Abstract Book

CONTROVERSES ET ACTUALITÉS EN CHIRURGIE VASCULAIRE CONTROVERSIES & UPDATES

Chairman IN VASCULAR SURGERY Jean-Pierre Becquemin

Co-chairman Venous Session JANUARY 19-21 2017 Jean-Luc Gérard MARRIOTT RIVE GAUCHE & CONFERENCE CENTER Co-chairman Hemodialysis angioaccesses Session PARIS, FRANCE www.cacvs.org Eric Chemla

Scientific Committee Eric Allaire Jean-Marc Alsac Michel Bartoli Pierre Bourquelot Ludovic Canaud Xavier Chaufour Nick Cheshire Frédéric Cochennec Eric Ducasse Hans-Henning Eckstein Michel Ferdani Jean-François Garbé ABSTRACT Yann Gouëffic Christos Liapis Ian Loftus Martin Malina Armando Mansilha BOOK Maxime Sibé Hence Verhagen Frank Vermassen Fabio Verzini

Venous Scientific Committee Claudine Hamel-Desnos Lowell Kabnick Michel Perrin Thomas Proebstle Chairman Pr Jean-Pierre BECQUEMIN MD, Professor of Vascular Surgery, IVPE, Champigny, France Table of contents Faculty authors Co-chairman Venous Session CONTROVERSIES & UPDATES IN VASCULAR SURGERY VASCULAR PROGRAM VENOUS PROGRAM Dr Jean-Luc GÉRARD AMIN Ali ...... 52 AMIN Ali ...... 70 MD, Paris, France BICKNELL Colin ...... 6 BONE Carlos ...... 74 BULBULIA Richard ...... 22 DROC Ionel ...... 84 Co-chairman Hemodialysis THURSDAY JANUARY 19 DONAS KOSTANTINOS ...... 20 EKLÖF Bo ...... 68, 77 angioaccesses Session FANNELI Fabrizio ...... 9 FRANCESCHI Claude ...... 71 Dr Eric CHEMLA DISEASES OF THE THORACIC AORTA ...... 6 MD, Vascular Surgeon, FERRER Ciro ...... 7 GÉRARD Jean-Luc ...... 73 DESCENDING AORTA ...... 8 London, United Kingdom GEROULAKOS George ...... 31 GREINER Milka ...... 72 HÖLZENBEIN Thomas ...... 62 KABNICK Lowell ...... 82 Scientific Committee KAKKOS Stravos ...... 23 ONIDA Sarah ...... 79 Pr Eric ALLAIRE FRIDAY JANUARY 21 KEIRSE Koen ...... 60 PAVEI Patrizia ...... 81 MD, PhD, Professor of Vascular Surgery, LAROCHE Jean-Pierre ...... 13 PERRIN Michel ...... 76 Créteil, France MAIN SESSION LEDERLE Frank ...... 12 RAMELET Albert-Adrien ...... 75 Dr Jean-Marc ALSAC LIAPIS Christos ...... 24 SHALHOUB Joseph ...... 78 MD, PhD, HEGP, Vascular Surgery LOFTUS Ian ...... 21,27 THOUVENY Francine ...... 69 Paris, France ANEURYSMS OF THE ABDOMINAL AORTA ...... 12 MALIKOV Serge ...... 56 VANHANDENHOVE Inga ...... 83 Pr Michel BARTOLI EVAR NEWS ...... 18 MILNER Ross ...... 18 WHITELEY Mark ...... 80 MD, PhD, Vascular Surgery, ANEURYSMS OF THE ABDOMINAL AORTA (continued) ...... 19 PRATESI Carlo ...... 64 CHU La Timone, Marseille, France CAROTID ...... 22 PROCZKA Robert ...... 30 Dr Pierre BOURQUELOT SPECIAL ISSUES: VASCULAR SURGEONS AT WAR ...... 32 REIJNEN Michel ...... 55 MD, Paris, France ROUSSEAU Hervé ...... 8 Pr Ludovic CANAUD SCHNEIDER Peter ...... 59 MD, PhD, Vascular Surgery, HEMODIALYSIS ANGIOACCESSES SESSION SIBÉ Maxime ...... 58 CHU, Montpellier, France SILLESEN Henrik ...... 26 Pr Xavier CHAUFOUR AVF CREATION - NATURAL HISTORY ...... 36 SULTAN Sherif ...... 32 MD, PhD, Vascular Surgery, CHU Rangueil,Toulouse, France PTA ...... 41 SUNDERDIEK Ulrich ...... 61 Pr Nicholas CHESHIRE SURVEILLANCE - ENDOVASCULAR CREATION ...... 43 TAZI MEZALEK Zoubida ...... 57 Professor of Vascular Surgery, COMPLICATIONS - GUIDELINES ...... 44 VAN SAMBEEK Mark ...... 14 London, United Kingdom VEITH Frank ...... 15 Pr Frédéric COCHENNEC VERHOEVEN Eric ...... 19 MD, PhD, Professor of Vascular Surgery, Créteil, France SATURDAY JANUARY 22 Pr Eric DUCASSE MD, PhD, Professor of Vascular Surgery, MAIN SESSION HEMODIALYSIS ANGIOACCESSES PROGRAM Bordeaux, France AL SHAKARCHI Julien ...... 36 Pr Hans-Henning ECKSTEIN OCCLUSIVE DISEASES OF THE LIMB ...... 52 BOURQUELOT Pierre ...... 47 MD, PhD, Vascular Surgeon, CALDER Francis ...... 40 INFRA INGUINAL, SFA ENDO REPAIR ...... 58 Munich, Germany FRANCO Gilbert ...... 45 Dr Michel FERDANI DE NOVO SFA LESIONS: MATERIAL, RESULTS, UNCERTAINTIES (CONT) ...... 59 GARCIA-MEDINA Jose ...... 41 MD, Vascular Surgeon IBEAS Jose ...... 43 Marseille, France VENOUS SESSION RAWA Marek ...... 37 Dr Jean-François GARBÉ SCHER Larry ...... 44 Vascular surgeon, SHEMESH David ...... 42 Agen, France DEEP VEIN ...... 68 TORDOIR Jan ...... 46 Pr Yann GOUËFFIC VULVAR VARICOSE VEINS and MISCELLANEOUS ...... 71 WILMINK Teun ...... 38 MD, PhD, Professor of Vascular Surgery, VEIN and THROMBOSIS ...... 76 CHU Nantes, France THERMAL or GLUE TECHNIQUES ...... 80 Pr Christos D. LIAPIS Professor of Vascular Surgery, Chaidari, Greece Pr Ian LOFTUS EPOSTERS Professor of Vascular Surgery, London, United Kingdom ANEURYSM ...... 88 Dr Martin MALINA ANEURYSM THORACIC ...... 104 MD, PhD, Vascular surgeon, Malmö, Sweden CAROTID ...... 114 Pr Armando MANSILHA DISSECTION AND OTHER PATHOLOGY ...... 120 Professor of Vascular Surgery, MISCELLANEOUS ...... 122 Porto, Portugal PERIPHERAL ...... 132 Dr Maxime SIBÉ VEIN ...... 148 Vascular surgeon, Clinique Tivoli, Bordeaux, France Dr Hence VERHAGEN Vascular surgeon, Rotterdam, The Netherlands Dr Frank VERMASSEN Vascular surgeon, Gent, Belgium Pr Fabio VERZINI MD, PhD, Professor of Vascular Surgery, Perugia, Italy

2 3 Thursday January 19 - Main program - Controversies & Updates in Vascular surgery in Vascular & Updates Controversies

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY DISEASES OFTHETHORACIC AORTA Colin Bicknell, GuyMartin Aortic arch. Imperial College London, London, United Kingdom United London, London, College Imperial 1. REFERENCE for hybridandendovascular techniquesshouldfocusonreducingthiscomplicationsignificantly. cedures aspartoftheirassessment. There isasignificantstroke rateafterthisprocedureandimprovements effective intheshorttermselectedpatients, shouldbecomparedtothelong-termresultsofhybridpro durable proximallandingzoneforthoracicstentgrafts. Endovascular approaches, althoughseemingly Our experiencehasshownthatarchhybridprocedurescanbeeffectiveintheshorttermandproduce a Overall extra-anatomicalgraftpatencywas 98.7%. of cases, suggesting that using hybrid procedures to gain a safe proximal landing zone is a durable option. at 5years. Re-interventiontotheproximal landingzonefortype1aendoleakwas requiredinonly5.7% group ofpatientsafter extensive aneurysmal disease treatment- 70% at1year, 68% at2years and 57% mean followupperiodof74.6monthsinthisgrouppatients, cumulativesurvival was asexpectedfora of proceduralstroke was 12.5%inelectivecases, 28.6%inemergencycasesand14.5%overall. Overa respectively, and3.6%overall. The Achilles heelofthisprocedureappearstobethatstroke. The rate 30-day mortalityforurgentandelectiveprocedureswas 2.1%and14.3%inelectiveemergencycases early effectivenessusingthistechniqueintermsoftechnicalsuccess(92.7%)andexclusionendoleak. endograft placement in zone0, 34.5% in zone 1 and38.2%in zone 2) has demonstrated an excellent Our seriesof55archhybridprocedures totally endovascular techniques. the effectivenessanddurabilityofhybridtechniquesisessentialasacomparisonwithopensurgical branched systemsfortheaorticarchareemergingwithencouragingshort-termresults. Understanding These techniquesarenowbeingchallengedbyfurtheradvances instentgraftdesign. Fenestrated and zone forstentgraftplacement. vian, carotid-carotidandascending-carotidbypassescanbeusedtocreateastableeffectivelanding sealing zoneofthoracicstentgraftstoavoidsternotomy/thoracotomyandcardiacbypass. Carotid-subcla patients havesignificantco-morbidity. Archhybridtechniqueshavebeendevelopedtoextend theproximal the aorticarchareachallengetotreatwithopensurgicaltechniques, especially as manyoftheseelderly Aneurysms ofthoracicaortaandaorticarchthatrequireproximalstentfixationsealingatthelevel Martin G, RigaC, Gibbs R, JenkinsM, HamadyM, BicknellC. JEndovasc Ther. 2016, Inpress Short- andLong-termResultsofHybrid Arch andProximal Descending Thoracic Aortic Repair: A Benchmark forNew Technologies. Arch hybridprocedures: aretheyeffectiveanddurable? 1 (27.3%ofpatientsrequiredaorticde-branchingtofacilitate 6 - -

Ferrer Ciro DISEASES OFTHETHORACIC AORTA Aortic arch. Vascular Surgery Unit, University La Sapienza, Rome, Italy Rome, Sapienza, La University Unit, Surgery Vascular 9. 8. 7. 6. 5. 4. 3. 2. 1. REFERENCES and iliacaccessabletoaccommodate22or24Fsheaths. ascending aorta <38 mm diameter, innominate artery <20 mm in diameter and >20 mm in sealing zone length, repair: nopriormechanicalaorticvalve replacement, ascendingaortic length >50mm, sealingzonewithinthe with cerebrovascular complicationrateof15.8%. The authorsalsodescribedfeasibilitycriteriaforarchbranched on 38patientstreatedwiththeCookarchbrancheddevice, Haulon by ahypotheticalflow-limitingstent-graftmisalignmentorembolizationevents. Intheirmulticenterexperience from theproximityofaorticvalve andcoronaryostia, andthepotentialneurologiccomplicationsinflicted for patientsdeemedunfitopenand/orhybridrepair. The majorconcernincomplexarchstent-graftingderives placement intheleftsubclavianartery(LSA). The endovascular approachtoarchpathologyiscurrently reserved It consistsofamaingraftforplacementintheaneurysmalsegmentaorta, andadedicatedbranchgraft for Rosa, CA, USA)isanoff-the-shelfsingle-branchdevicebasedonthe Valiant Captiviathoracicstent-graftsystem. allowing theperfusionofasinglearchbranchvessel. The Medtronic Valiant MonaLSA(MedtronicInc., Santa sheath fromafemoralaccessanddeployedinreversefashionintothedockingzoneofaorticcomponent, nal reverse branch and a side branch dedicated component. The side branch component is delivered through a Flagstaff, AZ, USA)isanoff-the-shelfsingle-branchdevicethatconsistsofaorticcomponentwithinter facilitating branchcannulation. The Gore TAG Thoracic BranchEndoprosthesis(TBE)(W.L. Gore& Associ- ates, was toseparatetheorificesofbranchesfromostiasupra-aortictrunks, preservingperigraftflowand wide andflexible, whereasthemiddle, thebranchbearingportion, isnarrowandstraight. The aimofthisdesign of twointernalbrancheswithanenlargedexternalopeningattheirdistalends. The endsoftheendograftare branched archdevice(CookMedical, Bloomington, IN, USA)isacustom-madethoracicstent-graftthat consists a largewindowinthesuperioraspectofendograftthatcanacceptoneortwoinnerbranches.The Cook (Bolton MedicalEspaÒa, Barcelona, Spain; BoltonMedical, Inc., Sunrise, FL, USA). The distinguishingfeature is stent-graft. The Boltonbranchedarchdeviceisacustom-madethoracicstent-graftbasedonRelayNBSplatform standard straightmodel, somecompanieshaveintheirportfolioacustom-madeoroff-the-shelfarchbranched approach tocomplexaorticarchdiseasebytheuseoffenestratedandbrancheddevices. Inadditiontothe tion ofthoracicendograftshasallowedtheapplicationtotalendovascular repairorminimally-invasive hybrid results atleastcomparablewiththoseofopensurgeryselectedcenters. for stent-graftplacement. ties. ingly usedasanalternativeinpatientswhowerepreviouslydeniedopensurgerybecauseofrelevant comorbidi after openarchrepairarestillhigh. that havebroughttheachievementofsaferoutcomesandreducedmortality. in the treatmentof aortic archpathology, having benefited inrecentyears fromthe technological improvements Any treatment of aortic arch disease is demanding and technically challenging. Open repair is the gold standard 2013;57:655-67. Andersen ND, Williams JB, HannaJM 2014;148:1709-16. tions. J Vasc Surg 2015;61: 339-46. diseases. J Thorac Cardiovasc Surg 2012;144:1286-300, 1300.e1-2. aortic repair. J Thorac Cardiovasc Surg2013;145(Suppl):S72-7. 2007;20:97-107. comparison betweenopenandhybridarchrepairusingpropensityscore- matchinganalysis. EurJCardiothorac Surg2014;46:32-9. 2013;25:107-15. Haulon S, Greenberg RK, SpearR De RangoP, Ferrer C, Coscarella C Cao P, DeRango P, CzernyM Kotelis D, Geisb¸schP, Attigah N Iba Y, Minatoya K, MatsudaH Moon MC, Morales JP, GreenbergRK. The aorticarchandascendingaorta: aretheywithintheendovascular realm?Semin Vasc Surg. Iba Y, Minatoya K, MatsudaH Ouzounian M, LeMaireSA, CoselliJS. Openaorticarchrepair: state-of-the-artandfutureperspectives. Semin Thorac Cardiovasc Surg 5, 6 5, Hybrid repair consists of a supra-aortic debranching procedure to secure a proximal landing zone required Hybridrepairconsistsofasupra-aorticdebranchingproceduretosecureproximallandingzonerequired Total endovascular archrepear: whatwelearnedsofar? et al et 7 et al et al et A variety ofdebranchingprocedurescanbeusedinpatientswitharchdiseases et al et et al et . Systematic reviewofclinicaloutcomesinhybridproceduresforaorticarch dissectionsandotherarch . Contemporary openaorticarch repairwithselectivecerebral perfusionintheera ofendovascular . Howshouldaorticarchaneurysmsbetreatedintheendovascular aorticrepairera? A risk-adjusted et al et . Total et al et . Global experience withaninnerbranched archendograft. J Thorac Cardiovasc Surg . Contemporary comparisonofaorticarchrepair byendovascular and opensurgicalreconstruc . Resultswith analgorithmicapproachtohybridrepairoftheaorticarch. J Vasc Surg 3, 4 3, vs vs Hybridortotalthoracicendovascular repair(TEVAR) havebeenincreas hemi-aortic archtransposition forhybridaorticarchrepair. J Vasc Surg2011;54:1182-6. 7 9 et al et .reported a30-daymortalityof13.2%, 8 Continueddevelopmentandevolu 1, 2 1, However, deathandstroke rates - - - - - Thursday January 19

CONTROVERSIES & UPDATES IN VASCULAR SURGERY Rousseau Hervé DESCENDINGAORTA Imaging. CHU Rangueil, Toulouse, France Toulouse, Rangueil, CHU remember toalways trustyourinterventionalinstincts, aboveallelse. Above all, wemustnotbecomethedaftdriverblindlyfollowinghis/her sat navofftheendofpierand As awhole, inmyview, thetrickistousethesedevicescriticallyandwithfullawareness oftheirfrailties. structures. Ifwedonotgetthisright, theendresultisaseries ofmajorcomplications. Grafts canleadtoamismatchbetweentheoverlaid3DpreoperativeCTandreallocationofarterial move duetorespiratoryandcardiacmotionthedeformationsimposedbystiffguidewiresStent injection and irradiation. However, it is important to acknowledge that target organs, are constantly on the Fusion imaging proved helpful for catheterization of target vessels, reducing time of intervention, contrast treatment ofentrytearsaswellforthemanagementresidualflowfalselumen. the fluoroscopic images in order tofacilitate deployment of acomplex aortic or branch endograft forthe the interventionistanddisplayedindividuallyorinanycombination. These dataarethensuperimposedon supra aorticandvisceralcollaterals. Duringtheprocedure, thedifferentmaskscouldeasilybeselectedby ed to each mask and virtual reference markers are placed to mark the dissection flap tears andthe major from the pre-operative CT scan prior to the procedure using a 3D workstation. Different colors are attribut Briefly, semi-automatedreconstructionsoftrueandfalselumen3Daorticvolumes(masks)arederived lumen andidentifyingperfusionofvisceralvesselsbythe2lumen. the operation to facilitate complex endovascular repair ofaorticdissections in locating the trueandfalse Current developmentsinimage-guidedtherapyallowacombinationofthese2imagingtechniquesduring location …)areavailable intheoperativeroom, onlyonaseparatescreen. tion androadmapping. The preoperativeCTA data(positionoftheaorticbranches, trueandfalselumen Conventional operative imaging systems provide only two-dimensional fluoroscopic images with subtrac and falselumenstocatheterizevisceralvessels. Endovascular repairofdissectionisprobablyonethemorechallengingproceduretonavigateintrue Benefitofintraoperativefusionimagingforaorticdissectionmanagement 8 - -

Fanneli Fabrizio DESCENDINGAORTA How tomanagethefalselumen. Sapienza University, Rome, Italy Rome, University, Sapienza 6. 5. 4. 3. 2. 1. REFERENCES FL thrombosiswithalowrateofcomplications. More studies are required to evaluate in deep alll these options and fiind the most suitable to increse the in increasedtheriskofspinalischemia. Extensive thoraciccoverage, whichisbelieved togiveagreaterrateoffalselumenthrombosis, mayresult disruption oftheFLusingscissorstechniqueorfunneltechnique. into the TL, enlargingitand compressingcompletelytheFL. Two moreoptionsarebasedonthecomplete Compression oftheFLcanbeachievedusingabaremetalstent, withhighradialforce, thatisdeployed with glue. the knickerbocker technique. Embolization of the FL cam also be done using coils alone or in combination group differentoptionsareavailable: embolizationcanbeperformedusingthecandy-plugtechniqueor FL managementisbasedontwodifferentstrategies: embolization/occlusionand compression. Inthefirst mortality, asreportedintheliterature. when comparedtoacutedissections(AAD). HoweverresidualpatencyoftheFLisnotapredictor5-year correlated with theaorticremodeling. Howeverinchronicdissections(CAD)FLthrombosisrateislower As reportedbyseveral Authors, falselumen(FL)thrombosiswithprogressivereductionofitsdiameteris cess butnowadays notallofthemareclear. primary entrytearandstimulatingremodelingofthethoracicaorta. Severalfactorsplayaroleinthispro dissection eitherintheacuteorchronicphase, withtheaimtoexcludefalselumen(FL), coveringthe Thoracic endovascular aorticrepair(TEVAR) representsavalid treatmentforcomplicatedtypeBaortic Tsilimparis N, Larena-Avellaneda A, DebusES. JEndovasc Ther. 2014Feb;21(1):117-22 Addressing persistentfalselumenflowinchronicaorticdissection: theknickerbocker technique. Kˆlbel T, CarpenterSW, Lohrenz C, investigators. J Vasc Surg. 2012Mar;55(3):629-640 composite devicedesign. LombardiJV, CambriaRP, NienaberCA, ChiesaR, Teebken O, Lee A, MossopP, Bharadwaj P; STABLE Jun;23(3):483-6 cluder Aortic ExtenderforDistalOcclusionofaLargeFalse Lumen Aneurysm inChronic Aortic Dissection. JEndovasc Ther. 2016 Candy-Plug Technique. JEndovasc Ther. 2016Jun;23(3):487-8 dissection. J Vasc Surg. 2014;60:1507-1513. aortic dissection: methodsandoutcomes. Ann Thorac Surg. 2014;97:588-595. Prospective multicenterclinicaltrial(STABLE) ontheendovascular treatmentofcomplicatedtypeBaorticdissection usinga Ogawa Y, NishimakiH, ChibaK, Murakami K, Sakurai Y, Fujiwara K, Miyairi T, Nakajima Y. Candy-Plug Technique UsinganEx Kˆlbel T, RohlffsF, DebusES, Tsilimparis N. Polytetrafluoroethylene Excludesthe False Lumen: ExpandingMaterialOptionsforthe Idrees J, RoselliEE, Shafii S, Reside J, Lytle BW. Outcomesafterfalselumenembolizationwithcoveredstentdevicesinchronic Patterson BO, CobbRJ, Karthikesalingam A, et al et . A systematicreviewofaorticremodelingafterendovascular repairoftypeB What arethenewtools, howtousethem? 9 - - Thursday January 19

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY ANEURYSMS OFTHEABDOMINALAORTA FrankLederle A. AAA infra renal. MD, Minneapolis, USA Minneapolis, MD, screening willlikely continue, butfirstweshouldgetthenumbersright. latter error was originally by theUS Preventive Services Task Force. Debate on the merits of aneurysm the differenceduetoinappropriateroundinginreportingofconfidenceintervals. Surprisingly, this the Western Australia trial. The 2015 papers either failed to use the latest reports from the trials or missed significant reductionintotalmortality. This remainstruewiththeadditionofnew longtermdatafrom ysis ofthelongesttermfollowupfourtrials AAA screeningclearlyshowsasmallbutstatistically thors perceivedasalackofdemonstratedreductionintotalmortalityfromscreening. Infact, meta-anal articles publishedin2015challengedthevalue ofultrasoundscreeningfor AAA basedonwhattheirau in disease-specific mortality as sufficient to conclude benefit from screening. However, several prominent als, have used disease-specific mortality as their primary outcome, and most authorities accept areduction Most trialsofscreeningforpotentiallyfatalconditions, includingtheabdominalaorticaneurysm(AAA)tri Docardiovascular drugsreduce AAA enlargement? 12 - - -

ANEURYSMS OFTHEABDOMINALAORTA Jean-Pierre Laroche Detection of AAA saveslife AAA infra renal. CHU Montpellier, Saint Eloi Hospital, Montpellier, France Montpellier, Hospital, Eloi Saint Montpellier, CHU http://www.hasante.fr/portail/upload/docs/application/pdf/2013-02/aaa syntheseou4pagesvfinale.pdf. HAS. Pertinence delamiseenplaced’unprogramme dedépistagedesanévrismesdel’aorteabdominale(AAA)enFrance; 2012 J Mal Vasc 2006;31:260ó76. vrismes del’aorteabdominale: argumentairesetrecommandationsdelaSociétéfrançaise demédecinevasculaire órapport final. Becker F, BaudJM, pourlegroupedetravail adhoc.Dépistage des anévrismesdel’aorteabdominaleetsurveillancepetitsané aortic aneurysm: Lessonsfrom Vesale 2013,JournaldesMaladies Vasculaires (2015)40, 340ó349 J.P. Laroche, F. Becker, J.M. Baud, G. Miserey, A. Jaussent, M.C. Picote, REFERENCES A. Bura-Rivière, I. Quéré,Ultrasound screeningofabdominal dtection canbeacheepandeffectivesolutionnthat’s France! cialities thatuseultrasound, havetodetect AAA inaseletedpopulation, inFrance thisunorganized AAA That’s themainproblem. Butwith AAA detectionwesavelife, it’s indisputbale. Eachphysicianofanyspe Of greatconcernforpatientswithsmall AAAs detectedatscreeningis theriskofunnecessaryprocedure”. success ofascreeningprogramlargelydependsonhowpatientsaremanagedafterthetest.... study 126life. Inthotherhandwefindasignificantnumberaneurysminwomen. AsLerderlesay: “The mm ofdiameter. We needdetectinaselectpopulation289patientsforone50mm AAA.We saveunthis 15 mm, 6.3%46/49mmand17.2%more than50mm(126 AAA).One AAA detected outofsixmeasure50 of thewomensmoked.61% ofthe AAA haveadiameterbetween30and39mm,n15.5%40 with asexratiowoman/menof1/5. The meanageofthe AAA: 68yearoldforwomenand75men, 90% With aprevalence of2%, 36500patientshavebeendetected. For the729 AAA, 605menand124women, ple eachyear. The goalofscreeningiscost-effectivereductioninthedeathtoll.In 2015wedetect729 AAA. tection, therapeuticmanagement, andmonitoring. AAA isaserious, common, diseasethatkills6000peo forAAA (Vesalius operation2014/2015)inordertoincreasepublicandphysicianawareness aboutAAAde years shouldbediscussed.Giventheimportanceofscreening, theSFMVsetupayearofnationalscreening is warranted inmen60yearsandover, especiallysmokers, andinfemalesmokers. Screeningbeyond75 factors withtheimportantroleofsmoking.Lessonsfrom Vesalius totake intoconsiderationare: screening lius data are consistent with those of the literature bothin terms of prevalence and for cardiovascular risk detected AAA was 33 mm (range 20 to 74 mm). The prevalenceof AAA was 1.7% in this population. Vesa of AAA intheage-basedtargetpopulation(3.12%formen, 0.27%forwomen). The mediandiameterof More than7000people(asmanywomenasmen)werescreenedin83centerswitha1.70%prevalence between 60and75years); theagelimitwas loweredto50yearsincaseofdirectfamilyhistory AAA. Vesaliusoperation. Beingaconsumeroperation, theselectioncriteriawerelimitedtoage(menandwomen ropolitan France andoverseasdepartmentsthatledtoaproposalforfree AAA ultrasound screening: the held amainstream communicationday on November21, 2013inFrance involvingparticipants from met published recommendationsfortargetedopportunisticscreeningin2006and2013respectively. The SFMV subject ofdebate. InFrance, theFrench Societyof VascularMedicine (SFMV)andtheHealth Authority (HAS) screening, theadvantages ofmassscreening Although aneurysmoftheabdominalinfra-renalaorta(AAA)meetscriteriawarrantingB modeultrasound Duel. Detectionof AAA. versus

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY ANEURYSMS OFTHEABDOMINALAORTA Mark Van Sambeek, Emielvan Disseldorp, Frans van de Vosse, RichardLopata AAA ruptures. Catharina Ziekenhuis Eindhoven, Department of Biomedical Engineering, The Netherlands The Engineering, Netherlands The Biomedical Netherlands of The Technology, of Department Eindhoven, University Surgery, Eindhoven, Eindhoven Vascular of Ziekenhuis Department Catharina Hospital, Catharina - - REFERENCES 75 ilarity indicesbetweenUSandCTwereverygoodranged0.900.96, andthe25 Regression analysisshowednosignificantrelationbetween wall stress anddiameterofthe AAA. The sim derived. For sevenpatients, CTdatawereavailable andanalyzedforgeometrywall stresscomparison. extracted from the 4D-US. WSA was performed and corresponding patient specific material properties were quired for40patients(AAAdiameter27-52mm). Patient specific AAAgeometries and wall motionwere In anotherstudywall stressanalysis(WSA)was performedusing4Dultrasound. 4D-USimageswere ac the presenceofaorticbifurcationinFOV doesnotinfluencethe wall stressesinhighstressregions. the proximalanddistalshouldersofaneurysmareinshortenedFOV. Wall stressresultsshowthat tries in10patients. Resultsrevealthatchanges inthe99 assessed theinfluenceofalimitedFOV byperforming wall stressanalysisonCT-based (total) AAAgeome the field-of-view(FOV) of3DUSislimitedandtheaorticbifurcation noteasilyimaged. Inastudywe However, performingwall stressanalysisbasedon3Dultrasound hasmanyadvantages overCT, although, strains andwall stressesbecomeavailable using3DUS. thereby morepatient-specificmaterialpropertiescanbederived. Alsopatient-specificandFEM-regularized the dynamicbehaviorof AAA wall, finiteelementmodelscanbecalibratedtothevesselmotionand and evenenablesthepossibilitytoacquirevessel’s motionduringthecardiaccycle(4DUS). Using Three-dimensional ultrasound (3D US) imaging overcomes abovementioned disadvantages of CT and MR, MRI, andtheunavailability ofpatient-specificmaterialproperties. agents forCTimaging, thelongscanningtimeandhighcostfor approach suffersfromseveraldrawbacks, suchastheuseofionizingradiationandnephrotoxiccontrast mostly performedusingcomputedtomographyandsparselywithmagneticresonanceimagingdata. This Wall stressanalysishasbeenintroducedtopredictthepotentialruptureriskof AAA wall, whichis 4D ultrasound. EurJ Vasc Endovasc Surg. 2016: epubaheadofprint 2016;49:2405-12. van DisseldorpEM, van DisseldorpEM, th , and95 th percentilewall stressesoftheUSandCTdatawereinagreement. et al et al et Canrupturebepredictedby4DUS Wall stressanalysis? . Patient specific wall stressanalysisandmechanicalcharacterizationof abdominal aortic aneurysmusing . Influenceoflimitedfield-of-viewon wallstressanalysisinabdominalaorticaneurysms. JBiomech. 14 th percentile wall stressesarelessthan10%when th , 50 th - - - ,

ANEURYSMS OFTHEABDOMINALAORTA Frank J.Frank Veith Why RCT’s andguidelinesareoftenmisleading: howtomake aproperdecision? EVAR 2. Leicester Royal Infirmary, Leicester, United Kingdom United Leicester, Infirmary, Royal Leicester 2. 1. tively, for ACS. Only 48%ofguidelinescontained suchrecommendations regardingSCS. Furthermore, when peri-CEA orperi-CAS medicaltreatment werefoundinonly50% and 32%ofapplicableguidelines, respec only 68%ofguidelinesregarding ACS, and in91%regardingSCS. Specificrecommendations regarding treatment recommendations. Any recommendations regarding generalmedicaltreatmentwereincluded in limited life-expectancyofmany suchpatients. There was alsoa notablevariation intheinclusionofmedical randomized datashowing thatanyprocedureimprovesoutcomesovermedical treatmentalone, andthe lines with respect to ACS and 84% of guidelines with respect to SCS.This is despite the absence of any medical comorbidities, orundefined reasons. Such endorsements were found in 49%ofapplicable guide CAS was alsovariably endorsedforpatientsconsidered athighrisk-for-CEA becauseofvascular anatomy, of thedangersCASforaverage-CEA-riskpatients was underrepresentedinmany oftheseguidelines. as goodCEAormedicaltreatmentaloneforstroke prevention. Randomizedtrialandregistryevidence CAS for ACS andSCSwerecommon, despitethe lackofrandomizedtrialdatashowingthatCASisatleast proximately 50%ofapplicableguidelines, whileapproximately 25% explicitlyopposedit. Endorsementsof plicable guidelines, while 30% explicitly opposed it. CAS was endorsed for average-CEA-risk SCS by ap was endorsed(recommended thatitshouldormaybeprovided)foraverage-CEA-risk ACS by63%ofap ACS. However, therewas amorenotablevariation incarotidarterystenting(CAS)recommendations. CAS dorsed carotid endarterectomy (CEA) for average-CEA-risk SCS, and 96% endorsed CEA for average-CEA-risk es leading to a variability in treatment recommendations. For instance, 100% of applicable guidelines en languages from 32 different writing groups, Abbott and colleagues have documented guideline weakness a comprehensive analysis of guideline treatment recommendations from 23 countries, published in six disease inpatientswithmoderateorsevereasymptomatic(ACS) orsymptomaticcarotidstenosis(SCS). In published systematicreviewof34currentinternationalguidelinesdealingwiththetreatmentcarotid tunately, theprocessofdefiningguidelinesisflawed, andthepotentialforthisishighlightedina recently knowledge whenitiscomplex, evolving, anddifficultforinterestedpartiestoassessontheirown. Unfor of this, guidelineshaveevolvedasaway tofacilitateoptimalpatientoutcomesbysummarizingcurrent vidual practitionerstojudgeobjectivelywhichoneofseveraltreatmentsisbestfortheirpatients. Because The managementofanumbermedicalconditionsiscontroversial. Itis, therefore, oftendifficultforindi Vasc Surg2013;57:3S-7S.) good physicianjudgmenttooptimizethecaredeliveredindividualpatientsandsocietyatlarge. (J processes sothatRCTscanbeevaluated adequatelyandfairly. Inthatway, theycanbeusedalongwith results inarticlesdescribingRCTsleadingjournals. All physiciansshouldrecognizethesevalue-limiting lem. This articleprovidesexamplesofmisleadingconclusionsand/ormisinterpretations(spinning)trial based onsucherrorsorbias-basedconclusionsandmisinterpretationscanfurthercompoundtheprob the effect of the trial misleading with an unintended detrimental result on medical practice. Guidelines error orbias. This plussubsequentmisinterpretationofthetrialresultsorconclusionsbyotherscanmake articles describing RCTs isthe potential for theconclusionsoftrial report to be misleading because of can also invalidate an RCT. Examples of these flaws and weaknessesare presented. Another problem with competence, randomization, applicability, endpoints, andthepopulationbeing studied. Idiosyncraticflaws treatment methodorcontrolarmmayinvalidate atrial. Sotoocandefectsinpatientselection, physician their value. These include flaws and weaknesses in the design and the timeliness of RCTs. Progress in a been deemed the best possible basis for good medical practice. However, several limitations may decrease The resultsofgoodrandomizedcontrolledtrials(RCTs)publishedinleadingpeer-reviewed journalshave States New York University and The Cleveland Clinic, New York, NY and Cleveland, Ohio, United United Ohio, Cleveland, and NY York, New Clinic, Cleveland The and University York New versus 1 , Peter Bell endo. Where are we? 2

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY and multi-registryanalyses. The criteriaonwhichguidelinesshouldbebasedcouldagreedinterna also include other evidence such aspropensity-matched trials (preferably multi-center), audited registries, future guidelinesshouldacknowledgetheflawsin the randomizedtrialsthatformtheirbasis. They should habits and resources. Therefore, aonesize fits allguidelinepolicy isprobably notappropriate. However, The treatmentofanyconditionwillvary withdifferentcountriesandareasoftheworlddependingonlocal problems discussedin Abbott procedural interventions. However, suchtrials will take many years to complete and may not address the carotid stenosis, andthatsuchtrialsmustinclude betterriskstratificationmodelsandmodernmedical edge thatnewevidence, includingfurthertrials, maybehelpfulinimprovingoutcomesfor patientswith sponsoring groupswritingthemand/orerrorsthattheirauthorsmake. Futureguidelinesshouldacknowl can only be explained by the differing and less than objective viewpoints of the individual physicians and jective andaccurateinterpretationoftheevidencebase. The numerousflawsincontemporaryguidelines management ofpatientsinroutinepractice. Standardizationofrecommendations would followfromob that currentinternationalcarotidmanagementguidelineshaveseriousflawsmayleadtosuboptimal standardized across guidelines, making interpretation and comparisonsdifficult. Itis, therefore, apparent ogy usedtosummarizetreatmentrecommendationsandtheevidenceinmakingthemwerenot patient benefit, andfailedtoexplainlimitationsofguidelinerecommendations. Furthermore, theterminol tions for ACS andSCS, failed toincludeafullydefinedproceduralstandardthatwouldimplyanoverall tained, andincludedinconsistencies ambiguities. They alsooftenconfusedproceduralrecommenda often accessibleonlyviaprofessionalaffiliationsratherthanpopularsearchengines, werenotself-con subgroups whoclearlyachievedastatistically significant benefitinthosetrials. Inaddition, guidelineswere definition inguidelinesencouragesproceduralover-utilization bynotlimitingendorsementstopatient Such definitionsshouldfollowdirectlyfromtherelevant randomizedtrials. The lackoftargetpopulation degree, the method of determining the stenosis, and the timing and territory of any previous stroke or TIA. for ACS andSCS, only7%and12%, respectively, completelydefinedcarotidstenosisaccordingto tal organizationalomissionsandotherproblemsacrossguidelines.1 For instance, ofapplicableguidelines and withCEA, andapersistenceofsignificantly higherrisksfromCAS. Abbott tional data. Suchdata, forexample, haveshownimprovedpatientoutcomeswithmedicaltreatmentalone guidelines oftenunderutilizeandundervalue quality, independentlyvalidated, non-randomizedobserva evaluate outcomesinroutinepractice, andarenotappropriateforansweringallmedicalquestions. Current medicine. Randomizedtrialscanbecomeobsolete, maybemisinterpreted, arenotusuallythebestway to can beusefulifwelldesignedandinterpretedwithoutbias, theyarenottheHolyGrailofevidence-based over-reliance on, andlimitationsof, randomizedtrialdataincurrentguidelines. Although randomizedtrials death ratestandards)havehardlyimpactedonguidelinerecommendations. Abbott patients withSCS(includingtheneedforbetterpatientselectionandtighterperi-proceduralstroke and tion ofbetter outcomes now in patients with ACS withoutprocedural intervention and its implications for proved byatleast80%sincetherandomizedtrialsofCEA of medicaltreatmentalone(encouragingahealthylifestyleandappropriateusemedication)hasim SCS) was derivedfromthesameold, andnowobsolete, randomizedtrials. The stroke preventionefficacy risk of stroke or death said to confer an overall patient benefit from CEA (usually 3% for ACS and 6% for patients whowererandomized12-34yearsago. Inaddition, whenincludedinthe guidelines, the30-day directly on old comparisons of carotid endarterectomy and what is now obsolete medical treatment in guidelines identified in the review by Abbott weaknesses incurrentinternationalguidelinesbroughttolightbywhattheyhavecommon. Inall34 from proceduralrecommendationsandomittedsummaries. Perhaps ofmore importancewerethe medical treatment recommendations were included, they were usually incomplete and often separated oversee guideline developmentandwriting, andsuggest treatmentoptionsfor thatcountry. Suchorgani would beimportant thatunbiasednational organizations, whicharenotsociety based, could beasked to procedure beencompared withotheravailable treatments? After suchagreementshavebeenreached, it question asked, ii)isthestudysufficientlypowered, iii) aretheevaluations contemporary; andiv)hasthe ance onsuchissuesas: i) aretheprimaryoutcomeend-pointsandrandomization appropriatetothe tionally andcouldinclude guidanceoftheacceptabilitystudies. For example, theycouldinclude guid et al et .’s review. The questionthatremainsis, canthissituation beimproved? et al et ., all procedural endorsements were based directly or in 16 versus medicaltreatmentbegan. The observa et al et . alsofoundfundamen et al et . highlightedthe ------

Abbott AL, Paraskevas KI, Kakkos SK, GolledgeJ, EcksteinHH, Diaz-Sandoval LJ, REFERENCES pose ofguidelines. better served. After all, facilitatingimprovedpatientoutcomesinroutine practiceshouldbethemainpur self-interest, allofwhichcandecreaseguidelinevalue. Onlyinthisway willtheinterestofpatientsbe ture guidelinesshouldbewritteninaway thateliminatesfactualerror, inconsistency, bias, anddoctor Veith FJ. Howcangoodrandomized controlledtrialsinleadingjournalsbesomisinterpreted?J Vasc Surg2013;57:3S-7S. Endovasc Surg(2016)51, 471-472. Veith FJ, BellPRF. HowManyof You CanReadButStillNotSee? A CommentonaRecentReviewofCarotidGuidelines. EurJ Vasc gement ofasymptomaticandsymptomaticcarotidstenosis. Stroke 2015;46(11):3288e301. ideal, butthenneitheristhepresentsystem. The key lessonlearnedfrom Abbott zations already exist in some countries. Some might say that this approach would be cumbersome and not 17 et al et . Systematicreviewofguidelinesforthemana et al et .’s reviewisthatfu - - - Friday January 20

CONTROVERSIES & UPDATES IN VASCULAR SURGERY EVAR NEWS Ross Milner punctures? Rightsideorleftside? How doyougetaccesfromabove: brachial, axillary, subclavian, conduitormultiple Approaches. Univeristy of Chicago, Chicago, USA Chicago, Chicago, of Univeristy ChEVAR Access Imageofaxillaryconduitwith4separate sheathsontherightside. FIGURE options todeliverparallelgrafts. Inaddition, theneedforoneormoreaccesswillbediscussed. in additiontothefemoralaccess. This talkwilladdresstherisksandbenefitsofdifferentarterialaccess advantages anddisadvantages. A limitationoftheChEVAR approachistheneedforupperextremityaccess pair (FEVAR) andChimneyendovascular repair(ChEVAR) usingparallelgrafts. Bothapproacheshavetheir proach. Endovascular approachestothistypeofanatomyincludeFenestrated endovascular aneurysmre Pararenal abdominalaorticaneurysmsremainchallengingtotreatfromanopenandendovascular ap

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ANEURYSMS OFTHEABDOMINALAORTA Eric Verhoeven,Katsargyris Athanasios Not atall, FEVAR offersexcellentimmediateandlongtermresults Round table. Howshortneck AAA shouldberepaired Short neckaneurysms. Klinikum Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany Nuremberg, Nuremberg, University Medical Paracelsus Nuremberg, Klinikum Efficacy anddurabilityinthemid-termappearverygood. Longertermresultswillbescrutinisedcarefully. FEVAR asafirstlinestrategy was associatedwithhightechnicalsuccessandlowoperativemortalityrate. CONCLUSIONS to 53.2±12.8mm(p<0.001). 98.1% ±0.6%, respectively. Meananeurysmsacdiameterdecreasedfrom60.2±9.3mmpreoperatively 1.4%, and90%±2.7%. Estimatedtarget vesselstentpatencyat1and3yearswas 98.6%±0.5%, and and 84.6%±3.0%, respectively. Estimatedfreedomfromreinterventionat1and3yearswas 96.1%± (2/281). Meanfollow-up was 21 ±15.9 months. Estimated survival at 1 and 3 years was 94.7% ± 1.6% open conversionduetoiliacrupture, and seventargetvessel complications. Thirty-day mortality was 0.7% (272/281). Technical failure includedoneintraoperativedeathduetoembolizationandcardiacarrest, one 60.2 ± 9.3mmand median proximal neck length 2 mm (range 0-10mm). Technical success was 96.8% A totalof281patients(245male, mean age72.1±7.7years)weretreated. Meananeurysmdiameterwas FIVE YEARS RESULTS in theEJVES, andanupdateonsevenyearswillbeprovided. tervention duringfollow-upwerecalculatedbyKaplanñMeieranalysis. Datawerepublishedforfiveyears target vesselpatency, endoleak, re-intervention, anddeath. Survival, targetvesselstentpatencyandrein maintained database. Analyzed outcomesincludedtechnicalsuccess, operativemortalityandmorbidity, within the period January 2010 - December 2016 will be included. Data were collected from a prospectively All consecutivepatientstreatedwithFEVAR forshort-neck, juxtarenal, orsuprarenalaorticaneurysms MATERIALS ANDMETHODS suitable pararenalaorticaneurysms. Outcomes of fenestrated endovascular aneurysm repair (FEVAR) as a first-line strategy for patients with OBJECTIVES

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY ANEURYSMS OFTHEABDOMINALAORTA Konstantinos Donas Parralel graftsarethebestoptionandcanbe standardized Round table. Howshortneck AAA shouldberepaired Short neckaneurysms. MD, Münster, Germany Münster, MD, able coveredstentsissafeandfinallythebestoptionforshortnecks. In summary, Ch-EVAR withstandarizeduseofflexibleabdominallowprofiledevicesandballoonexpand gulated shortnecks. The techniqueiscost-effective. nitinol endoskeleton andtheshortM-shapedstentsofEndurantshowexcellentcomformabilityinan arteries whichrepresentacontraindicationforuseoffenestratedendografting. Additionally, theflexible such astheEndurant(Medtronic)stent-graftsovercomesbarrieresofcalcified, stenosedorelongatediliac Ch-EVAR performedbyoff-the-shelfdevicesallowstreatmentintheurgent setting. Useofflexibledevices normal arterialperfusiontotheinvolvedtargetvessels. These grafts are designed to course in the aortic lumen outside the main stent-graft, aiming to maintain option. In this context, the use of chimney grafts (Ch-EVAR) is gaining in popularity and case applicability. A shortorabsentinfrarenalneckessentiallyexcludestandardEVAR asaviableorreasonabletreatment Juxtarenal aortic aneurysms (JAAs) pose significant challenges for endovascular aneurysm repair (EVAR).

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ANEURYSMS OFTHEABDOMINALAORTA Ian Loftus Why EVAS isthebestgraftforchimneys? Round table. Howshortneck AAA shouldberepaired Short neckaneurysms. St Georges Vascular Institute, London, United Kingdom United London, Institute, Vascular Georges St especially intermsofbranchpatency, reinterventionandaneurysmrelatedmortality. suitable forFEVAR orthoserequiringurgenttreatment. Midtolongtermdataondurabilityisimportant, ChEVAS isaneffectivetreatmentforjuxtarenal AAA, particularlyforthosepatientswithaneurysmsun CONCLUSION and longtermoutcomesofchimney-EVAS in200patients. An internationalregistry(ASCENDRegistry)iscurrentlyrunninginanumberofcentres, lookingatthe mid 2 endoleakinfollowup. 98% (61/62). There was oneprocedure-relateddeathwithin30-days. There was onetype1aand of 55ml. Procedural technical success with anabsenceof endoleak atcompletion was demonstrated in 20 (32.3%)2chimneysand8(12.9%)3chimneys). Meanpolymervolumewas 77.3ml, withamedian of 1.58chimneygraftsweredeployedperprocedure; 34cases(54.8%)involveddeploymentof1chimney, aneurysms weresuprarenaland52juxtarenal, allwereunsuitableforFEVAR oropenrepair. A mean We havetreated62patientsthusfar, comprising14womenand48men. The mean agewas 73years. 10 RESULTS ovascular therapiesofthevisceralaorta. data werecollectedforeachpatientundergoingChEVAS. Clinicaloutcomesdatawereinkeeping forend for openrepairorFEVAR. Detailed pre-, peri- and postoperativephysiological and aorticmorphological We establishedachimney-EVAS programmeatStGeorgesLondon, in2014, largelyforpatientsunsuitable METHODS treatment ofjuxta-renalabdominalaorticaneurysms(AAA). EVAS withchimneystents(ChEVAS) mayrepresentanalternativetofenestratedEVAR (FEVAR) forthe within theendobagsconformstoshapeofchimneystents, whilstmaintainingaproximalseal. endovascular aneurysmsealing(EVAS), theriskoftype1endoleakmaybereducedbecausepolymer devices may beassociated with risk oftype 1 endoleak due toguttering. When usedin combination with branches whentreatingjuxta-renalandsupra-renalaneurysms. Their usewithconventionalendovascular Chimney graftsmaybeplacedparalleltoanaorticstent-graftmaintainperfusionthroughvisceral OBJECTIVE

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY Bulbulia Richard CAROTID and theCarotidStenosis Trialists’ Collaboration Individual patientdatameta-analysisof VA, ACAS and ACST-1 trials The keys tounderstandingstroke riskinasymptomaticcarotiddisease- Risk ofstroke andhowtomake adecision? 2. Nuffield Department of Surgery, UNiversity of Oxford, Oxford, United Kingdom United Oxford, Oxford, of UNiversity Surgery, of Department Nuffield 2. 1. absolute stroke riskinthispopulation, butadditionofCEAhalves theremainingrisk. eral andcontralateralcarotidterritorystrokes. Contemporarymedicaltherapy, inparticularstatins, reduces CEA reducesthe10-yearriskofstroke inasymptomaticpatients, withsignificantreductionsinbothipsilat CONCLUSION group-specific differencesobservedbasedonparticipants’age(<75years), sex, or priordisease. similar efficacyforCEA(8.2% 0.42 0.90]). Subgroupanalysisofindividuals takingtriplemedicaltherapybeforeanystroke demonstrated in bothipsilateral(RR0.43[95%CI0.30-0.61])andcontralateralcarotidterritory strokes (RR0.61[95%CI 18.9%; RR0.55[95%CI0.46-0.65], p<0.0001). Allocation toimmediateCEAyieldedsignificantreductions However, followingasuccessfulprocedure, allocationtoimmediate CEAhalvedtheriskofstroke (12.4% During theperioperativeperiod, theriskofstroke ordeathwas 3.0% amongthosewhoreceivedCEA. RESULTS and lipid-loweringmedications(ie, triplemedicaltherapy). analyses wereconductedbasedonage, sex, priordisease, anduseofanti-thrombotic, anti-hypertensive dural stroke anddeathrates(safety), and nonperi-proceduralstroke rates(efficacy). Pre-specifiedsubgroup 1993-2003) wereincludedintheseintention-to-treat analysis. Primaryoutcomeswere30-dayperi-proce Patients randomised in the VA trial (n=444, 1983-87), ACAS (n=1662, 1987-1993), and ACST-1 (n=3120, METHODOLOGY carotid stenosispatients, takingintoaccountdifferencesinmedicaltherapy. Individual patient data analysiswas conducted to clarifytheefficacy andhazardsofCEAin asymptomatic RATIONALE Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, of University Health, Population of Department Kingdom Nuffield United Unit, Oxford, Studies Epidemiological Medical Research Council Population Health Research Unit, Clinical Trial Service Unit & & Unit Service Trial Clinical Unit, Research Health Population Council Research Medical 1 , Alison Halliday , Alison vs 14.2%; RR=0.52[95%CI0.35-0.77], p<0.0001). There werenosub 2 , onbehalfofthe ACST-1, ACAS, and VA collaborators, 22 1

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CAROTID Stravos Kakkos Progression ofasymptomaticcarotidstenosis: isitariskfactorofstroke? Risk ofstroke andhowtomake adecision? 3. University of Athens, Athens, Greece Kingdom Athens, United Athens, of London, University London, 3. College Greece Patras, Imperial 2. Patras, of University 1. 4. 3. 2. 1. REFERENCES progression. Furtherstudiesusingcurrentmedicaltherapymaybesuggested. of patientswithapproximatelytwicetheriskipsilateraleventsandstroke comparedtothosewithout demonstrated anon-significanttrend(P=.064). Inconclusion, progressionof ACS mayidentifyasubgroup other ultrasonic featuresobtained after image normalization(GSM, and JBA) DWAs of plaque instability, it sion whenaddedasacovariate inamultivariate modelalongsideclinical(historyofcontralateral TIAs) and in patientswithprogression: 1.92, 95%confidenceinterval 1.14to3.25). However, whenstenosisprogres progression (averageannualstroke rates of 0%, 1.1%and2.0%, respectively; LogRankP=.05; relativerisk stroke ratewas zeroinpatientswithregression, 9%ifthestenosiswas unchangedand16%iftherewas with progressionandzerointhoseregression. The eight-yearcumulativeipsilateralcerebralischemic occurred; 40 (67.8%) of themoccurred in patients whose stenosis was unchanged, 19 (32.2%) in those no changein856(76.4%)andprogression222(19.8%)patients. Duringfollow-up59ipsilateralstrokes ment and carotid duplex for uptoeight years (meanfollow-up: 4years). Regression occurred in 43 (3.8%), 1121 patientswithstenosisof50-99%ECST(inrelationtothebulb)underwent6-monthlyclinicalassess risk stratification value ofstenosisprogressionorregressionusingserial (6-monthly)duplexscanning. Risk ofStroke (ACSRS) study(anIUA internationalmulticentrenatural historystudy)assessedthestroke ment ofipsilateralsymptomsin45%afterfiveyearsfollow-up. The AsymptomaticCarotidStenosisand thors concludedthatoptimummedicaltreatmentfailedtopreventcarotiddiseaseprogressionordevelop gression, P=.02), althoughprogression was notasignificantpredictoronmultivariate analysis. The au (29%) andipsilateralneurologicalsymptomsdevelopedin13.7%( with Duplexforameanof3.6years(range0.3-6.7years). events. Inanothercohortstudy, Conradreportedon900 ACS in794patients, whichwerefollowedup sion of ACS withina6-to9-monthinterval detectedbyduplexpredictsmidtermclinicalcerebrovascular for stroke was 2.00(95%confidenceinterval 1.02to4.11, P=.035). The authorsconcludedthatprogres years. The incidenceofprogressionafteramedian7.5monthswas 9%andtheadjustedhazardratio with interval stenosisprogression. Subsequently, patientswerefollowedupclinicallyforamedianof3.2 ≥50% (NASCET). events. Sabetistudiedprospectively1065consecutivepatientswith ACS, howeveronly376ofthemwere and confirmedtheassociationbetweenstenosisprogressionriskoffutureipsilateralcerebrovascular Several natural history studies in patients with asymptomatic carotid stenosis (ACS) have investigated progression orregressionofasymptomatic carotidstenosis. J Vasc Surg2014;59(4):956-967 e1. cerebrovascular riskstratification. J Vasc Surg 2010;52(6):1486-1496. optimal medicaltherapy. J Vasc Surg2013;58(1):128-35 e1. graphy predictsadverseoutcomesincardiovascular high-riskpatients. Stroke 2007;38(11):2887-94. Kakkos SK, Nicolaides AN, Charalambous I, Thomas D, Giannopoulos A, Naylor AR, Nicolaides AN, Kakkos SK, Kyriacou E, GriffinM, SabetaiM, Thomas DJ, Conrad MF, Boulom V, Mukhopadhyay S, Garg A, Patel VI, CambriaRP. Progressionofasymptomaticcarotidstenosisdespite Sabeti S, SchlagerO, ExnerM, Mlekusch W, Amighi J, DickP, 1 1 Carotidduplexwas performedatbaselineandafter6to9monthsidentifypatients , Andrew Nicolaides , Andrew 2 , GeorgeGeroulakos et al et 23 . Progressionofcarotidstenosisdetectedbyduplexultrasono et al et 2

Plaqueprogressionoccurredin262arteries . Asymptomatic internalcarotid arterystenosisand 3 vs vs et al et 8.5% forthosewithoutplaquepro . Predictors andclinicalsignificanceof - 3, 4 3, ------

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY CAROTID Christos Liapis Internal carotidarterynear-total occlusionsisitjustifiedtooperateonthem? Risk ofstroke andhowtomake adecision? Athens Medical Center, Athens, Greece Athens, Center, Medical Athens near-total ICAocclusion infuturerandomizedcontrolledtrials. intervention isprobablyindicated. The resultsofourstudyunderlinetheneedforincludingpatientswith The treatmentofpatientswithinternal carotid arteryneartotalocclusionshouldbeindividualized and an CONCLUSIONS respect toalmostallthestudiedpotentialmodifiersinmeta-regressionanalysisamongeligiblestudies. mortality (P = 0.08) and restenosis (P = 0.08). No nominally significant effects were demonstrated with death (P=0.30), andMAE(P=0.99), whereas aborderlinesignificance was recordedconcerningoverall pooled IRsper100p-ysbetweenCEAandCAS, concerning TIA (P=0.96), stroke (P=0.44), stroke-related P =0.002)andCAS(IR1.64, P<0.001)studies. Nostatisticallysignificantdifferenceswererecordedin stroke incidence rates (IRs) per 100 patient-years (p-ys) of BMT (IR = 6.19) compared with CEA (IR = 2.24, tery neartotalocclusionweredeemedeligible. A statisticallysignificantdifference was recordedinpooled Five articlesonBMTandCEA, 8articlesonCEA, and11articlesonCASforpatientswithinternalcarotidar RESULTS adverse event(MAE), overallmortality, andrestenosis. ysis weretransientischemicattack(TIA), stroke, stroke-related death, myocardialinfarction(MI), major endarterectomy [CEA], andcarotidarterystenting[CAS]), whereasthemainendpointsofmeta-anal were analyzedgivingemphasisontheappliedtherapeuticapproach(bestmedicaltherapy[BMT], carotid A multipleelectronichealthdatabasesearchwas performedonallarticlespublished. All available data METHODS patients withnear-total ICAocclusion. literature andconductedameta-analysisaimingtoinvestigatetheappropriatetherapeuticapproachfor Study [ICSS])onbothsymptomaticandasymptomaticpatients. We undertookanextensivereview ofthe (Carotid Revascularization Endarterectomy patients withsuchangiographicfindingswereexcludedfromtherecentlycontactedrandomizedtrials with near-total internal carotid artery (ICA) occlusion still remains controversial. The main reason is that sion, pre-occlusion, pseudo-occlusion, stringsign, slimsign. The decisionforrevascularization inpatients The conditionofinternalcarotidarterynear-total occlusionhasbeengivenvarious nameslike sub-occlu BACKGROUND versus Stenting Trial [CREST] and International Carotid Stenting 24

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10. 9. 8. 7. 6. 5. 4. 3. 2. 1. REFERENCES term outcome. Am JNeuroradiol 2011;32:252e8. Cardiovasc Interv2010;75:1104e9 ment? Vasc Endovascular Surg2009;43:374e8 matic carotidstenosis: theInternationalCarotidStentingStudy(ICSS)randomised trial. Lancet2015;385:529e38. versus Endovasc Surg2009;37(4Suppl):1e19 disease: executivesummary. J Vasc Surg2011;54:832e6. Near-total Occlusion: An UpdatedMeta-analysis. Ann Vasc Surg. 2015Nov;29(8):1664-72 Gonz alezGarcia A, Gil-Peralta A, Mayol A, Barker CM, GomezJ, GrottaJC, Bowman JN, OlinJW, Teodorescu VJ, Ogata T, YasakaKanazawaM, Y, Bonati LH, DobsonJ, Featherstone RL, Mantese VA, Timaran CH, ChiuD, Liapis CD, BellPR, MikhailidisD, JJ,Ricotta AburahmaE, A, Ascher Mylonas SN, Antonopoulos CN, MoulakakisKG, KakisisJD, LiapisCD. ManagementofPatients withInternalCarotid Artery Vasc Surg2013;58:1512e7. Oka F, Ishihara H, KatoS, carotidendarterectomyfordisease. Stroke 2010;41(10Suppl):S31e4. et al et . Cerebral hemodynamicbenefitsaftercarotidarterystentinginpatientswithnearocclusion. J et al et et al et et al et et al et et al et . Feasibility ofcarotidarterystentinginpatientswithangiographic stringsign. Catheter et al et . Outcomesassociatedwithcarotidpseudo-occlusion. Cerebrovasc Dis2011;31: 494e8 . ESVSguidelines. Invasive treatmentforcarotidstenosis: indications, techniques. EurJ Vasc . UpdatedSocietyfor Vascular Surgeryguidelinesformanagementofextracranial carotid . The CarotidRevascularization Endarterectomy et al et . Carotidarterypseudo-occlusion: doesend-diastolicvelocitysuggestneedfortreat . Long-termoutcomesafterstenting et al et . Internalcarotidarterystentinginpatients withnearocclusion: 30-dayandlong- 25 versus endarterectomyfortreatmentofsympto versus Stenting Trial (CREST): stenting - -

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY CAROTID Henrik Sillesen stenosis Carotid plaquemorphologyisonlyrelevante toconsiderinsymptomaticcarotic Risk ofstroke andhowtomake adecision? Professor and Chairman, Dept. of Vascular Surgery, Rigshospitalet, Denmark Rigshospitalet, Surgery, Vascular of Dept. Chairman, and Professor these circumstances, plaquemorphologymayidentifythelesionsofhighestrisk! high for all cases, i.e. once a certain time has passed, for females, moderate stenotic lesions etc. Under For symptomaticcaseswehaveindicationsthattheriskisstillconsiderable. However, itmaynotbethat 4-5%. We remaintoseeavalidated methodthatcanachievethis. would gaini.e. anannualabsolutereduction intheriskofstroke, asubgroupwithanannualriskofmaybe However, consideringtheassociatedriskofintervention, i.e. 2-3%peryear, inordertoidentifyagroupthat identify thefewcarotidlesionsworthwhiletreatinginvasively, inordertoprovideaneffectivetreatment. less than 0.5% per year. This would, naturally, increase the interest for identification of factors that could data areavailable forasymptomaticcases. Here, theriskseemstohavedeclinedfrom2.5-3%maybe this declineprobablyaffectstheriskofbothsymptomaticandasymptomaticcarotiddiseasemost First ofall, theriskofstroke hasdeclinedingeneral, bothincaseofcarotiddiseaseandgeneral. Second, morphological factors. medications wererecommended. Thus, itisunknownhowmuchthesemedicationsaffecttheriskof However, most of the studies providing these data were performed before today’s intensive preventive Carotid plaquemorphologyhasbeenshowntobeassociatedwiththeriskoffutureipsilateralstroke. 26

CAROTID Ian Loftus, Kosmas Paraskevas Delay betweensymptomsandinterventionsmatters CEA results are thebesteverwhy? St Georges Vascular Institute, London, United Kingdom United London, Institute, Vascular Georges St of recurrentstrokes. The UKNational StrategyforStroke adoptedanevenmoreaggressive approachand sooner CEAis performedaftertheoccurrence ofa TIA/minor stroke, thebetter it isintermsofprevention 11% stillsufferedrecurrent neurologicaleventspriortosurgery. CEA showedthatalthough 85%ofthepatientsunderwentCEAwithin14days fromtheirindexsymptom, days. that theincidenceofrecurrent stroke was 5.2% within2days, 7.9%within7days and 11.2%within14 rent event between72hoursñ recurrent neurological event within the first 72 hours after their initial event, whereas 6.7% had a recur surgery delaying internal carotidarterystenosis. A studyfromSpain, forinstance,revascularization, than showedthat 20.9%ofpatientshada early rather to the riskofrecurrentstroke isevenhigherearlierthan2weeksin TIA patientswith anipsilateral50ñ99% reasonable is contraindications event no Level ofEvidence:index B)recommendation.are Subsequently, anumberofnaturalhistorystudiesshowedthat the there of and weeks 2 stroke fact thatthe “contraindications toearlyrevascularization” werenotdefined, this was aweak(ClassIIa;or within TIA with intervention patients for indicated is dations wererathermorecontroversial. The AHA guidelinesrecommendedthat “ within 2weeksofthelastneurologicalevent. The AHA and theEuropeanSocietyfor Vascular Surgery(in2009) in patientswith TIA/minor stroke. The UnitedKingdomNationalInstituteforClinicalExcellence(in2008) These observations ledtotherevisionofrecommendationregardingoptimaltimingforintervention CHANGES INCAROTID INTERVENTION GUIDELINES and thenoperateswitha0%risk. probably stillpreventmorestrokes (inthelongterm)thanasurgeonwhodelaysinterveningfor28days was alsodemonstratedthatasurgeonwhooperateswithin2weeks witha10%proceduralriskwould the earlyriskofstroke after TIA/minor stroke was onlyabout1ñ2%at7daysand2ñ4%30days.2 It to thestroke. occurring onthedayofstroke, 9%on thepreviousdayand43%atsomepointduring7daysprior ECST). TIA AspirinTrialand studies (Oxford Vascular Study and Oxfordshire Community Stroke Project) and 2 randomized trials (UK 2,416 patientswhopresentedwithanischemicstroke followingapreceding TIA using2populationñbased after 12weeks: 7.4%). 23.0%) andfellrapidlywithincreasingdelay(ARRat2ñ4weeks: 15.9%; ARR at4ñ12weeks: 7.9%; ARR 70ñ99% carotid stenosis randomized within 2 weeks of their last event (absolute risk reduction [ARR]: tiveness of CEAtoprevent recurrent strokes. The benefit fromthe operation was greatest inpatients with age (P=0.03)andtimefromthelastneurologicalevent to randomization (P=0.009) influencedtheeffec recently symptomatic carotid artery stenosis. and the NASCET was a turning point I terms of understanding the optimum timing or intervention for ated withanincreasedriskofperioperativestroke. transformation of the infarct, iii) operating early on arecently symptomatic unstable plaque was associ should bedelayedfor6ñ8weeksafteranischemicstroke becauseoftheincreasedriskhemorrhagic it was believed that: i)theriskofrecurrent TIA orstroke earlyaftera TIA episodewas nothigh, ii)CEA ed CEAforpatientswithin6monthsoftheirmostrecentischaemicneurologicalepisode revised several times in the last few years. The American Heart Association (AHA) guidelines recommend The optimaltiming for theperformance of carotid intervention after theonset of symptomshasbeen INTRODUCTION 10 Finally, astudyfromtheUKlooking intothereasonsresponsiblefordelayspriorto expedited 4 This observation was onceagainstrikinglydifferentfromthebeliefhelduntilthen, i.e. that 3 Rothwell 4 This showedthatthetimingofpreceding TIA was highlyconsistent, with17% 7 days and 3.7%between 7ñ14 days. 5 et al et

. thenanalyzedthetimingofrecurrentcerebrovascular eventsin 3 Rothwell and colleagues demonstrated that sex (P=0.003),

2 A subsequentanalysisofpooleddatafromtheECST 27 8 followedsoonafter, althoughthe AHA recommen 7 bothrecommendedtheperformanceofCEA 11 These resultsallpointtothefact thatthe 9 A similar study from Sweden showed when revascularization revascularization when ”. 1 . At thattime, 8 Besidesthe - - - - - 6 Friday January 20

CONTROVERSIES & UPDATES IN VASCULAR SURGERY Other studies have provided similar results. However, conflictingresults werereported fromSweden. tients), whereasitwas 0.8%in133patientswhounderwentsurgerybetween8and14days(1of133). of 41). The proceduralriskin167patientswhounderwentCEAwithin3ñ7dayswas 1.8%(3of167pa underwent CEAwithin48hoursoftheirmostrecentevent, witha30ñdaydeath/stroke rateof2.4%(1 risk was higherwhenCEAwas performedinthehyperacuteperiod. audit of475recentlysymptomaticpatientsundergoingCEAfailedtofindevidencethattheprocedural One oftheconcernsrelatingtourgentCEArelateperceivedincreasedperioperativerisk. A retrospective SAFETY OFPERFORMING CEAWITHIN48HOURS despite anytrialevidenceinsupportofa48ñhourthreshold. recommended that symptomaticpatientsshouldundergoCEAwithin48hoursofsymptom onset. This was method toreducerecurrentstroke rates. dited CEAwithoutincreasingperioperativebleeding complications. ExpeditedCEAisasafeandeffective is evidence that dual antiplatelet therapy started immediately may reduce recurrent events prior to expe antiplatelet therapyandhighñdosestatins)shouldbe implementedassoona TIA issuspectedandthere of earlyrecurrentneurologicaleventsafterafirst TIA/minorstroke. Bestmedicaltherapy(includingdual tive stroke/death dates. This observation furthergainssupportwhenviewed incontextoftheveryhighrisk to suggest that performance of very urgent CEA is not associated with a significant increase in periopera progressive shifttoevenearlierperformanceofsurgery(i.e. within48hours). The majorityofstudiesseem guidelines recommend performing CEA within 2 weeks of the most recent symptom, there seems to be a has led to a progressive reduction of the recommended optimal timing to surgery. Although most current The observation thattheriskofrecurrentstroke isgreaterinthefirst fewdaysafteraneurologicalevent CONCLUSIONS considering thehighrecurrentstroke ratesearlyafteraninitial event. that performingCEAwithin48hoursisassociatedwithanacceptablestroke/death risk, especiallywhen 1.04ñ2.59), butnotwhencomparedwith longerdelays. The resultsfrommoststudiesthereforesuggest ing CEAbetween3and7days(3.1% of symptomswas associatedwithasmallincreasein30ñdaystroke/death ratescomparedwithperform treated within14daysincreasedfrom37%to58%duringthesametime. Performing CEAwithin48hours 10ñ56) daysin2009to12(interquartilerange: 7ñ26)daysin2014, whereastheproportionofpatients showed that the median time from TIA/stroke to CEA decreased over time from 22 (interquartile range: January 2009andDecember2014from100UKhospitalsintheNational Vascular Registry. very urgent CEA werenot verified inarecent studyanalysing 23,235patients undergoing CEAbetween 4.24; 95%confidenceinterval: 2.07ñ8.70; P<0.001). The higherstroke/death ratesforpatientsundergoing higher stroke/death rates compared patients undergoing surgery 3ñ7 days after their event (odds ratio: perioperative complications: patientstreated0ñ2daysaftertheirqualifyingeventhadamorethan4ñfold 3ñ7, 8ñ14 and15ñ180 days, respectively. Bymultivariate analysis, time was anindependent risk factor for of 148)comparedwith3.6%(29804), 4.0%(27of677)and5.4%(52967)forpatients treated at the combinedstroke/death rateforpatientstreated0ñ2daysaftertheirqualifyingeventwas 11.5%(17 Swedish Vascular Registryanalyzeddatafor2,596symptomaticpatientsundergoingCEA andfoundthat vs . 2.0%, respectively; oddsratio: 1.64; 95%confidenceinterval: 28 12 Overall, 41of475(9%)patients 15 This study This 14 The - - - -

15. 14. 13. 12. Naylor AR. Time isbrain: anupdate. ExpertRevCardiovasc Ther 2015; 13: 1111ñ1126. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. REFERENCES tomatic carotidstenosis. Stroke 2009; 40: 2727ñ2731. nals fromthe American Heart Association/American Stroke Association. Stroke 2011; 42: 227ñ76. Guidelines forthepreventionofstroke inpatientswithstroke ortransient ischemicattack: aguidelineforhealthcareprofessio Cardiovascular Nursing, CouncilofClinicalCardiology, andInterdisciplinaryCouncilonQualityofCareOutcomesResearch. guidelines. Invasive treatmentforcarotidstenosis: indications, techniques. EurJ Vasc Endovasc Surg2009; 37(4Suppl): 1ñ19. dia/pdf/CG68FullGuideline.pdf. Acute Stroke andtransient Ischaemic Attack. London; Royal CollegeofPhysicians; 2008. Available at: www.nice.org.uk/niceme 817ñ820. symptomatic carotidstenosisinrelationtoclinicalsubgroupsandtimingofsurgery. Lancet2004; 363: 915ñ924. 29: 554ñ562. ment forhealthcareprofessionalsfromaspecialwritinggroupoftheStroke Council, American Heart Association. Stroke 1998; Ois A, CuadradoñGodia E, RodriguezñCampello A, JimenezñConde J, RoquerJ. Highriskofearlyneurologicalrecurrenceinsymp Furie KL, KasnerSE, Adams RJ, Albers GW, BushRL, Fagan SC, Liapis CD, BellPR, MikhailidisD, SiveniusJ, Nicolaides A, Fernandes eFernandes J, National Collaborating CentreforChronicConditions. Stroke: NationalClinicalGuidelineforDiagnosisandinitialManagementof Naylor AR. Time isbrain! Surgeon2007; 5: 23ñ30. Rothwell PM, Warlow CP. Timing of TIAs precedingstroke: timewindowforpreventionisveryshort. Neurology2005; 64: Rothwell PM, EliasziwM, Gutnikov SA, Warlow CP, BarnettHJ; CarotidEndarterectomy Trialists Collaboration. Endarterectomyfor Naylor AR. Delaymayreduceprocedural risk, butatwhatpricetothepatient?EurJ Vasc Endovasc Surg2008; 35: 383ñ391. Biller J, Feinberg WM, CastaldoJE, Whittemore, Harbaugh RE, DempseyRJ, Endovasc Surg2013; 46: 404ñ410. Ali M, StephensonJ, Naylor AR. Delaypriortoexpeditedcarotidendarterectomy: aprospectiveauditofpractice. EurJ Vasc 10.1016/j.ejvs.2016.05.031. [Epubaheadofprint] Endarterectomy intheUKNational Vascular Registry. EurJ Vasc Endovasc Surg2016Jun28. pii: S1078ñ5884(16)30166ñ6. doi: mittee. Very urgentcarotidendarterectomyconfersincreasedprocedural risk. Stroke 2012; 43: 1331ñ1335. the hyperacute periodafteronsetofsymptoms. EurJ Vasc Endovasc Surg2013; 46: 519ñ524. 2013; 8: 220ñ227. Loftus IM, Paraskevas KI, Johal A, Waton S, HeikkilaK, Naylor AR, Stromberg S, GelinJ, Osterberg T, BergstromGM, KarlstromL, OsterbergK; Swedish Vascular Registry(Swedvasc) SteeringCom Sharpe R, SayersRD, LondonNJ, BownMJ, McCarthyMJ, Nasim A, Johansson EP, Arnerlov C, Wester P. Riskofrecurrentstroke beforecarotidendarterectomy: the ANSYSCAP study. IntJStroke et al et 29 ; American Heart Association Stroke Council, Councilon et al et et al et . DelaystoSurgeryandProcedural RisksFollowing Carotid . Procedural risksfollowingcarotidendarterectomyin et al et . Guidelinesforcarotidendarterectomy: astate et al et ; ESVSGuidelinesCollaborators. ESVS - - - - - Friday January 20

CONTROVERSIES & UPDATES IN VASCULAR SURGERY CAROTID Do minimalincisionsforCEAreduceperipheralnervesdamageandP.O. strokes? Robert MichalProczka CEA results are thebesteverwhy? Center of Cardiology, Warsaw, Poland Warsaw, Cardiology, of Center 5. 4. 3. 2. 1. REFERENCES quick dischargingfromhospital. ation fromtheclassicendarterectomies. Smalloperatinginjurygaveacomforttopatientsandallowedfor Minimal invasive endarterectomyseemstobesaveandthenumberofcomplication donotdifferouroper CONCLUSION: months afterthesurgery. and twostrokes inSICE(1,9%)withnonervedamage. Inthefollow-up, dopplerultrasoundwas donethree day after surgery. In the second group of patients there were three strokes in CE (6,9%, one hemorrhagic) the OR. Inonecasetransienthoarsenessappeared. Patients wereusuallydischargedfromthehospitalone and one TIA wereobserved. In2casestherewas ableedingfromthewoundwhichneededrevisionin In thefirst presented groupofpatients 3(4,2%)postoperativestrokes; one hemorrhagic, oneischemic, RESULTS Between January 2015and August 2016wedid165 TEAs: 43-CEand112-SICE. my teamwas dividedintotwogroups: twoofusdidclassicendarterectomy/CE/, andthreeofusdidSICE. were not inserted. The arteriotomy was closed with primery continous suture /except one case/. After that incisions of artery and classic endarterectomies were done. If there were no signs of brain ischemia, shunt hanging onthereinsandreleasingposterior portion, thearterywas closedandelevated. Longitudinal found asthefirst, howevertherewereexceptions. Standarddoseof3000UNFH was administered. After ed.The incisionofthelength about 1,5-3,5cmwas madeoverthebifurcation of CCA. Usually, ECAwas 6. group. The majorityofthemwereoperatedunderlocalanesthesia Over 70minimalinvasive endarterectomiesofinternalcarotidarterieswereperformedintheprimary MATERIAL METHODS carotid endarterectomy/SICE. my primary sutureconventionalthrombendarterectomywithcarotidpatchplasty, andeversionendarterecto be agoldenstandard In theworldofrapiddevelopmentendovascular procedures, openendarterectomyisstillconsideredto PURPOSE versus The North American Symptomatic CarotidEndarterectomy Trial. GaryG.Ferguson atall.Stroke 1999;30:1751-1758 Anesthetic typeandriskofmyocardial infarctionaftercarotidendarterectomyintheCarotidRevascularization Endarterectomy sis. Piper C Apr;32:73-82. Trial (ECST).ECST’collaborative group. Lancet.1998 May9;351(9113):1379-87. Eversion endarterectomy Safety ofCarotidRevascularization inSymptomaticPatients withlessthan70 Years. DeRangoP Carotid stentingandendarterectomy. Yip HK Randomised trialofendarterectomyforrecentlysymptomaticcarotid stenosis: finalresults oftheMRCEuropeanCarotidSurgery 5 . The aimofthestudywas toeveluatetechnicalpossibility, effectiveness, andsafetyofasmall-incision Stenting Trial (CREST).HyeRJ et al et .Eur J Vasc Endovasc Surg. 1999Oct; 18(4): 339-43. 1,2,3,4 versus .Three methodsareacceptedforcarotidarterystenosis: endarterectomywith openthromboendarterectomyandpatchpastyforthetreatment ofinternalcarotidarterysteno et al et . J Vasc Surg. 2016Jul;64(1):3-8.e1 et al et . JCardiol.2016Jul1;214:166-74Int 30 6 . Antiplatelet therapywas notinterrupt et al et .2016 Surg. AnnVasc - - - -

CAROTID How topreventsurgicalcomplicationsofcarotidbodytumorresection? George Geroulakos Challenging carotid lesions National and Kapodestrian University of Athens, Athens, Greece Athens, Athens, of University Kapodestrian and National 6. Economopoulos K, Tzani A, Reifsnyder T. Adjunct endovascular interventionsincarotidbodytumors. J Vasc Surg 2015;61:1081-91 5. Paridaans MPM, van derBogtKEA, Jansen JC 4. 3. 2. 1. REFERENCES patients withashortlifeexpectancy. of theskull, forpatientswhohavecontralateralcranialnerveinjury, patientswithrecurrenttumorsand of CBTs There isnowagrowingbodyofevidenceonthesafetyandefficacyradiotherapyformanagement gery series did not discriminate between the subgroups undergoing preoperative embolization and open sur of cranialnerveinjurycouldnotdetermineifpreoperativeembolizationhadanyeffect, asmostpublished from theexcisionalonegroup(n=1686) increased hospitalstroke ratebuttheofpostoperativehaemorrhageorhaematomawas notdifferent that CBTresectionwhencombinedwithpreoperativeembolization(n=129)was notassociatedwithan retrospective studyintheUSAusingNationwideInpatientSample(2002-2006; 2117patients), showed method to reduce tumor vascularity and size, shorten the operative time and lessen the operative risk. A contributes tothehighincidenceofcranialnerveinjuries. Embolisationhasbeenadvocatedasaneffective Resection of CBTmaybeassociated with significant peroperativeblood lossthatobscurestheviewand age in casehaemorrhage occurs later during the operationand should be the surgical technique of choice identifying theadjacentnervesontumor’s cranialsideatanearlystage, maypreventaccidentaldam carotid artery tion anddissectingtowards thecranialsidewithligationofcaudally feedingbranchesoftheexternal Traditionally thesurgicalprocedurestartswithsubadventitialresectionofCBTfromcarotidbifurca (3.5% and2.4%respectively) struction hasagreaterincidenceofstroke (17.7%)andpostophaemorrhage(43.1%)thanexcisionalone CBT, whichmayincludereplacementoftheinternalcarotidartery. ExcisionofCBTandcarotidarteryrecon ipsilateral or contralateral. Imagingiscriticaltosoundoperativedecision-making in themanagement of the statusofextracranialandintracranialcirculationpresencesynchronoustumorseither Careful preoperativeplanningwithcrosssectionalimaging(MRIorCT)demonstratestheShamblingroup, operative complications(1.3%) permanent deficits(22.2%), 60patientsdevelopedapermanentstroke (3%)and26patientsdiedofpost ticles whichincluded2,175surgicallytreatedpatients, CBTresectionresultedin483newcranialnerves Carotid bodytumour(CBT)resectionisassociatedwithsignificantmorbidity. Inametaanalysisof67ar Surg 2009;43:457-461 VogelMousa AY, TR, Dombrovskiy VY JVascSurg 2009;49:1365-73 BMJ CaseRep2013.doi:10.1136/bcr-2012-006416 radiotherapy. Eur Arch Otorhinolaryngol2004;271:23-34 Kakkos SK, ReddyDJ, Shepard AD Joshi M, LattimerCR, ShahB, Geroulakos G. The knownunknowns ofperioperative stroke duringcarotidbodytumourresection. Suarez C, RodrigoJP, Mendenhall WM versus 1 . ItshouldbethepreferredapproachformanagementofverylargeCBTextendingtobase opensurgeryalone 4 . Ithasbeensuggestedthatthereversecraniocaudalapproach, thatcarriestheadvantage of et al et 2,3 6 . 1 et al et . . et al et . Contemporary presentation andevolutionofmanagementneckparagangliomas. . Carotidbodytumorsurgery: Managementandoutcomesinthe nation. Vasc Endovasc . Carotidbodyparagangliomas: asystemicstudyonmanagementwithsurgeryand et al et 2 A meta-analysisontheefficacyofembolizationprevention . EurJ Vasc Endovasc Surg 2013;46:634-629 31 5 ------. Friday January 20

CONTROVERSIES & UPDATES IN VASCULAR SURGERY awy Ireland Galway, SPECIALISSUES:VASCULAR SURGEONS AT WAR Endovascular managementofacuteaortictrauma Sherif Sultan 4. 3. 2. 1. sustainable. injury onthebasisofmeta-analysesandlargemulti-centreclinicalseries. Outcomesarelife-savingand Even intheabsenceofRCTs TEVAR isbecomingthecurrent standard intreatmentofacutethoracicaortic 81% andre-internvetionratesof16%, halfofwhicharerequiredwiththefirstmonth. term follow-uparedemonstrating long-term durability over adecade. They report 5 year survival rates of events andsurvival ratesof92%at30daysand88%oneyear. Europeanmultinationaltrialswithlonger vestigator Results from multicentre non-randomised trials such as the Rescue trial neurological andupperischemiaeventsatleastintheshorttomediumterm. vertebral arteryflow, althoughseriesreportsdemonstratepreferredoutcomesintermsofareduction Furthermore there is no definitive proofof theneed for chimneygrafting topreserve left subclavian and evidence islackingtosupportthesuperiorityofendovascular approachcomparedtoopenrepair. domised controlled trials (RCTs) arehighly challenging both practically and ethically. Therefore level-one and re-intervention at the forefront of concerns. As withmost life-threatening emergency situations ran long termdurability, especiallyinyoungerpatients, remainsunprovenwithconcernsoverdeviceintegrity without chimneygraftingoftheleftsubclavianarteryisassociatedwithfavourableearlyoutcomesbut vascular aorticrepair(TEVAR) hasovertaken opensurgicalrepairinthemajorityofcases. TEVAR, withor treatment option. However, thelessinvasive andmoreexpeditioustreatmentoptionsofthoracicendo Open surgicalrepairwas firstsuccessfullyundertaken in1959andsincethenithasremainedthestandard rate isconsiderableandonly10-15%ofpatientsreachthehospitalalive. through motorvehicleaccident, fallfromasubstantialheightand/orbluntthoracictrauma. The mortality ening surgicalemergency. Traumatic thoracicaorticinjuryhasanassociatedmortalityofupto8000perannumandisalife-threat Eur J Vasc Endovasc Surg. 2015Oct;50(4):460-5. doi: 10.1016/j.ejvs.2015.05.012. Epub2015Jul2. rability ofEndovascular RepairinBlunt Traumatic Thoracic Aortic Injury: Long-Term OutcomefromFour Tertiary Referral Centers. Sep;58(3):651-8. luation oftheredesignedconformableGORE TAG thoracic endoprosthesisfortraumatic aortictransection. J Vasc Surg. 2013 for bluntthoracic aorticinjury(RESCUEtrial). J Thorac Cardiovasc Surg. 2015Jan;149(1):155-61. injury. Cochrane DatabaseSystRev. 2015Sep25;(9):CD006642. Steuer J, BjörckM, Sonesson B, Resch T, DiasN, HultgrenR, Tunesi R, Wanhainen A, LachatM, Pfammatter T. Editor’s Choice–Du Farber MA, GigliaJS, StarnesBW, Stevens SL, HollemanJ, ChaerR, Matsumura JS; TAG 08-02clinicaltrialinvestigators. Eva Khoynezhad A, DonayreCE, Azizzadeh A, White R; RESCUEinvestigators. One-yearresultsofthoracic endovascular aorticrepair Pang D, Hildebrand D, Bachoo P.Thoracic endovascular repair(TEVAR) 3 , eachrecruiting50patientsdemonstratetechnicalsuccessratesof100%withnoneurological 1 The mostcommonaetiologyisrapidacceleration/decelerationinjurysustained 32 versus opensurgeryforblunttraumatic thoracic aortic 2 and the TAG 08-02 clinical trial in 1 4

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY 34

Friday January 20 angioaccesses Hemodialysis 35

AVF CREATION - NATURAL HISTORY AVF CREATION - NATURAL HISTORY Ulnar-Basilic AVF AVF and surgical microscope in adults Julien Al Shakarchi, Nicholas Inston Marek Rawa University Hospital Birmingham, Birmingham, United Kingdom Polyclinique “Zerhoun”, Meknes, Morocco

The fistula first initiative has promoted arteriovenous fistulas (AVF) as the vascular access of choice. To Surgeons in multiple specialties (neurosurgery, hand surgery, plastic surgery, ophthalmology, laryngology preserve as many future access options as possible, multiple guidelines advocate that the most distal AVF and even dentistry) have adopted the surgical microscope. possible should be created in the first place. Generally snuff box and radio-cephalic are accepted and well Nowadays, it would be inconceivable to operate a cataract, perform tympanoplasty, complete a free tissue described sites for AVFs however the forearm ulnar-basilic AVF is seldom used or recommended. The aim transfer flap, or re-attach a severed hand or finger without the use of a surgical microscope. of this study was to assess and systematically review the evidence base for the ulnar-basilic fistula and to In context of vascular surgery, the first article on the use of the microscope in children was published in critically appraise whether more attention should be given to this site. 1981. Electronic databases were searched for studies involving the creation of ulnar-basilic fistulas for dialysis The results were so good that one would have expected them to encourage the use of microscope in adults in accordance with PRISMA guidelines. The primary outcomes for this study were 1-year primary and sec- as well. ondary patency rates. Secondary outcomes were rates of haemodialysis access induced distal ischaemia Today, some thirty-seven years later, surprisingly, too many surgeons still perform AVF without using a (HAIDI) and infection. microscope. Following strict inclusion/exclusion criteria by 2 reviewers, eight studies were included in our review. In this paper the author describes the benefits that come from using the surgical microscope to practicing Weighted pooled data showed 1-year primary patency rate for ulnar-basilic AVFs of 53.0% (95% CI: 40.1- vascular access. 65.8%) with a secondary patency rate of 72.0% (95% CI: 59.2-83.3). HAIDI and infection rates were low. In addition, and based on his experience, he author seeks to understand why many surgeons refrain from Our review has shown that the ulnar-basilic AVF may be a viable alternative when a radio-cephalic AVF is using the microscope. not possible and dialysis is not required urgently. It has adequate 1-year primary and secondary patency It would seem that these reasons are subjective, since objectively, in seeing better one can only expect to rates. Whilst it may be a surgical challenge due to the small size of vessels, a microsurgical technique with operate better. the use of a microscope or magnifying loupes can overcome this. Friday January 20 January Friday CONTROVERSIES & UPDATES IN VASCULAR SURGERY IN VASCULAR & UPDATES CONTROVERSIES

36 37 AVF CREATION - NATURAL HISTORY FIGURES AVFs natural history Teun Wilmink Dept of Vascular Surgery, Birmingham, United Kingdom

OBJECTIVES to study primary failure, maturation times, and survival of common arteriovenous fistulae (AVF) to aid planning for vascular access, and to assess which strategy results in most dialysis days.

METHODS This was a longitudinal cohort study. Two databases of access operations and dialysis sessions over 9 years with 12-year follow-up were reviewed. Functional dialysis use is defined as achieving six consecutive dialysis sessions with two needles on AVF. Primary failure (PF) is failure to achieve functional dialysis use. Maturation time, calculated only for patients on dialysis with a central line at AVF operation, is defined from the operation date to the functional dialysis date. Cumulative patency, including PF, is calculated from the operation to date of AVF abandonment and is compared using Kaplan–Meier curves and adjusted hazard ratios (HRs).

RESULTS cumulative patency all AVF by type AVF A total of 1206 AVF, 689 (57%) radiocephalic AVF (RCAVF), 383 (32%) brachiocephalic AVF (BCAVF), and 134 (11%) brachiobasilic AVF (BBAVF), were analysed. PF was 23%. PF was lower for BCAVF (17%) than RCAVF (26%) and BBAVF (26%) (p = .006). PF was higher for women (OR 1.59, 95% CI: 1.21–2.09) and patients with vascular kidney disease (OR 1.69, 95% CI: 1.19–2.59). Median maturation time was 10.3 weeks. Cumulative patency was worse for BCAVF (HR 1.36, 95% CI: 1.03–1.81) and BBAVF (HR 1.63 95% CI: 1.12–2.38), for patients on dialysis at AVF creation (HR 1.55, 95% CI: 1.13–2.12), and diabetics (HR 1.55, 95% CI: 1.12–1.85). RCAVFs resulted in 3% more dialysis-person-years per 100 operations (figure 1) for all patients and in 15% more dialysis- person-years in the over 80s (figure 2).

CONCLUSION RCAVFs have higher PF, but better survival than other AVF, and result in more dialysis time. AVF created pre-dialysis have much better survival. An average maturation time of 10 weeks should be considered if planning to start dialysis on an AVF. Friday January 20 January Friday

Cumulative patency of AVF created in patients over 80 by type AVF

REFERENCES Wilmink T, Hollingworth L, Powers S, Allen C, Dasgupta I. Natural History of Common Autologous Arteriovenous Fistulae: Conse- quences for Planning of Dialysis Access. Eur J Vasc Endovasc Surg. 2016, 51(1):134-140. CONTROVERSIES & UPDATES IN VASCULAR SURGERY IN VASCULAR & UPDATES CONTROVERSIES

38 39 AVF CREATION - NATURAL HISTORY P TA Controversy. Pediatric vascular access Controversy. US or angiography guided PTA In London Using US and angiography is more efficient Francis Calder Jose Garcia-Medina1, Juan Jose Garcia-Alfonso2 London, United Kingdom 1. Hospital Reina Sofia, Murcia, Spain 2. Faculty of Medicine, Murcia, Spain Effective paediatric vascular access is vital in maintaining a child’s health until renal transplantation is possible. Careful assessment, family commitment and a multidisciplinary approach is fundamental to main- Angioplasty is the preferred treatment for vascular access (VA) stenosis 1. Corrective treatment, combined taining a dialysis program based on arteriovenous fistulae. with monitoring the VA for hemodynamically significant stenoses, could improve patency and reduce the We present the “London Experience” of managing children on haemodialysis with arteriovenous fistulae. incidence of thrombosis 2. It has been clearly demonstrated the efficacy of correcting a stenosis with angioplasty under fluoroscopy guidance, restoring the laboratory parameters used to detect it. Most recently data show how PTA under Color Doppler ultrasonography (CDU) is useful to maintain and to improve VA patency 3. This PTA under CDU guidance allows patients to avoid adverse reactions to contrast media 4. Ultrasound is also a feasible and useful tool in the management of thrombosed native fistulae, thus de- creasing radiation exposure, and has no detrimental effect on success rates (5). Although ultrasound has numerous advantages, it is not without disadvantages 5. For example, in brachial-cephalic fistulae, visu- alizing the passage through the cephalic arch in cases of severe stenosis may require the assistance of fluoroscopy. A similar difficulty occurs when passing from the vein into the artery through the anastomosis. The presence of stenoses between aneurysmal dilatations may be difficult to cross by ultrasound control because the guidewire easily coils into the aneurysm. A further disadvantage is the need for close coor- dination between the operator and assistant because more than two hands are needed to perform the procedure. In conclusion, we believe that it is more efficient to use fluoroscopy and ultrasound together to treat VA stenoses. Our purpose in this presentation is to report the feasibility, safety, and effectiveness of duplex ultrasound guidance as an adjunct to fluoroscopy and angiography in the treatment of dysfunc- tional dialysis fistulas.

REFERENCES 1. Turmel-Rodrigues L, Pengloan J, Blanchier D. Insufficient dialysis shunts: improved long-term patency rates with close hemodynamic monitoring, repeated percutaneous balloon angioplasty, and stent placement. Radiology 1993; 187: 273-8. 2. Smits JH, van der Linden J, Hagen EC, et al. Graft surveillance: venous pressure, access flow, or the combination? Kidney Int 2001; 59: 1551-8. 3. Bacchini G, La Milia V, Andrulli S, Locatelli F. Color Doppler ultrasonography percutaneous transluminal angioplasty of vascular access grafts. J Vasc Access. 2007 Apr-Jun;8(2):81-5. 4. Ascher E, Hingorani A, Marks N (2009) Duplex-guided balloon angioplasty of failing or nonmaturing arterio-venous fistulae for hemodialysis: a new office-based procedure. J Vasc Surg 50(3):594–599 5. García-Medina J. Value of duplex ultrasound assistance for thromboaspiration and dilation of thrombosed native arterio-venous Friday January 20 January Friday fistulae. Cardiovasc Intervent Radiol. 2013 Dec;36(6):1658-63. CONTROVERSIES & UPDATES IN VASCULAR SURGERY IN VASCULAR & UPDATES CONTROVERSIES

40 41 P TA SURVEILLANCE - ENDOVASCULAR CREATION Patient safety in vascular access planning and construction Doppler ultrasound: is it a third generation AVF surveillance method? David Shemesh Jose Ibeas Shaare Zedek Medical Center, Jerusalem, Israel Parc Tauli Sabadell, University Hospital. Barcelona. Spain

Patient safety refers to the absence of medical errors in health care systems. Adverse events occur when the Vascular Access (VA) complications produce high morbi-mortality, worsened quality of life, hospitalizations patient is harmed by medical management. Adverse events caused by an error are by definition “prevent- and costs. Screening of pathology with the first generation methods (urea analysis, recirculation, hemodi- able adverse events”. Beyond their economic cost, medical errors cause loss of trust in both the caregiver alysis device alarms, physical examination, etc) is very specific but may be no sensitive. That it means that and the healthcare system. 1 in this way pathology is usually late diagnosed and VA can be loosed. Second generation methods are VA flow determination. The techniques used are based either on dilution methods or on Duplex UltraSound Many interventions that are applicable in vascular access surgery are not costly and have a positive effect (DUS) examination which associates Doppler and Echography. But DUS was usually reserved for selected on patient safety outcome. Some examples are use of safety checklists, adherence to a care pathway, team patients and depends on its availability. DU has the advantage of flow measurement and image study in training, and sub-specialization in access surgery. the same examination.

Patients can and should be major contributors to their own safety, and as such, physicians should develop Latest evidence advices using DUS examination for surveillance of flow and diagnosis of pathology, with a new approach to involve them in the cycle of decision making through every step of their treatment. The angiography only for selected cases. The possibility to incorporate DUS in the Hemodialysis Unit with port- patient has to be empowered in order to gain the confidence to carry out safety-related behaviors. With- able devices, has made possible the pathology screening and its precise diagnosis in the same act, giving out empowerment, hemodialysis patients will never be able to take an active role in improving the safety the possibility not only to do flow screening but to image-control stenosis, masses and collections or to process. The natural paternalistic attitude of health care workers that “the doctor knows best” is the major determine confusing or alternative collaterals. barrier that needs to be overcome in order to increase patient involvement. 2 Working in a multidisciplinary approach protocol with all the specialties involved, allows treatment pri- There are many opportunities along the treatment path for the patient to be engaged in safety behaviors oritization depending on the flow rate and thrombosis risk; or dangerous pseudoaneurysms. It allows for and for the access team to ensure such behaviors by employing simple strategies. The advent of the ac- treatment orientation to surgical, interventional or even conservative approach and even mapping for cess center, based on multidisciplinary teamwork, has enhanced the potential to improve patient safety the next VA placement. Finally, the possibility of the US guided puncture mainly in the deep vessels or in by prevention of errors in planning and performing access surgery, avoiding delay in treatment of access pathological VA waiting for treatment, is a fundametal progresss. All this create a new concept, the US as malfunction and improving communication between the team members. a third generation method that can be used in the first approach and in most cases like the last one too.

Our access center algorithm of patient safety enhanced access planning starts at the first meeting with the patient, continues through the decision making process until the patient is scheduled for surgery, and includes post-operative care and follow up. The ultimate aim is the reduction of preventable errors and increasing patient safety by systematic assessments of patients and risk factors in all stages of the care pathway. 3

REFERENCES 20 January Friday 1. To err is human. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in Ame- rica; Institute of Medicine. ISBN: 978-0-309-26174-6 DOI: 10.17226/9728 2. Shemesh D, Olsha O, Goldin I, Danin S. Patient safety: the doctor’s perspective. J Vasc Access. 2015;16 Suppl 9:S118-20. 3. Shemesh D, Olsha O, Goldin I, Danin S. The patient’s role in patient safety and the importance of a dedicated vascular access team. Contrib Nephrol. 2015;184:234-50. CONTROVERSIES & UPDATES IN VASCULAR SURGERY IN VASCULAR & UPDATES CONTROVERSIES

42 43 COMPLICATIONS - GUIDELINES COMPLICATIONS - GUIDELINES Management of PTFE seromas Digital pressure measurements for HAIDI Larry Scher Gilbert Franco Montefiore Medical Center, Bronx, NY, USA Clinique Arago, PARIS, France

Perigraft seroma formation is related to the synergism of biochemical, mechanical and structural factors. Hemodialysis access-induced distal ischemia (HAIDI) is due to the diminution of perfusion pressure in the Seromas can be caused by excess graft porosity, exposure of grafts to caustic agents, immunologic or bi- presence of the low resistance arteriovenous fistula (AVF). More than steal which is common, associated ochemical factors and possibly by heparin exposure, use of nonsheathed tunnelers or other factors. ePTFE arterial stenotic lesions increase distal hypoperfusion resulting in hand ischemia. Various clinical grades is composed of nodes and fibrils with 80% void spaces filled with air. When the air in the void space is are observed in few patients (from 1 to 20%) shortly after access construction, or later on. Diagnosis pre- rapidly displaced all ePTFE grafts will persistently leak fluid. Ideally an implanted graft should have air dominantly based on clinical findings sometimes remains unclear and digital pressure measurements are displaced over 24-48 hours by body fluids with migration of fibroblasts into the interstices and deposition helpful to confirm and to evaluate the severity of ischemia. Arterial digital pressure (DP) is recorded in the of collagen. Immediate ultrafiltration through a vascular graft can be caused by premature “wetting” of third finger ipsilateral to the AVF by digital photoplethysmography (PPG) and compared to the opposite the graft with organic solvents or fat, which hinders the process of graft sealing. This process is affected arm. Basal digital pressure (BDP), digital brachial index (DBI), change in digital pressure with access com- by hemodynamic factors such as flow rate, blood pressure, oncotic pressure, alcohol or povidine-iodine pression (CDP) must be measured. BDP less than 60 mmHg or a DBI less than 0.4 are highly associated with contact or excess graft manipulation. Forcibly irrigating solutions through the graft wall can also cause im- hand ischemia. CDP less than 20% may be useful in identifying patients with ischemia who could benefit mediate ultrafiltration. Potential complications of untreated seromas include infection, wound dehiscence, from an access flow reduction. Preoperative assessment of the efficacy of distal radial artery ligation in skin necrosis, graft thrombosis or loss of available puncture sites. treatment of distal fistula HAIDI is easy by comparison of BDP measurements before and after occlusion of the radial artery. Digital pressure measurements prior to AVF construction should be part of evaluation of The overall incidence of dialysis access graft seromas ranges from 0.48% to 4.2%. Age, gender and diabe- upper-extremity perfusion to avoid HAIDI. Ability of the DBI to evaluate the risk of HAIDI has been some- tes do not affect incidence but there is a statistically significant difference in incidence between upper arm what controversial but for many authors DBI <0.6 identifies correctly patient at risk. Allen ‘test classically and forearm grafts. Observation without intervention may suffice for small seromas. When intervention is evaluate patency of palmar arch. A quantitative version using PPG under radial artery compression can be indicated, management strategies have included percutaneous drainage, open surgical treatment with ex- done. This is particularly interesting to test the ability of ulnar artery and palmar arch to supply the hand. If cision of the seroma capsule and replacement of the involved graft segment usually with alternative graft finger pressure drops below 80 mm Hg or if there is a more than 30% drop the test is abnormal and empha- materials and deployment of covered stents in the involved segment of graft. Strategies for management sizes the risk of HAIDI. Furthermore knowing BDP and that AVF construction is followed by a mean pressure of intraoperative serous ultrafiltration through the graft wall include graft replacement usually with alter- drop of 30 mm Hg it becomes easy to evaluate the risk of postoperative ischemia (DP

REFERENCES Dauria DM, Dyk P, Garvin P. Incidence and management of seroma after arteriovenous graft placement. J Am Coll Surg, 2006;203:506-11. Gargiulo NJ, Veith FJ, Scher LA, et al. Experience with covered stents for the management of hemodialysis polytetraflouroethylene graft seromas. J Vasc Surg, 2008;48:216-7. Padberg FT, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J Vasc 20 January Friday Surg, 2008;48:S55-80. CONTROVERSIES & UPDATES IN VASCULAR SURGERY IN VASCULAR & UPDATES CONTROVERSIES

44 45 COMPLICATIONS - GUIDELINES COMPLICATIONS - GUIDELINES CONTROVERSY. Guidelines should be international and based on solid Radial artery transposition for flow reduction evidence and not take into account local ressouces or availabilities. Pierre Bourquelot Yes Clinique Jouvenet, Paris, France Jan Tordoir MUMC, Maastricht, The Netherlands OBJECTIVE All surgical methods published to date for the reduction of excessive high-flow in native elbow fistulas for Many decisions around vascular access (VA) for hemodialysis (HD) warrant a collaborative decision-making dialysis have limitations [1-9]. We report a new surgical approach to flow reduction by transposition of the process. The goal of guidelines is to summarize and evaluate all the current available evidence to assist radial artery to the elbow level (VIDEO). physicians in selecting the best management strategies for patients needing a VA or for pathologies derived by VA. Each physician must make the ultimate decision regarding the particular care of an individual METHODS HD patient. 47 consecutive patients (Table 1) (22 women) with brachial artery to elbow vein autogenous fistula under- HD patients with VA are complex and subject to significant clinical practice variability, although a valid went flow reduction via replacement of brachial artery by transposed distal radial artery inflow (Fig 1, 2). evidence base is available to guide recommendations. The significant technical and medical advances in VA The new arteriovenous anastomoses were end-to-side either brachial-cephalic (n=19) or brachial-basilic have enabled guidelines to be proposed with greater supporting evidence than previously. However, many (n=28). The indications were hand ischemia (n=4), cardiac failure (n=13), concerns about future cardiac clinical situations involving patients have not been subjected to randomized clinical trials. By providing dysfunction [10] (n=23), and chronic venous hypertension resulting in aneurysmal degeneration of the vein information on the relevance and validity of the quality of evidence, the physician will be able to gather the (n=7). Mean patient age was 44 years (range, 3-82) (7 < 16 years) 11% were diabetic, 17% were smokers, most important and evidence-based information relevant to the individual patient. and mean BMI was 22. Mean fistula age before flow reduction was 2.5 years. These limited randomized studies especially involves arteriovenous fistulae (AVF), and the small sample size of the published studies with conflicting results highlight the need for larger multicentered randomized RESULTS study with hard clinical end points to evaluate the optimal strategy for both AVF and arteriovenous grafts Technical success was 91% (n=43 of 47). The mean flow rate dropped by 66% ±14% (Table 2). Clinical suc- (AVG). cess in symptomatic patients was 75% (n=18 of 24). The fistula eventually had to be ligated in 3 cases of Randomized studies can be performed on a national and/or international level, but might be flawed by in- cardiac failure because of insufficient clinical improvement. All 4 patients with hand ischemia were cured, sufficient number of included patients and inadequate power analysis. Larger patients cohorts are available with no recurrence during follow-up. Primary patency rates at one and three years were 61% ± 7% and in countries with access to greater number of HD patients and/or national patient data sets ( for instance 40% ± 8%. Secondary patency rates at 1 and 3 years were 89% ± 5% and 70% ± 8%. (Fig 3-4-5) www.usrds; www.renalreg.org). These facts warrant the need for international guidelines. Drawback might be differences in patient demographics between countries, which can influence study outcomes. In addi- CONCLUSION tion, different attitudes to the creation and maintainance of vascular access, may reflect national prefer- Transposition of the radial artery, a safe and effective technique, might now be considered in the surgical ences in the field of VA for hemodialysis. armamentarium of flow reduction techniques.

FIGURES Friday January 20 January Friday

Operating diagram CONTROVERSIES & UPDATES IN VASCULAR SURGERY IN VASCULAR & UPDATES CONTROVERSIES

Postop. angiography

46 47 TABLES

Patients 47 Age of patients (years) 44 ± 21 (range: 3 - 82), (7 < 16 years) Males/Females 25/22 Brachial-Cephalic: 19 AVF type Brachio-Basilic: 28 Age of AVF (years) 2.5 ± 2.1 (range: 8.9 - 0.1) Diabetics 5 Smokers 8 Hypertension 24 BSA (m²) 1.54 ± 0.41 (range: 0.46-2.10) BMI 22 ± 5 (range: 14-33) Ischemia: 4 (finger gangrene: 3, rest pain: 1) Three years later after kidney transplant Cardiac failure: 13 Indications for flow reduction Regarding cardiac outcome: 23 Venous hypertension: 7

Patients

Flow Preoperative Postoperative mL/min mL/min mL/min mL/min per 1.73 m² per 1.73 m² Mean 1681 2012 577 678 SD 499 742 310 416 Max 3000 4554 1900 2569 Min 800* 919 170* 234 Flow reduction up to 4 years * Child of 10 kgs: preop- flow = 2993 mL/min per 1.73 m². Pre and post operative mean flow

REFERENCES 1. van Duijnhoven EC, Cheriex EC, Tordoir JH, Kooman JP, van Hooff JP. Effect of closure of the arteriovenous fistula on left ventricular dimensions in renal transplant patients. Nephrol Dial Transplant 2001;16: 368-372. 2. Thermann F, Ukkat J, Wollert U, Dralle H, Brauckhoff M. Dialysis shunt-associated steal syndrome (DASS) following brachial accesses: the value of fistula banding under blood flow control. Langenbecks Arch Surg 2007;392:731-737. 3. Schneider CG, Gawad KA, Strate T, Pfalzer B, Izbicki JR. T-banding: a technique for flow reduction of a hyperfunctioning 20 January Friday arteriovenous fistula. J Vasc Surg 2006;43:402-405. 4. Bourquelot P, Corbi P, Cussenot O. Surgical improvement of high-flow arteriovenous fistulas. In: Sommer BG, Henry ML, editors. Vascular access for hemodialysis. New York: W.L. Gore & Associates Inc., Pluribus Press Inc; 1989. p. 124-130. 5. Chemla ES, Morsy M, Anderson L, Whitemore A. Inflow reduction by distalization of anastomosis treats efficiently high-inflow high-cardiac output vascular access for hemodialysis. Semin Dial 2007;20: 68-72. 6. Minion DJ, Moore E, Endean E. Revision using distal inflow: a novel approach to dialysis associated steal syndrome. Ann Vasc Surg 2005;19: 625-628. 7. Schanzer H, Schwartz M, Harrington E, Haimov M. Treatment of ischemia due to “steal” by arteriovenous fistula with distal artery ligation and revascularization. J Vasc Surg 1988; 7:770-773. 8. Zanow J, Kruger U, Scholz H. Proximalization of the arterial inflow: a new technique to treat access-related ischemia. J Vasc Surg Primary and secondary patency rates, standard errors, and numbers of patients at risk (between brackets) at the start of each 2006; 43: 1216-1221. interval 9. Vaes RH, Wouda R, van Loon M, van Hoek F, Tordoir JH, Scheltinga MR. Effectiveness of surgical banding for high flow in brachial artery-based hemodialysis vascular access. J Vasc Surg. 2015 Mar;61(3):762-6. CONTROVERSIES & UPDATES IN VASCULAR SURGERY IN VASCULAR & UPDATES CONTROVERSIES 10. Basile C, Lomonte C, Vernaglione L, Casucci F. The Relationship between the Flow of Arteriovenous Fistula and Cardiac Output in Hemodialysis Patients. Nephrol Dial Transplant; 2008;23: 282-287

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Saturday January 21 - Mainprogram - 51

CONTROVERSIES & UPDATES IN VASCULAR SURGERY Amin Ali OCCLUSIVE DISEASES OFTHELIMB Tricks toachieveendovascular repairoftotallyoccludediliacarteries Aorto Iliacsegment. Reading Health System, Reading, United States United Reading, System, Health Reading aortoiliac lesions includingmorphological stratificationandrevascularization recommendations 2007, TASC II report updated the morphological stratification and revascularization recommendations for their location, extension, andmorphology(stenosis mendations forinitialtreatment artery disease (PAD), included morphological stratifications of aortoiliac lesions with associated recom sive reportofthe TransAtlantic Inter-Society Consensus (TASC I, 2000)onthemanagement ofperipheral provement. Primarypatencyat4yearswas 76%andsecondary patencyof85% recanalization was accomplished in nearly 90%, withnearly all patients showing with marked clinical im including iliacarteryocclusion. Inaseriesof212 patients withchroniciliacarteryocclusions, successful loons, anduseofre-entrydeviceshavechangedthelandscapefortreatmentmorecomplex iliaclesions bidity. Over thepastfewyears, developmentof newNitinolstents, lowerprofilebuthigher pressurebal occlusion, theirpatencyisclosetopercutaneousendovascular interventionwithgoodresultandlessmor co-morbidities. Although extra-anatomicbypassesprovidelessinvasive methodtorevascularize aortoiliac sive angioplastyandstenting. This isparticularlyimportant when treatingelderly patients withmultiple of approximately90-95% bypass graft has been the standard treatment for severe aortoiliac occlusive disease, with 5 year patency advances inthemanagementofpatientswithsevereaortoiliacocclusive disease. Although aortobifemoral balloon catheterbyGruntzigandHopffin1974 obtained bysurgicalmeans. The methodbecamemorewidelyappliedfollowingtheintroductionof ticularly for stenosis in the aortoiliac area where the long term results appear to be nearly equal to those scorn by some surgeons. However, experience has shown it to be an acceptable method of treatment, par new erainthetreatmentofvascular diseases back, theintroductionofpercutaneoustransluminal angioplastybyDotterandJudkinsin1964heraldeda surgeons, recentliteraturedoesshow significant improvementintheirsuccessanddurability. Looking cularize ischemicextremity. Although thedurabilityofthesemethodshavebeenquestionedbyvascular lizing balloonangioplasty, stenting, atherectomy, laser, cryoplastyhaveprovidedvarious methodstorevas an interestintheminimallyinvasive therapyforperipheralvascular disease. Percutaneous techniquesuti the past10yearstreatmentofvascular diseasehadchangedgreatly. Technologic advances havefueled occurs whenbloodflowhasdecreasedtosuchacriticallevelthatthereistissueischemia, evenatrest. In progresses toischemicrestpain, tissueloss isalmostinevitableunlessthelimbrevascularized. Restpain process isprogressingandinterventionmaybenecessarybeforetissuelossoccurs. When claudication and thisisknownasLerichesyndrome. Progressionoftheclaudicationsuggeststhatatherosclerotic usually associatedwithaortoiliacstenosisorocclusion. Inthemalethismaybeassociatedwithimpotence and thighclaudicationsuggeststenosisorocclusionoftheiliacartery. Ifsymptomsarebilateral, thenitis involves thecalfmuscles, patientsmightcomplainofclaudicationinvolvingthebuttocksorthigh. Buttock Intermittent claudicationisoneofthemostreliablesymptomsvascular insufficiency. Althoughtypically atherosclerotic processinthediseasedsegment, 4. Reductionofcardiovascular morbidityandmortality. tional capacity with improvement of walking distance, 2. Prevention of limb loss, 3. Modification of the and 74 less, theEdinburgh Artery Study reported a disease prevalence of 17%in a population aged between 55 objective noninvasive tests such as ankle-brachial index (ABI). Based on a disease definition of ABI of. 9or between 40and60yearsofage, andupto6%inthoseover70. Howeverthese figures aremuchhigherif over theageof65. The prevalence ofsymptomaticPAD isestimatedatapproximately2%inallindividuals Peripheral arterial occlusive disease (PAD) is primarily a diseaseof the elderly population, especially those Atherosclerosis in its various forms is the leading cause of mortality and disability throughout the world. 1,2 . Any treatmentregimentargetedforPAD mustaddressfour objectives: 1. Improvementoffunc 5 , butassociatedwithhighermorbidityandmortality comparetominimallyinva

6 . Lesionsintheaorto-iliac segmenthavebeencategorizedaccordingto 3 . The method was metbyagreatdeal ofskepticism andeven 4 . Overthepastfewyears, therehavebeen considerable 52 vs . occlusion)withimplications oftheirtreatment. In 8 . The originalcomprehen 7 . Ingen ------

less difficult with highersuccessrate and improvedpatency. a crossingdevice, andtwore-entrydevices(OutbackPioneer) hasmadetreatmentofthisocclusion inability tocrosstheoccluded segmentandre-enterthedistaltruelumen. DevelopmentofaFrontrunner, angioplasty, theprimarycausefor acuteproceduralfailureinthetreatmentofiliacocclusion becamethe true lumenandfinallyby thefailureofballoonangioplasty. Withthedevelopmentofstentsto treatfailed to treatiliacocclusionwas initiallylimitedprimarilybythefailuretocrossocclusion, failuretoenterthe exchanged for a.035wiretofacilitateangioplasty and stenting ofthe iliac artery. Insummary, theability ing ofthecatheter. Oncetheneedle isdeployed, a.014wireispassedintothe truelumen. The .014wireis position ontheIVUSimage. The truelumenisidentifiedbyboththetwodimensionalandcolorflowimag curved retractableNitinolneedledistally. The needleprojectsaway fromtheIVUScatheterat12o’clock (IVUS) toaccessthedistaltruelumen. The Pioneercatheterhasahypo-tubethroughthelumenwith a exchanged fora.035wire. 2)PioneerCatheter(Medtronic Corp): thisdeviceusesintravascular ultrasound the 22Gneedleintodistaltruelumen. A .014wireisadvanced distallyintothetruelumenandwire devices onthemarket: 1)OutbackRe-entrydevice(CordisCorp): this6Fr. deviceuses fluoroscopytoplace the distaltruediseasefreearteriallumen. At times, thisrequiresusingare-entrydevice. There aretwo occluded segment. The ratelimitingstepforasuccessfulcrossingofaniliacocclusioninvolvesaccessing patent artery. Otherdevicesusinglaserorultrasoundtechnologyhasbeenusedtopenetrateandcrossthe bleeding isseenthroughthehubofcatheterandpassagea.035wireallowsaccesstodistal At time, truelumenre-entryispossibleby justusingthisdevice. Oncethetruelumenisentered, thenback the companionMicro-guide radio-opaque tip hydrophiliccatheterisadvanced untilthelesioniscrossed. ameter of2.3mm, andthecrossingprofileis0.039inchwithjawsclosed. Oncethelesioniscrossed, are actuatedinasee-sawfashionwithhandleontheproximalendofdevice. The jawopenstoadi passage through the occluded segment. The blunt microdissection uses a pair of rounded hinged jaws that crossing toolsuchasFrontrunner XP(CordisCorp)allowseasierpenetrationintotheproximalcapand philic wire. However, thephysicianmustbecarefulnottoperforateoccludediliacartery. Usinga sions withdensercalcification, longoccludedsegmentmayrequiremoreforcewhenpassingthehydro Forming aloopallowseasypassagethroughtheoccludedsegment, toward thereconstitutionpoint. Le profile (4 Fr.) anglecatheteradjacenttotheproximalcap, helpswithpenetratingtheoccludedsegment. recanalization. Hydrophilicwiresarecommonly usedtopassthroughtheoccludedsegment. Placingalow femoral, andrarelybrachialapproach. Both intraluminalandsubintimalspacecanbeusedforsuccessful ment, entering the distal true lumen. Lesions can be accessed from the Ipsilateral femoral, contralateral perforation canleadtoretroperitonealbleeding, enteringtheproximalcap, traversinglongcalcifiedseg part of TASC B, C, orDlesions. Treatment ofanoccludedsegmentintheiliaciscomplicatedby: iliac artery; CFA=common femoralartery; AAA= abdominalaorticaneurysm. Iliacocclusionisincludedas placement orotherlesionsrequiringopenaorticiliacsurgeryCIA=commonartery; EIA=external occlusions ofEIA-Iliacstenosesinpatientswith AAA requiringtreatmentandnotamenabletoendograft stenoses involvingtheunilateralCIA, EIAandCFA -UnilateralocclusionsofbothCIAand EIA-Bilateral occlusion -Diffusediseaseinvolvingtheaortaandbothiliacarteriesrequiringtreatmentmultiple with orwithoutinvolvementoforiginsinternaliliacand/orCFA Type Dlesions -Infra-renalaortoiliac occlusion that involves the originsofinternal iliac and/or CFA -Heavilycalcified unilateral EIAocclusion 3-10 cmlong, notextendingintotheCFA -UnilateralEIAstenosisextendingintotheCFA -UnilateralEIA volving theoriginsofinternaliliacorCFA Type Clesions-BilateralCIAocclusionsEIAstenoses stenoses totaling 3-10 cm involving the EIA not extending into the CFA - Unilateral EIA occlusion not in EIA Type B lesions - Short (<3 cm) stenosis of infra-renal aorta - Unilateral CIA occlusion - Single or multiple A lesions-Unilateral or bilateral stenoses ofCIA-Unilateralorbilateral single short(<3cm)stenosis of making treatmentrecommendationsfortypeBandClesions. TASC Classificationof AortoiliacLesions Type fully informedpatientpreference, andlocaloperator’s longtermsuccessratesmust beconsideredwhen gery is the preferredtreatment for good risk patients with typeClesions. The patient’s co-morbidities, the of choicefortypeDlesions. Endovascular treatmentisthepreferredfortypeBlesionsandsur in TASC I. Endovascular therapyisthetreatmentofchoicefortype A lesionsandsurgeryisthetreatment eral, eachlesioncategoryinthenew TASC IImorphologicalstratificationincludesmoreseverediseasethan 53 ------Saturday January 21

CONTROVERSIES & UPDATES IN VASCULAR SURGERY 8. ScheinertD 7. 6. 5. 4. 3. 2. 1. REFERENCES ot M Vogt supp);S5-67 (TASC). J Vasc Surg. 2000;31-S1-296 disease. Radiology1997; 204:87-96 Dotter-technik. DtshMed Wochenschr 1974; 99:2502-5. application. Circulation1964;30:654-70 population. IntJEpidemiol20:384-392, 1991 Norgren L Dormandy JA, Bosch JL A, Gruntzig Dotter CT Fowkes E et al et et al et et al et et al et et al et et al et et al et : Lowerextremityarterialdiseaseandagingprocess: areview. JClinEpidemiol45:529-542, 1992 : Meta-analysisoftheresultspercutaneoustransluminal angioplastyandstentplacementforaortoiliacocclusive : Edinburgharterystudy. Prevalence ofasymptomaticandsymptomaticperipheral arterialdiseaseinthegeneral et al et : Transluminal treatmentofarterioscleroticobstruction: descriptionofnewtechniqueandpreliminaryreportits : Inter-Society ConsensusfortheManagementofperipheral Arterial Disease(TASC II). J Vasc Surg. 2007;45(1 : Perkutane rekanalisationchronischerarteriellerverschlussemiteinemneuendilationskather: Modificationder . Stentsupportedrecanalizationofchroniciliacarteryocclusions. Am JMed2001; 110:708-15 : Managementofperipheral arterialdisease(PAD). TASC workinggroup. TransAtlantic Inter-society Consensus 54

OCCLUSIVE DISEASES OFTHELIMB Michel MPJReijnen Why coveredstentsarenotallthesameinaortoiliac occlusivedisease Aorto Iliacsegment. Rijnstate Hospital, Arnhem, The Netherlands The Arnhem, Hospital, Rijnstate should buildtheirownevidenceascharacteristicsmaydiffer. expandable andself-expandingcoveredstentswillenableatailormadedecisionmaking, butalldevices In conclusion, coveredstentsshouldbethechoiceinextensive AIOD. The availability ofvarious balloon their ownpro’s andcon’s. both CERABandthe AFX havebeenrelatedtoagoodoutcomeinsevere AIOD andbothtechniqueshave or internalPTFEcover). Comparativestudiesarestilllacking. When reconstructingtheaortic bifurcation, regard tothestentmaterial(Stainlesssteel recently, alternativeballoonexpandablestentswereintroduced thathavedifferentcharacteristicswith Most evidenceoncoveredstentswas obtainedwiththe Advanta V12 balloonexpandablestent. More AFX unibodyendograft. and thereforealternativestrategieshavebeendeveloped, suchastheCERABtechnique andtheuseof technique isfrequentlyusedforbilateral AIOD, butresultstendtobeinferiorthoseofisolatedlesions occlusive disease(AIOD), aswas shownbyvarious caseseries and randomized trials. The kissingstent The useofcoveredstentsincreasesthepatencyratesafterendovascular treatmentofextensiveaortoiliac

vs . CobaltChromium)andgraftdesign(encapsulated, external 55

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY OCCLUSIVE DISEASES OFTHELIMB Serguei Malikov, JulienKoenig, NiclaSettembre, ZakariyaeBouziane Sexual (dys)functionsfollowingaorticrepair, doweneedarandomizedtrial? Miscellaneous. Nancy University Hospital, Nancy, France Nancy, Hospital, University Nancy 11. Nevelsteen, A. Aorto-femoral reconstructionandsexualfunction: aprospectivestudy. EurJ Vasc Surg. 1990, Vol. 4, 247-251. 10. 9. 8. 7. 6. 5. Sabri, S. Sexualfunctionfollowingaorto-iliacreconstruction. Lancet. 1971, Vol. 4(2), 1218-9. 4. 3. 2. 1. REFERENCES side effectofinternaliliacarteriesembolizationonsexualfunction?Furtherstudiesareneeded. tions remainunresolvedastheimpactofsurgicalapproach: transperitonealorretroperitoneal? The shows thattreatmentwithEVAR is abettertechniqueforpreservingsexualfunction. Howevermanyques This pilotstudyconfrmstheimportantimpactofopenaortoiliacsurgeryonmalesexualfunction. Italso CONCLUSIONS patients 3monthsafterbothtreatments. cant changeinerectilefunction. The frequencyofsexualintercourseshadatendencytodecreaseforall disorders arerelatedtosympatheticplexusdamageduringopensurgery. For EVAR, wedidnotndsigni of patients, lossofejaculationsin45%andadecreasetheoverallsexualsatisfaction38.4%. Those months after intervention for open aorto iliac surgery showed a deterioration of erectile function in 42.8% 58.8% of all patients had impaired erectile function prior to surgery. The comparison of scores before and 3 RESULTS were enrolled: 16receivedendovascular aneurysmexclusion(EVAR) and20hadan open aortoiliacsurgery. quency of sexual intercourses and overall sexual satisfaction. In this bicentric prospective study 36 patients teria weresexualfunctionchangesthreemonthsaftertheintervention: erectilefunction, ejaculation, fre To evaluate erectilefunction, weusedSHIMsurvey(SexualHealthInventoryforMen). The assessmentcri METHODS quency ofpostoperativesexualdysfunction, comparingendovascular andopensurgeryinaortoiliacdisease. dysfunction remainsmultifactorialandpoorlyunderstood. The aimofourpilotstudywas toanalyzethefre ment byEVAR. Sincethen, severalstudieshaveconrmedthesefindings, eventhoughrecognizingthatsexual tence andejaculationdisorders. Besides, severalreportshavealsoraisedsexualdysfunctionissuesaftertreat shown thatthedamageofperi-aorticpelvicplexusduringaorto-iliacsurgerycanleadtobothsexualimpo tential consequenceofaortoiliacobstructivediseasesincethedescriptionLerichesyndrome. Lateritwillbe Sexual function is an important quality of life criterion for patients. Sexual impotence is recognized as a po 33, 983-9. VanSchaik, J. Nerve-preservingaorto-iliacreconstructionsurgery: anatomicalstudy andsurgicalapproach. J Vasc Surg. 2001, Vol. 2004, Vol. 11, 613-620. dovascular techniques. J Vasc Surg. 2009, Vol. 50, 492-9. 2004, Vol. 38(2), 157-165. Urology. 1997, Vol. 49, 822-830. diagnostic toolforerectiledysfunction. International JournalofImpotenceResearch. 1999, Vol. 11, 319-326 12(3), 186-191. Prinssen, M. Sexualdysfunctionafterconventionalandendovascular AAA repair: resultsofthe DREAMtrial. JEndovasc Ther. Pettersson, M. Prospectivefollow-upofsexualfunction afterelectiverepairofabdominalaorticaneurysmusingopen anden- Karkos, CD. Erectiledysfunctionafteropen Machleder, HI. SexualDysfunctionFollowing Surgical Therapy for Aorto-Iliac Disease. Vasc Endovasc Surg. 1975, Vol. 9(5), 283-287. Rosen, RC. The InternationalIndexofErectileFunction (IIEF): amultidimensionalscaleforassessmentoferectiledysfunction. Rosen, RC. Developmentandevaluation ofanabridged, 5-itemversionoftheInternationalIndexErectileFunction (IIEF-5)asa Jimenez, JC. Sexualdysfunctioninmenafteropenorendovascular repair ofabdominalaorticaneurysms. Vascular. 2004, Vol. abdominal aortic aneurysm. J Vasc Surg. 2003, 38, 745-52. Lederle, FA. Qualityoflife, impotence, andactivity levelinarandomized trial of immediaterepair

versus angioplastyaorto-iliacprocedures: aquestionnairesurvey. Vasc Endovasc Surg. 56 versus surveillanceofsmall ------

Mezalek Tazi Zoubida OCCLUSIVE DISEASES OFTHELIMB Takayasu disease: isitstillaroomforintervention? Miscellaneous. Service Médecine Interne, Université Mohammed V, Rabat, Maroc Rabat, V, Mohammed Université Interne, Médecine Service optimal immunomodulatorytherapybeforeandaftertheprocedure. vention in TA maybeimprovedbydetailedpreoperativemeasurement ofdiseaseactivity, andbyensuring (mostly infliximabandmostlyrefractory cases)showedfavorable results. Thus, outcomesof vascular inter a moreeffectiveanti-inflammatoryeffect. Infact, themajorityof TA patientstreatedwithbiologicagents The recentincreasing use ofbiologicalagents targeting tumornecrosisfactor(TNF- to developavalidated setofoutcomemeasuresforuseinclinicaltrials TA. went surgery, withclinicallyinactivediseaseandnormalacutephasereactants. Thus, thereisaclearneed cannot beexcluded, withactivearteritis detected inmorethanhalfofbiopsiesfrompatientshowunder nosuppressive therapy, withasignificantlyimprovedoutcomes. Eveninthesecircumstances, inflammation with yieldingconflictingresults. There areconvincingdatasupportingtheefficacyofperioperativeimmu computerised tomographyCT- scanindetectingpersistent arterialwall inflammationremaintobeproven, at thetimeofrevascularization. The sensitivityandspecificitypreoperative18F-fluorodeoxyglucose PET/ 5 to10years. The 5-yearcomplicationrateismarkedly increasedinpatientswithactiveinflammation Restenosis isfrequentforopensurgeryorpostangioplasty, reachingmorethan70%insomeseriesat is wellillustratedbyhigherrestenosisratesforangioplastythanseenwithopensurgery. and typicallyresultsinlongscarredfibroticstenosisthataresubstantiallychallenging forangioplasty. This and availability butalsoonthesiteandnatureofarteriallesions. Infact, TA isapan-muralarteritis between opensurgeryandendovascular approaches. The decisionmaydependinpartonlocalexpertise aortic regurgitationandaneurysmsrepairislesscommon. There arenoguidelinestodirectthechoice disease, severeclaudicationandischaemiarelatedtocoeliacormesentericarterystenosis. Surgeryfor trolled hypertensionsecondarytorenalarterystenosis, aorticcoarctation, symptomatic cerebrovascular Arterial stenoses/occlusionarethemostcommonlesionstreatedandprincipalindicationsuncon arterial injury, andtheneedforsurgicalorendovascular interventioninthemanagementof TA. in thenextdecade. Buttodaystill, delayedpresentationanddiagnosisstillcommonly resultsinextensive agnosis andacombinationimmunotherapymayresultinreducedrequirementforvascular intervention The diagnosisof Takayasu arteritis(TA) remainschallenging, particularlyearlyinitscourse. An earlierdi

57 α ) orIl-6mayresulton - - - - - Saturday January 21

CONTROVERSIES & UPDATES IN VASCULAR SURGERY Sibé Maxime INFRA INGUINAL,SFA ENDOREPAIR Do thelatestbarestentsjustifytheiruseinSFA/popliteal arteries? What about stents? De NovoSFA lesions: material, results, uncertainties Clinique Saint Augustin, Bordeaux, France Bordeaux, Augustin, Saint Clinique 8. 7. 6. 5. 4. 3. 2. 1. REFERENCES selected usingperforatedstentslaserandthelatestgenerationofwouldbeuseful. be confirmedbyfurtherprospectiveandrandomizedstudies. Astudycomparingforidenticallesionsand oral andpoplitealincludinglonglesions. primary patency, primary assisted, andsecondaryonetwoyearsinthestentingofsuperficialfem of barestents “conformable” or “flexible” confirmreadingrecentstudiespublishedin2016(againof formable stentcouldbestmeetthebiomechanicalstrengthofkneeandSFA restenosis ofstentsfracture domized studieswithpatencyrateatoneyearupdoubledcomparedto ATL alone. 10 cmlong. The gainofprimarystentingwithBMSperforatedlaserwas demonstratedbynumerousran domized studieshaveshownangioplastyalonefortheprimarypatencyrateat40%1yearlesions figures areinfluencedbythelengthofstentsandpresencediabetes. of systolicvelocitypopliteal found 24%ofrestenosisat6months, 49%at1year, 61.5%at2years. These study of 235 patients, measured by Doppler ultrasound the rate of intra-stent restenosis with calculation pression andlongitudinalextension, bending, twistingduringmovementsofthe lowerlimb. The superficialfemoralarteryandpoplitealsuffermajormechanicalstress: radialcompression, com Pacanowski JPJr3. femoropopliteal diseasewiththeSupera stent. Montero-Baker M1, Ziomek GJ2, LeonL3, Gonzales A4, DieterRS2, GaddCL5, Vascular Stentinthesuperficialfemoral andpopliteal arteries. JCardiovasc Surg. 2015;56(1):89-95. dual componentdesigninthesuperficialfemoral andpoplitealarteriesat6months. JCardiovasc Surg. 2013;54(4):447-453. helical interwovennitinolstentstotreatfemoropoplitealocclusivedisease. Chan YC1, ChengSW2, CheungGC2. stent (ev3)in TASC CandDfemoropopliteallesions. Journalof Vascular Surgery2011;54(4):1042-1050. Gao M1, ZhaoX1, Tao Y1, Wang L1, Xia M1, Tong Z1, HouC1, Hua Y2. dictors ofIn-stentRe-StenosisintheSuperficial Femoral Artery: Evaluation ofLong-Term OutcomesbyColorDuplexUltrasound. artery lesions: 12-monthresultsoftheDURABILITYIstudy. JEndovasc Ther. 2009;16:261-269. femoropopliteal stenting. J Am CollCardiol. 2005;45(2):312-315. J Vasc Surg. 2016Oct;64(4):1002-8. doi: 10.1016/j.jvs.2016.04.053. Epub2016Jul18. Analysis ofendovascular therapy for Piorkowski M, Freitas B, SteinerS, BotsiosS, Bausback Y, ScheinertD Piorkowski M, Freitas B, Schmidt A, Br‰unlichS, UlrichM, SchusterJ J Vasc Surg. 2015Nov;62(5):1201-9. doi: 10.1016/j.jvs.2015.05.030. Epub2015Jul11. Predictorsofrestenosisintheuse Bosiers M, DelooseK, CallaertJ, MoreelsN, Keirse K, Verbist J, Peeters P. ResultsoftheProtÈgÈEverFlex200-mm-longnitinol Ultrasound MedBiol. 2016Mar;42(3):717-26. doi: 10.1016/j.ultrasmedbio.2015.11.001. Epub2015Dec8. IncidenceandPre Bosiers M, Torsello G, GisslerHM, RuefJ, M¸ller-H¸lsbeck S, Jahnke T Scheinert D, ScheinertS, SaxJ, Piorkowski C, Br‰unlichS, UlrichM

4 ledtoreconsidertheperforatedstentslaseroffermoreflexibleandcon 6,7,8 This significantimprovementinpatency(greaterthan10%)to 58 et al et et al et et al et et al et . Prevalence andclinicalimpactofstentfractures after . Nitinolstentimplantationinlongsuperficial femoral . Twelve- monthexperiencewiththeGOREÆ TIGRISÆ . The use oftheGOREÆ TIGRISÆ Vascular Stentwith

3 All prospectiveandran 4 The associationwith 4,5 .New generations 1,2 A recent ------

Schneider Peter DENOVO SFA LESIONS:MATERIAL, RESULTS, UNCERTAINTIES Drug coatedballoonarefine: dotheyworkfor TASC CandDlesions? What about balloonsin2017? Kaiser Medical Center, Honolulu, United States United Honolulu, Center, Medical Kaiser 1. REFERENCES Early datafortheresultsofDCBsinlonglesionsareverypromising. CONCLUSION occlusions andothermorphologieshavenotbeenevaluated. pertains tolesionlength, whereas TASC C/Dlesionsthatincludecommonfemoraldisease, distalpopliteal patients withlesions>25cmrequired stents. Inconsideringtreatment of TASC C/Dlesions, alldatasofar demonstrated thatpost-DBCbailoutstentplacementismorelikely. IntheIN.PACT GlobalRegistry, 53%of no randomizedtrialsofpatientswithlonglesionstreatedDCBs. Studiesoflonglesionstodatehave with a mean lesionlength of 26cm and aone-year core lab adjudicated patency of 91%. IN.PACT GlobalRegistry, whichincludedalonglesioncohort of 157patientswithlesions>15cminlength one yearwas 83%, withameanlesionlengthof25cm. and restenosiswas 24%atoneyear. OneprospectivestudyfromItalydemonstratedthatDCBpatencyat eluting stentplacementformanagementoflonglesions. of 79%at12months. and Leipzig. DCBtreatment of lesions with a mean lengthof24cm demonstrated a duplex derived patency Two retrospectivestudieshavebeenpublishedthatincludelargeseriesofpatientsfromBadKrozingen DATA ONTASC C/DLESIONS years. population, DCBproducedsignificantlyhigherpatencyandlower TLR ratesthanballoonangioplastyat1-3 patency benefits. Mostofthedatathathasaccumulatedsofarpertainsto TASC AandBlesions. Inthis femoral-popliteal occlusive disease. Both randomized trial and registry data have demonstrated significant Drug coatedballoons(DCBs)haverecentlybecomeareasonableandacceptableoptionformanaging INTRODUCTION 6. Schneider. CharingCross April, 2016 5. 4. 3. 2. Study. JACC Cardiovasc Interv2016; 9:950 2014;21:359 Interv 2016;9:715 IN.PACT SFA Trial. (Manuscriptsubmitted) Schneider Micari Zeller Schmidt Rosenfield 1,2 et al et et al et The questionathandiswhetherthisbenefitextendstopatientswithlesionslongerthan 15cm. et al et et al et . Drug-coatedballoons et al et . 1-Year resultsofpaclitaxel-coated balloonsforlongfemoropoplitealarterydisease: evidencefromtheSFA-Long . Drug-coatedballoonsforcomplexfemoropopliteal lesions: 2-yearresultsofareal-worldregistry. JACC Cardiovasc . Durability ofeffectaftertreatmentwithadrug-coatedballoonforfemoropopliteallesions: 3-yearresultsof . Trial ofapaclitaxel-coatedballoonforfemoropoplitealarterydisease. NEnglJMed2015;373:145 3 Inanotherstudy, aretrospectiveanalysiswas performedofbothDCBanddrug vs . drug-elutingstentsfortreatmentoflongfemoropopliteallesions. JEndovasc Ther

59 5 Unpublisheddatahasalsobeenpresentedforthe 4 MeanlesionlengthforDCBpatientswas 19cm 6 There have been

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY Keirse Koen DENOVO SFA LESIONS:MATERIAL, RESULTS, UNCERTAINTIES Drug coatedballoons: aretheresultsdurable? What about balloonsin2017? Regional Hospital, Tienen, Belgium Tienen, Hospital, Regional rates andfreedomfrom TLR, especiallyfor TASC A andBlesions. Treatment ofdenovo SFA diseasewithDEBseemssafeandfeasible, showspromisingprimarypatency CONCLUSION months of89.0%(ascomparedtoPTA: 65.0%)anda TLR rateof5.2%(ascomparedtoPTA: 14.7%). Most recent published data from the Illuminate EU RCT showed an improved primary patency at twelve (Debellum; Katsanos; Pacifier; Levant I and Ranger)showedfor alltrials an improved TLR rate at6 months. .Pact SFA (averagelesionlength8.9cm)89.8%. RandomizeddatacomparingdrugcoatedballoonstoPTA B lesionstheLevant 2trial(averagelesionlengthof6.3cm)showedaprimarypatency73.5%andIn of available datashowsansustainedimprovementofprimarypatencyattwelvemonths. For TASC A and restenosis, scientificevidencetosupportourtitleisstilllackingtodayfordenovostenoses. Anoverview and orpoplitealartery. Although thereareclearindicationsofthebenefitsincaserestenosisorin-stent use ofdrugcoatedballoons(DEB), canpotentiallyreducethenumberandlengthofstentinginSFA Drugcoated balloonsarestillunderinvestigationintrialsfortheirusethefemoropoplitealarea. The

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Sunderdiek Ulrich DENOVO SFA LESIONS:MATERIAL, RESULTS, UNCERTAINTIES Germany Experience withanewdebulkingtechnology Debulking andCTO Dept. of Interventional Radiology, Center of Vascular Medicine, Marienhospital, Osnabrueck, Osnabrueck, Marienhospital, Medicine, Vascular of Center Radiology, Interventional of Dept. segments anditmayovercomethelimitationofballoonangioplastystentplacement. with DCBballoningoffersasafestrategyindebulkingcomplexlesionsevenchallenginganatomical These experience, aswellotherpublished data, demonstratethatrotationalatherectomyincombination CONCLUSION tion systemfreedomof TLR was 84%, withthelimitationofinconsistentfollow-up. was 94%, thestentratewas 12%. According toanalysisfromdataoftheelectronicalhospitaladministra Lesion lengthwas 2-28cm, withatotalof68%occlusions, 74%in the poplitealartery. Technical success RESULTS atherectomy alllesionsweredilatatedwithaDCB. In 2014/15weperformed 228 procedureswiththeJetStream System infemoropopliteal lesions. After with almostminimaldamagetothevesselwall. The tissuedebrisareaspiratedthroughthesideport. circumferential cuttingbladestodebulkbothhard(calcified, fibrotic)andsoft(thombus, plaque)tissues using arotationalatherectomysystem, the JetStreamSystemfromBostonScientific. Ithasdifferentialand We arecurrentlyperformingalmost150procedureswithatherectomy peryear, inmostofthemweare METHODS devices available whichallowdifferentmethodsofatherectomy. in order to prevent incomplete or eccentric stent expansion. So far, there are a few different atherectomy arteries. Inseverelycalcifiedvessels, atherectomycanalsobeusedto “prepare” thevesselpriorto stenting Atherectomy isaprocedureperformedtoremoveor “debulk” theatheroscleroticplaquefromdiseased at sixto24months. for femoral-popliteallesions, withhighproceduralsuccessrates, restenosisrates canbeashigh10-40% ation. Although theuseoflastgenerationself-expandingnitinolstentsmaybeaneffectivetreatment tion, recoil, anddisruptionoftheinternallamina, resultinginneo-intimaandsmoothmusclecellprolifer vascular strategies. Limitationsandcomplications of traditional and drug-eluting angioplasty are dissec the presenceofseverevascular calcificationpresentsasignificantproceduralchallengetocurrentendo Today, femoral-popliteal lesions are commonly treated endovascular with good clinical results. However,

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY DENOVO SFA LESIONS:MATERIAL, RESULTS, UNCERTAINTIES Thomas Hölzenbein, Ara Ugrurluoglu, Manuela Aspalter, Fatema Akhavan, Patrick Nierlich Infra inguinalveingraftstenosis: DEBorstents? What about balloonsin2017?Restenosis PMU Salzburg, Salzburg, Austria Salzburg, Salzburg, PMU well inclinicalandhemodynamicimprovementprimaryassistedpatencyrates. Paclitaxel andplainballoonangioplastyofsignificant infrainguinalveinbypassstenosesperformedequally CONCLUSIONS amputations (p:0.36)andeight were 88% related toassistedprimarypatency. Immediatehemodynamicandsustainedclinicalimprovementrates bypass stenosispergraft (Cox F, p:0.047) and redobypassprocedure (Cox F, p:0.0001)were significantly in-graft stenosis(CoxF, p:0.047), bypassfailure <6monthsaftersurgery(CoxF, p:0.013), morethanone 8 Repeat targetlesionrevascularization rateswere22%and14%(p: 0.17). At thelastfollowuptherewere were 88% Primary patencyrateswere88% up was 2.9 years in group A patients and 2.2 years in group B patients. No patient was lost to floow up. bypass characteristics(belowknee, p:0.82). Technical successratewas 100% forbothgroupsMeanfollow betes (p:0.6), coronaryarterydisease(p:1.0), smoking(p:1.0), preoperativeankle-brachialindes(p:0.8)or regard tomeanage(71.9yearsinbothgroups, p:0.99, hypertension(p:1.0), hyperlipidemia(p:0.5), dia (Group A, n=41) or by paclitaxel coated PTA (group B, n = 42). The groups did not differ significantly with From April 2008toNovember2014, 83infrainguinalveinbypassesweretreatedfor graftstenosisbyplain RESULTS standards wereapplied. and hemodynamicimprovement, limbsalvage andsurvival. Societyof Vascular Surgery(SVS)reporting pass PTA: Primary endpoints were primary and assisted primary patency. Secondary endpints were clinical A singlecenterretrospectiveanalysiswas conductedofconsectutivepatientstreatedbyinfrainguinal METHODS percutaneous transluminalangioplasty(PTA) inthetreatmentofinfrainguinalveinbypassstenosis. The aimofourstudyistocomparetheclinicalandhemodynamicoutcomesplain INTRODUCTION vs vs 7 bypassocclusions(p:0.74)forgroup A andBpatients, respectively. Inunivariate analysis, proximal vs vs vs vs 86% and70% 90% and77% vs vs vs vs 73% forgroup A andBpatinetsrespectively. There werethree 84% (p:0.76)forgroup A andBpatinetsatonetwoyearsrespectively. vs vs vs seven deaths(p:0.78)ingroup A andBpatientsrespectively. 87%and73% 62 vs 75%(p:0.19), andassistedprimarypatencyrates

vs paclitaxelcoated vs vs one major - -

patients undergoingplainballoon(Group A) orpaclitaxelcoatedballoon(GroupB)angioplastyofinfrainguinal veinbypassstenosis Primary assistedlatencyofgroup A plain balloon(Group A) orpaclitaxelcoatedballoon(GroupB)angioplasty ofinfrainguinal veinbypassstenosis Primary patencyofgroup A FIGURES vs vs group BpatientsKaplan-Meierestimationofthecumulativeprimarypatencyinundergoing vs groupBpatientsaplan-Meierestimationofthecumulativeprimary assistedpatencyin 63

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY Pratesi Carlo DENOVO SFA LESIONS:MATERIAL, RESULTS, UNCERTAINTIES Does heparin-bondedePTFEgraftimproveBTKbypasspatency? Infra inguinalsurgical repair Vascular Surgery, University of Florence, Florence, Italy Florence, Florence, of University Surgery, Vascular necessary. those obtainedwithautologoussaphenousvein in Literature. A prospective validation of such a score is thus suggestingaprimaryroleforHb-ePTFEinsuch patients, whohad5-yearresultswellcomparable with with excellent results. A category of low-risk patients with CLI treated with the indexed graft does exist, The useofHb-ePTFEbypassgraftsinpatientswithCLIwas associatedinthislargemulticentreexperience CONCLUSIONS from 5to11, 25.2%, p<0.001incomparisonwitheitherlow-risksubgroupormedium-risksubgroup). (scores 3and4, 49.2%, p<0.001incomparisonwithlow-risksubgroup)andhighrisksubgroup(scores significant differencesat5years: low-risk subgroup(scoresfrom0to2, 67.7%), medium-risksubgroup ranged from0to11; Kaplan-Meieranalysis for AFS ineachscoregroupidentifiedthreesubgroupswith ease, end-stagerenaldisease, tissuelossandpoorrun-offscorewerepredictorsof AFS. The integerscore estimated 5-year AFS ratewas 48.3%(SE0.024). At multivariate analysis, olderage, coronaryarterydis graft explantationoccurredin13cases(1.9%). Limbsalvage rateat5 yearswas 75.5%(SE0.021), while primary andsecondarypatencywere42.7%(SE0.025)54.1%0.026). Graftinfectionleading to low-up at all. Estimated 5-year survival rate was 62.7% (SE 0.025); the corresponding figures in terms of Median durationoffollow-upwas 25months(range1-156); only6patients (1%)hadnoavailable fol RESULTS formed andsubgroupsofriskwerestratifiedonthebasisprimaryendpoint. value. A qualitativeassessmentofthe Kaplan-Meier survival estimates for each integer score was per of each significant predictor atmultivariable analysis by 0.25and by rounding offto thenearest integer predictors of AFS at5years, andthenapredictiveriskscorewas constructedbydividingthe variate andmultivariable analyses with Kaplan Meierestimateswereusedtoidentifypotential significant were analyzedintermsofsurvival, primaryandsecondarypatencyamputationfreesurvival (AFS): uni tions wereretrospectivelycollectedinamulticenterregistrywithdedicateddatabase. Follow-up results below-knee revascularization forCLIinsevenItalianvascular hospitals. Dataconcerningtheseinterven Over a13-yearperiod, endinginMarch2015, aHb-ePTFEgraftwas implantedin683patientsundergoing METHODS the existenceofsubgroupspatientswithasignificantclinicalbenefitderivingfromitsuse. bypass graft(Hb-ePTFE)inpatientswithcriticallimbischemia(CLI)amulticentreregistryandtoassess To retrospectivelyevaluate longtermresultsofheparin-bondedexpandedpolytetrafluorethilene (ePTFE) AIM OFTHESTUDY

64 β -coefficient - - - - -

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Saturday January 21 - Venous session - CONTROVERSIES & UPDATES IN VARICOSE DISEASE IN VARICOSE & UPDATES CONTROVERSIES

DEEP VEIN DEEP VEIN History of deep vein reconstruction in CVD Cause of failure and complications of pelvic congestion embolization and how to Bo Eklöf avoid them Lund University, Sweden, Helsingborg, Sweden Francine Thouveny CHU Angers, Angers, France DEEP VENOUS REFLUX Modern history of deep venous reconstruction started with Bob Kistner’s pioneering work in Hawaii 1968 Efficacy of embolization for pelvic congestion syndrome has been demonstrated by several large series with with internal valvuloplasty in a patient with primary axial deep venous reflux. However, he was standing an excellent safety and a remarkably low rate of complications. As rare as they are, these complications on the shoulders of the Swedish pioneer Gunnar Bauer who 20 years earlier in 1948 using descending must be known and considered to be impaired, and the most frequent at least have to be exposed to venography had described idiopathic (primary) deep venous reflux which he treated by popliteal vein the patient as part of a strong relationship of trust. Per and post procedure pain is the most classic resection in more than 500 patients suffering from pain, swelling and ulceration. Bauer’s destructive with glue and foam, easily supported by medical treatment, and should be part of the initial information resection of the popliteal vein was now replaced by Kistner’s reconstructive repair of a floppy valve. of the patient. Migrations, classically described in the literature with coils must be discussed. They Modifications of Kistner’s repair was described by Raju, Sottiurai and Tripathy. Kistner also described decrease with the operator’s experience and a particular caution in short and large iliac tributaries. Gentle external valve repair. In secondary PT deep venous reflux he created transposition of the incompetent manipulation and soft catheters should avoid venous damage which is mainly cause of technical failure deep vein into a valve bearing segment, and Taheri axillary vein transplant into the popliteal vein in 1982. and recurrence. Recurrence can be treated by repeated embolization but differential diagnoses must then The European experience with deep venous valve repair started with Ingvar Eriksson in Uppsala, Sweden be considered with a particular attention. Numerous and various unexpected complications may occur in 1978 and Michel Perrin in Lyon, France in 1981. The creation of a neovalve in secondary PT venous reflux that are more often difficult to predict and described in isolated and inconstant formal reports. They are started with Pagnol in France 1999 and Maleti in Italy 2002. most often retrospectively explained by the complex functional anatomy, the multiple unseen connections of the involved venous systems and their structures in contact, especially urinary and nervous. A strong ACUTE THROMBOTIC DEEP VENOUS OBSTRUCTION knowledge of venous physiopathology and hemodynamics, with expertise of the different embolic agents The first venous thrombectomy for iliofemoral DVT was performed by Läwen in Germany 1937. This created used should avoid a large part of complications. But although rare, complications should be used as return a wave of enthusiasm around the world. In the US Mahorner together with many surgeons presented of experience to be reminded as well as their circumstances of occurrence. excellent early results, but poor late results led to abandonment. In Europe good results were presented from France (Leriche, Fontaine, Kiely), UK (Mavor and Galloway), Germany (Vollmar, Loeprecht), Austria (Denck). In Sweden we adopted the pioneering work of Kunlin and Loeprecht combining thrombectomy REFERENCES with a temporary AVF showing significant improvement of results in a RCT. Now the endovenous procedures Daniels et col. Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review. J Vasc Interv Radiol 2016;27:1478–1486 are taking over. Mahmoud et col. Efficacy of endovascular treatment for pelvic congestion syndrome. J Vasc Surg: Venous and Lym Dis 2016;4:355- 70 CHRONIC DEEP VENOUS OBSTRUCTION Champaneria et col. Embolisation or sclerotherapy of pelvic veins for reducing pelvic chronic pain. Health Technology Assessment; This can be due to PT disease or nonthrombotic iliac vein obstruction (May-Thurner or Cockett’s syndrome) vol 20, Issue 5, Jan 2016 where the main symptom is venous claudication and/or venous ulceration. A number of surgical procedures O’Brien et col. Diagnosis and treatment of the pelvic congestion syndrome. J Vasc Surg: Venous and Lym Dis 2015;3:96-106. Lopez AJ. Female Pelvic Vein Embolization: Indications, Techniques, and Outcomes. Cardiovasc Intervent Radiol 2015;38:806–820 have been recommended. The first femoro-femoral cross-over bypass was described by Palma in 1958. The Kuttinen et col. Pelvic Venous Insufficiency: Imaging, Diagnosis, Treatment Approaches, and therapeutic Issues. AJR 2015; 204:448– method of choice today is percutaneous endovenous angioplasty and stenting as described by Neglén and 458 Raju. Venbrux et col. Pelvic Varices Embolization. Women’s Health in Interventional Radiology – Springer 2012 Greiner M. Varices pelviennes symptomatiques : diagnostic et traitement. Pelv Perineol 2007;2: 27–32 Nicholson et col. Pelvic Congestion Syndrome, Who Should We Treat and How? Tech Vasc Interventional Rad 2006; 9:19-23

Kim et col. Embolotherapy for Pelvic Congestion Syndrome: Long-term Results. J Vasc Interv Radiol 2006; 17:289–297 21 January Saturday CONTROVERSIES & UPDATES IN VARICOSE DISEASE IN VARICOSE & UPDATES CONTROVERSIES

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DEEP VEIN VULVAR varicose veins and MISCELLANEOUS Aggressive endovascular management of ilio-femoral DVT is the “Key” in Vulvar varicose veins after pregnancy: Do we have to ligate the leak points? preventing post thrombotic syndrome Claude Franceschi1, Roberto Delfrate2, Massimo Bricchi2 Ali Amin 1. Centre Marie Therese Hopital Saint Joseph, Paris, France Reading Health System, Reading, United States 2. Clinica Filglie di San Camillo, Cremona, Italy

Acute deep vein thrombosis (DVT) affects more than 250,000 patients per year. Although up to 50% of OBJECTIVE the patients are asymptomatic, all are at risk for pulmonary embolism (PE). Symptomatic PE is the most The objective of this study was to assess the efficacy of the pelvic leaks surgical disconnection in woman. important acute complication of DVT, with more than 600,000 cases per year in the USA responsible for 200,000 deaths. Despite the percentage of asymptomatic patients, the sequelae of DVT can be devastat- CONTEXT ing and lifestyle limiting. DVT and post-thrombotic syndrome can produce pain, edema, leg discomfort, Pelvic leak points (PLP) may be responsible for vulvar, perineal and lower limbs varicose veins especially varicosities, skin hyperpigmentation, venous stasis ulcer and venous gangrene resulting in amputation. in women during and/or after pregnancy. The accurate anatomical and hemodynamic assessment of these Historically, treatment options have included preventing propagation of thrombus with anticoagulation, points, perineal (PP), inguinal (IP), clitoridian point (C P) and their surgical treatment under local anesthet- inferior vena cava filters (IVC) filters, surgical thrombectomy, systemic and catheter-directed thrombolysis ics as defined by Claude Franceschi (REF: 3 articles + Livre) is a new therapeutic option. and more recently mechanical thrombectomy and thrombolysis techniques. Recently, more aggressive minimally invasive techniques involving lysis and device combination treatment regimens to address large METHODS volume DVT (caval, iliofemoral, and femoral-popliteal) have been developed. Such “combination therapy” In this open-label trial 273 pelvic leak points free of pelvic congestion syndrome were assessed and have included use of AngioJect Rheolytic thrombectomy catheter, Trellis Isolated thromboslysis catheter marked with ultrasound and selected when refluxing at Valsalva + Paranà + squeezing maneuvers, then and EKOS. AngioJet RT system consisits of three components: a single use catheter, single use pump set, disconnected with mini-invasive surgery under local anesthesia in a single center. Surgery consisted of and a pump drive unit. 6 Fr. Xpeedior catheter has a working length of 120 cm which is introduced via a 6 selective division and non absorbable suture of the refluxing veins and fascias at the PP,IP and CP pelvic Fr. Sheath percutaneously over a .035 wire. The high velocity jets create a localized low pressure zone (Ber- escape point. noulli effect) for thrombus aspiration and maceration. The jets also provide the driving force for evacuation of thrombus particulate debris through the catheter. Activase (TPA) is a tissue plasminogen activator. It RESULTS has the property of fibrin enhanced conversion of plasminogen to plasmin. It binds to fibrin in a thrombus Ablation procedures: 273 PLP: PP (n= 170), IP (n = 100) and CP ( n=3). Follow up: Period =12 to 90 months and converts the entrapped plasminogen to plasmin. This initiates local fibrinolysis with limited systemic (Mean = 30.12 months). Controlled PLP (n= 273) No Pelvic leak reflux redo (n = 270) Pelvic leak reflux proteolysis. A prospective multicenter registry, the National Venous Thrombolysis Registry, was established redo (n= 3 ) where PP = 2 IP =1 in order to collect and analyze data for a large number of patients with lower extremity DVT treated with Catheter directed thrombolysis (CDT). Venous registry demonstrated that CDT was less effective in patient CONCLUSIONS with chronic DVT. Acute cases of DVT (<10 days) achieved complete lysisi almost twice as often as patients This study suggests that pelvic varicose embolization prior PLP reflux ablation is not necessary and indicat- with chronic DVT (>10days). It is also proposed that CDT is a better option for long term management of ed only in case of uncontrolled PLP reflux or when combined with pelvic congestion syndrome. DVT, since systemic anticoagulation, the current standard of care, neither promotes lysis nor the restora- The accurate ultrasound assessment of each specific pelvic leak as well as a peculiar surgical technique tion of valve function necessary for the prevention of PTS. The combination of using both pharmacological (vein division, non absorbable suture of veins and fascias) seems to be the key for satisfactory outcomes. and mechanical thrombolysis/thrombectomy is even more powerful. It decreases the dose and infusion time of thrombolytic drugs, with fewer bleeding complications and comparable procedure success to CDT alone. This combination, improves outcomes since it initially reduces the thrombus burden and it exposes a greater area of thrombus surface to the lytic agent. Saturday January 21 January Saturday

REFERENCES Garcia M, Lookstein R, Malhotra R, Amin A, Bilitz L, Leung D, Simoni E, Soukas P. Endovascular Management of Deep Vein Throm- bosis with Rheolytic Thrombectomy: Final Report of the Prospective Multicenter PEARL (Peripheral Use of AngioJet Rheolytic Thrombectomy with a Variety of Catheter Lengths) Registry. Journal of Vascular and Interventional Radiology (JVIR). Vol 26, issue 6. June 2015 Next Article: June 2015Volume 26, Issue 6, Pages 777–785 CONTROVERSIES & UPDATES IN VARICOSE DISEASE IN VARICOSE & UPDATES CONTROVERSIES

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VULVAR VARICOSE VEINS AND MISCELLANEOUS VULVAR VARICOSE VEINS AND MISCELLANEOUS Vulvar varicose veins after pregnancy: Do we have to embolize the leak points? Small Saphenous Vein (SSV) treatment: tips and tricks Milka Greiner Jean-Luc Gérard MD, Paris, France Paris, France

Valvular varices involve 4% of the women population. Varices are located on the labia majora and/or Incompetence of the great saphenous vein (GSV) is the most frequent cause of varicose vein disease. SSV minora and are usually noted after second pregnancy. Most often asymptomatic, they can be debilitating incompetence is identified in 20 % of patients presenting varicose veins. Because the ending of the SSV is especially when they are cause of pruritus and dyspareunia. They are isolated or associated with perineal variable as well as the proximity to the arteries and nerves, its treatment makes it more challenging than varices, lower limbs varices and may occur as part of pelvic congestion syndrome (PCS). for the GSV. In our practice the decision-making process is based on patient medical history and clinical symptoms. Two identities are to be separated: 1.small vulvar varices without PCS which need first line sclerothrapy, During sclerotherapy treatment (liquid or foam), vascular physicians are afraid of mistakenly injecting the 2.large vulvar varices (with or without PCS) which require complementary tests, at pelvic and abdominal artery companion to the SSV. By duplex it is easy to locate the exact position of the arteries. Even if ultra- level, such as venous echo-doppler before adequate treatment. sound guidance foam sclerotherapy (USGS) is safer, it may remain, fortunately a rare occurrence, a source of major events and litigation claims. Carefully locating the arteries and therefore delimitating a safety zone by pastel pencil would prevent this complication from arising. Thermal ablation: endovenous laser ablation (EVLA) or radiofrequency ablation (RFA) are described as minimally invasive techniques, but mainly for the GSV, and less frequently for the SSV. Guidelines recommend a mapping prior to any type of saphenous treatment; this is of course particularly true for the SSV. In addition, due to the improvement of the Duplex scan technology, it is also possible now to identify nerves (tibial, fibular and sural nerves) and do the mapping of the nerves. Therefore, during the tumescent anesthesia and under ultrasound guidance, the position of the nerves, which are previously identified, de- terminates a safe puncturing area with the needle, at a certain distance from them. Tumescent anesthesia would also permit isolating the nerves by pushing them away from the SSV. Saturday January 21 January Saturday CONTROVERSIES & UPDATES IN VARICOSE DISEASE IN VARICOSE & UPDATES CONTROVERSIES

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VULVAR varicose veins and MISCELLANEOUS VULVAR varicose veins and MISCELLANEOUS Endo Laser Ablation Foam (ELAF) Treatment of telangiectasies by microsurgery Carlos Bone Albert-Adrien Ramelet Palma de Mallorca, Spain Dpt Dermatology, Inselspital, Bern, Switzerland

With the aim of improving the treatment of truncal (main) varicose veins in a completely ambulatory Telangiectasias of the legs may be isolated. However, most of them are consecutive to an underlying manner without using local anesthesia, we have initiated a synergistic physicochemical procedure, venous reflux, which should be eliminated to obtain satisfying and long lasting results. This reflux may be involving the effect of an soft sclerosing foam, the energy transmitted and released by the laser to the easily detected at the clinical examination or with echography, if it is caused by a saphenous, a tributary, venous endothelium, thereby obtaining with this association the endothelium ablation with a frankly a large non saphenous vein insufficiency or the incompetence of a major perforator. In many patients, outstanding result. especially in therapy resistent telangiectasias, reflux may be difficult to establish. Side illumination is a The use of this synergistic technique has allowed us to reduce both the concentration of the sclerosing valuable help to detect feeding reticular veins, which should be treated by sclerotherapy, or phlebectomy. agent and the fluence delivered by the laser, avoiding the use of anesthesia, so that we have transformed Phlebectomy is also indicated to remove tiny underlying perforators. Subcutaneous curettage of large blue it on a purely outpatient procedure that can be done in the medical office, without strict operating room. telangiectasias with the harpoon of a sharp hook is quite effective in destroying large clusters of blue veins, and may be associated to sclerotherapy in tumescent anaesthesia (START Technique) to destroy therapy refractory telangiectasias. Complications are rare and excellent cosmetic and functional results may be achieved in one or 2 sessions.

REFERENCES 1. Ramelet A-A. Phlébologie esthétique. Télangiectasies : possibilités thérapeutiques. Cosmétologie et Dermatologie esthétique. 50- 470-C-10, 2010. Paris: EMC (Elsevier Masson SAS, Paris); 2010. 2. Ramelet AA. Ambulatory Phlebectomy. In: Alam M, Silapunt S, editors. Treatment of leg veins, 2nd ed. 2nd edition. Philadelphia: Elsevier; 2010. 3. Ramelet AA. Sclerotherapy in Tumescent Anesthesia of Reticular Veins and Telangiectasias. Dermatol Surg 2012;38(5):748-51. 4. Ramelet AA. La technique START (Sclerotherapy in Tumescent Anaesthesia of Reticular Veins and Telangiectasias). Phlébologie. 2012;65(2):13-7. Saturday January 21 January Saturday CONTROVERSIES & UPDATES IN VARICOSE DISEASE IN VARICOSE & UPDATES CONTROVERSIES

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VEIN and THROMBOSIS VEIN and THROMBOSIS Venous symptoms: the SYM vein consensus Are there differences in guidelines for management of CVD between Europe and Michel Perrin1, Bo G. Eklof2 for the SYM Vein group the US? 1. Vascular Surgery, Lyon, France Bo Eklöf 2. Vascular Surgery, Helsingborg, Sweden Lund University, Sweden, Helsingborg, Sweden

INTRODUCTION In 2011 SVS/AVF published The care of patients with varicose veins and associated chronic venous dis- Venous symptoms remain a challenge to deal with for multiple reasons. First, few books or articles in the eases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum in literature dedicated to chronic venous disorders give a precise description and definition of the so-called JVS. 1 14 guidelines based on 375 references were recommended or suggested using the GRADE system. “venous symptoms”. In addition, there is frequent confusion between signs and symptoms in the litera- In 2012 Lugli, Maleti and Perrin published a thorough review of these recommendations in Phlebolym- ture. The fact that venous symptoms are non-pathognomonic adds to the difficulty, because linking these phology ’bearing in mind that as Europeans we may have some divergence in opinion with our American symptoms with their etiology and their cause is still debated. The severity of the signs and the results of colleagues’. 2 In 2013 the British guidelines were presented – NICE guidelines on varicose veins: diagnosis investigations do not always correlate with the intensity of the symptoms. Lastly, the pathophysiology of and management, a comprehensive document including 250 pages. 3 In 2014 EVF/UIP published Manage- venous symptoms has not been clearly established, in particular in C0s patients? ment of CVD in the lower limbs – guidelines according to scientific evidence based on 1,097 references. 4 Precise physiopathologic knowledge should lead to more targeted and specific treatment In 2015 ESVS published Management of chronic venous disease – clinical practice guidelines of the ESVS with 66 recommendations based on 588 references. 5 There was a general agreement between the guide- AIM OF THE CONSENSUS lines on both sides of the Atlantic. A comparison will be presented. To create a document on venous symptoms in order to: - Describe venous symptoms: - Specify which components enable symptoms to be attributed to a venous cause REFERENCES - Determine their pathophysiology 1. Gloviczki P, Comerota AJ, Dalsing MC, Eklöf B, Gillespie DL et al. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg - Establish a score dedicated to the symptoms 2011; 53: suppl S. - Determine which clinical examination and investigations are useful for identifying the venous cause of 2. Lugli M, Maleti O, Perrin M. Review and comment of the 2011 Clinical practice guidelines of the Society for Vascular Surgery and symptoms the American Venous Forum. Phlebolymphology 2012; 19: 107-120. 3. Davies A, Azzam M, Bradbury A, Brookes J, Calam J, et al. NICE guidelines on Varicose veins: diagnosis and management. CG METHODS 168, July 2013. Nice.org.uk. 4. Nicolaides A, Kakkos S, Eklöf B, Perrin M, Nelzén O, et al. Management of chronic venous disorders of the lower limb. Guidelines To produce this consensus statement, an international group of 22 members from 14 countries was formed, according to scientific evidence. Inter Angio 2014; 33: 87-208. including vascular specialists (medical and surgical), dermatologists, a neurologist and a healthcare econ- 5. Wittens C, Davies AH, Baekgaard N, Broholm R, Cavezzi A, et al. Management of chronic venous disease. Clinical practice guide- omist. The first meeting was held in Paris in June 2014 during the XVth European Venous Forum meeting. lines of the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg 2015; 49: 678 – 737. The 23 participants were divided into 5 groups, one for each of the objectives described previously in the consensus objective. This second plenary meeting was held in St. Petersburg during the XVth EVF meeting in July 2015.Each manuscript was read during the plenary meeting and discussed during two 4-hour sessions. Then the corrected documents have been in circulation within each group until reaching a consensus

RESULTS The Sym Vein consensus article has been published: Perrin M, Eklöf B, van Rij A, Labropoulos N, Michael Vasquez M, Nicolaides A et al. Venous symptoms: the SYM Vein Consensus statement. International Angi- 21 January Saturday ology 2016;35(4):374-98. Symptoms listed in the article: Primary symptoms: Pain or aching, Venous claudication, Throbbing, Tightness, Heaviness, Fatigue, Feeling of swelling, Cramps, Itching, Restless legs,Tin- gling, Heat or burning sensation Secondary symptoms: disquiet, insomnia, ill-being, etc.

CONCLUSION SYM VEIN had make possible to: - establish a consensus statement specifically dedicated to symptoms - determine whether the presence of symptoms in the absence of signs is compatible with the diagnosis CONTROVERSIES & UPDATES IN VARICOSE DISEASE IN VARICOSE & UPDATES CONTROVERSIES of primary chronic venous disorders, and/or is predictive of the disease evolution - stimulate the development of new investigations allowing the identification of anomalies in C0s patients - measure the benefit of treatments in terms of symptoms relief after treatment

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VEIN and THROMBOSIS VEIN and THROMBOSIS RCT on GCS/LMWH vs LMWH in VTE prophylaxis Risks of Dvt and flying Joseph Shalhoub1, Alun H Davies1, GAPS Trial Investigators2 Sarah Onida, Alun H Davies 1. Imperial College London, London, United Kingdom Imperial College London, London, United Kingdom 2. GAPS Trial Investigators, United Kingdom Globalisation and internationalisation, combined with affordable air travel, has resulted in a steady, year BACKGROUND on year increase in the number of flights worldwide. Air travel has characteristically been considered a risk The evidence base upon which current global venous thromboembolism (VTE) prevention recommen- factor for the development of venous thromboembolic disease (VTE), including deep venous thrombosis dations have been made is not optimal. The cost of purchasing and applying Graduated Compression (DVT), particularly in the context of what is known as the “economy class syndrome”. The increased VTE Stockings (GCS) in surgical patients is considerable and has been estimated at £63.1 million each year in risk has been attributed to factors such as immobility, cramped positioning, dehydration and hypobaric England alone. hypoxia, leading clinicians to advise against air travel in the postoperative period and airline providers to provide advice to minimise this risk. Interestingly, many of these suggestions are not evidence based; OBJECTIVE in this talk, the risks of VTE and flying will be discussed; specifically, the risks relating to the immediate To determine whether low dose low molecular weight heparin (LMWH) alone is non-inferior to a combi- postoperative period following superficial venous intervention will be reviewed. nation of GCS and low dose LMWH for the prevention of VTE.

METHODS A randomised controlled Graduated compression as an Adjunct to Pharmacoprophylaxis in Surgery (GAPS) Trial [ISRCTN 13911492] will randomise adult elective surgical patients identified as being at moderate and high risk for VTE to receive either the current ‘standard’ combined thromboprophylactic LMWH with GCS mechanical thromboprophylaxis, or thromboprophylactic LMWH pharmacoprophylaxis alone. To show non-inferiority (3.5% non-inferiority margin) for the primary endpoint of all VTE within 90 days, 2236 patients are required. Recruitment will be from seven UK centres. Secondary outcomes include quality of life, compliance with stockings and LMWH, overall mortality, and GCS or LMWH-related complications.

Recruitment commenced in April 2016 with the seven UK centres coming ‘on-line’ in a staggered fash- ion. Recruitment will be over a total of 18 months with more than 300 participants randomised to date. The GAPS trial is funded by the UK National Institute for Health Research Health Technology Assessment [14/140/61]. Saturday January 21 January Saturday CONTROVERSIES & UPDATES IN VARICOSE DISEASE IN VARICOSE & UPDATES CONTROVERSIES

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THERMAL or GLUE TECHNIQUES THERMAL or GLUE TECHNIQUES 15 year follow-up of radiofrequency ablation of the great saphenous vein and what Is there a role for open venous surgery assuming thermal and non-thermal are the causes of recurrence in the long term – a single centre experience procedures are covered? Mark Whiteley1, Irenie Shiangoli1, Scott Dos Santos2, Tim Fernandez-Hart1, Judith Holdstock1 Patrizia Pavei 1. The Whiteley Clinic, Guildford, United Kingdom Azienda Ospedaliera di Padova, Padova, Italy 2. University of Surrey, Guildford, United Kingdom The traditional surgical technique is associated with about 20-30% of recurrence rate. The causes of re- BACKGROUND currences are technical or tactical in approximately 29% of the cases, while neovascularization is respon- Radiofrequency ablation for the treatment of varicose veins was introduced in the late 1990s in the form sible for another 29%. Moreover, more than 50% of recurrent varicose veins originates from the saphen- of the bipolar VNUS Closure® device, and rapidly gained favour with vascular surgeons worldwide. Howev- ous-femoral junction. To reduce the incidence of recurrences the following points seems to be important: er, no long-term data regarding the success of this treatment exists in the literature. We report the results 1. An accurate initial diagnosis in order to reduce tactical recurrences; 2. Varicose veins surgery should of the original VNUS Closure® device for the abolition of venous reflux at 15 years. be performed by trained surgeon; 3. Stripping of the Great Saphenous Vein (GSV) should be performed with invagination; 4. Closure of the fossa ovalis; 5. Suture of the Sapheno-femoral Junction exposed en- METHODS dothelium with a non absorbable suture. The complications of Varicose veins surgery include: Deep Vein We invited 189 patients originally treated using VNUS Closure® from March 1999 to December 2001 to Thrombosis (DVT), damage of the saphenous or sural nerve, infections, haematomas, haemorrage and return to our unit for duplex ultrasonography (DUS) performed by a sonographer blinded to the initial very rarely vascular lesions. The incidence of DVT in this kind of surgery is reported at a rate of about 1% treatment. Initial and 15 year scans were compared. Treatment outcome of the target vein was graded as and there is evidence from some studies that prophylaxis does not necessarily protect from DVT, therefore follows: 1- complete success (complete atrophy with no reopening); 2- partial success (at least one patent the systematic use of low molecular heparin is not indicated. Immediate deambulation after surgery and section not giving rise to recurrent varicose veins); 3- partial failure (one or more patent sections giving the use of elastic stockings are the first mean of prevention to be used. To prevent neurological damage rise to recurrent varicose veins); 4- complete failure (complete re-opening of treated vein). we can: 1. Perform a tailored stripping, avoiding long stripping when not indicated; 2. If necessary use an invaginating technique; 3. Use a very delicate dissection at the malleolus to avoid direct damage of the RESULTS nerve. Using a very delicate dissection at the sapheno-femoral or sapheno-popliteal junction the incidence Fifty-eight patients (91 legs, 101 truncal veins) returned for follow-up DUS, giving a 31.5% response rate of infections and lymphatic damage is very low. Varicose vein surgery should be performed on an ambu- (low due to the fact that many patients treated 15 years ago had either moved away or were deceased). latory basis with local or tumescent local anaesthesia, entailing a much more delicate surgical act and a DUS showed that a mean of 15.4 years post-procedure, 89% of patients achieved success with no clinical lower incidence of complications. recurrence in the originally treated veins. At follow-up, 52/91 legs (57.1%) demonstrated an improved CEAP score. De novo reflux was identified in 47/91 legs (51.6%) showing disease progression in veins that were originally competent. REFERENCES 1. Van Rji AM,Jones GT, Hill GB, Hons BSc, Jiang P. Neovascularization and the recurrent varicose veins: more histologic and ultrasound evidence. J Vasc Surg 2004; 40:296-302 CONCLUSIONS 2. Rudstrom H. Iatrogenic vascular injuries in varicose vein surgery: a systematic review World J Surg,2007 Jan;31(1):228-33 Ablation of truncal veins by Radiofrequency is capable of achieving excellent long-term technical success, as demonstrated by DUS. Saturday January 21 January Saturday CONTROVERSIES & UPDATES IN VARICOSE DISEASE IN VARICOSE & UPDATES CONTROVERSIES

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THERMAL or GLUE TECHNIQUES THERMAL or GLUE TECHNIQUES Arteriovenous fistula after thermal ablation: etiology and how to avoid it Complications and weird findings with local anesthaesia in varicose vein surgery Lowell Kabnick Inga Vanhandenhove New York University Langone Medical School, New York, USA AZ Monica, Antwerp, Belgium

Endovenous thermal ablation, laser or Radiofreqauency, is the mainstay of therapy for symptomatic vari- The surge of endovenous techniques in the last decade has made the use of general anaesthesia for ve- cose veins with saphenous venous insufficiency. Both procedures are efficacious with a high safety profile. nous interventions obsolete. While a lot of surgeons continue to operate under general or spinal anaesthe- Two new complications recognized unique to endothermal ablation are endothermal heat induced throm- sia, we know that local anaesthesia and tumescence are effective, comfortable for the patient and easily bosis and arteriovenous fistula (AVF). The presentation will limit the discussion to AVF. In a systematic performed by the surgeon. They are considered safer then general anaesthesia, but still may induce local review, there are more AVFs related to endolaser ablation than RFA. There are potentially serious sequelae or systemic adverse reactions. It is important that surgeons are able to recognise and adequately treat of post-ablation AVFs, including severe limb edema, high-output cardiac failure, steal syndrome with clau- these potential complications. dication, and distal ischemia. Most patients are asymptomatic, do not require further diagnostic imaging. The natural history of postoperative AVFs remains to be clarified; however, it seems that spontaneous closure is common. On the basis of our experience and review of the literature, in the absence of severe symptoms, we would recommend expectant management with clinical and DUS surveillance. Ways to avoid AVFs is to know anatomy, how to administer proper tumescent anesthesia, and non-ablative procedures.

REFERENCES Timperman PE. Arteriovenous fistula after endovenous laser treatment of the short saphenous vein. JVasc Interv Radiol 2004;15:625-67. Theivacumar NS, Gough MJ. Arterio-venous fistula following endovenous laser ablation for varicose veins. Eur J Vasc Endovasc Surg 2009;38:234-6. Vaz C, Matos A, Oliverira J, Nogueira C, Almeida R, Mendonc M. Iatrogenic arteriovenous fistula following endovenous laser therapy of the short saphenous vein. Ann Vasc Surg 2009;23:412. Saturday January 21 January Saturday CONTROVERSIES & UPDATES IN VARICOSE DISEASE IN VARICOSE & UPDATES CONTROVERSIES

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THERMAL or GLUE TECHNIQUES Treatment of varicose veins using steam pulses Ionel Droc1, R. Milleret 1. Bucarest, Romania

Steam is the latest of the thermal endovenous techniques to enter clinical use. It was introduced in 2008 as a cheaper but as effective alternative to laser and radio-frequency. The principle is to inject in the vein pulses of water vapors at 120°C, each pulse delivering 60 joules of energy in the lumen. Steam is injected under pressure: the first pulse dislodges the blood, the next ones heat the vein wall. A stainless steel catheter of 5F gauge is used, it is flexible enough to navigate through tortuosities without using a guide wire. Two lateral holes close to the tip eject the steam, avoiding the risk of heating deep veins when heating the junctions. A comparative animal study by S.Thomis and all 1 showed that immediate shrinking was more pronounced with steam than with Closure Fast ®radio frequency catheter and 1470 nm TULIP fiber ® laser. Perivenous damage was less seen, although the number of cases was not sufficient to obtain statistical significance. R.Milleret 2 published the results of a multi center study performed in France. Obliteration rate at 6 months was 96 %. A multicenter study of tributary ablation showed, with less pigmentation and inflammatory reactions than after foam sclerotherapy with 97% closure rate at 6 months. A second generation device allows elective ablation of tributaries and reticular veins (Miravas®) In conclusion, steam ablation is a safe alternative to other thermal techniques, it can be applied to tortuous or superficial veins which could not be treated by laser of radio frequency.

REFERENCES 1. Steam ablation versus radiofrequency and laser ablation: an in vivo histological comparative trial. Thomis S, Verbrugghe P, Milleret R, Verbeken E, Fourneau I, Herijgers P. Eur J Vasc Endovasc Surg. 2013 Sep;46(3):378-82. 2. Great saphenous vein ablation with steam injection: results of a multicentre study. Milleret R, Huot L, Nicolini P, Creton D, Roux AS, Decullier E, Chapuis FR, Camelot G. Eur J Vasc Endovasc Surg. 2013 Apr;45(4):391-6. Saturday January 21 January Saturday CONTROVERSIES & UPDATES IN VARICOSE DISEASE IN VARICOSE & UPDATES CONTROVERSIES

84 85 CONTROVERSIES & UPDATES IN VASCULAR SURGERY eposters

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aneurysm Vein coveredstentgraftrepairofmycoticaorticaneurysms-acasereportwithten Claire Dawkins, KlausOverbeck, SimonEngland, Andrew Brown year followup Sunderland Royal Hospital, Sunderland, United Kingdom United Sunderland, Hospital, Royal Sunderland rysms. Vein coveredstentsmaybeaeffectiveanddurableendovascular treatmentofsomemycoticaorticaneu CONCLUSION point CTfollowupshowsthevein-graftintactandunchangedwithaneurysmexcluded. discharged onthe9thpost-opdayoralLinezolidandCiprofloxacinfor4weeks. Atthe1, 5and10year neck withon-tableangiogramshowingnoendoleak. Post-op recoverywas unremarkableandthepatient ta insideashuttleballoonviarightfemoralcutdown. The stentgraftwas deployed acrosstheaneurysm stents. The stentgraftwas crimpedonto a20mmangioplastyballoonandintroducedintothepatient’s aor covered stent. The rightSFVwas used toconstructaspiralgraftandsuturedonto2overlappingPalmaz co-morbidities he was deemed unfit for open surgery. Ethics approval was obtained to treat him witha vein peri-aortic inflammation. This increasedinsizedespiteantibiotictherapy. Duetohishostileabdomenand infra-renal pseudo-aneurysm, 2.6cmbelowthelowerleftrenalarterywitha1.8cmdiameterneckand treated byopendrainageandalaparotomywithMRSAgrowingfromcentralline. CTshoweda4cm He hadundergoneasub-totalRoux-en-YR2gastrectomyandanastomoticleakwithabdominalsepsis A 73-year-old male was admitted with a three week history of malaise, rigors, abdominal and back pain. CASE SYNOPSIS provide anendovascular optionforautologousrepair. site remainscontroversialandlifelongantibiotictherapyisrequiredinmostcases. Vein coveredstentsmay endovascular stentgraftshavebeenusedwithmixedresults. Placingprostheticmaterialintoaninfected The mortalityisashigh35%withaincidenceoffurtherinfectivecomplications. Recentlyprosthetic and eitherin-siturepairorligationextra-anatomical bypass usingprosthetic grafts orautologousvein. Conventional treatmentofmycoticaorticaneurysmsinvolvesopensurgicalrepairrequiringalaparotomy INTRODUCTION 88 - -

Elshiekh Ahmed aneurysm Aneurysm ofthemostproximal(medial)branchProfundaFemoris Artery 2. BSc MBChB PhD FRCSI FRCS FRCSI PhD MBChB BSc 2. MRCS MBBCH 1. plications relatedtosurgeryattwoyearsfollowup. Profunda Femoris Artery inan85yearsoldmale. Successfulsurgicalligationwas performedwithnocom case reportwearepresentingaveryrareofaneurysmthemostproximal(medial)branch all femoralarteryaneurysms(1-2.6%), itismorelikely torupturethanotherperipheralaneurysms. Inthis the peripheralaneurysmsand1-2.6%offemoralaneurysms. Although, itisrelativelyuncommonamongst True ProfundaFemoris Artery Aneurysm (PFAA) isaveryrareconditionestimatedtopresentonly0.5%of 1 , NicholasMatharau 2 89 - EPOSTERS

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aneurysm Persistent endoleaktypeIItreatedwithOnyxLES(liquidembolicsystem): A. Lombardo, C. Busoni, D. Frigerio a casereport Vimercate Hospital, Vimercate (Monza e Brianza)- Vascular Surgery Department Surgery Vascular Brianza)- e (Monza Vimercate Hospital, Vimercate also at3monthCTscan. By liquidembolicsystemwegotanoptimalangiograficresult, nomoretypeIIendoleaksimmediatlyand RESULTS the procedurereleasingleftexternaliliacendoprosthesisextensiontostabilizedistalsealing. microcatheter introducedbetweentheendoprosthesisandwall artery atdistalneckpoint. We complete In July2016weperformedembolizationoftheaneurismalsacwith8mlOnyxLESthroughProgreat 68 mmmaximumdiameterinpersistenttypeIIendoleak. undertake astraightfollowuptill, after28month, anotherCTscanshownanenlargement ofthe AAA until After 15month: persistenceofendoleakandalso12mmenlargementsacdiameter. We decidedto a lefthypogastriccoilsembolizationand, secondary, surgicalclipclosureofIMAwithminilaparothomy. After 12month: persistenceoftypeIIendoleakandalso2mmenlargementsacdiameter. Soweperform After 1month: evidenceoftypeIIendoleakonCTscanfromIMAandacouplelumbararteries. aneurysm, inFebruary 2014, withapparentgoodresultimmediatly. and afemoro-femoralbypss, havinga55mminfrarenalaorticaneurysmand33rightcommoniliac A 79hearsoldwomanunderwent EVAR withanaorto-left uniliac device, aplugontherightiliac artery MATERIAL ANDMETHOD type IIendoleak, causingprogressiveenlargementoftheaneurysmalsac, afterotherdevicesfailures. Demostrating as in any case the availability of liquid embolic system is unique way to resolve persistent OBJECTIVE 90

aneurysm Blood lossandanopenapproachincreaselengthofhospitalstayinpatients Marang Makepe, HansrajRiteeshBookun, CassandraHidajat, JitendraJain, Margaret Nguyen undergoing abdominalaorticaneurysmrepair Department Vascular Surgery Unit, Melbourne Health Melbourne Unit, Surgery Vascular Department stay byover20days, addingsignificanthospitalcostsandadditionalburdenonhealthcareresources. blood lossinexcessofthreelitres, and an openapproach. Excessivebloodlosscanresultinaprolonged From thisdata, thetwomostsignificant factorsaffectingdurationofhospitalstayafter AAArepairare CONCLUSION intra-operative bloodlossofmorethanthreelitres(p<0.05). than threelitreshadameandurationofin-hospitalstay9.3days, comparedto35.5daysforestimated to endovascular repair(5.5days)(p<0.05). Patients withanestimatedintra-operativebloodlossofless died whilstinhospital. The averagedurationofstaywas longerforopen AAA repairs(14.9days)compared vascularly. The averagedurationofstayforall AAA repairswas 10.5days–thisexcludedfourpatientswho 27.9 kg/m2. 86ofthepatientshadanopenrepair(28emergencycases)withremaindertreatedendo 80.3% ofpatientsweremalewiththeaverageageatoperation74.5yearsandmeanbodymassindex of RESULTS and 20thSeptember2015. tified fromthe Australasian Vascular Audithavingundergone AAArepairbetweenthe1st January 2010 We retrospectivelyanalysedthedataof AAA repairsataregionalpublichospital. 163patientswereiden METHODS repair.dergoing AAA approach. This studyinvestigatedsurgicalfactorsaffectingthedurationofin-hospitalstayinpatientsun With ongoingfollow-up, theyaremorefrequentlyrepairedelectively, eitherviaanopenorendovascular Abdominal aorticaneurysms(AAA)areoftendetectedincidentallywhilstscreeningforotherpathology. OBJECTIVE 91

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY

aneurysm Totally percutaneousaneurysmsacembolizationduringendovascular aneurysm Luca Ferretto, SandroIrsara Italy repair Vascular and Endovascular Surgery Unit, Center for Vascular Medicine, ULSS 8 Asolo – Treviso, Treviso, – Asolo 8 ULSS Medicine, Vascular for Center Unit, Surgery Endovascular and Vascular 4. 3. 2. 1. REFERENCES their usualEVAR procedure. helpful tophysicianswhowishperformintraoperativesacembolization, withoutrelevant changesin description ofatotallypercutaneousapproach, withasingleaccessoneachfemoralartery: itcould be Nonselective sacembolizationduringEVAR issafeandfeasible.3,4 To ourknowledge, thisisthefirst CONCLUSIONS 3 and1patientsrespectively. 12-months follow-up: persistenttypeIIendoleaks, withnogrowthoftheaneurysmsac, isstillpresentin No complicationswererecorded. Ten patientshavefollow-upat6months, and5patientscompleted of double-componentfibringlue. Upto December2016, thetechniquehasbeenappliedin21patients. some coilsarereleasedthoughthe5Fcatheterintoaneurysmsac, followedbyinjectionof5to10 ml ed forthediagnostic catheter. The contralateral leg is deployed, thestandard guidewire isremoved and calibrated pigtailcathetercut1mmbeyondtheproximalradiopaquemarker (Figure 3)canbesubstitut sac, inaparallelfashionwiththecontralateralleg(Figure 2). To enhancefluoroscopicvisualization, a5-F (Figure 1). Then a5Fstraight65-cmlengthcatheterisadvanced overthestandardwireintoaneurysm a 0.035” hydrophilicstandardguidewireisplacedintotheaneurysmsacthroughsame16Fsheath main bodyisperformed. The contralaterallegcomponentisdeliveredtotheintendedpositionandthen component anda16Fsheathisusedonthecontralateralside. Standardplacementoftheendoprosthesis are placedoneachside. A 16or18FsheathisplacedfordeliveryoftheExcludertrunk-ipsilateralleg Percutaneous access of common femoral arteries is obtained and twosuture-mediated closure systems TECHNIQUE using theExcluderstent-graft. posed adjustmentofthetechniquemakes feasiblethetreatmentwithatotallypercutaneousapproach vention oftype2endoleak-relatedcomplicationsduringendovascular aorticrepair(EVAR).1,4 The pro To describeanoptimizationofapreviouslydescribedintraoperativesacembolizationtechniqueforpre PURPOSE embolization inpatientsatriskfortypeIIendoleak. J Vasc Surg. 2016Jan;63(1):32-8. type IIendoleak-relatedcomplications. J Vasc Surg. 2013 Apr;57(4):934-41. tive procedureinpreventingtypeIIendoleakafterendovascular aneurysmrepair. Interact Cardiovasc Thorac Surg 2010;11:78-82. type IIendoleak. JEndovasc Ther 2010;17: 517-24. Piazza M, SquizzatoF, Zavatta M, Piazza M, Frigatti P, ScrivereP, Pilon F, Tosato F, DanieliD, Ronsivalle S, Faresin F, Franz F, et al et et al et et al et . Intrasac fibringlueinjection afterplatinumcoilsplacement: theefficacyofasimpleintraopera et al et . Roleofaneurysmsacembolizationduringendovascular aneurysmrepairinthepreventionof . Aneurysm sac “thrombization” andstabilizationinEVAR: atechniquetoreducetheriskof . Outcomesofendovascular aneurysmrepairwithcontemporary volume-dependentsac 92 - - - -

Scrivere P. aneurysm Prevention oftype embolization techniqueincaseofabdominalaorticaneurysmtreatment 2. Interventional Radiology, Ospedale Santa Maria Della Misericordia -Udine Misericordia Della Maria Udine - Santa Misericordia Ospedale Della Radiology, Maria Santa Interventional 2. Ospedale Sugery, Vascular 1. midterm follow-upinhighriskpatientsforEII. intraoperative sacembolizationinEVAR procedurestopreventEIIanditscomplications intheshortand Although aprospectiverandomizedstudyisnecessary, EVAS techniquerepresentsavalid alternativetothe CONCLUSION Freedom fromEII-relatedreintervention was higheringroup A thaningroupC(93% In groupBfreedomfromEII-relatedreinterventionwas 100%. Furthermore group A hasanhigherincidenceoftype2endoleakthangroupB(4,6% comparison withgroup A (12% At 22 months follow up (range, 6 months to 4,3 years), group C has a significantly higher rate of EIIin The EIIincidencewas notstastisticallysignificantingroup AthaningroupB(4,6% vs The 30daysangio-CTscanrevealedasignificantlyhigherincidenceofEIIingroupCthan A(14% RESULTS Angio-CT scanfollow-upwas perfomedat1,6,12,24months. after theendograftrelease. evidence thepresenceofbloodflowasanempiricalparametertodetermineendoleak Measurement ofintrasacaneurysmpressurewas performedduringEVAR procedureingroup A andCto patients fortype2endoleak. arteries), sacthrombus and thesacvolume were considered important parameters to define thehighrisk The numberofpatentaorticsidebranches(inferiormesentericartery, lumbararteries, accessory renal standard EVAR (GroupC). ( Group A), 40patients(26%)underwentEVAS technique(GroupB)and50patients(32,5%)underwent Three groups were considered: 64 patients ( 41,5%) underwent EVAR with intraoperative sac embolization dominal aorticaneurysm. Between January 2012andMarch2016, 154patientsunderwentanendovascular treatmentforanab METHODS reduce andpreventtypeIIendoleak(EII). tion inendovascular aneurysmrepair(EVAR) withtheendovascular aneurysmsealingtechnique(EVAS) to The goalofthisretrospectivestudywas tocompareendovascular intraoperativeaneurysmsacemboliza INTRODUCTION 4,6%). 1 ,Silvestri A. II endoleak: roleofevas techniqueincomparisontosac 1 , G. Biasi vs 4,6%)andgroupB(12% 1 , M. Sponza 2 , P. Frigatti 93 vs 0%). 1 vs vs vs 2,5%). 90%). 0%). - - EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

aneurysm The Successful Treatment ofaProximal Type IEndoleakusingthe Aptus HeliFX Jonathan Porter, SamuelDebono, RaviGoel, Neil Wild, Peter Woodhead, Blackburn Haytham Al-Khaffaf, RobertSalaman, MarkO’Donnell EndoAnchor System Department of Vascular Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital, Hospital, Blackburn Royal Trust, NHS Hospitals Lancashire East Surgery, Vascular of Department appear tobesafeandeffectivetheirusecanexpectedincrease. but furtherstudiesareneededtoevaluate long-termdurabilityand re-intervention rates. Endoanchors both re-interventionandprimaryEVAR withhostileaorticneckanatomy. Earlyresults Endoanchors provideanadditionaltreatmentstrategyformanagingtypeIendoleaks. They havearolein CONCLUSION residual endoleak. with a32x80mmuncoveredstent(OptimedsinusXL). Follow-up CTA atoneandsixmonthsshowedno ployed circumferentiallyatthelevelofproximalendograft. The aorticneckwas furtherscaffolded proximal endograftballoonmouldingwithaReliant(Medtronic). EightEndoAnchorswerede The commonfemoralarterieswereaccessedpercutaneously, followedbyaninitialfiveminuteperiodof using EndoAnchors, andfinalscaffoldingwithastent. strategy includedprolongedballoonmouldingoftheproximalneck, directgraftfixationtotheaortic wall tion with a proximal cuff extension was precluded by the highly angulated neck. A trifecta therapeutic One-month post-procedure CTA demonstrated a posterior, proximal type I endoleak. Planned re-interven ic, Minneapolis, MN). Post-deployment imaging demonstrated good proximal sealing of the endograft. ceeded to elective EVAR one month later with theplacementofaMedtronic Endurant endograft (Medtron infrarenal AAA. Lowerlimbperfusionwas successfullyrestoredwithsurgicalembolectomy. The patientpro ography (CTA) imaging showed mobilethrombusattheleftfemoralbifurcation and anincidental 6.8cm An 85-year-old malepresentedwithsymptomsofacuteleftlegischaemia. Computed tomography angi CASE REPORT We reportacaseoftreatmentproximaltypeIendoleakusingHeliFXEndoAnchors(Medtronic). frequent re-interventionindication renal abdominalaorticaneurysms Endovascular aneurysmrepair(EVAR) issafe, effective, andthepreferredtreatmentformanaginginfra BACKGROUND 1-2 3-4 (AAA). Endoleaksremainacommoncomplication and arethemost . Type Iendoleaksareassociatedwithruptureandwarrant treatment. 94

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1. REFERENCES endoleak C)Onemonthfollow-upCTA showingresolutionofendoleak Interval CTimaging: A) OnemonthCTA demonstrating type-1endoleakB) Aptus Endoanchordeploymentwith noevidenceof 5. 4. 3. 2. Oct;60(4):885 –92. registry ofEndoAnchorsfortypeIaendoleaksandendograft migration inpatientswithchallenginganatomy. J Vasc Surg. 2014 Aortic SecurementSystemGlobalRegistry(ANCHOR) Workgroup Members. Resultsofthe ANCHOR prospective, multicenter Surg 2009;37:15e22. from EUROSTAR registry. EurJ Vasc Endovasc Surg2003;26:487e93. rysm. NEnglJMed2012;367:1988e97. 2010;362:1863e71. Greenhalgh RM, BrownLC, Powell JT, Jordan WD Jr, MehtaM, Varnagy D, Moore WM Jr, Arko FR, JoyeJ, Ouriel K, de Vries JP. Aneurysm Treatment usingtheHeli-FX™ Schlosser FJ, GusbergRJ, Dardik A, Fransen GA, Vallabhaneni SRSr, van MarrewijkCJ, Lederle FA, Freischlag JA, Kyriakides TC, et al et et al et . Aneurysm ruptureafterEVAR: cantheultimatefailurebepredicted?EurJ Vasc Endovasc et al et . Endovascular . Long-termcomparisonofendovascular andopenrepairofabdominalaorticaneu et al et . Ruptureofinfra-renal aorticaneurysmafterendovascularrepair: aseries versus openrepairofabdominalaorticaneurysm. NEnglJMed 95 -

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY ElKassaby Mohammed aneurysm Anatomical suitabilityofrupturedinfrarenalabdominalaorticaneurysmfor endovascular repairasafirstoption ** FRCSI, Vascular Surgery Consultant, UCHG Consultant, Surgery Egypt Ireland Vascular University, Galway, FRCSI, ** Hospital Mansoura College Medicine, of University Faculty surgery, * Department, Endovascular Surgery and Vascular 2. Vascular of Department 1. by adoptingamoreflexibleapproachtoinstructionsforuse. operative theatre. A larger number of patients can be fitted inthe protocolunder experienced handsand EVAR asa1stoptionprotocolfor rAAAiseffectiveandcanaccommodatemostofthepatientsreaching CONCLUSION 30-days mortalitywas 27.7%. and 2 we not (11%). 17 patients received EVAR (95%) and 1 had OSR (5%). 1ry technical success was 89%. (Range 53–114). 16patients(89%)wereanatomicallysuitableforEVAR accordingtoinstructionsforuse, 18 patientswereidentified. Meanage was 74years(Range58–89). Meananeurysmsacsize was 81mm RESULTS end pointsweremidtermmortality, hospitalandICUstay, andcomplicationrate. mary endpointswereanatomicalsuitabilityforEVAR, technicaland30daysclinicalsuccess. Secondary patient whoreceivedsurgicalrepaireitherEVAR orOSRbetweenOctober2010andDecember2015. Pri A retrospective analysis was carried out for pre-operative CTA images and mid term results of all rAAA METHODS 1st protocolanditsapplicability. who underwentsurgicalrepairinourpracticeoverthepast5yearstodetermineefficacyofthisEVAR protocol forruptured AAA. We analysedtheCTangiographyimagesandclinicaloutcomesofallrAAA are themainfactors limiting patient suitability for EVAR. Inourinstitution we haveanEVAR 1stoption proven toprovideshorttermbenefitcomparedopensurgicalrepair(OSR). Anatomical considerations Endo Vascular Aneurysm Repair (EVAR) for ruptured infra renal abdominal aortic aneurysms (rAAA) is INTRODUCTION Mansoura University Mansoura MD, MRCSI, Vascular Surgery Fellow, UCHG, Consultant and Lecturer of Vascular surgery, surgery, Vascular of Lecturer and Consultant UCHG, Fellow, Surgery Vascular MRCSI, MD, 1,2* , Muhammad Tubassam, 96 1** -

ElKassaby Mohammed aneurysm Endovascular Managementofalargeiliacarterypseudo-aneurysmcausedby failing hipreplacementprosthesis, casereportandtechnicalchallenges *** FRCSI, Vascular Surgery Consultant, UCHG Consultant, UCHG Surgery Vascular Consultant, FRCSI, Surgery *** Egypt Ireland Vascular University, Galway, MRCSI, ** Hospital Mansoura College Medicine, of University Faculty surgery, * Department, Endovascular Surgery and Vascular 2. Vascular of Department 1. proach andpre-operativeplanningisofparamountimportancetoreducemorbiditymortality. Failing oldhipreplacementprosthesis canleadtolifethreateningcomplications. Choiceofsurgicalap DISCUSSION ANDCONCLUSION Completion angiogramandfollowupCTA showedcompletesealingoftheaneurysm. thesis. A coveredstentgraftwas deployed across theleftexternal iliac arterytosealthepseudo-aneurysm. grade angiogram was performedtoidentify the neck ofthe aneurysm which was obscured by the hip pros was adopted. Ballooncontroloftheaortawas securedthroughleftfemoralaccess. Ante gradeandretro The patientwas vitallystable, withnoclinicalorlaboratoryevidenceofinfection. Endovascular approach eroding throughthehipbone. CT Angiogram showedlarge10cmpseudo-aneurysmoftherightiliacartery, withfailedhipprosthesis acute ischemiaandICUadmissionpostarrestoneyearago. side, lastonedonetwoyearsago. Healsohadleftbelowkneeamputationafteranepisodeofdelayed previous bilateralhipreplacementsurgerywithonerevisionontheleftsideandthreerevisionsright pulsating mass in right iliac fossa. He had history of Acromegaly, cardiomyopathy, atrial fibrillation and A 65yearsoldmalepresentedtoourserviceswithaone-week history ofsevererighthippainandlarge CASE REPORT for 3monthspost-op Covered stentgraftforinfectedpseudo-aneurysmsarereportedinliterature. Antibiotic coverisrequired plasty. They arereportedtohave7%mortalityand15%incidenceoflimbloss. Pseudo-aneurysm of theexternaliliac artery isararebutserious vascular complication of total hip arthro INTRODUCTION Mansoura University Mansoura MD, MRCSI, Vascular Surgery Fellow, UCHG, Consultant and Lecturer of Vascular surgery, surgery, Vascular of Lecturer and Consultant UCHG, Fellow, Surgery Vascular MRCSI, MD, 1,2* , W. Tawfick 1** , Muhammad Tubassam, 97 1*** - - - - EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY 98

ElKassaby Mohammed aneurysm Huge abdominalaorticaneurysms, aneverlastingchallengeforEVAR? Caseseries and literaturereview *** Professor of Vascular and Endovascular Surgery, Mansoura University, Egypt University, Egypt Mansoura University, Surgery, Mansoura Endovascular Surgery, and Vascular of Endovascular and Egypt Professor Vascular *** of Mansoura, Professor Medicine, MD, of ** Faculty hospital, * University Mansoura oping countries, wheremoresophisticated techniquesarestillverycostly. aneurysms. Open repair will continue to have an important role in the upcoming future, specially in devel Screening programsfor AAA aremandatorytodecreaselatediagnosiswithmoreincidenceofhugesized Huge aneurysmstendtohavehostileanatomy, notsuitableforEVAR CONCLUSION endoleak, andlatemortality. successful EVAR outsidetheIFUs, aneurysmswithhostileanatomyhasmoreincidenceofpost-operative aneurysm grows in 3 dimensions leading to increasing tortuosity and landing zone dilatation. Even with es attime of discovery. Hugeaneurysms (more than 10 cm)tendtohavemore difficult anatomy, asthe Absent screeningprogramsindevelopingcountriesleadstodelaydiagnosis, withlargeraneurysmsiz DISCUSSION mm (36%, N=4, P=0.05). length (73%, N=8, P=0.032), Neckangulation (55%, N=6, P=0.048)andneckdiametermorethan32 30 daysmortalitywas 0.09(N=1). The mainanatomicalfactorpreventingEVAR withinIFUswas neck for EVAR within IFUsofcommercially available devices. OpenSurgical repair was carried outfor all cases. done for AAA withananeurysmsizeof10cmor more. All casesidentifiedwerenotanatomicallysuitable Between January 2015and August 2016, 11outofatotal39 AAA interventionswereIdentifiedtobe RESULTS for suitabilityofEVAR withinIFUs. determine theanatomicalfeaturesof AAA witha sacdiameterof10cmormore, andtheywereassessed is a tertiary referral center for vascular surgery covering about 15millions population, was carried out to A retrospectiveanalysisofallinfrarenal AAA surgeriescarried out inMansouraUniversityhospital, which METHODS features thatcanrenderEVAR anon-feasibleoption. EVAR devicesallowstoaccommodatemoredifficultanatomies. Huge AAAoftenhashostileanatomical atomic suitabilityrepresentsthemainfactorthatcanrestrainendovascular repair. Recentdevelopmentin Several largeRCTshavedemonstratedearlysurvival benefitswhencomparedtoopensurgicalrepair. An Endovascular aneurysmrepair(EVAR) isbecomingthepreferredtreatmentstrategyfor AAA worldwide. INTRODUCTION MD MRCS, Lecturer of Vascular and Endovascular Surgery, Mansoura University, Egypt University, Mansoura Surgery, Endovascular and Vascular of Lecturer MRCS, MD * , HeshamSharaf ** , EhabSaad 99 *** - - - EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY EVAR 2013-2014 2012-13 2011-12 2010-11 2009-10 2008-09 2007-08 2006-07 Year aneurysm Aber A, Tong TS, Kearns B, ChilcottJ, Pearson T, MichaelsJA University of Sheffield, UK Sheffield, of University 2015 Health Economics & Decision Science, School of Health and Related Research (ScHARR), (ScHARR), Research Related and Health of School Science, Decision & Economics Health Mortality rate differencebetweenEVAR &OpenRepairofrAAA2006-07to2013-14 FIGURE 1 compared tomalepatients. among olderpatientsisincreasingandthemortalityratesfemaleremainpersistentlyhigh introduction of AAA screeningdidnotdecreasetheannualnumberofrAAAcases. Incidenceandmortality pared to EVAR, although some of thedifferences in mortality may bedue to differencesin case-mix. The Open repairofrAAAisassociatedwithhighermortalityratesamongallageandgendergroupswhencom CONCLUSIONS were male. The mortality among female remain higher than male patients presenting with rAAA (Figure 3). ment forrAAAfrom2002-03to2013-14is1324patients(95%CI1309.2-1338.3), 83.4%ofallthepatients 1.06 yearsfrom2002-03to2013-14. The meanannualnumberofpatientsundergoingsurgicalmanage years presenting with rAAA increased overtime (Figure 2) andtheaveragemean age ofpatientsincreased ty ofpatientswithrAAAwerebetweentheages70-79, howevertheproportionofpatientsolderthan 85 and the. EVAR was associatedwithalowermortalityratewhencomparedtoopenrepair(Figure 1). Majori 2015. 1863(10.8%)underwentendovascular repairofruptured AAA and15327 (89.2%)hadopenrepair. In total17190patientsreceivedsurgical intervention for ruptured AAA inEnglandfrom April 2002-March RESULTS mortality. bined to it to generate admission level data set. These index admission data were analysed for in hospital repair ofruptured AAA wereidentifiedandalltherelevant episodeswithinthesameadmissionwerecom end datewereexcluded. UsingappropriateICD-10&OPCS-4codesalltheepisodesofEVAR andopen 2014. Patients belowtheageof16, duplicatedepisodesandthosewithmissingadmissiondatesorepisode Hospital episodestatistic(HES)inpatientdatasetswereextractedfromthe1stof April 2002to31stMarch METHODS post-operative in-hospitalmortalityassociatedwithEVAR andopenrepairofrAAA. this studyusingtheadministrativedatasetofNationalHealthService(NHS)inEngland, weexamined ative mortalityfromemergencyrepairhasremainedhighwithsomestudiesreporting50%mortality. In Ruptured abdominalaorticaneurysm(rAAA)isacommonvascular emergency; theimmediatepost-oper INTRODUCTION versus OpenRepairofRuptured Abdominal Aortic Aneurysm inEngland2002- -0.22 -0.15 -0.26 -0.22 -0.21 -0.15 -0.32 -0.30 EVAR vsOpenRepair Rate difference 100 0.004 0.111 0.011 0.041 0.032 0.203 0.008 0.020 p-value (-0.38 --0.05) (-0.32 -0.03) (-0.46 --0.06) (-0.43 --0.01) (-0.41 --0.01) (-0.36 -0.06) (-0.53 --0.1) (-0.51 --0.08) Confidence Interval - - - - -

Gender Specific Post rAAArepairin-hospitalMortalityRates April2002-March2014 FIGURE 3 Percentage ofRuptured Aneurysms by Age (Years) from April 2002-March2014 FIGURE 2 101

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY Repair Aneurysm Endovascular aneurysm Aber A., al-RifaeiMM. University of Birmingham, Birmingham, UK Birmingham, Birmingham, of University analysis Cost-effectiveness Mid-term Abdominal AorticAneurysm: A School of Health & Related Research, University of Sheffiled, UK, Health Economics Unit, Unit, Economics Health UK, Sheffiled, of University Research, Related & Health of School However bothEVAR andOSRcostlessthanthesocietalwillingnessthresholdforQALYs gained. Performing ORonRAAAisacosteffectivestrategywithmarginallybetterNMBwhencomparedtoEVAR. CONCLUSION maximum willingnesstopayforaQALY commonlyusedintheUK. sensitivity analysisconfirmedthatbothtreatmentmodalitiesarecost-effectivemanagementoptionsat the net monetarybenefit(NMB)forOR was £3987-10939comparedtoEVAR withNMB£4307.5-9235.2. The below thelowermarginofsocietalwillingnesstopayinUK(£20000)foronegainedQALY. The £5547.9 and £5963.7, the QALYs were 0.493 and 0.498 respectively. Both treatments costs were well The costofEVAR andopenrepair combined withthecostsofcomplicationsoveroneyearwere RESULTS sensitivity analyses. fectiveness of EVAR and OR. The results from the modelwere assessed using one-way and probabilistic was donesothattheeconomicmodel captures theeffectsofpost-operative complications on thecost-ef complications wereobtainedfromliteratureonelectiverepairof AAA becauseoflackdataforRAAA. This NHS referencecostspublishedannuallybythedepartmentofhealth. Probabilities, outcomesforlong-term published literatureincludingIMPROVE, AJAX &NOTTINGHAM trials. The costdatawereobtainedfromthe A decisiontreemodelwas constructedandpopulatedwithprobabilities, outcomesandutilitydatafrom METHODS (QALYs) fromtheUKNationalHealthServicewitha1-yeartimehorizon. A model-basedcost–utilityanalysiswas performedestimatingmeancostsandquality-adjustedlife-years DESIGN treatment ofrupturedabdominalaorticaneurysms(RAAA). The aim of thisstudywas toanalyzethecost-effectiveness of EVAR compared with openrepair (OR) in the OBJECTIVES Versus OpenRepairforPatients withaRuptured 102 -

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aneurysm thoracic Endovascular And Hybrid TreatmentPathologiesOf TheOf TheEndovascular AorticArch: And Manuela Cherchi, StefanoCamparini A SingleCenterExperience Azienda Ospedaliera Brotzu, Cagliari, Italy Italy Cagliari, Brotzu, Ospedaliera Azienda aortic arch KEYWORDS available option, bothinelectiveandemergentpatients, sinceitisnotcustomade. to assureamoresecurelandingzone. This techniqueiswellcodifyedatourcenteranditalways an promising. As forthehybridsolution, sometimesanaggressiveapproachwithtotaldebranchingisneeded ence stillneedstobewidenedbeforebeingablestateconclusions, althoughtheworldwideresultsare double branchedgraftassureamoreanatomicalreconstruction of theaorticarch, buttheglobalexperi Both techniquesarefeasibletoourexperienceandledsuccessfulearlyresultsinselectedpatients. The CONCLUSION a RCCA-LCCAbypasstoextentthelandingzone. Noneurological complicationsoccuredinbothgroups. doleak. In the hybrid group, there were 3 redo operations, with the completion of LCCA-LSA bypass with all thepatientshadexcellentoutcomes, withagoodpatencyofthegraftat6monthsandnosignsen All the61patientssurvivedandweredismissedasymptomatic. Inthecustom-madeendovascular group RESULTS of thepatients. used onlyduringthedeploymentofdoublebranchedgraft. Cerebralfluiddrainage was usedinnone branched endovascular graft. All theoperationswereundergeneralanaesthesia, whilerapidpacingwas while 4 underwent total endovascular aortic repair: 3 using a custom-made double branched and 1 single lar Surgeryforpathologiesoftheaorticarch, 57underwentsupraorticvesseldebranchingplus TEVAR, From January 2009untilMarch2016, 61patientsweretreatedelectivelyatourUnitof Thoraco-Vascu METHODS pathologies oftheaorticarchandtocompareitmostrecentliterature. pros and cons to both procedures. The aim of our study is to report our experience in the treatment of the debranching) andthecustom-madetotalendovascular repair. Bothtechniquesarevaluable, butthereare performed inourUnitof Thoraco-Vascular Surgery: thehybridprocedure (TEVAR plussupraorticvessel ogies of the aortic arch, due to less morbidity and mortality. Among all, two different techniques are In the most recent years, thoracic endovascular repair has become the procedure of choice for the pathol INTRODUCTION 104

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aneurysm thoracic False aneurysmoftheaorticarchfistiliseinleftlung: Casereport R. Lakehal, F. Aimer, R. Bouharagua, A. Babouri, R. Boukarroucha, S. Bendjaballah, A. Brahami Department of heart surgery, Ehs El Riadh, Constantine, Algeria Constantine, Riadh, El Ehs surgery, heart of Department false aneurysm, aorticarch, hemoptysis, cardiopulmonarybypass, circulatoryarrest KEYWORDS because thespontaneousevolutionisfatal. Infact, theactualtreatmentissurgery. of the aortic arch. The indication for surgery is formal in all cases of pseudoanevrysm of the aortic arch Advances inimagerymake theangioscannerandMRAbestexamsfordetectingfalseaneurysms CONCLUSION The immediatepostoperativewereunfavorablewithafatalrefractorycardiogenicshock. RESULTS of thepulmonarybreach. compensation for the loss of aortic substance by alateral Dacron patch under circulatory arrest and closure pseudoaneurysm inthelatter. The interventionhad consistedafterflatteningofthepseudoaneurysmin shows ahugepseudoaneurysmofthe aortic archblocked bytheupper lobe oftheleftlung fistulizing of space. After installingafemoral-femoralCPBanddetachmentoftheleftlungintraoperativeexploration deep hypothermiaandcirculatoryarrest. The surgicalapproachwas aleftthoracotomyin4intercostal operated onunderextracorporealcirculatio, establishedbetweenthefemoralarteryandveinwith the falseaneurysmofaorticarch. ECGwas normal. Laboratorytestsshowedanemia. The patientwas a resultofhemoptysisaverageabundance. The suspectimage.A .chestangio-CTwas performedshowing Hospitalized forexplorationfollowingthediscoveryofchestX-rayopacityupperlobeleftlungas We reportthecaseofmen, 53yearsold, withahistoryof4meterdropfrombuildingtwoyearsago. METHODS and challengesencounteredbythesurgeons. and MRA. This clinical case is anopportunity for usto recall the seriousness of thisdisease for the patients, condition becauseoftheriskrupturerequiring an emergencysurgery. The diagnosisisbasedontheCTA Aneurysmal locationintheaorticarchisoutstanding, rarer than theascending aorta. This isaserious INTRODUCTION 105

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aneurysm thoracic Aneurysm oftheascendingaortaina06yearsoldgirl: Casereport R. Lakehal, F. Aimer, R. Bouharagua, R. Boukarroucha, S. Bendjaballah, A. Brahami Department of heart surgery, Ehs El Riadh, Constantine, Algeria Constantine, Riadh, El Ehs surgery, heart of Department Aortic, aneurysm, children, surgery, andcardiopulmonarybypass KEYS WORDS there altreatmentsisthesurgery. We notetheseverityofinflammatorysyndromeinchildren. dication is formal in all cases of aneurysms of the ascending aorta. Spontaneous evolution is fatal .in fact The CTangio andMRIangio aretheexaminationschoiceindetectionofaorticaneurysm.The operativein CONCLUSION and vasomotor refractory. The suiteimmediatepostoperatingwas unfavorablewithdeathofpatient withinflammatorysyndrome RESULTS in terminoterminaletube. after resectionofthesusascendingaortaaneurysmalrestorationaorticcontinuitybyDacronimplanted notomy .The peroperativeexplorationwas aorticaneurysmwithnormalsizeofsinus.The interventionhad of theupper mediastinum .The patient was operedunder cardiopulmonary bypass. The approach was ster at 19mm, aortaascendantat50mm. LV:35/21 mm. LV:35/21mm. ChestX-ray: CTI: 0.44withenlargement to rightjugularandveindilatedbycompression. Echocardiography: Aortic ring15mm, Sinusofvalsalva gio was realizedshowingtheaneurysmofascendingaorta, troncinnominatearteryplacelefttoreturn We report the case of 06 years old children who present since some months a turgor of jugular vein. CTan METHODS show thatchildrenarenotsavefromthisdisease. urgent surgery. The diagnosisisbasedontheCTangio andMRIangio.This caseisforusanopportunityto Aortic aneurysmisexceptionalinchildren.Itaseriousconditionbecauseoftheriskrupturerequiring INTRODUCTION 106 - - -

aneurysm thoracic Acute dissectiononaneurysmoftheascendingaortainaMarfan: Casereport R. Lakehal, R. Boukarroucha, F. Aimer, R. Bouharagua, A. Babouri, S. Bendjaballah, A. Brahami Department of heart surgery, Ehs El Riadh, Constantine, Algeria Constantine, Riadh, El Ehs surgery, heart of Department Marfan syndrome’s, malformation, dissectionandaneurysm KEY WORDS headset, andthecomplicationmusculosquelitiques. disciplinary andcontinues. The key elementsofthemonitoringareaorticroot, themitralvalve, the The announcementofthediagnosticisanintegralpartthroughcareprocess. Managementismulti CONCLUSION Inoperable patient. RESULTS challenge thispatientgiventheimportanceofchestdeformitiesandalteredgeneralstatus. wrist myopiaanddislocationofcristallin. Biologyiscorrect. The decisionofmedicochirurgicalstaffisto We haveamarfanoidaspectwithsignedkyphoscoliosis, anachnodactylie, adolichosteomelie, thumband racic: Aortic dissection type A on expansion aneurysmal of sinus 69/67 mm. Chest x-ray; scoliosis. Clinically: tion ofaortaandaorticinsufficiencyleftventricularfunctioncorrectinechocardiography. AngioCTtho major form, mother: minorform)cametotheemergencyforchestpainwhoplays foraweekwithdissec We reporttheobservation ofayoung woman aged36yearsatthefamilyhistory of Marfan(twobrothers, METHODS work istoshowthegravityofthisdisease. dilatation) .The prevalence ofthissyndromeisestimatedatonepersonfor5000births.The goalofthis may cause problems notably skeletal disorders (big size, scoliosis), ophthalmique (myopia), cardiac (aorta Marfan’s syndrome is a rare genetic disease. It is characterized by the achievement of one or several organs INTRODUCTION 107

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aneurysm thoracic False anastomoticaneurysms: Reportcase Lakehal Redha, Aimer Farid, BendjaballahSoumaya, BoukharouchaRadouane, Brahami Abdelmallek Department of heart surgery, Ehs El Riadh, Constantine, Algeria Constantine, Riadh, El Ehs surgery, heart of Department False aneurysm, surgery, cardiopulmonarybypass KEY WORDS the actualtreatmentissurgery. is formalinallcasesofpseudoanevrysmtheaorticbecausespontaneousevolutionfatal. Infact, False anastomoticaneurysmsjustify rapidinterventiontopreventtheirrupture. The indicationforsurgery CONCLUSION fogarty sensoranddeathin20daysbysepticshock. plicated by acureischemia of rightlower limb to18daywhobenefit fromoneofthedesobstruction by The suitesimmediateoperatingpostweremarksbyamediastinitis,endocarditis on aortic prosthesis com RESULTS of theroofleftatrium. false anevrysmale after evacuation of the hematoma.stregthening of the anastomosis by point and repair blood fromtheleftatriumroof. The gesturewas afterevacuation ofthehematomainsettingflat oro-femoral left and induction of circulatory arrest to 19: big proximal aneurysm with exteriorization of control realizedafteraweek. Procedureperexplorationafterinstallationofcardiopulmonarybypassfem periprothetique on the proximal anastomosis with increase of the false aneurysm on angiochest CT scan giochest CTscanmotivebychestpainorthererevealtheexternalization of controlwithfalseaneurysm with benefit from interventionof modified Bentall .The diagnostic wasreported inpost operating byan We reporttheobservation ofawomanaged64yearsoperatedfromaneurysmthesegments0and1 METHODS exceptional complicationinpostoperative. visible andletal.Support for associationreferencesurgicalrepair. The aimofourworkistoremind ofthis False anastomoticaneurysmsareexceptionalandserious. The mostseriouscomplicationisbreaking, impri INTRODUCTION 108

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CT2 1. Martin Serena aneurysm thoracic Simultaneous Endovascular Repairofa Thoracic Aortic InjuryduringPosterior 2. Consultant Interventional Radiologist Interventional Consultant 2. Pedicle ScrewRemoval Royal Victoria Hospital, Belfast Hospital, Victoria Surgeon Royal Vascular Consultant 3. deployment wiresandlossofthesterilefield. following risks; lossofaccess, damagetotheaccessvesselsandbleeding, displacementofthestentor groin accessandanendovascular stentinplace. This mustbecarriedoutwithextremecaretoavoid the aortic injuriesseveralfactorsmustbeconsidered. Inparticular, thechallengeofturningapatientwithopen guide screwplacementandreducesubsequentcomplicationrates. Duringendovascular repairofresultant Surgeons operatingnearhighriskvascular structuresshoulduseintra-operative imagingmodalitiesto CONCLUSIONS rior pediclescrewremoval withthepatientinrightdecubitusposition. We describeanovelmethodofsimultaneousendovascular repairofathoracicaorticinjuryduringposte techniques. Options described in the literature include; thoracotomy with open vascular repair and newer endovascular Given therarityofthiscomplicationthereisnoguidelineformanagementresultantaorticinjuries. two weeks post-operatively detected an incidental thoracic aortic injury due to a misplaced pedicle screw. A 72yearoldladyhadaposteriorspinalstabilisationforseverepaincausedbydiscitis. RoutineCTscan CASE HISTORY tive compromiseisrare, butnonetheless, resultantvascular injuriescanbelifethreatening. spinal stabilisation are rareandusuallydiscoveredlateonsubsequentimaging. Immediateperi-opera rates are higher whenimagingmodalities are used intra-operatively. Vascular injuries following posterior this increase in popularity, complications, including screws misplacement, arebeinghighlighted. Accuracy Posterior spinal stabilisationisatechnicallydemanding procedure whichisincreasing in popularity. Since INTRODUCTION

1 , RichardLindsay

2 , RobinBaker 109 3 - - EPOSTERS

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aneurysm thoracic Hybrid thoraco-abdominalaorticaneurysmrepair: minithoracotomyapproachto P. Scrivere, G. Biasi, A. Silvestri, M. Sponza, I. Vendramin, P. Frigatti perform theanterogradevisceralarteriesby-pass Ospedaliero Universitaria Santa Maria della Misericordia, Udine, Italy Udine, Misericordia, della Maria Santa Universitaria Ospedaliero thoraco-abdominal aneurysminhighriskpatients. ceral by-pass with high primary patency rate and low post-operative complications in the treatment of In conclusiontheminithoracotomyapproachtoascendingaortapermitsperformanterogradevis A 12monthsangio-CTscanprovedthepatencyofvisceralarteriesandexcludedanysignsendoleak. endograft toguaranteetherevascularization ofthecommonhepaticarteryandrightrenalartery. 3 monthlaterthepatientunderwentanexclusionofthoraco-abdominalaneurysmwithfenestrated dominal aneurysmdiameterandrevealedananomalousoriginofthehepaticartery. The postoperativeangio-CTscanshowedthepatencyofvisceralarteriesby-passes, anincreaseintheab space supportedbyvideo-assistedthoracoscopy. Subsequently thebifurcatedgraftwas tunneledthroughthechestanddiaphragminabdominal omy approachatthesecondintercostalspace. The surgicalaccessfortheproximalascendingaorticendtosideanastomosisconsistedinamini-thoracot anastomosis. An hybridvascular graftwas usedtoperformtheleftrenalarteryby-passwithsuturelessdistalend-to-end enteric artery(AMS)withsidetoendanastomosis. from theascendingaortatoceliactrunk(CT)withanendanastomosisandsuperiormes First ofalladebranchingthevisceralarterieswas performedwithananterogradebifurcatedby-pass two stages. Due tothecomorbidities, thepatientunderwentanhybridthoraco-abdominalaorticaneurysmrepairin ure. The patient suffered from an ischemic heart failure, atrial fibrillation, hypertension, mild chronic renal fail rysm withanhighgrowingrate(1cm/year)infollowupangio-CTscan. A 77yearsoldmalepatientcametoourDepartmentforanasymptomaticthoraco-abdominalaorticaneu 110 ------

M. Cappelle aneurysm thoracic Early interventionforcerebralmalperfusionafterhybridarchrepairofan aortobronchial fistula 3. Department of vascular surgery, az st. Lucas, assebroek, Belgium assebroek, Belgium Lucas, Leuven, st. az Belgium Leuven, surgery, Leuven, hospitals vascular Leuven, of university hospitals Department 3. radiology, university of surgery, Department 2. vascular of Department 1. inadvertent overstentingofacriticalsupra-aorticbranch. themselves. Ourcaseshowedthatthearch chimneytechniqueisaveryvaluable optionintheeventof Technique-related issues shouldbeprimarysuspectedwhenearlypostoperativeabnormalitiespresent vocal cordparalysis. Neverthelessnoischemiceventsemerged. The postoperativecoursewas complicatedbyseveralattemptstoextubate duetolaryngealedemaand pra-aortic bloodflow. thoracic stentgraft. Completionangiography showednoresidualendoleaksandrestaurationofthesu plugging theorificeofleftsubclavianarteryandtypeIbendoleak was treatedbyextendingthe chimney stentwas putintoplace(Advanta Atrium 10mmx58mm). The typeIIendoleakwas excludedby A retrogradepreoperativeangiographyconfirmedsevereflowrestrictionintheinnominateartery and a flow restrictionandanendoleaktypeIa, IbandII. Asneurologiceventsoccurredrepair was mandatory. A selectiveangiographyrevealedanoverstentingofhalftheostiuminnominatearterywithclear tolic pressuresdroppedbelow160mmHg. mentioned claudicationoftheupperextremitiesandpresentedtransientleft-sidedhemiparesiswhensys transthoracic echocardiography and a CT scan of the head, could not reveal a cause. Four days later she Initially herantihypertensiveagentswerehalted. A neurologicandcardiologicinvestigation, includinga Postoperatively thepatientpresentedheadacheandhypotensionwithorthostatism. a two-stepprocedure. performed preceded by debranching of the supra-aortic vessels by a carotidocarotidosubclavian bypass in origin oftheleftsubclavianartery. To treatthisaortobronchialfistula, athoracicaorticstentgrafting was A 76-yearoldwomanpresentedwithhemoptoeandapseudoaneurysmofthethoracicaortainvolving 1 , MaleuxG. 2 , Coppin V., 3 , TubbaxH. 111 3 , Fourneau I. 1 - - EPOSTERS

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aneurysm thoracic Elective ManagementofDescending Thoracic Aortic Aneurysm inEngland2002- Aber A, Tong TS, Kearns B, ChilcottJ, Pearson T, MichaelsJA University of Sheffield, UK Sheffield, of University 2015 Health Economics & Decision Science, School of Health and Related Research (ScHARR), (ScHARR), Research Related and Health of School Science, Decision & Economics Health rates. aneurysm highlightstheneedforfewermorespecialised centrestoreducemortalityandcomplications undergoing endovascular repair. The relativelylownumberofpatientsnationallycomparedtoinfra-renal some ofthedifferencesinmortalitymaybedueto case-mix. Mortalityremainshighforfemale patients This techniqueislessinvasive anditisassociatedwithreducedpost-operativemortalityrates, although dramatic increase ismainly due tothe feasibility of elective endovascular repair forpatients with dTAA. The annualnumberofelectiverepairdTAA increasedfromfive-fold2002to2015inEngland. The CONCLUSIONS open surgicalrepairrespectively. ed withendovascular operation. Mortalitywas 17% and 11%formale and female patients undergoing 0.06-1.15). Mortalityrateamongfemale patients was 7%comparedto3%percentformalepatientstreat endovascular repair respectively. The mortality incidence rate difference was 0.11 (95% confidence interval for patientsundergoingopenrepair. The incidencerateofmortalitywas 14.6%and3.8%foropen interval 2.5-9.3)forpatientsundergoingendovascular repairand5.7(95%confidenceinterval 6.7-4.7) male. The meanpost-operativein-hospitalmortalitywithinthesameadmissionwas 6.8(95%confidence patients hadendovascular repairand534(25%)hadopensurgicaloperation. 67%ofallpatientswere Between 2002and2015, 2143patientshadelectiverepairfordTAA intheNHSofEngland. 1609(75%) RESULTS identified. Trends ofelectiveendovascular andopenrepairwerecompared. sion dates, enddateswereexcluded. Usingrelevant ICD-10&OPCS-4codesalltherelevant episodeswere April 2002toMarch2015. Patients belowtheageof16, duplicateepisodesandthosewithmissingadmis inpatient hospitalmortality. NHSinpatienthospitalepisode statistic(HES)datawereextractedfromthe gical management of dTAA in England. The primary outcome measure was procedure and gender specific The purposeofthepresentstudywas toinvestigatetheprevalence andmortalityassociatedwiththesur METHODS paramount toimproveresourceallocationandguidepostoperativemanagement. the numberofcandidatesfordTAA repair. Population-level knowledgeofincidenceandoutcomesis increasing theirperioperativerisks. The introductionofthelessinvasive endovascular techniquesexpanded mortality andseveremorbidity. The patientspresentingwithdTAA oftenhaveother comorbidities, therefore The electiverepairofthedescendingthoracicaorticaneurysm(dTAA) isassociatedwithsignificantriskof INTRODUCTION 112 - - -

FIGURE 2 FIGURE 1 113

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY stenting Carotid carotid Eui-Jin Cho, Won-hyung Kim, Sung-Won Jin, Seung-Hwan Lee, Bum-JoonKim, Sang-Dae Kim, Se-HoonKim, Dong-JunLim, Sung-Kon Ha old age Korea University Ansan Hospital, Seoul, Korea, (South) Republic of Republic (South) Korea, Seoul, Hospital, Ansan University Korea Carotid Artery StentingPre-procedure FIGURES potentially beconsideredaprimarytreatmentchoiceforcarotidstenosispatientsofoldage. dural infection rates were higher in the CAS group. With proper infection control and prevention, CAS can Among carotidstenosispatientsofoldage, bothgroupsunderwentsuccessfultreatment, butperi-proce CONCLUSION the CEAgroupshowedahigherrateofperi-proceduralinfectionthanCAS(p=0.037)(Table 2). prognosis for both groupsalsoshowednodifference for stroke, myocardial infarction and death. However, groups. Bothgroupsshowednostatistically significantdifferencesintheirdemographics(Table 1). The We usedChi-squareanalysistocomparethedemographicsandprognosis betweentheCASandCEA RESULT reviewed complicationssuchasstroke, myocardialinfarction, deathandinfectionwith2yearsfollowup. patients werediagnosedandtreatedinourhospital. 21patientsweretreatedbyCAS, and13byCEA. We ebral infarction, transientischemicattack) whowereover70yearsold. From 2011to2014, atotalof43 We reviewedpatientswhowerediagnosedwithcarotidarterystenosis(over70%)symptoms(cer METHOD CAS inoldage, andcomparedprognosiscomplications. that canchangeprognosis. We thereforereviewedourcarotidstenosispatientswhoweregivenCEAor complications suchasmortalityandstroke rates. Inpatientswhoareolder, however, therearemanyfactors can bedoneunderlocalanesthesia. RecentstudieshavefoundthatCEAissuperiortoCASwithregards stenting (CAS)isalsoconsideredapotentialalternativetreatment, butislessinvasive thanCEA, becauseit ered aneffectivetreatmentforpreventionofstroke inpatientswithsymptomaticcarotidstenosis. Carotid Carotid stenosisisamajorcauseofemboliccerebralinfarction. Carotidendarterectomy (CEA)isconsid INTRODUCTION versus endarterectomyfortreatmentofcarotidarterystenosisin 114

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Carotid Endarterectomy: Intra-operative Post removal ofatheroma Carotid Endarterectomy: Intra-operative Thick atheromawas seenandremoved Carotid Artery StentingPost-procedure 115

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY 7. 6. 5. 4. 3. 2. 1. REFERENCES urinary tract infection, bloodstreaminfection, procedural siteinfection, andsoon. The periprocedural periodwas definedaswithin30daysofindexprocedure. Periprocedural Infectionswereconsistedofpneumonia, nia, urinarytract infection, bloodstreaminfection, procedural siteinfection, andsoon. * The periprocedural periodwas definedaswithin30daysofindexprocedure. Periprocedural Infectionswereconsistedofpneumo There was nostatisticaldifferencebetweenCASandCEAgroups TABLES 10. 9. 8. Periprocedural Infection* Death Myocardial Infarction Stroke 5 4 3 2 1 0 Modified Rankinscale Hemispheric stroke Transient ischemicattack Recent ischemicevent Current smoking Hyperlipidemia Hypertension Diabetes Mellitus Male Age Stroke 32.Suppl 1(2001): 325-325. Medicine 351.15(2004): 1493-1501. Alberts, Mark J. «Resultsofa multicenter prospectiverandomized trialofcarotidarterystenting Yadav, Jay S., substudy oftheInternationalCarotid StentingStudy(ICSS).» The LancetNeurology9.4(2010): 353-362. Therapeutic Medicine12.4(2016): 2639-2643. Journal ofMedicine355.16(2006): 1660-1671. national JournalofStroke (2016): 1747493016632237. results fromalargesinglecenterstudy.» Catheterization andCardiovascular Interventions(2016). Lancet 375.9719(2010): 957-959. 375.9719 (2010): 985-997. tomatic carotidstenosis(InternationalCarotidStentingStudy): aninterimanalysisofarandomised controlledtrial.» The Lancet Bonati, LeoH., Cho, SungShin, Mas, Jean-Louis, Morris, Stephen, Meller, StephanieM., Rothwell, Peter M. «Carotidstenting: moreriskythanendarterectomyandoftennobettermedicaltreatmentalone.» The International CarotidStentingStudyinvestigators. «Carotidarterystentingcomparedwithendarterectomyinpatientssymp stenosis: apreplanned meta-analysisofindividual patientdata.» The Lancet 376.9746 (2010): 1062-1073. Carotid Stenting Trialists’ Collaboration. «Short-termoutcome afterstenting et al et et al et et al et et al et et al et . «Protected carotid-arterystenting . «Newischaemic brain lesionsonMRIafterstentingorendarterectomyforsymptomatic carotidstenosis: a . «NationaltrendsincarotidendarterectomyandstentingKorea from2004to2013.»Experimentaland . «Cost-utilityanalysisofstenting . «Endarterectomy et al et . «Carotidstenting 1 0 1 2 CAS (n=21) 0 1(4.8%) 2(9.5%) 3(14.3%) 6(28.6%) 9(42.9%) 6(28.6%) 7(33.3%) 11(52.4%) 17(81.0%) 19(90.5%) 8(38.1%) 13(61.9%) 76.52 CAS (n=21) versus versus stentinginpatientswithsymptomaticseverecarotidstenosis.» New England endarterectomyforthetreatmentofcarotidarterystenosis: Contemporary versus versus endarterectomyinhigh-riskpatients.» NewEngland Journal of 116 endarterectomyintheInternationalCarotidStentingStudy.» Inter 4 0 1 1 CEA (n=13) 0 1(7.7%) 1(7.7%) 2(15.4%) 3(23.1%) 6(46.2%) 4(30.8%) 5(38.5%) 7(53.8%) 11(84.6%) 12(92.3%) 5(38.5%) 7(53.8%) 76.54 CEA (n=13) versus endarterectomy forsymptomaticcarotid vs . carotidendarterectomy.» 0.037 - 0.724 0.855 P-value 0.891 0.761 0.934 0.785 0.855 0.983 0.643 0.759 P-value - - -

Kerzmann A. carotid Carotid endarterectomyunderloco-regionalanaesthesiainprovincialhospital: factors influencingperi-operativeoutcomeandlong-term results 1. Dept. of Cardiovascular and Thoracic Surgery, CHU Sart-Tilman, Liège, Belgium Belgium Liège, Liège, Sart-Tilman, Sart-Tilman, CHU CHU Surgery, Thoracic Biostatistics, of and Dept. 2. Cardiovascular of Dept. 1. gery withaslesspossibleneurologicalcomplications. Loco-regional anaesthesiamaybedoesn’tbringthe surgeoninthebestconditionstosucceedcarotidsur gional anaesthesia. Occludedcontrolateral carotidwas theonlyfactorinfluencing thesurvival. We didn’tfindpredictor factorofperi-operativecomplicationforcarotidendarterectomyunderloco-re CONCLUSIONS (p=0,0086). was 80+/-4months. Presenceofoccludedcontrolateralcarotidwas theonlyfactorinfluencingsurvival complication. The multivariate analysisdidn’tshowpredictorofearlycomplication. The averagesurvival complication. No one of the pre-operative and per-operative investigated factors was predictor of early depression (1,2%), oneasymptomatic carotid thrombosis(1,2%)andonenonneurologicalnotspecified 4 strokes (4,7%)and2peripheralnervedamages(2,3%). Othersmorbiditieswerebleeding(3,5%), mental 71+/-9 yearsold. There was onedeath. 12endarterectomieshadearlycomplications(13,9%). There were 86 endarterectomieswererealized. 29women had31interventionsand54men55. Meanagewas RESULTS method. variate logisticmodelofregressionwas alsoused. The survival curveswereestimatedbytheKaplan-Meier the quantitativevariables andbymeansoftheexacttestFisher for thecategorized variables. A multi The relationbetweentheinvestigatedfactorsandcomplicationswas analyzedbylogisticregressionfor (18,1%). eversion 4,8%anddirectsuture1,2%)conversionofloco-regionalanaesthesiatogeneral investigated factors wereuseofshunt(65,1%), operative procedure (suture withprosthesis patch 94,0%, matic carotid(30,1%), stenosis≥90%(51,8%)andoccludedcontrolateralcarotid(9,6%). Per-operative (62,6%), diabetes(20,5%), ischemicheartdisease(33,7%), peripheralarterialdisease(30,1%), sympto than 80yearsold(18,1%), arterialhypertension(73,5%), tobaccodependence(56,6%), dyslipidemia January 2007andDecember 2013 inprovincial hospital. Pre-operative investigated factors wereagemore We reviewed retrospectively carotid endarterectomies under loco-regional anaesthesia realized between MATERIALS/METHODS gional anaesthesiainprovincialhospital. We assessperi-operativeoutcomeandlong-termresultsofcarotidendarterectomyrealizedunderloco-re INTRODUCTION 1 , N.Maes 2 , E. Boesmans 1 , J.O. Defraigne 117 1 - - - - - EPOSTERS

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carotid 18F-Fluoride and18F-fluorodeoxyglucosepositronemissiontomographyafter Alex T Vesey, William SAJenkins, James Rudd, NickLMills, Rustam Al-Shahi, Martin Dennis, William Whiteley, MarcRDweck&DavidENewby transient ischemicattackorminorstroke: case-controlstudy BHF Centre for Cardiovascular Sciences, University of Edinburgh of University Sciences, Cardiovascular for Centre BHF improve risk-stratificationandselectionofpatientswhomaybenefitfromintervention. 18F-Fluoride PET/CThighlightsculpritandphenotypicallyhigh-riskcarotidplaque. This hasthepotentialto CONCLUSIONS with plaquephenotype. trol patients. However, 18F-FDG did correlate with predicted cardiovascular risk (r=0.53, p=0.019) but not plaques butnooveralldifferencesinuptake wereobservedinculprit cardiovascular risk[r=0.65, p=0.002]). Carotid18F-FDGuptake appearedtobeincreasedin7/16culprit risk plaque features (remodeling index [r=0.53, p=0.003]; plaque burden [r=0.51, p=0.004]) and predicted tients (log10SUVmean0.29±0.10 contralateral plaques(log10SUVmean0.29±0.10 18F-fluoride uptake was increased inclinically adjudicatedculpritplaquescomparedtoasymptomatic On histologicalandmicroPET/CTanalysis, 18F-fluoride selectively highlighted micro-calcification. Carotid analysis ofexcisedplaque. and plaquephenotypeorpredictedcardiovascular risk. We alsoperformedmicroPET/CTandhistological culprit tothecontralateralasymptomaticartery, andassessedtherelationshipbetweenradiotraceruptake culprit carotidatheroma. We comparedstandardizeduptake values (SUVs)intheclinicallyadjudicated lar event: 18 patients with culprit carotid stenosis awaiting carotid endarterectomy and 8 controls without We performed18F-fluorideand18F-fluorodeoxygluosePET/CTin26patientsfollowingrecentneurovascu METHODS ANDRESULTS cose canidentifyculpritandhigh-riskcarotidplaque. and biologyofcarotidatherosclerosis. We soughttoassesswhether18F-fluorideor18F-fluorodeoxyglu Combined positronemissiontomography(PET)andcomputed(CT)canassessbothanatomy BACKGROUND versus 0.12±0.11, p=0.001). 18F-Fluorideuptake correlatedwithhigh- versus 118 0.23±0.11, p=0.001)andcomparedtocontrol pa versus contralateralplaquesorcon

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dissectionandother pathology Surgery ofaorticdissection: Resultsabout62patients R. Lakehal, R. Boukarroucha, F. Aimer, R. Bouharagua, S. Bendjaballah, A. Brahami Department of heart surgery, EHS Erriadh, Constantine, Algeria Constantine, Erriadh, EHS surgery, heart of Department Dissection, aortic, surgery, cardio-pulmonary bypass. KEY WORDS allows early diagnosis of secondary complications. In our series results are getting closer to literature data. development ofthispathologicalaortamandatesannual monitoringandclinicalimaging.This monitoring liative becauseitleavesinplaceamoreorlesslong aorta dissectedsegment. The riskofsecondaryecstatic aging andsurgerylargelycontributetoabettermanagement ofthesepatients. However, treatmentispal expertise, Earlydiagnosis, treatmentmustbeurgent(medicalandsurgical). Recentadvances inmedicalim The aorticdissectionisaseveralcardiovascular pathology.The managementinvolvesmultidisciplinary CONCLUSION (17.7%). (19%), Post operativecomplications: 7/62 (11%); Mortalityrate: 11deathsamong62patientsoperated tensive CareUnitstay: 0-26days, Average periodofhospitalization: 0-39days, ICUComplications: 12/62 • Aortic clamping: 22-200minutes; Inotropic+: 26/62patients; Ventilation varied: 6hoursto9days. In -ascending aortaprostheticreplacement+Prosthetic Aortic valve replacement: 06patients; reimplantation: 01patient; -Prosthetic Aortic valve replacement + ascending aorta and the right sinus Replacement+ right coronary -Prosthetic Aortic valve replacement + ascending and transverse aorta prosthetic replacement: 03 patients; -Replacement ofascendingaorta: 49patients; -BENTALL operation: 03patients; • Operativeprocedure: axillary cannulation: 04. pothermia: 28; Normothermia: 22; circulatory arrestindeephypothermia: 07; femoralcannulation: 58; 48 patientsoperatedaspartoftheemergency; SurgerywithCPB: Deephypothermia: 12; ModerateHy RESULTS aortic insufficiencyin43patientsgradeItoIV; aorticstenosisin02patients. diagnosis was madebychestCTscannerandechocardiography: ejectionfractionvaried from25.7to78% hours to4months.NYHAIIV; Sinusrhythmin60/62patients. The cardiothoracicindex: 0.5to0.78. The pressure was observedin38patients: (61%).The evolutionofthesymptomsvaried fromlessthan24 5760: 1.07%); Including27womenand35menwith an average age of52years(16-79years). High blood During the period of January to 2000 December 2015; 62 patients we reoperated of aorta dissection (62/ METHODS sis allowsearlytreatment. We reportpostoperativeresultsof62patientsoperatedinourcenter. Aortic dissectionisalife-threatening emergency, 1%ofsuddendeaths. Currently, medicalimagingdiagno INTRODUCTION 120 - - - - -

dissectionandother pathology Supravalvulaire aorticstenosis: Casereport R. Lakehal, R. Boukarroucha, F. Aimer, R. Bouharagua, A. Babouri, S. Bendjaballah, A. Brahami Department of heart surgery, Ehs El Riadh, Constantine, Algeria Constantine, Riadh, El Ehs surgery, heart of Department Supravalvulaire, aortic, stenosis, cardio-pulmonarybypass. KEY WORDS surgery. erated early. The prognosticisenhancedbytheadvances insurgicaltechniques. The treatmentconsistsof This isveryrarecongenitalheartdisease. Echocardiographyremainsthekey ofdiagnosis. Itmustbeop CONCLUSION The immediatepostoperativesuiteswerefavoredwithgradientaortic–leftventricledropto20mmhg. RESULTS conservation ofaorticvalve. by-pass anenlargementoftheleftcoronarysinusaccordingtoDOTY techniquewithDacronpatchand mitral valve, aorticbicuspidietype1, absenceofcoronaryanomalies. Ithasbenefitundercardio-pulmonary per-operatoire: Hipoplasieoftheleftcoronarysinus, anomalyofimplantationantero-externalpillar stenosis; meangradient AO-LV: 46mmhg, LV –aortic; LV: 48/26mm+HLV, RV: 20mm. Exploration abnormalities. Xraypulmonary: CTI: 0.48.ECG: RRSwithHVL. Echocardiography: supravalvulaire aortic exersion, palpitation and syncopes. Physical examination: murmur systolic in aortic home without other We reportedtheobservation ofpatient17hearsoldwithouthistorypresentedsinceoneyeardyspneaon METHODS congenital stenosis. ventricle Superior of 50 mm hg. This clinical case is for us an opportunity to recall of this type of aortic consists ofanaorticrootenlargementwithDacronpatch. Surgerywas indicatedifgradientaorticleft can beisolatedorpartof William syndrome.The diagnosisisbasedonechocardiography. The intervention Exceptional congenitalheartdisease(1for26000birth)characterizedbyrétrécissementofaorticlight. It INTRODUCTION 121

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miscellaneous Temporal arterybiopsy: animportantdiagnostictoolorarewewasting ourtime? Claire Dawkins, SophieMcGovern, KlausOverbeck Sunderland Royal Hospital, Sunderland, United Kingdom United Sunderland, Hospital, Royal Sunderland already strugglinghealthcareservice. ritis, irrespective of scoring or response to treatment, poses unnecessary surgery and risk to patients in an difficulties shouldbebiopsiedbutablanket Temporal BiopsyofallpatientswithsuspectedGiantCell Arte in management. Patients with a score of 2, those posing a specific diagnostic conundrum or with treatment Our recommendationistoconsider Temporal Artery Biopsyinpatientswherethereisachanceofchange CONCLUSION was agreatersuspicionofGiantCell Arteritis frombothresponsetotreatmentandbiopsyresult. the patient’s responsetosurgeryandina few casesthesteroidsweredecreasedslightlyfasterthanifthere negative temporalarterybiopsytheresultwas taken incontextwiththeclinicalpresentationand only 3patientswerecommencedontreatmentwhohadpreviouslynotbeen. Ofthemajoritywhohada underwent temporalarterybiopsy, theminoritywerefoundtobepositive. Ofthosewhotestedpositive Patients whounderwenttemporalarterybiopsywere foundtohavescoresbetween0and4. Ofthosewho RESULTS of 3ormorefromthe American CollegeofRheumatologycriteria. resulting changeinmanagement. DiagnosisforGiantCell Arteritis was taken fromtheguidelinesofascore College ofRheumatology’s diagnosticscorebothpriortoandfollowingtemporal arterybiopsyandany 2010 andMay2016. Datacollectionincludedthepatients’clinicalpicture, biopsyresult, the American This was aretrospective study of150patientswhounderwent Temporal Artery BiopsybetweenJanuary METHOD that aredeemedunreliableduetopatientshavingcommencedsteroidtreatmentpriorbiopsies. guidelines for thediagnosis of GiantCell Arteritis. Howeverthereisahighincidenceofnegativebiopsies Temporal Artery Biopsyformsoneofthe5diagnosticcriteriain American CollegeofRheumatology INTRODUCTION 122 -

miscellaneous Endoscopic lumbarsympathectomyforplantarhyperhidrosis: technique&early Sanjay Singh, Paul Wilson Kingdom experience University Hospital of Morecambe NHS Trust Royal Lancaster Infirmary, Lancaster, United United Lancaster, Infirmary, Lancaster Royal Trust NHS Morecambe of Hospital University The L3ganglionisisolated FIGURES compensation sweatingandminimalneuralgicmorbidity. tient satisfaction. Inourearlyexperience theprocedureappearstobesafeandeffectivewithlowratesof ablation) whichhasresultedinarelativelylowrateandextentofcompensationsweatingwithgoodpa we favoureda ‘minimal sympathectomy’(crushing/divisionofthechainaboveL3gangliaor opment and results from caseseries appear promising, withlow morbidity. Inoursmall series of patients, The surgicalmanagementofplantarhyperhidrosisusingendoscopiclumbarsympathectomyisinitsdevel CONCLUSIONS male patients. in bothpatientsandresolvedwithin6months. There was noreportedejaculatorydysfunctionin the two unilateral postsympatheticneuralgiaaffectingthethighandleg. The painaffectedtherightlegandthigh minimal. All patientsexperiencedcompleteanhidrosisattheirfirstfollow up. Two patientsdeveloped surgery was 97 (range 50-150) minutes. There were no intra-operative complications and blood loss was The patientsincluded8womenand2menwithagesrangedfrom16-43years. The averagedurationof RESULTS hyperhidrosis focussinguponit`sefficacyandoutcome.. To presentourearlyexperienceandminimalsympathectomytechniqueforthemanagementofplantar AIMS hyperhidrosis. present acaseseriesofendoscopiclumbarsympathectomy(ELS)performedatourvascular unitforplantar significant morbiditysuchasskinblistering, bacterialandfungalinfection social stigmatisation. We Clinicians areoftenlessaccustomedtomanagementofplantarhyperhidrosiswhichisassociatedwith Surgical managementofpalmar, axillary&facialhyperhidrosisisfamilartovascular andthoracicsurgeons. INTRODUCTION 123 - - EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY The sympatheticchainproximally anddistallyiseithercrushedwithtwo5mmclips, ordividedwithahookdiathermy 124

miscellaneous Periarterial digitalsympathectomy: aheroicsalvage forsevereischaemiaof Sanjay Singh, MoatasiemBukhari Kingdom Raynaud`s University Hospital of Morecambe NHS Trust Royal Lancaster Infirmary, Lancaster, United United Lancaster, Infirmary, Lancaster Royal Trust NHS Morecambe of Hospital University those whoarerefractorytomedicaltherapy. both extremities, inthosepatientswho have disablingsymptomssuchasischemicpainorulcerationand salvage andnotafutileexercise. We recommendthisproceduretobecarriedoutsalvage thedigitsin performed toevaluate theefficacyandsafetyofdigitalsympathectomy. Digitalsympathectomyisaheroic studies withstandardized inclusion criteria, timing for interventionandconsistent follow upshouldbe of pain, healingofulcersandpreservations ofthedigits. Howeverweacceptthatmulticentricprospective Our studyfindingsdemonstratethatdigitalarterysympathectomyisaneffectivetechniquefordiminution CONCLUSIONS under surveillance. Ulcerations andgangrenousareaswerehealedcompletelyin92.8%(13/14). The oneunhealedulceris Rest painwas resolvedinallthepatientsexcepttwowhere painreturnedincoldenvironment. medical treatments. ischemic painandhadproximalvesseldiseaseexcludedbyarterialduplexscanwererefractory to pain was presentinallpatients. All patientspresentedwithcoldintolerance, numbnessandworsening tomy forsevereischaemiawereincludedinstudy. Patient agesrangedfrom37to76years. Preoperative Eleven patients representing 48 affected digits (42 fingers and 6 toes) who underwent digital sympathec RESULTS ics andoutcomeswereanalysed. We reviewedalldigitalsympathectomiesperformedatourvascular unitbetween2006-2015. Demograph METHODS Raynaud’s refractorytomedicaltreatments. evaluate theoutcomeofdigitalsympathectomyforpatientswithsevereischaemiasecondaryto ical agents; behaviouralmodificationsandbiofeedbacktherapies. The aimofthepresentstudy was to they havealreadydevelopedrefractoryulcers. The currentconservative treatmentincludespharmacolog difficult and frustrating problem to solve. The patients areusually referred tothe vascular surgeons when Digital ischemia with ulceration and gangrene can be a manifestation of Raynaud’s phenomenon. It is a AIM 125 - - - EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY Jagia P miscellaneous Amplatzer vascular plugsinvascular diseasesinpatientswithcongenitalheart disease (CHD) 3. Professor, Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, India Delhi, New Sciences, Medical of Institute India All Radiology, 4. Cardiac Professor, 3. 2. 1. Types ofPlugs Table showing typesonplugscommercially available FIGURES of vesselswithhighflow. dium andlargevesselswherecoilsareineffective. AVP IIwas foundtobeespeciallyuseful intheclosure AVPs arecurrentlythedevicesof choicetooccludeavariety ofvascular communicationsspeciallyinme CONCLUSION with occlusionoftargetvessel. Noprocedurerelatedoraccesssitecomplicationsoccurred. (PDA) (n=3), andveno-venouscollaterals(n=2). Ofthese, 96%oftheplugscouldbedeployedsuccessfully to-pulmonary collaterals(n=17), closureofpatentBlalock-Taussig shunt(n=5), patentductusarteriosus malformation (AVM)(n=26) orpulmonary aneurysms(n=3), coronaryandsystemic AVM (n=10), aor implantation. The major indications for embolotherapy included embolisation of pulmonary arterio-venous AVP type I while 44(65%) received AVP II. Three patients received AVP III while two patient had AVP IV A totalof68 AVPs ofall4typeswereimplantedin50patients. 19(28%)vesselswereoccludedusing RESULTS of AVP usedandfollowupdetailsweredetermined. sizes, anatomiesandvarying hemodynamicsituations. Indicationsfortheuseof AVP, thetypeandnumber uary 2015was done. AVP isusedforembolizationandhasdifferentmodelssoastofit vascular A retrospectivereviewofproceduresemployingthe AVP atourinstitutebetweenJanuary 2005andJan MATERIAL ANDMETHODS in patientswithcongenitalheartdisease(CHD). To presentthevarious indicationsforuseof Amplatzer Vascular Plug(AVP) invascular diseasesespecially OBJECTIVES India Additional Professor, Cardiology, All India Institute of Medical Sciences, New Delhi, India Delhi, New Sciences, Medical of Institute India All Cardiology, Professor, Delhi, New Additional Sciences, Medical of Institute India All Radiology, Cardiac Professor, Additional Professor and Head, Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, India Delhi, New Sciences, Medical of Institute India All Radiology, Cardiac Head, and Professor 1 , S. Sharma 2 , G. Gulati 3 , S. Ramakrishanan 126 4 - - -

Aorto –Pulmonary collateral (APC)embolizationforlowcardiac outputstatefollowingcorrection surgeryfor Tetralogy ofFallot AVM. Follow-up CTangiography (H)doneafter10daysshownoflowacrossthefeeder, andpartialthrombosisofthe AVM. deployment (F)of12mm AVP II(yellowarrow)inthemainarterialfeeder. Checkangiography (G)showssluggishflowacrossthe Simple PAVM ina15yearoldchild: Selectivecatheterangiography(E) was donetodemonstrate thevascular anatomyfollowedby Rendered reformattedimage(C)depictingthesame. Axial lungwindows (D)showednootherparenchymallungabnormality in theleftlungwithaarterialfeederfromLPA (redarrow). Itdrains intotheleftlowerlobePulmonaryvein(bluearrow). Volume Simple PAVM ina15yearoldchild Axial (A)andoblique sagittalreformattedMIPimages(B)ofCT Angiography show alarge AVM 127

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY blue star)withPA fillingwerelaterembolizedusing coilsandgelfoam. (red arrow)(B)10mm AVP IIdeployedintheshuntfromaorticside, (C)noflowseenacrosstheBTS, (D)multiplecollaterals ( Modified Blalock Taussig Shunt(MBTS)embolization: (A)Selectiveangiogram showspatentleftMBTS(yellowarrow)fillingthe PA collateral channel. mm AVP IIdevicewas deployedintothecollateral channel(D)Checkcontrast injectionshows completeflowocclusion across the tortuous venouschannel(yellow arrow)draining intotheleftsided atrialchamber(blackstar)s/oveno-venouscollateral (C)14 (A) Antero posterior and(B)obliqueviewofselectiveinjectionintotheleftinnominate vein(bluearrow)showsfillingofalarge Large Veno –Venous Collateral inapatientofpost BidirectionalCavo–Pulmonarycirculationcausingpersistent desaturation 128

9. 8. 7. 6. 5. 4. 3. 2. 1. REFERENCES coronary arteryfistulawiththeamplatzer vascular plug. Pediatr Cardiol30:172–175. Wiegand G, SieverdingL, KaulitzR, HofbeckM(2009) Transarterial andtransvenous approachfortranscatheter closureofalarge back doorwhenthefrontislocked. CatheterCardiovasc Interv73:390–394. the newamplatzervascular plug. Cardiol Young 17:283–287. children withcongenitalheartdisease: A caseseries. CatheterCardiovasc Interv69:33–39. Embolization with Amplatzer vascular plug. RevPort Pneumol15:331–337. lar plugs. JInvasive Cardiol18:E121–E123. using the Amplatzer Vascular PlugII. Cardiovasc InterventRadiol33(5):1044–1048 using the Amplatzer vascular plug. Cardiovasc IntervRadiol31(2):411–414 Brown MA, BalzerD, LasalaJ. (2009)Multiplecoronaryarteryfistulaetreatedwithasingleamplatzer vascular plug: Checkthe Fischer G, Apostolopoulou SC, RammosS, KiaffasM, Kramer HH(2007) Transcatheter closureofcoronaryarterialfistulasusing Hijazi ZM. Newdeviceforpercutaneousclosureofaortopulmonary collaterals (2004)CatheterCardiovasc Interv63:482–485. Hares DL, Tometzki AJ, MartinR. (2007)Useoftheamplatzervascular occludertooccludelargevenousvesselsinadultsand Santos CS, Norte A, Ferreira I, Peirone AR, Spillman A, Pedra C. (2006)Successfulocclusionofmultiplepulmonaryarteriovenousfistulasusingamplatzer vascu Boixadera H, Tomasello A, QuirogaS, CordobaJ, Perez M, Segarra A. Successfulembolizationofaspontaneousmesocaval shunt Kretschmar O, Knirsch W, Bernet V (2008)Interventionaltreatmentofasymptomaticneonatalhepaticcavernoushemangioma et al et . (2009)Hereditaryhemorrhagictelangiectasiaandpulmonaryarteriovenousmalformations— 129 - EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY Stents Covered miscellaneous 1. REFERENCE question. ed. The randomized, patientandinvestigatorblindedCoBaGItrialwillprovideananswertothispatency Conclusion: Prospectivelyassessmentofthepatencycovered omized. Two othercentersareawaiting ofmedical-ethicalapproval. Currently, 4Dutchcentersactivelyparticipateinthistrial. Twenty of84patientsareincludedandrand RESULTS for theimplantedstentduring2yearsfollow-uptime. fectiveness willalsobedetermined. Patients, researchersanddoctors attheoutpatientclinicareblinded ment, freedom from restenosis, symptom recurrence and re-intervention, quality of life and total costs-ef giography at6, 12and24monthsafterstentplacement. Besidestheprimaryobjectiveofpatencyassess bare-metal or covered stent (Advanta V12-Atrium). During follow-up, patency will be assessed with CT-an Patients withatheroscleroticCMIeligibleformesenteric stentplacementarerandomizedforeithera METHODS patients withatheroscleroticCMI. The CoBaGItrialisdesignedtoprospectivelyassessthepatencyofcovered AIM this finding. rates for covered stents retrospectively. A randomized controlled trial is needed to prospectively confirm Bare-metal stentsarestandardcarecurrently, althoughOderich Endovascular therapyhasrapidlyincreasedandreplacedsurgeryasfirstchoiceoftreatmentinCMI. morbidity andmortality. prandial painandweightlosstopreventacute-on-chronicischemia, whichisassociatedwithhigh can causeChronicMesentericIschemia(CMI). Revascularization is needed for reliefofsymptomsaspost Atherosclerotic stenosisoftheceliacartery, superiormesenteric arteryand/orinferiormesenteric INTRODUCTION Louisa J.D. van Dijk – onbehalfoftheDutchMesentericIschemiaStudygroup(DMIS) Ischemia (CoBaGI): amulticenterrandomizedcontrolled trial 2. Department of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands The Rotterdam, Center, Medical University MC Erasmus 3. Radiology, of Department 2. equally 1. contributed authors *Both treatment ofchronicatheroscleroticmesentericarterialdisease. Journalofvascular surgery. 2013;58(5):1316-23. Oderich GS, ErdoesLS, LesarC, MendesBC, GloviczkiP, ChaS, The Netherlands The Netherlands The Rotterdam, Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, Rotterdam, Vlietland, & Gasthuis Franciscus Hepatology, and Center, Medical Gastroenterology of University MC Department Erasmus Hepatology, and Gastroenterology of Department versus 1,2 , Désiréevan Noord Bare-MetalStentsinChronic Atherosclerotic Gastrointestinal 1,3 , MarcoJ. Bruno 130 et al et . Comparisonofcoveredstents et al et versus . 1 *1 showedsignificantlyhigherpatency , Adriaan Moelker, Adriaan bare-metalstentsinCMIisneed versus versus bare-metalstentin baremetalstentsfor *2

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY Popplewell Matthew Bypass peripheral Gareth Bate angioplasty of outcomesinpatientsrandomisedtoinfra-poplitealveinbypassorplainballoon 2. Birmingham Clinical Trials Unit, Department of Medical Statistics, Birmingham, United Kingdom United Birmingham, Kingdom Statistics, United Medical of Birmingham, Surgery, Department Unit, Vascular of Trials Clinical Department Birmingham 2. Birmingham of University 1. or endovascular intervention astheirprimaryrevascularisation procedure. patients withSLIwhorequireIPrevascularisation andwhohavesuitable veinforbypassshouldhave VB Further randomisedcontrolledtrials, such asBASIL-2 CONCLUSIONS and theprimaryend-point(VB43.5 (18 ABPI. Medianlength of index hospital admission was significantly greater inthe VBthanin thePBA group (p=0.005) buttherewerenosignificant differencesinwoundhealing(figure4)ormeanimprovement in PBA (73%). Patients undergoing VB enjoyedquicker reliefofrestpain(figure3)whencomparedtoPBA from arterialintervention. Primarytechnical successwas non-significantlyhigherfor VB(86%)than for in thePBA group(table1). There was nosignificant differencein AFS(figure1), OS(figure2)orfreedom VB groupandmoreprevioussurgicalarterialintervention(p=0.03)anti-hypertensive(p=0.04)use for morechronickidneydisease(p=0.007)andnon-steroidalanti-inflammatorydruguse(p=0.02)in the The 56patientsrandomisedtoIP VB andthe48toIPPBA werenotsignificantlydifferentatbaselineexcept RESULTS ischaemic woundsandcessationofrestpain. of revascularisation was assessedbymeasurementofpreandpostprocedural ABPI andtimetohealingof re-intervention, immediatetechnicalsuccess, crossoverinterventions, andlengthofhospitalstay. Quality putation freesurvival (AFS); secondaryoutcomesincludedoverallsurvival (OS), freedomfromarterial Interrogation ofprospectivelygathereddatafromBASIL casereportforms. The primaryoutcomewas am METHODS (BASIL) trial oplasty (PBA) within the UK NIHR HTA-funded Bypass To compareoutcomesinpatientsrandomisedtoinfrapopliteal(IP)veinbypass(VB)orplainballoonangi OBJECTIVES vs . 10days, p<0.0001), therewas nodifferenceinmediantotalhospitalstaybetweenrandomisation versus 1 . 1 , SmitaaPatel angioplastyinsevereischaemiaoftheleg(basil)trial: acomparison 1 , HuwDavies 2 , Andrew Bradbury , Andrew vs . PBA 42days). 1 , JyotiNarayanswami 132 1 2 andBEST-CLI versus Angioplasty in Severe Ischaemia of the Leg 1 , MaryRenton 3 arerequiredtodeterminewhether 1 , Alex Sharp , Alex 1 , - -

Figure 4. Time tocessation ofrestpain Figure 3. Time tohealingofischaemicwounds Figure 2. Overall Survival to5years Figure 1. Amputation Free survival outto5years FIGURES 133

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY 3. 2. 1. REFERENCES Baseline characteristics TABLES Surgical Endovascular Previous Intervention Amitriptyline Gabapentin NSAIDs Opiates Paracetamol Warfarin Statin therapy Antihypertensive Clopidogrel Aspirin Medical therapy Tissue loss Clinical Presentation Never Ex Current Smoking Status Insulin dependentDM Diabetes (DM) Dialysis Angina Myocardial Infarction / TIA Stroke Chronic kidneydisease Comorbidities Male sex Age (years)(mean, SD) (BASIL): multicentre, randomised controlledtrial. Lancet. 2005;366(9501):1925-34. Adam DJ, BeardJD, Cleveland T, BellJ, Bradbury AW, Forbes JF, patients withcriticallimbischemia. Semin Vasc Surg. 2014;27(1):82-4. (BASIL-2) trial: studyprotocolforarandomised controlledtrial. Trials. 2016;17:11. Menard MT, Farber A. The BEST-CLI trial: amultidisciplinaryefforttoassesswhethersurgicalorendovascular therapy isbetterfor Popplewell MA, DaviesH, Jarrett H, BateG, Grant M, Patel S, Vein Bypass 74.0 (11.3) 19 (34%) 41 (73%) 13 (23%) 31 (55%) 36 (64%) 22 (39%) 34 (61%) 38 (68%) 46 (82%) 13 (23%) 29 (52%) 14 (25%) 10 (42%) 24 (43%) 11 (20%) 12 (21%) (n =56) 8 (14%) 1 (2%) 5 (9%) 5 (9%) 2 (4%) 4 (7%) 4 (7%) 2 (4%)

134 et al et et al et Plain Balloon Angioplasty Plain . Bypass . Bypass versus 77.2 (7.3) 25 (52%) 41 (85%) 16 (33%) 27 (56%) 23 (48%) 10 (21%) 14 (29%) 32 (67%) 28 (58%) 29 (60%) 12 (25%) 38 (79%) (n =48) versus 6 (13%) 7 (15%) 5 (10%) 5 (11%) 8 (35%) 8 (17%) 7 (15%) 3 (6%) 2 (4%) 1 (2%) 3 (6%) 0 (-) angioplastyinsevereischaemiaoftheleg-2 angioplastyinsevereischaemiaoftheleg

p-value 0.007 0.06 0.09 0.03 0.02 0.04 0.4 0.3 0.7 0.8 0.7 0.6 0.1 0.9 0.1 0.7 0.1 0.6 0.6 0.2 0.9 0.5 0.5

peripheral Case report: poplitealarterypseudoaneurismwitharterio-venousfistulaaftertotal Leonid Magnitskiy, MaximKuznetsov N°1, Moscow, Russia Moscow, N°1, knee replacement Pirogov Russian National Research Medical University (RNRMU), Department of faculty surgery surgery faculty of Department (RNRMU), University Medical Research National Russian Pirogov Result Popliteal arterypseudoaneurismwitharterio-venous fistula FIGURES artery andveinwas successfullyperformed. The patienthadnofurtherarterialcomplications. gery usingposteriorapproachwithresectionofthepseudoaneurism, end-to-endanastomosisofpopliteal after totalkneearthroplastywithsymptomsofchronicarterialandvenousinsufficiency. Open vascular sur a pin. We reportonacaseofpoplitealpseudoaneurismwithatrerio-venousfistulapresentedtous3years ing. The mostcommonmechanismofarterialinjuryisdirectpenetrationwithsawbladeorperforation Popliteal vascular traumaduringtotalkneearthroplastyisrare, butdangerousandmaybelimb-threaten

After resection 135 - - EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

peripheral The lowerextremitiesischemiaanddiabetic foot. Ourexperience Harieta Saracini, LauraLeci Tahiri, EshrefOsmani Vascular Clinic, Pristina, Albania Pristina, Clinic, Vascular Diabetes mellitus, earlyprevention, legamputation KEY WORDS multidisciplinary teampreventsamputationinmostcaseswithcomplicateddiabeticfoot. Early identificationofriskfactors, regular andcautiousevaluation aswellaggressivetreatmentina CONCLUSION • 14caseshavebeenwithoutreconstructingopportunities. out inthecruralregionand6patients(6.38%)amputation was carriedoutinthefemoralregion. tation ofthelegismadein37cases(39.36%), whilein11patients(11.70%)amputationwas carried cases (19.1%) while with the incision and necrectomy were treated 22 patients (23.4%). Finger ampu gical interventionwithaggressivesurgicaldebridementtoamputation. Dailytoiletismadeof18 bic bacterialflora, cytrobacter.Local treatmentinitiallyisdonewithdailytoiletsofthewoundorsur rococcus, Staphylococcus aureus, MRSA. Also was isolated Proteus mirabilis, mixed aerobic-anaero the presenceofinfectioninallanalyzedpatients. The mostcommonlyisolatedbacteriawas Ente over, femoro-poplitealbypassandfemoro-tibialisposteriorbypass. Inthewoundswab isconfirmed formed: aortobifemoral by pass, axillofemoral by pass, aortofemoral by pass, femoro-femoral Cross 61 outof94patients(64.89%)havebeenwithischemiaand33(35.1%)withoutischemia.We per RESULTS and theimportanceofvascular reconstructionastheprimarysurgicaltreatmentofchoice. how todealwithdiabeticfootinpatientsextremitiesischaemiadifferentstageofdevelopment, Increasing numbersofpatientsisbecomingevenmorealarming. The purposeofthispaperistoanalyze diabetes, wecan concluded that adiabetic foot represents health, as well social andeconomic problem. Given thattherelativelylargenumberofpatientstowhomcomplicationsaredevelopedtoedue INTRODUCTION 136 - - - - -

peripheral Fusion imagingreducestheneedforcontralateralorbrachialaccesswhenusingre- Sandip Nandhra, ClaireDawkins, Andrew Brown, KlausOverbeck entry catheterstocrosstotalaorto-iliacarteryocclusions Sunderland Royal Hospital, Sunderland, United Kingdom United Sunderland, Hospital, Royal Sunderland of complexaorto-iliacocclusionswas 100%successful. bilateral orbrachialarterialaccesstoimagetheaorta. Fusionimagingguidedre-entryinthissmallseries Fusion imageguidedcatheterre-entryintothedistalaortaappearstobesafeandmayreduceneed for CONCLUSION One limitedaorticdissectionwas treatedbyiliackissingstentsinabilateralocclusion. quired for the bilateral aorto-iliac occlusions. No cases of rupture or distal embolisation were encountered. re-canalised. There wereonlytwoofthecasescontralateralaccessforimaging. Nobrachialaccesswas re Successful re-entry was achieved in 100% of the patient’s resulting in all aorto-iliac occlusions successfully RESULTS was thenlinedprimarilywithcoveredstentgraftsdilatedto8–10mm. used toorientateare-entrycatheterintheaorta. The intimawas punctured close totheocclusion, which accurate matchintwoplanesusingthefusionC- Arm system. After afailedre-entryattempt, fusionwas of themaskusingboneandangiographicregistrationaccessfemoraliliacartery(s)tocreate an fusion hybrid C- armsystem. Within thededicated hybrid theatre on-table 2 and3dimensional registration waypoints was createdbysemi-automaticsegmentationthroughtheocclusion. This was uploadedontoa the workstationapre-operativefusionmaskofpre-proceduralCTangiogramusingcentrelinesand patients) withbetweenFontaine IIb(10-100meter)andFontaine IVstagediseasewereincluded. On A totalof7patientswitheitherunilateral (5 patients)orbilateral iliac anddistalaorticocclusions(2 METHODS single femoral access in unilateral and femoral access only in bilateral iliac and infrarenal aortic occlusions. to orientatethecatheterintwoplanes. Fusioncanallowsuccessfulre-entryusingdynamicimagingvia is requiredaswell. Traditional roadmappingisstaticanddoesnotallowtherequiredrotationofgantry bilateral femoralarteryaccessisrequired. Inbilateraltotaliliacocclusionimaging viaabrachialapproach Conventionally, whenusingare-entrycatheterintheaorta in patientswithunilateraltotaliliacocclusions, INTRODUCTION 137 - EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY A.Eldmarany Haitham peripheral Duplex guidedangioplastyforfemoro-poplitealarterialocclusivediseases; Ahmed Elmarakby feasibility andshort-termoutcomes 3. Lecturer of vascular surgery, Kasr Alaini hospital, Cairo University. University. Cairo hospital, Alaini University. Kasr University. Suef Cairo surgery, Beni surgery, hospital, vascular of Alaini vascular Kasr of Lecturer 3. surgery, professor vascular of Assistant 2. professor Assistant 1. In patientsatriskofdevelopingcontrastinducednephropathy, orwho haveprovenallergiestoiodinated CONCLUSION which was detected bycolorflowimaging. Three proceduralcomplicationswereobservedinthe formof2groinhematomasand1vesselperforation 0.64 andimprovedto0.83postoperatively. Nodistal emboliweredetectedoncompletionduplexscans. angioplasty (DGA)were129mm/s, showingareductionof62%. For alllesions, meanpreoperative ABI was mm/s afterangioplastywithanaveragereduction of 64%. MeanPSV2weeksfollowingduplexguided For stenotic lesions, the mean peak systolic velocity (PSV) prior to treatment was 340 mm/s and was 120 11 stentsweredeployedintheSFA andtheremaining5stentswereinabovekneepoplitealsegment. and plaquerecoilin4cases(19%). 10cases neededasinglestentwhilein3cases2stentswerenecessary. was neededin13(62%)cases. The reasonforstentplacementincluded: arterialdissectionin9cases(43%) duration rangedfrom45to130minutes(median: 87minutes). Placementofnitinolself-expandable stents technical successwas confirmedbycompletionduplexscanand was documentedinallcases. Procedure found in 12 cases (57%).The average length of the lesions in this study was (mean: 14 ± 4 cm). Immediate involving the SFA alone were found in 6 cases (29 %), while significant lesions in both the SFA and PA were and critical ischemia in10(48%). Isolatedpopliteal artery lesions were foundin3cases(14%)andlesions from 50to72years(mean: 61±11years). Disablingclaudicationwas theindicationin11cases(52%) 21 patients(15men&6women)withserumcreatininelevelsof≥1.5mg/dLwereselected. Ages ranged RESULTS artery (SFA) and/orpoplitealartery(PA). (CTO) ofthefemoro-poplitealarterial segmentaffectingthemiddleorlower1/3ofsuperficialfemoral 2015), whoprovedbyarterialduplexexaminationtohave>50%stenosisorcompletetotalocclusion ratory evidenceofrenalinsufficiencypresentedtoouroutpatientclinicbetween(January 2014toOctober This study included patients with peripheral arterial diseases (PAD); (Rutherford category: 3-6) and labo PATIENTS ANDMETHOD procedural complications, andclinicalimprovementafter3&6months. liteal endovascular proceduresunderduplexguidancealonewithassessmentofinitialtechnicalsuccess, need forradiationexposure. Objectives: To examinethefeasibilityofperformingperipheralfemoro-pop give thepotentiallynephrotoxic contrast agentsespeciallyinrenalimpairment patients andreducingthe study, wetriedtoperformtheangioplastyproceduresunderduplexguidancealonewithoutneed angioplasty procedures and is associated with increased patient morbidity and mortality. In this feasibility Contrast-induced nephropathy (CIN) is a well-known complication of conventional fluoroscopy guided INTRODUCTION ventional PTA. contrast media, duplexultrasound guidedPTA presentsa fairlysafeandperformablealternativetocon 1 3 , Ahmad Gamal , Ahmad 1 , Ayman Refaat , Ayman 138 2 , Ahmed Farghaly, Ahmed 1 ,

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Elsherif Mohamed peripheral Common Femoral Artery Endarterectomy. Mid Term Outcomes 2. Galway Clinic, Royal College of Surgeons of Ireland, Galway, Ireland Galway, Ireland, of Ireland Galway, Surgeons of Hospital, College College Royal Clinic, University Galway 2. Institute, Vascular Western 1. CFE isareliableanddependableprocedure, evenintheabsenceofgooddistalrunoff. CONCLUSION Amputation freesurvival was 100%inICFE, 80%inCFEAand 100%inCFEE(P=0.056). Re-intervention was requiredin26.9%ofprimaryclosures, 100% inCFEE(P=0.409). 82.9% inCFEAand100%CFEE(P=0.17). Secondarypatencywas 90%inICFE, 94.3%inCFEA, and was 90%inICFE, 74.3%inCFEAand95%CFEE(P=0.146). Primary assistedpatencywas 90%inICFE, At 2 years, binary restenosis was 10% in ICFE, 37%in CFEA and 14.3% inCFEE (P=0.039). Primary patency (P=0.056). groups (P=0.73). Sustainedhemodynamic successwas 30%inICFE, 54.3%inCFEAand23.8%CFEE and CFEE, butwas 85.7%inCFEA(p=0.035). Immediatehemodynamicsuccesswas similarinallthree in ICFEs, 94%inCFEAand100%forCFEE (p=0.274). Immediateclinicalsuccesswas 100%inbothCFE primarily, while39required patch closure (12 venous, 8 Dacron, 19 biological). Technical success was 100% CFEA and21underwentCFEE. Demographics were comparable inallgroups. Twenty-seven wereclosed 1134 requiredrevascularization. Sixty-sixpatientsunderwentCFE. Ten patientsunderwentanICFE, 35had From 2002to2015, 1512patients werereferredwithadiagnosisofcriticallimbischemia(CLI). Ofthose, RESULTS tation werenoted. demographics followup, clinicalimprovement; typesofCFEclosure, patencyratesandsurvival freeampu (CFEA) and concomitant CFE with Endovascular Aortic Aneurysm Repair (CFEE) were included. Patient All patients who underwent either isolated CFE (ICFE), CFEwith angioplasty for occlusive arterial disease METHODS procedures. clusive disease. We aimtoassessthemediumtermoutcomesofCFEwithorwithoutfurtherconcomitant Common femoralarteryEndartrectomy(CFE)isthestandardtreatmentforcommonoc BACKGROUND ANDAIM 1 , RuthCampbell 1 , Wael Tawfick 139 1 , NiamhHynes versus 12.8%withpatchclosures(P=0.279). 1,2 , SherifSultan 1,2 - - EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

peripheral Comparative evaluation ofpatients’andphysicians’expectationsregarding D. Peerboom, F. Smeets, E. Van Hoolst, S. Houthoofd, K. Daenens, I. Fourneau physician relationship outcome measurementsinperipheralarterialocclusive diseaseandthepatient- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium Leuven, Leuven, Hospitals University Surgery, Vascular of Department fore startingtreatmentcanhelptodefine PAD patientswhoareopentotrainingexercise. half ofPAD patientsexpectanimmediateimprovement. A surveyoftheexpectationsPAD patientsbe expectations always matchinindividualpatient-physicianteams. Incontrasttotheirsurgeons, lessthan Overall, PAD patientsandsurgeonsseemtohavesimilarexpectationsalthoughthisshouldnotmeanthat CONCLUSIONS 27% thoughtthiswas actuallythecase. All surgeonsstateditwas (very)importanttohavethesameexpectationsaspatients. However, only good physician(44% According toPAD patientsandsurgeons, beingacompetentsurgeonisthemostimportantqualityof tients (65%)andsurgeons(93%)expectthetreatmentstrategytobedecidedinconsensus. improvement ofthecomplaintsaftersurgery. For patient-physicianrelationshiptobesuccessful, PAD pa after treatment. However, incontrastwith93%ofsurgeons, only 46%ofPAD patientsexpect immediate Both PAD patients(75%)andsurgeons (73%)donotexpectachangeintheamountofmedication needed (31% successful is experiencing less pain (52% According toPAD patientsandsurgeons, themostimportantoutcomeparameterfortreatmenttobe RESULTS a self-developedquestionnaire. Hospitals Leuven, and15Flemishvascular surgeonswereasked about theirexpectationswiththehelpof Fifty fivepatients with PAD, randomly recruited atthe department of Vascular Surgery oftheUniversity METHODS tient-physician relationship. lar surgeonsforatreatmenttobesuccessfulandassesstheexpectationsregardingpa To investigatetheexpectationsofpatientswithperipheralarterialocclusivedisease(PAD) andvascu OBJECTIVES general. There isincreasingevidencethatalignmentofpatientandphysicianexpectationsimprovesoutcomein BACKGROUND vs . 27%). vs . 87%), followedbygivingclearinformation (39% vs . 67%), followed by a longer walking distance postoperatively 140 vs . 13%). - - - -

peripheral Patients preferredway ofquestioning ofqualitylife: A firstexplorationinpatients D. Peerboom, S. Vander Mijnsbrugge, S. Thomis, B. Bechter-Hugl, K. Daenens, S. Houthoofd, I. Fourneau with IntermittentClaudication Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium Leuven, Leuven, Hospitals University Surgery, Vascular of Department treatment ofheadandneckcancers. Oral Oncol. 2015 Dec;51(12):1132-7 Pollom EL, Wang E, Bui TT, REFERENCES implementation ofQOLsurveysandPROMsinthecareprogramforICpatients. an importantfactorinfluencingpatients’preferences. This shouldbetaken intoaccountwhenconsidering The majorityofICpatientspreferredtocompletethesurveyonpaperandwithassistance. Age maybe CONCLUSIONS individually, 13%was neutral. Patients <70yearsoldmoreoftenpreferredatablet. half ofthepatients(46%)preferredtoanswerquestionnaireswithassistance, 41%preferredtodothis (71%) preferredtofilloutthequestionnairesonpaper, 16%withthetabletand13% was neutral. About Mean ±SDagewas 70±8years. The vast majority of patients(79%)were men. The majorityofpatients RESULTS personal preferences. Group 4filled outthequestionnaires onpapier individually. Afterwards, patients wereasked abouttheir questionnaires on atabletindividually. Group3filledoutthe questionnairesonpaperwithassistance. different groups. Group1filledoutthequestionnairesonatabletwithassistance. Group2filledoutthe Questionnaire (WIQ) andtheEuroQOLEQ-5D. Duringaclinicalvisit, patientswererandomizedinto4 During thisinvestigation56ICpatientswerequestionedabouttheirQOLusingthe Walking Impairment All patientswererecruitedattheDepartmentof Vascular SurgeryoftheUniversityHospitalsLeuven. METHODS To investigatethepreferencesofpatientswithsymptomsICregardingmethodQOLassessment. OBJECTIVES about thepreferencesofpatientswithintermittentclaudication(IC). feasible, butpatients≥70yearsoldmaybenefitfrommoreassistanceduringthisprocess1. Littleisknown research inpatientswithheadandneckcancerconcludedthattheuseoftabletsforquestioningQOLwas tient management. Electronicdatacollectionisanattractivealternativeforpaper-based surveys. Previous Patient reportedoutcomemeasures(PROMs)andqualityoflife(QOL)assessmentgainimportanceinpa BACKGROUND et al et . A prospectivestudyofelectronic qualityoflifeassessmentusingtabletdevicesduringandafter 141 - EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

peripheral Pharmaco-mechanical thrombolysisinacuteDVT: retrospectiveanalysis Gowda GaneshG. New Delhi, India Delhi, New tion ofearlyclotburden, PTSandrecurrentDVTwhileutilizingminimallyticagent. Pharmaco-mechanical thrombolysisusingMPA guidingcatheterisasafeandeffectivemethodforreduc CONCLUSION them hadulcerorvenousclaudication. developed mild to moderate PTS and, 1(<3%) patient developed recurrent DVT during follow up. None of used was 44.2mg. There was nomajorbleedingorprocedurerelatingcomplications. Four (12%)patients out ofwhich14wereinCIV;13 ofthem weremanagedbyprimarystenting. The averagedoseofR-tpa Complete clot lysis was achieved in 24 (70%)patients. Underlying lesion was noted in 19 (55%)patients RESULTS was assessedusing Villalta scoringsystem. mean durationofthrombolyiswas 20hours. The meanfollowupwas 19months(12to42months). PTS in allpatientsfollowedbymechanicalthrombolysisandsubsequentpharmacological. The agent. IVCfilter was placedin19patients(57%). Ultrasoundguidedpoplitealveinpuncture was done (25 male, 9female; meanage40years)usingMPA guidingcatheter(7F/8F) withR-tpaasthrombolytic 33(34 limbs)patientswithsymptomaticilio-femoralDVTunderwentpharmaco-mechanicalthrombolysis METHODS To asses1yearpostthromboticsyndromeandrecurrentDVT. OBJECTIVES recombinant TPA forthrombusmacerationandaspiration. institutional experience of pharmaco-mechanical thrombolysis using simple MPA guiding catheter and chanical thrombolysisinviewofincreasedemphasisonearlyreductionclotburden. Hereweshareour The currentstandardofcareinmanagementacuteileofemoralDVTisshiftingtowards pharmaco-me BACKGROUND 142 - -

Keirse Koen peripheral Use ofDrugcoatedBalloonPTA asfirstlinetreatmentforall Femoropopliteal lesions H. Hart hospital, Tienen, Belgium Tienen, hospital, Hart H. SFA. Full24-monthdataandpreliminary 36-monthdatawillbepresentedatthecongress. cy ratesandfreedomfrom TLR andappearstohavebetterresultsascomparedPOBA orstentingofthe Treatment ofallreal-worldSFA diseasewithDEBseemssafeandfeasible, showspromisingprimarypaten CONCLUSION (80%). risk at24months. Mostpatientsimproved theirRutherfordassessment(95%)and ABI assessment Results showaprimarypatencyat12monthsof88.2%for86patientsriskresp. 80%for79patients at Safety andEfficacyendpointasdefinedinmethods was87.7.3%resp. 91.8%(85.6%at24m). Feasibility endpoint to treat all lesions only with DEB PTA and patent target vessel was 73.2% (98/134). The average. overall meanlesionlengthwas 80mm. The preliminarymeanfollow-uptime, todate, was 36monthson of 116limbstreatedandpresencemultipellesionsresultedin134thissubcohort. The claudication and13.2%presentedwithcriticallimbischemia. Bilaterallimbinclusionresultedinatotal Of the92patientsenrolled, 69.5%were menandthemeanagewas 69.5years. 86.8%hadintermittent RESULTS in thetargetvesselwithnoreintervention. freedom from>50%restenosisat12monthsasindicatedbyanindependentlyverifiedduplexPSVR <2.4 freedom fromclinicallydriven TLR within12monthsandprimarypatencymonths, definedas from majortargetlimbamputationandfreedom TLR within12months. The efficacyendpointis endpoint includes freedom from device-related and procedure-related mortality through 30 days, freedom of crossingthelesionandtreatingwithDEBsuccessfullywithoutanyadditionalstenting. Safety exclusion criteria as described in IN.PACT Global. Feasibility endpoint of the trial includes technical success ropopliteal diseasepresentedtoourcenterduringthisperiodofwhichthelesionmetinclusionand consecutively enrolled. Selectionbiaswas minimizedbyenrollingallpatientswithatheroscleroticfemo Between Nov2012andSep2014, 92patientswithlesionsinSFA extendingintopoplitealareawere METHODS to investigatethelong-termresults(up60months)byuseofDCBtechnology. lesions, restenosesandin-stentrestenosis)inasubcohortofpatientsincludedtheIN.PACT Globaltrial and orpoplitealartery. We havetreated116limbsconsecutivelywithSFA disease(including TASC CandD The use ofdrugcoated balloons (DCB), canpotentially reduce the number andlength of stenting in the SFA BACKGROUND 143 - - EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY Meirvenne Van E. peripheral Endovascular Treatment ofFemoropopliteal Arterial Disease. Does costrelatetooutcomeinasinglecentreexperience? 2. Department of interventional radiology, University Hospitals Leuven, Leuven, Belgium. Leuven, Leuven, Hospitals Belgium. Leuven, University Leuven, radiology, Hospitals interventional University of surgery, Department 2. vascular of Department 1. raises whetherthesemoderateresultsjustifyhighexpenses. patency buttheyenabletoachievethesameratesforincreasingseverityoflesions. The question at awiderangeofcostperprocedure. High costproceduresdonotresultinbetterclinical1-yearprimary femoropopliteal arterialdiseaseisnotasgoodexpectedfromtheresultsofclinicaltrialsandachieved This singlecentreexperienceshowsthatreallifeclinical1-yearpatencyoftheendovascular treatmentof CONCLUSIONS salvage ratewas 93.8%andsurvival ratewas 85.8%. (P=0.589), buthighcostsinterventionstreated moreseverelesions. At 1yearoffollowuptheoveralllimb ference inclinicalprimarypatencyratewas seenbetweenthehighcosts groupandthelowcosts treatment technique was not significantly different between groups (P= 0.989). Also no significant dif patency rate, was 55.0%forICand44.5%CLI(P=0.147). Clinicalprimarypatencyratestratifiedby and forcriticallimbischemia(CLI)in45.67%. Hemodynamicsuccess, definedas1-yearclinicalprimary Endovascular interventionwas performed on162limbs, fordisablingclaudication(IC)in54.33%ofcases RESULTS performed. Demographics, lesioncharacteristics, intraproceduraldetails, patencyandcostswerestudied. by endovascular means at the University Hospitals Leuven between January 2014 and January 2015 was A retrospectiveanalysisoftherecordsallpatientstreatedforfemoropoplitealarterialocclusivedisease METHODS able cost-effectivechoice. This analysisaimstorelatecostsoutcome. mostly based onlesion characteristics and surgeon’s preference, which does notalways match the favour used, aswellstenting, atherectomyoracombinationofthem. The choiceofendovascular techniquesis sive disease. Balloondilatationwithplainoldballoonangioplasty(POBA) ordrugcoatedballoon(DCB)are Endovascular treatmenthasbecomethefirstoptioninmanagementoffemoropoplitealarterialocclu AIMS 1 , S. Houthoofd 1 , K. Daenens 144 1 , G. Maleux 2 , I. Fourneau

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peripheral Clinical OutcomesafterIntra-arterial Thrombolysis forLowerLimbIschaemia – S. Whelan-Johnson,Debard, A. T. Ward,K. Augustine How Successfulisit? Musgrove Park Hospital, Taunton & Somerset NHS Foundation Trust, Taunton (United Kingdom ) Kingdom (United Taunton Trust, Foundation NHS Somerset & Taunton Hospital, Park Musgrove 1. www.parliament.uk, Departmentofhealth, July2014 REFERENCE Patients requiredanaverage of2.8daysonHDU, which costsinexcessof£1100/day1. Patients requiringsurgicalinterventionafter thrombolysis TABLE 1 thrombo-aspiration devices, itmaybecomemoreeffectivewithreducedHDUstayandlowercosts. time consumingandmanypatientsneedfurthersurgicalrevascularization. With theintroductionofnew Thrombolysis canproducesuccessfulresultsbutpatientsshouldbecarefullyselected. Itisbothcostlyand CONCLUSION from intracranialbleedingoccurredin4%. intervention (see Table 1). Within 30daysofthrombolysis,13% underwentmajoramputationanddeath nical successonthecompletionangiogram was seenin50%patients. 33%patientsrequiredsurgical in 62%casesandstentsplaced8%. 75%patientsrequired2ormorefollow-upangiogramsandtech graft occlusionin21%, occludedstentin8%andembolus4%. Concomitant angioplasty was performed The aetiologyofischaemiawas prostheticgraftocclusionin33%, acutearterialthrombosisin33%, vein 24 thrombolysis episodes were performed in 21 patients. Median age was 66 years and 85% were male. RESULTS giograms wereperformedtoassessprogress. continuous heparininfusionandpatientsweremonitoredonthehighdependencyunit(HDU). Serialan limb ischaemia, overa4yearperiodwas performed. Tissue plasminogenactivator (tPA) was usedwitha A retrospectiveanalysisofallpatientsinourcentrewhounderwentintra-arterialthrombolysisforlower METHODS often thoughttobelessinvasive butcanbeassociatedwithsignificantmorbidityandmortality. Catheter directed thrombolysis may be used to treat patients who present with acute limb ischaemia. It is INTRODUCTION Repair pseudoaneurysm&embolectomy Fasciotomies postthrombolysis Open thrombectomy, patchclosure&refashionioningdistalanastomosis Lower limbbypass Operation 145 4 4 8 17 Percentage patients(%)

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY Vesey Alex peripheral Ferumoxytol-enhanced MagneticResonance Angiography (FeMRA) -optimaldosing David Kingsmore and feasibility 1. BHF Centre for Cardiovascular Sciences, University of Edinburgh of School Medical University Glasgow Sciences, of University 2. Cardiovascular for Centre BHF 1. signal was obtainedatadoseof3.90mg/Kg, therewas littleaddedsignalatdosesabove2.5mg/Kg. FeMRA holdspotentialinpatientswithadvanced renalfailure. We havedemonstratedthatalthoughpeak CONCLUSION ing qualitywas diagnosticbyqualitativeassessment. There werenoadverseevents. observed. This predictedpeaksignal, withsignaldropabove3.90mg/Kgintheaorta. At 2.5mg/Kg, imag Successful imaging was performed in all patients. A parabolic relationship between signal and dose was Ferumoxytol dose. Regressionanalysiswas performed. Qualitativeimagingassessmentwas performed. in theaorticlumenpre-andpost-contrastsequences. MeanROIsignalwas recordedandplottedagainst was performedpre-contrastandaftereveryaliquotofFerumoxytol. Regionsofinterest(ROI)wereplaced fistulae imaged. Patients received4mg/Kgof Ferumoxytol individedaliquotsandaorto-iliac3D-FLASH patients had peripheral arterial imaging and were included in the analysis. The remaining 5 had dialysis 31 patientswithadvanced renalfailureandaclinicalindicationforimagingwereoffered3TFeMRA. 26 METHODS ANDRESULTS finding study. enhanced magnetic resonance angiography (FeMRA) inpatients with renalfailureandperformed a dose aging inothersettings. They alsoholdpromiseforangiography. We testedthefeasibilityofferumoxytol netic particlesofironoxide(ferumoxytol)aresafeinchronickidney disease andhavebeenusedforim Traditional contrastmediaareproblematicinadvanced chronickidneydisease. Ultrasmall superparamag BACKGROUND 1 , MartinHennessy 2 , Patrick Mark 2 , SokratisStoumpos 2 , GilesRoditi 146 2 2 , Aleksandra Radjenovic , Aleksandra 2 ,

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Regal Samer peripheral Endovascular-first strategyformanagementofperipheralarterialaneurysmsin Behcet’s Disease: A contemporary caseseries 2. 2. University 1. Mansoura University professor, associate Mansoura professor, Endovascular *** and associate Vascular MD, ** Endovascular and Vascular MD, * ease, isafeasibleandsafestrategythatcanallowforlessinvasive interventionsforsuchchallengingcases. Endovascular approach asafirstoptionfortreatmentofperipheralarterialaneurysmswithBehcet’s Dis CONCLUSION access site. 2 asprimaryinterventions on emergencybasis, 3forfailedEVR, andoneforapseudo-aneurysm at the Open repairwith1ryanastomosisorveingraftaddedPTFEwrappingwas carriedoutin6situations; Mean followupwas 34months(7-48months). Duringfollowupperiod, 3stentsoccluded. Open repairwas thefirstapproachin2cases(13%), presentingwithrupture. (69%), andassisted1rysuccessin1case(8%), andfailedin3(23%). Endovascular approachwas attempted in13aneurysms(12cases, 87%), with1rytechnicalsuccessin9 bosis (DVT). were associated with limb ischemia, and 3of the elective cases were associated with deep venous throm while the other 4 (27%)presented to emergency department with ruptures (P=0.023). Two of the ruptures Age rangedfrom23to48(Mean32.2)years. 10cases(11aneurysms, 73%)weremanagedelectively, Between January 2012andJanuary 2016, 14cases, with15peripheralarterialaneurysmswereidentified. RESULTS performed incaseoffailureornon-feasibilityendovascular repair(EVR). and January, 2016. An endovascular firstapproach was always sought. Opensurgicalrepair(OSR) was ripheral arterialaneurysmsassociatedwithBDandreceivedsurgicalinterventionbetweenJanuary, 2012 A retrospectiveanalysiswas carriedoutforprospectivelycollecteddata ofallcasespresentedwithpe PATIENTS ANDMETHODS pseudo aneurysmscandevelopatthelandingzonesandpuncturesitesforaccess appointing results, withhigh recurrence .Endovascular stent grafting is advised by manyauthors, however, tients, commonlyintheformofperipheralaneurysmswhichareproneforrupture. Surgicalrepairhasdis Behcet’s disease(BD)isamulti-systemdisease,with vascular complicationsrangingfrom(7-29%)ofpa INTRODUCTION College Hospital Galway (UCHG), Newcastle Road, Galway, Ireland Galway, Road, Newcastle (UCHG), Galway Hospital College Western Vascular Institute (WVI), Department of Vascular and Endovascular Surgery, University University Surgery, Endovascular and Vascular of Department (WVI), Institute Vascular Western Mansoura, Egypt Mansoura, Department of Vascular and Endovascular Surgery, Faculty of Medicine, Mansoura University, University, Mansoura Medicine, of Faculty Surgery, Endovascular and Vascular of Department surgery registrar UCHG registrar surgery MD, MRCS, Vascular and Endovascular assistant lecturer, Mansoura University. Vascular Vascular University. Mansoura lecturer, assistant Endovascular and Vascular MRCS, MD, 1* , TamerKhafagy 1** , MohammedElKassaby 147 1, 2*** - - - - - EPOSTERS

CONTROVERSIES & UPDATES IN VASCULAR SURGERY Jagia P vein Endovenous laserablation(EVLA)ofsymptomaticvaricose veinsusing1470nm wavelength diodelaser 3. Professor, Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, India Delhi, New Sciences, Medical of Institute India All Radiology, Cardiac Professor, 3. 2. 1. 4. 3. 2. 1. REFERENCES phlebitis haveemergedasmajorfactorsadverselyaffectingtheEVLAoutcomeinourpatients. tertiary health care center in India for the treatment of varicose veins. Tortuous GSV and previous thrombo These resultsre-emphasizethesafetyandefficacyofEVLAusing1470nm wavelength diodelaserina CONCLUSION showed competeocclusionofablatedveins. improved symptomstatusandvenousdisabilityscoreat1year. A 2-yearfollow-upinfiftysixpatients rate ofsuccessfulvenousocclusionwas 98.2%. Clinicalimprovement was seenin>96%patientswith tality ormajoradverseevents(DVT, PEornerveinjury)werenoted. At theendof1-year follow-ups, overall thrombophlebitis (8), tortuousGSV(13), GSVperforation(1)andpresenceofCFVthrombus(5). No mor The procedurewas technicallysuccessfulin95%.The causesoffailurewereGSVstenosisduetoprior RESULTS doppler studyupto1year. injecting perivenoustumescentanesthesia. Patients werefollowedupforclinicalimprovement andfor (GSV) and54shortsaphenousveins(SSV)weretreatedbyEVLAunderultrasound(US)guidanceafter All patients underwent a detailed pre-procedure doppler ultrasound. A total of 451 great saphenous veins patients were treated by EVLA using 1470 nm wavelength diode laser between August 2010-January 2016. In aprospective, non-randomized, consecutivelyenrolledsinglecentertrial, 505limbsin403consecutive Methods andMaterials length diodelaserinahospitalIndia Our experience ofEndovenous laser ablation (EVLA) of symptomatic varicose veins using 1470 nm wave PURPOSE petent saphenousveins. J Vasc InterventRadiol2004;15:1061-3. 2005;16:791 Timpermann PE, SichlauM, RyuRK. Greaterenergydeliveryimprovestreatmentsuccessofendovenouslaserincom Timperman PE. Prospectiveevaluation ofhigherenergygreatsaphenousveinendovenouslasertreatment. J Vasc InterventRadiol the 1470-nmdiodelaserusingradial fibreslim. Phlebology29:30–36 veins. Phlebology2009;24:26-30. Zerweck C, vonHodenbergE, KnittelM, Zeller T, Schwarz T (2014)Endovenouslaserablationofvaricose perforating veinswith Pannier F, RabeE, MaurinsU. Firstresultswithanew1470-nmdiodelaser forendovenousablationofincompetentsaphenous Professor and Head, Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, India Delhi, New Sciences, Medical India of Delhi, Institute New India All Sciences, Radiology, Medical of Cardiac Institute Head, India and All Professor Radiology, Cardiac Professor, 1 , S. Sharma 2 , G. Gulati 3 148 - - - -

when energised Laser machineand fiber The fiber emanatesredlight Presence ofsaphenofemoral refluxon valsalva Pre proceduredopplerimage ablation Varicose veins Tortuous dilated Varicose veinswithskin FIGURES

There isreductioninthevaricosities andmarkedly lessskin Pre ablationleg(left) andPost laserablation- At 3months(right) junction intodilatedGSV Doppler imageOnvalsalva, significant reversal offlowseenat Laser venousablationSchematicrepresentationof pigmentation atfollowup 149

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY 2 vein Comparison of1470nmLaserandRadial2ringFiber with1470nmLaserandRadial Robert Vlachovsky, Jan Bucek, RobertStaffa University, Brno, Czech Republic Czech Brno, University, Fiber inEndovenousLaser Ablation ofSaphenous Varicose Veins Vascumed The Vein Clinic, Brno, Prague, Czech Republic Czech Prague, Brno, Clinic, Vein The Vascumed 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. REFERENCES varicose vein, 1470nmlaser, radial 2ringfiber, endovenouslaserablation, VCSS KEYWORDS remove quality-of-lifelimitationsassociatedwithconventionalradialfiber. symptoms and comparable occlusion rates. In the early postoperative period,2-ring laser fiber seems to Endovenous treatmentofsaphenousveinrefluxwitheitherfibertypesresultsinclinicalimprovement of CONCLUSION significant differencesbetweenthegroupswereevident. VCSS scoresweresignificantlybetterinGroup2at1week(P<0.001). At6weeks, 6and12months, no Group 1, and 97.9% in Group 2. Rates of pain (3% Occlusion ratesat1and6weekswere100%inbothgroups, at6monthsand12were100%in RESULTS ovenous laserablationwithbothfibertypeswererecordedassecondaryendpoint. end¬point. Venous clinicalseverityscores(VCSS)forassessmentofquality-of-lifeoutcomesfollowingend occlusion rates at 1, 6 weeks and 6 and 12 months and pain in treated region were recorded as primary radial 2ringfiberand1470nmlaserinGroup2(48limbs)ordertoablatethesaphenous vein. Vein omized intotwogroups. They weretreatedwithradialfiberand1470nmlaserinGroup1(46limbs) From January 2013toSeptember2015, 94patients(94limbs)withprimaryvaricose veinswererand PATIENTS ANDMETHODS laser ablation(EVLA)ofsaphenousvaricose veinsofthelowerlimb. The aimofthisstudyistocomparetheclinicalefficacyandsafetytwolaserfibertypesinendovenous OBJECTIVE nd Surg: Venous andLym Dis2014; 2: 61-9. new cases. DermatolSurg2009; 35: 1206-14. Yamamoto T, SakataM. Influenceoffibersand wavelengthsonthe mechanismofactionendovenouslaserablation. J Vasc Van DenBosRR, NeumannM, DeRoosKP, Vasc Dis2014; 7: 239-45. radial fiber-1-year follow-up. Phlebology2015; 30: 86-90. fiber -follow-upaftersixmonths. Phlebology2011; 26: 35-9. great saphenousveinvaricosities: aprospectiverandomised clinicaltrial. EurJ Vasc Endovasc Surg 2010; 40: 254-9. Vasc Surg2010; 51: 1474-8. veins: resultsfromasinglepractice. Cardiovasc InterventRadiol2011; 34: 536-41. nous veinswiththe1470-nmdiodelaser? A prospectiverandomized studycomparing 15and25 W. Int Angiol 2009; 28: 32-7. Hirokawa M, Kurihara N. Comparisonofbare-tipandradial fiberinendovenouslaserablationwith1470 nmdiodelaser. Ann von HodenbergE, ZerweckC, KnittelM, Pannier F, RabeE, RitsJ, Doganci S, DemirkilicU. Comparisonof980nmlaserandbare-tipfibrewith1470 radial fibreinthetreatmentof Schwarz T, vonHodenbergE, FurtwänglerC, Prince EA, SoaresGM, Silva M, Maurins U, RabeE, Pannier F. Doeslaserpowerinfluencetheresults ofendovenouslaserablation(EVLA)incompetentsaphe Department of Surgery, St. Anne’s University Hospital, and Medical Faculty, Masaryk Masaryk Faculty, Medical and Hospital, University Anne’s St. Surgery, of Department Blind Study. Ann Vasc Dis. 2015;8(4):282-9. and Bare-Tip Fiber inEndovenousLaser Ablation ofSaphenous Varicose Veins: A Multicenter, Prospective, Randomized, Non- Hirokawa M, Ogawa T, Sugawara H, Shokoku S, SatoS. Comparison of1470nmlaserandRadial 2ring Fiberwith980nmLaser et al et . Endovenouslaserablationofgreatsaphenousveinsusinga1470nmdiodeandtheradial et al et . Impactoflaserfiberdesignonoutcomeendovenousablationlower-extremity varicose et al et et al et et al et . Endovenous laserablationofvaricose veins withthe1470nmdiodelaserusinga . Endovenouslaserablation-inducedcomplications: reviewoftheliterature and . Endovenouslaserablationofvaricose veinswiththe1470-nmdiodelaser. J 150 vs . 14.8 %) were lower in Group 2, but not significantly. - - -

vein Endovascular stentinginasuperiorvenacava syndrome Garali Wieme, Jean-PierreBequemin Paul d’Egine Hospital, Champigny, Paris Champigny, Hospital, d’Egine Paul option. The endovascular treatment of SCVS is safe effective and durable and should be the first line therapeutic CONCLUSION vascular treatment. can discusstheothermorecommoncausesofSVCS, speciallymalignantdiseasesandtheplaceofendo Through thisrareseverecomplicationofportcathter(onlyfewcasesarereportedinthelitterature), we complications. with animmediatepostoperativesymptomsrelief. At 9monthsfollowupsheiswellanddeveloppedno panding stent). The finalSVCcavogramconfirmedthepatencyof the stent. Theprocedure waseffective an endovascular treatment: transluminalangioplastyviatheleftjugularveinfollowedbystenting(self-ex port catheterwithatotalocclusionofthesuperiorcava extendedtotheleftinnominatevein.We optedfor We reportthecaseofa64-year- oldwomanadmettedwiththediagnosisofSVCSrelatedtoanindweling CASE REPORT asssociated withthesedevicesmayaccountforupto28%ofcasesSVCS. to theincreasinguseofintravascular devicessuchascentralvenouscathethersandpacemakers. Thrombi invasion orextrinsiccompressionbymalignancies. Actually, thereisarecentriseofbenignetiologiesdue symptoms duetoanobstructionofreturnflowinthesuperior Vena cave. In60-90%ofcase, itiscausedby Superior venacava syndrome(SVCS),describedby William Hunterin1757, isaclinicalentityincluding INTRODUCTION

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CONTROVERSIES & UPDATES IN VASCULAR SURGERY Regal Samer vein Venous aneurysms: thehiddendanger. A caseseriesandreviewofliterature *** MD, Vascular and Endovascular associate professor, Mansoura University Mansoura professor, associate MansouraUniversity University professor, Endovascular **** and associate Mansoura Vascular professor, MD, Endovascular *** and associate Vascular MD, ** Endovascular and Vascular MD, * 2. 1. We believethat VAs shouldbe promptlytreatedsurgicallytoavoidpossiblefatalPulmonaryembolism. CONCLUSION thrombosis (53.8%). Nosignificationcomplications werenoticed. while ligationandexcisionwas doneforfusiformcases(5cases)and2saccular aneurysmspresentingwith surgical correction. Tangential excision was donefornon-complicated saccular aneurysms (6cases, 46.2%), (9 cases, (69.2%). 2 cases had SSV aneurysm complicated with l paresthesia (15.3%). All cases underwent and 7werefemales(53.8%). All patientspresentedwithswellingsindifferentareas, mostlyintheneck We identified13 VAs in13patients. Meanage was 21.6years(Range7-42). 6casesweremales(46.2%), RESULTS A retrospectiveanalysisofcasespresentedwith VA BetweenJanuary 2011, andJanuary 2016. PATIENTS ANDMETHODS complications. Venous aneurysms(VA) areoftenunderestimatedasadangerousvascular conditionthancanleadtofatal INTRODUCTION College Hospital Galway (UCHG), Newcastle Road, Galway, Ireland Galway, Road, Newcastle (UCHG), Galway Hospital College Western Vascular Institute (WVI), Department of Vascular and Endovascular Surgery, University University Surgery, Endovascular and Vascular of Department (WVI), Institute Vascular Western Mansoura, Egypt Mansoura, Department of Vascular and Endovascular Surgery, Faculty of Medicine, Mansoura University, University, Mansoura Medicine, of Faculty Surgery, Endovascular and Vascular of Department surgery registrar UCHG registrar surgery MD, MRCS, Vascular and Endovascular assistant lecturer, Mansoura University. Vascular Vascular University. Mansoura lecturer, assistant Endovascular and Vascular MRCS, MD, 1* , TamerKhafagy 1** , KhalidEl Alfy 152 1*** , MohammedElKassaby 1, 2****

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EPOSTERS ORGANIZATION divine [id] Vérane Bergeron Moreau 17, rue Venture 13001 Marseille - France Tel. +33 (0) 491 57 19 60 Fax. +33 (0) 491 57 19 61 [email protected] www.divine-id.com www.cacvs.org