Chairman Jean-Pierre Becquemin French Scientific Committee Yves S. Alimi Jean-Luc GĂŠrard Eric Allaire Pierre Bourquelot Pascal Desgranges Hicham Kobeiter Jean Marzelle International Scientific Committee Piergiorgio Cao Nicholas Cheshire Hans-Henning Eckstein Christos D. Liapis Martin Malina Armando Mansilha
www.cacvs.org
Table of contents Chairman Pr Jean-Pierre Becquemin
MD, Professor of Vascular Surgery Créteil, France
CONTROVERSIES & UPDATES IN VASCULAR SURGERY THURSDAY JANUARY 23 Thoracic aorta: open, endo or hybrid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Scientific Committee Pr Yves S. Alimi
Aortic dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
Thoraco abdominal segment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
Dr Jean-Luc Gérard
FRIDAY JANUARY 24 Parallel session
MD, PhD, Professor of Vascular Surgery, Marseille, France MD, Paris, France
Pr Eric Allaire
MD, PhD, Professor of Vascular Surgery, Créteil, France
Tunneled catheters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16
Dr Pierre Bourquelot
Operative techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20
MD, Paris, France
Pr Pascal Desgranges
State of the art & future trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29
MD, PhD, Professor of Vascular Surgery, Créteil, France
Main session Imaging and navigation tools: where are we? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
34
Carotid latest news . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37
AAA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
45
Abdominal aorta and iliac arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
53
Visceral arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
57
Pr Hicham Kobeiter
MD, PhD, Professor of Vascular Radiology, Créteil, France
Dr Jean Marzelle MD, Créteil, France
International Scientific Committee Pr Piergiorgio Cao
SATURDAY JANUARY 25
MD, PhD, Professor of Vascular Surgery, Perugia, Italy
SFA: latest news from the endo technology and techniques . . . . . . . . . . . . . . . . . .
62
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
72
Professor of Vascular Surgery, London, United Kingdom
Legs arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
76
Pr Nicholas Cheshire
Pr Hans-Henning Eckstein
CONTROVERSIES & UPDATES IN VENOUS DISEASE
Christos D. Liapis
SATURDAY JANUARY 25
MD, PhD, Vascular surgeon, Munich, Germany Professor of Vascular Surgery, Chaidari, Greece
Dr Martin Malina
MD, PhD, Vascular surgeon, Malmo, Sweden
Pr Armando Mansilha
Professor of Vascular Surgery, Porto, Portugal
SESSION I: DEEP VEIN AND PERFORATOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
84
SESSION II: WHAT HAS CHANGED IN THE PAST 10 YEARS? . . . . . . . . . . . . . . . . . . . .
89
SESSION III: VASCULAR MALFORMATIONS. CLASSIFICATION AND TREATMENT . . .
94
SESSION IV: LIVE ULTRASOUND AND VIDEO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
98
SESSION V: SCLEROTHERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
103
SESSION VI: THERMAL TECHNIQUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
108
E-POSTERS AORTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
116
CASE REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
131
PAOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
143
RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
150
VASCULAR ACCESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
154
VEINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
157
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Faculty autors MAIN PROGRAM Yves S. ALIMI, Marseille, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Jean-Marc ALSAC, Paris, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Ali AMIN, West Reading, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Patrick BAGAN, Argenteuil, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Iris BAUMGARTNER, Bern, Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . 59 Colin BICKNELL, London, United Kingdom . . . . . . . . . . . . . . . . . . . . . . 15 Jan BLANKENSTEIJN, Amsterdam, The Netherlands . . . . . . . . . . . . . . 49 Léo BONATI, Basel, Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Giuseppe BONFORTE, Como, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Marc BOSIERS, Dendermonde, Belgium . . . . . . . . . . . . . . . . . . . . . . 45, 69 Benoît BOURA, Paris, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Pierre BOURQUELOT, Paris, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Armand BOURRIEZ, Rouen, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Jan BRUNKWALL, Cologne, Germany . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Bernard CANAUD, Bad Homburg, Germany . . . . . . . . . . . . . . . . . . . . . 17 Ludovic CANAUD, London, United Kingdom . . . . . . . . . . . . . . . . . . . . . 5 Piergiorgio CAO, Roma, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Xavier CHAUFOUR, Toulouse, France . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Roberto CHIESA, Milan, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Rachel CLOUGH, London, United Kingdom . . . . . . . . . . . . . . . . . . . . . . 35 Jack L. CRONENWETT, Lebanon, USA . . . . . . . . . . . . . . . . . . . . . . . 41, 67 Daniel DANZER, Sion, Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Alan DARDIK, New Haven, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Jean-Paul DEVRIES, Nieuwegein, The Netherlands . . . . . . . . . . . . . . . . 54 Koen R. DELOOSE, Dendermonde, Belgium . . . . . . . . . . . . . . . . . . . . . 70 Pascal DESGRANGES, Créteil, France . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Nicoletta FOSSATI, London, United Kingdom . . . . . . . . . . . . . . . . . . . . 30 Christopher GIBBONS, Oxfordshire, United Kingdom . . . . . . . . . . . . . 20 Monika GLOVICZKI, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Yann GOUËFFIC, Nantes, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Roger M. GREENHALGH, London, United Kingdom . . . . . . . . . . . . . . 74 Stéphan HAULON, Lille, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Ulf HEDIN, Stockholm, Sweden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Hassan HOSSEINI, Créteil, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Stavros KAKKOS, Patras, Greece . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Hicham KOBEITER, Créteil, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Tilo KÖLBEL, Hamburg, Germany . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Kimihiro KOMORI, Nagoya, Japan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Eric LADENHEIM, Fresno, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Miltos LAZARIDES, Athens, Greece . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Christos D. LIAPIS, Chaidari, Greece . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Hervé MAISONNEUVE, Paris, France . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Armando MANSILHA, Porto, Portugal . . . . . . . . . . . . . . . . . . . . . . . . . 79 Giustino MARCUCCI, Rome, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Tara MASTRACCI, Cleveland, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Richard MCWILLIAMS, Liverpool, United Kingdom . . . . . . . . . . . . . . . 13 Luis MENDES-PEDRO, Lisbon, Portugal . . . . . . . . . . . . . . . . . . . . . . . . . 57 Firas MUSSA, New York, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Vo NGUYEN, Olympia, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Gustavo ODERICH, Rochester, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Josette PENGLOAN, Nantes, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Nicola PIROZZI, Rome, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Janet POWELL, London, United Kingdom . . . . . . . . . . . . . . . . . . . . . . . 55 Alain RAYNAUD, Meudon, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Olgierd ROWINSKI, Galway, Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 François SAUCY, Lausanne, Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . 80 Peter SCHNEIDER, Honolulu, USA . . . . . . . . . . . . . . . . . . . . . . . . 36, 63, 76 Richard SHOENFELD, Newark, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Maxime SIBÉ, Bordeaux, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Eric STEINMETZ, Dijon, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Matthew THOMPSON, London, United Kingdom . . . . . . . . . . . . . . 8, 50 Isabelle VAN HERZEELE, Gent, Belgium . . . . . . . . . . . . . . . . . . . . . . . . 72 Marc VAN SAMBEEK, Eindhoven, The Netherlands . . . . . . . . . . . . . . . 48 Frank J. VEITH, Riverdale, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Pierfrancesco VEROUX, Catania, Italy . . . . . . . . . . . . . . . . . . . . . . . . . 25 Thomas ZELLER, Bad Krozingen, Germany . . . . . . . . . . . . . . . . . . . . . . . 68
VENOUS PROGRAM François-André ALLAERT, Dijon, France . . . . . . . . . . . . . . . . . . . . . . . 107 Annouk BISDORFF BRESSON, Paris, France . . . . . . . . . . . . . . . . . . . . 94 Mohamed BOUAYED, Oran, Algeria . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Anthony COMEROTA, Toledo, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Alun Huw DAVIES, London, United Kingdom . . . . . . . . . . . . . . . . 105-115 Alessandro FRULLINI, Figline Valdarno-Florence, Italy . . . . . . . . . . . . 104 Jean-Luc GÉRARD, Créteil, France . . . . . . . . . . . . . . . . . . . . . . . . . 98, 100 Peter GLOVICZKI, Rochester, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Manj GOHEL, London, United Kingdom . . . . . . . . . . . . . . . . . . . . . . . . 113 Jean-Jérôme GUEX, Nice, France . . . . . . . . . . . . . . . . . . . . . . . . . . 86, 103 Claudine HAMEL DESNOS, Caen, France . . . . . . . . . . . . . . . 99, 101, 103 Lowell S. KABNICK, New York, USA . . . . . . . . . . . . . . . . . . . . . . . . 92, 112 Philippe LEMASLE, Le Chesnay, France . . . . . . . . . . . . . . . . . . . . . . . . . 89 Oscar MALETI, Modena, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Martin MALINA, Malmö, Sweden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Armando MANSILHA, Porto, Portugal . . . . . . . . . . . . . . . . . . . . . . . . 111 Olle NELZEN, Uppsala, Sweden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Laure PERRISSIN-CHEVALIER, Arcueil, France . . . . . . . . . . . . . . . . . 102 Olivier PICHOT, Grenoble, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Eberhard RABE, Bonn, Germany . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Albert-Adrien RAMELET, Lausanne, Switzerland . . . . . . . . . . . . . . . . 91 Lars RASMUSSEN, Copenhagen, Denmark . . . . . . . . . . . . . . . . . . . . . . 109 Gilles SOULEZ, Montreal, Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Giorgio SPREAFICO, Padova, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Renate VAN DEN BOS, Rotterdam, The Netherlands . . . . . . . . . . . . . 108
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
T horacic aorta: open, endo or hybrid Can we stratify the operative risk of TEVAR? Matt Thompson SGVI, London, United Kingdom INTRODUCTION Thoracic endovascular aneurysm repair (TEVAR) is associated with less short-term mortality and morbidity than traditional open surgery. Despite this, serious adverse events occur in 10-15% of patients and the rate of all cause death at follow-up is high. The objective of this study was to develop a patient-specific risk stratification system to aid in pre-operative planning. METHODS The MOTHER database consists of five prospective clinical trials and a single institutional series. Logistic regression and Cox’s proportional hazard modelling were used to construct models using pre-operative variables to predict peri-operative and mid-term adverse events. ROC curve analysis and the Hosmer-Lemeshow test were used to determine discrimination and goodness of fit of the models. RESULTS Of 670 patients that underwent TEVAR for thoracic aneurysm, 5% died, 5% had a stroke and 3% developed spinal-cord injury (SCI) post-operatively. Independent predictors of 30-day death were age, non-elective surgery and the need for >2 devices (c-statistic=0.71). Stroke was predicted by female gender, previous stroke, coverage of the left subclavian artery and the need for >2 devices (c-statistic=0.77). SCI was predicted by female gender, smoking, previous stroke, non-elective surgery and the need for >2 devices (c-statistic=0.72). Aortic re-intervention was predicted by aneurysm length, maximum diameter and iliac tortuosity and a high-risk cohort could be identified. Patients could be successfully divided into tertiles of risk using the mid-term all-cause death model. CONCLUSION These models predict important outcomes following TEVAR relatively accurately. External validation of this risk stratification system is required before it can be introduced into clinical practice.
4
AIM The first decade of thoracic endovascular aortic repair (TEVAR) has demonstrated good short- and midterm outcomes. These results support endovascular repair as the procedure of choice for patients presenting with thoracic aortic diseases. Currently, 4 thoracic stent-grafts have achieved the CE labelling: Valiant (Medtronic Vascular, Santa Rosa, CA, USA), Zenith TX2 thoracic stent-graft with ProForm (Cook Medical, Bloomington, IN, USA), TAG (W.L. Gore & Associates, Flagstaff, AZ, USA) and the Relay Stent-graft (Bolton Medical, Sunrise,FL, USA). These stent-grafts have different features in term of stent-graft design (PTFE versus Dacron, stent framework) and delivery system. Knowledge of stent-graft conformability, radial force and accuracy of the delivery system is crucial to prevent devastating complications such as stent-graft collapse, type I endoleak, retrograde ascending aortic dissection and inadvertent coverage of the supra-aortic trunks. METHODS - Experimental study: This study has been performed using a benchtop pulsatile flow model and human cadaveric aortas too assess the conformability of the latest generation of thoracic stent-grafts as a function of oversizing and increasing aortic arch angulation. - Clinical study: A comprehensive review of the literature combined with a review of our single center experience has been performed to identify device related complications. RESULTS - Experimental study: The requirement for close conformability has influenced the design of next-generation devices. Manufacturers have modified devices and/or their deployment system to specifically address this problem. When compared to the results of our previous experimental test, these alterations have resulted in a marked improvement in the performance of commercially available stent-graft systems. - Clinical study: Regarding RTAD, inappropriate stent-graft oversizing, particularly in patients with aortic wall fragility, should be avoided. Iteration of stent-graft design will be important in reducing the incidence of RTAD, but the present study suggests that the presence of a bare proximal stent does not lead to an increased rate of RTAD. Considering the thoracic stent-graft collapse, accurate assessment of aortic arch anatomic features, as well as the choice and sizing of the device, may prevent this complication. Prevention of the risk of inadvertent coverage of the supra-aortic trunks is based on the choice of a stent-graft with a controlled delivery system. CONCLUSION Improvement in the performance of commercially available stent-graft systems combined with a proper knowledge of the different features of these stent-grafts will allow to prevent most of device relate.
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horacic aorta: open, endo or hybrid T Objective assessment of current stent grafts: which graft for which lesion Ludovic Canaud, Pascal Branchereau, Charles Marty-AnĂŠ, Pierre Alric Arnaud de Villeneuve Hospital, Montpellier, France
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
T horacic aorta: open, endo or hybrid Ascending aorta: is the endovascular approach realistic? How I do it. Tilo Kรถlbel University Heart Center Hamburg, Hamburg, Germany The current standard treatment for pathologies of the ascending aorta is open surgery. For patients with lesions such as dissection, aneurysm or rupture open surgery is the mainstay of treatment but includes substantial morbidity and mortality rates. Operative mortality from acute aortic type A dissection has decreased in recent years ranging from 7% to 17% owing to major advancements in ascending aortic surgery, but is still substantial especially in patients with older age, severe comorbidities and previous cardiac surgery. Thoracic endovascular aortic repair (TEVAR) has developed as a therapeutic alternative for open repair of the descending thoracic aorta during the last decade. However, technical and anatomical challenges persist for endovascular repair of the proximal segments of the aorta, rendering TEVAR an exceptional indication. Current problems of endovascular treatment from a downstream access-site include the inability to advance, control and deploy the endo-graft due to iliac and aortic pathology. Severe tortuosity of the iliac and aortic access vessels, the necessity to place a stiff guide-wire into the left ventricle and the shortness of currently available stent-graft introducing systems are further. To overcome theses limitations, alternative retrograde access-techniques have developed including subclavian access, conduits to iliac arteries, infrarenal and thoracic aorta. Antegrade access and transcardial stent-graft deployment might be an alternative access in patients unfit or with high risk for open surgery or retrograde access. MacDonald et al. have first described this access technique in an elective setting using a mini-thoracotomy as utilized for transapical aortic valve implantation. Other groups have adopted this technique and reported their experience. Potential advantages of transapical access include: avoidance of downstream access-problems, short distance with excellent trackability, pushability, rotational control, nearly unlimited profile, instant decompression of the pericardial tamponade, and availability, as transapical access is a standard technique for TAVI in many cardiovascular centers.
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horacic aorta: open, endo or hybrid T Hybrid techniques for the arch: are they effective and durable? Ciro Ferrer, Federica De Crescenzo, Carlo Coscarella, Gabriele Pogany, Piergiorgio Cao Vascular Surgery Unit - San Camillo Forlanini Hospital, Rome, Italy INTRODUCTION What is the best approach for aortic arch disease is currently debated. Most of the data available in literature is mainly based on limited series and heterogeneous populations. The aim of this study is to evaluate long term results of hybrid and endovascular procedures for aortic arch.
RESULTS The mean age of the patients was 69.8 years and 14 were females. Nineteen patients required total debranching for extension of the disease to zone 0. At 30 days, death, stroke, and spinal cord ischemia occurred in six, four, and three patients, respectively. Extension to ascending aorta (zone 0 landing) was the only multivariate independent predictor for perioperative mortality (odds ratio, 9.6; 95% confidence interval, 1.54-59.90; P =.015), but not for stroke. Four retrograde dissections, two fatal, occurred during the perioperative period. At 1, 3, and 5 years, Kaplan-Meier survival rates were 89.0%, 82.8%, and 70.9%, and freedom from persistent endoleak rates were 96.1%, 92.5%, and 88.3%, respectively. Over 5-year follow-up, 34 aneurysms shrank >5 mm, and four grew. Five reinterventions were required. Two supra-aortic vessel occlusions and no late aorta-related mortalities were recorded. CONCLUSIONS Despite the perioperative mortality risk, the late outcome of endovascular arch repair presents a low rate of aorta-related deaths and reinterventions and acceptable midterm survival. Furthermore, more than onethird of the aneurysms’ diameters decrease over 5 years as a measure of the long-term efficacy of treatment. Retrograde type A dissection remains a major concern in the perioperative period and careful arch approach is required.1 References
1. De Rango P, Cao P, Ferrer C, Simonte G, Coscarella C, Cieri E, Pogany G, Verzini F. Aortic arch debranching and thoracic endovascular repair. J Vasc Surg 2013.
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METHODS From 2005 to 2013, 104 consecutive patients underwent partial or total debranching associated with the positioning of one or more thoracic endografts. Rates of perioperative mortality and neurological complications, and mortality, endoleak, supra-aortic vessel patency, and arch diameter changes at 5 years were analyzed.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
ortic dissection A Controversy: Timing of TEVAR for uncomplicated acute type B dissection Early intervention is the best choice Jan Brunkwall, University Clinics, Cologne, Germany Acute Type B Dissection is a potentially lethal disease. Even though the mortality has decreased from 90% in the sixties, with modern antihypertensive medication and intensive care surveillance, the mortality is at the level of 6-10% the first 30 days according to several retrospective publications including the IRAD data. There are not sufficient reports on how patients with a primarily uncomplicated type B dissection are doing during the first 30 days. How many of these will develop a complication or even mortality is not fully reported. Most of the patients with a complicated dissection seem to enter the hospital with such a complication but some of the uncomplicated ones turn in to a complication like malperfusion, rupture, type A dissection, and even mortality. When treating these uncomplicated patients in the acute phase (<14days), there is the chance of â&#x20AC;&#x153;restitutio ad integrumâ&#x20AC;? especially if the dissection is a confined to only the thoracic aorta. The longer one waits the stiffer the membrane will get and the remodelling is harder to achieve. The ADSORB trial showed, that it was not dangerous to place a TAG device to cover the primary entry tear in acute type B dissections and that 10% of the patients in the BMT group switched over to the TAG group due to progression to the disease. During follow up for one year there were another 7% of the patients with progression of the disease in the BMT group. There was no progression of the disease in the TAG group. The good results of TEVAR in experienced hands and performed in the acute phase has also been shown in other publications. The reintervention rate and the mortality rates are lower than for BMT and open surgery. The reports on low mortality in patients with an uncomplicated type B dissection at discharge is not reflecting the real world as the morbidity and the mortality is to be seen within the first 2 weeks and then during a longer follow up of up to 5 years. The BMT safes lives compared to no BMT at all in the beginning according to a comparison with old historical data. The ADSORB trial was not designed for mortality, so we cannot state anything about this except that the mortality was low even in the BMT group. All the data presented on the better outcome of TEVAR when done after 14 days is based on retrospective data and with no BMT control group. Good results for the surgeon may not be the best for the patient. Compare with the shift in carotid endarterectomy for symptomatic patients with minor strokes to more early surgery instead of 6 weeks of waiting. So acute type B dissection is dangerous and in order to save life and gain healing, early intervention is necessary.
Delayed TEVAR is much preferable Matt Thompson, SGVI, London, United Kingdom BACKGROUND The Virtue registry, describes the mid-term clinical and morphological results of TEVR in patients with Type B aortic dissection. METHODS AND RESULTS The Virtue registry is a prospective, multi-centre clinical trial, which enrolled patients with complicated acute (<15 days), sub-acute (15-92 days) and chronic (>92 days) Type B aortic dissections treated with the Valiant endograft. 100 patients were enrolled and the clinical outcomes described at 3 years follow up. Analysis of aortic area and false lumen thrombosis rates defined the morphological response to TEVR in the three clinical groups. Three year all cause mortality (18%, 4% and 24%), dissection related mortality (12%, 4% and 9%) aortic rupture (2%, 0% and 4%), retrograde Type A dissection (5%, 0% and 0%) and aortic reintervention rates (20%, 22% and 39%) were respectively defined for patients with acute (50), sub-acute (24) and chronic (26) dissections. Analysis of aortic morphology observed that patients with sub-acute dissection demonstrated a similar degree of aortic remodelling to patients with acute dissection. Patients with acute and subacute dissection exhibited greater aortic plasticity than patients with chronic dissection. CONCLUSIONS The principle clinical findings suggest that TEVR is able to provide good protection from aortic related death in the mid-term but with a high rate of aortic reintervention. Analysis of aortic morphology has suggested that aortic remodelling in the sub-acute patients is similar to the acute group. Retention of aortic plasticity in the sub-acute group lengthens the therapeutic window for the treatment of uncomplicated Type B dissection.
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Aortic dissection Malperfusion and acute dissection type B: what is the best strategy Tara M. Mastracci The Cleveland Clinic Foundation, Cleveland, USA
The endovascular approach to malperfusion has included a variety of techniques, but most will agree modern solutions are a combination of thoracic stenting, branch vessel stenting, and fenestration. The thirty day mortality in centres which have reported this ranges from 0 to 25%, and represents a heterogeneous group of patients and approaches, making it challenging to gain insight into the best approach based on the reported literature alone. Where a good proximal landing zone exists, our centre favours placement of a thoracic stent as the first line approach to malperfusion. This addressed the issue of altered flow dynamics in the true lumen, which is very commonly the cause of malperfusion in our experience. As we gain more insight into this disease, we have thought that changing the flow dynamics between true lumen and false lumen, and not radial force alone is the reason why proximal thoracic stenting is successful. When primary thoracic stent does not resolve all malperfusion, and the large intimal tears above the celiac artery have been adequately covered, we adopt an approach of selective recanalization and stenting of branch vessels. Our experience with this, published this year, describes 61 patients with malperfusion over a 11 year span.3 Malperfusion in these patients occurred in at least one territory (including spinal cord 7/61 (12%), mesenteric 37/61 (61%), renal 45/61 (73%), and lower extremity 38/61 (62%).), but 43/61 patients had >1 bed effected, and 54/61 patients included mesenteric or renal involvement. Most patients were treated <24 hours after presentation (36/61, 59%). Thoracic stents were used in all patients, and branch vessel stenting in addition was required in 41% (25/61). Mortality was inversely associated with male sex (Hazard ratio [HR] 0.42 (0.18 – 0.96), p=0.04), quitting smoking (HR 0.31 (0.1 – 0.99), p=0.047) and positively associated with left subclavian artery occlusion (HR 2.97 (1.09- 8.11) p=0.034). The 30-day/in-hospital mortality was 21.3%. The 6-month, 1-year, and 5-year survival was 75% (95% CI, 65%-87%), 71% (95% CI, 61%-84%), and 56% (95% CI, 43%-74%), respectively. Our understanding of this lethal disease is still superficial, but it appears that endovascular techniques may improve outcomes compared with medical management. References
1. Nienaber C et al., Endovascular Repair of Type B Aortic Dissection: Long-Term Results of the Randomized Investigation of Stent Grafts in Aortic Dissection Trial. Circ Cardiovasc Interv. 2013: 6 2. Melissano G et al. Volume changes in aortic true and false lumen after the “PETTICOAT” procedure for type B aortic dissection. Journal of Vascular Surgery 2012; 55: 641 – 51. 3. Ryan C et al. Progress in Management of malperfusion syndrome from Type B Dissections. Journal of Vascular Surgery 2013; 57: 1283 – 90.
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The global understanding of aortic dissection has progressed significantly this year with the publication of long-term outcomes from the INSTEAD XL trial1, and in uncomplicated dissection, the field is becoming much more comfortable with the use of thoracic stents to promote aortic remodeling and change the natural history of the disease. However, complicated dissection, especially those which present with malperfusion, remain a challenging clinical problem which can be lethal very early in the presentation of the disease. In the IRAD database, visceral ischemia is the cause of death in 15.4% of patients (95% CI 8 – 22). Malperfusion can be dynamic or static, and can have a variety of etiologies including intimal dissection and complete occlusion of branch vessels, intimal tear of the dissection flap causing interrupted flow, or dissection flap collapse during systole.2 This makes the treatment of malperfusion a challenge, and the endovascular surgeon must have a good understanding of the disease, as well as the likely clinical scenario based on individual patient characteristics.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Figure
Angiogram of dissection with malperfusion.
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Aortic dissection Acute type B dissection: is closure of the proximal tear sufficient? Jean-Marc Alsac Hôpital Européen Georges Pompidou, Paris, France
In case of visceral malperfusion during the acute phase of the dissection, a higher pressure in the false lumen of the dissected aorta may lead to a «dynamic» compression of the true lumen where most collateral for visceral arteries arise.1 To promote the true lumen expansion and perfusion versus the false lumen pressure, the Zenith Dissection Endovascular System (Cook medical, Bloomington, Ind.) proposes a composite device with non-covered metal stents that extend into the thoracoabdominal aorta, below the proximal thoracic aortic stentgraft.2,3 In our experience of a systematic treatment for dynamic malperfusion complicating acute dissections, the Zenith Dissection Endovascular System achieved safely and effectively satisfactory clinical results in the short term. But the long term impact of this composite treatment on aortic remodeling remains to be determined. Regarding midterm evolution of aortic dissections, a persisting circulating flow in the false lumen of the dissection often promotes aneurysmal degeneration of the thoracoabdominal aorta. To avoid distal perfusion of the false lumen, we propose to adjunct a retrograde endovascular fenestration of aortic dissection flap to obtain a seal at the distal portion of the aortic stentgraft: the DEFINITE technique (Distal Endovascular Fenestration INsIde Thoracic Exclusion). This combined endovascular treatment could limit the frequent aneurysmal evolution of aortic dissection, and its fatal complications. References
1. Ryan C, Vargas L, Mastracci T, Srivastava S, Eagleton M, Kelso R, et al. Progress in management of malperfusion syndrome from type B dissections. J Vasc Surg. 2013 May;57(5):1283-90. 2. Nienaber CA, Kische S, Zeller T, Rehders TC, Schneider H, Lorenzen B, et al. Provisional extension to induce complete attachment after stent-graft placement in type B aortic dissection: the PETTICOAT concept. J Endovasc Ther. 2006 Dec;13(6):738-46. 3. Lombardi JV, Cambria RP, Nienaber CA, Chiesa R, Teebken O, Lee A, et al.; STABLE investigators. Prospective multicenter clinical trial (STABLE) on the endovascular treatment of complicated type B aortic dissection using a composite device design. J Vasc Surg. 2012 Mar;55(3):629-640.e2.
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Because of its less invasive and reproducible character, thoracic endovascular aortic repair became the treatment of choice for aortic dissections interesting the descending thoracic aorta. The placement of a covered stentgraft on the proximal tear of the dissection redirects blood flow in the true lumen, and treats most complications that may occur during the acute phase. However, the existence of other distal entry tears often leads reperfusion downstream of the stentgraft, which maintains a circulating flow in the false lumen of the dissection.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Aortic dissection Acute type B dissection. Closure of the infra diaphragmatic tear: how and when? Olgierd Rowinski Varsaw, Poland Thoracic endografting (TEVAR) is now considered the mainstay of treatment modalities in type B aortic dissections. This approach restores wide flow in the true lumen, closes the primary entry tear and helps induce thrombosis of the false channel. Combined with BMT, more than 90% of patients will benefit from this treatment modality. In the remaining patients, while TEVAR proves beneficial in aortic remodelling in the thoracic region adjacent to the endograft, further concern remains regarding the supra and infrarenal aorta as TEVAR usually fails to induce thrombosis of the abdominal aortic false lumen because of persisting reentry points at this level. We present various secondary endovascular methods that we have employed with a varying degree of success in order to promote false lumen thrombosis, prevent aortic dilatation and avoid rupture. The intention to treat was mainly based on the following indications: dilatation of the false lumen above 5 mm/year with persistent turbulent flow into the false dissection lumen on follow-up, the presence of compromised vessel patency with increasing static malperfusion and recurrent pain responding poorly to medical treatment, an AAA coexisting with a type B disscetion or a ruptured false lumen of the infrarenal aorta. The following different techniques were used alone or in conjunction: 1) occlusion of a reentry point at the level of the detached renal artery ostium using a covered peripheral stent, 2) occlusion of a major entry tear using an occlusion device 3) occlusion of distal reentry points (intimal defects) in the abdominal aorta using a straight or bifurcated endograft. Using these various endovascular techniques we were able to limit false lumen expansion and promote thrombosis in the majority of treated patients. Such an approach may prevent impeding rupture in patients not eligible for open aortic repair.
T horaco abdominal segment Open surgical technique for type IV TAAA: the latest improvements Xavier Chaufour CHU Rangueil, Toulouse, France Thoracoabdominal aneurysm type IV (TAA IV) represents only a minority of aortic aneurysms, but as it is an entirely abdominally located aneurysm, vascular surgeons are likely to see such aneurysms in their practice. Computed tomographic angiography of the aorta has become the gold standard for preoperative imaging. This modality is extremely useful in preoperative planning to aid in selection of appropriate open repair stratégies. The patient is positioned in right lateral décubitus for a thoraco-retroperitoneal retrorenal approach in the nine or tenth intercostal space without resection of rib. A short anterior diaphragm incision is associated with full dissection of the left crus ligament. The use of a self-retaining retractor allows short incision with stable operative field. The clamp-and-sew technique was used for all operations, Operative reconstruction consisted of one beveled proximal anastomosis incorporating the descending thoracic aorta, celiac, superior mesenteric artery, and right renal arteries origins and a side-arm graft to the left renal artery. Uncomplicated repair has a minimal risk of neurological injury and a low risk of renal failure requiring dialysis in patients without preoperative renal dysfunction or renal artery stenosis. Under these conditions intraoperative renal protection is not needed. If the patient has preoperative renal failure, then each kidney is perfused with 300 mL of cold (+4 ° C) Ringer’s lactate solution after opening the aneurysm. The infusion is undertaken for 4 - 5 min at 150 mm-Hg. Maintaining a high cardiac output and mean arterial pressure > 70 mm-Hg during and after surgery are two major elements to ensure satisfactory diuresis A simplified operative approach for type IV TAAA repair is associated with favorable perioperative results. Literature and own datas refute the need for surgical adjuncts commonly applied in more extensive TAAA and indicate that the hybrid operation is an illogical posture. Long-term survival equates that observed after routine AAA repair.
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horaco abdominal segment T Paraplegia following F and B EVAR: incidence, severity and ways to prevent it Richard McWilliams1, Fatameh Jafarzadeh2, Mike Desmond2 1. Royal Liverpool University Hospital, Liverpool, United Kingdom 2. Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Spinal cord ischaemia (SCI) is one of the major complications after fenestrated and branched EVAR. The GLOBALSTAR database of FEVAR in the UK records 5 cases of SCI in 318 registered patients. All were in grafts with four fenestrations which is consistent with the known increased risk of SCI with greater aortic coverage. For this reason the risk of paraplegia is much higher with thoracoabdominal branched grafts. Strategies to reduce the risk of SCI include preservation of the left subclavian and hypogastric arteries, minimising the length of aortic coverage, staging complex endovascular procedures, adjusting CSF and mean arterial pressures to maintain the spinal cord perfusion pressure and using dedicated paraplegia prevention branches in endografts. Neuromonitoring using evoked potentials has an established role in open repair of thoracoabdominal aortic aneurysms. Changes in the recorded traces are used to guide modifications to surgery and spinal cord perfusion pressure. Our endovascular service has a strong collaboration with the Liverpool Heart and Chest Hospital and we have started using motor evoked potential (MEP) monitoring during TEVAR and BEVAR. Monitoring is only valuable if there is a potential response strategy if the motor evoked potentials deteriorate. Unfortunately we do not have endografts which are resheathable so if the MEPs deteriorate during a procedure then the response strategy is aimed at increasing spinal cord perfusion through changes in CSF/mean arterial pressure and, if this fails, by trying to increase spinal cord perfusion directly by inducing an endoleak. MEP monitoring may also be used during a procedure to test occlude the last branch and decide if this should be left open as per a paraplegia prevention branch. Ischaemia from large groin sheaths and from arm access can complicate the interpretation of changes to MEPs. This presentation will discuss how we have established and use neuromonitoring in our TEVAR and complex aneurysm programme.
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
T horaco abdominal segment. Controversy: Off the shelf grafts. Are they needed and up to the job? Off the shelf grafts: are they needed and up to the job? For the motion Stephan Haulon CHRU Lille, Lille, France Fenestrated and branched endografts have evolved as an effective treatment option for patients with juxtarenal, pararenal and thoracoabdominal aneurysms. However, these technologies have required that they be specifically manufactured to fit an individual patients anatomy. More recently, off-the-shelf technologies have emerged as an additional option. These devices simplify case planning and preparation as visceral anatomy can be simply compared with device anatomical requirements. In addition, they are available for treatment of acute or symptomatic patients. When used within their indicated anatomical requirements, short-term results for some off-the-shelf fenestrated and branch grafts are comparable to their custom-manufactured counterparts.
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horaco abdominal segment. Controversy: Off the shelf grafts. Are they T needed and up to the job? Off the shelf grafts: are they needed and up to the job? Against the motion. Colin Bicknell Imperial College London, London, United Kingdom Despite an increasing role the major criticism of fenestrated/branched stent grafts is the delay and cost of bespoke production. Therefore a promise of off-the-shelf graft technology is very attractive.
Even if one admits that an off-the-shelf solution is the only viable prospect of treating this group of patients there are many unanswered questions. The main question is regarding tolerance of different anatomical configurations. With bespoke manufacturing fenestrations/branches can be matched exactly to the required height and clockface orientation. However if the fenestration/branch is misaligned there may be significant difficulties. Double diameter reducing ties and certainly intelligent catheter technologies will smooth the cannulation of vessels and introduction of branch stents, but the long-term durability of misaligned branches is yet to be understood due to aortic remodeling and the potential for fracture, kinking and dislocation. With dome shaped fenestrations, wide coeliac artery scallops and branch technology the number of patients that may be treated with a few graft configurations is thought to be acceptable in morphological studies 3,4. There should be some caution however, as urgent and emergency cases are well accepted to be significantly larger and have more complex anatomical configurations 5. The number of patients that may be treated and success of off-the-shelf grafts is yet to be proven. They are not “up to the job” at this present time. References
1. Robot-assisted antegrade in-situ fenestrated stent grafting. Riga CV, Bicknell CD, Wallace D, Hamady M, Cheshire N. Cardiovasc Intervent Radiol. 2009 May;32(3):522-4. 2. The role of robotic endovascular catheters in fenestrated stent grafting. Riga CV, Cheshire NJ, Hamady MS, Bicknell CD. J Vasc Surg. 2010 Apr;51(4):810-9 3. Toward an «off-the-shelf» fenestrated endograft for management of short-necked abdominal aortic aneurysms: an analysis of current graft morphological diversity. Nordon IM, Hinchliffe RJ, Manning B, Ivancev K, Holt PJ, Loftus IM, Thompson MM. J Endovasc Ther. 2010 Feb;17(1):78-85. 4. Off-the-shelf fenestrated endografts: a realistic option for more than 70% of patients with juxtarenal aneurysms. Sobocinski J, d’Utra G, O’Brien N, Midulla M, Maurel B, Guillou M, Azzaoui R, Roeder B, Resch TA, Haulon S. J Endovasc Ther. 2012 Apr;19(2):165-72. 5. Comparison of morphologic features of intact and ruptured aneurysms of infrarenal abdominal aorta. Hinchliffe RJ, Alric P, Rose D, Owen V, Davidson IR, Armon MP, Hopkinson BR. J Vasc Surg. 2003 Jul;38(1):88-92.
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Few vascular specialists would challenge the premise that this technology will play a major role in the future. It is very hard to argue against the need for off-the-shelf grafts but we should be mindful that with advances in technology, this may not be the only mechanism with which to treat urgent/emergency complex aneurysms. The technique of in-situ fenestration 1 or rapid in-house bespoke manufacturing would certainly challenge the need for off-the-shelf grafts with advances in imaging and robotics 2.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Tunneled catheters Prevention and treatment of sepsis Josette Pengloan
Nantes, France
Tunneled catheters (TC) are essential devices for patients on hemodialysis. However TC use is associated with a high morbidity and mortality rate related to inflammatory status and/or acute infection. Consequences are both reduction of patient survival and CVC lifespan. TC related bacteraemia (TCRB) rate has to be below 1 p 1000 TC days. Development of intraluminal bacterial biofilm is responsible of bacteraemia and/or distant abscesses; it is mainly initiated by the introduction of pathogens from skin flora during the maneuvers of TC connection and disconnection. The fundamental preventive measures are based on the strict application of hygiene rules during these procedures. Additional preventive measures are to be considered: locking solutions, early diagnosis and treatment of TC colonisation (based on monthly cultures of the content of each lumen before a dialysis session). Treatment is initiated if cultures of CVC content are positive and immediately in case of systemic signs. It is based on the association of systemic antibiotic treatment, antibiotic lock-solution and fibrinolytic treatment of TC and continued at least 2 weeks after cultures turn negative. CefazolineĂ&#x2019; and VancomycineĂ&#x2019; reserved to MRSA carriers are the preferred first-line antibiotics. With this protocol a rate of TCRB of 0, 3 p 1000 TC days can be achieved. A TC surveillance program has to be implemented with analyze of the results every each 3-6 months. In case of TCRB rate increase adherence to protocol and training of staff has to be evaluated and protocol revised if necessary. Many questions remain debatable: what design and material for TC? What is the best prophylactic lock-solution? How to eradicate Staphylococcus aureus which remains one of the most dangerous pathogen for haemodialyzed patients and cannot be predicted through monthly cultures of TC content?
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Tunneled catheters When should an infected catheter be changed? Bernard Canaud, HÊlène Leray-Moraguès, Leila Chenine
Montpellier University I - UFR Medicine & FMC Medical Board, Montpellier, France Tunneled central venous catheters (TCVC) are frequently used in hemodialysis (HD) patients to overcome either temporary or permanent vascular access problems. Despite international guideline recommendations, the prevalence of TCVC use remains high averaging 20% worldwide, with large intercountry variations (< 5% in Japan to > 40% in Belgium) reflecting differences in patient medical profiles and clinical practices. Infection remains a major burden for HD patients representing the second cause of hospitalization and mortality. Due to the immunodepression status of chronic kidney disease patients and multiple and repeated invasive acts (access needling, exploration, catheters), HD patients are predisposed to severe infection by direct blood bacterial seeding. In this context, TCVC represents an additive risk factor for infection (foreign material, permanent open access to blood, and repeated manipulations for HD connection) for whom incidence of blood stream infection (bacteremia) has been estimated 7 to 8 times higher as compared to native arterio-venous fistula. Several clinical measures have proved to be efficient in preventing and reducing TCVC related infections. These measures representing the basic of best clinical practices should be implemented in any dialysis units since they represent the best barrier against bacterial TCVC seeding. Strict hygienic handling and reinforced universal precautions of aseptic manipulation are the basic of TCVC use. These measures should be applied along TCVC lifecycle with the same precaution, from insertion to removal time, including catheter manipulations during HD sessions. Catheter locking solutions (CLS) based on dual activities (antithrombotic and antiseptic) offer a new and complementary option to minimize the risk of TCVC intraluminal bacterial contamination and colonization. CLS have been proved to be particularly efficient in reducing TCVC blood stream infection. CLS use represents an additional measure for preventing TCVC related infection is now strongly recommended by international recent guidelines. However, CLS must not be considered as an alternative, and cannot be substituted, to universal hygienic and aseptic precautions TCVC infection prevalence varies between 0.1 to 6.0 episodes per 1000 days according to literature data. Catheter-related infection covers several forms, from limited skin exit infection to tunnel or track infection (tunnelitis), including isolated bacteremia and septicemia. In all cases, TCVC-related infection must be considered as potential serious clinical condition bearing the risk of bacterial systemic dissemination with endocarditis (or osteomyelitis or lung or brain abscess) due to the high prevalence of Staphylococci species, and more rarely septic shock when Gram negative bacteria are involved. Facing TCVC-related infection situations, the main concerns for referent Physician are thrice: First, to evaluate gravity and potential risk of dissemination (form of infection, type of bacteria, comorbidities, early response to treatment); Second; to identify if the catheter is colonized and/or bacterial biofilm has taken place in the inner lumen of the catheter; Third, to explore alternative vascular access possibilities in case of TCVC removal. Infective endocarditis (IE) is a major risk and the most serious complication of HD patients in this setting with very poor outcomes as compared to general population. Therefore all immediate therapeutic actions including early TCVC removal must be considered to prevent this devastating complication. IE incidence is estimated 50 to 180 fold higher than the general population. The use of a TCVC is strongly associated with IE prevalence in HD patients exceeding 50 to 60% in some series. Curiously the tricuspid valve is rarely affected while the mitral valve is involved in more than 50% of cases, the aortic valve in more than 30% and involvement of both valves is relatively frequent. Staphylococcus Aureus and Staph. Species are the main cause of TCVC-related bacteremia among HD patients (2/3rd of cases). Enterococcus and streptococcus are less frequent (1/3rd of cases). Gram-negative species and Pseudomonas are very rarely found TCVC-related infection diagnostic is usually easy relying on clinical signs and symptoms, blood (peripheral and catheter) and/or catheter cultures and microbiological identification of pathogen. More difficult in practice is assessing prognosis and endoluminal contamination of catheter. Echocardiography and various imaging technics have been proposed to document disseminated septicemia and distant bacterial tissue seeding such endocarditis or abscess (lung, brain or bone). In all cases, TCVC-related infection must be considered as serious and critical condition in which immediate therapeutic action is needed and close
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
patient follow-up is required. Medical treatment consists in systemic antibiotic, targeting initially Staph. Aureus secondary adapted to bacteria species, combined with local antibiotic (skin, catheter lock solution) and/or dual catheter locking solution (fibrinolytic plus antibiotic). Clinical re-assessment is performed on a short period of time according to severity and treatment response. Catheter removal should be considered anytime as an option in case of extreme severity or poor response to initial treatment. Immediate, TCVC withdrawal should be considered when facing extended tunnelitis and/or sepsis and/or unusual bacteria and/or high risk patient. Delayed, TCVC removal must be considered after 24 to 48 hours of optimal medical treatment and persistence of infection symptoms. Another approach is sometimes proposed consisting in replacing TCVC over guide wire keeping the same subcutaneous track. This approach increases the risk of propagating bacteria, creating septicemia and should be abandoned. Now, if venous access is the only vascular access option possible then removal of infected catheter, followed by temporary use of acute catheter and then later on insertion of a second TCVC is highly recommended. Prolonged systemic antibiotic treatment (4 weeks) and antiseptic or antibiotic catheter locking must be considered to consolidate treatment efficacy in severe cases. In addition, it is important to mention that HD patients that had developed TCVC-related infection may present secondary and/or late distant complications (endocarditis, abscess) and therefore prolonged follow-up based on microbiological blood catheter culture, inflammatory biomarkers (CRP, fibrinogen) and hematological pictures (Leukocytes and Platelets count) must be maintained over 3 consecutive months. To conclude, infection of permanent TCVC constitutes a constant and potential serious hazard for HD patients that should be prevented by strict compliance to hygienic rules. Risks versus benefits of keeping in place TCVC must be considered carefully case by case. Optimal medical treatment including systemic antibiotic therapy and antibiotic catheter locking solution are the first line of treatment. Catheter removal must be considered in case of severe sepsis and when facing poor or incomplete control of infection for preventing occurrence of more severe complication such as endocarditis.
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Tunneled catheters Difficult catheter insertions Richard Shoenfeld
The Access Center at West Orange, West Orange, New Jersey, USA Central vein stenosis or occlusion is reported in up to 42% of patients with chronic or prior indwelling dialysis catheters1. Permacaths induce fibrin sheath formation, stenosis and ultimately, occlusion. In addition to consuming precious venous capital and ultimately compromising future ipsilateral or contralateral central venous access, central vein obstruction may result in SVC syndrome or disabling arm swelling. In the absence of infection and when feasible, recanalization/angioplasty remains the first line of treatment. Stenting is reserved for lesions unresponsive to angioplasty, for maintaining patency of recanalized conduits to the right atrium and/or for treatment of hemorrhage/tamponnade secondary to attempted recanalization. Central vein patency is perquisite for optimum chronic dialysis catheter tip position. The pathway we choose to reach a large central vein or the right atrium has little impact on catheter function. When jugular and subclavian access are no longer an option and recanalization is unobtainable, alternative cannulation may be safely performed via external jugular or other suitable collateral veins in or near the neck or by transfemoral or translumbar routes. Funaki et al. 2 described a novel technique for radiologic placement of tunneled dialysis catheters in occluded neck, chest or small thyrocervical collateral veins in central vein occlusion, allowing for recycling of previously abandoned access sites. More recently, new innovative techniques have proved to be safe and effective in recanalizing occluded central veins where conventional endovascular techniques have failed. Gimaraes et al. 3 reported using a Power Wire™ radiofrequency guide wire together with an intravascular loop snare and body flossing technique with angioplasty and stenting to safely restore patency to previously uncrossable central vein obstructions. In patients with true end-stage access needs, cannulation sites of last resort include the transhepatic4 and transrenal5 routes. Both of these approaches are at increased risk of procedural complications and catheter failure due to organ motion. References
1. Schillinger, F., D. Schillinger, R. Montagnac and T. Milcent (1991). «Post Catheterisation Vein Stenosis in Haemodialysis: Comparative Angiographic Study of 50 Subdavian and 50 Internal Jugular Accesses.» Nephrology Dialysis Transplantation 6(10): 722-724. 2. Funaki, B., G. X. Zaleski, J. A. Leef, J. N. Lorenz, T. Van Ha and J. D. Rosenblum (2001). «Radiologic placement of tunneled hemodialysis catheters in occluded neck, chest, or small thyrocervical collateral veins in central venous occlusion.» Radiology 218(2): 471-476. 3. Guimaraes, M., C. Schonholz, C. Hannegan, M. B. Anderson, J. Shi and B. Selby (2012). «Radiofrequency Wire for the Recanalization of Central Vein Occlusions that Have Failed Conventional Endovascular Techniques.» Journal of vascular and interventional radiology : JVIR 23(8): 1016-1021. 4. Smith, T. P., J. M. Ryan and D. N. Reddan (2004). «Transhepatic Catheter Access for Hemodialysis1.» radiology 232(1): 246-251. 5. Murthy, R., M. Arbabzadeh, G. Lund, H. Richard, A. Levitin and B. Stainken (2002). «Percutaneous Transrenal Hemodialysis Catheter Insertion.» Journal of vascular and interventional radiology : JVIR 13(10): 1043-1046.
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
perative techniques O Snuffbox fistula Chris Gibbons
Morriston Hospital, Swansea, United Kingdom The snuffbox AV fistula was first described over 30years ago but is less commonly used by access surgeons than the radiocephalic AV fistula at the wrist. However, it is the most distal AV fistula possible, thus giving the longest length of forearm cephalic vein for needling and is the ideal access for maximum venous preservation. In a series of 210 snuffbox AV fistulae in 201 patients, the patency was similar to that reported for wrist AV fistulas (82% at 6weeks, 65% at 12months and 45% at 5years). In this study patency was not affected by age or diabetes but was significantly worse in women than in men. After thrombosis, an ipsilateral wrist fistula was still possible in 45% of cases. In a personal series of the snuffbox AV fistula was the primary access in 52% of 1408 cases which was a major factor in the high prevalence of distal AV fistulas in our haemodialysis population (67% of all access and 76% of all permanent access). In a recent study from our unit, the application of a scoring system (DISTAL) using six factors has been found potentially to increase patency by 23% at the expense of 12% fewer snuffbox AV fistulas. References
Wolowczyk L, Williams AJ, Donovan KL, Gibbons CP. (2000) The Snuffbox Arteriovenous Fistula for Vascular Access. Eur J Vasc Endovasc Surg; 19: 70-76. Twine CP, Haidermota M, Woolgar JD, Gibbons CP, Davies CG. A scoring system (DISTAL) for predicting failure of snuffbox arteriovenous fistulas. Eur J Vasc Endovasc Surg 2012; 44: 88-91.
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perative techniques O Middle forearm fistula Giuseppe Bonforte
AO Ospedale Santâ&#x20AC;&#x2122;Anna Como, Como, Italy The distal radial-cephalic fistula (dRCF) proposed by Cimino-Brescia is recommended as the first and best hemodialysis access because requires an easy placement procedure. When is not feasible, guidelines suggest artero-venous fistula (AVF) placement in the upperarm. This second option, compared with a dRCF, enables an higher flow AVF, with a shorter maturation time and an earlier development of more easily available veins for hemodialysis. However, the surgical intervention required for the brachial artery inflow AVF placement has a greater risk of distal steal syndrome, arm ischemia and high output heart failure than the distal approach. In the last 30 years, the hemodialysis population has become older and sicker, comorbid factors have increased and the life expectancy in hemodialysis population has been increased, so nowadays it is even more important to create a working vascular access with as few complications as possible. Several studies have shown that the classic dRCF in this populations (older, sicker, high comorbid factors) has an increased rate of early failure (early thrombosis or failed maturation) and a limited primary unassisted patency due to the frequent need of surgical revisions or angiographic procedures, or both, with increased costs and reduced patient quality of life. On this basis, it is questionable if dRCF should be still considered as the first best choice for vascular access. The middle-forearm fistula (MAF), consisting of an anastomosis between proximal radial artery and the nearest suitable vein located in the antecubital fossa (median, perforating, or cephalic vein), is suggested as an alternative option. According to our results regarding primary assisted/unassisted patency rates and complications of middle-arm fistula, MAF demonstrated a good unassisted primary patency, suggesting that this kind of AVF could be a valuable alternative surgical approach when dRCF is not feasible in ESRD patients.
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
perative techniques O What is the less worst arteriovenous bypass at the upper limb? Miltos Lazarides
Democritus University, Alexandroupolis, Greece
European and USA guidelines encourage the increased use of autogenous AV fistulae as more durable access procedure ones matured. However approximately half of all AV fistulae performed fail.1 Although prosthetic AV grafts (AVG) are definitely not superior to AV fistulae, they present the only choice in selected patients in whom an autogenous fistula simply cannot be constructed. The presence of certain factors as advanced patient age, short life expectancy and suboptimal vascular anatomy may favour a prosthetic rather than an autogenous access, the latter being not better to an AVG in every clinical setting. Upper limb AVG may be straight forearm, looped forearm and upper-arm grafts. While straight forearm grafts have lower patencies, looped forearm and upper-arm grafts present similar 2-year secondary patency rates 51-70% in two systematic reviews.2,3 However revisions in the elbow area to maintain patency of looped forearm grafts may jeopardize future use of the arm veins, while basilic transposition was found preferable in a meta-analysis to looped forearm grafts.4 In contrast upper limb grafts present similar patency rates with basilic vein transposition and can still be created after its failure, representing a good last upper limb option. An additional indication of prosthetic grafts is the use of short PTFE segments in revisions of autogenous accesses, without further consumption of the venous capital by harvesting veins or compromising more proximal access sites,5 this practice is justified and encouraging patencies have been reported, especially when avoiding to cannulate the prosthetic segment. References
1. Dember LM et al. JAMA 2008; 299:2164-2171 2. Huber TS et al. J Vasc Surg 2003;38:1005-1011 3. Cull DL. Semin Vasc Surg 2011;24:89-95 4. Lazarides M et al. Eur J Vasc Endovasc Surg 2008; 36: 597-601 5. Georgiadis GS et al. J Vasc Surg 2005;41:76-81
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perative techniques O A new sterile elastic exsanguination tourniquet Eric Ladenheim LDAC Vascular Centers, Fresno California, USA
Because of the rising prevalence of obesity among dialysis patients techniques to superficialize the veins are frequently needed to enable cannulation of fistulas that would otherwise be too deep. However in the upper arm there is not enough space for the pneumatic tourniquet between the axilla and the surgical incision (s). Instead of doing these operations without a tourniquet we have utilized an ultra-narrow non-pneumatic elastic exsanguination tourniquet for preventative hemostasis during lipectomy, liposuction, superficial transposition and translocation of the vessels. We utilized the HemaClear surgical exsanguination tourniquet (OHK Medical Devices, Haifa Israel) This is a sterile elastic device which rolls over the limb starting from the fingers by pulling two handles. The Elastic exsanguination tourniquet is commercially available and packaged sterile. The elastic silicone ring provide sufficient pressure (220 +/- 30 mm Hg) to block arterial flow into the limb. It is available in several sizes to match the arm circumference. We routinely stage our upper arm AV fistulas by creating the fistula first and then performing a superficialization procedure once fistula function is assured. However, the very high blood flow in the limb during a secondary procedure can make the secondary procedure rather bloody without a tourniquet. By utilizing an ultra-narrow tournequet on the upper arm the secondary procedure can be done almost bloodlessly. Using the tournequet and having a dry surgical field has significantly reduced blood loss during AVF liposuction. It has also allowed for easier exposure through smaller incsions during transpositions promoting increased patient acceptance of the procedures. Upper Arm Lipectomy with Hemaclear Tournequet Elastic Exsanguination Tournequet Stays out of the way
References
Bourquelot PD. Preventive haemostasis with an inflatable tourniquet for microsurgical distal arteriovenous fistulas for haemodialysis. Microsurgery 1993; 14: 462-3. Jordan SC and Pescovitz MD. Presensitization: the problem and its management. Clin J Am Soc Nephrol 1: 421–432, 2006. Ladenheim E, “Our Technique for Performing Upper Arm Lipectomy of Arteriovenous Fistula Under Tourniquet Control Using the Hemaclear Surgical Exsanguination Tourniquet, Presented at VAS 8th International Congress, April 25-27, 2013 Prague, Czech Republic. Abstract published in Journal of Vascular Access, v. 14, No. 1 Jan-March 2013 Ladenheim E, Krauthammer J, Agrawal S, et al. “A sterile Elastic Exsanguination Tourniquet is Effective in Preventing Blood Loss during Hemodialysis Access Surgery”, Seminars in Dialysis, 2012 pp 689-692 (November-December)
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
perative techniques O Tagliatelle technique: a revolution in vascular access of the lower limbs? Benoit Boura, Faris Alomran, Alexandros Mallios, Romain de Blic, Alessandro Costanzo, Myriam Combes
Institut Mutualiste Montsouris, Paris, France
When all options of upper extremity vascular access are exhausted, vascular surgeons are required to consider a new lower extremity access 1. In the lower limb, publications show a high rate of infectious and thrombotic complications when prosthetic conduits are used 2. The use of a superficial femoral vein is known to be a complex procedure with risk of steal syndrome and recurent oedema 3, 4, 5. The greater saphenous vein (GSV) has proved previously to be a poor conduit due to its resistance to dilatation 6, 7. In such cases, we propose an alternative technique 8, using the GSV, harvested in the thigh and just below the knee, then longitudinally opened, freed from all valves, folded in 2, creating one anterior and one posterior vein panel, both sutured edge to edge as already described in other locations 9, 10, 11. The final result is a conduit which doubles the initial diameter suitable for haemodialysis. This new conduit is subcutaneously tunnelled and then anastomosed end to side to the superficial femoral artery in the mid-thigh. This has all the advantages of a native fistula without the morbidity associated with the superficial femoral vein graft. Also, we believe that this technique can be used in other anatomies, such as the upper limb in selected patients, not candidates for prosthetic graft. References
1. NFK-KDOQI: Clinical Practice For Vascular Access: update 2006. Am J Kidney Dis 2006, 48:248-272. 2. Antoniou GA, Lazarides MK, Georgiadis GS, Sfyroeras GS, Nikolopoulos ES, GIannoukas AD. Lower-extremity arteriovenous access for haemodialysis: a systematic review. Eur J Endovasc Surg 2009;38:365-72. 3. Bourquelot P, Rawa M, Van Laere O, Franco G. Long-term results of femoral vein transposition for erogenous arteriovenous hemodialysis access. J Vasc Surg 2012;56-2:440-5. 4. Gradman WS, Cohen W, Haji-Aghaii M. Arteriovenous fistula construction in the thigh with transposed superficial femoral vein: our initial experience. J vasc Surg 2001;33:968-75. 5. Gradman WS, Laub J, Cohen W. Femoral vein transposition for arteriovenous hemodialysis access: improved patients selection and intra-operative measures reduce postoperative ischemia. J Vasc Surg 2005; 41:279-84. 6. Pierre-Paul D, Williams S, Lee T, Gahtan V. Saphenous vein loop to femoral artery arteriovenous fistula: a practical alternative. Ann Vasc Surg 2004;18:223-7. 7. Correa JA, de Abreu LC, Pires AC, Breda JR, Yamazaki YR, Fioretti AC, Valenti VE, Vanderlei LC, Macedo H Jr, Colombari E, Mianda F Jr: Saphenofemoral arteriovenous fistula as hemodialysis access. BMC Surg 2010, 10:28. 8. Alomran F, Boura B, Mallios A, de Blic R, Costanzo A, Combes M. Tagliatelle technique for arteriovenous fistula creation using a greater saphenous vein semi-panel graft. J Vasc Surg 2013 May 1.doi:pii:S0741-5214 (13) 01277-9.10.1016/jvs 2013.06.082 (Epub ahead of print). 9. Mallios A, Boura B, Alomran F, Combes M. A new technique for reconstruction of the Aortic Bifurcation with Saphenous Vein Panel Graft.J Vasc Surg. 2013 May 1. doi:pii: S0741-5214(13)00556-9. 10.1016/j.jvs.2013.02.245. [Epub ahead of print]. 10. Mallios A, Boura B, Yankovic W, Costanzo A, Combes M. Replacement of infected prosthetic femoral graft with longitudinally Vein Patches. Eur J Vasc Endovasc Surg Extra 2012;23:e40-e41. 11. van Zitteren M, van der Steenhoven TJ, Burger DHC, van Berge Henegouwen DP, Heyligers JMM, Vriens PWHE. Spiral vein reconstruction of the infected abdominal aorta using the greater saphenous vein: preliminary results of the Tilburg experience. Eur J Vasc Endovasc Surg 2011;41:637-646.
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perative techniques. Controversy: Small veins at forearm AVF creation O Peroperative balloon angioplasty Pierfrancesco Veroux, Giaquinta A., Tallarita T., Sinagra N., Virgilio C., Zerbo D., Gloviczki P., Veroux M. University of Catania, Catania, Italy
PRIMARY BALLOON ANGIOPLASTY OF SMALL (≤2 MM) CEPHALIC VEINS IMPROVES PRIMARY PATENCY OF ARTERIOVENOUS FISTULAE AND DECREASES REINTERVENTION RATES.
Source: Vascular Surgery and Organ Transplant Unit, Department of Surgery, Transplantation and Advanced Technologies, University Hospital of Catania, Catania, Italy. veroux@unict.it
PURPOSE The purpose of this study was to evaluate the effect of primary balloon angioplasty (PBA) of cephalic veins with diameter≤2 mm on patency and maturation time of autogenous radiocephalic arteriovenous fistulae (AVF) for hemodialysis. METHODS Forty patients, all candidates for distal AVF, with a cephalic vein≤2 mm, were randomized to two different surgical procedures: (1) PBA of a long segment of the cephalic vein from the wrist up to the elbow (n=19); and (2) hydrostatic dilatation (HD) of a short venous segment (5 cm) at the level of the anastomosis (n=21). PBA was performed using a standard balloon 4×150 mm. Primary end points were primary patency and reintervention rates. Secondary end points were maturation time and the rate of working AVF. Follow-up included physical and duplex ultrasound (DUS) examinations at 1,4, and 8 weeks, and every 3 months thereafter. RESULTS Risk factors were homogeneously distributed between the two groups. Mean vein diameter was 1.8±0.2 mm for the PBA group and 1.7±0.2 mm for HD. Immediate success rate was 100% for PBA and 67% for HD groups (P=.04). Causes of failure in the HD group included early vein thrombosis in seven patients (33%). Mean fistula maturation time was 32 days in the PBA group and 55 days in the HD group (P=.04). During the mean follow-up of 7 months, three patients underwent drug-eluting balloon angioplasty for failure of AVF to mature due to stenosis (1 in the PBA group and 2 in the HD group). Six-month reintervention rate was significantly lower in the PBA group (5%) compared with the HD group (43%) (P=.02). At 6 months, primary patency rates were 95% in the PBA group and 57% in the HD group (P=.01). Working AVF rate was 100% in the PBA vs 90% in the HD group. CONCLUSIONS PBA of very small cephalic veins during the creation of a distal AVF for hemodialysis is a safe and feasible procedure. This technique assures excellent primary patency, maturation time, and dramatically decreases reintervention rate.
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References
1. National Kidney Foundation. Guidelines and commentaries. Available at: http://www.kidney.org/ professionals/KDOQI/guidelines.cfm. Accessed December 9, 2011. 2. Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK. Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int 2001;60:1443-51. 3. Young E. Vascular access. Current practice and practical aspects of management, ASN renal week 2000. Toronto: American Society of Nephrology; 2000, p. 377-85. 4. Murphy GJ, White SA, Nicholson ML. Vascular access for haemodialy- sis. Br J Surg 2000;87:1300-15. 5. Ascher E, Gade P, Hingorani A, Mazzariol F, Gunduz Y, Fodera M, et al. Changes in the practice of angioaccess surgery: impact of dialysis outcome and quality initiative recommendations. J Vasc Surg 2000; 31(1 Pt 1):84-92. 6. Kherlakian GM, Roedersheimer LR, Arbaugh JJ, Newmark KJ, King LR. Comparison of autogenous fistula versus expanded polytetrafluo- roethylene graft fistula for angioaccess in hemodialysis. Am J Surg 1986;152:238-43. 7. Oliver MJ, Rothwell DM, Fung K, Hux JE, Lok CE. Late creation of vascular access for hemodialysis and increased risk of sepsis. J Am Soc Nephrol 2004;15:1936-42. 8. Allon M, Robbin ML. Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions. Kidney Int 2002;62:1109-24. 9. Huijbregts HJ, Bots ML, Wittens CH, Schrama YC, Moll FL, Blank- estijn PJ, et al. Hemodialysis arteriovenous fistula patency revisited: results of a prospective, multicenter initiative. Clin J Am Soc Nephrol 2008;3:714-9. 10. Grogan J, Castilla M, Lozanski L, Griffin A, Loth F, Bassiouny H. Frequency of critical stenosis in primary arteriovenous fistulae before hemodialysis access: should duplex ultrasound surveillance be the stan- dard of care? J Vasc Surg 2005;41:1000-6. 11. Sidawy AN, Gray R, Besarab A, Henry M, Ascher E, Silva M Jr, et al. Recommended standards for reports dealing with arteriovenous hemo- dialysis accesses. J Vasc Surg 2002;35:603-10. 12. Arteriovenous Fistula First Breakthrough Coalition. Available at: http://www.fistulafirst.org. Accessed December 9, 2011. 13. Allon M, Lockhart ME, Lilly RZ, Gallichio MH, Young CJ, Barker J, et al. Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients. Kidney Int 2001;60: 2013-20. 14. Dixon BS, Novak L, Fangman J. Hemodialysis vascular access survival: Upper arm native arteriovenous fistula. Am J Kidney Dis 2002;39:92- 101. 15. Oliver MJ, McCann RL, Indridason OS, Butterly DW, Schwab SJ. Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas. Kidney Int 2001;60:1532-9. 16. Rocco MV, Bleyer AJ, Burkart JM. Utilization of inpatient and outpa- tient resources for the management of hemodialysis access complica- tions. Am J Kidney Dis 1996;28:250-6. 17. De Marco Garcia LP, Davila-Santini LR, Feng Q, Calderin J, Krishna- sastry KV, Panetta TF. Primary balloon angioplasty plus balloon angio- plasty maturation to upgrade small-caliber veins (ô?°&#x20AC;3 mm) for arterio- venous fistulas. J Vasc Surg 2010;52:13944. 18. Lipari G, Tessitore N, Poli A, Bedogna V, Impedovo A, Lupo A, et al. Outcomes of surgical revision of stenosed and thrombosed forearm arteriovenous fistulae for haemodialysis. Nephrol Dial Transplant 2007; 22:2605-12. 19. Tessitore N, Mansueto G, Bedogna V, Lipari G, Poli A, Gammaro L, et al. A prospective controlled trial on effect of percutaneous transluminal angioplasty on functioning arteriovenous fistulae survival. J Am Soc Nephrol 2003;14:1623-7. 20. TessitoreN,LipariG,PoliA,BedognaV,BaggioE,LoschiavoC,etal. Can blood flow surveillance and pre-emptive repair of subclinical ste- nosis prolong the useful life of arteriovenous fistulae? A randomized controlled study. Nephrol Dial Transplant 2004;19:2325-33. 21. Karakayali F, Basaran O, Ekici Y, Budakoglu I, Aytekin C, Boyvat F, et al. Effect of secondary interventions on patency of vascular access sites for hemodialysis. Eur J Vasc Endovasc Surg 2006;32:701-9.
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perative techniques. Controversy: Small veins at forearm AVF creation O Postoperative Balloon Angioplasty Alain Raynaud Clinique Alleray Labrouste, Paris, France
Creation of a radiocephalic fistula requires a cephalic vein able to enlarge, to mature and to be punctured 3 times a week. The minimal diameter, measured by ultrasonography, required for the cephalic vein depends on the surgeon and varies from 2 to 3 millimetres. Some proposed to dilate such small vein during the access creation. Every surgeon knows that a tiny trauma of the vein during access creation may lead to the occurrence of a stenosis and even that the trauma due to the turbulences at the anastomosis is the responsible for the occurrence of the post anastomotic stenosis. Dilatations cause a major trauma to the venous wall with high risks of rupture and of occurrence of venous stenoses. Knowing that a small but normal vein well fed by an artery will maturate normally but will require few more days or weeks, the per operative dilatation appears deleterious Moreover the measurement of venous diameter by ultrasonography is often underestimated, despite a well tighten tourniquet. When a phlebography is performed the injection of nitroglycerine upstream to the tourniquet sometime provides a supplementary venous dilatation. In such case, the preoperative dilatation will be not only deleterious but also useless. Actually, maturation failures of fistulas are due to an overlooked arterial or venous lesion or to a de novo lesion such as a post anastomotic stenosis; then, to dilate or to surgically redo the anastomosis (for the juxta anastomotic stenosis) will allow the maturation of the fistula. Such angioplasties are performed in better conditions with less risks of acute thrombosis because of the higher flow and with less risks of complication such as rupture the veins being partly matured so less brittle. CONCLUSION The dilatation of a small cephalic vein during an access creation is often useless and/or deleterious therefore it should not be performed
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Operative techniques. Lecture Vascular steal and ischemia after vascular access Pierre Bourquelot
Clinique Jouvenet, Paris, France
Distal ischemia following access creation may be related to steal of blood flow from the arterial system by the arteriovenous access (AVA), in association with artery disease. Most publications refer to “steal syndrome” but the term “hemodialysis access-induced distal ischemia” (HAIDI) would be more appropriate as the physiopathology of ischemia is not restricted to steal. After fistula creation, the flow that is increased in the proximal artery, above the anastomosis, is totally or partially diverted into the low-pressure venous system, instead of flowing down into the main artery or into collaterals to supply the distal extremity. The flow in the distal artery below the anastomosis will simultaneously decrease and may even become retrograde to the fistula, being supplied by collateral arteries. This retrograde flow is observed physiologically in >90% of forearm AVAs and very frequently in upper arm angioaccesses. Finally, when associated with arterial lesions preventing normal compensation by collateral flow, both antegrade and retrograde flow diversion into the fistula (steal) can result in insufficient blood supply to peripheral tissues and lead to clinical manifestations of distal ischemia (1–10% of patients). HAIDI is a serious complication of hemodialysis access related to the steal of arterial flow associated with artery disease, and is increasing as the numbers of patients who are ageing increase. Prevention of distal ischemia is difficult. Because there is less risk of ischemia an AVA must be created as distally as possible, even in elderly patients. Furthermore patients with occlusive disease of distal arteries must definitely be excluded from performing an autologous lower limb AVA. When present, proximal artery stenosis is best treated percutaneously. For upper arm accesses DRIL (distal revascularization-interval ligation) is the gold-standard technique for increasing flow and pressure in the distal arteries, and DRAL (distal radial artery ligation) is the most frequently used procedure for forearm AVAs. When associated with a high-flow AVA, ischemia may be treated effectively with surgical flow reduction techniques, as transposition of the radial artery or PTFE-distalization of the arterial anastomosis for upper arm access, and PRAL (proximal radial artery ligation) for forearm access, while the favorable results of two recently reported series using banding await confirmation. Although it results in access loss, fistula ligation may be necessary in some patients with distal ischemia. Finally, we proposed an algorithm for the surgical treatment of HAIDI. References
Bourquelot P. Hemodialysis access-induced distal ischemia (HAIDI): surgical management. In: Asif A, Agarwal AK et al., eds. Interventional Nephrology, New York, Mc Graw Hill Medical; 2012: p 601-614. Scheltinga MR, van Hoek F, Bruijninckx CM. Time of onset in haemodialysis access-induced distal ischaemia (HAIDI) is related to the access type. Nephrol Dial Transplant 2009;10:3198e204.
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tate of the art & future trends S A surgeon’s perspective Ulf Hedin
Dep Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden In the current tsunami of endovascular advances, questioning the future role for the traditional access surgeon is perhaps justified. Nevertheless, access surgery, despite these technical advancements, appears to remain a corner stone of modern access care. In fact, it is fair to state that the role of the surgeon on this scene should become even more in the centre of the stage. In predicting this development, the future surgical perspective includes a central role in access care organisation, a critical position in decision-making, responsibilities in registry aspects of follow-up and outcome, technical aspects on diagnostic tools and treatment modalities. Starting with organisational matters, accepted state of the art is that the surgeon should be engaged in the creation of a access team that cross professionally in a smooth and effective manner deals with everything from planning, to follow-up, problem solving, and quality control of access patients. Technical aspects include the development of a multi-skilled access surgeon with the capacity to deal with bedside duplex assessment of preoperative evaluation as well as access problems. In addition, and probably of most significant magnitude, the skills should be complemented with endovascular competence with a minimum requirement to achieve intraoperative problem solution capacity to utilize the technical advantage of endovascular adjunct procedures. Given the opportunity, there is no doubt in my mind that the multitude of approaches and considerations that are necessary to take in order to create a well-functioning access service will stand out as a feasible and attractive goal for the access surgeon of the future. Conventional access surgery is not going to die, it’s just being reborn into multifunctionality. References
Biological grafts for hemodialysis access: historical lessons, state-of-the-art and future directions. Dukkipati R, Peck M, Dhamija R, Hentschel DM, Reynolds T, Tammewar G, McAllister T. Semin Dial. 2013 Mar-Apr;26(2):233-9. Back to the future: how biology and technology could change the role of PTFE grafts in vascular access management. Roy-Chaudhury P, El-Khatib M, Campos-Naciff B, Wadehra D, Ramani K, Leesar M, Mistry M, Wang Y, Chan JS, Lee T, Munda R. Semin Dial. 2012 Sep-Oct;25(5):495-504. Hemodialysis access monitoring and surveillance, how and why? Haddad NJ, Winoto J, Shidham G, Agarwal AK. Front Biosci (Elite Ed). 2012 Jun 1;4:2396-401. Considerations in the optimal preparation of patients for dialysis. Saggi SJ, Allon M, Bernardini J, Kalantar-Zadeh K, Shaffer R, Mehrotra R; Dialysis Advisory Group of the American Society of Nephrology. Nat Rev Nephrol. 2012 Apr 10;8(7):381-9. Pharmacotherapy to improve outcomes in vascular access surgery: a review of current treatment strategies. Jackson AJ, Coats P, Kingsmore DB. Nephrol Dial Transplant. 2012 May;27(5):2005-16. Vascular access for dialysis in the United States: progress, hurdles, controversies, and the future. Wish JB. Semin Dial. 2010 NovDec;23(6):614-8. Novel insights into the pathobiology of the vascular access - do they translate into improved care? Diskin CJ. Blood Purif. 2010;29(2):216-29. What’s next after fistula first: is an arteriovenous graft or central venous catheter preferable when an arteriovenous fistula is not possible? James MT, Manns BJ, Hemmelgarn BR, Ravani P; Alberta Kidney Disease Network. Semin Dial. 2009 SepOct;22(5):539-44. Tunneled dialysis catheters: recent trends and future directions. Chan MR, Yevzlin AS. Adv Chronic Kidney Dis. 2009 Sep;16(5):38695. Advances and new frontiers in the pathophysiology of venous neointimal hyperplasia and dialysis access stenosis. Lee T, Roy-Chaudhury P. Adv Chronic Kidney Dis. 2009 Sep;16(5):329-38. Hemodialysis vascular access monitoring: current concepts. Allon M, Robbin ML. Hemodial Int. 2009 Apr;13(2):153-62. Vascular access: the past, present and future. Sands JJ. Blood Purif. 2009;27(1):22-7.
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tate of the art & future trends S An anaesthesiologist’s perspective Nicoletta Fossati
St George’s Hospital, London, United Kingdom Patients undergoing vascular access surgery for hemodialysis tend to have an array of co-morbidities that pose them at greater risk of perioperative complications and mortality. Moreover, surgery itself may challenge an already strained cardiovascular system by imposing an acute burden on the heart through the creation of a direct arteriovenous connection. Finally, general anesthesia can put patients at risk by interfering with a precarious homeostatic balance. The available evidence on vascular access outcomes largely focuses on patency or access complications rather than patient morbidity and mortality. There is even more limited evidence on how different anesthetic techniques may impact on patient outcomes in this setting 1, 2. Anesthetic options for hemodialysis access include local, regional and general anesthesia: all present advantages and drawbacks. Many procedures may be amenable to regional anesthesia; however, surgical and anesthetic skill mix, concomitant use of antiplatelet drugs and anticoagulants, and patient preference all play a role in choosing the most appropriate anesthetic technique. Increasing use of ultrasound guidance for regional anesthesia can improve block success rates and safety. Irrespective of anesthetic choice, close collaboration between surgeon and anesthesiologist is crucial to achieve optimal operating conditions, ensure patient comfort and minimize risks. As for all vascular surgery, maintaining adequate arterial blood pressure and perfusion levels and working towards cardiovascular stability are important intraoperative anesthetic goals. Hemodynamic monitoring would therefore appear pivotal in this group of patients. However, previous failed accesses and central venous cannulations, as well as the very sites of hemodialysis access surgery, may all contribute to making traditional invasive monitoring extremely difficult. Novel, less invasive cardiac output monitoring tools, such as the esophageal Doppler, look very promising in guiding intraoperative fluid management – typically challenging in renal failure patients – and optimizing the response to hemodynamic changes. REFERENCES
1. Solomonson MD, Johnson ME, Ilstrup D: Risk Factors in Patients Having Surgery to Create an Arteriovenous Fistula. Anesth Analg 1994;79:694-700. 2. Malinzak EB, Gan TJ: Regional Anaesthesia for Vascular Access Surgery. Anesth Analg 2009;109:976-80.
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State of the art & future trends An italians perspective Nicola Pirozzi
Dialysis population in Italy in growing, the actual incidence and prevalence reached 160 and 800 ESRD patient pmp respectively. As for other European countries the prevalence of elderly, diabetic and multi co-morbid patient increase every year. Therefore the task of vascular access creation and maintenance is increasingly challenging. Nonetheless the prevalence of patients treated by an autogenous - most of time distal – AV fistula is still relatively high (78%). A trend toward an increase of central vein catheter use in prevalent population is however unfortunately ongoing. The use of graft is quite limited (below 3%). Data on survival clearly shows the benefit of autogenous AVF (fig 1). Due to the scarce use of graft a comparison between AVF and graft can not be performed. The specialist who most often (up to 80%) is involved in vascular access creation and maintenance is a nephrologists (the so called nefrologo interventista). This subspecialty of nephrology differs, by respect of the US’s “interventional nephrology” by the fact that just endovascular procedures are performed by the latter, whereas mainly surgical procedure are performed by the nefrologo interventista. This discipline has been recently included as part of academic post-graduate training in nephrology. The operative procedures on vascular access are now part of the core curriculum of a nephrologists. The personal experience of the author will be shortly described.
Survival on dialysis: AVF vs CVC (data from RDL registry) AVF: arteriovenous fistula; CVC: central vein catheter
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Sapienza Università di Roma, Dipartimento di Medicina Clinica e Molecolare. UO Nefrologia e Dialisi, AO Sant’Andrea, Roma, Italy
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Lecture Money and Politics in America. Lobbying for changes. Vo Nguyen
Memorial Nephrology Associates, Olympia, USA
The 1997 National Kidney Foundation Kidney Dialysis Outcomes Quality Initiative (KDOQI) guideline targeted for 40% prevalent arterio-venous fistula (AVF) in use rate. The scientific basis by which KDOQI experts used to set the national AVF goal is unknown. A number of experts in the United States believe that a majority of American hemodialysis (HD) patients are too sick to have a functional AVF, leading to lower AVF rate in the US compared to the rest of the world. A randomized controlled trial study published in the Journal of the American Medical Association (JAMA 299:2164- 2171, 2008) showed that 60 % of all AVF placed, failed to mature. Based on an AVF maturation risk calculation formula, Dr Lok suggested that patients with very high risk of maturation failure should be considered for an alternative permanent access, e.g., graft (J Am Soc Nephrol 17: 3204–3212, 2006). The experts’ opinion may have led to excessive use of AV grafts. However, AV grafts frequently fail with recurrent stenosis and thrombosis and require more interventions as compared to AV fistulae (AVF) to remain functional. KDOQI recommended the routine surveillance/monitoring and pre-emptive angioplasty (PTA) of AV graft despite the absence of irrefutable clinical evidence of its benefits. A recent prospective, multicenter, randomized, controlled trial comparing stent graft and balloon angioplasty for failing AV grafts (New England Journal of Medicine 362: 494;2010) showed that six months after stent-graft placement, primary AVG patency was achieved only in 51% of patients compared with 23% in balloon-PTA groups. High rate of complications and high frequency of interventions are costly. The National Institute of Diabetes and Digestive and Kidney Diseases data base showed that annual cost of dialyzing a patient with an AV graft exceeded the cost for AVF patients by 19 058 US dollars in 2003. This financial manna may have led to an explosive growth in for-profit vascular access centers in the US and may have incidentally created a financial incentive to place and to maintain substandard vascular access. In mid 1990s, the Olympia (/Washington) dialysis program stopped using AV grafts and stopped monitoring and pre-emptive PTA of failing AV grafts. All AV graft were converted into secondary AVF. Within 4 years, over 90% of patients were dialyzed with AVF. In 2002, Northwest Renal Network (NWRN) 16 teamed up with the Olympia program to offer educational programs for network providers in facilities using less than 40% AVF. Within a year, AVF rates in these units went up from 31.4% to 40% (8.6% increase p< 0.001, chi square, J. Vascular Access 8: 3-11, 2007). Partly based on this regional success, the federal health insurance program, Medicare launched a national Fistula First Initiative in 2003. The vascular access reform has led to significant improvement in vascular access outcomes within the Northwest Renal Network, 68.2% of AVF, and nationally: 60.3% in December 2011. CONCLUSION Poor vascular access outcome in the US may be partly related to inappropriate KDOQI guidelines and unhealthy financial incentives promoting the use of substandard access. National and regional reforms using proven successful strategies and educational tools to change providers’ practice patterns have led to significant improvement despite high patients’ co-morbid factors.
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
I maging and navigation tools: where are we? How accurate is intra operative overlay imaging? Hicham Kobeiter, V. Tacher, J. Mayer, J-F. Deux, K. You, P. Desgranges, J-P. Becquemin, A. Rahmouni
CHU Henri Mondor, Créteil, France
Image guidance is a major tool in interventional radiology and endovascular therapy. Since the last decade, there has been significant improvement and new developments in image guidance. Two-dimensional (2D) angiography has developed into three-dimensional (3D) rotational angiography, and more recently, C-arm cone-beam computed tomography (CBCT) has enabled 3D volumetric imaging. These recent image acquisition capabilities have been developed to assist clinicians in performing procedures that could not be easily done with traditional fluoroscopy or digital subtraction angiography (DSA) alone. CBCT can be used to guide catheter placement for intra-arterial therapy, stent positioning in arterial or venous disease, needle placement and coil placement. In addition to image acquisition development, significant achievements have been seen in intra-procedural guidance software advancement that enables the use of multimodality image fusion (IF) to guide procedures. Image fusion and co-registration bring different imaging modalities together for targeting a specific location. The image fusion guidance has been reported as accurate and useful for a multiple applications in interventional radiology and endovascular procedures. A review of the few number of papers in the literature will be done showing some discrepancies depending on the method of the overlay and multiple other causes. References
1. Hakime A, Deschamps F, De Carvalho EG, Teriitehau C, Auperin A, De Baere T. Clinical evaluation of spatial accuracy of a fusion imaging technique combining previously acquired computed tomography and real-time ultrasound for imaging of liver metastases. Cardiovascular and interventional radiology. 2011 Apr;34(2):338-44. 2. Racadio JM, Babic D, Homan R, Rampton JW, Patel MN, Racadio JM, et al. Live 3D guidance in the interventional radiology suite. AJR American journal of roentgenology. 2007 Dec;189(6):W357-64. 3. Kobeiter H, Nahum J, Becquemin JP. Zero-contrast thoracic endovascular aortic repair using image fusion. Circulation 2011. 124(11):e280-2. 4. Type II endoleak embolization after endovascular abdominal aortic aneurysm repair with use of real-time three-dimensional fluoroscopic needle guidance.van Bindsbergen L, Braak SJ, van Strijen MJ, de Vries JP.J Vasc Interv Radiol. 2010 Sep;21(9):1443-7. 5. Intraoperative C-arm cone-beam computed tomography in fenestrated/branched aortic endografting.Dijkstra ML, Eagleton MJ, Greenberg RK, Mastracci T, Hernandez A.J Vasc Surg. 2011 Mar;53(3):583-90. 6. Multimodality image fusion-guided procedures: technique, accuracy, and applications. Abi-Jaoudeh N, Kruecker J, Kadoury S, Kobeiter H, Venkatesan AM, Levy E, Wood BJ. Cardiovasc Intervent Radiol. 2012 Oct;35(5):986-98. 7. Image fusion for hybrid repair of dislocated superior mesenteric branch of a branched endovascular aortic graft. Alomran F, Desgranges P, Majewski M, You K, Kobeiter H. J Vasc Surg. 2013 Feb 1.S0741-5214(12)02660-2. 8. Prediction of deformations during endovascular aortic aneurysm repair using finite element simulation. Kaladji A, Dumenil A, Castro M, Cardon A, Becquemin JP, Bou-Saïd B, Lucas A, Haigron P. Comput Med Imaging Graph. 2013 Mar;37(2):142-9 9. Image Guidance for Endovascular Repair of Complex Aortic Aneurysms: Comparison of Two-dimensional and Three-dimensional Angiography and Image Fusion. Tacher V, Lin M, Desgranges P, Deux JF, Grünhagen T, Becquemin JP, Luciani A, Rahmouni A, Kobeiter H. J Vasc Interv Radiol. 2013 Nov;24(11):1698-706
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I maging and navigation tools: where are we? Can we select by MRI the best treatment for a given patient? Rachel Clough, Peter Taylor
Guyâ&#x20AC;&#x2122;s and St Thomasâ&#x20AC;&#x2122; NHS Foundation Trust and Kingâ&#x20AC;&#x2122;s College London, London, United Kingdom Type B aortic dissection has a wide range of clinical manifestations, which are related to the pattern and extent of the dissection as well as branch vessel involvement. Clinical decision making is complex and is often based upon physician experience and subjective clinical judgment. The long-term outcome of patients with initially successful medical treatment is poor and not well understood. The majority of late deaths are caused by aortic-related complications, aneurysm expansion and rupture. Among patients who are at increased risk for developing complications, early prophylactic intervention might improve the overall long-term outcome. Aortic dilation and aneurysm formation may be associated with abnormal aortic wall biomechanics, blood flow patterns and wall shear stress and assessment of these parameters may be more important than the morphological measurements currently used. Functional imaging methods such as magnetic resonance (MR) are evolving and by combining anatomical and functional information in a single examination are able to provide a more comprehensive evaluation of aortic disease. MR imaging provides superior soft tissue contrast with the ability to depict and quantify functional parameters in three-dimensional high spatial resolution images with no ionising radiation. In this presentation MR imaging techniques will be presented which are able to provide structural, haemodynamic and biomechanical information regarding the aorta. This type of methodology will allow us to refine our understanding this disease and its unique variety of clinical manifestations and anatomic expressions. A patient-specific approach designed to intervene only in patients that are at high risk of developing complications should improve the long-term outcome of these patients.
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I maging and navigation tools: where are we? Puncture ultra sound guidance: to decrease access site complication Peter Schneider
Kaiser Foundation Hospital, Honolulu, USA
INDICATIONS Access related complications continue to be the most common adverse events associated with endovascular procedures, usually due to suboptimal initial placement of the access. Ultrasound permits a guided puncture that is accurate and anatomically based. We are currently using ultrasound guided micropuncture access for all endovascular arterial access and have decreased access related complications by more than 50% using this approach. We began with ultrasound for brachial artery punctures and it was so successful that we now use this approach for all access, including routine femoral access. This approach also permits more frequent use of closure devices since the puncture site is likely to be ideally placed on the common femoral artery. Optimal puncture site placement has been associated with a significantly lower overall risk of complications than when the puncture site is suboptimal (4% vs 18%) and also a lower risk of blood transfusion (3% vs 11%).1 Access guided with ultrasound was shown in a randomized trial to require fewer attempts and to result in fewer complications (1.4% vs 3.4%).2 TECHNIQUE In the common femoral artery, the optimal puncture site lies between the superior aspect of the femoral head and 1-2 cm proximal to the femoral bifurcation. Identify the common femoral artery and vein using manual compression with the probe. The artery is evaluated from cephalad to caudad to locate the femoral bifurcation and the inguinal ligament if possible. Disease within the artery is also interrogated. Typically, the common femoral vein and artery lie side-by-side. The ultrasound probe is placed perpendicular to the artery over the site along the artery that the operator has selected as the best puncture site. The micropuncture needle (21g) is introduced into the skin approximately 1-2 cm caudad to the location of the probe. The needle is advanced toward the artery at approximately 60 degrees. The duplex probe and needle tip are adjusted so that the needle is placed in the artery under direct ultrasound visualization. The needle tip is observed real-time as it enters the artery. CONCLUSION Reducing access related complications is essential to improving overall results. Use of ultrasound guidance to achieve access has reduced complications in our practice. References
1. Pitla et al. CCI. 2011;78:294 2. Seto, et al. JACC Int. 2010;3:751
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arotid latest news C Risk stratification methods for asymptomatic carotid plaques Stavros Kakkos1, Andrew Nicolaides2, Ioannis Tsolakis1 1. University of Patras, Patras, Greece 2. Imperial College London, London, United Kingdom
The incidence of stroke in patients with asymptomatic carotid artery stenosis > 60% 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 in carefully selected patients 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. Effective risk stratification has been possible in recent years, allowing the vascular surgeon to better select candidates for carotid intervention. Factors associated with a high risk of stroke include clinical characteristics (hypertension, age > 70, male gender, history of contralateral neurological symptoms and hypercholesterolaemia), stenosis characteristics (increasing severity of carotid stenosis, progression of carotid stenosis over time and contralateral carotid artery occlusion) and plaque characteristics (plaque ulceration and unstable carotid plaque morphology, based on ultrasound or MRI imaging). However, the decision to intervene should be based not only on risk stratification alone, but also on the anatomical characters of the stenosis, patient fitness for surgery and expected survival, the perioperative stroke and death rate of the surgeon and the willingness to take the small short-term risk of surgery for a possible greater long-term benefit. The ACSRS study has reported that not only the severity of stenosis, but also neurological history of the contralateral carotid and ultrasonic plaque features are independent powerful predictors of plaque instability and future stroke. These plaque features include the presence of juxtaluminal black areas (JBA) and discrete white areas (DWA). High risk groups with an annual risk of stroke of 4% to 10% and a low risk group (<1% annual risk) were identified. The latter group can be spared from carotid intervention and efforts can be concentrated to aggressive medical management and patient follow-up.
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
arotid latest news C TIA should be treated urgently, what about strokes? Hassan Hosseini
CHU Henri Mondor, CrĂŠteil, France
Patients with substantial (eg, 60â&#x20AC;&#x201C;99%) carotid artery narrowing are at increased risk of suffering a disabling or fatal ischaemic stroke in the carotid territory of the brain. The hazard is greater if they are already symptomatic (ie, have recently suffered some relevant neurological symptom, such as stroke or transient cerebral or retinal ischaemia). Carotid endarterectomy (CEA) can remove arterial narrowing, but the surgical procedure itself involves some immediate risk of perioperative death or stroke.There have been concerns that performing carotid endarterectomy (CEA) in the hyperacute period after onset of a transient ischaemic attack (TIA) or stroke may be associated with a significant increase in the procedural risk that could offset any long-term benefit to the patient. We will discuss safety, efficacy and limitations of urgent CEA for symptomatic patients with recent TIA or minor stroke.
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arotid latest news C CEA versus CAS: the latest RCT evidence Leo Bonati
Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland Randomised controlled trials consistently demonstrated a higher risk of peri-procedural non-disabling stroke with stenting than endarterectomy for treatment of symptomatic carotid stenosis. However, several factors differentially modify the peri-procedural risks of the two treatments: an excess stroke risk with stenting over endarterectomy has most consistently been demonstrated for elderly patients, and more recently patients with cerebral white matter disease, and possibly also those treated early after the initial cerebrovascular event. In addition, operator and procedure-related risk factors have been identified for stenting: peri-procedural stroke risk is higher for stents with open-cell than closed-cell design and decreases with higher current volume of procedures performed by the operator. The clinical relevance of silent peri-procedural complications is increasingly recognised: elevation of heart enzymes without other symptoms or signs of myocardial infarction, which is more common after endarterectomy, increases long-term mortality. Silent brain infarction on the other hand, which is more common in stenting, appears to increase the risk of recurrent clinically manifest cerebrovascular events in the near term. Long-term follow-up to 10 years after randomisation in the International Carotid Stenting Study (ICSS) reveals equal efficacy of stenting and endarterectomy in preventing fatal or disabling stroke, the trialâ&#x20AC;&#x2122;s primary outcome measure, and shows no difference in patientsâ&#x20AC;&#x2122; functional ability between the two procedures. There is also no difference in long-term risk of severe restenosis or occlusion of the carotid artery after completed treatment between the two arms. The choice between the two procedures in treating patients with symptomatic carotid stenosis is therefore best guided by factors influencing peri-procedural risks. On-going randomised trials investigate whether invasive revascularisation by stenting or endarterectomy offers additional benefit over best medical therapy in patients with asymptomatic or low-to-intermediate risk symptomatic carotid stenosis, and compare stenting versus endarterectomy in those patients with asymptomatic stenosis in whom revascularisation is deemed necessary.
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
arotid latest news C CEA: what is the current best patch if any? Alan Dardik
Yale University School of Medicine, New Haven, USA Patch angioplasty is commonly performed after carotid endarterectomy. Randomized prospective trials and meta-analyses have documented improved rates of perioperative and long-term stroke prevention as well as reduced rates of restenosis for patches compared to primary closure of the arteriotomy. Although use of vein patches is considered to be the â&#x20AC;&#x153;gold standardâ&#x20AC;? for patch closure, newer generations of synthetic and biological materials rival outcomes associated with vein patches. Bovine and porcine pericardium is widely used in surgery and is commonly used for a patch after arteriotomy during cardiovascular surgery. Pericardial patches have several advantages compared to prosthetic patches, including superior biocompatability, easy handling, less suture line bleeding and possibly reduced rates of infection. These advantages of pericardium have led to its common use during carotid endarterectomy. However, despite extensive clinical use and long term follow up, the mechanism of healing after patch implantation is still not well defined. We used a rat aortic patch model to assess pericardial patch early healing and examined Ephrin-B2, a marker of arterial identity, expression within the post-implantation patch. We also determined whether endothelial progenitor cells (EPC) are associated with early patch healing in the arterial environment. Both CD68-positive and Ephrin-B2 and CD34 dual-positive cells infiltrate the pericardial patch early after implantation, and patches have a luminal monolayer of cells at day 7. Arteriotomy closure via pericardial patch angioplasty shows patch adaptation to the arterial environment that may involve a foreign body response as well as localization of EPC. Arterial remodeling of pericardial patches support endothelialization and may represent a paradigm of healing of scaffolds used for tissue engineering.
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arotid latest news C CEA. Shunting and contra lateral carotid occlusion: never, always or in selected cases? Jack Cronenwett Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
PURPOSE This study investigated the association between surgeon practice pattern in shunt placement and 30-day stroke/death in patients undergoing carotid endarterectomy (CEA) with contralateral carotid occlusion (CCO). METHODS Among 6,379 primary isolated CEAs performed in the Vascular Study Group of New England (VSGNE) between 2002 and 2009, we identified 353 patients who underwent CEA in the setting of a contralateral carotid occlusion. We examined 30-day risk-adjusted stroke or death rate across the reason for shunt placement (no shunt, shunt placed routinely, and a shunt placed for an indication) as well as 2 distinct surgeon practice patterns in shunt placement (surgeons who selectively utilize a shunt (0-95% of their CEAs), or routinely utilize a shunt (>95% of their CEAs). RESULTS Of 353 patients with contralateral carotid occlusion, 33% underwent CEA without a shunt, 49% underwent CEA using a shunt placed routinely, and 18% had a shunt placed for a specific indication. There were no significant differences in rates of 30-day stroke or death across categories of reason for shunt use (3.4% no shunt, 4.0% routine shunt, 4.8% shunt for indication, p=0.891). However, across surgeon practice pattern in shunt use, the risk of 30-day stroke or death was higher for surgeons who selectively placed shunts and lower for surgeons who routinely placed shunts (5.6% selective, 1.5% routine, p=0.05). Stroke/death rates were lowest when individual surgeons’ intraoperative decisions reflected their usual pattern of practice: 1.5% stroke/death rate when “routine” surgeons placed a shunt, 3.4% when “selective” surgeons did not place a shunt, and 7.6% stroke/death rate for “selective” surgeons who placed a shunt (P = .05 for trend). CONCLUSION Shunt use for CCO during CEA is associated with fewer complications, but only if the surgeon uses a shunt as part of his or her routine practice during all CEAs. References
Impact of practice patterns in shunt use during carotid endarterectomy with contralateral carotid occlusion. Goodney PP, Wallaert JB, Scali ST, Stone DH, Patel V, Shaw P, Nolan BW, Cronenwett JL; Vascular Study Group of New England. J Vasc Surg. 2012 Jan;55(1):61-71.
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
arotid latest news C Video. CAS: technique makes all Ali Amin
Reading Health System, Reading, USA & MD, FACS, FACC, RVT Director of Endovascular Interventions Reading Hospital and Medical Center Stroke remains the leading cause of disability in the industrialized world, and carotid artery disease is a major cause of stroke. In the US alone, the incidence of stroke is approximately 600,000 per year, of which 60% are due to carotid artery disease. The treatment of stroke resulting from atherosclerotic stenotic lesions can be categorized as medical, surgical or endovascular. The first two types of treatment have been available traditionally. Carotid endarterectomy is a well established treatment of extracranial carotid atherosclerotic disease in symptomatic and asymptomatic lesions. Two large trials and other small ones that were conducted in the 1980s and 1990s involved a total of approximately 6000 patients with cerebral or retinal symptoms and corresponding atherosclerotic coronary artery disease. The European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) stopped recruiting in patients with severe stenosis (70%-99%) after fewer than 700 patients had been randomized in each trial. Positive results favoring surgery were evident for patients with 70%-90% stenosis measured angiographically. However, at that time, the benefit had not been detected for symptomatic patients with lesser degree of stenosis (moderate stenosis 50%-69%, mild stenosis <50%). In these large trials, patients with nonatherosclerotic disease, organ failure, underlying potentially fatal cancers, embolic cardiac lesions, and remote (> 6 months) ischemic symptoms were excluded. Extrapolation of the results of NASCET and ECST into clinical practice requires the acknowledgment of two facts. First, the reported surgical complication rate of stroke and death was the result of the care taken by the investigators to select surgeons with proven expertise. In NASCET, surgeons were required to provide evidence that they had achieved a perioperative complication rate of < 6%. The frequency of asymptomatic atherosclerotic carotid artery stenosis increases with age. It has been estimated that 2 million individuals in the United States older than 50 years have >50% stenosis of the carotid artery on one or both sides. The Asymptomatic Carotid Atherosclerosis Study (ACAS) randomized half the patients to the medical therapy arm and the other half to the carotid endarterectomy arm. Individuals with >60% stenosis had a benefit at 5 years favoring carotid endarterectomy. Ipsilateral stroke occurred in 11% of the patients in the medical arm compared with 5.1% in the surgical group. The benefit of carotid endarterectomy holds true only if the risk of death and stroke from the procedure is <6% for symptomatic patients and <3% for asymptomatic patients. Carotid artery stenting (CAS) has emerged as a less invasive technique to treat stenosis as a less invasive technique to treat stenosis of the carotid bifurcation. However, stenting atherosclerotic lesions of the carotid artery may cause far more devastating effects than those found in other vascular territories. A small embolic shower to the leg or kidney may be tolerated, but similar embolization to the brain may have severe consequences. The very stroke to be prevented by surgery or CAS may be precipitated by these procedures. The advent of percutaneous treatment of significant carotid artery stenosis dates back to the early 1980s with several groups reporting their experience in a handful of cases with reasonable success for both atheromatous and nonatheromatous lesions. In 1987, Theron and colleagues reported the first large series of carotid angioplasty including 6 patients with atherosclerotic lesions and 5 postsurgical restenostic lesions. In 1990, the same investigators treated 13 patients with significant carotid stenosis with distal protection devices. The Carotid and Vertebral Artery Transluminal Angioplasty Study was a prospective randomized study that compared carotid angioplasty with carotid endarterectomy. Stents were not used routinely. Only 26% of patients received a stent. The 30-day risk of storke and death was 10% in both groups. The surgical group has significantly more cranial nerve palsies, 8.7% versus 0%, and had more hematomas requiring treatment, 6.7% versus 1.2%. An international registry was formed that compiled the experiences of the centers involved in carotid stenting. Data for a total of 5200 carotid stenting procedures were presented. Most of these series included patients that would have been excluded from randomized surgery versus medical treatment trials because of additional risk factors. The technical success rate was >98%. The 30-day mor-
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tality was 0.84% and all stroke rates (major and minor) were 3.94%. In addition, the follow up data from the international registry showed a stroke rate of 3% during a period of 24 to 36 months and a restenosis rate of approximately 4%. These numbers seem to be very competitive with those of carotid endarterectomy. In NASCET, the stroke rate in the surgical arm over 3 years was 14 % and that of ACAS was 10% over 5 years. The procedural role of CAS is to eliminate the stenosis and prevention of embolism and stroke. The enthusiasm and interest in CAS has grown tremendously in recent years. This has paralleled the development of better stent and catheter technology dedicated to carotid arteries. Development of superior carotid access systems and embolic protection devices has lead to successful performance of safe and less traumatic carotid procedures. Case selection and meticulous technique is the corner stone of carotid artery stenting. Four vessel cerebral angiography is essential to plan for CAS. The information that should be obtained is the best angiographic view for the intervention, the significance of any arch disease, angulations, and extend of cerebral circulation. Antiplatelet therapy with plavix is essential and mandatory prior to CAS. Patient must comply with taking plavix after CAS. All blood pressure medications are usually withheld except possibly the beta-blocker. Venous access is very important in facilitating infusion of medication and fluid as need in anticipation of hypotension and bradycardia. A 4 Fr. Sheath allows excellent venous access with possible placement of pace wires to treat bradycardia. Avoid patients with recent stroke, < 4 weeks, is important. Hostile aortic arch, access limitation can be avoided by using radial/brachial access or just performing carotid endarterectomy. Right radial artery or brachial artery can be successfully used to access the right common carotid artery in case of bovine or type III arch. Insertion of a 6 Fr. Sheath minimizes trauma to the radial or brachial artery. Adequate level of anticoagulation is important. Heparin (100U/kg) is administered intra-arterially or intravenously to maintain an adequate anticoagulation level. This can be done with using heparin to keep ACT between 200-250 or utilizing Angiomax. Arch angiography should be routinely performed to evaluate for calcification, ostial lesion involving left common carotid and/or brachiocephalic trunk. Meticulous selective catheterization of the common, external and placement of the sheath at the distal common carotid artery is important to avoid embolization to the brain. This can be performed by using a 4 Fr. Vertebral tip or a Headhunter catheter. Exchange length (280 or 300 cm) stiff hydrophilic wire can be used to access the common carotid artery. The tip of the wire should be placed into the external carotid artery. A 90 cm sheath is placed just proximal to the carotid bifurcation. Cook shuttle sheath allows easy access into the common carotid artery given its shape of telescopic catheter and sheath combination. Selective angiography with AP and lateral position should show the best angle to perform carotid intervention. Magnification of the internal carotid artery allows passage of cerebral protection device through the highly stenotic carotid bifurcation and the lesion. Cerebral protection device, especially using a filter system, should be done few centimeters above where the stent is placed, in the straight portion of the ICA. Appropriate selection of the size of the protection device would decrease risk of cerebral embolization. Pre-dilatation with a low profile balloon (4X4) allows easier placement of the stent but more importantly, measuring the size (length and diameter) of the appropriate self-expandable stent. Length of the self-expandable stent should allow placement of the proximal portion into the common carotid artery to allow passage of retrieval device for removal of the filter system. Post stent angioplasty should result in a “good” but not “perfect” angiographic result. Aggressive post-dilatation can result in rupture or dissection. Angiography should be performed prior to the removal of the protection device to document adequate flow into the ICA and cerebral circulation. If any flow abnormality is noted, then a suction catheter/guide should be inserted to aspirated possible emboli/thrombotic material that are occluding the filter system. Finally, completion angiography is done to document intra-cranial circulation and compare it to pre-intervention angiography. Spasm should be treated with vasodilator and patience. Only time will result in the resolution of the carotid spasm. Heparin should not be reversed with protamine, and either a closure device
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
should be used or allow ACT to drift down below 200 before removing the sheath. If sheath in left in femoral artery for ACT to drift lower, then a short sheath should be inserted and the long one removed. Post procedure, close monitoring of blood pressure and neurologic status is even more important to avoid any kind of post procedure complications. It is very important to avoid either systemic hypo- or hypertension. Placement of an arterial line for post procedure blood pressure monitoring is not usually necessary. Early ambulation allows adjustment of the autoregulatory system and evaluation of possible hypotension. At times, patient may need adjustment of their blood pressure meds. In summary, carotid artery stenting plays an important role in the management of patients with carotid artery stenosis, especially those who are at high risk for carotid endarterectomy. Use of meticulous techniques and attention to details, allows for a successful outcome with minimal morbidity and mortality. The flow reversal system offers potential advantages in treating acute stroke by allowing flow reversal to assist with debris removal from the intracranial circulation. This system also provides advantage in patients with unstable plaque or thrombus burden, to remove potential debris or clot during CAS.
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AA A CAS. My favorite stent is...? Marc Bosiers
AZ Sint-Blasius, Dendermonde, Belgium For the treatment of carotid artery disease, my favorite stent is not on the market yet. In an endovascular treatment, the plaque is being contained by a stent and not removed as in carotid endarterectomy (CEA). At the end of the procedure, after removal of the embolic protection device (EPD), the stent is the only protector. The closed cell structure of a stent offers more plaque containment after the carotid artery stenting (CAS) procedure. For this reason, the Wallstent (Boston Scientific) and the Xact stent (Abbott Vascular) are good candidates for the treatment of (mainly symptomatic) carotid lesions because of their high scaffolding characteristics. The choice of the stent is also determined by the arterial anatomy and the morphology of the lesion. Because of this reason, the conformability, vessel wall adaptability and radial force are also important factors for the choice of an ideal carotid stent. New developments in carotid stent technology have to combine on one hand the high scaffolding characteristics with on the other hand an ideal conformability, vessel wall adaptability and radial force. The need for flexible, maximally scaffolding stents, which have the potential for reducing the late emboli, is obligatory to revive the CAS procedure again. Unfortunately, at this moment, an ideal conformable, flexible stent with specific intrinsic anti-embolic properties does not exist yet.
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
AA A Can preoperative myocardial perfusion SPECT test predict late CV death after AAA repair? Kimihiro Komori Division of Vascular Surgery, Department of Surgery, Nagoya University Graduates School of medicine, Nagoya, Japan
BACKGROUND After abdominal aortic aneurysm (AAA) repair, relatively low survival during long-term followup remains an unresolved issue. Stress myocardial perfusion single-photon emission computed tomography (SPECT) is an established tool not only to diagnose coronary artery disease (CAD) but also to predict outcome. In particular, the summed stress score (SSS), representing the extent of myocardial perfusion abnormality, can well predict future morbidity and mortality. However, little information is available about the prognostic value of myocardial SPECT findings after AAA repair. METHODS AND RESULTS This study followed 285 patients, all undergoing preoperative pharmacologic stress myocardial perfusion SPECT to determine summed stress score (SSS), then elective AAA repair by open AAA repair or endovascular aneurysm repair. The endpoint of the study was cardiac death. The median follow-up duration was 925 days (range, 541–1,095 days). Twenty four (8%) died during follow-up. We stratified the severity of CAD according to the previous literature: normal, SSS <4; mildly abnormal, SSS 4–8; moderately abnormal, SSS 9–13; and severely abnormal, SSS ≥14. Kaplan-Meier analysis showed that patients with SSS ≥9 had a significantly poorer prognosis than those with SSS <9 (76% vs. 93%, P=0.003). Multivariate Cox proportional hazards analysis indicated that SSS ≥9, diabetes, and chronic kidney disease ≥stage 3 could significantly and independently predict long-term cardiovascular mortality in patients after AAA repair, respectively. CONCLUSIONS Preoperative pharmacologic stress myocardial perfusion SPECT is a useful method to predict long-term cardiovascular mortality for patients undergoing elective AAA repair.
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AA A Can stent graft design influence cardiac outcome? Christos D. Liapis, Nikolaos P. Kadoglou, Konstantinos G. Moulakakis Attikon University Hospital, Chaidari, Greece
Although endovascular techniques for the repair of aortic pathologies have emerged as an effective alternative treatment modality to conventional open repair, limited data exists concerning the mechanical changes induced by endograft implantation. It can be assumed that the alterations of aortic mechanical properties can have a direct impact on heart output and may represent an increased risk factor for patients with already impaired cardiac compensatory mechanisms. Arterial stiffness is an independent marker of all-cause mortality and cardiovascular morbidity and mortality. Pulse wave velocity (PWV) is a valid, clinically feasible, and reproducible measure of arterial stiffening. In a recently reported prospective study we assessed changes in PWV in patients undergoing EVAR. Patients with AAA appeared to have significantly elevated PWV levels compared to controls, while stent-graft implantation was associated with statistically significant PWV increase. In a following prospective study, including 118 patients with AAA undergoing elective EVAR, we evaluated the effects of different types of endografts on PWV. The study revealed that the endograft type was an independent predictor of PWV change in the AAA group (Woven more than PTFE). Preliminary data of an ongoing trial in our Department suggests that stent-graft implantation in thoracic aorta leads to PWV increase. The haemodynamic effects of different endografts are under investigation. The influence that different aortic repair modalities exert on central hemodynamics depends widely on the site of intervention. It can be assumed that the hemodynamic impact exerted by a vascular prosthesis in the descending aorta may be more severe than implanting the endograft in the abdominal aorta. Increased arterial stiffness observed after EVAR and TEVAR represents a concern. The long-term impact of these mechanical changes on cardiovascular outcomes and the potential differential effects of different endografts on central haemodynamics require further investigation. References
1. Kadoglou N, Moulakakis K, Papadakis I, et al. Changes in Aortic Pulse Wave Velocity of Patients Undergoing Endovascular Repair of Abdominal Aortic Aneurysms. J Endovasc Ther. 2012;19:661-6. 2. Ioannou CV, Stergiopulos N, Katsamouris AN, et al. Hemodynamics induced after acute reduction of proximal thoracic aorta compliance. Eur J Vasc Endovasc Surg. 2003;26:195-204. 3. Tzilalis VD, Kamvysis D, Panagou P, et al. Increased pulse wave velocity and arterial hypertension in young patients with thoracic aortic endografts. Ann Vasc Surg. 2012;26:462-7. 4. Lantelme P, Dzudie A, Milon H, et al. Effect of abdominal aortic grafts on aortic stiffness and central hemodynamics. J Hypertens. 2009;27:1268-76. 5. Ioannou CV, Morel DR, Katsamouris AN, et al. Left ventricular hypertrophy induced by reduced aortic compliance. J Vasc Res. 2009;46:417-25. 6. Swillens A, Lanoye L, De Backer J, et al. Effect of an abdominal aortic aneurysm on wave reflection in the aorta. IEEE Trans Biomed Eng. 2008;55:1602-11.
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AA. Controversy: Will current stent grafts offer better results than A those used in RCT? Yes, and we have proofs of that Marc RHM van Sambeek, Rutger Stokmans, Pieter Broos, Joep AW Teijink, Philippe W Cuypers
Catharina Hospital Eindhoven, The Netherlands
INTRODUCTION Endovascular AAA repair (EVAR) is continuously evolving. Next-generation devices are intended to diminish complication and re-intervention rate, while broadening the applicability of EVAR. Besides randomized controlled trials (RCT) are registries essential tools to closely monitor the performance of current devices in a real-world setting. Benchmarking with historic registries and RCT’s might be helpful to put early results of contemporary registries in perspective. METHODS Original data of 7,321 EUROSTAR cases was merged with patient level data of 1,263 ENGAGE cases (March 2009 to April 2011) Groups were compared at baseline and on early outcome variables. We compared these results with the published data of EVAR I and DREAM Trial. RESULTS Perioperative conversion to open surgery occurred less often in ENGAGE (0.23% vs. 0.74%, p=0.04), In EVAR I trial primary conversion 1.9%, and perioperative mortality rates declined significantly in ENGAGE (2.27% vs. 1.27%, p=0.02) In the DREAM Trial perioperative mortality was 1.2%, in EVAR I 1.6%.. Oneyear all cause survival curves did not differ between EUROSTAR and ENGAGE, respectively 92.2±0.3% versus 92.5±0.7%, but AAA-related mortality within 1-year decreased from 2.9±0.2% in EUROSTAR to 1.53±0.3% in ENGAGE, p<0.01. Compared to EVAR I and Dream trial these numbers are not significant different. The occurrence of secondary interventions within the first year also declined in ENGAGE, 1-year post-operatively 8.27±0.4% of patients in EUROSTAR had undergone one or more secondary interventions, whereas this was only 5.86±0.7% in ENGAGE, p=0.02. Occurrence of secondary intervention in EVAR I and DREAM trial within 1 year are more that 10% CONCLUSION These results indicate that EVAR is getting better, possibly due to better insight into AAA pathophysiology and because new generation endografts seem to perform better. However, long-term follow-up is needed to confirm durability of these results. References
1. Hobo R, Buth J; EUROSTAR collaborators. Secondary interventions endografts. A EUROSTAR report. J Vasc Surg. 2006;43:896902. 2. Prinsen M, verhoeven ELG, Buth J, Cuypers PWM, van Sambeek MRHM, Balm R,Buskens E, Grobbee DE, Blankensteijn JD. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysm New Engl J Med 2004;351:1607-18. 3. EVAR Trial Participants. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial I); 30-day mortality results: randomised controlled trial. Lancet 2004;364:843-48. 4. DREAM Trial participants. Two-year outcome after conventional or endovascular Repair of abdominal aortic aneurysms. New Engl J Med 2005;362:2398-2405. 5. EVAR Trial participants. Endovascular repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 2005;365:2179-86. 6. Stokmans RA, Teijink JA, Forbes TL, Böckler D, Peeters PJ, Riambau V, Hayes PD, van Sambeek MR. Early results from the ENGAGE registry: real-world performance of the Endurant Stent Graft for endovascular AAA repair in 1262 patients. Eur J Vasc Endovasc Surg. 2012;44:369-75.
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AA. Controversy: Will current stent grafts offer better results than A those used in RCT? No, RCT conclusions remain valid Jan Blankensteijn VU Medical Center, Amsterdam, The Netherlands
The four randomized trial on endovascular aneurysm repair (EVAR1, DREAM, ACE, and OVER) have offered a wealth of evidence based data that can be used on a daily basis to inform our patients and help chose the best treatment option for their AAA. There is no question, however, these trials have lost some of their actuality. One important caveat when applying the data to our current practice is the AAA-patients we are faced with today being different from those we were treating when the trials were including patients, in terms of smoking habits, statins, antithrombotic medications, and along with these their comorbidity. While this questions the generalizability of the randomized patients already, there is another factor to be considered. The trials included patients with infrarenal AAA suitable for both open and endovascular repair - in that specific day and age. Consequently, with the availability of newer devices with broader inclusion criteria, the generalizability of the randomized trials further deteriorates over time. However, the question of this debate, in clear language, is whether new device technologies have made the randomized trial outcome-data obsolete. In this respect, we need to assess the main outcome criteria of the trials: short- and long-term overall survival. Will the new stentgrafts really have an impact on the operative mortality after EVAR? Short-term survival is probably driven predominantly by the shift of the operative risk-status of patients included (more advanced disease) and consequently the operative mortality is likely to increase for both open and endovascular repair (remember the EVAR-2 trial data). The trials reported a short-term survival benefit of 3%, which was then lost in the subsequent 1-3 years. This lag-time has been reported to be dependent on the preoperative risk-status also: lower surgical risks yield longer survival benefit from EVAR. The main drivers of long-term survival are patient age and risk status, not the type or brand of endograft, except for maybe the effect of reinterventions. However, the main driver of the reintervention rate is anatomical suitability for EVAR. While newer devices may avert the need for reinterventions, at the same time this effect may be counteracted by possibly less durable devices (lower profile, unproven technology) and the inclusion of more challenging anatomy, i.e. shorter more angulated aortic necks. CONCLUSIONS 1. Short-term survival benefit of endovascular over open repair and its gradual loss over time is largely independent of endograft evolution 2. Patient-selection drift may limit generalizability, but the risk-ratio of open versus endovascular repair may stay the same 3. Device-related failures and reinterventions are expected to decrease with better EVAR-device technology, but at the same time it can be expected to increase with more complex and lower profile devices and the inclusion of more difficult anatomies.
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AA. Controversy: Post EVAR surveillance is mandatory. A For the motion. If you don’t have an effective surveillance programme, don’t do EVAR. Matt Thompson
SGVI, London, United Kingdom
BACKGROUND Lifelong surveillance is standard after endovascular repair of abdominal aortic aneurysm (EVAR), but remains costly, heterogeneous and poorly calibrated. This study aimed to develop and validate a scoring system for aortic complications after EVAR, informing rationalized surveillance. METHODS Patients undergoing EVAR at two centres were studied from 2004 to 2010. Preoperative morphology was quantified using three-dimensional computed tomography according to a validated protocol, by investigators blinded to outcomes. Proportional hazards modelling was used to identify factors predicting aortic complications at the first centre, and thereby derive a risk score. Sidak tests between risk quartiles dichotomized patients to low- or high-risk groups. Aortic complications were reported by Kaplan–Meier analysis and risk groups were compared by log rank test. External validation was by comparison of aortic complications between risk groups at the second centre. RESULTS Some 761 patients, with a median age of 75 (interquartile range 70–80) years, underwent EVAR.Median follow-up was 36 (range 11–94) months. Physiological variables were not associated with aortic complications. A morphological risk score incorporating maximum aneurysm diameter (P <0.001) and largest common iliac diameter (measured 10mm from the internal iliac origin; P =0.004) allocated 75 per cent of patients to a low-risk group, with excellent discrimination between 5-year rates of aortic complication in low- and high-risk groups at both centres (centre 1: 12 versus 31 per cent, P <0.001; centre 2: 12 versus 45 per cent, P =0.002). CONCLUSION The risk score uses commonly available morphological data to stratify the rate of complications after EVAR. The proposals for rationalized surveillance could provide clinical and economic benefits.However, discrimination between low and high risk groups is insufficient to deny patients surveillance at present. Surveillance should be lifelong.
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AA. Video & technique. A How to explant a failed EVAR Roberto Chiesa, Enrico Maria Marone, Daniele Mascia
Vascular Surgery Department - San Raffaele Scientific Institute, Milano, Italy OBJECTIVES Despite several advances in endoluminal salvage for failed endovascular abdominal aortic repair (EVAR), in our experience an increasing number of cases necessitate delayed open conversion (dOC). METHODS EVAR patients requiring delayed (>30 days) conversion from 2005 to 2013 were prospectively collected in a computerized database including demographics, details of the aortoiliac anatomy, procedural and clinical success and postoperative complications. RESULTS Between 2005 and 2013, 67 patients were treated (54 electively) for aortic stent-graft explantation. Indications included 42 type I and III endoleak, 15 type II endoleak with aneurysm growth, 5 cases of material failures, 3 limb occlusion and 2 cases of stent-graft migration. Twenty-seven patients firstly received an unsuccessful treatement by means of endovascular approach. All fit for surgery patients with type I/III endoleak underwent directly dOC. Proximal cross-clamping was supraceliac in 7 cases (11%), suprarenal in 28 (42%) and infrarenal in 32 (47%). The removal of the stent-graft was complete in 29 cases and partial in 38 cases. Reconstructions included 66 cases in situ prosthetic repairs (17 cases with aorto-aortic bypass and 49 cases with aorto-bifemoral bypass) and 1 case of extra-anatomic bypass. Overall 30 days mortality was 1.9%. Overall morbidity was 31% mainly due to acute renal failure in 13 cases requiring in 1 case temporary haemodialysis. Mean hospitalization for survivors was 6 days (range, 5-27 days). Overall survival at mean follow-up of 19 months was 78%. CONCLUSIONS In recent years, widespread use of endovascular techniques for abdominal aortic aneurysms treatment has increased dramatically also in young patients regardless of their fitness for open repair. This tendency is reflected in the observation on an increasing number of late complications and in our experience a growing number of stent-graft has been explanted in last years. Delayed open conversion after endovascular abdominal aortic aneurysm seems to be a lifesaving procedure with satisfactory initial and mid-term results. Figures
- Endograft thrombosis Preoperative CT scan with 3D reconstruction showing right limb occlusion of a Bolton Treovance endograft. Intraoperative image showing partial removal and in-graft thrombosis. 51
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- Complete removal Intraoperativa images showing a complete removal of a Zenith Cook bifurcated endograft. - Partial removal Intraoperative image showing a proximal anastomosis between Dacron graft and aortic main body of a Zenith Cook bifurcated endograft in a case of partial removal.
References
1. J.P. Becquemin, L. Kelley, T. Zubilewicz, P. Desgranges, M. Lapeyre, H. Kobeiter. Outcomes of secondary interventions after abdominal aortic aneurysm endovascular repair. J Vasc Surg, 39 (2) (2004 Feb), pp. 298–305 2. A. Millon, A. Deelchand, P. Feugier, J.M. Chevalier, J.P. Favre, University Association for Research in Vascular Surgery (AURC). Conversion to open repair after endovascular aneurysm repair: causes and results. A French multicentric study. Eur J Vasc Endovasc Surg, 38 (4) (2009 Oct), pp. 429–434 3. K.G. Moulakakis, I. Dalainas, S. Mylonas, T.G. Giannakopoulos, E.D. Avgerinos, C.D. Liapis. Conversion to open repair after endografting for abdominal aortic aneurysm: a review of causes, incidence, results, and surgical techniques of reconstruction. J Endovasc Ther, 17 (6) (2010 Dec), pp. 694–702 4. F. Verzini, P. Cao, P. De Rango, G. Parlani, D. Xanthopoulos, G. Iacono et al. Conversion to open repair after endografting for abdominal aortic aneurysm: causes, incidence and results. Eur J Vasc Endovasc Surg, 31 (2) (2006 Feb), pp. 136–142 5. R. Chiesa, E.M. Marone, C. Brioschi, S. Frigerio, Y. Tshomba, G. Melissano. Open repair of pararenal aortic aneurysms: operative management, early results, and risk factor analysis. Ann Vasc Surg, 20 (6) (2006 Nov), pp. 739–746 6. R.L. Kelso, S.P. Lyden, B. Butler, R.K. Greenberg, M.J. Eagleton, D.G. Clair. Late conversion of aortic stent grafts. J Vasc Surg, 49 (3) (2009 Mar), pp. 589–595 7. J. May, G.H. White, J.P. Harris. Techniques for surgical conversion of aortic endoprosthesis. Eur J Vasc Endovasc Surg, 18 (4) (1999 Oct), pp. 284–289 8. C.J. Brinster, R.M. Fairman, E.Y. Woo, G.J. Wang, J.P. Carpenter, B.M. Jackson. Late open conversion and explantation of abdominal aortic stent grafts. J Vasc Surg, 54 (1) (2011 Jul), pp. 42–46 9. O.H. Koning, J.W. Hinnen, J.M. van Baalen. Technique for safe removal of an aortic endograft with suprarenal fixation. J Vasc Surg, 43 (4) (2006 Apr), pp. 855–857 10. D. Nabi, E.H. Murphy, J. Pak, C.K. Zarins. Open surgical repair after failed endovascular aneurysm repair: is endograft removal necessary? J Vasc Surg, 50 (4) (2009 Oct), pp. 714–721
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bdominal aorta and iliac arteries A Is stenting of the aortic bifurcation durable? Eric Steinmetz CHU le Bocage, Dijon, France
BACKGROUND Multidisciplinary guidelines used to recommending treating extensive aortoiliac occlusive disease (AIOD) by surgical revascularization. Even if surgical open treatment keeps the most efficient mean in terms of patency at long term, it generates substantial perioperative morbidity. Endovascular percutaneous technique is more and more performed even for severe Task C&D cases. We here in assess the durability of aortic bifurcation stenting. METHODS A literature review has been undertaken to check the long term outcome of aortic bifurcation occlusive disease treated by endovascular means. Risk factors, comorbities, lesions anatomy according to the TASK classification, associated lesions, were described. Different devices were used: bare metal stents, self-expandable stents, covered stents. Outcomes were technical success, clinical success, mortality, complications, long-term primary, and secondary patency rates. RESULTS The long-term (up to 10 years) results of aortic bifurcation arterial ballon-expandable stent and self-expanding stent placement in patients with arterial occlusive disease show a 10 year primary stent patency rate of 50 to 68% but a secondary assisted patency rate up to 86%. In addition there is a high overall mortality due to other cardiovascular causes and the rate of distal disease progression is close to the loss of stent patency rate. The use of covered balloon-expandable kissing stents provides superior patency at 2 years as compared with bare metal balloon-expandable stents, but there is currently a lack of longer term data. CONCLUSION Long-term follow-up of endovascular treatment with kissing stents for stenosis of the aortic bifurcation shows this technique reaching good results, though it does not justify doing away with classical revascularisation surgery, in a population with major cardiovascular risk factors.
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bdominal aorta and iliac arteries A When use a BMS when a covered stent? Jean-Paul De Vries1, Bram Fioole2
1. St. Antonius Hospital, Nieuwegein, The Netherlands 2. Maasstad Hospital, Rotterdam, The Netherlands INTRODUCTION In longer segment iliac artery atherosclerotic obstructions the use of primary stenting is preferred. Recently, PTFE covered, balloon expandable stents have been introduced in the iliac arteries, because they might lead to less intimal hyperplasia and in-stent restenosis. RESULTS So far, the evidence of the added value of covered iliac stenting has been limited to mainly non-randomized trials. In most of these retrospective and prospective series the freedom from binary restenosis at one year follow-up was >90%. The only randomized trial (COBEST trial) showed a significant improvement of freedom from binary restenosis at 18-months follow-up in favour of covered stents (92% versus 75%).1 Limitations of this randomized trial is the mixture of uncovered stents (even self expandable stents), subgroup analysis according to TASC-classification, and a potpourri of common iliac and external iliac artery obstructions. Recently the DISCOVER (Dutch iliac stent trial: covered balloon expandable versus uncovered balloon expandable stents in the common iliac artery) trial has been started. In this double-blind, multi-center trial patients are recruited with symptomatic advanced (>3 cm) atherosclerotic obstructions (stenosis and occlusions) of the common iliac artery only. Total number of patients that need to be recruited is 174. Patients will be randomized between covered Advanta V12 stents (Atrium Medical Inc., Hudson, NH, USA) and uncovered stents. Primary endpoint is absence of binary restenosis, and follow-up will be 24 months including duplex imaging. Preliminary results of the DISCOVER trial may be expected mid 2014. CONCLUSIONS Covered stents for iliac artery obstructions might lower intimal hyperplasia compared to uncovered stents. Current evidence is scarce and the recently started DISCOVER trial will focus on long-segment common iliac artery obstructions. References
1. Mwipatayi BP, Thomas S, Wong J, et al. A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease. J Vasc Surg 2011;54:1561-70.
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ontroversy. Ruptured AAA: is open surgery an outdated operation? C Early results from the IMPROVE trial for the management of ruptured abdominal aortic aneurysms Janet T. Powell Imperial College, London, United Kingdom
The Immediate Management of the Patient with Rupture: Open Versus Endovascular repair was a pragmatic, real-world, trial which randomised 613 patients with the clinical diagnosis of abdominal aortic aneurysm rupture, before definitive imaging and included unstable patients. Patients were randomised either to an endovascular strategy (n=316), where open repair was reserved for those anatomically unsuitable for conventional EVAR, or to open repair (n=297). The diagnostic accuracy for rupture was 87% and a further 4% had acute symptomatic aneurysms and a further 7% asymptomatic aneurysms. Overall intention to treat analyses showed no difference in either 30-day mortality or costs between the 2 randomised groups, which included patients who died before they received aneurysm repair (mortality 35% in endovascular strategy group and 37% in the open repair group). In the endovascular strategy group, 64% patients were suitable for EVAR, which carried a 30-day mortality of 25%. In the open repair group, the mortality from open repair was 37%. However, the time from randomisation to EVAR was longer than from randomisation to open repair: the number of endovascular patients who deteriorated and were rushed to open repair (rather than EVAR) was approximately balanced by the number of patients in the open repair group who were crossed over to EVAR because of medical frailty. Women benefitted more than men from an endovascular strategy. Patients in the endovascular strategy group also benefitted more by nearly always being discharged sooner and directly to home. Given, these initial findings, it is important to follow up patients for longer to provide robust cost-effectiveness evaluations.
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ontroversy. Ruptured AAA: is open surgery an outdated operation? C Latest news from the ECAR RCT Pascal Desgranges, Hicham Kobeiter, and THE ECAR INVESTIGATORS
Hôpital Henri Mondor, Créteil, France
The Endovasculaire vs. Chirurgie dans les Anévrysmes Rompus Prototocol trial also named ECAR is a prospective multicenter randomized controlled trial of endovascular aneurysm repair (EVAR) vs. conventional surgery (CS) in consecutive patients, eligible for both treatments, presenting with ruptured aorto iliac aneurysms (rAIA) in 16 centers. This study was supported by a grant from the French Ministry of Health under the publicly-funded, hospital-based, clinical research program in 2006 and was approved by the appropriate ethics committee in July 2007. The randomization unit was the week spent in each center. Patients presenting during the first week and subsequent odd-numbered weeks were managed by CS, and those presenting during the second week and subsequent even-numbered weeks by EVAR. The primary endpoint was mortality rate at 30 days, and the secondary endpoints were hospital mortality, severe complications (cardiac, pulmonary, digestive, renal, neurological), length of stay in intensive care unit and amount blood transfusion. The ECAR study hypothesis were a significant decrease of mortality and morbidity in the EVAR group vs. CS. The study began January 8, 2008 and ended in January 2013. One hundred and seven patients have been included. Definitive results on mortality/morbidity are awaited. An independent monitoring committee evaluates the serious adverse events at regular intervals. No imbalance in serious adverse events between the two arms has been found, and the committee has not issued any recommendation to stop the study. Some general results are of interest. Among all patients presenting at seven of the study centers with ruptured aortoiliac aneurysms, about 50% were eligible for the study (range, 35% to 63%). More than 95% of patients had a CT scan available upon arrival at the hospital (done outside the hospital).
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isceral arteries V Renal artery stenting: are there any indications left? Luis Mendes-Pedro
Renal artery stenosis (RAS) is a cause of arterial hypertension (AH) in around 1-4% of all hypertensive population but some selected groups, as patients with coronary disease, aortic aneurysm or resistent AH, seem to have higher prevalence. Some studies also suggested that, as in other arterial territories, stenosis frequently progress to complete occlusion and loss of renal function. Beyond AH, the RAS may present as ischemic nephropathy, renal atrophy and rarely flash pulmonar edema. Nevertheless, most patients have minor forms of isolated AH or are even asymptomatic. In these cases, the treatment approach of RAS is a matter of controversy. There are basically three therapeutical options: isolated medical treatment, conventional surgery and endovascular stenting. Conventional surgery continues to have a definite role in selected patients and its indications are clear and will be discussed. Percutaneous angioplasty was introduced in 1977-1978 by Mahler and Gruntzig and the use of stents was proposed by Dorros in 1983. Since then, a fast technical and methodological evolution was observed and modern endovascular surgery for atherosclerotic occlusive renal disease uses lower profile introducers, guiding-catheters and guidewires as well as the systematic stent deployment. Some authors also advise the use of embolic-protection systems. This endovascular approach is associated to an immediate technical success of >95%, very low mortality and low risk of major complications. The rate of restenosis is 10-20%. These good results from personal or institutional series were not reproduced in larger prospective trials (EMMA, DRASTIC, STAR) and the indications for renal stenting remain controverse. In 2009 came out the larger study (ASTRAL) which included more than 800 patients randomized for medical treatment or medical treatment plus renal stenting. The results did not show any significant benefit with stenting considering the endpoints AH control, renal function, mortality and timing to the first renal or cardiovascular event. The main criticism to the ASTRAL trial is the inclusion of patients only when assisting doctors were in doubt about the best treatment, thus perhaps excluding the most obvious (and appropriate?) indications and patients more prone to benefit from revascularization (selection bias). Other problems were the inclusion of insignificant/moderate lesions and of small kidneys (<6 cm), the absence of hemodynamic assessment methods and the high rate of major complications. The ASTRAL trial, as well as the remaining available scientific evidence, was not able to clearly define (or challenge) the indications for renal revascularization. At most, it suggest that in asymptomatic or moderately symptomatic (easily controlled AH) patients and/or with moderate stenosis, renal stenting may be equivalent to best medical treatment. In conclusion, renal artery revascularization remains a controverse issue. We defend that it should still be performed selectively in the classical clinical indications as tight stenosis associated to resistant or malignant AH, renal failure, flash pulmonary edema and particularly if the lesions are bilateral or the contralateral renal arery is occluded. Asymtomatic patients with less stenotic lesions should be carefully assessed before considering any type of revascularization.
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Lisbon Academic Medical Centre. Faculty of Medicine, University of Lisbon. Vascular Department of Hospital Santa Maria, Lisbon, Portugal
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
isceral arteries V Renal artery stenting: can we predict the success of RS? Monika Gloviczki Mayo Clinic, Rochester, USA
BACKGROUND The prevalence of renovascular disease due to atherosclerotic renal artery stenosis (ARAS) dramatically increases with advanced age and other risk factors of atherosclerosis, end-stage renal failure and heart failure. Despite advances in therapy of both hypertension and atherosclerosis, the management of ARAS remains a challenge. PATIENTSâ&#x20AC;&#x2122; SELECTION Significant ARAS decreases renal artery flow and contributes to hypertension with activation of the renin-angiotensin system. Impaired renal function might also be a consequence. Optimal evaluation must define the degree of renal artery stenosis, level of plasma renin activity, blood pressure control and renal function. A hemodynamically significant lesion needs to be confirmed to justify renal artery stenting (RAS). Duplex ultrasound will demonstrate a significant increase in flow-velocity and a trans-lesional gradient. Computed Tomographic (CT), Magnetic Resonance (MR) angiography and contrast arteriography, combined with direct arterial pressure measurements are available diagnostic techniques. Specific renal CT protocol can both quantify artery stenosis and demonstrate alterations of cortical and medullary perfusion and flow. To predict favorable outcome of RAS, new tools are emerging. Blood oxygen level-dependent MRI (BOLD MRI) is a noninvasive method measuring kidney tissue oxygenation. When vascular compromise overwhelms renal adaptive changes, an overt cortical hypoxia and expansion of medullary hypoxic zones can be shown. A prospective study that combined transjugular renal biopsies with BOLD MRI demonstrated activation of Transforming Growth Factor β and accumulation of tissue macrophages in addition to progressive interstitial fibrosis even in patients with preserved structure and function. CONCLUSIONS Current guidelines suggest that a decline in renal function during antihypertensive treatment, in particular with ACE inhibitors or angiotensin receptors blockers, a failure to achieve adequate blood pressure with optimal medical therapy and recurrent congestive heart failure are factors predicting success of RAS. A continuous research and development of new evaluation methods could further improve selection of candidates for RAS.
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isceral arteries V Renal denervation: how does it work, who should be treated? Iris Baumgartner University Hospital, Inselspital, Bern, Switzerland
Renal denervation: how does it work, who should be treated? (according to the expert consensus document from the European Society of Cardiology on catheter-based renal denervation)1
Anatomically, afferent and efferent sensory, chemo- and baroreceptor nerve fibres form a neural network within the adventitia of the renal artery. Renal afferent nerves connect the kidney with the hypothalamus, contribute to the sympathetic activity generated within the brain, and are activated by renal ischemia and high local adenosine concentrations. Efferent nerves innervate the kidney enhancing sodium and water retention, stimulating renin release, and altering renal blood flow. Their convenient location in the renal artery adventitia means that both the efferent and afferent fibres can be targeted by catheter-based approaches, thereby re-setting renal blood pressure regulation. The initial proof-of-concept study Simplicity HTN-1 and the multi-centre, prospective, randomized Simplicity HTN-2 trial investigated the effect of radiofrequency-based RND in patients with resistant hypertension. Baseline blood pressure was 177/100 and 178/96 mmHg, respectively, despite treatment with four or more antihypertensive drugs on average. RND resulted in significant systolic and diastolic blood pressure reductions that were first observed at 1 month and persisted out to 36 months. The response to treatment was defined as a reduction in systolic blood pressure (SBP) >10 mmHg at 6-month follow-up and was found in 84% of patients. However, RND is unlikely to significantly reduce pill burden in patients with treatment-resistant hypertension on at least three antihypertensive drugs of different types in adequate doses. The following criteria should be implemented in order to safely proceed RND: - office-based systolic BP ≥ 160 mmHg (≥ 150 mmHg diabetes type 2) - ≥ 3 antihypertensive drugs - exclusion of secondary hypertension - exclusion of pseudo-resistance using ambulatory blood pressure measurement - preserved renal function (although RND seems to be safe and effective in moderate-to-severe chronic kidney disease) - eligible renal arteries, i.e. no evidence of relevant renal artery atherosclerosis (defined as > 50% stenosis), presence of multiple renal arteries or main renal artery < 4mm in diameter or < 20 mm in length, no prior stenting revascularisation Current evidence from available clinical trials support the notion that catheter-based radiofrequency ablation of renal nerves reduce blood pressure and improved blood pressure control in patients with drug-resistant hypertension. RND can be considered as a therapeutic option in patients with resistant hypertension, whose blood pressure cannot be controlled by a combination of lifestyle modification and pharmacological therapy according to current guidelines. Reference
Expert consensus document from the European Society of Cardiology on catheter-based renal denervation. European Heart Journal April 2013. 59
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There is a large body of evidence indicating that sympathetic overdrive plays a crucial role in therapy resistant arterial hypertension. Catheter-based renal denervation (RND) offers an approach targeting sympathetic nerves within the adventitial layer of the renal artery.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
isceral arteries V Occluded and stenosed digestive artery: covered stent or bare stent? Gustavo Oderich Mayo Clinic, Rochester, USA
OBJECTIVE Endovascular revascularization has become the first treatment option in most patients with chronic mesenteric ischemia (CMI), relegating open surgical revascularization to patients who fail stenting or have an anatomy unsuitable for it. Despite the widespread acceptance of angioplasty and stenting and short-term advantages over open bypass, mesenteric stents are plagued by high rates of restenosis and re-interventions. The aim of this study was to compare outcomes of mesenteric angioplasty and stenting using iCAST covered stents (CS; Atrium, Hudson, NH) ) or bare metal stents (BMS) in patients with chronic mesenteric ischemia (CMI). METHODS We reviewed the clinical data of 225 patients (65 male and 160 female; mean age 72±12 yrs) treated for CMI at two academic centers (2000-2010). Outcomes were analyzed in patients who had primary intervention or re-intervention using BMS (n=164 patients/ 197 vessels) or CS (n=61 patients/ 67 vessels). Endpoints were freedom from restenosis, recurrence, re-interventions and patency rates. RESULTS Patients in both groups had similar demographics, cardiovascular risk factors and extent of disease. In the primary intervention group (mean follow up, 29±12 months), patients treated by CS had higher freedom from restenosis (92±6% vs 53±4%; P=0.003), recurrences (92±4% vs 50±5%; P=0.003), re-interventions (91±6% vs 56±5%; P=0.005) and better primary patency at 3-years (92±6% vs 52±5%; P<0.003) than for BMS. In the re-intervention group (mean follow up, 24±9 months), patients treated by CS had higher freedom from restenosis (89±10% vs 49±14%; P<0.04), symptom recurrence (100% vs 64±9%; P=0.001) and re-intervention (100% vs 72±9%; P=0.03) at 1-year and a trend towards improved primary patency at 1-year (100% vs 63±9%; P=0.054). Secondary patency rates were similar in both groups. CONCLUSIONS In this non-randomized study covered stents were associated with less restenosis, recurrences and re-interventions than bare metal stents in patients undergoing primary interventions or re-interventions for CMI. References
Oderich et al. Comparison of covered stents versus bare metal stents for treatment of chronic atherosclerotic mesenteric arterial disease. J Vasc Surg 2013
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
FA: latest news from the endo technology and techniques S Micro catheter for intra arterial thrombolysis Patrick Bagan1, Bassel Dakhil1, Hirad Farghadani2, Jean Claude Couffinhal1 1. Victor Dupouy Hospital, Argenteuil, France
2. St Marie Clinic, Osny, France
The aim of in situ fibrinolytic therapy is to quickly and completely salvage a vascular bed while reducing the risk of surgical complications. Protocols for in situ fibrinolysis typically require a stay in an intermediate care or intensive care unit and expose the patients to the risk of major bleeding complications. In three endovascular therapy units, we compared over a 30 months period in a population of 28 patients the arterial recanalisation rate, the total dose of fibrinolytic injected with respect to the length of the arterial occlusion, the morbidity rate and length of hospitalisation in the intermediate care unit between traditional in situ fibrinolysis and fibrinolysis with Clearway™ balloon, a low-pressure porous balloon micro-catheter. With an equivalent primary success rate, the dose of fibrinolytic agent needed was significantly lower in the micro-catheter group (82,000 units of Actosolv® per cm of occluded artery versus 260,000 units/cm, p=5.16.10-6). The average length of stay in the intermediate care unit was significantly shorter in the catheter group (1.1 days versus 3.9 days, p=0.049). Clearway™ balloon allows intrathrombus direct administration of fibrinolytic agent under low pressure and significantly reduces the dose needed. The hypotheses put forward to explain the lesser amount of fibrinolytic injected with the ClearWay™ catheter are first, the large diffusion surface area and second, the deformation of the thrombus by the balloon inflated at low pressure in using an atraumatic delivery system to the intima (low-pressure PTFE balloon). The balloon also distorts the thrombus and delivers the thrombolytic agent at a high local concentration. In summary, intra-arterial thrombolysis using the ClearWay™ balloon catheter is an effective method that can be used in conjunction with other revascularisation techniques in the treatment of acute peripheral arterial occlusions. It can be performed under local anaesthesia without a surgical approach. This method reduces the risk of bleeding complications and could be a preferred method in high-risk populations such as elderly patients and post-operative arterial thrombosis.
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FA: latest news from the endo technology and techniques S What are the new cto devices which are changing the game? Peter Schneider Kaiser Foundation Hospital, Honolulu, USA
STRATEGY AND TECHNIQUE In crossing any occlusion, the wire may go into the subintimal space or may stay in the true lumen. There are catheters designed to stay in the true lumen, such as the Crosser catheter (Bard), which is a mechanized, drill-like catheter that is meant to center itself with the true lumen. There are also CTO support catheters, such as Quickcross (Spectranetics) that is designed to work with a CTO wire and to be advanced across the true lumen. There is a co-axial CTO catheter system designed to pass with a manual push and the coaxial system combined with a CTO wire gives the operator extra leverage on the lesion (Cook Medical). The most common method of re-entry into the true lumen in the SFA and popliteal is by advancement of a loop of hydrophilic wire. The most common reason for the wire to stay in the subintimal space is calcification of the artery at the reentry site that keeps the wire from crossing the membrane of dissected intimal tissue between subintimal space and true lumen. If the wire does not spontaneously pop into the true lumen there are several options. A puncture can be performed of a distal artery, and a wire introduced from below. Another option is to use a re-entry device. Reentry catheters may be fluoroscopy guided (Outback, Cordis) or IVUS guided (Pioneer, Medtronic). The subintimal wire is exchanged for a stiff 0.14 in. guidewire. The reentry catheter is advanced and a needle in the tip of the catheter is advanced into the true lumen and a 0.014 in. guidewire is advanced from the reentry catheter into the true lumen. The direction of the needle may be guided by orientation as determined by multiple angles using fluoroscopy with the Outback catheter. Orthoganal views are obtained to locate the juxtaposition of the true and false lumens. The catheter may be oriented so that the needle points to the true lumen and the needle is advanced. The true lumen can be reentered 80% of the time using these devices, even when simpler methods have failed.(1) CONCLUSION CTO devices facilitate our ability to manage occlusions in the lower extremity. Many tools are available and when used in a stepwise fashion, usually result in success in crossing occlusions. References
1. Schneider et al. J Vasc Surg 2013;58:529-34
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INDICATIONS Lower extremity ischemic syndromes often present with chronic vessel occlusion and we have at our disposal new CTO devices to help make crossing an occlusion to be routine practice.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
ontroversy: Do we really need a stent in long SFA lesions? C Yes: Newest stents are perfect for the job Yann GouĂŤffic Department of vascular surgery, University hospital of Nantes, Nantes, France Currently, endovascular treatment of femoropopliteal lesions superior to 15-cm as a first-choice treatment remains controversial. Different types of endovascular devices could be used to treat long femoropopliteal lesions such as balloon catheter, bare metal or covered stent, drug eluting devices. Up today, nitinol self-expanding stents appears as the gold standart of the endovascular treatment femoropopliteal lesions inferior to 15-cm. Indeed nitinol alloys allows to scaffold the arterial wall, to prevent elastic recoil, negative remodeling and to keep a great flexibility in a tortuous physical environment. Through if most of these devices have been assessed in short femoropopliteal lesions, the results can not be generalised to longer femoropopliteal lesions. Indeed, the treatment of long femoropopliteal lesions is still challenging for different reasons especially related to the clinical stuatus of the patients, technical factors, mechanical stress submitted to the femoropopliteal axis and mechanical properties of the devices. Newer generations of longer nitinol self-expanding stents could allow endovascular treatment of longer femoropopliteal lesions thanks to their schaffolding properties and their resistance to compression and fracture in this tortuous physical environment. Recently, some studies have reported promising outcomes after primary stenting for long femoropopliteal lesions and suggest that newest stents are (nealry) perfect for the job.
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What can we expect from the next generation dual dual component SFA stent design? The ideal stent is a stent without jump, No fracture, no elongation and good radioopacity. Before endovascular concept was to force the artery. A new concept based on anatomical constraints of the SFA has led to the creation of second-generation stents, nitinol likely to adapt to the mechanics of the SFA, with less bridges, a spiral orientation and interwoven design. However restenosis and stent fractures remain a recurring problem. The study RESILIENT (LifeStent vs. PTA) showed that the low fracture suggests that mechanical fatigue of the stent is less important than the technical deployment in the etiology of fractures. Studies have shown that stent fractures were much more important in the long stentings in short stenting. The elongation of the stent at its source deployement is weakening its structure and leads to fractures, rather than its location in the SFA. Restenosis remains a poorly understood problem. inspired knowledge assets in coronary stenting to prevent restenosis appeared the coateds stents for SFA and more recently dual component stents designed to meet the problems of restenosis and stent fractures. This third - generation stent does it influence the results of stenting of the SFA? With our current knowledge and a greater appreciation of the anatomy of the SFA third generation stents are designed to move with the artery without trying to recover. The objective is to provide a maximum of flexibility in reducing the risk of fractures, allow axial compression while resisting stent elongation, natrally conforms and allows SFA movement. Since July 2012 until september 2013 I have implanted 65 stents third-generation (45 SFA and popliteal 13). For patients in stage 2 and 4. There were 77.2% of stenosis and 22.8% of thrombosis. the average lesion length was 5.3 cm. the follow-up was done clinically and with Doppler at 1,3,6,12,24 months. The method used is that of Kaplan-Meier. The results show an excellent primary patency but it will take two years to see if the rate of restenosis and fracture is actually decreased by this new concept. Figures
My experience: Primary patency. One restenosis at 6 months.
References
secondary patency.
1. Bosiers M et al. Nitinol stent implantation in long femoral artery lesions: 12 results of the DURABILITY I study.J. endovasc ther.2009 ;16 :261-269) 2. Scheinert D et al. Prevalence and clinical impact of stent fractures after femoropoplitealstenting.J.Am.coll.Cardiol.2005.jan 18 ;45(2) :312-5 3. Bosiers M et al. results of the Protégé Everflex 200 mm-long nitinol stent(EV3) in TASC C and D femoropopliteal lesions. Journal of Vascular Surgery 2011;54(4):1042- 1050 4. Laird J et al. Nitinol stent implantation vs balloon angioplasty for lesions in the superficial femoral and proximal popliteal arteries of paints with claudication: Three-year follow-up from the RESILIENT randomized trial. J. Endovascular Ther. 2012; 19:1-9 65
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FA: latest news from the endo technology and techniques S Dual component stents: do they improve SFA stenting? Maxime Sibé Clinique Tivoli, Bordeaux, France
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
FA: latest news from the endo technology and techniques S Why does EVH challenge endo repair of long lesion? Daniel Danzer Hopital de Sion, Sion, Switzerland To date, surgical repair of long SFA lesion gives better mid to long terms patency rates compare to endovascular treatment (up to 69% primary patency at 5 years versus 25% at 3 years respectively). To achieve such favourable results, the great saphenous vein is required to ensure long terms patency as well as resistance to infection especially in case of tissue loss. The required surgical trauma have lead to an increasing enthusiasm for endovascular procedure. Nevertheless percutaneous treatment of long and complex lesions often requires numerous technical skills, costly tools and drugs with frequent needs for reintervention, in order to achieve acceptable secondary patency rate. Furthermore the recurrent argument of similar results of endo in terms of clinical outcome against bypass is overused, limb salvage and overall survival doesn’t mean ambulation, pain relief or wound healing. In particular arterial ulcers healing is a slow process, which requires sustained vascularisation over time, better deserved by a bypass. Since the 90’ technical modifications have emerge in order to reduce the trauma of surgery but are still under recognized. Endoscopic venous harvesting decrease wound size, post operative discomfort and complication with a significant favourable impact on the length of stay compare to classical open vein harvesting (p<0.001). Furthermore endoscopic harvesting doesn’t preclude long term graft patency (p=0.5). Although surgical repair of long SFA lesion may not compete with endovascular treatment of ambulating patient in terms of LOS, endoscopic vein harvesting reduces the gap. Minimal invasive complete and durable vascular reconstruction using endoscopic harvested vein should be taken into account instead of an “endo first and only” bounded approach.
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FA: latest news from the endo technology and techniques S When are Prosthetic grafts as good as veins? Jack Cronenwett Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
METHODS We studied 1227 patients who underwent below-knee bypass for CLI, 223 of whom received a prosthetic graft to the below-knee popliteal artery (70%) or more distal target (30%). We used propensity matching to identify a patient cohort receiving single-segment saphenous vein but were similar to the prosthetic cohort in terms of demographics, graft origin/target, and antithrombotic regimen. Main outcome measures were graft patency and major limb amputation within 1 year. Secondary outcomes were bleeding complications (reoperation or transfusion) and mortality. We performed comparisons by conduit type and by antithrombotic therapy. RESULTS Patients receiving prosthetic conduit were more likely to be treated with warfarin than those with greater saphenous vein (57% vs. 24%, P < 0.001). After propensity score matching, we found no significant difference in primary graft patency (72% vs. 73%, P = 0.81) or major amputation rates (17% vs. 13%, Pâ&#x20AC;Ż= 0.31) between prosthetic and single-segment saphenous vein grafts. In a subanalysis of grafts to tibial versus popliteal targets, we noted equivalent primary patency and amputation rates between prosthetic and venous conduits. Whereas overall 1-year prosthetic graft patency rates varied from 51% (aspirin + clopidogrel) to 78% (aspirin + warfarin), no significant differences were seen in primary patency or major amputation rates by antithrombotic therapy (P = 0.32 and 0.17, respectively). Further, the incidence of bleeding complications and 1-year mortality did not differ by conduit type or antithrombotic regimen in the propensity-matched analysis. CONCLUSIONS Although limited in size, this study demonstrates that, with appropriate patient selection and aggressive antithrombotic therapy, 1-year outcomes for below-knee prosthetic bypass grafting can be comparable to those for greater saphenous vein conduit. References
Comparison of Graft Patency, Limb Salvage, and Antithrombotic Therapy Between Prosthetic and Autogenous Below-knee Bypass for Critical Limb Ischemia. Suckow BD, Kraiss LW, Stone DH, Schanzer A, Bertges DJ, Baril DT, Cronenwett JL, Goodney PP; Vascular Study Group of New England. Ann Vasc Surg. 2013 Sep 4, epub ahead of print.
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PURPOSE This study compared outcomes of below-knee prosthetic versus autogenous vein bypass grafts for critical limb ischemia (CLI) and the use of adjunctive antithrombotic therapy.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Controversy: When a stent is needed, do you choose a bare stent or a covered stent? Bare stent and Iâ&#x20AC;&#x2122;ll tell you why Thomas Zeller Universitäts-Herzzentrum Freiburg - Bad Krozingen, Bad Krozingen, Germany Endoprosthesis implantation in femoro-popliteal artery disease is an appealing concept to prevent ingrowth of neointima into the stent lumen which is the background of instent restenosis development. However, so far no study has shown a significant benefit for the implantation of Viabahn endoprosthesis over bare metal nitinol stent placement in lesions shorter than 20cm. The recently published VIASTAR trial has shown superior patency outcomes only for femoro-popliteal lesions longer than 20cm. Endoprosthesis implantation has some certain limitations such as unknown duration of dual antiplatelet therapy (4 weeks for bare metal nitinol stents), occlusion of potential collateral vessels and the higher device costs. Edge stenosis remains still the Achilles heel of endoprosthesis implantation in peripheral arterial disease. Thus, provisional bare metal nitinol stent placement remains the therapy of choice in TASC II A and B femoro-popliteal lesions. Second and third generation bare metal stent trials have resulted in satisfying 1-year primary patency rates of approximately 80% in these lesion subcohorts. Endoprosthesis implantation might be considered in TASC C and D lesions or in recurrent instent restenosis of nitinol stents.
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The most common mode of failure after technically successful stenting in the SFA is restenosis due to neointimal hyperplasia. Bare metal stents (BMS) are implanted in order to provide scaffolding for plaque that is pushed aside during PTA, and the chronic outward force ensures that vessel recoil is minimized. However, cells can continue to proliferate through the stent struts, eventually resulting in restenosis; the likelihood of this occurring is theoretically proportional to the length and severity of the lesion. A covered stent (CS), by contrast, provides a barrier to hyperplastic tissue ingrowth. The failure mechanism of a CS is more like that of a bypass graft: edge stenosis, possibly followed by CS thrombosis, is generally the culprit. These mechanisms are theoretically much less dependent on lesion length. Both BMS and CS for femoropopliteal occlusive disease treatment have been studied in the literature; however, lesion length and severity, term of study, and patency definitions in various studies have been different, making it hard to compare results. Luckily, we now have level-one evidence showing a difference between BMS and CS. The recently published VIASTAR study (Lammer et al., JACC, 2013) randomized the latest generation, heparin-bonded CS to BMS in patients with complex femoropopliteal lesions (average lesion length was 18 cm). This multicenter study showed a primary patency difference between the arms at one year in favor of CS (78.1% vs. 53.5%, P=0.009). The older VIBRANT study (Geraghty et al., JVS, 2013), which also randomized CS to BMS, showed no primary patency difference between the study arms. However, this study was done with a CS that did not have the heparin-bonded surface of the newer device. Additionally, CS devices in this study did not have a contoured proximal edge, and 5 mm devices werenâ&#x20AC;&#x2122;t available, which potentially led to greater oversizing. The VIPER study (Saxon et al., JVIR, 2013) was a single-armed, 119 limb study utilizing the newest version of CS. The patient demographics and lesion characteristics are similar to the previous studies mentioned. In this study, the heparin-bonded CS showed a one year primary patency rate of 73%. Additionally, there was no difference in the patency between patients with lesions <20cm and those with lesions >20cm, indicating that even very long lesions could be treated successfully. The results did show that CS oversized by <20% at the proximal edge (IFU recommends 5 to 20% oversizing) did significantly better (88% primary patency). Single-center results in 56 limbs treated with heparin-bonded CS (Lensvelt et al., JVS, 2012) again had similar lesion characteristics to the aforementioned studies and showed a 1-year primary patency rate of 76%, further confirming applicability of CS in difficult lesions. The single-armed 25-cm VIABAHNÂŽ Study enrolled lesions that are even more difficult than those studied in VIASTAR, VIPER and the Lensvelt study. This study, which only enrolled patients with lesion lengths greater than 20 cm, had 93% chronic total occlusions and a mean lesion length of 26.5 cm; all were treated with heparin-bonded CS. The interim 12-month primary patency is 66.7%, which is encouraging considering the extremely advanced disease of the patients studied. Data for the newest generation of heparin-bonded CS clearly show superior patency results to BMS when studied in difficult lesions. When a stent is required in femoropopliteal interventions, a covered stent should be chosen.
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Controversy: When a stent is needed, do you choose a bare stent or a covered stent? Covered stent without any doubt Marc Bosiers AZ Sint-Blasius, Dendermonde, Belgium
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Controversy: Critical limb ischemia. Endo or open first? Endo is the fisrt choice strategy Koen Deloose AZ Sint-Blasius, Dendermonde, Belgium Surgical bypass has been the golden standard of revascularization in the critical limb ischemic patient for years now. The progress in minimal invasive, endovascular techniques and technologies combined with the improving skills among interventionalists, however, is developing a major shift from bypass-surgery towards an endovascular approach first. The BASIL (Bypass vs. angioplasty in severe ischemia of the leg) trial is the only randomized trial comparing bypass to an endovascular approach. This study showed a similar amputation-free survival as well as quality of life between the two groups. However, the results of BASIL are no longer relevant. The devices and techniques for endovascular treatment have improved substantially over the past decade resulting in significantly improved acute outcome as compared to what was reported in BASIL. Results of several high quality, well controlled (randomized and non randomized) studies and registries, using modern endovascular techniques and technologies reveal one-year primary patency and limb salvage comparable to surgical bypass results using optimal vein bypass grafts, but of course, with tremendously lower morbidity and mortality rates. The issues of lack of adequate saphenous vein, poor distal targets and infected below the knee areas are all shifting the debate in favor of an endovascular first approach. Last but not least, endovascular first approach is also the preferred choice of our CLI patients. People in this modern time prefer minimal invasive approaches with short hospital stays over huge surgical incisions with long admissions on high dependency units. In summary, anno 2013, an endovascular first approach for our CLI patient, is the correct approach.
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Controversy: Critical limb ischemia. Endo or open first? Surgery should be first line Firas Mussa NYU Langone Medical Center, New York, USA
METHODS A cohort of 302 patients with CLI was identified between March 2007 and December 2010. Endovascular-first was selected if: 1) the patient had short (5-7cm occlusions or stenoses in crural vessels) 2) the disease in superficial femoral artery was limited to TASC II A, B or C and 3) no impending limb loss. Failures were defined as recurrent clinical signs and symptoms. Criteria for reintervention were the same as for primary intervention. RESULTS Endo-first was performed in 187 (62%) and open-first in 105 patients (35%). Secondary procedures (endo or open) were more common after open-first (68% vs. 55%; p= 0.029). Patients with above knee open first were less likely to undergo secondary interventions than those who underwent endo-first at same location, 58% versus 40% (p=0.003). Patients treated with rest pain were more like to undergo secondary interventions than those with ulcers, 29% versus 54% (p<0.0001). At five-years, mortality rates were higher among those without secondary interventions, 53% versus 39% (p=0.0096). However, amputation rates were higher in patients undergoing secondary interventions, 22% versus 5%, (p=0.0016). There was no difference in amputation free survival (AFS) based on need for secondary interventions, 49% versus 47%, (p=0.165). Patients with an initial open intervention followed by endovascular reintervention had a trend towards the best outcome with 70% five-year AFS. CONCLUSIONS At 5 years, selective revascularization strategy led to frequent reinterventions, higher in those treated with an open-first approach. While amputation rates were higher in those undergoing secondary interventions, mortality was higher among those without secondary interventions. Amputation free survival was not different in the two cohorts with a trend towards improved outcomes in those undergoing an open-first followed by endovascular reintervention.
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OBJECTIVES Patients with critical limb ischemia (CLI) remain at risk of significant limb loss despite timely intervention and reintervention. This study reports the fate of failed primary revascularization and their rescued approaches.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Miscellaneous Patient-specific rehearsal prior to EVAR: waste of time or increased safety? Isabelle Van Herzeele Ghent University Hospital, Ghent, Belgium Recent advancements in simulation science permit patient-specific rehearsal of endovascular repair of an infrarenal abdominal aortic aneurysm. By incorporating patient-specific imagery into endovascular simulations, real patient cases can be practiced before the actual operation. Evidence is emerging that this rehearsal may be valuable for improving case planning by selecting the appropriate patients and correct devices, including device type and size (length and diameter) since type I endoleaks may occur if a device was chosen too small or if the distal landing zone is incorrect. Furthermore, rehearsals may significantly impact on the treatment plan by identifying the optimal introduction side and by adjusting the position of the contralateral limb to facilitate cannulation. In EVAR cases, the identification of the optimal C-arm angulation (proximal and distally) in advance to eliminate the parallax may decrease the contrast use and the radiation dose for the patient, physician and the endovascular team. By providing the opportunity of unlimited practice, using a variety of endovascular tools and devices, techniques patient-specific rehearsals may optimize the preoperative preparation of the interventionalist and his/her team. Pitfalls or possible deviations from the initial treatment plan may be detected preoperatively leading to a more efficient use of the hybrid angiosuite. Furthermore, research has suggested that patient-specific rehearsal may also enhance human factor skills such as decision-making, coordination, leadership, communication and confidence during the real procedure. These cognitive and interactive skills complement technical competency are vital in the efficient and safe execution of complex tasks, especially in crisis situations. A randomized controlled trial across Europe is evaluating the potential of patient-specific rehearsal to enhance technical and non-technical performance, clinical safety and efficiency. References
Desender, Z.Rancic, R. Aggarwal, J. Duchateau, M. Glenck, M. Lachat, F. Vermassen, I. Van Herzeele. Patient-specific Rehearsal prior to EVAR: a Pilot Study. Eur J Vasc Endovasc Surg 2013; 45(6): 639-47 Willaert WI, Aggarwal R, Van Herzeele I, Plessers M, Stroobant N, Nestel D, Cheshire N, Vermassen F. Role of patient-specific virtual reality rehearsal in carotid artery stenting. Br J Surg. 2012 Sep; 99(9):1304-13 W.I.M. Willaert, R. Aggarwal, F. Daruwalla, I. Van Herzeele, A.W. Darzi, F.E. Vermassen, N.J. Cheshire. Simulated Procedure Rehearsal is More Effective than a Preoperative Generic Warm-up for Endovascular Procedures. Ann Surg 2012; 255(6): 1184-9 W.I.M. Willaert, R. Aggarwal, I. Van Herzeele, N.J. Cheshire, F.E.G. Vermassen. Recent Advancements in Medical Simulation: Patient-Specific Virtual Reality Simulation. World J Surg 2012; 36(7): 1703-12 LM Desender, I. Van Herzeele, R. Aggarwal, FE Vermassen, NJ Cheshire. Training with simulation versus operative room attendance. J Cardiovasc Surg (Torino). 2011 Feb;52(1):17-37 (IF 1,16)
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Evidence-based-medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. Current best evidence is based on research published in peer-reviewed journals. The critical appraisal of the literature is the method used to determine the best evidence. But literature is mostly flawed, as the pressure to publish has a high impact on the poor quality of publications. Authors want to please reviewers, editors in order to facilitate the manuscripts’ acceptance. Publishing good science, non-biased experiments is rare. Most of the papers are flawed. The spectrum is large from honest errors to fraud. Between errors and fraud that are both rare, the beautification of papers is very common. Examples: 1. Beautification of data is the process of reporting results of a research in a way that does not correspond to reality, in order to present them in a more favorable and attractive way; 2. 75 of 152 (49%) surgical randomized controlled trials showed some evidence of discrepancies between outcomes registered in protocols, and the outcomes published, most often related to omitting or introducing primary outcomes (Ann of Surgery, 2013, 1-6); 3. Reproducibility of data is poor: 237 of 434 (54.6%) cancer specialists declared having failed to reproduce data (PLOS ONE, May 2013, e63221); 4. Researchers in oncology and hematology at Amgen reproduced 6 out of 53 (11%) papers deemed ‘landmark studies’, and published in high-ranking journals (Nature, 29 March 2012); 5. ‘Imagipulate’ is frequent and hard to detect unless you inspect the image softwares; 6. ‘The average statistical power of studies in the neurosciences is very low. The consequences of this include overestimates of effect size and low reproducibility of results. There are also ethical dimensions to this problem, as unreliable research is inefficient and wasteful’ (Nature reviews neuroscience, April 2013)
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Miscellaneous The dark side of evidence based medecine Herve Maisonneuve University Claude Bernard Lyon 1, Lyon, France
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Controversy: Looking for truth: are RCTs the proper way? Of course, yes Roger Greenhalgh Imperial College, London, United Kingdom Dr. Veith finds any trial evidence “flawed” if the findings do not support his prevailing prejudice. The debate is about the relevance of high quality data and whether this impacts upon the clinical practice of modern day vascular specialists. In the “battle of the dinosaurs”, Professor Greenhalgh will show that evidence affects practice. He already knows that Dr. Veith is beyond conversion, but what will the audience think?
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Controversy: Looking for truth: are RCTs the proper way? Not at all, rcts can be misleading and do not reflect the real world Frank J. Veith New York University and The Cleveland Clinic, New York, New York and Cleveland, Ohio,
The results of randomized controlled trials (RCTs) published in leading peer reviewed journals are deemed the best possible basis for good medical practice. However, several limitations may decrease their value. These include flaws and weaknesses in the design and the timeliness of RCTs. Progress in a treatment method or control arm may invalidate a trial. So too can defects in patient selection, physician competence, randomization, applicability, end-points and the population being studied. Idiosyncratic flaws can also invalidate a RCT. Another problem with articles describing RCTs is the potential for the conclusions to be misleading because of error or bias. This plus subsequent misinterpretation of the trial results or conclusions by others can make the trial misleading with an unintended detrimental result on medical practice. Guidelines based on such errors or bias- based conclusions and misinterpretations can further compound the problem. This presentation will provide examples of misleading conclusions and/or misinterpretations (spinning) of trial results in articles describing RCTs in leading journals. All physicians should recognize these value-limiting processes so that RCTs can be evaluated adequately and fairly. In that way they can be used along with good physician judgment to optimize the care delivered to individual patients and to society at large.
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USA
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Leg arteries What is the angiosome concept? Is it more useful than pedal arch patency? Peter Schneider Kaiser Foundation Hospital, Honolulu, USA INDICATIONS Angiosome-guided revascularization leads to improved limb salvage rates, whether perfusion is restored using bypass or catheter-based techniques. Angiosome Guided Revascularization: Taylor and Palmer first introduced the angiosome concept in 1987. They analyzed the blood supply to the skin and subcutaneous tissues through ink injection studies, dissection, perforator mapping, and radiographic analysis of fresh cadavers. A 3-dimensional network of vessels was identified as the source blood supply for specific blocks of tissue, further interconnected by a rescue system called “choke-vessels”.1,2 The anatomical planning of vascular reconstruction based on angiosomes involves understanding the connections among the main foot and ankle branches and associated angiosomes. When normal anatomy is present, all three major arteries supplying the foot are patent with multiple arterial-arterial connections enhancing blood flow. Diabetic patients in particular are often subject to severe depletion of the foot collateral reserve thus emphasizing the need for more specific revascularization. 2,3 Iida et al. analyzed 203 limbs with non-healing ulceration or gangrene that underwent endovascular intervention. Two groups were compared, a direct group in which feeding artery flow to the site of ischemia was successfully acquired according to the angiosome concept versus an indirect group in which feeding artery flow was not successfully acquired. Limb salvage was significantly higher in the direct group over the indirect group for 1, 2, 3, and 4 years (direct 86%, 82%, 82%, 82%; indirect 69%, 64%, 64%, 64%).4 Alexandrescu et al. studied of diabetic ischemic foot wounds and BTK angioplasty. Significantly enhanced wound healing and freedom from amputation was identified in favor of the angiosome-targeted revascularization.5 Primary angioplasty of 369 limbs with ischemic ulceration of gangrene and isolated BTK lesions were divided into direct and indirect groups based on the angiosome concept. Results showed that rates for amputation free survival, freedom from major adverse limb events, and freedom from major amputation were significantly higher in the direct group than in the indirect group for up to 4 years after the index procedure.6 The role of collaterals and pedal arch has also been evaluated. Varela et al. retrospectively analyzed 76 ischemic ulcers, 35 of which were treated endovascularly based on the angiosome model. Ulcer healing at 1 year and limb salvage at 2 years were similar in the direct revascularization group and the indirect revascularization group when collaterals were robust, as compared to indirect revascularization alone. The authors concluded that the presence of a patent pedal arch or peroneal distal branches may significantly affect achieving limb salvage.7 Pedal arteries are anastomotic arteries but diabetics tend to have compartmentalization of flow and the arteries are more likely to be end arteries rather than anastomotic arteries. The diabetic population has a poor prognosis in critical limb ischemia with a need for amputation 5 to 10 times higher than in those without diabetes.8 CONCLUSION Angiosome-guided revascularization enhances the benefits of revascularization. References
1. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987 Mar;40(2):113-41. 2. Alexandrescu V, Hubermont G. The challenging topic of diabetic foot revascularization: does the angiosome-guided angioplasty may improve outcome. J Cardiovasc Surg (Torino). 2012 Feb;53(1):3-12. 3. Alexandrescu V, Söderström M, Venermo M. Angiosome Theory: Fact or Fiction? Scand J Surg 2012. 101: 125-131. 4. Iida O, Nanto S, Uematsu M, Ikeoka K, Okamoto S, Dohi T, et al. Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia. Catheter Cardiovasc Interv. 2010 May 1;75(6):830-6. 5. Alexandrescu V, Vincent G, Azdad K, Hubermont G, Ledent G, Ngongang C, et al. A reliable approach to diabetic neuroischemic foot wounds: below-the-knee angiosome-oriented angioplasty. J Endovasc Ther. 2011 Jun; 18(3):376-87.
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6. Iida O, Soga Y, Hirano K, Kawasaki D, Suzuki K, Miyashita Y, et al. Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions. J Vasc Surg. 2012 Feb; 55(2):363-370.e5. 7. Varela C, Acin F, de Haro J, Bleda S, Esparza L, March JR. The role of foot collateral vessels on ulcer healing and limb salvage after successful endovascular and surgical distal procedures according to an angiosome model. Vasc Endovascular Surg. 2010 Nov; 44(8):654-60. 8. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG; TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007 Jan; 45 Suppl S: S5-67.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Leg arteries Can we stent a popliteal artery? Yves Alimi, Jérémie Peidro, Mourad Boufi, Olivier Hartung, Mathieu Claudel, Florent Vernet, Bianca Dona CHU Nord, Marseille, France The distinguishing feature of the femoropopliteal segment is its high biomechanical stress associated with repetitive knee flexion 1. Despite the improved results seen with more recent stent designs, one of the limitations of stenting in the femoro-popliteal axis is then the potential for stent fracture, with a rate of 12 to 37% at 12 months in larges series, and its implication for mid-term clinical outcome 2-6. These results have been mainly collected in numerous studies of SFA stenting, when very few study focused on popliteal artery stenting for occlusive lesions have been published. This is the reason why we reviewed our patients treated with a popliteal artery stenting (PAS) for occlusive disease only, during a 4 years period. Forty eight patients (30 males; mean age: 74 years, 45-90), including 17 diabetics (35%) underwent a PAS in 53 legs (5 bilateral), for critical (n= 43, 81%) or acute ischemia (n= 10, 19%). A complete popliteal artery occlusion was noted in 15 legs (28%), a tight stenosis in 30 legs (57%), a femoro- above-knee popliteal bypass thrombosis in 6 legs (11%) and a popliteal artery trauma in 2 legs (4%). Fifty-six nitinol self-expanding stent were deployed with a mean diameter of 6 mm 5-8 and a mean length of 5 cm (3.8 – 15 cm), in the high (n= 39), mid (n= 10) or low (n=4) portion of the popliteal artery. An early death occurred in 2 patients (4.1%) and an early thrombosis in one case (2%). During a mean follow-up of 13 months (ranging from 1 to 36), 8 thrombosis (16%) and 5 redo stenosis (10%) occurred, symptomatic in respectively 6 and 1 cases. Primary and secondary patency with factors influencing patency will be presented during the oral communication. References
1. Kröger K, Santosa F, Goyen M. Biomechanical incompatibility of popliteal stent placement. J Endovasc Ther 2004;11:686–694. 2. Krankenberg H, Schluter M, Steinkamp HJ, Burgelin K, Scheinert D, Schulte KL, et al. Nitinol stent implantation versus percutaneous transluminal angioplasty in superficial femoral artery lesions up to 10 cm in length: the Femoral Artery Stenting Trial (FAST). Circulation 2007;116:285-92. 3. Laird JR, Katzen BT, Scheinert D, Lammer J, Carpenter J, Buchbinder M, et al. Nitinol stent implantation versus balloon angioplasty for lesions in the superficial femoral artery and proximal popliteal artery: twelve-month results from the resilient randomized trial. Circ Cardiovasc Interv 2010;3: 267-76. 4. Scheinert D, Scheinert S, Sax J, Piorkowski C, Braunlich S, Ulrich M, et al. Prevalence and clinical impact of stent fractures after femoropopliteal stenting. J Am Coll Cardiol 2005;45: 312-5. 5. Duda SH, Pusich B, Richter G, Landwehr P, Oliva VL, Tielbeek A, et al. Sirolimus-eluting stents for the treatment of obstructive superficial femoral artery disease: six-month results. Circulation 2002;106: 1505-9.uda SH, Bosiers M, Lammer J, Scheinert D, Zeller T, Tielbeek A, et al. Sirolimus-eluting versus bare nitinol stent for obstructive superficial femoral artery disease: the SIROCCO II trial. J Vasc Interv Radiol 2005;16: 331-8. 6. Duda SH, Bosiers M, Lammer J, Scheinert D, Zeller T, Tielbeek A, et al. Sirolimus-eluting versus bare nitinol stent for obstructive superficial femoral artery disease: the SIROCCO II trial. J Vasc Interv Radiol2005;16:331-8.
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Diabetic foot ulcers and their consequences not only can represent a major tragedy for the patient and his/ her family, but also place a significant burden on the healthcare systems and society in general. Diabetic patients may develop foot ulcers due to neuropathy (autonomic, sensory, and motor deficits), angiopathy or both. As a result of the additional immunopathy associated with diabetes, the probability of these wounds to become infected is extremely high. Diabetic foot infections can be classified in mild, moderate and severe according to local and systemic signs. Their identification should lead to a prompt and systematic evaluation and treatment, ideally performed by a multidisciplinary team. Decisions concerning empirical initial antibiotic agent(s), desirable route of administration, duration and need of hospitalization should be based on the more likely involved pathogen(s), the severity of the infection, the ulcer chronicity and the presence of significant ischemia. Wound cultures, ideally from ulcer tissue, are strongly advisable and can help guiding and narrowing the antibiotic spectrum. Appropriate wound care and off-loading should not be neglected. When revascularization is required, the correct timing can be crucial for limb salvage. Since the recurrence of ulcer and infection is high, the implementation of appropriate preventive measures can be critical. Ultimately, the definitive goal in the treatment of diabetic foot infections is to prevent the amputation catastrophe.
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L eg arteries Endodistal approach and infected diabetic foot. Why is it still and always a singular challenge? Armando Mansilha, Daniel Brand達o Faculdade de Medicina do Porto, Porto, Portugal
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
L eg arteries Hybrid approach for lower limbs ischemia Franรงois Saucy Unversity Hospital, Lausanne, Switzerland OBJECTIVES A combined open surgery and endovascular approach has a potential interest to improve midterm results of complex revascularization with limited complications. The aim of the study is to evaluate the hybrid approach used in patients with intermittent claudication or critical limb ischemia when multilevel arterial disease is present. Materials and methods: In a prospective study, we included 64 patients (mean age: 71 years) treated by a combined endovascular and open surgical approach between January 2008 and 2011. The patients are followed by a systematic clinical and ultrasound examination to assess the primary, primary assisted and secondary patency which were then analyzed by a Kaplan Meier analysis. Inhospital complications, death and amputation rates were registered a computerized database. A quality of life score (VascQoL) was also used to assess the clinical impact of hybrid revascularization. RESULTS We performed 69 hybrid procedures. Endovascular procedures were achieved to improve outflow in 47/69 (68%) and iliofemoral bypasses were the most frequent open surgical procedures (65%). The primary, primary assisted and secondary patency rate at 1 year were 39%, 66% and 81% respectively. The limb salvage rate was 94.2% The inhospital complication rate was 35%. The death and amputation rate at 30 days was 3%. The technical success was 100%. The clinical stages improvement was observed in 42/64 (61%). The VascQoL score revealed that patients physical activity improved after the revascularization in 58% associated with an improvement of wellbeing in 89%. The mean follow-up was 428 days [4-1140]. CONCLUSION The hybrid approach in multilevel arterial occlusive disease has acceptable midterm patency rates with good limb salvage when critical limb ischemia is present. Endovascular and open surgery are complementary and should be used selectively to improve the global results.
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L eg arteries Extreme distal autologous vein by-pass for limb salvage Giustino Marcucci, Andrea Siani, Federico Accrocca Ospedale San Paolo, Civitavecchia, Rome, Italy
MATERIALS AND METHODS In the last years the endovascular therapy has become the first approach to treat almost all lesions of the CLI also in the TASC II Classification type C and D lesions. However, the results are not always satisfactory, considering that the amputation rate in the last 10 years is not statistically changed. We performed from January 2005 to December 2012 twenty-seven distal extreme by-pass to the posterior tibial or pedidial artery utilizing always a reversed autologous great saphenous vein (GSV). Mean age was 71.5 years (5591), male 21. Twenty-one (91.3%) were diabetic, where almost always a deep debridement of necrotic or infected tissue was associated. A distal arterial cut was at first carried out to have a minimal back-flow. Then the bypass was performed in most cases from the popliteal artery. The good inflow to the pedal arteries allows to save enough foot, to heal in few months the foot wounds. RESULTS No death, but two early graft failures and three major amputations occurred during the perioperative period. Primary patency rate was 81.6% (=22) and secondary patency was 88.8% (=24). Three years primary and secondary patency rate were respectively 74.1% (=20) and 81.6% (=22). Early limb salvage rate was 88.8%, mid-term was 81.6% and fifteen minor amputations were performed in 13 patients. CONCLUSIONS The surgical distal bypass is a still useful and effective strategy in patients with severe lower extremity arterial disease.
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OBJECTIVES In patients with critical limb ischemia (CLI) with associated foot tissue loss particularly in the diabetic, the role of the extreme distal autologous vein by-pass for limb salvage is a valid alternative to the failed endovascular treatment.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
References
1. Spinelli F, Stilo F, Benedetto F, De Caridi G, La Spada M. Early and one-year results of infrainguinal bypass after failure of endovascular therapy. Int Angiol. 2011;30:156-63. 2. Pomposelli FB, Kansal N, Hamdan AD, Belfield A, Sheahan M, Campbell DR, Skillman JJ, Logerfo FW. A decade of experience with dorsalis pedis artery bypass: analysis of outcome in more than 1000 cases. J Vasc Surg. 2003;37:307-15. 3. Simons JP, Goodney PP, Nolan BW, Cronenwett JL, Messina LM, Schanzer A; Vascular Study Group of Northern New England. Failure to achieve clinical improvement despite graft patency in patients undergoing infrainguinal lower extremity bypass for critical limb ischemia.J Vasc Surg. 2010;51:1419-24. 4. Taylor SM, Kalbaugh CA, Blackhurst DW, Cass AL, Trent EA, Langan EM 3rd, Youkey JR. Determinants of functional outcome after revascularization for critical limb ischemia: an analysis of 1000 consecutive vascular interventions. J Vasc Surg. 2006;44:747-55.
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The new programs of therapeutic education of patient (ETP), wished by the Haute Autorité de Sante (HAS), must permit to better deal with patients presenting a heavy disease, requiring a multidisciplinary approach. Both medical and paramedical team of the vascular surgery departement emphasized the need for a more specific evaluation of chronic wounds, difficult to treat and prolonging the hospitalizations. Knowledge of increasingly complex wound dressings requires a specific formation. Together wih the Antipain Committee (CLUD) of our unit, we wished to build a team to educate the patient, to deal with his wounds, and to improve its quality of life. This program explains the various administrative and structural steps to create such a network of care and to obtain accrediatation by HAS. Who to contact? Is it necessary to be surrounded ? Who will coordinate this program? To who is it addressed? How is it financed? So many questions which make it possible to work out a solid file. In 2012, 32 patients were selected, 27 were included. Mean age was 73.8 years. Eleven programs were finished, There were 7 abandons, 2 deaths, and 7 programs are still running. Average duration of a finished program was 9.3 weeks. It is very important for an ETP program to lay down a therapeutic objective (here cicatrization) and several educational objectives (resumption of walk, daily activities, etc…) as of the entry in the program. Annual evaluation is required by the HAS to improve the quality of the program. A four-year evaluation will determine if the program works well as a whole to decide its continuation, if necessary its reorientation, or its stop. The development of a therapeutic program of education makes it possible to better coordinate the assumption of responsibility of the patients presenting of the chronic wounds. The follow-up of the dressings is improved by a specific consultation by a graduate nurse. We noted the importance of the educational objectives for the patients so that they better live their vascular disease. References
HAS-Inpes. 2007. Guide méthodologique. Structuration d’un programme d’éducation thérapeutique du patient dans le champ de la maladie chronique HAS. 2012. Auto-évaluation annuelle d’un programme d’éducation thérapeutique du patient. Guide pour les coordonnateurs et les équipes.
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L eg arteries Why and how educate patients with chronic wound of the leg Armand Bourriez, Jean Sabatier, Magalie Julien Clinique de l’Europe, Rouen, France
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION I: DEEP VEIN AND PERFORATOR S Deep venous reconstructive surgery for CVI. New procedures and tricks Oscar Maleti Hesperia Hospital, Modena, Italy Post thrombotic deep vein incompetence is an incapacitating disease which can lead to severe chronic venous insufficiency in most cases. Post thrombotic lesions are essentially of two types: - obstruction of various degree or occlusion - valve destruction with subsequent reflux. These two elements are variously correlated at different level. The most frequent correlation is proximal occlusion or obstruction (iliac level) associated with subinguinal reflux (below the inguinal ligament). The leading technique for treating proximal obstruction is stenting. Conversely the leading technique for treating obstruction located below the inguinal ligament is endophlebectomy. When we treat conditions characterized by proximal obtruction and distal reflux, the treatment should be divided into two actions. This allow us to check the degree of improvement obtained after the first treatment. The treatment of deep venous reflux in PTS is based on a precise strategy deriving from an accurate diagnostic phase, based on the integration of several investigation: duplex, venography in multiple projections, selective venography, air plethysmography, IVUS, CT scan or RMN in selected cases. This phase should give us information useful in addressing the treatment. The information we need is: - confirmation / exclusion of proximal obstruction / occlusion; - presence of axial reflux below the inguinal ligament, from groin to calf, via femoro-poplitea or by superficial or profunda transfer; - presence / absence of proximal competence of profunda vein; - profunda re-entry point; - feasibility of reaching the re-entry point by means of endovascular procedures; - presence and competence of great saphenous vein; - features at popliteal level (single or multiple popliteal vein); - calibre of femoral and popliteal vein; - the inflow of femoro-popliteal axes and if it improves after calf contraction; - calibre and competence of axillary vein; - presence of a double channel. The features described above address different technical choices. References
1. Perrin M, Gillet JL, Guex JJ. Syndrome post-thrombotique. Angéiologie 2003;19 (2040):12. EMC (Elsevier Masson SAS, Paris) 2. Neglen P, Hollis KC, Olivier J, Raju S. Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical and hemodynamic results. J Vasc Surg 2007;46:979-90. 3. Raju S, Darcey R, Neglen P. Unexpected major role for venous stenting in deep reflux disease. J Vasc Surg 2010;51:401-9 4. Puggioni A, Kistner RL, Eklof B, Lurie F. Surgical disobliteration of post thrombotic deep vein - endophlebectomy – is feasible. J Vasc Surg 2004;39:1048-52 5. Maleti O, Lugli M. Perrin M. Syndrome post-thrombotique. EMC – Cardiologie 2013;8(2):1-12 [Article 11-740-A-10]. 6. Kistner RL. Surgical repair of venous valve. Straub Clin Proc 1968;24:41-3 7. Kistner RL, Sparkuhl MD. Surgery in acute and chronic venous disease. Surgery 1979;85:31-43 8. Taheri SA, Lazar L, Elias S, Marchand P, Heffner R. Surgical treatment of postphlebitic syndrome with vein valve trans-plant. Am J Surg 1982;144:221-4 9. Maleti O, Lugli M. Neovalve construction in postthrombotic syndrome. J Vasc Surg 2006;43:794-9 10. Perrin MR. Results of deep vein reconstruction. Vasc Surg 1997;31:273-5 11. Rosales A, Jorgensen JJ, Slagsvold CE, Stranden E, Risum O, Kroese AJ. Venous valve reconstruction in patients with secondary chronic venous insufficiency. Eur J Vasc Endovasc Surg 2008;36:466-72 12. Lugli M, Guerzoni S, Garofalo M, Smedile G, Maleti O. Neovalve construction in deep venous incompetence. J Vasc Surg 2009;49:156-62
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What is the difference between the saphenous veins and the perforators? All penetrates the deep fascia transporting blood from the superficial venous system into the deep venous system and basically the saphenous veins are like two large perforators, that we gladly treat if they become incompetent. Why should we act differently regarding perforators? We know that perforator incompetence adds to global incompetence and to reduce incompetence perforator interruption is a way of achieving just that. It has been claimed that incompetent perforators (IPs) in superficial venous disease are just serving as re-entry points for the refluxing blood in saphenous veins and that the majority becomes normalized by simply treatment of the saphenous reflux. Unfortunately in real life that occurs very seldom. Two RCTs have shown that at most 30-40% regains competence but the majority remains incompetent1,2!Another common misunderstanding is that incompetent perforators are only harmful if they are combined with axial deep vein incompetence down to the actual perforator. That would probably be true if we were statues that never moved, but we do walk and that changes the situation. When we walk blood is forced up in the deep leg veins and if there is an incompetent perforator the blood will choose the easiest escape route, which leads to reflux in the perforator and a dramatically raised ambulatory venous pressure in the subcutaneous veins around the perforator. This can only be measured by cannulating a superficial vein connected to the perforator and might not show if a foot vein is cannulated. Therefore IPs in legs with or without superficial incompetence alone can also require treatment. Unfortunately such treatments are not as easily done as regular superficial varicose vein interventions and require certain skills, no matter which treatment option that is chosen. The number of IPs is linked to the severity of venous disease and it is also linked to varicose vein recurrence. It is difficult to see why most other incompetent veins ought to be treated and not perforators. Short term it is true that we have not seen any benefit of perforator interruption compared to superficial surgery alone, both regarding patients with leg ulcers2 and patients with less severe venous disease1. Very few C2-C3 patients have IPs and seldom require treatment whilst among leg ulcer patients the majority shows IPs. The lowest leg ulcer recurrence rates have been reported from series where superficial surgery and perforator interruption have been performed3. In a US series of hard to heal venous ulcers perforator ablation seemed to make a difference4. If you do not offer patients full treatment you will experience a less satisfying result and you will create unnecessary suffering for your patients. Although we do not have full scientific high level proof we know enough not to leave IPs in patients with severe venous disease1-5. References
1. Kianaifard et al. Br J Surg 2007;94:1075-80. 2. Nelzén et al. Br J Surg 2011;98:495-500. 3. Nelzén et al. Eur J Vasc Endovasc Surg 2007;34:605-12. 4. Lawrence et al. J Vasc Surg 2012;53:446-50. 5. Nelzén et al. Eur J Vasc Endovasc Surg 2012;46:372-7.
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ESSION I: DEEP VEIN AND PERFORATOR S Do we need to treat legs perforator vein? Pros Olle Nelzén Dept Vascular Surgery, Skaraborg Hospital, Skövde, Sweden
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION I: DEEP VEIN AND PERFORATOR S Do we need to treat legs perforator vein? Cons Jean-Jérôme Guex Cabinet de phlébologie, Nice, France We don’t need to treat medial leg perforators (formerly Cockett’s + Boyd’s + Dodd’s, etc ...) (MLPVs) They are an epiphenomenon of GSV insufficiency, essentially a drainage/re-entry for refluxing blood of GSV. Seldom existing alone apart from deep venous reflux (PTdisease) They usually disappear after treatment of GSV They are not usually responsible for skin changes Their treatment does not improve clinical results does not reduce recurrences Is not satisfactory surgery: Linton, SEPS, Stab avulsion Sclerotherapy: in the PV itself SO WHAT IS LEFT ? Criteria for possible treatment of a MLPV: PV has criteria of incompetence: x> 5mm, reflux > 0.5 sec PV remains huge (>5mm) and refluxing even after GSV ablation or there is NO incompetent GSV Is above a significant varicose cluster Rx of GSV not followed by clinical improvement POSSIBLE TREATMENTS US Guided foam ablation (not in PV itself since a small collateral artery is at risk of being injected). And Thermal ablation with special probes under US guidance have outdated all surgical techniques MAY BE USED IN SCANT SELECTED CASES HOWEVER, we need to treat other PVs: Femoral canal PVs have the same role as SFJ and SPJ and must be taken care of ! Lateral PVs as well as long as they «feed» a varicose network Subgluteal as well Gastrocnemian PVs are possibly reentries for SSV incompetence, same strategy as GSV and MLPVs Therapeutic options are the same: foam or thermal, with preference for foam
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ESSION I: DEEP VEIN AND PERFORATOR S Acute thrombosis for ilio femoral vein: thrombolysis or pharmaco-mechanical thrombolysis? Anthony Comerota Jobst Vascular Institute, Toledo, USA Acute iliofemoral deep vein thrombosis (DVT) is associated with the most severe postthrombotic morbidity when treated with anticoagulation alone. Successful catheter-directed thrombolysis (CDT) has been shown to reduce postthrombotic morbidity, improve quality of life, and reduce recurrent DVT. The question is, what is the best method of catheter-based therapy?
Pharmacomechanical techniques have been shown to reduce treatment time and improve success. Vedantham et al.2 demonstrated that pharmacomechanical techniques were significantly more effective than mechanical techniques alone. Lin et al.3 demonstrated significant advantage of pharmacomechanical techniques versus CDT alone with a reduction in the number of venograms, shorter ICU stay, shorter hospital stay, and fewer blood transfusions. Ultrasound accelerated thrombolysis was studied by Parikh et al.4 where they demonstrated a shorter infusion time and fewer bleeding complications with the ultrasound-accelerated catheter compared with historical controls of CDT. Martinez et al.5 evaluated isolated segmental pharmacomechanical thrombolysis versus CDT alone and demonstrated improved success, shorter treatment time, and lower doses of rt-PA delivered when the double-balloon pharmacomechanical technique was used. The addition of external pneumatic compression devices to the leg being treated with CDT has been shown to accelerate lysis compared to non-compressed limbs.6 In summary, pharmacomechanical techniques appear to improve lytic success, reduce treatment time, and reduce the necessary dose of plasminogen activators in catheter-based procedures for patients with iliofemoral DVT. References
1. Sillesen H, Just S, Jorgensen M, Baekgaard N. Catheter-directed thrombolysis for treatment of ilio-femoral deep venous thrombosis is durable, preserves venous valve function and may prevent chronic venous insufficiency. Eur J Vasc Endovasc Surg 2005;30(5):556-62. 2. Vedantham S, Vesely TM, Parti N, Darcy M, Hovsepian DM, Picus D. Lower extremity venous thrombolysis with adjunctive mechanical thrombectomy. J Vasc Interv Radiol 2002 Oct;13(10):1001-8. 3. Lin PH, Zhou W, Dardik A, Mussa F, Kougias P, Hedayati N, et al. Catheter-direct thrombolysis versus pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis. Am J Surg 2006 Dec;192(6):782-8. 4. Parikh S, Motarjeme A, McNamara T, Raabe R, Hagspiel K, Benenati JF, et al. Ultrasound-accelerated thrombolysis for the treatment of deep vein thrombosis: initial clinical experience. J Vasc Interv Radiol 2008 Apr;19(4):521-8. 5. Martinez Trabal JL, Comerota AJ, LaPorte FB, Kazanjian S, DiSalle R, Sepanski DM. The quantitative benefit of isolated, segmental, pharmacomechanical thrombolysis (ISPMT) for iliofemoral venous thrombosis. J Vasc Surg 2008 Dec;48(6):1532-7. 6. Ogawa T, Hoshino S, Midorikawa H, Sato K. Intermittent pneumatic compression of the foot and calf improves the outcome of catheter-directed thrombolysis using low-dose urokinase in patients with acute proximal venous thrombosis of the leg. J Vasc Surg 2005 Nov;42(5):940-4.
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Sillesen et al.1 reported a 93% technical success rate and one-year patency with normal valve function of 93% in 45 patients treated with CDT for iliofemoral DVT. However, mean treatment time was 71 hours, an obligation that may exceed that available to many clinicians and tax the patience of those being treated.
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION I: DEEP VEIN AND PERFORATOR S Behcet disease: an atypical DVT. Diagnosis and treatment Mohamed Bouayed, Y. Bachaoui, N. Turqui Universitary hospital, Oran, African countries BACKGROUND Venous disease is relatively common in Behcet’s disease. It often occurs by deep vein thrombosis (DVT) which have some changes and atypical seats. The purpose of this work, through the study and monitoring of a series of 73 DVT and through a literature review is to present the clinical, evolution and therapeutic DVT Behcet’s disease. MATERIALS Series of 73 patients is analyzed. The study is both retrospective and prospective.This last has started in our department in July 2010 and aims to assess the value of combination therapy (anticoagulants, corticosteroids, immunosuppressive drugs ) in some atypical locations of DVT of Behcet’s disease. 30 cases have an atypical form with sometimes unusual seats : subclavian (4 cases), axillary (2 cases), innominate trunk (two cases), superior vena cava (6 cases), inferior vena cava (5 cases), portal and cava (1 case), splenocolic venous trunk (1 case), great saphenous and common femoral vein (10 cases). These were often multiple locations at the same patient. The DVT is opening the disease Behcet in 8 cases. The anticoagulant which has treated the most recent patients is Rivaroxaban. Anti-vitamin K are not currently prescribed in our patients. RESULTS In cases where the diagnosis was made relatively late thrombosis tended to expand rapidly and attract a different seat. There were no cases of pulmonary embolism. Medical treatment was effective in all patients. 10 patients relapsed after stopping treatment. Among all other patients who did not stop treatment, there were three recurrences. CONCLUSION DVT Behcet’s disease may have atypical and unusual seats. The locations are often multiples. Extension of thrombosis is fast. The medical treatment is often effective. There are readily recurrent DVT from medical treatment discontinuation.
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ESSION II: WHAT HAS CHANGED IN THE PAST 10 YEARS? S Evolution of the duplex in the past 10 years Philippe Lemasle Le Chesnay, France
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For 10 years, the duplex scan has improved considerably, both in terms of ultrasound defined in terms of flow detection. This improved definition ultrasound is used to view sub-millimeter anatomical structures. The flow imaging, especially the wideband power mode used to view currently slow flow in vessels on the order of 0.5 mm. The only real question is whether these technical improvements allow better management of superficial venous insufficiency: It is important to accurately determine the character terminal or pre-terminal reflux of the saphenofemoral junction, where the current trend is not to intervene at its level?
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION II: WHAT HAS CHANGED IN THE PAST 10 YEARS? S Does long term follow-up confirm that high ligation is an obsolet procedure? Olivier Pichot CHU de Grenoble, Grenoble, France Sapheno-femoral junction (SFJ) residual stump and neovascularization are considered to be the main causes of recurrence after surgery; that is why surgeons have emphasized the necessity to perform an extended high ligation (flush sapheno-femoral ligation and ligature-section of the related SFJ tributaries), even if no surgical technique artifice has been demonstrated to be effective to really avoid SFJ neovascularization. Thermal and chemical ablations of the saphenous veins have introduced a new treatment concept based on the trunk ablation alone with preservation of the SFJ. Mid-term follow-up already demonstrated that this approach decrease significantly the incidence of neovascularization, but persistence of a saphenous stump could be considered as a remaining risk factor for recurrence. 1 Endo-venous procedures are used since more than ten years for the treatment of varicose veins of the lower limbs, and five years follow-up studies are now available. Five years is accepted to be a long-term follow-up, since this interval is long enough for the development of clinical recurrence.2 Even if high ligation and stripping has been considered as the gold standard, van Rij at long-term follow-up has observed clinical recurrence in 51% of the cases, and anatomical recurrence on duplex, in 23% of the cases at the SFJ and 52% of the cases at the sapheno-popliteal junction (SPJ), neovascularization accounting for 85% of recurrences at the SFJ and 62% of recurrences at the SPJ. 3 At 14 years follow-up after GSV primary surgery, Nelzen has observed with duplex groin recurrence in 38 % of the case, including residual stump and neovascularization. 4 At 5 years follow-up after radiofrequency (ClosurePlus®), clinical recurrence was observed in 27.4%, with an obliteration rate of 87.2%. During follow-up cases of failure was related to three different mechanisms: primary non occlusion (12.4%) , total or partial recanalisation (69.7%), or SFJ reflux draining in a lower thigh tributary (17.8%). 5 ClosureFast® improved the outcomes of radiofrequency with an occlusion rate of 91.9% and a reflux-free rate of 94.9% at 5 years follow-up. Clinical recurrence was observed as scattered varicose veins in 40.7% at 5 years but only 5.9% of the treated limbs had multiple varicose veins originating from the GSV. In a randomized prospective study, Rasmussen did not find any difference at 5 years follow-up between endovenous laser (EVL) and surgery with clinical recurrence observed in respectively 46.6 and 54.6%. On duplex reflux was observed in the groin respectively in 8 and 4% of the cases with more frequent reflux in the anterior accessory saphenous vein (AASV) after EVL and more frequent reflux in thigh perforators after surgery. 6 Because ultrasound guided foam sclerotherapy (UGFS) allows sequential sessions to perform reflux and varicose vein ablation, a precise comparison with surgery and thermal ablation is difficult to perform. Nevertheless, in Chien-Hsun Chen study, with a mean follow-up interval of 37.8 months (18-68), occlusion was achieved in 60.1% of the legs after one session of foam sclerotherapy, in 29.5% additional legs after a second session, and in 8.3% additional legs after a third session. 1.47 session was necessary to achieve GSV occlusion in the 19 patients with a follow-up period of longer than 5 years.7 All the available data on long-term follow-up do not demonstrate an inferiority of endovenous ablation, whatever the technique used, compared to surgery. We can conclude that high ligation is not useful in the treatment of saphenous reflux. References
1. Lurie F, Creton D, Eklof B, Kabnick L, et al. Prospective Randomised Study of Endovenous Radiofrequency Obliteration (Closure) Versus Ligation and Vein Stripping (EVOLVeS): Two-year Follow-up. Eur J Vasc Endovasc Surg 2005 : 29, 67–73 2. De Maeseneer M, Pichot O, Cavezzi A et al. Duplex ultrasound investigation of the lower limbs after treatment for varicose veins e UIP consensus document. Eur J Vasc Endovasc Surg 2011;42: 89-102. 3. van Rij AM, Jiang P, Solomon C, et al. Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmograpy. J Vasc Surg 2003;38: 935-43. 4. O. Nelzén O, Fransson I. Varicose Vein Recurrence and Patient Satisfaction 14 Years Following Combined Superficial and Perforator Vein Surgery: A Prospective Case Study. Eur J Vasc Endovasc Surg 2013 ; 46: 372-7. 5. Merchant R and Pichot O. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg 2005; 42:502-9. 6. Rasmussen L, Lawaetz M, Bjoern L, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation and stripping of the great saphenous vein with clinical and duplex outcome after 5 years. J Vasc Surg 2013; 58:421-6. 7. Chien-Hsun Chen, Cheng-Sheng Chiu, Chih-Hsun Yang. Ultrasound-Guided Foam Sclerotherapy for Treating Incompetent Great Saphenous Veins - Results of 5 Years of Analysis and Morphologic Evolvement Study
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What were the main changes in Phlebology over the past decade? Allow me to cherry pick some of the most relevant topics, deliberately not focusing on recent improvements in anticoagulation, thrombolysis, thrombectomy, stents, deep vein reconstructive surgery and embolization. Firstly, new technologies have emerged. The invention of foam and the generalization of ultrasonography have dramatically impacted sclerotherapy: injections can now accurately reach their desired targets (superficial and intrafascial veins). Thermic endovenous procedures (radiofrequency, laser, steam) can be performed under tumescent local anaesthesia, and only require minimal sick leave for patients. While these new technologies are likely to disseminate rapidly if European insurance companies recognize them, they could also become obsolete. Indeed, the preliminary encouraging results of substitute treatments like the injection of cyano-acrylate glue close to the junction just need confirmation. Likewise, surgery is also progressing thanks to the new hemodynamic concepts derived from Mullerâ&#x20AC;&#x2122;s phlebectomy. As such, ablating the varicose reservoir while conserving the saphenous vein became a valid option. Secondly, our understanding of compression therapy (specifically, on the symptoms and for the treatments of venous ulcers) has increased. The new dressings of leg ulcers represent a major advance, at least from a commercial perspective! Nevertheless, the suppression of reflux (surgery, sclerotherapy) remains much more important, and the relevance of ulcer excision has been validated in chronic cases. Thirdly, some treatments have disappeared during the last decade, including SEPS and paratibial fasciotomy. Despite their good results, these treatments certainly fell victim to the exaggerated enthusiasm that surrounded their introduction. Going forward, and because of the broad spectrum of chronic venous disorders, we should develop skills in numerous techniques. It is in the best interest of our patients!
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ESSION II: WHAT HAS CHANGED IN THE PAST 10 YEARS? S What has changed in phlebology in the past 10 years Albert-Adrien Ramelet Dpt of Dermatology, Bern, Switzerland
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ESSION II: WHAT HAS CHANGED IN THE PAST 10 YEARS? S Treatment of C2 varicose vein. It should never be reimbursed Lowell Kabnick New York University Vein Center, New York, USA I know that I am not going to be appreciated for my answers to the debate that C2 venous disease should not be a covered expense. We all agree that C2 disease alone, without symptoms, should not be covered. After all, even advanced venous disease should be treated for quality of life improvement. Perhaps this debate should be framed concerning C2S. The essential question regarding C2S disease is how to quantitate symptoms and the number of people that will advance to chronic venous disease. In reality, we do not have the answers. I know all of us would agree that advanced venous disease should be treated. Yes, we have a metric for those classifications: C3 swelling, C4 pigmentation changes and more, C5 healed ucer, and C6 open ulcer. The Bonn 2 Study demonstrated that there is a 4.8% progression from C2 disease to more advanced disease1; however, we are not able to isolate the subset that advances. In another epidemological study, only 3% of patients progressed to more advanced disease.2 In summary, I will show my colleagues: 1. all patients with C2 disease should not be treated 2. treatment of all C2 disease is not cost effective 3. the stratification of C2 disease with other objective modalities (VCSS) and patient reported outcomes would be more cost effective and appropriate to improve the quality of life. References
1. Rabe E, Pannier F, et al. Incidence of Varicose Veins Chronic Venous Insufficiency and Progression of Disease in the Bonn Vein Study 2. (personal communication) 2. Kostas T, et al. Chronic venous disease progression and modification of predisposing factors J Vasc Surg. 2010 Apr;51(4):900-7
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ESSION II: WHAT HAS CHANGED IN THE PAST 10 YEARS? S Treatment of C2 varicose vein. It should be reimbursed Eberhard Rabe1, Felizitas Pannier2 1. Department of Dermatology, University of Bonn, Bonn, Germany 2. Department of Dermatology, University of Cologne, Cologne, Germany INTRODUCTION Chronic venous disorders are among the most common diseases in the world. METHODS In the Bonn Vein Study I (BVS I), conducted in 2000, 3072 participants of the general population aged 1879 years took part in this study (1350 men, 1722 women). In a follow-up study 6.6 years later, the same population was investigated again. The aim was to identify the incidence of newly developed chronic venous disorders and of progression of pre-existing CVD. The participants were examined by clinical means and by duplex ultrasound in the same way as in BVS I. The response at follow-up after 6.6 years was 84.6%. RESULTS The prevalence for varicose veins (VV) rose from 22.7 to 25.1% and for CVI from 14.5 to 16%. The incidence for new varicose veins was 13.7% and for new CVI 13.0% per 6.6 years increasing with age. Participants with C-Class C2 as a maximum at BVS I increased to higher C-classes in 19.8% (nonsaphenous VV) and in 31.8% (saphenous VV). These results show a high incidence of app. 2% for varicose veins and for CVI per year. In the same time the incidence of progression to higher C-classes is very high. Risk factors for progression are higher age, obesity and presence of corona phlebectatica. SUMMARY Prevalence of CVI will increase in the future. VV should be treated in early C-stages to prevent VV in C2 to progress to CVI from venous edema to venous ulcers. Progression of C2 to higher C-stages reaches 31.8% in saphenous and 19.8% in non-saphenous VV in 6.6 years. At least those in C2-stage and on higher risk for progression should be treated early.
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Saturday January 25
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION III: VASCULAR MALFORMATIONS. S CLASSIFICATION AND TREATMENT Vascular malformation classification: Hamburg or ISSVA classification? Annouk Bisdorff-Bresson1, Michel Wassef1, Claude Laurian2, Gilles Soulez3, Emmanuel Houdart1 1. Hôpital Lariboisière, Paris, France
2. Hôpital Saint Joseph, Paris, France 3. Mc Gill, Montreal, Canada
The term “angioma” is often incorrectly used in the literature to name both vascular tumors and vascular malformations. It is important to have a common definition and language concerning “vascular anomalies” and to differenciate between tumors and malformations as their treatment options /follow up is different. Vascular malformations are congenital developmental errors concerning either lymphatic, arterial or/and the venous system. They might be present at birth, but are not always seen. They can appear at childhood, adolescence, or adulthood but will never disappear. They tend to grow proportionately at the same rate as the child. Tumors are made of proliferating endothelial cells, often associated with other vascular cells. They grow non-proportionately and some types (infantile hemangioma) tend to involute spontaneously. ISSVA classification is a very simple, binary clinical classification : differentiating vascular tumors (endothelial cell proliferation associated or not to high flow vessels) from vascular malformations (high and slow flow malformations divided in capillary, venous, lymphatic and arterial) and their complex combined syndromes (MCVL, PKW, KT…). It is a very helpful classification for a correct clinical diagnosis. . Wheras the Hambourg classification is a more complicated classification mainly used by vascular surgeons. It also classifies vascular malformations according to the type of predominant vessel. In each type, the classification differentiates truncular and extratruncular lesions and localized (limited) and infiltrating lesions. The concept of truncular lesions (malformation of large individual vessels) is clinically helpful as, for example, the risk of pulmonary embolism is different in truncular and extratunkular lesions. This differentiation might be helpful for a better understanding of the duplex ultrasound exam and for a more adequate treatment choice upon these results. Both classifications are quite different but each of them helps for a better understanding especially in lower and upper extremity VM’s as they are often made of large dysplastic vessels.
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ESSION III: VASCULAR MALFORMATIONS. S CLASSIFICATION AND TREATMENT Embolic agents to treat venous and lymphatic malformations: an overview of the past 10 years Annouk Bisdorff-Bresson1, Gilles Soulez2 1. Hôpital Lariboisiere, Paris, France 2. Mc Gill, Montreal, Canada
VM and LM’s are slow flow vascular malformations based on ISSVA classification. Consisting of abnormal dilated vascular channels lined by mature endothelium . The most important characteristics bearing an effect on sclerotherapeutic efficacy concerning Vm’s: is that of the venous drainage as described by Dubois and collegues and its location. In LM’s the adequate sclerosant agent choice, depends on the cyst size (macro ou microcysts), location and the patients’ age and weight. Sclerotherapy is a technique used to treat vascular slow flow malformations whereby a sclerosing agent is introduced into the endoluminal compartment to initiate vascular thrombosis and endothelial cell destruction most frequently by direct puncture technique. It is performed by an experienced interventional radiologist using a sclerosant (Ethanol 96 %, Aetoxisclerol foam 0,5 –3 %,Thrombovar, STS, glue, Onyx, bleomycine, doxycycline,…) under fluoroscopy and ultrasound guidance. It is an efficient procedure especially for well limited VM. Large pouches or deep draining veins expose to the risk of recanalisation and /or general sclerosant diffusion. Complications such as prolonged local swelling, skin necrosis, neural damages and cardiac arrest have been described with different agents. Endovascular diode laser treatment has shown good results in small VM lesions of the head and neck region (<2 cm) and on lymphatic vesicles. No major major new agents have been described lately. Ethanol remains the most efficient agent. Bleomycine gives promising results in VM and Lymphatic malformation treatments. Ethanol gel has just come up to the market and its efficiency needs to be verified on long term results. The “perfect agent” still doesn’t exists. Treatment aim is to occlude the venous pouch and avoid major efflux to the draining vein. Therefore the agent needs to be liquid , but also “controllable” and made out of a resorbable material, as most of the slow flow malformations are located in superficial and soft tissue areas. References
1. Bisdorff A , Mazighi M, Saint Maurice JP, Chapot R , Lukaszewicz AC, E Houdart. Ethanol threshold doses for systemic complications during sclerotherapy in venous malformations: a retrospective study. Neuroradiology 2011 Nov; 53 (11):891-4 2. Dompmartin A, Blaizol X, Theron J, Hammer F,Boon LM et al. Radio-opaque Ethycellulose-ethanol is a safe and efficient sclerosing agent in venous malformations. Eur Radiol. 2011 Dec;21(12):2647-56 3. Puig S, Aref H, Chigot V, Bonin B, Brunelle F. Classification of venous malformations in children and implication for sclerotherapy. Pediatritr Radiol 2003; 33:99-103. 4. Liu Y, Liu D, Wang Y, Zhang W, Zhao F. Clinical study of sclerotherapy of maxillofacial venous malformation using absolute ethanol and pingamycine. J Oral Maxillofac Surg 2009; 67:98-104
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Saturday January 25
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION III: VASCULAR MALFORMATIONS. S CLASSIFICATION AND TREATMENT Do we always need to target the nidus in AV-malformations? Point of view of the vascular surgeon Martin Malina Vascular Center, Skane Univ. Hospital, Malmรถ, Sweden High-flow arteriovenous (AV) malformations may present as limb- or life threatening lesions that are inaccessible for radical surgery. Attempts to treat AV malformations by surgical or endovascular obliteration of the afferent (feeding) vessels is generally considered futile because the shunt is likely to recur when new collaterals develop. Recurrence is more diffuse and thereby difficult or impossible to treat. Permanent obliteration of the nidus itself is for this reason regarded as the treatment of choice. Obliteration of the nidus, however, is challenging to achieve by embolisation because small particles or too gentle sclerosing agents pass through the nidus without obstructing it. Alternatively, particles may congest the afferent vessels without reaching the nidus, thereby leaving behind patent collaterals. The presence of multiple afferent and efferent vessels makes treatment even more difficult. For this reason, highly potent sclerosing agents such as alcohol are often used. Alcohol sclerotherapy is potentially dangerous and may cause severe local damage or systemic complications. Depending on the location of the lesion, limb loss, extensive gangrene or visceral injuries occur. Yet, the natural course of AV-malformations is difficult to predict: While some fistulas grow continuously, others remain stable for long periods of time. Furthermore, some high flow AV malformations do respond to particle embolisation favourably. The selection of patients for aggressive alcohol embolisation is therefore difficult. We present cases where the natural course of the AV malformation or its response to embolisation was surprisingly benign and durable although the nidus itself was not targeted. Potentially, some of these patients would have been injured by radical sclerotherapy or died if left untreated.
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ESSION III: VASCULAR MALFORMATIONS. S CLASSIFICATION AND TREATMENT Do we always need to target the nidus in AV-malformations? Point of view of the interventional radiologist Gilles Soulez1, Josee Dubois2, Annouk Bisdorff3 1. CHUM-University of Montreal, Montreal, Canada 2. CHUSJ-University of Montreal, Montreal, Canada 3. Hopital Lariboisière, Paris, France
The nidus of an arterio-venous malformation is defined by the site of the abnormal arterial network where the shunting between the arterial and the venous system occurs. The aim of the embolization is to close the AV shunting which is responsible of potential deleterious effect such as distal ischemia, venous congestion or hemorrhagic complications. In this setting, the nidus must always be targeted. However, depending of the anatomy of the AVM the approach to reach the nidus can be different. The most common and efficient way to close the AV-shunting is to embolize the nidus from the arterial side. This can be done endovascular approach or by direct puncture using a liquid embolic agent. Ethanol, cyanoacrylate or Onyx are liquid agents commonly used for AVM embolization. Ethanol combines embolizing and sclerosing properties and is less prone to recurrence after embolization. A venous approach can be used to close simultaneously the fistula and the nidus. Usually, the venous approach is performed after completion of embolization sessions on the arterial side by endovascular and percutaneous approach in order to decrease the flow. Thus, it is easier to close the draining vein with a mechanical agent (coils, Amplatzer plug) and complete sclerosis and obturation of the nidus by retrograde injection of liquid agent. In case of AV-Fistula, there is no nidus but only an abnormal communication between the artery and the vein. These direct fistulas can be closed by a mechanical embolization (coils, Amplatzer). Proximal occlusion on the arterial side must always be avoided since it will block the route for nidus embolization and stimulate the growth of the AVM.
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Saturday January 25
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION IV: LIVE ULTRASOUND AND VIDEO S Video. How to have homogenic and reproducible foam Jean-Luc Gérard Henri Mondor Hospital, Créteil, France Even if sclerotherapy has been a well-known practice for a long time, there is no consensus about a real standardized procedure and can vary greatly according to different practitioners. Several parameters can interfere with the results between 2 practitioners, especially concerning the sclerosing agent, the choice of the gas component, the liquid-to-gas ratio, the type of syringes, the diameter of the needles, or the choice of short/long catheters and the speed of puncturing the vein after preparing the foam and finally the speed with which the foam is injected. The quality of the bubble can vary with the type and concentration of the detergent. Frullini was most likely the first to emphasize that silicon, which is present in catheters and plastic syringes, interferes with the structure of the sclerosing foam by breaking the links of polar macromolecules thus reducing the half-life of the foam. The foam injected through a needle of varying gauges or a Venflon can affect the bubble size distribution and at least a 25-gauge could be the minimum size requisite. The foam is formed by mixing the liquid sclerosant with more often 4 parts of air, (1 part liquid to 4 parts gas) through 10 to 20 passes between the two syringes. Air is pushed from one syringe to another through a small connector piece with rapid and repeated movements (back and forth) of the plunger to create foam. Most often, a three-way topcock or female- female Luer Lock connector (double syringe system) are used. With the 3 ways, the hub is turned at about 30° rotation. This rotation narrows the stopcock passage generating high turbulence, but the quality of the microfoam depends on the degree of rotation of the hub which is more or less 30°. With the female-female Luer Lock connector the foam is more reproducible and does not depend on the angle of the hub rotation. All of these parameters can variably influence the results of foam sclerotherapy but limiting the variation of quality of the foam should not be dependent on the angle of hub rotation with a 3-way connector and therefore the double female-female syringe should be recommended References
Rabe E, Breu F, Cavezzi A, Smith PC, Frullini A, Gillet J, Guex J, Hamel-Desnos C, Kern P, Partsch B, Ramelet A, Tessari L, Pannier F. European guidelines for sclerotherapy in chronic venous disorders. Phlebology. 2013 Apr 4 Van Deurzen B, Ceulen RP, Tellings SS, VAN DER Geld C, Nijsten T. Polidocanol concentration and time affect the properties of foam used for sclerotherapy.Dermatol Surg. 2011 Oct;37(10):1448-55
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The direct puncture injection with a needle has always been the most widely used technique in visual sclerotherapy. This is also true when US guidance is used. The needle is directly attached to the syringe containing the foam sclerosant. Puncture and injection are performed directly into the target vein. The syringe will usually hold 2.5 ml or 3 ml, though some practitioners prefer 5 ml syringes. Siliconed syringes are preferable for a safer injection but some specialists prefer or unsiliconed syringes in order to preserve the quality of the foam. Little siliconed syringes represent a good compromise. The whole procedure is performed entirely under US control; the dominant hand performs the injection while the other holds the probe. For US guidance, one of the difficulties is that the image seen on the screen is in two dimensions, so the brain has to adapt. In addition, brain has to manage both hands acting separately. ECHOGRAPHIC SECTIONS The US frequency used is usually between 10 and 16 MHz. The US assessment is made in the B mode, pulse mode and color mode; both echographic sections, longitudinal and cross are used. The injection itself is performed in the B mode. The echographic section used for the injection may be a longitudinal or a cross (transversal) section, but intermediate sections are also possible, especially if the vein is sinuous. In longitudinal section: the probe is positioned parallel to the vein. The needles used should preferably be 22 Gauge (or at least 23 G), with a diameter of 0.7 mm and a length of 40 mm. The angle at which the needle is held in relation to the plane of the skin is generally 30-45° but it may vary depending on the thickness of the tissue through which it must penetrate. Through this section, the ultrasound image is better than that obtained with the cross section: the vein, with its anterior and posterior walls, and the needle are visible in great length; the good distribution of the foam into the vein can be easily checked. However, one must keep in mind that one of the difficulties of this section is that the US beam is much thinner than the transducer (thickness of the US beam is about 1 mm only). In transversal section: the probe is positioned perpendicularly to the vein. The length of the needle varies depending on the depth of the varicose vein. So, for choosing the adequate needle, distance from the selected location for puncturing the skin to the center of the target vein is measured. Note that the site chosen for puncturing should not be too close to the probe. Through the cross section, it is easier to reach the US beam, so that it would seem more comfortable for beginners. In addition, the entire vein wall (anterior, lateral, posterior walls) is visible. However the echographic images of the vein and of the needle are small: vein appears like a ring and needle like a dot. Consequently, the operator must ensure that the tip of the needle is well-positioned in the center of the vein lumen. In fact, the posterior wall can easily be crossed, with the needle tip in extravascular position. Others Depending on the vein sinuosities, especially for recurrent varicose veins, some intermediate sections can be used: for example, the probe is in a longitudinal position but the echographic image is transverse (vein image appears as a ring). CONCLUSION Two basic echographic sections can be used for US guidance puncture, the longitudinal and the cross sections. Both have advantages and disadvantages or even pitfalls that must be known by the practitioners.
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Saturday January 25
ESSION IV: LIVE ULTRASOUND AND VIDEO S Video. Ultraguidance puncture: ambiguity of longitudinal or cross section? Claudine Hamel-Desnos HĂ´pital PrivĂŠ Saint Martin, Caen, France
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION IV: LIVE ULTRASOUND AND VIDEO S Video. How a pastel pencil can change your practice for a safe ultra guidance puncture Jean-Luc GĂŠrard Henri Mondor Hospital, CrĂŠteil, France One factor influencing the clinical effectiveness of foam sclerotherapy is the speed of the injection between the production of the foam and the injection itself depending on the skill of the practitioner (this is especially true for beginners). The stability of the foam depends on the time elapsed after it is first generated. Because foam deteriorates quickly in the syringe, it must be injected as soon as possible. To minimize this time a small trick could help the practitioner for a swift administration. After locating the vein to be injected by duplex, we can draw with a pastel pencil, usable in gel, a line just under the probe. Like this we determine 2 zones; one above the line, which is the area of examination by duplex, and an area below the line, which is the puncturing zone. After reducing the PRF or duplex speed and checking the absence of even the smallest arteries, we can select a safe puncture zone, which will have been cleaned with an antiseptic agent. Just after the production of the foam, the probe is repositioned just above the line, which avoids having to identify once again the vein to be punctured. In this manner, the time between the production of the foam and the injection itself is kept to a bare minimum.
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In Ultrasound-guided sclerotherapy technique by direct puncture, the needle is directly attached to the syringe containing the foam sclerosant. The dominant hand performs the injection while the other holds the probe. The four stages of the procedure:: - Duplex-scan identification of the venous segment to be injected and the neighboring arterioles that are potential sources of complications; - Puncturing the vein under US control; - Checking the positioning of the needle and injection of the sclerosing agent under US control after venous blood backflow into the needle is checked; - Post-injection US control. In this final stage, the immediate impact of the procedure is assessed to see whether there might be a venous spasm and to ensure that the foam has been distributed evenly in the venous segments treated. The procedure must be fully performed under US control. The staged technique is used, in the order of proximal to distal leakage points. The US assessment (10-16Hz transducer) is made in the B mode, pulse mode and color mode, but the injection itself is performed in the B mode. The echographic section used for the injection may be a longitudinal or a transversal section, but intermediate sections are also possible, especially if the vein is sinuous. The syringe will usually hold 2.5 ml or 3 ml, though some practitioners prefer 5 ml syringes; a 22 Gauge needle, 40 mm in length is used for longitudinal section. Schematically, the concentration is chosen in relation to the diameter of the venous segment to be treated (see figure 1). The volumes to be injected generally depend on the length of the target vein. After the first foam syringe, depending on the reactivity of the vein (spasm) and the quality of the filling of the vein with the foam, additional injections can be performed or not. Figure 1
Ultrasound-guided foam sclerotherapy: Concentrations using POL (polidocanol) Foam production: 1 volume of POL + 4 volumes of air
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Saturday January 25
ESSION IV: LIVE ULTRASOUND AND VIDEO S Principle of the ultra-guidance sclerotherapy treatment by direct punction Claudine Hamel-Desnos, Claudine Hamel-Desnos H么pital Priv茅 Saint Martin, Caen, France
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION IV: LIVE ULTRASOUND AND VIDEO S Elastic Compression Stockings (ECS): What an evolution in 10 years! Laure Perrissin-Chevalier Médecin Produit Maladie Veineuse et Anémie, Laboratoires Innotech International, Groupe Innothera
Compression therapy is one of the oldest treatments, already existing at Hippocrates’s time but long associated with constraining, unaesthetic devices, lasting despite the nineteenth century rubber use innovation in the textile industry. With several centuries of use, no one can deny venous compression efficacy and empiric validity. Its indications, its degree of efficacy in each indication according to the pressure value applied to the leg, and the prescription guidelines, still need to be determined with clinical studies, to evolve from empiric to clinically proven data. In 2010, the French Medical Authority (HAS) published guidelines confirming the ECS efficacy based on robust clinical data – the first major step - for example, in the active treatment of ulcers, acute venous thrombosis and post thrombotic syndrome prevention. A number of other ECS indications such as venous thrombosis prevention in a medical or surgical context, are supported by expert consensus. As with chemical treatments, the efficacy/safety ratio is essential and key for compliance. Hemodynamic and clinical ECS efficacy is correlated with the pressure exerted on the ankle, this pressure is variable according to the patient’s morphology: a stocking which is too small will be very efficacious but not tolerated, whereas a stocking which is too loose, will be very well tolerated but totally inefficacious. The proper size choice is definitely of prime necessity for the prescription of a precise pressure and the recent stocking size chart allows for this – a second major step To improve compliance, manufacturers have developed noteworthy improvements regarding how stockings look. Stockings have now become quite close to fashion products; manufacturers also take into account « easy to use » characteristics, such as donning, stay up, etc.) - a third major step. What can we hope for in the future? Patients’ compliance, which cannot be without the doctors’ and surgeons’ full conviction.
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Treatment by sclerotherapy of reticular varices and telangiectasia is often preceded by a short initial examination, if one is performed at all. The aim of this presentation is to show just how important the right initial mapping is in ensuring the success of the treatment. To perform this mapping, a clinical examination with careful observation (sometimes under cold light) and an ultrasound (US) imaging examination are necessary. The equipment used consists of good, adjustable lighting and a Duplex scan device with a high frequency probe (13-16 MHz). Assessment is carried out with the patient in the standing position, then with the patient in the lying position. Sclerotherapy is always performed with the patient lying. A few clinical examples will demonstrate that US imaging can provide some very useful information to be used in determining the treatment strategy (the choice of injection points). Also, if necessary, it will enable the injection itself to be guided, even for small-calibre veins (minimum diameter of ≥1.5 or 2 mm) and those that are very close to the skin (minimum distance necessary in relation to the skin ≥2 mm). In conclusion, as for any sclerotherapy treatment, the success of sclerotherapy for reticular varices and telangiectasies is achieved through careful initial examination, making it possible to establish which sources of the disorder may be involved. This assessment should include a clinical examination as well as an US imaging examination.
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Saturday January 25
ESSION V: SCLEROTHERAPY S Sclerotherapy treatment of telangiectasies by ultrasound guidance Claudine Hamel-Desnos Hôpital Privé Saint Martin, Caen, France
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION V: SCLEROTHERAPY S Lafos: a mix between laser and foam sclerotherapy without tumescent anesthesia. Short term follow-up results Alessandro Frullini Studio medico flebologico, Figline Valdarno, Florence, Italy In order to enhance the treatment of insufficient saphenous vein with sclerosing foam, we have used a new technique called LAFOS (Laser Assisted Foam Sclerotherapy) in which a new specifically designed Ho:YAG laser has been used to shrink the vein immediately before sclerosing foam injection. This laser pre-treatment is capable to significantly reduce vein diameter thus less foam volume is necessary to ablate the vein with lower chance of complications. The procedure is performed in ambulatory setting as anesthesia is not required. We are presenting the short time results of the first 50 cases treated by LAFOS. The laser system we used has a 5W max average power with max 500 mJ per Pulse. The treatment was performed on 38 with insufficient Greater Saphenous Vein (GSV) and 12 Lesser Saphenous Vein (LSV) LAFOS. The mean of maximum diameter of GSV was 9,17 and 7,91 for LSV. Two GSV were previously unsuccesfully treated twice with two sessions of echoguided foam sclerotherapy. Vein shrinkage was easily achieved and the internal lumen diameter was reduced in association with thickening of the vein wall. Complete occlusion was always observed at one month, even in the two cases resistent to conventional treatment with sclerosing foam. No complications due to foam sclerotherapy were observed with the exception of minor bruisings that resolved uneventfully. Echoguided aspiration of intraluminal clots was routinely performed. No pain was referred during the laser procedure and no patients required anesthesia. In 8 patients adjustment of laser energy was necessary to avoid discomfort and most patients were unaware of the laser action. The immediate reduction of the vein caliber makes possible treating of large veins (over 1,4 mm), with sclerosing foam. This was a true coartation proven by histologic study (not a vasospasm). We believe that LAFOS could represent a true enhancement of foam sclerotherapy allowing better immediate occlusion rate and possibly better late outcome. References
A.Frullini. D. Fortuna Sclérothérapie à la mousse assistée par laser (LAFOS) : une nouvelle approche pour le traitement de l’incompétence des veines saphènes Phlébologie 2013;66:51-4
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Randomised controlled trials (RCTs) are considered gold standard in the assessment of the effectiveness of interventions. RCTs are designed to keep study groups as similar as possible, so that investigators can isolate and quantify the effect of the interventions of interest. Although random allocation of participants to different study groups theorectically eliminate allocation bias, this does not protect RCTs against other types of bias. Interestingly, even using a perfect randomisation method does not protect against selection bias. For example, selection bias could still occur if the investigator selectively excludes participants from a study because the investigator knows the allocation result if participate. Selection bias can be reduced with allocation concealment. Ascertainment bias occurs when results or conclusions of a study are systematically distorted by knowledge of which intervention each participant is receiving. Such bias can be reduced by blinding of the individuals involved including investigators and participants. In RCTs, biases could occur throughout the study process from planning to publication. During planning, the choice of questions and study designs, and trial regulations may cause biases. For example, the investigators may have a vested interest for a particular intervention due to various reasons including commercial interest from funding body and convenience of regulation. During the course of RCTs, the choice of study population, intervention including control group, and outcome measures are potential sources of bias. When reporting RCTs, the potential sources of bias could originate from handling of withdrawals, selective reporting, and most seriously, fraud. When disseminating the results, publication bias including preferential publication of studies with positive results may underestimate the importance of trials with negative findings. Sclerotherapy has been in the arsenal of the Vascular surgeon for decades and different studies, including randomised controlled trials, have taught us a lot about its use. It has been shown to be quick to administer, inexpensive, has a low frequency of adverse events, leads to early return to normal activity and is widely accepted by patients. Moreover, treatment can be repeated if necessary and it can be undertaken in an office-based environment. However, more recent RCTs have highlighted some of the issues associated with its use, namely, the lower rate of venous occlusions, higher rates of varicose vein recurrence and the need for repeated treatment. Even though these RCTs, on the whole, have been well-designed and carried out with good intention, they are not perfect and not comparable with one another. Indeed variations in sclerosants used, inclusion and exclusion criteria used, randomisation method used, duration of follow-up as well as outcome measured make it arduous to compare studies. Added to that, the number of patients recruited in the different RCTs is small, rendering difficult to actually find statistically significant differences between sclerotherapy and other techniques. Another problem which has arisen is the fact that some patients already have a preference for the technique they want employed on their varicose veins and, therefore, decline participation in these trials. Nevertheless, RCTs remain one of the best trial designs we currently have. It allows minimisation of bias which is even more prevalent in other study design In conclusion, despite often considered as gold standard, RCTs are often associated with various biases. Therefore, all RCTs should be planned, conducted and reported appropriately, and their findings should be interpreted with cautions.
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ESSION V: SCLEROTHERAPY S RCT studies are considered to be gold standard but are they biased? Roshan Bootun, Chung Lim, Alun Davies Imperial College, London, United Kingdom
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION V: SCLEROTHERAPY S The treatment of varicose veins, do you have a preference for efficiency or costeffectiveness? Jean-Jérôme Guex Cabinet de phlébologie, Nice, France We have a choice of treatments: Surgery, Endovenous thermal ablation, Endovenous, Chemical ablation under ultrasound guidance, Pharmaco mechanical (Clarivein®), SAPHEON® “Super-glueing”, and several others WHAT ARE THE ACTUAL CRITERIA OF CHOICE? - Efficacy = improved outcome = improvement of status - Side effects, complications and comfort of procedure - Recurrences after Rx: - Cost of initial procedure (unique or several) - Cost of re-do Rx - Cost of « maintainance Rx » EVALUATION OF OUTCOMES - Patient reported outcomes: QoL, VAS - Physician reported outcomes: VCSS, External audit, - Duplex US based and other instrumental outcomes: - The comfort of the procedure - Outpatient Vs Hospital procedure - Post op care -Discomfort, Pain, tenderness, swelling - Duration of the hospital stay: - days off, sick leave. SIDE EFFECTS OR COMPLICATIONS Death (isolated reports for general anesthesia, cryostripping, …), DVT, Sepsis, Skin burn, peripheral nerve damage, Visual disturbances, TIA, stroke, Residual discoloration, etc Recommendation of/to friends CAN WE EVALUATE COSTS? Initial costs which are made of: Doctor’s fees Room and equipment rental, disposable material, personnel, compression garment… And also Additional costs: off work days (society/patient), Re-do costs in case of recurrence, Treatment of complications/side effects, Maintainance costs (e.g. iterative sclerotherapy) Cost effectiveness analysis is a mathematical approach which helps evaluating the relationship between efficacy and cost. THE CONSUMER’S VIEW CEA/EBM information may help increase consumers’ confidence However, deeply routed in consumers are: More is better, Newer is better, Less invasive is better, You get what you pay for (and who is paying)
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ESSION V: SCLEROTHERAPY S How can statistics be manipulated? François André Allaert Chair of Medical Evaluation ESC Dijon & DIM CHU du bocage, Dijon, France
Among possible indiscretions, for example, is the analysis of patients to be removed from a study. Removing aberrant data known as outliers is a proper approach when done before unblinding, but is improper if done afterwards, when it is known whether such or such a patient received the treatment under study or the placebo. In this context, audits by the supervisory authorities check whether dates concord and this means only certain software can be used that traces all operations carried out on the database. Certain ways of presenting studies are also misleading and by focusing the analysis on this or that sub-population, or by biasing it initially, results can be portrayed more or less favourably. Another technique is to frenziedly repeat tests. With a risk alpha = 0.05, if you run 100 tests, five will come up positive by the workings of chance. This is why there are statistical rules designed to constrain ‘p’ depending on the number of tests conducted. Put simply, when lots of tests are run, the significance level can no longer be set at p<0.05 but must be at a lower value. Then again, very many tricks in the presentation of results can give the impression there are differences, among which changes of scale are the most common. This makes it look as though curves differ very significantly from one another whereas in fact the difference is tiny. Lastly, there is another way of making figures say anything, and this one is unintentional: conducting statistical tests without knowing much about them even if they look simple enough. Statistical tests are to clinical research what biological tests or Doppler ultrasound scans are to medicine: a form of supplementary examination which may or may not affirm a statistical hypothesis, in much the same way as a biological examination may or may not confirm a clinical diagnosis. Would you let a statistician perform a Doppler ultrasound scan even with today’s machines which make the job far easier, much as statistics software simplifies statistical testing?
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Does the popular saying that ‘you can make figures say what you want them to’ apply to statistics too? Yes, without a doubt; unless the analysis is carried out stringently and objectively. There are many ways to conduct statistical analyses and only a thorough examination of the methods used and the presentations made of the results can provide any guarantee.
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION VI: THERMAL TECHNIQUES S Endovenous therapies of saphenous veins, the evidence Renate van den Bos Erasmus MC, Rotterdam, The Netherlands Endovenous thermal ablation (EVTA) techniques are commonly used and very effective treatments for saphenous vein insufficiency. Quite a few randomized studies on endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) are yet available which report high obliteration rates at longer follow-up and favorable secondary outcomes. Comparisons between segmental RFA and EVLA suggest similar occlusion rates but better secondary outcomes for RFA. For endovenous steam ablation no RCTs are available yet, but the outcomes of the first studies are promising. Because of the high obliteration rates of EVTA, secondary outcomes such as pain scores and quality of life improvement have become increasingly important. To decrease pain and ecchymosis after EVLA, variations in fiber tip design and higher wavelengths have been proposed. However, there is yet no evidence available for the benefit of higher wavelength. Despite its regular use since more than 10 years, no consensus on a best treatment protocol for EVLA has been reached so far. This might be partly explained by a shortcoming of the knowledge of the underlying physics among frequent users. The modes of action of EVLA are discussed and some physical arguments are presented to elucidate the mechanism, hoping that better understanding of the EVLA physics may advance finding an optimal treatment protocol.
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ESSION VI: THERMAL TECHNIQUES S Medium term follow-up after the different techniques: RCT comparing surgery, chemical and thermal ablation Lars Rasmussen Danish Vein Centres, Copenhagen, Denmark
RESULTS 500 patients (580 legs) were randomized to one of the treatments. Results: At 3 years, eight (KM estimate, 7%), eight (KM estimate, 6.8%), 31 (KM estimate, 26.4%), and eight (KM estimate, 6.5%) of GSVs recanalized or had a failed stripping procedure (P < .01). Seventeen (KM estimate, 14.9%), 24 (KM estimate, 20%), 20 (KM estimate, 19.1%), and 22 (KM estimate, 20.2%) legs developed recurrent varicose veins (NS). The patterns of reflux and location of recurrent varicose veins were not different between the groups. Within 3 years after treatment, 12 (KM estimate, 11.1%), 14 (KM estimate, 12.5%), 37 (KM estimate, 31.6%), and 18 (KM estimate, 15.5%) legs were retreated in the CLF, EVLA, UGFS, and stripping groups, respectively (P < .01). VCSS, SF-36, and Aberdeen QOL scores improved significantly in all the groups with no difference between the groups. CONCLUSIONS All treatment modalities were efficacious and resulted in a similar improvement in VCSS and QOL. However, more recanalization and reoperations were seen after UGFS. (J Vasc Surg: Venous and Lym Dis 2013;1: 349-56.)
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INTRODUCTION This study compares the outcome 3 years after treatment of varicose veins by radiofrequency ablation (ClosureFast, CLF), laser ablation (EVLA), ultrasound-guided foam sclerotherapy (UGFS), or high ligation and stripping.
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION VI: THERMAL TECHNIQUES S Long term follow-up after endovenous laser ablation Giorgio Spreafico, P. Pavei, E.Giraldi,A. Nosadini, A. Piccioli, M. Ferrini, U. Baccaglini Centro Multidisciplinare di Day Surgery, Azienda Ospedaliera, UniversitĂ , Padova, Italy INTRODUCTION Papers about long term follow up of endovenous laser treatments are very rare, retrospective and with very few patients evaluated at the end of follow up. MATERIALS AND METHODS Our group performed a prospective observational study about 190 patients operated on with EVLA for great saphenous vein incompetence between 2003-4, followed up for 6 years. We defined as echocolordoppler failure (ECDF) the presence of a refluxing sapheno-femoral junction, with or without an anterior accessory saphenous vein (AASV) reflux or a recanalized saphenous trunk. RESULTS We observed a difference between clinical and echocolordoppler results. The majority of patients had an improvement or disappearance of the symptoms (88.4%), but one third of them (30%) revealed an ECDF. We categorized 3 kind of ECDFs: isolated refluxing junction (10.5%), refluxing junction and AASV reflux (7,8%), refluxing junction associated with recanalized saphenous trunk(11.5%) The multiple logistic regression analysis of the data identified as statistically significative risk factors for ECDFs a diameter of the junction or of the trunk larger than 8mm. DISCUSSION We choose the ECDF as end point, because duplex results are more grounded and consistent than clinical ones. In the very long term, the clinical relevance of some of these ECDFs, especially as regard isolated refluxing junction, is unknown. The multiple logistic regression analysis of the data shows as ECDFs risk factor, a caliper of the junction and/or of the saphenous trunk major than 8mm. This parameter should be collected using a standardized method of measurements and reported in all the papers.
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Quality of life (QoL), internationally defined by the World Health Organization as “the product of the interplay between social, health, economic and environmental conditions which affect human and social development”, has gradually increased its importance, once it reflects the patient perspective and sensitivity regarding the influence of the disease in daily life. Nowadays, there is a growing interest for patient-reported outcomes and the use of QoL questionnaires in patients suffering from CVD, which can provide important information regarding burden of illness that otherwise would not be able to be obtained. Highlighting the importance of patients QoL assessment is the association established between QoL (based on quality of life questionnaires) and the severity of disease progression. Despite all this growing interest about patient’s perspective and the large number of surgeries performed every year, there is a deficiency on the published data on QoL life assessments in patients with varicose veins. Several physician-generated measurements tools have been used, such as the CEAP classification (Clinical, Etiologic, Anatomic and Pathophysiologic) and the Venous Severity Scoring System (VSSS). Nevertheless patient-generated QoL tools has gained significant relief, enabling monitoring disease progression and response to treatment, as well as assessing quality of care provided and allowing the provision of important information not properly expressed by the statistical values of morbidity and mortality that physicians traditionally use. Among the patient-generated measurements tools, generic instruments – 36 Item Short Form Health Survey (SF-36) or Nottingham Health Profile (NHP) – allow comparison across populations of patients with different diseases, while disease-specific instruments – Chronic Venous Insufficiency Questionnaire (CIVIQ), Venous Insufficiency Epidemiological and Economic Study (VEINES), the Aberdeen Varicose Vein Questionnaire (AVVQ) or Charing Cross Venous Ulceration Questionnaire (CXVUQ) – are more sensitive to key dimensions of quality of life that are affected by specific diseases.
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ESSION VI: THERMAL TECHNIQUES S Quality of life after varicose vein surgery. Does the current evidence favour one method over another? Armando Mansilha, Daniel Brandão Faculdade de Medicina do Porto, Porto, Portugal
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION VI: THERMAL TECHNIQUES S Is EHIT depending of the learning curve? Lowell Kabnick New York University Vein Center, New York, USA Does Endothermal Heat Thrombosis Complication Depend on the Experience of the Physician? The treatment modality of choice in the setting of symptomatic varicose veins is endovenous ablation of the great saphenous vein (GSV). Endothermal Heat Induced Thrombosis (EHIT) of the GSV is an expected outcome, but what remains unclear is the clinical outcome of patients who present with this entity in close proximity to, or with extension into, the common femoral vein. With an incidence in the literature ranging from 0% to 16% (1-3), this has gained the attention of physicians treating this disease process. The following is the description for EHIT Classification: - Class 1: Venous thrombosis to the superficial-deep junction (i.e.; saphenofemoral junction or saphenopopliteal junction, but not extending into the deep system) - Class 2: Non-occlusive venous thrombosis, with an extension into the deep system of a cross sectional area of less than 50%. - Class 3: Non-occlusive venous thrombosis into the deep venous system, with an extension into the deep system of a cross sectional area of more than 50%. - Class 4: Occlusive deep vein thrombosis of the common femoral vein. Also examined was the extent of echogenicity within the thermally induced thrombosis and this was compared with de-novo thrombosis seen within a typical DVT. RESULTS From October 2007 â&#x20AC;&#x201C; December 2010 at New York University Vein Center 2,672 procedures (EVLA 662, RFA 2010) were performed. There were 78 EHIT II (Laser 21 vs. RFA 57) resulting in a total of 2.9%. Of note there was a diminishing trend amongst Interventionalists: - 1st year 5.2% - 2nd year 1.8% - 3rd year 0.4% CONCLUSION There is a decrease in this complication with experience; however, from personal experience, the presence of EHIT II will not reach 0.
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ESSION VI: THERMAL TECHNIQUES S When can the treatment of venous reflux for open ulcers (C6) be justified? Manj Gohel Addenbrookeâ&#x20AC;&#x2122;s Hospital, Cambridge, United Kingdom
However, there are many reasons to challenge this dogma. The influence of treating superficial reflux is likely to have been significantly underestimated in the ESCHAR trial. A quarter of patients in the surgery group refused to have surgery (but were analysed on intention to treat); the median delay to surgery was 7 weeks and surgical interventions would be considered suboptimal by modern endovenous standards, with residual reflux frequently seen. Moreover, the rapid and widespread adoption of office based, endovenous interventions has meant that many patients are now entirely suitable and willing to undergo minimally invasive endovenous ablation procedures. In addition, it is unreasonable to extrapolate the findings of a study where patients were generally compliant with compression, to the overall leg ulcer population, where compression therapy is often poorly tolerated. Recent non-randomised studies have suggested that excellent venous ulcer healing rates can be achieved by aggressive ablation of superficial reflux with ultrasound guided foam sclerotherapy, far higher than published healing rates with compression alone2. For these reasons, the Early Venous Reflux Ablation (EVRA) ulcer study was devised and has recently commenced recruitment at 6 centres in the United Kingdom. The study aims to evaluate the role of early endovenous ablation of superficial reflux (within 2 weeks), in addition to compression bandaging in patients with chronic venous ulceration. The primary outcome is time to ulcer healing. In conclusion, the perception that there is no benefit in treating superficial venous reflux in patients with active venous ulceration (C6) is probably not justified. There is a strong rationale for reflux ablation in patients who have poor compliance with compression. The results of the EVRA ulcer study should help define whether endovenous treatment of superficial reflux should become an early part of treatment for all patients with venous ulcers. References
1. Gohel MS, Barwell JR, Taylor M, Chant T, Foy C, Earnshaw JJ, et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. BMJ 2007;335(7610):83. 2. Kulkarni SR, Slim FJ, Emerson LG, Davies C, Bulbulia RA, Whyman MR, et al. Effect of foam sclerotherapy on healing and longterm recurrence in chronic venous leg ulcers. Phlebology 2012.
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The importance of treatment of venous reflux in patients with chronic venous ulceration was demonstrated unequivocally in the ESCHAR trial. Superficial venous surgery resulted in a significantly lower ulcer recurrence rate at 4 years1. However, no healing benefit was seen, resulting in the perception amongst many clinicians that there is no role for treating superficial reflux in patients with C6 disease.
CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION VI: THERMAL TECHNIQUES S Is it safe to treat varicose vein by thermal ablation below the knee? Peter Gloviczki Mayo Clinic, Rochester, MN, USA BACKGROUND Thermal injuries to the saphenous or sural nerves have been major concerns that limited apprpriate treatment of the below the knee segment of the great saphenous vein (BK-GSV) and the small saphenous vein (SSV) using thermal ablations. However, saphenous incompetence below the knee has been found to be a major source of recurrence and a major cause for reinterventions. We recently presented results of patients treated with thermal ablation of the BK-GSV (Gifford et al. J Vasc Surg: Ven Lymph Dis. 2013;1:112) METHODS The study included 387 patients treated between January 2010 and August 2012. Results of 38 patients who underwent thermal ablation of the BK-GSV on 47 limbs were retrospectively reviewed. RESULTS There were 22 females and 16 males, with a mean age of 51 years. 27 limbs were treated for simple varicose veins (C 1-3) and 20 for advanced insufficiency (C 4-6). Ablation was performed in 45 limbs (97%) utilizing the VenaCure EVLTTM laser vein treatment (AngioDynamics, Queensbury, NY) and 2 limbs using RFA (radiofrequency ablation) with ClosureFAST速 system (VNUS Medical Technologies, San Jose, CA). Mean GSV length ablated was 51.6 cm (range 26 to 65 cm). Ambulatory stab phlebectomy of branch varicosities was performed simultaneously in 37 (79%) limbs. All patients had tumescent anesthesia with circumferential injection immediately around the saphenous vein. All limbs were evaluated with ultrasound within 24 hours. There was no skin burn nor evidence of endovenous heat induced thrombosis. Transient hyperesthesia occurred in 1 patient (2.1%). Re-interventions were not needed during follow-up. Excellent results of small saphenous vein endovenous thermal ablations have been reported in the literature, with minor sensory deficit in 2.2 to 7.5%, with less chance of nerve injury when the vein was punctured at mid-calf level and using large amount of tumescent infusion. Routine visualization of the nerve using ultrasound was also reported. Paresthesia rates of as high as 8-13% were observed after thermal ablation of the BK-GSV. CONCLUSIONS Endovenous ablation of the refluxing BK-GSV can be performed safely, with a low rate of minor complications. Neuralgia cannot be completely excluded with thermal ablations of below the knee saphenous veins, however, evidence in the literature suggests that puncturing at midcalf level and using large amount of tumescent anesthesia will result in less chance of nerve injury. Randomized studies to clarify long term risks and benefits of thermal ablations of the below-the-knee segment of the incompetent saphenous vein are warranted.
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ESSION VI: THERMAL TECHNIQUES S Clarivein: the answer to avoiding heat treatment? Alun Huw Davies London, United Kingdom
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Ablation of truncal varicose veins has undergone significant change in the last 10 years. The development of endothermal techniques to ablate truncal veins involves the use of tumescent anaesthesia. The endothermal techniques have replaced classic surgery. However even less invasive techniques are being developed. Clarivein, a mechanical and chemical technique that does not require tumescent anaesthesia. The early results show comparative results at one year for ablation results to endothermal techniques. It would seem on basic modelling that is is as cost-effective as endothermal techniques. Techniques of retrograde ablation may have a particular role in the management of patients with venous ulceration. In summary, Clarivein is a novel technique that has many potential benefits over endothermal ablation and the results of ongoing RCT will help inform us further as to whether the potential benefits exist.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
AORTA Bilateral giant aneurysm of the common iliac artery Masmoudi Karray Sayda, Saida Messmoudi, Hassen Djmal, Aida Abdi, Hela Ben Jem창a, Faten Dhouib, Abedessalem Hentati, Mohamed Abedennadher, Imed Frikha
Department of Cardiovascular Surgery Habib Bourguiba Hospital, Sfax, Tunisia
Iliac artery aneurysms (IAAs) are commonly associated with abdominal aortic aneurysms (AAAs), and isolated IAAs are rare. Untreated, the natural history continued expansion and rupture with a high mortality rate. The common iliac artery is affected in 70% of cases, the internal iliac artery is affected in 20% of cases, and the external iliac artery is affected in 10% of cases. We report the case of 62-year-old man with a history of hypertension, a coronary disease with stenting and current smoking, who presented back pain with dysuria. On physical examination, he had a soft abdomen. The peripheral pulses were present and symmetric. Abdominal ultrasound demonstrated right common iliac aneurysm. CT scan of the aorta and lower limbs confirmed the aneurismal dilatation of the right common iliac artery measuring 80 mm * 60 mm and left common iliac aneurysm measuring 25 mm * 20 mm; the aorta and other artery were normal. We decided to attempt surgical treatment. Laparotomy was performed. We decided to perform a graft insertion technique using a bifurcation 18/9/9-mm Dacron graft. The postoperative period was uneventful. No ischemia was noticed in the lower limbs. At 6 months post-procedure, the patient remained asymptomatic. The CT scan is satisfactory. The isolated iliac artery aneurysm is a rare but serious because of the risk of rupture. The evolution can be silent and aneurysm can have enormous size. Endovascular techniques offer alternative therapies.
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AORTA Intraoperative alternatives during endovascular repair of the abdominal aortic aneurysm David Carrasco de Andrés, Fernando Utrilla Fernández, Rodrigo Yoldi Bocanegra, Estrella Navarro Muñoz, Rocío Rodríguez Carmona, José Moreno Escobar Torrecárdenas Hospital, Almería, Spain
OBJECTIVES Despite the correct study of a case, eventualities may occur during the surgery which require modification of the planned strategy. Here, we present two cases of abdominal aortic aneurysm treated by stenting. METHOD Case one: infrarrenal abdominal aortic aneurysm with occlusive iliac disease, planned for aorto mono-iliac stent-graft to the rigth side and femoro-femoral bypass, which needs remote external iliac endarterectomy for stenting, due to arteriographic image discrepancy regarding preoperative CT scan. Case two: infrarrenal aortic and bi-iliac aneurysm; at first time selective left hipogastic embolization is performed, to complete second time one month later (right hipogastric embolization and bifurcated stenting-graft). Patency of embolized hipogastric is checked, so stent is placed, no selective embolization of this hipogastric is done, for, in a third time, right hipogastric embolization and complete procedure with right external iliac extension. RESULTS Both cases with correct exclusion of the aneurysm, patency of the procedure, without early or late endoleaks, in postoperative CT scan control. CONCLUSIONS During the endovascular surgery, as in any surgery, changes of the planned strategy may occur. Intraoperative alternatives such as those presented, could be a solution for selected cases of endovascular repair of abdominal aortic aneurysm.
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E-POSTERS
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
AORTA The hepatorenal Bypass Hartmut Rimpler
Thoracic and Vascular Surgery Vivantes Clinic Friedrichshain, Berlin, Germany PROBLEM For debranching- procedures of thoracoabdominal aortic aneurysms, hybrid procedures of AAA Area IV, creation of landing zones, occlusion/stenosis of coeliac trunk or renal artery, the hepatorenal bypass is a good extraanatomical reconstruction. TECHNIQUE The surgical approach is a right subcostal incision similar a cholezystectomy with exposure of the renal artery behind vena cava or/and hepatic artery and behind the duodenum. The bypass linked the Arteria hepatica communis and the Arteria renalis dextra, all with Vena saphena magna material. RESULTS Between 2002 and 2013, 16 patients counting for a total of 18 surgical interventions where performed. Indication for operation where TAAA and AAA Part IV (n=8), stenosis of renal artery (n=4); occlusion of Arteria hepatica, anastomotic aneurysm of renal artery after debranching procedure (n=1) and landing zone (Truncus coeliacus) for TAA stenting (n=2). Procedure length was 2 hours and clamping time was on average 20 minutes. One postoperativ occlusion of hepatorenal bypass occurred (reocclusion of Truncus coeliacus), 2 revisions were needed (1x bypass kinking, 1x reconstruction of second renal artery) and 1 urethral stenosis emerged. In the case of TAAA and AAA Part IV we have done before a bypass from thoracic aorta to coeliac trunk, mesenteric artery and left renal artery about left thoracotomie and phrenotomie (n=8). In this cases after hepatorenal bypass stenting of TAA/BAA where performed. SUMMERY This form of intervention is safer and more simple in comparison to preceding surgical approaches.
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AORTA Results of ventana fenestrated stent-graft system in high risk juxtarenal and pararenal aortic aneurysms Marco Leopardi, Jean-Pierre Becquemin CHU Henri Mondor, Paris, Créteil, France
OBJECTIVE To report the short term and midterm results of a series of patient treated with the Ventana Fenestrated System (VFS) at our institution for high risk juxtarenal (JAA) and pararenal aortic aneurysms (PAA).
RESULTS Mean age was 72 years. Mean aneurysm diameter was 56.3 mm. Mean infrarenal neck length 4.1 mm (0 – 12). Mean duration of intervention was 185 ± 37 min, mean fluoroscopy time 44 ± 19 min, mean contrast used 136 ± 62 ml. Technical success was achieved in 88.9% of patients (9/10). In one patient, we observed in the first post operative day a stenosis of the SMA due to a lateral compression by the scallop, which was immediately treated with a percutaneous stent deployment. The same patient in the tenth post operative day developed an acute renal failure, in presence of patent renal arteries, a trash foot syndrome due to cholesterol embolization and an iliac VFS limb twisting with significant stenosis, treated by insertion of a covered stent. Mean in hospital stay was 9.2 ± 6.5 days. In-hospital mortality was 0%. At one month, we observed one chronic renal insufficiency, with patent renal arteries. Mean follow-up was 7.1 ± 4.6 months, during this period we observed no other complications, no sac enlargements, rupture or conversion. Post operative 6-month CT scans, available in all patients, demonstrated technical success in 100% of patients, no stent graft fracture or migrations. One patient died at 11 months from a non-aneurysm-related cause. CONCLUSIONS Our experience show that VFS is feasible, safe and effective as an “off the shelf” device. This device broadens stent graft application in JAAs and PAAs, with potentential advantages compared to other endovascular techniques. Further analysis and a longer follow-up are needed to confirm the safety of the VFS and its durability.
Demographic and risk factors Mean age (range) Male gender Hypertension Hypercholesterol Pulmonary disease Coronary disease Renal insufficiency History of smoking
Mean (range) or No. (%) (n = 9) 71.7 (59 – 88) 9 (100) 8 (88.8) 2 (22.2) 3 (33.3) 6 (66.6) 2 (22.2) 5 (55.5)
Table I. Preoperative demographic and risk factors
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METHODS VFS implantation started in seven international centers. As one of them, we treated nine patients. Patients met the criteria of enroment in the study. Demographic, anatomical, intraoperative and postoperative data were recorded by means of a prospectively collected database. Patients underwent examination, blood exams and CT-scan before and after surgery. Follow-up and CT-scans were planned at one, six months and yearly.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Characteristic Aneurism sac diameter, mm Aortic bifurcation diameter, mm Proximal neck diameter (Infra SMA), mm Proximal neck length (Infra SMA), mm Infrarenal neck diameter, mm Infrarenal neck length, mm SMA to aortic bifurcation, mm Renal artery diameter (R L), mm L 6.1 ± 1.2 (4-8) Iliac artery diameter, mm L 12.4 ± 1.4 (10-15) JAAs/PAAs
Mean ± SD (range) (n = 9) 56.3 ± 3.9 (51-60) 26.1 ± 6.6 (18-39) 29 ± 3.8 (25-33) 14.6 ± 8.1 (6-30) 28.8 ± 5 (21-35) 4.1 ± 3.7 (0-12) 137.1 ± 14 (113-160) R 6.7 ± 1.6 (4-8) R 11.7 ± 1.9 (9-14) 8/1
Table II. Preoperative anatomical data
Major adverse event Mortality Spinal cord injury Myocardial infraction Renal failure Intestinal ischemia Cholesterol embolization syndrome Type I endoleak Type II endoleak Type III endoleak SMA stenosis Renal artery stenosis Iliac graft limb stenosis
No. (%) (n = 9) 0 0 0 1 (11.1) 0 1 (11.1) 0 3 (33.3) 1 (11.1) 1 (11.1) 0 1 (11.1)
Table III. Major adverse events at one month
References
1. Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-71. 2. Haulon S, D’Elia P, O’Brien N, Sobocinski J, Perrot C, Lerussi G, et al. Endovascular repair of thoracoabdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2010; 39(2): 171-8. 3. Starnes BW, Tatum B. Early report from an investigator-initiated investigational device exemption clinical trial on physician-modified endovascular grafts. J Vasc Surg :58(2): 311-7. 4. GS Oderich, JJ Ricotta. Modified fenestrated stent grafts: device design, modifications, implantation, and current applications. Perspect Vasc Surg Endovasc Ther 2009;21:157-67. 5. Greenberg RK, Sternbergh WC, Makaroun M, Ohki T, Chuter T, Bharadwaj P, et al. Intermediate results of a United States multicenter trial of fenestrated endograft repair for juxtarenal abdominal aortic aneurysms. J Vasc Surg 2009;50(4):730-7 6. Haulon S, Amiot S, Magnan PE, Becquemin JP, Lermusiaux P, Koussa M, et al. An analysis of the French multicentre experience of fenestrated aortic endografts: medium-term outcomes. Ann Surg 2010; 251(2): 357-362. 7. Coscas R, Kobeiter H, Desgranges P, Becquemin JP. Technical aspects, current indications, and results of chimney grafts for juxtarenal aortic aneurysms. J Vasc Surg 2011;53:1520-7. 8. Quiñones-Baldrich WJ, Holden A, Mertens R,Thompson M, Sawchuk AP, Becquemin JP, et al. Prospective, multicenter experience with the Ventana Fenestrated System for juxtarenal and pararenal aortic aneurysm endovascular repair. J Vasc Surg 2013;58:1-9 9. Mertens RM, Bergoeing M, Mariné L, Valdés F, Krämer A, Vergara J. Ventana fenestrated stent-graft system for endovascular repair of juxtarenal aortic aneurysms. J Endovasc Ther 2012;19:173-8. 10. Holden A, Mertens R, Hill A, Mariné L, Clair DG. Initial experience with the Ventana fenestrated system for endovascular repair of juxtarenal and pararenal aortic aneurysms. J Vasc Surg 2013;75(5):1235-45
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AORTA Prediction model for delirium after open abdominal aortic aneurysm repair Masayuki Sugimoto, Hirofumi Morimae, Akio Kodama, Hiroshi Narita, Kiyoto Yamamoto, Kimihiro Komori
Division of Vascular Surgery, Graduate School of Medicine, Nagoya Univesity, Nagoya, Japan
METHODS 397 consecutive patients who underwent abdominal aortic aneurysm (AAA) open repair at our institution between April 2005 and June 2013 were retrospectively reviewed. All surgery was performed with transperitoneal approach under general anesthesia, mostly in combination with epidural anesthesia. Postoperative delirium was diagnosed from the description of their medical charts and nursing records according to Diagnostic Statistical Manual of Mental Disorders 4th Edition (DSM-IV) criteria. Mental alteration resulting from postoperative cerebrovascular events or preexisting mental disorders were excluded from delirious group. Parameters that showed significant difference in univariate analysis were subjected to a logistic regression analysis to construct a prediction model for risk of postoperative delirium. RESULTS 46 patients (11.5%) were identified as postoperative delirious. In univariate analysis, following parameters were significant; age, stroke, hyperlipidemia, FEV1.0, %VC, and BUN. Subsequent logistic regression analysis revealed that an age â&#x2030;Ľ 70 years (odds ratio [95%CI], 3.342[1.437-7.774]), blood loss â&#x2030;Ľ1517mL (2.707 [1.359-5.391]), and absence of hyperlipidemia (2.154 [1.060-4.374]) were significant risk factors. CONCLUSIONS Advanced age was a risk factor for delirium after AAA open repair as well as other surgery. Our results suggest that aged patients with much intraoperative blood loss require highly vigilant care in postoperative periods. Further studies are necessary to elucidate the relation between cholesterol and delirium.
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BACKGROUND Delirium is one of the most common complications after major surgery. It wastes a lot of unscheduled medical resources and results in poor morbidity. Amongst various non-cardiac surgery, aortic surgery is recognized as a high risk. We herein review our series of open repair for AAA and aim to construct a prediction model for postoperative delirium dependent on preoperative and intraoperative factors.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
AORTA Non-operative management of aortic graft infections Neena Randhawa, Peter Bungay, Peter Thurley, Timothy Rowlands Royal Derby Hospital, Derby, United Kingdom
INTRODUCTION Prosthetic graft infections remain one of the most serious complications of aortovascular surgery. The incidence varies between 0.7% - 2% with associated morbidity and mortality of up to 75%. The current management of aortic graft infection is surgical with few exceptions. AIM To explore the effectiveness of non-operative management of aortic graft infections. METHODS Retrospective case note review of all cases of aortic graft infections. RESULTS 5 patients with aortic graft infections were treated with a combination of percutaneous drainage and/or antibiotics. Patient 1, underwent an EVAR for mycotic aneurysm. He required multiple percutaneous drains for aortic graft infection post-operatively. At two and half year follow-up, the peri-graft collection has resolved and inflammatory markers have returned to normal. Patient 2 had an open repair of an inflammatory aortic aneurysm with silver graft. He required percutaneous drainage for the sac collection and 3-month course of intravenous antibiotics. At three year follow up, other than persisting renal impairment (dialysis not required), he has no evidence of continuing graft infection. Patient 3 had aortic graft infection following emergency open repair of a ruptured aneurysm. This was treated with prolonged course of antibiotics. At two year follow-up CT has shown resolution of the collection. Patient 4 required percutaneous drainage of a large infected retroperitoneal haematoma following an open repair of a ruptured aneurysm. Repeat scan at 2-week interval showed minimal residual collection with inflammatory markers returning to normal. Patient 5 developed a collection anterior to the graft, 7-days post emergency open repair. This was treated with percutaneous drainage and IV antibiotics. Conclusion Although the mainstay of treatment of aortic graft infection remains surgical, our series suggest treatment with antibiotics +/- percutaneous drainage is feasible and good short and medium term results are possible. References
Fatima J. Duncan AA. de Grandic E. et al. Treatment strategies and outcomes in patients with infected aortic andografts. J. Vasc Surg. 2013; 58(2):371-9 Igari K. Kudo T. Toyofuku T. et al. Treatment strategies for aortic and peripheral prosthetic graft infection. Surg Today. 2013. Lawrence PF. Conservative treatment of aortic graft infection. Semin Vasc Surg. 2011; 24(4):199-204. Jamel S. Attia R. Young C. Management of infected aortic graft with endovascular stent grafting. Diagn Intery Radiol. 2013; 19(1):66-9. Laohapensang K. Aworn S. Orrapi S. Rutherford RB. Management of the infected aortoiliac aneurysms. Ann Vasc Dis. 2012;5(3):33441.
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AORTA Early and 1-year results of custom-made scalloped/fenestrated thoracic aortic stentgrafts for challenging arch anatomy Nung Rudarakanchana1, Ali Alsafi2, Anisha Perera1, Bharpoor Singh1, Mohammad Hamady1, Colin Bicknell1 1. Imperial College London, London, United Kingdom 2. Imperial Healthcare NHS Trust, London, United Kingdom
OBJECTIVE To report our early and 1-year results with custom-made proximal scallop/fenestration thoracic aortic stent-grafts.
RESULTS There were 18 patients: 8 male, median age 71 years (range 35-81), median follow-up 11 months (range 2-42). Indication for intervention was aneurysmal disease (saccular aneurysm N=11 (4 proximal to the left subclavian (LSCA)); type II thoracoabdominal aneurysm (TAAA) N=3; descending thoracic fusiform aneurysm N=2; aneurysmal dilatation following type B dissection N=1), with 1 penetrating aortic ulcer. Six patients underwent hybrid repair (3 arch, 3 visceral). The scallop landing zone was LSCA in 14 patients, left common carotid in 2 (1 with LSCA fenestration), and neoinnominate in 1. Figure 2 shows an example of exclusion of a saccular aneurysm using an endograft with a LSCA scallop. Early in our series there was one deployment failure, which required immediate realignment. There were no endoleaks on completion angiography, conversions to open repair or retrograde dissections. In-hospital complication rate was 33%, including 3 strokes, early in the series and all in patients who underwent extra-anatomical bypass for extensive disease, and 1 paraplegia, in a patient with type II TAAA. Early type II endoleaks were identified in 2 patients, neither of whom required re-intervention. There was 1 death at 30-days, of a patient who underwent visceral hybrid repair for type II TAAA. One-year survival was 73%, with no late endoleaks or graft migration. CONCLUSIONS Technical results using custom-made scallop/fenestrated stent-grafts for complex thoracic aortic pathology are promising. Clinical results are satisfactory, with acceptable complication and mortality rates in this high-risk patient population. Figures Figure 1. The Relay scalloped endograft (Bolton Medical). The proximal scallop landing zone may be custom-made for either LSCA, left common carotid artery or the innominate artery.
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METHODS We performed a retrospective analysis of prospectively collected data on patients undergoing thoracic endovascular aneurysm repair (TEVAR) using the Relay scalloped endograft (Bolton Medical, Spain; Figure 1) between February 2009-June 2013 at our centre.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Figure 2. Exclusion of a saccular aneurysm using an endograft with a LSCA scallop.
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AORTA Does the 6 month post-Endovascular Aneurysm Repair (EVAR) scan change management? Rajesh Chatha, Timothy Rowlands, Bungay Peter Royal Derby Hospital, Derby, United Kingdom
OBJECTIVE There is no evidence-based standard follow up regime for the first year following EVAR. Our unit scans patients at 1, 6 and 12 months post-EVAR. The aim of this study is to see whether it is necessary to scan patients at 6 months.
RESULTS 1, 6 and 12 month scans were reviewed for 188 patients. 48.4% (n=91) had no abnormal findings. There were 107 abnormal findings in 97 patients. 35.1% (n=67) of patients had new abnormal findings at 1 month, of which only 11 patients actually necessitated a 6 month scan for monitoring. 12.7% (n=24) had abnormal findings at 6 months, 6 required a procedure having presented symptomatically around the 6 month scan. Only 1 finding (thrombus at the docking zone of a limb at risk of occlusion) required a procedure as a direct result of routine scanning. Comparison of the first 50 grafts against the last 50 grafts suggests that improvement of graft technology over the 6 years has shown an 80% reduction in thrombus occurrence. 8.5% (n=16) had abnormal findings at 12 months. 24 patients had fenestrated or transrenal EVARs. Recent anecdotal evidence of a renal stent fracture discovered at the 6 month scan, suggests more intensive monitoring is required for these patients until more evidence is available. In total, only 35 postEVAR 6 month scans were necessary. CONCLUSION It is safe to drop the routine 6 month post-EVAR scan in straightforward EVAR if the 1 month scan does not indicate otherwise. This would reduce patient radiation exposure and produce a financial saving.
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METHODS A retrospective review of scans and notes of patients following their EVAR between August 2006 and June 2012, to determine which patients had abnormal findings requiring re-intervention as a result of their scan.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
AORTA ÂŤControlledÂť embolization of visceral artery aneurysms Maria Misuraca1, Massucci Marco1, Ermanno Notarianni2, Alessandro Varroni1, Giovanni Bertoletti1
1. Department of Vascular and Endovascular Surgery, Latin, Italy 2. Department of Interventional Radiology, Latin, Italy
OBJECTIVE To evaluate the effectiveness of selective embolization of the aneurysm sac, preserving the integrity of the efferent branch and tributary artery of aneurysms involving the visceral arteries. METHODS 23 patients affected of visceral artery aneurysm were treated in a period from January 2001 to April 2013; five patients were selected for the study because they had an aneurysm with a favourable anatomy for this particular embolization technique. All these patients were treated in the last two years. The aneurysms were required to have a ratio F/N>1 (fund/neck). Follow-up was performed with CT-angiography at 6 and 12 months after the procedure. RESULTS Two patients had an aneurysm involving the celiac artery, 1 the hepatic artery, 1 the intermediate branch of the renal artery and 1 the splenic arteries. They were all asymptomatic patients with an occasional instrumental discovery. The technique consisted of the embolization of the fund of the aneurysm only. Coils in controlled release (GDCTM Boston Scientific) were used by selective catheterization of the fund of the aneurysm with a conical microcatheter of 2.4 fr proximally and 1.7 Fr distally (Excelsior SL -10, Boston Scientific). Technical success was achieved in all cases. Postoperative period was uneventfull. Mean follow-up was 7.3 months and there has not been any increase of the aneurysm sac or arterial thrombosis. No patient had to do a long-term antiplatelet therapy. DISCUSSION AND CONCLUSIONS Classic embolization of visceral aneurysms requires the closure of the interested arterial branch in many cases. In these cases could occurr severe organ ischemic complications. The technique of selective embolization with controlled release coils allows to preserve the downstream perfusion of the targeted organ securing the anatomic integrity of the arterial branch, even in conditions of extreme tortuosity without resorting to surgery. Figures
Aneurysm involving the celiac trunk
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Coil embolization of the aneurysm
Another view of CTreconstruction
CT angiography control at 6 mounths FU
CT angiography at 6 months FU
References
1. N Habib, S Hassan, R Abdou, E Torbey, H Alkaied, T Maniatis, et al. Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review. ASIR 2013; 7(4). 2. Ferrero E, Ferri M, Viazzo A, Robaldo A, Carbonatto P, Pecchio A, et al.: Visceral artery aneurysms, an experience on 32 cases in a single center: treatment from surgery to multilayer stent. Ann Vasc Surg 2011, 25(7):923–935. 3. Grotemeyer D, Duran M, Park EJ, Hoffmann N, Blondin D, Iskandar F, et al.: Visceral artery aneurysms--follow-up of 23 patients with 31 aneurysms after surgical or interventional therapy. Langenbeck’s archives Surg Deutsche Gesellschaft fur Chirurgie 2009, 394(6):1093–1100. 4. Kueper MA, Ludescher B, Koenigsrainer I, Kirschniak A, Mueller K, Wiskirchen J, et al.: Successful coil embolization of a ruptured gastroduodenal artery aneurysm. Vasc Endovascular Surg 2007, 41(6):568–571. 5. Koyazounda A, Jaillot P, Persico J, Thouret JM, Grand A: Aneurysm of the gastroduodenal artery ruptured into the peritoneum. Treatment by embolization. Presse Medicale (Paris, France: 1983 1994, 23(14):661–4. 6. Tulsyan N, Kashyap VS, Greenberg RK, Sarac TP, Clair DG, Pierce G, et al.: The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Offic Publ Soc Vasc Surg Int Soc Cardiovasc Surg North Am Chapter 2007, 45(2):276– 283. discussion 83. 7. Coll DP, Ierardi R, Kerstein MD, Yost S, Wilson A, Matsumoto T: Aneurysms of the pancreaticoduodenal arteries: a change in management. Ann Vasc Surg 1998, 12(3):286–291. 8. Matsuno Y, Mori Y, Umeda Y, Imaizumi M, Takiya H: Surgical repair of true gastroduodenal artery aneurysm: a case report. Vasc Endovascular Surg 2008, 42(5):497–499. 127
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3D CT reconstruction of the embolized aneurysm at 6 mounths F-U
Ratio F/N
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
AORTA Chimney graft technique: a safe and feasible approach to treat challenging urgent aortic aneurysm Maria Misuraca, Alessandro Varroni, Marco Massucci, Massimo Mastroddi, Mario Manno, Giovanni Bertoletti
Department of Vascular and Endovascular Surgery, Latin, Italy
Aortic aneurysm with aortic side branch involvement require extensive open surgical repair and are associated with high morbidity and mortality rates. Branched and fenestrated stent grafts offer an attractive treatment option but are not yet general applicable in the acute setting. Recent papers showed that EVAR with chimney technique (Ch-EVAR) yielded reasonable early outcome, both in acute and elective cases. This technique allows to increase the proximal or distal sealing zone using the available standard aortic stentgrafts, therefore, eliminating the manufacturing delays required for customised fenestrated and branched stent-grafts. Several case series have demonstrated the feasibility of Ch-EVAR. We report here a case of successful Ch-EVAR treatment of an abdominal aortic aneurysm involving the superior mesenteric artery (SMA). A 73-year-old man with a history of hypertension, ischemic heart disease and recurrent pancreatitis, presented with a 70-mm saccular suprarenal aneurysm and abdominal pain at the emergency room. EVAR was performed with chimney stenting to SMA artery and an aortic endoprosthetics cuff between celiac trunk and right renal artery using an oversizing of the main endoprosthesis of 25%. At one-year follow-up, AAA is completely excluded with the patency of the aortic branches and the absence of endoleaks. Suprarenal pathologies can be treated with the Chimney technique using directly available devices, which offers a parachute in patients not eligible for a branched or fenestrated stent graft. In conclusion, There is no doubt that Ch-EVAR lacks long term data at the moment. However, any attempt to exclude Ch-EVAR a priori from the armamentarium of therapeutic modalities for JAAs and suprarenal AAA is not meaningfull. Unfortunately, proximal type I endoleak could be a weak point of the tecnique, despite the good result achieved for our patient, therefore there is a need of a close follow-up and an accurate selection of the patients. Figures
Preoperative CT-angiography that displays an aortic aneurysm Intraoperative image Selective catheterization of right renal involving the origin of SMA artery as a landmark for distal landing zone of the main endoprosthetic body, and selective catheterization of SMA with the Viabahn already inside
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Intraoperative image Contemporary ballooning of the two endoprothesis
Intraoperative image Release of the prostethic cuff first and then the Viabahn
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Intraoperative image Check of the Viabahn
CT angiography at one year follow-up The images show the patency of the Viabahn and the downstream vasculature and the absence of endoleak
References
1. JL Tolenaar, HJA Zandvoort, FL Moll, JA van Herwaarden. Technical considerations and results of chimney grafts for the treatment of juxtarenal aneursyms. J Vasc Surg 2013;58:607-15. 2. J Brossier, R Coscas, C Capdevila, M Kitzis, M Coggia, O Goeau-Brissonniere. Anatomic feasibility of endovascular treatment of abdominal aortic aneurysms in emergency in the era of the chimney technique: impact on an emergency endovascular kit. Ann Vasc Surg 2013; 27: 844–850. 3. A Katsargyris, K Oikonomou, C Klonaris, I To pel, ELG Verhoeven. Comparison of Outcomes With Open, Fenestrated, and Chimney Graft Repair of Juxtarenal Aneurysms: Are We Ready for a Paradigm Shift? J Endovasc Ther. 2013;20:159–169. 4. KP Donas, T Bisdas, M Austermann, G Torsello. The Chimney Technique Has a Complementary Role in the Endovascular Repair of Juxtarenal Aortic Aneurysms: There Is No Need for a Paradigm Shift but for Accurate Patient Selection. J Endovasc Ther 2013;20:582–595. 5. KP Donas, G Torsello, T Bisdas, N Osada, E Schönefeld, GA Pitoulias. Early Outcomes for Fenestrated and Chimney Endografts in the Treatment of Pararenal Aortic Pathologies Are Not Significantly Different: A Systematic Review With Pooled Data Analysis J Endovasc Ther 2012; 19 (6): 723-728. 6. KP Donas, F Pecoraro, T Bisdas, M Lachat, G Torsello, Z Rancic et al. CT Angiography at 24 Months Demonstrates Durability of EVAR With the Use of Chimney Grafts for Pararenal Aortic Pathologies. J Endovasc Ther 2013; 20(1): 1-6. 7. P Jetty, D Husereau. Trends in the utilization of endovascular therapy for elective and ruptured abdominal aortic aneurysm procedures in Canada. J Vasc Surg 2012;56:1518-26.
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AORTA Aortic disease in Marfan syndrome – the continuing story... Katarina Vavrovicova 1, Katarina Kanalikova 2, Jan Tomka 1, Frantisek Zernovicky 1, Ivan Vulev 3, Rastislav Bazik 3, Tomas Dulka 1, Vladimir Sefranek 1
1. Dep. of Vascular Surgery, NUSCH, Bratislava, Slovakia 2. Dep. of Cardiology, NUSCH, Bratislava, Slovakia 3. Dep. of Diagnostics and Interventional Radiology, NUSCH, Bratislava, Slovakia
INTRODUCTION Marfan syndrome is inherited systemic connective tissue disease. Aneurysmatic dilatation of aorta is very common in those patients. Aortic root dilatation is most frequent and represents one of the main diagnostic criteria of the disease. However, dilatation (aneurysm) could be present at any other segment of aorta, too. Increase in aortic root diameter, increases the risk of aortic dissection or aortic rupture. In order to prevent this live threatening events, early intervention is needed. CASE REPORT 39-years old female patient with Marfan syndrome was first seen at our department during pregnancy (in 21st gestational week) in 1998. She was reffered to our center by gynaecologist. She presented with rapid progresion of aortic root dilatation during pregnancy (maximal aortic root diameter increases from 40 mm before pregnancy to 62 mm at first examination at our department in 5th month of pregnancy, up to 95 mm at time of delivery), with severe aortic valve regurgitation and gradualy developing signs of cardiac failure. She had been followed-up during hospitalisation by our cardiac and vascular team from 5th month of pregnancy till its termination by caesarean section in 8th month (36 week), indicated for high risk for dissection, cardiac complications. She delivered healthy female child with no signs of Marfan syndrome. Two weeks after, she underwent Bental surgery (replacement of aortic valve and root by composite graft). Surgery was withouth important complications. She had recovered quite quickly and had been doing well. She had been continuously, regularly, followed-up at our out-patient clinics. In 2005 abdominal aortic aneurysm had been diagnosed and for rapid progresion of dilatation, she underwent another preventive surgery – resection of aneurysm and implantation of aortobiiliac bypass with reinsertion of left renal artery. Surgery was again uneventful and she recovered from it easily. And again, she had been regularly followed-up in our center. At the beginning of September 2013 she had been admitted to our hospital for acute aortic event. In admission she presented with symtoms of chest and abdominal pain, hypertension, with no signs of pulse deficit, difference, malperfusion syndrome or other, neurological or cardiac complications. CTA examination diagnosed acute Standford B dissection. Entry of dissection was localised in the middle part of descending aorta, false lumen spread retrogradely, up to the area close to left subclavian artery origin. Distal end of dissection was near origins of truncus coeliacus and superior mesenteric artery. From this part aneurysmatic dilatation (with no dissection, maximal diameter 51 mm) continued up to juxtarenal part of aorta. We decided (according to multidisciplinary consensus of vascular specialists) for hybrid reconstruction. For acute phase, as a first step, endovascular treatment was realised. Two stentgrafts were implanted to achieve aorta remodeling, with whole entry covering and complete close of false lumen. The procedure was sucessful. As a second step we are planning surgical treatment of aneurysm localised distal to the dissection in thoraco-abdominal border region – implantation of in-lay prothesis from stentgraft with insertion to Y bypass graft together with visceral artery revascularisation. CONCLUSION As have been shown previously, the whole aorta is affected in Marfan syndrome patients. Effective, early preventive treatment of the disease lead to longer survival of patients. However, we should be prepared for, another, repeat aortic events, in different segments of yet “untreated“ aorta, as no specific treatment, that would stop the progression of the changes in aortic wall has been known. Complex solutions, repeat interventions are needed in those patients. Other aspect of the case report is to show the example how the presence of risk factors could cause more progressive dilatation of aorta. Uncovering their presence could help to reduce unfavorable live-threatening events.
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CASE REPORT Growth and aortic pseudoaneurysm formation in a patient with an Abdominal Aortic Aneurysm who received chemotherapy for Non-Hodgkin Lymphoma (NHLs) Diego Ruiz Chiriboga, Javier Rio Gómez, María Soledad Manzano Grossi, Luis Reparaz Asensio Hospital General Universitario Gregorio Marañón, Madrid, Spain
OBJETIVES We report the case of a patient, with history of NHLs in treatment with chemotherapy, who developed a symptomatic aortic pseudoaneurysm and accelerated growth of abdominal aortic aneurysm (AAA). METHOD A 73-year-old man, with history of a low grade NHLs since 2009 treated with radiotherapy and in the last year received 6 cycles of chemotherapy with rituximab and bendamustine for a recurrence mass in the mediastinum. He was referred to the vascular team because the last PET-CT scan showed inflammatory findings and possible aortic rupture; the patient had an AAA that has grown progressively in the last 8 months, and described chronic symptoms two months ago, of nausea, diarrhea, back pain and weight loss. RESULTS We decide to make an urgent endovascular treatment; we saw a pseudoaneurysm in the posterolateral wall of the infrarenal aorta without signs of rupture. We put a Gore Excluder® Aortic Endoprosthesis with good result. The initial postoperative was satisfactory without any complications. New CT scan, one week after the procedure, didn’t show any endoleaks. The patient was discharged after 10 days of surgery After 4 months of follow up the patient is asymptomatic, and in the control CT the inflammatory lesions around the aorta are disappearing. DISCUSSION AND CONCLUSIONS The need for adjuvant therapy in cancer treatment is a factor to be considered in the patients who has an AAA. Some authors concerns about the chemotherapy treatment in patients known to have AAA may result in enlargement and may increase the risk of rupture but there are no documented reports so far1 In our case it’s interesting to say that since the patient began with the treatment with rituximab and bendamustine the aneurysm had important changes. There have been some publications that describe the relationship in patients receiving chemotherapy and the formation of an aortic dissection because of its toxic effect on the endothelium cells in the aortic wall2. We recommend more studies to determinate what kind of patients that are in treatment with chemotherapy and AAA will need more control and monitoring in the follow up. Figures
Angiogram in OR
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Control CT 1 month after the surgery
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Control CT 4 months after the surgery
Final Angiogram
Pseudoaneurysm formation and inflamatory tissue around the aorta
Pet TC scan 3-Oct-2012
References
1. S. Lauro, G. Lanzetta, E. Bria, L. Trasatti, A. Gelibter, and A. Vecchione, “Antiblastic chemotherapy in the presence of abdominal aorta aneurysm (AAA): guidelines,” Anticancer Research, vol. 19, no. 2, pp. 1439–1444, 1999 2. Golden, M.A.; Vaughn, D.J.; Crooka, G.W.; Holland, A. & Bavaria, J.E. (1997). Aortic dissection in a patient receiving chemotherapy for Hodgkin’s disease. Angiology, Vol. 48, pp. 1063-1065
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CASE REPORT Rare case of pseudo aneurysm of common femoral artery injury resulting from closed reposition for hip-TEP Ibrahim Sharaf, Christian weschler, Georg Rothenbacher, Martin Storck Karlsruhe City Hospital, Karlsruhe, Germany
INTRODUCTION Iatrogenic arterial damage during closed hip replacement is a rare but potentially life- or limb-threatening complication.To the best of our knowledge, this is the first reported case of an avulsion injury to a common femoral artery during closed reposition for dislocated hip-TEP. CASE PRESENTATION A 82-year-old Caucasian woman was referr to us from the emergency medical service in our emergency unit with a suspected hip dislocation (right side). In the clinical examination the right leg was shortened and externally rotated. There was local tenderness over the right great trochanter, the mobility examination was due to the reported pain not.The X-ray examination of the pelvis and right hip showed a dislocation of the right hip-TEP without loosening sign. Under sedation, a reduction of the right hip joint was not possible. The pat. was unstable (bradykardia ) so Pat. was admitted the patient on intermediate care unit. Her hemoglobin was still only 70 gm/l despite being transfused with five units of blood. Her clotting profile was normal. It was thought that the patient had a hematoma which could be responsible for the pain, the swelling, and the drop in hemoglobin. The patient was transfused with four units of fresh frozen plasma. On the second day, since the patientâ&#x20AC;&#x2122;s hemoglobin remained low despite repeated transfusions, an emergency CT-angiogram was performed which showed pseudo aneurysm of the common femoral artery and an occlusion of the superficial femoral artery and the popliteal artery. After intense conversation with both daughters about the indication for urgent surgery, both have decided against surgery. The patient died two days later. CONCLUSION Iatrogenic arterial damage during closed reposition for hip-TEP is a rare but potentially life- or limb-threatening complication. Avulsion injuries and injuries to the common femoral artery may be uncommon, but they can still occur. Particular attention should be given to those who are known to have pre-existing atherosclerotic disease as these factors could make certain types of injury more likely to occur. References
1. Wilson JS, Miranda A, Johnson BL, Shames ML, Back MR, Bandyk DF: Vascular injuries associated with elective orthopaedic procedures. Ann Vasc Surg 2003, 17:641-644 2. A rare case of arterial avulsion presenting with occult blood loss following total hip arthroplasty: a case report. Claire Hall, Wasim S Khan, Sohail Ahmed and David H Sochart. Journal of Medical Case Reports 2009, 3:9320 3. Bansal R, Laing PW: Iatrogenic blunt arterial injury during hip fracture surgery. Acta Orthop Belg 2006, 72:96-99
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CASE REPORT “Hibernating kidney”: successful surgical salvage of prolonged renal failure after renal artery occlusion following EVAR Georg Rothenbacher1, Jost Jenkner1, Karl-Heinz Seitz2, Ibrahim Sharaf1, Martin Storck1
1. Dept. vascular thoracic surgery Klinikum Karlsruhe, Karlsruhe, Germany 2. Dept. nephrology Klinikum Karlsruhe, Karlsruhe, Germany
CASE REPORT A 72-year old patient underwent endovascular aortic aneurysm repair (EVAR) in an external institution. On day 3 he was transferred to our nephrology department because of acute renal failure requiring hemodialysis therapy. CT-scan and duplex-sonography showed occlusion of the left renal artery due to incorrect stent graft position with an atrophic kidney on the right side and chronic renal artery stenosis. Arterial perfusion signals in the periphery of the renal parenchyma were absent. Contrast enhanced ultrasound (CEUS), however, disclosed slowed parenchymal perfusion without signs of infarction. Percutaneous interventional revascularisation was technically not indicated. Therefore a splenorenal anastomosis was suggested, but the patient did not agree. Operation was then performed at day 18 after informed consent of the patient. Postoperative diuresis increased immediately and creatinine values fell to 2,8 mg/dl. Hemodialysis therapy was discontinued. The patient was discharged at day 8 after surgery. After 6 weeks creatinine had regressed to 1,8 mg/dl. CONCLUSION Operative salvage of the left kidney was successfully performed three weeks after acute renal failure following EVAR. “Slow-food” oxygen supply prevented ischemic renal necrosis, but subfiltration perfusion pressure resulted in a “hibernating kidney” with reversibility after splenorenal anastomosis. CEUS proofed parenchmal viability after acute renal artery overstenting. Delayed revascularisation after 18 days was able to restore kidney function in this patient.
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CASE REPORT Bilateral common carotid occlusion Luís Machado
Centro Hospitalar S. João - Serviço de Angiologia e Cirurgia Vascular, Porto, Portugal INTRODUCTION The incidence of common carotid artery (CCA) occlusion in stroke patients is estimated to vary from 1% to 5%. Bilateral CCA occlusion is extremely rare. We report a case of a female with symptomatic supra aortic trunk atherosclerotic disease, submitted to aorto-bicarotid bypass and left carotid-subclavian bypass. MATERIALS/METHODS A 57 year-old female, with history of hypertension, heavy smoker, and ischemic heart disease submitted to coronary angioplasty 2 years before. Referenced to our department because of peripheral arterial disease, with claudication for long distances. The patient also complains of sporadic dizziness, since 1 year before. She denied other neurologic symptoms. Absence of carotid pulses at the physical exam. Submitted to Doppler scan that reveals bilateral CCA occlusion. The digital subtraction angiography (DSA) confirms the CCA occlusion and stenosis of both subclavian artery (more than 50% at the left) and stenosis at the origin of left vertebral artery. Cerebral MRI show old hemispheric ischemic lesions. Despite of the slight symptoms there was a considerable risk of a major stroke, so we decided to perform an aorto-bicarotid bypass, from ascending aorta to internal carotid arteries and a left carotid subclavian bypass. RESULTS Surgery without any complications. No neurological deficits in the immediate post operative period. During the stay at ICU, on the 7th post operative day the patient develop cardiogenic shock. It was performed an echocardiogram that reveals a hemopericardium. She was submitted to urgent surgery, and revision of aortic anastomosis. Good progress during hospitalization, she was discharged at 18th day after initial surgery, without any neurologic deficits. The patient remains asymptomatic 3 years after surgery, with the bypass permeable confirmed by Doppler scan. CONCLUSIONS Most of aorto-bicarotid bypass reported in the literature were performed in patients with Takayasus´s Arterites, there were few reports for atherosclerotic disease treatment. The natural history of CCA occlusion is not well known. In this particularly patient, with occlusion of both CCA, and significant stenosis in other supra aortic arteries the risk of stroke was non-negligible. The surgical management appears to be a good solution to treat this kind of lesions, with low mortality and morbility, low neurological events and good patency of the bypass.
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CASE REPORT Embolization of a huge renal arteriovenous fistula with Amplatzer® Vascular Plug Luís Machado
Centro Hospitalar S.João - Serviço de Angiologia e Cirurgia Vascular, Porto, Portugal
INTRODUCTION Renal arteriovenous fistula (AVF) are uncommon. A huge fistula with large shunt can cause overloaded heart volume and sometimes failure. The renal function may also be compromised. In this case report we describe the treatment of an acquired high-flow renal AVF with the use of a Amplatzer® vascular plug. MATERIAL AND METHODS Male patient of 50 years. History of hypertension and IgA nephropathy with histological diagnosis after renal biopsy about 10 years ago. Referred to the Vascular Surgery department after undergoing CT angiography that revealed a «pseudo-aneurysm of a renal artery branch of the right kidney and probable AVF, with enlargement of the renal vein.» About two weeks before, the patient refers onset of dyspnea on minimal exertion and orthopnea. We performed an arteriography that demonstrated a huge AVF in dependence of an intrarenal branch of the posterior division of right renal artery. RESULTS After assessing their anatomy, we proceeded to the embolization of the AVF with a Amplatzer® vascular plug of 12x8 mm. Correct positioning and expansion of the plug was verified with the exclusion of AVF and normal patency of the other branches of the right renal artery. The next day, the patient referred improvement of the symptoms. Renal Doppler ultrasound was performed and demonstrated the exclusion of renal AVF. The patient remains asymptomatic 5 months after the procedure, with preserved renal function. CT angiography of control, confirmed the exclusion of the AVF and mild atrophy of the renal parenchyma at the lower back of the right kidney. CONCLUSIONS The procedures such as percutaneous renal biopsies or nephrostomies increased the number of acquired renal AVF. The traditional treatment was surgery, currently percutaneous embolization is a less invasive and effective treatment. In high-output fistulas, embolization is more difficult, with the risk of embolization to the pulmonary circulation. The use of Amplatzer® devices was the initial objective to avoid displacement of the coils, but have been used alone with good results in high output fistulae.
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CASE REPORT Percutaneous stenting for symptomatic stenosis of aberrant right subclavian artery Luis Machado Centro Hospitalar S.João - Serviço de Angiologia e Cirurgia Vascular, Porto, Poland
INTRODUCTION The aberrant right subclavian artery is the most common anomaly of the aortic arch, in which the artery originates after the origin of the left subclavian artery, at the posterior aorta. Occurs in about 0.5-1% of the population. It is usually asymptomatic, when it causes symptoms, these may be due to esophageal compression, aneurysmal disease or occlusion / stenosis of the artery. MATERIALS/METHODS Patient of 56 years old, male, with a history of progressive right arm claudication, associated with dizziness. At physical examination: radial pulse of lesser amplitude at the right side, blood pressure of 150/90 mmHg at the left and 90/70 mmHg at the right. No other significant alterations. Personal background: hypertension under antihypertensive drugs, smoking for nearly 15 years, dyslipidemia, ischemic heart disease with the need for surgical revascularization and ischemic stroke, without neurological deficits. In the investigation of the etiology of stroke it was performed a carotid and vertebral Doppler ultrasound that revealed reversal flow of the right vertebral artery. After it was performed a MRI which revealed an aberrant right subclavian artery with retro-esophageal and retro-tracheal route with a severe stenosis at its origin in the aortic arch, associated with reversal of flow in the ipsilateral vertebral artery. RESULTS It was made right brachial artery puncture, to perform arteriography that confirmed a severe stenosis at the origin of aberrant right subclavian artery. The lesion was treated with placement of balloon-expandable stent 10x29mm (Omnilink Elite®), with restoration of antegrade flow in right vertebral artery. The procedure progressed uneventfully, and the patient was discharged the day after, treated with double anti-aggregation. The patient remains asymptomatic 3 months after the procedure, with symmetrical radial pulses and blood pressures similar in both arms. CONCLUSIONS The treatment of a stenosis of aberrant right subclavian artery is usually surgical, there are a few cases reported of endovascular approach. We used percutaneous stenting for the treatment of high-grade stenosis in an aberrant subclavian that produced neurologic and upper extremity symptoms. This approach provides an attractive alternative to conventional surgical strategies, particularly in the high-risk patient.
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CASE REPORT Exostoses and vascular complications, two case reports and review of the literature Bahaa Nasr, Ali Badra, Pierre Gouny
CHU Brest - departmenent of cardiac thoracic and vascular surgery, Brest, France
Exostosis is a very common bone tumour. Complications occur in 4% of the cases (nerve compression, exostosis degeneration, orthopaedic complication), however vascular complications are rare. This is the report of two cases of vascular complications that occurred in two patients; one with a solitary form and the other with hereditary multiple exostoses. A review of the literature found 57 cases of lower limbs vascular complication, secondary to an exostosis. The most common vascular complication is the popliteal aneurysm. Femoral exostosis topography is found in 89% of the cases. A triggering trauma is found in 36% of the cases and the most common form was the solitary exostosis (58%). The treatment of these complications is surgical, and it treats the vascular lesion and the bone tumour at the same time. Surgical treatment of exostosis vascular complications is recommended as an urgent procedure, in order to prevent the occurrence of irreversible damages. Figures
Swelling in the lower third of the thigh
CT scan: pseudoaneurysm The exostosis rubbing in the popliteal of the right popliteal artery artery
References
1. Murphey MD, Choi JJ, Kransdorf MJ, Flemming DJ, Gannon FH. Imaging of osteochondroma : Variants and complications with radiologic-pathologic correlation. Radiographics 2000 ; 20 :1407-34. 2. Masson AF, Pullan JM, Aneurysm complicating exostosis. Br J Surg 1966 ; 53 :929-32. 3. Kover JH, Schwalbe N, Levowitz BS. Popliteal aneurysm due to osteochondroma in athletic injury. NY state J Med 1970 ; 70 :3001-3. 4. Manner R, Makinen E. Angiographic findings in a false popliteal aneurysm due to osteochondroma of the femur. Pediatr Radiol 1975 ; 3 :244-6.
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5. Solhaugh JH, Olerud SE. Pseudoaneurysm of the femoral artery caused by osteochondroma of the femur. A case report. J Bone Joint Surg Am. 1975 ; 57 :867-8. 6. Shah PJ. Aneurysm of the popliteal artery secondary to trauma from an osteochondroma of the femur : a case report and review of the literature. Br J Surg 1978 ; 65 :786-8. 7. Kieffer E, Maraval M, Tricot JF, Natali J. Aneurysm due to an exostosis of the upper end of the tibia. Rev Chir Orthop Reparatrice Appar Mot. 1978 ; 64 :155-62. 8. Leve L, Kalideen JM. Popliteal false aneurysm complicating osteochondroma. S Afr Med J 1979 : 187-55. 9. Greenway G, Resnick D, Bookstein JJ, Popliteal pseudoaneurysm as a complication of an adjacent osteochondroma : angiographic diagnosis. AJR Am J Roentgenol 1979 ; 132 :294-6. 10. Israels SJ, Downs AR. Traumatic aneurysm of the popliteal artery due to an osteochondroma of the femur. Can J Surg 1980â&#x20AC;Ż; 23 :270-2. 11. Metras D, Coulibaly AO, Calvy H, Acquaviva P, Ouattara K. Arterial thrombosis of the femoro-popliteal axis : an exceptional case of vascular complication by exostosis. J Mal Vasc 1981 ; 6 :289-91. 12. Ferriter P, Hirschy J, Kesseler H, Scott WN. Popliteal pseudoaneurysm. J Bone Joint Surg Am 1983 ; 65 :695-7. 13. Zini F, Negri V. A case of popliteal pseudoaneurysm caused by femoral exostoses. Acta Biomed Ateneo Parmense. 1984 ; 55â&#x20AC;Ż:43-7. 14. Ennker J, Freyschmidt J, Reilmann H, Dimovski D. False aneurysm of the femoral artery due to an osteochondroma. Arch Orthop Trauma Surg. 1984; 102:206-9. 15. Lizama VA, Zerbini MA, Gagliardi RA, Howell L. Popliteal vein thrombosis and popliteal artery pseudoaneurysm complicating osteochondroma of the femur. AJR Am J Roentgenol 1987 ; 148 :783-4.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
CASE REPORT Sciatic pain and foot drop: an uncommon manifestation of a hypogastric artery aneurism Sérgio Teixeira, Pedro Sá Pinto, Luís Loureiro, Tiago Loureiro, Diogo Silveira, Duarte Rego, Vitor Ferreira, João Gonçalves, Rui Almeida
Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
Hypogastric artery aneurisms constitute a rare form of the aorto-iliac aneurismatic disease. This condition is normally hard to diagnose given the deep localization of the artery in the pelvic region. Frequently, these aneurisms manifest in a late stage of their development by growing in size, forming fistulas or rupture. Here, we present the clinical case of a male patient, 84 years-old, with previous personal history of arterial hypertension, dyslipidemia, bilateral total hip replacement surgery and above-knee femoropopliteal bypass surgery of the right inferior limb due to a thrombosis of a popliteal aneurism. Four months after right hip replacement surgery, the patient progressively initiated sciatic pain and motor plus sensitive deficit with associated right foot drop. The electromyography performed revealed the existence of a grave axonal motor-sensitive lesion in the peroneal portion of the right sciatic nerve. To further clarify this lesion, the patient was submitted to a CT scan, which showed an aneurism of the right hypogastric artery (40 mm diameter in the anterior-posterior aspect and 50 mm width) which bulged into the sciatic foramen and compressed the sciatic nerve. Selective catheterization of the right hypogastric artery was later performed, percutaneously and contralaterally, followed by dissection and occlusion of the arterial lumen. In the follow-up period the patient evolved with significant decrease in the sciatic pain symptoms and maintenance of the established motor deficits. The control CT scan showed a decrease in the volume of the aneurismatic sac, which was entirely thrombosed. Hypogastric artery aneurisms represent an enormous medical challenge, not only in terms of diagnosis, but also regarding treatment. Case reports describing hypogastric artery aneurisms presenting with sciatic pain and foot drop are scarce. The surgically-induced dissection of the hypogastric artery was therapeutic, allowing the thrombosis of the aneurism. Figures
CT scan of the pelvis showing right hypogastric artery aneurism. Digital subtraction arteriogram showing occlusion of the right hypogastric artery.
References
1. Dix FP, Titi M, Al-Khaffaf H. The isolated internal iliac artery aneurysm—a review. Eur J Vasc Endovasc Surg 2005;30:119–29. 2. Parry DJ, Kessel D, Scott DH. Simplifying the internal iliac artery aneurysm. Ann R Coll Surg Engl 2001;83:302–8. 3. Singh R, Moores T, Maddox M, Horton A. Internal iliac aneurysm presenting with lower back pain, sciatica and foot drop. JSCR 2013; 2 (3 pages)
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CASE REPORT Total thoracic aorta replacement for recurrent aortobronchial fistula after endovascular treatment of distal aortic arch mycotic aneurysm Sang-Ho Cho, Young-Tae Kwak Kyung Hee University Hospital at Gangdong, Seoul, Republic of South Korea
INTRODUCTION Aortobronchial fistula (ABF) induced by a mycotic aortic aneurysm is life-threatening. Although early open thoracic surgery under cardiopulmonary bypass (CPB) is essential, the high mortality and morbidity associated with surgery may direct to alternative option, such as endovascular stenting. We report a case of recurrent aortobronchial fistula after stent grafting as early procedure for distal aortic arch mycotic aneurysm. PATIENT AND METHODS A 59-year-old man was admitted to emergency room following the occurrence of massive hemoptysis. About 1 month earlier, he had presented to the outpatient clinic to investigate the origin of the fever and antibiotics had been administered under a diagnosis of UTI. Enhanced computed tomography (CT) of the chest revealed the saccular aortic aneurysm on the distal arch (Figure A). Emergency stent grafting of the aneurysm was performed to control the hemoptysis caused by aortobronchial fistula. About 7 months after the stent grafting, the patient was readmitted with a recurrent massive hemoptysis (Fibure B). Remnant aortobronchial fistula (Figure C, black arrow) and recurrent local inflammation of thin aortic wall (Figure C, white arrow) caused the recurrent hemoptysis. RESULT We performed exclusion of the previous stent graft and graft replacement of ascending aorta, aortic arch, and proximal descending aorta under CPB. The patient had an uneventful postoperative course and recovered without any neurological complications. There has been no evidence of complication in the 28 months since his last operation. CONCLUSION Although it is still controversial, stent grafting of mycotic aneurysm is considered as an alternative or bridging procedure in selected patients. But, in our case, ABF of mycotic aortic aneurysm, remained hidden connection of ABF after stent grafting may cause recurrent life threatening massive hemoptysis. In conclusion, surgery to exclude infected aneurysm and ABF connection is essential procedure for a ABF of mycotic aneurysm.
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CASE REPORT Cystic adventitial disease of the popliteal artery Stephanie Donohue, Yann De Bast, Francoise Lefebvre
UCL, Bruxelles, Belgium
A 46-year-old man presented with a 3-month history of intermittent claudication involving the right calf after walking a distance of 30 meters. Obesity was his only risk factor for cardiovascular disease. On examination no pulse could be felt below the femoral artery on the right side. All pulses were present in the left leg. MRI imaging revealed a significant stenosis around of the popliteal artery due to cysts and cystic adventicial disease was diagnosed (Panel A).The intraoperative findings confirmed the clinical and radiologic diagnosis with release of a highly viscous and mucinous mass after enucleation of cysts from the adventicia. The preservation of the popliteal artery was possible (Panel B).No communication with the joint was noted.The patient became asymptomatic. Adventicial cystic disease is a rare disease, but it should be suspected in male patient aged between 40-50 years for whom no evidence of atherosclerotic disease has been underligned.
Cystic adventitial disease of the popliteal artery.
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PAOD Outcome analysis of infrapopliteal percutaneous transluminal angioplasty and pedal bypass graft surgery for individuals with critical limb ischemia A. Navickienė, A. Barkus, K. Čekas, E. Sirutavičiūtė, S.sudikas, D. Triponienė, V. Triponis Vilnius University, Vilnius, Lithuania
OBJECTIVE The aim of this study was to report our experience and long –term results of surgical revascularization of pedal arteries and infrapopliteal percutaneous transluminal angioplasty in diabetic patients, to assess the impact of diabetes, gender and age on limb salvage and to compare surgical bypass and endovascular therapy in patients with critical limb ischaemia. MATERIAL AND METHODS We retrospectively reviewed 193 pedal bypasses and 103 PTA procedures performed from January 1999 to March 2013. 84 patients in the open rapair group had endovascular treatment also. All patients were treated for chronic critical ischaemia. The indication for the use of pedal artery was a lack of tibial arteries with run-off to the foot. The greater saphenous vein as the conduit was used in 94% of the cases. Foot infection was present in 13% of patients. Mean age was 67. The male/ female ratio was 1,4/ 1. Diabetes mellitus was present in 74% of patients. The follow-up periods ranged from 1 to 60 months. The endpoints analysed were graft patency and limb salvage rates. RESULTS The cumulative patency in diabetic patients was 70% at 1 year and 49% at 3 years and in non diabetic patient the cumulative patency was 42% at 1 year and 24% at 3 years. Better results were achieved in diabetic patients.The difference between the patency rates in diabetic and no diabetic patients was significant (p=0,013) Limb salvage was 83% at 1 year and 73% at 3 years in diabetic patients. There were 20 major amputations performed for diabetic patients. Younger patients ( under 70 years old) were associated with better results for cumulative patency and limb salvage (p< 0,01). Amputation –free survival was broadly similar between the two treatment groups at 6 months, but intention to treat analysis demonstrated benefits of open surgery for patients surviving >2 years in terms of improved survival and amputation-free survival. CONCLUSIONS In the long term, pedal artery bypass for diabetic patients is a satisfactory option for limb salvage. Combining proximal endovascular techniques with pedal bypass has given promising results and should enhance bypass numbers.
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PAOD SFA: latest news from the endo technology and techniques Jan Heyligers St Elisabeth Hospital, Tilburg, The Netherlands
Femoropopliteal lesions are more frequently treated in an endovascular fashion over the last several years. In order to minimize re-stenosis and occlusion rates, novel strategies are evolving. The clinical use of drug eluting stents, drug coated endovascular grafts and drug coated balloons are progressively ongoing. Although vein bypass surgery reaches 5 year primary patency rates about 70%, these novel technologies result in a decline of open bypass surgery. As for the ZilverÂŽ PTXâ&#x201E;˘ Global Registry it is concluded after two years that outcomes with the paclitaxel-eluting stent support its sustained safety and effectiveness in patients with femoropopliteal artery disease, including the long-term superiority of the DES to PTA and to provisional BMS placement. Three-year results of the VIBRANT trial of VIABAHN endoprosthesis versus bare nitinol stent implantation for complex superficial femoral artery occlusive disease, concluded that longterm outcomes of complex superficial femoral artery disease intervention using the VIABAHN endograft and bare nitinol stents are similar. Excellent primary-assisted and secondary patency rates were achieved, with sustained augmentation of limb perfusion and quality-of-life measures. Patency rates diminish most rapidly in the first year after device implantation. Careful sizing of the device relative to vessel landing zones is essential for achieving optimal outcomes. The recently started RAPID trial is a multicenter randomized controlled patient blind trial that will provide evidence concerning whether the use of the Legflow paclitaxel/shellac coated balloons with nitinol stenting significantly reduces the frequency of restenosis in intermediate and long SFA lesions compared to standard PTA and stenting. A drug eluting bioresorbable scaffold seems to be very promising in coronary arteries. The transfer to the peripheral area is nowadays ongoing. Also, new endovascular devices to deliver drugs peri-vascularly are novel strategies to positively influence the outcome of endovascular SFA treatment.
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PAOD Clinical outcomes of endovascular treatment for isolated external iliac artery (EIA) occlusive disease Dindyal S.1, Lewis J.2, Akingboye AA.1, Bent C.1, Tai N.1, Walsh M.1, Fotadis N.1, Renfrew I.1, Mattson M.1, Kyriakides C.1 1. Barts and The London NHS Trust, The Royal London Hospital, London, United Kingdom 2. The Princess Alexandra Hospital, Harlow, Essex, United Kingdom
OBJECTIVE Percutaneous transluminal angioplasty (PTA) is the treatment of choice for common iliac arterial (CIA) occlusive disease with excellent patency rates. However, there are few reported clinical outcomes for isolated EIA disease. METHODS Data was prospectively collected over a 5 year period, 72 patients (80 limbs) underwent EIA PTA+/-stenting. Indications for intervention were graded according to Fontaineâ&#x20AC;&#x2122;s classification; moderate claudication (IIA)-7, severe claudication (IIB)-45, rest pain (III)-5 and critical limb ischaemia with tissue loss (IV)-15. Mean follow up was 12.4 months (range 6- 52 months). RESULTS 48 patients underwent PTA and 19 had PTA+stenting, there were 5(6.9%) failed attempt at stenting which all underwent open revascularization. 67 patients had successful PTA+/-stenting. Primary patency was maintained in 29(43.3%) and secondary patency was achieved in 10(15%). Of the patients that re-occluded, 14 were Fontaine IV; 7 had a redo PTA+stenting and the remaining 7 underwent open revascularization (3 of these patients had a below knee and 2 had digital amputations). 4 ulcers were completely healed and the remaining 3 continued conservative wound management. The remaining 14 patients; 7(10.4%) were managed conservatively and 7(10.4%) had surgery. 3(6.25%) complications were encountered (1 EIA rupture requiring emergency surgery and 2 large groin haematomas). There was 1 death following infra-inguinal revascularisation surgery. The total limb salvage rate 64/67(95.5%). CONCLUSION PTA for EIA occlusive disease should be used selectively as a bridge whilst definitive management is been planed, particularly for Fontaine IV patients, because endovascular short-term patency rates are poor compared with reported outcomes for CIA occlusive disease.
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PAOD Use of Drugcoated Balloon PTA as first line treatment for all SFA lesions Koen Keirse1, Bart Joos1, J端rgen Verbist2, Patrick Peeters2, Marc Bosiers3, Koen Deloose3, Joren Callaert3
1. H.Hart hospital, Tienen, Belgium 2. Imelda Hospital, Bonheiden, Belgium 3. A.Z. Sint-Blasius, Dendermonde, Belgium
BACKGROUND Drugcoated balloons have been proven efficient in BTK and is still under investigation in Trials for their use in the SFA.The use of drugcoated balloons (DEB), can reduce the number and length of stenting in the SFA. Although there are clear indications of the benefits in case of restenosis or in-stent restenosis, scientific evidence to support this title is still lacking today. We have treated 100 limbs consecutively with SFA disease (including TASC C and D lesions, restenoses and in-stent restenosis) in a subcohort of patients included in the IN.PACT Global trial to investigate the mid-term results (up to 24 months) in patients presenting with intermittent claudication or critical limb ischemia by use of DEB systems. METHODS Patient cohort is a subgroup of the prospective, non-randomized, multi-center, multi-national, controlled trial IN.PACT Global conducted in 1 site in Belgium. Between Nov 2012 and Oct 2013, 74 patients (100 limbs treated) were enrolled. The efficacy endpoint of the trial is freedom from clinically driven TLR within 12 months and primary patency within 12 months, defined as freedom from >50% restenosis at 12 months as indicated by an independently verified duplex ultrasound peak systolic velocity ratio (PSVR) <2.4 in the target vessel with no reintervention. Safety endpoint includes freedom from device-related and procedure-related mortality through 30 days, freedom from major target limb amputation and freedom from TLR within 12 months. RESULTS Of the 78 patients enrolled, 68.33% were men and the mean age was 69.9 years. 88% had intermittent claudication and 12% presented with critical limb ischemia. For lesion treatment, only 30% received a bailout stenting for residual stenosis of more 50% or flow-limiting dissections and these were considered as treatment failure. The overall mean lesion length was 149.6 mm. Preliminary results show a freedom from TLR at 6 months of 76% and a primary patency at 6 months of 74%. CONCLUSION Treatment of all real-world SFA disease with DEB seems safe and feasible, shows promising primary patency rates and freedom from TLR and appears to have lower bail-out stenting rates as compared to POBA and acceptable. As these preliminary 6-month data show promising results, full 6-month data and preliminary 12-month data will be presented at the congress.
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PAOD OffRoad™ re-entry catheter system for subintimal recanalization of chronic total occlusions in femoropopliteal arteries: primary safety and efficacy results of the re-ROUTE trial Koen Keirse1, Andrej Schmidt2, Erwin Blessing3, Ralf Langhoff4, Thomas Zeller5 1. Regional Hospital Heilig Hart Tienen, Tienen, Belgium 2. Park-Hospital Leipzig, Center for Vascular Medicine, Leipzig, Germany 3. University of Heidelberg, Heidelberg, Germany 4. Ev. Krankenhaus Königin Elisabeth, Berlin, Germany 5. Herzzentrum Bad Krozingen, Bad Krozingen, Germany
PURPOSE The objective of the Re-ROUTE Clinical Study (NCT01500031) is to provide additional clinical data regarding the safety and technical success of the OffRoad Re-Entry Catheter System (Boston Scientific, Natick, MA) for subintimal recanalization of chronic total occlusion (CTO) in the femoropopliteal arteries. METHODS AND RESULTS A total of 92 patients (mean age 70.3 ± 10.6 years; 70% male; mean lesion length 175.1 ± 85.4 mm) were enrolled in this prospective, single-arm, multicenter, post-market study conducted at 12 centers in Europe. To be eligible for the study, patients were required to have claudication or critical limb ischemia and a de novo or re-occluded CTO lesion in a native femoropopliteal artery. Target lesion length ≥ 1 cm and ≤ 30 cm and a minimum reference vessel diameter of 4 mm by visual assessment were required. Eighty seven patients were evaluable for the primary 30-day safety endpoint. The composite rate of device-related major adverse events (MAEs; ie, death, perforation requiring intervention, clinically significant peripheral embolism, and major amputation of the treated lower limb) was 3.4% (3/87). All 3 events were clinically significant peripheral embolisms and the event rate was lower than the prespecified acceptable threshold. Effectiveness was based on device technical success, defined as placement of a guidewire in the true lumen distal to a CTO as confirmed by an angiography core lab. The core lab-confirmed success rate was 92.1% (70/76), however, the core lab was unable to evaluate all cases due to lack of proper post-operative images. Site-reported technical success was 84.8% (78/92). Technical success rates exceeded the prespecified performance goal. CONCLUSION The RE-ROUTE trial results demonstrate acceptable performance of the OffRoad system in terms of safety and technical success.
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PAOD TopClosure® system as a substitute for skingraft in fasciotomy wounds Moris Topaz1, Narin Carmel2, Guy Topaz2, Alexander Kantarovsky3
1. Plastic surgery unit, Hillel Yaffe medical center, Hadera, Israel 2. Sackler School of medicine, Tel Aviv University, Tel Aviv Jaffa, Israel 3. Vascular Surgery Unit, Hillel Yaffe Medical Center, Hadera, Israel
BACKGROUND Compartment syndrome is a common complication following vascular surgery, leading to ischemia, requiring immediate surgical relief by adequate fasciotomy. Closure of fasciotomy wounds (FWs) most often require skin grafting followed by revision of the scars at a later stage. The TopClosure® System is an innovative device that attaches to the skin through a wide area of attachment, away from wound margins. It applies controlled, incremental, evenly-distributed vector-tension, in a dynamic, adjustable, reversible, zipper-like manner. OBJECTIVES To evaluate the efficiency of the TopClosure® system for direct closure of FWs as a substitute for skin grafting. METHODS Patients that underwent faciotomy of the lower limbs following vascular surgery, all requiring skin grafting for closure, were treated by TopClosure®. High-tension wound closure was managed by intraoperative cycling steps of stress relaxation through tension sutures, postoperatively through mechanical creep and skin secure until complete wound closure. Regulated negative pressure-assisted wound therapy (RNPT) was applied concurrently as a dressing method. RESULTS Nine FWs in 4 patients, with width ranging from 4-11cm were closed through delayed, direct closure using TopClosure®. In the first patient only, a skin graft was applied for closure of the contralateral wound. In another patient, an additional patch skin graft was needed for complete wound closure. No significant complications or unexpected events were associated with the use of the device. CONCLUSIONS The TopClosure® system, effectively, in a simple way, enabled primary closure of FWs, serving as a platform for application of both stress relaxation and mechanical creep. TopClosure® minimized the need for skin grafts and donor site morbidity by serving as a topical tension-relief platform for tension sutures. It enabled mobilization of skin and subcutaneous tissue without undermining of skin and early, direct wound closure with minimal local morbidity. Surgical time and hospital stay were reduced, and wound post-operative aesthetics was improved.
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PAOD Acute limb ischaemia in patients with cancer; a challenging problem ZDY Sun1, DA Russell1, MA Troxler1, P Selby2, DJA Scott3
1. Leeds General Infirmary, Leeds Teaching Hospitals Trust, Leeds, West Yorkshire, United Kingdom 2. Section of Oncology and Clinical Research, St. Jamesâ&#x20AC;&#x2122;s University Hospital, Leeds Teaching Hospitals Trust, Leeds, West Yorkshire, United Kingdom 3. Leeds Institute of Genetics and Health Therapeutics, University of Leeds, Leeds, West Yorkshire, United Kingdom AIMS The association between cancer and arterial thrombosis is well established, but the management remains controversial. We aimed to assess the incidence and outcome of acute limb ischaemia associated with advanced cancer in a tertiary oncology centre. METHODS A retrospective review of a prospectively maintained departmental database was conducted from 1st January 2010 to 31st May 2013. All cases of limb ischaemia associated with cancer were included. Patient demographics and cancer details were recorded. The mode of presentation was classified as acute limb ischaemia (onset within 24 hours) or sub-acute (onset beyond 24 hours). Outcome measures were 30-day major amputation and mortality rates. RESULTS Thirty patients (16 women, 14 men), median age 71 years (IQR 16 years) were identified. Presentation was acute in 40% (n=12) and sub-acute (median 14 days, IQR 18 days) in 60% (n=18). Conservative management with subcutaneous low molecular weight heparin or antiplatelet therapy was utilised in 70% (n=21), while 30% (n=9) underwent an intervention. 30-day mortality rate was 43% (n=13), causes of death were due to advanced cancer. 30-day major amputation rate was 7% (n=2), one in the intervention group and the other in the conservative treatment group. CONCLUSIONS Acute arterial limb ischaemia in the presence of advanced cancer is associated with high mortality, the causes of death were due to advanced cancer rather than limb ischaemia-related complications. This should be taken in to account when discussing treatment options with patients and relatives. A conservative approach seems possible in many patients with acceptable short-term limb salvage.
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CONTROVERSIES & UPDATES IN VASCULAR SURGERY
RESEARCH Sorafenib attenuates the development and progression of experimental aortic aneurysms by inhibiting angiogenesis and the ERK pathway Badri Vijaynagar, Nicholas Sylvius, Ana Verrisimo, Nikesh Dattani, Matt Bown, Robert Sayers, Edward Choke
University of Leicester, Leicester, United Kingdom
BACKGROUND Angiogenesis and extracellular signal-related kinase (ERK) pathway are key modulators of MMPs during abdominal aortic aneurysm (AAA) formation. This study investigated the effects of sorafenib (a multikinase inhibitor with antiangiogenic and ERK inhibitory properties) on experimental AAAs, and its in-vitro equivalent, 5-Br SU6668, on co-cultures of human AAA smooth muscle cells (SMCs) with aortic endothelial cells (AECs). METHODS ApoE-/-, mice were assigned to either 28 days of angiotensin-II (AngII) infusion alone (Group 1); AngII+sorafenib from day-1 (Group 2); AngII+sorafenib from day-10 (Group-3); or saline infusion (negative control, Group 4). Maximum aortic diameter was measured ex-vivo (microscope calipers) and in-vivo (Vevo2100 ultrasound on days – 0. -7, -14, -21 and -28). Tissue gene and protein expressions were quantified using QRT-PCR and immunochemistry respectively. In-vitro effects were investigated in co-cultures at 0, 4, 8, 24 and 48-hours using QRT-PCR and ELISA. RESULTS Sorafenib reduced the development (Group-2; 1.7±0.8 mm versus Group-1; 2.47±1mm, P=0.001) and progression (Group-3; 1.58±0.57 mm versus Group-1, P=0.0002) of AAAs. Elastin and collagen layers were preserved in sorafenib treated aortae. Sorafenib significantly reduced angiogenesis (CD34 cells), inflammatory infiltrates, expression of pro-angiogenic genes (RAF1, NRAS, PI3K, AKT3, VEGF, IL6) and MMP-2 and -9 protein expressions (all P<0.05). AngII led to increased phosphorylation (activation) of ERK, an effect which was reversed by sorafenib treatment. In-vitro, 5-Br SU6668 prevented ERK phosphorylation; and reduced IL-6 gene expression (P=0.04) and protein levels of MCP-1 and MMP2 (P<0.05) in co-cultures of human AAA SMCs and AECs. CONCLUSION Targeting angiogenic pathway via inhibition of ERK phosphorylation is a potential therapy to prevent AAA growth.
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RESEARCH Endovascular treatment of sincronous thoracic and abdominal aortic aneurisms – case report Tiago Loureiro, Pedro Sá Pinto, Rui Machado, Ivone Silva, Clara Nogueira, Carolina Vaz, Luís Loureiro, Diogo Silveira, Sérgio Teixeira, Duarte Rego, João Gonçalves, Vítor Ferreira, Rui Almeida Centro Hospitalar Porto - Hospital Santo António, Porto, Portugal
INTRODUCTION Synchronous thoracic and abdominal aortic aneurisms, an infrequently studied association, are relatively common. About a fourth of the patients diagnosed with an abdominal aortic aneurism present aneurismatic degeneration of the thoracic aorta. The simultaneous endovascular treatment is controversial by the fear of complications related with medullar ischemia. CASE REPORT An 82 years old male, ex-smoker, with irrelevant medical and surgical past, presented in the emergency department with sudden interscapular pain. Relieve could be obtained with NSAIDs. He had no relevant findings on physical examination: pulses were symmetrical in both arms and legs with slight tendency to hypertension. A Stanford type B dissection was diagnosed on angio-CT related to a thoracic aorta aneurysm with 64mm of diameter. Imagiologic study also revealed an infrarrenal abdominal aortic aneurysm with 70mm of diameter with no involvement of iliac arteries. The patient was admitted on intermediate care unit for pain relief and tension control. Two weeks later he was operated with a debranching technique associated with simultaneous endovascular exclusion of both the aneurisms. A right to left carotid and subclavian bypass was followed by TEVAR, aorto-uni-iliac EVAR and left to right femoral bypass. Coil embolization of the origin of the left subclavian artery was necessary later because of a maintained endoleak of the thoracic aneurysm. Postoperative period was uneventful. DISCUSSION The endovascular treatment of synchronous thoracic and abdominal aortic aneurisms can be performed in a multiple or single stage surgery. In the later, fear related with medullar ischemia doesn’t seem to justify according to the latest literature reports. Even though these report superior fluoroscopy times, greater amount of blood loss and exposure to contrast, the procedure is possible and safe on selected patients with comparable morbidity and mortality rates in the short term. References
Feasibility Of Concurrent Thoracic And Abdominal Aortic Endovascular Repair Muhammad Asad Khan, MD, Kuldeep Singh, MD, Jonathan Schor, MD, Jonathan Deitch, MD Staten Island University Hospital, Staten Island, NY Heart Lung Circ. 2012 Dec;21(12):803-5. doi: 10.1016/j.hlc.2012.07.006. Epub 2012 Aug 13.Concurrent endovascular repair of extensive thoracic aortic and infra-renal aorto-iliac aneurysms. Joseph G, Janakiraman E, Subban V, Jamesraj J, Mullasari AS Simultaneous Thoracic and Aortic Stent Graft Placement for Synchronous Aortic Disease Salvatore T. Scali, M.D.1, David H. Stone, M.D.2, Philip P. Goodney, M.D.2, Catherine K. Chang, M.D.1, Robert J. Feezor, M.D.1, Peter R. Nelson, M.D.,M.S.1, Scott A. Berceli, M.D.,Ph.D.1, Thomas S. Huber, M.D.,Ph.D.1, Adam W. Beck, M.D.1. University of Florida-Gainesville, Gainesville, FL, USA, 2Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA. J Vasc Surg. 2012 Oct;56(4):957-64.e1. doi: 10.1016/j.jvs.2012.03.272. Epub 2012 Jun 27.Safety of elective management of synchronous aortic disease with simultaneous thoracic and aortic stent graft placement Scali ST, Feezor RJ, Chang CK, Stone DH, Goodney PP, Nelson PR, Huber TS, Beck AW. High Frequency of Thoracic Aneurysms in Patients with Abdominal Aortic Aneurysms Emma Larsson, MD, Lia Vishnevskaya, MD, Bo Kalin, MD, PhD, Fredrik Granath, PhD, Jesper Swedenborg, MD, PhD, Rebecka Hultgren, MD, PhD Annals of Surgery. 2011;253(1):180-184.
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RESEARCH Preoperative vascular screening in the presence of aortic, carotid and peripheral pathology for patients undergoing their first arterial intervention: 18 month follow-up Nader Hamada
Galway University Hospital, Galway, Ireland
The aim of this paper was to determine prevalence and incidence of intervention required for concomitant Asymptomatic Vascular Disease (AVD) on patients undergoing their first elective peripheral arterial intervention. METHODS This is a prospective observational study Data was obtained on patients undergoing peripheral revascularisation, abdominal aortic aneurysmal (AAA) repair or carotid procedure from 2006 to 2009. Of 542 complex arterial procedures, 328 patients had their first vascular intervention. (PAD=127, AAA=97, CAD=83, concomitant AAA and PAD=21). Primary endpoint is detection of any concomitant asymptomatic AAA, CAS or PAD. Secondary endpoints are need for intervention of AVD detected on screening, and major adverse clinical events during follow-up. RESULTS Prevalence of AVD detected was 13% PAD, 51% CAS and 8%AAA. Symptomatic and Asymptomatic PolyVasBed patients had 11.4- and 8.16-fold increased likelihood for detection of asymptomatic CAS respectively (P<0.0001) relative to the remaining study population. Asymptomatic PolyVasBed patients had 8.2 fold increased likelihood of asymptomatic AAA, P<0.0001, compared to the remaining study population. Likelihood for intervention in Asymptomatic PolyVasBed is OR 5.740 (P=0.044) and Symptomatic PolyVasBed is OR 4.500 (P<0.001). Asymptomatic AAA detected in both symptomatic and asymptomatic vascular disease patients, is the strongest predicting factor of intervention in 18 months follow-up. In Asymptomatic PolyVasBed patients, CAS and AAA have the highest prevalence. CONCLUSIONS Screening for AVD is mandatory prior to any vascular intervention
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RESEARCH Comparison of effectiveness of antiseptics in Staphylococcus aureus infected surgical wounds with vascular prosthesis in rats Elvyra Staneviciute1, Andrej Podkopajev2, Vilma Kuzminskaite2, Otilija Kutanovaite2, Vytautas Jonas Triponis1, Vytautas Jonas Sirvydis3, Tomas Kacergius4, Agne Kirkliauskiene4, Inga Urte Builyte2, Linas Davainis2, Alvita Gincaite2, Gabriele Valiunaite2
1. Vilnius University, Faculty of Medicine and Vilnius City Clinical Hospital, Vilnius, Lithuania 2. Vilnius University, Faculty of Medicine, Vilnius, Lithuania 3. Vilnius University, Faculty of Medicine, Clinic of Heart and Vascular Diseases, Vilnius, Lithuania 4. Vilnius University, Faculty of Medicine, Department of Physiology, Biochemistry, Microbiology and Laboratory Medicine, Vilnius, Lithuania OBJECTIVES Surgical wound infection is a serious postoperative complication, associated with prolonged hospitalization, in¬creased treatment costs, mortality and morbidity rates. The role of antiseptics in treatment of infection is still not clear – controversial opinions require further research in this field. The objectives of this study were to develop an experimental model of infected surgical wound and to compare the efficacy of 0.1 % octenidine dihydrochloride + 2 % fenoxyethanol (“Octenisept®”), 10 % povidon-iodine (“Betadine®”) and 0.2 % chlorhexidine solution while treating Staphylococcus aureus infected surgical wounds with vascular prosthesis in rats. MATERIALS AND METHODS Four experimental groups of Wistar rats were formed. Each group consisted of 8 male rats of nearly same age and weight. For each rodent, a skin incision was performed paravertebrally. A patch of woven vascular graft was placed onto the muscular fascia and 1 ml of Staphylococcus aureus suspension adjusted to 5 McFarland standard was added to the wound. 5 days after inoculation wound specimens were taken. After Staphylococcus aureus infection was confirmed by microbiological testing, daily wound irrigations with antiseptics or sterile 0.9 % saline (control group) were started. Irrigations were applied every day for 5 days. RESULTS 5-day treatment with “Octenisept®” resulted in 97.68 % (p=0.002) decrease in number of Staphylococcus aureus colonies in wound cultures. The number of colonies of Staphylococcus aureus decreased by 61.74% in rats treated with “Betadine®” (p=0.0002). Number of colonies insignificantly decreased in group treated with 0.2 % chlorhexidine solution – 54.99 % (p=0.08) and increased in control group by 32.40 % (p=0.60). Comparing to control group, treatment with “Octenisept®”, “Betadine®” and 0.2 % chlorhexidine solution proved to be effective (p=0.004). CONCLUSIONS “Octenisept®” and “Betadine®” effectively treat Staphylococcus aureus infected surgical wounds with vascular prothesis in rats. Most significant results were achieved by treatment with “Octenisept®”.
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VASCULAR ACCESS Early outcomes of surgery for creation of arteriovenous access for hemodialysis Mohamed-Zied Ghariani, Sana Allal, Nadia Azabou, Sarra Zairi, Refek Kasraoui, Atef Ben Youssef, Tarek Kilani
Department of Thoracic and Cardio-Vascular Surgery, Abderrahmen Mami Hospital Ariana, Ariana, Tunisia INTRODUCTION Arteriovenous fistula has been proved through experience and hindsight, to be the best vascular access for chronic hemodialysis. In fact, it provides the highest blood flow rates andthe lowest circulationrates with fewer complications. The aim of this study was to assess the early postoperative morbidity and mortality in patients who underwent surgery to create an arteriovenous blood access for hemodialysis. MATERIAL AND METHODS From September 2012 to September 2013, 139 blood accesses for hemodialysis were created for 132patients. These were followed by 45 superficializations (basilic vein in 44 cases and cephalic vein one case). The mean age of our patients was 59.8 years [19-88]. The procedures included 9prostheticarteriovenous fistulae (AF) (6.5%) and 130 natives: 55 brachio-basilic (39.5%), 43radial (31%), 31 brachio- cephalic (22%) and 1 ulnar (0.7%). Follow-up was prospective and an actuarial analysis was performed. Only 15 patients (10.8%) were lost to follow-up. RESULTS There were no deaths recorded during the first 30 postoperative days (PO). The immediate post-operative complications were mostly thrombosis (2.8%), septic false aneurysms (FA) (1.4%), stenosis of the afferent artery (1.4%), steal syndrome (0.7%), hematoma (0.7%), wound infection (0.7%) and lymphorrhea (0.7%). Seven early reoperations (5 %) were required: 2 cases of septic FA, 2 cases of afferent artery stenosis, 1 case of steal syndrome, 1 case for prosthetic AF thrombosis and 1 patient for hematoma. Immediate post-operative complications of superficializations performed with an average period of one month were mainly infectious (8.8%) and hemorrhagic (4.4%). The average follow-up was 5.36 [0-13] months. The survival rate was 100% at 1 month. One late death related to the AF was observed at 2 months PO, secondary to septic shock complicating a prosthetic false aneurysm. Eight AF thromboses were observed beyond the 30thPO day with an average of 3.37 [2-8] months. Four late reoperations were performed: for a false aneurysm in 3 casesand for thrombosis of the afferent artery in 1 case. At one month PO, the primary patency rate was 95.6% and the secondary patency rate96.4%. The rate of indemnity from stenosis or thrombosis was 94.2% at one month. CONCLUSION Surgery for creating blood access for hemodialysis has satisfactory short-term results. Besides thrombosis, infections are a common cause of morbidity.
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VASCULAR ACCESS A comparison between one-stage and two-stage procedures for the creation of brachiobasilic arteriovenous fistulas Timothy Rowlands Royal Derby Hospital, Derby, United Kingdom
INTRODUCTION Vascular access is essential to end-stage renal failure patients requiring haemodialysis. Many patients require multiple fistula formation attempts in order to gain good access, making secondary and tertiary fistula options vital. Brachiobasilic fistulas are well established, but there is little evidence to compare the different surgical techniques in creating them. This study aimed to determine the patency and complication rates associated with these procedures.
RESULTS Early failure rates were 29.4% and 5% for one and two-stage procedures respectively. Complication rates at 1 month, 1 year and 2 years were not found to be significantly different. 23 additional radiological procedures were required on 15 fistulas; 17 were successful (73.9%). 84.6% of procedures performed on one-stage fistulas were successful, and 70% on two-stage fistulas. Using the Kaplan-Meier method, survival proportions were measured as 70.6%, 58.8% and 51.5% for the one-stage procedures, and 95%, 90% and 78% for the two-stage procedures at 1 month, 1 year and 2 years respectively (p=0.0385). CONCLUSION The data suggests creation of brachiobasilic fistulas using a two-staged procedure may result in improved patency rates. Complication rates were found to be statistically equivocal, with fistuloplasties and embolectomies shown to be effective in fistula salvage.
Kaplan-Meier curve showing the percentage survival of one-stage and two-stage brachiobasilic fistulas over time
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METHOD 37 brachiobasilic arteriovenous fistulas were constructed in 35 patients. These were secondary or tertiary access procedures for 78.4% of patients. 17 fistulas were created as one-stage procedures; 20 were made in two stages. Patency, complications and required interventions were recorded for each group at three time intervals.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
VASCULAR ACCESS Does arteriovenous fistula formation affect renal function? Timothy Rowlands Royal Derby Hospital, Derby, United Kingdom
INTRODUCTION It is well established that the creation of an arteriovenous fistula decreases systemic vascular resistance and increases sympathetic activity, resulting in increased cardiac contractility, heart rate and stroke volume thus increasing cardiac output1. Studies have shown transient occlusion of fistulas causes a rise in mean renal arterial perfusion pressure2. However, there is very little data exploring whether these changes affect renal function. This study aims to investigate the change in pre-dialysis renal function in patients who have undergone upper and lower arm arteriovenous fistula formations. METHOD 78 patients who underwent radiocephalic or brachiobasilic fistula formation were selected. 3 patients were excluded for incomplete data sets and 9 for commencing dialysis; leaving 30 radiocephalic and 36 brachiobasilic fistulas respectively. Creatinine and eGFR were recorded pre-operatively and at 30, 60 and 90 days post-operatively. ANOVA repeated measures test was applied for statistical analysis using GraphPad Prism to compare creatinine and eGFR changes across the two groups. RESULTS The mean patient age was 62 years with a range of 31-84 years. 37% and 33% of the renal failure patients who underwent radiocephalic and brachiobasilic fistula formations respectively had diabetic nephropathy listed as their aetiology. The mean eGFR at every time interval was 11 and 12 for radiocephalic and brachiobasilic fistulas respectively. Mean creatinine was 520, 513, 503 and 521 for radiocephalic and 492, 477, 490 and 462 for brachiobasilic fistulas pre-operatively, and at 30, 60, 90 days after creation respectively. This difference did not reach statistical significance. CONCLUSIONS The data suggests creation of arteriovenous fistulas has no effect on pre-dialysis renal function. There was no significant difference in post-operative renal function between the upper and lower arm fistula groups. References
1. Warren J, Nickerson J, Elkin D. The cardiac output in patients with arteriovenous fistulas J Clin Invest. 1951 February; 30(2): 210â&#x20AC;&#x201C;214 2. Epstein H, Post R, McDowell M. The effect of an arteriovenous fistula on renal hemodynamics and electrolyte excretion. J Clin Invest. 1953 March; 32(3): 233â&#x20AC;&#x201C;241
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VEINS Long-term results after implantation cava filters in patients with thrombophilia Khachatur Kurginyan
Venous thromboembolism is an important cause of morbidity and mortality, it occurs in approximately 1 in 1,000 people each year in the United States is developing to 600,000 cases of pulmonary embolism (PE), and about 200,000 deaths associated with pulmonary embolism. In most cases for the treatment of venous thrombosis with anticoagulants used successfully, which reduces the risk of recurrence of pulmonary embolism, reduces the incidence of deaths, their use is accompanied by an acceptable risk of hemorrhagic complications. When anticoagulant therapy is ineffective or contraindicated, leads to the development of complications requiring discontinuation of the drug, they should be cava filter. The analysis of the clinical course of pulmonary embolism (PE), and the effectiveness of anticoagulant and fibrinolytic therapy in patients with thrombophilia (TF). The results show the presence of thrombophilia 29.7 % of patients with pulmonary embolism. In patients with disorders of hemostasis embolism cava filter were more frequent than in patients with pulmonary embolism of unknown etiology. Thrombophilia - disturbances of hemostasis and hemorheology, characterized by increased tendency to develop thrombosis of blood vessels, which are based on irregularities in the various links of the hemostatic system and hemorheology. Numerous studies by various authors suggest that the risk of thromboembolic events has grown significantly in the presence of disturbances in several genes responsible for thrombophilia. Treatment and secondary prevention measures for pulmonary embolism, undertaken with the identified changes in the hemostatic system, to reduce the risk of disability and death of patients. METHODS The study involved 62 patients with thrombophilia who revealed a massive pulmonary embolism, about which was implanted vena cava filter with the possibility of removal. In a study of all patients was carried out blood sampling to determine the polymorphism of blood clotting. We determined the following parameters: prothrombin (F 2), the factor Leiden (F5), plasminogen activator inhibitor (PAI-I), methionine - synthase reductase (MTRR), platelet fibrinogen receptor (GPIII a). During the verification of the diagnosis of the patients underwent: catheter fragmentation and thrombolysis by recombinant prourokinase. In the analysis of the immediate results in 49 (79%) patients had a good result in 13 (21%) reported satisfactory results observed with partial thrombolysis. RESULTS In the long-term period after implantation of vena cava filter were examined 51 people. In 7 (13.7 %) patients were diagnosed with thrombosis of vena cava filter at 9 months. -1, And 11 months. -2, 17 month- 2, and 19 months. - 1; 26 months. - 1 patient. In all cases, the vena cava filter thrombosis occurred due to inadequate selection of doses of the anticoagulant. Good effect was observed in 44 (86.3 %) of patients on the background of continuous use of individually selected doses of anticoagulants. Thus, in the long term (6-36 months). Cava filter thrombosis was observed in 7 (11.3 %) patients. CONCLUSIONS Pathogenetically reasonable anticoagulants, based on the identified polymorphisms haemostatic system, provides a good long-term results after implantation of vena cava filter. The findings indicate the need for screening gemostaziogram to search for thrombophilia, which would enable specific, individually matched therapy, thereby improving the prognosis of the disease.
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State Research Center for Preventive Medicine, Moscow, Russia
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Figures
Frequency combinations of mutations
Gene polymorphisms of the hemostatic system
References
1. Torbicki A., Perrier A., Konstantinides S. et al. Guidelines on the diagnosis and management of acute pulmonary embolism. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). European Heart Journal 2008; 29 (18): 2276-2315. 2. Segal J.B., Eng J., Tamariz L.J., Bass E.B. Review of the evidence on diagnosis of deep venous thrombosis and pulmonary embolism. Ann Fam Med 2007; 5: 63-73. 3. Segal J.B., Streiff M.B., Hoffman L.V. et al. Management of venous thromboembolism: a systematic review for a practice guideline. Ann Intern Med 2007; 146: 211-22. 6. Roy P.M., Colombet I., Durieux P. et al. Systematic review and metaanalysis of strategies for the diagnosis of suspected pulmonary embolism. BMJ 2005; 331: 259. 4. Bauer K.A.// J. Thrombos. Haemost, 2003 V.1, 7 P 1429-1434. Heit J.A.//Arterioscler. Thromb.Vasc.Biol.2008.V.28 (3). P 370-372. 5. Passman MA, Dattilo JB, Guzman RJ, Naslund TC. J Vasc Surg. 2005;42:1027-1032. 6. Streiff MB. Vena caval filters: a comprehensive review. Blood 2000;95:3669-3677. 7. Ray CE, Kaufman JA. Complications of inferior vena cava filters. Abdom Imaging 1996;21:368-374. 8. Kraayenhagen R.A.,Anker P.S.,Koopman M.M. et al.l// Thromb.Haemost. 2000.V.83. P. 5-9.
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VEINS Endovenous 980-nm laser treatment of small saphenous veins in a series of 500 patients Christian Baraldi1, Mauro Carelli1, Tommaso Spina2
1. Department of Vascular and Endovascular Surgery, Tricarico Clinic, Belvedere Marittimo, Italy 2. Angiologist, Ambulatory of Vascular Medicine, Cariati, Italy
METHODS Incompetent SSV segments in 500 patients (416 women, 84 men) with a mean age of 51.4 years (range, 16 to 90 years) were treated with intraluminal ELT using a 980-nm diode laser (LASEmaR1000-Eufoton, Italy). The SSV diameter was measured by Duplex examination in an upright position in different SSV segments (1.5 cm below the saphenopopliteal junction and sural segment). These measurements were used to determine the optimal linear endovenous energy density (LEED) for each segment. During treatment, patients were maintained in the Trendelenburg position. Patients were evaluated clinically and by duplex scanning at 1 and 8 days, 1, 3 and 6 months, and at 1, 2, and 3 years to assess treatment efficacy and adverse reactions. RESULTS A total of 523 SSVs were treated. The mean diameter was 7.5 mm (range, 4.0 to 11.5). The LEED was tuned as a function of the initial SSV diameter measured in the orthostatic position, from 80 J/cm (4 mm) up to 140 J/cm (11.5 mm). At the 1-week follow-up, 13.6% of the patients reported moderate pain. In the immediate postoperative period, the closure rate was 99.9% and remained constant during the 4-year follow-up to reach 99.1%. After 1 year, a complete disappearance of the SSV or minimal residual fibrous cord was noted. Major complications have not been detected; in particular, no deep venous thrombosis. Ecchymoses were seen in 33%, transitory paresthesia was observed in 7%. There was no dyschromia, superficial burns, thrombophlebitis; palpable indurations was observed in 3%. Complementary phlebectomy was done in 87% of patients. Failures never occurred. CONCLUSION ELT of the incompetent SSV with a 980-nm diode laser appears to be an extremely safe technique, particularly when the energy applied is calculated as a function of the SSV diameter. It is associated with only minor effects. Currently, ELT has become the method of choice for treating superficial veins and has almost replaced the treatment of traditional ligation and stripping. References
1. Comparing the treatment response of great saphenous and small saphenous vein incompetence following surgery and endovenous laser ablation: a retrospective cohort study. Carradice D, Samuel N, Wallace T, Mazari FA, Hatfield J, Chetter I. Phlebology. 2012 Apr;27(3):128-34. doi: 10.1258/phleb.2011.011014. Epub 2011 Aug 3. 2. Surgery and endovenous techniques for the treatment of small saphenous varicose veins: a review of the literature. Tellings SS, Ceulen RP, Sommer A. Phlebology. 2011 Aug;26(5):179-84. Epub 2011 Feb 27. Review. 3. Endovenous laser ablation (EVLA) to treat recurrent varicose veins. Theivacumar NS, Gough MJ. Eur J Vasc Endovasc Surg. 2011 May;41(5):691-6. Epub 2011 Feb 26. 4. Does puncture site affect the rate of nerve injuries following endovenous laser ablation of the small saphenous veins? Doganci S, Yildirim V, Demirkilic U. Eur J Vasc Endovasc Surg. 2011 Mar;41(3):400-5. Epub 2010 Dec 30. 5. Laser saphenous ablations in more than 1,000 limbs with long-term duplex examination follow-up. Spreafico G, Kabnick L, Berland TL, Cayne NS, Maldonado TS, Jacobowitz GS, Rockman CR, Lamparello PJ, Baccaglini U, Rudarakanchana N, Adelman MA. Ann Vasc Surg. 2011 Jan;25(1):71-8. 159
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BACKGROUND In the past it was common to entirely remove the SSV by surgical procedure; however, recently minimally invasive techniques have taken over a significant number of varicose vein treatments. In recent years, endovenous laser treatment (ELT) has been proposed to treat incompetent small saphenous veins (SSV). This study reports the long-term outcome of ELT in a series of 500 patients.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
6. 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. Marsh P, Price BA, Holdstock J, Harrison C, Whiteley MS. Eur J Vasc Endovasc Surg. 2010 Oct;40(4):521-7. Epub 2010 Jul 23. 7. Conventional surgery and endovenous laser ablation of recurrent varicose veins of the small saphenous vein: a retrospective clinical comparison and assessment of patient satisfaction. van Groenendael L, Flinkenflögel L, van der Vliet JA, Roovers EA, van Sterkenburg SM, Reijnen MM. Phlebology. 2010 Jun;25(3):151-7. 8. Endovenous laser ablation for the treatment of recurrent varicose vein disease--a single centre experience. Nwaejike N, Srodon PD, Kyriakides C. Int J Surg. 2010;8(4):299-301. Epub 2010 Mar 20. 9. Endovenous laser ablation of the small saphenous vein sparing the saphenopopliteal junction. Janne d’Othée B, Walker TG, Kalva SP, Ganguli S, Davison B. Cardiovasc Intervent Radiol. 2010 Aug;33(4):766-71. Epub 2010 Jan 20. 10. Endovenous laser ablation (980 nm) of the small saphenous vein in a series of 147 limbs with a 3-year follow-up. Desmyttère J, Grard C, Stalnikiewicz G, Wassmer B, Mordon S. Eur J Vasc Endovasc Surg. 2010 Jan;39(1):99-103. Epub 2009 Oct 15. 11. Endovenous thermal ablation of superficial venous insufficiency of the lower extremity: single-center experience with 3000 limbs treated in a 7-year period. Ravi R, Trayler EA, Barrett DA, Diethrich EB. J Endovasc Ther. 2009 Aug;16(4):500-5. 12. Endovenous laser therapy of the small saphenous vein: patient satisfaction and short-term results. Trip-Hoving M, Verheul JC, van Sterkenburg SM, de Vries WR, Reijnen MM. Photomed Laser Surg. 2009 Aug;27(4):655-8. 15. 5-years of endovenous laser ablation (EVLA) for the treatment of varicose veins--a prospective study. Nwaejike N, Srodon PD, Kyriakides C. Int J Surg. 2009 Aug;7(4):347-9. Epub 2009 May 14.
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VEINS Hybrid techniques for treatment of varicose veins: combined new and conventional technologies Christian Baraldi1, Tommaso Spina2
We assessed the safety and efficacy of combined endovenous laser treatment (ELT) and traditional techniques for treatment of the saphenous veins insufficiency, based on experience, increasing endolaser procedure in patient often treated with stripping. Since September 2009 to September 2013, 1566 ELT procedures have been performed (great and small Saphenous vein) using a diode laser 1470 nm wavelength (LASEmaR1500-Eufoton, Italy) by a kit that includes ring optical fibers of 600 micron (KIT INVE, Eufoton, Italy). Local Echo-guided anesthesia have performed in all cases. Laser power is variable regarding veins diameter from 6 to 12 watts settled in continuous mode and the energy supplied (LEED) is personalized to morphologic vein characteristics. Power is always personalized to echographyc vein patterns (diameter, wall thickness, anatomic deep). In the 94% of all patients other techniques have been associated: microflebectomy (56%), varicectomy (12%), sclerofoam (30%), perforator vein closure (4%), stripping of lower extremity of great saphenus vein (GSV) (7%). This last procedure (stripping) combined to ELT is performed when tortuosity of GSV prevent laser endovenous treatment and when sclerofoam was contraindicated. In all cases (100%) has been detected the subjective symptomatologyâ&#x20AC;&#x2122;s fading, with an objective improvement of symptomatology after 1 month of the operation and of aesthetic profile. At 3 months after operation, in the 99.9% of all cases has been detected a complete occlusion of vein treated, and in the 0.01% of cases has been detected an early recanalization of Saphenous vein (initial learning curve only). At 6 months after operation has been detected a recanalization of Saphenous vein in the 1.5% of 145 operated patients. At 12 months after operation has been detected a long regurgitation without usual relapses in the 0.46% of 32 operated patients. No major complications occurred. One DVT (0.008%) occurred. Local transient paraesthesia at the ankle and midcalf level occurred in 5 patients (0,004%). In the 74% of patients we observed that vein treated disappear after 6 months. In all (100%) of patient treated with combined technique ELT-sclerofoam/varicectomy/mini stripping we assessed a total improvement of aesthetical and functional aspects. The endovenous laser treatment (ELT) of Saphenous veins is a minimally invasive surgical intervention, that often can be combined to other techniques performable by a Day-Surgery ever under ultra-sound guide and by a topical anesthesia. It can ensure good clinical and aesthetic results avoiding invasive procedures like stripping. Combined techniques personalized to the patientâ&#x20AC;&#x2122;s vein situation permit to obtain the best results and the best satisfaction of patients. References
Endovenous laser ablation of varicose perforating veins with the 1470-nm diode laser using the radial fibre slim. Zerweck C, von Hodenberg E, Knittel M, Zeller T, Schwarz T. Phlebology. 2012 Nov 15. Comparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins. Biemans AA, Kockaert M, Akkersdijk GP, van den Bos RR, de Maeseneer MG, Cuypers P, Stijnen T, Neumann MH, Nijsten T. J Vasc Surg. 2013 Sep;58(3):727-34.e1. doi: 10.1016/j.jvs.2012.12.074.
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1. Department of Vascular and Endovascular Surgery, Tricarico Clinic, Belvedere Marittimo, Italy 2. Angiologist ASP Cosenza, Ambulatory of Cariati, Italy
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
VEINS Endovenous laser treatment (ELT) of small saphenous vein: our experience Christian Baraldi1, Tommaso Spina2
1. Department of Vascular and Endovascular Surgery, Tricarico Clinic, Belvedere Marittimo, Italy 2. ASP Cosenza, Vascular Ambulatory of Cariati, Italy OBJECTIVE In recent years, endovenous laser treatment (ELT) has been proposed to treat incompetent great saphenous veins (GSV) as gold standard procedure. This study reports the safety, clinical and anatomic effectiveness of ELT for treating small saphenous veins (SSV). METHODS Since September 2011 to September 2013, ELT procedures have been performed for incompetent SSV segments in 180 patients (117 women, 63 men) with a mean age of 57 years (range, 19 to 81 years) were treated with intraluminal ELT using a 1470-nm diode laser (LASEmaR1000-Eufoton, Italy) by a kit that includes optical radial fibers of 600 micron (KIT RING, Eufoton, Italy). The SSV diameter was measured by Duplex examination in an upright position in two SSV segments (1.5 cm below the sapheno-popliteal junction and sural segment). These measurements were used to determine the optimal linear endovenous energy density (LEED) for treatment. Patients were evaluated clinically and by duplex scanning at 1 and 8 days, 1-3 and 8 months, and at 1 year to assess treatment efficacy and adverse reactions. RESULTS A total of 180 SSVs were treated. The mean diameter was 6.5 mm (range, 4.0 to 10.0). The LEED was tuned as a function of the initial SSV diameter measured in the orthostatic position, from 40 J/cm (4.0 mm) up to 80 J/cm (10 mm). At the 1-week follow-up, 11.4% of the patients reported mild pain. In the immediate postoperative period, the closure rate was 99.0% and remained constant during the 1-year follow-up (44,4% of all patients). After 1 year, a complete disappearance of the SSV or minimal residual fibrous cord was noted in the first 80 cases. Major complications have not been detected; in particular, no deep venous thrombosis. Ecchymosis were seen in 26%, transitory paresthesia was observed in 2%. No permanent nerve injury have been occurred. Complementary phlebectomy was done in 79% of patients. No failures occurred. CONCLUSIONS ELT of the incompetent SSV with a 1470-nm diode laser and a radial fiber appears to be an extremely safe technique, particularly when the LEED applied is calculated as a function of the SSV diameter. It is associated with only minor effects. Currently, ELT has become the method of choice for treating SSV and has almost replaced the treatment of traditional ligation and stripping. References
Randomized clinical trial of endovenous laser ablation versus conventional surgery for small saphenous varicose veins. Samuel N, Carradice D, Wallace T, Mekako A, Hatfield J, Chetter I. Ann Surg. 2013 Mar;257(3):419-26. doi: 10.1097/SLA.0b013e318275f4e4. Endovenous laser ablation in the treatment of small saphenous varicose veins: does site of access influence early outcomes? Samuel N, Wallace T, Carradice D, Shahin Y, Mazari FA, Chetter IC. Vasc Endovascular Surg. 2012 May;46(4):310-4. doi: 10.1177/1538574412443316. Does puncture site affect the rate of nerve injuries following endovenous laser ablation of the small saphenous veins? Doganci S, Yildirim V, Demirkilic U. Eur J Vasc Endovasc Surg. 2011 Mar;41(3):400-5. doi: 10.1016/j.ejvs.2010.11.029.
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VEINS Treatment of peripheral vascular malformation (PVM): a new concept of Low pressure sclerotherapy (LPS) Boughanmi Khawla, Khalil Hamza Maghreb Medical, Tunis, Tunisia
PURPOSE Intra lesion injection and compression of venous out flow, are responsible of an elevation intra lesion pressure that can induce peripheral diffusion of the sclerosis agent. we developed a concept of (LPS) by placing multiple needles in the (PVM) that allow free circulation of the sclerosant agent, these needles work as multiple valves that allow an out flow of the sclerosant agent. This technique is used for the treatment of low flow vascular malformation and peripheral AVM (nidus and venous side) MATERIALS AND METHODS In a period of 81 months (sept 2006-juin 2013) 162 patients were treated with this concept. 114 patients with venous malformations (VM) 28 patients with lymphatic malformation(LM): (26 patients with macro cystic lymphatic malformations and two patients with micro cystic lymphatic malformation and 20 patients with superficial arterio-venous malformations(AVM). 3% Foam with tetradecyl sulphate and since three year lauromacrogol 400 was used in all cases of VM (20-60 ml) and in two case of micro cystic lymphatic malformation. Absolute ethanol (AE) was used in 88 patients: 44 VM complementary to foam and 24 LM and 20 cases of peripheral AVM. Glue (isobutyl 2 cyanoacrylate) mixed with lipiodol was used in 4 cases of AVM complementary to (AE). Up to 7 sessions were performed per patient. RESULTS Technical success was reached in all cases. Loss of volume at MR was 25-80%Except two patients (large size VM) patients were Cosmetically improved and relieved of pain. Swelling of the lesion occurred in all patients and it was well tolerated and controlled with NSAID with resolution in few days (4-7days) significant complication occurred in 3 patients(Phlyctena, fistula or necrosisâ&#x20AC;Ś) treated conservatively. CONCLUSION LPS concept using foam and AE in our experience over six years has proven the technique to be effective with dramatic decreasing of complication. AE is used to treat macro cystic lymphatic malformation and superficial AVM and complementary to foam STS in some VM with extreme care concerning the volume injected.
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Sclerotherapy is actually the treatment of choice of slow flow vascular malformation using different agent including absolute ethanol, tetra decyl sulphate foam Ethibloc, bleomycin etc.. The most complications of such treatment are necrosis fistula at the site of puncture, pain and Inflammation of the treated lesion and in rare cases especially when we use ethanol, necrosis of surroundings tissues with bleeding, infection phlebitis and nerves damage. All these complications are due to the diffusion of the sclerosant agent outside the malformation, classically we try to avoid these complications by peripheral compression using digital compression or different tools as metallic rings with peripheral handing, or this compression cannot avoid always the passage of the sclerosing agent and a heavy anti-inflammatory treatment using steroid is frequently mandatory. We think that intra lesion injection and peripheral compression, are responsible of an elevation pression that induce peripheral diffusion of the sclerosant agent. We developed from more than six years a concept of low pression sclerotherapy by placing multiple needles (up to 10) in the vascular malformation that allow free circulation of the sclerosing agent these needles work as multiple valves that allow an exit of the sclerosing agent.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
Hand photo before sclerotherapy
MRI T2
Direct phlebogram with one needle
Direct phlebogram with three needles
Hand photo 3 month after sclerotherapy
One needle
Three needles
References
Four needles
1. Mulliken,JB,et al., Classification of pediatric vasc. lesions plastic& Reconstructive 1982 70 120-121. 2. Patricia E.Burrows,et al.,Percutaneous treatment of LFVM. JVIR May 2004(Vol 15,issue5,pages 431-445) 3. Ahmad I.Alomari,et al., Percutaneous sclerotherapy for lymphatic malformation:a retrosp. analysis of patient evaluated improvement. JVIR October 2006(Vol 17,Issue 5,Pages 431-445) 4. Yakes WF, et al.,Symptomatic vascular malformations ethanol embolotherapy. Radiology 1989 170 1059-1066 5 S Mitchell et al.,Pulmonary artery pressure changes during ethanol embolisation procedures to treat VM JVIR 2006;17:253-262 5. Stefan Puig, Hussein Aref, and Francis Brunelle1. Double-Needle Sclerotherapy of Lymphangiomas and Venous Angiomas in Children: A Simple Technique to Prevent Complications AJR 2003; 180:1399-1401.
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VEINS Changing practice from conventional surgery to endovenous (EVLA, VNUS and Foam) treatments produces excellent results for both long and short saphenous varicose veins Dindyal S1, Lewis J2, Woodburn K.R1
1. Royal Cornwall Hospital NHS Trust, Department of Vascular Surgery, Treliske, Truro, Cornwall, United Kingdom 2. The Princess Alexandra Hospital, Hamstel Road, Harlow, Essex, United Kingdom INTRODUCTION Endovenous treatments of superficial venous reflux are not yet widely available in NHS practice. We have established an NHS day-case local anaesthetic endovenous service. This study presents our initial experience with these techniques and their outcomes, which have consequently changed our venous practice.
RESULTS 280 patients (334 limbs) underwent endovenous surgery and underwent follow-up over a three year period. There were 227 women (81.1%) with a mean age = 57 (range 24-88). 144 had EVLA (110-LSV, 34SSV), 153 had VNUS (123-LSV, 26-SSV, 4-A-V malformations) and 37 had USS guided foam sclerotherapy alone or in combination (26-LSV, 7-SSV, 4-A-V malformations). Clinical and duplex follow-up at a median of 24.3 weeks (range 5-48) confirmed successful ablation in 96% of LSV and 97.3% of SSV and 100% of A-V malformations treated. 12/334 (3.6%) limbs required repeat treatment. Two patients had a presumed embolic phenomenon, a transient visual disturbance and a headache. CONCLUSION These preliminary results confirm the early success of endovenous treatment of the long saphenous system (96% success) and indicate that these results can be replicated in the short saphenous system (97.3% success). These data support the view that endovenous treatment of varicose veins is superior to the reported results for conventional surgery in the short-term, however long-term data is awaited.
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METHOD All patients undergoing endovenous surgery (endovenous laser ablation (EVLA), radiofrequency ablation (VNUS closureFAST), or USS guided foam sclerotherapy) by a single surgeon were entered into a venous database. Post-procedure clinical and venous duplex assessments were undertaken following treatment.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
VEINS A direct comparison of discomfort and analgesic use in patients undergoing either endovenous laser ablation or radiofrequency ablation Dindyal S.1, Lewis J.2, Woodburn K.R.1 1. Royal Cornwall Hospital NHS Trust, Department of Vascular Surgery, Treliske, Truro, Cornwall, United Kingdom 2. The Princess Alexandra Hospital, Hamstel Road, Harlow, Essex, United Kingdom
INTRODUCTION Endovenous treatment of superficial venous reflux is not readily attainable within the NHS system. An endovenous day-case service was established in a District General Hospital setting with the aim of developing a feasible model which may be implamented more widely in NHS practice. Both endovenous laser ablation (EVLA) and radiofrequency ablation (VNUS closureFAST) were offered for the treatment of superficial venous reflux. This study aimed to compare the two techniques with respects to both patient satisfaction and pain experienced in the post-operative period. METHODS 20 patients undergoing endovenous laser ablation (EVLA) and 20 undergoing radio-frequency ablation (VNUS closureFAST) were given a pre-designed questionnaire on the day of their surgery for either long and/ or short saphenous vein varicosities. RESULTS A questionnaire return rate of 31/40 (77.5%) was achieved. 15 patients underwent EVLA and 16 VNUS. The discomfort scores showed that both procedures were equally painful on the day of surgery. However, post-operatively the VNUS group reported significantly reduced pain on days 3 and 5 and then on days 10 and 14 post procedure, compared to the EVLA group. The VNUS group also used less analgesia than the EVLA group. CONCLUSION These results comparing patient discomfort caused by VNUS and EVLA show that VNUS causes less pain and requires less analgesia in the early post-operative period. The implications are that patients undergoing VNUS may be able to return to normal daily activities earlier than those undergoing EVLA.
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VEINS Mechanical thrombectomy with Trerotola compared to catheter directed thrombolysis in iliofemoral acute DVT Kang Woong Jun, Keun Myoung Park, In Sung Moon, Ji Il Kim, Jang Yong Kim
Division of Vascular and Endovascular Surgery, Department of Surgery, School of Medicine, Seoul, Republic of South Korea BACKGROUND Mechanical thromectomy of acute DVT is safe and effective in reducing thrombus burden. Pharmacomechanical thrombectomy(PMT) with percutaneous thrombectomy device(PTD) has great advantage because it can potentially reduce the dosage of the thrombolytic agents as well as overall procedure time comparing to conventional Catheter directed thrombectomy(CDT). We examined the results of PMT with the Trerotola and factors affecting outcomes.
RESULT The 98 limbs (left: 76 limbs, right: 22 limbs) of 90 patients (34 men) underwent 53 PMTs and 45 CDTs. There were no statistical difference of clinical characteristics between PMT and CDT group. There were IVC filter in 93 (95%), iliac vein stenting in 64 (65%). The limbs of symptom improvement were 36 limbs (68%) in PMT and 25 limbs(56%) in CDT group. Procedure time was shorter in PMT (723±636min) than CDT group (1759±564 min). (p<0.001) There was no difference in complications during procedure and patency rate during follow up duration (mean: 16.0±19.1,0-78 months). There was no factor associating with technical success of CDT and PMT. CONCLUSION PMT with the Trerotola device in acute iliofemoral DVT showed short procedure time with same results comparing to conventional CDT. References
1. Bush RL, Lin PH, Bates JT, Mureebe L, Zhou W, Lumsden AB. Pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis: safety and feasibility study. Journal of vascular surgery. 2004;40(5):965-70. 2. Enden T, Haig Y, Klow NE, Slagsvold CE, Sandvik L, Ghanima W, et al. Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet. 2012;379(9810):31-8. 3. Gorich J, Rilinger N, Sokiranski R, Kramer S, Mickley V, Schutz A, et al. Mechanical thrombolysis of acute occlusion of both the superficial and the deep femoral arteries using a thrombectomy device. AJR American journal of roentgenology. 1998;170(5):1177-80. 4. Lee KH, Han H, Lee KJ, Yoon CS, Kim SH, Won JY, et al. Mechanical thrombectomy of acute iliofemoral deep vein thrombosis with use of an Arrow-Trerotola percutaneous thrombectomy device. Journal of vascular and interventional radiology : JVIR. 2006;17(3):487-95. 5. Lin PH, Ochoa LN, Duffy P. Catheter-directed thrombectomy and thrombolysis for symptomatic lower-extremity deep vein thrombosis: review of current interventional treatment strategies. Perspectives in vascular surgery and endovascular therapy. 2010;22(3):152-63. 6. Manninen H, Juutilainen A, Kaukanen E, Lehto S. Catheter-directed thrombolysis of proximal lower extremity deep vein thrombosis: a prospective trial with venographic and clinical follow-up. European journal of radiology. 2012;81(6):1197-202. 7. Shatsky JB, Berns JS, Clark TW, Kwak A, Tuite CM, Shlansky-Goldberg RD, et al. Single-center experience with the Arrow-Trerotola Percutaneous Thrombectomy Device in the management of thrombosed native dialysis fistulas. Journal of vascular and interventional radiology : JVIR. 2005;16(12):1605-11. 8. Shi HJ, Huang YH, Shen T, Xu Q. Percutaneous mechanical thrombectomy combined with catheter-directed thrombolysis in the treatment of symptomatic lower extremity deep venous thrombosis. European journal of radiology. 2009;71(2):350-5. 9. Vashchenko N, Korzets A, Neiman C, Bachar GN, Ori Y, Belenky A, et al. Retrospective comparison of mechanical percutaneous thrombectomy of hemodialysis arteriovenous grafts with the Arrow-Trerotola device and the lyse and wait technique. AJR American journal of roentgenology. 2010;194(6):1626-9. 167
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METHODS This is retrospective study from prospective registered data base of the patients who underwent for acute iliofemoral DVT from Jan. 2005 to Dec 2011 in single institution. Patients’ clinical characteristics, procedures and their results of PMT group with the Trerotola device were compared to those of CDT.
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
VEINS Mechanical thrombectomy-assisted thrombolysis for acute symptomatic portal and superior mesenteric venous thrombosis Kang Woong Jun, In Sung Moon, Ji Il Kim, Jang Yong Kim Department of Surgery, Seoul St. Maryâ&#x20AC;&#x2122;s Hospital, The Catholic University of Korea, Seoul, Republic of South Korea
INTRODUCTION Acute portal vein and mesenteric vein thrombosis (PVMVT) is a rare and insidious disease that is associated with significant mortality and morbidity. Because its clinical manifestations are almost asymptomatic or nonspecific, diagnosis is often delayed, which can have lethal consequences. Due to recent advances in catheter-directed treatment, an endovascular approach has been adopted by several groups as an alternative method to revascularize affected vessels in PVMVT, and several case studies have reported success using this method to treat PVMVT. We report here two patients with PVMVT who were successfully treated by transhepatic percutaneous mechanical thrombectomy-assisted thrombolysis, while simultaneously avoiding unnecessary bowel resection. CASE A 40-year-old female presented to the emergency department with a 10-day history of vague abdominal pain, which had gradually aggravated and become intolerable. She had a 14-year drug history of oral contraceptives use, without any other medical history. An abdominal computed tomography scan showed extensive thrombosis involving the portal vein and superior and inferior mesenteric veins with jejunal loop dilation and diffuse wall thickening combined with a small amount of ascites (Fig 1). Using an AngioJet Spiroflex thrombectomy catheter (Medrad International, Minneapolis, MN, USA), we performed mechanical thrombectomy of the splenic vein and superior mesenteric vein, and then pulled the catheter back into the main portal vein (Fig 2). In the follow-up abdominal computed tomography scan, the PV and SMV were well opacified with a small amount of remnant thrombus (Fig 3). The patient was discharged on day 25 of her hospital stay. She is no longer taking oral contraceptives. CONCLUSION In patients with symptomatic PVMVT without symptoms and signs of surgical abdomen, mechanical thrombectomy-assisted thrombolysis via an endovascular approach may be a safe and effective treatment option. This approach enables rapid debulking of the thrombus and facilitates rapid recanalization of mesenteric and portal venous flow, which results in prompt subsidence of symptoms and prevents unnecessary bowel resection. This approach can also reduce potential bleeding complications in compromised patient by decreasing the duration and amount of thrombolytic agent used 4-7. However, more clinical data of the outcomes achieved using percutaneous mechanical thrombectomy-assisted thrombolysis to treat PVMVT are required; further long term follow-up and clinical studies are needed to determine the feasibility of an endovascular approach for treating this potentially fatal disease
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Initial CT scan
Percutaneous transhepatic thrombectomy using AngioJet
Follow up abdominal CT scan at the 16th hospital day
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References
1. Chen C. Direct thrombolytic therapy in portal and mesenteric vein thrombosis. J Vasc Surg 2012;56:1124-6. 2. Gertsch P, Matthews J, Lerut J, et al. Acute thrombosis of the splanchnic veins. Arch Surg 1993;128:341-5. 3. Chen C. Direct thrombolytic therapy in portal and mesenteric vein thrombosis. J Vasc Surg 2012. doi: 10.1016/j.jvs.2012.04.024. 4. Lopera JE, Correa G, Brazzini A, et al. Percutaneous transhepatic treatment of symptomatic mesenteric venous thrombosis. J Vasc Surg 2002;36:1058-61. 5. Zhou W, Choi L, Lin PH, et al. Percutaneous transhepatic thrombectomy and pharmacologic thrombolysis of mesenteric venous thrombosis. Vascular 2007;15:41-5. 6. Kim HS, Patra A, Khan J, et al. Transhepatic catheter-directed thrombectomy and thrombolysis of acute superior mesenteric venous thrombosis. J Vasc Interv Radiol 2005;16:1685-91. 7. Uflacker R. Applications of percutaneous mechanical thrombectomy in transjugular intrahepatic portosystemic shunt and portal vein thrombosis. Tech Vasc Interv Radiol 2003;6:59-69. 8. Nakayama S, Murashima N, Isobe Y. Superior mesenteric venous thrombosis treated by direct aspiration thrombectomy. Hepatogastroenterology 2008;55:367-70. 9. Rosen MP, Sheiman R. Transhepatic mechanical thrombectomy followed by infusion of TPA into the superior mesenteric artery to treat acute mesenteric vein thrombosis. J Vasc Interv Radiol 2000;11:195-8. 10. Ferro C, Rossi UG, Bovio G, et al. Transjugular intrahepatic portosystemic shunt, mechanical aspiration thrombectomy, and direct thrombolysis in the treatment of acute portal and superior mesenteric vein thrombosis. Cardiovasc Intervent Radiol 2007;30:1070-4. 11. Kumar S, Sarr MG, Kamath PS. Mesenteric venous thrombosis. N Engl J Med 2001;345:1683-8. 12. Wissgott C, Kamusella P, Andresen R. Percutaneous mechanical thrombectomy: advantages and limitations. J Cardiovasc Surg (Torino) 2011;52:477-84. 13. Morgan R, Belli AM. Percutaneous thrombectomy: a review. Eur Radiol 2002;12:20517. 14. Sharafuddin MJ, Hicks ME. Current status of percutaneous mechanical thrombectomy. Part I. General principles. J Vasc Interv Radiol 1997;8:911-21. 15. Sharafuddin MJ, Hicks ME. Current status of percutaneous mechanical thrombectomy. Part II. Devices and mechanisms of action. J Vasc Interv Radiol 1998;9:15-31.
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Figures
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
VEINS A case series demonstrating the safety and efficacy of onyx embolisation for pelvic and sapheno-femoral junction venous incompetence Nedal Katib, Sam Hwang Hwang, Ramon Varcoe Prince of Wales Private Hospital, Sydney, Australia
ABSTRACT To report the initial experience of Onyx embolization of venous incompetent perforators in the Lower Limbs and Pelvis METHODS Between December 2012 and October 2013 we had a total of 9 procedures on 8 patients. 6 patients were female and the mean age for all patients was 59.7 years of age (median 62 and range 35 â&#x20AC;&#x201C; 83 years). All patients had CEAP clinical classification scores C2 and above and 3 out of 8 had grade C6 (37.5%). All were symptomatic. 6 of the procedures were for Pelvic Vein tributaries (6/9, 66.6%), 2 were for recurrent Long Sapheno-Femoral Junction Vein Perforators (25%) and 1 was for a posterior thigh vein perforator post ipsilateral Long saphenous vein ablation. RESULTS Of the 8 patients who were treated with 9 procedures for symptomatic C2 â&#x20AC;&#x201C; C6 venous disease, 5 procedures required only one vial of Onyx (55.5%), 3 required 2-3 vials (33.3%) and 1 required 6 vials. All patients were discharged the same day or the following morning. The average follow up time was within 3-4 weeks. All patients reported satisfactory results at initial follow up along with improved clinical results. One patient developed Superficial Thrombophlebitis one week later and presented to emergency but did not require admission. She had complete resolution of symptoms within 2 weeks post op. There has been no recorded post op DVT or PE in any of the patients. CONCLUSION Onyx is a feasible and safe method in the embolization of pelvic and lower limb vein perforators. It has provided a shorter operative and shorter length of stay option for patients with recurrent sapheno-femoral junction incompetence.
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VEINS Quality-of-life assessment in patients after endovenous laser therapy and conventional surgery for great saphenous varicose veins Robert Vlachovsky, Robert Staffa, Jan Bucek, Tomas Novotny St. Anne´s University Hospital, Brno, Czech Republic
METHODS Between September 2010 and April 2012, 112 patients underwent surgery for varicose veins (56 laser ablation and 56 traditional surgery procedure). In both nonrandomized groups, preoperative VCSSs were recorded and clinical and duplex examinations were performed at 7 days, 4 weeks and 6 months after the procedure. VCSS scoring was repeated at follow-up visits. Procedure was offered only to patients who had persistent symptomatic venous disease CEAP clinical class C 2 - 4. No adjunctive treatments were perfomed for 6 months after procedure. All endovenous procedures were perfomed with tumescent local anesthesia with 1470 nm laser (Biolitec Ceralas E 1470 nm/15W/400, CeramOptec GmbH, Bonn, Germany). Ultrasound guidance was used to verify the catether position and to deliver tumescent anesthesia. RESULTS In the CS group, the respective preoperative, 7 days, 4 weeks and 6 months VCSS scores were as follows, 8.2 +- 2.3 in 56 limbs, 5.9 +- 2.0 in 51 limbs, 5.5 +- 2.1 in 45 limbs and 3.4 +- 1.5 in 42 limbs. In the EVLT group, the respective preoperative, 7 days, 4 weeks and 6 months VCSS scores were 8.1 +- 2.5 in 56 limbs, 4.9 +- 2.1 in 54 limbs, 3.9 +- 1.9 in 49 limbs and 3.2 +- 1.4 in 48 limbs. VCSS scores were significantly better in the EVLT group than the CS group at 7 days and at 4 weeks (P < 0.001). At 6 months, no significant differences between the groups were evident. CONCLUSION Treatment of saphenous vein reflex with either procedure results in clinical improvement of symptoms but, in the early postoperative period, endovenous laser therapy removes quality-of-life limitations associated with conventional surgery. We found the VCSS to be an efficient tool in outcome assessment after varicose vein procedures. References
1. Meissner MH, Moneta G, Burnand K, et al. The hemodynamics and diagnosis of venous disease. J Vasc Surg. 2007;46 (suppl S):4S-24S. 2. Rutherford RB, Padberg FT Jr, Comerota AJ, Kistner RL, Meissner MH, Moneta GL; American Venous Forumâ&#x20AC;&#x2122;s Ad Hoc Committee on Venous Outcomes Assessment. Venous severity scoring: An adjunct to venous outcome assessment. J Vasc Surg. 2000;31:1307-1312. 3. Perrin M, Dedieu F, Jessent V, Blanc MP. Evaluation of the new severity scoring system in chronic venous disease of the lower limbs: an observational study conducted by French angiologists. Phlebolymphology. 2006;13:6-16. 4. Vasquez MA. Guest Editorial: Why does outcome assessment dominate the landscape of vascular surgery? Am Venous Forum. Spring 2007;1:6.
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OBJECTIVE Reduction of symptoms associated with chronic venous insufficiency remains the main goal of conventional or endovenous varicose vein ablation. The venous clinical severity score (VCSS) was proposed in 2000 to asses the usefulness of an intervention in patients with chronic venous insufficiency. The validity of the score system was later evaluated and was confirmed by different groups and studies, and in 2007 was refined. Our prospective study was designed to compare quality-of-life outcomes following endovenous laser treatment (EVLT) and conventional surgery (CS) using venous clinical severity score (VCSS).
CONTROVERSIES & UPDATES IN VASCULAR SURGERY
VEINS The early fight against post-thrombotic syndrome. Results of combined proximal ilio-caval surgical venous thrombectomy, optional endovascular stenting of common iliac vein and distal local thrombolysis in extended thrombosis of iliio-caval and femoral deep veins Stephan Schlunke1, Andrej Isaak1, Luca Giovannacci2, Jos Van den Berg2 1. Ospedale La CaritĂ Locarno, EOC, Locarno, Switzerland 2. Ospedale Civico Lugano, EOC, Lugano, Switzerland
With a follow-up from 1 to 9 years, we present 17 cases of deep vein thrombosis extending in 5 cases from the vena cava to the calf, in the rest of the cases at least from common iliac vein to the popliteal region. All patient had acute symptoms, 3 of them with flegmasia coerulea dolens. Observing a minimal delay between onset of symptoms and operation of three days, in one case maximal fourteen days (ideally not more than 6 to 7 days), we could open up venous circulation in all 17 patients, saving all but one leg from post-thrombotical syndrome. Five patients showed an early re-thrombosis within 72 hours which we treated again surgically, completing the same maneuver combined with the construction of an arterio-venous fistula in 4 cases. One patientâ&#x20AC;&#x2122;s vein, suffering drug addiction with injections in the groin, could not be disobliterated. 2 other patients received the arterio-venous fistula during the primary treatment. The causes of thrombosis were 3 oncologic, 4 post-traumatic, 2 oral anticonception, smoking, dishydratation and bedrest, 1 from local compression after arterial endovascular procedure, 7 unknown. RESULTS 3 oncological patients died between 6 to 36 months after procedure from their primary disease, without recurrence and only mild venous symptoms. 1 patient was lost to follow-up after the first year, because he moved to a foreign country. The patient with drug addiction developed a post-thrombotic syndrome with ulcers. The remaining 12 patients showed in 11 cases a complete restitutio ad integrum with competent valvular system as documented by regular Duplex US scan. Only one patient which was operated on 15 days after onset of thrombosis has a reflux in the proximal femoral vein but only mild symptoms, well compensated by medium strength compressive stocking. The same patient was the only one to experience a pulmonar embolism, but not related to the procedure, as it could be already documented the day before surgery and had been the main complaint of the patientâ&#x20AC;&#x2122;s reason to consult our emergency department. 6 patients had a stent placed in their left common iliac vein for May Turner syndrome. 2 patient received a temporary vena cava filter. One patient experienced a local seroma at the groin which was removed and then healed well; no other complications were reported. All patients were anticoagulated for minimum one year; patients with competent valvular systems and without thrombophylia or thrmbogenic causes in their investigations could be dismissed from anticoagulation after this time period. CONCLUSION the combined surgical removal of acute thrombosis by Fogarty catheter and optional endovascular stent placement in the valveless iliac vein segment in case of stenosis or occlusion, associated with distal isolated local highly dosed thrombolysis and massaging out remaining material under adequate protection provides excellent results and should be considerated, especially in younger patients or in all patients with flegmasia cerulea dolens, even if caused by tumor occlusion. For this last category the aim of the treatment was only to provide a better quality of life when confrontated with limb-threatening venous thrombosis and/or severe pain. The procedure should take place between day 3 and maximum day 7 from onset of thrombosis to obtain the best results. Complete desoblitaration with maintained vavle function was obtained in 65% of all 17 patients and in 78% of the non oncological patients. The success of the method is due to the fact that it largely eliminates the disadvantages of systemic thrombolysis, as well as those of the conventional surgical thrombectomy, while retaining the advantages of both worlds. Figures
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Largiader J, Blattler W, Gloor B. Therapeutic concept for acute leg and pelvic venous thrombosis. Acta Chir Belg 2002;102:356 â&#x20AC;&#x201C; 61.
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