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MAYO - AGOSTO - EDICIÓN ESPECIAL SITE 2017
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Director V. Riambau Hospital Clinic. Villarroel 170, 08036 Barcelona España vriambau@clinic.ub.es
Editores asociados Cerezo, M. (Buenos Aires Argentina) Criado, F. (Baltimore, USA) Parodi, J.C. (Buenos Aires, Argentina) Dietrich, E.B. (Phoenix, AZ, USA) Montañá, X. (Barcelona, España) Gaines, P. (Sheffield, England)
Malina, M. (Malmo, Suecia) Veith, F. (New York, USA) Espinosa, G. (Rio de Janeiro, Brasil) Bechara, L. (Buenos Aires, Argentina)
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Editor honorario y fundador J.A. Jiménez Cossío
Comisión Editorial CELA Barrera, JG (Bucaramanga, Colombia) Barrera, J. (Bogotá, Colombia) Espíndola M. (Santiago, Chile) Fabiani, A. (Monterrey, México) Mosquera N. (Ourense, España) Serrano, MA. (Barcelona, España)
Consejo editorial
Cómo se leen los códigos QR 1.- Instále en el teléfono móvil la aplicación para descifrar códigos QR. 2.- Coloque la cámara del teléfono móvil sobre el código QR. 3.- Automáticamente enlazará con la página www.endovascular.es
Álvarez-Tostado, J. (Cleveland, USA) Balcazar, A. (La Paz, Bolivia) Botelho de Medeiros, D. (Lisboa, Portugal) Busquet, J. (París, Francia) Cao, P.G. (Roma, Italia) Cappocia, L. (Roma, Italia) Carbonell, J.P. (Medellin, Colombia) Carpenter, J.P. (Philadelphia, USA) Caserta, G. (Sao Paulo, Brasil) Cruz, L. (San José, Costa Rica) Da Rocha, M.F.M. (Sao Paulo, Brasil) Díaz-Durán, C. (Veracruz, México) Doblas, M. (Toledo, España) Egaña, J.M. (San Sebastián, España) Fajardo, D. (Bogotá, Colombia) Fernandes e Fernandes, J. (Lisboa, Portugal) Fernández-Fernández, J.C. (A Coruña, España) Fernández-Noya, J. (Santiago de C., España) Fernández-Samos, R. (León, España) Ferreira, L.M. (Buenos Aires, Argentina) Ferreira, M. (Rio Janeiro, Brasil) Galvagni, P. (Floridanapolis, Brasil) García Colodro, J.M. (Lugo, España) García, G. (Medellín, Colombia) García-Madrid, C. (Barcelona, España) Gastambide, C. (Montevideo, Uruguay) Greenberg, R.K. (Cleveland, USA) Giossa, W. (Montevideo, Uruguay) Hussein, E.A. (Cairo, Egipto) Koncar, I. (Belgrado, Serbia) Kramer, A. (Santiago, Chile) La Mura, R. (Buenos Aires, Argentina) Lerut, P. (Lovaina, Bélgica) Makaroun, M.S. (Pitsburg, USA) Marticorena, J. (Lima, Perú) Matsumura, J.S. (Chicago, USA) Menéndez, A. (San Juan, Puerto Rico) Mertens, R. (Santiago, Chile) Mestres, G. (Barcelona, España) Moll, F. (Utrecht, The Netherlands) Murillo, I. (Monterrey, México) Peeters, P. (Bonheiden, Belgium) Pitty, F. (Panamá, Panamá) Pontes, C. (Salvador de Bahía, Brasil) Poredos, P.I. (Ljubljana, Slovenia) Puech, P. (San Paulo, Brasil) Ramírez, J.C. (Asunción, Praguay) Reparaz, LM. (Madrid, España) Saldaña, G. (Monterrey, México) Sicar, G. (Saint Louis, U.S.A.) Teixera, J.F. (Porto, Portugal) Urgnani, F. (Barcelona, España) Valdes, F. (Santiago, Chile) Vaquero, C. (Valladolid, España) Verhoeven, E. (Nuremberg, Alemania) Von Ristow, A. (Río de Janeiro, Brasil)
RADIOLOGIA INTERVENCIONISTA Acitores, I. (Madrid, España) Blasco, J. (Barcelona, España) Bolia, A. (Leicester, UK) Canis, M. (Córdoba, España) De Blas, M. (San Sebastián, España) Echenagusía, A. (Madrid, España) Felices, J.M. (Murcia, España) Ferral, H. (New Orleans, USA) Fraire, V. (Monterrey, México) Garzón, G. (Madrid, España) González-Tutor, A. (Santander, España) Gregorio, M.A. de (Zaragoza, España) Hernández Lezana, A. (Madrid, España) Hilario, J. (Zaragoza, España) Katzen, B. (Miami, USA) Lammer, J. (Viena, Austria) López Ibor, J. (Madrid, España) Macho, J. (Barcelona, España) Marini, M. (A Coruña, España) Martín Palanca, A. (Málaga, España) Martínez, F. (Las Palmas, España) Muñoz, J.J. (Málaga, España) Palmaz, J.C. (Sant Antonio, USA) Palmero, J. (Valencia, España) Pueyo, J. (Mallorca, España) Pulpeiro, J.R. (Lugo, España) Real, M.I. (Barcelona, España) Reekers, J. (Amsterdam, The Netherlands) Reyes, R. (Las Palmas, España) Rousseau, H. (Toulouse, Francia) Ruiz-Salmerón, R. (Sevilla, España) Sánchez, J. (Madrid, España) Sancho, C. (Barcelona, España) Segarra, A. (Barcelona, España) Schönholz, C. (Charleston, SC) Tagarro, A. (Madrid, España) Tobío, R. (Madrid, España) Urtasun, F. (Pamplona, España) Verdú, P. (Alicante, España) Viaño, J. (Madrid, España) Ybañez, F. (Madrid, España) Zubicoa, S. (Madrid, España)
CARDIOLOGIA INTERVENCIONISTA Alfonso, F. (Madrid, España) Betriu, A. (Barcelona, España) Calabuig, J. (Pamplona, España) Cribier, A. (Rouen, Francia) Cubero, J. (Sevilla, España) Esplugas, E. (Barcelona, España) Fournier, J.A. (Sevilla, España) Goicolea, J. (Madrid, España) Hernández, T. (Madrid, España) Jiménez Cárcamo, J. (Miami, USA) Llovet, A. (Madrid, España) Macaya, C. (Madrid, España) Masotti, M. (Barcelona, España) Medina, A. (Las Palmas, España) Moris, C. (Oviedo, España) Nienaber, C. (Rostok, Germany) Pasadolos, J. (Vigo, España) Pey, J. (Madrid, España) Pico, F. (Murcia, España) Quininha, J. (Lisboa, Portugal) Ramee, S. (New Orleans, USA) Roubin, G.S. (New York, USA) Sáenz, M.E. (Costa Rica) Sancho Jaldón, J. (Cádiz, España) Serra, A. (Barcelona, España) Sobrino, N. (Madrid, España) Suárez de Lezo, J. (Córdoba, España) Wholey, M.H. (Pittsburg, USA)
Correspondencia científica VR Vascular Centre, SLP Igualada, 10 08173 Sant Cugat - Barcelona (ESPAÑA) e-mail: vriambau@gmail.com Diseño y Realización:
www.mclogotipo.com e-mail: mclogotipo@mclogotipo.com S.V.167-R-CM. Depósito Legal: M-41883-1997 ISSN: 1138-4379 Esta publicación esta registrada en el directorio DULCINEA www.accesoabierto.net/dulcinea/
www.sociedadcela.com
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CIRUGÍA VASCULAR
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VOLUMEN XX
MAYO - AGOSTO - EDICIÓN ESPECIAL SITE 2017
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Sumario / Contents
Técnicas Endovasculares se publica 3 veces al año Copyright© 1998. Ninguna de las partes de estas publicaciones puede reproducirse sin el previo consentimiento de la Editorial
The information and opinions expressed in the articles are exclusively those of the authors who are solely responsible of their contents. Técnicas Endovasculares is edited 4 times a year. Copyright © 1998. No part of the articles of this publication may be reproduced without the prior written permission of the editor.
Carta presentación V. Riambau, Presidente SITE
Session 1.
LIVE@SITE Hot Abdominal Aorta. Battle for standard EVAR
Session 3.
Free papers aorta and its branches
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Session 4.
A Top Secret Session in Abdominal Aorta repair
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Session 5.
Visceral and hypogastric endorepair
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Session 8.
IMAC@SITE: Aorta GREAT DEBATE: the filling approach
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Session 9.
Free papers aorta and its branches
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Session 10.
Hot Topics in Lower Limb (I)
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Session 11.
Free papers Lower Limb
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Session 12.
Hot Topics in Lower Limb (II)
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Session 13.
A Top Secret Session in lower limb revascularization
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Session 14.
Free papers Lower Limb
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Session 15.
Lower Limb great debate: Endo first. Motion: Endo should be the first option in Lower Limb
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Session 18.
AVM Multidisiciplinary session
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Session 19.
Free papers Miscellaneous
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Session 21.
Vascular Access
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Session 22.
What,s new in carotid stenting?
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Session 24.
Hot Topics in Thoracic Endografting
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Session 25.
Free papers Thoracic Aorta
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Session 26.
CSC@SITE: News from the heart
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Session 28.
How to do it@SITE: A Top Secret Session in thoracic endografting
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Session 30.
Venous Forum. Chronic Venous Disease: Chronic Venous Disease: ablation techniques and sclerotherapy; Future perspectives in varicose vein therapy
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Session 31.
Free papers Venous
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Session 32.
Disaster cases: The worse ENDOVENOUS case of my life
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Session TW1.
Young talent lower limb
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Session TW2.
Top secret sessions for your talent AAA
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Session TW3.
VEINS TRAINING SESSIONS. Site of Veins. How to do it sessions
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Satellite Symposium 3. Advanced Designs on the Endovascular Repair of the Aorta
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Calendario de Congreos
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Noticias desde la Industria
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Normas para los autores / Instructions for the authors
63-65 67
Boletín de suscripción
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La información presentada en los artículos expresa únicamente la opinión personal de los autores siendo responsables del contenido.
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Editorial
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editorial
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
PRESENTACIÓN
PRESENTATION
Un año más hemos afrontado de nuevo el reto de organizar el SITE 2017. En esta ocasión, Endovascular Foundation es la entidad organizadora con ayuda de los diferentes Comités y de Kuoni Congress.
Once again we have faced the challenge of organizing the SITE 2017. On this occasion, Endovascular Foundation is the organizing entity with the help of the different Committees and Kuoni Congress.
Como siempre hemos querido ofrecer las más actuales novedades e imaginar el futuro inmediato en todos aquellos temas que se relacionan con las terapéuticas endovasculares. Esta vez recuperamos el ambiente más académico regresando a la Facultad de Medicina de la Universidad de Barcelona, en donde se celebraron los primeros SITEs hace más de 15 años. Ello coincide con la oportunidad que brindan unas renovadas instalaciones, especialmente el Paraninfo y el Aula Magna. Además, desde la Organización creemos que es momento de recuperar el sentido más universitario para la discusión y progreso de las nuevas técnicas endovasculares en todos los territorios arteriales y venosos de los “pies a la cabeza”.
We have wanted to offer the latest developments and imagine the immediate future in all those issues that relate to endovascular therapeutics. This time we recovered the most academic atmosphere returning to the School of Medicine of the University of Barcelona, where the first SITEs were celebrated more than 15 years ago. This coincides with the opportunity offered by renovated facilities, especially the Auditorium and the Aula Magna. Moreover, from the Organization we believe that it is time to recover the most university sense for the discussion and progress of the new endovascular techniques in all the arterial and venous territories from the "feet to the head". In the scientific program, it is possible to emphasize an important presence of practical sessions of the hand of recognized experts. We refer to the "Top secret" and "Disaster cases" sessions presented by members of the international guest Faculty. These will be complemented with the "Problem Cases" and the "Registered Cases" sessions.
En el programa científico, cabe destacar una importante presencia de sesiones prácticas de la mano de reconocidos expertos. Nos referimos a las Sesiones “Top secret” y las “Disaster cases” presentadas por miembros del panel internacional de ponentes. Éstas serán complementadas con las sesiones de “Casos Problema” y los “Casos Registrados”.
As usual, competitive sessions such as free presentations, poster presentations or challenging cases, will offer the opportunity for participants to present their research and clinical cases. In addition they will be able to obtain Prize-grants for each one of the three categories.
Como es habitual, las sesiones competitivas de presentaciones libres, como presentación de posters o de casos problema ofrecerán la oportunidad a los participantes de exponer sus investigaciones y casos clínicos. Además podrán optar a obtener Premio-Becas para cada una de las tres categorías.
We hope to satisfy, once again, all the expectations of the attendees. And to make it easier, we will continue to enjoy our expert team of simultaneous translators so that the language does not imply any impediment. In this way, we want all participants to return to their workplaces with renewed energy and new ideas to improve care for their patients. This was also the vocation of the recently disappeared, Dr. E.B. Diethrich, who gave us his presence in some past editions of the SITE. What better tribute to his legacy than to continue to disseminate and share the experiences of the therapeutic endovascular revolutionaries.
Esperamos satisfacer, una vez más, todas las expectativas de los asistentes. Y para hacerlo más fácil, seguiremos disfrutando de nuestro experto equipo de traductores simultáneos para que el idioma no suponga ningún impedimento. De este modo, deseamos que todos los participantes regresen a sus lugares de trabajo con renovadas energías y nuevas ideas para mejorar la atención a sus pacientes. Esta era también la vocación del recientemente desaparecido, Dr. E.B. Diethrich, quien nos regaló su presencia en algunas ediciones pasadas del SITE. Qué mejor tributo a su legado que seguir divulgando y compartiendo las experiencias de las revolucionarias terapéuticas endovasculares.
With the desire to greet you personally in Barcelona at the end of the month of March, receive a big hug on behalf of the Organization of the SITE 2017.
V. Riambau SITE President
V. Riambau Presidente SITE
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Con el deseo de saludarles personalmente en Barcelona a finales del mes de Marzo, reciban un gran abrazo en nombre de la Organización del SITE 2017.
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
1
THE BENEFITS OF ANACONDA FOR STANDARD ANATOMIES: LONG-TERM RESULTS FOR ANACONDA ITALIAN REGISTRY.
Live@SITE Hot Abdominal Aorta. Battle for standard EVAR
AAA repair 2017: Making the case for increasing use of open surgery and no-treatment options for some patients with complex-anatomy aneurysms
Prof. Antonio Freyrie1 1University
Of Parma, Parma, Italy
Summary Aim. Anaconda is an infrarenal repositionable endograft for the endovascular treatment (EVAR) of abdominal aortic aneurysms (AAA). The Anaconda Italian Registry is an observational multicentre registry that started in Italy on March 2009. The aim of this study is to report the perioperative and long-term results of the Anaconda Italian Registry.
Dr. Frank J Criado
Once in the hands of an aorta specialist, it is almost always a discussion of how to repair an AAA (or TAA), and seldom if ever whether treatment and repair would be in the patient’s best interest.
Methods Patient data collection covered both retrospective and new cases. The inclusion criteria were: AAA with a maximum sac diameter ≥ 5 cm, AAA with quick expansion, AAA symptomatic or with a contained rupture, proximal neck length ≥ 15 mm and diameter of the proximal aortic neck between 16mm and 31.5 mm. No exclusion criteria were considered regarding aorto-iliac tortuosity, wall calcification and thrombosis and no exclusion criteria were considered over the patients age, comorbidities or life expectancy. Seven postoperative follow-up controls (visit and imaging) were required: at 30-days from the Anaconda implant, at 6 months, 1 year and then yearly up to 5 years. The end points were: perioperative and 5-years survival, freedom from type I proximal endoleak (EL), conversion free, iliac leg patency and main body dislocation.
Patients are often scared and fearful of the aneurysm diagnosis and the implied “time-bomb” concept that is so prevalent in our society (and medical community) today. And one sees frequently that small or relatively small aneurysm are being repaired, sometimes subjecting the patient to multiple and/or complex procedures because they involve difficult or borderline-unsuitable anatomy for an endovascular approach. Inevitably some patients will sustain complications, and occasionally die as a result – in the course of treating a pathology that would have been best to remain undiagnosed in the first place!. Complex aneurysms are those that cannot be treated optimally with standard surgical techniques or standard EVAR, and this hould be the basis of the guiding principles that will be summarized and discussed during the presentation.
Results
Also, we will present evidence showing that the risk of AAA rupture is really low or very low in most men until the sac reaches 6cm or larger in diameter.
An overall number of 1030 patients were enrolled in the Registry: 92,4% were male with a mean age of 78,2 years (range: 50-94 years). In the 82,1% of the cases the ASA class was ≥ 3. The mean aneurysmal sac diameter was 55,1±9.5 mm. The mean proximal aortic neck length was 26,5±12.31 mm. In the 6.3% of the cases a severe proximal neck angle was reported. The 5-years follow-up has been completed in 347 treated cases (33%). The 30-days and 5years results are reported in the Table.
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SESSION
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Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
30-days results
5-years results
Survival
98,9%
85,2%
Freedom from Type I EL
99,2%
98,2%
Conversion free
99,3%
95,5%
Iliac leg patency
98,3%
90,8%
Main body dislocation
0,2%
2,1%
Methods. Jotec® is a European company that manufactures and distributes different devices in both open and endovascular surgery. In this last field with the manufacture of both covered and uncovered stents, at the level of the thoracic and abdominal aorta and by iliac extension, endoprothesis and also auxiliary material.The added value of Jotec® primarily at the abdominal level is based on six pillars. Firstly, conventional prostheses for open surgery. Secondly, the offer of a competitive endoprothesis for the standard treatment of AAA on two E-vita and E-tegra platforms. Thirdly the possibility of treatment of iliac aneurysms generally linked to other abs with the endoprosthesis of E-iliac branch. Fourthly the availability of covered E-ventus stent for the treatment of pathology of the visceral arteries especially aneurysm and as a complement to the endoprosthesis with branches. Fifth, the use of a large open stent for the abdominal aorta such as the E-XL and sixth, and finally, the star product being the Extra-design platform for the treatment of thoracic-abdominal aneurysms.The E-desing platform is a very competitive product valuing the alternatives that exist in the market and offer endoprothesis fenestrated, low and especially with branches that with the possibility of the construction to the measure allows a variety of very great devices that combined with others allow To treat the pathology almost effectively with almost unlimited strategies and modulations. Custom manufacturing is quick, with little waiting time. On the other hand the assistance of proctor and especially engineers allows to adapt in a very tight way the device to the pathology optimizing the adequacy for the treatment of this. The support of images of the pathology to be treated of each patient, is used computerized with different programs, studying the morphology of the lesion especially sizes, angles, area of commitment, emergency of visceral arteries and a proposal is presented not only of the device, But also of technical therapeutic strategy that must be accepted by the surgeon before its manufacture showing its conformity, but allowing all kinds of considerations and alternative proposals.
These results were not affected by the proximal AAA neck anatomical characteristics. But the endograft repositioning during the implant was employed in a significant greater number of cases with a proximal severe neck angle.
Conclusion According to the perioperative and long-term results of the Anaconda Italian Registry, the Anaconda endograft seems to be safe and effective in the AAA treatment. The structural endograft characteristics as well as the possibility to reposition the main body seems to be effective in terms of proximal fixation and sealing. Definitive long-term results are required.
Is JOTEC abdominal platform adding value? Prof. Carlos Vaquero-Puerta
Department of Angiology and Vascular Surgery. University Hospital University of Valladolid. Spain
Backgroud. Since the possibility of treatment of the abdominal aortic aneurysm was proposed by endovascular technique, excluding the same with endoprosthetic devices, many have been proposed by the industry in order to facilitate the treatment and provide technical solution to this pathology. Many devices have been developed with varying luck over time, some surviving on the initial conceptual basis, others modifying and perfecting themselves and finally others emerging as a recent proposal. In some cases these devices have had a similar conceptual basis and in other cases have been very different from the rest.
Discussion. The added value of the proposal of the company Jotec®, not only is able to provide very competitive products to be able to treat in this case, the pathology of the abdominal arteries, but also the support that maintains technical assistance with the engineering department And their product specialists. This added value has also been understood by other companies, but perhaps the difference with the company Jotec®, is to allow a close collaboration that allows a great integration of equipment for the treatment of the patient from
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End points
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
whom the device is supplied, often with special characteristics And fully adapted to the patient and who should treat it, which is the vascular surgeon.
SESSION
3
References
Free papers aorta and its branches
COST-EFFECTIVENESS OF ENDOVASCULAR VS. OPEN REPAIR OF ABDOMINAL AORTIC ANEURYSM
San Norberto EM, Carrera S, Taylor JH, Vaquero C. Thirty years with a chronic juxtarenal aortic occlusion. J Vasc Surg. 2013 Apr;57(4):1128. Del Río Solá ML, Vaquero Puerta C. Endovascular Repair of a Descending Thoracic Aortic Aneurysm With an Aberrant Left Subclavian Artery Associated With an Infrarenal Aortic Aneurysm. Ann Thorac Surg. 2016 Jun;101(6):2386
Mr P Canning1, Mr W Tawfick1, Ms N Hynes2, Prof S Sultan2
Del Río Solá ML, Fuente Garrido R, Gutiérrez Alonso V, Vaquero Puerta C. Endovascular treatment of superior vena cava syndrome caused by malignant disease. J Vasc Surg. 2014 Jun;59(6):1705-6
1Western
Vascular Institute, Galway, Ireland, 2Western Vascular Institute & Galway Clinic, Galway, Ireland
Cenizo N, Gutierrez V, Vaquero C. Disección iatrogénica del arco aórtico en paciente con Marfan: reparación endovascualr mediante stent E-XL. Rev Esp Cardiol (en prensa)
Introduction
Brunwall J, Vaquero Puerta C, Heckenkamp J, Szopinski P, Egaña JM, Seifert S, Mertikian G, Rümenapf G, Assadian A, Buz S, Schäfer J. Prospective study of the i-iliac Stent Graft System in patients with common iliac artery aneurysm: 30 Day Results. Leipzig International Course LINC 2017. Leipzig Germany January 24-27.2017
Cost effectiveness of abdominal aortic aneurysm (AAA) repair is critical in the strategic mapping of vascular services delivery.
Objectives To compare the cost effectiveness of Endovascular Aneurysm Repair (EVAR) and Open Surgical Repair (OSR) for AAA. Primary endpoint is incremental-cost effectiveness ratio (ICER) of EVAR vs. OSR and aneurysm-related mortality. Secondary endpoints are cost-per-Quality-Adjusted-LifeYears (QALY), perioperative morbidity and mortality, reintervention and all cause mortality.
Material used All patients data for elective AAA repairs between 2002–2015 were analyzed.
Methodology used Demographics and outcomes were reported according to the Society for Vascular Surgery (SVS) guidelines. QALY was measured based on a Quality-of-Time-Spent-WithoutSymptoms-of-Disease or-Toxicity-of-Treatment (Q-TWiST) assessment.
4320 patients were refereed with AAA. 494 patients underwent an elective surgery: 401 EVARs and 93 OSRs.
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Results of the study
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Demographics and vascular-related risk factors were similar in both groups. EVAR had reduced perioperative morbidity (12.2% vs. 50%; p<0.001) and perioperative mortality rates (1.7% vs. 4.3%; p=0.130). Re-intervention was nonsignificantly higher in the EVAR group vs. the OSR group (11% vs. 8.6%; p=0.502). At three years, freedom from aneurysm-related mortality was non-significantly higher for EVAR at 96.3% vs. OSR 93.2% (p=0.219) while all-cause survival was lower for EVAR patients at 81.4% vs. 86.1% (p=0.159). At 3 years, EVAR patients had a non-significant increased QALY of 2.553 vs. OSR 2.439 (p=0.423). Operating room (p<0.001), total accommodation (p<0.001) and followup costs (p<0.001) were all significantly lower in EVAR patients while equipment costs for initial procedure (p<0.001) were significantly higher in EVAR patients. Reintervention costs were similar in both operations (p=0.472). Overall median cost of EVAR at 3 years was ¤14,747 vs. ¤17,319 for OSR (p<0.001). Median cost-per-QALY of EVAR was ¤5,776 vs. ¤7,101 for OSR, p<0.001 giving a median ICER for EVAR of ¤-11,623 per QALY gained.
Introduction In these last years we assisted to an exponential technological progress in both endovascular procedures and imaging diagnostic techniques. The less invasiveness of infrarenal AAA EVAR treatment can take advantage of peculiar technical features of some aortic stent-graft, such as repositionability and the vascular imaging without contrast medium such as intravascular ultrasound (IVUS).
Objectives We present our preliminary results on EVAR performed by repositionable AnacondaTM aortic stent-graft assisted during each step of the vascular navigation of the procedure by IVUS imaging.
Materials used From January 2015 to December2016 we performed 130 EVAR. In 25 pts (23 men and 3 women) we employed an AnacondaTM repositionable endograft assisted by IVUS navigation. The pts’s mean age was 63.9 years (range: 87 – 58). The inclusion criteria were type A or B aneurysm according to EUROSTAR classification, a neck lenght ≥15 mm, neck thrombosis ≤ 30%, no iliac stenosis and an iliac diameter between 7.5 and 15 mm. Methodology used: IVUS was employed in: 1) body delivery step for: Lowest Renal Artery (LoRA) visualization and aortic neck diameters measurement, and in: 2) limb delivery step for: hypogastric artery origin visualization, common iliac artery sizing and measurement of the distance between hypogastric origin and aortic stent-graft flow-divider. We matched IVUS and CT imaging findings concerning the clear visualization of the following vascular elements: Coeliac Trunk (CT), Superior Mesenteric (SM), Right Renal artery (RRA), Left Renal Artery (LRA) and LoRA and the following sizing parameters: aortic neck diameters, common iliac diameters and limbs lenght. Contrast medium was employed only if there wasn’t a clear IVUS vision of the target arteries and anatomic landmark, and always at the end of the procedure just to confirm the absence of any leak. The two x two table method analysis was employed to determine the ability of IVUS in comparison to angio-CT, to clearly visualize target vessel location. Continous variables were analysed by tStudent test and discrete variables by Chi-squared. Actuarial life-table analysis was employed for survival evaluation.
Conclusion of the study At 3 years, EVAR is cost-effective. An EVAR first policy saved ¤1.244,084 over a 12 year period.
REPOSITIONABLE ANACONDATM AORTIC STENT-GRAFT BY IVUS ASSISTED VASCULAR NAVIGATION. A LESS INVASIVE EVAR PROCEDURE IS POSSIBLE Dr. Gaetano La Barbera1, Dr Dario Mamhoud Parsaei1, Dr Fabrizio Valentino1, Dr Rorasio Lipari1, Dr Gabriele Ferro1, Prof Francesco Talarico1 1Dpt.
of Vascular Surgery, Civic Hospital, Palermo Italy, Palermo, Italia
Coeliac trunk, superior mesenteric and both renal arteries were always identified. LoRA was clearly identified in 88%
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Results of the study
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
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of the cases but in 3 because an aortic neck angulation > 60°. Four out 50 hypogastric arteries (8%) weren’t identified because ostium calcifications. Sizing parameters fitted in 100%. For visceral and RRAA visualization IVUS sensitivity and specificity was respectively 100% and 97.3%. Twentytwo out 25 pts (88%) with aortic angulation less than 60° had EVAR with less than 30 ml of contrast medium (p<.01). We obtained 100% technical success, no morbidity and mortality. The average contrast medium amount was 40 ml per procedure.
flexible biomaterial that could be used as base material for novel dissection grafts. The graft should improve patient’s life span by promoting tissue regeneration and restoring the original biomechanical properties of the diseased artery.
Materials used We have developed a polycaprolactone patch modified with a combination of gelatin, sodium chloride, squalene and extracellular matrix proteins. The mechanical properties of the patch were characterized using a dynamometer and a laser distance sensor. Infrared rays and scanning electronic microscopy were used to define the microstructure of the material. Human aortic smooth muscle and endothelial cells were used to test biocompatibility and cellular migration on the material.
Conclusions of the study IVUS is accurate in identifying health LoRA. In selected cases EVAR can be performed by repositionable aortic stent-graft IVUS assisted during vascular navigation. In the next future, thanks to technological progress EVAR could be feasible by only ultrasound assistance.
Methodology used Radial Young’s modulus and viscosity coefficient of the biomaterial were calculated using stress-strain and strain relaxation test. Cell migration was tested by inserting the patch in an in vitro model of cell injury. Cell number, morphology and functionality were tested in cells migrating towards the biomaterial.
NOVEL BIOMATERIAL FOR AORTIC DISSECTION GRAFTS
Results of the study Adding gelatin and sodium chloride changed the microstructure of the material by creating a net of homogeneously distributed interconnected pores throughout the surface. The addition of squalene reduced significantly the stiffness of the material. The patch promoted selective cellular migration as a function of the extracellular matrix components used.
Dr. Jordi Martorell1 Noemí Balà1, Alejandro Aranda1, Dr. Salvador Borrós1, Dr. Vicenç Riambau2, 1IQS
School Of Engineering, Barcelona, Spain, Clínic, Barcelona, Spain
2Hospital
Conclusions of the study Introduction Aortic dissection (AD) is defined as separation of the layers within the aortic wall. It is the most frequent and catastrophic manifestation of the so-called acute aortic syndrome (AAS) and its incidence is 6 per 100.000 people per year. Endovascular repair uses polymeric grafts that fix the tear but their material is inert, non-degradable and with mechanical properties very different to those of healthy arteries’. None of these grafts actively promotes false lumen clotting and resorption, nor vascular remodeling and regeneration.
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A biocompatible, porous and flexible biomaterial has been developed. Its mechanical properties are closer to those of healthy arteries and the patch promotes cellular migration after in vitro injury. Further research could turn this biomaterial into a suitable device for endovascular treatment of aortic dissections.
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Simposio Internacional sobre TerapĂŠutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - NĂşmero 2 - Mayo - Agosto 2017 - EdiciĂłn Especial SITE 2017
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T2EL. Often we detect a combination of different types that could be independent or connect with each other. Combined patterns most often lead to rapid sac enlargement and we are more prone to treat them earlier. We have developed several methods for recognizing the different types of endoleaks by imaging the patients in different positions which also helps diagnosing other EVAR complications. An imaging algorithm has also been developed
A Top Secret Session in Abdominal Aorta repair
Tips and tricks for ultrasound follow up in EVAR Dr. Nicos Labropoulos Professor of Surgery and Radiology
SESSION
Stony Brook University Medical Center Stony Brook, New York
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Endoleak is common complication after EVAR procedures. Despite the progress in the devices and placement of endografts a significant number of patients develop an endoleak. Not all the endoleaks are dangerous but followup is required and treatment is applied in those associated with aneurysm sac enlargement. Ultrasound imaging in experienced hands has reduced the need for serial CTA examination and has helped to manage the patients by reducing radiation and costs. In our center most patients are imaged with color Duplex ultrasound while the use of contrast is rare. Several techniques are being used to facilitate imaging and improve diagnosis. More recently, we have characterized the waveforms that exist in Type 2 Endoleaks (T2EL) and their effect on the aneurysmal sac size. Although T2EL is rarely associated with fatal rupture there are still being treated in patients with sac enlargement.
Visceral and hypogastric endorepair
Visceral and hypogastric endorepair. The best conditions for sandwich technique in iliac aneurysm repair Dr. Dr. Dr. Dr. Dr. Dr.
Xavier Yugueros1, Gaspar Mestres1, Savino Pasquadibisceglie1, Ana Apodaka1, Xavier Alomar2, Vincent Riambau1
1Vascular
Surgery Division. Hospital Clinic, Barcelona, Spain, 2Radiology Department. Clinica Creu Blanca, Barcelona, Spain
There were 4 different flow patterns of T2EL identified. These are high resistance low flow (HRLF), low resistance low flow (LRLF), low resistance high flow (LRHF) and to-fro flow (TFF). The type and number of vessels involved, the time of detection, evolution and need for treatment are taken into account for the management of the patients. Most of the T2EL result in spontaneous occlusion and are not associated with sac enlargement. A high flow or TFF T2EL has higher chances of resulting in sac enlargement, rupture and requiring re-intervention. More importantly we have also determined that T2EL may develop a year later after the EVAR and therefore all our patients are imaged indefinitely.
Introduction The iliac sandwich procedure (placing two conventional stent grafts side-by-side into an existing common iliac limb to create an off-the-shelf bifurcated component) is an adjuntive procedure in complex EVAR to extend the distal sealing to the external iliac artery preserving flow to the hypogastric vessels. Despite good initial results, sandwich procedure itself involves an inherent risk of a type III endoleak (as any parallel-stenting technique) due to gaps between devices. Therefore, adequate material selection and sizing should be specially considered.
In patients with Type 5 endoleaks although we two patients that ruptured no patient has form this type. We follow-up such patients but it is unlikely to intervene. The flow patterns for the Type 1 and Type 3 endoleaks are different from the
We present the results of an in vitro study where different materials, distinct oversizings, and different methods to measure them have been tested in order to dermine which
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
are the best conditions when appliying iliac sandwich techniques.
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Methods Four external iliac devices (16mm Endurant and 12mm A orfix limb extensions; 11 and 13mm Viabahn endografts) were tested with two distinct internal iliac stentgrafts (8mm Advanta/V12 and 8mm Viabahn), in a sandwich configuration in different proximal silicon iliac limbs models (10, 12, 14, 16 and 18mm). After remodeling all devices in a saline bath at 37ºC, the combinations were CT-scanned. Gutter size, parallel-stent compression and inadequate parallel-stent deployment (infolding) were recorded. Oversizing between both parallel stents and the iliac limbs models were examined in terms of added diameter, perimeter and area oversizing, being additionally compared.
IMAC@SITE: Aorta Great Devate: the filling approach
Aorta GREAT DEBATE: the filling approach – Against the motion Prof. Frederico Bastos Gonçalves
EndoVascular Aneurysm Sealing (EVAS) is an alternative endovascular solution for AAA patients that is conceptually different from standard EVAR. Introduction was associated with great expectations, potentially introducing a new paradigm in the endovascular management this disease.
Results All three sizing methods (diameter, perimeter and area) were highly correlated (diameter oversizing to perimeter and area oversizing correlation coefficient 0.998 and 0.997 respectively, P<0.001 for both); thus diameter oversizing was used for further comparisons. Increasing diameter oversizing (<30%, 30-55%, 55-75% and > 75%) showed a significant tendency towards smaller gutters (38.9, 12.2, 5.4 and 2.6 mm2, respectively, p<0.001), but also increasing parallel-stent compression (13.5%, 28.9%, 43.9% and 55.1%, p<0.001) and infolding (0%, 0%, 38% and 60%, p<0.001). There were no significant differences between the analyzed devices.
With EVAR, success is intimately associated with the capacity to produce a lasting seal between “healthy” aortic and iliac segments and the stentgraft. Even then, continuous pressurization of the aneurysm by retrograde perfusion from collaterals – type II endoleaks – may be of concern, particularly when associated with persistent aneurysm growth. EVAS appeared as an answer for standard EVAR’s limitations. Sealing was no longer dependent of the proximal and distal necks – the entire aneurysm was sealed, therefore no type I or III endoleaks were possible – and it got rid of the type II endoleak problem as well. EVAS simplified the procedure, made it readily available to a wider range of patients and reduced the need for secondary procedures, and consequently for long-term surveillance. Manufacturer’s instructions for use were very liberal (basically no neck required, great angulations allowed) and all expectations were high.
Conclusions better apposition of in vitro models is usually achieved when using 30-55% diameter oversizing; higher oversizing is related to smaller gutters but higher rates of malpositioning and parallel-stent compression. No clear recommendations in material selection can be performed. All sizing methods are highly correlated and predictable.
Results from the EVAS Forward Registry have shown us that not only type I endoleaks were possible, they are not that rare at 12 months (3.2%). Their occurence were partially explained by investigators as technical failures, learning curve and possibly resulting from treatment of patients with adverse anatomy. However, the “flag” of lower endoleak rate is essentially at the expense of less type II endoleaks, while the actual clinical importance of these remains debatable. Interestingly, type II endoleaks were still identified after EVAS and their significance is even more unclear than after standard EVAR.
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As usual, reality differs somewhat from expectations.
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Another concern with EVAS is how to measure success. It is difficult to follow these patients in the way physicians are used to, since both duplex ultrasound and CTA are difficult to interpret. As a paradigmatic example of this, no sac shrinkage (a common proxy for success with standard EVAR) can be expected.
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Free papers aorta and its branches
ACUTE OUTCOMES OF ENDOVASCULAR TREATMENT OF STENOSIS OF THE AORTA AND RENAL ARTERIES IN MANAGEMENT OF UNCONTROLLED HYPERTENSION AND LEFT VENTRICULAR DYSFUNCTION IN TAKAYASU’S ARTERITIS
At this point, uncertainty over the efficacy of the procedure (and how to determine it) means that more evidence is required before generalization. Particularly, EVAS falls short of providing the answer to complex AAA anatomy, unfit for standard EVAR, as demonstrated by data reporting the unanticipated presence of endoleaks. This view is also shared by the manufacturer, who recently changed the IFU’s to more “convencional” prerequisites, making the device only applicable to the same patients that could already be treated within IFU with standard EVAR. In conclusion, EVAS is innovative and may be a good alternative to EVAR for many patients. However, it does not yet seem to provide a solution for complex anatomies and durability is still largely unknown. For the time being, careful surveillance of treated patients and participation in registries seem wise. Only the future will tell if the filling approach is indeed fulfilling!.
Prof. Sanjiv Sharma1 1MD,
New Delhi, India
Introduction The impact of endovascular treatment of aortic or renal artery obstruction on the left ventricular function in presence of Takayasu’s arteritis is poorly studied. The influence of clinical activity on the follow up outcomes has also not been well demonstrated.
Objective: We evaluated the results of percutaneous transluminal angioplasty (PTA) in treatment of stenosis of aorta and renal arteries for control of uncontrolled hypertension, pulmonary oedema or left ventricular (LV) dysfunction caused by Takayasu’s arteritis, in active or inactive stage.
Materials A group of consecutive patients with Takayasu’s arteritis in a 4-year period were included. Diagnosis was based on the criteria established by Aortitis Syndrome Research Committee of Japan.
Informed written consent was obtained. Activity was assessed by measurement of ESR, C-reactive protein and carotid intimal-medial thickness. Active disease was treated by medical therapy prior to endovascular treatment, except in pulmonary oedema or LV dysfunction, when PTA was performed irrespective of clinical activity. PTA was done by femoral, brachial, carotid or trans-septal route using previously
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Methods
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
reported technique. Paired t-test was used to evaluate outcomes.
Métodos Se registran datos demográficos, factores de riesgo cardiovascular, presentación clínica según la Clasificación de Rutherford (CR), índice tobillo-brazo (ITB) previo al tratamiento, afectación anatómica, tratamiento realizado y complicaciones. Durante el seguimiento se evalúa la mejoría clínica según la CR, la permeabilidad primaria, primaria asistida y secundaria.
Results 126 patients (66 females, mean age, 11 years) underwent PTA, for aorta in 54 and renal artery in 72 (bilateral in 6) and in both locations in five patients. Technical success was achieved in 116 patients, without complication. Clinical success was achieved in 119 the immediate term; ejection fraction improved from 23+8% to52+9% (p<0.001) and blood pressure from 178+22/102+6 mm Hg to 138+20/ 86+8 mm Hg (p<0.01). Clinical improvement was seen irrespective of disease activity (active disease in 54).
Resultados Se trataron 30 pacientes implantándose 30 endoprótesis AFX Endologix. El 83% eran hombres (n=25). En cuanto a la situación clínica previa al tratamiento: 24 pacientes (83%) presentaban claudicación intermitente (CR I-III) y 5 (16,7%) isquemia crítica (CR IV-V). La localización de las lesiones a nivel aortoilíaco fue; bilateral en ambas Iliacas Primitivas en 17 pacientes (56.7%), unilateral en 11 (36.7%) y de 2 casos (6.7%) en Aorta terminal. Se trataron 12 casos (40%) con oclusión total de uno de los ejes ilíacos. Se obtuvo éxito técnico en 29 casos (96,7%). Un paciente requirió conversión a cirugía abierta. Los accesos femorales se abordaron de forma percutánea en 27 pacientes (90%). Se registraron 2 (7%) complicaciones relacionadas con el procedimiento; incluyendo 1 caso con rotura arterial y otro con sangrado desde acceso percutáneo que precisó reparación femoral.
Conclusions PTA is safe and effective in control of uncontrolled hypertension, pulmonary edema and LV dysfunction in the immediate term, irrespective of disease activity.
ENDOPRÓTESIS AFX PARA LA ENFERMEDAD OCLUSIVA AORTOILÍACA Cristina Alzate Arsuaga,
Ainhoa García Familiar, Maider Mendia Bravo, Mariano De Blas Bravo, Jose María Egaña Barrenechea Universitario Donostia, San Sebastian, España
La terapia endovascular mediante endoprótesis unimodular AFX Endologix para la Enfermedad oclusiva aorto-ilíaca (EOAI) ofrece una corrección anatómica y puede suponer una alternativa a la cirugía convencional con menor morbimortalidad.
En todos los puntos de estudio, la permeabilidad primaria fue > 90% y la permeabilidad primaria asistida y secundaria fueron del 100%. Dos pacientes requirieron una segunda intervención. En el primer control tras el alta, se detectó un caso de estenosis de ambas ramas protésicas y otro caso de trombosis de rama, se resolvió mediante kissing stent y fibrinólisis respectivamente.
Objetivos
Conclusión
El objetivo del estudio es evaluar la seguridad, la eficacia y la permeabilidad a corto plazo del uso de la endoprótesis AFX Endologix para el tratamiento de EOAI en nuestro centro.
Este es el mayor registro del tratamiento endovascular mediante la endoprótesis AFX Endologix en la EOAI en España. Se trata de una opción segura y eficaz, con alta tasa de éxito técnico y permeabilidad y baja tasa de complicaciones según nuestra experiencia, a la espera de sus resultados a largo plazo.
Introducción
Material Estudio descriptivo y retrospectivo de todos los pacientes tratados mediante AFX Endologix para el tratamiento de EOAI desde Enero 2013 a Diciembre de 2016.
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1Hospital
El tiempo medio de seguimiento fue de 11,6 +/- 11,9 meses (de 1 a 42 meses), 2 pacientes abandonaron dicho seguimiento. Todos los pacientes mejoraron en la CR y todos los pacientes que presentaban lesiones con pérdida tisular lograron la cicatrización al final del seguimiento.
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COST-EFFECTIVENESS OF ENDOVASCULAR VERSUS OPEN SURGICAL REPAIR OF RUPTURED ABDOMINAL AORTIC ANEURYSMS
Methodology used Demographics and outcomes were reported according to the Society for Vascular Surgery (SVS) guidelines. QALY was measured based on Quality-of-TimeSpent-Without-Symptoms-of-Disease-or-Toxicity-ofTreatment (Q-TWiST) assessment.
Mr P Canning1,
Results of the study
Ms N Hynes2, Mr W Tawfick1, Dr C Ahmed1, Prof S Sultan2
800 aneurysm surgeries were performed. 135 of these were emergency surgeries of whom 88 were for rAAA; (42 rEVARs and 46 rOSRs). Demographics and rAAA predictors of mortality were similar in both groups. Primary technical success (rEVAR 89.1% vs. rOSR 87.8%; p=0.1), perioperative morbidity (rEVAR 56.5% vs. rOSR 64.3%; p=0.457) and mortality (rEVAR 26.1% vs. rOSR.
1Western
Vascular Institute, Galway, Ireland, 2 Western Vascular Institute & Galway Clinic, Galway, Ireland
Introduction
28.6%; p=0.794) were non-significantly favorable and significantly lower in rEVAR patients at 3 years (rEVAR 74% vs. rOSR 90%; p=0.038). Three year aneurysm-related survival (rEVAR 65% vs. rOSR 62%; p=0.848) and all-cause survival (rEVAR 56% vs. rOSR 51%; p=0.577) were nonsignificantly higher in rEVAR patients. At 3 years, rEVAR patients had a non-significantly higher QALY of 1.671 vs. OSR 1.549 (p=0.502). Operating room (p=0.001) and total accommodation costs (p=0.139) were lower in rEVAR patients, while equipment (p<0.001), surveillance and reintervention (p<0.001) costs were higher. Median cost of rEVAR at 3 years was ¤23,352 vs. ¤20,494 for OSR (p<0.084). Median cost per QALYof rEVAR at 3 years was ¤13,974 vs. ¤13,230 for rOSR (p=0.296). ICER for rEVAR vs. rOSR was ¤23,426.
Cost effectiveness of Endovascular Aortic Aneurysm Repair (rEVAR) vs. Open Surgical repair (rOSR) for ruptured abdominal aortic aneurysm (rAAA) remains a controversial area.
Objectives To compare the cost effectiveness of rEVAR vs. rOSR for rAAA. Primary endpoint is incremental cost-effectiveness ratio (ICER) of rEVAR vs. rOSR and aneurysm-related mortality. Secondary endpoints are cost-per-Quality-AdjustedLife-Years (QALY), perioperative morbidity and mortality, reintervention and all-cause mortality.
Material used All patient data including demographics and outcomes for rAAA repairs between 2002–2015 were scrutinized.
Conclusion of the study
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At 3 years, the increased costs of rEVAR compared to rOSR are justified by it’s improvement in QALYs in a high volume centre.
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TW1
Concepts like predilatation, inflation time and concomitant medication (double antiplatelet therapy) should be kept in mind trying to achieve similar results in our patients than in the published trials.
Young talent lower Limb
DEB, where are they working better? Dr. Jorge Cuenca
Treatment using drug-eluting balloon (DEB) technology is gaining increasing acceptance. The idea of treating lesions with better permeability rates and lower incidence of restenosis than with simple angioplasty (POBA) without leaving behind material is more than attractive. On the other hand, its use would avoid stent complications, that is, stent fracture and intrastent restenosis. The commercial offer of different DEBs with several trials in different sectors and with indication in stenosis de novo or restenosis is ample. It has been suggested that prior to the validation of a given DEB, the initial studies of "proof of the concept" should be followed by studies that test their behavior in our usual environment, the so call “real world”. Not all the studies have proven the efficacy of DEB in different territories. The use of the different DEBs in lesions without severe complexity (such as those usually seen in patients who are claudicating over long distances) show good results in achievement of primary and secondary endpoints (usually absence of crinically driven target lession revascularisation, improvement of walk distance, limb salvage or primary patency). But this does not imply that when used in complex lesions, such as those found in our usual clinical practice, the performance and resultsof the particular DEB are going to be so good.
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DEBs have their limitations. In case of severe calcification they are not indicated. Moreover, in case of recoil or dissection that compromise the flow, they should rely on provisional stenting. If provisional stenting was needed, it has been recommended by some studies the use of spot stenting (based on the philosophy of leaving the less stented artery as possible). Taking all of this into account, both the claudicating patient and the patient with the most advanced PAD (critical limb ischemia) due to involvement in the femoropopliteal sector, constitute the group in which the use of the DEB can be supported with the greatest evidence. This is because we have clinical trials with DEB from various companies that have demonstrated the efficacy of BSD in the treatment of both short lesions and more complex lesions. Another different case where the DEB has showed its theorycal advantage against POBA or stent, is the restenosis. This has been endorsed by several trials. The restenotic plaque caracteristics is totally different from those of the plaque of the PAD...and DEB looks like working well in this situation aswell. The results could be improved with the use of atherectomy. The role of endovascular therapy in the tibial arteries is indeed challenger. The performance of DEB in this arterial bed has yet to be demonstrated. Although the results of the studies with some DEBs seem promising, we still have not enough data to support the use of DEB against POBA in this territory, alone or with atherectomy as adyuvant. Finally, the arteriovenous fistulas is another territory where the DEB could be helpful. The stenosis rate and restenosis is very common and improving the POBA results does not seem very difficult. Ir al sumario
SESSION
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
IN THE OR: TECHNICAL TIPS AND COMMON FAILURES IN FIRST COMPLEX PERIPHERAL CASES
The approach for treating a lesion in lower limbs can be: Contralateral Retrograde Antegrade Retrograde popliteal puncture
Dr. Luis Miguel Salmerón
Retrograde pedal micro-puncture When presented with a lesion in lower limbs, the following should be considered:
Contralateral Retrograde approach is indicated in the following cases
Whether it should be treated
When there are proximal and distal lesions (iliac and em-pop lesions)
The approach
When there is no stump in SFA
Which technique should be used?
When ipsilateral puncture is not recommended: The approach will be by guided echo puncture, we will avoid complications like hematoma, pseudoaneurysms and open surgery to expose the femoral artery. However, as we are surgeons, in some particular cases it could be necessary to expose the artery; it would be better to dissect the proximal superficial femoral artery (SFA) and to preserve the common femoral for a future by-pass. If the SFA has been accessed by surgical approach, the direction of the sheath can be changed and iliac and fem-pop lesions could be treated on the same side.
Previous by-pass Infection in the groin Open wounds Re-do
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Antegrade approach is indicated when there is a long and safe stump in SFA. If the popliteal or infrapopliteal zone are going to be treated, the best is to use a long sheath and put it as close to the lesion as possible. Antegrade approach allows you to use short material and ensure the best torque and more pushability
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Results of the study
Hot Topics in Lower Limb (I)
Results from several studies confimed the importance of this technique. Cioppa et al reported 90% primary patency rate at 1-y in 30 severly calcified lesions of the SFA treated with directional atherectomy followed by drug coated balloons. The DEFINITIVE AR a prospective, multi-center, randomized trial (directional atherectomy+DCB vs. DCB alone) showed a primary patency rate at 1 year of 93.4% for the combine treatment vs. 89.6% when the DCB was used alone without vessel preparation.
ROLE OF VESSEL PREPARATION IN THE TREATMENT OF THE SFA LESIONS
In the PANTHER study, vessel preparation was performed in 124 patients using a scoring balloon. A one-year primary patency of 91.8% was reported with a secondary patency rate of 81.2%.
Prof. Fabrizio Fanelli1,
Dr Alessandro Cannavale2 1"Sapienza"
University of Rome, Rome, Italy, 2Interventional Radiology Unit, Department of Radiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
Initial results of the lithoplasty device are very promising. In the DISRUPT PAD study 95 patients with symptomatic (Rutherford 2 to 4) calcified femoropopliteal lesions up to 15 cm in length. Technical success was achievede in alla cases and an acute gain of 3.0±0.8 mm and mean residual stenosis of 23.8±5.7%.
Introduction In the era of drug eluting devices, vessel preparation has become more and more popular especially in the presence of heavely calcified lesions.
Conclusions To increase the efficacy of endovascular technique, vessel preparation with atherectomy or debulking system are very promising because they can improve vascular remodelling, enhance drug diffusion in the vessel wall and promote drug effect reducing stenosis and improving tissue perfusion with the potential beneficial effect of increasing walking distance in claudicants, accelerating wound healing and contributing to limb salvage in CLI patients.
Objectives To evaluate when and how to perform vessel preparation in xthe presence of steno-obstructive diseases of the superficial femoral artery (SFA)
Material and Methodology Calcium represents the big enemy for all endovascular procedures. It makes vessels resistant to dilatation and subject to recoil, embolism and dramatically responsible for incidence and entity of dissections. Infact 71% of flow limiting dissections occur within a calcified vessel because the presence of calcium reduces so much the arterial wall elasticity that it cannot be compliant when a balloon is inflated. This problem has gained more and more popularity nowadays with the introduction of drug coated balloons when an “optimal” PTA is required to reduce the number of stents implanted. Different methods have been proposed to “prepare” the vessel such as: atherectomy, scoring balloons, lithoplasty.
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SESSION
12
Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
SESSION
11
Results of the study
Free papers Lower Limb
Four-teen patients with chronically occluded bypass with a mean age of 68,14 years (range 46-79) and 85,7% were males. More than 70% of the patients had diabetes, hypertension and dyslipidemia. The mean time from surgery to the endovascular recanalization was 43,31 months (range 6,5-107,2). Technical success was achieved in 100%. The mean follow-up period was 9,71 months (range 2-24).
EXTREME ENDOVASCULAR REVASCULARIZATION OF NATIVE ARTERY AFTER BYPASS FAILURE IN PATIENTS WITH CRITICAL LIMB ISCHEMIA
The cumulative primary patency and primary assisted patency calculated by Kaplan-Meyer analysis at 12 months were 85,7% (SE 0,611) and 92,9% (SE 0,607), respectively. The cumulative secondary patency and the limb salvage-rate at 1 year were 100%.
Dr Claudia Riera1,
Conclusions of the study
Marc Sirvent1, Pere Altés1, Carlos Esteban1, Montserrat Esturrica1, Secundino Llagostera1
Endovascular recanalization of chronic total occlusion of native artery in CLI patients with prior bypass failure is a feasible, safe, and effective option with excellent technical success, vessel patency, and limb salvage rates.
1Hospital
Universitari Germans Trias i Pujol, Badalona (Barcelona), Spain
Introduction
SEQUENTIAL PNEUMATIC COMPRESSION, A HOME THERAPY IN LIMB SALVAGE IN NON-RECONSTRUCTABLE CRITICAL LIMB ISCHEMIA
Lower extremity bypass (graft) failure in patients with limbthreatening ischemia carries an amputation rate of greater than 50%. Redo bypass is often difficult due to the lack of conduit, adequate target, or increased surgical risk.
Objetive
Dr M Zaki1,
The aim of this study is to evaluate the role of endovascular recanalization of the chronically occluded native arteries after bypass occlusion in patients with critical limb ischemia (CLI) and its outcomes.
Dr M Elsherif1, Mr W Tawfick1, Dr M El Sharkawy1, Ms N Hynes2, Prof S Sultan2 1Western
Vascular Institute, Galway, Ireland, 2Western Vascular Institute & Galway Clinic, Galway, Ireland
Material used A single-institution, retrospective review of patients with CLI and bypass failure, all of whom underwent endovascular revascularization of their native artery from December 2014 to September 2016. Early bypass failure (<30 days after bypass) were excluded.
Introduction Critical limb ischemia (CLI) is an increasingly alarming presentation of an advanced stage of underlying generalized circulatory failure.
Methodology used Demographics, comorbidities, technical success and followup (physical examination and duplex ultrasound at 1,3 and 6 months followed by 3-6 months intervals thereafter) were recorded. Descriptive and life-table analyses were performed.
Objective Critical limb ischemia (CLI) is an increasingly alarming presentation of advanced generalized circulatory failure.
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Dr Dr Dr Dr Dr
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DEBULKING WITH ROTATIONAL MECHANICAL THROMBECTOMY DEVICE IN FEMORO-POPLITEAL IN-STENT OCCLUSIONS OR STENOSES
Most patients presenting with CLI have profound cardiovascular comorbidities that hinder surgical intervention. Moreover, some patients present with non-reconstructable arterial anatomy. For this vulnerable cohort, primary amputation is often the only available option. This study aims at answering the question: Can sequential pneumatic compression (SPC) preclude amputation?
Dr. Bruno Migliara1
Material used
1Vascular
and Endovasular Unit, Pederzoli Hospital, Peschiera Del Garda, Italy
A retrospective analysis of 187 patients (262 limbs) prescribed the Artassist SPC compared outcomes between the group of patients who acquired the device and those who did not.
Introduction
Methodology used
In femoro-popliteal lesions stenting shows better patency than PTA, although treating in-stent restenosis (ISR) remains a frequent and challenging problem.
Patient data was analysed using statistical methords for outcomes such as limb salvage, amputation-free survival and improvement in toe pressures.
Different strategies to treat ISR (PTA alone, PTA with drug eluting balloon (DEB), covered stent, debulking devices) have been described with variable results. PTA alone showed very disappointing patency rates. In our experience, debulking seems to be the key to obtain better results.
Results of the study The mean age was 74.78 years, the median follow-up was 16 months, and the median duration of usage was 4 months. 81.72% of the patient acquired the device and 18.28% did not. The mean toe pressure was 61.4 mmHg pre-application, and 65 mmHg after application (p=0.071). Amputation-free survival was 98% and 96% for those who acquired the device and 90% and 84% for those who did not at 6 and 12 months, respectively. There was a non-significant association between limb salvage and device acquisition (p=0.714); however, there was a significant improvement in rest pain (p<0.0001), reduction in minor amputation (p=0.023), and amputation-free survival associated with using the device (p=0.01).
Objectives This study aims to evaluate the safety and efficacy, in terms of technical success, patency rates and limb salvage, of debulking, with percutaneous mechanical rotational thrombectomy, and PTA, with drug eluting balloon, in ISR.
Material In our Department, during a period of 2 years, 51 patients (33 male/ 18 female), with a mean age of 69,3±8,6 years, were treated with percutaneous mechanical thrombectomy and DEB PTA for in-stent occlusions (in 47 cases) or fempop level stenoses (in 4 cases).
Conclusions of the study Although limb salvage is the paramount ambition for patients referred to vascular services, some patients with CLI are better served with primary amputation. Although the mechanism of SPC action is still ambiguous, there is strong evidence to support its role in preventing minor amputation, prolonging amputation free survival, and improving rest pain in patients with non-reconstructable CLI; nevertheless, its role in prevention of major amputation lacks statistical significance.
The majority of them were in Rutherford Class 5; in 42 patients there was an SFA stent, in 7 a popliteal stent and in 2 a fem-pop stent.
Methodology
Results The technical success rate was 100%. In 6 patients it was
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Our study is based on a retrospective analysis of a continuous series of patients prospectively collected over a period of 2 years.
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Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
necessary to perform a double access, antegrade from the common femoral artery and retrograde directly through the stent. In all cases we performed an in-stent PTA with a drug eluting balloon; but in 9 cases it was necessary to implant an additional stent proximally or distally. We had 3 minor complications: 2 distal artery dissections and 1 stent fracture. During follow-up we had 11 re-occlusions (21,6%). We treated these patients with: 3 major amputations, 6 redothrombectomy procedures and 2 with bypass surgery. Primary patency is 78,4%, but secondary patency is 90,2%. Amputation free survival is 94,1%. During follow-up we had 9 deaths not related to the procedure.
Conclusions Our single centre experience with in-stent fem-pop debulking suggests that mechanical thrombectomy with percutaneous mechanical thrombectomy + DEB is safe and effective, with reduction of re-intervention, with rare (1 case) in stent fracture and without the risk of distal embolization, also in acute cases.
Objectives To evaluate the efficacy and safety of a new generation balloon-expandable stent-graft.
Material and Methodology used Very recently a new generation covered stent-graft have been proposed as a method of choice to treat the chronic occlusions of the iliac arteries. As known either a balloon –expandable or semf-expanding stent are suitable for the iliac teritoory and selection is performed on the basis of the lesion characteristics and locations.
Results of the study Holden et al, reported the first-in-human experience using a new generation covered stent-graft. A primary 30-day safety endpoint of 0% was described. Per-subject estimates of primary patency, freedom from target lesion revascularization, and freedom from target vessel revascularization were 100% at 1 and 6 months and 96.6% at 12 months. Estimates of assisted primary and secondary patency were both 100% at 12 months. Freedom from major adverse events at 12 months was 100%.
Conclusions
SESSION
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Hot Topics in Lower Limb (II)
CAN WE IMPROVE THE OUTCOMES IN ILIAC CTO WITH THE NEW STENT GRAFTS?
ENDOLUMINAL BY-PASS AND OPEN BY-PASS, IS THERE ANY DIFFERENCE?
Prof. Fabrizio Fanelli1,
Dr alessandro cannavale2 1"sapienza"
The positive first-in-human experience with the new generation balloon-expandable covered stent-graft suggests that this device will have an important role in the management of aortoiliac occlusive disease. The great advantages of this new-generation device are also correlated with a more safe conditions as rupture orarterial fissuration can be manage with the rapid impantation of a covered stent-graf. Howevere further experience in the iliac arteries are required.
University Of Rome, Rome, Italy,
2***
Interventional Radiology Unit, Department of Radiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, GLASGOW, UK
Introduction
The venous femoropopliteal bypass has been the gold standard for complex occlusive disease of the superficial femoral artery for decades. Endovascular alternatives have evolved rapidly and the heparin bonded Viabahn (W.L.Gore
New generation stent-graft can increase the outcome of total chronic occlusions of the iliac arteries.
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Dr. Michel Reijnen
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and Associates) could provide a valid alternative for surgery. 128 patients were randomized in two groups and treated with a surgical bypass or a heparin-bonded Viabahn. The clinical state and baseline anatomy was comparable between groups except for eh diameter of the popliteal artery, which was larger in the surgical group.
however there are no established general strategies, and the better option still remains the adoption of tailored therapeutic regimens on the basis of the graft material, of the level of the distal anastomosis and of the status of runoff vessels. The author will present his protocol of postoperative management of patients operated on with endovascular or open surgery for obstructive disease of the femoro-popliteal axis.
The mean lesion length was 23 cm in both groups. The admission time and 30-day morbidity rate was significantly lower in the endovascular group without 30-day mortality. There were no significant differences in primary, assistedprimary and secondary patency rates. At 30 days the Walking Impairment Questionnaire and RAND-SF36 scores were better for the Viabahn group while at one year this difference had disappeared. In conclusion, the heparin-bonded Viabahn seems to be a valid alternative for surgery, with a more rapid and sustained improvement in clinical state and quality of life.
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Free papers Lower Limb
RESULTS OF HYBRID BYPASS IN PATIENTS WITH TASC D LESIONS
A Top Secret Session in lower limb revascularization
Dr. Bruno Migliara1 1Vascular
and Endovasular Unit, Pederzoli Hospital, Peschiera Del Garda, Italy
MY PHARMACOLOGICAL PROTOCOL AFTER SF AND/OR BTK REVASCULARIZATION
Introduction In patients with critical limb ischemia (CLI) and total occlusion of the superficial femoral artery (SFA) or a femoro-popliteal segment (TASC D lesions), TASC II said that the first choice treatment has to be surgery.
Dr. Walter DORIGO
Department of Vascular Surgery, University of Florence, Italy
Considering the type of graft, there is a clear primary patency benefit for autologous veins in comparison to synthetic material for above the knee (ATK) bypasses. In case of unsuitable veins, heparin bonded PTFE graft is a good alternative.
There is no clear evidence in Literature concerning the best therapeutic regimen following open or endovascular revascularization of the superficial femoral and of the popliteal arteries. As far as endovascular repair is concerned, the everyday attitude mainly derives from the experience of the endovascular treatment of coronary artery disease, pushing towards a wide use of double antiplatelet therapy (DAPT), particularly when a stent or a stent-graft are used. However, recent meta-analyses did not find significant evidence for superiority of DAPT compared with mono antiplatelet treatment (MAPT). When data concerning open surgical bypass are examined, the evidence is even lower. MAPT, DAPT and oral anticoagulants have been used and studies,
But, in complex cases, with very calcified distal SFAs or popliteal arteries or with proximal or median popliteal artery occlusions, in which distal bypass anastomosis is difficult, hybrid bypass allows a sutureless anastomosis.
This study aims to evaluate the safety and efficacy, in terms of technical success, patency rates and limb salvage, of hybrid bypasses in femoro-popliteal occlusions.
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Objectives
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HEMODYNAMIC SIGNIFICANCE OF PERFUSION ANGIOGRAPHY PARAMETERS
Materials In our Department, from August 2013 to August 2016, 27 patients (18 male/ 9 female), with a mean age of 75,1±9,1 years, were treated with hybrid ATK bypasses for TASC D fem-pop occlusions. All patients had critical limb ischemia, the majority of them were in Rutherford Class 5. The median TcpO2 was 10,1 mmHg (2-25).
Dr. Efrem Gómez Jabalera1,
In all cases there was complete SFA occlusion, moreover there were: 16 significant stenoses of the common femoral artery, 12 popliteal occlusions, 13 very calcified distal superficial femoral or proximal popliteal arteries and 2 reinterventions for previous ATK bypasses.
Methodology Our study is based on a retrospective analysis of a continuous series of patients prospectively collected over a period of 3 years
Results Technical success rate was 100%, without major and minor complications. During follow-up we had: 4 deaths, not related with the procedure, in patients with an open bypass and complete wound healing; 7 occlusions (25,9%), 4 for infections and 3 for stenosis in the distal stent. We treated these patients with: 2 major amputations, 3 Rotarex procedures and 2 with redo-bypass surgery. Primary patency is 74,1%, but secondary patency is 85,2%. Amputation free survival is 92,6%. Median TcpO2 is 42,7 mmHg (30-55); there is complete wound healing in 22 (81,5%) patients, with an average of 62,3 days to obtain healing.
PhD Dr. Gaspar Mestres1, Dr. Luis Mariano Palena2, Dr. Marco Manzi2 1Hospital
Clínic De Barcelona, Barcelona, Spain, Abano Terme, Abano Terme, Italy
2Policlinico
Introduction Perfusion angiography (PA) is a post-processing software algorithm that does not require digital substraction angiography (DSA) or contrast medium injection. Given that their significance is unknown, PA parameters are not being used in decision-making processes.
Objectives Our study is a first attempt to demonstrate that PA parameters may provide valuable hemodynamic significance.
Material used On consecutive patients undergoing endovascular treatment (EVT) at Policlinico Abano Terme (Italy) for critical limb ischemia (CLI), standard angiographic studies of the limb and PA of the foot before undergoing EVT and thereafter were performed, measuring all its parameters (arrival time, time to peak, wash-in rate, width, area under the curve, and mean transit time).
Methodology
Our single centre experience suggests that hybrid graft is an effective alternative technique to re-vascularize patients with TASC D fem-pop lesions and with very calcified distal superficial femoral or proximal popliteal arteries, with occluded popliteal arteries and with previous ATK bypasses. This graft allows above the knee anastomosis rather than below.
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Demographic data and PA analysis on the foot were measured and TASC classification in femoro-popliteal (FPTASC) and below the knee (BTK-TASC) segments were assigned accordingly.
Results 74 consecutive patients were studied. Mean age was 71, 74% were men. 6 patients were excluded due to PA artefacts. All PA parameters showed significant improvements between PA performed previously and after EVT (p<0.03), according to angiographic findings. Wash-in rate was inversely related with both FP-TASC (p=0.026) and BTK-TASC (p=0.009) classifications, and arrival time had a direct relation with
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Conclusions
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BTK-TASC (p=0.032). The differences in BTK-TASC after EVT revealed a negative correlation with arrival time (p=0.005) and width (p=0.045).
Methods Patients were classified into two groups according to their indication: AAA vs. PAD. Data were collected from medical charts and digital hospital records. The primary endpoints were overall mortality (early and long term) and procedurespecific complications (graft occlusion or infection). Groups were compared using Kaplan-Meier survival analysis.
Conclusions Arrival time appears to be the most related PA parameter with BTK-TASC (for an isolated angiography and for differences after EVT). Wash-in rate seems to be more representative of the whole TASC classification of the limb, both FP-TASC and BTK-TASC.
Results One hundred and sixty-two patients were identified, 47 patients (2 females) in the AAA group and 115 (15 females) in the PAD group. There were no differences in patient demographics at baseline.? Revascularization was urgent in 26 (55%) patients in the AAA group and in 17 patients (15%) in the PAD group. Early death occurred in 9 (19,1%) and 11 patients (9,6%), respectively (P=0,092). None of these deaths were directly related to crossover complications, as infection or thrombosis. Median follow-up duration was 1,45 years (interquartile range of 4,08). Vital prognosis did not differ between groups. At 5 years, estimated mortality was 59% and 57%, respectively (P=0.27).?Complications related to the crossover bypass were identified in 7 patients in the AAA group (14,9%) and in 41patients of the PAD group (35,7%). Most complications were occlusions (71% vs 85%). Estimates for bypass-related complications at 5 years were 17% for the AAA group and 47% for the PAD group (P=0,036).
OUTCOME OF FEMORO-FEMORAL CROSSOVER BYPASS IN OCCLUSIVE VS. ANEURYSMATIC DISEASE Dr. Rita Soares Ferreira1,2,
Dr. Rodolfo Abreu1, Dr. Emilia Ferreira1, Dr. João Albuquerque e Castro1, Dr. Luís Mota Capitão1,2, Prof. Frederico Bastos Gonçalves1,2 1Hospital
Santa Marta, CHLC, Lisbon, Portugal, 2NOVA Medical School, Universidade Nova de Lisboa, Portugal
Conclusion
Outcome of patients with femoro-femoral crossover bypass for peripheral arterial disease (PAD) due to iliac occlusion is well characterized in literature. After endovascular repair of abdominal aortic aneurysm (AAA) using aorto-uni-iliac devices, a similar complementary extra-anatomic revascularization is necessary. However, the outcome for the latter is not well defined, and may not be comparable to patients with PAD.
Objectives Our objective is to characterize and compare the outcome of patients treated with femoro-femoral bypass for AAA vs. PAD.
Material We designed a retrospective comparative study in the setting of a tertiary referral center. All consecutive ?patients submitted to femoro-femoral crossover bypass from 2007 to 2012 were included.
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Our results suggest that femoro-femoral crossover bypass in the context of complementary revascularization of AAA patients treated with aorto-uni-iliac devices is associated with a significantly less complications than those performed in PAD patients. This should be taken into account when deciding the optimal treatment option for AAA patients, both in elective and acute settings.
Introduction
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MOTION: ENDO SHOULD BE THE FIRST OPTION IN LOWER LIMB - AGAINST THE MOTION
Lower Limb great debate: endo first
ENDO SHOULD BE THE FIRTS OPTION IN LOWER LIMB - AGAINST THE MOTION REBOUND
Prof. José Fernandes e Fernandes
MD, PhD, FACS, FRCS Eng, FESC, FEBVS
Endovascular management of proximal aorto-iliac disease has become first option for all occlusive lesions with few exceptions for extensive type D occlusions. The question remais, however, for femoro-popliteal and distal crural occlusive disease where debate is focused which treatment –open or endovascular-provides better clinical outcomes, less reinterventions and more cost-effectivness.
Dr. Walter DORIGO
Department of Vascular Surgery, University of Florence, Italy
Chronic obstructive disease of the superficial femoral artery (SFA) can be safely treated with both open surgery and endovascular repair; in the recent years a significant shift towards endovascular treatment occurred, and nowadays it represents the first line treatment in most patients. However, the long-term results of such procedures are still debatable; while the rates of patency of the treated arteries are satisfactory in short lesions, particularly in patients with intermittent claudication, in the presence of long lesions and of critical limb ischemia endovascular repair does not provide fair results in the mid and long-term setting, independently from the kind of device one can use. On the other hand, open surgical treatment with femoro-popliteal bypass still represents an excellent options in patients with low and mild surgical risk and extensive arterial involvement, providing good long-term patency and limb salvage rates, both in claudicants and in critical limb ischemia patients. As a consequence, the most recent guidelines suggest the use of endovascular repair as first line therapy in patients with short lesions and with longer lesions and high surgical risk, while in the presence of complex lesions and low and mild surgical risk, open surgical bypass still remains the preferred option.
Data from the Basil trial suggest better amputation freesurvival (AFS) and overall survival(OS) with bypass – first strategy, but no differences in quality of life and the initial advantages in cost- effectivness associated with endo repair being eroded by the need of reinterventions. Successful treatment depends on durability of the reconstruction and adjunctive treatments to eradicate infection and potentiate healing. Focus has been shifted from lesion assessment to a more comprehensive selection based on i) Clinical assessment: patient condition, severity of ischemia, extension of gangrene ii) Morphological characteristics and extension of the lesions iii) Availability of adequate venous conduit, thus providing a patient – tailored strategy. 269 procedures were performed for CLI during a 30 month period from January 2012 to June 2014, 130 open surgery (OS) 139 endovascular repair (ER) were selected on the above mentioned selection criteria. Overall survival at 18 months follow-up was 72% (OS) and 63% (ER) and amputation free survival was 87% on ER and 80% on OS, with no significant difference on the need of reinterventions on both groups.
The author will present the most recent data of Literature on this topic and the results of his own experience and will conclude that endovascular repair can be considered the first option only in certain subgroups of patients, while in other cases open surgery still is the best option.
These results of overall survival and limb salvage do compare very favorably with reports based on fixed strategies either OS or ER irrespective of patient and lesion assessments. So my position will be against the motion and to defend a patient tailored approach and also that prompt and adequate management should be adopted, because time is tissue.
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SESSION
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
The best approach to lymphatic and pure venous SESSION AVM Multidisiciplinary malformation
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Dr. Daniel Barnes
Conclusion: Sclerotherapy is a secure and effective treatment of low flow vascular malformations with a high rate of patients having a partial to complete response. Lymphatic macrocystic lesions tend to respond more often to treatment than mixed microcystic type.
session
THE BEST APPROACH TO LYMPHATIC AND PURE VENOUS MALFORMATION
SESSION
Barnes, Daniel1,
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Gomez, Fernando1, Stuart, Sam2, Patel, Premal2, Barnacle Alex2, 2.Hospital 2.Great
Clinic I Provincial de Barcelona, Barcelona, Spain. Ormond Street Hospital, London, UK
Free papers Miscellaneous
PSEUDOANEURISMA AXILAR DIAGNOSTICADO POR LESIÓN GLOBAL DEL PLEXO BRAQUIAL.
Abstract Low flow vascular malformations are benign vascular lesions, present at birth which can cause symptoms any time in life. Symptoms include aesthetic complaints, pain, swelling, thrombosis, bleeding and growth dysfunction.
Ms. Patricia Rodríguez Cabeza1,
Omar Andres Navarro, Albert Brillas Bastida, Óscar Roset Balada, Anna Presas Porcell, August Corominas Macias
Initially, surgery was the only option of treatment. During the last years, several studies assessing the utility of sclerotherapy with diverse agents have been reported in the literature. Percutaneous sclerotherapy is widely considered first line therapy for lymphatic and venous malformations. However, the lack of randomized trials makes difficult find reliable evidence of its effectiveness. Lately, some systematic reviews regarding this issue have been published. Different sclerosants have distinct advantages and associated complications. A review of the literature, description of the different techniques and agents, and an up-to date will be explained.
1Hospital
Universitari Dr. Josep Trueta de Girona, Girona, Spain
Introducción La lesión del plexo braquial por pseudoaneurisma de arteria axilar es una patología descrita en la literatura que cursa con dolor en la extremidad y déficit neurológico progresivo.
Recently, we reviewed our database of lymphatic malformations, and assessed 216 patients treated with ultrasound guided sclerotherapy over a 14 year period using a standardized technique using several sclerosants. We reviewed all the clinical records and a prospectively collected database. Purely macrocystic lesions had a statistically significant improved response to treatment compared to mixed or microcystic lesions. (p=0.001 IC=0.99). Despite this 65% of patients with microcystic or mixed lesions did demonstrate an improvement in lesion size and/or the symptoms with treatment.
Objetivos Exponer un caso de paciente con lesión global de plexo braquial iatrogénica aparecida a las 3 semanas postcolocación de stent en tronco celíaco vía axilar por compresión externa de pseudoaneurisma axilar tratado de forma endovascular.
Stent cubierto BeGraft 7x57 Bentley Innomed, guía Terumo hidrofílica 0.035, introductor Cordis 6 Fr.
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Material
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Métodos
Introduction
Paciente mujer en tratamiento con sintrom por arritmia cardíaca que en control en CCEE tras colocación de stent en tronco celíaco presenta importante dolor, edema e impotencia funcional en brazo izdo. EMG muestra una lesión plexular global postganglionar parcial a nivel antero-externo y posterior y completa a nivel antero-interno. Ante la sospecha de clínica compresiva se realiza un AngioTAC que objetiva pseudoaneurisma de arteria axilar de morfología bilobulada y 6 cm de diámetro. Se realiza intervención quirúrgica bajo anestesia general y abordaje abierto de arteria humeral a nivel del surco bicipital. Se cateteriza la arteria subclavia con guía de Terumo. La arteriografía intraoperatoria confirma la presencia del pseudoaneurisma por lo que se procede a colocación de stent cubierto tipo Begraft de 7 x 57. Posteriormente se realiza abordaje directo del pseudoaneurisma y exéresis del mismo para descompresión.
The approach technique in Carotid Artery Stenting (CAST) may be pivotal in reducing peri-operative stroke.
Objectives To compare Carotid Artery Endarterectomy (CEA) to transfemoral carotid artery stenting (F-CAST) and trans-cervical carotid artery stenting (C-CAST). Primary endpoints are stroke, myocardial infarction (MI) or death within 30 days after the procedure. Secondary endpoints included patency, re-intervention rates and 5year stroke free survival.
Material used Out of 9585 carotid patients referred, we performed 690 carotid interventions over 12 years. Patient demographic, risk factors and outcomes were analysed.
Resultados La arteriografía de comprobación muestra una total restitución de la luz arterial. La paciente presentó mejoría del dolor en la extremidad superior izda en el postoperatorio con mejoría parcial de la paresia de la mano.
Methodology used Multiple logistic regressions were used to control for comorbidity and anatomical high risk factors. Propensity scoring was used to adjust for baseline characteristics and selection bias, by matching co-variables. We matched 53 CEA and 53 CAST (34 F-CAST and 19 C-CAST) patients.
Conclusiones Los pseudoaneurismas de la arteria axilar postarteriografía pueden pasar desapercibidos dada la localización en la fosa de la misma. La sospecha clínica y su rápido diagnóstico y tratamiento son indispensables para evitar una lesión neurológica permanente
Results of the study Our total 30-day stroke/death for 690 carotid interventions was 1.44%. Thirty days stroke rate were 2.9%, 0%, 1.9% in the F-CAST, C-CAST and CEA respectively (p=0.75). Thirty days cardiac events was 0% in CAST group versus 1.9% in the CEA group (p=0.32). 30-day mortality was 1.9% in all 3 groups. 5-year stroke free survival was 94.3% in CEA, 97.1% in F-CAST and 100% in C-CAST (p=0.55). 5-year stenosis-free rates were 97.7% in CEA, 100% in FCAST and 88.2% in C-CAST (p=0.01). 5-year re-interventionfree rates were 100% in CEA, 97.1% in F-CAST and 100% in C-CAST (p=0.46).
CERVICAL CAROTID ARTERY AND GROIN STENTING APPROACH VERSUS CAROTID ENDARTERECTOMY Dr E Hegazy1,
Dr M Dulai1, Mr W Tawfick1, Dr N ElSafty1, Ms N Hynes2, Prof S Sultan2
Conclusion of the study CAST technology is still evolving, however C-Cast provides a safer option with significantly less risk of peri-operative stroke and combined postoperative stroke, MI and death.
Vascular Institute, Galway, Ireland, 2Western Vascular Institute & Galway Clinic, Galway, Ireland
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1Western
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TOTAL PERCUTANEOUS ENDOVASCULAR REPAIR OF COMPLEX AORTIC DISEASES: A CASE-CONTROL ANALYSIS FROM THE IPER REGISTRY
Results Between January 2010 and December 2014, 2,381 femoral accesses were collected into the "IPER Registry". The subanalysis identified 225 femoral accesses carried out for complex aortic aneurysm in 147 patients (group A) [14 thoracoabdominal (9.5%), 52 descending thoracic (37.4%), 21 pararenal (14.2%) and 60 aortoiliac aneurysms (40.8%)]; in 61.7% accesses (139/225) ≥ 24F sheath device was used. The remaining 2,156 femoral accesses were performed for standard EVAR using current available infrarenal device (group B). Technical success rate was 97.3% in group A (219/225) vs 96.8% in group B (2086/2156), p = .45. The incidence of perioperative complications was 1.4% in group A (3/225) and .8% in group B (13/2156), p = .26. The overall incidence of locoregional complications and conversion at 30-day was .5% in group A (1/225) and .2% in group B (5/2156) (p = .45). Presence of femoral calcifications and femoral artery diameter ≤ 7mm resulted to be a predictor of failure in two groups at multivariate analysis.
Dr. Matteo Barbante1,
Dr. Roberto Bisceglie1, Dr. Gianluca Citoni1, Dr. Riccardo Ciattaglia1, Dr. Fabio Massimo Oddi1, Pr. Arnaldo Ippoliti1, Pr. Giovanni Pratesi1 1University
of Rome "Tor Vergata", Rome, Italy
Introduction Conclusion
Effectiveness of total percutaneous endovascular aortic repair (PEVAR) is an established technique during aortic endografting. However the use of this technique for complex procedures, including thoracic and thoracoabdominal as well as pararenal and aorto-iliac aneurysms, is still debated.
This study confirms the feasibility of PEVAR in complex aortic procedure with high technical success rate and low accessrelated complication comparable to PEVAR for standard aortic repair.
Objective
RECIRCULATION PATTERNS CAN PREDICT CAROTID STENOSIS PROGRESSION
The aim of this study was to perform a case-control analysis of percutaneous closure procedure from the IPER registry comparing standard and complex endovascular aortic procedures.
Fabiola del Oso1,
Materials
Dr. Esaú Martínez2, Dr. Jordi Martorell1
The percutaneous closure performed using either Prostar XL or Proglide devices (Abbott Vascular, Santa Clara California) during standard and complex aortic endografting.
1IQS
School Of Engineering, Barcelona, Spain, de Mataró, Mataró, Spain
2Hospital
Methods Clinical data of consecutive patients from “IPER registry” were analyzed. Study population was divided in two groups. Data of PEVAR carried out for complex aortic repair using thoracic, fenestrated, and branched endografts (Group A) were compared to PEVAR for AAA using standard infrarenal endograft. Early results in the two groups were compared with the ?2 test. Univariate and multivariate analysis to identify potentially significant predictors of technical failure in the whole study group was performed.
Carotid artery stenosis (CAS) is mainly the result of atherosclerotic changes of the vessel wall which find paramount incidence in patients with vascular risk factors such as hypertension, elevated blood lipid levels, diabetes mellitus or genetic susceptibility. CAS is directly associated with stroke and other ischemic manifestations of systemic atherosclerosis, such as myocardial infarction and peripheral
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Introduction
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Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
SYSTEMATIC CT-ANGIO SURVEILLANCE AFTER EVAR SHOULD BE PATIENTTAILORED
vascular disease. Clinical research has extensively proven that the carotid bifurcation is a locus prone to significant atherosclerosis, being the local hemodynamic environment a major factor capable of triggering the development of this disease.
Dr. Joel Sousa1,
Objectives
Dr. João Neves1, Dr. José Fernando Teixeira1, Prof. Armando Mansilha1
In order to provide a comprehensive vision of the influence of local hemodynamic parameters on stenosis progression, a computational simulation using patient-specific 3D models of diseased carotid arteries is to be performed. Secondary to that is to elucidate a tentative triggering mechanism for stenosis rooted in abnormal recirculation patterns in the vicinities of the carotid bifurcation.
1Hospital
de S. João, Porto, Portugal
Introduction Periodic imaging is of paramount importance for early detection of complications after EVAR and computed tomographic angiography (CTA) is currently the most used imaging technique, due to its excellent resolution and availability. Although standardized follow-up protocols have been created, the risk for adverse events differs between patients depending on their baseline anatomic characteristics. As such, the modality of surveillance may adapt to preoperative risk factors, in order to avoid increased costs and adverse effects. In our institution, EVAR follow-up is performed according to the SVS EVAR follow-up protocol.
Materials & patients Ten patients with different degrees of CAS evaluated at Hospital de Mataró for atherosclerosis were included. Subjectspecific computational models of their carotid bifurcations were generated after processing computed tomography images. Transversal section velocity in the common carotid artery was measured via doppler ultrasound (DUS) and used as input for computational simulation.
Methodology A pulsatile parabolic velocity profile was imposed on the computational 3D models of the carotid and blood flow along the whole geometry was simulated. Calculated velocity at the external and internal carotid outlets was compared with velocity measured with DUS. Tangential and circumferential shear stress, recirculation and vorticity along the bifurcation were analysed and compared with flow patterns in healthy volunteers.
Aims The aim of this work is to evaluate the utility of the one year follow-up CTA imaging control in patients without previous known endoleaks.
Materials Patients with isolated infrarenal abdominal aortic aneurysms (AAA) treated by EVAR with at least two post-operative CTA’s (at one month and one year follow-up) and without intra-operative endoleaks were included.
Results We have observed correlations between different recirculation patterns and the degrees of carotid lesion using a patientspecific quantitative approach to CAS. High recirculation regions may indicate rapid disease progression. Tangential shear stress correlated worse with disease progression.
Primary endpoints were re-intervention rate and significant aneurysm sac growth (>5mm). Pre-operative neck length, angulation and configuration as well as post-operative endoleaks were evaluated. Tapered, short (<15mm) or angulated (>60º) aortic necks were defined as hostile. Preoperative lumbar and inferior mesenteric artery patency, as well as iliac diameter and calcification were assessed. Patients with endoleak in the first CTA were included in an endoleak group (EG) and compared to the total cohort of patients (TG). Agreement between groups was estimated with Cohen’s Kappa.
Conclusions Novel hemodynamic parameters like recirculation can better correlate with carotid artery stenosis progression and prognosis. Comprehensive simulations of diseased vessels can help vascular surgeons in better decision-making. Further development of the technique can allow better personalization of carotid artery stenosis treatment.
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Methods
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
USE OF CARBON DIOXIDE (CO2) IN DIAGNOSTICS AND TREATMENTS: COSTEFFECTIVENESS OF THIS APPLICATION.
Results Ninety consecutive patients treated by EVAR between 2009 and 2014 were retrospectively analysed (94,4% male; mean age 73,27). Mean follow-up was 30 months [12-107]. Twentytwo patients (24,4%) died during follow-up, with one aneurysm-related death. The endoleak rate was 28,9%, with 4,4% type I endoleaks, 22,2% type II and 2,2% type III. 88,5% of the endoleaks were diagnosed in the first month control CTA. In only three cases, late endoleaks were found (2 type Ia endoleaks; 1 type II endoleak).
Dr. Fabio Pereira1,
Dr Fabricio Rossi1, Dr Pablo Mendes1, Dr Eduardo Roque3, Acd Victor Pereira2, Dr Carlos Daher1, Dra Lara Rossi1
Patients in the endoleak group (EG; n=23) were then independently analysed and compared to the general cohort of patients (TG; n=90). The majority of the primary outcomes were found in the EG with substantial agreement between the two groups (re-interventions: EG=4 vs TG=6; kappa=0,752, p=0,000 / significant aneurysm sac growths: EG=9 vs TG=14; kappa = 0,789; p=0,001).
1ICA
- Instituto Capixaba De Angiologia, Vitória, Brazil, - Universiddade de Vila Velha, Vila Velha, Brazil, 3Hosp Metropolitano, Serra, Brazil 2UVV
Since hostile aortic neck was found associated with higher re-intervention rates (p=0,041) but not precocious endoleaks, patients with hostile aortic neck and/or endoleak diagnosed in the first CTA were then included in a high risk (HR) subgroup (n=41). All re-interventions and 85,9% of the significant sac growths (12/14) were found in this group, with almost perfect agreement with the general cohort (Kappa = 1,000 and Kappa = 0,910, respectively; p=0,000).
The angiography is a diagnostic method that allowed advances in studiy of vascular diseases in all territories. All evolution observed is based in technical vevelopment of contrast media and your capacity of offer morbidity to the patients. The nefrotoxicicidade and allergies are major limiting factors to the radiology contrast-dependent. The use of carbon dioxide (CO2) as a mean of contrast in radiology exist already since 1971, and this use is largely documented and studied, showing no reactions referred with toxicicidade and allergies. These factors opened a new field for its application in diagnostic and vascular treatment, for allergics patients or with limitations pertaining to renal dysfunction. At the same time, we know that contrast-induced nephropathy (CIN) is a complication with one worrying prevalence, not only that as to the clinical perspective, but too institutional and economic. Although we nows that the nephropathy contrast-induced (NCI) it is being a major problem on contemporary practice, it's actual epidemiological impact is difficult to measure. This fact have many associated factors, one of these is the low rate of data registry. The incidence of acute renal damage associated with NCI is estimated between 1 to 2% in patients without primary renal damage and can reach 25% in patients with bigger risk due associated diseases (chronic kidney disease, diabetes mellitus, elders, use of nephrotoxic drugs). The contrast nephropathy Increases mortality in all the patients groups, at medium and long term the protective measures available are not effective, which increases the need for further diferent options for carrying out radiological contrast studies.
Finally, in the low risk subgroup - patients without endoleak in the one month follow up CTA and proper neck anatomy-, no aortic related adverse outcomes were reported at 30 months of follow-up, with 0% aneurysm-related deaths, endoleaks or re-interventions.
Conclusion Patients with proper pre-operative aortic neck anatomy and without endoleaks diagnosed in the first month control CTA have no late endoleaks, re-interventions or aneurysm-related deaths, and therefore assessment by means of CTA at one year follow-up is unnecessary. In the future, risk stratification will allow patient-tailored EVAR follow-up protocols.
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Intruduction
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
Objectives
SESSION
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These patients can benefit from the use of CO2, with less development of CIN that those who today do with the use of iodinated contrast media. Still, we need to open more the indication protocol for the use of CO2 as a means of radiologic contrast. Here we will propose evaluate the use of CO2 for performing diagnosis and treatment in these patients with limitations for use of nephrotoxic substances, and that require intravascular use of contrast, and still improve their rates of CIN. We will propose too formulate protocols for patients known to be increased the CIN through the characterization of the cost-effectiveness of this application.
Vascular Access
SURGICAL AND ENDOVASCULAR APPROACH IN HEMODYNAMIC STEAL SYNDROME Prof. Jose A. Gonzalez-Fajardo
Material
(Hospital Universitario Doce de Octubre, Madrid)
We are using the CO2 as a contrast media to perform endovascular procedures, angiography, angioplasty, and angio-tomography. We think it is necessary the use this like kind of contrast media at extended kinds of procedures for radiological diagnosis in patientes with renal risk and with need of angiotomography, now virtually restricted only to use in endovascular interventions.
Abstract
Method Use of the carbon dioxide for treatment and diagnosis in patients with risk for kidney disease through direct injection of CO2 to study the abdominal aorta, visceral arterial vessels (mesenteric, renal, celiac), leg and arms vessels (including arterio-venous fistula), and veins. We pretend to extend the use of carbon dioxide for radiological diagnosis in patientes with renal risk with need of angiotomography too.
Results The use of CO2 as a means of contrast is able to show images totally compatible with the accomplishment of the majority of the radiological procedures that require the use of contrast, due to its capacity to be innocuous when used in an appropriate way, besides allowing diagnoses commonly not accessible to the standard contrast medium, because of its low viscosity comparing with that one.
Conclusion CO2 is a contrast media that produces a negative image, not nephrotoxic, non ionic, non allergenic, without viscosity, used to perform procedures that require vascular contrast in patients with high risk to kidney failure or that have allergy to iodinated contrast, or to reduce the volume of contrast used in long procedures.
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Access induced ischemia is an uncommon but devastating complication for patients maintained on hemodialysis. The construction of an arteriovenous access results in a predictable decrease in the perfusion pressure distal to the anastomosis, which can result in ischemia if the compensatory mechanisms are inadequate. Because many of the signs and symptoms are nonspecific, the diagnosis can be aided in equivocal cases with noninvasive vascular laboratory studies. A digital / brachial <0.45 index is suggestive of severe ischemic syndrome and is usually associated with pain at rest and / or trophic lesions on the fingers. The treatment goals are to reverse the hand ischemia and to preserve the access. There are a variety of different treatments, including correction of the inflow lesion, access ligation, limiting the flow through the access (Banding), distal revascularization with interval ligation (DRIL), revision using distal inflow (RUDI) or proximalization of arterial inflow (PAI). The optimal choice should be based on hemodynamic mechanisms and severity of symptoms in conjunction with the access type and patient comorbidities. A review of the underlying pathophysiology and treatment options will be provided. To date, the DRIL procedure has been the most consistently successful strategy. However, the particular circumstances of each case demand an individualization of treatment.
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
OPEN OR ENDOVASCULAR TREATMENT OF ANASTOMOTIC STENOSIS?
PRIMARY BALLOON ANGIOPLASTY OF SMALL VEINS IMPROVES AVF PATENCY
Dr. Jose Ibeas
Prof. Pierfrancesco Veroux
Parc Tauli Sabadell, Hospital Universitari. Sabadell, Barcelona
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.
Arteriovenous fistula (AVF) stenosis in haemodialysis must be corrected to ensure a flow that allows appropriate dialysis quality, to prevent the appearance of thrombosis and to increase access patency. Stenoses can be treated using endovascular methods (percutaneous transluminal angioplasty, PTA) or using surgical treatment. PTA is advantageous as it can be carried when performing the fistulography and preserves the vascular tree unlike surgery. On the other hand, however, it has a higher reincidence rate in comparison to surgical review. Surgical option, creating a new proximal anastomosis, shows more long-lasting results and does not require added procedures. However, it consumes part of the vascular tree. In treatment for juxtaanastomosis stenosis, which represents most AVF stenoses, there are no clinical trials comparing angioplasty with surgery and studies are usually in non-.controlled series. The only data available pertaining to controlled studies come from few retrospective studies of clinical series, with nonhomogenous results and a metanalysis which includes the previous series. This works find better results in surgery with reference to primary patency, with no difference in assisted patency.
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 x 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.
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.
In summary, although angioplasty can prolong vascular access life without significant differences in relation to surgery, the latter has improved primary patency with lower procedures to maintain assisted patency. So until now the surgical procedure seems more cost effective, although studies with a large enough sample size are needed to establish the indication.
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Results
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
patients a reduction technique was used. In the remaining 5 patients due to proximal occlusion of Anonimous Venous Trunk was not possible to assure patency of outflow line. In all of these patients the AFV closure was necessary.
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.
Conclusions Upper-limb elephantiasis, in presence of AVF for hemodialysis depends by high flow and out line flow stenosis. Conservative approach include Pta/stenting of proximal vein stenosis and open or endovascular reduction of high flow anastomosis.
UPPER-LIMB ELEPHANTIASIS DUE TO HIGH-FLOW AVF: WHICH TREATMENT? Prof. Pierfrancesco Veroux
SESSION
22
Purpose Upper-limb elephantiasis can develop in patients with ipsilateral high-flow AVF for hemodialysis and severe stenosis in the main outflow line of the Thorax, expecially in case of inadequate collateral pathways. The standard treatment include some techniques leading to AVF closure. The purpose of this study was to evaluate feasibility of endovascular or hybrid conservative treatments.
What,s new in carotid stenting?
UPDATE ON ASYMPTOMATIC CAROTID TRIALS Richard Bulbulia MA MD FRCS
Consultant Vascular Surgeon, MRC Population Health Research Unit, CTSU, Nuffield Department of Population Health, University of Oxford
Methods All patients with a well functioning AVF and ipsilateral upperlimb elephantiasis underwent an ECD at the site of AVF anastomosis, outflow vein and of Axillary and Succlavia veins, in order to detect anastomosis anomalies including stenosis and hemodynamic patterns and stenosis in the outflow line. In cases of suspected Anonymous Trunks or Superior Vena Cava occlusive diseases an Angio Ct scan was performed.
There are two critical questions in the management of asymptomatic patients with a significant carotid artery stenosis: “Procedure v No Procedure”: Should patients undergo a carotid procedure in addition to triple medical therapy (ie, anti-platelet therapy, statins and anti-hypertensive drugs) or should they just receive medical therapy alone?
The outflow line stenosis were first treated using PTA or Stenting. The reduction of AVF high flow were performed in case of inadequate results and persistence of limb oedema. The flow reduction techniques include endovascular partial occlusion of AVF anastomosis or open bending or reanastomosis.
“Surgery v Stenting”: If intervention is considered necessary, should it be carotid endarterectomy or carotid artery stenting?
The results of a recent IPD meta-analysis including over 5000 patients randomised to CEA v Medical Therapy in the VACS, ACAS and ACST-1 trials will be presented, and the rationale and progress of two ongoing trials (CREST-2 and ECST-2) comparing carotid intervention with contemporary medical therapy will be discussed.
Results Between January 2010 and December 2015, 15 consecutive patients with high flow AVF develop a ipsilateral upper-limb elephantiasis. In all patients was documented a severe stenosis or occlusion of out-flow line. In ten patients an endovascular procedure were performed. In all of those
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“Procedure v No Procedure”:
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
Concerning asymptomatic disease surgical indication is being reduced and our focus has shifted to select a high stroke - risk patient and stenosis, where intervention could be justified. Mapping of the lesion by identifying markers of plaque activity, severity of stenosis and bilateral involvement have been adopted in our practice with EAI (Enhanced Activity Index) of the plaque using High-Definition computer assisted Ultrasound (HDU) , to improve selection for intervention. CEA has been favored, surgical risk < 0.5% thus confirming that our strategy may yield better stroke prevention than OMT in this selected group of patients.
“Surgery v Stenting”: Recent reports of two North American trials that directly compared CEA vs CAS (CREST-1 and ACT-1) suggested both procedures conferred similar long-term protection against stroke, but were underpowered to detect a clinically meaningful difference. The ongoing ACST-2 trial is randomising asymptomatic patients to CEA vs CAS and will complete recruitment (n=3600) by the end of this decade. This trial will quadruple the evidence base for this important question and guide carotid practice throughout the 2020s and beyond.
Therefore, my way suggests that CEA is still the best method to prevent stroke in symptomatic patients with stenosis > 70% and also in highly selected and restricted group of patients with asymptomatic disease.
CAROTID STENOSIS – MY WAY J. Fernandes e Fernandes, MD, PhD, FACS, FRCS Eng, FESC, FEBVS
EMERGENT CAROTID REVASCULARIZATION: WHEN AND HOW?
Carotid disease continues to be an important cause of stroke in the western population. Neurological risk is higher in symptomatic patients, within the first week after the neurological event either a TIA or a minor stroke as demonstrated by the Oxford Vascular Study (2004). The neurological risk in asymptomatic carotid disease has been reduced very significantly due to improvements of medical management (OMT) and the subsequent need for carotid endarterectomy (CEA) or stenting (CAS) to prevent a stroke has lost favor within the vascular community, the indications of intervention being restricted to high risk group. Guidelines from different scientific societies, published reports from RCT’s and Registries have outlined the indications for carotid surgery, the selection criteria being the degree of stenosis >70 % and early intervention in symptomatic disease, CEA yielding better outcomes than CAS.
Prof. Francesco Speziale1,
Dr. Dr. Dr. Dr. Dr.
Laura Capoccia1, Pasqualino Sirignano1, Wassim Mansour1, Chiara Pranteda1, Martina Formiconi1
1Vascular
Carotid endarterectomy (CEA) in recently symptomatic patients can be performed at different time-points, depending on the goals of carotid (and brain) revascularization. We generally refer to early CEA when carotid revascularization is performed within 14 days from the onset of carotid-related neurological symptoms, very early or urgent CEA,when the intervention is performed within 48 hours, and emergent CEA when the intervention is performed within the first 6/12 hours from the onset of symptoms. Among the aims of early CEA we count the possibility of improving overall cerebral perfusion, reducing cumulative neuronal loss by restoring blood flow to the ischemic penumbra, removing a source of ongoing embolism, and preventing early progression of carotid stenosis towards thrombosis. If the two latter aims can be considered preventive, and they are common to all
In our experience CEA has been favored in symptomatic patients, aiming to perform it within one week following the neurological signal event, based on C-F Duplex Scan to measure severity of stenosis and brain CT-scan to assess the presence of brain infarcts and its size. The overall hospital neurological morbidity plus mortality was 2.1 % which was not different from 1.5 % in our previous experience, thus confirming that early treatment was not associated with increased stroke risk. Technical details and the value completion assessment will be discussed.
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and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “La Sapienza” University of Rome, ITALY
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Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
carotid revascularization procedures, the two former goals can be considered an attempt to be effectively curative to the brain, and are peculiar only of expedite CEA. Benefits of prompt carotid revascularization should always be balanced with risks that include the increased risk of intraoperative embolism, the reperfusion of brain zones with loss of autoregulation, the risk of hyperperfusion, and, above all, the hemorrhagic conversion of the brain acute infarct.
for the best treatment possible, including carotid revascularization in emergency. Urgent carotid duplex US (or supraortic vessels AngioCT in combination with brain images) just requires few minutes, and it can also be performed during systemic fybrinolytic agent administration whenever indicated. The ideal patients that can benefit from an emergent CEA are those with unstable symptoms: crescendo-TIA (cTIA) patients and those with a stroke-in-evolution (SIE). If Stroke guidelines suggest to perform expedite CEA in cTIA patients, SIE patients are still considered at high and prohibitive risk for emergent/urgent CEA, because of fear for brain ischemic area conversion into cerebral hemorrhage. Nevertheless, whenever carotid-related unstable symptoms are diagnosed, an expedite revascularization can be offered to the patient, since the risk of intracranial hemorrhage in CEA after thrombolysis is reported to be extremely low in major published series. In order to keep this brain risk to a minimum, a strict protocol should be developed in each hospital providing stroke treatment, with well-defined inclusion and exclusion criteria for emergent CEA.
In order to treat promptly a carotid plaque causing symptoms the real difficulty in most hospitals is to diagnose the cause of the stroke - the unstable carotid plaque - within the first hours after hospital admission, since no guidelines suggest to perform a carotid imaging in an emergent setting. At present, Stroke guidelines suggest to treat the brain in the very first hours following neurological deficit, ignoring the diagnosis of the cause that is generally postponed. Only in hospitals that can offer a 24 hours/7 days urgent duplex ultrasound service, or that can afford the costs of performing an AngioCT of supraortic vessels together with advanced brain images in the emergent setting, the diagnosis of an embolic carotid plaque could be made. And only once the diagnosis is made, stroke specialists can discuss and decide
Table. Urgent/emergent CEA protocol in use a tour Vascular and Endovascular Surgery Division Inclusion criteria
Clear time of onset of symptoms NIHSS score < 22 Recent ischemic hemispheric brain infarct < 1/3 of the middle cerebral artery area regardless of BBB disruption at CT or MRI scans ICA stenosis ³ 50% at US evaluation Patent middle cerebral artery in the detectable portion M1 and M2
Exclusion criteria
Not clear time of onset of symptoms
According to clinical presentation on admission
Severe neurological deficit (NHISS score > 22) Cerebral ischemia onset with seizures Previous ischemic or hemorrhagic stroke with residual severe deficit (Modified Rankin Scale³2) History of cerebral haematomas Any other cerebral disease with residual permanent deficit Recent ischemic hemispheric brain infarct > 1/3 of the middle cerebral artery area Presence of cerebral haemorrhage Brain tumor Cerebral arterio-venous malformation Cerebral aneurys
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According to CT or MRI scans on admission
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
At our Vascular Division in Rome, we developed an emergent/urgent CEA protocol that is mainly based on the grading of the presenting neurological symptoms by the National Institute of Health Stroke Scale (NIHSS score), and on the detection and measurement of the brain ischemic area, whenever present (Table). We reported in literature our experience of emergent/urgent CEA in 22 cTIA and 26 SIE patients treated between January 2005 and December 2009. Outcome measures in this prospective, single-center experience were perioperative (30-day) neurological mortality, NIHSS score variation, and hemorrhagic or ischemic stroke recurrence. Patients were evaluated according to clinical presentation (SIE or cTIA), timing of surgery, and presence of brain infarction on neuroimaging. CEAs were performed from 1 to 24 hours
TW2
Fenestrations: Lumen more than 17 mm, not in angulated anatomy, not if there is thrombus in the sealing and fenestrated zone
Top secret sessions for you talent AAA
It is very useful when one or more branches are precannulated. There are two options to access to the visceral arteries:
F-EVAR, DEVICE OPTIONS AND MY PERSONAL CHOICE
Proximal from the axillary artery Distal from the femoral artery
Dr. Luis Miguel Salmerón
Indications for F-EVAR: Yuxta-renal AAA without neck Infra-renal AAA with hostil neck: Length <10 mm, angulation > 60º, thrombus, reversed taper, etc. Thoraco-abdominal AA affecting visceral arteries. Ou et al. (1) made a systematic review of F-EVAR for juxtarenal and short-neck aortic aneurysm and concludes that fenestrated endovascular repair is a safe and efficient treatment, particularly for those deemed surgically high risk, but contemporary published literature does not produce a high enough level of evidence that leads to a change in treatment guidelines for juxtarenal or short-neck aneurysm. However, for patients older than 70 years with prominent risk factors, it may be a valid option. There are several options for F-EVAR: External branches: Lumen more than 27 mm, even in angulated anatomy
In my experience it is easier to access the visceral arteries from the axillary artery. You can have a silicone model of the aneurysm to treat and that can facilitate the case. There is potential for the loss of target vessels during or after f-EVAR procedures. Loss of a target vessel may lead to loss of its respective organ. The risk associated with this technique is mainly due to branch vessel ischemia or occlusion. The risk of kidney loss in some series of f-EVAR studies was 1.5% and the risk of mesenteric ischemia was 3.3%. Endoleak occurs in 22.5% of patients (all types) and about 8% of these require treatment. Most of the interventions performed to treat such endoleaks conducted using a minimally invasive approach. Due to the complexity of the technique, patients must be appropriately selected for f-EVAR, the procedure performed by highly experienced operators, and in centers with advanced, high-resolution imaging systems to minimize the risk of complications (2).
References 1. Ou J, Chan YC, Cheng SW. A Systematic Review of Fenestrated Endovascular Repair for Juxtarenal and Short-Neck Aortic Aneurysm: Evidence So Far. Ann Vasc Surg. 2015 Nov;29(8): 1680-8. 2. Shahverdyan R, Majd MP, Thul R, Braun N, Gawenda M, Brunkwall J. F-EVAR does not Impair Renal Function more than Open Surgery for Juxtarenal Aortic Aneurysms: Single Centre Results. Eur J Vasc Endovasc Surg. 2015 Oct;50(4):432-41
Internal branches: Lumen more than 22 mm, even in angulated anatomy
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SESSION
from onset of symptoms (mean, 10.16 ± 7.75). An ischemic brain lesion was detected in 4 patients with SIE and 8 patients with cTIA. All patients with cTIA presented a persistent NIHSS normal score before and after surgery. Twenty-five patients with SIE presented an NIHSS score improvement after surgery. Mean NIHSS score was 5.30 ± 2.81 before surgery and 0.54 ± 0.77 at discharge in the SIE group (P < .0001). One patient with SIE had a hemorrhagic transformation of an undetected brain ischemic lesion after surgery, with progressive neurological deterioration and death (2%). So, despite current guidelines do not support a policy of emergent CEA, a strict selection protocol could help identifying patients that can benefit from the intervention, and defining the role of emergent CEA.
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Simposio Internacional sobre Terapéutica Endovascular International Symposium on Endovascular Therapeutics
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
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SESSION
Hot Topics in Thoracic Endografting
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IMPACT OF HYPOTENSION AND SHOCK ON THORACIC AORTIC DIAMETER AND ENDOGRAFT SIZING FOR BTAI
Free papers Thoracic Aorta
EXTENSIÓN DEL SELLADO AÓRTICO EN EL TRATAMIENTO ENDOVASCULAR DE LAS DISECCIONES AÓRTICAS TIPO B Mr. Jose Damián Herrera Mingorance1,
Dr. Frank J Criado
Mr. Rafael Ros Vidal1, Ms. Silvia Lozano Alonso1, Mr. Eduardo Ros Die1, Mr. Jorge Bartolomé Cuenca Manteca1, Mr. Luis Miguel Salmerón Febres1
While not amply documented, there is a growing small body of evidence indicating that the diameter of the thoracic aorta, especially the descending aorta, is greatly impacted by hemodynamics within the vessel. Specifically, severe hypotension and hypovolemia can induce significant decrease in the measurable size (diameter) of the aorta, particularly so of course in younger individuals where the aortic wall is healthy and flexible such as we encounter in the treatment of victims of BTAI (blunt thoracic aortic injury).
1Unidad
Gestion Clínica de Angiología y Cirugía Vascular de Granada, Granada, Spain
Introducción el tratamiento endovascular de la disección aórtica tipo B de Stanford ha consistido clásicamente en el sellado exclusivo de la puerta de entrada proximal. En los últimos años la tendencia más generalizada es a realizar un sellado aórtico más extenso.
I tis not hard to imagine such events having a major impact in the process of endograft sizing for TEVAR treatment of BTAI, with the implied risk of unintentional under-sizing that could result in a suboptimal outcome. The available evidence will presented and summarized during the talk, and a set of guidelines and recommendations offered to the audience to optimize patient management in such situations.
Objetivo determinar las diferencias clínicas y de remodelado aórtico según la amplitud de cobertura aórtica realizada en el tratamiento endovascular de las disecciones tipo B de Stanford.
Material estudio analítico retrospectivo sobre 68 pacientes (8 mujeres, 11.6%) con una edad media de 61.1±11.1 años, intervenidos de manera endovascular entre los años 2003-2016 por disección aórtica aguda/subaguda (DAA, n=45) o crónica (DAC, n=23).
Metodología se recogen variables demográficas y patologías concomitantes, procedimiento realizado, complicaciones, morbimortalidad y remodelado aórtico durante el seguimiento. Se divide la muestra en aquellos con sellado exclusivo de la puerta de entrada de la disección en aorta torácica (grupo
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SESSION
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Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
1, G1, compuesto por 22 DAA y 23 DAC) y aquellos con un sellado más extenso (grupo 2,G2, compuesto por 12 DAA y 11 DAC). Se comparan G1 y G2, realizando un análisis por separado para disecciones agudas o crónicas.
Introduction The application of the SMFM in treating SCTBAD is, less known in regard to this technology’s potential to manage chronic dissections. It was reported that this device instigates the process of aortic remodelling and patent branch perfusion after implantation.
Resultados El seguimiento para las DAA fue de 34.6±43.3 meses. Se encontraron diferencias en la creatinina basal (G1:1.12±0.37, G2:1.54±0.73, p=0.02), el uso de contraste (G1:183.3±107.8cc, G2:283.4±111.6cc, p=0.03), la paraplejia (G1:9.8%, G2:0%, p=0.06) e isquemia aguda (G1:18.2%, G2:0%, p=0.03) postoperatorias, el fracaso renal agudo (G1:22.5%, G2:55.9%, p=0.02) y el ingreso prolongado (G1:17.7±11.5días, G2:11.3±5.3días, p=0.03). No hubo diferencias en la morbimortalidad y reintervenciones.
Objectives Managing symptomatic chronic type-B aortic dissection (SCTBAD) by the streamliner multilayer flow modulator (SMFM) is akin to the Provisional ExTension To Induce COmplete Attachment Technique (Petticoat), but with the ability of aortic remoulding. This study is investigating the SMFM’s capability to enact healing of SCTBAD.
Material used
El remodelado aórtico fue mayor en el G2, especialmente en aquellos con stent transvisceral (n=11) y en las DAA comparadas con las DAC. La degeneración aneurismática fue menor en G2 (G1:18.2%, G2:4.3%, p=0.06).
Clinical data for twelve cases comprising of pre/post-operative treatment of SCTBAD, was obtained from a multi-centre database hosted by the MFM® Global Registry, Ireland.
Methodology used
Conclusiones
A biomechanical analysis, by means of computational fluid dynamics modelling, of the haemodynamic effects and branch patency, associated with the use of the SMFM was performed for all cases. The dissections mean length was 30.23±13.3 cm. There were 30 SMFMs used, which covered 40 aortic branches.
según nuestra serie la cobertura aórtica amplia en las DAA se asocia a un mejor remodelado aórtico con menor riesgo de isquemia medular y de miembros inferiores, así como de degeneración aneurismática durante el seguimiento, sin diferencias en cuanto a la morbimortalidad.
Results of the study At 1-year follow-up, the true lumen volume increased from 175.74±98.83cm3 to 209.87±128.79cm3, while the false lumen decreased from 135.2±92.03cm3 to123.19±110.11cm3. The false lumen index decreased from 0.29±0.13 (pre-operative) to 0.21±0.15 (post-operative). The primary SMFM treatment of SCTBAD increased carotids perfusion by 35±21%, (P=0.0216) and suprarenal perfusion by 78±32%, (P=0.001). The wall pressure distribution, blended along the newly enlarged true lumen, while the false lumen wall pressure decreased by 6.23±4.81% for the primary group (cases 1–7) and by 3.84±2.59% for the secondary group (cases 8–12).
CFD ANALYSIS OF THE STREAMLINER MULTILAYER FLOW MODULATOR USING IN THE TREATMENT OF SYMPTOMATIC CHRONIC TYPE-B AORTIC DISSECTIONS Dr F Stefanov1,
Prof S Sultan2, Dr L Morris1, Ms A Elhelali1, Dr. Edel P Kavanagh2, Ms N Hynes2
SMFM reduces the false lumen wall pressure through flow modulation. It preserves all branches patency, minimising the incidence of the short-term complications. The SMFM is a valuable option in managing primary SCTBAD, without mid-term complications.
Mayo Institute of Technology, Galway, Ireland, Vascular Institute & Galway Clinic, Galway, Ireland
2Western
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1Galway
Conclusion of the study
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OUTCOMES OF CHRONIC SYMPTOMATIC AORTIC DISSECTION WITH THE STREAMLINER MULTILAYER FLOW MODULATOR
Results of the study: There were no reported ruptures or aortic related deaths. All cause survival was 85.3 % Twelve-month freedom from neurological events was 100%, and there were no incidences of end-organ ischemia, paraplegia or renal insult. Morphological analysis exhibited dissection remodelling by a reduction in longitudinal length of the dissected aorta, and false lumen volume. A statistically significant reduction in false lumen index (P=0.016) at 12 months, and a borderline significant increase in true lumen volume (P=0.053) confirmed dissection remodelling.
Prof S Sultan1,
Dr. Edel P Kavanagh1, Dr F Stefanov2, Ms A Elhelali2, Dr E Diethrich3, Ms N Hynes1
Conclusion of the study:
1Western
Vascular Institute & Galway Clinic, Galway, Ireland, 2Galway Mayo Institute of Technology, Galway, Ireland, 3Arizona Heart Institute, Phoenix, USA
The SMFM is an option in management of complex panaortic dissection. Results highlight SMFM implantation leads to dissection stabilization with no further aneurysm progression, and no retrograde type A dissection. TEVAR by SMFM ensued in freedom from aortic rupture, neurological stroke, paraplegia and renal failure. Further analysis of the global registry data will inform long-term outcomes.
Introduction The SMFM is a multilayered cobalt alloy bare metal implantable device. The 3 dimensional nature of the SMFM comprises multiple interlocked layers of wire, braided together to create a mesh. This mesh design alters blood flow from turbulent to laminar, inducing positive shear stresses along the aortic wall to promote endothelialisation along the luminal aspect of the SMFM and thrombosis of the aneurysm.
SYSTEMATIC REVIEW OF OPEN, HYBRID AND ENDOVASCULAR REPAIR FOR AORTIC ARCH PATHOLOGIES
Objectives Reported are initial 12-month outcomes of Chronic Symptomatic Aortic Dissection (CSAD) patients managed by the Streamliner Multilayer flow modulator (SMFM).
Ms A Elhelali1,
Ms N Hynes2, Dr F Jordan3, Dr. Edel P Kavanagh2, Prof S Sultan2
Material used
1Galway-Mayo
Institute of Technology, Galway, Ireland, Vascular Institute & Galway Clinic, Galway, Ireland, 3National University of Ireland Galway, Galway, Ireland
Out of 876 SMFM implanted globally, we have knowledge of 542. To date, 312 patients are maintained in the global registry, of which 38 patients were identified as having an aortic dissection (12.2 %). Indications included 35 Stanford Type B dissections, 2 Stanford Type A and B dissections, and 1 mycotic Stanford Type B dissection.
2Western
Aneurysm and dissection of the aortic arch are devastating diseases with 10.4 cases per 100,000 person-years, and 6 cases per 100,000 person-years recorded, respectively. Incidences are predicted to rise further. Current surgical techniques for treating these diseases include open surgical repair (OSR), hybrid repair (HR) and purely thoracic endovascular repair (TEVAR).
Methodology used: Patients data and CT’s were analysed using kaplain-Meier analysis and morphological analysis to establish freedom from rupture and aortic related death, reduction in false lumen index, patency of great vessels and visceral branches, and freedom of stroke, paraplegia, and renal failure.
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Introduction
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SYNGO I FLOW IMAGING TECHNIQUE DURING TEVAR FOR TYPE B CHRONIC AORTIC DISSECTION
Objectives This study aims to examine the safety and effectiveness of open surgical repair (OSR), hybrid repair and thoracic endovascular repair (TEVAR) in patients with aortic arch pathologies.
Dr. Giovanni Tinelli1,
Material used
Dr Alessandro Sticchi1, Dr Fabrizio Minelli1, Pr Francecso Snider1
An extensive electronic literature search was undertaken using EMBASE, PubMed, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews.
1Vascular
and Endovascular Unit. CardioVascular Department. Fondazione Policlinico Universitario A Gemelli - Catholic University Roma, ROMA, ITALIA
Methodology used We performed a meta-analysis to estimate the strength of the association according to the PRISMA-STROBE statement. The Newcastle-Ottawa Scale was used to assess the article quality.
Introduction Most of the technology development in the endovascular field concerns the imaging as helpful instrument of investigation and analysis. This is extremely important in the challenging treatment of the type B aortic dissection.
Results of the study Forty-three eligible studies with 6876 participants were identified. Hypertension, COPD, diabetes mellitus (DM) and cardiovascular disease (CVD) were significant risk factors across all three groups (P=0.001, P=0.033, P=0.006 and P=0.029 respectively). Pooled estimate for 30-day mortality, neurological events, paraplegia and renal impairment were significant for all three surgical interventions (P=0.0001). Thirty-day mortality was similar between OSR (4.67%) and hybrid repair (4%). Inhospital mortality was highest in the OSR group (9.40%), in comparison to hybrid repair and TEVAR with reported inhospital mortality at 7.1% and 0.72%, respectively. Stroke was 6.5% after OSR in comparison to hybrid repair at 5.9% and TEVAR at 2.1% (P=0.114), while paraplegia was reported similar in hybrid (1.77%) and TEVAR (1.52%), however paraplegia was reported in 0.52% of patients treated with OSR.
Objectives To study new software imaging in the type B aortic dissection
Material and Methodology used We report our first experience in four cases of a thoracic endovascular aortic repair (TEVAR) in the treatment of a type B chronic aortic dissection with the intraoperative analysis of the Syngo I Flow imaging software. We performed the treatments in our Hybrid Operating Room using the Siemens Artis Zeego angiography technology (Siemens Healthcare, Forchheim, Germany) and the Syngo workplace VC21B (Siemens Healthcare, Berlin and München, Germany) for the advanced imaging elaboration.
Conclusion of the study
Results of the study This technique can contribute to the strategic clinical decision
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The Syngo I Flow is a digital subtraction angiography (DSA) software released by Siemens in Hybrid Room Zeego; it elaborates in a single picture the media contrast dynamics contained in an angiogram. This image expresses through a colour code the equation of time and contrast media velocity diffusion. The imaging construction considers the time of maximum opacification of each pixel of the angiogram from the time of injection, therefore it gets a single informative picture about the distribution of the contrast medium through the vessels.
This study reported improved in-hospital mortality, stroke, and renal insufficiency for both hybrid repair and TEVAR. However paraplegia, stroke and mortality rates still remain noteworthy.
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offering instantaneously a single informative image of the angiographic phase during the treatment. We found this new imaging technic applied to the aortic dissections very helpful for the true and false lumen orientation and entry tear detection. The software analyses the contrast media diffusion highlighting the hemodynamic perspective before and after treatment.
Material used We retrospectively reviewed 60 patients who underwent TEVAR for complicated acute aortic dissection (AAD, n=29) and chronic aortic dissection (CAD, n=31) with a minimum CTA follow-up of three years. Inclusion clinical criteria were: signs of aortic rupture, malperfusion syndrome uncontrollable hypertension, anurysmal aortic diameter (>55 mm) and rapid growth (>10 mm/yr).
Conclusions of the study To the best of our knowledge, these are the first cases description of I Flow applied to the aortic dissection.
Patients with history of trauma, underlining inherited (eg. Marfan syndrome) and inflammatory disease (eg. Takayasu syndrome) were not included in this study, due to the specific nature of the aortic dissection.
ENDOVASCULAR REPAIR OF ACUTE AND CHRONIC AORTIC TYPE B DISSECTIONS: ANALYSIS OF FACTORS AFFECTING AORTIC REMODELING AND CLINICAL OUTCOME
Methodology used True lumen, false lumen, and total aortic short axis diameter were mesured with a semiautomatic method, above, at the level, and below the stent-graft. Six procedural factors such as: stent-graft oversizing, balloon dilatation after stent-graft deployment, number of stent-grafts implanted, length of covered thoracic aorta, coverage of left subclavian artery (LSA) and embolisation of LSA, were analyzed in relation to aortic remodeling
Dr Mariangela Santoni2,
Dr. Alessandro Cannavale1, Dr Marianna Gazzetti4, Dr Piergiorgio Nardis3, Dr Fabrizio Fanelli3
and other clinical outcomes. Comparison between continuous variables was made by Student's t test. Analysis of variance (ANOVA) was utilized to compare short axis, false lumen, and true lumen diameters during the follow-up period.
1NHS
Greater Glasgow And Clyde, Glasgow, United Kingdom, 2Department of Radiological Sciences, "Sapienza" University of Rome, Rome, Italy, 3Vascular and Interventional Unit, Department of Radiological Sciences, "Sapienza" University of Rome, Rome, Italy, 4Department of Vascular Surgery, "Sapienza" University of Rome, Rome, Italy
Univariate/multivariate analysis was used to assess relationship between procedural factors and multiple outcomes.
Results of the study A total of 100 stent-grafts were implanted in 60 consecutive patients with complicated AAD and CAD. Aorta remodeling consisting in false lumen thrombosis and shrinkage was more prominent in AAD than in CAD especially within the first 18 months. Of note, whole aortic size increased significantly above the stentgraft in AAD. Only in the AAD group increased aortic remodeling was signfficantly related to post-dilatation of the stent-graft. Type I and II endoleaks occurred in 17 patients (28%) and were inversely related to the LSA embolization after stent-graft deployment in the AAD, but not in the CAD.
Introduction Endovascular therapy in type B aortic dissection relies on covering the primary entry tear to initiate false lumen thrombosis, expand the true lumen and stimulate aortic remodeling in the acute phase and in preventing complications in the chronic setting. A recent issue is to understand long-term changes that occur in the stented segment and adjacent aorta in relation to different procedure techniques that may have influence on the future outcomes.
Aorta remodeling and occurence of endoleaks after TEVAR may be influenced by some procedural factors in patients with AAD such as post-dilatation with moulding balloon and LSA embolisation, but not in patients with CAD.
Objectives We sought to assess aortic remodeling after endovascular repair (TEVAR): in particular we investigated any factors that can potentially affect the clinical outcome and morphologic changes of acute and chronic type B aortic dissection.
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Conclusion of the study
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SESSION
CSC@SITE: News from the heart
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How to do it @ SITE: A Top Secret Session in thoracic endografting
HOW TO MANAGE MALPERFUSION SYNDROME IN ACUTE TYPE B DISSECTION
HOW TO PREVENT/SOLVE NEUROLOGICAL COMPLICATIONS DURING TAVI PROCEDURES
Prof. Germano Melissano
Dr. Luis Nombela-franco
Luca Bertoglio Andrea Kahlberg Enrico Rinaldi Roberto Chiesa
Abstract
From the Chair of Vascular Surgery “Vita – Salute” University, Scientific Institute H. San Raffaele Milan, ITALY (Chief of Department Prof. R. Chiesa)
Introduction of transcatheter aortic valve implantation (TAVI) has resulted in a paradigm shift in the treatment of symptomatic patients with intermediate-high risk or inoperable severe aortic stenosis. However this technique is not exempt of complications. Cerebrovascular events are considered as one of the most severe and worrisome complications after TAVI and are associated with poor prognosis. Their incident remains stable, or slightly lower, (around 2 to 4%) along time. However several studies report new cerebral lesions in a very high proportion of patients (~80%), which could be related with an increased risk of cognitive decline.
Please Address Correspondence to: Dr. Germano Melissano IRCCS H. San Raffaele Department of Vascular Surgery Via Olgettina, 60 20132 Milan, ITALY Fax: +3902.2643.7148 - PHONE. +3902.2643.7146 e-mail: g.melissano@hsr.it
Factors associated with very early cerebrovascular events seem to be related with maneuvers during the procedure (manipulation of the aortic valve and arch), but subacute events are probably more related with atrial arrhythmias and other comorbidities. We discuss several preventive strategies of this complication with different and complex mechanisms.
Objective To evaluate feasibility and safety of the PETTICOAT (Provisional ExTension To Induce COmplete Attachment) technique for type B aortic dissection, and its early and midterm technical and clinical success rate.
Methods From June 2005 to present, the PETTICOAT technique has been employed in 41 selected cases (31 men, median age of 58 yrs (range: 30 – 81) of type B aortic dissection with a compression or collapse of the true lumen. All procedures were performed under general anesthesia with perioperative cerebrospinal fluid drainage in 9 patients. Supra-aortic vessels re-routing was performed in 13 cases to obtain an adequate proximal landing zone: eleven cases of left carotidsubclavian artery bypass and two case of right to left common carotid artery bypass and left subclavian to common carotid artery bypass. Clinical follow-up visit and CT scan were obtained at 1, 6 and 12 months, and yearly thereafter.
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Results:
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A 30-day clinical success was achieved in 37 cases (90.3%): two case a type IA entry flow, one death for respiratory failure was observed and one open conversion for retrograde dissection. No mortality was recorded. Occlusion of visceral/renal arteries or device-induced tears in the intimal lamellae was not observed. Peri-procedural morbidity included temporary renal failure in 2 cases and postimplantation syndrome with fever and leukocytosis for 23 days in 1 case. One case of delayed paraparesis was recorded (2,4%). At a median follow-up of 34 months (R. 2 – 67 months), we observed a clinical success rate of 92%. No late occlusion of visceral or renal arteries or device was recorded at follow-up, one case of retrograde aortic dissection has been treated surgical after 3 months. Volumetric analysis of the lumina demonstrated the following relationship in the TL lumen: baseline 84 ± 29 cm3, postoperative 167 ± 31 cm3 (+98%), 1 year 193 ± 46 cm3 (+131%) and 2 years 216 ± 54 cm3 (+140%). FL lumen relationship were: baseline 332 ± 86 cm3, postoperative 286 ± 85 cm3 (-14%), 1 year 233 ± 81 cm3 (-30%) and 2 years 248 ± 112 cm3 (-32%).
Venous Forum: Chronic Venous Disease: ablation techniques and sclerotherapy; Future perspectives in varicose vein therapy
VENTAJAS DEL PROCEDIMIENTO ENDOLÁSER FOAM ABLATION PARA TRATAMIENTO DE VARICES TRONCULARES. (ELAF) Dr. Carlos Boné
Boné Salat. C. (1) Palma de Mallorca .Barcelona. Madrid. 1.Carlos Boné Salat. Centro de Tratamiento de Venas. C/ Baró de Pinopar nº 7-3ª 07012 Palma de Mallorca. Islas Baleares., Spain. E-mail : bone@doctorbone.com Propósito de la investigación: Comunicar la evolución y las ventajas del tratamiento sinérgico Endoláser y Espuma de esclerosante para el tratamiento ablativo de las varices tronculares de MMII.
Conclusions Our peri-operative and midterm follow-up results showed that the PETTICOAT technique for the treatment of aortic dissection can be safely used without affecting patency of the branches covered by the bare stent. A significant immediate increase in TL could be achieved with resolution of cases of dynamic malperfusion. Progressive remodeling of TL was recorded over the time with shrinkage of the FL mainly in the thoracic segment. However, these results need to be validated on a larger group of patients with a longer follow-up.
Materiales y Métodos Desde febrero del 2013 hasta la actualidad, se han tratado con esta técnica sinérgica ( Elaf ) 263 pacientes con una edad media de 47 años , sexo femenino predominante. Se han tratado 237 venas safenas internas y 26 venas safenas externas con reflujo superior a 1 segundo. El diámetro 1/2 tratado ha sido de 13.8 mm. Se han utilizado 3 longitudes de onda ( 810, 980 y 1470 nm ) mostrando mayor practicabilidad la de 980 nm, la energía liberada ha sido con una potencia de 1.5 w durante 3 segundos y con una fluencia máxima en todo el trayecto de 400 joules/cm2, el esclerosante utilizado en forma de espuma ha sido el polidocanol en concentración de 1.5% con un volumen medio de 4 ml.
Se ha utilizado una fibra óptica con doble canal y un difusor en el extremo distal específico para este tratamiento exclusivo (Veinlaf ) Pat.pendent. y/o un catéter simple de doble luz que también nos permite introducir la fibra óptica y administar la medicación .
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Solamente se utiliza anestesia local ( lidocaína al 1% ) en el punto de entrada de la fibra óptica.
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La administración de la medicación a baja concentración y la liberación de energía a baja fluencia ha sido de forma sinérgica.
7. Boné C. Historia y evolución de la aplicación de la técnica del láser endovenoso en el tratamiento de las varices. Angiología 2005;57 ( Supl I ) 527-530.
Resultados
8. Vuylsteke M.E., Mordon S.R. Endovenous laser ablation: a review of mechanisms of action. Ann. Vasc. Surg. 2012 ;26(3) : 424-433.
A la semana de control ecodoppler post-tratamiento, la oclusión y ausencia de flujo fue completa y a los dos años de control la fibrosis fue del 100% de los casos. De este modo se verifica la ablación completa con este método.
9. Frullini A. Fortuna D. Sclérothérapie à la mouse assistée par laser ( LAFOS ) : une nouvelle aproche pour le traitement de l´incompétence des veines saphènes. Phlébologie 2013,66,1,p.51-54. 10. Boné C. L´ Endolaser Ablation Foam ( ELAF), synergie d´action physico-chimique. Une nouvelle procédure pour le traitement ambulatoire des varices sans anesthésie locale. Phlébologie 2014,67,1,p. 26-29
Conclusiones Ante los resultados expuestos, es de destacar la seguridad, fiabilidad y éxito de esta nueva técnica. Se trata de un procedimiento estrictamente ambulatorio practicable en consulta médica con la asepsia pertinente. La ausencia de efectos indeseables así como de efectos secundarios nos permiten resaltar la gran eficacia de este tratamiento.
11. Smarandache A, Moreno J, Staicu A, Trelles M, Pascu ML . National Institute for Lasers ,Plasma and Radiation Physics, Bucharest http:// www.intechopen.com/books/nd-yaglaser/applications-of-polidocanol-in-varicose-vein-treatmentassisted-by-exposure-to-nd-yag-laser-radiatio
Somos conscientes de la necesidad de más estudios físicoquímicos para verificar la acción de la radiación láser sobre la espuma de polidocanol.
MECHANIC-CHEMICAL ABLATION FOR INTERNAL AND EXTERNAL SAPHENOUS VEINS. PROS AND CONS
Referencias 0 Orbach Ej. Sclerotherapy of varicose veins: utilization of intravenous air block. Am J Surg 1944:362-6 1. Cabrera Garrido JR, Cabrera-Olmedo JR, Garcia-Olmedo Dominguez MA. Elargissement des limites de la sclérothérapie: noveaux produits sclérosants. Phlebologie 1997; 50: 181-8.
Prof. Jose A. Gonzalez-Fajardo
(Hospital Universitario Doce de Octubre, Madrid)
3. Boné C. Tratamiento Endoluminal de las varices con láser de diodo. Estudio Preliminar. Revista Patología Vascular. Vol V. Enero 1999. Nº 1:31-39.
During the last decade, numerous minimally invasive methods have been developed for the treatment of venous insufficiency of the saphenous vein. These ablative methods have in common the percutaneous access, the use of locoregional anesthesia, short surgical times and satisfactory safety and efficacy results. However, these new endodermal techniques (laser or radiofrequency) require the use of tumescent anesthesia, which can be a source of discomfort and complications in the patient. Recently, a new mechanicalchemical system (Clarivein®) has appeared in the therapeutic arsenal of surgeons. This hybrid method minimizes the negative aspects of endothelial ablation, by eliminating anesthetic tumescence, and combines the application of an ecoguided sclerotherapy, which achieves venous occlusion by using a rotational disperser (3,500 rpm) within vessel lumen. This mechanical effect of intimal erosion induces
4. Navarro L, Mind R, Boné C. Endovenous láser : A New Minimally Invasive Method of Treatment for varicose veins. Preliminary observations using an 810 nm diode laser. Dermatol. Surg. 2001;27:117-122. 5. NavarroL, Boné C. L´energie laser intravenous dans le traitement des troncs veineux variqueux: Rapport sur 97 cas. Editions Phlébologiques Françaises, vol.54,nº3/2001,p.193200. 6. Boné C. Navarro L. Láser Endovenoso: una nueva técnica mínimamente invasiva para el tratamiento de las varices. ENDOLASER. Anales de Cirugía cardiaca y Vascular. 2001;7(3):184-188.
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2. Tessari L. Nouvelle technique d´obtention de la sclero-mousse. Phlébologie 2000 ; 53:129.
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vasospasm of the vein and greater efficacy of the sclerosant by agitating and extending the product in its walls. Although the results published so far indicate a rate of veno-occlusion of more than 90% and great safety (no venous thromboembolic events), its main drawbacks are the cost of the procedure and the occasional appearance of superficial thrombophlebitis, especially in patients with a Extrafascial or subdermal saphenous vein.
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Free papers Venous
POSTOPERATIVE PAIN AFTER ENDOVENOUS LASER TREATMENT WITH LASER WAVELENGTH 1470 NM AND 1560 NM IN PATIENTS WITH VARICOSE VEINS
CYANOACLRYLATE FOR VARICOSE VEIN TREATMENT: IS ITS COST JUSTIFIED? PROS AND CONS
Dr. Oleg Guzkov1,
Nikita Shichkin1, Natalya Tarasova1 1Yaroslavl
State Medical University, Yaroslavl, Russian Federation
Thomas M. Proebstle,
Dept. of Dermatology, University Medical Center Mainz, Germany and Private Clinic Proebstle, Mannheim, Germany
Introduction Laser wavelength 1560 nm is a new direction for treatment varicose veins. Data on the comparison of pain syndrome after EVLT between wavelength 1470 nm and 1560 nm are absent in the literature. This fact was the basis for a prospective study.
VenaSeal Cyanoacrylate Closure System is available in Europe since September 2011. Its efficacy has been proved by first-in-man feasibility and a European MultiCenterStudy. 3-Year results of these studies will be presented. Furthermore, a prospective randomize trial proved non-inferioprity in comparison to the well established ClosureFast/Venefit segmental ablation system.
Objectives Evaluation of pain syndrome after performing EVLT of GSV in the early postoperative period using wavelength 1470 nm and 1560 nm.
While CA for saphenous vein ablation is still expensive, the lack of nerve damage, the possibility to avoid tumescent local anesthesia during the procedure and the possibility to avoid postinterventional medical compression stockings makes it a very attractive alternative for many patients
Material used 316 patients (244 female) with primary varicose veins of the lower extremities. CEAP: C2 - C5. Patients age 21 to 79 years (Me 42,5; IQR 35-53). Methodology used: EVLT performed by diode laser 1470 nm (N=231) and 1560 nm (N=85). Assessment of pain was performed according to the visual analogue scale (VAS). The follow up was performed at 1, 3, 5, 7, 14 and 21 days after EVLT.
Comparing the two groups (1470 nm and 1560 nm), a significant difference between at various times after EVLT it was not detected. In the group where the used wavelength
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of 1470 nm, was an increase in the level of pain on 1st day after EVLT to 6% compared to preoperative pain from 3,3 to 3,6 points (p=0,03). On day 7, pain was lower values by 30% (p<0,0001). On the 14th and 21st day the pain was significantly lower in the 1,8 and 4,1-fold respectively. In the group with the wavelength 1560 nm decreased pain syndrome since postoperative days 3 to 29% (p=0,0006).
Objetivos
The median pain score was 2,5 (IQR 0-3,3). On the 7th and 14th day reduced pain by 49 and 74%, respectively. On the 21st day of the median pain score was 0 points, IQR 0-1,6, p<0,0001).
En los últimos 5 años (desde noviembre de 2011) hemos tratado en nuestro servicio 2173 pacientes consecutivos mediante radiofrecuencia con catéter Closure Fast, por presentar varices sintomáticas dependientes de insuficiencia de vena safena mayor, menor y/o anterior. Todos los pacientes estaban clasificados de CEAP 2 a 6.
Presentamos nuestra experiencia y los resultados obtenidos en nuestro centro en una seria de 2173 pacientes tratados con el catéter de radiofrecuencia Closure Fast.
Material
Conclusions of the study In applying the wavelength of 1470 nm was a significant increase in pain on the first postoperative day, while at the wavelength of 1560 nm is not amplified pain. A significant reduction in pain in the preoperative period was in both groups: at 1470 nm with 7 days of the postoperative period, and at 1560 nm with 3 days.
Métodos
RESULTADOS A CINCO AÑOS DE LA ABLACIÓN TÉRMICA CON RADIOFRECUENCIA PARA EL TRATAMIENTO DE LAS VARICES EN MIEMBROS INFERIORES
Resultados
Los casos se realizaron con tumescencia peri-venosa, 92% con sedación o anestesia raquídea, y en el 87% se realizó alguna técnica complementaria para el tratamiento de las tributarias varicosas (flebectomías o escleroterapia mediante foam de polidocanol). Se registró el éxito técnico de la intervención y se revisó a los pacientes a los 10 días, al mes, y a los 6, 12, 24, 36 y 48 meses. Los resultados se han analizado de manera retrospectiva.
Con un seguimiento medio de 38 meses, el éxito técnico de la intervención fue del 98,7%. La tasa de recanalización de la vena safena tratada fue del 2,2%. La tasa de reintervención debido a recurrencia de la enfermedad varicosa fue del 3,1%. La tasa de reintervención debida a recanalización de la vena safena fue del 1,3%. La reincorporación a la vida laboral fue de 3,4 días, obteniéndose una mejora en el VCSS de 5 puntos al año de seguimiento. No se observaron complicaciones mayores, objetivando un 6% de complicaciones menores.
Dr. Jose María Hípola1,
Dr. Dr. Dr. Dr. Dr.
Elena Pérez1, Silvia Limón1, Cristian Inglés1, Laura Balsalobre1, Juan Fontcuberta1
1Sanitas
Conclusión El tratamiento mediante la técnica de ablación térmica con radiofrecuencia con catéter Closure Fast ha demostrado ser seguro y eficaz en nuestra experiencia, con una baja tasa de complicaciones, baja tasa de recurrencia y recanalización de la vena safena y una rápida reincorporación a la actividad cotidiana.
Hospitales, Madrid, Spain
El tratamiento de la insuficiencia venosa mediante las técnicas endovenosas de ablación térmica, ya sea radiofrecuencia o endoláser, están ampliamente aceptados y constituyen el nuevo “gold estándar”.
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Introducción
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EVLA WITHOUT TUMESCENSE. PRELIMINARY SHORT AND MID-TERM RESULTS OF A PROSPECTIVE SERIE OF 120 PATIENTS USING 1470NM RADIAL FIBER.
anillo, de 1470nm de longitud de onda y energías por debajo de los 8W de potencia, sin tumescencia en todos aquellos casos en los que la anatomía de la VSI lo permitía. La gravedad de la enfermedad venosa crónica se determinó según la clasificación CEAP.
Resultados De los 120 pacientes incluidos en la serie 82 son mujeres y 38 varones. Ningún paciente tuvo dolor durante el procedimiento. Todos los pacientes fueron dados de alta en una media 2.5 horas después de la cirugía. Complicaciones menores: equimosis en región de punción, hipersensibilidad reversible en territorio ablacionado y parestesias cutáneas asociadas a las flebectomías reversibles 100%. Complicaciones mayores: quemadura 0,8% (1/120). Ningún paciente presentó TVP, TVS, FAV ni daño neurológico irreversible en el territorio safeno durante el seguimiento.
Dr. Rocío Láinez Rube1,
Dr. Rubén Rodríguez Carvajal1, Dr. Fernando Gallardo Pedrajas1, Dr. Patricia Hollstein Cruz1 1IVEI-
Hospital Quironsalud MarbellaCampo De Gibraltar, Cádiz, Spain
Introducción En los últimos años, los sistemas láser de mayor longitud de onda y nuevas fibras ópticas, han demostrado excelentes resultados a corto plazo en el tratamiento de las venas safenas y en la reducción de los efectos secundarios, en particular del dolor postoperatorio. Sin embargo, la anestesia local tumescente no garantiza un control completo del dolor si se asocian flebectomías al procedimiento, puede producir dolor y disconfort durante su ejecución y alarga el tiempo de ejecución. La realización de esta técnica mediante raquianestesia es segura, indolora y garantiza la realización de flebectomías asociadas efectivas pudiendo posibilitar la realización del procedimiento EVLA Sin tumescencia.
Conclusiones En nuestra experiencia, podemos decir que el tratamiento de la insuficiencia venosa mediante EVLA con fibra radial de doble anilllo y 1470 nm sin tumescencia es segura y eficaz, con un perfil bajo de efectos secundarios y complicaciones y una alta satisfaccio?n de nuestros a corto y medio plazo.
OBSTRUCCIÓN POSTTROMBOTICA CRONICA DEL FLUJO VENOSO ILIOFEMORAL. TRATAMIENTO ENDOVASCULAR MEDIANTE STENT.
Objetivos Demostrar la efectividad y seguridad del tratamiento de ablación laser endovenosa (EVLA) sin la utilización de tumescencia perivenosa.
Dr. MARIA AZUCENA Ayala Strub1,
Dr Luis Miguel Izquierdo Lamoca1, Dr Javier Rodriguez Padilla1, Dra Romina Zotta Desboeufs1, Dr Giussepe Corte1
Material Se incluyeron en el estudio 120 pacientes consecutivos intervenidos en nuestro Instituto de forma programada mediante dicho tratamiento endovascular, con diagnóstico de Insuficiencia Venosa Crónica sintomática estadios C2s-C6 de la CEAP.
1Angiologia
y Cirugía Vascular, Madrid, Spain
La trombosis venosa profunda que afectan a la vena ilíaca y de la vena cava desarrollan un síndrome post-trombótico más severo que aquellos con enfermedad femoropoplítea. Se ha tratado tradicionalmente sólo con terapia médica. Actualmente, la reparación endovascular se ha convertido en el tratamiento de elección.
Se realiza un estudio descriptivo prospectivo realizado entre febrero de 2015 y diciembre de 2016, seguimiento medio de 7,6 meses, analizando datos epidemiológicos, comorbilidad, resultados y complicaciones de dichos pacientes tratados mediante ablación láser endovenosa con fibra radial doble
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Introducción
Metodología
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ENDOVENOUS THERMAL ABLATION CAN BE USED TO TREAT GREAT SAPHENOUS VEIN OF ANY DIAMETER. VEIN SIZE IS NO REASON TO OPT FOR OPEN SURGERY.
Objetivo El tratamiento endovascular del síndrome postrombotico tiene el objetivo de mejorar la síntomatologia y calidad de vida de los pacientes
Material Se trata de un varón de 20 años de edad con antecedentes de múltiples accesos vasculares tanto centrales como periféricos en los ingresos hospitalarios prolongados en la infancia y antecedentes de TVP en MID, acude por varices importantes en MID y síndrome postróbotico iliofemoral bilateral
BSc Emma Dabbs1,
BSc Laurensius E Mainsiouw1, MD MS FRCS(Gen) FCPhleb Barrie A Price1, MS FRCS(Gen) FCPhleb Mark S Whiteley1,2 1The
Metodologia
Whiteley Clinic, Guildford, United Kingdom,
2University
of Surrey, Faculty of Health and Medical Sciences, Guildford, United Kingdom
Por vía femoral venosa bilateral se realiza recanalización e implante de 2 stents Zilver vena con la técnica de doble Barrel en VCI hacia ambas iliacas comunes extendiendo hasta hipogástrica en el lado derecho con 2 stents y en el lado izquierdo con 1 stent con el modelado posterior, posteriormente se extiende a femoral común derecha por encima del trocánter menor con 2 nuevos stents con buen control angiográfico final.
Introduction Endovenous laser ablation (EVLA) is a minimally invasive technique used in vascular surgery for the ablation of truncal venous reflux. Thermal ablation of the Great Saphenous Vein (GSV) has largely overcome the high varicose vein recurrence rate associated with high saphenous ligation and stripping. Despite this, the traditional surgical techniques still remain to be completely eliminated, with some practitioners classifying veins that have a large diameter, roughly classified between 8-15mm, as unsuitable for thermal ablation.
Resultados En controles posteriores en consultas, se observa retrombosis del sector iliaco venoso derecho sin empeoramiento de la clínica, por lo que se decide una nueva intervención. Por vía femoral derecha se realiza trombolisis fármaco-mecanica con TNK con angiojet con control angiografico suboptimo, por lo que se angioplastia con Balon con buen remodelado , pero con pequeña estenosis residual en vena femoral común, por lo que se implanta un nuevo stent con solapamiento de 3 cm con stent de vena iliaca externa, con buen resultado final. En un seguimiento de 11 meses, el paciente se encuentra bien con ambos ejes iliacos permeables.
Objectives To report on the distribution of GSV diameter treated by one consultant vascular surgeon, and the technique for ablating incompetent veins with wide diameters, using EVLA.
Material used GSV diameter measurements were obtained from all patients treated with EVLA by one consultant vascular surgeon over a time period of 5 years and 6 months.
Conclusión El tratamiento percutáneo de la obstrucción del flujo venoso post-trombótico es una excelente opción terapéutica con baja morbilidad y sin mortalidad. Se puede optener altas tasas de permeabilidad a medio plazo y mejoría clínica a medio plazo.
1470mn laser is percutaneously introduced into the distal GSV in the Seldinger technique. Tumescent anaesthesia is applied around, and throughout the length of the vein, to separate surrounding tissue, act as a heat shock, and enable appropriate venous constriction around the laser fibre tip. Tumescence and external compression by the ultrasound probe should concentrically compress the vein; if it has a wide diameter,
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Methodology used
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is an anionic surfactant that interacts with, and destroys the innermost venous endothelial cell layer. This exposes the underlying collagen, which activates the intrinsic coagulation cascade pathway, resulting in eventual vein fibrosis and reflux cessation. Many clinicians aspirate blood into the syringe upon procedure despite possible blood induced inactivation of STS, thereby consequentially injecting partially inactivated sclerosant.
the vein may constrict asymmetrically and develop lateral bulges, limiting the circumferential vein wall laser target. Therefore, multiple passes of the laser fibre into the various vein segments is necessary to achieve complete fibrosis and long-term venous occlusion.
Results of the study We analysed the vein diameter obtained from 2005 GVS’s (977 left and 1028 right) treated with EVLA. Venous diameter ranged from 2 to 42mm in the left leg, and 1 to 33mm in the right leg. Of this cohort, 16.66% (334/2005 (167/ 977 (17.1%) left GSV, 167/ 1028 (16.24%) right GSV)) was measured at 15mm or over, which is the upper limit for EVLA that has been recommended across the literature. All subjects returned approximately 8 weeks after this treatment to receive follow up ultrasound-guided foam sclerotherapy and upon examination the GSV was successfully occluded in all cases.
Objectives To quantify the volume of human blood needed to completely inactivate 1ml of sodium tetradecyl sulphate (STS), and comparing fresh blood and blood that has been stored in an ethylenediaminetetraacetic acid (EDTA) tube.
Material used 1000µl of 3% STS was measured into a 3ml syringe, and attached to a 3-way tap together with a 5ml syringe containing 3ml air. The stock solution contained 4ml foamed STS added to a set volume of blood, ranging from 0-1000µl in 250µl increments. 20ml stock solution, 15ml chloroform and 10ml Dimidium bromide sulphate was manually titrated against 0.004M benzethonium chloride (hyamine).
Conclusions of the study Thermal ablation of the GSV can proceed regardless of vein diameter when the multiple pass technique is applied, and whilst moderating for LEED. We suggest that open surgery should never be recommended and thermal ablation should always be administered for truncal venous reflux treatment.
Methodology used A series of manual titrations were carried out following a procedure developed at STD pharmaceutical products Ltd (Hereford, UK) and listed in the British Pharmacopeia. 3% STS stock solutions were made with increasing volumes of blood and titrated against benzethonium chloride to determine the active concentration (%w/v) of STS in solution.
IMPLICATION OF FOAM SCLEROSANT INACTIVATION BY HUMAN WHOLE BLOOD IN A LABORATORY SETTING
Results of the study A calculated approximation showed 0.3ml of blood is required to fully inactivate 1ml of 3% STS when made into a foam. A comparison was made between the use of fresh blood and blood stored in EDTA tubes. A two sample t-test (?=0.05) was performed on the two data sets and no significant difference in STS inactivation was found.
BSc Emma Dabbs1,
BSc Scott J Dos Santos1,2, BSc Laurensius E Mainsiouw1, BSc Alina A Sheikh1, BSc PhD Mike R Watkins3, MS FRCS (Gen) FCPhleb Mark S Whiteley1,2 1The
Whiteley Clinic, Guildford, United Kingdom, of Surrey, Faculty of Health and Medical Sciences, Guildford, United Kingdom, 3STD Pharmaceutical Products Ltd., United Kingdom
The data from our study has shown that a minimum of 0.3ml of blood is required to inactivate 1ml of 3% STS as a foam and it is not affected by storing blood in an EDTA tube. Our methodology suggests that during foam sclerotherapy treatment, blood should not be aspirated into the syringe to confirm position, and that ultrasound guidance is more appropriate for needle placement.
Introduction Sodium tetradecyl sulphate (STS) is a sclerosant used for ultrasound-guided foam sclerotherapy in the treatment of small varicose veins, and as a liquid for thread or spider veins. STS
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Conclusions of the study
2University
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SESSION
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Disaster cases: The worse ENDOVENOUS case of my life
GENERALIZED URTICARIA AFTER CYANOACRYLATE ABLATION OF THE GREAT SAPHENOUS VEIN OF A DENTIST
Generalized urticarial without Quincke Edema developed in a dentist days after cyanoacrylate occlusion of a Great Saphenous Vein. To control symptoms systemic corticosteroids were used for three weeks. In addition, systemic antihistamines were necessary for almost three months, before generalized urticarial disappeared.
Prof. Thomas Proebstle
Dept. of Dermatology, University Medical Center Mainz, Germany and Private Clinic Proebstle, Mannheim, Germany
TW3
low back pain, headache or rectal discomfort.
VEINS TRAINING SESSIONS. Site of Veins. How to do it sessions
Clinical examination can show vulvar varicosities, thickened cervix, cervical motion pain or ovarian palpation pain, as well as atypical leg varicosities.
Diagnosis
Pelvic venous congestion management
Abdominal ultrasound: Ovarian veins, compressive syndromes and pelvic varicosities. Transvaginal ultrasound: First choice to see pelvic varicosities. Criteria for pelvic varicosities are dilatation of pelvic veins, reverse flow within ovarian veins and dilated veins in the myometrium.
Dr. Esteban Javier Malo Benages
Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) provide visualization of the pelvic anatomy and compressive syndromes and could identify another causes of pelvic pain.
Introduction Chronic pelvic pain is one of the most common cause of women attending gynecology clinics. Pelvic congestion syndrome (PCS) is defined as chronic pelvic pain associated with pelvic varicosities and is one of the most common causes of chronic pelvic pain, together with endometriosis and pelvic inflammatory disease.
The venography is still the gold standard for the diagnosis of PCS, although it is usually performed to confirm the previous findings just before the pelvic embolization.
Treatment Pharmacologic agents to suppress ovarian function (medroxyprogesterone, gonadotropin-releasing hormone) have not proven long-term effectiveness.
Clinical presentation Although the most frequent symptoms of PCS are pelvic pain, dyspareunia and pelvic heaviness that worsen by standing up and can be relieved by lying down, there are a great variety of other symptoms that must be taken in account, such as bladder irritability, heaviness in the legs, dysmenorrhea, gastrointestinal syntoms, vulvar swelling,
Surgical approaches, such as hysterectomy with unilateral or bilateral oophorectomy and ovarian vein ligation and excision seem to be too aggressive solutions. Endovascular approach with bilateral ovarian vein
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SESSION
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embolization with a combination of coils and sclerosants is now the preferred technique, with good clinical results and low morbidity rates.
The venography is the gold standard for the diagnosis of NCS not only confirming anatomic findings but with the measure of Reno-cava pressure gradient that is significant if it is more than 3.
Conclusion
Treatment
PCS is a very common cause of chronic pelvic pain that can be diagnosed and treated with minimally invasive techniques with very good results and low morbidity rates.
The management depends upon the severity of the symptoms. There are different options: Open Surgery: Left renal vein transposition, left gonadal vein transposition, Reno-cava by-pass. Endovascular approach: left renal vein angioplastystent. Laparoscopic/robotic approach
However, we need more studies to create clear and strict protocols to improve patients selection and optimize outcomes.
NUTCRACKER SYNDROME MANAGEMENT
Conclusion Literature results show tan endovascular approach is a valid and minimally invasive therapeutic option in the treatment of the NCS. But is technically demanding and require a learning curve to avoid complications like migrations. In our experience we think that is the first choice in the treatment of this entity, but large studies and results are needed.
Dr. Marta Ramirez Ortega
Introduction The Nutcracker phenomenon is the compression of the left renal vein between the aorta and the superior mesenteric artery. When the patient with this anatomic phenomenon presents signs or symptoms due to left renal venous congestion (hematuria, flank pain, hypertension or pelvic congestion syndrome) we talk about Nutcracker Syndrome (NCS).
Clinical features This entity is far more frequent among women (between the second and the fourth decade). The symptoms vary from asymptomatic hematuria to severe pelvic congestion syndrome that is aggravated by physical activity or orthostatic position.
Doppler ultrasonography is the first diagnostic test in patients with suspected NCS with high sensitivity and specificity. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) provide visualization of the anatomy and could identify another etiological causes of hematuria and/or pain.
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Diagnosis
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Aortic arch pathology represents a challenging condition for cardiac and vascular surgeons; for this reason different alternatives, all of them including endovascular procedures, have been developed. As a first step, a thorough evaluation of the ascending aorta and comorbidities of the patient is required. Reports regarding this subject are very heterogeneous, making it difficult to compare the results for different techniques. Currently, conventional repair continues to be the gold standard procedure of repair for this anatomical region, against which all other techniques must be compared to. However; even in centers of excellence, classical open repair is associated with significant immediate mortality and stroke rates, which range from 5 % to 15 % and from 4 % to 12 %, respectively. These figures are even more relevant if it is taken into account that about 20 % - 40 % of the patients are rejected for treatment due to advanced age, comorbidities, emergency presentation, etc.
Satellite Symposium 3
AORTIC ARCH: A NEW FRONTIER IN THE ENDOVASCULAR REPAIR. Dr. Manuel Alonso
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Hybrid procedures for the arch can be a useful alternative for some of these patients, due to the fact that they are a less aggressive option than a conventional operation. The literature shows very variable results; however, there is no doubt that they still represent a major surgery, associated with significant mortality and morbidity rates. In a recent report, the results of hybrid procedures for aortic dissections and other pathologies of the arch were compared with the results of the “elephant trunk” or “frozen elephant trunk” technique, showing an immediate mortality rate of 11.9% (from 2% to 23 %), 13,2 % and 9.8 %, respectively. The incidence of perioperative stroke was 7.3 % (0.8 % – 18 %), 10.9 % and 6.2 %; respectively. A lower rate of SCI was observed in the debranching procedures group (4.3 % compared to 7 % for the other two techniques).
companies have developed specific short straight tube devices, their preliminary results are not well known and, on the other hand, the feeling exists that endovascular repair of the ascending aorta should be a more comprehensive concept that is still in its very early beginning.
Parallel conduits techniques have been successfully used in the arch by several authors and they can be useful as an individual resource in some patients; however, their use is surrounded by important controversy and uncertainty, considering that: 1) there is a high rate of type I endoleaks (from 11 % to 28 %), which can be even more dangerous here; 2) a reported immediate mortality rate up to 16.6 % in elective cases; and stroke and morbidity rates as high as 25 % and 27.2 %, respectively. Thus, there is a general consensus that these procedures in the arch should be limited to emergency cases and as a last alternative.
Moulakakis KG, Mylonas SN, Markatis F, et al. A systematic review and meta-analysis of hybrid aortic arch replacement. Ann Cardiothorac Surg 2013; 2:247-60.
References Cao P, De Rango P, Czerny M, et al. Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections and other arch diseases. J Thorac Cardiovasc Surg 2012; 144:1286-300.
Gelpi G, Vanelli P, Mangini A, et al. Hybrid aortic arch repair procedure: reinforcement of the aorta for a safe and durable landing zone. Eur J Vasc Endovasc Surg 2010; 40:70914. Tsilimparis N, Debus S, von Kodolitsch Y, et al. Branched versus fenestrated endografts for endovascular repair of aortic arch lesions. J Vasc Surg 2016; 64:592-599. Haulon S, Greember R, Spear R, et al. Global experience with an inner branched arch endograft. J Thorac Cardiovasc Surg 2014; 148:1709-1716.
Industry and technological developments, associated to an increasing operator´s expertise are already making it possible to perform a pure endovascular repair of the arch with specifically designed devices; some of them introducing new concepts for access and deployment. Even though, the experience with these devices is still limited and their use is currently restricted, promising results have been achieved with fenestrated and branched endografts in this anatomical area. In a recent multicenter report, including 27 patients, authors mention excellent results with a significant improvement of the mortality rate compared to their initial experience (3.7 % vs 23.6 %, p = .002).
Spear R, Haulon S, Ohki T, et al. Subsequent results for arch aneurysm repair with inner branched endografts. Eur J Vasc Endovasc Surg 2016; 51:380-385.
Endovascular repair of the ascending aorta poses special issues, mainly regarding the aortic valve and coronary arteries, and represents a tremendous additional challenge. In spite of the fact that isolated cases with focal disease have been reported and that some
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Lindblad B, BinJarb A, Holst J. Chimney grafts in aortic stent grafting: hazardous or Useful Technique?: Sistematic review of current data. Eu J Vasc Endovasc Surg 2015; 50:722-723.
Calendario de Congreos 2017
Calendario de Congresos Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
May Global Embolization Symposium and Technologies - GEST Europe 2017 May 31-June 3, 2017 Firenze Fiera Congress and Exhibition Centre Florence, Italy www.gest2017.eu
New Cardiovascular Horizons 18th Annual Conference May 31-June 2, 2017 The Roosevelt New Orleans New Orleans, LA www.ncvh.org
2017 Vascular Annual Meeting May 31-June 3, 2017 San Diego Convention Center San Diego, CA www.vascular.org/meetings/2017-vascularannual-meeting
June
July
I-MEET 2017
ISVS Symposium 2017
June 1-2, 2017 Radisson Blu Hotel Nice, France
July 19-22, 2017 Ramada Hotel Sibiu Sibiu, Romania
www.meetcongress.com
www.isvs2017.com
NCVH Vein Forum
CVC 2017: Arterial and Venous Endovascular Conference
June 03, 2017 New Orleans, LA www.ncvh.org/vein
Complex Cardiovascular Catheter Therapeutics (C3) June 27-30, 2017 Hilton Orlando Bonnet Creek Orlando, FL
July 24-27, 2017 Radisson Blu Aqua Chicago, IL www.cvcpvd.com
Phone: 800-282-3418
September
www.c3conference.net
VIVA 2017
SAM Santiago Aortic Meeting
September 11-15, 2017 Wynn Las Vegas Las Vegas, NV
Santiago de Compostela, Spain June 22-23 www.santiagoaorticmeeting.com/
18th European Venous Forum Meeting June 29-July 1, 2017 Alfandega Porto Congress Centre Porto, Portugal www.europeanvenousforum.org/
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www.vivaphysicians.org
Phone: (888) 513-VIVA Fax: (408) 225-3240
SITE UPDATE March 2nd Barcelona, SPAIN www.sitesymposium.com Ir al sumario
2017
Próximos Cursos y Congresos
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
eVidaVascular, el software para una óptima planificación de las operaciones de aneurisma de aorta eVidaVascular es un software de visualización avanzada de imágenes 3D diseñado por la empresa vasca Emedica para la planificación quirúrgica de los aneurismas de aorta a partir de estudios radiológicos de Tomografía Computarizada (CT). Una de las grandes ventajas de la herramienta es que consta de un sistema de segmentación de la aorta basado en dos sencillos pasos que permiten automatizar todo el proceso, que de otra forma debería hacerse de forma manual. Basta con crear la máscara e indicar un área y un punto semilla. La segmentación de imágenes resulta clave en el tratamiento de los aneurismas de aorta. La medición exacta del aneurisma gracias a las imágenes 3D posibilita la elección de la endoprótesis (stent) adecuada para la reparación endovascular (EVAR).
eVidaVascular posibilita esta medición de un modo sencillo y ágil, de manera que los cirujanos vasculares y radiólogos intervencionistas ven asegurados los procesos y minimizados los riesgos en las intervenciones quirúrgicas. Es especialmente útil para los enfermos con más urgencia. Emedica presentó oficialmente eVidaVascular el pasado marzo en el SITE de Barcelona (Simposio Internacional de Terapéutica Endovascular) con una excelente acogida entre los numerosos profesionales (cirujanos vasculares, cardiólogos y otros expertos) que se interesaron por su funcionamiento. eVidaVascular está ideada para el análisis y la planificación quirúrgica de aneurismas de aorta abdominal (AAA), aneurismas de aorta torácica (TAA), aneurismas de aorta toraco-abdominal (TAAA) y aneurismas de aorta ilíaca (IA). www.emedicahealth.com/evida/evidavascular
SOBRE EMEDICA Emedica es una ingeniería vasca especializa en software médico. Ofrece soluciones para el análisis, diagnóstico de enfermedades, planificación de operaciones en diferentes especialidades médicas y seguimiento de patologías. La empresa tiene como misión prioritaria resultar útil a los profesionales de la Medicina, y defiende que el mejor camino
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Noticias desde la Industria
para lograrlo es el desarrollo de soluciones tecnológicas en estrecha colaboración con ellos. La empresa surgió hace algo más de una década en el seno del centro de investigación Vicomtech, por lo que lleva impreso en su ADN el afán por explorar y desarrollar nuevas técnicas para la creación de software médico. El socio mayoritario de Emedica es el Grupo Alcor, especializado en el desarrollo de empresas tecnológicas en los sectores de Medicina, Aeronáutica, Automoción y Nuevas Tecnologías. www.emedicahealth.com
OTROS MÓDULOS Además de en eVidaVascular, Emedica dispone de otras soluciones de planificación y visualización. Una de ellas es Vascular Training, un software formativo que permite el análisis y la evaluación 3D de las estructuras vasculares, en especial de la arteria aorta. Su función es facilitar y mejorar el aprendizaje en las universidades y centros de formación de los futuros profesionales en cirugía vascular. La empresa trabaja asimismo en eVidaKnee, un software médico específico para los cirujanos ortopédicos que permite la observación y análisis de los cartílagos y huesos de la rodilla; y en eVidaOnco, que posibilita al oncólogo medir cuantitativamente la eficacia de los tratamientos farmacológicos en el cáncer de hígado. www.emedicahealth.com/es/vasculartraining
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Noticias desde la Industria
Noticias desde la Industria Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
Noticias desde la Industria
Cardiva en SITE Cardiva ha estado presente un año más en el congreso SITE, celebrado en Barcelona durante los dÌas 29, 30 y 31 de Marzo.
El Registro Luminor es un estudio multicéntrico, observacional prospectivo del tratamiento de lesiones estenóticas u oclusivas en el sector femoro-poplíteo y below the knee. El estudio, realizado íntegramente en España, consta de 215 pacientes. De ellos 98 con lesiones en el sector distal, siendo el 61,2% oclusiones totales y el 38,8% estenosis. Casi un 93% de los mismos presentaron un Rutherford 4-5. Los resultados que se han obtenido son a un año y muestran una permeabilidad primaria del 88,3%, así como una ausencia de TLR del 94,8%. También señalan una ausencia de amputación mayor del 85% y una tasa de supervivencia del 86%. En el registro han participado un total de 10 hospitales. Los dispositivos utilizados son Luminor 14 y Luminor 35, fabricados por iVascular. Posteriormente se ha incorporado también un nuevo miembro de la familia Luminor, para utilizar con guías de
0,018” (Luminor 18). El estudio aún está activo y se prevé su finalización en Mayo de 2017. Sobre Cardiva: Cardiva se dedica a la distribución de dispositivos médicos desde hace casi treinta años y su liderazgo está basado en ofrecer las mejores alternativas terapéuticas y un servicio rápido y eficaz al cliente. El portfolio de Cardiva incluye una amplia gama de productos para Neurorradiología y Radiología Intervencionista, Hemodinámica, Cirugía Vascular, Endovascular y Cardiaca, Dolor y Equipos y sistemas de información médica. Sobre iVascular iVascular es una joven empresa española dedicada al diseño, desarrollo y manufactura de tecnologías y dispositivos médicos para el tratamiento de las enfermedades cardiovasculares a través de la integración vertical de todos sus procesos des de la materia prima hasta el producto final.
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El SITE lleva celebrándose doce años, y en la edición de 2017 ha contado con la inscripción de más de 400 médicos, de los cuales el 56% son españoles y el resto provienen de todos los puntos del globo, destacando italianos, portugueses y alemanes, hasta completar las 28 nacionalidades presentes en esta edición. El programa científico del SITE han participado 140 ponentes que han cubierto 34 sesiones, 6 simposios satélites, casos complejos y casos registrados. Cardiva sigue comprometida con su lema de innovación y servicio, investigando permanentemente para ofrecer las mejores soluciones a sus clientes. Pagina web SITE: https://www.sitesymposium.com https://www.cardiva.com
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Excelentes resultados del Registro Luminor en el sector distal
Cardiva ha presentado productos estrella como las prótesis Anaconda y Anaconda fenestrada, el introductor Destino Twist (con punta direccionable) y el stent iVolution o la familia Luminor (iVascular). También, durante el mismo, se presentó un caso grabado de un implante de Anaconda Fenestrada de 4 fenestraciones realizado en el Servicio de angiología y cirugía vascular del Hospital Sao Joao de Oporto, del Dr. Jose Fernando Teixeira.
Noticias desde la Industria Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
Noticias desde la Industria
PRIMER IMPLANTE TREO AUI Bolton Medical tienen el placer de anunciar el primer implante aorto-uni-ilíaco (AUI) en la plataforma abdominal TREO a nivel mundial. Este implante fue realizado por el equipo de cirugía endovascular del Dr. Gabriel España conformado por la Dra. María Rubio y la Dra. Victoria García Prieto, el 17 de abril de 2017 en el Hospital Universitario Moncloa en Madrid. Con este lanzamiento, Bolton Medical consolida su plataforma abdominal TREO diseñado para el tratamiento de los AAA. El varón de 78 años presentaba un aneurisma abdominal con una longitud insuficiente para tratarlo con una endoprótesis bifurcada. Además, presentaba un trombo mural profuso en la carina por lo que se decide optar por una AUI como opción terapéutica para evitar el riesgo de colapso del muñón contralateral. El procedimiento duró unos 40 minutos logrando la completa exclusión del aneurisma, sin visualización de endofugas como se puede apreciar en la angiología final [imagen 1].
“lock stent” que proporciona anclaje a las extensiones al cuerpo principal. Además cuenta con un amplio abanico de medidas para lograr un tratamiento personalizado a cada paciente, ajustar el tratamiento y lograr así mayor durabilidad a largo plazo.
Sobre TREO AUI Bolton Medical lanzó su plataforma abdominal en 2014 y cuenta con datos clínicos con seguimiento a un año mostrando prometedores resultados. TREO ha sido diseñada para lograr la máxima durabilidad. Con su tecnología de doble fijación, es la única en el mercado que cuenta con sujeción suprarrenal e infrarenal e incluye la genuina tecnología
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Bolton Medical. Miami, Florida.
Normas para los autores
Normas para los autores Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
Editorial Trabajos originales Revisiones Casos clínicos Imágenes endovasculares Notas técnicas Zona catastrófica Novedades desde la industria Cartas al Director Bolsa de Trabajo e intercambio profesional Congresos
tamaño 12 (preferiblemente tipo Times, Arial o Currier), con interlineado doble y con las páginas numeradas. El idioma deberá ser Español o Inglés.
Revisiones Referencias Bibliográficas: Se numeraran según aparición correlativa en el texto. Para la citación de los trabajos se utilizarán las normas que aparecen detalladas en ‘Uniform Requeriments for Manuscripts Submitted to Biomedical Journals’, NEJM 1997; 336:309-316.
A modo de ejemplo:
Se asignará por invitación desde la redacción de TE.
Articulo: Kioka Y, Tanabe A, Kotani Y, Yamada N, Nakahama M, Ueda T, et al. Review of coronary artery disease in patients with infrarenal abdominal aortic aneurysm. Circ J 2002;66:1110-2
Trabajos originales:
Capitulo de Libro:
Se consideran trabajos originales aquellos que no hayan sido publicados en otros medios de comunicación escrita medica. Deberán constar de la estructura siguiente:
Coselli JS, Buket S, Crawford ES. Thoracic Aortic Aneurysms. En: Haimovici H, Ascer E, Hollier LH, Strandness DE, Towne JB, eds. Vascular Surgery. Cambridge (USA), Blackwell Science, 1996; 759-785
Editorial:
Resumen en Español y Abstract en Inglés (máximo 250 palabras) Introducción Material y Métodos Resultados Discusión y conclusiones Referencias Bibliográficas
Importante: Cada uno de los apartados anteriores iniciará página. En la primera página deberá figurar el título completo, los autores, el centro de trabajo, la persona de contacto para la correspondencia con su dirección postal y e-mail, la sección a la que va dirigida y la fecha de envío. Asimismo deberá confeccionar un titulo corto y facilitar palabras clave (mínimo de 3 y máximo de 6) El manuscrito se redactará con letras de
máximo de 5 tablas por trabajo. Cada tabla deberá identificarse con un breve texto explicativo.
Se aceptarán para su valoración aquellos trabajos de revisión que por su actualidad o controversia susciten la atención de los especialistas relacionados con las terapéuticas endovasculares. Se podrán solicitar explícitamente desde la redacción o bien someter libremente según iniciativa de sus autores. Deberán seguir las mismas normas de redacción y presentación que aparecen para los trabajos originales. No obstante, su estructuración deberá contemplar: Resumen (Español) y abstract (Inglés) Introducción Desarrollo Conclusiones Referencias Bibliográficas
Casos clínicos
Figuras: Las figuras irán numeradas (números árabes) correlativamente según aparición en el texto. Se aceptará un máximo de 5. Las imágenes deberán indicar su orientación. Las figuras en color se reproducirán del mismo modo si su interés lo hace imprescindible. De modo contrario, se reproducirán en escala de girses. Se adjuntará en página aparte los pies de figura.
Tablas: Las Tablas se numerarán con números romanos correlativos según su orden de aparición en el texto. Se aceptará hasta un
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Se aceptarán para su valoración los casos clínicos singulares y originales. Seguirán las normas de redacción ya mencionadas en apartados anteriores. Si bien su estructuración deberá ser: Resumen (Español) y Abstract (Inglés) máximo de 150 palabras Caso Referencias Bibliográficas (máximo de 5) Las Figuras estarán limitadas a tres como máximo.
Imágenes endovasculares Se aceptarán para su valoración aquellas imágenes relacionadas con las terapéuticas endovasculares que por su singularidad sean merecedoras de su publicación. Se acompañarán de texto (máximo 100 palabras) y referencias bibliográficas si se considera necesario en un máximo de 2. Sólo se aceptarán dos figuras.
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La redacción de Técnicas Endovasculares (TE) considerará para su publicación aquellos trabajos relacionados con la terapéutica endovascular. Las secciones que componen la revista son:
Normas para los autores
Normas para los autores Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
Notas técnicas Se aceptarán para su valoración aquellas modificaciones o innovaciones técnicas que se consideren de interés para los profesionales relacionados con las terapéuticas endovasculares. Se ilustrarán con un máximo de tres figuras y un texto máximo de 500 palabras. Se podrá acompañar de 5 referencias bibliográficas.
Bolsa de Trabajo e intercambio profesional Este espacio se reservará para anunciar oportunidades de trabajo o de formación en el campo de la terapéutica endovascular. El Departamento Comercial de TE convendrá con el anunciante, el coste de su anuncio.
Congresos Zona catastrófica Se aceptará para su valoración aquellas situaciones o procedimientos que condujeron a complicaciones singulares, resueltas o no satisfactoriamente, pero que de la experiencia se pueda derivar una enseñanza de interés para los profesionales relacionados con las terapéuticas endovasculares. Se seguirán las recomendaciones reflejadas en el apartado de ‘casos clínicos’.
Se incluirán todos aquellos acontecimientos científicos, congresos, reuniones, jornadas, simposios, etc, que por su interés merezcan ser anunciados a los profesionales relacionados con terapéuticas endovasculares. Su anuncio estará libre de cargo. Todos los manuscritos deberán ser dirigidos a e-mail: vriambau@gmail.com
Nota: El comité de redacción se reserva el derecho de rechazar aquellos trabajos o informaciones que no cumplan con las normas aquí expuestas o no se consideren de relevancia para su publicación en TE. Asimismo, desde el comité de redacción se propondrán modificaciones necesarias a los trabajos que se consideren oportunos. El comité de redacción se compromete a dar cumplida respuesta a todos los autores en el plazo de quince días desde su recepción en la redacción.
¡Revise su manuscrito y confirme su adecuación a las normas que aquí figuran antes de enviarlo a la redacción de TE!
Novedades desde la industria Los profesionales de la industria podrán disponer de un espacio que permitirá dar a conocer nuevos proyectos o productos a través de esta sección. Se aceptarán para su valoración textos (máximo 500 palabras) y figuras (máximo de tres) para este cometido. Se dará preferencia a las publicaciones procedentes de las industrias colaboradoras habituales de TE.
Cartas al Director
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En esta sección de dará cabida a todas las cartas que en la redacción se reciban a modo de sugerencia, crítica o comentario del fondo y forma de TE.
Instructions for the authors
Instructions for the authors Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
Editorial Originals Reviews Case Reports Endovascular Images Technical Notes Catastrophic Area News from the industry Letters to the Director Bag of Work and professional exchange Congress’ Agenda
numbered pages. The language will be Spanish or English.
Bibliographical References: They were numbered according to correlative appearance in the text. For the citation of the works the norms will be used that appear detailed in 'Uniform Requeriments for Manuscripts Submitted to Biomedical Journals', NEJM 1997; 336:309-316.
By way of example:
It will be assigned by invitation from the Editorial Board.
Article: Kioka AND, Tanabe TO, Kotani AND, Yamada N, Nakahama M, Ueda T, et to the one. Review of coronary artery disease in patients with infrarenal abdominal aortic aneurysm. Circ J 2002;66:1110-2
Original articles:
Book Chapter:
They are considered original works those that have not been published in other written media it prescribes. Language can be Spanish or English. They will consist of the following structure:
Coselli JS, Buket S, Crawford is. Thoracic Aortic Aneurysms. In: Haimovici H, Ascer AND, Hollier LH, Strandness OF, Towne JB, eds. Vascular Surgery. Cambridge (it USES), Blackwell Science, 1996; 759-785
Editorial:
Summary in Spanish and Abstract in English (maximum 250 words) Introduction Material and Methods Results Discussion and conclusions Bibliographical References
Important: Each one of the previous sections will begin page. In the first page it will figure the complete title, the authors, the work center, the contact person for the correspondence with their postal address and e-mail, the section to which goes directed and the shipment date. Also it will make a short title and to facilitate keywords (minimum of 3 and maximum of 6) The manuscript will be edited with size letters 12 (preferably types: Times, Arial or Currier), with having interlined double and with the
Figures: The figures will go numbered (Arab numbers) correlatively according to appearance in the text. A maximum of 5 will be accepted. The images will indicate its orientation. The figures in color will reproduce in the same way if their interest makes it indispensable. In a contrary way, they will reproduce in grey scale. The feet of figure will be attached in separated page.
Charts: The Charts will be numbered with correlative Roman numbers according to their appearance order in the text. It will be accepted until a maximum of 5 charts by work. Each chart will be identified with a brief explanatory text.
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Reviews They will be accepted for their valuation those revision works that raise the attention of the specialists related with the therapeutic endovasculares for their present time or controversy. They will be been able to request explicitly from the writing or to subject freely according to their authors' initiative. They will follow the same writing norms and presentation that you/they appear for the original works. Nevertheless, their structuring will contemplate: Summary (Spanish) and abstract (English) Introduction Development Conclusions Bibliographical References
Cases Reports They will be accepted for their valuation the singular and original clinical cases. They will already follow the writing norms as it was previously mentioned. Although their structuring will be: Summary (Spanish) and Abstract (English) maximum of 150 words Case Bibliographical References (maximum of 5) The Figures will be limited at three as maximum.
Endovascular Images They will be accepted for their evaluation those images related with the endovascular therapeutics that are worthy of their publication for their singularity. They will accompany of text (maximum 100 words) and bibliographical references if it is considered necessary in a maximum of 2. Two figures will only be accepted.
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Técnicas Endovasculares (TE) will consider for their publication those works related with the endovascular therapies. The sections that compose the journal are:
Instructions for the authors
Instructions for the authors Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
Technical Notes They will be accepted for their valuation those modifications or technical innovations that are considered of interest for the professionals related with the endovascular therapeutics. They will be illustrated with a maximum of three figures and a maximum text of 500 words. It will be able to accompany of 5 bibliographical references.
Bag of Work and professional exchange This space will be reserved to announce work opportunities or formation programmes in the field of the endovascular therapeutics. The Commercial Department of TE will propose the cost of their announcement.
Congress Agenda Catastrophic area It will be accepted for their evaluation those situations or procedures that led to singular, well resolved complications or not satisfactorily, but it can be derived a teaching experience for the professionals related with the endovascular therapeutics. The recommendations will be continued reflected in the section of ‘Case Reports’.
All those scientific events will be included, congresses, meetings, worshops, symposia, etc that deserve to be announced to the professionals related with endovascular therapeutics for their interest. Their announcement will be free of charge. All the manuscripts, it copies printed and in computer support, they will be directed to: e-mail: vriambau@gmail.com
Note: The editorial committee is reserved the right of rejecting those works or informations that don't fulfill the instructions here exposed or they are not considered of relevance for its publication in TE. Also, the editorial committee will communicate to the authors some necessary modifications to the works that are considered opportune. The editorial committee commits to give fulfilled answer to all the authors in the term of fifteen days from its reception in the editorial office.
Revise their manuscript and confirm their adaptation to the norms that here figure before sending it to the editorial of TE!
News from the industry The professionals of the industry will be able to have a space that will allow to give to know new projects or products through this section. They will be accepted for their evaluation texts (maximum 500 words) and figures (maximum of three) for this made. Preference will be given to the publications coming from the habitual collaborating industries of TE.
Letters to the Director
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In this section it will give space to all the letters that are received by way of suggestion, critic or comment of the contents and form of TE journal.
Boletín de suscripción 2017
Boletín de Suscripción 2017
Dirección de envío Nº Suscripción Nombre y Apellidos Nº
Dirección Población
C.P.
País
Piso
Provincia
Especialidad
Importe suscripción ESPAÑA
LATINOAMÉRICA
RESTO PAÍSES
Médicos
54 Euros
66 Euros 66 Euros
81 Euros 81 Euros
Instituciones, Bibliotecas, Hospitales Hospi
68 Euros
81 Euros 81 Euros
93 93 Euros Euros
*IVA incluido 4%
Forma de pago Cheque nominativo que adjunto
Enviar boletín de suscripción a:
Domiciliación bancaria
Técnicas Endovasculares Aribau, 237. Escalera B 3º-1ª 08021 BARCELONA (ESPAÑA)
Orden de pago/Domicialicación bancaria Le ruego tomen nota, que hasta nuevo aviso deberán adeudar en mi cuenta corriente con esa entidad, el recibo que anualmente y a mi nombre les será presentado para su cobro, por la suscripción de la Revista TECNICAS ENDOVASCULARES.
Nombre del Titular Banco/Caja de Ahorro Nº Sucursal
Nº c/c Calle
Nº
Población
C.P.
País Firma del Titular
En
a
de
201
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BOLETÍN DE SUSCRIPCIÓN AÑO 2017
Volumen XX - Número 2 - Mayo - Agosto 2017 - Edición Especial SITE 2017
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