic and Thoraco Abdominal Aneurysms More about TAAA. Endo or open. What are the scientific criteria of choice? Ciro Ferrer, Piergiorgio Cao Perugia, Italy

The possibility to manage aortic aneurysms by endovascular means has been one of the major innovations of the past 20 years in vascular surgery. Currently endovascular repair has become the predominant treatment option for thoracic (TAA) and abdominal aortic aneurysms (AAA) that comply with morphological feasibility criteria.1-4 Open Surgery (OS) still remains the gold standard in case of complex aortic aneurysms involving visceral vessels, nevertheless there are relatively few vascular surgeons undertaking open surgery for thoraco-abdominal aortic aneurysm (TAAA) offering patients low mortality and morbidity risk exposure.5-7 Similarly, there are only few centers involved in endovascular repair (ER) who report encouraging results with branched and fenestrated stentgrafts in TAAA.8 Reliable unbiased data comparing open and endovascular technique for complex aortic aneurysms involving thoraco-abdominal aorta are lacking. We recently reviewed the outcomes of all TAAA patients undergoing repair at three Italian vascular centers between January 2007 and December 2014, stratifying them according to treatment by ER or OS and comparing the outcomes using propensity score matching (1:1). Covariates included age, sex, aneurysm extent, hypertension, coronary disease, chronic pulmonary disease, diabetes, and renal function. The primary endpoint were mortality and paraplegia. Secondary endpoints included any spinal cord ischemia (SCI), renal and respiratory insufficiency and a composite of these complications or death at 30 days. All-cause survival and reintervention-freedom were also compared in the two groups. Out of 341 patients, 84 (25%) underwent ER and 257 underwent OS (75%). After propensity score matching (65 patients per group), no significant differences were observed in rates of 30-day mortality (7.7% in ER and 6.2% in OS; p=1), and paraplegia (9.2% and 10.8%; p=1). Any SCI, renal and respiratory insufficiency were 12.3% and 20% (p=0.34), 9.2% and 12.3% (p=0.78), and 0% and 12.3% (p=0.006), in ER and OS respectively. The incidence of composite endpoint was significantly lower in ER patients (18.5% in ER vs. 36.0% in OS; p=0.03). According to Kaplan Meier estimates, all-cause survival at 24 months was 82.8% in ER and 84.9% in OS with rates unchanged at 42 months (p=0.9). Reintervention-freedom rates were 91.0% vs. 89.7% at 24 months and 80.0% vs. 79.9% at 42 months, in ER vs. OS, respectively (p=0.3). In conclusion, a propensity score analysis in patients with TAAA undergoing repair suggests an early benefit from ER compared to OS with regards to composite endpoint due to reduced respiratory 30-day complications, while no significant differences were found in SCI and renal insufficiency at 30 days, and survival and reintervention rates at mid-term. REFERENCES 1. Demers P, Miller DC, Mitchell RS, Kee ST, Sze D, Razavi MK, Dake MD. Midterm results of endovascular repair of descending thoracic aortic aneurysms with first-generation stent grafts. J Thorac Cardiovasc Surg. 2004;127(3):664-73. 2. Cheng D, Martin J, Shennib H, Dunning J, Muneretto C, Schueler S, Von Segesser L, Sergeant P, Turina M. Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol. 2010;55(10):986-1001. 3. Giles KA, Pomposelli F, Hamdan A, Wyers M, Jhaveri A, Schermerhorn ML. Decrease in total aneurysm-related deaths in the era of endovascular aneurysm repair. J Vasc Surg 2009;49:543-51. 4. Schwarze ML, Shen Y, Hemmerich J, Dale W. Age-related trends 1 in utilization and outcome of open and endovascular repair for abdominal aortic aneurysm in the United States, 2001-2006. J Vasc Surg 2009;50: 722-9. 5. Jacobs MJ, Mommertz G, Koeppel TA, Langer S, Nijenhuis RJ, Mess WH, Schurink GW. Surgical repair of thoracoabdominal aortic aneurysms. J Cardiovasc Surg (Torino). 2007;48:49-58. 6. Coselli JS, Bozinovski J, LeMaire SA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg. 2007;83:S862-4; discussion S890-2. 7. Kazen UP, BlohmĂŠ L, Olsson C, Hultgren R. Open Repair of Aneurysms of the Thoracoabdominal Aorta. Thorac Cardiovasc Surg. 2015 Sep 24. [Epub ahead of print]. 8. Greenberg R, Eagleton M, Mastracci T. Branched endografts for thoracoabdominal aneurysms. J Thorac Cardiovasc Surg. 2010;140(6 Suppl):S171-8. 11

Thursday January 21

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Friday January 22 - Main program -

Lower Limb Occlusive Disease Drug Coated Balloons: Concepts, Products and How to Use Them

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

George Papandreou

Lutonix/CR Bard, New Hope, USA Restenosis is a common limitation of conventional angioplasty. Drug coated balloon catheters are designed to enhance the effects of mechanical dilatation through introduction of local pharmacological therapy in order to reduce restenosis. The development of DCB requires identifying an effective drug. Commercially available DCB products for peripheral arterial and coronary disease contain paclitaxel, a cytotoxic drug, in levels ranging from 2-3.5 μg/mm2. Formulations are designed to have appropriate drug level with excepients (carriers) that allow release of the drug (drug uptake) while also ensuring good coating adhesion to the balloon surface. Formulations are also designed to allow the drug to reside in tissue for a prolonged period of time, thus inhibiting neointimal hyperplasia. Pre-clinical animal studies evaluated the drug uptake by the vessel wall, as well as drug tissue levels over time. These studies also evaluated safety by histological examination of the effects of the drug on arterial tissue at various dose levels. In addition, histological examination of downstream tissue and elimination organs assessed the effect of any drug excess over time outside of the local vessel tissue.Recent human clinical studies have demonstrated the benefit of DCBs in the treatment of peripheral artery disease (PAD). The DCB long term effectiveness is dictated by two factors, first is the right combination of drug level and coating formulation, and, second, the proper use of the DCB itself. Optimal long term benefits from DCB catheters were obtained when good basic angioplasty deployment techniques were followed which allowed maximum drug uptake by the arterial tissue.

Lower Limb Occlusive Disease What you need to know to perform successful peripheral repair After one year what are the results of DES? Koen Keirse

Regional Hospital Tienen, Tienen, Belgium PURPOSE The MAJESTIC clinical study was designed to evaluate the performance of the Eluvia drug-eluting vascular stent system (Boston Scientific Corporation, Marlborough, MA, USA) for treating femoropopliteal artery lesions up to 110 mm in length. MATERIAL AND METHODS MAJESTIC is an ongoing, prospective, single-arm, multicenter clinical trial with investigative sites in Europe, Australia, and New Zealand. Eligible patients had chronic lower limb ischemia and de novo or restenotic lesions in the native superficial femoral artery and/or proximal popliteal artery. The primary efficacy endpoint was core laboratory-adjudicated 9-month primary patency (i.e., duplex ultrasound peak systolic velocity ratio of ≤2.5 and the absence of target lesion revascularization [TLR] or bypass). Major adverse events (MAEs), including all-cause death through 1 month, target limb major amputation through 12 months, and TLR through 12 months, were assessed. RESULTS Mean age (±SD) of the patients (N=57) was 69±9 years and 35% had diabetes. Baseline Rutherford category was 2 for 35%, 3 for 61%, and 4 for 4% of patients. Mean lesion length was 70.8±28.1 mm, and 65% 14

had severe calcification. Percent diameter stenosis was 86.3%Âą16.2%, and 46% of lesions were occluded. The primary endpoint was met with a 9-month primary patency of 94.4%. At 12 months, the primary patency rate was 96.1% (49/51) and the MAE rate was 3.8% (2 TLR events). There were no stent fractures at 12 months upon analysis by the angiographic core lab. Among patients with diabetes mellitus, the 12-month MAE rate was 0% (0/16) and primary patency was 100% (14/14).

Lower Limb Occlusive Disease What you need to know to perform successful peripheral repair DES: what happen after 5 years. Are DES still better than bare stents? Michael Dake

Stanford University, Stanford, CA, USA BACKGROUND This randomized controlled trial (RCT) evaluated clinical durability of Zilver PTX, a paclitaxel-coated drug-eluting stent (DES), for femoropopliteal artery lesions. Outcomes compare the overall DES group (primary and provisional DES) versus the standard care group (percutaneous transluminal angioplasty (PTA) and provisional Zilver bare metal stent (BMS)), and directly compare provisional DES versus provisional BMS. METHODS AND RESULTS Patients with symptomatic femoropopliteal artery disease were randomized to DES (n=236) or PTA (n=238). Approximately 91% had claudication and 9% had critical limb ischemia. Patients experiencing acute PTA failure underwent secondary randomization to provisional BMS (n=59) or provisional DES (n=61). The 12-month primary endpoints were met, showing superior event-free survival and primary patency for primary DES compared to PTA. Results were sustained through 5 years. Clinical benefit (79.8% versus 59.3%, p<0.01), primary patency (66.4% versus 43.4%, p<0.01), and freedom from reintervention (TLR, 83.1% versus 67.6%, p<0.01) for the overall DES group were superior to standard care. Similarly, clinical benefit (81.8% versus 63.8%, p=0.02), patency (72.4% versus 53.0%, p=0.03), and freedom from TLR (84.9% versus 71.6%, p=0.06) with provisional DES were improved over provisional BMS. These results represent >40% relative risk reduction for restenosis and TLR through 5 years for the overall DES compared to the standard care group and for provisional DES compared to provisional BMS. CONCLUSIONS The 5-year results from this large RCT provide long-term information previously unavailable regarding endovascular treatment of femoropopliteal artery disease. The Zilver PTX DES provided sustained safety and clinical durability compared to standard endovascular treatments. 15

Friday January 22

CONCLUSION Drug-eluting stent technology appears promising for treatment of the superficial femoral artery. MAJESTIC results showed that patients treated with the Eluvia drug-eluting stent sustained a high patency, low TLR rate and low MAE rate through 12 months.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Challenges in Lower Limb Endovascular Repair: How to Break the Limits One day surgery for endovascular repair: basic requirements and patientâ&#x20AC;&#x2122;s selection. US experience. Peter Schneider

Kaiser Foundation Hospital, Honolulu Hawaii, USA INTRODUCTION Consistent with further development of the endovascular revolution and the promulgation of minimally invasive techniques is the growing availability and popularity of one-day surgery. The advantages of oneday surgery include increased patient comfort, more convenience, and savings on hospital-based resources. The challenge is to make this process safe and efficient. The purpose of the talk is to review the rationale, data, requirements and patient selection for one-day surgery. DATA AND DISCUSSION One-day surgery is increasing significantly in the US. Typically, any procedure that can be safely converted to an outpatient procedure or a non-hospital based procedure is included in consideration. Diagnostic arteriograms, aortoiliac interventions, infrainguinal interventions, dialysis procedures, catheter-based embolizations, and venous procedures should be included. We have not performed carotid interventions on a one-day basis and continue to believe that blood pressure control and cardiac monitoring is essential. EVAR would be possible as an outpatient procedure but we have not yet done this. Among patients with CLI, it is typically the foot that necessitates the hospital stay. Among CLI patients with rest pain or stable, small areas of ulceration or gangrene, one-day procedures are performed. Some guidelines include the following. The access must be perfect in every case. We routinely use duplex to guide the needle into the artery at the site of least disease on the femoral artery. We use a closure device in most cases. After the case, the patient must stay at least 4 hours. A plan should be made with indications for converting the patient to an overnight stay based upon certain factors; elevated creatinine, pain, bleeding or hematoma, nausea, or blood pressure or hear rhythm problems. The follow up plan must be clear. We routinely call the patient on the following day to check up. CONCLUSION One-day surgery is emerging as a reasonable option for most endovascular procedures. Patient safety is related primarily to a secure access site.

Challenges in Lower Limb Endovascular Repair: How to Break the Limits Tibial arteries repair: when and how Peter Schneider

Kaiser Foundation Hospital, Honolulu Hawaii, USA INTRODUCTION Endovascular intervention or open bypass surgery can be used to heal critical limb ischemia in many patients. We are still learning which of these might offer the better results in each patient. However, the strategy used for bypass and that for endovascular treatment are different. DATA AND DISCUSSION Bypass for revascularization of critical limb ischemia (CLI) depends upon the presence of inflow, an adequate target vessel, and the availability of conduit. Endovascular treatment of CLI depends upon the anatomy of occlusive disease, the degree of foot damage, whether the correct angiosome can be reperfused, and several other factors. The open question is whether an endovascular approach can provide adequate revascularization given the highly varied array of disease patterns and patient factors that present. The clinical results from endovascular techniques, such as freedom from amputation, are typically better than anatomic results like patency. Limb salvage with intervention is often reported as 70-90% at one year. Therefore, distinguishing a difference requires large studies to adequately power the statistical analysis. Patients with Rutherford 4, 5, and 6, respectively, require a different approach. Sometimes simple and straight-forward interventions can reverse rest pain. Rest pain is often a result of multilevel disease. One of the strategies in patients with rest pain is not to intervene below the knee if there is an above knee lesion to treat. The metabolic requirements of healing exceed those of maintenance and the threshold pressure for healing gangrene is higher than that for rest pain (ankle pressures of 70mmHg vs. 50 mm Hg; or toe pressures of 50 vs. 30) Technical success rates for endovascular interventions in the management of severe tissue loss are quite good, but clinical success rates are lower. Exposure of vital foot or ankle structures or a heel gangrene and poor pedal runoff are the most challenging factors. Often in diabetics and renal failure patients, the pedal blood supply is compartmentalized as the various angiosomes do not collateralize well. In this situation, in-line flow to the foot may not directly perfuse the correct angiosome. Occluded tibial segments can usually be recanalized as long as there is ample patent outflow. While treating the proximal end of the tibial, avoid damage to other tibial vessels. Buddy wires can be used in complex situations, and sometimes “kissing” balloons are necessary in the proximal tibial vessels. Re-entry from the subintimal plane is easier in the tibial arteries than in the popliteal or tibioperoneal trunk (which is often heavily calcified). The arteries are smaller and straighter and with fewer branches and the intima in the patent segments tends to be thin. Open more than one vessel if possible any time the patient has large ulcers or gangrene. Endoluminal solutions do not seem to work very well for Rutherford 6. This may be because many tibial interventions do not provide the supraphysiolic levels of blood flow required to heal major tissue loss. Angioplasty balloons have become so low in profile that many operators are using the balloon angioplasty catheter as a recanalization catheter for tibial occlusions. If more than one balloon inflation is required, we recommend doing the more distal inflation first in a long lesion since the balloon’s profile changes significantly after the first inflation and may not be able to be subsequently advanced. Choose a single balloon that exceeds the length of the lesion, if possible, in preparation for a single site of inflation. A single inflation at the desired pressure is performed and then maintained for 3 minutes. A slow, deliberate, extended balloon inflation in only one location offers the best chance of avoiding dissection. If a significant dissection or an occlusion is present, repeat the angioplasty to slightly higher pressure. Stents are used selectively. If the dissection is not improved. CONCLUSION Success with tibial angioplasty for CLI can be enhanced with a thorough understanding of tibial disease patterns and treatment techniques. Patients with multilevel disease and Rutherford 4 or 5 ischemic changes can be treated with PTA with great success, especially if the correct angiosome can be revascularized. Patients with significant tissue loss in whom you can’t open a direct line to the correct pedal angiosome should be considered for bypass unless there are confounding surgical risks. 17

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Challenges in Lower Limb Endovascular Repair: How to Break the Limits Bypass in the leg after failed endo repair. Do the results compare to first line bypass? Julien Sfeir

Lebanese University Hospital, Geitaoui, Beirut, Lebanon OBJECTIVE All recent data suggest that percutaneous transluminal angioplasty (PTA) may be appropriate primary therapy for critical limb ischemia (CLI) even in infrapopliteal lesions. In our practice and in selected patients and depending on Lesions types, comorbidities and operative risk, we are treating patients with CLI by endovascular approach. Between 2011 and 2015 and in 24 high risk patients in whom primary PTA was the selected treatment, a conversion to distal Bypass surgery was done due to a failure of PTA and after having complete consent from the patients. METHODS Between January 2011 and January 2015, 24 high risk patients (Ejection fraction varied between 30% and 40%, severe COPD, renal impairment) selected for primary PTA, were operated for distal Bypass for CLI. Conversion to Bypass was due to a failure of recanalization of the lesion and to a complication of the procedure like extensive dissection or arterial rupture... The median age was 71 years, All patients were diabetic, Two patients had severe renal impairment under hemodialysis, five patients suffered from COPD. The male over female ratio was 19 men versus 5 women. Operations were done under general, regional or locoregional anesthesia. RESULTS 24 distal Bypass were done divided as follows: 11 in situ Bypass, and 13 by inverted GSV Bypass (11 to Proximal posterior tibialis, 2 to pedial artery, 3 to distal posterior tibialis, 3 to Anterior Tibialis, and 5 to Tibio-Peroneal Trunk). All interventions were done by the same surgical team. The mean operating time was 220 minutes, the mean time for hospital stay was 8 days. Follow up time average was at 18 months. Primary patency at 1 year and at 18 months were respectively 75% and 70%. Secondary patency also at 1 year and 18 months were respectively 82% and 80%. Limb salvage at one year was approximatly 80%. Mortality at 30 days was 12.5% (2 patients died of myocardial infarction and 1 died of respiratory failure following severe pneumonia). At 18 months the survival rate was around 65%. CONCLUSION When primary amputation is the only remaining option and after failed attempts of endovascular revascularization, and even in high risk patients, surgical Bypass must remain an option with a good average of survival, patency rates, and limb salvage.

ortic Occlusive Disease A Sexual dysfunction following aortic repair: do we need a trial? Sergue誰 Malikov, Julien Koenig, Nicla Settembre, Zakaryiae Bouziane Service de Chirurgie Vasculaire, Nancy, France

Sexual function is an important quality of life criterion for patients. Sexual impotence is recognized as a potential consequence of aortoiliac obstructive disease since the description of Leriche syndrome. Later it will be shown that the damage of peri-aortic pelvic plexus during aorto-iliac surgery can lead to both sexual impotence and ejaculation disorders. Besides, several reports have also raised sexual dysfunction issues after treatment by EVAR. Since then, several studies have confirmed these findings, even though recognizing that sexual dysfunction remains multifactorial and poorly understood. The aim of our pilot study was to analyze the frequency of postoperative sexual dysfunction, comparing endovascular and open surgery in aortoiliac disease. To evaluate erectile function, we used SHIM survey (Sexual Health Inventory for Men).The assessment criteria were sexual function changes three months after the intervention: erectile function, ejaculation, frequency of sexual intercourses and overall sexual satisfaction. In this bicentric prospective study 36 patients were enrolled: 16 received endovascular aneurysm exclusion (EVAR) and 20 had an open aortoiliac surgery. RESULTS 58.8% of all patients had impaired erectile function prior to surgery. The comparison of scores before and 3 months after intervention for open aorto iliac surgery showed a deterioration of erectile function in 42.8% of patients, loss of ejaculations in 45% and a decrease of the overall sexual satisfaction in 38.4%. Those disorders are related to sympathetic plexus damage during open surgery. For EVAR, we did not find significant change in erectile function. The frequency of sexual intercourses had a tendency to decrease for all patients 3 months after both treatments. This pilot study confirms the important impact of open aortoiliac surgery on male sexual function. It also shows that treatment with EVAR is a better technique for preserving sexual function. However many questions remain unresolved: the impact of the surgical approach: transperitoneal or retroperitoneal? The side effect of internal iliac arteries embolization on sexual function? Further studies are needed. REFERENCES 1. Jimenez, JC. Sexual dysfunction in men after open or endovascular repair of abdominal aortic aneurysms. Vascular. 2004, Vol. 12(3), 186-191. 2. Rosen, RC. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. International Journal of Impotence Research. 1999, Vol. 11, 319-326 3. Rosen, RC. The International Index of Erectile Function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997, Vol. 49, 822-830. 4. Machleder, HI. Sexual Dysfunction Following Surgical Therapy for Aorto-Iliac Disease. Vasc Endovasc Surg. 1975, Vol. 9(5), 283287. 5. Sabri, S. Sexual function following aorto-iliac reconstruction. Lancet. 1971, Vol. 4(2), 1218-9. 6. VanSchaik, J. Nerve-preserving aorto-iliac reconstruction surgery: anatomical study and surgical approach. J Vasc Surg. 2001, Vol. 33, 983-9. 7. Karkos, CD. Erectile dysfunction after open versus angioplasty aorto-iliac procedures: a questionnaire survey. Vasc Endovasc Surg. 2004, Vol. 38(2), 157-165. 8. Pettersson, M. Prospective follow-up of sexual function after elective repair of abdominal aortic aneurysm using open and endovascular techniques. J Vasc Surg. 2009, Vol. 50, 492-9. 9. Prinssen, M. Sexual dysfunction after conventional and endovascular AAA repair: results of the DREAM trial. J Endovasc Ther. 2004, Vol. 11, 613-620. 10. Lederle, FA. Quality of life, impotence, and activity level in a randomized trial of immediate repair versus surveillance of small abdominal aortic aneurysm. J Vasc Surg. 2003, Vol. 38, 745-52. 11. Nevelsteen, A. Aorto-femoral reconstruction and sexual function: a prospective study. Eur J Vasc Surg. 1990, Vol. 4, 247-251.

Friday January 22

ortic Occlusive Disease A Landscape of error in aortic procedure

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Colin Bicknell

Imperial College London, London, United Kingdom It is well known that a significant number of patients come to harm while in hospital 1. The highest rate of adverse events is in patients undergoing intervention, especially in patients undergoing vascular procedures2. Whilst the outcomes from endovascular techniques are a significant improvement on open surgery in elderly patients with major comorbidity, the potential for error may be increased 3. It is important to map the intra-operative error pattern, determinants of error, and impact on outcomes if improvements in safety are to be made. We have recently completed a multi-centre, observational study where twenty vascular teams in the UK, using structured post-operative debriefs, reported system errors in open and endovascular aortic procedures. In the lead up to the study teams trained in self-reporting of intra-operative errors and the debriefing tool in 88 cases showing a strong correlation between observer and teams for the number and type of errors per procedure. Subsequently, in 185 aortic cases, operating teams self-reported errors (median 3 errors/procedure (interquartile range 2-6)). Fourteen errors directly harmed twelve patients (6.5% of the cohort). There was a wide variety of errors reported, however, most frequently errors related to equipment (unavailability/failure/configuration/desterilization) and most frequent major or harm-producing errors were communication failures. Significant predictors of increased error rate were endovascular procedures, repair of thoracic aneurysms relative to other aortic pathologies and equipment unfamiliarity. Unfamiliarity with equipment was the single factor associated with increased major error rate. This study is important as the errors detected here, which were most often dealt with by expert teams, were related to adverse outcomes. Major intra-operative errors were associated with reoperation, major complications and death. In aortic procedures, there is a wide variety of errors made by specialist vascular teams over and above technical errors that are often the focus of training. This study found that errors are commonly caused by team-working and equipment-related issues, and are directly associated with patient harm in 6.5% of the cohort. There are many avenues for vascular surgeons to improve outcomes. As a priority, multi-disciplinary team-training, leadership development, effective technology utilisation, and new-device accreditation are recommended. REFERENCES 1. Vincent. Understanding and Responding to Adverse Events. N Engl J Med. 2003;348(11):1051–6. 2. Leape LL, Brennan TA, Laird N, Lawthers A, de Leval MR, Barnes BA, et al. THE NATURE OF ADVERSE EVENTS IN HOSPITALIZED PATIENTS Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377–84. 3. Albayati MA, Gohel MS, Patel SR, Riga C V, Cheshire NJW, Bicknell CD. Identification of patient safety improvement targets in successful vascular and endovascular procedures: analysis of 251 hours of complex arterial surgery. Eur J Vasc Endovasc Surg. 2011;41(6):795–802.

Carotid Not all stenosis are at risk of stroke. Which ones should not be missed? Stavros Kakkos1, Andrew Nicolaides2, Ioannis Tsolakis1 1. University of Patras, Patras, Greece 2. Nicosia Medical School, Nicosia, Cyprus

The incidence of stroke in patients with asymptomatic carotid artery stenosis > 60% NASCET, randomized in the medical arm of the ACAS and ACST studies, has been shown to be 2% per year, while in the surgical arm, carotid endarterectomy reduces the risk of stroke to 1% per year. Therefore 100 endarterectomies are needed to prevent one stroke in one year indicating that endarterectomy is generally not cost-effective, even in carefully selected patients like those included in these surgical trials. As a result, carotid endarterectomy is not routinely performed for asymptomatic stenosis is several countries, taking also into account the improving medical treatment regimens. In recent years, effective risk stratification has been made feasible, allowing the vascular surgeon to better select candidates for carotid interventions. Factors associated with a high risk of stroke include clinical, stenosis and plaque characteristics, and evidence of TCD embolisation or brain infarction. Clinical characteristics These include hypertension,1 age > 70,1 history of contralateral neurological symptoms 2, 3 and hypercholesterolaemia.2 Stenosis and plaque characteristics Particularly important in assessing stroke risk, stenosis characteristics include mainly carotid stenosis severity (high stroke rate with 80%-90% or pre-occlusive – 95% – lesions),3, 4 progression of carotid stenosis over time,5 and contralateral carotid artery occlusion.6 Plaque characteristics are also important for risk stratification. These include plaque ulceration on angiography or ultrasound,7 and unstable carotid plaque morphology, on ultrasound or MRI imaging. Several studies have demonstrated the importance of plaque echolucency measures, including visual – subjective – classification (plaque types 1 & 2), a low gray-scale median (GSM), and the presence of a juxtaluminal echolucent (black) area (JBA) or discrete white areas (DWA).3 Embolic signals on Transcranial Doppler (TCD) Asymptomatic embolic signals on TCD have been shown to predict future stroke,8 and when combined with plaque echolucency both were independent predictors of stroke.9 The presence of these two predictors identified a patient group with an 8% annual stroke risk. Brain infarction on CT scanning In a subset of the Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) study, 821 patients had CT brain scans.10 In 146 patients (17.8%), 8 large cortical, 15 small cortical, 72 discrete subcortical, and 51 basal ganglia ipsilateral infarcts were present, which were all considered likely to be embolic and classified as such. During a mean follow-up of 44.6 months, 102 ipsilateral hemispheric neurologic events (amaurosis fugax in 16, 38 transient ischemic attacks [TIAs], and 47 strokes) occurred. In 462 patients with NASCET 60% to 99% stenosis, the cumulative event-free rate at 8 years was 0.81 (2.4% annual event rate) when embolic infarcts were absent and 0.63 (4.6% annual event rate) when present (log-rank P =.032). In 359 patients with <60% stenosis, embolic infarcts were not associated with increased risk (log-rank P = .65). In patients with 60% to 99% stenosis, the cumulative stroke-free rate was 0.92 (1.0% annual stroke rate) when embolic infarcts were absent and 0.71 (3.6% annual stroke rate) when present (log-rank P = .002). In the subgroup of 216 with moderate 60% to 79% stenosis, the cumulative TIA or stroke-free rate in the absence and presence of embolic infarcts was 0.90 (1.3% annual rate) and 0.65 (4.4% annual rate), respectively (log-rank P =.005). The ACSRS study has reported that stenosis severity, the neurological history of the contralateral carotid and also ultrasonic plaque features are independent powerful predictors of plaque instability and future stroke. 4 Such plaque features include the presence and size of a JBA, with a high risk being observed if it exceeds 8mm2, and the presence of DWAs. High risk groups with an annual risk of stroke of 4% to 10%, where intervention should be considered, and a low risk group (<1% annual risk) were identified. The latter 21

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

group can be spared from carotid intervention and efforts can be concentrated to aggressive medical management, investigation for disease in other vascular beds, and patient follow-up. However, the decision to intervene should not be based exclusively on risk stratification, but also on the anatomical characteristics of the stenosis, patient fitness for surgery and expected survival, the perioperative stroke and death rate of the surgeon and patient willingness to take the small short-term risk of surgery for a possible greater long-term benefit. REFERENCES 1. Moore DJ, Miles RD, Gooley NA, Sumner DS. Noninvasive assessment of stroke risk in asymptomatic and nonhemispheric patients with suspected carotid disease. Five-year follow-up of 294 unoperated and 81 operated patients. Ann Surg 1985;202(4):491-504. 2. MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004;363(9420):1491-502. 3. Nicolaides AN, Kakkos SK, Kyriacou E, Griffin M, Sabetai M, Thomas DJ, et al. Asymptomatic internal carotid artery stenosis and cerebrovascular risk stratification. J Vasc Surg 2010;52(6):1486-1496 e1-5. 4. Kakkos SK, Griffin MB, Nicolaides AN, Kyriacou E, Sabetai M, Tegos T, et al. The size of juxtaluminal hypoechoic area in ultrasonic images of asymptomatic carotid plaques predicts the occurrence of stroke. J Vasc Surg 2013;57(3):609-618. 5. Kakkos SK, Nicolaides AN, Charalambous I, Thomas D, Giannopoulos A, Naylor AR, et al. Predictors and clinical significance of progression or regression of asymptomatic carotid stenosis. J Vasc Surg 2014;59(4):956-967 e1. 6. AbuRahma AF, Metz MJ, Robinson PA. Natural history of > or =60% asymptomatic carotid stenosis in patients with contralateral carotid occlusion. Ann Surg 2003;238(4):551-61; discussion 561-2. 7. Handa N, Matsumoto M, Maeda H, Hougaku H, Kamada T. Ischemic stroke events and carotid atherosclerosis. Results of the Osaka Follow-up Study for Ultrasonographic Assessment of Carotid Atherosclerosis (the OSACA Study). Stroke 1995;26(10):1781-6. 8. Markus HS, King A, Shipley M, Topakian R, Cullinane M, Reihill S, et al. Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study. Lancet Neurol 2010;9(7):663-71. 9. Topakian R, King A, Kwon SU, Schaafsma A, Shipley M, Markus HS. Ultrasonic plaque echolucency and emboli signals predict stroke in asymptomatic carotid stenosis. Neurology 2011;77(8):751-8. 10. Kakkos SK, Sabetai M, Tegos T, Stevens J, Thomas D, Griffin M, et al. Silent embolic infarcts on computed tomography brain scans and risk of ipsilateral hemispheric events in patients with asymptomatic internal carotid artery stenosis. J Vasc Surg 2009;49(4):902-9.

Carotid Duel. There is no need for a new trial comparing intervention and medical treatment for carotid stenosis For the motion Réda Hassen-Khodja, Elixène Jean-Baptiste Nice University Hospital, France

The legitimacy to perform carotid endarterectomy (CEA) in patients with asymptomatic carotid stenosis has been firmly established by two well-designed randomized controlled trials, the Asymptomatic Carotid Atherosclerosis Study (ACAS) and the Asymptomatic Carotid Surgery Trial (ACST). Both trials showed, with CEA compared to medical therapy alone, a 50% relative risk reduction in the 5-year risk of stroke from approximately 12% down to 6%. Several recent editorial reports questioned however the persistent validity of these results arguing that improvements in what now constitutes `optimal medical therapy (OMT)’ may have significantly reduced the natural risk of stroke compared to that observed in ACAS and ACST. Proponents of this theory had suggested the planning and launch of new clinical trials aiming to confirm their hypothesis. Some even envisioned to squarely turn down for CEA as much as 85% of patients with asymptomatic carotid stenosis presumably at low risk of stroke based on some fanciful criteria. Data directly evaluating contemporary OMT in patients with known carotid stenosis are sparse, and strategies to identify “high risk of stroke” asymptomatic patients are yet to yield any great advance. Proponents of the OMT as stand-alone treatment usually make a loo k for incriminating evidence without any equipoise. Most of their argumentation comes from a biased meta-analysis of disparate studies by Abbott et al. This meta-analysis has merged studies in patients harboring non-surgical mild and moderate (50-69% ECST) stenosis by duplex scan with those on severe (70-99% NASCET-criteria defined) carotid stenosis, with consequent dilution of the natural stroke risk in the arm under medical therapy alone. Moreover, results of the medical arm of the more contemporary ACST trial, with 80% of patients taking OMT on the later years, were not included in this meta-analysis. Ten-year follow-up data in the ACST trial demonstrated however a sustained benefit for CEA over OMT. Interestingly, both the single-center Oxford Vascular study by the Abbott group and the international multicenter Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) trial included in the meta-analysis, have reported increased risk of stroke with increasing grade of carotid stenosis. The level reached under medical therapy alone was at least similar, in patients with “surgical grade stenosis”, to the natural stroke risk reported in ACAS and ACST at variance with the Abbott meta-analysis conclusions. Moreover, convincing data exist showing that OMT can neither eliminate reliably carotid plaque progression nor stroke risk. Similarly, the cost-saving argumentation, commonly put forward, does not survive scrutiny more. The long-term associated serious disability and the cumulative cost of caring for patients with stroke are typically overlooked, while even a modest reduction in stroke risk would be in that regard cost effective. The economic burden of OMT alone should also include the cost of surveillance with necessity for multiple surveillance modalities and some new costly assessment tools, beyond the current uncertainty surrounding their usefulness and the frequency with which they should be updated. For all these reasons, a new trial, besides the several currently ongoing ones, will merely be a loss of time and money.

Friday January 22

arotid C ACST 2: 2000 patients randomized. What are the lessons?

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Alison Halliday

University of Oxford, Oxford, United Kingdom ACST-2 is an international randomised controlled trial comparing short and long term stroke prevention in patients randomised between surgery and stenting. Patients in ACST-2 have had no symptoms for at least 6 months in the carotid artery under consideration but they may have had previous symptoms or may have silent brain infarction. Over 2000 patients have been randomised out of 3600 planned, completion being December 2019. At this stage it is possible to describe the randomisation characteristics and risk factors of 2000 patients, together with the devices used and the blinded 30-day outcomes to date.

Carotid Is plaque morphology a predictor of neurological complication after CAS or CEA? Wesley Moore

Los Angeles, USA CREST demonstrated a higher periprocedural stroke and death (S+D) rate among patients randomized to CAS than CEA. In our current study, we examined the angiographic characteristics of the CREST patient population in order to determine if certain plaque characteristics could explain a higher risk for CAS compared to CEA. METHODS Patient and arterial characteristics were assessed as effect modifiers of the CAS-CEA treatment difference in 2,502 patients by the addition of factor-by-treatment interaction terms to a logistic regression model. RESULTS Lesion length and lesions that were not contiguous or were sequential and non-contiguous extending remote from the carotid bulb were identified as influencing the CAS-to-CEA S+D treatment difference. The mean lesion length in our patient population was 12.85mm. For those with longer lesion length (≥12.85 mm) the risk of CAS was higher than CEA (OR = 3.45; 95% CI: 1.21 – 9.83). Among patients with sequential or remote lesions extending beyond the carotid bulb, the risk for S+D was higher for CAS relative to CEA (OR = 9.21; 95% CI: 1.23 – 68.94). For the 37% of patients with lesions that were both short and contiguous, the odds of S+D in those treated with CAS was nonsigificantly 28% lower than for CEA (OR = 0.72; 95% CI: 0.21 – 2.46). CONCLUSION The higher S+D risk for those treated with CAS appears to be largely isolated to those with longer lesion length and/or those with sequential and remote lesions. In the absence of those lesion characteristics, CAS appears to be as safe as CEA with regard to periprocedural risk of S+D.

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Carotid Some tricks to improve CAS results. The use of proximal protection and mesh covered stents Peter Schneider

Kaiser Foundation Hospital, Honolulu Hawaii, USA INTRODUCTION Both carotid stenting (CAS) and carotid endarterectomy (CEA) provide long-term protection against stroke due to carotid disease, beyond the perioperative period. Currently CAS is used mainly among selected patients that are at high risk for CEA. This is because several randomized trials have shown that there is a higher risk of perioperative stroke, especially minor stroke, with CAS. The only way that CAS could be considered more broadly applicable is if the causes of CAS-related perioperative stroke could be addressed. In this talk, we will review two options in development for reducing the stroke risk of CAS; proximal protection and mesh covered stents. DATA AND DISCUSSION The main difference between CAS and CEA in the CREST Trial, ICSS, SPACE, and EVA-3S has been a higher rate of perioperative stroke with CAS. Stroke risk could be reduced with more complete cerebral protection. Studies with transfemoral, filtered CAS show that there is an increase in DW-MRI hits on immediate postop brain scans. Using detection of subclinical ischemic lesions as a surrogate for neurological damage, it has become clear that proximal protection offers more complete cerebral protection. This has been manifested clinically with use of the MOMA device (Armour Study) and the Parodi reversed flow device (Empire Study; Parodi device not currently available) or a direct transcervical approach to the neck with reversal of flow into a vein and proximal clamping of the artery. In addition, somewhere between one-third and half of perioperative stroke events occur between 24 hours and 30 days. This is long after the protection device has been removed, suggesting that the stent is not adequate by itself to scaffold and contain the lesion and that particulate matter can escape through the open cells of the stent. Mesh covered stents are in development using PET, PTFE, or Nitinol mesh and clinical studies are underway to define any potential advantages of this approach. CONCLUSION CAS must be made safer in the perioperative period to be more clinically useful. Some advancements that may assist in this endeavor include proximal protection and mesh covered stents.

Carotid Some tricks to improve CAS results Can CAS Improve Cognitive Function? Christos Liapis, Constantine Antonopoulos

University of Athens, Medical School, Athens, Greece Carotid artery stenting (CAS) has been proposed as an alternative procedure to carotid endarterectomy (CEA) for reducing the risk of stroke, at least in some subgroups of patients with significant extracranial carotid stenosis. Cognitive function is being increasingly recognized as an important outcome measure that affects patientâ&#x20AC;&#x2122;s well-being and functional status. However, the effect of CAS on neurocognitive functions in patients with extracranial carotid disease is still controversial. Several reports using transcranial Doppler have documented a significant number of microemboli during CAS 1, whereas diffusion-weighted magnetic resonance imaging (DW MRI) has revealed that a large proportion of patients may develop new brain lesions 2. Although most of the identified new cerebral infarcts after CAS are subclinical, there are concerns that these lesions might be associated with subtle long-term neurologic changes and deterioration of cognition 3. On the other hand, some studies, including a recent randomized control study (RCT) 4, reported an overall improvement in cognitive function after CAS. The controversy has been intense and prolonged, because many studies have evidenced that the procedure-associated microembolization may be associated with poor cognitive function and memory decline after CAS 1, but, on the contrary, others have evidenced an improve in cognitive function as a result of normalization of blood flow, especially among the elderly with severe carotid stenosis 5. As a consequence, it is difficult to predict whether CAS will ultimately result in improvement or worsening of cognitive function. A subgroup analysis of patients of the International Carotid Stenting Study (ICSS) undergoing neuropsychological examination showed that differences between CAS and CEA on cognition at 6 months after revascularization were small and not statistically relevant, despite new ischemic lesions found twice as often after CAS than after CEA 6. Chen et al. demonstrated that successful intervention increased cerebral perfusion and improved neurocognitive function in patients with asymptomatic ICA stenosis 7. Furthermore, a prospective study analyzed neuropsychological outcomes with a multiple domains test battery and DW MRI lesions evidenced that none of the cognitive domains decreased significantly at 72 hours after CAS and the overall cognitive performance was not significantly different between patients with and without new diffusion-weighted MRI lesions 8. As a result, due to the fact that current literature provides conflicting evidence concerning the effect of CAS upon cognitive function, a meta-analysis comprising of all available data may provide with additional information. In order to delineate the influence of CAS upon cognition, our recent meta-analysis 9 included all studies evaluating various domains of cognitive function before and after CAS, namely: a) global cognition using Mini-Mental State Examination (MMSE) and Rey Auditory Verbal Learning Test (RAVLT), b) executive function using Trail Making Test (TMT) A or Color Trails Test (CTT) A and TMT B or CTT B, c) language ability using Boston Naming Test (BNT), d) memory, e) attention/psychomotor speed and f) functional ability, using various cognitive tests. Sixteen studies were eligible, including a total of 626 CAS patients. A statistically significant improvement of global cognition was detected with MMSE, but not with RAVLT. Significant improvement of memory and attention/psychomotor speed was also detected, whereas no statistically significant effect on executive function (TMTA/CTTA and TMTB/CTTB), language ability (BNT) and functional ability was observed. The clinical assessment of cognitive function is usually difficult to perform. Many approaches regarding the timing of assessment after CAS and the type of tests have been used for that purpose. There are also various possible confounding factors such as age, symptomatic status, contralateral carotid or vertebral artery disease, severity of carotid stenosis, the use of protection devices and others. The results of our recently published meta-analysis suggested that CAS may be associated with improvement, at least in certain do27

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

mains of cognitive function. Given this background, it might be possible that the investigation of cognitive function with additional studies, evaluating the long-term effect of CAS in larger groups of patients may increase our understanding regarding the functional impact of extracranial carotid disease and may refine our selection criteria for revascularization. REFERENCES 1. Zhou W, Hitchner E, Gillis K, Sun L, Floyd R, Lane B, Rosen A. Prospective neurocognitive evaluation of patients undergoing carotid interventions. J Vasc Surg. 2012;56:1571-1578 2. Tulip HH, Rosero EB, Higuera AJ, Ilarraza A, Valentine RJ, Timaran CH. Cerebral embolization in asymptomatic versus symptomatic patients after carotid stenting. J Vasc Surg. 2012;56:1579-1584; discussion 1584 3. Gress DR. The problem with asymptomatic cerebral embolic complications in vascular procedures: What if they are not asymptomatic? Journal of the American College of Cardiology. 2012;60:1614-1616 4. Kougias P, Collins R, Pastorek N, Sharath S, Barshes NR, McCulloch K, Pisimisis G, Berger DH. Comparison of domain-specific cognitive function after carotid endarterectomy and stenting. J Vasc Surg. 2015;62:355-362 5. Tavares A, Caldas JG, Castro CC, Puglia P, Jr., Frudit ME, Barbosa LA. Changes in perfusion-weighted magnetic resonance imaging after carotid angioplasty with stent. Interv Neuroradiol. 2010;16:161-169 6. Altinbas A, van Zandvoort MJ, van den Berg E, Jongen LM, Algra A, Moll FL, Nederkoorn PJ, Mali WP, Bonati LH, Brown MM, Kappelle LJ, van der Worp HB. Cognition after carotid endarterectomy or stenting: A randomized comparison. Neurology. 2011;77:1084-1090 7. Chen YH, Lin MS, Lee JK, Chao CL, Tang SC, Chao CC, Chiu MJ, Wu YW, Chen YF, Shih TF, Kao HL. Carotid stenting improves cognitive function in asymptomatic cerebral ischemia. Int J Cardiol. 2012;157:104-107 8. Wasser K, Pilgram-Pastor SM, Schnaudigel S, Stojanovic T, Schmidt H, Knauf J, Groschel K, Knauth M, Hildebrandt H, Kastrup A. New brain lesions after carotid revascularization are not associated with cognitive performance. J Vasc Surg. 2011;53:61-70 9. Antonopoulos CN, Kakisis JD, Sfyroeras GS, Moulakakis KG, Kallinis A, Giannakopoulos T, Liapis CD. The impact of carotid artery stenting on cognitive function in patients with extracranial carotid artery stenosis. Annals of vascular surgery. 2015;29:457-469

Flash news. The Latest of EVAR Technology PTFe grafts

Marc Van Sambeek

Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands EVAR is a minimally invasive procedure designed to exclude an aneurysmal segment of the aorta from blood circulation. The EVAR procedure involves delivery of a stent graft compressed onto a catheter to an aneurysmal segment of the aorta from a remote access site, generally the femoral artery. Since its introduction, EVAR for the treatment of AAA has shown a lower operative and aneurysm related mortality in numerous clinical trials when compared with open surgical repair. Deviation from the required guidelines for abdominal aortic stent grafts has potentially negative clinical impacts. Analysis demonstrated that patients treated with challenging neck anatomy were at significantly increased risk for operative morbidity, additional adjunctive procedures at treatment, Type I endoleak at one year, and aneurysm related mortality at one year. In the context of these limitations of currently available endovascular stent grafts, interventionists have developed off-label endovascular techniques which can extend the potential pool of patients eligible for endovascular treatment, including patients with infrarenal AAA who do not have adequate anatomy to receive an endovascular graft. The continued off-label use of endovascular stent grafts to treat patient populations with challenging anatomy suggests a need for improved endovascular stent grafts so that these patients can be treated safely and effectively according to the manufacturer’s indications provided in the instructions for use. The GORE® EXCLUDER® Conformable AAA Endoprosthesis (CEXC Device) provides endovascular treatment of infrarenal AAA. The CEXC Device is a self-expanding stent-graft that is compressed onto a catheter which is used to advance and deploy the stent-graft at the target location. The delivery system includes a modality that facilitates the angulation of the delivery catheter in order to obtain a better alignment of the endograft in an angulated neck. The CEXC Device provides endovascular treatment of infrarenal AAA. The CEXC Device consists of two modular components: the Conformable EXCLUDER Trunk-Ipsilateral Leg Component (CEXC Trunk-Ipsi) and the Conformable EXCLUDER Aortic Extender Component (CEXC AE). The CEXC Trunk-Ipsi is designed to be used with the commercially available GORE® EXCLUDER® Contralateral Leg Endoprosthesis (EXC Contralateral Leg) and the GORE® EXCLUDER® Iliac Extender Endoprosthesis (EXC Iliac Extender), which provide additional extension and seal into the common iliac arteries. For all CEXC and EXC Device components, the graft material is expanded polytetrafluoroethylene (ePTFE) and fluorinated ethylene propylene (FEP), with an external nitinol (nickel titanium alloy) stent frame that supports the graft material. All components are constrained by an ePTFE / FEP constraining sleeve on their respective delivery catheters. Deployment is initiated by pulling a deployment line, which is attached to a knob on the delivery system handle, which opens the sleeve and allows the stentgraft to self-expand in situ. A clinical study will assess the safety and effectiveness of the GORE EXCLUDER Conformable AAA Endoprosthesis in patients who meet the IFU anatomic criteria and in patients with challenging anatomic presentation outside IFU. Between 10 and 15 clinical investigative Sites will enroll a total of 150 subjects to allow for the broad range of aortic necks lengths and aortic neck angulations to be in the study. CE mark for the GORE® EXCLUDER® Conformable AAA Endoprosthesis (CEXC Device) is anticipated in Q4 2015. Preliminary results of the first implantation will be presented.

Friday January 22

Flash news. The Latest of EVAR Technology Latest flexible graft design and early results

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Michel Bartoli

Aix-Marseille université, APHM, Hôpital de la Timone, Service de Chirurgie Vasculaire, Marseille, France The Zenith Alpha Endovascular Graft system was developed to meet the challenges of aortic disease. The Zenith Alpha Endovascular Graft system have been engineered for an easy repair that doesn’t compromise precision or control. Zenith Alpha Abdominal and Zenith Alpha Thoracic have been design to provide a durable repair that helps physicians to manage disease progression and give more patients successful long-term outcomes. 16F to 20F delivery system for Zenith Alpha Thoracic and 16F delivery system for Zenith Alpha Abdominal – An extensive range of sizes to suit many patient types. In 2015, to study report the initial results with those new devices, and both conclude to an expanded endovascular aortic repair applicability in patients with smaller access vessels 1, 2 REFERENCES 1. Illig KA, Ohki T, Hughes GC, et al. One-year outcomes from the international multicenter study of the Zenith Alpha Thoracic Endovascular Graft for thoracic endovascular repair. J Vasc Surg. 2015. 2. Torsello GF, Austermann M, Van Aken HK, et al. Initial clinical experience with the zenith alpha stent-graft. J Endovasc Ther. 2015;22:153-9.

Ruptured AAA Duel. Is the debate about ruptured aneurysms treatment over? Open surgery is as good as endo: lessons from improve trial Janet Powell

Imperial College, London, United Kingdom

Friday January 22

With the perspective of entire populations, for those who cannot reach a specialist endovascular centre, open surgery remains a better option than almost certain death for many patients with ruptured abdominal aortic aneurysms. Approximately one quarter of the case load will have juxta-renal aneurysms which cannot be treated by standard endovascular repair: there is no evidence as to whether these patients do better by transfer to a specialist endovascular centre (with attendant time delays and family distress) or with open surgery at the centre where they have been assessed. Unless there is such evidence, a place remains for open surgery in the management of ruptured AAA.

Ruptured AAA Open repair for rupture: recent tricks which have improved the results

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Adel Khayati, Jihed Laribi, Sana Chatti, Jalel Ziadi, Karim Kaouel, Imed Khanfir Department of cardio-vascular surgery. La Rabta Hospital, Tunis, Tunisia

Open repair remains the gold standard in the management of ruptured aortic aneurysms. But, it carries a high operative risk. The aim of this presentation is to try to define predictive factors influencing the outcome of surgery and to highlight on measures that may be of good prognosis. The authors give details of their recent experience with open repair in AAA (abdominal aortic aneurysms) rupture including a cohort of 62 patients. Shock sydrome occurs in 23 (37%) and pre-hospital ressucited cardiac arrest in 6 (10%). There are 7 (11%) in theatre preprocedure deaths. Intraperitoneal bleeding was founf in 14 (22%) and in 4 patients (6.5%) fistula into neighbour structure (vena cava or bowels) was diagnosed. Routinely Dacron graft was used except in one case (graft from both superficial veins). Everytime, at least one internal iliac artery was spared. Post operative course was dominated mainly by respiratory and renal disturbances. Twelve patients (19%) deceased after surgery giving an overall mortality of 19 (30%). in multivariate analysis the following factors appear to worse the prognosis: chronic bronchopneumopathy, shock sydrome and metabolic acidosis. In the discussion and after litterature review some recommandations are delivered in order to improve the results. We conclude that open repair in abdominal aortic aneurysms rupture is, probaly, still the best option.

How Can We Improve the Results of EVAR The dead space in AAA sac is the ultimate enemy EVAS: any doubt left after more than 300 procedures and the European register? Ian Loftus

St Georges Vascular Institute, London, United Kingdom

METHODS One hundred and five patients were treated with EVAS between March 2013 and November 2014. Prospective data were recorded on consecutive patients receiving EVAS. Data included demographics, preoperative aneurysm morphology and 30-day outcomes, including rates of endoleak, limb occlusion, reintervention and death. Post-operative imaging consisted of duplex ultrasound and computed tomographic angiography. RESULTS The mean age of the cohort was 76 ± 8 years and 12% were female. Adverse neck morphology was present in 72 (69%) patients, including aneurysm neck length <10mm (20%), neck diameter >32mm (18%), β-angulation >60° (21%) and conical aneurysm neck (51%). There was one death within 30 days. The incidence of type I endoleak within 30-days was 4% (n=4); all were treated successfully with transcatheter embolization. All four proximal endoleaks were associated with technical issues that resulted in procedure refinement, and all were in patients with adverse proximal aortic necks. The persistent Type 1 endoleak rate at 30-days was 0% and there were no Type 2 or Type 3 endoleaks. Angioplasty and adjunctive stenting were performed for postoperative limb stenosis in three patients (3%). CONCLUSIONS EVAS is associated with good early and mid term outcomes despite the necessity of procedural evolution in the early adoption of this technique. The EVAS Global registry is demonstrating similar outcomes. EVAS appears to be applicable to patients with challenging aortic morphology and endoleak rates should reduce with procedural experience. The utility of EVAS will be defined by the durability of the device in long-term follow-up, although the absence of Type 2 endoleaks is encouraging.

REFERENCES 1. Brownrigg JR, de Bruin JL, Rossi L, Karthikesalingam A, Patterson B, Holt PJ, Hinchliffe RH, Morgan R, Loftus IM, Thompson MM. Endovascular aneurysm sealing for infrarenal abdominal aortic aneurysms: 30-day outcomes of 105 patients in a single centre. Eur J Vasc Endovasc Surg 2015;50(2):157-64. 2. Böckler D, Holden A, Thompson M, Hayes P, Krievins D, de Vries JP, Reijnen MM. Multicenter Nellix EndoVascular Aneurysm Sealing system experience in aneurysm sac sealing. J Vasc Surg 2015;62(2):290-8.

Friday January 22

INTRODUCTION Endovascular aneurysm sealing (EVAS) has been proposed as a novel alternative to endovascular aneurysm repair (EVAR) in patients with infra-renal abdominal aortic aneurysms (AAA). The early clinical experience, technical refinements and learning curve of EVAS in the treatment of AAA in a single institutional experience of 105 patients with mid-term follow up, will be presented and put into the context of the global EVAS Registry of 300 cases1,2.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

How Can We Improve the Results of EVAR How to improve results and cost of EVAR Can we reduce costs and optimize EVAR procedures with Patient Rehearsal Simulators? Nicla Settembre1, Jean-NoĂŤl Albertini2, Zakaryae Bouziane1, Jean-Pierre Favre2, Serguei Malikov1 1. Service de chirurgie vasculaire, CHU Nancy Brabois, France 2. Service de chirurgie vasculaire, CHU Saint-Etienne, France

INTRODUCTION Endovascular procedures simulator technologies have greatly evolved over the last few years. Today, a wide range of patient specific peripheral procedures may be simulated including EVAR. These technologies have the potential not only to enhance training processes but also to reduce intraoperative complications. The aim of this study was to present our preliminary experience in patient-specific rehearsal of EVAR procedures. MATERIALS AND METHODS During the year 2014, eight patients were included in the study. Three Symbionix Angio Mentor Ultimate simulators were loaded with Gore, Vascutek and Medtronic endograft software. After loading pre-operative CT-scan DICOM images, patient specific rehearsal procedures were performed by three categories of operators (beginners, intermediates and experienced). Evaluation criteria were: procedure time, fluoroscopy time, contrast load, choice and handling of wires, catheters and stent-grafts, intraoperative complications (endoleak and coverage of side branches). RESULTS A significant improvement of evaluation criteria was observed for all operators throughout the study period. Various intraoperative strategies were used only by experienced and intermediate operators. CONCLUSION This preliminary study shows that EVAR patient specific rehearsal procedures using simulators have to potential to decrease procedure and fluoroscopy time, contrast load as well as the incidence of intraoperative complications. Randomized studies are currently underway in order to assess the impact of this strategy on patient postoperative outcome.

How Can We Improve the Results of EVAR How to improve results and cost of EVAR Hypnosis for EVAR: it works! Can you believe it? Asmaa Khaled, Velislav Slavov, Issam Benayed, Ayman Nasr, Lucie Derycke, Bachir Benamara, Youssef Touma, Hakim Haouache, Jean Pierre Becquemin, Gilles Dhonneur

OBJECTIVES The treatment of aneurysms of the abdominal aorta by endoprosthesis (stent) using a percutaneous strategy is optimal and safe therapeutic alternative to open surgery for the most fragile patients. Nevertheless such interventions are often performed under general anesthesia with systemic consequences. In our center, the anesthetic strategy has evolved over the past four years toward the use of medical hypnosis in the operating room. We conducted a study to assess the feasibility of medical hypnosis (MH) associated with local anesthesia of scarpas in this indication and compare its safety and efficacy with that of general anesthesia (GA). METHODS Aortic endoprosthesis procedures were allocated into 2 groups (Group 1: GA and Group 2: MH) mainly depended on the availability of an anesthesiologist experienced in medical hypnosis attending the operating room Based upon anticipated operating table of elective procedures, we managed to constitute 2 equal groups, including all consecutive patients during the study period. The following outcome parameters were compared between groups: success of the procedure, pain and comfort, t duration of the procedure, need for vasopressors introduction and dosage. RESULTS 52 patients were allocated into each of two groups. Patient characteristics were comparable in terms of risk factors and ASA scores. All aortic endoprosthesis were successfully done. None of the patients of MH requested conversion to general anesthesia. In MH, 23 patients were placed standard endoprosthesis but three complex cases included fenestrated endoprosthesis placement (n=2) and abdominal aneurysm ruptured in its initial phase (n=1). The durations of interventions, comfort and pain scores were comparable in both groups.. Five patients of MH group received vasopressors versus 20 patients in the GA group. When requested the total dosage of epinephrine was significantly lower in the MH group (number), although it remained low in both groups. CONCLUSION To our knowledge, this is the first study of this magnitude evaluating MH for acts of vascular surgery including endovascular treatment of aneurysms. MH promotes comfort and optimal interventional conditions appear to be safe and reliable. It allows preventing and reducing the use of vasopressors. Moreover, we observed that MH improved patient’s operating experience as well as both that of the medical and paramedical team in the operating room. A randomized study is now ongoing to consolidate these feasibility results.

Friday January 22

Department of Anesthesiology and Intensive Care Medicine, Henri Mondor University Hospital of Paris, Créteil, France Department of Vascular Surgery, Henri Mondor University Hospital of Paris, Créteil, France

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

How Can We Improve the Results of EVAR How to improve results and cost of EVAR Fascia suture is cheaper than preclosing device but is it as safe? Thomas Larzon Orebro, Sweden

OBJECTIVES To investigate whether the fascia suture technique (FST) can reduce access closure time and procedural costs in comparison to the Prostar technique (Prostar) in patients undergoing endovascular aortic repair and to evaluate short- and mid-term outcome of both techniques. DESIGN Randomised two-centre trial MATERIALS AND METHODS One hundred patients were randomised between June 2006 and December 2009 to access closure by either FST or Prostar. Primary endpoint was access closure time. Secondary outcome measures included access related costs and evaluation of the short- and mid-term complications. Evaluation was performed per- and postoperatively, at discharge, at 30 days and at 6 months follow-up. RESULTS Median access closure time was 12.4 minutes for FST and 19.9 minutes for Prostar, p<0.001. Prostar required 54 % longer procedure time than FST, mean ratio 1.54 (95 % CI 1.25 – 1.90, p<0.001) according to regression analysis. Adjusted for operator experience the mean ratio was 1.30 (95 % CI 1.09 – 1.55, p=0.005) and for patient body mass index (BMI) the mean ratio was 1.59 (95 % CI 1.28 – 1.96, p<0.001). The technical failure rate for operators at proficiency level was 5% (2/40) compared to 28% (17/59) for those at basic level, (p=0.003). The technical failure rate for operators at proficiency level was 4% (1/26) for FST and 7% (1/14) for Prostar, p=1.00, while corresponding rates for those at basic level were 27% (6/22) for FST and 30% (11/37) for Prostar, p=0.84. There was a significant difference in cost in favour of FST with a median difference of Euro 800 (95 % CI 710-927, p<0.001). CONCLUSIONS In aortic endovascular repair FST is a faster and cheaper technique in comparison to the Prostar technique.

How Can We Improve the Results of EVAR How to improve results and cost of EVAR Why stopping the follow up put your patients at risk Michel Bartoli

The aim of the surveillance after EVAR is to detect asymptomatic issues on the stentgraft to avoid potentially severe consequence such as aneurysm rupture or limb ischemia. All the study have demonstrated the need for this surveillance even with the last stentgraft generation. The results of the principal randomized trials have demonstrated the short term benefits of endovascular surgery over conventional surgery 1, 2. However, no difference were seen in total mortality or aneurysm related mortality in the long term, thus stopping the EVAR follow up we might observe an increased late mortality after this technique leading to make much more questionable the use of this technique to treat AAA. Some authors advocate to reduce or even to stop the follow-up in patients with initial good evolution after EVAR, in general this good evolution is defined as a significant diameter reduction of the sac. In our experience with have shown that exclusion of AAA with a diameter reduction of at least 10 mm significantly reduces the rate of secondary procedures and AAA rupture, however, in those patients we observed that even after an important diameter reduction the development of a very late type 1 endoleak is still possible even 10 years after graft implantation and lead to a fast AAA growth with a concomitant risk of rupture 3. In our mind aneurysmal disease progression plays an important role in the durability of endovascular therapy in the long term. Finally the recommendation from the North American and European society of vascular surgery based largely on expert opinion and high-quality evidence still recommend a lifelong surveillance after EVAR. To take into account the low rate of secondary procedure in patient with aneurysm sac decrease after EVAR color duplex ultrasonography is suggested as an alternative to CT imaging for annual postoperative surveillance 4. REFERENCES 1. Greenhalgh RM, Brown LC, Kwong GP, et al. 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;364:843-8. 2. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004;351:1607-18. 3. Soler RJ, Bartoli MA, Mancini J, et al. Aneurysm sac shrinkage after endovascular repair: predictive factors and long-term follow-up. Ann Vasc Surg. 2015;29:770-9. 4. Chaikof EL, Brewster DC, Dalman RL, et al. SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: executive summary. J Vasc Surg. 2009;50:880-96.

Friday January 22

Aix-Marseille universit茅, APHM, H么pital de la Timone, Service de Chirurgie Vasculaire, Marseille, France

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

How Can We Improve the Results of EVAR How to improve results and cost of EVAR What are the specific requirements and results of EVAR in Japanese patients? Kimihiro Komori

Division of Vascular Surgery, Department of Surgery, Nagoya University Graduates School of Medicine, Nagoya, Japan An industrially produced stent graft for abdominal aortic aneurysm repair was first approved by the Japanese Ministry of Health, Labour and Welfare (MHLW) in Japan in July 2006. The JACSM (Japanese Committee for Stentgraft Management) was established with the aim of ensuring the safe and proper reach of commercial stent grafts following their regulatory approval. Based on the practice standards developed by JACSM, the status of practising institutions, practising surgeons, and supervising surgeons were determined by JACSM and the all results of follow-up surveys were registered. After nine years, more than half of abdominal aortic aneurysms were treated. By August 2015, 534 institutions had met the practice standards. The number of practising surgeons has reached 1,192, and the number of supervising surgeons has reached 700. Practising institutions are obligated to report treatment results for individual cases in a case-registry system via the internet. There were 46,692 registered cases by August 2015. We are now reporting the outcomes of the 3,250 cases registered from July 2006 to June 2008. During the same period, EVAR was performed in 3,322 cases. Thus, the patient registration rate was 97%. The subjects included 3,209 of these patients for whom all data until hospital discharge were recorded (input rate 96%). The patients included 2,762 males and 447 females, with a mean age of 75.5 years. The mean aneurysm diameter was 51.7mm. As for comorbidities, hypertension was 63.8% and coronary artery disease was 29.8%. The postoperative complications at the time of discharge are as follows: 19 cases (0.6%) of hospital mortality, 35 cases (1.1%) of type I endoleaks, 395 cases (12.7%) of type II, 25 cases (0.8%) of type III, two cases (0.1%) of type IV, and five cases (0.3%) that were unclear. There were no cases of migration at the time of discharge. These excellent outcomes from the follow-up survey indicate the validity of the practice standards managed by JACSM.

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Friday January 22 - Vascular access -

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ascular Access News V Eradication of juxta-anastomosis stenoses in radio-cephalic fistulae: the RADAR technique Nirvana Sadaghianloo1, Alan Dardik2, Pierre-Emmanuel Haudebourg1, Elixène Jean-Baptiste1, Serge Declemy1, Réda Hassen-Khodja1

1. Centre Hospitalier Universitaire de Nice, Nice, France 2. Yale University School of Medicine, New Haven, USA

INTRODUCTION Although radial-cephalic fistulae are the preferred hemodialysis access, juxta-anastomotic stenosis is often responsible for their early failure.1-2 We hypothesized that wall ischemia from surgical manipulation leads to early juxta-anastomotic neointimal hyperplasia and failure of maturation,3 and that minimal venous dissection will improve fistula maturation and patency rates. We therefore developed a construction technique named Radial Artery Deviation And Reimplantation (RADAR) (Fig. 1).4 The aim of this study was to assess the safety and efficacy of the RADAR technique for primary fistulae, in comparison with traditional radial-cephalic fistulae. METHODS We retrospectively reviewed our prospectively maintained database of patients undergoing creation of radial-cephalic fistulae. All consecutive RADAR fistulae constructed between October 2014 and June 2015 were reviewed. Duplex-ultrasound examination was performed regularly to monitor maturation (access flow ≥ 500ml/min and venous diameter ≥ 5mm) and diagnose juxta-anastomotic stenosis. Primary patency, secondary patency, and reintervention rates were compared with those of our own historical control group, which included all consecutive traditional radial-cephalic fistulae 5 constructed between May 2013 and September 2014. Kaplan-Meier and Log-Rank analysis were used to estimate patency rates. Categorical variables were compared with Fisher exact test and continuous variables with the analysis of variance and post-hoc analysis. RESULTS 53 RADAR fistulae and 73 control fistulae were included. The mean follow-up was 7.9 months for RADAR group and 7.8 months for control group. Baseline patient characteristics were similar in both groups, although RADAR group included patients with significantly smaller veins (Table 1). 75% of RADAR fistulae (40/53) were mature by 6 weeks (mean access flow: 693 ml/min (±131); mean venous diameter: 6.3 mm (±0.9)) and 92% (49/53) were mature by 3 months (mean access flow: 756 (±179) ml/min; mean venous diameter: 6.8 (±1) mm). Access flow, venous diameter and arterial diameter increased significantly for all RADAR patients during follow up (Fig. 2). No ischemic syndrome or thrombosis occurred in RADAR group. At 6 months, the primary patency rate was 93% in RADAR group compared with 53% in control group (Fig. 3) A, p< 0.00001), and the secondary patency rate was 100% in RADAR group compared with 91% in the control group (Fig. 3B, p=0.008). The reintervention rate for juxta-anastomotic stenosis was 9% in RADAR group (1 on the vein at 8 months, and 4 on the artery, 1-3 months after creation), compared with 29% in the control group. CONCLUSION The RADAR technique for fistula construction provides excellent maturation and patency rates compared with traditional radial-cephalic fistulae with venous deviation.

Fig. 1. Schematic view of surgical techniques. Left panel: traditional radial-cephalic construction (control group). Right panel: the RADAR technique (Radial Artery Deviation And Reimplantation): only one aspect of the vein is dissected to receive the anastomosis, and the radial artery is deviated with its pedicle (artery + 2 veins).

Fig. 2. Access flow and vessel diameter.

Fig. 3. Patency rates of RADAR fistulae and control (SE <10%) 43

Friday January 22 - VASCULAR ACCESS

FIGURES

TABLE Control group (N= 73)

RADAR group (N=53)

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Variable Age (years) Gender Male Female Comorbidities Diabetes Hypertension Ischemic cardiac disease Dyslipidemia Tobacco use Medication Anticoagulant Antiplatelet Statin Erythropoietin Per-operative vessel diameters (mm) Artery Vein

P N 70

(%) or (±SD) (±13)

N 66

(%) or (±SD) (±17)

54 19

(74) (26)

37 16

(70) (30)

.70

25 60 8 16 12

(34) (82) (11) (22) (16)

16 41 1 11 9

(30) (77) (2) (21) (17)

.51 .50 .08 >.99 >.99

10 36 33 32

(14) (49) (45) (44)

8 23 18 11

(15) (43) (34) (21)

>.99 .59 .27 .008

2.7 3.6

±.6 ±1

2.5 3.1

±.4 ±.9

.07 .01

.12

SD: Standard deviation. REFERENCES 1. Badero OJ, Salifu MO, Wasse H, et al. Frequency of swing-segment stenosis in referred dialysis patients with angiographically documented lesions. Am J Kidney Dis 2008;51:93-8. 2. Al-Jaishi AA, Oliver MJ, Thomas SM, et al. Patency rates of the arteriovenous fistula for hemodialysis: a systematic review and meta-analysis. Am J Kidney Dis 2014;63:464-78. 3. Yang B, Janardhanan R, Vohra P, et al. Adventitial transduction of lentivirus-shRNA-VEGF-A in arteriovenous fistula reduces venous stenosis formation. Kidney Int 2014;85:289-306.Nous 4. Sadaghianloo N, Dardik A, Jean-Baptiste E, et al. Salvage of early failing radial-cephalic fistulae with techniques that minimize venous dissection. Ann Vasc Surg 2015;29:1475-9. 5. Rohl L, Franz HE, Mohring K, et al. Direct arteriovenous fistula for hemodialysis. Scand J Urol Nephrol 1968;2:191-5.

ricks of the Trade for a Safe Cannulation Technique T Make it easier (transposition, elevation and lipectomy) Pierre Bourquelot Paris, France

PURPOSE The purpose of this study is to report surgical techniques to facilitate cannulation of deep matured veins. METHODS AND RESULTS 1) Basilic vein tunnel superficialization with rerouting in an anterior tunnel is mandatory for brachial-basilic arteriovenous fistula (AVF), mostly performed in a second surgical stage (Fig.1A, 1B)1. The elevation technique, which could necessitate cannulation of the vein through the overlying scar, is not advisable. 2) Femoral vein superficialization is a one-stage surgical operation (Fig.2)2-3. Complications of this highflow AVF are distal ischemia (diabetes and occlusive arterial disease are contraindications), iliac vein stenosis due to intimal hypertrophy, and cardiac issues. Nevertheless, we have achieved high long-term patency rates (N = 70). Primary patency rates at 1 and 9 years were 91% ± 4% and 45% ± 11%, respectively. Secondary patency rates at 1 and 9 years were 84% ± 5% and 56% ± 9%, respectively. 3) Lipectomy for superficialization of the forearm radial-cephalic AVF was described for obese patients (Fig.3)4. Subcutaneous tissues are resected using two transverse incisions. Mobilization of the vein is avoided. At 3 years (N = 49), we recorded 63% ± 8% and 88% ± 7% primary and secondary patency rates, respectively. Finally, anterior transposition of the forearm basilic vein is not necessary when using microsurgery for creation of a distal ulno-basilic AVF. CONCLUSIONS Tunnel-transposition and lipectomy are efficient techniques to allow easy needling of deeply situated veins (upper-arm basilic vein and tight femoral vein), and cephalic vein in obese patients, respectively. LEGENDS

Fig.1A. Basilic vein tunnel superficialization (1st stage)

Fig.1B. Basilic vein tunnel superficialization (2nd stage) 45

Friday January 22 - VASCULAR ACCESS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Fig.2. Femoral vein superficialization

Fig.3. Lipectomy REFERENCES 1. Marzelle J. Bourquelot P. Abords vasculaires d’hémodialyse: principes, abords artérioveineux natifs. EMC - Techniques chirurgicales - Chirurgie vasculaire 2014; 9: 1-27 2. 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: 279-284 3. Bourquelot P.,Rawa M.,Van Laere O.,Franco G. Long-term results of femoral vein transposition for autogenous arteriovenous hemodialysis access. J Vasc Surg 2012; 56: 440-445 4. Bourquelot P.,Tawakol JB.,Gaudric J. Lipectomy as a new approach to secondary procedure superficialization of direct autogenous forearm radial-cephalic arteriovenous accesses for hemodialysis. J Vasc Surg 2009; 50: 369-374

ebate. Vascular Access in the Elderly: Native or Prosthetic? D A venous access is always better Selcuk Baktiroglu, Fatih Yanar

Istanbul Med.Fac. Gen.Surg.Clinic CAPA, Istanbul, Turkey There are huge differences in vascular access practice patterns among continents, countries, regions, hospitals and practising surgeons. Many authors report inferior patency rates of arteriovenous fistulas in elderly patients and others present contradictory results. There are centers and surgeons who perform exellent practices on the same patient groups. In a study by Hicks et al. all patients ≥18 years in the United States Renal Data System between the years 2006 and 2010 were analyzed. They found that the mortality benefit of AVF was consistently superior to that of AVG and HC for patients of all ages (all, P < .001), and concluded, AVF is superior to AVG and HC regardless of the patient’s age, including in octogenarians 1. Ravani et al. in their systematic review 2 found that, compared with persons with fistulas, those individuals with grafts had increased all-cause mortality (1.18) and fatal infection (1.36). Surgical training is key to both fistula placement and survival, and enhancing surgical training in fistula creation would help meet targets of the Fistula First Initiative. Saran et al., showed the risk of primary fistula failure was 34% lower when placed by surgeons who created >25 (vs. <25) fistulae during training 3. It was also shown by Choi et al. 4 that surgeon selection also has an important impact on access placement. Fistulae placement occurred in 98% vs. 71% for surgeon I and II, respectively, despite patients all have the same characteristics and similar findings on preoperative vascular mapping. HenricusHJ et al, in their study in 11 centers in the Netherlands has shown, hospital specific aspects predominantly determine primary failure of hemodialysis arteriovenous fistulas 5. Primary failure occurred in one third of the 395 patients. Primary failure rate among the participating centers varied from 8% to 50%. This study shows that the probability of primary failure is strongly related to the center of access creation, suggesting an important role for the vascular surgeon’s skills and decisions. Weale, et al. examined the effect of age group (<65, 65 to 79, >80) on functional outcomes in RCVAFs and BCAVFs, and found that age did not affect usability, primary or secondary patency of either RCAVFs or BCAVFs. They concluded, even patients >80 years who are considered suitable for surgical placement of access should not be denied a RCAVF solely because of age 6. Jennings, et al. stratified patients >65 years old into three 10-year increments by age. Functional patency data is compared with non-elderly patients aged 21 to 64 years treated during the same time period. They found AVFs are feasible and offer functional and timely AV access in older patients. There was no difference in functional access outcomes for older patients with subgroup age stratification. AVF patency rates were not statistically different in the elderly and non-elderly populations. Cumulative AVF patency for patients > 65 years of age was 96.9% at 12 months and 94.6% at 24 months 7. Borzumati et al. also concluded that, choosing vascular access sites to be created in elderly patients is no different than for younger patients–an AVF remains the gold standard in their study including 78 patients, aged ≥75 with a mean age of 82.5±7.5 8. In their retrospective study on hemodialysis patients older than 80 years, Oded Olsha et al. reported 24-month secondary patency of 84% for radial-cephalic (forearm) accesses and 88% for brachial-cephalic (upper arm) accesses. They concluded; contrary to recent recommendations favoring grafts for hemodialysis in patients older than 80 years, most elderly patients in this study were found to have vasculature that was suitable for autogenous access construction, with patency rates similar to those of their younger counterparts. Age alone should not disqualify patients older than 80 years from access surgery for hemodialysis 9.

Friday January 22 - VASCULAR ACCESS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

CONCLUSION Most elderly patients have suitable vessels for autogenous access construction, with patency rates similar to those of their younger counterparts,and it is possible to achieve >90 % AVF rates even among elderly patients.Early referral of CKD patients to nephrologists, early careful physical exam,preservation of arm veins,routine Doppler vessel mapping,early referral to the right institution and surgeons,monitoring and maintenance of AVF patency after construction are important points in reaching this high rates. REFERENCES 1. Hicks CW, et al.: Mortality benefits of different hemodialysis access types are age dependent. J Vasc Surg 2015 Feb;61(2):449-56. 2. Ravani P, et al.: Associations between Hemodialysis Access Type and Clinical Outcomes: A Systematic Review J Am Soc Nephrol. 2013 Feb 28; 24(3): 465–473. 3. Saran R et al.: Enhanced Training in Vascular Access Creation Predicts Arteriovenous Fistula Placement and Patency in Hemodialysis Patients, Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS), Ann Surg 2008;247: 885–891. 4. Choi KL et al.: Impact of surgeon selection on access placement and survival following preoperative mapping in the “Fistula First” era. Semin Dial.2008 Jul-Aug;21(4):341-5 5. HuijbregtsHJ et al: Hospital specific aspects predominantly determine primary failure of hemodialysis arteriovenous fistulas, J Vasc Surg 2007;45:962-7 6. Weale AR et al: Radiocephalic and brachiocephalic arteriovenous fistula outcomes in the elderly, J Vasc Surg 2008;47:144-50. 7. Jennings WC et al: Creating functional autogenous vascular access in older patient, J Vasc Surg 2011;53:713-9. 8. Borzumati M et al:Survival and complications of arteriovenous fistula dialysis access in an elderly population. J Vasc Access 2013;14 (4): 330-334 9. Olsha O et al: Vascular access in hemodialysis patients older than 80 years J Vasc Surg 2015;61:177-83.

ebate. Vascular Access in the Elderly: Native or Prosthetic? D A prosthetic option should always be favoured David Shemesh, Oded Olsha, Goldin Ilya

Shaare Zedek Medical Center, Jerusalem, Israel The KDOQI guidelines recommend radial cephalic fistula as the first approach to hemodialysis access. Elbow fistula comes second and third is the basilic vein. Only then should graft be an option1. But is this really justified in the elderly? These guidelines were first written in 1996 and are not relevant today following the dramatic increase in the number of elderly patients that has occurred since that time. Many elderly patients have comorbidities, mainly diabetes mellitus and ischemic heart disease, which increases the operative risk. Due to these comorbidities with their related hospitalizations the veins are exhausted, the arteries are severely calcified and the risk of primary failure is high. Even if we agree that native fistulas should be constructed, there is a high risk of maturation failure and these older patients may never use the fistula. The life expectancy of elderly patients on hemodialysis is so short that half of them will die within less than 2 years, suggesting that half of the fistulas would be unusable, 2-4 and providing a functioning radial cephalic fistula before they die is a target that is very difficult to meet. A meta-analysis of dialysis access outcome in elderly patients has recommended not placing radial cephalic fistulas, suggesting that resources should not be wasted on radial cephalic fistula in the elderly.5 The claim that fistulas do better than grafts is a myth. In fact there is sparse evidence in favor of fistulas over grafts. A review of 1,700 cases comparing fistulas and grafts found no difference in long-term patency. 6 Another study showed similar patency for grafts and fistulas but with higher primary failure in fistulas. 7 Complying with fistula first at any price will lead to 60% of the fistulas not being suitable for dialysis at six months.8 But if the survival of elderly patients with a catheter is only about 9 months many will die before ever using the fistula. Octogenarian patients with a fistula have a 77% greater risk of initiating dialysis via a catheter compared to those with a graft.9 Simply put, when we create a fistula in elderly patients we increase their risk of dying from catheter complications by 77%. Fistula first does not seem to be clearly superior to graft placement first in the elderly and graft might be a better option. Grafts can do better than fistulas, with many centers reporting excellent outcomes with grafts which are superior to those of native fistulas, with a secondary patency of 91% at one year. 10 The best option for the elderly patient is clearly an early cannulation graft with cannulation started within 48 hours (without the need for a tunneled catheter) and with an incomparable 93% secondary patency. 11 In conclusion in elderly patients graft construction, preferably using early cannulation grafts, is the gold standard for vascular access. It may even be better to place a catheter in the elderly patient rather than wasting resources on a radial cephalic fistula. REFERENCES 1. Clinical practice guidelines for vascular access. American journal of kidney diseases: the official journal of the National Kidney Foundation. 2006;48 Suppl 1:S176-247. 2. Letourneau I, Ouimet D, Dumont M, Pichette V, Leblanc M. Renal replacement in end-stage renal disease patients over 75 years old. American journal of nephrology. 2003;23(2):71-77. 3. Joly D, Anglicheau D, Alberti C, et al. Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes. Journal of the American Society of Nephrology: JASN. 2003;14(4):1012-1021. 4. Vachharajani TJ, Moossavi S, Jordan JR, Vachharajani V, Freedman BI, Burkart JM. Re-evaluating the Fistula First Initiative in Octogenarians on Hemodialysis. Clinical journal of the American Society of Nephrology: CJASN. 2011;6(7):1663-1667. 5. Lazarides MK, Georgiadis GS, Antoniou GA, Staramos DN. A meta-analysis of dialysis access outcome in elderly patients. Journal of vascular surgery. 2007;45(2):420-426. 6. Schild AF, Perez E, Gillaspie E, Seaver C, Livingstone J, Thibonnier A. Arteriovenous fistulae vs. arteriovenous grafts: a retrospective review of 1,700 consecutive vascular access cases. The journal of vascular access. 2008;9(4):231-235. 7. Lok CE, Sontrop JM, Tomlinson G, et al. Cumulative patency of contemporary fistulas versus grafts (2000-2010). Clinical journal of the American Society of Nephrology: CJASN. 2013;8(5):810-818. 8. Dember LM, Beck GJ, Allon M, et al. Effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis: a randomized controlled trial. JAMA: the journal of the American Medical Association. 2008;299(18):2164-2171. 9. DeSilva RN, Patibandla BK, Vin Y, et al. Fistula first is not always the best strategy for the elderly. Journal of the American Society of Nephrology: JASN. 2013;24(8):1297-1304. 10. Dammers R, Planken RN, Pouls KP, et al. Evaluation of 4-mm to 7-mm versus 6-mm prosthetic brachial-antecubital forearm loop access for hemodialysis: results of a randomized multicenter clinical trial. Journal of vascular surgery. 2003;37(1):143-148. 11. Tozzi M, Franchin M, Ietto G, et al. Initial experience with the Gore(R) Acuseal graft for prosthetic vascular access. The journal of 49 vascular access. 2014;15(5):385-390.

Friday January 22 - VASCULAR ACCESS

News HeRO device: central vein recanalization may be difficult

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Christine Jahn1, Y. Georg, E. Boatta1, T. Krummel, S. Gaertner, A. Gangi1

1. Imagerie A interventionnelle, NHC, Strasbourg, France

PURPOSE Central venous catheterization is one of the most common procedures performed. We evaluated the results using the HeRO Device in patient with central venous obstruction. MATERIAL AND METHODS In Two patients (1 male, 1 female; 52 -47 years old) the HeRO device was implanted after failed or infected AV access. The patients were diabetics (1), obese (1), smoker (1). The duration of dialysis prior to the HeRO placement was 15- 2 years. Patients presented both chronic brachiocephalic venous occlusion, jugular venous occlusion and superior vena cava patency. RESULTS Before HeRO device placement, one patient was treated by angioplasty and stenting , one patient was treated by venous PTFE graft after failed recanalization. Technical success was achieved in each case. The periprocedural complications were the high flow and hand ischemia; one patient needed the occlusion of the device in emergency. CONCLUSION The use of HeRO device is indicated in case of multiple failures of AVFs. A correct patient selection is essential to avoid implant failure and complications. DISCLOSURE No

ews N Lessons (and their practical consequences) learned from the REIN registry (French national audit) for poorly matured accesses in recently started haemodialysis patients

1. Ambroise ParĂŠ University Hospital, Boulogne-Billancourt, France 2. Equipe 5, Inserm UMR 1018, CESP; Paris-Sud University, Versailles St-Quentin University, Villejuif, France INTRODUCTION Current guidelines recommend to start hemodialysis (HD) with a functionnal arterio-venous fistula (AVF) that should be created 6 months before HD initiation. However, delay necessary to obtain a functionnal AVF (F-AVF) and determinants of non functionnal AVF (NF-AVF) risk at HD initiation are poorly known. PATIENTS AND METHODS Data was obtained from the French national REIN hemodialysis registry. We studied 53 092 incident HD adult patients in France between 2005 and 2012. A NF-AVF was defined by initiating HD on a catheter in patients whose AVF creation date was anterior to HD initiation. Adjusted odds-ratios (OR) of NF-AVF associated to demographic, and treatment factors were estimated through logistic regression. RESULTS In total, 8,9% patients started HD on a NF-AVF, 47,4% on a F-AVF, and 43,8% on a catheter. The NF-AVF patients were not different from the F-AVF patients regarding age, but women had a higher OR than men (1.34; CI: 1.24-1.44). The OR was also higher for diabetics (1.24; CI: 1.11-1.37) and patients who started HD in emergency (4.83; CI: 4.46-5.21). The OR also increased with the number of cardiovascular comorbidities. When the delay of AVF creation was <30 days, comprised between 1 and 2 months, 2 and 3 months, 3 and 6 months and >6 months, rates of NF-AVF were 41.6%, 12.4%, 7.7%, 5.6% and 7.0%, respectively, in men without diabetes and less than 2 cardiovascular comorbidities, whereas these rates were 55.6%, 17.7%, 12.8%, 8.2% and 8.7% in women, respectively. These rates increased by 62% and 58%, respectively, in men and women with comorbidities. Rates of NF-AVF may have been underestimated due to missing datas regarding AVF creation in patients initiating HD on a catheter. CONCLUSION In France, the majority of HD patients have an their AVF creation before starting HD. To be functionnal, a 60 days delay appears to be sufficient in men without comorbidities but 3 months or more are necessary in women of patients with comorbidities. Theses results underline the fact that guidelines regarding AVF creation should be tailored to take in account risk of each subgroup to start HD without a F-AVF.

Friday January 22 - VASCULAR ACCESS

Raphael Coscas1, Natalia Alencar de Pinho2, Marie Metzger2, Ziad Massy1, Benedicte Stengel2

ebate. The Native Access is… D A nightmare!

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Richard Amerling

Mount Sinai Beth Israel, New York, USA The native vascular access was a dream come true for chronic hemodialysis, but has turned into a nightmare for many patients. It must be recognized that and arteriovenous fistula (AVF) is beneficial only as vascular access for hemodialysis--in every other sense, it is pathological. Undue emotion has been inserted into this debate and has led to campaigns in favor of the AVF, and financial incentives for their use. AVFs have become larger and more toxic due to higher flow rates. Other modes of access have been demonized, and tremendous bias against them is evident. The negative effects of an AVF are many: high output heart failure, cardiomyopathy, pulmonary hypertension, steal syndrome, pulmonary embolism, subendocardial ischemia, cardiopulmonary recirculation, central vein stenosis, and failure to thrive.1 These toxic effects have been downplayed, or ignored, and patients are not fully informed before making decisions. The AVF must be viewed objectively as a lesser of evils, and not held up as an ideal. We are far from an ideal vascular access, and research should not be inhibited. Access strategies need to be individualized to each patient, and take into account their cardiovascular status and expected longevity. Exposure to access toxicity should be limited by “just in time” access surgery, peritoneal dialysis, preemptive transplantation, and prompt AVF ablation post-transplantation. Access complications need to be recognized and dealt with appropriately, if necessary by flow reduction or ligation. REFERENCE Amerling R, Ronco C, Kuhlmann M, Winchester JF. Arteriovenous Fistula Toxicity. Blood Purif 2011; 31.DOI: 10.1159/000322695

Friday January 22 - VASCULAR ACCESS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Saturday January 23 - Main program -

eripheral and Visceral Aneurysms P Epidemiology of popliteal aneurysms

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Anne Long

Hopital Edouard Herriot, Lyon, France Popliteal aneurysm (PA) is defined as a localized dilatation of the popliteal artery greater than 1.5 or 2 cm or greater than at least 1.5 times the adjacent normal vessel. The incidence is low in the general population, 1% in men older than 50 or between 65 and 80 1, 2. The incidence rises to 8% in patients with abdominal aortic aneurysm 3. In the Mayo Clinic database, PA was bilateral in 54% of the cases; an abdominal aortic aneurysm (AAA) was present in overall 54% patients, in 65 % patients with bilateral AP and 42% patients with unilateral AAA 4. In the Swedish Vascular Registry, PA was bilateral in 46.6% patients; an AAA was present in 37.4 % patients with bilateral AP and 28.1% patients with unilateral AAA 5. The natural history is embolization and acute thrombosis leading to acute limb ischemia and risk major amputation. The mean increase in diameter is poorly studied, estimated to 1.5 mm/year for PA > 2 cm versus 0.7 mm/ year for PA < 2 cm 6. In Sweden, the incidence of PA repair was estimated at 8.3 per million person-years between 1994 and 2001 5. In the Vascunet collaboration registry, the overall number of operations was 9.59 per million person-years between January 2009 and June 2012 7. Among surgical patients, 95.6 % were men, with a median age of 70 year. Risk factors were current smoking (44%), HTA (72.4 %), diabetes (16.2 %), and patients had an history of cerebrovascular events (9%), pulmonary (14%) or cardiac (37.1%) disease 7. Clinical presentation of the limb varied between no symptom (40%), chronic limb ischemia (39%) and acute limb ischemia (21%) 4. In the Vascunet registry, elective surgery was performed in 72 % PA and emergency surgery in 28% including 1.8 % ruptured PA 7. The major amputation rate was 2% 7, rising to 6.5 % in case or emergency repair: mortality was 0.1% after elective surgery, 1.6% after emergency for thrombosis and 11.1% after procedure for rupture. REFERENCES 1. Claridge M, Hobbs S, Quick C, Adam D, Bradbury A, Wilmink T. Screening for popliteal aneurysms should not be a routine part of a community-based aneurysm screening program. Vasc Health Risk Manag. 2006;2:189-91. 2. Trickett JP, Scott RA, Tilney HS. Screening and management of asymptomatic popliteal aneurysms. J Med Screen. 2002;9:92-3. 3. Diwan A, Sarkar R, Stanley JC, Zelenock GB, Wakefield TW. Incidence of femoral and popliteal artery aneurysms in patients with abdominal aortic aneurysms. J Vasc Surg. 2000:31:863-9. 4. Huang Y, Gloviczki P, Noel AA, Sullivan TM, Kalra M, Gullerud RE, Hoskin TL,Bower TC. Early complications and long-term outcome after open surgical treatment of popliteal artery aneurysms: is exclusion with saphenous vein bypass still the gold standard? J Vasc Surg. 2007:45:706-713; discussion 713-5. 5. Ravn H, Bergqvist D, Björck M; Swedish Vascular Registry. Nationwide study of the outcome of popliteal artery aneurysms treated surgically. Br J Surg. 2007;94:970-7. 6. Stiegler H, Mendler G, Baumann G. Prospective study of 36 patients with 46 popliteal artery aneurysms with non-surgical treatment. Vasa. 2002;31:43-6. 7. Björck M, Beiles B, Menyhei G, Thomson I, Wigger P, Venermo M, Laxdal E, Danielsson G, Lees T, Troëng T. Editor’s Choice: Contemporary treatment of popliteal artery aneurysm in eight countries: A Report from the Vascunet collaboration of registries. Eur J Vasc Endovasc Surg. 2014:47:164-71.

- Left popliteal aneurysm. Asymptomatic aneurysm with partial mural thrombus. Echography B mode, axial plane.

- Left popliteal aneurysm. Same patient. Echography B mode, sagittal plane.

Saturday January 23

FIGURES

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ypogastric Arteries during EVAR H Should they be preserved at all cost? Philippe Cuypers, Rutger Stokmans, Yannick ‘T Mannetje, Edith Willigendael, Joep Teijink, Marc Van Sambeek

Catharina Hospital, Eindhoven, The Netherlands

INTRODUCTION More than 20% of abdominal aortic aneurysms (AAAs) involve at least one common iliac artery (CIA)1. Whenever possible, the CIA will serve as a distal sealing site for endovascular aneurysm repair (EVAR). Iliac limbs up to 28 mm diameter are commercially available for the so-called bell- bottom technique. In cases of CIAs larger than 24 mm, however, extension of the stent graft into the external iliac artery (EIA) is often required to achieve adequate seal. Alternatively, in elective cases with suitable anatomy, common iliac aneurysms may be treated with iliac branch devices or sandwich techniques in order to maintain inflow into the IIA. The question is how far should one go and how many resources should be used to preserve the IIA? And, in case one chooses to extend the stentgraft into the EIA and cover the IIA, is preemptive coil-embolisation mandatory? OBJECTIVES We retrospectively analysed all patients who underwent EVAR with extension of the stentgraft into the EIA. In our center, coverage of the IIA during EVAR was routinely performed without coil embolisation. METHODS From January 2010 until May 2015, 86 patients (95.3% men; mean age 74.1 years) underwent EVAR with stent grafts extended into the EIA, all without prior coil embolisation. Aneurysm morphology was determined on preoperative computed tomography (CT) images. During follow-up, patients were interviewed about buttock claudication. The occurrence of endoleaks and evolution of aneurysm diameter were assessed on CT and duplex ultrasonography. RESULTS At baseline, the mid-common iliac artery (CIA) diameter was 33.5±16.8 mm. Mean follow-up was 25.3 ±18.5 months. Buttock claudication occurred in seven (22.6%) patients, which persisted after 6 months in only two cases of bilateral IIA coverage (clinical follow-up was initially performed on a subset of 32 patients and will be completed on all 86 patients by the time of presentation). Three type II endoleaks related to IIA coverage were observed. Only one of these needed treatment. Aneurysm growth was not observed. CONCLUSION Endovascular treatment of aortoiliac aneurysm with coverage of the internal iliac artery but without pre-emptive coil embolisation appears safe and effective and is very well tolerated by patients. This finding is in line with the results of other studies in this field. This approach saves operating time, contrast load and costs and may reduce complications compared to preoperative coil embolisation. However, a larger population and longer follow-up is required to confirm our findings. Because of the promising results of this technique, we recommend the use of branch devices, sandwich techniques or snorkels in selected cases only. REFERENCES 1. Armon MP, Wenham PW, Whitaker SC, Gregson RH, Hopkinson BR. Common iliac artery aneurysms in patients with abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 1998;15:255-7. 2. Farahmand P, Becquemin JP, Desgranges P, Allaire E, Marzelle J,Roudot-Thoraval F. Is hypogastric artery embolization during endovascular aortoiliac aneurysm repair (EVAR) innocuous and useful? Eur J Vasc Endovasc Surg 2008;35:429-35. 3. Tefera G, Turnipseed WD, Carr SC, Pulfer KA, Hoch JR, Acher CW. Is coil embolization of hypogastric artery necessary during endovascular treatment of aortoiliac aneurysms? Ann Vasc Surg 2004;18:143-6. 58

ow and When Embolize the Sac H Cone Beam Guidance for Type II Endoleak HervĂŠ Rousseau, Olivier Meyrignac, Bertrand St Lebes, Fatima Mokrane CHU Rangueil, Toulouse, France

Endovascular aneurysm management (EVAR) is hampered by persistent arterial blood flow in the aneurysm sac after treatment, known as endoleak (EL). Type II EL consists of blood flow from one or more aortic branch vessels. In most cases, this complication is observed without any management. If continued sac expansion and potential sac rupture is observed, endovascular reintervention is needed. A variety of options exist, depending on the source of EL and the anatomy. Inferior mesenteric artery EL is best treated by endovascular embolization through the superior mesenteric artery and Riolansâ&#x20AC;&#x2122; arc. In lumbar artery EL, success of endovascular embolization is limited, and when standard trans-arterial treatment is not accessible, direct percutaneous sac injection is a good option, but needs very precise imaging. CT guidance provides a good way to exactly puncture the EL percutaneously in most cases, but limited workspace and lack of fluoroscopy availability for the ensuing catheter manipulation hampers this technique. A novel way is performed on flat panel detector angiography units. By a rotation around the patients these units provide the possibility to create a cone-beam CT (CBCT) in the angio suite. Using the 3-dimensional dataset acquired with CBCT and specific soft wares, the embolization can be done under 3D Road mapping. During direct percutaneous sac injection, a needle path can be planned to puncture the nidus of the EL with great confidence and without danger of inadvertently perforating vital structures. After sac puncture, microcatheters can be inserted to embolize the origins of branch vessels and the aneurysm sac with thrombogenic agents or glue. As a whole, cone-beam CT guided procedures have higher accuracy with lower radiation dose compared to 2D angiography or conventional CT guided procedures. CBCT provide the imaging data to support treatment simulation and technology-aided treatment. Details of CBCT guided procedures will be detailed.

Saturday January 23

nusual Features of Endoleaks U Type III Endoleak: Mechanism and Detection

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Richard McWilliams

Royal Liverpool University Hospital, Liverpool, United Kingdom This presentation will deal only with fabric tears or type 3b endoleaks. These can be intermittent and are difficult to diagnose with certainty. The sequence of investigations and the imaging appearances will be discussed with reference to CT, US, CEUS and catheter angiography. Definitive diagnosis at angiography is rare. The cause of fabric holes is some function of the interaction of the fabric of the stent-graft with the endoskeleton and sutures. This will be a focussed talk looking at a potential cause of type 3b endoleak thought due to interaction between the fabric and endoskeleton and this will be beautifully illustrated with reference to two cases.

nusual Features of Endoleaks U Can Trauma Induce Type 3 Endoleak? Carlo Setacci

University of Siena, Siena, Italy INTRODUCTION Despite the significantly reduced associated morbidity and mortality, endovascular repair of an abdominal aortic aneurysm (EVAR) is not free of important complications. The aim of this study is to confirm if the occurrence of high-velocity traumas (HT) during EVAR follow up could facilitate late type 1, type 3 endoleak (EL) and limb occlusion due to migration, disconnection and material fatigue. METHODS All Patients underwent abdominal aortic procedures in our Department from the 1st January 2011 to the 31 December 2014 were prospectively included in a dedicated database. All patients received a telephonic interview to verify HT occurred during follow-up or,in case of secondary treatment, before the complication diagnosis. We, also, retrospectively analysed all patients underwent aortic reinterventions for late type 1,type 3 EL or limb occlusion (at least 6 months after primary procedure) due to migration, disconnection or graft material fatigue. To divide patients according to the risk of developing an EL we identified 7 predisposing factors(PF) (more than 10 mm distance between the lower renal artery and the covered graft, less than 10 mm of overlapping graft-aorta in the proximal neck, more than 60° of angulation between sovrarenal fixation stent and infrarenal graft, more than 60° between neck portion of the graft and the distal part, more than 90° between aortic part of the graft and 1 iliac limb, less than 25 mm overlapping in modular grafts, less than 15 mm of distal neck) at the follow-up Computed Tomography (CT) examination. We divided patients in three groups: group A (low risk for EL, PF≤2), group B (intermediate risk, 3-5 PF) group C (high risk, >5 PF). RESULTS During the study period we performed 37 secondary procedures (18 from our case series), 21 Type 1 EL, 8 type 3 EL and 7 limb occlusion. In the same period 254 Patients underwent EVAR. In complicated cases, 3 patients suffered an HT before developing the complication (3/37;8.1%), while in not complicated cases only 1 patients suffered HT (1/234; 0.4%). The analysis of the preoperative CT examination evidenced that patients with endoleak+HT were 2 in group B (intermediate risk) and 1 in group C (as the patients with no endoleak+ HT), while the other 34 complicated patients were 26 in group A and 8 in group B. CONCLUSIONS HT seem to increase the risk of type 1, type 3 EL and limb occlusion, during EVAR follow-up. Larger data are needed to confirm these preliminary findings.

Saturday January 23

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

J uxta / Supra Renal Aneurysm Does renal angulation and respiratory induced deformations affect the long term results of CH-EVAR and F-EVAR Ronald Dalman

Portola Valley, USA Complex EVAR (parallel grafting and fenestrated EVAR) can induce significant deformation of the stented renal arteries. The positioning of a covered stent into the renal artery from either the proximal or distal aorta can accentuate or change the branch origin and distal stent/renal artery angles, as well as change the maximal radius of curvature of the renal arteries. These deformations, characteristically downward deflection following parallel grafting and upward deflection following fenestrated EVAR, can in turn disturb renal artery flow and predispose to early or late renal stent thrombosis and kidney loss. This presentation will highly characteristic changes present following complex EVAR at peak inspiration, as well as deformations present at the extreme of inspiration and expiration, and correlate these to outcomes in both our own experience as well as that of the published literature. FIGURES

Renal deformation following complex EVAR Model geometries before and after Sn- and F-EVAR, and changes of renal arteries from pre- (blue) to post-op (grey) due to stent placement (red)

REFERENCES 1. Ullery BW, Chandra V, Dalman RL, Lee JT. Impact of renal artery angulation on procedure efficiency during fenestrated and snorkel/chimney endovascular aneurysm repair. J Endovasc Ther 2015;22:594-602. 2. Ullery BW, Lee JT, Dalman RL. Snokel/chimney and fenestrated endografts for complex abdominal aortic aneurysms. J Cardiovasc Surg (Torino) 2015;56:707-17. 3. Ullery BW, Suh GY, Lee JT, Stineman R, Dalman RL, Cheng CP. Geometry and respiratory-induced deformation of abdominal branch vessels and stents after complex endovascular aneurysm repair. J Vasc Surg 2015;61:875-84. 4. Tran K, Ullery BW, Lee JT. Snorkel/chimney stent morphology predicts renal dysfunction after complex endovascular aneurysm repair. Ann Vasc Surg 2015 Epub before print. 5. Suh GY, Choi G, Herfkens RJ, Dalman RL, Cheng CP. Respiration-induced deformations of the superior mesenteric and renal arteries in patients with abdominal aortic aneurysms. J Vasc Inter Radiol 2013;24:1035-42.

Saturday January 23

End stent angulation based on type, laterality of renal endografting in complex EVAR

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

J uxta / Supra Renal Aneurysm Duel. What is the best solution? EVAS + chimneys or F/B-EVAR? For EVAS + chimney Ian Loftus

St Georgeâ&#x20AC;&#x2122;s Vascular Institute, London, United Kingdom INTRODUCTION Fenestrated endografts are probably now the gold standard for the management of juxta-renal aneurysms. Large series demonstrate outcomes that are favourable compared to open surgery1. However there are anatomical and other limitations with regard to fenestrated technologies. This has led to the development of parallel graft solutions. Chimney stents alongside conventional endografts risk the formation of gutters, promoting Type 1 endoleaks2. Endovascular sealing with the Nellix device (EVAS) offers a novel solution for complex aneurysms, whereby parallel grafts can be deployed alongside the Nellix device. Polymer curing within the endobags will tend to mold around the renal/mesenteric stents, reducing the risk of guttering and subsequent endoleaks. A number of reports have demonstrated the feasibility of this technique3,4. We present the technique and outcomes of our early experience of the ch-EVAS technique. DRAFT RESULTS We have treated 47 patients with greater than 3 month follow up including 8 triple renal and mesenteric, 7 double and 32 single renal chimneys. These include 3 ruptured and 4 mycotic aneurysms, and 7 EVAR revisions. The majority of cases were unsuitable for FEVAR, and unfit for open surgery. There were 2 early deaths including one patient with a ruptures juxtarenal aneurysm. One elective patient died of multiple systemic embolization. Three early type 1 endoleaks were successfully treated with embolization. There was a single limb occlusion and renal stent stenosis treated successfully. CONCLUSIONS FEVAR remains the gold standard but ch-EVAS adds another option to the range of options for patients with complex aneurysms. These early results in hostile anatomies demonstrate good early and mid term outcomes, comparable to most series of FEVAR. Clearly mid and long-term outcomes will be essential to monitor the durability of this technique but for patient unfit for open repair, it offers the endovascular surgeon another option for the management of these difficult anatomies.

REFERENCES 1. British Society for Endovascular Therapy and the Global Collaborators on Advanced Stent-Graft Techniques for Aneurysm Repair (GLOBALSTAR) Registry. Early results of fenestrated endovascular repair of juxtarenal aortic aneurysms in the United Kingdom. Circulation 2012;125(22):2707-15. 2. Donas KP, Lee JT, Lachat M, Torsello G, Veith FJ; PERICLES investigators. Collected world experience about the performance of the snorkel/chimney endovascular technique in the treatment of complex aortic pathologies: the PERICLES registry. Ann Surg 2015;262(3):546-53. 3. Malkawi AH, de Bruin JL, Loftus IM, Thompson MM. Treatment of a juxtarenal aneurysm with the Nellix endovascular aneurysm sealing system and chimney stent. J Endovasc Ther 2014;21(4):538-40. 4. Hughes CO, de Bruin JL, Karthikesalingam A, Holt PJ, Loftus IM, Thompson MM. Management of a type ia endoleak with the nellix endovascular aneurysm sealing system. J Endovasc Ther 2015;22(3):309-11.

Dissection Imaging consideration for acute type B dissection Michael Dake

Stanford University, Stanford, CA, USA Determining the best method of treatment for individual patients with Type B aortic dissections has always presented a vexing challenge for physicians. Physicians are often faced with balancing the conservative approach of medical management with the more aggressive approaches of surgical or endovascular treatments. With the high surgical mortality for patients presenting with acute complicated Type B dissections, physicians have readily adopted thoracic endovascular aortic repair (TEVAR) as the accepted therapy for this condition. With newer TEVAR devices achieving a broad indication from the FDA approval for the treatment of all Type B dissections and new insights regarding physiological predictors of future complications, physicians have expanded their consideration of TEVAR to treat the multiple challenges of this etiology. In this regard, based on their performance in the study of acute complicated Type B dissection, both W.L. Gore and Medtronic were awarded an FDA indication to treat all Type B dissections with their devices. When considering a complex variety of relevant factors, such as the patientâ&#x20AC;&#x2122;s condition and various physiological predictors, an algorithmic approach may prove useful in deciding among treatment options. In essence, an algorithm is meant to provide a simplified, stream-lined guide to decision making when numerous input considerations exist and often complicate therapeutic considerations. REFERENCES 1. Dake MD, Thompson M, van Sambeek M, Vermassen F, Morales JP; DEFINE Investigators. DISSECT: a new mnemonic-based approach to the categorization of aortic dissection. Eur J Vasc Endovasc Surg. 2013;46:175-190.

Saturday January 23

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Saturday January 23 - Venous session -

eep vein D Concomitant Deep And Superficial Vein Disease - Be Aggressive In Treating Deep Obstruction With Every Patient

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Lowell Kabnick

NYU Langone Medical Center, New York, USA Which class of patients are we addressing? Certainly, we are addressing patients with advanced venous disease classified as C4b, C5, and C6. Included in the mix would be patients who have unilateral thigh, calf, and ankle edema with a fixed obstruction with associated superficial truncal reflux. So why treat deep venous obstruction first? Isolated superficial reflux rarely causes ulcerations.1 Reflux may improve as obstruction resolves, and results after treatment of obstruction are independent of reflux.2 In patients with advanced venous disease associated with pain and swelling, Neglen and Raju published their studies showing significant reduction in pain and swelling.3 In addition, ulcer healing rate with stent placement alone occurred in 58-89%.3,4 REFERENCES 1. Johnson et al, Isolated Reflux Rarely Causes Ulceration J Vasc Surgery 1995 2. Caps M et al, J Vasc Surg 1998 3. Alhalbouni S, Hingorani, A et al. Iliac-Femoral Venous Stenting for Lower Extremity Venous Symptoms Ann Vasc Surg 2012; 201;26:185-189 4. Raju S et al. Unexpected major role for venous stenting in deep reflux disease J Vasc Surg 2010; 51:401-8

eep vein D On Which Criteria Do You Select Your Stent For Ilio-Femoral Venous Obstruction? North American Point Of View Peter Gloviczki, Ying Huang

Mayo Clinic, Rochester MN, USA Venous stenting has been used with increasing frequency and lasting success to treat chronic ilio-femoral venous obstructions. Major criteria to select stenting include the clinical presentation of the patient, the etiology of the obstructions, the underlying venous anatomy and pathology and the patientâ&#x20AC;&#x2122;s operative or interventional risk. Diagnostic pre-procedure evaluation includes different imaging studies with an increasing emphasis based on intravascular ultrasound (IVUS). CLINICAL PRESENTATION Signs and symptoms of iliofemoral venous obstruction include leg swelling, pain, venous claudication, abdominal wall, lower extremity and suprapubic varicosity and stasis skin changes including venous ulcerations. Patients may present with symptoms of pelvic venous congestion. Presentation can be acute, subacute or chronic. ETIOLOGY Patients, who undergo thrombolysis for acute iliofemoral deep vein thrombosis (DVT) may have underlying iliac vein compression or obstruction. These lesions should be treated with iliofemoral stenting to avoid a high risk of recurrent acute DVT. Chronic obstruction can be non-thrombotic compression or obstruction of the iliac veins (May-Thurner syndrome) or thrombotic, chronic DVT. Malignancy or external compression by benign tumors must be recognized and treated accordingly. VENOUS ANATOMY AND PATHOLOGY The best candidates for iliofemoral venous stenting have common iliac vein stenosis due to May-Thurner syndrome. Thrombotic iliofemoral venous obstruction need longer stents or multiple stents with somewhat decreasing chance of success. Good inflow into the stent is critical and if needed, endophlebectomy with patch angioplasty needs to be performed for a hybrid procedure. Alternative is to place stent into the profunda femoris vein. Stents distal to the saphenofemoral junction do not perform well. It is important to recognize the underlying pathomechanism of the disease and assure that of the venous pathologies venous outflow obstruction and not infrainguinal valve incompetence dominates. SURGICAL OR INTERVENTIONAL RISK Chronic renal failure or underlying thrombophilia are potential risk factors for venous stenting. Sedentary or bedridden patient, high cardiac and pulmonary risk, retroperitoneal fibrosis or previous radiation may also contraindicate successful stenting. PREOPERATIVE DIAGNOSTIC EVALUATION FOR STENTING Duplex scanning, MR, CT and direct contrast venography with pressure measurements all can be used for patient selection, but IVUS is gaining increasing importance in recognition of non-thrombotic iliac vein compression. Absence of venous collaterals on contrast venogram is no longer a contraindication for stenting in symptomatic patients, if IVUS confirms significant ( >50%) iliac vein obstruction. SELECTION OF VENOUS STENT In North America WALLSTENTâ&#x201E;˘ Endoprosthesis is the only currently used stent for iliofemoral venous occlusion. For common iliac vein 14 to 18 mm stents are selected based on intraoperative measurement using venogram and IVUS; for the external iliac vein 12 to 14 mm stent is recommended. Over-sizing has caused chronic pain syndrome, while under-sizing increases stent thrombosis or stenosis. For hybrid procedures a temporary femoral arteriovenous fistula may be needed. 69

Saturday January 23

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

REFERENCES 1. Neglén P, Thrasher TL, and Raju S. Venous outflow obstruction: An underestimated contributor to chronic venous disease. J Vasc Surg 2003;38:879-85. 2. Hartung O, Otero A, Boufi M et al. Mid-term results of endovascular treatment for symptomatic chronic nonmalignant iliocaval venous occlusive disease. J Vasc Surg 2005;42:1138-44. 3. Raju S and Neglén P. High prevalence of nonthrombotic iliac vein lesions in chronic venous disease: a permissive role in pathogenicity. J Vasc Surg 2006;44:136-43. 4. Neglén P, Hollis KC, Olivier J, and Raju S. Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result. J Vasc Surg 2007;46:979-90. 5. Neglén P, Tackett TP Jr, and Raju S. Venous stenting across the inguinal ligament. J Vasc Surg 2008;48:1255-61. 6. Oguzkurt L, Tercan F, Ozkan U, and Gulcan O. Iliac vein compression syndrome: outcome of endovascular treatment with longterm follow-up. Eur J Radiol 2008;68:487-92. 7. Hartung O, Loundou AD, Barthelemy P, Arnoux D, Boufi M, and Alimi YS. Endovascular management of chronic disabling ilio-caval obstructive lesions: long-term results. Eur J Vasc Endovasc Surg 2009;38:118-24. 8. Rosales A, Sandbaek G, and Jorgensen JJ. Stenting for chronic post-thrombotic vena cava and iliofemoral venous occlusions: midterm patency and clinical outcome. Eur J Vasc Endovasc Surg 2010;40:234-40. 9. Wahlgren CM, Wahlberg E, and Olofsson P. Endovascular treatment in postthrombotic syndrome. Vasc Endovascular Surg 2010;44:356-60. 10. Garg N, Gloviczki P, Karimi KM et al. Factors affecting outcome of open and hybrid reconstructions for nonmalignant obstruction of iliofemoral veins and inferior vena cava. J Vasc Surg 2011;53:383-93. 11. Kurklinsky AK, Bjarnason H, Friese JL et al. Outcomes of venoplasty with stent placement for chronic thrombosis of the iliac and femoral veins: single-center experience. J Vasc Interv Radiol 2012;23:1009-15. 12. Meissner MH, Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Lohr JM, McLafferty RB, Murad MH, Padberg F, Pappas P, Raffetto JD, Wakefield TW, Society for Vascular Surgery, American Venous Forum. Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2012 May; 55(5):1449-62. 13. Raju S. Best management options for chronic iliac vein stenosis and occlusion. J Vasc Surg. 2013;57(4):1163-9. 14. Seager MJ, Busuttil A, Dharmarajah B, Davies AH. A systematic review of endovenous stenting in chronic venous disease secondary to iliac vein obstruction Eur J Vasc Endovasc Surg. 2015 Oct 10. [Epub ahead of print] 15. Raju S. Treatment of iliac-caval outflow obstruction. Semin Vasc Surg. 2015 Mar;28(1):47-53. Epub 2015 Jul 17

ome debates S DEBATE. Ambulatory phlebectomy as a simultaneous treatment after endothermal ablation is not mandatory Jean-Luc Gérard

Hôpital Henri Mondor Créteil, Paris, France There are two opposing views on ambulatory phlebectomy as a simultaneous treatment after endo thermal ablation The reasons for phlebectomy during the same session may be treatment of hemodynamically large varicose veins in one session, or for cosmetic results (treatment of visible varicose veins) and finally for cost effectiveness (lower extra costs if treated in one session) The reasons against phlebectomy during the same procedure are possibly the unnecessary treatment of tributaries (overtreatment) which may resolve (shrink) after saphenous ablation, undesirable side effects (hematoma, pain, inflammation, nerve damage, DVT, etc.), longer operation time, as well as higher costs According to the US guidelines 1, ambulatory phlebectomy is recommended for the treatment of varicose veins, performed with saphenous vein ablation, either during the same procedure or at a later stage (graduation 1B). If general anesthesia is required, concomitant phlebectomy saphenous ablation is recommended (graduation 1B). According to the UK guidelines Nice Recommendations 2013 2: If incompetent varicose tributaries are to be treated consider treating at the same time. However this recommendation is based only on one study carried out by Carradice 3 in 2009. If we look at this study, 48 patients were treated by endovenous laser ablation (EVLA) 24 patients of which were treated simultaneously with phlebectomy, and 24 without. The follow-up (F-U) of the patients was only 6 weeks. Due to this short panel of patients and short F-U these recommendations are weak! If we consider the cosmetic results, we could look at a study comparing laser ablation vs. surgery 4. Darwood randomized 42 EVLA 1 (12 watts pulse mode), 29 EVLA 2 (14 watts continuous mode) and 32 high ligation/ stripping ( HL/S) + phlebectomy. For the patients treated by EVLA the procedure was performed under tumescent anesthesia (outpatient) and cannulated adjacent to the knee. For the patients treated by surgery HL/S, general anesthesia was administered (operating room) and the stripping was at the knee level + multiple phlebectomies varicosities. At 3 months, on 100mm linear visual analogue scale, the patient satisfaction was respectively: 95 / 91 / 91 and the cosmetic outcome: 92/ 92 / 93. Whether a phlebectomy is performed or not, the satisfaction and cosmetic outcome were the same in the 3-arm. The potential problems of phlebectomy during the same session are increasing time of procedure, and if there are multiple varicosities the trend is more towards general anesthesia, increasing rate of paresthesia, deep vein thrombosis (DVT) and increasing time of sick leave. Firstly we have different studies analyzing subsequent resolution or regression of varicose veins without phlebectomy avoiding “overtreatment “, 4, 5, 6, 7 and if varicosities are still visible they can be managed at another time under local anesthesia. Secondly one study (multicenter) published by Hamel Desnos 8 comparing EVLA for patients under and over 75 years old, surprisingly showed that under local anesthesia the rate of paresthesia was 2.2 % compared to the 11.8% rate under general anesthesia, whatever the age of the patient. And thirdly some authors 9, 10, 11, 12, 13 found higher risk of thrombosis when phlebectomy are associated and both legs have been treated. The longer the procedure, the higher is the risk of DVT. And the corollary is the lower risk of thrombosis is under local anesthesia. The more quickly walking is resumed, the better. Nevertheless some randomized studies are favorable with concomitant phlebectomy 14, 15 but some are rather favorable with delayed phlebectomy 16 they found no significant differences in the Aberdeen Varicose Veins Questionnaire (AVVQ) score among patients undergoing laser treatment versus surgery at 6 weeks, despite the use of concomitant phlebectomies in the surgery group. DISCUSSION However, the most important thing remains the access site. The endovenous procedure is well documented in the literature: catheterization, tumescent anesthesia, positioning of the fiber tip, a procedure entirely 71

Saturday January 23

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

performed under ultrasound guidance, but we have little information on where the ideal puncture location should be. Indeed, it is current practice to access the main trunk of the GSV or the SSV at the lowest incompetence area. In fact, the key point is where to begin the endovenous procedure. Catheterization should be at the lowest part of the incompetent GSV under the knee but access from the incompetent tributary. The goal is to disconnect the competent part of the GSV from the incompetent part. If we catheterize the GSV at its lowest incompetence above an incompetent tributary, after treatment the blood will flow from the competent GSV toward the tributary and therefore a phlebectomy of this vein is required. If the access of the GSV is performed by using a distal incompetent tributary we are treating the GSV and the tributary at the same time and therefore no additional phlebectomy is needed. To avoid phlebectomy the access site is crucial. In a case of very sinuous veins, a hydrophilic guide wire can often be passed through the different bends, and the veins can be treated by endovenous ablation, once again avoiding phlebectomy. If several veins are incompetent, a double or triple introduction is needed to treat all of them and not only the GSV. For the GSV of the leg because we cannot correctly identify the GSV’s saphenous nerve, we should avoid treating the GSV below the junction between the upper third and middle third of the leg. Nevertheless access of the upper third of the GSV from the medial tributary even at the lowest part of the leg is possible because there is no nerve companion of the tributary. And after this, (after a period of one month minimum) if necessary the lowest part of the GSV and/or the tributaries can be easily treated by ultrasound-guided foam sclerotherapy (UGFS) IN CONCLUSION The access site is the key point and phlebectomy must be delayed to avoid overtreatment. It is less traumatic when the vein is shrunk and if necessary ultrasound-guided foam sclerotherapy (UGFS) may suffice. BIBLIOGRAPHIE 1. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, Lohr JM, McLafferty RB, Meissner MH, Murad MH, Padberg FT, Pappas PJ, Passman MA, Raffetto JD, Vasquez MA, Wakefield TW; Society for Vascular Surgery; American Venous Forum.The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011 May;53(5 Suppl):2S-48S 2. Marsden G, Perry M, Kelley K, Davies AH; Guideline Development Group. Diagnosis and management of varicose veins in the legs: summary of NICE (National Institute for health and Care Excellence) guidance. BMJ. 2013 Jul 24;347:f427 3. Carradice D, Mekako AI, Hatfield J, Chetter IC.Randomized clinical trial of concomitant or sequential phlebectomy after endovenous laser therapy for varicose veins.Br J Surg. 2009 Apr;96(4):369-75 4. Darwood RJ, Theivacumar N, Dellagrammaticas D, Mavor AI, Gough MJ.Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins.Br J Surg. 2008 Mar;95(3):294-301. 5. Monahan DL.Can phlebectomy be deferred in the treatment of varicose veins?J Vasc Surg. 2005 Dec;42(6):1145-9 6. Welch HJEndovenous ablation of the great saphenous vein may avert phlebectomy for branch varicose veins. J Vasc Surg. 2006 Sep;44(3):601-5. 7. Bush RL1, Ramone-Maxwell C Endovenous and surgical extirpation of lower-extremity varicose veins. Semin Vasc Surg. 2008 Mar;21(1):50-3. 8. Hamel-Desnos C1, Desnos P2, Allaert FA3, Kern P4; the “Thermal group” for the French Society of Phlebology and the Swiss Society of Phlebology. Thermal ablation of saphenous veins is feasible and safe in patients older than 75 years: A prospective study (EVTA study).Phlebology. 2014 Jun 18 9. PA Sutton, Y El-Duhwaib, J Dyer, AJ Guy: The incidence of post operative venous thromboembolism in patients undergoing varicose vein surgery recorded in Hospital Episode Statistics: Ann R Coll Surg Engl 2012; 94: 481–483 10. Knipp BS, Blackburn SA, Bloom JR, Fellows E, Laforge W, Pfeifer JR, Williams DM, Wakefield TW Endovenous laser ablation: venous outcomes and thrombotic complications are independent of the presence of deep venous insufficiency.J Vasc Surg. 2008 Dec;48(6):1538-45 11. Sufian S, Arnez A, Labropoulos N, Nguyen K, Satwah V, Marquez J, Chowla A, Lakhanpal S.: Radiofrequency ablation of the great saphenous vein, comparing one versus two treatment cycles for the proximal vein segment.Phlebology. 2014 Oct 17 12. Sufian S, Arnez A, Labropoulos N, Lakhanpal S.: Endovenous heat-induced thrombosis after ablation with 1470 nm laser: Incidence, progression, and risk factors.Phlebology. 2015 Jun;30(5):325-30 13. Marsh P, Price BA, Holdstock J, Harrison C, Whiteley MS.Deep vein thrombosis (DVT) after venous thermoablation techniques: rates of endovenous heat-induced thrombosis (EHIT) and classical DVT after radiofrequency and endovenous laser ablation in a single centre.Eur J Vasc Endovasc Surg. 2010 Oct;40(4):521-7 14. Lane TR, Kelleher D, Shepherd AC, Franklin IJ, Davies AH.Ambulatory varicosity avulsion later or synchronized (AVULS): a randomized clinical trial.Ann Surg. 2015 Apr;261(4):654-61. 72

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15. El-Sheikha J, Nandhra S, Carradice D, Wallace T, Samuel N, Smith GE, Chetter IC. Clinical outcomes and quality of life 5â&#x20AC;&#x2030;years after a randomized trial of concomitant or sequential phlebectomy following endovenous laser ablation for varicose veins.Br J Surg. 2014 Aug;101(9):1093-7 16. Brittenden J, Cotton SC, Elders A, Ramsay CR, Norrie J, Burr J, Campbell B, Bachoo P, Chetter I, Gough M, Earnshaw J, Lees T, Scott J, Baker SA, Francis J, Tassie E, Scotland G, Wileman S, Campbell MK.A randomized trial comparing treatments for varicose veins.N Engl J Med. 2014 Sep 25;371(13):1218-27

ome debates S Is there a place for phlebectomy? Denis Creton

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Clinique A. Paré, Nancy, France Phlebectomy has greatly improved since its initial description as cited by Robert Muller in 1966: under local anesthesia, removal of varicose veins by sagittal incision as small as some millimeters, performed with N° 1 scalpel blades, hooks and clips and closure of the incisions by simply bringing together the edges in an elasto-cotonned compressive bandage. Nowadays, in a standing position, the mapping precisely defines the areas where varicose veins are protruding. Anesthesia is ideally a tumescent local anesthesia (TLA) using isotonic sodium bicarbonate 1.4% as excipient (lidocaine dilution at about 0.003%) which allows an immediate and very deep anaesthesia without any sedation. The use of needles 18 gauge to perform incisions results in almost invisible scars after 30 days. The use of mini Pin-stripper allows stripping of incontinent tributaries and incontinent accessory saphenous veins. Phlebectomy also allows extracting saphenous trunk after invagination rupture or extracting a trunk for introducing an endovascular catheter. Every varicose vein can be removed by phlebectomy (foot varicose veins, big varicose veins and telangiectasias draining veins) except deep tortuous varicose veins, neovascular and recanalisation varicose veins or varicose veins embedded in trophic disorders or fibrosis tissue after numerous reoperation for recurrence. Phlebectomy has been said to be time-consuming, boring and painful for patients. In fact, in a bicentric and prospective study of 215 varicose veins surgery carried out without any sedation (including 32% strippings, 20% inguinal or popliteal incisions), there were 24 (3-63) phlebectomy incisions per surgery. Average surgery duration was 31 min (8 min - 1H15). Peroperative pain level (evaluated on a 1 to 10 analog visual scale) was significantly higher (3.4 versus 2.2) for more than 30 incisions 1. In another prospective bicentric study of 707 operations with the same operative acts, there were 20 (1-78) phlebectomy incisions. Average surgery duration was 24 min. Peroperative pain (1.5 on the day following surgery) and activity (normal or subnormal in 93% of the cases) was not related to the number of phlebectomies. Not to mention surgery cost 2, for patients it is interesting to perform all the surgical acts at one go: trunk treatment (stripping or endovascular technique) and phlebectomies. This one step treatment is carried out in a 30-minute operation, 45 minutes in operating room, and a few hours in surgical centre and in 80% of the cases without any sedation. Phlebectomy is performed in every varicose vein surgery and alone in 43.5% of the cases. It requires a lot of patience, a very good practice and determination, whereby it is a quick and effective operation. To the question “Is there still a place for phebectomy” the answer is “Phlebectomy not only has still a place but has always all the place!” REFERENCES 1. Creton D, Réa B, Pittaluga P, Chastanet S, Allaert FA. Evaluation of pain in varicose vein surgery under tumescent local anethesia using sodium bicarbonate as excipient without any intravenous sedation. Phlebology. 2012;27:368-73. 2. Carradice D, Mekako AL, Hatfield J, Chetter IC. Randomized clinical trial of concomitant or sequential phlebectomy after endovenous laser therapy for varicose veins. Br J Surg 2009;96:369-75

ome debates S DEBATE. Do we have to preserve the saphenous vein? Should we preserve the saphenous vein not mandatory Gilbert Franco

Clinique Arago, Paris, France Preserve the great saphenous vein for a possible bypass is a laudable intention, but how many bypass will be required in patients with venous insufficiency?Unknown. It would be more appropriate to evaluate the arterial risk in patients with risk factors for arterial disease and be conservative in this context if possible. Preserve the great saphenous vein when it is not dystrophic and merely treat only the varicose veins that only affect collateral by sclerotherapy or phlebectomy should be the aim in this context. The development of endovascular treatments of arterial desease greatly reduced the indications of revascularisation by femoro-popliteal and distal venous bypass . The coronary bypass now using the internal thoracic artery forgot the great saphenous vein. Systematically preserve a clearly pathological saphenous vein is nonsense because it is a poor material less reliable than graft that numerous studies attest. In most cases the tibial segment of the great saphenous vein remains healthy and can be used for surgery so this is the segment to preserve what is the case with thermal ablation and short stripping. This unnecessary preservation will condemn the patient to live with venous insufficiency and risk of subsequent complications by perpetuating an important stasis. On the other hand preservation of a vein would be justified not to destroy abusively sub normal vein. Unfortunately now the ease of thermal ablation leads too many patient with a reflux at duplex scan investigation to surgery . This is unfortunately the consequence of a lack of knowledge of the pathophysiology. Truncular reflux is the result of retrograde venous blood flow induced by the association of varicose vein effect of the muscle pump ,gravitation and can be observed in a short saphenous segment without any valvular incompetence. In this case any treatment destroying saphenous vein is inapropriate. Vascular access for hemodialysis is most likely the last bastion of classical Vascular Surgery where persists by pass indications to create vascular access when venous capital is exausted or to treat induced ischemia by DRIL . In this context venous allografts as BIO PROTEC used over 1,000 per year in France are an interesting substitute.Produced from saphenous veins collected during the surgical treatment of varicose veins or produced from saphenous veins collected from multi organ donation . The selection consists of eliminating all aneurysmal segment using healthy saphenous segment put end to end and sutured.The results of these bypasses without being as good as when using a fully healthy saphenous are acceptable. If the stripping is completely abandoned in favor of thermal methods the availability of this bioprosthesis significantly decrease. Removal of varicose veins can have beneficial effects beyond the treatment of varicose disease and the number of revascularization achieved through it exceeds all that has ever been done by conservative methods as CHIVA .

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ome debates S Treatment of telangiectasias by foam sclerotherapy under ultrasound guidance Claudine Hamel Desnos

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Médecine Vasculaire, Hôpital Privé Saint Martin, Caen-France SUMMARY Both the Duplex Ultrasound (DUS) and foam have revolutionized sclerotherapy and are now common practice in the assessment and treatment of varicose veins of the lower limbs. With regards to the reticular veins and telangiectasias, known as “C1”, according to the CEAP clinical classification, their use is progressing more ‘timidly’. Thus, in the European Guidelines published in 2014 1, it is specified that: -concerning the pre-treatment assessment before sclerotherapy: “In telangiectasias and reticular varicose veins, cw Doppler instead of DUS may be sufficient. -“Liquid sclerotherapy is considered to be the method of choice for the treatment of C1. Foam sclerotherapy is an additional treatment option for C1” Place of DUS for the pre-treatment assessment for the C1s A reticular vein measures 1 to 3 mm in diameter and telangiectasia less than 1 mm. Nowadays, the US probes available to the therapist in current consultation of phlebology, have sufficient resolution to visualize vessels of less than 1 mm. It is therefore technically possible to identify feeding reticular veins from a telangiectasia area, and by tracing these, the source of the proximal reflux can be located, if there is indeed one. The source of a proximal reflux can sometimes be a saphenous trunk that would have otherwise been ignored in the absence of a DUS assessment. The success of sclerotherapy depends on the assessment and the resulting choice of method, not only with regards to efficiency, but also when taking into account the limitation of post-operative side-effects (such as pigmentation, inflammation and matting). The pre-therapeutic DUS assessment is therefore just as significant for C1s as it is for any other kind of varicose vein. The role of foam for C1s The “poor reputation” that foam has received for C1s is due to supposedly more significant neurological secondary effects, compared with liquid sclerotherapy. Indeed, this difference has not clearly been demonstrated and the occurrence of these effects remains rare and is equivalent to those observed in all other foam sclerotherapy 2. The advantages of foam in the treatment of C1s are the same as those for the treatment of varicose veins: -more efficiency, with less sclerosing agent, fewer injection points, fewer sessions; -less painful injections; -less bleeding at the needle-puncture sites; -less risk for extravascular injections 3; -a tracing, “contrast” effect of the foam allows monitoring, after the injection, the distribution of the foam in the reticular veins and telangiectasias by ultrasound (in B mode). Weak concentrations should be used to make the foam: 0.125% for telangiectasia and 0.125 to 0.25% for reticular veins, with polidocanol. These concentrations in foam are “off-label” in France and their use remains the responsibility of the practitioner. Foam ultrasound guidance Technically it is possible to inject under ultrasound guidance 1mm vessels that are invisible to the naked eye. Like foam sclerotherapy of trunks and varicose veins, the distribution of foam is then visualized in the network concerned, and particularly in the reticular veins and telangiectasias. Let us note that Vincent 4 demonstrated that reticular veins and telangiectasias were equipped with valves, just as varicose veins are. Thus, the visualization, by the naked eye and in mode B, of the foam in the telangiectasia veins after an injection of a vein considered to be feeder, allows for the validation the pre-therapeutic diagnostic assessment by confirming the connections of the network in question and the incontinence of the micro-valves.

In conclusion, the advantages of ultrasound guidance and foam in the treatment of C1s by sclerotherapy, perfectly match those observed and recognized for any varico se veins. With the improvement of technology, it seems reasonable to believe that in the years to come, their usage will be more and more frequent in this indication.

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BIBLIOGRAPHY 1. Rabe E., Breu FX, Cavezzi A., Coleridge Smith P., Frullini A., Gillet JL., Guex JJ., Hamel-Desnos C., Kern P., Partsch B., Ramelet AA., Tessari L., Pannier F., for the Guideline Group. European guidelines for sclerotherapy in chronic venous disorders. Phlebology. 2014 Jul; 29(6):338-54 2. Willenberg T, Smith PC, Shepherd A, Davies AH. Visual disturbance following sclerotherapy for varicose veins, reticular veins and telangiectasias: a systematic literature review. Phlebology. 2013 Apr;28(3):123-31 3. Schuller-Petrovic S., Pavlovic M.D., Neuhold N., Brunner F., Wรถlkart G. Subcutaneous injection of liquid and foamed polidocanol: extravasation is not responsible for skin necrosis during reticular and spider sclerotherapy. JEADV 2011, 25: 983-986 4. Vincent JR, Jones GT, Hill GB, van Rij AM. Failure of microvenous valves in small superficial veins is a key to the skin changes of venous insufficiency. J Vasc Surg 2011; 54: 62S-9S

ome debates S Treatment of telangiectasias by laser Thomas Proebstle

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Dept Dermatology, University Medical Center Mainz, Germany Lasers are generally capable to treat leg telangiectasia, however the following applies: Small leg telangiectasia: For diameters below 0.5 mm and telangiectatic matting the FPDL at 595 nm is effective. The KTP laser at 532 nm is suitable on diameters below 0.7 mm. Multipass treatment or pulse stacking may improve clinical results. Larger telangiectasia up to 3 mm diameter can be effectively treated by long pulse Nd:YAG lasers with 1064 nm wavelength. Combination of laser treatment of leg telangiectasia with prior injection of a polidocanol foam seems to increase clearance rates dramatically, systemic injection of an indocyanine green dye prior to laser therapy may increase treatment success as well. Effective skin cooling is mandatory to avoid thermal skin damage. Appropriate cooling devices are dynamic spray cooling, contact cooling or cooled air. Cooled gels do not provide sufficient nor homogenous skin cooling. In human skin melanin is the main competing light absorber to hemoglobin, therefore laser treatment of telangiectasia can cause the side effect of long lasting hyperpigmentation. An increased epidermal melanin content after sun exposure – a so called tanned skin – therefore should be regarded a contraindication to cosmetic laser treatment of leg telangiectasia

REFERENCES Moraga JM, Smarandache A, Pascu ML, Royo J, Trelles MA. 1064 nm Nd:YAG long pulse laser after polidocanol microfoam injection dramatically improves the result of leg vein treatment: A randomized controlled trial on 517 legs with a three-year follow-up. Phlebol 2014: 29: 658–666.

clerotherapy & Miscellaneous S Sclerotherapy (techniques, tactics and results). The French method. Claudine Hamel-Desnos

Hôpital Privé Saint Martin, Caen, France Historically, three main techniques founded on different tactics have been used in sclerotherapy 1: - the bottom-up technique (Swiss technique, by Sigg). The distal varicose veins are treated first with a deferred treatment of the trunks if necessary. Numerous sessions are required for this lengthy treatment. - the Irish technique (Fegan technique) attaches primary importance to perforating veins which are treated first, usually leaving the trunks and junctions untreated. - The top-down technique (French technique by Tournay) consists in treating the highest or largest leakage points: saphenofemoral junctions or saphenopopliteal junctions, saphenous trunks, perforating veins, etc. The tributary veins are not initially treated, and are only injected at a later time if necessary. For the first two methods, a post-sclerotherapy compression is systematically applied and is considered to play a key role. For the Tournay technique, which provokes fewer inflammatory reactions than the other two techniques, compression only plays an accessory role and does not benefit from any particular recommendations with regards to sclerotherapy. The Fegan technique has currently been abandoned. To date, the Sigg technique has been adapted with a therapeutic proposal of chemical ablation modelled on selective phlebectomy (according to ASVAL – selective ablation of varicose veins under local anaesthesia): sclerotherapy of tributaries in first-line treatment attempts to eliminate the reflux of the saphenous vein, while preserving the saphenous vein itself. There is no real experience in this approach of sclerotherapy, which is for the moment more theoretical and not really applied in practice. Finally, it is the French Tournay method, initiated in the 1940s, and recommended by European guidelines  2, which is the most widely used today. It is based on different puncture levels, from top to bottom, and for better adaptability ideally requires using the puncture-injection sclerotherapy technique, directly with a needle: the needle is mounted directly onto the syringe which contains the sclerosing agent. The direct puncture-injection method is the basis of sclerotherapy and has always been used. It generally remains the most preferred technique by French phlebologists, as they seldom use long catheters, canula devices, or “butterfly” needles The main advantages of this method are: precision, swiftness of gesture, adaptability to all types of veins (from telangiectasias to saphenous trunks) and positioning, graduated injections are easier to perform with a change of concentration possible, and absence of tubing connections which may result in a degradation of the foam. However, it demands a longer learning process and more dexterity than the other techniques (the syringe needs to be handled by one hand only). This basic technique has benefited from significant improvements mainly achieved through ultrasound guidance and foam, but the principle remains the same. In all cases, the highest and largest leakage points, such as proximal segments of the incompetent saphenous trunks, are injected first 2. Traditionally, the French sclerotherapy foam technique, carried out under ultrasound guidance, includes four main steps (all of these are performed under permanent ultrasound guidance): - choice of vein puncture site; arterioles, which represent a danger, are located beforehand; - needle puncture and slight blood back-flow into the tip of syringe; - injection; - immediate post-injection checking: foam distribution in the veins and occurrence of the spasm. This US checking allows for an immediate evaluation and helps to decide if further injections are necessary, during the same session. This method was described in 2003 3 and then adopted by the French Health Authorities in 2004 (4) and by the European Guidelines in 2014 2. This method of injections by divided doses has the advantage of allowing for the concentration of the foaming agent to be modified depending on the diameter of the target vein, and furthermore allows for an adaptation of volumes required according to the parietal reaction of the vein (spasm) and the filling of 79

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CONTROVERSIES & UPDATES IN VARICOSE DISEASE

the foam. It is thus an ‘à la carte’ treatment for each patient and for each vein. With overdosing minimalized, there is less post-sclerotherapy inflammatory reactions for this technique, compared with the Sigg and Fegan methods. Moreover, the laboratory studies conducted by Watkins, 5 showed that once injected, the sclerosing agent is quickly deactivated by the blood in the vein. The author thus recommends the injection of “fresh foam”, in divided doses, to the target venous network, in order to obtain a more efficient sclerotherapy. Several foam injections rather than a single “bolus” dose might also reduce the risk of post-treatment deep vein thrombosis 6. There are no randomized studies that compare the French technique with the other techniques. A study by Wright simply shows that for sclerotherapy, among the investigators, the French phlebologists obtained better results than the European surgeons did; however, the surgeons were not all well experienced in sclerotherapy 7. In two sizable French studies, the rate of complete occlusion of the saphenous veins, one month after foam sclerotherapy, were respectively 90.3% and 93.4% 8,9. In the first study, 1025 saphenous veins (818 GSV and 207 SSV) were treated by 20 French phlebologists and in the second study, 331 small saphenous veins were treated by 22 French phlebologists. A controlled randomized French study compared foam sclerotherapy of the saphenous veins (using direct needle puncture, French technique), carried out either with elastic compression, or without compression post-procedure. The occlusion rate of the veins 3 months post-treatment was 100% for both groups, demonstrating that compression does not have an impact in the efficiency of this method 10. As a matter of fact, the French technique for sclerotherapy is part of a logical and tactical approach that other endovenous techniques for treatment of varicose veins (laser, radiofrequency, glue, MOCA…) apply naturally: priority treatment of proximal segments of the trunk, then the whole of the trunk concerned, from top to bottom. As for the tributary veins, they then benefit from an accessory treatment, which is not always indispensible and which could possibly be deferred 11. In conclusion, the French top-down technique, developed for sclerotherapy in the 1940s, remains the method of reference for all endovenous treatment of varicose veins of the lower limb. BIBLIOGRAPHY 1. Hamel-Desnos C., Moraglia L., Ramelet A-A. Sclérothérapie. In: La Maladie veineuse chronique. Elsevier Masson SAS 2015: 89126 2. Rabe E., Breu FX, Cavezzi A., Coleridge Smith P., Frullini A., Gillet JL., Guex JJ., Hamel-Desnos C., Kern P., Partsch B., Ramelet AA., Tessari L., Pannier F., for the Guideline Group. European guidelines for sclerotherapy in chronic venous disorders. Phlebology. 2014 Jul; 29(6):338-54 3. Hamel-Desnos C., Desnos P., Ouvry P. Nouveautés thérapeutiques dans la prise en charge de la maladie variqueuse: échosclérothérapie et mousse. Phlébologie 2003, 56, N°1, 41-8 4. ANAES. Traitement des varices des membres inférieurs. Rapport de l’Agence Nationale d’Accréditation et d’Evaluation en Santé. Service Evaluation en santé publique – Evaluation technologique Juin 2004 5. Watkins MR. Deactivation of sodium tetradecyl sulphate injection by blood proteins. Eur J Vasc Endovasc Surg. 2011; 41(4):521-5. Epub 2011/01/26 6. Yamaki T, Nozaki M, Sakurai H, Takeuchi M, Soejima K, Kono T. Multiple small-dose injections can reduce the passage of sclerosant foam into deep veins during foam sclerotherapy for varicose veins. Eur J Vasc Endovasc Surg. 2009; 37(3):343-8. Epub 2008/10/17 7. Wright D., Gobin J P., Bradbury AW., Coleridge-Smith P., Spoelstra H., Berridge D., Wittens C H A., Sommer A., Nelzen O., Chanter D. Varisolve® polidocanol microfoam compared with surgery or sclerotherapy in the management of varicose veins in the presence of trunk vein incompetence: European randomized controlled trial. Phlebology 2006; 21:180-90 8. Gillet JL, Guedes JM, Guex JJ, Hamel-Desnos C., Schadeck M., Lausecker M. Side effects and complications of foam sclerotherapy of the great and small saphenous veins: a controlled multicentre prospective study including 1025 patients. Phlebology 2009; 24: 131-138 9. Gillet J-L., Lausecker M., Sica M., Guedes J-M., Allaert FA. Is the treatment of the small saphenous veins with foam sclerotherapy at risk of deep vein thrombosis? Phlebology 2014; 29 (9): 600-7 10. Hamel-Desnos C, Guias B.J., Desnos P.R., Mesgard A. Foam sclerotherapy of the saphenous veins: randomized controlled trial with or without compression. Eur J Vasc Endovasc Surg 2010; 39: 500-7 11. Hamel-Desnos C. Ablation Thermique et traitements complémentaires. Phlébologie 2013, 66, 2: 70-78

clerotherapy & Miscellaneous S Sclerotherapy (techniques, tactics and results), the English method Huw Davies, Andrew Bradbury

Heart of England NHS FT, Birmingham, United Kingdom INTRODUCTION Although many publications have shown ultrasound-guided foam sclerotherapy (UGFS) to be clinically and cost effective, and the procedure has been recommended in national (UK NICE) guidelines, sclerotherapy is more operator dependent than endothermal ablation (ETA), and disappointing results have been reported even in large randomised controlled trials. What has become known as the ‘English’ method has been developed with the aim of maximising anatomic, haemodynamic and patient reported outcomes and minimising the need for retreatment. TECHNIQUES Truncal veins are cannulated (Optiva) under ultrasound (US) guidance at 10-20cm intervals and, after elevating the leg, injected with 2ml aliquots of ‘fresh’ foam comprising 3% sodium tetradecyl sulphate (STS) mixed 3-4:1 with room air via a 5mm filter. Tributaries and varices are cannulated at similar intervals, including as distally as possible (just above the “re-entry” perforators) and filled with 1% STS air foam. US monitoring is used to exclude inadvertent extravasation and ensure that all of the veins to be treated are in spasm and full of foam. Between injections, patients are asked to repeatedly platar/dorsi-flex their ankle to clear any foam from the deep system. Patients are bandaged (Pehahaft) for 2-3 days and placed in a European Class II stocking for 2-3 weeks. On review, any tender, lumpy, discoloured areas are aspirated under US guidance using local anaesthetic. TACTICS The key principle is to “close the front door” (the sapheno-femoral-popliteal junctions and other non-junctional perforators) and “close the back door” (re-entry perforators) and to fill all of the intervening veins with foam during one treatment session RESULTS Numerous publications attest to the safety, clinical and cost-effectiveness of the ‘English’ method which is associated with significant improvements in generic and disease specific health-related quality of life beyond 5 years, and a low rate of treatment, similar to those commonly reported after ETA. CONCLUSION The ‘English’ method is a safe, inexpensive, versatile, well tolerated and clinically effective technique for UGFS which can used to treat most (up to 90%) of patients affected by CEAP 2-6 lower limb venous disease.

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clerotherapy & Miscellaneous S Different Ways Of Making Foam; With 1% Pure Polidocanol, Or With 2 % Polidocanol. Are They Similar?

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Philippe Desnos

Cabinet dâ&#x20AC;&#x2122;Angeiologie, Caen, France The manufacture of sclerosing foam requires the use of a liquid ingredient which can be transformed into foam. The concentration of this active substance must be adapted to the vein being treated by sclerotherapy. Thus a large varicose vein will be immobilised with a highly concentrated product whilst telangiectasia will require a more diluted agent. Often manufacturers do not put products on the market whose concentration is adapted precisely to the practitionerâ&#x20AC;&#x2122;s needs. For example, in France, polidocanol is not available in the form of 1%. Consequently, many phlebologists mix a more concentrated product with physiological serum to obtain the desired concentration. Can this modification of the vehicle influence the quality of the resulting foam? In order to answer this question, we suggest comparing the physical characteristics of two foams; the first one in its native form developed with unmodified polidocanol, and the second one made from more concentrated polidocanol and diluted with a saline solution. So let us now compare the physical characteristics of a foam made of 1% native polidocanol with a foam made from diluted polidocanol and a saline solution. This comparison requires the implementation of an experiment plan where dilution is the only variable. The evaluation of the physical qualities being determined by the half-life and the microscopic analysis of the two. The results of this experimental plan are the subject of this communication.

clerotherapy & Miscellaneous S How to ensure the success of sclerotherapy? 10 rules to respect Claudine Hamel-Desnos

Hôpital Privé Saint Martin,Caen, France Sclerotherapy is a safe and efficient technique in the treatment of varicose veins of the lower limbs. Historically, it has been used for over a century but it is mainly since the advent of ultrasound guidance and sclerosing foam that it has been the subject of numerous scientific studies. It is indispensable in the therapeutic arsenal against varicose veins but must be practised according to certain rules of good practice, governed by the respect of guidelines and international recommendations. We report on 10 basic rules to respect for an optimal use of sclerotherapy. 1. The respect of prerequisites and of training. The operator needs to have had good training, specific to the practice of visual sclerotherapy and ultrasound guided sclerotherapy, and therefore must also possess the necessary prerequisites (a good knowledge of venous diseases, a good practice of venous Duplex Ultrasound). A regular activity in this practice is paramount. 2. The characteristics of the foam. • According to current recommendations, it should be made with a mixture of 1 volume of sclerosing agent for 4 (or 5) volumes of air, with the help of a two-way connector (or three-way stopcock). • It must be of good quality (with no visible bubbles). • It should be injected quickly enough after its preparation so as not to be injected in a degraded form (with the shortest possible time between its preparation and its use, <60 seconds). • Foam made with air is at its most sable. 3. The tactic. The initial assessment of the pathology must be established in a precise manner in order to apply the best possible tactic, adapted to each clinical case. Good dexterity does not suffice if the incorrect tactic is chosen. Thus, the choice of site for the first injection is decisive, established after a thorough clinical analysis and an ultrasound assessment of the situation, and in a logical tactic for a given area, all the whilst respecting the safety of the chosen site. 4. The planning of the injections. The injections are administered from the zones of reflux which are highest up, towards the distality, and from the largest varicose veins to the smallest ones. Staged injections allow for the action of the foam on the venous walls to be optimized, given that the sclerosing agent is extremely vulnerable once in contact with blood. 5. The choice of concentration of the sclerosing product is determined according to the diameter of the venous segment to be treated, which is measured while the patient is standing up. 6. The volume injected is determined by the occurrence of a spasm in the target vein and by the homogenous and compact filling of this vein by the sclerosing foam (criteria of judgment: ultrasound image in mode B, following the injection). The volumes injected are dosed and graduated so as to avoid overdosing (as opposed to administering a ‘bolus’ dose at a single point of injection). 7. The technique used. The direct needle puncture allows for optimal precision. 8. Ultrasound guidance should be used as soon as it is technically possible. Echo-sclerotherapy implies permanent ultrasound monitoring throughout the procedure, but also beforehand (during the assessment-location phase; the safety and pertinence of puncture sites), and afterwards (monitoring of the foam distribution and the occurrence of a spasm in the vein being treated). 9. The indications. These must be targeted correctly; technically, large saphenous veins (>6 mm) can be treated, but may provoke more recanalizations. 10. The follow-up on the assessment of efficiency after the foam sclerotherapy must not be performed too soon (at least 6 weeks post injection).

Saturday January 23

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

CONCLUSION The optimization of the treatment of varicose veins by sclerotherapy necessitates a skilled operator, good quality foam, which is injected quickly after its manufacture and administered in the most pertinent area tactically, commencing from the top, with injections being performed according to the direct needle puncture technique and under permanent ultrasound guidance. The doses must be adapted to each given case. BIBLIOGRAPHY 1. Rabe E., Breu FX, Cavezzi A., Coleridge Smith P., Frullini A., Gillet JL., Guex JJ., Hamel-Desnos C., Kern P., Partsch B., Ramelet AA., Tessari L., Pannier F., for the Guideline Group. European guidelines for sclerotherapy in chronic venous disorders. Phlebology. 2014 Jul; 29(6):338-54 2. Hamel-Desnos C, Moraglia L, Ramelet AA. SclĂŠrothĂŠrapie. In: La Maladie veineuse chronique. Elsevier Masson SAS 2015: 89-126

clerotherapy & Miscellaneous S Prevention of visual and neurologic disturbances after sclerotherapy with antiendothelin prophylaxis Alessandro Frullini

Studio flebologico, Figline Incisa Valdarno, Florence, Italy OBJECTIVES / PURPOSE STATEMENT 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). METHOD 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/day or a 150mg/kg/day 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. Moreover a multicentric trial (PROCOMET STUDY) was done on 540 patients submitted to sclerotherapy for CVD. One subgroup of patients was submitted to Aminaphtone prophylaxis. RESULTS 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 Human umbilical vein endothelial cell (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. In the patients where Aminaphtone prophylaxis was performed significant reduction of side effects was achieved in those sclerosed for teleangectasias and when migrani history was present (2,43% vs 0% and 38,4% vs 3,2% respectively) CONCLUSIONS 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. Due to the excellent safety profile of Aminaphtone, systematic prophylaxis is now performed in my office for all patients undergoing sclerotherapy.

Saturday January 23

clerotherapy & Miscellaneous S Various grades of recommendation in the management of primary varicose veins Michel Perrin

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Lyon, France

Lower limbs chronic primary superficial venous disease treatment of the has been subject of different recommendations that deserve to be analyzed by taking in account the societies which recommend them and the grading system used. - THE SVS/AVF guidelines were published in 2011.1 Most of their recommendation remain valid but are not fully applicable in Europe. The SVS/AVF guidelines were analyzed by an European team. 2 - In 2013 the European guide for sclerotherapy was available giving many information on this procedure including practical information.3 - In 2014 the guidelines of the European venous forum and the international Union of Angiology published a document on chronic venous disorders. 4 - The International guidelines on endovenous thermal ablation was published in 2015. This consensus document provides also many technical details. 5 The same year the European Society for vascular surgery endorsed a guideline on management of Chronic venous disease. 6 All the guidelines use the Guyatt grading, its grading scheme classifies recommendations as strong (grade 1) or weak (grade 2), according to the balance among benefits, risks, burdens, and possibly cost, and the degree of confidence in estimates of benefits, risks, and burdens. The system classifies quality of evidence as high (grade A), moderate (grade B), or low (grade C) according to factors that include the study design, the consistency of the results, and the directness of the evidence. 7 Only the ESVS guidelines use the European Society of Cardiology grading system. For each recommendation, the letter A, B, or C marks the level of current evidence. Weighing the level of evidence and expert opinion, every recommendation is subsequently marked as either class I, IIa, IIb, or III. The lower the class number, the more proven is the efficacy and safety of a certain The national Institute for health and Care Excellence (NICE) published in 2013 a document on varices veins of the leg and the recommendations were For people with confirmed varicose veins and truncal reflux: - Offer endothermal ablation (Radiofrequency ablation of varicose veins [NICE interventional procedure guidance 8] and Endovenous laser treatment of the long saphenous vein [NICE interventional procedure guidance 52]). - If endothermal ablation is unsuitable, offer ultrasound-guided foam sclerotherapy (see Ultrasound-guided foam sclerotherapy for varicose veins [NICE interventional procedure guidance 440]). - If ultrasound-guided foam sclerotherapy is unsuitable, offer surgery. If incompetent varicose tributaries are to be treated, consider treating them at the same time. 9 REFERENCES 1. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53:2S-48S 2. Lugli M, Maleti O, Perrin M. Review and Comment of the 2011 Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum. Phlebolymphology 2012: 19(3): 107-20 3. Rabe E, Breu FX, Cavezzi A, Coleridge Smith P,Frullini A, Gillet Jl et al. European guidelines for sclerotherapy in chronic venous disorders. Phlebology 2014;29:338-54 4. Management of chronic venous disorders. International Angiology.2014;33: 87-208 5. Pavlovic MD, Petrovic SS, Pichot O, Rabe E, Maurins U, Morrizon N, Pannier F.Guidelines of the First International Consensus Conference on Endovenous Thermal Ablation for Varicose Vein Disease â&#x20AC;&#x201C; ETAV Consensus Meeting 2012. Phlebology 2015:30:257-73 6. Management of Chronic venous disease. Clinical Practice Guidelines of the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg 2015:49: 678-737 86

7. Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians Task Force. Chest 2006; 129: 174–81. 8. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). European Heart Journal (2012) 33, 1635–1701 doi:10.1093/eurheartj/ehs092 9. National Institute for Health and Care Excellence. Varicose veins in the legs - the diagnosis and management of varicose veins. Clinical guideline 2013;168:1-248 TABLE Recommendations of operative procedures for the treatment of superficial refluxing veins from recent guidelines. (references)

Modern Surgery CHIVA ASVAL EVLA or RFA

SVS/AVF 185 GSV 2B* SSV 1B* NG 2B* 2C* 1B*

Steam Clarivein® Glue UGFS

NG NG NG

NG NG 1A*

NG NG III A**

1A* NG NG NG

1B*

I A**

NG NG 1A-1C* according to vein diameter NG

1B*

I A**

2C* 2C* 2C*

NG NG NG

NG IIa B** IIa B**

NG NG NG

Surgery

Thermal ablation versus UGFS (GSV) Thermal ablation versus Surgery (GSV) Surgery for PREVAIT UGFS for PREVAIT Endovenous thermal ablation for PREVAIT

EVF/IUA 187

ESVS 189

2A*

I B**

1 B* NG NG 1A*

NG II b B** II a B** GSV I A** SSV IIa B**

ETAV/IUP 188

NG NG NG 1A*

EGS 23

NG NG NG NG

*G uyatt’s grading; (190) ** Grading system of the European Society of Cardiology (191); NG, not graded. Abbreviations (scientific terms): ASVAL= Ablation Selective des Varices sous Anesthésie Locale. Ambulatory Selective Vein Ablation under Local anesthesia; CHIVA, Cure Hémodynamique de l’Insuffisance Veineuse en Ambulatoire. Conservative ambulatory HemodynamIc management of VAricose veins; EVLA, endovenous laser ablation; GSV, great saphenous vein; PREVAIT, presence of varices after operatIve treatment; SSV, small saphenous vein; UGFS, ultrasound guided foam sclerotherapy Abbreviations (scientific societies): EGS, European Guide for Sclerotherapy; ESVS, European Society of Vascular Surgery; ETAV/IUP, Endovenous Thermal Ablation for Varicose Vein Disease;/International union of Phlebology EVF/IUA, European Venous Forum/International Union of Angiology; SVS/AVF= Society of Vascular Surgery/ American Venous Forum.

Saturday January 23

Operative procedure

clerotherapy & Miscellaneous S Enjeux socio-économiques de la maladie veineuse

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

François-André Allaert

Département santé publique, Université de Liège, Belgique Sur le plan social, une étude conduite sur 1065 femmes1 exerçant une activité professionnelle montre que : 89,3% sont exposées professionnellement à des facteurs de risque susceptibles de favoriser la survenue de leur maladie veineuse ou de l’aggraver, 70,7% travaillent debout, 49,5% sont sédentaires, 20,9% travaillent dans une ambiance à température élevée. Ces divers facteurs se cumulant souvent chez une même femme. Cette situation est sans issue pour beaucoup d’entre elles : 91,1% répondaient qu’à moins de changer de métier il ne leur était pas possible de se soustraire à leurs facteurs de risque professionnels. Ce n’est pas possible car elles exercent souvent les seuls métiers qu’elles ont pu trouver: vendeuses, caissières, serveuses, employées de collectivités… 19,9% considéraient que leur maladie veineuse constitue un handicap important dans leur vie professionnelle. 1% seulement envisageait de pouvoir changer d’emploi. Une autre étude chez 3224 femmes âgées de 44 ± 10 ans exerçant une activité professionnelle 2 rapportait les résultats suivants : 26,8 % des femmes indiquaient que les troubles veineux augmentaient beaucoup la pénibilité de leur travail, 73,8% considéraient que leurs conditions de travail avaient aggravé leurs troubles veineux et 9% qu’ils en étaient à l’origine... Sur le plan économique, Le coût des biens et services médicaux induits par la prise en charge de la maladie veineuse est élevé mais il est difficile d’imaginer qu’il puisse en être autrement pour une pathologie dont la prévalence atteindrait 10 millions de personnes dans la population française. Le coût est régulièrement stigmatisé comme plus élevé en France que dans les autres pays alors qu’a priori la prévalence de la maladie veineuse n’est pas plus importante mais ces comparaisons sont mal fondées : elles ne prennent pas en compte l’ensemble des dépenses directes ou indirectes induites par la maladie veineuse aux différents stades. En particulier, ne pas tenir compte des dépenses liées aux soins d’ulcères ou à la chirurgie d’éveinage constitue un biais d’analyse important. Il en est de même de ne pas prendre en compte les coûts des arrêts de travail. La question est de savoir si une prise en charge efficace de la maladie veineuse aux stades précoces est susceptible de réduire ou non les coûts directs et surtout les coûts indirects dont l’évolution est quasi exponentielle en fonction du stade de gravité de la maladie. Pour simplifier, focalisons-nous sur un des déterminants majeurs des coûts indirects de la maladie veineuse à savoir sur la fréquence des arrêts de travail au décours des consultations. Cette fréquence varie de 1,5% pour le stade 2 à 3,9% pour le stade 3 puis triple pratiquement pour atteindre 12% pour les stades 4 et les stades 5 et 6 (11,3% et 13,8%) 3. Les stades 4, 5 ,6 représentent globalement 20% de la population atteinte d’une maladie veineuse et concernent 2 millions de patients parmi lesquels la moitié est en exercice professionnel soit 1 million. Sous l’hypothèse (très basse) de 2 consultations par an, on a alors 1 000 000 x 2 x 12% arrêts de travail d’une durée moyenne de 8 jours 1,2 auxquels il faut retrancher les 3 jours du délai de carence soit 1 200 000 jours de travail. Sur la base d’une indemnité quotidienne moyenne de 40 euros, les arrêts de travail induits par les seuls stades 4, 5 et 6 chez les femmes en exercice professionnel provoquent 48 000 000 d’euros de dépense. La lutte contre la maladie veineuse était coût/efficace et nous paierons socialement et économiquement l’abandon progressif de cette prise en charge, d’abord au travers du déremboursement des veinotoniques et désormais des restrictions aux prescriptions de la compression élastique. 1. Allaert FA, Verrieres JL, Urbinelli R. Conséquences médico-sociales de l’insuffisance veineuse diurne et nocturne sur la vie quotidienne des femmes. Angéiologie 1998 ; 50(4) : 55-61. 2. Allaert FA, Causse C. Pharmaco-épidémiologie de la prise en charge de l’insuffisance veineuse chronique en médecine générale. Angéiologie 2000 ; 52(4) : 8-16. 3. Causse C., Allaert F.A., Cazaubon M., Le Teuff G., Lecomte Y., Urbinelli R. Maladie veineuse et ergonomie du travail féminin. Angéiologie, mars 2003 ; n°1 vol.55 : 51-58.

clerotherapy & Miscellaneous S Call for excellence in the management of venous disease - role of European venous meetings and supranational societies Bo Eklöf

Lund University, Lund, Sweden The last 15 years are recognized by a marked interest for venous disease. At the Veith symposium in New York 2002 there were 7 papers presented in one late session Friday afternoon when the majority of the delegates vanished for the pleasures of the Big Apple. 12 years later, in 2014, there were 289 papers on venous disease presented during 3 days! It is difficult to satisfy the need for education and update on the progress in venous disease, and the venous part is expanding at major vascular meetings in Europe: this meeting on controversies in Paris in January;the Charing Cross meeting in London in April; the Maastricht meeting in May; the ESVS meeting in September. Phlebology has a strong tradition in Europe and the national societies are very active with annual scientific and educational meetings, e.g. France: Société Francaise de Phlebologie and Société de Phlebectomie ambulatoire; Germany: Deutsche Gesellschaft fur Phlebologie; Italy: Italian College of Phlebology;Spain. Several countries have formed alliances: Benelux Society of Phlebology in 1957; Scandinavian Venous Forum in 1963; RSM Venous Forum, UK in 1983; Balkan Venous Forum in 2009, now with 13 member countries; Baltic Venous Forum in 2009, now with 4 member countries; Russian Venous Forum under development. European Venous Forum. Stimulated by the success of the American Venous Forum, Andrew Nicolaides and Michel Perrin created the European Venous Forum in 1999 with the first meeting held in Lyon in 2000 with 168 participants. AVF was founded 1989 by members of the SVS and functions today as the venous arm of SVS. EVF should develop a similar relationship with ESVS. The 15th scientific EVF meeting was held in Paris in 2014 under the successful presidency of Jean-Luc Gillet, and the 16th scientific EVF meeting in Saint Petersburg under the excellent presidency of Evgeny Shaydakov with more than 600 participants. The next EVF meeting will be organized in London with Andrew Bradbury as president in July 2016. At the meeting in Saint Petersburg 32 scientific papers were selected from more than 200 abstracts, with 6 didactic sessions and an international exchange of award winning papers from AVF, ACP and the Japanese Society of Phlebology. EVF contributions in education: EVF annual scientific meeting; EVF Hands-on Workshop (EVF HOW); EVF HOW interactive website; EVF HOW Plus – advanced training; EVF guidelines: management of CVD, prevention and treatment of venous thromboembolism. EVF HOW started in 2010 as the educational arm of EVF. The 6th EVF HOW will take place in Krakow, Poland in October 2015 with a limit of 100 participants. 34 faculty experts from Europe and the US will deliver 40 lectures and 18 interactive case discussions on acute and chronic venous disease. The main emphasis is on hands-on activities at 24 workstations where each participant will spend 30 min in groups of four at each station where an interaction will take place with one faculty member and one industry expert at each station. All participants have access to the EVF HOW interactive website before, during and 1 year after the workshop including all presentations, important references and guidelines, case reports, videos of procedures and detailed information about the workstations. EVF HOW Plus are advanced courses where diagnostic and treatment modalities demonstrated at EVF HOW can be realized in real practice. The first two courses were organized in April and May 2015 in Modena, Italy under the enthusiastic leadership of Oscar Maleti and Marzia Lugli with four qualified vascular surgeons as learners in each course. The first course was on stenting of femoro-ilio-caval obstructions and the second on deep valve repair. Several courses are planned for 2016. European College of Phlebology (ECoP) was established in 2012 by Alun Davies, UK, Martin Neumann, the Netherlands, Eberhard Rabe, Germany and Cees Wittens, the Netherlands, primarily to stimulate optimal care for all patients in Europe suffering from venous disease with the objectives to create guidelines for the best medical care for the venous patient in Europe; standardize education and training: develop a European curriculum for phlebology; leading to a certificate of phlebology; request recognition by European Union of medical specialists (EUMS); apply for a multidisciplinary EUMS committee for phlebology. 89

Saturday January 23

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Future in Europe Build up guidelines, curriculum, education programs and certification processes in collaboration with ongoing efforts in Australia/NZ and the US â&#x20AC;&#x201C; do not reinvent the wheel!Learn from established French and German experience regarding education programs; Hopefully create a fruitful collaboration between EVF, ESVS, ECoP and the recently formed Multidisciplinary Joint Committee of the UEMS for phlebology under JJ Guex presidency.

clerotherapy & Miscellaneous S Saphenous pulsation on Duplex is a marker of severe chronic superficial venous insufficiency George Geroulakos, Lattimer CR, Azzam M, Kalodiki E, Makris GC Ealing Hospital and Imperial College, London, United Kingdom

BACKGROUND Pulsation is defined as a cyclical change in velocity that can be regular or irregular. Palpability or the detection of the pulse by touch, is not necessary to determine the presence of pulsation. Pulsatile flow in deep, perforating veins and varicose veins (VVs) has been described previously to support a hypothesis of arteriovenous (AV) fistulae in the pathogenesis of VVs. Its presence has also been suggested as a cause of failure of VV treatments. However, AV communications have never been adequately visualized and direct pressure tracings within leg veins have been inconclusive. The present study was observational aiming to investigate the prevalence and rate of spontaneous pulsation within the great saphenous vein (GSV) in volunteers and patients using color duplex and compare this to reflux and markers of disease severity. METHODS Twenty-seven consecutive patients (32 legs, median Venous Clinical Severity Score (VCSS) = 5 [0-11]) attending the VV clinic and 23 consecutive ambulatory normal volunteers (46 legs) had their GSV assessed at midthigh using color duplex. Subjects were examined standing with the hips resting against an adjustable couch, bearing weight on the contralateral leg, with the test leg touching the ground. The presence of flow and reflux were initially determined using manual calf compression. The GSV diameter and SP rate were then recorded after 2 minutes of dependency. The number of pulsations was counted from video recordings. RESULTS The resting SP, if present, was discrete, monophasic, of variable amplitude, antegrade, and irregular, irrespective of respiration. Pulsation was detected in 2/44 (4.5%) legs with C(0-1) (C part of CEAP), 9/17 (52.9%) legs with C(2-3), and 16/17 (94.1%) legs with C(4-6) (P < .05, z test of column proportions). Reflux occurred in 8/32 (25%) legs without SP (C(0) = 2, C(1) = 1, C(2) = 3, C(3) = 2). The median GSV diameter was significantly elevated in the presence of SP (no pulse: 3.5 [range, 1.5-8.1] mm; pulse: 7 [range, 4-9.4] mm; P < .0005). The median refluxing GSV diameter in GSV pulsators compared with nonpulsators was 7 (range, 4-9.4) mm; vs 5.1 (range, 2.7-8.1) mm, respectively (P = .003). The median SP rate in refluxing GSVs was 52 (range, 22-95) beats per minute. CONCLUSIONS The presence of a Duplex detectable SP is a common observation in patient with chronic venous insufficiency and it is a finding. It is detectable in 75% of patients with GSV reflux and significantly increases with clinical severity and saphenous diameter. It may be a marker of advanced venous disease and, as it is easy to record, it could supplement duplex evaluations of reflux. Further work is needed to establish the clinical relevance of the SP in terms of disease progression, recurrence after treatment, and as a hemodynamic marker of severity.

Saturday January 23

T hermal or glue techniques Reimbursement and possibilities to use the new thermal ablation techniques: difference between the European countries

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Inga Vanhandenhove

AZ Monica Antwerp, Antwerp, Belgium Following a discussion on the Linkedin ACP (American College of Phlebology) group about the new Medicare â&#x20AC;&#x153;4 EVLT maximum per lifetimeâ&#x20AC;? policy, it would be interesting to compare the reimbursement and authorisation to use EVLT catheters in the different European countries. In Belgium we have access to 1 catheter per patient per lifetime, so we have to think of future venous scenarios for each patient, before using this unique catheter. Europe may be united, but apparently not so much when it concerns medical treatments. An interesting comparison, potentially leading to medical shopping within the European Union?

hermal or glue techniques T 3-year follow-up RCT: radiofrequency ablation (fast) vs laser ablation (radial fiber) James Lawson, Stefanie Gauw, Clarissa van Vlijmen

Skin and Vein Clinic Oosterwal, Alkmaar, The Netherlands BACKGROUND Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA/ClosureFAST) of the incompetent great saphenous vein (GSV) are both associated with excellent technical and clinical outcomes for the treatment of varicose veins. ClosureFAST using RFA for heating up ablation coil is associated with less postprocedural pain and shorter recovery than EVLA bare fibre in several studies. 1,2 A newly-developed fibre (radial fibre, Biolitec) emits the laser energy radially with a lower power density promising better postoperative recovery 3 The aim of this study was to compare the techniques in a pragmatic prospective clinical trial METHODS In a comparative study of 310 patients with 345 legs, each leg with incompetence of the GSV were allocated equally into groups receiving either Covidien ClosureFAST (CF) (legs= 175) or Radial Fiber Biolitec AG (RaF) (legs=171). All procedures were performed with tumescent anesthesia without sedation Patients were randomized by treatment clusters (CF or RaF) in consecutive months. Patients were assessed at baseline and after treatment: 1 and 6 weeks weeks, 12, 24, 36, 48 months. Outcomes included: Anatomic (Duplex) occlusion rate, Quality of life (QoL), Venous Clinical Severity Score (VCSS), postoperative pain scores, time taken to return to normal function and back to work. Owing to the use of local anesthesia and different postoperative US picture of the procedures, blinding for patient and investigator was not possible. RESULTS Both groups were equal in baseline characteristics, VCSS and QoL scores. There was no difference in the favorably low VAS pain scores after both treatments during the first 14 days (VAS mean 0.54-2.19). No SAEs were observed. Back to work in mean 2.13 days after CF and 2.33 days after RaF. Total primary occlusion rate with Kaplan Meier statistics after 48 months was 94,9 % (SE .018) after CF and 96,1 % (SE .016) after RaF (P= .63). Similar amounts of clinically visible recurrences in accessory veins were seen in both groups. (CF= 23 and RaF = 16) Kaplan Meier Statistics showed freedom of AASV recurrence after 4 years in 74% of CF treated legs and 75,8 % of RaF legs. (P=.30) VCSS and AVVQ had similar and durable improvements in both groups between 6 weeks and 48 months. CONCLUSION RFA ClosureFast and Radial Fiber EVLA are both associated with minimal postprocedural pain and fast recovery. Both procedures are equal clinical effective in long term REFERENCES 1. Almeida JI, Kaufman J, Gรถckeritz O, Chopra P, Evans MT, Hoheim DF, et al. Radiofrequency endovenous closurefast versus laser ablation for the treatment of great saphenous reflux: A multicenter, single-blinded, randomized study (RECOVERY study). J Vasc Interv Radiol 2009, Jun;20(6):752-9. 2. Shepherd AC, Gohel MS, Brown LC, Metcalfe MJ, Hamish M, Davies AH. Randomized clinical trial of VNUS closurefast radiofrequency ablation versus laser for varicose veins. Br J Surg 2010, Jun;97(6):810-8. 3. Doganci S, Demirkilic U. Comparison of 980 nm laser and bare-tip fibre with 1470 nm laser and radial fibre in the treatment of great saphenous vein varicosities: A prospective randomised clinical trial. Eur J Vasc Endovasc Surg 2010, Aug;40(2):254-9.

Saturday January 23

T hermal or glue techniques RCT endovenous 940 nm laser ablation vs 1470 nm laser ablation (COLA trial) Wendy Malskat

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Erasmus MC, Rotterdam, The Netherlands BACKGROUND The independent effect of wavelength used for endovenous laser ablation (EVLA) on patient reported outcomes, health-related quality of life (HRQoL), success and complications has not yet been established in a RCT. Our aim was to compare two different wavelengths, with identical energy level and laser fibers, in patients undergoing EVLA. METHODS Patients with great saphenous vein (GSV) reflux were randomized into 940 nm or 1470 nm EVLA. The primary outcome was pain at one week. Secondary outcomes were satisfaction, days of analgesia use and days without normal activities at one week, HRQoL after 12 weeks, treatment success after 12 and 52 weeks, change in Venous Clinical Severity Score (VCSS) after 12 weeks and adverse events at one and 12 weeks. RESULTS A total of 139 legs were treated (940 nm EVLA, 68;1470 nm EVLA, 71). Patients in the 1470 nm EVLA group reported significantly less pain on a visual analogue scale (VAS), compared to 940 nm EVLA; median(IQR) VAS of 3(5) and 6(5) (p=.005). Duration of analgesia use was significantly shorter after 1470 nm EVLA; median(IQR) of 1(3) and 2(5) days (p=0.037). HRQoL and VCSS improved equally in both groups. There was no difference in treatment success rates. Complications were comparable in both groups, except for more superficial vein thrombosis 1 week after 1470 nm EVLA. CONCLUSION The only difference between 940 nm and 1470 nm EVLA is the short term patient reported tolerability one week postoperatively, with reduction of pain scores and duration of analgesia use after 1470 nm EVLA.

hermal or glue techniques T Risk Factor for Recurrence after RF Ablation Of GSV Thomas Proebstle1, Olivier Pichot2

1. Dept Dermatology, University Medical Center Mainz, Mainz, Germany 2. CHU Service de Chirurgie Vasculaire, Grenoble, France OBJECTIVE Identify predictors of anatomical and clinical success following radiofrequency segmental thermal ablation(RSTA) METHODS Logistic regression and proportional hazards analyses were used. Anatomical success was defined by ultrasound as a status of full occlusion or freedom from reflux. For definition of clinical success a relevant improvement of VCSS was used. RESULTS 235 of originally 295 GSVs treated by RSTA were available at 5-year FU. Predictors at baseline for persisting anatomical success over 5 years were (a) no adjunctive phlebectomy above-the-knee during RSTA (hazard ratio (HR)=2.9 for occlusion, p=0.011; HR=5.7 for reflux-free, p=0.002), and (b) a joint bivariate effect of high body mass index (BMI) and large GSV diameter. One-year clinical success likelihood was 7.26 (1.51 - 35.00) times greater (p=0.01) in patients without refluxing thigh tributaries draining into the GSV and 6.36 (1.64 - 24.66) times greater(p=0.008) for adjunctive below-the-knee phlebectomy performed concomitantly. No baseline refluxing accessory saphenous vein was predictive of 6.42(1.38 - 29.86), p=0.018, times higher likelihood(p=0.018) of 3-year clinical success. A combined effect of high BMI and large proximal GSV diameter at baseline was predictive of ongoing clinical success. CONCLUSION Bivariate BMI and GSV diameter was the dominant predictor of maintained anatomical and clinical success after RSTA of the GSV. Additional predictors for success were lack of thigh tributaries, lack of refluxing accessory saphenous veins and performing phlebectomy of calf tributaries at baseline. REFERENCES 1. Robertson LA, Evans CJ, Lee AJ, Allan PL, Ruckley CV, Fowkes FG. Incidence and risk factors for venous reflux in the general population: Edinburgh Vein Study. European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 2014;48(2): 208-214. 2. Shadid N, Nelemans P, Lawson J, Sommer A. Predictors of recurrence of great saphenous vein reflux following treatment with ultrasound-guided foamsclerotherapy. Phlebology / Venous Forum of the Royal Society of Medicine 2014. 3. Merchant RF, Pichot O, Closure Study G. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. Journal of vascular surgery 2005;42(3): 502-509; discussion 509. 4. Timperman PE. Prospective evaluation of higher energy great saphenous vein endovenous laser treatment. Journal of vascular and interventional radiology: JVIR 2005;16(6): 791-794. 5. Proebstle TM, Moehler T, Herdemann S. Reduced recanalization rates of the great saphenous vein after endovenous laser treatment with increased energy dosing: definition of a threshold for the endovenous fluence equivalent. Journal of vascular surgery 2006;44(4): 834-839. 6. Harlander-Locke M, Jimenez JC, Lawrence PF, Derubertis BG, Rigberg DA, Gelabert HA. Endovenous ablation with concomitant phlebectomy is a safe and effective method of treatment for symptomatic patients with axial reflux and large incompetent tributaries. Journal of vascular surgery 2013;58(1): 166-172. 7. Proebstle TM, Vago B, Alm J, Gockeritz O, Lebard C, Pichot O. Treatment of the incompetent great saphenous vein by endovenous radiofrequency powered segmental thermal ablation: first clinical experience. Journal of vascular surgery 2008;47(1): 151-156. 8. Calcagno D, Rossi JA, Ha C. Effect of saphenous vein diameter on closure rate with ClosureFAST radiofrequency catheter. Vascular and endovascular surgery 2009;43(6): 567-570.

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9. Khilnani NM, Grassi CJ, Kundu S, Dâ&#x20AC;&#x2122;Agostino HR, Khan AA, McGraw JK, Miller DL, Millward SF, Osnis RB, Postoak D, Saiter CK, Schwartzberg MS, Swan TL, Vedantham S, Wiechmann BN, Crocetti L, Cardella JF, Min RJ, Cardiovascular Interventional Radiological Society of Europe ACoP, Society of Interventional Radiology Standards of Practice C. Multi-society consensus quality improvement guidelines for the treatment of lower-extremity superficial venous insufficiency with endovenous thermal ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society of Europe, American College of Phlebology and Canadian Interventional Radiology Association. Journal of vascular and interventional radiology: JVIR 2010;21(1): 14-31.

hermal or glue techniques T How to ensure the success of traditional surgery in varicose vein treatment: 10 rules to respect Patrizia Pavei

Azienda Ospedaliera di Padova, Padova, Italy In the last years surgery has lost its supremacy over the other methods of treatment for varicose veins. In fact, in 2013 the National Health System of the United Kingdom issued new national Clinical Guidelines on the diagnosis and management of varicose veins in which surgery is considered only the third choice of treatment for this disease. Similar indications come from the United States. The comparison between the newer endovascular techniques and surgery is made towards traditional surgical treatment, namely flush high ligation and stripping, which is often carried on under general or spinal anesthesia. This kind of surgery is now obsolete. Nowadays, a tailored treatment based on a careful echocolordoppler mapping, performed on an ambulatory basis and under local anesthesia, is the term of comparison. The credit for this change goes to new concepts, that is to say, to the value of the terminal and pre-terminal valve of the sapheno-femoral (SF) junction, which make it possible to spare the SF junction itself. When dealing with the SF junction, we learn from the literature that almost half of the cases of great saphenous vein incompetence have a competent terminal valve. Why do we have to treat it? In this instance flush high ligation is not indicated. In the event of an incompetent terminal valve, the experience gained with endovascular procedures, specifically with laser and radiofrequency, shows that it does not necessarily mean recurrences. So we may ask ourselves whether a less invasive surgical procedure can be performed. If high ligation has to be performed, it should be done under local anesthesia and the invagination of the saphenous stump is suggested, together with the closure of the â&#x20AC;&#x153;fossa ovalisâ&#x20AC;?. The aim of these precautions is to reduce neovascularization. Neovascularization can also be minimized by using a delicate surgical technique and an adequate technical choice. The saphenous trunk may be preserved too. For example, Zamboni suggests sparing the saphenous trunk when a Duplex elimination test is positive and a competent terminal valve is found. Pittaluga proposes the so-called ASVAL method, in which the diameter of the vein is one of the parameters of choice. In any case, if stripping is indicated, only the refluxing segment of the trunk has to be treated. Nowadays, it is possible to use less invasive surgical approaches, such as phlebectomies, ASVAL, the Chiva method, a tailored stripping with or without flush high ligation or a simplified high ligation. In our opinion, in case of a competent terminal valve, a stripping without flush high ligation can always be performed, namely with a simple ligature of the proximal saphenous trunk; whereas, if a reflux of the terminal valve is present, a simplified high ligation can be done. The ideal setting for varicose vein surgery is the ambulatory one, associated with a tumescent local anesthesia. In the literature, there are several papers confirming the feasibility of stripping under local tumescent anesthesia. Even though endovascular thermoablative methods are becoming more and more popular, traditional surgery still gives good results, as confirmed by several randomized trials, but it should be done following modern concepts. In conclusion, so as to be competitive, surgery has to be guided by a very accurate pre-operative echocolordoppler examination, and needs to be less aggressive. Finally it has to be done in an ambulatory setting and at low cost. REFERENCES 1. www.nice.org.ul/accreditation: The diagnosis and management of varicose veins. Issued:July 2013 2. Pittaluga et al. Midterm results of the surgical treatment of varices by phlebectomy with conservation of a refluxing trunk. J Vasc Surg 2009;50:107-18 3. Rasmussen et al. Randomized clinical trial comparing endovenous laser ablation and stripping of the great saphenous vein with clinical and duplex out come after 5 years. J Vasc Surg 2013;58-2:421-426 4. Van Den Velden et al. Five â&#x20AC;&#x201C;year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins. Br J Surg 2015;102:1184-1194 5. Brittenden et al.A randomized trial comparing treatments for varicose veins N Engl J Med 2014;371:

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T hermal or glue techniques 10 rules to respect to ensure the success of: laser ablation Lowell Kabnick

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

NYU Langone Medical Center, New York, USA There are many steps that an interventionalist should take into consideration in order achieve the best laser truncal ablation results. If you have the following: correct patient who has the appropriate venous symptoms, complete physical exam including venous zone of influence, corresponding duplex exam for GSV insufficiency, and you perform the proper step by step procedure, then the patient will have the best results. I will present at least ten Kabnick rules to follow to ensure the best patient outcome with laser ablation. In general, most of these guidelines will apply to any truncal ablation. Since the history, physical exam, and duplex examination are extremely important, I would be remiss not to mention them in passing. In addressing these rules in terms of performing the procedure, there are several important key steps to take into consideration as well, which include patient comfort, set-up of procedure room, ultrasound skills, venous access, wire and catheter skills, laser fiber placement, tumescent anesthesia delivery, and energy delivery. Finally, regarding postoperative management: is important or does it matter? What is the evidence for post-ablation compression, duplex, or controlled activity? I will address these questions as well, in order to present a complete picture of how to ensure the success of laser ablation. REFERENCES Kabnick, L.S. Venous Laser Updates: New Wavelength or New Fibers? Vascular Disease Management, March 2010, Volume 7, No. 3, pg 77-81. Spreafico G, Kabnick L.S., Berland T, et al.Laser Saphenous Ablations in More Than 1,000 limbs with Long-Term Duplex Examination Follow-up. Annual Vascular Surgery, January 2011; 25(1)71-78. Sadek, M., Kabnick, L.S., Berland, T., Chasin, C., Cayne, N., Maldonado, T., Rockman, C., Jacobowitz, G., Lamparello, P. Endovenous Laser Ablation using Higher Wavelength Lasers results in Diminished Post Procedural Symptoms. Journal of Vascular Surgery, June 2011 Vol: 53, page 67S Sadek, M., Kabnick, L.S, Berland, T., Cayne, N., Mussa, F., Maldonado, T., Rockman, C., Jacobowitz, G., Lamparello, P., and Adelman, Mark. Update on Endovenous Laser Ablation: 2011. Perspectives in Vascular Surgery and Endovascular Therapy, November 29, 2011. Dexter, D., Kabnick. L.S., Berland, T., Jacobowitz, G., Lamparello, P., Maldonado, T., Mussa, F., Rockman, C., Sadek, M., Giammaria, L.E., and Adelman, M. Complications of Endovenous Lasers. Phlebology, March 2012; 27: 40-45. Rudarakanchana N., Berland T.L., Chasin C., Sadek M., Kabnick L.S. Arteriovenous fistula after endovenous ablation for varicose veins. Journal of Vascular Surgery, May 2012; 55(5):1492-4.

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ePosters

101

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ORTA A Neoaortic Xenoprosthetic Grafts For Treatment Of Mycotic Aneurysms And Aortic Grafts: Case Series And Literature Review C. Anibueze, V. Sankaran, U. Sadat, YG. Wilson, RE. Brightwell, MS. Delbridge, PW. Stather

Department of Vascular Surgery, Norfolk and Norwich University Hospital, Colney Lane, Norwich, Norfolk, NR4 7UY, Norwich, United Kingdom BACKGROUND There is no international consensus about the optimum management of infected aortae (mycotic aneurysms, infected aortic grafts). Neoaortoiliac reconstruction has advantages over extra anatomical bypass grafting; however use of autologous vein or cadaveric homografts for this purpose has limitations. Arterial repair using xenoprosthetic patches is associated with lower infection rate compared to the use of prosthetic material. This case series and literature review reports the use of xenoprothetic bovine biomaterial for neoaortic repair of mycotic aneurysmal disease and infected aortic grafts. RESULTS Six patients underwent bovine aortic repair between 2013-2015: an infected dacron aorto-biiliac graft causing iliac pseudoaneurysm, an infected dacron aortic graft from open repair later relined with endovascular stent graft, a mycotic iliac aneurysm, and 3 mycotic aortic aneurysms. Median age 69.5 years (range 67-75 years). All were treated with bovine reconstructed aortic grafts or patches. Peri-operative and 30-day mortality was 0%. Median follow-up 13 months (range 2 – 23 months). Post-operative contrast enhanced-computed tomography did not show any evidence of infection at the operative site in all patients. Freedom from re-infection and re-intervention was 100%. CONCLUSIONS Xenoprosthetic (bovine) neoaortic grafts are an effective method to treat infected aortae with excellent short term freedom from infection and reintervention. Optimum duration of post-operative antibiotic therapy remains undetermined. Further cases and longer follow up are required. REFERENCES 1. Yeager RA, Porter JM. Arterial and prosthetic graft infection. Ann Vasc Surg. 1992;6(5):485-91. 2. Eshaghy B, Scanion PJ, Amirparviz F, Moran JM, Erkman-Balis B, Gunnar RM: Mycotic aneurysm of brachial artery. A complication of retrograde catheterization. JAMA 1974;228(12):1574–1575. 3. Monson RC 2nd, Alexander RH: Vein reconstruction of a mycotic internal carotid aneurysm. Ann Surg 1980;191(1):47–50. 4. Chan FY, Crawford ES, Coselli JS, Safi HJ, Williams TW Jrl. In situ prosthetic graft replacement for mycotic aneurysm of the aorta. Ann Thorac Surg. 1989;47(2):193-203. 5. O’Hara PJ, Hertzer NR, Beven EG, Krajewski LG. Surgical management of infected abdominal aortic grafts: review of a 25 year experience. J Vasc Surg. 1986;1(1):36-42. 6. Robinson JA, Johansen K. Aortic sepsis: is there a role for in situ graft reconstruction? J Vasc Surg. 1991;13(5):677-82. 7. Beck AW, Murphy EH, Hocking JA, Timaran CH, Arko FR, Clagett GP. Aortic reconstruction with femoral-popliteal vein: graft stenosis incidence, risk and reintervention. J Vasc Surg. 2008;47(1):36-43. 8. Ali AT, Modrall JG, Hocking J, Valentine RJ, Spencer H, Eidt JF, Clagett GP. Long-term results of the treatment of aortic graft infection by in situ replacement with femoral popliteal vein grafts. J Vasc Surg. 2009;50(1):30-9. 9. Chung J, Clagett GP. Neoaortoiliac system (NAIS) procedure for the treatment of the infected aortic graft. Semin Vasc Surg. 2011;24(4):220-6. 10. McCready RA, Bryant MA, Fehrenbacher JW, Beckman DJ, Coffey AC, Corvera JS, Hormuth DA, Wozniak TC. Long-term results with cryopreserved arterial allografts (CPAs) in the treatment of graft or primary arterial infections. J Surg Res. 2011;168(1):e149-53. 11. McMillan WD, Leville CD, Hile CN. Bovine pericardial patch repair in infected fields. J Vasc Surg 2012;55(6):1712-5. 12. Czerny M, von Allmen R, Opfermann P, Sodeck G, Dick F, Stellmes A, Makaloski V, Buhlmann R, Derungs U, Widmer MK, Carrel T, Schmidli J. Self-made pericardial tube graft: a new surgical concept for treatment of graft infections are thoracic and abdominal aortic procedures. Ann Thorac Surg. 2011;92(5):1657-62. 13. Kubota H, Endo H, Noma M, Tsuchiya H, Yoshimoto A, Takahashi Y, Inaba Y, Matsukura M, Sudo K. Equine pericardial roll graft replacement of infected pseudoaneurysm of the aortic arch. J Cardiothorac Surg. 2012;7:45 14. Kubota H, Endo H, Noma M, Tsuchiya H, Yoshimoto A, Takahashi Y, Inaba Y, Matsukura M, Sudo K. Equine pericardial roll graft replacement of infected pseudoaneurysm of the ascending aorta. J Cardiothorac Surg. 2012;7:54 15. Yamamoto H, Yamamoto F, Ishibashi K, Motokawa M. In situ replacement with equine pericardial roll grafts for ruptured infected aneurysms of the abdominal aorta. J Vasc Surg. 2009;49:1041-5. 102

ORTA A Single Centre Experience Following The Introduction Of A Percutaneous Endovascular Aneurysm Repair First Approach Mohammed Ashrafi, Qusai Al-Jarrah, Mayooreshan Anandrajah, Ray Ashleigh, Mark Welch, Mohamed Baguneid University Hospital of South Manchester, Manchester, United Kingdom

METHODS A retrospective cohort study on all patients’ over a 2 year period following the introduction of a percutaneous EVAR first approach was performed. The primary end point was technical success which was defined as successful deployment of the SMCDs and access site haemostasis. The procedure was performed by consultants and trainees under appropriate supervision. Outcomes were analysed using a combination of Pearson’s Chi-squared test and Student’s t test for categorical and continuous data, respectively. RESULTS Fifty three patients (46 male and 7 female; mean age 75.2) underwent percutaneous EVAR. Percutaneous EVAR was technically successful in 41/53 patients (77.4%) and 83/96 access sites (86.5%). Factors associated with failure were common femoral artery (CFA) diameter (P=0.045) and CFA calcification of greater than 50% (P=0.0001). There was a trend for CFA depth of > 40mm from the skin to be associated with higher failure rate (P=0.064). The incidence of access site infection was significantly higher in the failure group (P=0.008) as was procedure duration (P=0.026). CONCLUSIONS Introduction of a percutaneous EVAR first approach has a not insignificant failure and complication rate. Percutaneous EVAR failure occur more often in patients with unfavourable access site anatomy. Success rate can be improved with careful patient selection, a proficient technique and appropriate operator experience.

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INTRODUCTION New aortic graft technologies with low profile delivery systems have allowed specialists to adopt a change from surgical endovascular aneurysm repair (EVAR) to percutaneous EVAR utilising suture-mediated closure devices (SMCDs). The aim was to evaluate our experience following the introduction of a percutaneous EVAR first approach utilising Perclose Proglide (Abbott Vascular) SMCDs at a tertiary vascular institution looking at efficacy, complications and identification of factors that could predict failure.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ORTA A Patient-Specific EVAR Rehearsal: Realism And Impact On The Endovascular Team Abhinav Bhansali1, Liesbeth Desender2, Isabelle Van Herzeele2, Mario Lachat3, Colin Bicknell4, Frank Vermassen2

1. Faculty of Medicine, Imperial College London, London, United Kingdom 2. Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium 3. Department of Vascular Surgery, Zurich University Hospital, Zurich, Switzerland 4. Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, London, United Kingdom INTRODUCTION Virtual-reality simulation enables patient-specific rehearsal (PsR) of endovascular aneurysm repairs (EVARs). This allows the interventionalist and his team to practise and evaluate the real case on patient-specific anatomy, trial different approaches and endovascular equipment, and thus optimise the treatment plan. We aimed to evaluate the realism of PsR of EVAR procedures, and its usefuleness to the endovascular team. METHODS Patients with infrarenal aortic or iliac aneurysms, suitable for EVAR, were enrolled. The rehearsal and corresponding ‘real’ EVAR procedure were performed by the same endovascular team. All team members completed a post-PsR questionnaire evaluating their EVAR experience. This subjective questionnaire evaluated the realism, technical issues and human aspects pertinent to PsR on a Likert scale from 1 (not al all) to 5 (very much). RESULTS 100 patients were enrolled. The questionnaire was completed by 99 lead interventionalists, 57 assistants and 43 scrub nurses. Of these, 62/99 (63%) of lead implanters, 36/57 (63%) of assistants, and 27/43 (63%) of scrub nurses were highly experienced in EVARs (> 50 cases). The realism of PsR was rated highly (median 4, IQR 3-4), especially that of the simulated angiographies of the aorta (median 4, IQR 4-5) and iliac vessels (median 4, IQR 4-5). The lead interventionalist found the rehearsal useful for selecting the optimal C-arm angulation (median 4, IQR 4-5). PsR was recognised as a helpful tool to prepare team members individually (median 4, IQR 3-5) and together as a team (median 4, IQR 4-4), improve communication (median 4, IQR 3-4) and encourage confidence (median 4, IQR 3-4) prior to the actual intervention. CONCLUSION PsR offers training and learning opportunities in case-specific, realistic EVAR scenarios. Our subjective evaluation of highly experienced endovascular teams indicates that this technology may (1) facilitate optimal C-arm angulation, (2) improve non-technical skills and (3) prove invaluable to team preparedness. Ultimately, this may impact procedural efficiency and patient safety.

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ORTA A Surgical Treatments After Ascending Aorta And Aortic Arch Repair Complications Marco Leopardi1, Yamume Tshomba1, Luca Bertoglio1, Enrico Rinaldi1, Giampiero Negri2, Germano Melissano1, Roberto Chiesa1 1. Vascular Surgery Unit San Raffaele Scientific Institute, Milano, Italy 2. Thoracic Surgery Unit San Raffaele Scientific Institute, Milano, Italy

AIM Complications after ascending aorta and aortic arch repair can lead to uncommon reinterventions, which are particularly challenging and burdened with high morbidity and mortality. We report our single-center experience in the treatment of this complex pathology, using different surgical approaches.

RESULTS In 13 cases the index procedure was an endovascular or hybrid procedure on the aortic arch performed at our Department, for an in-house reintervention rate of 6.9% (13/188). In 10 cases the cause of reintervention was stent-graft distal migration (Fig. 1), treated by means of endovascular relining in all cases, associated with adjunctive supra-aortic trunks debranching via sternotomy in 6 cases. In 6 cases the cause of reintervention was retrograde ascending aortic dissection, in 1 case ascending aortic anastomotic pseudoaneurysm following supra-aortic trunk debranching (Fig. 2), and in 1 case mediastinitis following implantation of an endovascular plug previously used to treat an ascending aortic pseudoaneurysm. In these last 8 cases, all patients were treated by means of ascending and arch surgical replacement under deep hypothermic circulatory arrest (DHCA) and antegrade cerebral perfusion (ACP). No 30-day mortality was observed. Major perioperative morbidity included 1 paraplegia, 1 minor stroke, 1 bleeding requiring reintervention, and 3 cases of respiratory failure requiring prolonged intubation (2) or tracheostomy (1). CONCLUSION In our experience, incidence of serious complications requiring reinterventions following ascending aorta or aortic arch repair is not negligible. Redo surgery in ascending aorta and aortic arch is feasible in high-volume and experienced centers, as it often requires hybrid repair via midline sternotomy, or surgical replacement under DHCA and ACP.

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METHODS In the period between 1999 and 2015, at our tertiary Vascular Unit, 18 patients underwent a redo surgery on ascending aorta and aortic arch. We observed prospectively all patients treated for ascending aorta, aortic arch and thoracic aortic procedures and reviewed retrospectively to collect data on redo patients.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

CAPTIONS

Fig.1 Distal stent-graft migration

Fig.2 A. Anastomotic pseudoaneuryms of the ascending aorta in previous zone 0 aortic arch repair B. Intraoperative arch reconstruction C. Postoperative result

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ORTA A Aorto-Oesophageal Fistula Sulaiman Al Shamsi, Shahinda Seidahmed, Shahinda Seidahmed, Shahinda Alanwar Royal Hospital, Muscat, United Arab Emirates

REFERENCES 1. Thoracic Endovascular Aortic Repair: A National Survey: R. Chiesa, G. Melissano, E.M. Marone, M.M. Marrocco-TrischittamA. Kahlberg. Vascular Surgery, Scientific Institute H. San Raffaele, ‘Vita-Salute’ University School of Medicine, Via Olgettina 60, 20132 Milano, MI, Italy 2. Int J Vasc Med. 2011;2011:649592. doi: 10.1155/2011/649592. Epub 2011 Sep 6.Aortoesophageal fistula after endovascular aortic aneurysm repair of a mycotic thoracic aneurysm.Gavens E1, Zaidi Z, Al-Jundi W, Kumar P. 3. Eur J Cardiothorac Surg. 2014 Mar;45(3):452-7. doi: 10.1093/ejcts/ezt393. Epub 2013 Jul 31. New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications. Czerny M1, Eggebrecht H, Sodeck G, Weigang E, Livi U, Verzini F, Schmidli J, Chiesa R, Melissano G, Kahlberg A, Amabile P, Harringer W, Horacek M, Erbel R, Park KH, Beyersdorf F, Rylski B, Blanke P, Canaud L, Khoynezhad A, Lonn L, Rousseau H, Trimarchi S, Brunkwall J, Gawenda M, Dong Z, Fu W, Schuster I, Grimm M. 4. Aortoesophageal Fistula After Thoracic Aortic Stent-Graft Placement: A Rare but Catastrophic Complication of a Novel Emerging Technique Holger Eggebrecht, MD?; Rajendra H. Mehta, MD, MS?; Alexander Dechene, MD‡; Konstantinos Tsagakis, MD†; Hilmar Kühl, MD§; Sebastian Huptas, MD?; Guido Gerken, MD‡; Heinz G. Jakob, MD†; Raimund Erbel, MD? 5. Secondary aortoesophageal fistula after thoracic endovascular aortic repair for a huge aneurysm Akhmadu Muradi Masato Yamaguchi. Atsushi Kitagawa. Yoshikatsu Nomura,Takuya Okada,Yutaka Okita,Koji Sugimoto 6. J Vasc Surg. 2003 Apr;37(4):886-8. Secondary aortoesophageal fistula after endoluminal exclusion because of thoracic aortic transection. Hance KA1, Hsu J, Eskew T, Hermreck AS 7. Kieffer, E., Chiche, L., and Gomes, D. Aortoesophageal fistula: value of in situ aortic allograft replacement. Ann Surg. 2003; 238: 283–290 8. Saito, A., Motomura, N., Hattori, O., Kinoshita, O., Shimada, S., Saiki, Y. et al. Outcome of surgical repair of aorto-eosophageal fistulas with cryopreserved aortic allografts. Interact Cardiovasc Thorac Surg. 2012; 14: 532–537 9. Presented at the Thirty-third Annual Meeting of the Southern Association for Vascular Surgery, Tucson, Ariz, Jan 14-17, 2009. Paul J. Riesenman, MD, MS, Mark A. Farber, MD 10. The Management of Aortic Stent-Graft Infection: Endograft Removal Versus Conservative Treatment Montse Blanch, Jennifer Berjón, Ramon Vila, Josep Maria Simeon Antonio Romera, Santiago Riera, Marc Antoni Cairols Department of Angiology and Vascular Surgery, Hospital Universitari de Bellvitge, 08907 Barcelona, Spain. Annals of Vascular Surgery (Impact Factor: 1.17). 05/2010; 24(4):554.e1-5. DOI: 10.1016/j.avsg.2009.11.003 Source: PubMed

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Thoracic endovascular Aortic repair (TEVAR) is a minimally invasive procedure for the treatment of thoracic aortic aneurysms, aortic dissection and traumatic aortic injury. Though it is superior to the open surgical repair considering it is a far less invasive but it’s still having its complications like paraplegia, stroke, migration of the device, endoleak, and infection which may present as Aorto-oesophageal fistula (AEF).AEF is a rare and fatal complication of TEVAR with an incidence of 1.6-1.9% 1.We are presenting a case who developed AEF 20 days after he had TEVAR And treated conservatively with repair of esophagus and followed by antibiotic therapy for 6 moths only. investigations of the follow post treatment were normal.

ORTA A Aneurysm Sac Volume And Diameter After Evar. Do They Represent The Same?

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Joel Sousa, João Rocha-Neves, Jose Pinto, Armando Mansilha, José Teixeira Hospital de S.João, EPE, Oporto, Portugal

AIMS To compare risk factors and their impact in the evolution of aneurysmal sac volume (ASV) and maximum aneurysm transverse diameter (ATD) in patients submitted to EVAR. METHODS A total of 57 patients treated by EVAR were evaluated (93% male; mean age of 72,6 years [56-85]). The mean follow-up period was 13 months. Maximum ATD and ASV were measured in the pre-operative and latest pos-operative angio-CT. Growth of > 5mm in diameter or more than 3% in volume in the pos-operative CT were considered significant. Aneurysmal sac calcification, neck thrombus, neck angulation, endoleak and re-intervention were evaluated. RESULTS This study demonstrated that there is positive correlation between ASV and ATD (p<0,001). Presence of endoleak is significantly associated with growth of the aneurysmal sac, both in maximum diameter (p<0,001) and volume (p=0,002). There was a trend suggesting that neck thrombus >2mm (p=0,077) and neck angulation (>60º) (p=0,066) were related with diameter increase but not volume (p= 0,510 and 0,453). No association was found between the presence of sac calcification and the post-operative behaviour of the aneurysmal sac. Re-intervention was associated with ATD growth of >5mm (p=0,034) but not with ASV growth of >3% (p=0,152). CONCLUSIONS Aneurysmal sac diameter and volume have a positive correlation. Endoleak influences both variables, but neck thrombus and neck angulation appear to influence sac diameter only. ATD growth was associated with higher re-intervention. This study suggests that certain anatomic factors influence aneurysm transverse diameter more than they influence volume. Since both these parameters have a positive correlation, authors believe some ATD growths represent only remodelling phenomena of the sac and thrombus and not true aneurysm sac growth. Further studies are required.

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ORTA A Expanding Indications For EVAR And TEVAR Stevo Duvnjak

Odense University Hospital, Odense, Denmark

MATERIALS AND METHODS 1 Case: AORFIX stent graft to treat highly angulated aneurysm neck- case report 82-year-old lady with asymptomatic 5,8 cm big AAA. Infrarenal aortic neck angulation 84Â° and angulated iliac artery. Access vessels â&#x20AC;&#x201C;very important ( Aorfix stent graft -20-22Fr). The stent graft is placed according to the instruction of use without difficulties and without complications. Three month C contrast enhanced control was without endoleak or other complications 2. Case: Bolton custom-made stent graft with scallop for celiac trunk A 59-year-old male with saccular aorta descdedens aneurysm treated with TEVAR. Control revealed endoleak type 1 B- attempt to treat with coils embolization, but still endoleak present. To obtain better distal sealing zone decided to place custom-made stent graft with scallop for the celiac trunk. The stent graft is placed without complication and control showed good result and no endoleak. CT control one year after showed no endoleak and patent celiac trunk. CONCLUSION Continuous development in stent graft technology allowed us to treat more patients, however, the anatomical constraint must be respected for every technology. FIGURES

Aorfix stent graft. Fig. 1 Pre operative CT showed highly angulated infrarenal aortic neck

Aorfix stent graft. Fig. 2 Control angiography after stent graft deployment

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PURPOSE Presenting two challenging cases, one treated with Aorfix stent graft and another case with thoracic aorta aneurysm treated with custom-made stent graft with scallop for the celiac trunk.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Aorfix stent graft. Fig. 3 Control CT without endoleak

Custom-made Bolton stent graft.Fig. 1 Contrast enhanced CT showed endoleak type 1 B and close aneurysm relation to the celiac trunk

Custom-made Bolton stent graft. Fig. 2 Intraoperative angiography and proper orientation of teh scallop

Custom-made Bolton stent graft. Fig. 3 Control angiography after stent graft deployment

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REFERENCES 1. Malas MB, Jordan WD, Cooper MA, Qazi U, Beck AW, Belkin M, Robinson W, Fillinger M. Performance of the Aorfix endograft in severely angulated proximal necks in the PYTHAGORAS United States clinical trial. J Vasc Surg. 2015;62:1108-18 2. Da Rocha M, Riambau VA. Experience with a scalloped thoracic stent graft: a good alternative to preserve flow to the celiac and superior mesenteric arteries and to improve distal fixation and sealing. Vascular. 2010;18:154-60

ORTA A Principles for management of iatrogenic type A aortic dissection

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Amber Jiskani, Philemon Gukop, Aziz Momin, V. Chandrasekaran

Department of cardiothoracic surgery, St Georgeâ&#x20AC;&#x2122;s university hospital, London, United Kingdom INTRODUCTION Intraoperative Type A aortic dissection is a rare pathology with incidence of 0.06-0.32%. It is associated with a high mortality between 30-50%. It could exponentially increase the risk profile of a simple operation. Some associated risk factors have been identified. Modification of these risk factors could reduce the incidence of the pathology. Prompt diagnosis and management, with the aid of intraoperative trans-oesophageal echocardiography/epi-aortic ultrasound has been shown to reduce the mortality to 17%. It is essential that all cardiac surgeons and patients with risk factors are aware of this entity 1, 2. CASE REPORT We illustrate the principles of management of this pathology with the case of a 62 year old lady who developed acute type A aortic dissection while undergoing minimally invasive mitral valve repair. Her past medical history is remarkable for hypertension, ascending aorta 4.3 cm. She developed fluctuation in blood pressure during femoral cannulation. TOE confirmed the diagnosis and this was successfully repaired via sternotomy with DHCA at 18C. DISCUSSION Risk factors for intraoperative type A aortic dissection include hypertension, peripheral vascular disease, advance age >65 years, large diameter of the aorta, use of steroid, pre-existing aortic pathology, femoral arterial cannulation and high cardiopulmonary bypass pressures >120 mmHg 1, 3, 4. Its risk factors, strategy for prompt identification and management should be armamentarium of all cardiac surgeons. Patients should be informed of intraoperative aortic dissection as a possible risk of cardiac surgery especially in patients with identifiable risk factors. Our case demonstrates a patient with identifiable risk factors for intraoperative type A aortic dissection, namely hypertension and enlarged aorta, intraoperative she had a period of hypertension during femoral cannulation. The immediate availability of intraoperative TOE facilitated a prompt diagnosis of the pathology. Prompt strategy of immediate repair of the dissection via sternotomy and alternative arterial cannulation site with deep hypothermic circulatory arrest facilitated a good outcome for the patient. Intraoperative type A aortic dissection has been reported in all types of cardiac surgery including off pump coronary artery bypass surgery. All arterial cannulation sites have been identifies as possible initiation sites. Intraoperative trans-oesophageal echocardiography (TOE)/ Epi-aortic ultrasound is the gold standard for prompt diagnosis of intraoperative aortic dissection, although clinical observation is also essential 5. Once identified separation from cardiopulmonary bypass and pursuit of alternative cannulation site with repair of the aortic dissection under deep hypothermic circulatory arrest is the treatment strategy. Risk factor modification include avoiding cannulation of significantly diseased arterial site, clamping of pressurised aorta, torqueing of partial clamp and minimal handling of arteries may prevent the occurrence of this pathology. CONCLUSION Intraoperative type A aortic dissection is a rare but important pathology with high morbidity and mortality. Identifiable risk factors can be managed to enhance outcome. Patient consent for cardiac surgery should include a mention of this entity. BIOGRAPHY Amber jiskani is a Junior cardiothoracic surgery trainee at St Georgeâ&#x20AC;&#x2122;s university hospital.

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ORTA A Treatment of dacron graft aneurysm Didem Melis Oztas1, Murat Ugurlucan1, Omer Ali Sayin1, Y覺lmaz Onal2, Mehmet Barburoglu2, Mehmet Akif Onalan1, Cagla Canbay1, Metin Onur Beyaz1, Bulent Acunas2, Ufuk Alpagut1, Enver Dayioglu1

1. Istanbul University, Istanbul Medical Faculty, Cardiovascular Surgery, Istanbul, Turkey 2. Istanbul University, Istanbul Medical Faculty, Radiology, Istanbul, Turkey

METHODS The patient underwent aortobifemoral bypass procedure with an 18x9mm, 45cm knitted polyester vascular graft (FlowNit Bioseal, JOTEC Vascular Prosthesis) in 2010. In 2013, he presented with occlusion of right limb of the graft. He underwent cross-over graft to right femoral artery bypass with a saphenous vein. He presented with enlargement of the left femoral pulsatile mass. A computerized tomography angiography indicated Dacron graft dilation (35x31 mm body size and 28x24 mm left leg size) and a 5cm in diameter left femoral aneurysm. RESULTS He underwent aortouniliac endovascular stent grafting (Medtronic Endovascular, Santa Roja, Calif., US). Then surgical removal of the left femoral aneurysm and replacement with an 8mm PTFE graft was performed. CONCLUSIONS Intrinsic Dacron graft failure occurs in approximately 0,5-3%. Dacron graft aneurysms are rare disorders. Most cases present generalized dilation. There are multifactorial reasons of the pathology; such as mostly fabrication flaws, faulty preoperative management related to methods of sterilization, bio-deterioration related to hematomas or infection, and material fatigue. The risk of aneurysm rupture is very rare. Endovascular treatment is a relatively safe option for the treatment of the dilated Dacron grafts.

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OBJECTIVE Dacron grafts are frequently used during surgical revascularization procedures. Graft thrombosis or infection are well known complications. However, aneurysm formation is extremely rare. In this report, we present Dacron graft aneurysm of left limb of aortobifemoral bypass graft in a 50-year-old male patient.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

FIGURES

Preoperative computed tomography angiography showing dacron graft dilation (28,4 mm body size, 14 mm leg size) and a 50 mm in diameter left femoral aneurysm together with cross-over femoral bypasses with saphenous vein grafts.

Postoperative control computed tomography angiography.

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ORTA A A Pain In The Buttock: Iliac Branch Devices Versus Internal Iliac Artery Embolization During Elective Infrarenal EVAR Natasha Chinai, Emma Pappworth, James Coulston, Paul Eyers, Timothy Ward, Kajendra Balasubramanium, Andrew Stewart, Ian Hunter Musgrove Park Hospital, Taunton, United Kingdom

OBJECTIVE To compare outcomes in patients undergoing either Iliac Branch Device (IBD) insertion or internal iliac artery (IIA) embolization as an adjunct procedure during elective endovascular abdominal aortic aneurysm repair (EVAR).

RESULTS From 237 infrarenal EVARs, 28 had adjunctive procedures to the iliac arteries. 12 patients had an IBD; 6 with contralateral embolization of IIA. There was 1 technical failure and 1 Type II endoleak. 16 patients had IIA embolization only (8 left, 5 right, 3 bilateral). Telephone follow-up was at a median of 12 months (range 6-60). 2 patients from each group died prior to the study. New erectile dysfunction developed in 4 embolization and 0 IBD patients. (p=0.06) Persistent new buttock claudication (either side) occurred in 42% (3 IBD, 7 IIA, p= 0.3). New ipsilateral buttock claudication developed in 1/9 patients with preserved IIA perfusion by IBD and 8/15 with an occluded IIA (p=0.03). In the IBD group, 1 patient developed contralateral claudication (with IIA embolization) and 2 developed ipsilateral claudication (1 technically successful; 1 failed with IIA occlusion). CONCLUSION Preservation of IIA patency with successful IBD reduces postoperative ipsilateral buttock claudication when compared with IIA occlusion. The incidence of erectile dysfunction may also be lowered.

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METHODS All patients undergoing elective infrarenal EVAR with internal iliac adjunct in a vascular centre over a 4-year period were identified from prospective local and national databases. Case notes and procedural images were reviewed. Patients were contacted by telephone to assess post-operative symptoms and impact on quality of life. Statistical analysis was with the ChiÂ˛ test.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ORTA A A Completed Cycle Audit Of Pre-Operative Assessment Of EVAR Patients In The Royal Derby Hospital Aimee Rowe, Timothy Rowlands

Royal Derby Hospital, Derby, United Kingdom EVAR (Endovascular Aneurysm Repair) is a surgical and radiological intervention used to treat abdominal aortic aneurysms (AAA). Patients requiring this surgical intervention to treat a AAA usually have cardiovascular co-morbidity and carry a significant degree of operative risk. At the Royal Derby Hospital (UK) our elective EVAR patients were seen in a General Surgery nurse-led Pre-Operative Assessment (POA) clinic. A retrospective audit of all Elective EVAR patients seen for POA for the year 2012 showed that standard PreOp clinic was not providing adequate investigation of this patient group, in line with published guidance. The initial audit recommended the introduction of a dedicated Elective EVAR Pre-Operative Assessment Clinic (EEPOAC), which started in 2013. This would ensure assessment by a senior Anaesthetist experienced in vascular surgery. To assess the efficacy of the clinic the audit was repeated retrospectively to cover a six month period in 2014. The functional status classifications (ASA grade) and degree of co-morbidity was comparable between the 2012 and 2014 cohorts. Repeat audit showed that the introduction of a dedicated POA clinic improved the pre-operative assessment of elective EVAR patients, although some areas remain below gold standard. The majority of patients are now seen by a Consultant Anaesthetist with experience in vascular surgery and are having appropriate pre-operative investigations, such as blood tests. There is still discrepancy as to the cardiovascular investigations being performed however this has lead to recommendations to the clinic to ensure the most appropriate investigations are provided on an individual patient basis. The audit has also suggested further audit to investigate our â&#x20AC;&#x2DC;expeditedâ&#x20AC;&#x2122; patient group, who fall between elective and emergency, who are missing out on standardised pre-operative assessment.

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ORTA A Endovascular Aneurysm Repair Versus Open Repair For Patients With A Ruptured Abdominal Aortic Aneurysm: A Mid-Term Cost-Effectiveness Analysis Ahmed Aber, Matt Bown, Robert Sayers

Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom OBJECTIVES The aim of this study was to analyze the cost-effectiveness of EVAR compared with open repair (OR) in the treatment of ruptured abdominal aortic aneurysms (RAAA).

METHODS A decision tree model was constructed and populated with probabilities, outcomes and utility data from published literature including IMPROVE, AJAX & NOTTINGHAM trials. The cost data were obtained from the NHS reference costs published annually by the department of health. Probabilities, outcomes for long-term complications were obtained from literature on elective repair of AAA because of lack data for RAAA. This was done so that the economic model captures the effects of post-operative complications on the cost-effectiveness of EVAR and OR. The results from the model were assessed using one-way and probabilistic sensitivity analyses. RESULTS The cost of EVAR and open repair combined with the costs of the complications over one year were £5547.9 and £5963.7, the QALYs were 0.493 and 0.498 respectively. Both treatments costs were well below the lower margin of the societal willingness to pay in the UK (£20000) for one gained QALY. The net monetary benefit (NMB) for OR was £3987-10939 compared to EVAR with NMB £4307.5-9235.2. The sensitivity analysis confirmed that both treatment modalities are cost-effective management options at the maximum willingness to pay for a QALY commonly used in the UK. CONCLUSION Performing OR on RAAA is a cost effective strategy with a marginally better NMB when compared to EVAR. However both EVAR and OSR cost less than the societal willingness threshold for the QALYs gained. REFERENCES 1. Reimerink J, van der Laan MJ, Koelemay MJ, Balm R, Legemate DA. (2013)Systematic review and meta-analysis of population-based mortality from ruptured abdominal aortic aneurysm Br J Surg, 100 (11): 1405–1413 2. Reimerink JJ, Hoornweg LL, Vahl AC, Wisselink W, van den Broek TA, et al. (2013). Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial Ann Surg, 258: 248–256 3. Parodi JC, Palmaz JC, Barone HD. (1991) Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg. 5:491–9. 4. Greenhalgh, R. M., L. C. Brown, G. P. Kwong, et al.(2004) 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. 364:843–848 5. Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT, Jr, Matsumura JS, Kohler TR, et al. (2009) Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA, 302:1535–42. 6. Hinchliffe RJ, Bruijstens L, MacSweeney ST, Braithwaite BD. (2006) A randomised trial of endovascular and open surgery for ruptured abdominal aortic aneurysm – results of a pilot study and lessons learned for future studies. Eur J Vasc Endovasc Surg, 32 (5) (2006), pp. 506–513 7. Powell JT, Sweeting MJ, Thompson MM, Ashleigh R, Bell R,et al. (2014) Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial BMJ, 348: f7661

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DESIGN A model-based cost–utility analysis was performed estimating mean costs and quality-adjusted life-years (QALYs) from the UK National Health Service with a 1-year time horizon.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

8. Kapma MR, Dijksman LM, Reimerink JJ, et al. (2014) Cost-effectiveness and cost-utility of endovascular versus open repair of ruptured abdominal aortic aneurysm in the Amsterdam Acute Aneurysm Trial. Br J Surg. 2014;101(3):208-15 9. National Institute for Health and Care Excellence (NICE). Guide to the Methods of Technology Appraisal 2013. 10. Young KC, Awad NA, Johansson M, Gillespie D, Singh MJ, Illig KA. (2010) Cost-effectiveness of abdominal aortic aneurysm repair based on aneurysm size. Journal of Vascular Surgery. 51(1):27–32. 11. Van Beek SC, Conijn AP, Koelemay MJ, Balm R. (2014) Endovascular aneurysm repair versus open repair for patients with ruptured abdominal aoric aneurysm: Systematic review and meta-analysis of short term survival. Eur J Vasc Endovasc Surg 10785884(14) 12. Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. ( 2008) Endovascular versus open repair of abdominal aortic aneurysms in the medicare population. New England Journal of Medicine. 358(5):464–474. 13. van Marrewijk CJ, Leurs LJ, Vallabhaneni SR, Harris PL, Buth J, Laheij RJ. (2005) Risk-adjusted outcome analysis of endovascular abdominal aortic aneurysm repair in a large population: how do stentgrafts compare? J Endovasc Ther. 12:417–29. 14. CEA Registry, Tufts Medical Center. accessed April 2014. https://research.tufts-nemc.org/cear4/SearchingtheCEARegistry/ SearchtheCEARegistry.aspx

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ORTA A Use Of Chimney Grafts For Visceral Aneurism Complicating EVAR Andrea Angelini, Gianluigi Nigro, Elisa Dimitri, Luciano Carbonari Ospedali Riuniti Ancona, Ancona, Italy

CASE REPORT A 81 y.o. man presented with a large symptomatic para-renal aneurysm (p-AAA) measuring 8 cm in diameter involving the origin of the major visceral trunks. The aneurism developed after 7 years from a previous endovascular emergent aortic repair (EVAR) with a right uni-iliac endograft with passive suprarenal fixation plus femoro-femoral crossover for a contained rupture of an infrarenal abdominal aortic aneurysm. The patient was admitted in the emergency department with important back and abdominal pain without signs of hemodynamic instability. The past medical history accounted for a previous aorto-coronary bypass for coronary artery disease, moderate chronic obstructive pulmonary disease and a mild chronic renal failure due to left kidney atrophy. In regard to his previous EVAR procedure, a CT scan was promptly performed and a large degenerative aneurysm involving the visceral segment of the abdominal aorta cranial to the free-flow was revealed, furthermore causing a large type I endoleak around the uni-iliac aortic endoprosthesis (Fig.1, 2, 3, 4, 5). The telltaling radiological findings of peri-aortic inflammation and very thin wall were suggestive for an impending rupture, therefore, considering the poor general status and high surgical risk of open repair, the patient was scheduled for a re-do procedure associated with visceral “Chimney Graft” rebranching (ch-EVAR). The procedure was performed via a single right femoral access plus bilateral brachial accesses. In an antegrade fashion the three visceral vessels (the coeliac trunk, the superior mesenteric artery and the remaining right renal artery) were engaged from the upper limbs. After telescopic deployment of a 10 cm long thoracic aortic endograft with 10% oversizing via the femoral artery, three flexible covered stents (8-7-6 mm in diameter and 10 cm in length) were respectively released in each vessel in a “chimney graft technique”. It followed a careful post dilation of each branch parallel to the aortic cuff. The final angiography showed a good placement of the devices with complete aneurysm exclusion and no signs of endoleaks. Surgery was performed under general anesthesia, total duration of surgery was 3.30 hours, two of which under fluoroscopy. The patient was dismissed on 10th postoperative day without neurological impairments and in fair general conditions. A post-operative CT scan confirmed complete aneurysm exclusion and regular patency of the three branches. (see Fig. 3) DISCUSSION Due to the patient’s multiple comorbidities, ch-EVAR was the the most promising therapeutic option 3-4 to offer in this complex p-AAA complicating EVAR. In fact, recent studies 5 report quite positive outcomes in the short-term counting 6% chimney-related mortality and 93% long-term patency in high risk population and urgent setting. Although a triple chimney stenting may be in relationship with a high rate of leak 6, it is known that this can be somehow prevented by assuring enough overlap of the stents at the sealing zone and by choosing the correct size of the endograft. Accurate preoperative measuring and planning is therefore crucial for such purpose. In this setting, the pre-planned choice of a thoracic conical endograft, which is known to have a higher radial force, played a major role for the success of the operation because it allowed a more precise sealing around the stents and at the graft-in-graft junction. Except for the post dilation of the visceral chimney stents, we do not find useful the dilation of the main graft as in tight spaces, displacement or compression of the stents are a real concern. In conclusion, the treatment of p-AAA can be technically challenging, especially in patients undergone to previous aortic procedures. ch-EVAR confirmed its feasibility and safety as bail-out method for urgent cases providing that every possible pitfall is taken care of during planning. 119

EPOSTERS

INTRODUCTION The use of chimney grafts in complex visceral aneurysm endovascular repair is a well-known 1 yet controverse 2 technique. Use in re-do procedures or aneurysmal complications post-endovascular aortic repair (EVAR) has been however very seldom reported3. We report a case with some very peculiar challenging variables where

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

FIGURES

Pre-operative CT scan, right renal artery

Pre-operative CT scan, superior mesenteric artery

Pre-operative CT scan, type Ia endoleak

Pre-operative CT scan, VR reconstruction

Post operative CT scan, right renal artery

Post operative CT scan, superior mesenteric artery 120

Post operative CT scan, volume rendering reconstruction

REFERENCES 1. J Endovasc Ther. 2015 Aug;22(4):568-74. A 12-Year Experience With Chimney and Periscope Grafts for Treatment of Type I Endoleaks. 2. Eur J Vasc Endovasc Surg. 2015 Sep 11. Chimney Grafts in Aortic Stent Grafting: Hazardous or Useful Technique? Systematic Review of Current Data. Lindblad B, Bin Jabr A, Holst J Malina M. 3. Ann Surg Treat Res. 2014 May;86(5):274-7. Repair of type I endoleak by chimney technique after endovascular abdominal aortic aneurysm repair. Kim NH, Kim WC, Jeon YS, Cho SG, Hong KC. 4. Ann Surg. 2015 Sep;262(3):546-53. Collected world experience about the performance of the snorkel/chimney endovascular technique in the treatment of complex aortic pathologies: the PERICLES registry. Donas KP, Lee JT, Lachat M, Torsello G, Veith FJ; PERICLES investigators. 5. J Endovasc Ther. 2015 Aug;22(4):575-7. Commentary: Could the Chimney Technique Become the “Holy Grail“ of Endovascular Treatment for Type Ia Endoleaks After EVAR? Donas KP, Torsello G.

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Post operative CT scan, celiac trunk

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ORTA A Early And Mid-Term Results Of The Frozen Elephant Trunk Procedure Using The Thoraflex Hybrid Prosthesis For Treatment Of Extensive Thoracic Aortic Disease Christian Gerges, Xavier Chaufour, Jean Porterie, Etienne Grunenwald, Christophe Cron, Marylou Para, Yves Glock, Bertrand Marcheix

CHU Toulouse Rangueil, Toulouse, France

OBJECTIVES To describe early and mid-term results of extensive thoracic aortic disease treatment by frozen elephant trunk (FET) procedure using the Thoraflex Hybrid prosthesis. METHODS From January 2014 to May 2015, 20 patients were treated: 7 aneurysms and 13 aortic dissections (9 acute dissections); 7 interventions were redo and aortic root surgery was associated in 9 patients. Procedures consisted of one stage frozen elephant trunk via a median sternotomy, under cardiopulmonary bypass, moderate hypothermia and selective antegrade cerebral perfusion. Clinical and CT scan follow up was scheduled at 1, 3, 6 and 12 months. RESULTS Two patients died (2/20=10%) on post-operative day 4 and 5. The cause of death was one myocardial infarction (redo surgery for chronic dissection) and one mesenteric ischemia (elective surgery for atheromatous aneurysm). Mean follow up was 211,2Âą116days. One patient was successfully reoperated because of type 1 distal endoleak at 3 months (atheromatous aneurysm). The other aneurysms were completly excluded and false lumen in the descending aorta thrombosed in all cases of aortic dissections. CONCLUSIONS The FET using the Thoraflex Hybrid prosthesis makes possible the treatment of extensive disease of the thoracic aorta. Operative mortality should not be underestimated despite substantial technical improvement. Mid term results seem to be interesting especially when FET technic is performed in the setting of acute aortic dissection. FIGURES

La Thoraflex

Deployment

122

Anastomose

Thoraflex Description And Available Size

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Aneurysm

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

TABLES Mortality Clot removal Renal failure Recurrent nerve paralysis Ventilation >24h

2 4 11 4 9

Mortality-morbidity Nb de patients Ratio M/F Age Aneurysm Acute Dissection Chronic Dissection Redo Surgery Aortic Root

20 (16/4) 59 7 9 4 7 9

Demographics Follow up Endoleak Reintervention

254,2 2 2

+/- 116,8 (15-400)

Follow-up REFERENCES M Shrestha, Beckmann E, Krueger H, Fleissner F, Kaufeld T, Koigeldiyev N, Umminger J, Ius F, Haverich A, Martens A. The elephant trunk is freezing: The Hannover experience. J Thorac Cardiovasc Surg. 2015 May;149(5):1286-93. Di Bartolomeo R, Pantaleo A, Berretta P, Murana G, Castrovinci S, Cefarelli M, Folesani G, Di Eusanio M. Frozen elephant trunk surgery in acute aortic dissection. J Thorac Cardiovasc Surg. 2015 Feb;149(2 Suppl):S105-9. Katayama A, Uchida N, Katayama K, Arakawa M, Sueda T. The frozen elephant trunk technique for acute type A aortic dissection: results from 15 years of experienceâ&#x20AC; . Eur J Cardiothorac Surg. 2015 Feb;47(2):355-60; Moulakakis KG, Mylonas SN, Markatis F, Kotsis T, Kakisis J, Liapis CD. A systematic review and meta-analysis of hybrid aortic arch replacement. Ann Cardiothorac Surg. 2013 May;2(3):247-60. Ius F, Fleissner F, Pichlmaier M, Karck M, Martens A, Haverich A, Shrestha M. Total aortic arch replacement with the frozen elephant trunk technique: 10-year follow-up single-centre experience. Eur J Cardiothorac Surg. 2013 Nov;44(5):949-57 Roselli EE, Rafael A, Soltesz EG, Canale L, Lytle BW. Simplified frozen elephant trunk repair for acute DeBakey type I dissection. J Thorac Cardiovasc Surg. 2013 Mar;145(3 Suppl):S197-201. Verhoye JP, Anselmi A, Kaladji A, FlĂŠcher E, Lucas A, Heautot JF, Beneux X, Fouquet O. Mid-term results of elective repair of extensive thoracic aortic pathology by the Evita Open Plus hybrid endoprosthesis only. Eur J Cardiothorac Surg. 2014 May;45(5):812-7

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ORTA A A challenging internal iliac aneurysm - Case report Mario Moreira

Centro Hospitalar e Universitรกrio de Coimbra, Coimbra, Portugal

EPOSTERS

Internal iliac artery (IIA) aneurysms, while rare, carry a significant risk of mortality if they rupture. Endovascular intervention, when feasible, is the preferred method of treatment. Percutaneous direct puncture of the aneurysmal sac under image guidance, followed by embolization of the sac and feeding arteries, has been shown to be a good alternative in selected cases. The authors present a 79-year-old male with an asymptomatic 8.3cm left IIA aneurysm and long background history of interventions. He had undergone, in 2002, a right IIA ligation and PTFE interposition in common iliac artery (CIA) for ruptured right IIA aneurysm. At 1 year follow up, detected a 3cm left CIA aneurysm that extends to IIA and a 3.4cm infra-renal aortic aneurysm. Submitted to partial aneurysm resection and interposition of a bifurcated aorto-bi-iliac graft and left IIA ligation. An angio-CT on July 2011 showed a 6.3cm left IIA aneurysm supplied by feeding arteries with partial sac enhancement. From then on, two CT-guided percutaneous embolisation were attempted with no satisfactory results. CT-guided direct puncture of IIA aneurysms adds to the armamentarium of minimally invasive modalities. It can be useful in isolated IIA aneurysms that develop after AAA repair or when intra-arterial access is not possible. On the failure of the first attempts, should we repeat it till we succeed?

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ORTA A Surgical infrarenal “Neo-neck” technique during elective conversion after evar with suprarenal fixation Stefano Bonvini, Valentina Wassermann, Mirko Menegolo, Paola Scrivere, Michele Piazza, Franco Grego Clinic of Vascular and Endovascular Surgery of Padua University, Padova, Italy

OBJECTIVES Conversion of a previous endovascular aneurysm repair (EVAR) with suprarenal fixation is a challenging situation even in the elective setting. The outcomes of a technique based on preservation of the first proximal covered stent of the endograft, used as a “neo-neck” for proximal anastomosis, are presented. METHODS From 2001 to 2014, nine patients underwent elective conversion of a previous suprarenally fixed EVAR. After supraceliac clamping, the aneurysm sac was opened and the endograft identified; the fabric was cut beyond the first covered stent together with its native aortic wall in order to create a “neo-neck.” An aortic balloon was inflated into the visceral aorta to avoid back bleeding. A Dacron bifurcated tube graft (Intergard, Maquet) was then sutured to the neo-neck mimicking endobanding, passing the stitches into the aortic wall and the first covered stent. RESULTS The mean age was 68 years (range, 52–84 years). The stent grafts removed were four Zenith (Cook Medical), three Endurant (Medtronic), and two E-vita (Jotec). The indication for conversion was type 1A (n = 2), type 2 (n = 2), and type 3 (n = 1) endoleak, complete endograft thrombosis (n = 2), and abdominal pain with sac enlargement with no radiological sign of endoleak (n = 2). Blood loss was 1,428 mL (range 500–3,000 mL); the visceral ischemic time to perform the proximal anastomosis was 23.5 min ± 2.3 min). The post-operative complication rate was 11% (n = 1/9) related to a case of sac wall bleeding requiring re-intervention; mortality at 30 days was 0%. At 22 months (range, 8–41) the computed tomography angiogram demonstrated no signs of leaks or anastomotic pseudoaneurysm. CONCLUSIONS Preservation of the proximal covered stent of an endograft with suprarenal fixation used as an infrarenal “neo-neck” with incorporation of the aorta to the suture line during elective surgical explantation simplifies the procedure, and can be achieved with very low early morbidity and mortality; furthermore, it seems to be durable over mid-term follow up.

FIGURES - Figure 1. The “Neo-neck” The “ neo-neck ” ( first covered stent and infrarenal aortic wall) used as the site for the proximal anastomosis with the Dacron graft, sutured in an end to end fashion, passing the stitches into the aortic wall and through the first covered stent; the aortic balloon is in fl ated at the level of the visceral aorta to avoid back bleeding. 126

Three dimensional reconstruction of abdominal computed tomography angiogram performed during follow up Three dimensional reconstruction of abdominal computed tomography angiogram performed during follow up after late open conversion for failed EVAR in three different endografts with suprarenal fi xation. White arrows indicate the site of hybrid proximal anastomosis. (A) Endurant II; (B) Zenith Flex; (C) Zenith Low Profile.

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The â&#x20AC;&#x153;endobandingâ&#x20AC;&#x153; In all the cases the stitches were passed as deeply as possible into the aorta at the level of the bottom of the fabric covered stent mimicking endobanding.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ORTA A Symptomatic recurrent aortic arch aneurysm successfully treated by total endovascular aortic repair Monica Vescovi, Raffaello Bellosta, Luca Luzzani, Claudio Carugati, Francesca Bontempi, Antonio Sarcina Poliambulanza Foundation, Brescia, Italy

We present a case report with the double chimney-grafts in the aortic arch using a device designed for the iliac branch. A 76 years old man was admitted to our department with dysphonia and dysphagia. He underwent two years before to TEVAR for aneurysm of the aortic arch, left subclavian artery embolization with Vascular Plug and left common carotid bare metal stent to preserve carotid flow. The patient was classified ASA IV (American Society of Anesthesiologists classification) and the risk evaluation according to the European System for Cardiac Operative Risk Evaluation (EuroSCORE2) was 6.18. Urgent CT scan showed an increasing diameter of aneurysm of aortic arch because of type IA endoleak. To obtain an adequate proximal neck for conventional TEVAR, the double chimney-graft technique was chosen as an option. Under general anesthesia the left common femoral artery, the right subclavian artery and the left common carotid artery were exposed. Then through carotid approach a stentgraft 8 by 10 and through 12Fr sheath into axillary artery an hypogastric component of Iliac branch device were inserted into the ascending aorta. Simultaneously a thoracic stent graft through common femoral artery was introduced. Next, rapid left-ventricular pacing with reduction of systolic blood pressure (<60 mmHg) was applied to prevent the bloodstream-induced dislocation of the grafts. The thoracic stent graft was deployed, directly followed by the deployment of the chimney-grafts, which was completed by balloon modelling. A final angiogram showed patency of chimney graft and complete resolution of endoleak. Post-operative CT scan showed no endoleaks and patency of the grafts. Postoperative course was uneventful and patient was discharged at 8Th day. In order to obtain a good sealing between chimney stentgraft and artery for the size of the anonymous trunk usually greater than 10 mm the hypogastric component of iliac branch device can be a good solution because its 16 mm proximal diameter. FIGURES

First CT with increasing diameter of aneurysm arch

Stentgrafts in ascendent aorta

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Postoperative CT 2

REFERENCES Efficacy and durability of the chimney graft technique in urgent and complex thoracic endovascular aortic repair Adel Bin Jabr, MD, Bengt Lindblad, MD, PhD, Nuno Dias, MD, PhD, Timothy Resch, MD, PhD, and Martin Malina, MD, PhD, Malmö, Sweden J Vasc Surg 2015;61:886-94 Contemporary comparison of aortic arch repair by endovascular and open surgical reconstructions Paola De Rango, MD, PhD,a Ciro Ferrer, MD,b Carlo Coscarella, MD,b Francesco Musumeci, MD,c, Fabio Verzini, MD, PhD, FEBVS,a Gabriele Pogany, MD,b Andrea Montalto, MD,c and Piergiorgio Cao, MD, FRCS,b Perugia and Rome, Italy (J Vasc Surg 2015;61:33946.) Thoracic endovascular aortic repair with the chimney graft technique Wouter Hogendoorn, MD,a,b Felix J. V. Schlösser, MD, PhD,a Frans L. Moll, MD, PhD,b, Bauer E. Sumpio, MD, PhD,a,c and Bart E. Muhs, MD, PhD,a,c New Haven, Conn; and Utrecht, The Netherlands (J Vasc Surg 2013;58:502-11.) Endovascular Aortic Repair Combined with Chimney Technique in the Treatment of Stanford Type B Aortic Dissection Involving Aortic Arch Hong Liu,1,2,3 Chang Shu,1 Xin Li,1 Tun Wang,1 Ming Li,1 Quan-Ming Li,1 Kun Fang,1 and Shalong Wang,1 Changsha, China and Tianjin, China Ann Vasc Surg 2015; 29: 758–763 Case Report A Case of Ruptured Aortic Arch Aneurysm Successfully Treated by Thoracic Endovascular Aneurysm Repair with Chimney Graft Yohei Kawatani, Yujiro Hayashi, Yujiro Ito, Hirotsugu Kurobe Yoshitsugu Nakamura, Yuji Suda, and Takaki Hori Hindawi Publishing Corporation Case Reports in Surgery Volume 2015, Article ID 780147, 5 pages The chimney-graft technique for preserving supra-aortic branches: a review Konstantinos G. Moulakakis1,2, Spyridon N. Mylonas1,2,3, Ilias Dalainas1, George S. Sfyroeras1, Fotis Markatis1, Thomas Kotsis3, John Kakisis1, Christos D. Liapis1 Ann Cardiothorac Surg 2013;2(3):339-346 Triple-barrel Graft as a Novel Strategy to Preserve Supra-aortic Branches in Arch-TEVAR Procedures: Clinical Study and Systematic Review R. Shahverdyan *, M. Gawenda, J. Brunkwall 2012 European Society for Vascular Surgery. Published by Elsevier Ltd.

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Postoperative CT

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ORTA A The complexity and challenge in endovascular repair of aneurysms with severely angulated neck, the report of two cases Andre M. Cancela, Meirelles GV, Luis S. Indaiatuba, S찾o Paulo, Brazil

Severely angulated neck (> 60째) it is still a challenge in EVAR. It is recognized as an important risk factor of failure of endovascular repair and increases difficulty in delivery system introduction, stent-graft deployment and can increase of type I endoleak. The current stent-graft systems were designed primarily as straight neck sealing zone systems. Even if the US FDA indication states > 60째, other concurrent hostile neck attributes were not taken into account for these situations, such as a short (< 15 mm), reverse taper of > 30%, extensive thrombus or calcifications. When the proximal sealing zone displays multiple hostile factors, the probability of successful short-and long-term outcome diminishes significantly. The main challenge in treating patients with severely angulated neck lies in accurately positioning the stent-graft to maximize its inherent ability to conform to the neck and form an adequate sealing for proper AAA exclusion. Our purpose is to report two cases with a high angulated neck successfully treated and discuss important aspects for the effective management.

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UPRA AORTIC TRUNKS S Cerebral Protection With Right And Left External Carotid Artery Cross Over Bypass For Pulsatile Flow Inside The Internal Carotid Arteries During Aortic Debranching Murat Ugurlucan1, Didem Melis Oztas1, Omer Ali Sayin1, Y覺lmaz Onal2, Mehmet Barburoglu2, Mehmet Akif Onalan1, Metin Onur Beyaz1, Cagla Canbay1, Ergin Arslanoglu1, Seda Yildirim1, Bulent Acunas2, Nilgun Bozbuga1, Ufuk Alpagut1, Enver Dayioglu1 1. Istanbul University, Istanbul Medical Faculty, Cardiovascular Surgery, Istanbul, Turkey 2. Istanbul University, Istanbul Medical Faculty, Radiology, Istanbul, Turkey

METHODS The first patient was a 59-year-old obese female patient with chronic obstructive pulmonary disease and previous history of ascending aortic replacement for acute Type 1 aortic dissection and the second one was a 92 year-old male with arch and descending aortic aneurysm. We planned an endovascular procedure for treatment in both cases following debranching of left common carotid and subclavian arteries. RESULTS The operation was performed with general anesthesia in the female and local-regional anesthesia in the male patient. Right and left carotid arteries and left subclavian artery were prepared. An external cross bypass was performed between the external carotid arteries with a 6mm PTFE graft. In the male patient an appropriate length Y graft for left carotid and left subclavian arteries debranching was created with a ringed 8mm PTFE graft on the table. The proximal anastomosis of the Y graft was performed end-to-side to the right common carotid artery. The left common carotid artery was ligated proximally and the anastomosis of one branch of the Y graft was performed end-to-end to the left common carotid artery. Then the cross over external carotid artery bypass was removed. The left subclavian artery was ligated and remaining branch of the Y graft was anastomosed end to end to the left subclavian artery. Patient was neurologically stable throughout the procedure. In the female patient the left common carotid artery was clamped, transsected and an 8mm PTFE graft was anastomosed end to end to the left common carotid artery. Another 8mm PTFE graft was anastomosed end to side to the left subclavian artery which was anastomosed to the graft that was previously anastomosed to the left common carotid artery. Then the anastomosis of the graft of the left common carotid artery was performed end to side to the right common carotid artery. At the end of the procedure, the left subclavian artery was ligated and cross over external carotid artery bypass was removed. Neurological deficit did not occur. CONCLUSIONS An external cross over bypass between the external carotid arteries provides continuous pulsatile blood flow to the internal carotid arteries during debranching of left common carotid and left subclavian arteries. Hence, this makes the procedure very safe as neurologically.

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OBJECTIVES Endovascular stent graft repair of the thoracic aortic aneurysms sometimes requires debranching of the aortic arch and re-implantation of the left common carotid and left subclavian arteries to the brachiocephalic trunk. Cerebral protection has utmost importance during this procedure.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

FIGURES

The bypass performed on the skin by 6 mm PTFE graft between both external carotis arteries is seen.

Postoperative computed tomography (CT) Angiography view of the debranching graft.

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UPRA AORTIC TRUNKS S A novel shunt for patients intolerant to cross-clamping during carotid surgery Murat Ugurlucan1, Didem Melis Oztas1, Omer Ali Sayin1, Mehmet Akif Onalan1, Metin Onur Beyaz1, Cagla Canbay1, Siraslan Bakhseliyev1, Kaan Altunyuva1, Ufuk Alpagut1, Enver Dayioglu1 1. Istanbul University, Istanbul Medical Faculty, Cardiovascular Surgery, Istanbul, Turkey 2. Istanbul University, Istanbul Medical Faculty, Radiology, Istanbul, Turkey

METHODS Among 145 patients who underwent carotid endarterectomy between March 2010 and October 2015, 11 (5,6%; 8 men and 3 women; age range 52-77years) could not tolerate carotid clamping. We used an alternative carotid shunt, made from a venous catheter, a three-way stopcock, and a serum line, which aided non-compromised cerebral flow during the surgery of these patients. RESULTS Three patients had bilateral lesions and the remainder had unilateral disease. The degree of stenosis ranged from 70 to 95 %. Temporary carotid clamping resulted in neurologic events, such as loss of consciousness in all and tremor in one, in <10 seconds (range, from immediately to 8 seconds after clamping). Full neurologic function was regained between 15-30 seconds after releasing the clamps. All of the patients tolerated the procedure well with the support of our novel shunt. Shunt flow was adequate in all patients and no neurologic deterioration occurred after carotid clamping. The mean carotid clamp time was 28.11 Âą 14.19 min. There was no mortality and all patients were followed up for a mean period of 14.6 Âą 4.9 months, uneventfully. The shunt flow was tested ex-vivo using a cardiopulmonary bypass machine filled with blood to simulate human body and adjusted to run at different blood pressure levels and compared with the flow rates of commercially available shunts in the market, i.e. Inahara-Pruit and Javid. Flow of the home-constructed shunt indicated similar rates with Inahara-Pruit and better rates than Javid. CONCLUSIONS An alternative, simple shunt can be easily constructed in the operating room or clinic, using an angiocatheter, a three-way stopcock, and a serum line can provide adequate cerebral flow and permit safe carotid endarterectomy for those rare patients with carotid artery stenosis, who cannot tolerate even seconds of carotid occlusion. The major advantage of this home constructed shunt over the available shunts in the market is that it is inserted without carotid clamping; hence, there is no cerebral ischemia time.

FIGURE An alternative, simple shunt can be easily constructed in the operating room or clinic, using an angiocatheter, a three-way stopcock, and a serum line 133

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OBJECTIVE A group of patients with carotid artery disease are at high-risk for general anesthesia and deserves carotid endarterectomy with regional anesthesia. Carotid clamp intolerance is a known issue and may also occur in this particular patient population. Even less than 30 seconds of temporary clamping of the carotid arteries to deploy a standard marketed shunt may be eventful in these patients. We present a novel shunt that we made from simple medical equipment in this patient population for safe carotid endarterectomy.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ISCERAL ARTERIES V Emergency Revascularization For Acute-On-Chronic Mesenteric Ischemia: 8-Year Experience Tiago Ferreira, Augusto Ministro, Pedro Martins, Ana Evangelista, Emanuel Silva, Luís Silvestre, Luís Mendes Pedro, José Fernandes e Fernandes Vascular Surgery Department, Hospital de Santa Maria - CHLN, Lisbon, Portugal

INTRODUCTION Acute mesenteric ischemia is an infrequent and often underdiagnosed condition that still carries a high mortality rate. Among its various etiologies, acute arterial thrombosis is most frequently seen in elderly patients with multiple cardiovascular risk factors and occurs almost universally in the setting of subclinical atherosclerotic disease of the visceral arteries. Some of the cases may have an insidious onset or present as an acute deterioration in patients who were chronically symptomatic. The authors present their experience in emergency revascularization for acute-on-chronic mesenteric ischemia over an 8-year period. METHODS Data from patients who underwent emergency revascularization for acute mesenteric ischemia over an 8-year period (March 2007 – March 2015) were retrospectively reviewed. Cases of acute ischemia due to arterial embolus, nonocclusive mesenteric ischemia, mesenteric venous thrombosis and aortic dissection were excluded. A history of protracted symptoms was specifically sought. Patient demographics, surgical treatment and short-term outcomes were analyzed. RESULTS A total of 14 patients were included in the review (8 women and 6 men; mean age 71 years; age range 4386 years). Hypertension (43%), cigarette smoking (29%) and coronary artery disease (29%) were the most prevalent cardiovascular risk factors. There was previous history of abdominal pain in all patients, with a duration ranging from 2 weeks to 3 years. All patients had CT-angiography demonstrating atherosclerotic disease of the mesenteric vasculature with occlusion of at least one vessel. Abdominal exploration and surgical bypass were universally performed (8 prosthetic, 6 venous). Two of the patients underwent more than one revascularization procedure, including one hybrid intervention. Bowel resection was performed in 64% of patients (9/14). Thirty-day mortality was 36% (5/14). CONCLUSIONS Acute bowel ischemia can be the end result of chronic atherosclerotic disease of the visceral vessels, affecting patients who are often frail and have multiple medical comorbidities. Acute deterioration of long-standing symptoms may indicate irreversible compromise of intestinal viability, which translates into high rates of bowel resection. Prompt revascularization and removal of necrotic bowel offer the best chance of survival.

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ISCERAL ARTERIES V Aneurysms Of Visceral Arteries Olexander Usenko, Iryna Shevchenko, Pavlo Nikulnicov, Arkadii Danylets, Oleg Babii

Aneurysm of the celiac artery is an uncommon clinical problem; fewer than 180 cases have been reported in the world medical literature. Most patients are symptomatic at the time of diagnosis1. Rupture of celiac artery aneurysms is associated with significant clinical morbidity and mortality rates. On the basis of abdominal aortic aneurysm data, the risk of celiac artery aneurysm rupture can range from 5% for aneurysms that are from 15 to 22 mm in diameter to 50% to 70% for aneurysms with a diameter of more than 32 mm2. Early recognition and accurate characterization of this vascular anomaly is essential, because the operative mortality rate increases from approximately 5% to 40% when the aneurysm has ruptured at the time of surgical intervention3,4 We present a case of 29 year old male who had a chronic epigastric pain for 1mounth. Computed tomographic angiography detected aneurysm of visceral trunk from its bifurcation to splenic artery with diameter 6.6x6.5 cm. Second aneurysm was detected from bifurcation of visceral trunk to common hepatic artery, with diameter 3,7x4 cm. Next aneurism, in the middle third of splenic artery had diameter 7.3x5.3 cm. Also there were aneurism of arteria mesenterica surerior with 3 cm in diameter and several aneurysms of its branches with maximum diameter 1,8 cm. Comorbid conditions include low platelets level and high rheumatoid factors. At surgery laparotomy was used to approach aneurysms of visceral trunk and its branches. A curved vascular clamp was placed on the aorta at the base of the celiac trunk, and the distal tributaries were clamped. Aneurysms were resected. Common hepatic artery was occluded, it’s origin and the origin of the celiac artery were oversewn. Spleen was enlarged to 22x8x3.5 cm with hemorrhage inside, as result spleenectomy was performed. Splenic vein was thrombosed. The branches to aneurism of splenic artery ware ligated, after it no pulsation was registered on it and the last one wasn’t resected. On bacteriological examination of wall of the aneurysms mycotic nature of them were approved. A computed tomographic scan in early postoperative period didn’t show any significant complications or signs of hepatic or other organs insufficiency. The patient made an uncomplicated recovery and was discharged after 11 days. REFERENCES 1. D. Michael McMullan, Michael McBride, James J. Livesay, Kathryn G. Dougherty, Zvonimir Krajcer. Celiac Artery Aneurys.Tex Heart Inst J. 2006; 33(2): 235–240. [PubMed] 2. Rokke O, Sondenaa K, Amundsen S, Bjerke-Larssen T, Jensen D. The diagnosis and management of splanchnic artery aneurysms. Scand J Gastroenterol 1996;31:737–43.[PubMed] 3. Graham LM, Stanley JC, Whitehouse WM Jr, Zelenock GB, Wakefield TW, Cronenwett JL, Lindenauer SM. Celiac artery aneurysms: historic (1745–1949) versus contemporary (1950–1984) differences in etiology and clinical importance. J Vasc Surg 1985;2:757– 64.[PubMed] 4. Stanley JC, Whitehouse WM Jr. Splanchnic artery aneurysms. In: Rutherford RB, ed. Vascular surgery. 6th ed. Philadelphia: Elsevier Saunders; 2005. p. 1565–81.

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Shalimov’s National institution of surgery and transplantology, Kyiv, Ukraine

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ASE REPORT C Complex Hybrid Multiple Treatments In Case Of A Complicated Chronic Type B Dynamic Dissection Paola Scrivere1, Giovanna Biasi1, Massimo Sponza2, Alice Silvestri1, Paolo Frigatti1 1. Chirurgia Vascolare - Ospedale Santa Maria della Misericordia, udine, Italy 2. Radiologia Interventistica - Ospedale Santa Maria della Misericordia, Udine, Italy

A 47 years old male patient with a chronic type B dissection, previously treated for a type A dissection complicated with an asymptomatic mediastinal abscess in follow up, arrived at the hospital with fever and abdominal pain. The angioâ&#x20AC;&#x201C; CT scan showed an infection-related rupture of a pseudoaneurysm in the left common iliac artery. Therefore the infrarenal aortic tears were surgically fenestrated and an aortic- left internal iliac artery bypass associated with left femoral artery by-pass and aortic- right femoral artery by-pass were performed using an aortic allograft. One year later the patient underwent an urgent angio-CT Scan for chest pain, revealing an infection-related pseudoaneurysm of the proximal ascending aortic anastomosis. An Hybrid procedure was performed: ascending aortic open repair associated with a total arch debranching of the supra-trunk vessels and an aortic arch exclusion with thoracic endograft deployment and a left subclavian artery embolization. One month later the patient suffered from abdominal pain related to an acute mesenteric ischemia. The angio-CT scan showed the presence of three lumen (two false lumen and one small true lumen) in the thoracoabdominal portion of the aorta with an inadequate perfusion of superior mesenteric artery ( AMS) and left renal artery LRA) related to a dynamic occlusion of the true lumen, subsequentely proved at the intravascular ultrasound (IVUS). A thoracic stent graft was deployed between the thoracic endograft and the proximal anastomosis of the abdominal aortic allograft after the revascularization with snorkel technique of SMA and LRA. A 30 month angio-CT scan demonstrated the patency of visceral arteries and the regular anastomosis diameter of the ascending aorta graft and of the abdominal aortic allograft. Therefore chronic type B dissection represents a dynamic process. A patient-specific strategy has to be tailored, considering open surgical, total endovascular or hybrid approach.

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CASE REPORT Rare Coeliaco-Mesenteric Trunk Aneurysm: Combined Surgical and Endovascular Solution Neena Randhawa, Peter Bungay, John Quarmby, James kirk, Timothy Rowlands Royal Derby Hospital, Derby, United Kingdom

INTRODUCTION Visceral artery aneurysms are extremely rare. The most common form of these aneurysms is coeliac axis aneurysm, usually involving the individual arteries. There have been approximately 180 case reports of such aneurysms since 1745, usually by anecdote. The majority of these are asymptomatic and often picked up as incidental findings. These are associated with high morbidity and mortality. AIM We present an unusual case of a patient with an aneurysm of a common origin of the coeliac and superior mesenteric arteries (SMA) and itâ&#x20AC;&#x2122;s management. CASE A 68 years old gentleman was identified to have 5.2cm infra-renal abdominal aortic aneurysm on abdominal ultrasound but CT identified this visceral artery aneurysm with normal abdominal aorta. He was otherwise fit and well and asymptomatic. Discussion at our vascular multidisciplinary team (MDT) meeting explored several different options including total surgical repair and combined endovascular options. He underwent a laparotomy with the intent of ligation of the aneurysm and multiple grafting however primary ligation proved impossible. The splenic artery was ligated at the origin and dacron graft was used to anastomose to the aorta. After recovering from this procedure the patient then underwent a further endovascular procedure, which permitted embolisation of the common hepatic artery and a covered stent from aorta into the superior mesenteric artery, thus permitting total exclusion of the aneurysm. The arterial supply of the liver was thus maintained from the bypassed splenic artery via pancreatic collaterals and gastro duodenal artery to the distal part of the hepatic artery (see Fig.). The patient was discharged on clopidogrel and remains well at 12 month follow up. DISCUSSION This unusual case of common origin coeliac axis/ SMA aneurysm highlighted the need for a flexible multi-disciplinary approach in patient management.

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ASE REPORT C A Rare Presentation Of Primary Antiphospholipid Syndrome

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Lu鱈s Machado

Department of Angiology and Vascular Surgery, S.Jo達o Hospital Center, Oporto, Portugal Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by a combination of arterial and/or venous thrombosis and recurrent fetal loss, often accompanied by elevated titers of antiphospholipid antibodies. The authors describe an unusual case of a 41 years old patient with APS, presenting with tight claudication and acute limb ischemia. The patient attended the emergency department because of sudden pain, paresthesias and pallor of the right foot, associated with a history of right buttock claudication that started 2 weeks before. On physical examination we were unable to detect right distal pulses or Doppler flow. It was performed an arteriography of the lower limbs that revealed occlusion of the right hypogastric artery with thrombus protrusion to the common iliac artery, occlusion of tibioperoneal trunk and the anterior tibial artery. He was submitted to thrombectomy of the right leg, having recovered anterior tibial pulse. Post-operative arteriography continues to demonstrate thrombus protrusion of the internal iliac to the common iliac. It was decided to exclude that lesion as it was the likely source of distal embolization. A covered stent 8x40mm (Bard速 Fluency速,Murray Hill, NJ, EUA) was placed in the right common iliac artery to cover the thrombus. Thrombophilia screening shows positive for lupus anticoagulant (LA). The patient was discharged on the 7th day, with palpable pedal pulse, medicated life-long with aspirin and anticoagulation with warfarin. Three month after the patient was asymptomatic and repeats thrombophilia screening that still positive for LA. The commonest arterial events of APS are stroke and transient ischemic attack. Other clinical manifestations including peripheral arterial disease, aortic occlusion and intracardiac thrombus have also been described, but in less than 5% of the patients. Early diagnosis allows appropriate management with long term anticoagulation, reducing morbidity and mortality related to arterial and venous occlusions.

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CASE REPORT Thoracic Outlet Syndrome Arising From An Extra-Pleural Lipoma Shayan Ahmed1, Jason Lewis2, Ahmed Abidia1, William Partridge1, Mohamad Hamady3, Zaid Aldin1 1. The Princess Alexandra Hospital, Harlow, United Kingdom 2. The Royal London Hospital, London, United Kingdom 3. Imperial College Healthcare NHS Trust, London, United Kingdom

Thoracic outlet syndrome refers to a spectrum of symptoms in the upper limb caused by compression of the neurovascular bundle as it courses within the inter-scalene triangle. Here, we describe an unusual presentation and outline itâ&#x20AC;&#x2122;s investigation and management. A 51 year old mechanic presented with a history of swelling and discomfort in the left arm associated with prominent varicosities and weakness of grip. A chest radiograph revealed a soft tissue mass in the apex of the left lung. Left subclavian vein stenosis was confirmed using duplex sonography. Computer topographical imaging revealed a large pleural lipoma extending into the axilla. The patient presented electively for excision of the lipoma, which led to resolution of his symptoms.

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FIGURES

Digital Subtraction venography of the left upper limb. Tapering of the subclavian vein at the level of the first rib with a cluster of superficial veins.

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Chest radiograph of left apical mass. A soft tissue mass in the apex of the left lung. The absence of a cervical rib is confirmed.

Excision of left pleural lipoma. The 4.5cm x 11.8cm lipoma extended into the thoracic cavity and was closely related to the axillary vasculature. 140

ASE REPORT C Hybrid Solution For Ruptured Thoracic Aortic Aneurysm José Oliveira-Pinto1,2, Joel Sousa1, João Rocha-Neves1,2, Sérgio Moreira-Sampaio1,2, José Teixeira1 1. Hospital de São João, Porto, Portugal 2. Faculty of Medicine of Oporto, Porto, Portugal

AIMS To present a case report of a hybrid solution for a ruptured thoracic aortic aneurysm with an unsuitable anatomy for TEVAR.

RESULTS Considering the location of the aneurysm, as well as the aortic anatomy, a hybrid solution was planned. A TEVAR with fixation in landing zone 1 was the chosen intervention, and the patient undergone a previous left common carotid-carotid bypass, with proximal ligation of the left common carotid artery. To overcome the aortic tortuosity, surgical exposure of the right axilar artery was performed, with selective catheterization of the aorta through it and creation of an axilo-femoral “through-and-through” with a stiff guidewire (Fig. 2). Successful deployment of the endoprosthesis was performed. Control angiogram revealed a type II endoleak in the dependence of the left subclavian artery, and selective embolization with coils was later performed. Final angiogram revealed complete exclusion of the aneurysm, with no endoleaks and patency of the left vertebral, intermamary and tireocervical arteries. The patient remained in the Intensive Care Unit for 21 days, and was discharged to his local hospital 60 days after the intervention. CONCLUSIONS Endovascular correction for ruptured thoracic aortic aneurysms is the gold-standard procedure, as long as the anatomy is suitable for the correct navigation, placement and deployment of the endoprosthesis. In more complex anatomies, hybrid procedures with ingenious solutions are frequently necessary. FIGURES

Extreme aortic tortuosity

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METHODS This is a case report of a 79 years old male, with known medical history of congestive heart failure and hypertension. The patient described a 3 week long history of mild hemoptysis. In the emergency service a thoraco-abdominal angio-CT was performed and revealed a ruptured descending thoracic aortic aneurysm, with 50mm of largest diameter and extending from the origin of the left common carotid artery. Bilateral common iliac aneurysms and bilateral internal iliac aneurysms. Extreme tortuosity of the aortic artery was noted, with an “S” conformation determined by two kinks: the first of approximately 170º located about 10cm above the thoracoabdominal transition and the second of 95º above the aortic bifurcation (Fig. 1).

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Axilo-femoral “through-and-through” guidewire technique.

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ASE REPORT C Challenging Case Of Complicated Aneurysmal Persistent Sciatic Artery Ehab Elashaal, Ayman Saad, Farouk Alreshaid

King Fahd University Hospital, Alkhobar, KSA, Egypt

CASE SUMMARY A 58-year-old man presented with acute right limb ischemia of 18-hour-duration. He also had right gluteal pulsatile mass of one year duration which was misdiagnosed as sciatica. Preoperative CT angiography revealed type IIa PSA and embolic infra-genicular popliteal occlusion. Patient underwent emergency popliteal embolectomy, intra-arterial tPA infusion (thrombolysis) and prophylactic fasciotomy. Completion angiogram showed patent posterior tibial artery and planter arch. One week later, the patient underwent endovascular stenting of PSA. within few hours afterthe procedure, he developed progressive acute right lower limb ischemia. CT angiogram showed distal thrombosis of posterior tibial artery. Trials of catheter directed thrombolysis for 36 hours have failed. The patient underwent urgent left popliteal artery thromboembolectomy. However, his condition did not improve, so right below knee gluten amputation was done, followed by 2ry sutures then healed completely within 6 weeks DISCUSSION Aneurysm formation occurs in about 40% of PSA.2, It usually presents as a pulsatile gluteal mass. Less frequently, patients present with sciatic neuropathy, distal ischemia or rupture. Aneurysm exclusion alone either by ligation or endovascular embolization 3 is mandatory in case of incomplete type, Because of potential damage to the adjacent sciatic nerve; exposure and surgical dissection of the aneurysm are not recommended. In complete type; as in our case; a femoro-politeal interposition graft should precede the aneurysm exclusion as a standard treatment.4 The endovascular stent graft placement has been reported as an effective method of repair for PSA aneurysm5, provided that there are no significant associated compressive symptoms, but it still has the risk of distal embolization, as occurred in our case who has only one tibial vessel survived from the thrombo-embolictomy trial, these conditions but the limb in highly progressive ischemic course. CONCLUSION Asymptomatic PSA should be followed up closely without any intervention. However, symptomatic PSA should be managed as early as possible to avoid serious complications. Management of aneurysmal PSA is mainly by endovascular embolization either alone as in case of incomplete type or with femoro-popliteal bypass in complete type, endovascular stent graft has accepted outcome. Micro-embolization from the aneurysm is a rare complication during endovascular intervention and may pass unnoticed, but it might be hazardous especially in borderline distal circulation.

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BACKGROUND Persistent Sciatic Artery (PSA) is a rare congenital vascular anomaly found in 0.03-0.06% of the population. It is either symptomatic or asymptomatic. It may present as a pulsatile gluteal mass. However it can cause acute critical limb ischemia with serious complications. It is classified into: type I: complete PSA with normal femoral artery, type II: complete PSA with abnormal femoral artery (IIa) or absent femoral artery (IIb and types III and type IV: incomplete PSA with normal femoral artery. The only difference is that the upper part of sciatic artery has persisted in type III, while it is the lower part in type IV. In type V, the PSA originates from the median sacral artery either with a normal femoral artery (Va) or an abnormal one (Vb).1

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

REFERENCES 1. Papon X, Picquet J, Fournier HD, Enon B and Mercier Ph. Persistent sciatic artery: report of an original aneurysm-associated case. Surg Radiol Anat 1999;21:151-153. 2. El Fakir Y, Gueddari FZ, Hamani L, Y Bjilou, R Dafiri and F Imani. Imagerie de l’anverysme sur artere sciatique persistante. propos d’un cas avec revue de la litterature. Medecine du Maghreb 1999;77:23-26. 3. Ooka T, Murakami T, Makino Y. Coil embolization of symptomatic persistent sciatic artery aneurysm: A case report. Ann Vasc Surg 2009;23:411:e1–e4. 4. Van Hooft IM, Zeebregts CJ, van Sterkenburg SM, et al. The persistent sciatic artery. Eur J Vasc Endovasc Surg 2009;37:585–591. 5. Sylvain BRETON M.D., Bernard SENECAIL M.D., Thomas HEBERT M.D., Michel NONENT M.D. Department of radiology, University Hospital, Brest, France Laboratory of Anatomy, Faculty of Medecine, Brest, France (2008, Jun 3). Endovascular treatment of aneurismal persistent sciatic artery: a real alternative, http://www.eurorad.org/case.php?id=6648 FIGURES

Types of persistent sciatic artery

CT angiogram showing the Rt aneurysmal PSA notice fading of the dye in the diseased side although presence of politeal pulsation when the patient presented by acute ischemia

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Completion angiogram after Completion angiogram after Completion angiogram after Coventional angiogram showing thrombo-emolectomy showing thrombo-emolectomy showing thrombo-emolectomy showing the aneurysm notice post aneuproximal tibial vessels patency tibial vessels patency Planter arch patency rysmal stenosis Only the posterior tibial is patent

AP view during stent graft deployment

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Catheter dircted thrombolysis trial just after Completion angiogram showing faliure of The below knee amputation stump after 16 development of post intervention acute thrombolysis trial the same picture was days ischemia seen after the 2nd trial of thrombo-embolectomy

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ASE REPORT C Persistent Sciatic Artery Aneurysms Complicated With Acute Limb Ischemia, Two Steps Management Amr Nour, Sulaiman Al Shamsi

Royal Hospital - ministry of health, sultanate of oman - muscat, United Arab Emirates Persistent sciatic artery (PSA) is a rare arterial anomaly with 0.025-0.04% reported incidence. It is the major blood supply of the lower limbs during early fetal life. The artery is prone to atherosclerotic changes and artery degeneration with aneurysmal formation which has its consequent complications and risk of distal embolization. Management should not be delayed to avoid limb lose. A 50 years old male presented with a painful left gluteal mass of several months progression, diagnosis of PSA with 2 aneurysmal dilatations confirmed by a computed tomographic angiogram and a catheter angiogram. He was complicated with acute left lower limb ischemia before the definitive planned management. A femoropopliteal bypass with in situ saphenous vein graft plus endarterectomy of the tibioperoneal trunk and vein patch graft was performed. Subsequently coil embolization of the PSA using vascular plug was done successfully with complete cut of flow.

EPOSTERS

FIGURES

Computed tomography angiogram showing persistent left sciatic artery

Reconstruction of angio. CT posterior view showing complete left sciatic artery with 2 aneurysmal dilatation and hypoplastic femoral artery

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Angio CT showing patent left PSA

Angio CT showing occluded left PSA

148

REFERENCES 1. Erturk SM, Tatli S. Persistent sciatic artery aneurysm. J Vasc Interv Radiol 2005;16:1407-1408. 2. Mikin V. Nilesh H. Joseph R. et al. Persistent sciatic artery presenting with limb ischemia. J Vasc Surg 2013;57:225-9. 3. Benjamin C, William F. Massive Aneurysm in a Persistent Sciatic Artery. Ann Vasc Surg 2010; 24: 1135.e13-1135.e18. 4. De Boer MT, Evans JD, Mayor P, Guy AJ. An aneurysm at the back of a thigh: a rare presentation of a congenitally persistent sciatic artery. Eur J Vasc Endovasc Surg 2000;19:99-100. 5. Jones WS, Patel MR, Mills JS. A case of mistaken identity: persistent sciatic artery stenosis as a cause of critical limb ischemia. Catheter Cardiovasc Interv 2011;77:308-12. 6. Brantley SK, RigdonEE,Raju S.Persistent sciatic artery:embryology, pathology, and treatment. J Vasc Surg 1993;18:242-248. 7. John V. Bjoern K. Lisa T. et al. Concurrent thrombosed aneurysmal sciatic artery and anomalous aortic arch. J Vasc Surg 2011;54:222-4 8. Brancaccio G, Falco E, Pera M, Celoria G, Stefanini T, Puccianti F. Symptomatic persistent sciatic artery. J Am Coll Surg 2004;198:158. 9. Kubota Y, Kichikawa K, Uchida H, et al. Coil embolization of a persistent sciatic artery aneurysm. Cardiovasc Intervent Radiol 2000;23:245-247. 10. Shiayin Y, Kevin R, Michael M, et al. Bilateral Persistent Sciatic Artery with Aneurysm Formation and Review of the Literature. Ann Vasc Surg 2014; 28: 264.e1e264.e7. 11. Fearing NM, Ammar AD, Hutchinson SA, Lucas ED. Endovascular stent graft repair of a persistent sciatic artery aneurysm. Ann Vasc Surg 2005;19:438e41. 12. Victoria S, Monica H, Jose M, et al. Persistent Sciatic Artery. Ann Vasc Surg 2010; 24: 691.e7-691.e10 13. Green P. On a new variety of the femoral artery. Lancet 1832;1:730-731 14. Lekehal B, Taberkant M, Sefiani Y, et al. Aneurysm of a persistent sciatic artery: five case reports. J Mal Vasc 2001;26:60-64 15. Urayama H, Tamura M, Ohtake H, Watanabe Y. Exclusion of a sciatic artery aneurysm and an obturator bypass. J Vasc Surg 1997;26:697-699.

149

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Post PSA coil embolization

ASE REPORT C Concomitant Occlusive And Aneurysmal Iliac Arteries Lesions In Behcet’s Disease

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Sayda Masmoudi1, Hassen Djmal1, Hela Ben Jemaa1, Ayman Maalej2, Imed Frikha1

1 . Department of Cardiovascular Surgery, Habib Bourguiba Hospital, Sfax, Tunisie 2. Departement of Radiology and Interventional Radiology, Habib Bourguiba Hospital, Sfax, Tunisie Arterial aneurysms are uncommon vascular manifestations of Behçet’s disease and linked to severe prognosis. We present a case of a 47-year-old-man with a history of Behçet’s disease. He was admitted for a right lower limb thrombophlebitis. Doppler ultrasound demonstrated an occlusion of the left external iliac artery and an aneurysm of the right common iliac artery whose diameter was 60 mm. CT scan of the aorta and lower limbs confirmed the occlusion of the left external iliac artery and aneurismal dilatation of the right common iliac artery measuring 60 mm. We decided to attempt endovascular treatment. We made an exclusion of the aneurysm by placing a stent graft and recanalization of the external iliac artery. A final opacification was made showing an exclusion of the aneurysm of the right common iliac artery and permeability of left external iliac artery. At 2 years post-procedure, the patient remained asymptomatic. The CT scan is satisfactory. A solitary iliac aneurysm in Behçet’s disease is exceptional. Open surgery presents a high complication rate. The postoperative course is often complicated by graft occlusion and recurrence of aneurysms, leading to a relatively high mortality rate. Endovascular treatment is a safe alternative, being increasingly recommended for the management of vascular complications in Behçet’s disease.

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ASE REPORT C Extra-Anatomical Aorto-Carotid Artery By-Pass In Case Of Tracheo-Bracheocefalic Fistula Alice Silvestri1, Giovanna Biasi1, Massimo Sponza2, Paolo Frigatti1

In 2012 a 54 years old patient underwent total laringectomy with tracheostomy and subsequently radiotherapy for laryngeal epidermoid carcinoma associated with laterocervical metastasis. In 2013 the patient underwent an urgent angiography for massive haemorrhage throught the tracheostomy. The angiography showed the presence of a fistula between the trachea and the brachiocefalic artery/right common carotid artery (RCCA). Therefore a covered stent was placed into the brachiocefalic artery and RCCA, associated with the embolization of right subclavian artery with plug. At thirty days follow-up laringeal endoscopy revealed the presence of a decubitus lesion on the anterior tracheal wall caused by the covered stent graft. Therefore we performed an extra-anatomical aorto-right internal carotid artery bypass. The graft was positioned under the sternum and behind the sternocleidomatoideus muscle. At the end the covered stent was removed and the tracheal lesion was covered with remainig tissue of the RCCA. A specific antibiotic therapy, based on the cultural examination of tissue biopsy, was immediately performed according to the infectious diseases consultant. At 24 months AngioCT scan bypass was patent with no evidence of infections.

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1. Chirurgia Vascolare- Ospedale Santa Maria della Misericordia, Udine, Italy 2. Radiologia Interventistica- Ospedale Santa Maria della Misericordia, Udine, Italy

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ASE REPORT C Progressive Proximal Anastomosis Aneurysm Of An Aortobifemoral Prosthesis Including A Dominant Accessory Renal Artery Kim Taeymans, Peter Goverde, Katrien Lauwers, Paul Verbruggen Vascular clinic ZNA Stuivenberg, Antwerp, Belgium

INTRODUCTION Male patient 62-y-old with a history of aortobifemoral prosthesis presents with a progressive proximal anastomosis aneurysm including a dominant accessory left renal artery. METHOD Hybrid procedure under general anesthesia. Access from a bifemoral and left brachial open approach and placement of three 7Fr sheats. A guidewire was introduced in an antegrade manner and we visualised the aneurysm and the left accessory renal artery. After catheterisation of this renal artery and PTA of the narrow ostium, we tried to place an ePTFE encapsulated covered balloon expandable stainless steel stent but this was impossible due to the very sharp angle between renal artery and aorta. Then we placed an ePTFE encapsulated covered self expandable nitinol stent and pushed it upwards with a retrograde introduced snare kit. Then we were able to place the covered balloon expandable stainless steel stent from the brachial approach in the earlier placed nitinol stent to secure the stent in this position. Placement of a 12x61mm covered balloon expandable stent and postdilatation at about 15 mm above the distal stent margin. In the distal conic segment we placed two covered balloon expandable iliac stents in a kissing stent configuration and they were inflated simultaneously. RESULTS Angiographic control showed exclusion of the aneurysm with optimal flow in aorta, iliac arteries and in the renal chimney graft. CONCLUSION This case shows that the CERAB (Covered Endovascular Reconstruction of the Aortic Bifurcation) technique can be used safely for the endovascular treatment of difficult proximal anastomotic pseudoaneurysms of aortobifemoral grafts.

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ASE REPORT C Surgical repair of common carotid artery pseudoaneurysm Miguel Lemos Gomes, Luis Silvestre, João Vieira, Gonçalo Sobrinho, Luis Mendes Pedro, José Fernandes e Fernandes, Luis Mendes Pedro

Department of Vascular Surgery, Hospital Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal

CASE REPORT Twenty-two years old male patient, victim of a gunshot wound in the right cervical region, admitted in another institution in cardiac arrest, successfully treated at the time. One year after the initial event, the patient had a pulsatile and expandable mass in the right anterior cervical region (Fig. 1) that caused dysphonia and dysphagia. After the diagnosis of pseudoaneurysm of the right common carotid artery (performed by doppler ultrasound and confirmed by computed tomography angiography), the patient was submitted, under general anesthesia and continuous electroencephalographic monitoring and without the use of shunt, to resection of the pseudoaneurysm (Fig. 2) and PTFE bypass grafting (Fig. 3). The procedure and the postoperative period elapsed without complications. DISCUSSION AND CONCLUSION The type of treatment depends on the nature and location of the lesion, as well as the patient’s age and comorbidities. Surgical procedures, endovascular techniques or a combination of the two have been described. The ligation of the carotid artery is now a last resort practice and only used at life saving situations due to its high morbidity and mortality. Conventional surgical reconstructions remain as the gold standard for most authors due to its security, reduced perioperative complications and excellent long-term results. Endovascular techniques are a credible alternative with growing popularity but with few cases described. FIGURES

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INTRODUCTION Common carotid artery pseudoaneurysms are rare and have been associated with both penetrating and blunt trauma. Intervention is almost always mandatory, due to the risk of rupture or embolization. Treatments are tailored to the specific patient on a case-by-case basis. This report describes an unusual case of common carotid artery pseudoaneurysm and reviews the diagnostic and treatment modalities available.

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ASE REPORT C Severe acute ischemia of the hand after radial artery cannulation: report of 2 critical cases Rachid Zaghloul, Bright Benfor, Comlan Mawuko Blitti, Abdellatif Bouarhroum UHC Hassan II, Fez, Morroco, Fez, Morocco

INTRODUCTION The use of the radial artery catheterization is very broad in intensive care anesthesia for monitoring blood pressure, given the simplicity of the gesture and the accessibility of the radial artery; however it is not devoid of risks and dramatic complications that can compromise the functional prognosis of the hand. The following case reports describe 2 rare clinical aspects, severe acute ischemia, and severe ischemia with gangrene of the hand subsequent to radial artery cannulation.

DISCUSSION The use of the radial artery catheterization is very broad in anaesthesia and intensive care for monitoring blood pressure, hand ischemia following radial artery cannulation is an uncommon 1 but potentially serious complication that can engage the functional prognosis of the upper limb; It is often due to the combination of a radial arterial occlusion at the puncture or distally and an absence of locum by the ulnar artery 2. However, some authors report other causes of the ischemia such as variant arterial anatomy, with a “dominant” radial artery 3.The incidence of radial artery flow occlusion or transient thrombosis after cannulation has been reported to range from 0.2% up to 88% 4-5. Pre-operative assessment using Allen’s test or Doppler to confirm ulnar artery patency and using the smallest possible diameter of catheter for the shortest possible time will reduce the risk of hand ischemia 1. CONCLUSION These cases suggest that an early diagnosis and management of the ischemia of the hand subsequent to radial artery cannulation are mandatory to avoid a dramatic clinical outcome. FIGURES

- Figure 1: acute ischemia of the hand corresponding to the radial territory after withdrawal Radial artery catheter. 155

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CASE REPORTS There were two patients, a 65-year-old men and a 16-year-old girl admitted to the intensive care unit for management of the postoperative course. They presented a severe ischemic syndrome of the hand following the cannulation of the radial artery. In both cases the surgical treatment consisted at an embolectomy and repair of the artery; in the first case (Fig. 1), surgical revascularization allows the rescue of the hand (Fig. 2), while in the second case, the amputation was unavoidable (Fig. 3).

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

- Figure 2: the normal appearance of the hand after surgery.

- Figure 3: severe ischemia of the hand extended to the forearm subsequent to radial artery cannulation. REFERENCES 1. K.l, LEE, J.G. MILLER and G. LAITAUNG HAND ISCAEMIA FOLLOWING RADIAL ARTERY CANNULATION JOURNAL OF HAND SURGERY ( britsh and Eurpean Volum, 1995) 20B:4: 493-495. 2. M. Almoubarik, J.-Y. Marandon*, M. Fischler. Hand ischaemia after radial artery catheterization: Don’t elude Allen test. Lettres à la rédaction / Annales Françaises d’Anesthésie et de Réanimation 29 (2010) 592–598. 3. R James Valentine, MD, FACS, J Gregory Modrall, MD, FACS, G Patrick Clagett, MD, FACS. Hand Ischemia after Radial Artery Cannulation. J Am Coll Surg 2005;201:18–22. © 2005 by the American College of Surgeons) 4. Brzezinski M, Luisetti T, London MJ. Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesth Analg 2009;109:1763–81. 5. Wilkins RG. Radial artery cannulation and ischaemic damage: a review. Anaesthesia 1985;40:896–9. 156

ASE REPORT C Disseminated intravascular coagulation treated after successful endovascular aortoiliac repair Miguel Lemos Gomes, João Vieira, Gonçalo Sobrinho, Ruy Fernandes, Luis Mendes Pedro, José Fernandes e Fernandes

Department of Vascular Surgery, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal Aortic aneurysm (AA) is a rare cause of disseminated intravascular coagulation (DIC). The authors report a case of 81 year-old male patient, who presented with intraoral hemorrhage, hematuria, melenas and ecchymosis of the dorsum and of the abdominal wall, after being medicated with etoricoxib for a back pain. During the etiologic study, an abdominal aortic aneurysm that extended to the left common and internal iliac arteries was discovered. The patient was diagnosed as having aortic aneurysm induced DIC. After endovascular repair, the patient’s bleeding tendency was interrupted, with improvement of his abnormal laboratory findings. The definitive treatment of DIC is removal of the underlying disease; in this case, endovascular correction was proven effective in treating the aortic aneurysm, terminating the stimulus for DIC.

EPOSTERS

FIGURES

Patient presenting ecchymosis of the dorsum and of the abdominal wall

omputed tomography demonstrating an abdominal aortic aneurysm and C a left common/internal iliac aneurysm

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3D Computed tomography demonstrating absence of any endoleak

Patient after 3 months of the procedure

158

ASE REPORT C Challenges of concomitant common and internal iliac artery aneurysms: a challenging case Michael Siah, Vahram Ornekian, Edward Woo

Endovascular treatment of iliac artery aneurysms has revolutionized the options vascular surgeons have to treat this challenging disease process and has resulted in an ability to provide patients with minimally invasive yet durable repairs. The presence of concomitant aneurysmal disease of common and internal iliac arteries presents a challenge to the endovascular surgeon charged with preserving flow to the pelvic situation. Our case of a 74 year old gentleman presenting with intermittent lower extremity paralytic symptoms is an especially challenging one owing to complex tortuous external iliac artery anatomy and large saccular internal iliac aneurysms. The patientâ&#x20AC;&#x2122;s prohibitive cardiac risk meant an all endovascular option was in his best interest and we proceeded to use technology currently available to successfully exclude and seal both his common and internal iliac arteries with preservation of pelvic flow. His aneurysms were excluded using a snorkel sandwich technique involving double barrel covered stent grafts landed from the bilateral internal and external iliac arteries into the common iliacs bilaterally. We employed a combination of balloon expandable and self expanding covered stent grafts as well as traditional EVAR limbs which were built down from an EVAR main body seated at the iliac bifurcation. Our patient did extremely well postoperatively, did not suffer any compromise to pelvic arterial flow, and was followed with a postoperative duplex that revealed the lack of endoleak. Subsequent CT angiography also confirmed preservation of hypogastric flow with aneurysm exclusion and lack of gutter leak. He will continue to be followed per our routine protocol to monitor for late expansion. REFERENCES Lobato AC, Camacho-Lobato L. The sandwich technique to treat complex aortoiliac or isolated iliac aneurysms: Results of midterm follow up. Journal of Vascular Surgery. 2013; 57(2): 26S-34S. Moise MA, Woo EY, Velazquez OC, et al. Barriers to endovascular aortic aneurysm repair: past experience and implications for future device developement. Vascular and Endovascular Surgery. 2006; 40: 197-203. Murphy EH, Woo EY. Endovascular management of common and internal iliac artery aneurysms: how iliac branch grafting may become a first line treatment option. Endovascular Today. 2012; March. Krupski WC, Selzman CH, Floridia R, et al. Contemporary management of isolated iliac artery aneurysms. Journal of Vascular Surgery. 1998; 28(1):1. FIGURES

Pre-operative 3D reconstruction

159

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MedStar Washington Hospital Center, Washington, USA

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Bilateral distal hypogastric access

Follow up 3D reconstruction

160

ASE REPORT C From a rupture thoracic aneursym to a full throracoabdominal endovascular exclusion, finally treated by aneurysmorrhaphy Christian Gerges, Benoit Lebas, Xavier Chaufour

We report a case of an 80 years old man that presented initially for a ruptured thoracic aneurysm. In July 2010, a successful endovascular repair, using a thoracic endoprosthesis (Talent, Medtronic), was carried out associated to a left thoracic drainage with full recovery in two weeks.At that time he was noted to have an infra-renal aortic aneurysm of 64 mm with a 15 mm proximal neck. In November 2010, the AAA was excluded with an aorto-bi-iliaque endoprosthesis (Anaconda Vascutek ),A non supra-renal fixation device was chosen due to presence of an intra-renal aneurysm of 33 mm. In July 2011 the CT showed a full exclusion of the thoracic aneurysm with an unchanged visceral aorta. The infrarenal AAA was measured at 72 mm with no type 1 endoleak, but a large type 2 endoleak due to patent IMA and 2 lumbar arteries. In January 2013 the CT showed the development of a type 1b endoleak from the thoracic endoprosthesis with an aneurysm measured at 94 mm, associated with a growth of the AAA that was measured at 97mm (type 2 endoleak). A type 1a endoleak from the bifurcated infra-renal endoprosthesis was discussed. In June 2013, a fenestrated endoprosthesis (Zenith, Cook, four fenestrations) was deployed into the previous thoracic and infra-renal endoprosthesis.The procedure was carried out uneventfully with full recovery in one week and no paraplegia. In July 2013 the CT showed patent visceral and renal arteries with no endoleak related to the thoracic and fenestrated endoprosthesis, yet the persistence of the type 2 endoleak from his infra-renal endoprosthesis and an increase in his AAA sac diameter of 105 mm. A small laparotomy was realised, pressure into the aneurysm sac was monitored prior and after ligation of the inferior mesentric artery, with only a decrease of 12 mmHg. The aneurysm sac was opened without clamping of the endoprothesis, and a clot was removed carefully without any manipulation of the endoprosthesis. Major back flow was coming from two big lumbars arteries which were ligated (1,2 liters of blood was treated with the cell saver). The sac was closed by aneurysmorrhaphy. CONCLUSION In this case, the infra renal aneurysm excluded by endovascular approach, has kept growing during three years (from 64 to 105 mm) due to major type 2 endoleak. It developed at the same time and was associated with the progression of the aneursymal disease. Aneurysmorrhaphy was the last resort in order to fully exclude the aneurysm. Five years after the first procedure, the patient is asymptomatic with full exclusion of his thoracoabdominal aneurysm disease. REFERENCE Rutherfordâ&#x20AC;&#x2122;s Vascular Surgery 7th edition

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CHU Toulouse Rangueil, Toulouse, France

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

FIGURES

Left hemothorax post aortic rupture

Thoracic endoprosthesis

Interrenal aneurysm progression

Infra-renal aneurysmal sac of 105 mm

Increase of excluded infrarenal aneurysme to a diameter of 97mm

162

Final result post laparotomy and aneurysmorrhaphy

EPOSTERS

Controle post fenestrated endoprosthesis

163

ASE REPORT C False aneurysm of arch aortic fistulizing in the left lung

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Redha Lakehal, Abdelmalek Brahami EHS EL RIADH, Constantine, Algeria

OBJECTIVES Aneurysmal location in the aortic arch is outstanding, rarer than the ascending aorta. This is a serious condition because of the risk of rupture requiring an emergency surgery. The diagnosis is based on the CTA and MRA. This clinical case is an opportunity for us to recall the seriousness of this disease for the patients and challenges encountered by the surgeons. METHODS We report the case of a men, 53 years old, with a history of a 4 meter drop from a building two years ago. hospitalized for exploration following the discovery of a chest X-ray opacity of the upper lobe left lung as a result of hemoptysis average abundance. The suspect image.A .chest angio-CT was performed showing the false aneurysm of the aortic arch. ECG was normal. Laboratory tests showed anemia. The patient was operated on under extra corporeal circulatio, established between the femoral artery and femoral vein with deep hypothermia and circulatory arrest. The surgical approach was a left thoracotomy in 4 left intercostal space. After installing a femoral-femoral CPB and detachment of the left lung intraoperative exploration shows a huge pseudoaneurysm of the aortic arch blocked by the upper lobe of the left lung fistulizing of pseudoaneurysm in the latter. The intervention had consisted after flattening of the pseudoaneurysm in compensation for the loss of aortic substance by a lateral Dacron patch under circulatory arrest and closure of the pulmonary breach. RESULTS The immediate postoperative were unfavorable with a fatal refractory cardiogenic shock. CONCLUSION Advances in imagery make the angio scanner and the MRA the best exams for detecting false aneurysms of the aortic arch. The indication for surgery is formal in all cases of pseudoanevrysm of the aortic arch because the spontaneous evolution is fatal. In fact, the actual treatment is surgery.

KEYWORDS false aneurysm, aortic arch, hemoptysis, cardiopulmonary bypass, cardiac arrest

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ASE REPORT C A rare case of mycotic pseudo-aneurysm of the common iliac artery Joel Sousa, João Rocha-Neves, José Pinto, Jorge Costa-Lima, Armando Mansilha, José Teixeira Hospital de S. João, EPE, Oporto, Portugal

METHODS This is a case report of a 39 years old female, with a previous medical history of Tetralogy of Fallot, surgically corrected 28 years ago. The patient was first admitted in our institution due to a severe aortic and pulmonary insufficiency, secondary to an infective endocarditis. Replacement of the aortic and tricuspid valves was emergently performed, with full recovery from this acute event. During the pos-operative period, the patient developed an acute limb ischemia of the right lower limb. Trans-femoral tromboembolectomy was performed and pathological examination of the extracted material was required, which demonstrated the presence of fungal hyphae. The subsequent cardiac imaging study demonstrated no apparent relapse of the infection, with trans-esophageal echocardiogram revealing any valvular vegetations. An abdomino-pelvic angio-CT was then performed, and revealed the presence of a volumous pseudo-aneurysm of the right common iliac artery, with 4 cm of largest diameter (Fig. 1). RESULTS Due to the risk of infection, the patient was proposed open surgical correction of the lesion. Great saphenous vein from the ipsilateral limb was harvested, and used to create a spiralled venous conduit of equivalent diameter with the common iliac artery (Fig. 2). Aneurismectomy with partial removal of the common right iliac artery was performed, and circulation was restored with an interposition venous graft between the common iliac and the external iliac, with ligation of the internal iliac artery. The pathologic study of the removed artery revealed structural changes compatible with infectious pseudo-aneurysm, and the imunohystoquimic study confirmed the presence of fungal hifae in its structure. The pos-operative period went with no complications and the patient was discharged 60 days after admission, with no evidence of re-infection. CONCLUSION Mycotic pseudo-aneurysms are rare entities in all arterial territories. Despite some reported cases of iliac pseudo-aneurysms in patients previously submitted to renal transplantation, mycotic pseudo-aneurysms of the common iliac arteries secondary to infectious endocarditis are an extremely rare event, not reported in the literature.

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AIMS To report a case of mycotic pseudo-aneurysm of the right common iliac artery in a patient with infective endocarditis, first presenting as an embolic acute limb ischemia, and successfully treated with a spiralled vein graft.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

FIGURES

Angio-CT revealing a volumous pseudo-aneurysm of the right common iliac

Spiralled vein graft

166

ESEARCH R Investigation Of Biomechanical Indices Indicating AAA Rupture Risk Using Real Time 3D Speckle Tracking Ultrasound Wojciech Derwich1, Andreas Wittek2, Christopher Blase, Thomas Schmitz-Rixen

1. Department of Vascular and Endovascular Surgery, J.W. Goethe University, Frankfurt/Main, Germany 2. Institute for Cell Biology and Neuroscience, J.W. Goethe University, Frankfurt/Main, Germany

PATIENTS AND METHODS In a prospective study biomechanical properties of the aortic wall were initially examined in 46 patients with a normal aorta (younger than 60 y n = 21, older than 60 y n = 25) and in 19 patients with infrarenal aortic aneurysm using real-time 3D speckle tracking ultrasound. Subsequently, after transforming primary coordinates in 35 patients with infrarenal aortic aneurysm, a high resolution 4D model of the aorta was constructed to determine regions with pathological strain. In selected cases, based on inverse modeling patient-specific material properties were calculated from the dynamic deformation of the aneurysm wall. Finally, distribution of wall stress in the aortic aneurysm was simulated with patient-specific and population-mean material properties. RESULTS The infrarenal aorta in young patients had a significantly higher mean circumferential strain amplitude than the infrarenal aortic aneurysm. However, the low mean circumferential strain amplitude in the aneurysm was characterized by high spatial heterogeneity expressed by a high spatial heterogeneity index and the local strain ratio (p <0.05). The mean global strain amplitude was significantly higher in the aneurysm neck than in the aneurysm bulge (p <0.05). Areas with maximum local circumferential strain were predominantly localized in the posterolateral region of the aneurysm wall. Using patient-specific material properties the calculated peak wall stress was higher for the individual than when population-mean material properties were applied (an example: 2.109 MPa compared to 0.912 MPa). CONCLUSIONS Real time 3D speckle tracking ultrasound allows qualitative and quantitative description of wall areas in the infrarenal aortic aneurysm with maximum strain amplitude and localization of those regions. Employing finite element analysis with patient-specific material properties opens a perspective for disclosing determinants indicating higher aneurysm rupture risk.

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INTRODUCTION Infrarenal aortic aneurysm rupture is still associated with high mortality. Therefore, it is important to determine characteristics indicating instability of the aneurysmal aortic wall, which could lead to rupture 1. Parameters such as maximum aneurysm diameter, aneurysm growth rate and aneurysm morphology allow only limited prediction of aortic rupture 2. Biomechanical analysis employing the finite element method can provide additional information, primarily based on the geometry of the infrarenal aorta gained from a static CT angiography 3. Dynamic representation of the pulsating aorta has so far only been possible with phase-contrast MR angiography, which is not practicable for cost effective aneurysm screening. Real time 3D speckle tracking ultrasound combines advanced, dynamic imaging with real time, bed side, rupture risk stratification 4-8. This study aimed to analyze biomechanical properties of the infrarenal aortic aneurysm with 4D ultrasound to identify wall areas with higher rupture risk.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

FIGURES

Mean circumferential wall strain amplitude

Spatial heterogeneity index

Peak wall stress in AAA calculated with patient specific material properties 168

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REFERENCES 1. Vande Geest JP, Wang DH, Wisniewski SR, Makaroun MS, Vorp DA. Towards a noninvasive method for determination of patient-specific wall strength distribution in abdominal aortic aneurysms. Ann Biomed Eng. 2006; 34:1098-106. 2. Maier A, Gee MW, Reeps C, Pongratz J, Eckstein HH, Wall WA. A comparison of diameter, wall stress, and rupture potential index for abdominal aortic aneurysm rupture risk prediction. Ann Biomed Eng. 2010; 38:3124-34. 3. Gasser TC, Auer M, Labruto F, Swedenborg J, Roy J. Biomechanical rupture risk assessment of abdominal aortic aneurysms: model complexity versus predictability of finite element simulations. Eur J Vasc Endovasc Surg. 2010; 40:176-85. 4. Bihari P, Shelke A, Nwe TH, Mularczyk M, Nelson K, Schmandra T, Knez P, Schmitz-Rixen T. Strain measurement of abdominal aortic aneurysm with real-time 3D ultrasound speckle tracking. Eur J Vasc Endovasc Surg. 2013; 45:315-23. 5. Wittek A, Karatolios K, Bihari P, Schmitz-Rixen T, Moosdorf R, Vogt S, Blase C. In vivo determination of elastic properties of the human aorta based on 4D ultrasound data. J Mech Behav Biomed Mater. 2013; 27:167-83. 6. Karatolios K, Wittek A, Nwe TH, Bihari P, Shelke A, Josef D, Schmitz-Rixen T, Geks J, Maisch B, Blase C, Moosdorf R, Vogt S. Method for aortic wall strain measurement with three-dimensional ultrasound speckle tracking and fitted finite element analysis. Ann Thorac Surg. 2013; 96:1664-71. 7. Wittek A, Derwich W, Karatolios K, Fritzen CP, Vogt S, Schmitz-Rixen T, Blase C. A finite element updating approach for identification of the anisotropic hyperelastic properties of normal and diseased aortic walls from 4D ultrasound strain imaging. J Mech Behav Biomed Mater. 2015 Sep 28. 8. Derwich W, Wittek A, Pfister K, Nelson K, Bereiter-Hahn J, Fritzen CP, Blase C, Schmitz-Rixen T.High Resolution Strain Analysis Comparing Aorta and Abdominal Aortic Aneurysm with Real Time Three Dimensional Speckle Tracking Ultrasound. Eur J Vasc Endovasc Surg. 2015 Sep 18.

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

ESEARCH R Obstructive lymphedema of lower limbs can be successfully controlled by silicone tube implants replacing obliterated lymphatics-four years follow-up Waldemar Olszewski, Marzanna Zaleska Central Clinical Hospital, Warsaw, Poland

BACKGROUND Obliteration of lymphatics recognized as lymphedema is followed by stasis of edema fluid with dilatation of intercellular space The question arouse whether decongestion of edematous tissue can be accomplished by implantation of artificial channels replacing function of lymphatics and support tissue fluid flow by application of external compression. AIM To follow effect of silicone tube implants replacing obliterated collecting lymphatics MATERIAL AND METHODS Study included 36 patients with lymphedema of lower limbs stage III and IV. All patients developed edema after histerectomy and radiotherapy with inflammatory episodes, 5 had infectious skin incidents in the past. Lymphoscintigraphy showed lack of flow of tracer from foot to the groin. Three medical grade hydrophobic silicone tubes o.d.3.2, i.d. 1.8 mm, perforated every 2 cm, were implanted subcutaneously from mid-calf to hypogastrium. Subcutis and node fragments were taken for on-plate bacteriology. Elastic stockings grade II and two weeks of intermittent pneumatic compression were applied postoperatively. RESULTS After 3-4 years mean decrease in circumference in mid-calf was from 1.5 -5 cm (3-17%) and increase in elasticity by 7-23%. On lymphoscintigraphy tracer was seen in tubes or around them. On ultrasonography accumulation of fluid around tubes could be shown. In 4 cases inflammatory episodes at calf and hypogastric end of implant were observed. Retrospective analysis of bacteriology from time of implantation revealed presence of Proteus, Acinetobacter and Neisseria. CONCLUSIONS Silicone tube implants in lymphedematous is a low-invasive effective method for decompression of obstructive lymphedema. Bacteriology of deep tissues at time of implantation is helpful for controlling infective inflammation episodes with specific antibiotics.

170

ESEARCH R The Analysis Of Risk Alleles In Patients With Vein Thrombosis And Chronic Vein Insufficiency In Latvia Irina Kajuna1, Vita Rovite2, Helena Mikazhane3, Valda Stanevicha3 1. Baltic vein clinic, Riga, Latvia 2. Latvian Biomedical Research and Study Center, Riga, Latvia 3. Riga Stradins University, Riga, Latvia

INTRODUCTION A number of single nucleotide polymorphisms (SNP) have been linked to higher risk of venous thrombosis (VT) (El-Galaly et al 2013). The clinical value of SNP genotyping has not been established in patients with deep vein thrombosis (DVT). Well known genetic risk factors F5 rs6025 (Factor V Leiden) mutation or deficiencies in coagulation inhibitors are present only in about 30% of DVT cases (Rosendaal, 1999).

MATERIALS AND METHODS The data collected in 2013-2014 years for 141 patients (52 patients with confirmed VT; 89 patients with HVI stage C3 -C6 ). In the control group were included 235 (110 men un 125 women) individual average age 53.1±14.1, body mass index (BMI) 28,12±4,96. Genotyping was performed using an Applied Biosystems TaqMan SNP Genotyping Assay after manufacturer’s protocol on ViiA™ 7 Real-Time PCR System. Statistical analysis was carried out with Plink 1.06 software. The additive model of inheritance was used in logistic regression for each SNP adjusting for sex, age, BMI. RESULTS The F5 (rs6025) risk allele was significantly associated with higher VT risk p=0.017, OR=4.37. Risk alleles in genes SERPINC1 (rs2227589), FGG (rs20066865), F11 (rs2289252) showed significant association with VT SERPINC1 (rs2227589) p=0.05, OR=0.41; FGG (rs20066865) p=0.018,OR=1.79; F11 (rs2289252) p=0.028, OR=1.65 but due to small group this association did not withstand the permutation test and Bonfferoni correction. Risk alleles in genes F2 (rs1799963), SELE (rs5361), CYP4V2 (rs13146272), GP6 (rs1613662) did not show significant association with VT accordingly F2 (rs1799963) p=0.62; SELE (rs5361) p=0.71; CYP4V2 (rs13146272) p=0.81, GP6 (rs1613662) p=0.82. In the combined samples group with VT and HVI, the F5 (rs6025) risk allele was not significantly associated with higher VT risk p=0.07945. Risk alleles in genes SERPINC1 (rs2227589), FGG (rs20066865), F11 (rs2289252) showed significant association in combined samples group VT and HVI - SERPINC1 (rs2227589) p=0.022, OR=0.52; FGG (rs20066865) p=0.022,OR=1.49; F11 (rs2289252) p=0.014, OR=1.47 but due to small group this association did not withstand the permutation test and Bonfferoni correction. The F11 (rs2289252) gene risk allele was significantly associated with higher HVI C4-C6 risk p=0.028, OR=1.65, this association withstand the permutation test and Bonfferoni correction. CONCLUSIONS 1) For patients with VT statistically relevant connection was found with F5 (rs6025) gene risk allele. 2) Risk alleles in genes SERPINC1 (rs2227589), FGG (rs20066865), F11 (rs2289252) showed significant association with VT, but larger group is required to prove this association. 3) Risk alleles in genes F11 (rs2289252) showed significant association with HVI C3-C6.

171

EPOSTERS

OBJECTIVE To investigate the risk alleles in genes F5 (rs6025), F2 (rs1799963), SELE (rs5361), SERPINC1 (rs2227589), FGG (rs20066865), CYP4V2 (rs13146272), F11 (rs2289252), GP6 (rs1613662) in patients with VT and HVI C3-V6.

172

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

AOD P Use of Drugcoated Balloon Pta As First-Line Treatment for all Femoropopliteal Lesions Koen Keirse1, Bart Joos1, Wouter Van Den Eynde2, Jurgen Verbist2, Patrick Peeters2 1. Hospital Tienen, 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. The overall mean lesion length was 149.6 mm. MAE rate at 30 days was reported 14.1%. Twelve months results show a freedom from TLR at 12 months of 90.6% and a primary patency of 90.4%. Freedom from amputation at 12 months was reported 98.3% and a mortality rate of 2.1%. 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. Full 12 month and preliminary 24 month data will be presented at the congress.

173

EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

AOD P Early Results Of The Use Of A Next Generation Drug Coated Balloon For The Treatment Of Femoropopliteal Atherosclerotic Lesions Kim Taeymans, Peter Goverde, Katrien Lauwers, Paul Verbruggen Vascular clinic ZNA Stuivenberg, Antwerp, Belgium

INTRODUCTION We wanted to investigate a next generation drug coated balloon on safety, efficacity and patency for the treatment of stenotic and/or occlusive femoropopliteal arterial lesions. MATERIAL & METHODS We used the Legflow Paclitaxel releasing peripheral balloon (Cardionovum, Bonn, Germany) with a unique ‘SAFEPAX’ balloon surface drug coating. This new generation balloon catheter is covered with a coating based on nanocrystalline PTX particles (non-visible 0.1µm ). Because of the stable and unique balloon surface coating characteristics, it does not require the use of an extra protection and insertion tool. Furthermore it cannot be wiped or fall off the balloon surface during catheter manipulation. RESULTS Single centre, prospective, consecutive, physician initiated, real-life ongoing registry. From June 2013 till November 2014 we included 51 patients treated with the Legflow for de novo, recurrent and in-stent stenosis or occlusion in the femoropopliteal area. Mean lesion lenght was 102,6 mm. Technical success: 100 %. In more then 50% of the cases no predilation balloon was used. Bail out stenting: 20 %. There was no evidence for distal embolisation. Follow-up was done with ultrasound. 6 months primary patency was 92 % and the preliminary results for 1 year seem promising with 76 % primary patency. CONCLUSION The drug coated balloon technology seems to improve the mid- and long-term durability of the SFA endovascular treatment.The early results using the new generation Legflow DCB are very encouraging, it is a safe and reliable balloon but long-term results need to be obtained with larger patient groups.

174

AOD P Endovascular Therapy As A First Line Of Treatment In Patients With Severe Aortoiliac Occlusive Disease Patrick Berg, Roland Stroetges

Marienhospital Kevelaer, Kevelaer, Germany OBJECTIVE Feasibility and safety of an endovascular therapeutic approach was prospectively assessed in consecutive patients with severe aorto-iliac disease.

RESULTS Technical success was obtained in all patients. In three cases lesions could not be recanalized on one side and the patients were treated with an aorto-monoilical device and crossover bypass. Primary patency was 95,9% at 1 year, while secondary patency was 100% at 1 year. 3 patients had an occlusion of one iliac artery treated in 2 cases with Rotarex and PTA. 1 patient had a crossover bypass during follow-up. There was a 30 day mortality of 5/74 patients (6,8%) due to 1 myocardial infarction, 2 respiratory failures, 1 inhalation pneumonia and 1 mesenteric ischemia for a patient treated with an acute Leriche syndrom. Survival rate at 3 months was 93%, at 2 years 91,2%. 3 patients had a minor amputation, no patient had a major amputation. 10 patients had a postoperative groin hematoma, one patient had an intraoperative disrupture of an iliac artery treated with a covered stent. 26 stentgrafts were used, 1 fenestrated stentgraft and 7 chimney grafts. 201 covered stents were used, mean of 2,7/patient. CONCLUSIONS Endovascular technique appears to be a safe and feasible alternative to open surgical reconstruction of the aortic bifurcation in complex occlusive disease. There is a need for dedicated stentgrafts for occlusive disease because the radial force of conventional stentgrafts doesnâ&#x20AC;&#x2122;t allow to treat the lesions without the help of BX stents.

175

EPOSTERS

MATERIAL AND METHODS Between January 2013 and August 2015, 74 patients (46 male, 28 female) suffering from severe claudication (75,7%) or critical limb ischemia (24,3%) due to obstructive lesions at the level of the aortic bifurcation were treated with endovascular techniques. 11 patients also presented with an infrarenal aortic aneurysm (14,9%). The median age was 63 years (range 44-85 years). Lesion morphology was evaluated by CT angiography. 23 TASC-II C lesions, and 51 TASC-II D lesions were treated. Follow up was a median 7,4 months (range 23,9 months) and consisted of clinical examination and duplex ultrasound examination.

AOD P Endovascular Endarteriectomy

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Thomas Douchy, Sigi Nauwelaers, Herman SchroĂŤ, Geert Lauwers, Wouter Lansink ZOL, Genk, Belgium

A 59 year old patient presents herself with right sided claudication. Medical history includes an angioplasty and stenting of the left proximal common iliac artery (CIA). MRI shows a critical stenosis of the proximal right CIA. Endovascular angioplasty and stenting of the right CIA in kissing procedure is planned. Bilateral retrograde puncture of the common femoral artery and placement of a 6F sheath is performed. Angiography shows an occlusion of the right CIA, a high placement of the old iliac stent above the bifurcation to the left CIA and flow running throught the struts of the stent in the right CIA. An attempt to canalize the right CIA fails because the wire enters through the struts of the stent. With a universal flush catheter and Terumo 0.035 coming from left we manage to retrieve the guidewire in the right groin. The wire is pushed upward through both sheaths and seems to enter the aorta. A balloon expandable stent is placed in the right CIA while the stent in the left CIA is inflated with a drug coated balloon. Angiography shows good flow to the left CIA with perfusion of the lumbar arteries but no flow to the right iliac axis due to dissection of the aorta which starts about 1 cm below the right renal artery. An attempt to perforate the dissection flap proximal of the iliac bifurcation with a win wire fails. A Terumo 0.035 wire is placed from the left sheath trough the proximal perforation and retrieved through the right sheath. In an attempt to split the dissection flap the wire is pulled down through both sheaths. The result was an endarteriectomy flap occluding the left iliac axis. We now had to perform an aortic and bifurcation stenting in Eifel tower configuration to solve the problem. FIGURES

Common iliac artery stenosis

aortic dissection

176

aortic endarteriectomy flap

Eifel tower configuration Eifel tower configuration

EPOSTERS

REFERENCES T. Douchy Endovascular endarteriectomy Treatment common iliac artery stenosis Aortic dissection Eifel tower construction

177

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

AOD P Retrograde Popliteal Approach To Subintimal Angioplasty Of The Superficial Femoral Artery: Six Years Experience Jason Lewis1, Cara Baker2, Marjanne Decamps3, Nick Law4, Zaid Al- Dabbagh4, Zaid Aldin3 1. The Royal London Hospital, London, United Kingdom 2. Frimley Park Hospital, London, United Kingdom 3. The Princess Alexandra Hospital, Harlow, United Kingdom 4. Chase Farm Hospital, Enfield, United Kingdom

PURPOSE The percutaneous approach to the SFA usually requires either ipsilateral or contralateral common femoral access. This is can be made difficult by flush occlusion of the SFA origin. An alternative approach is retrograde puncture of the popliteal artery. However, few studies have reported published results on this approach. The purpose of this study is to present our experience with subintimal SFA angioplasty from a popliteal approach in patients with intermittent claudication or critical limb ischaemia. METHODS The indication for SFA angioplasty was short distance claudication (<50 yards) and critical limb ischemia. Cases were prospectively identified and reviewed at 3 months post procedure. Further 3-6 monthly followup occurred at the discretion of the examining vascular surgeon. Improvement in claudication distance and extent of tissue healing was evaluated. PROCEDURE All subintimal angioplasty via a popliteal approach were performed by a consultant interventional radiologist. A 5F or 6F catheter was introduced. Heparin (3-5000 IU) was given intra-arterially. A hydrophilic, curved tip guide wire (180cm long, 0.0035 diameter, Terumo, Japan) was advanced into the subintimal plane between the atheromatous core and the adventia. Following advancement and development of the subintimal track, the wire re-enters the true lumen. A balloon catheter (4-6 mm in diameter) is passed to the distal aspect of the lesion and inflated manually for 10 seconds to expand the neo-lumen. The catheter was then withdrawn. Papaverine (80mg) was given intra-arterially to relieve distal spasm. RESULTS 43 subintimal angioplasties via a popliteal approach were performed in 35 patients over a six- year period. Mean follow up was 11.2 months (range 1-42 months). Successful re-cannulation was achieved in 77% of limbs and restoration of flow on post procedure angiography was achieved in 72%. Symptomatic improvement occurred in 77% of cases. 50% of those with critical limb ischemia had resolution of rest pain or signs of tissue healing. However, in 4 cases the popliteal artery could not be punctured and in 4 cases re-entry into the CFA lumen could not be achieved. In two cases there was failure to advance the guide wire leading to a mid-thigh perforation in 1 case. A total of 3 complications were recorded; 1 hematoma, 1 mid-thigh perforation and a stable dissection flap of the CFA, none of which required further treatment. There were no instances of radiological or symptomatic embolism. CONCLUSION This approach provides a safe minimally invasive alternative to bypass surgery in high-risk surgical candidates in whom an anterograde approach is not feasible or was unsuccessful.

178

EPOSTERS

FIGURES

Subintimal angioplasty A hydrophilic, curved tip guide wire (180cm long, 0.0035 diameter, Terumo, Japan) is advanced into the subintimal plane between the atheromatous core and the adventia.

Completion Angiogram Following advancement and development of the subintimal track, the wire re-enters the true lumen. A balloon catheter (4-6 mm in diameter) is passed to the distal aspect of the lesion and inflated manually for 10 seconds to expand the neo-lumen. A completion arteriogram is performed to confirm patency, adequacy of flow and preservation of runoff.

179

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

AOD P Patient-Tailored Revascularization For Critical Limb Ischemia - Clinical Outcomes At 2-Year Follow-Up Augusto Ministro, Tiago Ferreira, Emanuel Silva, Miguel Lemos Gomes, Mariana Moutinho, Ana Evangelista, Ruy Fernandes e Fernandes, Gonçalo Sobrinho, Carlos Martins, Luís Mendes Pedro, José Fernandes e Fernandes Vascular Surgery Department, Hospital de Santa Maria - CHLN, Lisbon, Portugal

Critical limb ischemia (CLI) is still a major healthcare burden with a generally unfavorable prognosis. Despite the established value of open surgery and growing familiarity with endovascular techniques, there is still much debate over the best initial therapeutic option. The authors reviewed the experience of a single center in infrainguinal revascularization for CLI over 30 months to assess the efficacy of a tailored approach to patient and lesion morphology. Data from consecutive patients with CLI as defined on TASC II guidelines subjected to endovascular and open bypass procedures between January 2012 and June 2014 were retrospectively reviewed. Selection of the revascularization procedure was based upon patient fitness, extension and morphology of the occlusive lesions and expected survival. Immediate and early failures of revascularization and amputation rate during follow-up for open bypass (group A) and endovascular revascularization (group B) were compared. The main clinical outcome analyzed was amputation-free survival at 12 months. Two hundred and forty one patients underwent 269 procedures; median follow-up was 10 months (range, 1-35 months). Group A included 130 limbs and group B 139 limbs. Mean age was 68 years in group A (range: 39-91) and 71 years (range: 41-95) in group B. Hypertension was the main cardiovascular risk factor in group A (81%), followed by smoking (54%) and diabetes (53%). Group B had a higher prevalence of diabetes (75%) followed by hypertension (53%). Ninety percent of limbs in the open bypass group had TASC D lesions, and great saphenous vein was the preferred conduit. Most lesions in the endovascular group were TASC B-C, with primary stenting in 66% of cases. Primary patency at 12 months was 72% and 69% for groups A and B, respectively. Re-intervention rates were 7.7% for open surgery and 11% for endovascular revascularization. Early mortality was 4% and 1% in groups A and B, respectively. Major amputation was performed in 12 patients in group A and 15 patients in group B. Amputation-free survival at 12 months was not significantly different between groups (92% in group A vs. 89% in group B, p=0.87). These results support the policy of a patient/lesion tailored approach to revascularization in CLI patients based upon clinical evaluation of patient condition, anatomy of the occlusive disease and saphenous vein availability. A patient/lesion tailored approach was associated with low mortality, reduced re-intervention rates and an excellent 1-year amputation-free survival.

180

AOD P Clinical results of denatured human umbilical vein prosthesis: A systematic review and meta-analysis of comparative studies Chumpon Wilasrusmee1, Suthas Horsirimanont1, Boonying Siribumrungwong2, Ammarin Thakkinstian3, Napaphat Poprom1

1. Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand 2. Department of Surgery, Faculty of Medicine, Thammasat University Hospital, Thammasat University, Pathumthani, Thailand 3. Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

METHODS A literature search of the MEDLINE and Scopus was performed to identify comparative studies reporting outcomes of BP, PTFE, and autologous veins graft (VG) in peripheral vascular reconstructions. The outcome of interest was graft patency. Two reviewers independently extracted data. Meta-analysis with a random-effect model was applied to pool a risk ratio (RR) across studies. RESULTS Among 584 articles identified, 7 studies (4 randomized controlled trials (RCT) and 3 cohorts) comprising 1,343 patients were eligible for pooling. Six studies compared BP with PTFE and 3 studies compared PTFE with VG. Among BP vs PTFE, pooling based on 3 RCTs yielded the pooled RR of 1.54 (95% CI: 1.10, 2.16), indicating 54% higher graft patency in VG than PTFE. Adding the 3 cohorts in this pooling yiled similar results with the pooled RR of 1.31 (95% CI: 1.10, 1.57) (Fig. 1). The pooled RR of graft patency for BP vs VG was 0.75 (95% CI, 0.54, 1.06), indicating 25% lower graft patency but not significant in BP than VG. CONCLUSIONS Our first meta-analysis indicated that the biosynthetic prosthesis might be benefit over PTFE by increasing graft patency. An updated meta-analysis or a large scale randomized control trial is required to confirm this benefit.

181

EPOSTERS

AIMS Biosynthetic prosthesis (BP) has been reported as a safe alternative to polytetrafluoroethylene (PTFE) in vascular reconstruction. However, efficacy of BP remains controversial. We, therefore, conducted a systematic review to summarize previous available evidences comparing the BP and PTFE in terms of clinical outcomes.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

AOD P The Impact Of Angiosome-Targeted Distal Endovascular Procedure On Healing Rate And Outcome In Critical Lower Limb Ischemia Alec Duinslaeger, Timothy Versyck, Alexander Croo, Caren Randon, Frank Vermassen Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium

INTRODUCTION 3-10% of the worldwide population is suffering from peripheral arterial disease and 1-3% will ultimately develop critical limb ischemia (CLI). One of the options to avoid major amputation and secure a better quality of life is an endovascular revascularisation. The angiosome-concept divides the foot into six anatomic regions (angiosomes) fed by distinct source arteries arising from the posterior tibial, anterior tibial and peroneal arteries. This study investigates whether an endovascular procedure to the artery directly feeding the ischemic angiosome has an impact on wound healing, major amputation and mortality rate. METHODS Retrospective analysis with prospective follow-up was performed at Ghent University Hospital of 131 non-healing ischemic wounds requiring endovascular revascularisation in 109 patients. For every patient the site of the ulcer, the treated artery and the outcome were identified. Based on this information the legs were divided into direct revascularisation (DR) and indirect revascularisation (IR). RESULTS DR feeding the ulcer area was achieved in 88 legs (67%) compared with IR in 43 legs (33%). Revascularisation was performed to the anterior tibial artery (42%), posterior tibial artery (26%) and peroneal artery (32%). There were no differences between the two groups in comorbidities and wound characteristics except for ulcer localisation and the treated vessel. DR was not able to accomplish a higher healing rate, lower amputation rate or lower mortality rate compared to IR (p= .258, p= .828, p= .775). Wound healing reduces the risk of mortality (p= .007). Wound infection (p= .038), high CRP (p= .007), renal insufficiency (p= .024) and a history of major amputation (p= 0.043) decrease wound healing rate. Patients who need a re-operation have a higher risk for minor amputation (p= .004). CONCLUSION Revascularisation plays a crucial role in the treatment of ischemic lower extremity wounds. Similar results were obtained with regard to healing rates, limb salvage and mortality after DR compared to IR. Therefore revascularisation should not be denied to patients in whom only indirect revascularisation is possible.

182

AOD P Outcomes Following Lower-Limb Angioplasty In Diabetes Mellitus (DM) Danielle Lowry, Parth Narendran, Mujahid Saeed, Alok Tiwari

University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom INTRODUCTION Patients with DM are generally considered to have poorer outcomes following lower limb angioplasty (LLA). However, this conclusion is based on cohorts who are poorly matched for potential confounding factors1-3. To address this, we compared two cohorts who were carefully matched for cardiovascular risk factors.

RESULTS There were 153 well-matched patients in each cohort. The median length of follow up was 2.4 years (IQR 1.6-3.7 years). Kaplan-Meier curves showed significantly worse amputation-free-survival in the DM group (log rank test P=0.001) (Fig. 1). At one year, the survival probability estimates were 0.90SEÂą0.02 vs. 0.81Âą0.03 (DM vs. non-DM). The same trend was seen for mortality, major and minor amputation (P=0.003, 0.011 and 0.009, respectively). There was no significant difference in proportion requiring revascularisation (P=0.59). CONCLUSION We show for the first time that, when major confounding factors are accounted for, DM remains a significant risk factor for amputation and all-cause mortality in patients with established peripheral vascular disease. The presence of DM does not have an impact on the rate of revascularisation procedures. FIGURE

REFERENCES 1. Bakken AM, Palchik E, Hart JP, Rhodes JM, Saad WE, Davies MG. Impact of diabetes mellitus on outcomes of superficial femoral artery endoluminal interventions. J Vasc Surg 2007; 46(5): 946-58; discussion 58. 2. Lee MS, Rha S-W, Han SK, et al. Comparison of Diabetic and Non-Diabetic Patients Undergoing Endovascular Revascularization for Peripheral Arterial Disease. Journal of invasive cardiology 2015; 27(3): 167-71. 3. Abularrage CJ, Conrad MF, Hackney LA, et al. Long-term outcomes of diabetic patients undergoing endovascular infrainguinal interventions. J Vasc Surg 2010; 52(2): 314-22.e1-4. 183

EPOSTERS

METHODS All patients who underwent LLA between July 2010 and May 2015, at a large UK-based tertiary-teaching-hospital, were identified. Those with DM were matched, for age, sex, ethnicity, smoking, hypertension, hypercholesterolaemia and renal status, with a patient without DM (IBM SPSS). The primary outcome was amputation-free-survival. Secondary outcomes were subsequent revascularisation (percutaneous or open), minor amputation, major amputation and all-cause mortality.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

AOD P The Disparity Between The Prevalence Of Peripheral Arterial Disease And Geographical Distribution Of Endovascular Trials In The Femoropopliteal Region Cameron G. Robertson, Dominic PJ. Howard, Conor Marron, Ian Spark Flinders Medical Centre, Adelaide, Australia

OBJECTIVES Endovascular therapy for treating peripheral arterial disease (PAD) is evolving rapidly. Differing risk factor profiles between countries are changing the worldwide distribution of PAD and trials for therapy need to match this change to ensure that treatments are appropriate for the population that requires them. The aim of this study was to compare the geographical distribution of endovascular studies in the femoropopliteal region with the prevalence of PAD. METHODS A systematic review of the literature was conducted to July 2015. Medline, EMBASE, and the Cochrane CENTRAL registry were searched for randomised controlled trials of endovascular interventions involving drug-coated balloons, drug-eluting stents, bare nitinol stents, and heparin-bonded covered stents in the femoropopliteal region. The location of study centres was extracted and compared to recently published geographical prevalence data.1 RESULTS Full text reviews were conducted for 280 citations and 14 randomised controlled trials were identified comprising 240 study centres. All 240 study centres were located in high income countries. Based on recent prevalence data, there are 255 000 people with PAD per study centre investigating endovascular therapies in high income countries compared with 140 million people with PAD and no study centres in low/middle income countries. CONCLUSIONS Trials investigating endovascular interventions in the femoropopliteal region are unequally distributed worldwide and do not reflect the evolving distribution of PAD. 69.7% of the world burden of PAD is not represented by the existing literature. Further studies in a broader geographical distribution are needed before study results can be confidently applied to all populations. REFERENCES 1. Fowkes FG, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013; 382: 1329-40.

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AOD P VIPs Technique (Viabhan Padova Sutureless) Technique: Long-Term Results In The Treatment Of Peripheral Arterial Disease Stefano Bonvini1, Valentina Wassermann1, Sebastiano Tasselli2, Michele Piazza1, Mirko Menegolo1, Franco Grego1 1. Clinic of Vascular and Endovascular Surgery of Padua University, padova, Italy 2. Vascular Surgery Division, Trento Hospital, Trento, Italy

METHODS Patients with rest pain or non-healing ulcer disease (Rutherford class IV or V), angiographic complete long superficial femoral artery occlusion (TASC IID) and reconstitution of a patent circumferentially calcified above-knee popliteal artery were included in the study. After prior failed attempts of SFA endovascular recanalization, demonstration of no adequate veins for autogenous bypass, patients underwent ViPS procedures at our center between 2010 and 2015. Arterial cross-clamping and bypass suture to the target artery were avoided using ViPS standardized technique, based on a preoperatively on-bench modified Viabhan stent graft manually sutured to an expanded polytetrafluoroethylene vascular graft, which is then connected to the native vessel in a sutureless fashion. The standardized follow-up protocol included: post-procedural angiograms, CTA before discharge, clinical examination and duplex ultrasonography at 6, 12 months and subsequently yearly. Postoperative antiplatelet therapy was introduced. Freedom from occlusion was assessed using Kaplan Meyer analysis. RESULTS 15 patients underwent a femoral to above-knee popliteal artery bypass using the VIPs technique (one bilateral) for critical limb ischemia. Post-operative technical success was achieved in 100% of cases. Mean follow-up was 46 months, achieved by 8 patients (50%). During this period 3 patients died for causes unrelated to the procedure; in 2 patients, due to the occlusion of the bypass, a femoral below-the-knee popliteal artery bypass was performed, but subsequently major amputation was necessary in both cases. Ultrasound evaluation demonstrated graft patency, no signs of leak, kinking or popliteal dissection in remaining patients. CONCLUSIONS The VIPs technique revascularization in peripheral arterial disease (TASC II D) can achieve good long-term results relatively to primary patency. REFERENCES Stefano Bonvini, MD, PhD, Joseph J. Ricotta, MD, Michele Piazza, MD, Luca Ferretto, MD and Franco Grego, MD, Padova, Italy; Atlanta, Ga. ViPS technique as a novel concept for a sutureless vascular anastomosis. J Vasc Surg 2011;54:889-92 Ferretto L,MD, Piazza M,MD, Bonvini S,MD, PhD, Battocchio P,MD, Grego F, MDRicotta JJ, MD. ViPS (Viabahn Padova Sutureless) Technique: Preliminary Results in the Treatment of Peripheral Arterial Disease. Ann Vasc Surg 2012;26: 34-39

185

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BACKGROUND Purpose of this retrospective study was to investigate long-term outcomes (46 months, range 21-61) of the Viabhan Padova Suturless (ViPS) technique for TASC II D lesions in case of challenging anastomosis due to circumferential calcification of distal target arteries in patients with critical limb ischemia and peripheral arterial occlusive disease.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

FIGURE

Primary Patency TABLE Characteristics Side Age Gender Rutherford class Hypertension Hypercholesterolemia Coronary artery disease DM2 Dialysis BPCO Current smoker ASA class AKP artery Tibial (number of vessel) GVS

pz1 Left 72 M

pz2 Right 74 M

pz3 Left 72 F

pz4 Right 63 M

pz5 Left 76 M

pz6 Left 85 F

pz7 Left 63 M

pz9 Left 71 M

pz10 Left 77 M

pz11 Right 68 M

pz12 Right 82 M

pz13 Left 81 M

pz14 Right 79 M

pz15 Right 80 M

Yes

No No No

Yes Yes No

No Yes No

No Yes Yes

Yes No Yes

Yes Yes No

No No No

Yes Yes No

Yes No No

Yes Yes Yes

No Yes Yes

No Yes No

Yes

III CA

III HC

III

III HC

III

II HC

III

NS ePTFE (7) Viabhan (7mm)

Used Propaten (7mm) Viabhan (7mm)

CFE

General

Used Propaten (7mm) Viabhan (7mm) ReCFE + profundoplasty Epidural

Yes

50 Fem-BTK bypass; Major amputation

21 Fem-BTK bypass; Major amputation

Graft (mm)

ePTFE(7)

Viabhan (mm)

Viabhan (6mm)

Associated procedures Anesthesia Technical success Follow-up Secondary procedures

NS NS Propaten ePTFE (7mm) (7) Viabhan Viabhan (7mm) (7mm) II-fem Bypass

Used Used Used Used NS Propaten ePTFE ePTFE Propaten ePTFE (7mm) (7) (7) (8mm) (7) Viabhan Viabhan Viabhan Viabhan Viabhan (6 mm) (6 mm) (6 mm) (7mm) (6 mm) -

PTA SFA

CFE

NS Propaten (7mm) Viabhan (6 mm) -

Used Used Propaten ePTFE (7mm) (7) Viabhan Viabhan (7mm) (7mm) -

Epidural Epidural General Epidural Epidural Epidural General General General Epidural

1 NS Propaten (7mm) Viabhan (6 mm) CFE

General Epidural

HC, heavily calcified; CA, challenging anatomy; NS, not suitable for by-pass creation; ASA, American Society of Anesthesiologists; GSV, great saphenous vein; CFE, common femoral endarterectomy; il-fem, iliofemoral; ePTFE, expanded politetrafuoroethylene 186

AOD P Remote Hybrid Endo-Endarterectomy: Early Results Stefano Bonvini1, Valentina Wassermann1, Sebastiano Tasselli2, Mirko Menegolo1, Michele Piazza1, Franco Grego1, Michele Piazza1 1. Clinic of Vascular and Endovascular Surgery of Padua University, padova, Italy 2. Vascular Surgery Division, Trento Hospital, Trento, Italy

METHODS A consecutive series of eight patients with TASC C/D lesions of external iliac artery (EIA) underwent remote endo-endarterectomy through the exposure of the homolateral common femoral artery and a percutaneous access gained at the controlateral groin. The latter permitted to advance a guidewire over the aortic bifurcation, across the occluded external iliac artery, into the common femoral artery. A longitudinal arteriotomy of the common femoral artery was performed, the guidewire was caught, and an occlusive balloon was inserted from the percutaneous access and inflated into the common and the first tract of the external iliac artery to avoid back bleeding. The Vollmar ringstripper and an over-the-wire embolectomy catheter were advanced homolaterally up to the inflated balloon. The latter was inflated beyond the Vollmar ringstripper, both were rectracted simultaneously; the plaque was cut and completely removed as demonstrated by a post-procedural intraoperative angiography. The remote iliofemoral endarterectomy was in all cases performed in combined with the endarterectomy of the homolateral femoral bifurcation. The procedures were all performed under local anesthesia. RESULTS Patients’ mean age was 66 years (range, 50-80). Indications for remote iliac endarterectomy were severe claudication in 4 (50%) and rest pain in 4 (50%). Initial technical success was achieved in 7 patients (87,5%). 1 patient needed a thrombectomy using a Fogarty catheter and a stent was placed due to irregularities present in the external iliac artery. The mean length of follow-up was 12 months (range, 1-12). No perioperative and postoperative re-stenosis, occlusions occurred within the first 30 days and in the post-operative period. CONCLUSIONS An angioplasty balloon introduced controlaterally permits to avoid back bleeding from the common and internal iliac arteries and to protect the aortoiliac bifurcation. Therefore remote endo-endarterectomy results more secure and retrograde dissections are less likely. This technique offers a safe and effective alternative to conventional laparotomy in patients with severe concomitant pathologies. FIGURES

Intraoperative Angiography An occlusive balloon is inserted controlaterally. The Vollmar ringstripper and the guidewire are present

Homolateral femoral artery exposure and controlateral percutaneous access A longitudinal arteriotomy of the common femoral artery is visible, with the fem-fem “through and through“ 187

EPOSTERS

PURPOSE To describe early results of remote hybrid external iliac endo-endarterectomy using a fem-fem “throughand-through” guidewire access.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Plaque removal Retraction of the Vollmar ringstripper and the Thrombectomy catheter with a complete plaque removal TABLES Characteristics Pz 1 Side Left Age 77 Gender M Rutherford class IV Hypertension Yes Hypercholesterol No emia Coronary artery No disease DM2 No Dialysis No BPCO Yes Current smoker Yes ASA class III Anesthesia Local Technical No success Additional Thrombecprocedures tomy + EIA stenting Associated Common procedures femoral artery EA Follow-up (mo.) 21

Pz 2 Left 54 M III Yes No

Pz 3 Left 57 M IV No Yes

Pz 4 Right 63 M IV No No

Pz 5 Left 67 M III No Yes

Pz 6 Right 60 M III Yes Yes

Pz 7 Right 64 M III Yes Yes

Pz 8 Right 59 M IV No No

Yes

No No No Yes III Local Yes

Yes No No Yes III Local Yes

Yes No Yes Yes III Local Yes

Common femoral artery EA 20

Common femoral artery EA 28

Common femoral artery EA 25

Common femoral artery EA 3

Common femoral artery EA 2

Common femoral artery EA 26

EIA External iliac Artery; EA endarterectomy; ASA, American Society of Anesthesiologist. REFERENCES Remote iliac artery endarterectomy: seven-year results of a less invasive technique for iliac artery occlusive disease. Smeets L, MD, Gerrit-Jan de Borst, MD, Jean-Paul de Vries, MD, PhD, Jos C van den Berg, MD, PhD, Gwan H Ho, MD, PhD, Frans L Moll, MD, PhD. (J Vasc Surg 2003;38: 297-304. Remote endarterectomy: lessons learned after more than 100 cases. John D. Martin, MD, Jon A. Hupp, MD, Mark O. Peeler, MD, and Patricia B. Warble, CRNP, Annapolis, Md. (J Vasc Surg 2006;43: 320-6) Stent-assisted Remote Iliac Artery Endarterectomy:An Alternative Approach to Treating Combined External Iliac and Common Femoral Artery Diseas. G. Simo, P. Banga, G. Darabos, I. Mogan. 2011 European Society for Vascular Surgery. 078-5884/$36

188

PAOD Recanalization Of Chronically Occluded Aorto-Femoral Dacron Grafts- Tecnique And Results Dimitar Nikolov, Nikola Kolev, Stefan Stefanov

The aorto-iliac bypass surgery has the best primary and secondary patency of all the procedures for peripheral arterial disease. In the case of graft thrombosis timely thrombectomy, combined with some kind of utflow-procedure usually provides salvage of the bypass. In rare cases patients are presented with chronically occluded grafts and still need revascularization. Intraoperatively these grafts are found not full of thrombus but fibrotic and shrinked. Redo surgery, extra-anatomical bypass or endovascular recanalization of the native vessels are then taken into account. We present four cases of chronically occluded dacron grafts (two branches of aorto-bifemoral bypasses and two ilio-femoral bypasses), with documented or suspected graft thrombosis for over an year. All the patients were operated under regional anesthesia. The graft was directly opened at the distal part in the groin and balloon angioplasty and stenting of the proximal part was performed. The distal runoff was achieved by synthetic patch angioplasty in 2 cases and graft interposition to the deep femoral artery in the other two. All the four grafts were successfully recanalized without any complications and remained patent for 12 to 72 months. The technique described here is a good additional option for revascularization of a specific group of patients. Longer follow-up of more patients and reproducibility of the results are needed. FIGURES

- CT of occluded left branch of aorto-bifemoral graft

189

EPOSTERS

City Clinic, Sofia, Bulgaria

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

- Intraoperative angiography of recanalized left branch

- CT- angiography after 36 months. The left branch(stented and not stented part) has reached the diameter of the right branch

REFERENCES 1. Soulen MC, Bonn J, Shapiro MJ. Recanalization of an occluded aortoiliac bypass graft with Palmaz stents. J Vasc Interv Radiol. 1991 Nov;2(4):497-501 2. Kondo Y, Dardik A, Muto A, Nishibe M, Nishibe T. Primary stent placement for late complete occlusion after aortoiliac reconstructive surgery: report of a case. Surg Today. 2009;39(5):418-20

190

AOD P Endoluminal intervention for critical limb ischemia after failed open infrainguinal revascularization: endovascular ultimate challenging solutions Anita Quintas, Gonçalo Alves, José Aragão Morais, Frederico Bastos Gonçalves, Maria Emilia Ferreira, Joao Albuquerque Castro, Luis Mota Capitão

Department of Angiology and Vascular Surgery, Santa Marta Hospital, Lisbon, Portugal INTRODUTION Lower limb bypass failure is a challenging clinical scenario associated with a more than 50% amputation rate. 1,2 After failure of convencional infra-inguinal revascularization, endovascular intervention is still possible and reasonable, in particular for patients suffering from limb-theatning ischemia and lacking adequate conduits or additional revascularization options. 1,2

RESULTS The failed grafts consisted of: three femoro-popliteal infragenicular vein bypasses and one composite sequencial graft femoro-popliteal-posterior tibial. All four patients presented with critical limb ischemia after thrombosis of infragenicular bypasses (two with rest pain (Rutherford Category 4) and two with tissue loss (Rutherford Category 5). All four cases had severely diseased native circulation with chronic total occlusion of the superficial femoral-popliteal segment, representing complex long TASC-II D lesions, particularly fibrotic and calcified. Contralateral femoral acess was used in two cases, ipsilateral femoral acess was used in one patient and brachial access was used in another. Three cases required retrograde punction of: the popliteal infragenicular artery, the tibio-peroneal trunk, the posterior tibial artery and of the profunda femoris artery in the tight. The retrograde recanalization was followed by antegrade PTA after performing the rendezvous technique Recanalization of native CTO of the entire femoro-popliteal segment (Fig. 1) was performed in three patients using an intentional subintimal approach, complemented with kissing balloon angioplasty of superficial and profunda femoris arteries in one case (Fig. 2). In the remaining case iliofemoral and profunda femoris artery PTA was performed (Fig. 3). Primary therapy was PTA, with two cases of adjunctive stenting. Drug-coated balloons were used in two cases. Critical limb ischemia resolved in all patients (Fig.4). At a short follow-up time the patients remain asymptomatic with maintained patency of the recanalized vessels. CONCLUSIONS Endoluminal recanalization of complex chronic total oclusion of the native circulation can be an effective strategy for limb salvage after below-the-knee bypasses failure. This ultimate solution is particularly important in those patients without alternative conduits or a distal target vessel.

191

EPOSTERS

METHODS We report 4 diferent endovascular solutions in recanalization of severely diseased native arterial occlusions in the setting of failed below-the-knee bypass. Feasibility, safety and outcomes are revised and technical details presented.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

FIGURES

REFERENCES 1. Simosa H, Malek J, Schermerhorn M, et al; Endoluminal intervention for limb salvage after failed lower extremity bypass graft; J Vasc Surg 2009; 49; 1426-30. 2. Wrigley C, Vance A, Niesen T, et al; Endovascular Reacanalization of Native Chronic Totoal Occlusions in Patietns with Failed Lower-Extremity Bypass Grafts; J VAsc Interv Radiol 2014; 25: 1353-1359

192

EINS V May-Thurner Syndrome Tony Soares, José Tiago, Viviana Manuel, Carlos Martins, José Fernandes e Fernandes

May-Thurner Syndrome (MTS) is the symptomatic presentation of chronic pulsatile extrinsic compression of the left iliac vein by the right common iliac artery against the lumbar vertebral body 1,2. We present a 68 years-old woman with history of chronic edema in the left lower limb referenced to Vascular Surgery consult with a computed tomography scan revealing left iliac vein compression. Phlebography confirmed a stenosis in the confluence of the left common iliac vein with the inferior vena cava and a dilated left ovarian vein collateral compatible with the diagnosis of MTS (Fig. 1). The lesion was treated with venous angioplasty using a Zilver Vena™ Venous Self-Expanding Stent on the left common iliac vein (Fig. 2). The patient was discharged in the next day with antiplatelet therapy and anticoagulation. She had a notorious resolution of the limb edema, achieving a comparable diameter with the contralateral leg. Previously considered a rare clinical finding, the recent proliferation of endoluminal approach to treat deep venous thrombosis (DVT) have augmented the diagnostic incidence of iliac vein compression 3. This anatomic variation have an estimated prevalence of about 22-24% in asymptomatic population 2,4. On the other hand, iliac venous spurs were identified in roughly half of the patients with left iliac venous thrombosis 5. MTS is more common in young female in the third to fifth decade of life and usually presents with DVT or chronic venous insufficiency 1. Invasive phlebography is still considered the gold standard to diagnose iliac vein compression 1. In the last years, endovascular procedures have gained an important role in the treatment of iliac venous spurs over medical and/or surgical approach 6. High technical success (87-100%) and primary patency rates (79-98.7%) were reported with endovascular treatment 3,6–9. Evidence-based clinical practice guidelines from Society for Vascular Surgery and American Venous Forum recommend self-expanding metallic stents for chronic iliocaval compressive syndromes detected through endovascular technics to remove thrombus 10. The optimal duration of anticoagulation after angioplasty with stent is not yet determined, lacking evidence-based recommendations to be provided, however, in most cases, it is suggested a 6 months period 6,9,10. MTS is more common than previously thought, being important to keep a high index of suspicion to detect the syndrome. Endovascular approach is an accepted technique that gained an important role to treat this pathology with great results. FIGURES

May-Thurner Syndrome before treatment A phlebography confirmed stenosis in the confluence of the left common iliac vein with the inferior vena cava compatible with localization of the right common iliac artery. A dilated left ovarian vein collateral can also be observed 193

EPOSTERS

Clínica Universitária de Cirurgia Vascular, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Faculdade de Medicina da Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

May-Thurner Syndrome after treatment Resolution of left common iliac vein stenosis after venous angioplasty with stenting. Normal collateral venous circulation was also restored. REFERENCES 1. Fazel R, Froehlich JB, Williams DM, Saint S, Nallamothu BK. A Sinister Development. N Engl J Med. 2007;357(1):53-59. doi:10.1056/NEJMcps061337. 2. Kibbe MR, Ujiki M, Goodwin a. L, et al. Iliac vein compression in an asymptomatic patient population. J Vasc Surg. 2004;39(5):937-943. doi:10.1016/j.jvs.2003.12.032. 3. Bozkaya H, Cinar C, Ertugay S, et al. Endovascular Treatment of Iliac Vein Compression (May-Thurner) Syndrome: Angioplasty and Stenting with or without Manual Aspiration Thrombectomy and Catheter-Directed Thrombolysis. Ann Vasc Dis. 2015;8(1):21-28. doi:10.3400/avd.oa.14-00110. 4. May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology. 1957;8(5):419427. doi:10.1177/000331975700800505. 5. Mickley V, Schwagierek R, Rilinger N, Gorich J, Sunder-Plassmann L. Left iliac venous thrombosis caused by venous spur: Treatment with thrombectomy and stent implantation. J Vasc Surg. 1998;28(3):492-497. doi:10.1016/S0741-5214(98)70135-1. 6. Oâ&#x20AC;&#x2122;Sullivan GJ, Semba CP, Bittner C a, et al. Endovascular management of iliac vein compression (May-Thurner) syndrome. J Vasc Interv Radiol. 2000;11(7):823-836. doi:10.1016/S1051-0443(07)61796-5. 7. Hurst DR, Forauer AR, Bloom JR, Greenfield LJ, Wakefield TW, Williams DM. Diagnosis and endovascular treatment of iliocaval compression syndrome. J Vasc Surg. 2001;34(1):106-113. doi:10.1067/mva.2001.114213. 8. Liu Z, Gao N, Shen L, et al. Endovascular treatment for symptomatic iliac vein compression syndrome: a prospective consecutive series of 48 patients. Ann Vasc Surg. 2014;28(3):695-704. doi:10.1016/j.avsg.2013.05.019. 9. Ye K, Lu X, Li W, et al. Long-Term Outcomes of Stent Placement for Symptomatic Nonthrombotic Iliac Vein Compression Lesions in Chronic Venous Disease. J Vasc Interv Radiol. 2012;23(4):497-502. doi:10.1016/j.jvir.2011.12.021. 10. Meissner MH, Gloviczki P, Comerota AJ, et al. Early thrombus removal strategies for acute deep venous thrombosis: Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2012;55(5):1449-1462. doi:10.1016/j.jvs.2011.12.081.

194

EINS V TIVAPS related complications: does the interval between placement and first use and the neutropenia-inducing potential of the chemotherapy regimens influence their incidence? A four-year prospective study on 4045 patients Athanasios Kakkos1, Lucie Bresson1, Delphine Hudry1, Sophie Cousin2, Cyril Lervat1, Emilie Bogart1, Jean Pierre Meurant1, Sophie El Bedoui1, Gauthier Decanter1, Karine Hannebicque1, Claudia Regis1, AgnĂ¨s Hamdani1, Nicolas Penel1, Emmanuelle Tresch1, Fabrice Narducci1 1. Centre Oscar Lambret, Lille, France 2. Institut BergoniĂŠ, Bordeaux, France

MATERIAL AND METHODS Between January 2010 and December 2013, 4045 consecutive patients were included in this observational, single center prospective study. Most common implantation sites were internal jugular vein (68,2%) (ultrasound guided) and external jugular vein (23,3%). Patients were followed up for six months after the last chemotherapy administration unless the device was removed earlier for complication. The chemotherapy regimens were classified as low (<10%), intermediate (10-20%) and high (>20%) risk for neutropenia. RESULTS The overall removal rate for complications was 7,2%, with 5,3% arriving at less than a month from the administration of the last chemotherapy regimen. They include TIVAPS-related infection (2,5%), port expulsion (1%), chemotherapy product extravasation (0,4%), mechanical problems (0,3%), return of the chamber (0,3%) and thrombosis (0,1%). No statistically significant difference was found in the complications rate among the different port implantation sites. The factor most predictive of port removal for complications was the interval between insertion and first use of the TIVAPS. A cut-off of 7 days was statistically significant (p= 0.007), as the removal rate was 8,6% when this interval was 0 to 6 days and 5,6% when it was equal or superior to 7 days. Another factor associated with the TIVAPS complications rate was the neutropenia-inducing potential of the chemotherapy regimens used, with removal for complications involved in 5,5% of low risk regimens, versus 9,4% for the intermediate and high risk regimens (p=0.003). CONCLUSION An interval of 7 days between placement and first use of the TIVAPS reduces their removal rate for complications. The intermediate and high risk for neutropenia chemotherapy regimens show statistically higher TIVAPS removal rates for complications than the low risk regimens. KEYWORDS Observational study; totally implantable venous access port systems; removal for complications; time interval between placement and first use; neutropenia-inducing potential of chemotherapy regimens

195

EPOSTERS

BACKROUND Totally Implantable Venous Access Port Systems (TIVAPS) are widely used in oncology, but complications are frequent, sometimes necessitating device removal and consequently delays in chemotherapy. The aim of this study was to investigate the impact of the time interval between TIVAPS placement and first chemotherapy and the neutropenia inducing potential of the chemotherapy administered on port removal for complications.

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

EINS V Chronic venous insufficiency, new concept to understand pathophysiology at microvascular level Omar Mutlak, Mohammed Aslam, Nigel Standfield Imperial College London, London, United Kingdom

BACKGROUND Chronic venous insufficiency (CVI) has complicated pathophysiology background. Several studies has investigated CVI, however the real mechanism of developing CVI end stages is not yet clear1. Researchers has mentioned development of venous hypervolemia and microvascular ischemia as a consequence of venous insufficiency2,3, even though, no clear picture has been established. The aim of this study is to investigate the effect of induced venous hypovolaemia on CVI at microvascular level. MATERIAL AND METHODS A prospective clinical study for three months, involved recruiting patient from vascular clinic at teaching hospital, ethical approval from local ethics comity obtained. Thirty six participants (C4-C6) selected out of 62 patients, all patients have ankle brachial pressure index between 0.8 and 1.2 mmHg. Participants divided to two groups, first group (group A) is a control group and the second group (group B) perform regular dorsiflexion of the foot to evacuate venous blood from lower limbs. Each group subdivided to two groups according to the type of treatment, group A1, A2 and group B1, B2. Assessment performed on two occasions, first, at the beginning of the trial and the second after 3 months, assessment included full history and clinical examination, ABPI, Duplex scan and tcPO2 measurements. RESULTS Thirty six patients showed low tcPO2 level at the beginning of the study which is an indication of micro vascular ischemia. At the end of the trial the picture was completely different, group B participants (group B1,B2) who perform dorsiflexion of the foot showed significant increase in transcutaneous oxygen level (P>0.05). On the other hand, group A patients (group A1, A2) showed no difference in their measurements (P<0.05).Conclusions:Regular evacuating of peripheral venous system has improved tissue oxygenation at skin level. Although inflammatory process and other factors could contribute in developing skin changes and ulceration, venous hypervolemia may be the main contributing factor in developing microvascular ischemia (venous ischemia). FIGURES

Figure. 1: Measurments of tcPO2 (mmHg)at the beginning of the study. 1. group A1 (no treatment) 2. group A2 (compression therapy) 3. group B1 (dorsiflexion) 4. group B2 (dorsiflexion & compression therapy) 196

REFERENCES 1. Hjerppe A, Saarinen JP, Venermo MA, Huhtala HS, Vaalasti A. Prolonged healing of venous leg ulcers: the role of venous reflux, ulcer characteristics and mobility. J of Wound Care 2010; 1 9:474-484. 2. Franzeck UK, Haselbachp S, Bollinger A. Microangiopathny of cutaneous blood and lymphatic capillaries in chronic venous insufficiency. J of biology and Medicine 1993; 66: 37-46. 3. Steins A; H채fner HM; Hahn M; J체nger M. Microcirculation in Chronic Venous Insufficiency. Phlebology 2002; 17: 115-120.

197

EPOSTERS

Figure. 2: Measurments of tcPO2 (mmHg) after 3 months. 1. group A1 (no treatment) 2. group A2 (compression therapy) 3. group B1 (dorsiflexion) 4. g roup B2 (dorsiflexion & compression therapy)

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