BOOK of ABSTRACTS the European Society for Vascular Surgery 30Th Annual Meeting Tivoli Hotel and Congress Centre

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BOOK OF ABSTRACTS The European Society for Vascular Surgery 30th Annual Meeting Tivoli Hotel and Congress Centre

Copenhagen, Denmark 28-30 September

Disclaimer - This Book of Abstracts has been produced using author-supplied copy. Editing has been restricted to minor spelling corrections where appropriate, otherwise every effort has been made to reproduce the abstracts as originally submitted. The organiser and publishers assume no responsibility for any injury and/or damage to persons or property as a matter of product liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein. In view of rapid advances in medical sciences, independent verification of diagnoses and drug doses is recommended.

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EVST SESSION 1 – CASE REPORT Wednesday, 28 September 09:00 – 10:45…………………….P. 13 CR 009 ENDOVASCULAR RECANALIZATION OF ENDOGRAFT LIMB OCCLUSION AFTER ENDOVASCULAR AORTIC FAILED FULLY MINIMALLY INVASIVE STAGED REPAIR CR 001 TREATMENT OF A GIANT AORTIC SAC ANEURYSM IN Carlota Fernandez Prendes, Sara Busto Suarez, Ahmad EXTREMELY HOSTILE ABDOMEN AFTER OPEN Amer Zanabili Al-Sibbai, Jose Manuel Llaneza Coto, Lino REPAIR OF A RUPTURE ABDOMINAL AORTIC Antonio Camblor Santervas, Manuel Alonso Perez

ANEURYSM. Andres Reyes Valdivia, Africa Duque Santos, Juan SCIENTIFIC SESSION 1 – THORACIC AORTA Sanchez Corral, Javier Blazquez Blazquez, Julia Ocaña Wednesday, 28 September: 11:15 – 13:00…………………….P 26 Guaita, Claudio Gandarias Zúñiga OP 001 NEW FACILITATED METHOD FOR F-EVAR AND B- CR 002 REPAIR OF MULTIPLE ANEURYSMS IN TAKAYASU EVAR ARTERITIS AND FAMILY PLANNING Krister Liungman, Anders Wanhainen, Kevin Mani, Florian Enzmann, Manuela Aspalter, Patrick Nierlich, Julio Linus Bosaeus, Mario Lachat Ellacuriaga San Martin, Thomas Hölzenbein OP 002 T-BRANCH IN THORACOABDOMINAL ANEURYSM CR 003 TREATMENT ANEURYSM OF A RIGHT AORTIC ARCH AND Tomasz Jakimowicz, Jacek Szmidt, Piotr Hammer, ABERRANT LEFT SUBCLAVIAN ARTERY: HYBRID Grzegorz Witek, Sławomir Nazarewski TREATMENT Marvin E. Garcia Reyes, Valentín Fernández Valenzuela, OP 003 ARTERIOTOMY CLOSURE DEVICES IN EVAR, Daniel Gil Sala, Jose Manuel Domínguez González, Sergi TEVAR, AND TAVR: A SYSTEMATIC REVIEW AND Bellmunt Montoya META-ANALYSIS OF INDICATIONS, COMPLICATIONS AND DURATION OF TREATMENT. CR 004 SEMICONVERSION AS A DEFINITIVE TREATMENT FOR Bastiaan P. Vierhout, Robert Pol, Mostafa El Moumni, PERSISTENT TYPE 2 ENDOLEAK CAUSING Clark J. Zeebregts ANEURYSM SAC ENLARGEMENT Alexander Croo, Eva-Line Decoster, Isabelle Van OP 004 LATE RESULTS OF THORACOABDOMINAL AORTIC Herzeele, Frank Vermassen ANEURYSM OPEN REPAIR WITH RESPECT TO DIFFERENT VISCERAL ARTERY REVASCULARIZATION TECHNIQUES CR 005 ENDOVENECTOMY OF THE FEMORAL VEINS FOR Andrea Kahlberg, Riccardo Miloro, Angela M. POST-THROMBOTIC SYNDROME WITH VENOUS Ferrante, Luca Bertoglio, Daniele Mascia, Enrico CLAUDICATION Rinaldi, Germano Melissano, Roberto Chiesa Silvan Jungi, Thomas Wyss, Pascal Kissling, Vladimir

Makaloski, Daniel Becker, Juerg Schmidli OP 005 EARLY AND MID-TERM OUTCOME OF

FENESTRATED AND BRANCH CR 006 MANAGEMENT OF ABDOMINAL AORTIC PROTHETO- THORACOABDOMINAL AORTIC REPAIR WITH DUODENAL FISTULA BY IN-SITU REPLACEMENT WITH RENOVISCERAL INCORPORATION AND A CUSTOM MADE BIFURCATED AORTOILIACAL SUPRACOELIAC COVERAGE. BOVINE PERCARDIUM XENOGRAFT Andreas Koutsoumpelis, Massimo Vezzosi Mauro Juliette Brusa, Stefan Ockert, Robert Seelos Lafrancesco, Aaron Ranasinghe, Jorge Mascaro, Martin Claridge, Donald Adam CR 007 FAMILIAL ABDOMINAL AORTIC ANEURYSM Koen M. Van De Luijtgaarden, Frederico Bastos OP 006 SURGICAL TREATMENT OF 52 PATIENTS Gonçalves, Sanne Hoeks, Dittmar Böckler, Robert Jan WITH MIDAORTIC DYSPLASTIC SYNDROME Stolker, Hence Verhagen Valeriy Arakelyan, Inna Chshieva, Vasil Papitashvili, Nazim Gamzaev, Nikita Gidaspov Natalya Bortnikova CR 008 VASCULAR AND ENDOVASCULAR INTERVENTIONS IN RETRO-PERITONEAL SARCOMA. OP 007 MODIFIED REVERSED FROZEN ELEPHANT TRUNK Mohamed Abdelhamid, Joseph Hockley, Shirley Jansen, FOR THORACOABDOMINAL AORTIC REPAIR IN A Stefan Ponosh PIG MODEL Sebastian Debus, Tilo Kölbel, Daniel Manzoni, Anna Dupree, Henrik Rieß Nikolaos Tsilimparis, Sabine H. Wipper

Copenhagen, Denmark • 28-30 September 1

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OP 008 TREATMENT TRENDS AND OUTCOMES OF OPEN AND ENDOVASCULAR THORACOABDOMINAL EVST POSTER SESSION AORTIC REPAIRS IN A SINGLE CENTER Wednesday, 28 September 16:00 – 17:00……………………P. 48 Gustavo S. Oderich, Ying Huang, Mauricio Ribeiro, Thomas C. Bower, Alberto Pochettino, Manju Kalra, PP 001 POPLITEAL ANGIOSARCOMA AS A LATE EVOLUTION Mark D. Fleming, Randall R. DeMartino, Peter OF PREVIOUSLY TREATED POPLITEAL ANEURYSM Gloviczki Manuela Cherchi, Luigi Pibiri, Stefano Camparini

PP 002 A CASE OF MOBILE AORTIC ARCH THROMBUS OP 009 THORACO-ABDOMINAL OPEN REPAIR IN PATIENTS SYNDROME WITH SYSTEMIC EMBOLISATION WITH PREVIOUS THORACIC ENDOGRAFTING Stephan Micallef Eynaud, Francesca Aquilina, Ian Said, Enrico Rinaldi, Germano Melissano, Luca Bertoglio, Adrian Mizzi, Sinisa Pejkic Andrea Kahlberg, Daniele Yamume Tshomba,

Roberto Chiesa. PP 003 IATROGENIC TYPE A DISSECTION IN A MARFAN’S SYNDROME PATIENT REPAIRED USING E-XL® STENT SCIENTIFIC SESSION 2 - PRIZE SESSION Liliana Fidalgo Domingos, Noelia Cenizo, Vicente Wednesday, 28 September 14:00 – 15:30……………………P. 38 Gutiérrez, Isabel Estévez, Diana Gutiérrez, Carlos Vaquero

OP 010 LONG-TERM OUTCOME AFTER CAROTID ARTERY PP 004 SUSPECTED TYPE IIIB ENDOLEAK. AN INTRASAC STENTING – A POPULATION BASED MATCHED "NEO-VASCULARIZATION LIKE" IMAGE FOLLOWING COHORT STUDY – INFERIOR OUTCOME OF CAROTID SUPRARENAL FIXATION EVAR WITH ADJUNCTIVE STENTING IN LONG TERM FOLLOW UP SELF-EXPANDABLE NITINOL STENT DUE TO SHORT Magnus Jonsson, David Lindström, Peter Gillgren, Anders NECK. Wanhainen, Jonas Malmstedt Andres Reyes Valdivia, Africa Duque Santos, Juan Sanchez Corral, Javier Blazquez Blazquez, Julia Ocaña OP 011 A PROFICIENCY-BASED STEPWISE ENDOVASCULAR Guaita, Claudio Gandarias Zúñiga CURRICULAR TRAINING (PROSPECT) PROGRAM ENHANCES PERFORMANCE IN REAL LIFE: A PP 005 STENTING FOR STENOTIC AORTO-RENAL BYPASS RANDOMIZED CONTROLLED TRIAL Miguel Lemos Gomes, Gonçalo Sobrinho, João Vieira, Heidi Maertens, Frank Vermassen, Nathalie Moreels, Luís M. Pedro, José Fernandes e Fernandes Isabelle Van Herzeele PP 006 SURGICAL TREATMENT OF INFERIOR MESENTERIC OP 012 RADIATION-ASSOCIATED DNA DAMAGE IN ARTERY ANEURYSM OPERATORS DURING ENDOVASCULAR AORTIC Jelena Timofejeva, Aina Kratovska, Kaspars Staudzs, REPAIR Patricija Ivanova, Arturs Ligers, Vitalijs Zvirgzdins Tamer El-Sayed., Patel A.S, Saha P., Lyons O., Ludwinski F., Abisi S., Gkoutzios P., Black S., Smith A., Modarai B. PP 007 OPEN SURGERY OF LERICHE’S SYNDROME IN A PATIENT WITH CROSSED FUSED RENAL ECTOPIA OP 013 DISTAL SEAL DYNAMICS AND CLINICAL AND DUPLICATION OF THE INFERIOR VENA CAVA. CONSEQUENCES AFTER ENDOVASCULAR David Garbaisz, Csaba Csobay-Novak, Zsuzsa Nagy, ANEURYSM REPAIR Zoltan Szeberin Nelson Gomes Oliveira, Frederico Bastos Gonçalves, Marie Josee van Rijn, Klaas Ultee, Sander Ten Raa, Sanne PP 008 KISSING-COVERED-STENT FOR AORTOILIAC DISEASE Hoeks, Robert Stolker , Hence Verhagen Mariel Stefania Riedemann Witsuba, Carol E. Padrón Encalada, Amer Zanabili Al-Sibbai, Lino A. Camblor OP 014 A NATIONWIDE STUDY ON TREATMENT OF MYCOTIC Santervás, Jose M. Llaneza Coto, Manuel Alonso Pérez ABDOMINAL AORTIC ANEURYSMS 1994-2014 Karl Sörelius, Wanhainen, Martin Björck, Mia Furebring, PP 009 “EXTENDED POSTERIOR APPROACH” FOR GIANT Peter Gillgren, Kevin Mani POPLITEAL ANEURYSM EXTENDED TO SUPERFICIAL FEMORAL ARTERY OP 015 MECHANOCHEMICAL ABLATION VS. Tomoki Cho THERMOABLATION IN THE TREATMENT OF GSV REFLUX: A RANDOMIZED TRIAL PP 010 A CASE OF ACCIDENTAL STENT DEPLOYMENT: WHAT Sari Vähäaho, Osman Mahmoud, Karoliina Halmesmäki, WE DID? Anders Albäck, Pirkka Vikatmaa, Katariina Noronen, Maarit Burak Acikgoz, Elif Guneysu, Ali A. Kavala, Senel Altun, Venermo, Ayman Hasaballah Vedat Bakuy

PP 011 EHLERS-DANLOS SYNDROME TYPE IV: CAN WE PREVENT A TRAGEDY?

Sérgio Teixeira, Pedro Sá Pinto, Carlos Veiga, João Gonçalves, Ivone Silva, Duarte Rego, Vitor Ferreira, Gabriela Teixeira, Inês Antunes, Rui Almeida

Copenhagen, Denmark • 28-30 September 2

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SESSION 3 – AORTA SESSION 4 - MISCELLANEOUS (1) Wednesday, 28 September 16:00 – 17:30……………………P. 63 Thursday, 29 September 08:00 – 09:00………………………P. 74

OP 016 VARIATIONS IN ABDOMINAL AORTIC ANEURYSM OP 024 DEGRADATION PHENOMENA ON SECOND TREATMENT: ONE DISEASE, TWO GUIDELINES, GENERATION OF EXPLANTED AORTIC TEXTILE ELEVEN COUNTRIES ENDOGRAFTS Adam W. Beck, Kevin Mani, Art Sedarkyan, Jialin Mao, Nabil Chakfe, Yannick Georg, Agnes Bussmann, Frederic Maarit Venermo, Rumi Faizer, Sebastian Debus, Heim Julie Papillon, Elie Girsowicz, Charline Delay, Christian Behrendt, Salvatore Scali, Martin Altreuther, Delphine Dion, Anne Lejay, Fabien Thaveau

Marc Schermerhorn, Barry Beiles, Zoltan Szeberin, OP 025 DIASTOLIC BLOOD PRESSURE AS AN INDEPENDENT Nikolai Eldrup, Gudmundur Danielsson, Ian Thomson, RISK FACTOR FOR PERIPROCEDURAL EVENTS George Heller, Martin Björck, Jack Cronenwett FOLLOWING CAROTID ENDARTERECTOMY IN ASYMPTOMATIC PATIENTS (ON BEHALF OF THE OP 017 THE BEST CONDITIONS FOR 2 AND 3 PARALLEL ACST-1 COLLABORATIVE GROUP) STENTING DURING EVAR: AN IN VITRO STUDY Djurre De Waard, Gert-Jan de Borst, Richard Bulbulia, Gaspar Mestres, Xavier Yugueros, Ana Apodaka, Alison Halliday Savino, Pasquadibisceglie, Xavier Alomar, Vincent Riambau OP 026 CONTECI PROGRAM. A NEW WAY TO CONTROL PERIPHERAL ARTERIAL DISEASE USING THE NEW TECHNOLOGIES AND THE PATIENT EMPOWERMENT. OP 018 CHANGES IN RENAL ANATOMY AFTER FENESTRATED RANDOMIZED TRIAL ENDOVASCULAR ANEURYSM REPAIR Meritxell Davins, Vicenç Artigas Raventós, Xavier Borràs Blandine Maurel, Youcef Lounes, Mau Amako, Pérez, Elisabet Palomera Fanegas, Mateu Serra Prat, Dominique Fabre, Adrien Hertault, Jonathan Sobocinski, Jesús Alós Villacrossa Rafaelle Spear, Richard Azzaoui, Tara M. Mastracci, Stephan Haulon OP 027 A NOVEL PREDICTION TOOL TO PREDICT MOBILITY OUTCOME AFTER LOWER EXTREMITY AMPUTATION OP 019 EVAR WITH FLARED ILIAC LIMBS HAS A HIGH RISK OF SECONDARY TO PERIPHERAL ARTERIAL DISEASE LATE TYPE 1B ENDOLEAK AND/OR DIABETES Daphne Gray, Jan S. Brunkwall, Michael Gawenda Joseph Czerniecki, Aaron Turner, Rhonda Williams, Mary Lou Thompson, Kevin Hakimi, Gregory Landry, Dan Norvell OP 020 FEMALE SEX IS AN INDEPENDENT RISK FACTOR FOR WORSE CLINICAL OUTCOMES IN ABDOMINAL AORTIC OP 028 ASSESSMENT OF FOOT PERFUSION BEFORE AND ANEURYSM TREATMENT. A SECONDARY DATA AFTER REVASCULARIZATION OF CRITICALLY ANALYSIS OF THE NATIONWIDE GERMAN D R G ISCHEMIC FOOT USING INDOCYANINE GREEN MICRODATA 2005-2013 FLUORESCENCE IMAGING Matthias Trenner, Andreas Kuehnl, Hans-Henning Nicla Settembre, Anders Albäck, Petteri Kauhanen, Eckstein Kristyna Spillerova, Maarit Venermo

OP 021 LESSON LEARNED WITH THE USE OF ILIAC BRANCH SESSION 5 - CAROTID DEVICES: 10 YEAR RESULTS IN 150 CONSECUTIVE Thursday, 29 September 08:00 – 09:00…………………………81

PATIENTS Gianbattista Parlani, Gioele Simonte, Luca OP 029 INDIVIDUAL PATIENT DATA ANALYSIS OF 5226 Farchioni, Giacomo Isernia, Enrico Cieri, Massimo PATIENTS IN THE ASYMPTOMATIC CAROTID Lenti, Piergiorgio Cao, Fabio Verzini SURGERY TRIALS - BENEFITS AND HAZARDS OF IMMEDIATE SURGERY IN PATIENTS TAKING OP 022 THE LONG-TERM DURABILITY OF INTRAOPERATIVELY CONTEMPORARY MEDICAL THERAPIES (ON BEHALF PLACED OF PALMAZ STENTS FOR THE TREATMENT OF ACST-1, ACAS & VACS COLLABORATORS AND THE OF TYPE IA ENDOLEAKS AFTER EVAR OF AAA CSTC) Mohammed Abdulrasak, Timothy Resch, Björn Alison Halliday, Hongchao Pan, Peter Rothwell, Richard Sonesson, Jan Holst, Thorarinn Kristmundsson Bulbulia, Richard Peto Nuno Dias OP 030 A SYSTEMATIC REVIEW AND META-ANALYSIS OF OP 023 THE UK PILOT STUDY ON MULTI-LAYER FLOW- OUTCOMES FOLLOWING STAGED/SYNCHRONOUS MODULATING STENTS FOR THORACO-ABDOMINAL CAROTID ARTERY STENTING AND CORONARY AND PERI-RENAL ANEURYSMS: RESULTS AT THREE ARTERY BYPASS SURGERY YEARS. Kosmas Paraskevas, Sarah Nduwayo, Athanasios Chris Lowe, Ferdinand Serracino-Inglott, Ray Ashleigh, Saratzis, Ross Naylor Charles McCollum

Copenhagen, Denmark • 28-30 September 3

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OP 031 SHUNTING DURING CAROTID ENDARTERECTOMY: OP 039 TEN YEARS’ EXPERIENCE WITH COMMUNITY WHAT WE HAVE LEARNED FROM DIFFUSION- CLAUDICATION CLINICS WEIGHTED MAGNETIC RESONANCE IMAGING. Colin Wood, M.C Ruiz, M.M Mirghani, E. Allen, L. Elke Wybaillie, Patrick Seynaeve, Hans Pottel, Gunter De Crawford, A. McCusker, E. Brankin, R.N Scott Smul, Paul Wallaert, Philip Lerut OP 040 DRUG-ELUTING BALLOON ANGIOPLASTY VERSUS OP 032 THE NATIONAL NORWEGIAN CAROTID STUDY; TIME UNCOATED BALLOON ANGIOPLASTY IN PATIENTS FROM SYMPTOM DEBUT TO SURGERY IS TOO LONG, WITH FEMOROPOPLITEAL ARTERIAL OCCLUSIVE GIVING ADDITIONAL NEUROLOGICAL EVENTS DISEASE: A META-ANALYSIS OF RANDOMIZED Knut Eivind Kjørstad, Svein T. Baksaas, Dorte CONTROLLED TRIALS Bundgaard, Erik Halbakken, Terje Hasselgård, Geir T. Hidde Jongsma, Joost Bekken, Jean-paul de Vries, Hence Jørgensen, Anne H. Krog, Kirsten Krohg-Sørensen, Elin Verhagen, Bram Fioole Laxdal, Sven R. Mathisen, Gudmundur V. Oskarsson, Synnøve Seljeskog, Inge Settemsdal, Beate Viddal, Frode OP 041 A HIGH ANKLE-BRACHIAL INDEX IS ASSOCIATED Aasgaard, Erney Mattsson WITH ALL-CAUSE MORTALITY IN A POPULATION WITHOUT CARDIOVASCULAR DISEASE. THE REGICOR OP 033 SIGNIFICANT ASSOCIATION OF ANNUAL HOSPITAL STUDY VOLUME WITH THE RISK OF INHOSPITAL STROKE OR Alina Velescu, Albert Clará Velasco, Judith Peñafiel DEATH FOLLOWING CAROTID ENDARTERECTOMY Muñoz, Lidia Marcos Garcia, Jaume Marrugat de la Iglesia, BUT NOT CAROTID STENTING: SECONDARY DATA Roberto Elosua Llanos ANALYSIS OF THE STATUTORY GERMAN CAROTID QUALITY ASSURANCE DATABASE OP 042 PREVALENCE OF MAJOR LOWER LIMB AMPUTATION Andreas Kuehnl, Pavlos Tsantilas, Christoph Knappich, ACROSS DENMARK AND ITS RELATIONSHIP WITH Sofie Schmid, Thorben Breitkreuz, Alexander Zimmermann REVASCULARIZATION, DEMOGRAPHY AND DISEASE RISK FACTORS OP 034 SURGICAL TREATMENT OF CAROTID BODY TUMORS Louise Skovgaard Londero, Annette Høgh, Kim Houlind, William Stone, Samuel Money, Victor Davila, Richard Jes Lindholt Fowl, Thomas Bower SESSION 7 - BASIC SCIENCE OP 035 FATE OF DISTAL FALSE ANEURYSMS COMPLICATING Thursday, 29 September 16:00 – 17:30………………………..P. 98 INTERNAL CAROTID ARTERY DISSECTION: A SYSTEMATIC REVIEW OP 043 CIRCULATING LEVELS OF VEGF-ASSOCIATED Kosmas Paraskevas, Andrew Batchelder, Ross Naylor GROWTH FACTORS IN END-STAGE PERIPHERAL

ARTERIAL DISEASE OP 036 IMPACT OF DIFFERENT PROCEDURAL VARIABLES ON Olli Hautero, Juho Jalkanen, Mikael Maksimow, Sirpa THE RISK OF IN-HOSPITAL STROKE OR DEATH AFTER Jalkanen, Harri Hakovirta CAROTID ENDARTERECTOMY AND CAROTID ARTERY

STENTING IN ROUTINE PRACTICE: A SECONDARY OP 044 UPREGULATION OF 14Q32 MICRORNAS IN HUMAN DATA ANALYSIS OF THE STATUTORY NATIONWIDE SUBCUTANEOUS ADIPOSE TISSUE OF PATIENTS GERMAN QUALITY ASSURANCE DATABASE WITH CRITICAL LIMB ISCHEMIA AT RISK OF MAJOR Christoph Knappich, Andreas Kuehnl, Pavlos Tsantilas, AMPUTATION Sofie Schmid, Thorben Breitkreuz, Michael Kallmayer, Yael Nossent, Sabine Welten, Ming Tao, Alban Alexander Zimmermann, Hans-Henning Eckstein Longchamp, Szymon Kielbasa, Paul Quax, Keith Ozaki

SESSION 6 – PAD OP 045 A NOVEL ANTI-INFLAMMATORY BIOMARKER THAT Thursday, 29 September 11:15 – 12:30………………………P. 91 PREDICTS PERIPHERAL VEIN GRAFT FAILURE Michael Sobel, Mayumi Yagi, Gale L. Tang, Ted R. Kohler, OP 037 COST EFFECTIVENESS ANALYSIS OF HEPARIN- Errol S. Wijelath, Richard D. Kenagy, Katherine T. Moreno VERSUS STANDARD POLYTETRAFLUOROETHYLENE GRAFT ALONGSIDE A RANDOMISED CONTROLLED OP 046 DIFFERENTIAL GENE EXPRESSION DURING TRIAL WITH FIVE YEARS FOLLOW-UP PROGRESSION OF HUMAN ABDOMINAL AORTIC Jes S. Lindholt, Marie Villemoes, Kim C. Houlind, Bo ANEURYSM Gottschalksen, Christian N. Pedersen, Martin Rasmussen, Gabor Gäbel, Frank Schönleben, Irene Hinterseher, Charlotte Wedel, Morten B. Bramsen, Rikke Søgaard Hendrik Bergert, Jan H. Lindeman

OP 038 CONTEMPORARY CARDIOVASCULAR RISK AND SECONDARY PREVENTIVE DRUG TREATMENT PATTERNS IN PERIPHERAL ARTERIAL DISEASE PATIENTS UNDERGOING REVASCULARIZATION Birgitta Sigvant, Björn Kragsterman, Marten Falkenberg, Marcus Thuresson, Joakim Nordanstig

Copenhagen, Denmark • 28-30 September 4

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0P 047 FURTHER INSIGHTS INTO TISSUE ENGINEERED OP 056 ENDOVENOUS LASER THERAPY (ELT) OF SMALL DIAMETER VASCULAR GRAFTS: IMPACT OF SAPHENOUS VEIN REFLUX USING THULIUM LASER SURFACE MODIFICATION ON PATENCY AND IN VIVO (TM, 1940NM) WITH RADIAL FIBER - ONE YEAR COMPATIBILITY. RESULTS Max Theodor Wacker, Dieter Klemm, Maximilian Anna Esipova, Claus-Georg Schmedt, Slobodan Dikic, Scherner, Carolyn Weber, Kaveh Eghbalzadeh, Stefanie Abhay Setia, Sahit Demhasaj, Thomas Dieckmann, Marius- Reinhardt Thorsten Mircea Tipi, Ronald Sroka

OP 048 CAN PERITONEUM BECOME AN ARTERY? OP 057 RECONSTRUCTION OF THE VENOUS OUTFLOW OF PERITONEUM AS AN ARTERIAL GRAFT MATERIAL IN A THE LOWER EXTREMITY IN POST-THROMBOTIC LARGE MAMMAL SYNDROME AND ILIAC VEIN COMPRESSION Petter Davik, Martin Altreuther, Erney Mattsson SYNDROME Timme Van Vuuren, Mark A. de Wolf, Carsten W. SESSION 8 – MISCELLANEOUS (2) Arnoldussen, Ralph L. Kurstjens, Jorinde H. van Laanen, Friday, 30 September 08:00 – 09:00 …………………………P. 105 Houman Jalaie, Rick de Graaf, Cees H. Wittens.

OP 049 VAS Q- AN INNOVATIVE EXTERNAL SUPPORT DEVICE OP 058 ENDOVASCULAR RECANALIZATION OF CHRONIC IMPROVES FUNCTIONALITY OF ARTERIOVENOUS NON-MALIGNANT OBSTRUCTION OF THE INFERIOR FISTULAS: PILOT STUDY RESULTS VENA CAVA Eric Chemla Ole Jørgen Grøtta, Tone Enden, Gunnar Sandbæk, Dag Bay, Carl-Erik Slagsvold, Gard F. Gjerdalen, Jørgen J. OP 050 PTFE THIGH LOOPS PROVIDE BETTER PRIMARY Jørgensen, Antonio Rosales PATENCY, THAN OTHER VASCULAR ACCESS LOCATIONS OP 059 TO COVER OR NOT TO COVER, THAT IS THE Peter Konstantiniuk, Stefanie Santler, Georg QUESTION” - RECTUS FEMORIS MUSCLE FLAPS IN Schramayer, Florian Prüller, Ulrike Demel, Tina Cohnert GROIN DEFECTS AFTER VASCULAR SURGERY Jurek Conings, Jan Willem Daemen, Ilse Mostaert, Jan- OP 051 DIASTOLIC DIAMETER MEASUREMENTS ON THE Willem Elshof, Marc Scheltinga, Barend Mees THORACIC AORTA CAN LEAD TO ACCURATE SIZING OF ENDOGRAFTS IN YOUNG PATIENTS OP 060 NEGATIVE PRESSURE WOUND THERAPY TO Peter Sotonyi, Csaba Csobay-Novak, Daniele M. PREVENT GROIN INFECTIONS AFTER VASCULAR Fontanini, Brigitta Szilagyi, Kalman Huttl SURGERY - A RANDOMIZED CONTROLLED TRIAL Julien Hasselmann, Tobias Kühme, Stefan Acosta OP 052 THREE-DIMENSIONAL CONTRAST-ENHANCED ULTRASOUND IMPROVES THE DETECTION AND SESSION 10 - MISCELLANEOUS (3) CLASSIFICATION OF ENDOLEAKS FOLLOWING Friday, 30 September 10:30 – 12:15…………………………P. 119 ENDOVASCULAR ANEURYSM REPAIR. Chris Lowe, Abeera Abbas, Steven Rogers, Lee Smth, Jonathan Ghosh, Charles McCollum OP 061 10-YEAR EXPERIENCE OF CRYOPRESERVED ARTERIAL ALLOGRAFTS OP 053 FOLLOW-UP OF FASCIAL SUTURE AFTER Anne Lejay, Charline Delay, Elie Girsowicz, Bettina ENDOVASCULAR ANEURYSM REPAIR WITH DUPLEX Chenesseau, Mathieu Roussin, Vincent Meteyer, Fabien ULTRASOUND Thaveau, Yannick Georg, Nabil Chakfe Kim Bredahl, Kristian Fredholm, Lars Lönn, Katja Vogt, Henrik Sillesen, Jonas Eiberg, Kim Bredahl OP 062 THE DANCAVAS PILOT STUDY OF MULTIFACETED SCREENING FOR SUBCLINICAL CARDIOVASCULAR OP 054 PREVENTION OF INCISIONAL HERNIA AFTER DISEASE IN MEN AND WOMEN AGED 65-74 ABDOMINAL AORTIC ANEURYSM REPAIR (AIDA Thomas Vedel Kvist, Jes S. Lindholt, Lars M. Rasmussen, STUDY) Rikke Søgaard, Jess Lambrechtsen, Flemming H. Holger Diener, Hans Henning Eckstein, Heiner Wenk, Steffensen, Lars Frost, Michael H. Olsen, Hans Mickley, Johannes Gahlen, Richard Kellersmann, Jochen Jesper Hallas, Grazina Urbonaviciene, Martin Busk, Grommes, Eric Verhoeven, Harald Daum, Thomas Hupp, Kenneth Egstrup, Axel Diederichsen Sebastian Debus OP 063 LONG-TERM RESULTS OF THE NAIS PROCEDURE FOR AORTIC-GRAFT INFECTIONS AND MYCOTIC SESSION 9 - VENOUS/WOUND ANEURYSMS: A SINGLE-CENTER EXPERIENCE Friday, 30 September 09:00 – 10:00…………………………P. 112 Valerie Gauvin, Julien Bernatchez, Pascal Rheaume

OP 055 A SYSTEMATIC REVIEW OF STENTING IN THE MANAGEMENT OF ACUTE DEEP VENOUS THROMBOSIS Mohamed A. H. Taha, Andrew Busuttil, Roshan Bootun, Alun H. Davies

Copenhagen, Denmark • 28-30 September 5

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OP 064 A MULTICENTRE RANDOMISED CONTROLLED TRIAL OF PATIENT-SPECIFIC REHEARSAL PRIOR TO EVAR: PO 004 CHANGES IN CHOROIDAL THICKNESS AFTER IMPACT ON PROCEDURAL PLANNING AND TEAM CAROTID ENDARTERECTOMY USING ENHANCED PERFORMANCE DEPTH IMAGING OPTICAL COHERENCE Liesbeth Desender, Isabelle Van Herzeele, Zoran Rancic, TOMOGRAPHY Mario Lachat, Johan Duchateau, Colin Bicknell, Nung Fabien Layrere, Elixene Jean-Baptiste, Elisabeth Nguyen, Rudarakanchana, Joep Teijink, Jan Heyligers, Frank Jacques Chofflet, Jérome Doyen, Réda Hassen-Khodja, Vermassen Pierre Gastaud

OP 065 A 12 WEEK HOME EXERCISE PROGRAMME PO 005 CAROTID STENOSIS TREATMENT: DEFINING AUGMENTED WITH NORDIC POLE WALKING PRACTICE PATTERNS ACROSS THE GLOBE IMPROVES THE QUALITY OF LIFE AND ABPIS OF Maarit Venermo, Grace Wang, Randall DeMartino, Nikolaj CLAUDICANTS. MOST PATIENTS CONTINUE TO USE Eldrup, Art Sedrakyan, Jialin Mao, Barry Beiles, Gabor THEIR POLES AND IMPROVE THEIR WALKING Menyhei, Kevin Mani, Martin Altreuther, Ian Thomson, Pius DISTANCE AT ONE YEAR Wigger, Gudmundur Danielsson, Jack Cronenwett, Martin Jonathan Beard, Clare Spafford, Clare Oakley Björck

OP 066 THE FATE OF PATIENTS WITH INTERMITTENT PO 006 THE COMBINED RISK OF STROKE OR DEATH IS CLAUDICATION IN THE 21ST CENTURY REVISITED - ASSOCIATED WITH AGE, BUT NOT WITH SEX IN RESULTS FROM THE CAVASIC STUDY PATIENTS TREATED WITH CEA OR CAS IN ROUTINE Barbara Rantner, Barbara Kollerits, Johannes PRACTICE IN GERMANY – RISK OF STROKE IS Pohlhammer, Marietta Stadler, Claudia Lamina, Slobodan ASSOCIATED WITH AGE IN CAS PATIENTS ONLY Peric, Peter Klein-Weigel, Hannes Mühlthaler, Gustav Andreas Kuehnl, Sofie Schmid, Pavlos Tsantilas, Fraedrich, Florian Kronenberg Christoph Knappich, Michael Kallmayer, Thorben Breitkreuz, Alexander Zimmermann, Hans-Henning OP 067 EYE DOSE REDUCTION WITH VARIOUS X-RAY Eckstein PROTECTION SHIELDS DURING ENDOVASCULAR PROCEDURES PO 007 MULTICENTER EXPERIENCE WITH IN SITU Sara Bruce, Kevin Mani, Karolina Lindskog, Lars FENESTRATION FOR ENDOVASCULAR AORTIC ARCH Jangland, Anders Wanhainen REPAIR: DATA FROM THE ARCHIF REGISTRY Reinhard Kopp, Yoshiaki Katada, Norio Hongo, Björn OP 068 KIDNEY VOLUME CHANGE IN PATIENTS WITH TYPE B Sonesson, Leonard Tse, Sean Crawford, Piotr M. Kasprzak AORTIC DISSECTION IN RELATION TO PERFUSION FROM TRUE OR FALSE LUMEN PO 008 THE EFFICACY OF PHARMACOLOGICAL Nikolaos Tsilimparis, Ruth Jacobi, Fiona Rohlffs, Sabine PRECONDITIONING IN CAROTID ENDARTERECTOMY Wipper, Axel Larena-Avellaneda, E. Sebastian Debus, Tilo Maxim Kuznetsov, Anatoly Karalkin, Anatoly Fedin, Kölbel Alexander Knyazev, Nikolay Kunicin

POSTERS PRESENTATIONS PO 009 PATTERNS OF ACUTE ISCHEMIC STROKES AFTER …………………………………………………………………….P. 128 CAROTID ENDARTERECTOMY AND THERAPEUTIC

IMPLICATIONS PO 001 EARLY CAROTID ENDARTERECTOMY AFTER Fabien Lareyre, Elixene Jean-Baptiste, Juliette Raffort, INTRAVENOUS THROMBOLYSIS IS SAFE Caroline Weil, Laurent Suissa, Nirvana Sadaghianloo, Pirkka Vikatmaa, Petra Ijäs, Lauri Soinne, Maarit Venermo Serge Declemy, Réda Hassen- Khodja

INFLUENCE OF METABOLIC SYNDROME ON THE PO 010 SAFETY, TOLERABILITY AND PHARMACOKINETICS OF SHORT AND LONG-TERM OUTCOME AFTER CAROTID A NOVEL HUMAN PHOSPHORYLCHOLINE ANTIBODY PO 002 ENDARTERECTOMY (PC-MAB) IN PATIENTS WITH PERIPHERAL ARTERIAL Linda Visser, Bas M. Wallis de Vries, Udo J. Mulder, DISEASE UNDERGOING Martijn Uyttenboogaart, Sterre van der Veen, Clark J. THROMBOENDARTERECTOMY OR VEIN GRAFT Zeebregts, Robert A. Pol BYPASS Claes Bergmark, Karin Wåhlander, Per Blom, Knut PO 003 DEVELOPMENT OF A MICROSIMULATION MODEL TO Pettersson, Eva Karlöf PREDICT STROKE AND LONG-TERM MORTALITY IN ADHERENT AND NON-ADHERENT MEDICALLY PO 011 PRE-OPERATIVE PREDICTORS OF POOR OUTCOMES MANAGED AND SURGICALLY TREATED IN PATIENTS UNDERGOING SURGICAL LOWER OCTOGENARIANS WITH ASYMPTOMATIC EXTREMITY REVASCULARISATION SIGNIFICANT CAROTID ARTERY STENOSIS Mohammed Ashrafi, Rohini Salvadi, Philip Foden, Thomas Luebke, Jan Brunkwall Stephanie Thomas, Mohamed Baguneid

Copenhagen, Denmark • 28-30 September 6

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PO 012 WHEN IS SUPERVISED EXERCISE THERAPY PO 021 COMPLEX INFRA-POPLITEAL REVASCULARISATION IN CONSIDERED USEFUL FOR INTERMITTENT OCTOGENARIANS AND NONAGENARIANS WITH CLAUDICATION: AN UPDATE OF THE DUTCH CRITICAL LIMB ISCHAEMIA: IMPACT OF VASCULAR SURGEONS’ ATTITUDE TOWARDS MULTIDISCIPLINARY INTEGRATED CARE ON MID- CONSERVATIVE MANAGEMENT TERM OUTCOME Gert-Jan Lauret, David Hageman, Lindy N. Gommans, Justinas Silickas, Lukla Biasi, Sanjay D. Patel, Talia Lea, Mark J. Koelemay, Marc R. van Sambeek, Joep A. Teijink Tommaso Donati, Athanasios Diamantopoulos, Konstantinos Katsanos, Judith Partridge, Jugdeep Dhesi, PO 013 TRENDS IN THE PROGNOSIS OF PATIENTS WITH Hany Zayed INTERMITTENT CLAUDICATION AND CRITICAL LIMB ISCHEMIA IN THE NETHERLANDS PO 022 A 20-YEAR EXPERIENCE OF SUPERFICIAL ARTERY Steven Van Haelst, Carla Koopman, Frans L. Moll, Ilonca AUTOGRAFT RECONSTRUCTION FOR TREATMENT OF H. Vaartjes, Gert Jan de Borst POPLITEAL ARTERY ANEURYSMS Pierre Maitrias, Valerie Molin, Marie Bensussan, Thierry PO 014 DIFFERENTIAL IMPACT OF BYPASS SURGERY AND Reix ANGIOPLASTY ON ANGIOSOME-TARGETED INFRAPOPLITEAL REVASCULARIZATION IN DIABETICS PO 023 TREATMENT OF CRITICAL LIMB ISCHEMIA BY Nicla Settembre, Kristyna Spillerova, Fausto Biancari, THERAPEUTIC ANGIOGENESIS IN PATIENTS WITH NO Anders Albäck, Maarit Venermo REVASCULARIZATING OPTIONS: RESULTS AFTER AUTOLOGOUS TRANSPLANTATION OF PO 015 INFRAPOPLITEAL ENDOVASCULAR INTERVENTIONS HEMATOPOIETIC PROGENITORS CELLS WITH SELECTIVE STENTING IN COMPLEX LESIONS Raul Lara-Hernandez, Pascual Lozano-Vilardell, Antonia DOES NOT RIVAL GREAT SAPHENOUS VEIN BYPASS Sampol Mayol, Enrique Manuel-Rimbau Muñoz, Ramon Hasan Dosluoglu, Sikandar Z. Khan, Mariel Rivero, Linda Riera Vazquez, Armando Mena Dura Harris, Maciej Dryjski PO 024 BARTHEL FRALTY INDEX CAN BE ONE OF THE PO 016 DREAM AND REALITY – COVERED STENTGRAFT AS PREDICTORS OF TWO-YEAR MORTALITY AFTER TREATMENT OF SUPERFICIAL ARTERY LESIONS DISTAL BYPASS IN PATIENTS WITH CRITICAL LIMB Michael Gawenda, Daphne Gray, Robert Shahverdyan, ISCHEMIA Roland Thul Akio Koyama, Masayuki Sugimoto, Hiroshi Banno, Kimihiro Komori PO 017 OPEN SURGERY IS THE FIRST-LINE TREATMENT TO INFRAPOPLITEAL LESIONS IN CRITICAL LIMB PO 025 EFFECT OF DIABETES MELLITUS ON WALKING ISCHEMIA DISTANCE PARAMETERS AFTER SUPERVISED Taku Kokubo, Naoko Ohkubo, Shinsuke Kikuchi, Yumi EXERCISE THERAPY FOR INTERMITTENT Sasajima, Tadahiro Sasajima CLAUDICATION Gert-Jan Lauret, David Hageman, Lindy N. Gommans, PO 018 MEASUREMENT OF MICROCIRCULATION SUGGESTS Marc R. Scheltinga, Joep A. Teijink THAT ANGIOSOME SHUNTING EXCISTS MAINLY THROUGH ANGIOGRAPHICALLY VISIBLE PO 026 DISTRIBUTION OF INFRA-POPLITEAL PERIPHERAL COLLATERALS VASCULAR DISEASE IN PATIENTS WITH DIABETES Mette Berggren-Olsen, Johnny Christensen, Hanne Birke- MELLITUS COMPARED TO PATIENTS WITHOUT Sørensen, Kim Houlind Danielle Lowry, Mujahid Saeed, Parth Narendran, Alok Tiwari PO 019 OUTCOME FOR POPLITEAL STENTS GRAFTS ARE COMPARABLE TO BYPASS GRAFTS FOR POPLITEAL PO 027 IMPACT OF CHRONIC KIDNEY DISEASE ON THE ARTERY ANEURYSM (PAA) OUTCOMES OF PATIENTS UNDERGOING Irwin Mohan, Kerry Hitos, Bernie Bourke, Barry Beiles REVASCULARIZATION FOR CRITICAL LIMB ISCHAEMIA Asimakis Gkremoutis, Thomas Schmitz-Rixen ENDOVASCULAR AND OPEN REPAIR OF POPLITEAL PO 020 ARTERY ANEURYSMS: TEN-YEARS EXPERIENCE PO 028 TOE PRESSURE IS A BETTER INDICATOR OF A Anne Lejay, Benjamin Del Tatto, Mathieu Roussin, PATIENT’S PERIPHERAL ARTERIAL DISEASE AND Charline Delay, Elie Girsowicz, Vincent Meteyer, Yannick CARDIOVASCULAR RISK THAN THE ANKLE BRACHIAL Georg, Fabien Thaveau, Nabil Chakfe INDEX Petteri Kauhanen, Mirjami Laivuori, Harri Hakovirta, Anders Albäck, Maarit Venermo

Copenhagen, Denmark • 28-30 September 7

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PO 029 THE 2-YEARS FOLLOW-UP RESULTS OF A PO 038 MORPHOLOGY OF THE DISSECTED AORTA PREDICTS STRUCTURED COMPREHENSIVE MULTIDISCIPLINARY EARLY AND LATE ADVERSE OUTCOME AFTER TEVAR PROTOCOL ON THE LOWER EXTREMITY IN ACUTE COMPLICATED TYPE B AORTIC AMPUTATION RATES IN A COHORT OF PATIENTS DISSECTION WITH DIABETIC FOOT ULCERS Christian Smedberg, Johnny Steuer, Rebecka Hultgren, Anas Alzahrani, Hasan Alzahrani Martin Delle, Linus Blohmé, Christian Olsson

PO 030 SUBJECTS WITH PERIPHERAL ARTERIAL DISEASE PO 039 ANALYSIS OF ACUTE KIDNEY INJURY AND CHRONIC SURVIVING TEN YEARS HAVE A SUBSTANTIAL RISK KIDNEY DISEASE AFTER TAAA REPAIR WITH FOR DETERIORATION OF LEG PROBLEMS BRANCHED STENTGRAFTS Fredrik Sartipy, Birgitta Sigvant, Fredrik Lundin, Eric Beatrix Cucuruz, Reinhard Kopp, Piotr M. Kasprzak, Wahlberg Konstantinos Gallis, Karin Pfister, Lucian Costin

PO 031 BETTER LONG TERM RESULT OF AMPUTATION FREE PO 040 FEASIBILITY AND OUTCOMES OF LOCAL SURVIVAL FOR WOMEN IN SPINAL CORD ANAESTHESIA FOR ENDOVASCULAR REPAIR OF STIMULATION FOR CRITICAL LIMB ISCHEMIA RUPTURED ABDOMINAL AORTIC ANEURYSMS Wolfgang Oswald, Peter Konstantiniuk, Maurice Tomka, Jorg L. De Bruin, Ronelle Mouton, Jack Brownrigg, Simon Philipp Jud, Tina Cohnert Howell, Robert J. Hinchliffe

PO 032 RESULTS OF COMPLETE FOLLOW-UP AT 2 YEARS OF PO 041 EVAR: AORTA-UNI-ILIAC ENDOGRAFT, 10 YEARS HEPARIN-BONDED PTFE BELOW-KNEE FEMORO- EXPERIENCE POPLITEAL BYPASS IN PATIENTS WITH CRITICAL Bahaa Nasr, Benedicte Albert, Charles-Henri David, Ali LIMB ISCHEMIA IN A MULTICENTRIC REGISTRY Badra, Jacques Braeso, Pierre Gouny Paolo Ottavi, Walter Dorigo, Gabriele Piffaretti, Raffaele Pulli, Patrizio Castelli, Carlo Pratesi PO 042 TYPE II ENDOLEAK PREVENTION BY INFERIOR MESENTERIC ARTERY EMBOLIZATION DURING PO 033 CONTEMPORARY MANAGEMENT AND OUTCOME ENDOVASCULAR ANEURYSM REPAIR IN HIGH RISK AFTER LOWER EXTREMITY FASCIOTOMY IN PATIENTS VASCULAR SURGERY Makoto Samura, Noriyasu Morikage, Yuriko Takeuchi, Carl Magnus Wahlgren, Charlotte Wesslén Takasuke Harada, Osamu Yamashita, Kotaro Suehiro, Kimikazu Hamano PO 034 ENDOVASCULAR-FIRST APPROACH FOR MANAGEMENT OF INFRA-INGUINAL ARTERIAL PO 043 BIOMECHANICAL CHANGES DURING ABDOMINAL DISEASE: PREDICTORS OF OUTCOME AORTIC ANEURYSM GROWTH Ahmed Elmallah, Elrasheid A. H. Kheirelseid, Sophia T. Christian Gasser, Raoul Stevens, Andrii Grytsan, Angelov, Adrian O'Callaghan, Zenia Martin, Sean M. Jacopo Biasetti, Moritz Lindquist Liljeqvist, Joy Roy O'Neill, Mary Paula Colgan, Prakash Madhavan PO 044 CHANGES AND REGIONAL DIFFERENCES IN THE PO 035 GUTTER SIZE AND MIDTERM OUTCOMES AFTER TREATMENT OF ABDOMINAL AORTIC ANEURYSMS IN ENDOVASCULAR ANEURYSM REPAIR WITH THE FINLAND DURING 2000-2014 CHIMNEY GRAFT PROCEDURE Matti T. Laine, Sani Laukontaus, Pekka S. Aho, Ilkka Hector W. de Beaufort, Elena Cellitti, Quirina M. de Kantonen, Anders Albäck, Maarit Venermo Ruiter, Michele Conti, Frans L. Moll, Santi Trimarchi, Constantijn E.Hazenberg, Joost A. van Herwaarden PO 045 POSTOPERATIVE EVAR SURVEILLANCE – ULTRASOUND FINDINGS THAT PROMPT FURTHER PO 036 BRANCHED ENDOVASCULAR AORTIC REPAIR FOR INTERVENTION THORACOABDOMINAL AORTIC ANEURYSMS Elizabeth Li, Lewis Meecham, Zahid Khan, Jeremy TREATED BY SINGLE STEP OR OPEN BRANCH Newman, Michael L. Wall STAGED PROCEDURES: PREVENTION OF SPINAL CORD AND MESENTERIC ISCHEMIA. PO 046 OUTCOME AFTER TURNDOWN FOR ELECTIVE AND Reinhard Kopp, Beatrix Cucuruz, Konstantinos Gallis, EMERGENCY ABDOMINAL AORTIC ANEURYSM Karin Pfister, Markus Janotta, Piotr M. Kasprzak SURGERY Joshua D. Whittaker, Lewis Meecham, Adrian Jennings, PO 037 IN SITU ANTEROGRADE LASER FENESTRATIONS Micheal Wall, Jeremy Newman DURING ENDOVASCULAR REPAIR FOR AORTIC ANEURYSM PO 047 ILIAC CALCIUM SCORE: A NEW PREDICTOR OF LONG- Dominique Fabre, Sarah Hamdi, Philippe Brenot, Carlos TERM MORTALITY AFTER ENDOVASCULAR REPAIR Garcia Alonso, Claude Angel, Elie Fadel OF ABDOMINAL AORTIC ANEURYSM Roberta Vaccarino, Mohammed Abdulrasak, Timothy Resch, Giuseppe Asciutto, Björn Sonesson, Nuno V Dias

Copenhagen, Denmark • 28-30 September 8

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INCIDENCE OF SMALL ABDOMINAL AORTIC PO 057 ANEURYSMS RUPTURE, RISK FACTORS PO 048 NATIONWIDE ANALYSIS OF ABDOMINAL AORTIC ASSESSMENT AND OUR EXPERIENCE WITH RUPTURE ANEURYSM REPAIR EPIDEMIOLOGY IN SWEDEN RISK PREDICTION BASED ON WALL STRESS OVER TWO DECADES ASSESSMENT Fredrik Lilja, Kevin Mani, Anders Wanhainen Lubos Kubicek, Robert Staffa, Robert Vlachovsky, Stanislav Polzer PO 049 12 YEARS OF FEVAR FOLLOW-UP FROM A SINGLE UK CENTRE PO 058 THE FATE OF UNEXPECTED EVENTS OCCURRING IN Iain Roy, Alistair Millen, Srinivasa Vallabhaneni, Steven STANDARD EVAR Jones, James Scurr, Richard McWIlliams, John Brennan, Andrea Vacirca, Gianluca Faggioli, Rodolfo Pini, Enrico Robert Fisher Gallitto, Chiara Mascoli, Antonio Freyrie, Mauro Gargiulo, Andrea Stella PO 050 ANEURYSM RUPTURE RISK STRATIFCATION WITH USE OF REAL TIME 3D SPECKLE TRACKING PO 059 ENDOVASCULAR AORTIC REPAIR OF INFRARENAL ULTRASOUND AND FINITE ELEMENT ANALYSIS AORTIC ANEURYSMS: EQUAL EARLY RESULTS AFTER Thomas Schmitz-Rixen, Wojciech Derwich, Andreas EVAR WITHIN IFU AND EVAR WITH PRIMARY Wittek, Christopher Blasé, ENDOANCHOR FIXATION FOR HOSTILE NECK Reinhard Kopp, Piotr M. Kasprzak, Thomas Muck, Hanna PO 051 MAGNETIC RESONANCE IMAGING OF THE Apfelbeck, Beatrix Cucuruz INTRALUMINAL THROMBUS IN ABDOMINAL AORTIC ANEURYSMS – A QUANTITATIVE AND QUALITATIVE PO 060 INCREASED EXPERIENCE ALLOW MORE COMPLEX EVALUATION AND CORRELATION TO GROWTH RATE REPAIRS OF AORTOILIAC ANEURYSMS WITHOUT Carsten Behr-Rasmussen, Lise Gammelgaard, Ernst- INFLUENCING MID-TERM RESULTS OF EVAR WITH Torben Fruend, Jes S. Lindholt ILIAC BRANCHED DEVICES Andrea Xodo, Giuseppe Asciutto, Björn Sonesson, PO 052 OCCLUSION BALLOON AS AN ACHILLES HEEL OF Timothy Resch, Nuno V Dias REVAR – IMPACT OF MULTIDISCIPLINARY SIMULATION ON THE PREOPERATIVE PROCESS PO 061 CONTROVERSIES IN DIAGNOSTIC CRITERIA FOR Pekka Aho, Leena Vikatmaa, Leila Niemi-Murola, Ville ABDOMINAL AORTIC ANEURYSM; IS BODY SURFACE Päivinen, Mia Kantomaa, Maarit Venermo OF IMPORTANCE? Joachim Starck, Katarina Björses, Fredrik Lundgren, PO 053 ADJUSTED HOSPITAL OUTCOMES REPORTED IN THE Anders Gottsäter, Björn Sonesson, Jan Holst DUTCH SURGICAL ANEURYSM AUDIT AFTER 2 YEARS OF ELECTIVE ANEURYSM SURGERY PO 062 QUALITY OF LIFE ASSOCIATIONS TO Niki Lijftogt, Anco Vahl, J.F. Hamming CARDIOPULMONARY EXERCISE TESTING IN PATIENTS UNDERGOING ABDOMINAL AORTIC PO 054 SUPRARENAL AORTIC INTERVENTION IN AUSTRALIA ANEURYSM REPAIR AND NEW ZEALAND. REINTERVENTION, SCOLLOPS Amy Harwood, Hashem Barakat, Edward Broadbent, AND FENESTRATIONS INCREASES PATIENT RISKS, George Smith, Daniel Carradice, Ian Chetter BUT OPEN ANEURYSM SURGERY STILL INCREASES MORTALITY. PO 063 FEASIBILITY OF IMAGED-BASED FUSION SOFTWARE Irwin Mohan, Kerry Hitos, Barry Beiles, Bernie Bourke IN ENDOVASCULAR AORTIC REPAIR Blandine Maurel, Bijan Modarai, Tara Mastracci, Said PO 055 COMMON ILIAC ARTERY ANEURYSM IN MEN WITH Abisi, Neville Dastur, Paul Hayes, Graeme Penney, Tom SCREENING DETECTED ABDOMINAL AORTIC Carrell ANEURYSMS Achilleas Karkamanis, Kevin Mani, Sverker Svensjö, PO 064 PARALLEL STENTING TECHNIQUE IN A SANDWICH Khatereh Djavani Gidlund, Martin Björck, Anders CONFIGURATION FOR HYPOGASTRIC Wanhainen PRESERVATION DURING EVAR: AN IN-VITRO STUDY Xavier Yugueros, Gaspar Mestres, Savino PO 056 EVALUATION OF FIVE DIFFERENT ANEURYSM Pasquadebisceglie, Xavier Alomar, Ana Apodaka, Vincent SCORING SYSTEMS TO PREDICT MORTALITY IN Riambau RUPTURED ABDOMINAL AORTIC ANEURYSM PATIENTS PO 065 PATIENT-SPECIFIC TRAINING PRIOR TO Cornelis G. Vos, Çagdas Ünlü, D Werson, HPA van ENDOVASCULAR ANEURISM REPAIR: THE USE OF 3D Dongen, M.A. Schreve, JPPM de Vries PRINTED MODELS. Inez O. Torres, Simon Benabou, Nelson De Luccia

Copenhagen, Denmark • 28-30 September 9

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PO 066 PROLONGED OR RENEWED ICU STAY AFTER AAA PO 076 THE USE OF ULTRASOUND-GUIDED FISTULOPLASTY REPAIR - “A CRASH INVESTIGATION” AND STENTING FOR SALVAGE OF STENOSED Hamid Gavali, Kevin Mani, Gustaf Tegler, Rafael Kawati, ARTERIOVENOUS HAEMODIALYSIS FISTULAE. Lucian Covaciu, Anders Wanhainen Kate Stenson, Mark Young, Eric Chemla, Gary Maytham

PO 067 MID-TERM RESULTS WITH THE FENESTRATED PO 077 BASILIC VEIN TRANSPOSITION: SINGLE CENTRE ANACONDA ENDOGRAFT FOR SHORT-NECK INFRA- EXPERIENCE RENAL AND JUXTA-RENAL ABDOMINAL AORTIC Duarte Rego, Clara Nogueira, António N. Matos, Paulo ANEURYSM REPAIR Almeida, Rui Almeida Martijn Dijkstra, Louise Blankensteijn, Ignace Tielliu, Michel Reijnen, Clark Zeebregts PO 078 PROXIMAL RADIAL-CEPHALIC ARTERIOVENOUS FISTULA: IS IT AN OPTION AFTER WRIST PO 068 EXPRESSION OF MICRORNA MIR-191, MIR-455-3P AND ARTERIOVENOUS FISTULA FAILURE? MIR-1281 IN PATIENTS WITH ABDOMINAL AORTIC Raffaella Mauro, Laura Cacioppa, Jacopo Giordano, ANEURYSM AND THE ROLE AFTER ENDOVASCULAR Rodolfo Pini, Mohammad Abualhin, Gianluca Faggioli, REPAIR. Mauro Gargiulo, Andrea Stella Edwaldo E. Joviliano, Emanuel R. Tenorio, Daniela P. D. C. Tirapelli PO 079 CAN 3-D ULTRASOUND BE USED FOR FINITE ELEMENT ANALYSIS AND COMPUTATIONAL FLUID PO 069 EPIDEMIOLOGY OF ABDOMINAL AORTIC ANEURYSM DYNAMICS OF ABDOMINAL AORTIC ANEURYSMS? IN PORTUGAL – WHAT HAS CHANGED OVER 15 Chris Lowe, Ben Owen, Steven Rogers, Wisam Al-Obaidi, YEARS? Partha Mandal, Alistair Revell, Charles McCollum Marina Dias-Neto, José F. Ramos, Alberto Freitas PO 080 FEASIBILITY OF AN INTRAOPERATIVE CONTRAST- PO 070 ADJUSTED HOSPITAL OUTCOMES REPORTED IN THE ENHANCED CONE BEAM CT IMAGE FUSION FOR DUTCH SURGICAL ANEURYSM AUDIT AFTER THE NAVIGATION GUIDANCE IN FENESTRATED AND FIRST YEARS OF REGISTRATION OF ACUTE BRANCHED EVAR ANEURYSM SURGERY. Quirina D. De Ruiter, Frans L. Moll, Joost A. van Niki Lijftogt, Anco Vahl, J.F. Hamming Herwaarden, Constantijn E. Hazenberg

PO 071 ROBOTIC INFERIOR VENA CAVAL SURGERY PO 081 ACCURATE ENDOLEAK DIAGNOSIS USING TEMPORAL William Stone, Samuel Money, Victor Davila, Richard INFORMATION OBTAINED ON CONTRAST ENHANCED Fowl, Erik Castle ULTRASOUND IMAGING Iain Roy, Alexandra Colby, Steven Wallace, Gabriela PO 072 THE PREVALENCE OF CHRONIC VENOUS DISEASE Czanner, Srinivasa Vallabhaneni WORLDWIDE. AN EPIDIOMOLOGICAL ANALYSIS. THE FINAL RESULTS OF THE VEIN CONSULT PROGRAM. PO 082 THE ROLE OF SHORT-TERM HIGH-DOSE Marc E. Vuylsteke, Roos Colman, Sarah Thomis, PREPROCEDURAL STATIN TREATMENT IN Geneviève Guillaume, Ivan Staelens PREVENTION OF CONTRAST-INDUCED NEPHROPATHY PO 073 VARICOSE VEIN SURGERY, DOES IT MATTER WHO Ruben Strijbos, Jan Willem Hinnen, Olivier Koning DOES IT? Ricardo Castro-Ferreira, Alberto Freitas, José Pinto, PO 083 ANALYSIS OF PREOPERATIVE CT AND CAROTID Dalila Rolim, José Vidoedo, Emanuel Silva, André PLAQUE GENE EXPRESSION DEMONSTRATE Marinho, Rodolfo Abreu, Andreia Coelho, Paulo ASSOCIATIONS BETWEEN CALCIFICATION AND Gonçalves-Dias, Sérgio M. Sampaio, Adelino Leite- PLAQUE-STABILIZING PROCESSES Moreira, Armando Mansilha, José F. Teixeira Eva Karlöf, Nuno Dias, Håkan Almqvist, Claes Bergmark, Lars Maegdefessel, Ljubica Perisic, Ulf Hedin PO 074 100 ULCERATED LIMBS TREATED WITH ULTRASOUND GUIDED FOAM SCLEROTHERAPY; IS LONG TERM PO 084 THE RELATIVE THROMBUS AREA IS RELATED TO THE RECURRENCE RELATED TO RECANALISATION? RELATIVE THROMBUS VOLUME AND PREDICTS PEAK Julia Howard, Clare Wakely, Fiona Slim, Colin Davies, WALL STRESS IN ABDOMINAL AORTIC ANEURYSMS. Sachin Kulkarni, Mark Whyman, Richard Bulbulia, Keith Antti Siika, Moritz Lindquist Liljeqvist, Rebecka Hultgren, Poskitt Christian Gasser, Joy Roy

PO 075 MACROSCOPIC EN HISTOLOGICAL SCORING OF PO 085 CAROTID PLAQUE INFLAMMATION ASSESED WITH MECHANOCHEMICAL ENDOVENOUS ABLATION USING 18F-FDG PET/CT AND LP-PLA2 IS HIGHER IN THE CLARIVEIN DEVICE IN AN ANIMAL MODEL. SYMPTOMATIC PATIENTS. Doeke Boersma, Steven van Haelst, Ramon van Eekeren, Alicia Bueno, Francisco Acín, García Pilar, Cristina Michel Reijnen, Jean Paul de Vries, Gert Jan de Borst Cañibano, Antonio Ferruelo, Jose L. Fernandez-Casado

Copenhagen, Denmark • 28-30 September 10

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PO 086 DOES DUPLEX VELOCITY RATIOS MEASUREMENT PO 095 VALUE BASED HEALTH CARE-LESSONS IN COST RENDER GRADING OF CAROTID ARTERY STENOSIS EFFECTIVENESS FROM VASCULAR PLICS DATA MORE RELIABLE? Neeraj Beeknoo, Brendan Sloane, Hiren Mistry, Hani Slim, Arkadiusz Migdalski, Artur Krzywicki, Paweł Brazis, Domenico Valenti, Hisham Rashid, Raghvinder Pal Singh Radosław Piotrowicz, Patryk Włoszczyk, Krzysztof Gambhir Lackowski, Arkadiusz Jawień PO 096 MANAGEMENT OF SMALL ABDOMINAL AORTIC PO 087 DUPLEX AND CONTRAST-ENHANCED ULTRASOUND ANEURYSMS – WHAT PATIENTS WANT, WHAT VERSUS COMPUTED TOMOGRAPHY ANGIOGRAPHY SURGEONS NEED FOR SURVEILLANCE AFTER ENDOVASCULAR AORTIC Regent Lee, Amy Jones, Lucy Folford-Smith, Felicity ANEURYSM REPAIR Woodgate, Kirthi Bellamkonda, Katherine Hurst, Ismail Kim K. Bredahl, Mikkel Taudorf, Lars Lönn, Katja Vogt, Cassimjee, Ashok Handa Henrik Sillesen, Jonas P. Eiberg PO 097 ARTERIAL AND VENOUS THROMBOSIS IN HIGH PO 088 ASSESSMENT OF ROLE OF ANKLE-BRACHIAL INDEX ALTITUDE : AN ENIGMA (ABI) AND TRANSCUTANEOUS TISSUE OXYGEN Rishi Dhillan TENSION (TCPO2) MEASUREMENT FOR THE RISK OF NON-HEALING AND AMPUTATION IN DIABETIC PO 098 RECURRENCE RATE OF TRANSPLANT RENAL PATIENTS WITH LEG ULCER ARTERY STENOSIS FOLLOWING ANGIOPLASTY WITH Chithra Rajagopalan, Vijay Viswanathan, Bamila Selvaraj, OR WITHOUT STENTING Seena Rajsekar, Linu Daniel Abdulwhab Elmghrbee, Amar Eltweri, Stalin Dharmayan, Atul Bagul, Tahir Doughman PO 089 LYSOPHOSPHATIDYLCHOLINE ACYLTRANSFERASE 3 OVEREXPRESSION PROMOTES ATHEROSCLEROSIS PO 099 INADEQUATE HEALTH LITERACY IN PATIENTS WITH Hiroki Tanaka, Nobuhiro Zaima, Tetsumei Urano, ARTERIAL VASCULAR DISEASE Mitsutoshi Setou, Naoki Unno Ruben Strijbos, Jan Willem Hinnen, Ronald van den Haak, Bart Verhoeven, Olivier Koning PO 090 INTRA-PLAQUE CALCIUM AND ITS RELATION WITH CAROTID ATHEROSCLEROSIS PROGRESSION PO 100 LONG-TERM OUTCOMES OF TEVAR FOCUSED ON Lucas Ribé, Manuel Miralles, Manel Arrébola Emma BIRD-BEAK AND OVERSIZING IN BLUNT TRAUMATIC Plana, Francisco España THORACIC AORTIC INJURY Marvin E. Garcia Reyes, José M. Domínguez González, PO 091 EXTRACELLULAR MATRIX REMODELING IN Gabriela Gonçalves Martins, Valentín Fernández ABDOMINAL AORTIC ANEURYSM: INVESTIGATION OF Valenzuela, Jordi Maeso Lebrun, Sergi Bellmunt Montoya NEO-EPITOPE BIOMARKERS Cristina Pantoja Peralta, Signe Holm Nielsen, Anna PO 101 OUTCOME FOLLOWING TIBIAL BYPASS AND TIBIAL Hernandez Aguilera, Vicente Martín Paredero, Morten ANGIOPLASTY COMPARED USING PROPENSITY Asser Karsdal, Jorge Joven Maried, Federica Genovese SCORE MATCHING Justinas Silickas, Sanjay Patel, Lukla Biasi, Ioannis PO 092 THE ROLE OF IMMUNOHISTOCHEMICAL EXPRESSION Paraskevopoulos, Talia Lea, Athanasios Diamantopoulos, OF THE ST2 RECEPTOR (ST2L/IL-1R) IN Konstantinos Katsanos, Hany Zayed ATHEROSCLEROTIC PLAQUES OF SYMPTOMATIC AND ASYMPTOMATIC PATIENTS PO 102 PERIOPERATIVE BLOOD GLUCOSE LEVELS Cristina Galeandro, Raffaele Pulli, Domenico Angiletta, INFLUENCE OUTCOME AFTER INFRAINGUINAL Marco Ciccone, Andrea Marzullo, Ripalta Paglione, Noemi BYPASS AND ENDOVASCULAR THERAPY Ventrella, Michele Tedesco, Isabella Patruno Justinas Silickas, Sanjay Patel, Lukla Biasi, Tommaso Donati, Talia Lea, Konstantinos Katsanos, Natasha Patel, PO 093 DEVELOPMENT OF TISSUE-ENGINEERED STENT- Stephen Thomas, Hany Zayed GRAFTS COMPOSED OF BIORESORBABLE POLY-L- LACTIC ACID SCAFFOLD STENTS AND PO 103 PROSPECTIVE EVALUATION OF A STANDARDIZED DECELLULARIZED BLOOD VESSELS PROTOCOL USING NEUROMONITORING, Kentaro Matsubara, Hideaki Obara, Tatsuya CEREBROSPINAL FLUID DRAINAGE AND EARLY LIMB Shimogawara, Hirokazu Yamada Kazuki Tajima, Hiroshi REPERFUSION TO PREVENT SPINAL CORD INJURY Yagi, Yuko Kitagawa DURING ENDOVASCULAR THORACOABDOMNAL REPAIR PO 094 THE ROLE OF EVAR SIMULATION IN BOOSTING Mauricio Ribeiro, Gustavo Oderich, Peter Banga, Jan LEARNING CURVE OF TRAINEE Hofer, Meaghan Cazares, Stephen Cha, Peter Gloviczki, Vincenzo Vento, Laura Cercenelli, Chiara Mascoli, Enrico Alejandro Rabinstein Gallitto, Gianluca Faggioli, Antonio Freyrie, Emanuela Marcelli, Mauro Gargiulo, Andrea Stella

Copenhagen, Denmark • 28-30 September 11

Content

PO 104 CONTRALATERAL ILIAC VEIN OCCLUSION AFTER ILIAC VEIN STENTING Keunmyoung Park, Yong Sun Jeon, Soon Gu Cho, Kee Chun Hong

PO 105 A PROSPECTIVE COHORT STUDY OF THE INCIDENCE OF VASCULAR SURGICAL SITE INFECTION USING DIALKYLCARBAMOYLCHLORIDE COATED POSTOPERATIVE DRESSINGS Nelson Bua, George Smith, Daniel Pan, Tamsin Nash, Ian Chetter

PO 106 THE ROLE OF GLYCERYL TRINITRATE PATCHES IN ARTERIOVENOUS FISTULA MATURATION: A RANDOMISED, DOUBLE-BLINDED, PLACEBO CONTROLLED TRIAL. Martin Joinson, Damian McGrogan Yazin Marie Cecilio Andujar Mary Dutton Hari Krishnan, James Hodson, David van Dellen, Nicholas Inston

PO 107 IN VITRO QUANTIFICATION OF GUTTER FORMATION AND COMPRESSION OF CHIMNEY GRAFTS IN RELATION TO RENAL FLOW IN CHIMNEY EVAR AND EVAS CONFIGURATIONS Jorrit Boersen, Erik Groot Jebbink, Esme Donselaar, Simon Overeem, Eliene Starreveld, Cornelis Slump, Jean- Paul De Vries, Michel Reijnen

Copenhagen, Denmark • 28-30 September 12

Scientific Session

EVST SESSION 1 – CASE REPORTS

CR 001 FAILED FULLY MINIMALLY INVASIVE STAGED TREATMENT OF A GIANT AORTIC SAC ANEURYSM IN EXTREMELY HOSTILE ABDOMEN AFTER OPEN REPAIR OF A RUPTURE ABDOMINAL AORTIC ANEURYSM

Institution: Vascular and Endovascular Surgery Department, Ramón y Cajal University Hospital, Madrid (Spain)

Authors Presenting: Reyes Valdivia A., Duque Santos A., Osorio Ruiz A., Redondo López S., Ocaña Guaita J., Gandarias Zúñiga C.

Introduction: Aortic sac enlargement after open repair of abdominal aortic aneurysm (AAA) is a rare complication. We present a case with a complete minimally-invasive strategy.

Methods: An 80-year-old man, with previous history of hypertension and ruptured AAA in 2005 treated with aorto-biiliac bypass open repair. The post-operative was complicated with an abdominal compartment syndrome and bowel ischemia that required sigmoidectomy with colostomy and the "Bogota bag" technique. He was finally discharged and lost in follow-up. Eleven years later, he was admitted in the emergency department for abdominal pain. An urgent angio-CT scan showed a 100 mm bilobed aneurysm sac, a patent bifurcated graft that had heavy calcified stenosis on the proximal anastomosis, no signs of rupture or pseudoaneurysm. Control angiography of the abdominal aorta didn’t show any leak.

Results: We performed a minimally invasive treatment due to extreme hostile abdomen and aortic sac enlargement probably secondary to porosity of the aortic graft. Retrograde access through both common femoral arteries was required, contralateral "through and through" technique was required due to kinked and calcified iliac access. Two balloon-expandable cobalt-chrome covered stents were deployed using the “kissing-stent technique” in the infrarrenal aorta going into the proximal graft, which was stenotic and heavily calcified. Subsequently, two self-expandable PTFE covered stents were deployed through each branch of the previous graft distally. The postoperative course was uneventful. Ten days later, eco-guided puncture into the smaller aortic sac was performed, 500 ml of straw-colored fluid was drained. The histo-pathology exam revealed histiocytes. One month later second puncture of the largest sac was done, and injection of iodine glue was done. AngioCT scan at 6 months showed aneurysm sac shrinkage. At 9th month patient appeared in the emergency department with fever, abdominal pain and colonic bleeding. CT scan showed gas in the sac, so explantation and in-situ silver graft reconstruction was performed. Postoperative course was uneventfull.

Conclusions: The standard treatment of aortic sac enlargement secondary to porosity of the graft is open surgery, with explantation/change of the previous graft. Extreme hostile abdominal access was a big limitation in this case, and treatment with a fully minimally invasive approach by endovascular treatment and CT guided puncture and drainage was decided. However, infection of the graft appeared in the follow-up and was probably caused by perforation of the colon while puncture technique. Whenever possible, open repair is still the gold-standard of treatment in this unusual disease.

Copenhagen, Denmark • 28-30 September 13

Scientific Session

CR 002 REPAIR OF MULTIPLE ANEURYSMS IN TAKAYASU ARTERITIS AND FAMILY PLANNING

Institution: Department for Vascular and Endovascular Surgery, PMU Salzburg, Salzburg, Austria

Authors Presenting: Florian Enzmann, Manuela Aspalter, Patrick Nierlich, Julio Ellacuriaga San Martin, Thomas Hölzenbein

Introduction: Takayasu arteritis (TA) is a chronic large vessel vasculitis affecting the aorta and its major branches that can cause occlusive or aneurysmal vessel degeneration. Clinical presentation varies greatly, depending on the vascular involvements and the extent of disease, which often delays definitive diagnosis.

Methods: Case report.

Results: We report the case of a 26-year-old Asian female presenting with a 6-months history of haemoptysis, recurrent fever, right sided Horner's syndrome. No distal pulses at the right arm. At the time of admission she was pregnant for 3 months. An MRI angiography showed an aneurysm of the right subclavian artery with distal occlusion and multiple aneurysms of the descending aorta. Screening for an infectious disease was inconclusive. The patient requested elective repair after delivery, because she was afraid of a miscarriage.

Within 2 weeks after diagnosis the subclavian aneurysm became tender and contained rupture was diagnosed, so the aneurysm was resected and a bypass from the brachiocephalic trunk to the axillary artery with greater saphenous vein was performed. Histology proved Takayasu arteritis, and steroid therapy was initiated. Four months later she had stillbirth due to unknown reasons.

Then TEVAR was performed for the descending aortic aneurysms. PET-CT showed no signs of active under prednisolone and azathioprine. After one year the patient wished to get pregnant again, so azathioprine was replaced with Tocilizumab, a monoclonal antibody against Interleukin-6 receptor. After another two years she gave birth to a healthy boy via caesarian section. At 5-year follow up the axillary vein bypass is patent and the aortic aneurysm is excluded after TEVAR. No signs of further supra aortic or renal artery pathology. A further pregnancy is currently planned.

Conclusion: We present a rare case of Takayasu arteritis with simultaneous subclavian artery and thoracic aortic aneurysm formation. It highlights the complexity of disease management in young female patients with a persistent wish for pregnancy.

Copenhagen, Denmark • 28-30 September 14

Scientific Session

CR 003 ANEURYSM OF A RIGHT AORTIC ARCH AND ABERRANT LEFT SUBCLAVIAN ARTERY: HYBRID TREATMENT

Institution: Hospital Vall d´Hebron, Barcelona, Spain

Authors Presenting: Marvin E. Garcia Reyes, Valentín Fernández Valenzuela, Daniel Gil Sala, Jose Manuel Domínguez González, Sergi Bellmunt Montoya

Introduction: Congenit variations of aortic arch are uncommon, but it is less frequent when we are talking about right-sided aortic arch accompanied by an aberrant origin of the left subclavian artery, which is only found in 0.1% of the world population. The finding of aneurismatic disease in this condition turns out to be a high complexity surgical challenge requiring a lot of therapeutically means.

Methods: We present a 67 year old male with an aneurysm in a right aortic arch in its distal section and an aberrant left subclavian artery. The origin of the supraaortic branches was, in order, left carotid artery, right carotid artery, right subclavian artery and aberrant left subclavian artery.

Because of the anatomic complexity and technical difficulties to make a complete aortic arch reconstruction, we proceeded to a three-stage surgery strategy:

1st surgery: aorto-bicarotid bypass with bifurcated Dacron graft with ligation of the both carotid in its origins.

2nd surgery: right carotid-subclavian bypass (because the dominant vertebral artery was the right one) and proximal occlusion of the right vertebral artery with an Amplatzer device.

3rd surgery: Exclusion of the aneurysm with thoracic graft stent by femoral acces and occlusion of the left subclavian artery with coils by left humeral acces

Results: The patient had good postsurgery course, presenting only pericardic efussion that had a good evolution with medical treatment. At six and twelve months CTA follow-up showed absence of endoleaks and another complications.

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Copenhagen, Denmark • 28-30 September 15

Scientific Session

Conclusion: The hybrid treatment of aortic arch aneurysms offers less morbi-mortality due to no need of aortic clamping and extracorporeal circulation. In addition, there is less risk of paraplegia. The multiple- stage surgery strategy extends the treatment options in high risk patients with aneurysms and anatomy as complex as the aortic arch.

References: A.R. Hastreiter, I.A. D'Cruz, T. Cantez. Right-sided aorta. Part1: Occurring of right aortic arch in various types of congenital heart disease. Br Heart J, 28 (1966), pp. 722–725

Copenhagen, Denmark • 28-30 September 16

Scientific Session

CR 004 SEMICONVERSION AS A DEFINITIVE TREATMENT FOR PERSISTENT TYPE 2 ENDOLEAK CAUSING ANEURYSM SAC ENLARGEMENT

Institution: Department of Thoracic and Vascular surgery, University Hospital Ghent Belgium, Ghent, Belgium

Authors Presenting: Alexander Croo, Eva-Line Decoster, Isabelle Van Herzeele, Frank Vermassen

Introduction: Type II endoleak is encountered in 10% up to 30% after endovascular repair of abdominal aortic aneurysms (EVAR) and accounts for more than 60% of all reinterventions. The aim of this study was to evaluate semiconversion as a final treatment in post-EVAR patients with aneurysm sac enlargement and persistent type II endoleaks.

Methods: Our prospectively collected database was reviewed to identify those cases in which semiconversion was performed. CTA before and after the initial EVAR and semiconversion procedure were analyzed for endoleaks and sac enlargement. The technique entailed banding of the proximal neck with a Teflon graft, removal of thrombus within the aneurysm sac, suturing of bleeding side branches and aneurysmraphy.

Results: Nine patients with a median age of 76 years (IQR 72 – 81) were treated by semiconversion because of persistent type II endoleaks causing aneurysm sac enlargement of the abdominal aorta. The median aneurysm size at the initial EVAR was 58mm (IQR 51 – 76mm) with a type II endoleak at the final angiography in 4 cases. At 6 months CTA noted a type II endoleak in 7 cases. Four patients were treated by coiling of side branches, but aneurysm size still increased and at follow-up CTA showed persistent endoleaks in two patients. Semiconversion was performed at a median of 47 months (IQR 29 – 82) post-EVAR with a median aneurysm size at the time of semiconversion of 72mm (IQR 64 – 85mm, median 32% aneurysm size increase). In all patients bleeding side branches were oversewn. The procedure was successful in all patients with no perioperative deaths. Postoperative CTA showed a median 36% decrease in aneurysm size. At follow-up no type II endoleak or increase of the aneurysm sac was detected. All but one patient are still alive, one died 53 days after semiconversion non-aneurysm related.

Conclusion: Semiconversion is a safe and effective treatment option for patients with persistent type II endoleak causing aneurysm sac enlargement. It is less invasive compared to entire stent-graft removal, avoids aortic cross clamping and is efficient in treating persistent type II endoleak.

References: 1. Hinchliffe RJ, Singh-Ranger R, Whitaker SC, Hopkinson BR. Type II endoleak: transperitoneal sacotomy and ligation of side branch endoleaks responsible for aneurysm sac expansion. J Endovasc Ther. 2002;9:539-42.

2. Mangialardi N, Ronchey S, Orrico M, Serrao E, Alberti V, Fazzini S, Pecoraro F, Setacci C. Surgical conversion with graft salvage as a definitive treatment for persistent type II endoleak causing sac enlargement. J Vasc Surg. 2015;62:1437-41.

Copenhagen, Denmark • 28-30 September 17

Scientific Session

CR 005 ENDOVENECTOMY OF THE FEMORAL VEINS FOR POST-THROMBOTIC SYNDROME WITH VENOUS CLAUDICATION

Institution: Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland

Authors Presenting: Silvan Jungi, Thomas Wyss, Pascal Kissling, Vladimir Makaloski, Daniel Becker, Juerg Schmidli

Introduction: Post-thrombotic syndrome after iliofemoral deep vein thrombosis is common. It can lead to disability due to venous claudication. Symptoms can be relieved if venous drainage is restored. Stenting for iliac vein stenosis is accepted. However, stenting below the inguinal ligament shows higher rates of in-stent restenosis. We report a case of surgical desobliteration of the femoral veins for post- thrombotic syndrome with venous claudication.

Methods: One year after an iliofemoral deep vein thrombosis the patient suffered from venous claudication. Duplex sonography and magnetic resonance imaging showed an obstructive 6.5 cm long and dense intraluminal scar tissue in the common femoral vein extending into the deep and the femoral vein. The iliac vein was patent as were popliteal and femoral veins. An endovenectomy of the common femoral, the deep and the distal femoral vein, was performed. The removed specimen consisted of a maze of lumina and multiple web-like adhesions to the venous wall.

Results: Unobstructed venous drainage was successfully restored and venous claudication completely eliminated. Duplex sonography at three months follow-up confirmed patent femoral veins and no signs of restenosis. The valves of the femoral vein were competent.

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Conclusion: An endovenectomy of the femoral veins can be performed safely to relieve veno-occlusive symptoms by reestablishing venous drainage from the lower extremity. The intraluminal dense scar tissue can be removed easily. Patients with chronic femoral venous obstruction may benefit more often from endovenectomy than suspected. A multicenter prospective study with long-term follow up would be desirable.

Copenhagen, Denmark • 28-30 September 18

Scientific Session

CR 006 MANAGEMENT OF ABDOMINAL AORTIC PROTHETO-DUODENAL FISTULA BY IN-SITU REPLACEMENT WITH A CUSTOM MADE BIFURCATED AORTOILIACAL BOVINE PERCARDIUM XENOGRAFT

Institution: Vascular Surgery, Kantonsspital Luzern, Luzern, Switzerland

Authors Presenting: Juliette Brusa, Stefan Ockert, Robert Seelos

Introduction: Abdominal aortic graft infection with enteric fistula is a condition with a high mortality due to sepsis, comorbidities, age and surgical technical challenges. Besides extraanatomic repair, in-situ replacement of the infected graft with various strategies (deep femoral vein, homografts, artificial grafts with antibiotic coating) have been reported in literature with inconsistent results to control infection. For this condition the use of xenograft is not restricted to availability, relatively cheap compared to homografts and the results reported so far are encouraging. This case report focuses on the technical aspects of aortic graft replacement to treat graft-enteric fistulae with a self-designed bovine pericardium bifurcated graft.

Methods: Case report of an aortic graft infection treated with a self-designed bovine pericardium aortobiiliacal graft with mid term follow up.

Results: A 70 years old polymorbid patient presented with aortic dacron graft infection 3 years post implantation for AAA. Graft infection and enteric fistula was confirmed by means of positive cultures (multiple fungal and bacterial pathogens), endoscopy, CT and PET-scan. The infected aortoiliacal dacron prosthesis was removed and in situ replaced by a bovine xenograft. The graft was made out of one pericardium sheet (Lemaitre®) with geometrical calculation according to CT and intraoperative sizing and fashioned in a backtable procedure. Additional duodenal resection, omentum plasty and extensive debridement was performed. Postoperatively an acute on chronic thigh stump ischemia had to be treated by profundal thrombectomy. No local or systemic septic complications occurred. The patient received long term antibiotic for 2 months postoperatively. Follow up at 3 years showed no signs of clinical infection and in CT the xenograft was unsuspicious regarding infection or degeneration.

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Copenhagen, Denmark • 28-30 September 19

Scientific Session

Conclusion: Aortic graft replacement in the presence of an enteric fistula is a challenging situation with a selection of different graft materials that can be applied. The use of bovine pericardium allows a technical feasibel self-production of a bespoke biological graft fitting on the patient’s anatomy and is furthermore available at relatively low costs. Problems connected to deep femoral vein harvesting, homograft supply restriction and aortic stump bleeding in extraanantomic repair can be avoided and therefore it may serve as an alternative strategy.

Copenhagen, Denmark • 28-30 September 20

Scientific Session

CR 007 HIGHER POSTOPERATIVE MORTALITY AFTER ENDOVASCULAR ANEURYSM REPAIR IN PATIENTS WITH FAMILIAL ABDOMINAL AORTIC ANEURYSM

Institution: 1. Erasmus University Medical Center, Rotterdam, Netherlands 2. Hospital de Santa Marta, Lisbon, Portugal, 3University Hospital Heidelberg, Heidelberg, Germany

Authors Presenting: Koen M. Van De Luijtgaarden, Frederico Bastos Gonçalves, Sanne Hoeks, Dittmar Böckler, Robert Jan Stolker, Hence Verhagen

Introduction: To determine the influence of a positive family history on the clinical success of endovascular aneurysm repair (EVAR).

Methods: From March 2009 to April 2011, 1262 AAA patients with abdominal aortic aneurysms (AAA) treated with EVAR were enrolled in a prospective industry sponsored global registry. Patients were classified into familial and sporadic AAA patients according to baseline clinical report forms. Clinical characteristics, aneurysm morphology and follow-up were obtained prospectively. The primary endpoint was clinical success after EVAR, a composite of technical success and freedom from the following complications: AAA increase > 5 mm, endoleak type I and III, aneurysm rupture, conversion, secondary procedures, migration and occlusion. Secondary endpoints were the individual components of clinical success, aneurysm-related mortality and all-cause mortality. Duration of follow-up was 4 years for all patients.

Results: Of the 1262 AAA patients (89.5% male and mean age 73.1 years), 6.8% (86) patients reported a positive family history and were classified as familial AAA. Patients with familial AAA were more often female (18.6% versus 9.9%; P = .012), and no difference in aneurysm morphology was observed. There was no significant difference in clinical success between patients with familial and sporadic AAA (70.1% versus 79.3%; P = .116. Patients with familial AAA suffered from more stent graft occlusion (8.2% versus 3.8%; P = .048). Familial AAA had a higher aneurysm-related mortality (5.8% versus 1.4% after four years of follow-up; P = <.001, Figure 1), mostly explained by a higher postoperative mortality (4.7% versus 1.0%, P = .004).

Conclusion: The current study shows no significant difference in clinical success after endovascular repair in familial or sporadic AAA patients. However, despite no identifiable anatomical differences, the higher postoperative mortality as showed by the aneurysm-related mortality suggests that these patients react differently to endovascular repair. Consequently family history should be accounted for in the decision making process.

Copenhagen, Denmark • 28-30 September 21

Scientific Session

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Copenhagen, Denmark • 28-30 September 22

Scientific Session

CR 008 VASCULAR AND ENDOVASCULAR INTERVENTIONS IN RETRO-PERITONEAL SARCOMA

Institution: Vascular & Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Australia

Authors Presenting: Mohamed Abdelhamid, Joseph Hockley, Shirley Jansen, Stefan Ponosh

Introduction: Retro-peritoneal sarcoma is a rare tumour that accounts for 1-2% of solid tumours. Its overall incidence is 0.3-0.4% per 100,000 and the peak incidence is the fifth decade. These tumours are usually large on presentation and adjacent retro-peritoneal structures are usually involved including the major blood vessels. We present the vascular and endovascular management of a case of extensive retro-peritoneal leiomyosarcoma that incorporated the abdominal aorta (AA).

Methods: 53 years Caucasian lady was found to have large retro-peritoneal sarcoma. Pre-operative CT showed 11(AP)x12(CC)x11(transverse) cm irregular mass that encased the infra-renal AA, lumbar arteries, inferior mesenteric artery, median sacral artery, the aortic bifurcation and common iliac arteries and the left renal artery. After extensive investigations and counselling, the patient underwent en-bloc resection of the sarcoma including the infra-renal AA and its bifurcation, left kidney and loop of small bowel. The vascular reconstruction involved aorto-bi-iliac graft and vein patch repair of the inferior vena cava. The patient required 26 units of blood, 5 units of platelets, 21 units of FFP, and 18 units of cryoprecipitate intra-operatively.

Results: The patient had very complicated recovery including vascular complications. She developed pseudoaneurysm of the right renal artery that required endovascular stenting. Then she developed pancreatic fistula and pancreatic ascites that was thought it might endanger the aortic graft. For this, the patient had relining of the aortic graft with endoluminal aortic graft using Gore bifurcated device with chimneys into the right renal and superior mesenteric arteries and embolization of the left internal iliac artery to secure all the anastomosis of the open aortic graft.

After stormy recovery, the patient was discharge home after 71 days in hospital. PET scan two and half months later, did not show any signs of aortic graft infection. CTA four months post-operatively showed patent SMA and right renal stents and patent endoluminal graft with no signs of graft infection.

Conclusion: This is a classic case of retro-peritoneal sarcoma that required extensive vascular and endovascular interventions. Vascular involvement represents an integral part of the sarcoma service especially in the retro-peritoneal area. It is essential to utilize all the possible vascular and endovascular facilities and expertize in the sarcoma cases when required.

Copenhagen, Denmark • 28-30 September 23

Scientific Session

CR 009 ENDOVASCULAR RECANALIZATION OF ENDOGRAFT LIMB OCCLUSION AFTER ENDOVASCULAR AORTIC REPAIR

Institution: Department of Angiology and Vascular Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain

Authors Presenting: Carlota Fernandez Prendes, Sara Busto Suarez, Ahmad Amer Zanabili Al-Sibbai, Jose Manuel Llaneza Coto, Lino Antonio Camblor Santervas, Manuel Alonso Perez

Introduction: Endovascular aortic aneurysm repair (EVAR) has been widely used to treat abdominal aortic aneurysms (AAA). The most common complication requiring reintervention is the presence of endoleaks. Another possible complication is endograft limb occlusion, with an incidence of 2.6- 7.4%1. There are a number of different treatment strategies to restore perfusion to the occluded limb, from bypass procedures, most commonly femorofemoral bypass grafting, to an endovascular approach, including some combination of mechanical thrombectomy, angioplasty with or without stenting and thrombolysis.

Methods: Between April 2003 and December 2015, 434 patients underwent elective EVAR procedures for AAA in our institution. A total of 8 patients (1.84%) presented with endograft limb occlusion. The limb occlusion rate per endograft was 0.35% (1/283) for Excluder, 2.63% (2/76) for Endurant, 3.84% (1/26) for Talent, 5.26% (2/38) for Anaconda, 1 out of 1 Incraft and 1 out of 1 E-Tegra. The first 5 cases were treated with femoro-femoral bypass grafting and the last 3 patients were treated by an endovascular approach. We report the aforementioned 3 cases managed by endovascular recanalization.

Results: Case 1: 79 year old male who underwent EVAR of a 6 cm infrarenal AAA with an Endurant® bifurcated stent graft. 1 month after graft placement, the patient presented with acute ischemia of the left limb. An angiography was performed demonstrating an occluded left endograft limb. Suboptimal mechanical guide-wire based thrombectomy was performed, followed by placement of an Advanta® and a Viahban® stent graft due to the presence of a luminal filling defect. Completion angiography demonstrated an optimal result. At 10 month follow-up the patient has presented no further complications.

Case 2: 64 year old male who underwent EVAR of a 5.5 cm infrarenal AAA with an Anaconda® endograft. 51 months after graft placement the patient was diagnosed of left endograft limb occlusion by means of a routine eco-Doppler examination. Upon clinical interrogation, the patient referred left intermittent claudication at 100 meters for the past 6 months. Revascularization was accomplished by kissing balloon angioplasty of the bifurcation with 2 Advanta® stent grafts followed by placement of a Viahban® stent graft in the left limb (Image1). Completion angiography demonstrated an optimal result. At 5 month follow-up the patient has presented no further complications.

Case 3: 67 year old male who underwent EVAR of a 5.9 cm infrarenal AAA with an Anaconda® endoprothesis. 6 months later the patient was admitted referring right invalidating buttock claudication associated with rest pain. Endovascular recanalization was accomplished with an Advanta® stent graft in the proximal section of the occluded limb, 2 Viahban® in the middle portion and a Luminex® stent in the distal portion. Completion angiography demonstrated an immediate optimal result. At 10 month follow-up the patient has presented no further complications.

Copenhagen, Denmark • 28-30 September 24

Scientific Session

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Conclusion: Endograft limb occlusion is one of the possible complications of EVAR treatment. There is no general consensus regarding the best treatment option; endovascular recanalization can be a successful strategy for both acute as well as chronic thrombosis in selected patients, being able to perform an extraanatomical bypass if revascularization is not accomplished.

References: 1. Mehta M, Sternbach Y, Taggert JB, Kreienberg PB, Roddy SP, Paty PS, et al. Long-term outcomes of secondary procedures after endovascular aneurysm repair. J Vasc Surg. 2010;52:1442-9.

Copenhagen, Denmark • 28-30 September 25

Scientific Session

SCIENTIFIC SESSION 1 - THORACIC AORTA

OP 001 NEW FACILITATED METHOD FOR F-EVAR AND B-EVAR

Institution: 1. Uppsala University Hospital, Department of Surgery, Uppsala, Sweden 2. Department of Vascular Surgery, Universitätskrankenhaus Zurich, Zurich, Switzerland

Authors presenting: Krister Liungman, Anders Wanhainen, Kevin Mani, Linus Bosaeus, Mario Lachat

Introduction: A common problem during visceral artery catheterisation in f/b-EVAR procedures is the difficulty to achieve stable guidewire position in challenging vascular anatomy. Another problem is to access the target artery through the graft fenestration. A third difficulty relates to insertion of the sheath into the target artery, to position the bridging stentgraft, without loss of an acquired guidewire position. These problems are addressed in the development of a new endovascular tool, the guide-wire fixator. The guidewire fixator is designed as a self-expandable Nitinol braid that secures the distal position of the guidewire. The 0.035” guidewire has a distal stopper that interacts with the fixator to increase the radial force and anchoring of the guidewire upon tension. The guidewire is designed with a removable core, which allows the guidewire to change from a stiff shape to extreme pliability.

Methods: The safety and functionality of the device was investigated in an animal model, and in a clinical trial in man. Animal testing eleven pigs Swedish land race with a mean weight of 80 kg were used. Delivery and retrieval of the device was tested in 44 tests in the coeliac artery, Superior mesenteric artery, and the left and right renal artery in 11 pigs. Thrombotic occlusion of the device was tested by deposition of the device in the target arteries for 4 hours, with hourly angiography. The force of fixation was tested by incremental application of a pulling force until the anchored guidewire fixator lost fixation in the target artery. Target artery patency and traumatic damage was investigated by angiography at the end of the procedure.

Clinical trial: The clinical trial was conducted in 10 patients with aortic aneurysm. Delivery and retrieval was tested with the fixator positioned in the contralateral Hypogastric artery. The device anchoring quality was tested by application of a pulling force above 3.0 N. Target artery patency and traumatic damage was tested by angiography at the end of the procedure and CT-angiography at 30 days.

Results: Animal testing Delivery and retrieval was uneventful in all but one case, where a welding broke. No cases of occlusion, arterial injury or dissection were recorded in 44 tested arteries. Two clots less than one mm were found on one device. The mean force necessary to dislocate the device was 7.6 N (2.35-17.9N).

The clinical trial verified the findings from the preclinical animal study. No angiographic sign of arterial trauma was found and no device-related thrombotic arterial occlusion occurred.

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Copenhagen, Denmark • 28-30 September 26

Scientific Session

Conclusion: The device was considered to be safe and functional in the tested preclinical animal model. The preclinical test results were verified in the clinical trial. Clinical implications Distal fixation ensures guidewire position. It also allows the surgeon to reposition the proximal end, while retaining the distal position. The guidewire may then be re-routed to a new access by use of a through and through catheter, which enables completely new guidewire technique, one such being a facilitated method for f/b-EVAR. The guidewire fixator offers an opportunity to perform fenestrated and branched endovascular aneurysm repair with pre- cannulation of visceral arteries. This would reduce the risks and challenges associated with visceral cannulation during f/b-EVAR, and offer an opportunity for development of new off-the-shelf technologies for complex aortic repair. Examples of device applicability are presented, with demonstration of f-EVAR procedures performed in animal and bench models.

Copenhagen, Denmark • 28-30 September 27

Scientific Session

OP 002 T-BRANCH IN THORACOABDOMINAL ANEURYSM TREATMENT

Institution: Department of General, Vascular and Transplant Surgery, the Medical University of Warsaw, Warsaw, Poland

Authors presenting: Tomasz Jakimowicz, Jacek Szmidt, Piotr Hammer, Grzegorz Witek Sławomir Nazarewski

Introduction: The main disadvantage of endovascular treatment of thoracoabdominal aneurysm was the delay of endograft production. Off-the-shelf T-branch stent-graft was created to fill this gap. The aim of the study was to present our experience in thoracoabdominal aneurysm treatment using T-branch stent-graft.

Methods: Endovascular treatment of thoracoabdominal aneurysm with custom-made device (CMD) started in our Department in 2010. From 2013 T-branch stent-graft has also been used. We operated total 123 patients including 32 branched CMD (Cook and Jotec) and 91 T-branch devices (including 29 urgent cases of symptomatic aneurysm or diameter exceeding 90 mm). We use T-branch more frequent as our experience improved reaching 100% in last 44 cases. In case of the lack of one visceral vessel (celiac trunk in 12, RRA in 2 and LRA in 4 patients) the corresponding branch has been occluded in 17 cases (both: RRA and CT in one patient). We also occluded 3 additional, small renal arteries and 2 splenic arteries originating independently from the aneurysm in urgent cases.

Results: In all cases T-branch implantation with all planned visceral vessels revascularization was feasible. In one patient it required 3 attempts to left renal artery with unfavourable, very sharp angle. The total perioperative mortality was 11% (10 patients; 5-17,2 % in urgent and 5-8,1% in elective cases). There was no postoperative renal insuficiency requiring dialysis nor visceral ischemia in cases with splenic artery occlusion.

Conclusion: T-branch stentgraft could be used to treat most thoracoabdominal aneurysms and should be considered as the first choice device. Branched CMD should be reserved for cases with very unfavourable anatomy when treatment delay is justified.

Copenhagen, Denmark • 28-30 September 28

Scientific Session

OP 003 ARTERIOTOMY CLOSURE DEVICES IN EVAR, TEVAR AND TAVR: A SYSTEMATIC REVIEW AND META-ANALYSIS OF INDICATIONS, COMPLICATIONS AND DURATION OF TREATMENT

Institution: Surgery, Wilhelmina Hospital Assen, Assen, (Division of Vascular Surgery), University Medical Center Groningen, Groningen, Netherlands

Authors presenting: Bastiaan P. Vierhout, Robert Pol, Mostafa El Moumni, Clark J. Zeebregts

Introduction: Percutaneous approaches, to introduce endovascular devices in order to exclude aortic or cardiac pathologies, are gaining widespread adoption. The objective of this review was to assess the assets and liabilities in the use of arteriotomy closure devices (ACD’s), compared to surgical cutdown (SCD) to the common femoral artery (CFA).

Methods: A systematic literature search with predefined search terms was performed using the databases PubMed, EMBASE and the Cochrane Library from January 2000 to January 2016. All studies reporting on ACD, measuring at least 12 Fr., and SCD were assessed for eligibility. Included were randomized controlled trials and case-control studies comparing both techniques. Risk of bias was assessed regarding randomization, allocation and selective outcome reporting. Patient characteristics and exclusion criteria were compared. Complications, procedure times and hospital length of stay (HLOS) were evaluated in a pooled analysis.

Results: We included 16 trials describing 7 555 vascular access sites for the meta-analyses; 4 trials were randomized and reported with low risk of bias, but blinding was absent in all included trials. Most trials mentioned exclusion of calcified and scarred CFA’s or iliac kinking/stenosis. General anesthesia was used in 50% (290/576) of the procedures and trials with routine ultrasound- or fluoroscopy-guided access (7/16) did not show lower conversion-rates. The overall conversion rate was 4.9% (134/2740) with the percutaneous access technique.

Complications treated without re-intervention were more often seen in the SCD group (2.7% vs. 5.8%, OR=0.44, CI 0.27- 0.72)(Figure 1). The number of secondary interventions was comparable between groups (3.9% vs. 3.5%, OR=0.99, CI 0.74-1.32). ACD was related to significantly less postoperative seromas (0.1% vs. 1.7%, OR 0.16, 95% CI 0.06-0.39), femoral neuropathy (0% vs. 0.1%, OR 0.15, CI 0.03-0.91), wound dehiscence (0% vs. 0.5%, OR 0.14, CI 0.03-0.78) and surgical site infections (SSI’s)(0.5% vs. 2%, OR 0.38, CI 0.26-0.61). Postoperative pseudoaneurysms were significantly more common in the ACD group (0.5% vs. 0.1%, OR 3.5, CI1.33-9.2). Duration of surgery (DOS) and HLOS were both reduced in the ACD group compared to the SCD group, with a mean difference of 19 minutes (OR 0.45; CI 0.23-0.89) and 1 day (OR 0.36; CI 0.17-0.79)(4 trials), respectively. When comparing all trials non-parametrically the significance of the difference of both DOS and HLOS disappeared. In current literature reports on ACD of the CFA, blinding of the assessors was neither mentioned nor possible. This introduces a biased effect estimate. Most of the included trials used a consecutive cohort, which may introduce an allocation bias.

Copenhagen, Denmark • 28-30 September 29

Scientific Session

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Conclusion: ACD’s are applicable in most patients indicated for an endovascular- or TAVR procedure. ACD’s inflict less minor wound complications (seroma, neuropathy, dehiscence or SSI’s) compared to SCD, but treatment duration will not be largely reduced.

Legend Figure: Significantly fewer complications in ACD treated in a non-operative fashion.

Copenhagen, Denmark • 28-30 September 30

Scientific Session

OP 004 LATE RESULTS OF THORACOABDOMINAL AORTIC ANEURYSM OPEN REPAIR WITH RESPECT TO DIFFERENT VISCERAL ARTERY REVASCULARIZATION TECHNIQUES

Institution: 1. Vita-Salute University - San Raffaele Scientific Institute, Milano 2. Catholic University of Sacred Heart Medical School, Rome, Italy

Authors presenting: Andrea Kahlberg, Riccardo Miloro, Angela M. Ferrante, Luca Bertoglio, Daniele Mascia, Enrico Rinaldi, Germano Melissano, Roberto Chiesa

Introduction: In the rising era of endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs), the analysis of long-term survival and visceral vessels patency after open surgical repair is crucial to allow future comparisons between these different approaches. This study reports the late outcomes of a single-center experience on open TAAA repair, focusing on the results of different techniques adopted for renal and splanchnic revascularization.

Methods: Data were analyzed for 382 consecutive TAAA repairs performed between January 2009 and July 2015 (294 males; mean age 65.9 ± 10.1 years). TAAA extent was classified as Crawford types I (32), II (138), III (106), and IV (102) and Safi type V (4). Surviving patients were followed-up by means of computed tomography angiography (CTA) and office visit at 3 and 12 months, and yearly thereafter. Kaplan-Meier analysis was performed for overall survival, patency of reconstructed visceral vessels (celiac trunk, CT; superior mesenteric artery, SMA, right renal artery, RRA; left renal artery LRA), and reinterventions on visceral arteries. Also, visceral vessel long-term patency was analyzed in subgroups of patients according to the revascularization strategy (patch-inclusion of all vessels, Group 1; LRA separate reattachment + patch inclusion of the remaining vessels, Group 2; separate reattachment of all visceral vessels, Group 3).

Results: In-hospital mortality and paraplegia occurred in 7.6% and 8.1% of patients, respectively. Of the 353 survivors, 338 adhered to follow-up protocol, and adequate CTA images were available in 247 patients (952 visceral vessels analyzed). Overall survival was 87%, 84% and 64% at 1, 3, and 5 years, respectively. At the same time-points, visceral vessel patency was 99%, 98% and 98% for CT, 100%, 100% and 100% for SMA, 100%, 96% and 96% for RRA, and 91%, 87% and 82% for LRA. Estimates for reinterventions on visceral vessels were 1.2%, 6.3% and 17% at the same time- points, respectively. Patients experiencing occlusion of at least one visceral vessel at follow-up were 10/94 (10.6%) in Group 1, 17/127 (13.4%) in Group 2, and 2/26 (7.7%) in Group 3.

Conclusion: Open TAAA repair performed in high volume centers remains a safe and durable method, even in the endovascular era. Long-term patency of visceral vessels is high, irrespective of the technique used for revascularization. The left renal artery appears to be the vessel most prone to occlusion in time, even in case of single separate reattachment.

Copenhagen, Denmark • 28-30 September 31

Scientific Session

OP 005 EARLY AND MID-TERM OUTCOME OF FENESTRATED AND BRANCH THORACOABDOMINAL AORTIC REPAIR WITH RENOVISCERAL INCORPORATION AND SUPRACOELIAC COVERAGE

Institution: 1. Birmingham Complex Aortic Team, Heart of England NHS Foundation Trust 2. Birmingham Complex Aortic Team, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom

Authors presenting: Andreas Koutsoumpelis, Massimo Vezzosi, Mauro Iafrancesco, Aaron Ranasinghe, Jorge Mascaro, Martin Claridge, Donald Adam

Introduction: The extent of endovascular aneurysm repair may have more of an impact on the outcome of treatment than the anatomical extent of the aneurysm. Fenestrated (FEVAR) and branch (BEVAR) endovascular aortic repair with renal and visceral stent-grafting and a proximal landing zone above the coeliac axis (Society for Vascular Surgery classification zone 6) is considered to be one of the most complex EVAR procedures.

Methods: Interrogation of a prospective database identified 178 patients [144 men; median age 73 (range, 54- 85) years] with pararenal (n=35) and thoracoabdominal aortic aneurysms (n=143) who underwent endovascular thoracoabdominal aortic repair with renal and visceral stent-grafting and supracoeliac aortic coverage [FEVAR (n=124), BEVAR (n=54)] between December 2008 and April 2016. All patients were high-risk or turned down for open repair. Median aneurysm diameter was 65 (range, 53-110) mm. Fifty patients had undergone prior aortic repair. Patients who had FEVAR with renal (RA) and superior mesenteric (SMA) fenestrations and a coeliac axis (CA) scallop were excluded.

Results: Supracoeliac coverage was <40mm in 60 patients and >40mm in 118 patients. A total of 684 branch vessels (mean 3.8/patient) were targeted for preservation [CA 156 (46 branches, 110 fenestrations), SMA 177 (44b, 133f), RA 337 (53b, 284f), hypogastric 11(b), arch 3(f)] and 659 (mean 3.7/patient) were stent-grafted. Four target vessels (0.6%) occluded intra-operatively. Axillary artery access was required in 96 patients and iliac bypass/conduit/endografting for access in 17 patients. Further adjuvant procedures were required in 35 patients: left carotid-subclavian bypass (n=9), femoro- femoral cross-over bypass (n=4), hypogastric artery bypass (n=2), femoral aneurysm repair (n=2), temporary axillo-femoral bypass (n=1), renal artery bypass (n=2), and renal artery chimney endograft (n=1). The 30-day mortality was 0.6% (n=1). Five patients (2.8%) developed spinal cord ischaemia (SCI) requiring specialist rehabilitation. There was a significant decrease in the incidence of SCI with introduction of a spinal cord protection protocol (SCPP) and selective staging of the endovascular repair [pre-SCPP: 4 of 26 (15%), 20 with >40mm coverage and 0 staged vs. with SCPP: 1 of 152 (0.7%), 98 with >40mm coverage and 60 staged; p=0.001 Fisher’s Exact Test). One patient developed acute renal failure (ARF) requiring long-term dialysis and a further patient commenced dialysis which was planned before the procedure. Actuarial survival at 1, 2 and 4 years was 93%, 91% and 77%, respectively. Actuarial freedom from re-intervention at 1, 2 and 4 years was 90%, 83% and 76%, respectively.

Conclusion: In a high-volume specialist aortic centre, endovascular thoracoabdominal aortic repair with renal and visceral stent-grafting and supracoeliac coverage can be performed safely (with a low risk of death, SCI and ARF) and is durable in the medium-term. The introduction of a spinal cord protection protocol and selective use of staged endovascular repair have contributed to a significant reduction in the incidence of SCI while avoiding the use of prophylactic cerebrospinal fluid (CSF) drainage.

Copenhagen, Denmark • 28-30 September 32

Scientific Session

OP 006 SURGICAL TREATMENT OF 52 PATIENTS WITH MIDAORTIC DYSPLASTIC SYNDROME

Institution: Vascular Surgery, Scientific Center of Cardiovascular Surgery named after Bakulev, Moscow, Russian Federation

Authors presenting: Valeriy Arakelyan, Inna Chshieva, Vasil Papitashvili, Nazim Gamzaev, Nikita Gidaspov, Natalya Bortnikova

Introduction: Thoracoabdomibal and abdominal aortic dysplastic syndorm or hypoplasia is uncommon and often complicated with coexisting splanchnic and renal artery occlusive disease. This study was undertaken to define the clinical and anatomic indications for surgical treatment, as well as the technical issues and outcomes of different operative technique.

Methods: Fifty-two patients, 23 males and 29 females, underwent surgical treatment of thoracic and abdominal aortic hypoplasia from 2000-2016 at the Bakoulev center for cardio-vascular surgery. Patient ages in years ranged from 5-10 (n 4), 11-15 (n 16),16-20 (n 15), and 21-49 (n 17). The mean age was 14.4 years. Congenital disease (n 48), inflammatory aortitis (n 3), and iatrogenic trauma (n 1) were suspected etiologies. Aortic coarctations were suprarenal (n 35), intrarenal (n 16), or infrarenal (n 1), and stenoses were commonly found in the celiac axis (n 3), SMA (n 3), and renal artery (n 14).

Results: Major clinical manifestations included: aortic and renal artery-related secondary hypertension (n 51), symptomatic lower extremity ischemia (n 2), and intestinal angina (n 3). Primary aortic reconstructive procedures included: thoracoabdominal bypass (n 46), patch aortoplasty (n 1), or an an aortic interposition graft (n 5). Primary splanchnic (n 3) or renal (n 13) arterial reconstructions were performed as simultaneous (n 42) or staged (n 10) procedures in relation to the aortic surgery. There was no post-operative mortality or secondary interventions. Hypertension was cured orimproved in all patients. Benefits existed regarding elimination of extremity ischemia (n 2) and mesenteric angina (n 3). With a median follow up of 75 months (range, 12-180), all the aortic bypasses were patent and one adjunctive renal artery bypass graft with aortic bypass was occluded 21 months postoperatively.

Conclusion: Middle aortic syndrome represents a complex vascular disease. Considering the patients young age with a long life expectancy, aggressive surgical treatment could be beneficial. Lifelong follow up to monitor complications and disease progression is necessary.

Copenhagen, Denmark • 28-30 September 33

Scientific Session

OP 007 MODIFIED REVERSED FROZEN ELEPHANT TRUNK FOR THORACOABDOMINAL AORTIC REPAIR IN A PIG MODEL

Institution: 1. Department of vascular medicine, University Heart Center Hamburg-Eppendorf 2. Department of general-, visceral- and thoracic surgery, University-Center Hamburg-Eppendorf, Hamburg, Germany

Authors presenting: E. Sebastian Debus, Tilo Kölbel, Daniel Manzoni, Anna Dupree, Henrik Rieß, Nikolaos Tsilimparis, Sabine H. Wipper,

Introduction: Thoracoabdominal aortic repair still is a challenging procedure associated with high perioperative mortality and morbidity in both open and endovascular reconstruction. We developed a six-branched modified reversed Frozen Elephant Trunk (rFET) with a proximal stentgraft for retrograde delivery to the descending aorta and a distal six-branched abdominal prostheses for open repair, to avoid thoracotomy, extracorporeal circulation (ECC) and to reduce cross-clamping time. Technical feasibility, operating and clamping time were compared to conventional open aortic repair (CR) in a pig model.

Methods: Thoracoabdominal aortic repair via retroperitoneal access without ECC was performed in 6 pigs per group (75-85kg). For CR thoracoabdominal aorta was exposed, after crossclamping proximal and distal aortic anastomosis were performed and successively coeliac trunk (CT), superior mesenteric artery (SMA), right and left renal arteries (RA) and finally iliac arteries were implanted. For rFET the right iliac branch was first temporarily anastomosed end-to-side to the distal aorta maintaining periprocedural retrograde visceral and antegrade aortoiliac blood flow. After infracoeliac crossclamping CT was devided and the proximal stent-grafted part was deployed in the descending aorta via the coeliac ostium. Visceral and renal arteries were successively anastomosed to the side- branches of the graft. Technical feasibility, hemodynamics, and ischemic time of related organs were evaluated. Final angiography was performed.

Results: Graft deployment was successful in all 6 animals in both groups. All pigs were hemodynamicaly stable during the entire procedure. Total aortic clamping time was 88.3±16.3min during CR and 4.2±1,0min during rFET. Selective ischemic times were for CT 11±2.4min vs. 25.3±3,3min, for SMA 8.8±2.3min vs. 36.6±6.2, for RRA 13.4±3.8min vs. 56.1±9.2min, for LR 21.2±4.7min vs. 66.1±11.1min, for RIA 8.8±1.9min vs. 75.2±14.2min, and for LIA 7.8±2.3 vs. 88.3±16.3min (HHG vs. CR, p<0.05). Angiography confirmed patent side branches and successful graft implantation.

Conclusion: Thoracoabdominal aortic repair using rFET can successfully be performed in pigs. Crossclamping time and visceral ischemia significantly can be reduced in comparison to CR. Furthermore thoracotomy and ECC with concomitant increased perioperative risk could be avoided. This hybrid procedure might be a useful alternative treatment option to solely open and endovascular repair in men.

Copenhagen, Denmark • 28-30 September 34

Scientific Session

OP 008 TREATMENT TRENDS AND OUTCOMES OF OPEN AND ENDOVASCULAR THORACOABDOMINAL AORTIC REPAIRS IN A SINGLE CENTER

Institution: Mayo Clinic, Rochester, MN, United States

Authors presenting: Ying Huang, Gustavo S. Oderich, Mauricio Ribeiro, Thomas C. Bower, Alberto Pochettino, Manju Kalra, Mark D. Fleming, Randall R. DeMartino, Peter Gloviczki

Introduction: Fenestrated and branched endovascular aortic repair (F-BEVAR) has been increasingly utilized to treat thoracoabdominal aortic aneurysms (TAAAs). This study evaluates anatomical suitability, treatment trends and outcomes of open surgical repair (OSR) and F-BEVAR of TAAAs in a single center.

Methods: We reviewed the clinical data of 303 consecutive patients treated for TAAAs by OSR or F-BEVAR since initiation of an advanced endovascular aortic program in 2007. Anatomical feasibility for F- BEVAR was assessed using computed tomography. Clinical outcomes were analyzed for elective and ruptured Type IV and Types I-III TAAAs, including 30-day mortality, major adverse events (MAEs) and 1-year patient survival and freedom from re-interventions.

Results: There were 136 patients (45%, 9 ruptured [6.6%]) treated by OSR (mean age, 61±14 years) and 167 (55%, 7 ruptured [4.2%]) treated by F-BEVAR (mean age, 75±7.9 years, P<.001). Selection of F-BEVAR increased from 14% in the first two years to 77% in the last two years of experience (P<.001). OSR patients had more dissections, were younger and had lower rates of coronary artery disease and stage III-V chronic kidney disease, but similar comorbidity severity scores compared to F-BEVAR patients. Forty-one OSR patients (30%) were not considered candidates for F-BEVAR because of genetically triggered aortic diseases in 29 (21%) or anatomical unsuitability in 15 (11%). Thirty-three OSR patients (30%) would have required adjunctive open surgical procedures to achieve suitability. Thirty-day mortality was 8.1% (n=11, elective 6.3%, ruptured 33%) for OSR and 3.6% (n=6, elective 3%, ruptured 14%) for F-BEVAR (P=.09). Thirty-day mortality was similar for elective Type IV (0% vs 0%) and Types I-III TAAAs (8% vs 7.6%) treated by OSR or F- BEVAR, respectively (Table). In the F-BEVAR group, 30-day mortality decreased from 15% (n=5) in the first 33 patients to 0% in the last 33 patients (P=0.05). OSR was associated with more MAEs and higher rates of myocardial infarction, respiratory failure, dialysis and longer hospital stay, independent of TAAA Type. Spinal cord injury was for Type IV (7.4% vs 2.1%) and Types I-III TAAAs (5.2% vs 6.1%) treated by OSR or F-BEVAR, respectively. At 1-year, patient survival and freedom from any reintervention was similar in both groups.

Copenhagen, Denmark • 28-30 September 35

Scientific Session

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Conclusion: F-BEVAR was associated with less MAEs, shorter hospital stay, and similar 30-day mortality for all types of TAAAs. Despite the increasing utilization of F-BEVAR, OSR plays an essential role in the care of TAAA patient because of anatomical unsuitability or genetically triggered aortic diseases.

Copenhagen, Denmark • 28-30 September 36

Scientific Session

OP 009 THORACO-ABDOMINAL OPEN REPAIR IN PATIENTS WITH PREVIOUS THORACIC ENDOGRAFTING

Institution: Chair of Vascular Surgery, Scientific Institute H. San Raffaele, "Vita Salute" San Raffaele University of Milan, Milano, Italy

Authors presenting: Enrico Rinaldi, Germano Melissano, Luca Bertoglio, Andrea Kahlberg, Daniele Mascia, Yamume Tshomba, RobertoChiesa

Introduction: Open repair of thoraco-abdominal aneurysms (TAA) may be technically more demanding in case of previous open or endovascular repair of any aortic segment. Previous endovascular thoracic treatment might create aortic wall inflammation and pulmonary adhesions with increasing risk of perioperative bleeding and pulmonary failure. The aim of this study is to evaluate whether a previous descending thoracic endovascular repair might influence the outcomes of TAA open repair.

Methods: All TAA patients undergoing open repair between January 2008 and July 2015 were included in a prospective database. Among 404 open repairs performed (standard group), 29 patients (24 males; median age 66, r. 45-78 years) had a previous endovascular repair of thoracic aorta (REDO group). We excluded open conversion due to type IA and III endoleaks, infections and fistulas. All cases presented with a distal progression of the aneurysmatic disease (3 type I, 9 type II, 13 type III and 4 type IV TAAs). The REDO group had the same preoperative risk factors as the standard group. The primary end points were mortality, spinal cord ischemia, respiratory and renal and insufficiency. Secondary end points included blood loss, operative time, ICU stay, the length of hospital stay.

Results: Primary endpoints: 30 days mortality rate 24.1% (7.18% standard group, p=0.001), spinal cord ischemia rate 13.8% (14.1% standard group, p=0.964), respiratory failure rate 13.8% (4.95% standard group, p=0.0442) and renal failure rate 27.6% (26.2% standard group, p=0.869). Secondary endpoints: mean bood loss 7062 mL (5246 mL standard group, p=0.018), mean operative time 5,39 hours (4,79 hours standard group, p=0.021), mean ICU stay 3.4 days (2.7 days standard group, p=0.068), length of hospital stay 10.7 days (10.4 days standard group, p=0.852)

Conclusion: Previous thoracic endovascular repair is a significant preoperative risk factor for patients requiring subsequent open TAA repair. Not only does it increase the complexity of the repair with longer operative time and blood loss but also there is a worsening in terms of both mortality and respiratory morbidity.

Copenhagen, Denmark • 28-30 September 37

Scientific Session

SCIENTIFIC SESSION 2 – PRIZE SESSION

OP 010 LONG-TERM OUTCOME AFTER CAROTID ARTERY STENTING – A POPULATION BASED MATCHED COHORT STUDY– INFERIOR OUTCOME OF CAROTID STENTING IN LONG TERM FOLLOW UP

Institution: 1. Department of Molecular Medicine and Surgery, Clinical science and education, Södersjukhuset, Karolinska Institutet, Stockholm 2. Department of Surgical Sciences, Uppsala Universuty, Uppsala, Sweden

Authors presenting: Magnus Jonsson, David Lindström, Peter Gillgren, Anders Wanhainen, Jonas Malmstedt

Introduction: Carotid artery stenting (CAS) is a less invasive technique than carotid endarterectomy (CEA) for prevention of stroke in patients with carotid artery stenosis, and is becoming more widely performed. Little is, however, known about the long-term results after CAS outside the RCTs, and consequently the generalizability of these observations has been questioned.

Methods: Nationwide matched cohort study of all patients registered in the National Swedish Vascular Registry (Swedvasc) treated with CAS between 2005 and 2012. For every CAS patient two controls treated with CEA matched for gender, age and indication (symtomatic/asymtomatic) during the same time period were randomly chosen. Postoperative stroke was identified by cross-matching the entire cohort with the national In Patient Registry (IPR) supplemented with charts review. Primary endpoint was ipsilateral stroke or death >30-days postoperatively. +Standard Cox proportional hazards (PH) model was used for outcomes. Models were adjusted for pre-specified covariates known to affect outcome after CAS and CEA; diabetes, hypertension, cardiac disease, current smoking, pulmonary disease and renal insufficiency

Results: A total of 1157 patients were included, 409 CAS and 748 CEA; 73% men with mean age 70 years and 69 % were symptomatic. Risk factor profile was similar between the two groups. The median follow up time for the primary endpoint was 4.1 years, (IQR 2.4-5.8), equivalent to 3994 person-years of observation. During follow up, the study population had 394 hospitalization episodes with a stroke diagnosis registered in the IPR. We managed to obtain charts for 393 out of these 394 episodes (99.7%). One-hundred-thirty-three of the hospitalizations were due to a new stroke event, and 12 patients had more than one stroke. Within 30 days, there was no difference between the groups with respect to any stroke or death; 14 patients in the CAS group (3.4 %) and 24 patients in the CEA group (3.2 %), p = 0.86. Ipsilateral stroke or death >30-days postoperatively occurred in 96/395 (24.3%) in the CAS-group vs 121/725 (16.7%) in the CEA-group (adjusted HR 1.59, 95% CI 1.16- 2.19). The corresponding rates for death were 19.8% vs 15.6% (HR 1.17, 95% CI 0.84-1.63), for ipsilateral stroke >30 days 7.0% vs 2.7% (HR 3.47, 95% CI 1.61-7.50), and for any stroke or death >30 days 27.6% vs 18.9% (HR 1.56, 95% CI 1.17-2.10) for the CAS-group and CEA-group respectively. The Kaplan-Meier plots for the risks of stroke and death at 6 years are shown in figure 1.

Copenhagen, Denmark • 28-30 September 38

Scientific Session

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Conclusion: In this nationwide cohort study, including all primary CAS-procedures in Sweden, a substantially (59%) increased risk for late stroke or death after CAS compared to CEA was observed. This increased risk is mainly because of an increased rate of ipsilateral stroke after the periprocedural period indicating that CAS is not as durable as CEA for treatment of carotid artery stenosis.

Copenhagen, Denmark • 28-30 September 39

Scientific Session

OP 011 A PROFICIENCY-BASED STEPWISE ENDOVASCULAR CURRICULAR TRAINING (PROSPECT) PROGRAM ENHANCES PERFORMANCE IN REAL LIFE: A RANDOMIZED CONTROLLED TRIAL

Institution: Ghent University Hospital, Ghent, Belgium

Authors presenting: Heidi Maertens, Frank Vermassen, Nathalie Moreels, Isabelle Van Herzeele

Introduction: Evolution in vascular surgery requires optimization of skills training to provide effective and safe patient care. The aim of this study is to evaluate the impact of a Proficiency-based Stepwise Endovascular Curricular training (PROSPECT) program to learn basic endovascular skills and to assess transferability of these skills to real life interventions in a hybrid angiosuite.

Methods: After performing baseline knowledge and technical skills tests 32 surgical trainees were randomized into three groups stratified according to level of experience. The first group (N=11) received e- learning and simulation training according to the PROSPECT program. The second group (N=10 only had access to e-learning, whilst the controls (N=11) did not receive any additional training. Subsequently, all subjects performed two endovascular interventions treating symptomatic iliac and/or superficial femoral artery stenosis on real patients under supervision. Assessments were carried out using OSATS derived Global Rating Score (GRS) and Examiner Checklist. Operative metrics, performances and patient outcomes were compared between all groups; adjusted for case difficulty and trainees’ clinical experience. Secondary outcomes included improved knowledge and technical performance in the intervention groups 6 weeks and 3 months after completing training, assessed by pre-post-test design.

Results: Fifty-eight endovascular procedures were performed on fifty-five patients. No differences in trainees’ baseline variables were found between the three groups. The trainees required on average 517mins (range 280-830, SD 156) completing e-learning and 256mins (range 118-900, SD 252) performing simulation sessions to achieve competency. Trainees who completed PROSPECT showed superior technical performance with significantly less supervisor takeovers during life procedures compared to trainees receiving only e-learning or traditional education (Table 1). The supervisor felt significantly more confident in allowing trainees to perform both non-complex and complex endovascular procedures after simulation training (P=0.006). Procedural parameters, intraoperative (dissections, perforations) and postoperative complications (haemorrhage, infection, restenosis, amputation, bypass surgery) were not significantly different at 30 days (Table 1). Although the acquired technical skills decrease over time, expert levels seem to be maintained up to 3 months after program completion.

Copenhagen, Denmark • 28-30 September 40

Scientific Session

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Conclusion: Trainees who had to access to PROSPECT performed better during non-complex endovascular interventions in the hybrid angiosuite in comparison to trainees who received only e-learning or solely traditional education. Significantly more supervisor takeovers in the non-simulation groups were noted to avoid complications. Based on this study every trainee should have the opportunity to learn knowledge and technical endovascular skills at their own pace prior to treat real patients to provide safe and high quality surgical care.

Copenhagen, Denmark • 28-30 September 41

Scientific Session

OP 012 RADIATION-ASSOCIATED DNA DAMAGE IN OPERATORS DURING ENDOVASCULAR AORTIC REPAIR

Institution: 1. Academic Department of Vascular Surgery, Cardiovascular Division, King's College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at King's Health Partners, St Thomas' Hospital 2. Department of Radiology, King's College Hospital, 3. Department of Interventional Radiology, St Thomas' Hospital, London, United Kingdom

Authors presenting: Tamer El-Sayed, Ashish S. Patel, Prakash Saha, Oliver Lyons, Francesca Ludwinski, Rachel Bell, Sanjay Patel, Tommaso Donati, Hany Zayed, Morad Sallam, C Jason Wilkins, Mark Tyrrell, Michael Dialynas, Becky Sandford, Said Abisi, Panos Gkoutzios, Stephen Black, Alberto Smith, Bijan Modarai

Introduction: Endovascular aneuyrsm repair (EVAR) is now the mainstay of treatment for aortic aneurysms. As the number and complexity of EVARs performed increases, there is a growing concern over the cumulative dose of radiation to which patients and operators are exposed. Studies to date have used conventional methods (dose area product [DAP] and dosimeters) to measure radiation exposure during EVAR but little is known about the biological consequences of this exposure. DNA damage in lymphocytes is a sensitive marker of radiation exposure. The aim of this study was to determine: (i) the biological consequences of radiation exposure to both patients and operators after EVAR, (ii) whether this differs according to the case complexity; and (iii) whether there are inter-individual sensitivities to radiation exposure as evidenced by markers of DNA damage in circulating lymphocytes.

Methods: Temporal changes in peri-operative lymphocyte count were measured in patients following EVAR and open AAA repair. The expression of markers of DNA damage and repair, gamma-H2AX (ɣH2AX), phosphoATM (pATM) were measured in circulating CD3+ lymphocytes in patients before, during and 24 hours after infrarenal EVAR (IEVAR), complex (branched/fenestrated [BEVAR/FEVAR]) and open aortic cases using multi-colour flow cytometry and immunofluorescence staining. For operators, ɣH2AX and pATM were measured in circulating lymphocytes before and 24 hours after open and endovascular repair. Individual susceptibility to radiation damage was determined by irradiating operators’ blood samples in vitro.

Results: There was a greater fall in patient lymphocyte count following endovascular (n=118) compared with open (n=35) aortic repair (66.6±3.5 vs 43.6±4.1% respectively, P<0.0001). Recovery of lymphocyte count was significantly reduced after EVAR (P<0.007). In patients, there was a 5-fold increase in lymphocyte expression of ɣH2AX and pATM immediately after standard (P<0.001, n=25) and complex (P<0.001, n=32) EVAR compared with open repair (n=13) and the induction of ɣH2AX correlated with DAP (P<0.02, r=0.2). Delivery of contrast did not induce ɣH2AX or pATM in lymphocytes in vitro. In operators, there was a significant increase in lymphocyte ɣH2AX and pATM expression after complex (P<0.005, n=15), but not standard EVAR (n=14), or open AAA repair (n=14). There was a significant difference in operator (n=6) sensitivity to radiation exposure (P<0.0001 by 2way ANOVA). In both patients and operators, ɣH2AX/pATM levels returned to normal 24 hours after all endovascular repairs.

Copenhagen, Denmark • 28-30 September 42

Scientific Session

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Conclusion: Our studies show that DNA damage occurs in both patients and operators as a consequence of radiation exposure during endovascular aneurysm repair. Such biodosimetry, aimed at measuring circulating markers of DNA damage, may be a more appropriate guide to the true biological consequences of radiation exposure than current dosimetery methods used to dictate “safe” exposure levels. A better understanding of the processeses that result in ɣH2AX/pATM expression during endovascular interventions, as well as the long term consequence of this raised expression, may allow a better estimation of the increased lifetime-attributable risk of cancer for both patients and operators.

Copenhagen, Denmark • 28-30 September 43

Scientific Session

OP 013 DISTAL SEAL DYNAMICS AND CLINICAL CONSEQUENCES AFTER ENDOVASCULAR ANEURYSM REPAIR

Institution: Vascular Surgery, Anesthesiology, Erasmus University Medical Center, Rotterdam, Netherlands

Authors presenting: Nelson G. Oliveira, Frederico Bastos Gonçalves, Marie Josee van Rijn, Klaas Ultee, Sander Ten Raa, Sanne Hoeks, Robert Stolker, Hence Verhagen

Introduction: In contrast to the proximal sealing zone, the distal sealing zones receive sparse attention during follow-up after EVAR. We evaluated the dynamics of the iliac attachment zone, and its association with clinical events.

Methods: A tertiary institution’s prospective EVAR database was inquired to identify common iliac arteries at risk. Internally validated measurements of the seal zones were made, using centre-lumen line reconstructions. First, we investigated the dynamics of the distal sealing zone, including iliac artery dilatation and endograft limb retraction over time. Additionally, we tried to identify risk factors for dilatation, limb retraction and distal seal complications (defined as type 1B endoleak or pre-emptive distal endograft extension due to loss of seal) by performing multivariable regression analysis.

Results: Of 452 primary EVAR patients treated from 2004 to 2012, 93 were excluded from analysis, (8 had infectious aneurysms, 38 had anastomotic aneurysms, 1 was a traumatic aneurysm and 64 patients did not have two postoperative CT scans), leaving 341patients (mean age 72y, 12% female, 597 common iliac arteries) for analysis. Median follow-up was 4.7 years. Iliac artery diameter at the seal zone changed significantly over time, from 14mm to 15mm (P<0.001) at 30 day imaging, and to 18mm (P<0.001) at last available imaging. Among patients treated with ≥24mm diameter endografts, median iliac dilatation was 4.0mm (17.8%) (Interquartile range [IQR] 7.6-37.0%) while in the remaining patients it was 3.0mm (19.9%) (IQR 6.7-33.3%) (P=0.96). Iliac dilatation ≥20% at the measuring point in the distal seal zone occurred in 295 cases (49.4%) and exceeded the implanted endograft in 170 (28.7%). Follow-up time was found as an independent risk factor for iliac artery dilatation beyond endograft (OR 1.4 per year, 95%CI 1.3-1.5) while oversizing >15% reduced the risk of this event (OR 0.7, 95%CI 0.5-1.0). Limb retraction ≥5mm was identified in 54 patients (9.1%). Iliac endograft diameter ≥24mm (OR 3.3, 95% CI 1.7-6.4) and iliac artery dilatation beyond the endograft (OR 2.1, 95%CI 1.2-3.8) were independent risk factors. There were 34 (5.7%) iliac seal complications. In these cases, median iliac seal length at 30-day imaging was 17.5mm (IQR 5.0 – 26.0) while it was 29.0 among (20.0 – 38.0) the remaining population (P<0.001). Independent risk factors included iliac endograft retraction, baseline AAA diameter and follow-up time, while increased initial postoperative iliac seal length decreased the risk of iliac seal complications (Table). No associations were found regarding iliac occlusion events.

Copenhagen, Denmark • 28-30 September 44

Scientific Session

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Conclusion: The iliac seal zone is dynamic after EVAR. Iliac dilatation and endograft limb retraction are common findings over follow-up that may lead to clinically relevant loss of iliac seal. Our results suggest that iliac seal complications may be minimized by increasing the iliac seal length during EVAR. We recommend a distal iliac seal length of at least 30mm, particularly in patients with large aneurysms and those receiving ≥24mm diameter iliac endografts.

Copenhagen, Denmark • 28-30 September 45

Scientific Session

OP 014 A NATIONWIDE STUDY ON TREATMENT OF MYCOTIC ABDOMINAL AORTIC ANEURYSMS 1994-2014

Institution: 1. Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, 2. Department of Medical Sciences, Section of Infectious Diseases, Uppsala 3. Department of Surgery, Södersjukhuset, Institution of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden

Authors presenting: Karl Sörelius, Anders Wanhainen, Martin Björck, Mia Furebring, Peter Gillgren, Kevin Mani

Introduction: Mycotic (primary infected) aortic aneurysms are rare, life threatening and complex. Current knowledge on treatment is scarce and based on small single-centre case series with heterogenic case-mixes. This nationwide multicentre study aims to assess surgical treatment for mycotic aneurysms of the abdominal aorta (MAAAs).

Methods: All patients treated for MAAAs between 1994 and 2014 were identified in the Swedish vascular registry, Swedvasc. All 27 vascular units in Sweden participated in retrieving data and retrospective chart review according to a predefined protocol.

Results: 132 patients with 144 MAAAs were identified, constituting 0.6% of all treated abdominal aortic aneurysms (1994- 2000 0.2%, 2001-2007 0.6%, and 2008-2014 0.9%). Median age was 70 years (Standard deviation SD 9.2), 91 (69%) were men, 94 (71%) had cardiovascular comorbidity, 51 (39%) were immunosuppressed, and 50 (38%) presented with rupture. The aneurysms were located in the paravisceral aorta in 17 patients (13%), infrarenal 104 (79%), iliac 3 (2%) and multiple aortic segments in 8 (6%). Positive blood culture was obtained in 87 (66%). The three most prevalent infectious agents were Streptococcus sp (n=28, 21% of all MAAA patients), Staphylococcus aureus (n=21, 16%), and Salmonella sp (n=12, 9%). Open repair (OR) was performed in 62 patients (47%); aortic resection and extra-anatomical bypass (n=7), in-situ reconstruction (n=50), patch plasty (n=3); 2 died perioperatively. Endovascular aneurysm repair (EVAR) was performed in 70 (53%), including fenestrated/branched EVAR (n=8), and hybrid visceral deviation and stentgrafting in (n=7). EVAR was first introduced in 2001 and has since constituted 60% of all surgery for MAAA. EVAR was performed in 46% of patients presenting with rupture and 57% of those with intact MAAA. 3-months survival improved over time (71% 1994-2000 and 88% 2001-2014), and was better for non-ruptured- compared with ruptured MAAA (93% vs 76%, p=0.003), and for EVAR compared with OR (96% vs 74%, p<0.001). Total survival was at 3- months 86% (95% CI 80-92%), 1-year 78% (71-86%), 5- years 59% (50-68%), and 10-years 39% (27-51%). Mean follow-up among survivors (>90-days) was 64 months (range 3-324). Antibiotics were administered for a mean of 29 weeks, range 0-360 weeks. Infection-related death occurred in 22 patients (17%; 23% after OR and 11% after EVAR); 68% occurred within the first year.Reoperation was performed in 30 patients (23%; 22% after OR and 24% after EVAR).

Conclusion: In this nationwide analysis of MAAA-treatment over two decades, endovascular approach was increasingly used. This enabled surgical treatment in elderly, comorbid patients, with improved survival at three months without increasing the risk of serious infectious complications or reinterventions.

Copenhagen, Denmark • 28-30 September 46

Scientific Session

OP 015 MECHANOCHEMICAL ABLATION VS. THERMOABLATION IN THE TREATMENT OF GSV REFLUX: A RANDOMIZED TRIAL

Institution: 1. Dept. of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland 2. Dept. of Vascular Surgery, Assiut University, Assiut, Egypt

Authors presenting: Sari Vähäaho, Osman Mahmoud, Karoliina Halmesmäki, Anders Albäck, Pirkka Vikatmaa, Katariina Noronen, Maarit Venermo, Ayman Hasaballah

Introduction: Several treatment options exist for the treatment of great saphenous vein (GSV) reflux. Nowadays many favour endovenous techniques, the newest of them being based on other methods than thermal energy to seal the vein, thus eliminating the need for tumescent anaesthesia and the risk of thermal injury to adjacent tissues. This randomized study compares endovenous mechanochemical ablation (EVMCA) (ClariVein, Vascular Insights) with endovenous thermoablation (EVTA) (endovenous laser abtion with 1470 nm diode laser (Biolitec)), or radiofrequency ablation (VNUS Closure FAST)) in the treatment of primary insufficiency in the GSV with varicose veins.

Methods: We randomized 125 patients with duplex-ultrasound verified reflux in the GSV and C2-C4 disease to undergo either EVTA or EVMCA. The treatments took place between 31.1.2014 and 26.10.2015. Before discharge and at one week the patients reported pain scores in the Visual Analogue Scale (VAS). Follow-ups ensued at one month and at one year after the treatment, consisting of duplex ultrasound examination and disease-specific quality-of-life-questionnaire (AVVSS). All patients underwent one-month follow-up and to date, 69 patients have attended the 1-year follow-up.

Results: The two groups of patients are very similar in the basic attributes: no significant differences (ns) exist in the mean age (49.8 years (SD 12.7) in the EVTA group vs. 50.9 years (SD 11.9) in the EVMCA group , (p= 0.58)), the mean GSV diameter at saphenofemoral junction ((8.9 mm (SD 2.0) vs. 9.4 mm (SD 2.4) respectively (p=0.19)), or the preoperative Cclassification between the groups (C2:C3:C4 was 38:14:14 vs. 31:14:13). No significant differences appeared between the groups in the mean stay in the operating room (65.4 (SD14.8) min in EVTA group, and 69.9 (SD 13.8) min in EVMCA group (p=0.08)), or in the mean postoperative stay in the recovery room (101.1 (SD 35.7) min vs. 87.4 (SD 44.0) (p=0.063)). Patients in the EVMCA group needed significantly less sedative medication (propofol) perioperatively, with the mean amount being 78.4 mg (SD39.1) compared to EVTA group’s 34.6 mg (SD22.2) (p<0.001). The median VAS scores during the procedure, at the time of discharge or at one week were did not differ between the groups. The mean length of the sick leave measured 5.0 (SD 3.8) days after EVTA and 4.3 (SD 3.2) days after EVMCA (p=0.3). At one month, all the treated GSV’s were occluded. One patient (1.7%), treated with EVMCA, had reflux at the saphenofemoral junction, but not in the GSV. Sensory nerve injury occurred in four (6.3%) EVTA patients, compared to none in the EVMCA group (p=0.053). To date, we have carried out one-year follow-up on 34 (57.6%) EVTA patients and 35 (53.0%) EVMCA patients. Reflux in the upper 20 cm of the GSV appeared in three patients, all in the EVMCA group (one-year freedom from reflux 91.2% vs 100% (ns)). In one of these patients the GSV was fully open and two of them showed partial recanalization. During the first postoperative year, none of the patients received additional treatments.

Conclusion: Between endovenous thermal ablation techniques and mechanochemical ablation, no differences exist in the perioperative and clinical outcome measures. Comparing these techniques, the one-year recurrent reflux rate is not statistically different. Mechanochemical ablation seems a feasible option in the treatment of GSV reflux and varicose veins. However, in order to make further conclusions, long-term results are needed.

Copenhagen, Denmark • 28-30 September 47

Scientific Session

EVST - POSTER SESSION

PP 001 POPLITEAL ANGIOSARCOMA AS A LATE EVOLUTION OF PREVIOUSLY TREATED POPLITEAL ANEURYSM

Institution: Azienda Ospedaliera Brotzu, Cagliari, Italy

Authors Presenting: Manuela Cherchi, Luigi Pibiri, Stefano Camparini

Introduction: Angiosarcomas of the popliteal artery are rare malignancies that have insidious presentation and are associated with a poor survival rate. We present a case of late evolution in a patient with previous popliteal aneurysms treated with femoro-popliteal bypass.

Methods: A 64 year-old woman presented with leg edema and a painful pulsless lump in the left popliteal fossa. The patient had fever (> 39 °C) and anaemia. She had a history of right mastectomy plus chemo and radiotherapy for breast cancer and 4 years before she had undergone left femoro-popliteal PTFE bypass for the correction of a popliteal aneurysm. Color-Duplex ultrasound and CT scan confirmed the patency of the femoro-popliteal bypass and showed the presence of a 74mm completely thrombosed aneurysmatic sac, distally and medially related to 2 different ipodense cystic formations, respectively of 13 and 31 mm. An IRM was performed, however no further information was achieved. The patient underwent aneurysmectomy plus lumpectomy of a cystic formation which was strongly adherent to the aneurysmatic sac. The resected material considested in a pseudocystic formation (12x6x4 cm) that was made of two extremities: a spheric one (7,5 x 6,5 cm) that was strictly adherent to an elogated one (5x3,5 cm). During her hospital stay, the patient developed a septic status, so infective and neurological consultations plus head and chest CT scan were perfomed detecting multiple lesions, which were considered as simply infective, but eventually revealed to be methastatic. Histological analysis of the bulk mass arrived 22days after and revealed a high grade malignant neoplasm, compatible for angiosarcoma. The tumor was positive for vascular markers (CD31, CD34, factor VIII) and negative for epithelial markers (cytokeratin AE1/AE3, S100, EMA, HBM45) when evaluated by immunohistochemical techniques.

Results: The patient's hospitalization and diagnostic path were influenced by the rarity of the pathology. The hystopathological diagnosis took 22 days to arrive, while the patient underwent progressive worsening of her genaral conditions. She had constant fever (> 38 °C), persistent anaemia and leg oedema. After a week from the operation, there was a sudden decay of her clinical conditions, characterized by epileptic crisis, loss of consciousness and comatose state with a moderate recovery in the next 12 hours. A neurological consultation was requested and a Brain CT scan showed three osteolysis areas in the right parietal area and in the left frontal and median area. In the following days the overall clinical conditions deteriorated markedly with fever, dyspnoea, convulsions and finally coma. The patient was septical although the hemocultures were initially negative. She underwent several imaging examinations under the suspition of a flogistic disease: she now had brain and pulmonary lesions, pleural effusion and mediastinum lymphadenopaties. When the hystological diagnosis arrived the patient's clinical conditions were very compromised. She had had several critical convulsive episodes, accompanied by clonic movements of the left foot. The patient was eventually emiparetic. Eventually, the hemocultures became positive for Candida albicans. She died 17 days after the hystological diagnosis.

Conclusion: Our case shows how rare tumors, like angiosarcoma, are challenging in terms of diagnosis and threatment. Their clinical and imaging detection is often complicated and even the most trained physicians may fail with suspecting such an uncommon malignancy.

Copenhagen, Denmark • 28-30 September 48

Scientific Session

PP 002 A CASE OF MOBILE AORTIC ARCH THROMBUS SYNDROME WITH SYSTEMIC EMBOLISATION

Institution: Vascular Surgery, Radiology, Mater Dei Hospital, Malta, Msida, Malta

Authors Presenting: Stephen Micallef Eynaud, Francesca Aquilina, Ian Said, Adrian Mizzi, Sinisa Pejkic

Introduction: Thromboembolic events may originate within the thoracic aorta. While the great majority occur in patients with atherosclerotic or aneurysmal disease, large thrombi may form in a younger and apparently healthy patient. The precise pathophysiology of this extremely rare condition can be difficult and sometimes impossible to ascertain.

Methods: A 64 year-old gentleman was admitted to our acute hospital in view of severe right flank pain. A computerised tomography angiography (CTA) revealed a large thrombus originating from the aortic arch with a tail floating into the descending aorta and systemic embolisation to the right renal and internal iliac arteries. The patient was treated with therapeutic intravenous heparin anticoagulation without further thromboembolic complications.

Results: Clinicians must be aware of the prothrombotic risk factors potentially resulting not only in venous but also systemic arterial thromboembolic complications. Whilst still a clinical rarity, thoracic aortic mural thrombi are being diagnosed more frequently owing to the wide-spread use of ever more sophisticated diagnostic imaging. As more cases are reported, we may look forward to a consensus in the currently controversial management of this rare but potentially devastating condition. Image:

Conclusion: Due to the widespread availability of advanced diagnostic imaging, thoracic aortic thrombi will continue to be encountered with increasing frequency, particularly in asymptomatic patients. Embolic events arising from thrombi within a nonaneurysmal, nonatherosclerotic aorta are a rare but possibly emergent and highly morbid condition. Further studies are needed to outline the natural history of these thrombi and the outcome of various therapeutic interventions to define the optimal treatment strategy.

References: 1.Machleder HI, Takiff H, Lois JF, Holburt E. Aortic mural thrombus: an occult source of arterial thromboembolism. J Vasc Surg 1986;4:473–8. 2.Lozano P, Gomez FT, Julia J, et al. Recurrent embolism caused by floating thrombus in the thoracic aorta. Ann Vasc Surg 1998;12:609–11.12. Scott DJ, White JM, Arthurs ZM. Endovascular management of a mobile thoracic aortic thrombus following recurrent distal thromboembolism: a case report and literature review. Vasc Endovascular Surg 2014;48(3):246–50.

Copenhagen, Denmark • 28-30 September 49

Scientific Session

PP 003 IATROGENIC TYPE A DISSECTION IN A MARFAN’S SYNDROME PATIENT REPAIRED USING E-XL® STENT

Institution: Angiology and Vascular Surgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain

Authors Presenting: Liliana Domingos, Noelia Cenizo, Vicente Gutiérrez, Isabel Estévez, Diana Gutiérrez, Carlos Vaquero

Introduction: Patients with Marfan’s syndrome are generally affected by cardiovascular complications located mainly in the aortic root and ascending aorta [1,2], which makes them prone to multiple reoperations during their lifetime. Each new intervention becomes technically more complex and life threatening then the anterior. These aortic wall´s problem can lead to other complications, such as iatrogenic type A aortic dissections, to which open surgery remains the gold standard treatment [3]. Endovascular repair is now available for management of aortic disease and is widely used in descending thoracic and abdominal area, offering a less invasive repair that can be used alone (chimney techniques, fenestrated stent graft, branched stent graft) or combined with open surgery (hybrid repair) [4]. Since its release, the E-XL® stent (Aortic Stent, Jotec®GmbH, Heehingen, Germany), has been used to treat the primary aortic pathology as well as its complications. We use an E-XL® stent to treat an iatrogenic type A postoperative dissection located in the aortic arch in a Marfan´s patient.

Methods: A 35-year-old man with Marfan syndrome, who had undergone an elective ascending aorta substitution due to dilatation of the aortic root in 2011, was referred to our hospital because severe aortic insufficiency. Cardiac valvular surgery was performed, replacing the native aortic valve for a mechanic prosthetic valve. During the immediate postoperative period a computed tomography (CT) scan showed a type A aortic dissection from the brachiocephalic artery to the origin of the left subclavian artery (figure a). At the time of the diagnosis the patient was asymptomatic, but due to his Marfan's syndrome, presented a very high risk of degeneration and/or progression of the intimal flap, so it was decided to treat it. Given the patient’s comorbidities, instead of proceed with open surgery, it was decided to implant an E-XL® stent (32x28x130mm) in order to repair the aortic arch while leaving pervious the supra-aortic arteries (figure b). No supra-aortic malperfusion or embolic events were detected.

Results: The 3 month follow-up CT-scan shows total thrombosis of false lumen and permeability of the supraaortic arteries. The patient remained asymptomatic.

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Conclusion: This case represents an off guide use of the E-XL® stent, in a patient that had recently undergone an open-chest surgery re-operation. Marfan’s syndrome patients are prone to have other cardiovascular disorders that may require other open-chest surgery during their lifetime. Endovascular therapy can provide a useful alternative in a less invasive way, which may minimize further complications in this type of patients.

Copenhagen, Denmark • 28-30 September 50

Scientific Session

References: [1] Yuan S, Jing H: Marfan’s Syndrome: an overview. Sao Paulo Med J, 2010; 128(6): 360-6.[2] Kumar A, Agarwal S: Marfan syndrome: An eyesight of syndrome. Meta Gene 2, 2014; 96-10, [3] Treasure T, Takkenberg J, Pepper J: Surgical management of aortic root disease in Marfan syndrome and other congenital disorders associated with aortic root aneurisms. Postgrad Med J, 2016; 92:112-117. [4] Resh T, Hongku K, Dias N et al: Techniques for aortic arch endovascular repair. J Cardiovasc Surg, 2016 Mar 05 [Epub ahead of print].

Copenhagen, Denmark • 28-30 September 51

Scientific Session

PP 004 SUSPECTED TYPE IIIB ENDOLEAK. AN INTRASAC "NEO-VASCULARIZATION LIKE" IMAGE FOLLOWING SUPRARENAL FIXATION EVAR WITH ADJUNCTIVE SELF-EXPANDABLE NITINOL STENT DUE TO SHORT NECK.

Institution: Vascular and Endovascular Surgery Department, Interventional Radiology Department, Ramon y Cajal University Hospital, Madrid, Spain

Authors Presenting: Andres Reyes Valdivia, Africa Duque Santos, Juan Sanchez Corral, Javier Blazquez Blazquez, Julia Ocaña Guaita, Claudio Gandarias Zúñiga

Introduction: An 83 year-old man with coronary heart disease, chronic obstructive pulmonary disease with oxygen therapy and with previous abdominal surgery several years before was scheduled for endovascular aortic repair for a 8 mm infrarenal short neck aneurysm.

Methods: Aneurysm morphology was studied and analyzed with Osyrix software. A 45 degrees antero- posterior angle with 32 degrees infrarenal angle was described. Short neck was defined for a 8mm neck length. Previous reports have demonstrated that standard EVAR in short necks is feasible, with special care in oversizing. Adjunctive procedures as proximal fixation with endostaples or with high- radial force stents may avoid migration in the mid-term. A 25% oversized self-expandable suprarenal fixation endograft was selected. Adjunctive self- expandable nitinol stent was deployed in the proximal neck.

Results: Procedure was performed without complications. Final operative angiography showed a very late endoleak considered to be type II. Two days after the procedure an urgent CT-scan was asked due to abdominal pain. Mesenteric ischemia or any vascular reason was ruled out but an interesting finding appeared. A neo-vascularization "like" intra-sac image. Two days after the same image was found. One month and six month CT-scan showed no aneurysm sac enlargement and the neo- vascularization "like" image disappeared. Engineers from endograft home were asked for CT-scan image analysis, but besides known proximal infolding of the nitinol-self expanding stent, no further answer o reasons of this image was given. A possible type IIIb endoleak was and is suspected, so further CT-scan with sac analysis will be done for follow-up.

Image:

Copenhagen, Denmark • 28-30 September 52

Scientific Session

Conclusion: Endograft early failure is not a usual finding. Small fabric holes in polyester are described in the literature, but reports on this are scare and usually happen in the long term with earlier generation endografts. We cannot be sure this image to be an endograft failure nor a type IIIb endoleak but for sure it mimics and appear to be one. Further and closer follow up with sac evolution will reveal (or not) the reason of this curious image.

References: Type IIIb endoleak, endograft failure

Copenhagen, Denmark • 28-30 September 53

Scientific Session

PP 005 STENTING FOR STENOTIC AORTO-RENAL BYPASS

Institution: Hospital Santa Maria - Centro Hospitalar Lisboa Norte, Lisboa, Portugal

Authors Presenting: Miguel Lemos Gomes, Gonçalo Sobrinho, João Vieira, Luís M. Pedro, José Fernandes e Fernandes

Introduction: Despite the controversy in the endovascular treatment of renal artery (re) stenosis, the number of such procedures is increasing, substituting open surgery. In either type of procedure (open or endovascular), there is a long-term risk of restenosis. Surprisingly, only a few cases document the use of the endovascular technique for treatment of aorto-renal bypass stenosis.

Methods: The authors describe a case of covered stenting for aorto-renal bypass stenosis.

Results: The patient, a 69-year-old male, had undergone aorto-bifemoral graft interposition and a bypass to the right renal artery (atrophic left kidney), using the right great saphenous vein as conduit, for treatment of a juxta-renal aortic aneurysm. After thirteen years, a computed tomography angiography was ordered after deterioration of renal function; there were no alterations regarding the patient’s blood pressure. Due to the decline of his renal function and to the patient’s comorbidities, it was decided that it was best an endovascular intervention. The procedure was uneventful and the patient improved his renal function, documenting the success of an endovascular resolution.

Conclusion: It is the first case describing the use of a covered stent in these situations. The authors believe that the technical success of the intervention is achieved with proper selection of the material for the patient's anatomy and with dilation at relatively high pressures. The use of a covered stent provides additional safety when dilating venous conduits at high pressures.

Copenhagen, Denmark • 28-30 September 54

Scientific Session

PP 006 SURGICAL TREATMENT OF INFERIOR MESENTERIC ARTERY ANEURYSM

Institution: Department of Vascular Surgery, Department of Interventional Radiology, Riga East University Hospital, Riga, Latvia

Authors Presenting: Jelena Timofejeva, Aina Kratovska, Kaspars Staudzs, Patricija Ivanova, Arturs Ligers, Vitalijs Zvirgzdins

Introduction: The inferior mesenteric artery (IMA) aneurysms are extremely rare of all visceral arterial aneurysms and only reported sporadically. We report a case of 49-year-old male, who was consigned to the hospital by general physician with diagnosis of peripheral artery disease. The finding of IMA aneurysm was incidental. The aim of this case report is to show a surgical treatment of rare visceral aneurysm.

Methods: The patient has a diagnosis of thromboangiitis obliterans for 25 years. On admission there were no abdominal symptoms. Digital subtraction aortography revealed stenosis of both iliac arteries, occlusion of the left femoral and superior mesenteric artery, stenosis of IMA and fusiform post– stenotic aneurysm of the proximal part of the IMA.

Results: The patient underwent surgical treatment of IMA aneurysm, because endovascular treatment was anticipated vessel sacrifice, which was not possible due to superior mesenteric artery occlusion and high risk of mesenteric ischemia. Transperitoneal approach to the abdominal aorta was performed, the intraoperative findings revealed an occlusion of the superior mesenteric artery, stenosis of inferior mesenteric artery and 3.5 cm Ø poststenotic IMA aneurysm in 5 cm long segment. We faced compensatory hypertrophied and tortuous collateral arteries in the mesenterium. IMA aneurysm was excluded by interposition of aorto-mesenterial bypass (to IMA) and performed with a 6 mm Dacron graft. The aneurysmal sack sutured over the prosthesis. The postoperative period was without complications. Patient was discharged from hospital on 5th postoperative day without any symptoms of mesenterial ischemia.

Conclusion: Surgical approach is a safe and good option to visceral aneurysm treatment in selective cases where endovascular intervention is complicated.

References: 1. John W. Hallett, Joseph L. Mills. Comprehensive Vascular and Endovascular Surgery. 2nd Edition. 2009; 358-372.

Copenhagen, Denmark • 28-30 September 55

Scientific Session

PP 007 OPEN SURGERY OF LERICHE’S SYNDROME IN A PATIENT WITH CROSSED FUSED RENAL ECTOPIA AND DUPLICATION OF THE INFERIOR VENA CAVA.

Institution: Heart and Vascular Center, Department of Vascular Surgery, Semmelweis University, Budapest, Hungary

Authors Presenting: David Garbaisz, Csaba Csobay-Novak, Zsuzsa Nagy, Zoltan Szeberin

Introduction: Crossed fused renal ectopia with duplication of the inferior vena cava is a rare combined renal and venous anomaly. In case of aortoiliac occlusive disease unsuitable for endovascular solution, detailed planning of open surgery is crucial, since avoiding renal ischemia, venous and ureteral injury is essential during aortic repair.

Methods: A 44-year old female patient with a long history of moderate claudication presented with a recent onset gangrene of the right hallux. Her medical history included smoking, acute myocardial infarction and hypertension. CT angiography (CTA) showed significant stenosis of the terminal abdominal aorta and crossed fused renal ectopia as well as duplication of the inferior vena cava. Endovascular procedure was not feasible because of high possibility of the exclusion of the dominant right renal artery originating from the diseased aortic segment above the aortic bifurcation. We performed an open thrombendarterectomy of the aortic bifurcation with Dacron patch plasty using left retroperitoneal approach.

Results: The patient had an uneventful postoperative period and she was discharged home on the 7th postoperative day.

Conclusion: Diseases of the distal aorta associated with rare congenital renal and venous abnormalities may be unsuitable for endovascular treatment. In these cases open surgery remains a feasible option. Thorough analysis of preoperative images is important to choose the best surgical modality in order to avoid complications related to the anatomic abnormalities during surgery.

Copenhagen, Denmark • 28-30 September 56

Scientific Session

PP 008 KISSING-COVERED-STENT FOR AORTOILIAC DISEASE

Institution: Vascular Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain

Authors Presenting: Mariel S. Riedemann Wistuba, Carol E. Padrón Encalada, Amer Zanabili Al-Sibbai, Lino A. Camblor Santervás, Jose M. Llaneza Coto, Manuel Alonso Pérez

Introduction: Improvement of endovascular devices and surgeon's skills have contributed to consider the endovascular therapy as a first option even in cases of complex aortoiliac disease. Although international guidelines still recommend surgical reconstruction for this kind of lesions,1 there is a growing number of studies describing the advantages of an endovascular approach.2,3 Kissing stent technique has proved to be a feasible technique in extensive iliac lesions that involve aortic bifurcation,4 even though reports showing confident mid and long-term results are scarce. The use of covered stents potentially prevents the intimal hyperplasia by introducing a mechanical barrier between endothelium and the arterial lumen. Herein we analyze short -term results of treatment with kissing- covered-stent for patients with chronic obstructive aortoiliac disease (COAID)

Methods: A descriptive analysis from a prospective database including patients with COAID who had been treated using the kissing stent technique with covered stents from September 2014 to December 2015

Results: 28 consecutive patients were treated using the kissing technique with covered stents. 85,7 % of them were male. Mean age was 62,2 ± 8,8 years old (ranging from 49 to 86). The risk for anesthesia was estimated as follows: 50% ASA II, 42,9 % ASA III and 7,1 % ASA IV. 3 patients had previous aortoiliac procedures for chronic arterial occlusion. According to Rutherford classification, there were 19 cases in IV category, 3 cases in V category, and 6 in VI category. With regard to the TASC classification of the lesions: 3,6% were type A, 17,9% type B, 21,4% type C and 57,1% of the cases were type D. Overall 89,3 % of the patient suffered from complete occlusions, of which 40 % were bilateral occlusions. Involvement of the aorta was observed in 5 cases; the occlusion was below the inferior mesenteric artery in 3 of them and the remaining 2 patients had juxtarenal occlusions. An approach from the left humeral artery was performed in 7 patients (25 %) and a re-entry catheter device was used in 5 patients. A pure percutaneous approach was used in 57,1% of the patients. 42,9 % of the patients needed an associated additional procedure, and the most frequent of them was a femoral endarterectomy (14 endarterectomies in 10 patients). Overall, technical success was achieved in 92,8% of the cases. Two patients with bilateral iliac occlusions in whom it was only possible to perform recanalization of one side, an “L” technique was used for both lower limbs revascularization. The kissing technique was made with self expanding covered stents in 14 patients and with balloon-expandable covered stents in other 12. An average of 4,2 (2 to 8) covered stents per patient were used. There were no perioperative deaths. One patient needed an open surgical revision of the groin due to early thrombosis of the femoral common artery in which a percutaneous closure device was used, and no other complications occurred. Follow up protocol includes Yao´s index and duplex scan postoperatively at 6, 12 months and yearly thereafter. Mean follow-up was 6,4 ± 5,5 months with no occlusions registered during this period of time (primary patency rate 100 %), even though one patient needed limb amputation due to extensive necrosis of the foot (Category VI Rutherford´s classification)

Conclusion: Kissing- covered-stent procedures for treatment of COAID is a promising technique, even for TASC D lesions, showing excellent short-term results that need to be confirmed at long-term in order to be adopted as the gold standard treatment for these patients

References: 1. Jaff Michael R., White CJ, Hiatt WR, et al. An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries: A Supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II): The TASC

Copenhagen, Denmark • 28-30 September 57

Scientific Session

Steering Comittee. Ann Vasc Dis. 2015; 8(4): 343–357. 2. Donato G De, Bosiers M, Setacci F, Deloose K, Galzerano G, Verbist J, et al. 24-Month Data From The Bravissimo, A Large Scale Prospective Registry On Iliac Stenting For Tasc A&B And Tasc C&D Lesions. Ann Vasc Surg. 2014;(2015). 3. Sachwani GR, Hans SS, Khoury MD, King TF. Results of iliac stenting and aortofemoral grafting for iliac artery occlusions. J Vasc Surg. 2011;57(4):1030–7. 4. Pulli R, Dorigo W, Fargion A, Angiletta D, Azas L, Pratesi G, et al. Early and Midterm Results of Kissing Stent Technique in the Management of Aortoiliac Obstructive Disease. Ann Vasc Surg. 2012;29(3):543– 50.

Copenhagen, Denmark • 28-30 September 58

Scientific Session

PP 009 “EXTENDED POSTERIOR APPROACH” FOR GIANT POPLITEAL ANEURYSM EXTENDED TO SUPERFICIAL FEMORAL ARTERY

Author Presenting: Tomoki Cho

Introduction: Generally, popliteal artery aneurysms have been addressed surgically by a medial, posterior, and lateral approach 1)2). The standard operation consists in ligation and bypass insertion using a medial approach, but sac enlargement or even rupture due to collateral pathway during follow-up has been reported. Accordingly, we have designed a new approach that exposes the superficial femoral artery and entire popliteal artery without changing the patient’s position or dividing any muscles.

Methods: A 72-year-old man with intermittent claudication was admitted to our hospital. Computed tomography revealed the giant thrombosed popliteal aneurysm extending from mid-superficial femoral artery to middle popliteal artery. Surgery was performed due to a high-risk of rupture. An S-shaped skin incision was made in the popliteal fossa. The below knee popliteal artery was exposed. We could not expose the proximal side of the giant aneurysm originated proximal to the foramen of the adductor magnus. We extended the skin incision to the proximal toward, and exfoliated the medial side of semitendinosus muscle. We could expose the superficial femoral artery in this approach like in a medial approach. The giant aneurysm was made an incision, and the branches from the aneurysm were completely closed. A saphenous vein graft was sewn in end-to-end fashion to the superficial femoral artery with 6-0 monofilament running suture. After the proximal anastomosis was completed, the graft was placed under tension and tailored to the correct length. Distal anastomosis was then performed with same procedure. The wound was easily closed because reconstruction of the muscles was not required.

Results: By this approach, we extended a skin incision of the normal posterior approach to the proximal side, and exposure of superficial femoral artery which is similar to field of vision by medial approach is enabled by grinding semimembranosus and semitendinosus muscles passively to the outside. We named this approach “Extended posterior approach”. As the advantages of this approach, we can observe proximal and distal sides of aneurysms in a good exposure on the same skin incision, and process blanches from aneurysms under direct vision of whole aneurysms. Good long-term results of the medial and posterior approach for the treatment of popliteal aneurysms have been reported 3)4)5). Popliteal aneurysms are treated with exclusion and bypass by median approach. However, excluded aneurysms can transmit systemic pressure from persistent flow through collateral arteries, resulting in aneurysm growth and rupture. Mehta et al. and Ebaugh et al. reported that in 7〜23 % of the patients popliteal artery aneurysm increased 6)7). In recent years, the treatment of popliteal artery aneurysms by endovascular surgery are reported 8)9). However, endovascular repair patency is inferior to open repair, and the amputation risk tended to be higher. The patients at high risk for open repair or without suitable vein should be considered as candidates for endovascular repair.

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Copenhagen, Denmark • 28-30 September 59

Scientific Session

Conclusion: This approach is very easy and useful, because it does not need position changing, and provides a good field of vision from proximal side to distal side of popliteal artery aneurysms.

References: 1. Szilagyi DE, Whitcomb JG, Smith RF. Anteromedial approach to the popliteal artery for femoropopliteal arterial grafting. AMA Arch Surg 1959;78:647-51. 2. Esses GE, Johnson WC. The lateral approach to the proximal popliteal artery for popliteal to anterior tibial artery bypass. J Am Coll Surg 1994;178-77-8. 3. Beaeth BD, Moore WS. The posterior approach for repair of popliteal artery aneurysms. J Vasc Surg 2006;43:940-5. 4. Dorigo W, Pulli R, Innocenti AA, Azas L, Fargion A, Chiti E, et al. A 33-year experience with surgical management of popliteal artery aneurysms. J Vasc Surg 2015;62:1176-82. 5. Mazzaccaro D, Carno M, Dallatana R, Settembrini AM, Barbetta I, Tassinari L, et al. Comparison of posterior and medial approaches for popliteal artery aneurysms. J Vasc Sur 2015;62:1512-20. 6. Ebaugh JL, Morasch MD, Matsumura JS, Eskandari MK Meadow WS, Pearce WH. Fate of excluded popliteal artery aneurysms. J Vasc Surg 2003;37:954-9. 7. Mehta M, Chanpagne B, Darling 3 RC, Robby SP, Kreinverg PB, Ozsvath KJ, et al. Outcome of popliteal artery aneurysms after exclusion and bypass: Significance of residual patent branches mimicking type 2 endoleaks. J Vasc Surg 2004;40:886-90. 8. Hogendoorn W, Schlosser FJ, Moll FL, Muhs BE, Hunink MG, Sumpio BE. Decision analysis model of repair versus endovascular treatment in patients with asymptomatic popliteal artery aneurysms. J Vasc Surg 2014;59:651-6. 9. Cervin A, Tjarnstrom J, Ravn H, Acosta S, Hultgren R, Welander M, et al. Treatment of popliteal aneurysms by open and endovascular surgery: A comtemporary study of 592 procedures in Sweden. Eur J Vasc Surg 2015;50:342-50.

Copenhagen, Denmark • 28-30 September 60

Scientific Session

PP 010 A CASE OF ACCIDENTAL STENT DEPLOYMENT: WHAT WE DID?

Institution: Department of Cardiovascular Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey

Authors Presenting: Burak Acikgoz, Elif Guneysu, Ali A. Kavala, Senel Altun, Vedat Bakuy

Institution: The endovascular procedures for peripheral arterial diseases are important alternatives for open surgeries especially in the group of patients with high operative risk. Endovascular procedures can lead to various complications which can be hazardous. Here we present a case of misdeployment of a stent and occlusion in brachial artery.

Methods: A 68-year-old male patient admitted to hospital with bilateral lower extremity claudication. On physical examination the patient was pulseless on the left lower extremity and left and right ABI were 0, 42 and 0, 72, respectively. The duplex ultrasound showed monophasic dampened flow pattern bilaterally. CT angiography revealed the occlusion of the left common iliac artery and stenosed right common iliac artery. The patient had type C lesion according to the TASC II classification. The patient was scheduled for endovascular therapy.

Results: Because the lesion in the left iliac artery could not be passed via left femoral puncture, the site of the puncture was relocated to brachial artery. Through brachial artery catheterization, the left iliac artery was predilated by drug-eluted balloon and then stented with a balloon expandable stent. The stent for the right iliac artery was deployed via brachial artery and opened with malposition in the brachial artery accidentally. The angiography showed no contrast passage through brachial artery. The brachial artery was exposed via cut-down and the stent was removed. The thrombi were obtained from brachial artery. The brachial arteriotomy was repaired with 6/0 prolene. The arterial flow was achieved after the operation.

Conclusion: A precious care should be given to the deployment of the stent especially through small sized arteries. When the misdeployment occurs, the surgical team should be ready for an immediate surgical repair.

Copenhagen, Denmark • 28-30 September 61

Scientific Session

PP 011 EHLERS-DANLOS SYNDROME TYPE IV: CAN WE PREVENT A TRAGEDY?

Institution: Serviço de Angiologia e Cirurgia Vascular, Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal

Authors Presenting: Sérgio Teixeira, Pedro Sá Pinto, Carlos Veiga, João Gonçalves, Ivone Silva, Duarte Rego, Vitor Ferreira, Gabriela Teixeira, Inês Antunes, Rui Almeida

Introduction: Ehlers-Danlos Syndrome Type IV (EDS-IV) is caused by a rare autosomal dominant mutation in the COL3A1 gene, responsible for the synthesis of type III procollagen. These patients show higher risk of premature death following arterial, uterine or visceral rupture.

Methods: The patient was a 42 years old woman with a personal history of iron deficiency anemia, episodes of syncope for the past two months, and a family history of sudden death in first-degree relatives: grandmother, mother, uncles and cousin. The patient came to the ER complaining of intense abdominal pain, vomiting and loss of consciousness. On examination, she was hemodynamically stable and presented the typical facies of EDS-IV, several ecchymosis, increased skin elasticity and a tender non-pulsatile mass in the lower right abdominal quadrant. Angio-CT scan showed: dissection and rupture of the right common iliac artery associated with a large retroperitoneal haematoma; a splenic artery aneurysm, 5.8 cm in diameter; and a large left cystic retroperitoneal collection, 8.7 cm in diameter, interpreted as a former retroperitoneal bleed.

Results: The right iliac artery rupture was treated by placing two covered endoprosthesis (8x50 mm and 9x50 mm). Post-operatively a right common femoral artery false aneurysm, 2cmx3cm in size, formed at the puncture site. In a second time surgery the splenic aneurysm was excluded after proximal and distal ligation of the splenic artery. Post-operatively the patient showed raised inflammation markers without an identifiable infection point. Twenty days after surgery the patient showed hemodynamic instability and right hypochondrium tenderness. Angio-CT scan revealed a left liver lobe rupture with active bleeding. A left lateral hepatectomy with packing for haemostasis was performed. The patient died with a haemorrhagic shock, associated with consumption coagulopathy and multiple organ dysfunction syndrome.

Conclusion: No current therapies can delay the appearance of complications associated with EDS-IV. Even though most patients survive the first and second major complications, this syndrome results in premature death, with a life expectancy of 48 years. The presence of arterial, uterine or visceral rupture in young patients should be a warning sign for the present of EDS-IV.

Copenhagen, Denmark • 28-30 September 62

Scientific Session

SCIENTIFIC SESSION 3 – AORTA

OP 016 VARIATIONS IN ABDOMINAL AORTIC ANEURYSM TREATMENT: ONE DISEASE, TWO GUIDELINES, ELEVEN COUNTRIES

Institution: 1.Department of Surgical Sciences, Uppsala University, Uppsala, Sweden 2.Healthcare Policy and Research, Weill Cornell Medical College, New York, United States 3.Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland 4. Division of vascular surgery, University of Minnesota, Minneapolis, United States 5. Department of vascular medicine, University Heart Center Hamburg – Eppendorf, Hamburg, Germany 6. Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, United States 7. Department of Vascular Surgery, St Olavs Hospital, Trondheim, Norway 8. Beth Israel Deaconess Medical Center, Boston, United States 9. Australian and New Zealand Society for Vascular Surgery, East Melbourne, Australia 10. Department of Vascular Surgery, Semmelweis University, Budapest, Hungary 11. Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Arhus, Denmark 12. National University Hospital of Iceland, Department of Surgery, Reykjavik, Iceland 13. Department of Vascular Surgery, Dunedin School of Medicine, Dunedin Hospital, Dunedin, New Zealand 14. Departments of Cardiovascular Surgery, University Hospital, Berne, Switzerland 15. Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Hanover, United States

Authors presenting: Adam W. Beck, Kevin Mani, Art Sedarkyan, Jialin Mao, Maarit Venermo, Rumi Faizer, Sebastian Debus, Christian Behrendt, Salvatore Scali, Martin Altreuther, Marc Schermerhorn, Barry Beiles, Zoltan Szeberin, Nikolai Eldrup, Gudmundur Danielsson, Ian Thomson, George Heller, Martin Björck, Jack Cronenwett

Introduction: The International Consortium of Vascular Registries (ICVR) represents vascular surgical registries across three continents. We sought to evaluate international variations in the contemporary management of AAA.

Methods: Registry data regarding intact (iAAA) and ruptured (rAAA) repair during 2010-2013 were collected from eleven countries. Differences in management of patients with AAA were assessed.

Results: A total of 51,153 patients were included, 44,089 treated for iAAA (86%) and 7,064 for rAAA (14%). The proportion of repairs performed for rAAA varied from 8% in the USA Vascular Quality Initiative registry to 29% in Finland (p<0.01). The proportion of repairs performed with EVAR varied from 28% in Hungary to 79% in the USA for iAAA, and from 5% in Denmark to 52% in the USA for rAAA (p<0.01). Within the entire cohort 23% were octogenarians (range: 12% Hungary to 29% Australia, p<0.01) and 18% were women (range: 12% Switzerland to 21% USA, p<0.01). Intact aneurysms were <5.5cm in size at treatment in 31% of male patients (range: 6% Iceland to 41.4% Germany), and <5.0 cm in size in 12% of female patients (range 0% Iceland to 16% in the USA). Countries that more frequently used EVAR tended to repair smaller diameter AAAs (trend: correlation coefficient 0.49, p=0.15), and these countries also had a lower proportion of rAAA repairs (correlation coefficient 0.74, p=0.01).

Copenhagen, Denmark • 28-30 September 63

Scientific Session

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Conclusion: International registry collaboration provides an opportunity to study treatment variation across countries, elucidate gaps and help define optimal practices. Despite existing homogenous recommendations from both the Society for Vascular Surgery and the European Society for Vascular Surgery, significant variations exist in AAA management, most notably for AAA diameter at intact repair and utilization of EVAR. Although repair of <5.5cm AAA in men and <5.0 cm in women is not encouraged by current guidelines, this practice at the country level was coincident with a lower proportion of rAAA repairs. Given limitations of registry data, this relationship certainly cannot be defined as causal, and future prospective studies by this group will help define these relationships further.

Copenhagen, Denmark • 28-30 September 64

Scientific Session

OP 017 THE BEST CONDITIONS FOR 2 AND 3 PARALLEL STENTING DURING EVAR: AN IN VITRO STUDY

Institution: 1. Vascular Surgery Department, Cardiovascular Diseases Institute. Hospital Clinic Barcelona, Spain, Barcelona 2. Vascular Surgery Department, Hospital Universitario Cruces. Barakaldo, Bizkaia – Spain, Barakaldo 3. Department of Radiology, Clínica Creu Blanca, Barcelona – Spain, Barcelona, Spain

Authors presenting: Gaspar Mestres, Xavier Yugueros, Ana Apodaka, Savino, Pasquadibisceglie, Xavier Alomar, Vincent Riambau

Introduction: Following our previous published 1 parallel-stent in-vitro study, the aim of this study is again to identify which endograft-parallel stent combination, and to what degree of oversizing, may result in the most adequate fit in a juxtarenal abdominal aneurysmal neck, but when using a double or triple parallel-stent (chimneys) technique.

Methods: In-vitro silicon aneurysmal neck models of different diameters, with two and three side-branches (simulating both renal and superior mesenteric arteries), were constructed. Two different endografts (three diameters each) with two or three parallel-stents (of 6-6mm, or 6-6-8mm) were tested (Medtronic-Endurant endograft with balloon-expandable Bentley-BeGraft, and Gore-Excluder endoprosthesis with self-expanding Gore-Viabahn), applying three endograft- oversizing degrees (15%, 30% and 40%). After remodeling using the kissing-balloon technique at 37ºC, the 36 endograft- stent-oversizing combinations were scanned by computed tomography (CT). The size of the results in gutters, parallel- stent compression and main stentgraft infolding were recorded.

Results: Increasing oversizing (15%, 30% and 40%) showed a non-significant tendency towards smaller gutters and similar parallel-stent compression, but it significantly increased infolding, mainly for Excluder-Viabahn combination, and more in 3 parallel-stent models (0-67-100% and 0-0-100%, P=0.043 and 0.011 for Excluder-Viabahn in 3 and 2 parallel- stent models, and 0-0-67% and 0-0- 33%, P=0. 076 and 0.325 for Endurant-BeGraft). Excluder-Viabahn combination showed significant lower gutters (8.2, 22.6mm2, P=0.002 and 14.4, 23.3mm2, P=0.009 for 2 and 3 parallel-stents), but with higher stent compression (18%, 2%, P<0.001and 15%, 2%, P=0.007) than Endurant-BeGraft combinations for all oversizings (Image 1).

Image:

Conclusion: When using the parallel-stent technique during EVAR for 2 and 3 parallel-stents, this in-vitro study shows that increasing endograft oversizing is related to a tendency to smaller gutters and not increasing stent compression. However, infolding appears in most 40% oversized models, and is more frequent with 3 than 2 parallel-stents, and with Excluder-Viabahn than Endurant-BeGraft combinations; thus, 30% oversizing is the most optimal oversizing (and only 15% for Excluder- Viabahn with 3 parallel stents). Lower gutters, but higher stent compression, are achieved with Excluder-Viabahn than with Endurant-BeGraft combinations.

Copenhagen, Denmark • 28-30 September 65

Scientific Session

References: Mestres G, Uribe JP, García-Madrid C, Miret E, Alomar X, Burrell M, et al. The best conditions for parallel stenting during EVAR: an in vitro study. European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 2012;44:468–73. Donas KP, Lee JT, Lachat M, Torsello G, Veith FJ. Collected world experience about the performance of the snorkel/chimney endovascular technique in the treatment of complex aortic pathologies: the PERICLES registry. Annals of surgery 2015;262:546–53; discussion 552–3.

Copenhagen, Denmark • 28-30 September 66

Scientific Session

OP 018 CHANGES IN RENAL ANATOMY AFTER FENESTRATED ENDOVASCULAR ANEURYSM REPAIR

Institution: 1. The Royal Free Hospital, London, United Kingdom, 2. Aortic Centre, CHRU of Lille , Lille, France

Authors presenting: Blandine Maurel, Youcef Lounes, Mau Amako, Dominique Fabre, Adrien Hertault, Jonathan Sobocinski, Rafaelle Spear, Richard Azzaoui Tara M Mastracci, Stephan Haulon

Introduction: To assess short and long-term movement of renal arteries after fenestrated endovascular aortic repair (FEVAR).

Methods: All consecutive patients who underwent FEVAR at our institution with a custom-made device (CMD) designed with a fenestration for the superior mesenteric artery (SMA) and both renals, a high resolution computed tomography angiogram (CTA) and a minimum of 1 year follow-up were included. Angulation between the renal artery trunk and the aorta, clock-position of the origin of the renal arteries, distance between the origin of the renal arteries and the origin of the SMA, and target vessel occlusion were retrospectively collected on the preoperative, post-operative (<6 months) and on the last (>12 months) CTA using a dedicated 3D workstation. Results are expressed in median and interquartile range, and the variation between the pre and post-operative or follow-up measurements was calculated and compared. Results: From October 2004 to June 2015, 100 patients were operated on with such a CMD design and 86% of the imaging was available for accurate analysis. The median follow-up was 27.3 months (22.7-50.1). No renal occlusions occurred among these patients. We found a significant change in the absolute value of the renal trunk angulation of both renal arteries on the post-operative compare with the pre-operative CTA (16° difference upward [10- 26], p<0.0001]) but no significant motion thereafter (p=0.54). Regarding the absolute value of change in the renal clock positions: on the left side we found significant movement between the postoperative and the pre-operative CTA (15 minutes [0-30], p=0.02) as well as a significant movement during the follow-up (30 minutes [15-45], p<0.01); on the right side, the movement was only significant on the post-operative CTA (15 minutes [15-30], p<0.001) without significant change during the follow-up (p=0.25). No changes were noticed on the distance between renal and SMA ostia, with an absolute difference of 1.5 mm [1-2.5] between pre-operative and follow-up CTA.

Conclusion: The renal arteries demonstrate tolerance to permanent changes in angulation after FEVAR of approximately 16° upward trunk movement and of 15 to 30 minutes ostial movement without adverse consequences on patency after an average of 2 years follow up. The distance between the target vessels remains stable overtime. These results may suggest accommodation to sizing errors and thus a compliance to off-the shelf devices in favorable anatomies.

Copenhagen, Denmark • 28-30 September 67

Scientific Session

OP 019 EVAR WITH FLARED ILIAC LIMBS HAS A HIGH RISK OF LATE TYPE 1B ENDOLEAK

Institution: Clinic of Vascular and Endovascular Surgery, University Hospital Cologne, Cologne, Germany

Authors presenting: Daphne Gray, Jan S. Brunkwall, Michael Gawenda

Introduction: Reinterventions are still the achilles´ heel of endovascular aneurysm repair. While problems of the proximal landing zone are widely described, the distal landing zone is rarely investigated in the literature. Ectatic common iliac arteries (CIA) can be treated with flared iliac limbs, but the risk of a late type 1b endoleak could be increased when a dilated artery is used as sealing zone. As an alternative to flared limbs, iliac side branch stent grafts using could be implanted in patients with a distal diameter of ≥16mm in the CIA. Aim of the study was to evaluate the risk of late type 1b endoleak after standard EVAR in patients having common iliac artery limbs ≥20 mm (the distal CIA diameter 16mm or larger) compared to those being <20mm.

Methods: We performed a retrospective analysis of all patients treated with EVAR in our institution between 2006-2012. Included were patients with available information about the used iliac stent grafts as well as a minimum follow-up of 3 years with contrast-enhanced CT or if they had reached the endpoint (type 1b endoleak) earlier. Out of 692 limbs (346 patients), 147 had CT follow up less than 3 years, 91 had only duplex ultrasound as follow-up imaging, 107 were lost to follow-up, 35 had iliac side branch stent graft, 30 had the landing zone in the external iliac artery, 27 limbs had unreliable sizing records, and 17 had occluded iliac arteries, leaving 238 (34,4%) iliac limbs left for the analysis.

Results: Mean CT- follow-up was 52,4 (min-max 33-116) months. Mean oversizing for iliac limb sizing was 17,7% (range 5-60%). Absence of immediate type 1b endoleak in a post-implantation CT scan (max. 30 days after implantation) was documented for all iliac limbs. Eighteen type 1b endoleaks occurred during follow up (7,6%) with the first diagnosis after a mean of 37,7 months, range: 4 – 96). There were 177 iliac limbs with iliac stent graft diameter <20mm (Group I), and 61 with a diameter of ≥20mm (group II). Eleven (18%) of the 61 iliac limbs ≥20mm (Group I) developed a type 1b endoleak during follow-up in contrast to 7/177 (4%) (Group II) with <20mm in diameter (p=0,001). Odds ratio was 5,3 for iliac limbs ≥20mm to develop a type 1b endoleak. The ROC curve analysis indicated a limb size of 19mm as cut-off for a higher probability to develop a type 1b endoleak (Graph 1/Table 1).

Image:

Copenhagen, Denmark • 28-30 September 68

Scientific Session

Conclusion: Patients treated with iliac limbs ≥20mm showed a higher risk for type 1b endoleak in comparison to patients treated with distal iliac limb diameter less than 20mm in diameter. The occurrence of endoleak was late (mean 37 months). The primary use of an iliac side branch stent graft could be discussed in larger common iliac arteries.

Copenhagen, Denmark • 28-30 September 69

Scientific Session

OP 020 FEMALE SEX IS AN INDEPENDENT RISK FACTOR FOR WORSE CLINICAL OUTCOMES IN ABDOMINAL AORTIC ANEURYSM TREATMENT. A SECONDARY DATA ANALYSIS OF THE NATIONWIDE GERMAN D R G MICRODATA 2005-2013

Institution: Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

Authors presenting: Matthias Trenner, Andreas Kuehnl, Hans-Henning Eckstein

Introduction: Several studies showed that an increasing age and comorbidities are predictors for worse outcomes in open (OAR) and endovascular (EVAR) treatment for abdominal aortic aneurysms (AAA). The aim of this study was to analyze the interaction of female sex and in-hospital mortality after AAA treatment in a nationwide cohort.

Methods: The data were extracted from DRG statistic from the research data centers of the German Federal Statistical Office, which covers all in-patient cases (except psychiatry and special services). All cases with diagnosis of non-ruptured AAA (ICD-10 GM I71.4) and procedure codes (OPS 2005-2013) for EVAR (OPS 5-38.a1) or OAR (OPS 5-38.45, 5-38.47) treated from 2005-2013 were included. The data were analyzed using standard statistical methods (including Elixhauser Score for comorbidities, crude relative risk (RR) calculation). To adjust for sex, age, type of procedure, Elixhauser score, type of diagnosis (principal vs. secondary) and type of admission, a multilevel regression model with robust error variance was applied. The primary endpoint was in-hospital mortality, secondary endpoints were other organ complications.

Results: 84,631 cases were identified, of whom 10,039 (11.9%) were females. Women were 2.6 years older than men (♀73.7±8.5; ♂ 71.1±8.2; p<.0001) and had a higher Elixhauser Score (p<.0001). EVAR was used less frequently in women (♀48.1%; ♂ 54.7%; p<.0001). The overall in-hospital mortality was higher in women (♀5.0% versus ♂3.1%; RR[95%CI]= 1.60[1.45-1.75]), which was true after EVAR (♀2.8% versus ♂1.5%; RR=1.90[1.58-2.28]) and OAR respectively (♀6.8%; ♂5.0%; RR=1.36[1.22-1.52]). Complications were more frequent in females (peripheral arterial occlusions: ♀4.8% versus ♂3.8%; RR= 1.25[1.14-1.37], mesenteric thrombosis and embolism: ♀1.8% versus ♂1.0%; RR= 1.81[1.54-2.12], renal thrombosis and embolism: ♀0.8% versus ♂0.5%; RR=1.56[1.23-1.98]). The multivariable regression analysis identified patient´s age (adjusted RR=1.06[1.05-1.06]), an increased Elixhauser Score (RR=1,10[1,09- 1,10]) and female sex as independent risk factors for higher in-hospital mortality (RR=1.16[1.04-1.28]).

Conclusion: Women are older when receiving AAA treatment and are less likely to receive EVAR. Other risk factors (age, comorbidities) also put women at a disadvantage. Mortality and complication rates in females are higher for OAR and EVAR. Besides age and comorbidity, female sex is an independent clinical risk factor for higher in-hospital mortality. Based on these findings, increased caution needs to be exercised when treating AAA in women.

Copenhagen, Denmark • 28-30 September 70

Scientific Session

OP 021 LESSON LEARNED WITH THE USE OF ILIAC BRANCH DEVICES: 10 YEAR RESULTS IN 150 CONSECUTIVE PATIENTS

Institution: 1. Unit of Vascular Surgery, Santa Maria della Misericordia Hospital, University of Perugia, Perugia 2. GVM Research and Care, Cotignola and Rome, Italy

Authors presenting: Gianbattista Parlani, Gioele Simonte, Luca Farchioni, Giacomo Isernia, Enrico Cieri, Massimo Lenti, Piergiorgio Cao, Fabio Verzini

Introduction: Iliac branch device (IBD) endografting has become an appealing solution for endovascular repair of extensive aorto-iliac aneurysms. Nevertheless, no large series with long-term follow-up of IBD are available. The aim of the present study was to analyse long-term outcome of IBD in a consecutive series of patients to look for predictive factors for clinical success.

Methods: Between 2006 and 2016, 150 consecutive patients were enrolled in a prospective database. Indications included unilateral or bilateral common iliac artery aneurysm (CIA) combined or not with abdominal aneurysm (AAA). Patients were routinely followed up with duplex and computed tomography. Data were reported according to the Kaplan–Meier method.

Results: There were 142 males, mean age 74 years. Preoperative median CIA diameter was 37.9±8.5 mm. Ninety-three patients had an associated AAA >35 mm (mean 51.6±11.6 mm), 21 patients presented hypogastric aneurysm (HA). Twenty-six patients (17.3%) underwent isolated IBD repair and 124 (82.7%) patients received associated endovascular aortic repair (EVAR). Five bilateral IBDs were implanted. Fifteen patients had previous aorto-biiliac procedure and received isolated IBD with axillary approach. One-hundred-thirty-three procedures were performed with the Cook IBD device while 22 patients received Excluder IBE device (Gore). Self-expanding stent-grafts for the hypogastric artery were used in 117 cases, while balloon-expandable endografts were used in 38 patients. Technical success rate was 96 %, with no mortality. Nine patients presented target hypogastric occlusion during follow up; five of these occlusion occurred in the perioperative period. Two patients experienced external iliac occlusion in the first month. At a mean follow-up of 41.6±3.6 months (range 1–120) CIA growth >3 mm was detected in 12 cases (7.7%). Iliac endoleak developed in 4.5% patients. Estimated survival was 93.4, 72.0 56.1% at 1, 5 and 10 years respectively Estimated patency rate of internal iliac branch was 94.2, 93.3 and 89.2% at 1, 5 and 10 years respectively. Patients with hypogastric aneurysm were more likely to experience internal iliac branch occlusion (23,8% vs 3,1%; p=0,003) Rates of freedom from any reintervention were 94.9, 82.7 and 69.8% at 1, 5 and 10 years respectively. No late ruptures or AAA-related death occurred during follow-up.

Conclusion: Long-term results show that IBD implant offers excellent outcomes up to 10 years with high patency rates and low risk of re-intervention. These data support the IBD implantation as a first line treatment of iliac aneurysms References: Long-term results show that IBD implant offers excellent outcomes up to 10 years with high patency rates and low risk of re-intervention. Appropriate case selection plays a significant role in the outcome of the procedure.These data support the IBD implantation as a first line treatment of iliac aneurysms.

Copenhagen, Denmark • 28-30 September 71

Scientific Session

OP 022 THE LONG-TERM DURABILITY OF INTRAOPERATIVELY PLACED OF PALMAZ STENTS FOR THE TREATMENT OF TYPE IA ENDOLEAKS AFTER EVAR OF AAA

Institution: Vascular Center, Malmö, Malmo, Sweden

Authors presenting: Mohammed Abdulrasak, Timothy Resch, Björn Sonesson, Jan Holst, Thorarinn Kristmundsson, Nuno Dias

Introduction: Type Ia endoleak is associated with aneurysm expansion and rupture and aggressive treatment is recommended as soon as possible. Proximal Palmaz stents are one treatment alternative with well proven short-term results. However, little is known about the long-term. This study aims to study the long-term results of the intraoperative placement of Palmaz stent for the treatment of proximal (Type Ia) endoleaks during EVAR of AAA.

Methods: Patients receiving intraoperative proximal Palmaz stent due to type Ia endoleak between 1998 and 2012 were reviewed retrospectively concerning pre-, intra- and post-operative data. Pre-operative and follow-up imaging was reviewed for anatomical changes for AAA sac and at different visceral levels of the aorta (Celiac trunk, SMA, Lowest renal artery and 9 mm below lowest renal). Survival was calculated with life tables. Relative survival comparing acute (ruptured and symptomatic) with elective EVAR patients concerning patients with follow-up ≥ 3 months was also performed. For the anatomical changes, Wilcoxon signed rank test was used for comparisons of significance. For the life tables, log-rank test was used.

Results: One hundred and twenty five patients were included (83 elective, 22 ruptures and 20 symptomatic). Thirty-six (34%) patients out of 105 with an available pre-operative CT were outside the IFU, while 43 (41%) had conical aortic necks. Nine patients died peri-operatively. Median follow-up was 43 (15- 72) months. Six patients had late AAA-related deaths. There were 51 re-interventions of which 7 were type Ia endoleak related. Primary and assisted freedom from type Ia endoleak five years postoperatively was 84 ± 4 % and 89 ± 3 %, respectively. The visceral aortic diameter increased significantly between the 1st and the latest post-operative images in 15 / 91 (16 %), 12 / 91 (13 %), 34 / 91 (37 %) and 30/ 91 (33 %) patients at the levels of coeliac trunk, SMA, lowest renal artery and 9 mm distal to lowest renal artery, respectively. Sixteen (18 %) out of these 91 patients exhibited ≥ 5 mm AAA expansion. Five-year primary, primary- assisted and secondary success were 55 ± 5 %, 66 ± 5 % and 71 ± 5 % respectively. For patients with follow-up ≥ 3 months, there was no significant (P> 0.05) difference in survival, clinical success or assisted type Ia endoleak for the acute (N=30) versus elective (N=76) EVAR. There was a significantly higher primary freedom from type Ia endoleak ( P=0.025) in elective EVAR when comparing with acute EVAR.

Conclusion: Intraoperatively placed Palmaz stents seem to confer a high freedom from type Ia endoleaks on the long- term. Palmaz stents are an acceptable bailout solution for intraoperative type Ia endoleaks, especially in the acute setting, but should not be used in extending the application of elective infrarenal EVAR to more demanding anatomies.

Copenhagen, Denmark • 28-30 September 72

Scientific Session

OP 023 THE UK PILOT STUDY ON MULTI-LAYER FLOW-MODULATING STENTS FOR THORACO-ABDOMINAL AND PERI-RENAL ANEURYSMS: RESULTS AT THREE YEARS.

Institution: 1. Department of Vascular and Endovascular Surgery, University Hospital of South Manchester 2. Department of Academic Surgery, University of Manchester 3. Department of Vascular and Endovascular Surgery, Manchester Royal Infirmary 4. Department of Vascular and Endovascular Surgery, University Hospital South Manchester, Manchester, United Kingdom

Authors presenting: Chris Lowe, Ferdinand Serracino-Inglott, Ray Ashleigh, Charles McCollum

Introduction: We previously reported our early experience using the first-generation multi-layer flow modulating stent (MFMS) for patients with thoraco-abdominal (TAAA) and perirenal aneurysms (PAA) who were unsuitable for conventional EVAR and unfit for open repair. We encountered continued aneurysm growth, device component dislocation and re-intervention. Our study patients have now completed at least 3 years follow-up and we report the outcomes.

Methods: Patients with TAAA and PAA unfit for open surgery and with no conventional options for endovascular repair were recruited by two UK vascular units. Follow-up included CTA at 1, 3, 6, and 12 months, then annually until 3 years. Outcome measures included 30 day mortality, growth-free survival, branch vessel patency, complications, re-intervention and maximal aortic diameter.

Results: MFMS were implanted in 14 patients (6 PAA, 8 TAAA) between October 2011 and March 2014 with one (7%) 30 day death and 11 (79%) surviving to 12 months. The median aneurysm growth was 9 mm in the first 12 months following implantation. At current follow-up to death or at least 3 years, eleven patients (79%) have died including four confirmed ruptures, one presumed rupture, one confirmed dissection with rupture, one MI post-op (procedure related), one multi-organ failure following re-intervention (procedure related) one myocardial infarction (MI) (out of hospital - unrelated), one pneumonia (not device or procedure related), and one decompensated liver failure (unrelated). Continued aneurysm growth occurred in all patients who suffered rupture or dissection. AAA diameter remains stable in two of the three surviving patients. Fifty of 51 covered aortic branches remained patent with no embolic episodes or symptoms of ischaemia in any patient. MFMS dislocation occurred in four patients, leading to re-intervention in two. A total of six re-interventions were performed in five patients (35%) with one post re-intervention death.

Conclusion: These first-generation MFMS were unstable and dislocated frequently. It is uncertain whether MFMS implantation influenced the natural history of these aneurysms as none decreased in size, but two remain stable after a mean of 42.5 months. Although side branch patency was maintained, rupture or dissection occurred in 43% of patients and our results do not support the continued use of these first-generation devices. Further development is needed as this technology has potential as demonstrated by the control of aneurysm rupture in three and growth in two patients.

Copenhagen, Denmark • 28-30 September 73

Scientific Session

SCIENTIFIC SESSION 4 – MISCELLANEOUS (1)

OP 024 DEGRADATION PHENOMENA ON SECOND GENERATION OF EXPLANTED AORTIC TEXTILE ENDOGRAFTS

Institution: 1. CHU Strasbourg, Strasbourg 2. LPMT, Mulhouse 3. GEPROVAS 4. Vascular Surgery, CHU Strasbourg, Strasbourg, France

Authors presenting: Nabil Chakfe, Yannick Georg, Agnes Bussmann, Frederic Heim Julie Papillon, Elie Girsowicz, Charline Delay, Delphine Dion, Anne Lejay, Fabien Thaveau

Introduction: First generation of textile endografts (EG) demonstrated poor stability related to stent and fabric degeneration. New generations demonstrated dramatic improvements and are used in more and more challenging locations. However, EG-related complications still remain. The goal of the study was to characterize ageing phenomena and contribute in explaining particular complications such as endotension.

Methods: From January 2011 to March 2016, 104 EP were collected as a part of the Geprovas European retrieval program. 72 were textile EG. We analysed the first 45 textile EG we collected. EG were products from Medtronic, Cook, Bolton, Vascutek and “home-made”. There were 33 abdominal and 12 thoracic EG implanted for a mean duration of 3.8 years (2 days – 13.5 years). Main reasons for explantation were endoleak (22), infection (4) and thrombosis (4). EG were processed with a standardized ISO 9001 certified process associating macroscopic and microscopic studies before and after cleaning. Analyses were performed on cleaned EG using a “Keyence VHX – 600” light omicroscope with a magnification from 20x to 200x and every defect was recorded using a specific classificat developed with textile engineers taking into account the cause of degradation with 16 items, as well as the number and size of defects visible on the graft. To compare the level of degradation of different EG of different size, cuts and holes were normalized to the textile surface, giving a value k which is indicating the amount and size of defects per area Observations were correlated with information provided by physicians.

Results: We observed mechanical degradation on EG. We showed that the pre-damaging in the sheath promotes textile rupture. The probability of finding a tear on a kink is 10% higher than next to it (Figure 1). 82% of EG showed some evidence of damage caused by compression. EG design influenced the degradation process. Knots situated on a stents’ detour are 16 % more likely to break than those on a straight part. 2,1 % of the knots fixing the stent to the fabric were completely cut and 2,9 % are pa damaged. The most observed cause of damage was abrasion with 2 types: abrasion between several filaments in the knot moving against each other and abrasion between the knot and its environment in the artery. Degradation of EG fabric is mostly caused by abrasion. For fabric as well as stitching filaments, fatigue has be observed but stayed a minor problem. Most common reasons for abrasion were the dynamic friction between the fabric and the stent or between the textile and its environment in the body (Figure 2). Influence of duration of implantation: average k coefficient demonstrated a tendency to increase with time. M importantly dispersion of values was also growing, and more and more high values were observed after several years. Figure 3 shows the average EG degradation with time (black points) as well as the highest and lowest values observed for each time step.

Copenhagen, Denmark • 28-30 September 74

Scientific Session

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Conclusion: Current textile EG generations demonstrate ageing phenomena leading to multiple holes tears and cuts that could explain endotension. Further studies including more explants are necessary to make correlation with specific models and implantation conditions, as well as separate mechanical tests on prototypes in order to simulate the EG implantation environment.

Copenhagen, Denmark • 28-30 September 75

Scientific Session

OP 025 DIASTOLIC BLOOD PRESSURE AS AN INDEPENDENT RISK FACTOR FOR PERIPROCEDURAL EVENTS FOLLOWING CAROTID ENDARTERECTOMY IN ASYMPTOMATIC PATIENTS (ON BEHALF OF THE ACST-1 COLLABORATIVE GROUP)

Institution: 1. Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom 2. Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands 3. Nuffield Department of Population Health, Clinical Trial Service Unit, Oxford, United Kingdom

Authors presenting: Djurre De Waard, Gert-Jan de Borst, Richard Bulbulia, Alison Halliday

Introduction: Benefits of carotid endarterectomy (CEA) in stroke prevention partly depend on periprocedural risks. Although systolic hypertension is thought of as a risk factor for periprocedural events, effects of diastolic blood pressure (dBP) are often ignored. In a recent post-hoc analysis of ICSS, diastolic blood pressure was associated with adverse outcome after CEA in symptomatic patients. We aimed to identify whether this was also a risk factor for periprocedural stroke or death in asymptomatic patients in the Asymptomatic Carotid Surgery Trial (ACST-1).

Methods: In ACST-1, 3120 patients with severe asymptomatic carotid stenosis thought suitable for revascularization were randomly assigned to CEA or indefinite deferral of surgery. To investigate this, we analysed first asymptomatic CEA’s in the surgical cohort. In a univariate logistic regression, baseline patient characteristics (age, gender, medical history, medical treatment, blood pressure, grade of stenosis, echolucency, infarction on imaging) were used to compare odds ratios for periprocedural (<30 days) stroke or death. Then, multivariate analysis was performed using risk factors with a p-value <0.3 from univariate analysis.

Results: CEA was performed on a total of 1425 patients in the surgical cohort (1560 patients). In total, 42 patients (2.9%) had periprocedural death or stroke, of which most (48%) occurred on the day of surgery. In univariate analysis diastolic blood pressure >90mmHg was the only risk factor significantly associated with periprocedural stroke or death (OR=1.90; 95% CI 1.03 – 3.51, p=.04). Mean sBP and dBP at randomization were 154 mmHg (SD=22) and 83 mmHg (SD 11). In multivariate analysis dBP remained the only independent risk factor (OR=2.06; 95% CI 1.04 – 4.06, p=.04).

Conclusion: In ACST-1, diastolic blood pressure was the only independent risk factor for stroke or death following CEA in asymptomatic patients. This suggests that careful treatment to lower diastolic blood pressure in asymptomatic patients undergoing CEA could prevent stroke or death. This important finding is in concordance with recent evidence from symptomatic patients.

Copenhagen, Denmark • 28-30 September 76

Scientific Session

OP 026 CONTECI PROGRAM. A NEW WAY TO CONTROL PERIPHERAL ARTERIAL DISEASE USING THE NEW TECHNOLOGIES AND THE PATIENT EMPOWERMENT. RANDOMIZED TRIAL

Institution: 1. Vascular Surgery Department, Mataro Hospital, Mataro 2. Surgery Department, Medicine Department, Autonomous University of Barcelona, Barcelona 3. Research Department, Mataro Hospital, Mataro, Spain

Authors presenting: Meritxell Davins, Vicenç Artigas Raventós, Xavier Borràs Pérez, Elisabet Palomera Fanegas, Mateu Serra Prat, Jesús Alós Villacrossa

Introduction: The current increase in chronic diseases calls for changes to the health system. It is necessary to promote expert patient in chronic disease. The expansion of new technologies gives us new tools to face new challenges, providing efficiency, expertise and autonomy. The characteristics of peripheral arterial disease make possible to promote expert patient and the self-management. In order to bring these concepts together we created a telemedicine program promoting expert patient for increasing the quality of life and satisfaction of patients and improving the efficiency of the health system.

Methods: Randomized clinical trial on patients with peripheral arterial disease in intermittent claudication grade. They were randomized into two groups: intervention arm (IA) using CONTECI program for self- managing and control arm (CA), followed as usual vascular visits.

Results: The trial included 150 patients. 1 year follow up. Rest pain decreased in the telematics arm (8.4% vs 1.4% p=0.05) and ulcers were diagnosed more and quickly in telematics arm (10% CA vs 16% (IA). Quality of life improve 67.36 to 76.78 in IA p=0.047. Satisfaction increased in telematics arm after the study (67.36 baseline vs 76.78 p=0.03 finally). The scheduled visits decreases 95.95% and the emergency visits decreased too.

Conclusion: We concluded that self-monitoring using telemedicine is feasible for patients with intermittent claudication. The program promotes the expert patient. The CONTECI program adds value to the control of PAD patients, encouraging active patients, raising satisfaction in the control of the disease and improving healthcare efficiency without signs of clinical inferiority

Copenhagen, Denmark • 28-30 September 77

Scientific Session

OP 027 A NOVEL PREDICTION TOOL TO PREDICT MOBILITY OUTCOME AFTER LOWER EXTREMITY AMPUTATION SECONDARY TO PERIPHERAL ARTERIAL DISEASE AND/OR DIABETES

Institution: 1. Rehabilitation Medicine, Biostatistics, University of Washington, Seattle 2. Vascular Surgery, Oregon Health and Science University, Portland 3. Epidemiology, Spectrum Research, Tacoma, United States

Authors presenting: Joseph Czerniecki, Aaron Turner, Rhonda Williams, Mary Lou Thompson, Kevin Hakimi, Gregory Landry, Dan Norvell

Introduction: Mobility is a key determinant of quality of life after amputation. In the patient centric model of care it is important to enable patients to participate in health care decisions through shared decision- making, especially when there is outcome uncertainty. Although numerous retrospective studies have evaluated factors associated with mobility outcome after amputation, there is little information available to guide surgeon/patient communication regarding amputation level and probable mobility outcome. This research will present a patient specific prediction tool (AMPREDICT – Mobility) that enables the prediction of the probability of independence in BASIC or ADVANCED mobility at 1-year post initial dysvascular major lower extremity amputation.

Methods: Two multisite prospective cohort studies during consecutive 4-year time periods (2005-2009 and 2010-2014) were conducted at a University Hospital, a Level 1 Trauma Center and 5 VA Medical Centers, on individuals undergoing their first major lower extremity amputation (transfemoral, transtibial, transmetatarsal) due to complications of peripheral vascular disease or diabetes. Multiple demographic, psychological, co-morbid medical, and social predictors were collected in the peri- amputation period. The primary outcomes were BASIC and ADVANCED mobility as measured by the Locomotor Capability Index (LCI-5). Combined data were used for model development and internal validation. Backwards stepwise logistic regression was used to select the final predictors. Variables were retained with a p-value <.20. To quantify the discrimination of each model, we estimated the C-statistic and the discrimination slope. Calibration was assessed using the Hosmer- Lemeshow goodness-of-fit test and comparing observed proportions to the estimated probabilities. Internal validity of each model was assessed with bootstrap sampling.

Results: 12-month follow-up was reached by 157 of 200 (79%) enrolled participants. Among these, 54(34%) did not achieve independence in BASIC mobility, while 103 (65%) achieved independence in BASIC mobility. Fifty-one (32%) of those that achieved independence in BASIC mobility achieved independence in ADVANCED mobility. Predictive factors associated with reduced odds of achieving BASIC mobility were increasing age and BMI, the presence of COPD, dialysis, diabetes, and poor to fair self-rated health. White and married individuals had higher odds of achieving BASIC mobility. The prediction model for ADVANCED mobility retained the same variables with the exception of diabetes. Both models showed strong discrimination with C-statistics of 0.88 and 0.86, respectively. The mean difference in predicted probabilities of BASIC (ADVANCED) mobility for those who did and did not achieve this outcome was 41% (36%), suggesting good discrimination. Tests for calibration and observed versus predicted plots suggested good fit for both models; however, the precision of the estimates of the mobility probabilities was modest. Internal validation through bootstrapping demonstrated some over- optimism of the predictive models with the optimism- adjusted C-statistics for BASIC and ADVANCED mobility being .77 and .75, respectively.

Copenhagen, Denmark • 28-30 September 78

Scientific Session

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Conclusion: AMPREDICT-mobility is a user-friendly tool that enables the patient specific prediction of 12- month BASIC and ADVANCED mobility at each major lower extremity amputation level in dysvascular amputees, based upon pre-operative factors. This predictive tool can enhance patient/surgeon communication and decision-making at the time of amputation surgery.

Copenhagen, Denmark • 28-30 September 79

Scientific Session

OP 028 ASSESSMENT OF FOOT PERFUSION BEFORE AND AFTER REVASCULARIZATION OF CRITICALLY ISCHEMIC FOOT USING INDOCYANINE GREEN FLUORESCENCE IMAGING

Institution: Vascular Surgery, Helsinki University Hospital, Helsinki, Finland

Authors presenting: Nicla Settembre, Anders Albäck, Petteri Kauhanen, Kristyna Spillerova, Maarit Venermo

Introduction: Critical limb ischemia (CLI) is a clinical diagnosis, confirmed by objective tests, usually ABI, toe pressure (TP) and TcPO2. Indocyanine green fluorescence imaging (ICG-FI) is a diagnostic modality for assessing the perfusion of tissues. Although some application has been described of ICG-FI in the assessment of ischemic foot, the technique is uncommon in vascular surgery. Our aim was to study the usefulness of ICG-FI in the quality control of revascularization.

Methods: One hundred and one patients with 104 CLI limbs were studied with ICG-FI using SPY Elite. ABI and TP were measured in all patients. After ICG-FI, assessment of circulation was done using time- intensity curve derived from two regions of interest. Three parameters were derived from the curves: Maximum ingress, meaning the absolute value of the maximum intensity; ingress rate, meaning the value from the time intensity curve describing the increase in maximum ingress per seconds and SPY10, which is the intensity achieved during the first 10 seconds after the foot starts to gain intensity.

Results: Ninety-five technically successful procedures was achieved, 63 (66.3%) endovascular and 32 (33.7%) surgical revascularizations. In 9 (9.5%) patients, an open line from the aorta to the foot was not achieved due to a failure to recanalize the occlusion (n=7) or due to distal embolization (n=2). The mean ingress values before and after the procedure in patients who underwent successful revascularization were 81 ± 47 units and 120 ± 5 units of ingress (p<.001) and ingress rates 4.2 ± 4 units/second and 8.0 ± 6.2 units/second (p=.001), respectively. In the PTA patients in whom the revascularization was unsuccessful, no changes were seen in the hemodynamic parameters. In 6 (8.8%) patients who underwent technically successful revascularization, the SPY values were worse after the revascularization than at the baseline. In all cases an explanation was found in closer evaluation.

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Conclusion: ICG-FI with SPY Elite provides reliable information on the success of revascularization, in addition to implicating possible failure if there is no improvement in the ICG-FI variables. It gives valuable information to complement traditional assessment methods.

Copenhagen, Denmark • 28-30 September 80

Scientific Session

SCIENTIFIC SESSION 5 - CAROTID

OP 029 INDIVIDUAL PATIENT DATA ANALYSIS OF 5226 PATIENTS IN THE ASYMPTOMATIC CAROTID SURGERY TRIALS - BENEFITS AND HAZARDS OF IMMEDIATE SURGERY IN PATIENTS TAKING CONTEMPORARY MEDICAL THERAPIES (ON BEHALF OF ACST-1, ACAS & VACS COLLABORATORS AND THE CSTC)

Institution: University of Oxford, Oxford, United Kingdom

Authors presenting: Alison Halliday, Hongchao Pan, Peter Rothwell, Richard Bulbulia, Richard Peto

Introduction: Between 1983 and 2003 (with follow up until 2008) three randomised trials compared carotid endarterectomy (CEA) plus medical therapy vs medical therapy alone in a total of 5226 patients with tight currently asymptomatic carotid stenosis. Using individual patient data (IPD), this presentation examines the hazards and benefits of both treatment options and compares outcomes by intention- to-treat and per-protocol analysis.

Methods: Patients randomised in the VACS (444, 1983-87), ACAS (1662, 1987-1993) and ACST-1 (3120, 1993-2003) trials were included in intention-to-treat and per-protocol analyses. The analyses were stratified by trial, sex and age at entry.

Primary outcomes (analysed separately and together):

1. 30-day peri-procedural stroke and death rates (ie safety) 2. Non-perioperative stroke rates (ie efficacy) Secondary outcomes: 1. Fatal/disabling stroke or peri-operative death 2. Fatal/disabling non-perioperative stroke 3. Non-perioperative carotid territory stroke (overall & fatal/disabling)

Analyses of primary and secondary outcomes for the following subgroups were performed: Gender, age, prior use of antithrombotic, BP-lowering and lipid-lowering therapy

Results: Results from these trials included follow up over a 25-year period and separate trial results showed striking similarity to the overall result. Peri-operative stroke or death occurred in 2.8% of those receiving non-symptomatic CEA, and in 4.1% who had CEA after symptoms.The 10-year risk of any stroke or perioperative death by allocated treatment was 20.1% for medical therapy alone vs 14.8% for CEA, corresponding to an absolute risk reduction (ARR) of 5.3% (p=0.0009). The rate ratio (RR) of the first non-perioperative stroke for CEA vs medical therapy alone was 0.55 [95%CI 0.46-0.65, p<0.0001] in favour of CEA. For patients on lipid-lowering therapy, peri-operative stroke or death occurred in 2.2% of the non-symptomatic CEAs, and in 3.7% of the symptomatic CEAs. The 10-year risk of any stroke or perioperative death by allocated treatment was 15.6% vs 10.1% (ARR 5.5%, p=0.005) and for first non-perioperative stroke the RR was 0.52 [95%CI 0.39-0.70, p<0.0001] in favour of CEA. Per-protocol analysis produced similar results, the overall RR of the first non- perioperative stroke being 0.48 in favour of CEA [95%CI 0.40-0.58, p<0.0001].

Conclusion: The benefit of immediate surgery for asymptomatic tight carotid stenosis is clear from these analyses. Both intention to treat and per-protocol analyses showed that, for men and women up to 75 years, on contemporary medical treatments, CEA halved 10-year stroke risk. Lipid-lowering therapy led to both lower overall stroke risk and lower peri-procedural stroke and death risk, so use of statins will reduce stroke risk, but the addition of CEA will halve the remaining risk (1.5% vs 0.7% pa) for at least the next 10 years.

Copenhagen, Denmark • 28-30 September 81

Scientific Session

OP 030 A SYSTEMATIC REVIEW AND META-ANALYSIS OF OUTCOMES FOLLOWING STAGED/SYNCHRONOUS CAROTID ARTERY STENTING AND CORONARY ARTERY BYPASS SURGERY

Institution: Department of Vascular Surgery, Leicester Royal Infirmary, Leicester, United Kingdom

Authors presenting: Kosmas Paraskevas, Sarah Nduwayo, Athanasios Saratzis, Ross Naylor

Introduction: The management of patients undergoing coronary artery bypass (CABG) with concurrent carotid disease remains controversial. Strategies include; (i) isolated CABG, (ii) staged/synchronous carotid endarterectomy (CEA) + CABG and (iii) staged/synchronous carotid artery stenting (CAS) + CABG. Numerous systematic reviews have evaluated outcomes after staged/synchronous CEA+CABG, but few have evaluated outcomes after staged/synchronous CAS+CABG.

Methods: Systematic review based on PRISMA recommendations with searches of PubMed/Medline, Embase and Cochrane databases by two investigators (KP, SN). Synchronous procedures involved CAS+CABG being performed on the same day, while staged interventions involved at least one day’s delay between CAS and CABG.

Results: The systematic review identified 32 eligible studies, involving 2997 patients (synchronous = 550; staged = 2378). The majority of patients (85%) were neurologically asymptomatic and had a unilateral stenosis (74%), while 26% had bilateral stenoses or stenosis + contralateral occlusion. Overall; 30-day death/stroke was 6.9% (95%CI 5.4-8.8); death/stroke/MI was 7.9% (95%CI 6.8-9.2). Studies published up to 2009 reported 30-day death/stroke of 10.6% (95%CI 7.6-14.7) vs 5.2% (95%CI 3.8-6.9) after 2009, while 30-day death/stroke/MI was 12.6% prior to 2009 (95%CI 9.4-16.5) vs 7.2% (95%CI 6.0-8.5) for publications after 2009. In a cohort where >80% of patients were asymptomatic and where >80% had a unilateral stenosis; 30-day death/stroke was 6.7% (95%CI 4.9-9.2), while death/stroke/MI was 8.5% (95%CI 6.4-11.3). There was insufficient data to perform meaningful outcome analyses on symptomatic patients. Staged CAS+CABG was associated with 30-day death/stroke of 8.6% (95%CI 6.9-10.6) vs 5.6% (95%CI 3.8-8.1) after synchronous procedures. Death/stroke/MI was 9.9% (95%CI 7.9-12.2) following staged procedures vs 6.3% (95%CI 4.3- 8.9) after synchronous interventions. There were five peri-procedural antiplatelet treatment (APRx) strategies; (1) no APRx (30-d death/stroke/MI = 4.1% (95%CI 1.7-9.4); no data on bleeding complications); (2) single APRx pre CAS and CABG then dual APRx after CABG (30d death/stroke/MI 6.8% (95%CI 3.8-11.6); 7.6% bleeding complications); (3) dual APRx preCAS down to 1 APRx preCABG (30d death/stroke/MI 9.8% (95%CI 7.1-13.5); 3.3% bleeding complications); (4) dual APRx preCAS, both stopped preCABG (30d death/stroke/MI 14.5% (95%CI 5.9-31.7); 0% bleeding complications); (5) dual APRx preCAS and continued through CABG (30d death/stroke/MI 9% (95%CI 3.1-23.4); 1% bleeding complications).

Conclusion: In a cohort of predominantly asymptomatic patients with unilateral stenoses, outcomes following staged/synchronous CAS+CABG were broadly comparable to previous systematic reviews evaluating the roles of staged/synchronous CEA+CABG. Whilst formal statistical comparisons were not possible (data too heterogeneous), the systematic review suggested that synchronous (same day) interventions did not incur excess risks, compared with staged interventions. There is, however, no consensus as to what is the optimal APRx strategy during staged/synchronous CAS+CABG. Staged/synchronous CAS+CABG is an alternative to CEA+CABG. However, even though procedural risks may have decreased over time, it remains questionable whether the observed 6-9% risks of procedural death/stroke can be justified in a cohort of asymptomatic patients with predominantly unilateral carotid disease who probably face low risks of peri-operative stroke following CABG without prophylactic CEA or CAS.

Copenhagen, Denmark • 28-30 September 82

Scientific Session

OP 031 SHUNTING DURING CAROTID ENDARTERECTOMY: WHAT WE HAVE LEARNED FROM DIFFUSION- WEIGHTED MAGNETIC RESONANCE IMAGING.

Institution: AZ Groeninge Kortrijk, University of Leuven, KULAK, Kortrijk, Belgium

Authors presenting: Elke Wybaillie, Patrick Seynaeve, Hans Pottel, Gunter De Smul, Paul Wallaert, Philip Lerut

Introduction: The use of a shunt during carotid endarterectomy (CEA) remains controversial. Assessment of shunting should be based on measuring cerebral ischemia. In the last years, diffusion-weighted magnetic resonance imaging (DWI) is increasingly used to identify cerebral ischemia. In this study, we want to assess the role of shunting in the occurrence of cerebral embolization during CEA, as detected by DWI.

Methods: 366 CEA procedures, with a policy of selective shunting, were included in this retrospective cohort study for a period of 7 years. Two medical databases were reviewed to collect data on shunt use, perioperative neurological events and postoperative DWI. The primary outcome measure was the incidence of an emboligenic ischemic DWI lesion ipsilateral to the side of surgery. The incidence of these DWI lesions was compared between the shunting and the non- shunting group. A subgroup analysis was performed to differentiate between asymptomatic and symptomatic carotid stenosis.

Results: Shunt use was similar in both asymptomatic and symptomatic carotid stenosis group (21.8% vs. 26.2%, respectively; p=0.38). The overall incidence of emboligenic DWI lesions is 8.7% (32/366). In the non-shunting group (n=280), a 7.1% incidence is reported, whereas in the shunting group (n=86), a 14.0% incidence is seen (borderline non-significant difference; p=0.08). In the asymptomatic carotid stenosis group, there were significantly more emboligenic DWI lesions when a shunt was used, compared to when no shunt was used (16.3% vs. 5.7% incidence, respectively; p=0.03). In the symptomatic carotid stenosis group, no difference in incidence of emboligenic DWI lesions was found when a shunt was used or not (10.8% vs. 9.6%; p=0.76). Only one patient with an emboligenic DWI lesion presented with a stroke; all other lesions were clinically silent (31/32; 97%).

Conclusion: There is a tendency for higher incidence of emboligenic DWI lesions when using a shunt during CEA. Subgroup analysis for the asymptomatic carotid stenosis group shows a statistically significant higher incidence of emboligenic DWI lesions when a shunt was used, compared to when no shunt was used. Most of these emboligenic DWI lesions are clinically silent. The clinical relevance of cerebral embolization during CEA is still under debate. Therefore, the use of a shunt during CEA must be carefully considered especially in asymptomatic patients.

References: Pennekamp CW, Moll FL, de Borst GJ. The potential benefits and the role of cerebral monitoring in carotid endarterectomy. Curr Opin Anaesthesiol. 2011;24(6):693-697. Chongruksut W, Vaniyapong T, Rerkasem K. Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting) - Review. Cochrane Database Syst Rev. 2014;6:CD000190. Schnaudigel S, Groschel K, Pilgram SM, et al. New brain lesions after carotid stenting versus carotid endarterectomy: A systematic review of the literature. Stroke. 2008;39:1911- 1919. Aburahma AF, Mousa AY, Stone PA. Shunting during carotid endarterectomy. J Vasc Surg. 2011;54(5):1502-1510. Müller M, Reiche W, Langenscheidt P et al. Ischemia after carotid endarterectomy: comparison between transcranial Doppler sonography and diffusion-weighted MR imaging. Am J Neuroradiol. 2000;21(1):47-54. Ghogawala Z, Westerveld M, Amin-Hanjani S. Cognitive outcomes after carotid revascularization: the role of cerebral emboli and hypoperfusion. Neurosurgery. 2008;62(2):385-395.

Copenhagen, Denmark • 28-30 September 83

Scientific Session

Plessers M, Van Herzeele I, Vermassen F et al. Neurocognitive functioning after carotid revascularization: a systematic review. Cerebrovasc Dis Extra. 2014 Jun 24;4(2):132-48. Schauber MD, Fontenelle LJ, Solomon JW, et al. Cranial/cervical nerve dysfunction after carotid endarterectomy. J Vasc Surg. 1997;25(3):481-487.

Copenhagen, Denmark • 28-30 September 84

Scientific Session

OP 032 THE NATIONAL NORWEGIAN CAROTID STUDY; TIME FROM SYMPTOM DEBUT TO SURGERY IS TOO LONG, GIVING ADDITIONAL NEUROLOGICAL EVENTSSHUNTING DURING CAROTID ENDARTERECTOMY: WHAT WE HAVE LEARNED FROM DIFFUSION-WEIGHTED MAGNETIC RESONANCE IMAGING.

Institution: 1. University Hospital of North Norway, Tromsø 2. Haugesund Hospital, Haugesund 3. Østfold Hospital, Fredrikstad 4. Vestfold Hospital, Tønsberg 5. Molde Hospital, Molde 6. Bodø Hospital, Bodø 7. Oslo University Hospital, Oslo 8. Haukeland University Hospital, Bergen 9. Hamar Hospital, Hamar 10. Drammen Hospital, Drammen 11. Akershus University Hospital, Lørenskog 12. Ålesund Hospital, Ålesund 13. Stavanger University Hospital, Stavanger 14. St. Olav's University Hospital, Trondheim, Norway

Authors presenting: Knut Eivind Kjørstad, Svein T. Baksaas, Dorte Bundgaard, Erik Halbakken, Terje Hasselgård, Geir T. Jørgensen, Anne H. Krog, Kirsten Krohg-Sørensen, Elin Laxdal, Sven R. Mathisen, Gudmundur V. Oskarsson, Synnøve Seljeskog, Inge Settemsdal, Beate Viddal, Frode Aasgaard, Erney Mattsson

Introduction: Recommendations for timing of surgical treatment of symptomatic carotid stenosis vary from within 48 hours (UK) to within 2 weeks (e.g.in Norway) from onset of symptoms. The aim of the study was to observe all patients in Norway operated upon for symptomatic carotid stenosis during one year with respect to; 1) the time from the index event to surgery and its neurological consequences, 2) the level in the health care system causing delay in surgical treatment, and 3) the possible relation between perioperative use of platelet inhibitors and recurrent neurological symptoms.

Methods: All 15 hospitals in Norway performing carotid endarterectomy (CEA) contributed to this prospective national multicenter study. Patients were included when referred to surgery, and after written informed consent was obtained. We defined the index event as the neurological event promoting contact with the health care system.

Results: 371 patients were eligible for inclusion between April 1st 2014 and March 31st 2015, and 368 patients (99.2 %) were included. The index events were; minor stroke in 39.4 %, transitory ischemic attack in 36.7 %, amaurosis fugax in 17.4 %, and major stroke in 6.0 % of the patients. 54 % of the patients contacted their family doctor on the day of the index event. The primary health care referred 84.2 % of the patients to hospital on the same day as examined. In-hospital median time from arrival to referral for vascular surgery was three days, and after seven days 82.9 % of the patients had been referred. Median time between referral to the operative unit and actual CEA was five days, and 10 days after referral to vascular surgery 81.5 % had been operated. Overall, 61.7 % of the patients were operated within 2 weeks after the index event (see figure).

There were no deaths between referral for surgery and time of CEA, but 25 patients (6.8 %) suffered a new neurological event while waiting for surgery. Less than half of the patients (44.0 %) who suffered a new neurological event were on a platelet inhibitor other than ASA. Among those that did not face a new neurological event the percentage was 74.6 (p = 0.01, Pearson’s Chi-Square test). There was no difference between the two groups with respect to use of ASA.

Copenhagen, Denmark • 28-30 September 85

Scientific Session

Thirteen patients (3.5 %) suffered a perioperative stroke (6 major and 7 minor), and the 30-day mortality rate was 0.5 %. The combined 30-day mortality and stroke rate was 3.8 %. Nearly all patients were controlled one month or later after discharge (99.2%). Seven patients (1.9 %) had persistent signs of peripheral nerve injury at the control. No patients showed signs of new neurological events.

Image:

Conclusion: This national study with almost complete inclusion and follow up shows a delay emerging at the level of the patient and in-hospital, including the departments of vascular surgery. The delay is connected with new neurological symptoms. Use of a second platelet inhibitor other than ASA is associated with reduced risk of having a new neurological event after symptom debut.

Copenhagen, Denmark • 28-30 September 86

Scientific Session

OP 033 SIGNIFICANT ASSOCIATION OF ANNUAL HOSPITAL VOLUME WITH THE RISK OF INHOSPITAL STROKE OR DEATH FOLLOWING CAROTID ENDARTERECTOMY BUT NOT CAROTID STENTING: SECONDARY DATA ANALYSIS OF THE STATUTORY GERMAN CAROTID QUALITY ASSURANCE DATABASE

Institution: 1. Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich 2. AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen 3. Institute for Medical Informatics, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany

Authors presenting: Andreas Kuehnl, Pavlos Tsantilas, Christoph Knappich, Sofie Schmid, Thorben Breitkreuz, Alexander Zimmermann

Introduction: This study analyzed the association between hospital volume and the risk of stroke or death following carotid endarterectomy (CEA) and carotid artery stenting (CAS) on a national level in Germany.

Methods: Secondary data analysis using microdata from the nationwide statutory German quality assurance database on all surgical or endovascular carotid interventions on the extracranial carotid artery between 2009 and 2014. Hospitals were categorized into empirically determined quintiles according to annual case volume. The resulting volume thresholds were 10, 25, 46, and 79 for CEA, and 2, 6, 12, and 26 for CAS procedures. The primary endpoint was any stroke or death prior to hospital discharge. For risk-adjusted analyses, a multilevel regression model with robust error variance was applied.

Results: The analysis included 161,448 CEA and 17,575 CAS procedures. In CEA patients, the crude risk of stroke or death decreased monotonically from 4.2% [95% confidence interval 3.6%–4.9%] in low- volume hospitals (first quintile 1–10 CEA/year) to 2.1% [2.0%–2.2%] in hospitals providing ≥80 CEA/year (fifth quintile; p<0.001 for trend). The overall risk of any stroke or death in CAS patients was 3.7% [3.5%–4.0%], but no trend regarding annual volume was seen (p =0.304). Risk-adjusted analyses confirmed a significant inverse relationship between hospital volume (categorized or continuous) and the risk of stroke or death after CEA but not CAS procedures.

Conclusion: This study demonstrates an inverse volume–outcome relationship in CEA-treated patients. No significant association between hospital volume and the risk of stroke or death was found for CAS.

Copenhagen, Denmark • 28-30 September 87

Scientific Session

OP 034 SURGICAL TREATMENT OF CAROTID BODY TUMORS

Institution: 1. Surgery, Mayo Clinic Arizona, Phoenix 2. Surgery, Mayo Clinic, Rochester, United States

Authors presenting: William Stone, Samuel Money, Victor Davila, Richard Fowl, Thomas Bower

Introduction: Carotid body tumors (CBTs) are rare. Current management guidelines may include genetic testing for succinate dehydrogenase (SDH) mutations, were indicated. We performed an institutional review of the surgical management of CBT.

Methods: A retrospective analysis (1994-2015) of CBT excisions at our institution was performed. Data was obtained regarding demographics, genetic testing (if performed), intraoperative details, postoperative morbidity and long term outcomes. Data from the first CBT excision was included in patients with bilateral tumors. Genetic testing was routinely offered in patients with a family history of CBT or multiple paragangliomas.

Results: 183 CBTs were excised (124 female, 67.7%). 106(57.9%) patients presented with a neck mass and 24(12.1%) patients presented with tenderness or neck pain. 3(1.6%) presented with cranial nerve dysfunction. 34(18.6%) had a family history of CBT. CT(57.9%) or MRI(51.3%) were the most commonly used imaging modalities. 73(39.8%) patients underwent preoperative angiography and 62(84.5%) of them underwent embolization and/or internal carotid balloon occlusion testing. Mean tumor diameter was 3.2cm (range=0.6-7.2cm). There were 71(38.8%), 75(41%), and 37(20.2%) Shamblin type 1, 2, and 3 tumors respectively. Average operating time was 224 minutes (range=52- 696 minutes). Average blood loss was 143.9 mL (range=10-2000 mL). 26(14.2%) underwent arterial ligation, most commonly the external carotid artery (n=15). Arterial reconstruction with an interposition graft was required in 10. Patch angioplasty was performed in 4. Cranial nerve injury was permanent in 10 (5.5%). 382 lymph nodes were excised and all were benign. There were no deaths within 30 days. 18 patients underwent SDH testing and 17 tested positive. Positive genetic testing had a correlation with earlier age at operation (p<0.0001) and symptomatic presentation (p=0.0266). Only 1 patient presented with malignant disease 2 years after CBT excision

Conclusion: CBT can be treated with minimal morbidity and mortality; however, the subgroup of patients with positive SDH mutations may represent a variant group of patients. Vascular surgeons should be aware of genetic testing to identify patients, and family members, who should undergo additional preoperative testing and monitoring for other paragangliomas. Concomitant lymph node dissection does not appear to add value in absence of clinic suspicion for malignancy

Copenhagen, Denmark • 28-30 September 88

Scientific Session

OP 035 FATE OF DISTAL FALSE ANEURYSMS COMPLICATING INTERNAL CAROTID ARTERY DISSECTION: A SYSTEMATIC REVIEW

Institution: 1. Northern Vascular Centre, Freeman Hospital, Newcastle 2. Department of Vascular Surgery, Leicester Royal Infirmary, Leicester, United Kingdom

Authors presenting: Kosmas Paraskevas, Andrew Batchelder, Ross Naylor

Introduction: About 13-49% of internal carotid artery dissections (ICADs) may be complicated by the development of a false aneurysm. To date, there has been no consensus as to how these patients should be managed. A systematic review of the literature was performed to establish the clinical course, expansion rates and optimal treatment of post- ICAD false aneurysms.

Methods: PubMed/Medline, Embase and Cochrane databases were systematically searched until April 1, 2016 for studies reporting clinical outcomes and imaging surveillance in patients who were found to have developed a false aneurysm associated with ICAD, with specific emphasis on the fate of the non- operated false aneurysm.

Results: Eight studies reported on the course/clinical outcome of ICAD-associated false aneurysms in 166 patients. Of these: 5/166 false aneurysms (3%) increased in size; 86/166 (52%) remained unchanged in diameter; 35/166 (21%) diminished in size; 32/166 (19%) resolved completely; 3/166 (2%) thrombosed; and 5/166 (3%) were repaired surgically. Another 4/166 underwent late surgery (0.5-5 years later). During the course of surveillance, none of the non-operated false aneurysms associated with spontaneous ICAD gave rise to any new neurological or compressive symptoms.

Conclusion: In this systematic review, >95% of non-operated false aneurysms affecting the distal internal carotid artery that developed after an ICAD did not increase in size and were not associated with any delayed neurological symptoms suggesting that conservative management and serial surveillance is the optimal mode of treatment. As nearly all studies suffered from serious bias, reporting standards for diagnosis and follow-up are needed in order to better define their natural history.

Copenhagen, Denmark • 28-30 September 89

Scientific Session

OP 036 IMPACT OF DIFFERENT PROCEDURAL VARIABLES ON THE RISK OF IN-HOSPITAL STROKE OR DEATH AFTER CAROTID ENDARTERECTOMY AND CAROTID ARTERY STENTING IN ROUTINE PRACTICE: A SECONDARY DATA ANALYSIS OF THE STATUTORY NATIONWIDE GERMAN QUALITY ASSURANCE DATABASE

Institution: 1. Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich

2. AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany

Authors presenting: Christoph Knappich, Andreas Kuehnl, Pavlos Tsantilas, Sofie Schmid, Thorben Breitkreuz, Michael Kallmayer, Alexander Zimmermann, Hans-Henning Eckstein

Introduction: In Germany, all open surgical and endovascular procedures on the carotid bifurcation have to be documented in a nationwide carotid registry. The object of the present investigation was to analyze the association between different periprocedural variables and the in-hospital risk of stroke or death after carotid endarterectomy (CEA) and carotid artery stenting (CAS), respectively.

Methods: Patients who were treated electively for asymptomatic or symptomatic carotid artery stenosis were included. Data were available for patients who underwent CEA between 2009 and 2014, and those who received CAS between 2012 and 2014. All data were extracted from the statutory nationwide quality assurance databank held by the Institute for Applied Quality Improvement and Research in Health Care (AQUA Institute). We investigated the associations between different procedural and perioperative variables [CEA: type of anaesthesia, type of surgical technique, use of intraoperative neurophysiological monitoring, intraoperative morphological control, perioperative antiplatelet medication; CAS: stent design, stent material, application of neurophysiological monitoring, periprocedural antiplatelet medication, use of embolic protection device (EPD)] and the risk of any stroke or death until hospital discharge. Risk ratios (RR) were assessed by univariate and multivariable regression analyses.

Results: A total of 142,074 elective CEA (39,7% symptomatic, mean age 70.7 years, 67.8% male) and 13,086 CAS (36.1% symptomatic, mean age 69.7 years, 69.7% male) procedures were available for this analysis. The primary endpoint occurred in 1.8% of patients who underwent CEA and 2.4% of those treated with CAS. For patients treated with CEA, the multivariable analysis revealed an independent association with lower risks of in- hospital stroke or death for local anesthesia (vs. general anesthesia, RR 0.85, 95% CI 0.75–0.95), intraoperative morphological control by duplex ultrasound (RR 0.74, 95% CI 0.63–0.88) or angiography (RR 0.80, 95% CI 0.71–0.90), and perioperative antiplatelet medication (RR 0.83, 95% CI 0.71–0.97). CEA with primary closure (vs. CEA with patch plasty, RR 1.41, 95% CI 1.03–1.91) was associated with a higher primary endpoint rate. In patients who received CAS, the multivariable analysis showed the use of an EPD to be exclusively associated with a lower rate of in-hospital stroke or death (adj. RR 0.65, 95% CI 0.50–0.85).

Conclusion: Our data demonstrate, that local anaesthesia, intraoperative morphological control by angiography or duplex ultrasound, and perioperative antiplatelet medication in patients treated with CEA, and usage of an EPD in those treated with CAS were independently associated with lower rates of in- hospital stroke or death in a real world scenario.

Copenhagen, Denmark • 28-30 September 90

Scientific Session

SCIENTIFIC SESSION 6 - PAD

OP 037 COST EFFECTIVENESS ANALYSIS OF HEPARIN- VERSUS STANDARD POLYTETRAFLUOROETHYLENE GRAFT ALONGSIDE A RANDOMISED CONTROLLED TRIAL WITH FIVE YEARS FOLLOW-UP

Institution: 1. Department of Cardiovascular and Thoracic Surgery, Odense University Hospital 2. Cardiovascular centre of Excellence in Southern Denmark, University of Southern Denmark, Odense 3. Cardiovascular centre of Excellence in Southern Denmark, University of Southern Denmark, Odensen 4. Department of Vascular Surgery, Kolding hospital, Kolding 5. Department of Vascular Surgery, Slagelse Hospital, Slagelse 6. Department of Vascular Surgery, Aalborg University Hospital, Aalborg 7. Department of Vascular Surgery, Rigshospitalet, Copenhagen 8. Cardiovascular Research Unit, Viborg hospital, Viborg 9. Department of Public Health, Aarhus University, Aarhus, Denmark

Authors presenting: Jes S. Lindholt, Marie Villemoes, Kim C. Houlind, Bo Gottschalksen, Christian N. Pedersen, Martin Rasmussen, Charlotte Wedel, Morten B. Bramsen, Rikke Søgaard

Introduction: New technologies in cardiovascular surgery have contributed to increasing costs of peripheral arterial disease management over the last decades. The objective of this study is to assess the cost effectiveness of heparin- versus standard polytetrafluoroethylene graft as treatment for peripheral arterial disease from a health care sector perspective.

Methods: Danish participants (n=426) of the Scandinavian Propaten trial, which w as a randomised controlled trial conducted in Denmark, Norway and Sweden during the years 2005-2014, were included. Inclusion was restricted to patients who were scheduled for a bypass surgery in either femoro- femoral or femoro-popliteal. Analysis is based on the intention-to-treat principle and five years of register-based follow-up on health care service use (general practice, prescription medication and hospital use related to cardiovascular disease), graft survival and overall survival. Mean costs and outcomes (95% bootstrapped confidence intervals) are reported. Discounting of 3% per year are applied for costs and life years all monetary estimates are in 2015-DKK. Subgroup analyses are planned for +/- critical ischemia. Sensitivity analyses are conducted to assess the robustness of results to graft prices and societal consequences to production, among others.

Results: Preliminary results indicate that there is no significant overall difference between the groups with respect to the use of general practice, prescription medication, and hospital admission for cardiovascular disease; the difference in total health care costs is DKK 3271 (95%CI -22530; 29073). With respect to graft survival and overall survival, the heparin graft lead to small and insignificant improvements of 11 days (95% CI -115; 137) on graft survival and 16 days (95% CI -68; 97) on overall survival, respectively. For the subgroup with critical ischemia, the heparin graft tended to lead to lower costs and longer survival. For the subgroup with none-critical ischemia, the opposite was found as the heparin graft lead to higher costs and shorter survival. The production loss due to sick leave was investigated for patients who were part of the labour force at baseline (16%) and this was no different between randomization groups. Conclusion: These preliminary results point at a weak probability for heparin being cost effective for the total population of patients with peripheral arterial disease. The result however seems to mask bidirectional results for the subgroups of critical and non-critical ischemia, as the heparin graft seems to be cost effective for the group with critical ischemia and not cost effective for the group with none-critical ischemia.

Copenhagen, Denmark • 28-30 September 91

Scientific Session

OP 038 CONTEMPORARY CARDIOVASCULAR RISK AND SECONDARY PREVENTIVE DRUG TREATMENT PATTERNS IN PERIPHERAL ARTERIAL DISEASE PATIENTS UNDERGOING REVASCULARIZATION

Institution: 1. Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm 2. Department of Surgical Sciences, Vascular Surgery, Uppsala 3. Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg 4. Statisticon AB, Uppslala 5. Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital and Academy, Gothenburg, Sweden

Authors presenting: Birgitta Sigvant, Björn Kragsterman, Marten Falkenberg, Marcus Thuresson, Joakim Nordanstig

Introduction: Interventions for peripheral arterial disease (PAD) are increasing due to rising disease prevalence and an increased access to minimally invasive techniques. The aim of this study was to investigate current risk for cardiovascular (CV) events and preventive pharmacological treatment patterns for revascularized PAD patients.

Methods: This observational, retrospective cohort study analyzed prospectively collected data between 2008– 2013 from mandatory Swedish national health-care registries, including the Prescribed Drug Register. The Swedish National Register for Vascular Surgery database was used to identify revascularized PAD patients. The risk for CV events (a composite of myocardial infarction, ischemic stroke or CV death) and preventive drug treatment patterns was analyzed. A Cox proportional-hazard regression model was used to explore risk- and preventive factors for suffering a CV event.

Results: 18742 patients were analyzed. Critical limb ischemia (CLI) was the most common indication for revascularization (63%) and CLI patients were older (mean 77 years) compared to those with intermittent claudication (IC) (mean 70 years). More men were intervened for IC (n=3798 vs 3161, p<.001) CV event rates at 12, 24 and 36 months were 16.8% (95% CI 16.1-17.6), 25.9% (25.0-26.8) and 34.3% (33.2-35.4) in patients with CLI and 5.1% (4.5-5.6), 9.5% (8.7-10.3) and 13.8% (12.8- 14.8) in patients with IC. Patients with IC were treated with aspirin and statins more frequently compared to CLI patients (73.5% versus 61.5%, p <.001) and (72.5% versus 52.4%, p <.001) respectively, at admission for revascularization. Among all analyzed PAD patients, any anti-platelet therapy, statins, angiotensin enzyme inhibitors/angiotensin receptor blockers and beta-blockers were used by 73%, 60%, 57% and 49% at admission for revascularization. Aspirin use at admission increased from 66% to 75% within three month after revascularization, corresponding figures for clopidiogrel was 7% to 24% respectively. Any antiplatelet or anticoagulant therapy along with statin treatment was offered to 65 % of IC patients and 45% of CLI patients. Statin therapy was associated with reduced CV events (HR 0.76, 95% CI 0.71- 0.81 p<0.001), while treatment with aspirin was not.

Conclusion: Revascularized PAD patients are still at high risk for CV events, as approximately one out of ten IC patients and one out of four CLI patients will suffer a major CV event within two years. The most commonly used drug was aspirin, which was not associated with CV event reduction. The medical therapy provided to revascularized PAD patients thus remains sub-optimal and efforts to address this partly unmet medical need is warranted.

References: Disclosure of Interest: B. Sigvant Honoraria Support from: Independent research grant, B. Kragsterman Honoraria Support from: Independent research grant, M. Falkenberg: None Declared, M. Thuresson: None Declared, J. Nordanstig Honoraria Support from: Independent research grant

Copenhagen, Denmark • 28-30 September 92

Scientific Session

OP 039 TEN YEARS’ EXPERIENCE WITH COMMUNITY CLAUDICATION CLINICS

Institution: 1. Department of Vascular Surgery, NHS Lanarkshire 2. Department of Vascular Surgery, NHS Ayrshire and Arran 3. Business Intelligence Development Team 4. Primary Care, NHS Lanarkshire, Glasgow, United Kingdom

Authors presenting: Colin Wood, M.C Ruiz, M.M Mirghani, E. Allen, L. Crawford, A. McCusker, E. Brankin, R.N Scott

Introduction: In 2004 the waiting time for the Vascular Out Patient Clinic (VOPC) at one of the hospitals in Lanarkshire reached 511 days. Many patients referred to VOPC did not have peripheral arterial disease (PAD). The few patients who did have PAD rarely needed any hospital investigations or treatment. In 2005, as a result of collaboration between a local vascular surgeon and general practitioner, we introduced nurse-led Community Claudication Clinics (CCCs) with the aim of reducing waiting times for assessment and diagnosis, and introducing a more cost effective approach designed to ensure earlier appropriate risk factor modification and lifestyle advice, with more rapid referral to VOPC when necessary.

Methods: Retrospective analysis of 5570 patients identified from a prospectively collated database through a combination of electronic case note review, radiology archive software (PACS) review and theatre database analysis.

Results: The CCC service has grown from a clinic in a single health centre to a regional service managed by NHS Lanarkshire in ten localities around the county. Between June 2006 and December 2015, 5570 patients were assessed at CCCs. The average waiting time was 81 days (+/- S.D. 42). The cost for one attendance is estimated at £15 for CCCs, compared with £156 for VOPC. 3400 (61%) had Intermittent Claudication (IC) excluded as the cause of their leg pain by one visit to our CCCs in primary care. 2170 (39%) of patients had the diagnosis of IC confirmed. 1002 (18%) met agreed criteria for referral to VOPC for specialist surgical assessment. Of this subgroup, 650 (65%) did not require any vascular imaging and were treated conservatively; 198 (20%) underwent arterial imaging but did not require open surgery or endovascular intervention; and 164 (16%) had imaging and intervention as shown below in Fig 1.

Image:

Conclusion: 82% of patients referred to the CCCs with suspected PAD were managed by that service in primary care. CCCs are safe and offer quicker and more cost-effective access to appropriate risk factor modification, supported by a multidisciplinary team. In the important subgroup who required referral from CCCs (in primary care) to VOPC (in hospital), about one third needed vascular imaging or intervention. There was no evidence of any delay to necessary treatment.

Copenhagen, Denmark • 28-30 September 93

Scientific Session

OP 040 DRUG-ELUTING BALLOON ANGIOPLASTY VERSUS UNCOATED BALLOON ANGIOPLASTY IN PATIENTS WITH FEMOROPOPLITEAL ARTERIAL OCCLUSIVE DISEASE: A META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Institution: 1. Vascular surgery, Maasstad Hospital, Rotterdam 2. Vascular surgery, Sint Antonius Hospital, Nieuwegein 3. Vascular surgery, Erasmus medical centre, Rotterdam, Netherlands

Authors presenting: Hidde Jongsma, Joost Bekken, Jean-paul de Vries, Hence Verhagen, Bram Fioole

Introduction: The optimal percutaneous treatment for femoropopliteal occlusive arterial disease has yet to be assessed. This systematic review and meta-analysis assessed the efficacy of drug-eluting balloons (DEBs) compared with uncoated balloons (UCBs) for the treatment of femoropopliteal arterial occlusive disease.

Methods: We used Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement (PRISMA) standards to systematically search the electronic databases of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for trials comparing DEBs versus UCBs in the femoropopliteal arteries. All articles were critically assessed for relevance, validity, and availability of data regarding patient and lesion characteristics and outcomes. All data were systematically pooled, and meta- analysis was performed on binary restenosis, late lumen loss (LLL), target lesion revascularization (TLR), major amputation, mortality, and changes in the ankle-brachial index (ABI) and the Rutherford-Baker classification.

Results: From 364 screened articles we included nine trials, all of which had a low risk of bias. We found a significant reduction of binary restenosis at 6 months (14.3% versus 40.1%, P < .0001), binary restenosis at 1 year (26.6% versus 47.4%, P = 0.008), LLL at 6 months (–0.80 mm, P < .00001), TLR at 1 year (10.4% versus 26.9, P = .0008), and TLR at 2 years (13.8% versus 40.7%, P = .0003) after DEB angioplasty compared with UCB angioplasty. The difference in amputation rate and mortality was not significant. Definitions on changes in ABI and Rutherford classifications were heterogeneous and therefore could not be pooled in sufficient numbers.

Conclusion: When compared with uncoated balloon angioplasty, the use of DEBs in the treatment of femoropopliteal arterial obstructions results in a significant decrease of binary restenosis, TLR, and LLL at short-term and midterm follow-up. Data on clinical end points, such as change in ABI and Rutherford- Baker classification, are too heterogeneous, and more research with uniform reporting standards is necessary.

Copenhagen, Denmark • 28-30 September 94

Scientific Session

OP 041 A HIGH ANKLE-BRACHIAL INDEX IS ASSOCIATED WITH ALL-CAUSE MORTALITY IN A POPULATION WITHOUT CARDIOVASCULAR DISEASE. THE REGICOR STUDY

Institution: 1. Angiology and Vascular Surgery, Hospital del Mar, Barcelona, Spain 2. Epidemiology and Public Health, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain

Authors presenting: Alina Velescu, Albert Clará Velasco, Judith Peñafiel Muñoz, Lidia Marcos Garcia, Jaume Marrugat de la Iglesia, Roberto Elosua Llanos

Introduction: The clinical significance of a high ankle-brachial index (ABI) and it´s relationship to cardiovascular disease (CVD) and mortality is controversial. The aim of this study was to estimate the association between a high ABI >1.39 and coronary heart disease (CHD) and all-cause mortality in a Mediterranean population without CVD.

Methods: A prospective population-based cohort study of 6352 subjects was followed up for a median 5.9 years. Subjects under 35 years, with a history of CVD or an ABI <0.9 were excluded. All incident CHD events (angina, myocardial infarction, coronary revascularization) and all-cause mortality were recorded. Results: 5628 subjects fulfilled the inclusion criteria, of which 5466 (97.12%) had a normal ABI whereas 162 (2.88%) had an ABI>1.39. During follow-up 234 (4.16%) participants presented a CHD event and 294 (5.22%) died. An ABI>1.39 was associated with a higher incidence of CHD events in the univariate (p=0.033) but not in the multivariate survival Cox regression analysis. An ABI>1.39 was independently associated with all-cause mortality (HR=1.628;p=0.019), cardiovascular (HR=2.445;p=0.02) and cancer mortality (HR=1.788;p=0.05). The profile of individuals with high ABI revealed as independent related factors: age (OR=1.029;p<0.01), female sex (OR=0.42;p<0.01), diabetes (OR=1.686;p<0.01), elevated body mass index (OR=1.044;p=0.016), high diastolic blood pressure (OR=0.973;p<0.001) and high total cholesterol level (OR=0.995;p=0.024).

Conclusion: In subjects without CVD, those with a high ABI do not present greater CHD events rate than those with a normal ABI. However, they do have a clear association with mortality, regardless of its cause, which identifies them as a risk population.

Copenhagen, Denmark • 28-30 September 95

Scientific Session

OP 042 PREVALENCE OF MAJOR LOWER LIMB AMPUTATION ACROSS DENMARK AND ITS RELATIONSHIP WITH REVASCULARIZATION, DEMOGRAPHY AND DISEASE RISK FACTORS

Institution: 1. Cardiothoracic- and vascular surgery, Odense University Hospital, Odense 2. Vascular surgery, Viborg Hospital, Viborg 3. Vascular surgery, Kolding Hospital, Kolding, Denmark

Authors presenting: Louise Skovgaard Londero, Annette Høgh, Kim Houlind, Jes Lindholt

Introduction: Although advances in revascularization procedures have expanded the treatment options, PAD is still heavily associated with major amputations of the lower limb. A decrease in lower limb amputations has been described, but whether the drop in amputation rate can be attributed only to better preventive care or to increase in revascularization procedures performed also, is unknown. Variation in incidence of major amputation across municipalities has been shown and might reflect differences in socio-economic levels or in the structure of healthcare delivery. There are currently few data on incidence and impact of revascularization on major lower limb amputation in Denmark. The incidence of major lower limb amputation caused by PAD is described and variation across Denmark will be explored.

Methods: A dataset containing data on all patients undergoing major amputation between January 1, 1997 – December 31, 2014 were subtracted from the Danish National Patient Registry. Patients with a primary or secondary PAD diagnosis, related to the major amputation and ≥ 50 years of age was included. Major amputation was defined as an amputation above the ankle. Data on patient comorbidity and prescribed medication were obtained from The Danish Patient registry and the Medical Register of the Danish Medicines Agency, while information on socioeconomic variables and numbers of population was obtained from statistic Denmark. The period was subdivided into three groups; 1997–2002, 2003─2008 and, 2009─2014. Incidence rates were calculated using the combined number of procedures for each period the numerator with the denominator derived by combining the mid-year population estimates for the population ≥ 50 years for the three periods.

Results: A total of 12 947 first time major amputations were performed between 1997–2014 corresponding to an overall incidens rate 38.12 per 100.000 inhabitants, significantly decreasing over time (p<0.001) The incidence rate for major amputations differed between municipalities in all three periods and was mean (SD): 41.22(13.98 ), 37.99(12.9), and 31.89(9.11) per 100.000, respectively. In the same period the incidence for a vascular reconstruction was 199.12 per 100.000, but significantly increasing over time (p=0.001). A difference in incidence rate between municipalities was also seen in all three periods, mean (SD): 161.23(46.28), 196.12(44.84), and 222.11(60.99) per 100.000, respectively. A shift in amputation level was observed with an above knee/below knee ratio of 0.87 in the first period and 1.56 in the last and significantly more patients had had vascular reconstructions prior to amputation in the later period (34.2%, 39.7%, and 47.7%, respectively (p<0.001)). The impact of co-morbidity, socioeconomic factors, and revascularization on major lower limb amputation in Denmark is being analyzed and will be presented at the ESVS 2016.

Conclusion: During 1997–2014 the incidence of major amputations in patients with PAD was significantly decreasing, while at the same period a significant increase in vascular reconstructions was seen. An inequality in major lower limb amputation rates across Denmark was observed, but declined markedly during the study period, moving towards more similar amputations rates nationwide.

Copenhagen, Denmark • 28-30 September 96

Scientific Session

SESSION 7 – BASIC SCIENCE

OP 043 CIRCULATING LEVELS OF VEGF-ASSOCIATED GROWTH FACTORS IN END-STAGE PERIPHERAL ARTERIAL DISEASE

Institution: 1. Department of Vascular Surgery, University of Turku and Turku University Hospital 2. Medicity Research Laboratory, Department of Microbiology and Immunology, University of Turku, Turku, Finland

Authors presenting: Olli Hautero, Juho Jalkanen, Mikael Maksimow, Sirpa Jalkanen, Harri Hakovirta

Introduction: The aim of the present study was to assess the correlation between the circulating levels of vascular endothelial growth factor (VEGF) and other suggested therapeutic growth factors with the degree of ischaemia in patients with different clinical manifestations of periferal arterial disease (PAD) according to the Rutherford's classification.

Methods: The study cohort consists of 226 consecutive patients admitted to the vascular department of our university hospital. PAD patients were sorted into groups according to the Rutherford’s classification after a clinical assessment. Ankle-brachial pressure indices (ABI) and absolute toe pressure values (TP) were measured. Serum levels of circulating VEGF, hepatocyte growth factor (HGF) and basic fibroblast growth factor (bFGF) were analysed.

Results: A regression analysis was conducted comparing the named serum growth factor levels to the Rutherford’s classes. The levels of VEGF (P < 0.005), HGF (P < 0.001) and bFGF (P < 0.05) increased significantly as the ischaemic burden became more severe according to the Rutherford’s classification. Also ABI (P < 0.001) and TP (P <0.001) had statistically significant inverse correlations with the Rutherford’s classes.

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Conclusion: Our present observations suggest that the circulating levels of VEGF and other suggested therapeutic growth factors are significantly increased as the degree of ischaemia becomes more severe. These findings present a new perspective to earlier minor positive effects of genetherapies utilizing VEGF, HGF and bFGF since the levels of these growth factors are naturally high in end- stage PAD.

Copenhagen, Denmark • 28-30 September 97

Scientific Session

OP 044 UPREGULATION OF 14Q32 MICRORNAS IN HUMAN SUBCUTANEOUS ADIPOSE TISSUE OF PATIENTS WITH CRITICAL LIMB ISCHEMIA AT RISK OF MAJOR AMPUTATION

Institution: 1. Leiden University Medical Center, Leiden, Netherlands 2. Harvard Medical School, Boston, United States

Authors presenting: Yael Nossent, Sabine Welten, Ming Tao, Alban Longchamp, Szymon Kielbasa, Paul Quax, Keith Ozaki

Introduction: Critical limb ischemia (CLI) is the most severe manifestation of peripheral arterial disease (PAD) and is an important contributor to patient morbidity and mortality. The use of reliable biomarkers to identify patients at risk of major amputation could assist both patients and physicians in clinical decision making in CLI treatment. Over the past decade, microRNAs have been identified as stable markers for the detection of cardiovascular disease. The aim of this study was to identify microRNAs that can be used as suitable biomarkers to identify CLI patients at risk of major amputation.

Methods: Subcutaneous adipose tissue (SAT) samples were collected from patients that underwent major amputation as a result of CLI and from patients that underwent elective knee-replacement (controls). In a second study population from a different medical center, SAT samples, as well as perivascular adipose tissue (PVAT) samples were collected from amputation patients only. Multiplex qPCRs, followed by individual qPCR confirmation, were performed to determine differential microRNA expression between amputation and control samples (n=6 for multiplex qPCR and n=18 for individual qPCRs per group). In addition, microRNA expression was measured in SAT and PVAT samples of amputation patients in the second study population (n=6). ROC curve analyses were performed to determine sensitivity and specificity for 6 differentially expressed microRNAs.

Results: Multiplex qPCR analyses demonstrated global downregulation of microRNA expression in SAT samples of amputation patients compared to controls. However, eight microRNAs were upregulated in amputation patients. Six out of the eight upregulated microRNAs belong to a single microRNA gene cluster, the 14q32 cluster. We confirmed significant upregulation of 14q32 microRNAs miR- 127, miR-134, miR-370, miR-376c, miR-411 and miR-539 in SAT of amputation patients compared to controls. ROC curve analyses showed an area under the curve (AUC) of greater than 0.96 for all microRNAs in the studied population, which was highly significant (p<0.01 for all microRNAs). Upregulation of 14q32 microRNAs in SAT and in PVAT of amputation patients was validated in the second study population. Here, AUCs lay between 0.78 and 0.97 for all microRNAs (p<0.05 for miR- 370 and miR-376c and p<0.01 for miR-127, miR-134, miR-411 and miR-539).

Conclusion: In conclusion, we found that six 14q32 microRNAs are significantly upregulated in the SAT and PVAT of CLI amputation patients. We demonstrate for the first time that 14q32 microRNAs miR-127, miR- 134, miR-370, miR-376c, miR-411 and miR-539 in SAT are promising biomarkers to identify patients at risk of major lower limb amputation.

Copenhagen, Denmark • 28-30 September 98

Scientific Session

OP 045 A NOVEL ANTI-INFLAMMATORY BIOMARKER THAT PREDICTS PERIPHERAL VEIN GRAFT FAILURE

Institution: 1. Vascular Surgery, University of Washington and VA Puget Sound HCS 2. Vascular Surgery, University of Washington, Seattle, United States

Authors presenting: Michael Sobel, Mayumi Yagi, Gale L. Tang, Ted R. Kohler, Errol S. Wijelath, Richard D. Kenagy, Katherine T. Moreno

Introduction: In spite of great advances in endovascular therapies, leg bypass with autogenous vein is still frequently required for peripheral arterial disease (PAD). However, primary graft failure may occur in up to 30% within the first two years, due to vein graft stenosis and/or thrombosis. A deranged inflammatory response to injury is suspected as the underlying pathobiology, but there are no known specific therapies, nor biologic markers for vein graft failure. Humans have natural antibodies that target a common inflammatory component of damaged cell membranes, phosphorylcholine (PC), which is exposed during cell injury. We performed an observational study of patients undergoing leg bypass, to see if their plasma levels of this anti-inflammatory IgM antibody correlated with the long term outcomes of their bypass grafts.

Methods: A prospective, observational study of patients undergoing infrainguinal bypass with autogenous vein (excluding those on hemodialysis, and operations for aneurysmal disease). The primary outcome was the loss of primary patency (loss of graft flow, or surgical or endovascular intervention for a critical vein graft stenosis). Secondary outcome was the composite of myocardial infarction, stroke, and vascular death. Patients were followed regularly at clinically prescribed intervals to assess for graft and cardiovascular events. Pre- and postoperative plasma samples were assayed for levels of anti-PC IgM with the CVDefine kit from Athera Biotechnologies (Solna, Sweden).

Results: 141 patients were followed for an average of 1.7 years (1 month to 7.4 years). Their mean age was 66 (46-91), 91% were white males. Indications for surgery were claudication (Fontaine II-39, 27.7%), rest pain (Fontaine III-30, 21.3%), and critical ischemia with ulceration (Fontaine IV-72, 51.1%). During follow-up, 44 (31%) of grafts lost primary patency due to thrombosis (11) or intervention for critical graft stenoses (33). Kaplan-Meier survival analysis revealed that primary graft patency was significantly worse in the patients in the lowest quartile of preoperative anti-PC IgM levels, compared with those in the top three quartiles (log rank p=.027). Combining primary graft and secondary cardiovascular endpoints, K-M survival showed a similar pattern of worse outcomes in the lowest quartile of anti-PC IgM levels (p=.06). Clinical factors known to affect graft patency were equally distributed within the two categories of IgM levels (including indication for surgery, intraoperative technical difficulties, length or diameter of graft). Multivariate Cox proportional hazards analysis revealed that patients with IgM values in the lowest quartile had a 2-fold increased risk of graft failure (95% confidence interval: 1.05-3.69), even after accounting for these other factors.

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Copenhagen, Denmark • 28-30 September 99

Scientific Session

Conclusion: Low levels of the naturally occurring, anti-PC IgM are associated with vein bypass graft failure, and higher levels may be protective. These effects may be mediated by the anti-inflammatory actions of the antibody, which are thought to quench the inflammatory effects of the exposed PC in damaged vascular cells. This novel biological mediator may be a useful marker to identify patients at higher risk of graft failure, and offers the potential for novel, directed therapies for vascular inflammation and its consequences.

Copenhagen, Denmark • 28-30 September 100

Scientific Session

OP 046 DIFFERENTIAL GENE EXPRESSION DURING PROGRESSION OF HUMAN ABDOMINAL AORTIC ANEURYSM

Institution: 1. Vascular and Endovascular Surgery, Clinic for General, Visceral, Vascular and Transplant Surgery Ludwig-Maximillians-University, Munich 2. Vascular and Endovascular Surgery, Clinic for General, Visceral, Vascular, and Thoracic Surgery Charité, Berlin 3. Clinic for Vascular and Endovascular Surgery Helios Clinic, Erfurt, Germany 4. Division of Vascular Surgery Leiden University Medical Center, Leiden, Netherlands

Authors presenting: Gabor Gäbel, Frank Schönleben, Irene Hinterseher, Hendrik Bergert, Jan H. Lindeman

Introduction: The etiology of abdominal aortic aneurysm (AAA) is complex, with environmental and genetic risk factors. Some risk factors have been identified, but the molecular mechanisms responsible for the initiation, progression and rupture of AAAs remain unknown. Recently microarray studies have been used to elucidate a more global gene expression profile for AAA. Our goal was to identify genes that are specifically involved in the progression and rupture of AAAs.

Methods: Full thickness aortic wall tissue specimens were collected from patients with stable AAA (n=31) and ruptured AAA (n=17) as well as patients with an AAA ≤55 mm (n=15) and with an AAA >70 mm (n=16) undergoing open repair. Total RNA was isolated from the aortic tissues. Whole genome HumanHT-12 v4 Expression BeadChips (Illumina) were used to assess gene expression and identify genes with differences in mRNA levels between stable and ruptured AAA samples as well as small and large AAAs. We searched for overlapping genes in our analysis and validated these candidate genes with rtPCR in a third set of samples (n=65) and performed functional and immunohistochemical analyses.

Results: In total, 262 genes were differentially expressed (logFC >1 and P<.05) between stable and ruptured AAA and 138 genes between small and large AAAs. There was an overlap of 8 up- and 4 downregulated genes between the two analyses. We confirmed overexpression of ADAMTS9, ANGTL4, HILPDA, GFPT2, LOX, SRPX2, STC1 and decreased expression of CCL4L1, GAL3ST4, and FCGBP in ruptured AAAs by qRT-PCR. ANGPTL4, HILPDA, LOX, SRPX2 and FCGBP gene expression showed a correlation with aortic diameter. Immunohistochemical and functional analyses for upregulated genes confirmed their origin from fibroblast and their proangiogenic properties.

Conclusion: The current study provides further insights into AAA pathobiology, including a role of recently unknown genes relevant to progression and rupture of AAA. Our results highlight the key role of angiogenesis for AAA progression and rupture. The results may help to direct future research as well as aid in development of therapeutic options for the medical treatment of AAA.

Copenhagen, Denmark • 28-30 September 101

Scientific Session

OP 047 FURTHER INSIGHTS INTO TISSUE ENGINEERED SMALL DIAMETER VASCULAR GRAFTS: IMPACT OF SURFACE MODIFICATION ON PATENCY AND IN VIVO COMPATIBILITY

Institution: 1. Nanocellulose R&D, Polymet Jena Association, Weimar 2. Department of Cardiothoracic Surgery, University Hospital of Cologne, Köln 3. Jenpolymer Materials, 4Polymet Jena Association, Jena, Germany

Authors presenting: Max Theodor Wacker, Dieter Klemm, Maximilian Scherner, Carolyn Weber, Kaveh Eghbalzadeh, Stefanie Reinhardt Thorsten

Introduction: Many patients do not have suitable autologous vessels for bypass surgery due to previous harvest or chronical vascular diseases. Small diameter tissue engineered blood vessels (TEBV) might be a promising approach to address this problem. However, the creation of TEBV remains one of the most challenging topics in experimental vascular surgery.

Methods: Between 2011 and 2015, the common carotid arteries of sheep (n=28) were replaced by tubular implants based on the natural polymer biocellulose (bacterial nanocellulose, BNC) produced by Acetobacter xylinum using glucose as a source of carbon. The BNC tubes with a length of 100 mm had an inner diameter of 4.0-5.0 mm. As a first group, 10 sheep received standard BNC tubes produced on bamboo templates for a period of 3 months. The following 18 sheep received BNC tubes that were surface modificated by inversion. This second group was subdivided into a group (n=9) receiving the antiplatelet agents ASS and Clopidogrel and into a control group (n=9). The functional in vivo performance was analyzed by performing Doppler ultrasonography postoperatively and at 4, 12 and 18 weeks after implantation. After explantation, the grafts were analyzed by extracellular matrix stains, electron microscopy and immunostaining with respect to a) technical feasibility, b) ability of providing a scaffold for the neoformation of a vascular wall and c) their proinflammatory potential.

Results: In the first group, the patency rate was 50% and in the second group 33%. The sub group analysis of the second group showed that 67% (n=6) of the grafts in the medication group and 0 % (n=9) of the control group were still patent. Doppler ultrasound examinations confirmed excellent functional performance of the grafts. The blood flow velocity of the patent grafts did not differ significantly in comparison to the contralateral native vessel in both groups. Extracellular matrix stains and immunostaining revealed a neoformation of a vascular wall-like structure along the BC-scaffold comprising of immigrated vascular smooth muscle cells. Electron microscopy scans revealed a confluent luminal endothelial cell layer on the tubes of the first group and the immigration of VSMCs in the BNC-matrix in both groups. Conclusion: Although the patency rate is not yet satisfactory, these data indicate that BNC-grafts provide a stable scaffold for the neoformation of a three-layered vascular wall resulting in the production of stable small diameter vascular conduits. Surface modification seems to be one of the key factors for endothelialization and therefore represents a promising target for further research.

Copenhagen, Denmark • 28-30 September 102

Scientific Session

OP 048 CAN PERITONEUM BECOME AN ARTERY? PERITONEUM AS AN ARTERIAL GRAFT MATERIAL IN A LARGE MAMMAL

Institution: 1. Surgical Department, Vascular department, St Olavs Hospital, Trondheim, Norway

Authors presenting: Petter Davik, Martin Altreuther, Erney Mattsson

Introduction: The ideal vascular graft material has yet to be identified. Autologous blood vessels and synthetic materials are used to make arterial grafts but are imperfect. Dacron and ePTFE grafts lack anticoagulation properties, causing thrombosis of low flow and small diameter grafts. Synthetic grafts can also develope intimal hyperplasia1 causing luminal narrowing and occlusion, become infected and require removal, and are expensive to make. Therefore, a patient’s own vessels make the best grafts in many settings. However a person only has a limited number of ´spare´arteries, even for small artery disease. For diseased large arteries, autologous graft vessels are always very scarce or non-existent.Thus, the perfect vascular graft remains unidentified. Peritoneum as a graft material has previously been examined in some smaller animals(2,3,4) These grafts have generally remained patent and showed signs of arterialisation after a period of implantation into the arterial circulation. How this arterialisation comes about is uncertain. We examine the peritoneum as an arterial graft material in a large mammal, and hypothesize that some plasticity exists even in mature peritoneal cells, that arterialization may take place due to altered cellular function in the transplanted tissue.

Methods: Sheep of the Norwegian Dalasau type were used in this study. Each sheep received implantation of a peritoneal graft with its adhering abdominal fascia into their common carotid arteries by end to end anastomosis, followed five months later by graft extraction. 6 sheep were included. 4 sheep received autologous grafts (graft material from their own peritoneum), while 2 male sheep received allogenous transplant grafts, with peritoneum from female donors.

Results: Five months after graft implantation, 4 in 5 implanted grafts were still patent. 1 sheep developed an early pseudoaneurysm and was euthanized after shortly implantation. 3 in 4 open grafts showed aneurysmatic changes. 1 graft was patent and without aneurysm. In all grafts a marked wall thickening had taken place. In the flimsy peritoneum a fibromuscular layer similar to an artery´s media had developed, as well an endothelial lining indistinguishable from the adjacent carotid artery endothelium. Microscopic examination showed alpha-actin positive smooth muscle cells organised in a stratified circular pattern through the ´media´layer, interwoven with connective tissue cells. Vasomotor analysis remarkably showed that the previously inert peritoneum now had developed both vascocontractility as well as endothelium-independent vasoconstriction.

Conclusion: This study shows that peritoneum with its adhering fascia can theoretically be used as an arterial graft material in a large mammal, though the risk of aneurysmatic change is significant. This is however likely to improve as the technique of graft formation and technical skills develop. Two sheep received transplant grafts from other sheep and showed the same adaptive arterialisation as did the autologous transplant grafts. Sequenom DNA genotyping to identify the origin of the cells that make up the extracted grafts are currently under way. This will delineate further how the striking arterialisation in this graft model takes place; as a result of mature peritoneal cells altering their function in response to being moved to a new environment with new demands? Or does the implantation of peritoneum into the vasculature trigger an influx of host cells where peritoneum serves as a scaffold for the creation of a new vessel?

Copenhagen, Denmark • 28-30 September 103

Scientific Session

References 1) Physiol. Res. 58 (Suppl. 2): S119-S139, 2009. MINIREVIEW Blood Vessel Replacement: 50 years of Development and Tissue Engineering Paradigms in Vascular Surgery. 2) Novel Vascular Graft Grown Within Recipient’s Own Peritoneal Cavity. Campbell et al, Circulation Research, 85:1173-1178. (1999) 3) The Peritoneum as a Natural Scaffold for Vascular Regeneration. Stefano Bonvini et al. 2012 4) Acta Veterinaria Hungarica 56 (3), pp. 411–420 (2008)

Copenhagen, Denmark • 28-30 September 104

Scientific Session

SESSION 8 – MISCELLANEOUS (2)

OP 049 VAS Q- AN INNOVATIVE EXTERNAL SUPPORT DEVICE IMPROVES FUNCTIONALITY OF ARTERIOVENOUS FISTULAS: PILOT STUDY RESULTS

Institution: Vascular Institute, St. George’s University Hospitals Foundation Trust, London, United Kingdom

Authors presenting: Eric Chemla

Introduction: Patients in need of dialysis treatment depend on vascular access. Arteriovenous fistula (AVF), is the gold standard for access, however, while superior to other access methods, it is associated with high early failure rates which necessitates frequent interventions intended to maintain AVF functionality. Large series have shown that although native AVFs have a low rate of complications and improved longevity of use when functional, they suffer from relatively poor early patency rates with more than half being unsuitable for dialysis use by one year. The precise reasons for these early failures remain to be fully elucidated, although it is clear that inability to increase inflow often results from perianastomotic stenosis and venous neointimal hyperplasia. Turbulent flow has been identified as a driver for neointimal hyperplasia and as a cause of stenosis. VasQ, is a new external support device, implanted over the arteriovenous fistula. Targeting the juxta-anastomotic area, the VasQ adjusts anastomosis geometry, regulates flow patterns, and supports the venous wall thereby facilitating fistula maturation and longevity. We present results of a Pilot prospective study, enrolling 20 patients with a follow up period of 6 months. Study objectives included assessment of the implantation procedure and fistula maturation and patency rates.

Methods: The trial was conducted as a prospective, single-arm study design so as to determine device safety and initial efficacy. The study was conducted at St. George’s Vascular Institute, St. George’s University Hospitals Foundation Trust, London, UK. 20 Patients were enrolled. Patients were eligible if they were referred for creation of a new brachiocephalic fistula with non-stenotic vein and artery diameter ≥3mm, and free of significant co-morbidities which can prevent study completion. The VasQ device was threaded proximally on the vein prior to anastomosis suturing and subsequently lowered distally onto the anastomosis after completion. Patients were followed for 6 months post- procedure, with Doppler ultrasound examinations performed at 1, 3, and 6 months. Fistula was considered matured if Doppler measurements showed venous outflow ≥500 ml/min and vein diameter ≥5mm

Results: Between June 2014 and January 2015, two surgeons implanted VasQ in 20 patients. Device implantation easily integrated with the routine fistula procedure. All patients were free from any device related complications. One patient died following a myocardial infarction. At 1, and 3 months fistula maturation rate were 75% and 79%, Primary patency rates at 1, 3 and 6 months were 95%, 79% and 79%. mean outflow rates at 1,3 and 6 months were 1130ml/min and 1426ml/min, and 1304 ml/min. mean vein diameters were 6.6mm, 8.4mm and 10 mm at 1,3 and 6 months respectively. Conclusion: The VasQ used in autogenous brachiocephalic AVFs is associated with higher short- and medium-term maturation and patency rates for externally supported AVFs than previously reported. Larger, longer-term prospective studies are required in order to confirm these promising results. VasQ may obviate some of the problems implicated in early AVF failure providing a fixed outflow diameter and shielding the anastomosis from adhesions and inflammatory reaction.

Copenhagen, Denmark • 28-30 September 105

Scientific Session

OP 050 PTFE THIGH LOOPS PROVIDE BETTER PRIMARY PATENCY, THAN OTHER VASCULAR ACCESS LOCATIONS

Institution: 1. Department of Surgery, Division of Vascular Surgery 2. Department of Internal Medicine, Medical University of Graz, Graz, Austria

Authors presenting: Peter Konstantiniuk, Stefanie Santler, Georg Schramayer, Florian Prüller, Ulrike Demel, Tina Cohnert

Introduction: For performing haemodialysis a vascular access is needed. In lack of the best option, an autologous vein, a PTFE graft may be implanted. The goal of our study was to determine factors that influence the primary patency (PP) of these prosthetic shunts.

Methods: Between December 1998 and December 2014 a total of 490 PTFE grafts were implanted. Operative data were collected prospectively in a specialised database, follow up data were retrieved retrospectively from the hospital data system and from the patients. After exclusion of 51 shunts for several reasons (extension, interpositions in the same area, no proper use) 439 prostheses remained for statistical analysis. The following parameters were investigated concerning the primary patency (time between implantation and first thrombosis): institution performing dialysis, gender, age, material of prosthesis (four different types of PTFE grafts from two different manufacturers), shape of the prosthesis (tapered vs. non-tapered), surgeon, shuntlocation (upper arm straight, upper arm loop, lower arm loop, brachiojug. straight, thigh loop). A subgroup of 43 patients with 59 shunts was available for thrombophilia screening including homocysteine, lipoprotein A, activated protein C resistance (APCR), protein C activity, protein S activity, lupus activated partial thromboplastin time (aPTT), lupus anticoagulant, cardiolipin antibodies and ß2-glycoprotein antibodies. PP was calculated with SPSS 23.0.0.0 using the Kaplan Meier method. Differences between subgroups were calculated with Cox Regression. P-values below 0.05 were considered significant.

Results: Mean age was 63 years, 42.1% (185/439) were male, 57.9% (254/439) female. The overall PP was 23.32 months.

Influencing factors: Institution performing dialysis: p = 0.11, gender: p = 0.27, age: p = 0.13, material of prosthesis: p = 0.87, shape of prosthesis: 0.001 (non tapered: 25.36, tapered: 14.19), surgeon 0.52, shuntlocation: p = 0.03 (loop forearm: 15.32, straight upper arm: 24.19, loop upper arm: 15.32, straight brachiojug: 16.24, loop thigh: 33.30), homocysteine: p = 0.52, lipoprotein A: p = 0.65, APCR: p = 0.002 (APCR <2.9: 9.22, APCR >= 2.9: 22.83), protein C activity: p = 0.17, protein S activity: p = 0.09 (<100%: 16.86, >=100%. ): 9.65), lupus anticoagulant: p = 0.21, Factor V Leiden mutation: p = 0.08 (no mutation: 18.28, mutation: 6.4), prothrombin mutation G20210A: not found, cardiolipin antibodies: p = 0.05 (<= 2.5 U/ml: 24.49, >2.5 U/ml: 9.06), ß2-glycoprotein antibodies: p = 0.112

Conclusion: In our data tapered prostheses had a significantly worse PP. This might be due to the fact, that this is a non-randomized trial and it is up to the surgeon, which type of prosthesis is implanted. If the surgeon is not satisfied with the quality of the artery intraoperatively he might decide to use a tapered prosthesis to prevent the limb from a steal phenomenon. Shuntloops on the thigh were significantly better and should be favored in case of questionable local situation on the arms. All patients with Factor V Leiden mutation (11.8% of all) showed pathologic APCR values and a significantly lower PP. A higher level of cardiolipin antibodies was significantly associated with a low PP. This was surprising since the cardiolipin antibody levels of all patients were within ‘normal’ range according to the Sydney criteria from 2008. This might be due to the different surface of a PTFE prosthesis being comparable to autologous vessels.

Copenhagen, Denmark • 28-30 September 106

Scientific Session

OP 051 DIASTOLIC DIAMETER MEASUREMENTS ON THE THORACIC AORTA CAN LEAD TO ACCURATE SIZING OF ENDOGRAFTS IN YOUNG PATIENTS

Institution: 1. Heart and Vascular Center, Semmelweis University 2. Department of Geometry, University of Technology and Economics, Budapest, Hungary

Authors presenting: Peter Sotonyi, Csaba Csobay-Novak, Daniele M. Fontanini, Brigitta Szilagyi, Kalman Huttl

Introduction: In recent years, endovascular aortic repair (EVAR) has become the first-line treatment for acute aortic syndrome. Computed tomography angiography (CTA) is used in the preoperative evaluation of interventions. As the image quality is improving, elimination of motion artifacts caused by the pulsation of the surrounding tissues and the aorta itself is crucial, for which electrocardiogram (ECG) gating has become the most popular method. However, systolic- diastolic motion of the aorta raises new challenges. Can routine use of diastolic images for preoperative evaluation cause undersizing of endografts? Our previous study showed that aortic pulsatility is clinically irrelevant in old patients, but it decreases with age. In our recent study we are focusing on young patients, whether or not aortic pulsatility has an effect on endograft sizing in this population.

Methods: In our research 52 young (<50 years) patients’ CTA scans were examined (35 male, 41,1 ± 7,3 years mean age). The study was executed on readily available coronary CT angiography (CCTA) images obtained from patients who have been evaluated for coronary aortic disease. A Philips Brilliance iCT was used for imaging, using prospective ECG triggering. Diastolic phase native scans were compared to systolic phase contrast enhanced CTA scans. A Philips IntelliSpace Portal workstation was used to measure systolic and diastolic cross-sectional areas in 3 localizations on the scanned segment of the descending aorta. Effective diameter was calculated from the cross-sectional area, then artoic strain [(dmax – dmin)/dmin] was derived. Repeated measurements by two expert radiologists were performed independently to assess inter- and intraobserver variability.

Results: Significant differences (p<0,001) between systolic and diastolic diameters were found on all three measured locations of the descending aorta. The mean pulsatility on the three spots was 7,1 ± 3,7%; 7,6 ± 4,3% and 8,6 ± 4,4%. Differences in strain values between the measured locations were not significant, while the diameter in the lower third of the scanned segment is shorter than in the upper third (p=0,015). Neither age, nor other clinical parameters were found to be correlated with aortic strain in this population. Both intra- and interobserver reliability was excellent with an intraclass correlation coefficient >0.9.

Conclusion: Our study shows that descending aortic strain can be measured precisely and reliably on images of routine coronary CTA examinations with native scans acquired during systole. In contrast to the previously examined old patient cohort, a more relevant aortic strain can be measured in younger patients. Nevertheless, as the average thoracic aortic strain was still lower than 10%, routine use of systolic phase imaging cannot be recommended: it has no clinical benefit for the vast majority of the patients but increases the risk of motion artefacts. We also demonstrated that large interindividual differences are present in the scale of thoracic aortic strain, a phenomenon that needs further investigations to be fully understood.

Copenhagen, Denmark • 28-30 September 107

Scientific Session

OP 052 THREE-DIMENSIONAL CONTRAST-ENHANCED ULTRASOUND IMPROVES THE DETECTION AND CLASSIFICATION OF ENDOLEAKS FOLLOWING ENDOVASCULAR ANEURYSM REPAIR.

Institution: 1. Department of Academic Surgery, University of Manchester 2. Department of Vascular and Endovascular Surgery 3. Independent Vascular Services, University Hospital South Manchester, Manchester, United Kingdom

Authors presenting: Chris Lowe, Abeera Abbas, Steven Rogers, Lee Smth, Jonathan Ghosh, Charles McCollum

Introduction: Life-long surveillance following EVAR is recommended to detect stent-graft related complications, of which, endoleak is by far the most common. The move away from computed tomographic angiography (CTA) based surveillance following EVAR has seen an evolving role for ultrasound modalities. Three-dimensional contrast-enhanced ultrasound (3D-CEUS) has potential to refine ultrasound-based diagnosis of endoleak and reduce the need for CTA and catheter angiography. This study compares the ability of 3D-CEUS and CTA to detect and classify endoleaks following EVAR. Inter-operator variability for detection and classification of endoleak by 3D-CEUS was studied. The 3D-CEUS diagnosis was compared with the CTA but also on the final decision of the vascular multi-disciplinary team (MDT).

Methods: Patients undergoing CTA as part of the EVAR surveillance programme were recruited. Patients attended for 3D-CEUS on the same day as the CTA or as close to the same date as possible. 3D- CEUS was performed using SonoVue contrast and a freehand 3D-US system using electromagnetic tracking, coupled with a Philips iU22 unit. For both CEUS and 3D-CEUS, images were acquired by an accredited and experienced vascular scientist. Each image pair was then independently analysed by two blinded vascular scientists with experience in CEUS and 3D-CEUS. Each CTA was analysed and reported by a consultant vascular interventional radiologist. Inter-operator reliability of 3D-CEUS was examined with the kappa statistic.

Results: 100 paired CTA, CEUS and 3D-CEUS studies were analysed. Assuming CTA to be the gold standard, the sensitivity, specificity, positive, and negative predictive value of 3D-CEUS to detect all endoleaks was 96%, 91%, 90%, and 96% respectively. Taking the MDT decision to be the ‘gold standard’, the sensitivity, specificity, positive, and negative predictive value of 3D-CEUS was 96%, 100%, 100% and 96%. The kappa statistic for inter-operator agreement of endoleak presence and type was 0.89. 3D-CEUS more accurately reflected the final MDT decision on the presence and type of endoleak.

Conclusion: 3D-CEUS is more sensitive and accurate than CTA for endoleak detection and classification following EVAR. 3D-CEUS is now our investigation of choice if the AAA continues to grow or an endoleak is detected on standard duplex imaging.

Copenhagen, Denmark • 28-30 September 108

Scientific Session

OP 053 FOLLOW-UP OF FASCIAL SUTURE AFTER ENDOVASCULAR ANEURYSM REPAIR WITH DUPLEX ULTRASOUND

Institution: 1. Department of Vascular Surgery, Department of Interventional Radiology, Rigshospitalet, University of Copenhagen, Denmark 2. Faculty of Health and Medical Science, University Copenhagen 3. Copenhagen Academy for Medical Education and Simulation, Capital Region of Denmark, Copenhagen, Denmark

Authors presenting: Kim Bredahl, Kristian Fredholm, Lars Lönn, Katja Vogt, Henrik Sillesen, Jonas Eiberg

Introduction: Fascia suture is an alternative technique for femoral artery access site hemostasis after endovascular aneurysm repair (EVAR)1,2. Vascular complications such as pseudo-aneurysm formation and stenosis in the femoral artery after fascial suture are a challenge. The aim of the study was to report the incidence and clinical outcome of access related vascular injury and subsequent intervention after fascial suture technique using duplex ultrasound pre-operatively and three months post-operatively.

Methods: Between February 1st 2011 and July 31st 2014, all patients who underwent EVAR with attempted fascial suture were included. During the study period, 245 patients underwent EVAR, 3 were unilateral and thus 487 groins were examined of which 175 groins were excluded leaving 312 groins for further analysis. The reason for exclusion were planned cut-down (n= 51), closure device (n=14) and cut-down due to surgeons preferences (n=110), mainly due to heavily calcified common femoral arteries (n=92). Data were prospectively collected and retrospectively analyzed. The access arteries were investigated with duplex ultrasound pre-operatively and after three months. A peak systolic velocity ratio of two or higher defined significant stenosis. Online medical records were used to identify primary failures, reoperations and re-hospitalization related to femoral artery access site within three months.

Results: Fascia closure failed in 29 groins out of 312 and at three month follow-up of the remaining 283 groins no patients suffered stenotic lesions at the access site and pseudo-aneurysm formation was seen in 13 patients, of which one had thrombin injection and 12 were treated conservatively (Table I). Between discharge and three month follow-up, one patient with pedal pulses after EVAR suffered from acute limb ischemia and was treated successfully with a cross-over bypass. Wound infections were seen in seven patients, needing surgical revision in four.

Image:

Conclusion: Fascial suture in EVAR is associated with a low complication rate, excellent clinical outcomes and can be performed in two third. Access site stenosis did not occur in this study and pseudo-aneurysm formations were infrequent and benign.

Copenhagen, Denmark • 28-30 September 109

Scientific Session

References: 1. Montán C, Lehti L, Holst J, Björses K, Resch T. Short- and Midterm Results of the Fascia Suture Technique for Closure of Femoral Artery Access Sites After Endovascular Aneurysm Repair. J Endovasc Ther 2011;18 :789–96. 2. Larzon T, Roos H, Gruber G, Henrikson O, Magnuson A, Falkenberg M et al. Editor’s Choice - A Randomized Controlled Trial of the Fascia Suture Technique Compared with a Suture-mediated Closure Device for Femoral Arterial Closure after Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2015;49(2):166–7

Copenhagen, Denmark • 28-30 September 110

Scientific Session

OP 054 PREVENTION OF INCISIONAL HERNIA AFTER ABDOMINAL AORTIC ANEURYSM REPAIR (AIDA STUDY)

Institution: 1. Vascular surgery, University Heart Center, University of Hamburg Eppendorf, Hamburg 2. Vascular surgery, Technical University Munich, Munich 3. General &vascular Surgery, Klinikum Bremen Nord, Bremen 4. Vascular surgery, Klinikum Ludwigsburg, Ludwigsburg 5. Vascular surgery, Universitätsklinik Würzburg, Würzburg 6. Vascular surgery, Universitätsklinik RWTH Aachen, Aachen 7. Vascular surgery, Universitätsklinik Nürnberg, Nürnberg 8. Vascular surgery, Asklepios Klinik Harburg, Hamburg 9. Vascular surgery, Katharinenhospital Stuttgart, Stuttgart, Germany

Authors presenting: Holger Diener, Hans Henning Eckstein, Heiner Wenk, Johannes Gahlen, Richard Kellersmann, Jochen Grommes, Eric Verhoeven, Harald Daum, Thomas Hupp, Sebastian Debus

Introduction: After midline incisions, the formation of incisional hernias remains one of the most common late surgical complications.A clinical correlation between Abdominal Aortic Aneurysms (AAA) and hernias is well documented. Increasing evidence suggests a propensity between AAA and abdominal wall hernias as well as inguinal hernias.The reported incidence of incisional hernia postrepair of Abdominal Aortic Aneurysm (AAA) after midline incision varies between 10 to 38%. The high frequency of incisional hernia formation in the AAA patients suggests the presence of a structural defect within the fascia. Although the precise aetiology remains obscure, it is suggested that connective tissue abnormalities may occur in patients susceptible to aneurysm disease that affect wound healing, thus predisposing patients to incisional hernia after AAA repair.

Methods: This is a prospective, randomized, controlled, multicenter clinical investigation with patients undergoing elective median laparotomy for Abdominal Aortic Aneurysm (AAA) repair. The primary objective of this clinical investigation is to test the hypothesis that insertion of an Ultrapro mesh placed in onlay technique (group A) is superior to suturing alone (Monoplus Suture material, group A), and will reduce the hernia formation rate within the first year from 30% to 10% of the patient population. A secondary objective is a non-inferiority of MonoMax suture material (group C) in comparison to MonoPlus (group A)

Results: 108 patients were randomized between February 2011 and July 2013. The compare of demographic data, risk factors and co-morbidities did not reveal structural differences between the study groups. After 12 months 4.55 % of the patients with an additional implanted mesh in onlay position (group B) had developed an incision hernia versus 21.74% undergoing midline closure using two monofilaments suture loops (group A). In group C 18.18% of patients with 12- months-follow-up had an incision hernia. Non-parametric binominal testing assuming a hernia rate of 20 % or 30 % after 12 months was performed. For group A and C, herniation significantly differing from 20% (p=0.499 respectively p=0.543) or 30 % (p=0.269 respectively p=0.165) could be refused, while the number of hernias in group B significantly differed from 20 % (p=0.048) and 30 % (p=0.004). Wound healing disorders occurred in15.19%. Notable differences were visible in formation of seromas which were exclusively found in patients of group B (19.23 %) but not in group A or C. In total, re- surgery of the abdominal wall was performed in n=11 patients (10.68 %). This number also includes n=4 non- emergency interventions (revision of the abdominal wall because of persistent seroma or repair of incision hernia).

Conclusion: Additional mesh in onlay position after median laparotomy for AAA can reduce hernia rate significantly.

Copenhagen, Denmark • 28-30 September 111

Scientific Session

SESSION 9 – VENOUS/WOUND

OP 055 A SYSTEMATIC REVIEW OF STENTING IN THE MANAGEMENT OF ACUTE DEEP VENOUS THROMBOSIS

Institution: Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, Fulham Palace Road,London , W6 8RF, United Kingdom

Authors presenting: Mohamed A. H. Taha, Andrew Busuttil, Roshan Bootun, Alun H. Davies

Introduction: Deep venous thrombosis (DVT) involving the ilio-femoral vein is associated with significant morbidity. Percutaneous endovascular interventions (PEVI) for acute DVT allow for detailed examination of the vein segment in question following thrombus resolution and in most cases unmasks the causative lesion. Treating iliac vein stenosis/compression with venous stenting is thought to reduce the recurrence rate of DVT as well as reduces the severity of symptoms of post thrombotic syndrome (PTS). The aim of this review is to evaluate the impact of venous stenting on the presence of chronic venous insufficiency symptoms, recurrence of thrombosis and stent patency and the optimal duration of anticoagulation following stent placement.

Methods: Embase and Medline databases (from 1949 to Feb 2016) were interrogated to identify studies looking at stenting in patients with acute ilio-femoral DVT. Additional references were manually added from reviews and opinion articles included in our initial search. The extracted data was tabulated and descriptive statistics were performed using Excel (Microsoft, Redmond, WA). The inclusion criteria were: (1) Randomised controlled studies for acute venous stenting (2) Case series that included more than 5 stenting patients in their series (3) Lower limb venous stenting (4) Studies published in English (5) Human studies.

Results: Seven hundred and eighty-one articles were initially identified from database search. Additional references were obtained by manually checking reviews and original investigations. Following title and abstract screening, 49 articles were included. The 49 studies included 843 patients (850 limbs) stented acutely. Only patients who were stented during the thrombolytic procedure were included in the analysis for stent patency. Primary, assisted primary and secondary patency rates 12 months after stent placement were 85.80%, 87.06% and 91.61%, respectively. PTS was assessed in most studies, although recognised tools were only employed in 18 studies (Villalta; 9, Modified Villalta; 1, VCSS; 1 and CEAP; 7). With the overall PTS rate 8.3% of patients in studies that reported PTS as an outcome measure. The incidence of stent re-thrombosis (both early and late) ranged from 5% to 25%. In 98% of the included studies, anticoagulation was administered to all patients who underwent venous stenting and, in 16% of studies, patients received additional antiplatelet therapy consisting of aspirin and/or clopidogrel. The duration of anticoagulation treatment was not guided by the stenting procedure in 75% of studies but guided by the pre-existing predisposing factors 95%. Quality of life questionnaires employed in 22% of included studies and a RCT identified an improvement in VCSS (7.57±0.27 vs. 0.69±0.23) and CIVIQ (22.67±3.01 vs. 39.34±6.66) between both test and control groups, which a high statisticalsignificance for the difference in VCSS and CIVIQ in control and treatment groups (p<0.001).

Conclusion: Venous stenting for an acute DVT of the lower extremity appears to be an effective endovascular optionwith a high patency rate up to 1 year as well as reducing the incidence of post-thrombotic syndrome and recurrent DVTs. Further studies with longer-term follow-up would allow for a better assessment of this technique and to determine the optimal length of anticoagulation therapy after stent placement and the impact on quality of life.

Copenhagen, Denmark • 28-30 September 112

Scientific Session

OP 056 ENDOVENOUS LASER THERAPY (ELT) OF SAPHENOUS VEIN REFLUX USING THULIUM LASER (TM, 1940NM) WITH RADIAL FIBER - ONE YEAR RESULTS

Institution: 1. Department for Vascular Surgery, Diakonie-Klinikum Schwaebisch Hall, Schwaebisch Hall 2. Laser Research Laboratory, LIFE Centre, Ludwig-Maximilians-University, Munich, Germany

Authors presenting: Anna Esipova, Claus-Georg Schmedt, Slobodan Dikic, Abhay Setia, Sahit Demhasaj, Thomas Dieckmann, Marius- Mircea Tipi, Ronald Sroka

Introduction: The use of endovenous laser therapy (ELT) with longer wavelengths (e.g. 1470nm) is indicated to be advantageous over ELT with shorter waveleghts (e.g. 810-980nm). The 1940nm Thulium-Laser is claimed to target and heat water (as opposed to hemoglobin) in the bloodstream. In this clinical study the one-year results of the ELT application of 1940nm laser with respect to feasibility, effectiveness and safety are reported.

Methods: In this single center, prospective observational study, 138 patients with saphenous reflux (great saphenous vein - GSV and small saphenous vein - SSV) were treated with 1940nm laser (radial fiber) with continuous pullback (1mm/sec). The choice of anesthesia was general, spinal or only tumescent. The tumescent anesthesia was infiltrated in all cases perivenous in the saphenous sheath under ultrasound guidance (USG). Simultaneous miniphlebectomy was performed in all cases additionally ligation of insufficient perforators were performed in selected patients. Clinical evaluation by means of color duplex sonography, clinical examination, standardized questionnaire and pro-forma was done preoperatively and postoperatively after 3 days, 4 weeks, 6 months and 12 months. The data was collected and tabulated with respect to demographics, vein morphology, longitudinal endovenous energy density (LEED), postoperative pain intensity, analgesia requirement, resumption of daily activities and persistent reflux.

Results: A total of 138 patients corresponding to 177 saphenous veins were operated (female/male ratio 107/70, mean age 55years, range 23-90 years). The 3 day and 4 week follow up rate was 100%. 135 (76.3%) saphenous veins were followed up at 12 months. The mean preoperative maximum diameter of the GSV was 6.9mm (range 3.3-11.3mm) and of the SSV was 5.1mm (range 2.6- 10.0mm). The mean LEED applied was 59.2 Joules/cm (range 30.0-98.2 J/cm) for GSV and 47.3 J/cm (range 30-70 J/cm) for SSV. The complete occlusion of the treated saphenous vein was defined as absence of flow on color Doppler imaging and was achieved in 174/177 (98.3%) subjects at 4 weeks and 132/135 (97.7) patients at 12 months. Partial occlusion was observed in three patients and was defined as reflux >3cm distal to the junction. The mean length of non-occluded stump at the junction between saphenous vein and deep vein was 0.5cm (range -3.6 to 5.0cm) 4 weeks postoperativ. Mean postoperativ reduction of the diameter of GSV and SSV at 1 year was 40% and 56% respectively (p<0.05%). In the early postoperative phase paraesthesia was observed in 15/177 (8.5%), ecchymosis in 4/177 (2.3%), lymphocoele in 1/177 (0.6%), hyperpigmentation in 1/177 (0.6%). Endovenous heat induced thrombus (EHIT) propagation was observed in 4/177 (2.3%) subjects. There were no skin burns or phlebitis. No patient reported severe pain. The mean postoperative pain intensity (Visual Analoge Scale) was 1.3. The mean convalescence period was 2 days (1-30d). No long-term complications and recurrent reflux was observed at 1 year follow-up.

Conclusion: ELT using Thulium laser (1940nm) with radial fiber efficiently eliminates the reflux in the saphenous veins by occlusion and significant diameter reduction with no reflux recurrence at 1 year follow up. The complication rates are less or comparable to the other endothermal and surgical procedures. These benefits are offered with low postoperative pain, analgesia requirement and rapid convalescence.

Copenhagen, Denmark • 28-30 September 113

Scientific Session

OP 057 RECONSTRUCTION OF THE VENOUS OUTFLOW OF THE LOWER EXTREMITY IN POST-THROMBOTIC SYNDROME AND ILIAC VEIN COMPRESSION SYNDROME

Institution: 1. Department of Surgery, Maastricht University Medical Centre 2. Cardiovascular Research Institute, Maastricht University, Maastricht 3. Department of Radiology, Viecuri Medical Centre, Venlo, 4Department of Radiology, Maastricht University Medical Centre, Maastricht, Netherlands, 5. Department of Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany

Authors presenting: Timme Van Vuuren, Mark A. de Wolf, Carsten W. Arnoldussen, Ralph L. Kurstjens, Jorinde H. van Laanen, Houman Jalaie, Rick de Graaf, Cees H. Wittens.

Introduction: Deep venous obstructive (DVO) disease is a condition which can have a great impact on daily activities and quality of life. This obstruction can be divided in two main categories: intraluminal vein damage and extra luminal vein compression. Intraluminal changes mainly consist of post-thrombotic scarification following a deep vein thrombosis; known as the post thrombotic syndrome (PTS). PTS is mainly characterized by pain and heaviness in rest or during mobilisation, and skin changes in the lower leg. Extraluminal vein compression consists mainly of the iliac vein compression syndromes (IVCS) caused by arteries compressing the iliac vein; such as in the May-Thurner syndrome. Both types of obstruction can lead to chronic impaired venous outflow of the leg and result in symptoms linked to chronic venous disease. Up till now there was no good treatment modality. With the introduction of percutaneous transluminal angioplasty, recanalization and stenting with or without open surgical techniques a definitive solution for DVO patients may be apparent. The objective of this study was to evaluate the mid-term technical and clinical outcome of endovascular and hybrid treatment in venous obstructive disease.

Methods: All prospective gathered data of patients treated in our tertiary referral centre between September 2009 and January 2016 were evaluated. Patients with an acute deep vein thrombosis were excluded. Patients were categorized into subpopulations based on their treatment procedure; (1) IVCS patients or (2) P-PTS patients treated by sole endovascular means, and (3) hybrid PTS (H-PTS) patients treated by both endovascular and open-surgical techniques. Stent patency rates (Kaplan-Meier estimation), complication rates, Venous Clinical Severity Score (VCSS) and Villalta score were analysed.

Results: A total of 421 lower extremities in 369 patients were treated (IVCS n=87, P-PTS n=196, H-PTS n=86). Average age was 43 years and 70%, were female. Primary patency rates at 60-months follow- up were 90.4%, 63.5%, and 36.7%, for the IVCS, P-PTS and H-PTS subpopulations respectively. Assisted-primary patency rates were 100%, 81.1%, and62.0%, respectively. Secondary patency rates were 89.1% and 72.1% for P-PTS and H-PTS subpopulations, respectively. Complication rates consisted mainly of minor bleeding complications without the need for reoperations (n=32), stenosis (n=56) or reocclusion (n=69) needing an additional procedure to retain stent patency. Significant improvements in venous claudication, VCSS, and Villalta score were seen in all subgroups.

Conclusion: Reconstruction of a deep venous outflow obstruction of the lower extremity is safe and effective in both iliac vein compression and post-thrombotic syndrome showing a significant improvement in clinical scores with acceptable complication rates. Patency rates are clearly related to the extensiveness of disease and invasiveness of the primary intervention.

Copenhagen, Denmark • 28-30 September 114

Scientific Session

OP 058 ENDOVASCULAR RECANALIZATION OF CHRONIC NON-MALIGNANT OBSTRUCTION OF THE INFERIOR VENA CAVARECONSTRUCTION OF THE VENOUS OUTFLOW OF THE LOWER EXTREMITY IN POST-THROMBOTIC SYNDROME AND ILIAC VEIN COMPRESSION SYNDROME

Institution: 1. Department of Radiology and Nuclear Medicine, Oslo Vascular Centre 2. Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway

Authors presenting: Ole Jørgen Grøtta, Tone Enden, Gunnar Sandbæk, Dag Bay, Carl-Erik Slagsvold, Gard F. Gjerdalen, Jørgen J. Jørgensen, Antonio Rosales

Introduction: Chronic obstruction of the inferior vena cava (IVC) may result from previous thrombosis or congenitalanomaly. The clinical presentation of an IVC obstruction is either symptoms of post thrombotic syndrome (PTS) or related to a reduced cardiac preload. PTS patients have traditionally been conservatively treated with anticoagulation and compression stockings. More aggressive approaches for IVC obstruction have been reported including surgical reconstruction and endovascular recanalization with stents. For both approaches there is so far little documentation. We report our experience with endovascular recanalization with stenting of the IVC.

Methods: A retrospective study of patients with IVC obstruction verified with CT- and/or MRI venography and accepted for endovascular recanalization at Oslo University Hospital Aker during 2010-2015. Patients with PTS were categorised according to the CEAP classification. Symptom severity was assessed using the venous clinical severity score (VCSS). Twenty patients were accepted for IVC stenting; median age 43 (range 15-63) years, nine were women. Median follow-up was 25 (3-70) months. Sixteen patients presented with post-thrombotic symptoms of the leg including venous claudication, oedema, recurrent deep venous thrombosis (DVT), or leg ulcer(s). Seven patients were in CEAP category C3, two in C4, one in C5 and six were C6. Venous claudication was the main treatment indication for C3-4. Four patients had a history of dyspnoea and episodes of syncope during physical activity, but no PTS symptoms. The endovascular procedure was performed in a hybrid angiosuite under general anaesthesia and full anticoagulation. Ultrasound guided access through the right internal jugular vein and femoral veins. After passing the obstruction, self- expanding, large diameter Wallstents® (18-24 mm) were placed, gaining outflow at the intrahepatic IVC. The iliac confluens was reconstructed in 16 patients. Inflow was obtained from the iliacs in six patients and from the femoral level in ten. Large diameter balloons were used for pre- and postdilatation. Follow-up was performed at 3, 6, 12, 18 months, and yearly thereafter included clinical evaluation and colour duplex ultrasound (CDU). Results: Recanalization with stenting of the IVC was technically successful in 19/20 patients. There were no major complications. One patient with PTS died of unrelated causes after 3 months. At final follow-up 15/19 (78%) had open IVC stents. The 24 months primary patency was 8/12 (67%) and secondary patency was 10/12 (83%). One of four with stent occlusion experienced worsening of symptoms compared to baseline. During follow-up reintervention were performed in four patients. VCSS improved in 9 patients with PTS symptoms, was unchanged in 4 and worse in one. Median VCSS preoperatively was 8.5 (range 3-25). At final follow-up median VCSS was 7 (range 2-23). 5/9 reported cessation of venous claudication at final follow-up. Among the four patients with a suspected reduced cardiac preload there were no episodes of syncope during follow-up. Three reported unrestrained physical activity, and one improved physical performance. In total 13 of 19 patients experienced sustained clinical improvement.

Conclusion: Endovascular recanalization of chronic IVC obstruction is technically feasible, safe and leads to substantial clinical improvement.

Copenhagen, Denmark • 28-30 September 115

Scientific Session

OP 059 “TO COVER OR NOT TO COVER, THAT IS THE QUESTION” - RECTUS FEMORIS MUSCLE FLAPS IN GROIN DEFECTS AFTER VASCULAR SURGERY

Institution: 1. Department of vascular surgery, Maastricht university medical center, Maastricht 2. Department of vascular surgery, Viecuri Hospital, Venlo 3. Department of vascular surgery, Maxima Medical Center, Veldhoven 4. Department of vascular surgery, European Vascular Center Aachen-Maastricht, Maastricht, Netherlands

Authors presenting: Jurek Conings, Jan Willem Daemen, Ilse Mostaert, Jan-Willem Elshof, Marc Scheltinga, Barend Mees

Introduction: Vascular surgery complications in the groin can lead to significant soft tissue defects and serious life threatening infections and are therefore challenging for surgeons. Worldwide the sartorius flap is the most used and described technique for coverage of groin defects. The rectus femoris flap is an alternative technique to cover these defects without any tension. For this technique, a distal incision is made on the upper leg in the musculus rectus femoris to detach the muscle, tunnel it subcutaneously and cover the groin. The aim of this study was to evaluate the results of the rectus femoris flap as a tool in treating groin defects.

Methods: In the Netherlands, data was collected in three centers of all patients undergoing rectus femoris flap coverage of groin defects between 2000 and 2015. In total, 77 groin defects were treated in 70 patients. Outcomes were defined as clinical success (recovery and hospital discharge without major bleeding, sepsis or amputation), survival, 30-day complication rate and reintervention after the index operation of the rectus femoris flap.

Results: Indications for rectus femoris muscle flap coverage of groin defect were hematoma or bleeding, blow- out, false aneurysm, wound infection, infected non-human implant, and re-do bypass surgery. Initial procedures included a large variety of bypasses and endovascular procedures. The average number of previous operations in the groin of interest was 2.1 (range 1 - 6). Clinical success was 76% (53/70 patients). A total of 17 patients died because of sepsis (n=8), postoperative unsuccessful reanimation (n=1), massive bleeding (n=1), heart failure (n=1) and other causes than vascular or flap related (n=6). No amputations were described. A total of 23 groin complications was seen after rectus femoris flap coverage including infection (n= 8), graft loss (n=15), bleeding (n=6), blow-out (n= 2) and necrosis of the muscle flap (n= 1). In 1 patient there was a donor site complication due to bleeding.

Conclusion: This is the largest European series of rectus femoris flaps for vascular surgery groin complications and demonstrates that this technique is an effective treatment for coverage of large groin defects. The outcomes confirm the significant morbidity and mortality of this patient group.

Copenhagen, Denmark • 28-30 September 116

Scientific Session

OP 060 NEGATIVE PRESSURE WOUND THERAPY TO PREVENT GROIN INFECTIONS AFTER VASCULAR SURGERY - A RANDOMIZED CONTROLLED TRIAL

Institution: Vascular Center, Vascular Center, Malmö - Lund, Skåne University Hospital, Malmö, Sweden

Authors presenting: Julien Hasselmann, Tobias Kühme, Stefan Acosta

Introduction: Negative pressure wound therapy (NPWT) is regularly used in the treatment of infected wounds but its role in the prevention of surgical site infections (SSI) and other wound complications is less explored.Groin incisions are frequently used in endovascular and open vascular surgical procedures and associated with a significant risk for SSI. The vascular center in Malmö has used a wound surveillance registry since 2005 that has shown an increasing rate of SSI. Since a pharmacological approach with a change of the center’s antibiotic prophylaxis failed to improve SSI rates (1), a randomized controlled trial (RCT), INVIPS-Trial (*Incisional NPWT on vascular surgical inguinal incisions in the prevention of SSI), was initiated to evaluate if prophylactic NPWT on primarily closed groin incisions may prevent SSI in vascular surgical patients.

Methods: This prospective RCT registered at ClinicalTrials.gov (Identifier: NCT01913132) includes all elective patients undergoing vascular surgical procedures with groin incisions at this vascular center. This study is made up of two different arms, an OPEN arm which includes patients undergoing open vascular procedures (e.g. TEA, femoropopliteal bypass) and an EVAR arm which includes patients undergoing Endovascular Aortic Repair (EVAR). To prove that PICO (Smith & Nephew), a NPWT pad dressing, reduces the SSI rate of open inguinal procedures from 30% to 10%, 147 groin incisions are required. A SSI rate reduction from 4.4% to 1% in case of EVAR requires 497 groin incisions (80% power, 5% significance level). Randomized patients receive either the NPWT or the standard wound dressing (Vitri Pad, ViTri Medical, Sweden) at the end of the procedure. In case of bilateral incisions, NPWT is applied to one, and the standard dressing to the contralateral groin incision (Figure 1). While the standard dressing is routinely changed on day two postoperatively, the NPWT-dressing is left in place for seven days according to the manufacturer’s instructions. The diagnosis SSI is made according to the diagnostic criteria defined by the Centers for Disease Control and Prevention (CDC), USA.

Results: Two hundred two patients were included in this interim analysis. In the OPEN arm, 36 groin incisions analyzed in the NPWT group and 37 in the control group. The overall wound complication rate in the NPWT group and the control group was 9/36 (25%) and 13/37 (35.1%), respectively (p=0.41). SSI in the NPWT group was observed in 4/36 (11.1%) compared to 9/37 (24.3%) in the control group (p=0.04), without differences between the groups regarding patient and operative characteristics. In the EVAR arm, 114 groin incisions analyzed in the NPWT group and 129 in the control group. The overall wound complication rate in the NPWT group and the control group was 9/114 (7.9%) and 11/129 (8.5%), respectively (p=0.41). SSI in the NPWT group was observed in 3/114 (2.6%) compared to 6/129 (4.7%) in the control group (p=0.18), without differences between the groups regarding patient and operative characteristics.

Copenhagen, Denmark • 28-30 September 117

Scientific Session

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Conclusion: The SSI rate in the OPEN arm of the trial was significantly reduced in the NPWT group compared to the control group, whereas no difference in SSI rates was observed between the groups in the EVAR arm. Application of NPWT may be advantageous in vascular procedures at high risk for SSI.

References: (1) Hasselmann, J., Kuhme, T. and Acosta, S. (2015) Antibiotic Prophylaxis with Trimethoprim/Sulfamethoxazole instead of Cloxacillin Fails to Improve Inguinal Surgical Site Infection Rate after Vascular Surgery. Vascular and Endovascular Surgery, 49, 129-134. http://dx.doi.org/10.1177/1538574415600531

Copenhagen, Denmark • 28-30 September 118

Scientific Session

SESSION 10 – MiSCELLANEOUS (3)

OP 061 10-YEAR EXPERIENCE OF CRYOPRESERVED ARTERIAL ALLOGRAFTS

Institution: New Hospital Civil, Strasbourg, France

Authors presenting: Anne Lejay, Charline Delay, Elie Girsowicz, Bettina Chenesseau, Mathieu Roussin, Vincent Meteyer, Fabien Thaveau, Yannick Georg, Nabil Chakfe

Introduction: The aim of this study was to analyze complications and outcomes of cryopreserved arterial allografts used as vascular substitute in the setting of vascular prosthetic infection, aorto-enteric fistula, or lower limb revascularization without venous material available.

Methods: A retrospective analysis of prospectively collected data concerning all consecutive interventions performed with cryopreserved arterial allografts between January 2005 and December 2014 was conducted. 5-year outcomes included survival, primary patency and allograft-related reintervention for allograft disruption, aneurysmal degeneration or anastomotic aneurysm. Multivariate analysis was performed in order to identify risk factors for death, thrombosis or reintervention.

Results: During this time, 79 cryopreserved allografts were used: 42 for vascular prosthetic infection (Group 1), 11 for aorto-enteric fistula (Group 2) and 26 for femoro-tibial bypasses in the absence of venous material (Group 3). Mean follow-up was 54 months. 5-year survival was 61% in Group 1, 34% in Group 2 and 41% in Group 3 respectively. 5-year primary patency was 65%, 89% and 25% in Group 1, 2 and 3 respectively. 5-year allograft-related reintervention was 61%, 34% and 23% in Group 1, 2 and 3 respectively. Absence of antifungal therapy appeared as risk factor for death (HR=2.30; 95% CI=1.50- 3.61, p<0.05) and reintervention (HR=2.46; 95% CI=1.57-3.32, p<0.01) and denutrition appeared as risk factor for thrombosis (HR=3.52; 95% CI=1.54-3.94, p<0.01).

Conclusion: Cryopreserved arterial allografts outcomes are tempered by suboptimal 5-year outcome with high reintervention rates. Multidisciplinary care is mandatory in order to improve long-term outcome.

Copenhagen, Denmark • 28-30 September 119

Scientific Session

OP 062 THE DANCAVAS PILOT STUDY OF MULTIFACETED SCREENING FOR SUBCLINICAL CARDIOVASCULAR DISEASE IN MEN AND WOMEN AGED 65-74

Institution: 1. Elitary Research Centre of Individualised Medicine in Arterial Disease, Odense C, Denmark 2. Department of Cardiothoracic and Vascular Surgery, Elitary Research Centre of Individualised Medicine in Arterial Disease, Odense C 3. Department of Public Health and Department of Clinical Medicine, Aarhus C 4. Department of Cardiology, University Hospital Odense Svendborg, Svendborg 5. Department of Cardiology, Vejle Hospital, Vejle 6. Department of Cardiology, Diagnostic Centre, Regional Hospital Silkeborg, Silkeborg 7. Department of Cardiology, University Hospital Odense 8. Institute of Pharmacology, Department of Cardiology, Diagnostic Centre, Regional Hospital Silkeborg 9. Department of Cardiology, Elitary Research Centre of Individualised Medicine in Arterial Disease, Odense C, Denmark

Authors presenting: Thomas Vedel Kvist, Jes S. Lindholt, Lars M. Rasmussen, Rikke Søgaard, Jess Lambrechtsen, Flemming H. Steffensen, Lars Frost, Michael H. Olsen, Hans Mickley, Jesper Hallas, Grazina Urbonaviciene, Martin Busk, Kenneth Egstrup, Axel Diederichsen

Introduction: This pilot study of a large population-based randomized screening trial investigated feasibility, acceptability and relevance (prevalence of clinical and subclinical cardiovascular disease (CVD) and proportion receiving insufficient prevention) of a multifaceted screening for CVD.

Methods: 2.060 Danish randomly selected men and women aged 65–74 were offered 1) low dose non-contrast computed tomography to detect coronary artery calcification (CAC) and aortic/iliac aneurysms, 2) detection of atrial fibrillation (AF), 3) brachial and ankle blood pressure measurements and 4) blood levels of cholesterol and HbA1c. Web- based self-booking and data-management was used to diminish the administrative burden.

Results: Attendance rates were 64.9% (n=678) and 63.0% (n=640) for men and women, respectively. 39.7% received recommendation of medical preventive actions. Prevalence of aneurysms were 12.4% (CI 95%: 9.9; 14.9) in men and 1.1% (CI 95%: 0.3; 1.9) in women, respectively (p<0.001). A CAC score above 400 was found in 37.8% of the men and 11.3% of the women (p<0.001) along with a significant increase in median CAC score with age (p=0.03). Peripheral arterial disease was more prevalent in men than women with 18.8% (CI 95%: 15.8; 21.8) and 11.2% (CI 95%: 8.7; 13.6), respectively. No significant differences between the sexes were found in regard to newly discovered AF (men: 1.3%, women: 0.5%), potential hypertension (men: 9.7%, women: 11.5%), hypercholesterolemia (men: 0.9%, women: 1.1%) or diabetes mellitus (men: 2.1%, women: 1.3%).

Conclusion: Screening for CVD seemed more prudent in men than women. The attendance rates were acceptable compared to other screening programs and the logistical structure of the screening program proved successful.

Copenhagen, Denmark • 28-30 September 120

Scientific Session

OP 063 LONG-TERM RESULTS OF THE NAIS PROCEDURE FOR AORTIC-GRAFT INFECTIONS AND MYCOTIC ANEURYSMS: A SINGLE-CENTER EXPERIENCE

Institution: Vascular surgery, CHU de Quebec, Quebec City, Canada

Authors presenting: Valerie Gauvin, Julien Bernatchez, Pascal Rheaume

Introduction: Since the neo-aortoiliac system (NAIS) procedure was first described, the treatment of aortic graft infections and mycotic aneurysms has markedly evolved. Many centers have published their short- term and mid-term results using this procedure but evidence is limited regarding longer follow-up. The goal of this study was to evaluate the long-term outcome of a single center’s cohort of patients treated with a NAIS reconstruction for aortic infections and to identify variables associated with a negative outcome.

Methods: 75 patients who underwent a NAIS procedure at our institution from January 2000 to December 2015 were identified using our center’s database. Demographics, clinical presentation, operative data, post-operative and long-term outcomes were collected.

Results: NAIS reconstructions were performed for 56 aortic graft infections (including 21 aorto-enteric fistulas) and 19 aortic mycotic aneurysms. The graft configuration mostly associated with infection was aortobifemoral (71%). Peroperative cultures were positive in 55 patients (73,4%) and 27% were polymicrobial. Thirty-day mortality was 13% and in-hospital mortality was 17%. Significant postoperative complications included 3 major amputations (4%) and 8 anastomotic ruptures from reinfection (11%). Perioperative death predictors included diagnosis at presentation (aortic graft infections vs mycotic aneurysms), positive per-operative cultures, fungal infections and postoperative anastomotic rupture of the NAIS. Primary graft patency at 1 and 5 years were 84% and 63%, and secondary patency rates were 95% and 92% respectively. Limb salvage at 5 years was 95%. First-year survival was 83% and five-year survival was 63%.

Conclusion: These results indicate that the NAIS procedure is a reliable option to treat aortic infections with acceptable perioperative complications. Ultimately, most patients demonstrate a favorable long-term outcome after the postoperative period. Indeed, the durability of the procedure is its best feature and is demonstrated by excellent graft patencies, and low amputation and reinfection rates.

Copenhagen, Denmark • 28-30 September 121

Scientific Session

OP 064 A MULTICENTRE RANDOMISED CONTROLLED TRIAL OF PATIENT-SPECIFIC REHEARSAL PRIOR TO EVAR: IMPACT ON PROCEDURAL PLANNING AND TEAM PERFORMANCE

Institution: 1. Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium 2. Department of Vascular Surgery, Zurich University Hospital, Zurich, Switzerland 3. Department of Vascular and Thoracic Surgery, St. Maarten Hospital, Duffel, Belgium 4. Department of Surgery and Cancer, Imperial College London, London, United Kingdom 5. Department of Vascular Surgery, Catharina Hospital, Eindhoven 6. Department of Vascular Surgery, St. Elisabeth Hospital, Tilburg, Netherlands 7. Department of Vascular and Thoracic Surgery, Ghent University Hospital, Ghent, Belgium

Authors presenting: Liesbeth Desender, Isabelle Van Herzeele, Zoran Rancic, Mario Lachat, Johan Duchateau, Colin Bicknell, Nung Rudarakanchana, Joep Teijink, Jan Heyligers, Frank Vermassen

Introduction: Advancements in virtual-reality simulation now permit patient-specific rehearsal (PsR) prior to endovascular aneurysm repair (EVAR), enabling the endovascular team to practice and evaluate the procedure prior to treating the real patient, and thus optimise the treatment plan. This multicentre randomised controlled trial aims to evaluate the utility of PsR as a preoperative planning and briefing tool.

Methods: Patients with an infrarenal aortic or iliac aneurysm suitable for EVAR were recruited in six vascular centres across Europe. Cases were randomised to preoperative PsR (intervention group) or postoperative PsR (control group). Prior to rehearsal, the lead implanter completed a treatment plan questionnaire focussing on the choice of stentgraft, diameter, length and number of stentgrafts, and the C-arm angulation to visualise the target landing zones. The data were compared with the C-arm angles and stentgrafts used during the real EVAR procedure. Additionally, all team members (lead implanter, assistant, and scrub nurse) completed a questionnaire evaluating realism, technical issues, and human factor aspects pertinent to PsR, on a Likert scale from 1 (not at all) to 5 (very much).

Results: 100 patients were enrolled between September 2012 and June 2014. Following preoperative PsR, the interventionalist changed their plan to visualise proximal and distal landing zones in 25/50 (50%) and 40/49 (81.6%) cases respectively. The diameter or length of the main body of the stentgraft, contralateral limb, or iliac extensions was adjusted in 12/50 (24%), 21/50 (42%), and 16/50 (32%) of cases, respectively. At least one of the above-mentioned parameters was changed in 44/50 (88%) cases. There was no statistically significant difference in change of treatment plan between experienced (> 50 EVAR cases) and inexperienced lead interventionalists (p = 0.19). 199 subjective questionnaires post-PsR were completed. 62/99 (63%) of lead interventionalists, 36/57 (63%) of assistants and 27/43 (63%) of scrub nurses who completed the questionnaire were highly experienced in EVAR (> 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 individual team members (median 4, IQR 3-5) and the entire 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: Patient-specific rehearsal prior to EVAR can be useful as a preoperative planning and briefing tool, even for experienced interventionalists. It has a significant influence on the treatment plan. Subjective ratings indicate that this technology may facilitate planning of optimal C-arm angulation and improve non-technical skills, particularly team preparedness.

Copenhagen, Denmark • 28-30 September 122

Scientific Session

OP 065 A 12 WEEK HOME EXERCISE PROGRAMME AUGMENTED WITH NORDIC POLE WALKING IMPROVES THE QUALITY OF LIFE AND ABPIS OF CLAUDICANTS. MOST PATIENTS CONTINUE TO USE THEIR POLES AND IMPROVE THEIR WALKING DISTANCE AT ONE YEAR

Institution: 1. Sheffield Vascular Institute 2. STEPS Physiotherapy and Circulation Clinic, Sheffield, United Kingdom

Authors presenting: Jonathan Beard, Clare Spafford, Clare Oakley

Introduction: Supervised Exercise Programmes (SEPs) for claudicants can have problems with cost, availability and compliance. These problems can be avoided with Home Exercise Programmes (HEPs), but these may not be as clinically effective. Our previous RCT demonstrated that a 12 week HEP augmented with Nordic Pole Walking (NPW) significantly improved walking distance compared to Normal Walking (NW).1

The objectives of this study were to:

1. To collect longer-term follow up information on walking distance, speed and compliance from the participants in our original RCT of a 12 week HEP augmented with NPW.

2. To look at quality of life (QoL), and ankle-brachial pressure indices (ABPIs) after a 12 week HEP+NPW. This was done because QoL was not assessed in the RCT and there was a suggestion of improved ABPIs.

Methods: The 38 patients with intermittent claudication, who completed the original RCT, were followed up at 6 & 12 months. Frequency, distance and speed of walking were recorded. A further 21 claudicants were recruited to a 12 week HEP+NPW to look at QoL and ABPIs.

Results: Long-term compliance was excellent: 98% of the patients in the NPW group were still walking with poles at 12 months, compared to 74% of the control (NW) group. The NPW group increased their mean weekly distance (WD) to 17.5km by 12 months, with a mean speed of 4.2km/h. The control group increased their WD from 4.2km to 5.6km and speed to 3.3km/h. Freidman’s test showed the results to be highly significant (p=0.0061). The resting ABPIs of the 21 patients in the second study increased significantly from baseline (Mean = 0.75, SD= 0.12), to week 12 (Mean = 0.85, SD= 0.12), t = (20) -8.89, p=0.000 (two-tailed). All WIQ and EQ5D parameters improved significantly and mean health scores improved by 79%.

Conclusion: The QoL of claudicants participating in a 12 week HEP augmented with NPW improved dramatically. The significant improvement in ABPI suggested in our previous study has also been confirmed. Participants continue to improve their walking distance and speed at one year with excellent compliance. Their improvement and compliance is much better than that reported by many SEPs, with lower costs. Our results justify a multi-centre RCT comparing existing SEPs with a HEP augmented by NPW.

References: Spafford C, Oakley C, Beard J. Nordic Pole Walking is more effective than a standard Home Exercise Programme in improving walking distance in patients with intermittent claudication: A prospective randomised study. British Journal of Surgery 2014; 101: 760 - 767

Copenhagen, Denmark • 28-30 September 123

Scientific Session

OP 066 THE FATE OF PATIENTS WITH INTERMITTENT CLAUDICATION IN THE 21ST CENTURY REVISITED - RESULTS FROM THE CAVASIC STUDY

Institution: 1. Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University Innsbruck, Innsbruck, Austria 2. Diabetes Research Group, King's College London, London, United Kingdom 3. 3rd Medical Department of Metabolic Diseases and Nephrology, Hietzing Hospital, Vienna, Austria 4. Clinic for Angiology, Helios Klinikum Berlin-Buch, Berlin, Germany 5. Clinic for Surgery, Bezirkskrankenhaus Schwaz, Schwaz 6. Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria

Authors presenting: Barbara Rantner, Barbara Kollerits, Johannes Pohlhammer, Marietta Stadler, Claudia Lamina, Slobodan Peric, Peter Klein-Weigel, Hannes Mühlthaler, Gustav Fraedrich, Florian Kronenberg

Introduction: Patients with intermittent claudication carry a high risk for cardiovascular complications. The TransAtlantic Inter-Society Consensus (TASC) Group estimated a five year total mortality of up to 30% for these patients, the majority dying due to cardiovascular causes. We investigated whether this evaluation is still applicable in nowadays patients.

Methods: The CAVASIC Study included 255 male PAD patients with intermittent claudication who were prospectively followed for a median of 7 years. During follow-up overall mortality, vascular morbidity and mortality as well as local PAD outcomes were assessed.

Results: During entire follow-up, overall mortality reached 16.1% (n=41). Most patients died from cancer (n=20). Half of patients (n=22; 8.6%) died within the first five years. Incident cardiovascular events were observed among 70 patients (27.5%), 54 (21.2%) experienced a complication during the first five years. Vascular mortality was as low as 5.1% (n=13) for the entire and 3.1% for the first five years of follow-up. Prevalent coronary artery disease did not increase the risk to die from all or vascular causes. PAD symptoms stayed stable or improved in the majority of patients (67%) during follow-up. Patients with PAD treatment at baseline carried a higher risk for reintervention after three years of follow-up.

Conclusion: Compared with proposed frequency estimates from TASC the proportion of cardiovascular events did not markedly decrease over the last 2 decades. Vascular mortality, however, was surprisingly low among our study population. The data at hand might indicate that nowadays patients more frequently survive cardiovascular events. A relevant number died from cancer.

Copenhagen, Denmark • 28-30 September 124

Scientific Session

OP 067 EYE DOSE REDUCTION WITH VARIOUS X-RAY PROTECTION SHIELDS DURING ENDOVASCULAR PROCEDURES

Institution: 1. Dep. of Medical Physics, Uppsala University Hospital 2. Dep. of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden

Authors presenting: Sara Bruce, Kevin Mani, Karolina Lindskog, Lars Jangland, Anders Wanhainen

Introduction: The potential risk of radiation exposure during endovascular surgery is a subject of great interest today. Radiation exposure of the eye can induce cataract and in 2011 the International commission on Radiological Protection, ICRP, lowered the lifetime eye dose threshold from 2000 mSv to 500 mSv, and the recommended occupational annual dose limit from 150 mSv to 20 mSv based on a review of recent epidemiological studies. Physicians working with interventional procedures can potentially receive eye doses that exceed this limit. Consequently, the use of protective shields such as personal eyewear (glasses and visors) and ceiling mounted shields has increased.The aim of this study was to investigate the reduction of the dose to the eyes with commercially available x-ray protective shields commonly used today.

Methods: Measurements were performed with a Siemens Axiom Artis FD hybrid theatre C-arm using an EVAR protocol, with posteroanterior projection (PA) and lateral projection (X-ray tube on the same side as the “physician”). An anthropomorphic thorax phantom (“patient”) was placed on the table and an anthropomorphic head phantom (“physician”) was positioned at the left side of the table at a height of 180 cm. Three X-ray protective eyeglasses, a visor and a ceiling mounted shield were evaluated (table 1), all with >90% reduction (70kV) according to the vendors. Dose rates were measured (repeatedly four times) with calibrated Unfors EDD-30 dosimeters at the front of the eyes with and without protection. The doses rates varied with minor changes in the set-up (placement of eyewear and dosimeter as well as the set-up of the physician and patient) and all measurements were performed with three comparable set-up geometries.

Results: The baseline dose rate (without protection) was 12 ± 2 µGy/min (mean ± std) at the left eye and 7 ± 2 µGy/min at the right eye for PA projection, and 38 ± 3 µGy/min and 14 ± 2 µGy/min for lateral projection. The eye dose reductions are given in table 1. The reductions changed with set-up geometries and an interval is therefore given. The glasses with space for personal glasses underneath (eyeglass C) offered the highest dose reduction. The reduction to the left eye (PA) was 80 % compared to only 10-50 % reduction with the other glasses. When personal glasses were used underneath eyeglass C the gap between the protective glasses and the head increased and the dose reduction was very much reduced. The downward angled visor reduced the dose (left eye, PA) with up to 75 % whereas the non-angled visor only reduced up to 15 % of the dose. When the ceiling mounted shield was used the reduction was >90 % to both eyes.

Copenhagen, Denmark • 28-30 September 125

Scientific Session

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Conclusion: The present study indicates that several of the protective eyewear used today offer a highly limited dose reduction to the physician. The extent of eye coverage achieved with protective eyewear is of great importance in achieving adequate dose reduction. A proper use of ceiling mounted shield is essential for adequate protection of the eye lens and glasses/visors should only be used as complement.

Copenhagen, Denmark • 28-30 September 126

Scientific Session

OP 068 KIDNEY VOLUME CHANGE IN PATIENTS WITH TYPE B AORTIC DISSECTION IN RELATION TO PERFUSION FROM TRUE OR FALSE LUMEN

Institution: 1. German Aortic Center 2. German Aortic Center Hamburg 3. Vascular Medicine, University Heart Center Hamburg, Hamburg, Germany

Authors presenting: Nikolaos Tsilimparis, Ruth Jacobi, Fiona Rohlffs 1Sabine Wipper, Axel Larena-Avellaneda, E. Sebastian Debus, Tilo Kölbel

Introduction: Volume of the kidneys is known to correlate well with separate function of each kidney. We aim to investigate the natural history of renal function and renal volume over time after type B aortic dissection and its correlation to perfusion of the renal arteries from the true (TL), false (FL) or both lumina (BL).

Methods: 69 patients with type B aortic dissection were treated during a 5-year period in our institution. Renal function, renal volume and false/true lumen perfusion of the kidneys were evaluated for all subjects included. Data was retrospectively collected from contrast CTs of good quality to measure renal volume at five different time points (1=baseline CT scan, 2=0-3 months after baseline CT, 3=3-12 months after baseline CT, 4=12-24 months after baseline CT, 5=24-48 months after baseline CT). Renal function was controlled by GFR and creatinine. Renal volume as well as vascularization of the renal arteries off TL, FL or BL were calculated and described from the CT-scans using the TeraRecon Aquarius program.

Results: 69 patients with type B aortic dissection (16 female, 53 male) met the study criteria and had sufficient quality CT scans at baseline and follow-up. 55.1% had an acute dissection and 44.9% a chronic dissection. 64 patients underwent TEVAR, five were treated conservatively. At baseline, distribution of perfusion was: 68.1%TL, 20.3%FL, 10.1%BL for the right renal artery and 73.9%TL, 15.9%FL, 7.2%BL for the left renal artery. The volume of the right and the left kidney both decreased from baseline to latest CT-scan by 4.6% for the right kidney and by 7.5% for the left kidney. Mean Creatinine value increased from 1.19 at baseline to 1.26 mg/dl at latest follow-up (p<0.01).Left renal volume decreased by 16% when vascularization originated from BL, 7.3% when from TL and 2.3% when originating from FL (one way ANOVA p>0.1).The right renal volume decreased by 15% when vascularization originated from BL, 10% when from TL and remained unchanged -0.3% when originating from FL (one way ANOVA p>0.1).

Conclusion: Although not reaching statistical significance in this small cohort of patients, renal volume appears to decrease more frequently when the artery of the respective kidney originates from both lumens. This could be potentially attributed to an on-off phenomenon caused by the dissection membrane at the ostium of the vessel, affecting the perfusion of the kidney.

Copenhagen, Denmark • 28-30 September 127

Poster Presentations

PO 001 EARLY CAROTID ENDARTERECTOMY AFTER INTRAVENOUS THROMBOLYSIS IS SAFE

Institution: Department of Vascular Surgery, Department of Neurology Helsinki University Hospital, Helsinki, Finland

Authors presenting: Pirkka Vikatmaa, Petra Ijäs, Lauri Soinne, Maarit Venermo

Introduction: Carotid endarterectomy (CEA) should be performed as early as possible after carotid artery stroke to prevent recurrent strokes. However, the safety of CEA very early (within 48 hours) after intravenous thrombolysis (IVT) is unclear and therefore CEA is often postponed with the cost of preventing recurrent strokes.

Methods: We searched our hospital-based registers containing data on all vascular surgery procedures (HUSCVASC) and IVT (Helsinki Stroke Registry) for patients treated with IVT and subsequent CEA for carotid artery stroke from 2005 to October 2015.

Results: 79 patients were treated with IVT and subsequent CEA. CEA was performed at median 7 days after IVT (95%CI 9-28, range 0-349 days). 41 patients were operated within 7 days, 18 within 72 hours, 12 within 48 hours and 3 patients within 6 hours from symptom onset. 6 recurrent strokes (incidence 7.6%) occurred in patients waiting for CEA at median 4,5 days from symptom onset (range 2 to 9 days). The incidence of peri/post-operative stroke was 5.1% (n=4) and they occurred in patients operated 2-32 days after IVT, none of them was lethal. Risk of postoperative stroke was not associated with time between IVT and CEA (HR 1.019, 95%CI 0.955-1.089). Hyperperfusion was nonsignificantly more common in patients operated within 48 hours (23.1% vs 7.6%, p=0.120) but did not lead to serious complications (ICH or seizures).

Conclusion: CEA within 48 hours after IVT appears safe. Hyperperfusion might be more common, but with careful treatment of blood pressures serious complications can be refrained.

Copenhagen, Denmark • 28-30 September 128

Poster Presentations

PO 002 INFLUENCE OF METABOLIC SYNDROME ON THE SHORT AND LONG-TERM OUTCOME AFTER CAROTID ENDARTERECTOMY

Institution: Surgery, Internal medicine, Neurology, UMCG, Groningen, Netherlands

Authors presenting: Linda Visser, Bas M. Wallis de Vries, Udo J. Mulder, Martijn Uyttenboogaart, Sterre van der Veen Clark J. Zeebregts, Robert A. Pol

Introduction: Metabolic syndrome (MetS), a condition which is characterized by hypertension, obesity and a pre- diabetic state, is a risk factor for cardiovascular disease. Over the past years, the incidence of MetS has increased in the Western world. Previous studies have shown a positive association between MetS and impaired outcome after carotid endarterctomy (CEA). The aim of this study is to determine the influcence of MetS on short-term (30 days) and long-term adverse events and survival after (CEA).

Methods: Between January 2005 and December 2014 all patients undergoing carotid artery revascularization were prospectively recorded in a vascular registry, from which the data were retrospectively analyzed. MetS was defined based on the presence of three or more of the following criteria: hypertension (blood pressure >140/90 or use of antihypertensive medication); serum triglycerids >150 mg/DL; high-density lipoprotein <40 (male)/<50 (female); fasting serum glucose >110 (or use of antidiabetic medication); and body mass index (BMI) >30. Primary endpoints were mortality and occurrence of transient ischemic attack (TIA)/cerebrovascular accident (CVA) and myocardial infarction (MI), as well as a composite endpoint of TIA/CVA and death in the 30 day outcome analysis, and of TIA/CVA/MI in the long term analysis. Secondary outcome variables were any surgical complications and hospital length of stay.

Results: A total of 564 interventions were performed in 525 patients. Two hundred and forty-four interventions (43.3%) were performed in patients who were identified as having MetS. Of the five criteria used to define MetS, hypertension was the most prevalent, with an overall incidence of 96.7%. The mean age was 68.6 years, and 72.9% of procedures were performed in men. The majority of patients were performed because of symptomatic disease (83.2%). There were no significant differences in symptoms and degree of ipsi- and contralateral stenoses between patients with and without MetS. Median follow-up was 46.8 months. There was no significant difference for all the outcome variables we investigated. Twenty-four patients (no MetS 3.4% vs MetS 5.3%; p=0.27) had an early adverse neurological event after surgery, with 10 patients (10/564; 1.8%) developing a TIA and 13 patients (13/564; 2.3%) developing an ipsilateral minor ischemic CVA. Of the aforementioned events, three patients died after the CVA, all in the MetS group (p=0.08). One patient had a TIA on the contralateral side. The 30-day all-cause mortality rate was 1.2% (no MetS 0.9% vs MetS 1.6%; p=0.47), with one death intra-operatively. The 30-day combined end-point TIA/CVA/death was 4.8% (no MetS 4.1% vs MetS 5.7%; p=0.36) After 30 days, the combined end-point TIA/CVA/MI was 8.3% (no MetS 8.1% vs MetS 8.6%; p=0.83). There was no difference in two- and five year survival (no MetS 95.3% and 81.6% and MetS 94.7% and 85.0%; p=0.86). Patients with diabetes mellitus (DM), regardless of the serum blood glucose level, had significantly more ipsilateral cerebrovascular events after 30 days (no DM 1.6% vs DM 7.9%; p=0.001)

Copenhagen, Denmark • 28-30 September 129

Poster Presentations

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Conclusion: Patients suffering from carotis stenosis can safely be treated by carotid endarterectomy, with a low incidence of early and late neurological events and MI. The presence of MetS has no significant negative effect on both short- and long term outcomes, and therefore it’s presence should not be a reason to refrain from treating patients with carotid stenosis by CEA. However, patients with DM have significantly higher risk of ipsilateral cerebrovascular events.

Copenhagen, Denmark • 28-30 September 130

Poster Presentations

PO 003 DEVELOPMENT OF A MICROSIMULATION MODEL TO PREDICT STROKE AND LONG-TERM MORTALITY IN ADHERENT AND NON-ADHERENT MEDICALLY MANAGED AND SURGICALLY TREATED OCTOGENARIANS WITH ASYMPTOMATIC SIGNIFICANT CAROTID ARTERY STENOSIS

Institution: Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany

Authors presenting: Thomas Luebke, Jan Brunkwall

Introduction: The primary study objective was to develop a microsimulation model to predict preventable first-ever and recurrent strokes and mortality for a population of medically or surgically managed octogenarians with substantial (>70%) asymptomatic carotid artery stenosis and comparing an adherent to an real-world non-adherent best medical treatment (BMT) regimen subjected to the sex.

Methods: A Monte Carlo microsimulation model was constructed with a 14-year time horizon and with 10000 patients. Probabilities and values for clinical outcomes were obtained from current literature.

Results: The stratification of the microsimulation estimates by treatment strategy within the female group of octogenarians demonstrated a statistically significant lower stroke rate during follow-up for CEA compared to non-adherent BMT (p < 0.0001) as well as compared to adherent BMT (p < 0.0001). In male octogenarians, the CEA strategy was associated with statistically significant lower stroke rates compared to adherent and non-adherent BMT, as well, (p < 0.0001, and p < 0.0001, respectively). For each treatment strategy, female octogenarians had a statistically significant longer overall long- term survival compared to male octogenarians (p < 0.0001, each). In terms of stratification by the sex, in octogenarian men and women long-term survival was significantly better for adherent BMT compared to non-adherent BMT, and CEA was associated with a significant better long-term survival compared to non-adherent BMT.

Conclusion: In the present microsimulation, in case of real-world drug adherence it was likely that a strategy of early endarterectomy was beneficial in octogenarians with significant asymptomatic carotid artery disease in comparison with BMT alone.

Copenhagen, Denmark • 28-30 September 131

Poster Presentations

PO 004 CHANGES IN CHOROIDAL THICKNESS AFTER CAROTID ENDARTERECTOMY USING ENHANCED DEPTH IMAGING OPTICAL COHERENCE TOMOGRAPHY

Institution: 1. Ophtalmologic surgery, vascular surgery, Nice 2. University Hospital, Nice cedex, France

Authors preseting: Fabien Layrere, Elisabeth Nguyen, Jacques Chofflet, Jérome Doyen Réda, Hassen-Khodja, Pierre Gastaud, Elixene Jean-Baptiste

Introduction: Although fugax amaurosis is a well-known acute complication of unstable carotid plaque, the influence of both chronic severe carotid stenosis and carotid endarterectomy on ocular tissues has been so far poorly evaluated. The choroid is a highly vascular structure supplying the outer retinal layers with blood derived from the carotid circulation. Spectral-domain optical coherence tomography has been used to assess noninvasely the choroidal thickness in a number of retinal conditions such as age-related macular degeneration, central serous chorioretinopathy, or polypoidal choroidal vasculopathy. The goal of this study was to measure subfoveal choroidal thickness, before and after endarterectomy, in patients suffering from severe carotid stenosis.

Methods: Thirty-six patients suffering from severe carotid stenosis were included in this prospective pilot study. The subfoveal choroidal thickness was measured bilaterally before and after the surgery using enhanced depth imaging optical coherence tomography (EDI OCT).

Results: Mean age was 74±8 years (range, 59-89 years). Fifteen (15) patients were women (41.7%). The mean subfoveal choroidal thickness (SFCT) significantly increased bilaterally one month after the surgery. The mean SFCT was 210±72 µm at baseline, 224±74 µm at 1 month (p<0,001), and 226 ± 74 µm at 3 months (p=0.2), on the ipsilateral side to the carotid stenosis. On the contralateral side, the SFCT also increased but moderately: the mean SFCT was 214±50 µm at baseline, 218 ±49 µm at 1 month (p=0.005), and 220±49 µm at 3 months (p=0,054) after the surgery. There were no significant differences between the ipsilateral SFCT and the contralateral side preoperatively (p>0.05). No correlation was found between the SFCT and age, axial length, degree of carotid stenosis, clinical symptoms and risk factors for cardiovascular disease.

Conclusion: The mean subfoveal choroidal thickness significantly increased bilaterally one month after carotid endarterectomy. However, choroidal thickness wasn’t significantly thinner in eyes ipsilateral to the carotid stenosis preoperatively in this study. Further studies are needed to deepen our knowledge on this topic.

Copenhagen, Denmark • 28-30 September 132

Poster Presentations

PO 005 CAROTID STENOSIS TREATMENT: DEFINING PRACTICE PATTERNS ACROSS THE GLOBE

Institution: 1. University of Pennsylvania, Philadelphia 2. Mayo Clinic, Minnesota, United States 3. Aarhus University Hospital, Aarhus, Denmark 4. Weill CornellMedical College, New York, United States 5. Australasian Vascular Audit, Melbourne, Australia 6. University of Pecs, Pecs, Hungary, 7. Uppsala University, Uppsala, Sweden 8. St Olavs Hospital, Trondheim, Norway 9. Dunedin School of Medicine, Dunedin Hospital, Dunedin, New Zealand 10. Kantonsspital Winterthur, Winterthur, Switzerland 11. National University Hospital of Iceland, Reykjavik, Iceland, 12. Dartmouth-Hitchcock Medical Center, Hanover, United States

Authors presenting: Maarit Venermo, Grace Wang, Randall DeMartino, Nikolaj Eldrup, Art Sedrakyan, Jialin Mao, Barry Beiles, Gabor Menyhei, Kevin Mani, Martin Altreuther, Ian Thomson, Pius Wigger, Gudmundur Danielsson, Jack Cronenwett, Martin Björck

Introduction: Optimal patient selection as well as the preferred treatment modality for carotid artery disease remains incompletely defined. We examined the current practice among 11 countries participating in the International Collaboration of Vascular Registries (ICVR) from 2010-2013 to compare patient selection with particular focus on asymptomatic patients as well as the role of carotid stenting (CAS).

Methods: Data from the Vascunet (Quality Improvement Collaboration including European and Australasian countries) and United States Vascular Quality Initiative (VQI). Carotid endarterectomy (CEA) or CAS treatment of asymptomatic versus symptomatic patients were analyzed for variation between countries as well as among centers in each country.

Results: Among 51,670 total procedures, CEA was used in 90% and 55% were done for symptomatic stenosis. Gender representation varied across countries, with the proportion of women being lower in Switzerland (29%) and Australia (30%) and highest in the US (40%, p<0.01). Significant variation was observed in the percentage of patients treated for asymptomatic stenosis, ranging from 0% in Denmark to 60% in the US (Figure 1A). Within each country there was also substantial center-level variation that was most pronounced in Australia, Hungary and the US (Figure 1B). The percentage of asymptomatic patients treated with CAS varied from 0% in Denmark, Finland, Iceland and New Zealand to 13% in Sweden, with the greatest center-level variation noted in the U.S. (0%>80%) and Australia (0%>70%). Octogenarians made up 15% of asymptomatic patients. Of the asymptomatic patients undergoing CAS, there was notable variation in the proportion of octogenarians treated, ranging from 0% in Norway, to 22% in Australia. The percentage of symptomatic patients treated with CAS varied from 0% in Denmark, Iceland and New Zealand to 19% in the US, with the largest amount of center-level variation observed in Australia (0%>100%) and the US (0%>96%). Octogenarians made up 19% of the symptomatic cohort. Of the symptomatic patients undergoing CAS, there was significant variation in the proportion of octogenarians treated, ranging from 0% in Norway, to 27% in Australia.

Copenhagen, Denmark • 28-30 September 133

Poster Presentations

Image:

Conclusion: Despite significant evidence on treatment options for carotid artery disease internationally, there is large variation in the proportion of asymptomatic patients selected for CEA/CAS among countries and centers participating in ICVR. Wide variability exists in the use of CAS for asymptomatic and symptomatic disease. Additional variation exists in the treatment of women and octogenarians. These data reflect institutional and national biases in carotid disease treatment which provide important data to inform and unify best practices.

Copenhagen, Denmark • 28-30 September 134

Poster Presentations

PO 006 THE COMBINED RISK OF STROKE OR DEATH IS ASSOCIATED WITH AGE, BUT NOT WITH SEX IN PATIENTS TREATED WITH CEA OR CAS IN ROUTINE PRACTICE IN GERMANY – RISK OF STROKE IS ASSOCIATED WITH AGE IN CAS PATIENTS ONLY.

Institution: 1. Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, 2. Technical University of Munich, Munich, 2AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany

Authors presenting: Andreas Kuehnl, Sofie Schmid, Pavlos Tsantilas, Christoph Knappich, Michael Kallmayer, Thorben Breitkreuz, Alexander Zimmermann, Hans-Henning Eckstein.

Introduction: Current guidelines on carotid stenosis recommend that patient's age and sex should be taken into account in the decision-making process. However, the underlying evidence for sex- and age-specific guideline recommendations arise from subgroup analyses of RCTs and thus, must be considered observational by nature. Although the risk of an information bias in RCTs can be considered low, strict eligibility criteria applied in RCTs may have induced a relevant selection bias that reduces generalizability. Therefore, this study analyze the association between sex and age, and the risk of in-hospital stroke or death following CEA and CAS on a national level in Germany.

Methods: Secondary data analysis using individual patient data (clinical rather than administrative) from the nationwide statutory German quality assurance database on all (99.1%) elective carotid endarterectomies (n=142,074) and carotid stenting procedures (n=13,086) performed between 2009 and 2014. Patients age was categorized in groups (<65 years, 65–69 years, 70–74 years, 75–79 years, and 80 or more years) as well as analyzed as a continuous variable. The primary outcome was any in-hospital stroke or death. Secondary outcomes were death (alone) and stroke (alone). For risk-adjusted analyses (incl. interactions between sex and age), a multilevel regression model was applied.

Results: Patients treated with CEA and CAS were predominately male (68% and 70%, respectively). The mean age for CEA and CAS patients was 71±9 years and 70±9 years, respectively. With respect to the neurological presentation on admission, 60% of CEA patients and 64% of CAS patients were asymptomatic. CEA patients were classified as ASA I/II, ASA III, and ASA IV/V in 29%, 68%, and 3%, respectively. The corresponding proportions in CAS patients were 62%, 36%, and 2%. The overall rate of any stroke or death was 1.8% (2,611/142,074) in CEA patients and 2.4% (317/13,086) in patients receiving CAS. In CEA patients younger than 65 years, 65–69 years, 70–74 years, 75– 79 years, and 80 or more years, the risk of any in-hospital stroke or death was 1.4%, 1.7%, 1.8%, 1.9%, and 2.6%, respectively (p<0.001 for trend). The corresponding percentages for CAS patients were 1.3%, 2.2%, 2.2%, 3.1%, and 4.4%, respectively (p<0.001 for trend). Multivariable regression analysis revealed that age was significantly associated with a higher risk of any in-hospital stroke or death in CEA and CAS patients (relative risk per 10 years increase: CEA 1.19 [1.14-1.24], CAS 1.54 [1.35-1.75]). Sex was not associated with the risk of any in-hospital stroke or death, nor does it significantly modify the age effect in CEA and CAS patients. In CEA and CAS patients (symptomatic and asymptomatic), the risk of death was associated with age (p<0.001 for trend, respectively). The risk of stroke was associated with age in CAS patients only (symptomatic and asymptomatic, p<0.001 for trend, respectively).

Conclusion: This study revealed that patient's age, but not sex was associated with a higher risk of in-hospital stroke or death after CEA and CAS for symptomatic and asymptomatic patients in routine practice in Germany. Although the limitations of a secondary analysis of observational (routine) data must be considered, the association between age and the risk of any in-hospital stroke or death seems to be stronger in CAS compared with CEA patients. While mortality was associated with age in CEA and CAS patients, the stroke risk was associated with age in CAS patients only.

Copenhagen, Denmark • 28-30 September 135

Poster Presentations

PO 007 MULTICENTER EXPERIENCE WITH IN SITU FENESTRATION FOR ENDOVASCULAR AORTIC ARCH REPAIR: DATA FROM THE ARCHIF REGISTRY.

Institution: 1. Department of Diagnostic Radiology, Medical and Dental University, Tokyo, Japan 2. Department of Vascular Surgery and Endovascular Surgery, University Hospital Regensburg, 3. Regensburg, Germany, 3Department of Radiology, Oita University, Oita, Japan, 4Vascular Center Malmö-Lund, University Hospital Malmö, Malmö, Sweden, 5Toronto General Hospital, University of Toronto, Toronto, Canada

Authors presenting: Reinhard Kopp, Yoshiaki Katada, Norio Hongo, Björn Sonesson, Leonard Tse, Sean Crawford, Piotr M. Kasprzak

Introduction: In situ fenestration of aortic stent grafts for treatment of aortic arch aneurysms is a new option for aneurysm exclusion, performed either as total endovascular aortic repair or in combination with supraaortic debranching. So far, only few reports have shown perioperative and short- to midterm results of in situ fenestrations for aortic arch aneurysms. We have collected the multicenter experience of seven centers in the ARCHIF registry including patients treated with in situ fenestration for aortic arch aneurysms and analyzed perioperative outcome and long term follow up.

Methods: Based on the reports available in situ fenestrations were performed under extracorporal circulation or with extraanatomic bypass procedures. In situ fenestrations were created using stiff wires, needles or laser catheters with cutting balloons completed by implantation of covered connecting stent grafts. Single in situ fenestrations for the left subclavian artery (LSA) were excluded.

Results: Between 2009-2015 fourteen patients were treated by in situ fenestration for treatment of aortic arch aneurysms at seven different institutions. In situ fenestrations were performed for the brachiocephalic trunk (n=14), the LCCA (n=11) and the LSA (n=7). Technical success for intended in situ fenestrations was 93.5 % (29/31), with additional supraaortic bypass procedures performed in 7 patients. No perioperative mortality was reported, with 16.6 % severe cerebrovascular events. So far, four patients died during follow-up, all from diseases unrelated to their aortic arch pathologies. Follow-up was 1-60 months with a mean survival time of 33.8 + 8.3 months and 2 endovascular aortic reinterventions.

Conclusion: Supraaortic in situ fenestration with antegrade cerebral perfusion of the brachiocephalic trunk and the left CCA is a valuable treatment option in selected patients with aortic arch aneurysms.

Copenhagen, Denmark • 28-30 September 136

Poster Presentations

PO 008 THE EFFICACY OF PHARMACOLOGICAL PRECONDITIONING IN CAROTID ENDARTERECTOMY

Institution: Department of Surgery, Russian State Medical University, Moscow, Russian Federation

Authors presenting: Maxim Kuznetsov, Anatoly Karalkin, Anatoly Fedin, Alexander Knyazev, Nikolay Kunicin

Introduction: Despite operative technique of carotid endarterectomy (CEA) is being constantly improved cerebral complications and postoperative cognitive deficit may occur due to transient intraoperative hypoxia related to the procedure. We assessed the effects of pharmacological preconditioning with neuroprotective agent on cerebral perfusion and cognitive outcomes after CEA.

Methods: We recruited 64 patients (51-84 years) with uni- and bilateral carotid stenosis eligible for CEA. Group 1 (n=31) received a neuroprotective agent - deproteinized hemoderivate (Actovegin) 1200 mg intravenously daily for 10 days prior surgery. Group 2 (n=33) was operated without pharmacological preconditioning. Cerebral perfusion was measured by single-photon emission computed tomography before and 7 days after surgery in both groups. Tomograms were analyzed by qualitative and quantitative analysis assessing the distribution and accumulation of radioisotope in cerebellum, frontal, parieto-temporal and occipital lobes of the brain. Perfusion value was calculated as a percentage ratio to the reference area (cerebellum) where the blood flow was considered as 100%. Diffusion-weighted magnetic resonance imaging (DW-MRI) was performed in both groups before and after intervention to detect symptomatic and asymptomatic cerebral ischemic lesions and cognitive outcomes were assessed by mini-mental state examination (MMSE).

Results: In each group uni- and bilateral lesions of carotid arteries were diagnosed in 52% and 48% of patients accordingly. Both groups were comparable by demographics, cognitive status and perfusion parameters at baseline (p=0.85). At day 7 cerebral perfusion in all regions improved in both groups compared to baseline (p<0.01). However, in group 1 perfusion in worst perfused areas improved by 30% compared to 21% in group 2 and the mean perfusion value in all areas improved by 19% and by 11% accordingly. The difference between groups was statistically significant (p<0.001). Inter- regional changes of perfusion within the same hemisphere by more than 20% was detected in 26% of patients in group 1 compared to 56% of patients in group 2. In group 1 DW-MRI showed hyperintensive lesions in 5% of patients with uni- and in 12% with bilateral stenosis compared to 21% and 48% of patients in group 2 accordingly. No major or minor ischemic events or neurological deficit occurred in both groups after surgery. Cognitive decline (MMSE score 25-27) was detected in 85% of patients in both groups at baseline. At day 7 MMSE scores 28-30 was observed in 39% of patients in group 1 compared to 31% of patients in group 2.

Conclusion: Pharmacological preconditioning with neuroprotective agent Actovegin can be potentially beneficial for improvement of cerebral perfusion and cognitive outcomes in patients undergoing CEA.

Copenhagen, Denmark • 28-30 September 137

Poster Presentations

PO 009 PATTERNS OF ACUTE ISCHEMIC STROKES AFTER CAROTID ENDARTERECTOMY AND THERAPEUTIC IMPLICATIONS

Institution: Vascular Surgery, Stroke Center Unit, Nice University Hospitalm, Nice cedex, France

Authors presenting: Fabien Lareyre, Juliette Raffort, Caroline Weil, Laurent Suissa, Nirvana Sadaghianloo, Serge Declemy, Réda Hassen-Khodja, Elixene Jean-Baptiste

Introduction: Acute ischemic strokes following surgical treatment of carotid stenosis may be dramatic and lead to substantial disability, functional dependence and mortality. The mechanisms involved in the occurrence and severity of such strokes are not always elucidated. We postulated that the early patterns of the ischemic cerebral lesions on diffusion-weighted and perfusion-weighted magnetic resonance imaging (MRI) may underline pathophysiologic mechanisms and have different implications for treatment.The goal of this study was to analyse the topographic patterns of acute ischemic stroke following carotid endarterectomy, report the vascular mechanisms involved in stroke development and investigate potential therapeutic implications.

Methods: Data were prospectively collected for consecutive patients who underwent carotid endarterectomy in a single university hospital. All patients who experienced postoperative acute ischemic stroke had had immediate brain MRI. Based on the MRI datasets, the lesion patterns of acute stoke after carotid endarterectomy were retrospectively characterized. Morphology of the Circle of Willis, the 3D time- of-flight (TOF) of the cerebral arteries and status of the carotid circulation were also analysed in order to determine the vascular mechanisms involved in stroke development. Demographic data, procedural characteristics and acute treatment were also recorded.

Results: Between January 2008 and May 2015, 821 patients were treated surgically for a symptomatic or asymptomatic carotid stenosis. Nineteen (19) patients (2.3%) had an acute ischemic stroke after surgery. Embolic mechanism of stroke was reported for 12 patients (63.2%), hemodynamic mechanism for 2 patients (10.5%) and mixt mechanism for 5 patients (26.3%). Compared to the embolic group, patients with hemodynamic or mixt stroke tended to have more arterial hypoplasia or aplasia within the Circle of Willis (hypoplasic anterior cerebral artery: 57% vs 33% and hypoplasic posterior cerebral artery: 71% vs 42%), although this did not reach statistical significance. An asymmetry on 3D-TOF was observed in 60% and 50% of patients with hemodynamic and mixt stroke and 25% of patients with embolic stroke. The latter 3 patients with embolic stroke underwent successful mechanical thrombectomy using stent-retriever devices (NIHSS score around 0 at discharge).

Conclusion: In this cohort, embolic mechanism leading to postoperative stroke was more frequently observed than hemodynamic mechanism. Immediate characterisation of the cerebral lesion by postoperative brain MRI was of utter most importance allowing nowadays rapid identification of patients eligible to specific treatment such as mechanical thrombectomy.

Copenhagen, Denmark • 28-30 September 138

Poster Presentations

PO 010 SAFETY, TOLERABILITY AND PHARMACOKINETICS OF A NOVEL HUMAN PHOSPHORYLCHOLINE ANTIBODY (PC-MAB) IN PATIENTS WITH PERIPHERAL ARTERIAL DISEASE UNDERGOING THROMBOENDARTERECTOMY OR VEIN GRAFT BYPASS

Institution: 1. Department of Molecular Medicine and Surgery, Karolinska, Institute and Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden, 2. Smerud Medical Research International, Oslo, Norway, 3. Athera Biotechnologies AB, Stockholm, Sweden

Authors presenting: Claes Bergmark, Per Blom, Knut Pettersson, Eva Karlöf

Introduction: Target vessel failure after revascularisation remains a major clinical problem and a deranged inflammatory response to injury is suspected as the underlying pathobiology. There are however no known specific therapies, nor biologic markers identifying this problem. Humans have natural antibodies that target a common inflammatory component of damaged cell membranes, phosphorylcholine (PC), which is exposed during cell injury. In large human cohorts, low levels of anti-PC IgM have been associated with a significantly increased risk of cardiovascular disease (CVD), and in particular an increased risk for vein graft failure in patients with peripheral arterial disease (PAD). PC-mAb, a novel fully human therapeutic IgG1 antibody mimicking endogenous antibodies to PC, is developed for secondary prevention in patients undergoing revascularisation for PAD. PC-mAb is safe and well tolerated in healthy volunteers.

Methods: A prospective, double-blind, randomized, placebo-controlled study, including male and female patients with peripheral arterial disease in the lower limb scheduled for thromboendarterectomy or vein graft bypass. The randomization is done in blocks of 3 active and 1 placebo. A single 30 min iv injection of study medication (2mg/kg, later increased to 4mg/kg) or placebo is given 15±3 h prior to surgery. The patients are followed for 12 weeks with visits days 1-4, 7 and 14 and at 5 weeks and 12 weeks after surgery.

Primary objective: Safety and tolerability. The primary evaluation parameters: adverse events, ECG, vital signs and safety laboratory, including immunogenicity evaluation.

Secondary objective: Pharmacokinetics

Exploratory objectives: IgM anti-PC level, hs-troponin I and serum inflammation markers. Magnetic resonance imaging (MRI) is performed within day 2-5 and at 5 weeks after drug administration to investigate target vessel morphology and arterial function (post-ischemic hyperemia in skeletal muscle) in the contralateral leg.

Results: The study is ongoing and in April, 12 patients have been randomized (9 males, median age 74, range 60-84 years, all Caucasian). The treatment has been well tolerated and an increase in dose from 2 mg/kg to 4 mg/kg has been implemented. A novel MRI protocol to evaluate effects on both target vessel morphology and general arterial function has been applied successfully on the patients, data are currently analysed. A preliminary pharmacokinetic analysis of the 4 first patients indicate roughly similar drug exposure levels as in healthy volunteers. There was a slight reduction in serum levels of PC-mAb in the operative period, indicating that the PC epitope was generated during the surgical intervention.

Conclusion: This novel fully human phosphorylcholine therapeutic IgG1 antibody (PC-mAb) has been given as pretreatment the day before thromboendarterectomy or vein graft bypass surgery to patients with peripheral arterial disease. It has so far shown good safety and tolerability. Preliminary data indicate that the target is exposed during the intervention and that the pharmacokinetic properties of PC-mAb will allow for bi-weekly or once monthly administration. Data will be available for presentation in September.

Copenhagen, Denmark • 28-30 September 139

Poster Presentations

PO 011 PRE-OPERATIVE PREDICTORS OF POOR OUTCOMES IN PATIENTS UNDERGOING SURGICAL LOWER EXTREMITY REVASCULARISATION

Institution: Department of Vascular and Endovascular Surgery, Department of Medical Statistics, Department of Microbiology, University Hospital of South Manchester, Manchester, United Kingdom

Authors presenting: Mohammed Ashrafi, Rohini Salvadi, Philip Foden, Stephanie Thomas, Mohamed Baguneid

Introduction: Surgical lower extremity revascularisation (LER) can lead to poor outcomes that include delayed hospital discharge, in-hospital mortality and major amputations, and readmissions. The aim of this study was to identify pre-operative predictors associated with these poor clinical outcomes.

Methods: All patients (n=635; mean age 69; male 67.4%) who underwent surgical LER over a 5 year period (2010-2014) in a single tertiary vascular and endovascular institution were identified using hospital episode statistics data. Patients considered to have suffered a poor outcome (Group A) included all in-hospital mortality and major amputations, delayed discharges with a length of stay (LOS) over one standard deviation above the mean or any readmission under any specialty within 12 months. Group A included 247 patients (38.9%) and the good outcome group included the remaining 388 patients (61.1%). Group B consisted of 99 patients which were randomly selected to provide a 25% representation of the good outcome group. Continuous data were summarised as the mean ± standard deviation and categorical data were described as counts and percentages. Univariate analyses were performed using chi-squared tests, Fisher’s exact tests and t-tests, as appropriate. Predictors of poor outcome were assessed using a multivariable logistic regression analysis. A P value of <0.05 was considered statistically significant.

Results: Mean LOS was 14.4 ± 17.5 days, 12 month readmission rate was 29.1% and in-hospital mortality and major amputation rate was 2.7% and 1.4%, respectively. Pre-operative factors associated with poor outcome identified by univariate analyses were age (70.7 vs. 67.4 years; P=0.035); pre- admission residence other than own home (7.8% vs. 1%; P=0.016); previous lower limb vascular procedures (42.7% vs. 28.3%; P =0.013); atherosclerotic disease burden (46.4% vs. 28.3%; P=0.002); tissue loss (41.5% vs. 18.2%; P<0.001); severe limb ischaemia (intermittent claudication 34.5% vs. 51.5%, severe limb ischaemia 51.5% vs. 28.3%, Other 14.0% vs. 20.2%; P=0.001); emergency presentation (47.2% vs. 26.3%; P<0.001) and American Society of Anesthesiologist’s grade 4 (1 0.9% vs. 1.1%, 2 25.7% vs. 37.2%, 3 66.4% vs. 57.4%, 4 7.1% vs. 4.3%; P=0.037). Multivariable logistic regression analyses identified pre-admission residence other than own home (OR 9.0; 95% CI 1.2-70.1; P=0.036), atherosclerotic disease burden (OR 2.2; 95% CI 1.3-3.8; P=0.003) and tissue loss (OR 3.0; 95% CI 1.6-5.3; P<0.001) as independent, statistically significant pre-operative predictors of poor outcome. Of those patients discharged, group A had a significantly higher rate of major amputation (15.4% vs. 1%; P<0.001) and graft infection (14.3% vs. 0%; P<0.001) compared to group B at a median follow up time of 2.27 and 2.03 years, respectively.

Conclusion: Recognition of pre-operative predictors of poor outcome should inform case selection and identify high risk patients requiring intensive perioperative optimisation and post discharge follow up.

Copenhagen, Denmark • 28-30 September 140

Poster Presentations

PO 012 WHEN IS SUPERVISED EXERCISE THERAPY CONSIDERED USEFUL FOR INTERMITTENT CLAUDICATION: AN UPDATE OF THE DUTCH VASCULAR SURGEONS’ATTITUDE TOWARDS CONSERVATIVE MANAGEMENT

Institution: 1. Department of Vascular Surgery, Catharina Hospital, Eindhoven 2. Department of Vascular Surgery, Academic Medical Center, Amsterdam, Netherlands

Authors presenting: Gert-Jan Lauret, David Hageman, Lindy N. Gommans, Mark J. Koelemay, Marc R. van Sambeek, Joep A. Teijink

Introduction: The aim of the present study was to reassess thoughts and considerations among Dutch vascular surgeons for prescribing supervised exercise therapy (SET). As in 2011, a first nationwide survey among Dutch vascular surgeons was conducted. Several arguments not to refer patients with intermittent claudication (IC) for SET were reported, such as cardiopulmonary comorbidity.1 It was concluded that these apparent contraindications for SET, in fact, are just indications for participation in an exercise program.

Methods: Dutch vascular surgeons, fellows and senior residents in vascular surgery were asked to complete a 26-question survey. The survey consisted of three open-ended questions, six multiple-choice questions, and ten yes/no questions, addressing factors considered relevant or important for prescribing SET, such as patient characteristics and comorbidity.

Results: In total, 124 respondents (male 82%, mean age 46 years), including 104 vascular surgeons, completed the survey. Compared to the previous survey in 2011, SET was more often considered useful as primary treatment for IC patients with chronic obstructive pulmonary disease (86% of respondents in 2015 versus 66% in 2011) and congestive heart failure (75% of respondents in 2015 versus 70% in 2011). However, in patients with aortoiliac stenosis/occlusion, SET was less frequently thought to be useful (63% of respondents in 2015 versus 71% in 2011). Degree of disability in employment (90%), degree of limitations in activities of daily living (87%), and anatomic location of the stenosis/occlusion (70%) were considered the most important factors in the decision to perform a vascular intervention.

Conclusion: Compared to the previous survey of 2011, Dutch vascular surgeons appear to have a more positive attitude towards SET for IC patients with cardiopulmonary comorbidity. However, in patients with aortoiliac stenosis or occlusion SET remains underutilized.

References: 1. Lauret GJ, van Dalen HC, Hendriks HJ, van Sterkenburg SM, Koelemay MJ, Zeebregts CJ, Peters RJ, Teijink JA. When is supervised exercise therapy considered useful in peripheral arterial occlusive disease? A nationwide survey among vascular surgeons. Eur J Vasc Endovasc Surg. 2012 Mar;43(3):308-12.

Copenhagen, Denmark • 28-30 September 141

Poster Presentations

PO 013 TRENDS IN THE PROGNOSIS OF PATIENTS WITH INTERMITTENT CLAUDICATION AND CRITICAL LIMB ISCHEMIA IN THE NETHERLANDS

Institution: Vascular Surgery, Julius Center for health sciences and primary care, Clinical epidemiology, UMC Utrecht, Utrecht, Netherlands

Authors presenting: Steven Van Haelst, Carla Koopman, Frans L. Moll, Ilonca H. Vaartjes, Gert Jan de Borst

Introduction: In the past two decades, major shifts and advancements have been developed especially in the endovascular treatment and secondary medication prevention of peripheral arterial disease. We sought to analyze whether these changes are reflected in a decrease in mortality in patients with intermittent claudication (IC) or critical limb ischemia (CLI) in the Netherlands.

Methods: A nationwide hospital-based cohort was constructed, consisting of 36,954 IC patients (13,867 day clinic and 23,087 hospital admissions between 1998 and 2010, the cohort comprised 62.9% men, age 65.7±12.4 years). Furthermore, 16,374 CLI patients (1,322 day clinic and 15,052 hospital admissions, 56.1% men, age 66.4±17.1 years) between 1998 and 2010 were included. We split the cohort into two timeframes: 1998-2004 and 2005-2010 for comparison. 30-day mortality was excluded from the analysis, to exclude per-admission complications. Mortality rates were compared to a representative sample of the general Dutch population (n=51,812) by Cox proportional hazard models, adjusting for differences in: age, sex, marital status, ethnicity, neighbourhood socioeconomic status, urbanization degree and Charlson comorbidity index.

Results: In IC patients, 1-year and 5-year mortality risk slightly decreased from 8.5% and 30.5% in 1998-2004 to 8.4% and 29.9% in 2005-2010. In CLI patients, 1-year and 5-year mortality risk decreased from 24.3% and 54.9% to 22.0% and 54.2% in 1998-2004 and 2005-2010 respectively. In 1998-2004, 5- year adjusted cardiovascular and all-cause mortality risk was significantly higher in patients with IC compared to the general population: HR 2.97 (95% CI 2.90-3.03) and HR 1.2.04 (95% CI 2.00-2.08) respectively. In CLI patients the cardiovascular mortality HR was 4.18 (95% CI 4.11-4.25) and all- cause mortality HR 3.24 (95% CI 3.20-3.29) during the same timeframe. In 2005-2010, 5-year adjusted cardiovascular and all-cause mortality significantly decreased in IC patients to HR 2.50 (95% CI 2.41-2.58, P<0.001) and HR 1.78 (95% CI 1.73-1.84, P<0.001) compared to the general population. In CLI patients the HR decreased to 3.89 (95% CI 3.81-3.98, P<0.001) and 2.91 (95% CI 2.86-2.97, P<0.001) respectively.

Conclusion: Mortality risks for both CI and CLI patients over the last two decades significantly declined in the Netherlands as compared to the general population. Yet, the contemporary absolute (cardiovascular) mortality risk remains high and the prognosis for these patients is still profoundly worse.

Copenhagen, Denmark • 28-30 September 142

Poster Presentations

PO 014 DIFFERENTIAL IMPACT OF BYPASS SURGERY AND ANGIOPLASTY ON ANGIOSOME-TARGETED INFRAPOPLITEAL REVASCULARIZATION IN DIABETICS.

Institution: 1. Oulu University Hospital, Oulu, Finland 2. Helsinki University Hospital, Helsinki, Finland

Authors presenting: Nicla Settembre, Kristyna Spillerova, Fausto Biancari, Anders Albäck, Maarit Venermo

Introduction: We aimed to evaluate the impact of angiosome-targeted (direct) revascularization according to revascularization method in diabetic patients.

Methods: The study cohort compromises of 545 diabetic patients with critical limb ischemia and tissue lesion (Rutherford 5, 6). All patients underwent infrapopliteal revascularization, either endovascular (PTA) or open surgical bypass, between January 2008 and December 2013. Patients were followed retrospectively with the median follow-up of 36 months. Primary outcome measures were wound healing and leg salvage; amputation free survival was secondary. To an univariate analysis we included 22 variables (age, gender, risk factors, CRP-level, creatinine-level, patency of pedal arch, type of procedure and the information if the revascularization was direct or indirect); factors with p- value<0.2 were thereafter included to the multivariate analysis. Differences in the outcome after direct revascularization, bypass surgery and PTA, were adjusted by estimating a Cox proportional hazard analysis.

Results: The overall wound-healing rate at one year was 60.3%; direct surgical bypass achieved the best rate (77%), while indirect PTA the worst (52%). Cox proportional hazards analysis showed that direct revascularization (HR 1.4, 95%CI 1.5–1.9), bypass surgery (HR 1.4, 95%CI 1.5–29) and C-reactive protein≤10 mg/dL (HR 1.03, 95%CI 1.00–1.06) associated with improved wound healing, whereas the healing tendency after indirect PTA was the poorest (HR 0.6, 95%CI 0.46–0.81, p<0.0001). The overall amputation rate at one year was 25.1%. Cox proportional hazards analysis indicated that haemodialysis (HR 2.62, 95%CI 1.53–4.45), indirect PTA (HR 1.45, 95%CI 1.09-1.93) and C- reactive protein≥10 mg/dL (HR 1.08, 95%CI 1.05–1.10) were independent predictors for major amputation. There was no significant difference in leg salvage after direct bypass, direct PTA and indirect bypass, however indirect PTA predicted poorer leg survival. (Figure 1) Image:

Conclusion: In diabetic patients, the indirect endovascular revascularization leads to poorest wound healing and leg salvage. Thus, endovascular procedure should be performed according to the angiosome concept. In bypass surgery, however, the concept is of a less value and selection of the outflow artery should be based on the best runoff.

Copenhagen, Denmark • 28-30 September 143

Poster Presentations

PO 015 INFRAPOPLITEAL ENDOVASCULAR INTERVENTIONS WITH SELECTIVE STENTING IN COMPLEX LESIONS DOES NOT RIVAL GREAT SAPHENOUS VEIN BYPASS

Institution: 1. University at Buffalo- State University of New York, 2. University at Buffalo- State University of New York, VA Western NY Healthcare System, Buffalo, NY, United States

Authors presenting: Hasan Dosluoglu, Sikandar Z. Khan, Mariel Rivero, Linda Harris, Maciej Dryjski

Introduction: Infrapopliteal endovascular revascularization has been adopted primarily due to its less invasive nature and similar secondary patency and limb salvage rates as compared to surgical bypass, albeit with higher reintervention rates. We have adopted an aggressive endovascular-first approach, even in patients with complex infrapopliteal disease but we still prefer bypass in good risk patients with good saphenous vein. The goal of our study was to compare long term outcomes of infrapopliteal endovascular interventions and surgical bypass to see if there is a difference in limb salvage.

Methods: 346 patients (397 limbs) who underwent infrapopliteal endovascular interventions (EV) and bypass (B) procedures with single piece autologous great saphenous vein (GSV) from 09/01/2002 to 12/31/2014 were included. Patient characteristics, patency, limb salvage and survival rates were compared.

Results: 81 patients (88 limbs) underwent bypass (B) procedures and 265 patients (309 limbs) underwent EV interventions. The EV patients were older (EV 73±10 vs. 68.5±10 yrs, P=.001)and had a higher percentage of diabetics (EV 74% vs. B 46.9%, P<.001) and tissue loss (EV 90.9% vs. 60.5%, P<.001). 57 % EV and 65% B had multilevel interventions. In the EV group, patients either underwent angioplasty only (PTA) (209 limbs) or selective drug-eluting stent (DES) (37 limbs) or bare-metal stent placement (BMS) (63 limbs). 36-month (55.4±4.3 EV vs 68.3±5.6 B) and 60-month (51.4± 4.8 EV vs 68.3±5.6 B) primary patency was not significantly different (P=.08). 36-month (80.1± 3.6 EV vs 83.3±4.6 B) and 60-month (77.8±4.2 EV vs 83.3±4.6 B) secondary patency was not significantly different. (P=.642). 36-month (71.3±3.3EV vs 88.5±3.9B) and 60-month (69.0±3.6 EV vs 88.5±3.9 B) limb salvage was significantly better in the bypass group. (P=.005). 60-month amputation free survival was EV 23.1±3.1 and 48.0± 7.0 in the bypass group. (P <.001) In subgroup analysis, 36-month (PTA 71.1±3.8, PTA +DES 64.6±14.0, PTA +BMS 72.4±8.3, bypass 88.5±3.9) and 60-month limb salvage ( PTA 69.7±3.9, PTA +DES 64.6±14.0, PTA + BMS 65.2±10.2, bypass 88.5±3.9) were significantly different. (P=.037)(Figure)

Copenhagen, Denmark • 28-30 September 144

Poster Presentations

Image:

Conclusion: Infrapopliteal endovascular interventions in patients with complex disease included adjunctive stenting in approximately 40% of cases, which resulted in similar patency rates as compared to GSV bypass. However, limb salvage was significantly better after GSV bypass. Bypass with GSV remains the best option for infrapopliteal revascularization but acceptable limb salvage can be achieved with endovascular interventions with adjunctive use of stents in complex lesions.

Copenhagen, Denmark • 28-30 September 145

Poster Presentations

PO 016 DREAM AND REALITY – COVERED STENTGRAFT AS TREATMENT OF SUPERFICIAL ARTERY LESIONS

Institution: Department of Vascular and Endovascular Surgery, Heart center, University Hospital of Cologne, Cologne, Germany

Authors presenting: Michael Gawenda, Daphne Gray, Robert Shahverdyan, Roland Thul

Introduction: The treatment paradigms for symptomatic SFA lesions have changed from open to endovascular therapy over the past two decades, with 80% open surgery in the first decade and 61% endovascular interventions in the second decade. Influenced by the complex compression, torsion, flexion, contraction, and extension forces of the lower extremity, postintervention complications such as in- stent restenosis and stent fracture have undermined the superiority of endovascular treatment. The application of the Viabahn (formerly Hemobahn) endoprosthesis (W.L. Gore & Associates, Flagstaff, AZ, USA), as a flexible, self-expanding device consisting of an expanded polytetrafluoroethylene (ePTFE) lining with an external nitinol frame extending along its entire length, might resolve these problems. The objective of this study was to evaluate clinical outcomes and patency rates using the Viabahn endoprosthesis in femoropopliteal lesions. Additionally, a systematically review of the current body of evidence for the Viabahn stent-graft in the treatment of SFA occlusive diseases and quantify related outcomes [patency] was performed.

Methods: We retrospectively evaluated all consecutive patients receiving the Viabahn ePTFE graft at our institution from August 2011 to February 2016. Patients were excluded if Viabahn stent implantation was performed for treatment of aortoiliac disease, popliteal aneurysm exclusion, or sealing of an iatrogenic vessel perforation.Patient demographics, comorbidities, pre-procedural ankle brachial indices (ABIs) and Fontaine/Rutherford Classification were collected along with a complete clinical history and physical examination. Indication for the procedure was classified as either lifestyle limiting claudication or critical limb ischemia. A systematic review was performed using the available databases from inception until 1 March 2016 (data of final search): PubMed, Embase, Web of Science, SciFinder, Cochrane Central Register of Controlled Trials, and BIOSIS Previews.

Results: A total of 95 limbs in 93 patients underwent endovascular therapy and subsequent Viabahn stent graft implantation from August 2011 to February 2016 for TASC-II Type C and D femoropopliteal lesions. The mean age was 71 years with a majority of the population being men (57%). Fifty-three limbs (55.8%) underwent intervention for lifestyle limiting claudication (Rutherford Class 2–3). The remaining 42 limbs (43.2%) were treated for critical limb ischemia (Rutherford Class 4–6). An average of 1.4 (range, 1-4) stent grafts was used per lesion with a mean diameter of 6 mm range, 5- 8) and mean stent length of 18.1 cm (range, 5-35). The average follow-up from the index procedure date was 374 days (range 1–1177 days). The overall 1-year primary patency rate was 45.5% (SE +/-5.7%). There were a total of 35 limbs, which experienced re-interventions (36.8%), mostly due to occlusion (30 limbs) In the published RCT primary patency with the Viabahn was between 65 and 72%, in published observational studies between 44 and 80%.

Conclusion: There is a great inconsistency in published primary patency of Viabahn as treatment of superficial artery lesions. Moreover, the own findings were at the bottom of these results and could not fulfil the expectations in the success of treatment. Further analysis and research might be necessary to improve the patients’ outcome.

Copenhagen, Denmark • 28-30 September 146

Poster Presentations

PO 017 OPEN SURGERY IS THE FIRST-LINE TREATMENT TO INFRAPOPLITEAL LESIONS IN CRITICAL LIMB ISCHEMIA

Institution: 1 Vascular Center, Edogawa Hospital, Tokyo, Japan 2. Vascular Surgery, Asahikawa Medical University, Japan 3. Hokkaido Univarsity of Education, Asahikawa, Japan

Authors presenting: Taku Kokubo, Naoko Ohkubo, Shinsuke Kikuchi, Yumi Sasajima, Tadahiro Sasajima

Introduction: As for the treatment of critical limb ischemia (CLI), the limb salvage is not accomplished without revascularization. Two options for arterial reconstruction are available to address the CLI associated with these pathologies: open (bypass) surgery and/or endovascular therapy (EVT). Paramalleolar or below-the-ankle bypasses using a vein graft have been established as first-line treatment, whereas EVT has prevailed as an effective treatment of CLI with comparable outcomes. Thus, the “Endo- first vs. Open-first” battle to treat infrapopliteal lesions in patients with CLI has continued throughout the current decade. To compare the outcome of Endo-first with Open-first revascularization, our results were summarized in patients with CLI after infrapopliteal bypass grafting.

Methods: From July 2012 to June 2015, 153 limbs from 131 patients performed infrapopliteal bypass grafting were studied. After preceding EVT, the case which were underwent bypass surgery were 48 limbs/42 patients (EVT-first group: Ef group). The case which bypass surgery without preceding EVT were 105limbs/131 patients (Open-first group: Of group).

Results: The incidence of end stage renal disease with hemodialysis was significantly higher in Ef group (71% versus 57%). There were no significant differences in the age and the cardiac performance. Survival rates at 1 and 3 years were 57%, 42% in Ef group, 86% and 68% in Of group, respectively. The 3- year cumulative primary patency rate and amputation-free survaival rate were 73%, 80% in Ef group and 82%, 87% in Of group. There was significant difference between Ef group and Of group in amputation-free survival rate (Log Rank P<0.03).

Conclusion: This study show that in comparison with EVT-first revascularization to the infrapopliteal lesion, open- first was higher amputation-free survival rate. We believe that bypass surgery to infrapopliteal lesion should be first-line treatment to the patients with CLI.

Copenhagen, Denmark • 28-30 September 147

Poster Presentations

PO 018 MEASUREMENT OF MICROCIRCULATION SUGGESTS THAT ANGIOSOME SHUNTING EXISTS MAINLY THROUGH ANGIOGRAPHICALLY VISIBLE COLLATERALS

Institution: 1. Department of Radiology, Kolding Hospital, Kolding, Denmark 2. Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark 3. Department of Vascular Surgery, Kolding Hospital, Kolding, Denmark

Authors presenting: Mette Berggren-Olsen, Johnny Christensen, Hanne Birke-Sørensen, Kim Houlind

Introduction: In patients with critical limb ischemia, current guidelines recommend revascularization of the best available vessel crossing the ankle regardless of location. These guidelines are based on the theory that the procedure will be beneficial to the foot and the patient no matter which vessel is chosen for revascularization, even if collaterals are not angiographically visible. As an alternative approach when planning revascularization the angiosomes concept can be used, advocating direct revascularization to the relevant part of the foot, even if another target vessel is of better quality.

Methods: Angiography was performed in 19 patients before and after below the knee angioplasty. Target vessels were chosen following the current guidelines. Microcirculation of the foot was pre- and postoperatively assessed using combined laser Doppler and light guided spectrophotometry (O2C). This device simultaneously measured oxygen saturation and blood flow in 2 mm and 8mm depth. Measurements were performed with the patient’s leg in horizontal and elevated position respectively in seven predetermined locations on the foot, corresponding to the angiosomes as defined by Taylor, supplemented with the hallux as an independent measuring position. Based on the total of the 38 x- ray angiographies all angiosomes were divided in three groups: directly vascularized, indirectly vascularized through visible collaterals and not vascularized through visible collaterals. These three groups are compared according to the O2C readings.

Results: Flow as well as oxygen tension were significantly higher in the directly vascularized angiosomes than in the not visibly vascularized angiosomes (p<0.01), and in the angiosomes vascularized through visible collaterals than in the not visibly revascularized angiosomes (p<0.01). No differences were found between the directly vascularized angiosomes and the angiosomes perfused through angiographically visible collaterals in flow (P=0.72) or oxygen tension (p=0.46).This was regardless to depth of measurements and position of leg. Image:

Conclusion: In this study we found a significant higher flow and oxygen saturation in direct vascularized angiosomes and in angiosomes vascularized through angiographically visible collaterals compared to not vascularized angiosomes, but there was no difference between direct vascularized

Copenhagen, Denmark • 28-30 September 148

Poster Presentations

angiosomes and angiosomes vascularized through visible collaterals. Our results indicate that revascularization through the “best available vessel” will only increase microperfusion in the ischemic part of the foot in case this part of the foot is connected to the revascularized angiosome by angiographically visible collaterals and not by shunting through the microcirculation. These findings speak in favor of a strategy that lies in between the “best available vessel” strategy and the classical “angiosomes” theory, including knowledge of angiographically visible collaterals when choosing the outflow vessel for revascularization.

References: Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg. 1998; 102:599-616, Varela C, Acín F, de Haro J, Bleda S, Esparza L, March JR. The role of foot collateral vessels on ulcer healing and limb salvage after successful endovascular and surgical distal procedures according to an angiosome model. Vasc Endovascular Surg. 2010;44:654-60, Söderström M, Albäck A, Biancari F, Lappalainen K, Lepäntalo M, Venermo M. Angiosome-targeted infrapopliteal endovascular revascularization for treatment of diabetic foot ulcers. Jour Vasc Surg. 2013;57:427-35, Kabra A, Suresh K, Vivekanand V, Vishnu M, Sumanth R, Nekkanti M. Outcomes of angiosome and non-angiosome targeted revascularization in critical lower limb ischemia. Jour Vasc Surg. 2013;57:44-49, Rother U, Kapust J, Lang W, Horch RE, Gefeller O, Meyer A. The angiosome concept evaluated on the basis of microperfusion in critical limb ischmia patients – an oxygen to see guided study. Microcirculation 2015;22:737-743, Armstrong EJ, Bishu K, Waldo SW. Endovascular treatment og infrapopliteal peripheral artery disease. Curr Cardiol Rep. 2016;18:34

Copenhagen, Denmark • 28-30 September 149

Poster Presentations

PO 019 OUTCOME FOR POPLITEAL STENTS GRAFTS ARE COMPARABLE TO BYPASS GRAFTS FOR POPLITEAL ARTERY ANEURYSM (PAA).

Institution: Vascular Surgery, Westmead Hospital, University of Sydney, Sydney, Australia

Authors presenting: Irwin Mohan, Kerry Hitos, Bernie Bourke, Barry Beiles

Introduction: The Australasian Vascular Audit is a prospective bi-national database for all vascular procedures. We analyzed data for popliteal artery aneurysm (PAA) interventions from 2010 to 2014.

Methods: PAA repair was performed on 1316 patients, either by bypass (920) or stent (396). 77.7% (1022) were elective procedures, and 14.4% were semi-urgent, and 8.0% were emergency. The great majority of patients were male (94.5%), and median age was 72 years for males and 74 years for females. Bypass graft or stents terminated below knee in 94.2% of all operative repairs. Median length of stay was 2 days for stents and 8 days for bypasses. Data were collected up to discharge and used to perform a univariate analysis and create multiple regression models. Data were assessed using SPSS, p< 0.05 was considered significant.

Results: 920 patients had a bypass, 89.9% of bypasses were with vein, however the treating surgeon considered the vein quality suboptimal in 7.0%. Graft occlusion occurred in 37 (4.0%) bypasses and 5 (1.3%) stents (p=0.009). Wound complications occurred in 3.6% of bypasses, and 1.5% of stents procedures (p=0.042). Limb amputation occurred in 5 limbs after bypass but 0 limbs after stenting. Death, amputation or graft occlusion occurred in 7 stented patients (1.8%) and 38 patients with bypass (4.1%), (p=0.031). Overall, bypass grafts, IHD, urgent or emergency procedures increased the risk of any complication (p< 0.001). A sub-optimal conduit increases the risk of occlusion or amputation by 6.8 times compared to a good quality conduit (95% CI: 3.09-15.06; P<0.0001). The risk of death, occlusion or amputation increases with emergency repair by 3.3-fold compared to an elective procedure (95% CI: 1.47-7.52; P=0.004), and an ASA score of IV increases the risk by 5.3 times (95% CI: 1.73-16.12; P=0.003). The risk for failed repair or reintervention increases for a 1- vessel or blind popliteal compared to a 3 vessel runoff (OR: 3.13; 95% CI: 1.28-7.65; P=0.013); and the risk of amputation or occlusion also increases for a 1 vessel or blind popliteal when compared to 3 vessel runoff (OR: 2.72; 95% CI: 1.26-5.89; P=0.011).

Conclusion: Stent grafts are comparable to bypasses with less morbidity. A good quality conduit is essential. Urgent or emergency surgery in symptomatic patients increases the risks of reintervention, graft occlusion, amputation or death from PAA repair. Graft occlusion and amputation rates an almost threefold increase for single vessel or blind runoff.

Copenhagen, Denmark • 28-30 September 150

Poster Presentations

PO 020 ENDOVASCULAR AND OPEN REPAIR OF POPLITEAL ARTERY ANEURYSMS: TEN-YEARS EXPERIENCE

Institution: New Hospital Civil, Strasbourg, France

Authors presenting: Anne Lejay, Benjamin Del Tatto, Mathieu Roussin, Charline Delay, Elie Girsowicz, Vincent Meteyer, Yannick Georg, Fabien Thaveau, Nabil Chakfe

Introduction: The purpose of this study was to report mid-term outcome after open repair or endovascular repair of popliteal artery aneurysms.

Methods: This monocentric and retrospective study included all consecutive patients treated for popliteal artery aneurysm between January 2004 and December 2013. Patients were divided into 2 groups: open repair and endovascular repair. Demographics, clinical and radiological data were reviewed and outcome was analyzed under the supervision of the Departement of Biostatistics.

Results: 131 popliteal artery aneurysms were treated in 119 patients: 87 performed in open repair and 44 performed with endovascular repair. Mean age was 70 ± 20 years in open repair and 72 ± 15 years in endovascular repair respectively (p=NS). There was no difference between both groups concerning comorbidities or radiological data (AAP diameter or run-off). 30-day mortality was 3.4% vs 2.3% and 30-day morbidity was 26.5% vs 17.5% in open repair vs endovascular repair respectively (p=NS). Mean follow up was 2.4 years. The 2-year primary-, primary assisted-, secondary patency and limb salvage rates were respectively 84.9%, 90.7 %, 92.2% and 89.5% for open repair and 83.3%, 90.5%, 95.2% and 87.8% for endovascular repair (p=NS). Emergency surgery appeared as risk factor for amputation either in open repair or in endovascular repair (HR 9.56, p<0.01).

Conclusion: Open repair or endovascular repair of popliteal artery aneurysm provides acceptable results. The high amputation risk in the setting of emergency highlights the need to depict asymptomatic popliteal artery aneurysms before they become symptomatic and require emergency surgery.

Copenhagen, Denmark • 28-30 September 151

Poster Presentations

PO 021 COMPLEX INFRA-POPLITEAL REVASCULARISATION IN OCTOGENARIANS AND NONAGENARIANS WITH CRITICAL LIMB ISCHAEMIA: IMPACT OF MULTIDISCIPLINARY INTEGRATED CARE ON MID- TERM OUTCOME

Institution: Department of Vascular and Endovascular Surgery, Department of Radiology, Department of Ageing and Health, Guy's and St.Thomas' NHS Foundation Trust, London, United Kingdom

Authors presenting: Justinas Silickas, Lukla Biasi, Sanjay D. Patel, Talia Lea, Tommaso Donati, Athanasios Diamantopoulos, Konstantinos Katsanos, Judith Partridge, Jugdeep Dhesi, Hany Zayed

Introduction: The incidence of Critical Limb Ischaemia (CLI) is exponentially rising among our aging population. There is a paucity of scientific evidence on best management and clinical outcome of infra-popliteal (IP) revascularisation in elderly CLI patients.

Methods: A prospectively collected database was analysed to identify consecutive octogenarian and nonagenarian patients who underwent IP revascularisation (bypass or angioplasty) for CLI (Rutherford 4-6) in a single centre between 2010-2014. Primary endpoints were overall Amputation- Free-Survival (AFS) and Overall Survival (OS) at 1 and 2 years. Secondary endpoints were primary, assisted-primary, secondary patency and Limb-Salvage (LS) rates by Kaplan-Meier analysis. Univariate and multivariate analyses were performed to find factors predicting outcome.

Results: A total of 129 limbs in 120 patients were treated with IP bypass (n=42) and endovascular (n=87) revascularisation with a mean age of 85(±5) years. The overall perioperative mortality rate was 2%. The overall primary patency, assisted-primary patency and secondary patency were 58%, 65% and 70%, respectively at 12 months and 34%, 48% and 59% at 24 months. Primary, assisted-primary and secondary patency analysed by treatment method (endovascular vs. bypass) was 54% vs. 52%, 61% vs. 70%, 69% vs. 75% at 1 year and 21% vs. 36%, 24% vs. 62%, 31% vs. 72% at 2 years. The overall AFS at 12 and 24 months was 62% and 46% respectively; AFS was 71% - 68% in the bypass group and 53% - 21% in the Endovascular group (P<0.001). LS was 89% at 12 months and 84% at 24 months, with no significant difference between the bypass and endovascular groups (P=0.24). OS by Kaplan-Meier was 68% and 54% at 1 and 2 years respectively. Diabetes (P=.046) and low eGFR (P=.041) were predictors of worse AFS and OS, respectively. Analysis of discharge destination showed that 79% of patients returned to independent or assisted living at home, 15% required further bed based rehabilitation, and only 6% were discharged to a nursing home.

Image:

Copenhagen, Denmark • 28-30 September 152

Poster Presentations

Conclusion: IP revascularisation (either endovascular or surgical) is feasible and effective in octogenarians and nonagenarians with CLI. By adopting a patient-tailored approach, both revascularisation strategies have satisfactory technical and clinical outcomes in this high-risk group. Subgroup analysis suggests that bypass surgery may have better mid-term secondary patency and AFS rates.

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(9901):1329-40. 2. Slim H, Tiwari A, Ahmed A, Ritter JC, Zayed H, Rashid H. Distal versus ultradistal bypass grafts: amputation-free survival and patency rates in patients with critical leg ischaemia. Eur J Vasc Endovasc Surg 2011; 42(1):83-8. 3. Arvela E, Venermo M, Söderström M, Korhonen M, Halmesmäki K, Albäck A, et al. Infrainguinal percutaneous transluminal angioplasty or bypass surgery in patients aged 80 years and older with critical leg ischaemia. Br J Surg. 2011; 98(4):518-26. 4. Brosi P, Dick F, Do DD, Schmidli J, Baumgartner I, Diehm N. Revascularization for chronic critical lower limb ischemia in octogenarians is worthwhile. J Vasc Surg 2007; 46:1198–1207. 5. Partridge JS, Harari D, Martin FC, Dhesi JK. The impact of pre-operative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a systematic review. Anaesthesia 2014; 69 Suppl 1:8-16.

Copenhagen, Denmark • 28-30 September 153

Poster Presentations

PO 022 A 20-YEAR EXPERIENCE OF SUPERFICIAL ARTERY AUTOGRAFT RECONSTRUCTION FOR TREATMENT OF POPLITEAL ARTERY ANEURYSMS.

Institution: Amiens University Hospital, Amiens, France

Authors presenting: Pierre Maitrias, Valerie Molin, Marie Bensussan, Thierry Reix

Introduction: Using a superficial artery autograft can be an alternative to retroarticular by-pass, especially when the great saphenous vein is missing. We report long-term outcomes of this approach.

Methods: Data from patients with popliteal artery aneurysms treated by superficial femoral artery transposition between 1995 and 2015 were retrospectively collected. The popliteal artery was exposed above and below the knee through a medial approach. The superficial femoral artery was harvested at the upper third of the thigh and placed in popliteal position with end-to-end anastomosis. The superficial femoral artery was replaced by a polytetrafluoroethylene tube graft. Patencies were calculated with the Kaplan-Meier method.

Results: Seventy-seven popliteal artery aneurysms in 69 patients (68 men; median age, 65 years) were treated using a superficial artery autograft. Indications were symptomatic or complicated aneurysms in 32 (41%) cases. Ten (13%) aneurysms were thrombosed and 67 (87%) were patent. At surgery, 33% had a single vessel runoff. Reconstruction was performed as an emergency procedure in 19 (25%) cases. There was no perioperative death. One early thrombosis due to prosthesis infection occured and required transfemoral amputation. Median follow-up was 108 months (range, 1-220). During follow-up, 4 (6%) successful transluminal dilatations were performed because of stenosis. Three (4%) evolutive aneurysms required reintervention. One aneurysmal dilatation of the autograft required repeat surgery. Thrombosis occured in 11 (14%) cases. A successful repeat surgery was peformed in 7 patients. Two patients had wide claudication and 2 patients had no symptoms. Overall limb salvage was 96%. At 3 years, the primary, primary-assisted and secondary patencies were 84%, 87% and 96% respectively. At 10 years, the rates were 74%, 82% and 92% respectively. Emergency surgery and poor distal runoff were associated with significantly lower primary patency.

Conclusion: The good technical and clinical outcomes of this study showed that superficial arterial reconstruction is a safe and durable treatment option in patients with popliteal artery aneurysms who lack suitable saphenous vein. Long-term patency results, similar to vein results, suggest that this technique is a good alternative to prosthetic by-pass crossing the knee joint.

Copenhagen, Denmark • 28-30 September 154

Poster Presentations

PO 023 TREATMENT OF CRITICAL LIMB ISCHEMIA BY THERAPEUTIC ANGIOGENESIS IN PATIENTS WITH NO REVASCULARIZATING OPTIONS: RESULTS AFTER AUTOLOGOUS TRANSPLANTATION OF HEMATOPOIETIC PROGENITORS CELLS

Institution: 1. Vascular Surgery, Haematology, Hospital Universitari Son Espases, Palma. Balearic Islands 2. Cardiovascular Surgery, Hospital General Universitario, Valencia, Spain

Authors presenting: Raul Lara-Hernandez, Pascual Lozano-Vilardell, Antonia Sampol Mayol, Enrique Manuel-Rimbau Muñoz, Ramon Riera Vazquez, Armando Mena Duran

Introduction: In recent years, optimal results have been published using endothelial progenitor cells for the treatment of critical limb ischemia (CLI), in what has been termed Therapeutic Angiogenesis. The objective of our study has been to assess the eficacy and safety of the treatment with autologous hematopoietic CD34+ stem cell transplantation (cell therapy) in patients with diagnosis of non revascularizating CLI.

Methods: Non randomized, open, single arm, prospective observational study, with a historical cohort as control group. Protocol approved by Hospital Ethics Committee. Treatment group: patients with CLI without revascularizating options under cell therapy and conventional treatment ( pain killer, haemorrheologic, antiplatelet, vasodilator). Control group: patients with the same diagnosis only under conventional treatment. Multivariate, propensity score and Kaplan-Meier statistical analysis.

Results: Angiogenesis group: 45 patients (50 limbs). Control group: 120 patients. Follow up: 41.6±34.9 months [2.1-111.7]. There was a reduction in amputation rate in patients undergoing angiogenic treatment (42.2% Angiogenesis –vs- 96.6% Controls; RR 0.025 CI95% 0.008-0.08, p=0.0001) with no significant difference in mortality between groups (Angiogenesis 28.8% -vs- Controls 33.3%, p=0.7). Diabetes was identified as prognostic factor for amputation (Diabetes OR 7.240 CI95% 2.176-24.093 p=0.001). However, the rate was lower among diabetic patients undergoing angiogenic therapy (56.2% Angiogenesis -vs- 96,6% Controls; RR 0.046, CI95% 0.011-0.189, p=0.0001). There was a reduction in Visual Analogue Scale (VAS) score for pain after treatment (8.78±1.13 Basal – vs- 4.5±3.6 Final; p=0.001). Limb salvage rate at 1 and 3 years was 76% and 63% in Angiogenesis group, compared with 18% and 5% in the Control group (log rank=0.0001). It was stablished a minimum dose of 1.2x106CD34+/kg to achieve endpoint. There were no complications associated with treatment.

Conclusion: Treatment of non revascularizating CLI by autologous hematopoietic CD34+ stem cell transplantation is a safe and effective therapy. Limb salvage rates are higher than those achieved with conventional treatment.

References: 1. Sprengers R, Moll F, Verhaar Y. Stem Cell Therapy in PAD. Euopean Journal of Vascular and Endovascular Surgery 2010; 39: s38-s43 2. Lara Hernández R, Lozano Vilardell P, Blanes P, Torreguitart N, Galmés N, Besalduch J. Safety and efficacy of therapeutic angiogenesis as a novel treatment in patients with critical limb ischemia. Annals of Vascular Surgery 2010: 24(2); 287-294 3. Fadini G, Agostini C, Avogaro A. Autologous stem cell therapy for peripheral arterial disease. Meta-analysis and systematic review of the literature. Atherosclerosis 2010; 209: 10-17 4. Bura A, Planat-Benard V, Bourin P, Silvestre JS, Gross F, Grollean JL, Saint-Lebese B, Peyrafite JA, Fleury S, Gadelorge M, Taurand M, Dupuis-Coronas S, Leobon B, Casteilla L. Phase I trial: the use of autologous cultured adipose-derived stroma/stem cells to treat patients with non- revascularizable critical limb ischemia. Cytotherapy 2014; 16: 245-257 5. Furmston J, Patel A, Ludwinski F, Zuzel V, Bajwa A, Saha P, Smith A, Modarai B. Angiogenic cell therapy for critical limb ischaemia: an update on concepts and trials. J Cardiovasc Surg 2014: 55 (5): 641-654

Copenhagen, Denmark • 28-30 September 155

Poster Presentations

PO 024 BARTHEL FRALTY INDEX CAN BE ONE OF THE PREDICTORS OF TWO-YEAR MORTALITY AFTER DISTAL BYPASS IN PATIENTS WITH CRITICAL LIMB ISCHEMIA

Institution: Devision of vascular surgery, Department of surgery, Nagoya University School of Medicine, Nagoya, Japan

Authors presenting: Akio Koyama, Masayuki Sugimoto, Hiroshi Banno, Kimihiro Komori

Introduction: The European Society of Cardiology guidelines and the American College of Cardiology Foundation/American Heart Association 2005 updated guidelines were revised to indicate that life expectancy of more than 2 years is an important factor in the selection of the initial revascularization procedure for critical limb ischemia (CLI) patients. They are usually aged and have significant comorbidity, which are associated with frailty characteristics. However, little information is available about the frailty and predictors of 2-year mortality after distal bypass in CLI patients. Therefore, the aim of this study was to identify prognostic factors of 2-year mortality, including some frailty scores.

Methods: From 2006 to 2014, consecutive patients who underwent primary distal bypass for critical limb ischemia due to chronic atherosclerotic disease and could be available for follow-up for 2-years were included. These remaining patients were stratified into 2 groups according to 2-year mortality. After univariate analysis, only the significant variables were included in the logistic regression model to determine independent predictors of 2-year mortality. The Barthel index and National Surgical Quality Improvement Program (NSQIP) modified Frailty Index were used as frailty score. Per-limb basis analysis was performed. A p-value <.05 was considered statistically significant.

Results: During the study period, 71 distal bypasses were performed. With the exception of 21 cases with follow-up period less than 730 days, 50 cases were included in this analysis. 32 (64%) cases were men, and mean age was 69 years old. 37 (74%) cases had diabetes, 33 (66%) had coronary arterial disease, and 34 (68%) had dialysis. Rutherford classification 4, 5 and 6 of the index limb was 11, 29, and 10 limbs. The mean preoperative ABI and SPP were 0.49 and 17mmHg, respectively. The mean postoperative ABI and SPP were 0.78 and 52mmHg, respectively. 30-day mortality was 2%. Mean follow-up was 870 days. The inflow vessel was common femoral artery in in 18 limbs, the superficial femoral artery in 6 limbs, the above knee (AK) popliteal artery in 9 limbs, the below knee (BK) popliteal artery in 13 limbs, and the other artery in 4 limbs. The outflow target vessel was the anterior tibial artery in 7, the posterior tibial artery in 17, the peroneal artery in 4, the dorsalis pedis artery in 13, the plantar artery in 6, and the other artery in 3 limbs. Minor amputation was performed in 23 cases. Overall survival at 2 years after revascularization was 68%. After univariate analysis 5 significant preoperative factors were identified. They were dialysis-dependent end stage renal failure, serum albumin level < 2.5mg/dl, body mass index < 18.5 kg/m2 Rutherford 6, Barthel index. On multivariate analysis Barthel index was the only independent risk factor. Analysis of the ROC curve showed that the Barthel index had an area under the curve of 0.924 (95% confidence interval [CI]:0.849-0.999; SEM, 0.038; P<0.001) for the prediction of 2-year mortality. According to the ROC curve, the best cut-off point for the Barthel index was 63 (sensitivity, 88%; specificity, 81%;)

Conclusion: The most patients with CLI have frailty characteristics, however, there are no reports concerning about the relationship between frailty and prognosis. Barthel index can be useful in estimating mid- term prognosis after distal bypass.

Copenhagen, Denmark • 28-30 September 156

Poster Presentations

PO 025 EFFECT OF DIABETES MELLITUS ON WALKING DISTANCE PARAMETERS AFTER SUPERVISED EXERCISE THERAPY FOR INTERMITTENT CLAUDICATION

Institution: Department of Vascular Surgery, Catharina Hospital, Eindhoven, Department of Vascular Surgery, Máxima Medical Center, Veldhoven, Netherlands

Authors presenting: Gert-Jan Lauret, David Hageman, Lindy N. Gommans, Marc R. Scheltinga, Joep A. Teijink

Introduction: Some believe that many patients with intermittent claudication (IC) may be unsuitable for supervised exercise therapy (SET), based on the presence of comorbidities and the possibly increased risks. The aim of this study was to summarize evidence and to address literature gaps on the potential influence of diabetes mellitus (DM) on the response to SET in patients with IC.

Methods: Articles were obtained by a search in MEDLINE, EMBASE and CENTRAL. Two authors independently assessed articles including randomized and nonrandomized studies that investigated the effect of DM on walking distance after SET in patients with IC. Considered outcome measures were maximal, pain-free and functional walking distance (meters).

Results: The literature search identified 962 potentially relevant and unique articles. After title and abstract screening and subsequent full-text evaluation, three articles met inclusion criteria. All three reported on maximal walking distance (MWD, n = 845 patients), two smaller studies reported on pain-free walking distance (PFWD, n = 87 patients) whereas the largest study reported on functional walking distance (FWD, n = 758 patients). Improvement in MWD, PFWD and FWD was reported for both diabetic and nondiabetic IC patients. In one study, MWD was 111 meter (128%) longer in the non- DM group compared to the DM group after three months of follow-up (198 meter versus 87 meter, respectively, P = .056). In a second study, the non-DM group demonstrated a significant increase in PFWD (114 meter) after three months of follow-up, whereas there was no statistically significant increase for the DM group (54 meter). On the contrary, the largest study of this review did not demonstrate any adverse effect of DM on MWD and FWD after SET. The MWD of diabetic and nondiabetic patients with IC are reported in Figure 1.

Image:

Conclusion: Conflicting results were reported on the effect of diabetes mellitus (DM) when walking distances of diabetic and nondiabetic patients with intermittent claudication (IC) were compared. However, patients with DM and IC do demonstrate improved walking distance parameters after supervised exercise therapy (SET). As a consequence, SET should not be denied to DM patients suffering from IC.

Copenhagen, Denmark • 28-30 September 157

Poster Presentations

PO 026 DISTRIBUTION OF INFRA-POPLITEAL PERIPHERAL VASCULAR DISEASE IN PATIENTS WITH DIABETES MELLITUS COMPARED TO PATIENTS WITHOUT

Institution: Vascular Surgery, Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom

Authors presenting: Danielle Lowry, Mujahid Saeed, Parth Narendran, Alok Tiwari

Introduction: Diabetes mellitus (DM) predisposes to atherosclerotic disease1. Patients with DM and peripheral disease have poorer outcomes compared to patients without DM (NDM) 2. It is anecdotally that patients with DM have a predisposition towards a higher burden of atherosclerotic disease below the knee. The aim of this study was to test this hypothesis in a cohort of patients who had been closely matched for potential confounding factors.

Methods: All patients who had a lower limb angiogram between July 2010 and May 2014 at a single centre were identified. Patients with DM were matched for age (±5 years), sex, ethnicity, smoking status, hypertension, hypercholesterolaemia and renal impairment to a NDM patient. Only exact matches were included. Outcome data was also collected. All angiograms were scored using an extended and modified version of the Bollinger score to assess morphological changes in 16 infra-inguinal arterial segments. The summated score for each crural vessel was also calculated. Zero is normal artery, 15 represents occlusion in over half of the segment. The primary outcome was difference in Bollinger score in all segments. Secondary outcomes were amputation free survival, major amputation and further revascularisation, assessed using survival curves.

Results: There were 153 patients in each cohort and they were identically matched for all demographics (p=1.00). There was no significant difference in median length of follow up (2.4 years IQR 1.38-3.78 vs 2.3 IQR 1.24-3.34) however those with DM were more likely to have critical ischaemia as their indication (54% vs 32%, p<0.001) and require an emergency procedure (29% vs 11%, p<0.001). The only individual arterial segment that had a significant difference in median Bollinger score was the proximal third of the posterior tibial artery (PTA). Those with DM had a median score of 3 (IQR 0-15) and NDM had a score of 0 (1-13, p=0.038). However, the summated scores of the crural vessels showed that those with DM had significantly higher median scores in the anterior tibial artery and PTA. The PEA appears to be relatively spared in both cohorts (Table 1). Patients with DM had significantly poorer amputation free survival and higher major amputation rates (log rank test p=0.001 and 0.009 respectively). There was no significant difference in rates of further revascularisation (p=0.590).

Copenhagen, Denmark • 28-30 September 158

Poster Presentations

Image:

Conclusion: This data supports the hypothesis that DM predisposes to infra-popliteal disease. In DM the PEA may be the optimal target for durable surgical revascularisation. Ever after potential confounding factors have been accounted for DM remains a major risk factor for major amputation and mortality.

References: 1. American Diabetes Association. Standards of Medical Care in Diabetes—2012. Diabetes Care. ;35(Supplement 1):S11-S63. 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):167-171.

Copenhagen, Denmark • 28-30 September 159

Poster Presentations

PO 027 IMPACT OF CHRONIC KIDNEY DISEASE ON THE OUTCOMES OF PATIENTS UNDERGOING REVASCULARIZATION FOR CRITICAL LIMB ISCHAEMIA

Institution: Department of Vascular and Endovascular Surgery, University Hospital Frankfurt Main, Germany

Authors presenting: Asimakis Gkremoutis, Thomas Schmitz-Rixen, The CRITISCH collaborators

Introduction: Chronic kidney disease (CKD) has been shown to be an independent risk factor for adverse cardiovascular events in the general population. The prevalence of peripheral artery disease (PAD) and its most severe form, critical limb ischaemia (CLI), is remarkably high among patients with renal insufficiency. However, studies regarding the perioperative outcomes in patients with CKD without dialysis after treatment for CLI are limited and few is known about the first-line treatment approach in this specific subgroup. To evaluate the impact of CKD on outcomes of patients with co-prevalence of CLI and CKD undergoing revascularization, we initiated a post-hoc analysis of the patient cohort of the CRITISCH registry, which was primarily designed to depict the real-world practice for the treatment of CLI in Germany.

Methods: We analyzed the perioperative in-hospital data of patients, who were included in the CRITISCH registry and suffered from CKD. We compared them to patients with normal renal function. The type of first-line treatment and the composite endpoint of amputation and/or death were evaluated, as well as the risk for major adverse events and treatment failure. A multivariate logistic regression analysis assessed risk factors for the primary und secondary endpoints.

Results: Among 1200 patients included, 424 patients (35%) with preexisting CKD were identified. An endovascular revascularization (ER) was performed in 251 patients (59%). 86 patients (20%) received a bypass (BS) as a first-line treatment; a femoral artery patchplasty (FAP)was performed in 29 patients (7%). Conservative treatment (CT) was offered to 46 patients (11%) and 12 patients (3%) underwent a major amputation (PMA) as first-line treatment of choice. The composite endpoint (in- hospital amputation-free survival) amounted to 96% (n=242), 91% (n=78), 90% (n=26), 91% (n=42) respectively. Letality reached 2%, 6%, 10% and 4% in the ER, BS, FAP and CT group respectively. In the last group (PMA) letality amounted to 17% (n=2). Limb loss was observed in 2%, 5%, 7% and 4% in the first four groups. The multivariate regression analysis showed that patients with CKD had an increased risk for death (odds ratio, (OR)=5.53, 95% confidence interval (CI): 1.92-15.9) and haemodynamic failure (OR=1.80, 95% CI: 1.19-2.72) compared to patients with normal renal function.

Conclusion: Endovascular treatment was the most common first-line treatment of choise offered to this particular patient subgroup. Patients treated endovascularly showed a reduced risk of death compared to bypass surgery or femoral patchplasty, although the risk of amputation was comparable between the groups. CKD patients receiving treatment for CLI showed a noticeably increased risk of death and hemodynamic failure.

Copenhagen, Denmark • 28-30 September 160

Poster Presentations

PO 028 TOE PRESSURE IS A BETTER INDICATOR OF A PATIENT’S PERIPHERAL ARTERIAL DISEASE AND CARDIOVASCULAR RISK THAN THE ANKLE BRACHIAL INDEX

Institution: 1. Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland 2. Department of Vascular Surgery, Turku University Hospital, Turku, Finland

Authors presenting: Petteri Kauhanen, Mirjami Laivuori, Harri Hakovirta, Anders Albäck, Maarit Venermo

Introduction: The Ankle Brachial Index (ABI) is a basic tool in screening for peripheral arterial disease. Several studies have shown that patients with an ABI of less than 0.9 have an increased risk of cardiovascular disease. The ABI measurement is prone to errors though, and may give falsely high results in patients who suffer from mediasclerosis of peripheral arteries. When measuring only the ABI, a significant group of patients may be left without further investigations or treatment. However, toe pressure (TP) can also be measured alongside the ABI noninvasively. TP is an accurate indicator of the peripheral vascular status of a patient with less susceptibility to errors than ABI.

Methods: In Helsinki University Hospital all the ABI and TP measurements done in the vascular laboratory have been registered in the HUSVASC-registry. The TPs have been routinely measured since 2000. This material consists of over 24000 measurements from over 6000 patients during the years 1990-2009. The Cause of death registry of Statistics Finland provided the causes and dates of death until the end of 2014. The data has been processed with SPSS statistics and survival analysis has been carried out with Kaplan-meier analysis. The first ABI and TP measurements of each patient were analysed.

Results: For the ABI measurements, the poorest survival was found in the patient group with an ABI of over 1.3 the mean survival being 46.8 months (95% CI 36.2-57.4). For patients with an ABI of less than 0.50 the mean survival time was 82.8 months (CI 78.4-87.2), with an ABI of 0.5-0.89 it was 114.9 months (CI 109.0-120.7), and with an ABI of 0.9-1.3 it was 127.6 (CI 117.9-137.3). The maximum follow-up time was close to 300 months. For the toe pressure measurements, there was a clear correlation with toe pressure value and survival. The patients with a toe pressure of less than 30 had the lowest mean survival, 64 months (CI 59.4-68.7). For patients with a TP of 30-49.9 it was 80.2 (CI 73.9-86.5), for patients with a TP of 50-79.9 it was 102.2 (CI 96.0-108.5), and for patients with a TP of over 80 it was 116.9 (CI 110.5-123.3). The maximum follow-up time was close to 200 months. The patients with a normal ABI, 0.9-1.3, were analysed separately. In this group (n=649) almost half of the patients (46.1%) had a toe pressure of less than 80 and 21.3% had a TP of less than 50. The mean survival time for patients with TP of less than 30 was 55.4 months (95%CI 40.6-70.2), for patients with TP of 30-49.9 71.3 (CI 59.4-83.1), for patients with TP of 50-79.9 106.2 (CI 94.9-117.6), and for patients with a TP of over 80 it was 116.0 months (CI 108.6-123.3).

Conclusion: The results show, that the survival of the patients with an abnormally high (over 1.3) ABI is considerably lower than patients with a lower ABI. This should be taken into consideration in clinical practice as perhaps a more aggressive treatment plan compared to other patients. The correlation with TP and survival was clear. We found a considerable amount of patients with a normal ABI but lowered TP. Furthermore, over 20% of these patients had a TP of less than 50. When considering, for example, patients with ulcers, a TP of less than 50 might implicate that the blood flow is not sufficient for the ulcer to heal and only measuring the ABI can lead the clinician astray. This might cause a lack or delay in diagnostics and treatment causing further morbidity for the patients. Our conclusion is that TP is a better indicator for PAD and cardiovascular risk than ABI.

Copenhagen, Denmark • 28-30 September 161

Poster Presentations

PO 029 THE 2-YEARS FOLLOW-UP RESULTS OF A STRUCTURED COMPREHENSIVE MULTIDISCIPLINARY PROTOCOL ON THE LOWER EXTREMITY AMPUTATION RATES IN A COHORT OF PATIENTS WITH DIABETIC FOOT ULCERS

Institution: Surgery, King Abdulaziz University, Jeddah, Saudi Arabia

Authors presenting: Anas Alzahrani, Hasan Alzahrani

Introduction: Diabetics are more prone to ulcer ulceration and foot infection and subsequent amputation. Limb amputation is preventable in 80-90% of these cases, if patients adopt the appropriate preventive measures. Management of diabetic foot ulcers (DFU) is often poor and outcome is disappointing while cost is high.The aim of this study is to evaluate the short and mid-term effectiveness of a structured comprehensive multidisciplinary protocol on the lower extremity amputation (LEA) rates in a cohort of diabetics with foot ulcer in Jeddah, Saudi Arabia.

Methods: A prospective study was designed. Patients with DFU were consecutively included according to inclusion criteria in a “one stop” DFU multidisciplinary clinic under the administration of the vascular surgery division of a Saudi teaching hospital. All patients were subjected to structured protocol that was based on the best clinical practice guidelines of managing DFU. Patients were followed-up over 2 years. LEA (major or minor) was defined as the primary outcome. Patients who were lost for follow up or died before the primary outcome were censored. Unadjusted Kaplan-Meier curves were constructed to describe the time to LEA. Multivariate Cox regression models were used to identify the adjusted risk factors for LEA.

Results: A total of 105 patients with DFU were studied. Average age was 57(±11.7) years and 68% were males. Eleven percent was smokers. Majority 93 % had type 2 diabetes and 80% were have been diabetic for 3 years or more. About one fifth (22%) had a history of LEA. The sites of the DFU were: 30% distal forefoot, 12% proximal heel, 44% planter, 11% dorsum and 3% malleoli. Infection was observed in 11%, neuropathy in 21%, nerou-ischaemia in 50%, ischemia in 7% and other in 11% of the studied DFU. 26% were ranked in category 3 or more in Wagner classification. Using Kaplan- Meier survival estimates, the cumulative hazards of LEA were 9%, 13% and 14% at 6 months, 1 and 2 years respectively. The adjusted Cox regression showed that smokers had increased risk of LEA by 7.8 folds over time (HR 7.83 PV 0.01) compared to non-smokers. Patients with history of previous LEA had 5.6 folds increased risk of LEA over time (HR 5.55 PV 0.01) compared to those who were not subjected to LEA.

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Copenhagen, Denmark • 28-30 September 162

Poster Presentations

Conclusion: A multidisciplinary and holistic approach to manage patients with diabetic foot ulcer seems effective in achieving better limb salvage rates in this cohort of patients. Similar “one-stop” clinics are recommended in developing countries to achieve better patients’ compliance. Smokers and patients with previous history of LEA are at a higher risk of LEA.

References: 1. Peripheral, I. O. "Peripheral arterial disease in people with diabetes." Diabetes care 26.12 (2003): 3333 2. Singh, Nalini, David G. Armstrong, and Benjamin A. Lipsky. "Preventing foot ulcers in patients with diabetes." Jama 293.2 (2005): 217-228 3. Ramsey, Scott D., et al. "Incidence, outcomes, and cost of foot ulcers in patients with diabetes." Diabetes care 22.3 (1999): 382-387

Copenhagen, Denmark • 28-30 September 163

Poster Presentations

PO 030 SUBJECTS WITH PERIPHERAL ARTERIAL DISEASE SURVIVING TEN YEARS HAVE A SUBSTANTIAL RISK FOR DETERIORATION OF LEG PROBLEMS

Institution: 1. Department of Clinical Science and Education, Karolinska Institutet, Section of Vascular Surgery, Södersjukhuset, Stockholm 2. Department of Clinical Science and Education, Karolinska Institutet, Section of Vascular Surgery Centralsjukhuset. 3. Landstinget i Värmland, Karlstad, 4Dept. of Health and Medicine, Linköping University, Stockholm, Sweden

Authors presenting: Fredrik Sartipy, Birgitta Sigvant, Fredrik Lundin, Eric Wahlberg

Introduction: An increasing number of peripheral arterial disease (PAD) patients are offered revascularization due to availability of modern, minimally invasive endovascular techniques. This possibility may alter the indications for surgery and make more patients eligible for interventions, but mortality rates and the prognosis of the leg symptoms should also influence these decisions. The aim of this population- based longitudinal study was to determine survival, development of leg symptoms and functionality over a ten-year period in PAD patients.

Methods: A cohort of 5080 subjects was assembled 2004 by randomly inviting 8000 Swedish inhabitants aged 59-89 to PAD screening (1). The subjects were classified by ABI and symptoms to having asymptomatic PAD (APAD), intermittent claudication (IC) or severe limb ischemia (SLI). The remaining subjects served as reference. The surviving part of the cohort was reexamined 2015 and data was collated with national registers on survival and vascular intervention. The patients who had undergone a procedure for PAD (N=51) were excluded from the analysis. Classification of the surviving subjects into the subgroups was repeated to identify shifts between the groups. Besides mortality rates, the analyses included change over time in mean intra-individual difference, m∆i in ABI, walking distance (m∆iWd) and walking speed (m∆iWs). The latter two derived from Walking Impairment Questionnaire scores. Differences between baseline data and 2015 were tested with Wilcoxon signed-rank test.

Results: At follow up the mortality rates in the cohort (N=4926) was 50% (N=261) for APAD subjects, 59% (N=174) for IC and 72% (N=47) for SLI. Twenty four % (N=985) of subjects without PAD had died. Of surviving subjects with APAD 32% (N=48) became symptomatic, and only 14 % (N=76) of the references. Thirty-one % (N=23) of IC subjects changed to the SLI stage. ABI decreased over time in all groups besides SLI. The m∆i was -0.04 (SD 0.36, p=.89) for the APAD group, -0.10 (0.43, p=.05) for the IC, +0.16 (0.56, p=.05) for SLI and -0.12 (0.28, p=.00) for the references. The groups displayed a minor symptomatic progression of leg problems, where m∆iWd was -23.4 (SD 34.8) for APAD, -18.7 (42.3) for IC and -15.2 (29.5) for references. For APAD patients m∆iWs was -26.9 (26.8), for IC s patients it was -19.1 (22.2) and -18.4 (24.4) for references. Differences over time was significant (p=.000) for all groups except SLI.

Conclusion: There is still a high mortality for subjects with PAD. Subjects surviving ten years have a substantial risk for progression of leg problems. One third of APAD and IC subjects deteriorate in to a more severe PAD stage, and ABI and walking ability changes support this pattern. For SLI this was not observed, probably a consequence of the few patients surviving. These findings may support a liberal use of revascularization procedures of low risk, besides aggressive cardiovascular prevention, in IC patients.

References: 1) Sigvant, B., et al., A population-based study of peripheral arterial disease prevalence with special focus on critical limb ischemia and sex differences. J Vasc Surg, 2007. 45(6): p. 1185-91.

Copenhagen, Denmark • 28-30 September 164

Poster Presentations

PO 031 BETTER LONG TERM RESULT OF AMPUTATION FREE SURVIVAL FOR WOMEN IN SPINAL CORD STIMULATION FOR CRITICAL LIMB ISCHEMIA

Institution: Department of Vascular Surgery, Department of Angiology, Medical University Graz, Graz, Austria

Authors Presenting: Wolfgang Oswald, Peter Konstantiniuk, Maurice Tomka, Philipp Jud, Tina Cohnert

Introduction: Patients with critical limb ischemia (CLI) Fontaine stage III or IV are in need of revascularization. In case of lack of suitable surgical or interventional revascularization options a spinal cord stimulator (SCS) can be implanted achieving pain reduction and microcirculatory improvement. The goal of our study was to determine factors influencing long term amputation free survival in SCS-implanted vasculopathic patients.

Methods: Between December 1998 and July 2015 52 patients considered unsuitable for revascularization underwent SCS implantation (mean age 67.7 ± 9.2 years; 38 men, 14 women). All procedures were performed under local anesthesia using electrodes placed into the thoracic epidural space and connected to a programmable stimulation device located in the subcutaneous tissue of the buttock or lateral abdominal wall. Surgical data including follow up information were collected prospectively in a dedicated vascular database. The impact of influencing factors was calculated retrospectively. The primary endpoint was survival without major limb amputation (thigh or lower limb). Follow-up time was up to 15.9 years with a mean of 5.8 years. The following factors were examined: age, gender, diabetes, stage of peripheral artery disease (PAD), determining their influence on amputation free survival using Kaplan-Meier curves and Cox regression analysis using SPSS 22. Significance was considered by a p value less than 0.05.

Results: Mean amputation free survival (AFS) was 6.7 years (95% CI 5.1 to 8.3). Patient age was a significant factor on AFS (p = 0.01). AFS in patients aged under 70 was 7.7 years (5.5 to 9.8), in patients above 70 5.2 years (3.3 to 7.2). Gender was a significant factor on AFS (p = 0.01). Mean AFS in male patients was 5.3 years (3.6 to 6.9), in female patients 9.6 years (7.3 to 12.0). Stage of PAD was not a significant factor on AFS (p = 0.20), nor was presence of diabetes (p = 0.26).

Conclusion: Two factors revealed significant differences in amputation free survival: age at implantation and gender. Older patients in general have shorter life time expectancy thus better results for younger patients were conceivable. A distinct longer limb salvage rate in women was unexpected. Subgroup analysis revealed age equally distributed for both men and women thus male sex and age above 70 are risk factors for shorter AFS. Despite the primarily high costs of the SCS implantation this method shows to be an effective tool for long term limb salvage in highly selected patients suffering from CLI not suitable for revascularization. Evaluation of CLI patients for SCS implantation in dedicated centers should be offered to more patients preventing major amputations, especially in women.

Copenhagen, Denmark • 28-30 September 165

Poster Presentations

PO 032 RESULTS OF COMPLETE FOLLOW-UP AT 2 YEARS OF HEPARIN-BONDED PTFE BELOW-KNEE FEMORO-POPLITEAL BYPASS IN PATIENTS WITH CRITICAL LIMB ISCHEMIA IN A MULTICENTRIC REGISTRY

Instituion: 1. Vascular Surgery, University of Insubria, Varese, Italy 2. Vascular Surgery, Unversity of Bari, Bari, Italy 3. Vascular Surgery, University of Florence, Florence, Italy

Authors presenting: Paolo Ottavi, Walter Dorigo, Gabriele Piffaretti, Raffaele Pulli, Patrizio Castelli, Carlo Pratesi

Introduction: Aim of the study was to evaluate 2-year results of below-knee femoro-popliteal bypass with heparin bonded ePTFE graft performed in patients with critical limb ischemia after the assessment of follow- up completeness in a multicentric registry

Methods: Over a thirteen year period, ending in March 2015, a heparin bonded prosthetic graft (HbePTFE; Propaten Gore-Tex®, W.L. Gore & Associates Inc, Flagstaff, AZ) was implanted in 683 patients undergone below-knee (BK) revascularization for critical limb ischemia in seven Italian hospitals. Data concerning these interventions were collected in a multicenter registry with a dedicated database. Follow-up was performed within the third postoperative month, at 12 months and then yearly and consisted of clinical examination, ankle-brachial index (ABI) measurements, and graft duplex exam. To have a group of patient with a complete 2-year follow-up (follow-up index equal to 1) we excluded from the analysis all the patients who had a follow-up time shorter than 24 months and did not have any event during those two years; the remaining 574 patients formed our study group (84% of patients with CLI and BK bypass). The analysis of follow-up events in those patients was stopped at 24 months and the results were reported in terms of primary (the possibility to maintain a functioning graft without adjunctive interventions) and secondary (the possibility to restore graft patency when a thrombosis occurred) graft patency, limb salvage (the absence of amputation at above-knee or below-knee level) and amputation-free survival (freedom from above the ankle amputation and from all-cause mortality) with Kaplan-Meier curves and life-table analysis.

Results: Primary intervention was performed in 423 patients, whereas the remaining 176 had a reintervention following a ipsilateral previous open or endovascular procedure. Critical limb ischemia was present in all the cases; 292 (49%) patients had a Rutherford’s class 4 ischemia, while 222 (37%) and 85 (14%) patients had a class 5 and 6 ischemia, respectively. Two-hundred and eighty-three (47%) patients had more than one patent outflow vessel, while the remainders had only one patent tibial vessel. Median duration of follow-up was 24 months (range, 0-24). During follow-up, 90 deaths, 77 thromboses and 47 amputations occurred. Estimated 2-year survival rate was 78.9% (SE 0.02); the corresponding figures in terms of primary and secondary patency were 74.2% (SE 0.02) and 80.5% (SE 0.025). Limb salvage rate at 2 years was 85.5% (SE 0.02), while amputation-free survival was 69.2% (SE 0.02).

Conclusion: In a large cohort of patients with CLI operated on with HBePTFE bypass graft, complete follow-up results at 2 years showed excellent outcomes of the indexed graft, with rates of patency and limb salvage well comparable with those reported in Literature with the use of autologous materials

Copenhagen, Denmark • 28-30 September 166

Poster Presentations

PO 033 CONTEMPORARY MANAGEMENT AND OUTCOME AFTER LOWER EXTREMITY FASCIOTOMY IN VASCULAR SURGERY

Institution: Karolinska Institutet, Stockholm, Sweden

Authors Presenintg: Carl Magnus Wahlgren, Charlotte Wesslén

Introduction: Acute compartment syndrome (ACS) is a challenging and recognized complication to vascular surgery revascularizations. It can cause significant morbidity if not treated early. There is a lack of current outcome data after lower extremity fasciotomy. The aim of this study was to investigate the epidemiology, management and early outcomes of fasciotomy in vascular surgery.

Methods: Retrospective cohort study of all patients who have undergone lower extremity fasciotomy at a single university centre between January 2008 and December 2014. Patient demographics, operative techniques, and outcomes were analysed. All fasciotomies that were performed as a single surgery were defined as therapeutic. If the fasciotomy was performed in combination with revascularisation, it was defined as prophylactic, unless clearly specified as therapeutic in the medical records.

Results: The cohort (n = 113 limbs; 108 patients; 50% women; mean age was 74±12 years [range 50-97 years]) included 84 limbs undergoing revascularization for acute limb ischemia, 10 limbs related to acute aortic disease (dissection n=3; ruptured abdominal aortic aneurysm n=4; thrombosed aorta n=3), and 19 limbs elective vascular surgery. Five patients underwent bilateral lower extremity fasciotomy. Sixty-four (57%) limbs had signs of ACS and underwent a therapeutic fasciotomy, while 49 (43%) fasciotomies were prophylactic. After endovascular interventions there were 22 (19%) therapeutic fasciotomies performed. A four-compartment fasciotomy was performed in 82% (n=93) of limbs with a double incision technique. The shoelace technique for gradual skin closure was used in 109 limbs (96%). Split thickness skin graft was required in 10.8% and vacuum-assisted closure treatment in 10.7%. Complications included haemorrhage and reoperation 6.2%, dialysis 16%, intensive care unit admission 26%, 30-day wound infection 30%, and signs of lower extremity nerve deficit 32%. The mean length of stay in hospital was 11±9.1 days. At 30-day follow-up, the amputation rate was 13% (14/107 limbs) and mortality 23% (25/108 patients).

Conclusion: Compartment syndrome is primarily related to acute ischaemic conditions. Endovascular treatment followed by fasciotomy is increasingly common. There are significant complications related to lower extremity fasciotomy in vascular surgery.

Copenhagen, Denmark • 28-30 September 167

Poster Presentations

PO 034 ENDOVASCULAR-FIRST APPROACH FOR MANAGEMENT OF INFRA-INGUINAL ARTERIAL DISEASE: PREDICTORS OF OUTCOME

Institution: Vascular Surgery, St James's Hospital, Dublin, Ireland

Authors presenting: Elrasheid A. H. Kheirelseid, Sophia Angelov, Ahmed Elmallah, Adrian O'Callaghan, Zenia Martin, Sean M. O'Neill, Mary Paula Colgan, Prakash Madhavan

Introduction: Endovascular treatment of peripheral arterial disease offers a lower morbidity compared to surgical bypass, at the expense of limited durability. Despite technical and device evolution, specific subpopulations respond poorly to angioplasty. We sought to assess the outcomes of infra-inguinal angioplasty and to identify factors associated with early failure.

Methods: A prospectively maintained database was used to identify patients undergoing angioplasty between 2000 and 2015. Regression analysis was performed to determine predictors of outcome, using SPSS.

Results: 1713 procedures were performed on 1356 limbs in 1195 patients. 62.4% were male. Mean age 72.5± 10.9 years.41% had coronary artery disease and 15.4% renal disease. Median follow up was 20 months (IQ range 4.01 -55.5). Indications were; acute ischemia (4.6%), claudication (27%) and critical ischemia (68.4%). Technical success rate was 91.1%. The 30-day mortality was 3.2%. Primary and secondary patency at 20 months was 69.5% and 86.9%, respectively, and reintervention required in 21.4%. Predictors of early failure identified in the study included intervention for critical ischemia (p<0.001), poor run-off (p<0.001) and C and D TASC II groups (p=0.001). In addition, amputation was predicted by old age (p=0.018), poor run-off (p<0.001) and TASC C (p=0.048).

Conclusion: Factors predicting success in infra-inguinal intervention are similar to those required for successful bypass, although with a low morbidity rate in what is a high risk patient population. An endovascular first strategy is an acceptable management strategy for this patient group

Copenhagen, Denmark • 28-30 September 168

Poster Presentations

PO 035 GUTTER SIZE AND MIDTERM OUTCOMES AFTER ENDOVASCULAR ANEURYSM REPAIR WITH THE CHIMNEY GRAFT PROCEDURE

Intitution: 1. Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands 2. Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy 3. Thoracic Aortic Research Center, Policinico San Donato IRCCS, San Donato Milanese, Italy

Authors presenting: Hector W. de Beaufort, Elena Cellitti, Quirina M. de Ruiter, Michele Conti, Frans L. Moll, Santi Trimarchi Constantijn E. Hazenberg, Joost A. van Herwaarden

Introduction: We describe our experience with endovascular aneurysm repair (EVAR) with the use of chimney grafts for visceral aortic branch preservation.

Methods: Patients treated with a chimney graft procedure at University Medical Center Utrecht between October 2009 and May 2015 were included for analysis. Patients who were not considered eligible for open surgical repair nor for conventional, branched or fenestrated endovascular repair were selected. A standardized operating procedure with left brachial or axillary artery cut-down access for the chimney grafts and bilateral femoral artery cut-down access for the aortic main device was used. Outcomes were noted according to the Society for Vascular Surgery reporting standards. Additionally, evolution of gutter size over time was determined. Estimated rates of survival, freedom from aneurysm growth, and clinical success at 24-months follow-up were calculated.

Results: Thirty-three patients (mean 77.1±6.9 years, 87.9% male) with a mean preoperative maximum aneurysm diameter of 71.7±13.5 mm were included. A total of 54 out of an intended 54 chimney grafts were deployed. Primary technical success and thirty-day secondary clinical success rates were 87.9% and 84.8%, respectively. Initial outcomes included two postoperative deaths (6.1%), two type Ia endoleaks (6.1%), and two patients with a chimney graft occlusion (6.1%). Median follow-up duration was 20 months (interquartile range 6.5 – 33.5 months). During follow-up, three aneurysm- related deaths (9.1%), one case of type Ib endoleak (3.0%), two cases of chimney graft thrombosis (6.1%), one distal stent graft limb occlusion (3.0%), one stent graft infection (3.0%), and one case of bowel ischemia (3.0%) occurred. Six patients (18.2%) underwent a total of eight late reinterventions; distal limb extension (6.1%), coil/glue embolization (6.1%), Palmaz stent placement (3.0%), repeat EVAR (3.0%), femoro-femoral bypass (3.0%). Gutter size decreased in 95% of patients. At 24 months, estimated survival rate was 75.4% (SE±8.2%), estimated secondary clinical success rate was 72.0% (SE±8.7%), and estimated freedom from aneurysm growth was 79.5% (SE±8.3%).

Conclusion: Endovascular aneurysm repair with a chimney procedure offers good short- and midterm outcomes in high-risk patients. Gutter size decreases over time and type Ia endoleak and chimney graft thrombosis rates are low, but other concerns about long-term durability remain unanswered. The chimney procedure should remain reserved for those patients for whom there is no alternative treatment option until long-term outcomes become known.

Copenhagen, Denmark • 28-30 September 169

Poster Presentations

PO 036 BRANCHED ENDOVASCULAR AORTIC REPAIR FOR THORACOABDOMINAL AORTIC ANEURYSMS TREATED BY SINGLE STEP OR OPEN BRANCH STAGED PROCEDURES: PREVENTION OF SPINAL CORD AND MESENTERIC ISCHEMIA.

Institution: Department of Vascular Surgery and Endovascular Surgery, University Hospital Regensburg, Regensburg, Germany

Authors presenting: Reinhard Kopp, Beatrix Cucuruz, Konstantinos Gallis, Karin Pfister, Markus Janotta, Piotr M. Kasprzak

Introduction: Branched endovascular aortic repair (BEVAR) has become an accepted option for treatment of thoracoabdominal aortic aneurysms (TAAA). Staged procedures with temporary aneurysm sac perfusion (TASP) was shown to reduce the risk of spinal cord ischemia in patients with extended aortic aneurysmal disease. However, further results on perioperative outcome, analysis of organ function, neurologic complications and follow-up data are required.

Methods: Patients with TAAA were treated with branched EVAR between 09/2007 and 09/2015 using a single step or open branch staged procedure with temporary aneurysm sac perfusion. Non-completed side branches were completed after 1-12 months. Postoperative spinal cord motor dysfunction was classified according to the Tarlov scale and mesenteric ischemia was defined as laparotomy for suspected or proven intestinal malperfusion.

Results: 114 patients were treated with BEVAR, 46 without an aneurysm sac perfusion (single-step) and 68 with open branch and TASP. In 7 Patients the open branch was not completed for various reasons. Technical success, duration of intervention, contrast volume and the rate of early reinterventions were similar in both groups. The combined number of days on the intensive care unit and the hospital stay was longer in the staged open branch group. The risk of paraplegia was reduced in the open branch TASP group (4.9 %) in comparison to the single step group (26 %, p<0.001). Intestinal malperfusion requiring laparotomy was observed in 9 patients (7.9 %), with small bowel or colon resections in eight patients. Mesenteric ischemia with intestinal resection was more frequently observed in the single step group (15.2 % vs 1.6 %, p=0.010). Perioperative mortality was similar in both groups (8.7 % vs 7.3 %), including one patient (1.6 %) who died during the open branch interval.

Conclusion: Staged procedures using the open branch concept with temporary aneurysm sac perfusion seem to improve outcome after branched EVAR for TAAA.

Copenhagen, Denmark • 28-30 September 170

Poster Presentations

PO 037 IN SITU ANTEROGRADE LASER FENESTRATIONS DURING ENDOVASCULAR REPAIR FOR AORTIC ANEURYSM

Institution: Department of vascular surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France

Authors presenting: Dominique Fabre, Sarah Hamdi, Philippe Brenot, Carlos Garcia Alonso, Claude Angel, Elie Fadel

Introduction: We report the technique and preliminary outcomes of a Laser fenestrated Endograft (LfEVAR) developed as an emergency procedure for Thoraco abdominal Aortic Aneurysm (TAAA) or Pararenal Aortic Aneurysm (PAAA).

Methods: We select patients with TAAA and PAAA unfit for open surgery that could not wait for Custom Made Device. LfEVAR is a physician-modified technique requiring sequential steps. After a preliminary stenting of each visceral and renal artery, a standart stentgraft is deployed in the aorta. Laser fenestration is performed using a steerable stable sheath positioned in the stentgraft lumen in front of each visceral artery ostia. After progressive dilation of the laser fenestration, bridging stents are placed and flared to insure accurate perfusion of the visceral arteries.

Results: During 2015, we performed 89 endovascular Aortic repair. Only 7 patients were treated using LfEVAR as an emergency procedure. Two Crawford type V TAAA, and 5 PAAA were treated using a LfEVAR. Laser fenestration and patency of all visceral arteries was successfully achieved in all cases for 6 man. There were no fenestration-related complications. A secondary procedure, at one week, was required to treat a type III endoleak between the two thoracic grafts. CT scan control at 3 and 6 months were satisfactory, without any endoleak.

Conclusion: In situ anterograde LfEVAR is a feasible and effective option for emergency procedure for patients unfit to open surgery. Longer follow-up is required to determine the durability of this technique

References: Georgiadis GS, van Herwaarden JA, Antoniou GA, et al. Systematic Review of Off-the-Shelf or Physician-Modified Fenestrated and Branched Endografts. J Endovasc Ther.2015 Oct 23. Redlinger RE Jr Ahanchi SS, Panneton JM, et al. In situ laser fenestration during emergent thoracic endovascular aortic repair is an effective method for left subclavian artery revascularization. J Vasc Surg. 2013 Nov;58(5):1171-7 Murphy EH, Dimaio JM, Dean W, et al. Endovascular repair of acute traumatic thoracic aortic transection with laser-assisted in-situ fenestration of a stent-graft covering the left subclavian artery. J Endovasc Ther 2009;16:457-63. Ahanchi SS, Almaroof B, Stout CL, et al. In situ laser fenestration for revascularization of the left subclavian artery during emergent thoracic endovascular aortic repair. J Endovasc Ther 2012;19: 226-30.

Copenhagen, Denmark • 28-30 September 171

Poster Presentations

PO 038 MORPHOLOGY OF THE DISSECTED AORTA PREDICTS EARLY AND LATE ADVERSE OUTCOME AFTER TEVAR IN ACUTE COMPLICATED TYPE B AORTIC DISSECTION

Institution: 1. Department of Surgery, Stockholm South Hospital, Stockholm, Sweden 2. Karolinska University Hospital, Department of Vascular Surgery, Stockholm, Sweden 3. Department of Radiology, Stockholm South Hospital, Stockholm, Sweden 4. Karolinska University Hospital, Department of Thoracic Surgery, Stockholm, Sweden

Authors presenting: Christian Smedberg, Rebecka Hultgren, Martin Delle, Linus Blohmé, Christian Olsson, Johnny Steuer

Introduction: During the last decade, Thoracic EndoVascular Aortic Repair (TEVAR) has revolutionized the management of patients with acute complicated type B aortic dissection, as survival of these patients has improved dramatically. However, there is still controversy as to whether or not to offer TEVAR to patients who present without acute complications, and, if so, when to treat. Lately, the dynamic course of aortic dissection during the first weeks-months has been characterized, and the period from two weeks until three months after the acute onset has been described as the sub-acute phase. The focus has now shifted to identifying morphological predictors that may aid in deciding who and when to treat. The aim of the study was to analyze early and late outcome in patients undergoing TEVAR for acute/sub-acute non-traumatic type B aortic dissection, with the particular aim to identify prognostic morphological characteristics.

Methods: The study group consisted of 53 patients who underwent TEVAR for complicated acute/sub-acute dissection during the 12-year period 2004-2015. As endovascular aortic interventions are centralized in Stockholm to two major hospitals, and open surgical repair of the thoracic aorta is further centralized to one of the centers, the patients thus comprised all cases treated in Stockholm, with a clearly defined catchment area. No patient underwent open surgical repair. Demographic data, pre- and intra-operative variables, as well as early and late outcome were registered. The CT scan upon which the decision to implant the aortic stentgraft was made was retrospectively thoroughly examined with respect to plausible morphological features related to the outcome.

Results: The incidence of the use of TEVAR increased from 0.1/100,000 in 2004 to 0.3/100,000 in 2014. Of the 53 patients, nearly half (24 patients; 45%) underwent TEVAR within 48 h after onset of symptoms, another 20 within the first two weeks, and nine were treated in the sub-acute phase. Median age was 63 years (range, 32-88) and roughly two thirds (34 patients; 62%) were men. The predominant indication for TEVAR was malperfusion (24 patients; 45%), followed by (imminent) rupture (9 patients; 17%). Ten patients with malperfusion required branch-vessel stenting in addition to TEVAR. The 30-day mortality was 17% (nine patients). Eight of the nine patients were treated within the first 48 h; TEVAR in that phase was found to be associated with impaired outcome (crude OR 14.0, 95% CI 1.6-122; p=0.007) as was branch-vessel stenting (crude OR 9.8, 95% CI 2.0-49; p=0.008). All the nine patients dying within 30 days hade a false lumen area at the level of the tracheal bifurcation exceeding 50%, a finding significantly associated with increased mortality (p=0.04), rendering 25% 30-day mortality in case of false lumen area >50% (n=36) at that segment, compared to 0 if the false lumen area was <50% (n=17 patients). Moreover, a maximum aortic diameter >40 mm was related to an increased probability of endoleak (p=0.021). One-year survival was 79%, five-year survival 65%.

Conclusion: The outcome was dramatically impaired in patients undergoing TEVAR within 48 h, and all the early deaths demonstrated a false lumen area >50% of the total aortic cross sectional area at the level of the tracheal bifurcation. The latter finding may become an important tool for future risk stratification of patients considered to have a primarily uncomplicated aortic dissection, in order to categorize the patients into low- and high-risk groups, respectively, as to the risk to develop acute complications, necessitating TEVAR.

Copenhagen, Denmark • 28-30 September 172

Poster Presentations

PO 039 ANALYSIS OF ACUTE KIDNEY INJURY AND CHRONIC KIDNEY DISEASE AFTER TAAA REPAIR WITH BRANCHED STENTGRAFTS

Institution: Department of Vascular Surgery and Endovascular Surgery, University Hospital Regensburg, Regensburg, Germany

Authors presenting: Beatrix Cucuruz, Piotr M. Kasprzak, Konstantinos Gallis, Karin Pfister, Lucian Costin, Reinhard Kopp

Introduction: Postoperative acute or chronic renal dysfunction might have relevant impact on patient's outcome after complex endovascular aortic repair. The aim of this study is to investigate the incidence of acute kidney injury (AKI) and chronic kidney disease (CKD) after aortic aneurysm repair with branched stentgrafts (BEVAR).

Methods: Between 07/2007-03/2015 a total of 104 patients underwent thoracoabdominal aneurysm (TAAA) repair with standard or custom-made BEVAR. 52/104 patients received staged procedure with open branch temporary aneurysm sack perfusion for SCI prevention. Serum creatinine and glomerular filtration rate at baseline, during 48 h following BEVAR, at discharge, after one and two years and at last follow-up were evaluated. Branch patency was assessed by ultrasound and CTA.

Results: AKI occurred postoperatively in 42/104 (40%; preoperative creatinine 1.27±0.08 mg/dl; GFR 63.2±3.7; after 48 h, creatinine 2.2±1.6 mg/dl, p<0.001; GFR 34.7±2.9; p<0.001) with recovery until discharge in 24/42 (57%) patients. Nevertheless, 18/42 (42%) had progression of CKD and 6 patients needed permanent dialysis. After two years CKD increased in 12 patients compared to discharge, 7 (58%) of them have had postoperative AKI. Postoperative AKI is a significant risk factor for CKD after BEVAR (p=0.01). Risk factors for postoperative AKI were renal branch stenosis, embolism or dissection as a composite parameter (p=0.02) and single step procedures (p=0.016). Patients with CKD stage 4 and 5 had the highest perioperative mortality with reduced survival during follow up (median 6 months, p=0.008).

Conclusion: Postoperative AKI is a significant risk factor for CKD after TAAA repair with BEVAR. Staged procedures diminish the incidence of postoperative AKI and might prevent the development of CKD after BEVAR.

Copenhagen, Denmark • 28-30 September 173

Poster Presentations

PO 040 FEASIBILITY AND OUTCOMES OF LOCAL ANAESTHESIA FOR ENDOVASCULAR REPAIR OF RUPTURED ABDOMINAL AORTIC ANEURYSMS.

Institution: 1. St George's Hospital, Vascular Institute, London, United Kingdom 2. Anaesthetics, North Bristol NHS trust, Bristol, United Kingdom 3. St George's Hospital, Vascular Institue, London, United Kingdom 4. University of Bristol, Bristol, 5Vascular Institute, St George's Hospital, London, United Kingdom

Authors presenting: Jorg L. De Bruin, Ronelle Mouton, Jack Brownrigg, Simon Howell, Robert J. Hinchliffe

Introduction: Endovascular aneurysm repair (EVAR) is the procedure of choice for elective surgery for abdominal aortic aneurysm and is being used increasingly for ruptured AAA (rAAA). Post-hoc analysis of the IMPROVE trial observed a lower 30-day mortality with LA in emergency EVAR.1 It remains to be established whether LA is a feasible technique for rAAA, how commonly it is being used and what the outcomes are. The aim of this study was to assess feasibility and outcomes of local anesthesia during endovascular treatment of rAAA using real world data from the United Kingdom National Vascular Registry (NVR).

Methods: We compared data from the NVR for patients treated with EVAR for rAAA according to anaesthesia type. The primary outcome was 30-day mortality. Length of stay and postoperative complications were also evaluated.

Results: In 2014, 267 patients with a rAAA were treated with EVAR in 57 hospitals in the UK. One hundred and twenty two patients (45.7%) underwent EVAR under LA, 19 patients (7.1%) under regional anesthetic (RA) and 126 patients (47.2%) under general anesthesia (GA). Patient characteristics, ASA class, cardiovascular risk factors and aortic morphology were similar between the three groups. No statistically significant difference in 30-day mortality was observed between treatment groups (Figure 1). Mean Length of Stay (LOS) was also similar among the three groups; LA 12.8 days (95% CI 10.2-15.3) vs RA 14.3 days (95% CI 6.3-22.3) vs GA 13.1 days (95% CI 10.1-16.1), (p-value 0.922). There were also no significant differences in complications or the distribution of the number of complications. 28 of the patients had one complication in the LA group (23.0%), 3 patients in the RA group (15.8%) and 24 patients (19.0%) in the GA group (p=0.795) (Table 1). Image:

Copenhagen, Denmark • 28-30 September 174

Poster Presentations

Conclusion: The use of LA for endovascular aneurysm repair for rAAA is widespread, although it is not Universally used. LA is safe with comparable 30-day mortality and outcomes when analysing the prospectively collected data from the NVR.

References: Powell JT, Hinchliffe RJ, Thompson MM, Sweeting MJ, Ashleigh R, Bell R, Gomes M, Greenhalgh RM, Grieve RJ, Heatley F, Thompson SG, Ulug P. Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm. IMPROVE trial investigators, Br J Surg.101 (3): 216-24; 2014.

Copenhagen, Denmark • 28-30 September 175

Poster Presentations

PO 041 EVAR: AORTA-UNI-ILIAC ENDOGRAFT, 10 YEARS EXPERIENCE

Institution: Laboratoire de traitement de l'information médicale - LaTIM, INSERM- U1101, Vascular surgery, Cardiac surgery, CHU Cavale Blanche, Brest, France

Authors presenting: Bahaa Nasr, Benedicte Albert, Charles-Henri David, Ali Badra, Jacques Braesco, Pierre Gouny

Introduction: Treatment with aorta-uni-iliac endograft is often mentioned in heterogeneous studies mixing any type of graft used in the endovascular abdominal aortic aneurysms repair (EVAR). The aim of this tudy is to describe the aorto-uni-iliac endograft long-term results and primarily to evaluate the impact of a femoral-femoral bypass on the patient’s follow-up.

Methods: Seventy-two patients were treated by aorto-uni-iliac endograft + femoral-femoral bypass between January 2003 and December 2014. A retrospective analysed was performed from a prospectively maintained database. Follow-up included clinical examination and computed tomography scan at 1, 6 months and yearly thereafter

Results: The patients were mostly male (70%) with a mean age of 76± 8 years old. Twenty patients (28%) were treated for acute ruptured aneurysm. The mean follow-up was of 61 months. Technical success was of 98,6%. Seventeen major complications were reported in 14 patients (1 abdominal compartment syndrome, 2 myocardial infarction, 1 postoperative haemorrhage, 5 stroke, 5 digestive ischemia and 3 limb ischemia). Fifteen patients presented postoperative renal failure of which 4 were dialysed. The rate of perioperative mortality was of 9,7% (n=7). Overall survival rate was of 82%, 71% and 48% at 1, 5 and 10 years respectively. Freedom from re-intervention rate was 89%, 70% and 54% at 1, 5 and 10 years respectively. The freedom from re-intervention related to femoral- femoral bypass complications rate was 95%, 89% and 81% at 1, 5 and 10 years respectively. Femoral-femoral bypass primary patency rate was 97% at 1 year, 90% at 5 years and 82% at 10 years.

Conclusion: The use of an aorto-uni-iliac endograft avoids the catheterization problems and minimizes radiation exposure during EVAR procedures. In our study, the femoral-femoral bypass, accused of being the weak point of this technique, does not increase the complications risk or the rate of re-intervention.

Copenhagen, Denmark • 28-30 September 176

Poster Presentations

PO 042 TYPE II ENDOLEAK PREVENTION BY INFERIOR MESENTERIC ARTERY EMBOLIZATION DURING ENDOVASCULAR ANEURYSM REPAIR IN HIGH RISK PATIENTS

Institution: Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan

Authors presenting: Makoto Samura, Noriyasu Morikage, Yuriko Takeuchi, Takasuke Harada, Osamu Yamashita, Kotaro Suehiro, Kimikazu Hamano

Introduction: Type II endoleak (ELII) is considered to be associated with an increased incidence of adverse outcomes after endovascular aneurysm repair (EVAR), such as aneurysm sac enlargement and a need for reintervention. When ELII occurs, treatment is considered difficult. Therefore, it is important to ensure good results from EVAR so ELII is prevented, rather than treating it when it occurs. The aim of this study was to evaluate whether inferior mesenteric artery (IMA) embolization during EVAR in patients with morphological risk factors is an effective method of preventing postoperative ELII.

Methods: Between September 2014 and April 2016, 140 patients underwent standard EVAR. As identified in our previous study, the vascular morphological characteristics of patients considered to have a high risk of ELII are as follows: (1) patency of the IMA with a luminal diameter at the origin ≥ 3mm, (2) patency of the IMA (also < 3 mm) and at least 1 lumbar artery with a diameter ≥ 2 mm, and (3) patency of the IMA (also < 3mm) and aortoiliac-type aneurysm. Based on preoperative evaluation of this criteria, 68 patients were defined as having high risk for ELII and randomly assigned to group A (EVAR with IMA embolization; n=31) or group B (EVAR without embolization; n=32). The remaining 72 patients were defined as having low risk for ELII (group C). Computed tomographic (CT) angiography and color duplex ultrasound imaging were performed before discharge, and at 3, 6, and 12 months after EVAR to evaluate ELII and assess aneurysmal diameter.

Results: Technical success of IMA embolization was 90.3% (3/31) in group A, with no complications occurring related to the procedure. Operation time (186.0 minutes [range, 107-482] vs. 166.5 minutes [range, 102-439], respectively; P= .23), fluoroscopic time (53.6 minutes [range, 25.4-151.2], vs. 53.1 minutes [range, 21.9-181.3], respectively; P= .44), and volume of contrast dye (49.4 ml [range, 15-120] vs. 43.0 ml [range, 20-150], respectively; P= .77) were similar for groups A and B. The median follow- up period was 5.7 months (range, 0.1–15.5 months). Postoperative ELII frequency was significantly lower in group A compared to group B (10.3% [3/28] vs. 40.6% [13/32]; P=.009). Patients in group C had the lowest ELII rate compared to groups A and B (4.2% [3/72]). The frequencies of aneurysm sac shrinkage ≥ 5 mm (17.8% [5/28] vs. 6.3% [2/32], respectively) were similar in groups A and B. There was no expansion ≥ 5mm of any aneurysm sac and no ELII-related reintervention needed in both groups during the follow-up period.

Conclusion: This randomized study confirms that IMA embolization during EVAR for patients at high risk for ELII is a feasible, safe, and effective method for preventing ELII during the early follow-up period. Further studies are needed to support similar results at long-term follow-up.

Copenhagen, Denmark • 28-30 September 177

Poster Presentations

PO 043 BIOMECHANICAL CHANGES DURING ABDOMINAL AORTIC ANEURYSM GROWTH

Institution: 1. Eindhoven University of Technology, Eindhoven, Netherlands, 2. KTH Royal Institute of Technology, Stockholm, Sweden, 3. The Johns Hopkins University, Baltimore, United States, 4. Karolinska University Hospital and Institute, Stockholm, Sweden

Authors presenting: T.Christian Gasser, Raoul Stevens, Andrii Grytsan, Jacopo Biasetti, Moritz Lindquist Liljeqvist, Joy Roy

Introduction: The maximum diameter and its expansion over time are clinically used to predict the risk of Abdominal Aortic Aneurysm (AAA) rupture. However, both indices lack the power to describe the rupture risk of individual cases. In contrast a biomechanics-based AAA rupture risk assessment allows a highly individualized analysis [1-3]. Such biomechanical indices are based on information at a single time point and currently little is known how biomechanical parameters develop over time. Consequently, the present work aims at exploring the correlation of biomechanical parameters with AAA growth.

Methods: Four patients with a total of 23 Computer Tomography-Angiography (CT-A) scans at different time points were analyzed. Patient-specific AAA geometries were segmented from CT-A images at each time point, see image (a). Finite Element (FE) calculations and Computational Fluid Dynamics (CFD) were used to predict AAA wall stress [3] and blood flow velocity [4], respectively. Geometrical and biomechanical parameters were extracted, and statistical correlations amongst them explored.

Results: The image below illustrates typical computational results. (b) Rupture risk index plot derived from the structural biomechanical analysis at Mean Arterial Pressure (MAP) loading. (c) Wall Shear Stress (WSS) distribution at t=0.4s of the cardiac cycle derived from a CFD computation. Both, structural and hemodynamical biomechanical variables correlated with (Intra-luminal thrombus) ILT volume and AAA volume growth. Strongest correlations with baseline properties were seen between ILT volume and the minimum scalar shear rate of blood (-0.845), the maximum WSS (-0.757) and the biomechanical rupture risk (0.693). Strongest correlations with growth properties were seen between AAA volume growth and the maximum WSS (-0.654), the minimum scalar shear rate of blood (- 0.636), and the biomechanical rupture risk (0.589).

Image:

Conclusion: Specifically, the strong positive correlations of biomechanical risk with ILT volume as well as AAA volume growth indicate that these parameters may be related to AAA rupture risk. Previously a similar conclusion has been drawn from analyzing purely clinical data [5]. Consequently, the suitability of monitoring ILT volume and AAA volume growth as additional risk indictors should be explored in larger studies.

Copenhagen, Denmark • 28-30 September 178

Poster Presentations

References: [1] Fillinger MF, Raghavan ML, Marra SP, Cronenwett J-L, Kennedy FE. In vivo analysis of mechanical wall stress and abdominal aortic aneurysm rupture risk. Journal of Vascular Surgery. 2002; 36:589-597. [2] Vande Geest JP, Martino ES, Bohra A, Mackaroun MS, Vorp DA. A biomechanics-based rupture potential index for abdominal aortic aneurysm risk assessment: demonstrative application. Ann N Y Acad Sci 2006; 1085: 11–21. [3] T.C. Gasser, A. Nchimi, J. Swedenborg, J. Roy, N. Sakalihasan, D. Böckler, A. Hyhlik-Dürr. A novel strategy to translate the biomechanical rupture risk of abdominal aortic aneurysms to their equivalent diameter risk: Method and retrospective validation. Eur. J. Vasc. Endovasc. Surg. 2014; 47:288-95. [4] Jacopo Biasetti, Fazle Hussain, and T Christian Gasser. Blood flow and coherent vortices in the normal and aneurysmatic aortas: a fluid dynamical approach to intra-luminal thrombus formation. Journal of The Royal Society Interface, page rsif20110041, 2011. [5] Stenbaek J, Kalin B, Swedenborg J. Growth of thrombus may be a better predictor of rupture than diameter in patients with abdominal aortic aneurysms. European Journal of Vascular and Endovascular Surgery. 2000; 20:466-499.

Copenhagen, Denmark • 28-30 September 179

Poster Presentations

PO 044 CHANGES AND REGIONAL DIFFERENCES IN THE TREATMENT OF ABDOMINAL AORTIC ANEURYSMS IN FINLAND DURING 2000-2014

Institution: Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland

Authors presenting: Matti T. Laine, Sani Laukontaus, Pekka S. Aho, Ilkka Kantonen, Anders Albäck, Maarit Venermo

Introduction: Abdominal aortic aneurysms (AAA) have up to 80% mortality in the case of rupture. Surgical treatment of AAA has changed significantly during the recent decades from open surgery to endovascular aneurysm repair (EVAR). This has reduced surgical mortality and allowed for surgery also on patients with significant comorbidities. During the study period secondary health care in Finland was organized by 20 hospital districts (excluding Åland Islands), each with a central hospital as a referral center treating AAA. Five university hospitals provided tertiary services for the hospital districts and also served as central hospitals for their own districts. All central hospitals and university hospitals performed open surgery (OS), EVAR was performed only in university hospitals. Our goal was to look at the differences between regions of Finland in the treatment of AAA.

Methods: This was a registry-based retrospective study. Data on all patients treated for either ruptured or nonruptured AAA in all Finnish hospitals during 2000-2014 came from the Care Register for Health Care (HILMO) of the National Institute for Health and Welfare (THL).

Results: There were 6927 operations for AAA from 2000 to 2014. There was a clear increase in the number of operations, 2038 during 2000-2004, 2344 during 2005-2009 and 2545 during 2010-2014. The number of operations for RAAA was steady (mean 108/year, range 86-118), but operations for nonruptured AAA increased from 1509 during 2000-2004 to 2010 during 2010-2014. During the first five-year period 14% of nonruptured aneurysms were treated by EVAR and during the last period 41%. Mean age of patients was 72.2 years, 71.6 for men and 76.3 for women. EVAR patients were older than OS patients, 75.5 vs 71.0. Patient age increased during the study period, 2000-2004 mean age was 70.7, 2005-2009 72.5 and 2010-2014 73.2. The proportion of patients operated at central hospitals as opposed to university hospitals decreased from 34% to 25% for nonruptured AAA and from 39% to 30% for RAAA. The number of operation for nonruptured AAA per 100 000 inhabitants per year varied across Finland, from 4.5 in Helsinki and Uusimaa hospital district to 9.8 in Lapland hospital district. The lowest number of RAAA operations were performed for patients living in South Ostrobothnia hospital district, 1.3, and highest in Itä-Savo hospital district, 4.2. The number of patient treated by EVAR differed considerably between hospital districts (see Figure) as did the proportion of RAAA operations to nonruptured AAA operations. In Itä-Savo 1.89 nonruptured AAA were operated for every RAAA compared to 5.59 in Central Ostrobothnia. In South Karelia only 3% of nonruptured AAA were referred to other hospitals as opposed to 77% in Itä-Savo.

Copenhagen, Denmark • 28-30 September 180

Poster Presentations

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Conclusion: There were large regional differences in the treatment of AAA. The proportion of patients treated by EVAR has increased significantly during the past 15 years, but this change has not been uniform across the country. In some hospital districts a patient’s chance to get EVAR was low as almost all patients were treated by OS. The shift towards EVAR is likely the reason for increasing age of patients undergoing AAA repair. The incidence of AAA in Finland is not known as there is no national screening program. Some of the differences in the number of AAA operations is likely to be due to regional differences in incidence but other factors may contribute to these findings as well.

Copenhagen, Denmark • 28-30 September 181

Poster Presentations

PO 045 POSTOPERATIVE EVAR SURVEILLANCE – ULTRASOUND FINDINGS THAT PROMPT FURTHER INTERVENTION

Institution: Russell's Hall Hospital, Birmingham, United Kingdom

Authors presenting: Elizabeth Li, Lewis Meecham, Zahid Khan, Jeremy Newman, Michael L. Wall

Introduction: EVAR surveillance in the UK has moved to regular ultrasound scanning in place of CT to reduce; radiation exposure, reducing contrast induced kidney injury and reducing institutional costs. Our centre practices regular ultrasound surveillance with CT angiography (CTA) should more detailed information be required. Currently, there are no set guidelines of what US findings should trigger a CTA. Here, we present our experience from our surveillance programme.

Methods: A prospectively updated database documenting all EVAR follow up was interrogated for patients who had triggered a CT angiogram via either MDT decision; recommendation by the sonographer, or radiologist, or surgeon. Data spanned 4 years from a single vascular hub. Statistical analysis was performed in SPSS.

Results: 156 patients’ follow up data was examined: 37 CTA scans were necessary following us assessment. The agreement between US and CTA sac size was excellent r=0.94, p<0.0001. The mean increase in sac size on US is 7.4mm (±2.8mm SD), correlated with CTA was r=0.93 p<0.001 . When an endoleak was detected with an increase in sac size is 5.4mm (±2.3mm SD) the US vs CTA measure of increase in size correlation again is excellent r=0.98 p<0.001 and there was 73% agreement on the type of endoleak. Where a new 1a/1b was detected without an increase in sac size, the agreement between US vs CTA is r=0.92 p<0.05 and there was 86% agreemet on type of endoleak. 13 patients required CTA due to abnormal shape or unobtainable views. Of the patients who US suggested increase sac size, or new endoleak, 29% required re-intervention. There were no patients who required re-intervention was did not have an expanding sac, new leak or type 1a/1b positively identified on US prior to the re-intervention event.

Conclusion: US and CTA shows excellent agreement in assessing sac size and identifying endoleaks and US can reliably identify patient will require a re-intervention. US is a reliable, practical and safe method of surveillance for the growing population of patients being monitored post EVAR.

Copenhagen, Denmark • 28-30 September 182

Poster Presentations

PO 046 OUTCOME AFTER TURNDOWN FOR ELECTIVE AND EMERGENCY ABDOMINAL AORTIC ANEURYSM SURGERY

Instituion: Vascular, Anaesthetics, Russells Hall Hospital, Dudley, England, Birmingham, United Kingdom

Authors presenting: Joshua D. Whittaker, Lewis Meecham, Adrian Jennings, Micheal Wall, Jeremy Newman

Introduction: Abdominal Aortic Aneurysms (AAA) carry significant risk of death due to rupture. Surgical intervention, be it endovascular or open, carries a significant risk of morbidity and mortality. For some patients, the risk of surgical intervention outweighs the risk of mortality from AAA rupture and they are “turned down” for elective and emergency surgical repair. Little is known about the course of the disease in such patients.

Methods: This is a retrospective observational study of a prospectively maintained database. All patients referred to the Black Country Vascular MDT form January 2013 and turned down for AAA intervention were included. Where available; AAA size, CPET result and cause of death were collected for analysis. Statistical analysis was performed in SPSS.

Results: N=106 patients. Mean age at turndown was 84.22 years (95%CI 83.95-85.49). Mean AAA size at turndown was 65mm (CI 62.99-67.95). Median time of turndown list was 339 days (IQR 150-676). 35.8% (n=38) of the population had deceased, with a median survival time of 154 days (IQR 25- 270). Patients that were deceased had significantly larger AAA (mean 70.85, CI 66.30-75.39) compared to those surviving to date (mean 62.51, CI 59.81-65.22, P=0.004). Using Kaplan-Meier analysis, probability of 1-year survival in the whole population was 0.67 (CI 0.60-0.77). Probability of 2-year survival was 0.55 (CI 0.44-0.69). When sub-divided by axial dimension survival probability at 2 years was greatest in those with <50mm AAA (0.84) and reduced as axial dimension of AAA increased (no survivors at 2 years with AAA dimensions >90mm), although this was not significant. Of the 38 deceased patients 24 had accessible cause of death. 41.67% of these were due to ruptured AAA. There was no significant difference in AAA size between those dying of ruptures and those dying of other causes (P=0.85, mean 70.18 and 71.50mm respectively). Since the advent of CPET testing 15.5% had tests prior to turndown. Of these the median anaerobic tolerance was 8.8 (IQR 7.1-9.3) and median peak VO2 was 11.8 (IQR 10.55-13.35).

Conclusion: Being turned down for AAA repair carries a significant short term risk of mortality, although not statistically significant in this study, there is a trend to shorter survival with very large AAA (>80mm). Quantifiable CPET data suggest these patients have poor physiological reserve. This should be a consideration when assessing people with a high co-morbid burden for suitability of AAA repair.

Copenhagen, Denmark • 28-30 September 183

Poster Presentations

PO 047 ILIAC CALCIUM SCORE: A NEW PREDICTOR OF LONG-TERM MORTALITY AFTER ENDOVASCULAR REPAIR OF ABDOMINAL AORTIC ANEURYSM

Insitution: Vascular centrum, Skåne University Hospital, Malmö, Sweden

Authors presenting: Roberta Vaccarino, Mohammed Abdulrasak, Timothy Resch, Giuseppe Asciutto, Björn Sonesson, Nuno V Dias

Introduction: Abdominal aortic aneurysm (AAA) is associated with an increased mortality, mostly due to cardiovascular events. Moreover, aorto-iliac calcifications are associated with increased of mortality in patients with peripheral occlusive disease. Proper patients selection is crucial when identifying patients that will benefit from elective AAA repair. The aim of this study was to evaluate the potential association between the presence of aorto-iliac calcifications, assessed by calcium score, EVAR patients and long-term mortality, particularly caused by cardiac events.

Methods: All patients with preoperative non-contrast enhanced CT scan that underwent infrarenal EVAR of non-ruptured AAA between 2004 and 2012 at a single tertiary referral centre were included. Patients with only contrast enhanced CT scans or with metal artefacts or missed arterial segments were excluded. Retrospective chart review was done to identify preoperative co-morbidities. Postoperative mortality and cause of death were retrieved from the Swedish national population registry and hospital charts. Agatston calcium score was measured from the aortic bifurcation to common femoral arteries using a dedicated postprocessing software (TeraRecon, San Mateo, CA, USA). Values are presented as median and interquartile range in parenthesis or absolute number and percentage in parenthesis. Exact non-parametric tests were used. Survival was estimated with lifetables and log- rank test was used for comparison. Cox regression model was used to evaluate the impact of the different factors on survival.

Results: 500 patients underwent infrarenal EVAR during the study period. Of these, 294 patients with sufficient imaging quality were included (260 (88.4%) male; 74 (70-79) years old; 58 (54-77) mm AAA). 236 (80.3%) patients underwent elective EVAR of asymptomatic AAAs while the remaining were performed on acute basis for symptomatic aneurysms. Six (2.0%) patients died within 30 days of EVAR. The remaining patients were followed-up for a median of 61 (43-87) months after EVAR. Estimated overall survival at 1, 3, 5, 8 and 10 years was 97±1%, 84±2%, 72±3%, 50±4% and 33±5%, respectively. Calcium score was 8614 (4519-14264). Patients within the highest quartile of aorto-iliac calcium score had significantly lower cardiac event-free survival (estimates at 1, 5 and 10 years of 93±3%, 83±5% and 41±13% respectively) when compared to all of the remaining patients with less significant calcifications (estimates at 1, 5 and 10 years of 98±0,9%, 95±2% and 83±5%, respectively; P<0,0001, Figure 1). The effect was kept after adjusting for pre-operative age, cardiac disease, renal insufficiency and diabetes in the Cox regression model.

Figure 1 – Survival plot for patients with high Calcium score (highest quartile, solid line) and low Calcium score (1st-3rd quartiles, dashed line).

Copenhagen, Denmark • 28-30 September 184

Poster Presentations

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Conclusion: Aorto-iliac calcification assessed by calcium score independently predicts the long-term mortality after EVAR of AAA. This may potentially be helpful in the future in the risk stratification of patients with AAA.

Copenhagen, Denmark • 28-30 September 185

Poster Presentations

PO 048 NATIONWIDE ANALYSIS OF ABDOMINAL AORTIC ANEURYSM REPAIR EPIDEMIOLOGY IN SWEDEN OVER TWO DECADES

Institution: Uppsala University, Uppsala, Sweden

Authors presenting: Fredrik Lilja, Kevin Mani, Anders Wanhainen

Introduction: The epidemiology and management of abdominal aortic aneurysms (AAA) has changed drastically in the past decades, with implementation of nationwide screening programs, introduction of endovascular repair (EVAR), and reduction in prevalence of disease. This report aims to assess recent trends in AAA-repair epidemiology in Sweden in this context.

Methods: Primary AAA repairs registered in the nationwide Swedish Vascular Registry (Swedvasc) 1994-2014 were analyzed with regards to patient characteristics, repair incidence, repair technique, and outcome. Four time periods were compared; 1994-1999, 2000-2004, 2005–2009, and 2010-2014.

Results: The incidence of intact AAA (iAAA) repair increased (+48% from first to last period, p<0.001) predominantly among octogenarians (+184%, p<0.001). The utilization of EVAR increased (58% of all iAAA-repairs 2010-2014), especially among octogenarians (80% of all iAAA-repairs 2010-2014). During the last time period, however, the incidence of iAAA-repair stabilized, despite an increasing number of screening-detected AAAs operated on (19% of all iAAA repairs 2010-2014). Short- and long-term outcome after iAAA repair continued to improve, most pronounced among octogenarians (30-day mortality -78%, p<0.001).The incidence of ruptured AAA (rAAA) repair steadily decreased (- 25% from first to last period, p<0.001) and the use of EVAR for ruptures increased (30% of all rAAA- repairs 2010-2014). The previously observed improvement of short- and long-term outcome (30-day mortality -26%, p<0.001) stalled during the last time period.

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Conclusion: For the first time, a halt in the increasing incidence of iAAA repair could be identified. This trend- break occurred despite a continued increase in the surgical treatment of octogenarians and screening-detected aneurysms. Additionally, the rAAA-repair incidence continued to decrease. These findings, together with the continued improvement in survival after AAA repair, may have important impact on planning of vascular surgical services.

Copenhagen, Denmark • 28-30 September 186

Poster Presentations

PO 049 12 YEARS OF FEVAR FOLLOW-UP FROM A SINGLE UK CENTRE

Institiution: Liverpool Vascular & Endovascular Service, Interventional Radiology, Royal Liverpool University Hospital, Liverpool, United Kingdom

Authors presenting: Iain Roy, Alistair Millen, Srinivasa Vallabhaneni, Steven Jones, James Scurr, Richard McWIlliams, John Brennan, Robert Fisher

Introduction: fEVAR is an established treatment of juxta & para-renal aortic aneurysms. Previously published case series predominately report short & medium term outcomes of early cases. We report the outcomes of all our cases, including long term outcomes of early cases. We also demonstrate the changing configuration of grafts being implanted in practice. We exclusively use the Cook Zenith Fenestrated device.

Methods: The aim of this analysis is to assess the outcomes from a single UK centre. We performed an analysis of our prospectively maintained EVAR surveillance database augmented with matched data from our entries on the BSET GLOBALSTAR registry. Patients with any branched components or fenestrations as part of a thoracic aneurysm repair were excluded. Statistical analysis was undertaken using SPSS v22.0 (IBM Corp). Kaplan Meier survival analysis was used for survival outcomes, time analysed was from date of operation to the end of the analysed period. Target vessels were analysed from time of operation to last surveillance scan.

Results: 173 cases were included in the analysis performed between 2003 and 2015 (inclusive). Median follow-up was 34 months (IQR 18 – 75), median age was 76 years (IQR 70-79) & median aneurysm size (at operation) was 63mm (IQR 59-70). Number of target vessels per stent graft has been increasing over time (Image: Percentage of stent-grafts by number of target vessels by calendar year). Combined inpatient & 30 day mortality was 5.2%, the majority of inpatient deaths being the result of cardiac or embolic target vessel events. 1, 5 & 10 year all-cause mortality was 9%, 39% & 69% respectively. No late deaths are known to be aneurysm related. Secondary intervention free survival was 85%, 56% & 27% at 1,5 & 10 years. 40 (23%) patients required at least one secondary intervention in the analysed follow-up.

Copenhagen, Denmark • 28-30 September 187

Poster Presentations

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Conclusion: Over time our institution has been increasing the number of target vessels in each fEVAR stent graft. Long term survival following fEVAR remains poor, mainly due to co-morbid patients. Secondary interventions are common but can maintain high target vessel perfusion rates. Catastrophic loss of target vessels is rare. Our outcomes are comparable to published international series and UK registry data.

Copenhagen, Denmark • 28-30 September 188

Poster Presentations

PO 050 ANEURYSM RUPTURE RISK STRATIFCATION WITH USE OF REAL TIME 3D SPECKLE TRACKING ULTRASOUND AND FINITE ELEMENT ANALYSIS

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

Authors presenting: Thomas Schmitz-Rixen, Wojciech Derwich, Andreas Wittek, Christopher Blasé

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. Parameters such as maximum aneurysm diameter, aneurysm growth rate and aneurysm morphology allow only limited prediction of aortic rupture. 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. Real time 3D speckle tracking ultrasound combines advanced, dynamic imaging with real time, bed side, rupture risk stratification. This study aimed to analyze biomechanical properties of the infrarenal aortic aneurysm with 4D ultrasound to identify wall areas with higher rupture risk.

Methods: In a prospective study biomechanical properties of 57 patients with infrarenal aortic aneurysm were examined using real-time 3D speckle tracking ultrasound (4D ultrasound). After transforming primary coordinates a high resolution 4D model of the aorta was constructed to determine regions with pathological strain and calculate the global parameter describing the heterogeneity of aneurysm wall strain. In selected cases, based on inverse modeling patient-specific material properties were calculated from the dynamic deformation of the aneurysm wall. Finally, distribution of wall stress in the aortic aneurysm was simulated with patient-specific and population-mean material properties.

Results: The infrarenal aortic aneurysm shows low amplitude of longitudinal and circumferential strain, but high spatial heterogeneity. The aneurysm neck is biomechanicaly much activer region than aneurysm bulge, respectively with higher longitudinal (p<0.01) and circumferential (p<0.01) strain amplitude. Areas with maximum local longitudinal and circumferential strain were predominantly localized in the posterolateral region of the aneurysm wall that corresponds with the most frequent regions of aneurysmal rupture. The areas with maximum local strain amplitude are localised not necessarily in the region with the highest aneurysm diameter.

Copenhagen, Denmark • 28-30 September 189

Poster Presentations

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Conclusion: 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. The maximum local strain must not necessarily occur it the region with the highest aneurysm diameter. Employing finite element analysis with patient-specific material properties opens a perspective for disclosing determinants indicating higher aneurysm rupture risk.

Copenhagen, Denmark • 28-30 September 190

Poster Presentations

PO 051 MAGNETIC RESONANCE IMAGING OF THE INTRALUMINAL THROMBUS IN ABDOMINAL AORTIC ANEURYSMS – A QUANTITATIVE AND QUALITATIVE EVALUATION AND CORRELATION TO GROWTH RATE

Institution: 1. Radiology, Viborg Hospital, Viborg, Denmark 2. Elitary Research Centre of Individualised Treatment of Arterial Diseases (CIMA), Cardiovascular Centre of Excellence (CAVAC), Department Of Heart, Lung and Vascular Surgery T, Odense, Denmark

Authors presenting: Carsten Behr-Rasmussen, Lise Gammelgaard, Ernst-Torben Fruend, Jes S. Lindholt

Introduction: The intraluminal thrombus (ILT) is still not fully understood regarding abdominal aortic aneurysm (AAA) growth. This study presents novel information on the presence and morphological traits of the ILT and growth rate of AAAs within a screening cohort, evaluated with ultrasound (US) and magnetic resonance imaging (MRI).

Methods: 46 patients from the VIVA1 study and 1 patient from the outpatient clinic was included in the study. All underwent a non-contrast enhanced MRI. Presence (yes/no) of an ILT was noted and if present, divided into 5 morphological categories. Confounders were adjusted for in a multiple linear regression analysis.

Results: Mean age at time of MRI was 75.47 years ± 2.92 (SD). Mean growth rate was 1.96 mm/year ± 0.87 (SD). Observation time was 5.51 years ± 0.84 (SD). ILT was present in 20.00%, 88.89%, 81.25%, 100% and 100% in the AAA size groups measured by US 30-34.9 mm, 35-39.9 mm, 40-44.9 mm, 45-49.9 mm and 50-54.9 mm respectively. Presence of any sort of ILT resulted in a significant increased growth rate of 1.09 mm/year 95%CI [0.50:1.70] unadjusted and adjusted 1.28 mm/year 95 %CI [0.69:1.88]. Introducing thrombus categories based upon the visual morphology viewed on MRI, all types of thrombus where associated with increased growth rate compared to “no thrombus”. The presence of a thin circumferential thrombus was associated with most increased growth rate of 2.24 mm/year 95% CI [1.22:3.25].

Conclusion: In this smaller study with long observation time, presence of ILT is associated with increased growth rate of the AAAs. There is a tendency that certain types of thrombi are related to accelerated growth.

References: Grondal N, Sogaard R, Henneberg EW, Lindholt JS. The Viborg Vascular (VIVA) screening trial of 65-74 year old men in the central region of Denmark: study protocol. Trials 2010;11:67..

Copenhagen, Denmark • 28-30 September 191

Poster Presentations

PO 052 OCCLUSION BALLOON AS AN ACHILLES HEEL OF REVAR – IMPACT OF MULTIDISCIPLINARY SIMULATION ON THE PREOPERATIVE PROCESS

Institution: Anesthesiology, Vascular Surgery, Helsinki University Hospital, Helsinki, Finland

Authors presenting: Pekka Aho, Leena Vikatmaa. Leila Niemi-Murola, Ville Päivinen, Mia Kantomaa, Maarit Venermo

Introduction: Endovascular treatment of RAAA requires a lot of knowledge, skills and practice of a wide range of hospital professionals: vascular surgeons, anesthesiologists, scrub and anesthesia nurses as well as radiographers. In our hospital we treat annually almost 30 CT-verified RAAA patients, more than half nowadays with rEVAR. The implantation of the stent graft per se is not the most difficult part of the rEVAR procedure. The surgeons are few and they are experienced with the procedure and equipment. However, the most challenging has been the new situation where, in addition to the traditional surgical instrumentation and rapid transfer of the patient to the table,, preparing the patient for local anesthesia in permissive hypotonia and scrubbing and draping for occlusion balloon insertion as well as preparing the ultrasound and c-arm. Organized training is essential to familiarize the personnel with endovascular equipment. The aim of the current study is to 1) describe a simulation intervention targeting to rapid process of the RAAA patient from door to occlusion balloon in place; 2) report our first experience and progress in the simulation sessions and 3) to evaluate progress in the treatment of rEVAR patients between 2013-2016.

Methods: In order to streamline the rEVAR process, we started 8/2015 to arrange multidisciplinary simulation sessions with a patient simulator using the hybrid theatre as a real environment. We aimed to optimize the admission protocol from door to knife to allow quickest possible occlusion balloon insertion. All simulations included a briefing session, simulation and debriefing, where the videorecorded simulation session was analyzed,

Results: Altogether 30 rEVARs and 63 open RAAAs were performed during 2013-2015. Between 8/15 and 3/16 we organized 8 simulation sessions for 64 employees working with rEVAR patients in OR. The OR door to balloon time decreased from 32 minutes (min) to 22 min between the first and second simulation. Thereafter, the time has shortened to 11-13 min, including 3-5 min of resuscitation on table. Before the simulation project, the median time from door to knife was 121 min (IQR 70-227) compared to 62 after the initiation of the simulation sessions (IQR 51-134) (p=0.2). The most significant change was seen in the time lap from the patient´s arrival to the OR until fully prepared for the operation, a median of 65 min (IQR37-73) vs 17 min (IQR 14-23 minutes)(p<0.001) before and after, respectively 33 rEVARs were performed during 1/2013-3/2016. In these patients an occlusion balloon was inserted in most cases, but inflated in only five patients. One patient needed CPR during operation. Seven patients were treated in general anesthesia (GA), and 26 in local anesthesia, eight of which were later converted to GA. Abdominal compartment syndrome (ACS) developed to 7 patients and three of them died within 30 days postoperatively. The 30-day mortality was 5/33 (15%).

Copenhagen, Denmark • 28-30 September 192

Poster Presentations

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Conclusion: Simulations significantly reduce the time delay from door to knife (or occlusion balloon) in critically ill RAAA patients.

Copenhagen, Denmark • 28-30 September 193

Poster Presentations

PO 053 ADJUSTED HOSPITAL OUTCOMES REPORTED IN THE DUTCH SURGICAL ANEURYSM AUDIT AFTER 2 YEARS OF ELECTIVE ANEURYSM SURGERY

Institution: 1. Onze Lieve Vrouwe Gasthuis, Amsterdam 2. Leiden University Medical Center, Leiden, Netherlands

Authors presenting: Niki Lijftogt, Anco Vahl, J.F. Hamming

Introduction: To identify best practise in health care the Dutch Surgical Aneurysm Audit (DSAA)1 was introduced in 2012 and is mandatory since 2013 for all primary Abdominal Aortic Aneurysm (AAA) operations in the Netherlands. When comparing hospital outcomes risk-adjustment for patient- and disease specific characteristics is necessary. The aims of this study are to present the DSAA hospital outcomes of elective aneurysm surgery, investigate the clinical validity of V-POSSUM2 and the effect of the Vascular (physiology only)-POSSUM3.4, as risk-adjustment model for hospital comparisons.

Methods: From January 2013- December 2014 all elective patients were included for analysis. The calibration and discrimination was analysed according to Hosmer-Lemeshow and the C-statistic by means of V-POSSUM. Hospital mortality was risk-adjusted by V (p)-POSSUM re-estimated on the Dutch population or as the original model, plotted by hospital volume.

Results: A total number of 4579 patients had elective surgery. EVAR was performed in 74.8%. Postoperative mortality was 1.9%: 0.9% after EVAR and 5.0% after OSR. V-POSSUM predicted a mortality of 3.5% (95% CI; 2.9-4.1) after EVAR compared to 5.3% (95% CI; 4.1-6.5) after OSR (Hosmer-Lemeshow p<0.001). The discriminative ability of V-POSSUM was moderate, with a C-statistic of 0.719. Risk- adjustment by the re-estimated V (p)-POSSUM did not have any effect on hospital variation for adjusted mortality. Risk-adjustment for the original model was not informative due to overestimation of mortality for the total population. Image:

Copenhagen, Denmark • 28-30 September 194

Poster Presentations

Conclusion: Mortality was in line with the literature for EVAR in the DSAA. Predicted mortality by V-POSSUM for EVAR differed significantly compared with the observed mortality explained by the implementation of EVAR and improved prognosis of patients undergoing elective AAA surgery. Case-mix adjustment by means of V(p)-POSSUM showed to have almost no effect on hospital positions meaning a decreased importance of the variables included.

References: 1. www.clinicalaudit.nl. 2. Copeland GP, Jones D, Walters M. POSSUM: A scoring system for surgical audit. Br J Surg. 1991;78(3):355-360. 3. Prytherch DR, Ridler BM, Beard JD, Earnshaw JJ, Audit and Research Committee, The Vascular Surgical Society of Great Britian and Ireland. A model for national outcome audit in vascular surgery. Eur J Vasc Endovasc Surg. 2001;21(6):477-483. doi: 10.1053/ejvs.2001.1369 [doi]. 4. Prytherch DR, Sutton GL, Boyle JR. Portsmouth POSSUM models for abdominal aortic aneurysm surgery. Br J Surg. 2001;88(7):958-963. doi: bjs1820 [pii].

Copenhagen, Denmark • 28-30 September 195

Poster Presentations

PO 054 SUPRARENAL AORTIC INTERVENTION IN AUSTRALIA AND NEW ZEALAND. REINTERVENTION, SCOLLOPS AND FENESTRATIONS INCREASES PATIENT RISKS, BUT OPEN ANEURYSM SURGERY STILL INCREASES MORTALITY

Institution: Vascular Surgery, Westmead Hospital, University of Sydney, Sydney, Australia

Authors presenting: Irwin Mohan, Kerry Hitos, Barry Beiles, Bernie Bourke

Introduction: The Australia and New Zealand Society for Vascular Surgery (ANZSVS) recently established the Australasian Vascular Audit, a prospective bi-national database for all vascular procedures. We analyzed 5-year data for suprarenal aortic interventions from 2010 to 2014.

Methods: 11,671 aortic procedures were performed, 64.4% (7462) were treated endovascularly (EVAR) and 35.6% with open surgery (OPEN). EVAR patients were older (76 vs 73 years) ; median aneurysm diameters were 57mm(EVAR) vs 60mm(OPEN). 291 patients treated had true suprarenal/thoracoabdominal aneurysms, and 4630 patients had suprarenal fixation by EVAR; fenestrated EVAR grafts was performed in 5.2% (594 patients); and 1007 OPEN patients had a suprarenal clamp. Suprarenal fixation was performed in 62.1% of EVARs and thoracic aortic fixation in 0.6%; 26 patients had proximal endoleak reintervention by EVAR. Data were analysed using SPSS, univariate analysis and multivariate modelling was performed, p< 0.05 was considered significant.

Results: Post-operative bleeding, wound complications, and unplanned return to theatre, cardiac, respiratory and renal complications were more frequent with OPEN, (p<0.001). Supra-renal clamps were employed in 24.4% of OPEN cases; death rates were 5.1% overall, 1.7% for EVAR vs 11.4% for OPEN, (p<0.0001). Symptomatic AAA increased the odds of a complication or death by 1.57 (95% CI: 1.17-2.11; P<0.003) compared to elective aneurysm. Re-intervention to repair endoleak was associated with 3.5 times increased risk of complication or death (p<0.001). Scallops, and fenestrations also increased the risk of any complication or death by 2.8 and 3.5 fold respectively (p<0.001). A failed repair increases the odds of complications by 2.5 times and death by as much and 9 times (P<0.0001), although only age, and an ASA score influenced this, (p<0.05). Age, diabetes and renal failure increased the risks of death after aneurysm repair, (p<0.05). A fenestrated aortic device configuration increases the risk of death by 6.7 times compared to usual EVAR configurations (P=0.002).

Conclusion: Complications including death were more frequent in the OPEN group, but suprarenal clamps were required in almost a quarter of cases. ASA Score and symptomatic aneurysms increased the risks from AAA repair regardless of technique. Significantly increasing risk was noted for patients with endografts having scollops, fenestrations and reintervention for endoleak.

Copenhagen, Denmark • 28-30 September 196

Poster Presentations

PO 055 COMMON ILIAC ARTERY ANEURYSM IN MEN WITH SCREENING DETECTED ABDOMINAL AORTIC ANEURYSMS

Institution: Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden

Authors presenting: Achilleas Karkamanis, Kevin Mani, Sverker Svensjö, Khatereh Djavani Gidlund Martin Björck, Anders Wanhainen,

Introduction: A nationwide screening program for abdominal aortic aneurysm (AAA) targeting 65-year old men was introduced in Sweden in 2006 and was fully implemented in 2015. The aim of the present study was to analyze the prevalence of common iliac artery aneurysm (CIAA) in 65-year old men with a screening detected AAA or a subaneurysmal aorta (SAA).

Methods: All 65-year old men were offered an abdominal aortic ultrasound examination in the county of Uppsala 2006-2014 and in the county of Gävleborg 2009-2014. An AAA was defined as an aortic diameter ≥30mm and a SAA as 25-29 mm. All subjects with an AAA or SAA had a simultaneous ultrasound examination of their common iliac arteries (CIA). A CIAA was defined as a CIA diameter ≥18 mm, according to the ISCVS/SVS Ad Hoc Committee.

Results: Of 35582 men invited 26334 (86%) attended. A total of 451 (1.7%, 95% CI 1.6-1.9%) AAA and 335 (1.3%, 95% CI 1.1-1.4%) SAA were identified, of whom 623 (79%) had a reliable CIA ultrasound examination. The mean maximum CIA-diameter was 16 mm (range 8-60 mm). A total of 162 patients had a concomitant CIAA (26%; 95% CI 23-30%), 1/3 bilateral. Subjects with a CIAA had significantly larger aortic diameter compared to those with normal CIA (aortic diameter 37mm vs 33mm, p<0,001). The prevalence of CIAA was higher among patients with AAA compared to those with SAA (30% vs 22%, p=0,028). Seventeen out of total 19 large CIAA (≥30mm) were found in AAA-patients. The largest CIAA (60mm) was, however, found in a man with SAA.

Image:

Conclusion: CIAA is relatively common in 65-year old men with a screening detected AAA or SAA. Most CIAAs were, however, small. Follow-up data are being collected to determine the future clinical relevance of these CIAA detected at AAA screening.

Copenhagen, Denmark • 28-30 September 197

Poster Presentations

PO 056 EVALUATION OF FIVE DIFFERENT ANEURYSM SCORING SYSTEMS TO PREDICT MORTALITY IN RUPTURED ABDOMINAL AORTIC ANEURYSM PATIENTS

Institutiton: 1. Vascular surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands 2. Vascular surgery, Anesthesiology, Antonius Ziekenhuis, Nieuwegein, Netherlands

Authors presenting: Cornelis Vos Çagdas, Ünlü Werson, HPA van Dongen, M.A. Schreve, JPPM de Vries

Introduction: Ruptured abdominal aortic aneurysms (RAAA) are associated with a high overall mortality (up to 25- 35%) within 30 days when offered surgical treatment, regardless whether open or endovascular treatment is performed. Risk-prediction models can provide valuable information on surgical risks, guide clinical decision-making and help identify patients that should not be operated on to prevent futile surgery. Finally, they can be used to evaluate clinical outcome. Different aneurysm scores are available. New ones (with only four parameters) are being developed, such as the Dutch Aneurysm score (DAS). The purpose of the present study is to compare and externally validate these scoring models.

Methods: The present study selected consecutive patients who presented with RAAA in two large hospitals (Medisch Centrum Alkmaar and St. Antonius Nieuwegein) between 2005 and 2015. Variables necessary to retrospectively evaluate the scoring systems were registered in the patient medical files. The diagnostic performance of the five scores was compared.

Results: The present study included 347 consecutive patients with RAAA. There were 298 males (85.9%) and mean age was 72.6 (SD 8.1). The Receiver Operating Characteristic (ROC) curves for the DAS, Glasgow Aneurysm Scale (GAS), Edinburgh Ruptured Aneurysm Score (ERAS), Vancouver Scoring System (VSS) and the Hardman Index are shown in figure 1. The area under the curve for the VSS (0.716, 95% 0.647-0.786) was better than other scoring systems. The new DAS (0.664, 95%CI 0.592 - 0.736) was comparable with the more complex Hardman Index (0.664, 95%CI 0.592 - 0.736). The ERAS (0.621, 95% 0.543-0.700) and GAS (0.591, 95% 0.517-0.665) were outperformed by the other scoring system.

Conclusion: The VSS is the best predictor in available scoring systems in RAAA patients. Therefore it can serve as a reliable tool to predict mortality, to inform patients and guide clinical decision-making. However an almost perfect prediction is needed to withhold intervention.

Copenhagen, Denmark • 28-30 September 198

Poster Presentations

PO 057 INCIDENCE OF SMALL ABDOMINAL AORTIC ANEURYSMS RUPTURE, RISK FACTORS ASSESSMENT AND OUR EXPERIENCE WITH RUPTURE RISK PREDICTION BASED ON WALL STRESS ASSESSMENT

Institution: 1. 2nd Department of Surgery, St. Anne´s University Hospital in Brno, 2. Institute of Solid Mechanics, Mechatronics and Biomechanics, Brno University of Technology, Brno, Czech Republic

Authors presenting: Lubos Kubicek, Robert Staffa, Robert Vlachovsky, Stanislav Polzer

Introduction: ESVS guidelines indicate the repair of asymptomatic AAA when its maximal diameter is more than 5.5 cm. Our own experience is, that a substantial portion of ruptured AAA is smaller and would be indicated for dispensarization even if found before the rupture. Our goal was to determine portion of small ruptured AAA in our centre in years 2009-2012 along with finding potential risk factors. Our centre cooperates with biomechanical engineers to create a new algorithm for AAA rupture prediction based on computer the wall stress analysis.

Methods: We had 41 cases (male n=32, female n=9) of ruptured AAA in our centre in years 2009-2012, all treated by open repair. We used CT finding to measure maximal diameter of all AAA to reveal a percentage of small AAA. Data from medical history (COPD, gender, hypertension, DM) were statistically tested to reveal a relation with a diameter of ruptured AAA. During our cooperation with engineers we are providing samples of AAA wall from open repair, which are mechanically tested and outcomes are used to create a precise algorithm of finite elements analysis and thus allows us to predict the risk of rupture of particular AAA.

Results: The portion of small ruptured AAA was 17.1 % (7 out of 41 cases). Average value of diameter was 8.4 cm. Diameters of ruptured AAA of patients with COPD were significantly bigger (p=0.047). Hypertension was presented in vast majority of patients (n=38). Females lived to the higher age before rupture than males (p=0.004), but there was no significant difference in AAA diameter (p=0.487). Finite element algorithm was so far able to find a spots of high wall stress of majority tested AAA and thus mark an AAA with high rupture risk even if it would be indicated for dispensarization according it´s diameter. Bigger study to prove its efficiency is yet to begin.

Conclusion: A significant portion (17.1 %) of ruptured AAA treated in our centre during the years 2009-2012 were small and wouldn´t be indicated for repair if found before the rupture. These findings support the effort to find some new methods of rupture prediction. Such methods could be use of new biomarkers or computer wall stress assessment, also tested in our centre. Quest to find better method of AAA rupture prediction is continuing.

Copenhagen, Denmark • 28-30 September 199

Poster Presentations

PO 058 THE FATE OF UNEXPECTED EVENTS OCCURRING IN STANDARD EVAR

Institution: Vascular Surgery, Bologna University, Bologna, Italy

Author presenting: Andrea Vacirca, Gianluca Faggioli, Rodolfo Pini, Enrico Gallitto, Chiara Mascoli, Antonio Freyrie, Mauro Gargiulo, Andrea Stella

Introduction: A number of unexpected events (UE), such as unplanned arteries coverage or rupture, may occur in Standard EVAR and can hamper the outcome of the procedure. This study aims to evaluate the possible long-term effect of UE in patients undergoing standard EVAR.

Methods: All standard EVAR procedures, defined as aorto-bi-common-iliac endograft performed according to the IFU of the appropriate manufacturer and accomplished from 2012 to 2015, were retrospectively analysed in order to identify all UE, which were classified into four different groups: Group I endoluminal defect, such as stenosis, dissection or compression of iliac arteries and endograft mainbody or iliac legs; Group II type I and III endoleak; Group III unplanned hypogastric or renal artery coverage; Group IV surgical access complication, such as thrombosis or plaque dissection of the femoral artery. Follow-up was performed by doppler ultrasound, contrast enhanced doppler ultrasound or CT scan, with one year interval, if not necessary earlier. Outcome results were analysed by Kaplan-Maier curve and compared with those of uneventful cases (UC).

Results: Between 2012 and 2015, 302 patients underwent standard EVAR with different types of infrarenal and suprarenal fixation endograft. An UE occurred in 57(18.9%) cases and in 89.4% of them an adjunctive treatment was performed. In Group I, 26/27(92.6%) cases were treated with endovascular relining, such as mainbody or iliac artery/leg stenting or iliac leg extension deployment; in Group II, 20/20(100%) cases were treated with cuff deployment or forced ballooning and in one case surgical conversion; in Group III, 1/6(16.6%) case of unplanned hypogastric/renal artery coverage was treated (all 5/5 hypogastric coverage cases were left untreated and 1/1 case of renal coverage was treated with renal artery stenting); in Group IV, 4/4(100%) cases were treated with femoral bypass. At 24 months follow-up, the UE group had similar results compared with UC group in terms of late type I-III endoleak, lower limb ischemia, buttock claudication and renal failure requiring hemodialysis (overall complications rate 32.4 ± 15% UE vs 10 ± 3.9% UC, P=0.3; late type I-III endoleak 15.6 ± 10.2% UE vs 8.2 ± 3.8% UC, P=0.9; late lower limb ischemia 19.9 ± 15% UE vs 1.3 ± 1% UC, P=0.09; buttock claudication 0% UE vs 10 ± 0.3% UC, P=0.6; renal failure requiring hemodialysis 0% in both groups). UE Group I showed a significant higher rate of late lower limb ischemia compared with UC group (11.1 ± 10.5% Group I vs 1.3 ± 1% UC, P=0.03). Freedom from reintervention was similar between the two groups (70.3 ± 15.4% UE vs 95.8 ± 2.5% UC, P=0.4). Image:

Copenhagen, Denmark • 28-30 September 200

Poster Presentations

Conclusion: UE may affect a number of aspects during standard EVAR procedure and need adjunctive manoeuvres in a significant number cases; however the long-term outcome is generally not influenced by the occurrence of these unexpected events, if adequately addressed. Nevertheless if endoluminal defects arise during the primary procedure, the incidence of late lower limb ischemia is increased.

Copenhagen, Denmark • 28-30 September 201

Poster Presentations

PO 059 ENDOVASCULAR AORTIC REPAIR OF INFRARENAL AORTIC ANEURYSMS: EQUAL EARLY RESULTS AFTER EVAR WITHIN IFU AND EVAR WITH PRIMARY ENDOANCHOR FIXATION FOR HOSTILE NECK

Institution: Department of Vascular Surgery and Endovascular Surgery, University Hospital Regensburg, Regensburg, Germany

Authors presenting: Reinhard Kopp, Piotr M. Kasprzak, Thomas Muck, Hanna Apfelbeck, Beatrix Cucuruz

Introduction: Treatment of infrarenal aortic aneurysms is frequently performed by endovascular aortic repair (EVAR). Patients with a hostile infrarenal aortic neck treated outside the instructions for use (IFU) were shown to have increased rates of type Ia endoleaks, stent graft migration and higher reintervention rates. Primary proximal stent graft fixation with EndoAnchors at the level of the infrarenal aorta might reduce early endoleak rates and prevent aneurysm progression.

Methods: Patients with an infrarenal aortic neck suitable for EVAR within the instructions for use (IFU) were treated by standard stent graft implantation (Gore C3 Excluder). Patients with a hostile neck, as defined by an infrarenal neck length < 15 mm, conical neck or angulation > 60o were treated with EVAR+EndoAnchor fixation. During follow-up endoleaks, reinterventions, aneurysm diameter were documented and aneurysm volume was determined using a TeraRecon workstation.

Results: Thirty patients (male 96.7 %; age: mean 73 years) with a follow-up of at least 12 months were treated for infrarenal aortic aneurysms with a mean diameter of 5.6 cm. Eighteen patients fulfilled the IFU and received standard EVAR, while 12 had a hostile infrarenal neck with EVAR + primary EndoAnchor fixation. Mean 7.3 anchors/patient (range 6-10) were used for proximal stent graft fixation. Preperative aneurysma volume was 103 cm3 (range: 38.1 -155) in the standard EVAR group and 104 cm3 (range: 39.8 – 173) in the EVAR+EndoAnchor group. Perioperative data were similar for both groups with no type I endoleak, although 6 type II endoleaks (33 %) and 1 late reintervention were observed in the standard EVAR group, while patients in the EVAR+EndoAnchor group had 2 type II endoleaks (16 %) with no reintervention. During follow-up after 1 year aneurysm volume decreased in 89 % (volume shrinkage – 34 cm3) in the standard EVAR group and in 67 % (volume shrinkage -18 cm3; p=0.29) in the EVAR+ EndoAnchor group.

Conclusion: Outcome after one year showed similar results regarding lack of type I endoleak and aneurysm shrinkage between the standard EVAR patients and those treated by EVAR+EndoAnchor for challenging infrarenal hostile neck. Primary EndoAnchor implantation might therefore be recommended to prevent early EVAR failure and to improve outcome in selected patients with hostile neck.

Copenhagen, Denmark • 28-30 September 202

Poster Presentations

PO 060 INCREASED EXPERIENCE ALLOW MORE COMPLEX REPAIRS OF AORTOILIAC ANEURYSMS WITHOUT INFLUENCING MID-TERM RESULTS OF EVAR WITH ILIAC BRANCHED DEVICES

Institution: 1. Vascular Centre Malmö, Skåne University Hospital, Malmö, Sweden, 2. Vascular Surgery, Department of Surgery, University of Insubria, Varese, Italy

Authors presenting: Andrea Xodo, Giuseppe Asciutto, Björn Sonesson, Timothy Resch, Nuno V. Dias

Introduction: Iliac branched devices (IBDs) allow preservation of the internal iliac artery (IIA) in patients with aneurysmatic disease extending into the common iliac artery. Initial reports of IBD use have been favorable. The aim of the present study was to evaluate if the mid-term results of IBD use could be sustained even with the acceptance of more liberal preoperative anatomies accompanying the increasing experience at a single centre.

Methods: Ninety-three patients (68 (IQR 65-73) years old) underwent implantation of 107 IBDs (14 bilateral repairs) between March 2004 and October 2014. The median diameter of the synchronous aortic aneurysms was 59 (47-68) mm while the median common iliac artery diameter at the operated side was 33 (27-38) mm. The median diameter of the treated IIA was 9 (7-11) mm. A COOK Zenith Branch Device was used in 105 cases (83 Side Branch (ZBIS), 14 Helical Branch and 8 bifurcated–bifurcated iliac Branch), while a Gore Excluder Iliac Branch was used in two cases. In 10% of the cases, the IBDs were implanted distally either to the superior or inferior gluteal artery or the anterior division of the IIA. Follow-up included CTA one month post-implantation and yearly thereafter. For the learning curve analysis, ZBIS devices were divided in early (42 implants, group A) and late-phase (41 implants, group B) groups. Non-parametric tests were used. Survival was estimated with life tables with comparisons done with log-rank test.

Results: Technical success was achieved in 93%. Median follow-up was 34 (18-62) months. Primary clinical success rate was 90±3% (SE) at 1 year, 86±3% at 2 years and 80±4% at 5 years. Among the 17 re-interventions performed during the follow-up (16 endovascular, and 1 open), only one was done in order to restore the patency of an IBD (primary patency 88±3%, primary assisted patency 90±3%, primary assisted clinical success 90±3%, all at 5 years). Five of thirteen IBDs occlusions that occurred during follow-up were asymptomatic, while in eight cases the patients developed buttock/leg claudication. Eleven occlusions (85%) occurred during the first year post-implant. Only one was aneurysm-related (rupture) death occurred during follow-up. Implants distal to the main IIA were performed mostly in the late phase (two implants in group A, seven implants in group B). Seven IBDs were positioned in the superior gluteal artery (two in group A and five in group B) and two IBDs (both group B) were implanted either in the inferior gluteal artery or at the anterior division of the IIA. Patients in group A had more coronary artery disease (p .022); otherwise the two groups had similar comorbidities. The iodine dose used as well as the operation time were significantly higher (<.0001) in patients from group A). IBD patency was similar in the 2 groups (P =.274). Bilateral IBD treatment showed similar results in terms of patency and technical success compared to unilateral implants in both groups. A landing zone distal main IIA and the implantation of the IBDs as a redo operation after primary open or endovascular repair did not influence IBD patency negatively.

Conclusion: Increasing experience with IBD implantation allows good results at the mid-term even with more anatomically complex EVAR in patients with aorto-iliac aneurysms.

Copenhagen, Denmark • 28-30 September 203

Poster Presentations

PO 061 CONTROVERSIES IN DIAGNOSTIC CRITERIA FOR ABDOMINAL AORTIC ANEURYSM; IS BODY SURFACE OF IMPORTANCE?

Institution: 1. Department of vascular disease, Skåne University Hospital-Malmö, Malmö, Sweden 2. Kalmar County Hospital, Department of General Surgery, Kalmar, Sweden

Authors presenting: Joachim Starck, Katarina Björses, Fredrik Lundgren, Anders Gottsäter 1Björn Sonesson, Jan Holst

Introduction: Screening for abdominal aortic aneurysm (AAA) in elderly men reduces aneurysm related mortality. An AAA has sometimes been defined as infrarenal aortic diameter 50% larger than predicted according to body surface area (BSA), whereas the AAA definition used in screening is an infrarenal aortic diameter of >30 mm. As this figure is not adjusted for BSA, there is a need to determine whether aortic diameters <30 mm in men with low BSA represent pathology. The aim of the study was to investigate correlations between aortic diameter and BSA in order to refine screening- surveillance procedures. We also evaluated whether smoking habits affected these correlations.

Methods: An observational single centre cohort study of 25136 65-year old men invited to the AAA screening in Malmö 2010- 2015. Of the 19738 (78.5%) attending, 14884 (75.4%) completed a health questionnaire and were included in the study. Aortic diameter was related to weight, length, and smoking habits. Linear regression analysis was performed between BSA and aortic diameter, taking smoking habits into account.

Results: AAA defined as aortic diameter >30 mm was found in 227 men (1.5 %). Mean aortic diameter in the whole population was 19.5 mm (SD 4.1), 2025 men (14%) were current smokers, 7930 (52%) ex- smokers, and 4900 (33%) never-smokers. BSA and aortic diameter correlated weakly but significantly among never smokers (rho = 0.31; p<0.001), and even weaker (rho = 0.25; p<0.001) among ever smokers. The slope of the linear regression was steeper among current smokers than in the other groups.

Conclusion: There was a significant but weak correlation between BSA and aortic diameter. In men with low BSA, infrarenal aortic diameter <30 mm might still be 50% larger than predicted according to their BSA. Further follow-up of these subjects is warranted to investigate if they could have an “aneurysm-information”, challenging currently used AAA definitions.

Copenhagen, Denmark • 28-30 September 204

Poster Presentations

PO 062 QUALITY OF LIFE ASSOCIATIONS TO CARDIOPULMONARY EXERCISE TESTING IN PATIENTS UNDERGOING ABDOMINAL AORTIC ANEURYSM REPAIR.

Institution: Academic Vascular Department, University of Hull, Hull, United Kingdom

Authors presenting: Amy Harwood, Hashem Barakat, Edward Broadbent, George Smith, Daniel Carradice, Ian Chetter

Introduction: Perioperative assessment of patients undergoing repair of their abdominal aortic aneurysm (AAA) is crucial in determining risk and long-term clinical outcomes. Cardiopulmonary exercise testing (CPEX) is increasingly being used in preoperative assessments of patients undergoing abdominal aortic aneurysm repair (AAA). CPEX testing involves measuring both the respiratory oxygen uptake (VO2) and carbon dioxide production (VCO2) at varying levels and intensities4 to provide the assessor with two main outcomes; VO2MAX and the anaerobic threshold (AT). These outcomes have been shown to be predictive of postoperative mortality and morbidity in non-cardiac surgical intervention. The object of this study was to establish if health-related quality of life (HR-QOL) outcome as measured by two questionnaires was predictive of overall fitness level, as determined by the CPEX outcome.

Methods: Prospective data from consecutive patients undergoing CPEX between September 2011 and September 2013 was analysed. The main CPEX parameters included anaerobic threshold (AT) and maximum oxygen uptake (VO2MAX). Ventilatory equivalents for oxygen (VE/VO2) and carbon dioxide (VE/VCO2), AT time and total time were also recorded. Two self-administered questionnaires were completed independently prior to CPEX assessment. The questionnaires used were the generic Short-Form 8 (SF8) and the European Quality of Life questionnaire (EuroQol). Correlations were performed between the main outcome variables as mentioned above and the two questionnaires; namely SF8 and EuroQol. Prior to analysis all data was tested for normality, as all data was normal a Pearson’s correlation coefficient was used.

Results: The study included 107 patients with a mean age of 73.5±7.1. 89.7% were male with 65 patients undergoing open repair and the remaining 42 undergoing endovascular repair. Patients who underwent EVAR were significantly older (p < 0.001), however there were no other statistically significant differences. None of the CPEX variables were well correlated to either questionnaire. The closest correlation was between VO2MAX and the SF8 questionnaire r = 0.4.

Conclusion: Patient self-reported exercise tolerance has always been regarded as a good indicator for preoperative fitness and self-reported physical status is often using during risk assessment. These results show that patient reported quality of life is poorly associated to outcomes derived from a cardiopulmonary exercise test. As such CPEX should be used as part of routine pre-operative assessment and utilized in the clinical decision making process of all centres.

Copenhagen, Denmark • 28-30 September 205

Poster Presentations

PO 063 FEASIBILITY OF IMAGED-BASED FUSION SOFTWARE IN ENDOVASCULAR AORTIC REPAIR

Institution: 1. Guy's and St Thomas' NHS Foundation Trust 2. Royal Free Hospital NHS Fondation Trust, 3. Complex Aortic Surgery,The Royal Free Hospital, 4. Guy's and St Thomas' Hospital, 5. Frimley Park Hospital, 6. Cambridge University Hospital, London, 7. Cydar Limited, Cambs, 8. Cydar Limited, London, United Kingdom

Authors presenting: Blandine Maurel, Bijan Modarai, Tara Mastracci, Said Abisi, Neville Dastur, Paul Hayes, Graeme Penney, Tom Carrell

Introduction: Fusion imaging techniques that rely on hardware-based tracking have been found to decrease contrast and radiation dose, but require a large investment in capital equipment. The aim of this study is to determine the feasibility of using imaged-based fusion software to guide endovascular aortic procedures.

Methods: A prospective multicentred study was designed where an image based fusion system [CYDAR] was installed at 4 test sites through the United Kingdom between December 2014 and September 2015. All patients scheduled to undergo an X-ray guided intervention in an anatomic zone covered by the technology (ie paravertebral: e.g. aortoiliac, spinal, retroperitoneal, pelvic), and who had had a pre-operative CT scan were invited to participate if they were aged 18 or over and able and willing to comply with the study requirements. Segmentation was performed according to manufacturer’s specification, and fusion images were transmitted to a separate monitor in each theatre using a cloud based system. Descriptions of procedural characteristics and accuracy of fusion image were collected.

Results: In total, 109 patients were recruited into the trial. Over the course of the study, there were a mix of aortic procedures: 56% complex fenestrated ± branched endovascular aortic repairs; 12 % standard endovascular aneurysm repair; 11% thoracic aneurysm repair; 17 % iliac and mesenteric angioplasty and stents; 5% others. No false positive registrations were reported out of a total of 15331 2D-3D registrations displayed. 2802 of these images were sampled at random for visual verification. To check verification sensitivity 25% (720, ‘false’) had random mean 3mm* translational or rotational errors inserted. In blind testing, no errors were detected in the 2079 (75%) registrations showing the ‘true’ registration solutions. Positive predictive value was 100% with a lower 95% confidence interval of 99.8%. The mean time taken to return and display an updated 3D overlay in response to patient/table/ X-ray set movement was 8.395s and the Mean Cydar running time was 161 mins (22- 417m). The median X-ray dose (Dose Absorbed Product) was 101.0 Gycm2 (0.19 -784.0) and the median iodinated contrast dose was 112 ml (15-300). At the highest volume site, two case control groups had sample sufficient to warrant comparison against historic case controls sizes: 3 fenestrated (3F) repairs n= 9; 4-branched (4B) repairs n=8. Student’s t-test (one-tailed) showed a statistically significant reduction in iodinated contrast use in both groups (3F 38% reduction, p=0.018; 4B 41% reduction, p=0.008).

Conclusion: Use of an image-based fusion system is accurate and robust in aortic procedures. Further research is needed to determine the power of this technique for reduction in radiation dose.

*FYI- This 3mm error was selected as pilot testing had showed 3mm to be the threshold at which visual verification was able to consistently detect an error.

Copenhagen, Denmark • 28-30 September 206

Poster Presentations

PO 064 PARALLEL STENTING TECHNIQUE IN A SANDWICH CONFIGURATION FOR HYPOGASTRIC PRESERVATION DURING EVAR: AN IN-VITRO STUDY

Institution: 1. Vascular surgery division, Hospital Clinic de Barcelona, Spain 2. Radiology department, Clinica Creu Blanca, Barcelona, Spain 3. Vascular surgery department, Hospital de Cruces de Barakaldo, Bilbao, Spain

Authors presenting: Xavier Yugueros, Gaspar Mestres, Savino Pasquadebisceglie, Xavier Alomar, Ana Apodaka, Vincent Riambau

Introduction: The objective of this in-vitro study is to analyze parallel stenting technique in a sandwhich configuration for external iliac and hypogastric preservation in an aorto-iliac arterial aneurysm without distal common iliac neck, testing combinations of different devices and different oversizings.

Methods: Four different external iliac endografts (16 mm Medtronic-Endurant and 12 mm Lombard-Aorfix limb extensions; 11 and 13mm Gore-Viabahn endografts) were in-vitro tested with two different internal iliac stentgrafts (8mm Atrium-Advanta/V12 and 8mm Gore-Viabahn) in a sandwich configuration (Fig 1A) into different proximal plastic iliac limbs models (10, 12, 14, 16, 18 mm) simulating distal common iliac aneurysms without common iliac neck. After remodeling all devices using the kissing-balloon technique into a saline bath at 37oC, the combinations were CT-scanned. Gutter size, parallel-stent compression and endograft malpositioning/infolding were recorded. Model oversizing was examined in terms of added diameter, perimeter and area oversizing which were additionally compared.

Results: Model diameter, perimeter and area oversizings were highly correlated (Correlation coefficient 0,998 and 0,997 respectively, P<0,001 for both); thus diameter oversizing was used for further comparisons. Increasing added diameter oversizing (<30%, 30-55%, 55-75% and > 75%) showed a significant tendency towards smaller gutters (38.9, 12.2, 5.4, 2.6 mm2 p<0.001) but also increasing parallel-stent compression (13.5, 28.9, 43.9, 55.1 % p<0.001) and malpositioning/infolding (0, 0, 38, 60% p<0.001; Fig 1B to 1D). There were no differences (higher or lower gutters or compression) between any devices analyzed despite a non significant tendency to higher malpositioning using Atrium-Advanta/V12 than Gore-Viabahn as parallel-stent (35% vs 10%, p=0.062).

Image:

Copenhagen, Denmark • 28-30 September 207

Poster Presentations

Conclusion: Better apposition was usually achieved when using 30-55% diameter oversizing for the hypogastric sandwich technique. Higher oversizing was related to smaller gutters but higher rate of malposistiong/infolding and parallel stentgraft compression in all analyzed devices. Diameter oversizing was usefull for sandwhich technique sizing and predicting optimal devices deployment.

Copenhagen, Denmark • 28-30 September 208

Poster Presentations

PO 065 PATIENT-SPECIFIC TRAINING PRIOR TO ENDOVASCULAR ANEURISM REPAIR: THE USE OF 3D PRINTED MODELS

Institution: Vascular Surgery, São Paulo University Medical School, São Paulo, Brazil

Authors presenting: Inez O. Torres, Simon Benabou, Nelson De Luccia

Introduction: Endovascular technique has become an established option for repair of aortic aneurysm, but remains a technically challenging surgery.1 Training based on simulations may shorten the learning curve and avoid the exposure of patients to unnecessary risks.2,3 3D printing is an emerging technology, capable of producing patient-specific models4-9 that can be used for training in endovascular infrarenal aneurysm repair (EVAR). This study evaluates the impact of training vascular surgery residents at a tertiary hospital in Brazil prior to EVAR using 3D printed patient-specific models.

Methods: This was a prospective, controlled (before and after) trial conducted at São Paulo University Medical School. During a 2-year period, ten residents in the final year of vascular surgery residency were consecutively enrolled in Control Group (5 residents and 23 patients operated in 2014) or Training Group (5 residents and 24 patients operated in 2015). The residents from the Control Group studied the patients’Computed Tomography (CT), programmed and performed the surgery under supervision of a senior vascular surgeon. The residents from the Training Group, in addition to that, practiced all the steps of the surgery in a 3D printed patient-specific model 24–72 hours in advance of the surgery on the patient. After the simulations, the residents answered a subjective questionnaire. Objective parameters were analyzed and compared between the two groups. The data is shown in median and interquartile range 25-75 (IC). Mann-Whitney test was used to compare the groups.

Results: Total procedure time reduced in 25% (Control 240 minutes IC187,5-310 x Training 180 minutes IC 147.5-210 p=0.0024), total fluoroscopy time reduced in 23% (Control 30 minutes IC25-39 x Training 23 minutes IC16.7-29.2 p=0.012) and volume of contrast reduced in 26% (Control 75ml IC60-106.2 x Training 55ml IC 45-67.5 p=0.01) after specific-patient training was implemented in the service. Training helped to define the position of the contra-lateral limb gate and the best catheter for gate cannulation, reducing gate cannulation time in 70% (Control 7 minutes IC3-14 x Training 2 minutes IC1.25-4.5). The length measurements made by the residents using the 3D-printed models were more accurate than the ones using CT alone (analysing Spearman coefficient and ICC). According to the subjective questionnaire, training in the models was considered useful by the residents because it improved their confidence and their knowledge about the case and the endovascular material. There was no difference in technical success rate comparing the 2 groups. Image:

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Conclusion: Patient-specific training prior to EVAR at a tertiary hospital in Brazil improved residents’ surgical performance (regarding fluoroscopy time, surgery time and volume of contrast used) and self- confidence.

References: 1.Davis GR, Illig KA, Yang G, Nguyen T, Shames ML. An approach to EVAR simulation using patient specific modeling. Ann Vasc Surg 2014;28:1769–74. doi: 10.1016/j.avsg.2014.05.007. 2.Neequaye SK, Aggarwal R, Brightwell R, Van Herzeele I. Darzi1 A, Cheshire N.J.W. Identification of skills common to renal and iliac endovascular procedures performed on a virtual reality simulator. Eur J Vasc Endovasc Surg 2007;33:525e532. 3.Neequaye SK, Aggarwal R, Van Herzeele I, Darzi A, Cheshire NJ. Endovascular skills training and assessment. J Vasc Surg 2007;46:1055-64. doi: 10.1016/j.jvs.2007.05.041. 4.Starosolski ZA, Kan JH, Rosenfeld SD, Krishnamurthy R, Annapragada A. Application of 3-D printing (rapid prototyping) for creating physical models of pediatric orthopedic disorders. Pediatr Radiol 2014;44:216-21. Epub 2013 Nov 8. doi: 10.1007/s00247-013-2788-9. 5.Haverman. TM, Karagozoglu KH, Prins HJ, Schulten EA, Forouzanfar T. [Rapid prototyping: a very promising method]. Ned Tijdschr Tandheelkd 2013;120:136-41. 6.Torres K, Staśkiewicz G, Śnieżyński M, Drop A, Maciejewski R. Application of rapid prototyping techniques for modelling of anatomical structures in medical training and education. Folia Morphol (Warsz) 2011;70:1-4. 7.Preece D, Williams SB, Lam R, Weller R. "Let's get physical": advantages of a physical model over 3D computer models and textbooks in learning imaging anatomy. Anat Sci Educ 2013;6:216-24. Epub 2013 Jan 24. doi: 10.1002/ase.1345. 8.Petzold R, Zeilhofer H-, Kalender WA. Rapid prototyping technology in medicine—basics and applications. Comput Med Imaging Graph 1999;23:277–84. doi: 10.1016/S0895-6111(99)00025-7. Rengier F, Mehndiratta A, von Tengg-Kobligk H, et al. 3D printing based on imaging data: review of medical applications. Int J Cars 2010;5:335–41. doi: 10.1007/s11548-010-0476-x.

Copenhagen, Denmark • 28-30 September 210

Poster Presentations

PO 066 PROLONGED OR RENEWED ICU STAY AFTER AAA REPAIR – “A CRASH INVESTIGATION”

Institution: Section of Vascular Surgery, Section of Anesthesiology, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden

Authors presenting: Hamid Gavali, Kevin Mani, Gustaf Tegler, Rafael Kawati, Lucian Covaciu, Anders Wanhainen

Introduction: Prolonged intensive care (ICU) stay after abdominal aortic aneurysm (AAA) repair is a marker for failure and complications. The aim was to investigate the frequency and outcome of prolonged ICU stay after AAA repair in the endovascular era.

Methods: All patients operated on for AAA between 1999 and 2013 at Uppsala University hospital were identified. Pre-, peri- and postoperative data were retrieved from the Swedish Vascular registry, the Swedish Intensive Care registry, the National Population registry, and case records. Prolonged ICU stay was defined as ≥48h or ICU readmission during primary hospital stay. Patients surviving ≥48h were included in the analysis.

Results: A total of 725 patients were identified, of which 707 (97.5%) survived ≥48h; 563 patients (79.6%) underwent intact AAA repair and 144 patients (20.4%) ruptured AAA repair. A total of 548 patients (77.5%) required <48h of intensive care, 115 (16.3%) 2-6 days, and 44 (6.2%) ≥7days. In addition, 18 patients (3.2%) where readmitted to the ICU. The rate of prolonged ICU stay declined considerably over time, from 41.4% of all AAA repairs in 1999 to 7.3% in 2013, p <0.001. During the same time period the rate of endovascular aortic repair (EVAR) increased from 6.9% in 1999 to 78.0% in 2013, p <0.001. Prolonged ICU stay occurred in 73.6% (95% CI 63 - 82%) of ruptures undergoing open repair and 15.8% (1.2 - 30%) of those undergoing EVAR. After intact repair, the rate was 24.2% (95% CI 16 - 31%) for open repair and 3.4% (0.8 – 16%) for EVAR.Predictors for prolonged ICU stay included rupture (Odds Ratio 3.8, p<0.001), open repair (Odds Ratio 5.5, p<0.001) and transfusion volume (Odds Ratio 1.1 per bag of plasma, p<0.001). Gender, smoking, and preoperative comorbidities were not significantly associated with prolonged ICU stay.A prolonged ICU stay was significantly associated with a reduced survival (30-day survival: <48h ICU 98.2% vs 2-6 days 93.0% vs ≥7 days 81.8%, p<0.001, and 90-days: 97.1% vs 86.1% vs 63.6%, p<0.001 respectively). Kaplan-Meier estimated 1-year and 5-year survival rate was 94% and 72% for those with <48h ICU stay vs. 76% and 56% for those with prolonged ICU stay. Long-term outcome was however similar in the two groups when focusing on those surviving 90-days postoperatively, (<48 hours ICU 1-year 97% and 5-years 73% vs. prolonged ICU 95% and 70%).

Image:

Conclusion: The frequency of prolonged ICU stay has declined significantly after AAA repair, mainly due to the increased use of EVAR. Prolonged ICU stay was associated with a high short-term mortality. Long term outcome among those surviving the first 90 days was, however, less affected.

Copenhagen, Denmark • 28-30 September 211

Poster Presentations

PO 067 MID-TERM RESULTS WITH THE FENESTRATED ANACONDA ENDOGRAFT FOR SHORT-NECK INFRA-RENAL AND JUXTA-RENAL ABDOMINAL AORTIC ANEURYSM REPAIR

Institution: 1. Surgery, Division of vascular surgery, University Medical Center Groningen, Groningen, The Netherlands 2. Surgery, Rijnstate hospital, Arnhem, The Netherlands

Authors presenting: Martijn Dijkstra, Louise Blankensteijn, Ignace Tielliu, Michel Reijnen, Clark Zeebregts,

Introduction: The fenestrated Anaconda endograft (Vascutek, Renfrewshire, Scotland) was introduced in 2010 and showed promising short-term results with high technical success rates and low morbidity. The aim of this study was to present the mid-term results in patients treated with the fenestrated Anaconda endograft in The Netherlands.

Methods: Patients treated using the fenestrated Anaconda endograft in The Netherlands between May 2011 and February 2015 were included. Follow up consisted of computed tomography angiography (CTA) at one month and one year, and duplex yearly thereafter with additional CTA if indicated using a standard protocol. Survival analysis was conducted using Kaplan Meier estimates.

Results: A total of 60 patients were included, 48 (80%) patients were treated for juxta-renal aneurysms and 12 (20%) were short-neck infrarenal aneurysms. Mean aneurysm size was 64 mm (±9). A total of 140 fenestrations were incorporated. Median follow up was 15.5 months (IQR 11.2 – 26). All cause mortality was 11.7% (n=7). Cause of death was pneumosepsis (n=1), congestive heart failure (n=1), cardiac arrhythmia (n=1), hemorrhagic CVA (n=1), bowel ischemia (n=1) and unknown (n=2). 30- day peri-operative mortality was 3.4 % (n=2). No aneurysm related mortality was observed. Main body primary and secondary endograft patency were 98.3 % and 100%, respectively. Fenestrations primary and secondary patency were 90% and 95%, respectively. One patient experienced aneurysm rupture due to a persistent type I endoleak and successfully underwent conversion to open surgery. Overall mid-term clinical success rate was 88.3%. Image:

Conclusion: The fenestrated Anaconda is a viable alternative to current fenestrated endografts for the treatment of complex abdominal aortic aneurysms. High clinical success and acceptable mortality and morbidity contribute to good mid-term results.

Copenhagen, Denmark • 28-30 September 212

Poster Presentations

PO 068 EXPRESSION OF MICRORNA MIR-191, MIR-455-3P AND MIR-1281 IN PATIENTS WITH ABDOMINAL AORTIC ANEURYSM AND THE ROLE AFTER ENDOVASCULAR REPAIR

Institution: Surgery and Anatomy, Ribeirao Preto Medical School University of Sao Paulo, Ribeirão Perto, Brazil

Authors presenting: Edwaldo E. Joviliano, Emanuel R. Tenorio, Daniela P. D. C. Tirapelli

Introduction: MicroRNAs (miRNAs) are small sequences of non-coding RNAs that control diverse cellular functions by promoting degradation or inhibition of translation of specific mRNAs. Profile aberrant expressions of miRNAs have been linked to human diseases, including cardiovascular dysfunction. The aim of this study was to evaluate the expression and the response of microRNAs to endovascular repair of abdominal aortic aneurysm (AAA) based on serum levels.

Methods: This was a prospective study including thirty consecutive patients undergoing elective endovascular repair for abdominal aortic aneurysm without endoleaks following 180 days. Total RNA was extracted from whole blood samples of patients with AAA and is then made to quantify miR-191, miR-455-3p, and miR-1281 (known hyper expressed in patients with AAA) with specific probes two moments: preoperative and 180 days after surgery.

Results: Thirty patients were enrolled (4 females, 13%; mean age 68 ± 9 years, average diameter of AAA: 5.8 ± 0.8 cm). Samples were divided into two groups (pre and post treatment). These data showed that miR-191, miR-455-3p, and miR-1281 have elevated serum expression in patients with AAA and serum levels of the evaluated miRNAs were significantly lower after 180 days postoperatively (miR- 191 = p <0.0001; miR-455-3p = p <0.0007 and miR-1281 = p <0.0001).

Conclusion: The treatment of the aneurysm with endovascular repair leads to a decrease in serum levels of the microRNAs miR-191, miR-455-3p, and miR-1281 suggesting a possible use as biomarkers for patients with AAA. Further studies are necessary to validate these findings.

Copenhagen, Denmark • 28-30 September 213

Poster Presentations

PO 069 EPIDEMIOLOGY OF ABDOMINAL AORTIC ANEURYSM IN PORTUGAL – WHAT HAS CHANGED OVER 15 YEARS?

Institution: São João Hospital Center, Faculty of Medicine, University of Porto, Porto, Portugal

Authors presenting: Marina Dias-Neto, José F. Ramos, Alberto Freitas

Introduction: Recent studies from United Kingdom, Sweden, Australia and New Zeeland have shown reductions in abdominal aortic aneurysm (AAA) incidence, prevalence and mortality (1). Weather this is happening in Portugal is unknown and these findings may have implication for screening programs. The aim of this study is to determine trends in AAA incidence and mortality in Portugal.

Methods: Cause-specific mortality provided from National Institute of Statistics and hospital admissions and repair procedures related to ruptured and nonruptured AAA were obtained from 2000 to 2014. Poisson regression was used to estimate the variation over time of the following variables: incidence of admissions and repair procedures due to ruptured and non ruptured AAA (subanalysis by gender and by age <75 years old or ≥75 years old), age at the time of admission due to ruptured and nonruptured AAA, hospital mortality (ratio between number of admissions where patient end up to die and total number of admissions) and national mortality (ratio between number of deaths and total number of residents). To account for changes in age structure of the population over time, age direct standardization was performed (using World Health Organization world standard population).

Results: From 2000 to 2014, admissions due to ruptured AAA and repair procedures of ruptured AAA increased, respectively, 2.3% (p=0.021) and 2.2% (p=0.038) per year (Figure 1). Admissions due to ruptured AAA that was not submitted to repair remain constant during that period. The growth of admissions due to ruptured AAA was statistically significant in men (p=0.027) but not in woman and in patients ≥75 years old (p=0.006) but not in patients <75 years old. In the same period, admissions due to nonruptured AAA and repair procedures of nonruptured AAA increased, respectively, 2.4% (p<0,001) and 6.9% (p<0,001) per year. Repair of nonruptured AAA increased both in men (6.9%, p<0.001) and in women (6.4%, p<0.001), in patients with ages <75 years old (6.2%, <0.001) and ≥75 years old (8.7%, p<0.001). Hospital mortality for nonruptured AAA decreased 4.6% per year (p<0.001) but remain constant for ruptured AAA. In the second half of the analysed period, AAA- specific mortality decreased 3.6% per year (p=0.019) per year. Image:

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Poster Presentations

Conclusion: Differently from other Western countries, incidence of admissions due to ruptured AAA and hospital mortality have not decreased in Portugal. Patients admitted due to ruptured AAA have become older and more often men. The lower hospital mortality in nonruptured AAA repair might reflect improvements in the treatment provided to these patients and contribute, at least in part, to the observed lower AAA-specific mortality.

References: (1) Choke E, Vijaynagar B, Thompson J, Nasim A, Bown MJ, Sayers RD. Changing epidemiology of abdominal aortic aneurysms in England and Wales: older and more benign? Circulation. 2012 Apr 3;125(13):1617-25.

Copenhagen, Denmark • 28-30 September 215

Poster Presentations

PO 070 ADJUSTED HOSPITAL OUTCOMES REPORTED IN THE DUTCH SURGICAL ANEURYSM AUDIT AFTER THE FIRST YEARS OF REGISTRATION OF ACUTE ANEURYSM SURGERY

Institution: 1. Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands 2. Lieve Vrouwe Gasthuis, Amsterdam, The Nethelrands 3. Leiden University Medical Center, Leiden, The Netherlands

Authors presenting: Niki Lijftogt, Anco Vahl, J.F. Hamming

Introduction: The Dutch Surgical Aneurysm Audit (DSAA)1 was introduced in 2012 and mandatory since 2013 for all primary, acute and elective, Abdominal Aortic Aneurysm (AAA) operations in the Netherlands. In order to identify best practise, hospital outcomes have to be risk-adjusted for patient- and disease specific characteristics. The aim of this study was to present the first results after acute symptomatic (SAAA) and ruptured (RAAA) aneurysm surgery, investigate the clinical validity of the V-POSSUM2 and use a modified Vascular (physiology only)-POSSUM3,4 as a base for risk-adjustment for hospital comparisons.

Methods: From January 2013-December 2014 all acute operated patients were included for analysis. The calibration and discrimination was analysed according to Hosmer-Lemeshow and the C-statistic by means of V-POSSUM. Hospital mortality was risk-adjusted by the modified V p)-POSSUM with setting included and re-estimated on the Dutch population or by the original model, plotted by hospital volume.

Results: A total number of 1319 patients had acute AAA surgery and were included for further analysis. EVAR was performed in 39.3%. Mortality was 15.6% and 27.4% after EVAR and OSR respectively. Observed mortality after RAAA + EVAR was 22.2% and 32% after RAAA + OSR. Observed SAAA mortality was 5.2% after EVAR, compared to 10.5% after OSR. V-POSSUM predicted mortality differed only significantly for RAAA OSR patients 28.6% (95% CI; 25.5-31.5) compared to observed mortality. Calibration of V-POSSUM was lacking with a higher expected mortality than observed in the high-risk groups, and a lower expected mortality in the low-risk groups. (Hosmer-Lemeshow p<0.001) The overall discriminative ability of V-POSSUM was moderate, with a C-statistic of 0.713. Outcome in low volume hospitals was highly dependent of chance. The percentage of EVAR was higher in high-volume hospitals, though not significant. Risk-adjustment by the re-estimated modified V(p)-POSSUM did have effect on variation between hospitals and changed hospital positions. Image:

Conclusion: Overall postoperative mortality was in line with the literature. Prediction by means of V-POSSUM showed significant differences for RAAA OSR patients compared with the population the model originated from while EVAR has become increasingly important. When comparing hospitals, risk- adjustment for case-mix has shown to be important considering the change in hospital position. An updated use of the variables present in the V(p)-POSSUM with setting included can be helpful for future perspectives.

Copenhagen, Denmark • 28-30 September 216

Poster Presentations

Copenhagen, Denmark • 28-30 September 217

Poster Presentations

PO 071 ROBOTIC INFERIOR VENA CAVAL SURGERY

Institution: Surgery, Mayo Clinic Arizona, phoenix, United States

Authors presenitng: Samuel MoneyWilliam Stone, Victor Davila, Richard Fowl, Erik Castle

Introduction: Inferior vena caval (IVC) surgery is uncommon and has traditionally been performed through open surgical approaches. Renal cell carcinoma with IVC extension generally requires vena cavotomy and reconstruction. Open removal of malpositioned IVC filters is occasionally required after failed attempts at endovascular retrieval. As our experience with robotic surgery has advanced, we have applied this technology to surgery of the IVC. We reviewed our institution’s experience with robotic surgical procedures involving the IVC to determine its safety and efficacy

Methods: A retrospective review of all patients undergoing robotic surgery from 2011 to 2014 was performed. Operative reports that specifically included cavotomy and repair were included. Data was obtained detailing pre-operative demographics, post-operative morbidity and mortality.

Results: Ten (6 male) robotic vena caval procedures were performed at our institution. Seven patients (70%) underwent robotic nephrectomy with removal of IVC tumor thrombus and retroperitoneal lymph node dissection. Three patients (30%) underwent robotic explantation of an IVC filter after multiple failed endovascular attempts at removal. The mean age of patients with renal cell carcinoma was 65.4 years (range 55-74 years). Six (86%) patients had right sided malignancy. All patients had T3b lesions at time of diagnosis. Mean tumor length extension into the IVC was 5cm (range 1-8 cm). Average operative time for patients undergoing surgery for renal cell carcinoma was 273 minutes (range 137-382 minutes). Average intraoperative blood loss was 428mL (range 150-1200 mL). The mean age of patients with IVC filter removal was 33 years (range 24-41years). Average time from IVC filter placement until robotic removal was 35.5 months (range 4.3-57.3 months). Before patients were offered robotic IVC filter removal, a minimum of 2 endovascular retrieval attempts were performed. Average operative time for patients undergoing IVC filter removal was 163 minutes (range 131-202 minutes). Average intraoperative blood loss was 250mL (range 150-350 mL). All procedures were completed robotically. The mean length of stay for all patients was 3.5 days (range 1-8 days). All patients resumed ambulation on post-operative day one. Regular diet was resumed in 9 of 10 patients (90%) on post-operative day two. One patient with a renal tumor sustained a colon injury during initial adhesiolysis which was recognized at the initial operation and repaired robotically. Robotic radical nephrectomy and caval tumor removal was then completed. Three (30%) patients received blood transfusions post-operatively and none required intraoperative blood transfusion.

Conclusion: Robotic IVC surgery is uncommon. Our initial limited experience demonstrates the safety and efficacy of robotic IVC surgery.

Copenhagen, Denmark • 28-30 September 218

Poster Presentations

PO 072 THE PREVALENCE OF CHRONIC VENOUS DISEASE WORLDWIDE, AN EPIDIOMOLOGICAL ANALYSIS. THE FINAL RESULTS OF THE VEIN CONSULT PROGRAM

Institution: 1. Department of public health Biostatistics Unit, University of Ghent, Gent, Belgium 2. Vascular Surgery, University Hospitals of Leuven, Leuven, Belgium 3. Department of Cardiovascular and Thoracic Surgery, University Hospital Mont-Godinne, Mont- Godinne, Belgium 4. Vascular Surgery, University Hospital of Brussels, Brussel, Belgium

Authors presenting: Marc E. Vuylsteke, Roos Colman, Sarah Thomis, Geneviève Guillaume, Ivan Staelens

Introduction: The purpose of this study is to measure the prevalence of chronic venous disease worldwide and to look for intercontinental differences. Also the possible influence of risk factors was assessed.

Methods: A survey was carried out in 23 different countries. Patient recruitment was done by general practitioners (GP). Each GP screened 10-20 consecutive patients older than 18 years. Patient characteristics, prevalence of risk factors, symptomatology and C-classification were noted. We looked for possible differences in prevalence and risk factors in different geographic areas: Asia(A), Eastern Europe(EE), Latin America(LA)and Western Europe(WE).

Results: In total 120338 patients were included. The average age was 52.3 years and the female predominance 69.32 %. In total 69.94 % of included patients were diagnosed having CVD (C1-C6). Chronic venous insufficiency (CVI) (C3-C6) was noted in 32.3% and advanced venous disease (AVD) (C5-C6) in 9.09%. The prevalence of respectively CVD (51.9% A, 70.18% EE, 68.11% LA, 73.36% WE), CVI (19.84% A, 29.9% EE, 26.62% LA, 36.45% WE) and AVD (1.28% A, 2.87% EE, 3.96 LA, 14.02% WE) was significantly higher in Western Europe. Estimated probabilities for having CVD, CVI and advanced VD, corrected for age and separately reported for gender, confirms the regional disparities. Estimated probability for a female patient (average age 52.3y) having AVD was 6.4% in WE compared to 1.1% in A, 1.5% in EE, 1.8% in LA. Risk factors such as age and body mass index (BMI), smoking, having regular exercise and having a positive family history differ significantly between regions. Patients in WE (median 55 years) and EE (median 56years) were significantly older than those from LA (median 43 years) and A (median 45 years). Obesity (BMI>30) was higher in EE (27.57%) compared to WE (17.75%), LA(16.7%) and A(15.12%). The number of births differs significantly between regions with the highest number in A followed by WE, LA and EE. A major risk factor, family history of CVD, varies significantly between the regions, with the highest rate in LA (50.27%) and lowest rate in A (19.97%). Regular exercise and smoking are more commonly noted in WE, respectively 41.32% and 23.84%, compared to other regions. Model-based probabilities with age as a categorical variable (age groups 18-34y, 35-50y, 50-65y, and <65years) corrected for risk factors were calculated. Depending on the age-group and gender most risk factors had a significant effect on the probability for CVD. Only in the age group more than 65years old, significant differences in the probability of CVD, CVI and advanced VD, between the different regions could be found. The highest prevalence was noted in WE.

Conclusion: Chronic venous disease is very common and the prevalence differs between the different geographical areas. However after correction for risk factors, only in the older female age group (>65y)a significant difference in probability could be retained.

Copenhagen, Denmark • 28-30 September 219

Poster Presentations

PO 073 VARICOSE VEIN SURGERY, DOES IT MATTER WHO DOES IT?

Institution: 1. Vascular Surgery, Hospital São João, 2. Physiology and cardiothoracic surgery department, FMUP, Porto Portugal 3. Hospital São João, Porto, Portugal 4. Hospital Padre Américo, Penafiel, Porto, Portugal 5. Hospital Santa Maria, Lisboa, Portugal 6. Hospital Universitário de Coimbra, Coimbra, Portugal 7. Hospital Santa Marta, Lisboa, 9Hospital de Gaia, Gaia, Portugal

Authors presenting: Ricardo Castro-Ferreira, Alberto Freitas, José Pinto, Dalila Rolim, José Vidoedo, Emanuel Silva, André Marinho, Rodolfo Abreu, Andreia Coelho, Paulo Gonçalves-Dias, Sérgio M. Sampaio, Adelino Leite-Moreira, Armando Mansilha 1José F. Teixeira

Introduction: Varicose vein (VV) surgery is the most common vascular procedure in Europe. It is a technique frequently performed by surgeons without vascular specialization. We aim to describe the frequencies and compare the results of VV surgery in Portugal, performed by vascular or general surgeons.

Methods: Every patient submitted to VV surgery between 2004 and 2014, whose information was contained within in the national administrative database of healthcare was included in the study. In a random sample of 275 patients (145 from 6 departments of vascular surgery and 130 of 7 departments of general surgery) a phone enquiry was performed.

Results: Close to 124000 patients were identified, 48% were operated by general surgery, 39% by vascular surgeons and in 13% it was not possible to identify the specialty. Nineteen deaths were registered (no differences between groups). In the general surgery group, 15% of patients were hospitalized for 3 or more nights compared to 3% in the vascular group (p<0.001). The evaluation of the 275 phone enquires revealed that patients operated by vascular surgeons have less residual varices (p<0.001), are more satisfied with the surgical scars (p<0.001), are less time absent from work (27 vs 41 days, p<0,001) and return faster to routine exercise (41 vs 60 days, p<0.001). In the vascular group, 90% of the patients would again be operated in the future vs 79% in the general group (p<0.001). The ratio of short vs long stripping of the great saphenous vein was 57/43 in the vascular group and 15/85 in the general group (p<0,001). Short stripping was associated with less post-operative pain (p<0.001) and a faster return to routine exercise (41 vs 54 days, p=0.019). A significant and similar improvement in the quality of live assessed by the CIVIQ-14 score was observed in both groups after surgery. The majority (97%) of the inquired patients had a venous ultrasonography performed prior to surgery, but only a subset of patients of the vascular group (15%) had their VV marked with an ultrasound executed in the moment of the surgery. When that occurred, less residual varices (p<0.001) and higher general satisfaction with the surgery were reported (p=0,031).

Conclusion: In the past 10 years, the majority of VV surgery in Portugal has been performed by general surgeons. This study highlights important advantages when it is performed by vascular surgeons. Should this be enough to promote a praxis change?

Copenhagen, Denmark • 28-30 September 220

Poster Presentations

PO 074 100 ULCERATED LIMBS TREATED WITH ULTRASOUND GUIDED FOAM SCLEROTHERAPY; IS LONG TERM RECURRENCE RELATED TO RECANALISATION?

Institution: Department of Vascular Surgery, Gloucestershire Hospitals NHS, Cheltenham, United Kingdom

Authors presenting: Julia Howard, Clare Wakely, Fiona Slim, Colin Davies, Sachin Kulkarni, Mark Whyman, Richard Bulbulia, Keith Poskitt

Introduction: Long term data from the ESCHAR study demonstrated that superficial venous surgery reduces the risk of ulcer recurrence. The aim of this study was to assess the effect of recanalization with new reflux following ultrasound guided foam sclerotherapy (UGFS) on long term ulcer recurrence in patients with chronic venous ulceration.

Methods: Open (CEAP 6) or recently healed (CEAP 5) chronic venous leg ulcers were treated with UGFS between July 2010 and August 2012. Venous Duplex scans were performed at two weeks and annually for four years. Recanalization was classified as ‘complete’ when the lumen was patent in a previously occluded vein and ‘segmental’ when there was a reduction in the length of occlusion. One, two, three and four-year ulcer recurrence rates were calculated using Kaplan-Meier survival analysis. Two-tailed Chi-Squared test was used to assess association between recanalization and recurrence at 4 years.

Results: A total of 100 limbs were treated in 92 patients; 86 were CEAP 5 and 14 were CEAP 6. At two weeks, complete or short segment occlusion was demonstrated in 99/100 legs. Complete follow-up was 93%, 88%, 80% and 50% at one, two, three years and four years respectively. Seven limbs (five patients) did not undergo a Duplex scan at one year; one patient died of unrelated causes, one patient (two limbs) underwent endothermal treatment, one patient underwent surgery, one patient moved and one patient (two limbs) suffered an unrelated stroke. Complete recanalization with reflux was reported in 17 limbs and segmental recanalization with reflux in 36 limbs at four years. Kaplan- Meier survival analysis showed ulcer recurrence rates at one, two, three and four years as 2.3%, 5.1%, 11.3% and 12.4% respectively. Ulcer recurrence was not associated with recanalization of the treated veins at four years (5/53 recurrences in recanalized veins Vs 5/40 no recurrences in non- recanalized veins; p=0.89, Chi-Squared test).

Conclusion: Long term ulcer recurrence rates were low in this study with recanalization of the treated veins failing to predict long term ulcer recurrence.

Copenhagen, Denmark • 28-30 September 221

Poster Presentations

PO 075 MACROSCOPIC EN HISTOLOGICAL SCORING OF MECHANOCHEMICAL ENDOVENOUS ABLATION USING THE CLARIVEIN DEVICE IN AN ANIMAL MODEL

Institution: 1. Vascular Surgery, UMC Utrecht, Utrecht, The Netherlands 2. Surgery, Rijnstate Ziekenhuis, Arnhem, The Netherlands 3. Vascular Surgery, St Antonius Ziekenehuis, Nieuwegein,The Netherlands

Authors presenting: Doeke Boersma, Steven van Haelst, Ramon van Eekeren, Michel Reijnen, Jean Paul de Vries, Gert Jan de Borst

Introduction: Non-thermal ablation techniques (NTNT) such as Mechanochemical endovenous ablation (MOCA) have been developed to avoid tumescent anaesthesia, and reduce heat-induced (nerve) injury and postprocedural pain . MOCA combines mechanical injury with simultaneous infusion of a liquid sclerosans. Even though MOCA has proven to be a safe therapy and clinical results are promising, the exact working mechanism remains unknown. The aim of our experiments was to study the effect of MOCA on the vein wall.

Methods: In 18 full grown goats a total of 36 lateral saphenous veins (LSV) were treated according to human protocol (Aetoxysklerol 2%, withdrawal 7 seconds per centimeter). Nine goats were enrolled in an acute experiment, with harvesting within 45 minutes, to evaluate acute tissue reaction. Veins of nine other goats were examined six weeks after treatment to determine delayed tissue reaction and venous occlusion. The veins were divided equally over 3 groups: 1. MOCA ablation, 2. mechanical ablation (without sclerosans) and 3. liquid sclerotherapy. The histological effects of treatment non the vein wall and perivenous tissue was systematically evaluated and scored by 2 independent and blinded researchers. This study was conducted according to good laboratory practice and approved by the board on ethics on animal experiments (DEC Utrecht).

Results: The average diameter of the LSV was 4.0±0.5mm at the site of introduction. Technical success was achieved in all but one LSV. The mean treatment time was 14 (9-22) minutes. In the acute experiment, macroscopic evaluation showed that all veins were filled with blood and no perforation or hematoma was observed. Hyperpigmentation was seen after MOCA and sclerotherapy. In the follow-up cohort, no major complications were noted. Histological examination within the acute experiment showed that the mechanical action of the ClariVein device induced only limited injury the endothelium and no damage to other layers of the vein wall. Mechanical ablation (alone or in MOCA) led to significant vasoconstriction in comparison to sclerotherapy. In the MOCA follow-up group, 4 out of 6 veins were fully or partially occluded. The remaining 2 veins showed a patent lumen with limited intimal hyperplasia of 20-25% of the lumen area. The occluded segments consisted mainly of organized thrombus and surrounding intimal hyperplasia (figure 1). No occlusions was seen in both sclerotherapy and mechanical treatment, significantly less compared with MOCA (p=0.036).

Copenhagen, Denmark • 28-30 September 222

Poster Presentations

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Conclusion: Mechanochemical endovenous ablation is significantly more effective than its separated components: mechanical ablation or sclerotherapy. The occlusion consists of a combined organized thrombus and surrounding intimal hyperplasia. Surprisingly, the mechanical action showed only limited damaging effect to the endothelium and no injury to the other layers of the vein wall. Therefore, previous hypotheses of the working mechanism should be revised.

Copenhagen, Denmark • 28-30 September 223

Poster Presentations

PO 076 THE USE OF ULTRASOUND-GUIDED FISTULOPLASTY AND STENTING FOR SALVAGE OF STENOSED ARTERIOVENOUS HAEMODIALYSIS FISTULAE

Institution: St George's Vascular Institute, St George's Vascular Unit, London, United Kingdom

Authors presenting: Kate Stenson, Mark Young, Eric Chemla, Gary Maytham

Introduction: Autogenous and prosthetic arteriovenous accesses are commonly used for the delivery of haemodialysis. These accesses can be affected by the development of stenoses, leading to low volume-flow rates, inadequate dialysis and failure. This study describes the use of ultrasound-guided fistuloplasty (UGF) and stent placement in the management of access stenoses.

Methods: From November 2013, 29 UGF procedures were carried out at our institution by a single surgeon. All of the accesses treated were in the upper limb. The treated accesses included 8 brachiocephalic accesses, 7 prosthetic brachio-axillary accesses, 7 radiocephalic accesses, 7 brachial vein transpositions and 1 ulnar-cephalic access. Access anatomy and function were determined pre-, intra- and postoperatively by duplex ultrasound. Loss of primary patency was considered to be complete occlusion of the access or restenosis requiring further intervention

Results: All 29 procedures involved UGF. Stents were placed in 16 cases. There was a 96.6% technical success rate. One procedure resulted in vessel rupture, which was treated with ligation. The mean increase in brachial artery volume flow was 135% (-25 – 300%). At the time of reporting, the mean primary patency was 241.0 days (13 – 770 days). At the time of reporting, 20 accesses were functioning satisfactorily. 7 patients required further procedures, in these cases the mean primary patency was 160.4 days (13 – 261 days). 2 patients died during the study, in both cases the access was running satisfactorily.

Conclusion: Ultrasound-guided fistuloplasty and stenting is an effective technique for the salvage of stenosed arteriovenous accesses. The technique offers advantages including avoidance of contrast medium and radiation exposure, soft tissue visualization during stent placement, and immediate assessment of access function.

Copenhagen, Denmark • 28-30 September 224

Poster Presentations

PO 077 BASILIC VEIN TRANSPOSITION: SINGLE CENTRE EXPERIENCE

Institution: 1. Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Porto Portugal 2. Centro Hospitalar do Porto - Hosp. Sto. António, Porto, Portugal

Authors presenting: Duarte Rego, Clara Nogueira, António N. Matos, Paulo Almeida, Rui Almeida

Introduction: Maintenance of a good vascular access for hemodialysis is one of today’s Medicine’s challenges. Autologous access’ superiority, both in patency and cost-effectiveness, is acknowledged worldwide. The increasing survival of hemodialysis patients results in the depletion of superficial and cannulatable venous capital justifying the growing interest in the use of basilic vein. In this work we review and describe the results of our series of basilic transpositions.

Methods: Basilic vein transpositions were performed in two stages: first, creation of the fistula; second, transposition of the vein using only 3 small incisions in the arm. Data were retrospectively collected from all procedures made between September 2005 and November 2012. Patency and complication rates were the primary outcomes evaluated.

Results: A total of 276 basilic veins were transposed. It was the first access in 15,9% (n=44) of the cases. 8% (n=22) of the fistulas were never used due to thrombosis. Secondary patency rates at one and two years were, respectively, 84% and 66,3%. Complications occurred in 61,6% (n=170) of fistulas and 65,9% (n=112) of which had to undergo surgical or endovascular revision. The most frequent complication was vein stenosis (39,7% of late complications, n=92).

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Conclusion: Despite its greater technical complexity, transposed basilic vein represents a hemodialysis access with good patency rates. Complication rates, although high, are inferior to those of CVC or prosthetic grafts. These results support the use of the transposed basilic vein as haemodialysis access after the brachiocephalic fistula.

Copenhagen, Denmark • 28-30 September 225

Poster Presentations

PO 078 PROXIMAL RADIAL-CEPHALIC ARTERIOVENOUS FISTULA: IS IT AN OPTION AFTER WRIST ARTERIOVENOUS FISTULA FAILURE?

Institution: Vascular Surgery, Policlinico S.Orsola-Malpighi-University of Bologna, Bologna, Italy

Authors presenting: Raffaella Mauro, Laura Cacioppa, Jacopo Giordano, Rodolfo Pini, Mohammad Abualhin, Gianluca Faggioli, Mauro Gargiulo, Andrea Stella

Introduction: Brachiocefalic fistula (BCF) has been accepted widely as a first option after failure of the radial- cephalic arteriovenous fistula at the wrist (W-RCAVF), but few studies have reported outcomes of another option, i.e. the proximal radial-cephalic arteriovenous fistula (P-RCAVF) and a direct comparison of P-RCAVF with BCF is lacking. Aim of our study is therefore to compare W-RCAVF, P-RCAVF and BCF.

Methods: From January 2013 to December 2015, 486 patients underwent arteriovenous access for hemodialysis and were recorded and retrospectively reviewed. Three groups of 30 patients with similar risk factors were selected blindly for the comparison of W-RCAVF, P-RCAVF and BCF outcomes. All the surgical procedures were performed by a single vascular surgeon. Follow-up was performed at 6, 12 and 24 months and primary and assisted-primary patency rates, early failure rate, ease of cannulation, complications and overall survival were evaluated. Ease of cannulation was defined as an easy identification of the vein through palpation, an easy thrill feeling, and a number of attempts to insert the needle ≤ 2.

Results: The median age for W-RCAVF, P-RCAVF and BCF was 68,7 ± 30.2 years, 67.6 ± 28.5 and 67.2 ± 18.8 respectively and 78.4%, 74.1%, 50.0% were male in each group. Early failure rate was 5.4 %, 3.7 % and 3.3%, respectively (p= 0.90). The primary-assisted patency rate was significantly lower in the P-RCAVF group compared with the two other groups (66.7% vs 84.8%, and 100% at 24 months, p=0.05). The survival rate at 24 months was similar in the three groups (65%, 70% and 62%respectively p=0.61). Ease of cannulation was 100%, 89.9% and 96.8%, (p=0.02), and complication rate were 18.9 %, 22.2 % and 24.1%, respectively. Complications included: 7 haematomas for W-RCAVF, 1 pseudoaneurysm and 5 haematomas for P-RCAVF, 1 case of steal syndrome and 6 haematomas for BCF.

Conclusion: P-RCAVF showed ease of cannulation, early failure, survival and complication rates similar to W- RCAVF and BCF, however primary assisted patency rate is significantly lower. Therefore, our analysis suggests that P-RCAVF is a disadvantageous alternative to BCF, in case of W-RCAVF failure.

Copenhagen, Denmark • 28-30 September 226

Poster Presentations

PO 079 CAN 3-D ULTRASOUND BE USED FOR FINITE ELEMENT ANALYSIS AND COMPUTATIONAL FLUID DYNAMICS OF ABDOMINAL AORTIC ANEURYSMS?

Institution: 1. Department of Vascular and Endovascular Surgery, University Hospital South Manchester 2. Department of Academic Surgery 3. School of Mechanical Aerospace and Civil Engineering, University of Manchester, 4. Independent Vascular Services, University Hospital South Manchester, Manchester, United Kingdom

Authors presenting: Chris Lowe, Ben Owen, Steven Rogers, Wisam Al-Obaidi, Partha Mandal, Alistair Revell, Charles McCollum

Introduction: Modelling of the artery wall and haemodynamic properties via FEA and CFD may provide more patient-specific assessments of rupture risk than maximal diameter alone. Clinical uptake has been limited as CT imaging involving ionizing radiation and nephrotoxic contrast is inappropriate for AAA surveillance. 3-D ultrasound (3D-US) is inexpensive, risk-free and has the potential to provide AAA geometries for biomechanical analysis. AAA geometries derived from 3D-US and CT imaging were compared for their value in biomechanical analysis in 20 AAA patients being assessed for AAA repair.

Methods: Twenty patients undergoing CTa for AAA also underwent magnetically tracked freehand 3D-US on the same day. AAA models from CTa and 3D-US were created by interactive segmentation using ‘ImFusion Suite’ software (ImFusion GmbH). CFD and FEA were performed using commercially available STAR CCM+ and ABAQUS software respectively.

Results: Median AAA (range) diameter in our 20 patients of mean body mass index (BMI) 26.3 kg/m2 was 6.25cm (4.3 – 8.5cm). Three 3D-US images were of inadequate quality due to a combination of tortuous AAA anatomy and high BMI. In 16, not all the anatomical features could be adequately seen or segmented. A 3-D image including the neck, wall, bifurcation, intra-luminal thrombus and patent lumen suitable for both CFD and FEA was created in one patient and used for simulation. On FEA, the location of peak wall stress (PWS) was identified in the same region on the right postero-inferior AAA wall in both the CTa and 3D-US simulations. The PWS in the CTa model was 5.36 MPa and in the 3D-US model was 7.61 MPa (See figure). Assuming the CTa model to be the most accurate, the 3D-US geometry over-estimated the PWS by 42%. In CFD, the overall bulk flow was comparable between simulations derived from both CT and 3D-US. Areas of lowest wall sheer stress (WSS) were identified in similar locations by CT and 3D-US, however WSS values arising from the 3D-US derived data were higher by a factor of 1.5 - 2 than values from the CTa data.

Copenhagen, Denmark • 28-30 September 227

Poster Presentations

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Conclusion: Biomechanical simulation of AAAs using 3D-US is challenging but feasible. Both FEA and CFD are highly sensitive to small geometrical differences; hardware and software development is required to both improve image quality and precision for biomechanical analysis. Upgrading the US imaging instrument, developing ECG-gating for US image acquisition, the use of ultrasound contrast and switching to an optically-tracked 3D system are likely to provide significant improvements.

Copenhagen, Denmark • 28-30 September 228

Poster Presentations

PO 080 FEASIBILITY OF AN INTRAOPERATIVE CONTRAST-ENHANCED CONE BEAM CT IMAGE FUSION FOR NAVIGATION GUIDANCE IN FENESTRATED AND BRANCHED EVAR

Institution: Vascular Surgery, UMC Utrecht, Utrecht, The Netherlands

Authors Presenting: Quirina D. De Ruiter, Frans L. Moll, Joost A. van Herwaarden, Constantijn E. Hazenberg

Introduction: To develop and validate a methodology for 3D image guidance technique for complex abdominal endovascular aortic repair that excludes the need for image co-registration and includes aortic deformation by stiff wires or stent delivery grafts, using contrast-enhanced cone-beam computed tomography (ce-CBCT).

Methods: A 3D ce-CBCT was considered in patients undergoing a fenestrated or branched EVAR intervention, with a minimum of 3 target vessels in the visceral area (TVs), and an adequate kidney function. The ce-CBCT was acquired in all cases using the Abdomen XperCT Roll protocol (10 sec rotation time and 2 sec scan time delay), with the Philips Allura FD 20 Clarity system installed in a hybrid operation room. The ce-CBCT was planned after stent graft insertion, to include the aortic vessel deformation by the stent graft delivery system, but before stent graft deployment. Optimal contrast protocol (flow, volume, contrast dilution) and XperCT post-processing parameters (cube size, reconstruction filters, image resolution, vessel segmentation and viewing settings) were optimized in the development phase. In the validation phase, ce-CBCT was acquired by a standardized contrast and acquisition protocol and was incorporated into the standard workflow for complex EVAR. Primary endpoint in the development phase was feasibility of the ce-CBCT to assist during TV vessel cannulation. Primary endpoint in the validation phase were sharpness of the 3D ce-CBCT as the primary overlay (at a 5-points scale, from very bad to very good) rated by a single observer, and if adequate visualization of all required TV origin’s was reached. Secondary endpoints were the procedural outcome regarding procedure time, contrast volume, and radiation dose parameters.

Results: In 29 patients undergoing a fenestrated or branched EVAR, a ce-CBCT was successfully acquired. In 7 interventions, the development phase, image overlay was shown feasible, but vessel outline sharpness fluctuated between interventions due too inadequate contrast dilution (30-40% contrast dilution). The minimum contrast volume that we found to maintain a minimum (moderate) sharpness vessel outline in all interventions was achieved at a flow of 8 ml/s, with a of 45% (for juxta-renal) and 50% for suprarenal aneurysms contrast dilution, and 100ml of total volume per scan. The median age of the 22 patient, from undergoing a fenestrated or branched EVAR where the ce-CBCT with the standardized protocol was 74 ±7.9) year; mean BMI was 26.6 ±3.4. Sharpness of the vessel outline was rated as moderate in 3 interventions (13%), good in 5 interventions (23%) and very good in 14 interventions (64%). Using the standardized protocol 74 of the 76 TV origin vessel outlines could be segmented and visualized intraoperative. Median contrast volume was 180 ml [140, 220], median [IQR]) Fluoroscopy time was 92.5 min [69, 113], median [IQR]), Dose Area product was 461 Gycm2 [342, 611] and median [IQR]), and Cumulative Air Kerma was 3.0 Gy [2.6, 4.0]. The mean DAP for a single ce-CBCT was 16.5 ±3.1 Gycm2, which was 4.6 ±2.5 % of the cumulative DAP dose.

Conclusion: The use of ce-CBCT for 3D image guidance for fenestrated and branched EVAR is feasible, when the contrast and acquisition parameter settings are optimized, and provides a valuable alternate to image fusion with pre-operative CTA.

Copenhagen, Denmark • 28-30 September 229

Poster Presentations

PO 081 ACCURATE ENDOLEAK DIAGNOSIS USING TEMPORAL INFORMATION OBTAINED ON CONTRAST ENHANCED ULTRASOUND IMAGING

Insitution: 1. Liverpool Vascular & Endovascular Service, Liverpool, United Kingdom, 2. Vascular Laboratory, Liverpool Vascular & Endovascular Service, 3. Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom

Authors Presenitng: Iain Roy, Alexandra Colby, Steven Wallace, Gabriela Czanner 3Srinivasa Vallabhaneni 1

Introduction: Accurate diagnosis of endoleaks is important to prevent failure of endovascular aneurysm repair. The main imaging modalities of post-EVAR surveillance, Enhanced CT and Duplex sonography are capable of demonstrating endoleaks and the type of endoleak is assumed from its anatomical relationship. Coherence contrast ultrasound imaging with newer contrast agents (CEUS) improves sensitivity of detection of blood flow. Since blood flow enhancement could be noted in real time, we envisaged further benefits.

Methods: The aims of our study were: 1) Establish the feasibility of measuring temporal characteristics of endoleak enhancement in relation to stent-graft flow lumen, 2) establish if temporal characteristics can be used to distinguish endoleak types, and 3) establish the temporal cut-off to distinguish graft- related endoleaks from type II endoleaks. Video files of all CEUS scans (May 2010 – July 2015) where reviewed by one of two observers blinded to diagnosis. Time delay between contrast opacification of stent-graft lumen and of the endoleak were measured. Final diagnosis of endoleak type was established by review of CEUS, CT Angiography, Catheter angiography and MDT minutes.

Results: From a total of 118 CEUS scans, 65 with an endoleak had a recording sufficiently archived to allowtemporal characteristics to be reviewed. Nine of these were Type I/III endoleaks and 56 type II endoleaks. Natural LOG transformation was used to establish normal distribution. Independent T- Test confirmed a difference in mean 1.1 (95% CI, 1.1-2.1, p<0.001). Binomial Logistical Regression & ROC curve analysis established optimum cut off time to differentiate endoleak types as 3.41 seconds, with a Sensitivity of 1.0 (95% CI, 0.66-1.0) and Specificity of 0.91 (95% CI, 0.80-0.97).

Conclusion: CEUS can be used to document temporal characteristics of endoleaks, making it a highly Sensitive and Specific method of distinguishing graft-related endoleaks from type II endoleaks. This require external validation before widespread use.

Copenhagen, Denmark • 28-30 September 230

Poster Presentations

PO 082 THE ROLE OF SHORT-TERM HIGH-DOSE PREPROCEDURAL STATIN TREATMENT IN PREVENTION OF CONTRAST-INDUCED NEPHROPATHY

Insitution: Vascular Surgery, Jeroen Bosch Hospital 's - Hertogenbosch, The Netherlands

Authors Presenitng: Ruben Strijbos, Jan Willem Hinnen, Olivier Koning

Introduction: The administration of intravascular contrast media is frequently used in diagnostic and therapeutic interventions in clinical practice. Contrast-induced acute kidney injury (CIAKI) is an important complication, which might lead to persistent worsening of the renal function and even the need of dialysis. Furthermore, CIAKI has been associated with prolonged hospitalisation, expansion of costs and increased morbidity and mortality. Besides their lipid-lowering effect, statins possess also anti- inflammatory, antithrombotic and antioxidant effects, so administration of statins before a procedure with iodinated contrast media may be helpful in prevention of CIAKI.

Methods: A literature study was conducted and PubMed and the Cochrane Library were searched. Last few years several randomised controlled trails were performed to determine the efficacy of short-term high-dose statins pretreatment, so the search was restricted to meta-analyses. A total of 5 studies were eligible and reviewed.

Results: All meta-analyses found a significant reduction in the risk of CIAKI with short-term high-dose preprocedural statin treatment compared to treatment with a placebo and/or low-dose statin pretreatment (figure 1). A subanalysis according to the risk factors chronic kidney disease and diabetes mellitus showed also significant risk reduction with administration of statins compared to the control population. Finally, in a pooled cohort of 4042 patients was hemodialysis necessary in 6 patients; none of these patients did receive short-term high-dose statins preprocedurally.

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Copenhagen, Denmark • 28-30 September 231

Poster Presentations

Conclusion: Recent meta-analyses show the efficacy of short-term high-dose preprocedural statin treatment in patients undergoing procedures with intravascular contrast media. Nevertheless, future research will be necessary before implantation in clinical practice, focussing on optimal treatment strategies for the different procedure and patient populations with consideration of possible adverse events.

Copenhagen, Denmark • 28-30 September 232

Poster Presentations

PO 083 ANALYSIS OF PREOPERATIVE CT AND CAROTID PLAQUE GENE EXPRESSION DEMONSTRATE ASSOCIATIONS BETWEEN CALCIFICATION AND PLAQUE-STABILIZING PROCESSES

Insitution: 1. Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden 2. Vascular Centre, Skåne University Hospital, Malmö, Sweden 3. Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden 4. Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden

Authors Presenting: Eva Karlöf, Nuno Dias, Håkan Almqvist, Claes Bergmark, Lars Maegdefessel, Ljubica Perisic, Ulf Hedin

Introduction: Unstable carotid stenosis is one of the major extra cranial causes of embolic stroke, where we currently lack diagnostics to identify patients and plaque with increased risk. The purpose of this study was to examine the association between plaque calcification estimated by pre-operative Computed Tomography (CT) and molecular pathways in carotid plaque to clarify whether this parameter sharpens the assessment of plaque instability.

Methods: Plaques from patients with symptomatic (S, defined as TIA, minor stroke or amaurosis fugax) and asymptomatic (AS) carotid stenosis (>70% NASCET) were part of the Biobank of Karolinska Endarterectomies (BiKE). Calcification ratio was measured on pre-operative CT angiography using the TeraRecon software, with calcification threshold set to >400 HU. Two non-overlapping cohorts were included in the study: pilot cohort comprising n=2 high-calcified plaques (calcification ratio 17% and 36%) and n=2 low (5% and 5%); and an extended discovery cohort with n=19 high-calcified (calcification ratio 18-65%) and n= 21 low-calcified plaques (0-9%). All groups were corrected for the number of S and AS patients. RNA isolated from the plaques was analysed with the global gene expression analysis (Affymetrix microarrays), followed by gene set enrichment and pathway mapping performed on differentially expressed genes. Results were adjusted for age and gender, as well as for multiple comparisons using Bonferroni correction. Significance was considered when p <0.05.

Results: A strong correlation was found between the calcification ratio and gene expression alterations where the most up regulated genes in high-calcified plaque were lncRNA MALAT1 (86 fold, x), myocardin (8x) and smooth muscle actin (5x). Some of the most down-regulated genes were MMP7 (-9x), LPL (-6x), and CD36 (-4.5x). The most enriched biological pathways in high-calcified plaque were osteoblast differentiation (10.3x, p = 0.03), bone formation (9.4x, p = 0.0001), cell proliferation (2.8x, p = 0.02), smooth muscle contraction (13.4, p = 0.02), extracellular matrix organization (5.6x, p = 0.03) and the regulation of blood vessel size (8.9x, p = 0.049) while the foam cell differentiation (- 18.4x, p <0.0001), the regulation of cholesterol storage (-42x, p <0.0001) and collagen catabolism (- 15.3x, p = 0.002) were down-regulated.

Conclusion: The results suggest that the calcification ratio is associated with gene expression in carotid plaques where a high degree of calcification correlates with biological pathways that contribute to plaque stability. Assessment of the calcification ratio by CT angiography can be a tool for the evaluation of plaque vulnerability. Further efforts will focus on extended pathway and network analysis based on gene expression in high- vs. low-calcified plaques as well as experimental validation of the findings in the disease tissue.

Copenhagen, Denmark • 28-30 September 233

Poster Presentations

PO 084 THE RELATIVE THROMBUS AREA IS RELATED TO THE RELATIVE THROMBUS VOLUME AND PREDICTS PEAK WALL STRESS IN ABDOMINAL AORTIC ANEURYSMS

Insitution: 1. Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden 2. Department of Solid Mechanics, Royal Institute of Technology, Stockholm, Sweden

Authors Presenting: Antti Siika, Moritz Lindquist Liljeqvist, Rebecka Hultgren, Christian Gasser, Joy Roy

Introduction: Recent publications regarding abdominal aortic aneurysm (AAAs) have investigated a novel measure called the thrombus ratio, and shown that it relates to the growth of the AAA. It is, in the transverse section of the AAA, the ratio between the area of the lumen (inner area, IA) and the area of thrombus. However, it has not been established how this measure relates to the true 3D volume ratio or to finite element analysis (FEA)-derived biomechanical parameters. We aim to assess how the ILT-area-ratio correlates to the ILT-volume-ratio and to biomechanical rupture parameters.

Methods: FEA and radiologic measurements were performed in 51 patients that had asymptomatic AAAs with high-quality CTAs available. Radiologic measurements also were performed in CTAs of 38 ruptured AAAs. At the location of the maximal diameter, the diameter, the lumen area and the vessel area were measured perpendicularly to the centerline. FEA was performed to calculate volumetric and biomechanical parameters of the asymptomatic AAAs, using A4 Clinics Software (VASCOPS, Austria).

Results: The ILT-area-ratio was closely related to the ILT-volume ratio (r = 899, 95% CI [0.823 - 0.942]; p < 2.2*10-16). The ILT-area-ratio showed an inverse relation to PWS (r = -.517 [-.694 - -.281]; p = .0001035). The maximal diameter was also associated with PWS (r = .535 [.304 - .706]; p = 5.279*10- 8). The IA showed a stronger, positive, correlation to PWS than did the ILT-area-ratio (r = .659 [0.468 - 0.791]; p = 4.336*10-8). The lumen volume showed an even stronger relation to PWS than did the IA, r = .783 [.647 - .871] (p = 1.149*10-8).For an additional 30 patients with ruptured AAA 2D- radiologic characteristics were assessed. There was no difference in mean ILT-area-ratios between ruptured AAAs and non-ruptured AAAs, 51.13% (SD=26.73%) vs 59.39% (SD=25.33) (p=0.1198369). There was a difference between these groups with regards to maximal diameter, 57.8 mm (SD=8.9 mm) vs 79.2 mm (SD=17.95 mm) (p=2.211391*10-9).

Conclusion: The 2D ILT-area-ratio is related to the 3D ILT-volume ratio of the complete vessel. Both measures showed a negative correlation to PWS. The lA showed a strong positive correlation to PWS, which was stronger than the correlation displayed by maximal diameter. These results suggest that the ILT- area-ratio is a good proxy for the total 3D ILT-volume-ratio and that the reported increase in growth with an increasing ILT-area-ratio works via a mechanism that is independent from PWS.

Copenhagen, Denmark • 28-30 September 234

Poster Presentations

PO 085 CAROTID PLAQUE INFLAMMATION ASSESED WITH 18F-FDG PET/CT AND LP-PLA2 IS HIGHER IN SYMPTOMATIC PATIENTS

Insitutoin: Angiología y Cirugía Vascular, Nuclear Medicine Department, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES) Fundación para la Investigación Biomédica del HUG , Hospital Universitario de Getafe, Madrid, Getafe, Madrid, Spain

Auhtors presenting: Alicia Bueno, Francisco Acín, García Pilar, Cristina Cañibano, Antonio Ferruelo, Jose L. Fernandez- Casado

Introduction: Identifying parameters that might suggest biological activity in carotid artery plaques inducing clinical symptoms, would improve the actual risk stratification that would lead to better treatment decisions. The aim of this study is to asses the level of agreement between of 2-deoxy-2-[18F]fluoro-D-glucose (18F-FDG) uptake on positron emission tomography (PET) scan in carotid artery plaques, plasmatic levels of Lp-PLA2 and cerebrovascular symptoms.

Methods: 48 consecutive patients with carotid stenosis >70% and scheduled for endarterectomy or carotid stent were included in the study from november 2011 to september 2015. Clinical characteristics and cardiovascular risk factors were registered. 45 patients were examined with a hybrid PET/CT and SUVmax values were taken for analysis. Blood samples from 29 patients were taken and plasma stored at -70ºC for subsequent Lp-PLA2 analysis. Plasma Lp-PLA2 levels were determined using commercial kits (Human PLA2G7/PAF-AH/Lp-PLA2 DPLG70 from R&D Systems, UK) following manufacturer´s recommendations. The Lp-PLA2 kit has a minimum detectable concentration of 0.074 ng/mL. The local Commitee for Medical Research Ethics approved the study and informed written consent was obtained from all patients.

Results: There was no statistical significant difference between symptomatic and aymptomatic groups regarding age, gender, hypertension, diabetes, hypercholesterolemia and smoking history. Prior history of coronary artery disease was more frequent in asymptomatic carotid stenosis (p=0.025). Peripheral arterial disease was more frequent in asymptomatic carotid stenosis (p=0.012). 18F-FDG uptake was significantly higher in symptomatic carotid plaques, with median SUVmax 1.9 in symptomatic plaques, and 1.4 in asymptomatic plaques (p<0.001). Lp-PLA2 plasmatic levels were significantly higher in symptomatic plaques, with a median 74.9 ng/ml in asymptomatic plaques and 190.2 ng/ml in symptomatic plaques. HsPCR levels were significantly higher in patients with symptomatic carotid plaques (p=0.022).

Conclusion: 18F-FDG uptake on PET/CT and plasmatic levels of Lp-PLA2 show statistical significant correlation with symptomatic status of carotid plaques. These results ratify previous reports and provide further evidence supporting the use of 18F-FDG PET/CT for the detection of inflammation of atherosclerotic plaques. Different model designs are needed to elucidate between a simple marker or a casual role of Lp-PLA2 in atherosclerosis.

Copenhagen, Denmark • 28-30 September 235

Poster Presentations

PO 086 DOES DUPLEX VELOCITY RATIOS MEASUREMENT RENDER GRADING OF CAROTID ARTERY STENOSIS MORE RELIABLE?

Insitution: Vascular Surgery, L. Rydgier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland

Authors presenting: Arkadiusz Migdalski, Artur Krzywicki, Paweł Brazis, Radosław Piotrowicz, Patryk Włoszczyk, Krzysztof Lackowski, Arkadiusz Jawień

Introduction: A number of different criteria are used to grade carotid artery stenosis in duplex scan investigations. Walker and Naylor have shown that in some cases practitioners are not sure where the criteria they use come from or how they were derived. A recording of peak systolic velocity (PSV) in the jet point of narrowest part of carotid plaque is still one of the most commonly used method. Resent recommendations advocate peak systolic velocity (PSV) and end-diastolic velocity (EDV) recording in both internal and distal common carotid arteries; the use of internal carotid PSV of >1.25 m/s and >2.3 m/s and a Peak Systolic Velocity Ratio of >2 and >4 to indicate >50% and >70% stenosis respectively; and the use of the St Mary’s Ratio to grade >50% stenoses in deciles. The aim of our study was to assess the usefulness of Peak Systolic Velocity Ratio and St Mary’s Ratio measurement to be more precise in duplex scan internal carotid artery stenosis grading comparing to Peak Systolic Velocity (PSV) measurement alone.

Methods: 71 consecutive patients (85 carotid arteries) with moderate and severe carotid stenosis (≥50%) were included into the present study. 19.7 % of examined patients had bilateral carotid stenosis (n=14). The median stenosis calculated with PSV criteria was 50% (Range 50-90%). The median stenosis calculated with Complex criteria was 50% (Range 40-90%). Bland and Altman plot analysis was used to compare two clinical methods of measurement (PSV alone vs complex criteria: PSV, PSV Ratio, St Mary’s Ratio).

Results: Only 44 measurements (51,8%) were identical for both methods. Single PSV measurement compared to complex criteria would deliver 11 (24,4%) overestimated measurements for 50% stenosis and 4 (57,1%) for 70% stenosis.

Conclusion: Bland and Altman analysis clearly shows that measurement of carotid stenosis using only PSV cannot be used interchangeably with complex criteria. Our study shows that using only PSV to evaluate degree of internal carotid artery stenosis means that in most cases stenosis is calculated as greater than using complex criteria. Basing of our study results we conclude that the use of ICA PSV alone in grading stenosis cannot be regarded a safe approach we should routinely recourse to PSV and St Mary’s ratios measurement in all cases of significant ICA stenosis.

References: 1. Walker J, Naylor AR. Ultrasound based measurement of carotid stenosis >70%: an audit of UK practice. Eur J Vasc Endovasc Surg 2006;31:487-490. 2. Oates CP, Naylor AR, Hartshorne T, Charles SM, Fail T, Humphries K, Aslam M, Khodabakhsh P. Joint Recommendations for Reporting Carotid Ultrasound Investigations in the United Kingdom. Eur J Vasc Endovasc Surg (2009) 37, 251-261.

Copenhagen, Denmark • 28-30 September 236

Poster Presentations

PO 087 DUPLEX AND CONTRAST-ENHANCED ULTRASOUND VERSUS COMPUTED TOMOGRAPHY ANGIOGRAPHY FOR SURVEILLANCE AFTER ENDOVASCULAR AORTIC ANEURYSM REPAIR

Insitution: 1. Deparment of Vascular Surgery, Department of Interventional Radiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark 2. Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark 3. Copenhagen Academy for Medical Education and Simulation, Capital Region of Denmark, Copenhagen, Denmark

Authors presenting: Kim K. Bredahl, Mikkel Taudorf, Lars Lönn, Katja Vogt, Henrik Sillesen, Jonas P. Eiberg

Introduction: Surveillance after endovascular aortic aneurysm repair is mandatory and computed tomography angiography (CTA) is considered the standard image modality1. Computed tomography angiography means exposure to ionizing radiation and use of nephrotoxic contrast agents and therefore colour duplex ultrasound (DUS) and contrast-enhanced ultrasound (CEUS) replacement has been suggested 2. The benefit of CEUS as compared to DUS remains controversial3. Moreover, the clinical implications of endoleaks missed by either technique have been poorly addressed. The primary aim of this study was to analyse the diagnostic efficacy of DUS and CEUS using a biphasic CTA as the gold standard. And secondly, to estimate the clinical implications of endoleaks missed by duplex and contrast-enhanced ultrasound detected by CTA.

Methods: Between August 1st 2011 and October 31st 2014, all patients with endovascular repair of aorto-iliac aneurysms were prospectively and consecutively enrolled. Contrast-enhanced ultrasound was added to the existing surveillance protocol; DUS, plain abdominal X-ray in two planes and CTA three or 12 months after stent implantation (Fig. 1).

Results: In 278 patients enrolled, endoleaks were detected in 46, 69, and 68 patients by DUS, CEUS and CTA, respectively. The sensitivity and specificity of DUS and CEUS were 46 % and 93 %, 85 % and 95 %, respectively. Contrast-enhanced ultrasound and CTA were diagnostically equivalent, as opposed to DUS and CTA (p = 0.002.). At enrolment, CTA called for re-intervention due to seven type I endoleaks and four type II endoleaks. These endoleaks were also detected by CEUS, however, DUS failed in three cases; a limb extension, a 2nd cuff, and finally an intended coil- embolization.During 876 days (range, 615 – 1476 days) of median follow-up, endoleaks type II (n=10) missed by CEUS or CTA (n=11) were never associated with sac-expansion and reintervention, as opposed to endoleaks type II (n=37) missed by duplex ultrasound. In six out 37 cases, delayed clinical consequences were observed: rupture (n=1), open repair due to symptomatic AAA (n=1), Palmaz stent insertion (n=1) and coil-embolization (n=3). Image:

Copenhagen, Denmark • 28-30 September 237

Poster Presentations

Conclusion: Surveillance with contrast-enhanced ultrasound detected all significant endoleaks after endovascular aortic aneurysm repair in this study. Therefore, a revised post-EVAR surveillance imaging programme should be considered.

References: 1. Moll FL, Powell JT, Fraedrich G, Verzini F, Haulon S, Waltham M, et al. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg 2011;41 Suppl 1:S1–58. Doi: 10.1016/j.ejvs.2010.09.011. 2. Mirza T, Karthikesalingam A, Jackson D, Walsh SR, Holt PJ, Hayes PD, et al. Duplex ultrasound and contrast-enhanced ultrasound versus computed tomography for the detection of endoleak after EVAR: systematic review and bivariate meta-analysis. Eur J Vasc Endovasc Surg 2010;39(4):418– 28. Doi: 10.1016/j.ejvs.2010.01.001. 3. Karthikesalingam A, Al-Jundi W, Jackson D, Boyle JR, Beard JD, Holt PJE, et al. Systematic review and meta-analysis of duplex ultrasonography, contrast-enhanced ultrasonography or computed tomography for surveillance after endovascular aneurysm repair. Br J Surg 2012;99(11):1514–23. Doi: 10.1002/bjs.8873.

Copenhagen, Denmark • 28-30 September 238

Poster Presentations

PO 088 ASSESSMENT OF ROLE OF ANKLE-BRACHIAL INDEX (ABI) AND TRANSCUTANEOUS TISSUE OXYGEN TENSION (TCPO2) MEASUREMENT FOR THE RISK OF NON-HEALING AND AMPUTATION IN DIABETIC PATIENTS WITH LEG ULCER

Insitution: General Medicine/Diabetology, Diabetics Research Centre, Podiatry, Diabetes Research Centre, Chennai, India

Authors presenting: Chithra Rajagopalan, Vijay Viswanathan, Bamila Selvaraj, Seena Rajsekar, Linu Daniel

Introduction: Management of ischeamic leg ulcers in a diabetic patient is a challenging situation, especially when assessing the wound healing potential. Ankle-brachial index (ABI) is the non-invasive modality used in all such cases, but it reliability is questionable, in calcified pedal vessels, which is common in diabetics. In such situations, transcutaneous tissue oxygen tension (TcpO2) measurement, being not affected by vessel calcification, can be used to predict the risk of non-healing and amputation in diabetic patients with leg ulcer.

Methods: This is a prospective, observational single centre study conducted in a diabetic tertiary care centre in India. Diabetic patients with leg ulcers seen during the period of 06 months were included and followed up according to a comprehensive wound-care protocol. Base line demographics, clinical features, lab results, wound characteristics and end results were collected using a performa and were recorded in Microsoft excel sheet and statistical analysis were performed using SPSS.

Results: 564 patients were enrolled (M:F = 381:183). The median time for wound healing was 41± 5 days. Probability of healing in relation to BMI, smoking, infection, Nephropathy, glycemic control was studied. Smoking (p = <0.0001) and HbA1C (p = <0.001) were the significant associated factors in non-healing of ulcers. Wounds associated with a TcpO2 reading <20 mmHg demonstrated a significantly decreased probability of healing compared with those associated with a TcpO2 >40 mmHg (p=0.008). There were 32 major and 62 minor amputations. The overall amputation rate increased with decreasing TcpO2 (p=0.014). Probability of ulcer healing was best assessed by TcpO2 than by ABI.

Conclusion: Routine assessment of TcpO2 is suitable as a clinical screening tool for estimating the risk of non- healing in diabetic foot ulcer patients. It is also a better tool than routinely used ABI.

References: 1.Transcutaneous oxygen pressure measurement in diabetic foot ulcers: mean values and cut-point for wound healing. Yang C, Weng H, Chen L, et al. J Wound Ostomy Continence Nurs. 2013 Nov- Dec; 40(6):585-9 2. Predictive value of routine transcutaneous tissue oxygen tension (tcpO2) measurement for the risk of non-healing and amputation in diabetic foot ulcer patients with non-palpable pedal pulses Ladurner R, Küper M, Königsrainer I, Löb S, et al. Med Sci Monit. 2010 Jun;16(6):CR273-7. 3. Profile of Diabetic Foot Complications and its Associated Complications - A Multicentric Study

Copenhagen, Denmark • 28-30 September 239

Poster Presentations

PO 089 LYSOPHOSPHATIDYLCHOLINE ACYLTRANSFERASE 3 OVEREXPRESSION PROMOTES ATHEROSCLEROSIS

Institution: 1. Medical Physiology, Hamamatsu University School of Medicine, Hamamatsu, Japan 2. Applied biological Chemistry, Kinki University, Nara, Japan 3. Anatomy, Vascular Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan

Authors presenting: Hiroki Tanaka, Nobuhiro Zaima, Tetsumei Urano, Mitsutoshi Setou, Naoki Unno

Introduction: Free arachidonic acid (AA) is a precursor of lipid mediators such as leukotriene and prostaglandin, which could induce inflammation and may be associated with progression of atherosclerosis. Recent studies suggested that lysophosphatidylcholine acyltransferase 3 (LPCAT 3) is the enzyme that converts lysophosphatidylcholine and free AA into phosphatidylcholine (PC) containing arachidonic acid (arachidonic PC), and regulate intracellular free AA levels(fig.1). However, the association of LPCAT3 with atherosclerosis in human arterial samples has not been been identified. To gain insight into arachidonic PC metabolism involving LPCAT 3, human atherosclerotic tissues was analyzed with imaging mass spectrometry (IMS), which can visualize the distribution of lipid molecules in the tissue sections.

Methods: Atherosclerotic tissue was obtained from femoral arteries of 15 patients (15 limbs) with peripheral artery disease (PAD) tissues, when they underwent the bypass surgery. To identify the localization of arachidonic PC or other lipid molecules in the tissue, IMS was used. Conventional and immunostaining were also performed for histopathological study.

Results: The different distribution of lipid molecules among atherosclerotic regions classified in PAD tissues was revealed by IMS. Atherosclerotic region was classified to the following four groups; A: adaptive thickening of smooth muscle cell and macrophage foam cells, B: pools of extracellular lipid, C: fibrous thickening, D: thrombus/ fissure and hematoma. The comparison of the accumulated lysophosphatidylcholine (lysoPC), arachidonic PC among the groups resulted to be A < B < C < D, A > B > C > D, respectively (fig.2). Similarly, the number of LPCAT 3 positive cells was in the order of A > B > C > D. Most of the LPCAT 3 positive cells were correspond to SMC.

Image:

Conclusion: We identified that the changes in the distribution of both arachidonic PC and LPCAT3 were similar according to the progression of the atherosclerosis, which suggested that the interaction of LPCAT3 with lysoPC may be associated with the progression of atherosclerosis.

Copenhagen, Denmark • 28-30 September 240

Poster Presentations

PO 090 INTRA-PLAQUE CALCIUM AND ITS RELATION WITH CAROTID ATHEROSCLEROSIS PROGRESSION

Insitution: Angiology and Vascular Surgery, Fundación IIS La Fe, La Fe University Hospital, Valencia, Spain

Authors presenting: Lucas Ribé, Manuel Miralles, Manel Arrébola, Emma Plana, Francisco España

Introduction: Calcification of the plaque may play a protective role against atherosclerosis (AE) progression. The aims of this study were: 1. To analyse the evolution of calcium (Ca) content in AE plaques and its relation with volume change of the arterial wall. 2. To assess the relationship between arterial calcification and Ca-Phosphorus (Ca-P) metabolism.

Methods: Design: Cohorts, repeated measurements. 45 asymptomatic patients with >50% stenosis (doppler ultrasound) of the internal carotid artery (ICA) were included. Determinations: Contrast mold volume and Ca content (quantitative CT angiography). Agatston score: Ca volume (mm3) x radiological density (Hounsfield Units, HU) in volumetric reconstruction (volume rendering) of the carotid bifurcation. The examination was repeated in all patients at 12 months to assess the variation in Ca content and the degree of volumetric stenosis at the bifurcation, as indirect measurement of progression/regression of carotid atherosclerosis. Bone densitometry (T score, Z score), biochemistry and Ca-P metabolism (Ca, P, vitamin D, PTH, osteopontin, osteoprotegerin). Statistical analysis: mean +/- SD, t-test and regression analysis.

Results: CT angiogram showed an increase of the average volume of the arterial wall (decrease of contrast mold volume) compared to baseline values (475.45 +/-155.6 mm3x H.U vs. 501.3 +/- 171.9 mm3x H.U. vs. p= 0.04), as well as an increase of intra-plaque Ca (64.58 +/- 57.8 mm3x H.U vs. 56.8 +/- 52.3 mm3x H.U. p=0.002). However, an inverse correlation between baseline Ca content and volumetric stenosis progression of the bifurcation (r= - 0.481; p<0.001) was observed. In addition, a direct relationship between an increase of the intra-plaque calcium content and the vitamin D plasma levels (r= 0.4; p=0.025) and femur Z score (r= 0.378; p=0.047) was shown.

Conclusion: The results of this study suggest that a higher content of Ca confers a decreased trend of carotid plaque progression, and may eventually protect from developing thromboembolic events. Although it is not possible to establish an absolute relationship, those mechanisms that regulate bone calcium deposition through Ca-P metabolism may also be involved in the process of arterial calcification.

References: 1- Miralles M, Merino J, Busto M, Perich X, Barranco C, Vidal-Barraquer F. Quantification and characterization of carotid calcium with multi-detector CT-angiography. Eur J Vasc Endovasc Surg. 2006 Nov;32(5):561-7. 2- Miralles M, Arrébola M, Bruguer S, Lago A, Lara R. Volumetric assessment of the carotid bifurcation: an alternative concept to stenosis grading. Ann Vasc Surg. 2015 Apr;29(3):411-8.

Copenhagen, Denmark • 28-30 September 241

Poster Presentations

PO 091 EXTRACELLULAR MATRIX REMODELING IN ABDOMINAL AORTIC ANEURYSM: INVESTIGATION OF NEO-EPITOPE BIOMARKERS

Institution: 1. Angiology and Vascular Surgery, Hospital Joan XXIII, Tarragona, Spain 2. Nordic Bioscience, Herlev, Denmark, 3. Unitat de Recerca Biomèdica, Hospital Universitari Sant Joan, Insitut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Reus, Spain

Authors presenting: Cristina Pantoja Peralta, Signe Holm Nielsen, Anna Hernandez Aguileram, Vicente Martín Paredero Morten Asser Karsdal, Jorge Joven Maried, Federica Genovese

Introduction: Abdominal Aortic Aneurysm (AAA) is a degenerative disease that affects the elderly population. It is characterized by a progressive dilation and rupture of the abdominal aortic wall due to extensive remodeling of the aortic extracellular matrix (ECM). Degradation of structural proteins may hinder the resistance to hemodynamic forces and be responsible of rupture of the aortic wall. The aim of this study was to investigate the arterial remodeling in AAA patients by specific neo-epitope biomarkers of ECM remodeling.

Methods: Serum samples from 70 surgical candidates (SC) (median aneurysm diameter 56 mm) and 34 non- surgical candidates (NSC) (median aneurysm diameter 46 mm) with AAA were collected and analyzed. The aneurysm size and characteristics were evaluated by a CT scan, following the Clinical Practice Guidelines of the European Society for Vascular Biology for management of AAA. Demographic data and vascular parameters were gathered. Specific neo-epitope biomarkers of MMP-generated collagen type IV (C4M), MMP-generated versican (VCANM), MMP-generated C- reactive protein (CRPM), MMP-generated vimentin (VICM), MMP-generated elastin (ELM2) and alpha smooth muscle actin (α-SMA) were measured by ELISAs.

Results: Serum levels of VCANM and CRPM correlated with the size of the aneurysm (r=-0.255, p=0.012 and r=0.280, p=0.006, respectively). C4M, VCANM and CRPM were significantly elevated in SC compared to NSC with AAA (p=0.002; p=0.026; p=0.013, respectively). VICM, ELM2 and α-SMA did not show any correlation to the size of the aneurysm nor significant difference between SC and NSC. C4M was the best marker to separate SC to NSC (AUC=0.685).

Conclusion: Serum levels of VCANM and CRPM correlated significantly with the size of aneurysm, whereas C4M, VCANM and CRPM levels were elevated in serum from SC compared to NSC. This suggests that neo-epitope ECM biomarkers may be used to investigate arterial remodeling in AAA patients. If such markers can be used in clinical practice to separate SC from NSC needs to be further investigated.

Copenhagen, Denmark • 28-30 September 242

Poster Presentations

PO 092 THE ROLE OF IMMUNOHISTOCHEMICAL EXPRESSION OF THE ST2 RECEPTOR (ST2L/IL-1R) IN ATHEROSCLEROTIC PLAQUES OF SYMPTOMATIC AND ASYMPTOMATIC PATIENTS

Institution: Vascular Surgery, DETO, University of Bari, Bari, Italy

Authors presenting: Cristina Galeandro, Domenico Angiletta, Marco Ciccone, Andrea Marzullo, Ripalta Paglione, Noemi Ventrella, Michele Tedesco, Isabella Patruno, Raffaele Pulli

Introduction: ST2 (suppression of tumorigenity) has been described as a receptor for the interleukin-33, a member of the IL-1 family of cytokines. It is associated to coronary artery disease, all-causes mortality and cardiovascular mortality. The present study was designed to assess the immunohistochemical expression of the ST2 receptor (ST2L/Il-1R) in atherosclerotic plaques of symptomatic and asymptomatic patients who underwent a carotid endarterectomy (CEA).

Methods: In the study were enrolled 41 patients (23 asymptomatic and 18 symptomatic). Data regarding risk factors, comorbidities, clinical status and morphological parameters were recorded in a dedicated database. All patients underwent CEA in a standard fashion by the same physicians. The plaques were removed and fixed in formalin. With immunohistochemical method the ST2 receptor (ST2L/Il- 1R) in atherosclerotic plaques was detected. Appropriate statistical analysis (chi-square test for non parametric values and anova test for parametric values) for the comparison between the two groups was used.

Results: All the clinical and morphological parameters were uniformly distributed between the two groups, with a mild predominance of degree of calcification in asymptomatic cases (p= 0.01). ST2L expression was found to be more evident as a membrane pattern in macrophages when observing carotid atherosclerotic plaques of symptomatic patients, rather than in asymptomatic patients’ plaques (77.7% vs 39.1%; p= 0.015), and its expression was particularly remarkable in VI type plaque (on the basis of AHA classification). Significantly, ST2L was marked by the endothelium of neoangiogenetic vessels on the shoulder region of the plaque, but not (apart from a few cases) in the endothelium covering the residual lumen of the vessel.

Conclusion: The ST2L immunohistochemical expression was for the first time investigated in a large number of human carotid atherosclerotic plaques, as for its pattern of distribution in the different plaque cell populations. ST2L was particularly remarkable on macrophages, as a membrane pattern, of symptomatic patients’ plaques. Considering our data, we hypothesize that ST2L/IL33 axis may drive the mechanism of plaque development and eventually rupture.

Copenhagen, Denmark • 28-30 September 243

Poster Presentations

PO 093 DEVELOPMENT OF TISSUE-ENGINEERED STENT-GRAFTS COMPOSED OF BIORESORBABLE POLY- L-LACTIC ACID SCAFFOLD STENTS AND DECELLULARIZED BLOOD VESSELS

Insitution: 1. Surgery, Keio University School of Medicine, Tokyo, Japan 2. Kyoto Medical Planning Co., Ltd, Kyoto, Japan

Authors presenting: Kentaro Matsubara, Hideaki Obara, Tatsuya Shimogawara, Hirokazu Yamada, Kazuki Tajima, Hiroshi Yagi, Yuko Kitagawa

Introduction: Endovascular aortic repair (EVAR) is now widely used as treatment of several aortic diseases. However, the advantage of EVAR for infected aortic diseases (e.g. mycotic aneurysm and aortoenteric fistula) is limited because of infection of the permanent implanted stent-graft. The final goal of our study is to develop tissue-engineered stent-grafts composed of bioresorbable Poly-L- lactic acid stents (BRS) and decellularized blood vessels which provide a scaffold for host cell recruitment. This next generation stent-graft is expected to integrate with aortic wall over time and has the potential to reduce the risk of stent-graft infection after EVAR. The aims of this study are to assess the decellularization of porcine vessels, to create the tissue-engineered stent-graft and to evaluate early adaptation after implantation in porcine model.

Methods: Porcine iliac arteries and veins were harvested and stored at -80°C until decellularization. After thawing, the vessels were decellularized with Sodium dodecyl sulphate and Triton X-100. The decellularized vessels were evaluated by means of histology, DNA quantification and tensile strength test. To create the tissue-engineered stent-graft, the decellularized vein was attached inside the BRS with absorbable sutures. Porcine model of surgical interposition grafting of iliac artery was performed as a preliminary evaluation to assess early performance and durability of this stent-graft before use of endovascular treatment. After two weeks, the stent-graft was studied with digital subtraction angiography, intravenous ultrasound (IVUS) and histologic methods.

Results: Histological analyses of decellularized arties and veins indicated all cellular removal and high degree of preservation of the extracellular matrix. The DNA quantification of the decellularized vessels showed more than 97% reduction as compared to fresh vessels. The tensile strength of the decellularized vessels were comparable to those of the fresh vessels. Since the decellularized veins could preserve its mechanical properties, the veins were selected as the graft component of the tissue-engineered stent-graft (Image). Surgical interposition grafting was successfully performed without bleeding from the surface. Digital subtraction angiography and IVUS after two weeks revealed well patency and no aneurysmal changes. The inner surface of the stent-graft was largely covered with endothelial cells. Image:

Conclusion: Decellularized vessels using our method had well-preserved extracellular matrix and mechanical properties. We detected short-term patency and durability of the tissue-engineered stent-graft in the preliminary porcine model.

Copenhagen, Denmark • 28-30 September 244

Poster Presentations

PO 094 THE ROLE OF EVAR SIMULATION IN BOOSTING LEARNING CURVE OF TRAINEE

Institution: Experimental Diagnostic and Specialty Medicine Dept. (DIMES), University of Bologna, Bologna, Italy

Authors presenting: Vincenzo Vento, Laura Cercenelli, Chiara Mascoli, Enrico Gallitto, Gianluca Faggioli, Antonio Freyrie Emanuela Marcelli, Mauro Gargiulo, Andrea Stella

Introduction: Endovascular aortic repair (EVAR) is a valid option in the treatment of abdominal aortic aneurysms and should be part of every vascular surgeon armamentarium. Since vascular residency program should include adequate EVAR training, simulation may help to gain confidence with these procedures. The purpose of this study was to evaluate and quantify procedural skills improvements in vascular residents through participation in a series of simulated EVAR procedures.

Methods: Ten vascular surgery residents of different level of experience were recruited and divided in two groups of 5 (“Trainee Group” and “Control Group”). Each group included 3 junior residents (postgraduate year [PGY] 1-2) and 2 senior residents ([PGY] 3-4). All participants attended a preliminary standardized orientation session to practice on an endovascular simulator (Angio Mentor Dual Slim, 3D Systems/Simbionix, Littleton, CO USA). Subsequently, at a first session (t0), each participant of both groups performed two simulated EVAR cases (one “simple” and one “complex” anatomy). After two weeks, other two EVAR simple/complex cases were simulated by each participant in a final session (t1). In the period between t0 and t1, each resident in the Trainee Group performed a total of six simulated EVAR procedures divided in three separate sessions, while the Control Group did not train on simulator any more. At t0 and t1, both quantitative and qualitative analysis were provided. Quantitative analysis was by metrics provided by the simulator which included total procedural time (TP), total fluoroscopy time (TF), time for contralateral gate cannulation (TG) and volume of contrast medium (CM) used. Qualitative analysis was adapted for EVAR procedures using a Likert scale which evaluated participant’s skills involving major EVAR procedural steps by assigning a score from 1 to 5 for each of seven performance criteria and calculating a Total Performance Score (TPS). Analysis of data across the two groups included paired t-tests and Wilcoxon signed-rank tests.

Results: All residents in the Trainee Group significantly reduced Tp (mean = 47.7±12.4 vs 31.5±7.7 min, t0 vs t1, P <0.05), TF (mean = 24.7±8.5 vs 18.4±4.4 min,, P <0.05) and CM used overtime (mean =121±37 vs 85±26 ml, P <0.05), but not TG (mean =5.4±4.6 vs 3.1±3.5 min, P=0.284). In the Control Group metrics did not change significantly in any field (mean TP = 55.2±10.5 vs 45.5±10.3 min; mean TF = 17.9±6.9 vs 13.5±6.3 min; mean CM = 132±51 vs 102±42 ml; mean TG = 5.7±3.9 vs 7.9±5.0 min, all P >0.05). The average Trainee Group qualitative TPS improved significantly (P<0.05) after rehearsal sessions when compared with the Control Group (Figure). Image:

Conclusion: Simulation is an effective method to improve competence and confidence of vascular residents with EVAR procedures. EVAR rehearsal on simulator can reduce overall procedure and fluoroscopy time, independently from trainee experience, and improve subjective qualitative measures of performance. Further studies are needed to assess the role of simulation-based training in the performance in real clinical settings.

Copenhagen, Denmark • 28-30 September 245

Poster Presentations

PO 095 VALUE BASED HEALTH CARE-LESSONS IN COST EFFECTIVENESS FROM VASCULAR PLICS DATA

Insitution: King's College Hospital, London, United Kingdom

Authors presenting: Neeraj Beeknoo, Brendan Sloane, Hiren Mistry, Hani Slim, Domenico Valenti, Hisham Rashid, Raghvinder Pal Singh Gambhir

Introduction: To extract maximum value from the health care pound or Euro we need to know the actual costs of the vascular surgical procedures. Patient-level information and costing systems (PLICS) allows us to look at these costs. Only be understanding these costs can we provide cost effective vascular service.

Methods: PLICS data of a tertiary vascular unit was interrogated for the financial year 2014-2015 and first two quarters of 2015-2016. The procedure codes and income codes of commonly performed vascular procedures were fed into the data held by the financial team of the hospital. Based on the activity during the study period, average cost and average income of each procedure was obtained. This data was then further analysed to understand the costing and how to possibly increase the cost effectiveness of the procedures.

Results: In the study period of 18 months, PLICS information was available for over 800 inpatient and 700 day case surgery procedures. In addition there was information about 6500 outpatient consultations. 106 carotid endarterectomy procedures were recorded to have been performed at an average cost of £6198 each, against an average income of £5167. The average length of stay (ALOS) was 4 days. 46 distal bypasses to tibial arteries with ALOS of 17.3 days had cost £16,756 against an income of £14,061. The average cost of an EVAR was £ 25,015 and for FEVAR £40,397 against average incomes of £13,439 and £14,871 respectively. A major amputation of the leg (above knee) generated an income of £12,547 but cost £29,672. Radiofrequency ablation of unilateral varicose veins in an office suite under LA cost £691 while the same procedure done in Day Surgery unit under GA cost £1301 against an average tariff of £1124. Outpatient appointments cost the trust £203 for the first consult and £134 for a follow up visit. In depth analysis of the cost types revealed that theatre cost, medical and nursing staff costs accounted for about 43% of the costs, clinical supplies accounted for another 13% of costs but a major bulk of the costs was the overhead costs at 18%.

Conclusion: Analysis of PLICS data shows that we need to work differently to make the service cost effective. For some procedures like carotid endarterectomy and distal bypasses we can certainly reduce the ALOS. For others like varicose vein procedures, the message is very clear, most of these procedures have to become office based procedures and be done in a non-theatre setting. For EVARS and FEVARS we need to work together with the industry and the regulators to effect cost reductions and attract better best practice tariffs. Above all if we truly want to achieve value based health care for vascular patients, we need to refocus on primary prevention.

Copenhagen, Denmark • 28-30 September 246

Poster Presentations

PO 096 MANAGEMENT OF SMALL ABDOMINAL AORTIC ANEURYSMS – WHAT PATIENTS WANT, WHAT SURGEONS NEED

Insitution: Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom

Authors presenting: Regent Lee, Amy Jones, Lucy Folford-Smith, Felicity Woodgate, Kirthi Bellamkonda, Katherine Hurst Ismail Cassimjee, Ashok Handa

Introduction: The epidemiology of AAA is changing. Outcomes for aortic surgery have improved over the last two decades. Novel biomarkers for AAA progression may be emerging. There is increasing emphasis on patient preferences for treatment and precision medicine, yet the accepted practice for surveillance of small AAAs does not take these advances into account. We investigated patient preferences and perception on the management of small AAAs in a contemporary setting.

Methods: A survey was administered to AAA patients to members of the public from March 2016. Quoting contemporary epidemiologic [delayed AAA onset] and surgical outcome data [<2% mortality for routine open surgical repair (OSR), <0.5% mortality for endovascular repair (EVAR)], routine recovery time and long term follow up plans for surgery, we asked their preferences for the management in the hypothetical scenario where they had just been diagnosed with a small (4cm) AAA and a novel biomarker predicted the AAA to be fast growing. A similar survey was concurrently administered to health care professionals (HCP) who have direct roles in the management of AAA patients. We asked the HCPs what they thought the patients’ preferences would be in such a scenario.

Results: To date we have received 111 responses from patients and members of the public. In the scenario where the biomarker predicts the AAA will be fast growing, therefore likely to reach operative threshold in a few years, 45% of them would prefer to have surgery early, while they are younger and fitter. Amongst them, 26% preferred OSR, 36% preferred EVAR, while 38% will follow the surgeon’s recommendation (SR) in terms of the type of surgical repair. The other 47% will follow the SR as to whether to have early surgery or not. Very few preferred deferring surgery (4%) or were unsure (4%). A high proportion of respondents (76%) were willing to consider taking part in a clinical trial to test if early surgery in such a scenario will be beneficial. When asked what they viewed as more important in terms of benefit from having surgery earlier, 62% chose improvements in quality of life (31%) or reductions in their anxiety about having an AAA (31%) as more important than making them live longer. Amongst the 63 responses from HCPs (including 45 physicians) regarding the same scenario, 49% thought patients would prefer to have AAA surgery early; 33% thoughts patients would follow the SR; 6% of HCPs thought patients would prefer to defer surgery; 11% were unsure of what the patients would prefer. These were similar to patients’ preference (Chi-square p=0.16). In the case of early surgery, the HCPs’ perception of what patients would want in terms of the type of surgical repair was also similar to that of the patients’ (OSR 16%; EVAR 39%; per SR 45%). (Chi-square p=0.45). The majority of HCPs (95%) would consider recommending their patients to take part in a clinical trial to test if early surgery in such a scenario would be beneficial.

Copenhagen, Denmark • 28-30 September 247

Poster Presentations

Image:

Conclusion: Patients with fast growing small AAAs want to have early surgery rather than surveillance, and will be willing to take part in new clinical trials to test the benefit of early surgery. In such trial(s), they view improvement in quality of life and riddance of anxiety about AAA as equally important to prolonging life expectancy. The perceptions of health care professionals align with the patient preferences. Surgeons need to develop novel biomarker(s) of AAA progression to promote precision care in vascular surgery, and account for patient preferences in the design of future trials.

Copenhagen, Denmark • 28-30 September 248

Poster Presentations

PO 097 ARTERIAL AND VENOUS THROMBOSIS IN HIGH ALTITUDE: AN ENIGMA

Authors presenting: Rishi Dhillan

Introduction: High altitude has been implicated to lead to a transient Hypercoagulable state. Due to the employability profile, a large part of our clientele which includes healthy young males, has to be stationed at High altitude areas for 2 to 3 years. A relatively large number of cases suffer from Thrombosis without any known co-morbidities. This study aimed at evaluating the demographic profile of patients suffering from High altitude induced thrombosis, identifying any pre-existing thrombophilic state and the clinical and surgical outcome of these patients. This is the largest study focusing on occurrence of thrombosis while staying at High altitude areas.

Methods: This was a prospective non - randomized study. The data of the patients treated for High altitude induced thrombosis at Army Hospital (R&R) between 2013 and 2015 were included. Patients were prospectively followed for at least six months for clinical and surgical outcomes and thrombophilic markers. They were also divided into two groups based upon altitude – Group I(9000 to 14999ft)(n=33) and Group II(above 15000ft)(n=23). Statistical analysis was done using SPSS version 18.0 software.

Results: A total of 56 patients were included in the Study with 31 cases of Arterial thrombosis and 26 cases of Venous thrombosis with one patient suffering both arterial and venous thrombosis. All patients were male. There was one mortality due to Short bowel syndrome in a case of SMA thrombosis with Acute limb ischemia. The age range was 23 to 53 years (Mean - 35.82). There were 28 tobacco consumers, of which 19 suffered arterial thrombosis and 9 suffered venous thrombosis (p=0.032). 10 patients had a hereditary thrombophilic factor positive, including 4 patients with positivity of two factors. The mean Altitude above sea level was 13610.41 feet. The mean duration of stay at High altitude before the onset of Thrombosis was 14.78 months for Group I and 5.74 months for Group II(p=0.001). The Femoro-popliteal segment was involved in 61% of arterial and 63% of venous cases whereas the infra-popliteal segment was affected in 28% arterial and 18% of venous cases. Thrombectomy was done for19 patients (16 after over 24hrs of onset of symptoms) of arterial thrombosis and rest were placed on medical management as there was no immediate threat to limb viability. There was one mortality – A case of SMA thrombosis with Acute limb ischemia. 20 patients became claudicants and 10 patients are asymptomatic. There were 4 amputations- all minor (forefoot or toe amputations).

Conclusion: This is the largest study investigating Thrombosis at High altitude. It shows that Arterial thrombosis is as common as Venous thrombosis at High altitude. The finding of many patients with pro-coagulant states suggests the role of High altitude as a triggering or precipitating factor for thrombosis. Our subgroup analysis suggested higher incidence of thrombosis even with a shorter stay as altitude increases. This study also establishes the role of delayed thrombectomy for arterial thrombosis and Catheter directed Thrombolysis for Venous thrombosis in almost all cases of High altitude thrombosis with good surgical outcomes.

References: 1. Genton E, Ross AM, Takeda YA, Vogel JHK. Alterations in blood coagulation at high altitude. In: Vogel JHK, ed. Hypoxia, High Altitude and the Heart. Basel: S Karger, 1970; 5: 32–9. 2. Anand AC, Jha SK, Saha A, Sharma V, Adya CM. Thrombosis as a complication of extended stay at high altitude. Natl Med J India 2001;14:197-201. 3. Kumar S. High altitude induced deep venous thrombosis: A study of 28 cases. Indian J Surg 2006;68:84-8. 4. Fagenholz PJ, Gutman JA, Murray AF, Noble VE, Wu A, Zeimer G, et al. Arterial thrombosis at high altitude resulting in loss of limb. High Alt Med Biol 2007;8:340-7. 5. Kotwal J, Apte CV, Kotwal A, Mukherjee B, Jayaram J. High altitude: A hypercoagulable state: Results of a prospective cohort study. Thromb Res 2007;120:391- 7. 6. RPS Gambhir, Vembu Anand, Surinder Singh Khatana, VS Bedi. A Brief Review of High Altitude Thrombosis. Ind J Vasc Surg 2014; 1: 20-23. 7. Anand AC, Saha A, Seth AK, Chopra GS, Nair V, Sharma V. Symptomatic portal system thrombosis in soldiers due to extended stay at extreme altitude. J Gastroenterol Hepatol 2005;20:777-83.

Copenhagen, Denmark • 28-30 September 249

Poster Presentations

PO 098 RECURRENCE RATE OF TRANSPLANT RENAL ARTERY STENOSIS FOLLOWING ANGIOPLASTY WITH OR WITHOUT STENTING

Insitution: Renal Transplant, Leicester University Hospitals, Leicester, United Kingdom

Authors presenting: Abdulwhab Elmghrbee, Amar Eltweri, Stalin Dharmayan, Atul Bagul, Tahir Doughman

Introduction: The prevalence of transplant renal artery stenosis (TRAS) had previously been reported in our unit as 5%. The gold standard of its diagnosis is angiogram but it is an invasive procedure not without burdens. We assess the recurrence rate of transplant renal artery stenosis following angioplasty and whether surveillance is warranted following any intervention.

Methods: This was a retrospective audit, the medical record of all renal transplant patients were checked in our institution to identify those who required angiogram and angioplasty with or without stenting.

Results: Fifteen patients formed the basis of this audit; 10 male and five female, median follow up was 30 months (range; 13-102 months), renal function deterioration was the main indication for investigation (93 %), doppler scan detected TRAS in 87% of patients, angiogram performed in all patients. Angioplasty without stenting was performed in 11 patients (73 %) and four patients had stent (27 %), the recurrence rate was 27 % versus 0 % respectively, none of these patients had surveillance scan and the recurrence was picked up due to further deterioration in renal function. The mean serum creatinine level on the last follow up was 195 umol/L, (95 % CI 140 – 250).

Conclusion: Transplant renal aretery stenosis recurrence after angioplasty alone is evident and it may lead to graft loss. When these patients are found to have transplant renal artery stenosis, there is a risk of damage to the kidney by TRAS as well as by contrast during angiography. Whether, Serial Duplex Ultrasound scan has a role in the detection of asymptomatic TRAS, to avoid the increased risks of damage caused by both the contrast and the TRAS itself is a subject for debate. As there are no clear guidelines about how to manage TRAS, there is need for further studies on a larger scale.

Copenhagen, Denmark • 28-30 September 250

Poster Presentations

PO 099 INADEQUATE HEALTH LITERACY IN PATIENTS WITH ARTERIAL VASCULAR DISEASE

Insitution: Vascular Surgery, Jeroen Bosch Hospital's - Hertogenbosch, The Netherlands

Authors presenting: Ruben Strijbos, Jan Willem Hinnen, Ronald van den Haak, Bart Verhoeven, Olivier Koning

Introduction: Health literacy (HL) is defined as the degree to which patients have the capability to obtain, process and understand basic health information and services needed to make appropriate health decisions. Patients with arterial disease are a large subset of the population visiting the vascular surgeon with specific characteristics which are associated with inadequate HL. Knowledge about HL is important in the context of supplying medical information and inadequate HL is consistently associated with poorer health outcomes. Nevertheless, there is no literature describing the actual magnitude of this possibly relevant problem in patients with arterial disease.

Methods: In this ongoing cross-sectional study, patients with arterial vascular disease visiting the outpatient clinic were randomly included and screened for inadequate health literacy (HL) with the validated Newest Vital Sign - Dutch (NVS-D). A score of < 4 out of 6 identified individuals with inadequate HL. Age, gender, highest education level and reason for consultation were also registered. Statistical (sub) analyses were performed with the chi-square test and multiple logistic regression.

Results: Currently, 91 patients are already included. The mean NVS-D score was 1.75 (SD ± 1.964, median 1). The prevalence of inadequate health literacy (HL) was 77 %. Subanalysis showed a significant higher prevalence of inadequate HL in the group of elderly (p = 0.001), female patients (p = 0.019) and patients with a lower education level (p = 0.017). No significant difference was found between patients with peripheral arterial occlusive disease or abdominal aortic aneurysma (p = 0.24). Furthermore, age (i.e. adult versus elderly) was identified as an independent predictor for inadequate HL (p = 0.004).

Conclusion: The (preliminary) results of this study show a prevalence of inadequate health literacy of 77 % in patients with arterial vascular disease, with a significant higher prevalence in the subgroups of the elderly, female patients and patients with a lower education level. The found prevalence suggests the need to further discover and critically review the best methods to supply medical information for this subset of patients.

Copenhagen, Denmark • 28-30 September 251

Poster Presentations

PO 100 LONG-TERM OUTCOMES OF TEVAR FOCUSED ON BIRD-BEAK AND OVERSIZING IN BLUNT TRAUMATIC THORACIC AORTIC INJURY

Institution: Vascular Surgery Department, Vall d´Hebron Hospital, Barcelona, Spain

Authors presenting: Marvin E. Garcia Reyes, José M. Domínguez González, Gabriela Gonçalves Martins, Valentín Fernández Valenzuela, Jordi Maeso Lebrun, Sergi Bellmunt Montoya

Introduction: TEVAR has emerged as the preferred treatment for patients with blunt traumatic thoracic aortic injury (BTTAI), but as these patients are often young there are several concerns regarding long-term outcome.Some papers have described the clinical importance of bird-beak configuration and oversizing and its association with adverse clinical events, although they had combined different aortic diseases1,2,3. We present one of the most follow up series described about BTTAI. The purpose of this paper is to evaluate the long-term outcomes of TEVAR for BTTAI in terms of complication, reinterventions and survival focused on bird-beak configuration and oversizing.

Methods: This was a retrospective consecutive case series. Patients who underwent TEVAR for BTTAI at a trauma center were included. Ishimari´s classification was used. The principal endpoints were migration, collapses, intragraft mural thrombosis (IMT), reinterventions and survival. The secondary endpoints were the relation between complications, oversizing and bird-beak. Descriptive analysis was performed with measures of central tendency and dispersion; categorical variables were described in percentages and numeric variables in averages. Categorical variables were compared by using Chi square test and U of Mann-Whitney test.

Results: Between October/1999 to January/2015 a total of 34 patients were included. The median age was 36 years, and 21% were women. 12% had a type II injury, 73% type III and 15 type IV of the Ishimari classification. Proximal oversizing mean was 19% (range 8% to 27%) and the distal oversizing was 27% (range -20% to 50%). The mean postoperative follow-up was 98 months (range, 12 to 198 months). Bird-Beak configuration was seen in 65% with a protrusion extension mean 16mm (sd 7.4mm) and angle mean 51º (sd 16º), one case of a proximal type I endoleak that evolved to a stent graft collapse, requiring reintervention. No migration was seen; mean of changes were 1.5mm. We found seven IMT; one of them developed a nearly occlusive parietal thrombosis, 1 year after the initial procedure. Four (9%) patients required reintervention: 2 postoperative revascularizations of the left subclavian artery and 2 aortic reinterventions (endovascular treatment of a collapsed stent graft and open repair after thrombosis stent graft). All reinterventions were successfully performed and no additional complications were registered during follow-up. We had no early or late mortality. Patients with complications had significantly higher proximal oversizing 23% vs. 17% oversizing in the group with no complications (p=0.007). The distal oversizing was not significantly correlated (27% vs. 26%, p=0.8). No statistical association between complications and birdbeak. Patients with complications had significantly higher proximal oversizing (23% vs. 17%, p=0.007). The distal oversizing was not significantly correlated (27% vs. 26%, p=0.8)

Copenhagen, Denmark • 28-30 September 252

Poster Presentations

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Conclusion: TEVAR had good results in long term follow-up without mortality. Complications seem to be related to proximal oversizing. Bird-beak was not related to complications contrary to other publications, but our sample is small. The effects of bird-beak configuration and oversizing must be studied to determine the impact in young patients on the degenerative changes that take place in the aging aorta.

References: 1. Ueda T, Fleischmann D, Dake MD, et al. Incomplete endograft apposition to the aortic arch: bird- beak configuration increases risk of endoleak formation after thoracic endovascular aortic repair. Radiology. 2010; 255:645-652. 2. Fayad A. Thoracic endovascular stent graft with a bird’s beak sign. Can J Anaesth 2008; 55 (11): 785 – 786. 3. Canaud L Alric P, Laurent M, et al. Proximal fixation of thoracic stent-grafts as a function of oversizing and increasing aortic arch angulation in human cadaveric aortas. J Endovasc Ther 2008; 15 (3): 326 – 334.

Copenhagen, Denmark • 28-30 September 253

Poster Presentations

PO 101 OUTCOME FOLLOWING TIBIAL BYPASS AND TIBIAL ANGIOPLASTY COMPARED USING PROPENSITY SCORE MATCHING

Institution: Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom

Authors presenting: Sanjay Patel, Lukla Biasi, Ioannis Paraskevopoulos, Justinas Silickas, Talia Lea, Athanasios Diamantopoulos, Konstantinos Katsanos, Hany Zayed

Introduction: Both infrapopliteal (IP) bypass surgery and endovascular intervention have been shown to have good outcomes in patients with critical limb ischaemia (CLI), though there are no randomised trials to guide treatment choices. Our aim was to compare the outcomes of these treatments using Propensity Score (PS) matching in order to correct for selection bias and confounding factors.

Methods: We compared outcomes in consecutive patients undergoing IP bypass (BS) and IP angioplasty (EV) for CLI (Rutherford 4-6) at a single institution following PS matching. The end points were primary, primary assisted and secondary vessel patency and amputation free survival (AFS) using Kaplan Meier analysis and compared using the log rank test.

Results: The initial cohort (n=279) differed significantly with respect to the incidence of diabetes (P=.024), eGFR (P=.006), total lesion length (P<.001) and Rutherford classification (P=.008). These factors were used to construct the PS model which yielded a matched cohort of 125 limbs in each group. Primary patency (P=0.014), assisted primary patency (P=0.003), secondary patency (P<0.001) and AFS (P=.043) were significantly better after BS compared to EV. However limb salvage was similar (P=.161), and minor complications (p=.008) as well as length of hospital stay (P=0.001) were worse in the BS group.

Conclusion: Our data supports a pragmatic approach where patients with a suitable vein conduit and acceptable operative risk are considered for bypass; whereas in those with a higher operative risk an EV strategy is considered first.

Copenhagen, Denmark • 28-30 September 254

Poster Presentations

PO 102 PERIOPERATIVE BLOOD GLUCOSE LEVELS INFLUENCE OUTCOME AFTER INFRAINGUINAL BYPASS AND ENDOVASCULAR THERAPY

Instituion: Guy's and St Thomas' NHS Foundation Trust, Guy's and St Thomas NHS Foundation Trust, London, United Kingdom

Authors presenting: Sanjay Patel, Justinas Silickas, Lukla Biasi, Tommaso Donati, Talia Lea, Konstantinos Katsanos Natasha Patel, Stephen Thomas, Hany Zayed

Introduction: Poor perioperative blood glucose management is associated with increased morbidity and mortality after infrainguinal and coronary artery bypass surgery. The influence of perioperative hyperglycaemia on restenosis and patency following infrainguinal revascularisation among diabetic patients is largely unknown.

Methods: Consecutive diabetic patients undergoing primary infrainguinal bypass surgery (BS) or endovascular therapy (EV) for critical limb ischaemia were identified. Daily capillary blood glucose (CBG) data was collected retrospectively up to 7 days post operatively along with pre and 3 month post procedural haemoglobin A1C levels. Mean and standard deviation of CBG and area under the curve (AUC) method were used to correlate against the study endpoints (primary, assisted primary and secondary patency and binary restenosis).

Results: In patients undergoing infra-inguinal bypass (N=42) a mean peri-operative CBG level greater than 7mmol/L was associated with reduced primary patency (P=0.01) and a higher level of binary restenosis (P=0.042), with no significant difference in assisted primary patency (P=.36) and secondary patency (P=.46). A lower primary patency was also found in patients with a HbA1C level of greater than 48mmol/mol both pre (P=0.027) and 3 months post operatively (P=0.047). The EV group consisted of 76 patients with 160 vessels treated. A high perioperative CBG level (>7) and HbA1C level (>48) was associated with lower primary patency (P=.011 and P.004), assisted primary patency (P=.019 and P=.004), secondary patency (P=.047 and P=.018) and a higher binary restenosis rate (P=0.042 and P=.032).

Conclusion: Poor perioperative glycaemic control is associated with lower patency and higher incidence of restenosis after infrainguinal revascularisation in diabetic patients.

Copenhagen, Denmark • 28-30 September 255

Poster Presentations

PO 103 PROSPECTIVE EVALUATION OF A STANDARDIZED PROTOCOL USING NEUROMONITORING, CEREBROSPINAL FLUID DRAINAGE AND EARLY LIMB REPERFUSION TO PREVENT SPINAL CORD INJURY DURING ENDOVASCULAR THORACOABDOMNAL REPAIR

Insitution: Mayo Clinic, Rochester, MN, United States

Authors presenting: Mauricio Ribeiro, Gustavo Oderich, Peter Banga, Jan Hofer, Meaghan Cazares, Stephen Cha 1Peter Gloviczki, Alejandro Rabinstein

Introduction: Spinal cord injury (SCI) is the most devastating complication of open and endovascular repair of thoracoabdominal aortic aneurysms (TAAAs). The aim of this study was to analyze the role of continuous intra-operative motor evoked (MEP) and somatosensory evoked potential (SSEP) monitoring, cerebrospinal fluid (CSF) drainage and early limb reperfusion to prevent SCI in patients undergoing fenestrated-branched endovascular repair (F-BEVAR) of TAAAs.

Methods: 68 consecutive patients (49 male, mean age 75±7 years old) with TAAAs treated by F-BEVAR were enrolled in a prospective, non-randomized single-center study (09/2014-03/2016). All patients received CSF drainage, permissive hypertension (mean arterial pressure [MAP] > 80 mmHg), and intra-operative MEP/SSEP monitoring. Staged repair was used for type I-II TAAAs. In patients with changes in MEP/SSEPs, a standardized protocol was used to optimize spinal cord perfusion and restore LE blood flow. Follow up included clinical examination, laboratory studies, duplex ultrasound and computed tomography imaging at discharge, 1-month, 6-months and yearly. End-points adjudicated by independent clinical event committee included mortality, major adverse events (MAEs) and rates of immediate and delayed (>6 hours) spinal cord injury (SCI). All patients with SCI had neurologic evaluation.

Results: There were 36 patients with Type IV (mean 59±10% aortic coverage) and 32 with Type I-III TAAAs (mean 78±16% aortic coverage). Severe stenosis or occlusion of at least one internal iliac artery was present in 30 patients (44%). Fourteen patients (21%) had staged repairs. A total of 265 renal- mesenteric arteries were targeted by 147 fenestrations and 118 branches (mean 3.9±0.7 vessels/patient). Temporary or permanent conduits were used in 22 patients (32%) and 28 limbs (23 femoral, 5 iliac). Pre-operative CSF drainage was successful in 65 patients (96%). A stable MEP/SSEP was achieved in all patients, but 4 had some type of technical issue. Forty-four patients (65%) had >75% decrease in MEP or SSEP amplitude in 67 limbs (Figure). MEP changes started at 45±33 minutes after obtaining vascular access and were more prominent at the side of placement of the aortic component. MEP and SSEP amplitude improved with maneuvers in 8 patients (18%) and returned to baseline with restoration of LE flow in all remaining 36 patients (82%). Two patients (3%) had the repair left incomplete (1 un-stented contra-lateral limb, 1 un-stented right renal branch) because of difficulty to maintain target MAP in a patient with severe heart failure who had reversible MEP changes, and difficulty to catheterize the renal artery in a patient with chronic dissection, respectively. In these two patients, the repair was completed with no difficulties in 1 and 3 days, respectively. There was no 30-day mortality and 15 patients (22%) had MAEs. There was no immediate SCI. One patient had delayed paraplegia on postoperative day 3 after a single-stage repair of a contained ruptured Type II TAAA which was complicated by intra-operative rupture. This patient had complete recovery to full ambulatory status at 5 months. All patients were ambulatory with no evidence of SCI.

Copenhagen, Denmark • 28-30 September 256

Poster Presentations

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Conclusion: This prospective non-randomized study using a standardized strategy to prevent SCI was associated with no mortality and no permanent paraplegia in patients treated for TAAAs with F- BEVAR. Continued clinical experience is needed to determine the efficacy of neuromonitoring as part of this preventive protocol.

Copenhagen, Denmark • 28-30 September 257

Poster Presentations

PO 104 CONTRALATERAL ILIAC VEIN OCCLUSION AFTER ILIAC VEIN STENTING

Insitution: Radiology, Surgery, Inha university hopsital, Incheon, Republic Of Korea

Authors presenting: Keunmyoung Park, Yong Sun Jeon, Soon Gu Cho, Kee Chun Hong

Introduction: Stenting in iliac vein occlusion is common procedure in acute or chronic venous occlusion. The optimal procedure remains controversy. When venous stents extended into the vena cava, there were risk of contralateral iliac vein thrombosis. But there were rare report about contralateral occlusion after iliac venous stenting.Stenting in iliac vein occlusion is common procedure in acute or chronic venous occlusion. The optimal procedure remains controversy. When venous stents extended into the vena cava, there were risk of contralateral iliac vein thrombosis. But there were rare report about contralateral occlusion after iliac venous stenting.

Methods: We retrospectively reviewed prospectively collected data from Jan. 2009 to Oct. 2015 in patients with symptomatic acute or chronic iliocaval venous obstruction who underwent stenting at our institution. Data were collected by use of reporting standard for Endovascular treatment of LE DVT of JVIR. The incidence and treatment of contralateral iliac vein occlusion were analyzed.

Results: 124 iliocaval stents were placed. Of these patients, 28 received ipsilateral stents that extended into the IVC and partially across the contralateral common iliac vein orifice; 3 (10%) of these had venous occlusion. All patients were maintained by lifelong anticoagulation. Two patients underwent stent insertion with stent wall destruction for contralateral occlusion after catheter direct thrombolysis.

Conclusion: ata, it appears that stenting across the iliocaval confluence can be done safely but stenting can result in a small number of new contralateral occlusion. If there were no singnificant complaint, it’s possible to treat with only anticoagulation.

Copenhagen, Denmark • 28-30 September 258

Poster Presentations

PO 105 A PROSPECTIVE COHORT STUDY OF THE INCIDENCE OF VASCULAR SURGICAL SITE INFECTION USING DIALKYLCARBAMOYLCHLORIDE COATED POSTOPERATIVE DRESSINGS

Institution: Academic Vascular Unit, Hull Royal infirmary, Hull, United Kingdom

Authors presenting: Nelson Bua, George Smith, Daniel Pan, Tamsin Nash, Ian Chetter

Introduction: Surgical site infection (SSI) rates are particularly high (up to 20%) in vascular surgery patients, reflecting the significant co-morbidities in this group. Dressings coated with highly hydrophilic Dialkylcarbamoylchloride (DACC) irreversibly bind multiple types of bacteria and should prevent their ingress into wounds. We aimed to determine if the use of coated postoperative dressings could reduce SSIs in non-implant vascular surgery.

Methods: Between August 2015 to February 2016, we followed 100 consecutive patients before and 100 after the introduction of DACC coated post-operative dressing for surgical sites at a single vascular centre. Wounds were reviewed at day 5 and day 30 according to the ASEPSIS score to determine the presence of SSI. Dichotomous outcomes of SSI versus no SSI were assessed using a two tailed Chi-Squared test with Yates correction.

Results: The 200 patients included 120 males with mean age 63(range 27-97) including 184 /200 current or ex-smokers and 91/200 diabetics. SSI at 5 days was significantly lower in the DACC coated dressings’ group compared to standard dressings (1/100 versus 10/100: p=0.01).Subsequent SSI rate from 5 to 30 days between DACC and standard dressings was not significantly different (9/99 versus 9/90: p=0.85).

Conclusion: DACC coated dressings showed a significant reduction in SSI rates at 5 days post procedure (p=0.01). No statistically significant difference in SSI was seen beyond 5 days post procedure. DACC coated dressings appear to have value in SSI prophylaxis in this patient group and would warrant further investigation.

Copenhagen, Denmark • 28-30 September 259

Poster Presentations

PO 106 THE ROLE OF GLYCERYL TRINITRATE PATCHES IN ARTERIOVENOUS FISTULA MATURATION: A RANDOMISED, DOUBLE-BLINDED, PLACEBO CONTROLLED TRIAL

Institution: 1. Department of Renal Transplantation and Vascular Access Surgery, Department of Renal Transplantation and Vascular Access Surgery, Department of Renal Research, Department of Renal Research, Department of Statistics, Queen Elizabeth Hospital, Birmingham, 2. Department of Renal and Pancreas Transplantation, Central Manchester Foundation Trust, Manchester, United Kingdom

Authors presenting: Melanie Field, Damian McGrogan, Yazin Marie, Martin Joinson, Cecilio Andujar, Mary Dutton, Hari Krishnan, James Hodson, David van Dellen, Nicholas Inston

Introduction: Arteriovenous fistulas (AVF) are critical for haemodialysis, but maturation rates remain poor. Experimental and anecdotal evidence has supported the use of transdermal GTN patches. However, there is no robust evidence for their use in this setting. The aim of this randomised, double-blinded, placebo controlled study was to determine whether use of a GTN patch aids arteriovenous fistula maturation.

Methods: Patients referred for arteriovenous fistula formation were eligible. The GTN or placebo were applied immediately following surgery and left in situ for 24hrs. The primary outcome measure was the change to venous diameter following fistula formation at six weeks. The secondary outcome measure was clinical fistula patency at six weeks.

Results: 200 patients were recruited (533 screened). Following randomization, 101 were assigned the placebo group and 99 the GTN group. Of these, 81 and 86 respectively completed surgery, and had follow up data available at six weeks. The improvements in venous diameter were similar in the two groups, with a mean increase of 2.3±1.9mm in the placebo group, compared to 2.2±1.8mm in the GTN group (p=0.704). The fistula failure rate did not differ significantly between the two study groups, at 23% for placebo and 28% for GTN (p=0.596).

Conclusion: We conclude that GTN transdermal patches used for the immediate postoperative 24 hours confer no benefit in terms of arteriovenous fistula maturation.

Copenhagen, Denmark • 28-30 September 260

Poster Presentations

PO 107 IN VITRO QUANTIFICATION OF GUTTER FORMATION AND COMPRESSION OF CHIMNEY GRAFTS IN RELATION TO RENAL FLOW IN CHIMNEY EVAR AND EVAS CONFIGURATIONS

Institution: 1. University of Twente, Enschede, 2. Rijnstate Hospital, Arnhem, 3. Antonius Hospital, Nieuwegein, Netherlands

Authors presenting: Jorrit Boersen, Erik Groot Jebbink, Esme Donselaar, Simon Overeem, Eliene Starreveld , Cornelis Slump, Jean-Paul De Vries, Michel Reijnen

Introduction: The chimney technique has been successfully used to treat juxtarenal aortic aneurysms. The two main issues with this technique are gutter formation (GF) and chimney graft (CG) compression, which may induce a risk for type 1A endoleaks and stent thrombosis, respectively. In this in-vitro research the geometry of chimney Endovascular Aortic Repair (EVAR) configurations was compared to chimney configurations with the EndoVascular Aneurysm Sealing (EVAS) system.

Methods: Seven flow phantoms were constructed, including one unstented control and 6 chimney EVAR (Endurant and AFX) or EVAS (Nellix) configurations, combined with either balloon-expandable (BE) or self-expanding (SE) CGs with an intended higher positioning of the right CG in comparison to the left CG. Geometry analysis was based on measurements at 3-dimensional (3D) CT angiograms, and included gutter volume and CG compression, quantified by the ratio between maximal and minimal diameter (D-ratio). In addition, renal artery flow was studied in a physiological flow model and compared to the control.

Results: The average gutter volume was 297.5 ± 151.1 mm3 with the lowest gutter volume in the EVAS– Viabahn (61.6 mm3) and the largest in the AFX–Advanta-V12 configuration (559.6 mm3). The maximum D-ratio was larger in SE CGs than in BE CGs in all configurations (2.02 ± 0.34 vs. 1.39 ± 0.13). The CG compression had minimal influence on renal volumetric flow (right: 390.7 ± 29.4 mL/min vs. 455.1 mL/min; left: 423.9 ± 28.3 mL/min vs. 410.0 mL/min in the control).

Conclusion: The present study showed that gutter volume is lower in chimney-EVAS than in chimney-EVAR configurations, with the lowest CG compression in combination with the Advanta-V12. Further research is required to assess clinical implications of these findings.

Copenhagen, Denmark • 28-30 September 261