Dr. José Fernando Teixeira - portovascularsymposium.com · 30 dias de 1,4% (cirurgia aberta tem mortalidade de 3,6% ) e com taxas de permeabilidade dos vasos alvo de 87 a 95% a 5

Dear Colleagues, Dear Friends, The changing pattern of the treatment of vascular disease evolves with new technology available every year, highlights being focused not only in new materials and devices, that permit less invasive surgery, but also improving the knowledge of the disease process from genetics to environmental factors. This International Symposium continues to endorse the novelty of the Angiology and Vascular Surgery fields, in an interactive learning process, including main debates and live cases transmission, topic correlated. In 2015 we expand the number of clinical cases, the broadcasting and transmission facilities, and the National Faculty involved in the live cases, again inviting some of the European references to work with us, with their skilled experience and recognized expertise. For the very first time the Symposium was granted with 12 CME European credits (ECMEC) by the European Accreditation Council for Continuing Medical Education (EACCME). We are most grateful to our Colleagues, Nurses and Technicians, healthcare providers from our Department and from the OR and Angiosuite of Hospital São João, to all Sponsors, to the Radiology and Surgical Autonomous Management Units, to the SITE and LINC platforms for their collaboration and support, and to all that, with their commitment, made possible to jointly drive this initiative. Be welcome to Porto, join us, enjoy the city and save the date for 2016! José Fernando Teixeira Symposium President







PresidentDr. José Fernando Teixeira

Scientific EndorsementCentro Hospitalar de São João EPEFaculdade de Medicina da Universidade do PortoAdministração Regional de Saúde do NorteSociedade Portuguesa de Angiologia e Cirurgia Vascular Sociedade Portuguesa de Cirurgia Cardio-Torácica e Vascular

AccreditationUEMS-EACCME® - 12 CME/AMA category 1 credits

Live Cases and Handbook Dra. Ana Sofia FerreiraDra. Dalila RolimDr. João Rocha NevesDr. Joel SousaDr. José Pedro PintoDr. José Almeida LopesDr. Luís MachadoDra. Marina NetoDr. Mário VieiraDr. Pedro AlmeidaDr. Ricardo Ferreira

Poster Evaluation CommitteeDr. Paulo DiasDr. Eurico NortonDr. Alfredo Cerqueira

Logistics CoordinationDr. Mário Marques VieiraDra. Ana Sofia Ferreira

Web SupervisorJoão Rocha Neves

Web DesignerCarlos Miguel

Serviço de Angiologia e Cirurgia Vascular do Centro Hospitalar S. João EPE & Associação ANGIOVASC

Secretary General Prof. Doutor Sérgio Sampaio

Honorary PresidentsProf. Doutor António BragaDra. Fernanda Viana Prof. Doutor Roncon de Albuquerque

Organizing Committee

Prof. Doutor Roncon de AlbuquerqueDr. José Fernando TeixeiraProf. Doutor Sérgio Sampaio Dr. Joel Ferreira Sousa

Participants

A. Dinis da GamaA. Rocha e SilvaAlbuquerque de MatosAlexandra CanedoAna EvangelistaAna Sofia FerreiraAntónio Assunção Armando Mansilha Carlos MartinsCarlos Vaquero Celso CarrilhoDalila RolimDiogo Cunha e SáDuarte MedeirosEmília FerreiraEmílio SilvaEric Verhoeven Fernandez NoyaFernando Ramos Frederico Bastos Gonçalves Gabriel AnacletoGeorge GeroulakosGiovanni PratesiGonçalo AlvesGonçalo CabralGuedes VazHugo Francisco Rodrigues Ignacio LojoIsabel Vilaça J. Costa LimaJ. Fernandes e FernandesJoana CarvalhoJoana Martins Joana FerreiraJoão Albuquerque e CastroJoão Almeida PintoJoão Silva e CastroJoão VasconcelosJoel Sousa

José Carlos VidoedoJosé Fernando TeixeiraJosé FrançaJosé Pedro PintoLeonor VasconcelosLuís AntunesLuís MachadoLuis Mendes PedroLuís Mota CapitãoLuís SilvestreManuel MartínezMarco Manzi Maria José BarbasMarina NetoMario LachatMário MacedoMário VieiraMarzia LugliMatas do CampoMichael PiorkowskiMiguel LoboMiguel MaiaNilo MosqueraÓscar GonçalvesPaulo Gonçalves DiasPedro Henrique AlmeidaPedro AmorimPedro BrandãoPedro Paz DiasPereira AlbinoR. Roncon de AlbuquerqueRicardo FerreiraRui AlmeidaRui MachadoRuy Fernandes e FernandesSérgio SampaioSérgio SilvaTimmy ToledoVincent Riambau

LisboaPortoCoimbra Vila Nova de GaiaLisboaPortoBragaPortoPortoValladolidGuimarãesPortoLisboa LisboaLisboaPortoNurembergaS. de CompostelaPorto Lisboa Coimbra LondresFlorençaLisboaLisboaVila Nova de GaiaLisboa CoruñaPortoPortoLisboaPortoPortoLisboaPortoPenafielLisboaPenafielPorto

Penafiel PortoFunchalPortoLisboaCoimbraPortoLisboa LisboaLisboa S. de Compostela Abano LisboaPortoZurichLisboaPortoModenaBarcelonaFrankfurtVila Nova de GaiaPenafielOrenseCoimbraPortoPortoLisboaVila Nova de GaiaPortoLisboaPortoPortoPortoPortoLisboaPortoLisboaAngra do HeroísmoBarcelona

Vincent RiambauMario LachatJorge Fernandes NoyaJoão Albuquerque e Castro

29may

Porto Palácio - Plenary Room Hospital de São JoãoThe SITE SessionComplex abdominal aortic aneurysms Complex aneurysm

Live Cases

Rui Almeida, Miguel LoboMarco Manzi, Emília Ferreira

The Great DebatesThrombectomy – Do we really need a device?

12.00-

12.25Specificities: grafts, stents and native arteries. Miguel

Maia

12.30-

12.55Do we really need a device? João

Vasconcelos

13.00-

13.25Time to quit. Luís

Silvestre

13.30-

14.30Lunch

Type IV thoracoabdominal aneurysm - branched EVAR. Eric

Verhoeven

Celiac trunk aneurysm and dissection. Michael

Piorkowski

SFA occlusive disease - stenting.

Michael Piorkowski

Current stenting issues

08.30-

08.55Fenestrated vs “inventive solutions”.

João Albuquerque

e Castro

09.00-

09.25Is one of the solutions really more cost-effective? Leonor

Vasconcelos

09.30-

09.55

How far can we go with each type of imaging equipment?

MarioLachat

10.00-

10.25Debranching? – Why? Mario

Lachat

10:30-

10.55How to standardize complex aortic repair? Vincent

Riambau

11.00-

11.30Opening Ceremony

11.30-12.00

Coffee Break

Live Case 1 Comment:Leonor Vasconcelos

Live Case 2 CommentMiguel Maia

Live Case 3 CommentCosta Lima

Carlos Vaquero, Duarte Medeiros,Albuquerque de MatosLuís Mendes Pedro, Frederico Gonçalves

29may

Porto Palácio - Plenary Room Hospital de São JoãoThe Great DebatesHypogastric arteries management in EVAR

Live CasesHypogastric arteries

IBD EVAR.João

Albuquerque e Castro

IBE EVAR. Jorge Fernandes

Noya

Retrograde access I.Marco Manzi

Retrograde access II. MarcoManzi

14.30-

14.55None, one, both. When? Sérgio

Sampaio

15.00-

15.25Bell-bottom. Is it finished? Rui

Machado

15.30-

15.55

Cook’s IBD vs Gore’s IBE. Is an evidence-based choice possible?

GiovanniPratesi

16.00-

16.30Coffee-break

16.30-

16.55

How well/bad do inventive solutions perform in this setting?

Frederico Bastos

Gonçalves

17.00-

17.25Still space for open solutions? Gonçalo

Cabral

17.30-

17.55

Common iliac and hypogastric arteries aneurysms - clinical behaviour.

George Geroulakos

Working our way up

Live Case 4 CommentJoana Carvalho

Live Case 5 CommentJoão Almeida Pinto

Live Case 6 CommentAna Evangelista

Live Case 7 CommentGuedes Vaz

IBD EVAR.João

Albuquerque e Castro

IBE EVAR. Jorge Fernandes

Noya

Retrograde access I.Marco Manzi

Retrograde access II. MarcoManzi

Matas do CampoCarlos VaqueroRoncon de AlbuquerqueRui MachadoMario Lachat

30may

Porto Palácio - Plenary Room Hospital de São JoãoThe Great Debates“Standard” EVAR

Live CasesMinor changes, classical endografts

Luís Mota-Capitão, Michael PiorkowskiAntónio Assunção, Pedro Brandão, Pedro Amorim

The LINC SessionDrug eluting balloons

Incraft.Nilo

Mosquera

Endurant 2S. Rui Machado

Drug eluting balloon I. Pedro Paz Dias

Drug eluting balloon II. Fernando Ramos

Drug eluting balloon III. Nilo Mosquera

Delivering drug to the superficial femoral artery

08.30-

08.55

Twenty-five years after its debut, did EVAR prove to be superior to open repair as a AAA treatment?

Américo Dinis da Gama

09.00-

09.25If feasible, should we deny it?

Fernandes e

Fernandes

09.30-

09.55Which graft for which patient?

Jorge Fernandes

Noya

10.00-

10.25

New and oncoming endografts for EVAR and TEVAR: emerging technological concepts.

Vincent Riambau

10.30-

10.55

Ruptured EVAR: Should it be the standard approach?

MarioLachat

11.00-

11.30Coffee-break

11.30-

11.55

If cost was not a problem, would you always use them?

Luís Mendes Pedro

12.00-

12.25

Since cost is always a problem, when should they be used?

Gonçalo Alves

12.30-

12.55

Retreatment after a drug eluting balloon treatment.

Marco Manzi

13.00-

13.25Are all DEB’s born equal? Vincent

Riambau

Live Case 1 CommentDiogo Cunha e Sá

Live Case 2 CommentJosé França

Live Case 3 CommentMário Macedo

Live Case 4 CommentMaria José Barbas

Live Case 5 CommentTimmy Toledo

30may

Porto Palácio - Plenary Room Hospital de São JoãoThe Great DebatesAcute deep venous thrombosis

Live CasesVenous session

Chronic venous obstruction

Iliac chronic obstructionstenting. Marzia

Lugli

May-Thurner stenting.Paulo

Gonçalves Dias

Arteriovenous malformation treatment. Ignacio

Lojo

17.00-

17.25Contraindications. João Silva

e Castro

17.30-

17.55When one cannot remain purely endo. Carlos

Vaquero

18.00-

18.25May-Thurner treatment – what evidence?

José Carlos

Vidoedo

POSTER SESSION - WINNER SELECTION

Marzia Lugli, Manuel Martinez, João Paulo SantosAlexandra Canedo, Sergio Silva, Luís Antunes

Marzia Lugli, Manuel Martinez, João Paulo SantosAlexandra Canedo, Sergio Silva, Luís Antunes

14.30-

14.55

When not to think on anything else besides anti-coagulation?

Gabriel Anacleto

15.00-

15.25Pulmonary pressure assessment. Mandatory? Ignacio

Lojo

15.30-

15.55

Last guidelines on acute deep venous thrombosis intervention - critical appraisal.

Paulo Gonçalves

Dias

16.00-

16.25The big “dont’s“ in acute intervention.

Hugo Francisco Rodrigues

16.30-

17.00Coffee Break

Live Case 6 CommentArmando Mansilha

Live Case 7 CommentPereira Albino

Live Case 8 CommentCelso Carrilho

Iliac chronic obstructionstenting. Marzia

Lugli

May-Thurner stenting.Paulo

Gonçalves Dias

Arteriovenous malformation treatment. Ignacio

Lojo

SPEA

KER

S LE

CTU

RES

29may

Endoproteses fenestradas/ramificadas versus “ soluções inventivas”

Até há relativamente pouco tempo o tratamento de aneurismas justarenais, para renais e toraco-abdominais era feito por cirurgia aberta. As endoproteses fenestradas ou ramificadas surgiram ( primeiro reporte 1999 - M. Lawrence-Brown ) para tratar por via endovascular aneurismas toraco-abdominais tipo III ou IV e abdominais cujas características morfológicas são impeditivas de utilização das endoproteses existentes no mercado ou seja colos curtos (inferiores 10 mm ), aneurismas justa-renais e para-renais. As ditas “ soluções inventivas “ são processos de solucionar exactamente os mesmos casos recorrendo a endoproteses colocadas em paralelo. As próteses fenestradas/ramificadas são desenhadas e fabricadas de acordo com a anatomia do doente, recorrendo a combinações de fenestrações e ramos de modo a adequar a prótese ás necessidades morfológicas identificadas. Por este motivo exigem um planeamento muito trabalhoso e rigoroso e sendo desenhadas especificamente para uma anatomia tem periodos de fabrico mais ou menos prolongados. Algumas anatomias nomeadamente angulação aortica superior a 45º , artérias ilíacas estreitas particularmente se calcificadas, artérias alvo com lesões muito significativas ou bifurcações muito perto do ostium são contra-indicação para uso destas endoproteses. A sua colocação é também muito exigente quer quanto aos “skills” endovasculares dos intervencionistas quer quanto á tecnologia necessária á sua implantação, é absolutamente necessário efectuar o procedimento numa angio-suite ou idealmente em sala cirúrgica híbrida Os resultados obtidos com estas próteses são muito satisfatórios com uma mortalidade a 30 dias de 1,4% (cirurgia aberta tem mortalidade de 3,6% ) e com taxas de permeabilidade dos vasos alvo de 87 a 95% a 5 anos Os enxertos em paralelo são uma solução alternativa permitindo o uso simultâneo de várias das técnicas descritas, chaminé, periscópio, sanduíche . Obviamente que o planeamento é também exigente e a necessidade de grande qualidade técnica dos operadores é mandatória. Em termos de necessidades tecnológicas é menos exigente que a endoprotese fenestrada/ ramificada sendo passível de ser efectuada em Bloco Operatório. A grande vantagem das próteses em paralelo é a sua disponibilidade. Com o material que habitualmente existe em stock é possivel tratar a maioria dos casos que surgem. Outra vantagem é a independência das próteses na relação umas com as outras o que permite acomodar melhor a enorme mobilidade vascular abdominal. A grande critica é o facto de estarmos a utilizar todo um conjunto de material ( endoprotese, e stents cobertos ) de um modo totalmente fora das instruções de uso.

João Albuquerque e Castro, MD

Chefe de Serviço de Angiologia e Cirurgia Vascular

no Hospital de Santa Marta ( C.H.L.C.)

Presidente da Direcção da Sociedade Portuguesa de

Angiologia e Cirurgia Vascular

Outro importante problema são as goteiras entre as próteses, origem de endoleaks significativos. Alguns estudos tentam encontrar a melhor escolha entre os diversos stents cobertos disponíveis e as várias endoproteses principais mas nenhum é conclusivo. Estão também descritas algumas técnicas de redução de volume das goteiras mas também aqui as soluções não são totalmente satisfatórias Quando pretendemos analisar os resultados desta duas técnica encontramos vários problemas: em primeiro lugar o pequeno numero de casos e a inexistência de resultados a médio e longo prazo, em segundo lugar a total falta de standartização sendo enorme a variabilidade principalmente quanto á escolha do tipo de prótese usada na chaminé ou periscópio. Nos resultados obtidos taxa de mortalidade a 30 dias de 0,6% e taxas de preservação permeabilidade dos vasos alvo de 97% Existem na literatura uns poucos estudos comparativos das duas técnicas, nenhum é randomizado, todos são retrospectivos e são identificáveis muitos outros viés, mas as conclusões são uniformes e traduzem-se em “- As series são limitadas e retrospectivas mas a análise de resultados a curto e médio prazo evidencia que não existe diferença estatisticamente significativa entre as endoproteses fenestradas/ ramificadas e as em paralelo “ Nos resultados conhecidos parece também não haver qualquer diferença significativa quer na mortalidade relacionada com eventos aorticos quer na taxa de necessidade de intervenções secundarias. Em conclusão ambas as técnicas parecem obter resultados satisfatórios mas são ambas de planeamento e execução difícil sendo os melhores resultados obtidos no centro de maior volume.

Is one of the solutions really more cost-effective?

Approximately 20% to 30 % of patients with abdominal aortic aneurysms (AAA) are unsuitable candidates for standard endovascular aortic aneurysm repair (EVAR), mainly due to anatomic constrains related to proximal neck anatomy. On the other and open surgical repair for these complex abdominal aortic aneurysms is associated with high mortality rate in high-risk patients. To overcome these challenges, a variety of endovascular procedures have emerged to extend proximal landing zones. These include fenestrated/ branched grafts (f-EVAR/ b-EVAR), surgeon-modified devices and parallel grafts, such as chimney, periscope and sandwich techniques. Research to date indicates that there may be a reduction in immediate post-operative mortality in this endovascular approaches when compared to open surgery. However, these devices are newer, more expensive and less studied than the stent grafts used in other parts of the aorta, with significant lack of information on cost effectiveness and long term results. In an ideal world the words "economy " and " health " should only very rarely be used in the same sentence and the latter be considered a value beyond price. Unfortunately resources are limited and choices are necessary. In the health technology assessment the question of the availability of this technology begins as policy, analysis and recommendation are scientific and in the end the decision will always be political! Sometimes scientific data are not solid enough to allow a political decision about the acceptability of a given treatment. Nigel Armstrong et al recently published in Health Technology Assessment a systematic review of clinical effectiveness studies on endovascular aneurysm repair for justarenal and thoracoabdominal aneurysms and showed that no comparative study has been done that could provide reliable clinical effectiveness data. All studies that compared either f-EVAR or b-EVAR with either open surgery or no surgery explicitly selected patients based on prognosis, i.e. essentially the populations for each comparator were not the same. Therefore, it was decided that a cost-effectiveness analysis evaluating f-EVAR and b-EVAR was not possible.

Leonor Vasconcelos

Vascular Surgeon

Hospital de Santa Marta (CHLC)

F-EVAR has been appointed as a valid treatment option in both low and high-risk patients, with low operative mortality, comparing favorably to open surgery in terms of morbidity. Parallel graft techniques can be currently recommended only as a bail out in unintentionally overstented branches, or in the urgent setting in patients unfit for open repair, or in elective poor surgical cases unsuitable for f-EVAR At present time the devices used are expensive and it is important that available resources are targeted to those who will benefit from their use. The available data does not allow to conclude clearly about the best alternative, at the lowest cost, for the treatment of complex abdominal aorta aneurysms. The initial question remains unanswered. Common sense and an individualized analysis of each particular case remains the key to find out which solution, if any, is really more cost-effective.

Debranching? – Why?

In the endovascular era, when aortic pathology cannot be treated endovascularly, open aortic surgery is usually considered. Unfortunately, latter treatment option carries high risk, especially in extensive thoraco-abdominal aortic aneurysms and considerable number of patients will not fit biologically for such invasive procedure.

Moreover, overall open surgery expertise is rapidly decreasing and therefore outcomes after conventional open surgery, even for low risk patients, may significantly worsen in near future. Debranching the renovisceral vessels, to allow secondary endoaortic repair with standard EVAR devices (tubular and bifurcated stentgrafts), seems less invasive procedure. But unfortunately, some centers have reported high complication rates. However, appropriate debranching strategy and tools (like the hybrid graft) allow to address complex anatomies with acceptable complication rates and could therefore play increasing rule in future.

Mario Lachat, MD, PhD

Head of Vascular Surgery University Hospital Zurich

Especificidades da trombectomia percutânea: bypass; stent e artérias

Introdução A cirurgia convencional tem desempenhado um papel, nem sempre eficaz, na trombose vascular aguda. Os resultados da trombectomia cirúrgica são ainda mais dececionantes na trombose aguda do bypass ou stent. Com a evolução das técnicas e dos materiais endovasculares, as alternativas percutâneas adquiriram um lugar fundamental na orientação e no tratamento destes doentes. Desenvolvimento Em contraste com a trombólise sistêmica, a trombólise dirigida por cateter permite a infusão localizada, intra-trombo, de trombolítico em quantidades inferiores e em concentrações potencialmente maiores. O agente mais usado é o activador do plasminogénio tecidual recombinante (rTPA). A trombólise dirigida por cateter está aprovada pela FDA para uso na isquemia aguda, especialmente com menos de 14 dias de evolução, e para a trombose venosa profunda aguda. Além disso, também é frequentemente utilizada na trombose precoce de stent e bypass periférico. Outras alternativas disponíveis são os cateteres de aspiração (Export®, Medtronic. Eliminate®, Terumo). Apresentam a vantagem de um manuseamento mais simples. Mais recentemente, surgiu a alternativa da trombectomia mecânica percutânea. A maioria destes materiais permite a infusão simultânea de trombolítico. Estes métodos farmaco-mecânicos associam a dissolução mecânica do trombo com uma melhor penetração local do trombolítico. Essencialmente, para além do efeito mecânico, visam diminuir significativamente a duração da terapêutica trombolítica, reduzindo as complicações e os custos associados. Os métodos mecânicos são divididos em rotacionais, reolíticos ou com recurso a ultrasons. Os aparelhos rotacionais, tais como o Trerotola® (Arrow) e o Amplatz Thrombectomy Device® (Microvena) utilizam uma hélice de elevada rotação para macerar o trombo. O Angiojet® (Possis) utiliza um jacto salino de elevada pressão com posterior aspiração do trombo fragmentado. O Ekos® (Ekos Corporation), com ultrasom, é constituído por múltiplos transdutores de evelada frequência, em forma radial, que permitem uma fragmentação do trombo e assim melhor penetração do trombolítico.

Miguel Maia, MD, FEBVS, RVT

Assistente Hospitalar em Angiologia e Cirurgia Vascular

Centro Hospitalar do Tâmega e Sousa EPE

Certificação em Eco-Doppler Vascular pela A.R.D.M.S.

(American Registry for Diagnostic Medical Sonography)

desde 2008

O cateter Trellis® (Covidien) combina a oscilação de um fio guia com a infusão do trombolítico, entre o balão proximal e o balão distal, delimitando o segmento tratado. Conclusão As opções endovasculares para a realização trombectomia percutânea são variadas e a sua escolha, depende em grande medida, da familiaridade e dos resultados institucionais.

Trombectomia- precisamos mesmo de um dispositivo?

Introdução

A abordagem das oclusões trombóticas ou embólicas arteriais agudas foi revolucionada com a introdução do catéter Fogarty de embolectomia nos anos 601. Desde então, uma série de dispositivos têm sido concebidos para tromboembolectomia puramente percutânea, desde a aspiração simples e o uso do dispositivos reolíticos, passando pela fragmentação mecânica de trombos, até à combinação de fragmentação mecânica e lise farmacológica. Trombólise guiada por catéter (TDC) Durante os anos 90 três estudos multicêntricos randomizados foram publicados comparando a trombólise e a cirurgia, nas oclusões arteriais. No estudo Rochester2 foram randomizados 114 doentes com isquemia aguda dos membros para tratamento com urocínase ou cirurgia imediata. As taxas de sobrevida livres de amputação ao final do 1º ano foram superiores no grupo submetido a tratamento com urocínase (75%), comparando com aqueles sujeitos a cirurgia imediata (52%), diferença esta estatisticamente significativa. Tal foi associado a uma maior taxa de mortalidade no grupo cirúrgico por complicações cardiopulmonares perioperatórias. O segundo estudo multicêntrico, Surgery versus Thrombolysis for Ischemia of the Lower Extremity (STILE) trial3, englobou a randomização de 393 pacientes submetidos ora a tratamento trombolítico (urocínase/rt-PA) ora a tratamento cirúrgico. Relativamente àqueles com duração de sintomas > 14 dias, os que foram submetidos a intervenção cirúrgica tiveram menor taxa de amputação aos 6 meses (3% vs. 12%). Pelo contrário, naqueles com sintomas de menor duração (<14 dias), as menores taxas de amputação foram observadas no grupo submetido a tratamento trombolítico (11% vs. 30%). No estudo multicêntrico TOPAS (Thrombolysis or Peripheral Arterial Surgery) trial4, foram comparadas a terapia com urocínase recombinante e a cirurgia primária em 544 doentes com oclusões das artérias nativas/de bypass dos membros inferiores, com duração igual ou inferior a 14 dias. Não foram encontradas diferenças significativas nas taxas de sobrevida livres de amputação ou de mortalidade entre os grupos, aquando da alta hospitalar e aos 6 meses. Dentro do grupo submetido a trombólise, aqueles com oclusões de bypass tiveram melhores outcomes clínicos e menores taxas de complicação quando comparados com os doentes com oclusões da circulação nativa. Em doentes com isquemia aguda a técnica TDC (trombólise direta guiada por catéter) leva à resolução do trombo com resultados clínicos satisfatórios em 75-92% dos doentes5. Os fatores relacionados com o maior sucesso são: 1) oclusão de enxerto < 14 dias, 2) sucesso na ultrapassagem da oclusão do enxerto com fio guia, 3) permeabilidade de pelo menos 1 ano do enxerto antes do evento trombótico e 4) a existência de lesão

João Vasconcelos, MD

Assistente hospitalar de Angiologia e Cirurgia Vascular

Centro Hospitalar do Tâmega e Sousa

Trombectomia- precisamos mesmo de um dispositivo?

Introdução

A abordagem das oclusões trombóticas ou embólicas arteriais agudas foi revolucionada com a introdução do catéter Fogarty de embolectomia nos anos 601. Desde então, uma série de dispositivos têm sido concebidos para tromboembolectomia puramente percutânea, desde a aspiração simples e o uso do dispositivos reolíticos, passando pela fragmentação mecânica de trombos, até à combinação de fragmentação mecânica e lise farmacológica. Trombólise guiada por catéter (TDC) Durante os anos 90 três estudos multicêntricos randomizados foram publicados comparando a trombólise e a cirurgia, nas oclusões arteriais. No estudo Rochester2 foram randomizados 114 doentes com isquemia aguda dos membros para tratamento com urocínase ou cirurgia imediata. As taxas de sobrevida livres de amputação ao final do 1º ano foram superiores no grupo submetido a tratamento com urocínase (75%), comparando com aqueles sujeitos a cirurgia imediata (52%), diferença esta estatisticamente significativa. Tal foi associado a uma maior taxa de mortalidade no grupo cirúrgico por complicações cardiopulmonares perioperatórias. O segundo estudo multicêntrico, Surgery versus Thrombolysis for Ischemia of the Lower Extremity (STILE) trial3, englobou a randomização de 393 pacientes submetidos ora a tratamento trombolítico (urocínase/rt-PA) ora a tratamento cirúrgico. Relativamente àqueles com duração de sintomas > 14 dias, os que foram submetidos a intervenção cirúrgica tiveram menor taxa de amputação aos 6 meses (3% vs. 12%). Pelo contrário, naqueles com sintomas de menor duração (<14 dias), as menores taxas de amputação foram observadas no grupo submetido a tratamento trombolítico (11% vs. 30%). No estudo multicêntrico TOPAS (Thrombolysis or Peripheral Arterial Surgery) trial4, foram comparadas a terapia com urocínase recombinante e a cirurgia primária em 544 doentes com oclusões das artérias nativas/de bypass dos membros inferiores, com duração igual ou inferior a 14 dias. Não foram encontradas diferenças significativas nas taxas de sobrevida livres de amputação ou de mortalidade entre os grupos, aquando da alta hospitalar e aos 6 meses. Dentro do grupo submetido a trombólise, aqueles com oclusões de bypass tiveram melhores outcomes clínicos e menores taxas de complicação quando comparados com os doentes com oclusões da circulação nativa. Em doentes com isquemia aguda a técnica TDC (trombólise direta guiada por catéter) leva à resolução do trombo com resultados clínicos satisfatórios em 75-92% dos doentes5. Os fatores relacionados com o maior sucesso são: 1) oclusão de enxerto < 14 dias, 2) sucesso na ultrapassagem da oclusão do enxerto com fio guia, 3) permeabilidade de pelo menos 1 ano do enxerto antes do evento trombótico e 4) a existência de lesão

João Vasconcelos, MD

Assistente hospitalar de Angiologia e Cirurgia Vascular

Centro Hospitalar do Tâmega e Sousa

corrigível. Os fatores associados com pior outcome após a realização de trombólise são: diabetes, hábitos tabágicos ativos e enxerto protésico. Após se ter ultrapassado a lesão com um fio guia, é colocado um catéter e a terapia lítica iniciada. Existem vários tipos de catéteres disponíveis no mercado dedicados à trombólise, mas não existe evidência sólida relativamente à superioridade deles relativamente a outros tipos. Qualquer catéter que seja possível colocar no local alvo pode ser utilizado para a libertação de agentes trombolíticos. Existem várias técnicas estabelecidas para a libertação de trombólise farmacológica, a destacar: 1- A perfusão regional intra-arterial não seletiva na qual o catéter é posicionado proximalmente à oclusão e a seletiva quando o catéter é colocado na porção proximal da oclusão. 2- Perfusão intratrombo quando o agente fibrinolítico é libertado dentro da oclusão. Este é o método mais comummente utilizado, com resultados superiores6. A mobilização anterógrada ou retrógrada gradual do catéter, durante o tratamento, e o método constante ou decrescente da perfusão, assim como a administração em bólus, são outros fatores a ponderar quando se realiza a TDC7. Trombectomia percutânea O uso de balões Fogarty são o mais simples, mais barato e mais rápido método de trombectomia em comparação com os dispositivos de trombectomia percutâneos dedicados (DTP). Em doentes com isquemia aguda e múltiplas comorbilidades que contraindicam a cirurgia ou trombólise, a hipocoagulação isolada está associada a altas taxas de amputação e mortalidade8. Nestes casos, a trombectomia isolada poderá ter aqui o seu papel. Um dos métodos percutâneos para a remoção de trombos alternativa à cirurgia aberta é a trombectomia de aspiração percutânea (TAP). É de fácil utilização, de baixo custo e rápida, na qual é utilizado um catéter de grande calibre (6-8F) ou de menor diâmetro (5F) para as artérias crurais. O catéter é conetado a uma seringa e aspirado vigorosamente. Embora a maioria dos DTPs têm aprovação pela CE para trombectomia de enxertos de diálise e fístulas nativas, a sua aplicação na isquemia aguda dos membros (IAM) deve ter em conta não só o sucesso na repermeabilização local assim como a inexistência de embolização periférica. Desta forma os dispositivos com aspiração de fragmentos são os preferidos na IAM: Hydrolyzer, sistema Oasis, AngioJet, ThrombCat, Bacchus Trellis, OmniSonics Resolution Wiree o sistema Ekos Lysus. Só alguns destes dipositivos foram estudados para o sistema periférico. Com o sistema Rotarex foram obtidas taxas de sucesso de 95%, com 9% de embolizações distais. O risco de perfuração/disseção é altamente dependente da correta posição intravascular do fio guia. Wissgott9 documentou 1% (3/265) de perfurações e Zeller10 menciona 9%. O risco de perfuração é especialmente alto nas artérias calcificadas. Este fenómeno está relacionado com o facto das placas calcificadas serem aspiradas e haver fixação destas na entrada da hélix. Após a remoção do material trombótico/embólico muitas vezes é necessária angioplastia ou stenting concomitante. O catéter Hydrolyser demonstra ter menos propensão para a formação de neoíntima quando comparado com a trombectomia por Fogarty convencional, em modelos animais in vivo. Quando comparado com o sistema Angiojet, o Hydrolyzer produziu menos taxas de embolização. As taxas de sucesso para enxertos e artérias nativas são de 88% e 73% respetivamente, sendo que 42% dos pacientes necessitaram de trombólise adicional7. O sucesso técnico do sistema Angiojet Rheolytic varia de 56 a 95% com permeabilidades primárias de 68 e 58% no 1o e 3os anos, respetivamente. Foram verificados 9,8% de embolizações distais e 75% de preservação de membro aos 2 anos. Em 29% dos casos foi necessária trombólise adicional. Os sistemas reolíticos podem através da hemólise

induzida levar à insuficiência renal secundária à libertação de hemoglobina pelo que o aporte de fluidos deve ser assegurado. Dada a inexistência de estudos controlados, multicêntricos, randomizados a comprovar a eficácia de DTPs, não existem claras indicações para a sua aplicação na IAM. No entanto vários ensaios clínicos sublinham a segurança e eficácia destes dispositivos e o seu uso torna-se especialmente necessário nos casos com contraindicação absoluta para a administração de agentes líticos ou nos casos em que a trombólise não está indicada ou foi ineficaz. A trombectomia mecânica percutânea está recomendada nos casos de isquemia aguda IIb de Rutherford e em doentes com alto risco cirúrgico, dada a morosidade da trombólise. Os dispositivos acoplados à ultrassonografia, como o OmniSonics OmniWave Endovascular System e o Ekos Lysus system parecem promissores. Finalmente, em 2014, a empresa Penumbra lançou o sistema Indigo especificamente para o sistema arterial periférico, lançando igualmente boas perspetivas na trombectomia abaixo do joelho11. Trombectomia farmacomecânica O uso combinado de terapias mecânicas e trombolíticas (farmacomecânicas) é utilizado para aumentar o efeito lítico e reduzir o tempo de procedimento, especialmente nas situações de isquemia avançada, nas quais o tempo é crucial para a viabilidade do membro, com minimização do risco hemorrágico associado à TDC. A TAP por si só tem uma taxa de sucesso de 31 %, mas a combinação de trombólise e TAP permite obter sucesso em até 90 % dos casos com limb-salvages de 86% e permeabilidades primárias de 58% aos 4 anos de follow-up12. Vários dispositivos de trombectomia são usados em conjunto com agentes trombolíticos por forma a acelerar a rapidez de trombólise. Kasirajan et al13 comparou pacientes com isquemia aguda dos membros tratados com o catéter Angiojet e controlos históricos submetidos a técnicas cirúrgicas convencionais. Dos 65 casos tratados com Angiojet, 44 tiveram associada trombólise concomitante. A taxa de amputação durante o 1º mês não teve diferença significativa entre os grupos cirúrgico vs. endovascular (11% vs. 14%; p = 0.57). No entanto, no grupo Angiojet a taxa de mortalidade precoce foi inferior (7.7% vs. 22%; p = 0.037). Trombectomia venosa As guidelines clínicas da Society of Interventional Radiology (2006) e da American Heart Association (2011)14 sugerem a consideração de TDC para pacientes selecionados com trombose venosa profunda (TVP) proximal extensa, ao passo que as guidelines de 2012 (American College of Chest Physicians)15 sugerem anticoagulação ao invés de TDC. Um recente estudo multicêntrico (CaVenT)16 mostrou existir uma redução relativa de 26% (41% vs. 56%, p = 0.047) na síndroma pós-trombótica aos 2 anos em doentes com TVP proximais submetidos a TDC. Uma análise de custo-eficácia deste estudo foi publicada em 2013 com resultados encorajadores17. Os investigadores reportaram 3% de hemorragias major no grupo TDC. No entanto este estudo é imbuído de limitações uma vez que a amostra é de somente 189 doentes distribuídos por 4 centros do sul da Noruega, não tendo sido avaliada a trombectomia farmacomecânica, que poderá ser mais eficaz e com menos riscos associados. Com base na evidência disponível as Guidelines da Society for Vascular Surgery e da American Venous Forum18 recomendam estratégias de remoção precoce do trombo em pacientes autónomos com boa capacidade functional e com primeiro episódio de TVP femoro-ilíaca com < 14 dias de duração (Grau 2C). Existe uma forte recomendação para o uso destes métodos em pacientes com isquemias ameaçadoras do membro devido a obstruções venosas femoro-ilíacas (Grau 1A). São sugeridas ainda estratégias farmacomecânicas sobre as trombolíticas puras, se existirem recursos para tal. A trombectomia cirúrgica deve ser considerada se a terapêutica trombolítica estiver contraindicada (Grau 2C).

A maior parte dos estudos sobre a aplicação de terapêuticas farmacomecânicas a nível do sistema venoso são de baixa qualidade e de díficl comparação, mas sugerem benefícios importantes na redução da morbilidade da síndrome pós-trombótica. Existe extrema variação na descrição das populações de pacientes com TVP, dos métodos endovasculares utilizados e dos resultados apresentados dos estudos nesta área, diminuindo a sua relevância para aqueles profissionais que a tratam. Em 2009, três comités da Society of Interventional Radiology publicaram normas de publicação nesta área no sentido da uniformização de dados futuros19. Aguardam-se os resultados do estudo ATTRACT, cuja admissão de doentes terminou em dezembro 2014 com 692 doentes. Será o primeiro estudo americano, multicêntrico (50 centros), randomizado, que determinará qual o impacto clínico a longo prazo das terapêuticas endovasculares no tratamento da TVP20. Dados provenientes de 1 ano de follow-up do estudo Dutch CAVA também se aguardam21. Nestes dois estudos serão também testados dispositivos mecânicos adicionais por forma a encurtar o tempo de tratamento.

Conclusão

A trombólise intra-arterial percutânea guiada por catéter é um método seguro e eficaz no tratamento da isquemia aguda dos membros, desde que a seleção dos doentes e a monitorização do procedimento seja assegurada. Apesar de serem necessários mais estudos para estabelecer o papel de dispositivos de trombectomia percutânea no sistema periférico, a trombectomia mecânica pode atualmente ser aplicada em combinação com a infusão lítica em casos selecionados nos quais a recanalização rápida é exigível ou como procedimento único quando a administração de trombolíticos está contraindicada. A nível do sistema venoso profundo aguardam-se os resultados de estudos multicêntricos e randomizados que avaliem o real benefício na redução do síndrome pós-trombótica e quais os riscos inerentes aos procedimentos percutâneos. Referências: 1-Fogarty TJ, et al: A method for extraction of arterial emboli and thrombi. Surg Gynecol Obstet 116:241–244, 1963.

2- Ouriel K, et al: A comparison of a thrombolytic therapy with operative revascularization in the initial treatment of acute peripheral arterial ischemia. J Vasc Surg 19:1021–1030, 1994.

3- The STILE Trial: Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity. Ann Surg 220:251–266, 1994.

4- Ouriel K, et al: For the Thrombolysis or Peripheral Arterial Surgery (TOPAS) investigators: A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. N Engl J Med 338:1105–1111, 1998.

5- Creager MA, et al: Acute limb ischemia. N Engl J Med 366:2198–2206, 2012.

6- Kessel DO, Berridge DC, Robertson I: Infusion techniques for peripheral arterial thrombolysis. Cochrane Database Syst Rev 1:CD000985, 2004.

7- Karnabatidis D, Spiliopoulos S, Tsetis D, Siablis D: Quality Improvement Guidelines for Percutaneous Catheter-Directed Intra-Arterial Thrombolysis and Mechanical Thrombectomy for Acute Lower-Limb Ischemia. Cardiovasc Intervent Radiol 34:1123–1136, 2011.

8- Braithwaite BD, et al: Management of acute leg ischemia in the elderly. Br J Surg 85:217–220, 1998.

9- Wissgott C, Kamusella P, Richter A, Klein-Weigel P, Steinkamp HJ: Mechanical rotational thrombectomy for treatment thrombolysis in acute and subacute occlusion of femoropopliteal arteries: retrospective anaylsis of the results from

1999 to 2005. Fortschr Röntgenstr 180:1–7, 2008.

10 - Zeller T, Frank U, Burgelin K, Schwarzwälder U, Horn B, Flugel P, Neumann F: Longterm results after recanalization of acute and subacute thrombotic occlusions of the infra-aortic arteries and bypass-grafts using a rotational thrombectomy device. Fortschr Röntgenstr 174:1559–65, 2002.

11- Yamada R1, Adams J, Guimaraes M, Schönholz C: Advantages to Indigo mechanical thrombectomy for ALI: device and technique. J Cardiovasc Surg (Torino). 56(3):393-400, 2015.

12- Zehnder T, et al: Percutaneous catheter thrombus aspiration for acute or subacute arterial occlusion of the legs: how much thrombolysis is needed? Eur J Vasc Endovasc Surg 20:41–46, 2000.

13- Kasirajan K, et al: Rheolyticthrombectomy in the management of acute and subacute limb threatening ischemia. J Vasc Interv Radiol 12:413–421, 2001.

14-M.R. Jaff, M, et al: Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation, 123 (16): 1788–1830, 2011.

15-C. Kearon, E, et al: Antithrombotic therapy for VTE disease. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141 (2): e419S–e494S, 2012.

16-Enden T, et al: Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomized controlled trial. Lancet 379:31e8, 2012.

17-Enden T, Resch S, White C, Wik HS, Kløw NE, Sandset PM: Costeffectiveness of additional catheter-directed thrombolysis for deep vein thrombosis. J Thromb Haemost 11(6):1032e 42, 2013.

18-Meissner M, et al: Early thrombus removal strategies for acute deep venous thrombosis: Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 55:1449-62, 2012.

19-Vedantham S, et al: Reporting Standards for Endovascular Treatment of Lower Extremity Deep Vein Thrombosis. J Vasc Interv Radiol 20:S391–S408, 2009.

20-Vedantham S, et al: Rationale and design of the ATTRACT Study: a multicenter randomized trial to evaluate pharmacomechanical catheter-directed thrombolysis for the prevention of postthrombotic syndrome in patients with proximal deep vein thrombosis. Am Heart J. 165(4):523-530.e3, 2013.

21-DUTCH CAVA-trial: CAtheter Versus Anticoagulation Alone for Acute Primary (Ilio)Femoral DVT. (NL28394). http://clinicaltrials.gov/ct2/show/NCT00970619.

Hypogastric Preservation and EVAR. None, one, both – when?

Flow interruption to the Internal Iliac Artery (IIA) is sometimes an option when performing EVAR. Absence of a distal landing zone on the Common Iliac Artery, adequate to receive a standard limb, usually mandates one of the following: use of a bell-bottom limb, IIA sacrifice (either by embolization or simple coverage), or IIA preservation (using an endograft system including a hypogastric branch or by resorting to parallel grafting). A choice must therefore be made, between a suboptimal repair with highly questionable durability (bell-bottom limb), a tailored off-label parallel endografting procedure, the use of commercially available IIA branched endografts, or taking the risk of interrupting the hypogastric circulation. It’s a complex decision, in which technical expertise, procedure complexity, cost, and clinical performance (perioperative complications and repair durability) must all be taken into account. The array of approved hypogastric branched endografts is increasing, and the anatomical suitability is therefore widening. The decision regarding hypogastric preservation today is sometimes, in fact, between 3 different options: none, one or both. This issue’s decision-making process is all but standardized. Two of the most feared complications, pelvic (including colonic) ischemia an spinal cord ischemia are remarkably absent from the literature, when it comes to frequency reports. When can only assume an exceedingly high publication bias. Two other complications from hypogastric flow interruption are better known: buttock claudication and sexual disfunction. Buttock claudication may reach an incidence of 30% when unilateral interruption is performed and almost 40% after bilateral interruption. Sexual disfunction has been reported in around 20% after either uni or bilateral flow interruption to the hypogastric circulation. We will present a systematic review with meta-analysis on this topic, and currently available evidence supporting different strategies will be discussed.

Sérgio Moreira Sampaio, MD, PhD, FEBVS

Assistente Hospitalar Graduado de Angiologia e Cirurgia

Vascular

Professor auxiliar convidado - Faculdade de Medicina da

Universidade do Porto

Bell-Bottom Technic- Uma alternativa para preservar a circulação arterial pélvica

O tratamento endovascular o aneurisma da aorta, representa actualmente uma atractiva alternativa á cirurgia convencional. O Evar apresenta no curto prazo uma menor mortalidade, uma menor morbilidade, um menor tempo de internamento e um menor consumo de derivados de sangue. Contudo Evar tem várias limitações, uma das quais é o diâmetro das artérias ilíacas comuns, sendo que Armon MP et al (1998) refere que 20% dos aneurismas aórticos envolvem as artérias ilíacas comuns. Quando existem aneurismas ilíacos comuns (> 20mm de diâmetro), podem ser necessárias técnicas adicionais para uma completa exclusão dos aneurismas.

Entre as técnicas utilizadas, podemos efectuar a oclusão das artérias ilíacas internas com coils e a extensão da endoprotese a artéria ilíaca externa, ou simplesmente extensão da endoprotese a artéria ilíaca externa . Farahmand P et al (2008) demonstrou que a taxa de complicações da primeira alternativa ocasionava um numero superior de complicações isquémicas .Nós próprios sempre que empregamos a extensão da endoprotese à artéria ilíaca externa, fizemo-lo na grande maioria dos casos isoladamente. Contudo a oclusão das artérias ilíacas internas, sobretudo se bilateralmente pode ocasionar um a isquemia pélvica de maior ou menor gravidade, e que se pode manifestar segundo Bekdachek(2015) por, claudicação nadegueira (1-56%) , disfunção eréctil (10-45%), isquemia cólica (9-15%) ,isquemia ciática (<1%9 ou necrose glútea (<1%).

Assim e sempre que possível, devem ser poupadas ambas as artérias ilíacas internas ou pelo menos uma, já que devido à intensa colateralidade existente entre elas, podemos com alguma segurança sacrificar uma

Como forma de manter as artérias ilíacas internas, existem varias possibilidades, das quais as mais elegantes são os IBD (Internal Branch Device) e os IBE (Internal Branch Extension) .Estas endoproteses para serem utilizadas necessitam contudo da existência de critérios anatómicos, o que nem sempre acontece. O custo elevado destas endoproteses tem limitado o seu uso indiscriminado.

Outras técnicas, também elegantes, são as conhecidas técnicas de endoproteses paralelas, adaptadas das técnicas desenvolvidas por Lobato et al (Chimneys ,Sandwiches,periscopes,etc).Este publica que as técnicas de sandwich tem menos complicações que a Bell bottom e a extensão à artéria ilíaca externa. A vantagem destas técnicas é um custo mais baixo, estarem mais facilmente disponíveis para utilização, mas os resultados são menos consistentes. Neste sector não temos experiencia na utilização destas técnicas.

Rui Machado, MD, PhD, FEBVS

Consultor de Angiologia e Cirurgia Vascular HSA/CHP

Prof. Conv. de Angiologia e Cirugia Vascular ICBAS/UP

Outra técnica bastante aplicada ,é conhecida como Bell Bottom .Esta, implica a aceitação de que um aneurisma ilíaco comum com diâmetro máximo ate 25mm, pode ser tratado com uma endoprotese até 28 mm de diâmetro . Esta técnica tem como vantagens, a sua fácil aplicação seu baixo custo e a sua disponibilidade. Como desvantagens a possibilidade de desenvolvimento de endoleak tipo IB por crescimento do aneurisma ilíaco. Na nossa experiencia, utiliza-mos esta técnica em aneurisma com diâmetro máximo de 25mm,em doentes idosos e em doentes com necessidade acrescida de preservação da permeabilidade da artéria ilíaca interna . Nestes doentes, há uma necessidade acrescida de vigilância por tc.Torsello G et al (2010) refer que aneurismas ilíacos <30mm podiam ser tratados com segurança, cor um risco baixo de endoleak tipo IB e que as complicaçoes podiam ser tratadas por via endovascular .Naughton et al (2012) refere que a taxa de complicações é menor com a utilização da técnica de Bell Bottom do que com a extensão da endoproteses á artéria ilíaca externa

Como ultima alternativa, existe a cirurgia hibrida em que se faz uma extensão à artéria ilíaca externa da endoprotese e simultaneamente realiza-se uma pontagem à artéria ilíaca interna . Na nossa experiência, esta técnica demonstrou uma baixa agressividade fisiológica e boa patencia da pontagem.

Concluímos, afirmando a existência de várias alternativas terapêuticas para ultrapassar o envolvimento aneurismático das artérias ilíacas comuns, e que a escolha da técnica vai depender da idade do doente e suas condicionantes (por exemplo existência de disfunção eréctil) , do envolvimento uni ou bilateral, da disponibilidade de IBD ou IBE , da urgência do tratamento e da experiencia da equipe ,tentando sempre que possível manter permeável uma artéria ilíaca interna .

Cook’s IBD vs Gore’s IBE. Is an evidence-based choice possible?

Introduction

Although isolated common iliac artery (CIA) aneurysms are rare, uni or bilateral CIA aneurysms have been reported in up to 43% of patients with intact abdominal aortic aneurysm (AAA)1,2. Despite several recent improvements in endovascular abdominal aortic aneurysm repair (EVAR), aorto-iliac aneurysms still represent a limitation for EVAR applicability and the best strategy to manage such disease has not been identified yet3.

Currently, standard endovascular approach requires endograft limb extension beyond the iliac bifurcation into the external iliac artery (EIA), with uni or bilateral internal iliac artery (IIA) exclusion. This procedure is not entirely benign; although major pelvic ischemic complications, such as colonic and spinal cord ischemia are uncommon, the reported incidence of buttock claudication and sexual dysfunctions ranges from 12 to 45% of the cases4-6.

In order to prevent the development of pelvic ischemic symptoms, a variety of hybrid and alternative techniques have been described to preserve direct IIA flow7, although their applicability is limited by the increased invasiveness and technical complexity of the procedure.

Iliac branch devices

Iliac branch device (IBD) has been introduced as a new valid endovascular approach to deal with extensive aorto-iliac aneurysms, allowing aneurysms exclusion with preservation of antegrade flow of the internal iliac artery. Different devices, each one with specific technical features, have been introduced on the market in the last few years.

Cook Iliac Branch Device

The Zenith bifurcated iliac sidebranch device – ZBIS (William Cook Inc, Bloomington, Ind) has been the first to be available in a off the shelf configuration and for this reason it is the most studied in the literature so far. It derives from the Cook Zenith TFLE leg extension, which is based on independent longitudinal stainless-steel Z stent combined with a Dacron fabric; a nitinol side branch is attached to the leg in a 30° angle. The device is preloaded into a dedicated introduction system with a 20 F OD profile and is intended

Giovanni Pratesi, MD

Vascular Surgeon

Associate Professor at the Unit of Vascular Surgery, Department

of Biomedicine and Prevention, University of Roma Tor Vergata

Medical specialization in Vascular Surgery at the Division of

Vascular Surgery of the University of Siena

to be used in conjunction with a standard or fenestrated Zenith aortic component. Eight different sizes are available, providing treatment options for a wide range of patients with aortoiliac or iliac aneurysms. The ZBIS device can be schematically divided into three different components: common iliac segment has a fixed diameter of 12 mm and is available in two different lengths, 45 and 61 mm; external iliac segment configuration has two diameters, 10 and 12 mm, and two lengths, 41 and 58 mm; internal iliac side branch has a fixed 8 mm diameter and 10 mm length. An indwelling catheter passes through the internal iliac branch in order to facilitate the iliac branch and hypogastric artery cannulation. Radiopaque markers help with precise positioning.

Gore Iliac Branch Endograft

Gore recently introduced the Excluder Iliac Branch Endoprosthesis (IBE) (W. L. Gore & Asso- ciates, Flagstaff, AZ, USA), a bifurcated endograft based on the design of the Gore Excluder abdominal aortic aneurysm platform.

The Gore IBE offers a two-component design: the iliac branch component and the dedicated internal iliac component. The Iliac branch component has a fully supported sinusoidal nitinol stent design combined with a ePTFE luminal surface characterized by a sutureless stent to graft attachment. The low profile delivery system (18-Fr introducer sheath) associated with the high conformability of the Gore limbs makes the IBE an endovascular option able to offer good adaptation even in tortuous iliac arteries. This component has a fixed 23 mm proximal diameter, a fixed overall 10 cm length, with a 5.5 cm length to gate, whereas three different distal leg diameters are available, 10, 12 and 14.5 mm. It has been designed to be used in conjunction with either a 23 or 27 mm contralateral leg endoprosthesis.

The dedicated internal iliac component is a self-expandable endograft compatible with a 12-Fr introducer sheath and is based on the design of Excluder iliac legs. This component has a fixed 16 mm proximal diameter and a fixed 7 cm overall length. Distal diameters are available in three different configurations: 10, 12 and 14.5 mm.

Another novel technical feature of the IBE is the removable guidewire tube, which provides a small channel within the constrained device for the introduction of a second guidewire to precannulate the internal iliac gate.

Results

Although more than 1000 iliac branch devices have been implanted worldwide, published literature is scarce, with only a few clinical series. In the last decade in fact, a number of studies have assessed the feasibility and safety of this novel endovascular technique reporting conflicting outcomes, mainly related to the mixed use of different generations device and not standardized patient selection criteria8-10. However, results of iliac branch stent grafts have been encouraging, with technical success rates of greater than 95% in most reports. Karthikesalingam and associates11 reported a systematic analysis of 9 studies that included 196 patients treated with IBDs. Technical success ranged from 85% to 100%. There were no aneurysm-related deaths. Only 1 patient with patent IBD complained of buttock claudication. Late thrombosis of the IBD occurred in 24 patients (12%) and resulted in buttock claudication in 12 (50%). Endoleak rates were exceedingly low, with only 1 type I (0.5%) and 2 type III endoleaks (1%). Type II endoleaks were treated conservatively and were not associated with sac expansion. Reinterventions were

required in 12 patients (6%), including 5 with occlusion stent graft limbs to the external iliac artery.

When looking at long-term outcomes, most experiences in literature are based on limited number of cases providing few data on the real long-term durability of this technique11,12. We recent report our 4-year experience on 85 iliac branch endograft on 81 patients13. Procedural technical success was achieved in 80 patients (98.7%) with no perioperative mortality. During the first 30 postoperative days, one IBD occlusion was observed. In three patients (3.7%), a distal type I IBD endoleak was detected at the first computed tomography (CT) scan. As in all these cases a large covered stent was used in the internal iliac side branch (Large Diameter Advanta V12, Atrium Medical Hudson, NH, USA), a significant association between the distal type I endoleak and ectatic hypogastric main trunk was observed (Fisher’ s exact test c2 : 20.9; p . 0.002). The mean follow-up duration was 20.4 months (SD ± 15.4). Seven patients (8.6%) died due to non-aneurysm-related causes with an estimated overall survival of 89.5% and 76.7% at 24 and 48 months, respectively. Aneurysm-related deaths, conversions to open repair or aneurysm ruptures did not occur. No additional IBD occlusion was observed, with an estimated IBD patency of 98% at 48months No ipsilateral buttock claudication was observed in patients with a patent IBD in the follow-up. Neither late proximal type I and III endoleak nor new cases of distal type I IBD endoleak were detected with the estimated freedom from any endoleak at 48 months being 88.3%. Three patients (3.7%) underwent a secondary procedure during follow-up, in only one case IBD-related. The estimated freedom from re-intervention at 48 months was 88.3%.

These results are in line with Parlani et al. experience on 100 cases14, which reported a periprocedural technical success rate of 95%, with no mortality and two external iliac occlusion in the first month. In this experience, at a median follow-up of 21 months (range 1-60) aneurysm growth >3 mm was detected in four iliac (4%) arteries. Iliac endoleak (one type III and two distal type I) developed in three patients and buttock claudication in four patients. Estimated patency rate of internal iliac branch was 91.4% at 1 and 5 years. Freedom from any reintervention rate was 90% at 1 year and 81.4% at 5 years. No late ruptures occurred.

All these data are based on the use of the Cook Iliac Branch Device. When looking at the results of the new Gore Iliac Branch Endograft there is only one paper published in literature reporting the 30-day outcomes of this new device15. Seven Gore IBE were implanted in 5 patients. Technical success and branch patency was 100%. The two bilateral cases were conducted in general anesthesia with femoral cut-down. The other 3 cases were managed in local anesthesia and percutaneous approach. There was no 30-day mortality or major complications. In 1 of the 2 bilateral cases an endovascular relining with bare stents was required due to a compression of iliac legs at level of aortic bifurcation.

In our Institution between September 2013 and March 2015, 19 Gore IBE have been implanted in 15 patients (mean age 69.2±7.7 years) for the presence of an uni or bilateral aorto-iliac aneurysm or an isolated iliac aneurysm. Mean aortic diameter was 51.5±13.7 mm, with a mean common iliac artery diameter of 37.1±12.4 mm. All the IBE were successfully deployed and technical success was achieved in all patients in absence of major complications. Intraoperative adjunctive procedures were required in 3 patients consisting of two cases of external iliac artery stenting and hypogastric divisional branch embolization in one case. All patients were treated under local anesthesia with percutaneous access using the Preclose technique. A type III endoleak was diagnosed at

the 30-day CT scan and was successfully treated with a distal extension. Mean follow-up duration was 9.3±4.5 months. No additional reinterventions were required during this period and the estimated 12 months freedom from reinterventions rate was 92.8% with a 12 months IBE patency of 100%. Three type II endoleaks were detected, in all cases not associated with aneurysm sac enlargement with a 79.2% freedom from endoleak at 12 months.

Conclusions

Iliac branch device (IBD) has been introduced as a new valid endovascular approach to deal with extensive aorto-iliac aneurysms, allowing aneurysms exclusion with preservation of antegrade flow of the internal iliac artery. Two different dedicated off-the-shelf devices are currently available with specific technical features and proper anatomical inclusion criteria. Despite an evidence-based choice is not possible due to the lack of comparative studies, a tailored device selection can be used for the single patient on the basis of preoperative anatomy. Preliminary data suggest that the sinusoidal nitinol stent design of the Gore IBE might perform better in presence of tortuous external iliac artery and aneurysmal involvement of the hypogastric artery.

References

1. Hinchliffe RJ, Alric P, Rose D, Owen V, Davidson IR, Armon MP, et al. Comparison of morphologic features of intact and ruptured aneurysms of infrarenal abdominal aorta. J Vasc Surg 2003;38(1):88e92.

2. Dorigo W, Pulli R, Troisi N, Alessi Innocenti A, Pratesi G, Azas L, Pratesi C. The treatment of isolated iliac artery aneurysm in patients with non-aneurysmal aorta. Eur J Vasc Endovasc Surg. 2008 May;35(5):585-9.

3. Lin PH, Chen AY, Vij A. Hypogastric artery preservation during endovascular aortic aneurysm repair: is it important? Semin Vasc Surg. 2009;22(3):193-200.

4. Rayt HS, Bown MJ, Lambert KV, ET al. Buttock claudication and erectile dysfunction after internal iliac artery embolization in patients prior to endovascular aortic aneurysm repair. Cardiovasc Intervent Radiol 2008; 31:728-34.

5. Bratby MJ, Munneke GM, Belli AM, et al. How safe is bilateral internal iliac artery embolization prior to EVAR? Cardiovascular Interv Radiol 2008; 31:246-53.

6. Vandy F, Criado E, Upchurch GR Jr, Williams DM, Rectenwald J, Elison J. Transluminal hypogastric artery occlusion with an Amplatzer vascular plug during endovascular aortic aneurysm repair. J Vasc Surg 2008; 45:1121-24.

7. Pratesi G, Pulli R, Fargion A, Marek J, Troisi N, Dorigo W, Innocenti AA, Pratesi C. Alternative hybrid reconstruction for bilateral common and internal iliac artery aneurysms associated with external iliac artery occlusion. J Endovasc Ther. 2009 Oct;16(5):638-41

8. Haulon S, Greenberg RK, Pfaff K, Francis C, Koussa M, West K. Branched grafting for aortoiliac aneurysms. Eur J Vasc Endovasc Surg 2007;33:567-74.

9. Ziegler P, Avgerinos ED, Umscheid T, Perdikides T, Erz K, Stelter WJ. Branched iliac bifurcation: 6 years experience with endovascular preservation of internal iliac artery flow. J Vasc Surg 2007;46:204-10.

10. Tielliu IF, Bos WT, Zeebregts CJ, Prins TR, Van Den Dungen JJ, Verhoeven EL. The role of branched endografts in preserving internal iliac arteries. J Cardiovasc Surg. 2009;50(2):213-8.

11. Karthikesalingam A, Hinchliffe RJ, Holt PJ, Boyle JR, Loftus IM, Thompson MM. Endovascular aneurysm repair with preservation of the internal iliac artery using the iliac branch graft device. Eur J Vasc Endovasc Surg. 2010;39:285-294.

12. Ferreira M, Monteiro M, Lanziotti L. Technical aspects and midterm patency of iliac branched devices. J Vasc Surg. 2010;51(3):545-50

13. Pratesi G, Fargion A, Pulli R, Barbante M, Dorigo W, Ippoliti A, Pratesi C. Endovascular treatment of aorto-iliac aneurysms: four-year results of iliac branch endograft. Eur J Vasc Endovasc Surg. 2013;45(6):607-9.

14. Parlani G, Verzini F, De Rango P, Brambilla D, Coscarella C, Ferrer C, Cao P.

Long-term results of iliac aneurysm repair with iliac branched endograft: a 5-year experience on 100 consecutive cases. Eur J Vasc Endovasc Surg. 2012;43(3):287-92

15. Ferrer C, De Crescenzo F, Coscarella C, Cao P. Early experience with the Excluder® iliac branch endoprosthesis. J Cardiovasc Surg. 2014;55(5):679-83

Hypogastric arteries management in EVAR: How well/bad do “inventive”

solutions perform in this setting?

Management of hypogastric artery involvement in aorto-iliac aneurysm disease is a controversial issue, particularly when preservation is considered necessary. Before the advent of iliac-branched devices, iliac artery preservation was only possible by open revascularization of off label use of parallel grafts.

When preservation is not considered necessary, the debate revolves around the necessity of pre-emptive embolization vs. simple coverage of the iliac artery by extending the device into the external artery. Evidence shows that preemptive coil embolization may create more harm than advantage, due to the risk of atheroembolism from guidewire and catheter manipulation. Proximal hypogastric embolization using Amplatz plugs is preferable when anatomically possible, but may come with an added risk of buttock claudication or erectile dysfunction.

When hypogastric preservation is considered necessary, three endovascular options remain: large diameter iliac limbs, or bell-bottoms, create seal up in common iliac arteries up to 25mm in diameter. Extreme bell-bottoms have been described using aortic cuffs as extensions. Durability and persistent risk of rupture are concerning, however. Another possibility is the use of commercially available iliac branched devices (IBDs), allowing direct flow into the hypogastric while preserving distal seal at the external iliac artery.

Alternatively, parallel grafts may be used for hypogastric preservation. These are off-label applications of currently available covered stents used in conjunction with standard abdominal endografts. They represent creative solutions often originated from bailout or rescue situations and have been proposed as primary endovascular solutions in elective cases as well.

There is little evidence in literature to support any of these techniques, but small series report surprisingly good outcomes. Lobato et al have published on the use of the sandwich technique, with acceptable mid-term results. Primary patency at 12 months was 94%. Wu et al, from Korea, have recently published their experience on a crossover chimney technique, with primary patency of 93% at a similar mean follow-up of14 months and no AAA-related mortality. Long-term follow-up is largely unknown to date.

Frederico Bastos Gonçalves , MD, PhD, FEBVS

Vascular Surgeon

Hospital de Santa Marta, CHLC, Lisbon, Portugal

Auxiliary Professor

NOVA University, Lisbon, Portugal

Other inventive techniques have been described, like the external-to-internal “cross-stent” technique or in-situ fenestration and stenting. These are anecdotic reports with very limited follow-up, however, and probably represent extreme bailout solutions. Potentially, endosealing (EVAS) may also be used to create long chimneys that extend into the hypogastric arteries, but no reports exist to date.

In summary, the creativity of men is well expressed in the multiple off-label applications of parallel grafts and similar hypogastric revascularization strategies. However, one must bear in mind that these applications are scarcely supported by literature, may be dangerous to patients and jeopardize the procedure, and may even be more costly than on-label solutions like IBDs. Learning about these techniques is important to be able to solve complicated and/or complex situations with minimal damage, but elective use is probably unwise.

Hypogastric arteries management in EVAR – Still space for open solutions?

Iliac artery aneurysms are present in up to 40 % of all abdominal aortic aneurysms (AAA), and these tend to be bilateral in 50% of the cases1. This prevalence of iliac artery aneurysms poses a challenge when it comes to endovascular aneurysm repair (EVAR), given the absence of a distal landing zone for the iliac graft limbs, that doesn’t jeopardize hypogastric perfusion. The prevalence of pelvic ischemia after uni or bilateral internal iliac artery (IIA) occlusion has been extensively studied, but the commonest feature of this entity is its unpredictability. The consequences of IIA occlusion range from buttock claudication (16-50%) 2, 3, erectile dysfunction (15-17%) and spinal cord ischemia, to the most feared, which is, by far, ischemic colitis (2%) 4.

The risk factors for ischemic colitis include occlusion of a previously patent inferior mesenteric artery (IMA), previous colon surgery and stenosis or occlusion of celiac or superior mesenteric arteries. Nevertheless, in clinical practice, ischemic colitis commonly results from embolization of pelvic circulation during EVAR deployment 5, 6.

The progress of endovascular techniques, has granted several solutions for patients whose anatomy precludes the implantation of a device that preserves IIA flow. They span from proximal coil embolization/coverage of IIA, leaving a small common iliac aneurysm in place by using large limbs or a bell bottom technique, to the most elegant, maintaining prograde flow into the IIA with a bifurcated stent graft (IBD) or sandwich techniques.

From our point of view, all of these options have some drawbacks. Even though unilateral occlusion of an IIA is probably well tolerated, there will always be a patient for whom this simple procedure will turn into a fatal event, and science still can’t anticipate this grim fate. Intentionally leaving a small iliac aneurysm in place may not be harmful giving the life expectancy of this particular group of patients, but it will surely increase the probability of re-intervention. The best endovascular option is undoubtedly the implantation of an IBD, but these grafts are associated with additional economical costs and often lead to cumbersome procedures, with prolonged surgical and radiation exposure times and greater contrast use.

Besides, there are still multiple anatomical issues that pose relative contraindications for endovascular revascularization of the IIA’s. These include IIA aneurysms, tortuosity of iliac vessels, along with all the contraindications of EVAR itself, which not even new grafts and materials can overcome.

So, is there still space for open solutions in hypogastric arteries management?

Of course there is.

Gonçalo Cabral, MD

Vascular Surgeon – Hospital Beatriz Ângelo, Loures

The combination of any of the major risk factors for colon ischemia, already cited, with one of these anatomical issues is, in our opinion, a formal indication for conventional surgery. But we go further, when it comes to choose between open and endovascular aneurysm repair.

Open repair is extremely versatile, allowing for multiple solutions and intraoperative decision making that is just not possible in EVAR, where planning is everything.

A simple common iliac aneurysm, that implies having to choose between one of these advanced technological solutions, if IIA is to be preserved, is often treated with a straightforward operation consisting of a bifurcated graft anastomosed to the iliac bifurcation, without affecting substantially surgical time or morbidity. Even if the iliac bifurcation is slightly dilated, a bevelled graft can most of the times be adapted to this anatomy, with the advantage of counteracting the normal increase in vessel diameter that is aggravated by the radial force of any stent graft.

Because beauty is simplicity, the act of performing an aortobifemoral interposition with ligation of the common iliac is itself an elegant way of maintaining IIA perfusion.

The same applies to IMA management, where open surgery allows for its re-implantation whenever one believes it provides an advantage for the patient. This is often crucial when ligation or endoaneurysmorrhaphy of the IIA’s is the only solution, providing at least one collateral pathway for colon perfusion, with just 15 minutes of extra surgical time.

But if aneurismal involvement of the iliac bifurcation or proximal IIA is present, direct revascularization of one or both IIA is also technically feasible and safe.

In our centre we have performed such procedure in the following fashion:

- Dissection on the aorta and iliac vessels;

- Circumferential mobilization of the internal iliac artery, without using vascular references, to minimize risk of vein injury;

- Distal clamping first to avoid embolization of pelvic and limb arteries, using a Satinsky clamp for the IIA

- End-to-end proximal anastomosis of a bifurcated graft to the aorta;

- End-to-end distal anastomosis of the graft limb to the IIA;

- End-to-side anastomosis of a graft to the external iliac or femoral artery;

- Prosthesic-prosthesic anastomosis

This sequence allows for easier performance of the anastomosis to the IIA, without disturbance from a prosthetic limb already anastomosed to the femoral or external iliac arteries.

Most studies reveal that this procedure is safe and has good long-term patency results (89% at 1 year and 72.5% at 5 years) 7.

Even though in most centres worldwide, EVAR has now become the first line treatment for AAA, we still believe, and have the numbers to support open surgery as the gold standard for AAA in acceptable risk patients, thanks to its durable and proven results.

The key is adequate evaluation of surgical risk. When it comes to choosing between open repair and EVAR, one must have in mind that the more complex the endovascular procedure, the greater will be the associated risks, in terms of morbidity and mortality, and this is a topic that is seldom discussed. Everyone has to agree that the implantation of a fenestrated or branched graft does not pose the same risks as of an infra-renal graft

in patient with a 3 cm neck, and this has to influence decision making. The case for hypogastric arteries management is not different, and even more relevant, because the conventional surgery counterpart at this level is much less aggressive than a thoracoabdominal open repair, and allows to maintain flow in one artery that EVAR never spares – the IMA.

So, whenever pelvic ischemia is worrysome, as it always should be, the decision to simply occlude an IIA must not be taken lightly. From an ecological point of view it is desirable to maintain all vessels perfused, and this is surely the safest way to keep our patients colon, buttocks and spinal cord in good condition.

When it comes to decide whether to perform a complex endovascular procedure or a simple conventional surgery, good judgement, careful risk stratification and personal/centre experience must come into play, for our patients to have the best possible care.

But once again, beauty is simplicity...

In our hospital, during the last two years, we treated 48 patients with AAA. Of these, 37 were treated with bifurcated grafts (77%), 11 to the iliac bifurcation and 5 to the femoral arteries, with the remainder being iliac⁄femoral combinations. 4 direct IIA revascularizations were performed and 8 IMA were re-implanted (17%). We have performed EVAR in only 8% of the patients that presented to us with AAA, with the remainder being treated by open surgery, with a perioperative mortality rate of 1.6%. We are proud of these results, even though we have an overall small casuistic, there is still space for improvement.

References:

1. Olsen PS, Schroeder T, Agerskov K, et al.: Surgery for abdominal aortic aneurysms. A survey of 656 patients. J Cardiovasc Surg (Torino). 32:636-642 1991 1939327

2.Criado FJ, Wilson EP, Velazquez OC, et al.: Safety of coil embolization of the internal iliac artery in endovascular grafting of abdominal aortic aneurysms. J Vasc Surg. 32:684-688 2000 11013031

3. Arko FR, Lee WA, Hill BB, et al.: Hypogastric artery bypass to preserve pelvic circulation: improved outcome after endovascular abdominal aortic aneurysm repair. J Vasc Surg. 39:404-408 2004 14743144

4. Geraghty PJ, Sanchez LA, Rubin BG, et al.: Overt ischemic colitis after endovascular repair of aortoiliac aneurysms. J Vasc Surg. 40:413-418 200415337866

5. Dadian N, Ohki T, Veith FJ, et al.: Overt colon ischemia after endovascular aneurysm repair: the importance of microembolization as an etiology. J Vasc Surg. 34:986-996 2001 11743550

6. Lee ES, Bass A, Arko FR, et al.: Intraoperative colon mucosal oxygen saturation during aortic surgery. J Surg Res. 136:19-24 2006 16978651

7. E. Maugin, P. Abraham, A. Paumier, G. Mahé, B. Enon, X. Papon, J. Picquet: Patency of Direct Revascularisation of the Hypogastric Arteries in Patients with Aortoiliac Occlusive Disease; European Journal of Vascular and Endovascular Surgery, Volume 42, Issue 1, July 2011, Pages 78–82

Common and internal iliac aneurysms. Clinical behaviour

Introduction

Iliac aneurysms are uncommon but rupture has a high mortality rate. The aim of this report is to review the clinical behaviour of the common and internal iliac aneurysms.

Methods: A literature review was performed using internet database PubMed followed by manual cross referencing of relevant articles.

Results

The normal range of the diameter of the common iliac artery is 0.97-1.23cm. An aneurysm of the common iliac artery is defined a permanent localised dilatation greater than 2cm. Expansion rates for aneurysms smaller than 3cm is 0.11cm/year and for aneurysms 3-5cm is 0.26cm/year. Hypertension is a factor associated with an increased rate of expansion of the aneurysms. A survey of the members of the vascular society of the UK and Ireland in 2014 has shown that existing guidelines for non ruptured iliac aneurysms are out of touch with current practice and most surgeons would wait till the diameter is more than 4cm to intervene. Treatment of isolated common iliac aneurysms has increased since the introduction of endovascular techniques and is associated with lower elective mortality and morbidity.

Isolated internal iliac aneurysms are rare with an estimated incidence of 0.3% to 0.5% of all intra-abdominal aneurysms. As the aneurysms enlarge, could rupture or cause symptoms from pressure to adjacent organs (ureter, bladder, rectum, small bowel, external iliac vein and lumbosacral nerve trunks). Several authors suggest repair of internal iliac aneurysms when their diameter is larger than 3cm. The introduction of endovascular techniques has provided promising results and fewer complications and shorter hospital stay compared to open repair. Preservation of internal iliac flow is associated with reduced incidence of buttock claudication. Bilateral iliac artery occlusion could lead to a variety of pelvic ischaemic symptoms to a small number of patients.

Conclusion

There are no evidence based recommendations of the size of iliac artery aneurysms that can be safely managed conservatively with ultrasound monitoring. The introduction of endovascular techniques for the management of iliac aneurysms has significantly reduced mortality and morbidity. Current literature strongly recommends avoidance of bilateral artery embolization if possible.

George Geroulakos, MD, PhD

Professor at Attikon Hospital, University of Athens and

Imperial College, London

SPEA

KER

S LE

CTU

RES

30may

Twenty-five years after its debut, did EVAR prove to be superior to open

repair as an AAA treatment

Introduction:

Abdominal aortic aneurysm is a segmental, full-thickness dilatation of the abdominal aorta, exceeding the normal vessel diameter by 50%, located between the level of the renal arteries origin, down to the aortic bifurcation. Although it was previously believed that aneurysms were a form of atherosclerosis, aortic aneurysm disease is now recognized as a distinct degenerative process, involving all layers of the arterial wall. The pathophysiology of aortic aneurysm can be characterized by four main events: infiltration of the vessel wall by lymphocites and macrophages; destruction of elastin and collagen in the media and adventicia by proteases, including matrix metalloproteinases; loss of smooth-muscle cells with thinning of the media; and finally, neovascularization. Several drugs have been evaluated for their potential to limit abdominal aortic aneurysms growth including beta-blockers and anti-inflammatory agents, statins, antiplatelet agents and an antibiotic, doxycycline, but none of these drugs have been shown to provide a benefit. In view of this failure of medication on the control of the aneurysm growth and risks of rupture, two mechanical approaches have been emerged along the years and are currently available. The open repair, performed since 1950’s; and the endovascular repair, first performed in 1987 by the russian surgeon Nikolai Volodos and disseminated in 1990 by the argentin surgeon Juan Parodi and coworkers, a quarter of century ago.

Methods:

An enormous amount of work and research has been dedicated, along the years, until now, to assess both methods in order to identify their merits and specifities, indications and contraindications, benefits, faults and failures. It seems to make sense to ask ourselves if a quarter of century after its implementation and following enormous progress registered in technology, device advances and accumulated experience, is the endovascular approach able to be regarded as a better alternative to the old fashioned open repair for the prevention of the rupture, which is the main goal of the intervention and I am going to try to answer to the question, according to data taken from the literature, associated to my own experience with open repair.

Dinis da Gama, MD, PhD

Vascular Surgeon

Hospital da Luz, Lisboa

Results:

One cooperative study, EUROSTAR, from the year 2000, lead by Peter Harris and four randomized controlled studies (the british EVAR1, conducted by Roger Greenhalgh in 2010, the dutch DREAM, published in 2010 and lead by Jan Blankensteijn, the French ACE from 2011 under the leadership of J.P.Becquemin and finally, the North American OVER, conducted by Frank Lederle in 2012) serve the basis of my purpose. To summarize the possible comparison of these two approaches for the contemporary AAA management, I must say that EVAR has a lower peri-operative mortality, is a selective method, with well known constraints and limitations, is feasible in high risk patients with favorable anatomy, do not prevent absolutely the aneurysm rupture, courses with a high-rate of medium and long-term complications, related to the aneurysm and endoprosthesis, has a questionable long-term durability, requires a life-time CT surveillance and shows a poor cost effectiveness. Open repair has a higher peri-operative mortality, is a non-selective method and has an “universal” utilization in terms of anatomy, etiology and morphology of the aneurysm, is more suited for good or acceptable risk patients, prevents absolutely the aneurysm rupture, courses with fewer rates of post-operative complications related to the prosthesis, has an already proved long-term durability, its surveillance is based on the regular clinical examination and, finally, demonstrates a favorable cost-effectiveness. Despite my scepticism, I have to admitt that EVAR has been extremely well succeeded for the last decade and has becoming more popular and the method of choice, at least in the U.S., as is well depicted in this graph (Fig.1). But this is not a scientific argument, due to the numerous non-scientific and human feelings that may play a significant role in the option from one or another method. I am talking about the patients’ preference, as well as the surgeons’ preference. For the common patient, and even doctor, EVAR is seen as a simple method, easy to carry out, causing minimal discomfort or distress. Contrarily, open repair is invasive, painful, uncomfortable and even hostile. Surgeon’s preference play also an important role, based on its competence, skills, expertise and results obtained with both methods.

Conclusions:

Trying to answer the question which is the theme of my presentation and looking forward, there still remain a series of questions and challenges that must be answered before one may consider EVAR as a better approach then OR in the management of AAA, a quarter of century after its introduction in clinical practice, and they are related to selectivity, prevention of rupture, complications, biologic behavior, costs and finally, and education dilema: How to train and educate the new generations of vascular surgeons with open repair, in order to deal with complex, complicated or unfit aneurysms for endovascular repair ? A sort of questions and challenges for the new coming generations of vascular surgeons to answer and to solve.

Which graft for which patient?

The introduction of endovascular abdominal aortic aneurysm (AAA) repair has revolutionized the therapeutic approach to patients with AAA. The devices used to perform endovascular AAA repair have also changed dramatically. The purpose of this presentation is to provide an overview of the currently available and upcoming options for endovascular AAA repair.

The technological investment in this particular field allied with increasing experience progressively challenged morphological restrains, extending treatment to patients with complicated anatomy. Adverse anatomy clearly affects outcomes, and so, judicious patient and device selection are key to achieving sustained clinical success.

All of the commercially available abdominal aortic endograft devices perform well when used within the confines of their instructions for use. Unfortunately, unfavorable anatomy tends to present a challenge for all endovascular specialists. The proximal seal zone is a key point, and it is the one of the most important criteria to choose a device concerned about the durability of the repair. The distal seal zone is the next issue of concern. Iliac limb diameter and conformability can influence the choice of device. In these situations, a thorough knowledge of the limits of the endografts is essential to improve device performance.

Understanding of the benefits and limitations of the endograft devices creates a higher level of confidence for the implanting physician, which may improve patient outcomes.

We are currently using fourth-generation devices to treat AAAs. With more than 20 years of clinical experience with endovascular repair, the characteristics of the ideal stent graft have been identified. The optimal graft needs to be durable, conformable, trackable, precise, and it must come in a broad range of diameters and lengths. Postoperative limb patency and device imaging are also important consider-ations. All of these factors play into the choice of graft.

With the evolution of aortic stent graft devices over the last 20 years, it is now far easier to choose a device that is ideally suited for specific anatomic configurations. Although most patients can be treated with many of the commercially available endografts, there are particular instances when we are biased to a specific device based on either published data, delivery profile, delivery trackability, device conformability/flexibility, accuracy of deployment, and/or anatomic constraints.

Next evolution of aortic stent graft devices will be used in more complex anatomies within the confines of their instructions for use, improving our results.

Jorge Fernández Noya, MD

Deparment: Angiology and Vascular Surgery

Institution: University Clinical Hospital. Santiago de Compostela.

Spain

Ruptured EVAR: Should it be the standard approach?

RCT of EVAR in ruptured AAA have showed in general equivalency, respectively "non-inferiority" and some specific advantages over open surgery. But, considering juxtarenal or suprarenal AAAs (19% of all AAA in IMPROVE) there is justified criticism, mainly because none of the RCT were designed to address latter pathologies by EVAR. But from a practicable point of view, if the access vessels are appropriate for stentgraft introduction, as it is generally the case, EVAR can be performed in all patients with neck length >5-10mm with standard devices and in patients with neck length <5mm with parallel grafts (Chimney/Periscopes), physician modified (fenestrated) stent-grafts or the upcoming off-the-shelf branched stent-grafts.

As overall experience with open surgery in (r)AAA decreases and on the other hand increasing number of endovascular tools and techniques to address pararenal AAA have been developed, it seem logical to invest in logistics and algorithms enabling EVAR in all incomers and in training.

Mario Lachat, MD, PhD

Head of Vascular Surgery University Hospital Zurich

Drug-coated balloons: if cost were not a problem, would you always use

them?

Introduction:

Drug-eluting or drug-coated balloons (DCB) are now available as a new tool for lower limb angioplasty (PTA). They are used in superficial femoral artery (SFA) and below the knee (BTK) lesions and can be aplied in different settings: primary atherosclerotic lesions, restenosis after PTA, stenosis, total occlusions and also in short or extensive and complex disease. The usefulness of DCB should be tested against the other established endovascular methods to treat the SFA and BTK arteries namely simple balloon angioplasty, the use of nitinol stents and angioplasty with drug-eluting stents (DES).

Results:

Several studies showed a clear benefit of DCB over simple PTA in SFA TASC II A,B,C and D lesions, including complete occlusions. However, in more complex and extensive disease the need to assist DCB angioplasty with stents, to fix localized problems, is not uncommon (around 20%). The comparison with DES is less compelling, despite the trend to non-inferiority of DCB but with the advantage of leaving no metalic material “behind”. Nevertheless, the results of DES platforms are associated to very good results in longer follow-up periods than the ones provided in DCB trials. The cost issue remains controversial and some published analysis suggest that the overall cost of a DCB strategy may be cost-effective. Conclusions:

DCB have some advantages over other endovascular approaches of SFA occlusive disease and short and mid-term results seem to be very promising. However, in my view, its use should not be universal as long-term patency and re-intervention rates are not yet clear. Presently, they may be considered as a useful tool, among others, to recanalize SFA and BTK lesions and its use should be selective.

Luís Mendes Pedro, MD, PhD, FEBVS

Vascular Surgeon

Associate Professor of Vascular Surgery.

Vascular Surgery Consultant

Hospital Santa Maria, CHLN, Lisboa, Portugal

Lisbon Academic Medical Centre

Lisbon Cardiovascular Institute

.

Drug coated balloon: Since cost is always a problem, when should they

be used?

O tratamento endovascular da doença arterial obstrutiva infrainguinal sintomática constitui um tratamento de primeira linha na maioria dos doentes, sobretudo se existir um elevado risco cardiovascular ou se a expectativa de vida for inferior a 2 anos. (1, 2) Apesar da angioplastia transluminal do sector femoro-popliteu ter uma elevada taxa de sucesso inicial, a restenose ocorre em 60% dos casos. (1) No sector infrapopliteu este problema é ainda mais evidente, existindo uma elevada taxa de restenose aos 12 meses e de target lesion revascularization (TLR). (3)

Os bare metal stents (BMS) e os drug-eluting stents (DES) demonstararam taxas menores de TLR, comparativamente à angioplastia com balão. Mais recentemente, os drug coated balloons (DCBs) surgiram como uma opção terapêutica para o tratamento endovascular da doença arterial obstrutiva infrainguinal. Estes estão associados a uma menor taxa de TLR e ao mesmo tempo, evitam os riscos relacionados com os stents como a restenose intrastent e a fractura. Deste modo, salvaguardam a hipótese para todas as opções de revascularização, se existir necessidade de re-intervenção. (4)

Os DCBs melhoram as taxas de permeabilidade primária nas lesões de novo do sector femoropopliteu em comparação com a angioplastia standard e podem ser particularmente benéficos nas restenoses intrastent do mesmo sector. (1, 5, 6)

Relativamente ao sector infrapopliteu é uma área mais controversa. O único estudo prospectivo, multicentrico e randomizado realizado, IN.PACT DEEP, revelou resultados de não inferioridade relativamente à restenose e TLR, associados, no entanto, uma maior taxa de amputação no grupo dos DCBs. (6)

Vários estudos de análise do custo-eficáfica dos DCBs têm sido realizados, tendo em conta o gasto inicial com o este dispositivo e o custo associado ao follow-up da revascularização incial e eventual necessidade de re-intervenção.

Kearns et al. realizaram uma análise do custo-eficácia dos vários métodos para revascularização endovascular da doença arterial infrainguinal, concluindo que os DCBs têm um menor custo ao longo do tempo do que a angioplastia com balão standard,

Gonçalo Ramalho Alves, MD

Vascular Surgeon

Hospital de Santa Marta (CHLC)

angioplastia com stent e angioplastia com DES. Esta conclusão, baseou-se na premissa que uma permeabilidade mais prolongada está relacionada com menor custos para o sistema de saúde, uma vez que se associa a menor numero de re-intervenções. (7)

Diehm et al. compararam o uso de DCBs versus angioplastia com balão standard no sector femoropopliteu, sendo favorável em termos económicos para o sistema de saúde quando os custos são avaliados ao longo de 12 meses e não tendo em conta apenas o gasto com o procedimento incial. (8) (Tabela 1)

Conclusão

Tendo em conta os resultados clínicos dos estudos realizados com DCBs e a análise custo-eficácia, os autores concluem que existe evidência científica para a sua utilização no sector femoropopliteu, sobretudo se lesões mais complexas e restenoses intrastent no sector femoropopliteu. Já no sector tíbio-peroneal, não existe, até à data, evidência favorável, sendo a sua utilização apenas suportada por pequenas séries individuais.

Bibliografia

(1) Tepe et al. Drug-coated balloon versus standard percutaneous transluminal angioplasty for the treatment of superficial femoral and popliteal peripheral artery disease - 12 month results from the IN.PACT SFA randomized trial. Circulation 2015; 131: 495-502.

(2) Bradbury et al. Angioplasty in severe ischaemia of the leg (BASIL) trial: A survival prediction model to facilate clinical decision making. J Vasc Surg 2010; 51 (Supplement 1): 52S-68S

(3) Liistro et al. Drug-eluting balloon in peripheral intervention for below the knee angioplasty evaluation (DEBATE-BTK). A randomized trial in Diabetic Patients with critical limb ischemia. Circulation 2013 128: 615-621.

(4) Pietzch et al. Economic analysis of endovascular interventions for femoropopliteal arterial disease: a systematic review and Budget Impact Model for the United States and Germany. Catheterization and Cardiovascular interventions 2014; 84: 546-554.

Tabela 1: Custos associados a angioplastia com balão standard e com DCBs no sector femoropopliteu. in Cost-effectiveness analysis of paclitaxel-coated balloons for endovascular therapy of femoropopliteal arterial obstructions. Journal Endovascular Therapy 2013

(5) Scheinert et al. The LEVANT I (Lutonix paclitaxel-coated balloon for the prevention of femoropopliteal restenosis) trial for femoropopliteal revascularization: first-in-human randomized trial of low-dose drug-coated balloon versus uncoated balloon angioplasty. JACC Cardiovasc Interv 2014; 7(1): 10-9.

(6) Zeller et al. Drug-eluting balloon versus standard balloon angioplasty for infrapopliteal arterial revascularization in critical limb ischemia: 12-month results from the IN.PACT DEEP randomized trial. J Am coll Cardiology 20144;64(15):1568-76.

(7) Kearns et al. Cost-effectiveness analysis of enhancements to angioplasty for infrainguinal arterial disease. British Journal of Surgery 2013; 100: 1180–1188.

(8) Diehm et al. Cost-effectiveness analysis of paclitaxel-coated balloons for endovascular therapy of femoropopliteal arterial obstructions. Journal Endovascular Therapy 2013; 20: 819-825.

Retreatment after a drug eluting balloon treatment

DEBs have demonstrated a solid role in the treatment of arterial stenotic and occlusive lesions in diabetic and non diabetic patients in SFA-POP tract; a little bit different appears their use in BTK area, where controversial and not univocal results are reported. Anyway, the main problem is the retreatment of the DEBs treated vessels re-stenotic or re-occluded both, in multilevel disease above all. An accurate check of the proper deployment in size and extension (geographic miss) should be performed first. According to the concept of “leaving no metal behind”, an option, could be a change in the DEB choice. Despite the same drug (Paclitaxel), a different eccipient and carrier could be more efficient in transferring the drug into the vessel’s wall leading to a better or worst outcome. Another option could be the association of a debulking procedure as atherectomy, with a DEB again; it could be possible to avoid the re-coiling and mechanical aspects which often affects calcificated lesion, respect to myointimal hyperplasia alone. Finally, the association of DEB and mimetic stents or DES could be evaluated.

Marco Manzi, MD

Director of Interventional Radiology Unit -

Foot & Ankle Clinic Policlinico Abano Terme

When not to think on anything else besides anticoagulation

Introduction:

Deep venous thrombosis (DVT) affects 1.0 /1000 people each year. In the EEC there are an estimated 543 000 venous thromboembolism (VTE) related deaths per year. Late consequences of DVT include posthrombotic syndrome (PTS), that affects until 23 % of patients and 4 to 6% will have a leg ulcer as a result. Since 1961 it is established that DVT should be treated with anticoagulation, to prevent thrombus extension, early recurrence and pulmonary embolism or death.

Methods:

The SVS/AVF recommendation was followed, regarding precision in the anatomic terminology of DVT diagnosis. Thus, leg DVT was divided in iliofemoral, femoropopliteal and isolated calf vein thrombosis. A review of the current guidelines and recent literature was carried out. Recommendations for anticoagulation alone as the treatment of choice for DVT were reviewed by topographic thrombosis localization. Indications for other forms of treatment, complimentary to anticoagulation, were also searched.

Results:

Current guidelines (ACCP, SVS/AVF, NICE and AHA) were issued in 2011/2012. There is a relative consensus regarding therapy of DVT located to the calf veins (where patients should start anticoagulation if they are symptomatic and there is a risk of thrombus progression) and to the femoropopliteal segment (anticoagulation). On the other hand, iliofemoral thrombosis has the highest rates of recurrence, and results in venous claudication and leg ulcer in a high number of patients (15% will develop an ulcer, in 5 years). A thrombus removal strategy, in this cohort of patients, is currently under discussion. As systemic thrombolysis had poor results with high risk of bleeding, other strategies were proposed: catheter directed thrombolysis, pharmacomechanical techniques or even surgical venous thrombectomy. AHA and SVS/AVF guidelines suggested thrombus removal for selected patients with a first episode of iliofemoral DVT, while ACCP guidelines were more conservative (suggestion of anticoagulant therapy alone).

Gabriel Anacleto, MD

Vascular Surgeon

Centro Hospitalar e Universitário de Coimbra

The CAVENT study, published in 2012, showed an absolute risk reduction of PTS at 2 years of 14.4%, in patients with iliofemoral DVT, who were submitted to catheter directed thrombolysis plus anticoagulation (vs standard anticoagulation alone). A Cochrane Library review (2014) also states that thrombolysis reduces PTS by a third, in proximal DVT.

Conclusions:

Trying to answer the question which is the theme of my presentation and looking forward, there still remain a series of questions and challenges that must be answered before one may consider EVAR as a better approach then OR in the management of AAA, a quarter of century after its introduction in clinical practice, and they are related to selectivity, prevention of rupture, complications, biologic behavior, costs and finally, and education dilema: How to train and educate the new generations of vascular surgeons with open repair, in order to deal with complex, complicated or unfit aneurysms for endovascular repair ? A sort of questions and challenges for the new coming generations of vascular surgeons to answer and to solve.

Pulmonary pressure assessment. Mandatory?

Introduction:

Acute pulmonary embolism (PE) is an under-diagnosed but potentially fatal condition. This condition presents with a wide clinical spectrum, from asymptomatic small PE to lifethreatenin one causing cardiogenic shock. Depending on the estimated risk of an adverse outcome, treatment with thrombolysis or embolectomy may be indicated in high-risk individuals. Conversely, early hospital discharge or even home treatment with anti-coagulation may be considered in low risk PE. Thus, a systematic approach to risk stratification is essential in guiding the management of patients diagnosed with acute PE. Evidence-based prognostic tools such as clinical scores, echocardiography, computed tomography scans, and cardiac biomarkers will be discussed.

Results:

HEMODYNAMIC CONSEQUENCES OF ACUTE PULMONARY EMBOLISM Anatomically massive PE has been defined as having more than 50% obstruction of the pulmonary vasculature or the occlusion of two or more lobar arteries. The hemodynamic response to an acute PE depends not only the size of the embolus and the degree of pulmonary vasculature obstruction, but also on the physiologic reaction to the neurohumoral factors released and the underlyingcardiopulmonary status of the patient. In acute PE, both mechanical obstruction and hypoxic vasoconstriction increase pulmonary vascular resistance, and this initiates a series of hemodynamic derangements leading to RV dysfunction. The release of humoral factors, such as serotonin from platelets, thrombin from plasma and histamine from tissue also contribute to pulmonary artery vasoconstriction. As a consequence of the elevated pulmonary resistance, the highly compliant RV dilates acutely. Cardiac output is decreased further by impaired distensibility of the left ventricle (LV) from the leftward shift and flattening of the interventricular septum during systole/early diastole, and impaired LV filling during diastole. Myocardial ischemia also worsens RV function by increased oxygen demands due to elevated wall stress and decreased oxygen supply from elevated right-sided pressures.

Ignacio Lojo Rocamonde, MD

Vascular Surgeon

Hospital Quiron - Salud. A Coruña.

Spain

.

CLASSIFICATION OF RISK The prognosis of acute PE correlates most directly with the degree of hemodynamic compromise and RV dysfunction Based on the clinical presentation, presence of RV dysfunction and elevated biomarkers, high-risk PE has a short-term (in-hospital or 30-day) mortality risk of > 15%. Non high-risk patients are more heterogenous and are further stratified into intermediate risk (short term mortality risk of 3 to 15%) and low risk (short term mortality risk of less than 1%) RISK ASSESSMENT BASED ON PRESENCE OF RIGHT VENTRICULAR DYSFUNCTION The majority of patients with acute PE are stable at time of diagnosis, but this may not necessarily imply a benign course. Patients may appear stable initially because the development of RV failure and cardiogenic shock can be delayed as the vicious cycle of elevated pulmonary resistance, RV dilatation, and the RV hypokinesis unfolds. In stable patients with acute PE, the presence of RV dysfunction is associated with a high mortality rate. Echocardiography Echocardiography is non-invasive and able to provide very useful information promptly. Besides the evidence of RV dysfunction and elevated pulmonary arterial pressures, other echocardiographic features with prognostic implications include: A right-to-left shunt, such as a patent foramen ovale (PFO): evidence of a PFO in patients with acute PE was associated with higher mortality rate (33% vs. 14%) and higher incidence of peripheral thromboembolic events A free-floating right heart thrombus: The mortality rate of about 20% within 24 hours of diagnosis, and mortality is significantly linked with the occurrence of cardiac arrest Computed tomography Contrast enhanced computer tomography (CT) of the pulmonary arteries is increasingly used as a first-line imaging modality for PE diagnosis. The anatomical distribution and burden of embolic occlusion of the pulmonary arterial bed can be assessed easily by CT. However, the anatomical assessment seems less relevant for risk stratification than assessment based on functional (hemodynamic) consequences of PE. Ventilation-perfusion scintigraphy Lung ventilation-perfusion scintigraphy (V/Q scan) is a well-established diagnostic test used in patients suspected of PE. Perfusion defects due to PE increase with the number and size of emboli, without corresponding ventilation compromise (“mismatch” defects). Risk assessment based on biomarkers of myocardial injury Cardiac troponins I and T as well as NT-pro brain natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP) have emerged as promising tools for risk stratification: Cardiac troponins: Cardiac troponins may be increased in patients with PE, even in the absence of coronary artery disease. Patients with an elevated troponin I or troponin T levels had an increased risk for short-term mortality or PE-related deaths Brain natriuretic peptide: Right ventricular dysfunction is associated with increased myocardial stretch which leads to the release of BNP and its amino terminal portion, NT-proBNP. In acute PE, increasing levels of BNP or NT-proBNP predict the severity of RV dysfunction and mortality.

Summary of evidence on the prognostic value of biomarkers Many studies did not perform an extensive comparison between all the available biomarkers, thus it remains debatable which biomarker will yield the best prognostic value. Another limitation is biomarker thresholds were determined retrospectively, thus no consistent cut-off values were used in the studies. Despite this, it appears BNP/NT-proBNP and cardiac troponins could be used as rule-out tests. The presence of RV dysfunction on echocardiography in patients with elevated NT-proBNP (cut-off of 1000 pg/mL) or cardiac troponins (cut-off of 0.04 ng/mL) is associated with a 10-fold increase in complication risk compared with patients biomarker levels below threshold. RISK OF RECURRENCE Recurrent PE can occur despite adequate anticoagulation therapy in patients who had survived an acute PE. Patients with unprovoked PE (PE occurring in the absence of established risk factors or predisposing illnesses) are at a higher risk for recurrent PE compared to patients with risk factors for PE. In addition, patients who presented with a first symptomatic PE are at a 4-fold increased risk of recurrent symptomatic PE compared to patients who presented with deep venous thrombosis without symptoms of PE.

Conclusions:

Risk stratification of acute PE is fundamental not only to select an appropriate treatment strategy, but also to potentially reduce costs of management. An appropriate risk stratification algorithm would include clinical, imaging and biomarkers. High risk PE is diagnosed in the presence of shock or persistent hypotension and should warrant urgent management. Thrombolysis with alteplase (rtPA), streptokinase, or urokinase is the recommended therapy. Embolectomy could represent an alternative therapy for patients with shock in the acute setting when thrombolysis has been unsuccessful. Hemodynamically stable patients without RV dysfunction or myocardial injury are at low risk for PE-related adverse events. In the remaining normotensive patients, a plausible strategy is to combine biomarkers with echocardiography. The presence of RV dysfunction and myocardial injury identifies patients at intermediate risk. Whether intermediate risk patients will have any survival benefit with early initiation of reperfusion therapy (and what type of therapy) is not well accepted. Current recommendations proposed thrombolysis be instituted in selected patients at high risk for adverse events without contraindications and intravenous unfractionated heparin should be reserved to conditions in which thrombolysis is contraindicated.

Last Guidelines on Acute Deep Venous Thrombosis Intervention: Critical

Appraisal

“And take the case of a man who is ill. I call two physicians: they differ in opinion. I am

not to lie down and die between them: I must do something. “

Samuel Johnson

Objective:

We aim to provide an explicit appraisal of the clinical evidence on acute DTV intervention The referred guidelines are listed below and will be reviewed.

Discussion:

Many healthcare and clinical decisions have substantial consequences and involve important uncertainties and trade-offs. The hallmark of an evidence-based practitioner is one who reflects on their clinical decision-making and uses research evidence to reduce clinical uncertainty and guide their practice. This specifically involves integrating clinical expertise, the patient’s individual situation and preferences, and the best available clinical evidence. In that context, guidelines are an important summary knowledge instrument and should be interpreted as a guide to be applied in the setting of clinical judgment. Until 2008, guidelines for the treatment of patients with acute deep venous thrombosis (DVT) recommended only anticoagulation. Since then published guidelines do suggest some benefit in early thrombus removal strategies with respect to reducing the incidence of the post-thrombotic syndrome.

Guidelines:

Kearon C, Kahn SR, Agnelli G, Goldhaber SZ, Raskob G, Comerota AJ: Antithrombotic therapy for venous thromboembolic disease: ACCP evidence-based clinical practice guidelines (8th ed). Chest 133(6Suppl):454S–545S, 2008. Erratum in: Chest 134:892, 2008.

Paulo Gonçalves Dias, MD

Vascular Surgeon

Hospital São João

Jaff MR, et al: Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 123:1788–1830, 2011. Kearon C, Akl E, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dantali F, Crowther M, Kahn SR: Antithrombotic therapy and prevention of thrombosis. ACCP evidence based clinical practice guidelines (9th ed). Chest 141(2 Suppl):e419S–494S, 2012. Meissner MH, Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Lohr JM, McLafferty RB, Murad MH, Padberg F, Pappas P, Raffetto JD, Wakefield TW: Early thrombus removal strategies for acute deep venous thrombosis: Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2012 May; 55(5):1449-62. Nicolaides AN, Fareed J, Kakkar AK, Comerota AJ, Goldhaber SZ, Hull R, Myers K, Samama M, Fletcher J, Kalodiki E, Bergqvist D, Bonnar J, Caprini JA, Carter C, Conard J, Eklof B, Elalamy I, Gerotziafas G, Geroulakos G, Giannoukas A, Greer I, Griffin M, Kakkos S, Lassen MR, Lowe GD, Markel A, Prandoni P, Raskob G, Spyropoulos AC, Turpie AG, Walenga JM, Warwick D: Prevention and treatment of venous thromboembolism: International Consensus Statement. Int Angiol. 2013 Apr; 32(2):111-260

Drug-coated balloons: if cost were not a problem, would you always use

them?

Objectives:

Practical revision of common mistakes and errors while planning and executing intervention in acute deep venous thrombosis.

Methods:

Revision of literature contraindications for acute intervention in DVT and T&T on what to avoid and what needs to be taken into account while planning the procedure.

Results:

Acute DVT can be divided into proximal and distal. The treatment modality depends on clinical presentation, urgency of intervention and anatomical considerations, among others. It can be basically divided into pharmacological and/or invasive treatment. Several key point should be addressed: Start with correct imaging. US is mandatory and can confirm isolated distal DVT involvement or proximal iliac extension. Access the need for invasive intervention. Do not perform unneeded procedures in distal DVT, in old and not active patients or with anticoagulation contraindications. Access the lungs and the right heart. Don’t do an invasive procedure that can jeopardize the patient’s life. Access your logistic capacities. Don’t start a DVT program if you cannot have your patient under strict surveillance or open access to an angio room. Choose the access wisely and the correct timing. Make sure you have natural or artificial filters. Don´t start these procedures without backup. Have adequate training. Venous and arterial procedures are not the same, nor should they be addressed in a similar fashion.

Conclusions:

Intervention in acute DVT is not straightforward and can sometimes be challenging. Awareness of the possible complications and correct planning are essential and should not be overlooked.

Hugo Rodrigues, MD

Vascular Surgeon

Hospital das Forças Armadas and Hospital Garcia de Orta

.

Chronic venous obstruction Contra-indications to stenting

The patients groups who this technique is applied include acute DVP post thrombus removal, chronic venous occlusion post DVT, chronic venous stenosis post catheters and venous compression especially in cancer, May-Thurner syndrome or post radiotherapy.

Patients with significant limb symptoms, including pain, swelling, dermatitis, ulcer or recorrent cellulitis, who had failed conservative therapy were considered for intervention.

The accepted anatomic areas are above the common femoral vein (CFV),and the stents have limited applications below the inguinal ligament.

Self -expanding stents work best in the venous system. Larger stents do better than smaller ones and the oversize must be 10-20 %.Common stent diameters vary from 10 to 16 mm.

Contrary to arterial stenting, venous stents can be safely placed in the venous system across the inguinal ligament with small risk of narrowing, focal development of in-stent restenosis or stent fractures.

Bacteriemia is a relative contraindication for stent placement due to the potencial for chronic infection.

Impaired renal function is a relative contraindication as for all other endovascular procedure with contrast agents.

In areas with previous radiation or surgical dissection we must be careful and consider the need of a covered stents

The key point for successful venoplasty is a good inflow.Some inflow problems may be impossible to correct because of the severity of post-thrombotic disease involving the femoral and profunda vein segments. If the inflow is impaired, the treated segment will likely occlude.

In good anatomical conditions iliac vein stents demonstrated a primary patency of 75% ,primary -assisted patency of 92%,and secondary potency of 93% with good clinical outcomes.

João Silva e Castro, MD

Especialidade de Angiologia e Cirurgia Vascular pelo Hospital

de Santa Marta e pela Ordem dos Médicos.

Consultor de Angiologia e Cirurgia Vascular do Hospital de

Santa Marta.

Coordenador do Departamento de Angiologia e Cirurgia

Vascular do Hospital Cuf-Infante Santo.

When one cannot remain purely endo

Introduction:

Chronic venous occlusion occurs by various causes such as the, invasive tumor infectious different etiology, although recently the introduction of catheters and venous intravascular devices triggered numerous situations of both partial and total occlusions of the veins. The varied, infection, tumor, iatrogenic, congenital etiology. The varied location affecting both the neck veins, the superior and inferior vena cava, visceral veins, and upper and lower extremities. Abstention from treatment, through preventive anticoagulation with unclogging conventional surgical and endovascular bypass and angioplasty with stent and the latter primarily as a basis for treatment. Indications especially centered prevent progression of occlusion and especially to reduce or relieve the ecstasy occlusive syndrome. The aim of the publication is to make an assessment of the current status of implementation of both conventional and endovascular surgical procedures, assess the situation by the data provided in the literature and compare them with those obtained in their own experience in the treatment of occlusion chronic venous.

Methods:

The experience of the Angiology and Vascular Surgery of the University Hospital of Valladolid in Spain in the last 10 years, where we believe has broken the endovascular venous treatment level is presented. In the assessment of all patients treated conservatively, endovascular treatment and conventional treatment, it has made an assessment of patient demographics. We analyzed the causes that have caused as infectious, congenital, and resulting from the implementation of devices or catheters. A special analysis of situations implantation pacemaker leads and catheters for hemodialysis is performed. It analyzes one of the most common causes such as tumor with progressive chronic venous occlusions sector. Special attention are affected veins and locating them treatment are also considered to have been made in time evaluation.

Carlos Vaquero-Puerta, MD, PhD, FEBVS

Full Professor of Vascular Surgery at University of

Valladolid

Head of Service of Angiology and Vascular Surgery of the

University Hospital of Valladolid. Spain

Director of Laboratory of Surgical Research and

Experimental Techniques.

Results:

The results in almost all cases have been improvement in patients with reduction of clinical symptoms. It has often been palliative especially in progressive and advanced neoplasic problems. In all cases, and if it has had time to mint, they have established pathways collateral circulation.

Conclusions:

However, there are cases where it is not possible endovascular option to be technically impossible application, the treatment required excision or be advisable to present it as an adjunct to other surgical actions such as tumor excision. About 50 years ago, the MOST etiology of superior vena cava (SVC) obstructions was infectious in nature. Later, malignant diseases were the predominant cause of SVC obstruction, in 90% of the cases. At present, 35% of SVC obstructions are Caused by the Increased use of intravascular devices: such as catheters and pacemaker wires. In the case of management of SVC syndrome Associated with Involves malignant disease treatment of the cancer and alleviating the obstructive symptoms. The intravascular stent placement Achieved symptomatic relief quicker than irradiation or chemotherapy. We believe that the endovascular option can be an excellent therapeutic tool primarily for minimally invasive nature and can be performed under local anesthesia in patients of poor general condition. When possible is the main indication.

May-Thurner syndrome - what evidence?

Introduction:

Virchow was the first author to be credited with describing iliac vein compression. Isolated left lower extremity swelling secondary to left iliac vein compression was first described by McMurrich in 1908. It was not until 1957 that May and Thurner brought much attention to the anatomic variant thought responsible for Virchow’s observation. They found that the right iliac artery compressed the left iliac vein against the fifth lumbar vertebra in 22–32% of 430 cadavers. It was first defined clinically by Cockett and Thomas in 1965.

Discussion:

Whether “iliac vein compression syndrome” or “iliocaval compression syndrome” these terms may be used interchangeably, but they all describe the phenomenon of left-sided vein compression by the right iliac artery causing left iliofemoral deep venous thrombosis (DVT). Nowadays the term “nonthrombotic iliac vein lesions” (NIVL) which can involve both the right and left iliac veins as well as multiple other named venous segments is gaining consensus. May-Thurner syndrome (MTS) can thus trigger a proximal DVT and present in an acute form or preclude the progression to chronic signs and symptoms, secondary to venous hypertension (edema, pain, venous claudication), better defined by the CEAP classification and quality of life scores. Worth mention at this point the increased risk of recurrent thrombosis and post-thrombotic syndrome that results in most cases after a proximal DVT . The diagnosis should be based mainly on anatomic criteria since hemodynamic criteria have too many flaws that can be expressed in the fact that a normal exam does not exclude the existence of obstruction to the outflow. Venography once considered the gold standard diagnostic test because of the ability to demonstrate an area of compression where the right iliac artery crosses the left iliac vein as well as venous collateral vessels from the left iliac system to the right iliac system, has been replaced in the last years by magnetic resonance (MR) venography and computed tomography (CT) venography, which can demonstrate iliocaval obstruction and associated abnormalities.

José Carlos Vidoedo, MD, FEBVS

Vascular Surgeon

Centro Hospitalar Tâmega e Sousa

Both, MR imaging and CT are suited, although not perfect, for diagnosing May-Thurner syndrome, with the left common iliac vein being compressed by the overlying right common iliac artery. Among all imaging tests intravascular ultrasound (IVUS) appears to be most accurate in estimating the morphological degree and extent of iliac vein stenosis and visualizing details of intraluminal lesions, such as intraluminal trabeculation in post thrombotic vessels. A color Doppler ultrasound looking specifically at the right internal jugular vein, both popliteal and both common femoral veins is prudent in terms of planning the most efficient site to safely access the critical lesion. Interrogation of the iliac veins with this method has several pitfalls, such as patient biotype, operator expertise reliance, etc. Surgical techniques for bypassing venous obstructions were developed in the mid-20th century, with femorofemoral venous bypass as described by Palma and Esperon in 1960 being the longest used technique. As a consequence of disappointing results of venous surgery, previous treatment algorithms limited indication for revascularization to advanced clinical stages (CEAP clinical class 4-6) or failure of compression therapy. The dismal results of surgical treatment directed research to the use of self expanding stents. The first cases were described in the venous system of a dog by Wright. Zollikofer in 1988 and Antonucci in 1992 reported the first clinical results of venous self-expanding stents. Neglén, Thrasher and Raju in a large study with 447 limbs treated by stenting between 1996 and 2002 showed the importance of venous obstruction for chronic venous insufficiency. Taking into account the low complication and good clinical success rates of endovascular therapy, indications for treatment were broadened including patients with CEAP clinical class 3 and chronic venous outflow obstructions if compression therapy has failed. Endovascular revascularization therapy is being considered even in cases of successful compression therapy, as it treats the underlying cause of disease. Stenting of the iliac veins can also be considered in the presence of nonthrombotic obstructive venous lesions in the iliocaval segment with a degree of stenosis of more than 30% and the presence of venous collaterals. In a recent comprehensive review on the endovascular treatment options for iliac vein stenosis or occlusion, Raju acknowledged that most of the published papers present single-arm retrospective case series, in what turns to be moderate quality of evidence. Grade 1B recommendation is given for patients with active ulcer, disabling symptoms and failure conservative therapy. For patients with less severe symptoms only grade 2B (weak recommendation: benefits and risks closely balanced and/or uncertain) should be applied. Many healthcare and clinical decisions have substantial consequences and involve important uncertainties and trade-offs. The hallmark of an evidence-based practitioner is one who reflects on their clinical decision-making and uses research evidence to reduce clinical uncertainty and guide their practice. This specifically involves integrating clinical expertise, the patient’s individual situation and preferences, and the best available clinical evidence. In that context, guidelines are an important summary knowledge instrument and should be interpreted as a guide to be applied in the setting of clinical judgment. Until 2008, guidelines for the treatment of patients with acute deep venous thrombosis (DVT) recommended only anticoagulation. Since then published guidelines do suggest some benefit in early thrombus removal strategies with respect to reducing the incidence of the post-thrombotic syndrome.

Conclusion:

In conclusion, based on the best available evidence, venous stenting is safe and effective for the treatment of iliac vein lesions, providing clinical relief (ulcer healing), even with significant reflux. Furthermore open surgery is not precluded. The comparisons between open/endo, endo/endo are difficult given methodology and materials differences. Future research should focus on the role of IVUS, degree of correctable stenosis, silent versus symptomatic obstructions, the importance of obstruction versus reflux and hemodynamic metric for obstruction

Documents

Dr. José Fernando Teixeira - portovascularsymposium.com · 30 dias de 1,4% (cirurgia aberta tem mortalidade de 3,6% ) e com taxas de permeabilidade dos vasos alvo de 87 a 95% a 5