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Abstract book

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

International Scientific Committee


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

www.cacvs.org

Table of
contents

Faculty authors

CONTROVERSIES & UPDATES IN VASCULAR SURGERY


THURSDAY JANUARY 21

VASCULAR PROGRAM

Thoracic and Thoraco Abdominal Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

FRIDAY JANUARY 22
Chairman
Pr Jean-Pierre Becquemin

MD, Professor of Vascular Surgery


Crteil, France

Main session

Dr Jean-Luc Grard

Lower Limb Occlusive Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


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

Pr Eric Allaire

Vascular access

Scientific Committee
Pr Yves S. Alimi

MD, PhD, Professor of Vascular


Surgery, Marseille, France
MD, Paris, France

MD, PhD, Professor of Vascular


Surgery, Crteil, France

Dr Pierre Bourquelot
MD, Paris, France

Pr Pascal Desgranges

MD, PhD, Professor of Vascular


Surgery, Crteil, France

Pr Hicham Kobeiter

MD, PhD, Professor of Vascular


Radiology, Crteil, France

Dr Jean Marzelle

Vascular Access News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


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

14
16
19
21
29
31
33

42
45
47
50
52

SATURDAY JANUARY 23

MD, Crteil, France

I nternational Scientific


Committee Committee
Pr Piergiorgio Cao

MD, PhD, Professor of Vascular


Surgery, Perugia, Italy

Dr Eric Chemla

MD, Vascular surgeon,


London, United Kingdom

Pr Nicholas Cheshire

Professor of Vascular Surgery,


London, United Kingdom

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

Pr Christos D. Liapis

Professor of Vascular Surgery,


Chaidari, Greece

Peripheral and Visceral Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


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

VENOUS PROGRAM

Jean-Nol ALBERTINI, St Etienne, France . . . . . . . . . . . . . . . . 34


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

56
58
59
60
62
65

Franois-Andr ALLAERT, Dijon, France . . . . . . . . . . . . . . . . 88


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

CONTROVERSIES & UPDATES IN VARICOSE DISEASE


Deep vein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Some debates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sclerotherapy & Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Thermal or glue techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

68
71
79
92

Pr Ian Loftus

Professor of Vascular Surgery,


London, United Kingdom

EPOSTERS

MD, PhD, Vascular surgeon,


Malm, Sweden

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

Dr Martin Malina

Pr Armando Mansilha

Professor of Vascular Surgery,


Porto, Portugal

Pr Fabio Verzini

Professor of Vascular Surgery,


Perugia, Italy

102
131
134
136
167
173
193

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Thursday January 21
- Main program -

4

5

Thoracic and Thoraco Abdominal Aneurysms


Proximal issues. Should we choose specific stent-graft for a specific anatomy?

Mourad Boufi

Matt Thompson

St Georges Vascular Institute, London, United Kingdom

BACKGROUND
Surveillance is mandatory for all patients with a small thoracic aortic aneurysm (TAA). The frequency of
surveillance imaging however is not evidence based as few data exist on TAA growth rates. This study
aimed to determine the rate of TAA expansion and to inform optimal surveillance intervals for individuals
based on TAA diameter.

Marseille, France
INTRODUCTION AND OBJECTIVES
Extension of thoracic endovascular aortic repair (TEVAR) indication to different pathologies and landing
zones raises the question relating the extent to which stent-grafts can be compatible with different anatomies.
The association between morphology and complications after TEVAR seems evident. However, there are no
clear recommandations defining morphological criteria which influence outcomes.
The present study aims to analyse the different factors favoring the occurrence of two types of complications endoleak and mispositioning and in particular, the relationship between these phenomena and
aortic anatomy.

METHODS
The cohort comprised 995 patients with small TAA for whom morphological data were available from serial
CT scans. Each patient had a minimum of 2 sequential and dated CT scans prior to undergoing repair of
the TAA. Annualised growth rates based on diameter at presentation and time taken to reach a theoretical intervention threshold of 55m was calculated. The number of patients that would have achieved the
threshold undetected was determined based on simulated imaging intervals of 6 months, 1, 2 and 3 years.

MATERIALS AND METHODS


Between 2007 and 2014 patients admitted for TEVAR, with a proximal landing zone located in the aortic
arch, were retrospectively reviewed.
The study involved 73 patients (58 men, 54 21 years) treated for traumatic aortic rupture (n=28), type
B aortic dissection (n=24), penetrating aortic ulcer (n=4), intramural hematoma (n=2) and thoracic aortic
aneurysm (n=15). Pre and postoperative computed tomographic angiography were examined to analyse
the presence of endoleak and quantify mispositioning (discrepancy between the planned and the achieved
landing zone). Different anatomical factors were calculated by means of Matlab script: aortic angulation
within a 30 mm range at the proximal deployment zone, landing zone angle, aortic tortuosity index, curvature radius and arch width.

RESULTS
Scans from 995 patients were analysed. The mean aortic expansion rate was 2.76mm / year for all patients,
with an exponential increase in expansion rate at sizes above 45mm. By one-year post-presentation, 36%
of those with a starting diameter of 50-54mm and 25% of those with a starting diameter of 45-49mm
had expanded to beyond the 55mm treatment threshold. Conversely, no patients with a diameter at presentation of 30-39mm and only 5% of those with a TAA diameter at presentation of 40-44mm achieved
threshold size within 2 years.

RESULTS
Primary type I endoleaks were noted in 5 cases (7%). Over a mean follow-up of 35 months (range 3- 95
months), secondary endoleaks were detected in 2 patients (3%) and stent-graft migration in 3 patients
(4%).
Mispositioning varied from 2 to 15 mm. A cut-off value of 11 mm was identified to be at risk of adverse
clinical events.
Multivariable analysis identified the following anatomic criteria as independant risk factors of complications: landing zone angle for the risk of type I endoleak (HR =1.38, 95% CI 1.02- 1.88, p=0.03) with a cutoff value of 160 and tortuosity index for the occurrence of mispositioning (OR=241.4, 95% CI=1- 6149,
p=0.05) with a cut-off value of 1.68

DISCUSSION
Based on a threshold of 55mm for intervention, most patients with a maximal aortic diameter of <40mm
could safely undergo surveillance at 2 yearly intervals. Those with a diameter of >50mm should be optimised for repair if this is clinically appropriate due to the subsequent rapid expansion observed.

CONCLUSION
The present study clearly reveals the impact of anatomy on the occurrence of complications at the proximal
deployment zone and argue for the limits of the stent-grafts currently available. Specific devices should be
required for these complex anatomies.

Thursday January 21

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Thoracic and Thoraco Abdominal Aneurysms


Expansion, risk of rupture: are our current guidelines still valid?

Thoracic and Thoraco Abdominal Aneurysms


Proximal issues. Left subclavian branch: technique and preliminary results

CHU Rangueil, Toulouse, France

PLACEMENT OF THE DEVICE


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

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

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

DEVICE SELECTION
Planning of the procedure is done with a 3D workstation after computed tomography angiography including the aorta from the level of the aortic annulus to the femoral arteries. The analysis must include: orientation of the supra-aortic trunk vessels and identification of sufficient sealing zones within the normal
aorta, each of supra-aortic target artery and the descending thoracic aorta. Careful examination of the
access site (brachial and femorals) is also done.

Thursday January 21

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Herv Rousseau, Bertrand St Lebes

Thoracic and Thoraco Abdominal Aneurysms


More about TAAA. Endo or open. What are the scientific criteria of choice?
Ciro Ferrer, Piergiorgio Cao

Patrick Kelly

Perugia, Italy

Sanford Health, Sioux Falls, USA


The possibility to manage aortic aneurysms by endovascular means has been one of the major innovations
of the past 20 years in vascular surgery. Currently endovascular repair has become the predominant treatment option for thoracic (TAA) and abdominal aortic aneurysms (AAA) that comply with morphological
feasibility criteria.1-4 Open Surgery (OS) still remains the gold standard in case of complex aortic aneurysms
involving visceral vessels, nevertheless there are relatively few vascular surgeons undertaking open surgery
for thoraco-abdominal aortic aneurysm (TAAA) offering patients low mortality and morbidity risk exposure.5-7 Similarly, there are only few centers involved in endovascular repair (ER) who report encouraging
results with branched and fenestrated stentgrafts in TAAA.8 Reliable unbiased data comparing open and
endovascular technique for complex aortic aneurysms involving thoraco-abdominal aorta are lacking.

BACKGROUND
Endovascular repair of thoracoabdominal aneurysms has provided an alternative for patients who are not
candidates for open surgical repair. No branch devices are yet approved in the US for commercial use.
OBJECTIVE
To demonstrate a novel endovascular technique for repairing all types of TAAAs and to present the initial
outcomes obtained with a physician-modified TAAA device.
MATERIAL AND METHODS
The procedures involved a physician-modified thoracic stent graft and infrarenal stent graft. Twenty three
patients, 14 male and 9 female, were treated between March of 2012 and July 2014. Baseline, Index, 6
month, and 1-year single-center outcomes were collected retrospectively. Twenty two were followed to 1
month, 18 patients were followed to 6 months, and 14 patients were followed to 1 year. Twelve of the 23
would meet the patient selection criteria of our current physician-sponsored IDE. There were 2 Crawford
type 1s, 4 type 2s, 6 type 3s, 5 type 4s, and 6 type 5s.

We recently reviewed the outcomes of all TAAA patients undergoing repair at three Italian vascular centers
between January 2007 and December 2014, stratifying them according to treatment by ER or OS and comparing the outcomes using propensity score matching (1:1). Covariates included age, sex, aneurysm extent,
hypertension, coronary disease, chronic pulmonary disease, diabetes, and renal function. The primary endpoint were mortality and paraplegia. Secondary endpoints included any spinal cord ischemia (SCI), renal
and respiratory insufficiency and a composite of these complications or death at 30 days. All-cause survival
and reintervention-freedom were also compared in the two groups.
Out of 341 patients, 84 (25%) underwent ER and 257 underwent OS (75%). After propensity score matching (65 patients per group), no significant differences were observed in rates of 30-day mortality (7.7%
in ER and 6.2% in OS; p=1), and paraplegia (9.2% and 10.8%; p=1). Any SCI, renal and respiratory insufficiency were 12.3% and 20% (p=0.34), 9.2% and 12.3% (p=0.78), and 0% and 12.3% (p=0.006), in ER
and OS respectively. The incidence of composite endpoint was significantly lower in ER patients (18.5%
in ER vs. 36.0% in OS; p=0.03). According to Kaplan Meier estimates, all-cause survival at 24 months was
82.8% in ER and 84.9% in OS with rates unchanged at 42 months (p=0.9). Reintervention-freedom rates
were 91.0% vs. 89.7% at 24 months and 80.0% vs. 79.9% at 42 months, in ER vs. OS, respectively (p=0.3).
In conclusion, a propensity score analysis in patients with TAAA undergoing repair suggests an early benefit from ER compared to OS with regards to composite endpoint due to reduced respiratory 30-day complications, while no significant differences were found in SCI and renal insufficiency at 30 days, and survival
and reintervention rates at mid-term.

RESULTS
Average procedure time was 297 minutes with an average fluoro time of 96 minutes and 103 mL of contrast used. Eighty four of 85 target vessels were successfully stented and 83 of the 84 target vessels remained patent throughout the follow-up. In the group meeting IDE patient selection criteria, there was an
average length of stay of 7 days with no in hospital or 30 day death, no cases of paraplegia, and one case
of renal failure which resolved. There was one death at 11 months from a CVA. In the group not meeting
IDE patient selection criteria, there was an average length of stay of 9.5 days, with no in hospital or 30
day death, two cases of paraplegia, and six cases of temporary or permanent renal failure. There were 8
deaths in the 1 year follow-up with no aneurysm-related death. Of the patients that dont meet the IDE
selection criteria, four of the patients were emergent ruptures, three were chronic type B dissections, and
the remaining four either had suprarenal fixated stents or an occluded renal.
CONCLUSIONS
Early results show that a TAAA device can be implanted safely. The repair appears to be durable with excellent branch vessel patency, with some patients being more than three years from the index procedure.
More experience with the device is needed and will be obtained in our newly granted PS-IDE (G140207)
and with an industry manufactured device, namely the Valiant Thoracoabdominal Stent Graft System which
was recently approved for human use.

10

REFERENCES
1. Demers P, Miller DC, Mitchell RS, Kee ST, Sze D, Razavi MK, Dake MD. Midterm results of endovascular repair of descending thoracic aortic aneurysms with first-generation stent grafts. J Thorac Cardiovasc Surg. 2004;127(3):664-73.
2. Cheng D, Martin J, Shennib H, Dunning J, Muneretto C, Schueler S, Von Segesser L, Sergeant P, Turina M. Endovascular aortic
repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative
studies. J Am Coll Cardiol. 2010;55(10):986-1001.
3. Giles KA, Pomposelli F, Hamdan A, Wyers M, Jhaveri A, Schermerhorn ML. Decrease in total aneurysm-related deaths in the era of
endovascular aneurysm repair. J Vasc Surg 2009;49:543-51.
4. Schwarze ML, Shen Y, Hemmerich J, Dale W. Age-related trends 1 in utilization and outcome of open and endovascular repair for
abdominal aortic aneurysm in the United States, 2001-2006. J Vasc Surg 2009;50: 722-9.
5. Jacobs MJ, Mommertz G, Koeppel TA, Langer S, Nijenhuis RJ, Mess WH, Schurink GW. Surgical repair of thoracoabdominal aortic
aneurysms. J Cardiovasc Surg (Torino). 2007;48:49-58.
6. Coselli JS, Bozinovski J, LeMaire SA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg.
2007;83:S862-4; discussion S890-2.
7. Kazen UP, Blohm L, Olsson C, Hultgren R. Open Repair of Aneurysms of the Thoracoabdominal Aorta. Thorac Cardiovasc Surg.
2015 Sep 24. [Epub ahead of print].
8. Greenberg R, Eagleton M, Mastracci T. Branched endografts for thoracoabdominal aneurysms. J Thorac Cardiovasc Surg.
2010;140(6 Suppl):S171-8.

11

Thursday January 21

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Thoracic and Thoraco Abdominal Aneurysms


New stent grafts for the thoracic and thoraco abdo segment.
Complete Endovascular Debranching: design considerations

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Friday January 22
- Main program -

12

13

Lower Limb Occlusive Disease


Drug Coated Balloons: Concepts, Products and How to Use Them

had severe calcification. Percent diameter stenosis was 86.3%16.2%, and 46% of lesions were occluded.
The primary endpoint was met with a 9-month primary patency of 94.4%. At 12 months, the primary patency rate was 96.1% (49/51) and the MAE rate was 3.8% (2 TLR events). There were no stent fractures at 12
months upon analysis by the angiographic core lab. Among patients with diabetes mellitus, the 12-month
MAE rate was 0% (0/16) and primary patency was 100% (14/14).

Lutonix/CR Bard, New Hope, USA

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

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

Lower Limb Occlusive Disease


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

Lower Limb Occlusive Disease


What you need to know to perform successful peripheral repair
After one year what are the results of DES?

BACKGROUND
This randomized controlled trial (RCT) evaluated clinical durability of Zilver PTX, a paclitaxel-coated
drug-eluting stent (DES), for femoropopliteal artery lesions. Outcomes compare the overall DES group (primary and provisional DES) versus the standard care group (percutaneous transluminal angioplasty (PTA)
and provisional Zilver bare metal stent (BMS)), and directly compare provisional DES versus provisional
BMS.

Koen Keirse

Regional Hospital Tienen, Tienen, Belgium


PURPOSE
The MAJESTIC clinical study was designed to evaluate the performance of the Eluvia drug-eluting vascular
stent system (Boston Scientific Corporation, Marlborough, MA, USA) for treating femoropopliteal artery
lesions up to 110 mm in length.

METHODS AND RESULTS


Patients with symptomatic femoropopliteal artery disease were randomized to DES (n=236) or PTA (n=238).
Approximately 91% had claudication and 9% had critical limb ischemia. Patients experiencing acute PTA
failure underwent secondary randomization to provisional BMS (n=59) or provisional DES (n=61). The
12-month primary endpoints were met, showing superior event-free survival and primary patency for primary DES compared to PTA. Results were sustained through 5 years. Clinical benefit (79.8% versus 59.3%,
p<0.01), primary patency (66.4% versus 43.4%, p<0.01), and freedom from reintervention (TLR, 83.1%
versus 67.6%, p<0.01) for the overall DES group were superior to standard care. Similarly, clinical benefit
(81.8% versus 63.8%, p=0.02), patency (72.4% versus 53.0%, p=0.03), and freedom from TLR (84.9%
versus 71.6%, p=0.06) with provisional DES were improved over provisional BMS. These results represent
>40% relative risk reduction for restenosis and TLR through 5 years for the overall DES compared to the
standard care group and for provisional DES compared to provisional BMS.

MATERIAL AND METHODS


MAJESTIC is an ongoing, prospective, single-arm, multicenter clinical trial with investigative sites in Europe, Australia, and New Zealand. Eligible patients had chronic lower limb ischemia and de novo or restenotic lesions in the native superficial femoral artery and/or proximal popliteal artery. The primary efficacy
endpoint was core laboratory-adjudicated 9-month primary patency (i.e., duplex ultrasound peak systolic
velocity ratio of 2.5 and the absence of target lesion revascularization [TLR] or bypass). Major adverse
events (MAEs), including all-cause death through 1 month, target limb major amputation through 12
months, and TLR through 12 months, were assessed.

CONCLUSIONS
The 5-year results from this large RCT provide long-term information previously unavailable regarding endovascular treatment of femoropopliteal artery disease. The Zilver PTX DES provided sustained safety and
clinical durability compared to standard endovascular treatments.

RESULTS
Mean age (SD) of the patients (N=57) was 699 years and 35% had diabetes. Baseline Rutherford category was 2 for 35%, 3 for 61%, and 4 for 4% of patients. Mean lesion length was 70.828.1 mm, and 65%
14

Stanford University, Stanford, CA, USA

15

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

George Papandreou

Challenges in Lower Limb Endovascular Repair: How to Break the Limits


Tibial arteries repair: when and how
Peter Schneider

Peter Schneider

Kaiser Foundation Hospital, Honolulu Hawaii, USA

Kaiser Foundation Hospital, Honolulu Hawaii, USA


INTRODUCTION
Endovascular intervention or open bypass surgery can be used to heal critical limb ischemia in many
patients. We are still learning which of these might offer the better results in each patient. However, the
strategy used for bypass and that for endovascular treatment are different.

INTRODUCTION
Consistent with further development of the endovascular revolution and the promulgation of minimally
invasive techniques is the growing availability and popularity of one-day surgery. The advantages of oneday surgery include increased patient comfort, more convenience, and savings on hospital-based resources.
The challenge is to make this process safe and efficient. The purpose of the talk is to review the rationale,
data, requirements and patient selection for one-day surgery.

DATA AND DISCUSSION


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

DATA AND DISCUSSION


One-day surgery is increasing significantly in the US. Typically, any procedure that can be safely converted
to an outpatient procedure or a non-hospital based procedure is included in consideration. Diagnostic
arteriograms, aortoiliac interventions, infrainguinal interventions, dialysis procedures, catheter-based embolizations, and venous procedures should be included. We have not performed carotid interventions on
a one-day basis and continue to believe that blood pressure control and cardiac monitoring is essential.
EVAR would be possible as an outpatient procedure but we have not yet done this. Among patients with
CLI, it is typically the foot that necessitates the hospital stay. Among CLI patients with rest pain or stable,
small areas of ulceration or gangrene, one-day procedures are performed. Some guidelines include the
following. The access must be perfect in every case. We routinely use duplex to guide the needle into the
artery at the site of least disease on the femoral artery. We use a closure device in most cases. After the
case, the patient must stay at least 4 hours. A plan should be made with indications for converting the
patient to an overnight stay based upon certain factors; elevated creatinine, pain, bleeding or hematoma,
nausea, or blood pressure or hear rhythm problems. The follow up plan must be clear. We routinely call the
patient on the following day to check up.
CONCLUSION
One-day surgery is emerging as a reasonable option for most endovascular procedures. Patient safety is
related primarily to a secure access site.

CONCLUSION
Success with tibial angioplasty for CLI can be enhanced with a thorough understanding of tibial disease patterns and treatment techniques. Patients with multilevel disease and Rutherford 4 or 5 ischemic changes can
be treated with PTA with great success, especially if the correct angiosome can be revascularized. Patients
with significant tissue loss in whom you cant open a direct line to the correct pedal angiosome should be
considered for bypass unless there are confounding surgical risks.
16

17

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Challenges in Lower Limb Endovascular Repair: How to Break the Limits


One day surgery for endovascular repair: basic requirements and patients selection.
US experience.

 ortic Occlusive Disease


A
Sexual dysfunction following aortic repair: do we need a trial?
Sergue Malikov, Julien Koenig, Nicla Settembre, Zakaryiae Bouziane

Julien Sfeir

Service de Chirurgie Vasculaire, Nancy, France

Lebanese University Hospital, Geitaoui, Beirut, Lebanon


Sexual function is an important quality of life criterion for patients. Sexual impotence is recognized as a
potential consequence of aortoiliac obstructive disease since the description of Leriche syndrome. Later it
will be shown that the damage of peri-aortic pelvic plexus during aorto-iliac surgery can lead to both sexual
impotence and ejaculation disorders. Besides, several reports have also raised sexual dysfunction issues after
treatment by EVAR. Since then, several studies have confirmed these findings, even though recognizing that
sexual dysfunction remains multifactorial and poorly understood. The aim of our pilot study was to analyze
the frequency of postoperative sexual dysfunction, comparing endovascular and open surgery in aortoiliac
disease.
To evaluate erectile function, we used SHIM survey (Sexual Health Inventory for Men).The assessment criteria
were sexual function changes three months after the intervention: erectile function, ejaculation, frequency
of sexual intercourses and overall sexual satisfaction. In this bicentric prospective study 36 patients were enrolled: 16 received endovascular aneurysm exclusion (EVAR) and 20 had an open aortoiliac surgery.

OBJECTIVE
All recent data suggest that percutaneous transluminal angioplasty (PTA) may be appropriate primary therapy
for critical limb ischemia (CLI) even in infrapopliteal lesions.
In our practice and in selected patients and depending on Lesions types, comorbidities and operative risk, we
are treating patients with CLI by endovascular approach. Between 2011 and 2015 and in 24 high risk patients
in whom primary PTA was the selected treatment, a conversion to distal Bypass surgery was done due to a
failure of PTA and after having complete consent from the patients.
METHODS
Between January 2011 and January 2015, 24 high risk patients (Ejection fraction varied between 30% and
40%, severe COPD, renal impairment) selected for primary PTA, were operated for distal Bypass for CLI. Conversion to Bypass was due to a failure of recanalization of the lesion and to a complication of the procedure
like extensive dissection or arterial rupture... The median age was 71 years, All patients were diabetic, Two
patients had severe renal impairment under hemodialysis, five patients suffered from COPD. The male over
female ratio was 19 men versus 5 women. Operations were done under general, regional or locoregional
anesthesia.

RESULTS
58.8% of all patients had impaired erectile function prior to surgery. The comparison of scores before and 3
months after intervention for open aorto iliac surgery showed a deterioration of erectile function in 42.8%
of patients, loss of ejaculations in 45% and a decrease of the overall sexual satisfaction in 38.4%. Those disorders are related to sympathetic plexus damage during open surgery. For EVAR, we did not find significant
change in erectile function. The frequency of sexual intercourses had a tendency to decrease for all patients 3
months after both treatments.
This pilot study confirms the important impact of open aortoiliac surgery on male sexual function. It also
shows that treatment with EVAR is a better technique for preserving sexual function. However many questions remain unresolved: the impact of the surgical approach: transperitoneal or retroperitoneal? The side
effect of internal iliac arteries embolization on sexual function? Further studies are needed.

RESULTS
24 distal Bypass were done divided as follows: 11 in situ Bypass, and 13 by inverted GSV Bypass (11 to Proximal posterior tibialis, 2 to pedial artery, 3 to distal posterior tibialis, 3 to Anterior Tibialis, and 5 to Tibio-Peroneal Trunk). All interventions were done by the same surgical team.
The mean operating time was 220 minutes, the mean time for hospital stay was 8 days. Follow up time
average was at 18 months. Primary patency at 1 year and at 18 months were respectively 75% and 70%.
Secondary patency also at 1 year and 18 months were respectively 82% and 80%. Limb salvage at one year
was approximatly 80%. Mortality at 30 days was 12.5% (2 patients died of myocardial infarction and 1 died
of respiratory failure following severe pneumonia). At 18 months the survival rate was around 65%.

REFERENCES
1. Jimenez, JC. Sexual dysfunction in men after open or endovascular repair of abdominal aortic aneurysms. Vascular. 2004, Vol.
12(3), 186-191.
2. Rosen, RC. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a
diagnostic tool for erectile dysfunction. International Journal of Impotence Research. 1999, Vol. 11, 319-326
3. Rosen, RC. The International Index of Erectile Function (IIEF): a multidimensional scale for assessment of erectile dysfunction.
Urology. 1997, Vol. 49, 822-830.
4. Machleder, HI. Sexual Dysfunction Following Surgical Therapy for Aorto-Iliac Disease. Vasc Endovasc Surg. 1975, Vol. 9(5), 283287.
5. Sabri, S. Sexual function following aorto-iliac reconstruction. Lancet. 1971, Vol. 4(2), 1218-9.
6. VanSchaik, J. Nerve-preserving aorto-iliac reconstruction surgery: anatomical study and surgical approach. J Vasc Surg. 2001, Vol.
33, 983-9.
7. Karkos, CD. Erectile dysfunction after open versus angioplasty aorto-iliac procedures: a questionnaire survey. Vasc Endovasc Surg.
2004, Vol. 38(2), 157-165.
8. Pettersson, M. Prospective follow-up of sexual function after elective repair of abdominal aortic aneurysm using open and endovascular techniques. J Vasc Surg. 2009, Vol. 50, 492-9.
9. Prinssen, M. Sexual dysfunction after conventional and endovascular AAA repair: results of the DREAM trial. J Endovasc Ther.
2004, Vol. 11, 613-620.
10. Lederle, FA. Quality of life, impotence, and activity level in a randomized trial of immediate repair versus surveillance of small
abdominal aortic aneurysm. J Vasc Surg. 2003, Vol. 38, 745-52.
11. Nevelsteen, A. Aorto-femoral reconstruction and sexual function: a prospective study. Eur J Vasc Surg. 1990, Vol. 4, 247-251.

CONCLUSION
When primary amputation is the only remaining option and after failed attempts of endovascular revascularization, and even in high risk patients, surgical Bypass must remain an option with a good average of survival,
patency rates, and limb salvage.

18

19

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Challenges in Lower Limb Endovascular Repair: How to Break the Limits


Bypass in the leg after failed endo repair. Do the results compare to first line
bypass?

 ortic Occlusive Disease


A
Landscape of error in aortic procedure

 arotid
C
Not all stenosis are at risk of stroke. Which ones should not be missed?

Stavros Kakkos1, Andrew Nicolaides2, Ioannis Tsolakis1

Imperial College London, London, United Kingdom

It is well known that a significant number of patients come to harm while in hospital 1. The highest rate of
adverse events is in patients undergoing intervention, especially in patients undergoing vascular procedures2.
Whilst the outcomes from endovascular techniques are a significant improvement on open surgery in elderly
patients with major comorbidity, the potential for error may be increased 3. It is important to map the intra-operative error pattern, determinants of error, and impact on outcomes if improvements in safety are to be made.
We have recently completed a multi-centre, observational study where twenty vascular teams in the UK, using
structured post-operative debriefs, reported system errors in open and endovascular aortic procedures.

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

In the lead up to the study teams trained in self-reporting of intra-operative errors and the debriefing tool in
88 cases showing a strong correlation between observer and teams for the number and type of errors per
procedure. Subsequently, in 185 aortic cases, operating teams self-reported errors (median 3 errors/procedure
(interquartile range 2-6)). Fourteen errors directly harmed twelve patients (6.5% of the cohort).
There was a wide variety of errors reported, however, most frequently errors related to equipment (unavailability/failure/configuration/desterilization) and most frequent major or harm-producing errors were communication failures.
Significant predictors of increased error rate were endovascular procedures, repair of thoracic aneurysms
relative to other aortic pathologies and equipment unfamiliarity. Unfamiliarity with equipment was the single
factor associated with increased major error rate. This study is important as the errors detected here, which
were most often dealt with by expert teams, were related to adverse outcomes. Major intra-operative errors
were associated with reoperation, major complications and death.
In aortic procedures, there is a wide variety of errors made by specialist vascular teams over and above
technical errors that are often the focus of training. This study found that errors are commonly caused by
team-working and equipment-related issues, and are directly associated with patient harm in 6.5% of the
cohort.
There are many avenues for vascular surgeons to improve outcomes. As a priority, multi-disciplinary team-training, leadership development, effective technology utilisation, and new-device accreditation are recommended.
REFERENCES
1. Vincent. Understanding and Responding to Adverse Events. N Engl J Med. 2003;348(11):10516.
2. Leape LL, Brennan TA, Laird N, Lawthers A, de Leval MR, Barnes BA, et al. THE NATURE OF ADVERSE EVENTS IN HOSPITALIZED
PATIENTS Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):37784.
3. Albayati MA, Gohel MS, Patel SR, Riga C V, Cheshire NJW, Bicknell CD. Identification of patient safety improvement targets in
successful vascular and endovascular procedures: analysis of 251 hours of complex arterial surgery. Eur J Vasc Endovasc Surg.
2011;41(6):795802.

20

1. University of Patras, Patras, Greece


2. Nicosia Medical School, Nicosia, Cyprus

21

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Colin Bicknell

Rda Hassen-Khodja, Elixne Jean-Baptiste


REFERENCES
1. Moore DJ, Miles RD, Gooley NA, Sumner DS. Noninvasive assessment of stroke risk in asymptomatic and nonhemispheric patients
with suspected carotid disease. Five-year follow-up of 294 unoperated and 81 operated patients. Ann Surg 1985;202(4):491-504.
2. MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid
endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004;363(9420):1491-502.
3. Nicolaides AN, Kakkos SK, Kyriacou E, Griffin M, Sabetai M, Thomas DJ, et al. Asymptomatic internal carotid artery stenosis and cerebrovascular risk stratification. J Vasc Surg 2010;52(6):1486-1496 e1-5.
4. Kakkos SK, Griffin MB, Nicolaides AN, Kyriacou E, Sabetai M, Tegos T, et al. The size of juxtaluminal hypoechoic area in ultrasonic
images of asymptomatic carotid plaques predicts the occurrence of stroke. J Vasc Surg 2013;57(3):609-618.
5. Kakkos SK, Nicolaides AN, Charalambous I, Thomas D, Giannopoulos A, Naylor AR, et al. Predictors and clinical significance of progression or regression of asymptomatic carotid stenosis. J Vasc Surg 2014;59(4):956-967 e1.
6. AbuRahma AF, Metz MJ, Robinson PA. Natural history of > or =60% asymptomatic carotid stenosis in patients with contralateral
carotid occlusion. Ann Surg 2003;238(4):551-61; discussion 561-2.
7. Handa N, Matsumoto M, Maeda H, Hougaku H, Kamada T. Ischemic stroke events and carotid atherosclerosis. Results of the Osaka
Follow-up Study for Ultrasonographic Assessment of Carotid Atherosclerosis (the OSACA Study). Stroke 1995;26(10):1781-6.
8. Markus HS, King A, Shipley M, Topakian R, Cullinane M, Reihill S, et al. Asymptomatic embolisation for prediction of stroke in the
Asymptomatic Carotid Emboli Study (ACES): a prospective observational study. Lancet Neurol 2010;9(7):663-71.
9. Topakian R, King A, Kwon SU, Schaafsma A, Shipley M, Markus HS. Ultrasonic plaque echolucency and emboli signals predict stroke
in asymptomatic carotid stenosis. Neurology 2011;77(8):751-8.
10. Kakkos SK, Sabetai M, Tegos T, Stevens J, Thomas D, Griffin M, et al. Silent embolic infarcts on computed tomography brain scans and
risk of ipsilateral hemispheric events in patients with asymptomatic internal carotid artery stenosis. J Vasc Surg 2009;49(4):902-9.

22

Nice University Hospital, France

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

23

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

 arotid
C
Duel. There is no need for a new trial comparing intervention and medical
treatment for carotid stenosis
For the motion

group can be spared from carotid intervention and efforts can be concentrated to aggressive medical management, investigation for disease in other vascular beds, and patient follow-up. However, the decision to
intervene should not be based exclusively on risk stratification, but also on the anatomical characteristics
of the stenosis, patient fitness for surgery and expected survival, the perioperative stroke and death rate
of the surgeon and patient willingness to take the small short-term risk of surgery for a possible greater
long-term benefit.

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

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

Wesley Moore

University of Oxford, Oxford, United Kingdom

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

Los Angeles, USA


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

24

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Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Alison Halliday

Carotid
Some tricks to improve CAS results
Can CAS Improve Cognitive Function?

Peter Schneider

Christos Liapis, Constantine Antonopoulos

Kaiser Foundation Hospital, Honolulu Hawaii, USA

INTRODUCTION
Both carotid stenting (CAS) and carotid endarterectomy (CEA) provide long-term protection against stroke
due to carotid disease, beyond the perioperative period. Currently CAS is used mainly among selected
patients that are at high risk for CEA. This is because several randomized trials have shown that there is
a higher risk of perioperative stroke, especially minor stroke, with CAS. The only way that CAS could be
considered more broadly applicable is if the causes of CAS-related perioperative stroke could be addressed.
In this talk, we will review two options in development for reducing the stroke risk of CAS; proximal protection and mesh covered stents.

University of Athens, Medical School, Athens, Greece


Carotid artery stenting (CAS) has been proposed as an alternative procedure to carotid endarterectomy
(CEA) for reducing the risk of stroke, at least in some subgroups of patients with significant extracranial
carotid stenosis. Cognitive function is being increasingly recognized as an important outcome measure that
affects patients well-being and functional status. However, the effect of CAS on neurocognitive functions
in patients with extracranial carotid disease is still controversial. Several reports using transcranial Doppler
have documented a significant number of microemboli during CAS 1, whereas diffusion-weighted magnetic
resonance imaging (DW MRI) has revealed that a large proportion of patients may develop new brain lesions 2. Although most of the identified new cerebral infarcts after CAS are subclinical, there are concerns
that these lesions might be associated with subtle long-term neurologic changes and deterioration of
cognition 3. On the other hand, some studies, including a recent randomized control study (RCT) 4, reported
an overall improvement in cognitive function after CAS. The controversy has been intense and prolonged,
because many studies have evidenced that the procedure-associated microembolization may be associated
with poor cognitive function and memory decline after CAS 1, but, on the contrary, others have evidenced
an improve in cognitive function as a result of normalization of blood flow, especially among the elderly
with severe carotid stenosis 5. As a consequence, it is difficult to predict whether CAS will ultimately result
in improvement or worsening of cognitive function.

DATA AND DISCUSSION


The main difference between CAS and CEA in the CREST Trial, ICSS, SPACE, and EVA-3S has been a higher
rate of perioperative stroke with CAS. Stroke risk could be reduced with more complete cerebral protection.
Studies with transfemoral, filtered CAS show that there is an increase in DW-MRI hits on immediate postop brain scans. Using detection of subclinical ischemic lesions as a surrogate for neurological damage, it
has become clear that proximal protection offers more complete cerebral protection. This has been manifested clinically with use of the MOMA device (Armour Study) and the Parodi reversed flow device (Empire
Study; Parodi device not currently available) or a direct transcervical approach to the neck with reversal
of flow into a vein and proximal clamping of the artery. In addition, somewhere between one-third and
half of perioperative stroke events occur between 24 hours and 30 days. This is long after the protection
device has been removed, suggesting that the stent is not adequate by itself to scaffold and contain the
lesion and that particulate matter can escape through the open cells of the stent. Mesh covered stents are
in development using PET, PTFE, or Nitinol mesh and clinical studies are underway to define any potential
advantages of this approach.

A subgroup analysis of patients of the International Carotid Stenting Study (ICSS) undergoing neuropsychological examination showed that differences between CAS and CEA on cognition at 6 months after revascularization were small and not statistically relevant, despite new ischemic lesions found twice as often
after CAS than after CEA 6. Chen et al. demonstrated that successful intervention increased cerebral perfusion and improved neurocognitive function in patients with asymptomatic ICA stenosis 7. Furthermore,
a prospective study analyzed neuropsychological outcomes with a multiple domains test battery and DW
MRI lesions evidenced that none of the cognitive domains decreased significantly at 72 hours after CAS
and the overall cognitive performance was not significantly different between patients with and without
new diffusion-weighted MRI lesions 8. As a result, due to the fact that current literature provides conflicting
evidence concerning the effect of CAS upon cognitive function, a meta-analysis comprising of all available
data may provide with additional information.

CONCLUSION
CAS must be made safer in the perioperative period to be more clinically useful. Some advancements that
may assist in this endeavor include proximal protection and mesh covered stents.

In order to delineate the influence of CAS upon cognition, our recent meta-analysis 9 included all studies
evaluating various domains of cognitive function before and after CAS, namely: a) global cognition using
Mini-Mental State Examination (MMSE) and Rey Auditory Verbal Learning Test (RAVLT), b) executive function using Trail Making Test (TMT) A or Color Trails Test (CTT) A and TMT B or CTT B, c) language ability
using Boston Naming Test (BNT), d) memory, e) attention/psychomotor speed and f) functional ability, using
various cognitive tests. Sixteen studies were eligible, including a total of 626 CAS patients. A statistically
significant improvement of global cognition was detected with MMSE, but not with RAVLT. Significant
improvement of memory and attention/psychomotor speed was also detected, whereas no statistically significant effect on executive function (TMTA/CTTA and TMTB/CTTB), language ability (BNT) and functional
ability was observed.
The clinical assessment of cognitive function is usually difficult to perform. Many approaches regarding the
timing of assessment after CAS and the type of tests have been used for that purpose. There are also various possible confounding factors such as age, symptomatic status, contralateral carotid or vertebral artery
disease, severity of carotid stenosis, the use of protection devices and others. The results of our recently
published meta-analysis suggested that CAS may be associated with improvement, at least in certain do26

27

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

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

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

28

Marc Van Sambeek

Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands


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

29

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Flash news. The Latest of EVAR Technology


PTFe grafts

mains of cognitive function. Given this background, it might be possible that the investigation of cognitive
function with additional studies, evaluating the long-term effect of CAS in larger groups of patients may
increase our understanding regarding the functional impact of extracranial carotid disease and may refine
our selection criteria for revascularization.

Flash news. The Latest of EVAR Technology


Latest flexible graft design and early results

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

Aix-Marseille universit, APHM, Hpital de la Timone, Service de Chirurgie Vasculaire, Marseille,


France

Janet Powell

Imperial College, London, United Kingdom

The Zenith Alpha Endovascular Graft system was developed to meet the challenges of aortic disease. The
Zenith Alpha Endovascular Graft system have been engineered for an easy repair that doesnt compromise
precision or control. Zenith Alpha Abdominal and Zenith Alpha Thoracic have been design to provide a
durable repair that helps physicians to manage disease progression and give more patients successful
long-term outcomes. 16F to 20F delivery system for Zenith Alpha Thoracic and 16F delivery system for
Zenith Alpha Abdominal An extensive range of sizes to suit many patient types. In 2015, to study report
the initial results with those new devices, and both conclude to an expanded endovascular aortic repair
applicability in patients with smaller access vessels 1, 2

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

REFERENCES
1. Illig KA, Ohki T, Hughes GC, et al. One-year outcomes from the international multicenter study of the Zenith Alpha Thoracic Endovascular Graft for thoracic endovascular repair. J Vasc Surg. 2015.
2. Torsello GF, Austermann M, Van Aken HK, et al. Initial clinical experience with the zenith alpha stent-graft. J Endovasc Ther.
2015;22:153-9.

30

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Michel Bartoli

31

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

How Can We Improve the Results of EVAR



The dead space in AAA sac is the ultimate enemy
EVAS: any doubt left after more than 300 procedures and the European register?

Department of cardio-vascular surgery. La Rabta Hospital, Tunis, Tunisia

Ian Loftus

St Georges Vascular Institute, London, United Kingdom


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

INTRODUCTION
Endovascular aneurysm sealing (EVAS) has been proposed as a novel alternative to endovascular aneurysm
repair (EVAR) in patients with infra-renal abdominal aortic aneurysms (AAA). The early clinical experience,
technical refinements and learning curve of EVAS in the treatment of AAA in a single institutional experience of 105 patients with mid-term follow up, will be presented and put into the context of the global
EVAS Registry of 300 cases1,2.
METHODS
One hundred and five patients were treated with EVAS between March 2013 and November 2014. Prospective data were recorded on consecutive patients receiving EVAS. Data included demographics, preoperative aneurysm morphology and 30-day outcomes, including rates of endoleak, limb occlusion, reintervention and death. Post-operative imaging consisted of duplex ultrasound and computed tomographic
angiography.
RESULTS
The mean age of the cohort was 76 8 years and 12% were female. Adverse neck morphology was present in 72 (69%) patients, including aneurysm neck length <10mm (20%), neck diameter >32mm (18%),
-angulation >60 (21%) and conical aneurysm neck (51%). There was one death within 30 days. The
incidence of type I endoleak within 30-days was 4% (n=4); all were treated successfully with transcatheter
embolization. All four proximal endoleaks were associated with technical issues that resulted in procedure
refinement, and all were in patients with adverse proximal aortic necks. The persistent Type 1 endoleak
rate at 30-days was 0% and there were no Type 2 or Type 3 endoleaks. Angioplasty and adjunctive stenting
were performed for postoperative limb stenosis in three patients (3%).
CONCLUSIONS
EVAS is associated with good early and mid term outcomes despite the necessity of procedural evolution
in the early adoption of this technique. The EVAS Global registry is demonstrating similar outcomes. EVAS
appears to be applicable to patients with challenging aortic morphology and endoleak rates should reduce
with procedural experience. The utility of EVAS will be defined by the durability of the device in long-term
follow-up, although the absence of Type 2 endoleaks is encouraging.

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

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Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Adel Khayati, Jihed Laribi, Sana Chatti, Jalel Ziadi, Karim Kaouel, Imed Khanfir

How Can We Improve the Results of EVAR



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

Nicla Settembre , Jean-Nol Albertini , Zakaryae Bouziane , Jean-Pierre Favre ,


Serguei Malikov1
1

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

1. Service de chirurgie vasculaire, CHU Nancy Brabois, France


2. Service de chirurgie vasculaire, CHU Saint-Etienne, France

INTRODUCTION
Endovascular procedures simulator technologies have greatly evolved over the last few years. Today, a wide
range of patient specific peripheral procedures may be simulated including EVAR. These technologies have
the potential not only to enhance training processes but also to reduce intraoperative complications. The
aim of this study was to present our preliminary experience in patient-specific rehearsal of EVAR procedures.

OBJECTIVES
The treatment of aneurysms of the abdominal aorta by endoprosthesis (stent) using a percutaneous strategy is optimal and safe therapeutic alternative to open surgery for the most fragile patients. Nevertheless such interventions are often performed under general anesthesia with systemic consequences. In our
center, the anesthetic strategy has evolved over the past four years toward the use of medical hypnosis in
the operating room. We conducted a study to assess the feasibility of medical hypnosis (MH) associated
with local anesthesia of scarpas in this indication and compare its safety and efficacy with that of general
anesthesia (GA).

MATERIALS AND METHODS


During the year 2014, eight patients were included in the study. Three Symbionix Angio Mentor Ultimate
simulators were loaded with Gore, Vascutek and Medtronic endograft software. After loading pre-operative
CT-scan DICOM images, patient specific rehearsal procedures were performed by three categories of operators (beginners, intermediates and experienced). Evaluation criteria were: procedure time, fluoroscopy
time, contrast load, choice and handling of wires, catheters and stent-grafts, intraoperative complications
(endoleak and coverage of side branches).

METHODS
Aortic endoprosthesis procedures were allocated into 2 groups (Group 1: GA and Group 2: MH) mainly depended on the availability of an anesthesiologist experienced in medical hypnosis attending the operating
room Based upon anticipated operating table of elective procedures, we managed to constitute 2 equal
groups, including all consecutive patients during the study period. The following outcome parameters were
compared between groups: success of the procedure, pain and comfort, t duration of the procedure, need
for vasopressors introduction and dosage.

RESULTS
A significant improvement of evaluation criteria was observed for all operators throughout the study period. Various intraoperative strategies were used only by experienced and intermediate operators.

RESULTS
52 patients were allocated into each of two groups. Patient characteristics were comparable in terms of
risk factors and ASA scores. All aortic endoprosthesis were successfully done. None of the patients of MH
requested conversion to general anesthesia. In MH, 23 patients were placed standard endoprosthesis but
three complex cases included fenestrated endoprosthesis placement (n=2) and abdominal aneurysm ruptured in its initial phase (n=1). The durations of interventions, comfort and pain scores were comparable in
both groups.. Five patients of MH group received vasopressors versus 20 patients in the GA group. When
requested the total dosage of epinephrine was significantly lower in the MH group (number), although it
remained low in both groups.

CONCLUSION
This preliminary study shows that EVAR patient specific rehearsal procedures using simulators have to potential to decrease procedure and fluoroscopy time, contrast load as well as the incidence of intraoperative
complications. Randomized studies are currently underway in order to assess the impact of this strategy
on patient postoperative outcome.

CONCLUSION
To our knowledge, this is the first study of this magnitude evaluating MH for acts of vascular surgery including endovascular treatment of aneurysms. MH promotes comfort and optimal interventional conditions
appear to be safe and reliable. It allows preventing and reducing the use of vasopressors. Moreover, we observed that MH improved patients operating experience as well as both that of the medical and paramedical team in the operating room. A randomized study is now ongoing to consolidate these feasibility results.

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Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

How Can We Improve the Results of EVAR



How to improve results and cost of EVAR
Can we reduce costs and optimize EVAR procedures with Patient Rehearsal
Simulators?

How Can We Improve the Results of EVAR



How to improve results and cost of EVAR
Why stopping the follow up put your patients at risk

Thomas Larzon

Michel Bartoli

Orebro, Sweden

Aix-Marseille universit, APHM, Hpital de la Timone, Service de Chirurgie Vasculaire, Marseille,


France

OBJECTIVES
To investigate whether the fascia suture technique (FST) can reduce access closure time and procedural
costs in comparison to the Prostar technique (Prostar) in patients undergoing endovascular aortic repair
and to evaluate short- and mid-term outcome of both techniques.

The aim of the surveillance after EVAR is to detect asymptomatic issues on the stentgraft to avoid potentially severe consequence such as aneurysm rupture or limb ischemia. All the study have demonstrated the
need for this surveillance even with the last stentgraft generation. The results of the principal randomized
trials have demonstrated the short term benefits of endovascular surgery over conventional surgery 1, 2.
However, no difference were seen in total mortality or aneurysm related mortality in the long term, thus
stopping the EVAR follow up we might observe an increased late mortality after this technique leading to
make much more questionable the use of this technique to treat AAA. Some authors advocate to reduce or
even to stop the follow-up in patients with initial good evolution after EVAR, in general this good evolution
is defined as a significant diameter reduction of the sac. In our experience with have shown that exclusion
of AAA with a diameter reduction of at least 10 mm significantly reduces the rate of secondary procedures
and AAA rupture, however, in those patients we observed that even after an important diameter reduction
the development of a very late type 1 endoleak is still possible even 10 years after graft implantation and
lead to a fast AAA growth with a concomitant risk of rupture 3. In our mind aneurysmal disease progression
plays an important role in the durability of endovascular therapy in the long term. Finally the recommendation from the North American and European society of vascular surgery based largely on expert opinion
and high-quality evidence still recommend a lifelong surveillance after EVAR. To take into account the low
rate of secondary procedure in patient with aneurysm sac decrease after EVAR color duplex ultrasonography is suggested as an alternative to CT imaging for annual postoperative surveillance 4.

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

REFERENCES
1. Greenhalgh RM, Brown LC, Kwong GP, et al. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet. 2004;364:843-8.
2. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic
aneurysms. N Engl J Med. 2004;351:1607-18.
3. Soler RJ, Bartoli MA, Mancini J, et al. Aneurysm sac shrinkage after endovascular repair: predictive factors and long-term follow-up. Ann Vasc Surg. 2015;29:770-9.
4. Chaikof EL, Brewster DC, Dalman RL, et al. SVS practice guidelines for the care of patients with an abdominal aortic aneurysm:
executive summary. J Vasc Surg. 2009;50:880-96.

CONCLUSIONS
In aortic endovascular repair FST is a faster and cheaper technique in comparison to the Prostar technique.

36

37

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

How Can We Improve the Results of EVAR



How to improve results and cost of EVAR
Fascia suture is cheaper than preclosing device but is it as safe?

Kimihiro Komori

Division of Vascular Surgery, Department of Surgery, Nagoya University Graduates School of


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

38

Friday January 22

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

How Can We Improve the Results of EVAR



How to improve results and cost of EVAR
What are the specific requirements and results of EVAR in Japanese patients?

39

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Friday January 22
- Vascular access -

40

41

FIGURES

Nirvana Sadaghianloo1, Alan Dardik2, Pierre-Emmanuel Haudebourg1,


Elixne Jean-Baptiste1, Serge Declemy1, Rda Hassen-Khodja1

1. Centre Hospitalier Universitaire de Nice, Nice, France


2. Yale University School of Medicine, New Haven, USA

INTRODUCTION
Although radial-cephalic fistulae are the preferred hemodialysis access, juxta-anastomotic stenosis is often
responsible for their early failure.1-2 We hypothesized that wall ischemia from surgical manipulation leads
to early juxta-anastomotic neointimal hyperplasia and failure of maturation,3 and that minimal venous
dissection will improve fistula maturation and patency rates. We therefore developed a construction technique named Radial Artery Deviation And Reimplantation (RADAR) (Fig. 1).4 The aim of this study was to
assess the safety and efficacy of the RADAR technique for primary fistulae, in comparison with traditional
radial-cephalic fistulae.

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

METHODS
We retrospectively reviewed our prospectively maintained database of patients undergoing creation of
radial-cephalic fistulae. All consecutive RADAR fistulae constructed between October 2014 and June 2015
were reviewed. Duplex-ultrasound examination was performed regularly to monitor maturation (access
flow 500ml/min and venous diameter 5mm) and diagnose juxta-anastomotic stenosis. Primary patency, secondary patency, and reintervention rates were compared with those of our own historical control
group, which included all consecutive traditional radial-cephalic fistulae 5 constructed between May 2013
and September 2014. Kaplan-Meier and Log-Rank analysis were used to estimate patency rates. Categorical variables were compared with Fisher exact test and continuous variables with the analysis of variance
and post-hoc analysis.
RESULTS
53 RADAR fistulae and 73 control fistulae were included. The mean follow-up was 7.9 months for RADAR
group and 7.8 months for control group. Baseline patient characteristics were similar in both groups, although RADAR group included patients with significantly smaller veins (Table 1). 75% of RADAR fistulae
(40/53) were mature by 6 weeks (mean access flow: 693 ml/min (131); mean venous diameter: 6.3 mm
(0.9)) and 92% (49/53) were mature by 3 months (mean access flow: 756 (179) ml/min; mean venous
diameter: 6.8 (1) mm). Access flow, venous diameter and arterial diameter increased significantly for all
RADAR patients during follow up (Fig. 2). No ischemic syndrome or thrombosis occurred in RADAR group.
At 6 months, the primary patency rate was 93% in RADAR group compared with 53% in control group
(Fig. 3) A, p< 0.00001), and the secondary patency rate was 100% in RADAR group compared with 91%
in the control group (Fig. 3B, p=0.008). The reintervention rate for juxta-anastomotic stenosis was 9% in
RADAR group (1 on the vein at 8 months, and 4 on the artery, 1-3 months after creation), compared with
29% in the control group.

Fig. 2. Access flow and vessel diameter.

CONCLUSION
The RADAR technique for fistula construction provides excellent maturation and patency rates compared
with traditional radial-cephalic fistulae with venous deviation.

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


42

43

Friday January 22 - VASCULAR ACCESS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

 ascular Access News


V
Eradication of juxta-anastomosis stenoses in radio-cephalic fistulae:
the RADAR technique

TABLE

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

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

T ricks of the Trade for a Safe Cannulation Technique


Make it easier (transposition, elevation and lipectomy)

RADAR group
(N=53)

Pierre Bourquelot

P
N
70

(%) or (SD)
(13)

N
66

(%) or (SD)
(17)

54
19

(74)
(26)

37
16

(70)
(30)

.70

25
60
8
16
12

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

16
41
1
11
9

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

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

10
36
33
32

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

8
23
18
11

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

>.99
.59
.27
.008

2.7
3.6

.6
1

2.5
3.1

.4
.9

.07
.01

.12

Paris, France

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

SD: Standard deviation.


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

CONCLUSIONS
Tunnel-transposition and lipectomy are efficient techniques to allow easy needling of deeply situated veins
(upper-arm basilic vein and tight femoral vein), and cephalic vein in obese patients, respectively.
LEGENDS

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

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


44

45

Friday January 22 - VASCULAR ACCESS

Control group
(N= 73)

 ebate. Vascular Access in the Elderly: Native or Prosthetic?


D
A venous access is always better

There are huge differences in vascular access practice patterns among continents, countries, regions, hospitals and practising surgeons. Many authors report inferior patency rates of arteriovenous fistulas in elderly
patients and others present contradictory results. There are centers and surgeons who perform exellent
practices on the same patient groups.
In a study by Hicks et al. all patients 18 years in the United States Renal Data System between the years
2006 and 2010 were analyzed. They found that the mortality benefit of AVF was consistently superior to
that of AVG and HC for patients of all ages (all, P < .001), and concluded, AVF is superior to AVG and HC
regardless of the patients age, including in octogenarians 1.
Ravani et al. in their systematic review 2 found that, compared with persons with fistulas, those individuals
with grafts had increased all-cause mortality (1.18) and fatal infection (1.36). Surgical training is key to
both fistula placement and survival, and enhancing surgical training in fistula creation would help meet
targets of the Fistula First Initiative.
Saran et al., showed the risk of primary fistula failure was 34% lower when placed by surgeons who created >25 (vs. <25) fistulae during training 3. It was also shown by Choi et al. 4 that surgeon selection also
has an important impact on access placement. Fistulae placement occurred in 98% vs. 71% for surgeon I
and II, respectively, despite patients all have the same characteristics and similar findings on preoperative
vascular mapping.
HenricusHJ et al, in their study in 11 centers in the Netherlands has shown, hospital specific aspects predominantly determine primary failure of hemodialysis arteriovenous fistulas 5. Primary failure occurred in
one third of the 395 patients. Primary failure rate among the participating centers varied from 8% to 50%.
This study shows that the probability of primary failure is strongly related to the center of access creation,
suggesting an important role for the vascular surgeons skills and decisions.
Weale, et al. examined the effect of age group (<65, 65 to 79, >80) on functional outcomes in RCVAFs
and BCAVFs, and found that age did not affect usability, primary or secondary patency of either RCAVFs or
BCAVFs. They concluded, even patients >80 years who are considered suitable for surgical placement of
access should not be denied a RCAVF solely because of age 6. Jennings, et al. stratified patients >65 years
old into three 10-year increments by age. Functional patency data is compared with non-elderly patients
aged 21 to 64 years treated during the same time period. They found AVFs are feasible and offer functional
and timely AV access in older patients. There was no difference in functional access outcomes for older patients with subgroup age stratification. AVF patency rates were not statistically different in the elderly and
non-elderly populations. Cumulative AVF patency for patients > 65 years of age was 96.9% at 12 months
and 94.6% at 24 months 7.
Borzumati et al. also concluded that, choosing vascular access sites to be created in elderly patients is no
different than for younger patientsan AVF remains the gold standard in their study including 78 patients,
aged 75 with a mean age of 82.57.5 8.
In their retrospective study on hemodialysis patients older than 80 years, Oded Olsha et al. reported
24-month secondary patency of 84% for radial-cephalic (forearm) accesses and 88% for brachial-cephalic
(upper arm) accesses. They concluded; contrary to recent recommendations favoring grafts for hemodialysis
in patients older than 80 years, most elderly patients in this study were found to have vasculature that was
suitable for autogenous access construction, with patency rates similar to those of their younger counterparts. Age alone should not disqualify patients older than 80 years from access surgery for hemodialysis 9.

Fig.2. Femoral vein superficialization

Fig.3. Lipectomy
REFERENCES
1. Marzelle J. Bourquelot P. Abords vasculaires dhmodialyse: principes, abords artrioveineux natifs. EMC - Techniques chirurgicales
- Chirurgie vasculaire 2014; 9: 1-27
2. Gradman WS.,Laub J.,Cohen W. Femoral vein transposition for arteriovenous hemodialysis access: improved patient selection and
intraoperative measures reduce postoperative ischemia. J Vasc Surg 2005; 41: 279-284
3. Bourquelot P.,Rawa M.,Van Laere O.,Franco G. Long-term results of femoral vein transposition for autogenous arteriovenous
hemodialysis access. J Vasc Surg 2012; 56: 440-445
4. Bourquelot P.,Tawakol JB.,Gaudric J. Lipectomy as a new approach to secondary procedure superficialization of direct autogenous
forearm radial-cephalic arteriovenous accesses for hemodialysis. J Vasc Surg 2009; 50: 369-374

46

Istanbul Med.Fac. Gen.Surg.Clinic CAPA, Istanbul, Turkey

47

Friday January 22 - VASCULAR ACCESS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Selcuk Baktiroglu, Fatih Yanar

David Shemesh, Oded Olsha, Goldin Ilya


The KDOQI guidelines recommend radial cephalic fistula as the first approach to hemodialysis access. Elbow fistula comes second and third is the basilic vein. Only then should graft be an option1. But is this really
justified in the elderly? These guidelines were first written in 1996 and are not relevant today following the
dramatic increase in the number of elderly patients that has occurred since that time. Many elderly patients
have comorbidities, mainly diabetes mellitus and ischemic heart disease, which increases the operative
risk. Due to these comorbidities with their related hospitalizations the veins are exhausted, the arteries
are severely calcified and the risk of primary failure is high. Even if we agree that native fistulas should be
constructed, there is a high risk of maturation failure and these older patients may never use the fistula. The
life expectancy of elderly patients on hemodialysis is so short that half of them will die within less than 2
years, suggesting that half of the fistulas would be unusable, 2-4 and providing a functioning radial cephalic
fistula before they die is a target that is very difficult to meet. A meta-analysis of dialysis access outcome in
elderly patients has recommended not placing radial cephalic fistulas, suggesting that resources should not
be wasted on radial cephalic fistula in the elderly.5 The claim that fistulas do better than grafts is a myth.
In fact there is sparse evidence in favor of fistulas over grafts. A review of 1,700 cases comparing fistulas
and grafts found no difference in long-term patency. 6 Another study showed similar patency for grafts and
fistulas but with higher primary failure in fistulas. 7 Complying with fistula first at any price will lead to
60% of the fistulas not being suitable for dialysis at six months.8 But if the survival of elderly patients with
a catheter is only about 9 months many will die before ever using the fistula. Octogenarian patients with a
fistula have a 77% greater risk of initiating dialysis via a catheter compared to those with a graft.9 Simply
put, when we create a fistula in elderly patients we increase their risk of dying from catheter complications
by 77%. Fistula first does not seem to be clearly superior to graft placement first in the elderly and graft
might be a better option. Grafts can do better than fistulas, with many centers reporting excellent outcomes with grafts which are superior to those of native fistulas, with a secondary patency of 91% at one
year. 10 The best option for the elderly patient is clearly an early cannulation graft with cannulation started
within 48 hours (without the need for a tunneled catheter) and with an incomparable 93% secondary
patency. 11 In conclusion in elderly patients graft construction, preferably using early cannulation grafts, is
the gold standard for vascular access. It may even be better to place a catheter in the elderly patient rather
than wasting resources on a radial cephalic fistula.

REFERENCES
1. Hicks CW, et al.: Mortality benefits of different hemodialysis access types are age dependent. J Vasc Surg 2015 Feb;61(2):449-56.
2. Ravani P, et al.: Associations between Hemodialysis Access Type and Clinical Outcomes: A Systematic Review J Am Soc Nephrol.
2013 Feb 28; 24(3): 465473.
3. Saran R et al.: Enhanced Training in Vascular Access Creation Predicts Arteriovenous Fistula Placement and Patency in Hemodialysis Patients, Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS), Ann Surg 2008;247: 885891.
4. Choi KL et al.: Impact of surgeon selection on access placement and survival following preoperative mapping in the Fistula First
era. Semin Dial.2008 Jul-Aug;21(4):341-5
5. HuijbregtsHJ et al: Hospital specific aspects predominantly determine primary failure of hemodialysis arteriovenous fistulas, J Vasc
Surg 2007;45:962-7
6. Weale AR et al: Radiocephalic and brachiocephalic arteriovenous fistula outcomes in the elderly, J Vasc Surg 2008;47:144-50.
7. Jennings WC et al: Creating functional autogenous vascular access in older patient, J Vasc Surg 2011;53:713-9.
8. Borzumati M et al:Survival and complications of arteriovenous fistula dialysis access in an elderly population. J Vasc Access
2013;14 (4): 330-334
9. Olsha O et al: Vascular access in hemodialysis patients older than 80 years J Vasc Surg 2015;61:177-83.

48

Shaare Zedek Medical Center, Jerusalem, Israel

REFERENCES
1. Clinical practice guidelines for vascular access. American journal of kidney diseases: the official journal of the National Kidney
Foundation. 2006;48 Suppl 1:S176-247.
2. Letourneau I, Ouimet D, Dumont M, Pichette V, Leblanc M. Renal replacement in end-stage renal disease patients over 75 years
old. American journal of nephrology. 2003;23(2):71-77.
3. Joly D, Anglicheau D, Alberti C, et al. Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes. Journal of the American Society of Nephrology: JASN. 2003;14(4):1012-1021.
4. Vachharajani TJ, Moossavi S, Jordan JR, Vachharajani V, Freedman BI, Burkart JM. Re-evaluating the Fistula First Initiative in Octogenarians on Hemodialysis. Clinical journal of the American Society of Nephrology: CJASN. 2011;6(7):1663-1667.
5. Lazarides MK, Georgiadis GS, Antoniou GA, Staramos DN. A meta-analysis of dialysis access outcome in elderly patients. Journal
of vascular surgery. 2007;45(2):420-426.
6. Schild AF, Perez E, Gillaspie E, Seaver C, Livingstone J, Thibonnier A. Arteriovenous fistulae vs. arteriovenous grafts: a retrospective
review of 1,700 consecutive vascular access cases. The journal of vascular access. 2008;9(4):231-235.
7. Lok CE, Sontrop JM, Tomlinson G, et al. Cumulative patency of contemporary fistulas versus grafts (2000-2010). Clinical journal
of the American Society of Nephrology: CJASN. 2013;8(5):810-818.
8. Dember LM, Beck GJ, Allon M, et al. Effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis: a randomized
controlled trial. JAMA: the journal of the American Medical Association. 2008;299(18):2164-2171.
9. DeSilva RN, Patibandla BK, Vin Y, et al. Fistula first is not always the best strategy for the elderly. Journal of the American Society
of Nephrology: JASN. 2013;24(8):1297-1304.
10. Dammers R, Planken RN, Pouls KP, et al. Evaluation of 4-mm to 7-mm versus 6-mm prosthetic brachial-antecubital forearm loop
access for hemodialysis: results of a randomized multicenter clinical trial. Journal of vascular surgery. 2003;37(1):143-148.
11. Tozzi M, Franchin M, Ietto G, et al. Initial experience with the Gore(R) Acuseal graft for prosthetic vascular access. The journal of
49
vascular access. 2014;15(5):385-390.

Friday January 22 - VASCULAR ACCESS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

 ebate. Vascular Access in the Elderly: Native or Prosthetic?


D
A prosthetic option should always be favoured

CONCLUSION
Most elderly patients have suitable vessels for autogenous access construction, with patency rates similar
to those of their younger counterparts,and it is possible to achieve >90 % AVF rates even among elderly
patients.Early referral of CKD patients to nephrologists, early careful physical exam,preservation of arm
veins,routine Doppler vessel mapping,early referral to the right institution and surgeons,monitoring and
maintenance of AVF patency after construction are important points in reaching this high rates.

News
HeRO device: central vein recanalization may be difficult

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

1. Imagerie A interventionnelle, NHC, Strasbourg, France

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


Benedicte Stengel2

PURPOSE
Central venous catheterization is one of the most common procedures performed. We evaluated the results
using the HeRO Device in patient with central venous obstruction.

MATERIAL AND METHODS


In Two patients (1 male, 1 female; 52 -47 years old) the HeRO device was implanted after failed or infected
AV access. The patients were diabetics (1), obese (1), smoker (1). The duration of dialysis prior to the HeRO
placement was 15- 2 years. Patients presented both chronic brachiocephalic venous occlusion, jugular venous occlusion and superior vena cava patency.

1. Ambroise Par University Hospital, Boulogne-Billancourt, France


2. Equipe 5, Inserm UMR 1018, CESP; Paris-Sud University, Versailles St-Quentin University,
Villejuif, France
INTRODUCTION
Current guidelines recommend to start hemodialysis (HD) with a functionnal arterio-venous fistula (AVF)
that should be created 6 months before HD initiation. However, delay necessary to obtain a functionnal AVF
(F-AVF) and determinants of non functionnal AVF (NF-AVF) risk at HD initiation are poorly known.

RESULTS
Before HeRO device placement, one patient was treated by angioplasty and stenting , one patient was
treated by venous PTFE graft after failed recanalization. Technical success was achieved in each case. The
periprocedural complications were the high flow and hand ischemia; one patient needed the occlusion of
the device in emergency.

PATIENTS AND METHODS


Data was obtained from the French national REIN hemodialysis registry. We studied 53 092 incident HD
adult patients in France between 2005 and 2012. A NF-AVF was defined by initiating HD on a catheter in
patients whose AVF creation date was anterior to HD initiation. Adjusted odds-ratios (OR) of NF-AVF associated to demographic, and treatment factors were estimated through logistic regression.

CONCLUSION
The use of HeRO device is indicated in case of multiple failures of AVFs. A correct patient selection is essential to avoid implant failure and complications.

RESULTS
In total, 8,9% patients started HD on a NF-AVF, 47,4% on a F-AVF, and 43,8% on a catheter. The NF-AVF
patients were not different from the F-AVF patients regarding age, but women had a higher OR than men
(1.34; CI: 1.24-1.44). The OR was also higher for diabetics (1.24; CI: 1.11-1.37) and patients who started HD
in emergency (4.83; CI: 4.46-5.21). The OR also increased with the number of cardiovascular comorbidities.
When the delay of AVF creation was <30 days, comprised between 1 and 2 months, 2 and 3 months, 3 and
6 months and >6 months, rates of NF-AVF were 41.6%, 12.4%, 7.7%, 5.6% and 7.0%, respectively, in men
without diabetes and less than 2 cardiovascular comorbidities, whereas these rates were 55.6%, 17.7%,
12.8%, 8.2% and 8.7% in women, respectively. These rates increased by 62% and 58%, respectively, in
men and women with comorbidities. Rates of NF-AVF may have been underestimated due to missing datas
regarding AVF creation in patients initiating HD on a catheter.

DISCLOSURE
No

CONCLUSION
In France, the majority of HD patients have an their AVF creation before starting HD. To be functionnal, a
60 days delay appears to be sufficient in men without comorbidities but 3 months or more are necessary
in women of patients with comorbidities. Theses results underline the fact that guidelines regarding AVF
creation should be tailored to take in account risk of each subgroup to start HD without a F-AVF.

50

51

Friday January 22 - VASCULAR ACCESS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

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

 ebate. The Native Access is


D
A nightmare!

Richard Amerling

Mount Sinai Beth Israel, New York, USA


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

Friday January 22 - VASCULAR ACCESS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

REFERENCE
Amerling R, Ronco C, Kuhlmann M, Winchester JF. Arteriovenous Fistula Toxicity. Blood Purif 2011; 31.DOI: 10.1159/000322695

52

53

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Saturday January 23
- Main program -

54

55

FIGURES

 eripheral and Visceral Aneurysms


P
Epidemiology of popliteal aneurysms

Hopital Edouard Herriot, Lyon, France


Popliteal aneurysm (PA) is defined as a localized dilatation of the popliteal artery greater than 1.5 or 2 cm
or greater than at least 1.5 times the adjacent normal vessel.
The incidence is low in the general population, 1% in men older than 50 or between 65 and 80 1, 2.
The incidence rises to 8% in patients with abdominal aortic aneurysm 3.
In the Mayo Clinic database, PA was bilateral in 54% of the cases; an abdominal aortic aneurysm (AAA)
was present in overall 54% patients, in 65 % patients with bilateral AP and 42% patients with unilateral
AAA 4. In the Swedish Vascular Registry, PA was bilateral in 46.6% patients; an AAA was present in 37.4%
patients with bilateral AP and 28.1% patients with unilateral AAA 5.
The natural history is embolization and acute thrombosis leading to acute limb ischemia and risk major
amputation.
The mean increase in diameter is poorly studied, estimated to 1.5 mm/year for PA > 2 cm versus 0.7 mm/
year for PA < 2 cm 6.
In Sweden, the incidence of PA repair was estimated at 8.3 per million person-years between 1994 and
2001 5. In the Vascunet collaboration registry, the overall number of operations was 9.59 per million person-years between January 2009 and June 2012 7.
Among surgical patients, 95.6 % were men, with a median age of 70 year. Risk factors were current smoking (44%), HTA (72.4 %), diabetes (16.2 %), and patients had an history of cerebrovascular events (9%),
pulmonary (14%) or cardiac (37.1%) disease 7.
Clinical presentation of the limb varied between no symptom (40%), chronic limb ischemia (39%) and
acute limb ischemia (21%) 4.
In the Vascunet registry, elective surgery was performed in 72 % PA and emergency surgery in 28% including 1.8 % ruptured PA 7.
The major amputation rate was 2% 7, rising to 6.5 % in case or emergency repair: mortality was 0.1% after
elective surgery, 1.6% after emergency for thrombosis and 11.1% after procedure for rupture.

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

REFERENCES
1. Claridge M, Hobbs S, Quick C, Adam D, Bradbury A, Wilmink T. Screening for popliteal aneurysms should not be a routine part of
a community-based aneurysm screening program. Vasc Health Risk Manag. 2006;2:189-91.
2. Trickett JP, Scott RA, Tilney HS. Screening and management of asymptomatic popliteal aneurysms. J Med Screen. 2002;9:92-3.
3. Diwan A, Sarkar R, Stanley JC, Zelenock GB, Wakefield TW. Incidence of femoral and popliteal artery aneurysms in patients with
abdominal aortic aneurysms. J Vasc Surg. 2000:31:863-9.
4. Huang Y, Gloviczki P, Noel AA, Sullivan TM, Kalra M, Gullerud RE, Hoskin TL,Bower TC. Early complications and long-term outcome after open surgical treatment of popliteal artery aneurysms: is exclusion with saphenous vein bypass still the gold standard?
J Vasc Surg. 2007:45:706-713; discussion 713-5.
5. Ravn H, Bergqvist D, Bjrck M; Swedish Vascular Registry. Nationwide study of the outcome of popliteal artery aneurysms treated
surgically. Br J Surg. 2007;94:970-7.
6. Stiegler H, Mendler G, Baumann G. Prospective study of 36 patients with 46 popliteal artery aneurysms with non-surgical treatment. Vasa. 2002;31:43-6.
7. Bjrck M, Beiles B, Menyhei G, Thomson I, Wigger P, Venermo M, Laxdal E, Danielsson G, Lees T, Trong T. Editors Choice:
Contemporary treatment of popliteal artery aneurysm in eight countries: A Report from the Vascunet collaboration of registries.
Eur J Vasc Endovasc Surg. 2014:47:164-71.

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

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Anne Long

 ow and When Embolize the Sac


H
Cone Beam Guidance for Type II Endoleak

Philippe Cuypers, Rutger Stokmans, Yannick T Mannetje, Edith Willigendael, Joep Teijink,
Marc Van Sambeek

Herv Rousseau, Olivier Meyrignac, Bertrand St Lebes, Fatima Mokrane

CHU Rangueil, Toulouse, France

Catharina Hospital, Eindhoven, The Netherlands

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

INTRODUCTION
More than 20% of abdominal aortic aneurysms (AAAs) involve at least one common iliac artery (CIA)1.
Whenever possible, the CIA will serve as a distal sealing site for endovascular aneurysm repair (EVAR). Iliac
limbs up to 28 mm diameter are commercially available for the so-called bell- bottom technique. In cases
of CIAs larger than 24 mm, however, extension of the stent graft into the external iliac artery (EIA) is often
required to achieve adequate seal. Alternatively, in elective cases with suitable anatomy, common iliac
aneurysms may be treated with iliac branch devices or sandwich techniques in order to maintain inflow
into the IIA. The question is how far should one go and how many resources should be used to preserve
the IIA? And, in case one chooses to extend the stentgraft into the EIA and cover the IIA, is preemptive
coil-embolisation mandatory?
OBJECTIVES
We retrospectively analysed all patients who underwent EVAR with extension of the stentgraft into the
EIA. In our center, coverage of the IIA during EVAR was routinely performed without coil embolisation.
METHODS
From January 2010 until May 2015, 86 patients (95.3% men; mean age 74.1 years) underwent EVAR with
stent grafts extended into the EIA, all without prior coil embolisation. Aneurysm morphology was determined on preoperative computed tomography (CT) images. During follow-up, patients were interviewed
about buttock claudication. The occurrence of endoleaks and evolution of aneurysm diameter were assessed on CT and duplex ultrasonography.
RESULTS
At baseline, the mid-common iliac artery (CIA) diameter was 33.516.8 mm. Mean follow-up was 25.3
18.5 months. Buttock claudication occurred in seven (22.6%) patients, which persisted after 6 months in
only two cases of bilateral IIA coverage (clinical follow-up was initially performed on a subset of 32 patients and will be completed on all 86 patients by the time of presentation). Three type II endoleaks related
to IIA coverage were observed. Only one of these needed treatment. Aneurysm growth was not observed.
CONCLUSION
Endovascular treatment of aortoiliac aneurysm with coverage of the internal iliac artery but without
pre-emptive coil embolisation appears safe and effective and is very well tolerated by patients. This finding
is in line with the results of other studies in this field. This approach saves operating time, contrast load
and costs and may reduce complications compared to preoperative coil embolisation. However, a larger
population and longer follow-up is required to confirm our findings. Because of the promising results of
this technique, we recommend the use of branch devices, sandwich techniques or snorkels in selected
cases only.
REFERENCES
1. Armon MP, Wenham PW, Whitaker SC, Gregson RH, Hopkinson BR. Common iliac artery aneurysms in patients with abdominal
aortic aneurysms. Eur J Vasc Endovasc Surg. 1998;15:255-7.
2. Farahmand P, Becquemin JP, Desgranges P, Allaire E, Marzelle J,Roudot-Thoraval F. Is hypogastric artery embolization during
endovascular aortoiliac aneurysm repair (EVAR) innocuous and useful? Eur J Vasc Endovasc Surg 2008;35:429-35.
3. Tefera G, Turnipseed WD, Carr SC, Pulfer KA, Hoch JR, Acher CW. Is coil embolization of hypogastric artery necessary during
endovascular treatment of aortoiliac aneurysms? Ann Vasc Surg 2004;18:143-6.
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 ypogastric Arteries during EVAR


H
Should they be preserved at all cost?

 nusual Features of Endoleaks


U
Can Trauma Induce Type 3 Endoleak?

Richard McWilliams

Carlo Setacci

Royal Liverpool University Hospital, Liverpool, United Kingdom

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

University of Siena, Siena, Italy


INTRODUCTION
Despite the significantly reduced associated morbidity and mortality, endovascular repair of an abdominal
aortic aneurysm (EVAR) is not free of important complications. The aim of this study is to confirm if the occurrence of high-velocity traumas (HT) during EVAR follow up could facilitate late type 1, type 3 endoleak
(EL) and limb occlusion due to migration, disconnection and material fatigue.
METHODS
All Patients underwent abdominal aortic procedures in our Department from the 1st January 2011 to the
31 December 2014 were prospectively included in a dedicated database. All patients received a telephonic
interview to verify HT occurred during follow-up or,in case of secondary treatment, before the complication diagnosis. We, also, retrospectively analysed all patients underwent aortic reinterventions for late
type1,type 3 EL or limb occlusion (at least 6 months after primary procedure) due to migration, disconnection or graft material fatigue. To divide patients according to the risk of developing an EL we identified 7
predisposing factors(PF) (more than 10 mm distance between the lower renal artery and the covered graft,
less than 10 mm of overlapping graft-aorta in the proximal neck, more than 60 of angulation between
sovrarenal fixation stent and infrarenal graft, more than 60 between neck portion of the graft and the
distal part, more than 90 between aortic part of the graft and 1 iliac limb, less than 25 mm overlapping in
modular grafts, less than 15 mm of distal neck) at the follow-up Computed Tomography (CT) examination.
We divided patients in three groups: group A (low risk for EL, PF2), group B (intermediate risk, 3-5 PF)
group C (high risk, >5 PF).
RESULTS
During the study period we performed 37 secondary procedures (18 from our case series), 21 Type 1 EL, 8
type 3 EL and 7 limb occlusion. In the same period 254 Patients underwent EVAR. In complicated cases, 3
patients suffered an HT before developing the complication (3/37;8.1%), while in not complicated cases
only 1 patients suffered HT (1/234; 0.4%). The analysis of the preoperative CT examination evidenced that
patients with endoleak+HT were 2 in group B (intermediate risk) and 1 in group C (as the patients with no
endoleak+ HT), while the other 34 complicated patients were 26 in group A and 8 in group B.
CONCLUSIONS
HT seem to increase the risk of type 1, type 3 EL and limb occlusion, during EVAR follow-up. Larger data
are needed to confirm these preliminary findings.

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 nusual Features of Endoleaks


U
Type III Endoleak: Mechanism and Detection

Ronald Dalman

Portola Valley, USA


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

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

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

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J uxta / Supra Renal Aneurysm


Does renal angulation and respiratory induced deformations affect the long term
results of CH-EVAR and F-EVAR

Dissection
Imaging consideration for acute type B dissection
Michael Dake

Ian Loftus

Stanford University, Stanford, CA, USA

St Georges Vascular Institute, London, United Kingdom


Determining the best method of treatment for individual patients with Type B aortic dissections has always
presented a vexing challenge for physicians. Physicians are often faced with balancing the conservative
approach of medical management with the more aggressive approaches of surgical or endovascular treatments. With the high surgical mortality for patients presenting with acute complicated Type B dissections,
physicians have readily adopted thoracic endovascular aortic repair (TEVAR) as the accepted therapy for
this condition.
With newer TEVAR devices achieving a broad indication from the FDA approval for the treatment of all
Type B dissections and new insights regarding physiological predictors of future complications, physicians
have expanded their consideration of TEVAR to treat the multiple challenges of this etiology. In this regard, based on their performance in the study of acute complicated Type B dissection, both W.L. Gore and
Medtronic were awarded an FDA indication to treat all Type B dissections with their devices.
When considering a complex variety of relevant factors, such as the patients condition and various physiological predictors, an algorithmic approach may prove useful in deciding among treatment options. In
essence, an algorithm is meant to provide a simplified, stream-lined guide to decision making when numerous input considerations exist and often complicate therapeutic considerations.

INTRODUCTION
Fenestrated endografts are probably now the gold standard for the management of juxta-renal aneurysms. Large series demonstrate outcomes that are favourable compared to open surgery1.
However there are anatomical and other limitations with regard to fenestrated technologies. This has led
to the development of parallel graft solutions. Chimney stents alongside conventional endografts risk the
formation of gutters, promoting Type 1 endoleaks2.
Endovascular sealing with the Nellix device (EVAS) offers a novel solution for complex aneurysms, whereby parallel grafts can be deployed alongside the Nellix device. Polymer curing within the endobags will
tend to mold around the renal/mesenteric stents, reducing the risk of guttering and subsequent endoleaks.
A number of reports have demonstrated the feasibility of this technique3,4. We present the technique and
outcomes of our early experience of the ch-EVAS technique.
DRAFT RESULTS
We have treated 47 patients with greater than 3 month follow up including 8 triple renal and mesenteric,
7 double and 32 single renal chimneys. These include 3 ruptured and 4 mycotic aneurysms, and 7 EVAR
revisions. The majority of cases were unsuitable for FEVAR, and unfit for open surgery.
There were 2 early deaths including one patient with a ruptures juxtarenal aneurysm. One elective patient
died of multiple systemic embolization. Three early type 1 endoleaks were successfully treated with embolization. There was a single limb occlusion and renal stent stenosis treated successfully.

REFERENCES
1. Dake MD, Thompson M, van Sambeek M, Vermassen F, Morales JP; DEFINE Investigators. DISSECT: a new mnemonic-based
approach to the categorization of aortic dissection. Eur J Vasc Endovasc Surg. 2013;46:175-190.

CONCLUSIONS
FEVAR remains the gold standard but ch-EVAS adds another option to the range of options for patients
with complex aneurysms. These early results in hostile anatomies demonstrate good early and mid term
outcomes, comparable to most series of FEVAR. Clearly mid and long-term outcomes will be essential to
monitor the durability of this technique but for patient unfit for open repair, it offers the endovascular
surgeon another option for the management of these difficult anatomies.

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

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J uxta / Supra Renal Aneurysm


Duel. What is the best solution? EVAS + chimneys or F/B-EVAR?
For EVAS + chimney

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Saturday January 23
- Venous session -

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

Lowell Kabnick

Peter Gloviczki, Ying Huang

NYU Langone Medical Center, New York, USA

Which class of patients are we addressing? Certainly, we are addressing patients with advanced venous
disease classified as C4b, C5, and C6. Included in the mix would be patients who have unilateral thigh,
calf, and ankle edema with a fixed obstruction with associated superficial truncal reflux. So why treat
deep venous obstruction first? Isolated superficial reflux rarely causes ulcerations.1 Reflux may improve
as obstruction resolves, and results after treatment of obstruction are independent of reflux.2 In patients
with advanced venous disease associated with pain and swelling, Neglen and Raju published their studies
showing significant reduction in pain and swelling.3 In addition, ulcer healing rate with stent placement
alone occurred in 58-89%.3,4

Mayo Clinic, Rochester MN, USA


Venous stenting has been used with increasing frequency and lasting success to treat chronic ilio-femoral
venous obstructions. Major criteria to select stenting include the clinical presentation of the patient, the
etiology of the obstructions, the underlying venous anatomy and pathology and the patients operative
or interventional risk. Diagnostic pre-procedure evaluation includes different imaging studies with an increasing emphasis based on intravascular ultrasound (IVUS).
CLINICAL PRESENTATION
Signs and symptoms of iliofemoral venous obstruction include leg swelling, pain, venous claudication,
abdominal wall, lower extremity and suprapubic varicosity and stasis skin changes including venous ulcerations. Patients may present with symptoms of pelvic venous congestion. Presentation can be acute,
subacute or chronic.

REFERENCES
1. Johnson et al, Isolated Reflux Rarely Causes Ulceration J Vasc Surgery 1995
2. Caps M et al, J Vasc Surg 1998
3. Alhalbouni S, Hingorani, A et al. Iliac-Femoral Venous Stenting for Lower Extremity Venous Symptoms Ann Vasc Surg 2012;
201;26:185-189
4. Raju S et al. Unexpected major role for venous stenting in deep reflux disease J Vasc Surg 2010; 51:401-8

ETIOLOGY
Patients, who undergo thrombolysis for acute iliofemoral deep vein thrombosis (DVT) may have underlying
iliac vein compression or obstruction. These lesions should be treated with iliofemoral stenting to avoid a
high risk of recurrent acute DVT. Chronic obstruction can be non-thrombotic compression or obstruction
of the iliac veins (May-Thurner syndrome) or thrombotic, chronic DVT. Malignancy or external compression
by benign tumors must be recognized and treated accordingly.
VENOUS ANATOMY AND PATHOLOGY
The best candidates for iliofemoral venous stenting have common iliac vein stenosis due to May-Thurner
syndrome. Thrombotic iliofemoral venous obstruction need longer stents or multiple stents with somewhat
decreasing chance of success. Good inflow into the stent is critical and if needed, endophlebectomy with
patch angioplasty needs to be performed for a hybrid procedure. Alternative is to place stent into the
profunda femoris vein. Stents distal to the saphenofemoral junction do not perform well. It is important
to recognize the underlying pathomechanism of the disease and assure that of the venous pathologies
venous outflow obstruction and not infrainguinal valve incompetence dominates.
SURGICAL OR INTERVENTIONAL RISK
Chronic renal failure or underlying thrombophilia are potential risk factors for venous stenting. Sedentary
or bedridden patient, high cardiac and pulmonary risk, retroperitoneal fibrosis or previous radiation may
also contraindicate successful stenting.
PREOPERATIVE DIAGNOSTIC EVALUATION FOR STENTING
Duplex scanning, MR, CT and direct contrast venography with pressure measurements all can be used
for patient selection, but IVUS is gaining increasing importance in recognition of non-thrombotic iliac
vein compression. Absence of venous collaterals on contrast venogram is no longer a contraindication for
stenting in symptomatic patients, if IVUS confirms significant ( >50%) iliac vein obstruction.
SELECTION OF VENOUS STENT
In North America WALLSTENT Endoprosthesis is the only currently used stent for iliofemoral venous
occlusion. For common iliac vein 14 to 18 mm stents are selected based on intraoperative measurement
using venogram and IVUS; for the external iliac vein 12 to 14 mm stent is recommended. Over-sizing has
caused chronic pain syndrome, while under-sizing increases stent thrombosis or stenosis. For hybrid procedures a temporary femoral arteriovenous fistula may be needed.

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

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

Hpital Henri Mondor Crteil, Paris, France


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

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

performed under ultrasound guidance, but we have little information on where the ideal puncture location
should be. Indeed, it is current practice to access the main trunk of the GSV or the SSV at the lowest incompetence area. In fact, the key point is where to begin the endovenous procedure. Catheterization should be at
the lowest part of the incompetent GSV under the knee but access from the incompetent tributary. The goal
is to disconnect the competent part of the GSV from the incompetent part. If we catheterize the GSV at its
lowest incompetence above an incompetent tributary, after treatment the blood will flow from the competent
GSV toward the tributary and therefore a phlebectomy of this vein is required. If the access of the GSV is
performed by using a distal incompetent tributary we are treating the GSV and the tributary at the same time
and therefore no additional phlebectomy is needed. To avoid phlebectomy the access site is crucial.
In a case of very sinuous veins, a hydrophilic guide wire can often be passed through the different bends,
and the veins can be treated by endovenous ablation, once again avoiding phlebectomy. If several veins are
incompetent, a double or triple introduction is needed to treat all of them and not only the GSV.
For the GSV of the leg because we cannot correctly identify the GSVs saphenous nerve, we should avoid
treating the GSV below the junction between the upper third and middle third of the leg. Nevertheless
access of the upper third of the GSV from the medial tributary even at the lowest part of the leg is possible
because there is no nerve companion of the tributary. And after this, (after a period of one month minimum)
if necessary the lowest part of the GSV and/or the tributaries can be easily treated by ultrasound-guided
foam sclerotherapy (UGFS)

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CONTROVERSIES & UPDATES IN VARICOSE DISEASE

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

IN CONCLUSION
The access site is the key point and phlebectomy must be delayed to avoid overtreatment. It is less traumatic when the vein is shrunk and if necessary ultrasound-guided foam sclerotherapy (UGFS) may suffice.
BIBLIOGRAPHIE
1. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, Lohr JM, McLafferty RB, Meissner MH, Murad MH,
Padberg FT, Pappas PJ, Passman MA, Raffetto JD, Vasquez MA, Wakefield TW; Society for Vascular Surgery; American Venous
Forum.The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society
for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011 May;53(5 Suppl):2S-48S
2. Marsden G, Perry M, Kelley K, Davies AH; Guideline Development Group. Diagnosis and management of varicose veins in the legs:
summary of NICE (National Institute for health and Care Excellence) guidance. BMJ. 2013 Jul 24;347:f427
3. Carradice D, Mekako AI, Hatfield J, Chetter IC.Randomized clinical trial of concomitant or sequential phlebectomy after endovenous laser therapy for varicose veins.Br J Surg. 2009 Apr;96(4):369-75
4. Darwood RJ, Theivacumar N, Dellagrammaticas D, Mavor AI, Gough MJ.Randomized clinical trial comparing endovenous laser
ablation with surgery for the treatment of primary great saphenous varicose veins.Br J Surg. 2008 Mar;95(3):294-301.
5. Monahan DL.Can phlebectomy be deferred in the treatment of varicose veins?J Vasc Surg. 2005 Dec;42(6):1145-9
6. Welch HJEndovenous ablation of the great saphenous vein may avert phlebectomy for branch varicose veins. J Vasc Surg. 2006
Sep;44(3):601-5.
7. Bush RL1, Ramone-Maxwell C Endovenous and surgical extirpation of lower-extremity varicose veins. Semin Vasc Surg. 2008
Mar;21(1):50-3.
8. Hamel-Desnos C1, Desnos P2, Allaert FA3, Kern P4; the Thermal group for the French Society of Phlebology and the Swiss Society of Phlebology. Thermal ablation of saphenous veins is feasible and safe in patients older than 75 years: A prospective study
(EVTA study).Phlebology. 2014 Jun 18
9. PA Sutton, Y El-Duhwaib, J Dyer, AJ Guy: The incidence of post operative venous thromboembolism in patients undergoing varicose vein surgery recorded in Hospital Episode Statistics: Ann R Coll Surg Engl 2012; 94: 481483
10. Knipp BS, Blackburn SA, Bloom JR, Fellows E, Laforge W, Pfeifer JR, Williams DM, Wakefield TW Endovenous laser ablation:
venous outcomes and thrombotic complications are independent of the presence of deep venous insufficiency.J Vasc Surg. 2008
Dec;48(6):1538-45
11. Sufian S, Arnez A, Labropoulos N, Nguyen K, Satwah V, Marquez J, Chowla A, Lakhanpal S.: Radiofrequency ablation of the great
saphenous vein, comparing one versus two treatment cycles for the proximal vein segment.Phlebology. 2014 Oct 17
12. Sufian S, Arnez A, Labropoulos N, Lakhanpal S.: Endovenous heat-induced thrombosis after ablation with 1470nm laser: Incidence, progression, and risk factors.Phlebology. 2015 Jun;30(5):325-30
13. Marsh P, Price BA, Holdstock J, Harrison C, Whiteley MS.Deep vein thrombosis (DVT) after venous thermoablation techniques:
rates of endovenous heat-induced thrombosis (EHIT) and classical DVT after radiofrequency and endovenous laser ablation in a
single centre.Eur J Vasc Endovasc Surg. 2010 Oct;40(4):521-7
14. Lane TR, Kelleher D, Shepherd AC, Franklin IJ, Davies AH.Ambulatory varicosity avulsion later or synchronized (AVULS): a randomized clinical trial.Ann Surg. 2015 Apr;261(4):654-61.
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Is there a place for phlebectomy?

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DEBATE. Do we have to preserve the saphenous vein?
Should we preserve the saphenous vein not mandatory

Denis Creton

Clinique A. Par, Nancy, France

Gilbert Franco

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

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

REFERENCES
1. Creton D, Ra B, Pittaluga P, Chastanet S, Allaert FA. Evaluation of pain in varicose vein surgery under tumescent local anethesia
using sodium bicarbonate as excipient without any intravenous sedation. Phlebology. 2012;27:368-73.
2. Carradice D, Mekako AL, Hatfield J, Chetter IC. Randomized clinical trial of concomitant or sequential phlebectomy after endovenous laser therapy for varicose veins. Br J Surg 2009;96:369-75

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Clinique Arago, Paris, France

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Treatment of telangiectasias by foam sclerotherapy under ultrasound guidance

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

Claudine Hamel Desnos

Mdecine Vasculaire, Hpital Priv Saint Martin, Caen-France

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

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

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Treatment of telangiectasias by laser

 clerotherapy & Miscellaneous


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Sclerotherapy (techniques, tactics and results). The French method.

Thomas Proebstle

Claudine Hamel-Desnos

Dept Dermatology, University Medical Center Mainz, Germany

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

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

REFERENCES
Moraga JM, Smarandache A, Pascu ML, Royo J, Trelles MA. 1064 nm Nd:YAG long pulse laser after polidocanol microfoam injection
dramatically improves the result of leg vein treatment: A randomized controlled trial on 517 legs with a three-year follow-up.
Phlebol 2014: 29: 658666.

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Huw Davies, Andrew Bradbury


INTRODUCTION
Although many publications have shown ultrasound-guided foam sclerotherapy (UGFS) to be clinically
and cost effective, and the procedure has been recommended in national (UK NICE) guidelines, sclerotherapy is more operator dependent than endothermal ablation (ETA), and disappointing results have been
reported even in large randomised controlled trials. What has become known as the English method has
been developed with the aim of maximising anatomic, haemodynamic and patient reported outcomes and
minimising the need for retreatment.
TECHNIQUES
Truncal veins are cannulated (Optiva) under ultrasound (US) guidance at 10-20cm intervals and, after
elevating the leg, injected with 2ml aliquots of fresh foam comprising 3% sodium tetradecyl sulphate
(STS) mixed 3-4:1 with room air via a 5mm filter. Tributaries and varices are cannulated at similar intervals,
including as distally as possible (just above the re-entry perforators) and filled with 1% STS air foam.
US monitoring is used to exclude inadvertent extravasation and ensure that all of the veins to be treated
are in spasm and full of foam. Between injections, patients are asked to repeatedly platar/dorsi-flex their
ankle to clear any foam from the deep system. Patients are bandaged (Pehahaft) for 2-3 days and placed in
a European Class II stocking for 2-3 weeks. On review, any tender, lumpy, discoloured areas are aspirated
under US guidance using local anaesthetic.
TACTICS
The key principle is to close the front door (the sapheno-femoral-popliteal junctions and other non-junctional perforators) and close the back door (re-entry perforators) and to fill all of the intervening veins
with foam during one treatment session

BIBLIOGRAPHY
1. Hamel-Desnos C., Moraglia L., Ramelet A-A. Sclrothrapie. In: La Maladie veineuse chronique. Elsevier Masson SAS 2015: 89126
2. Rabe E., Breu FX, Cavezzi A., Coleridge Smith P., Frullini A., Gillet JL., Guex JJ., Hamel-Desnos C., Kern P., Partsch B., Ramelet AA.,
Tessari L., Pannier F., for the Guideline Group. European guidelines for sclerotherapy in chronic venous disorders. Phlebology.
2014 Jul; 29(6):338-54
3. Hamel-Desnos C., Desnos P., Ouvry P. Nouveauts thrapeutiques dans la prise en charge de la maladie variqueuse: chosclrothrapie et mousse. Phlbologie 2003, 56, N1, 41-8
4. ANAES. Traitement des varices des membres infrieurs. Rapport de lAgence Nationale dAccrditation et dEvaluation en Sant.
Service Evaluation en sant publique Evaluation technologique Juin 2004
5. Watkins MR. Deactivation of sodium tetradecyl sulphate injection by blood proteins. Eur J Vasc Endovasc Surg. 2011; 41(4):521-5.
Epub 2011/01/26
6. Yamaki T, Nozaki M, Sakurai H, Takeuchi M, Soejima K, Kono T. Multiple small-dose injections can reduce the passage of sclerosant foam into deep veins during foam sclerotherapy for varicose veins. Eur J Vasc Endovasc Surg. 2009; 37(3):343-8. Epub
2008/10/17
7. Wright D., Gobin J P., Bradbury AW., Coleridge-Smith P., Spoelstra H., Berridge D., Wittens C H A., Sommer A., Nelzen O., Chanter
D. Varisolve polidocanol microfoam compared with surgery or sclerotherapy in the management of varicose veins in the presence of trunk vein incompetence: European randomized controlled trial. Phlebology 2006; 21:180-90
8. Gillet JL, Guedes JM, Guex JJ, Hamel-Desnos C., Schadeck M., Lausecker M. Side effects and complications of foam sclerotherapy
of the great and small saphenous veins: a controlled multicentre prospective study including 1025 patients. Phlebology 2009; 24:
131-138
9. Gillet J-L., Lausecker M., Sica M., Guedes J-M., Allaert FA. Is the treatment of the small saphenous veins with foam sclerotherapy
at risk of deep vein thrombosis? Phlebology 2014; 29 (9): 600-7
10. Hamel-Desnos C, Guias B.J., Desnos P.R., Mesgard A. Foam sclerotherapy of the saphenous veins: randomized controlled trial
with or without compression. Eur J Vasc Endovasc Surg 2010; 39: 500-7
11. Hamel-Desnos C. Ablation Thermique et traitements complmentaires. Phlbologie 2013, 66, 2: 70-78

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RESULTS
Numerous publications attest to the safety, clinical and cost-effectiveness of the English method which
is associated with significant improvements in generic and disease specific health-related quality of life
beyond 5 years, and a low rate of treatment, similar to those commonly reported after ETA.
CONCLUSION
The English method is a safe, inexpensive, versatile, well tolerated and clinically effective technique for
UGFS which can used to treat most (up to 90%) of patients affected by CEAP 2-6 lower limb venous disease.

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Sclerotherapy (techniques, tactics and results), the English method

the foam. It is thus an la carte treatment for each patient and for each vein.
With overdosing minimalized, there is less post-sclerotherapy inflammatory reactions for this technique,
compared with the Sigg and Fegan methods.
Moreover, the laboratory studies conducted by Watkins, 5 showed that once injected, the sclerosing agent
is quickly deactivated by the blood in the vein. The author thus recommends the injection of fresh foam,
in divided doses, to the target venous network, in order to obtain a more efficient sclerotherapy.
Several foam injections rather than a single bolus dose might also reduce the risk of post-treatment deep
vein thrombosis 6.
There are no randomized studies that compare the French technique with the other techniques.
A study by Wright simply shows that for sclerotherapy, among the investigators, the French phlebologists
obtained better results than the European surgeons did; however, the surgeons were not all well experienced in sclerotherapy 7.
In two sizable French studies, the rate of complete occlusion of the saphenous veins, one month after
foam sclerotherapy, were respectively 90.3% and 93.4% 8,9. In the first study, 1025 saphenous veins (818
GSV and 207 SSV) were treated by 20 French phlebologists and in the second study, 331 small saphenous
veins were treated by 22 French phlebologists. A controlled randomized French study compared foam
sclerotherapy of the saphenous veins (using direct needle puncture, French technique), carried out either
with elastic compression, or without compression post-procedure. The occlusion rate of the veins 3 months
post-treatment was 100% for both groups, demonstrating that compression does not have an impact in
the efficiency of this method 10.
As a matter of fact, the French technique for sclerotherapy is part of a logical and tactical approach that
other endovenous techniques for treatment of varicose veins (laser, radiofrequency, glue, MOCA) apply
naturally: priority treatment of proximal segments of the trunk, then the whole of the trunk concerned,
from top to bottom. As for the tributary veins, they then benefit from an accessory treatment, which is not
always indispensible and which could possibly be deferred 11.
In conclusion, the French top-down technique, developed for sclerotherapy in the 1940s, remains the method of reference for all endovenous treatment of varicose veins of the lower limb.

 clerotherapy & Miscellaneous


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

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How to ensure the success of sclerotherapy? 10 rules to respect
Claudine Hamel-Desnos

Hpital Priv Saint Martin,Caen, France

Cabinet dAngeiologie, Caen, France


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

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

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CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Philippe Desnos

Alessandro Frullini

BIBLIOGRAPHY
1. Rabe E., Breu FX, Cavezzi A., Coleridge Smith P., Frullini A., Gillet JL., Guex JJ., Hamel-Desnos C., Kern P., Partsch B., Ramelet AA.,
Tessari L., Pannier F., for the Guideline Group. European guidelines for sclerotherapy in chronic venous disorders. Phlebology.
2014 Jul; 29(6):338-54
2. Hamel-Desnos C, Moraglia L, Ramelet AA. Sclrothrapie. In: La Maladie veineuse chronique. Elsevier Masson SAS 2015: 89-126

Studio flebologico, Figline Incisa Valdarno, Florence, Italy


OBJECTIVES / PURPOSE STATEMENT
A possible cause of sclerotherapy complications could be the release of Endothelin 1 (ET 1). We have studied in vivo and in vitro the anti-ET1 action of Aminaftone (AMNA).
METHOD
We studied 3 groups of rats treated with polidocanol (POL) sclerotherapy: the group C, control, and the
groups G1 and G2, that received respectively a 30mg/kg/day or a 150mg/kg/day of AMNA for 15 days
before sclerotherapy. In vitro studies were performed on HUVEC cells: cells survival was analyzed in presence of AMNA and POL at different concentrations, and ET 1 level measurement was performed through
an immunoenzymatic assay. Moreover a multicentric trial (PROCOMET STUDY) was done on 540 patients
submitted to sclerotherapy for CVD. One subgroup of patients was submitted to Aminaphtone prophylaxis.
RESULTS
Rats in group C showed an early mortality of 40%. This value was only 13,3 % and 20 % in group G1 and
G2. The treatment with AMNA 6g/ml did not affect Human umbilical vein endothelial cell (HUVEC) viability. After POL 0,05% and 0,5% treatments, HUVEC were viable in 44,36 % and 2,25% respectively. After
AMNA pre-treatment and POL treatment, ET 1 cellular release was significantly lower after 6 (p<0.01) and
12 hours (p<0.05) in respect to control without AMNA. In the patients where Aminaphtone prophylaxis
was performed significant reduction of side effects was achieved in those sclerosed for teleangectasias
and when migrani history was present (2,43% vs 0% and 38,4% vs 3,2% respectively)
CONCLUSIONS
This study confirms ET 1 release after sclerotherapy and lower in vivo mortality in G1 and G2 groups gives
us a clue of ET-1 possible role in generating side effects. Aminaftone has been proven to be effective in inhibition of ET 1 release from endothelial cells after sclerotherapy. Due to the excellent safety profile of Aminaphtone, systematic prophylaxis is now performed in my office for all patients undergoing sclerotherapy.

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Prevention of visual and neurologic disturbances after sclerotherapy with antiendothelin prophylaxis

CONCLUSION
The optimization of the treatment of varicose veins by sclerotherapy necessitates a skilled operator, good
quality foam, which is injected quickly after its manufacture and administered in the most pertinent area
tactically, commencing from the top, with injections being performed according to the direct needle puncture technique and under permanent ultrasound guidance. The doses must be adapted to each given case.

7. Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidelines:
report from an American College of Chest Physicians Task Force. Chest 2006; 129: 17481.
8. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). European Heart Journal (2012) 33,
16351701 doi:10.1093/eurheartj/ehs092
9. National Institute for Health and Care Excellence. Varicose veins in the legs- the diagnosis and management of varicose veins.
Clinical guideline 2013;168:1-248

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Various grades of recommendation in the management of primary varicose veins
Michel Perrin
Lyon, France

TABLE
Recommendations of operative procedures for the treatment of superficial refluxing veins from recent guidelines. (references)

Lower limbs chronic primary superficial venous disease treatment of the has been subject of different
recommendations that deserve to be analyzed by taking in account the societies which recommend them
and the grading system used.
- THE SVS/AVF guidelines were published in 2011.1
Most of their recommendation remain valid but are not fully applicable in Europe. The SVS/AVF guidelines
were analyzed by an European team. 2
- In 2013 the European guide for sclerotherapy was available giving many information on this procedure
including practical information.3
- In 2014 the guidelines of the European venous forum and the international Union of Angiology published
a document on chronic venous disorders. 4
- The International guidelines on endovenous thermal ablation was published in 2015. This consensus
document provides also many technical details. 5
The same year the European Society for vascular surgery endorsed a guideline on management of Chronic
venous disease. 6
All the guidelines use the Guyatt grading, its grading scheme classifies recommendations as strong (grade
1) or weak (grade 2), according to the balance among benefits, risks, burdens, and possibly cost, and the
degree of confidence in estimates of benefits, risks, and burdens. The system classifies quality of evidence
as high (grade A), moderate (grade B), or low (grade C) according to factors that include the study design,
the consistency of the results, and the directness of the evidence. 7
Only the ESVS guidelines use the European Society of Cardiology grading system. For each recommendation, the letter A, B, or C marks the level of current evidence. Weighing the level of evidence and expert
opinion, every recommendation is subsequently marked as either class I, IIa, IIb, or III. The lower the class
number, the more proven is the efficacy and safety of a certain
The national Institute for health and Care Excellence (NICE) published in 2013 a document on varices veins
of the leg and the recommendations were
For people with confirmed varicose veins and truncal reflux:
- Offer endothermal ablation (Radiofrequency ablation of varicose veins [NICE interventional procedure
guidance 8] and Endovenous laser treatment of the long saphenous vein [NICE interventional procedure
guidance 52]).
- If endothermal ablation is unsuitable, offer ultrasound-guided foam sclerotherapy (see Ultrasound-guided foam sclerotherapy for varicose veins [NICE interventional procedure guidance 440]).
- If ultrasound-guided foam sclerotherapy is unsuitable, offer surgery.
If incompetent varicose tributaries are to be treated, consider treating them at the same time. 9

Operative procedure

Steam
Clarivein
Glue
UGFS

NG
NG
NG

NG
NG
1A*

NG
NG
III A**

1A*
NG
NG
NG

1B*

NG

I A**

NG

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

1B*

NG

I A**

NG

NG

2C*
2C*
2C*

NG
NG
NG

NG
IIa B**
IIa B**

NG
NG
NG

NG
NG
NG

Surgery

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

EVF/IUA
187

ESVS
189

2A*

I B**

1 B*
NG
NG
1A*

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

ETAV/IUP
188

NG
NG
NG
1A*

EGS
23

NG
NG
NG
NG

* Guyatts grading; (190)


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

REFERENCES
1. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases:
Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53:2S-48S
2. Lugli M, Maleti O, Perrin M. Review and Comment of the 2011 Clinical Practice Guidelines of the Society for Vascular Surgery
and the American Venous Forum. Phlebolymphology 2012: 19(3): 107-20
3. Rabe E, Breu FX, Cavezzi A, Coleridge Smith P,Frullini A, Gillet Jl et al. European guidelines for sclerotherapy in chronic venous
disorders. Phlebology 2014;29:338-54
4. Management of chronic venous disorders. International Angiology.2014;33: 87-208
5. Pavlovic MD, Petrovic SS, Pichot O, Rabe E, Maurins U, Morrizon N, Pannier F.Guidelines of the First International Consensus Conference on Endovenous Thermal Ablation for Varicose Vein Disease ETAV Consensus Meeting 2012. Phlebology
2015:30:257-73
6. Management of Chronic venous disease. Clinical Practice Guidelines of the European Society for Vascular Surgery. Eur J Vasc
Endovasc Surg 2015:49: 678-737
86

Modern Surgery
CHIVA
ASVAL
EVLA or RFA

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

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Enjeux socio-conomiques de la maladie veineuse

CONTROVERSIES & UPDATES IN VARICOSE DISEASE

Franois-Andr Allaert

Dpartement sant publique, Universit de Lige, Belgique

Bo Eklf

Sur le plan social, une tude conduite sur 1065 femmes1 exerant une activit professionnelle montre que:
89,3% sont exposes professionnellement des facteurs de risque susceptibles de favoriser la survenue
de leur maladie veineuse ou de laggraver, 70,7% travaillent debout, 49,5% sont sdentaires, 20,9%
travaillent dans une ambiance temprature leve. Ces divers facteurs se cumulant souvent chez une
mme femme. Cette situation est sans issue pour beaucoup dentre elles : 91,1% rpondaient qu moins
de changer de mtier il ne leur tait pas possible de se soustraire leurs facteurs de risque professionnels.
Ce nest pas possible car elles exercent souvent les seuls mtiers quelles ont pu trouver: vendeuses, caissires, serveuses, employes de collectivits 19,9% considraient que leur maladie veineuse constitue
un handicap important dans leur vie professionnelle. 1% seulement envisageait de pouvoir changer demploi. Une autre tude chez 3224 femmes ges de 44 10 ans exerant une activit professionnelle2
rapportait les rsultats suivants : 26,8 % des femmes indiquaient que les troubles veineux augmentaient
beaucoup la pnibilit de leur travail, 73,8% considraient que leurs conditions de travail avaient aggrav
leurs troubles veineux et 9% quils en taient lorigine...
Sur le plan conomique, Le cot des biens et services mdicaux induits par la prise en charge de la maladie
veineuse est lev mais il est difficile dimaginer quil puisse en tre autrement pour une pathologie dont
la prvalence atteindrait 10 millions de personnes dans la population franaise.
Le cot est rgulirement stigmatis comme plus lev en France que dans les autres pays alors qua priori
la prvalence de la maladie veineuse nest pas plus importante mais ces comparaisons sont mal fondes:
elles ne prennent pas en compte lensemble des dpenses directes ou indirectes induites par la maladie
veineuse aux diffrents stades. En particulier, ne pas tenir compte des dpenses lies aux soins dulcres
ou la chirurgie dveinage constitue un biais danalyse important. Il en est de mme de ne pas prendre
en compte les cots des arrts de travail. La question est de savoir si une prise en charge efficace de la
maladie veineuse aux stades prcoces est susceptible de rduire ou non les cots directs et surtout les
cots indirects dont lvolution est quasi exponentielle en fonction du stade de gravit de la maladie. Pour
simplifier, focalisons-nous sur un des dterminants majeurs des cots indirects de la maladie veineuse
savoir sur la frquence des arrts de travail au dcours des consultations. Cette frquence varie de 1,5%
pour le stade 2 3,9% pour le stade 3 puis triple pratiquement pour atteindre 12% pour les stades 4 et
les stades 5 et 6 (11,3% et 13,8%) 3.
Les stades 4, 5 ,6 reprsentent globalement 20% de la population atteinte dune maladie veineuse et
concernent 2 millions de patients parmi lesquels la moiti est en exercice professionnel soit 1 million.
Sous lhypothse (trs basse) de 2 consultations par an, on a alors 1 000 000 x 2 x 12% arrts de travail dune dure moyenne de 8 jours 1,2 auxquels il faut retrancher les 3 jours du dlai de carence soit
1 200 000 jours de travail. Sur la base dune indemnit quotidienne moyenne de 40 euros, les arrts de
travail induits par les seuls stades 4, 5 et 6 chez les femmes en exercice professionnel provoquent 48 000
000 deuros de dpense.
La lutte contre la maladie veineuse tait cot/efficace et nous paierons socialement et conomiquement
labandon progressif de cette prise en charge, dabord au travers du dremboursement des veinotoniques
et dsormais des restrictions aux prescriptions de la compression lastique.

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

1. Allaert FA, Verrieres JL, Urbinelli R. Consquences mdico-sociales de linsuffisance veineuse diurne et nocturne sur la vie quotidienne des femmes. Angiologie 1998 ; 50(4) : 55-61.
2. Allaert FA, Causse C. Pharmaco-pidmiologie de la prise en charge de linsuffisance veineuse chronique en mdecine gnrale.
Angiologie 2000 ; 52(4) : 8-16.
3. Causse C., Allaert F.A., Cazaubon M., Le Teuff G., Lecomte Y., Urbinelli R. Maladie veineuse et ergonomie du travail fminin.
Angiologie, mars 2003 ; n1 vol.55 : 51-58.

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Lund University, Lund, Sweden

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Call for excellence in the management of venous disease - role of European venous
meetings and supranational societies

George Geroulakos, Lattimer CR, Azzam M, Kalodiki E, Makris GC


Ealing Hospital and Imperial College, London, United Kingdom

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

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Saphenous pulsation on Duplex is a marker of severe chronic superficial venous
insufficiency

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

T hermal or glue techniques


Reimbursement and possibilities to use the new thermal ablation techniques:
difference between the European countries

James Lawson, Stefanie Gauw, Clarissa van Vlijmen


Inga Vanhandenhove

Skin and Vein Clinic Oosterwal, Alkmaar, The Netherlands

AZ Monica Antwerp, Antwerp, Belgium


BACKGROUND
Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA/ClosureFAST) of the incompetent
great saphenous vein (GSV) are both associated with excellent technical and clinical outcomes for the
treatment of varicose veins. ClosureFAST using RFA for heating up ablation coil is associated with less
postprocedural pain and shorter recovery than EVLA bare fibre in several studies. 1,2 A newly-developed
fibre (radial fibre, Biolitec) emits the laser energy radially with a lower power density promising better
postoperative recovery 3 The aim of this study was to compare the techniques in a pragmatic prospective
clinical trial

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

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

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T hermal or glue techniques


3-year follow-up RCT: radiofrequency ablation (fast) vs laser ablation (radial fiber)

T hermal or glue techniques


RCT endovenous 940 nm laser ablation vs 1470 nm laser ablation (COLA trial)

T hermal or glue techniques


Risk Factor for Recurrence after RF Ablation Of GSV

Thomas Proebstle1, Olivier Pichot2

Erasmus MC, Rotterdam, The Netherlands


BACKGROUND
The independent effect of wavelength used for endovenous laser ablation (EVLA) on patient reported
outcomes, health-related quality of life (HRQoL), success and complications has not yet been established
in a RCT. Our aim was to compare two different wavelengths, with identical energy level and laser fibers,
in patients undergoing EVLA.

1. Dept Dermatology, University Medical Center Mainz, Mainz, Germany


2. CHU Service de Chirurgie Vasculaire, Grenoble, France
OBJECTIVE
Identify predictors of anatomical and clinical success following radiofrequency segmental thermal ablation(RSTA)
METHODS
Logistic regression and proportional hazards analyses were used. Anatomical success was defined by
ultrasound as a status of full occlusion or freedom from reflux. For definition of clinical success a relevant
improvement of VCSS was used.

METHODS
Patients with great saphenous vein (GSV) reflux were randomized into 940 nm or 1470 nm EVLA. The
primary outcome was pain at one week. Secondary outcomes were satisfaction, days of analgesia use
and days without normal activities at one week, HRQoL after 12 weeks, treatment success after 12 and
52 weeks, change in Venous Clinical Severity Score (VCSS) after 12 weeks and adverse events at one and
12 weeks.

RESULTS
235 of originally 295 GSVs treated by RSTA were available at 5-year FU. Predictors at baseline for persisting anatomical success over 5 years were (a) no adjunctive phlebectomy above-the-knee during RSTA
(hazard ratio (HR)=2.9 for occlusion, p=0.011; HR=5.7 for reflux-free, p=0.002), and (b) a joint bivariate
effect of high body mass index (BMI) and large GSV diameter. One-year clinical success likelihood was 7.26
(1.51 - 35.00) times greater (p=0.01) in patients without refluxing thigh tributaries draining into the GSV
and 6.36 (1.64 - 24.66) times greater(p=0.008) for adjunctive below-the-knee phlebectomy performed
concomitantly. No baseline refluxing accessory saphenous vein was predictive of 6.42(1.38 - 29.86),
p=0.018, times higher likelihood(p=0.018) of 3-year clinical success. A combined effect of high BMI and
large proximal GSV diameter at baseline was predictive of ongoing clinical success.

RESULTS
A total of 139 legs were treated (940 nm EVLA, 68;1470 nm EVLA, 71). Patients in the 1470 nm EVLA
group reported significantly less pain on a visual analogue scale (VAS), compared to 940 nm EVLA; median(IQR) VAS of 3(5) and 6(5) (p=.005). Duration of analgesia use was significantly shorter after 1470 nm
EVLA; median(IQR) of 1(3) and 2(5) days (p=0.037). HRQoL and VCSS improved equally in both groups.
There was no difference in treatment success rates. Complications were comparable in both groups, except
for more superficial vein thrombosis 1 week after 1470 nm EVLA.
CONCLUSION
The only difference between 940 nm and 1470 nm EVLA is the short term patient reported tolerability one
week postoperatively, with reduction of pain scores and duration of analgesia use after 1470 nm EVLA.

CONCLUSION
Bivariate BMI and GSV diameter was the dominant predictor of maintained anatomical and clinical success after RSTA of the GSV. Additional predictors for success were lack of thigh tributaries, lack of refluxing
accessory saphenous veins and performing phlebectomy of calf tributaries at baseline.
REFERENCES
1. Robertson LA, Evans CJ, Lee AJ, Allan PL, Ruckley CV, Fowkes FG. Incidence and risk factors for venous reflux in the general population: Edinburgh Vein Study. European journal of vascular and endovascular surgery: the official journal of the European Society
for Vascular Surgery 2014;48(2): 208-214.
2. Shadid N, Nelemans P, Lawson J, Sommer A. Predictors of recurrence of great saphenous vein reflux following treatment with
ultrasound-guided foamsclerotherapy. Phlebology / Venous Forum of the Royal Society of Medicine 2014.
3. Merchant RF, Pichot O, Closure Study G. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as
a treatment for superficial venous insufficiency. Journal of vascular surgery 2005;42(3): 502-509; discussion 509.
4. Timperman PE. Prospective evaluation of higher energy great saphenous vein endovenous laser treatment. Journal of vascular
and interventional radiology: JVIR 2005;16(6): 791-794.
5. Proebstle TM, Moehler T, Herdemann S. Reduced recanalization rates of the great saphenous vein after endovenous laser treatment with increased energy dosing: definition of a threshold for the endovenous fluence equivalent. Journal of vascular surgery
2006;44(4): 834-839.
6. Harlander-Locke M, Jimenez JC, Lawrence PF, Derubertis BG, Rigberg DA, Gelabert HA. Endovenous ablation with concomitant
phlebectomy is a safe and effective method of treatment for symptomatic patients with axial reflux and large incompetent tributaries. Journal of vascular surgery 2013;58(1): 166-172.
7. Proebstle TM, Vago B, Alm J, Gockeritz O, Lebard C, Pichot O. Treatment of the incompetent great saphenous vein by endovenous
radiofrequency powered segmental thermal ablation: first clinical experience. Journal of vascular surgery 2008;47(1): 151-156.
8. Calcagno D, Rossi JA, Ha C. Effect of saphenous vein diameter on closure rate with ClosureFAST radiofrequency catheter. Vascular and endovascular surgery 2009;43(6): 567-570.

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Wendy Malskat

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

T hermal or glue techniques


How to ensure the success of traditional surgery in varicose vein treatment: 10 rules
to respect
Patrizia Pavei

Azienda Ospedaliera di Padova, Padova, Italy


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

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10 rules to respect to ensure the success of: laser ablation
Lowell Kabnick

NYU Langone Medical Center, New York, USA


There are many steps that an interventionalist should take into consideration in order achieve the best
laser truncal ablation results. If you have the following: correct patient who has the appropriate venous
symptoms, complete physical exam including venous zone of influence, corresponding duplex exam for
GSV insufficiency, and you perform the proper step by step procedure, then the patient will have the best
results. I will present at least ten Kabnick rules to follow to ensure the best patient outcome with laser
ablation. In general, most of these guidelines will apply to any truncal ablation. Since the history, physical
exam, and duplex examination are extremely important, I would be remiss not to mention them in passing. In addressing these rules in terms of performing the procedure, there are several important key steps
to take into consideration as well, which include patient comfort, set-up of procedure room, ultrasound
skills, venous access, wire and catheter skills, laser fiber placement, tumescent anesthesia delivery, and
energy delivery. Finally, regarding postoperative management: is important or does it matter? What is the
evidence for post-ablation compression, duplex, or controlled activity? I will address these questions as
well, in order to present a complete picture of how to ensure the success of laser ablation.

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CONTROVERSIES & UPDATES IN VARICOSE DISEASE

REFERENCES
Kabnick, L.S. Venous Laser Updates: New Wavelength or New Fibers? Vascular Disease Management, March 2010, Volume 7, No.
3, pg 77-81.
Spreafico G, Kabnick L.S., Berland T, et al.Laser Saphenous Ablations in More Than 1,000 limbs with Long-Term Duplex Examination
Follow-up. Annual Vascular Surgery, January 2011; 25(1)71-78.
Sadek, M., Kabnick, L.S., Berland, T., Chasin, C., Cayne, N., Maldonado, T., Rockman, C., Jacobowitz, G., Lamparello, P. Endovenous
Laser Ablation using Higher Wavelength Lasers results in Diminished Post Procedural Symptoms. Journal of Vascular Surgery, June
2011 Vol: 53, page 67S
Sadek, M., Kabnick, L.S, Berland, T., Cayne, N., Mussa, F., Maldonado, T., Rockman, C., Jacobowitz, G., Lamparello, P., and Adelman,
Mark. Update on Endovenous Laser Ablation: 2011. Perspectives in Vascular Surgery and Endovascular Therapy, November 29,
2011.
Dexter, D., Kabnick. L.S., Berland, T., Jacobowitz, G., Lamparello, P., Maldonado, T., Mussa, F., Rockman, C., Sadek, M., Giammaria,
L.E., and Adelman, M. Complications of Endovenous Lasers. Phlebology, March 2012; 27: 40-45.
Rudarakanchana N., Berland T.L., Chasin C., Sadek M., Kabnick L.S. Arteriovenous fistula after endovenous ablation for varicose
veins. Journal of Vascular Surgery, May 2012; 55(5):1492-4.

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ePosters

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101

 ORTA
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Single Centre Experience Following The Introduction Of A Percutaneous
Endovascular Aneurysm Repair First Approach

C. Anibueze, V. Sankaran, U. Sadat, YG. Wilson, RE. Brightwell, MS. Delbridge, PW. Stather

Mohammed Ashrafi, Qusai Al-Jarrah, Mayooreshan Anandrajah, Ray Ashleigh, Mark Welch,
Mohamed Baguneid

Department of Vascular Surgery, Norfolk and Norwich University Hospital, Colney Lane, Norwich,
Norfolk, NR4 7UY, Norwich, United Kingdom

University Hospital of South Manchester, Manchester, United Kingdom

BACKGROUND
There is no international consensus about the optimum management of infected aortae (mycotic aneurysms, infected aortic grafts). Neoaortoiliac reconstruction has advantages over extra anatomical bypass
grafting; however use of autologous vein or cadaveric homografts for this purpose has limitations. Arterial
repair using xenoprosthetic patches is associated with lower infection rate compared to the use of prosthetic material. This case series and literature review reports the use of xenoprothetic bovine biomaterial
for neoaortic repair of mycotic aneurysmal disease and infected aortic grafts.

INTRODUCTION
New aortic graft technologies with low profile delivery systems have allowed specialists to adopt a change
from surgical endovascular aneurysm repair (EVAR) to percutaneous EVAR utilising suture-mediated closure devices (SMCDs). The aim was to evaluate our experience following the introduction of a percutaneous
EVAR first approach utilising Perclose Proglide (Abbott Vascular) SMCDs at a tertiary vascular institution
looking at efficacy, complications and identification of factors that could predict failure.
METHODS
A retrospective cohort study on all patients over a 2 year period following the introduction of a percutaneous EVAR first approach was performed. The primary end point was technical success which was defined
as successful deployment of the SMCDs and access site haemostasis. The procedure was performed by
consultants and trainees under appropriate supervision. Outcomes were analysed using a combination of
Pearsons Chi-squared test and Students t test for categorical and continuous data, respectively.

RESULTS
Six patients underwent bovine aortic repair between 2013-2015: an infected dacron aorto-biiliac graft
causing iliac pseudoaneurysm, an infected dacron aortic graft from open repair later relined with endovascular stent graft, a mycotic iliac aneurysm, and 3 mycotic aortic aneurysms. Median age 69.5 years
(range 67-75 years). All were treated with bovine reconstructed aortic grafts or patches. Peri-operative and
30-day mortality was 0%. Median follow-up 13 months (range 2 23 months). Post-operative contrast enhanced-computed tomography did not show any evidence of infection at the operative site in all patients.
Freedom from re-infection and re-intervention was 100%.

RESULTS
Fifty three patients (46 male and 7 female; mean age 75.2) underwent percutaneous EVAR. Percutaneous
EVAR was technically successful in 41/53 patients (77.4%) and 83/96 access sites (86.5%). Factors associated with failure were common femoral artery (CFA) diameter (P=0.045) and CFA calcification of greater
than 50% (P=0.0001). There was a trend for CFA depth of > 40mm from the skin to be associated with
higher failure rate (P=0.064). The incidence of access site infection was significantly higher in the failure
group (P=0.008) as was procedure duration (P=0.026).

CONCLUSIONS
Xenoprosthetic (bovine) neoaortic grafts are an effective method to treat infected aortae with excellent
short term freedom from infection and reintervention. Optimum duration of post-operative antibiotic therapy remains undetermined. Further cases and longer follow up are required.
REFERENCES
1. Yeager RA, Porter JM. Arterial and prosthetic graft infection. Ann Vasc Surg. 1992;6(5):485-91.
2. Eshaghy B, Scanion PJ, Amirparviz F, Moran JM, Erkman-Balis B, Gunnar RM: Mycotic aneurysm of brachial artery. A complication of
retrograde catheterization. JAMA 1974;228(12):15741575.
3. Monson RC 2nd, Alexander RH: Vein reconstruction of a mycotic internal carotid aneurysm. Ann Surg 1980;191(1):4750.
4. Chan FY, Crawford ES, Coselli JS, Safi HJ, Williams TW Jrl. In situ prosthetic graft replacement for mycotic aneurysm of the aorta. Ann
Thorac Surg. 1989;47(2):193-203.
5. OHara PJ, Hertzer NR, Beven EG, Krajewski LG. Surgical management of infected abdominal aortic grafts: review of a 25 year experience. J Vasc Surg. 1986;1(1):36-42.
6. Robinson JA, Johansen K. Aortic sepsis: is there a role for in situ graft reconstruction? J Vasc Surg. 1991;13(5):677-82.
7. Beck AW, Murphy EH, Hocking JA, Timaran CH, Arko FR, Clagett GP. Aortic reconstruction with femoral-popliteal vein: graft stenosis
incidence, risk and reintervention. J Vasc Surg. 2008;47(1):36-43.
8. Ali AT, Modrall JG, Hocking J, Valentine RJ, Spencer H, Eidt JF, Clagett GP. Long-term results of the treatment of aortic graft infection
by in situ replacement with femoral popliteal vein grafts. J Vasc Surg. 2009;50(1):30-9.
9. Chung J, Clagett GP. Neoaortoiliac system (NAIS) procedure for the treatment of the infected aortic graft. Semin Vasc Surg.
2011;24(4):220-6.
10. McCready RA, Bryant MA, Fehrenbacher JW, Beckman DJ, Coffey AC, Corvera JS, Hormuth DA, Wozniak TC. Long-term results with
cryopreserved arterial allografts (CPAs) in the treatment of graft or primary arterial infections. J Surg Res. 2011;168(1):e149-53.
11. McMillan WD, Leville CD, Hile CN. Bovine pericardial patch repair in infected fields. J Vasc Surg 2012;55(6):1712-5.
12. Czerny M, von Allmen R, Opfermann P, Sodeck G, Dick F, Stellmes A, Makaloski V, Buhlmann R, Derungs U, Widmer MK, Carrel T,
Schmidli J. Self-made pericardial tube graft: a new surgical concept for treatment of graft infections are thoracic and abdominal
aortic procedures. Ann Thorac Surg. 2011;92(5):1657-62.
13. Kubota H, Endo H, Noma M, Tsuchiya H, Yoshimoto A, Takahashi Y, Inaba Y, Matsukura M, Sudo K. Equine pericardial roll graft replacement of infected pseudoaneurysm of the aortic arch. J Cardiothorac Surg. 2012;7:45
14. Kubota H, Endo H, Noma M, Tsuchiya H, Yoshimoto A, Takahashi Y, Inaba Y, Matsukura M, Sudo K. Equine pericardial roll graft replacement of infected pseudoaneurysm of the ascending aorta. J Cardiothorac Surg. 2012;7:54
15. Yamamoto H, Yamamoto F, Ishibashi K, Motokawa M. In situ replacement with equine pericardial roll grafts for ruptured infected
aneurysms of the abdominal aorta. J Vasc Surg. 2009;49:1041-5.
102

CONCLUSIONS
Introduction of a percutaneous EVAR first approach has a not insignificant failure and complication rate.
Percutaneous EVAR failure occur more often in patients with unfavourable access site anatomy. Success
rate can be improved with careful patient selection, a proficient technique and appropriate operator experience.

103

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

 ORTA
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Neoaortic Xenoprosthetic Grafts For Treatment Of Mycotic Aneurysms And Aortic
Grafts: Case Series And Literature Review

 ORTA
A
Surgical Treatments After Ascending Aorta And Aortic Arch Repair Complications

Abhinav Bhansali1, Liesbeth Desender2, Isabelle Van Herzeele2, Mario Lachat3,


Colin Bicknell4, Frank Vermassen2

Marco Leopardi1, Yamume Tshomba1, Luca Bertoglio1, Enrico Rinaldi1, Giampiero Negri2,
Germano Melissano1, Roberto Chiesa1

1. Faculty of Medicine, Imperial College London, London, United Kingdom


2. Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
3. Department of Vascular Surgery, Zurich University Hospital, Zurich, Switzerland
4. Department of Surgery and Cancer, Imperial College London, St Marys Hospital, London,
United Kingdom

1. Vascular Surgery Unit San Raffaele Scientific Institute, Milano, Italy
2. Thoracic Surgery Unit San Raffaele Scientific Institute, Milano, Italy

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

INTRODUCTION
Virtual-reality simulation enables patient-specific rehearsal (PsR) of endovascular aneurysm repairs (EVARs).
This allows the interventionalist and his team to practise and evaluate the real case on patient-specific
anatomy, trial different approaches and endovascular equipment, and thus optimise the treatment plan.
We aimed to evaluate the realism of PsR of EVAR procedures, and its usefuleness to the endovascular team.

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

METHODS
Patients with infrarenal aortic or iliac aneurysms, suitable for EVAR, were enrolled. The rehearsal and
corresponding real EVAR procedure were performed by the same endovascular team. All team members
completed a post-PsR questionnaire evaluating their EVAR experience. This subjective questionnaire evaluated the realism, technical issues and human aspects pertinent to PsR on a Likert scale from 1 (not al all)
to 5 (very much).

RESULTS
In 13 cases the index procedure was an endovascular or hybrid procedure on the aortic arch performed
at our Department, for an in-house reintervention rate of 6.9% (13/188). In 10 cases the cause of reintervention was stent-graft distal migration (Fig. 1), treated by means of endovascular relining in all cases, associated with adjunctive supra-aortic trunks debranching via sternotomy in 6 cases. In 6 cases the
cause of reintervention was retrograde ascending aortic dissection, in 1 case ascending aortic anastomotic
pseudoaneurysm following supra-aortic trunk debranching (Fig. 2), and in 1 case mediastinitis following
implantation of an endovascular plug previously used to treat an ascending aortic pseudoaneurysm. In
these last 8 cases, all patients were treated by means of ascending and arch surgical replacement under
deep hypothermic circulatory arrest (DHCA) and antegrade cerebral perfusion (ACP). No 30-day mortality
was observed. Major perioperative morbidity included 1 paraplegia, 1 minor stroke, 1 bleeding requiring
reintervention, and 3 cases of respiratory failure requiring prolonged intubation (2) or tracheostomy (1).

RESULTS
100 patients were enrolled. The questionnaire was completed by 99 lead interventionalists, 57 assistants
and 43 scrub nurses. Of these, 62/99 (63%) of lead implanters, 36/57 (63%) of assistants, and 27/43 (63%)
of scrub nurses were highly experienced in EVARs (> 50 cases). The realism of PsR was rated highly (median
4, IQR 3-4), especially that of the simulated angiographies of the aorta (median 4, IQR 4-5) and iliac vessels
(median 4, IQR 4-5). The lead interventionalist found the rehearsal useful for selecting the optimal C-arm
angulation (median 4, IQR 4-5). PsR was recognised as a helpful tool to prepare team members individually
(median 4, IQR 3-5) and together as a team (median 4, IQR 4-4), improve communication (median 4, IQR
3-4) and encourage confidence (median 4, IQR 3-4) prior to the actual intervention.

CONCLUSION
In our experience, incidence of serious complications requiring reinterventions following ascending aorta or aortic arch repair is not negligible. Redo surgery in ascending aorta and aortic arch is feasible in
high-volume and experienced centers, as it often requires hybrid repair via midline sternotomy, or surgical
replacement under DHCA and ACP.

CONCLUSION
PsR offers training and learning opportunities in case-specific, realistic EVAR scenarios. Our subjective
evaluation of highly experienced endovascular teams indicates that this technology may (1) facilitate optimal C-arm angulation, (2) improve non-technical skills and (3) prove invaluable to team preparedness.
Ultimately, this may impact procedural efficiency and patient safety.

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 ORTA
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Patient-Specific EVAR Rehearsal: Realism And Impact On The Endovascular Team

CAPTIONS

 ORTA
A
Aorto-Oesophageal Fistula
Royal Hospital, Muscat, United Arab Emirates

Thoracic endovascular Aortic repair (TEVAR) is a minimally invasive procedure for the treatment of thoracic
aortic aneurysms, aortic dissection and traumatic aortic injury. Though it is superior to the open surgical
repair considering it is a far less invasive but its still having its complications like paraplegia, stroke, migration of the device, endoleak, and infection which may present as Aorto-oesophageal fistula (AEF).AEF is a
rare and fatal complication of TEVAR with an incidence of 1.6-1.9% 1.We are presenting a case who developed AEF 20 days after he had TEVAR And treated conservatively with repair of esophagus and followed
by antibiotic therapy for 6 moths only.
investigations of the follow post treatment were normal.
REFERENCES
1. Thoracic Endovascular Aortic Repair: A National Survey: R. Chiesa, G. Melissano, E.M. Marone, M.M. Marrocco-TrischittamA.
Kahlberg. Vascular Surgery, Scientific Institute H. San Raffaele, Vita-Salute University School of Medicine, Via Olgettina 60, 20132
Milano, MI, Italy
2. Int J Vasc Med. 2011;2011:649592. doi: 10.1155/2011/649592. Epub 2011 Sep 6.Aortoesophageal fistula after endovascular
aortic aneurysm repair of a mycotic thoracic aneurysm.Gavens E1, Zaidi Z, Al-Jundi W, Kumar P.
3. Eur J Cardiothorac Surg. 2014 Mar;45(3):452-7. doi: 10.1093/ejcts/ezt393. Epub 2013 Jul 31.
New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications.
Czerny M1, Eggebrecht H, Sodeck G, Weigang E, Livi U, Verzini F, Schmidli J, Chiesa R, Melissano G, Kahlberg A, Amabile P, Harringer W, Horacek M, Erbel R, Park KH, Beyersdorf F, Rylski B, Blanke P, Canaud L, Khoynezhad A, Lonn L, Rousseau H, Trimarchi S,
Brunkwall J, Gawenda M, Dong Z, Fu W, Schuster I, Grimm M.
4. Aortoesophageal Fistula After Thoracic Aortic Stent-Graft Placement: A Rare but Catastrophic Complication of a Novel Emerging
Technique
Holger Eggebrecht, MD?; Rajendra H. Mehta, MD, MS?; Alexander Dechene, MD; Konstantinos Tsagakis, MD; Hilmar Khl,
MD; Sebastian Huptas, MD?; Guido Gerken, MD; Heinz G. Jakob, MD; Raimund Erbel, MD?
5. Secondary aortoesophageal fistula after thoracic endovascular aortic repair for a huge aneurysm
Akhmadu Muradi Masato Yamaguchi. Atsushi Kitagawa. Yoshikatsu Nomura,Takuya Okada,Yutaka Okita,Koji Sugimoto
6. J Vasc Surg. 2003 Apr;37(4):886-8.
Secondary aortoesophageal fistula after endoluminal exclusion because of thoracic aortic transection.
Hance KA1, Hsu J, Eskew T, Hermreck AS
7. Kieffer, E., Chiche, L., and Gomes, D. Aortoesophageal fistula: value of in situ aortic allograft replacement. Ann Surg. 2003; 238:
283290
8. Saito, A., Motomura, N., Hattori, O., Kinoshita, O., Shimada, S., Saiki, Y. et al. Outcome of surgical repair of aorto-eosophageal
fistulas with cryopreserved aortic allografts. Interact Cardiovasc Thorac Surg. 2012; 14: 532537
9. Presented at the Thirty-third Annual Meeting of the Southern Association for Vascular Surgery, Tucson, Ariz, Jan 14-17, 2009.
Paul J. Riesenman, MD, MS,
Mark A. Farber, MD
10. The Management of Aortic Stent-Graft Infection: Endograft Removal Versus Conservative Treatment
Montse Blanch, Jennifer Berjn, Ramon Vila, Josep Maria Simeon
Antonio Romera, Santiago Riera, Marc Antoni Cairols
Department of Angiology and Vascular Surgery, Hospital Universitari de Bellvitge, 08907 Barcelona, Spain.
Annals of Vascular Surgery (Impact Factor: 1.17). 05/2010; 24(4):554.e1-5. DOI: 10.1016/j.avsg.2009.11.003
Source: PubMed

Fig.1 Distal stent-graft migration

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

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Sulaiman Al Shamsi, Shahinda Seidahmed, Shahinda Seidahmed, Shahinda Alanwar

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Expanding Indications For EVAR And TEVAR

Joel Sousa, Joo Rocha-Neves, Jose Pinto, Armando Mansilha, Jos Teixeira

Stevo Duvnjak

Hospital de S.Joo, EPE, Oporto, Portugal

Odense University Hospital, Odense, Denmark

AIMS
To compare risk factors and their impact in the evolution of aneurysmal sac volume (ASV) and maximum
aneurysm transverse diameter (ATD) in patients submitted to EVAR.

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

METHODS
A total of 57 patients treated by EVAR were evaluated (93% male; mean age of 72,6 years [56-85]). The
mean follow-up period was 13 months. Maximum ATD and ASV were measured in the pre-operative and
latest pos-operative angio-CT. Growth of > 5mm in diameter or more than 3% in volume in the pos-operative CT were considered significant. Aneurysmal sac calcification, neck thrombus, neck angulation, endoleak and re-intervention were evaluated.

MATERIALS AND METHODS


1 Case: AORFIX stent graft to treat highly angulated aneurysm neck- case report 
82-year-old lady with asymptomatic 5,8 cm big AAA. Infrarenal aortic neck angulation 84 and angulated iliac artery. Access vessels very important ( Aorfix stent graft -20-22Fr). The stent graft is placed
according to the instruction of use without difficulties and without complications. Three month C contrast
enhanced control was without endoleak or other complications
2. Case: Bolton custom-made stent graft with scallop for celiac trunk
A 59-year-old male with saccular aorta descdedens aneurysm treated with TEVAR. Control revealed
endoleak type 1 B- attempt to treat with coils embolization, but still endoleak present. To obtain better
distal sealing zone decided to place custom-made stent graft with scallop for the celiac trunk. The stent
graft is placed without complication and control showed good result and no endoleak. CT control one
year after showed no endoleak and patent celiac trunk.

RESULTS
This study demonstrated that there is positive correlation between ASV and ATD (p<0,001). Presence of endoleak is significantly associated with growth of the aneurysmal sac, both in maximum diameter (p<0,001)
and volume (p=0,002). There was a trend suggesting that neck thrombus >2mm (p=0,077) and neck angulation (>60) (p=0,066) were related with diameter increase but not volume (p= 0,510 and 0,453). No
association was found between the presence of sac calcification and the post-operative behaviour of the
aneurysmal sac. Re-intervention was associated with ATD growth of >5mm (p=0,034) but not with ASV
growth of >3% (p=0,152).

CONCLUSION
Continuous development in stent graft technology allowed us to treat more patients, however, the anatomical constraint must be respected for every technology.

CONCLUSIONS
Aneurysmal sac diameter and volume have a positive correlation. Endoleak influences both variables, but
neck thrombus and neck angulation appear to influence sac diameter only. ATD growth was associated
with higher re-intervention.

FIGURES

This study suggests that certain anatomic factors influence aneurysm transverse diameter more than they
influence volume. Since both these parameters have a positive correlation, authors believe some ATD
growths represent only remodelling phenomena of the sac and thrombus and not true aneurysm sac
growth. Further studies are required.

Aorfix stent graft. Fig. 1 Pre operative CT showed highly


angulated infrarenal aortic neck

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


deployment

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

Custom-made Bolton stent graft.Fig. 1 Contrast enhanced CT


showed endoleak type 1 B and close aneurysm relation to the
celiac trunk

Custom-made Bolton stent graft. Fig. 2 Intraoperative


angiography and proper orientation of teh scallop

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


stent graft deployment

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

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Aorfix stent graft. Fig. 3 Control CT without endoleak

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Principles for management of iatrogenic type A aortic dissection

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

Department of cardiothoracic surgery, St Georges university hospital, London, United Kingdom

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

INTRODUCTION
Intraoperative Type A aortic dissection is a rare pathology with incidence of 0.06-0.32%. It is associated
with a high mortality between 30-50%. It could exponentially increase the risk profile of a simple operation. Some associated risk factors have been identified. Modification of these risk factors could reduce the
incidence of the pathology. Prompt diagnosis and management, with the aid of intraoperative trans-oesophageal echocardiography/epi-aortic ultrasound has been shown to reduce the mortality to 17%. It is
essential that all cardiac surgeons and patients with risk factors are aware of this entity 1, 2.

OBJECTIVE
Dacron grafts are frequently used during surgical revascularization procedures. Graft thrombosis or infection are well known complications. However, aneurysm formation is extremely rare. In this report, we
present Dacron graft aneurysm of left limb of aortobifemoral bypass graft in a 50-year-old male patient.
METHODS
The patient underwent aortobifemoral bypass procedure with an 18x9mm, 45cm knitted polyester vascular
graft (FlowNit Bioseal, JOTEC Vascular Prosthesis) in 2010. In 2013, he presented with occlusion of right
limb of the graft. He underwent cross-over graft to right femoral artery bypass with a saphenous vein. He
presented with enlargement of the left femoral pulsatile mass. A computerized tomography angiography
indicated Dacron graft dilation (35x31 mm body size and 28x24 mm left leg size) and a 5cm in diameter
left femoral aneurysm.

CASE REPORT
We illustrate the principles of management of this pathology with the case of a 62 year old lady who developed acute type A aortic dissection while undergoing minimally invasive mitral valve repair. Her past
medical history is remarkable for hypertension, ascending aorta 4.3 cm. She developed fluctuation in blood
pressure during femoral cannulation. TOE confirmed the diagnosis and this was successfully repaired via
sternotomy with DHCA at 18C.
DISCUSSION
Risk factors for intraoperative type A aortic dissection include hypertension, peripheral vascular disease,
advance age >65 years, large diameter of the aorta, use of steroid, pre-existing aortic pathology, femoral
arterial cannulation and high cardiopulmonary bypass pressures >120 mmHg 1, 3, 4.
Its risk factors, strategy for prompt identification and management should be armamentarium of all cardiac surgeons. Patients should be informed of intraoperative aortic dissection as a possible risk of cardiac
surgery especially in patients with identifiable risk factors.
Our case demonstrates a patient with identifiable risk factors for intraoperative type A aortic dissection,
namely hypertension and enlarged aorta, intraoperative she had a period of hypertension during femoral
cannulation. The immediate availability of intraoperative TOE facilitated a prompt diagnosis of the pathology. Prompt strategy of immediate repair of the dissection via sternotomy and alternative arterial cannulation site with deep hypothermic circulatory arrest facilitated a good outcome for the patient.
Intraoperative type A aortic dissection has been reported in all types of cardiac surgery including off pump
coronary artery bypass surgery. All arterial cannulation sites have been identifies as possible initiation sites.
Intraoperative trans-oesophageal echocardiography (TOE)/ Epi-aortic ultrasound is the gold standard for
prompt diagnosis of intraoperative aortic dissection, although clinical observation is also essential 5. Once
identified separation from cardiopulmonary bypass and pursuit of alternative cannulation site with repair
of the aortic dissection under deep hypothermic circulatory arrest is the treatment strategy.
Risk factor modification include avoiding cannulation of significantly diseased arterial site, clamping of
pressurised aorta, torqueing of partial clamp and minimal handling of arteries may prevent the occurrence
of this pathology.

RESULTS
He underwent aortouniliac endovascular stent grafting (Medtronic Endovascular, Santa Roja, Calif., US).
Then surgical removal of the left femoral aneurysm and replacement with an 8mm PTFE graft was performed.
CONCLUSIONS
Intrinsic Dacron graft failure occurs in approximately 0,5-3%. Dacron graft aneurysms are rare disorders.
Most cases present generalized dilation. There are multifactorial reasons of the pathology; such as mostly
fabrication flaws, faulty preoperative management related to methods of sterilization, bio-deterioration
related to hematomas or infection, and material fatigue. The risk of aneurysm rupture is very rare. Endovascular treatment is a relatively safe option for the treatment of the dilated Dacron grafts.

CONCLUSION
Intraoperative type A aortic dissection is a rare but important pathology with high morbidity and mortality.
Identifiable risk factors can be managed to enhance outcome. Patient consent for cardiac surgery should
include a mention of this entity.
BIOGRAPHY
Amber jiskani is a Junior cardiothoracic surgery trainee at St Georges university hospital.

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

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

OBJECTIVE
To compare outcomes in patients undergoing either Iliac Branch Device (IBD) insertion or internal iliac
artery (IIA) embolization as an adjunct procedure during elective endovascular abdominal aortic aneurysm
repair (EVAR).
METHODS
All patients undergoing elective infrarenal EVAR with internal iliac adjunct in a vascular centre over a
4-year period were identified from prospective local and national databases. Case notes and procedural
images were reviewed. Patients were contacted by telephone to assess post-operative symptoms and impact on quality of life. Statistical analysis was with the Chi test.
RESULTS
From 237 infrarenal EVARs, 28 had adjunctive procedures to the iliac arteries. 12 patients had an IBD; 6
with contralateral embolization of IIA. There was 1 technical failure and 1 Type II endoleak. 16 patients had
IIA embolization only (8 left, 5 right, 3 bilateral). Telephone follow-up was at a median of 12 months (range
6-60). 2 patients from each group died prior to the study. New erectile dysfunction developed in 4 embolization and 0 IBD patients. (p=0.06) Persistent new buttock claudication (either side) occurred in 42% (3
IBD, 7 IIA, p= 0.3). New ipsilateral buttock claudication developed in 1/9 patients with preserved IIA perfusion by IBD and 8/15 with an occluded IIA (p=0.03). In the IBD group, 1 patient developed contralateral
claudication (with IIA embolization) and 2 developed ipsilateral claudication (1 technically successful; 1
failed with IIA occlusion).

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

CONCLUSION
Preservation of IIA patency with successful IBD reduces postoperative ipsilateral buttock claudication when
compared with IIA occlusion. The incidence of erectile dysfunction may also be lowered.

Postoperative control computed tomography angiography.

Postoperative control computed tomography angiography.

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FIGURES

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Endovascular Aneurysm Repair Versus Open Repair For Patients With A Ruptured
Abdominal Aortic Aneurysm: A Mid-Term Cost-Effectiveness Analysis

Aimee Rowe, Timothy Rowlands

Ahmed Aber, Matt Bown, Robert Sayers

Royal Derby Hospital, Derby, United Kingdom

Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom

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

OBJECTIVES
The aim of this study was to analyze the cost-effectiveness of EVAR compared with open repair (OR) in the
treatment of ruptured abdominal aortic aneurysms (RAAA).
DESIGN
A model-based costutility analysis was performed estimating mean costs and quality-adjusted life-years
(QALYs) from the UK National Health Service with a 1-year time horizon.
METHODS
A decision tree model was constructed and populated with probabilities, outcomes and utility data from
published literature including IMPROVE, AJAX & NOTTINGHAM trials. The cost data were obtained from the
NHS reference costs published annually by the department of health. Probabilities, outcomes for long-term
complications were obtained from literature on elective repair of AAA because of lack data for RAAA. This
was done so that the economic model captures the effects of post-operative complications on the cost-effectiveness of EVAR and OR. The results from the model were assessed using one-way and probabilistic
sensitivity analyses.
RESULTS
The cost of EVAR and open repair combined with the costs of the complications over one year were
5547.9 and 5963.7, the QALYs were 0.493 and 0.498 respectively. Both treatments costs were well
below the lower margin of the societal willingness to pay in the UK (20000) for one gained QALY. The
net monetary benefit (NMB) for OR was 3987-10939 compared to EVAR with NMB 4307.5-9235.2. The
sensitivity analysis confirmed that both treatment modalities are cost-effective management options at the
maximum willingness to pay for a QALY commonly used in the UK.
CONCLUSION
Performing OR on RAAA is a cost effective strategy with a marginally better NMB when compared to EVAR.
However both EVAR and OSR cost less than the societal willingness threshold for the QALYs gained.
REFERENCES
1. Reimerink J, van der Laan MJ, Koelemay MJ, Balm R, Legemate DA. (2013)Systematic review and meta-analysis of population-based mortality from ruptured abdominal aortic aneurysm Br J Surg, 100 (11): 14051413
2. Reimerink JJ, Hoornweg LL, Vahl AC, Wisselink W, van den Broek TA, et al. (2013). Endovascular repair versus open repair of
ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial Ann Surg, 258: 248256
3. Parodi JC, Palmaz JC, Barone HD. (1991) Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc
Surg. 5:4919.
4. Greenhalgh, R. M., L. C. Brown, G. P. Kwong, et al.(2004) Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004.
364:843848
5. Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT, Jr, Matsumura JS, Kohler TR, et al. (2009) Outcomes following endovascular
vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA, 302:153542.
6. Hinchliffe RJ, Bruijstens L, MacSweeney ST, Braithwaite BD. (2006) A randomised trial of endovascular and open surgery for
ruptured abdominal aortic aneurysm results of a pilot study and lessons learned for future studies. Eur J Vasc Endovasc Surg, 32
(5) (2006), pp. 506513
7. Powell JT, Sweeting MJ, Thompson MM, Ashleigh R, Bell R,et al. (2014) Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial BMJ, 348: f7661

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A Completed Cycle Audit Of Pre-Operative Assessment Of EVAR Patients In The
Royal Derby Hospital

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

INTRODUCTION
The use of chimney grafts in complex visceral aneurysm endovascular repair is a well-known 1 yet controverse 2 technique. Use in re-do procedures or aneurysmal complications post-endovascular aortic repair
(EVAR) has been however very seldom reported3. We report a case with some very peculiar challenging
variables where
CASE REPORT
A 81 y.o. man presented with a large symptomatic para-renal aneurysm (p-AAA) measuring 8 cm in diameter involving the origin of the major visceral trunks. The aneurism developed after 7 years from a previous
endovascular emergent aortic repair (EVAR) with a right uni-iliac endograft with passive suprarenal fixation plus femoro-femoral crossover for a contained rupture of an infrarenal abdominal aortic aneurysm. The
patient was admitted in the emergency department with important back and abdominal pain without signs
of hemodynamic instability. The past medical history accounted for a previous aorto-coronary bypass for
coronary artery disease, moderate chronic obstructive pulmonary disease and a mild chronic renal failure
due to left kidney atrophy. In regard to his previous EVAR procedure, a CT scan was promptly performed
and a large degenerative aneurysm involving the visceral segment of the abdominal aorta cranial to the
free-flow was revealed, furthermore causing a large type I endoleak around the uni-iliac aortic endoprosthesis (Fig.1, 2, 3, 4, 5). The telltaling radiological findings of peri-aortic inflammation and very thin wall
were suggestive for an impending rupture, therefore, considering the poor general status and high surgical
risk of open repair, the patient was scheduled for a re-do procedure associated with visceral Chimney
Graft rebranching (ch-EVAR). The procedure was performed via a single right femoral access plus bilateral
brachial accesses. In an antegrade fashion the three visceral vessels (the coeliac trunk, the superior mesenteric artery and the remaining right renal artery) were engaged from the upper limbs. After telescopic
deployment of a 10 cm long thoracic aortic endograft with 10% oversizing via the femoral artery, three
flexible covered stents (8-7-6 mm in diameter and 10 cm in length) were respectively released in each vessel in a chimney graft technique. It followed a careful post dilation of each branch parallel to the aortic
cuff. The final angiography showed a good placement of the devices with complete aneurysm exclusion
and no signs of endoleaks. Surgery was performed under general anesthesia, total duration of surgery was
3.30 hours, two of which under fluoroscopy. The patient was dismissed on 10th postoperative day without
neurological impairments and in fair general conditions. A post-operative CT scan confirmed complete
aneurysm exclusion and regular patency of the three branches. (see Fig. 3)
DISCUSSION
Due to the patients multiple comorbidities, ch-EVAR was the the most promising therapeutic option 3-4 to
offer in this complex p-AAA complicating EVAR. In fact, recent studies 5 report quite positive outcomes in
the short-term counting 6% chimney-related mortality and 93% long-term patency in high risk population
and urgent setting. Although a triple chimney stenting may be in relationship with a high rate of leak 6,
it is known that this can be somehow prevented by assuring enough overlap of the stents at the sealing
zone and by choosing the correct size of the endograft. Accurate preoperative measuring and planning is
therefore crucial for such purpose. In this setting, the pre-planned choice of a thoracic conical endograft,
which is known to have a higher radial force, played a major role for the success of the operation because
it allowed a more precise sealing around the stents and at the graft-in-graft junction. Except for the post
dilation of the visceral chimney stents, we do not find useful the dilation of the main graft as in tight spaces, displacement or compression of the stents are a real concern. In conclusion, the treatment of p-AAA
can be technically challenging, especially in patients undergone to previous aortic procedures. ch-EVAR
confirmed its feasibility and safety as bail-out method for urgent cases providing that every possible pitfall
is taken care of during planning.

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8. Kapma MR, Dijksman LM, Reimerink JJ, et al. (2014) Cost-effectiveness and cost-utility of endovascular versus open repair of
ruptured abdominal aortic aneurysm in the Amsterdam Acute Aneurysm Trial. Br J Surg. 2014;101(3):208-15
9. National Institute for Health and Care Excellence (NICE). Guide to the Methods of Technology Appraisal 2013.
10. Young KC, Awad NA, Johansson M, Gillespie D, Singh MJ, Illig KA. (2010) Cost-effectiveness of abdominal aortic aneurysm
repair based on aneurysm size. Journal of Vascular Surgery. 51(1):2732.
11. Van Beek SC, Conijn AP, Koelemay MJ, Balm R. (2014) Endovascular aneurysm repair versus open repair for patients with
ruptured abdominal aoric aneurysm: Systematic review and meta-analysis of short term survival. Eur J Vasc Endovasc Surg 10785884(14)
12. Schermerhorn ML, OMalley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. ( 2008) Endovascular versus open repair of abdominal aortic aneurysms in the medicare population. New England Journal of Medicine. 358(5):464474.
13. van Marrewijk CJ, Leurs LJ, Vallabhaneni SR, Harris PL, Buth J, Laheij RJ. (2005) Risk-adjusted outcome analysis of endovascular
abdominal aortic aneurysm repair in a large population: how do stentgrafts compare? J Endovasc Ther. 12:41729.
14. CEA Registry, Tufts Medical Center. accessed April 2014. https://research.tufts-nemc.org/cear4/SearchingtheCEARegistry/
SearchtheCEARegistry.aspx

Pre-operative CT scan, right renal artery

Post operative CT scan, celiac trunk

Pre-operative CT scan, superior mesenteric artery

Post operative CT scan, volume rendering reconstruction

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

Pre-operative CT scan, type Ia endoleak

Pre-operative CT scan, VR reconstruction

Post operative CT scan, right renal artery

Post operative CT scan, superior mesenteric artery


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FIGURES

Christian Gerges, Xavier Chaufour, Jean Porterie, Etienne Grunenwald, Christophe Cron,
Marylou Para, Yves Glock, Bertrand Marcheix

CHU Toulouse Rangueil, Toulouse, France

OBJECTIVES
To describe early and mid-term results of extensive thoracic aortic disease treatment by frozen elephant
trunk (FET) procedure using the Thoraflex Hybrid prosthesis.
METHODS
From January 2014 to May 2015, 20 patients were treated: 7 aneurysms and 13 aortic dissections (9 acute
dissections); 7 interventions were redo and aortic root surgery was associated in 9 patients. Procedures
consisted of one stage frozen elephant trunk via a median sternotomy, under cardiopulmonary bypass,
moderate hypothermia and selective antegrade cerebral perfusion. Clinical and CT scan follow up was
scheduled at 1, 3, 6 and 12 months.
RESULTS
Two patients died (2/20=10%) on post-operative day 4 and 5. The cause of death was one myocardial
infarction (redo surgery for chronic dissection) and one mesenteric ischemia (elective surgery for atheromatous aneurysm). Mean follow up was 211,2116days. One patient was successfully reoperated because of
type 1 distal endoleak at 3 months (atheromatous aneurysm). The other aneurysms were completly excluded and false lumen in the descending aorta thrombosed in all cases of aortic dissections.

Aneurysm

Anastomose

Anastomose

Thoraflex Description And Available Size

CONCLUSIONS
The FET using the Thoraflex Hybrid prosthesis makes possible the treatment of extensive disease of the thoracic aorta. Operative mortality should not be underestimated despite substantial technical improvement.
Mid term results seem to be interesting especially when FET technic is performed in the setting of acute
aortic dissection.
FIGURES

La Thoraflex

Deployment

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Early And Mid-Term Results Of The Frozen Elephant Trunk Procedure Using The
Thoraflex Hybrid Prosthesis For Treatment Of Extensive Thoracic Aortic Disease

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

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A challenging internal iliac aneurysm - Case report

2
4
11
4
9

Mario Moreira

Centro Hospitalar e Universitrio de Coimbra, Coimbra, Portugal


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

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

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

Demographics
Follow up
Endoleak
Reintervention

254,2
2
2

+/- 116,8 (15-400)

EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

TABLES

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

124

125

Stefano Bonvini, Valentina Wassermann, Mirko Menegolo, Paola Scrivere, Michele Piazza,
Franco Grego
Clinic of Vascular and Endovascular Surgery of Padua University, Padova, Italy

OBJECTIVES
Conversion of a previous endovascular aneurysm repair (EVAR) with suprarenal fixation is a challenging
situation even in the elective setting. The outcomes of a technique based on preservation of the first proximal covered stent of the endograft, used as a neo-neck for proximal anastomosis, are presented.
METHODS
From 2001 to 2014, nine patients underwent elective conversion of a previous suprarenally fixed EVAR.
After supraceliac clamping, the aneurysm sac was opened and the endograft identified; the fabric was
cut beyond the first covered stent together with its native aortic wall in order to create a neo-neck. An
aortic balloon was inflated into the visceral aorta to avoid back bleeding. A Dacron bifurcated tube graft
(Intergard, Maquet) was then sutured to the neo-neck mimicking endobanding, passing the stitches into
the aortic wall and the first covered stent.

The endobanding In all the cases the stitches were passed as deeply as possible into the aorta at the level of the bottom of the
fabric covered stent mimicking endobanding.

RESULTS
The mean age was 68 years (range, 5284 years). The stent grafts removed were four Zenith (Cook Medical), three Endurant (Medtronic), and two E-vita (Jotec). The indication for conversion was type 1A (n =
2), type 2 (n = 2), and type 3 (n = 1) endoleak, complete endograft thrombosis (n = 2), and abdominal
pain with sac enlargement with no radiological sign of endoleak (n = 2). Blood loss was 1,428 mL (range
5003,000 mL); the visceral ischemic time to perform the proximal anastomosis was 23.5 min 2.3 min).
The post-operative complication rate was 11% (n = 1/9) related to a case of sac wall bleeding requiring
re-intervention; mortality at 30 days was 0%. At 22 months (range, 841) the computed tomography angiogram demonstrated no signs of leaks or anastomotic pseudoaneurysm.

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

CONCLUSIONS
Preservation of the proximal covered stent of an endograft with suprarenal fixation used as an infrarenal
neo-neck with incorporation of the aorta to the suture line during elective surgical explantation simplifies the procedure, and can be achieved with very low early morbidity and mortality; furthermore, it seems
to be durable over mid-term follow up.

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

127

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

 ORTA
A
Surgical infrarenal Neo-neck technique during elective conversion after evar with
suprarenal fixation

Monica Vescovi, Raffaello Bellosta, Luca Luzzani, Claudio Carugati, Francesca Bontempi,
Antonio Sarcina
Poliambulanza Foundation, Brescia, Italy

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

Postoperative CT

REFERENCES
Efficacy and durability of the chimney graft technique in urgent and complex thoracic endovascular aortic repair
Adel Bin Jabr, MD, Bengt Lindblad, MD, PhD, Nuno Dias, MD, PhD, Timothy Resch, MD, PhD, and Martin Malina, MD, PhD, Malm,
Sweden J Vasc Surg 2015;61:886-94
Contemporary comparison of aortic arch repair by endovascular and open surgical reconstructions
Paola De Rango, MD, PhD,a Ciro Ferrer, MD,b Carlo Coscarella, MD,b Francesco Musumeci, MD,c, Fabio Verzini, MD, PhD, FEBVS,a
Gabriele Pogany, MD,b Andrea Montalto, MD,c and Piergiorgio Cao, MD, FRCS,b Perugia and Rome, Italy (J Vasc Surg 2015;61:33946.)
Thoracic endovascular aortic repair with the chimney graft technique
Wouter Hogendoorn, MD,a,b Felix J. V. Schlsser, MD, PhD,a Frans L. Moll, MD, PhD,b, Bauer E. Sumpio, MD, PhD,a,c and Bart E.
Muhs, MD, PhD,a,c New Haven, Conn; and Utrecht, The Netherlands (J Vasc Surg 2013;58:502-11.)
Endovascular Aortic Repair Combined with Chimney Technique in the Treatment of Stanford Type B Aortic Dissection Involving Aortic
Arch
Hong Liu,1,2,3 Chang Shu,1 Xin Li,1 Tun Wang,1 Ming Li,1 Quan-Ming Li,1 Kun Fang,1 and Shalong Wang,1 Changsha, China and
Tianjin, China Ann Vasc Surg 2015; 29: 758763
Case Report A Case of Ruptured Aortic Arch Aneurysm Successfully Treated by Thoracic Endovascular Aneurysm Repair with Chimney
Graft Yohei Kawatani, Yujiro Hayashi, Yujiro Ito, Hirotsugu Kurobe Yoshitsugu Nakamura, Yuji Suda, and Takaki Hori Hindawi Publishing Corporation
Case Reports in Surgery
Volume 2015, Article ID 780147, 5 pages
The chimney-graft technique for preserving supra-aortic branches: a review
Konstantinos G. Moulakakis1,2, Spyridon N. Mylonas1,2,3, Ilias Dalainas1, George S. Sfyroeras1, Fotis
Markatis1, Thomas Kotsis3, John Kakisis1, Christos D. Liapis1 Ann Cardiothorac Surg 2013;2(3):339-346
Triple-barrel Graft as a Novel Strategy to Preserve Supra-aortic Branches in Arch-TEVAR Procedures: Clinical Study and Systematic
Review
R. Shahverdyan *, M. Gawenda, J. Brunkwall 2012 European Society for Vascular Surgery. Published by Elsevier Ltd.

FIGURES

First CT with increasing diameter of aneurysm arch

Postoperative CT 2

Stentgrafts in ascendent aorta

128

129

EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

 ORTA
A
Symptomatic recurrent aortic arch aneurysm successfully treated by total
endovascular aortic repair

 UPRA AORTIC TRUNKS


S
Cerebral Protection With Right And Left External Carotid Artery Cross Over Bypass
For Pulsatile Flow Inside The Internal Carotid Arteries During Aortic Debranching

Andre M. Cancela, Meirelles GV, Luis S.

Murat Ugurlucan1, Didem Melis Oztas1, Omer Ali Sayin1, Ylmaz Onal2,
Mehmet Barburoglu2, Mehmet Akif Onalan1, Metin Onur Beyaz1, Cagla Canbay1,
Ergin Arslanoglu1, Seda Yildirim1, Bulent Acunas2, Nilgun Bozbuga1, Ufuk Alpagut1,
Enver Dayioglu1

Indaiatuba, So Paulo, Brazil

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

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

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

130

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

 ORTA
A
The complexity and challenge in endovascular repair of aneurysms with severely
angulated neck, the report of two cases

 UPRA AORTIC TRUNKS


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

OBJECTIVE
A group of patients with carotid artery disease are at high-risk for general anesthesia and deserves carotid
endarterectomy with regional anesthesia. Carotid clamp intolerance is a known issue and may also occur
in this particular patient population. Even less than 30 seconds of temporary clamping of the carotid arteries to deploy a standard marketed shunt may be eventful in these patients. We present a novel shunt
that we made from simple medical equipment in this patient population for safe carotid endarterectomy.
METHODS
Among 145 patients who underwent carotid endarterectomy between March 2010 and October 2015, 11
(5,6%; 8 men and 3 women; age range 52-77years) could not tolerate carotid clamping. We used an alternative carotid shunt, made from a venous catheter, a three-way stopcock, and a serum line, which aided
non-compromised cerebral flow during the surgery of these patients.

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

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

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

132

An alternative, simple shunt can be easily constructed in the


operating room or clinic, using an angiocatheter, a three-way
stopcock, and a serum line

133

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

FIGURES

 ISCERAL ARTERIES
V
Aneurysms Of Visceral Arteries
Olexander Usenko, Iryna Shevchenko, Pavlo Nikulnicov, Arkadii Danylets, Oleg Babii
Shalimovs National institution of surgery and transplantology, Kyiv, Ukraine

Tiago Ferreira, Augusto Ministro, Pedro Martins, Ana Evangelista, Emanuel Silva,
Lus Silvestre, Lus Mendes Pedro, Jos Fernandes e Fernandes
Vascular Surgery Department, Hospital de Santa Maria - CHLN, Lisbon, Portugal

Aneurysm of the celiac artery is an uncommon clinical problem; fewer than 180 cases have been reported
in the world medical literature. Most patients are symptomatic at the time of diagnosis1. Rupture of celiac artery aneurysms is associated with significant clinical morbidity and mortality rates. On the basis of
abdominal aortic aneurysm data, the risk of celiac artery aneurysm rupture can range from 5% for aneurysms that are from 15 to 22 mm in diameter to 50% to 70% for aneurysms with a diameter of more than
32mm2. Early recognition and accurate characterization of this vascular anomaly is essential, because the
operative mortality rate increases from approximately 5% to 40% when the aneurysm has ruptured at the
time of surgical intervention3,4
We present a case of 29 year old male who had a chronic epigastric pain for 1mounth. Computed tomographic angiography detected aneurysm of visceral trunk from its bifurcation to splenic artery with
diameter 6.6x6.5 cm. Second aneurysm was detected from bifurcation of visceral trunk to common hepatic
artery, with diameter 3,7x4 cm. Next aneurism, in the middle third of splenic artery had diameter 7.3x5.3
cm. Also there were aneurism of arteria mesenterica surerior with 3 cm in diameter and several aneurysms
of its branches with maximum diameter 1,8 cm. Comorbid conditions include low platelets level and high
rheumatoid factors.
At surgery laparotomy was used to approach aneurysms of visceral trunk and its branches. A curved vascular clamp was placed on the aorta at the base of the celiac trunk, and the distal tributaries were clamped.
Aneurysms were resected. Common hepatic artery was occluded, its origin and the origin of the celiac
artery were oversewn. Spleen was enlarged to 22x8x3.5 cm with hemorrhage inside, as result spleenectomy was performed. Splenic vein was thrombosed. The branches to aneurism of splenic artery ware ligated,
after it no pulsation was registered on it and the last one wasnt resected. On bacteriological examination
of wall of the aneurysms mycotic nature of them were approved.
A computed tomographic scan in early postoperative period didnt show any significant complications or
signs of hepatic or other organs insufficiency. The patient made an uncomplicated recovery and was discharged after 11 days.

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

REFERENCES
1. D. Michael McMullan, Michael McBride, James J. Livesay, Kathryn G. Dougherty, Zvonimir Krajcer. Celiac Artery Aneurys.Tex Heart
Inst J. 2006; 33(2): 235240. [PubMed]
2. Rokke O, Sondenaa K, Amundsen S, Bjerke-Larssen T, Jensen D. The diagnosis and management of splanchnic artery aneurysms.
Scand J Gastroenterol 1996;31:73743.[PubMed]
3. Graham LM, Stanley JC, Whitehouse WM Jr, Zelenock GB, Wakefield TW, Cronenwett JL, Lindenauer SM. Celiac artery aneurysms:
historic (17451949) versus contemporary (19501984) differences in etiology and clinical importance. J Vasc Surg 1985;2:757
64.[PubMed]
4. Stanley JC, Whitehouse WM Jr. Splanchnic artery aneurysms. In: Rutherford RB, ed. Vascular surgery. 6th ed. Philadelphia: Elsevier
Saunders; 2005. p. 156581.

CONCLUSIONS
Acute bowel ischemia can be the end result of chronic atherosclerotic disease of the visceral vessels,
affecting patients who are often frail and have multiple medical comorbidities. Acute deterioration of
long-standing symptoms may indicate irreversible compromise of intestinal viability, which translates
into high rates of bowel resection. Prompt revascularization and removal of necrotic bowel offer the best
chance of survival.

134

135

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

 ISCERAL ARTERIES
V
Emergency Revascularization For Acute-On-Chronic Mesenteric Ischemia:
8-Year Experience

C
 ASE REPORT
Rare Coeliaco-Mesenteric Trunk Aneurysm: Combined Surgical and Endovascular
Solution

Paola Scrivere1, Giovanna Biasi1, Massimo Sponza2, Alice Silvestri1, Paolo Frigatti1

Neena Randhawa, Peter Bungay, John Quarmby, James kirk, Timothy Rowlands

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

INTRODUCTION
Visceral artery aneurysms are extremely rare. The most common form of these aneurysms is coeliac axis
aneurysm, usually involving the individual arteries. There have been approximately 180 case reports of
such aneurysms since 1745, usually by anecdote. The majority of these are asymptomatic and often picked
up as incidental findings. These are associated with high morbidity and mortality.

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

136

Royal Derby Hospital, Derby, United Kingdom

AIM
We present an unusual case of a patient with an aneurysm of a common origin of the coeliac and superior
mesenteric arteries (SMA) and its management.
CASE
A 68 years old gentleman was identified to have 5.2cm infra-renal abdominal aortic aneurysm on abdominal ultrasound but CT identified this visceral artery aneurysm with normal abdominal aorta. He was
otherwise fit and well and asymptomatic. Discussion at our vascular multidisciplinary team (MDT) meeting
explored several different options including total surgical repair and combined endovascular options. He
underwent a laparotomy with the intent of ligation of the aneurysm and multiple grafting however primary
ligation proved impossible. The splenic artery was ligated at the origin and dacron graft was used to anastomose to the aorta. After recovering from this procedure the patient then underwent a further endovascular procedure, which permitted embolisation of the common hepatic artery and a covered stent from aorta
into the superior mesenteric artery, thus permitting total exclusion of the aneurysm. The arterial supply of
the liver was thus maintained from the bypassed splenic artery via pancreatic collaterals and gastro duodenal artery to the distal part of the hepatic artery (see Fig.). The patient was discharged on clopidogrel and
remains well at 12 month follow up.
DISCUSSION
This unusual case of common origin coeliac axis/ SMA aneurysm highlighted the need for a flexible multi-disciplinary approach in patient management.

137

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

 ASE REPORT
C
Complex Hybrid Multiple Treatments In Case Of A Complicated Chronic Type B
Dynamic Dissection

CASE REPORT
Thoracic Outlet Syndrome Arising From An Extra-Pleural Lipoma

 ASE REPORT
C
A Rare Presentation Of Primary Antiphospholipid Syndrome

Shayan Ahmed1, Jason Lewis2, Ahmed Abidia1, William Partridge1, Mohamad Hamady3,
Zaid Aldin1

Department of Angiology and Vascular Surgery, S.Joo Hospital Center, Oporto, Portugal

1. The Princess Alexandra Hospital, Harlow, United Kingdom


2. The Royal London Hospital, London, United Kingdom
3. Imperial College Healthcare NHS Trust, London, United Kingdom

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

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

EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Lus Machado

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

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Jos Oliveira-Pinto1,2, Joel Sousa1, Joo Rocha-Neves1,2, Srgio Moreira-Sampaio1,2,


Jos Teixeira1
1. Hospital de So Joo, Porto, Portugal
2. Faculty of Medicine of Oporto, Porto, Portugal

AIMS
To present a case report of a hybrid solution for a ruptured thoracic aortic aneurysm with an unsuitable
anatomy for TEVAR.
METHODS
This is a case report of a 79 years old male, with known medical history of congestive heart failure and
hypertension. The patient described a 3 week long history of mild hemoptysis. In the emergency service a
thoraco-abdominal angio-CT was performed and revealed a ruptured descending thoracic aortic aneurysm,
with 50mm of largest diameter and extending from the origin of the left common carotid artery. Bilateral
common iliac aneurysms and bilateral internal iliac aneurysms. Extreme tortuosity of the aortic artery was
noted, with an S conformation determined by two kinks: the first of approximately 170 located about
10cm above the thoracoabdominal transition and the second of 95 above the aortic bifurcation (Fig. 1).
RESULTS
Considering the location of the aneurysm, as well as the aortic anatomy, a hybrid solution was planned. A
TEVAR with fixation in landing zone 1 was the chosen intervention, and the patient undergone a previous
left common carotid-carotid bypass, with proximal ligation of the left common carotid artery. To overcome
the aortic tortuosity, surgical exposure of the right axilar artery was performed, with selective catheterization of the aorta through it and creation of an axilo-femoral through-and-through with a stiff guidewire
(Fig. 2). Successful deployment of the endoprosthesis was performed. Control angiogram revealed a type
II endoleak in the dependence of the left subclavian artery, and selective embolization with coils was later
performed. Final angiogram revealed complete exclusion of the aneurysm, with no endoleaks and patency
of the left vertebral, intermamary and tireocervical arteries. The patient remained in the Intensive Care Unit
for 21 days, and was discharged to his local hospital 60 days after the intervention.

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

CONCLUSIONS
Endovascular correction for ruptured thoracic aortic aneurysms is the gold-standard procedure, as long as
the anatomy is suitable for the correct navigation, placement and deployment of the endoprosthesis. In
more complex anatomies, hybrid procedures with ingenious solutions are frequently necessary.
FIGURES

Extreme aortic tortuosity


Excision of left pleural lipoma. The 4.5cm x 11.8cm lipoma extended into the thoracic cavity and was closely related to the axillary
vasculature.
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Hybrid Solution For Ruptured Thoracic Aortic Aneurysm

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Challenging Case Of Complicated Aneurysmal Persistent Sciatic Artery
King Fahd University Hospital, Alkhobar, KSA, Egypt
BACKGROUND
Persistent Sciatic Artery (PSA) is a rare congenital vascular anomaly found in 0.03-0.06% of the population. It is either symptomatic or asymptomatic. It may present as a pulsatile gluteal mass. However it can
cause acute critical limb ischemia with serious complications. It is classified into: type I: complete PSA with
normal femoral artery, type II: complete PSA with abnormal femoral artery (IIa) or absent femoral artery
(IIb and types III and type IV: incomplete PSA with normal femoral artery. The only difference is that the
upper part of sciatic artery has persisted in type III, while it is the lower part in type IV. In type V, the PSA
originates from the median sacral artery either with a normal femoral artery (Va) or an abnormal one (Vb).1
CASE SUMMARY
A 58-year-old man presented with acute right limb ischemia of 18-hour-duration. He also had right gluteal pulsatile mass of one year duration which was misdiagnosed as sciatica. Preoperative CT angiography revealed type IIa PSA and embolic infra-genicular popliteal occlusion. Patient underwent emergency
popliteal embolectomy, intra-arterial tPA infusion (thrombolysis) and prophylactic fasciotomy. Completion
angiogram showed patent posterior tibial artery and planter arch. One week later, the patient underwent
endovascular stenting of PSA. within few hours afterthe procedure, he developed progressive acute right
lower limb ischemia. CT angiogram showed distal thrombosis of posterior tibial artery. Trials of catheter
directed thrombolysis for 36 hours have failed. The patient underwent urgent left popliteal artery thromboembolectomy. However, his condition did not improve, so right below knee gluten amputation was done,
followed by 2ry sutures then healed completely within 6 weeks
DISCUSSION
Aneurysm formation occurs in about 40% of PSA.2, It usually presents as a pulsatile gluteal mass. Less
frequently, patients present with sciatic neuropathy, distal ischemia or rupture. Aneurysm exclusion alone
either by ligation or endovascular embolization 3 is mandatory in case of incomplete type, Because of
potential damage to the adjacent sciatic nerve; exposure and surgical dissection of the aneurysm are not
recommended. In complete type; as in our case; a femoro-politeal interposition graft should precede the
aneurysm exclusion as a standard treatment.4 The endovascular stent graft placement has been reported
as an effective method of repair for PSA aneurysm5, provided that there are no significant associated compressive symptoms, but it still has the risk of distal embolization, as occurred in our case who has only one
tibial vessel survived from the thrombo-embolictomy trial, these conditions but the limb in highly progressive ischemic course.

Axilo-femoral through-and-through guidewire technique.

CONCLUSION
Asymptomatic PSA should be followed up closely without any intervention. However, symptomatic PSA
should be managed as early as possible to avoid serious complications. Management of aneurysmal PSA is
mainly by endovascular embolization either alone as in case of incomplete type or with femoro-popliteal
bypass in complete type, endovascular stent graft has accepted outcome. Micro-embolization from the
aneurysm is a rare complication during endovascular intervention and may pass unnoticed, but it might be
hazardous especially in borderline distal circulation.

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Ehab Elashaal, Ayman Saad, Farouk Alreshaid

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

EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

REFERENCES
1. Papon X, Picquet J, Fournier HD, Enon B and Mercier Ph. Persistent sciatic artery: report of an original aneurysm-associated case.
Surg Radiol Anat 1999;21:151-153.
2. El Fakir Y, Gueddari FZ, Hamani L, Y Bjilou, R Dafiri and F Imani. Imagerie de lanverysme sur artere sciatique persistante. propos
dun cas avec revue de la litterature. Medecine du Maghreb 1999;77:23-26.
3. Ooka T, Murakami T, Makino Y. Coil embolization of symptomatic persistent sciatic artery aneurysm: A case report. Ann Vasc Surg
2009;23:411:e1e4.
4. Van Hooft IM, Zeebregts CJ, van Sterkenburg SM, et al. The persistent sciatic artery. Eur J Vasc Endovasc Surg 2009;37:585591.
5. Sylvain BRETON M.D., Bernard SENECAIL M.D., Thomas HEBERT M.D., Michel NONENT M.D.
Department of radiology, University Hospital, Brest, France
Laboratory of Anatomy, Faculty of Medecine, Brest, France (2008, Jun 3).
Endovascular treatment of aneurismal persistent sciatic artery: a real alternative, http://www.eurorad.org/case.php?id=6648

Types of persistent sciatic artery

AP view during stent graft deployment

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

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145

Amr Nour, Sulaiman Al Shamsi

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

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

FIGURES

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

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Persistent Sciatic Artery Aneurysms Complicated With Acute Limb Ischemia,
Two Steps Management

Computed tomography angiogram showing persistent left sciatic artery

Reconstruction of angio. CT posterior view showing complete left sciatic artery


with 2 aneurysmal dilatation and hypoplastic femoral artery

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147

Post PSA coil embolization


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

Angio CT showing occluded left PSA

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Angio CT showing patent left PSA

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Concomitant Occlusive And Aneurysmal Iliac Arteries Lesions In Behcets Disease

 ASE REPORT
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Extra-Anatomical Aorto-Carotid Artery By-Pass In Case Of Tracheo-Bracheocefalic
Fistula

1 . Department of Cardiovascular Surgery, Habib Bourguiba Hospital, Sfax, Tunisie


2. Departement of Radiology and Interventional Radiology, Habib Bourguiba Hospital, Sfax,
Tunisie

Alice Silvestri1, Giovanna Biasi1, Massimo Sponza2, Paolo Frigatti1

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

Arterial aneurysms are uncommon vascular manifestations of Behets disease and linked to severe prognosis.

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

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

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

 ASE REPORT
C
Surgical repair of common carotid artery pseudoaneurysm
Miguel Lemos Gomes, Luis Silvestre, Joo Vieira, Gonalo Sobrinho, Luis Mendes Pedro,
Jos Fernandes e Fernandes, Luis Mendes Pedro

Kim Taeymans, Peter Goverde, Katrien Lauwers, Paul Verbruggen

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

Vascular clinic ZNA Stuivenberg, Antwerp, Belgium

INTRODUCTION
Male patient 62-y-old with a history of aortobifemoral prosthesis presents with a progressive proximal
anastomosis aneurysm including a dominant accessory left renal artery.

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

METHOD
Hybrid procedure under general anesthesia. Access from a bifemoral and left brachial open approach and
placement of three 7Fr sheats. A guidewire was introduced in an antegrade manner and we visualised the
aneurysm and the left accessory renal artery. After catheterisation of this renal artery and PTA of the narrow ostium, we tried to place an ePTFE encapsulated covered balloon expandable stainless steel stent but
this was impossible due to the very sharp angle between renal artery and aorta. Then we placed an ePTFE
encapsulated covered self expandable nitinol stent and pushed it upwards with a retrograde introduced
snare kit. Then we were able to place the covered balloon expandable stainless steel stent from the brachial approach in the earlier placed nitinol stent to secure the stent in this position. Placement of a 12x61mm
covered balloon expandable stent and postdilatation at about 15 mm above the distal stent margin. In the
distal conic segment we placed two covered balloon expandable iliac stents in a kissing stent configuration
and they were inflated simultaneously.

CASE REPORT
Twenty-two years old male patient, victim of a gunshot wound in the right cervical region, admitted in
another institution in cardiac arrest, successfully treated at the time. One year after the initial event, the
patient had a pulsatile and expandable mass in the right anterior cervical region (Fig. 1) that caused
dysphonia and dysphagia. After the diagnosis of pseudoaneurysm of the right common carotid artery
(performed by doppler ultrasound and confirmed by computed tomography angiography), the patient was
submitted, under general anesthesia and continuous electroencephalographic monitoring and without the
use of shunt, to resection of the pseudoaneurysm (Fig. 2) and PTFE bypass grafting (Fig. 3). The procedure
and the postoperative period elapsed without complications.

RESULTS
Angiographic control showed exclusion of the aneurysm with optimal flow in aorta, iliac arteries and in
the renal chimney graft.

DISCUSSION AND CONCLUSION


The type of treatment depends on the nature and location of the lesion, as well as the patients age and
comorbidities. Surgical procedures, endovascular techniques or a combination of the two have been described. The ligation of the carotid artery is now a last resort practice and only used at life saving situations
due to its high morbidity and mortality. Conventional surgical reconstructions remain as the gold standard
for most authors due to its security, reduced perioperative complications and excellent long-term results.
Endovascular techniques are a credible alternative with growing popularity but with few cases described.

CONCLUSION
This case shows that the CERAB (Covered Endovascular Reconstruction of the Aortic Bifurcation) technique
can be used safely for the endovascular treatment of difficult proximal anastomotic pseudoaneurysms of
aortobifemoral grafts.

FIGURES

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Progressive Proximal Anastomosis Aneurysm Of An Aortobifemoral Prosthesis
Including A Dominant Accessory Renal Artery

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Severe acute ischemia of the hand after radial artery cannulation: report of 2 critical
cases

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Rachid Zaghloul, Hamza Naouli, Abdellatif Bouarhroum


UHC Hassan II, Fez, Morroco, Fez, Morocco

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

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

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

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

Miguel Lemos Gomes, Joo Vieira, Gonalo Sobrinho, Ruy Fernandes, Luis Mendes Pedro,
Jos Fernandes e Fernandes

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

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

FIGURES

EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

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C
Disseminated intravascular coagulation treated after successful endovascular aortoiliac repair

Patient presenting ecchymosis of the dorsum and of the abdominal wall

- Figure 3: severe ischemia of the hand extended to the forearm subsequent to radial artery cannulation.
REFERENCES
1. K.l, LEE, J.G. MILLER and G. LAITAUNG HAND ISCAEMIA FOLLOWING RADIAL ARTERY CANNULATION JOURNAL OF HAND SURGERY ( britsh and Eurpean Volum, 1995) 20B:4: 493-495.
2. M. Almoubarik, J.-Y. Marandon*, M. Fischler. Hand ischaemia after radial artery catheterization: Dont elude Allen test. Lettres la
rdaction / Annales Franaises dAnesthsie et de Ranimation 29 (2010) 592598.
3. R James Valentine, MD, FACS, J Gregory Modrall, MD, FACS, G Patrick Clagett, MD, FACS. Hand Ischemia after Radial Artery Cannulation. J Am Coll Surg 2005;201:1822. 2005 by the American College of Surgeons)
4. Brzezinski M, Luisetti T, London MJ. Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesth Analg 2009;109:176381.
5. Wilkins RG. Radial artery cannulation and ischaemic damage: a review. Anaesthesia 1985;40:8969.
156

Computed tomography demonstrating an abdominal aortic aneurysm and


a left common/internal iliac aneurysm

157

Michael Siah, Vahram Ornekian, Edward Woo

MedStar Washington Hospital Center, Washington, USA


Endovascular treatment of iliac artery aneurysms has revolutionized the options vascular surgeons have
to treat this challenging disease process and has resulted in an ability to provide patients with minimally
invasive yet durable repairs. The presence of concomitant aneurysmal disease of common and internal
iliac arteries presents a challenge to the endovascular surgeon charged with preserving flow to the pelvic
situation. Our case of a 74 year old gentleman presenting with intermittent lower extremity paralytic symptoms is an especially challenging one owing to complex tortuous external iliac artery anatomy and large
saccular internal iliac aneurysms. The patients prohibitive cardiac risk meant an all endovascular option
was in his best interest and we proceeded to use technology currently available to successfully exclude
and seal both his common and internal iliac arteries with preservation of pelvic flow. His aneurysms were
excluded using a snorkel sandwich technique involving double barrel covered stent grafts landed from the
bilateral internal and external iliac arteries into the common iliacs bilaterally. We employed a combination
of balloon expandable and self expanding covered stent grafts as well as traditional EVAR limbs which
were built down from an EVAR main body seated at the iliac bifurcation. Our patient did extremely well
postoperatively, did not suffer any compromise to pelvic arterial flow, and was followed with a postoperative duplex that revealed the lack of endoleak. Subsequent CT angiography also confirmed preservation of
hypogastric flow with aneurysm exclusion and lack of gutter leak. He will continue to be followed per our
routine protocol to monitor for late expansion.

3D Computed tomography demonstrating absence of any endoleak

REFERENCES
Lobato AC, Camacho-Lobato L. The sandwich technique to treat complex aortoiliac or isolated iliac aneurysms: Results of midterm
follow up. Journal of Vascular Surgery. 2013; 57(2): 26S-34S.
Moise MA, Woo EY, Velazquez OC, et al. Barriers to endovascular aortic aneurysm repair: past experience and implications for future
device developement. Vascular and Endovascular Surgery. 2006; 40: 197-203.
Murphy EH, Woo EY. Endovascular management of common and internal iliac artery aneurysms: how iliac branch grafting may
become a first line treatment option. Endovascular Today. 2012; March.
Krupski WC, Selzman CH, Floridia R, et al. Contemporary management of isolated iliac artery aneurysms. Journal of Vascular Surgery.
1998; 28(1):1.
Patient after 3 months of the procedure
FIGURES


Pre-operative 3D reconstruction

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Pre-operative 3D reconstruction

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Challenges of concomitant common and internal iliac artery aneurysms:
a challenging case

Christian Gerges, Benoit Lebas, Xavier Chaufour


CHU Toulouse Rangueil, Toulouse, France

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

Bilateral distal hypogastric access

CONCLUSION
In this case, the infra renal aneurysm excluded by endovascular approach, has kept growing during three
years (from 64 to 105 mm) due to major type 2 endoleak. It developed at the same time and was associated with the progression of the aneursymal disease. Aneurysmorrhaphy was the last resort in order to fully
exclude the aneurysm. Five years after the first procedure, the patient is asymptomatic with full exclusion
of his thoracoabdominal aneurysm disease.
REFERENCE
Rutherfords Vascular Surgery 7th edition

Follow up 3D reconstruction

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From a rupture thoracic aneursym to a full throracoabdominal endovascular
exclusion, finally treated by aneurysmorrhaphy

Left hemothorax post aortic rupture

Thoracic endoprosthesis

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FIGURES

Controle post fenestrated endoprosthesis

Interrenal aneurysm progression

Infra-renal aneurysmal sac of 105 mm

Increase of excluded infrarenal aneurysme to a diameter of 97mm

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Final result post laparotomy and aneurysmorrhaphy

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A rare case of mycotic pseudo-aneurysm of the common iliac artery

Redha Lakehal, Abdelmalek Brahami

Joel Sousa, Joo Rocha-Neves, Jos Pinto, Jorge Costa-Lima, Armando Mansilha, Jos Teixeira

EHS EL RIADH, Constantine, Algeria

Hospital de S. Joo, EPE, Oporto, Portugal

OBJECTIVES
Aneurysmal location in the aortic arch is outstanding, rarer than the ascending aorta. This is a serious
condition because of the risk of rupture requiring an emergency surgery. The diagnosis is based on the CTA
and MRA. This clinical case is an opportunity for us to recall the seriousness of this disease for the patients
and challenges encountered by the surgeons.

AIMS
To report a case of mycotic pseudo-aneurysm of the right common iliac artery in a patient with infective
endocarditis, first presenting as an embolic acute limb ischemia, and successfully treated with a spiralled
vein graft.
METHODS
This is a case report of a 39 years old female, with a previous medical history of Tetralogy of Fallot, surgically corrected 28 years ago. The patient was first admitted in our institution due to a severe aortic and pulmonary insufficiency, secondary to an infective endocarditis. Replacement of the aortic and tricuspid valves
was emergently performed, with full recovery from this acute event. During the pos-operative period, the
patient developed an acute limb ischemia of the right lower limb. Trans-femoral tromboembolectomy was
performed and pathological examination of the extracted material was required, which demonstrated the
presence of fungal hyphae. The subsequent cardiac imaging study demonstrated no apparent relapse of the
infection, with trans-esophageal echocardiogram revealing any valvular vegetations. An abdomino-pelvic
angio-CT was then performed, and revealed the presence of a volumous pseudo-aneurysm of the right
common iliac artery, with 4 cm of largest diameter (Fig. 1).

METHODS
We report the case of a men, 53 years old, with a history of a 4 meter drop from a building two years ago.
hospitalized for exploration following the discovery of a chest X-ray opacity of the upper lobe left lung as
a result of hemoptysis average abundance. The suspect image.A .chest angio-CT was performed showing
the false aneurysm of the aortic arch. ECG was normal. Laboratory tests showed anemia. The patient was
operated on under extra corporeal circulatio, established between the femoral artery and femoral vein with
deep hypothermia and circulatory arrest. The surgical approach was a left thoracotomy in 4 left intercostal
space. After installing a femoral-femoral CPB and detachment of the left lung intraoperative exploration
shows a huge pseudoaneurysm of the aortic arch blocked by the upper lobe of the left lung fistulizing of
pseudoaneurysm in the latter. The intervention had consisted after flattening of the pseudoaneurysm in
compensation for the loss of aortic substance by a lateral Dacron patch under circulatory arrest and closure
of the pulmonary breach.

RESULTS
Due to the risk of infection, the patient was proposed open surgical correction of the lesion. Great saphenous vein from the ipsilateral limb was harvested, and used to create a spiralled venous conduit of equivalent diameter with the common iliac artery (Fig. 2). Aneurismectomy with partial removal of the common
right iliac artery was performed, and circulation was restored with an interposition venous graft between
the common iliac and the external iliac, with ligation of the internal iliac artery. The pathologic study of
the removed artery revealed structural changes compatible with infectious pseudo-aneurysm, and the
imunohystoquimic study confirmed the presence of fungal hifae in its structure. The pos-operative period
went with no complications and the patient was discharged 60 days after admission, with no evidence of
re-infection.

RESULTS
The immediate postoperative were unfavorable with a fatal refractory cardiogenic shock.
CONCLUSION
Advances in imagery make the angio scanner and the MRA the best exams for detecting false aneurysms
of the aortic arch. The indication for surgery is formal in all cases of pseudoanevrysm of the aortic arch
because the spontaneous evolution is fatal. In fact, the actual treatment is surgery.

CONCLUSION
Mycotic pseudo-aneurysms are rare entities in all arterial territories. Despite some reported cases of iliac
pseudo-aneurysms in patients previously submitted to renal transplantation, mycotic pseudo-aneurysms
of the common iliac arteries secondary to infectious endocarditis are an extremely rare event, not reported
in the literature.

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

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False aneurysm of arch aortic fistulizing in the left lung

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

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

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

PATIENTS AND METHODS


In a prospective study biomechanical properties of the aortic wall were initially examined in 46 patients
with a normal aorta (younger than 60 y n = 21, older than 60 y n = 25) and in 19 patients with infrarenal
aortic aneurysm using real-time 3D speckle tracking ultrasound. Subsequently, after transforming primary
coordinates in 35 patients with infrarenal aortic aneurysm, a high resolution 4D model of the aorta was
constructed to determine regions with pathological strain. In selected cases, based on inverse modeling
patient-specific material properties were calculated from the dynamic deformation of the aneurysm wall.
Finally, distribution of wall stress in the aortic aneurysm was simulated with patient-specific and population-mean material properties.

Spiralled vein graft

RESULTS
The infrarenal aorta in young patients had a significantly higher mean circumferential strain amplitude
than the infrarenal aortic aneurysm. However, the low mean circumferential strain amplitude in the aneurysm was characterized by high spatial heterogeneity expressed by a high spatial heterogeneity index and
the local strain ratio (p <0.05). The mean global strain amplitude was significantly higher in the aneurysm
neck than in the aneurysm bulge (p <0.05). Areas with maximum local circumferential strain were predominantly localized in the posterolateral region of the aneurysm wall. Using patient-specific material properties the calculated peak wall stress was higher for the individual than when population-mean material
properties were applied (an example: 2.109 MPa compared to 0.912 MPa).
CONCLUSIONS
Real time 3D speckle tracking ultrasound allows qualitative and quantitative description of wall areas
in the infrarenal aortic aneurysm with maximum strain amplitude and localization of those regions. Employing finite element analysis with patient-specific material properties opens a perspective for disclosing
determinants indicating higher aneurysm rupture risk.

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FIGURES

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

Mean circumferential wall strain amplitude

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

FIGURES

Spatial heterogeneity index

Peak wall stress in AAA calculated with patient specific material properties
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The Role Of MMP2 In Development Of Aneurysm In Combination With The
Transplantation Model

Waldemar Olszewski, Marzanna Zaleska

Zuzanna Rowinska6, Simone Gorressen1, Thomas Koeppel2, David Lovett3,


Petra Lynen-Jansen7, Hubert Schelzig6, Alma Zernecke4, Elisa Liehn5

Central Clinical Hospital, Warsaw, Poland

1. University Hospital Dsseldorf, Institute for Pharmacology and Clinical Pharmacology,
Dsseldorf, Germany
2. Hospital St.Georg, Vascular Surgery, Hamburg, Germany
3. San Franciso Veterans Affairs Medical Center, San Francisco, USA
4. University Hospital of Wrzburg,Institute of Clinical Biochemistry and Pathobiochemistry,
Wrzburg, Germany
5. RWTH Aachen University, IMCAR, Aachen, Germany
6. University Hospital Dsseldorf, Vascular Surgery, Dsseldorf, Germany
7. RWTH Aachen University, Aachen, Germany

BACKGROUND
Obliteration of lymphatics recognized as lymphedema is followed by stasis of edema fluid with dilatation
of intercellular space The question arouse whether decongestion of edematous tissue can be accomplished
by implantation of artificial channels replacing function of lymphatics and support tissue fluid flow by application of external compression.
AIM
To follow effect of silicone tube implants replacing obliterated collecting lymphatics
MATERIAL AND METHODS
Study included 36 patients with lymphedema of lower limbs stage III and IV. All patients developed edema
after histerectomy and radiotherapy with inflammatory episodes, 5 had infectious skin incidents in the past.
Lymphoscintigraphy showed lack of flow of tracer from foot to the groin. Three medical grade hydrophobic
silicone tubes o.d.3.2, i.d. 1.8 mm, perforated every 2 cm, were implanted subcutaneously from mid-calf to
hypogastrium. Subcutis and node fragments were taken for on-plate bacteriology. Elastic stockings grade
II and two weeks of intermittent pneumatic compression were applied postoperatively.

INTRODUCTION
The role of MMPs in aneurysm formation is mainly based on their collagenolytic properties that contribute
to the degeneration of the extracellular matrix (ECM). The studies allowed the characterization of the specific role of MMP2 in the degeneration of the extracellular matrix (ECM) through the study of MMP2-transgenic (CD1 background) /MMP-2/LacZ mice harbouring the LacZ reporter gene/ mice. In combination with
the transplantation model, we investigated a path of aneurysm development.

RESULTS
After 3-4 years mean decrease in circumference in mid-calf was from 1.5 -5 cm (3-17%) and increase in
elasticity by 7-23%. On lymphoscintigraphy tracer was seen in tubes or around them. On ultrasonography
accumulation of fluid around tubes could be shown. In 4 cases inflammatory episodes at calf and hypogastric end of implant were observed. Retrospective analysis of bacteriology from time of implantation
revealed presence of Proteus, Acinetobacter and Neisseria.

METHODS
We have orthotopically transplanted infrarenal abdominal MMP2-tg aortic segments treated with elastase
into CD1 mice and CD1 aortas treated with elastase in MMP2-tg mice (n = 4-6 mice) (anastomosis time 22
minutes). Subsequently, both groups of mice were monitored by ultrasound for 6 weeks.
RESULTS
Six weeks after surgery CD1 aortas treated with elastase transplanted into MMP2-tg mice developed larger aneurysms compared to MMP2-tg aortic segments treated with elastase transplanted into CD1 mice.
CD1 aortas treated with elastase transplanted into MMP2-tg mice showed significantly increased levels of
-galactosidase expression and larger neointimaformation when compared toMMP2-tg aortic segments
treated with elastase transplanted into CD1 mice.

CONCLUSIONS
Silicone tube implants in lymphedematous is a low-invasive effective method for decompression of obstructive lymphedema. Bacteriology of deep tissues at time of implantation is helpful for controlling infective inflammation episodes with specific antibiotics.

CONCLUSIONS
These results indicate that the presence of MMP2 in vessel wall cells versus circulating cells plays an important role in the development of aneurysms.

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Obstructive lymphedema of lower limbs can be successfully controlled by silicone
tube implants replacing obliterated lymphatics-four years follow-up

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Use of Drugcoated Balloon Pta As First-Line Treatment for all Femoropopliteal
Lesions
Koen Keirse1, Bart Joos1, Wouter Van Den Eynde2, Jurgen Verbist2, Patrick Peeters2

Irina Kajuna1, Vita Rovite2, Helena Mikazhane3, Valda Stanevicha3

1. Baltic vein clinic, Riga, Latvia


2. Latvian Biomedical Research and Study Center, Riga, Latvia
3. Riga Stradins University, Riga, Latvia

1. Hospital Tienen, Tienen, Belgium


2. Imelda Hospital, Bonheiden, Belgium

BACKGROUND
The use of drugcoated balloons (DEB) in the SFA is currently still under investigation in Trials. Although
there are clear indications of the benefits in case of restenosis or in-stent restenosis, scientific evidence to
support the title of abstract is still lacking today. We have used DEB treatment for 116 consecutive limbs
to challenge the title.

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

METHODS
Patient cohort is a subgroup of the prospective controlled trial IN.PACT Global conducted at our institution.
Between Oct 2012 and Sep 2014, 92 patients (116 limbs treated) were enrolled. The efficacy endpoint of
the trial is freedom from clinically driven TLR and primary patency within 12 months. Safety endpoint includes freedom from MAE through 30 days, freedom from target limb amputation and freedom from TLR
within 12 months.

OBJECTIVE
To investigate the risk alleles in genes F5 (rs6025), F2 (rs1799963), SELE (rs5361), SERPINC1 (rs2227589),
FGG (rs20066865), CYP4V2 (rs13146272), F11 (rs2289252), GP6 (rs1613662) in patients with VT and HVI
C3-V6.
MATERIALS AND METHODS
The data collected in 2013-2014 years for 141 patients (52 patients with confirmed VT; 89 patients with
HVI stage C3 -C6 ). In the control group were included 235 (110 men un 125 women) individual average
age 53.114.1, body mass index (BMI) 28,124,96. Genotyping was performed using an Applied Biosystems TaqMan SNP Genotyping Assay after manufacturers protocol on ViiA 7 Real-Time PCR System.
Statistical analysis was carried out with Plink 1.06 software. The additive model of inheritance was used in
logistic regression for each SNP adjusting for sex, age, BMI.

RESULTS
Of the 92 patients enrolled, 88% had intermittent claudication and 12% presented with critical limb ischemia. For lesion treatment, only 30% received a bail-out stenting for residual stenosis or flow-limiting
dissections. The overall mean lesion length was 149.6 mm. MAE rate at 30 days was reported 14.1%.
Twelve months results show a freedom from TLR at 12 months of 90.6% and a primary patency of 90.4%.
Freedom from amputation at 12 months was reported 98.3% and a mortality rate of 2.1%.

RESULTS
The F5 (rs6025) risk allele was significantly associated with higher VT risk p=0.017, OR=4.37. Risk alleles in
genes SERPINC1 (rs2227589), FGG (rs20066865), F11 (rs2289252) showed significant association with VT SERPINC1 (rs2227589) p=0.05, OR=0.41; FGG (rs20066865) p=0.018,OR=1.79; F11 (rs2289252) p=0.028,
OR=1.65 but due to small group this association did not withstand the permutation test and Bonfferoni
correction. Risk alleles in genes F2 (rs1799963), SELE (rs5361), CYP4V2 (rs13146272), GP6 (rs1613662)
did not show significant association with VT accordingly F2 (rs1799963) p=0.62; SELE (rs5361) p=0.71;
CYP4V2 (rs13146272) p=0.81, GP6 (rs1613662) p=0.82. In the combined samples group with VT and
HVI, the F5 (rs6025) risk allele was not significantly associated with higher VT risk p=0.07945. Risk alleles in genes SERPINC1 (rs2227589), FGG (rs20066865), F11 (rs2289252) showed significant association
in combined samples group VT and HVI - SERPINC1 (rs2227589) p=0.022, OR=0.52; FGG (rs20066865)
p=0.022,OR=1.49; F11 (rs2289252) p=0.014, OR=1.47 but due to small group this association did not
withstand the permutation test and Bonfferoni correction. The F11 (rs2289252) gene risk allele was significantly associated with higher HVI C4-C6 risk p=0.028, OR=1.65, this association withstand the permutation test and Bonfferoni correction.

CONCLUSION
Treatment of all real-world SFA disease with DEB seems safe and feasible, shows promising primary patency rates and appears to have lower bail-out stenting rates as compared to POBA in other SFA trials.
As these 12-month data show promising results. Full 12 month and preliminary 24 month data will be
presented at the congress.

CONCLUSIONS
1) For patients with VT statistically relevant connection was found with F5 (rs6025) gene risk allele.
2) Risk alleles in genes SERPINC1 (rs2227589), FGG (rs20066865), F11 (rs2289252) showed significant
association with VT, but larger group is required to prove this association.
3) Risk alleles in genes F11 (rs2289252) showed significant association with HVI C3-C6.

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The Analysis Of Risk Alleles In Patients With Vein Thrombosis And Chronic Vein
Insufficiency In Latvia

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Endovascular Therapy As A First Line Of Treatment In Patients With Severe Aortoiliac
Occlusive Disease

Kim Taeymans, Peter Goverde, Katrien Lauwers, Paul Verbruggen

Patrick Berg, Roland Stroetges

Vascular clinic ZNA Stuivenberg, Antwerp, Belgium

Marienhospital Kevelaer, Kevelaer, Germany

INTRODUCTION
We wanted to investigate a next generation drug coated balloon on safety, efficacity and patency for the
treatment of stenotic and/or occlusive femoropopliteal arterial lesions.

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

MATERIAL & METHODS


We used the Legflow Paclitaxel releasing peripheral balloon (Cardionovum, Bonn, Germany) with a unique
SAFEPAX balloon surface drug coating. This new generation balloon catheter is covered with a coating
based on nanocrystalline PTX particles (non-visible 0.1m ). Because of the stable and unique balloon
surface coating characteristics, it does not require the use of an extra protection and insertion tool. Furthermore it cannot be wiped or fall off the balloon surface during catheter manipulation.

MATERIAL AND METHODS


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

RESULTS
Single centre, prospective, consecutive, physician initiated, real-life ongoing registry. From June 2013 till
November 2014 we included 51 patients treated with the Legflow for de novo, recurrent and in-stent
stenosis or occlusion in the femoropopliteal area. Mean lesion lenght was 102,6 mm. Technical success:
100%. In more then 50% of the cases no predilation balloon was used. Bail out stenting: 20 %. There was
no evidence for distal embolisation. Follow-up was done with ultrasound. 6 months primary patency was
92 % and the preliminary results for 1 year seem promising with 76 % primary patency.

RESULTS
Technical success was obtained in all patients. In three cases lesions could not be recanalized on one side
and the patients were treated with an aorto-monoilical device and crossover bypass. Primary patency was
95,9% at 1 year, while secondary patency was 100% at 1 year. 3 patients had an occlusion of one iliac
artery treated in 2 cases with Rotarex and PTA. 1 patient had a crossover bypass during follow-up. There
was a 30 day mortality of 5/74 patients (6,8%) due to 1 myocardial infarction, 2 respiratory failures, 1
inhalation pneumonia and 1 mesenteric ischemia for a patient treated with an acute Leriche syndrom.
Survival rate at 3 months was 93%, at 2 years 91,2%. 3 patients had a minor amputation, no patient had
a major amputation. 10 patients had a postoperative groin hematoma, one patient had an intraoperative
disrupture of an iliac artery treated with a covered stent. 26 stentgrafts were used, 1 fenestrated stentgraft
and 7 chimney grafts. 201 covered stents were used, mean of 2,7/patient.

CONCLUSION
The drug coated balloon technology seems to improve the mid- and long-term durability of the SFA endovascular treatment.The early results using the new generation Legflow DCB are very encouraging, it is a
safe and reliable balloon but long-term results need to be obtained with larger patient groups.

CONCLUSIONS
Endovascular technique appears to be a safe and feasible alternative to open surgical reconstruction of
the aortic bifurcation in complex occlusive disease. There is a need for dedicated stentgrafts for occlusive
disease because the radial force of conventional stentgrafts doesnt allow to treat the lesions without the
help of BX stents.

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Early Results Of The Use Of A Next Generation Drug Coated Balloon For The
Treatment Of Femoropopliteal Atherosclerotic Lesions

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Endovascular Endarteriectomy
ZOL, Genk, Belgium

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

aortic endarteriectomy flap

Eifel tower configuration Eifel tower configuration

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

EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

Thomas Douchy, Sigi Nauwelaers, Herman Schro, Geert Lauwers, Wouter Lansink

FIGURES

Common iliac artery stenosis

aortic dissection

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FIGURES

Jason Lewis1, Cara Baker2, Marjanne Decamps3, Nick Law4, Zaid Al- Dabbagh4, Zaid Aldin3
1. The Royal London Hospital, London, United Kingdom
2. Frimley Park Hospital, London, United Kingdom
3. The Princess Alexandra Hospital, Harlow, United Kingdom
4. Chase Farm Hospital, Enfield, United Kingdom

PURPOSE
The percutaneous approach to the SFA usually requires either ipsilateral or contralateral common femoral access. This is can be made difficult by flush occlusion of the SFA origin. An alternative approach is
retrograde puncture of the popliteal artery. However, few studies have reported published results on this
approach. The purpose of this study is to present our experience with subintimal SFA angioplasty from a
popliteal approach in patients with intermittent claudication or critical limb ischaemia.
METHODS
The indication for SFA angioplasty was short distance claudication (<50 yards) and critical limb ischemia.
Cases were prospectively identified and reviewed at 3 months post procedure. Further 3-6 monthly followup occurred at the discretion of the examining vascular surgeon. Improvement in claudication distance and
extent of tissue healing was evaluated.

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Retrograde Popliteal Approach To Subintimal Angioplasty Of The Superficial Femoral
Artery: Six Years Experience

PROCEDURE
All subintimal angioplasty via a popliteal approach were performed by a consultant interventional radiologist. A 5F or 6F catheter was introduced. Heparin (3-5000 IU) was given intra-arterially. A hydrophilic,
curved tip guide wire (180cm long, 0.0035 diameter, Terumo, Japan) was advanced into the subintimal
plane between the atheromatous core and the adventia. Following advancement and development of the
subintimal track, the wire re-enters the true lumen. A balloon catheter (4-6 mm in diameter) is passed to
the distal aspect of the lesion and inflated manually for 10 seconds to expand the neo-lumen. The catheter
was then withdrawn. Papaverine (80mg) was given intra-arterially to relieve distal spasm.
RESULTS
43 subintimal angioplasties via a popliteal approach were performed in 35 patients over a six- year period.
Mean follow up was 11.2 months (range 1-42 months). Successful re-cannulation was achieved in 77% of
limbs and restoration of flow on post procedure angiography was achieved in 72%. Symptomatic improvement occurred in 77% of cases. 50% of those with critical limb ischemia had resolution of rest pain or signs
of tissue healing. However, in 4 cases the popliteal artery could not be punctured and in 4 cases re-entry
into the CFA lumen could not be achieved. In two cases there was failure to advance the guide wire leading
to a mid-thigh perforation in 1 case. A total of 3 complications were recorded; 1 hematoma, 1 mid-thigh
perforation and a stable dissection flap of the CFA, none of which required further treatment. There were
no instances of radiological or symptomatic embolism.

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

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

CONCLUSION
This approach provides a safe minimally invasive alternative to bypass surgery in high-risk surgical candidates in whom an anterograde approach is not feasible or was unsuccessful.

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Clinical results of denatured human umbilical vein prosthesis:
A systematic review and meta-analysis of comparative studies

Augusto Ministro, Tiago Ferreira, Emanuel Silva, Miguel Lemos Gomes, Mariana Moutinho,
Ana Evangelista, Ruy Fernandes e Fernandes, Gonalo Sobrinho, Carlos Martins,
Lus Mendes Pedro, Jos Fernandes e Fernandes

Chumpon Wilasrusmee1, Suthas Horsirimanont1, Boonying Siribumrungwong2,


Ammarin Thakkinstian3, Napaphat Poprom1

1. Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University,


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

Vascular Surgery Department, Hospital de Santa Maria - CHLN, Lisbon, Portugal

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

180

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

181

EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

 AOD
P
Patient-Tailored Revascularization For Critical Limb Ischemia - Clinical Outcomes At
2-Year Follow-Up

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

University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom

Alec Duinslaeger, Timothy Versyck, Alexander Croo, Caren Randon, Frank Vermassen
Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium

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

INTRODUCTION
3-10% of the worldwide population is suffering from peripheral arterial disease and 1-3% will ultimately
develop critical limb ischemia (CLI). One of the options to avoid major amputation and secure a better
quality of life is an endovascular revascularisation. The angiosome-concept divides the foot into six anatomic regions (angiosomes) fed by distinct source arteries arising from the posterior tibial, anterior tibial
and peroneal arteries. This study investigates whether an endovascular procedure to the artery directly
feeding the ischemic angiosome has an impact on wound healing, major amputation and mortality rate.

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

METHODS
Retrospective analysis with prospective follow-up was performed at Ghent University Hospital of 131
non-healing ischemic wounds requiring endovascular revascularisation in 109 patients. For every patient
the site of the ulcer, the treated artery and the outcome were identified. Based on this information the legs
were divided into direct revascularisation (DR) and indirect revascularisation (IR).

RESULTS
There were 153 well-matched patients in each cohort. The median length of follow up was 2.4 years
(IQR 1.6-3.7 years). Kaplan-Meier curves showed significantly worse amputation-free-survival in the DM
group (log rank test P=0.001) (Fig. 1). At one year, the survival probability estimates were 0.90SE0.02
vs. 0.810.03 (DM vs. non-DM). The same trend was seen for mortality, major and minor amputation
(P=0.003, 0.011 and 0.009, respectively). There was no significant difference in proportion requiring revascularisation (P=0.59).

RESULTS
DR feeding the ulcer area was achieved in 88 legs (67%) compared with IR in 43 legs (33%). Revascularisation was performed to the anterior tibial artery (42%), posterior tibial artery (26%) and peroneal artery
(32%). There were no differences between the two groups in comorbidities and wound characteristics
except for ulcer localisation and the treated vessel. DR was not able to accomplish a higher healing rate,
lower amputation rate or lower mortality rate compared to IR (p= .258, p= .828, p= .775). Wound healing
reduces the risk of mortality (p= .007). Wound infection (p= .038), high CRP (p= .007), renal insufficiency
(p= .024) and a history of major amputation (p= 0.043) decrease wound healing rate. Patients who need
a re-operation have a higher risk for minor amputation (p= .004).

CONCLUSION
We show for the first time that, when major confounding factors are accounted for, DM remains a significant risk factor for amputation and all-cause mortality in patients with established peripheral vascular
disease. The presence of DM does not have an impact on the rate of revascularisation procedures.

CONCLUSION
Revascularisation plays a crucial role in the treatment of ischemic lower extremity wounds. Similar results
were obtained with regard to healing rates, limb salvage and mortality after DR compared to IR. Therefore
revascularisation should not be denied to patients in whom only indirect revascularisation is possible.

FIGURE

REFERENCES
1. Bakken AM, Palchik E, Hart JP, Rhodes JM, Saad WE, Davies MG. Impact of diabetes mellitus on outcomes of superficial femoral
artery endoluminal interventions. J Vasc Surg 2007; 46(5): 946-58; discussion 58.
2. Lee MS, Rha S-W, Han SK, et al. Comparison of Diabetic and Non-Diabetic Patients Undergoing Endovascular Revascularization
for Peripheral Arterial Disease. Journal of invasive cardiology 2015; 27(3): 167-71.
3. Abularrage CJ, Conrad MF, Hackney LA, et al. Long-term outcomes of diabetic patients undergoing endovascular infrainguinal
interventions. J Vasc Surg 2010; 52(2): 314-22.e1-4.
182

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

 AOD
P
The Impact Of Angiosome-Targeted Distal Endovascular Procedure On Healing Rate
And Outcome In Critical Lower Limb Ischemia

 AOD
P
VIPs Technique (Viabhan Padova Sutureless) Technique: Long-Term Results In The
Treatment Of Peripheral Arterial Disease

Cameron G. Robertson, Dominic PJ. Howard, Conor Marron, Ian Spark

Stefano Bonvini1, Valentina Wassermann1, Sebastiano Tasselli2, Michele Piazza1,


Mirko Menegolo1, Franco Grego1

Flinders Medical Centre, Adelaide, Australia

1. Clinic of Vascular and Endovascular Surgery of Padua University, padova, Italy
2. Vascular Surgery Division, Trento Hospital, Trento, Italy

OBJECTIVES
Endovascular therapy for treating peripheral arterial disease (PAD) is evolving rapidly. Differing risk factor
profiles between countries are changing the worldwide distribution of PAD and trials for therapy need to
match this change to ensure that treatments are appropriate for the population that requires them. The aim
of this study was to compare the geographical distribution of endovascular studies in the femoropopliteal
region with the prevalence of PAD.

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

METHODS
A systematic review of the literature was conducted to July 2015. Medline, EMBASE, and the Cochrane
CENTRAL registry were searched for randomised controlled trials of endovascular interventions involving
drug-coated balloons, drug-eluting stents, bare nitinol stents, and heparin-bonded covered stents in the
femoropopliteal region. The location of study centres was extracted and compared to recently published
geographical prevalence data.1

METHODS
Patients with rest pain or non-healing ulcer disease (Rutherford class IV or V), angiographic complete long
superficial femoral artery occlusion (TASC IID) and reconstitution of a patent circumferentially calcified
above-knee popliteal artery were included in the study. After prior failed attempts of SFA endovascular recanalization, demonstration of no adequate veins for autogenous bypass, patients underwent ViPS procedures at our center between 2010 and 2015. Arterial cross-clamping and bypass suture to the target artery
were avoided using ViPS standardized technique, based on a preoperatively on-bench modified Viabhan
stent graft manually sutured to an expanded polytetrafluoroethylene vascular graft, which is then connected to the native vessel in a sutureless fashion. The standardized follow-up protocol included: post-procedural angiograms, CTA before discharge, clinical examination and duplex ultrasonography at 6, 12 months
and subsequently yearly. Postoperative antiplatelet therapy was introduced. Freedom from occlusion was
assessed using Kaplan Meyer analysis.

RESULTS
Full text reviews were conducted for 280 citations and 14 randomised controlled trials were identified
comprising 240 study centres. All 240 study centres were located in high income countries. Based on recent
prevalence data, there are 255 000 people with PAD per study centre investigating endovascular therapies
in high income countries compared with 140 million people with PAD and no study centres in low/middle
income countries.
CONCLUSIONS
Trials investigating endovascular interventions in the femoropopliteal region are unequally distributed
worldwide and do not reflect the evolving distribution of PAD. 69.7% of the world burden of PAD is not
represented by the existing literature. Further studies in a broader geographical distribution are needed
before study results can be confidently applied to all populations.

RESULTS
15 patients underwent a femoral to above-knee popliteal artery bypass using the VIPs technique (one
bilateral) for critical limb ischemia. Post-operative technical success was achieved in 100% of cases. Mean
follow-up was 46 months, achieved by 8 patients (50%). During this period 3 patients died for causes
unrelated to the procedure; in 2 patients, due to the occlusion of the bypass, a femoral below-the-knee
popliteal artery bypass was performed, but subsequently major amputation was necessary in both cases.
Ultrasound evaluation demonstrated graft patency, no signs of leak, kinking or popliteal dissection in remaining patients.

REFERENCES
1. Fowkes FG, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM, et al. Comparison of global estimates of prevalence
and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013; 382: 1329-40.

CONCLUSIONS
The VIPs technique revascularization in peripheral arterial disease (TASC II D) can achieve good long-term
results relatively to primary patency.
REFERENCES
Stefano Bonvini, MD, PhD, Joseph J. Ricotta, MD, Michele Piazza, MD, Luca Ferretto, MD and Franco Grego, MD, Padova, Italy; Atlanta, Ga. ViPS technique as a novel concept for a sutureless vascular anastomosis. J Vasc Surg 2011;54:889-92
Ferretto L,MD, Piazza M,MD, Bonvini S,MD, PhD, Battocchio P,MD, Grego F, MDRicotta JJ, MD. ViPS (Viabahn Padova Sutureless)
Technique: Preliminary Results in the Treatment of Peripheral Arterial Disease. Ann Vasc Surg 2012;26: 34-39

184

185

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

 AOD
P
The Disparity Between The Prevalence Of Peripheral Arterial Disease And
Geographical Distribution Of Endovascular Trials In The Femoropopliteal Region

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

PURPOSE
To describe early results of remote hybrid external iliac endo-endarterectomy using a fem-fem throughand-through guidewire access.
METHODS
A consecutive series of eight patients with TASC C/D lesions of external iliac artery (EIA) underwent remote
endo-endarterectomy through the exposure of the homolateral common femoral artery and a percutaneous
access gained at the controlateral groin. The latter permitted to advance a guidewire over the aortic bifurcation, across the occluded external iliac artery, into the common femoral artery. A longitudinal arteriotomy
of the common femoral artery was performed, the guidewire was caught, and an occlusive balloon was
inserted from the percutaneous access and inflated into the common and the first tract of the external iliac
artery to avoid back bleeding. The Vollmar ringstripper and an over-the-wire embolectomy catheter were
advanced homolaterally up to the inflated balloon. The latter was inflated beyond the Vollmar ringstripper,
both were rectracted simultaneously; the plaque was cut and completely removed as demonstrated by a
post-procedural intraoperative angiography. The remote iliofemoral endarterectomy was in all cases performed in combined with the endarterectomy of the homolateral femoral bifurcation. The procedures were
all performed under local anesthesia.

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

pz1
Left
72
M

pz2
Right
74
M

pz3
Left
72
F

pz4
Right
63
M

pz5
Left
76
M

pz6
Left
85
F

pz7
Left
63
M

pz9
Left
71
M

pz10
Left
77
M

pz11
Right
68
M

pz12
Right
82
M

pz13
Left
81
M

pz14
Right
79
M

pz15
Right
80
M

IV

IV

IV

IV

Yes

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

Yes

No

No

Yes

Yes

No

Yes

Yes

Yes

Yes

No

No

Yes

No

Yes

Yes

No

No

No

Yes

Yes

No
No
No

Yes
Yes
No

No
Yes
No

No
Yes
Yes

No
Yes
Yes

Yes
No
Yes

Yes
Yes
No

No
No
No

Yes
Yes
No

Yes
No
No

Yes
Yes
Yes

No
Yes
Yes

No
Yes
No

No
Yes
No

Yes

Yes

No

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

II

III
CA

III
CA

III
HC

III

III
HC

II

III

III

II
HC

III

III

III

III

NS

NS
ePTFE
(7)
Viabhan
(7mm)

Used
Propaten
(7mm)
Viabhan
(7mm)

CFE

General

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

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

48

50

52

52

55

57

61

42

59

49

53

61

50
Fem-BTK
bypass;
Major
amputation

30

21
Fem-BTK
bypass;
Major
amputation

Graft (mm)

ePTFE(7)

Viabhan (mm)

Viabhan
(6mm)

Associated
procedures
Anesthesia
Technical
success
Follow-up
Secondary
procedures

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

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

PTA SFA

CFE

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

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

Epidural Epidural General Epidural Epidural Epidural General General General Epidural

RESULTS
Patients mean age was 66 years (range, 50-80). Indications for remote iliac endarterectomy were severe
claudication in 4 (50%) and rest pain in 4 (50%). Initial technical success was achieved in 7 patients (87,5%).
1 patient needed a thrombectomy using a Fogarty catheter and a stent was placed due to irregularities present in the external iliac artery. The mean length of follow-up was 12 months (range, 1-12). No perioperative
and postoperative re-stenosis, occlusions occurred within the first 30 days and in the post-operative period.
CONCLUSIONS
An angioplasty balloon introduced controlaterally permits to avoid back bleeding from the common and internal iliac arteries and to protect the aortoiliac bifurcation. Therefore remote endo-endarterectomy results
more secure and retrograde dissections are less likely. This technique offers a safe and effective alternative
to conventional laparotomy in patients with severe concomitant pathologies.

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

FIGURES

CFE

General Epidural

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

Intraoperative Angiography An occlusive balloon is inserted


controlaterally. The Vollmar ringstripper and the guidewire are
present

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

EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

FIGURE

Dimitar Nikolov, Nikola Kolev, Stefan Stefanov


City Clinic, Sofia, Bulgaria

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

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

Pz 2
Left
54
M
III
Yes
No

Pz 3
Left
57
M
IV
No
Yes

Pz 4
Right
63
M
IV
No
No

Pz 5
Left
67
M
III
No
Yes

Pz 6
Right
60
M
III
Yes
Yes

Pz 7
Right
64
M
III
Yes
Yes

Pz 8
Right
59
M
IV
No
No

Yes

Yes

Yes

Yes

No

No

Yes

No
No
No
Yes
III
Local
Yes

No
No
No
Yes
III
Local
Yes

Yes
No
No
Yes
III
Local
Yes

Yes
No
No
Yes
III
Local
Yes

Yes
No
Yes
Yes
III
Local
Yes

Yes
No
Yes
Yes
III
Local
Yes

Yes
No
Yes
Yes
III
Local
Yes

Common
femoral
artery EA
20

Common
femoral
artery EA
20

Common
femoral
artery EA
28

Common
femoral
artery EA
25

Common
femoral
artery EA
3

Common
femoral
artery EA
2

Common
femoral
artery EA
26

FIGURES

EIA External iliac Artery; EA endarterectomy; ASA, American Society of Anesthesiologist.


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

188

- CT of occluded left branch of aorto-bifemoral graft

189

EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

PAOD
Recanalization Of Chronically Occluded Aorto-Femoral Dacron Grafts- Tecnique And
Results

Anita Quintas, Gonalo Alves, Jos Arago Morais, Frederico Bastos Gonalves,
Maria Emilia Ferreira, Joao Albuquerque Castro, Luis Mota Capito

Department of Angiology and Vascular Surgery, Santa Marta Hospital, Lisbon, Portugal
INTRODUTION
Lower limb bypass failure is a challenging clinical scenario associated with a more than 50% amputation
rate. 1,2 After failure of convencional infra-inguinal revascularization, endovascular intervention is still possible and reasonable, in particular for patients suffering from limb-theatning ischemia and lacking adequate conduits or additional revascularization options. 1,2
METHODS
We report 4 diferent endovascular solutions in recanalization of severely diseased native arterial occlusions
in the setting of failed below-the-knee bypass. Feasibility, safety and outcomes are revised and technical
details presented.
RESULTS
The failed grafts consisted of: three femoro-popliteal infragenicular vein bypasses and one composite sequencial graft femoro-popliteal-posterior tibial. All four patients presented with critical limb ischemia after
thrombosis of infragenicular bypasses (two with rest pain (Rutherford Category 4) and two with tissue loss
(Rutherford Category 5). All four cases had severely diseased native circulation with chronic total occlusion of the superficial femoral-popliteal segment, representing complex long TASC-II D lesions, particularly
fibrotic and calcified. Contralateral femoral acess was used in two cases, ipsilateral femoral acess was
used in one patient and brachial access was used in another. Three cases required retrograde punction of:
the popliteal infragenicular artery, the tibio-peroneal trunk, the posterior tibial artery and of the profunda
femoris artery in the tight. The retrograde recanalization was followed by antegrade PTA after performing
the rendezvous technique Recanalization of native CTO of the entire femoro-popliteal segment (Fig. 1) was
performed in three patients using an intentional subintimal approach, complemented with kissing balloon
angioplasty of superficial and profunda femoris arteries in one case (Fig. 2). In the remaining case iliofemoral and profunda femoris artery PTA was performed (Fig. 3). Primary therapy was PTA, with two cases of
adjunctive stenting. Drug-coated balloons were used in two cases. Critical limb ischemia resolved in all
patients (Fig.4). At a short follow-up time the patients remain asymptomatic with maintained patency of
the recanalized vessels.

- Intraoperative angiography of recanalized left branch

CONCLUSIONS
Endoluminal recanalization of complex chronic total oclusion of the native circulation can be an effective
strategy for limb salvage after below-the-knee bypasses failure. This ultimate solution is particularly important in those patients without alternative conduits or a distal target vessel.
- CT- angiography after 36 months. The left branch(stented and not stented part) has reached the diameter of the right branch

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

190

191

EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

 AOD
P
Endoluminal intervention for critical limb ischemia after failed open infrainguinal
revascularization: endovascular ultimate challenging solutions

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May-Thurner Syndrome
Clnica Universitria de Cirurgia Vascular, Hospital de Santa Maria, Centro Hospitalar Lisboa
Norte, Faculdade de Medicina da Universidade de Lisboa, Centro Acadmico de Medicina de
Lisboa, Lisbon, Portugal
May-Thurner Syndrome (MTS) is the symptomatic presentation of chronic pulsatile extrinsic compression of
the left iliac vein by the right common iliac artery against the lumbar vertebral body 1,2.
We present a 68 years-old woman with history of chronic edema in the left lower limb referenced to Vascular Surgery consult with a computed tomography scan revealing left iliac vein compression. Phlebography confirmed a stenosis in the confluence of the left common iliac vein with the inferior vena cava and
a dilated left ovarian vein collateral compatible with the diagnosis of MTS (Fig. 1). The lesion was treated
with venous angioplasty using a Zilver Vena Venous Self-Expanding Stent on the left common iliac vein
(Fig. 2). The patient was discharged in the next day with antiplatelet therapy and anticoagulation. She had
a notorious resolution of the limb edema, achieving a comparable diameter with the contralateral leg.
Previously considered a rare clinical finding, the recent proliferation of endoluminal approach to treat
deep venous thrombosis (DVT) have augmented the diagnostic incidence of iliac vein compression 3. This
anatomic variation have an estimated prevalence of about 22-24% in asymptomatic population 2,4. On the
other hand, iliac venous spurs were identified in roughly half of the patients with left iliac venous thrombosis 5. MTS is more common in young female in the third to fifth decade of life and usually presents with DVT
or chronic venous insufficiency 1. Invasive phlebography is still considered the gold standard to diagnose
iliac vein compression 1. In the last years, endovascular procedures have gained an important role in the
treatment of iliac venous spurs over medical and/or surgical approach 6. High technical success (87-100%)
and primary patency rates (79-98.7%) were reported with endovascular treatment 3,69. Evidence-based
clinical practice guidelines from Society for Vascular Surgery and American Venous Forum recommend
self-expanding metallic stents for chronic iliocaval compressive syndromes detected through endovascular
technics to remove thrombus 10. The optimal duration of anticoagulation after angioplasty with stent is
not yet determined, lacking evidence-based recommendations to be provided, however, in most cases, it is
suggested a 6 months period 6,9,10.
MTS is more common than previously thought, being important to keep a high index of suspicion to detect
the syndrome. Endovascular approach is an accepted technique that gained an important role to treat this
pathology with great results.
FIGURES

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

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

Tony Soares, Jos Tiago, Viviana Manuel, Carlos Martins, Jos Fernandes e Fernandes

Athanasios Kakkos1, Lucie Bresson1, Delphine Hudry1, Sophie Cousin2, Cyril Lervat1,
Emilie Bogart1, Jean Pierre Meurant1, Sophie El Bedoui1, Gauthier Decanter1,
Karine Hannebicque1, Claudia Regis1, Agns Hamdani1, Nicolas Penel1,
Emmanuelle Tresch1, Fabrice Narducci1
1. Centre Oscar Lambret, Lille, France
2. Institut Bergoni, Bordeaux, France

May-Thurner Syndrome after treatment Resolution of left common iliac vein stenosis after venous angioplasty with stenting. Normal
collateral venous circulation was also restored.

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

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

MATERIAL AND METHODS


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

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TIVAPS related complications: does the interval between placement and first use
and the neutropenia-inducing potential of the chemotherapy regimens influence
their incidence? A four-year prospective study on 4045 patients

Omar Mutlak, Mohammed Aslam, Nigel Standfield


Imperial College London, London, United Kingdom

BACKGROUND
Chronic venous insufficiency (CVI) has complicated pathophysiology background. Several studies has investigated CVI, however the real mechanism of developing CVI end stages is not yet clear1. Researchers has
mentioned development of venous hypervolemia and microvascular ischemia as a consequence of venous
insufficiency2,3, even though, no clear picture has been established. The aim of this study is to investigate
the effect of induced venous hypovolaemia on CVI at microvascular level.

Figure. 2: Measurments of tcPO2 (mmHg) after 3 months.


1. group A1 (no treatment)
2. group A2 (compression therapy)
3. group B1 (dorsiflexion)
4. g roup B2 (dorsiflexion & compression therapy)

MATERIAL AND METHODS


A prospective clinical study for three months, involved recruiting patient from vascular clinic at teaching
hospital, ethical approval from local ethics comity obtained. Thirty six participants (C4-C6) selected out
of 62 patients, all patients have ankle brachial pressure index between 0.8 and 1.2 mmHg. Participants
divided to two groups, first group (group A) is a control group and the second group (group B) perform
regular dorsiflexion of the foot to evacuate venous blood from lower limbs. Each group subdivided to two
groups according to the type of treatment, group A1, A2 and group B1, B2. Assessment performed on two
occasions, first, at the beginning of the trial and the second after 3 months, assessment included full history
and clinical examination, ABPI, Duplex scan and tcPO2 measurements.

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

RESULTS
Thirty six patients showed low tcPO2 level at the beginning of the study which is an indication of micro
vascular ischemia. At the end of the trial the picture was completely different, group B participants (group
B1,B2) who perform dorsiflexion of the foot showed significant increase in transcutaneous oxygen level
(P>0.05). On the other hand, group A patients (group A1, A2) showed no difference in their measurements
(P<0.05).Conclusions:Regular evacuating of peripheral venous system has improved tissue oxygenation at
skin level. Although inflammatory process and other factors could contribute in developing skin changes
and ulceration, venous hypervolemia may be the main contributing factor in developing microvascular
ischemia (venous ischemia).
FIGURES

Figure. 1: Measurments of tcPO2 (mmHg)at the beginning of the study.


1. group A1 (no treatment)
2. group A2 (compression therapy)
3. group B1 (dorsiflexion)
4. group B2 (dorsiflexion & compression therapy)
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Chronic venous insufficiency, new concept to understand pathophysiology
at microvascular level

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