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1
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1
Director
V. Riambau
Hospital Clinic. Villarroel 170, 08036 Barcelona España
[email protected]
Editores asociados
Cerezo, M. (Buenos Aires Argentina)
Criado, F. (Baltimore, USA)
Parodi, J.C. (Buenos Aires, Argentina)
Dietrich, E.B. (Phoenix, AZ, USA)
Montañá, X. (Barcelona, España)
Gaines, P. (Sheffield, England)
Malina, M. (Malmo, Suecia)
Veith, F. (New York, USA)
Espinosa, G. (Rio de Janeiro, Brasil)
Bechara, L. (Buenos Aires, Argentina)
Editor honorario
y fundador
J.A. Jiménez Cossío
Comisión Editorial
CELA
Barrera, JG (Bucaramanga, Colombia)
Barrera, J. (Bogotá, Colombia)
Espíndola M. (Santiago, Chile)
Fabiani, A. (Monterrey, México)
Mosquera N. (Ourense, España)
Serrano, MA. (Barcelona, España)
Consejo editorial
Cómo se leen
los códigos QR
1.- Instále en el teléfono móvil
la aplicación para descifrar
códigos QR.
2.- Coloque la cámara
del teléfono móvil
sobre el código QR.
3.- Automáticamente enlazará
con la página
www.endovascular.es
RADIOLOGIA INTERVENCIONISTA
Acitores, I. (Madrid, España)
Blasco, J. (Barcelona, España)
Bolia, A. (Leicester, UK)
Canis, M. (Córdoba, España)
De Blas, M. (San Sebastián, España)
Echenagusía, A. (Madrid, España)
Felices, J.M. (Murcia, España)
Ferral, H. (New Orleans, USA)
Fraire, V. (Monterrey, México)
Garzón, G. (Madrid, España)
González-Tutor, A. (Santander, España)
Gregorio, M.A. de (Zaragoza, España)
Hernández Lezana, A. (Madrid, España)
Hilario, J. (Zaragoza, España)
Katzen, B. (Miami, USA)
Lammer, J. (Viena, Austria)
López Ibor, J. (Madrid, España)
Macho, J. (Barcelona, España)
Marini, M. (A Coruña, España)
Martín Palanca, A. (Málaga, España)
Martínez, F. (Las Palmas, España)
Muñoz, J.J. (Málaga, España)
Palmaz, J.C. (Sant Antonio, USA)
Palmero, J. (Valencia, España)
Pueyo, J. (Mallorca, España)
Pulpeiro, J.R. (Lugo, España)
Real, M.I. (Barcelona, España)
Reekers, J. (Amsterdam, The Netherlands)
Reyes, R. (Las Palmas, España)
Rousseau, H. (Toulouse, Francia)
Ruiz-Salmerón, R. (Sevilla, España)
Sánchez, J. (Madrid, España)
Sancho, C. (Barcelona, España)
Segarra, A. (Barcelona, España)
Schönholz, C. (Charleston, SC)
Tagarro, A. (Madrid, España)
Tobío, R. (Madrid, España)
Urtasun, F. (Pamplona, España)
Verdú, P. (Alicante, España)
Viaño, J. (Madrid, España)
Ybañez, F. (Madrid, España)
Zubicoa, S. (Madrid, España)
CARDIOLOGIA INTERVENCIONISTA
Alfonso, F. (Madrid, España)
Betriu, A. (Barcelona, España)
Calabuig, J. (Pamplona, España)
Cribier, A. (Rouen, Francia)
Cubero, J. (Sevilla, España)
Esplugas, E. (Barcelona, España)
Fournier, J.A. (Sevilla, España)
Goicolea, J. (Madrid, España)
Hernández, T. (Madrid, España)
Jiménez Cárcamo, J. (Miami, USA)
Llovet, A. (Madrid, España)
Macaya, C. (Madrid, España)
Masotti, M. (Barcelona, España)
Medina, A. (Las Palmas, España)
Moris, C. (Oviedo, España)
Nienaber, C. (Rostok, Germany)
Pasadolos, J. (Vigo, España)
Pey, J. (Madrid, España)
Pico, F. (Murcia, España)
Quininha, J. (Lisboa, Portugal)
Ramee, S. (New Orleans, USA)
Roubin, G.S. (New York, USA)
Sáenz, M.E. (Costa Rica)
Sancho Jaldón, J. (Cádiz, España)
Serra, A. (Barcelona, España)
Sobrino, N. (Madrid, España)
Suárez de Lezo, J. (Córdoba, España)
Wholey, M.H. (Pittsburg, USA)
Correspondencia científica
VR Vascular Centre, SLP
Igualada, 10 - 08173 Sant Cugat
Barcelona (ESPAÑA)
e-mail: [email protected]
Diseño y Realización:
www.sociedadcela.com
www.mclogotipo.com
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CIRUGÍA VASCULAR
Álvarez-Tostado, J. (Cleveland, USA)
Balcazar, A. (La Paz, Bolivia)
Botelho de Medeiros, D. (Lisboa, Portugal)
Busquet, J. (París, Francia)
Cao, P.G. (Roma, Italia)
Cappocia, L. (Roma, Italia)
Carbonell, J.P. (Medellin, Colombia)
Carpenter, J.P. (Philadelphia, USA)
Caserta, G. (Sao Paulo, Brasil)
Cruz, L. (San José, Costa Rica)
Da Rocha, M.F.M. (Sao Paulo, Brasil)
Díaz-Durán, C. (Veracruz, México)
Doblas, M. (Toledo, España)
Egaña, J.M. (San Sebastián, España)
Fajardo, D. (Bogotá, Colombia)
Fernandes e Fernandes, J. (Lisboa, Portugal)
Fernández-Fernández, J.C. (A Coruña, España)
Fernández-Noya, J. (Santiago de C., España)
Fernández-Samos, R. (León, España)
Ferreira, L.M. (Buenos Aires, Argentina)
Ferreira, M. (Rio Janeiro, Brasil)
Galvagni, P. (Floridanapolis, Brasil)
García Colodro, J.M. (Lugo, España)
García, G. (Medellín, Colombia)
García-Madrid, C. (Barcelona, España)
Gastambide, C. (Montevideo, Uruguay)
Greenberg, R.K. (Cleveland, USA)
Giossa, W. (Montevideo, Uruguay)
Hussein, E.A. (Cairo, Egipto)
Koncar, I. (Belgrado, Serbia)
Kramer, A. (Santiago, Chile)
La Mura, R. (Buenos Aires, Argentina)
Lerut, P. (Lovaina, Bélgica)
Makaroun, M.S. (Pitsburg, USA)
Marticorena, J. (Lima, Perú)
Matsumura, J.S. (Chicago, USA)
Menéndez, A. (San Juan, Puerto Rico)
Mertens, R. (Santiago, Chile)
Mestres, G. (Barcelona, España)
Moll, F. (Utrecht, The Netherlands)
Murillo, I. (Monterrey, México)
Peeters, P. (Bonheiden, Belgium)
Pitty, F. (Panamá, Panamá)
Pontes, C. (Salvador de Bahía, Brasil)
Poredos, P.I. (Ljubljana, Slovenia)
Puech, P. (San Paulo, Brasil)
Ramírez, J.C. (Asunción, Praguay)
Reparaz, LM. (Madrid, España)
Saldaña, G. (Monterrey, México)
Sicar, G. (Saint Louis, U.S.A.)
Teixera, J.F. (Porto, Portugal)
Urgnani, F. (Barcelona, España)
Valdes, F. (Santiago, Chile)
Vaquero, C. (Valladolid, España)
Verhoeven, E. (Nuremberg, Alemania)
Von Ristow, A. (Río de Janeiro, Brasil)
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JUNIO 2015 - EDICI N ESPECIAL SITE-CELA 2015
1
Sumario-Contents
Editorial
Vicente Riambau - Presidente - Luis Bechara - Co-Presidente
07
Programa Científico / Scientific Program
Miércoles 24 Junio - Wednesday, June 24th
Sesión 1
ADELANTOS EN TRATAMIENTO ENDOVASCULAR EN MIEMBROS INFERIORES
ADVANCES IN LOWER LIMB ENDOVASCULAR TREATMENT
09
Sesión 2
APORTES PARA EL MANEJO ENDOVASCULAR DE LA AORT A
CONTRIBUTIONS FOR ENDOVASCULAR MANAGEMENT OF THE AORTA
10
Sesión 3
INDICACCIONES Y ESTRATEGIAS PARA ENDOPRÓTESIS AÓRTICAS: MÁS ALLÁ DE LA EVIDENCIA
INDICATIONS AND STRATEGIES IN AORTIC ENDOGRAFTING: BEYOND THE EVIDENCE
Sesión 4
NUEVAS TÉCNICAS DESDE LA
NEW TECHNIQUES FROM LA
12
Sesión 5
NUEVAS EXPECTATIVAS EN EL TRATAMIENTO ENDOVASCULAR DE PATOLOGÍAS DESAFIANTES
NEW EXPECTATIONS IN ENDOVASCULAR TREATMENT OF CHALLENGING PATHOLOGIES
13
Sesión 6
APORTES MODERNOS PARA PATOLOGÍAS DIFÍCILES DE RESOLVER
MODERN CONTRIBUTIONS FOR DIFFICULT DISEASES TO SOLVE
16
Jueves 25 Junio - Thursday, June 25th
Sesión 8
OPCIONES ACTUALES EN EL TRATAMIENTO DE LAS LESIONES OCLUSIVAS (TASC II-C Y D)
DE LA ARTERIA FEMORAL SUPERFICIAL
CURRENT THERAPEUTIC OPTIONS IN THE MANAGEMENT OF SUPERFICIAL FEMORAL ARTERY OCCUSIVE DISEASE
(C-D LESIONS)
25
Sesión 10
TEMAS NO RESUELTOS EN REVASCULACIÓN ENDOVASCULAR DE LAS EXTREMIDADES INFERIORES
UNSOLVED ISSUES IN LOWER LIMB ENDO-REVASCULARIZATION
27
Sesión 11
REVASCULARIZACIÓN POR DEBAJO DE LA RODILLA: NECESITAMOS SABER MÁS
BTK REVASCULARIZATION: WE NEED TO KNOW MORE
33
Sesión 13
SESIÓN DE ALTO SECRETO: CONSEJOS Y TRUCOS.
TOP SECRET SESSION: TIPS AND TRICKS.
36
Viernes, 26 Junio - Friday, June 26th
Sesión 14
TEMAS CLAVE EN EL TRATAMIENTO ENDOVASCULAR DE LOS AAA
KEY ISSUES IN ENDOVASCULAR TREATMENT OF AAA
63
Sesión 16
EL DILEMA DE LA HIPOGÁSTRICA
THE HYPOGASTRIC DILEMMA
66
Sesión 18
COMO MEJORAR RESULTADOS EN AAA YUSTA Y PARARRENALES
HOW TO IMPROVE OUTCOMES IN YUXTA AN PARARRENAL AAA
71
Sesión 19
OPCIONES “ON AND LABEL” PARA EL TRATAMIENTO DE LOS AAA YUSTA Y PARARRENALES: DONDE RESIDEN SUS VENTAJAS?
ON AND OFF LABEL APPROACHES FOR YUSTA AND PARARRENAL AAA WHERE ARE THEIR ADVANTAGES?
73
Sesión 20
NUNCA MÁS: LECCIONES APRENDIDAS DEL PÑEOR CASO ENOVASCULAR DE MI VIDA
NEVER AGAIN: LESSONS LEARNT FROM THE WORST ENDOVASCULAR CASE OF MY LIFE
76
Sábado, 27 Junio - Saturdy, June 27th
No part of the articles of this
publication may be reproduced
without the prior written
permission of the editor.
TODO LO QUE NECESITAS SABER SOBRE LA DISECCIÓN AÓRTICA TIPO B
ALL YOU NEED TO KNOW ABOUT AORTIC TYPE B DISSECTION
Sesión 24
¿QUE HAY DE NUEVO PARA LA AORTA ASCENDENTE Y EL ARCO?
WHAT’S NEW FOR ASCENDING & ARCH?
100
Sesión 25
AORTA DESCENDENTE Y TÓRACO-ABDOMINAL
DESCENDING AND THORACO-ABDOMINAL AORTA
100
Poster SITE
Calendario de Congresos - Congress Calendary
Noticias desde la Industria - News from the Industry
Normas para los autores
Instructions for the Authors
05
94
102
128
129
132
134
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The information and opinions
expressed in the articles are
exclusively those of the authors
who are solely responsible of their
contents.
Técnicas Endovasculares is edited
3 times a year. Copyright © 1998.
Sesión 21
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Luis R Leon Jr.
Miguel F Montero-Baker
Editorial
Volumen XVII - Número 3 - Septiembre-Diciembre 2014
En este número especial de Técnicas
Endovasculares el lector encontrará la
colección de los abstracts y resúmenes de
todos los contenidos del programa científico
del SITE-CELA 2105.
In this special issue of Técnicas
Endovasculares the reader will find the
collection of abstracts and summaries of all
the contents of the scientific program of the
SITE-CELA 2105.
El detalle de las sesiones ayudará a los
congresistas a poder seleccionar su
participación Además, no se perderá la
información de aquellas sesiones que, por
coincidir en el tiempo, no hayan sido
presenciadas.
The details of the sessions will help the
attendees to be able to select their
participation. Moreover you will not lose the
information from those concomitant sessions
that coincide in time and you have not been
witnessed.
Desde estas páginas queremos darles la
más calurosa bienvenida al Congreso.
From these pages we want to give the
warmest welcome to the Congress.
Vicente Riambau
Presidente
Luis Bechara
Co-Presidente
Comité Científico
CELA
Directores
Honorarios
Co-Directores
del Programa
Directores
del Programa
Comité Científico
SITE
S. Benites Palacio
A. Menéndez
J.P. Carbonell
F. Pitty
A. Esperon Percovich
Á. Razuk
A. Fabiani
G. Rubio Argüello
M. de Blas
X. Montañá
F. Criado
J. Palmaz
J.M. Egaña
J.C. Parodi
K. Ivancev
F. Veith
J.M. Macho
E. Roche
M. Sabaté
R. Trillo
J. Fernández-Noya
G. Mestres
N. Mosquera
P. Gaines
07
D. Scheinert
J. Maeso
J.F. Teixeira
M. Miralles
F. Verzini
F. Moll
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Comité Organizador SITE-CELA
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11
IX
Simposio Internacional sobre Terapéutica Endovascular
International Symposium on Endovascular Therapeutics
Congreso Latinoamericano de Cirugía Endovascular
Cirujanos Endovasculares de Latino América
Volumen XVIII - Número 1 - Junio 2015
Sesión 1
Ligadura alta de la USF
y sus tributarias con
ablación láser
endovascular del
conducto safeno. 10
Años de experiencia.
Dr. Juan Carlos Krapp.
MD, PhD
Presidente de la Sociedad Argentina de
Flebología y Linfología.
Profesor Adjunto de la Carrera de
Especialista en Flebología y Linfología de
la Universidad Católica Argentina.
Las técnicas endovasculares termoablativas en el tratamiento de las venas
varicosas, se han difundido por la
seguridad, eficacia y su rápida
recuperación. Paralelamente a estos
buenos resultados, han ido reportándose
efectos secundarios no deseados y las
propuestas para evitarlos y mejorar la
performance de los resultados a largo
Angioplastia tibial VS
bypass con vena:
Como y cuando
Luis Mariano Ferreira
Hospital de Clínicas José de San Martín.
Buenos Aires. Argentina
Los pacientes con isquemia crítica de
miembro asociado a enfermedad arterial
infra-poplítea se caracterizan por ser
pacientes de alto riesgo cardiovascular
y presentar generalmente lesiones multisegmentarias. La mayoría son diabéticos
de larga data, son generalmente
sedentarios y muchos no han
experimentado una progresión típica de
la claudicación a la lesión trófica. La
CELA-SITE Sesión 1 / CELA SITE Session 1
ADELANTOS EN TRATAMIENTO ENDOVASCULAR EN MIEMBROS INFERIORES
ADVANCES IN LOWER LIMB ENDOVASCULAR TREATMENT
Moderador / Moderator M. Ferreira
Panelistas / Panellists S. Benites Palacio, G. Rubio Argüello, I. Escotto
plazo. Actualmente se han publicado
estudios, que hablan del destino del
muñón largo de safena que se deja y el
aumento de las recurrencias varicosas
en zona inguinal y muslo. La técnica de
ablación endovascular, difundida a través
de guías de procedimiento, indica
posicionar la fibra láser, por debajo de la
vena epigástrica superficial, respetando
las venas tributarias localizadas entre la
válvula terminal y pre-terminal, dejando
de lado la gran variedad anatómica de
la USF. Ante el hallazgo de trombosis en
distintos estadios, clasificados por
Cabnick (EHIT), se indico realizar la
ablación a mayor distancia, pero aún así,
disminuídos los efectos trombóticos,
persiste el fenómeno hemodinámico
producto de la eliminación del sistema
vensoso superficial, que obliga a que
todo el flujo de sangre se evacúe
únicamente por el Sistema Venoso
Profundo. Esto provoca la dilatación
brusca de la vena femoral común, la que
facilita de esta forma, la dilatación del
anillo de implantación de la válvula ostial
terminal y con ello, el inicio de un nuevo
reflujo hacia safena y tributarias, llevando
severidad del cuadro dependerá del
grado de obstrucción, desarrollo de
colaterales, carga del ejercicio y las
características de la persona. La
evolución natural de estos pacientes lleva
a la pérdida del miembro. El foco está
puesto en llevar la mayor cantidad de
sangre lo más cercana a la lesión.
La decisión terapéutica deberá balancear
el riesgo clínico – quirúrgico, y
características del árbol arterial. Cuando
hablamos de riesgo nos referimos a
cualidades como sobrevida,
comorbilidades, re-operaciones o la
presencia de un conducto venoso
adecuado, entre otros. Cuando nos
referimos a anatomía arterial, focalizamos
en la topografía y tipos de lesión, vasos
de salida, características de la placa.
Cualquiera sea la decisión, tres factores
09
a la recurrencia varicosa. La técnica
endovascular cerrada, tiene básicamente
un gran defecto, deja un muñón largo
de GVS, (2,5 a 3cm) hecho que ha sido
reportado durante décadas, como la
mayor falla de técnica terapéutica que
origina la recurrencia varicosa postquirúrgica en varices de la USF. La
recurrencia varicosa en muslo, es
principalmente por esta falla técnica,
probado por la evidencia en extensos
estudios. El reflujo que se produce desde
la vena femoral común hacia la safena
no ligada, luego de la ablación del
conducto safeno, canaliza todo el flujo
venoso del miembro inferior por el sistema
profundo, esto acelera la progresión de
la enfermedad y hará que el muñon
safeno residual, reciba el reflujo desde la
vena femoral común, y produzca en poco
tiempo una recurrencia, desde la USF.
Conclusiones:
Se propone una terapéutica mixta de la
USF insuficiente, con ligadura quirúrgica
alta de la USF y de sus tributarias,
asociada con ablación endovascular láser
del conducto safeno (sin striping) hasta
son fundamentales. La presencia de un
equipo multidisciplinario, poseer la
tecnología adecuada y las habilidades
técnicas necesarias para cualquiera de
los dos abordajes.
Existen múltiples meta-análisis, estudios
prospectivos y retrospectivos que
muestran la eficacia tanto para los
procedimientos abiertos como
Endovasculares.
Las recomendaciones sin embargo
parecen por ahora recomendar la cirugía
abierta para aquellos pacientes con mejor
expectativa de vida, con lesiones con
mucha necrosis o infección o cuando las
lesiones arteriales son múltiples y de difícil
recanalización. Un aspecto a puntualizar
es que el estudio BASIL determinó que
aquellos pacientes que la primera línea
el tercio medio de pantorrilla para evitar
lesión neurológica. Creemos que esta
técnica, aborda los tres factores básicos
para un correcto y duradero resultado a
largo plazo, efectuando el tratamiento
anatómico, hemodinámico y con visión
de la progresión de la enfermedad
venosa. Esto presenta muchos beneficios
sobre la ablación cerrada clásica. Se
elimina la posibilidad de efectos
secundarios como TVP o TEP, neuritis y
sobre todo, mejora la eficacia a largo
plazo, disminuyendo la recurrencia al
mínimo, que solo se presenta cuando
hay reflujos No-safenos. Las incisiones
quirúrgicas son mínimas y el conducto
safeno se ablaciona con láser (sin efectuar
stripping). El paciente evoluciona con
dolor mínimo, menos hematomas, sin
neurítis, sin peligro de TVP o TEP (por
EHIT), con menores tasas de recurrencia
varicosa o re-permeabilización del
conducto, por eliminar casi todas las
posibilidades de nuevos reflujos de origen
safeno-femoral.
de tratamiento fue el endovascular y
fracasó, el resultado del abordaje abierto
de rescate fue peor.
Es fundamental también enfocar hacia
el cuidado pre, intra y postoperatorio del
pie y del paciente. Tratamiento antibiótico,
desbridamientos, inmovilización,
descargas, aceleradores de cicatrización,
tratamiento estricto y vigoroso de los
factores de riesgo son factores que
repercutirán en la sobrevida y
recuperación.
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Miércoles 24 Junio
Wednesday, June 24th
11
IX
Christian Bianchi
Loma Linda VA Healthcare System,
Loma Linda, USA
Introduction:
Patients at risk for major amputations
present with variable degrees of lower
NOVEDADES DESDE
EL CEREBRO
Flow Diverting Stents:
Indicaciones y
Resultados tras más de
5 años de experiencia
clínica
Dr. J.Blasco
Neurorradiología Intervencionista
C.D.I.
Hospital Clínic de Barcelona
Miércoles 24 Junio
Sesión 2
Coiling de la
mesenterica inferior:
la mejor opción para
el tratamiento del
endoleak tipo ll
Dr. Marcelo H. Cerezo
Instituto Argentino de la Aorta, Hospital
Español de La Plata, Argentina.
extremity ischemia, different types of
tissue loss, physiological and functional
status.
Objectives:
To evaluate the long term outcome,
healing rates, hemodynamic outcomes,
and freedom from major adverse lower
extremity of patients presenting with PAD
and tissue loss.
and palliative limb care. On an intention
to treat, Wound presentation, wound care
provided, wound care associated
procedures, healing rates, need for late
revascularization, prevalence of major
amputations, wound recurrences,
recurrences management and survival
were analyzed.
received palliative limb care. Overall
wound healing was documented in 70%
of the cohort. Limb salvage was 75%. In
those patients receiving revascularization,
no difference was observed when open
was compared to endovascular. Vascular
reinterventions were needed in 86
instances. Overall 1, 3, 5 year survival
was 67%, 42% and 18% respectively.
Results:
Conclusions:
Patients were stratified according to
management strategies which include:
revascularization, aggressive local wound
care without revascularization
(conservative group), primary amputation
Between January 2006 and November
2014, 601 patients were enrolled.
271 patients (38.5%) meet criteria for
revascularization, 258 patients (36.3%)
were allocated to a conservative
approach. Primary amputation was
indicated in 68 patients and 112 patients
Since the appearance of flow diverters
around 2009, its use for the treatment of
intracranial aneurysms has clearly
increased. Flow diverters led us to a
different approach in the endovascular
treatment of intracranial aneurysms, in
terms of extrasacular treatment compared
to the classical intrasacular treatment.
These devices have been used for those
aneurysms untreatable with standard
techniques, but with an increasing
understanding of their safety and efficacy,
indications have spread over all different
types of aneurysms. Although
complications may be higher in those
patients treated with flow diverters, careful
attention should be paid to the specific
type of aneurysms we are dealing with,
and to the intrinsic risk of those lesions.
In aneurysms > 10 mm, the annual
rupture rate has been shown to be up to
4.37% and in giant aneurysms (>25 mm)
this rate may go up to 33.4%. In this type
of aneurysms, surgical treatment is often
challenging and can be associated with
significant morbidity. Moreover, simple
coiling has been shown to be a nondefinitive treatment in many cases, with
a recurrence rate of 39%. Giant and big
aneurysms have been typical indications
for flow diverters during all these years,
however many people in the INR
community are now advocating for
extending the indications of flow diverters
to small, unruptured, saccular aneurysms.
Pros and cons will be presented with an
specific emphasis on the latest reviews
in the literature and our own experience.
Methods:
A tailored approach to this heterogeneous
high risk group is reasonable.
For those patients deemed “limb salvage
candidates”, the limb preservation rate
is acceptable. Survival of this population
is limited.
APORTES PARA EL MANEJO ENDOVASCULAR DE LA AORTA
CONTRIBUTIONS FOR ENDOVASCULAR MANAGEMENT OF THE AORTA
Moderador / Moderator F. Criado
Panelistas / Panellists J.C. Parodi, L. Bechara, L. León, R. Mertens
Introducción:
Métodos:
El endoleak tipo 2 es una situación que
se presenta en el seguimiento de un
EVAR, con una frecuencia según autores
entre un 6 y un 25%. Arterias lumbares
y mesentérica inferior (MI) suelen ser las
fuentes mas comunes de este leak,
siendo el de mesentérica menos
frecuente, dado que, en la mayoría de
las ocasiones, la MI suele estar ocluída
al tiempo del EVAR. Cuando esta
situación se presenta, se han postulado
varios métodos de resolución, siendo el
coiling de la MI el preferido por nosotros.
Sobre un total de 850 EVAR realizados
en nuestra experiencia en el Instituto
Argentino de la Aorta, Hospital Español
de La Plata, Argentina, hemos tomado
como referencia los últimos 5 años, en
donde se han tratado 242 Aneurismas
Abdominales por esta vía. La tasa de
aparición de endofugas tipo 2 ha sido
del 13%, siendo el 20 % de estas
generadas por una MI permeable. Todos
los casos fueron detectados dentro de
los controles tomográficos del primer año
de seguimiento. Se evaluaron las técnicas
10
de coiling, ligadura laparoscópica y
punción translumbar.
Resultados:
De los 7 casos evaluados (20%), se
descartó la ligadura laparoscópica en 4
de ellos por abdomen hostil, la punción
translumbar se descartó en 5 casos por
potencial angulación excesiva de la aguja
de punción, con riesgo de perforación
visceral. No se descartó ningún caso
para coiling. La técnica triaxial fue utilizada
en todos los casos, por acceso femoral
por punción. La cantidad de microcoils
volver al sumario
Estrategias clínicas y
seguimiento de
pacientes con PAD
presentando pérdida de
tejidos
11
IX
utilizados fue de 5 + 2.
El éxito técnico fue del 100%. No se
registró a la fecha recidiva del leak de MI
aunque uno de los casos presenta
actualmente leak por conexión Iliolumbar
derecha, no observada durante el
Manejo de las
infecciones
de aorta y
endoprótesis
Prof Dr. Fernando Ibáñez C.
procedimiento de corrección de la fuga
de MI.
Conclusiones:
El endoleak tipo 2 por MI es una situación
poco frecuente. De las técnicas
disponibles para su corrección, la única
que no encontró contraindicaciones para
su realización fue la de coiling del tronco
de la MI. Se debe dominar la técnica de
uso de microcateteres para este
procedimiento. La colocación de coils
en el tronco de la arteria MI es un
procedimiento factible y seguro, debiendo
ser precavidos al embolizar, por el
potencial riesgo de oclusión de la
circulación del tronco común de las
arterias sigmoideas.
Introducción con frecuencia del problema Presentación de casos clínicos de nuestro servicio
Métodos diagnósticos utilizados con especial énfasis en imágenes
Manejo conservador y quirúrgico:
Ventajas e inconvenientes de cada conducta
Miércoles 24 Junio
Sesión 3
Resultados y discusión con revisión del tema
INDICACCIONES Y ESTRATEGIAS PARA ENDOPRÓTESIS AÓRTICAS: MÁS ALLÁ DE LA EVIDENCIA
INDICATIONS AND STRATEGIES IN AORTIC ENDOGRAFTING: BEYOND THE EVIDENCE
Panelistas / Panellists V. riambau, L. Bechara, A. Fajardo, N. Mosquera, L. Sánchez
calf tributary. Any difference in the bubble
movement related to limb elevation,
immobilisation-mobilisation has been
assessed furthermore.
Adverse events:
do we have
pathophysiological
evidences?
1° Step
(Is ir safe to perfom foam
sclerotherapy?)
2- the possible changes of bubble
propagation induced by various
therapeutic procedures (such as limb
elevation, immobility after the injections,
etc.)
Lorenzo Tessari
Foam sclerotherapy, which started to be
diffused ten years ago, radically changed
phlebology world; furthermore the usage
of duplex guidance and of colour-duplex
control of our treatments, led us to assess
the pathways and diffusion of the
microbubbles of sclerosant foam; as a
result a few hypotheses have been
formulated on foam bubbles propagation,
whereas, in comparison, no studies have
been performed on liquid sclerosants
from this point of view
Several authors highlighted the necessity
to study and assess the propagation of
the gas microbubbles and/or of the drug
within the bubbles in this “modern”
sclerotherapy
The aim of this study is to highlight:
1- if bubbles and drug are linked or
separated in their pathway within the
blood stream
3- if labelling the sclerosant drug with
labelled technetium (Pertecnetato
99mTCO4-) may be a correct procedure
to highlight the pathway and propagation
of the sclerosant drug in foam
sclerotherapy.
A first study with echocardiography has
been performed on one patient: the arrival
time of the bubbles and their persistence
modalities and time within the atrium
(after a standardised injection of
sclerosant foam) have been monitored
and calculated in different time intervals.
Four mls of foam (Tessari method) of
Polidocanol 0,5%+CO2 O 2 have been
injected in the left great saphenous vein
and in a right posterior calf tributary; in
another case 4 mls of sclerosant foam
(Tessari method) of Polidocanol 0.5% +
air have been injected in a left posterior
11
The second study has been performed
to assess the possibility to label sclerosant
drug/microbubble with label technetium
(Pertecnetato 99mTCO4The same patient has been investigated
indifferent times as to his pulmonary
transit and his captation of the labelled
marker within his captation organs (thyroid
in primis, salivary gland, kidneys ,
stomach, etc.); more in details the
following assessment have been
performed:
1- The pathway of FREE 99mTCO42- The pathway of 99mTCO4- within
sclerosant foam made with
Polidocanol 2% + air
3- The pathway of 99mTCO4- within
sclerosant foam made with
Polidocanol 2% +CO2 O 2
4-The pathway of 99mTCO4- within
sclerosant foam made with Sodium
Tetradecylsulfate 1% + CO2 O 2
5- The pathway of 99mTCO4- within
sclerosant foam made with Sodium
Tetradecylsulfate 1% + air
Results
The three main outcomes of our studies
are summarised below:
1-By means of echocardiography it is
not possible to highlight any link between
drug and bubbles
2- Elevation of the limb and post-injection
limb immobility significantly influence the
passage of the microbubbles in the blood
stream/heart propagation
3-The labelling of the sclerosant drug
with Pertecnetato 99mTCO4- is not an
adequate procedure to highlight the
pathway of the sclerosant drug in foam
sclerotherapy; further details will be
provided on this part of the studies
4- is absolutely necessary, at this point,
apply new study:
2° Step
Aims: following to a few in vitro trials
which showed sclerosant drug interaction
with blood components, this experimental
trial was designed to assess in vivo
binding between sodiumtetradecysulfate
(STS) drug, which is contained on
sclerosant foam (SF) microbubbles, and
blood proteins.
Patients and Methods: two different
groups of patients were submitted to
ultrasound guided foam sclerotherapy
volver al sumario
Hospital Salvador y Clínica Alemana,
Santiago Chile
11
IX
with 3% STS +CO2O2 based SF, which
was formed through Tessari method. In
group A 4 patients (2 great saphenous
vein (GSV), 1 small saphenous vein (SSV),
1 Alcock canal vein (ACV)) had 5 cc
injection of SF. Immediately before the
injection (T0) and 1’, 5’ and 10’ after the
injection blood samples were retrieved
from left brachial vein. In group B 5 cc
of SF were injected in a varicose tributary
of the leg of two patients with GSV
incompetence. Immediately before , 1’,
3’, 5’ and 10’ after the injection, blood
Miércoles 24 Junio
Sesión 4
samples from the homolateral common
femoral vein and from left brachial vein
were retrieved. Titration of free STS and
of total, protein-bound STS (BSTS) were
performed by means of a solvent assisted
extraction and a molecular filter with a
10KdA cut off (for protein filtration).
Results: in group A (brachial vein samples)
BSTS (total STS) titration was respectively
0%at T0, 0.5% (GSV and SSV injection)
and 8% (ACV injection) after 1’, 5-7%
(GSV and SSV) and 37% (ACV) after 5’,
9-21% (GSV and SSV) and 38% (ACV)
Resultados:
Dr. Juan Pablo Carbonell
1) Entre mas compleja sea la anatomía
aortica tratada es mas importante el
acceso por arriba desde la arteria
subclavia o arteria axilar
Introduccion:
Es una realidad el impacto de la terapia
endovascular en el tratamiento de la aorta
en los últimos 20 años. La endoprotesis
modificada por el Cirujano o Home made
es una valiosa alternativa en el tratamiento
de la patología compleja de la aorta
toracoabdominal en casos
seleccionados.
proteins bind STS of SF microbubbles in
less than 1’. More importantly no free
(active) STS has been found in common
femoral vein and beyond pulmonary
circulation. Conversely BSTS
(pharmacologically inactive) is tracked
throughout the lower limb and central
veins circulation.
Conclusions: this in vivo study definitely
proved that when injecting 3% STS SF
in the veins of the lower limbs, blood
NUEVAS TÉCNICAS DESDE LA
NEW TECHNIQUES FROM LA
Moderador / Moderator M. Cerezo
Panelistas / Panellists F.Ibáñez, G. Espinosa, C. Timarán
La endoprotesis
estandar modificada
por el cirujano en la
propia sala operatoria
Fundación Valle del Lilli, Cali, Colombia
after 10’. Free STS titration at T0, after
1’, 5’ and 10’ was 0% in all samples. In
group B (common femoral vein samples)
BSTS (total STS) concentration (μg/ml)
at T0, after 1’, 3’, 5’ and 10’ was: 0,
0.568, 13, 24, 6 and 8.67 for the first
patient, and 0, 42.9, 18.5, 8.33, 5.43 for
the second patient. Free STS titration
was 0 (nil) in all samples for both patients.
Debido a la diversidad de la patología
aortica tratada es mas importante hablar
de las lecciones aprendidas que de los
resultados de morbimortalidad. Los
tópicos aprendidos mas importantes son
los siguientes.
2) Entre mayor sea el segmento aórtico
a cubrir es mas importante realizar el
procedimiento en 2 o 3 etapas para
disminuir el riesgo de paraplejia.
con angulaciones hasta 90 grados a nivel
de las arterias renales (condición
anatómica que puede llegar a ser una
contraindicación para la endoprotesis
“custom made” )
5) Los trombos a nivel de la aorta
yuxtavisceral son un riesgo importante
para el ateroembolismo, complicación
esta que puede llegar ser fatal para el
paciente
Conclusiones:
La terapia endovascular con endoprotesis
modificadas por el Cirujano es una opción
muy valida que nos ha permitido tratar
pacientes con patología aortica urgente
y patología de la aorta toracoabdominal
compleja.
6) Hemos aprendido a realizar
ramificaciones a los vasos viscerales
desde una fenestracion, sobre todo en
las arterias renales que son las anatomías
mas difíciles de tratar.
Objetivo:
Mostrar como lo hacemos y nuestros
resultados, principalmente en el manejo
de aneurismas yuxtarrenales,
toracoabdominales y disecciones de
aorta tipo B complicada.
Desde Diciembre del 2008 en nuestra
institución se han realizado un total de
71 pacientes con endoprotesis
modificada (ver imágenes), se ha tratado
patología aortica muy diversa desde
aneurismas yuxtarrenal hasta el
cubrimiento total de la aorta
toracoabdominal con compromiso de la
arteria subclavia o la arteria hipogástrica.
3) Si hay compromiso de la arteria
subclavia o hipogástrica, esta se debe
revascularizar se ser posible, si se debe
ocluir este procedimiento se deba realizar
en un tiempo adicional.
4) El despliegue secuencial de la
endoprotesis con acceso braquial o axilar
nos ha permitido tratar patología aortica
12
volver al sumario
Materiales y metodos:
11
IX
Luis Bechara Zamudio
La ruptura de un aneurisma de aorta
torácica es una emergencia que requiere
urgente diagnóstico y tratamiento. No
obstante, en pacientes con ruptura no
traumática, el tratamiento definitivo puede
Endoprotesis
fenestrada/con ramas
durante emergencias
aorticas agudas
Fajardo, Andrés
Las endoprotesis fenestradas han sido
introducidas para el manejo de
aneurismas yustarrenales/pararrenales y
toracoabdominales. Así también se han
introducido las endoprotesis con ramas
o una combinación de
ramas/fenestraciones para el tratamiento
de aneurismas toracoabdominales. Los
primeros reportes en dispositivos
fenestrados datan de la ultima parte de
los años 90.
La mortalidad de pacientes que se
presentan con aneurismas rotos, varia
dramáticamente de acuerdo a la técnica
de reparo. Se ha mostrado en múltiples
reportes el beneficio del manejo
endovascular de estos pacientes, con
disminución de la mortalidad que varia
Miércoles 24 Junio
Sesión 5
Disecciones Aorticas:
Experiencia en Puerto
Rico
Angel Menéndez
ser tardío, frecuentemente debido a la
complejidad para realizar diagnostico por
una presentación atípica.
Existen muchas complicaciones para el
tratamiento, ya que son ancianos y
poseen comorbilidades que aumentan
el riesgo de complicaciones
perioperatorias, por lo cual el tratamiento
quirúrgico convencional no se considera.
Concomitantemente, durante los últimos
10 años, el tratamiento endovascular de
la aorta se ha desarrollado para tratar
los aneurismas de aorta torácica y
pueden ser colocadas hoy en forma
percutánea sin anestesia general.
En estudios que comparan la anestesia
local con la anestesia general, no
encontraron diferencias en mortalidad a
los 30 días, a pesar de que la anestesia
local se realizó en pacientes más viejos
y con más problemas cardíacos y
respiratorios, a pesar de lo cual
presentaron menor tiempo de cirugía y
de estadía hospitalaria, y de
complicaciones postoperatorias que el
grupo de la anestesia general. Durante
6 años, utilizamos anestesia local en la
colocación de endoprotesis abdominales
y torácicas.
Presentamos 5 casos (3 mujeres y 2
varones) que presentaron ruptura de
aorta torácica no traumática, tratados
entre 7 y 10 días posteriores a la ruptura,
en pacientes entre 65 y 92 años. Todos
fueron tratados durante las primeras 24
ha de haber sido trasladados desde otra
institución, donde se los declaró no
quirúrgicos. Los 5 pacientes fueron
tratados con anestesia local.
de 25 a 40 por ciento.
Aproximadamente el 40% de los
pacientes que se presentan con un
aneurisma roto infrarrenal no son
candidatos a manejo endovascular. Las
mayores causas son la anatomía del
cuello y la longitud de este. Si se incluyen
aneurismas pararrenales y
toracoabdominales, la proporción es aun
mayor.
Las endoprotesis fenestradas tienen
muchas limitaciones para su uso en
emergencias aorticas. Cuando se
ordenan a la compañía, su fabricación y
posterior envió dura aproximadamente
3 a 4 semanas, lo que lo convierte en
una opción no viable en situaciones de
emergencia. También están, las
endoprotesis modificadas por cirujano,
que podrían ser usadas para estos casos.
Sin embargo, la modificación de prótesis
es un proceso complicado que solo se
debe utilizar por cirujanos con mucha
experiencia y que estén amparados por
protocolos de investigación adecuados.
Hay múltiples reportes en la experiencia
de centros de referencia en el manejo de
emergencias aorticas con prótesis
fenestradas y fenestradas/ramificadas
con buenos resultados a corto y mediano
plazo.
Una posibilidad que se ha abierto, es el
uso de prótesis estandarizadas(“off the
shelf”). La idea es que un porcentaje muy
alto(70%) de pacientes con aneurismas
pararrenales/yustarrenales pueden ser
tratados con un dispositivo único. En un
reporte inicial de la prótesis p-Branch
por la Cleveland Clinic, dos pacientes
fueron tratados de manera urgente con
el dispositivo con buenos resultados. El
porcentaje real de los pacientes que
pueden ser tratados con estos
dispositivos es todavía incierto y los
estudios clínicos que se están llevando
a cabo en estos momentos podrían
ayudar a aclarar esto.
Otro dispositivo que ha estado en
desarrollo es el T-Branch(Ramificado
toracoabdominal). El porcentaje de
pacientes que pueden ser tratados con
este dispositivo estandarizado varia de
50 a 80% dependiendo del reporte. La
disminución del perfil de la endoprotesis
ha servido para aumentar el numero de
pacientes que pueden ser tratados con
el dispositivo. Esta prótesis seria de
mucha utilidad si puede servir una
población larga de estos pacientes, pues
la mortalidad asociada a aneurismas
toracoabdominales rotos esta entre el
40-80%.
Siempre va a haber dificultades en
pacientes que se presenten con
variaciones anatómicas, bifurcaciones
tempranas, arterias con diámetros
pequeños y múltiples arterias renales.
Así que la estandarización, no es una
opción que va a abarcar a todos los
pacientes.
En resumen, los dispositivos
estandarizados(“off the shelf”), serian
ideales en la patología aguda. Sin
embargo existe una población en que
no va a ser posible el uso de estas
prótesis. El uso de ramas podría dar una
mayor flexibilidad al momento de usar
dispositivos en casos de emergencia,
resultando en una disminución marcada
de la mortalidad. Las prótesis modificadas
por cirujano, se mantienen como una
opción, pero deben ser reservadas para
centros de excelencia, con protocolos
de investigación bien documentados.
NUEVAS EXPECTATIVAS EN EL TRATAMIENTO ENDOVASCULAR DE PATOLOGÍAS DESAFIANTES
NEW EXPECTATIONS IN ENDOVASCULAR TREATMENT OF CHALLENGING PATHOLOGIES
Moderador / Moderator A. Fabiani
Panelistas / Panellists Z.Krajcer, A. Esperon, M.Espíndola
Introduction:
Objective:
All cases of thoracic aortic dissection
Type B according to the Standford
classification that were treated
endovascularly (TEVAR) from 2006 to
2015 were revised. Also, acute cases
with rupture of the false lumen and
chronic complicated stable cases were
included in the revision.
The objective of this retrospective analysis
is to evaluate the results of the
endovascular treatment of thoracic
dissections Type B in patients treated in
a single institution. This is the only report
of non-traumatic dissections of the
thoracic aorta that has been done in
Puerto Rico.
13
Materials Used and
Methodology:
The clinical files of all patients treated
endovascularly were evaluated and those
patients that had not attended their
annual follow up were contacted to restart
their post-procedure treatment. The
patients were also asked about the
medical control of their arterial pressure.
volver al sumario
AAT rotos con
tratamiento tardío bajo
anestesia local
11
IX
(TEVAR) desde el 2006 hasta el presente.
También se incluyó casos agudos con
ruptura del falso lumen y casos crónicos
complicados estables.
Objetivos:
El objetivo de este análisis retrospectivo
es evaluar los resultados del tratamiento
endovascular de disecciones torácicas
Tipo B en pacientes tratados en una
institución. Es el único reporte de
disecciones no traumáticas de la aorta
torácica en Puerto Rico que se ha
realizado.
Introducción:
Se revisó los casos de disección aortica
torácica Tipo B según la clasificación de
Stanford, tratados endovascularmente
Material Usado y Metodología:
Global experience
with ovaton prime
stent graft
Methodology used:
Z. Krajcer
Introduction:
Three-year outcomes from a global study
of the Ovation Abdominal Stent Graft
System for endovascular aneurysm repair
Objectives:
This study evaluated the safety and
effectiveness outcomes of the Ovation
Abdominal Stent Graft System
(TriVascular Inc., Santa Rosa, California)
for endovascular repair of abdominal
aortic aneurysms (AAAs).
Material used:
TriVascular Ovation Abdominal Stent Graft
System
Evar y riñón
en herraura
Alejandro Fabiani,
Tecnológico de Monterrey, México
Una de las malformaciones renales más
frecuentes es el riñon en herradura (HSK)
y se puede detectar en 0,25% de la
Se evaluaron los expedientes clínicos de
todos los pacientes tratados
This prospective, multicenter, single-arm
trial enrolled 161 patients at 36 sites in
the United States, Germany, and Chile.
The Ovation system utilizes a trimodular
design with the aortic body delivered via
a flexible, hydrophilic-coated, 14F outer
diameter delivery system. The aortic
body is comprised of a low-permeability
PTFE graft, a suprarenal nitinol stent with
integral anchors to achieve active fixation
to the aortic wall, and polymer-filled
proximal rings that accommodate the
aortic neck and create a conformable
seal without exerting outward radial force.
The iliac limbs are comprised of highly
flexible nitinol stents encapsulated in lowpermeability PTFE that are packaged in
an ultra-low-profile 13- to 14-F OD
delivery system. Main inclusion criteria
of the study included proximal aortic neck
length ≥7 mm, inner neck diameter
between 16 and 30 mm, distal iliac
landing zones length ≥10 mm, and
diameter between 8 and 20 mm. Patients
were treated under a common protocol,
including clinical and imaging follow-up
población total. (1) con un rango de 0,15
y 0,33% (2) siendo más frecuente en
hombres. Su asociación con aneurismas
de aorta abdominal (AAA) no es frecuente
y se ha reportado en 1 cada 710
autopsias. (3)
En la mayoría de los casos, la fusión entre
ambos riñones se ve en el polo inferior
por tejido renal normal. (5) y en algunas
ocasiones (15%) es el tejido de tipo
displásico-fibroso. (6). En la mayoría de
los casos es asintomático con función
14
endovascularmente y aquellos pacientes
que no habían asistido a sus citas de
seguimiento anuales, fueron citados a la
clínica para reanudar el tratamiento postprocedimiento. Los pacientes fueron
entrevistados sobre el control médico de
su presión arterial.
Resultados:
Conclusiones:
En pacientes con disecciones Tipo B
complicadas y en pacientes estables con
buena anatomía, TEVAR debe ser
considerado como una opción
terapéutica que logra disminuir los riesgos
de desarrollar patología aortica
disminuyendo la mortalidad y morbilidad
asociada a esta.
Todos los pacientes tratados están vivos
y solo uno de los pacientes requirió una
re-intervención para controlar una fuga
Tipo I. No se reportó ninguna mortalidad
ni casos de paraplejia. Ningún paciente
requirió drenaje del líquido
cefalorraquídeo. En todos, el falso lumen
se trombosó y dejo de crecer.
at discharge, 30 days, 6 months, and
annually through 5 years. A Clinical Events
Committee adjudicated adverse events,
an independent core laboratory analyzed
imaging, and a Data Safety and
Monitoring Board provided study
oversight.
were performed in only 10 patients (6.2%)
through 1 year. Complete follow-up data
are now available through 3 years. There
were no ruptures or conversions and the
imaging core lab did not observe any
type I, III, or IV endoleaks or migration.
Conclusions of the study:
Results of the study:
The Ovation stent graft was implanted
successfully in 161 patients (100%). The
primary safety endpoint in the study,
major adverse event rate at 30 days, was
2.5% with 0% Device Related Major
Adverse Events. Treatment success,
defined as technical success and freedom
from AAA enlargement, type I and IV
endoleaks, rupture, or conversion to open
repair, was 99.3% at 1 year. The 1-year
safety outcomes included a 6.2% major
adverse event rate, 0.6% AAA-related
mortality, and 1.9% all-cause mortality.
The imaging core laboratory reported no
type I, III, or IV endoleaks or stent graft
migration. There were no AAA ruptures
or conversions to open surgical repair,
and AAA-related secondary procedures
renal normal. (7)
Sólo el 0,12% de los pacientes que
requieren la reparación AAA tiene un
coincidente HSK. (4) pero representa un
desafío debido a su distribución vascular
y vía urinaria anormal en un 60-80% de
los casos (8).
La reparación endovascular del aneurisma
(EVAR) parece ser una buena opción,
pero la mayoría de las publicaciones son
reportes de casos aislados.
Aquí les presentamos una serie colectiva
The 3-year results of the Ovation
Abdominal Stent Graft System
demonstrate excellent safety and
effectiveness in treatment of patients with
AAAs, particularly in patients with
challenging anatomic characteristics,
including short aortic necks and narrow
iliac arteries. A multicenter European
post-market study was initiated by
TriVascular to determine the performance
of the Ovation system under real-world
conditions. Between May 2011 and
January 2013, 501 patients from 30
European sites were prospectively
enrolled in the registry. Complete patient
data are available through 1 year and
suggest the Ovation system is safe and
effective in a real-world setting, with
results similar to the clinical study.
de diez casos de EVAR y HSK y su
evolución.
Material y método:
Colectamos la experiencia de casos no
publicados de EVAR en pacientes con
HSK de 5 grupos de Cirujanos Vasculares
de 3 países diferentes. Todos los datos
se recogieron de forma retrospectiva y
se analizó la demografía, el estado clínico,
la presentación clínica, la morfología
anatómica del aneurisma y del de HSK,
volver al sumario
Results: All the patients intervene are
alive and only one patient required a
second intervention to control a Type I
leak. There was no mortality or cases of
paraplegic reported. No patient required
drainage of the cerebrospinal liquid.
Conclusions: In patients with complicated
Type B dissections and in stable patients
with healthy anatomy, TEVAR should be
considered a therapeutic option that
lowers risks of developing an aortic
pathology and decreasing the mortality
and morbidity associated with it.
11
IX
Resultados
Diez pacientes con AAA asociados con
HSK fueron tratados con EVAR. La edad
media fue de 67 años (47-81 años), y 7
eran varones. El 80% eran fumadores o
tenían antecedentes de tabaquismo y el
70% tenía hipertensión. Sólo había un
paciente con diabetes y 6 de los 10 eran
tratados por disñlipemia. Sólo un paciente
presentó enfermedad pulmonar
obstructiva crónica (EPOC) y otro
paciente presentaba alteración de la
función renal como consecuencia de un
síndrome nefrótico.
El diámetro medio de aneurisma aórtico
fue 60,3 mm (rango de 49-81mm).
(Tabla 1)
Un total de 35 arterias estaban
involucrados en el suministro renal. Hubo
13 arterias renales derecha (RRA), 13
arterias renales Izquierda (LRA) y 9
Arterias Istmo (IA).
En 5 pacientes no presentó IA, con 3
pacientes 1 RRA y 1 LRA y 2 pacientes
2 RRA y 2 LRA). Cuatro pacientes
presentaron 2 IA. En 3 de ellos 1 RRA y
1 LRA y en uno de ellos 1 RRA y 2 LRA.
Un paciente presentó una IA, 2 RRA y 1
LRA. (Tabla 2)
En 9 casos se realizó EVAR con prótesis
estándares (3 Cook, 3 Medtronic, 2
Endologix y 1 Nellix) y 1 caso con una
endoprótesis fenestrada hecha a medida
(Zenit).
La media de tiempo quirúrgico fue de
103 minutos (40-180 min) (datos
disponibles en 9 de los diez casos) y la
Reconstrucción
Endovascular en
Oclusion Iliocava
Objetivos
Vanessa Rubio
Material
Introducción
El impacto de la enfermedad venosa
oclusiva Iliocava es severo, ya que influye
en la calidad de vida del paciente y en
su capacidad funcional. El tratamiento
endovascular ha demostrado ser efectivo
para restablecer el retorno venoso en la
enfermedad oclusiva tanto aguda como
crónica y mejorar la calidad de vida del
paciente.
Mostrar que el tratamiento endovascular
brinda al paciente una oportunidad de
mejorar su calidad de vida a largo plazo
al resolverle la oclusión iliocava.
Revisión de la literatura actual sobre el
tema y casos de pacientes de nuestro
grupo con enfermedad oclusiva iliocava
y su resolución endovascular
Metodología
Agrupación de la enfermedad según su
presentación inicial en cuatro grupos:
Trombosis Venosa Profunda (TVP) Aguda,
Oclusión Crónica (Síndrome Post
trombótico), Retrombosis y Compresión
extrínseca (No trombótica). La elección
de la técnica de reconstrucción
endovascular se determina por la
extensión, el sitio y el tipo de obstrucción.
Resultados del estudio
En la trombosis aguda se utiliza el
tratamiento médico a base de
anticoagulación y elasto compresión, sin
15
media de volumen de medios de
contraste fue de 65 ml (40-120 ml) (datos
disponibles en 8 de 10 pacientes).
Siete pacientes se recuperaron en la UCI
y estuvieron allí hasta el día siguiente y
la media de estancia hospitalaria fue de
4,2 días (1-14 días).
Sólo un paciente con insuficiencia renal
previa elevó los valores de Creatinina
sérica, recuperando los niveles previos
al EVAR a los 3 meses. No se reportaron
otras complicaciones y todos los
aneurismas fueron excluidos éxito sin
detectarse endofugas.
En un seguimiento medio de 36 meses
(1-108) todos los pacientes están vivos
y sin ninguna complicación relacionada
con el aneurisma.
embargo la mejoría clínica no es suficiente
para un estilo de vida normal. Al tratarse
con anticoagulación únicamente, a 5
años: el 90% de los pacientes desarrollan
insuficiencia venosa, el 15% desarrollan
úlceras de estasis, el 15% claudicación
venosa y 40% presentan ambulación
restringida.
La trombolisis y recanalización
espontánea tras TVP ocurre sólo en 20%
de la TVP ilio femoral. Estos pacientes
desarrollan enfermedad oclusiva crónica
con síndrome post trombótico severo y
posibilidad de retrombosis.
La trombectomía farmacomecánica logra
excelentes resultados para
repermeabilización del sistema venoso
en agudo, complementando con
angioplastia y stenting para asegurar un
flujo venoso de retorno adecuado. El
stenting es el método de elección para
tratar la enfermedad.
El uso indiscriminado de filtros de vena
cava profilácticos se refleja en mayores
complicaciones trombóticas en la vena
cava inferior. La presencia de un filtro de
vena cava inferior vuelve el procedimiento
Conclusión:
La reparación endovascular del
aneurisma de aorta abdominal (EVAR) en
pacientes con riñón en herradura (HSK)
parece ser un método seguro y eficaz
tanto en forma inmediata como a
mediano plazo.
de repermeabilización más complejo, sin
embargo no es contraindicación para su
manejo, ya que el stenting de la vena
cava inferior con un filtro es seguro.
Conclusiones del estudio
Las alternativas terapéuticas
endovasculares utilizadas han mostrado
ser efectivas restableciendo el flujo
venoso en obstrucciones severas.
volver al sumario
así como el resultado inmediato y
evolución a largo plazo.
11
IX
Luis Bechara Zamudio
En 1951, Raúl Carrea y Mahels Molins,
realizaron en Buenos Aires, el primer
abordaje carotideo, publicado en español
en 1955 (1). Eastcott publicó un caso
similar en inglés en 1954 (2),
Durante los primeros años, utilizamos la
técnica vertical sobre el borde anterior
del esternocleidomastoideo (ECM),
primero con anestesia general y luego,
con bloqueo regional de C2, C3 y C4.
Hace seis años cambiamos por las
técnicas que describimos a continuación:
Técnica
Se fija la cabeza en hiperextensión y
realizamos marcaciones en el cuello,
recordando que:
1) El borde superior del cartílago tiroides
corresponde a C4 y a la bifurcación
carotidea.
Miércoles 24 Junio
Sesión 6
La experiencia con
acceso arterio venoso
hibrido
y evita lesiones nerviosas, especialmente
del nervio cervical transverso.
2) El cruce de la vena yugular externa
(VYE) con el borde posterior del ECM
corresponde a C6 y la salida del plexo
cervical superficial.
3) Pueden existir de uno a tres pliegues
horizontales en el cuello, debiendo
utilizarse el que se dirige al borde superior
del cartílago tiroides, el cual señala la
bifurcación carotidea. El uso del
ecodoppler ayuda a confirmar el nivel de
la bifurcación.
Durante los primeros 4 años, realizamos
el bloqueo de C3 a un cm por encima
del nivel del cartílago tiroides, sobre el
borde posterior del ECM. Punzamos con
una aguja 21 G y profundizamos hasta
sentir el plano óseo, donde inyectamos
10 cm de lidocaina al 2 %.
Por encima de la VYE, donde se
encuentra el plexo cervical superficial,
inyectamos otros 10 cm en forma radiada
desde atrás del ECM. Finalmente
inyectamos sobre la zona de incisión.
La incisión es de 2.5-3.5 cm desde el
borde anterior del ECM, siguiendo el
pliegue elegido. Si la incisión es pequeña,
podemos prolongar medio centímetro
arriba y abajo en forma de Z. La incisión
transversa mejora la reacción cicatrizal
Se palpa el latido carotideo por debajo
del ECM Colocamos un separador hacia
abajo, buscamos y reparamos la ACC.
La inervación arterial y de su fascia esta
dada por el vago y glosofaringeo, por lo
cual puede requerir el uso de 1-2 cc de
xilocaina periarterial. Se instruirá al
paciente que puede quedar disfónico por
minutos.
Seguidamente, colocamos el separador
hacia arriba y buscamos la ACE y la ACI.
Luego, probamos la tolerancia a la
isquemia durante 1-2 minutos, mediante
el clampeo de la ACI, a fin de seleccionar
quienes usarán shunt.
El plexo cervical está formado por las
raíces anteriores de N1 a N4, y mediante
diversas anastomosis, se obtiene el plexo
cervical superficial (sensitivo) y el profundo
(motor).
Hace dos años, creímos innecesario el
bloqueo de C3, ya que no requerimos la
anestesia motora, por ser la anestesia
sensitiva, dada por el plexo cervical
superficial, la que cubre los sectores
abordados por la incisión transversal. La
anestesia regional, sumado a un abordaje
Loma Linda VA Healthcare System, Loma
Linda, USA
Creemos que es una técnica útil y de
bajo riesgo, de tal manera que la
utilizamos para realizar otras cirugías
como los puentes carotido- carotideos
o endarterectomías carótideas más stent
proximales o para el uso de ingreso de
catéteres para facilitar la colocación de
una endoprótesis.
APORTES MODERNOS PARA PATOLOGÍAS DIFÍCILES DE RESOLVER
MODERN CONTRIBUTIONS FOR DIFFICULT DISEASES TO SOLVE
Moderador / Moderator C.Bianchi
Panelistas / Panellists N. Mosquera, F. Bautista Sánchez, G. Rubio Argüello
Introduction:
Conclusions:
Arteriovenous access when the proximal
axillary vein is a suitable option that is
underutilized.
Hybrid arteriovenous to the axillary vein
outflow is feasible. Extended non
dominant access for a mean of 6 months.
Hybrid graft has same risk profile of all
prosthetic grafts regarding infection.
Objectives:
Dr. Christian Bianchi
transverso, es considerado un
procedimiento mínimamente invasivo,
mucho más cuando la anestesia se realiza
solamente sobre los planos superficiales.
En 200 casos no necesitamos cambiar
de anestesia en ninguno.
To evaluate our centers experience with
the hybrid arteriovenous graft
Methods:
Retrospective review of a prospectively
collected data set on hemodialysis access
Results:
Fourteen patients were entered. Mean
age of 70 years. Ninety-three percent
were males. Eighteen grafts were
implanted.
Comorbidities are shows in table one.
16
Patients were on dialysis for a mean of
33 months and received an average of
three AV access procedures prior to
hybrid implantation. Patency data showed
a median primary, patency of 5.8 months.
Primary assisted re intervention was
required in two patients (15 days and 13
months). Complications included infection
in 3 cases, ( all explanted) and 2 cases
of steal syndrome.
volver al sumario
Nuevas formas de
anestesia y abordaje
carotideo
11
IX
disconfort en este particular grupo de
pacientes, quienes, en general, están
cursando la etapa terminal de su
enfermedad neoplásica. La
desobstrucción de la VCS se erige como
un tratamiento paliativo de suma
importancia para mejorar la calidad de
vida.
Dr. Marcelo H. Cerezo
Métodos:
Hospital La Plata, Argentina
Introducción:
La obstrucción extrínseca de la Vena
Cava Superior, (VCS) debido a procesos
orgánicos compresivos vecinos es la
principal causa de este síndrome, en
donde la fibrosis de la VCS por catéteres
y cables marcapasos aparecen con
mucha menor frecuencia. La signosintomatología es bien característica e
invalidante, siendo el edema en esclavina
y la disnea productores de un gran
Disección de aorta tipo
B complicada:
reemplazo de la aorta
toracoabdominal en
etapas.
en los últimos 10 años hemos tratado
por vía endovascular 7 pacientes con
esta patología, todos con compresión
extrínseca por metástasis tumorales o
por tumor directamente, siendo 6 de ellos
nativos del tórax, más específicamente
de pulmón y una metástasis mediastínica
derecha de un linfoma en etapa terminal.
5 pacientes fueron mujeres y 2 varones.
La media etaria fue de 68 años (+- 12).
Todos los pacientes fueron manejados
con anestesia local y NLA. Se utilizó
abordaje venoso femoral común derecho
corrección endovascular en etapas es
una muy buena opción.
Objetivos:
Mostar que entre más compleja sea la
patología de la aorta TA el reparo
endovascular en etapas surge como una
muy buena opción con menos riesgos
de complicaciones.
Introduccion:
La disección de aorta (DA) tipo B
complicada ha sido principalmente de
tratamiento quirúrgico, pero la corrección
quirúrgica de toda la aorta
toracoabdominal (TA) tiene una alta
morbimortalidad, es por esto que la
Reparo endovascular de
la diseccion
toracoabdominal tipo B
complicada: una
alternativa posible y
confiable
Juan Pablo Carbonell1, 2, Jorge
Velasquez1, Juan Sebastián Calle2,
Álvaro I Sánchez2
Para la reconstrucción TA se uso una
prótesis de PTFE anillado de 8 mm para
la derivación carotido subclavia y las
endoprotesis utilizadas fueron TX2
(COOK), TX2 modificada para el reparo
fenestrado de la aorta visceral y una
endoprotesis de GORE C3 para el reparo
de la aorta abdominal.
1
2
Resultados:
Los 7 pacientes presentaron reversión
parcial o total de la sintomatología en las
primeras 24 hs. Objetivamente se
visualizó la descompresión abrupta de
Metodologia:
por punción en 6 ocasiones y braquial
izquierdo por disección en 1. 2 stents
expandibles por balón y 5
autoexpandibles fueron utilizados. Las
lesiones fueron cruzadas en todos los
casos utilizando cuerdas hidrofílicas 0.035
sobre catéter coronario derecho, incluso
en 4 de los casos en que existía oclusión
de la VCS. En todas las ocasiones se
utilizó la misma técnica de dilatación
progresiva con balones, hasta lograr un
diámetro de 10 mm mínimo, para
implantar el stent y llevarlo a diámetro
de VCS menos 10-20%. Esta técnica
tiene por objeto lograr la fijación del stent.
Todos los pacientes continuaron con
antiagregacíon simple.
Fundación Valle del Lili, Cali, Colombia
Universidad ICESI, Cali, Colombia
Introduccion:
El reparo endovascular se viene utilizando
como alternativa quirúrgica en
disecciones toracoabdominales
complicadas y no complicadas. Sin
embargo, en los aneurismas desecantes
que involucran la aorta toracoabdominal
el papel del reparo endovascular sigue
siendo controversial, y el reparo abierto
continúa siendo considerado como la
técnica de elección.
17
Paciente de 69 años, quien presenta una
DA tipo B complicada con aneurisma
toracoabdominal tipo II y aneurisma iliaco
derecho de 5.0 cm. Se realizo el reparo
de toda la aorta TA en etapas:
1 etapa: Derivación carotideo subclavio
izquierdo con PTFE anillado de 8 mm
2 etapa: TEVAR y oclusión del origen
de la subclavia izquierda
3 etapa: FEVAR de la aorta abdominal
visceral con endoprotesis Home made
4 etapa: EVAR mas embolizacion de la
hipogástrica derecha
Resultados:
la hipertensión venosa superficial a nivel
de hombros y cuello en todos los casos.
No hubo ningún caso de migración del
stent, posiblemente debido a que se
permitió una estenosis residual posterior
a la angioplastia de 10 a 20% deliberado,
motivo por el cual entendemos que
tampoco hubo rupturas de la VCS en la
angioplastía. El promedio de sobrevida
de los pacientes fue de 8 meses, con un
rango de 2 a 16 meses. No hubo
reoclusiones o reestenosis de los stents,
controlados por TAC.
Conclusiones:
El tratamiento endovascular del Síndrome
de VCS es un método factible y seguro.
La mejoría del signo-sintomatología es
rápida. En un paciente portador de una
patología terminal, la resolución
endovascular de esta patología mejora
significativamente la calidad de vida.
Pseudoaneurisma de la iliaca externa
que se corrigió de forma endovascular.
No hubo mortalidad ni paraplejia
relacionada con los procedimientos.
Conclusion:
El reparo endovascular en etapas de toda
la aorta toracoabdominal es factible y es
una alternativa que parece tener menos
riesgos de mortalidad y paraplejia. Es
muy importante el seguimiento para la
corrección de endofugas y
complicaciones. Sera muy importante el
seguimiento a largo plazo para validar el
reparo endovascular de toda la aorta TA
en etapas.
Hubo éxito técnico en todos los
procedimientos, presento una endofuga
tipo I que se corrigió con otra
endovascular y presento un
Objectivo:
Describir nuestra experiencia con una
cohorte de 12 pacientes que
desarrollaron aneurisma disecante de la
aorta toracoabdominal que tuvieron
reparo endovascular completo en una
misma institución entre los años 20112015.
Metodos:
Se realizo una revisión de los registros
médicos de pacientes que desarrollaron
aneurisma discecante de la aorta
toracoabdominal a los cuales se les
realizó reparo endovascular completo de
la aorta torácica descendente y aorta
abdominal.
Resultados:
El promedio de edad fue de 54 años
(rangos entre 38-71 años). Ocho (67%)
fueron hombres. La hipertensión fue la
comorbilidad mas común en ocho
pacientes (67%), seguido por la
enfermedad de Marfan en cinco
pacientes (42%). En seis pacientes (50%)
se realizo un reparo total de la aorta en
2 tiempos, y en tres pacientes (25%) se
volver al sumario
Tratamiento
endoluminal del
síndrome de vena cava
superior.
11
IX
logro en 3 tiempos. El tiempo promedio
de reparo endovascular fue de 240
minutos, y el tiempo promedio del reparo
endovascular fenestrado fue de 315
minutos. La necesidad de transfusión
sanguínea fue del 58% (7 pacientes), con
un promedio de cuatro unidades de
glóbulos rojos por paciente. En el
seguimiento de estos pacientes, las
endofugas tipo I se observaron en tres
Endovascular repair of
complicated type B
thoracoabdominal
aortic
Dissection: a feasible
and valid alternative
pacientes (25%), las tipo II en tres
pacientes (25%), y las tipo III en un
paciente (8%). Cuatro de estos pacientes
requirieron un procedimiento adicional
para lograr una oclusión total del
aneurisma disecante y la corrección de
la endofuga. En un paciente se encontró
falla renal (8%). En un paciente paraplejia
transitoria (8%); este paciente se recupero
totalmente en menos de 48 horas. Un
standard. Objective:
We described our experience with a
cohort of 12 patients with
thoracoabdominal aortic post dissection
aneurysms that underwent a total
endovascular aortic coverage in a single
institution during 2011-2015. Methods:
Introduction:
Endovascular repair is advocated for
uncomplicated and complicated
dissections of the thoracoabdominal
aorta. However, in post dissection
aneurysms involving the
thoracoabdominal aorta, the role of
endovascular repair is in debate, and
open repair still is the gold
Retrospective review of clinical records
of patients with
thoracoabdominal aortic post dissection
aneurysms who underwent complete
endovascular coverage of the
descendent thoracic and abdominal
aorta. Results:
Mean age was 54 years (ranged
between 38 and 71 years). There were
eight (67%) males. Hypertension was
the most common comorbidity in eight
(67%) patients, followed by Marfan
paciente (8%) murió durante la
hospitalización y posterior al
procedimiento endovascular.
Conclusiones:
La oclusión completa de los aneurismas
disecantes crónicos que involucran la
aorta toracoabdominal es posible, con
pocas complicaciones, y con baja
incidencia de paraplejia transitoria y
syndrome in five (42%) patients. In six
patients (50%) the total
thoracoabdominal aortic coverage was
achieved in
two procedures. Three patients (25%)
required three procedures to achieve
total aortic coverage. The average time
of endovascular procedure was 240
minutes. During the endovascular
placement of the fenestrated stentgrafts, the average time of endovascular
procedure was 315 minutes. Blood
transfusion was required in seven (58%)
patients, with an average of four
units of red blood cells per patient. At
follow up evaluations, Type-I
endoleaks were observed in three (25%)
patients, Type-II endoleaks in three
(25%) patients, and a Type-III endoleak
in one (8%) patient. Four of these
patients require and additional
endovascular procedure to achieve total
occlusion of the dissection aneurysm
and correction of the endoleak. muerte. Nosotros recomendamos que
las intervenciones endovasculares
completas se realicen entre dos y tres
tiempos quirúrgicos para evitar
complicaciones como paraplejia, falla
renal y muerte.
Transient renal failure occurred in one
patient (8%). Transient paraplegia
was observed in only one patient (8%);
this patient achieved total recovery
in 48 hours. One (8%) patient died during
hospitalization following theendovascular
procedure.
Conclusion:
Complete occlusion by endovascular
coverage of chronic post
dissection aneurysms involving the
thoracoabdominal aorta is feasible, with
few complications and low incidence of
transient paraplegia and deaths. We
recommend that the extensive
endovascular approach could be
performed in staged two or three
endovascular procedures, to avoid
complications such as paraplegia, renal
failure and death. Abstract
Ferreira, Mariano; Carnero,
Lisandro; Escordamaglia,
Sergio; La Mura, Ricardo
Clínica La Sagrada Familia,
Buenos Aires (Argentina)
Introducción:
Un metaanalisis publicado en
2002 demostró que la cirugía
abierta del paciente con
aneurisma roto se asociaba a
un mortalidad promedio del
48%, y que dichas cifras no se
habían podido modificar en los
últimos 20 años. El tratamiento
endovascular del aneurisma de
aorta (TEVA) surge
esencialmente como una
alternativa menos invasiva para
pacientes de alto riesgo
quirurgico. Cuesta, por tanto,
tratar de pensar en pacientes
con más alto riesgo que aquel
que se presenta con un
aneurisma roto (AAA-r).
Las limitantes anatómicas y
especialmente la logística
hicieron en sus inicios a la
técnica endovascular de difícil
implementación para el
tratamiento del paciente con
aneurismas complicados. Sin
embargo en tiempos recientes,
con los avances técnicos y
tecnológicos las posibilidades
de ofrecer esta alternativa menos
invasiva se ha hecho factible y
segura. La postura de la
Insttución es brindar el protocolo
endovascular como “primera
opción de tratamiento” para los
pacientes con aneurismas rotos.
Objetivo:
El motivo de la presentación es
mostrar nuestro protocolo
quirúrgico de tratamiento del
paciente con aneurisma de aorta
abdominal roto (AAA-r)
de la presión arterial sistólica
(PAS) de ingreso:
hemodinámicamente estable
(PAS ≥ 80 mm Hg), inestables
(PAS <80 mm Hg durante >10
minutos). Los resultados
incluyeron mortalidad a 30 días,
en el seguimiento y
complicaciones postprocedimiento.
Métodos:
Conclusiones del
estudio:
El tratamiento endovascular del
AAA-r, siguiendo un estricto
manejo clínico quirúrgico, es
factible y seguro, especialmente
en pacientes estables bajo
anestesia local.
El análisis estadístico se realizó
mediante test de Fisher.
Material:
Resultados:
Diecisiete pacientes fueron
tratados bajo protocolo de
“abordaje endovascular primero”
e “hipotensión hemostática”. Se
clasificó la población en función
Los mortalidad a 30 días fue
23,5%. El éxito técnico se logró
en 94,1%. Si bien, ambos
grupos tuvieron comorbilidades
similares, los pacientes estables,
18
operados bajo anestesia local,
presentaron una tasa de
mortalidad del 7,7% (p<0.02).
volver al sumario
Tratamiento
endovascular
del aneurisma
de aorta roto
11
IX
Abstract
Introducción:
Los endoleaks tipo II constituyen
una causa importante de
reoperación a mediano y largo
plazo utilizando endoprótesis de
última generación. Tienen la
potencialidad de llevar al
Semana del
aneurisma de aorta:
experiencia en
hospital
universitario en la
deteccion precoz
del aneurisma
Ferreira, Mariano; Pinto,
Diego; Mansilla, Iván;
Sastriques, Eduardo; Masino,
Martín; La Mura, Ricardo
Hospital de Clínicas José de San
Martín, Buenos Aires (Argentina)
Tratamiento
extenso de la aorta
torácica con
técnica "hibrida".
Seguimiento a
mediano plazo
Girela, Alejandro Germán;
Bertoni, Hernán Gabriel,
De la Vega, Alejandro;
Barbosa, Fernando; Quiroga,
José María; Sapulvera, Óscar
Instituto Cardiovascular del Sur,
Cipolletti (Buenos Aires)
crecimiento e incluso ruptura del
aneurisma. Exigen además un
seguimiento imaginológico
distinto. Sin embargo no existen
pautas claras en cuanto a su
algoritmo terapéutico.
Objetivo:
mostrar un abordaje efectivo
para pacientes con endoleak
tipo II luego del tratamiento
endovascular del aneurisma de
aorta abdominal.
de una endoprótesis de última
generación. Mediante
seguimiento clínico y estudios
tomogra?ficos, fueron incluidos
en el estudio sólo aquellos
pacientes que cumplieron con
un estricto control de
seguimiento.
Metodología:
Material:
Los datos fueron volcados en
una base de datos (Microsoft
Excel 97) y luego fueron
analizados empleando el
paquete estadístico (Medcalc v
11).
Se estudio en forma
retrospectiva una población de
282 pacientes con aneurismas
de aorta, luego de la colocación
Resultados del estudio:
Se detectaron 18 pacientes con
endoleak tipo II persistente
Introducción:
Material:
El rastreo para aneurismas de
aorta abdominal (AAA) reduce
la mortalidad relacionada con el
aneurisma a casi la mitad en un
plazo de 4 años, principalmente
mediante la reducción de la
incidencia de ruptura del
aneurisma.
Durante los meses de
Noviembre de 2012, 2013 y
2014 se organizó la “Semana
del Aneurisma de Aorta”. Fueron
convocados hombres entre los
60 y 80 años, con antecedentes
de tabaquismo. La campaña
consistió en realizar en forma
gratuita en Consultorios
Externos del Hospital una
ecografía abdominal para medir
la aorta en su diámetro máximo.
Objetivo:
Los fundamentos de la campaña
fueron disminuir la mortalidad
asociada al aneurisma basados
en la detección precoz, crear
alianzas estratégicas y
multisectoriales para la detección
del aneurisma y finalmente
introducir en la población general
el concepto “aneurisma de aorta
abdominal”.
(endoleak luego de 1 año del
tratamiento), de los cuales 16
desarrollaron crecimiento del
saco aneurismático. Dicho
endoleak fue la única causa
detectada de reintervención.
Siguiendo un protocolo estricto,
mediante técnicas transarteriales
o laparoscópicas se obtuvo el
tratamiento efectivo del
endoleak. No se registró
mortalidad o ruptura relacionada.
En el caso de endoleak por
arterias lumbares (11p), el
tratamiento efectivo consistió en
la embolización del vaso
aferente, eferente y del nido
utilizando coils electrocoagulables. Los provenientes
de la arteria mesentérica inferior
(5p) fueron tratados por vía
endovascular o laparoscópica.
ecografías. Fueron
seleccionados 3215 personas
que cumplían con los criterios
de inclusión. Se detectaron 171
pacientes con aneurisma de
aorta, 106 con diámetro menor
a 4cm y 34 con diámetro
superior a 5cm. Todos los
pacientes recibieron un informe
escrito para su médico de
cabecera. A los pacientes con
aneurismas de más de 5cm se
les sugirió consulta inmediata
con especialista.
hay todavía muchos aspectos
prácticos por mejorar que
incluyen técnicas para optimizar
la captación del paciente, definir
los intervalos de vigilancia y el
manejo de pacientes con
aneurismas pequeños para
reducir la ansiedad y su riesgo
cardiovascular. Sin duda, los
riesgos asociados al tratamiento
endovascular del AAA justifican
su detección en nuestro medio
universitario.
Conclusiones del
estudio:
El Endoleak tipo II tiene en
general un comportamiento
benigno. La gran mayoría se
trombosa espontáneamente. El
estudio demostró que tratar sólo
aquellos endoleaks
“persistentes” con crecimiento
aneurismático es una conducta
segura no asociada a
mortalidad. La táctica se
relacionó al vaso culpable y
características clínicas del
paciente. Los tratamientos
aplicados fueron exitosos.
Metodología:
Prospectivo observacional
descriptivo
Resultados:
Previa firma del consentimiento
informado, se realizaron 3564
Introduccion:
Objetivos:
Las enfermedades quirúrgicas
de la Aorta Torácica fueron
patrimonio de la cirugía
convencional. Cuando hay que
abordar el Arco Aórtico es
necesario realizar hipotermia
sistémica, parada circulatoria y
protección cerebral. Con la
cirugía “Hibrida” (Debranching +
TEVAR), es posible realizar
intervenciones mas extensas
sobre la Aorta Torácica con
menor morbi.moratidad.
Mostrar nuestra experiencia con
la Técnica “HÏBRIDA” en
diferentes patologías de la Aorta
Torácica que involucran el Arco
Aórtico y el seguimiento a
mediano plazo
Material:
Desde el año 2.005 a la fecha
tratamos 17 pacientes con
técnica Híbrida. Las
enfermedades fueron: Divertículo
de Kommerel (1 caso) Aneurisma
de Arco Aórtico (1 caso) Fístula
Aortoesofácia (1 caso)-
19
Conclusión:
A pesar de la evidencia de que
los programas de rastreo
reducen la incidencia de la
ruptura del aneurisma y es
probable que sean rentables,
Coartación Aórtica con
nacimiento aberrante de ambas
arterias subclavias (1 caso)Disección Aortica Tipo I- De
Backey (13 casos).
se realiza by pass a la arteria
subclavia izquierda quedando
siempre excluida en el tiempo
endovascular
Resultado:
Metodo:
En todos, la técnica Híbrida se
realizó en dos tiempos, en el
primero (Debranching):se
confeccionan los By pass a los
troncos Supra aórticos con
ligadura proximal de los mismos
y en el segundo se completa
con el implante de Endoprotesis.
En las Disecciones Aórticas No
La mortalidad asociada a la
Técnica: 1 caso (5,8%)debido al
desgarro de la anastomosis del
debranching sobre la Aorta
provocada por el stent libre de
la endoprotesis. El los pacientes
con Sindrome de Marfán
evolucionaron con redisecciones
y dilatación de la Aorta
Tóracoabdominal. NO tuvimos
volver al sumario
Tratamiento del
Endoleak tipo II:
Algoritmo
terapeutico
11
IX
Abstract
Conclusiones:
Tecnica hibrida
(quirugicaendovascular)
en el manejo de la
patologia compleja
del arco aortico
conlleva una alta tasa de morbimortalidad. Mediante un
procedimiento híbrido
(quirúrgico-endovascular), sin
CEC ni PH, se logra la
desfuncionalización o
“debranching” del arco aórtico
(DAC), creando una zona
suficiente de anclaje en el arco
nativo para posteriormente cubrir
con una endoprótesis todas las
zonas aórticas necesarias.
Espíndola, Manuel, Baeza,
Cristian; Mora, Javier; Uribe,
Juan; Salas, Cristian;
Sepúlveda, Edgardo
Clínica Las Condes, Santiago
de Chile (Chile)
La cirugía “Hibrida” es una
excelente alternativa a la cirugía
convencional ya que permite
tratar grandes extensiones de la
Objetivo.
Analizamos nuestra experiencia
con el uso del DAC en patología
compleja del arco aórtico.
Introducción.
La cirugía convencional de la
patología compleja del arco
aórtico y la aorta descendente,
con circulación extracorpórea
(CEC) y paro hipotérmico (PH),
Material y metodo.
Estudio
prospectivo de las
ventajas del uso de
la radiofrecuencia
para el manejo de
las varices de los
miembros
inferiores
telangiectasias y síntomas leves
de pesadez hasta el desarrollo
de úlceras venosas, en este
espectro las varices de
miembros inferiores representan
la principal manifestación ; el
manejo quirúrgico por medio de
la extracción de la safena ha
demostrado ser muy mórbido,
generar incapacidades laborales
prolongadas y alta incidencia de
recurrencia a 3 años.
El uso de los métodos
Endovasculares se ha
posicionado como una
alternativa eficaz y comprobada,
mejor que los métodos
convencionales; en el siguiente
trabajo mostramos nuestra
experiencia con 176 pacientes
manejados con radiofrecuencia
para la insuficiencia de safena
mayor y menor con seguimiento
a tres meses.
Cesár Jiménez
Centro Intehral De Heridas Y
Enfermedades Venosas Cinthev.
Bogota, Colombia
Introduccion:
La insuficiencia venosa crónica
de los miembros inferiores es
una entidad muy frecuente en el
hemisferio occidental,
abarcando desde las
Entre Enero de 2009 y
Septiembre de 2014, se
operaron 25 pacientes (edad
media 66,0 años ± 15,7. 76%
Aorta Toracica con muy buenos
resultados.
En Sme de Marfán el tratamiento
endovascular continúa siendo
controvertido
Las endoprtotesis demostraron
excelente adaptabilidad y
resistencia en el tiempo
El seguimiento a mediano plazo
hace posible el uso de ésta
técnica, aún en Disecciones
Aórticas
hombres). En 18 pacientes el
DAC fue en agudo por disección
aórtica; en 6 por aneurisma, y 1
por úlcera aórtica complicada.
Las estrategias del
procedimiento fueron
determinadas en forma individual
para cada paciente.
de los cuales 7 se les hizo un
bypass carótido-subclavio y a 2
se les hizo además un bypass
carótido-carotídeo para poder
cubrir la aorta hasta las zonas 1
y 2. Se logró el despliegue
exitoso de la endoprótesis en el
100%. El seguimiento promedio
fue de 13,6 meses ± 16,2. La
mortalidad intra-hospitalaria fue
de 3 pacientes (12,0%): 1
durante el procedimiento, 1 por
AVE postoperatorio, 1 por
neumonía postoperatoria. 4
pacientes presentaron AVE
perioperatorio (16,0%). No se
presentó sangrado
postoperatorio del DAC. No
hubo fugas directas proximales
de la endoprótesis en ningún
caso. La sobrevida acumulada
por el método de Kaplan Meier
a los 5 años es del 90,6%.
Discusion/conclusion.
y retorno a las actividades
laborales o diarias del paciente
rutinarias y se analizaron los
aspectos técnicos del
procedimiento
venosa el 95% presento cierre
a los tres meses del
procedimiento
Resultados.
Según la estrategia utilizada se
establecieron dos grupos. Grupo
“2 tiempos” (DAC previo a la
endoprótesis): 16 casos, de los
cuales, 10 recibieron reemplazo
de aorta ascendente + DAC (7
a tronco innominado (TI) y
carótida izquierda (CI) y 3 a TI,
CI y subclavia Izquierda (SI)) y a
6 pacientes de este grupo, se
les realizó sólo DAC (4 a TI-CI y
2 a TI-CI-SI). Grupo “1 tiempo”
(DAC y endoprótesis): 9 casos,
Objetivo:
Mostrar la experiencia del
manejo de varices de miembros
inferiores con la técnica de
radiofrecuencia y demostrar sus
ventajas a corto plazo, la baja
incidencia de complicaciones y
el retorno a las actividades
laborales de manera temprana
Se realizó un estudio prospectivo
donde se siguieron 176
procedimientos Endovasculares
de radiofrecuencia para varices
de miembros inferiores en un
periodo de tres meses, con
seguimientos a la semana y
luego al primer , segundo y
tercer mes post quirúrgicos;
examinando la incidencia de
complicaciones, dolor durante
el procedimiento y post
quirúrgico, cierre de ulceras
venosas, tiempo de incapacidad
20
Resultados:
De los 176 procedimientos
realizados no se observó
ninguna complicación mayor o
menor, los pacientes
presentaron escalas de dolor del
procedimiento menores a 3 y de
dolor postquirúrgico menores
a 5, los pacientes retornaron a
sus actividades laborales en un
promedio de 5 a 7 días con uso
escaso de analgésicos, la
mayoría de pacientes se realizó
ablación de la safena mayor y el
paciente de mayor edad
intervenido fue de 92 años ,
todos los procedimientos se
realizaron anestesia tumescente
y de los pacientes con ulceración
Este es un grupo de pacientes
muy graves, con alta
complejidad técnica en su
reparación y que además tiene
una alta morbimortalidad
asociada al procedimiento
quirúrgico convencional. Nuestro
abordaje, en comparación a lo
publicado en series tradicionales,
es menos invasivo, tiene menor
tasa de sangrado post
operatorio y una menor tasa de
complicaciones neurológicas
mayores y sin casos de
paraplejia. Este procedimiento
es técnicamente más simple,
reproducible y podría
proponerse como el manejo
estándar de esta patología.
Conclusión:
el uso de la radiofrecuencia
como método Endovascular
para el manejo de la insuficiencia
venosa de miembros inferiores
es segura y con muy bajas tasas
de complicaciones, presentado
bajo dolor durante el
procedimiento y luego de el, con
disminución del tiempo de
retorno a las actividades
laborales y disminución del
consumo de analgésicos; por lo
que consideramos es una
opción muy adecuada para el
manejo de las varices en cambio
de la cirugía tradicional con altos
índices de complicación, recidiva
y tiempos de incapacidad
prolongados.
volver al sumario
daños neurológicos en ningún
paciente y durante el
seguimiento NO encontramos
Endofugas, ni daño estructural
de las endoprótesis.
11
IX
Abstract
Ferreira, Mariano; Sastriques,
Eduardo; Massino, Martín;
La Mura, Ricardo
Hospital de Clínicas José de San
Martín, Buenos Aires (Argentina)
Tratamiento
endovascular de
aneurisma de
arteria hepatica en
sufrimiento
Icasuriaga, Andrés; Esperón,
Alejandro; Langleib, Marcelo;
Piegas, Juan; Alvez, Martin;
Volpi, Mauricio
Correccion
endovascular
de aneurisma
yuxtavisceral
con tecnica de
chimeneas y
snorkels
Castillo, Sergio (1); Fabiani,
Alejandro (2); Cisneros Tinoco,
Miguel Ángel (1); Martínez
Escamilla, Yara (1); Baltazar
Barquera, Daniel (1)
Instituto de Seguridad y Servicios
Sociales para los trabajadores
del Estado (IS), Veracruz (México)
(1); Tecnológico de Monterrey,
Monterrey (México)(2)
Introduccion:
Los aneurismas de la aorta
abdominal son una alteración
frecuente en mayores de 65
años. La prevalencia aumenta
exclusión completa del
aneurisma.
además colocar una extensión
del lado derecho. El
procedimiento fue exitoso, no
registrando complicaciones en
periodo postoperatorio.
Ingresa compensado
hemodinámicamente. En la
AngioTC se visualiza aneurisma
de aorta roto con hematoma
retroperitoneal. La imagen
arterial muestra compromiso de
ambas arterias ilíacas, trombosis
extensa de la arteria hipogástrica
izquierda y arteria renal accesoria
izquierda (polar inferior). Por
disección femoral bilateral y bajo
anestesia local y apoyo con
neuroleptoanalgesia, se
comenzó embolizando la arteria
hipogástrica derecha, luego se
colocó el cuerpo principal de la
endoprótesis bifurcada, luego
se procedió a embolizar la arteria
renal y colocar la rama
contralateral. Fue necesario
Introduccion:
Objetivo:
Resultado:
Conclusiones:
El aneurisma de arterias
viscerales son patologías poco
frecuentes pero de complicarse
tienen elevada morbimortalidad.
Presentamos un caso clínico de
aneurisma de arteria hepática
en sufrimiento y su tratamiento
endovascular.
Sescribir la experiencia
terapéutica de este caso
desafiante y actualización de
bibliografía.
Se llevo a cabo tratamiento
Endovascular, realizándose de
necesidad embolizacion con
coils de arteria hepática
conservando arteria hepática
accesoria con buena evolución
clinica y paraclinica.
El abordaje endovascular, desde
el punto de vista terapéutico, de
este tipo de lesiones, en casos
seleccionados, es un recurso
factible y eficaz.
al incremento de la esperanza
de vida. Lo más común es
infrarrenal y solo 5% suprarrenal.
Esta circunstancia aumenta la
morbimortalidad quirúrgica; sin
embargo con el advenimiento
de los dispositivos para
tratamiento endovascular esta
ha disminuido.
derecha para cuerpo principal y
femoral izquierda con introductor
17 Fr, así como abordaje
humeral con introductor 9 Fr
largo 55cm , se colocó por vía
femoral derecha cuerpo principal
bifurcado Endológix FX BA 28100/ L16-40, , se canúlan
ambas renales vía femoral y se
coloca Viabahn 6mm x 150mm
para renal derecha y 7mm x
150mm para la renal izquierda,
orientando su segmento
proximal hacia la aorta terminal.
Por vía humeral se canúla
mesentérica superior y tronco
celiaco y se colocan Stents
recubiertos Viabahn 8mm x 150
mm para cada uno de los vasos,
posteriormente se coloca
primera extensión 28-28 C95020 Endológix, impactando los
stents renales contra
Endoprótesis principal
traslapándose con cuerpo
principal 5cm, finalmente se
coloca segunda extensión A34-
34/C 100-O20 recubriendo los
stents de vasos viscerales, con
un traslape de 3cm.
lo tanto a largo plazo se sabe
poco de la permeabilidad. El
tratamiento endovascular con
la técnica de chimenea o snorkel
resulta ser una adecuada opción
terapéutica en pacientes cuyas
comorbilidades impiden la
cirugía abierta. Si bien las
endoprótesis fenestradas
hechas ad hoc o home made
son consideradas de elección
para casos como el antes
descrito, existen ciertas
limitaciones para su uso en
Latinoamérica. Estas, están
relacionadas con los costos, la
calidad requerida en los estudios
de imágenes previos, las
habilidades y entrenamiento de
los operadores y el tiempo de
confección. En contrapartida,
para el uso de chimeneas y
snorkels no hacen falta
habilidades endovasculares
especiales y los materiales que
se utilizan son de uso habitual
en casi todos los medios.
Introducción:
En tiempos recientes, con los
avances técnicos y tecnológicos
las posibilidades de ofrecer esta
alternativa endovascular para el
paciente con aneurisma roto se
ha hecho factible y segura. La
postura de la Insttución es
brindar el protocolo
endovascular como “primera
opción de tratamiento” para los
pacientes con aneurismas rotos.
Existen sin embargo ciertas
restricciones anatómicas
relativas como la necesidad o
posibilidad de comprometer la
irrigación renal o pelviana,
necesarias para lograr la
Objetivo:
Reportar un caso de aneurisma
de aorta abdominal con
extensión al segmento visceral
con técnica de chimeneas y
snorkels y discutir su utilidad en
Latinoamérica.
Meterial y metodologia.
Masculino de 77 años,
hipertenso con antecedente de
tabaquismo intenso, a quien de
manera fortuita se detectó
aneurisma infrarrenal de 6.4cm
y suprarrenal de 5.4 cm tratado
de manera endovascular con
abordaje directo de femoral
Objetivo:
presentar un paciente con
aneurisma de aorta abdominal
roto con anatomía compleja.
Material:
Varón de 76 años con aneurisma
de aorta roto infrarrenal
Métodos:
Case report
Material y metodo:
Descripción de un caso clínico
poco frecuente de una paciente
con aneurisma hepático en
sufrimiento y su resolución
terapéutica.
21
Resultado:
En algunas series de casos, la
morbimortalidad descrita y las
endofugas son del 4.3 a 7.1%,
y del 25% respectivamente, en
nuestro caso ambas
complicaciones fueron nulas.
Durante los primeros 12 meses,
la permeabilidad primaria se
reporta hasta de un 97.8%,
nosotros observamos una
permeabilidad del 100% al mes.
1-3
Discusion:
Hay pocas series, de pacientes
con aneurisma de aorta
abdominal yuxtarrenal y
suprarrenal que describan la
revascularización de más de tres
vasos y mucho menos de los 4
vasos (renales, mesentérica
superior y tronco celiaco) y por
Conclusiones del
estudio:
El tratamiento endovascular del
AAA-r, siguiendo un estricto
manejo clínico quirúrgico, es
factible y seguro. La realización
de prácticas adyuvantes para
lograr la exclusión completa y
rápida del aneurisma podrían
estar justificadas.
volver al sumario
Embolizacion
arterial en el
contexto del
tratamiento
endovascular
del aneurisma
de aorta roto
11
IX
Abstract
Carbonell, Juan Pablo;
Velásquez, Jorge
Fundación Valle del Lili, Cali
(Colombia)
Tratamiento
endovascular de un
aneurisma
juxtarenal con
ruptura contenida
y chimeneas
renales bilaterales
Menéndez, Ángel
Introducción:
Una de las opciones
terapéuticas para el tratamiento
endovascular de los aneurismas
aórticos juxtarenales (EVAR) es
el uso de chimeneas y los
injertos fenestrados. En el caso
de los aneurismas con ruptura
contenida podría suponer un
riesgo de daño al riñón si no se
utilizan medidas de protección
renal como corrección del
“shock” hipovolémico.
Tratamiento hibrido
de la patología
compleja de la
aorta toracica
Gastambide, Carmelo; Bigalli,
Daniel; Amorin, Rosario;
Esperón, Alejandro
la aorta TA en etapas:
1 etapa: Derivación carotido
subclavio izquierdo con PTFE
anillado de 8 mm
2 etapa: TEVAR y oclusión del
origen de la subclavia izquierda
3 etapa: FEVAR de la aorta
abdominal visceral con
endoprotesis Home made
4 etapa: EVAR más
embolización de la hipogástrica
derecha
Introduccion:
La disección de aorta (DA) tipo
B complicada ha sido
principalmente de tratamiento
quirúrgico, pero la corrección
quirúrgica de toda la aorta
toracoabdominal (TA) tiene una
alta morbimortalidad, es por esto
que la corrección endovascular
en etapas es una muy buena
opción.
Para la reconstrucción TA se
usó una prótesis de PTFE
anillado de 8 mm para la
derivación carotideo subclavia y
las endoprotesis utilizadas fueron
TX2 (COOK), TX2 modificada
para el reparo fenestrado de la
aorta visceral y una endoprotesis
de GORE C3 para el reparo de
la aorta abdominal.
Objetivos:
Metodologia:
Mostar que entre más compleja
sea la patología de la aorta TA
el reparo endovascular en etapas
surge como una muy buena
opción con menos riesgos de
complicaciones.
Paciente de 69 años, quien
presenta una DA tipo B
complicada con aneurisma
toracoabdominal tipo II y
aneurisma iliaco derecho de 5.0
cm. Se realizó el reparo de toda
Resultados:
Objetivo: Presentar el caso de
un paciente varón de 73 años
que llegó a la sala de emergencia
con un diagnóstico de un
aneurisma de la aorta abdominal
juxtarenal con ruptura contenida
y dilatación aneurismática de la
arteria iliaca común derecha.
Además el paciente se
consideraba uno de alto riesgo
ya que tenía una cirugía de colón
previa y enfermedad pulmonar
obstructiva crónica. A pesar de
tener una creatinina sérica de
1.7 se opta por el tratamiento
endovascular. Se utilizó ambas
arterias braquiales como rutas
de acceso para lograr implantar
los injertos cubiertos que van a
hacer las chimeneas que se
utilizaron para aumentar la zona
proximal de anclaje del injerto.
donde se le drenó una efusión
pleural derecha utilizando un
tubo de pecho. Una vez estable,
se transfirió al piso intermedio
con una creatinina sérica de 1.7.
Este paciente el día de su alta
sufrió un infarto del miocardio y
falleció.
are contained, this could pose
a risk of kidney damage if renal
protection measures as
correction of hypovolemic
"shock" are not used.
Hubo éxito técnico en todos los
procedimientos, presento una
endofuga tipo I que se corrigió
con otra endovascular y
presento un Pseudoaneurisma
Objective:
El paciente luego del
procedimiento fue trasladado a
la unidad de cuidado intensivo
One of the therapeutic options
for the treatment of juxtarenal
endovascular aortic aneurysms
(EVAR) is the use of chimneys
and fenestrated grafts. In the
case of ruptured aneurysms that
To present the case of a 73year-old male patient who came
to the emergency room with the
diagnosis of a contained
ruptured aneurysm of the
juxtarenal abdominal aorta and
aneurysmal dilatation of the right
common iliac artery. Also, the
patient was considered a highrisk patient because he had a
previous colon surgery and
chronic obstructive pulmonary
disease. Despite having a serum
creatinine of 1.7, and
endovascular treatment was
opted for. Both brachial arteries
were used as access routes to
be able to implant the endograph
that would work as the chimneys
that would increase the proximal
Hasta hace algunos años el
tratamiento endovascular de la
aorta torácica solo era planteable
en aquellos pacientes con
enfermedad de la aorta
descendente.
Es cada vez mas frecuente la
realización de procedimientos
híbridos que permiten extender
el tratamiento endovascular en
las patologías del arco aórtico y
aorta ascendente. El concepto
es la confección de bypass a los
troncos supraorticos y ligadura
de las ramas nativas conocido
como “ debranching”. El
debranching puede ser total o
parcial según se incluya la
revascularización del tronco
arterial braquiocefálico, anatómico
o extra antómico incluyendo el
primero una esternotomía.
Estos procedimientos son una
alternativa a la cirugía
convencional que tiene una alta
morbimortalidad.
El cuello proximal en el
tratamiento endovascular es de
vital importancia, siendo un punto
crítico. Estos tratamiento
combinados permitirían el
implante de la endoprotesis en
una zona segura evitando una de
las complicaciones mas temidas
como lo son las endofugas
Presentamos un caso clínico de
un paciente con una disección
crónica de aorta tipob asociada
a un aneurisma que compromete
Resultado:
Conclusiones:
El uso de chimeneas es una
opción segura para tratar
pacientes con aneurismas
aórticos abdominales
juxtarenales con ruptura
contenida y de alto riesgo para
la cirugía convencional del
aneurisma aórtico abdominal.
Introduction:
22
de la iliaca externa que se
corrigió de forma endovascular.
No hubo mortalidad ni paraplejia
relacionada con los
procedimientos.
Conclusion:
El reparo endovascular en
etapas de toda la aorta
toracoabdominal es factible y es
una alternativa que parece tener
menos riesgos de mortalidad y
paraplejia. Es muy importante el
seguimiento para la corrección
de endofugas y complicaciones.
Sera muy importante el
seguimiento a largo plazo para
validar el reparo endovascular
de toda la aorta TA en etapas.
zone of anchorage of the graph.
Result:
The patient after the procedure
was transferred to the intensive
care unit where he had a
standing pleural effusion drained
using a chest tube. Once stable,
he was transferred to the
intermediate floor with a serum
creatinine of 1.7. The day of
discharge, this patient suffered
a massive heart attack and died.
Conclusions:
The use of chimneys is a safe
option for treating patients with
a contained ruptured aneurysm
of the juxtarenal abdominal aorta
and who are considered high
risk for conventional surgery of
abdominal aortic aneurysm.
el arco y la aorta torácica
ascendente. Se le realizo un
tratamiento en dos tiempos; un
debranching completo de los
troncosuprarorticos con un
reemplazo de la aorta
ascendente y cayado y la
confeccion de un bypass
coronario. Posteriormente se le
realizo el implante de dos
endoprotesis.
volver al sumario
Disección de aorta
tipo B complicada:
Reemplazo
de la aorta
toracoabdominal
en etapas
11
IX
Abstract
Aneurisma de aorta
abdominal y
de arteria iliaca
común asociado
con arteriopatia
obstructiva
ileofemoral. Reto
para la terapéutica
endovascular.
Gastambide, Carmelo;
Esperón, Alejandro; Amorin,
Rosario; Icasuriaga, Andrés
Riñón en herradura
y AAA gigante
y manejo
endovascular
con endoprotesis
fenestrada custom
made
Barrera Carvajal, Juan
Para el planeamiento del
tratamiento endovascular de los
aneurismas de aorta abdominal
se debe realizar un análisis
cuidadoso del cuello (forma,
tamaño, calcificaciones o
trombos, angulaciones),
diámetro del aneurisma,
tortuosidad de los vasos iliacos,
etc. siendo además muy
importante analizar el diámetro
y estado de los ejes
ileofemorales ya que estos
constituyen el sector inicial de
la entrada de los dispositivos.
Una incorrecta valoración de los
mismos puede provocar
complicaciones con elevada
mortalidad, como lo es la rotura,
disección u obstrucción de eje
iliaco femoral.
Lo más frecuente es la
confección, previo al acceso del
dispositivo de un conducto
protésico a nivel ilíaco por
abordaje retroperitoneal.
Presentamos un caso clínico en
el que coexisten la patología
aneurismática de la aorta
abdominal e iliaca primitiva con
estenosis severa del eje ilíaco
externo femoral.
Este paciente presenta doble
reto terapéutico: por un lado la
conservación de la arteria
hipogástrica y por otro planear
la vía de ascenso del dispositivo
ya que no se contaba con eje
ilaco primitivo adecuado que nos
permitiera la confección de un
conducto protésico.
Se realizó una endarterectomia
del eje ilacoexternofemoral por
vía extraperitoneal hasta el origen
de la arteria hipogástrica.
Posteriormente se realizó el
implante de una endoprotesis
con rama iliaca más un cuerpo
aortobiiliaco.
División de Cirugía Vascular y
Endovascular - Departamento
de Cirugía - Fundación
Cardiovascular de Colombia
(Colombia)
la línea media, con Aneurisma
de Aorta de 8.6 cm de Diametro
x 7.8 centimetros, por debajo
de las arterias renales y por
encima de la bifurcación de las
iliacas.
En historia clínica de urología y
estenosis pielo-ureteral.
Nefropatia obstructiva derecha
y estenosis pieloureteral
secundaria a compresión por la
dilatación aortica,
Angiotomografia Abdominal
muestra tortuosidad de iliacas
con diametros derecho de 17
mm e izquierdo de 28 mm, Con
clara indicación quirúrgica y sin
cuello próximal con ramas
renales y viscerales proximales
y angulación infrarenal, se realiza
diseño de endoprotesis con
fenestraciones para arteria
mesenterica superior, renal
derecha y renal izquierda mas
scalop en tronco celíaco, y
segmento aórtico bifurcado a
ilíacas, preservando las dos
arterias ilíacas internas o
hipogastricas, se realiza
procedimiento en Septiembre
de 2014 con seguimiento 3
meses, 6 meses y endofuga en
el origen de rama renal derecha,
programada para manejo en
Mayo 2015 y se llevaran ultimas
imagenes al Barcelona Junio
2015. Paciente de 67 años Hipertenso
Controlado con diagnóstico
incidental por ultrasonido de
AAA asintomático, Urotac inicial
Feb 2014, Riñón en Herradura
desviado hacia la izquierda de
SAVE the date
volver al sumario
!
"
!"!#$
23
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11
IX
Sesión 8
Current
Therapeutic
Options in the
Management of
Superficial Femoral Artery
Occlusive
Disease
Carlo Pratesi, Raffaele Pulli, Walter
Dorigo - Vascular Surgery, University
of Florence
The current worldwide trend in the
treatment of peripheral arterial disease
(PAD) is towards an increase in
endovascular procedures in the
infrainguinal district.
However, the role of the open repair with
a femoro-popliteal bypass is still debated
and in our opinion there still a room for
traditional surgery in the presence of
complex lesions involving the superficial
femoral artery and the popliteal and tibial
vessels . In this field, vein bypass provides
better results than prosthetic grafts, but
in selected cases and not only in the
absence of a suitable vein, new modified
grafts may be used with satisfactory
results.
To retrospectively compare early and
follow-up results of endovascular
procedures, open surgical and hybrid
open and endovascular management of
femoro-popliteal obstructive disease in
a single centre experience, we analyzed
our database about all procedures
performed from January 2005 to
December 2014. In this period of time
567 interventions for superficial femoral
OPCIONES ACTUALES EN EL TRATAMIENTO DE LAS LESIONES OCLUSIVAS (TASC II-C Y D)
DE LA ARTERIA FEMORAL SUPERFICIAL
CURRENT THERAPEUTIC OPTIONS IN THE MANAGEMENT OF SUPERFICIAL FEMORAL ARTERY OCCUSIVE
DISEASE (C-D LESIONS)
Moderador / Moderator G. Biamino
Panelistas / Panellists A. Fajardo, T. Zeller
artery (SFA) obstructive disease were
performed at our institution; in 304 cases
a fem-pop bypass was carried out (group
1), while 209 patients underwent an
endovascular procedures (group 2); in
54 patients an hybrid intervention
(endarterectomy and patching of the
femoral bifurcation with endovascular
recanalization of the superficial femoral
and popliteal arteries ) was performed
(group 3). Results were separately
analyzed on the basis of clinical
presentation (claudicants vs critical limb
ischemia (CLI). Early results in the three
groups were compared with ?2 test.
Follow-up results were analyzed with
Kaplan-Meyer curves and compared with
log rank test
There were no differences between the
three groups in terms of demographic
data, comorbidities, risk factors for
atherosclerosis. Interventions were
performed for severe claudications in 293
patients (97 in group 1, 159 in group 2
and 37 in group 3). Among the 274
patients operated on for CLI, 207 were
in group 1, 50 in group 2 and only 17 in
group 3. All the patients in group 1 had
TASC II C and D lesions (both in
claudicants than in CLI patients), while
the corresponding figure in group 2 was
21% and 48%, and in group 3 92% and
100%, respectively in claudicants and
CLI patients. In group 1, an above-theknee fem-pop bypass was performed in
18% of claudicants and 9% of CLI
patients; in group 2 an isolated
revascularization of the superficial femoral
artery was performed in 83% of
claudicants and in 14% of CLI patients;
the corresponding figures in group 3 were
78% and 64% respectively.
Early results
Claudicants
There were two technical failures, 1 in
group 2 and 1 in group 3, in both cases
due to the impossibility to cross the lesion.
There were two perioperative deaths,
both in group 1 (mortality rate 2%, p=ns
25
Finally 2 patients had asymptomatic
thromboses and were medically
managed. In group 2 one patient with
perioperative thrombosis underwent a
new unsuccessful endovascular attempt
with a consequent major amputation. In
the remaining patient a conversion to
open repair was needed . As a
consequence the thirty-day amputation
rate was 2.8% in group 1 (6 pts) and 2%
in group 2 (1 pt). There were neither
thrombosis, nor amputations in group 3
(p=ns).
Fig 1: primary patency in patients treated
for claudicatio intermittens. (CI1=bypass
surgery; CI2=endovascular procedures;
CI3=hybrid interventions)
Follow-up
in comparison with the other groups).
Five perioperative thrombosed occurred,
three in group 1 and 1 in group 2 and 3
each. There were no perioperative
amputations.
Claudicants
CLI
Four technical failures (8%) occurred, all
in group 2 (p=0.01 in comparison with
group 3). Two of them were due to the
impossibility to re-entry in the true lumen
after a subintimal recanalization. Two
patients required a conversion to surgical
bypass, one patient deferred a bypass,
while the remaining patint refused further
interventions. There were two
perioperative deaths, both in group 1
(mortality rate 0.9%, p=ns).
Fourteen perioperative thromboses
occurred, twelve in group 1 and 2 in
group 2 ( p=0.001). Four patients had
successful thrombectomy, but in one of
them a below-the knee amputation was
unavoidable for foot ischemia, although
the bypass was patent; in 2 patients
surgical thrombectomy was ineffective
and a major amputation was performed;
in 2 cases a new bypass was performed,
but in one of them a new thrombosed
led to a major amputation; in the two
dead patients a thrombosis was recorded
in one case leading to major amputation.
Mean duration of follow-up was 34
months (range 1-120 months) and 95%
of patients accomplished a regular followup.
Survival rates at 5 years were 78% in
group 1, 93% in group 2, while no deaths
occurred in group 3 (p<0.001; log-rank
15.6). At the same time interval, primary
patency rates were 52% in group 1, 65%
in group 2 and 31% in group 3,
respectively (p=0.001, log rank 15.3; Fig.
1); the corresponding figures in terms of
secondary patency were 67%, 83% and
38%, respectively (p=0.001, log rank
14.8).
In this group of patients, although they
were originally claudicants, 6 late
amputations occurred. The rate of limb
preservation at five years was 94% in
group 1, 98% in group 2 and 95% in
group 3 (p=ns).
CLI
Survival rates at 5 years were67% in
group 1, 76% in group 2, 57% in group
3 (p=0.1; log-rank 3.5). At the same time
interval, primary patency rates were 43%
in group 1 and 24% in group 2 (p=0.07;
log rank 5.1; Fig. 2). In group 3 the
duration of follow-up is still too short for
having five-year results. Anyway the 12month primary patency rate is 15%. and
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Jueves 25 Junio
Thursday, June 25th
11
IX
In the current daily practice it is crucial
to distinguish the results of different
method in the treatment of the SFS
obstructive disease on the bases of
clinical presentation. In claudicants a first-
In patients with complex lesions, not
amenable with endovascular treatment
e with contraindications to open surgery,
an hybrid approach is feasible, but the
results are still poor, suggesting an
increasing role for non-operative
management in such situations. On the
other hand, our results in patients with
CLI, seem to confirm those from other
studies (BASIL trial). Open surgery
provides significantly better long-term
with a mild increasing of perioperative
risk, and it can be recommended in
patients with a good life expectancy.
rate and, consequently, use of stent in
treating CTO has grown. Clinical
outcome of SFA stenting have been
disappointing in early reports, mainly
because of intimal hyperplasia, negative
remodelling, recoil and stent fracture.
All these aspects of SFA stenting
represent a possible cause of restenosis.
Stent design and materials have changed
along the years with an increased patency
rate of new devices in comparison with
stainless steel, balloon expandable stents
leading to better clinical outcome, at least
in the shortterms.
Recent studies have evaluated the
efficacy and durability of interwoven
selfexpandable nitinol stent in the
treatment of complex femoro-popliteal
artery lesions and results at 2 years
demonstrated very high patency rate
(72.8%) and fracture resistance.
Unfortunately, studies focused on long
term results of SFA stenting with
conventional self expandable nitinol stent
has shown that, despite the
widespread use of nitinol devices, in stent
restenosis (ISR) due to neo-intimal
hyperplasia still remains a limit of
endovascular treatment.
Different treatment approach has been
proposed to reduce the high ISR rate
(drug coated balloon, drug eluted stents,
covered stent).
On our opinion, for SFA CTO, since
restenosis still remains a major concern,
indication for endovascular treatment
Conclusions
Fig 2: primary patency in patients treated
for critical limb ischemia. (IC1=bypass
surgery; IC2=endovascular procedures;
IC3=hybrid interventions)
Why and when do
i use nitinol
stent?
Dr. Claudio Rabbia
Vascular Radiology - Città della Salute e
della Scienza di Torino – Italy
Chronic total occlusion (CTO) of
superficial femoral artery (SFA) remains
a clinical problem and there is not a
definitive consensus about the best
Studies reported in literature have shown
balloon angioplasty has poor patency
Michael D. Dake, M.D.,
for the Investigators
experiencing acute failure (e.g., ≥30%
residual stenosis) underwent secondary
randomization to provisional stenting with
Zilver BMS or Zilver PTX. Follow-up
included event-free survival (EFS) and
primary patency by duplex ultrasound
core laboratory analysis.
Purpose:
Results:
Why and when do
i use des
The Zilver PTX multinational, prospective,
randomized trial compared the safety
and effectiveness of the Zilver PTX stent
to balloon angioplasty (PTA) and bare
metal stenting (BMS) in the superficial
femoral artery (SFA).
Methods:
Patients with de novo or restenotic SFA
lesions were randomized to Zilver PTX
stent placement or PTA. PTA patients
line endovascular approach could be
suggested, considering that open surgery
provides similar results, but with a higher
perioperative risk.
As previously reported, 479 patients were
enrolled in the United States, Japan, and
Germany, and 5-year follow-up is
complete. The 5-year freedom from TLR
(target lesion revascularization) rate is
significantly higher for the Zilver PTX
group compared to the standard care
group, which includes optimal PTA and
provisional BMS (83.1% vs. 67.6%,
p<0.01). This represents a 48% reduction
26
However, endovascular treatments offer
similar long-term limb salvage rate and
it can be considered as a valid alternative
in high-risk patients with poor life
expectancy.
There are still insufficient data concerning
hybrid treatment in patients with CLI, but
we can suppose that this strategy may
be effective in high selected patients.
Only if we are able to take into account
all the different preoperative issues, we
could choose the right procedure in the
right patient.
must be discussed with patient with
respect of surgical alternative. The
procedure should start from
balloonangioplasty.
In case of restenosis, drug coated balloon
can be employed with improved results.
A nitinol self-expandable stent should be
deployed just in bailout cases (elastic
recoil, very calcified lesions with
inadequate result, poor outcome after
sub-intimal revascularization) and in these
cases, the implantation of an interwoven
nitinol stent should be considered.
*R: randomized clinical trials, S: single arm study
in reinterventions through 5 years.
Regarding effectiveness, the 5year
patency rate for the Zilver PTX group is
superior to the standard care group
(66.4% vs. 43.4%, p<0.01), which
represents a 41% reduction in restenosis
through 5 years. Provisional stenting with
Zilver PTX versus Zilver BMS continues
to demonstrate significant benefit of the
paclitaxel coating through 5 years, with
patency rates of 72.4% and 53.0%,
respectively (p=0.03), which represents
a 41% reduction in restenosis through 5
years due to the drug.
volver al sumario
31% in group 3, respectively (p=0.001,
log rank 15.3); the corresponding figures
in terms of secondary patency were 60%
and 35%, respectively in group 1 and 2
(p=0.08, log rank 4.4). Twelve-month
secondary patency rate in group 3 is
56%. Thirty-two major amputation were
recorded, leading to a limb salvage rate
of 76% and 81% (p=ns) in the two
groups. In group 3 the corresponding
figure at 12-month is 94%.
11
IX
PTX randomized and single-arm studies. J Am Coll
Cardiol 2013;61:2417-27.
lesions (>10cm)
Conclusions:
The 5-year results show sustained safety
and effectiveness with the Zilver PTX
drug-eluting stent, which may represent
a new gold standard for the treatment
of SFA disease.
1 Dake M, Ansel GM, Jaff MR, et al. Paclitaxel-eluting
stents show superiority to balloon angioplasty and bare
metal stents in femoropopliteal disease: twelve-month
Zilver PTX randomized study results. Circ Cardiovasc
Interv 2011;4:495-504.
2 Dake M, Ansel GM, Jaff MR, et al. Sustained safety
and effectiveness of paclitaxel-eluting stents for
femoropopliteal lesions: 2-year follow-up from the Zilver
Drug-eluting stent trial results for long
Fernández Noya, Jorge
University Clinical Hospital, Santiago de
Compostela (Spain)
Jueves 25 Junio
Thursday, June 25th
Sesión 10
Is mechanical
atherectomy a
useless tool?
Jos C. Van den Berg
Endovascular therapy is developing
rapidly and offers a less invasive
alternative to bypass surgery that has
been considered a gold standard in the
treatment of complex infrainguinal lesions.
Low primary patency rates and acute
treatment failures due to dissection or
elastic recoil have been reduced by using
Introduction: Methods
The treatment of long superficial femoral
artery (SFA) chronic total occlusions
(CTOs) remains controversial. There are
several endovascular treatment options
available for the recanalization of these
lesions: Percutaneous transluminal
angioplasty (PTA) alone, nitinol
stents,drug-eluting balloons, drug elluting
stents and stents-graft.
In the complex-long lesions the use of
the Viabahn endograft to create an
endoluminal bypass provides an
angiographically optimal primary result
while potential restenosis is limited to the
proximal and distal edges of the endograft
resulting in a length-independent
restenosis rate.
Objetive
To show how we can improve the results
in terms of patency and limb salvage
with the use of the Viabahn endograft.
Better understanding of optimal device
sizing and procedural technique have
resulted in better patency rates in even
the most complex SFA lesions. Strategies
to optimize procedural success and to
treat late complications such as
restenosis and/or thrombosis from the
4 Zeller T. Oral presentations. 2014.
literature are showed in this presentation
as well as our experience in the treatment
of critical limb ischemia patients.
Conclusions
Percutaneous e-PTFE stent-grafting with
the Viabahn stent graft is a viable
treatment option for complex lesions in
the SFA in patients with critical limb
ischemia.
Primary, secondary patency and limb
salvage rates, in the literature as well as
in our experience from June 2010 to June
2015 show good results, comparable to
historical surgical outcomes using PTFE
grafts as bypass conduits.
TEMAS NO RESUELTOS EN REVASCULACIÓN ENDOVASCULAR DE LAS EXTREMIDADES INFERIORES
UNSOLVED ISSUES IN LOWER LIMB ENDO-REVASCULARIZATION
Moderador / Moderator G. Biamino
Panelistas / Panellists A. Fajardo, T. Zeller
nitinol stent placement. However stent
fractures, poor vessel wall apposition
due to calcification as well as intimal
hyperplasia causing in-stent restenosis
impair better long term results. In
particular, long occlusions and in-stent
restenosis result in a high rate of
restenosis after angioplasty with or
without stent placement.
Atherectomy offers the theoretical
advantage of debulking and reshaping
the arterial wall which should help to
reduce the need for stenting by limiting
elastic recoil and dissection. However
early results with the Simpson
atherectomy device could not confirm
the theoretical advantages of
atherectomy. New device concepts and
different methods like orbital atherectomy,
27
and rotational atherectomy have proved
safety and have shown good results in
the single-arm registries and even in
some comparative trials. They still need
to prove their superiority over
conventional balloon angioplasty with or
without provisional stenting. A recently
published meta-analysis of atherectomy
of the femoropopliteal artery could not
confirm any procedural advantage nor
clinical outcome improvement in
atherectomy compared to conventional
balloon angioplasty with bail-out stenting.
For de novo lesions it can be concluded
that in case of successful intraluminal
lesion crossing, directional atherectomy
and orbital atherectomy can give similar
results as primary stenting with the
advantage of not leaving stent material
behind and using lower insufflation
pressure in order to minimize vessel wall
trauma. In case of in-stent restenosis,
the most promising results seen to offer
debulking techniques as directional
atherectomy and laser atherectomy in
addition to drug-eluting balloon
angioplasty. In the future more
randomized trials will be needed to further
confirm and also precisely define
indications for atherectomy in complex
infrainguinal lesions.
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FOR SFA TOTAL
OCCLUSIONS...
Why and when do
I use covered
stents? 3 Dake M, Scheinert D, Tepe G, et al. Nitinol stents with
polymer-free paclitaxel coating for lesions in the superficial
femoral and popliteal arteries above the knee: twelvemonth safety and effectiveness results from the Zilver
PTX single-arm clinical study. J Endovasc Ther
2011;18:613-23.
11
IX
Rabih Chaer, MD
OBJECTIVE:
Thrombolysis as a treatment for acute
limb ischemia (ALI) has become a firstline therapy based on studies published
over 2 decades ago. The purpose of this
study was to assess outcomes of patients
treated for ALI using contemporary
thrombolytic agents and endovascular
techniques.
METHODS:
Consecutive patients with ALI of the lower
extremities treated between 2005 and
Clinical significance of
embolic events in
patients undergoing
endovascular
femoropopliteal
interventions with or
without embolic
protection devices
Bernardo C. Mendes MD; Gustavo S.
Oderich MD
Mayo Clinic, Rochester
Objective:
The purpose of this study was to evaluate
the incidence and clinical significance of
embolic events in patients undergoing
endovascular femoropopliteal
interventions with or without embolic
protection devices (EPDs).
Methods: We reviewed the clinical data
of 566 patients treated by 836
endovascular femoropopliteal
interventions for lower extremity
claudication (46%) or critical limb ischemia
(54%) from 2002 to 2012. Outcomes
were analyzed in 74 patients/ 87
2011 were identified, and their records
were retrospectively reviewed. All patients
were treated with tissue plasminogen
activator delivered via catheter-directed
thrombolysis (CDT) and/or
pharmacomechanical thrombolysis (PMT),
with other adjunctive endovascular or
surgical interventions. Procedural
success, thrombolysis duration, and 30day and long-term outcomes were
obtained for the whole series and were
also compared between the CDT and
PMT groups. Limb salvage and survival
were assessed using time-to-event
methods, including Kaplan-Meier
estimation and Cox proportional hazards
models.
RESULTS:
A total of 154 limbs were treated in 147
patients presenting with ALI (Rutherford
class I, 9.7%; class IIa, 70.1%; class IIb,
20.1%). The mean follow-up was 15.20
months (range, 0.56-56.84 months).
Indications for intervention included
interventions performed with EPDs
(Spider Rx, Covidien, Plymouth, MN) and
513 patients/ 749 interventions performed
without EPDs. TASC classification, runoff scores and embolic events were
analyzed. End-points were morbidity,
mortality, re-intervention, patency and
major amputation rates.
Results:
Both groups had similar demographics,
indications, cardiovascular risk factors
and run-off scores, but patients treated
with EPDs had significantly (P<0.05)
longer lesions (109±94 vs 85±76mm)
and more often had occlusions (64% vs
30%) and TASC C/D lesions (56% vs
30%). Embolic events occurred in 35 of
836 interventions (4%), including 2 (2%)
performed with EPD and 33 (4%) without
EPD (P=0.35). Macroscopic debris was
noted in 59 (68%) filter baskets. Embolic
events were not associated with lesion
length, TASC classification, run-off scores,
treatment type or indication, but were
independently associated with occlusion.
Patients who had embolization required
more re-interventions (20% vs 3%,
P<.001) and major amputations at 30days (11% vs 3%, P=0.02). There was
no difference in hospital stay (2.4±4 vs
1.6±2 days, P=0.08), re-intervention (2%
vs 4%) and major amputation (1% vs 4%)
28
embolization (14.3%), thrombosed
bypass (36.4%), thrombosed stent
(26.6%), native artery thrombosis (24.0%),
and thrombosed popliteal aneurysm
(3.2%). Technical success was achieved
in 83.8% of cases, with a 30-day mortality
rate of 5.2%. Procedural complications
included systemic bleeding (5.2%),
access site hematoma (4.5%), acute renal
failure (1.9%), and distal embolization
(9.7%). The mean runoff score decreased
from 13.42 preintervention to 7.43
postintervention. Adjuvant
revascularization procedures were
required in 89.0% of patients and were
endovascular (68.8%), hybrid (9.1%), or
open (11.0%). Only 3.2% of patients
required a fasciotomy. The overall rate of
major amputation was 15.0% (18.1% for
CDT only, 11.3% for PMT; P = NS).
Predictors of limb loss by Cox
proportional hazards models included
end-stage renal disease (hazard ratio
[HR], 8.563; P < .001) and poor pedal
outflow, with an incremental protective
effect for improved pedal outflow (HR,
0.205; P < .001 for one pedal outflow
vessel; HR, 0.074; P < .001 for ≥ two
pedal outflow vessels). Gender, smoking,
diabetes, Rutherford score, runoff score,
thrombosed popliteal aneurysm, and PMT
were not significant predictors of limb
loss. The use of PMT was a significant
predictor of technical success (odds ratio,
2.67; P = .046).
CONCLUSIONS:
Endovascular therapy with thrombolysis
using tissue plasminogen activator
remains an effective treatment option for
patients presenting with mild or moderate
lower extremity ALI, with equal benefit
derived with CDT or PMT. Patients with
end-stage renal disease or poor pedal
outflow have an increased risk of limb
loss and may benefit from alternative
revascularization strategies
among patients treated with or without
EPD, respectively. The two patients who
developed embolization with EPDs had
no clinical sequela and required no reintervention. Most emboli were
successfully treated by catheter aspiration
or thrombolysis, but 8 patients (24%)
treated without EPD required prolonged
hospital stay, 7 (21%) had multiple reinterventions, 1 (3%) had unanticipated
major amputation, and 1 (3%) died from
hemorrhagic complications of
thrombolysis. Median follow up was 20
months. At 2-years, primary patency and
freedom for re-intervention was similar
for TASC A/B and TASC C/D lesions
treated with or without EPDs.
feared complication of percutaneous
interventions with potential devastating
clinical sequelae. It occurs in 1 to 20%
of patients undergoing iliac, femoral and
popliteal interventions. The use of embolic
protection devices (EPDs) has been well
accepted for carotid interventions and in
select patients with coronary saphenous
vein graft lesions.3-5 While EPDs have
been designed and clinically tested for
these procedures, its use during lower
extremity revascularization has been
criticized because of questionable
significance of embolic events, increased
cost and potential risk of complications
such as vessel trauma or entrapment of
the filter basket.6, 7
Conclusions:
Methods
Rates of embolization are low in patients
undergoing endovascular femoropopliteal
interventions with (4%) or without (2%)
EPD. Embolization is more frequent in
patients with occlusions. While emboli in
patients with EPD had no clinical sequel,
those treated without EPD require multiple
re-interventions in 21% or resulted in
major amputation or death in 3%. Late
outcomes were similar in patients treated
with or without EPDs.
We retrospectively reviewed the clinical
data of consecutive patients treated for
chronic lower extremity arterial
insufficiency between 2002 and 2012.
Indications for endovascular
revascularization were claudication or
critical limb ischemia. Patients with acute
or acute on chronic symptoms were
excluded from the study. Endovascular
interventions consisted of angioplasty
alone (PTA), angioplasty with primary or
secondary stenting (PTAS) and
percutaneous atherectomy. Patients who
had hybrid femoral endarterectomy
Introduction
Distal embolization is a well-known and
volver al sumario
Contemporary
outcomes of
endovascular
interventions for acute
limb ischemia
11
IX
combined with endovascular
femoropopliteal intervention were also
analyzed. End-points were presence of
embolization and macroscopic debris on
the filter basket, mortality, morbidity, reintervention, patency and major
amputation rates.
Technique of embolic
protection
The decision to use EPD was left at the
discretion of the treating physician. These
were favored during atherectomy
procedures and for recanalization of longsegment occlusions, particularly in those
patients with single-vessel run-off. Most
commonly contra-lateral trans-femoral
access was used and a 5-7 Fr hydrophilic
sheath was positioned in the common
femoral artery (Fig 1).
A 0.014-inch Spider RX embolic
protection device (Covidean, Plymouth
MN) was advanced via the 0.035-inch
catheter and deployed at or below the
level of the knee joint. A 0.018-inch V18
guidewire (Boston Scientific, Natick, MA)
was advanced via the 0.035-inch catheter
to be used as a “buddy wire” to provide
support for interventions done using
0.035-inch system. This facilitated
advancement of 0.035-inch stents and
retrieval of the filter basket. After
successful endovascular
revascularization, the EPD was retrieved,
examined and baskets with debris were
photographed for documentation.
Results
A total of 566 patients were treated with
836 femoropopliteal endovascular
interventions during the study period.
From this group, 74 patients underwent
87 interventions (10%) using EPDs, and
513 patients had 749 (90%) interventions
performed without EPDs. There were 468
(55%) male and 368 (44%) female
patients with a mean age of 72 ± 11
years (range, 28 to 105). Demographics,
indications for revascularization and
cardiovascular risk factors were similar
in both groups. Interventions were
performed for native artery lesions in 604
cases (72%) or to treat femoropopliteal
restenosis in 232 (28%). Patients in the
EPD group had significantly more
extensive disease as compared to those
treated without distal protection. The EPD
group had longer lesions (109 ± 94 vs
85 ± 76 mm; P<.03), and more often had
interventions performed for occlusions
(64% vs 30%; P<.001) and for TASC II
C/D lesions (56% vs 30%; P<.001). Runoff scores were similar for both groups
(4.4 ± 3 vs 4.7 ± 3; P=0.3), respectively.
Balloon angioplasty was used in 822
(98%) interventions and primary or
secondary stenting using self-expandable
stents in 367 (44%). The mean number
of stents was 1.8 (range, 1 to 8). Total
treatment segment averaged 145 ± 107
mm (range, 10 to 510). Atherectomy was
used in 38 interventions (5%) and selfexpandable stent-grafts (Viabahn, WL
Gore, Flagstaff, AZ) in 30 (4%). A hybrid
approach with femoral endarterectomy,
patch angioplasty or interposition graft
was performed in 49 interventions (6%).
Patients with EPD were more often
treated with bare metal self-expandable
29
Embolic events
Embolic events occurred in 35
interventions (4%), including two (2%)
performed with EPD and 33 (4%) without
EPD (P=0.35). Presence of occlusion was
the only predictor for embolization by
univariate analysis. Use of bare metal
stents, angioplasty or atherectomy was
not associated with embolization. The
location of emboli was at distal tibial
vessels in 19 cases (54%), proximal tibial
vessels in 11 (31%), below-knee popliteal
artery or tibioperoneal trunk in three (9%)
and SFA in two (6%)
Two patients treated with EPD had
embolic events, both located in distal
tibial arteries, with complete resolution
after immediate administration of t-PA
via the catheter. The complete resolution
with t-PA indicates that the emboli may
have originated for thrombus formation,
potentially beyond the EPD due to
stagnant flow or inadequate systemic
heparinization.
In the 33 patients who had embolization
after interventions without EPD, 25 were
treated immediately with t-PA infusion in
16 and catheter aspiration in ten. Other
adjunctive measures were intra-arterial
volver al sumario
stents (61% vs 42%; P<.001), stentgrafts (10% vs 3%; P<.01) and
atherectomy (14% vs 4%; P<.001), with
similar number of hybrid procedures in
both groups (7% vs 6%; P=0.8) (Table).
Total treatment length (198 ±120 mm vs
138 ± 103 mm; P<.0001) was longer in
the EPD group as compared to patients
treated without EPD, respectively.
Technical success was achieved in 93%
of the interventions, with no differences
between the groups. The diameter of the
EPD varied from 3 to 7 mm, and a 6 mm
Spider™ Rx was used in 38% of cases.
Two patients (2.3%) had decreased flow
caused by the EPD. In one patient filter
retrieval was difficult using the 0.014 wire,
which prompted routine use of the double
wire technique described in Figure 1.
11
IX
Early outcomes
Should we treat
popliteal
aneyrysms by
endovascular
means?
Introduction
Michele Antonello
Clinic of Vascular and Endovascular
Surgery, DCTV, Univeristy of Padua, Italy
Patients with embolic events required
more early re-interventions (20% vs 3%,
P<.001) and early major amputations
(11% vs 3%, P=.02) than those who did
not have an embolization, with no
difference in length of hospital stay (2.8
± 6 vs 2.3 ± 4; P=0.5). There was no
difference in hospital stay (2.4±4 vs 1.6±2
days, P=.08), re-intervention (2% vs 4%,
P=0.4) and major amputation (1% vs 4%,
P=0.3) among patients treated with or
without EPD, respectively. None of the
two patients who had small emboli with
EPD developed clinical sequel or required
re-intervention. In the group treated
without EPD, eight (24%) patients
required prolonged hospital stay, seven
(21%) had re-interventions performed to
restore lower extremity flow and one (3%)
had major unanticipated amputation. This
patient developed embolization of large
calcific material to the tibioperoneal trunk
and proximal anterior tibial artery, which
was not felt to be amenable to
endovascular maneuvers by the treating
physician, resulting in acute ischemia and
leading to below-knee amputation. One
patient died from hemorrhagic
complications of thrombolytic therapy
used to treat an embolic event. The
patient was an 84 years-old female with
multiple co-morbidities, morbid obesity,
end-stage renal disease on peritoneal
Popliteal artery aneurysm (PAA) is the
most frequent localization of peripheral
arterial aneurysm. Surgical repair is the
most chosen treatment which as a
postoperative early complication rate of
about 16%.
In this scenario the advantages linked to
a mini-invasive approach have led to a
significant increase in the number of
endovascular popliteal artery aneurysm
repair (EVPAR).
EVPAR Vs Open Repair
There is only one prospective randomized
trial comparing the EVPAR and OR of
asymptomatic PAAs, in which the authors
enrolled 15 cases in each arm of
treatment, with a mean follow-up period
of 46 months. EVPAR was performed
using the Hemobahn/Viabahn endograft
30
dialysis and chronic atrial fibrillation, who
developed puncture-related hemorrhage
and multisystem organ failure during
thrombolytic therapy. The patient expired
after care was withdrawn per advanced
directives and family request.
Late outcomes
Mean follow-up was 14 months for the
EPD group (range 0-43 months) and 21
months for patients treated without EPD
(range 0-114 months). Late outcomes
were analyzed separately in patients with
TASC A/B and TASC C/D lesions. Primary
patency in 2 years was 70% for TASC
A/B lesions, with no difference among
patients treated with (68%) or without
EPD (70%; P=0.4). Freedom from reintervention was also similar after two
years, (68% for the EPD vs 72% for the
non-EPD group; P=0.3). Primary patency
at 2 years for TASC C/D lesions was
57%, and was significantly lower than
patients with TASC A/B lesions (P<.01).
There were no differences in primary
patency rates at one year in patients
treated with (81%) or without EPD (68%;
P=0.5). Freedom from re-intervention was
also similar after 18 months (83% for the
EPD vs 67% for the non-EPD group;
P=0.4). Comparing patients who had
embolic events to those who did not,
there were no differences in primary
and OR with bypass (GSV) and
endoaneurysmorraphy performed through
a medial approach. Results revealed no
differences between the two cohorts of
patients.
A meta-analysis of studies comparing
EVPAR and OR was published in 2008.
Only 3 studies were included, comprising
141 PAAs, of which 26 were treated
endovascularly. In the OR group a PTFE
graft was used in 21% of the cases. No
significant differences were detected
between the two treatments in the longterm.
Finally a recent review (13 June 2014)
performed by the Cochrane Collaboration
conclude that there are not enough data
to determine the effectiveness of EVPAR
versus OR; a large multicenter
randomized control trial is ongoing and
may provide more information in the
future.
patency and freedom from re-intervention
after one year for TASC A/B (86% vs
78% and 86% vs 80%) or TASC C/D
lesions (67% vs 70% and 73% vs 76%),
respectively (P=0.4).
In summary, in this single-center,
retrospective, non-randomized study,
clinically significant embolic events were
uncommon after endovascular
femoropopliteal interventions performed
with or without EPDs. Embolic events
were associated with recanalization of
chronic total occlusions. Although
patients treated with EPDs had more
advanced lesions, rates of embolization
were lower in this group, albeit this did
not reach statistical significance.
Importantly, none of the patients who
had emboli with EPD developed clinical
sequel or required re-intervention,
whereas one in four patients who
developed embolization without EPD
required escalating level of care. At the
present time, these devices cannot be
recommended for routine use, but should
be considered in patients with occlusions
and in those undergoing atherectomy,
based on results of this study and other
reports. Further analysis with a larger
subset of patients, in a prospective, multicenter randomized setting is desirable to
better understand the role of EPDs in
lower extremity endovascular
revascularizations.
Conclusions
Although further confirmatory studies are
needed, EVPAR has been found to
provide successful aneurysm exclusion
with good long-term patency rate,
excellent limb salvage and survival. A
close surveillance, particularly during the
first post-operative year is mandatory. In
the long-run after EVPAR there is a
significant aneurysmal sac shrinkage
which may play a key role in maintaining
good long-term results. An appropriate
pre-operative planning, patient’s selection,
the use of proper endograft and an
accurate intraoperative performance are
essential steps, to obtain these results.
volver al sumario
nitroglycerin in two patients, angioplasty
and stenting at the location of the
embolization in two patients, and retrieval
of the embolic material using an EPD or
over-the-wire embolectomy in one patient
each. Of the patients who underwent
immediate treatment, 12 had complete
resolution, six had improvement and
seven had no change. Among the 13
patients with persistent emboli, seven
were started in continuous catheterdirected thrombolysis using t-PA. A total
of 11 re-interventions for thrombolytic
recheck or catheter-exchange were
required among these seven patients. At
the time of the last thrombolytic recheck,
five had complete resolution, one had
improvement, and one had no change.
Eight patients (23%) with emboli
underwent no additional treatment,
including seven patients who had small
emboli, which was not considered to be
clinically significant and was associated
with refilling via other collateral branches.
Of the 35 patients who had emboli,
complete resolution was noted in 18
(51%), partial resolution in seven (20%)
and no resolution in three (9%). None of
the seven patients who had small emboli
left untreated developed clinical sequela.
Macroscopic debris was noted in in 59
(68%) filter baskets, 39 of which were
described as moderate or severe amount
of debris (45%).
11
IX
Enrique Puras
A medida que nuestra comprensión de
las complejas bases moleculares y
genéticas de la enfermedad
aterotrombótica se expande , la medicina
moderna se mueve hacia un tratamiento
más individualizado del paciente con
Enfermedad Arterial Periférica (EAP). Las
aparición de nuevos medicamentos
puede ayudarnos a tratar todo el espectro
de las distintas etapas aterotrombóticas
de la aterosclerosis , sin dejar de atender
como objetivos de tratamiento a los
factores de riesgo cardiovasculares de
los pacientes.
pacientes de EAP requieren tratamiento
local, principalmente angioplastia
transluminal percutánea (PTA) ± stent,
endarterectomía, y/o cirugía de bypass
dependiendo de los síntomas, la
anatomía, morfología de la lesión, y la
comorbilidad. La terapia endovascular
(TEV) se indica cada vez más como el
primer paso debido a la reducción de la
morbilidad y la mortalidad en
comparación con la cirugía, que sigue
siendo la elección en el caso de fallo o
para las lesiones no adecuados para TEV.
Por otra parte, los avances tecnológicos
con los dispositivos y stents, ahora
permiten el tratamiento de segmentos
largos, contribuyendo al uso generalizado
de TEV en la EAP. Aunque los resultados
iniciales TEV son buenos, con una baja
incidencia de fallos agudos, la incidencia
de reestenosis oscila entre ~ 10% y el
50% después de 1 año, dando lugar a
frecuentes reintervenciones.
Aunque las técnicas intervencionistas
para el tratamiento endovascular de la
EAP han avanzado, hay una necesidad
médica insatisfecha de avances paralelos
en el capítulo farmacológico. En los
últimos años nos hemos visto obligados
a adaptar y aplicar los resultados de los
estudios realizados en Cardiología, a los
pacientes tratados por métodos de TEV,
por isquemia crítica de MMII. A día de
hoy no existen consensos médicos
universalmente aceptados para el manejo
de pacientes sometidos a tratamiento de
lesiones TASK A-D en los sectores iliacos,
femorales o poplíteos distales.
Terapia Antiagregante
Las guías terapéuticas actuales dan alta
recomendación al tratamiento con
antiagregantes plaquetarios porque
reducen el riesgo de infarto de miocardio,
ictus o muerte por causa vascular en
pacientes con EAP (ACCF/AHA
Guidelines 2011, ESC 2011),
recomendando el tratamiento con
aspirina (AAS) en monoterapia en dosis
diaria de 75-325 mg o de clopidogrel 75
mg al día como tratamiento antiagregante
seguro y eficaz para los pacientes con
EAP.
El ensayo CAPRIE, (clopidogrel en
comparación con aspirina en pacientes
con riesgo de episodios isquémicos),
demostró un beneficio significativo de la
terapia con clopidogrel con respecto a
la terapia con AAS en pacientes con IM
reciente, ictus o EAP sintomática durante
los 36 meses de duración del ensayo
(CAPRIE Steering Committee 1996).
Lamentablemente, en las guías de EAP,
sigue sin especificarse la duración del
tratamiento con clopidogrel asociado con
aspirina, a diferencia de lo aceptado en
el Sindrome Coronario Agudo (SCA) y
los tratamientos con stents simples o
farmacoactivos a este nivel.
En el estudio CAMPER, se hizo un intento
para evaluar la efectividad de la terapia
antiplaquetaria dual (TAPD) con
clopidogrel y aspirina versus aspirina sola,
en pacientes con EAP sometidos a TEV.
Por desgracia, este ensayo fue
interrumpido prematuramente debido a
la baja inclusión de pacientes. En el
estudio Mirror, (el primer ensayo
publicado sobre este tema, 80 pacientes
que se sometieron a TEV en el segmento
femoropoplíteo fueron asignados al azar
a la aspirina más clopidogrel o aspirina
solamente. Los resultados están a favor
de TAPD después de 6 meses de
tratamiento.
anticoagulación, preservando la
hemostasia y sin inducir un riesgo de
hemorragia exceso, podría ser la
estrategia óptima para la prevención de
eventos isquémicos.
Koppensteiner et al realizaron un estudio
en 275 pacientes sometidos a PTA
femoro poplítea y compararon 3 meses
de heparina de bajo peso molecular
adyuvante (HBPM a dosis profiláctica)
más aspirina a largo plazo con aspirina
a largo plazo. La adición de HBPM no
redujo la incidencia global de la reestenosis, aunque para los pacientes
con PAD más grave, la combinación de
aspirina y HBPM parecía ser beneficioso.
No existe una recomendación firme
acerca de la dosis a utilizar de heparina
en los procedimientos endovasculares.
Las intervenciones de alto riesgo (sector
infrapopliteo) pueden beneficiarse de
administrar dosis de 75 a 100 U/Kg,
mientras que situaciones menos
complejas como una angioplastia iliaca
sólo requieren dosis entre 25-50U/Kg.
Las HBPM aunque presentan perfiles de
seguridad y eficacia altos no han
conseguido introducirse en esta
indicación terapéutica por carecer de un
método sencillo de control de
anticoagulación.
Al contrario que la inhibición indirecta de
la trombina generada por la heparina los
inhibidores directos son más específicos
contra la trombina soluble o la ligada a
trombo. La bivaliridina, ha sido más
extensamente estudiada en
procedimientos cardiológicos mostrando
en muchos estudios una reducción muy
significativa del los end points de muerte,
infarto o hemorragia mayor. El estudio
Approve, demostró un alto nivel de
eficacia y seguridad para la bivalirudina
cuando se aplico como único
anticoagulante en el tratamiento
endovascular de pacientes con isquemia
de MMII. Su aplicación en práctica clínica
no ha tenido mucho éxito a pesar de
este buen perfil ello está muy
probablemente ligado a su elevado coste
económico.
Resistencia antiplaquetaria
Terapia Anticoagulante
La TEV inevitablemente daña el endotelio
y expone el subendotelio a la circulación
sanguínea y a la activación de plaquetas
y factores de coagulación. Por lo tanto,
una combinación de inhibición plaquetaria
y un modesto nivel estable de
31
Hay sobradas evidencias de que no todos
los pacientes reciben el tratamiento
antiplaquetario adecuado, bien por el
fenómeno de la “resistencia” o por una
respuesta variable” al fármaco o por un
aumento en el riesgo de sangrado.
Así, en los últimos tiempos podemos
hablar de una oleada en el desarrollo de
pruebas de laboratorio para identificar a
los individuos que responden mal. La
respuesta antiplaquetaria pobre, o la alta
reactividad de plaqueta sobre tratamiento,
se han asociado con peores resultados
isquémicos después de tratamientos
coronarios percutáneos. Disponemos
recientemente de varios ensayos con el
uso de equipos de detección del nivel
de la reactividad de plaqueta a “pie de
exploración” pero aún no han mostrado
una ventaja clínica clara.
En el momento actual no existe un
consenso aceptado sobre como manejar
esta situación de “resistencia” al
clopidogrel. Una opción válida puede ser
la de incrementar las dosis tanto de carga
inicial como de dosis de mantenimiento.
Las causas conocidas de esta baja
reactividad al clopidogrel son los
polimorfismos genéticos del CYP2C19
(que confieren cuatro tipos de patrones
de metabolización rápido, extenso,
intermedio o pobre), las interacciones
metabólicas con drogas como el
omeprazol y la presencia de ciertas
comorbilidades como la diabetes mellitus
y la insuficiencia renal crónica.
pacientes que utilizan clopidogrel siguen
teniendo alta reactividad plaquetaria, que
era la razón para el desarrollo de los
antagonistas del receptor P2Y12,
prasugrel y ticagrelor. Todos los ensayos
clínicos realizados subrayan el potencial
de ticagrelor para lograr un efecto
antiplaquetario rápido y sostenido, que
podría ser revertido y podría superar la
falta de respuesta y la variabilidad entre
pacientes tratados con clopidogrel,
respondiendo así a las principales
limitaciones de la terapia con clopidogrel.
Nuevas Drogas
El Edoxabán es inhibidor directo y
reversible del factor Xa con un perfil
farmacocinético predecible. Actualmente
se están incluyendo pacientes en el
estudio ePAD (ClinicalTrials.gov
identificador NCT01802775), que es un
ensayo aleatorio, en pacientes con EAP
que tiene como objetivo evaluar la
seguridad y eficacia potencial de añadir
edoxabán a la aspirina después de la
angioplastia femoropoplítea ± stent
comparado con la práctica actual de
tratamiento con clopidogrel y aspirina.
Los pacientes deben ser asignados al
azar dentro de las 4 horas después de
volver al sumario
Que hay de nuevo en el
tratamiento adyuvante
en revascularización
endovascular de las
extremidades
inferiores.
11
IX
un procedimiento de TEV realizado con
éxito y con hemostasia establecida.
El Vorapaxar es un antagonista, por vía
oral, del receptor de proteasa activado
(PAR), que inhibe la activación de las
plaquetas inducida por trombina y es
eficaz en la prevención secundaria de la
aterotrombosis. En el estudio (TRA 2 °
P) -TIMI 50, el Vorapaxar se comparó
con placebo en 26.449 pacientes
estables con aterosclerosis establecida
como infarto de miocardio previo,
accidente cerebrovascular isquémico o
enfermedad arterial periférica (PAD) para
lograr reducir significativamente la
aparición de muerte, infarto de miocardio
(IM), o accidente cerebrovascular. La
mejora y eficacia en los resultados
trombóticos con vorapaxar se acompaño
por un aumento en la incidencia de
hemorragia moderada o grave y
hemorragia intracraneal; este última se
detectó principalmente en pacientes con
historia previa de enfermedad
cerebrovascular tipo ACVA.
En conclusión, la escasez de
conocimientos para mejorar la
permeabilidad y los resultados clínicos
mediante una terapia antitrombótica
segura y efectiva después de TEV merece
más estudio.
Una revisión de los últimos ensayos de
farmacoterapia en el tratamiento
adyuvante en revascularización
endovascular de las extremidades
inferiores revela una escasez de datos
que apoyen cualquier régimen
antitrombótico para prevenir la
reestenosis u oclusión. Esta falta de
evidencia científica ha obligado a pautas
de práctica clínica en el manejo de
pacientes con EAP sometidos a TEV que
se trasladan del conocimiento de TEV
en el árbol coronario.
Operative
thrombectomy for
acute thrombosis of
lower extremity bypass
grafts
allow exposure for operative repair of an
outflow problem once a thrombectomy
is performed. This approach, however,
usually requires general anesthesia. In
addition, operating in a scarred field can
make for a more difficult dissection, with
greater blood loss and a higher risk of
post operative infection1.
of the foot. A clear sterile isolation bag
can be placed on the foot to aid in
evaluation of perfusion of the foot after
revascularization. Cases should be
performed in a fluoroscopy capable room
with digital subtraction angiography
available, ideally in a hybrid OR suite.
and over the wire) as well as a #5 Fogarty
Graft Thrombectomy Catheter (Edwards
Lifesciences, Irving, CA) (Figure 2a, b)
should be available. For tibial arteries, a
smaller #2 Fogarty balloon thrombectomy
catheter should also be available.
Frank J. Veith, MD
Introduction
Lower extremity revascularization for
arterial occlusive disease is performed
for symptoms ranging from claudication
to limb threatening ischemia, ulceration
and gangrene. While autologous vein is
usually considered the best conduit when
open surgical bypass is required, a
prosthetic graft such as PTFE
(Polytetrafluroethylene) may be an
acceptable option when autologus vein
is not available. Generally, when used
for lower extremity revascularization, PTFE
has inferior patency rates compared to
autologus vein, especially when used
below the knee. When a PTFE graft
occludes, a patients symptoms can vary
from being completely asymptomatic to
having acute limb threatening ischemia.
Depending on the severity of symptoms,
treatment options include observation,
percutaneous thrombectomy/ lysis, open
operative thrombectomy with or without
graft revision, and reconstruction of a
new bypass.
Most causes for graft failure have been
shown to involve the distal anastamosis
or progressive distal disease1-2.
Therefore, when operative intervention is
required to open an occluded graft, older
teachings involved dissecting out the
distal anastamosis primarily. Open
access to the distal anastamosis would
This chapter describes a technique for
open thrombectomy of acutely
thrombosed lower extremity PTFE bypass
grafts that can be performed under local
anesthesia. In addition, the technique
can avoid a difficult dissection in a scarred
field while allowing for the treatment of
inflow or outflow lesions using
interventional techniques.
Preoperative Planning
If time permits, a good preoperative CTA
or MRA can be very useful in identifying
inflow lesions, outflow lesions and
progressive atherosclerotic disease that
is present. It can also help identify the
location and course of the graft for
planning a surgical access site. Prior
operative notes should be reviewed to
ascertain the location of the proximal and
distal anastamoses, the course of the
graft, and any difficulties encountered
during the original procedure. If the graft
thrombosis is less than 2 weeks old and
time permits, percutaneous lysis may be
considered 3. Discussions should be
undertaken with the patient and the family
about the possible operative risks
(including possible limb loss), possible
need for fasciotomy if ischemia has been
prolonged, as well as the possible need
for a new revascularization if the
thrombectomy does not work.
Technique
Usually, both groins and the ipsilateral
leg are fully prepped including the majority
32
The majority of cases using this technique
can be performed under local anesthesia
with sedation. Prior operative notes and
imaging should be reviewed to choose
a graft access site. The chosen incision
site should be made over an easily
accessible virginal area of the graft. A
subcutaneous graft is usually easily
located by palpation. Otherwise, the
upper thigh is a convenient access site
if the graft is tunneled anatomically under
the sartorius muscle. This exposure
allows for easy graft access and can
allow for muscle coverage of the exposed
portion of graft. If the graft is difficult to
locate, intraoperative ultrasound can be
very useful. Ring enforced PTFE grafts
are usually easy to identify under
ultrasound guidance.
Local anesthesia is given and a length of
about 5-10 cm of graft is exposed.
Double looped umbilical tape or vessel
loops are placed at either end for
hemostasis during the procedure (Figure
1). Rubber lined Fogarty hydrogrip
clamps should also be available for graft
hemostasis. The patient is then
systemically anticoagulated, usually to
an activated clotting time of > 250
seconds. A transverse graftotomy then
can be made about 1/3 the circumference
of the graft. Rings are not purposefully
removed to keep the outer layer on the
PTFE. Older grafts can become very
fragile and without this outer layer, closure
of the graftotomy can be quite challenging
as the graft can tear. For femoral and
popliteal grafts, #3 and #4 Fogarty balloon
thrombectomy catheters (both regular
The authors prefer to address the distal
anastamosis first. Fogarty balloon
thrombectomy catheters with 1/3
strength contrast for the balloon are
passed distally under fluoroscopic
guidance (previously described) 4-5 to
retrieve the thrombus in a standard
fashion. If the Fogarty balloon
thrombectomy catheter cannot be
passed distal to the anastamosis, under
fluoroscopic guidance, an .014” or .018”
wire with a hydrophilic tip can usually be
passed with the aid of an angled catheter.
An over the wire Fogarty balloon
thrombectomy catheter can then be
passed and thrombectomy can proceed
under fluoroscopic guidance. With 1/3
strength contrast in the balloon, one can
usually see narrowed areas by
deformation of the balloon during
passage4-5. If there is back bleeding,
an 11 Fr sheath can be used with the
double looped umbilical tape for
hemostasis (Figure 3). The wires and
Fogarty catheters can be passed through
the sheath and the sheath can be
removed as the balloon catheter is
withdrawn. A Fogarty hydrogrip clamp
and finger compression can maintain
hemostasis until the sheath can be
replaced. Once thrombectomy is
performed, an angiogram can be
performed. This should be done via a
gentle injection of contrast near the
anastamosis with an inserted catheter
so as to not force potential emboli distally.
Commonly, there is a plug (platelets/fibrin)
at the distal anastomosis that can be
difficult to remove with a regular Fogarty
balloon thrombectomy catheter. To
remove this distal plug, a Fogarty Graft
volver al sumario
11
IX
Attention is next focused on the proximal
end. A # 4 Fogarty balloon
thrombectomy catheter is then passed
proximally, and a thrombectomy of the
proximal end is performed under
fluoroscopic guidance. Hemostasis is
What’s New on CCSVI?
Michael D. Dake
Recent data from the literature suggest
a greater role of chronic venous
insufficiency in the pathogenesis of a
variety of brain disorders. The goal of this
Jueves 25 Junio
Thursday, June 25th
Sesión 11
Revascularización por
debajo de la rodilla.
Deben ser tratados
estos pacientes del
mismo modo
Jose Ignacio Blanes
obtained with a Fogarty hydrogrip
clamp/finger compression and then the
11 Fr sheath is placed and the double
looped umbilical tape is tightened. The
Fogarty balloon catheter can be passed
through the sheath for repeat
thrombectomy. An angiogram can be
performed by passing an angled catheter
proximal to the anastamosis, injecting
contrast via the catheter while aspirating
via the 11 Fr sheath. This can avoid
flushing of debris into the native
circulation. If needed, the Fogarty Graft
Thrombectomy Catheter can then be
carefully passed proximally through the
11Fr. sheath and used as previously
described. Any inflow lesions can then
be treated interventionally with angioplasty
and or stent placement via the 11 Fr
sheath as needed. Once the treating
physician is content with the inflow and
outflow, the graft is filled with heparinized
saline and the transverse graftotomy can
be primarily closed. Perfusion of the
foot can be assessed by palpating for a
pulse or by doppler examination, and by
the appearance of the foot through the
clear sterile plastic bag. If there is any
talk is to review the contributions made
in 2014 to our enhanced understanding
of the safety and efficacy of the
endovascular or open surgical treatment
of chronic venous obstruction in patients
with a variety of pathologies including
multiple sclerosis, transient global
amnesia, Alzheimer’s disease, Parkinson’s
disease, postural orthostatic tachycardia
syndrome, transient monocular blindness,
question of adequate perfusion, an
angiogram can be performed via a
micropuncture sheath placed into the
graft. Unless it is necessary for
hemostasis, the heparinization is not
usually reversed, especially for tibial
bypasses. The decision to keep the
patient heparinized should individualized,
but is generally preferred for tibial
bypasses.
In the event that distal lytic therapy is
needed, a sheath can be inserted into
the exposed graft below the graftotomy
via a separate skin puncture and a lytic
catheter and/or wire can be placed.
The wound can then be closed and lytic
therapy can be given with a planned trip
back to the endovascular suite for repeat
imaging and repair of the puncture site.
Conclusion
The aforementioned technique can be a
useful technique to open acutely
thrombosed PTFE bypass grafts using a
combination of open and interventional
techniques. It can be performed under
local anesthesia in the majority of cases,
headaches, and spontaneous intracranial
hypertension. Open surgical interventions
including, but not limited to operative
venous bypass, transposition, venoplasty,
and vein interposition have been reported.
Endovascular procedures detailed in the
medical literature include balloon
angioplasty, cutting or scoring balloon
angioplasty, self-expanding and balloon
expandable stent placement, and stent-
and can avoid the need for operating in
a scarred field. This technique adds to
the armamentarium for the treatment of
thrombosed bypass grafts in the ischemic
limb.
1. Ascer E, Collier P, Gupta SK, Veith FJ. Reoperation
for polytetrafluoroethylene bypass failure: the
importance of distal outflow site and operative
technique in determining outcome. J Vasc Surg
1987;5:298-310.
2. Veith FJ, Gupta S, Daly V. Management of early
and late thrombosis of expanded
polytetrafluoroethylene (PTFE) femoropopliteal
bypass grafts: favorable prognosis with appropriate
reoperation. Surgery 1980;87:581-7.
3. Ouriel K, Veith FJ, Sasahara AA. Thrombolysis
or peripheral arterial surgery: phase I results. TOPAS
Investigators. J Vasc Surg 1996;23:64-73;
discussion 4-5.
4. Lipsitz EC, Veith FJ. Fluoroscopically assisted
thromboembolectomy: should it be routine? Semin
Vasc Surg 2001;14:100-6.
5. Parsons RE, Marin ML, Veith FJ, et al.
Fluoroscopically assisted thromboembolectomy:
an improved method for treating acute arterial
occlusions. Ann Vasc Surg 1996;10:201-10.
grafting. In general, all these therapies
have been used to treat stenosis and/or
occlusions of the jugular and/or azygous
veins associated with increased collateral
venous drainage. The relationship
between anatomic findings and any
symptoms related to the range of
neurological disorders listed above has
not been established and further research
is required. CELA-SITE Sesión 11 / CELA SITE Session 11
REVASCULARIZACIÓN POR DEBAJO DE LA RODILLA: NECESITAMOS SABER MÁS
BTK REVASCULARIZATION: WE NEED TO KNOW MORE
Moderador / Moderator D. Scheinert
Panelistas / Panellists F. Veith, F. Criado
Servicio Angiología y Cirugía Vascular.
Instituto Cardiovascular. Consorcio
Hospital General Universitario . Valencia.
Resumen
Las lesiones arteriales infrapopliteas o
distales son características de la úlceras
isquémicas, pues aparecen en más del
95% de ellas, solas o asociadas en más
del 50% de los casos a lesiones del
sector femoropoplíteo. Pueden
33
presentarse clínicamente como isquemia
crítica clásica, clínica y hemodinámica,
con úlcera o necrosis más obstrucción
arterial y criterios hemodinámicos de
isquemia crítica, o bien como isquemia
crítica clínica exclusivamente, de
tendencia más actual, con necrosis o
úlcera más obstrucción arterial, sin
cumplir los criterios hemodinámicos,
generalmente en pacientes con pie
diabético.
La historia natural de la isquemia crítica,
es a la cronicidad, sobreinfección y
amputación, en pacientes que por otra
parte, presentan otro tipo de
comorbilidad, como diabetes,
insuficiencia cardíaca, deshidratación,
desnutrición y como factor emergente,
insuficiencia renal.
Los pacientes pueden ser tratados de
forma conservadora o mediante
revascularización, sea abierta o
volver al sumario
Thrombectomy Catheter is used. Use of
this catheter is key to the success of the
procedure and can help avoid the need
for exposure of the distal anastamotic
site. This catheter must be passed and
used under fluoroscopic guidance to
avoid severe injury to the native artery
(Figure 4a). The catheter is passed to
the distal aspect of the graft, carefully
deployed in the distal graft and not in the
artery, under fluoroscopic guidance, and
the graft is stripped of the material that
is not removable by a regular Fogarty
(Figure 4b). The catheter can be passed
through the 11 Fr sheath. An angiogram
is then again performed (Figure 5a,b) .
At this point, the outflow lesions can be
treated interventionally as needed with
balloon angioplasty and stent placement
where appropriate. The graft is then filled
with hepranized saline solution and
clamped with a hydrogrip clamp.
11
IX
endovascular, con la que se obtienen
resultados mucho mejores. Además de
las lesiones arteriales, debemos tratar
las lesiones locales (úlceras – necrosis)
así como las comorbilidades del paciente
Aunque la revascularización abierta
mediante bypass ha sido el gold standard
para la revascularización de los pacientes
con lesiones distales, la revascularización
endovascular se está imponiendo al
obtener resultados similares en cuanto
cicatrización de las úlceras y salvamento
de extremidad, con mucha menor
morbimortalidad.
objetivamente probada, y solamente para
registros o estudios añadir los criterios
hemodinámicos. Es más, los criterios de
inclusión en recientes estudios están
intentando estandarizar la definición de
ICC con criterios objetivos, basándose
únicamente en la clásica definición de
Fontaine, sin criterios hemodinámicos,
principalmente porque la mera presencia
de necrosis o úlcera más obstrucción
arterial, sobre todo en pacientes
diabéticos, supone un mal pronóstico,
tanto en cicatrización de la lesión como
en viabilidad de la extremidad (1)
tienen lesiones arteriales infrapoplíteas y
en más de un 90%, lesiones a otros
niveles, tanto iliacas como femorales. En
este grupo de pacientes, solamente el
60% de pacientes son diabéticos, y se
ha demostrado que los diabéticos tienen
mayor predominio de lesiones distales y
los pacientes fumadores, de lesiones
proximales. Además, un gran número de
pacientes presentan comorbilidades
graves, como insuficiencia cardíaca
congestiva (24%), enfermedad coronaria
(64%) o enfermedad renal crónica terminal
(30%) (2).
Desarrollo
Isquemia Crítica y lesiones
arteriales infrapoplíteas
Fig. 3.- Recanalización Tibial
posterior y tibial anterior
Historia Natural de los
pacientes con isquemia Crítica
Fig 1.- Abordaje anterógrado femoral
común
Por tanto, podemos diferenciar dos
grupos de pacientes con lesiones
arteriales infrapopliteas: aquellos con ICC
clínica y hemodinámica, menos
frecuentes y aquellos con ICC clínica,
principalmente úlceras diabéticas
isquémicas, en las que, a pesar de tener
menor grado de isquemia hemodinámica,
presentan otros factores, como la
neuropatía, infección e inmunopatía.
Ambos grupos requieren una
optimización de la presión de perfusión
en los tejidos isquémicos para mejorar
los resultados de cicatrización y
salvamento de extremidad.
La diferencia entre ambos estriba en la
localización y extensión de las lesiones
arteriales.
En el primer grupo, con ICC clínica y
hemodinámica, el 91% de los pacientes
34
La historia natural de los pacientes con
ICC clásica es mala, tanto para el
paciente como para la extremidad. Al
año de su aparición, la mortalidad oscila
según las series entre un 15 y un 35%,
muy superior en pacientes mayores de
Fig. 2.- Obstruccion de tres
troncos infrapoplíteos
En el segundo grupo, con ICC clínica,
no hemodinámica, principalmente
pacientes con úlceras diabéticas
isquémicas, las lesiones son también
predominantemente en el sector
infrapoplíteo, un 92%, con lesiones
multinivel, sobre todo femoral superficial,
de menor gravedad, obstrucciones cortas
o estenosis y en menos del 50% (3).
80 años, y una pérdida de extremidad
entre un 20 y un 40% (4,5). En los
pacientes diabéticos con úlcera, la
presencia de isquemia facilita la aparición
de infección, retrasa la cicatrización y es
factor de peor pronóstico para la
amputación. Entre un 20 y un 30% de
los pacientes con infección moderada o
severa e isquemia sufren una amputación
mayor (6).
Tratamiento
El tratamiento recomendado en los
pacientes con ICC es la revascularización,
Los pacientes sometidos a
volver al sumario
El concepto de Isquemia Crónica Crítica
(ICC) hace referencia a la situación de
isquemia por estenosis/obstrucción
arterial que reduce la presión de perfusión
hasta el punto de alterar de forma grave
la microcirculación y el flujo de nutrientes
a los tejidos, poniendo en riesgo la
extremidad. Inicialmente, en los años 50,
el diagnóstico se basaba en datos
clínicos, grados III y IV de Fontaine. Más
tarde, con la utilización de los métodos
hemodinámicos como la presión en el
tobillo y en el dedo, la necesidad de
demostrar una relación causal entre los
datos clínicos y las lesiones obstructivas
arteriales supuso un problema, por lo
que la clasificación de Rutherford de los
años 80 incluyó criterios hemodinámicos
objetivos. El primer documento de
consenso de ICC, de 1991, incluyó
criterios clínicos (ulcera, necrosis o dolor
en reposo) y criterios hemodinámicos,
presión en tobillo y dedo o presión
transcutánea de oxígeno. Esta definición
reflejaba una isquemia de un nivel tal que
provoca cambios microcirculatorios que
comprometen la integridad tisular con
una alta tasa de amputación y mortalidad,
a fin de poder definir sobre todo aquellos
pacientes que podrían cicatrizar sin
necesidad de revascularización, pues en
esos momentos, la revascularización
conllevaba una alta morbimortalidad y
mediante tratamiento local y sistémico,
podía conseguirse la cicatrización y
mejoría en un alto número de pacientes,
a pesar de la alta tasa de recidivas. Ya
en el TASC recomiendan utilizar criterios
clínicos, ulcera, necrosis o dolor en
reposo, con obstrucción arterial
11
IX
La revascularización de las lesiones
infrapoplíteas se ha realizado mediante
cirugía abierta, by-pass a arterias
maleolares o del pie, como gold standard,
emergiendo en los últimos años la
terapeútica endovascular (TEV). La cirugía
abierta, aunque con mejores resultados
en cuanto a permeabilidad, 72% a 3 años
frente a un 48% de la TEV, tiene una tasa
de salvamento de extremidad similar,
82% a 3 años (7). Además, la
morbimortalidad es superior mediante
cirugía abierta, 5.7 vs 1.3 de mortalidad,
3.4 vs 1.3 de complicaciones sistémicas
y 13.7 vs 2.2% de complicaciones locales
en relación a la TEV (8).
La TEV es preferible realizarla mediante
anestesia local, por abordaje anterógrado
(fig. 1) directo en femoral común. Tras
realizar un estudio angiográfico de todas
las lesiones en dos proyecciones,
debemos realizar un plan de tratamiento.
Para la permeabilidad del procedimiento,
el outflow es muy importante, por lo que
extender la revascularización hasta el
Deb in btk
lesions:
are we sure?
Prof. Thomas Zeller, MD
Clinic Cardiology and Angiology II
Head Physician Department Angiology
Internist, Angiologist, Cardiologist,
Hypertension specialist DHL®
The long-term success of below-theknee (BTK) endovascular procedures has
been improving but remains inadequate
for todays’ clinical requirements.
Restenosis after plain balloon angioplasty
(POBA) ranges from 42% at 12 months
for lesions <3cm to 69% at 3 months for
arco plantar o más allá es esencial. El
mejor resultado es obtener flujo arterial
directo al pie. Preferentemente, debe
revascularizarse la arteria que va
directamente a la lesión. La teoría de los
angiosomas ha ganado mucha
aceptación últimamente, aunque todavía
no está consolidada. En las lesiones
infrapoplíteas, la angoplastia simple con
balón es lo más indicado. Solamente en
casos muy concretos, como fallo de la
angioplastia, o lesiones ostiales en el
origen de los troncos distales, debe
utilizarse un stent. Además, el stent puede
dificultar las reintervenciones. Una arteria
infrapoplítea normal por encima del tobillo
tiene entre 2.5 y 3 mm de diámetro y por
debajo de éste entre 1.5 y 2 mm. Se
deben revascularizar el mayor número
de troncos posibles (fig 2 y 3) (9).
Conclusión
La ICC y la úlcera isquémica diabética
es una patología muy grave y muy
fecuente, donde predominan las lesiones
infrapoplíteas. LA mejor opción opción
terapeútica es la revascularización,
idealmente endovascular, Dada su baja
morbimortalidad, se recomienda tratar a
todos los pacientes como primera línea
mediante TEV.
lesion length of 18.4cm. A meta-analysis
of BTK angioplasty indicated that the 1year patency of POBA was 58.1+4.6%
and the limb salvage rate was 86.0+2.7%.
Despite the number of approved DEB
catheters in the EU, there is a paucity of
well-controlled data on the use of this
tool in the BTK vasculature. Early signals
suggested that restenosis is less common
than after POBA and tends to be more
focal and with fewer reocclusions if
treatment failure occurs. Schmidt et al.
treated long lesions (mean 17.3cm) and
3-month angiographic restenosis was
27.4%. Most of the restenoses were
focal. In the DEBATE BTK trial, a
randomized controlled trial of DEB vs.
POBA, both restenosis (27% vs. 74%,
p=0.001), and TLR (18% vs. 43%,
p=0.003) were reduced at 1 year.
Complete wound healing occurred in
86% vs. 67% (p=0.01) and there were
no significant differences in terms of major
limb amputation.
35
Bibliografía
1.- Becker F, Robert-Ebadi H, Ricco JB, Setacci
C, Cao P, de Donato G et al. Critical Leg
Ischemia: Definitions, EPidemiology, clinical
presentation and prognosis. Eur J Vasc Endovasc
Surg 2011; 42 (S2), S4-S12
2.- Rueda CA, Nehler MR, Perry DJ, McLafferty
RB, Casserly IP, Hiatt WR et al. Patterns of artery
disease in 450 patients undergoing
revascularization for critical leg ischemia:
Implications for clinical trial design. J VAsc Surg
2008; 47: 995-1000
3.- Graziani L, SIlvestro A, Bertone V, Manara E,
Andreini R, Sigala A, et al. Vascular onvolvement
in diabetic subjects with ischemic foot ulcer: A
new morphologic categorization of disease
severity. Eur J Vasc Endovasc Surg 2007; 33:
453-460
4.- Belch J, Hiatt WR, Baumgartner I, TAMARIS
investigators. Effect of fibroblast growth factor
NV1FGF on amputation and death: a randomised
placebo controlled trial of gene therapy in critical
limb ischaemia. Lancet 2011; 377:1929-1937
However, the IN.PACT DEEP multicenter
randomized controlled trial that tested
the same device could not confirm the
initial single center study findings
regarding either efficacy or clinical safety.
As a consequence the IN.PACT
Amphirion DEB product was withdrawn
from the market. The IN.PACT DEEP trial
compared the performance of the
IN.PACT Amphirion DEB with POBA in a
2 to 1 randomization protocol in 358
patients with pre-specified primary
endpoints for efficacy (TLR and LLL) and
safety (all-cause death, major
amputations or TLR). All patients were
analyzed at 1-year follow-up for their
clinical endpoints whereas a subcohort
of patients with lesions ≤ 10cm in length
underwent an angiographic control for
assessment of the technical endpoints.
Primary efficacy results of DEB vs. POBA
were CD-TLR of 9.2% vs.13.1%
(P?=?0.291) and LLL of 0.61±0.78 vs.
0.62±0.78mm (P?=?0.950). Primary
5.- Brossi P, Dick F, Do Do Dai, Schmidli J,
Baumgartner I, Diehm N. Revascularization for
chronic lower limb ischemia in octogenarians is
worthwile. J VAsc Surg 2007; 46: 1198-207.
6.- Lavery LA, Armstrong DG, Murdoch DP,
Peters EJG, Lipsky BA. Valodation of the
Infectious Disease Society of America`s Diabetic
Foot Infection Classification System. CID 2007;
44: 562-565.
7.- Romiti M, Albers M, Cardoso F, Durazzo AES,
Braganza CA, De Luccia N. Meta-analysis of
infrapopliteal angioplasty for chronic critical limb
ischemia. J Vasc Surg 2008; 47: 975-81.
8.- Doslouglu HH, Lall P, Cherr GS, Harris LM,
Dryjski ML. Superior limb salvage with
ndovascular therapy in octogenarians with critical
leg ischemia. J Vasc Surg 2009; 50: 305-16.
9.- Reekers JA, Lammer J. DIabetic foot and
PAD: the endovascular approach. Diabetes
Metab Res Rev 2012; 28 (suppl): 36-39).
composite safety endpoint was 17.7%
vs. 15.8% (P?=?0.021) and met the noninferiority hypothesis. A safety signal
driven by major amputations through 1
year was observed in the DCB vs. POBA
arm (8.8% vs. 3.6%; P = 0.080).
There is currently widespread opinion to
suggest that DEB is likely to substantially
improve the success of endovascular
procedures for BTK disease. However,
the recent results of the IN.PACT DEEP
study that alarmed in terms of safety and
lack of efficacy, suggest that an
abundance of caution is reasonable.
There exists vital need for further
investigation of DEB in a variety of BTK
lesion subsets and clinical conditions.
volver al sumario
revascularización por ICC clásica, tienen
una tasa de salvamento de la extremidad
del 85-90% frente a un 60-70% en
aquellos no revascularizados (5). En
pacientes diabéticos, el salvamento de
extremidad es del 98% a 3 años mediante
la revascularización (3).
11
IX
Jueves 25 Junio
Thursday, June 25th
SESIÓN DE ALTO SECRETO: CONSEJOS Y TRUCOS...
TOP SECRET SESSION: TIPS AND TRICKS..
Moderador / Moderator C. Setacci
Panelistas / Panellists L. Reparaz, J. Maeso
Sesión 13
My tips and tricks in
bending areas
Prof. Thomas Zeller, MD
Clinic Cardiology and Angiology II
Head Physician Department Angiology
Internist, Angiologist, Cardiologist,
Hypertension specialist DHL®
Common femoral artery (CFA): Open
surgical revascularization is considered
as the goldstandard for the treatment of
CFA lesions – thrombendartherectomy
for atheromateous lesions and
embolectomy for embolic lesions.
However, controlled data about this
strategy is sparse and there exist relevant
limitations and risks of an open surgical
approach such as scarred tissue in case
of redo-procedures and the increasing
prevalence of obesity resulting in an
increased morbidity up to 5% including
major hematoma, wound infection and
fistulas. Opposite to the common believe,
the CFA region is not exposed to
extensive external forces, this is more
likely the proximal SFA and distal external
iliac artery. Thus, the endovascular
approach including stent placement has
become an attractive alternative in
patients being unfit for surgery. Single
centre data suggest comparable
outcomes of POBA and stent implantation
with regard to acute treatment success,
patency rate and freedom from TLR as
compared to the interventional treatment
of the pelvic arteries (residual stenosis
<30% in approx.. 93%, 1-year restenosis
rates 20-32% and freedom from TLR 7687%). Directional atherectomy (DA) with
or without DEB may become the
treatment of choice even in calcified
lesions. Initial results for DA are promising
with 1-year restenosis rate of 12% and
freedom from TLR of 95%. A randomized
controlled trial comparing the
endovascular approach and surgical
revascularization (PESTO-CFA) is on the
way.
Popliteal artery (PA): Similar to the CFA
the PA is considered at least as a no
stent zone due to extensive external
forces applied to the artery. A recent RCT
comparing direct stenting using a slotted
tube nitinol stent compared to POBA with
provisional stent placement (ETAP study)
suggested similar technical outcomes of
both approaches up to 2 years post
procedure favoring the provisional
stenting approach in daily practice
(primary patency about 60%). However,
recent improvements in stent technology
including interwoven nitinol mesh designs
(Supera stent) and dual component stents
combining nitinol rings with ePTFE
interconnections (Tigris stent) significantly
improved the stent performance in terms
of primary 1- and 2-year patency rates
of 87% and 78%. Nevertheless, a
stentless approach in this particular vessel
location is very attractive offered by DA
and DEB or the combination of both.
Early DEB (THUNDER study) and DA
(DEFINITIVE LE) data suggest similar
outcomes for the treatment of the PA as
compared to the SFA with primary 1-year
patency rates in the range of 80%, for
the combination therapy (DEFINITIVE AR)
the patency rate was almost 90%.
In summary, stent placement using
dedicated stents – BMS & DES - in
popliteal position seems to be safe. In
order to avoid stent placement
atherectomy, DEB or the combination of
both is an attractive approach which
needs further investigation.
Abstract
Ruiz Chiriboga, Diego
Fernando; Ayala Strub, María
Azucena; Manzano Grossi,
María Soledad; de la Torres
Scherak, Octavio Daniel;
García Boyano; Fernando;
Reparaz Asensio, Luis Manuel
Palabras clave: arteria femoral,
reintervención, complicaciones
Introduccion:
Las lesiones arteriales puede ser
secundarias a múltiples factores
como la radiación, el uso de
drogas, las cirugías previas y la
infección. Las complicaciones
asociadas se relacionan con
sangrado, infección, isquemia,
embolización, pérdida de la
extremidad.
Objetivo:
Presentamos el caso de una
mujer de 43 años, con
antecedentes de cáncer de recto
tratado con radioterapia hace 7
años, y múltiples
reintervenciones en el miembro
inferior derecho (MID) por
episodios de isquemia aguda
manejadas mediante
trombectomía transfemoral (2),
infundibulización de la arteria
femoral profunda(FP), stent
iliaco, y un bypass femoropoplíteo con PTFE.
Materiales y métodos
El paciente acude la urgencia
por sangrado inguinal derecho,
se realiza un bypass venoso
bifurcado desde la transición
iliofemoral a la FP y superficial
(FS), con recanalización
endovascular del eje
femoropopliteo y explante de la
prótesis recuperando pulsos
distales, tras 1 mes de ingreso,
con curas y seguimiento de las
heridas es dada de alta.
Resultados
A los 8 meses acude por signos
de isquemia aguda por oclusión
de la rama FS y estenosis en la
FP. Se decide programar para
recanalización retrógrada de la
36
rama venosa a la FP usando un
stent tipo Viabahn de bajo perfil,
la paciente preciso doble
antiagregación y anticoagulación
(ACO) por 4 meses, actualmente
esta con ACO y antiagregación
simple por sangrado digestivo.
A los 7 meses de la intervención
en AngioTC no se evidencian
signos de reestenosis ni
complicaciones clínicas
asociadas.
medida extrema dada la
localización de la lesión.
Ciertamente, se necesita un
seguimiento minucioso con el
fin de ver los resultados a largo
plazo y determinar la
permeabilidad de dicha
reparación así como futuras
complicaciones.
Discusión y
conclusiones
El caso presentado fue un reto
para el equipo quirúrgico dadas
las múltiples complicaciones y
comorbilidad que presento la
paciente.
El uso de un stent en la FP
atravesando el ligamento inguinal
es una técnica de recurso y una
volver al sumario
Medidas extremas
sobre la arteria
femoral tras
múltiples
complicaciones y
reintervenciones
11
IX
Abstract
Rubio, Vanessa;
Rubio, Gustavo
CETEN Guadalajara,
Guadalajara (Mexico)
Endovascular
revascularization of
iliac arteries in
patients with
critical limb
ischemia due to
multilevel occlusive
disease
Avetisyan, Artur
Medical Center after Vladimir
Avagyan, department of vascular
surgery, Yerevan (Armenia)
Endovascular
treatment in
chronic
femoroiliocaval
obstruction: a case
report
Julio Cesar, Ellacuriaga San
Martin; Thomas, Hölzenbein;
Ara, Ugurluoglu
Department of Vascular and
Endovascular Surgery PMU,
Salzburg (Austria)
Introduction:
Percutaneous endovenous stent
placement is an alternative to
surgery in the treatment of
chronic venous obstruction (1).
However, this procedure is
infrequently reported (2). We
Problema
En un paciente masculino en la
sexta década de la vida
destacándose en sus factores
de riesgo diabetes mellitus tipo
2 de mas de 20 años de
evolución, hipertensión arterial
e hipertrigliceridemia que acude
por presentar úlcera isquémica
en el talón del pie derecho de 4
meses de evolución, con dolor
intenso y sin mejoría con los
cuidados locales regulares,
catalogándose en el angiosoma
de la arteria peronea; destaca
que la paciente presenta pulsos
palpables en arteria tibial
posterior y arteria tibial anterior.
Dificultad
Revascularizar los segmentos
arteriales dependientes de la
arteria peronea, sin embargo
con los abordajes
convencionales anterógrado y
retrógrado no se logra
revascularizar el angiosoma
referido, preciso para eliminar la
úlcera necrótica existente.
Critical limb ischemia frequently
occurs on a background of
significant comorbidities and
associated with poor prognosis,
wich requires urgent
management. Disease severity
and patient comorbidities
influence the choice of
management, wich on the one
hand must be preferably
minimally invasive and lest timeconsuming and, on the other
hand efficient enough for limb
salvage.
The study was a retrospective
single-center study that included
18 male patients with critical limb
ischemia and multilevel
atherosclerotic disease involving
suprainguinal and infrainguinal
arteries , treated from January
2012 to july 2014 (median followup of 8 months).
Stents for revascularization of
iliac arteries were used in 17
patients. In 1 case PTA of
external iliac artery was
performed without stenting. In
8 cases endovascular iliac repair
was combined with a surgical
common femoral
endarterectomy.
Technical success was obtained
in 100% of cases. Hemodynamic
report a patient with Factor V
Leiden mutation who underwent
venous stent placement due to
chronic femoroiliocaval
obstruction.
vesical bleeding. The cause of
this bleeding was due to renal
lithiasis as well as
schistosomiasis; both conditions
probably decompensated by the
initial treatment. Genetic testing
showed Factor V Leiden
mutation and prothrombin gene
mutation G20210A.
Venography showed right-to-left
collateralization forming a
spontaneous Palma shunt as
well as a partially recanalized
right femoroiliocaval thrombosis
(Fig.1-A).
We performed an angioplasty
and stenting of the right common
femoral vein, external iliac vein,
common iliac vein and inferior
vena cava (IVC). 4x40 mm and
6x60 mm drug-eluting balloons
were used to pre-dilate the pelvic
veins and three 11x40 mm
stents were placed. A 70%
Objectives:
To describe the clinical
presentation, imaging and
outcome in a patient with chronic
femoroiliocaval obstruction and
underlying coagulation
impairment.
Methods:
A 41-year-old male patient was
admitted with growing pain and
edema of the right leg. He
presented with two previous
events of deep venous
thrombosis for which he was
placed on rivaroxaban. This
therapy, however, was switched
to phenprocoumon due to
37
Como Evitar
Control estricto de los factores
de riesgo en este tipo de
pacientes y cuidados de higiene
local para evitar lesiones
cutáneas distales complejas
para su curación.
o dirigidas con imagen de las
arterias calcificadas, y
especificamente el
aprovechamiento de las
arteriolas colaterales que
comunican entre si los diferentes
angiosomas y poder llevar así
un flujo arterial directo.
Como Solucionarlo
Mostrando las diferentes
alternativas de solución
endovascular: abordajes
anterógrados , retrógrados;
utilizando técnicas como Road
Mapping, punciones ecoguiadas
and clinical
success/improvement was
achieved in 15 of 17 limbs.
During the follow-up period one
patient died from myocardial
infarction. One diabetic patient
needed bellow-knee amputation
despite a patent common iliac
artery stent. Another major
amputation was performed due
to acute thrombosis of stented
segment. Only one patient
required second
revascularization procedure femoropopliteal bypass.
In conclusion, revascularization
of an inflow (iliac arteries)
obstruction by means of
endovascular techniques with
or without common femoral
artery endarterectomy can be
sufficient for limb salvage in most
patients with multilevel
atherosclerotic disease of lower
extremities suffering from critical
limb ischemia.
Figure 1. Chronic femoroiliocaval
obstruction with spontaneous Palma
shunt formation before (A) and after
stenting (B). Note the disappearance
of collaterals in this latter.
stenosis of the IVC was treated
with a 10x40 mm balloon. Finally,
an 8x30 mm stent was used on
the common femoral vein.
Phlebography showed a regular
contrast of the right pelvic and
the IVC without extravasation at
these levels (Fig.1-B). After the
volver al sumario
Revascularizacion
tibial atipica
11
IX
Abstract
Discussion:
Our patient fitted the two main
criteria for surgical treatment of
femoroiliocaval obstruction: pain
and edema (3). He was exposed
to several risk factors besides
his underlying coagulopathy.
We chose the endovascular
approach given the lower
morbidity and mortality, higher
Endovascular
strategies when an
occlusion of the
superficial femoral
artery includes an
occluded stent
García Familiar, Ainhoa;
Larrañaga Oyarzaball, Ioar;
Diéz Blanco, Egoitz; Alzate
Arsuaga, Cristina; de Blas
Bravo, Mariano; Egaña
Barrenechea, José María
Donostia University Hospital, San
Sebastián (Spain)
Introduction:
Endovascular treatment of
superficial femoral artery
occlusions remains a technical
challenge, particularly those
Fistula iliocava con
gran repercusion
hemodinamica
Rubio, Vanessa;
Rubio, Gustavo
CETEN Guadalajara,
Guadalajara (Mexico)
long-term patency rate, shorter
hospital-stay after surgery and
probable low rate of in-stent
restenosis (4). The patient was
discharged with improvement of
his chief complaints and no
complications were reported
during early follow-up. This
patient has an important
underlying coagulopathy that will
result in new thrombotic events
in the long run unless he receives
adequate control and advice on
preventing risk factors by the
hematology department (5).
Conclusion:
including the occlusion of a
previous stent which require instent recanalisation at this level.
Methodology used:
Objectives:
To report the endovascular
management of an occlusion of
the superficial femoral artery
which includes an occluded
stent.
Material used:
A 60-year-old male with a history
of superficial femoral artery
stenting 10 years ago,
developed left calf claudication
becoming progressively worse
over 6 months (stage 3 of
Rutherford). He experienced no
improvement despite supervised
training and optimal medical
treatment. MRangio showed left
occlusion with a stump and
recanalisation in the distal
superficial femoral artery.
Problema
Paciente masculino de 73 años
de edad enviado al
departamento con aumento de
volumen de miembro pélvico
izquierdo, con datos de
insuficiencia respiratoria severa,
dolor en región inguinal
izquierda; un eco doppler color
de pierna izquierda refiere
trombosis venosa profunda de
vena femoral superficial
izquierda. El paciente se aprecia
en mal estado general; la Rx de
The outcome of this report
shows that percutaneous
endovenous stenting resolves
pain and edema caused by
femoroiliocaval obstruction with
no complications during the early
follow-up. However, in this case,
inherent thrombophilia is the
underlying cause of occlusion
and a poor long term outcome
may be expected.
Endovascular treatment was
decided.
In an antegrade direction,
subintimal recanalisation of the
occluded segment proximal to
the stent was attempted.
Reentry into the stent was
unsuccessful and so, retrograde
access was obtained in the distal
superficial femoral artery. In-stent
recanalisation was achieved from
retrograde approach, but reentry
into the true lumen at the level
of the stump turned out
impossible.
A balloon from antegrade access
and a balloon from retrograde
access were both advanced to
this level of the occluded
superficial femoral artery above
the stent. This way, simultaneous
balloon angioplasty from
antegrade and retrograde
approaches was used to cross
the occlusion but no success
torax con gran cardiomegalia y
apicalización del flujo pulmonar;
destaca entre sus antecedentes
haber sido sometido a cirugía
por Aneurisma de Aorta
Abdominal 15 años previos
efectuándose derivación
aortobiliaca. Se somete a
estudio de Angiotac de aorta
apreciando dilatación
aneurismática de arteria iliaca
izquierda con flujo simultáneo
de aorta y vena cava inferior.
38
References:
1. Neglén P. Chronic venous
obstruction: diagnostic considerations
and therapeutic role of percutaneous
iliac stenting. Vascular 2007; 15:27380.
2. Titus JM, Moise MA, Bena J, Lyden
SP, Clair DG. Iliofemoral stenting for
venous occlusive disease. J Vasc Surg
2011; 53(3):706-12
3. Neglén P. Endovascular treatment of
chronic iliofemoral venous obstruction
– a review. Phlebolymphology
2003;43:204-11
4. Garg N, et al: Factors affecting
outcome of open and hybrid
reconstructions for nonmalignant
obstruction of iliofemoral veins and
inferior vena cava. J Vasc Surg 2011;
53:383–93.
5. Neglén P, et al: Stenting of the venous
outflow in chronic venous disease: longterm stent-related outcome, clinical,
and hemodynamic result. J Vasc Surg
2007; 46:979–90.
was obtained.
A Pioneer Plus reentry device
with intravascular ultrasound
guidance was advanced in an
antegrade fashion. With the
reentry catheter, a needle was
deployed to puncture the balloon
advanced from retrograde
access, introducing a guidewire
inside the balloon and
connecting both spaces. That
guidewire was removed together
with the balloon from retrograde
access.
Angioplasty was performed with
a 5-mm balloon. Angiogram
revealed dissection of all the
superficial femoral artery and so,
two self-expanding bare nitinol
stents were deployed (6x150mm
Ev3 Everflex and 6x80mm Ev3
Everflex).
Angioplasty with a 5-mm balloon
was employed to obtain
hemostasis in the distal
superficial femoral artery.
Hemostasis at right femoral
artery was managed with
Perclose Proglide vascular
closure device.
Dificultad
clínicas como la presentada en
este paciente.
Eliminar el pseudoaneurisma con
fístula arteriovenosa iliocava
izquierda, en un paciente en mal
estado general y restituir la
continuidad aortoiliaca con
rapidez para evitar el deterioro
clínico del paciente.
Como Evitar
Efectuando técnica quirúrgica
adecuada para evitar
complicacaiones anastomóticas
que deriven en situaciones
Technical success was achieved.
The patient was discharged
home a few hours later free of
complications.
In the follow-up at 6 months, the
patient showed complete
symptom resolution.
Conclusions:
Endovascular management of
occlusions can be highly
demanding, and so multiple
techniques and devices are
required to face these complex
lesions.
Como Solucionarlo
Analizando los antecedentes del
paciente; establecer la causa
del estado de sobrecarga
ventricular y combinar abordajes,
técnicas endovasculares y
dispositivos, para solucionar en
forma completa la complicación
existente, evitando la muerte del
paciente.
volver al sumario
procedure, the patient showed
resolution of pain and
improvement of edema. During
follow-up, no complications were
reported.
11
IX
Abstract
Rubio, Vanessa;
Rubio, Gustavo
CETEN Guadalajara, Guadalajara
(Mexico)
Symptomatic acute
pseudoaneurysm
of the right hepatic
artery with aberrant
origin from the
superior mesenteric
artery in a patient with
hereditary hemorragic
telangectasia
Peinado Cebrián, Javier;
Salgado Lopetegui, Christian;
Lamarca Mendoza, Maria Pilar;
Montoya Ching, Ricardo;
Estébanez Seco, Santiago;
Flores Herrero; Ángel
Introduction:
Hereditary Hemorragic
Telangiectasia (HHT) is a rare
autosomic dominant disease
consistent in vascular dysplasias
that affect different organs,
including skin, lungs,
gastrointestinal tract and brain.
Liver involvement includes
telangiectases, arteriovenous
shunting, hepatic arterial dilatation,
focal liver lesions, and ischemic
Valve in valve
invagination
Morrison Polo, Guillermo;
Jiménez Quevedo, Pilar;
Nombela Franco, Luis; Biagioni,
Corina; Almeria, Carlos; Garcia,
Eulogio
Hospital Clínico San Carlos,
Madrid (Spain)
Problema
Femenino de 42 años con historia
de Trombosis venosa profunda en
forma espontánea 4 años previos
se estableció el diagnóstico de
Síndrome de May Thurner tratada
en su momento con Filtro de Vena
Cava, Trombolisis sistémica y
Stent en Vena Iliaca Izquierda se
mantuvo bajo tratamiento
anticoagulante por 30 meses solo
destaca haber iniciado terapia
hormonal de sustitución 3 meses
previos .
Acude por cuadro de 72 hrs de
evolución caracterizado por
cholangitis, and its prevalence
ranges from 8 to 31 % in
retrospective studies. Liver
involvement with typical
presentation has been reported in
more than 50 cases. Several cases
of aneurysm of the main hepatic
artery have also been reported.
Nevertheless, pseudoaneurysms
are not considered among typical
manifestations of HHT, and to our
knowledge there is no one
reported in the literature.
In a systematical analysis of the
celiac axis anatomy, variations in
the origin of the main hepatic artery
(MHA) were described in 3,71 %,
being the origin in superior
mesenteric artery (SMA) the most
frequent variation (3% of all
patients).
Objectives:
To report an hybrid (open and
endovascular) technique for the
treatment of an acute,
symptomatic pseudo aneurysm
affecting the MHA with an aberrant
origin in SMA, in a patient with
HHT.
Abstract:
The invagination of an aortic valve
prosthesis Core Valve is a rare
complication. We report a case in
a patient of 78 years old woman
with severe symptomatic aortic
stenosis. STS score: 2.1 Euroscore
6.5% presented to the Heart team
and accepted to Transcatheter
aortic valve implantation due to
fragility. During the Core Valve No.
29 mm implantation the prosthesis
migrated to ascending aorta and
edema de ambas extremidades
inferiores, dolor severo y continuo
en hipogastrio. Se estableció el
diagnóstico de Trombosis Iliocava
Bilateral extensa que involucra el
filtro de vena cava colocado con
antelación y ambas venas iliacas
primitivas.
farmacomecánica y utilizar algún
tipo de recontrucción
endovascular. Sobreviene una
complicación severa con sangrado
retroperitoneal que exige tomar
medidas para evitar la muerte del
paciente.
Como Evitar
Dificultad
Reconstruir en forma endovascular
el eje Iliocavo bilateral, colocar un
filtro de vena cava recuperable en
posición suprarrenal, por la alta
carga trombótica existente en la
paciente, efectuar trombectomía
Efectuando técnica endovascular
meticulosa y reconocer los posible
mecanismos de lesión vascular en
una reconstrucción de vena cava
inferior.
Como Solucionarlo
Existen alternativas con técnicas
endovasculares complejas,
diferentes accesos y dispositivos,
convertir al paciente y llevarlo a
cirugía abierta dilucidando si se
requiere un abordaje
transabdominal o retroperitoneal
y / ó vigilancia médica con
restitución hemática y
observación.
Results:
Physical exam confirmed existence
of an epigastrium-located
abdominal pulsatile mass, with a
palpable thrill over it and at right
hypochondrium. An abdominal
bruit was audible at the same
locations. At first evaluation, the
patient remained hemodynamically
stable (Blood pressure 120/70 mm
Hg, Heart Rate 72 bpm) and
without analytic signs of acute
bleeding (Hemoglobin 12 mg/dl,
Hematocrit 42 %). Under suspicion
of symptomatic abdominal
aneurysm, an emergency angio
TC was performed, in which a non
ruptured, 5 cm in diameter
pseudoaneurysm, dependent on
a MHA with anomalous origin from
the SMA was diagnosed. Findings
compatible with hepatic
manifestations of the previously
diagnosed HHT were found as well
(tortuosity and dilation of the MHA,
the Right Hepatic Artery and the
intrahepatic branches,
hepatomegaly, intrahepatic
arteriovenous fistulas).
An hybrid (surgical and
endovascular) emergent plan was
designed, in order to exclude the
pseudoaneurysm. Under general
anestesia, an aorto-MHA by pass
with a 6 mm PTFEe graft was
performed, and the MHA was
ligated just distal to the
pseudoaneurysm. Then, through
a left brachial arterial access,
exclusion of the origin of the MHA
was performed with a balloon
expandible endoprosthesis
delivered at the SMA, crossing
the anomalous origin of the MHA.
The completion arteriography
confirmed complete exclusion of
the pseudoaneurysm and patency
of the by pass, the distal MHA and
the SMA.
a second prosthesis Core Valve
No 29 mm was implanted
successfully. However the
aortogram following the
implantation showed a peak
gradient of 50 mmHg. Carefully
evaluation of the morphology of
the two valves showed an
invagination of the metallic
structure of the second prosthesis.
To improve the functionality of the
prosthesis a post dilatation with a
balloon valvuloplasty was planned,
however it was impossible to
advance retrograde a valvuloplasty
balloon No 26 mm due to the
balloon hooked with valve struts.
Since the patient remains
hemodynamically stable a second
intervention was scheduled. In the
second procedure a AV loop was
performed. First a Berman catheter
was used to cross anterograde
the prosthesis through interatrial
septum puncture. The catheter
was advanced until the
descending aorta and through the
catheter a hydrophilic wire was
introduced that was snared and
was externalized through the
femoral artery. Subsequently a
balloon Valvuloplasty No 23 mm
was advanced anterograde and
was successfully positioned
inside the prosthesis. The post
dilatation was performed
obtaining an improvement of the
intussusception with a peak
transvalvulargradient of 10
mmHg and mild paravalvular
regurgitation.
Material (Patient):
The patient is a 64 year old
woman, diagnosed of HHT since
20 years ago with recurrent
epistaxis as the only clinical
manifestation of the disease. She
presented a 48 hours evolution of
acute onset abdominal pain
associated with palpable pulsatile
mass previously inadvertent.
Methodology (description
of diagnostic and
treatment procedure):
39
The patient did not present
complications related to the
intervention. Postoperative
physical exam revealed painless,
non-pulsatile abdominal mass.
Discharge occurred at 9th
postoperative day. Angio TC
follow-up was performed at
discharge, 1 month and 6 months
after intervention, revealing
complete exclusion of the
pseudoaneurysm, which had
shrunk to 3 cm at 6th month. The
patient remained completely
asymptomatic since the 1st
postoperative month.
Conclusions:
Pseudoaneurysm are a not
previously described complication
related to hepatic affection in HHT.
Variations on the anatomy can
complicate the management of
some vascular diseases that would
be easily solved in normal
anatomies. Hybrid procedures are
an alternative in such cases.
volver al sumario
Complicacion severa
durante
reconstruccion
iliocava endovascular
11
IX
Abstract
Flores, Carlos; Santoscoy I.,
Joaquín; Loya S., Jesús;
Padilla B., Ricardo; Sáenz T.,
Ricardo; López R., Miguel
Médicos adscritos al servicio
de Angiología y Cirugía Vascular
del Hospital Central Universitario
de Chihuahua, Chihuahua
(México)
Resumen.
Las oclusiones aórticas agudas
constituyen una entidad clínica
que representa un riesgo de
morbimortalidad muy alto si no
se recibe el manejo adecuado y
oportuno. El presente reporte
de caso describe el tratamiento
por vía endovascular de un
paciente hombre de 66 años
con antecedente de tabaquismo
intenso, diabetes mellitus,
Endovascular de la
patologia de aorta
toracica
descendente:
resultados a largo
plazo
Mertens, Renato; Insunza,
Martín; Ordenes, Maria Jesús;
Valdés, Francisco; Mariné,
Leopoldo; Bergoeing, Michel
Departamento de Cirugía
Vascular y Endovascular,
Universidad Católica de Chile,
Santiago (Chile)
claudicación intermitente y
disfunción eréctil. En
Angiotomografía se encuentra
oclusión de aorta de tipo
trombótica por debajo de las
arterias renales extendiéndose
hasta iliacas externas. Se
procede a realizar abordaje por
ambas femorales, se coloca
stent tipo Palmaz montado
sobre balon maxi 25mm x 4cm
para conseguir la fijación del
trombo, luego se coloca stent
recubierto tipo Advanta de
16mm a nivel infrarenal, después
se colocan dos stents tipo
Advanta V12 de 9mm dilatados
mediante técnica de kissing
balloon. Posteriormente se
extiende cobertura hacia iliaca
derecha mediante stent tipo Epic
de 10mm x 80mm y en iliaca
contralateral con stent Innova
de 8mm x 80mm. El paciente
recupera pulsos en ambas
extremidades inferiores y
desarrolla una nefropatía por
isquemia-reperfusión y por
medio de contraste que revierte
favorablemente en su
posoperatorio.
Conclusión.
Abstract:
A pesar de no contar con un
nivel de evidencia adecuado
para la indicación primaria de la
cirugía endovascular para tratar
este tipo de patología, es factible
aplicarla para resolverse en
casos específicos como este.
Acute aortic occlusion
constitutes a clinical entity that
represents a high risk of
morbidity and mortality if proper
and timely adecuate
management is not established
. This case report describes an
endovascular treatment of a 66
years old male heavy smoker
patient with a history of diabetes,
intermittent claudication and
erectile dysfunction .
The angiographic aortogram
image demostrates an infrarenal
thrombotic type oclusión with
extention to external iliac arteries.
Both common femoral arteries
are exposed and dissected, long
introducers are placed and a
Palmaz type stent is mounted
over balloon maxi 25mm x 4cm
to achieve fixation of the
thrombus, followed by a
placement of a coated Advanta
16mm type stent in the infarenal
aorta, two stents Advanta V12
9mm are placed on the common
iliac arteries, and expanded by
kissing balloon technique .
subsecuent coverage of the right
Introducción.
penetrantes, 3 otros. Todos se
trataron mediante inserción de
endoprótesis vía femoral. Se
utilizaron dispositivos
Medtronic® 52%, Cook® 24%,
Gore® 18%, Bolton® 4% y otras
2%.
La reparación endovascular de
aorta torácica se ha establecido
como gold standard de
tratamiento de diversas
patologías por sus excelentes
resultados inmediatos. Los
resultados tardíos no son
reportados con frecuencia y
cuando ha ocurrido, se ha
descrito alta tasa de
reintervenciones.
Objetivo.
Evaluar resultados alejados de
nuestra serie iniciada en 2001,
con seguimiento mínimo de 5
años.
Pacientes. Entre mayo 2001 y
julio 2009 tratamos 116
pacientes consecutivos, edad
60.4 años (24-86), 90%
hombres. Indicaciones: 52
disecciones agudas o crónicas,
42 aneurismas, 14 lesiones
traumáticas, 5 úlceras
Endovascular
management of
aortic occlusion
Dr. Carlos Flores R.*, Dr.
Joaquin Santoscoy I.*, Dr.
Jesús Loya S.*, Dr. Ricardo
Padilla B.**, Dr. Ricardo Saenz
T.**, Dr. Miguel López R.**.
* Division of Angiology and
Vascular Surgery, Hospital
Central Universitario de
Chihuahua, Mexico.
** Residents of specialty.
Metodología.
Estudio retrospectivo, se realiza
seguimiento clínico e
imagenológico. Se construyen
curvas de sobrevida y se utiliza
test de Log Rank para realizar
comparaciones entre curvas o t
test para comparar variables
contínuas.
Resultados.
Seguimiento promedio: 82,2
meses (0 - 157) durante el cual
fallecen 40 pacientes (34.5%),
7 de ellos (6%) por su
enfermedad aórtica de base: 4
(3.4%) antes de 30 días por
complicaciones (mortalidad
40
operatoria) y 3 tardíamente: una
infección de prótesis, una
ruptura de aneurisma y otra
posible ruptura en portador de
endofuga (EF) tipo I que fallece
súbitamente. Tres pacientes
fallecen alejadamente por otra
patología aórtica: dos por
disección tipo A y uno por
aneurisma abdominal roto. Los
30 restantes por otras causas,
principalmente cáncer e
insuficiencia respiratoria. La
sobrevida actuarial a 5 y 10 años
fue 80.2% y 60.2% (ES: 3.7 y
8.1). 21 pacientes (18.1%)
requirieron un total de 31
intervenciones aórticas alejadas:
15 pacientes (12.9%) sobre el
segmento aórtico tratado (16
reintervenciones: 13 EF tipo I, 3
EF tipo III) y 6 (5.2%) sobre
segmentos aórticos diferentes.
La sobrevida libre de
reintervención a 10 años con
error stantard menor a 10% fue
iliac stent extends with an Epic
10mm x 80mm type and
contralateral iliac stent Innova
type 8mm x 80mm is placed.
The patient regains pulses in
both lower limbs and developed
contrast nephropathy and for
reperfusion recovered renal
function to preoperative levels.
Conclusion.
Despite an unadecuated level of
evidence for the primary
indication of endovascular
aproach to treat this pathology
it is feasible to apply to be
solved in specific cases like the
presented.
de 100% para trauma, 71.8%
para disección y 63.4% para
aneurisma, siendo significativa
la diferencia entre trauma y el
resto de las patologías (p<0.05).
Conclusión.
El tratamiento endovascular
sobre la aorta descendente
presenta excelentes resultados
inmediatos y a largo plazo,
previniendo eficazmente la
mortalidad derivada de la
enfermedad original. El
tratamiento del trauma parece
ser curativo, pero el control
alejado con imágenes deriva en
frecuentes intervenciones
aórticas tardías en el resto de
las patologías.
volver al sumario
Manejo
endovascular de
oclusion aortica
11
IX
Abstract
Erben, Young; Bjarnason,
Haraldur; Oladottir, Oladottir;
Oderich, Gustavo; Gloviczki,
Peter
Mayo Clinic, Rochester (USA)
Introduction
and Objective: Chronic, most
frequently post-thrombotic
occlusion of the inferior vena cava
(IVC) is rare. Results of
endovascular recanalization (ER)
with angioplasty and stenting have
been encouraging and the aim of
this study was to evaluate our
experience.
Material and Methods:
Clinical data of 66 patients, who
underwent ER for chronic, nonmalignant IVC occlusion between
January 2001 and August 2014
were retrospectively reviewed.
Primary outcomes included
morbidity and mortality, secondary
outcomes included patency and
resolution of symptoms.
Results:
Forty-five of 66 patients (68%)
were male and mean age was 43
years (range: 17-83 years).
Symptoms were present for a
mean of 8.1 ± 8.6 years. CEAP
score was 3, 4a, 4b, 5 and 6 in
41, 2, 1, 3 and 19 patients,
respectively. Forty-seven (71%)
had previous deep venous
thrombosis (DVT), thirteen (20%)
had DVT with pulmonary
embolism (PE) and six (9%) had
a previous iatrogenic injury or
side branches to one of the
renovisceral arteries, distal aortic
or iliac extensions with secondary
side branch completion. Primary
endpoints of the study were
overall technical success, side
branch patency, perioperative
mortality and the rate of severe
spinal cord ischemia.
Temporary
aneurysm sac
perfusion as an
adjunct to prevent
paraplegia during
branched
endovascular aortic
repair for
thoracoabdominal
aortic aneurysms
Introduction:
Kopp, R.; Kasprzak, P.M.
Methods:
Vascular and Endovascular
Surgery, University Hospital
Regensburg, Regensburg
(Germany)
Patients were treated for TAAA
with bEVAR between 07/2007
and 02/2014. Temporary
aneurysm sac perfusion was
performed by non-completion of
Ninety-eight patients were treated
for TAAA (mean diameter 6.6 +
1.6 cm) with branched aortic stent
grafts with (n=46) or without
(n=52) TASP. Overall technical
success including aneurysm
exclusion, absence of persistent
line flow to the foot and reperfuse
distal ischemic tissue.
Often, obstructive lesions are
located at the malleolar level or
below the ankle (BTA) involving
dorsalis pedis and plantar arteries
of the infra-malleolar level.
BTA procedure should be
performed through an antegrade
(femoral, popliteal, tibial, peroneal)
approach. The 0.014-inch guide
wire should be used to negotiate
through the lesions and an
appropriately sized, low profile
plan balloon angioplasty catheter
used to dilate the lesion. If the
lesion is too tight or impossible
to cross with a 0.014-inch guide
wire, then a 0.018-inch hydrophilic
tip guide wire should be used.
Sometimes, with standard
antegrade approaches, success
rate of revascularization remain
poor and techniques of
recanalization of below the knee
and foot arteries can be
inadequate, in relation to chronic
total occlusion with diffuse
calcification and involvement of
foot arteries compromising distal
run off at the foot level.
In these cases, in addition to
traditional approaches, retrograde
access, transcollateral
recanalization, a pedal-plantar
loop technique can help achieving
successful revascularization.
Recently, a percutaneous
Below the ankle:
when to go there.
Technical tips and
image issues
Dr Claudio Rabbia
Vascular Radiology – Città della
Salute e della Scienza di Torino –
Italy
Infrapopliteal plain balloon
angioplasty (PTA) is the first line
therapy for chronic limb ischemia
(CLI) treatment in patients with
obstructive disease of
infrapopliteal
artery in order to restore a straight-
We report our experience with
the concept of temporary
aneurysm sac perfusion (TASP)
and secondary staged side
branch completion to prevent
severe spinal cord ischemia after
branched endovascular aortic
repair (bEVAR) for
thoracoabdominal aortic
aneurysm (TAAA).
Results:
41
congenital hypoplasia. Twenty five
(38%) had an IVC filter in place
and 23 (35%) had a
thrombophilia. IVC occlusion was
infrarenal in 47, suprarenal in 18
and suprahepatic in 1 patient. All
patients underwent sequential
angioplasty and stenting. One or
both iliac veins were stented
including the IVC bifurcation. Preand post-stenting pressure
gradients were 4.3 ± 2.9 and 0.7
± 1.0 mmHg, respectively
(p<0.001). Three patients had
complications: one IVC
hematoma, groin hematoma and
femoral vein thrombosis each.
There was no mortality. Follow-
up was 41.3 ± 34.2 months.
Three patients were lost to follow.
Primary patency, primary assisted
and secondary patency at 36
months was 80%, 88% and 91%
respectively. Resolution of
symptoms occurred in 55 patients
(83%).
type I or III endoleak, TASP side
branch patency and secondary
side branch completion was
35/40 (87.5 %). Secondary TASP
side branch completion was
performed after median 26 days
(range: 1-370 days). The rate of
early reinterventions for
renovisceral side branch
complications was 15/380 (3.9
%) and perioperative mortality
7/98 (7.1 %; 4 non-TASP, 3
TASP). Clinical evidence of severe
spinal cord ischemia or paraplegia
was reduced in the TASP group
as compared to the non-TASP
group (3/46 vs 12/52, p=0.023).
One TASP patient died 4 months
after bEVAR during the TASP
interval from suspected
aortobronchial fistula.
retrograde transmetatarsal
arteries access followed by
retrograde recanalization of foot
and tibial arteries has been
proposed.
All these approaches are
minimally invasive and can be
employed in very challenging
cases such as absence of a
proximal occlusion stump, in
cases where advancement of the
guide wire is impossible for
dissection or perforation
in the proximal tract, as in case
of failure of subintimal
revascularization.
A very important issue in BTA
procedures is the pharmacological
administration.
All patients must be administered
dual antiplatelet therapy (aspirin
100 mg per day plus clopidogrel
75 mg per day) for at least four
days before the procedure
and 5000 U of non-weighted
heparin must be administered
during the procedure after sheath
placement, followed by 1000 U
per hour during the intervention.
To prevent vasospasm,
intraarterial infusion of small
amount of nitroglycerine
should be considered.
After the procedure, all patients
must receive dual antiplatelet
therapy for six
months and aspirin for life then
after.
Conclusions:
Endovascular recanalization for
non-malignant symptomatic IVC
occlusions is technically
challenging, however, it is safe
and durable. Mid-term patency
is excellent and 83% of the
patients have partial or complete
resolution of symptoms.
Conclusions:
The concept of temporary
aneurysm sac perfusion (TASP)
after bEVAR for TAAA is feasible
and seems to reduce the risk of
severe spinal cord ischemia. Early
side TASP branch completion
within 4 weeks is recommended
to reduce the risk of rupture. In
selected patients, a longer TASP
interval might improve
neurological rehabilitation from
spinal cord ischemia.
volver al sumario
Endovascular
recanalization for
chronic occlusion of
the inferior vena
cava
11
IX
Abstract
Iván Murillo
Tibial revascularization is a
rapidly growing part of
endovascular practice. Many of
the principles, techniques, and
devices required to make this
happen have been adopted from
Iliocava obstruction:
diagnostic and
therapeutic
strategies
other vascular beds. The best
factors suggesting success are
in cases where the foot damage
is minimal an also where the
runoff into the foot is intact.
The long-term patency of tibial
angioplasty and stenting may be
only fair but limb salvage is often
achieved without bypass.
Successful guidewire
deployment requires knowledge
of choices. The goal is to choose
the most appropriate guidewire
first as often as posible and to
know what to do next if the first
choice turns out to be a best.
There are a full range of
guidewires available.
Basic and advanced access for
sheaths placed outside the heart
is with 0.035 in. ( Coaxial
Systems). However one major
advantage of the lower profile
0.014 guidewire, is that it is less
likely to be unresponsive after
passing through a tight lesión
and need small plataforms
(Monorail Systems) Most
occlusions can also be crossed
and treated with various
guidewires supported by certain
catheters and other devices
using specialized techniques.
We need to have a differents
guidewire types. Starling,
selective, exchange, speciality.
With diferent lenght, diameter,
stiffness, coating, tip shape.
The potential for constructing
different catheter head shapes
is unlimited. Although hundreds
are currently being marketed,
most endovascular practice is
base don the consistent and
well-developed use of just a few
types in most individual
practices. Each specialist has
funcional favorites. Flush and
selective catheters have
divergent purposes and
substantially different
appearances. In general we used
flush catheters, straight catheter,
selective catheters, complex
curves catheters,long benit
tip,hook shape. Its important
knowed the kind of lession to
choice wich catheter will be
usefull trackability, pushability,
crossability, steerability, and
french.
The use of appropiate diagnostic
tools is essential in determining
obstructive ethiology for the
disease. Endovascular treatment
strategies have proven to restore
venous outflow adequately with
resolution of severe venous
obstruction and improval of the
patient´s quality of life.
obstruction that results in post
obstructive venous insufficiency.
thrombotic and non thrombotic
(extrinsic compression)
obstructions.
accurate diagnosis of the
underlying disease is essential
for the best therapy and
approach.
Material
Literature review on the subject
and personal experience with
cases of patients with thrombotic
and non thrombotic iliocaval
disease.
Conclusiones del estudio
Introducción
Objetivos
Metodología
Chronic Iliocaval Obstruction,
thrombotic or non thrombotic in
origin, accounts for severe post
obstructive venous insufficiency.
Show that appropiate diagnostic
and therapeutic strategies are
essential for diagnosis and
treatment of an underlying venous
Patients with chronic post
obstructive venous insufficiency
and their classification into two
sub groups of patients:
Patients with extrinsic
compression develop venous
insufficiency on the long term and
remain undiagnosed until they
generally present with a
thrombotic event. Patients with
proximal deep venous thrombosis
develop chronic obstructive
disease with severe post
thrombotic syndrome. An
Recanalization of
chronic iliofemoral
and caval
obstructions
Chronic venous obstructions have
been treated by means of bypass
surgery until endovascular
treatment emerged as a valuable
alternative. With the introduction
of new imaging modalities,
recanalization techniques and
novel stent design the
endovascular approach gained
even more popularity and
suprassed surgery as the primary
treatment option.
Recanalization of chronic
iliofemoral and caval obstructions
proved safe and efficient with
excellent mid- and long-term
patency rates. When postthrombotic trabeculations extend
below the femoral confluence,
proper inflow can be facilitated
by endophlebectomy of common
femoral vein and creation of an
arteriovenous fistula.
Adequate anticoagulation,
measures to improve inflow
(mobilization, compression
stockings, pneumatic
compression) and outflow, using
dedicated venous stents and
good follow-up for early detecting
stent-failure are essential for an
optimal outcome.
venosas intrapélvicas, tanto en
número como en calibre. Estas
estructuras serán de morfología
varicosa, y presentan alteraciones
en el flujo. Su principal síntoma
es el dolor pélvico crónico, a
consecuencia de la hipertensión
venosa pélvica. Dicha
hipertensión puede tener diversas
etiologías, pudiendo ser
provocada por una compresión
anatómica (de origen centrípeto)
o provenir de un reflujo (de origen
centrífugo), además de poder
presentar una etiología mixta.
Es esencial diferenciar la patología
causada por reflujo de la causada
por compresiones pues el
abordaje terapéutico variará
significativamente. En el SCP
causado por reflujo se
desarrollarán principalmente
varices pélvicas, responsables de
los síntomas. Dichas varices van
a derivar tanto de los ejes
gonadales como de los ejes
iliacos internos. En función del
paciente y, principalmente, de la
integridad del suelo pélvico, se
producirán o no fugas a los
miembros inferiores, que tendrán
que ser tratadas igualmente.
en bipedestación y suele estar
relacionado con mujeres que han
tenido varios embarazos. Otros
síntomas incluyen la pesadez
perineal, dispareunia,
dismenorrea, disuria,
constipación, y la aparición de
varices atípicas genitales, en
pequeña fosa y/o en miembros
inferiores.
Gustavo Rubio Argüello
Houman Jalaie
Objetivos
terapéuticos y
protocolo en el
tratamiento del
reflujo venoso
pélvico
Javier Leal Monedero
El Síndrome de congestión
pélvica (SCP), consiste en un
aumento de las estructuras
42
En nuestra unidad, tras más de
25 años estudiando las diferentes
patologías venosas pélvicas, y
los diferentes tipos de reflujos que
se pueden encontrar, hemos
desarrollado un protocolo tanto
de estudio como terapia.
La manifestación clínica más
frecuente de este signo fisiológico
es el dolor pélvico, de tipo
crónico, no cíclico y con más de
6 meses de evolución, sin causa
ginecológica asociada. Aumenta
The knowledge and use of
diagnostic tools and of the
diverse therapeutic endovascular
strategies is essential for the
clinical improvement of these
patients.
El diagnóstico se realiza mediante
exploración no invasiva, utilizando
Eco Doppler color transvaginal y
transparietal, que presenta una
precisión diagnóstica de hasta un
volver al sumario
Below the knee:
Basic material to
use, when to go
there and what you
should never do
11
IX
Abstract
obtiene mediante flebografía
pélvica, pudiendo realizarse
simultáneamente el tratamiento.
El tratamiento de indicación será
la embolización de los ejes
insuficientes.
How to aviod them
in primary varicous
vein treatment
to apply foam sclerotheray or
other strategies? (Tessari)
1. There is a common
controversial issue. Spare or not
to spare saphenous trunk? Is
that the key to avoid future
varicous vein recurrences? (All
panelists: Pittaluga, Whiteley,
Tessari… and Audience)
2. Is the ASVAL technique really
going to decrease long term
recurrences? Or it is just a shortterm esthetic surgery, with
expected recurrences?
(Pittaluga)
3. What about CHIVA? Past or
present? (all, audience)
4. Or are the endoluminal
systems ( thermal,
physicochemical etc... ) going
to be the key in this never ending
story? (Whiteley)
5. Or maybe great saphenous
vein foam sclerotherapy? Which
elements do you analyze in order
Protocolo
diagnóstico e
indicaciones
terapeúticas de
embolización
Enrique Puras
Pelvic venous insufficiency is a
true (although still not completely
understood) entity due to intraabdominal reflux of the gonadal
axis and/or the hypogastric
tributaries. This intra-abdominal
reflux can be primary (congenital
valveless or reflux due to
multiparity of the ovarian veins)
or secondary to compression
En resumen, el estudio de la
6. Pelvic reflux study is
mandatory in all cases in order
to decrease varicous veins
recurrences? How do you
recommend this approach ? Or
pelvic embolization as the main
cause of recurrences? (Whiteley)
WHEN VARICOUS VEIN
RECURRENCE OCCURS
7. When recurrence occurs, how
should we treat it? Please! Give
us a simple guide to follow…
We will show you different
pictures of varicous recurrencies:
for every picture a short
comment from all the panelists
(do you recommend a specific
scanning? and therefore which
strategy would you apply?)
Picture 1. Spread varicosities
Picture 2. Isolated varicous
veins
Picture 3. Big trunks in thigh
or leg
syndromes, such as MayThurner and Nutcracker.
Its clinical presentation can be
as pelvic congestion syndrome
(PCS), varicose veins,
thrombosis or incidental finding.
Pelvic congestion syndrome can
be defined as a chronic pelvic
pain (more than six months) in
the absence of a gynaecological
aetiology, that usually worsen by
standing-up or in situations that
increase intraabominal pressure
(Valsalva, pregnancy or
premenstrual period) and can be
relieved by lying down. Other
symptoms can be dyspareunia,
bladder irritability, haemorrhoids
and heaviness and cramps in
the legs.
patología venosa pélvica actúa
sobre dicha patología así como
en los reflujos a miembros
inferiores. La terapia mediante
embolización de los ejes
insuficientes pélvicos ha sido
eficaz hasta en un 97% de los
casos, tanto en mujeres como en
hombres, siendo prácticamente
mínimas las complicaciones
encontradas.
So, in conclusion… Recurrence
after CHIVA: thermoablation?
After Stripping: Foam or redo
surgery? Catheter or direct
injection foam sclerotherapy?
Which product and how?
(Tessari, all and audience)
2. In real practice when do you
think valve replacement is
indicated to? Furthermore… who
in the audience has any
experience in this treatment ?
(all and audience)
8. A comment from the
moderators: We have different
tools to treat all the types of VV.
Do you think we can cure venous
insufficiency? Should we explain
to the patient that we offer
treatments to control
recurrencies or avoid
complications ... Which message
do you give your patient before
the treatment? (all the panel)
3. What’s next in vein
recanalization?
2. Percutaneous Valve
replacement
1. What about the “new” and
“promising” (from more than one
decade ago...) results of the
percutanoeus valve
replacements? Will they arrive
to our patients? (all)
Varicose veins due to pelvic
venous insufficiency are usually
vulvar varicose veins or lower
extremity varicose veins in
atypical localizations, such as
the posterolateral region of the
thigh, perineal region or nonsapheno-femoral reflux.
Differential diagnosis in these
patients is lengthy and includes
pelvic inflammatory disease,
endometriosis, pelvic tumors,
interstitial cystitis, and
inflammatory bowel disease.
Diagnostic protocol for
pelvic venous
insufficiency should
include:
1. Clinical findings: Pelvic
43
1. We have seen (and heard)
techniques and results about
vein recanalization… But should
I say interesting techniques and
just promising results? What is
lacking in this story? Better
indications, better hands or
better materials? (Jalaie)
2. Management of Deep venous
disease and/or acute deep
thrombosis is frequently lead by
medical specialists
(Pneumologists, Hematologists,
…). Are this the reason of the
reluctance to an aggressive
approach? (Pittaluga, Whiteley)
audience, Ménendez)
4. Are there geographic (USA vs
Europe) differences related to
management approach? (all)
4. Vascular
malformations and
birthmarks approaches
1. Vascular malformations (and
some birthmarks) are one of the
most difficult diseases to treat
as vascular endotherapists…
Which is the way to treat them?
Mainly with foam sclerotherapy?
(Tessari)
Mainly with endovascular
embolization? (Whiteley,
Jalaie)
Is open surgery still an
option? (all, Pitaluga)
3. Is the lack of knowledge in its
physiopathology, the reason of
the controversial results? (All,
2. As in other fields in vascular
diseases (like complex
aneurysms), do you think it
should be advisable to establish
specialized and reference
centers and teams? (Texeira,
Menendez)
congestion syndrome with no
gynaecological aetiology and/or
atypical varicose veins.
2. Duplex ultrasound
(transvaginal and
transabdominal):
a. Non-invasive, inexpensive
and accurate.
b. The criteria for identifying
PCS on US are dilation of
pelvic veins more than 6 mm,
reversal of the flow within
ovarian veins, polycystic
changes within the ovaries,
and dilated veins in the
myometrium.
3. CT and MR:
a. For those practice with nonskilled operators using
transvaginal ultrasound.
b. Provide a more
comprehensive assessment of
the pelvic anatomy with
multiplanar imaging and
reconstruction, which is
nonoperator dependent.
c. Helpful for procedural
planning.
d. Time resolved MRV: Great
correlation with venography.
4. Venography:
It should image the four veins
responsible for venous return
from the pelvis: both internal
iliac veins and both gonadal
veins. The study should be
performed with and without a
Valsalva maneuver and
preferably with a tilt table in
reverse Trendelenburg.
volver al sumario
96%. En otras ocasiones será útil
disponer de otras técnicas de
imagen como el angioTAC y la
angioRM, especialmente cuando
se exploran síndromes
compresivos. Sin embargo, la
confirmación diagnóstica se
11
IX
Abstract
atives of medical therapy vs
intervention with potential
adjuvant psychotherapy should
be a part of treatment,
addressing the side effects and
benefits of these options.
What are the most
important features of
a coil for pelvic
embolization?
appointments
Dr. D. Ignacio Mª Lojo
Rocamonde
Jefe de Servicio Angiología,
Cirugía Vascular y Endovascular
HOSPITAL QUIRÓN – CORUÑA
Pelvic congestion syndrome
(PCS) is associated with pelvic
varicosities that result in chronic
pelvic pain, especially in the
setting of prolonged standing,
coitus, menstruation and
pregnancy. Although the
underlying pathophysiology of
pelvic congestion syndrome is
unclear, it probably results from
a combination of dysfunctional
venous valves, retrograde blood
flow, venous hypertension, and
dilatation.
PCS typically affects multiparous
women of reproductive age.
Most women present with non
cyclic lower abdominal or pelvic
pain, usually described as a dull
ache or fullness that persists for
4- 6 months.
Some women with PCS present
with minimal tono pelvic pain but
instead have progressive hip
pain, lower extremity varicose
veins, or persistent genital
arousal as the sole manifestation.
Chronic pelvic pain (CPP) affects
approximately one third of all
women and accounts for 20%
of out patient gynecology
We should consider these
indications for therapeutic
embolization:
1. Symptomatic Pelvic
congestion syndrome.
2. Vulvar and atypical varicose
veins (posterior thigh, lateral
thigh) of the extremities.
3. Recurrence after treatment of
low extremity varicose veins.
4. Persistent symptoms after
treatment of low extremities
varicose veins despite absent
vulvar and low extremity varicose
veins.
On cross-sectional computed
tomography (CT) and magnetic
resonance (MR) imaging, pelvic
varicosities appear as dilated,
tortuous, tubular structures in
the uterine adnexa. Additionally,
CT and MR imaging provide
complete examination of pelvic
anatomy and can identify
For most patients, PCS is a
treatable disease if diagnosed
and treated correctly. The
multiple variations in pelvic vein
anatomy and pelvic varicosities
mandate accurate preinterventional imaging to ensure
embolization is effective for
symptom relief. Future studies
need to focus on creating more
3. Coils deployed until to get
an antegrade flow in proximal
ovarian vein and deploying
coils to approximately 10 cm
the junction ovarian-renal vein.
The most important features of
a coil for pelvic embolization are:
a. Controlled release: provides
better control and easy
repositioning.
Fig.4. Right hypogastric vein pretreatment
b. Oversize and appropriate
length: more effectively and
reduces complications.
c. Flexible: correct technique
for released vein.
Fig.2. Left ovarian vein pre-treatment
coexisting pathology, such as
compressive tumors.
Transcatheter embolization of
the ovarian veins typically is
performed after failed medical
management and is increasingly
being used as the primary
treatment for PCS. Parameters
for undergoing embolization
include confirmation of pelvic
varicosities with venography (fig.
1); the presence of associated
CPP or dyspareunia (in the
absence of other gynecologic
causes); or the presence of
severe labial, perineal, or lower
extremity varicosities.
d. Configuration: 2D and 3D
for a correct implant
technique.
e. Thrombogenic coating
fibers: dacron, platinum,
hydrogel, polypropylene to
facilitate venous occlusion.
In the period 2005 - 2014 have
treated 61 patients with a mean
age of 40.9 years. The right
ovarian vein has been treated
most frequent failure in 64.7%
of cases, bilateral embolization
Embolization is carried
performed by the sandwich
technique mixed, the steps of
the technique are (fig. 2,3):
Fig.1. Diagnostic venography:
confirmation of pelvic varicosities
elaborate but strict criteria for
diagnosing PCS to improve
patient selection and optimize
outcome and prevent obliteration
of vital collaterals.
2. Polidocanol foam 2% for to
close periuterines varicose
veins.
Imaging studies cannot diagnose
PCS but can confirm a distinctive
clinical pattern of varicosities that
when present in the setting of
pelvic symptoms can help
identify patients who require
further diagnostic work- up.
Pelvic ultrasound is usually the
first-line imaging modality in
patients with suspected PCS.
Although both transabdominal
and transvaginal ultrasound can
be used, the transvaginal
approach with Doppler
evaluation is generally preferred
because it provides better
visualization of the pelvic venous
plexus and allows dynamic
examination of blood flow
through tortuous pelvic veins.
Conclusion
1. Coils deployed in ovarian
vein distally of 12 to 20 mm in
diameter over 30 to 50 cm in
length.
44
Fig.3.Left ovarian vein post-treatment:
antegrade flow in proximal ovarian
vein.
Fig.5. Right hypogastric
vein post-treatment
was performed in 24.5% and
the hypogastric vein in 27.4%
(fig. 4,5). Vascular access was
the right femoral vein in 51.8%
and the right basilica vein in
49.2% of cases. Technically
successful ovarian vein
embolization was 96.8%. There
were no complications. At followup the clinical results obtained
were asymptomatic in 65.7%,
significant relief in 27.8% and no
relief in 6.5% of the cases. At
volver al sumario
Venography should not be used
as the primary imaging mode for
diagnosis of PCS but rather
reserved for patients who have
suspected PCS necessitating
intervention based on prior
noninvasive imaging or in
patients whose noninvasive
imaging is equivocal
A discussion with the patient
about the positives and neg-
11
IX
Abstract
In conclusion, PCS is a common
condition with significant
physical and psychosexual
consequences. Diagnosis of
reflux PCS is based on doppler
ultrasound and venography
therapeutic. We suggest
treatment of pelvic congestion
Actitud general
ante la
insuficiencia
venosa crónica y su
afectación pélvica y
de miembros
inferiores.
Javier Leal Monedero
Sindrome
congestivo pélvico:
resultados de 100
casos
Hospital Universitario de la
Ribera –Alzira –Valencia
syndrome and pelvic varices
with coil embolization or
transcatheter sclerotherapy,
used alone or together. The coils
used must be controlled release
of suitable size and flexible
length and with thrombogenic
coating fiber.
1. Huang C, Shelkey J, Singh H, Silvis M.
Chronic hip pain as a presenting symptom
in pelvic congestion syndrome. J Vasc
Interv Radiol 2013; 24:753–755.
3. Freedman J, Ganeshan A, Crowe PM.
Pelvic congestion syndrome: the role of
interventional radiology in the treatment
of chronic pelvic pain. Postgrad Med J
2010; 86:704–710.
2. Bora A, Avcu S, Arslan H, Adali E,
Bulut.The relation between pelvic varicose
vein sand lower extremity venous
insufficiency in women with chronic pelvic
pain. JBR-BTR 2012; 95: 215–221.
4. Monedero JL, Ezpeleta SZ, Perrin M.
Pelvic congestion síndrome can be treated
operatively with good long-term results.
Phlebology 2012; 27 (Suppl 1):65–73.
5. Asciutto G, AsciuttoKC ,Mumme
A,Geier B. Pelvic venous incompetence:
reflux patterns and treatment results. Eur
J Vasc Endovasc Surg 2009; 38:381–386.
En el estudio de la Insuficiencia
Venosa de Miembros Inferiores
(MMII) se ha demostrado que
hasta en un 32% de los casos
se requiere de una valoración
venosa pélvica, al estar afectado
también este sector y ser el
origen del reflujo a MMII. Si
entendemos que el sistema
venoso funciona como una red,
se comprende que el aumento
de presión en sectores
superiores conlleva la
transmisión, siempre que haya
vías, a los sectores inferiores.
Es importante evaluar la
situación del suelo pélvico en el
control de los puntos de fuga a
los MMII, pero también es
importante el estudio y
valoración de los puntos de fuga
dependientes de eje de vena
iliaca interna a isquiática y MMII,
no relacionado directamente con
la insuficiencia del suelo pélvico.
Si el estudio venoso en MMII no
entraña también la valoración de
los puntos de fuga pélvicos, y
del estado de la pelvis en
general, la recidiva varicosa
puede surgir hasta en más del
80% de los casos. Esto ocurre
no por una repermeabilización
de los ejes safenos, sino por los
ejes “atípicos” que conectan con
los MMII.
Se entiende que para evitar
estas recidivas, en aquellos
casos que se sospeche la
presencia de fugas por las
características clínicas, se tendrá
que incorporar al estudio y
evaluación de la Insuficiencia
Venosa Crónica de MMII por
reflujo el estudio y valoración de
los reflujos desde los troncos
venosos pélvicos, tanto
principales como secundarios.
Además, no hay que descartar
el estudio de posibles
compresiones venosas pélvicas,
que también pueden conducir a
la aparición de reflujos y fugas
hacia los MMII.
Objetivo:
informado previo a entrar en el
estudio. Se realizo flebografía
por puncion de la vena femoral
derecha mediante anestesia
local en todas ellas y
cateterizacion selectiva de la
venas ovárica izda y derecha asi
como de hipogástricas.
como incompetencia de las
venas, a la presencia de
columna liquida en las venas
estudiadas tras la maniobra de
valsalva )
Pacientes con
Flebografia negativa
para IVO
En el resto de estudios 49 (38%)
la flebografía no demostró
incompetencia venosa
Todos los pacientes con
resultado negativo se remitieron
a otra especialidad
En aquellas pacientes en las que
se demostro incompetencia
venosa , se realizo una
embolizacion selectiva de dichas
venas en el mismo
procedimiento.
Un (48%) de pacientes tenian 2
embarazos
Conclusiones:
El objetivo de este estudio fue
establecer la correlacion entre
sindorme pélvico congestivo e
insuficiencia de varices ováricas
como posible causa del mismo
Asi como establecer la relacion
entre el numero de embarazos
y la presencia de insuficiencia
de venas ováricas
Material:
El síndrome pélvico congestivo
(SPC) es una entidad conocida
aunque poco estudiada.
Este es un estudio prospectivo
en el que han tomado parte 95
paciente con 107 exploraciones
que fueron seleccionadas de la
consulta de Cirugia Vascular
Se caracteriza principalmente
por Dolor pélvico, pesadez
pélvica y dispareunia
La edad promedio fue de 42
años (30 a 65 ) y con un
promedio de 2.7 hijos
Las causas de este síndrome
son varias y principalmente ,
endometriosis, enfermedad
pélvica inflamatoria e
insuficiencia de venas ováricas
(IVO) entre otros.
La gran mayoría 88% acudieron
quejándose de varices en las
extremidades y solo un 12%
acudieron directamente por
síntomas sugestivos de SPC
Se presenta principalmente en
mujeres multíparas en una edad
aproximada de 40 años
Metodos:
Introduccion:
References
En todas las pacientes con
sospecha clinica de SPC se
obtuvo consentimiento
La evaluación de la
sintomatología pre y post
tratamiento fue hecha mediante
una escala visual simple donde
0 fue no dolor y 10 el dolor mas
intenso .
Resultados:
De los 95 pacientes estudiados
en 12 se realizo una segunda
flebografia por peristencia de la
sintomatología dando un total
de 107 exploraciones de las
cuales un total de 58 (62%)
presentaron insuficiencia de las
venas de uno o mas ejes
venosos pelvicos , (definiendose
45
No cambio en los síntomas pre
y post flebografia
Un (52%) de paciente tenían 3
o mas embarazos .
La mejoría clínica esta
directamente relacionada con la
embolizacion
Pacientes con
flebografía positiva para
IVO
No todos los pacientes con SPC
presentan varices pélvicas
Sintomas
Pre tratamiento
Post tratamiento (2meses)
2 Años
Dolor pélvico 7.2
4.19 (p-0.00)
1.1(p-0.000)
Pesadez pélvica 6.68
4.14 (p-0.00)
2.0(p-0.000)
Dispareunia 7.71
4.05 (P-0.00)
3.5(p-0.000)
Creemos que la Flebografia es
el método de eleccion para
estudiar estos pacientes
La IVO como causa de SCP es
mucho mas alta de lo que se
reconoce.
volver al sumario
mean follow-up of 21 months
93.5% of patients reported
symptom relief.
11
IX
Abstract
Fausto Passariello
Introduction
The cure Conservatrice
Hémodynamique de
l’Insuffisance Veineuse en
Ambulatoire (CHIVA)1 can be
strategically and tactically
modified in order to allow
endovenous Office Based CHIVA
procedures (OB CHIVA). Here
LASER experience is described.
Objectives
To transfer CHIVA procedures to
specialists rooms in a systematic
and simplified organization of
the working environment, in
order to reduce to a minimum
the required resources without
any change in security2.
Material used
Ultrasound devices: GE Logiq E
and Toshiba Xario, 7.5-13 MHz
probes.
LASER diode devices: 808 nm
Eufoton bare tip fiber. 1470 nm
Biolitec radial fiber, both 600 ?.
VCSS, Aberdeen and RAND
scores. Clinical, ultrasound and
survey follow up.
Tumescent anaesthesia: Solution
and quantity. US guided injection
and length of tumescence.
Methodology used
Venous Mapping was performed
as described elsewhere3-5. The
caliber and number of the
washing and draining tributaries
of the saphenous femoral
junction (SFJ) were recorded as
well the length of the venous
closure and the free distance
from SFJ.
CHIVA crossotomy is a flush
ligation of the SFJ which
respects all the tributary of the
arch.
OB CHIVA uses instead the
Riobamba Draining Crossotomy
(RDC), where Riobamba
(Ecuador) is the town where the
RDC was firstly performed. The
RDC respects one or more
tributaries of the arch, using
them as washing vessels of the
SFJ, while draining vessels have
the aim of preserving the caudal
GSV trunk.
A simplified diagnostic algorithm
guides the therapeutic choices,
requiring only a quick answer to
three simple questions:
1. Is the terminal valve
competent/incompetent ?
2. Is the reflux confined
to the GSV or deviated
towards incompetent GSV
tributaries ?
3. In the latter case, is the
GSV reflux abolished by the
simple digit compression of
the tributaries (Reflux
elimination test or RET)?
The algorithm catches essentially
the shunts I, I+ II and III and the
subsequent therapy. However,
the user is not required to know
anything about shunts
classification.
The target of the therapy is
considered the SFJ closure
preserving at least one washing
vessel, a condition which is
described in the X-Paste
terminology by the 0,1 decimal
code6. However, several different
results can be observed, as
reported in the PASTE
literature7,8. In rare cases a
floating thrombus occurs,
peripherally or centrally directed,
though it has generally no
consequences.
The indications to the OB CHIVA
procedures are the relative
contra-indications to the surgical
crossotomy.
Interventions
Actually only a limited and
anecdotal experience is
available.
hemodynamic (closure)
immediate result.
13 cases were treated. 6M 7F,
aged 47.9 +/- 15.2 yo (32-78yo),
10RT 3LT limbs. Clinical CEAP
class was mainly C2 (C1 0, C2
10, C3 0, C4 2, C5 0, C6 1).
Long term follow-up
The height of the groin was 74.5
+/- 6.1 cm. The height of the
first re-entry perforator 36.3 +/14.2 cm. The mid-thigh GSV
calibre 7.4 +/- 3.2 mm.
The number of washing vessels
2.5 +/- 1.1. Maximum washing
calibre 3.3 +/- 1.7 mm. Number
of draining vessels 1.9 +/- 0.7.
Maximum draining calibre 2.1
+/- 0.5 mm.
As to procedures, only LASER
was used: 12 cases with 808nm,
power 14w, LEED 140 J/cm and
1 case with 1470nm, power 6w,
LEED 60 J/cm. The used
pullback speed was always 0,1
cm/s. Phlebectomy was
associated in 8 cases, while
foam ultrasound guided
sclerotherapy (FUGS) in 5 cases.
Results of the study
Only anecdotal results are
available. 1 case with clinical and
ECD follow-up at 5 y, 1 case
with clinical/survey follow-up at
4 y.
Immediate follow-up
The immediate follow-up (1-3
days) is available in all cases and
shows good clinical results in
the 100% (13/13) of cases, while
washing and draining were
satisfying in 92% (12/13) of
cases. Reflux was present in
3/13 (23%) of cases, but
complete incompetence only in
8% (1/13) of cases. Reflux was
ascribed to an insufficient
administered energy in 2 cases,
while in 1 case it was a very light
reflux due to the mild
incompetence of an arch
tributary, used as a washing
vessel.
One additional case (14 cases
in total) was treated with a FUGS
RDC of the shorter saphenous
vein (SSV) with good clinical and
46
Though only an anecdotal
experience is at the moment
available, the available
obsevations provide useful
suggestions. Only 4 patients,
including the FUGS SSV
treatment had a long term
observation.
In all examined cases (4/4,
100%) clinical conditions were
functionally satisfying, while only
2/4 complained about
aesthetical results. One of them
complained for matting after
FUGS at 1y, 3y and 4y, while the
other one for residual tributary
varicosities with aesthetic
impairment at 5y.
No change at 1y was recorded
in the case of complete recanalization at 3d, but in an
unexplainable manner clinical
conditions markedly improved
from C6 to C5 at 1y (complete
healing of 2 ulcers and ankle
circumference decrease of 1
cm). As already remarked, since
the beginning it appeared clear
that due to technical problems
in these cases the administered
LASER energy was insufficient.
The SSV FUGS case had also a
symptomatic pelvic shunt which
was not treated at all. After 1y,3y
and 4y she still complained for
the persistence of the pelvic
symptoms, while only a partial
refluxing re-canalization was
detected by Doppler at 4y with
no important hemodynamic
impairment.
The last case was a GSV
Riobamba LASER draining
crossotomy (RLDC), planned to
be performed with 4 washing
vessels and observed with a
follow-up at 5y, showing the
complete closure of the GSV
arch below a small tributary. The
closure could be described in XPaste terminology by the
0,001107 decimal code6. The
tributary however was lightly
incompetent and jumped the
GSV closure, transmitting below
a low intensity reflux and feeding
only some aesthetical tributary
veins in the leg. GSV was totally
occluded for 9.5 cm and a partial
closure was present distally for
a total of 15 cm, GSV being
therefore patent for a great part
of its length. Apart from the
peripheral light reflux jump, this
case is a good example of long
term closure.
Discussion
Data are not sufficient for a
reliable analysis, but it could be
concluded that the greater the
number of the washing vessels,
the greater the probability of
having a jumping and refluxing
parallel channel.
As the strategy isn’t still well
established, it could be useful
to reduce the procedure to a
planned minimum, delaying
phlebectomies and FUGS to a
second moment.
The X-Paste terminology should
be used as much as possible in
order to increase our knowledge
of the GSV/SSV stump evolution.
In the same way, X-PASTE can
describe also the distal
behaviour.
Finally, it could be interesting to
record the length of the patent
GSV, i.e. not involved in the
saphenous closure, in order to
measure the re-usability of the
trunk for any useful future use.
Conclusions
A clinical protocol was designed
in order to simplify diagnostic
and therapeutic procedures3.
An OB CHIVA register is actually
available to gather cases
performed by other groups and
it is freely accessible on a
specialized website 9,10.
Though the OB CHIVA
experience is at the moment
preliminary and anecdotal, OB
CHIVA seems a promising
strategy and a simplified
organization of CHIVA in a more
friendly environment.
volver al sumario
Chiva strategy can
be performed in
office based setting
–the vasculab
experience.
11
IX
Abstract
1. Franceschi C. Theorie et pratique de la
Cure C.H.I.V.A. Theorie et pratique de la
Cure (C)onservatrice (H)emodynamique de
l' (I)nsuffisance (V)eineuse en (A)mbulatoire.
Editions de l'Armancon, Precy-sous-Thyl,
1988.
2. Passariello F. Office Based Chiva (OB
Chiva). Acta Phlebol 2011;12:26-7.
3. Passariello F, Ermini S, Cappelli M, Delfrate
R, Franceschi C. The office based CHIVA. J
Vasc Diagnostics 2013:1:13-20.
4. Comment to: The office based CHIVA, by
Passariello F, Ermini S, Cappelli M, Delfrate
R, Franceschi C. Veins & Lymphatics.
ByblioLab.2013.11.
5. The office based CHIVA. An open access
VLAB multicenter research protocol.
http://www.vasculab.it/obchiva.xml
6. Passariello F. X-PASTE: A ready-made
model for thrombosis evolution in the human.
(in press) Presented at the “Hemodyn 2013”
Meeting, Napoli, the II Vasculab Conference.
Accademia Aeronautica, Pozzuoli, November
7th–9th, 2013.
7. Wright D, Morrison N, Recek C,
PassarielloF. Post Ablation Superficial
Thrombus Extension (PASTE) into the
common femoral vein as a consequence of
endovenous ablation of the great saphenous
vein.Acta Phlebol 2010;11:59–64.
8. Passariello F. Post ablation superficial
thrombus extension (PASTE) as a
consequence of endovenous ablation. An
up-to-date review. Reviews in Vascular
Medicine 2/2014; 2(2): 62–66.
9. Passariello F, Gammuto P. Office based
CHIVA: a conceptual variation of CHIVA. The
OB CHIVA Survey. Reviews in Vascular
Medicine 12/2014; 2(4):123-126.
10. The Office Based CHIVA website,
available at the address
http://www.vasculab.it/obchiva/obchiva.xml
Accessed April 13th, 2015.
Chiva strategy gets
better results than
conventional
varicous surgery
Jordi Maeso Lebrun
Hospital Universitari Vall
d’Hebron, Barcelona
We began with CHIVA
(Haemodynamic treatment of
venous insufficiency
ambulatory) in June 1990. Up
to 1995 we used both CHIVA
Is the asval
technique
really overcoming
the chiva
limitations?
Docteur Paul Pittaluga
Riviera Veine Institut,
Monaco
Introduction
A mini-invasive surgical
approach preserving the
saphenous vein has been
described for the first time as
a “method” in 2005 called the
ASVAL (Ambulatory Selective
Varices Ablation under Local
anesthesia), while the CHIVA
cure (French acronym of Cure
Hémodynamique de
l’Insuffisance Veineuse
Ambulatoire) had been
described previously by
Franceschi at the end of the
1980s.
There are two methods
sparing the saphenous vein
for the treatment of varicose
veins with an hemodynamic
approach. However these two
methods are fundamentally
different and we will explain
why we think that the ASVAL
could be able to overcome
the CHIVA limitations.
and stripping at the same
time. But since 1995, we have
not used stripping at all, and
we operate on all our patients
only by CHIVA. This change
was based on better 3-year
results, as we reported in
2001. We compared patients
who underwent stripping with
a group treated by CHIVA, and
we had better results in the
CHIVA group.
When we do CHIVA technique
in contrast to stripping and
other techniques, we do not
destroy the great saphenous
vein (GSV).
The differences
between ASVAL and
CHIVA
The ASVAL and the CHIVA are
both saphenous sparing
procedures, based on an
hemodynamic approach,
which could be confusing for
differentiate this two
procedures.
The therapeutic principle
described by Franceschi in
1988 is to improve the
hemodynamics of SVN by
splitting the column of
hydrostatic pressure and
disconnecting veno-venous
shunts by interrupting the
incontinent axes at strategic
levels (sapheno-femoral
junction, perforator)
depending on a precise
preoperative Duplex-scan
assessment, in order to obtain
a system well drained, with
low pressure and high flow.
In order to summarize the
differences between ASVAL
and CHIVA:
• The CHIVA cure and the
ASVAL method are have
opposite theoretical
foundations and therapeutic
principles
• CHIVA: does not call into
question the descending
theory of varicose vein
development, treatment is
47
There are many reasons to
preserve the saphenous vein:
Because there is no
scientific reason for
saphenous ablation,
To achieve a draining
system, which can only
be done by preserving the
GVS
Saphenous vein diameter
decreases after CHIVA.
If we don’t remove it, we
can use it to treat other
diseases.
There are no randomised trials
reporting the long-term results
of ablative saphenous vein
techniques. We have three
about CHIVA. I present this
randomised trials.
Conclusion:
We can treat venous
insufficiency without
eliminating GSV with good
results
Evidence shows a very
good outcome with this
technique
based on strategic ligations
of the saphenous vein in order
to create a draining flow from
the superficial to the deep,
the varicose veins don’t need
to be ablated, universal
treatment indicated in all
cases of superficial venous
insufficiency
• ASVAL: based on ascending
or multifocal evolution theory
of the varicose disease from
the tributaries towards the
saphenous vein, treatment
consists on the careful
preservation of the entire
saphenous vein, with the goal
to obtain a reversibility of the
saphenous reflux, focused on
the treatment of the varicose
veins, not possible in all cases
of varicose disease.
• For the CHIVA that is the
hemodynamic disturbance
that creates the varicose
disease while at the opposite
for the ASVAL that is the
varicose disease that creates
the hemodynamic
disturbance.
• The CHIVA can be applied
in all indications of venous
insufficiency from C1 to C6,
while the ASVAL has limits in
its indications beyond which
the saphenous vein has to be
treated
Why do we defend
ASVAL against
CHIVA ?
The CHIVA partisans argue
that the scientific evidences
are supporting their theory
thanks to the publication of
RCTs, which are at the highest
level of evidence.
Three RCT comparing CHIVA
and stripping have been
published:
Zamboni et al observed that
for treatment of patient with
a venous ulcer CHIVA led
to a higher healing rate
(100% vs 96% P<0.02) and
a lower recurrence rate (9
vs 38% P<0.05) at 3 years
of follow-up.
Carandina et al reported at
10 years of follow-up better
results for CHIVA for the
frequency of varicose veins
recurrence (8 vs 35%
P<0.0038)
Parès et al showed a lower
frequency of varicose veins
recurrence after CHIVA that
after stripping at 5 years of
follow-up (31.1% vs 52.7%
P<0.001)
First of all, we have to notice
that all of these studies have
been conducted by CHIVA
partisans, none of them by
independent expert.
volver al sumario
References
11
IX
Abstract
In the study of Parès et al all of
the stripping have be done under
general or epidural anesthesia
while the CHIVA cures were
performed under local
anesthesia, which is a bias for
the evaluation of the
postoperative side-effects,
considered at a secondary
endpoint.
The most serious limit concerns
in both studies the main criterion
of evaluation that was the
“failure” of the treatment by the
assessment of a recurrence. The
definition of a failure and a
recurrence is totally unclear in
this study, mixing clinical
recurrences (using the Hobb’s
classification) and sub-clinical
recurrences (assessed by Duplex
scan).
Can we combine
hemodynamic and
ablation
techniques?
Sergi Bellmunt
The controversial nature of the
CHIVA cure, as well as its
conceptual complexity and
difficult execution by non CHIVA
experts, can explain the poor
results experienced by many
surgeons in the late nineties, and
why few teams still practice the
technique despite after a big
initial enthusiasm.
Parès said himself in its
conclusion that “proper surgical
execution [of CHIVA] was
guaranteed by the experience
of the surgeons—as evidenced
by their training as angiologists
and vascular surgeons, their
years of surgical practice and
the volume of patients treated
per year. » and « if training in this
method is not possible, a
properly executed stripping
intervention is better than a
poorly executed CHIVA
intervention ».
One can consider that a
technique, which is not
applicable by the largest part of
practitioners, is not a good
technique for the treatment of a
common disease.
The CHIVA supporters promote
the preservation of the SV
essentially so that it is available
for use as arterial bypass
material at a later date. But one
could question this use because
of the ligation of the SV during
the CHIVA procedure, leading to
a significant frequency of
postoperative saphenous
thrombosis.
The most serious opposition
against CHIVA should be against
its universal feature. How can it
be accepted that a theory
asserts explaining all aspect of
a such complex disease which
is the venous insufficiency, and
that a treatment excludes all the
other ones affirming to be able
to treat all cases of venous
insufficiency situation without
exception.
The CHIVA partisans have
founded their assertions on the
application of physical laws for
which there is no proof of full
applicability on the venous
system.
Even if these physical principles
are applicable, the venous
system is a chaotic system in
which the change of one variable
(for example the competence of
a perforator) can modify the
whole system. It appears very
pretentious to assert that CHIVA
can represent the whole
functioning of the venous
system, explains its dysfunctions
and offers a unique and
unquestionable option for its
treatment.
At the opposite to CHIVA, the
ASVAL method is based on the
ascending evolution theory of
the venous insufficiency,
supported by an increasing
number of publications and
experts. As the venous disease
is progressive, the indications of
the ASVAL are limited in
accordance with the importance
of the saphenous damages.
presence of saphenous reflux,
may be the first-line treatment
apart from the evolved stages,
because it is minimally invasive
and efficient enough.
Therefore the ASVAL doesn’t
exclude the other techniques of
treatment (stripping, endovenous
ablations) that can be indicated
depending on the stage of the
evolution of the venous disease
and the special situation
represented by each different
cases.
Conclusion:
No procedure can characterize
itself as “radical” with regard to
the treatment of varices,
probably because of the natural
history of varicose disease,
whose evolutionary nature differs
from patient to patient, thereby
calling into question the
traditional dogma of the
descending evolution, but also
the dogmas of CHIVA.
Consequently, regardless of the
treatment technique, it is logical
to contemplate a long-term
follow-up for the patients treated
for varices, with the adaptation
of the procedures and the choice
of techniques on a case-by-case
basis, with indications defined
in function of the hemodynamic
pattern, the clinical situation and
the patient concerns.
The ASVAL has its proper
indications and doesn’t exclude
the other techniques of treatment
while the CHIVA is the only
technique applicable in all of the
cases of venous insufficiency
according to its partisans.
Therefore the ASVAL appears
much more realistic.
Within this context, the choice
of a treatment limited to
phlebectomy, even in the
Introduction
Objectives
El objetivo del tratamiento CHIVA
es eliminar los shunts venovenosos mediante la
desconexión de los puntos de
fuga, la preservación de la vena
safena y el drenaje venoso
normal de los tejidos
superficiales de la extremidad.
CHIVA, entendida como una
estrategia, se puede realizar
mediante cirugía abierta, como
es habitual, o por medio de
procedimientos endovasculares
como el láser, la radiofrecuencia
o la escleroterapia.
Estudiar los resultados de la
aplicación de una estrategia
CHIVA usando técnicas
endovasculares para el cierre
del punto de fuga.
radiofrecuencia endovenosa del
tercio proximal de la vena
safena. El tratamiento de las
varices dependientes se realizó
mediante flebectomía y/o
fleboesclerosis complementaria.
Material used
Methodology used
Se incluyeron pacientes con
insuficiencia ostial de safena
interna y/o externa, con varices
dependientes e indicación de
reparación (C>=2 de la CEAP).
A estos pacientes se les realizó
cirugía, con estrategia CHIVA,
realizando el cierre del punto de
fuga (válvula ostial) mediante
Estudio de cohortes
48
Despite the absence of RCT, the
ASVAL appears more simple to
understand and easy to perform
by the wide majority of
practitioners, while the CHIVA
requires a perfect understanding
of its conceptual complexity and
a very good technical training
for its performance.
punto de fuga principal, que se
mantuvo a lo largo de todo el
seguimiento.
Conclusions of the study
La estrategia CHIVA puede ser
aplicada mediante la
combinación de diferentes
técnicas, entre ellas las
endovasculares.
Se han realizado 37
intervenciones en 34 pacientes
y se han seguido durante una
media de 12 meses (entre 1 y
38 meses). En el 100% de los
pacientes se logró un cierre del
volver al sumario
Concerning the paper of
Carandina there are some
important bias concerning the
randomization procedure:
among the 180 patients
matching the criteria of inclusion,
30 patients have been excluded
because of a refusal to be
included in the stripping group,
while none of the patient refused
to be included in the CHIVA
group. In addition the same
teams did not treat the two
groups and the number of
patients lost for follow up was
significantly higher in the
stripping group than in the
CHIVA group (28% vs 6%).
11
IX
Abstract
Alun H. Davies
Figure 1: Scierosant being aerated via the Tessari technique
Introduction
Chronic venous disease is a
highly prevalent condition in the
Western World. Reported
prevalence figures estimate that
80% of the population displays
evidence of venous disease, with
approximately 1/3 suffering from
varicose veins[1].
Venous disease is not only highly
prevalent, but also has a
significant impact on patients’
quality of life. Individuals with
varicose veins have reduced
quality of life scores[2], and there
is evidence that the rate of
depression is more than double
that of the general population[3].
European and US data have
estimated the cost of venous
disease at approximately 1-2%
of the total – health care
budget[4], while the UK National
Health Service (NHS) spends
£400-600 million annually[5].
2013, have described the role
of UGFS in the treatment of
patients with varic ose veins.
Sclerotherapy
Sclerotherapy entails the
injection of a chemical sclerosant
inside a vein, with the aim of
causing localized inflammation
and scarring. This can be
administered to treat anything
from dilated tributaries and major
truncal veins to small venules
and telangiectasiae. Three kinds
of sclerosants exist: chemical,
osmotic irritants and detergents.
In the United Kingdom
detergents are most commonly
used (sodium tetradecyl sulphate
1-3% and polydocanol 0.5-3%).
Sclerotherapy is now
administered in its aerated form,
or foam (Figure 1).
The decision as to whether a
treatment is funded by the NHS
or is at the individual’s expense
is influenced by a number of
factors, including patient and
clinician preference, resource
provision and local funding.
These last two factors rely heavily
on clinical guidelines providing
evidence – based guidance on
the assessment and
management of specific health
conditions.
Complications are uncommon,
including allergic reactions and
anaphylaxis, DVT (~1%), skin
pigmentation and tissue
necrosis, particularly in case of
extravasation. Neurological
complications are rare (<1%) but
may be serious, including
cerebrovascular accident (CVA),
transient ischaemic attack (TIA),
visual disturbances and
migraines. These are more likely
to occur in patients with a rightto-left cardiac shunt[6].
Ultrasound Guided Foam
Sclerotherapy (UGFS) is a
recognized treatment modality
for venous disease. The latest
NICE guidelines, published in
Historically, sclerotherapy was
administered in its liquid form.
Over the last 10 years ultrasound
guided foam sclerotherapy
(UGFS) has become the
standard of treatment. This has
been found to be more effective
and equally safe as liquid
sclerotherapy for the treatment
of truncal disease[7]. Foam
enhances the effect of the
sclerosant by displacing blood
within the vein, maximizing the
contact area between sclerosant
and vein wall[8], increasing
fibrosis and reducing the risk of
thrombosis.
The advantage of sclerotherapy
is that it is a quick procedure,
relatively inexpensive, with
minimal pain to the patient and
a fast recovery time.
The UK CLASS[9] trial assessed
the cost effectiveness of
ultrasound-guided foam
sclerotherapy (UGFS) when
compared to endovenous laser
ablation (EVLA) or surgery forthe
treatment of primary varicose
veins. The study recruited 798
participants, who were
randomized to the three arms.
Surgery was found to be the
most expensive treatment
modality, particularly due to the
overhead costs associated with
theatre use. Over a six-month
follow-up period, UGFS and
EVLA were less expensive
compared to surgery. However,
UGFS was found to yield less
gain in quality-adjusted life-years
(QALYs), compared to EVLAs
The authors extrapolated the trial
data over a five-year period; the
projected figures showed that at
five years
EVLA was the most cost
49
The National Institute for Health
Research published a systematic
review and economic evaluation
of minimally invasive techniques
to treat varicose veins[10]. The
clinical effectiveness, safety and
cost-effectiveness of UGFS,
EVLA and RFA were compared
to open surgery, liquid
sclerotherapy and conservative
management. 34 randomized
controlled trials were analyzed.
The assessment found that
differences in terms of clinical
outcomes were negligible.
However, pain was reduced in
UGFS and RFA when compared
to open surgery an EVLA, whilst
recurrence was reduced in the
EVLA and FS groups. FS was
found to be very cost effective,
whilst quality of life scores were
reduced in open surgery.
The effectiveness of UGFS has
been extensively assessed. A
prospective study on 977
patients followed up patients
with CEAP class 2-6 disease
being treated for primary and/or
recurrent truncal disease[11].
This found that UGFS was
associated with a low
complication and retreatment
rate. At a mean follow up of 28
months, 13% of legs required
further treatment. Complication
rates were low, with a 0.4%
incidence of venous
thromboembolism and 0.5%
having transient neurological
disturbance in the form of visual
abnormalities.
The Cochrane Collaboration
evaluated sclerotherapy versus
other treatment measures for the
treatment of GSV varices. UGFS,
EVLT and RFA have all been
found to be at least as effective
as surgery[12]. No significant
differences were identified with
regards to treatment failure or
recurrence.
However, individual studies have
suggested that recanalization
rates may be higher in UGFS. A
randomized controlled trial on
500 patients randomized to
EVLT, RFA, foam or surgery
revealed a 1-year recanalization
rate of 16.3% in the foam group,
approximately three times higher
than the other cohorts. However,
foam and RFA were better
tolerated than EVLT and
surgery[13]. The effectiveness of
sclerotherapy appears to be
dependent on the size of the
vein to be treated[14, 15] and
the presence of distal great
saphenous vein reflux[16].
Overall, the evidence suggests
that UGFS is a cost effective and
appropriate treatment modality
for venous disease in selected
patients. This is reflected in the
NICE guidance on the diagnosis
and management of varicose
veins, published in July 2013. It
provides evidence-based
recommendations for the referral
and treatment of patients with
volver al sumario
effective treatment modality,
when taking into account the
cost to perform it and the qualityadjusted life-years (QALYs)
gained.
According to the
nice guidelines,
it is true that
sclerotherapy
changes the
paradigm?
11
IX
Abstract
national standards for the
treatment modalities to be used
for these patients.
NICE Guidelines 2013[17]
The guidance is represented in
Table 1.
NICE guidance aims to provide
healthcare professionals with
national, evidence based
standards for the diagnosis and
management of different disease
processes, reducing the
heterogeneity of treatment
modalities across the country.
The updated NICE guidance on
the diagnosis and management
of the patient with varicose veins
covers a number of criteria,
including guidance with respect
to who should be referred from
primary to secondary care and
References
1. Beebe-Dimmer, J.L., et al., The
epidemiology of chronic venous
insufficiency and varicose veins. Ann
Epidemiol, 2005. 15(3): p. 175-84.
2. Darvall, K.A., et al., Generic healthrelated quality of life is significantly worse
in varicose vein patients with lower limb
symptoms independent of CEAP clinical
grade. Eur J Vasc Endovasc Surg, 2012.
44(3): p. 341-4.
3. Sritharan, K., T.R. Lane, and A.H.
Davies, The burden of depression in
patients with symptomatic varicose veins.
Eur J Vasc Endovasc Surg, 2012. 43(4):
p. 480-4.
4. Van den Oever, R., et al., Socioeconomic impact of chronic venous
insufficiency. An underestimated public
health problem. Int Angiol, 1998. 17(3):
p. 161-7.
Endolaser foam
ablation of truncal
veins. (Elaf).
Carlos Boné Salat
Centro de Tratamiento de Venas.
C/ Baró de Pinopar nº 7-3ª
07012 Palma de Mallorca.
Islas Baleares., Spain.
E-mail: [email protected]
The guidance encourages
primary care practitioners to refer
patients with symptomatic
varicose vein disease for early
assessment and management,
where appropriate. This includes
patients with symptoms such as
pain, aching, discomfort,
swelling, heaviness and itching),
skin changes, superficial
thrombophlebitis and previous
or current ulceration.
Patients should be assessed
with a venous duplex to assess
both the superficial and deep
5. Ruckley, C.V., Socioeconomic impact
of chronic venous insufficiency and leg
ulcers. Angiology, 1997. 48(1): p. 67-9.
6. Sarvananthan, T., et al., Neurological
complications of sclerotherapy for
varicose veins. J Vasc Surg, 2012. 55(1):
p. 243-51.
7. Rabe, E., et al., Efficacy and safety of
great saphenous vein sclerotherapy using
standardised polidocanol foam (ESAF):
a randomised controlled multicentre
clinical trial. Eur J Vasc Endovasc Surg,
2008. 35(2): p. 238-45.
8. Pannier, F., E. Rabe, and G. for the
Guideline, Results from RCTs in
Sclerotherapy: European Guidelines for
Sclerotherapy in Chronic Venous
Disorders*. Phlebology, 2014. 29(1
suppl): p. 39-44.
9. Tassie, E., et al., Cost-effectiveness
of ultrasound-guided foam sclerotherapy,
Purpose:
With the aim of improving the
treatment of truncal (main)
varicose veins in a completely
ambulatory manner without
using local anesthesia, we have
initiated a synergistic
physicochemical procedure,
involving the effect of an
sclerosing foam the energy
transmitted and released by the
laser to the venous endothelium,
thereby obtaining with this
association the endothelium
ablation with a frankly
outstanding result.
The use of this synergistic
venous systems, providing
anatomical and haemodynamic
data essential to plan
intervention.
With regards to management,
the guidance is very clear.
Conservative management, in
the form of graded compression
therapy, should only be used if
interventional treatment is not
indicated. Following
interventional treatment, they
should not be used for more
than 7 days.
In addition to encouraging early
referral, the NICE guidance
highlights the importance of
minimally invasive tools, such as
endothermal ablation
(radiofrequency or laser) and
endovenous laser ablation or surgery as
treatment for primary varicose veins from
the randomized CLASS trial. Br J Surg,
2014. 101(12): p. 1532-40.
10. Carroll, C., et al., Clinical effectiveness
and cost-effectiveness of minimally
invasive techniques to manage varicose
veins: a systematic review and economic
evaluation. Health Technol Assess, 2013.
17(48): p. i-xvi, 1-141.
11. Bradbury, A.W., et al., Ultrasoundguided foam sclerotherapy is a safe and
clinically effective treatment for superficial
venous reflux. J Vasc Surg, 2010. 52(4):
p. 939-45.
12. Nesbitt, C., et al., Endovenous
ablation (radiofrequency and laser) and
foam sclerotherapy versus open surgery
for great saphenous vein varices.
Cochrane Database Syst Rev, 2014. 7:
p. CD005624.
technique has allowed us to
reduce both the concentration
of the sclerosing agent and the
energy/fluence delivered by the
laser, so that we have
transformed it on a purely
outpatient procedure that can
be done in the medical office ,
without the strict operating
room.
Materials and methods:
We treated 73 patients, 68
females and 5 males with a
mean age of 46 years. We have
treated 77 incontinent greather
50
UGFS.
Conclusion
Patients with varicose veins and
truncal reflux should be offered
endothermal ablation as a first
– line therapy to treat the long
(LSV) or short saphenous vein
(SSV) reflux.
Over the last ten years the
treatment of venous disease has
significantly changed, moving
from open surgery to
endovenous techniques.
Sclerotherapy has retained its
role as a safe and effective
treatment modality for tributary
and truncal disease, particularly
in its aerated form. NICE
guidance has confirmed its role
as a safe and effective alternative
to endovenous ablation. This is
echoed by the UK
Commissioning Guidance
Guidelines[18] and the Clinical
practice guidelines of the Society
for Vascular Surgery[19].
If endovenous ablation is not
possible, e.g. in small or tortuous
veins, UGFS should be
employed. Open surgery,
previous considered the “gold
standard” intervention for
varicose vein surgery, should be
the last resort when treating
these patients. When necessary,
concomitant phlebectomies
should be performed to treat
tributaries.
13. Rasmussen, L.H., et al., Randomized
clinical trial comparing endovenous laser
ablation, radiofrequency ablation, foam
sclerotherapy and surgical stripping for
great saphenous varicose veins. Br J
Surg, 2011. 98(8): p. 1079-87.
14. Barrett, J.M., et al., Microfoam
ultrasound-guided sclerotherapy
treatment for varicose veins in a subgroup
with diameters at the junction of 10 mm
or greater compared with a subgroup of
less than 10 mm. Dermatol Surg, 2004.
30(11): p. 1386-90.
15. Cavezzi, A.F.A.R.S.T.L., Treatment
of Varicose Veins by Foam Sclerotherapy:
Two Clinical Series. Phlebology, 2002.
17: p. 13-18.
17. Excellence, N.I.f.H.a.C., Varicose
veins in the legs. NICE quality standard
67. 2014: p. 1-30.
18. Franklin, I.J., Berridge D., Bradbury
A., Davies A., Vaughan M., Evans D.,
Calam J., Krishna R., Commissioning
guide: Varicose Veins. 2013: p. 1-14.
19. Gloviczki, P., et al., The care of
patients with varicose veins and
associated chronic venous diseases:
clinical practice guidelines of the Society
for Vascular Surgery and the American
Venous Forum. J Vasc Surg, 2011. 53(5
Suppl): p. 2S-48S.
16. Shadid, N., et al., Predictors of
recurrence of great saphenous vein reflux
following treatment with ultrasoundguided foamsclerotherapy. Phlebology,
2014.
saphenous veins and 2 short
saphenous veins all with an reflux
greater than 1 second and an
average dilatation of 13.8 mm.
Under ultrasound guidance we
have channeled internal
saphenous veins with a double
lumen catheter positioning the
optical fiber tip at 2 cm of the
sapheno-femoral and saphenopopliteal junction . We
introduced through one of the
channels the optical fiber laser
and by the other channel we
have infiltrated the sclerosing
polidocanol foam at 1.5 %,
previously prepared with a
stopcock or a female-female
transfer device. The new process
consists in infiltrating 0.3-0.4 cc
doses of the sclerosing foam
every 1-2 mm and synergistically
releasing laser energy at a power
of at 1.5-2 watts every millimeter
by slowly withdrawing the
catheter and the optical fiber.
We used only local anesthesia
in the access point of the
catheter to the saphenous vein.
Patients remained with an elastic
compression for 2 weeks and
analgesia/anti-inflammatory
meds if needed.
volver al sumario
this condition and details the role
of UGFS in the treatment of
patients with varicose veins.
11
IX
Abstract
The day after the procedure all
internal saphenous veins treated
were occluded, remaining totally
occluded at one year of
treatment. The absence of pain
during the procedure was the
usual; only one patient presented
discrete inflammatory signs in
the middle third of the thigh. It
appears that physico-chemical
synergism of foam sclerotherapy
and laser action opens a
complementary new treatment
for truncal varicose veins, without
the need of perivenous
anesthesia, tumescent and/or
truncal, thus becoming a purely
outpatient treatment without the
need of an strict surgical
environment.
Key Words: Endolaser,
Sclerosing agent, Foam,
Synergy, physico-chemical
Ablation.
Introduction
The use of minimally invasive
techniques for the treatment of
truncal varicose veins has been
a major advance in their
treatment, becoming a surgical
treatment in a less aggressive
and purely outpatient procedure.
All techniques used nowadays
appear to be effective in
experienced hands. The practice
of Endovenous laser and their
results demonstrates its high
efficiency. To perform the
procedure local anesthesia in
several ways is used:
perivenous, tumescent and/or
truncal. Since the energy
released inside the vein and in
contact with the vascular
endothelium produces a thermal
ablation, analgesia-anesthesia
is required to proceed correctly.
In this new method we use the
synergy of two techniques
without the need for local
anesthesia for ablation of truncal
varicose veins and it can be
performed at the medical office
with the appropriate aseptic
precautions.
There are no limits in diameter
at the level of venous confluents
or on their pathway ; in fact the
immediate response is perfectly
verifiable by ultrasound (venous
spasm). This immediate
response is achieved with a
volume not exceeding 8-10 ml
of the sclerosing agent
polidocanol microfoam at 1.5%
-2% injected and controlled
under ultrasound . This allows
us to complement the action
synergistically with the thermal
energy of the laser with a
minimum dose, thus not
requiring the use of anesthesia
and converting this procedure
in strictly ambulatory.
Without doubt, the synergistic
action of these two procedures
transform the dynamics of the
treatment of varicose veins in a
strictly outpatient procedure
without requiring anesthesia
throughout the venous pathway.
Materials and methods
From February 2013 to the
present 79 truncal veins ( 77
greather saphenous veins and
two short saphenous veins ) ,
have been treated. The mean
age was 46 years. The mean
diameter of the treated veins was
13.8 mm. All patients were
diagnosed and studied with color
Doppler ultrasound in orthostatic
possition . Reflux in all cases
was greater than 1 second. Four
patients underwent bilateral
treatment.
A complete blood test and an
EKG study was performed on all
patients. The day of the
procedure patients were allowed
food and liquids without any
restriction and no medication
was administered before the
procedure. All patients signed a
written informed consent. The
procedure has been practiced
at a medical office without
sedation and only with local
anesthesia exclusively at the
point of entry of the catheter and
optical fiber.
We drew the patient with a
permanent marker
predominantly on discrete
abduction and/or supine position
according to Saphenous Vein
to treat with ultrasound
guidance. Only the entry point
of the optical fiber was marked.
A double lumen catheter was
used. The entry point may be
done with Seldinger technique
or by dissection, disconnection
and introducing the catheter after
ligated the vein distal end. We
proceed advancing the catheter
up to 2 cm of the saphenofemoral junction under
ultrasound guidance. Being
placed the fiber inside a channel
we can see at any time the laser
light guide. Only local anesthesia
is required at the entry point.
For this technique satisfies the
requirements for synergy we
have used a double system,
and treated with a dual lumen
catheter through which is
inserted first the optical fiber of
400-600 microns and the other
channel is reserved for the
introduction of the sclerosing
agent previously converted to
foam by the technique of
stopcock or with the use of a
female-female bioconector.
Nowadays we use a special
optical fiber of laser for this
purpose. In this way we act at
the same time introducing a
foam sclerosing agent with
ultrasound control, and releasing
the laser energy alternatively. The
routine is to introduce the
sclerosing microfoam and
shooting at the same time or 23 seconds after the laser once
it is verified the vasospasm and
this is performed in a retrograde
way.
The reaction and the synergistic
effects are immediate and we
can verify the venous spasm by
ultrasound and can notice the
crackling action of thermal
energy. The big advantage is that
no anesthesia is required
throughout the course of the vein
to be treated.
The concentration of the
sclerosing agent used is 1.5-2%
polidocanol manufacturing the
51
foam with 4-6 ml of the
sclerosing agent and 2-3 ml of
air. We only need about 8 to 10
ml of soft microfoam / soft foam
sufficiently stable to achieve the
desired effect (venous spasm).
The first and largest desired
effect is the above mentioned,
because it supposses the
endothelial irritation effect, and
it is increased and enhanced by
the thermal effect of the laser
energy in the lumen and/or
venous endothelial wall.
Energy used was 1.5-2.5 Watt
for 3 seconds intermittently
and/or continuously, alternating
with the administration of the
polidocanol foam. We should
not forget the effect enhanced
by the dual channel. And thus
acting in a short period pulses,
we obtained truly exceptional
results with a 100% occlusion.
The procedure takes less than
5 minutes once channeled the
vein and inserted the catheter.
Total time of the technique took
around 30 minutes.
In cases of patients with
associated tortuous tributary
veins, we proceeded in a first
step to the introduction of
polidocanol microfoam and at
the end of the procedure we
performed a segmental
microsurgery of the greater veins
pathways in connection with the
saphenous vein. We can leave
for a second time the treatment
of these veins (R III), whenever
necessary.
At all times the patient has been
controlled by ultrasound showing
the positioning of the fiber at 2
cm of the saphenofemoral/popliteal junction, the
immediate effect of spasm that
occurs when you inject the foam
sclerosing agent and also
observing the effect of the energy
released by the laser. Catheter
and fiber retraction has been
slow, thus allowing a synergistic
effect of sclerosing foam and of
the energy released by the laser.
These synergistic effects have
allowed us to reduce all
parameters, quantity and
concentration of the sclerosing
agent (only 8-10 ml of sclerosing
foam) and between 1.5 - 2.5
watts of power, depending on
the laser used. For this treatment
we have been used Polidocanol
1-2% diluted with saline and
mixed with air in a relation of 6
ml of this solution and 3 ml of
air. We have used several Lasers
810 -980 – 1740 nm and we
found a similar effectiveness. At
these small powers we have
tested the laser either in the
pulsed mode or continuous
mode, according to the laser
system used.
The channeling of the saphenous
vein was performed with different
catheters: 23 cm catheter5.0Fr,
(CookCheck-Flo Performer
Introducer September 5F);
subsequently double-lumen
catheters have been used
(BardAccessSystems5 Fand6 F).
Conventional optical fibers with
rounded tips have been used.
Nowadays we use a new optical
fiber that allows us to reduce the
time and improve the
procedure.
During the treatment, the
patients have tolerated perfectly
energy release without showing
discomfort at the most warmth
sensation. At the end of the
treatment a bandage and /or
compression stocking was
placed and the patient was
discharged. Patients were
reviewed in a week and at
1month, three and six months.
Results
For our procedure it seems
easier the insertion of the
catheter and optical fiber by
dissection, after placement of
local anesthesia at the entry
point, although we have also
performed it with the Seldinger
technique.
The use a new optical fiber to
greatly simplified the treatment.
It is simple to prepare the foam
sclerosing agent 1-2% with
either ambient air stopcock or
female-female connector.
volver al sumario
Results:
11
IX
Abstract
With this proposed method we
have been able to reduce the
laser energy to 1.5-2 w,
compared with the Endolaser
usual doses (10-12 w).
Time and /or energy release is
between 3-5 seconds, millimeter
by millimeter and removing the
catheter and fiber slowly.
We have not used in any case
perivenous, tumescent and/or
truncal anesthesia, being this
one of the great gains of this
technique that allows us to
perform the procedure in a fully
ambulatory way and in a
conventional treatment room.
In all cases performed we have
obtained a 100% of total
occlusion.
We underline that the tightness
that is typically felt (produced)
after a week with the
conventional Endolaser, has
disappeared in 90% of cases.
With this technique no bruising
References
1. OrbachEj. Sclerotherapy of
varicose veins: utilization of intravenous
air block. Am J Surg 1944:362-6
2. Cabrera Garrido JR, Cabrera-Olmedo
JR, Garcia-Olmedo Dominguez MA.
Elargissement des limites de la
sclérothérapie: noveaux produits
sclérosants. Phlebologie 1997; 50: 1818.
3. Tessari L. Nouvelle technique
dóbtention de la sclero-mousse.
Phlébologie2000 ; 53:129.
Advantages of laser
ablation combined
with sclerotherapy
Dr. Carlos boné salat
Flebólogo
was produced in any of the
cases.
We also did not observed cases
of paresthesia or numbness.
We have observed only one case
of discrete inflammation along
the venous pathway in the
middle 1/3 of the thigh, which
was solved with an elastic
compression and antiinflammatory drugs.
The evolution of this synergistic
procedure process is optimistic,
because of these preliminary
results, although new studies
with more patients and a longer
period of monitoring are needed
to verify the results obtained to
date.
Discussion
Endovenous techniques
currently offer a safe and
effective solution for the
treatment of truncal varicose
veins. The need for a preliminary
study of the patient with a
4. Boné C. Tratamiento Endoluminal de
las varices con láser de diodo. Estudio
Preliminar. Revista Patología Vascular.
Vol V. Enero 1999. Nº 1:31-39.
5. Navarro L, Mind R, Boné C.
Endovenous láser : A New Minimally
Invasive Method of Treatment for
varicose veins.Preliminary observations
using an 810 nm diode laser. Dermatol.
Surg. 2001;27:117-122.
6. Navarro L, Boné C. Lénergie laser
intravenous dans le traitement des
troncs veineux variqueux: Rapport sur
97 cas. Editions Phlébologiques
Françaises, vol.54,nº3/2001,p.193-200.
1) Utilizar sinergicamente dos
tecnicas al mismo tiempo (
endolaser+foam)
2) Por medio de una fibra óptica
especial que nos permite:
A. Administrar la energia
deseada al endotelio vensoso
así como la concentracion y
volumen deseado de
microespuma de
esclerosante. Baja dosis y
concentracion de foam y baja
potencia y fluencia de láser.
doppler instrumental diagnosis
is unquestionable. The decision
to use one technique or another
is professional-dependent
because both offer the
experienced practitioner and the
patient an excellent result.
Requiring hospital environment
sterile anesthesia, sedation etc
... somehow hamper the
patient's predisposition to
practice any surgical technique,
that is why the outpatient
techniques offer a real
opportunity for patients with this
type of pathology .
For outpatient treatment, we
believe that the current proposal
of the synergistic combination
of techniques, obviating the use
of anesthesia, can be a correct
protocol and marks an important
turning point in the practice of
these procedures.
From our point of view we
believe that the association of
low Endolaser fluence and the
synergistic use of low or soft
7. Min RJ, Zimmet SE, Isaacs MN,
Forrestal MD. Endovenous laser
treatment of the incompetent greater
saphenous vein. J Vasc. Interv. Radiol
2001;12:1167-71
8. Boné C. Navarro L. Láser
Endovenoso: una nueva técnica
mínimamente invasiva para el
tratamiento de las varices.
ENDOLASER. Anales de Cirugía
cardiaca y Vascular. 2001;7(3):184188.
9. Min RJ, Khilnani N, Zimmet SE.
Endovenous laser treatment of
saphenous vein reflux: long-term results.
J Vasc. Interv. Radiol 2003;14:991-6
3) No requiere anestesiar todo
el trayecto de la vena por tanto
evitamos la
anestesia
tumescente,perivenosa y/o
troncular
4) Transformar todo el
procedimiento en un acto
puramente ambulatorio que
puede afectuarse en consulta
medica sin necesidad de ser
practicado en quirófano.
5) Reducción importante del
tiempo operatorio ( 30 ´)
52
sclerotherapy foam
concentration for the treatment
of truncal varicose veins without
the use of anesthesia, provide a
safe and effective outcome for
patients. The satisfaction level
is very high, in great part due to
the ambulatory character of the
technique.
Conclusions
- The synergistic use of an soft
sclerosing foam agent and the
release of laser energy into the
incompetent vein shows: an
initial vasospasm followed by a
controlled ablative action of the
laser, achieving a reduction in
diameter of the treated vein and
the resulting ablation and
subsequent fibrosis of the vessel,
without the need for local
anesthesia.
- Occlusion was obtained
virtually in 100% of cases.
- This new procedure is a
synergistic physicochemical
10. Kabnick L. Outcome of different
endovenous laser wavelengths for great
saphenous vein ablation. J Vasc. Surg
2006;43:88-93
11. Boné C. Historia y evolución de la
aplicación de la técnica del láser
endovenoso en el tratamiento de las
varices. Angiología 2005;57 ( Supl I )
527-530.
technique, enhancing one to the
other, that offers very good
results, because with lower laser
thermal energy and less amount
and concentration of the
sclerosing agent, ablation is
achieved in the treated vein
segment.
- The fact of not requiring local
anesthesia to practice this
technique underlines its
minimally invasive nature and
therefore can be done in
conventional cure rooms.
- It is a completely outpatient
procedure, safe and effective ,
so we think it is a technique that
can complement existing ones
and we consider it extremely
practical and we believe it can
facilitate the treatment of truncal
varicose veins .
- Obviously, more cases and
longer follow up periods are
needed to verify these
preliminary results.
13. Frullini A. Fortuna D. Sclérothérapie
à la mouse assistée par laser (LAFOS):
une nouvelle aproche pour le traitement
de líncompétence des veinessaphènes.
Phlébologie 2013,66,1,p.51-54.
14. Boné C. Endolaser Foam Ablation
( ELAF ): Physico-chemical synergy.
New outpatient procedure of truncal
varicose veins without local anesthesia.
Phlébologie 2014,67,1p.26-29
12. Vuylsteke M.E., Mordon S.R.
Endovenous laser ablation: a review of
mechanisms of action. Ann. Vasc. Surg.
2012;26(3) : 424-433.
6) Evitar los efectos indeseables
del tratamiento con foam :
inflamación,flebitis
química,sclerus intravenoso por
tanto no requiere extracción del
mismo y por tanto se evitan las
hiperpigmentaciones.
7) Evitar los posibles efectos
indeseables de la accion del
láser: quemaduras y parestesias.
8) No hay limitaciones de
diametro
9) Las varices tributarias pueden
tratarse con foam y/o
flebectomia al mismo tiempo y/o
en un segundo tiempo.
10) Creemos que es la técnica
que ofrece mejores resultados
con un minimo gesto : oclusion
del 100%.
volver al sumario
Proportions are always the same.
11
IX
Abstract
Dr. José A. González-Fajardo
Servicio de Angiología y Cirugía
Vascular. Hospital Clínico
Universitario de Valladolid.
Introducción
Durante la última década,
numerosos métodos
mínimamente invasivos han sido
desarrollados para el tratamiento
de la insuficiencia venosa de la
vena safena. Estos métodos
ablativos tienen en común el
acceso percutáneo, el empleo
de anestesia loco-regional,
tiempos quirúrgicos cortos y
resultados de seguridad y
eficacia satisfactorios. Sin
embargo, estas nuevas técnicas
endotermales (láser o
radiofrecuencia) requieren del
empleo de anestesia
tumescente, que puede ser
fuente de disconfort y
complicaciones en el paciente.
Recientemente, un nuevo
sistema mecánico-químico
(Clarivein®) ha aparecido en el
arsenal terapéutico de los
cirujanos (1, 2). Este método
híbrido minimiza los aspectos
negativos de la ablación
endotermal, al prescindir de la
tumescencia anestésica, y
combina la aplicación de una
escleroterapia ecoguiada, que
consigue la oclusión venosa al
utilizar un dispersor rotacional
(3.500 rpm) dentro de la luz del
vaso. Este efecto mecánico de
erosión intimal induce un
vasoespasmo de la vena y una
mayor eficacia del esclerosante
al agitar y extender el producto
en sus paredes. Aunque los
resultados hasta ahora
publicados (3) indican una tasa
de veno-oclusión superior al
90% y una gran seguridad (no
fenómenos tromboembólicos
venosos), uno de sus
inconvenientes ha sido la
aparición ocasional de
tromboflebitis superficial,
especialmente en aquellos
pacientes con una vena safena
extrafascial o subdérmica.
Sistema clarivein
El sistema de veno-oclusión
Clarivein® consta de dos partes
esenciales: un catéter de
infusión, y una empuñadura
manual que controla su rotación
(Fig. 1). El catéter es flexible, con
marcas centimetradas en su
superficie, y con una apertura
distal por la que se perfunde el
esclerosante. Este catéter
dispone de un dispersor en su
punta que facilita mediante su
rotación el daño intimal de la
pared venosa y la agitación de
la solución perfundida con la
sangre. La configuración del
dispersor en forma de “palo de
golf” ha sido optimizada para
permitir la ablación mecánicoquímica de la vena, tratándose
de un cable estéril de acero
inoxidable que se extiende a lo
largo de la luz del catéter. Este
catéter debe purgarse con
solución salina antes de su uso.
Posteriormente, se coloca
dentro de la vena a través del
introductor de acceso
percutáneo, facilitando su
navegación hasta la confluencia
safeno-femoral o safeno-poplítea
con movimientos suaves de giro
que permitan su avance por los
lagos venosos o trayectos
tortuosos de la vena safena.
La empuñadura manual contiene
una batería de 9V que controla
la rotación del cable dispersor.
Antes de su uso se debe
confirmar que la carga eléctrica
es adecuada con el encendido
de una luz verde al apretar el
gatillo. Una vez que la punta del
catéter se posiciona
adecuadamente en la vena (2
cm de la unión safeno-femoral
para safena interna o en la curva
fascial de la safena externa), se
conecta al soporte de agarre.
Este anclaje es irreversible en el
sentido de que no podrá
desmontarse de la empuñadura
manual de fijación; tan sólo se
permitirá su carga o descarga
para la fijación de la jeringa con
la solución esclerosante. El
ensamblaje del catéter es óptimo
cuando se escucha un clic de
cierre, lo que permitirá la rotación
del cable dispersor y la perfusión
controlada y manual del fármaco
a través del sistema.
Sistema de Veno-oclusión Clarivein con sus
componentes
Detalles técnicos
En relación con su empleo
clínico, debemos tener en cuenta
los siguientes aspectos técnicos:
1. Verificar ecográficamente el
tamaño de la vena y su
morfología. El sistema no debe
emplearse en venas safenas
excesivamente tortuosas (que
imposibiliten el paso del catéter)
o con un diámetro igual o
superior a los 20 mm de
diámetro, ya que el daño parietal
mecánico conseguido por el
dispersor rotacional es mínimo.
En venas safenas con diámetros
superiores a 10 mm es
aconsejable la realización de una
ligera compresión manual que
facilite ese contacto.
2. Además de seleccionar
adecuadamente la longitud de
catéter (45 o 65 cm), se debe
determinar la concentración y
volumen del esclerosante en
relación con la vena a tratar
(longitud y diámetro). Aunque
una tabla está disponible para
calcular la infusión, en el caso
del polidocanol (etoxisclerol al
2%) se recomienda no superar
los 8 cm3 y separar la solución
en 2 jeringas de 4 cm3. Esto
nos facilitará la perfusión manual
a través del dispositivo y una
distribución homogénea a lo
largo de la vena.
3. El empleo de eco-doppler es
esencial para la aplicación de
este sistema. Los ultrasonidos
son necesarios para la
canulación eco-guiada de la
vena, el posicionamiento
53
adecuado de la punta del catéter
y la comprobación al finalizar el
procedimiento de que los
resultados han sido adecuados,
es decir, la oclusión de la vena
safena sin que el trombo se
extienda a la vena femoral
común o vena poplítea.
4. Aunque el producto suele
publicitarse de que no necesita
anestesia o que ésta queda
reducida al punto de canulación,
nuestra recomendación es que
debe hacerse en condiciones
quirúrgicas óptimas y con
sedación. No aconsejamos el
empleo de anestesia local, ya
que induce un vasoespasmo de
la vena y la aleja de la superficie
cutánea haciendo más difícil su
canulación percutánea. La
anestesia local debería
considerarse si se realiza un
pequeño acceso quirúrgico
abierto para la introducción del
catéter a través de la vena.
5. El catéter debe situarse a 2
cm del cayado safeno y es
recomendable iniciar la rotación
del dispersor durante unos
segundos sin perfundir ninguna
solución. Esta maniobra induce
un vasoespasmo de la vena,
genera mayor daño intimal y
minimiza posteriormente que la
perfusión de esclerosante
alcance el sistema venoso
profundo.
6. La técnica de empleo requiere
de las dos manos: mientras una
de ellas realiza la perfusión del
esclerosante y la retirada lenta
del catéter (pull-back), la otra
debe controlar el
posicionamiento de la punta
mediante una compresión ligera
de la piel. Esta sencilla maniobra
nos ayudará a localizar por la
vibración cutánea el
emplazamiento del dispersor
dentro del trayecto varicoso y a
distribuir adecuadamente el
volumen de esclerosante a lo
largo de la vena.
7. El catéter tiene que
mantenerse recto y es
fundamental tener en mente que
toda rotación debe
acompañarse de una retirada
lenta del sistema (Fig. 2). La
rotación del catéter sin perfusión
ni pull-back suele atrapar restos
valvulares venosos que pueden
obstruir el sistema de perfusión,
lo que se percibirá en un ruido
más rudo del motor y en una
mayor dificultad en la infusión
manual del esclerosante.
Cuando esto ocurra sugerimos
que se realice una pequeña
tracción para desplazar la punta
del catéter a otra zona inferior y
si la dificulta en la infusión
persiste desmontar y recolocar
el catéter en la “pistola” del
dispositivo.
8. La realización de un pull-back
adecuado (lento y uniforme) es
esencial para obtener una venooclusión apropiada. Si la retirada
del sistema se realiza rápida, es
previsible que los resultados no
sean los deseados. La velocidad
estimada es de unos 6-7 segundos
entre cada marca del catéter.
volver al sumario
ABlación
mecánico-química
de la vena safena
11
IX
Abstract
Conclusiones
La realización de un pull-back adecuado es esencial para obtener una veno-oclusión óptima. El catéter
tiene que mantenerse recto y toda rotación del dispersor debe acompañarse de una retirada lenta del
sistema que permita la perfusión uniforme del esclerosante.
9. Cuando se haya perfundido
la mitad del volumen de
esclerosante (lo que equivaldría
aproximadamente a la mitad del
catéter, 15-20 cm), se debe
retirar el introductor de acceso
a la vena a la posición más
proximal del catéter, cambiar la
jeringa de esclerosante (si fuese
necesario) y proseguir la ablación
mecánico-química de la vena sin
introductor para evitar que el
dispersor rotacional quede
atrapado en él. El sistema
rotacional y de perfusión debe
mantenerse hasta la aparición
de una marca blanca en el
catéter (a 8 cm de la punta),
posteriormente puede tratarse
unos 2-3 cm adicionales.
Besides the
product, strategy is
also important
have revolutionised the
management of varicose veins.
Procedures are indeed
increasingly being carried out as
day-cases or even as officebased interventions. Over the
past few years, even more
products have come onto the
market, with the promise of
improving the management of
the condition even further. Most
of them can be separated into
being either thermal techniques
(TT) or non-thermal, nontumescent (NTNT) technique.
R.Boothun, TRA Lane,
AHDAVIES
Varicose vein disease is a
common condition, causing
physical symptoms and affecting
the quality of life of patients1-5.
Treatment has been shown to
lead to both improvement in
symptoms and quality of life68. The conventional method of
treatment has been surgery, but
since the turn of the century,
newer, less invasive techniques
have been introduced and these
10. Por último, es necesario
realizar un vendaje compresivo
durante al menos las primeras
48 horas. En casos de vena
safena extrafascial es
recomendable aplicar una
compresión específica del
trayecto safeno (como un rodillo)
sobre la que iría el vendaje
elástico general del miembro. El
Endothermal Ablation
Endothermal techniques have
been around for more than a
decade and involve the
vendaje garantiza que la
compresión sea continua y que
el paciente no retire la
compresión elástica por
incomodidad durante ese
periodo crítico de veno-oclusión.
Posteriormente, se sustituirá por
una media elástica de
compresión que podrá retirarse
durante la noche y que deberá
usar en las primeras 2 semanas.
Es importante aconsejar al
paciente que realice
movimientos de dorso-flexión
del pie y una movilización precoz
transmission of thermal energy,
either from a radiofrequency
catheter or from a laser diode,
to vein wall. Their introduction
has transformed the
management of varicose veins,
so that, both the American
Venous Forum (AVF) (USA) and
the National Institute of Clinical
Excellence (NICE) (UK) have
recommended endovenous
thermal ablation as first line
treatment of varicose veins9, 10.
Radiofrequency Ablation
Radiofrequency ablation (RFA)
involves the transmission of heat
energy directly from an active
electrode to the venous
endothelium at a frequency
54
Los estudios hasta ahora
publicados son escasos y con
pequeño número de pacientes
(1-3). Todos parecen coincidir
en unas altas tasas de venooclusión al año de tratamiento
y la ausencia de complicaciones
mayores, especialmente
fenómenos tromboembólicos
venosos. La simplicidad de este
sistema es una de las grandes
ventajas frente a los sistemas
de ablación endotermal. En
términos de calidad de vida (4),
parece asociar menor dolor
postoperatorio y un retorno más
precoz a las actividades
laborales o diarias. Uno de sus
inconvenientes es la aparición
ocasional de tromboflebitis
superficial en venas safenas
extrafasciales, que suele remitir
con tratamiento antiinflamatorio
y el uso tópico de cremas
heparinoides. Aunque se
precisen de estudios a largo
plazo para validar sus resultados,
esta técnica de ablación
mecánico-química debe
considerarse como una
alternativa eficaz y segura para
el tratamiento de la insuficiencia
de vena safena.
ranging from 200 to 3000
kHz11. Radiofrequency (RF)
heats the narrow rim of tissue
(<1mm) which is in direct contact
with the electrode, while heat
transfer to the deeper tissues
occurs via conduction. The end
result is collagen contraction of
the vein wall or
thermocoagulation of the vein
wall11.
Goldman (2000) reported on 10
patients (12 limbs) with GSV
incompetence undergoing
radiofrequency ablation using a
Closure® catheter (VNUS
Technologies, Sunnyvale, CA,
USA). Following tumescent fluid
instillation and catheter device
positioning to within 1-2cm from
Referencias.
1. Boersma D, Van Eekeren RRJP,
Werson DAB, van der Waal RIF,
Reijnen MMJP, de Vries JPPM.
Mechanochemical endovenous
ablation of small saphenous vein
insufficiency using the ClariVein device:
one-year results of a prospective
series. Eur J Vasc Endovasc Surg
2013; 45: 299-303.
2. van Eekeren, Ramon R J P,
Boersma D, Elias S, Holewijn S,
Werson D et al. Endovenous
mechanochemical ablation of great
saphenous vein incompetence using
the ClariVein device: a safety study.
J Endovasc Ther 2011; 18: 328-334.
3. Elias S, Lam YL, Wittens CHA.
Mechanochemical ablation: status and
results. Phlebology 2013; 28 (suppl1): 10-14.
4. Van eekeren RRJP, Boersma D,
Konijn V, Vries JPPM, Reijnen MMJP.
Postoperative pain and early quality
of life after radiofrequency ablation
and mechanochemical endovenous
ablation of incompetent great
saphenous veins. J Vasc Surg 2012;
57: 445-50.
the sapheno-femoral junction
(SFJ), the RFA generator was
activated. Once the catheter had
reached 85°C for 30 seconds,
the catheter was pulled back at
a rate of 3.5cm/min11. At 3 and
6 months, all patients had
ablated GSVs and resolution of
all their pre-operative
symptoms11. A catheter
enabling segmental ablation was
subsequently introduced
(ClosureFast, VNUS Medical
Technologies Inc., San Jose, CA,
USA) and it offered the possibility
of treating truncal veins in
segments at a temperature of
120°C during 20-second
treatment cycles rather than the
pullback method utilised by
volver al sumario
como prevención de episodios
tromboembólicos venosos.
11
IX
Abstract
In a multicentre trial, the same
group demonstrated a GSV
occlusion rate of 91.9% and rate
of absence of reflux of 94.9% at
5 years13. The clinical morbidity
as assessed using a Venous
Clinical Severity Score (VCSS)
improved significantly compared
to baseline.
Endovenous Laser
Treatment (EVLT)
Around the same time, another
method to treat varicose veins
was initiated. Navarro et al.
(2001) described a series of 33
patients (44 legs) with GSV
incompetence who underwent
laser treatment. The distal tip of
the laser fibre was positioned 12cm below the SFJ and
tumescent local anaesthetic
(lidocaine 0.5% without
adrenaline) was infiltrated. Laser
energy was delivered at a
wavelength of 810nm along the
GSV as the laser fibre was slowly
pulled back in 3-5mm
increments. After a mean followup of 4.2 months, all 40 treated
GSV segments were found to
be occluded (100%)14.
A second study by Proebstle et
al. (2002) confirmed the efficacy
of EVLT in treating 26 patients
(31 limbs) with GSV
incompetence15. The technique
used was similar to the one from
Navarro et al (2001), except that
a 940nm laser system was
utilised. A complete occlusion
rate of 97% was demonstrated
up to 28 days after treatment
15. One patient consented to
having EVLT as part of his
conventional surgery with EVLT
administered immediately
following ligation of the SFJ, but
before stripping. Macroscopic
examination of the vein wall
revealed reddening,
carbonisation or even perforation
at those sites where the laser
fibre tip was closest to the vein
wall during delivery of laser
energy. Microscopic examination
showed that there was gross
vein wall destruction due to
direct impact of the laser beam.
The durability of the technique
was again illustrated in another
prospective, non-randomised
study of 490 patients (499
limbs)16. The initial follow-up at
1 month showed an occlusion
rate of 98% (490 of 499 limbs
treated), dropping to 97.5% (310
of 318 legs treated) by year 1
and 93.4% (113 of 121 legs
treated) by year 216.
Comparison of endothermal
methods and their complications
The endothermal techniques
have been compared and both
techniques seem to have similar
efficacy in terms of anatomical
success and improvement in
quality of life (QoL) 17, 18.
However, even though it appears
that RFA is less painful than
EVLT17, 19, there is equivocal
evidence as to whether RFA
leads to earlier return to normal
activities.
Both endothermal methods are
also associated with a number
of complications such as pain,
bruising, thrombophlebitis, skin
burns, skin pigmentation, nerve
damage, deep vein thrombosis
and endothermal heat-induced
thrombosis (EHIT)20, 21.
Foam Sclerotherapy
Sclerosing solutions react with
endothelium damaging it
(endosclerosis) and causing
fibrosis (endofibrosis) of the
vessel lumen22. Orbach (1944)
initially described the so-called
‘air block’ technique23, but after
high rates of treatment failures,
the 1990s saw the resurgence
of sclerotherapy when new
methods of transforming liquid
sclerosants into foam were
described24. Sclerosing agents
used as foam displace venous
blood and increase endothelial
contact, thereby, augmenting
their sclerosing power25. One
of the most widely used
technique to produce foam is
the Tessari method, which
requires two syringes and a
three-way tap and enables the
production of a stable and
compact foam25. The optimal
formulation was found to be one
part liquid sclerosant to four
parts air25. Evolution of the
technique have continued, with
the introduction of ultrasound
guidance (ultrasound guided
foam sclerotherapy) or catheter
directed foam sclerotherapy for
the treatment of truncal veins2628. Two of the most common
sclerosing solutions available are
sodium tetradecylsulphate (STS)
and polidocanol (POL), with foam
sclerosants being found to be
superior to the liquid version29.
The VANISH-2 trial was a
randomised, blinded multicentre
trial looking at polidocanol
endovenous microfoam (PEM)
injections to treat GSV
incompetence. PEM delivers a
low-density sterile polidocanol
injectable microfoam from a
proprietary canister system38.
A very precise ratio of oxygen
and carbon dioxide (65:35) with
low nitrogen content is the gas
mixture used in the technique,
which allows formation of
microfoam with stable bubbles
measuring no greater than
500μm. At week 8, the occlusion
rate was 83% in the PEM 0.5%
group compared to 86% in the
1.0% PEM group38.
The efficacy of foam
sclerotherapy is somewhere
between 72% to 88%18, 30-33.
Mechanochemical
Ablation
The longest data to date
following UGFS has been
reported by Darvall et al.
(2014)34. They described the
patient-reported outcomes 5-8
year following treatment with
UGFS. Out of the initial 351
patients (479 limbs) treated, 285
(81.2%) attended follow-up a
minimum of 5 years later. Using
a Kaplan-Meier plot, they
estimated the proportion of their
cohort requiring retreatment at
5 years to be 15.3%. The same
group also demonstrated that,
as well as improving the quality
of life of patients, UGFS is less
painful and leads to earlier return
to work compared to surgery3537.
55
Complications associated with
UGFS include phlebitis, skin
pigmentation, thromboembolism
(pulmonary embolus or deep
vein thrombosis) as well as
neurological symptoms such as
migraines, transient ischaemic
attacks or visual disturbances30,
39. The occurrence of
neurological symptoms have
been attributed to the presence
of a patent foremen ovale (PFO),
a common finding in the
population (20-30%)39.
The ClariVein®
mechanochemical ablation
(MOCA) device (Vascular
Insights, Madison, CT, USA)
combines an endovenous
mechanical method using a
rotating wire with simultaneous
injection of liquid sclerosant40.
The wire rotates at 3500
rotations per minute, injuring the
venous intima while the
sclerosant is infused through an
opening close to the catheter
tip40.
Studies so far have shown
MOCA to have a short-term
occlusion rate close to 90% and
to lead to improved QoL of
patients40-43. Moreover, it is
apparent that MOCA is also less
painful than endothermal
methods like RFA even though
it is unclear if it leads to earlier
return to work/normal
activities44, 45. Hopefully, the
MARADONA trial
(Mechanochemical endovenous
Ablation versus RADiOfrequeNcy
Ablation in the treatment of
primary great saphenous vein
incompetence), designed to
directly compare the anatomical
and clinical success rate of
MOCA compared to RFA over 5
years, be able to provide
answers as to the long-term
efficacy of the technique46.
Cyanoacrylate Glue
The Sapheon Venaseal Closure
System (Sapheon Inc., Santa
Rosa, Calif, USA) makes use of
cyanoacrylate (CA) glue to treat
venous incompetence. N-butyl
cyanoacrylate is an adhesive
liquid monomeric agent which
quickly polymerises and
becomes solid when it comes
into contact with a solution
containing anions (e.g., with the
hydroxyl groups in blood)47. This
subsequently leads to occlusion,
marked inflammatory endothelial
response, and, ultimately
fibrosis47. The polymerisation
of CA has revealed three distinct
stages48. The initial phase
(phase I) demonstrated a linear
rate of increasing tensile forces
lasting less than 10 seconds
followed by phase II which had
a more constant tensile force
(lasting up to 1 minute).
Polymerisation was, however,
not achieved in either phases. A
final step (phase III) started at
the end of the second phase
and was characterised by an
exponential rise in the tensile
forces which lead to complete
polymerisation48.
Early studies indicate an
occlusion rate of greater than
90%49-51. The VeClose study,
a multicentre randomised
controlled trial comparing
cyanoacrylate embolisation and
radiofrequency ablation for
refluxing great saphenous veins
showed that, at the 3 month
point, the occlusion rates was
volver al sumario
Goldman (2000)11, 12. After
percutaneous access was
obtained, the 7-cm segmental
heating catheter was inserted
and positioned between 1-2cm
below the sapheno-femoral
junction (SFJ). Tumescent fluid
was injected to control
treatment-related pain, reduce
the diameter of the vein being
treated and protect surrounding
structures from heat damage12.
At the initial catheter position
close to the SFJ, two 20-second
cycles were delivered, with each
subsequent segments receiving
only one cycle. At the 6 months
follow-up, the occlusion rate
based on a Kaplan-Meier
method was 99.6%12.
11
IX
Abstract
Conclusion
The management of varicose
veins has changed considerably
over the past decade.
Endothermal techniques are the
current gold standard, but the
newer NTNT, especially MOCA
and cyanoacrylate glue, are
attempting to challenge this.
Longer term studies of these
methods are ongoing and,
hopefully, will be able to clarify
the respective advantages of
each.
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volver al sumario
99% for CA and 96% for the
RFA group52. The quality of life
improvement was similar in both
groups.
11
IX
Abstract
liquid content and gasses which
were absorbable. As implied by
the title, the original microfoam
was created in an ad-hoc
manner by a beating process
which concluded when the foam
became stiff, like meringue.
Dr David Wright
To take the concept to an
approvable pharmaceutical
product, the characteristics had
to be measured, defined and
reproducible, the product had
to be sterile and then proven to
be both safe and effective.
VP Medical Affairs, BTG
International
Injectable microfoam has its
origin in Spain having been
invented by Dr Juan Cabrera in
1993; the specific characteristics
of his ‘microfoam’ were uniform
small bubbles with relatively low
Is it possible
improve tessari´s
foam?
Enric Roche
Clinica Vascular Barcelona,
Hospital Universitari Sagrat
Cor/General de Catalunya.
Barcelona.Spain
Introduction
All those reasons convinced us
to look for a new system which
solves those weak points. We
had the opportunity to develop
a prototype which is useful for
making stable and versatile foam
with a standardized system.
European
Guidelines for
Sclerotherapy in
Chronic Venous
Disorders
Fidel Fernández Quesada
Early studies confirmed
effectiveness but also highlighted
issues concerning the presence
of bubbles in the circulation and
the presence of sclerosant on
the surface of the bubbles but
without clinical side effects.
Objectives:
The aim of the study was to
demonstrate the feasibility of a
new system of standardized
foam fabrication and its
superiority in front of Tessari´s
method in terms of stability and
versatility.
Material and method
This method consists in a
magnetic stirrer with adjustable
speed on which we place a
sterile container. Inside the
container, there is a rotating
piece, which rotates upon
actuation of the agitator system.
The cover of the receptacle
contains a valve, which allows
the introduction of sclerosing
product and gas. Gas mixture
introduction is done by a
introducer piece which is split in
two parts: one for inject gas and
the other for expelling the air.
We used 0.5% and 2%
Sclerotherapy is a widely used
approach for treatment of
venous disorders, and possibly
increase its use over other
techniques because of its good
aesthetic results, its low
aggressiveness, good tolerance
and especially the preference of
therapists and patients.
Non clinical studies
demonstrated in-vitro and invivo that while bubbles persisted
in the circulation, bubbles did
not contain additional residual
polidocanol and that oxygen :
carbon dioxide gas mixture was
rapidly absorbed such that it did
not obstruct the
microvasculature, in a rat and
also in a large dog model.
In a definitive study, 82 patients
with patent foramen ovale (PFO)
and great saphenous
incompetence were treated with
Varithena®; 60 patients were
shown to have bubbles in the
middle cerebral artery during or
immediately after treatment.
Despite the presence of
numerous small bubbles, there
Polidocanol (POL) either with
atmospheric air or a mixture of
O2/CO2 50/50%. The liquid/gas
ratio in Tessari’s system was 1cc
/ 3 cc. Latex free syringes of 10
cc BD brand and B/Braun and
3way stopcock were used
(Twenty passes). Foamer system
automatically obtained the
necessary gas to form the foam.
For each foam, the half-life for
drainage and the bubble size
were measured.
Results:
Foams obtained by the agitator
showed a half-life for drainage
of 6.5±3 and 10.6± 3 minutes
(IC 95%) for 0.5% and 2% AES
respectively. Tessari´s foam
presented half-lives of 1.1 ±0.5
min and 2.0 ±0.5 (95 % CI) for
0.5% and 2% respectively. By
using the mixed gas (O2/CO2)
with POL 2%, half-lives of
2.2±0.5 minutes were obtained
In the past two decades, foam
sclerotherapy has a prominent
role versus the classic liquid
treatment, due to several causes,
most effectively, be visible
sonographically and especially
its high acceptance by patients.
In 2003 and 2006, in Tegernsee,
Germany European Consensus
57
were no neurological adverse
events and no subclinical events
on diffusion weighted MRI.
In the pivotal studies 1 and 2,
511 patients were treated for
symptomatic saphenofemoral
junction and trunk vein
incompetence and visible
varicose veins. Primary,
secondary and all tertiary
endpoints were met with clinical
significance (p<0.001).
Importantly, the primary and
secondary endpoints were
patient orientated with reduction
in symptoms and improvement
in appearance.
FDA submission contained data
from numerous non clinical
studies and 13 clinical studies
from 1333 patients
demonstrating that Varithena®
improved symptoms and
appearance. Adverse events
were generally mild and
expected, overall thromboses
were identified in 7.1%, they
were generally small and
asymptomatic, the most
common being extension of
thrombus at the saphenofemoral
junction. There were no
pulmonary emboli diagnosed.
FDA approval was granted on
25 November 2013, nearly 14
years after the first clinical study
was started. Varithena® is
currently marketed commercially
in the US and as yet is not
approved in any other territory.
with the stirring compared to
1.0±0.5 minutes obtained by
Tessari’s method. The liquid
fraction of the foams prepared
with the present method were
0.093 ±0.0009 with 0.5% AES
and 0.081 ±0.016 with 2% AES.
These fractions correspond to
1/9 and 1/10 ratios. Using
O2/CO2 the gas ratio was 1/6
(0.14 ± 0.02). Foams prepared
with 2% AES are more stable
than those prepared with 0.5%,
irrespective of gas and method
used. Relative width of 2% foam
was greater than 0,5%.
Consistently the foams prepared
with air are significantly more
stable than those prepared with
the mixture O2/CO2.
Measurements showed that
Tessari’s method generates
wider bubbles size distributions,
resulting in significant
populations of oversized bubbles
(diameters larger than 150 mm).
Therefore Tessari´s foam was
more heterogeneous
Meeting on Foam Sclerotherapy,
was held the first and second
Edition of this important
consensus, that which
represents an important advance
in the standardization,
dissemination and knowledge of
sclerotherapy, indications, risks
and techniques. Those
consensus are based on the
relevant opinions of variuos
experts at European level, and
contributed fundamentally to the
settlement of sclerotherapy as
a first line treatment tool in
venous disease. Moreover, they
have been the basis for a huge
number of national consensus
and guidelines all over the world.
Conclusion
This system is useful in
manufacturing foam with air as
well as with a gas mixture of
O2/CO2. It is a versatile system
to make foam because it is
possible to obtain high quality
foams from 0,5% to 2% or
higher. The resulting foam is
more than five times more stable
compared to Tessari´s method
when using air and twice when
using a mixture of O2/CO2. The
higher the concentration of
Polidocanol the greater is the
stability. The standardization of
parameters and ease of
manufacture can be useful in
offices where sclerotherapy is a
common practice.
volver al sumario
Varithena ® from
kitchen to fda
approvall
11
IX
Abstract
Guidelines recommendations are
graded graded according to the
American College of Chest
Physicians Task Force
recommendations on Grading
Strength of Recommendations
and Quality of Evidence in
Clinical Guidelines
Adverse Events: do
we have
pathophysiological
evidences?
(Is it safe to perform
foam sclerotherapy?
1° Step
I. Tessari L*, Cavezzi A**, Izzo
M***, Zini F°, M. Tessari°°°,
Stefania De Feo****, Daniela
GRIGOLATO***** Fanelli R°°
* Glauco Bassi Foundation, Trieste, ** Vascular
Unit Clinic Stella Maris, S.Benedetto del Tronto,
*** Math. Tech. Med. Univ. Studi Ferrara, °
Casa di Cura Città di Parma, Parma, °° Mario
Negri Pharmacology Institute, Milan, °°° Studi
Tessari Peschiera del Garda.*** Servizio di
Cardiologia Casa di Cura Dr. P. Pederzoli
Peschiera del Garda Verona Italy ***** Servizio
Autonomo di Medicina Nucleare Ospedale
Maggiore Borgo Trento Verona Italy
Email: [email protected]
Foam sclerotherapy, which started
to be diffused ten years ago,
radically changed phlebology world;
furthermore the usage of duplex
guidance and of colour-duplex
control of our treatments, led us to
assess the pathways and diffusion
of the microbubbles of sclerosant
foam; as a result a few hypotheses
have been formulated on foam
bubbles propagation, whereas, in
comparison, no studies have been
performed on liquid sclerosants
from this point of view
Several authors highlighted the
necessity to study and assess the
propagation of the gas
microbubbles and/or of the drug
within the bubbles in this “modern”
sclerotherapy
The content of the guidelines
provides not only legal support
The aim of this study is to highlight:
1- if bubbles and drug are linked or
separated in their pathway within
the blood stream
2- the possible changes of bubble
propagation induced by various
therapeutic procedures (such as
limb elevation, immobility after the
injections, etc.)
3- if labelling the sclerosant drug
with labelled technetium
(Pertecnetato 99mTCO4-) may be
a correct procedure to highlight the
pathway and propagation of the
sclerosant drug in foam
sclerotherapy.
A first study with echocardiography
has been performed on one patient:
the arrival time of the bubbles and
their persistence modalities and
time within the atrium (after a
standardised injection of sclerosant
foam) have been monitored and
calculated in different time intervals.
Four mls of foam (Tessari method)
of Polidocanol 0,5%+CO2 O 2
have been injected in the left great
saphenous vein and in a right
posterior calf tributary; in another
case 4 mls of sclerosant foam
(Tessari method) of Polidocanol
0.5% + air have been injected in a
left posterior calf tributary. Any
difference in the bubble movement
related to limb elevation,
immobilisation-mobilisation has
been assessed furthermore.
The second study has been
performed to assess the possibility
to label sclerosant
drug/microbubble with label
technetium (Pertecnetato
99mTCO4The same patient has been
investigated indifferent times as to
his pulmonary transit and his
captation of the labelled marker
within his captation organs (thyroid
in the use of a treatment that in
many cases can be considered
off-label, also is a useful
compendium of the indications,
contraindications, techniques,
studies and monitoring results
should be considered when
perform sclerotherapy
treatments.
The aim of the presentation is to
in primis, salivary gland, kidneys ,
stomach, etc.); more in details the
following assessment have been
performed:
1 - The pathway of FREE
99mTCO42 - The pathway of 99mTCO4within sclerosant foam made with
Polidocanol 2% + air
3 - The pathway of 99mTCO4within sclerosant foam made with
Polidocanol 2% +CO2 O 2
Sodium Tetradecylsulfate 1% +
CO2 O 2
Sodium Tetradecylsulfate 1% + air
Results
The three main outcomes of our
studies are summarised below:
1 - By means of echocardiography
it is not possible to highlight any
link between drug and bubbles
2 - Elevation of the limb and postinjection limb immobility significantly
influence the passage of the
microbubbles in the blood
stream/heart propagation
3 - The labelling of the sclerosant
drug with Pertecnetato 99mTCO4is not an adequate procedure to
highlight the pathway of the
sclerosant drug in foam
sclerotherapy; further details will be
provided on this part of the studies
4- is absolutely necessary, at this
point, apply new study:
2° Step
Aims: following to a few in vitro trials
which showed sclerosant drug
interaction with blood components,
this experimental trial was designed
58
highlight and summarize the
main aspects of the European
Guidelines such as definition of
sclerotherapy, indications,
contraindications, complications
and risks (adverse effects, severe
adverse effects), Patient
informed consent, diagnosis
before sclerotherapy and
documentation, management of
sclerotherapy of varicose veins
(sclerosing agents, liquid and
foam sclerotherapy, injection
technique and material,
ultrasound-guided sclerotherapy,
foam production, volumes and
concentration) and
potsprocedure management to
provide a practical resume of
most significative aspect of
sclerotherapy use in clinical
practice.
to assess in vivo binding between
sodiumtetradecysulfate (STS) drug,
which is contained on sclerosant
foam (SF) microbubbles, and blood
proteins.
Conclusions:
Patients and Methods: two different
groups of patients were submitted
to ultrasound guided foam
sclerotherapy with 3% STS
+CO2O2 based SF, which was
formed through Tessari method. In
group A 4 patients (2 great
saphenous vein (GSV), 1 small
saphenous vein (SSV), 1 Alcock
canal vein (ACV)) had 5 cc injection
of SF. Immediately before the
injection (T0) and 1’, 5’ and 10’ after
the injection blood samples were
retrieved from left brachial vein. In
group B 5 cc of SF were injected
in a varicose tributary of the leg of
two patients with GSV
incompetence. Immediately before
, 1’, 3’, 5’ and 10’ after the injection,
blood samples from the homolateral
common femoral vein and from left
brachial vein were retrieved. Titration
of free STS and of total, proteinbound STS (BSTS) were performed
by means of a solvent assisted
extraction and a molecular filter with
a 10KdA cut off (for protein filtration).
Results: in group A (brachial vein
samples) BSTS (total STS) titration
was respectively 0%at T0, 0.5%
(GSV and SSV injection) and 8%
(ACV injection) after 1’, 5-7% (GSV
and SSV) and 37% (ACV) after 5’,
9-21% (GSV and SSV) and 38%
(ACV) after 10’. Free STS titration
at T0, after 1’, 5’ and 10’ was 0%
in all samples. In group B (common
femoral vein samples) BSTS (total
STS) concentration (μg/ml) at T0,
after 1’, 3’, 5’ and 10’ was: 0, 0.568,
13, 24, 6 and 8.67 for the first
patient, and 0, 42.9, 18.5, 8.33,
5.43 for the second patient. Free
STS titration was 0 (nil) in all samples
for both patients.
this in vivo study definitely proved
that when injecting 3% STS SF in
the veins of the lower limbs, blood
proteins bind STS of SF
microbubbles in less than 1’. More
importantly no free (active) STS has
been found in common femoral vein
and beyond pulmonary circulation.
Conversely BSTS
(pharmacologically inactive) is
tracked throughout the lower limb
and central veins circulation.
Referencias.
Parsi K, Exner T, Connor DE, Herbert A, Ma
DD, Joseph JE. Thelytic effects of detergent
sclerosants on erythrocytes,
platelets,endothelial cells and microparticles
are attenuated byalbumin and other plasma
components in vitro. Eur J VascEndovasc
Surg 2008;36:216e23.
Parsi K, Exner T, Connor DE, et alt. In vitro
Effects of Detergent Sclerosants on
Coagulation, Platelets and Microparticles
Eur J VascEndovasc Surg 34,731-740 (2007)
Parsi K, Exner T, et alt. In vitro Effects of
Detergent Sclerosants on Antitrombotic
Mechanism Eur J VascEndovasc Surg 2009
M.R. Watkins Deactivation of Sodium
Tetradecyl Sulphate
Injection by Blood ProteinsEur J Vasc
Endovasc Surg (2011) xx, 1e5
Cavezzi A, Tessari L. Foam sclerotherapy
techniques: different gases and methods of
preparation, catheter versus direct injection.
Phlebology 2009;24:247e51.
L. Tessari, P.G. Giorgetti, D Grigolato, May
sclerotherapy cause a pulmonary injury?
Preliminary results with dynamic scans of the
thorax using 99mTc pertecnethate Abstract,
XVI World Meeting of the Union Internationale
de Phlebologie Montecarlo 31/08/2009 04/09/2009
L. Tessari, P.G. Giorgetti, D Grigolato, A.
Vicentini,S DeFeo,Chasing the bubbles and
the drug in foam sclerotherapy; Abstract
9th International Congress of Phlebology
Duplex Ultrasound and endovenous treatments
Bologna, ITALY April 4-5, 2008
H. Milleret, H. Mehier, Foam and Lungs: a
scintigraphic study. Abstract and Presentations
ACP Tucson 2007 may
volver al sumario
In 2012, a conference organized
by the German Society of
Phlebology in Mainz, with the
behalf of 22 European
Phlebological Societies, gave
rise to the appearance of the
first European guidelines for
clinical practice in sclerotherapy,
which has meant a step further
(higher legal representation and
institutional support). The
11
IX
Abstract
Houman Jalaie
La anticoagulación
és la única
terapéutica basada
en la evidencia:
¿los nuevos
anticoagulantes
son todos iguales?
Dr. F. García-Bragado Dalmau.
Servicio de Medicina Interna.
Hospital Universitario Dr. Josep
Trueta. Girona.
El objetivo de la anticoagulación
en el tratamiento de la trombosis
venosa profunda (TVP) es doble;
en la fase aguda el objetivo es
evitar la progresión del trombo,
mientras que en la fase de
tratamiento a largo plazo el
objetivo es evitar las
recurrencias.
El tratamiento clásico de la TVP
consiste en la utilización de
heparina de bajo peso molecular
(HBPM) o heparina no
fraccionada (HNF) en la fase
aguda de tratamiento, por su
rápido inicio de acción, seguida
de fármacos antivitaminas K
(AVK) en las fases de tratamiento
a largo plazo y extendido si
procede. (1)
In this review we evaluated the
effect of different suggested
factors associate with the
outcome after recanalization of
chronic venous obstruction
(CVO).
Hemodynamic factors:
Based upon literature no clear
suggestions can be made to
identify the risk of stent occlusion
in association with the
hemodynamic effects. However
it is evident that ensuring optimal
in- and outflow of the stented
tract is key in maintaining the
patency.
Los AVK son unos
anticoagulantes eficaces pero
tienen múltiples inconvenientes
entre los que cabría mencionar
la variabilidad de su acción
anticoagulante interindividual,
por polimorfismos genéticos
responsables del 50 al 60% de
variabilidad de las dosis
necesarias (2), e intraindividual
por su interacción con alimentos
y con múltiples fármacos (3).
Además, su ventana terapéutica
es muy estrecha, en un INR
(International Normalized Ratio)
entre 2 y 3, de manera que
cuando el INR es inferior a 2 la
incidencia de trombosis aumenta
mientras que cuando es superior
a 3 lo que aumenta son las
hemorragias. Estos
inconvenientes obligan en la
práctica clínica diaria a que a
todos los pacientes
anticoagulados con AVK se les
deba de monitorizar el INR con
la finalidad de ajustar las dosis.
Patient selection:
Noninvasive imaging modalities
are used to divide patients in
three subgroups based on the
place and extension of postthrombotic changes. Moreover
it should be noted that AV fistula
in selected patients can reduce
the risk of thrombosis or reocclusion.
Geometry:
Excessive oversizing of the stent
and stent compression from
outside are considered to be
associated with stent occlusion.
(7) y muy pronto dispondremos
de edoxabán (8), todos ellos
inhibidores directos del factor
Xa. Todos ellos tienen un inicio
y cese de acción rápido; no
tienen interacciones con
alimentos y muchas menos
interacciones con fármacos que
los AVK; su acción
farmacocinética y
farmacodinamica es predecible,
lo cual hace que se
puedan administrar a dosis fijas
y sin necesidad de
monitorización y además, los
estudios han demostrado que
son coste-eficaces. En la tabla
nº 1 se exponen las principales
diferencias entre los AVK y los
NAOD.
Los NAOD tienen también
algunos inconvenientes. Todos
ellos, en diferente grado, tienen
eliminación por vía renal lo cual
Additionally, overlapping rigid
stents, unnatural angel between
stents and in-stent kinking are
other geometrical factors related
to worse outcome after venous
recanalization.
Anticoagulation:
Result:
impaired inflow or outflow,
presence of a hypercoagulability,
total number of treated
segments and use of stents
designed for implantation in
arterial system are associated
with decreased stent patency.
Adequate peri-and postoperative
anticoagulation has a crutial role
in stent patency. There is no data
regarding the duration of
anticoagulation therapy and
recommendations vary between
6 weeks to 6 months.
implica que cuando hay
insuficiencia renal el área bajo la
curva aumenta. Su uso está
contraindicado en pacientes con
enfermedad renal crónica en
estadio 4 y 5, mientras que en
aquellos en estadio 3 se
aconseja reducir la dosis. Una
recomendación fuerte es calcular
el filtrado glomerular antes de
prescribir un NAOD y
periódicamente mientras el
paciente continúe en
tratamiento.
Otro inconveniente es que no
disponemos en condiciones de
práctica clínica habitual de
pruebas de laboratorio que nos
informen del nivel de
anticoagulación. Las pruebas de
las que disponemos tienen
únicamente un valor cualitativo.
Para dabigatran existen ya
pruebas con muy buena
correlación entre los niveles del
fármaco y el grado de
anticoagulación, como son el
tiempo de ecarina o el tiempo
de trombina diluido [Hemoclot];
mientras que para los inhibidores
del factor Xa pronto
dispondremos de test
cromogénicos.
Otro inconveniente es que
actualmente no disponemos de
antídotos específicos; si bien,
están en fase de desarrollo muy
avanzado (9,10) y pronto
dispondremos de ellos. Sin
embargo, este inconveniente
desde mi modesto punto de
vista se ha magnificado ya que
la realidad es que para revertir
el efecto de los AVK con vitamina
K se tarda de 12 a 24 horas, y
este es el tiempo de vida media
de los NAOD; así ante un
paciente anticoagulado con AVK
Los nuevos anticoagulantes
orales de acción directa (NAOD)
van dirigidos contra una única
diana de los factores de la
coagulación. El ximelagatran fue
la prueba de eficacia de que un
único inhibidor de un factor de
la coagulación era eficaz (4), si
bien hubo de retirarse por
problemas de hepatotoxicidad.
Hoy disponemos ya de tres
NAOD, el dabigatran etexilato
(5) un inhibidor directo del factor
II; el rivaroxabán (6), el apixabán
volver al sumario
What predicts
outcome after
recanalization of
chronic venous
obstruction:
hemodynamic
factors, stent
geometry, patient
selection,
anticoagulation
orother factors?
59
11
IX
Abstract
Finalmente, el principal
inconveniente para su uso es el
precio; si bien las agencias
reguladoras, a la luz de los
ensayos clínicos, han autorizado
su comercialización, los agentes
proveedores han puesto
muchísimas restricciones para
poder utilizarlos.
Los cuatro NAOD se han
estudiado en ensayos en fase 3
para evaluar su eficacia y
seguridad en el tratamiento de
la enfermedad tromboembólica
venosa (ETV) (TVP) o embolia
pulmonar (EP). En todos ellos la
variable principal de eficacia fue
la ETV recurrente o la muerte
por ETV mientras que la variable
principal de seguridad fueron la
hemorragia mayor (HM) en los
de apixabán y edoxabán y una
variable compuesta de HM más
hemorragia no mayor pero
clínicamente relevante (HCR) en
los de dabigatran y rivaroxabán.
En todos ellos el comparador
fue el tratamiento convencional
con HBPM seguido de AVK con
un INR entre 2 y 3 y en todos
ellos se excluyeron a los
pacientes con enfermedad renal
crónica estadio 4 o 5.
Dabigatran se estudió en dos
ensayos, RE-COVER (11) (n =
2.553) y RE-COVER II (12) (n =
2.554); doble ciego, en los que
los pacientes tras recibir un
mínimo de 5 días de enoxaparina
eran aleatorizados a recibir
dabigatran 150 mg/12h o
warfarina durante 6 meses. Un
análisis agrupado de los datos
de los dos ensayos (13) mostró
que en cuanto a la eficacia
dabigatran no fue inferior (HR
1.09; IC 95% 0.76 – 1.57) y si
mostró superioridad en la
seguridad ya que si bien en la
tasa de HM no hubo diferencias
desde la aleatorización, si las
hubo en la fase de tratamiento
oral doble ciego (HR: 0.60; IC
95%: 0.36 – 0.99) y la tasa de
cualquier hemorragia fue
significativamente inferior con
dabigatran (HR: 0.70; IC 95%:
0.61 – 0.79). Dabigatran se
evaluó también en el tratamiento
extendido de la ETV en dos
ensayos (14), el estudio REMEDY (n = 2.856) de no
inferioridad, aleatorizado, doble
ciego y doble simulación y
comparado con warfarina; y el
RE-SONATE (n = 1.343) de
superioridad, doble ciego
comparado con placebo. En
ambos estudios los pacientes
fueron aleatorizados tras haber
recibido un tratamiento estándar
por un episodio de ETV y la
dosis de dabigatran fue de 150
mg/12h. Dabigatran mostró no
inferioridad frente a warfarina
para la prevención de
recurrencias (HR: 1.47; IC 95%:
0.80 – 2.68) y mostró una mayor
seguridad con una tendencia a
y
una menor tasa de HM
(HR:0.52; IC95%: 0.27-1.02) y
superioridad significativa en la
variable de HM + HCR (HR:0.54;
IC95%: 0.41-0.71); mientras
que, comparado con placebo y
como es lógico dabigatran
mostró una mayor eficacia con
una reducción del riesgo relativo
del 92% (HR:0.08; IC95%: 0.020.25), sin diferencias
significativas en la tasa de HM
(HR: 1.0 IC95%: 0.00-1.0).
Rivaroxabán se estudió en dos
grandes ensayos en fase 3, el
EINSTEIN – DVT (15) (n = 3.449)
y el EINSTEIN – EP (16) (n =
4.832); los dos fueron abiertos
y los pacientes aleatorizados a
recibir rivaroxabán (15 mg/12 h
durante 3 semanas seguidos de
20 mg/24h) o enoxaparina y AVK
durante 3, 6 o 12 meses a
criterio del investigador. El
análisis de los datos agrupados
de ambos estudios (17) con un
total de 8.281 pacientes mostró
que con relación a la eficacia
rivaroxabán mostró no
inferioridad (HR 0.87; IC
95%:0.66-1.19); tampoco hubo
diferencias en la variable
compuesta de seguridad de HM
más HCR (HR:0.93; IC
95%:0.81-1.06), pero sí mostró
una significativa superioridad
sobre el tratamiento
convencional en la variable de
HM (HR:0.54; IC 95%:0.37 –
0.79, p=0.0018). Rivaroxabán
se evaluó también en un estudio
doble ciego comparado con
placebo de extensión en el que
1.197 pacientes, después de
haber recibido tratamiento
estándar por un episodio de ETV
fueron aleatorizados a recibir
rivaroxaban 20 mg/24h o
placebo durante 6 o 12 meses;
el estudio EINSTEIN-EXT (15).
Como es lógico, rivaroxabán
mostró una eficacia superior al
placebo (HR: 0.18; IC 95%:0.090.39, p<0.001); mientras que
las HM sucedieron en el 0.7%
(4 pacientes) de los que fueron
tratados con rivaroxabán y en
ninguno de los tratados con
placebo.
Apixabán se evaluó en el ensayo
en fase 3 AMPLIFY (18) en el
que 5.244 pacientes con TVP o
EP fueron aleatorizados a recibir
apixabán (10 mg/12h durante
una semana seguida de 5
mg/12h) o tratamiento
convencional con enoxaparina
60
warfarina durante 6 meses.
Apixabán mostró no inferioridad
en la eficacia (RR: 0.84; IC
95%:0.60-1.18); mientras que
seguridad, tanto en la variable
de HM (RR: 0.31; IC 95% 0.170.55, p=0.001) como en la
variable compuesta de HM más
HCR (RR: 0.44; IC 95%: 0.360.55, p<0.001). Apixabán se
evaluó también en un estudio
de extensión, el AMPLIFY-EXT
(19) en el que 2.486 pacientes,
después de haber recibido
tratamiento por un episodio de
ETV, fueron aleatorizados a
recibir en doble ciego apixabán
5mg/12h, apixabán 2,5 mg/12h
o placebo durante 12 meses.
Ambas dosis de apixabán
mostraron una eficacia superior
frente a placebo [5 mg/12h
(RR:0.36; IC 95% 0.25-0.53);
2,5 mg/12h (RR:0.33; IC
95%:0.22-0.48); mientras que
con relación a la seguridad no
hubo diferencias frente a
placebo con ambas dosis de
apixabán, ni en las HM [5
mg/12h (RR:0.25; IC 95%:0.032.24); 2,5 mg/12h (RR:0.49; IC
95%:0.09-2.64)] ni en la variable
compuesta de HM más HCR [5
mg/12h (RR:1.62; IC 95%:0.922-73); 2,5 mg/12h (RR:1.20; IC
95%:0.69-2.10).
El último NAOD en ser evaluado
ha sido edoxabán en el ensayo
en fase 3 HOKUSAI (20) en el
que un total de 8.240 pacientes
(4.921 con TVP y 3.319 con EP)
volver al sumario
y una hemorragia grave no nos
queda más remedio que utilizar
factores procoagulantes
endovenosos al igual que se
hace en los anticoagulados con
los NOAD.
11
IX
Abstract
Recientemente van Es y col (21)
publicaron los resultados de un
metanálisis de los 6 ensayos en
fase 3 de los NAOD, con un total
Bibliografia.
1.- Kearon C, Akl EA, Comerota AJ et al.
American College of Chest Physicians.
Antithrombotic therapy for VTE disease.
Antithrombotic Therapy and Prevention of
Thrombosis. 9th ed: American College of
Chest Physicians Evidence-Based Clinical
Practice Guidelines. Chest
2012;14(2)(suppl):e419S-e494S.
2.- Carlquist J F, Anderson JL. Using
pharmacogenetics in real time to guide
warfarin initiation: a clinician update.
Circulation 2011; 124:2554-2559.
3.- Holbrook A, Pereira JA, Labiris R,
McDonald H, Douketis JD, Crowther M et
al. Systematic overview of warfarin and its
drug and food interactions. Arch. Intern.
Med. 2005;165:1096-1106.
4.- Olsson SB. Executive steering
committee of the SPORTIF III Investigators.
Stroke prevention with the oral direct
thrombin inhibitor ximelagatran compared
El tratamiento
intervencionista de
la trombosis
venosa aguda no
supone una ventaja
ante el tratamiento
médico
Pascual Lozano
El tratamiento médico
convencional de la trombosis
venosa profunda (TVP) con
anticoagulantes, ha demostrado
prevenir de forma efectiva la
extensión del trombo y disminuir
la tasa de recurrencia de la TVP
de 27.023 pacientes, 13.512
tratados con NAOD y 13.511
con AVK. En cuanto a la variable
de eficacia, en el análisis
agrupado los NAOD mostraron
una no inferioridad en
comparación con los AVK; sin
embargo los NAOD mostraron
superioridad frente a los AVK,
con una reducción significativa
del 39% en la tasa de
hemorragias mayores (RR: 0.61;
IC 95%: 0.45-0.83). De forma
paralela se mostraron también
superiores en las variables de
hemorragias intracraneales y
hemorragias fatales con una
reducción del 63% (RR: 0.37;
with warfarin in patients with non-valvular
atrial fibrillation. Randomized controlled trial.
Lancet 2003;362:1691-1698.
5.- Sanford M, Plosker G. Dabigatran
etexilate. Drugs. 2008;68:1699-1709.
6.- Perzborn A, Rohering S, Straub A,
Kubitza D, Mueck W, Laux V. Rivaroxaban:
a new oral factor Xa inhibitor. Artherioscler.
Thromb. Vasc. Biol. 2010; 30:376-381.
7.- Watson J, Whiteside G, Perry C.
Apixaban. First global approval. Drugs.
2011;71:2079-2089.
8.- Camm AJ, Bounameaux H. Edoxaban:
a new oral direct factor Xa inhibitor. Drugs.
2011; 71:1503-1526.
9.- Schiele F, van Ryn J, Canada K,
Newsome C, Sepulveda E, Park J et al. A
specific antidote for dabigatran: functional
and structural characterization. Blood.
2013;121:3554-3562.
(1). Sin embargo, no disuelve el
trombo, por lo que hasta un 50%
de los pacientes desarrollarán a
medio plazo el denominado
síndrome postrombótico con
dolor edema, cambios cutáneos
y ulceración en los casos más
graves.
Los pacientes con TVP iliaca o
femoral son los que más riesgo
tienen de desarrollar síndrome
postrombótico, así, los
tratamientos que eliminan el
trombo de forma activa en estos
pacientes son atractivos ya que
teóricamente, reducirán el riesgo
de síndrome postrombótico. En
los últimos años han comenzado
a aparecer publicaciones sobre
el tratamiento con trombolisis
IC 95%:0.21-0.68) y del 64%
(RR: 0.36; IC 95%:0.15-0.84).
En cambio en las variables de
hemorragias mayores
gastrointestinales y hemorragias
no mayores pero clínicamente
no relevantes no hubo
diferencias significativas con los
AVK.
El beneficio clínico neto, definido
como la variable compuesta del
primer episodio de un
acontecimiento relevante
(recurrencia de ETV, muerte por
ETV o hemorragia mayor) fue
más favorable en los tratados
con NAOD (3,2%) que en los
tratados con AVK (4.%)
10.- Portola Pharmaceuticals. Andexanet
alfa in healthy volunteers who received the
factor Xa inhibitor apixaban. ISTH Congress.
October 14 2013. San Francisco.
11.- Schulman S, Kearon C, Kakkar AK,
Mismetti P, Schellong S, Eriksson H et al.
RE-COVER Study group. Dabigatran versus
warfarin in the treatment of acute venous
thromboembolism. N. Engl. J. Med.
2009;361:2342-2352.
12.- Schulman S, Kakkar AK, Schellong S,
Goldhaber SZ, Eriksson H, Mismetti P. et
al. A randomized trial of dabigatran versus
warfarin in the treatment of venous
thromboembolism (RE-COVER II). ASH
Annual Meeting. Abstract. Blood
2011;118:205
13.- Schulman S, Kakkar AK, Goldhaber
SZ, Schellong S, Eriksson H, Mismetti P et
al. Treatment of acute venous
thromboembolism with dabigatran or
warfarin a pooled analysis. Circulation
2014;129:764-772.
química o mecánica o
combinada, en los pacientes
con TVP proximal (ilio-femoral).
En estos estudios se pone de
manifiesto que la trombolisis
puede reducir la incidencia de
síndrome postrombótico, de
obstrucción venosa y del reflujo
venoso, sin embargo en estos
estudios, datos como la
mortalidad, la tasa de
embolismo pulmonar, la tasa de
hemorragias es más difícil de
encontrar ya que la calidad de
la evidencia de estos estudios
es baja, la mayoría son estudios
observacionales, con pocos
pacientes y sin cohortes de
comparación y con muchas
pérdidas de seguimiento (2).
61
El análisis de subgrupos,
pacientes con peso > a 100 Kg
y aquellos con un aclaramiento
entre 30 – 49 ml/min fueron
consistentes con los resultados
globales de eficacia; mientras
que en los subgrupos de
aquellos con edad > a
75 años y en los pacientes con
cáncer los NAOD mostraron una
eficacia superior a los AVK.
Para finalizar y formulando la
pregunta que da título a esta
presentación, ¿son todos los
NAOD iguales? La respuesta es
sí y no. En cuanto a la eficacia
la respuesta es sí, todos ellos
mostraron no inferioridad frente
14.- Schulman S, Kearon C, Kakkar AK,
Schellong S, Eriksson H, Branstra D et al.
Extended use of dabigatran, warfarin or
placebo in venous thromboembolism. REMEDY and RE-SONATE trial Investigators.
N. Engl. J. Med. 2013;368:709-718.
15.- The EINSTEIN – DVT Investigators.
Oral rivaroxaban for symptomatic venous
2010;363:2499-2510.
16.- The EINSTEIN – PE Investigators. Oral
rivaroxaban for the treatment of
symptomatic pulmonary embolism. N. Engl.
J. Med. 2012;366:1287-1297.
17.- Büller HR on behalf of the EINSTEIN
Investigators. Oral rivaroxaban for the
treatment of symptomatic venous
thromboembolism: a pooled analysis of the
EINSTEIN-DVT and EINSTEIN-PE studies.
Abstract 20. 54th ASH Annual Meeting.
December 2012. Atlanta GA.
En un estudio observacional
recientemente publicado y que
incluía a más de 90.000
pacientes hospitalizados y con
TVP (3), sólo a un 4% de estos
pacientes se les realizó
trombolisis. La trombolisis, en
estos pacientes, no aumenta la
mortalidad hospitalaria
comparada con la
anticoagulación aislada. Sin
embargo la tasa de
complicaciones, sí aumenta de
forma significativa: tasas de
trasfusión de hemoderivados,
de embolia pulmonar, de
hemorragia intracraneal, y la
necesidad de colocación de filtro
de vena cava. Por lo tanto en
la actualidad no disponemos de
a los AVK en los ensayos
pivótales y en el metanálisis de
van Es (21) no hubo evidencia
de heterogeneidad (I2 = 0%).
Sin embargo, por lo que hace
referencia a la seguridad o
hemorragias la respuesta es no,
y la heterogeneidad fue notable
en el análisis de hemorragias
mayores, hemorragias mayores
gastrointestinales y hemorragias
no mayores pero clínicamente
relevantes (I2 = 51% al 85%).
En la variable de hemorragias
mayores únicamente apixabán
y rivaroxabán en el ensayo
Einstein – PE (16) mostraron
superioridad sobre los AVK.
18.- Agnelli G, Büller HR, Cohen A, Curto
M, Gallus AS, Johnson M et al. Oral
apixaban for the treatment of acute venous
2013;369:799-808.
19.- Agnelli G, Büller HR, Cohen A, Curto
M, Gallus AS, Johnson M et al for the
AMPLIFIFY – EXT Investigators. Apixaban
for extended treatment of venous
2013;368:699-708.
20.- The HOKUSAI – VTE Investigators.
Edoxaban versus warfarin for the treatment
of symptomatic venous thromboembolism.
N. Engl. J. Med. 2013;369:1406-1415.
21.- van Es N, Coppens M, Schulman S,
Middeldorp S, Büller HR. Direct oral
anticoagulants compared with vitamin K
antagonists for acute venous
thromboembolism: evidence for phase 3
trials. Blood 2014;124:1968-1975.
ninguna evidencia que
demuestre que la trombolisis sea
igual o superior a la
anticoagulación.
Bibliografia.
1. Mannucci PM, Poller L. Venous
thrombosis and anticoagulant therapy.
Br J Haematol 2001;114:258-70
2. Casey ET, Murad MH, ZumaetaGarcia M et al. Treatment of acute
iliofemoral vein thrombosis. J Vasc Surg
2012;55:1463-73
3. Bashir R, Zack C, Zhao H, Comerota
AJ, Bove AA. Comparative outcomes
of catheter-directed thrombolysis plus
anticoagulation vs anticoagulation alone
to treat lower-extremity proximal deep
vein thrombosis. JAMA Intern Med
2014;174:1494-501
volver al sumario
fueron aleatorizados, tras recibir
un mínimo de 5 días de
enoxaparina, a recibir edoxabán
60 mg/24h o 30 mg/24h en
aquellos pacientes con un peso
inferior a 60 Kg o un
aclaramiento de creatinina entre
30 y 50 ml/min o warfarina.
Edoxabán se mostró no inferior
en la eficacia (HR: 0.89; IC
95%:0.70-1.13) mientras que
seguridad (HR: 0.81; IC
95%:0.71-0.94, p=0.004).
volver al sumario
11
IX
Sesión 14
La oclusión de rama
es una complicación
preocupante:
¿Cómo podemos
prevenirla?
Andrés Fajardo
El reparo endovascular de aneurismas
de la aorta abdominal se ha llevado a
cabo por mas de 20 años . Una de las
principales complicaciones reportadas,
es la oclusión de las ramas iliacas. Esto
lleva a múltiples procedimientos
secundarios, aumentando el costo para
el sistema de salud.
El porcentaje reportado es variable de
acuerdo a la fuente de información. Este
es de 0 a 7% para la mayoría de las
prótesis. Hay múltiples reportes en la
literatura que analizan la incidencia y el
reporte de esta complicación, así como
los factores que inciden y ponen al
Evar vs open repair for
ruptured aaas:
The recent randomized
trials do not help
Frank J. Veith, MD
Although some vascular surgeons are
convinced that EVAR is superior to open
repair for the treatment of ruptured
abdominal aortic aneurysms (RAAAs),
the issue remains controversial. The
nay-sayers for the superiority of EVAR
in this setting claim that all data showing
superior outcomes for EVAR are flawed
by patient selection, and they demand
level 1 evidence from randomized
comparisons of EVAR and open repair.
TEMAS CLAVE EN EL TRATAMIENTO ENDOVASCULAR DE LOS AAA
KEY ISSUES IN ENDOVASCULAR TREATMENT OF AAA
Moderador / Moderator R. Greenhalgh
Panelistas / Panellists R. Aun, R. Mertens
paciente en riesgo de la oclusión de la
rama.
Publicaciones de Oshwin, Carrocio y
Conway, identificaron el despliegue de
la rama iliaca en la arteria iliaca externa
como un factor de riesgo para la
trombosis de la rama. Hay evidencia
conflictiva en cuanto al uso de stents
autoexplandibles como prevención para
la trombosis de la extensión iliaca. De
importancia clínica, también se ha
reportado que si la trombosis de la rama
se produce en la iliaca externa en vez
de la iliaca común, hay un riesgo mayor
de amputación.
También hay artículos que asocian el
uso de dispositivos de primera
generación con un aumento en la
incidencia de la trombosis de la rama
iliaca. Sin embrago, también podría haber
un aumento de trombosis de rama en
los dispositivos que se presenten con
un bajo perfil, dado a que se podrían
tratar arterias con mayor enfermedad
ateroesclerótica y con menor diámetro.
El registro ENGAGE, documento una
incidencia de trombosis de la rama iliaca
de 3.4% en la prótesis Endurant, lo que
disminuye un poco el temor de un
Three such randomized controlled trials
(RCTs) have recently published or
presented their results: the AJAX or
Amsterdam (Dutch) trial1 , the ECAR or
French trial2 and the IMPROVE or UK
trial3. All three trials concluded that 30day mortality outcomes after EVAR are
no better than those after open repair.
However, in these three trials this
conclusion is rendered unjustified or
misleading because of serious flaws or
misinterpretation of the trial data. Let
us examine the specifics.
The AJAX and ECAR trials randomized
small numbers (116,107) of patients and
had the serious flaw of excluding
hypotensive or unstable RAAA patients.
Such high risk patients are precisely the
ones who are most likely to have better
outcomes with EVAR than with open
repair. Therefore, exclusion of these high
risk patients precludes these trials from
63
aumento de riesgo con prótesis de bajo
perfil. Este registro también asocio la
incidencia de la oclusión de la rama a
extensión hacia a arteria iliaca eterna,
diámetro de la iliaca externa menor de
10 mm, diámetro del aneurisma menor
de 59 mm y una deformación en la
prótesis(kink).
En caso de enfermedad de la arteria
femoral común y de la arterias iliacas
distales al sitio de sellado de la rama
iliaca, esta se asocia con un aumento
de la trombosis de la extensión iliaca.
Por lo que una corrección de la
enfermedad aterosclerótica podría
ayudar a disminuir el riesgo de trombosis.
Una revisión mas reciente de los factores
que predisponen a la oclusión de la rama
iliaca fue publicada este año por Mantas
et al. En esta estudio de 439 pacientes
se demostró una trombosis de rama de
4%, usando diferentes endoprotesis. Los
factores que se asociaron a un aumento
de la incidencia de esta complicación,
fueron una angulación en las arterias
iliacas mayor a 60 grados, calcificación
superior al 50% y una sobredimensión
de la prótesis con respecto al diámetro
de la arteria iliaca mayor a 15 por ciento.
demonstrating the advantage EVAR
might have in the overall population of
patients with RAAAs. In addition, both
these trials may have used, in a
suboptimal fashion, 3 adjuncts generally
believed to improve EVAR outcomes.
Better usage of fluid restriction
(hypotensive hemostasis), supra-aortic
balloon control and open abdomen
treatment of abdominal compartment
syndrome might have further improved
the EVAR outcomes in both trials.
In contrast to these two smaller RCTs,
the larger UK IMPROVE trial was
conducted in 30 high volume centers.
Although 652 possible RAAA patients
were excluded for various reasons, the
trialists did randomize 613 patients with
a diagnosis of RAAA to either an
ENDOVASCULAR STRATEGY (316
patients) or OPEN REPAIR (297 patients).
Patients were randomized before CT
En conclusión, la oclusión de la rama es
una complicación que se presenta en
un numero importante de pacientes que
requieren reparo endovascular de
aneurismas de la aorta abdominal y en
determinados casos puede llevar a
perdida de la extremidad. Un análisis
cuidadoso, con buena selección de los
puntos de sellado y con una decisión
adecuada de la prótesis a utilizar de
acuerdo a la anatomía del paciente es
vital para prevenir esta complicación. La
evaluación de la angiografía final, sin
guías rígidas es de suma importancia.
El uso de Ultrasonido intravascular podría
ser útil en detectar dobleces en la
prótesis que no son visibles en modo
bidimensional. El uso de stents
autoexpandibles con buena fuerza radial,
ha demostrado ayudar a la prevención
de la trombosis de la rama iliaca. Tambien
se debe analizar la corrección de la
enfermedad ateroesclerótica distal a los
puntos de sellado, para mejorar el flujo
de salida, especialmente si se esta
sellando en la iliaca externa.
scans were performed. The 30-day
mortality in the Endovascular Strategy
group was 35%; in the Open Repair
group it was 37%. Obviously there was
no significant difference, and a primary
conclusion of the main IMPROVE trial
article3 was “A strategy of endovascular
repair was not associated with significant
reduction in 30-day mortality”. This was
paraphrased in various news report
headlines as, “NO DIFFERENCE
BETWEEN ENDOVASCULAR & OPEN
REPAIR”.
However, the detailed data from the
IMPROVE trial must be examined closely
to see why these conclusions are
misleading. Of the patients randomized
to the Endovascular Strategy group, only
154 (about half) actually underwent
EVAR; 112 had an open repair and 17
had no treatment. The 30-day mortality
in this group was 27% for those treated
volver al sumario
Viernes, 26 Junio
Friday, June 26th
11
IX
their 30-day survival will be superior. If
one adds to this the fact that patients
undergoing EVAR are less likely to receive
no treatment, the conclusion is
inescapable: EVAR is superior to Open
Repair for the treatment of patients with
RAAAs.
Nowadays evar is
always the first choice
for ruptured aaa
treatment: con
Methods
Roberto Chiesa
Vascular Surgery, “Vita – Salute”
University, Scientific Institute H. San
Raffaele
Milan, ITALY
Introduction
Endovascular aortic repair (EVAR) is a
well-established technique to treat
abdominal aortic aneurysms (AAAs), and
it is well proven that it offers lower
perioperative mortality compared with
open repair in the treatment of elective
patients with no signs of rupture.1,2
So far, EVAR advantages are also
expected for the treatment of ruptured
AAA (rAAA): aortic clamping is avoided,
no general anesthesia is required,
ischemic injuries are reduced, as also
hypothermia and blood loss.
However, not every patient can be
addressed to endovascular therapy in
rAAA due to anatomical and clinical
conditions. On the other hand, open
surgery is a consolidated technique to
treat emergent patients with proven
results.
Thus, those treating RAAA patients must
learn how to do EVAR in this setting,
including acquiring expertise in all the
adjuncts and strategies that can improve
EVAR outcomes in such patients. We
do not need further RCTs to confuse the
issue any more.
Several observational trials in literature
were published comparing EVAR and
open repair for rAAA, whose failed to
prove a difference in early mortality
between endovascular and open repair.
There are some biases to be considered
in these studies, like small number of
patients, heterogeneity of the population,
unclear definition of unstable patients.
The French ECAR trial randomized 107
patients, only stable and with suitable
EVAR morphology. They concluded that
no significant statistical difference in 30day mortality between the two groups
has been observed, although reasonably
low mortality rates were reported for
both REVAR and ROR. Interestingly,
among seven of the 14 recruiting centers,
only 50% of patients were eligible for
randomization.3
Bibliografia.
1. Reimerink JJ, et al. Endovascular repair versus
open repair of ruptured abdominal aortic aneurysms:
a multicenter randomized controlled trial. Ann Surg
2013;258:248-56.
3. IMPROVE trial Investigtors, Powell JT, et al.
Endovascular or open repair strategy for ruptured
abdominal aortic aneurysm: 30 day outcomes from
IMPROVE randomised trial. BMJ 2014;348:f7661.
2. Desgranges P, Kobeiter H, and the ECAR
Investigators. Results of the ECAR RCT comparing
EVAR and open repair for Ruptured AAAs. Presented
at the 2013 VEITHsymposium.
www.veithondemand.com/2013
mortality.5 A further analysis of rAAA
morphology on those patients showed
that short aneurysm necks adversely
influence mortality after open repair of
rAAA and preclude conventional EVAR.
This may help explain why observational
studies, but not randomized trials, have
shown an early survival benefit for
EVAR.6 Barnes et al showed that
anatomic suitability for EVAR seems to
be associated with lower mortality
following open repair of rAAA, which may
reflect technical difficulty.7
Not all patients can be randomized
between the two techniques, because
not every patients would be anatomically
fit for EVAR. (Fig.1)
In some retrospective studies is found
as a large percentage between 60 %
and 80 % of patients were unsuitable
for EVAR as they presented short or
conical proximal neck, or pararenal
aneurysms. 7-9
Other non-anatomical contraindication
for EVAR could be represented by
chronic renal insufficiency, that can be
worsened by iodine contrast during
EVAR, and by the suspicion of associated
infection or fistula.
In the real world, not all patients are
hemodinamically stable to be evaluated
with a CT-scan and undergo a proper
aortic sizing for EVAR, and even more
not a large number of them is
anatomically suitable for EVAR, as shown
A multicenter trial conducted in
Netherland, the AJAX trial, randomized
116 of 520 RAAA patients (22%) in the
Amsterdam region. AJAX found no
significant difference in severe
complications (REVAR, 42%; ROR, 47%)
or death (REVAR, 21%; ROR, 25%).
However a correct interpretation of these
data is difficult because almost 80% of
patients were not randomized,
interobserver agreement on the
computed tomography (CT) diagnosis
of rupture was imperfect, and EVARsuitable but severely unstable patients
were not transferred to centers capable
of doing REVAR as well as ROR. 4
IMPROVE trial, which is a large analysis
on 613 patients, showed that EVAR was
not associated with a reduction of
64
Fig. 1 Horse shoe kidney. An example of anatomical unsuitable case for EVAR.
volver al sumario
by EVAR, and 38% for those treated by
open repair. Of the patients randomized
to the Open Repair group, 36 actually
had EVAR, 220 had open repair and 19
had no treatment. The 30-day mortality
in this Open Repair group was 22% for
those undergoing EVAR and 37% for
those undergoing open repair. Overall
in the two randomized groups, taken
together, the 30-day mortality for RAAA
patients actually treated by EVAR was
25% and for those actually treated by
Open Repair, it was 38%.
Clearly the conclusion of the IMPROVE
trial should have been, in patients with
a RAAA, if they can be treated by EVAR,
11
IX
A comprehensive range of endovascular
material should be always available in
the hospital, and all the vascular surgery
stuff (including surgeons,
anesthesiologists, technicians and
nurses)should be specifically trained on
emergent EVAR. Those two features are
not always available in peripheral
hospitals.
Fig. 2 Two cases of abdominal hematoma. A relative contraindication to EVAR, open repair is indicate
in order to reduce the risk of compartment syndrome.
in literature. Furthermore, unstable
patients are usually presenting with a
free ruptured aneurysm and large
retroperitoneal hematoma, and this is
known to account for a high risk of
complications following EVAR, mainly
abdominal compartment syndrome in
up to 27% of patients.10 (Fig.2)
So, in anatomically unfit patients, as well
as in really unstable ones, we believe
that surgery remains the treatment of
choice.
Our Experience
From 1993 to 2014, 409 patients were
treated for rAAA, representing
approximately 8% of all 5,329 patients
treated for AAA at our centre. 397 (97%)
were treated with open repair and 12
(3%) with EVAR.
Patients addressed to EVAR were
carefully selected among more stable
patients, without large retroperitoneal
hematoma (max diameter < 10 cm), with
advanced age or comorbidities
contraindicating open surgery, and with
suitable anatomic features.
hemoglobin < 8 g/dl) were 207 in open
group (52.1%) and 3 in EVAR group
(25%).
In open group, 18 patients had
hemoperitoneum (4.5%), in 47 (11.8%)
a supraceliac clamping was performed,
and an aorto-bi-ilac reconstruction was
performed in 40 patients (10.1%). In
EVAR group we performed 8 bifurcated
reconstructions (66.6%) and 4 aorto-uniiliac endograft with femoro-femoral cross
over bypass (33.3%).
Intraoperative mortality occurred in 9
patients (2.3%) in open group and in no
case after EVAR. Perioperative mortality
was 29% in open repair (116 patients)
and 8% for EVAR group (1 patient).
Perioperative complications observed in
open and EVAR groups were
respectively: respiratory failure 44% and
25%, renal failure 33% and 17%, cardiac
complications 21% vs 17%, and bowel
ischemia 5% vs 0%.
In high volume centers with a large
experience on elective AAA surgical
repair, open surgery remains relatively
safe also in emergency, it could stop
bleeding in a short time, with prompt
aortic clamping and prosthetic
substitution. Furthermore open repair
allows removing intra abdominal
hematoma, bowel visualization with the
aim to prevent intestinal ischemia,
abdominal compartment syndrome
(ACS), respiratory failure and infection.
In case of signs or suspicion of ischemia
the abdomen can be left open with the
positioning of a negative pressure wound
dressing.
It has been also shown that the
development of ACS after repair of rAAA
is associated with increased mortality,
especially in EVAR-treated patients. The
higher intraoperative blood and blood
product requirements associated with
ACS in EVAR patients suggest that one
potential cause of early ACS is continued
hemorrhage from lumbar and inferior
mesenteric vessels through the ruptured
aneurysm sac. 11
Discussion
Mean age was 71.3 years for open group
and 77.6 for EVAR group. Preoperative
risk-factors were identified as following:
coronary artery disease (CAD) in 131
patients (33.0%) for open group and 4
(33.3%) in EVAR group, chronic
obstructive pulmonary disease (COPD)
in 117 (29.5%) and 5 (41.6%), chronic
renal insufficiency 36 (9.1%) and 1 (8.3%)
and ASA score 3 in 205 patients (51.6%)
and 7 (58.3%) and ASA 4 in 192 patients
(48.4%) and 5 (41.7%) respectively.
In our experience, the majority of patients
was considered not anatomically suitable
for emergent EVAR or presented such
hemodynamic instability to be addressed
to emergent open surgical repair.
Anatomical limitation such short aortic
neck, major angulation, presence of
thrombus or calcification, polar renal
arteries, or iliac tortuosity represents a
major limitation to perform EVAR in
emergency. Also, a number of cases
presented with suspect of associated
infection or aortoenteric fistula, thus
contraindicating endovascular repair.
Unstable patients (i.e. presenting with
cardiac arrest, or unconsciousness,
On the other hand, EVAR is an extremely
appealing alternative, and it offers
65
Conclusions
In our experience open repair remains
the most used solution to treat rAAA,
especially in highly unstable patients.
EVAR should be reserved for stable and
anatomically fit patients, in order to
achieve best results. Open repair is the
most reliable treatment especially in high
volume centers.
References
1.Lederle FA, Freischlag JA, Kyriakides
TC, et al. Long-term comparison of
endovascular and open repair of abdominal
aortic aneurysm. The New England journal
of medicine. Nov 22 2012;367(21):19881997.
2.Greenhalgh RM, Brown LC, Powell JT,
Thompson SG, Epstein D, Sculpher MJ.
Endovascular versus open repair of
abdominal aortic aneurysm. The New
England journal of medicine. May 20
2010;362(20):1863-1871.
3.Desgranges P, Kobeiter H, Castier Y,
Senechal M, Majewski M, Krimi A. The
Endovasculaire vs Chirurgie dans les
Anevrysmes Rompus PROTOCOL trial
update. J Vasc Surg. Jan 2010;51(1):267270.
4.Reimerink JJ, Hoornweg LL, Vahl AC,
et al. Endovascular repair versus open
repair of ruptured abdominal aortic
aneurysms: a multicenter randomized
controlled trial. Ann Surg. Aug
2013;258(2):248-256.
5.Powell JT, Sweeting MJ, Thompson MM,
et al. Endovascular or open repair strategy
for ruptured abdominal aortic aneurysm:
30 day outcomes from IMPROVE
randomised trial. BMJ (Clinical research
ed.). 2014;348:f7661.
6.The effect of aortic morphology on perioperative mortality of ruptured abdominal
aortic aneurysm. European heart journal.
Jan 27 2015.
7.Barnes R, Kassianides X, Barakat H,
Mironska E, Lakshminarayan R, Chetter
IC. Ruptured AAA: suitability for
endovascular repair is associated with
lower mortality following open repair. World
journal of surgery. May 2014;38(5):12231226.
8.Rose DF, Davidson IR, Hinchliffe RJ, et
al. Anatomical suitability of ruptured
abdominal aortic aneurysms for
endovascular repair. J Endovasc Ther. Jun
2003;10(3):453-457.
9.Wilson WR, Fishwick G, Sir Peter RFB,
Thompson MM. Suitability of ruptured AAA
for endovascular repair. J Endovasc Ther.
Dec 2004;11(6):635-640.
10.Mehta M, Paty PS, Byrne J, et al. The
impact of hemodynamic status on
outcomes of endovascular abdominal
aortic aneurysm repair for rupture. J Vasc
Surg. May 2013;57(5):1255-1260.
11.Rubenstein C, Bietz G, Davenport DL,
Winkler M, Endean ED. Abdominal
compartment syndrome associated with
endovascular and open repair of ruptured
abdominal aortic aneurysms. J Vasc Surg.
Mar 2015;61(3):648-654.
volver al sumario
promising results, especially for stable
patients with contained AAA rupture,
elderly patents, and presence of severe
comorbid conditions.
11
IX
Janet T Powell
Aim:
To report the longer-term outcomes
following either a strategy of
endovascular repair first or open repair
of ruptured abdominal aortic aneurysm,
which are necessary for both patient and
clinical decision-making.
Type ii endoleak are a
real concern: how can
we treat them today?
Michele. Antonello
Clinic of Vascular Endovascular Surgery,
DCTV, University of Padua Italy
Introduction.
Currently endovascular aneurysm repair
(EVAR) of abdominal aortic aneurysms
(AAA) is an effective alternative treatment
to traditional open surgery, due to its low
invasiveness and its low rate of peri- and
post-operative complications. However,
EVAR lacks its advantages during midand long-term follow-up, because of a
higher incidence of re-intervention mainly
due to the onset of endoleak type II (EII).
Recent studies seems to show a
Viernes, 26 Junio
Friday, June 26th
Sesión 16
with similar re-intervention rates in each
group. The endovascular strategy group
and open repair groups had average
total hospital stays of 17 and 26 days
respectively, p<0.001. Patients surviving
rupture had higher average EQ-5D utility
scores in the endovascular strategy
versus open repair groups, mean
differences 0.087 (95% CI 0.017, 0.158),
0.068 (95% CI -0.004, 0.140) at 3 and
12 months, respectively. There were
indications that QALYs were higher and
costs lower for the endovascular first
strategy, combining to give an
Incremental Net Benefit of £3877 (95%
CI £253, £7408) or €4356 (95% CI €284,
€8323).
Conclusion:
reduction in the incidence of EII
performing an intraoperative embolization
of the aneurysmal sac with fibrin glue
and coils during EVAR (embo-EVAR). To
verify such results a randomized
prospective study was performed in
patients considered at higher risk for EII
(3 pairs of patent lumbar artery, an inferior
mesenteric artery with a diameter >3mm,
2 pairs of lumbar artery + sacral artery).
volume-dependent dose of coils and
fibrin:
Aneurysmal sac volume and anatomical
characteristics were evaluated before
and after the procedure using the Osirix
Pro 4.0 software. The presence of EII
and volume variations were evaluated
during the follow-up period, performing
angio-CT scans at 3, 6, 12, and 24
months after EVAR.
Methods.
Results.
Between January 2012 and May 2014
patients considered at high risk for type
EII were randomly assigned to received
standard treatment (group A) or Embo
EVAR (group B). Embo-EVAR, consists
in the preventive embolization of the
aneurismal sac using an aneurysm
Comorbidities, peri-operative risk,
aneurysm dimension and anatomical
features were similar for group A (n=51)
and group B (n=42). The mean operative
time was also comparable (group A:
159.8 ± 57.6 min; group B: 165.8 ± 45.5
min; p=0,92). The rate of type EII at the
completion angiography was equivalent
in both groups (15,7% in group A; 16,7%
in group B; p=1), but during the followup at the angio-CT scans there was a
higher rate of type EII in group A at 3
months (41.1% vs 19.0%; p=0.01), 6
months (26.7% vs 12.1%; p<0.05), 12
months (27.7% vs 12.0%; p<0.05) and
24 months (20% vs 8.3%; p=0.24).
Patients in group A showed a significantly
lower decrease in aneurysm volume
compared to group B, especially at 6
months (1.72 ± 24.8 vs -11.6 ± 19.7;
p=0.01 ) and 12 months (-0.1 ± 33.5 vs
-17.7 ± 27.4; p=0.03) of follow up. In
group A the volume decreased only in
patients without EII, whereas in group B
it decreased in a similar way either in the
presence or absence of EII. Freedom
from EII-related re-intervention was
significantly lower in group A (p<0.05).
Methods & results:
This pragmatic multicentre (29 UK, 1
Canada) trial randomised 613 patients
with a clinical diagnosis of ruptured
aneurysm; 316 to an endovascular first
l strategy (if aortic morphology is suitable,
open repair if not) and 297 to open repair.
The principal 1-year outcome was
mortality; secondary outcomes were reinterventions, hospital discharge, healthrelated quality of life (EQ-5D), costs,
Quality-Adjusted-Life-Years (QALYs) and
cost-effectiveness (Incremental Net
Benefit).
At 1-year, all-cause mortality was 41.1%
for the endovascular strategy group and
45.1% for the open repair group, odds
ratio 0.85 (95 %CI 0.62, 1.17) p=0.325,
Conclusions:
Preliminary results of randomization seem
to confirm the effectiveness of emboEVAR in the prevention of EII, aneurysmal
sac volume shrinkage, and reduction of
EII-related secondary interventions in
patients at high risk of EII.
EL DILEMA DE LA HIPOGÁSTRICA
THE HYPOGASTRIC DILEMMA
Panelistas / Panellists A. Fabiani, L. Reparaz
Better yet, avoid covering the
hypogastric in the first place!
Pros and cons of landing inside
a large – diameter common iliac
artery
Frank J. Criado, M.D.
An endovascular first strategy for
management of ruptured aneurysms
does not offer a survival benefit over 1year but offers patients faster discharge
with better quality of life and is costeffective.
Clinical trial registration: ISRCTN
48334791
Presentation Outline:
Distal limb landing in a large-diameter (but nonaneurysmal) common iliac artery has become far better
accepted that it was in the past;
Availability of flared and large diameter endograft limbs
have made this possible;
The potential for progressive dilation of such iliac arteries
is real but relatively small;
66
Limb extension into the external iliac artery is an imperfect
solution because of the implied coverage of the
hypogastric artery and the much increased risk for limb
thrombosis;
Guidelines and fundamental principles surrounding
these issues will be discussed in detail during the talk.
volver al sumario
Evar for ruptured aaa:
improve update on
survival and costeffectiveness
11
IX
1. Device design
2. Anatomical considerations
3. Implantation Technique
4. Long term results
Angiologia Cirugía Vascular y
Endovascular
Hospital Universitari Doctor Peset.
Valencia. SPAIN
The ZBIS is based on the Zenith Flex
platform which consists of a Stainless
steel Z-stent skeleton and a polyester
fabric, that has a side branch for the
internal iliac artery that is mated to it
using an additional bridging covered
stent.
There are three main types of IBD
resulting of the evolution of this device
( Fig 1):
The common iliac artery (CIA) and the
Internal iliac artery (IIA) are involved in
aneurysmal disease in about 40% of
patients with abdominal aortic
aneurysm1,23.
In addition, long term failure can occur
because of the loss of seal at the distal
attachement site, as stated by different
authors when a large size common iliac
artery was chosen for distal endograft
landing 4
It has been recognized that the
interruption of the pelvic flow is
associated with variable risk of
complications including buttock or tight
claudication, erectile dysfunction,
ischemic colitis, gluteal or perineal
necrosis, or spinal cord injury.
Even though these consequences are
not thought to have a big clinical impact
when compared with their equivalent
open surgical repair, they are also matter
of major concern.
The preservation of pelvic flow to the IIA
with an endovascular solution, has been
achieved by different means, including
the parallel stent-grafts, or retrograde
perfusion from the ipsilateral femoral
artery with a cross-over fem-fem bypass.
However, the evolution of endovascular
techniques has made feasible to exclude
the aortic aneurysm and the common
iliac aneurysms, preserving the straight
arterial flow to the internal iliac artery,
and several devices have been
described, that are currently available in
the market.
In order to know which are the particular
features of a given device, that makes it
different from the others, in this case the
Cook Iliac Branch Device, ZBIS™, the
focus is to be put on four points:
With a length of at least 10 mm (2030mm being preferred)
Several markers identify the proximal
and distal tips of the ZBIS as well as
the sidebranch.
With a diameter acceptable for proper
sealing (<6mm or >10mm)
3. The BB-IBD, is the latest
development, and consists on the
addition of the helical side-arm to the
ipsilateral (long) limb of a bifurcated
aortic device. This bifurcated graft is
intended to use as the distal
bifurcated component of a fenestrated
endograft, and it makes sense
because it eliminates 2 modular joints
from the IBD, and it also allows the
cannulation from the contralateral
femoral, through a self sealing
fenestration immediately cranial to
the ostium of the helical branch. This
self sealing fenestration is also used
in conjunction of a preloaded wire in
a manner identical to the standard
IBD.
Device Design:
Francisco Gómez Palonés
access through the branch with a
sheath .
Fig.-1: Types of Cook IBD configurations
1. Straight side-arm (S-IBD): It has a
short overlapping zone, and intended
to be mated with a balloonexpandable covered stent. This type
has different references, depending
on the length of the proximal part
(45/61cm) the length of the distal limb
(41-58cm) , and the diameter of the
distal limb( 10-12mm).
2. The Helical – IBD, has a flexible
longer side arm which is intended for
use with a self-expandable stent graft,
providing a longer overlapping zone.
This type of IBD is intended for cases
with large iliac aneurysms since it
requires additional room for a relatively
bulky device.
Both devices are loaded in a 20F
delivery system with an hydrophilic
coating, and include preloaded
catheter through the branch and out
of the proximal edge of the device.
This catheter allows the introduction
of a wire which is snared from an
alternative site (usually the
contralateral groin but also the
brachial approach) and provides ready
67
The S-IBD is the most common being
employed since it has CE approval
since November 20065. Most of the
following text is addressed to this
particular device ( ZBIS), which is by
far the one with thousands of cases
imlanted all over the world, and
precedes other competitors by more
than 8 years. The other two types of
Cook IBD, are available under custom
made device request.
Anatomical considerations
The Iliac branched device is intended to
give a proper common iliac artery
exclusion while maintaining direct flow
to the hypogastric artery. Therefore it is
indicated when the common iliac artery
is aneurysmal or when it is not possible
to find a proper seal at the common iliac
artery.
The anatomical requirements for
implantation of the Cook ZBIS, are
defined at the Instructions for use ( IFU)
• Adequate iliac/femoral access
compatible with a 20F (7.7mm OD)
introduction system.
• Non-aneurysmal external iliac artery
fixation segment with
A length of at least 20 mm
With an outer-to-outer diameter
greater than 8mm and no larger than
11mm
• Luminal diameter at iliac bifurcation >
16 mm
• Non-aneurysmal internal iliac artery
segment distal to the aneurysm
Not all the anatomical conditions that
may preclude a successful implantation
are included in the IFU, and not all the
limitations stated at the IFU are always
found to be so limiting, according to
different experienced endovascular
surgeons
Kartikesalingam et al, report that the
manufacturer criteria was accomplished
by 29% of a series of 51 patients/66
IIA, but 38% of the cases were found
to be feasible, by very experienced
endovascular surgeons6. The authors
conclude thar the applicability of the
ZBIS is low, and finde that the most
common adverse feature is the
coexisting internal iliac artery aneurysm.
Austermann et all, described how to
manage IIA aneurysm using IBD in a
series of 16 consecutive patients7,
reporting excellent results.
A later report from Pearce et al8 showed
that only 18,2% of a series of 99 patients
with common Iliac aneurysm were
deemed anatomically suitable for Cook
ZBIS. The most common reason for
exclusion was unsuitable IIA diameter
(68,7%) followed by an IIA aneurysm
distal to the landing zone (11.1%) ,
narrow external iliac artery (10.1%), short
CIA ( 9.1%), EIA length <20mm (7,1%)
and short CIA < 50 mm (6.1%).
In this report the authors compared the
anatomic suitability of another recently
launched IBD device ( Gore IBE™), and
found 25% of the anatomies fit the Gore
Device. A 13,5% of the excluded for
the GoreIBE , fit the Cook ZBIS, and on
the other side 20,9% excluded for ZBIS
fit the GoreIBE. The most common
cause for exclusion of the Gore IBD, was
a proximal CIA diameter < 17mm in
39.4%, followed by an inadequate IIA
volver al sumario
The cook approach:
what makes it different
from other available
iliac branched devices?
11
IX
diameter (<6.5 or >13.5) in 37,3%, AortaHypo length <165mm or CIAlength <
40mm in 24.2%, CIAdiameter < 25mm
in 16.2%, and Distal CIAdiameter<14mm
in 13.1% of the cases.
stiff wire and the iliac branch device. In
such circumstances, the contralateral
sheath and stenting may have problems
to properly advance them to the target
site.
The number of exclusion criteria per
case, were 1 or 2 in the ZBIS criteria,
but there were 2,3,4 or even 5 exclusion
criteria in some of the cases unfit for the
Gore Device.
This option that avoids the use of the
preloaded catheter has also been
described for the Cook ZBIS 10.
Table 1.Current anatomical challenges
for IBD
Another important feature of the ZBIS is
that the graft is attached to the delivery
system by a proximal and distal fixations
that allows a better option for positioning
and orientation
The same Zenith flex platform that has
offered such successful and durable
implantations may have some
drawbacks, such as reduced device
flexibility, and larger delivery system profile
Conclusions:
The Cook ZBIS, is currently the most
used iliac branched device with the
largest experience.
Its applicability is still low being the most
limiting anatomic feature the one related
to the internal iliac artery, but the
experience achieved and the different
device configurations available expand
its applicability.
Bisdas et al, have also reported an
interesting experience using the ZBIS to
succesfully repair aneurysmal
transformation of distal seal zones after
EVAR9. That means that some of the
IFU are not followed, and the brachial
axillary access was required in almost
all cases. An excellent result was
achieved with the ZBIS, in this series.
Implantation Technique
The ZBIS is introduced through the
ipsilateral femoral artery and requires a
remote access to cannulate both the
iliac branch and the internal iliac artery
which finally will require to be mated.
Usually the contralateral femoral is
suggested and used, but it is also
possible and sometimes advisable to go
from a brachial access. For this purpose
a unique feature of this device, is a
preloaded catheter that helps to direct
a wire which is snared from the remote
site to have a through & through access
and thus ease and give external support
for the IIA cannulation and stenting.
The other current devices also require a
through and through access, but don´t
have a preloaded catheter and that may
be a shortcoming when the through wire
inadvertently and externally crosses the
that could also be related to the
preloaded catheter. This features could
be improved by incorporating the latest
Cook’s aortic technology including spiral
nitinol stents. However these issues have
seldom been advocated a real problem
that precludes the use of the ZBIS.
The implantation technique has been
described elsewhere 11 ,12,13 and
essentially is the one the later developed
devices currently follow.
Long term results
If something is an advantage with the
Cook iliac branch device above the other
available devices, is the experience
achieved.
Even though the implanted cases exceed
the number of published papers, the
overall results reported, agree that is a
feasible, safe and durable device,
specially with the current device which
has several improvements compared
with the first generation uni-body device.
The results described in table 2, show
that published series consist of an
average of 30 cases, a technical success
above 90%, and a midterm (6 months
to 5 years) of 70%.
68
From a technical point of view this device
has unique features like the preloaded
catheter that allows an easier cannulation
from different remote sites for the iliac
branch and IIA not only the contralateral
femoral artery.
References
1 Armon MP, Wenham PW, Whitaker SC, Gregson RH,
Hopkinson BR. Common iliac artery aneurysms in patients
with abdominal aortic aneurysm. Eur J Vasc Endovasc
Surg. 1998;15:155-157.
2 Hobo R, Synbrandy JEM, Harris P, Buth J. Endovascular
repair of abdominal aortic aneurysms with concomitant
iliac artery aneurysm: outcome analysis of the EUROSTAR
experience. J Endovasc Ther. 2008;15:12-22.
3 F.J. Gómez-Palonés, J.L. Briones-Estébanez, J.M.
Zaragozá-García, A. Plaza-Martínez, E. Ortiz-Monzón:
Implicaciones de la arteria hipogástrica en la reparación
de aneurismas aortoilíacos. ANGIOLOGÍA 2008; 60 (Supl
1): S15-S24
4 Schanzer A, Greenberg RK, Hevelone N, et al.
Predictors of abdominal aortic aneurysm sac enlargement
after endovascular repair. Circulation 2011;123:2848e55.
5 www.businesswire.com/news/home/20061010005872
/en/Cooks-Zenith-Branch-Endovascular-Graft-ReceivesCE#.VSJOZ1yYWKM.
6 Karthikesalingam, A; Hinchliffe, Robert J.; Malkawi,
AH ; Holt, PJ; Loftus, IM;Thompson, MM: Morphological
Suitability of Patients With Aortoiliac Aneurysms for
Endovascular Preservation of the Internal Iliac Artery
Using commercially Available Iliac Branch Graft Devices.
J Endovasc Ther. 2010;17:163–171
The more recent iliac branch devices,
add interesting features and globally
increase the potential cases to be treated
with one or other system, but individually
do not offer a great change in treatment
options with similar anatomic challenges.
Some improvements in the classical
platform of the ZBIS could increase
feasibility for a larger number of cases,
but it seems a development of the
bridging stents specifically dedicated for
the branched and IIA would be more
likely to improve the overall anatomic
suitability.
7 Austermann,M ; Bisdas,T; Torsello,G; Bosiers,MJ;
Lazaridis,K; Donas, KP: Outcomes of a novel technique
of endovascular repair of aneurysmal internal iliac arteries
using iliac branch devices. J Vasc Surg 2013; 58( 5):
1186 - 1191
8 Pearce, BJ; Varu,VN; Glocker,R; Novak, Z; Jordan,WD;
Lee, JT: Anatomic Suitability of Aortoiliac Aneurysms for
Next Generation Branched Systems . Ann Vasc Surg
2015; 29: 69–75
9 Bisdas,T; Weiss K; Donas, K P; Schwindt, A; Torsello,G;
Austermann, M: Use of Iliac Branch Devices for
Endovascular Repair of Aneurysmal Distal Seal Zones
After EVAR. J Endovasc Ther. 2014;21:579-586
10 C. Nice ;V. Bhattacharya ;H.Y. Ashour : Modified
Technique for Iliac Branched Stent-Graft Insertion. EJVES
Extra (2008) 16, 33e35
11 Greenberg RK, West K, Pfaff K: Beyond the aortic
bifurcation: branched endovascular grafts for
thoracoabdominal and aortoiliac aneurysms. J Vasc Surg
2006;43:879e86.
12 Haulon S, Greenberg RK, Pfaff K, Francis C, Koussa
M, West K: Branched grafting for aortoiliac aneurysms.
Eur J Vasc Endovasc Surg 2007;33:567e74
14 Dias NV, Resch TA, Sonesson B, Ivancev K, Malina
M. EVAR of aortoiliac aneurysms with branched stentgrafts. Eur J Vasc Endovasc Surg 2008;35(6):677e84
volver al sumario
These circumstances may limit the proper
implantation, and need to be taken into
account in order to plan additional
techniques or materials to overcome
such issues.
Table 2 .Literature review
11
IX
13 Serracino-Inglott F, Bray AE, Myers P. Endovascular
abdominal aortic aneurysm repair in patients with common
iliac artery aneurysmsdinitial experience with the Zenith
bifurcated iliac side branch device. J Vasc Surg 2007;46:
211e7.
16 Greenberg RK, West K, Pfaff K, Foster J, Skender
D, Haulon S, et al. Beyond the aortic bifurcation: branched
endovascular grafts for thoracoabdominal and aortoiliac
aneurysms. J Vasc Surg 2006;43(5):879e86. discussion
86e87.
14 Dias NV, Resch TA, Sonesson B, Ivancev K, Malina
M. EVAR of aortoiliac aneurysms with branched stentgrafts. Eur J Vasc Endovasc Surg 2008;35(6):677e84
17 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(2):204e10.
Hypogastric artery
occlusion is safe, B
Frank J. Veith, MD
Instances arise in vascular surgery where
patients being treated for abdominal
aortic aneurysms have concomitant iliac
artery aneurysms. In many of these
cases, the distal common iliac artery is
aneurysmal, and in some instances
interruption of one or both hypogastric
The Gore approach.
What makes it different
from other available
iliac branched devices
• Endovascular Durability?
• Cost/effectiveness in the long
term?
Fabio Verzini, Md, PhD, FEBVS, Gioele
Simonte, MD, Selena Pelliccia, MD,
Luca Farchioni, MD, Beatrice Fiorucci,
MD, Gianbattista Parlani, MD
18 Tielliu IF, Bos WT, Zeebregts CJ, Prins TR, Van Den
Dungen JJ, Verhoeven EL. The role of branched
endografts in preserving internal iliac arteries. The J
Cardiovasc Surg 2009;50(2): 213e8.
arteries is needed to completely exclude
the aneurysm. The importance of
preserving one or especially both of these
vessels during repair of aortoiliac
aneurysms (AIAs) is stressed in the
vascular surgery literature. Hypogastric
interruption, particularly bilateral, during
standard open aortic aneurysm repair
has historically been reported to be
associated with considerable morbidity,
and the advent of endovascular
aneurysm repair (EVAR) has rekindled
the interest in hypogastric artery
interruption because of the frequent lack
of adequate distal fixation sites in the
aneurysmal common iliac arteries. These
situations may require exclusion of one
or both hypogastric arteries and
prompted us to reevaluate the risks and
consequences of hypogastric artery
interruption.
effective seal and distal fixation is one of
the major anatomic challenges of
conventional endovascular aneurysm
repair (EVAR).
components of different lengths including
a bifurcated iliac branch and an internal
iliac or hypogastric branch with common
iliac artery (CIA) and internal iliac artery
(IIA) fixation, respectively.
Extensive iliac aneurysm repair exposes
a twofold major safety issue: preservation
of pelvic circulation to avoid ischaemic
complications and durable effective
exclusion of the aneurysm to prevent
risk of rupture in the long term.
Long-term durability and efficacy are still
unsolved issues limiting the generalization
of the iliac side branch endograft
implantation procedure.
To evaluate efficacy and mid-term results
of the GORE® EXCLUDER® Iliac Branch
Endoprosthesis.
Presence of common iliac artery
aneurysm preventing achievement of an
Main differences with other available iliac
side branched grafts are low profile (16
Fr) and the unique conformability of the
iliac limbs, even in cases of extremely
tortuous anatomy. The Gore approach
provides a dedicated internal iliac stent
graft as well as the repositionability of
the endograft once partially deployed.
Retrospective analysis of data of all
patients treated with the Iliac Branch
device in a single center.
e. Results of the study
c. Material used
a. Introduction
In this presentation, the morbidity of
unilateral and particularly bilateral
hypogastric artery interruption in patients
undergoing either standard open surgical
or endovascular AIA repair is reviewed.
It will be shown that unilateral and even
bilateral hypogastric artery occlusion is
generally safe in such uncomplicated
patients, although it may in about 1520% of patients cause troublesome
buttock claudication. Accordingly
d. Methodology used
b. Objectives
Unit of Vascular Surgery, Ospedale S.
Maria della Misericordia, University of
Perugia, Perugia, Italy
20 G. Parlani a, F. Verzini a, P. De Rango a,*, D. Brambilla
a, C. Coscarella b, C. Ferrer b, P. Cao: Long-term Results
of Iliac Aneurysm Repair with Iliac Branched Endograft:
A 5-Year Experience on 100 Consecutive Cases. Eur J
Vasc Endovasc Surg 43 (2012) 287e292
The GORE® EXCLUDER® Iliac Branch
Endoprosthesis (GORE® EXCLUDER®
IBE) is a branched endoprosthesis in an
integrated system constituted of two
69
Between November 2013 and March
2015 ten patients underwent
endovascular exclusion of aortoiliac
aneurysm with Gore C3 plus GORE®
EXCLUDER® Iliac Branch
Endoprosthesis.
effective methods for preserving
hypogastric artery flow have been
developed and are being used
increasingly. These techniques should
be used whenever possible in patients
who have or will undergo extensive
coverage of the thoracic aorta in a TEVAR
procedure, in patients requiring
interruption of the subclavian arteries,
and in patients with impaired flow through
the superior or inferior mesenteric
arteries. In all these circumstances
hypogastric artery occlusion is associated
with an increased incidence of spinal
cord ischemia and paraplegia or
paraparesis.
Technical success was achieved in all
cases with complete exclusion of
aneurysm sac at completion angiogram
except for one case of type II endoleak.
No perioperative death or major
complication was recorded.
No aneurysm growth was detected
during follow-up as well as no late
endoleak detection.
Internal iliac component patency was
maintained in all cases.
f. Conclusions of the study
Results obtained in our preliminary series
are encouraging and are consistent with
data from our previous study on iliac
aneurysm repair with Zenith iliac branch
device (Cook, Bloomington, IN, USA).
This suggests an important role of the
learning curve effect on IBD outcomes
in addition to the specific device
characteristics.
Nevertheless, further data and long-term
follow-up are needed to obtain definitive
conclusions.
volver al sumario
15 Malina M, Dirven M, Sonesson B, Resch T, Dias N,
Ivancev K. Feasibility of a branched stent-graft in common
iliac artery aneurysms. J Endovasc Ther
2006;13(4):496e500.
19 Verzini F, Parlani G, Romano L, De Rango P, Panuccio
G, Cao P. Endovascular treatment of iliac aneurysm:
Concurrent comparison of side branch endograft versus
hypogastric exclusion. J Vasc Surg 2009;49(5):1154e61.
11
IX
Salvatore Brugaletta
Thorax Institute, Hospital Clinic, University
of Barcelona, Spain.
Drug-eluting stents (DES) are widely used
as devices of first choice in percutaneous
coronary intervention (PCI). However,
certain concerns are associated with the
use of DES, i.e. delayed arterial healing
with a subsequent risk of neo
atherosclerosis, late stent thrombosis
and hypersensitivity reactions to the DES
polymer. 1 Therefore, a stent type made
of a bioresorbable material could provide
the desirable transient vessel support
without compromising the restoration of
normal vessel biology, vessel imaging or
treatment options in the long run. The
Absorb Bioresorbable Vascular Scaffold
(BVS, Abbott Vascular, Santa Clara, CA),
which consists of a PLLA bioresorbable
scaffold with poly D, L-lactide
bioresorbable (PDLLA) coating that
releases the antiproliferative drug
everolimus, was the first fully
bioresorbable scaffold to receive a CE
mark. 2 A comparable PLLA-based
scaffold coated with myolimus has
completed its first-in-man study with
encouraging results and also obtained
a CE mark and is also on the market. 3
This short article will concentrate on the
only widely available BVS, the Absorb
scaffold.
The ABSORB Cohort A and Cohort B
trials included only non-complex lesions
with low-risk patients. Placement of BVS
proved to be feasible and safe, with major
adverse cardiac events and stent
thrombosis rate similar to Xience V. Based
on the clinical safety demonstrated in
the first studies (ABSORB Cohort A and
B), the everolimus-eluting BVS acquired
a CE mark in Europe and has since
become commercially available. 4, 5
However, to further expand the indication
for BVS use in more complex coronary
lesions and acute coronary syndrome
patients, the BVS Expand, ABSORB
Extend and ABSORB II and BVS STEMI
first study, respectively, were initiated.
To explore the performance of BVS in a
larger group of patients with different
operators, the ABSORB Extend study
was initiated in more than 100 non-US
sites worldwide. Recently, an interim
analysis on the 12-month clinical
outcome of the 512 first BVS implanted
patients demonstrated a favourable
clinical outcome and safety profile:
cardiovascular death, ischemia-driven
major adverse cardiac events and target
vessel failure occurred in 0.4, 4.3 and
4.9?% of patients, respectively. The
incidence of scaffold thrombosis was
low (0.8?%). 6 Propensity-matched
clinical outcomes at 1-year between
Absorb Cohort B/ Extend patients and
Xience V patients from Spirit Cohorts
showed identical cardiovascular death,
hierarchical major adverse cardiac event
and stent thrombosis rates for BVS
compared with second-generation DES
(Xience V) (0.3 vs. 0.6?%, 5.2 vs. 5.5?%
and 0.5 vs. 0.5?%, respectively).7
Interestingly, target vessel failure rates
were significantly lower in BVS compared
with DES (5.5 vs. 8.6?%, respectively,
p?=?0.04). A 2-year follow-up
propensity-matched analysis confirmed
the non-inferiority of BVS compared with
Xience V. 8 Interestingly, the results from
a propensity-matched analysis of 250
patients, comparing patients implanted
with BVS with patients implanted with
Xience V in the SPIRIT IV trial, showed
a decrease in angina pectoris reported
by the sites through adverse event
reporting at 1 year (16.0 vs. 28.1?%,
respectively). 6 This difference was highly
significant and probably accounts for the
lower target vessel failure rate in the BVS
group. Also, the percentage of angina
diagnosed through adverse event
reporting was notably lower with BVS
than that reported in previous large
interventional trials (FREEDOM (sirolimuseluting stent/ paclitaxel-eluting stent):
21?%; SYNTAX (paclitaxel-eluting stent):
28?%; COURAGE (bare metal stent:
34?%). 7 This finding was recently
confirmed by the ABSORB II trial at 1year, which is the first randomised (2:1),
prospective, single-blinded, multicentre
trial, in which 501 patients were assigned
to the ABSORB BVS or a secondgeneration everolimus-eluting coronary
stent (Xience Prime). 9 Further follow-up
is needed to confirm this observation on
the potential reduction of post-PCI
70
angina. If confirmed, repeat angiography
with or without additional coronary
intervention would be significantly
reduced. This could greatly impact on
patient quality of life and additionally
reduce healthcare costs. The ABSORB
IV trial, recently started in the US, was
designed with angina reduction as
primary endpoint between BVS and
everolimus-eluting metallic stent.
BVS in complex coronary lesions has
been evaluated in various registries. The
6-month outcome data of the Italian allcomer patient GHOST-EU registry,
including 1189 patients with moderate
to high complex lesion and/or patient
characteristics, were reported, showing
acceptable rates of cardiovascular death
(1.0 %), target vessel myocardial
infarction (2.0 %) and of target lesion
failure (4.4 %). 10 Definite scaffold
thrombosis rates were 1.7 % at 6
months. Also, the Academic Medical
Centre single-arm first experience,
including a high number of complex
patients, showed a somewhat higher
major adverse cardiac event rate at this
time point, especially related to scaffold
thrombosis. The investigators claim that
this was due to a learning curve where
major changes were made with regard
to lesion preparation and post-dilatation
to achieve full scaffold expansion and
avoiding underexpansion as observed in
the first scaffold thrombosis cases. 11
Conversely, a propensitymatched
analysis from the single centre San
Raffaele Scientific Institute BVS registry
(Milan, Italy), comparing BVS (n = 92)
with Xience V (n = 92) in complex lesions
(83.9 % B2 or C lesions, 45.2 %
bifurcations), did reveal similar early
outcomes of BVS to second-generation
DES and no evidence for increased
scaffold thrombosis rates. 12
An interesting clinical application for BVS
is STEMI, as bioresorbable scaffolds may
seal the vulnerable plaque, restoring
coronary vasomotion and pulsatility. 13
Wiebe and co-workers presented a first
report on the short-term outcome of
STEMI patients treated with an
everolimus-eluting bioresorbable scaffold:
twenty-five patients with 31 lesions were
included with a procedural success rate
of 97 % and major adverse cardiac event
rate of 8.3 % during a mean follow-up
period of 137 days. 14 Gori et al. reported
the short-term results in 150 consecutive
patients (unstable angina 16 %, NSTEMI
40 %, STEMI 44 %), treated with in total
194 BVS between May 2012 and July
2013. These patients were compared
with 103 consecutive control patients
who received a DES (XIENCE Prime).
Major adverse cardiac event rates at 30
days and 6 months were similar between
the two groups. Scaffold thrombosis
occurred in three BVS patients and two
DES patients within the first month. 15
In the BVS STEMI First study, a
prospective, single-arm, monocentre
safety and feasibility study, 49 STEMI
patients were treated with a BVS (direct
stenting in 32.7 % and predilatation in
67.3 %). The procedural success rate of
BVS implantation was 97.9 %. TIMI flow
III was obtained in 91.7 % of patients
after BVS implantation. At 30 days, the
major adverse cardiac event rate was
2.6 % (one patient with a non-Q-wave
myocardial infarction in a non-target
vessel). Target lesion failure (composite
of cardiac death, target-vessel myocardial
infarction or ischemia-driven target lesion
revascularisation) did not occur and there
were no cases of scaffold thrombosis.
16 Additionally, in the prospective Prague
19 trial, BVS were implanted in
consecutive STEMI patients from
December 2012 until August 2013. 17
The BVS device success rate was 98 %.
Target lesion revascularisation of 1.3 %,
and a stent thrombosis and major
adverse cardiac event rate of 1.3 and
2.6 %, respectively, with an average
follow-up of about 6 months have been
reported. Recently a propensity score
matching comparison between 290
STEMI patients treated by BVS and 290
STEMI patients treated by everolimuseluting metallic stents has been reported:
whereas at 1-year there were no
differences in terms of device-oriented
endpoint (cardiac death, target vessel
myocardial infarction and target lesion
revascularization), a slight higher device
thrombosis of BVS device was reported
in the early phase. 18
Eventually, all these data have variously
showed a comparable safety and efficacy
of BVS devices over metallic stents, with
some concerns on thrombosis and some
interesting data on angina reduction.
New data and new technological
advancement of this technology are
waited during the coming years for
confirming these preliminary results.
volver al sumario
Update on clinical
evidence for
Bioresorbable
techniques
11
IX
1.Joner M, Finn AV, Farb A, Mont EK, Kolodgie FD,
Ladich E, Kutys R, Skorija K, Gold HK and Virmani
R. Pathology of drug-eluting stents in humans: delayed
healing and late thrombotic risk. J Am Coll Cardiol.
2006;48:193-202.
2.Serruys PW, Garcia-Garcia HM and Onuma Y. From
metallic cages to transient bioresorbable scaffolds:
change in paradigm of coronary revascularization in
the upcoming decade? European heart journal.
2012;33:16-25.
3.Verheye S, Ormiston JA, Stewart J, Webster M,
Sanidas E, Costa R, Costa JR, Jr., Chamie D, Abizaid
AS, Pinto I, Morrison L, Toyloy S, Bhat V, Yan J and
Abizaid A. A next-generation bioresorbable coronary
scaffold system: from bench to first clinical evaluation:
6- and 12-month clinical and multimodality imaging
results. JACC Cardiovasc Interv. 2014;7:89-99.
4.Serruys PW, Onuma Y, Dudek D, Smits PC, Koolen
J, Chevalier B, de Bruyne B, Thuesen L, McClean D,
van Geuns RJ, Windecker S, Whitbourn R, Meredith
I, Dorange C, Veldhof S, Hebert KM, Sudhir K, GarciaGarcia HM and Ormiston JA. Evaluation of the second
generation of a bioresorbable everolimus-eluting
vascular scaffold for the treatment of de novo coronary
artery stenosis 12-month clinical and imaging
outcomes. J Am Coll Cardiol. 2011;58:1578-88.
5.Serruys PW, Ormiston JA, Onuma Y, Regar E,
Gonzalo N, Garcia-Garcia HM, Nieman K, Bruining
N, Dorange C, Miquel-Hebert K, Veldhof S, Webster
M, Thuesen L and Dudek D. A bioabsorbable
everolimus-eluting coronary stent system (ABSORB):
Viernes, 26 Junio
Friday, June 26th
Sesión 18
Troubleshootings for
challenge cannulations
in fenestrated/
branched endografts:
can we leace
“impossible”
fenestrations open?
Eric LG Verhoeven
Endovascular Surgery1, Paracelsus
Medical University Nürnberg, Klinikum
Nürnberg Süd, Nürnberg, Germany
2-year outcomes and results from multiple imaging
methods. Lancet. 2009;373:897-910.
6.Abizaid A, Costa JR, Jr., Bartorelli AL, Whitbourn
R, van Geuns RJ, Chevalier B, Patel T, Seth A, Stuteville
M, Dorange C, Cheong WF, Sudhir K and Serruys
PW. The ABSORB EXTEND study: preliminary report
of the twelve-month clinical outcomes in the first 512
patients enrolled. EuroIntervention. 2014.
7.Chevalier B. An interim 12-month propensity adjusted
comparison of clinical outcomes of ABSORB patients
to Xience V patients. ESC 2013.
8.Carrie D. An interim 24-month propensity score
analysis comparison of clinical outcomes of ABSORB
EXTEND and ABSORB Cohort B patients to Xience
V patients. EuroPCR 2014.
9.Serruys PW, Chevalier B, Dudek D, Cequier A, Carrie
D, Iniguez A, Dominici M, van der Schaaf RJ, Haude
M, Wasungu L, Veldhof S, Peng L, Staehr P,
Grundeken MJ, Ishibashi Y, Garcia-Garcia HM and
Onuma Y. A bioresorbable everolimus-eluting scaffold
versus a metallic everolimus-eluting stent for ischaemic
heart disease caused by de-novo native coronary
artery lesions (ABSORB II): an interim 1-year analysis
of clinical and procedural secondary outcomes from
a randomised controlled trial. Lancet. 2015;385:4354.
10.Capodanno D, Gori T, Nef H, Latib A, Mehilli J,
Lesiak M, Caramanno G, Naber C, Di Mario C,
Colombo A, Capranzano P, Wiebe J, Araszkiewicz A,
Geraci S, Pyxaras S, Mattesini A, Naganuma T, Munzel
T and Tamburino C. Percutaneous coronary
intervention with everolimus-eluting bioresorbable
vascular scaffolds in routine clinical practice: early
and midterm outcomes from the European multicentre
GHOST-EU registry. EuroIntervention. 2015;10:114453.
11.Kraak RP, Hassell ME, Grundeken MJ, Koch KT,
Henriques JP, Piek JJ, Baan J, Jr., Vis MM, Arkenbout
EK, Tijssen JG, de Winter RJ and Wykrzykowska JJ.
Initial experience and clinical evaluation of the Absorb
bioresorbable vascular scaffold (BVS) in real-world
practice: the AMC Single Centre Real World PCI
Registry. EuroIntervention. 2015;10:1160-8.
12.Costopoulos C, Latib A, Naganuma T, Miyazaki T,
Sato K, Figini F, Sticchi A, Carlino M, Chieffo A,
Montorfano M and Colombo A. Comparison of early
clinical outcomes between ABSORB bioresorbable
vascular scaffold and everolimus-eluting stent
implantation in a real-world population. Catheter
Cardiovasc Interv. 2015;85:E10-5.
13.Brugaletta S, Radu MD, Garcia-Garcia HM, Heo
JH, Farooq V, Girasis C, van Geuns RJ, Thuesen L,
McClean D, Chevalier B, Windecker S, Koolen J,
Rapoza R, Miquel-Hebert K, Ormiston J and Serruys
PW. Circumferential evaluation of the neointima by
optical coherence tomography after ABSORB
bioresorbable vascular scaffold implantation: can the
scaffold cap the plaque? Atherosclerosis.
2012;221:106-12.
14.Wiebe J, Mollmann H, Most A, Dorr O, Weipert K,
Rixe J, Liebetrau C, Elsasser A, Achenbach S, Hamm
C and Nef H. Short-term outcome of patients with
ST-segment elevation myocardial infarction (STEMI)
treated with an everolimus-eluting bioresorbable
vascular scaffold. Clin Res Cardiol. 2014;103:141-8.
15.Gori T, Schulz E, Hink U, Wenzel P, Post F, Jabs
A and Munzel T. Early outcome after implantation of
Absorb bioresorbable drug-eluting scaffolds in patients
with acute coronary syndromes. EuroIntervention.
2014;9:1036-41.
16.Diletti R, Karanasos A, Muramatsu T, Nakatani S,
Van Mieghem NM, Onuma Y, Nauta ST, Ishibashi Y,
Lenzen MJ, Ligthart J, Schultz C, Regar E, de Jaegere
PP, Serruys PW, Zijlstra F and van Geuns RJ.
Everolimus-eluting bioresorbable vascular scaffolds
for treatment of patients presenting with ST-segment
elevation myocardial infarction: BVS STEMI first study.
Eur Heart J. 2014;35:777-86.
17.Kocka V, Maly M, Tousek P, Budesinsky T, Lisa L,
Prodanov P, Jarkovsky J and Widimsky P.
Bioresorbable vascular scaffolds in acute ST-segment
elevation myocardial infarction: a prospective
multicentre study 'Prague 19'. Eur Heart J.
2014;35:787-94.
18.Brugaletta S, Gori T, Low AF, Tousek P, Pinar E,
Gomez-Lara J, Scalone G, Schulz E, Chan MY, Kocka
V, Hurtado J, Gomez-Hospital JA, Munzel T, Lee CH,
Cequier A, Valdes M, Widimsky P, Serruys PW and
Sabate M. Absorb bioresorbable vascular scaffold
versus everolimus-eluting metallic stent in ST-segment
elevation myocardial infarction: 1-year results of a
propensity score matching comparison: the BVSEXAMINATION Study (bioresorbable vascular scaffolda clinical evaluation of everolimus eluting coronary
stents in the treatment of patients with ST-segment
elevation myocardial infarction). JACC Cardiovasc
Interv. 2015;8:189-97.
COMO MEJORAR RESULTADOS EN AAA YUSTA Y PARARRENALES
HOW TO IMPROVE OUTCOMES IN YUXTA AN PARARRENAL AAA
Moderador / Moderator Z. Krajcer
Panelistas / Panellists J.Busquet, M. de Blas
To answer the question posed by the
organizing committee of IV SITE 2015,
our prospectively maintained database
of fenestrated and branched stent-grafts
for complex aortic aneurysms was
queried. Within the study period (20012014), 457 patients were treated with
fenestrated grafts for complex abdominal
aortic aneurysms, and 214 with
fenestrated/branched grafts for thoracoabdominal aneurysms (TAAA). In total,
1712 vessels were targeted with
fenestrations or branches (scallops
excluded).
The main reason to stent a fenestration
with a covered stent is to achieve a
perfect sealing, but also to maintain the
fenestration in perfect position. In the
early days, we also used non-covered
stents in short-necked aneurysms, but
abandoned that in favor of a better
71
sealing, but also because covered stents
(Atrium V12, Atrium-Maquet) produced
better patency rates. Branches in TAAA
branched grafting (TAAAB) need to be
mated with covered stents to achieve
exclusion of the aneurysm, and to
maintain flow into the target vessel. To
achieve success with catheterization and
stenting, every available tool should be
available and used if needed, including
lower profile wires and catheters, and
additional guiding sheaths. The database
revealed 29 (1.7%) vessels that could
not be catheterized and stented intraoperatively in an antegrade manner.
In four (0.2%) vessels, all renal arteries,
stenting proved impossible, but the
fenestration seemed well aligned, without
evidence of endoleak. Further FU showed
good position without endoleak in three
cases. In the fourth case, it was decided
to stent the fenestration from above, as
sealing seemed compromised in the
longer term. This procedure was
uneventful.
In 12 (0.7%) vessels, stenting proved
impossible, and the target vessel lost.
In total, seven (0.74%) renal arteries out
of 942 targeted vessels in FEVAR cases
were lost. We could not catheterize four
renal arteries, which resulted in occlusion,
but without an endoleak. Three additional
renal arteries were lost: One renal artery
rupture required embolization, one
lumbar artery was stented instead of the
renal artery; one renal artery in a ruptured
case could not be catheterized and the
endoleak successfully treated with a cuff
and a chimney, and endostaples. In
TAAAB cases, five vessels (5/770, 0.65%)
could not be catheterized. One calcified
celiac artery occluded during
volver al sumario
References
11
IX
“impossible”
fenestrations open?
Will virtual reality &
robotics be mandatory
for planning and
treating complex aaa.
Nick J. Cheshire
Imperial College London & University of
Ghent, Belgium
Virtual reality simulation began with
generic datasets used as a training
exercise for novice interventionalists.
More modern systems can now
incorporate real patient data and have
been used in the carotids and - more
What’s next in vascular
image to improve
results in complex
aortic endovascular
therapy?
Rachel E. Clough
NIHR Academic Clinical Lecturer
Guy’s and St Thomas’ NHS Foundation
Trust and King’s College London
Using Image Fusion
During Endovascular
Procedures
Stéphan Haulon, MD, PhD
Aortic Centre, Vascular Surgery, Hôpital
Cardiologique, CHRU Lille, France,
Abstract
Endovascular abdominal aortic aneurysm
repair (EVAR) was developed to reduce
the risks associated with open surgery
and provide a treatment option for
patients not eligible to open surgery. To
Endovascular Surgery1, Paracelsus
To answer the question posed by the
organizing committee of IV SITE 2015,
our prospectively maintained database
of fenestrated and branched stent-grafts
for complex aortic aneurysms was
queried. Within the study period (2001-
recently - the infrarenal aorta to rehearse
a real implant before an operation. This
has become known as mission rehearsal
and has been an interest in our
departments for the last 10 years,
culminating in a trial currently being run
by our colleagues in Ghent, Belgium.
Mission rehearsal can able surgeons and
their teams to practice real operations
prior to surgery. Our preliminary findings
suggest that overall operative time,
imaging time, imaging angles and tool
selection may all be improved by using
virtual reality pre-operative mission
rehearsal. One of the limitations is the
proof quality of haptic feedback – making
the rehearsal procedure much less
realistic than a subsequent real life
intervention.
In the context of juxta renal and para
renal aneurysms, very little data exists
to practically guide us on the value of
mission rehearsal. The technology
currently available can simulate the
anatomy but not the tortuosity of access,
in particular, haptic difficulties required
to cannulate the renal arteries cannot
currently be appropriately mimicked..
We continue to work in this interesting
field and are looking for ways to improve
haptic feedback.
With regard to robotics and complex
aortic interventions, our evidence is a
little more advanced. Using a variety of
ex vivo and in vivo models of complex
aneurysm repair we been able to show
that a flexible and steerable robotic
system can reduce overall procedure
time, imaging time, wall contact number
and force, catheter movements and
cannulation path length. In clinical
practice we have shown reduced path
length and cannulation time for renal
artery fenestrations.
Complex endovascular repair requires
additional cannulation tasks that increase
the intraoperative procedure time,
fluoroscopy time, radiation dose and
volume of radiographic contrast
compared with standard endovascular
aortic repair.
The occurrence of a technical
complications and the duration of the
intervention have been shown to
significantly influence the incidence of
in-hospital mortality and severe
complications. Imaging systems have
therefore evolved to facilitate these
challenging procedures. Standard intraprocedural imaging is two-dimensional
(2D) X-ray fluoroscopy using either a
mobile C-arm or a fixed-room flat panel
detector. The latest hybrid operating
rooms have advanced imaging
applications such as contrast-enhanced
cone beam computed tomography (CT)
and pre-operative CT angiography image
fusion with the live fluoroscopy. There
are also a number of adjuncts available
such as electromagnetic or ultrasound
based localisation systems and robotic
navigations systems. The integration of
magnetic resonance pre-procedural
imaging and intra-operative guidance
may further refine complex aortic
endovascular intervention.
increase the number of patients eligible
to this minimally invasive procedure, there
has been recent development of complex
devices (fenestrated and branched
endografts) requiring concomitant
advances in intra-operative imaging
applications.
Imaging systems have therefore evolved
to facilitate these challenging procedures.
For example, fixed rooms’ flat panel
detectors have demonstrated strong
imaging superiority over standard two
dimensional (2D) fluoroscopy imaging
systems (mobile C-arms) which are limited
by overheating and image degradation,
particularly when performing complex
EVAR. Hybrid rooms, combining an
optimal open surgical environment and
advanced imaging capabilities are
currently replacing mobile C-arms in the
operative room. Fixed flat panel rooms
benefit from more tube power, excellent
image quality, and customizable X-ray
dose levels. Additionally, latest generation
rooms have the ability to acquire threedimensional (3D) images through a Carm rotation around the patient, also
called Cone Beam Computed
Tomography (CBCT). These 3D images
of the anatomy generated at the time of
the procedure can then be fused with
live fluoroscopy, in order to provide a 3D
roadmap that facilitates endovascular
navigation. Pre-operative Computed
Tomography Angiography (CTA) images
can also be fused with live fluoroscopy.
Then, depending on the room
manufacturer, imaging protocols can
slightly vary. When following good
practices and the As Low As Reasonably
Achievable (ALARA) principle, it is possible
to achieve excellent clinical outcomes
with a simple workflow and low X-Ray
exposure levels.
We will report our experience of image
fusion during endovascular procedures,
and in particular complex EVAR, in a
high-volume center dedicated to aortic
repairs, performed by operators focusing
on minimizing radiation exposure.
Eric LG Verhoeven
72
Summary:
at the moment virtual reality mission
rehearsal for juxta and pararenal
aneurysms is not sufficiently
technologically advanced to contribute
to real life planning. Regarding robotics
there is a growing body of evidence that
complex aneurysms treated by
endovascular grafts benefit from the use
of a steerable catheter system.
volver al sumario
Troubleshootings for
challenge cannulations
in fenestrated/
branched endografts:
can we leace
11
IX
Sesión 19
A more flexible and
repositionable
endograft fits better for
complex anatomies:
the anaconda
fenestrated platform
Fenestrated anaconda
tm endograft for shortneck and juxta/pararenal aortic aneurysms:
premliminary italian
experience.
Andrea Stella
Trucos, dentro y fuera
de las instrucciones de
uso, para las
endoprótesis
fenestradas en la
reparación de los AAA
yuxtarrenales
Fajardo, Andrés
El reparo endovascular de aneurismas
yustarrenales de la aorta abdominal ha
sido introducido con muy buenos
resultados. Como cualquier procedimiento
complejo, el nivel de experiencia de el
cirujano es importante en los resultados.
Adecuada selección de los pacientes es
vital en el resultado postoperatorio y el
mantenimiento de buenos resultados a
largo plazo. Pacientes con aortas muy
anguladas en el área visceral presentan un
problema durante la planeación y el
procedimiento. También, los pacientes
OPCIONES “ON AND LABEL” PARA EL TRATAMIENTO DE LOS AAA YUSTA Y PARARRENALES: DONDE
RESIDEN SUS VENTAJAS?
ON AND OFF LABEL APPROACHES FOR YUSTA AND PARARRENAL AAA WHERE ARE THEIR
ADVANTAGES?
Moderador / Moderator M. Malina
Panelistas / Panellists J.Brunkwall, J. Powell
Aims.
The AnacondaTM Fenestrated Endograft
(Vascutek, Inchinnan, United Kingdom)
is a new device that could be used to
treat challenging aortic aneurysms(AAA)
involving the abdominal visceral vessels.
The aim of the present study was to
report the preliminary results of the Italian
multi-centers experience, Italian
Anaconda Fenestrated study group.
advanced vessels analysis. Primary
endpoints were technical success(TS)
and 30-day clinical success(CS).
Secondary endpoints were: adverse
events (type I/III endoleaks, target visceral
vessels occlusion) / re-interventions
FEVAR-related and AAA-related mortality
during the follow-up.
Results.
Patients underwent fenestrated
endovascular aneurysm repair(FEVAR)
using AnacondaTM Fenestrated
Endograft, between May2012 and
November2014, were prospectively
enrolled. Clinical, morphological, intra
and post operative data were collected.
Indications for FEVAR included AAA with
proximal neck unsuitable for standard
EVAR. Planning was performed on the
computed tomography angiography
using dedicated software for the
Twenty-six patients (male, mean age
74±7years, ASAIII/IV:16/10) underwent
FEVAR using AnacondaTM Fenestrated
Endograft in 11 Italian institution for 5
short neck AAA and 21 juxta/para-renal
AAA. An overall of 67 target visceral
vessels were accommodated by using
of fenestrations. Fenestrated endograft
with 1, 2, 3 and 4 fenestrations were
used in 1, 10, 14 and 1 cases,
respectively. A bifurcated and tube
endograft was planned in 23 and 3
cases, respectively. In 17/26 (65%) cases
the endograft was repositioned during
the procedure and in 14/26 (54%) cases
con iliacas muy tortuosas o calcificadas
podrían presentar inconvenientes durante
el avance de la endoprotesis o la
manipulación durante la cirugía.
La participación del cirujano es muy
importante desde la planeación. Un
entendimiento de la endoprotesis creada
con todas las posibles dificultades a
encontrar es básica.
Buenos accesos iliacos son requeridos
para estos procedimientos. La evaluación
de las arterias iliacas bilaterales es de suma
importancia, y se recomienda la creación
de conductos iliacos (abiertos o
endovasculares) si es necesario.
Una población de pacientes muy
interesante y complicada es la que ha
tenido reparos previos(abierto o
endovascular) de un aneurisma abdominal
con degeneración proximal de la aorta.
Aparte de la dificultad de manipular la
prótesis, también nos encontramos con el
problema de cuerpos cortos distales a las
arterias renales, lo que lo hace en ocasiones
casi imposible de crear una prótesis
adecuada. En los Estados Unidos, las
reglas de fabricación de estas prótesis
fenestradas son muy estrictas y se requiere
de cierta distancia mínima para poder
fabricarlas. Otro inconveniente que se
puede encontrar es la presencia de fijación
suprarrenal de la prótesis inicial, que puede
obstruir el ostio de la arterias viscerales,
haciendo mas difícil la canulacion y avance
de los catéteres e introductores.
Asegurar tener un inventario adecuado con
todos los insumos necesario para el
procedimiento es de suma importancia,
así como la creación de un equipo
dedicado a estos procedimientos, que
incluye anestesia, enfermería, técnicos de
radiología e instrumentadores. Esto ayudara
a que los procedimientos sean mucho mas
estandarizados y si se presentan
alteraciones durante el mismo, se este
capacitado para realizar el ajuste necesario.
El uso de salas hibridas, adecuadas para
estos casos tan complejos, ha ayudado a
tener una mejor imagen intraoperatoria con
disminución de la radiación y el volumen
de contraste. La fusión con escanografia
es otra herramienta que ha demostrado
contribuir aun mas a una disminución en
estos parámetros.
Intraoperatoriamente hay muchos pasos
a seguir, y el conocimiento de las posibles
Methods.
73
almost 1 target visceral vessel was
cannulated from the brachial access. TS
was achieved in 24/26 (92%) patients (2
type I endoleak?). All the target visceral
vessels were successfully cannulated
and stented. An occlusion of 1 renal
artery and 1 type III endoleak (between
the aortic endograft and renal artery
stent-graft) occurred within the first week.
The 30-day mortality was 3.6% (1/26).
The 30-days CS was 80%. The mean
follow-up was 12months (range:1-33).
No type I/III endoleaks and target visceral
vessels occlusion occurred during the
follow-up. There were not re-interventions
FEVAR-related and AAA-related mortality.
Conclusions.
The AnacondaTM Fenestrated Endograft
can be used to treat challenging AAA
involving the abdominal visceral vessels.
Larger experiences and long-term data
are mandatory to confirm this treatment
as safe and effective also in the mid and
long term follow-up.
dificultades a encontrar, así como la manera
de solucionarlas es de suma importancia
para poder asegurar buenos resultados y
evitar complicaciones. Desde la orientación
inicial de la prótesis hasta la introducción
y despliegue de las extensiones iliacas hay
muchos trucos a seguir. La canulacion de
las arterias viscerales y posterior avance
de los introductores, puede generar
dificultades y una adecuada técnica y uso
de múltiples trucos va a facilitar estos
pasos. Disecciones y perforaciones de las
arterias renales y mesentéricas, son
complicaciones muy raras, pero que tienen
un impacto muy grande en los resultados
del procedimiento. Conocer diferentes
técnicas para su manejo intraoperatorio
es de suma importancia.
En resumen, las endoprotesis fenestradas
se han convertido en una herramienta muy
útil para el manejo de los aneurismas
yustarrenales y pararrenales. La selección
de pacientes es vital. Un entendimiento de
la endoprotesis desde la planeación y de
las posibles dificultades a encontrar, con
un vasto conocimiento de los diferentes
trucos es indispensable para obtener los
mejores resultados.
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Friday, June 26th
11
IX
Gustavo S. Oderich MD1, Leonardo
Reis de Souza MD1, Jan Hofer RN1,
Peter Banga MD1, Jean Wigham RN1,
Stephen Cha MS2, Thanila Macedo
MD3 and Peter Gloviczki MD1
Gonda Vascular Center, Mayo Clinic;
Abstract
Fenestrated and branched stent-grafts
have been increasingly utilized to extend
the indications of endovascular aortic
aneurysm repair (EVAR) to patients with
complex aneurysms involving the visceral
arteries. Clinical access to fenestrated
and branched endografts has been
limited in many centers due to regulatory
issues, added cost, lack of physician
training and additional time delays for
customization and manufacturing. The
average time for device customization
by the manufacturer ranges from 6 to 8
weeks, a limitation that may be avoided
once “off-the-shelf” devices become
available. Because of the time delay,
manufactured patient-specific devices
are not a viable option to treat patients
with rapidly enlarging, symptomatic or
contained ruptured aneurysms.
Physician-modified endovascular grafts
(PMEGs) have been widely used in many
centers to overcome the aforementioned
difficulties.
Mayo Clinic experience
We reviewed clinical data of 207
consecutive patients (164 male, mean
age 76±9 years old) treated for PRA/
TAAAs using fenestrated and branched
stent-grafts. Choice of device evolved
from PMEGs (2007-2013) to MSGs
(2012-2014) in patients enrolled in
prospective physician-sponsored
investigational device exemption
protocols (PS-IDE). End-points were 30day mortality, major adverse events
(MAEs), patient survival, freedom from
type I/III endoleak, sac growth (>5mm),
primary target vessel patency and reintervention.
In this study there were 138 patients
were treated by PMEGs, 69 had MSGs.
131 patients had PRAs (82 PMEGs, 49
MSGs), 76 had TAAAs (56 PMEGs, 20
MSGs). PMEGs patients had larger
aneurysms, more cardiac, pulmonary
and kidney disease, and higher
comorbidity scores (P<0.05). A total of
672 visceral arteries in both groups were
incorporated by fenestrations in 589,
scallops in 60 and directional branches
in 23. For the entire cohort, 97 patients
(47%) had 4-vessel designs and average
number of targeted visceral
vessels/patient was 3.2?0.9. Among
patients treated for PRAs, number of
74
patients with 4-vessel designs and mean
number of targeted visceral
arteries/patient was similar in both
groups. However, for TAAAs patients
treated by manufactured devices had
significantly (P<0.004) more 4-vessel
designs (95% vs 61%) and higher
number of targeted visceral arteries
(4.1?0.4 vs 3.5?0.8). Technical success
was 98% for PMEGs and 99.6% for
MSGs (P=0.9). 30-day mortality was 1%
for PRAs (PMEGs 1%, MSGs 0%,
P=0.44) and 7% for TAAAs (PMEGs 9%,
MSGs 0%; P=0.17).
There were more (P<0.05) MAEs among
PMEG patients treated for PRAs (44%,
24%) and TAAAs (58%, 25%). Mean
follow up was longer in PMEG patients
(31±21, 12±7 months; P<0.0001). At 1year, PMEGs and MSGs had similar
freedom from type I/III endoleaks (PRAs:
95±4%, 99±1%; TAAAs: 100%, 100%),
sac growth (PRAs: 99±1%, 100%;
TAAAs: 97±3%, 100%), primary target
vessel patency (PRAs: 97±1%, 98±1%,
TAAAs: 98±1, 97±2%) and reintervention (PRAs: 85±5%, 93±4%;
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Evolution from
physician-modified
endografts to
manufactured
fenestrated and
branched endografts to
treat pararenal and
thoracoabdominal
aortic aneurysms
11
IX
TAAAs: 82±5%, 100%). Survival was
lower (P<0.05) in PMEGs patients treated
for PRAs (84±3%, 98±2%) and TAAAs
(78±5%, 100%). At 5-years, 20 PMSG
patients (14%) developed type I/III
endoleak and 10 (7%) had sac growth.
In the PMEG group, patient survival,
freedom from type I/III endoleak, sac
growth, primary target vessel patency
and re-intervention at 3- and 5-years was
71±4%/63±5%, 87±3%/76±7%,
96±2%/80±6%, 96±1%/96±1%, and
71±5%/57±7%, respectively.
Conclusion:
Patients treated by PMEGs had higher
clinical risk and larger aneurysms,
reflecting the more liberal indication of
MSGs under PS-IDE protocols. Despite
differences, both devices were implanted
with similar technical success, mortality,
endoleak, sac growth, vessel patency
and re-intervention rates. At late follow
up, PMEGs were associated with
significant rate (14%) of type I/III
endoleaks and sac growth (7%).
Michel Reijnen
Chimney grafts have been used as a
bailout procedure to treat unintentionally
overstented target vessels during EVAR
and as an alternative for FEVAR. The
major concern with this technique is the
occurrence of “gutters” between the
chimney graft, the main graft, and the
aortic wall, leading to type Ia endoleaks.
Another concern is that stent
compression may affect chimney graft
patency. Endovascular sealing of
aneurysms (EVAS), using the Nellix
endoprosthesis was introduced in an
attempt to reduce the incidence of
reinterventions due to endoleaks and
migration. The Nellix system consists of
dual balloon-expandable stent-grafts
surrounded by endobags that, once
adequately positioned, are filled with fast
curing polymer to obliterate the aneurysm
sac, maintain endograft position, and
restrict retrograde flow from side
branches that could lead to endoleaks.
The combined use of the Nellix
endoprosthesis and chimney grafts might
prevent gutter formation and reduce stent
compression.
To March 2015 nine patients, with a
median age of 72 years, were treated
with chimney-EVAS. There were 6 juxtaand 3 pararenal aneurysms, with a mean
diameter of 62 ± 6,0 mm, of which two
75
were acute procedures. The infra SMA
neck length and diameter were 16,0 ±
4,5 mm and 25,0 ± 2,6 mm, respectively.
The operation time was 147 (91-242)
min. Five single and 4 double chimney
procedures were performed and Advanta
V12™ stents was used in all cases. After
a median follow-up of 6 months (range
0-12 months) there were no endoleaks,
all chimney grafts remained patent, no
re-interventions were performed and the
renal function was stable. CT analysis
showed no gutter formation and a
maximum stent compression of 17,5%
(7,7%-37,1%).
Chimney in combination with EVAS is a
safe and feasible procedure and the
polymer-filled endobags may overcome
gutter formation and subsequent type
Ia endoleaks.
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Initial results of
endovascular sealing
of aneurysms (evas),
using the nellix
endoprosthesis, in
combination with
chimney grafts
11
IX
Sesión 20
Nunca más: lecciones
aprendidas del peor
caso endovascular de
mi vida
Andrés Fajardo
Paciente de 66 años con AAA y
aneurisma de la arteria iliaca común de
2.6 cm(Figura 1). Historia medica de
Hipertension e hiperlipidemia
controladas. Activo. Se lleva a sala de
operaciones para manejo endovascular
de AAA y de aneurima de iliaca derecha.
Procedimiento llevado a cabo sin
inconvenientes.
Reparo efectuado con protesis Zenith
de Cook. Debido al tamaño de la iliaca
derecha un conversor de 28 mm fue
usado para preservar flujo pélvico.
Tiempo de fluoroscopia fue de 12
minutos, con 50 ml de contraste
usados(Figura 2).
NUNCA MÁS: LECCIONES APRENDIDAS DEL PÑEOR CASO ENOVASCULAR DE MI VIDA
NEVER AGAIN: LESSONS LEARNT FROM THE WORST ENDOVASCULAR CASE OF MY LIFE
Moderador / Moderator C. Timerán, P. Gaines, C. Donayre
Presentadores / Presenters R. Chaer, Z. Krajcer, M. Jacobs, L. Sánchez, et al
dieta y con laboratorios clínicos estables.
Readmitido a hospital periférico con dolor
lumbar y anemia. Transferido a nuestra
institución donde se realiza escanografia
abdominal que evidencia una ruptura de
la arteria iliaca derecha. Paciente llevado
de urgencia a la sala de operaciones
donde se procede con embolizacion de
la arteria hipogástrica derecha con
extensión de la rama iliaca hasta la Iliaca
externa (Figura 4). Intraoperatoriamente
tuvo periodos de inestabilidad
hemodinámica y desarrollo distención
abdominal con aumento de presiones
de la via aérea por lo que se realizo
laparotomía decompresiva. Paciente
intubado por una semana, con cierre de
la laparotomía en el dia postoperatorio
numero 4. Paciente desarrollo trombosis
venosa de la iliaca derecha y su
hospiatlizacion total fue de 2 semanas
con una recuperación que le tomo varios
meses.
Paciente fue dado de alta el primer dia
postoperatorio, ambulatorio, tolerando
Never again: lessons
learnt from the worst
endovascular case of
my life
Prof. Michael Jacobs
A 13-year-old boy suffering from
coarctatio was treated in another country
with a covered stent. Several months
later he received another stent because
of residual stenosis. In April 2013 he was
admitted with a ruptured thoracic aorta
for which a thoracic endograft was
implanted. In May 2013 he received an
additional TEVAR more proximally. In
June of that year he developed massive
hematemesis, caused by an aortoesophageal fistula due to protusion of
stent material in to the esophagus.
Another endograft was introduced more
proximal, covering the left subclavian
artery, as well as a chimney in the left
carotid artery to preserve cerebral flow.
The boy survived this second challenge
also but now had mediastinitis, aortoesophageal fistula, intra-aortic stents
and endografts in-situ and a chimney
graft in the left carotid artery. He was
referred to our center in a hemodynamic
stable situation.
We decided to explant all foreign material
via left thoracotomy under circulatory
arrest and antegrade selective brain
76
Figura 1
Figura 3
Figura 2
Figura 4
perfusion. The left chest was cleaned
and a 15 mm diameter and 6 cm long
homograft was implanted at the level of
the left carotid artery with inclusion of
the left subclavian artery. The small hole
in the esophagus was closed and a large
latissimus dorsi flap was wrapped around
the homograft, also covering the fistula.
The boy received parenteral nutrition and
recovered well. Because of continued
fever and elevated infection parameters,
a rethoracotomy was performed to clean
and rinse the area. Four weeks later, he
had hematemesis again and an
esophagus clip was implanted. Six weeks
after our aortic repair he developed
another almost lethal bleeding for which
an emergency endograft implantation
was performed. We were obviously back
to the dreadful situation based on a fistula
between the homograft and the
esophagus. Given this devastating
situation we decided to perform a radical
operation: first, via sternotomy, an extraanatomic 20 mm ringed PTFE graft was
proximally anastomosed to the supracoronary aorta in an end-to-side fashion
and a 10 mm graft connected to the
brachio cephalic artery. The left carotid
artery was over sewn (normal TCD and
EEG). The graft was routed at the right
side of the heart and distally
anastomosed to the supra-celiac aorta
in an end-to-side fashion. Following, the
patient was turned on the right side and
via the left thoracotomy the homograft,
including the endograft, was explanted
and the distal descending thoracic aortic
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Viernes, 26 Junio
Friday, June 26th
11
IX
stump over sewn. The left subclavian
artery was treated with an occluder.
The boy recovered remarkably well and
fast. The infection parameters normalized
and a contrast swallow X-ray showed
absence of leaking at the level of the
pre-existent fistula.
Finally the boy could fly back to his
country and now 18 months later he is
perfectly OK, playing soccer and making
progress in school. I had the pleasure to
meet him in his own environment where
he showed me all the well healed scars
with a huge smile.
Post-operative image of extra-anatomic
aortic repair with resection of descending
aorta from supra-coronary aorta to supra
celiac aorta.
Peter Gaines
Multiple visceral und
peripheral
embolization during
initial staged thoracic
aortic repair for TAAA
Kasprzak PM
my life
Rabih Chaer
15 yrs ago I was asked to be part of the
evaluation of a new thoracic stent graft.
To me the device really did not makes
sense; the individual stents were to long
to conform to the curve of the arch of
aorta, and the apex of the struts I thought
would be too traumatic. However I was
flattered to be involved in the evaluation
and recruited a patient with chronic aortic
dissection as my first case. following
placement of the device there was a
proximal type 1 endoleak. Following
balloon dilatation there was a larger
endoleak, probably due to a tear in the
dissection flap. A large Palmaz stent did
not resolve the problem, neither did a
proximal Gore TAG device. After 12 hrs
the case was concluded.
The patient awoke with bilateral
hemispheric infarcts resulting in bilateral
spasticity, bladder and bowel
incontinence.
Endovascular Surgery, University Hospital
Regensburg, Germany
We report the lethal outcome of a patient
treated for a thoracoabdominal aortic
aneurysm (TAAA) with intended
implantation of a branched endograft
under neurophysiological control using
motor evoked potentials (MEPs).
However, during distal thoracic aneurysm
exclusion ending in a kinked aortic
segment just above the diaphragm MEPs
indicated loss of motoric potentials with
suspected spinal cord ischemia. Mean
blood pressure was elevated, spinal fluid
removed and the procedure
discontinued. Unfortunately, the patient
developed visceral ischemia with liver
failure, intestinal and peripheral ischemia
and died within 48 hours. Based on this
experience, we discuss interpretation of
MEPs analysis and propose inclusion of
the renovisceral aortic segment during
the initial step of staged
thoracoabdominal aortic repair, with open
branches for organ perfusion, especially
in kinked and thrombosed TAAAs.
This is the case of a patient with laryngeal
cancer who underwent extensive
chemoradiation, followed by neck
dissection and laryngectomy.
He sustained bilateral carotid artery
blowout in a sequential manner. The first,
which was the right side, was treated
with carotid ligation with no neurologic
sequalae. This was followed by blowout
of the left carotid few days later, which
was treated with a covered stent.
This case highlights a series of
complications following this endovascular
intervention, leading to several
reoperations and ongoing problems.
Discussion of carotid blowout and repair
options for this difficult situation will be
presented.
77
Lessons
1. All devices are not equal.
2. Believe your instincts when you
think a device is not suitable for the
job.
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my life
11
IX
Abstract
Carlo Setacci
Objectives:
Carotid Artery Stenting (CAS)
has a higher rate of advers
events at early time (30 days) in
comparison with Carotid
Endarterectomy (CEA). This is a
preliminary report of 30 days
results of CAS in a multicentre
italian registry using a double
layer micromesh design carotid
stent.
procedural data were
prospectively collected in a
dedicated database.
Neurological evaluation of all
patients was scheduled at 24h,
48h and 30 days after the
procedure. Intra procedural
Optical Coherence Tomography
(OCT) evaluation data were
collected, if available, and frames
were analysed off-line, in a
dedicated core laboratory
CAS/CEA (1 Symptomatic). In
all cases technical succes was
achieved. A subgroup of 6
patients received Magnetic
Resonance evaluation of
cerebral parenchyma before and
24 hours after the procedure
and only in 1 case, 3 new lesions
in the ipsilateral hemisphere and
2 in controlateral were evident
at 24 hours RM control. The
OCT evaluation was done in 14
patients with lower rate of plaque
prolapse in comparison with
previous published series using
other available stents. No advers
events (death, Stroke or TIA)
occurred in all Patients, at 1
month follow-up.
Conclusion:
This is the first report using this
promising technology, OCT
evaluation seems to show some
advantages in CAS using the
double layer micromesh design
carotid stent. More data are
required to demonstrate the non
inferiority of CAS in comparison
with CEA at early time, but the
preliminary data are encouraging
Chief of Vascular and
Endovascular Surgery Unit
Department of Medicine, Surgery
and Neuroscience University of
Siena Past-President of
European Society for Vascular
Surgery Past-President of Italian
Society for Vascular and
Endovascular Surgery
Materials and methods:
Flow diverting
stents:
indicaciones y
resultados tras más
de 5 años de
experiencia clínica
Since the appearance of flow
diverters around 2009, its use
for the treatment of intracranial
aneurysms has clearly increased.
Flow diverters led us to a
different approach in the
endovascular treatment of
intracranial aneurysms, in terms
of extrasacular treatment
compared to the classical
intrasacular treatment. These
devices have been used for
those aneurysms untreatable
with standard techniques, but
with an increasing understanding
of their safety and efficacy,
indications have spread over all
different types of aneurysms.
Although complications may be
higher in those patients treated
with flow diverters, careful
attention should be paid to the
specific type of aneurysms we
are dealing with, and to the
intrinsic risk of those lesions. In
aneurysms > 10 mm, the annual
rupture rate has been shown to
be up to 4.37% and in giant
aneurysms (>25 mm) this rate
may go up to 33.4%. In this type
of aneurysms, surgical treatment
is often challenging and can be
associated with significant
morbidity. Moreover, simple
coiling has been shown to be a
non-definitive treatment in many
cases, with a recurrence rate of
39%. Giant and big aneurysms
have been typical indications for
flow diverters during all these
years, however many people in
the INR community are now
advocating for extending the
indications of flow diverters to
small, unruptured, saccular
aneurysms. Pros and cons will
be presented with an specific
emphasis on the latest reviews
in the literature and our own
experience.
estudio previo a la realización
de un procedimiento terapéutico
las técnicas de imagen son de
gran importancia, siendo en la
mayoría de casos un factor clave
tanto en la indicación del
procedimiento como en su
planificación, aportando
información etiológica,
anatómica y fisiopatológica
imprescindible.
La tomografía computarizada
(TC) y la resonancia magnética
(RM) son técnicas diagnósticas
que presentan aplicaciones
clínicas ampliamente conocidas
en la patología neurovascular.
En las unidades de urgencia el
uso de la TC en pacientes con
clínica sugestiva de ictus es
habitual como prueba
diagnóstica inicial, permitiendo
rápidamente diferenciar los ictus
isquémicos de hemorrágicos,
así como de otras patologías.
Una vez alcanzado el
diagnóstico, un estudio más
detallado mediante técnicas
como la angiografía por TC/RM
y/o la perfusión por TC/RM
permiten definir adecuadamente
la etiología y las posibilidades
que tiene este paciente de
beneficiarse de terapias
endovasculares. De esta forma
esta información asociada al
estado clínico definirán los
criterios para indicar el
tratamiento necesario en cada
grupo de pacientes. La
importancia de las técnicas
diagnósticas no sólo se
demuestran en el ámbito de
urgencias, sino también en el
manejo de patologías de
diagnóstico incidental, como es
el caso del manejo de los
aneurismas no rotos, en donde
los estudios angiográficos son
básicos no sólo en el diagnóstico
sino también en la selección de
aquellos pacientes que son
tributarios de tratamiento. Una
vez se ha decidido el tratamiento
más adecuado para cada
paciente, la planificación
cuidadosa del procedimiento a
realizar es imprescindible, y en
esta etapa nuevamente las
pruebas de imagen cumplen un
papel primordial, siendo
necesario que éstas sean lo
suficientemente detalladas para
aportar la información
anatómica y fisiopatológica
necesaria, caracterizando la
extensión de la enfermedad
vascular que pueda contribuir al
síndrome clínico, así como
permitir decidir los materiales
más idóneos para cada terapia,
inferir los probables efectos del
tratamiento y el curso clínico
posterior.
Dr. Jordi Blasco
Neurorradiología Intervencionista
C.D.I.
Hospital Clínic de Barcelona
Importancia y
aplicación de las
técnicas
diagnósticas en la
selección de
pacientes y
planificación
terapéutica.
Dr. Napoleón Macías
La utilización apropiada de las
técnicas diagnósticas es
fundamental para un adecuado
manejo del paciente con
patología neurovascular. En el
All Patients underwent CAS
using the RoadSaver Carotid
Stent (Terumo Leuven, Belgium)
in three high-volume italian
centers were prospectively
included in the registry.
Demographics of all Patients,
plaque characterization and
Results:
Thirty-six patients were included
in the registry. Median age was
73(24 males).5 Patients were
symptomatic (2 TIA and 3
MINOR STROKE) and 9 cases
suffered a restenosis after
78
volver al sumario
State of the art in
carotid stenting:
where we are today
and to where we
are going
tomorrow?
11
IX
What’s new in tavi?
Dra. Pilar Jimenez-Quevedo
Hospital Clínico San Carlos ,
Madrid
Bioresordable
devices in clinical
use
Tommaso Gori
Professor for translational
vascular medicine
2. Medizinische Klinik für
Kardiologie und Angiologie
University Medical Center Mainz,
Germany
Future of
bioresorbable
techniques
Josep Gomez Lara
The first revolution in
interventional cardiology was
performed by Andreas Gruentzig
in 1977. A man with stable
angina was treated with plain
old balloon angioplasty (POBA)
and remained without
symptoms, with excellent
angiographic result, at long-term
follow-up (1). However, POBA
treatment of coronary lesions
was associated in a large
number of patients with acute
artery recoil, occlusive
dissections and ischemic-driven
target lesion revascularization.
The second revolution was the
advent of coronary metallic
stents. Puel and Sigwart
implanted the first coronary stent
in 1986 (2). Metallic stents
Based on the Partner I and
Pivotal trial transcatheter aortic
valve replacement (TAVR) has
been incorporated into the
treatment strategy for high-risk
and inoperable patients with
severe aortic stenosis. In this
regard the 5-years of the Partner
I trial was recently published
showing that no structural valve
deterioration requiring reintervention in patients treated
with TAVR during the follow up.
In addition, the 2 years
outcomes of CoreValve US
Pivotal Trial revealed the
superiority in survival seen at 1
year for TAVR over SAVR was
maintained up to 2 years.
Despite theses favorable results
of the fist generation devices
procedural complications such
us stroke, vascular
complications, paravalvular leak
and conduction disturbances
remain a concern with TAVR.
With the advent of the secondgeneration device (Sapien 3)
those complications has been
dramatically reduced. In this
regard the preliminary results of
the PARTNER II S3 Trial showed
that the risk of death at 30-days
in high-risk and inoperable
patients was 1.6% (transfemoral
group), major vascular
complications 5%, annular
rupture 0.2% coronary occlusion
0.3%, new parecemaker 10%
and significant (moderate-severe)
paravalvular regurgitation which
is related with worse long term
outcome: 3.7% and 0.1%
respectively. This study also
included a cohort of intermediate
risk patients showing similar
results. Following this striking
data it is time to move on to treat
with TAVR lower risk patients
with aortic stenosis.
Everolimus-eluting bioresorbable
vascular scaffolds (BVS) have
been recently introduced in more
than 60 countries worldwide for
the treatment of de novo
coronary lesions. Analogue to
metal stents, BVS initially provide
mechanical scaffolding,
preventing acute occlusion and
early recoil, and release
everolimus for the inhibition of
neointima proliferation.
Thereafter, the resorption of the
scaffold struts has been
hypothesized to protect vascular
geometry/biomechanics, and,
longterm, allow positive
remodeling. The latter concepts
extend beyond the traditional
treatment with metal stents, and
phenomena such as the
restoration of vasomotion, late
luminal gain (in contrast to late
luminal loss), and expansive
remodeling have been
advocated as potential
advantages of BVS over
traditional metal stents. Initial
results from simple lesions
appear to be encouraging, as
they demonstrate a safety
comparable to that of mpdern
DES and a lower incidence of
angina during follow-up.
Disturbingly, real-world registries
have reported a relatively high
incidence of in-stent thrombosis,
which however appears to be
completely prevented by
application of BVS-specific
patient selection and
implantation strategies. The
mechanisms of this observation,
and the possibilities to prevent
BVS thrombosis, are discussed. avoided the risk of acute recoil
and minimized the risk of
occlusive dissections.
Consequently, coronary artery
stenting has progressively
replaced balloon angioplasty as
the preferred method of PCI.
However, a large number of
patients presented with stent
restenosis and ischemic-driven
target lesion revascularization at
follow-up. The third revolution in
interventional cardiology
consisted in the addition of an
antiproliferative drug eluting the
metallic stents. Drug-eluting
stents (DES) decreased
dramatically the neointimal
response and reduced the risk
of stent restenosis (3). Therefore,
DES replaced conventional
metallic stents for treatment of
coronary artery disease; but has
been associated with the risk of
stent thrombosis at long-term
follow-up (4). Stent thrombosis
is a severe complication mainly
caused by the lack of metallic
strut coverage due to its
inhibition to the neointimal
response. Different strategies,
such as prolonged anti-platelet
therapy or novel DES less prone
to stent thrombosis, have been
developed in order to prevent
stent thrombosis. Bioresorbable
vascular scaffolds (BVS) can
overcome the risk or stent
thrombosis at long-term followup. Therefore, many
cardiologists have defined this
new technology as the fourth
revolution in interventional
cardiology.
Although angiographic late and
very-late ST are rare, the
cumulative incidence per year is
around 0.8% with bare metal
stents (BMS), 0.7-1.5% with firstgeneration drug-eluting stents
(DES) and 0.5-0.7% with
second-generation DES at 2-3
years follow-up (5-7). Moreover,
it is remarkable that the
incidence of late stent
thrombosis is permanent and
does not decrease at very longterm term follow-up (8).
Therefore, implantation of BVS
in patients with long life
expectancy is probably one of
the most interesting targets of
bioresorbable technology. On
the other hand, the most
common predictors of very-late
stent thrombosis are: STelevation myocardial infarction
(STEMI), stent length and left
anterior descending (LAD)
stenting (5). Therefore,
implantation of BVS in patients
with STEMI and patients
requiring long scaffolded
segments (such as patients with
chronic total occlusions) are
other interesting targets of
bioresorbable technology.
However, BVS are also been
investigated in other unusual
indications for coronary stenting:
treatment of non-stenotic and
non-culprit “vulnerable plaques”
and treatment of active patients
with effort angina.
The PROSPECT trial evaluated
the three major epicardial vessels
with intravascular ultrasound of
697 patients with acute coronary
syndromes (ACS) (9). After
treatment of the culprit lesion
patients were follow-up for a
minimum of 3 years. Coronary
events were documented in 20%
of patients (50% related to the
culprit lesion and 50% to nonculprit lesions). Analysis of nonculprit plaques at study inclusion
developing coronary events at
follow-up showed that “high risk
plaques” had the following
characteristics: plaques with
thin-cap fibroatheromas or
plaques characterized by a large
plaque burden, a small luminal
area or some combination of
these characteristics (9). The
PROSPECT II trial will evaluate
preventive treatment of nonculprit plaques with similar IVUS
findings in ACS patients
(https://clinicaltrials.gov/ct2/sh
ow/study/NCT02171065).
The second “unusual” indication
of BVS is the implantation in
active patients with effort angina.
Preliminary data of the first
randomized trial comparing BVS
with the ¨standard of care¨
everolimus-eluting metallic stents
in stable patients showed a
significant reduction of angina
symptoms in patients treated
with BVS (10). A total of 25-50%
of patients with stable coronary
79
volver al sumario
Abstract
11
IX
Abstract
coronary vessel geometry and
restoration of the shear stress
forces (17,18). The BVS
provides considerable
restoration of normal vascular
function once the bioresorption
process has been finished, then
vessels can react to pulsatile
flow, positively remodel and
respond normally to endothelial
factors, allowing the artery to
respond to the shear stress
(15,19). Therefore, BVS can be
of interest in active patients with
effort angina in order to restore
the “physiologic” response of
the coronary artery to exercise.
The ABSORB IV trial will evaluate
the angina status of almost
5,000 patients treated with
Absorb versus EES as primary
end-point
(https://clinicaltrials.gov/ct2/sh
ow/study/NCT02173379).
Update on clinical
evidence for
bioresordable
techniques
type made of a bioresorbable
material could provide the
desirable transient vessel support
without compromising the
restoration of normal vessel
biology, vessel imaging or
treatment options in the long run.
The Absorb Bioresorbable
Vascular Scaffold (BVS, Abbott
Vascular, Santa Clara, CA), which
consists of a PLLA bioresorbable
scaffold with poly D, L-lactide
bioresorbable (PDLLA) coating
that releases the antiproliferative
drug everolimus, was the first fully
bioresorbable scaffold to receive
a CE mark. 2 A comparable
PLLA-based scaffold coated with
myolimus has completed its firstin-man study with encouraging
results and also obtained a CE
mark and is also on the market.
3 This short article will concentrate
on the only widely available BVS,
the Absorb scaffold.
Salvatore Brugaletta
Thorax Institute, Hospital Clinic,
University of Barcelona, Spain.
Drug-eluting stents (DES) are
widely used as devices of first
choice in percutaneous coronary
intervention (PCI). However,
certain concerns are associated
with the use of DES, i.e. delayed
arterial healing with a subsequent
risk of neo atherosclerosis, late
stent thrombosis and
hypersensitivity reactions to the
DES polymer. 1 Therefore, a stent
Bibliografia.
1.Meier B. The first patient to undergo
coronary angioplasty--23-year follow-up.
N Engl J Med 2001;344:144-5.
2.Sigwart U, Puel J, Mirkovitch V, Joffre
F, Kappenberger L. Intravascular stents
to prevent occlusion and restenosis after
transluminal angioplasty. N Engl J Med
1987;316:701-6.
3.Morice MC, Serruys PW, Sousa JE et
al. A randomized comparison of a
sirolimus-eluting stent with a standard
stent for coronary revascularization. N Engl
J Med 2002;346:1773-80.
4.Stettler C, Wandel S, Allemann S et al.
Outcomes associated with drug-eluting
and bare-metal stents: a collaborative
network meta-analysis. Lancet
2007;370:937-48.
5.de la Torre-Hernandez JM, Alfonso F,
Hernandez F et al. Drug-eluting stent
thrombosis: results from the multicenter
Spanish registry ESTROFA (Estudio
ESpanol sobre TROmbosis de stents
FArmacoactivos). J Am Coll Cardiol
2008;51:986-90.
6.de la Torre Hernandez JM, Alfonso F,
Gimeno F et al. Thrombosis of secondgeneration drug-eluting stents in real
practice results from the multicenter
Spanish registry ESTROFA-2 (Estudio
Espanol Sobre Trombosis de Stents
Farmacoactivos de Segunda Generacion2). JACC Cardiovasc Interv 2010;3:9119.
7.Tada T, Byrne RA, Simunovic I et al. Risk
of stent thrombosis among bare-metal
stents, first-generation drug-eluting stents,
The ABSORB Cohort A and
Cohort B trials included only noncomplex lesions with low-risk
patients. Placement of BVS
proved to be feasible and safe,
with major adverse cardiac events
and stent thrombosis rate similar
to Xience V. Based on the clinical
safety demonstrated in the first
studies (ABSORB Cohort A and
B), the everolimus-eluting BVS
acquired a CE mark in Europe
and has since become
commercially available. 4, 5
However, to further expand the
indication for BVS use in more
complex coronary lesions and
acute coronary syndrome
patients, the BVS Expand,
ABSORB Extend and ABSORB
II and BVS STEMI first study,
respectively, were initiated.
To explore the performance of
BVS in a larger group of patients
with different operators, the
80
and second-generation drug-eluting stents:
results from a registry of 18,334 patients.
JACC Cardiovasc Interv;6:1267-74.
8.Brodie B, Pokharel Y, Fleishman N et al.
Very late stent thrombosis after primary
percutaneous coronary intervention with
bare-metal and drug-eluting stents for STsegment elevation myocardial infarction:
a 15-year single-center experience. JACC
Cardiovasc Interv 2011;4:30-8.
9.Stone GW, Maehara A, Lansky AJ et al.
A prospective natural-history study of
coronary atherosclerosis. The New England
journal of medicine 2011;364:226-35.
10.Serruys PW, Chevalier B, Dudek D et
al. A bioresorbable everolimus-eluting
scaffold versus a metallic everolimus-eluting
stent for ischaemic heart disease caused
by de-novo native coronary artery lesions
(ABSORB II): an interim 1-year analysis of
clinical and procedural secondary
outcomes from a randomised controlled
trial. Lancet 2015;385:43-54.
11.Cohen DJ, Van Hout B, Serruys PW et
al. Quality of life after PCI with drug-eluting
stents or coronary-artery bypass surgery.
The New England journal of medicine
2011;364:1016-26.
12.Weintraub WS, Boden WE, Zhang Z et
al. Cost-effectiveness of percutaneous
coronary intervention in optimally treated
stable coronary patients. Circulation
Cardiovascular quality and outcomes
2008;1:12-20.
13.Hofma SH, van der Giessen WJ, van
Dalen BM et al. Indication of long-term
endothelial dysfunction after sirolimuseluting stent implantation. European heart
journal 2006;27:166-70.
ABSORB Extend study was
initiated in more than 100 nonUS sites worldwide. Recently, an
interim analysis on the 12-month
clinical outcome of the 512 first
BVS implanted patients
demonstrated a favourable clinical
outcome and safety profile:
cardiovascular death, ischemiadriven major adverse cardiac
events and target vessel failure
occurred in 0.4, 4.3 and 4.9?%
of patients, respectively. The
incidence of scaffold thrombosis
was low (0.8?%). 6 Propensitymatched clinical outcomes at 1year between Absorb Cohort B/
Extend patients and Xience V
patients from Spirit Cohorts
showed identical cardiovascular
death, hierarchical major adverse
cardiac event and stent
thrombosis rates for BVS
compared with secondgeneration DES (Xience V) (0.3
14.van Liebergen RA, Piek JJ, Koch KT,
de Winter RJ, Lie KI. Immediate and longterm effect of balloon angioplasty or stent
implantation on the absolute and relative
coronary blood flow velocity reserve.
Circulation 1998;98:2133-40.
15.Serruys PW, Ormiston JA, Onuma Y
et al. A bioabsorbable everolimus-eluting
coronary stent system (ABSORB): 2-year
outcomes and results from multiple imaging
methods. Lancet 2009;373:897-910.
16.Gomez-Lara J, Brugaletta S, Diletti R
et al. A comparative assessment by optical
coherence tomography of the performance
of the first and second generation of the
everolimus-eluting bioresorbable vascular
scaffolds. European heart journal
2011;32:294-304.
17.Bourantas CV, Papafaklis MI, GarciaGarcia HM et al. Short- and long-term
implications of a bioresorbable vascular
scaffold implantation on the local
endothelial shear stress patterns. JACC
18.Gomez-Lara J, Brugaletta S, Farooq V
et al. Angiographic geometric changes of
the lumen arterial wall after bioresorbable
vascular scaffolds and metallic platform
stents at 1-year follow-up. JACC
19.Sarno G, Bruining N, Onuma Y et al.
Morphological and functional evaluation
of the bioresorption of the bioresorbable
everolimus-eluting vascular scaffold using
IVUS, echogenicity and vasomotion testing
at two year follow-up: a patient level insight
into the ABSORB A clinical trial. The
international journal of cardiovascular
imaging 2012;28:51-8.
vs. 0.6?%, 5.2 vs. 5.5?% and 0.5
vs. 0.5?%, respectively).7
Interestingly, target vessel failure
rates were significantly lower in
BVS compared with DES (5.5 vs.
8.6?%, respectively, p?=?0.04).
A 2-year follow-up propensitymatched analysis confirmed the
non-inferiority of BVS compared
with Xience V. 8 Interestingly, the
results from a propensitymatched analysis of 250 patients,
comparing patients implanted
with BVS with patients implanted
with Xience V in the SPIRIT IV
trial, showed a decrease in angina
pectoris reported by the sites
through adverse event reporting
at 1 year (16.0 vs. 28.1?%,
respectively). 6 This difference
was highly significant and
probably accounts for the lower
target vessel failure rate in the
BVS group. Also, the percentage
of angina diagnosed through
volver al sumario
atherosclerosis treated with
metallic stent implantation
remain with effort angina despite
optimal medical treatment and
absence of stent restenosis at
1 year (11,12). The most
plausible cause of persistent
effort angina after stent
implantation is endothelial and
microcirculatory dysfunction.
Coronary circulation matches
the myocardial blood supply and
oxygen consumption. Metallic
stent implantation has been
related with endothelial
dysfunction and impaired
coronary blood flow reserve
(relation between coronary blood
flow at rest and maximal
hyperemia) of the treated vessel
at 1 year (13,14). BVS provide
temporary vessel scaffolding,
being completely resorbed
within 2–3 years (10,15). It has
been shown that the mechanical
forces of the BVS applied to the
vessel wall have completely
disappeared without shrinkage
of the device at 6 - 12 months
after implantation (16). This has
been extensively demonstrated
with the restoration of the
vasomotion of the scaffolded
segment, restoration of the
11
IX
Abstract
Bibliografia.
1.Joner M, Finn AV, Farb A, Mont EK,
Kolodgie FD, Ladich E, Kutys R, Skorija K,
Gold HK and Virmani R. Pathology of drugeluting stents in humans: delayed healing and
late thrombotic risk. J Am Coll Cardiol.
2006;48:193-202.
2.Serruys PW, Garcia-Garcia HM and Onuma
Y. From metallic cages to transient
bioresorbable scaffolds: change in paradigm
of coronary revascularization in the upcoming
decade? European heart journal. 2012;33:1625.
3.Verheye S, Ormiston JA, Stewart J, Webster
M, Sanidas E, Costa R, Costa JR, Jr., Chamie
D, Abizaid AS, Pinto I, Morrison L, Toyloy S,
Bhat V, Yan J and Abizaid A. A nextgeneration bioresorbable coronary scaffold
system: from bench to first clinical evaluation:
6- and 12-month clinical and multimodality
imaging results. JACC Cardiovasc Interv.
2014;7:89-99.
4.Serruys PW, Onuma Y, Dudek D, Smits
PC, Koolen J, Chevalier B, de Bruyne B,
Thuesen L, McClean D, van Geuns RJ,
Windecker S, Whitbourn R, Meredith I,
Dorange C, Veldhof S, Hebert KM, Sudhir K,
Garcia-Garcia HM and Ormiston JA.
Evaluation of the second generation of a
bioresorbable everolimus-eluting vascular
has been evaluated in various
registries. The 6-month outcome
data of the Italian all-comer patient
GHOST-EU registry, including
1189 patients with moderate to
high complex lesion and/or patient
characteristics, were reported,
showing acceptable rates of
cardiovascular death (1.0 %),
target vessel myocardial infarction
(2.0 %) and of target lesion failure
(4.4 %). 10 Definite scaffold
thrombosis rates were 1.7 % at
6 months. Also, the Academic
Medical Centre single-arm first
experience, including a high
number of complex patients,
showed a somewhat higher major
adverse cardiac event rate at this
time point, especially related to
scaffold thrombosis. The
investigators claim that this was
due to a learning curve where
major changes were made with
regard to lesion preparation and
post-dilatation to achieve full
scaffold expansion and avoiding
underexpansion as observed in
the first scaffold thrombosis
cases. 11 Conversely, a
propensitymatched analysis
from the single centre San
Raffaele Scientific Institute BVS
registry (Milan, Italy), comparing
scaffold for the treatment of de novo coronary
artery stenosis 12-month clinical and imaging
outcomes. J Am Coll Cardiol. 2011;58:157888.
5.Serruys PW, Ormiston JA, Onuma Y, Regar
E, Gonzalo N, Garcia-Garcia HM, Nieman K,
Bruining N, Dorange C, Miquel-Hebert K,
Veldhof S, Webster M, Thuesen L and Dudek
D. A bioabsorbable everolimus-eluting
coronary stent system (ABSORB): 2-year
outcomes and results from multiple imaging
methods. Lancet. 2009;373:897-910.
6.Abizaid A, Costa JR, Jr., Bartorelli AL,
Whitbourn R, van Geuns RJ, Chevalier B,
Patel T, Seth A, Stuteville M, Dorange C,
Cheong WF, Sudhir K and Serruys PW. The
ABSORB EXTEND study: preliminary report
of the twelve-month clinical outcomes in the
first 512 patients enrolled. EuroIntervention.
2014.
7.Chevalier B. An interim 12-month propensity
adjusted comparison of clinical outcomes of
ABSORB patients to Xience V patients. ESC
2013.
8.Carrie D. An interim 24-month propensity
score analysis comparison of clinical
outcomes of ABSORB EXTEND and ABSORB
Cohort B patients to Xience V patients.
EuroPCR 2014.
9.Serruys PW, Chevalier B, Dudek D, Cequier
A, Carrie D, Iniguez A, Dominici M, van der
BVS (n = 92) with Xience V (n =
92) in complex lesions (83.9 %
B2 or C lesions, 45.2 %
bifurcations), did reveal similar
early outcomes of BVS to
second-generation DES and no
evidence for increased scaffold
thrombosis rates. 12
An interesting clinical application
for BVS is STEMI, as
bioresorbable scaffolds may seal
the vulnerable plaque, restoring
coronary vasomotion and
pulsatility. 13 Wiebe and coworkers presented a first report
on the short-term outcome of
STEMI patients treated with an
everolimus-eluting bioresorbable
scaffold: twenty-five patients with
31 lesions were included with a
procedural success rate of 97 %
and major adverse cardiac event
rate of 8.3 % during a mean
follow-up period of 137 days. 14
Gori et al. reported the short-term
results in 150 consecutive
patients (unstable angina 16 %,
NSTEMI 40 %, STEMI 44 %),
treated with in total 194 BVS
between May 2012 and July
2013. These patients were
compared with 103 consecutive
control patients who received a
DES (XIENCE Prime). Major
Schaaf RJ, Haude M, Wasungu L, Veldhof
S, Peng L, Staehr P, Grundeken MJ, Ishibashi
Y, Garcia-Garcia HM and Onuma Y. A
bioresorbable everolimus-eluting scaffold
versus a metallic everolimus-eluting stent for
ischaemic heart disease caused by de-novo
native coronary artery lesions (ABSORB II):
an interim 1-year analysis of clinical and
procedural secondary outcomes from a
randomised controlled trial. Lancet.
2015;385:43-54.
10.Capodanno D, Gori T, Nef H, Latib A,
Mehilli J, Lesiak M, Caramanno G, Naber C,
Di Mario C, Colombo A, Capranzano P, Wiebe
J, Araszkiewicz A, Geraci S, Pyxaras S,
Mattesini A, Naganuma T, Munzel T and
Tamburino C. Percutaneous coronary
intervention with everolimus-eluting
bioresorbable vascular scaffolds in routine
clinical practice: early and midterm outcomes
from the European multicentre GHOST-EU
registry. EuroIntervention. 2015;10:1144-53.
11.Kraak RP, Hassell ME, Grundeken MJ,
Koch KT, Henriques JP, Piek JJ, Baan J, Jr.,
Vis MM, Arkenbout EK, Tijssen JG, de Winter
RJ and Wykrzykowska JJ. Initial experience
and clinical evaluation of the Absorb
bioresorbable vascular scaffold (BVS) in realworld practice: the AMC Single Centre Real
World PCI Registry. EuroIntervention.
2015;10:1160-8.
81
adverse cardiac event rates at 30
days and 6 months were similar
between the two groups. Scaffold
thrombosis occurred in three BVS
patients and two DES patients
within the first month. 15 In the
BVS STEMI First study, a
prospective, single-arm,
monocentre safety and feasibility
study, 49 STEMI patients were
treated with a BVS (direct stenting
in 32.7 % and predilatation in 67.3
%). The procedural success rate
of BVS implantation was 97.9 %.
TIMI flow III was obtained in 91.7
% of patients after BVS
implantation. At 30 days, the
major adverse cardiac event rate
was 2.6 % (one patient with a
non-Q-wave myocardial infarction
in a non-target vessel). Target
lesion failure (composite of cardiac
death, target-vessel myocardial
infarction or ischemia-driven
target lesion revascularisation) did
not occur and there were no
cases of scaffold thrombosis. 16
Additionally, in the prospective
Prague 19 trial, BVS were
implanted in consecutive STEMI
patients from December 2012
until August 2013. 17 The BVS
device success rate was 98 %.
Target lesion revascularisation of
12.Costopoulos C, Latib A, Naganuma T,
Miyazaki T, Sato K, Figini F, Sticchi A, Carlino
M, Chieffo A, Montorfano M and Colombo
A. Comparison of early clinical outcomes
between ABSORB bioresorbable vascular
scaffold and everolimus-eluting stent
implantation in a real-world population.
Catheter Cardiovasc Interv. 2015;85:E10-5.
13.Brugaletta S, Radu MD, Garcia-Garcia
HM, Heo JH, Farooq V, Girasis C, van Geuns
RJ, Thuesen L, McClean D, Chevalier B,
Windecker S, Koolen J, Rapoza R, MiquelHebert K, Ormiston J and Serruys PW.
Circumferential evaluation of the neointima
by optical coherence tomography after
ABSORB bioresorbable vascular scaffold
implantation: can the scaffold cap the plaque?
Atherosclerosis. 2012;221:106-12.
14.Wiebe J, Mollmann H, Most A, Dorr O,
Weipert K, Rixe J, Liebetrau C, Elsasser A,
Achenbach S, Hamm C and Nef H. Shortterm outcome of patients with ST-segment
elevation myocardial infarction (STEMI) treated
with an everolimus-eluting bioresorbable
vascular scaffold. Clin Res Cardiol.
2014;103:141-8.
15.Gori T, Schulz E, Hink U, Wenzel P, Post
F, Jabs A and Munzel T. Early outcome after
implantation of Absorb bioresorbable drugeluting scaffolds in patients with acute
coronary syndromes. EuroIntervention.
2014;9:1036-41.
1.3 %, and a stent thrombosis
and major adverse cardiac event
rate of 1.3 and 2.6 %,
respectively, with an average
follow-up of about 6 months have
been reported. Recently a
propensity score matching
comparison between 290 STEMI
patients treated by BVS and 290
STEMI patients treated by
everolimus-eluting metallic stents
has been reported: whereas at
1-year there were no differences
in terms of device-oriented
endpoint (cardiac death, target
vessel myocardial infarction and
target lesion revascularization), a
slight higher device thrombosis
of BVS device was reported in
the early phase. 18
Eventually, all these data have
variously showed a comparable
safety and efficacy of BVS devices
over metallic stents, with some
concerns on thrombosis and
some interesting data on angina
reduction. New data and new
technological advancement of this
technology are waited during the
coming years for confirming these
preliminary results.
16.Diletti R, Karanasos A, Muramatsu T,
Nakatani S, Van Mieghem NM, Onuma Y,
Nauta ST, Ishibashi Y, Lenzen MJ, Ligthart
J, Schultz C, Regar E, de Jaegere PP, Serruys
PW, Zijlstra F and van Geuns RJ. Everolimuseluting bioresorbable vascular scaffolds for
treatment of patients presenting with STsegment elevation myocardial infarction: BVS
STEMI first study. Eur Heart J. 2014;35:77786.
17.Kocka V, Maly M, Tousek P, Budesinsky
T, Lisa L, Prodanov P, Jarkovsky J and
Widimsky P. Bioresorbable vascular scaffolds
in acute ST-segment elevation myocardial
infarction: a prospective multicentre study
'Prague 19'. Eur Heart J. 2014;35:787-94.
18.Brugaletta S, Gori T, Low AF, Tousek P,
Pinar E, Gomez-Lara J, Scalone G, Schulz
E, Chan MY, Kocka V, Hurtado J, GomezHospital JA, Munzel T, Lee CH, Cequier A,
Valdes M, Widimsky P, Serruys PW and
Sabate M. Absorb bioresorbable vascular
scaffold versus everolimus-eluting metallic
stent in ST-segment elevation myocardial
infarction: 1-year results of a propensity score
matching comparison: the BVSEXAMINATION Study (bioresorbable vascular
scaffold-a clinical evaluation of everolimus
eluting coronary stents in the treatment of
patients with ST-segment elevation myocardial
infarction). JACC Cardiovasc Interv.
2015;8:189-97.
volver al sumario
adverse event reporting was
notably lower with BVS than that
reported in previous large
interventional trials (FREEDOM
(sirolimus-eluting stent/ paclitaxeleluting stent): 21?%; SYNTAX
(paclitaxel-eluting stent): 28?%;
COURAGE (bare metal stent:
34?%). 7 This finding was recently
confirmed by the ABSORB II trial
at 1-year, which is the first
randomised (2:1), prospective,
single-blinded, multicentre trial,
in which 501 patients were
assigned to the ABSORB BVS or
a second-generation everolimuseluting coronary stent (Xience
Prime). 9 Further follow-up is
needed to confirm this
observation on the potential
reduction of post-PCI angina. If
confirmed, repeat angiography
with or without additional coronary
intervention would be significantly
reduced. This could greatly
impact on patient quality of life
and additionally reduce healthcare
costs. The ABSORB IV trial,
recently started in the US, was
designed with angina reduction
as primary endpoint between BVS
and everolimus-eluting metallic
stent.
BVS in complex coronary lesions
11
IX
Abstract
(Abbott Vascular, Santa Clara,
California), MV-surgery, and
conservative treatment in highsurgical-risk patients
symptomatic with severe mitral
valve regurgitation (MR).
BACKGROUND Up to 50% of
severe MR are denied for surgery
due to high perioperative risk.
Transcatheter MV repair might
be an alternative.
Consecutive patients (n=139)
treated with transcatheter MV
repair were included.
Comparator surgically (n= 53)
and conservatively (n= 59)
Background:
Methods:
Catheter ablation (CA) relieves
symptoms in atrial fibrillation (AF),
but freedom from AF is not
assured. Thus, oral
anticoagulation (OAC) remains
necessary in high stroke risk
patients. Left atrial appendage
(LAA) occlusion (LAAO) has
proved a viable alternative for
preventing thrombo-embolic
complications.
Objectives: To determine longterm clinical effects of combining
CA and LAAO in one single
procedure.
Symptomatic patients with drugrefractory AF (CHADS2 ≥1) and
indications for LAAO were
included. TEE was performed to
assess LAA
size/anatomy/thrombus. After
CA, LAAO was performed using
the Watchman device. At 3
months, OAC was switched to
Aspirin/Clopidogrel if LAAO
criteria were met.
Results: From Sept 2009-Oct
2013, 62 patients (22 female,
age 64±8 years, CHADS2 2.5)
underwent combined procedure.
mitral valve incompetence. The
procedure mainly relies on the
guidance with echocardiography
as mitral leaflets are not visible
at angiography. Therefore, it is
of utmost importance for the
intervencionist to learn and
understand what the
echocardiographic views of the
mitral valve are at each step.
More importantly, it is the use of
a common language between
the echocardiographist and the
interventionist in order to carry
out a real team approach during
the procedure of implantation.
Echocardiography provides an
essential tool to position the
device and particularly to clip
both mitral leaflets. Additionally,
it provides a safety check up for
the procedure as it can readily
detect complications, particularly
pericardial effusion and cardiac
tamponade during the
procedure, among others.
In left atrial appendage closure,
use of echocardiography
additionally allows for the
selection of the size of the
occluder device and its adequate
position into the appendage.
Both procedures start with a
transeptal puncture. In case of
the Mitraclip implant and in order
to provide an adequate
maneuver within the left atrium,
a posterosuperior punture is
recommended while in the case
of appendage closure, a more
inferoposterior puncture is
pursued; the latter allows for a
direct enfacing of the appendage
once the atrial septum is crossed
Methods
The goal of this study was to
compare survival between
transcatheter mitral valve (MV)
repair using MitraClip system
Watchman laa
closure combined
with catheter
ablation in af
patients:
First results from
st-antonius
hospital
Jan Van der Heyden, MD, PhD
IMaging during
mitraclip
implantation and
left atrial
appendage closure
Marta Sitges, MD, PhD
Hospital Clinic, University of
Barcelona
Echocardiography plays an
essential role in guiding
percutaneous interventions such
as mitral valve repair or closure
of the left atrial appendage.
The implantation of a Mitraclip
device is currently the most used
percutaneous approach to treat
Results
The log EuroSCORE was higher
in the transcatheter MV repair
group (23.9± 16.1%) than in the
surgically (14.2 ±8.9%) and
conservatively (18.7 ±13.2%, p
< 0.0001) treated patients. Left
ventricular ejection fraction was
higher in surgical patients (43.9
± 14.4%, p ? 0.003), with similar
Jan Van der Heyden, MD, Ph D
Objectives
treated patients were identified
retrospectively. Surgical risk was
based on the logistic European
System for Cardiac Operative
Risk Evaluation (log EuroSCORE)
or the presence of relevant risk
factors, as judged by the heart
team.
82
values for the transcatheter MV
repair (36.8 ±15.3%)
and conservatively treated (34.5
±16.5%) groups. After 1 year of
follow-up, the transcatheter MV
repair and surgery groups
showed similar survival rates
(85.8% and 85.2%, respectively),
whereas 67.7% of conservatively
treated patients survived. The
same trend was observed after
the second and third years. After
weighting for propensity score
and controlling for risk factors,
both the transcatheter MV repair
(hazard ratio [HR]: 0.41, 95%
confidence interval [CI]: 0.22 to
0.78, p =0.006) and surgical
(HR: 0.52, 95% CI: 0.30 to 0.88,
p=0.014) groups showed better
survival than the conservatively
treated group. The transcatheter
MV repair and surgical groups
did not differ (HR: 1.25, 95% CI:
0.72 to 2.16, p= 0.430).
Indications for LAAO included
history of stroke despite OAC
(29.0%), contraindications for
OAC (24.2%), high stroke risk
(24.2%), and miscellaneous
reasons (22.6%). LAAO resulted
in complete acute closure in all,
with a median number of 1
device. After a median followup of 38 (range 25-45) months,
95% of the patients met the
criteria for successful sealing
and 78% could discontinue
OAC, while recurrence of AF was
documented in 42%. During
long-term follow-up, 3 ischemic
strokes were observed with an
annual stroke risk of 1.7% which
is lower than the expected
annual risk of 6.5%.
Conclusions
Despite a higher log
EuroSCORE, high-surgical-risk
severe MR treated with
transcatheter MV repair show
similar survival rates compared
with surgically treated patients,
with both displaying survival
benefit compared with
conservative treatment.
Conclusion:
LAAO combined with CA for AF
can be performed successfully
and safely in one single
procedure, with a lower than
expected stroke rate. Further
studies are necessary to
determine which patients benefit
most from the combined
therapy.
Figure 1. Biplane echocardiography to guide atrial septal puncture.
by. Defining the precise site of
transeptal puncture is definitely
facilitated by the use of
echocardiography (Figure 1).
Once the septum is crossed,
wire and catheters interchanges
are controlled under echo
surveillance, thus early detecting
potential thrombus or
compications such as aortic
punture or cardiac perforation
(atrial Wall). Later on stradling
volver al sumario
Survival of
transcatheter
mitral valve repair
compared with
surgical and
conservative
treatment in highsurgical-risk
patients
11
IX
Abstract
and positioning of the device
towards the mitral valve is guided
by echocardiography. The
adequate orientation of the clip,
perpendicular to the closing or
coaptation line of the valve has
to be checked and
echocardiography, particularly
three-dimensional echo (Figure
2), is the only imaging tool that
provides a unique view to check
this issue. Finally, clipping of the
leaflefts is performed under
echocardiographic guidance,;
namely echocardiography
becomes the eyes of the
interventional physician
performing the implant. Finally,
the result of the implant in terms
of elimination of mitral
regurgitation is evaluated using
color Doppler.
Assessment of the appendage
size can be readily performed
by multiplane transesopahegal
echo; the selection of the size
of the occluder device is based
on an average made from
echocardiographic and
angiographic measurements.
With echocardiographc guiding
the device is positioned into the
appendage and its adequate
position is checked. The final
result of the implantation is also
evaluated.
Spine osteomyelitis
and juxtarenal
aneurysm: a tricky
situation. Is there a
place for evar? A
case report and
literature review
Complejo Hospitalario de
Pontevedra, Pontevedra (Spain)
Crecimieto del
saco aneurismático
a los treinta días de
exclusión
endovascular de
aaa
Introduction:
Aneurysms affecting the aorta
at the renal arteries level are a
threatening pathology that
require an aggressive surgery
with high morbidity and mortality
rates. When this pathology
combines with spine
osteomyelitis the infection is
endovascular del aneurisma
infrarrenal, suele relacionarse
con endofugas, habitualmente
tipo 1 o 3 y deben corregirse a
la brevedad pues tienen un alto
riesgo de ruptura.
Material y método:
Fabiani, Alejandro; Carrillo,
Miguel; González Camid,
Melipe; Quintanilla, Juan
Tecnológico de Monterrey,
Monterrey (México)
Introduccion:
El aumento del volumen del saco
residual en los primeros días
luego del tratamiento
Paciente de 48 años, sexo
masculino, obeso, sin
antecedentes patológicos
conocidos, que ingresa a la sala
de emergencias por presentar
insuficiencia cardíaca secundaria
a fibrilación auricular de alta
respuesta.
Se compensa al paciente y en
los estudios de imágenes se
detecta aneurisma de aorta
abdominal infrarrenal, de 80 mm
de diámetro, con cuello proximal
angulado (>90º).
almost guaranteed, even if there
is no fever or other signs of
accompanying sepsis. EVAR is
a controversial but an alternative
technique with increasing
acceptance between vascular
surgeons in this field, because
it has lesser complications, and,
surprisingly, has shown good
results. Although the main
concern about this kind of
treatment is the possibility of
persistent infection, several
treatments associated, based
on a long-term antibiotic therapy
and drainage, have minimized
the above mentioned probability.
Objective: We report a clinical
case of a juxtarenal false
aneurysm in a high risk patient
successfully performed by using
the parallel graft technique with
local anesthesia, and discuss
the use of endovascular
therapies as a bridge to open
surgery or as a palliative
Se realiza EVAR con
endoprótesis bifurcada Endurant
II, Medtronic, evolucionando bien
en su post-operatorio.
Ante la presistencia de su
fibrilación auricular y la
necesidad de anticoagulación
se realiza angioTC de control a
las 2 semanas del
procedimiento, constantandose
presencia de material de
contraste en saco residual y
aumento de 20% del volumen
del mismo. Se realiza ecodoppler que muestra aflujo de
sangre al saco aneurismático a
través de 2 arterias lumbares,
no pudiéndose confirmar la
presencia de endoleak tipo 1.
Se decide no iniciar
anticoagulación hasta nuevo
control dos semanas mas tarde.
A los 30 días del procedimiento,
se realizan nuevamente estudios
de imagen que no muestrans
diferencias con los previos. El
estudio Ecocardiográfico transe
sofágico, mostro trombos en la
orejuela izquierda.
Se decide entonces realizar
angiografía que muestra
endoleak tipo 2 a partir de reflujo
proveniente de la mesentérica
inferior y de dos ramas lumbares.
Se realiza cateterismo selectivo
de ambas hipogástricas y
superselectivo de sus ramas
hasta llegar a las arterias
lumbares reponsables de la
endofuga y se embolizan con
metacrilato. Posteriormente a
través de la mesentérica superior
y sus ramas se logra acceder al
ostium de la mesentérica inferior
83
management in this scenario.
Conclusion:
EVAR and long-term antibiotic
therapy could be a feasible
treatment for aortic infections
affecting high surgical risk
patients.
y al saco residual,
embolizandose el mismo con
diferentes tipos de coils y
metacrilato.
Resultado:
El control angiográfico mostro
desaparición de las endofugas.
A los 5 días de la embolización
se repitió eco doppler que
mostró ausencia de flujo en el
saco residual y se comenzó con
la anticoagulación.
El paciente evoluciona
asintomático.
Conclusión:
El endoleak tipo 2 puede
ocasionar aumento del volumen
del saco aneurismático residual
y en tal circunstancia, debe ser
tratado.
volver al sumario
Caicedo Valdés, Diego; Moy
Petersen, Juan Carlos;
Moncayo León, Karla;
Villardefrancos Gil, Rosa
Figure 2. Three-dimesnional
echocardigraphy showing an
“enface” view of the mitral valve to
check the adequate perpendicular
position of the Mitraclip device
during the implant
11
IX
Abstract
y lavado de la colección del
retroperitoneo. El cultivo de la
colección y los hemocultivos
fueron positivos para stafilococo
metisilino sensible.
Se realizaron 4 lavados del
retroperitoneo y recibió
tratamiento antibiótico
endovenoso por 45 días, se dio
salida a los 62 días de haber
ingresado a la clínica con
antibiótico oral de por vida. Se
realizo angiotac de control a los
3 meses el cual es satisfactorio.
Conclusion:
Material and methods
Outcome
Conclusion
Palmaz stent was placed in the
fishmouth to attach the calcified
plaque to the aortic wall.
Previously superior mesenteric
artery (SMA) and right renal
artery were protected by placing
a 7F and 5F sheet, respectively.
We made a Chimney by
emplacing a balloon expandable
stent (Isthmus 7x39mm) to
ensure the flow to the SMA
In perioperative arteriography
and in 1-month follow up CT
scan we could check correct
patency of SMA and both renal
arteries, correct fishmouth
opening, correct aortobiiliac
endograft patency and correct
exclusion of the aneurysmal sac.
Despite the strange complication
and the dangerous surgery,
endovascular surgery, once
again, can solve a serious
problem with a minimal invasive
approach.
Introduction:
Methodology used:
Endovascular management with
fenestrated stent-grafts of
chronic post-dissection
thoracoabdominal aneurysms is
complex. The main technical
challenge relates to the fact that
visceral branches can also
originate from the false lumen.
CTangio is performed showing
that all visceral branches, except
for the left renal, are patent and
originate from the true lumen.
Left renal artery originates from
the false lumen but its ostium
can be identified in the true
lumen some millimeters above.
Several reentry tears are
observed, mainly in the proximal
abdominal aorta and in both iliac
bifurcations.
Angiography is considered the
essential and key step before
treatment. Besides supporting
findings from CTangio,
angiogram confirms the feasibility
of left renal artery canalisation
from the true lumen.
Then, fenestrated endovascular
repair is planned. When
planning, height of left renal
fenestration is placed taking into
account the ostium in the true
lumen, instead of its origin in the
false lumen. Cerebrospinal fluid
drainage catheter is implanted.
Femoral arteries are surgically
exposed.
Firstly, a thoracic module is
deployed (Cook ZTA-P-28-155).
Later, fenestrated endograft is
implanted and visceral branches
are catheterised. Canalisation of
left renal artery is achieved,
without the need of perforating
the stiff chronic dissection flap.
Begraft stents are deployed:
8x27mm + 7x23mm in celiac
trunk, 7x27mm in superior
mesenteric, 6x22 mm in right
renal, 6x38mm in left renal. A
bifurcated body is placed distally
and finally, two iliac extensions
are opened out proximally to the
iliac bifurcations (ZSLE-16-74ZT and ZSLE-20-74-ZT).
observed. Instead of extending
to the external iliacs, we prefer
to preserve both hipogastric
arteries as a protective maneuver
to prevent spinal cord ischemia.
In the follow-up, the impact of
these iliac reentry tears will be
assessed.
La aortitis infecciosa de la aorta
o también llamado aneurisma
micotico es una patología
catastrófica asociado a una alta
mortalidad independientemente
del tratamiento que se realice,
aquí presentamos un reparo
endovascular exitoso.
Mostrar el reparo endovascular
de la aorta toracoabdominal
como una alternativa valida en
la aortitis infecciosa.
Paciente de 50 años sin
antecedentes de importancia,
quien presenta una aortitis
infecciosa de la aorta
toracoabdominal con
compromiso de todos los vasos
viscerales, quien adicionalmente
presenta una falla orgánica
múltiple. Estando cursando un
shock séptico se lleva a reparo
endovascular con endoprotesis
fenestrada de COOK (home
made) y posteriormente se
realiza lumbotomia para drenaje
Objective
We report the case of a 71-yearold man with Aorfix endograft
whose 1-month follow up CT
scan objectified an extensive
calcified atherosclerotic plaque
in the aortic lumen that it wasn't
in the preoperative study. The
plaque partially closes the
fishmouth of endograft. The
patient was asymptomatic.
Fenestrated
endovascular
repair of a chronic
post-dissection
thoracoabdominal
aneurysm
García Familiar, Ainhoa; de
Blas Bravo, Mariano;
Larrañaga Oyarzabal, Ioar;
Díez Blanco, Egoitz; Sánchez
Abuín, Javier; Egaña
Barrenechea, José María
Objective:
Carbonell, Juan Pablo;
Velásquez, Jorge
Fundación Valle del Lili, Cali
(Colombia)
Minimal invasive
approach for
treatment a strange
complication after
placement of aortic
endograft
Roset Balada, Oscar; Andrés
Navarro, Omar; Brillas Bastida,
Albert; Rodríguez Cabeza,
Patricia; Presas Porcell, Anna
Donostia University Hospital, San
Sebastián (Spain)
Objetivos:
To report the fenestrated
endovascular repair of a chronic
post-dissection
thoracoabdominal aneurysm
with the left renal artery
originating from the false lumen.
Material used:
A 44-year-old female with Marfan
syndrome and a history of mitral
valvuloplasty, presents with
aneurysmal degeneration up to
a maximum diameter of 58 mm,
in the follow-up of a type B
chronic dissection from D10 to
iliac bifurcations.
84
Se muestra un caso exitoso de
reparo endovascular fenestrado
de la aorta toracoabdominal en
un paciente con aortitis
infecciosa y shock séptico. Hay
que esperar el seguimiento a
mediano y largo de este
paciente.
Conclusions of the
study:
Endovascular treatment with
fenestrated stent-grafts of
chronic post-dissection
thoracoabdominal aneurysms is
feasible; requires a thorough pretreatment study and planning;
and can play an important role
in the management of this
pathology if long-term results
confirm initial good outcomes.
Final angiography shows
patency of all visceral branches
and sealing of the dissected
abdominal aorta. Retrograde
filling of the false lumen from iliac
bifurcations reentry tears is
volver al sumario
Introduccion:
Aortitis infecciosa
de la aorta
toracoabdominal:
reparo
endovascular
fenestrado exitoso
11
IX
Abstract
Introduction
Material used
We highlight a challenging case
of urgent endovascular repair of
an aortic arch pseudoaneurysm
and subsequent type 1a
endoleak, which was
successfully managed with
radiological embolisation.
Zenith Alpha low profile, tapered
thoracic stent graft
ZSLE limb reinforced with Bard
fluency stent graft
12mm Amplatzer plug
Embolisation coils
Methodology
Objectives
Popplewell, Matthew ; Bevis,
Paul; Ganeshan, Arul; Adam,
Donald; Claridge, Martin
Heart of England Foundation
Trust, Birmingham (U.K.)
To demonstrate how a complex
thoracic arch aneurysm can be
managed successfully using an
array of different endovascular
technologies to achieve a
satisfactory haemodynamic
result.
A 77 year-old lady presented
with a symptomatic 70mm aortic
arch pseudoaneurysm. The
patient was declined open repair
by cardiothoracic surgery due
to comorbidity. To permit
endovascular repair, a Dacron
carotid-carotid-subclavian
bypass was performed. The
main aortic arch was stented
with a Cook Zenith Alpha low
profile, thoracic tapered stent
Antegrade
endovascular
repair of an
isolated internal
iliac artery
aneurysm
Quintas, Ana; Albuquerque e
Castro, Joao; Bastos
Gonçalves, Frederico; Aragao
de Morais, Jose; Ferreira,
Maria Emilia; Mota Capitao,
Luis
Introdution
Isolated internal iliac artery
aneurysms (IIAA) are unusual
with an estimated prevalence of
0,03%. The traditional approach
to internal iliac aneurysms is
open repair, witch is technically
challenging and associated with
considerable morbidity and
mortality.
Objectives
Report a case of an 55mm left
internal iliac aneurysm treated
via antegrade stent graft implant
preserving hypogastric flow.
Results
artery, using a crossover
technique. Despite the acute
angle of aortic bifurcation and
iliac tortuosity, anterograde
acess to the internal iliac artery
was achieved and the aneurysm
was excluded with two iliac
Endurant II Medtronic stent
grafts 14x16x82 (inverted ontable) + 16x16x82.
Conclusion
Results
The final angiogram showed
good permeability of internal iliac
and its branches and no
endoleaks (Figure 2). The patient
was discharged at postoperative
day 3 with no complications. The
1 month CTA showed good
perfusion of internal iliac artery
and its collaterals with no
endoleaks (Figure 3).
Figure 1
Hospital of Santa Marta, Lisboa
(Portugal)
with an innominate artery
chimney graft (Cook ZSLE limb
reinforced with a Bard Fluency).
The left carotid artery was ligated
below the bypass and the left
subclavian artery origin was
occluded with a 12mm
Amplatzer plug proximal to left
vertebral artery.
Post-operative imaging revealed
a type 1a endoleak from the
chimney graft gutter.
Endovascular access was
gained via the left brachial artery
and the occluded Amplatzer plug
was crossed with a wire and
catheter, in preference to direct
sac puncture, to allow coiling of
the aneurysm sac and thrombin
injection.
Material used
Medtronic® Endurant II iliac limbs
ETWL1616C82EE and
ETWL1613C83EE, Medtronic®
Shealth SENSH1628W,
Vanchie3 Van Schie Cook®
Catether, hydrophilic guidewire
260cm, Boston Scientific®
Amplatz guidewire 260cm,
Case Report
Figure 2
A 68 year old male with previous
medical history notorious for
current smoking and urotelial
tumor was presented to our
vascular department with a
55mm internal iliac aneurysm
(Figure 1). Proximal and distal
landing zones were present,
measuring 14x25mm and
11x27,5mm. Endovascular
repair via contralateral femoral
access and sheath crossover
was planned. After femoral
cutdown and 5000 units of nonfractioned heparin IV, a 16F
sheath was placed at the origin
of the affected hypogastric
85
Figure 3
Post-radiological intervention
angiography revealed that the
endoleak had entirely resolved.
The patient remains well at 3
months.
Conclusion
This case demonstrates that a
complex thoracic arch aneurysm
can be repaired using a chimney
technique, and that an Amplatzer
occlusion device can be crossed
with a wire to treat an on-going
endoleak with satisfactory
results.
Femoral contralateral acess is a
valid and feasable option for the
endovascular stent-graft
exclusion of internal iliac
aneurysms even in the presence
of an acute aortic bifurcation and
significative tortuosity. In the
presence of good proximal and
distal landing zones, preservation
of internal iliac perfusion through
antegrade stent graft placement
is technically a feasible and
effective technique that can
prevent potencial serious
complications associated with
sacrifice of the internal iliac
artery. It should therefore be
regarded as a first choice
therapy option for suitable
aneurysms.
volver al sumario
Hybrid chimney
endovascular
repair of thoracic
arch aneurysm with
radiological
embolisation of
endoleak
11
IX
Tratamiento hibrido
de aneurisma de
divertículo de
kommerell
Gastambide, Carmelo; Amorin,
Rosario; Martin, Juan
Se estima que la incidencia de
anomalías del arco aórtico afecta
a un 0.5-3% de la población
El arco aórtico izquierdo con una
arteria subclavia derecha
Management of
cephalic arch
stenosis
David Shemesh
Department Of Surgery and
Hemodialysis Access Center
Jerusalem, Israel
Cephalic vein anatomy dictates
that radial cephalic fistulas drain
via both the basilic vein and the
cephalic vein, thus the flow in
the cephalic arch is low relative
to brachial cephalic fistulas in
which the entire flow drains via
Treatment of
centra venous
occlusive disease
in patients with
arteriovenous
fistula
David Shemesh
Department of Surgery and
Hemodialysis Access Center,
Jerusalem, Israel
Central venous occlusive disease
(CVOD) ipsilateral to dialysis
access is common, with an
incidence of 2%–40%, but is
mostly asymptomatic. In
12%–13% of patients,
symptomatic CVOD causing
upper extremity, facial or breast
aberrante constituye la anomalía
vascular congénita mas
frecuente del arco aórtico, con
un prevalencia del 0.4-2%. En
el 60% de los casos la arteria
subclavia derecha aberrante
nace de un segmento dilatado
del arco aórtico, denominado
divertículo de Kommerell . EL
3-8% de estos presenta
aneurisma del divertículo de
Kommerell .
Debido a la baja frecuencia de
esta patología las indicaciones
de tratamiento quirúrgico no son
claras sin embargo se han
reportado en la literatura ruptura
y disección de los mismos.
Estudios histopatológicos
demostraron la presencia de
necrosis quística de la capa
media de la pared del divertículo
lo que podría explicar el riesgo
de disección y ruptura. El
conocimiento acumulado de
esta patología asociado a los
avances de los estudios
imagenológicos y de los
tratamiento ha hecho que
algunos autores autores
aconsejen se mas
intervencionistas en las fases
tempranas de los divertículos.
Si bien permanece aun en
debate, es mayoritariamente
aceptado considerar el
tratamiento cuando el diámetro
del orificio del divertículo es
mayor de los 30mm y/o cuando
el diámetro del aneurisma del
divertículo o de la aorta
adyacente es mayor de 50mm.
El tratamiento quirúrgico del
divertículo de Kommerell esta
asociado a una alta
morbimortalidad , el tratamiento
hibrido con trasposición y/o
bypass de los
troncosupraorticos y reparación
endovascular se presenta como
una buena opción.
Presentamos un caso de un
paciente con una arteria
subclavia derecha aberrante con
un gran aneurisma de un
divertículo de Kommerell que fue
tratado mediante un
procedimiento hibrido, quirúrgico
– endovascular.
the cephalic arch. The
pathophysiology of cephalic arch
stenosis (CAS) is poorly
understood. The high flow,
combined with anatomical
characteristics of the cephalic
arch, causes intimal hyperplasia,
which results in
hemodynamically significant
stenoses in up to 39% of
patients with brachial cephalic
fistula, whereas in radial cephalic
fistula CAS is very rare. Surgical
procedures for CAS include
transposition of the cephalic vein
to the basilic or axillary vein and
banding of high output fistulas.
Soon after the emergence of
endovascular techniques, the
surgical approach was replaced
by balloon angioplasty.
Unfortunately the results of
angioplasty are short lived with
a 42% primary patency rate at
6 months. Bare stents have been
used to salvage the fistula after
failed angioplasty, but with poor
results due to stent related
exaggeration of neo-intimal
proliferation. Stent grafts have
outperformed bare metal stents
in the cephalic arch and offer a
potential alternative to balloon
angioplasty in recurrent stenosis.
Stents must be completely
covered to prevent in segment
stenosis, and should be flexible
to avoid kinking by the curved
portion of the vein in the cephalic
arch. If the stent is not accurately
deployed there is a risk of axillary
vein occlusion. 10% of fistulas
will eventually fail after stenting
as a result of occlusion of the
axillary vein by the stent.
However, with an aggressive
surveillance and maintenance
program fewer than 3 % of
patients will no longer have that
arm available for access
construction due to axillary vein
occlusion.
Of all the techniques for treating
CAS, bare stents are associated
with the worst outcome. The
primary patency of stent grafts
at one year is 32% to 73%,
which is similar to the primary
patency for surgical revision
(25% to 79%). Flow reduction
surgery has a similar outcome
to vein bypass and stent graft.
In conclusion there is as yet no
ideal stent. Even with accurate
stent placement using
completely covered and flexible
stent grafts are not ideal for
stenting the cephalic arch.
Most importantly, we have
learned that we should avoid
stenting if possible, but when
we have to stent we should use
a stent graft, and we must
continue searching for better
treatment modalities for the
future. Drug coated balloons are
now in the forefront of research
but there is not yet any published
data relating to CAS.
swelling and compromised
dialysis may lead to loss of
dialysis access unless some
form of intervention is carried
out. There is no ideal treatment
for COVD. Although surgery can
result in prolonged patency, the
associated morbidity and lack
of widespread expertise have
prevented it from becoming the
mainstay of treatment.
Endovascular percutaneous
transluminal angioplasty (PTA)
is therefore the accepted
treatment for symptomatic
patients. However, poor primary
patency rates are common after
PTA due to elastic recoil or
recurrent intimal hyperplasia
requiring repeated dilations,
often at short intervals, to
maintain reasonable secondary
patency rates. Bare metal stents
have been used to try to
overcome this shortcoming but
have not demonstrated a definite
advantage in long-term patency
over PTA.
There have been few studies,
none of them randomized, of the
use of stent grafts in central vein
lesions related to dialysis access,
but these have shown
encouraging results. AnayaAyala et al (19) reported
25patients with 12-month
secondary and access patency
rates of 100% and 94%,
respectively. Kundu et al (20)
reported 14 hemodialysis
patients with central vein
occlusion with primary patency
of 100% at 9 months, and Jones
et al (21) reported a primary
assisted patency rate of 75% at
24 months in 30 patients with
dialysis access fistulas.
Verstandig et al recently reported
the results of stent grafts in
CVOD with long-term follow-up
in 52 patients. This study
demonstrated access patency
rates of 85% at 24 months after
intervention and 72% at 36
months after intervention.
A major disadvantage of stent
grafts is the possible covering
of major venous confluences but
careful stent graft selection and
placement may avoid this
problem. Coverage of the
contralateral brachiocephalic
confluence can be avoided by
careful localization of this
landmark and correct choice of
stent graft. The benefit of
prolonging access patency
should be weighed against the
potential loss of this access for
dialysis catheters.
In conclusion, our data confirms
the good long-term patency of
stent grafts reported in previous
studies, but it also demonstrates
that careful technique must be
used to accurately deploy the
stent grafts and to avoid
covering major vein confluences
if possible. Maintaining patent
confluences may minimize future
access loss. Knowledge of the
status of both internal jugular
veins is important in deciding
whether or not to insert a stent.
86
volver al sumario
Abstract
11
IX
Ultrasound-guided
endovascular
treatment for
vascular access
dysfunction
J.M Abadal MD, PhD
Hospital Universitario Severo
Ochoa. Madrid
The aim of this presentation is
to show the advantages of the
endovascular treatment of
Endovascular vs
open treatment of
juxta-anastomotic
AVF stenosis
Dr. Jose Ibeas
Parc Tauli Sabadell, Hospital
Universitari.
Sabadell, Barcelona
Arteriovenous fistula (AVF)
stenosis in haemodialysis must
be corrected to ensure a flow
that allows appropriate dialysis
quality, to prevent the
appearance of thrombosis and
to increase access patency.
Stenoses can be treated using
endovascular methods
(percutaneous transluminal
How to improve
secondary patency
for prosthetic av
access
Patricia Bermúdez
End-stage renal disease is a life
threatening condition which
needs renal transplantation or
lifelong dialysis. The number of
dialysis-dependent patients is
constantly growing worldwide,
so dialysis access is utmost
malfunctioning arterio venous
fistulas (AVF) guided by
ultrasound (US) over
conventional fluoroscopy
guidance. Up to 80% of the AVF
endovascular procedures can
be performed solely with US
guidance and these are: Balloon
angioplasty,
mechanical/chemical
thrombectomy and stent
placement. The only limitation
would be stenosis in subclavian
vein or superior vena cava
because the lack of visualization
with US.
The most direct benefit is the
avoidance of radiation exposure
to the patient and physician.
Dialysis patients have a four-fold
increase on diagnostic imaging
test compared to other
chronically ill patients. Moreover
endovascular procedures to
repair AVF need to be repeated
to maintain patency. This
impacts in high cumulative
radiation exposures.
Radiation to the physician is also
eliminated. Although these
procedures do not carry an
excessive fluoro time, they are
performed with the X- Ray tube
near the physician and with
scarce filtration of the x-ray
beam due to the thinness of the
arm/wrist of the patient.
Obviously with US guidance
there is no need to use contrast,
reducing the cost of the
intervention. Procedure can be
performed in patients with
iodinated contrast allergy or with
renal impairment.
Technically US gives a more
reliable view of the anatomy and
pathophysiology of the diseased
AVF. Vessel diameter is more
accurate than in angiography,
because a real measure from
wall to wall is calculated. This
results in a better selection of
PTA balloons with a more
precise balloon to vessel ratio.
US add besides imaging
guidance, hemodynamic flow
criteria. Significant from nonsignificant stenosis can be
differentiated with systolic peak
velocities and AVF blood flow
can be registered as surveillance
parameter resembling dialysis
data.
angioplasty, PTA) or using
surgical treatment. PTA is
advantageous as it can be
carried when performing the
fistulography and preserves the
vascular tree unlike surgery. On
the other hand, however, it has
a higher reincidence rate in
comparison to surgical review.
Surgical option, creating a new
proximal anastomosis, shows
more long-lasting results and
does not require added
procedures. However, it
consumes part of the vascular
tree. In treatment for juxtaanastomosis stenosis, which
represents most AVF stenoses,
there are no clinical trials
comparing angioplasty with
surgery and studies are usually
in non-.controlled series. The
only data available pertaining to
controlled studies come from
two retrospective studies of
clinical series, with nonhomogenous results. Both
articles find better results in
surgery with reference to primary
patency, with no difference in
assisted patency.
A prospective study comparing
both techniques was carried out
in our centre, a university hospital
with a reference population of
485,000 inhabitants, in 2
consecutive periods on a cohort
of similar characteristics, using
a follow-up protocol and
treatment indication. Efficacy
and safety was analyzed in the
first phase (PTA group) and in
the second (surgical group).
Assisted patency of PTA was
performed with PTA itself when
there was no surgical indication
due to early relapse and assisted
patency of surgery was
performed with surgery.
However, PTA was performed if
the patient could not be
submitted to a new
reanastomosis. 139 procedures
were performed: 63 PTA and
76 surgical interventions . There
were no differences in age
(67.2±14.7 years), gender (67%
M and 33% F) or time in
haemodialysis (42±30 months).
Location of AVF were radial:
68% and humeral: 32%, with
significant dominance in radial
territory for surgery (p<0.005).
The primary patency was
significantly better for surgery
(Long Rank: p<0.005) and with
a trend but not significant for
secondary patency at 1, 2, 3
and 4 years. PTA: 72, 66, 61
and 61% and for: 80, 77, 77 and
77% (Log Rank: 0.289). The
complications of PTA were 3%
(2 minor vein ruptures, resolved
with compression and stent) and
no complications were described
for surgery.
In summary, although
angioplasty can prolong vascular
access life without significant
differences in relation to surgery,
the latter has improved primary
patency with lower procedures
to maintain assisted patency. So
until now the surgical procedure
seems more cost effective,
although studies with a large
enough sample size are needed
to establish the indication.
importance to the chronic kidney
disease population.
include venous hypertension,
pseudoaneurysm formation and
neurological disorders.
concepts: flow diffuser, graft
geometry and anastomotic
geometry.
Intimal hyperplasia is responsible
for stenosis at the graft-vein
anastomosis. Reasons proffered
for intimal hyperplasia include:
compliance mismatch between
the vein and graft, boundary
layer separation, enhanced
particle residence time,
increased low sheer stress and
high flow velocity of blood at the
anastomosis. Efforts at reducing
the incidence of intimal
hyperplasia have evolved from
research into the following
Occlusion is an important
vascular access-related
complication, which is mostly
caused by stenosis and also by
hypotension, dehydration,
infection, compression, or other
conditions.
Endovascular treatment (ET) has
been introduced as a treatment
modality for the management of
VA related complications.
Conventionally, surgical therapy
has been the mainstay of
treatment for such
complications, but it is now
being replaced by ET, a less
invasive therapy for occlusion.
While citing a lack of randomized
data to support it, the K/ DOQI
Vascular Access Guidelines
prefer venous preservation, rapid
return to dialysis and less
invasiveness of the
percutaneous technique over
surgery. The K/DOQI guidelines
Autogenous fistulae are the
vascular access of choice
because of their longevity and
inherently low infection risks, but
the number of fistulae is limited
to the arterial and venous
anatomy, that is why
arteriovenous grafts are a
common option for permanent
hemodialysis access.
Complicactions associated with
synthetic grafts are stenosis with
or without graft thrombosis,
infection and vascular steal
syndrome. Other complications
87
Occlusion precludes HD, and
therefore, it can give rise to fatal
consequences.
We are going to review occlusion
treatment possibilities which are
going to permit us improving
secondary patency.
volver al sumario
Abstract
11
IX
Abstract
Endovascular techniques to
declot hemodialysis grafts
include the evaluation of the
outflow veins, thrombus removal,
the treatment of lesions
responsible for graft demise, and
the dislodging of the arterial plug.
Techniques for declotting
hemodialysis fistulae include
pulse-spray and lyse-and-wait
techniques using urokinase,
mechanical thrombectomy with
compliant balloons, and many
mechanical thrombectomy
devices.
We present our preliminary
results of 70 thrombosis grafts
that were treated with
Hidrodynamic percutaneous
thrombectomy.
The clinical data collected from
patients’ files included patient
age and sex, type of access and
its location. In addition, we
recorded time from creation of
the arteriovenous graft to the
first declotting procedure, the
type of declotting procedure,
number and location of stenosis,
size and type of the balloon
angioplasty, stent/stent graft
placement, median number of
procedures per patient, average
time to reintervention and the
number of angioplasties
performed between two
consecutive graft occlusions. It
was also collected time from
Endovascular
treatment
modalities for low
and high flow
vascular
malformations
Jos C. Van den Berg
graft occlusion/dysfunction to
radiologic intervention,
complications of the procedure,
residual findings (eg, occlusion,
thrombus, stenosis, and
aneurysm), and outcome of the
procedure. Procedure success
was evaluated on technical and
clinical bases
We use mechanical
thrombectomy with “Angio-jet”
system in all cases. Angioplasty
in one or more lesions after
thrombectomy was performed
in all accesses.
The AngioJet device relies on a
high-pressure saline jet passing
from the tip of a catheter, then
up the catheter shaft to an
exhaust pump external to the
patient. A low-pressure zone at
the catheter tip is the result; this
draws thrombus into the jet
stream, causing maceration and
extraction.
All procedures are carried under
local anesthesia in the
interventional radiology unit.
Patients with a suspected
thrombosed fistula are referred
urgently. Patients are scheduled
urgently for the next available
appointment, usually within
24–48 h. The procedure is
carried out by one of five
interventional radiologists with
vascular access experience.
Then the patient undergoes
ultrasound evaluation in the
interventional suite to confirm
thrombosis and it is used to
guide the puncture via the
Seldinger technique. Six-French
sheaths are inserted in an
antegrade and retrograde
direction. A five-French catheter
Arterio-venous malformations
(AVMs) are congenital vascular
malformations (CVMs) that result
from birth defects involving the
vessels of both arterial and
venous origins, resulting in direct
communications between the
different size vessels or a
meshwork of primitive reticular
networks of dysplastic minute
vessels which have failed to
mature to become 'capillary'
and 0.035-inch wire are passed
in an antegrade fashion through
the occluded venous limb into
the patent central veins. The
AngioJet DVX catheter is passed
over a 0.035-inch wire through
the thrombus. The AngioJet DVX
catheter is then passed
retrograde toward the arterial
anastomosis. After
thrombectomy, angiography
delineates stenoses, and these
are treated with angioplasty.
In case of vascular ruptured stent
graft is positioned if compression
of the lesion is not enough. No
thrombolytic drugs are used
before, during, or after the
procedure. Heparin (up to 5000
iU) is used intraoperatively at the
discretion of the radiologist.
Antibiotics are not routinely used
A life analysis table is provided
in Table 1. A total of 70
thrombectomies were
performed.
Primary patency at 1, 3, and 6
months was 73%, 56%, and
42%, respectively. Secondary
patency at 12 months 61%
Complications occurred in 7
patients. Six of them were minor
complications (5 limited
haematomas and one
bronchospasm). A
gammagraphic examination of
ventilation/perfusion was
performed in the patient who
experienced the bronchospasm
which was negative for
pulmonary embolism. There
was a major complication:
arterial anastomosis rupture
occurred post-angioplasty and
the patient required surgical
intervention with surgical repair
of the graft, with no more
complications and without any
sequelae
thrombosed accesses. Being
minimally invasive, the technique
is accepted by the patients. The
high rate of clinical effectiveness
and the fact that the access can
be used immediately if urgent
dialysis is needed are additional
factors that favor endovascular
techniques.
Further research to identify the
causes of intermediate graft
thrombosis is necessary
With the increasing number of
patients requiring hemodialysis,
this is becoming a real growth
area for interventional
radiologists
Table 1
Comparison with the literature
with other series:
The mean age was 67 years
(range 36-84). There was a slight
predominance to male sex (22
men, 56% and 17 women, 44%)
and averag e patient age was
67 years. Location of grafts was
25 in the upper arm and 14 in
the lower limb.
The time to Intervention was 2448 hours in 59 procedures (84%)
, and more than 48 in 16%.
Median number of procedures
per patient was 2,2. Median
follow up was 503 days ( 16,8
months) (p25:153-p75:736)
Technical success rate for
thrombectomies was 97%
(68/70) and clinical success rate
was 86% (60/70 procedures)
vessels termed "nidus". These
lesions are defined by shunting
of high velocity, low resistance
flow from the arterial vasculature
into the venous system in a
variety of fistulous conditions.
AVMs remain the most
challenging and potentially limb
or life-threatening form of
vascular anomalies. The
anatomic, pathological and
hemodynamic characteristics,
88
Summary and
conclusions:
Like others, we agree to perform
an aggressive endovascular
approach in treating failing or
the secondary effects on the
surrounding tissues and the
systemic manifestations should
be defined. Basic diagnostic
tools are Duplex sonography
followed by MRI or CT scanning.
Although many classifications
have been developed that
provide a better understanding
of the biology and natural history
of AVMs, the definition of the
vascular anomaly should be
according to the Hamburg
classification and should
separate vascular tumors from
vascular malformations. The next
step is to separate high flow from
low flow AVMs, in order to
choose optimal therapy.
Guidelines will be provided in
this presentation.
volver al sumario
have recommended
endovascular techniques to
restore function of thrombosed
hemodialysis prosthetic grafts,
which should have a clinical
success rate of at least 85% and
that primary patency at three
months should be at least 40%.
volver al sumario
11
IX
What’s New on
CCSVI
Michael D. Dake
Recent data from the literature
suggest a greater role of chronic
venous insufficiency in the
pathogenesis of a variety of brain
Planeando zonas
de anclaje en
iliacas complejas:
sandwiches,
periscopios, stents
paralelos
Alejandro Fabiani,
Tecnológico de Monterrey,
México
los aneurismas de aorta (EVAR)
ha excedido en la actualidad las
indicaciones clásicas y muchos
procedimientos se llevan
adelante en pacientes con una
anatomía no adecuada para el
Planning and
sizing evar: do it
yourself! A basic
schema to follow.
Fernando Gallardo
disorders. The goal of this talk
is to review the contributions
made in 2014 to our enhanced
understanding of the safety and
efficacy of the endovascular or
open surgical treatment of
chronic venous obstruction in
patients with a variety of
pathologies including multiple
sclerosis, transient global
amnesia, Alzheimer’s disease,
Parkinson’s disease, postural
orthostatic tachycardia
syndrome, transient monocular
blindness, headaches, and
spontaneous intracranial
hypertension. Open surgical
interventions including, but not
limited to operative venous
bypass, transposition,
venoplasty, and vein interposition
have been reported.
EVAR. La industria ha
comenzado a ofrecer diferentes
opciones hechas a medida para
cada paciente y otras de uso
estándar (off the shelf) aplicables
a la gran mayoría de los casos.
Pero estas tecnologías no están
aún disponibles en todos los
medios y suelen tener un costo
elevado.
Entre tanto, se han improvisado
diferentes opciones que pueden
realizarse con los materiales
disponibles en la mayoría de los
sitios y con resultados
alentadores..
Se discutirán aquí las opciones
disponibles para el manejo de
aneurismas ilíacos en los que
no es posible respetar las
indicaciones de uso de las
endoprótesis estándares y se
debe recurrir a la utilización de
técnicas de salvamento de las
hipogástricas a través de
técnicas como los sándwiches,
periscopios, stents paralelos. Se
darán algunos Tips técnicos para
facilitar su realización y asegurar
buenos resultados y finalmente
se presentarán los resultados
reportados con estas técnicas.
at radiological workstations. For
endovascular therapist who
begins to use this software,
preoperative navigation within
the vessels and accurate
measurements are the primary
objectives, enabling them to
accurately plan an EVAR.
Objectives:
The objectives of this work are:
a) remark the differences
between measuring-sizingplanning, b) review the evolution
of planning EVAR over last years,
c) present a basic schema with
the principles of measuring and
sizing EVAR focused on the key
Introduction:
The sizing, which is the first step
of endovascular aneurysm repair
(EVAR), is essential for a
successful procedure. Several
sizing methods have been
assessed, using highly
sophisticated and expensive
radiological workstations and
software. Endovascular
specialist must be able to master
this first step using reliable
software, with results that are
as accurate as those obtained
Figure 1: MPR, VR and CPR modality views.
90
Endovascular procedures
detailed in the medical literature
include balloon angioplasty,
cutting or scoring balloon
angioplasty, self-expanding and
balloon expandable stent
placement, and stent-grafting.
In general, all these therapies
have been used to treat stenosis
and/or occlusions of the jugular
and/or azygous veins associated
with increased collateral venous
drainage. The relationship
between anatomic findings and
any symptoms related to the
range of neurological disorders
listed above has not been
established and further research
is required. steps for a succesfully planning.
Endovascular surgeons that
perform EVAR should acquire
the necessary skills to perform
all the steps in planning and
sizing of the procedure and not
limit their participation in the
procedure to the implantation of
the aortic endoprosthesis.
Matherial and methods:
Precise preoperative study of
the aortic anatomy based on
high-quality preoperative
computerized tomography
angiography scans (CTA) is
required to determine EVAR
suitability and to accurately size
the endograft and plan the
procedure. Multidetector row CT
and 3D workstation analysis
have now replaced the old “ gold
standard” intra-arterial digital
subtraction angiography for
assessing the vascular anatomy.
New generation of 3D
workstations are now intuitive
and “ easy-to use”, which makes
them accessible to vascular
surgeons and radiologists alike.
Endograft sizing software
including three-dimensional (3D)
reconstructions of the
preoperative computed
volver al sumario
Abstract
11
IX
Abstract
A basic schema of measuring
and sizing is presented, and it
could be summarized in 8 key
points:
1. Size of the aneurysms:
Hostile / complex anatomies,
measures “in-in” or “out-out”.
Endofugas tipo ii
que se necesita
resolver. ¿Cómo se
maneja en vuestro
centro?
Franciso Gómez Palonés
Servicio de Angiología Cirugía
Vascular y Endovascular
Hospital Universitari Dr Peset.
Valencia. SPAIN
La dimensión del
problema
2. Access evaluation: Degree
of ilio-femoral arterial
occlusive disease,
angulations.
3. Aortic Neck evaluation:
Angulations, diameter, length,
thrombus, calcium.
4. Aortic bifurcation: Lumen,
calcium, area.
5. Iliacs evaluation: Internal
diameters, angulations.
6. Aorta Length: Estimation
of longitudinal devices
placement with the centreline.
7. C-Arm
Angulations:Calculated
before the procedure with VR
and MPR techniques.
Figure 2: Evaluation of C-Arm angulations prior to the EVAR
in a document that should be
visible for the main operator
during the procedure.
preoperative measuring and
planning process. The routine
use of 3D workstations for EVAR
planning and a basic schema in
measuring and sizing are useful
tools that should be mandatory
in everyday practice to enhance
short and mid-term EVAR
results.
8. Check the adaptability of
endovascular stock and the
own endovascular´s skills
limitations of the team.
It is recommended to report all
the points of this basic schema
Conclusions of the
study:
en el tiempo. Aunque lo primero
se ha conseguido con una gran
mejoría de los resultados
inmediatos con respecto a la
cirugía abierta, sus resultados a
largo plazo, sin embargo, aun
arrojan ciertas sombras, pues
metaanálisis de ensayos
grandes, reflejan que se
encuentran casos de mortalidad
por rotura del aneurisma en el
seguimiento, y en la mayoría de
casos esta en relación con
endofugas.
Fig1.-Endofuga y embolización de arteria mesentérica inferior
EVAR could be consider as a
relatively simple procedure but
its execution requires a detailed
Figure 3: Example of a basic schema
of an infrarrenal EVAR planning, with
detailed information of technical and
anatomical issues.
Las endofugas tipo 2
consitituyen un problema
importante por dos motivos:
• Por su elevada frecuencia
aneurismas de aorta se ha
consolidado como una opción
terapéutica cas de primera
elección, que logra la exclusión
del aneurisma con una
incidencia muy baja de morbimortalidad comparado con la
cirugía abierta.
• Por que motiva controles
recuentes con exploraciones
diversas, y a menudo
actuaciones terapéuticas,
aunque sin un criterio unánime
sobre como y cuando tratarlas,
Sus objetivos son que la
exclusión sea completa y
efectiva, y eso implica duradera
Una revisión sistématica1 del
año 2013, que agrupa 32
estudios retrospectivos no
Se estima que en torno al 1020% de los casos tras EVAR
presentan endofugas tipo 2
ENDOFUGA TIPO 2VÍA AMI
aleatorizados con un total de
21744 casos de EVAR,
identifica:
• Un 10,2% de los casos tienen
una endofuga tipo 2 tras EVAR
• Un 35,4% se resuelve
espontáneamente
91
EMBOLIZACIÓN SELECTIVA AMI
• Un 0,9% con endofuga tipo 2
aislada sufrió la rotura del AAA,
pero lo que es más alarmante
es que en un 40% de ellos la
rotura se produjo sin crecimiento
previo del aneurisma.
Actuaciones preventivas
Debido a la incertidumbre que
estos datos generan y a pesar
de ser poco frecuentes, se han
intentado establecer variables
que puedan predecir la
persistencia de endofugas tipo
2 después de la reparación
volver al sumario
tomography angiography (CTA)
and stretch reconstructions
perpendicular to a
semiautomatically generated
centerline are now widely
available for endovascular
surgeons, nevertheless, a
degree of judgment by the
planner/operator is required. It
is first necessarty to understand
the three basic processing mode
of DICOM reconstructions:
Multiplanar Reconstruction
(MPR), Volume Rendering (VR)
and Centerline Plan
Reconstruction (CPR).
11
IX
Abstract
entre el 50 y 80% de los casos
durante los primeros 6 meses
tras el procedimiento de
EVAR12,13,14..
Por lo tanto, la actuación
preventiva sistemática para
prevenir una potencial endofuga
tipo 2, que es benigna en la
mayoría de los casos no parece
ser la actitud generalizada.
Se considera razonable
plantearse actuaciones
preventivas en los casos en los
que concurran 2 o más de las
condiciones que se asumen
favorecedoras de endofugas
persistentes.
Fig 2.-Endofuga y embolización de lumbares via arteria hipogástrica
• Ausencia de trombo mural
• Diámetro grande del
aneurisma
• Ausencia de trombo mural
• Presencia de arteria
mesentérica inferior
permeable
• Presencia de varias arterias
lumbares permeables, sobre
todo si es en número mayor
de 4.
• Anticoagulación mantenida
Aunque comparados estos
factores, para algún autor7 la
presencia de arteria mesentérica
inferior permeable y de
lumbares, parecían tener un
mayor peso predictivo.
mesentérica inferior
11preoperatoriamente.
• Embolización de arteria
hipogástrica vs exclusión de
la misma, en casos en los
que no se puede preservar
Aunque cuando estos
procedimientos son efectivos a
la hora de ocluir la potencial
fuente de endofuga, no siempre
se ha asociado a una
desaparición completa de
endofugas tipo dos, o incluso
no siempre se ha asociado a
reducción del tamaño del
aneurisma a pesar de haber
eliminado las endofugas.
Se ha constatado también que
las endofugas tipo 2 tienden a
la resolución espontáneamente
También debido a la
incertidumbre del problema, la
actuación sobre una endofuga
tipo 2 es variable.
En una revisión sistemática de
10 series con 231 pacientes con
endofugas tipo 2 aisladas15 en
la que se clasificaron los
pacientes según la actitud a
seguir:
• Conservadora:
Seguimiento y expectación
• Tratamiento selectivo: Tan
sólo en caso de persistencia
superior a 6 meses o
crecimiento del saco
• Agresiva: Tratamiento de
toda endofuga tipo2 que
Basados en estos datos,
algunos autores han abogado
por una actuación preventiva,
describiendo técnicas como:
El análisis de meta –regresión
no mostró diferencias
significativas entre ninguna de
las estrategias adoptadas
comparadas con la
conservadora, en cuanto mejoría
en la regresión del saco
aneurismático.
Una vez decidida la necesidad
de ocluir la endofuga tipo 2 se
plantea la disyuntiva de qué
método emplear16. Dentro de
ellos se incluyen varios:
Quirúrgicos
• Ligadura con cirugía abierta
• Ligadura vía laparoscópica
• Inyección intrasaco via
quirúrgica
• Conversión completa a
cirugía abierta
Endovascular
Protocolo del centro:
A pesar de que actitudes
variadas pueden tener su
justificación nuestro plan de
actuación se basa en:
Actuación preventiva:
• Indicación: Gran saco
aneurismática con nula o
escaso contenido de trombo
mural + presencia de AMI y/o
lumbares e numero mayor de
4 o de calibre >2 mm
Método:
• Embolización selectiva de
arterias hipogástricas cuando
no se puede preservar o
cuando es aneurismática.
• Inyección de Trombina
intrasaco.
Actuación terapéutica:
Indicación:
• Endofuga tipo 2 persistente
más de 12 meses.
• Embolización transarterial
• Endofuga tipo 2 asociada
a aumento del diámetro del
aneurisma > 5 mm.
• Embolización “transsealing”
(a través de la zona de
sellado, entre endoprótesis
y la pared arterial)
• Método: de forma
progresiva según el éxito
obtenido con el método
inicial:
• Embolización “trans-saco”
• Embolización selectiva por
caeteterismo selectivo vía
arteria mesentérica superior> arcada Riolano->A
mesentérica inferior o
hipogástrica para llegar a
lumbares (Fig1 y Fig2)
La tendencia es a agotar las
opciones menos invasivas, y en
• Técnica PASE ( “roadside”):
accediendo entre la prótesis
y la pared arterial ( Fig 3)
• Punción guiada por TC /
eco directa del saco e
inyección de trombina/colas
biológicas/Onix/ coils.
• La inyección intraoperatoria
de trombina9,
• Trombinización y
estabilización del saco10 con
la misma finalidad que
combina la liberación de coils
intrasaco asociados a
trombina durante el
procedimiento de implante.
• La embolización selectiva
de lumbares y/o arteria
La valoración de los resultados,
no se registró ninguna rotura de
aneurismas y el tamaño del
aneurisma se mantuvo estable
o se redujo en general.
esta decisión tiene que ver la
experiencia del equipo, y los
medios de imagen disponibles.
• Otras alternativas.
Referencias
1 F. Bastos Gonçalves, N. F. Oliveira andH.
J. M. Verhagen: Type II endoleak after
endovascular aneurysm repair (Br J Surg
2013; 100: 1262–1270
Fig 3.-Embolización “trans-seal”
92
volver al sumario
endovascular. En diversos
trabajos2,3,4,5,6,7,8 se han
implicado múltiples causas que
incluyen:
Actuación
intervencionista sobre
endofuga tipo 2
persista más allá de los 3
meses.
11
IX
Abstract
3 El Batti S, cochennec F, Roudot-Thoraval
F, Becquemin JP. Type II endoleaks after
endovascular repair of abdominal
aorticaneurysm are not always a benign
condition. J Vasc Surg 2013;57:1291-8.
4 Timaran CH, Ohki T, Rhee SJ, Veith FJ,
Gargiulo NJ 3rd, Toriumi H et al. Predicting
aneurysm enlargement in patients with
perisitent type II endoleaks. J Vasc Surg
2004;39:1157- 62.
5 van Marrewijk CJ, Fransen G, Laheij RJ,
Harris PL, Buth J; EUROSTAR
collaborators. Is a type II endoleak after
EVAR a harbinger of risk? Causes and
outcome of open conversión and aneurysm
ruptura during follow-up. Eur J Vasc
Endovasc Surg 2004;27:128-37.
Below the knee:
Basic material to
use, when to go
there and what you
should never do
Abstract:
Tibial revascularization is a
rapidly growing part of
endovascular practice. Many of
the principles, techniques, and
devices required to make this
happen have been adopted from
other vascular beds. The best
Acquiring endo
skills for evar:
learning from
simulation/ other
experiences.
Minimal
requirements in the
or.
Nick J. Cheshire
Imperial College London,
University of Ghent Belgium
6 Warrier R, Miller R, Bond R, Robertson
IK, Hewitt P, Scott A. Risk factors for type
II endoleaks after endovascular repair of
abdominal aortic aneurysms. ANZ J Surg
2008;78:61-3.
9 Zanchetta M, Faresin F, Pedon L, et al.
Intraoperative intrasac thrombin injection
to prevent type II endoleak after
endovascular abdominal aortic aneurysm
repair. J Endovasc Ther. 2007;14:176–83.
7 Abularrage CJ, Crawfor RS, Conrad MF,
Lee H, Kwolek CJ, Brewster DC et al.
Preoperative variables predict
persistenttype 2 endoleak after
endovascular aneurysm repair. J Vasc Surg
2010;52:19-24.
10 Ronsivalle, S; Faresin, F; Franz, F;
Rettore, C; Zanchetta, C; Olivieri,A:
Aneurysm Sac ‘‘Thrombization’’ and
Stabilization in EVAR: A Technique to
Reduce the Risk of Type II Endoleak. J
ENDOVASC THER 2010;17:517–524
8 Velazquez OC, Baum RA, Carpenter JP,
Golden MA, Cohn M, Pyeron A et al.
Relationship between preoperative patency
of the inferior mesenteric artery and
subsequent ocurrence of type II endoleak
in patients undergoing endovascular repair
of abdominal aortic aneurysms. J Vasc
Surg 2000;32:777-88.
11 Nevala,T; Biancari,F; Manninen,H;
Matsi,P; Mäkinen,K; Ylönen, K; Perälä, J:
Inferior Mesenteric Artery Embolization
before Endovascular Repair of an
Abdominal Aortic Aneurysm: Effect on Type
II Endoleak and Aneurysm Shrinkage. JVIR
21(2): 181–185
13 Parent FN, Meier GH, Godziachvili V,
LeSar CJ, Parker FM, Carter KA et al. The
incidence and natural history of type I and
II endoleaks: a 5-year follow-up assessment
with color duplex ultrasound scan. J Vasc
Surg 2002;35:474-81.
16 Torres A; Gomez-Palones F; Edo G;
Molina V; Ortiz,E: Endofugas tipo 2 después
de EVAR. In Complicaciones de los
procedimientos endovasculares. Ed.Carlos
Vaquero. PROCIVAS,SLNE. Valladolid
2014. ISBN 978-84-617’0292-3. Págs
117-131
14 Faries PL, Cadot H, Agarwal G, Kent
KC, Hollier LH, Marin ML. Management of
endoleak after endovascular aneurysm
repair: cuffs, coils and conversion. J Vasc
Surg 2003;37:1155- 116
15 Karthikesalingam,A; Thrumurthy,SG;
Jackson,D; Choke,E; Sayers,RD; Loftus,IM;
Thompson, MM; Holt PJ:Current Evidence
Is Insufficient to Define an Optimal
Threshold for Intervention in Isolated Type
II ndoleak After Endovascular Aneurysm
Repair J Endovasc Ther April 2012 19:
200-208
12 Gelfand DV, White GH, Wilson SE.
Clinical significance of type II endoleak after
endovascular repair of abdominal aortic
aneurysm. Ann Vasc Surg 2006;20:69-74.
factors suggesting success are
in cases where the foot damage
is minimal an also where the
runoff into the foot is intact.
The long-term patency of tibial
angioplasty and stenting may be
only fair but limb salvage is often
achieved without bypass.
Successful guidewire
deployment requires knowledge
of choices. The goal is to choose
the most appropriate guidewire
first as often as posible and to
know what to do next if the first
choice turns out to be a best.
There are a full range of
guidewires available.
Basic and advanced access for
sheaths placed outside the heart
is with 0.035 in. ( Coaxial
Systems). However one major
advantage of the lower profile
0.014 guidewire, is that it is less
likely to be unresponsive after
passing through a tight lesión
and need small plataforms
(Monorail Systems) Most
occlusions can also be crossed
and treated with various
guidewires supported by certain
catheters and other devices
using specialized techniques.
We need to have a differents
guidewire types. Starling,
selective, exchange, speciality.
With diferent lenght, diameter,
stiffness, coating, tip shape.
The potential for constructing
different catheter head shapes
is unlimited. Although hundreds
are currently being marketed,
most endovascular practice is
base don the consistent and
well-developed use of just a few
types in most individual
practices. Each specialist has
funcional favorites. Flush and
selective catheters have
divergent purposes and
substantially different
appearances. In general we used
flush catheters, straight catheter,
selective catheters, complex
curves catheters,long benit
tip,hook shape. Its important
knowed the kind of lession to
choice wich catheter will be
usefull trackability, pushability,
crossability, steerability, and
french.
Simulated environments for the
acquisition of endovascular skills
range from simple desktop
models to full immersion virtual
reality simulation. All of these
models allow the trainee to
practice everything from access,
to tool choice, to steering within
the vasculature and ultimately
to proceeding with complex
interventions. All of these models
have been shown to improve the
function of trainees when
assessed within the simulated
environment. Very little data
exists to show that this
information can transition into
real life clinical intervention and
improve outcomes for patients.
There are many reasons why
this difficult leap into clinical proof
has not yet been reached.
We have experience with simple
light based models that allow
students to practice within a
plastic or glass model. We have
used both camera simulation
and direct vision during practice
deployment. We also have
significant experience with virtual
reality and with real patient data
in a simulatIon system. Our
suggested minimum
requirements for OR experience
includeaccess to the femoral
artery, passage of a non
traumatic wire, under screening,
through the iliac arteries into the
aorta, replacement with a stiff
wire, angiography including
choice of imaging angle to gain
the best neck and iliac artery
images, contra-lateral leg
cannulation. Other skills that
need to be acquired include
device specific deployment,
femoral artery closure devices
and specific intra operative
imaging techniques..
The training requirements laid
down by training bodies in
individual countries need to work
with those with experience of
simulation to understand how
specific training requirements
can be matched to the simulator
strengths.
93
volver al sumario
2 Gallagher KA, Ravin RA, Meltzer AJ, Khan
MA, Coleman DM,Graham AR et al.
Midterm outcomes after treatment of type
II endoleaks associated with aneurysm sac
expansion. J Endovasc Ther 2012;19:182192.
11
IX
Abstract
Cuellos hóstiles en
evar: diferentes
problemas
requieren
diferentes
soluciones.
Dr. Omar Andrés Navarro.
El caballo de batalla del EVAR,
está en las reintervenciones
por endoleaks, migración o fallo
del dispositivo, esto está
relacionado con anatomías
desfavorables, sobretodo
cuando hablamos de cuellos
hostiles. Podríamos definir como
cuello hostil, aquel con al menos
una de las siguientes
características: diámetro mayor
de 28 mm, angulación >60°,
longitud < 10 mm, cuello cónico,
con trombo o severamente
calcificado.
los aneurismas (EVAR)
generalmente no estaba
recomendada para aquellos
pacientes con anatomía del
cuello hostil. Sin embargo el
desarrollo de nuevos
dispositivos, la irrupción de
endoprótesis fenestradas y las
técnicas CHIMPS, permiten que
actualmente esto no sea así y
que dispongamos de un abanico
bastante amplio de posibilidades
a la hora de planificar EVAR en
con cuello hostil infrarenal.
A parte de técnicas CHIMPS o
fEVAR, se han desarrollado
nuevos dispositivos con
diferentes características que
pueden hacer que nos
atrevamos cada vez más a
implantar dispositivos standars
en cuellos desfavorables.
Analizamos varios de los
diferentes tipos de dispositivos
que hay en el mercado y damos
una visión personal de las
ventajas de cada uno de ellos,
así como de sus puntos débiles
y de las diferentes técnicas de
recurso para abordar un cuello
hostil.
Los pacientes con aneurisma de
aorta abdominal y cuello hostil
por tanto pueden ser tratados
mediante EVAR/EVAS. Sin
embargo de momento siempre
necesitaremos un seguimiento
cuidadoso y a largo plazo.
Sesión 21
Disección no
complicada tipo B:
Nuevos predictores de
riesgo morfológicos
Arturo Evangelista
Servei de Cardiología. Hospital
Universitari Vall d´Hebron
Barcelona
To date, no study has shown that general
elective TEVAR in the subacute phase
of aortic dissection reduces mortality.
Therefore, identifying clinical and imaging
predictors of poor prognosis seems
mandatory for selecting patients who
may benefit from more aggressive
management.
Predictors of Complications
by imaging techniques:
a) Maximum Aortic Diameter. Maximum
aortic dilatation after acute phase is a
major predictor of complications during
follow-up. CT but also MRI are better
than TEE in the measurement of the
aorta size distal to the aortic root.
Aneurysmal dilatation of the dissected
TODO LO QUE NECESITAS SABER SOBRE LA DISECCIÓN AÓRTICA TIPO B
ALL YOU NEED TO KNOW ABOUT AORTIC TYPE B DISSECTION
Moderador / Moderator V. Riambau
Panelistas / Panellists A. Evangelista, M. Jacobs
aorta will occur in the 25-40% of patients
surviving acute type B aortic dissection.
Secondary dilatation of the aorta during
follow-up of aortic dissection has been
considered a significant predictor of aortic
rupture. An aortic diameter >45 mm in
descending thoracic aorta after acute
phase and a patent false lumen has been
related to aneurysm development in the
false lumen (>60 mm) and surgical
reintervention. Diameter > 60 mm or
annual growth > 5 mm imply a high risk
of aortic rupture. Other studies have
shown maximum FL diameter in the
proximal part of descending aorta to be
a predictor of complications. However,
this diameter has low reproducibility,
mainly due to movement of the intimal
flap.
b) Patent false lumen
In addition to aortic diameter, a consistent
predictor of outcomes in acute type B
aortic dissection has been the
hemodynamic status of the false lumen,
classically divided into either a
thrombosed false lumen or a patent false
lumen. Studies have shown that
completely thrombosed false lumina have
improved outcomes, while patent false
lumina imply an increased risk of aortic
expansion and death. Persistence of
patent false lumen in descending aorta
94
is common in both dissection types and
has been strongly associated with poor
prognosis. Total thrombosis of the false
lumen, considered a precursor of
spontaneous healing, is a rare event,
even after surgical repair of a type A
aortic dissection. A persistent false lumen
can be found in most type B aortic
dissections during follow-up and in more
than 70% of type A aortic dissections
after surgical repair. After type A
dissection repair, patent false lumen in
descending aorta is linked to survival at
5 years. Thus, intraoperative TEE for
eliminating the entry tear, and not just
repairing the ascending aorta, is of great
importance. The high incidence of total
false lumen thrombosis in several series
may indicate that intramural hematomas,
which have a different evolution pattern,
were included in these studies
c) Partial false lumen
thrombosis
Studies have shown that completely
thrombosed false lumina have improved
outcomes, while patent false lumina carry
an increased risk of aortic expansion and
death. However, in the IRAD series,
partial thrombosis of the false lumen,
defined as the concurrent presence of
both flow and thrombus and present in
a third of patients, was the strongest
independent predictor of follow-up
mortality with a 2.7 fold increased risk
of death compared to patients with
patent false lumen without thrombus
formation. Prospective studies using CT
or MR for assessing the whole aorta are
required to confirm these results.
d) Entry Tear Size
The prognostic value of entry tear size
and a high false lumen pressure pattern
has not been adequately analyzed to
date. TEE and CT are better than MRI
in the assessment of entry tear size and
location. When the entry tear is small,
the flow volume that enters the false
lumen is low and thus the false lumen
pressures will be low. Entry tear≥ 10
mm, when located in the proximal part
of the dissection, conferred the poorest
prognosis adjusted for the remaining
predictors (Figure 1). The combination
of a large entry tear and indirect signs
of high pressure of the false lumen,
distinguishable by imaging techniques,
should be considered as a predictor of
aortic enlargement and a close followup by imaging techniques is advisable.
e) True Lumen Compression
True lumen compression is an indirect
sign of high false lumen pressure.
However, true lumen compression is not
volver al sumario
Sábado, 27 Junio
Saturdy, June 27th
11
IX
Figure 2
an easy variable to analyze, there exist
limitations secondary to intimal flap
movement during the cardiac cycle, or
local factors, as in spyroid dissection,
that may reduce reproducibility of this
to evolve with rapid false lumen
enlargement and aortic complications.
f) False lumen flow.
secondary aneurysms
after chronic type B
dissections should be
the first therapeutic
option.
Treatment in the acute phase is clearly
advocated for dissections complicated
by rupture, abdominal end-organ
ischemia, lower limb ischemia, persistent
pain, and refractory hypertension.
Regardless of the type of treatment,
approximately 20% to 30% of patients
suffering an acute type B dissection will
develop a post-dissection aneurysm.
The goal in the treatment of a postdissection aneurysm is no different to
treating non-dissection aneurysms: The
aneurysm needs to be excluded from
the blood flow and pressure. Due to the
lack of an adequate distal landing zone
above the visceral branches of the aorta
in most cases, a post-dissection
aneurysm is often to be regarded as a
thoraco-abdominal aneurysm .
Eric LG Verhoeven, MD, PhD.
Endovascular Surgery, and Radiology,
Paracelsus Medical University Nürnberg,
Klinikum Nürnberg Süd, Nürnberg,
Germany
False lumen flow volume of aortic
dissection assessed by contrast
echocardiography or MRI is a predictor
of aortic dilation and clinical events in
patients with chronic descendi ng aorta
Introduction
Endovascular repair
Type B dissections are usually classified
according to the onset of symptoms as
acute (≤14 days) or chronic (> 14 days).
For many years, medical treatment was
considered the first treatment option for
uncomplicated type B dissections. Newer
insights seem to favour endovascular
repair in a large proportion of
uncomplicated acute type B dissections.
Conventional thoracic endografting can
be a viable approach for secondary
aneurysms limited to the thoracic aorta.
This clinical scenario however is rare.
In chronic type B dissections involving
the thoracoabdominal aorta complete
aneurysm exclusion requires using
fenestrated and/or branched endografts.
This clinical entity involves additional
95
dissection. The presence of high total
flow volume in the false lumen with
significant diastolic retrograde flow
identifies the subgroup of patients with
a higher risk of complications in whom
more aggressive management would be
indicated (Figure 2).
technical challenges. One specific feature
in this pathology is the usually narrow
true lumen. This has to be taken into
account when deciding whether to use
fenestrations or branches. Branches are
more suitable when target vessels
present with sharp downward take-off,
but require more room in the true lumen.
This extra room can be created by
deployment of a tube graft first with a
distal landing zone a few cm above the
visceral branches of the aorta, with the
purpose to expand the true lumen.
Fenestrations must usually be
catheterized from below and require less
true lumen space, but are more difficult
to plan with regard to correct orientation.
A second technical challenge relates to
visceral branches originating from
different lumina. In such cases,
perforation of the stiff chronic dissection
flap is required to obtain access to the
vessels originating from the false lumen.
Puncture of the dissection flap with a
needle (e.g. TIPPS needle) or the stiff
end of a wire have both been used to
address this issue.
Nuremberg experience
Our experience in the treatment of post-
dissection aneurysms with F/Br-EVAR
includes 26 patients (22 male, mean age
64.6 ± 8.1 years) treated from October
2010 to October 2014.
All cases were technically successful but
in one case, a retroperitoneal approach
was needed for renal artery
catheterization. Two (7.7%) patients died
within 30-days postoperatively, one due
to multiple organ failure and one due to
cardiac de-compensation. Renal function
impairment occurred in one (3.8%)
patient. Perioperative spinal cord
ischemia (SCI) occurred in 4 (15.4%)
patients. One (3.8%) patient suffered
paraplegia with significant improvement
prior to discharge, and three (11.5%)
patients suffered transient paraparesis
with complete recovery prior to
discharge. One (3.8%) patient developed
late (6 months) SCI with urinary
incontinence and lower limb weakness
due to regression of a type II endoleak.
Mean follow-up (FU) was 16.2 months
(range 1-54 months). One late death was
graft related and occurred 26 months
postoperatively due to an
aortoesophageal fistula. Three target
vessel occlusions were noticed (2 renal
arteries, 1 celiac trunk) during FU. In one
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Figure 1
11
IX
case an iliac-renal bypass was carried
out, the remaining two cases were
asymptomatic and did not require
treatment. Endoleaks were diagnosed
in 14 (53.8%) patients during FU. These
included three (11.5%) type Ib endoleaks,
all from the left renal artery (LRA). Three
(11.5%) patients had distal type Ib
endoleaks from dissected iliac arteries.
Eight (30.8%) patients had type II
endoleaks. Reintervention was required
in three (11.5%) patients for Ib endoleak
from the LRA. These were successfully
treated with stent-graft extension deeper
into the target vessel. Aneurysm sac
regression during FU was significant
(p=0.007) from 67.4 ± 6.4 mm to 59.1
± 7.5mm with a false lumen thrombosis
rate of 83.3% for patients that completed
12 month FU.
Is the petticoat
technique really useful
for type b aortic
dissection?
Methods:
Results:
From June 2005 to present, the
PETTICOAT technique has been
employed in 39 selected cases (29 men,
median age of 58 yrs (range: 30 – 81) of
type B chronic aortic dissection with a
compression or collapse of the true lumen.
Devices commercialized by two different
manufacturers were employed: Cook and
Jotec. All procedures were performed
under general anesthesia with
perioperative cerebrospinal fluid drainage
in 9 patients. Supra-aortic vessels rerouting was performed in 13 cases to
obtain an adequate proximal landing zone:
eleven cases of left carotid-subclavian
artery bypass and two case of right to
left common carotid artery bypass and
left subclavian to common carotid artery
bypass. Clinical follow-up visit and CT
scan were obtained at 1, 6 and 12
months, and yearly thereafter.
A 30-day clinical success was achieved
in 35 cases (89.7%): two case a type IA
entry flow, one death for respiratory failure
was observed and one open conversion
for retrograde dissection. No mortality
was recorded. Occlusion of visceral/renal
arteries or device-induced tears in the
intimal lamellae was not observed. Periprocedural morbidity included temporary
renal failure in 2 cases and postimplantation syndrome with fever and
leukocytosis for 23 days in 1 case. One
case of delayed paraparesis was recorded
(2,6%). At a median follow-up of 34
months (R. 2 – 67 months), we observed
a clinical success rate of 92%. No late
occlusion of visceral or renal arteries or
device was recorded at follow-up, one
case of retrograde aortic dissection has
been treated surgical after 3 months.
Volumetric analysis of the lumina
demonstrated the following relationship
From the Chair of Vascular Surgery
“Vita – Salute” University,
Scientific Institute H. San Raffaele, Milan,
ITALY
Objective(s):
To evaluate feasibility and safety of the
PETTICOAT (Provisional ExTension To
Induce COmplete Attachment) technique
for type B aortic dissection, and its early
and midterm technical and clinical
success rate.
Us dissection trial for
acute complicated type
B dissection. Two year
results
Michael D. Dake, M.D.
Determining the best method of treatment
for individual patients with Type B aortic
dissections has always presented a vexing
challenge for physicians. Physicians are
often faced with balancing the conservative
1. Verhoeven EL, Paraskevas KI, Oikonomou K, Yazar O, Ritter W, Pfister K, Kasprzak P. Fenestrated and
branched stent-grafts to treat post-dissection chronic aortic aneurysms after initial treatment in the acute
setting. J Endovasc Ther 2012; 19: 343-9.
Conclusion
2. Oikonomou K, Kopp R, Katsargyris A, Pfister K, Verhoeven EL, Kasprzak P. Outcomes of
Fenestrated/Branched Endografting in Post-Dissection Thoraco-abdominal Aortic Aneurysms. Eur J Vasc
Endovasc Surg 2014; 48: 641-8.
Endovascular treatment is feasible for
secondary aneurysms after type B
dissections. Standard thoracic
endografting is an option in a minority
of patients, when the aneurysm extend
is limited to the thoracic segment.
Fenestrated and branched devices are
the way to go to treat post-dissection
thoraco-abdominal aneurysms.
approach of medical management with
the more aggressive approaches of
surgical or endovascular treatments. With
the high surgical mortality for patients
presenting with acute complicated Type
B dissections, physicians have readily
adopted thoracic endovascular aortic
repair (TEVAR) as the accepted therapy
for this condition.
With newer TEVAR devices achieving a
broad indication from the FDA approval
for the treatment of all Type B dissections
and new insights regarding physiological
predictors of future complications,
physicians have expanded their
consideration of TEVAR to treat the
96
in the TL lumen: baseline 84 ± 29 cm3,
postoperative 167 ± 31 cm3 (+98%), 1
year 193 ± 46 cm3 (+131%) and 2 years
216 ± 54 cm3 (+140%). FL lumen
relationship were: baseline 332 ± 86 cm3,
postoperative 286 ± 85 cm3 (-14%), 1
year 233 ± 81 cm3 (-30%) and 2 years
248 ± 112 cm3 (-32%).
Conclusions:
Our peri-operative and midterm followup results showed that the PETTICOAT
technique for the treatment of aortic
dissection can be safely used without
affecting patency of the branches covered
by the bare stent. A significant immediate
increase in TL could be achieved with
resolution of cases of dynamic
malperfusion. Progressive remodeling of
TL was recorded over the time with
shrinkage of the FL mainly in the thoracic
segment. However, these results need
to be validated on a larger group of
patients with a longer follow-up.
volver al sumario
Germano Melissano
References
11
IX
predictors, an algorithmic approach may
prove useful in deciding among treatment
options. In essence, an algorithm is meant
to provide a simplified, stream-lined guide
to decision making when numerous input
considerations exist and often complicate
therapeutic considerations. A useful
algorithm should help discriminate
between choices on a high-level and
prioritize the relevance of various concerns
while also providing the necessary detail
for justifying every decision step. The
algorithm with this abstract attempts just
that, by providing a simple linear structure,
which has depth to support each step.1
Additionally, the algorithm is stratified
left–to-right and top-to-bottom to reflect
the clinical urgency of treatment.
Controversy:
Secondary aneurysms
after chronic type B
dissections should be
the first therapeutic
option – CON
aneurysm typically expands in the proximal
descending aortic part first and involves
the descending aorta in various degrees
of diameter increase. If the dissection
occurs in patients suffering from
connective tissue disease, the aneurysm
formation is usually more aggressive and
extensive.
removed. In the abdominal part of the
dissected aorta, the celiac axis and
superior mesenteric artery come of the
true lumen in the majority of cases. The
left renal most often originates from the
false lumen. Surgical repair requires careful
resection of the septum and
revascularization, reimplantation or
selective bypass grafting, depending on
the local morphology of the visceral and
renal arteries. In our experience, a post
dissection TAAA is operated according to
the same protocol as degenerative TAAA’s
and clinical outcome is comparable.
Michael J Jacobs, European Vascular
Center Aachen-Maastricht
Department of Surgery, PO Box 5800,
6202 AZ Maastricht, the Netherlands
Descending thoracic and thoraco
abdominal aortic aneurysms (TAAA) can
have different etiology and underlying
diseases. Post type B dissection
aneurysms differ significantly from
degenerative aneurysms. For example, in
the latter group, the majority of intercostal
and lumbar arteries are occluded whereas
in post dissection aneurysms these
segmental vessels are patent.
In general, post dissection aneurysms
develop in case of patent false lumen, The
New imaging
techniques for aortic
dissection: can we
identify high risk
patients ?
Rachel E. Clough
In the majority of cases, the proximal intima
tear is located at or just distal to the origin
of the left subclavian artery. Typically, the
false lumen bulges in the outer curve and
this is the location of the first aneurysm
formation. Obviously, if the aorta is already
dilated prior to the dissection, further
expansion is to be expected.
In open surgical repair of post dissection
TAAA, the proximal anastomosis has to
be performed in a (relatively) healthy and
non-dissected aortic segment. This
requires cross clamping proximal to the
left subclavian artery, in the majority of
cases between the left carotid and left
subclavian arteries. The rigid septum has
to be opened and removed in order to
allow a firm and secure anastomosis.
Following, the descending aorta is cross
clamped in sequential steps in order to
limit massive back bleeding from the patent
intercostal arteries and to reimplant
important segmental vessels. Also in this
phase, the longitudinal septum has to be
Type B aortic dissection has a wide range
of clinical manifestations, which are related
to the pattern and extent of the dissection
as well as branch vessel involvement.
Clinical decision making is complex and
is often based upon physician experience
and subjective clinical judgment. The longterm outcome of patients with initially
successful medical treatment is poor and
not well understood. The majority of late
deaths are caused by aortic-related
complications, including aneurysm
expansion and rupture. Early prophylactic
intervention might improve the overall
long-term outcome in patients who are
at increased risk for developing
97
Endovascular repair of post dissection
TAAA has been shown to be feasible (12). Major drawbacks, however, are
determined by
• proximal entry tear, requiring carotidsubclavian bypass or even more proximal
re-routing,
• rigid intimal septum, not allowing
adequate apposition of the endograft with
subsequent type 1a endoleak,
References
1. Dake MD, Thompson M, van Sambeek M,
Vermassen F, Morales JP; DEFINE
Investigators. DISSECT: a new mnemonicbased approach to the categorization of aortic
dissection. Eur J Vasc Endovasc Surg.
2013;46:175-190.
• inappropriate strategy in case of young
patients with connective tissue disease.
Based on these issues we would
recommend open repair for postdissection TAAA, especially in young
patients and patients with connective
tissue disease (3).
1. Endovascular management of chronic
post-dissection aneurysms.
Oikonomou K, Katsargyris A, Ritter W,
Spinelli D, Seto Y, Verhoeven EL.
Ann Cardiothorac Surg. 2014
May;3(3):307-13. doi: 10.3978/j.issn.2225319X.2014.04.02
2. Fenestrated and branched stent-grafts
to treat post-dissection chronic aortic
aneurysms after initial treatment in the
acute setting.
Verhoeven EL, Paraskevas KI, Oikonomou
K, Yazar O, Ritter W, Pfister K, Kasprzak
P.
J Endovasc Ther. 2012 Jun;19(3):343-9.
doi: 10.1583/12-3860R.1.
• high percentage of type 2 endoleaks
due to patent segmental vessels,
3. Open repair in chronic type B dissection
with connective tissue disorders.
• difficulty of perforating a rigid septum to
allow introduction of the main body stent
graft and side branches,
Jacobs MJ, Schurink GW.
• technical failure of cannulating the
visceral and renal arteries,
complications.
Aortic dilation and aneurysm formation
may be associated with abnormal aortic
wall biomechanics, blood flow patterns
and wall shear stress and assessment of
these parameters may be more important
than the morphological measurements
currently used. Functional imaging
methods such as magnetic resonance
(MR) are evolving and by combining
anatomical and functional information in
a single examination are able to provide
a more comprehensive evaluation of aortic
disease. MR imaging provides superior
soft tissue contrast with the ability to depict
and quantify functional parameters in
Ann Cardiothorac Surg. 2014
May;3(3):325-8. doi: 10.3978/j.issn.2225319X.2014.05.02. Review
three-dimensional high spatial resolution
images with no ionising radiation.
In this presentation MR imaging techniques
will be presented which are able to provide
structural, haemodynamic and
biomechanical information regarding the
aorta. This type of methodology will allow
us to refine our understanding this disease
and its unique variety of clinical
manifestations and anatomic expressions.
A patient-specific approach designed to
intervene only in patients that are at high
risk of developing complications should
improve the long-term outcome of these
patients.
volver al sumario
multiple challenges of this etiology. In this
regard, based on their performance in the
study of acute complicated Type B
dissection, both W.L. Gore and Medtronic
were awarded an FDA indication to treat
all Type B dissections with their devices.
When considering a complex variety of
relevant factors, such as the patient’s
condition and various physiological
11
IX
Santi Trimarchi
Thoracic Aortic Research Center,
Policlinico San Donato IRCCS, University
of Milan, Milan, Italy.
Influence of Clinical
Presentation on the Outcome
of Acute B Aortic Dissection
Acute type B aortic dissection (ABAD) is
a cardiovascular emergency in which
morbidity and mortality is often related to
the clinical conditions at presentation.
Patients with stable hemodynamic status
and absence of branch vessel involvement
and/or periaortic hematoma are classified
as uncomplicated and are treated
conservatively with strict blood pressure
regulation. In-hospital outcome of this
group is excellent with mortality as low as
1-3%.
Rupture or impending rupture, organ
malperfusion, expanding false lumen, and
refractory pain or hypertension, despite
adequate treatment categorize patients
as complicated ABAD and require
intervention. In this cohort, although
improved endovascular and surgical
techniques, the in-hospital mortality
remains high (Table 1). Although selection
bias may be possible, knowledge of
significant risk factors for mortality may
contribute to a better management and
a more defined risk-assessment in patients
affected by ABAD. (Ref 1)
The IRAD Classification System
for Characterizing Survival after
Aortic Dissection, Classification
of Aortic Dissection Based on
Time: the Hyperacute phase
Mortality in both acute Type A and Type
B aortic dissection is high, in particular in
those patients in which the clinical
conditions present catastrophic
complications. Typically, such patients are
diagnosed at earlier stage compared to
stable patients and, of consequence, show
a very strict interval time between onset
of symptoms and definitive therapy. Based
on these observation, IRAD proposes a
new temporal classification, in which aortic
dissection is stratified into 4 temporal
groups and by treatment type. This new
classification highlights the importance of
the initial 24 hours after the acute event,
as the interval time during which the natural
course of the acute dissection is
associated with the higher rate of mortality
(Figure 1). In addition, the new IRAD
classification provides also a more refined
assessment of survival as it evolves over
the first 60 days following symptom onset.
These data could help physicians in early
and late decisions making of patients
affected by acute aortic dissection. (Ref
2)
Importance of Aortic Diameter
in Type B Dissection
The vast majority of patients with ABAD
present with a descending aortic diameters
< 5.5 cm prior to dissection, and do not
fall within the guidelines for elective
descending thoracic aortic repair. Although
it is not indicated to operate patients at
lower threshold for preventing B dissection,
aortic diameter measurements do not
appear to be a useful parameter to prevent
aortic dissection, and other methods are
needed to identify patients at risk for
ABAD. (Ref 3)
About one fifth of patients with ABAD do
not present with any aortic dilatation.
These patients are more frequently females
and younger, when compared with
patients with aortic dilatation. Further
research is needed to investigate risk
factors for aortic dissection in the absence
of aortic enlargement. (Ref 4)
Aortic expansion after ABAD
White race and a small initial aortic
diameter were associated with increased
aortic expansion during follow-up, while
decreased aortic expansion was observed
among females, patients with intramural
hematoma (IMH), and those on calcium
channel blockers. These data raise the
possibility that the use of calcium channel
blockers following ABAD may reduce the
rate of aortic expansion, and therefore
further investigation is warranted. (Ref 5)
Table 1 In Hospital management and mortality of all type B patients. [adapted from Trimarchi et al. Ref 1]
overall incidence of IMH is 6.3%, more
often observed in the descending (58%)
rather than in the ascending aorta (42%).
Typically, IMH occurs in older patients
compared to classic dissection (68.7
versus 61.7 years), malperfusion and pulse
deficits are rare, and progression to frank
dissection occurs in 16% to 36% of
patients, including retrograde into
ascending. IRAD showed an association
between increasing hospital mortality and
the proximity of IMH to the aortic valve,
irrespective of medical or surgical
treatment. (Ref 6)
Type B aortic intramural hematoma (IMHB)
is characterized by a crescentic thickening
of the descending aorta in absence of an
intimal flap or entry tear, resulting from a
hemorrhage within the aortic wall. Initially,
it was believed that this condition was
relatively rare compared to classic ABAD,
although presenting with similar
symptoms, morbidity and mortality rates.
However, more recent studies suggest
that the incidence of IMHB is much higher,
and may account for > 20% of all ABAD
in some series. In IMHB, IRAD reports an
overall mortality rate of 6 %, 13 % after
surgery and 5 % after medical treatment.
The outcome is slightly favorable
compared with classic ABAD in the acute
setting (Table 2). IMHB shows a relative
unpredictable course, and in the absence
of suitable predictors for high-risk
IMH type B
IMH is an atypical form of aortic dissection,
with no dissection flap and with a medial
hematoma. IRAD data showed that the
98
Figure 1 Kaplan Meier Survival Curve for Acute Type B Aortic
Dissection. [Adapted from Booher et al. Ref 2]
volver al sumario
The natural history of
uncomplicated type b
dissection, pau and imh:
the irad knowledge
11
IX
should be reserved for complicated
patients. (Ref 7)
General consideration Aortic
Dissection (AD), Penetrating
Aortic Ulcer (PAU), Intramural
Hematoma (IMH)
References
1. Influence of clinical presentation on the outcome of
acute B aortic dissection: evidences from IRAD.
Trimarchi S, Tolenaar JL, Tsai TT, Froehlich J, Pegorer
M, Upchurch GR, Fattori R, Sundt TM 3rd, Isselbacher
EM, Nienaber CA, Rampoldi V, Eagle KA. J Cardiovasc
Surg (Torino). 2012 Apr;53(2):161-8
2. The IRAD Classification System for Characterizing
Survival after Aortic Dissection Classification of Aortic
Dissection Based on Time. Anna M. Booher MD, Eric
M. Isselbacher MD, Christoph A. Nienaber MD, FACC,
FESC, Santi Trimarchi MD, Arturo Evangelista MD,
FESC, Daniel G. Montgomery BS et al., Am J Med, in
press.
False lumen occlusion
techniques: are they
effective?
Tilo Kölbel
Chronic aortic dissection includes different
previous histories such as residual
dissection after surgical repair of a
DeBakey type I aortic dissection, dissection
after ascending aortic repair for other
pathologies, and chronic type B aortic
dissection. Despite the different
background, the risk for future
complications in chronic aortic dissection
is mainly related to false-lumen aneurysmal
dilatation and rupture. The aim of therapy
in chronic aortic dissection is to prevent
false lumen dilatation and aortic related
death. Endovascular stent-graft therapy
aims to reduce or abolish flow in the false
lumen.
Since the introduction of thoracic
endovascular aortic repair (TEVAR) for the
combined with close follow-up should be
administered in all patients and intervention
3. Descending aortic diameter of 5.5 cm or greater is
not an accurate predictor of acute type B aortic
dissection. Trimarchi S, Jonker FH, Hutchison S,
Isselbacher EM, Pape LA, Patel HJ, Froehlich JB, Muhs
BE, Rampoldi V, Grassi V, Evangelista A, Meinhardt G,
Beckman J, Myrmel T, Pyeritz RE, Hirsch AT, Sundt Iii
TM, Nienaber CA, Eagle KA. J Thorac Cardiovasc Surg.
2011 Sep;142(3):e101-7. Epub 2011 May 17.
4. Acute type B aortic dissection in the absence of
aortic dilatation. Trimarchi S, Jonker FH, Froehlich JB,
Upchurch GR, Moll FL, Muhs BE, Rampoldi V, Patel
HJ, Eagle KA; International Registry of Acute Aortic
Dissection (IRAD) investigators. J Vasc Surg. 2012 Apr
13.
treatment of aortic dissection type B in
1998, it has become the mainstay of
operative treatment for acute complicated
type B aortic dissection, offering a clear
benefit with lower mortality and morbidity
rates compared to open surgical repair.
TEVAR in aortic dissection is based on
the implantation of thoracic tubular stentgrafts to cover the proximal entry tear and
thereby redirect flow into the true lumen.
This strategy intends to depressurize and
thrombose the false lumen, and promote
aortic remodeling in a majority of patients
with acute aortic dissection. Response to
this treatment strategy is limited in patients
with chronic dissections with a reduced
capacity for aortic remodeling due to the
thickened and fibrotic degenerated intimal
flap. A significant proportion of patients
have persistent and significant false lumen
flow despite placement of a thoracic stentgraft even where long lengths of the
thoracic aorta are covered. Large re-entry
tears at the level of the visceral aorta or
further distally are particularly responsible
for persistent false lumen flow.
This limited response to endovascular
treatment in chronic aortic dissection is
99
5. Aortic Expansion After Acute Type B Aortic Dissection.
Jonker FH, Trimarchi S, Rampoldi V, Patel HJ, O'Gara
P, Peterson MD, Fattori R, Moll FL, Voehringer M,
Pyeritz RE, Hutchison S, Montgomery D, Isselbacher
EM, Nienaber CA, Eagle KA; International Registry of
Acute Aortic Dissection (IRAD) Investigators. Ann Thorac
Surg. 2012 Jul 7.
7. Intramural Hematoma of the Descending Aorta:
differences and similarities with acute B dissection. Jip
L. Tolenaar, Kevin M. Harris, Gilbert R. Upchurch, Jr.,
Vincenzo Rampoldi, Arturo Evangelista, Frans L. Moll,
James B. Froehlich, Marco di Eusanio, Kim Eagle, Santi
Trimarchi. Presented at SCVS March 2013, to be
published.
6. Acute aortic intramural hematoma: an analysis from
the international registry of acute aortic dissection.
Harris KM, Braverman AC, Eagle KA, Woznicki EM,
Pyeritz RE, Myrmel T, Peterson MD, Voehringer M,
Fattori R, Januzzi JL, Gilon D, Montgomery DG, Nienaber
CA, Trimarchi S, Isselbacher EM, Evangelista A.
Circulation. 2012 Sep 11;126(11 Suppl 1):S91-6.
caused by the continued pressurization
from persistent retrograde false-lumen
flow to intercostal and bronchial arteries
from downstream entry-tears. Retrograde
filling and pressurization leads to late aortic
expansion in 35% of patients treated by
TEVAR for chronic type B aortic dissection.
The lack of aortic remodeling and false
lumen aneurysmal dilatation caused by
continued perfusion of the false lumen
causes late aortic death as has been
recently shown by Mani et al. in 2013. In
patients with ruptured chronic false lumen
aneurysm after type A and B aortic
dissection the persisting retrograde filling
may lead to continued bleeding despite
TEVAR down to the celiac artery to cover
the descending aortic entry-tears.
Novel techniques have been introduced
recently to prevent retrograde flow into
the thoracic false lumen. Fenestrated stentgrafts allow longer segment coverage and
thereby to abolish further distal entry tears.
Other techniques to exclude the thoracic
false lumen from aneurysmal dilatation are
the “candy-plug technique” and the
“knickerbocker technique”, which both
aim at false-lumen occlusion at the distal
descending thoracic aorta.
Residual dissection after previous
ascending aortic repair is a specifically
challenging condition as treatment usually
involves the supra-aortic branches, which
might be dissected. Open treatment
strategies are often limited due to
comorbidities, the previous surgery and
the complex anatomy requiring seal of
true and false lumen. Hybrid techniques
have been introduced using debranching
techniques or frozen-elephant trunk repair
and early results of these techniques are
promising for aortic arch repair, but there
is no published data for residual
dissections as a subgroup. The
introduction of new fenestrated and
branched aortic arch endografts have
shown promising results in single centers
and allow to treat these difficult pathologies
without the use for cardiopulmonary
bypass. This presentation will focus on
newer endovascular strategies for false
lumen exclusion and endovascular arch
repair for residual dissection.
volver al sumario
patients, a complication-specific approach
should be adopted. Medical treatment
AD, PAU and IMH present differences:
• PAU is more common in older patients,
associated with atherosclerosis (aorta,
coronaries), while aortic dissection and
IMH have very limited systemic
atherosclerosis.
• In patients with PAU, the intima is
thickened with cratered, while in patients
with AD and IMH, the intima is generally
smooth.
ABAD, PAU and IMH present similarities:
• These entities present an overlap in
intimal and medial changes.
• Both likely share common mechanisms
with inflammation and expression of
metalloproteinase’s (MMPs).
• Medial degeneration with apoptosis is
common.
AD, PAU and IMH Treatment
• The treatment for AD and IMH is the
same, both for type A & B.
• The treatment for PAU is still not totally
defined, although the distinction between
those involving ascending and descending
seems appropriate as well.
11
IX
Sesión 24
Uncommon accesses
for ascending and arch
endografting
Tilo Kölbel
Biomechanics
implications for
ascending endografting
Rachel E. Clough
Sábado, 27 Junio
Saturdy, June 27th
Sesión 25
For elective treatment
of taaa my first choice
is : branched
endografts.
Eric LG Verhoeven, MD, PhD.
Endovascular Surgery, Paracelsus
¿QUE HAY DE NUEVO PARA LA AORTA ASCENDENTE Y EL ARCO?
WHAT’S NEW FOR ASCENDING & ARCH?
Moderador / Moderator A. Azizzadeh
Panelistas / Panellists B. Zipfel, C.Timarán
Stenotic, elongated, kinked and
aneurysmatic aortoiliac vessels can
complicate endovascular access for
introduction and deployment of aortic
stent-grafts. In these cases, the common
femoral artery cannot be used as an
access-vessel without further medical
measures. Despite all technical
improvements, access complications in
women remain especially common due
to the smaller vessel diameter of the iliac
vessels. This must be taken into account
during the planning stage of the
operation. Due to the vessel diameter of
the chosen access vessels, thoracic stent
graft systems often require insertion
systems with larger diameters than those
used for the infrarenal aorta.
Endovascular techniques can be used
to achieve a sufficient diameter of the
pelvic arteries. Furthermore, open
retroperitoneal access to the aortoiliac
arteries with or without the use of graftconduits may facilitate safe and
successful delivery of an aortic endograft.
In rare cases, supraaortic vessels can
be used as an access vessel for
endograft delivery. Transapical and
transseptal approaches for accessing
the ascending aorta and the aortic arch
are other potential routes for reaching
the thoracic aorta if the transfemoral
route is compromised.
Endovascular solutions are now
preferable to open surgery in the
management of many vascular
pathologies. Dissection of the ascending
aorta has historically been treated with
open surgical repair. Endovascular repair,
despite its unique difficulties, has
emerged as a potential alternative with
successful isolated reports describing
the use of devices originally designed
for the descending aorta. Although initially
successful the durability of these
procedures remains to be seen. The
proximity of the thoracic aorta to the
heart and lungs results in a hostile
environment with repetitive
biomechanical forces and the intrathoracic aorta is subject to physiological
forces secondary to both cardiac and
respiratory motion. Quantification of
three-dimensional (3D) aortic positional
changes secondary to cardiac and
respiratory motion is challenging due not
only the high requirements of the image
acquisition schemes but also due to
difficulties quantifying the non-uniform
movement of the aorta. In this
presentation new magnetic resonance
(MR) imaging methodology will be
described which can quantify
deformation of the aorta in 3D over time
using four-dimensional (4D) MR imaging
techniques. The displacement of the
aorta will be quantified separately for
displacement due to cardiac and
respiratory motion. It will be shown that
the displacements are complex and time
varying, and greatest in the ascending
aorta, where they were accompanied by
a large rotational component. It will be
explained how advances in imaging
technology and the development of
dedicated software are mandatory to
provide a better understanding of
complex aortic biomechanics and to
guide the design of a new generation of
endografts for the ascending aorta.
AORTA DESCENDENTE Y TÓRACO-ABDOMINAL
DESCENDING AND THORACO-ABDOMINAL AORTA
Moderador / Moderator G. Oderich
Panelistas / Panellists R. Clough, S. Trimarchi
Background
Operative treatment of thoracoabdominal
aortic aneurysms (TAAA) represents a
continuing challenge for vascular
surgeons. Open surgical repair is still
associated with remarkable perioperative
mortality and complications, despite
improvements in the surgical technique
and perioperative care.1 A nationwide
study in the US reported in-hospital
postoperative mortality of 22.3%
following elective TAAA open repair, with
even higher rates for low-volume
surgeons and hospitals2. Postoperative
morbidity is also significant, including
100
cardiopulmonary complications, acute
renal failure, and spinal cord ischemia
with paraparesis or paraplegia.2 Although
lately, some reference centers report
operative mortality rates < 10% with
open repair3, 4, the composite adverse
outcome, including operative death, renal
failure, stroke, or spinal cord ischemia
(SCI), remains high (up to 16%). 3, 4
Endovascular techniques starting from
infrarenal abdominal aortic aneurysms
gradually evolved to address more
complex pararenal and suprarenal
aneurysms, and finally also TAAA.
Endovascular treatment of TAAA with
the use of fenestrated and branched
stent-grafts is gaining increasing interest
among selected centers.5-7 The
technique initially was used as a last
option for ‘poor’ surgical candidates.
Accumulating experience and improving
outcomes led gradually to a broader
indication including also low(er) risk
patients.
Experience
During the period January 2004 - March
2015 a total of 225 patients (173 male,
52 female, mean age 68.7 ± 7.6 years)
with TAAA have been treated with
volver al sumario
Sábado, 27 Junio
Saturdy, June 27th
11
IX
References:
1.Safi HJ, Miller CC, 3rd, Huynh TT, Estrera AL, Porat
EE, Winnerkvist AN, et al. Distal aortic perfusion and
cerebrospinal fluid drainage for thoracoabdominal and
descending thoracic aortic repair: ten years of organ
protection. Ann Surg 2003;238:372-80.
open/endovascular aortic procedures.
Technical success was 95.1% (214/225).
Thirty-day operative mortality was 7.6%
(17/225), with an in-hospital mortality of
8.9% (20/225). Perioperative SCI was
observed in 21(9.3%) patients, including
permanent paraplegia in three (1.3%)
patients. Estimated survival at 1, 2, and
5 years was 83.2% ± 3.1%, 77.8% ±
2.Cowan JA, Jr., Dimick JB, Henke PK, Huber TS,
Stanley JC, Upchurch GR, Jr. Surgical treatment of
intact thoracoabdominal aortic aneurysms in the United
States: hospital and surgeon volume-related outcomes.
J Vasc Surg 2003;37:1169-74.
3.Schepens MA, Heijmen RH, Ranschaert W, Sonker
U, Morshuis WJ. Thoracoabdominal aortic aneurysm
repair: results of conventional open surgery. Eur J
Vasc Endovasc Surg 2009;37:640-5.
Intentional temporary
sac perfusion prevents
paraplegia after
endovascular repair of
thoracoabdominal
aortic aneurysms
Introduction:
Kasprzak PM, Cucuruz B, Gallis K,
Janotta M, Wagenschwanz
M, Kopp R
Methods:
Vascular and Endovascular Surgery,
University Hospital Regensburg,
Regensburg, Germany
Systematic review and
meta-analysis of
multilayer flow
modulator in the
management of
complex
thoracoabdominal
aortic pathologY
Sherif Sultan
We report our experience with the
concept of temporary aneurysm sac
perfusion (TASP) and secondary staged
side branch completion to prevent severe
spinal cord ischemia after branched
endovascular aortic repair (bEVAR) for
thoracoabdominal aortic aneurysm
(TAAA).
Patients were treated for TAAA with
bEVAR between 07/2007 and 02/2014.
Temporary aneurysm sac perfusion was
performed by non-completion of side
branches to one of the renovisceral
arteries, distal aortic or iliac extensions
with secondary side branch completion.
Primary endpoints of the study were
overall technical success, side branch
Western Vascular Institute, Department
of Vascular and Endovascular Surgery,
University Hospital Galway, National
University of Ireland, Galway, Ireland,
Galway Clinic, Royal College of Surgeons
of Ireland affiliated hospital, Doughiska,
Galway, Ireland
3.6%, and 66.9% ± 6.4%, respectively.
Estimated target vessel stent patency at
1, 2, and 5 years was 98% ± 0.6%, 97%
± 0.8%, and 94.2% ± 1.5%, respectively.
Estimated freedom from reintervention
at 1 and 3 years was 89.1% ± 2.5%,
and 79.2% ± 4.6%, respectively.
4.Lemaire SA, Price MD, Green SY, Zarda S, Coselli
JS. Results of open thoracoabdominal aortic aneurysm
repair. Ann Cardiothorac Surg 2012;1:286-92.
5.Chuter TA, Gordon RL, Reilly LM, Goodman JD,
Messina LM. An endovascular system for
thoracoabdominal aortic aneurysm repair. J Endovasc
Ther 2001;8:25-33.
101
In our experience, endovascular repair
of TAAA with fenestrated and branched
stent-grafts appears safe and effective
in the mid-term. In our center
endovascular repair of TAAA represents
now the first line treament option for
patients with suitable anatomy.
7. Verhoeven EL, Katsargyris A, Bekkema F,
Oikonomou K, Zeebregts CJ, Ritter W, Tielliu IF. Tenyear Experience with Endovascular Repair of
Thoracoabdominal Aortic Aneurysms: Results from
166 Consecutive Patients. Eur J Vasc Endovasc Surg.
2015 Jan 17doi: 10.1016/j.ejvs.2014.11.018 [Epub
ahead of print]
6.Greenberg RK, Haulon S, Lyden SP, Srivastava SD,
Turc A, Eagleton MJ, et al. Endovascular management
of juxtarenal aneurysms with fenestrated endovascular
grafting. J Vasc Surg 2004;39:279-87.
patency, perioperative mortality and the
rate of severe spinal cord ischemia.
Results:
Ninety-eight patients were treated for
TAAA (mean diameter 6.6 + 1.6 cm) with
branched aortic stent grafts with (n=46)
or without (n=52) TASP. Overall technical
success including aneurysm exclusion,
absence of persistent type I or III
endoleak, TASP side branch patency
and secondary side branch completion
was 35/40 (87.5 %). Secondary TASP
side branch completion was performed
after median 26 days (range: 1-370 days).
The rate of early reinterventions for
renovisceral side branch complications
was 15/380 (3.9 %) and perioperative
mortality 7/98 (7.1 %; 4 non-TASP, 3
TASP). Clinical evidence of severe spinal
January 2008 to 2015 for health related
and biomedical science literature,
pertaining to the MFM. Primary outcome
was aneurysm-related survival.
Secondary outcomes were all-cause
survival, stroke, spinal cord ischemia,
renal impairment and branch vessel
patency
Background:
The aim of this review is to consider
evidence for the Multilayer Flow
Modulator (MFM) device in management
patients with complex thoracoabdominal
aortic aneurysm (TAAA) or dissection.
Methods: A methodical search of all
health databases was conducted from
Conclusions
Results:
A total of 15 studies (3 prospective
studies, 3 observational reviews and 9
case reports) were included. The mean
age of patients was 68.85years (+/-12.34
years), mean aneurysm diameter was
6.67cm (±1.57cm). Technical success
cord ischemia or paraplegia was reduced
in the TASP group as compared to the
non-TASP group (3/46 vs 12/52,
p=0.023). One TASP patient died 4
months after bEVAR during the TASP
interval from suspected aortobronchial
fistula.
Conclusions:
The concept of temporary aneurysm sac
perfusion (TASP) after bEVAR for TAAA
is feasible and seems to reduce the risk
of severe spinal cord ischemia. Early side
TASP branch completion within 4 weeks
is recommended to reduce the risk of
rupture. In selected patients, a longer
TASP interval might improve neurological
rehabilitation from spinal cord ischemia.
reported in 15 studies was 77.2 %.
Aneurysm related survival at one year
was 78.7% (±3.92%). One year all-cause
survival was 53.7 % (±3.94%). There
were no reported cases of spinal cord
ischemia or renal insult.
Conclusion:
The MFM appears safe in management
of TAAA, once operators abide to its
Indications for Use. Since the MFM is a
new technology, there is paucity of longterm follow-up data, a lack of
comparative studies and a requirement
for randomized clinical trials and
continued assessment.
volver al sumario
fenestrated and branched stent-grafts
under the supervision of the senior
author. Mean TAAA diameter was 70 ±
9.4mm. Types of TAAA were: type I,
n=20 (8.9%), type II, n=62 (27.6%), type
III, n=67 (29.8%), type IV, n=58 (25.8%),
and type V, n=18 (8%). One hundred
and two (45.3%) patients had previously
undergone one or more
11
IX
Poster SITE
Brillas i Bastida, Albert; Roset
Balada, Óscar; Rodríguez
Cabeza, Patricia; Presas
Porcell, Anna; Andrés Navarro,
Omar Aitor
Hospital Dr Trueta, Girona (Spain)
Introducción:
Las complicaciones en
endarterectomías carotídeas son
muy poco frecuentes pero de mal
pronóstico en muchas ocasiones.
En este caso nos centramos en
una complicación muy rara de
dicha cirugía y su resolución.
Objetivos:
Exponer la resolución
endovascular de un
pseudoaneurisma de carótida
interna extracraneal
diagnosticado tras 30 días de ser
intervenido de endarterectomía
carotídea con cierre mediante
parche sintético y uso de shunt.
Material:
Introductor 5 Fr Avanti (Cordis®),
Catéter Vertebral 5 Fr (Terumo
®), Introductor Destination
(Terumo®) 6 Fr 90 cm
Multipurpose, Guía Standard (
Terumo®) 150 cm punta
angulada, Guía Sti? (Terumo®)
260 cm, Viabahn 7*50 ( Gore®).
Metodología:
Varón de 75 años que, al mes de
ser intervenido de estenosis
carotídea preoclusiva sintomática,
presenta clínica de afasia y
hemiparesia derecha. Se realiza
TAC objetivándose ausencia de
infarto cerebral y presencia de
pseudoaneurisma de
2.1x1.4x1.2cm en carótida
interna a 35mm de su inicio, lesión
causada, por la localización, por
el balón distal del shunt. Se
plantea intervención urgente y,
dada la localización casi
intracraneal, se decide
tratamiento endovascular.
Mediante punción femoral se
procede a colocación de Viabahn
de 7*50mm desde extremo distal
del parche hasta carótida
intracraneal.
Resultados:
Se consiguió una correcta
exclusión del aneurisma con
excelente resultado angiográfico
y fue dado de alta sin incidencias.
Conclusiones:
El pseudoaneurisma de carótida
interna tras cirugía carotídea es
una entidad poco frecuente
asociado al uso de parche y de
aparición tardía; o menos
frecuente aún, de aparición
temprana relacionado con fallo
de técnica quirúrgica o infección.
El tratamiento, según las series,
puede ser conservador o
quirúrgico; clásicamente mediante
cirugía abierta o más actualmente
endovascular. La reparación
endovascular con stent cubierto
es una opción eficaz para el
tratamiento de lesiones en
carótida interna distal, de difícil
acceso con cirugia abierta.
Endovascular
revascularization of
iliac arteries in
patients with
critical limb
ischemia due to
multilevel occlusive
disease
Sultanyan T.L., Avetisyan A.A.,
Kamalyan T.L., Manukyan L.R.
Medical Center after Vladimir
Avagyan, department of vascular
surgery, Yerevan (Armenia)
Critical limb ischemia frequently
occurs on a background of
significant comorbidities and
associated with poor prognosis,
wich requires urgent
management. Disease severity
and patient comorbidities
influence the choice of
management, wich on the one
hand must be preferably minimally
invasive and lest time-consuming
and, on the other hand efficient
enough for limb salvage.
The study was a retrospective
single-center study that included
18 male patients with critical limb
ischemia and multilevel
atherosclerotic disease involving
suprainguinal and infrainguinal
arteries , treated from January
2012 to july 2014 (median followup of 8 months).
Stents for revascularization of iliac
arteries were used in 17 patients.
In 1 case PTA of external iliac
artery was performed without
stenting. In 8 cases endovascular
iliac repair was combined with a
surgical common femoral
endarterectomy.
Technical success was obtained
in 100% of cases. Hemodynamic
and clinical
success/improvement was
achieved in 15 of 17 limbs.
During the follow-up period one
patient died from myocardial
infarction. One diabetic patient
needed bellow-knee amputation
despite a patent common iliac
artery stent. Another major
amputation was performed due
to acute thrombosis of stented
segment. Only one patient
required second revascularization
procedure - femoropopliteal
bypass.
In conclusion, revascularization
of an inflow (iliac arteries)
obstruction by means of
endovascular techniques with
or without common femoral artery
endarterectomy can be sufficient
for limb salvage in most patients
with multilevel atherosclerotic
disease of lower extremities
suffering from critical limb
ischemia.
Our experience in
the treatment of
visceral artery
aneurysm during
the last 12 years.
Introduction of
endovasculars
TECHNIQUES.
102
Pantoja Peralta, Cristina; Arefai,
Bahaa; Sepúlveda Grisales,
Julio; Gómez Moya, Benet;
Martin Paredero; Vicente
Introduction and
objective:
The aim of our study is to analyze
our experience in the
management of visceral artery
aneurysm (VAAs) and review our
protocols and techniques
regarding the endovascular
procedures.
Material and Methods:
Between 2001 and 2013, 32
patients (17 males; mean age:
62.4 [range: 38-77] years) with
visceral artery aneurysms (VAAs)
were admitted into our center.
The site of aneurysmal disease
was: splenic artery (13), hepatic
artery (4), superior mesenteric
artery (3), pancreaticoduodenal
artery (1), gastroduodenal artery
(2), celiac axis (2), gastric artery
(1), and renal artery (13). Two
patients (6.25%) presented with
an aneurysm rupture. We analyze
these patients to assess the type
of procedure and its success.
The follow-up period ranged
between 12 and 60 months.
Results:
Sixteen cases received an
endovascular treatment. Primary
technical success was achieved
in fourteen patients. Endovascular
failures included one case of
endoleak after stenting, one
incomplete embolization. In 7
cases, the surgical treatment was
performed successfully. The total
survival rate was 96.8%.
Conclusion:
The potential risk of rupture is the
principle reason for the treatment
of VAAs. In most cases, an
endovascular approach permits
in most cases a less aggressive
treatment and a shorter hospital
admission. Although not all VAAs
are tributary of endovascular
treatment, we consider that a
trained endovascular surgeon
could solve most of the cases.
Benefits are the conservation of
organ perfusion, fewer
complications and next day
hospital discharge. An economic
study is still needed to verify the
efficiency of these procedures.
Tratamiento
endovascular del
aneurisma popliteo
Introducción:
Los Aneurismas de la arteria
poplítea tradicionalmente han sido
reparados mediante un
procedimiento quirúrgico abierto.
Sin embargo, asociado a un
desarrollo tecnológico incesante,
la reparación endovascular del
aneurisma de arteria poplítea
(REVAP) se ha impuesto en
pacientes anatómicamente
seleccionados, debido a su
naturaleza menos invasiva.
Objetivo:
Presentamos nuestros resultados
a largo plazo para REVAP.
Método: Se trata de una revisión
retrospectiva de todos los
pacientes que se sometieron a
tratamiento en una sola institución
académica entre Enero de 2010
a Enero de 2015. Estos pacientes
fueron evaluados para determinar
la permeabilidad de la
endoprótesis, la presencia de
endoleak, la necesidad de una
intervención secundaria y la
sobrevida global y libre de
amputación.
Un total de 23 miembros en 21
pacientes fueron tratados
mediante REVAP durante el
período de estudio. Todos los
procedimiento se realizaron
mediante la colocación de una
endoprótesis Viabahn® (Gore,
Flagstaff, AR, USA) con un
volver al sumario
Reparacion
endovascular de un
pseudoaneurisma
de carótida interna
tras tea por el uso
de shunt
11
IX
Poster SITE
Conclusiones del
estudio:
Con adecuados resultados en el
seguimiento a largo plazo el
REVAP parece ser una alternativa
adecuada en pacientes
seleccionados, acompañada de
excelentes tasas de
permeabilidad y preservación de
la extremidad. Una correcta
preselección anatómica nos
permitió obtener buenos
resultados.
Protocolo para el
uso de celulas
pluripotenciales en
el tratamiento de
pacientes con
isquemia
critica.Estudio
experimental con
seguimiento a 6
meses. Proceltric
Jiménez, César;
Pacheco, Claudia
asintomáticos hasta la isquemia
critica representada por dolor en
reposo y perdida tisular, los cuales
en algunos casos no tienen más
opción que la amputación; el uso
de células madre ha demostrado
estimular la arteriogenésis
Objetivo:
Realizar un protocolo de
aplicación de células madre para
el tratamiento de pacientes con
isquemia crítica de los miembros
inferiores
Se realizó un estudio experimental
prospectivo no aleatorizado a 6
meses con 8 pacientes, con
isquemia crítica de los miembros
inferiores, sin opciones de
revascularización quirúrgica o
endovascular. Al grupo de
pacientes les administró un
concentrado de células madre
mononucleares hematopoyéticas
derivadas de la medula ósea y
procesadas por la tecnología
SmartPrep de TERUMO Y se
inyectaron en la extremidad
isquémica. Se evaluó la
sintomatología clínica, la distancia
de claudicación y los índices de
presiones en el período pre
implante y durante un periodo de
6 meses luego del procedimiento
Resultados:
No se observaron efectos
adversos secundarios al
tratamiento. Se observó una
mejoría en el primer mes,
situación que se mantuvo a los
tres y a los seis meses de
implantados, representado en
aumento de la distancia de
marcha, mejoría del dolor y cierre
de heridas isquémicas;
igualmente se observó mejoría
en los valores del índice tobillo
brazo. No se presentaron
complicaciones ni mortalidad
asociada al procedimiento.
Clínica del Occidente, Bogotá
(Colombia)
Conclusión:
Introduccion:
El uso de células madre
derivadas de la medula ósea e
inyectadas en la extremidad
isquémica, por vía intramuscular
La enfermedad arterial periférica
abarca desde pacientes
resulta eficaz, al lograrse
incrementar la distancia de
claudicación, mejorar el dolor en
reposo y cierre de heridas
isquémicas; además se demostró
ser un procedimiento seguro y
sin complicaciones o mortalidad
asociada.
Estrategias
endovasculares
para la resolucion
de un caso
complejo con
enfermedad
oclusiva venosa
Rubio, Vanessa;
Rubio, Gustavo
CETEN Guadalajara, Guadalajara
(Mexico)
Problema
Se presenta el caso de un varón
de 53 años con historia de
Trombosis venosa profunda
iliofemoral izquierda en 2010,
después de someterse a la cirugía
de columna. Presentó
claudicación venosa severa, dolor
crónico y el edema de la pierna
izquierda. La flebografía inicial
mostró obstrucción completa de
su segmento iliofemoral izquierda
con abundantes colaterales.
de la enfermedad venosa
obstructiva severa, con buenos
resultados angiográficos y
clínicos.
Como Evitar
Con un tratamiento resolutivo en
forma inicial inmediata después
de la trombosis se evitará la
constitución de un síndrome
postrombótico , donde la secuela
venosa con fibrosis caprichosas
complican muchas veces los
intentos de recanalización con
técnicas endovasculares.
Como Solucionarlo
Decidimos usar un lazo a través
del acceso yugular derecho para
capturar la guía distal,
manteniendo la tensión y hasta
entonces, con un apoyo
adecuado, hemos sido capaces
de atravesar la oclusión con el
catéter hidrofílico 4 Fr; que
progresivamente cambiado por
balones de angioplastia 4 mm, 5
mm, 7 mm y 8 mm. Colocamos
dos stents autoexpandibles
14mm desde encima de la unión
iliocava a la dilatación de la vena
femoral proximal con balones de
angioplastia de 9 mm, 10 mm y
12 mm intra stent después de la
colocación del stent. El resultado
angiográfico fue excelente, así
como la mejoría clínica del
paciente.
Introduccion:
La hemostasia luego delos
procedimientos endovascualres
por via femoral se puede hacer
con compresión o con el uso de
dispositivos de cierre percutáneo
(DCP); hacia 1990 estos
dispositivos surgieron como una
opción al uso de la compresión
manual dadas sus ventajas.
Los DCP deben ser de fácil
aplicación, permitir una
hemostasia efectiva y rápida,
cómodos para el paciente,
permitir una nueva punción
femoral y baja incidencia de
complicaciones los
procedimientos Endovasculares
cada día son más comunes para
el manejo de la enfermedad
arterial, el acceso anterógrado
se utiliza para pacientes con
dificultad en el paso contralateral
sobre la iliaca ( crosss over) y
especialmente en los casos de
enfermedad arterial infra poplítea
donde se tiene más capacidad
de empuje y maniobralidad de
los dispositivos Endovasculares
; la punción anterógrada es más
compleja de hacer con reparos
anatómicos diferentes y mayor
incidencia de complicaciones
dada la dificultad para la presión
manual, es por esto que en este
estudio se utilizó el sistema de
cierre percutáneo Angioseal para
control vascular
Objetivo:
Dificultad
Síndrome postrombótico grave
puede conducir a la claudicación
venosa y la discapacidad. Las
técnicas endovasculares han
evolucionado para ofrecer un
tratamiento con alta tasa de éxito
y menor morbilidad.
Después de varios intentos de
cruzar ipsilateralmente utilizando
guias hidrófilicas 0,035 y 0,014
guías, logramos cruzar con el
0,035 guía hidrófilica justo por
encima de la bifurcación ilíaca.
Estábamos en la parte distal de
la vena cava, pero que no podía
soportar seguir adelante con un
catéter 4 fr. El tratamiento
endovascular ofrece un conjunto
de herramientas para la mejora
103
Efectividad y
seguridad del
sistema de cierre
percutaneo
angioseal para
punciones
femorales
anterogradas
Estudio
prospectivo a 3
meses en 35
pacientes
Jiménez, César
Realizar un protocolo de
implantación del dispositivo de
cierre percutáneo Angioseal y
demostrar su efectividad y
seguridad
Se realizó un estudio prospectivo
no aleatorizado a 3 meses, donde
se implantaron 35 Angioseal para
el cierre percutáneo de punciones
anterógradas. Se evaluaron las
variables demográficas, la
incidencia de complicaciones,
tipo de procedimiento y
seguimiento a 3 meses.
Resultados:
Clínica del Occidente, Bogotá
(Colombia)
No se observaron efectos
adversos o complicaciones a la
implantación del Angioseal por
volver al sumario
promedio de 1.2 stents por
extremidad. La edad media de
los pacientes fue de 72 años
(rango, 66-84). El éxito técnico
se consiguió en el 100%. Las dos
criterios de selección fueron al
menos dos vasos de salida, y una
diferencia del diámetro arterial de
los sitios de anclaje proximal a
distal no mayor del 30%. El
tiempo medio de seguimiento fue
de 32 meses. Dos pacientes
fallecieron por causas no
relacionadas a las 9 y 32 meses.
Se detectaron dos pacientes con
endoleaks durante el seguimiento
sin repercusión clínica. La tasa
de permeabilidad primaria es del
100%. No hubo casos de pérdida
de miembro durante el período
de seguimiento, siendo las tasas
de sobrevida general de 91.3%.
11
IX
Poster SITE
Conclusión:
El uso del sistema de cierre
percutáneo Angioseal, para el
cierre de punciones anterógradas
para procedimientos
Endovasculares es seguro y
confiable.
Design, validation
and implementation
of a proficiencybased stepwise
endovascular
curricular training
(prospect) program
Maertens, Heidi (1); Van
Herzeele, Isabelle (1); Aggarwal,
Rajesh (2); Desender, Liesbeth
(1); Vermassen, Frank (1)
Department of Thoracic and
Vascular Surgery, Ghent
University Hospital, Ghent
(Belgium) (1); Arnold & Blema
Steinberg Medical Simulation
Centre, McGill University,
Montreal (Canada) (2)
Introduction
Increase in minimally invasive
techniques, implementation of
residents’ working hour
restrictions and increased focus
on patient safety pose challenges
to surgical education. Simulationbased training has been
introduced to allow structured
skills acquisition in a safe
environment. Furthermore,
training in a proficiency-based
manner, focusing on training to
expert-derived performance
criteria, allows maximal skill
acquisition and skill transfer to
the operating room.
Objectives
This study aimed to design,
validate and demonstrate the
feasibility of a PROficiency-based
StePwise Endovascular Curricular
Training (PROSPECT) addressing
the three core components of
knowledge, technical skills and
human factor skills in a modular
approach. Each module consists
of web-based learning as well as
hands-on simulation training.
Material used
Technical endovascular skills
training and assessment was
carried out on the ANGIO
MentorTM Express System
(Simbionix USA Corp., Cleveland,
Ohio, USA).
Methodology used
A comprehensive structured
curriculum for endovascular
management of symptomatic
vascular disease in the lower limbs
(Rutherford classification 2-5;
stenosis of iliac/superficial femoral
artery disease) was developed.
Construct validity was
investigated. Performances were
assessed using multiple-choice
questionnaires (MCQ), valid
simulation metrics, Global Rating
Scorings (GRS) and Examiner
Checklists. Senior-year medical
students were recruited at Ghent
University Hospital. Vascular
surgeons, who had performed
over 100 endovascular
procedures as primary operator
during the last 2 years, were
invited to participate during
conferences. Feasibility was
assessed by two final-year
medical students who were
trained according to this new
endovascular curriculum.
Twenty-nine medical students
and 20 vascular surgeons
participated. Vascular surgeons
obtained higher MCQ scores
(median 24.5-22.0 vs. 15.0-12.0;
P<0.001). Students took
significantly longer to treat any
iliac or femoral artery stenosis
(3.3-14.8 vs. 5.8-30.1 min.;
P=0.001-0.04) while in more
complex cases, fluoroscopy time
was significantly higher in students
(8.3 vs. 21.3 min.; P=0.002; 7.3
vs. 13.1 min.; P=0.03). In all cases
vascular surgeons scored higher
on GRS (51.0-42.0 vs. 29.5-18.0;
P<0.001) and Examiner
Checklists (81.5-75.0 vs. 54.543.0; P<0.001). Based upon
median expert scores,
proficiency-levels were
determined. Two students
completed the entire training
program and reached proficiency
for each step within a 3-month
period during their internships.
A feasible and validated
endovascular curriculum to train
cognitive, technical and nontechnical endovascular skills has
been developed. A randomisedcontrolled trial has been initiated
to investigate its effect on
performances in real-life, patient
outcomes and cost-effectiveness
Treatment of focal
aortic disease by
thoracic
endovascular aortic
repair is associated
with high success
and low morbidity
and mortality
Crawford, Angela; Hayon,
Solomon; Huffner, Michael;
Harris, Donald; Sarkar,
Rajabrata; Crawford, Robert
University of Maryland,
Department of Surgery, Division
of Vascular Surgery, Baltimore
(USA)
Introduction.
Thoracic endovascular aortic
repair (TEVAR) is an established
treatment for patients with
thoracic aortic dissection,
aneurysm, or trauma, and is the
treatment of choice if anatomy is
104
favorable. However, it is poorly
studied for less common aortic
pathologies, such as penetrating
aortic ulcer (PAU), intramural
hematoma (IMH), and
pseudoaneurysms (PSA).
Together, these may be
considered as focal aortic lesions,
and often present as acute aortic
syndrome with clinically apparent
critical aortic disease.
Objective.
To review the use of TEVAR in
the treatment of patients with
focal aortic lesions.
Materials and
Methodology.
This was a retrospective analysis
of a 10-year TEVAR series at a
aortic referral center; patients with
aortic injury were excluded.
TEVAR was performed using
standard technique. The study
group was patients undergoing
repair of focal aortic disease (PAU,
IMH, or PSA), while patients with
non-focal disease (dissection or
non-traumatic aneurysm) served
as controls for comparison. The
primary outcome was inpatient
mortality, and secondary
outcomes were neurologic
complications, duration of
mechanical ventilation, and
hospital length of stay. Groups
were compared by chi-square or
Student’s t tests as appropriate,
with a P < 0.05 accepted as
significant.
Results.
TEVAR was performed in 135
patients with 100% technical
success. 50 had focal aortic
disease, including 16 PAU, 11
PSA, and 5 IMH; 18 patients had
multiple lesions, primarily PAU
with IMH. Patients in the control
group included 48 patients with
dissection and 37 with aneurysm.
Comorbidities were similar
between groups. Patients with
focal aortic disease were more
likely to be symptomatic (82% vs
63%, P=0.03) or have acute aortic
syndrome (94% vs 65%,
P=0.0001), and had a lower
incidence of chronic renal failure
(6% vs 35%, P=0.0001). Patients
with focal disease had similar
rates of postoperative neurologic
deficits as the control group (4%
vs. 13%, P=0.13), but had a trend
toward shorter duration of
mechanical ventilation. Overall
mortality was 6%, and was
significantly lower for patients with
focal aortic lesions (0% vs 9%,
P=0.03).
Conclusions.
Although they are less common
than aortic dissection or rupture,
focal aortic lesions collectively
represent a relatively common
indication for TEVAR at an highvolume aortic disease referral
center. These lesions are often
symptomatic, and patients usually
present with acute aortic
syndrome. Despite this emergent
nature, TEVAR is a highly effective
treatment and is associated with
similar perioperative morbidity and
lower mortality than patients
treated for dissection or rupture.
While this study did not include
patients with lesions that were
observed, and the natural history
of asymptomatic, incidental focal
aortic lesions is uncertain, these
findings suggest focal aortic
disease can be treated by elective
TEVAR with an acceptable risk
profile prior to onset of acute
aortic syndrome. Future study
should determine long-term
outcomes and aortic remodeling
after TEVAR for focal aortic
lesions.
Branched ilíaco
asociado al evar:
nuestra
experiencia
Bargay Juan, Pau; Zaragozá
García, José Miguel; Gómez
Palonés, Francisco; Ramírez
Montoya, Mauricio; Plaza
Martínez, Ángel; Sala
Almonacil, Vicente
volver al sumario
vía retrograda, y no se observaron
complicaciones a largo plazo en
ninguno de los 35 pacientes
evaluados; ningún paciente
presento hematomas, isquemias
arteriales o sangrados luego de
la implantación del dispositivo y
se logró la hemostasia de manera
completa en todo el grupo de
pacientes
11
IX
Poster SITE
El 20% de los aneurismas de
aorta infrarrenal (AAIR) asocian
ilíacas comunes (AIC)
aneurismáticas. El dispositivo iliac
branch (IB) permite preservar el
flujo anterógrado de la arteria
hipogástrica (AH) con el fin de
evitar la isquemia pélvica.
Objetivo:
Analizar los resultados a corto y
medio plazo de los dispositivos
IB implantados en nuestro
servicio.
Materiales y métodos
Estudio descriptivo, unicéntrico
y prospectivo, en el que incluimos
27 IBs asociados a EVAR,
implantados en 21 pacientes de
forma consecutiva entre 20072014.
Analizamos parámetros pre e
intraoperatorios: diámetros ilíacos,
material endoprotésico empleado,
radiación, tiempo quirúrgico y
éxito técnico
En el seguimiento valoramos:
función renal postoperatoria,
permeabilidad primaria y
secundaria, tiempo de
seguimiento, crecimiento ilíaco y
la aparición de claudicación glútea
ipsi y contralateral.
Resultados:
La media de edad fue de 72 años,
todos varones.
El 77% asociaron AAIR >50mm.
El diámetro medio de AIC y de
AH fue de 29.9 mm (r:19-66) y
8.2mm (r:6-12) respectivamente.
Se implantaron 22 dispositivos
ZBIS® y 5 IBEs®, y en la
extensión hipogástrica 77% stent
recubierto balón-expandible y
23% auto-expandible.
La tasa de éxito técnico inmediato
fue del 93%, un caso de fracaso
fue por imposibilidad de
colocación del dispositivo y otro
por trombosis de rama
hipogástrica. El tiempo medio de
intervención global fue de 292
min (r:140-460), la dosis de
irradiación 234 Gy/cm2 (r:49-
501), el tiempo de escopia de
60.8 min (r:23-138) y el contraste
utilizado 258 ml (r:100-555). No
se evidenció empeoramiento de
la función renal postoperatoria.
El seguimiento medio de 31
meses (r:2-91), supervivencia
global del 87% y del 100%
relacionada con el aneurisma a
los 30 meses. De los tratamientos
exitosos, la permeabilidad
primaria y secundaria fue del 96%
a los 30 meses, por un caso de
trombosis de ilíaca externa a los
7 meses post-implantación.
Se objetivó una disminución
significativa del diámetro de la IC
de 3,8mm y un crecimiento de la
AH en 1.1mm (p<0.001)
No se observó sintomatología de
isquemia pélvica del lado tratado
con éxito durante el seguimiento,
sin embargo en el contralateral
con sellado en ilíaca externa se
presentó en el 62% de los casos
(5 pacientes).
Conclusión:
El IB asociado al EVAR es un
tratamiento factible con buena
permeabilidad a corto y medio
plazo sin asociar aumento de
morbi-mortalidad.
Aneurisma
micótico de origen
tuberculoso en un
paciente con arco
bovino: tratamiento
endovascular
García Reyes, Marvín Ernesto;
Álvarez García, Beatriz;
Fernández Valenzuela, Valentín;
Gené Mola, Anna; Maeso
Lebrum, Jordi; Bofill Brosa,
Ramón
Vascular, Hospital Universitario
Vall d´Hebron, Barcelona (Spain)
Introducción
Los aneurismas de origen
tuberculoso que afectan a la aorta
son raros pero potencialmente
mortales si no son tratados
oportunamente. El tratamiento
descrito clásicamente es la terapia
antituberculosa y cirugía abierta,
pero en los últimos años el
tratamiento endovascular lha sido
descrito como alternativa.
Presentamos el caso de un
aneurisma de origen tuberculoso
en un paciente con arco bovino.
Caso
Paciente de 35 años que consultó
por 7 meses de pérdida de peso,
2 meses de fiebre, diaforesis, tos
y adenopatías inguinales, axilares
y cervicales. En la radiografía de
tórax se describe dilatación del
arco aórtico (que en las
radiografías previas no se
observaba) y engrosamiento hiliar
derecho por lo que se realiza
angioTAC torácico demostrando
un aneurisma sacular del arco
aórtico que presentaba como
variación anatómica un arco
bovino; también lesiones
cavitadas en el lóbulo pulmonar
derecho con adenopatías en
múltiples cadenas ganglionares
y hepatoesplenomegalia. Se
realizó cultivo de esputo y de la
secreción de las adenopatías
siendo diagnosticado de
tuberculosis diseminada.
Se inció terapia antituberculosa
y se decidió realizar reparación
endovascular del aneurisma. Se
excluyó el aneurisma con
endoprotesis torácica Relay Plus
de Bolton Medical de 28x150mm
cubriendo el origen de la subclavia
izquierda.
Discusión
Con el desarrollo de la terapia
endovascular las indicaciones se
han expandido a los aneurismas
micóticos. A pesar que,
actualmente no hay muchos
casos descritos con este tipo de
aneurismas y con esta variación
anatómica, este abordaje ofrece
menos complicaciones. Aunque
no queda claro si aumenta el
riesgo de recurrencia de infección
por lo que es necesario realizar
un seguimiento a largo plazo.
105
Conclusión
Materials used
El tratamiento endovascular de
aneurismas tuberculosos es una
alternativa terapéutica en
pacientes seleccionados.
We have developed a customized
software able to reproduce any
vascular geometry from 4D-MRI
data and to model flow velocity
profiles at the level of the
sinotubular junction. Geometry
and velocity field are the input of
computational fluid dynamic
simulations with fluid-structure
coupling performed at the
Barcelona Supercomputing
Center.
4D-mri coupled to
fluid dynamics
simulations to
improve patient
management
Methodology used
Martorell, Jordi (1); Pons,
Ramón (1); Dux-Santoy, Lydia
(2); Rodríguez-Palomares, José
F. (2); Molins, José Javier (1);
Evangelista, Artur (2)
IQS School of Engineering,
Universitat Ramon Llull, Barcelona
(Spain) (1); Hospital Vall d'Hebron,
Barcelona (Spain) (2)
Introduction
Fluid dynamics at the aortic valve
may be one of the leading
explanations of aortic aneurysms.
Ascending aorta aneurysms is a
major cause of morbidity and
mortality including aortic
dissection, aortic rupture and
heart failure secondary to aortic
regurgitation. Patients with
hypertension, aortic valve
stenosis, bicuspid aortic valve, or
connective tissue diseases are at
a high risk to develop an aortic
aneurysm. Patient management
after diagnosis is critical, especially
in the ascending aorta since no
endovascular treatment is
available.
Objectives
To describe fluid dynamics
parameters such as
circumferential and tangential wall
shear stress gradients, vorticity,
circulation and helicity that better
correlate with aneurysm
progression in the ascending
aorta in patients with bicuspid
aortic valve using computational
fluid dynamics.
Simulations were performed using
4D-MRI data from healthy
volunteers and patients with
bicuspid aortic valve. Flow
recirculation, shear stress
gradients, vorticity, circulation and
helicity were evaluated and
compared to the data extracted
from 4D-MRI, adjusting the
stiffness of the aorta as a key
parameter to match simulation
with reality.
Simulations based on 4D-MRI
reconstructions are a
comprehensive and predictive
tool to map the regions with
higher risk of aneurysm
development. Fair reconstruction
of the aortic geometry and the
velocity profile at the sinotubular
junction sufficed to reliably
reproduce the blood flow profiles.
Patient monitoring and follow-up
will confirm our hypotheses and
establish solid correlations
between fluid dynamics and
aneurysm progression.
4D-MRI combined with high-end
computational modeling play an
important role to improve patient
management in subjects with an
increased risk of ascending aortic
aneurysm.
volver al sumario
Introducción:
11
IX
Poster SITE
Manvelyan, Rafael
Introduction: Chronic arterial occlusive disease
of lower limbs nowadays is
extremely actual problem. More
than 250000 amputations of
lower limbs are carried out in
Europe and US causing huge
damage to social and economic
situation and lead to irrecoverable
loss of life quality of patients.
Objectives:
To evaluate the results of isolated
endovascular and hybrid
procedures in critical limb
ischemia treatment.
Materials: The 18 patients with critical limb
ischemia were observed. Age of
patients was from 56 until 85
years old. The average age was
70.5 years old. We treated
2(11.1%) women and 16 (88.9%)
men. In all cases the clinical stage
of ischemia was Fontain III - IV.
Co-existing pathologes –diabetes
mulitus in 6 cases (33.3%), arterial
hyperthension in 2 cases (11.1%)
and renal disease was determined
in 1 patient (5.5%). Methods:
In all cases the diagnostic
complex, including duplex
scanning and laboratory exams
were done. In 7 cases (38.8%)
was used CT-angio. The isolated balloon angioplasty
of superficial femoral, popliteal
and cruris arteries was performed
in 9 cases (50%). The balloon
angioplasty and stenting of
common iliac andexternal iliac
arteries in combination with
balloon angioplasty of superficial
femoral and popliteal arteries was
made in 4 cases (22.2%). The hybrid procedures include:
a) balloon angioplasty of femoral
or iliac segment with
profundoplasty 3 cases (16.6%);
b) short allo-prosthesis of
superficial femoral artery with
ballon angioplasty below the knee
in 1 case (5.55%); c) balloon
angioplasty of external iliac artery
with femoro-femoral alloprosthesis in 1 case (5.55%).
5 (27.8%) patients with coronary
artery disease simultaneously
were performed coronarography
with coronary stenting in 1 case.
Results: Successful revascularization with
arterial flow in all levels including
pedal was riched in 15 cases
(83.3%). In 2 cases (11.1%) was
improvement of regional blood
flow. In 1 case (5.55%)
amputation was made below the
knee.
Conclusion: The isolated endovascular or
hybrid procedures are effective
in treatment of critical limb
ischemia caused by longer arterial
occlusions.
Evar en aneurisma
pequeño
Ferreira, Mariano
Introducción:
La cirugía endovascular del
aneurisma del aneurisma de aorta
indicada como primera opción
presenta ciertas limitaciones,
especialmente las anatómicas.
La ausencia de cuello proximal
fuerza a la utilización de
endoprótesis fenestradas o
chimeneas. Sin embargo en la
balanza se debería comparar los
riesgos y costos de la
endoprótesis fenestrada,
respecto de la utilización de un
endoprótesis estándar con
inficación por fuera de las
instrucciones de uso.
Otro aspecto es operar al
paciente con un aneurisma por
debajo de los 55mm para evitar
que pierda la posibilidad de
tratamiento endovascular
Objetivo:
Material used:
Mostrar un paciente con
aneurisma pequeño con
indicación anatómica límite.
Patient clinical report.
Material:
Varón de 75 años que se
presenta estable pero con
con cuello cónico, con trombos
circunferenciales, de más de
28mm y diámetro máximo
de52mm
Métodos:
Case report
Colocación de endoprótesis
aórtica bifurcada.
Conclusiones del
estudio:
Estudios han demostrado que el
tratamiento endovascular podría
estar indicado en pacientes con
aneurismas de 50mm
especialmente en cuellos
proximales que podrían perderse
durante el seguimiento.
Endovascular
treatment of a renal
artery aneurysm
with the moret’s
technique: case
report
Ferreira, Joana (1); Pires,
Vanessa (2); Sousa, Pedro(3)
CHTMAD - vascular surgery(1);
CHTMAD- internal medicine(2);
CHTMAD- radiology(3)
Introduction:
Renal artery aneurysm is a rare
pathology, present in 0.01-1.30%
of the population and it is
frequently associated with
hypertension. Endovascular
treatment is the first option due
to its low morbidity and mortality.
Objectives:
The authors report a clinical case
of a renal artery aneurysm treated
with Moret´s technique.
106
Methodology used:
44 years old women was followed
up due to uncontrolled
hypertension with three drugs
(amlodipine 5mg; lisinopril 20mg
and hydrochlorothiazide 12.5mg).
During the investigation, she
performed an abdominal
ultrasound and angioTC which
showed a 36 mm right renal artery
aneurysm. An endovascular
correction was performed. From
the right femoral artery using a
reinforced RDC sheath 6F and a
C1 5F catheter from CooK®, we
select the right renal artery. The
Moret’s technique was performed
using two 0.018’’ guidewires. One
was introduced in the aneurism
sac and through it, a
microcatheter was used to deploy
coils. The other guidewire was in
the renal artery efferent to the
aneurysm. Through this guidewire
a 4mmx2 cm balloon was inflated.
The balloon inflation occluded
temporarily the aneurysm neck in
order to avoid coil migration,
which were deployed through the
microcatheter.
After the intervention, arterial
pressure control was achieved
with lisinopril 10 mg and
hydrochlorothiazide 12.5mg. The
angioTC at six months
demonstrated complete
aneurysm exclusion.
Balloon assisted coil embolization
or Moret´s technique is frequently
employed in the treatment of intracranial aneurysms with a large
neck. It consists in the aneurysm
embolization while the neck is
temporary occluded with a
balloon, stopping coil migration
and stabilizing the microcatheter.
The advantage of this technique,
comparing with the embolization
through the stent mesh is avoiding
its use, and in this way minimizing
the complications associated with
stenting- like fractures, migration
or thrombosis. Moreover, balloon
assisted coil embolization is a
simple and cheap procedure and
can be used in arteries with a
small diameter.
Conclusions of the
study:
Moret´s technique is efficacious,
safe and simple and its
applicability in vascular pathology
could be expanded.
Tight junction
expression and
efflux activity
correlate with
shear stress in
microvascular
endothelial cells at
the blood-brain
barrier
Garcia Polite, Fernando (1,2);
del Rey-Puech, Paula (1,3);
Martorell, Jordi (2); O'Brien,
Caroline C. (1); Elazer R.,
Edelman (1,4); Balcells,
Mercedes (1,3)
Institute for Medical Engineering
and Science, Massachusetts Inst.
of Technology, Cambridge (USA)
(1); Department of Chemical
Engineering, IQS School of
Engineering, Univ Ramon Llull,
Barcelona (Spain) (2); Department
of Biological Engineering, IQS
School of Engineering,Univ
Ramon Llull, Barcelona (Spain)
(3); Cardiovascular Division,
Brigham and Women's Hospital,
Harvard Medical School, Boston
(USA) (4)
Endothelial cell phenotype at the
brain microvasculature is
characterized by the presence of
inter-endothelial tight junctions
and a large list of sophisticated
membrane transport proteins.
This provides the endothelial layer
at the Blood-Brain Barrier (BBB)
with a highly restrictive
permeability of solutes from blood
circulation to the brain. This brain
protective behavior is also
influenced by external factors. On
one side, astrocytes surrounding
capillary microvessels induce
volver al sumario
Critical limb
ischemia: what can
be done
11
IX
Poster SITE
Capillary-like shear stress is
estimated to be of 10 – 20
dyn·cm-2 and evidence suggests
an optimal BBB phenotype under
these conditions. Recent data
though suggest that
microvascular flow is amplified
with age as a result of arterial
stiffening in upstream vasculature.
We hypothesize that these flow
alterations lead to a dysfunctional
Blood-Brain Barrier and altered
endothelial phenotype, as a result
of direct applied stress and
indirectly in downstream cells.
The study proposed was divided
in three steps. First, we exposed
healthy human brain
microvascular endothelial cells
(HBMVEC) to astrocyte
conditioned media (ACM) and
pathophysiological flow. Then,
we developed a novel dynamic
culture disposition where
HBMVEC were cultured under
different shear stress levels but
sharing the same culture media.
This new arrangement allowed
the study of indirect effects of
altered shear stress on the
endothelium downstream.
Expression levels of tight junction
markers (Zonula Occludens 1,
Claudin 5) and efflux transporters
(P-glycoprotein) were measured
by Western Blot. Finally,
permeability assays were
performed in dynamic cultures
using a custom-made parallel flow
chamber. Permeability of Pglycoprotein substrates were
measured in different dynamic
conditions and compared to static
and inhibited conditions.
Results from Western Blot
analysis showed that, while
capillary-like shear stress
upregulates all markers, higher
shear stress down-regulates tight
junction proteins (Zonula
Occludens 1, Claudin 5) and
transporters expression (Pglycoprotein). Such trend also
correlates with P-glycoprotein
activity, where permeability
decreased with capillary-like shear
stress but was increased again
with increasing shear.
Our results suggest that shear
stress is not necessarily a factor
that benefits brain microvascular
endothelial cells. High shear stress
levels induce an alteration of
Blood-Brain Barrier phenotype,
exposing the central nervous
system to an increasing access
of exogenous solutes. Further
study is required to fully
characterize the effect of shear
stress on the neurovascular unit
and mechanisms that control its
function.
Blood-brain Barrier
Phenotype Is
Impacted By
Cellular
Components And
Its Interaction
del Rey-Puech, Paula (1,2);
Garcia-Polite, Fernando (1,3);
Martorell, Jordi (3); Roquer,
Jaume (4); Ois, Ángel (4);
Balcells, Mercedes (1,2)
Institute for Medical Engineering
and Science, Massachusetts Inst.
of Technology, Cambridge (USA)
(1); Department of Biological
Engineering, IQS School of
Engineering,Univ Ramon Llull,
Barcelona (Spain) (2); Department
of Chemical Engineering, IQS
School of Engineering, Univ
Ramon Llull, Barcelona (Spain)
(3); Neurovascular Research
Group, Neurology Department,
IMIM, Barcelona (Spain) (4)
Statistics are frightening in that
no family is safe from neurological
disease. Alzheimer´s disease (AD)
is the most common type of
dementia in the elderly population
with 36 million AD patients
worldwide. Current in vitro BloodBrain Barrier (BBB) models are
not able to mimic all aspects of
in vivo human BBB. The
hypothesis of this study is that
the existing gap between current
in vitro models of BBB and the
clinical phenotype could be
shortened by understanding
better the interactions and the
communication between human
brain microvascular endothelial
cells (HBMVEC) and human
astrocytes (HA). Our results could
help to better understand the
BBB physiology thus developing
in vitro models that mimic the
neurovascular unit.
The characterization of BBB key
markers (tight junctions, efflux and
solute carrier transporters) was
analyzed by protein quantification
(Western Blotting) and localization
(immunofluorescence). The BBB
phenotype was assessed in
different scenarios comparing
monocultures of HBMVEC or the
cell line hCMEC/D3 in co-cultures
with HA. The interaction of
endothelial cells with HA was
studied in different co-culture
conditions: influenced by the
physical distance between them
(from direct contact to different
membrane thickness), membrane
material, porosity and cell spatial
configuration. The studies were
performed in either static or
dynamic conditions. For the latter,
endothelial cells were exposed to
controlled shear stress in a
custom-made PDMS parallel flow
chamber. This device allows coculture of two different cell types
at each side of the membrane
that separates both chambers.
The chamber size allows high cell
seeding density, making it suitable
for imaging and proteomic
analysis.
The HBMVEC expression pattern
is rapidly lost once cells are
deprived from their natural
environment. Different
approaches can recover BBB
phenotype, including co-culture
with other glial cells, shear stress
or spatial culture configuration.
We have studied the extent of
endothelial cell phenotype
recovery upon interaction with
neighboring cells in different
conditions. Our results indicate
that the commonly used in vitro
107
systems are not able to replicate
in vivo conditions. The resulting
BBB phenotype is dependent on
the model selection, obtaining
different and sometimes even
contradictory results between
different in vitro models and
between in vitro and in vivo.
A deeper understanding of the
nature of the interactions between
the key players of the BBB in the
different co-culture environments
is crucial to properly analyze the
generated data. Adequate culture
conditions are indispensable to
design an in vitro model which
can reproduce the clinical
scenario.
Late type i (B)
endoleaks after
evar: detection in
the follow up and
treatment
Craven-Bartle Coll, Antonella;
Conejero Gómez, Rosario;
Arribas Aguilar, Felipe Neri;
Martín Cañuelo, Jorge; García
Turrillo, Emilio; Rodríguez
Piñero, Manuel
UGC Intercentros Cádiz-Jerez (H.
Puerta del Mar y H. Jerez), Cádiz
(Spain)
Introduction
Treatment of late endoleak is the
most frequent cause of reintervention after EVAR.
Objectives
We reviewed the cases of type
Ib endoleaks detected and treated
in our hospital during follow-up
of 192 cases of EVAR ( February
2009 to March 2015).
Material and
methodology
Three cases of type Ib endoleaks
were diagnosed (1,56%), by
computed tomography
angiography (CTA). Two of these
cases were due to proximal
migration of iliac extensions.
Case 1:
86 years old man with history of
infrarenal abdominal aortic
aneurysm (AAA) (5.8cm) and right
common iliac (CI) aneurysm
(4,1cm) excluded by Anaconda
bifurcated stent graft (B30,
FL17x23x130 right iliac bifurcation
and FL17x21x130 left CI). After
18 months, CTA shows
permeability and growth of the
right CI aneurysm (5cm) with
proximal migration of the right
iliac extension. The type 1b
endoleak was resolved by right
femoral dissection and humeral
puncture for catheterization of the
right branch (through-and-through
wire access); two Endurant
extensions were implanted
(16x24x124 and 16x16x85) to
right external iliac (EI).
Case 2:
58 year old male with a
functioning renal transplant at
right CI and history of exclusion
of infrarenal AAA of 5.5 cm ( right
CI of 2cm) by Zenith bifurcated
stent graft (B28-11, right E-2456 and left E-20-73). After two
years, in CTA, aneurysm sac
growth was evident, with proximal
migration and kink of the right
iliac extension being housed in
the AAA. It was resolved with
catheterization of the right branch
through ipsilateral femoral artery
access, angioplasty balloon
(Mustang 12x40mm) to angle
correction and implementation of
new extension to right CI
(Endurant 16x24x124) the renal
transplant thus remaining
permeable.
Case 3:
77 years old male with infrarenal
AAA of 8.5 cm with extension to
aortic bifurcation and both CI (right
CI of 3cm and left CI of 4cm),
excluded by Gore bifurcated stent
graft (RLT311415), two
extensions to left EI (PXC121000
and PXL161007) and one
extension to right CI (PXL
161407). After 18 months, in CTA,
aortic aneurysm sac growth was
detected, with type Ib endoleak
at right CI, which was not visible
volver al sumario
and/or upregulate BBB
properties. On the other side,
blood circulation induces wall
shear stress on the endothelium,
a physiological stimuli which has
a significant effect on cells along
the vascular tree.
11
IX
Poster SITE
RESULTS:
In all three cases the complaints
were detected and the late type
Ib endoleaks sealed, stopping the
growth detected in these
aneurysms.
CONCLUSIONS:
Post-implant follow-up is very
important to enable the detection
and treatment of these potentially
risky late complications.
The choice treatment for most
endoleak after EVAR is the
The fate of type ii
endoleak after
endovascular
aneurysm repair in
infrarenal aortic
aneurysm
Kwon, Tae-Won; Han, Youngjin
Department of Surgery, Asan
Medical Center, University of
Ulsan College of Medic, Seoul
(Republic of Korea)
Astract
Introduction: Type II endoleak (EL2) is commonly occurred after
endovascular aneurysm repair
(EVAR). Usually, that is needed
long-term follow up than
immediate intervention.
Objective:
The aim of this study was to
evaluate the risk factor and the
fate of EL-2 after EVAR.
Materials & Methods:
A total of 239 consecutive
patients who underwent EVAR
from January 2007 to December
2012 at our medical center were
evaluated retrospectively. 89
patients who had saccular or
ruptured aneurysm, Type I or III
endoleak and follow-up within 1
year were excluded. The clinical
characteristics, anatomical
features of aneurysm and follow
up records were compared
patients who had EL-2 with
patients who didn’t have any
endoleak.
The predictive
factors and clinical
outcomes of
aneurysm sac
shrinkage after
endovascular
aneurysm repair in
infrarenal aortic
aneurysm
Kwon, Tae-Won; Han, Youngjin
Department of Surgery, Asan
Medical Center, University of
Ulsan College of Medic, Seoul
(Republic of Korea)
Results:
Of the 150 patients, 53 patients
(35.3%) demonstrated EL-2 on
CT angiography over a median
follow-up 42 months (1484months). A multiple regression
model showed that female (OR,
50.7; P = 0.048) and occluded
inferior mesenteric artery (IMA)
(OR, 0.27; P = 0.040) was a
predictor for EL-2 after EVAR.
Patient with EL-2 had a significant
sac shrinkage compared to
patients without EL-2 (11.5mm
vs 2.3mm, P = 0.001). 16 patients
(30.1%) of EL-2 resolved within
6months. Of the 37 patients with
persistent EL-2, 9 patients
underwent embolizations of IMA
or lumbar arteries, but 2 patients
showed continuous EL-2. There
was no rupture of sac and
migration of stent grafts during
observation periods.
Conclusions:
EL-2 increase in patients who are
females or have patent IMA
preoperatively and have adverse
effect in sac shrinkage. But it is
not associated with sac rupture
and other complications.
Abstract
Introduction: Aneurysm sac
shrinkage or enlargement after
endovascular aneurysm repair
(EVAR) is one of the most
important prognosis factors.
Especially the reduction in
diameter over 10mm of aneurysm
sac is thought as indication of
successful EVAR.
Objectives:
evaluate the predictive factor and
clinical outcomes of sac shrinkage
after EVAR.
Materials & Methods:
A total of 239 consecutive
patients who underwent EVAR
from January 2007 to December
2012 at our medical center were
evaluated retrospectively. 76
patients who had saccular or
ruptured aneurysm and followup within 1 year were excluded.
The clinical characteristics,
anatomical features of aneurysm
and follow up records were
compared patients who had sac
shrinkage over 10mm with
patients who didn’t have on CT
scan during follow-up periods.
Results:
Of the 163 patients, 65 patients
(39.9%) whose aneurysm sac
was reduced over 10mm had
more smoking history (OR, 2.63;
P = 0.032), less coronary artery
disease (OR, 0.25; P = 0.010)
and less any type endoleak (OR,
0.14; P = 0.001) compared to the
108
patients who didn’t on multivariate
analysis. Second intervention was
less performed in sac shrinkage
group (4.6% vs 18.4%, P =
0.010). There was no rupture and
adverse event in sac shrinkage
group during observation periods.
Objectives
Conclusions:
Material used
Patients with sac shrinkage over
10mm after EVAR have smoking
history or less coronary artery
disease or less any endoleak and
have favor long-term outcomes.
Short form-36 (SF-36) and
EuroQol 5D (EQ5D)
questionnaires were sent to
previous participants of the
JUVENTAS trial. The design of
the JUVENTAS trial has been
previously published.
Quality of life after
treatment with
autologous bone
marrow derived
cells in no-option
severe limb
ischemia
Peeters Weem, Stefanie (1);
Teraa, Martin (1); den Ruijter,
Hester (2); de Borst, Gert Jan
(1); Verhaar, Marianne (3); Moll,
Frans (1)
Department of Vascular Surgery,
University Medical Center Utrecht,
Utrecht (The Netherlands) (1);
Laboratory of Experimental
Cardiology, University Medical
Center Utrecht, Utrecht (The
Netherlands) (2); Department of
Nephrology and Hypertension,
University Medical Center Utrecht,
Utrecht (The Netherlands) (3)
Introduction
Quality of life (QoL) is an important
outcome in evaluating the
treatment success in no-option
severe limb ischemia. The
randomized, double blind,
placebo-controlled JUVENTAS
trial, investigating the effect of
bone marrow derived
mononuclear cell (BMMNC)
administration in no-option severe
limb ischemia, showed an
improved QoL at six months as
compared to baseline in both the
treatment as well as the placebo
group.
evaluate whether the improved
QoL persisted beyond six months
follow-up, whether this differed in
both trial arms, and how major
amputation influences QoL.
Methodology used
A norm-based scoring method
was applied to report the results
of the SF-36. The results of the
long-term follow-up were
compared with baseline and six
months follow-up and the results
of both trial arms were compared,
as well as were the results of
patients with and without
amputation.
109 patients responded to the
questionnaires. Median follow-up
since inclusion was 33 months
(interquartile range, IQR, 21.2 to
50.6) for the BMMNC and 36
months (IQR 21.4 to 50.9) for the
placebo group. The improvement
in QoL at six months persisted in
both arms at a median follow-up
of 35 months. The long-term QoL
did not differ between the
BMMNC and placebo group in
any of the SF-36 or EQ5D
domains. Patients with and
without a major amputation had
similar QoL scores.
Approximately three years after
inclusion, QoL in patients with nooption severe limb ischemia was
still increased as compared to
baseline, but not different
between the BMMNC and
placebo arms. This suggests that
the increase in QoL is not due to
the extra care and attention during
study participation.
volver al sumario
in previous CTA controls. First
attempt at exclusion of type Ib
endoleak with an iliac extension
to iliac bifurcation (PLC 161000
Gore), by ipsilateral femoral
access. After 3 months,
recurrence of type Ib endoleak.
It was resolved by implantation
of a new iliac extension (16-10124 ENDURANT) to EI; right
hipogastryc artery was previously
embolized with coils (Interlock
(018) 6 x 20 and 8 X 20).
11
IX
Poster SITE
long term results.
Proof for this are the prospective
randomized multicenter study by
PROEBSTLE as well as our
histological examinations with 5year –resiults.
Brachmann, Karin
Kliniken Leipziger Land, Leipziger
(Germany)
Background
In Germany , the crossectomy
following the BABCOCK
procedure and the stripping oft
the great saphenous vein were
considered as the „ gold
standard“ in varicose treatment
since 1907. Only in the late
nineties oft he last century was a
new and less invasive treatment
of varicose vein developed: the
endovenous obliteration. Initially
the modern endovenous
procedures were perceived as
untrustworthy and even rejected
by some collegues.
Methods
For the therapy of varicose veins
is it neceserry to have an
– individual concept of treatment
– Pathology conform treatment
– Alternative endovenous
treatment options are:
1.) Closure FAST
2.) Laser therapy
3.) Foam sclerotherapy
4.) Steam
5.) Mechano / Chemo / Acrylate
Results
In the last 10 years we have
launched a number of studies on
the comparison of the traditional
with the modern methods of
treatment. We give a brief
overview oft he current data
situation worldwide and we see
no difference in clinical recurrence
rate between the methods and
all groups improved in VCSS,
AVVSS and QOL.
Conclusion
In my opinion the circular
endoluminal thermo frequency
ablation is the best process
regarding evaluation, safety and
Short-term proximal
neck degeneration
and acute type ia
endoleak in an
infrarrenal aaa
treated by a
chimney tecnique
Estébanez, Santiago; Flores,
Ángel; Orgaz, Antonio, Gil,
José; Leal, Ignacio; Peinado,
Javier
Hospital Virgen de la Salud,
Toledo (Spain)
associated Type Ia endoleak.
Urgent endovascular surgery was
performed to exclude endoleak.
After careful evaluation of the
proximal neck in the OR suite, it
revealed a possible distal
migration of the body of the graft,
so we tried a proximal cuff. The
angiography control showed
persitence of endoleak after
placement of the cuff, so we tried
another proximal cuff and a
Chimney technique in right renal
artery to increase proximal neck
length and sealing zone.
Afterwards, angiography control
showed patency of both renals,
and no endoleaks.
remains a major technical
challenge, requiring careful
planning, effective cerebral
protection and reduced ischemia
time to minimize complications.
Technical simplification must be
associated with good long-term
results and several surgical
approaches may be used.
Results:
Material and Methods
The patient did not present any
complication. The patient was
discharged at third postoperative
day without any remarks. 30-day
follow up CT scan showed no
leaks.
We followed 42 patients (pts) with
this pathology from January 2008
to March 2015. Acute dissections
and pseudoaneurysms were
excluded, by the particularities of
these diseases and specific
treatment. 30 pts were operated
with the following diagnoses: 13
pts with aneurysm of the middle
arch and descending aorta, 4 pts
with type A chronic dissection
associated with either type B
chronic dissection or aneurysm
of the descending aorta, 3 pts
with type B chronic dissection
associated with ascending or arch
aneurysm, 10 pts with MegaAorta Syndrome. They were
divided into 4 groups according
to the chosen surgical technique:
A. Frozen Elephant Trunk (FET)
B. Hybrid Procedure: Off-pump
Debranching followed by TEVAR
(Lz 0/1)
C. Hybrid Procedure: On-pump
Debranching followed by TEVAR
(Lz 0)
D. Ascending aorta replacement
followed by TEVAR (Lz 3)
We show a Type Ia endoleak in
a women with an infrarrenal
abdominal aortic aneurysm (AAA)
treated by EVAR who presents a
degeneration of the proximal neck
with an acute onset of abdominal
pain and mesogastric pulsatile
mass.
Conclusions:
Objetives:
Chronic
multisegmental
disease of the
thoracic aorta:
different surgical
options
Material:
The patient is a 78 year old
woman, diagnosed of atrial
fibrillation, cardioembolic ischemic
stroke in 2009 and treated in our
department for AAA by EVAR on
July 2013. She presented a 48
hours evolution of acute onset
abdominal pain associated with
palpable pusatile mass.
Methodology:
At first evaluation, the patient was
hemodinamically stable. An
emergency angio TC showed
aneurysm neck dilatation and an
Review all patients with chronic
multisegmental disease of the
thoracic aorta followed in our
Departments’ Outpatient Clinic
of Thoracic Aortic Diseases to
evaluate surgical results and
follow-up in different approaches.
Conclusion
Introduction:
We present one case of a 78 year
old women with an AAA treated
in our department on July 2013
who presents a 48 hours
evolution an abdominal pain and
mesogastric pulsatile mass.
Objectives
cerebral protection in the FET
group, which in turn generally
doesn’t need TEVAR as it already
consists in an hybrid prosthesis.
It is also this group that has the
longest time of procedure and
the highest hospital mortality and
morbidity although better
medium-long term results, with
no late mortality registered. Three
pts made the 1st surgery but did
not complete the procedure
planned for different reasons, and
died. Of the 12 pts not intervened,
7 died from refusing or awaiting
surgery and 5 are being studied
or awaiting surgical appointment.
We present a patient with an
acute type Ia endoleak solved by
means of a chimney technique,
showing the efficacy of this
procedure as a recue technique
in emergency situations.
Cruz Tomás, António;
Rodrigues, Luís; Laranjeira
Santos, Álvaro; Fragata, José
Serviço de Cirurgia
Cardiotorácica, Hospital de Santa
Marta, CHLC, Lisboa (Portugal)
Introduction
Chronic aneurysms and
dissections involving various
segments of the thoracic aorta
are a rare but serious disease,
associated with inexorable death
if not corrected. The surgicalanesthetic risk is high and surgery
109
These numbers do not allow any
statistical conclusions. FET seems
the most interesting technique for
the definitive correction it
provides, although associated
with a higher operative mortality,
requiring a correct selection of
patients. Hybrid procedures,
surgical debranching (off-pump)
and TEVAR seem to be excellent
choices, with very positive results
in short-term but associated with
a high late mortality, even
considering the comorbidities and
older age of this group. Using
CPB to replace the ascending
aorta with debranching of the
supra-aortic vessels followed by
TEVAR can be an alternative to
FET. It will be needed greater
experience and more follow-up
time to draw definite conclusions.
The only certainty is that without
surgery mortality is inevitable at
medium-term.
Results
Mean age is very similar in all
groups except in group B, which
is slightly higher. There is a male
prevalence across all groups. In
group D there is no need for a
debranching and in group B
patients are not cross-clamped.
There’s only need for
cardiocirculatory arrest with
volver al sumario
Treatment
strategies for
varicose veins status update 2014
11
IX
Poster SITE
Hynes, Niamh (1); Waters,
Peadar (2); Veerasingam, Dave
(3); Sultan, Sherif (1, 2)
Western Vascular Institue, Galway
Clinic, Galway (Ireland) (1);
Western Vascular Institute,
Galway University Hospital,
Galway (Ireland ) (2); Department
of Cardiothoracic Surgery, Galway
University Hospital Galway
(Ireland) (3)
Introduction/Objectives
We aim to assess minimally
invasive and adaptive surgical
techniques for Thoracoabdominal
aortic (TAA) disease.
Material
used/Methodology used
From October 2008 to October
2014, 46 patients presented with
TAA pathology. 61%(28) were
male, 80% were ASA Grade III or
higher, with mean age 66.4years.
Two were acute complicated type
B dissection, three were traumatic
aortic transsection and two were
ruptured.
Five patients underwent hybrid
visceral debranching followed by
thoracic endovascular aortic
repair (TEVAR). Twenty patients
underwent chimney or snorkel
stent placement in the subclavian
or renal vessels. Twelve patients
underwent multilayered stenting.
Thirty-day mortality was 10.8%
and 30-day morbidity was 6.25%.
No patient developed rupture,
paraplegia or stroke. 5-year
aneurysm-related survival was
89.1% (95%CI=75.6%-95.9%).
All cause survival was 64%
(95%CI=48.5%-77.2%) at one
year and 58.1% (96%CI=42.8%72.2%) at 5 years. No aneurysm
expansion was observed. Two
patients required re-intervention
for graft migration.
Data presented demonstrates
that minimally invasive techniques
for TAA pathologies are safe,
prudent and viable in non-elective
treatment of thoracic aortic
pathologies.
Propagation of
spontaneous
thrombosis and
post ablation
superficial
thrombus
extension (paste):
a common
frame.The new xpaste score
were proposed, where F stands
for Foam, G for Glue and T for
treatment.
PASTE is definitively wider than
the other terms and is
undoubtedly the best descriptor
for post-EVA thrombosis
extension. An extended local
score (0-9), wider than in the
other methods (0-4), is used and
a global synthetic score resumes
the extension in all the venous
segments.
The X-PASTE local score is
based on the observation of a
sequence of overlapped couples
of segments, the FOCUS and the
NEXT, according to the
physiologic direction of flow. The
same concept is hidden also in
ETIT, even if never clearly
declared.
hour learning period.
The following cases are
unclassifiable with ETIT, while they
are easily classifiable with the XPASTE score.
•The goal of the Endo-venous
procedures. (X-PASTE: 0,1)
•The FOCUS partial thrombosis
with extension to the NEXT
segment, which can occur for
instance during the evolution of
a complete thrombosis. (XPASTE: 7,7)
•The FOCUS floating thrombus,
not extended to the junction. (XPASTE: 0,9)
Discussion
The local classification is
completely compatible with ETIT.
All ETIT scores which were
previously gathered can be still
Passariello , Fausto
Centro Diagnostico Aquarius,
Napoli (Italy)
Introduction
Post Ablation Superficial
Thrombus Extension (PASTE) is
the thrombosis extension from
the termination of the saphenous
trunk and in continuity with the
closure post-Endo-venous
ablation (EVA). PASTE can occur
in the saphenous femoral junction
(SFJ) or in the saphenous popliteal
junction (SPJ).
Objectives
To describe the new X-PASTE
score for post-LASER or RadioFrequency thrombosis extension.
In addition the same score can
be used also in the description of
spontaneous thrombosis.
Methodology used
Endo-venous Heat Induced
Thrombosis (EHIT) and several
other terms (EFIT, EGIT, ETIT)
When the FOCUS is occluded,
the scores 1-4 are perfect
analogues of ETIT, but the local
score adds the value 5 for the
floating thrombus. When the
FOCUS is patent (or also in partial
thrombosis) the local classification
adds the scores 6-9 respectively.
0 is the score of a completely
patent couple.
The rationale of the X-PASTE
global classification is the
extension of the local score from
the junction towards the last
peripheral segments which are
involved in the thrombosis,
applying the same procedure in
sequence to all the chain. A final
procedure rebuilds then the global
score starting from the local ones.
Several clinical examples are
shown practically, in order to
document the effectiveness of
the method, which is also
straightforward, after a short 1-
110
reused as X-PASTE local scores.
In addition, the local classification
is much wider than ETIT and
allows the classification of
unclassifiable cases.
X-PASTE addresses also the
cause of thrombosis extension
and is an efficient tool in the
follow-up of thrombosis evolution.
The global classification can be
further extended to branching
sequences, where the
confluence points share the same
local score.
The X-PASTE classification can
be also used in the description of
the spontaneous thrombosis.
In this case there is no starting
point both in time (when ?) and
in space (where ?).
However, these 2 values can be
estimated:
* In space, the sequence of
involved segments can be
stopped centrally at the last
partially/totally occluded Tjunction.
* In time, the starting point can
be substituted by the first
thrombosis observation or also
estimated by the anamnesis.
These points allow the description
of the occluded venous system.
An extended local score (0-9),
wider than in the other methods
(0-4), is proposed and a global
synthetic score resumes the
extension in all the venous
segments.
In addition, the X-PASTE
classification is also able to
describe efficiently the
spontaneous thrombosis.
References
1. Wright D, Morrison N, Recek
C, Passariello F. Post Ablation
Superficial Thrombus Extension
(PASTE) into the common femoral
vein as a consequence of
endovenous ablation of the great
saphenous vein. Acta Phlebol
2010;11:59-64.
2. King T, McGreevey C, Bulger
C, Davis A, Vayuvegul S. Incidence
of VTE after endovenous LASER
ablation: 46574 cases. Presented
to the “Hemodyn 2013”, the II
Vasculab Conference. Accademia
Aeronautica, Pozzuoli, Nov 7 th 9 th, 2013.
3. Passariello F. Post ablation
superficial thrombus extension
(PASTE) as a consequence of
endovenous ablation. An up-todate review. Reviews in Vascular
Medicine Volume 2, Issue 2, June
2014, Pages 62–66.
4. Passariello F. X-PASTE. A readymade model for thrombosis
evolution in the human. Presented
to the “Hemodyn 2013”, the II
Vasculab Conference. Accademia
Aeronautica, Pozzuoli, Nov 7th9th, 2013
5. Passariello F. The X-PASTE
score: going far over PASTE, EHIT,
EGIT, EFIT and ETIT. Poster to 5
th-8 th April 2014 - London,
United Kingdom.
6. Passariello F. La nouvelle
classification X-PASTE pour la
thrombose après Laser ou RadioFréquence. (The new X-PASTE
classification for post Laser or
Radio-Frequency thrombosis
extension) Presented to the “JIFA
2015”, Paris, Nov 30th-31st,
2015.
volver al sumario
Thoracic abdominal
endovascular
aneurysm repair
(TEVAR) with
chimney grafts,
hybrid techniques
and multi-layer
stenting in the
management of
Thoracoabdominal
Aortic Pathologies
11
IX
Poster SITE
Piña, Rolando; Tripodi, Paolo;
Mestres, Gaspar; Yugueros,
Xavier; Sánchez, Fabio;
Riambau, Vicente
arterias Mesentérica Superior y
Renales fueron preservadas con
stent.
Durante el procedimiento no hubo
incidentes. En el control
angiográfico inmediato post
cirugía no se evidenció
endofugas. El paciente fue dado
de alta a las 36 horas del
procedimiento. El el angioTC de
control al mes confirmó la
exclusión del aneurisma.
Conclusiones
Hospital Clinico de Barcelona.
Cirugia Vascular, Barcelona
(Spain)
Objetivo
Ofrecer tratamiento óptimo y
duradero debido a sus
enfermedades de base y a una
importante angulación y rotación
de la aorta a nivel
infradiafagmático con el
compromiso de los troncos
viscerales en el aneurisma.
Se reafirma que el tratamiento
endovascular es una excelente
alternativa para aneurismas
seleccionados de la aorta
Toracoabdominal.
La elección de una endoprótesis
con tres fenestraciones y una
rama nos permitió dar mayor
seguridad y durabilidad del
procedimiento evitando la
migración proximal del cuerpo
distal con el potencial riesgo de
isquemia visceral secundaria.
Caso
Se presenta caso clínico de
TEVAR en paciente masculino de
66 años con aneurisma de aorta
descendente Crawford V, de
doce años de evolución en
seguimiento permanente y
crecimiento abrupto en el último
año alcanzando los 67 mm de
diámetro mayor. Dentro de sus
antecedentes mórbidos
destacaba: Cardiopatía coronaria
con Sd Coronario Agudo en 2008
que requirió dos stents y EPOC
con FEVı de 87%. Se decidió en
Comité de Aorta realizar
tratamiento endovascular con
endoprótesis a medida con
fenestraciones a mesentérica
superior y ambas renales, y una
rama para el tronco celíaco , con
la finalidad sellar en aorta
abdominal y evitar así la migración
hacia proximal en el seguimiento
tardío,
El procedimiento fue realizado
con anestesia regional y con
abordaje percutáneo por punción
bajo ecografía en ambas arterias
femorales.
La rama a tronco celiaco y las
Angiografía tc en la
planificación
preoperatoria de
los colgajos de
perforantes en
cirugía plástica
Guerrero, Rubén; Pons,
Gemma; Núñez, Claudia;
Sarria, José; Gómez, Fernando;
Méndez, Jorge Eliecer
Hospital de Sant Pau, Barcelona
(Spain)
seleccionar la perforante
dominante y valorar su calibre y
ramificación subcutánea.
Objetivos
Evaluar la utilidad de la angiografía
TC en la planificación preoperatoria de cirugía de
perforantes en diferentes tipos
de colgajos.
Material
Se revisaron los angioTC para
estudio de perforantes realizados
en nuestro centro desde enero
de 2011 a enero de 2014 (N=202)
y se compararon con los
hallazgos intraoperatorios. Se
realizaron 96 colgajos tipo DIEP,
25 SIEA, 51ALTF, 18 TDAP y 12
SGAP.
Metodología
Los estudios se realizaron en 2
TCs de 16 y 256 detectores
(Philips Brilliance 16-slice y Philips
Brilliance iCT).
Las imágenes se revisaron de
manera conjunta por un radiólogo
y un cirujano plástico. Se
seleccionó la arteria perforante
dominante y su posición se
identificó mediante un sistema de
coordenadas X e Y respecto a
un punto de referencia anatómico.
La referencia anatómica es
variable en función del tipo de
colgajo.
Antes de la cirugía, las
coordenadas obtenidas para
cada perforante se transfirieron
a la piel del paciente y se confirmó
su presencia mediante ecodoppler.
Introducción
Los colgajos de perforantes
constituyen una evolución en
cirugía reconstructiva gracias a
su adaptabilidad al defecto a ser
reconstruido y a la disminución
de morbilidad de la zona donante.
La identificación de la perforante
dominante del colgajo es esencial
para realizar cirugías más seguras
y rápidas. El angioTC permite
llevar a cabo una evaluación preoperatoria de los vasos
perforantes del colgajo,
Encontramos una muy buena
correlación entre los hallazgos
del angioTC y de la cirugía en los
colgajos DIEP (99%), SGAP (97%)
y ALTF (98%).
En los colgajos SIEA (80%) la
correlación fue menos exacta, ya
que la arteria epigástrica inferior
es inconstante y su identificación
en TC requiere una curva de
aprendizaje. Así pues, los datos
del último año muestran una
correlación del 92%.
En el colgajo TDAP (83%) la
diferencia entre la posición del
111
paciente al realizarse el TC y la
posición en la mesa quirúrgica es
la causa de una menor
correlación. Sin embargo, todas
las perforantes se encontraron
en un área de 2 cm2 alrededor
de la coordenada encontrada en
el angioTC.
Conclusiones
Actualmente el angioTC es un
método de diagóstico preoperatorio imprescindible para
planificar colgajos de perforantes.
Gracias a su elevada precisión,
nos ayuda a seleccionar la
perforante dominante que
vascularizará de forma fiable
nuestro colgajo y en
consecuencia se llevarán a cabo
cirugías más seguras y en menor
tiempo.
Un correcto conocimiento
anatómico y del tipo de cirugía
es fundamental para obtener
unos óptimos resultados.
Endovascular
aneurysm repair
using the endurant
ii according to the
on-label vs. Offlabel conditions
Lamarca Mendoza, María Pilar;
Orgaz Pérez-Grueso, Antonio;
Flores Herrero, Ángel; Leal
Lorenzo, José Ignacio; Gil
Sales; José; Peinado Cebrián,
Francisco Javier
Hospital Virgen de la salud,
Toledo (Spain)
Introduction:
Endovascular repair of an
abdominal aortic aneurysm
(EVAR) is sometimes not
performed in accordance to the
instructions for use (IFU) because
of an unfavorable anatomy of the
patient.
Objectives:
To compare the early and
midterm results in patients with
an abdominal aortic aneurysm
(AAA) treated with Endurant II®
(Medtronic Vascular, Santa Rosa,
CA, USA) according to devicespecific IFU vs those treated in
off-label situation.
Material used:
Between September 2012 and
February 2015, 49 consecutive
patients (48 men,1 women) with
an AAA were treated with the
Endurant II device in our unit.
Methodology used:
Demographic, anatomical,
intraoperative and follow-up data
on patients in whom the endograft
was used on-label in EVAR were
compared restrospectively with
the corresponding data of
patients with off-label endograft
use.
Results:
Of the 49 patients, 31 (63%) were
treated according to IFU and 18
(37%) were treated off-label. Both
groups were comparable
according to baseline
characteristics. Technical success
was 100% in both groups (p NS).
There were no 30-day mortality
and no deaths during surveillance
with a median follow-up time of
2.40 years. 11 patients
experienced endoleak (EL): 7 type
II (14%), 2 type Ia (2%) and 2 type
Ib (2%). Type Ia EL was observed
in 1 patient in the IFU group and
in 1 patient in the off-label group
(3’2% vs. 5’5% respectively,
p>0’05). Type Ib EL was only
observed in the non IFU group
(11’1% vs 0%,p 0’291). Type II
EL was observed in 5 patients in
the on-label groups and in 2
patients in the off-label Group
(16’1% vs 28’6%, p 0’291). 3 of
these patients required
reintervention, 1 in the on-label
group and 2 in the off-label group
(3’2% vs 11’2%,p 0’377)
Life table analisis showed a free
of reintervention estimated
survical of 2.65 years (on-label
patients) and 2.516 (off-label)
without significant differences (p
= 0.886). Median follow-up was
876’76.
volver al sumario
Aneurisma
toracoabdominal
tipo v: como
asegurar la
durabilidad del
tratamiento
endovascular
11
IX
Poster SITE
Most early and midterm outcome
of EVAR in wich endografts were
used off-label were similar with
those used off-label.
EVAR may be performed safely
in high risk patients with
unfavorable anatomy. Long term
follow-up will be necessary to
confirm the benefit of treating
these high risk anatomic patients
damp pulse wave with input data
from experiments where
polymeric arterial models are
expanded in a controlled
atmosphere.
Materials used
In order to implement tests in a
lab environment different materials
are analyzed to perform pulse
flow monitoring. PDMS and
ePTFE tubes were chosen for this
study.
Methodology used
Heart Beat Pulse
Damping For
Medical Materials
Martorell, Jordi; Aparicio, Jordi;
Reyes, Guillermo; Balcells,
Mercedes; Menacho, Joaquín;
Amador García – Granada,
Andrés
Introduction
Recent evidence suggests a link
between cardiovascular and
neurodegenerative diseases.
Interestingly there are common,
yet independent, risk factors
associated with them. The
socalled epidemics of the 21st
century do not only take millions
of lives yearly, but also carry
tremendous socio-economic
burden for patients, their families
and the society as a whole. Microhemorrhages and amyloid plaque
deposition co-localize in the
cortex. The cause of cerebral
micro-bleeds remains unresolved,
though associations have been
made with aortic stiffness,
increased pulse wave velocity,
and aging. Indeed, changes in
pulsatile shear stress provoked
by arterial stiffening inherent to
the aging process, or indirect flow
effects on the immunological
system, extend to the brain, an
organ with low peripheral
resistance.
Objectives
The aim of this research is to
create a mathematical model
showing how stiff arteries do not
Tubes were cut and subjected to
cycles of expansion and
relaxation. Data obtained from
material testing was analyzed and
fitted to a mathematical model.
PDMS and ePTFE have similar
behavior although silicone is more
elastic (the hysteresis loop is
smaller), so the ePTFE absorbs
more energy. Material stiffness
prevented hysteresis and reduced
pulse damping.
Objectives.
Aneurysms of the internal iliac
arteries are a rare entity in
isolation, with a rate of 10-20%
abdominal aortic aneurysm
partnership. They deserve special
attention due to its high, up to
70% mortality by break.
Material.
68-Year-old patient presented
as background: smoking,
hypertensive, anticoagulated atrial
fibrillation, aortobiiliaco by AAA
bypass 9 years ago, CIA type
ostium secundum evolved with
income recently decompensated
heart failure.
Endovascular
treatment of giant
aneurysms
hypogastric
Conejero Gomez, Rosario;
Craven Bartle Coll, Antonella;
Arribas Aguilar, Felipe; Garcia
Turrillo, Emilio; Martin Cañuelo,
Jorge; Rodriguez Piñero,
Manuel
U.G.C. ANGIOLOGIA Y CIRUGIA
VASCULAR INTERCENTRO
CÁDIZ- JEREZ, Cádiz (Spain)
Mertens, Renato; Bergoeing,
Michel; Valdés, Francisco;
Marine, Leopoldo; Krämer,
Albrecht
Escuela de Medicina - Pontificia
Universidad Católica de Chile,
Santiago (Chile)
Methodology.
It is referred by casual discovery
in CT of abdomen of right internal
iliac aneurysm de108 mm
maximum diameter and 60 mm
left It notes, in addition, dilatation
of both common iliac winding and
with large angles, aneurysm 25
mm right common femoral artery,
as well as right
ureterohidronefrosis.
Pulse damping due to arterial
expansion is produced mainly at
aortic arteries where expansion
reaches values of around 50%.
Further studies are required with
softer materials which are more
similar to real arteries where the
ratio of inertial force to
deformation force is greater.
Poster
Debranching para
el tratamiento
endovascular de la
patologia del arco
aortico.
Experiencia y
resultados
Results.
We carry out treatment by both
iliac aneurysm endovascular
exclusion with branches of
Endurant II. On right side from
iliac joint with 16 * 13 * 120 mm
and common iliac left with branch
16 * 13 * 92 mm, associating the
implantation of two stent balloonexpandable in kissing in fork 9 *
59 mm and plasty of femoral
common right. Excellent final
inspection and studying without
ischemic complications in the
postoperative period.
Conclusions
The hypogastrics aneurysms are
rare and most are diagnosed by
chance. Open correction of these
lesions is a technically difficult
procedure with considerable
morbidity and mortality, by which,
in high-risk patients, endovascular
exclusion it think of choice,
although it needs proper planning
and have provided alternatives to
solve any incidents that may arise
112
Objetivo:
la aorta torácica descendente ha
significado una reducción
significativa de la morbimortalidad
asociada a su reparación. Sin
embargo, en caso de lesiones
del arco aórtico aún no hay
prótesis comerciales con ramas
disponibles. La cirugía tradicional
del arco aórtico es de alto riesgo,
con cifras reportadas de
mortalidad 3%-10% y morbilidad
neurológica 3%-13%. Para evitar
la morbimortalidad asociada a la
reparación abierta se han
diseñado estrategias de
debranching del arco aórtico para
permitir el uso de endoprótesis
estándar. Reportamos la
experiencia en nuestro centro.
Material y Método:
Estudio retrospectivo entre los
años 2004 a 2014. Se revisaron
las fichas clínicas de todos los
pacientes sometidos a
debranching del arco aórtico
seguido de reparación
endovascular mediante implante
de endoprótesis. Se registraron
los datos demográficos, factores
de riesgo cardiovasculares,
tiempo de evolución, exámenes
de laboratorio, estadía y tipo de
revascularización realizada. La
mortalidad perioperatoria fue
definida como la muerte del
paciente durante la misma
hospitalización o durante los
primeros 30 días posteriores al
procedimiento; la morbilidad
perioperatoria fue definida bajo
los mismos parámetros. Se
registró el seguimiento clínico y
la sobrevida mediante consulta
en el Registro Civil e Identificación.
Para el análisis estadístico se
utilizó el software Graph Pad
versión 5.0.
Resultados:
Se intervinieron un total de 15
pacientes, 13 varones, edad
promedio 67,9 ± 10,3 años. La
lesión fue de etiología
aneurismática en 12 (6 como
complicación crónica de
disección), post traumática en 2
(1 agudo) e infecciosa en uno. El
diámetro promedio del aneurisma
fue de 6,4 ± 2,5 cm. El
debranching consistió en: Bypass
caróto – carotídeo – subclavio en
8, aorto bi carotídeo en 4 y caroto
– carotídeo en 3; se utilizó oclusor
subclavio en 5. El tiempo entre
el debranching y el implante de
endoprótesis fue de 16,4 ± 20,2
días en 10 pacientes diferidos y
simultáneo en 5. La zona anclaje
proximal en el arco fue: Z0=5,
Z1=9 y Z2=1. No hubo mortalidad
operatoria. Un paciente requirió
reparación de linfocele subclavio.
La estadía mediana fue de 6 días
(3-85). Dos pacientes con bypass
aorto bi carotídeo presentaron
morbilidad multisistémica.
Seguimiento promedio 23,1 ±
28,4 meses. Ocho pacientes
fallecidos durante el seguimiento
alejado, 1 por infección de
endoprótesis y otro por
mediastinitis. Sobrevida promedio
26,6 ± 29,1 meses.
Conclusión:
El debranching del arco aórtico
es una alternativa aceptable para
permitir el tratamiento
endovascular. El uso de
esternotomía se acompañó de
una alta morbilidad en esta serie.
Se espera que las endoprótesis
con rama sean una mejor
alternativa.
volver al sumario
Conclusions of the
study:
11
IX
Poster SITE
Biagioni. Corina; JiménezQuevedo. Pilar; Nombela, Luis;
Morrison Polo, Guillermo;
Almería, Carlos; García, Eulogio
Hospital Clínico San Carlos de
Madrid, Madrid (Spain)
Abstract
Transcatheter aortic valve
implantation (TAVI) has become
an important alternative for the
treatment of inoperable and highrisk patients with symptomatic
severe aortic stenosis. Despite
the constant device
improvements and growing
experience of centers performing
the procedure, several
complications may occur.
Coronary occlusion during TAVI
is a potentially fatal complication
that requires prompt recognition,
adequate hemodynamic support
and rapid restoration of the blood
flow.
Case report
We present the case of an 87year-old female with a history of
hypertension, atrial fibrillation and
hepatitis C that was admitted due
to heart failure and functional class
III (NYHA). Transthoracic
echocardiogram showed a
significant aortic stenosis (mean
gradient 56 mmhg and aortic
valve area 0,6mm?), mild to
moderate mitral regurgitation,
normal left ventricular fraction and
moderate pulmonary
hypertension. Coronary
angiography revealed normal
coronary arteries with a nondominant right coronary artery
(RCA). Based on her age and
surgical risk (logistic Euro SCORE:
13.6%; STS: 5.6%), the patient
was referred to transfemoral TAVI.
Intraoperative transesophageal
echocardiography (TEE) showed
a mobile 9, 5 x 8, 5 mm mass,
adherent to the right coronary
cusp of the aortic valve, reaching
the ostium of the RCA -possibly
corresponding to a papillary
fibroelastoma. The distance from
the aortic annulus to the RCA
ostium was 10mm. TAVI was
performed with implantation of a
23 mm Sapien XT prosthesis.
Immediately after valve
implantation, the patient
developed severe and maintained
hypotension with five episodes of
ventricular fibrillation.
Intraprocedural TEE revealed a
severe tricuspid regurgitation due
to right ventricle dilatation and
dysfunction. Aortography showed
complete occlusion of the RCA
ostium. A drug-eluting stent was
implanted in the RCA with
restoration of coronary flow and
immediate reversal of shock
condition. The patient was
discharged after uneventful
hospitalization with normal
function of right and left ventricles.
At nine-month follow up the
patient presented functional class
I (NYHA).
Endovascular
treatment of
iatrogenic type b
aortic dissection
after bronchial
artery embolization
Conclusion
Case report:
Coronary obstruction following
TAVI is a rare but potentially fatal
complication, being more frequent
in women and with the balloonexpandable prosthesis. Although
there is little information about
predictors, anatomical factors
(small aortic root <30mm,
coronary height <12mm) might
be related with higher risk. This
highlights the importance of a
good pre-procedural evaluation
of the patients in order to avoid
this severe complication. To the
best of our knowledge, this is the
first report of a non-dominant
RCA occlusion complicates with
right ventricle infarction and
cardiogenic shock, successfully
treated with percutaneous
coronary intervention.
Male, 58 years-old, with history
of hypertension, smoking and
COPD. Admitted for elective
bronchial artery embolization
aimed to treat severe recurrent
hemoptysis due to chronic
bronchiectasis. During this
procedure, the patient
experienced excruciating back
and chest pain. The angiogram
showed a localized dissection flap
in the proximal descending
thoracic aorta near the site of
entry for the embolization
procedure. The patient developed
a hypertensive crisis and, as the
back pain was worsening, an
AngioCT scan was taken and
showed a Stanford Type B AD
associated to an intramural
hematoma. No signs for aortic
rupture or peripheral organ
malperfusion were noticed. The
patient was transferred for our
department.
Rodrigues, Goncalo; Valentim,
Hugo; Silva e Castro, João;
Ferreira, Emilia; Albuquerque
e Castro, João; Mota Capitão,
Luis
Hospital de Santa Marta, Lisboa
(Portugal)
Introduction:
Bronchial artery embolization has
become a mainstay in the
treatment of hemoptysis because
it possesses high rates of
immediate clinical success
coupled with low complication
rates. We report an unusual case
of Iatrogenic Type B Aortic
Dissection (AD) after this
procedure and how we managed
it.
Results:
The patient underwent urgent
TEVAR, using a Valiant Captivia
113
® 30x30x150mm, landing zone
4, with 100% technical success,
no endoleaks, no major
intercurrences. The patient had
an eventful post-op and was
discharged at day 2,
asymptomatic, no major operative
complications. The patient was
reviewed 1 and 3 months postop with no recurrence of back
pain or hemoptysis.
Discussion and
conclusions:
Although relatively rare, iatrogenic
AD is a major complication of any
catheter intervention and may be
life threatening. Sometimes,
iatrogenic AD decreases or
disappears completely with
conservative treatment because
the site of entry is often quite small
and it does not have an obvious
re-entry site/patent false lumen.
However, in contrast to
spontaneous AD, patients with
iatrogenic AD are more likely to
develop fatal complications. In
this case, as the patient had
refractory back pain and a difficultto-control hypertension, with high
risk of AD progression and aortic
rupture, we decided to perform
a TEVAR. Moreover, there is
recent literature describing the
use of covered aortic stents to
occlude the ostia of the bronchial
arteries and successfully treat
hemoptysis.
Endovascular Surgery, University
Hospital Galway, National
University of Ireland, Galway,
(Ireland) (1); Galway Clinic, Royal
College of Surgeons of Ireland
affiliated hospital, Doughiska,
Galway (Ireland) (2); GMedTech,
Department of Biomedical
Engineering, Galway Mayo
Institute of Technology, Galway
(Ireland)(3), Cardiovascular and
Thoracic Surgery, Arizona Heart
Foundation, Phoenix, Arizona (
U.S.A.) (4)
Introduction/Objective
The aim of this review is to
consider evidence for the
Multilayer Flow Modulator (MFM)
device in management patients
with complex thoracoabdominal
aortic aneurysm (TAAA) or
dissection.
Material
used/Methodology
A methodical search of all health
databases was conducted from
January 2008 to 2015 for health
related and biomedical science
literature, pertaining to the MFM.
Primary outcome was aneurysmrelated survival. Secondary
outcomes were all-cause survival,
stroke, spinal cord ischemia, renal
impairment and branch vessel
patency
Evaluation of the
multilayer flow
modulator in the
management of
complex
thoracoabdominal
aortic pathology: a
systematic review
and metanalysis
Hynes, Niamh (1,2); ElHelali,
Ala (1,3); Diethrich, Edward B.
(4); Morris, Liam (3); Delassus,
Patrick (3); Sherif Sultan (1,2)
A total of 15 studies (3
prospective studies, 3
observational reviews and 9 case
reports) were included. The mean
age of patients was 68.85years
(+/-12.34 years), mean aneurysm
diameter was 6.67cm (±1.57cm).
Technical success reported in 15
studies was 77.2 %. Aneurysm
related survival at one year was
78.7% (±3.92%). One year allcause survival was 53.7 %
(±3.94%). There were no reported
cases of spinal cord ischemia or
renal insult.
The MFM appears safe in
volver al sumario
Right coronary
artery obstruction
following
transcatheter aortic
valve implantation
11
IX
Poster SITE
Contemporary
management of
critical lower limb
ischaemia in tasc d
lesions with
subintimal
angioplasty in
femoro-popliteal
lesions , tibial
angioplasty and
sequential
compression
biomechanical
device for infrainguinal arterial
occlusion.
Experience and
quality of life
outcome learned
over 25 years.
Hynes, Niamh (1); Sultan, Sherif
(1, 2); Waters, Peadar (2);
Veerasingam, Dave (3)
Endovascular Surgery, Galway
University Hospital, Galway
(Ireland) (1); Department of
Vascular and Endovascular
Surgery, Galway Clinic, Dublin
Road, Galway (Ireland) (2);
Department of Cardiothoracic
Surgery, Galway University
Hospital, Galway (Ireland) (3)
Material
used/Methodology used
From 2002-2012, 5876 patients
were referred with Peripheral
Vascular Disease. Of these 987
had CLI, 798 had intervention.
Of 441 patients studied, 190
patients (206 procedures) has
Subinitmal Angioplasty (SIA) for
TASC D femero-popliteal
occlusions, 80 patients (89
procedures) had Tibial Balloon
and Cool Eximer Laser
Angioplasty (TBA) for tibial
occlusions and 171 patients with
severe CLI, not suitable for
revascularization, joined the
Sequential Compression
Biomechanical Device (SCBD)
program. Mean age was 74+8years.
Peri-operative mortality was 1.6%
for SIA vs 0% for TBA. Length of
hospital stay was TBA 3.8 +/-2
days vs SIA 14 +/-16 days,
p<0.0001. 5-year freedom from
Major Adverse Events was 68%
for SIA, 59% for TBA, and 62.5%
for SCBD, p=0.1935 .
5-year freedom from target lesion
revascularization was 85.9% for
SIA and 79% for TBA. One-year
sustained clinical improvement
was 82.8% of SIA, 68% of TBA
and 68% for SCBD.
83% SCBD patients had no rest
pain within one week. Gangrene
remained dry and nonprogressive. Ulceration healed in
93%. No device-related
complications occured. 5-year
Limb salvage was 94%.
Quality Time spent Without
Symptoms of disease or Toxicity
of treatment (Q-TWiST) was 24.7
months for SIA and 8.5 months
for TBA and was 38.13 for SCBD.
Cost per Quality Adjusted-Life
Years for SIA was €5,662.79,
€12,935.18 for TBA and
€2,943.56 for SCBD
Introduction/Objectives
We aim to evaluate a
comprehensive lower limb salvage
program for management of
Critical Limb Ischaemia (CLI).
All treatment pathways were costeffective, minimally invasive and
allowed rapid patient turnover
without compromising limb
salvage.
Complex
multisegmental
aortic repair using
a hybrid prosthesis
- a single center
experience
Rodrigues, Luís; Laranjeira
Santos, Álvaro; Cruz Tomás,
António; Magalhães Manuel;
Afonso, Daniel; Fragata, José
Hospital de Santa Marta, Lisboa
(Portugal)
Introduction
The Frozen Elephant Trunk
technique (FET) is indicated in
multisegmental aortic pathology.
Compared to the classical
technique described by Borst in
1980 this aproach enables
avoiding a 2nd surgical
intervention and eliminates the
time interval between the 2 stages
reducing the mortality and
morbidity usually associated to
this type of procedure.
In recente years technical
modifications have been
introduced aiming to simplify the
intervention, reduce surgical time,
beter protect the cerebral
circulation and thus improve the
overall performance by making it
increasingly effective and
reproducible.
Objectives
To review and presente our single
center experience with this
technique using the hybrid
prosthesis E-Vita Open Plus ®.
Material and
Methodology
From June 2010 to March 2015
this technique was used in 12
patients, mean age 63.8 years
(50-75), 7 were men, with the
following diagnoses: 2 patients
with chronic type B dissection
associated with arch/ascendig
aorta aneurysm, 7 patients with
medial arch and descending
thoracic aorta aneurysm, 3
patients with Mega Aorta
Syndrome. The most common
114
comorbidities were: high blood
pressure in all patients, Chronic
Obstructive Pulmonary Disease
in 5 patients, chronic renal failure
in two patients, chronic atrial
fibrillation in 3 patients and severe
peripheral arterial disease in 1
patient.
One patient had previous surgical
intervention in the ascending
aorta. All were operated by the
same surgeon using similar
surgical technique: Extracorporeal
Circulation, deep hypothermia,
cardio-circulatory arrest with
bilateral selective antegrade
cerebral perfusion, the prosthesis
was anchored in landing zone 2
or 3 with extra-anatomic
reimplantation of the supra-aortic
vessels, monitoring of cerebral
perfusion was performed using
the INVUS ® system.
Results
Two patients died in days 3 and
4 after surgery, both with
mesenteric ischemia. Two
patients experienced prolonged
ventilation complicated by
pneumonia. In the remaining
patients there was no major
complication in the postoperative
period. The mean ICU and length
of hospital stay were respectively
52h and 9 days.
All patients are routinely followed
in our Thoracic Aortic Disease
Outpatient Consultation. The
accumulated follow-up time is 96
months, no patients were lost to
follow-up.
The first patient in the series (June
2010) required a completion of
the procedure with 2 TEVARs in
the descending aorta, at 6
months and 4 years after the initial
intervention, both interventions
were uneventfull. All survivors are
asymptomatic without evidence
of other complications. There was
no late mortality.
Conclusions
The small number of patients and
short follow-up period in most of
these cases do not allow us to
draw definitive conclusions.
However, the results seem to be
encouraging considering the
complexity of the underlying
pathology and associated
comorbidities. Shorter
Extracorporeal circulation and
cardiocirculatory arrest times as
well as good cerebral and visceral
protection are essencial. With a
greater surgical expertise and a
better selection of cases the
results will surely improve in the
near future.
Disección tipo B
Barrera Carvajal, Juan; Holguín,
Juliana; Espinel, Camilo;
Medina, Libardo; Saaibi, José
Federico; Figueredo, Antonio;
Murcia, Adriana; Barrera, Juan
Guillermo
Endovascular - Departamento de
Cirugía - Fundación
(Colombia)
Introduccion
El tratamiento de la disección
aórtica tipo B en el contexto del
síndrome aórtico agudo está
experimentando cambios con el
TEVAR por lo que actualmente
se acepta como estrategia de
primera línea en el ámbito de la
disección complicada; con los
avances tecnológicos de las
endoprótesis y en manos de
cirujanos expertos esta
intervención se considera segura
y puede salvar vidas, logrando a
corto y mediano plazo la
remodelación de la pared de la
aorta mediante el cubrimiento de
la entrada proximal, bloqueando
el flujo en la falsa luz y permitiendo
a su vez la expansión de la luz
verdadera. De acuerdo a lo
anterior el TEVAR ofrece una
opción segura con resultados
favorables en la disminución de
la mortalidad perioperatoria.
Objetivos
El objetivo de este trabajo es
describir la experiencia del grupo
de cirugía vascular en conjunto
volver al sumario
management of TAAA, once
operators abide to its Indications
for Use. Since the MFM is a new
technology, there is paucity of
long-term follow-up data, a lack
of comparative studies and a
requirement for randomized
clinical trials and continued
assessment.
11
IX
Poster SITE
Materiales y métodos:
Se presenta un trabajo
descriptivo, retrospectivo, de
corte transversal de las pacientes
con diagnóstico de disección tipo
B agudo complicado con
tratamiento endovascular en el
servicio de hemodinamia. Se
intervinieron veinte y cuatro
pacientes que ingresaron por
urgencias a quienes se les hizo
el diagnóstico de disección tipo
B aguda complicada. La
información se obtuvo de
registros consignados entre Enero
de 2011 y Diciembre de 2014.
Dentro de los datos se evaluó la
edad, antecedentes, prótesis
utilizadas, evaluación tomográfica
posterior a la intervención,
complicaciones, días de estancia
en unidad de cuidado intensivo,
reintervenciones y desenlace final.
un éxito técnico del 100%, con
una morbimortalidad asociada a
este grupo de pacientes
aceptable, logrando una
remodelación completa en la
pared aórtica de los pacientes
que sobrevivieron al
procedimiento.
Disección tipo A
Barrera Carvajal, Juan; Holguín,
Juliana; Espinel, Camilo;
Medina, Libardo; Saaibi, José
Federico; Figueredo, Antonio;
Murcia, Adriana; Barrera, Juan
Guillermo
Endovascular - Departamento de
Cirugía - Fundación
(Colombia)
Introducción:
Resultados:
Se describen un total de 24
pacientes que fueron intervenidos
durante un periodo comprendido
entre Enero de 2011 y diciembre
de 2014 con edades entre 13 a
74 años (pacientes masculinos),
con edades entre 52 a 77 años
(pacientes femeninos), edad
promedio en hombres 55,3 y en
mujeres 63,3, de los cuales 4
pacientes ingresaron en estado
de choque, 2 pacientes
requirieron cobertura de la
subclavia, 2 requirieron cirugía
debranching con TEVAR
simultaneo, con una mediana de
cobertura de la aorta 150mm,
con un éxito técnico para esta
cohorte del 100%, muertes
hospitalarias 4, paraplejia 2, IRC
que requirieron diálisis 2,
reintervenciones 1 y 20 pacientes
con TAC de control que
evidencian remodelación
completa de la pared aórtica.
Conclusiones:
El manejo endovascular de la
disección tipo B aguda
complicada está asociada con
El tratamiento de la disección
aórtica tipo A aguda realizando
sustitución de la aorta ascendente
y el arco logra buenos resultados
a corto plazo, pero varios
pacientes quedan con desgarros
de la íntima distal o una falsa luz
permeable en la aorta
descendente. En esta serie, se
presenta la experiencia de 5 años
con la técnica Lupiae, una técnica
de reparación aórtica híbrida para
los pacientes con disección
aórtica tipo A aguda.
Objetivos:
describir la experiencia del grupo
de cirugía cardiovascular en
conjunto con el servicio de
hemodinamia, en el tratamiento
híbrido en la disección tipo A
aguda.
Materiales y métodos:
Se presenta un trabajo
descriptivo, retrospectivo, de
corte transversal de pacientes
con diagnóstico de disección tipo
A agudo con tratamiento híbrido
en el servicio de cirugía
cardiovascular. Se intervinieron 7
pacientes que ingresaron por
urgencias a quienes se les hizo
el diagnóstico de disección tipo
A aguda. La información se
obtuvo de registros consignados
entre Enero de 2010 a Diciembre
de 2014. Dentro de los datos se
evaluó la edad, antecedentes,
prótesis utilizadas, evaluación
tomográfica posterior a la
intervención, complicaciones, días
de estancia en unidad de cuidado
intensivo, reintervenciones y
desenlace final.
Resultados:
Se describen un total de 7
pacientes que fueron intervenidos
durante un periodo comprendido
entre Enero de 2011 a diciembre
de 2014, con una relación 4:3
hombre y mujer en los cuales se
utilizó técnica de Lupiae, con una
mediana de cobertura de la aorta
150mm, con un éxito técnico para
esta cohorte del 100%, muertes
hospitalarias 1, reintervenciones
1 y los 7 pacientes con TAC de
control que evidencian
remodelación completa de la
pared aórtica.
Conclusiones:
El manejo híbrido de la disección
tipo A aguda permite que aparte
de lograr una zona de aterrizaje
para la prótesis de dacrón en la
aorta ascendente distal también
logre la reparación de cualquier
desgarro de la íntima residual que
permita llenar un falso lumen
patente por lo tanto la técnica de
Lupiae parece estar asociada con
una alta probabilidad de
trombosis del falso lumen y bajas
tasas de reoperaciones en la
aorta distal.
Rotura de
Aneurisma de
arteria subclavia
derecha
Dra. I. Serramito Veiga, Dr.
Fernández Noya, Dra. Vázquez
Dopazo, Dra. Méndez
Fernández
115
Vascular
Complejo Hospitalario
Universitario de Santiago de
Compostela
Resumen:
Los aneurismas de arteria
subclavia son extremadamente
raros y representan el 1% de los
aneurismas periféricos. La
mayoría cursan de forma
asintomática por lo que suele
tratarse de un hallazgo casual en
alguna prueba radiológica. La
presentación clínica como rotura
aneurismática es excepcional y
supone una emergencia vital, con
exige un tratamiento quirúrgico
complejo, con una elevada
morbimortalidad. El tratamiento
endovascular es una opción
terapéutica efectiva y sencilla
técnicamente, si existe segmento
proximal para su fijación.
Presentamos un caso de
aneurisma roto de arteria
subclavia derecha en un varón
de 83 años, reparado mediante
implante de endoprótesis, con
control angiográfico
intraoperatorio y angioTC de
control postoperatorio que
muestran exclusión de aneurisma
y ausencia de endofuga.
Miocardiopatia
dilatada como
potencial fonte
embólica sistémica
Autores: Pedro Pinto Sousa,
Miguel Lobo, Hugo Louro,
Ricardo Gouveia, Jacinta
Campos, Andreia Coelho, Rita
Augusto, Pedro Monteiro,
Alexandra Canedo
Serviço: de Angiologia e Cirurgia
Vascular,
Instituição: Centro Hospitalar Vila
Nova de Gaia/Espinho
Contatos:
[email protected]
918356470
Introdução:
A miocardiopatia dilatada
idiopática é uma patologia do
miocárdio, cujo diagnóstico é de
exclusão e se caracteriza por
uma ineficiente contractilidade e
dilatação ventricular.
Eventos embólicos pulmonares
ou sistémico são raros, ocorrendo
em 5-10% dos doentes. Ocorrem
principalmente em doentes com
insuficiência cardíaca em classe
avançada e cardiomegalia.
Caso clínico:
Doente do sexo feminino, 59
anos, sem antecedentes pessoais
de relevo. Deu entrada no SU do
Hospital da área de residência
por quadro de dor gemelar direita
de instalação súbita associada a
parestesia e arrefecimento do
membro.
Manteve-se em estudo com
progressiva deterioração do
estado de consciência da doente,
perfil hemodinâmico e progressão
para choque cardiogénico.
Realizou angioTC abdominal que
revelou trombose da artéria ilíaca
comum direita, da artéria
mesentéria superior e artéria renal
bilateralmente. Realizou,
também, ecocardiograma que
identificou miocardiopatia dilatada
e trombo mural em ambos os
ápex ventriculares.
Foi transferida para este Hospital
e admitida na sala de emergência
em ventilação mecânica e
choque. Realizada laparotomia
exploradora com aparente
viabilidade instestinal. Intra
operatóriamente confirmou-se
progressão do quadro para
trombose da artéria ilíaca e
femoral comum esquerda.
Procedeu-se a
tromboembolectomia das artérias
renais bilateralmente, artéria
mesentérica inferior e femoropoplítea-distal bilateralmente.
Posteriormente, a doente foi
internada na Unidade de
Cuidados Intensivos com
evolução desfavorável do quadro
clínico e analítico acabando por
falecer ao 16º dia pós operatório.
volver al sumario
con el servicio de hemodinamia,
en el tratamiento endovascular
de la disección tipo B aguda
complicada.
11
IX
Poster SITE
A presença de trombo a nível
ventricular em doentes com
miocardiopatia dilatada é um
achado frequente, podendo
atingir 40% dos doentes,
segundo a literatura.
No entanto, segundo estudos
prévios, a deteção de trombose
intracardíaca não é preditivo claro
de futuro evento embólico
sistémico.
Carece, por isso, de evidência
quais os doentes que realmente
beneficiam de anti coagulação
de forma a prevenir eventos
catastróficos como o aqui
descrito. O ecocardiograma e a
angioRM seriados poderão ser
extremamente úteis na
caracterização do trombo e
estratificação dos doentes com
maior risco de tromboembolismo.
Aneurisma da aorta
abdominal em
doente submetido
a procedimento
Chimney
Autores: Pedro Pinto Sousa,
Daniel Brandão, Vitor Martins,
Ricardo Gouveia, Jacinta
Campos, Andreia Coelho, Rita
Augusto, Pedro Monteiro,
Alexandra Canedo
Serviço: de Angiologia e Cirurgia
Vascular
Instituição: Centro Hospitalar Vila
Nova de Gaia/Espinho
Contactos:
[email protected]
918356470
Introdução:
A correção endovascular de um
aneurisma justa-renal, para-renal
ou toraco-abdominal implica,
muitas vezes, técnicas complexas
associadas a uma relevante
morbi-mortalidade. As técnicas
endovasculares com Parallel
Grafts (Ch-EVAR) surgiram como
uma alternativa viável para
patologia aneurismática da aorta
que requer revascularização renal
ou visceral.
Caso clínico:
Doente do sexo masculino, 75
anos, com antecedentes
pessoais de claudicação
intermitente gemelar para
distâncias curtas, tabagismo,
HTA , neoplasia vesical submetido
a cistectomia e ureteroileostomia
e aneurisma da aorta abdominal
com recusa para tratamento
cirúrgico.
Admitido no SU e avaliado por
Urologia por quadro de dor
abdominal localizada na fossa
ilíaca direita. Realizou ecografia
abdominal que identificou
aneurisma da aorta abdominal
com cerca de 74 mm de maior
diâmetro, trombo mural e
suspeita de rotura.
Realizou angioTC que confirmou
justa-renal com diâmetro máximo
de 79x85mm mas sem imagem
compatível com rotura.
Associadamente identificou-se
espessamento segmentar do
cólon sigmóide.
Complementou-se o estudo com
realização de colonoscopia que
confirmou neoformação
vegetante e estenosante no cólon
sigmóide.
Nesta sequência, efetuou-se
correção percutânea de
aneurisma por técnica de
Chimney com libertação de corpo
de endoprótese Gore® excluder
28x12x18 após seletivação de
ambas as artérias renais por
punção axilar esquerda seguida
de libertação de stent renal direito
e esquerdo recobertos.
Não se registaram intercorrências
de relevo no pós operatório
imediato, mantendo o doente
função renal conservada. Teve
alta orientado para o Serviço de
Cirurgia Geral onde foi,
posteriormente, submetido a
sigmoidectomia complicada por
lesão ureteral, desenvolvimento
de insuficiência renal aguda com
necessidade de hemodiálise
apesar de manter stent’s renais
permeáveis.
Discussão e
Conclusões:
O papel do Ch-EVAR no
tratamento de aneurismas
complexos da aorta abdominal
continua sujeito a algumas
controvérsias. Apesar de ter bons
resultados a curto prazo tendo
em consideração as limitações
anatómicas do colo aórtico, os
resultados a longo prazo em
termos de durabilidade, qualidade
da fixação protésica proximal e
sealing continuam a ser um fator
de preocupação. Ainda assim,
parece-nos uma alternativa viável
e a considerar em casos
específicos como este.
Colección
periaórtica en
enfermo con alta
comorbilidade.
Autores: Alba Méndez
Fernández, Rebeca Vázquez
Dopazo, Oskarina Silva
González, Javier Villaverde
Rodriguez, Manual Martínez
Pérez.
Centro de traballo: Servicio de
Anxioloxía e Cirurxía Vascular,
Hospital Clínico Universitario de
Santiago de Compostela.
Correo electrónico:
[email protected]
Teléfono: 679 858218.
Introducción:
Ante un enfemro con colección
periaórtica, cabe realizar extensos
estudios para o diagnóstico
diferencial, así como probas
invasivas de imaxe e biopsias.
Hoxe en día a iatroxenia
postpunción arterial, así como
infección posterior preséntase
con maior frecuencia dado
incremento de realización de
procedementos percutáneos.
Material e métodos:
Varón de 59 anos, pluripatolóxico,
en programa de trasplante
hepático, con hiperesplenismo e
116
pancitopenia.
É hospitalizado por
empeoramento clínico e analítico,
con febre e dolor lumbar. En
anxioTC evidénciase masa
prevertebral e periaórtica (D12L2) sen fuga de contraste.
Hemocultivos positivos para
SAMS.
Realízase BAG (biopsia aspiración
con agulla fina) da colección,
sendo negativo o cultivo
microbiolóxico, con anatomía
patolóxica suxestiva de
procedemento
inflamatorio/abscesificación, polo
que se trata con antibioterapia
de amplo espectro.
Dúas semanas despois, en
anxioTC control, observánse
cambios nas características da
colección, con fuga de contraste:
compatible con pseudoaneurisma
aórtico en cara posterior, a nivel
de tronco celíaco.
Resultados:
Inicialmente, dada a gravidade
da situación clínica do enfermo
con alta morbimortalidade,
decídese tratamento
conservador.
Un mes despois, o enfermo
evoluciona favorablemente. Ante
o diagnóstico diferencial de
pseudoaneurisma: micótico,
iatroxénico, ou ambos, valóranse
o tratamento, existindo a
posibilidade das técnicas
endovasculares e de cirurxía
aberta. As opción endovasculares
plantexadas eran embolización,
ou implante de endoprótese (pero
tendo en conta a localización:
tronco celíaco e arteria
mesentérica superior, faría falla
un dispositivo do que non se
dispón de inmediato), polo que
se decide intervención cirúrxica.
Mediante toracofrenolaparotomía,
accédese directamente a cara
posterior de aorta, onde se
observa orificio de sangrado, e
gran hematoma circundante (sen
datos macroscópicos de
infección), polo que se resolve
con sutura directa aórtica.
Previamente realizárase bypass
axilo-bifemoral para minimizar o
risco de isquemia.
Conclusións:
A opción de técnicas
endovasculares podería ser de
gran axuda en enfermos con alta
comorbilidade, pero como terapia
“intermedia” para a resolución do
momento agudo se a sospeita é
de proceso infeccioso.
É unha gran vantaxe a realización
de sutura directa en zonas de
posible infección, para evitar a
súa perpetuación. Pese a que
neste caso, dado o antecedente
de procedemento percutáneo
recente, cabería pensar na
iatroxenia como 1ª opción.
Pseudo-aneurisma
infeccioso em
shunt
arteriovenoso –
caso clinico
AUTORES: Ricardo CastroFerreira, Joel Sousa, Dalila
Rolim, Jorge Costa Lima, Paulo
Gonçalves Dias, José Teixeira
Instituição: Hospital de S.João,
Serviço de Angiologia e Cirurgia
Vascular
Endereço Postal: Rua da Guarda,
nº 541, 4825-391 Santo Tirso
Email:
[email protected]
Tlm 00351915506427
Tipo de apresentação: Poster
Introdução
Os pseudoaneurismas
constituem uma complicação rara
dos shunts arteriovenosos em
pacientes hemodialisados. Estas
lesões são geralmente
multifactoriais na sua origem,
acreditando-se que o aumento
da pressão venosa secundária a
estenoses venosas proximais,
desenvolvida em shunts cujo
material de enxerto se encontra
danificado, desempenhe um
papel significativo na sua
patogénese. Na grande maioria
das vezes este dano ao shunt é
resultado das multiplas
canulações que se sucedem ao
longo do tempo de vida do
volver al sumario
Discussão e
Conclusões:
11
IX
Poster SITE
Objectivos:
Apresentação de um caso clínico
de um doente com pseudoaneurisma de shunt arteriovenoso do membro superior
esquerdo, de etiologia infecciosa.
Material e Métodos:
Doente do sexo masculino, 58
anos de idade, dislipidemico,
hipertenso e insuficiente renal
crónico em programa regular de
hemodiálise por shunt arteriovenoso no braço esquerdo.
Recorreu ao SU por tumefacção
dolorosa e edema do membro
superior esquerdo associados a
febre com duas semanas de
evolução. Observou-se erosão
cutânea e exsudação na região
do shunt, contudo ainda sem
exposição de prótese ou
hemorragia activa. O pulso radial
era palpável. No estudo
imagiológico, o ecoDoppler
revelou a presença de um falso
aneurisma da artéria braquial e
oclusão do shunt arteriovenoso.
O doente foi internado para
instituição de antibioterapia e
decisão cirúrgica.
Resultados:
O doente foi submetido a
correcção cirúrgica, com
exclusão do falso aneurisma,
remoção em bloco do
componente infectado da prótese
e segmento lesado de artéria
braquial, com revascularização
por anastomose braquial topoa-topo. Pós-operatório decorreu
sem complicações, tendo o
doente cumprido ciclo de
antibioterapia em internamento
com posterior alta ao 6º dia pósoperatório.
grave dos doentes em programa
regular de hemodiálise. A
detecção da presença de sinais
de infecção, local ou sistémica,
deve sempre alertar para o
eventual risco de infecção do
material protésico e como tal
desencorajar a utilização do shunt
até melhor esclarecimento do
quadro, sob risco de
desenvolvimento de
complicações, uma das quais o
pseudo-aneurisma. Neste caso,
a canulação persistente do shunt
apesar dos sinais evidentes de
infecçao que se vinham a
manifestar, resultou na
propagação da infecção com
consequente desenvolvimento de
pseudo-aneurisma, complicação
grave e com desfecho
potencialmente tragico pelos
riscos de hemorragia e ruptura
inerentes. Uma melhor
monitorização destas situações
por parte dos profissionais
responsáveis pelas técnicas de
hemodiálise é assim necessária,
tendo em vista não só a
preservaçao do acesso vascular,
como também a prevenção desta
e outras complicações possiveis
e indesejáveis.
Uso do dispositivo
“Excluder Iliac
Branch
Endoprosthesis”
para preservar
arteria
hipogástrica.
AUTORES: Alba Méndez
Fernández, Jorge Fernández
Noya, Nilo J. Mosquera
Arochena, Manuel Martínez
Pérez.
CENTRO DE TRABALLO:
Servicios de Anxioloxía e Cirurxía
Vascular do Complexo
Hospitalario Universitario de
Santiago de Compostela e
Complexo Hospitalario
Universitario de Ourense.
Conclusões:
As infecções de shunt
arteriovenoso constituem uma
complicação potencialmente
CORREO ELECTRÓNICO:
[email protected]
Teléfono: 679 858218.
Introducción:
A dilatación aneurismática das
arterias ilíacas é unha das
preocupacións para a reparación
endovascular. Preservar o fluxo
na arteria hpogástrica é unha
consideración importante para
previr complicacións por isquemia
pélvica.
Describimos a nosa experiencia
e resultados co dispositivo
“Excluder Iliac Branch
Endoprosthesis” no tratamento
de aneurismas ilíacos, onde se
ofrece como unha boa opción no
caso de anatomías difíciles, pola
súa adaptabilidade ante arterias
ilíacas tortuosas.
Kisses, bailarinas,
curvas y otros
asuntos…
hablamos de EVAR,
por supuesto!!
F Gallardo Pedrajas, J
Fernández Noya, J Villaverde
Rodríguez, M Martínez Pérez.
vascular. Complexo Clinico
Universitario de Santiago.
Email contacto:
[email protected]
Tlfo: 636880784
Introducción:
Material e métodos:
Dende xaneiro do 2014 ata
xaneiro do 2015, no Complexo
Hospitalario Universitario de
Santiago de Compostela e no
Universitario de Ourense,
tratáronse 25 arterias ilíacas, en
17 enfermos, mediante o implante
deste branch ilíaco.
Tódolos enfermos eran varóns
agás un único caso de muller,
con idades comprendidas entre
67 e 85 anos.
O seguimento estase realizando
mediante anxioTC a 1 mes e a 1
ano se non hai complicacións, e
Eco-doppler aos 3 e 6 meses.
Resultados:
Obtívose un éxito técnico en 24
dos casos, con implantación
exitosa agás en un caso no que
se ocliuíu a arteria hipogástrica
como complicación. Este
enfermo presenta claudicación
glútea, manténdose tódolos
demais enfermos tratados,
asintomáticos.
A mortalidade foi do 0%. A media
de días de hospitalización foi de
3,5.
Conclusións:
Estes resultados, orientan a
considerar esta técnica unha
alternativa efectiva para o
tratamento dos aneurismas
ilíacos, evitando as complicacións
isquémicas da oclusión
hipogástrica, como é a
claudicación glútea.
117
El objetivo de esta comunicación
es presentar diversas alternativas
de tratamiento y soluciones
técnicas a problemas reales que
surgen al realizar terapia
endovascular en reparación de
Aneurismas de Aorta Abdominal
(AAA) infra-renales (EVAR) que
presentan características
anatómicas a nivel de la
bifurcación aorto-biilíaca
consideradas como hostiles.
Material y método:
El cuello aórtico infrarrenal es
reconocido como uno de los
elementos claves para el
resultado con éxito en el
tratamiento (EVAR) ya que las
características anatómicas de
este segmento de aorta
constituyen la primera causa
anatómica de exclusión en
tratamiento EVAR. Por este
motivo la mayoría de las
comunicaciones y trabajos
publicados que abordan EVAR
en anatomías aórticas complejas
u hostiles se centran en el cuello
aórtico infra-renal.
Sin embargo en muchos otros
casos casos la limitación
anatómica a EVAR puede
aparecer a nivel de angulaciones
severas, de la presencia de
trombo o calcio, de accesos
ilíacos complejos o a nivel
termino-aórtico debido a una
bifurcación aórtica estrecha
(menos de 16 mm).
El problema de las bifurcaciones
aórticas de menos de 16 mm se
ha solventado clásicamente
mediante el implante de una
endoprótesis Aorto –Uni ilíaca y
la realización de un by pass
femoro-femoral cruzado. Aunque
esta es una alternativa válida y
eficaz ya demostrada, debe
tenerse en cuenta el añadido de
complicaciones y aumento de
comorbilidad para el paciente que
siempre implica una cirugía de
revascularización extraanatómica.
En este trabajo revisamos casos
clínicos reales de AAA tratados
con éxito en nuestro centro
durante el período 2014-15 en
los que se emplearon los
dispositivos y trucos técnicos que
se describen y que permitieron
el implante de endoprótesis
bifurcadas en terapia EVAR en
bifurcaciones aórticas estrechas
y complejas:
1. Conocimiento y disponibilidad
de endoprótesis en cuyas IFU´s
incluyen bifurcaciones estrechas
(<16 mm): Ovation (trivascular) ,
Evita (Jotec), AFX, Nellix
(Endologix).
2. Empleo de endoprótesis
trimodulares de nueva
generación: disminuir el diámetro
de la extensión ilíaca empleada.
3. Técnica de liberación
simultánea de ambas extensiones
Ilíacas.
4. Técnica de Kissing Ballon a
nivel de bifurcación aórtica tras
liberación.
5. Liberación de las ramas de la
endoprótesis en posición de
bailarina (cruzadas)
deliberadamente.
Conclusiones:
Aunque las bifurcaciones aórticas
estrechas no son la causa más
frecuentes de limitación
anatómica en EVAR, es
importante que los cirujanos
vasculares que planifican y
realizan terapia EVAR conozcan
alternativas de tratamientos y
soluciones en estos casos
complejos.
En nuestra experiencia con el
empleo de habilidades técnicas
y mediante la selección
cuidadosa del dispositivo más
volver al sumario
acesso. Contudo, existem outras
etiologias possiveis para este
dano estrutural, de que é o
exemplo a infecção, causa pouco
comum e frequentemente
menosprezada na sua gravidade
e potenciais complicações.
11
IX
Poster SITE
F Gallardo Pedrajas, J
Fernandez Noya, J Villaverde
Rodríguez, M Martínez Pérez.
vascular. Complexo Clinico
Universitario de Santiago.
Email contacto:
[email protected]
Tlfo: 636880784
Objetivo:
presentar un protocolo rápido
(menos de 15 minutos) y eficaz
para poder realizar un esquema
con medidas y planificación en
terapia de reparación
endovascular de aneurismas de
aorta infra-renal rotos (R-EVAR)
en situaciones de emergencia.
Introducción:
En la terapia EVAR las medidas
y planificación detallada del caso
a tratar basadas en el
procesamiento de las imágenes
obtenidas en los estudios
angioTC multicorte es
imprescindible para el éxito final
del procedimiento. El
procesamiento y planificación
pueden ser realizados mediante
distintas estaciones de trabajo
disponibles en el mercado, y
todos los especialistas que
realizan terapia endovascular
deben tener los conocimientos
necesarios para realizar las
medidas y planificación en terapia
EVAR e implicarse en la elección
del dispositivo y no limitarse al
acceso vascular o al implante
manual del dispositivo durante el
procedimiento.
En situaciones de emergencia
vital como lo es el aneurisma de
aorta abdominal roto (AAA-R) el
tiempo disponible para medir y
planificar el tratamiento
endovascular está
dramáticamente disminuido. Este
motivo ha sido considerado
durante muchos años como una
contraindicación relativa al
tratamiento endovascular en
AAA-R o con datos de ruptura
inminente, junto a la disponibilidad
de un stock limitado de material
endovascular para poder afrontar
el caso con seguridad.
Material y método:
En este trabajo presentamos un
protocolo empleado por nuestro
centro para ayudar a recordar los
pasos clave en planificación y
medidas en casos urgentes de
AAA-R.
Mediante el empleo de la palabra
SANTIAGO y con una regla
nemotécnica se describen 8
pasos que deben ser siempre
tenidos en cuenta:
S: Size of the aneurysm (máximo
diámetro: aorta e ilíacas) y
visualizar Volumen Rendering.
A: Access (valoración de accesos
femorales)
N: Neck (características:
diámetro in-in, longitud, trombo,
calcio, clock time)
T: bifurcaTion (características:
diámetro, longitud, trombo, calcio)
I: Iliacs ( valorar: calcio, trombo,
diámetros internos, longitud)
A: Angulations (cuello, ilíacas)
G: LenGth – LonGitud (
Centerline con distancia de
renales a bifurcación aórtica e
ilíacas)
O: OK material (revisar que
tenemos stock disponible para lo
que necesitamos)
Tras anotar los 8 puntos clave
revisados junto a un esquema del
caso recomendamos tener ese
documento en un lugar visible en
todo momento para el equipo
que realiza el procedimiento (en
nuestro grupo en el arco en C,
bajo una funda estéril trasparente).
Conclusiones:
La terapia endovascular en rotos
ha demostrado claramente un
incremento en la supervivencia
respecto a la cirugía aórtica
abierta, especialmente en
pacientes inestables y con
elevada comorbilidad,
pudiéndose realizar con anestesia
local y sin sedo-relajación del
paciente. Consideramos que los
equipos quirúrgicos con
experiencia en terapia
endovascular programada y en
planificación EVAR deben de ser
capaces de afrontar esta urgencia
vital con las garantías suficientes
y de modo eficaz, así como
disponer del stock endovascular
necesario para poder realizarlo.
Doença adventicial
quística da artéria
poplítea – Exérese
adventicial
Autores: Duarte Rego, Paulo
Almeida, Tiago Loureiro, Luís
Loureiro, Diogo Silveira, Lisa
Borges, Sérgio Teixeira, João
Gonçalves, Vitor Ferreira,
Gabriela Teixeira, Inês Antunes,
Rui Almeida
Centro Hospitalar do Porto
Serviço de Cirurgia Vascular
TLM: 967343977
Introdução:
A doença adventicial quística é
uma causa rara de claudicação
intermitente. Caracteriza-se pelo
desenvolvimento de múltiplos
quistos na túnica adventícia. A
sua etiopatogenia não está
definitivamente estabelecida
sendo que a maioria da evidência
científica aponta para um defeito
no desenvolvimento embrionário
das artérias não axiais. Este
diagnóstico deve ser suspeitado
em homens claudicantes sem os
tradicionais fatores de risco
cardiovascular. A confirmação
diagnóstica pode basear-se no
eco-doppler, angioTAC,
angiografia ou angioRM sendo
esta última o exame de referência.
Das várias opções terapêuticas
destacam-se a exérese da túnica
adventícia, a aspiração
percutânea dos quistos
(associada a recidiva) e a exérese
do segmento arterial afetado e
reconstrução arterial com
pontagem.
118
Caso Clínico:
Homem de 60 anos, hipertenso
e dislipidémico, sem DM ou
tabagismo. Observado no SU por
edema da perna direita com 3-4
dias de evolução, sem outras
queixas associadas, com pulsos
distais bilateralmente, cujo estudo
por eco-doppler revelou imagem
sugestiva de quistos da parede
da artéria poplítea. Reobservado
na consulta após um mês, com
queixas recentes de
arrefecimento do pé direito e
hipostesias. Pulsos distais do
MIE, ausentes à direita (com pulso
poplíteo), com teste de Buerger
positivo. Realizou eco-doppler
que revelou estenose pré-oclusiva
da artéria poplítea condicionada
pelo crescimento dos quistos
adventiciais. O angioTAC
confirmou estes achados. Dada
a rápida evolução do quadro
considerou-se existir o risco de
progressão do quadro para
oclusão arterial decidindo-se pela
intervenção precoce, tendo-se
realizado no mesmo dia a exérese
da túnica adventícia da artéria
poplítea, por abordagem
posterior, com bom resultado
clínico e imagiológico final.
Discussão:
Dada a raridade desta patologia,
não existem estudos que
comparem as diferentes formas
de tratamento da doença
adventicial quística. No entanto,
os casos descritos de exérese
da túnica adventícia e respetivos
quistos apresentam resultados
positivos, parecendo por isso
uma técnica adequada desde
que a artéria esteja permeável e
sem lesão médio-intimal
estabelecida. São necessários
estudos com follow-up alargado
para determinar o risco de
complicações tardias,
nomeadamente de recidiva ou
degeneração aneurismática.
Enxerto peroneal
vascularizado
autólogo no
tratamento de
fractura complexa
da diáfise do fémur
– caso clínico
Autores: Diogo Silveira1, Rui
Machado1, César Silva2, Luís
Loureiro1, Tiago Loureiro1, Lisa
Borges1, Sérgio Teixeira1,
Duarte Rego1, Vítor Ferreira1,
João Gonçalves1, Gabriela
Teixeira1, Inês Gonçalves1,
Maria do Sameiro Pereira1, Rui
Almeida1
(1) Serviço de Angiologia e
Cirurgia Vascular, Hospital Santo
António - Centro Hospitalar do
Porto
(2) Serviço de Ortopedia e
Traumatologia, Hospital Santo
António – Centro Hospitalar do
Porto
Primeiro autor: Diogo Silveira
Contactos:
[email protected], +351 91
8385952
Tipo de Apresentação:
Comunicação oral
Introdução:
Os enxertos peroneais autólogos
vascularizados permitem uma
transferência óssea para
tratamento de defeitos ósseos
resultantes de traumatismos,
ressecções tumorais ou pseudoartroses congénitas. Este tipo de
enxertos permitem ao osso
manter as suas propriedades
osteocondutivas, osteoindutivas
e osteogénicas, sendo por isso
ideais para preenchimento de
grandes defeitos ou
reconstruções complexas,
especialmente em leitos pouco
vascularizados.
Material e Métodos:
Apresentação de caso clínico.
Revisão da literatura.
Caso clínico e
resultados:
Foi realizado o tratamento
cirúrgico de fractura cominutiva
complexa da diáfise do fémur em
jovem na terceira década de vida,
volver al sumario
Protocolo Evar
(S.A.N.T.I.A.G.O.):
Medidas y
Planificación Evar
en Urgencias.
11
IX
Poster SITE
stopped the procedure. CT at
48h confirmed angiographic
findings so a second embolization
through contralateral US-guided
superficial femoral artery was
made. Onyx was injected after
MP crossover of ABFB trough
microcatheter of LCFA.
Results:
Patient underwent successful
embolization of both arteries close
to aneurysm sac. Completion
angiography didn´t show any
apparent residual endoleak (Fig.
2). Patient had complete clinical
improvement after second
procedure and remained
asymptomatic. CT available at
last follow up (5th month) showed
no evidence of residual endoleak
and a little shrinkage in aneurysm
diameter (86 mm).
Fig. 1
Conclusão:
A reconstrução de grandes
defeitos ósseos com enxertos
vascularizados peroneais é uma
técnica viável com resultados
funcionais muito satisfatórios. Um
planeamento detalhado, o
conhecimento da vascularização
peroneal, a técnica de
anastomose arterial e o tipo de
fixação óssea são o factores de
maior importância prognostica e
de sucesso terapêutico.
Challenging
retrograde
embolization to
treat expanding
internal iliac
aneurysm after
surgical repair
Authors: Ana Ferreira, Eurico
Norton, Alfredo Cerqueira,
Sérgio Sampaio, José Teixeira.
Discussion/Conclusion:
IIAAs may grow and rupture after
exclusion, leading to challenging
decision and treatment. Multiple
collateral pathways between the
femoral and the internal iliac artery
can be embolized with a wide
range of materials. This is a
feasible technique, with minimal
surgical aggression and low
complication rate with few cases
reported in literature.
Fig. 2
previous aorto-bifemoral bypass
(ABFB) with proximal and distal
(external iliac) ligation 18 months
before, for abdominal (5.6-cm
diameter) and internal iliac 6.4cm diameter aneurysm and its
successful embolization with
ethylene vinyl alcohol (Onyx®).
Introduction:
After surgical or endovascular
aortic aneurysm repair a
persistent preexisting internal iliac
aneurysm may continue to grow
leading to a challenging treatment
once there is no direct aneurysm
access.
Aims:
We present a case of a 10-cm
left internal iliac aneurysm in a 77year-old male who underwent a
Material and methods:
Patient was admitted at
emergency with abdominal pain,
hematuria (CRF dialysis patient),
and a 2.0 g/L Hb decrease. CT
scan showed persistent flow in
the left iliac artery. Diameter
enlargement from 6.4 cm to 10.0
cm had occurred in the last 18
months. First angiography (Fig.
1) was performed by left brachial
access showing collateral flow
from the lateral circumflex femoral
artery (LCFA)(*) to the superior
gluteal artery and from the medial
circumflex femoral artery
(MCFA)(**) to the obturador (O)
artery. A two-step embolization
was then performed. First
embolization was achieved
through left brachial access, using
a 6F sheath and a Multipropose
(MP) selective catheterization of
the profunda femoral artery,
followed by supraselective MCFA
catheterization (microcatheter 1.5
F); Onyx® was used. Completion
angiogram showed slower but
persistent flow in aneurysm sac
in dependence of the LCFA artery.
Once the patient was
uncomfortable and poor left hand
perfusion was obvious, we
119
EVAR asociado a
embolización de
arteria
hipogástrica,
nuestra
experiencia.
M. Mosquera; X. Fariña; J.
Vidal, C. Gallego, E. Fraga,
J.M Encisa.
Universitario de Vigo
El manejo endovascular de los
aneurismas de aorta con
afectación iliaca continúa siendo
conflictivo para los cirujanos
vasculares. En el momento actual
la irrupción de nuevos dispositivos
en el mercado amplía las
posibilidades terapéuticas pero ,
hasta el momento, la
embolización de arterias
hipogástricas era la solución
endovascular más habitual en
nuestro centro.
Realizamos un estudio descriptivo
retrospectivo de los pacientes
tratados consecutivamente entre
Marzo de 2009 y Junio de 2014
en nuestro servicio mediante
EVAR y embolización de una o
ambas arterias iliacas internas
(AII).
Se trata de 14 pacientes, 3 de
ellos con embolización bilateral
de AII, en los que analizamos la
incidencia de claudicación glútea,
necrosis glútea y escrotal,
isquemia de colon e isquemia de
plexo lumbo-sacro. La técnica
quirúrgica se llevó a cabo en uno
o dos tiempos y el material
utilizado para la embolización
fueron dispositivos Amplatzer (
I, II) o coils .
El número de casos es limitado
para sacar conclusiones pero la
incidencia del 42% de
claudicación glútea en nuestros
pacientes nos lleva a intentar
preservar, en la medida de lo
posible, la permeabilidad de AII.
Aneurisma
aterosclerótico
isolado da
bifurcação femoral
com sobreinfeção
e em rotura
João Gonçalves, Sérgio
Teixeira, Ivone Silva, Pedro Sá
Pinto, Luís Loureiro, Tiago
Loureiro, Lisa Borges, Diogo
Silveira, Duarte Rego, Vítor
Ferreira, Gabriela Teixeira, Inês
Antunes, Rui Almeida.
Vascular.
Hospital de Santo António –
Centro Hospitalar do Porto.
joaopedrogoncalves53400@hot
mail.com – 910554665
volver al sumario
resultante de traumatismo em
acidente de viação, com enxerto
peroneal vascularizado livre. O
procedimento consistiu em
isolamento do peróneo e da sua
artéria nutritiva, secção óssea e
sua transferência para a diáfise
femoral fracturada, seguido de
fixação interna com parafusos e
anastomose em arterial láteroterminal na artéria femoral
superficial adjacente. O pósoperatório decorreu sem
intercorrências, tendo-se
conseguido uma completa
consolidação óssea. Não
ocorreram complicações
vasculares.
11
IX
Introdução/Objetivos:
Os aneurismas ateroscleróticos
da artéria femoral comum (AFC)
são raros e geralmente
associados a doença
polianeurismática. Não é habitual
terem extensão à bifurcação
femoral.
São mais frequentes em homens,
idosos, fumadores e hipertensos,
sendo a sua rotura muito
incomum.
A infeção de um aneurisma préexistente é rara e condiciona um
risco de rotura importante.
Este trabalho tem por objetivo a
apresentação do caso clínico de
um aneurisma aterosclerótico
isolado da bifurcação femoral,
infetado e em rotura.
patológica revelou tratar-se de
um aneurisma verdadeiro de
etiologia aterosclerótica. Não se
verificou, após estudo
imagiológico, a presença de
outros aneurismas.
Conclusões:
Os aneurismas infetados
apresentam-se como um desafio
de tratamento, pois a rotura
arterial, a presença de um
território infetado e, por vezes, a
localização anatómica não
permitem uma abordagem
simples, nem conservadora.
Neste caso clínico demonstra-se
uma combinação de entidades
relativamente raras (aneurisma
femoral aterosclerótico isolado e
infetado).
Resultados:
Indivíduo do sexo masculino, 72
anos, com hábitos tabágicos e
antecedentes de DM tipo 2, HTA,
dislipidemia e internamento
recente por pneumonia, que
recorreu ao SU de um hospital
periférico no contexto de uma
tumefação inguinal esquerda, não
pulsátil, com sinais inflamatórios
exuberantes e dor associada,
com 4 dias de evolução.
Por suspeita de abcesso inguinal,
realizou TC pélvico que revelou
a presença de um abcesso
inguinal adjacente a um
aneurisma da artéria femoral
comum com envolvimento da
bifurcação da mesma artéria e
em rotura.
O doente foi transferido para o
SU do nosso hospital, onde foi
submetido a aneurismectomia
femoral e a pontagem bifurcada
entre a artéria ilíaca externa e as
artérias femoral superficial e
femoral profunda com veia
grande safena invertida.
Após a cirurgia, o doente,
permaneceu sob antibioterapia
de largo espectro, tendo sido
necessárias duas re-intervenções
para remoção de tecidos
desvitalizados infetados. Teve alta
ao 39.º dia pós-operatório.
Verificou-se a presença de
estafilococos áureos no estudo
microbiológico da parede do
aneurisma e a anatomia
Isquemia distal
grave inducida por
farmaco
Coraizaca–Chicaiza N.,
Senin–Fernández M.,
Martínez–Pérez M.
Vascular, Complejo Hospitalario
de Santiago
de Compostela, Santiago de
Compostela, Galicia, España.
psoriasica intensa que provoco
isquemia distal grave en manos
y pies con lesiones de dedos.
Se instauro tratamiento
vasodilatador con
Prostaglandina (PGE1) y se
obtuvo mejoría clínica en manos,
no obteniendo resultado
satisfactorio en pies, obligando
las lesiones a una amputación
transmetatarsiana de los
mismos.
Conclusion
Se comenta este caso
excepcional y la necesidad de
un control extremo de fármacos
involucrados en tratamientos
(con efectos adversos ya
advertidos en la ficha técnica)
que pueden producir lesiones
isquémicas irreversibles con la
consiguiente amputación.
Pseudoaneurismas
femorales post
punción: 3 formas
de tratamiento
Oskarina Silva, Eugenio Senín,
Rebeca Vazquez, Alba Méndez,
Manuel Martínez
Compostela
Introduccion
La mayoría de los casos de
isquemia distal de las
extremidades, es producida por
patología degenerativa,
inflamatoria, espástica, o
infecciosa. La etiología toxica es
excepcional y la medicamentosa
extraordinariamente rara.
Objetivo
Reportar un caso de lesión distal
grave, tras tratamiento
farmacológico.
Caso clinico
varón de 41 años de edad,
sometido a tratamiento con
Anticuerpo monoclonal, anti
factor de necrosis tumoral alfa
(INFLIXIMAB) por crisis
La alta frecuencia de
procedimientos percutáneos que
se realizan en la actualidad tanto
con fines diagnósticos como
terapéuticos, y que precisan el
uso de catéteres e introductores
de gran calibre (angiografías,
cateterismos, implantes de
válvulas cardíacas, cirugía
endovascular, hemofiltros, etc),
así como la necesidad de
antiagregación/ antiagregación
en gran parte de estos pacientes,
han incrementado de forma
significativa la aparición de ciertas
complicaciones frecuentes en los
pacientes sometido a estos
precedimientos, como los
hematomas, y en menor cantidad
las fístulas arteriovenosas y los
pseudoaneurismas arteriales. Es
120
debido a esto que los servicios
de cirugía vascular deben
plantearse diferentes opciones
para su tratamiento, de acuerdo
a las características que
presentan.
De todas estas complicaciones,
los pseudoaneurismas suelen
presentar un importante reto
terapéutico, debido a la diversidad
de presentación de los mismos.
La compresión local o por
ultrasonido ha sido usada durante
muchos años, pero tiene
indicaciones limitadas y un alto
índice de recidivas. En estos
casos, o cuando se presentan
psedoaneurismas de mayo
tamaño, se solía optar por la
cirugía convencional, pero con el
uso más frecuente del eco
Doppler, y el desarrollo de
materiales heomostáticos más
eficientes, se ha podido
desarrollar una técnica para
trombosis de los mismos,
mediante punción ecoguiada.
Presentamos 50 pacientes
tratados por esta patología en
nuestro servicio en los últimos 5
años, comparando 3 técnicas
diferentes para su resolución:
compresión local, cirugía
convencional, e inyección
ecoguiada de trombina,
demostrándose la eficiencia de
ésta última técnica para resolver
de forma sencilla y poco
traumática esta complicación.
Aneurismas y
disecciones
arteriales mútiples
y de presentación
rápida y progresiva
en pacientes
jóvenes
Oskarina Silva, Alba Méndez,
Isabel Serramito, Fernando
Gallardo, Rebeca Vázquez,
Manuel Martínez.
Compostela
Las lesiones arteriales
aneurismáticas y disecantes en
pacientes jóvenes, obedecen casi
en su totalidad a patología
congénita del sistema vascular.
Dentro de este tipo, el Síndrome
de Ehler- Danlos es una de las
etiologías a descartar.
El síndrome de Ehler- Danlos se
presenta en 4 tipos, siendo el IV
el de mayor afectación vascular.
Las lesiones suelen presentarse
a lo largo de la vida del paciente
en diferentes localizaciones.
Existe una variedad excepcional,
caracterizada por una
presentación rápida, múltiples y
con varias formas lesionales
simultáneas
paciente de 23 años que presentó
hemoperitoneo espontáneo con
shock hemorrágico por lo que se
le realiza laparotomía exploradora
urgente, y tras evidenciarse
sangrado en hilio esplénico, se le
realiza esplenectomía. A los 15
días de la cirugía presenta nuevo
hemiperitoneo por lo que se
interviene de forma urgente,
comprobándose importante
sangrado el hilio hepático, se
sutura la arteria hepática y tras
hemostasia abdominal, es
trasladado en helicóptero a
nuestro centro. En el
postoperatorio presenta múltiples
complicaciones vasculares como:
aneurismas y disecciones en
tronco celíaco, mesentérica
superior y ambas ilíacas y
pseudoaneurismas femoral
derecho y cubital izquierdo que
precisaron intervención
quirúrugica por nuestro servicio.
Además presentó TVP poplítea
derecha TEP derecho.
Basándose en todos estos
hallazgos, y tras realizar estudios
para descartar múltiples
etiologías, es diagosticado de
Síndrome de Ehler- Danlos tipo
IV rápidamente progresivo
(catastrófico).
La excepcionalidad del caso que
se plantea como un reto
terapéutico y una situación de
impotencia para el tratamiento
de la misma por parte del cirujano
vascular, es el motivo de su
presentación
volver al sumario
Poster SITE
11
IX
Poster SITE
Marina Dias-Neto1,2,
José Fernando Ramos1,
José Fernando Teixeira1
Vascular do Hospital de São
João, Porto
1
2 Email:
[email protected];
Mobile phone: 00351
916750433.
A 37 years-old female patient was
seen at the emergent attendance
due to increasingly rest pain and
cold feeling of her right foot that
started 12 hours earlier.
She was an active smoker and
had hypercholesterolemia. Four
years ago she had myocardial
acute ischemia and was
submitted to coronary stenting.
Her usual medication included
aspirin, atorvastatin and ramipril.
Four and three days before
admission, she underwent two
solarium sessions. After the
second session, she developed
first-degree burns covering almost
the entire surface of trunk and
limbs with areas of seconddegree burns in left lower limb,
right upper limb and back. She
remained at home taking
analgesic medication and oral
hydration.
On the day of attendance she
experienced increased rest pain
on right foot. On physical
examination, right foot was pale,
cold, pulseless and absent flow
signals in anterior tibial, posterior
tibial and peroneal arteries were
noticed. There was no sensory
loss or muscle weakness. Left
foot, popliteal and femoral pulses
were all palpable.
An arteriogram was performed
immediately. This revealed widely
patent vessels from the common
femoral artery to the vessels of
the calf, with occlusion of the right
posterior tibial artery in the lower
third of the leg and occlusion of
the right anterior tibial artery at
the level of the ankle, which
precluded inflow to the foot
(Figure 1). Because arteriography
did not show any reconstructable
options, patient was maintained
on heparin and calcium channel
blockers.
Further undertaken
electrocardiogram and
echocardiogram were normal,
such as laboratorial analysis
including autoimmunity
parameters. After nine days of
hospital stay, there was
improvement of the ischemic
signals and triphasic pedal
Doppler signal was evident.
Patient was discharged under
hipocoagulation. Two months
after admission she returned her
normal activities without limitation.
Fístula
arteriovenosa
poplítea iatrogénica
– a propósito de um
caso clínico
Lisa Borges, Carlos Pereira,
Arlindo Matos, Luís Loureiro,
Tiago Loureiro, Diogo Silveira,
Sérgio Teixeira, Duarte Rego,
João Gonçalves, Vítor Ferreira,
Rui Almeida.
Vascular – Hospital Geral de
Santo António – Centro Hospitalar
do Porto
Endereço electrónico do primeiro
autor: [email protected]
Telefone do primeiro autor:
+351919363619
Introdução
A lesão vascular poplítea
secundária a substituição total
do joelho é rara, com uma
incidência de 0.03 – 0.51%.1,2
A lesão arterial pode provocar
trombose, com consequente
isquemia do membro, ou pode
traduzir-se por uma laceração
complicada por hemorragia, falso
aneurisma ou fístula arteriovenosa
(FAV). Os mecanismos de lesão
podem ser directos (traumatismo
por protrusão do material
ortopédico ou pelos instrumentos
cirúrgicos ou lesão térmica pelo
electrocautério), ou indirectos
(estiramento arterial causado pela
retracção ou pela manipulação
da articulação).3
O diagnóstico imagiológico
destas lesões por tomografia
computadorizada angiográfica
pode ser dificultado pelo artefacto
causado pela prótese.
Caso clínico
Doente do sexo feminino, 66
anos, submetida a intervenção
cirúrgica para colocação de
prótese total do joelho esquerdo
aos 60 anos. Desde essa data
com queixas de dor e edema da
perna, motivo pelo qual foi
enviada à consulta de Cirurgia
Vascular. Ao exame objectivo,
121
apresentava edema gemelar do
membro inferior esquerdo e sopro
audível na fossa poplítea, sem
frémito palpável, sem outras
alterações.
O ecodoppler arterial e venoso
do membro inferior esquerdo
revelou permeabilidade luminal
dos eixos venoso e arterial, com
evidência de fluxo arterial na veia
poplítea, sem outras alterações.
A tomografia computadorizada
angiográfica do abdómen e
membros inferiores revelou
ectasia da veia poplítea esquerda,
sendo a mesma contrastada
precocemente, na fase arterial,
sugerindo FAV poplítea, mas este
método de avaliação foi
comprometido pelo artefacto
causado pela prótese do joelho.
A arteriografia do membro inferior
esquerdo revelou contrastação
precoce das veias poplítea,
femoral e ilíaca, sem outras
alterações.
A doente foi submetida a
intervenção cirúrgica, com
abordagem da veia e da artéria
poplíteas através de incisão em
S na face posterior da fossa
poplítea, confirmando-se FAV
poplítea, com tributárias
abundantes e exuberantes da
veia poplítea. Procedeu-se a
laqueação das referidas tributárias
e interrupção da fístula através
de arteriorrafia e venorrafia
poplíteas.
O período pós-operatório
decorreu sem intercorrências.
Aos 6 meses de follow-up, a
doente encontra-se
assintomática, com regressão
total do edema gemelar e com
ecodoppler que demonstra
permeabilidade dos eixos arterial
e venoso do membro inferior
esquerdo, sem alterações.
implantação de uma endoprótese
numa região articular de flexão.
Bibliografia
1. Pal A, Clarke JMF, Cameron
AEP. Case Series and Literatura
Review: Popliteal artery injury
following total knee replacement.
Int J Surg 2010; 8: 430 – 5.
2. Novotny K, Pádr R, Landor I,
Sosna A. Vascular Injuries in Joint
Replacement Surgery. Acta Chir
Orthop Traumatol Cech 2011;
78(3): 200 – 7.
3. Hans SS, Shepard AD, Reddy
P et al. Iatrogenic arterial injuries
of spine and orthopedic
operations. J Vasc Surg 2011;
53: 407 – 13.
4. Mylankal KJ, Johnson B, Ettles
DF. Iatrogenic Arteriovenous
Fistula as a Cause for Leg Ulcers:
A Case Report. Ann Vasc Disc
2011; 4(2): 139 – 42.
5. Martin RT, Aléman AC. Fístula
arteriovenosa y pseudoaneurisma
poplíteo tras una meniscectomía
artroscópica. Tratamiento
endovascular com endoprótesis
Viabhan®. Radiología 2012; 54(1):
94 – 5.
6. Franz RW, Jump MA.
Endovascular repair of posttraumatic, concomitant popliteal
artery pseudoaneurysm and
arteriovenous fistula. Int J Angiol
2009; 18(1): 41 – 4.
7. Rathod JR, Dhomne S, Taori
K et al. Endovascular Stent Graft
for post-Traumatic Superficial
Femoral Artery Pseudoaneurysms
with Arteriovenous Fistula: 6
Months Follow-Up of 2 Cases. Int
Radiol 2011; 5(11): 26 – 34.
Conclusão
A opção terapêutica preferida
actualmente no tratamento de
fístulas arteriovenosas do
membro inferior é a exclusão
endovascular por stent
coberto.4,5,6,7 Neste caso em
particular, os autores preferiram
uma abordagem cirúrgica
convencional para evitar a
volver al sumario
An odd cause of
foot acute ischemia
11
IX
Poster SITE
Marina Dias-Neto1,2, José
Fernando Ramos1, Paulo
Gonçalves Dias1, Maria Luís
Silva1, José Fernando Teixeira1
1Serviço
de Angiologia e Cirurgia
Vascular do Hospital de São
João, Porto
Email:
[email protected];
Mobile phone: 00351
916750433.
2
A 24 years-old female patient was
referred to vascular surgery due
to walking pain and sporadic
nocturnal rest pain in the posterior
muscle group of her left leg
starting two years earlier. She
was kept under conservative
therapy with analgesic medication
for exacerbations. The pain had
progressed to the point of limiting
his normal daily activities such as
climbing stairs.
Twelve years before she was
submitted to surgical excision of
a vascular anomaly in the lateral
gastrocnemius muscle but the
histologic result was not available.
In the previous two years she
underwent image assessment but
results were not consistent.
Ultrasound findings suggested
haemangioma, magnetic
resonance mentioned a vascular
tumour (Figure 1) and biopsy was
favourable to recurrence of
angioma but there were no
elements to confirm this
diagnosis.
Orthopaedics and oncology
opinion was against a new
surgical resection and against
radiotherapy (because high
radiation dose would be needed
with possible sequel to the
patient). At this point an
arteriogram was obtained and
she was brought to vascular
surgery consultation.
On physical examination, a deep
non-pulsatile mass was palpable
in the middle third of the left leg.
There was no cutaneous
involvement. Foot, popliteal and
femoral pulses were all palpable.
Angiogram revealed an
hypervascular lesion with
exuberant arterial afferents
predominantly from muscular
arteries originating proximal to the
peroneal artery emergence but
also from posterior tibial and
peroneal arteries. There was also
draining veins filing early with
contrast. Although there was no
definitive diagnosis, arterial
embolization seemed feasibly and
was carried out with Onyx through
anterograde left femoral artery
(Figure 2). Immediate postoperatory corticoid and ketorolac
therapy was started. She
experienced no pain or leg
swelling after embolization and
was discharged after 4 days. After
six months of follow up she
remained asymptomatic, free of
analgesic medication and
presented mass reduction on
magnetic resonance (Figure 1).
Pseudo aneurisma
da artéria vertebral
José Pedro Pinto MD1,2;
Ricardo Castro-Ferreira MD1,2;
Pedro Almeida MD1; João
Rocha-Neves MD1 ; Jorge
Costa-lima MD1; José
Fernando Teixeira MD1
– Serviço de Angiologia e
Cirurgia Vascular do Centro
Hospitalar São João;
1
2 – Departamento de Fisiologia e
Cirurgia Cardiotorácica,
Faculdade de Medicina da
Universidade do Porto (FMUP);
Instituição: Hospital de S. João,
Vascular
Tlm 00351969515160
Introdução
Pseudoaneurismas da Artéria
Vertebral são lesões raras, graças
à sua proteção anatómica,
principalmente no segmento V2
cujo trajeto é predominantemente
interósseo.
Apesar das múltiplas etiologias,
são habitualmente de causa
traumática, nomeadamente
lesões de arma de fogo,
hiperextensão do pescoço ou
iatrogenia.
Os aneurismas vertebrais exigem
frequentemente tratamento
cirúrgico, especialmente quando
sintomáticos. Está descrita
abordagem endovascular ou
cirurgia convencional.
Material e Métodos
Neste caso apresentamos um
doente do sexo masculino, de 32
anos, enfermeiro, com
antecedentes de artrodese
anterior de C4-C7 em 2008.
Recorre ao SU por notar uma
tumefação cervical esquerda
pulsátil com 2 dias de evolução.
Ao exame objetivo apresentava
dor ligeira à movimentação, sem
sinais inflamatórios e sem défices
neurológicos.
Realizou Angio-TC no SU que
demostrou: " Pseudo - aneurisma
na região cervical direita com 49,2
(CC) x 43,7 (T) x 42,9 (AP) mm
de maiores dimensões,
correspondendo ao segmento
V2 da artéria vertebral esquerda
com trombo mural no seu
interior”.
Resultado
Foi realizada laqueação da origem
da artéria vertebral esquerda, que
decorreu sem intercorrências.
No período pós-operatório o
doente manteve-se
hemodinamicamente estável,
apirético, sem dificuldade
respiratória ou queixas álgicas.
À data de alta, ao exame
neurológico não revelava
alterações, à excepção de
síndrome de Horner incompleto
esquerdo, provavelmente
sequelar a intervenção cirúrgica
com abordagem supra-clavicular
esquerda.
O eco-doppler pós-operatório
demonstrava ausência de fluxo
na artéria vertebral esquerda.
Discussão
Atendendo à escassez de séries
publicadas de pseudo -
122
aneurismas traumáticos da artéria
vertebral, os critérios para escolha
entre cirurgia convencional ou
endovascular carecem ainda de
maior validação. A cirurgia
endovascular tem surgido como
primeira opção em séries mais
recentes mas está contraindicada
em pacientes com infeção
bacteriana ativa, pacientes que
não receberam dupla antiagregação prévia à cirurgia ou
nos quais a mesma está
contraindicada ou ainda em
pacientes com stents prévios.
Além destas, existem ainda
considerações morfológicas que
excluem a possibilidade de
tratamento endovascular. No
nosso caso, dado tratar-se de
um pseudoaneurisma de elevado
diâmetro e com colo largo, nos
quais a embolização
endovascular acarreta riscos
acrescidos, decidiu-se, com
sucesso, pela laqueação da
origem da artéria vertebral
esquerda.
Opções
terapêuticas para
lesões TASC D
aorto-ilíacas num
hospital
universitário
Autores: Luís Loureiro, Rui
Machado, Tiago Loureiro,
Diogo Silveira, Lisa Borges,
Sérgio Teixeira, Duarte Rego,
Vitor Ferreira, Joao Gonçalves,
Rui de Almeida
Vascular do Hospital de Santo
Porto, Portugal
lesões aortoilíacas tipo D de
acordo com a TASC II devem ser
tratadas por cirurgia
convencional. Os autores
apresentam vários doentes com
lesões TASC D em que se
demonstra que este critério é
apenas um dos múltiplos que
devem ser aplicados.
Apresentamos tratamentos por
cirurgia convencional, híbrida e
endovascular deste tipo de lesões
em doentes com isquemia crítica
num hospital universitário.
Materiais e métodos
Revisão de processos clínicos e
imagiológicos de doentes com
isquemia crítica por lesões
arteriais classificadas como tipo
D de acordo com a TASC II,
tratados de diferentes formas.
Foram analisados a clínica,
angioTC e angiografias,
tratamentos realizados,
resultados e seguimento.
Resultados
Um total de seis doentes foi
escolhido como exemplo e
analisados, correspondendo às
seis lesões aorto-ilíacas descritas
pela TASC II como tipo D. A idade
média dos doentes foi 68,3anos
(54-78), sendo todos do sexo
masculino. A clínica era de dor
em repouso em 50% e lesão
trófica em 50%. O tratamento foi
cirurgia convencional em 50%,
cirurgia híbrida em 34% e cirurgia
endovascular em 16%. O
seguimento médio foi de 110
dias(10-196).
Discussão
A indicação da terapêutica
cirúrgica mantém-se baseada nos
sintomas, risco clínico, tipo
morfológico de lesão e
experiência do centro/cirurgião
sendo difícil definir um protocolo
terapêutico uniforme.
Introdução
A Inter-Society Consensus for the
Management of Peripheral Arterial
Disease (TASC II) publicada em
2007 pretendeu uniformizar a
classificação das lesões
obstrutivas arteriais de acordo
com critérios morfológicos. As
volver al sumario
Embolization of a
symptomatic leg
vascular anomaly
with Onyx
11
IX
Poster SITE
Autores: Rui Machado, Carlos
Pereira, Luís Loureiro, Tiago
Loureiro, Lisa Borges, Rui de
Almeida
Vascular do Hospital de Santo
Porto, Portugal
O entrapment da artéria poplítea
é uma causa rara de isquemia
dos membros inferiores. Como
tal, alguns cirurgões nunca
tiveram contacto com esta
patologia.
Os autores apresentam o vídeo
de uma cirurgia efectuada a um
doente do sexo masculino, 50
anos e claudicação incapacitante
bilateral. O doente apresentava
clínica e imagiologicamente sinais
de entrapment da artéria poplitea
(tipo II) bilateralmente.
O tratamento foi realizado em
dois tempos cirúrgicos.
Descreve-se a técnica cirúrgica
utilizada para este tipo de
entrapment (hipertrofia da cabeça
medial do gastrocnémio).
La fibrinolisis
¿es una opción
válida para mejorar
la permeabilidad
de las
reconstrucciones
infrainguinales?
R. Vázquez Dopazo, J.
Fernández Noya, N. Coraizaca
Chicaiza, O. Silva González, M.
Martínez Pérez.
Compostela.
Rebeca Vázquez Dopazo
dopazo84gmail.com
Tlf.+0034629761251
La oclusión aguda de una
reconstrucción arterial
convencional o endovascular
lleva consigo, además del cuadro
de isquemia aguda, en ocasiones,
la imposibilidad de una nueva
revascularización y la pérdida de
extremidad.
El tratamiento fibrinolítico
inmediato no sólo puede mejorar
el cuadro isquémico sino también
salvar la reconstrucción arterial
al permitir detectar la causa de
la oclusión. Presentamos nuestra
experiencia en la terapia
fibrinolítica con Urokinasa en el
tratamiento de las trombosis de
reconstrucciones arteriales
infrainguinales. Para ello hemos
realizado un análisis de los
pacientes intervenidos mediante
esta técnica desde enero del
2007 a enero del 2015. Se
analizaron un total de 29
pacientes (17.24% mujeres y
82.75% varones) con una edad
media de 65.48 años. El 79.32
% presentaban trombosis de
bypass protésico y el 20.68%
eran portadores de Viabahn.
Obtuvimos un éxito técnico inicial
del 86.20% .En todos ellos, salvo
en un paciente fué indentificada
la lesión causante de la oclusión.
El porcentaje de complicaciones
fue del 32% y la mortalidad
perioperatoria del 8 %.
A vista de nuestra experiencia
creemos que la terapia fibrinolítica
implantada precozmente, puede
ser una actitud válida para mejorar
la permeabilidad de las
reconstrucciones arteriales
fémoro-poplíteas.
Oligúria induzida
pelo exercício em
doente com
aloenxerto renal
Sérgio Teixeira, Pedro Sá Pinto,
Ivone Silva; João Gonçalves;
Luís Loureiro; Tiago Loureiro;
Diogo Silveira; Lisa Borges;
Duarte Rego; Vítor Ferreira;
Gabriela Teixeira; Inês Antunes;
Rui Almeida
Vascular.
Centro Hospitalar do Porto –
Hospital Geral de Santo António.
[email protected]
00351 964813414
Comunicação Oral
A transplantação renal, por
norma, é realizada em doentes
com elevado risco cardiovascular.
Embora incomum, a estenose
dos eixos ilíacos proximais à
artéria do rim transplantado pode
ser uma causa de disfunção do
enxerto.
Este trabalho pretende apresentar
um caso clínico de disfunção do
enxerto renal, com variações
circadianas no débito urinário
dependentes da deambulação,
secundária a estenose da artéria
ilíaca comum (AIC) proximal à
anastomose do enxerto.
Caso Clínico:
Trata-se de uma doente do sexo
feminino, 51 anos, com doença
renal crónica de origem
desconhecida, múltiplos fatores
de risco cardiovascular
(hipertensão arterial, dislipidemia,
tabagismo, obesidade, diabetes
melitos tipo 2) e doença arterial
periférica (grau IIa pela
classificação de LericheFontaine), submetida a
transplante renal com aloenxerto
de cadáver. Cerca de 19 meses
após o transplante renal, iniciou
agravamento progressivo da
função do enxerto, sem alteração
da medicação ou eventos
agudos. A diurese apresentava
um predomínio noturno (quando
se encontrava em decúbito dorsal
e não deambulava). Realizou
avaliação do enxerto renal por
ecodoppler, que mostrou um rim
globalmente bem perfundido,
índices de resistência de 0.6,
curvas de morfologia monofásica
na artéria ilíaca externa proximal
e distalmente ao local da
anastomose arterial e estenose
hemodinamicamente significativa
na AIC (confirmada por
arteriografia do sector aortoilíaco). Durante o período de
123
estudo, apresentou episódio de
edema agudo do pulmão com
anúria, ocorrendo a necessidade
de reiniciar hemodiálise.
Foi efetuada angioplastia
transluminal percutânea de
ambas as AIC’s por kissing
balloon e posterior kissing stent
com bom resultado imagiológico
e hemodinâmico final.
No período pós-intervenção,
houve uma recuperação
progressiva da diurese e da
função renal, com retorno aos
valores de creatinina basais.
Discussão/Conclusão:
Este caso retrata o “roubo” renal
provocado pela presença de uma
estenose com significado
hemodinâmico nos eixos arteriais
proximais à anastomose do
enxerto. Neste contexto, as
baixas resistências vasculares
periféricas secundárias ao
exercício condicionam uma
diminuição da perfusão do
enxerto renal.
As terapêuticas endovasculares,
tendo em conta a sua baixa
morbilidade, assumem-se como
terapêuticas de primeira linha
neste tipo de doentes, permitindo
a normalização da função do
enxerto renal.
Endoleak tipo ii
como causa de
endoleak tipo i
Gabriela Teixeira, Rui
Machado, Luís Loureiro, Tiago
Silveira, Sérgio Teixeira, Duarte
Rego, Vítor Ferreira, João
Gonçalves, Inês Antunes,
Arlindo Matos, Rui Almeida
Centro Hospitalar do Porto
Vascular
[email protected]
+351 91 996 85 86
Introdução
O Endoleak Tipo II (T2EL) tem um
curso relativamente benigno, com
percentagem elevada de
resolução espontânea (~80%) e
risco mínimo de ruptura (<1%),
estando a correção cirúrgica
apenas indicada nos casos em
que há crescimento de saco
aneurismático. Contudo, está
descrito na literatura a
possibilidade dos T2EL
condicionarem o aparecimento
de endoleak tipo I ou tipo III, o
que altera o seu prognóstico.
Objetivos
Apresentação clínica e
imagiológica de um caso clínico
em que um endoleak tipo II
condiciona o aparecimento de
endoleak tipo I. Revisão da
literatura sobre o tema.
Materiais e Métodos
Revisão do processo clínico e
imagiológico do doente. Revisão
da literatura existente sobre a
matéria no Google Scholar,
Medline e Cochrane Library.
Resultados
Caso Clínico:
Sexo masculino, 63 anos de
idade, médico, com antecedentes
de etilismo (100g/dia), tabagismo
pesado (100 UMA), DPOC,
disfagia sequelar a cirurgia e
radioterapia por carcinoma
espinocelular da cavidade oral e
internamento em Maio de 2012
por hiponatremia euvolémica
hiposmolar multifatorial, com
suspeita de demência
frontotemporal por deterioração
cognitiva. Reinternado em Junho
de 2012 por hiponatremia e
pneumonia nosocomial. A
20/06/2012, decorrente da
investigação da pneumonia,
achado imagiológico de
espessamento parietal da aorta
descendente sugerindo úlcera
penetrante da aorta torácica, com
hematoma periaórtico. Fez
angioTC seriadas objetivando
crescimento da úlcera: 11mm (3º
dia) e 13mm (6º dia). Entretanto,
estado clínico agravado por
paragem cárdio-respiratória após
engasgamento, tendo sido
admitido na UCI. Assim, doente
com múltiplas co-morbilidades,
DNR e indicação cirúrgica só se
esperança média de vida superior
a 1 ano.
volver al sumario
VIDEO
Entrapment da
artéria poplítea
11
IX
Poster SITE
Discussão
O T2EL é o endoleak mais
comum, assim como a
complicação pós-EVAR mais
frequente, com uma incidência
estimada de 10%1. A sua história
natural é relativamente benigna,
com 80% de taxa de remissão
espontânea2 e taxa de ruptura
inferior a 1%3.
A indicação cirúrgica só se impõe
quando este endoleak condiciona
um crescimento progressivo do
saco aneurismático.4 No entanto,
os T2EL podem condicionar
outras complicações, estando
reportada a associação com
endoleaks tipo I e tipo III,
extravasamentos ocultos ou de
postura, buracos na linha de
sutura ou falência tardia de
prótese.5
Um estudo retrospetivo com 42
pacientes com crescimento do
saco aneurismático por endoleak
tipo II documentou um
diagnóstico inesperado de
endoleak tipo I ou tipo III em 21%
dos pacientes.6 Numa casuística
de Sidloff et al7, que estudou 904
pacientes consecutivos
submetidos a EVAR, dos 27
doentes que desenvolveram
endoleak tipo I, 6 tinham endoleak
tipo II. Contudo, o estudo conclui
que a associação entre estes dois
endoleaks não é estatisticamente
significativa.
“Endoleak type II”
and Rupture of a
Popliteal Artery
Aneurysm after
Elective Surgical
Approach: A Case
Report
Conclusões
Centro Hospitalar de Vila Nova
de Gaia e Espinho
Vascular
[email protected]
Contact – 00351916919113
Com a descrição deste caso,
colocamos a possibilidade de um
endoleak tipo II condicionar o
aparecimento endoleak tipo I, o
que altera o seu prognóstico dito
benigno.
Authors: Coelho, A.; Lobo, M.;
Meira, J. ; Barreto, P. ; Gouveia,
R.; Sousa, P.; Campos, J.;
Augusto, R.; Canedo, A.;
Introduction
Bibliografia
1 Type II endoleak: conservative
management is a safe strategy. Sidloff
DA, Gokani V, Stather PW, Choke
E, Bown MJ, Sayers RD. Eur J Vasc
Endovasc Surg. 2014 Oct;48(4):3919.
2 Rutherford's Vascular Surgery, Jack
L. Cronenwett and K. Wayne
Johnston. Chapter 132, 2046-2061
3 Type II endoleak after endovascular
aneurysm repair. Sidloff DA, Stather
PW, Choke E, Bown MJ, Sayers RD.
- Br J Surg - September 1, 2013;
100 (10); 1262-70
4 Is a type II endoleak after EVAR a
harbinger of risk? Causes and
outcome of open conversion and
aneurysm rupture during follow-up.
Van Marrewijk CJ, Fransen G, Laheij
RJ, Harris PL, Buth J; EUROSTAR
Collaborators. Eur J Vasc Endovasc
Surg. 2004 Feb;27(2):128-37.
5 Re: 'Type II Endoleak: Conservative
Management Is a Safe Strategy'
Gomes Oliveira NF, Bastos
Gonçalves F, Verhagen HJ. Eur J
Vasc Endovasc Surg. 2014 Nov 4
6 Outcomes of percutaneous
endovascular intervention for type II
endoleak with aneurysm expansion.
Aziz A, Menias CO, Sanchez LA,
Picus D, Saad N, Rubin BG, Curci
JA, Geraghty PJ. J Vasc Surg. 2012
May;55(5):1263-7
7 Type II endoleak: conservative
management is a safe strategy. Sidloff
DA, Gokani V, Stather PW, Choke
E, Bown MJ, Sayers RD. Eur J Vasc
Endovasc Surg. 2014
Oct;48(4):3919.
Popliteal artery aneurysms are
rare in the general population (1%
prevalence). They are found
almost exclusively in men, and
approximately 50% are bilateral
and 30-50% of patients may have
an associated abdominal aortic
aneurysm. The concomitant
presence of aneurysms in other
vascular territories is rather rare.
There are several possible surgical
approaches to popliteal
aneurysms including exclusion of
the aneurysm and bypass or
endoaneurysmorrhaphy and
interposition of a prosthetic
conduit. The latter has the
advantage of allowing ligature of
collateral blood flow to the
aneurismal sac from genicular
arteries thereby diminishing the
risk of post-operative aneurysm
growth mimicking type II
endoleak.
Case Report
The patient is a 79-year-old man,
regularly followed-up in another
institution for multisectorial
aneurismal disease (including
aortic, celiac trunk, common,
internal and external iliac arteries,
and popliteal arteries), after being
submitted to emergency repair of
a popliteal aneurysm (50 mm
diameter) in 2006 due to acute
ischemia of the left inferior limb.
The procedure was performed
through posterior approach with
interposition of a prosthetic
conduit. In 2007 he was
124
submitted to elective open
treatment of the right popliteal
artery aneurysm (40 mm
diameter) by posterior approach
with proximal and distal ligation
of the aneurysm without
bypass with a prosthetic conduit.
Seven years later he was admitted
in the emergency department of
our hospital with a rapidly
expanding mass in the right
popliteal fossa. The popliteal,
posterior tibial and pedal pulse
were palpable. The CTA revealed
a functioning bypass and a
contained rupture of the popliteal
artery aneurysm with the
formation of a false aneurysm,
confirmed intra-operatively with
the identification of 3 genicular
arteries backbleeding to the
aneurismal sac.The procedure
consisted of
endoaneurysmorrhaphy of the
collaterals and hematoma
drainage through the posterior
approach. The patient recovered
with no complications.
Isquemia aguda do
membro superior
por embolização de
aneurisma da
artéria braquial em
doente com FAV da
prega do cotovelo
previamente
laqueada
Joel Sousa1; João RochaNeves1; Augusto RochaSilva2; Eurico Norton2;
Jorge Costa Lima3;
José Teixeira José4
1- Interno de Cirurgia Vascular do
Hospital de S. João
Assistente Hospitalar de
Cirurgia Vascular do Hospital de
S. João
3- Assistente Hospitalar
Graduado de Cirurgia Vascular
do Hospital de S. João
4- Director de Serviço do Serviço
de Cirurgia Vascular do Hospital
de S. João
Contactos:
[email protected]
Telefone: +351 913662417
2-
Introdução:
Discussion
Popliteal artery aneurysm rupture
after exclusion and bypass is a
rare event. In this case, rupture
ocurred without prodromal
symptoms, after significant
aneurysm expansion. Continued
perfusion originating in a
retrograde fashion through the
superior and inferior lateral
genicular arteries is believed to
be responsible for the growth of
the popliteal aneurysm after
successful exclusion from
antegrade arterial flow. Continued
perfusion resulted in continued
pressurization of the aneurysm
sac (similar to type II endoleaks
after EVAR). A conclusion to this
case report might me that
popliteal artery aneurysms that
have been successfully treated
by exclusion and bypass may
benefit from postoperative
ultrasound examination to ensure
no increase in size has occurred
Os aneurismas da artéria de
inflow das fistulas arterio-venosas
constituem uma complicação
rara, ocorrendo particularmente
em pacientes transplantados sob
imunossupressão.
Objectivos:
Apresentação de um caso clínico
de isquemia do membro superior
por embolia, com ponto de
partida em aneurisma da artéria
braquial, em contexto de fístula
arteriovenosa (FAV) braquiocefálica laqueada 5 anos antes. Caso clínico:
anos. Iniciou programa regular
de hemodiálise em 2001 por FAV
braquiocefálica esquerda, por IRC
de etiologia indeterminada.
Submetido a transplante renal
em 2003 e laqueação de FAV em
2009 por síndrome de roubo da
mão. Como antecedentes
relevantes, destacam-se múltiplos
factores de risco cardiovascular
e patologia psiquiátrica,
devidamente medicados e
controlados.
Deu entrada no Hospital de S.
João com quadro de
arrefecimento da mão esquerda,
volver al sumario
No período que se seguiu, doente
com boa evolução clínica e
analítica, sendo que após 30 dias
se apresentava vígil, orientado e
colaborante, com normonatremia,
estável do ponto de vista
cognitivo e com resolução da
pneumonia. Foi revista a
indicação cirúrgica do doente,
tendo-se decidido intervir. A
23/07/2012 foi submetido a
exclusão de úlcera aórtica
descendente com endoprótese
Medtronic Valiant 26x100x26.
Em angioTC de controlo realizada
a 13/09/2012, documentou-se
aneurisma estável, com endoleak
tipo II proveniente de artéria
intercostal. Achado confirmado
em angioTC de 03/10.
Em angioTC de controlo de
23/01/2013 observa-se aumento
do tamanho do aneurisma, com
extremidade distal da prótese
protuindo para dentro do
aneurisma, constatando-se assim
endoleak tipo I e tendo sido
colocada extensão com nova
endoprótese a 01/04/2013
(endoprótese recoberta Valiant
26/26/150) .
Aos 20 meses de follow up, após
correção de endoleak, doente
encontra-se com bom estado
geral, activo social e
profissionalmente, com saco
aneurismático estável.
11
IX
Poster SITE
Resultados:
No pós-operatório imediato, com
reversão total das queixas e sinais
de má perfusão do membro. Sem
limitação funcional.
Por Cirurgia Vascular, com
condições para alta ao 3º dia pósoperatório. Teve alta orientado
para a consulta externa de C.
Vascular, onde foi observado
algumas semanas após, com
manutenção da estabilidade
clínica descrita à data de alta.
Conclusões:
Tendo em conta a sua elevada
patência e baixa taxa de
complicações, a fistula
arteriovenosa constitui o acesso
vascular de eleição para
hemodiálise em pacientes com
insuficiência renal terminal.
Menos comum, a degeneração
aneurismática da artéria de inflow
pode constituir uma complicação
das fistulas arteriovenosas para
hemodiálise, provavelmente
como consequência do elevado
fluxo da mesma durante um longo
período de tempo. Esta
degeneração não é prevenida
após laqueação ou trombose da
fístula, e está mesmo associada
com história de transplante renal
e imunossupressão subsequente.
Embora a dilatação aneurismática
se desenvolva ao longo de um
vasto período de tempo, um
rápido aumento do diâmetro do
aneurisma é normalmente
descrito alguns dias a meses
antes da avaliação. Clinicamente
manifesta-se na maioria dos
casos por dor e edema, com o
desenvolvimento de uma
tumefacção clinicamente
evidente. A embolização distal
está descrita em
aproximadamente 30% dos
casos, devendo-se normalmente
à mobilização de trombo
geralmente presente no interior
do aneurisma. A compressão
nervosa com consequentes
parestesias pode ocorrer, embora
seja rara.
Constituem indicações para a
correcção da dilatação
aneurismática, a presença de
diâmetro superior a 30mm,
complicações (embolização distal
ou dor) e possibilidade técnica.
Idealmente deve dar-se
preferência a condutos autólogos,
sendo a veia cefálica ou basílica
ipsilateral, se não dilatada, o
conduto de eleição.
Rotura pós eva
A propósito de
2 casos clínicos
Vítor Ferreira, Rui Machado,
Joana Martins, Luís Loureiro,
Tiago Loureiro, Lisa Borges,
Diogo Silveira, Sérgio Teixeira,
Duarte Rego, João Gonçalves,
Rui Almeida
Vascular – Hospital de Santo
António, Centro Hospitalar do
Porto
[email protected]
Telemóvel: 934778240
Introdução:
O objectivo do EVAR é a
prevenção da rotura do
(AAA). No entanto, a taxa de
rotura é 0.5-1.2% por ano após
o tratamento endovascular. A
maioria das roturas ocorre nos
primeiros 3 anos e a causa mais
frequente é o endoleak (tipo I e
III). Outros factores associados à
rotura são: grande diâmetro do
aneurisma pré procedimento,
endoleak tipo II persistente (> 6
meses) e o sexo feminino.
Apresenta-se dois casos clínicos
de rotura aneurismática após
tratamento endovascular, ambos
provocados por endoleak tipo I.
Caso 1:
83 anos, sexo masculino.
Antecedentes de cardiopatia
isquémica (CABG), bloqueio
auriculo-ventricular (portador de
pace-maker). Foi submetido a
tratamento electivo de AAA em
Dezembro de 2005 com
endoprótese aorto-bi-iliaca
Medtronic® Talent. Manteve
follow-up em consulta externa
com controlo anual por TAC. Em
2009 é admitido no Serviço de
Urgência por dor hipogástrica e
náuseas. Fez angioTC abdominal
que evidenciava migração caudal
da endoprótese com rotura
aneurismática. Foi submetido a
tratamento endovascular urgente
com colocação de extensor
aórtico Medtronic® Endurant,
sem intercorrências intraoperatórias. Faleceu ao 3º dia de
pós-operatório por complicações
cardíacas.
Caso 2:
86 anos, sexo masculino.
Antecedentes de HTA,
cardiopatia isquémia, DPOC, IRC
estadio III. Submetido a
tratamento endovascular de AAA
em 2003 com endoprótese
Medtronic® Talent noutra
instituição hospitalar. Em 2006
apresentou endoleak tipo 2
tratado com laqueação de
artérias lombares e artéria
mesentérica inferior na mesma
instituição e em 2012 endoleak
tipo 1b, tratado com extensor
ilíaco esquerdo. Em 2013 é
admitido no Serviço de Urgência
da nossa instituição com rotura
do aneurisma com 17cm de
diâmetro e é tratado com
colocação de extensor aórtico.
Na 2º semana pós-operatório por
apresentar novo endoleak tipo I
foi submetido a re-dilatação do
125
extensor. Durante o internamento
apresentou agravamento da
insuficiência renal com
necessidade de início de
hemodiálise.
Conclusão:
Apesar de um follow-up
adequado, a rotura aneurismática
pós tratamento endovascular por
ocorrer e constitui a falência do
tratamento. Esta é associada a
elevada morbilidade e
mortalidade. Nos casos
apresentados a rotura foi
provocada por endoleak tipo I e
migração distal da prótese, pondo
em questão se a fixação não
activa pode estar relacionada.
Aortoesophageal
fistula –
endovascular
repair, the
emergency solution
for a fatal condition
J. Campos, P. Barreto, V.
Martins, J. Vasconcelos, R.
Gouveia, P. Sousa, A. Coelho,
R. Augusto, A. Canedo
Introduction:
Aortoesophageal fistula (AEF) is
an extremely rare cause of
massive upper gastrointestinal
bleeding associated with a high
morbidity and mortality.
We report a case of successful
emergency endovascular repair
of a life-threatening haemorrhage
from an AEF.
Case report:
A 65 year-old man was admitted
in the emergency department of
a referring Hospital with an upper
gastrointestinal bleeding. He had
a previous history of gastric
cancer, submitted to total
gastrectomy (esophagojejunal
anastomosis) and adjuvant
chemo and radiotherapy about
ten years ago. The patient was
submitted to an upper digestive
endoscopic exam that showed a
15mm diameter defect in the
distal wall of the esophagus, just
above the esophagojejunal
anastomosis, with no signs of
active bleeding. Twenty-two
hours after admission he
developed massive hematemesis
and melena with hypovolemic
shock and was admitted to the
intensive care unit. An emergency
right thoracotomy was performed,
a Sengstaken-Blakemore tube
was inserted and inflated but
failed to stop the bleeding. During
the surgery the patient
experienced two episodes of
cardiac arrest responding to
cardiopulmonary and fluid
resuscitation. A computed
tomography angiography (CTA)
showed an AEF just above the
esophagojejunal anastomosis.
The patient was transferred to
our hospital where an emergent
placement of a thoracic aorta
stent-graft (Medtronic Captivia®)
was achieved, to prevent fatal
exsanguination. Final angiogram,
after Sengstaken-Blakemore tube
deflation, showed closure of the
AEF. Subsequent CTA three days
later revealed well positioning and
permeability of the stent-graft and
no signs of continuing bleeding.
No other events were reported
during hospital stay and the
patient was again transferred to
the referring Hospital, three days
after the procedure, under
parenteral nutrition and
intravenous antibiotic therapy.
The patient remained
hemodynamically stable, and
extubation was performed. The
subsequent post-procedure
course was uneventful and the
patient was discharged to a
hospital in France where he
resides. No follow-up information
was achieved after this
transference.
Conclusions:
Endovascular stent-grafting is an
effective and minimally invasive
alternative in treating AEF in the
emergency setting. This approach
allows the patient to recover from
the initial insult and undergo an
elective and more definitive repair
at a later time.
Apresentação pretendida: Poster
Jacinta Maria Pinto Campos
Centro Hospitalar de Vila Nova de
Gaia/Espinho
Vascular
E-mail: [email protected]
Contacto telefónico: 933907327
volver al sumario
dor e parestesias com algumas
horas de evolução. Sem défice
motor aparente à admissão.
Refere história de tumefacção da
prega do cotovelo, de
aparecimento súbito
aproximadamente 1 semana
antes, e assintomática até então,
altura em que após manipulação
da mesma terão surgido os
sintomas que motivaram a vinda
à urgência. Ao exame objectivo,
sem pulsos braquial, radial e
cubital. Fluxometria com sinal
trifásico na origem da artéria
axilar.
Admitido para realização de
arteriografia, a qual revelou
aneurisma da artéria braquial com
aproximadamente 3cm de
diâmetro máximo, com trombo
mural abundante, assim como
trombose dos eixos arteriais
distalmente ao mesmo.
Submetido a aneurismectomia
da artéria axilar, bypass braquiobraquial com veia grande safena
invertida e tromboembolectomia
dos eixos distais do membro
superior. No final da intervenção,
com pulso radial palpável.
11
IX
Poster SITE
João Gonçalves, Sérgio
Teixeira, Ivone Silva, Pedro Sá
Pinto, Luís Loureiro, Tiago
Silveira, Duarte Rego, Vítor
Ferreira, Gabriela Teixeira,
Inês Antunes, Rui Almeida.
Vascular.
Centro Hospitalar do Porto.
joaopedrogoncalves53400@hot
mail.com – 910554665
Resultados:
Os aneurismas ateroscleróticos
da artéria femoral comum (AFC)
são raros e geralmente
associados a doença
polianeurismática. Não é habitual
terem extensão à bifurcação
femoral.
São mais frequentes em homens,
idosos, fumadores e hipertensos,
sendo a sua rotura muito
incomum.
A infeção de um aneurisma préexistente é rara e condiciona um
risco de rotura importante.
Este trabalho tem por objetivo a
apresentação do caso clínico de
um aneurisma aterosclerótico
isolado da bifurcação femoral,
infetado e em rotura.
anos, com hábitos tabágicos e
antecedentes de DM tipo 2, HTA,
dislipidemia e internamento
recente por pneumonia, que
recorreu ao SU de um hospital
periférico no contexto de uma
tumefação inguinal esquerda, não
pulsátil, com sinais inflamatórios
exuberantes e dor associada,
com 4 dias de evolução.
Por suspeita de abcesso inguinal,
realizou TC pélvico que revelou
a presença de um abcesso
inguinal adjacente a um
aneurisma da artéria femoral
comum com envolvimento da
bifurcação da mesma artéria e
em rotura.
O doente foi transferido para o
SU do nosso hospital, onde foi
submetido a aneurismectomia
femoral e a pontagem bifurcada
entre a artéria ilíaca externa e as
artérias femoral superficial e
femoral profunda com veia
grande safena invertida.
Após a cirurgia, o doente,
permaneceu sob antibioterapia
de largo espectro, tendo sido
necessárias duas re-intervenções
para remoção de tecidos
desvitalizados infetados. Teve alta
ao 39.º dia pós-operatório.
Verificou-se a presença de
estafilococos áureos no estudo
microbiológico da parede do
aneurisma e a anatomia
patológica revelou tratar-se de
um aneurisma verdadeiro de
etiologia aterosclerótica. Não se
verificou, após estudo
imagiológico, a presença de
outros aneurismas.
Conclusões:
Os aneurismas infetados
apresentam-se como um desafio
de tratamento, pois a rotura
arterial, a presença de um
território infetado e, por vezes, a
localização anatómica não
permitem uma abordagem
simples, nem conservadora.
Neste caso clínico demonstra-se
uma combinação de entidades
relativamente raras (aneurisma
femoral aterosclerótico isolado e
infetado).
volver al sumario
Aneurisma
aterosclerótico
isolado da
bifurcação femoral
com sobreinfeção
e em rotura
126
volver al sumario
11
IX
Calendario de Congresos - Congress Calendary
July
07
July 2-4, 2015
September
16th Annual Meeting of the EVF
St. Petersburg, Russia
09
www.europeanvenousforum.org
September 10-13, 2015
ISVS 2015
The Athens Hilton Hotel
Athens, Greece
www.isvscongress.com
July 11, 2015
ESVS Annual Meeting 2015
Alfandenga Conference Center
Porto, Portugal
San Diego Cardiovascular
Interventions 2015
San Diego, CA
www.esvs.org
www.sdinterventions.com
08
August 01, 2015
Phone: +351 211 147 160
Fax: +351 211 147 169
www.cirse.org
NCVH New Jersey:
Comprehensive Cardiology
Symposium
Bally’s Atlantic City Hotel
Atlantic City, NJ
Contact: www.ncvh.org/ncvh-new-jersey
Southeast Structural Heart Symposium
Saturday, August 15, 2015
JW Marriott Atlanta Buckhead
Atlanta, GA
www.isesonline.org/ises-southeast.html
IDEAS 2015
Centro de Congressos de Lisboa
Lisbon, Portugal
www.aorticideas.org
volver al sumario
August
CIRSE 2015
Congress Center
Lisbon, Portugal
128
11
IX
Palex Medical SA
lanza al mercado
el nuevo Balón de
Valvuloplastia Aórtica
V8®
La empresa Palex Medical SA anuncia el lanzamiento
al mercado de la nueva generación de Balones de
Valvuloplastia Aórtica V8® (InterValve). La Valvuloplastia
Aórtica se suele realizar en pacientes que presenten
Estenosis Aórtica. El procedimiento consiste en la
dilatación de la válvula aórtica severamente calcificada
con un balón con el fin de romper el calcio, mejorar la
apertura y así permitir un mejor funcionamiento de la
misma.
El V8® es un balón que tiene forma de 8, de inflado
rápido y que mantiene la cintura durante el
procedimiento. El Balón V8® permite:
• Realizar una hiperextensión de las valvas (mejora su
función)
• Fijar fácil y rápidamente el balón en el anillo aórtico
(se autocoloca)
• Prescindir de la estimulación rápida (inflado y desinflado
muy rápido)
Beneficios para el paciente:
- mejoría de la función valvular
- menor riesgo de afectación del anillo aórtico
- menor isquemia e hipotensión
- menor riesgo de afectación del ritmo cardíaco
volver al sumario
Con V8®, Palex Medical SA sigue aportando al día-adía de los profesionales sanitarios soluciones que
incrementan la calidad de vida del paciente y promueven
la mejora del servicio asistencial sanitario.
Para más información consulte www.palexmedical.com
o síganos en Twitter @PalexMedical.
129
11
IX
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130
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IX
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131
11
IX
Editorial
Trabajos originales
Revisiones
Casos clínicos
Imágenes endovasculares
Notas técnicas
Zona catastrófica
Novedades desde la industria
Cartas al Director
Bolsa de Trabajo e intercambio
profesional
Congresos
tamaño 12 (preferiblemente tipo Times, Arial
o Currier), con interlineado doble y con las
páginas numeradas. El idioma deberá ser
Español o Inglés.
Revisiones
Referencias Bibliográficas:
Se numeraran según aparición correlativa en
el texto. Para la citación de los trabajos se
utilizarán las normas que aparecen detalladas
en ‘Uniform Requeriments for Manuscripts
Submitted to Biomedical Journals’, NEJM 1997;
336:309-316.
A modo de ejemplo:
Se asignará por invitación desde la redacción
de TE.
Articulo: Kioka Y, Tanabe A, Kotani Y, Yamada
N, Nakahama M, Ueda T, et al. Review of
coronary artery disease in patients with
infrarenal abdominal aortic aneurysm. Circ J
2002;66:1110-2
Trabajos originales:
Capitulo de Libro:
Se consideran trabajos originales aquellos que
no hayan sido publicados en otros medios de
comunicación escrita medica. Deberán constar
de la estructura siguiente:
Coselli JS, Buket S, Crawford ES. Thoracic
Aortic Aneurysms. En: Haimovici H, Ascer E,
Hollier LH, Strandness DE, Towne JB, eds.
Vascular Surgery. Cambridge (USA), Blackwell
Science, 1996; 759-785
Editorial:
Resumen en Español y Abstract en Inglés
(máximo 250 palabras)
Introducción
Material y Métodos
Resultados
Discusión y conclusiones
Referencias Bibliográficas
Importante:
Cada uno de los apartados anteriores iniciará
página. En la primera página deberá figurar el
título completo, los autores, el centro de trabajo,
la persona de contacto para la correspondencia
con su dirección postal y e-mail, la sección a
la que va dirigida y la fecha de envío. Asimismo
deberá confeccionar un titulo corto y facilitar
palabras clave (mínimo de 3 y máximo de 6)
El manuscrito se redactará con letras de
máximo de 5 tablas por trabajo. Cada tabla
deberá identificarse con un breve texto
explicativo.
Se aceptarán para su valoración aquellos
trabajos de revisión que por su actualidad o
controversia susciten la atención de los
especialistas relacionados con las terapéuticas
endovasculares. Se podrán solicitar
explícitamente desde la redacción o bien
someter libremente según iniciativa de sus
autores. Deberán seguir las mismas normas
de redacción y presentación que aparecen
para los trabajos originales. No obstante, su
estructuración deberá contemplar:
Resumen (Español) y abstract (Inglés)
Introducción
Desarrollo
Conclusiones
Referencias Bibliográficas
Casos clínicos
Figuras:
Las figuras irán numeradas (números árabes)
correlativamente según aparición en el texto.
Se aceptará un máximo de 5. Las imágenes
deberán indicar su orientación. Las figuras en
color se reproducirán del mismo modo si su
interés lo hace imprescindible. De modo
contrario, se reproducirán en escala de girses.
Se adjuntará en página aparte los pies de
figura.
Tablas:
Las Tablas se numerarán con números
romanos correlativos según su orden de
aparición en el texto. Se aceptará hasta un
132
Se aceptarán para su valoración los casos
clínicos singulares y originales. Seguirán las
normas de redacción ya mencionadas en
apartados anteriores. Si bien su estructuración
deberá ser:
Resumen (Español) y Abstract (Inglés)
máximo de 150 palabras
Caso
Referencias Bibliográficas (máximo de 5)
Las Figuras estarán limitadas a tres como
máximo.
Imágenes endovasculares
Se aceptarán para su valoración aquellas
imágenes relacionadas con las terapéuticas
endovasculares que por su singularidad sean
merecedoras de su publicación. Se
acompañarán de texto (máximo 100 palabras)
y referencias bibliográficas si se considera
necesario en un máximo de 2. Sólo se
aceptarán dos figuras.
volver al sumario
La redacción de Técnicas Endovasculares
(TE) considerará para su publicación aquellos
trabajos relacionados con la terapéutica
endovascular. Las secciones que componen
la revista son:
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Notas técnicas
Se aceptarán para su valoración aquellas
modificaciones o innovaciones técnicas que
se consideren de interés para los profesionales
relacionados con las terapéuticas
endovasculares. Se ilustrarán con un máximo
de tres figuras y un texto máximo de 500
palabras. Se podrá acompañar de 5 referencias
bibliográficas.
Bolsa de Trabajo e intercambio
profesional
Este espacio se reservará para anunciar
oportunidades de trabajo o de formación en
el campo de la terapéutica endovascular. El
Departamento Comercial de TE convendrá
con el anunciante, el coste de su anuncio.
Congresos
Zona catastrófica
Se aceptará para su valoración aquellas
situaciones o procedimientos que condujeron
a complicaciones singulares, resueltas o no
satisfactoriamente, pero que de la experiencia
se pueda derivar una enseñanza de interés
para los profesionales relacionados con las
terapéuticas endovasculares. Se seguirán las
recomendaciones reflejadas en el apartado de
‘casos clínicos’.
Se incluirán todos aquellos acontecimientos
científicos, congresos, reuniones, jornadas,
simposios, etc, que por su interés merezcan
ser anunciados a los profesionales relacionados
con terapéuticas endovasculares. Su anuncio
estará libre de cargo.
Todos los manuscritos deberán ser dirigidos
a e-mail: [email protected]
Nota:
El comité de redacción se reserva el derecho
de rechazar aquellos trabajos o informaciones
que no cumplan con las normas aquí expuestas
o no se consideren de relevancia para su
publicación en TE. Asimismo, desde el comité
de redacción se propondrán modificaciones
necesarias a los trabajos que se consideren
oportunos. El comité de redacción se
compromete a dar cumplida respuesta a todos
los autores en el plazo de quince días desde
su recepción en la redacción.
¡Revise su manuscrito y confirme su
adecuación a las normas que aquí figuran
antes de enviarlo a la redacción de TE!
Novedades desde la industria
Los profesionales de la industria podrán
disponer de un espacio que permitirá dar a
conocer nuevos proyectos o productos a través
de esta sección. Se aceptarán para su
valoración textos (máximo 500 palabras) y
figuras (máximo de tres) para este cometido.
Se dará preferencia a las publicaciones
procedentes de las industrias colaboradoras
habituales de TE.
Cartas al Director
volver al sumario
En esta sección de dará cabida a todas las
cartas que en la redacción se reciban a modo
de sugerencia, crítica o comentario del fondo
y forma de TE.
133
11
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Editorial
Originals
Reviews
Case Reports
Endovascular Images
Technical Notes
Catastrophic Area
News from the industry
Letters to the Director
Bag of Work and professional exchange
Congress’ Agenda
numbered pages. The language will be Spanish
or English.
Bibliographical References:
They were numbered according to correlative
appearance in the text. For the citation of the
works the norms will be used that appear
detailed in 'Uniform Requeriments for
Manuscripts Submitted to Biomedical
Journals', NEJM 1997; 336:309-316.
By way of example:
It will be assigned by invitation from the Editorial
Board.
Article: Kioka AND, Tanabe TO, Kotani AND,
Yamada N, Nakahama M, Ueda T, et to the
one. Review of coronary artery disease in
patients with infrarenal abdominal aortic
aneurysm. Circ J 2002;66:1110-2
Original articles:
Book Chapter:
They are considered original works those that
have not been published in other written media
it prescribes. Language can be Spanish or
English. They will consist of the following
structure:
Coselli JS, Buket S, Crawford is. Thoracic
Aortic Aneurysms. In: Haimovici H, Ascer AND,
Hollier LH, Strandness OF, Towne JB, eds.
Vascular Surgery. Cambridge (it USES),
Blackwell Science, 1996; 759-785
Editorial:
Summary in Spanish and Abstract in
English (maximum 250 words)
Introduction
Material and Methods
Results
Discussion and conclusions
Bibliographical References
Important:
Each one of the previous sections will begin
page. In the first page it will figure the complete
title, the authors, the work center, the contact
person for the correspondence with their postal
address and e-mail, the section to which goes
directed and the shipment date. Also it will
make a short title and to facilitate keywords
(minimum of 3 and maximum of 6)
The manuscript will be edited with size letters
12 (preferably types: Times, Arial or Currier),
with having interlined double and with the
Figures:
The figures will go numbered (Arab numbers)
correlatively according to appearance in the
text. A maximum of 5 will be accepted. The
images will indicate its orientation. The figures
in color will reproduce in the same way if their
interest makes it indispensable. In a contrary
way, they will reproduce in grey scale. The
feet of figure will be attached in separated
page.
Charts:
The Charts will be numbered with correlative
Roman numbers according to their appearance
order in the text. It will be accepted until a
maximum of 5 charts by work. Each chart will
be identified with a brief explanatory text.
134
Reviews
They will be accepted for their valuation those
revision works that raise the attention of the
specialists related with the therapeutic
endovasculares for their present time or
controversy. They will be been able to request
explicitly from the writing or to subject freely
according to their authors' initiative. They will
follow the same writing norms and presentation
that you/they appear for the original works.
Nevertheless, their structuring will contemplate:
Summary (Spanish) and abstract (English)
Introduction
Development
Conclusions
Bibliographical References
Cases Reports
They will be accepted for their valuation the
singular and original clinical cases. They will
already follow the writing norms as it was
previously mentioned. Although their structuring
will be:
Summary (Spanish) and Abstract (English)
maximum of 150 words
Case
Bibliographical References (maximum of 5)
The Figures will be limited at three as
maximum.
Endovascular Images
They will be accepted for their evaluation those
images related with the endovascular
therapeutics that are worthy of their publication
for their singularity. They will accompany of
text (maximum 100 words) and bibliographical
references if it is considered necessary in a
maximum of 2. Two figures will only be
accepted.
volver al sumario
Técnicas Endovasculares (TE) will consider
for their publication those works related with
the endovascular therapies. The sections that
compose the journal are:
11
IX
Technical Notes
They will be accepted for their valuation those
modifications or technical innovations that are
considered of interest for the professionals
related with the endovascular therapeutics.
They will be illustrated with a maximum of three
figures and a maximum text of 500 words. It
will be able to accompany of 5 bibliographical
references.
Bag of Work and professional
exchange
This space will be reserved to announce work
opportunities or formation programmes in the
field of the endovascular therapeutics. The
Commercial Department of TE will propose
the cost of their announcement.
Congress Agenda
Catastrophic area
It will be accepted for their evaluation those
situations or procedures that led to singular,
well resolved complications or not satisfactorily,
but it can be derived a teaching experience
for the professionals related with the
endovascular therapeutics.
The recommendations will be continued
reflected in the section of ‘Case Reports’.
All those scientific events will be included,
congresses, meetings, worshops, symposia,
etc that deserve to be announced to the
professionals related with endovascular
therapeutics for their interest. Their
announcement will be free of charge.
All the manuscripts, it copies printed and in
computer support, they will be directed to:
Note:
The editorial committee is reserved the right
of rejecting those works or informations that
don't fulfill the instructions here exposed or
they are not considered of relevance for its
publication in TE. Also, the editorial committee
will communicate to the authors some
necessary modifications to the works that are
considered opportune. The editorial committee
commits to give fulfilled answer to all the
authors in the term of fifteen days from its
reception in the editorial office.
Revise their manuscript and confirm their
adaptation to the norms that here figure
before sending it to the editorial of TE!
News from the industry
The professionals of the industry will be able
to have a space that will allow to give to know
new projects or products through this section.
They will be accepted for their evaluation texts
(maximum 500 words) and figures (maximum
of three) for this made. Preference will be given
to the publications coming from the habitual
collaborating industries of TE.
Letters to the Director
volver al sumario
In this section it will give space to all the letters
that are received by way of suggestion, critic
or comment of the contents and form of TE
journal.
135
11
IX
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