· Matteo Longhi Outcome evaluation after deep vein interventions Matteo Longhi 16H00 - 16H30...

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12-13TH APRIL 2019PORTO PALÁCIO HOTEL CONGRESS CENTER

XX INTERNATIONAL SYMPOSIUM OFANGIOLOGY AND VASCULAR SURGERY

Live cases from Porto and other international centers

Symposium Academy

LIVE CASES

Endorsed by

Organization:Associação Angiovasc

Serviço de Angiologia e Cirurgia VascularCentro Hospitalar de São João

Alameda Prof. Hernâni Monteiro, 4200 - 319 [email protected]

www.live.com.pt

The EMT14264 - XX INTERNATIONAL SYMPOSIUM OF ANGIOLOGY AND VASCULAR SURGERY – Porto Live 2019 from 12/04/2019 to 13/04/2019 in PORTO, Portugal is: COMPLIANT

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12-13TH APRIL 2019 PORTO PALÁCIO HOTEL CONGRESS CENTER

INDEX Our message 7

Participants / Faculty 8

Program at a glance 9

Speakers Lectures Friday 15 Saturday 31 Live Cases Overview 51 Live Transmissions from International Centers 53 Live Transmissions from CHU S. João 57

Devices 69

Save the Date 96

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PresidentDr. José Fernando Teixeira

Vice-PresidentProf. Doutor Sérgio Sampaio

Secretary GeneralDr. Pedro Henrique Almeida

Honorary PresidentsProf. Doutor Roncon de AlbuquerqueDr.ª Fernanda Viana

Emeritus PresidentProf. Doutor António Braga

Organizing committeeServiço de Angiologia e Cirurgia Vascular do Centro Hospitalar Universitário São João EPE & Associação Angiovasc

Dr. José Fernando TeixeiraProf. Doutor Sérgio SampaioDr. Pedro Henrique AlmeidaDr.ª Marina Dias NetoDr. Ricardo GouveiaDr. João Rocha NevesDr. Ricardo Castro FerreiraDr. Joel Ferreira SousaDr. José Pedro PintoDr. Tiago SoaresDr. Luís GamasDr. António NevesDr.ª Filipa Jácome

International Cases CoordinationDr. Ricardo Gouveia

Oporto Cases and Materials CoordinationDr.ª Marina Dias Neto

HandbookDr. António NevesDr. José Pedro PintoDr. João Rocha NevesDr. Pedro Henrique Almeida

Live CasesDr.ª Marina Dias NetoDr. Ricardo GouveiaDr. Luís GamasDr. António NevesDr. Tiago Soares

Web SupervisorDr. João Rocha Neves

WebmanagerCarlos Miguel Fernando Logistics coordination Dr.ª Marina Dias NetoDr. Ricardo Gouveia

Event ManagementAna Santos – In BLOOM

Graphic DesignerIsabel Monteiro – Next Color

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Dear Colleagues,

On the 20th edition of the Porto International Vascular Symposium, the longest running vascular initiative of our City, we adopted the name Porto LIVE, from Live International Vascular Event.

A name that was born embracing the pioneering live transmission initiatives we developed during the previous five years from Hospital São João, this year expanded to Italy, Germany, Spain and China reference transmission Centres.

This recognition greatly honoured us and is creating a new scientific and educative event without parallel in Portugal, still Hospital based, endorsed by LINC, SITE and CLIC events, approved by Medtech and Infarmed and recognized by our National Societies.

Driving such an event implies a huge commitment from the selected Faculty that joins us, organizers, speakers, moderators, an outstanding PCO, and the Industry that year after year is supporting a unique interactive platform.

Carefully selecting the topics, highlighting controversial issues, presenting the most modern clinical evidence, we pretend to give our audience an updated panorama of the Vascular Challenges of the moment and the solutions to be pointed, from theory to practical management.

We hope to match all those expectations and offer you an interesting debate you can LIVE in our beautiful city of PORTO.

Welcoming you all, and being grateful for your presence, join us at Porto Palacio Hotel during those two days of Vascular expertise knowledge presentation and sharing.

Be part of the Porto LIVE 2019 experience!

José Fernando Teixeira PortoLIVE 2019 Chair

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PARTICIPANTS / FACULTY

Adelino Leite Moreira PortoAlba Méndez Fernández Santiago Compostela Alberto Dias da Silva Porto Albuquerque de Matos Coimbra Alfredo Cerqueira Porto Álvaro Laranjeira Santos LisboaAna Evangelista Lisboa Ângelo Carneiro Porto António Assunção Braga António Cruz Tomás Lisboa António Neves Porto Armando Lobato São Paulo Armando Mansilha PortoCelso Carrilho GuimarãesChang Shu BeijingDalila Rolim Porto David Planer Tel AvivDuarte Medeiros Lisboa Elena Herrero Andaluzia Emílio Silva Porto Eurico Norton Porto Fausto Pinto Lisboa Fernandes e Fernandes Lisboa Filipa Jácome Porto Filipe Macedo Lisboa Francesco Spinelli Rome Gabriela Teixeira Porto Giovanni Torsello MunsterGonçalo Cabral Lisboa Ignacio Lojo Coruña Isaac Martinez Madrid Isabel Vilaça Porto Javier Martinez Gámez Andaluzia Joana Carvalho PortoJoana Ferreira Guimarães João Albuquerque e Castro Évora João Almeida Pinto PortoJoão Rocha Neves PortoJoão Silva e Castro Lisboa João Vasconcelos Penafiel Joel Ferreira Sousa Porto Jorge Almeida PortoJorge Costa Lima Porto José Almeida Lopes Porto José Carlos Vidoedo Penafiel José Daniel Menezes Lisboa José Fernando Ramos Porto José Fernando Teixeira Porto José Neves Lisboa José Oliveira Pinto Porto José Pedro Pinto Porto Jürg Gresser Zurich Laura Capoccia Roma Leonor Vasconcelos Lisboa

Luís Antunes Coimbra Luís Gamas Porto Luís Machado Porto Luís Mendes Pedro Lisboa Luís Mota Capitão Lisboa Luís Silvestre Lisboa Manuel Alonso OviedoManuel Fonseca Coimbra Marco Manzi Abano Maria Emília Ferreira Lisboa Marina Neto Porto Mario LaChat Zurich Marzia Lugli Modena Martin Austermann MunsterMatteo Longhi Modena Mauro Gargiulo BolognaMichael Piorkowski FrankfurtMiguel Angel de Gregorio ZaragozaMiguel Lobo Vila Nova de Gaia Nelson Oliveira Ponta DelgadaNiels Baeckgaard Copenhagen Nilo Mosquera Orense Óscar Gonçalves Coimbra Paulo Almeida Porto Paulo Correia PortoPaulo Dias Porto Paulo Pinho PortoPedro Brandão Vila Nova de Gaia Pedro Henrique Almeida Porto Pedro Paz Dias Porto Pedro Sousa PortoPereira Albino LisboaPiotr Kasprzak RegensburggRicardo Castro Ferreira Porto Ricardo Gouveia Vila Nova de Gaia Ricardo Vale Pereira Coimbra Rita Augusto Vila Nova de Gaia Roberto Ferraresi Bergamo Rocha e Silva PortoRoger Rodrigues PortoRoncon de Albuquerque PortoRubén Rodríguez Carvajal Marbella Rui Almeida PortoRui Machado Porto Sérgio Sampaio Porto Sérgio Teixeira Porto Sobrinho Simões PortoTenreiro Machado PortoTheodoros Kratimenos Athens Tiago Soares Porto Timmy Toledo Angra do Heroísmo Vincent Riambau Barcelona

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PROGRAM AT A GLANCE

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SEsSiOnS & LEcTurES

PORTO PALÁCIO HOTEL CONGRESS CENTER CHU S. JOÃO INTERNATIONAL CENTERS

LIve CAseS

China | BeijingProf Chang Shu

Procedure:2 TEVAR

(1 in situ fenestration,1 on table fenestration)

Commentary 1st case:Pedro Sousa, Pedro Brandão

Commentary 2nd case:Luís Silvestre, António Cruz Tomás

Germany | MunsterGiovanni Torsello / Martin

AustermannProcedure:

EVAR + endoanchors / chimneyCommentary:

Duarte Medeiros, Nelson Oliveira

Italy | Bergamo Roberto Ferraresi

Procedure:Infrainguinal PAOD

Lecture:Hybrid deep vein arterialization

– pros and cons.Commentary:

Joana Ferreira, Ricardo Gouveia

ORJoão Albuquerque e Castro

Procedure:ChEVAR

Commentary:Paulo Dias, Fernando Ramos

AngiosuiteMiguel Ángel De Gregorio

Procedure:Pelvic embolization –

Amplazter® PlugsLecture:

Pelvic Congestion Syndrome. Metal occlusive agents.

Commentary:Paulo Correia, Pereira Albino

09H00 - 10H30 AORTIC DISSECTION

Chairpersons: Paulo Pinho, Rui AlmeidaSecretary: João VasconcelosQuestions / Commentary: Rui Machado, Duarte Medeiros

Repair of descending thoracic aortic aneurysms with Ankura Thoracic Stent GraftTheodoros Kratimenos

Current results with Chimney TEVAR in Aortic Arch Lesions: how to get themMario Lachat

Total Endovascular Aortic Arch Repair in an endovascular fashion in 2019Manuel Alonso

10H30 - 11H00 COFFEE-BREAK

11H00 - 12H30 AORTIC DISSECTION

Aneurysms after dissections. Fenestrated and Branched grafts performancePiotr Kasprzak

How pliable (and how much does it matter) can a thoracic endograft be?Vincent Riambau

Total Arch Repair and Epiaortic Vessels debranching in acute type A dissectionPreparing a safe proximal landing zone for TEVARÁlvaro Laranjeira

12H30 - 13H00 OPENING SESSION

13H00 - 14H30 LUNCH

FRIDAY 12TH APRIL 2019 MORNING

INT

INT

INT

CHUSJ

CHUSJ

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SEsSiOnS & LEcTurES


LIve CAseS

FRIDAY 12TH APRIL 2019 AFTERNOON

Italy | BolognaMauro Gargiulo

Procedure:EVAR / TEVAR (+ CO2)

Commentary:João Almeida Pinto, João Rocha

Neves

Spain | Jaen - AndaluziaJavier Martínez Gámez

Procedure:Carotid StentCommentary:

Augusto Rocha e Silva, Ângelo Carneiro

Box CaseNexus® aortic arch stent graft in a patient with prior TEVAR

type 1A EndoleakDavid Planer

Commentary:João Silva e Castro, Isabel Vilaça

Italy | Abano Marco Manzi

Lecture:The Presto technique – how to

do itProcedure:

Infrainguinal PAODCommentary:Sérgio Teixeira

Box CaseSupera® in External Iliac and

Common Femoral ArteryNelson OliveiraCommentary:

Dalila Rolim

AngiosuiteVincent Riambau

Procedure:CTAG® Active control TEVAR

(Sponsored by GORE)Commentary:

Duarte Medeiros, Jorge Almeida

14H30 - 15H00 CONFERENCE

Chairs: Adelino Leite Moreira, Augusto Rocha e Silva

From precision medicine, to narrative/ realistic medicine in vascular pathologySobrinho Simões

15H00 - 16H30 ANEURYSMS

In memoriam of Prof. Doutor João Martins Pisco: Fernandes e Fernandes

Chairpersons: Maria Emília Ferreira; Fernandes e FernandesSecretary: Timmy ToledoQuestions / Commentary: Ricardo Vale Pereira, Isabel Vilaça, Gonçalo Cabral

Isolated iliac aneurysms. Best endovascular optionsMario Lachat

Iliac branches – what’s the toll, when you go bilateralAlba Méndez Fernández

Complex aortic iliac aneurysms: a comparative study between bell bottom vs sandwich techniques vs hypogastric embolization Armando Lobato

EVAR under vascular ultrasound – how doable is it? Mario Lachat


17H30 - 19H00 ANEURYSMS

Endoanchors in 2018 Piotr Kasprzack

Chimneys: not all endoleaks are born equalNilo Mosquera

Long-term results after standard EVAR with the Endurant® and Excluder® Stent-Grafts José Oliveira Pinto

Aortic arch endograft: optimal management of the supra aortic vesselsDavid Planer

VBX®’s in the aortic context (Sponsored by GORE)Isaac Martinez

INT

INT

INT

CHUSJ

13

SEsSiOnS & LEcTurES


LIve CAseS

Italy | Modena Marzia Lugli Procedure:

Venous stentingCommentary:

Niels Baeckgaard

AngiosuiteMario Lachat

Procedure:Porcelain Aorta TEVAR

Commentary:Adelino Leite-Moreira, José

Carlos Vidoedo

AngiosuiteMichael Piorkowski

Procedure:PAOD CTO

Fem-Pop recanalization (SUPERA / XCIENCE – Abbott)

Commentary:Pedro Paz Dias

ORRubén Rodríguez Carvajal

Procedure:Venous Stent / IVUS

(Venovo – BARD) Commentary:

Paulo Almeida, Manuel Fonseca

ORRubén Rodríguez Carvajal

Procedure:Bypass percutaneous

thrombectomy(AngioJet – Boston Scientifi c)

Commentary:Miguel Lobo, Gonçalo Cabral

09H00 - 10H30 CAROTIDS

Chairpersons: Roncon de Albuquerque, Albuquerque de MatosSecretary: Roger RodriguesQuestions / Commentary: Alberto Dias da Silva

TCAR - Present and Future of the Carotid Stent? Rubén Rodríguez Carvajal

Stent-related complications in CAS – periprocedural or also afterwards? Laura Capoccia

Choosing a carotid stent – current evidence Elena Herrero Martínez / Javier Martínez Gámez

From ultrassound to CT – A new carotid stenosis conversion formulaTenreiro Machado


11H00 - 12H30 PAOD & VISCERAL ISCHEMIA

Chairpersons: Luis Mota Capitão, Óscar GonçalvesSecretary: Timmy ToledoQuestions / Commentary: Ana Evangelista

Is there room for a different PTA balloon? Laura Capoccia

Endovascular and Open Treatment of Chronic Mesenteric IschemiaFrancesco Spinelli

Rheolytic Thrombectomy for arterial thrombosis. When and How I use it. Rubén Rodríguez Carvajal

13H00 - 14H30 LUNCH

SATURDAY 13TH APRIL 2019 MORNING

CHUSJ

CHUSJ

CHUSJ

CHUSJ

INT

14

SEsSiOnS & LEcTurES


LIve CAseS

AngiosuiteMichael Piorkowski

Procedure:PAOD CTO atherectomy +

Stellarex® (Philips)

Commentary:Luís Machado, Luís Antunes

AngiosuiteIgnacio Lojo Procedure:

MAV embolization Commentary:

Gabriela Teixeira, Miguel Lobo

ORNilo Mosquera

Procedure:Zenith Alpha Abdominal

(COOK) Commentary:

Celso Carrilho, Leonor Vasconcelos

Box CaseEndovascular treatment of

aortic arch aneurysms with a double-branch device

Luís Mendes PedroCommentary:

David Planer

Box CaseChimney of the aortic arch for

the treatment of endoleak type Ia after TEVAR

Rita Augusto Commentary:Piotr Kasprazk

14H30 - 15H00 CONFERENCE

Chairs: Filipe Macedo

Major Challenges in Cardiovascular Medicine – A look into the futureFausto Pinto

15H00 - 16H30 VEINS

Chairpersons: José Daniel Menezes, Armando Mansilha Secretary: Joana CarvalhoQuestions / Commentary: António Assunção, Gonçalo Cabral

Nutcracker syndrome management: the entity behind abdominal/ pelvic venous insuffi ciencyRubén Rodríguez Carvajal

Beyond venous stentsMatteo Longhi

Outcome evaluation after deep vein interventionsMatteo Longhi


16H30 - 18H30 VEINS

Sizing venous stentsMatteo Longhi

Epidemiology and level of DVTNiels Baeckgaard

Early thrombus removal after the ATTRACT studyNiels Baeckgaard

Large vein obstructions. Is there a specifi c way / tool to cross them? Ignacio Lojo

18H30 - 19H00 CLOSING SESSION

SATURDAY 13TH APRIL 2019 AFTERNOON

CHUSJ

CHUSJ

CHUSJ

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12TH APRILSPEAKERSLECTURES

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IntroductionThe aim of the presentation is to show the results for patients with atherosclerotic aneurysm of the

descending thoracic aorta treated with a new commercially available thoracic stent graft (Ankura) in a single-center retrospective review of prospectively collected data.

The Ankura™ Thoracic Stent Graft is designed for endovascular treatment of various descending thoracic aorta diseases. It is constructed by an e-PTFE dual membrane and in between the two e-PTFE layers there are self-expanding nitinol springs with sinusoidal shape. The proximal part of the endoprosthesis has bare stents which are embedded in the graft and are released by a tip capture system. The graft is premounted on a kink-resistant delivery system with hydrophilic coating and provided with an easy and operator friendly deployment process.

The operator can choose between straight or tapered grafts with diameters from 20 up to 46mm and lengths between 40 up to 200mm. Regarding the instruction for use adequate femoral/iliac access and proximal or distal landing zone ≥15mm length, and 18-42mm width are recommended.

MethodsThe technical success rate is estimated, as also the in-hospital and 30-day mortality, and mortality at the

end of follow-up as well as complication and re-intervention rate. Post operation follow-up was made by computed tomography angiography 1 month, 6 months and yearly thereafter.

ResultsA total of 30 patients (80% male; mean age, 73.7 ± 6.33 years) were treated with Ankura Thoracic Stent

Graft (Lifetech, Shenzhen, China) for descending thoracic aortic aneurysm from February 2014 until June 2017. Technical success of the thoracic endovascular aortic repair (TEVAR) was 97% (29/30 patients). No aorta-related deaths were recorded during follow-up. During the early postoperative period, two patients (7%) with long DTA coverage developed paralysis or paraparesis, which immediately resolved after lumbar drainage. Two symptomatic patients treated outside instructions for use (7%) developed early type IA endoleak and one patient (3%) developed type IB endoleak; type II endoleak was recorded in 3% of the study cohort. During the 30-day postoperative period, two patients died of non-TEVAR-related causes, one of gastrointestinal bleeding and the other of pulmonary infection. During a median follow-up of 31.7 (range, 38.4) months, two more patients also died of non-TEVAR-related causes, one of stroke from carotid artery disease and the other of motor vehicle trauma. In the rest of the cohort, no other adverse events were noted.

ConclusionAnkura thoracic stent graft seems to be a safe and effective endoprosthesis for the treatment of decending

thoracic aortic aneurysms as it showed 0% aneurysm related mortality and demonstrated very low endoleak and complication rateduring follow-up. Yet longer follow up period is needed to further test the long term efficacy and durability of the endoprosthesis.

Repair of descending thoracic aorta aneurysms with Ankura Thoracic Stent Graft

Vascular and non Vascular Interventional RadiologistEVAGGELISMOS GENERAL HOSPITAL OF ATHENS / INTERVENTIONAL RADIOLOGY UNIT, ATHENS / GREECEMember of: Hellenic Radiology Society; Greek Society of Interventional Radiology (GSIR) since 2006; European Congress of Radiology (ECR); Cardiovascular Interventional Radiology Society of Europe (CIRSE) since 2007; Elected Member in the Scientific Society of “Evaggelis-mos” General Hospital of Athens since 2011, Elected Member in the Faculty of the Hellenic Society of Interventional Radiology where I serve as cashier since 2014; Hellenic delegate for Interventional Radiology division in European Union of Medical Specialists (UEMS) since 2017.

THEODOROS KRATIMENOS

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Current literature review highlights little outcome differences inbetween the differents endovascular option, even in complete endovascular arch repair. This hold true for parallel grafts technique, despite they are reported to be mostly used as bailout, in emergent situation or when other methods are not possible. Main drawbacks are the off-lable use of devices not having been developped for this purpose and a relative high number of endoleaks, especially so called gutter endoleaks. Latter are very specific to the technique and do mostly seal spontaneously within 30 days.Moreover, overall amount of reintervention, especially due to endoleaks seems to be quite similar to other endovascular options. There are so far few reports about long-term outcomes, but in our experince with 41 patients followed for a mean of 42 months (SD 28; 0-109) show stable evolution with sac regression in most and no patient having died from aneurysm rupture.

In our experience, key points are using rather small sized parallel stentgrafts that are primary relined with self-expandable stents and using only one parallel graft crossing the proximal aortic stentgraft landing zone, eventually in combination with one or two parallel stentgraft crossing the distal aortic landing zone. In addition and as general rule for all endovascular procedures, we inform patients about potential reinterventions and request agreeing to participate to long-term follow-up controls.

Current results with Chimney TEVAR in Aortic Arch Lesions: how to get them.

University of Zurich | UZHDepartment of Cardiovascular Surgery

MARIO LACHAT

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The most common indications for arch repair are type A dissections, unspecific aneurysms (atherosclerotic elderly patients), and some type B dissections. The gold standard treatment for arch repair continues to be open surgery that improved its results due to anaesthesia and critical care advances alongside a better patient selection and improvements in brain protection (selective cerebral perfusion, moderate hypothermic circulatory arrest) and surgical technique (e.g. branched hybrid grafts). Excellent result were reported by Steepani F et al. in a recent meta-analysis review about the outcomes of open total arch replacement in the recent era showing an estimated 5.3 % operative mortality rate with permanent and transient neurologic deficit at a pooled rate of 3.4 % and 5.2 % respectively. However; up to 40 % of the patients are rejected for a conventional open arch intervention and approximately 50 % of them will die due to rupture. For that reason, different endovascular approaches have been developed; mainly: hybrid procedures, parallel conduits, fenestrated and branched endografts.

Hybrid procedures can be classified depending on if they are intra or extra-thoracic interventions. Those intra-thoracic procedures have got no different mortality rates compared to conventional surgery in selected centres, as Konstantinos et al. mention in a systematic review comparing hybrid aortic arch replacement with conventional techniques.

An alternative endovascular option for endovascular arch repair are parallel conduits techniques: they are lesser invasive and easier than fenestrated or branched endografts; using conventional devices they can be implemented in emergency o urgent cases. However the scientific value of reported studies is low and there are many unsolved questions regarding the type of endografts and conduits, endoleaks, long-term results, etc. Currently, no company supports this indication at the arch and recently published guidelines consider that these techniques can be an option in urgent TEVAR requiring a seal in zones 0-2 without adequate options for open surgery or supra-aortic debranching and as a bail-out strategy in cases where unintended obstruction of supra-aortic vessels occurred during TEVAR; so they are not recommended as a routine strategy if other strategies (open surgery, branched/fenestrated stent grafts) are available.

More anatomical endovascular options seem to be the future of an endovascular approach to the arch pathology. Endografts with a scallop can be a useful tool to obtain a sufficient sealing zone in the inner curvature and a much longer length needs to be covered in the outer curvature of the arch close to the origin of a vessel. Reported experience with this technique is scarce, even though it has showed good results. Fenestrated arch endografts are not widely used in Europe and the largest published experience comes from 35 centres in Japan recruiting 363 patients with sealing in zone 0, achieving outstanding results (30-day mortality rate 1.6 %, stroke and paraplegia rates 1.8 % and 0.8 % respectively). On the other hand, there are endografts with one, two or even 3 branches (exceptional). Recently, the most frequently used platforms are from Cook and Bolton Medical, both are mainly dual branched devices; however a new concept, the Nexus (EndoSpan) device that can combine a branch with a fenestration, has just received the CE mark approval. In any case, arch branched endografts require an adequate quality of the ascending aorta in order to achieve effective and durable

Total Endovascular Aortic Arch Repair in an endovascular fashion in 2019.

Head of Department of Vascular Surgery, Hospital Universitário Central de Astúrias Associate Professor of Surgery.Oviedo / SpainEuropean Society for Vascular Surgery (ESVS), Sociedad Española de Angiología y Cirugía Vascular.

MANUEL ALONSO

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results; and some local conditions, like residual dissections with a very narrowed true lumen at the arch, can be a contraindication or make these procedures extremely challenging, despite of the fact that a report from Houlon et al. found that more than 70 % of the patients with aortic arch aneurysms after open ascending aortic replacement for type A dissection were anatomically suitable for treatment with inner branch endografts. The initial experience with these devices is characterized by the impact of the learning curve on the results. Overall, results show immediate morality rates ranging from 0 (T. Kuratani; Veith symposium 2017), to 16.7 % (Italian Registry; J Vasc Surg 2019) and TIA/stroke rates between 3 % and 25 %; meanwhile, long-term results are scarcely known but they seem to be promising and durable. The most recent recommendations from the EACTS and ESVS state that endovascular aortic arch repair in zone 0 should be considered in patients unfit for open surgery and with suitable anatomy (Class IIA, Level B) and that these procedures should be performed in centres with adequate volume and expertise in open and endovascular arch repair.

As final considerations; it can be maintained that novel endovascular techniques have increased the possibilities of treatment for patients with aortic arch disease. These new endovascular procedures are expected to reduce morbidity and mortality rates in comparison with conventional arch surgery; however, some key issues must be taken into account: proximal sealing zone, stroke rate, endoleaks, long-term durability, etc. Due to a clear selection bias; comparing outcomes between endovascular (high-risk patients) and open intervention (standard-risk patients) is not possible and in any case, currently aortic arch treatment, using endovascular techniques o by conventional open surgery continues to be a challenging procedure.

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Patients with Type B Aortic Dissection (TBAD) are at risk for developing a post-dissection thoracoabdominal aortic aneurysm during follow-up. This doesn’t depend of the type of treatment in the acute setting. Fenestrated and branched stent-grafting (F/B-TEVAR) can be used to treat this pathology.

Between 2010 and 2017 a total of 71 consecutive patients has been operated with F/B-TEVAR for TAAA in chronic aortic dissection in two vascular institutions experienced in endovascular techniques (Regensburg, Nuremberg).

Results showed that applied technique is feasible and associated with low perioperative mortality and acceptable perioperative morbidity. Mid-term results demonstrate a high rate of complete false lumen thrombosis and aneurysm regression. Due to the significant reintervention rate authors recommend rigorous follow up. Whereas some distal reinterventions could be explained by a staging strategy, it is advisable to use longer bridging covered stents. No ruptures occurred during follow-up.

Aneurysms after Dissections. Fenestrated and Branched grafts performance.

University Hospital in Regensburg, Germany - head of the Department of Vascular, Endo-vascular Surgery – 1995-2017. Director in the Clinic of Vascular Surgery in Nuremberg (1984-1995).

P. M. KASPRZAK

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How pliable (and how much does it matter), can a thoracic endograft be?

Endovascular repair of descending thoracic aorta (DTA) is considered as first interventional option for most part of the aortic disorders. However many unmet needs and issues are still limiting its applicability. One of the major limitations is related to the existing gaps in evidence. Clear and robust evidence is still needed in many aspects of the management of DTA pathologies. In numerous clinical scenarios, adequate trials are lacking. Besides those gaps in evidence, it is well recognised that thoracic endografting (TEVAR) is technically evolving in order to overcome technical and device-related complications and limitations. We can deploy endografts in any aortic segment: in the descending, in the ascending, in the arch, even preserving aortic branches. Nevertheless, from the pure technical point of view, current generations of endografts still need more development and improvement. Durability remains the major concern for any endovascular treatment, and thoracic endografting is not an exception. As Galenus said, the physician is only the nature’s assistant, thoracic endograft should also follow the natural anatomy instead of fighting against it. We will focus the following pages on the graft conformability and compliance, both related to durability and safety of thoracic endografting. We will review the state-of-the-art of the current concerns associated with the anatomical and hemodynamic modifications induced by the thoracic endograft strength, stiffness and straightness and their implications for the future thoracic endograft designs.

In consequence, we would need more compliant and flexible devices with a clear anatomical adaptability to the tortuous thoracic aortas. That improvement would reduce SINE, migration and disconnection issues. Due to the displacement forces acting in the distal aspect of the descending thoracic aorta, more active fixation should be required. Besides some recent improvements in new thoracic endograft generations, more conformable endografts are expected to be more harmonic with arch anatomy. Endografts that better mimic the aortic compliance are anticipated. The hemodynamic effects related to endograft stiffness could be minimized with more flexible and compliant devices.

We encourage our partners, engineers and manufacturers, to join us, as physicians and implanters, to focus all efforts to develop better and more durable thoracic devices, that should follow the natural anatomy instead of fighting against it.

Professor and Chief of Vascular Surgery Division, Cardiovascular Institute, Hospital Clínic of BarcelonaPast President ESVS (2009-2011)Vicepresident ISVS (2008-2010)

VINCENT RIAMBAU

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Introduction: The surgical techniques, proximal ascending and hemiarch repair, for emergent acute type A aortic dissection (ATAAD), leaves a dissected arch and the distal aorta with a patent FL in, as many as 80% of patients. Additional entry tears in the arch or further and new entry tears induced, during the distal suture line in very fragile tissues, maintain the FL pressurized. In a significant number of patients, the residual dissected aorta is prone to progressive aneurysm development and/or a chronic malperfusion syndrome is maintained, both are associated with poor outcomes and need for reoperation / reintervention at a later time.

Methods: We developed a surgical reproductible technique, easy to use in an emergent set, without the several constraints associated to an emergent frozen elephant technique (FET).

Briefly, this patient tailored surgical strategy is an open procedure in the arch, to allow and facilitate future endovascular repairs of the distal thoracic aorta, and gain time for a long-run correct planning, looking for the advantages of a complete arch repair, without the potential drawbacks and risk factors inherent of an emergent FET surgery.

Results: We construct, in a side table, a bi/trifurcated patient tailored conduit to replace the ascending aorta and (almost) total arch. Allowing BCT and LCCA (LSA if necessary) debranching and re-routing to the proximal aorta. We obtain enough length proximal LZ for 2nd stage additional TEVAR (if necessary) a few days/weeks later with the lamella still mobile. Is possible to proceed with bare stents in abdominal aorta, as a PETTITCOAT and STABILIZE techniques in the downstream aorta if indicated.

Conclusions: Our goal is to promote FL complete thrombosis and positive aorta remodeling.

Preparing a safe proximal landing zone for TEVAR

Cardiothoracic SurgeonHospital Santa Marta Lisboa

ÁLVARO LARANJEIRA SANTOS

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MANUEL SOBRINHO SIMÕES

Professor e Investigador na área de Bioquímica da Universidade do Porto IPATIMUP – Instituto de Patologia e Imunologia Molecular da Universidade do Porto

From precision medicine, to narrative / realistic medicine in vascular pathology

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MARIO LACHAT

University of Zurich | UZHDepartment of Cardiovascular Surgery

Isolated iliac aneurysms. Best endovascular options.

Taking into account the indication is given, there are nowadays several options to treat isolated iliac artery aneurysms partially or completely by endovascular means. Some repair options are based on the use of dedicated iliac branched device (Cook, Gore, Jotec,…) and some on off-label use of off-the-shelf devices. Here some insights of latter techniques.

1) Parallel grafts techniques a. Sandwich technique b. Real chimney technique: i. With the chimney originating from the native infrarenal aorta ii. With the periscope originating from the external iliac aretrey

2) Hybrid repair whereas, a. a conduit from the ipsilateral common iliaca artery or contralateral femoral artery to the ipsilateral

femoral artery is combined with the use of a so called banana stentgraft (extending from the ipsilateral external iliac artery to the hypogastric artery)

b. a bypass from the external iliac artery revascularises the hypogastric artery, in combination with a common iliac to external iliac stengrafting. Most useful in this contect, is it to use the VORTEC to revascularise the hypogastric artrey.

3) In the emergency setting, embolisations techniques of the hypogastric artery and/or it’s branches may be preferred option especially in unstable patients, as it can be performed ipsilateral transfemorally.

Finally, the decision which option will be chosen and the in situ construction technique are depending on the local (endovascular) anatomy, but also eventually on the endoluminal anatomy of the arch and its branches. Not rarely, a trough and through guide wire (axillo-femoral) may help to straighten the iliac axis for better introduction/ positioning and deployment of the iliac (branched) stentgraft. Finally, the hypogastric artery may be accessible only from a supraaortic access.

All the above technique have been showed to be equivalent and excellent regading mid- to long-term outcomes and therefore nowadays, a partially or complete endovascular patient-specific approach to maintain perfusion of at least one hypogastric artery is possible in most cases. In ruptured cases embolisation of the hypogastric seems justified in order to speed-up sealing and improving survival.

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Aneurysmal degeneration of the iliac arteries (common, internal, external iliac) can occur in isolation or in association with other large vessel aneurysms (eg, abdominal aorta). Up to 40% abdominal aortic aneurysm have common iliac disease.

The etiology of the iliac aneurysms is the usual in our patients (Smoking, Male gender, Advancing age, Caucasian race, Atherosclerosis…).

Symptoms do not typically occur unless the aneurysm is large and are primarily related to compression of surrounding structures.

The relative and absolute recommendation about surgical indications for iliac artery aneurysm are minimum diameters of 3 - 4 cm. Most physicians recommend surgical approach if diameter more than 3 cm (Rupture under 3cm is very rare).

Seventy percent of iliac aneurysms occur in the common iliac artery, while 20 and 10 percent are found in the internal and external iliac arteries, respectively. Approximately two thirds of patients with iliac artery aneurysm have involvement of more than one segment of the iliac arterial tree; one third of IAAs are bilateral.

At this time, vascular surgeons should be concerned about pelvic circulation: buttock claudication, impotence, colonic ischemia, spinal ischemia.

With bilateral occlusion the mortality and morbidity increase significantly (colon and spinal ischemia are directly related to hypogastric patency).

For the treatment of the iliac aneurysms there are different options: Coil-and-cover or multiples techniques for preservation of internal iliac artery perfusion.

To maintain the patency of internal iliac artery have been decribed techniques like Hybrid procedures, “sándwich techniques”, “bell-bottom”, and dedicated iliac branch devices.

The iliac branch devices have subsequently been developed specifically, and recent papers show that the bilateral preservation with them, can be achieved with excellent technical success, branch patency and low rates of reinterventions. Extra fluoro rates and procedural time were minimal when compared with unilateral approach. The second iliac branch does not increase operative risk and there is no significative difference in patency or reintervention between uni- and bilateral treatment.

Because of this, we can support the bilateral preservation, with significant decrease in morbidity and mortality for patients.

Iliac branches – what’s the toll, when you go bilateral

Angiology and Vascular Surgery Department Staff.HOSPITAL CLÍNICO UNIVERSITARIO DE SANTIAGO DE COMPOSTELASANTIAGO DE COMPOSTELA – GALICIA – SPAIN

ALBA MÉNDEZ FERNÁNDEZ

27


PURPOSE: To assess the outcome comparison between hypogastric artery occlusion (HAO), bell bottom technique (BBT) and sandwich technique (ST). Primary end points included technical success rate, patency rate, procedure-related or unrelated early and late mortality rates early and late complication rates (pelvic ischemia, endoleak, migration and aneurysm rupture).

METHODS: A prospective study enrolled 122 consecutive patients undergoing elective EVAR to treat AIA from January 2000 to December 2016. In this group of patients, a total of 244 CIAA were treated using one or two technique(s) together and distributed in three groups: ST (Group I), HAO (Group II) and BBT (Group III) Outcomes between these three groups were compared.

RESULTS: Kaplan-Meier survival analysis shows Group II with higher incidence in late type II endoleak (p-value: 0.035) and early buttock claudication (p-value: 0.007). Group III had higher risk of late type I B endoleak, iliac limb endograft migration aneurysm rupture and related late mortality (p-value: 0.000; p-value: 0.000; p-value: 0.002; p-value: 0.000; respectively). HA primary patency rate was higher in Group III compared to Group I (p-value: 0.03). Group III patency was 100% and Group I patency was 94,2%. Survival rate was higher in Group I and lower in Group III, with statistical significance (p-value: 0.00).

CONCLUSION: Based in this prospective study, BBT can be used in a safe way in AIA with CIAA < 20 mm. Bilateral HAO should be avoided due to significant high early mortality rates. Unilateral HAO can be used in severe HA stenosis and/or a very poor runoff, HA trunk < 4 mm but without celiac trunk and/or superior mesenteric artery and/or deep femoral artery occlusion. ST should be used in CAAA > 20 mm, HA >=4mm in diameter and HA with good runoff.

Endovascular Repair Of Bilateral Aortoiliac Aneurysms Involving Hy-pogastric Artery: A Comparison With Different Endovascular Approach-

es: Hypogastric Occlusion, Bell-Bottom And Sandwich Techniques

São Paulo Vascular & Endovascular Institute (ICVE-SP), São Paulo, BrazilSão Paulo Federal University (UNIFESP-EPM), São Paulo, Brazil

ARMANDO LOBATO

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Durability of treatment is one of the crucial issues in endovascular treatment of aortic aneurysms. In increasing number of cases loss of seal and graft migration with endoleak are responsible for the long term failure of abdominal (EVAR) as well as thoracic (TEVAR) endovascular repair. Diseased aortic wall at the level of the proximal and distal landing zone including thrombus, calcification, kinking and progressive dilatation, may impact the long-term durability of an endovascular repair.

Endoanchors have shown comparable results to a hand sewn aortic anastomosis and may be used in a majority of stent grafts on the market. Indications for use include primary implantation to secure the proximal or distal landing zone in case of hostile anatomy or intraoperative Type I endoleak / suboptimal apposition to the aortic wall, as well as secondary use for the treatment of Type I endoleaks and stent-graft migration accompanied by a proximal or distal extension of the stent-graft.

We analysed the data from the literature as well as perioperative results of the first 100 patients treated with Endoanchors during primary and secondary interventions. Our experience shows high technical success associated with low complication rate.

EndoAnchors in 2018

University Hospital in Regensburg, Germany - head of the Department of Vascular, Endo-vascular Surgery – 1995-2017. Director in the Clinic of Vascular Surgery in Nuremberg (1984-1995).

P. M. KASPRZAK

29


IntroductionMany endografts are currently available for standard endovascular repair of infrarenal abdominal aortic

aneurysms (EVAR). Comparison of long-term outcomes between devices might aid in this decision process, but comparative data is scarce. The purpose of this study is to report long-term clinical outcomes of two commercially available endoprosthesis, the Endurant (Medtronic Vascular, Inc., Minneapolis, MN, USA) and the Excluder (W. L Gore & Associates, Flagstaff, USA) stent-grafts.

MethodsPatients undergoing standard EVAR from July 2004 to December 2011 in a single institution with the

Endurant or the Low-Porosity Excluder endografts were eligible. Only patients treated for intact degenerative abdominal infrarenal aneurysms (AAA) were included. All measurements were performed on center-lumen line reconstructions obtained on dedicated software. Primary endpoint was primary clinical success, defined as clinical success without the need for an additional or secondary surgical or endovascular procedure. Neck-related events (a composite of type 1A endoleak, neck-related secondary intervention or migration >5mm), neck morphology changes, renal function and overall-survival were secondary endpoints.

ResultsPatients treated with the Endurant stent-graft had wider (neck-diameter >28mm: 27.3% vs 1.7%, P<.001;

neck diameter (mm): 27mm [IQR 24-29] for Endurant and 24mm [IQR 22-25] for Excluder, P<.001) and more angulated necks (β-angle>60º: 26.7% vs 12.5%, P=.004). Oversizing was greater in the Endurant group (16% IQR [12-22] vs 13% IQR [8-17] respectively, P<.001). Patients treated outside device-IFU regarding proximal neck: 16.7% in the Endurant and 17.3% in the Excluder group (P=.720).

Seven-year primary clinical success was 54.7% for the Endurant and 58.1% for the Excluder group, respectively (P=.53). Freedom from neck-related events at 7 years was 76.7% for the Endurant and 78.8% for Excluder group, respectively (P=.94). The Endurant stent-graft (HR 2.7, CI95% 1.3-5.8, P=.009) was an independent predictor of significant renal function decline. Neck dilatation was greater in Endurant-implanted patients (13% [2-22] vs 4% [0-10], P<.001). Overall survival at 7 years was 61.4% in the Endurant and 50.3% (N=50, SE=.047) in the Excluder group (P=.39).

ConclusionThis study reveals that durable and sustainable results can be obtained with either of these late generation

devices. This suggests that careful planning and a tailored device selection taking into account the patient’s anatomy are more relevant determinants than the graft model itself to obtain clinical success. The Endurant endoprosthesis seems to be associated with a higher rate of neck dilatation and faster eGFR decline, but further studies with longer follow-up are necessary to determine the clinical relevance of these findings.

Long-Term Results After Standard Evar with the Endurant and Excluder Stent-Grafts.

Angiologist and Vascular Surgeon Department of Angiology and Vascular Surgery, Hospital de São João. Porto / PORTUGAL.

Member of: European Society for Vascular Surgery; Sociedade Portuguesa de Angiologia e Cirurgia Vascular; Portuguese Representant of International Union of Angiology; Helper for Angiol-ogy and Vascular Surgery Division in European Union of Medical Specialists (UEMS) since 2017; Sociedade Portuguesa de Cirurgia Cardiotorácica e Vascular.

JOSÉ OLIVEIRA-PINTO

30


Aortic arch pathology has been conventionally treated by open surgical approach. Open surgical arch repair is a high risk surgery that requires hypothermic circulatory arrest and therefore many patients remain untreated. In the last decade, evolving hybrid and endovascular aortic repair techniques became a valid alternative to open surgical arch replacement. Although these techniques are less invasive than open repair, one of the main complexities in endovascular repair of aortic arch is the approach to the supra-aortic vessels. There is no single technique proved to be superior to the others, and there is no data regarding direct comparisons between different techniques. Furthermore, since the field is evolving, with several novel technologies being currently evaluated, there is no long term follow up.

In this presentation, different endovascular / hybrid approaches for aortic arch repair will be presented with emphasis on the management of the supra-aortic vessels. Advantages and disadvantages of each method will be discussed and a suggested algorithm will be presented.

Aortic arch endograft: optimal management of the supra aortic vessels

David Planer, MD, MScDirector, Center for Endovascular InterventionsHeart InstituteHadassah - Hebrew University Medical CenterJerusalem, Israel

DAVID PLANNER

31


13TH APRILSPEAKERSLECTURES

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Stroke is one of the most important Cardiovascular major events in our environment. It is the 2nd cause of Death in Europe, affecting more than 1.400.000 people every year and causing disability in more than 50% of patient who suffer it. Its impact in the financial cost of European countries makes Stroke a main target for prevention therapies, primary or secondary. Regarding carotid stenosis as a focus for 1/3 of Strokes, CAS and CEA has been the traditional alternatives for treatment, despite the best medical therapy. CEA is still today the gold standard of treatment, and still CAS is presenting x2 periprocedural Stroke rate due to the problem of Embolization. Different neuroprotection system has been developed to protect the brain during CAS, but only proximal protection systems with flow reversal and transcervical carotid approach have shown periprocedural stroke rates comparable to CEA. TCAR is the last evolution of transcervical carotid artery Stenting, and the data available in the first trial shown that this technique could signify a change of paradigm for treatment of carotid stenosis disease.

TCAR: Present and Future of Carotid Stenting?

Hospital Quironsalud Marbella, Marbella. SpainChief. Department of Angiology, Vascular and Endovascular Surgery.SEACV (Sociedad Española de Angiologia y Cirugia Vascular)ESVS (European Society of Vascular Surgery)

RUBÉN RODRÍGUEZ CARVAJAL

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Stent-Related Complications In CAS – Periprocedural or Also Afterwards?

The main aim of carotid artery revascularization is brain embolism primary and secondary prevention. Complications occurring during carotid revascularization can unfortunately vary from clinically-silent microembolism, still related to neurocognitive decline in some series, to major stroke and stroke-related death. Those complications can occurr both in the intraprocedural and postprocedural period in both endoarterectomy (CEA) and stenting (CAS). In order to decrease to a minimum the rate of embolism during CAS different techniques and adjuncts have been developed over time, such as the use of a stent (to constrain and block the plaque on the wall), of an intraprocedural embolic protection device (distal filters or flow-reversal intraoperative systems), or, more recently, of mesh-covered stents that enhance plaque coverage and so the capability of preventing plaque debris migration to the brain. Particularly the latters have the potential of decreasing embolism to the brain in the whole periprocedural period, thus preventing not only the intraprocedural brain complications, but also the “off-table” events. So from the deployment and well through the so-called “plaque healing period” new generation stents can enhance plaque coverage and decrease debris migration. We have tested the CGuard micronet-covered embolic prevention system in a multicenter prospective Registry called IRON-GUARD, including 200 patients and whose main results were a 0% 30-day major cardiovascular event rate and an extremely low diffusion-weighted-magnetic-resonance-imaging-detected lesions rate (19%). Those promising results were confirmed at 12 months with no major neurological adverse event, stent thrombosis or external carotid occlusion recorded and one asymptomatic restenosis reported at 3 months. In a randomized controlled trial (Peri-Procedural brain lesions Prevention in CAS - 3PCAS) we aimed to compare peri-procedural incidence of new diffusion-weighted-magnetic-resonance-imaging (DWMRI) brain lesions in CAS patients treated by CGuard™stent or Wallstent™. From January 2015 to October 2016 58 patients with asymptomatic carotid stenosis ≥70% were submitted to preoperative DW-MRI scan, to exclude the presence of preoperative silent cerebral lesions and then were randomized to CGuard or Wallstent. DWMRI was performed immediately after the intervention and at 72-hour postoperatively. Moreover, pre and postoperative Mini-Mental-State-Examination Test (MMSE) and a Montreal-Cognitive-Assessment (MoCA) test were conducted, and S100β and NSE neurobiomarkers were measured at 5-time points (preoperatively, 2, 12, 24, and 48 hours postoperatively). In 29 CGuard patients, 1 developed a minor stroke and 8 silent new lesions were observed in the 72h-DWMRI (31%): 4 lesions were ipsilateral, and 4 lesions were contra or bilateral. In 29 Wallstent patients, 7 clinically-silent new lesions were found in the 72h-DWMRI (24.1%; p=0.38). In 4 cases lesions were ipsilateral and in 3 cases contra or bilateral. S100B values doubled at 48 hours in 24 patients, and among them 12 presented new DWMRI lesions. 48-h S100B increase was significantly related to 72-h DWMRI lesions (p=0.012). Both stents showed an acceptable rate of subclinical neurological events with no significant differences at 72-hour DWMRI between groups. However bilateral/contralateral lesions rate suggests that periprocedural neurological damage may have extra-carotid sources and so future techniques and investigations should focus on avoiding stenting-concurrent sources of embolism.

Rome/Italy

VASCULAR AND ENDOVASCULAR SURGERY DIVISION, DEPARTMENT OF SURGERY “PARIDE STEFANINI”POLICLINICO UMBERTO I. “LA SAPIENZA” UNIVERSITY OF ROME, ITALY

LAURA CAPOCCIA

35


Peripheral arterial disease treatment can nowadays count on several and different strategies and devices. In past years we have witnessed (and have took part in) a minimally-invasive treatment of superficial femoral artery mainly based on stenting of the stenotic segment, with some cases of extensively, and rarely excessively, stenting. Little by little, the world vascular community has changed view, with a renewed awareness for possible complications following extensive stenting, and the widespread around the world of the “leave nothing behind” concept. Drug-coated balloons and bioresorbable stents have appeared and increasingly spread on the world stage. Together with them new devices specifically developed to reduce angioplasty complications have been conceived and implemented. Among those, the so-called nitinol-constrained balloon has proposed itself as a partial solution to the dissection and restonosis issue. In our Vascular and Endovascular Surgery Division at Univeristy “La Sapienza”, Policlinico Umberto I of Rome, Italy, we have tested the use of “nitinol-constrained” balloon (Chocolate, TriReme Medical Inc., Pleasanton, CA-USA) and drug-coated balloon (DCB) in severely claudicant patients. Between December 2014 and December 2016 eighty-one (84 limbs) consecutive Rutherford category (RC) 3 patients treated for superficial femoral artery (SFA) and popliteal arterial (PA) disease by nitinol-constrained balloon followed by DCB were enrolled. Bailout stenting was performed by Zilver PTX implantation. We assessed intraoperative technical success and bailout-stenting rates as well as clinical improvement, ankle-brachial index (ABI) modification, primary patency (PP), and secondary patency (SP) rates at follow-up. Sixty-eight patients (83.9%) were male and 31 (38.2%) diabetics. Fifty-five limbs (65.5%) presented occlusion (CTO) that was longer than 150 mm in 18 limbs. Bailout stenting rate was 9.5% (8/84). All patients completed 30-day follow-up with a primary patency of 100%, and 61 patients went back to be completely asymptomatic (RC = 0). Mean follow-up was 12.3 ± 5.6 months with an overall PP of 98.8%, and SP of 98.8%. At mid-term analysis, no differences in outcomes were recorded between stenosis and CTOs with a PP of 96.5 and 96%, respectively (p = 0.725). The length of CTO impacted early results: in cases of CTOs < 150 mm, PP was 100%, while in CTOs > 150 mm it decreased to 83.3% (p = 0031). ABI at 12-month was significantly higher with respect to preoperative values in the whole cohort (p < 0.001).

The results of this preliminary experience has changed our approach to SFA and popliteal artery occlusive disease. Vessel preparation and dissection prevention are pivotal in obtaining good early and long-term results in peripheral arterial disease patients.

Is There Room For A Different Pta Balloon?

Rome/Italy

VASCULAR AND ENDOVASCULAR SURGERY DIVISION, DEPARTMENT OF SURGERY “PARIDE STEFANINI”POLICLINICO UMBERTO I

“LA SAPIENZA” UNIVERSITY OF ROME, ITALY

LAURA CAPOCCIA

36


Endovascular therapy for treatment of CMI has gained wide acceptance over the last two decades, due to improvement of diagnostic tools and increased ability to cross the chronic total occlusions. In a recent review and meta-analysis, Alahdab and coll. (1) collected 100 studies with over 18,000 patients, comparing the outcomes of Endovascular (EV) versus Open Repair (OR) for CMI. This paper, as other previous reviews of the Literature, points out the potential advantage of Endovascular treatment in terms of early mortality and morbidity, compared to Open Repair.

In this review overall in-hospital mortality was 8% for OR, compared to 2 % for EV repair, and in hospital complications were 54% for OR compared to 27% after EV. These data justify the seven-fold increase in EV procedures in the US, and probably worldwide, in the treatment of CMI. Some previous meta-analyses are consistent with these data, although some report similar outcomes for both treatments, with a better patency for the OR group. Another large report from Pecoraro (2), of the Zurich University Group, with 1795 patients in 43 studies, reported a clear advantage in mortality and morbidity in the EV group despite a lower patency rate and no difference in late survival. Interestingly enough, the percentages did not change in the last two decades, despite the improvement in EV materials and skill. The mortality reported in these studies appears to be lower than the 9 to 13% mortality rates reported from the statewide and nationwude databases from 1988 to 2009. This can be due to a different performance of the most experienced Centres publishing their data and the “real world”. All these studies support the current EV-first approach for treatment of CMI.

The large meta-analysis by Aladhab and coll. is the result of a collaborative work by the Mayo Evidence Based Practice Center, the Ain-Sham University of Cairo, and the University of Florida College of Medicine in Gainesville. A previous review of the Literature also came from the Mayo Clinic in 2009 (3), and in 2010 (4) the group of the Mayo reported their large experience on open treatment of CMI in a modern setting with a high-level endovascular skill and facilities. From the analysis of their experience it clearly comes out that the patients candidates to EV repair are not the same as those submitted to OR, the choice of either modality of cure being a result of the evaluation of the extent of the lesion and the risk profile of the patient, favouring a patient-tailored approach based on the data of the Literature and the experience of the Centre.

The same occurred in our experience along the years, with an increasing number of Mesenteric angioplasties and stenting, but a still important amount of open repairs. After a long lasting experience with over 100 antegrade Aorta to celiaco-mesenteric arterial reconstructions performed from 1990 up to now, an EV-first option is not accepted, as some patients are clearly unfit for EV repair due to young age, extensive calcifications, multivessel disease, access problems and risk of dissection.

Therefore, in conclusion, we believe that a simple comparison between EV and OR, as in other fields of our Discipline, is a nonsense and a modern Vascular Team should provide both treatments with equal level of skill and facilities, choosing the treatment modality on the base of the features of each single patient. This is particularly difficult at the current time, as the risk of losing the skill in OR is great in the EV era, and the

Endovascular And Open Repair For Treatment of Chronic Mesenteric Ischemia (CMI)

Rome/Italy

Unit of Vascular Surgery,University Campus Bio Medico di Roma

FRANCESCO SPINELLI

37


prominent task of the Surgeons of the age of the Senior Author is to transmit the open skill and technique to the younger generations.

Bibliography:1. Fares Alahdab, MD,a,b Remy Arwani, MD,c Ahmed Khurshid Pasha, MD, d Zayd A. Razouki, MBChB, MS,d Larry J.

Prokop, MLP,a,e Thomas S. Huber, MD,f and M. Hassan Murad, MD, MPH,a, A systematic review and meta-analysis of endovascular versus open surgical revascularization for chronic mesenteric ischemia (J Vasc Surg 2018;-:1-8.)

2. Pecoraro F., Rancic Z., Lachat M., Mayer D., et al. Cronic Mesenteric Ischemia: critical review and guidelines for management. Ann Vasc Surg. 22013, 27: 113-122

3. Gustavo S. Oderich, Rafael D. Malgor, and Joseph J. Ricotta II. Open and Endovascular Revascularization for Chronic Mesenteric Ischemia: Tabular Review of the Literature Ann Vasc Surg 2009; 23: 700-712

4. Gustavo S. Oderich, MD, Peter Gloviczki, MD, and Thomas C. Bower, MD Open Surgical Treatment for Chronic Mesenteric Ischemia in the Endovascular Era: When It is Necessary and What is the Preferred Technique? Semin Vasc Surg 23: 36-46; 2010

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Percutaneus Trombectomy is starting to be present as an usual tool for the vascular teams, useful for practically all the territories when an acute thrombosis could appear. The Rheolytic thrombectomy with the Angiojet® system has shown to be effective and safe in the arterial territory, available for the treatment of acute arterial thrombosis as data from the PEARL registry show. The Solent® Omni catether is the catheter’s serie specially dedicate for the arterial field. It allows to treat arteries from 1,5 to 8 mm of diameter safety and that make it useful practically in all the arteries field, except for the pulmonary embolism where it has no IFU indication. The Reolysis process is fast and effective but it has some limits due to the haemolysis process induced by the serum vortex itself. I present our experience with this device in some cases and some tips and tricks of its us.

Rheolityc Thrombectomy for arterial Thrombosis. When and How I use it.



39


Cardiovascular Medicine has evolved exponentially over the last few years. That was due to several reasons, mostly related to the technological development, in parallel to the clinical questioning and knowledge advancements. I have identified the following areas as potential major challenges that we’ll be facing over the next few years in the cardiovascular field:

• Early detection of disease, identifying early markers of disease processes (genetics, biomarkers, etc)• Identification of new surrogates of CV disease (What and how to diagnose and treat?)• Developing new targets/new molecules• Technological developments in diagnosis (ex: Molecular Imaging)• Technological developments in treatment (ex: artificial heart)• Remote monitoring and treatment• New prognostic markers• Society vs medical goals for CV disease• Fighting inequalities on health care assess• Harmonization of Medical Training

It will be our capacity as a scientific community to develop and implement strategies to face these major challenges, that will determine the success of our actions.

Desafios principais em medicina cardiovascular: um olhar para o futuro / Major challenges in cardiovascular medicine: a look into

the future

Lisboa-PortugalDiretor do Dpt Coração e Vasos do CHULN/Head of Department, University HospitalDiretor da FMUL / Dean Lisbon School of Medicine, Universidade de LisboaPresident Elect World Heart Federation/Past-President European Society of Cardiology (ESC)

FAUSTO J. PINTO

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The Nutcracker syndrome is a rare pathology that it is often misunderstood, undiagnosed and undertreated. Renal symptoms related to Nutcracker syndrome are well established and known, but its relationship with Pelvic Venous Insufficiency and the Pelvic congestion Syndrome is not well framed. Some reports in the literature has tried to explain how the secondary drainage of the renal vein through the gonadal vein could develop in a venous hypertension problem for the pelvic region. We report our experience and lessons learned from our PELVIC registry, a retrospective serie of over 350 patients where we have found a higher presence of NutCracker phenomenon related directly with the development of Pelvic congestion syndrome, and how we manage this syndrome regarding the diagnosis process and the treatment decision taking always prioritizing the clinical findings in each patient.

Nutcracker Syndrome management: the entity behind abdomino-pelvic venous insufficiency.



41


Endovascular recanalisation of chronic obstruction of iliofemoral or caval veins gives very good patency. However, patency decreases if the common femoral vein and its side branches are also involved. Without adequate inflow, the patency of stented iliocaval segments drops dramatically. This suggest that treatment of diseased common femoral, femoral and profunda veins is required to ensure adequate inflow.

Iliac venous stenting has for the most part been successful, with primary, assisted-primary, and secondary patency rates of 57%, 80%,and 86%, respectively, in post-thrombotic patients, with low complications rate. However, if the stent is extended below the inguinal ligament, there is at least a 3.8-fold risk of stent occlusion in post-thrombotic limbs. Despite the icreased risk of occlusion, many post-thombotic patitents require stenting into the common femoral vein to adequately treat skip lesions and areas of residual stenosis which, if left untreated, might lead to recurrent thrombosis.

In literature the endophlebectomy alone is associated with post-operative thromboisis of 20-30%.

Endophlebectomy with endoluminal femoro-ilio-caval recanalization is a viable option in this cases.

The endophlebectomy is performed through the removal of synechiae and septae from the common femoral vein, patch closure of the venotomy is performed using bovine pericardium or saphenous vein. The iliac venous system, and, if necessary, vena cava are sequentially recanalized with guidewire passage, ballon dilatation, and subsequent stenting. In general, Wallstent are preferred because of their radial strength and their braided design that allows very low risk of stent fracture under the inguinal ligament. The intravascular ultrasound (IVUS) is used routinely to identify the correct proximal and distal landing zone.

By performing a hybrid procedure of open endovenectomy and endoluminal recanalization, several important anatomical derangements can be corrected. First, the profunda femoris orifices can be disobliterated, thus allowing maximal drainage from the thigh and lower leg. Second, the multiple recanalization channels of outflow from dense fibrinous tissue with synachiae in the CFV or CFV occlusions are cleared into the distal EIV.

This procedure results in remarkable improvement in the clinical signs and symptoms of post-thombotic syndrome.

Beyond venous stent

Hesperia Hospital Modena, ItalyDept. Cardiovascular SurgeryInternational Center of Deep Venous SurgeryNational Reference Training Center in Phlebology (UEMS)

MATTEO LONGHI

42


The treatment of deep venous obstruction has recently become a topic of particular interest: nowadays, every medical conference or convention has a section dedicated to this disease.

The two main causes of the signs and symptoms of deep venous obstruction can be found in the inferior vena cava region:

- Post thrombotic syndrome (PTS)- Non Thrombotic Iliac Vein LesionsThe signs and symptoms associated with venous obstruction vary considerably, from asymptomatic edema

with associated pain to invalidating symptoms and ulcers. Venous obstruction plays an important role in the clinical expression of chronic venous disease, especially as regards pain. Debilitating venous claudication can be found in 15-44% of patients.

The literature results support the hypothesis that treatment of the disease causing iliac outflow obstruction makes it possible to achieve an improvement of symptoms, regardless of the presence or absence of associated venous reflux.

In our clinical experience, in fact, patients affected by mixed obstructive-reflux chronic venous insufficiency, (52%) showed a clinical improvement after treatment for the obstructed outflow alone, while in (26.3%) it was also necessary to correct the reflux of the deep venous system during the follow-up period in order to achieve a clinical improvement.

Special mention should go to those patients with the most severe symptoms, i.e. the presence of active ulceration (CEAP C6). In our series, (15.6%) presented with this symptom, and treatment of the obstructed outflow made it possible to achieve complete healing in 70% cases.

Similar to previous studies, our results showed that the majority of patients with chronic venous insufficiency achieved a subjective and objective improvement of their symptoms either immediately after treatment or during the follow-up period. Our general rate of clinical improvement is 73% at 24 months which is in line with the results of the Neglen and Raju group.

In the event of a worsening of the clinical condition after an initial remission following the endovascular treatment, our current practice is to carry out IVUS-assisted phlebography to discover the reason for the renewed outflow obstruction. In such cases, there may be a malfunctioning of the stent due to its distal migration, or there may be an intra-stent stenosis or acute thrombosis.

Literature data demonstrate the importance of a correct clinical and instrumental follow-up to ensure long-term patency of the implant; in particular, post-operative diagnostic protocol with a control ultrasound scan in the first two weeks and another after one month plays a key role in detecting any early endoluminal thrombosis.

The results also show the complexity of treating patients affected by deep venous insufficiency, particularly when both obstruction and reflux are present. In these cases, the possibility of being able to delay the surgical correction of the reflux until after the obstruction has been treated is often the only way of achieving a substantial clinical improvement for the patient.

Outcome evaluation after deep vein interventions


MATTEO LONGHI

43


Sizing venous stent

Element involved in venous stenting are vein wall features, length, etiology and venous shape.

We need always to consider the correct diameter and the high wall compliance of veins.

Depending on obstruction etiology (primary or secondary) we will have to deal with different lengths, our goal is to perform healthy to healthy treatment.

Shape of veins is irregular. Area measurements are more precise and safe in sizing correctly the stents to be implanted.

IVUS role during outflow obstruction endovascular procedures is essential; it allows to evaluate the morphologic degree of stenosis, length of lesions, correct proximal and distal landing zone.

Frequently, in secondary patients, we need to stent across the inguinal ligament to avoid squeezing and insure inflow, in this cases we have to consider the risk of stent fracture.

In patients affected by very long lesions (secondary patients) it is often necessary to use numerous stents. In these cases, taking into account the venous compliance, the correct overlapping between the stents must be at least two centimeters. Otherwise there is the risk of incurring disconnections between stents.

Requirements of vein-dedicated stents is capability to achieve and maintain vein patency in order to contrast high chronic outward forces (COF). The chronic outwaed forces are post thrombotic fibrosis, determining vein rigidity and compression sites as NIVL crossing point and the inguinal ligament.

Stent performance is influenced by the interaction between: stent material and stent design and to an other side from vessel wall and surrounding structures.

Radial resistive force (RRF) is the force exerted by the stent to dilate the surrounding tissues and maintain patency.

Vein-dedicated stents to mantain the long term patency need to keep the RRF>COF.


MATTEO LONGHI

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The incidence of primary symptomatic DVT in the lower extremities without pulmonary embolism has been decreasing during the last 5-6 decades to about 50-100 per 100.000 annually in the western world. The number is added around 25 % with PE plus DVT (VTE). DVT is in all studies mostly left-sided, even the calf vein thrombosis and 2-3 fold more frequent above knee. The left-sided iliac vein compression syndrome is supposed to be the reason. The women is in persuasion in the fertile age, otherwise men have a higher representation. The incidence increases with age especially in people aged 60-65 years. One of 12 middle-aged adults will develop VTE during remaining lifetime. Acquired main risk factors are malignancy, hospitalization, immobilization, trauma, infection, acutely ill medical patients, postsurgical conditions, hormone therapy, pregnancy/postpartum period and obesity. Obesity plays nowadays more and more a significant cause. The most common inherited risk factor is a non-O blood type, which is associated with double the risk of VTE. Another common thrombophilia is heterozygous factor V Leiden gene mutation, which increases the risk of VTE by a factor of 3-8. Severe thrombophilia comprising homozygous factor V Leiden, lupus anticoagulant and deficiency of antithrombin, protein C or protein S increases the risk of DVT by a factor of 20-80. Unprovoked DVT counts for almost half of the patients.

African Americans have a higher incidence of DVT compared to Caucasians, whereas Asians have a lower incidence. A seasonal variation occurs with a higher VTE incidence in the winter, peaking in February. The rate of recurrent VTE is around 15% the first year and 30% after 5 years.

Almost half of VTE events occur unrelated to current or recent hospitalization. For hospitalized patients the majority of VTE events occur after discharge.

It seems that the DVT incidence has reached a more or less steady level in the last 2 decades, which calls for intensively education and more use of risk assessment scales for use of prophylactic regimes.

Epidemiology and level of DVT

MD, vascular and general surgeonAssoc prof emerGentofte Hospital, Rigshospitalet, University of Copenhagen, Denmark

Board member of European Venous Forum (EVF)Past president EVF 2009Member scientific committee EVF 2019

NIELS BÆKGAARD

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The American ATTRACT trial is the most comprehensive RCT about early endovenous thrombus removal for deep venous thrombosis in the lower extremities (DVT). Never has a study been mentioned, promoted and wished as this study. The reason was somewhat disappointing results from the Norwegian CaVenT 4-centre study comparing continuous catheter-directed thrombolysis for proximal DVT versus anticoagulation with about 100 patients in each arm. Difference in prevention of PTS, scored with Villalta scale, was found in favor of CDT after 2 and 5 years (2016). The disappointment concerned the high rate of PTS in both groups (43 % vs 71%) at 5 years without difference in QoL.

The 56-centre ATTRACT trial with more than 300 patients in each arm did include iliofemoral and femoropopliteal DVT without power calculation for each level, as was the case in the CaVenT trial. Unlike this trial, the ATTRACT trial used different treatment modalities including adjunctive mechanical devices. The 2-year results from 2018 could not show difference in PTS (Villalta score > 4), 47% vs 48%.

It has been known for many years, that PTS is more frequent and serious with iliac and common femoral vein involvement compared to more distally thrombosed vein segments. Equally, it has been recognized, that there is a 4-5 fold higher rate of recanalization of the femoral vein compared to the iliac vein in patients managed with medical measures alone, particularly on the left side. Furthermore, postthrombotic changes at 3 months assessed with ultrasonography are directly correlated with an increased risk of recurrent DVT and PTS. A new ATTRACT publication in 2019 targeted to the iliofemoral DVT subgroup of patients revealed significant difference, in favor of thrombolysis, in PTS with Villalta score > 9, 18% vs 28%. Only difference in disease-specific QoL was found, not in the generic part. There was no difference in bleeding complications between the groups and no difference in recurrent DVT.

Some months later, the publication with results from the femoropopliteal subgroup of patients did not show difference in prevention of PTS, 41% vs 41%.

All the results does highlight the value of early endovenous thrombus removal for acute iliofemoral DVT thus at least in reducing the proportion of patients developing moderate-severe PTS. This is supported by other non-RCT´s showing even lower PTS rates. However, the treatment modality, as the method of choice, is uncertain.

Early thrombus removal after the ATTRACT trial

MD, vascular and general surgeonAssoc prof emerGentofte Hospital, Rigshospitalet, University of Copenhagen, Denmark

Board member of European Venous Forum (EVF)Past president EVF 2009Member scientific committee EVF 2019

NIELS BÆKGAARD

46


Deep vein thrombosis (DVT) is a common vascular condition that is associated with significant rates of morbidity and mortality. Although pulmonary embolism and recurrent venous thrombosis are well-knownconsequences of DVT,an important,under appreciated, chronic consequence of DVT is post-thrombotic syndrome (PTS). PTS develops in 20% to 50% of patients with DVT, even when appropriate anticoagulant therapy is prescribed to treat the DVT. On the basis of its high incidence and prevalence, PTS is the single most frequent complication of DVT.

Manifestations of PTS vary from mild clinical symptoms or signs to more severe manifestations such as chronic leg pain that limits activity and ability to work, intractable edema, and leg ulcers. PTS has been shown to have significant, adverse effects on quality of life and productivity, and is costly as measured by health resource utilization, direct costs, and indirect costs.

Venous hypertension, secondary to DVT, is thought to represent a significant part of the underlying pathophysiology for development of PTS. Risk factors of PTS include recurrent ipsilateral DVT, older age, elevated body mass index (BMI) and pre-existing primary venous insufficiency. Additionally, proximal DVTs (especially with involvement of the iliofemoral venous outflow tract) portends a higher risk of PTS compared to distal (calf) DVT.

Postthrombotic syndrome is diagnosed on the basis of the symptoms and signs mentioned. Special scoring systems have been developed (e.g., Villalta, Ginsberg, and Brandjes scores), which assign point scores to the symptoms and signs according to their severity.

The primary diagnostic imaging technique used is duplex ultrasonography. If iliac/caval obstructions are suspected, computed tomographic (CT) or magnetic resonance (MR) venography aids further clarification. Gadolinium-enhanced MRvenography is particularly well suited to reliable detection of intraluminal trabeculae and vascular wall thickening.

The goal of treatment for postthrombotic syndrome is symptomatic relief, since the condition itself is not curable. Compression therapy is used, the effects of which include the following: reducing the diameter of the vein and hence, improving venous valvular function, and accelerating venous backflow, and preventing and reducing leg edema. Exercise training and physiotherapy aim to improve symptoms, mainly by improving the calf muscle pump function.

If severe symptoms of postthrombotic syndrome persist and the patient’s quality of life is markedly impaired, especially by venous claudication and/or a venous ulcer that is not healing, indicating that conservative treatment has failed, surgical treatment should be considered.

In the treatment of postthrombotic syndrome any intervention carried out should be the least invasive

Large vein obstructions. Is there a specific way/tool to cross for them

Chief of Department of Angiology and Vascular Surgery. Quiron- Salud Hospital. La Coruña. Spain.

IGNACIO Mª LOJO-ROCAMONDE

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possible, with the aim of alleviating symptoms and improving quality of life. For this reason, endovascular recanalization appears to be an appropriate form of treatment; if it fails, no progression of symptoms occurs and open surgery remains as a further option.

The recommendations and technical details in the long venous recanalization are:

1.Best performed in hybrid room

2.Regional/general anesthesia for angioplasty and stenting

3.Therapeutic anticoagulation pre, per, and post procedure

4. Access: - Ultrasound-guided Access: Femoral, thigh, popliteal, jugular, contralateral- 4-9 to 11F sheath- Combination of stiff and semi stiff terumo wires usually sufficient- May need access from above or contralateral side

5. Traversing the Obstruction:- Long stiff sheath for support 4F for initial cross then 8/11F- Guiding catheter (0.038)- Stiff glide or stiff tipped TCO wire- Keep components close together for support- Capability for frequent injection to confirm intraluminal position- Hydrophilic wire for crossing (J-straight-micro)- Small extravasations are not important- Large extravasations: stop then repeat the procedure 3-4 week later- After entering IVC change with superstiff wire- Sometimes start with small balloons (4-10 mm)- Up to 30 atm pressure for predilatation - Use 10%-20% stent oversize

6. Stent implant:- Use of dedicated stent depending on the anatomical area: IVC: High radial force, low flexibility, large diameter. CIV, EIV and CFV: Radial force, high flexibility, long and large diameters- At least 2 cm stent overlap- Stent can across inguinal ligament- Stent is deployed at least 1-2 cm into the IVC- Bilateral stenting at iliac confluence is not mandatory (sometimes needed)- Aggressive postdilation

Key messages1.Postthrombotic syndrome occurs in about 20% to 50% of patients in whom deep vein thrombosis has

been diagnosed, and has considerable socioeconomic consequences.

2.The following therapeutic options exist:- Conservative treatment- Open surgical procedures- Endovascular recanalization and hybrid procedures.

3. Only when conservative treatment has failed should an invasive procedure be considered.

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4. Endovascular recanalization can be considered as the treatment of choice for chronic obstruction of the iliac vein. Regarding the procedure, it is necessary to take into account:

- The high cost of venous intervention is still a problem - There is now a dedicated venous stent that offer a big advantage - We will have more and more venous intervention in the future- All modalities are done in conjunction with the best medical treatment References:1. The epidemiology of venous thromboembolism. Circulation. 20032. VTE Impact Assessment Group in Europe (VITAE). Venous thromboembolism (VTE) in Europe: the number of VTE events

and associated morbidity and mortality. Thromb Haemost. 20073. Effect of prolonged treatment with compression stockings to prevent post-thrombotic sequelae: a randomized

controlled trial. J Vasc Surg. 20084. Determinants and time course of the post-thrombotic syndrome after acute deep venous thrombosis. Ann Intern Med.

20085. Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society

on Thrombosis and Haemostasis. Definition of post-thrombotic syndrome of the leg for use in clinical investigations: a recommendation for standardization. J Thromb Haemost. 2009

6. Determinants of health-related quality of life during the 2 years following deep vein thrombosis. J Thromb Haemost. 2008

7. Postthrombotic syndrome and quality of life in patients with iliofemoral venous thrombosis treated with catheter-directed thrombolysis. J Vasc Surg. 2011

8. Economic burden and cost determinants of deep vein thrombosis during 2 years following diagnosis: a prospective evaluation. J Thromb Haemost. 2011

9. The postthrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies: a scientific statement from the American Heart Association. Circulation. 2014

10. Safety and Effectiveness of Stent Placement for Iliofemoral Venous Outflow Obstruction Systematic Review and Meta-Analysis. Circ Cardiovasc Interv. 2015

LIVE CASES

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SYMPOSIUM LIVE CASES – OVERVIEW

External Transmissions Porto – Angiosuite Porto – Operating Room

FRIDAY 12TH APRIL China | Beijing

TEVAR in situ / on table fenestration (Lifetech)

Chang Shu

Treatment of Pelvic Congestion Syndrome with Vascular Plugs

(Amplatzer® Abbott)Miguel Ángel De Gregorio

Chimney technique for juxtarenal AAA

(Endurant® Medtronic)João Albuquerque e Castro

Germany | MunsterJuxtarenal AAA

(Medtronic)Giovanni Torsello

Subacute Type B Dissection treated with TEVAR

(CTAG Active Control® GORE)Vincent Riambau

Italy | BergamoInfrainguinal PAD

(Medtronic)Roberto Ferraresi

Spain | Jaen - AndaluziaCarotid stenting of symptomatic

ICA stenosis (Abbott)Javier Martínez Gámez

Italy | BolognaCO2 EVAR (Cook)Mauro Gargiulo

Italy | AbanoInfrainguinal PAD

Marco Manzi

SATURDAY 13TH APRILItaly | Modena

Ilio-femoral venous recanalization and stenting

Marzia Lugli

Hybrid correction of aortic arch aneurysm in a patient with

Porcelain Aorta(CTAG active control® GORE)

Mario Lachat

Right iliac venous recanalization and stenting under IVUS guidance

(Venovo®, Bard)Rubén Rodríguez Carvajal

Femoropopliteal recanalization and stenting with mimetic stents(Supera® and Xience® Abbott)

Michael Piorkowski

Subacute venous bypass recanalization with percutaneous

trombectomy (Angiojet®, Boston)

Rubén Rodríguez Carvajal

Femoral recanalization with rotational atherectomy and

drug-eluting angioplasty(Phoenix® and Stellarex®, Philips)

Michael Piorkowski

Embolization of an arteriovenous malformation of the forearm(Coils Concerto® and ONIX®,

Medtronic)Ignacio Lojo

Updates in the treatment of non-complex AAA

(Zenith Alpha® Cook)Nilo Mosquera

LIVE TRANSMISSIONS FROM INTERNATIONAL

CENTERS

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Description:• Female, 56 years-old• Comorbidities: current smoker, dyslipidemia. Mild mitral and aortic valve regurgitation.• Diagnosis: amaurosis fugax left eye. • Angio-CT: left ICA stenosis >70% (NASCET).

Images:

Procedure Steps:1) Ultrasound-guided percutaneous femoral access.2) Left CCA catheterization and selective angiography to confi rm diagnosis.3) Cerebral protection device (Emboshield NAV6 Abbott vs MoMa Invatec).4) Deployment of carotid stent (Acculink Abbott).

Carotid stenting of symptomatic ICA stenosis(Acculink® Abbott)

Dr. Javier Martínez Gámez. Complejo Hospitalario de Jaén

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Ilio-femoral venous recanalization and stentingMarzia Lugli, Modena

Description:• Male, 46 years-old.• Medical history: LAC positive (Lupus Anticoagulant); fi rst DVT episode 11 years ago, subsequent

recurrence despite anticoagulant therapy. • Diagnosis: Chronic Venous Insuffi ciency CEAP C6 left limb caused by post-thrombotic proximal

obstruction and femoro-popliteal refl ux.• Procedure: a) step 1: ilio-femoral obstruction treatment by venoplasty and stenting b) step 2: deep vein valve reconstruction (to be performed in the future)

Images:

Procedure Steps:1) Femoral vein ultrasound-guided catheterization at mid-thigh2) IVUS scanning3) Venoplasty 4) Stenting5) Final IVUS assessment and completion Venography

LIVE TRANSMISSIONS FROM CHU S. JOÃO

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Description:• Female, 55 yo presenting with pelvic pain• Physical examination: left limb oedema• Comorbidities: none• Diagnosis: Pelvic Congestion Syndrome

Images:

Procedure Steps:1) Ultrasound-guided percutaneous puncture for access.2) The preferred vascular access is the right internal jugular vein or the left if it is not accessible.3) Introduction of a 90-cm, 7-F introducer sheath.4) Catheterization over a hydrophilic guide wire to target the ovarian and internal iliac veins.5) Embolization is started in the right ovarian vein, followed by the left ovarian vein, and fi nishing with

the internal iliac veins (right and left). 6) Embolization with Vascular Plugs.7) Occlusion is confi rmed venography performed after embolization

Treatment of Pelvic Congestion Syndrome with Vascular Plugs (Amplatzer® Abbott)

Miguel Ángel De Gregorio

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Description:• Male 67 yo• Comorbidities: Hypertension, Type 2 Diabetes• Diagnosis: Subacute uncomplicated Type B aortic Dissection with the following features: a) aortic diameter ≥40 mm during acute phase b) elliptical confi guration of the true lumen c) patent false lumen d) proximal descending thoracic aorta false lumen diameter ≥22 mm on initial imaging e) single entry tear immediately distal to the left subclavian artery

Images:

Procedure Steps:1) Carotid-subclavian bypass 2) Thoracic endografting in landing zone 2

Subacute Type B Dissection treated with TEVAR(CTAG Active Control® GORE)

Vincent Riambau

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Chimney technique for juxtarenal AAA(Endurant® Medtronic)

João Albuquerque e Castro

Description:• Male, 85 years old • Comorbidities: ex-smoker, arterial hypertension, diabetes, CAD• Diagnosis: Juxtarenal AAA with 59 mm

Images:

Procedure Steps:1) Ultrasound-guided percutaneous puncture of both common femoral arteries and right axillary

access2) Catheterization of both renal arteries from the arm3) Positioning of the long sheaths and balloon-expandable covered stents (Advanta V12®) inside the

renal arteries 4) Deployment of the main body graft and of the renal stents5) Synchronous ballooning of the aortic endoprosthesis and the renal stents6) Deployment of the iliac extensions and respective ballooning7) Final angiogram8) Percutaneous closure of the common femoral arteries with Proglide® and direct closure of the

axillary access

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Description:• Male, 68 yo • Comorbidities: arterial hypertension, diabetes, dyslipidemia, POAD• Diagnosis: Aortic arch aneurysm with 61mm; severe aortic calcifi cation• Step 1 was performed one week before consisting of a complete debranching of the supra-aortic

trunks with bypasses to left and right subclavian arteries and left and right common carotid arteries using the following approaches: right and left supraclavicular approach and left and right cervical approach; proximal anastomosis was performed at the ascending aorta after its endarterectomy through sternotomy and extracorporeal circulation.

Images:

Procedure Steps:1) Ultrasound-guided percutaneous puncture of both common femoral arteries 2) Positioning of the C-arm for optimum visualization of the ascending aortic bypass take-off 3) Deployment of the endoprosthesis under reduced cardiac output 4) Final angiogram5) Percutaneous access closure

Hybrid correction of aortic arch aneurysm in a patient with Porcelain Aorta (CTAG active control® GORE)

Mario Lachat

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Description:• Female, 86 yo • Diagnosis: Left lower limb CLTI, Rutherford grade 5• Comorbidities: arterial hypertension, dyslipidemia, hip replacement in right lower limb• CT angiography: chronic total occlusion of the SFA down to P2 plus with a proximal stump of about

2mm; one single runoff vessel (anterior tibial artery); posterior tibial artery seems to be patent down to the foot but stenosis in the tibioperoneal trunk.

Images:

Procedure Steps:1) Contralateral retrograde femoral access and crossover 2) Placement of a 6F sheath3) Guidewire crossing of the lesion (Command-18 and/or stiff GW with support catheter)4) Retrograde puncture if needed5) Plain balloon angioplasty and deployment of Supera stent6) BTK angioplasty with provisional stenting using Xience

Femoropopliteal recanalization and stenting with mimetic stents (Supera® and Xience® Abbott)

Michael Piorkowski

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Description:• Male, 65 yo• Comorbidities: smoker, arterial hypertension, diabetes, dyslipidemia, cerebral vascular disease,

obstructive sleep apnea syndrome.• Diagnosis: Left Lower Limb CLTI, Rutherford grade 5• ABI: 0.94R and 0.65L• CT angiography: chronic total occlusion of left SFA with 13cm of lenght

Images:CT angiography images

Procedure Steps:1) Contralateral retrograde femoral access and crossover 2) Placement of a 7F sheath3) Guidewire crossing of the lesion (Command-18 and/or stiff GW with Quick-cross support catheter)4) Retrograde puncture of need to ensure an intraluminal position of the GW5) Rotational atherectomy with Phoenix® of left SFA6) Angioplasty with the drug-eluting balloon Stellarex®

Femoral recanalization with rotational atherectomy and drug-eluting angioplasty

(Phoenix® and Stellarex®, Philips)Michael Piorkorwsky

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Description:• Female, 34 yo • Right ilio-femoral deep venous thrombosis 6 years ago• Physical examination: supra-pubic varicose veins and lower limb chronic venous disease CEAP C3s• Diagnosis: post-thrombotic lesions in the right venous axis

Images:

Procedure Steps:1) Patient in Supine position.2) Bilateral access to common left vein and a distally to healthy femoral vein at the hip in right side. 3) GW progression from the right tight to the IVC.4) Angioplasty and Stenting of all the right iliac axis until the femoral bifurcation. 5) Guidance under IVUS and angiography as needed.

Right iliac venous recanalization and stenting under IVUS guidance(Venovo®, Bard)


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Description:• Male, 54 yo• Presented to the hospital 5 days after sudden onset of ischemia of the right limb• Comorbidities: ex-smoker; trauma with shotgun complicated with right leg ischemia repaired with

venous femoropopliteal (P3) bypass surgery 20 years ago; drop foot• Diagnosis: subacute venous bypass occlusion• Angiography: confi rms lack of opacifi cation of the bypass; occlusion of the distal SFA, popliteal

artery, tibioperonial trunk with opacifi cation of the posterior tibial artery (no other runoff vessels).

Images:

Procedure Steps:1) Contralateral retrograde femoral access and crossover 2) Placement of a 6F sheath3) Catheterization of the venous bypass4) Percutaneous trombectomy with AngioJet® 5) Control angiogram

Subacute venous bypass recanalization with percutaneous trombectomy (AngioJet®, Boston)


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Description:• Male, 52 yo• Asymptomatic swelling on the forearm• Physical examination: port-wine stain colored swelling on anterior surface of right elbow• Diagnosis (RMA and angiogram): high fl ow arteriovenous malformation

Images:

Procedure Steps:1) Right retrograde femoral access2) Placement of a 4F sheath3) Angiogram to identify the arterial afferences to the AVM4) Arterial catheterization with microcatheter (Progreat and/or Rebar)5) Embolization with Coils and ONYX

Embolization of an arteriovenous malformation of the forearm(Coils Concerto® and ONIX®, Medtronic)

Ignacio Lojo

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Description:• Male, 52 yo • Comorbidities: ex-smoker, arterial hypertension, dyslipidemia, obesity, CABG, cerebral vascular

disease and obstructive sleep apnea syndrome• Diagnosis: Infra-renal AAA with 55mm

Images:

Procedure Steps:1) Ultrasound-guided percutaneous puncture of both common femoral arteries2) Main body graft deployment 3) Ipsilateral iliac extension graft deployment4) Contralateral limb catheterization and contralateral iliac extension graft deployment5) Percutaneous access closure

Updates in the treatment of non-complex AAA(Zenith Alpha® Cook)

Nilo Mosquera

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SAVETHE DATE

13-14TH MARCH 2020PORTO PALÁCIO HOTEL CONGRESS CENTER

XXI INTERNATIONAL SYMPOSIUM OFANGIOLOGY AND VASCULAR SURGERY

in collaboration with:

Organization:Associação AngiovascServiço de Angiologia e Cirurgia VascularCentro Hospitalar de São JoãoAlameda Prof. Hernâni Monteiro, 4200 - 319 [email protected]

Main Sponsors

ABBOTT MEDICALANGIODROID

CARDIVACOOK MEDICAL - BIOSONDA

BDBOSTON SCIENTIFIC

GORE - MEDICINÁLIA CORMÉDICAIBERDATALIFETECH

MEDTRONICOVERPHARMA

SERVIER PORTUGALTERUMO AORTIC

Major Sponsors

ANGELINI BAYER

CARDINAL HEALTH MAQUET PORTUGAL - GETINGE GROUP

Sponsors

ALFASIGMACONSESSUS

FERRERMEDIBAYREUTH

MEDINFARPHILIPS

SMITH & NEPHEW

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ign

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