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Inferior Mesenteric Supply | Advanced UFE
Inferior Mesenteric Supply | Advanced UFE
2016chapterfibroidfundalmyomectomyovarianpelvicpriorsbvSIRsupplysurgerytubaluterus
DEBATE: Stenting Is The Ideal Treatment For Nutcracker Syndrome
DEBATE: Stenting Is The Ideal Treatment For Nutcracker Syndrome
bailoutbranchcomplicationdistallyendovascularengageleftleft renalmigrationpatientsrenalrenal veinstentstentingstentssurgerysurgicaltreatedvein
Negative Impact Of MIs On Life Expectancy After AAA Repair: What Can Be Done To Improve It
Negative Impact Of MIs On Life Expectancy After AAA Repair: What Can Be Done To Improve It
aneurysmalaneurysmsaorticatheroscleroticcardiacCardiac rehabilitation after aortic aneurysm repairchroniccohortcoronarydiseaseendovascularenrollevarinfrarenalinstanceischemiakidneymayomortalitymyocardialoptimizingpatientsperioperativepredictorsurvivalsystematictherapeuticvascular
MRV And CTV In Imaging Of Pelvic And Abdominal Venous Compressive Syndromes: Which Is Better And Why
MRV And CTV In Imaging Of Pelvic And Abdominal Venous Compressive Syndromes: Which Is Better And Why
Ablavaraortaarrowarterybloodcalfcavacavalclassicclinicalcompressivecongestioncontrastdeepdegreeetiologyextravascularextremityfiltersgadoliniumgonadaliliacimaginginforminfrarenalleftleft renalluminalmodalitiesnitinolovarianpatientpelvicPelvic Congestion Syndrome due to Nutcracker syndromepoolposteriorpresencerenalstatusstentstentingstentssuprarenalswellingthrombusvariantveinvenographyvenousvertebral
Eliminating Avoidable Disasters In The OR And Managing Them When They Occur
Eliminating Avoidable Disasters In The OR And Managing Them When They Occur
criticaleventincisioninstrumentmedicaloperatingpacificpatientpeerperformedpriorprotocolrobustsentinelstakeholderssurgerysurgical
DEBATE: Not So: Many TAAAs Are Best Treated By Open Surgery: Technical Pearls To Improve Results
DEBATE: Not So: Many TAAAs Are Best Treated By Open Surgery: Technical Pearls To Improve Results
aneurysmaneurysmsatrialbeveledcaudalcentercenteredcenterscollateralscorddistalextentextracorporealfavorfenestratedhospitalsincisionischemialatzlowermedicaremortalityneurologicoperativeparaplegiapatientpelvicperformedperfusionperioperativephysiologicproximalratesrenalrevascularizationroutinespinalsuturetechniquestermsthoracoabdominaltvarversusvisceralvolume
Tips And Tricks In The Treatment Of Carotid Aneurysm: A Surgeon’s Perspective
Tips And Tricks In The Treatment Of Carotid Aneurysm: A Surgeon’s Perspective
accountinganeurysmaneurysmsanticoagulationapproacharteryatheroscleroticbasebifurcationcarotidcarotid arterycervicodiffersdiseasedysplasticendovascularetiologyhybridipsilateralligationmortalitymycoticneurologicocclusiveoccurringpatencyrarereconstructionreconstructiveReconstructive Aneurysmorrhaphyrevascularizationsaphenoussegmentsegmentssequelaeskullstentstentedstentingstentssurgerysurgicalsymptomstakayasutherapeuticthoracicthrombus
A New Valiant Manifold Based Device (Medtronic) With Multiple Branches For Treating TAAAs: How Does It Work And 2-Year Results
A New Valiant Manifold Based Device (Medtronic) With Multiple Branches For Treating TAAAs: How Does It Work And 2-Year Results
aortadissectiondynamicsendoleaksevolvedflowgraftsimplantmimicmortalitypatencyprettyproximalrenalretrogradesheathtypevesselsvisceral
New Developments In The Management Of Thoracic Outlet Syndromes (TOSs): Neurogenic, Venous And Arterial
New Developments In The Management Of Thoracic Outlet Syndromes (TOSs): Neurogenic, Venous And Arterial
inconsistentnetherlandsneurogenicoutcomesoutletpatientsreportingseveritystandardizesurgerytalktextbookthoracic
Value Of A Vascular Surgeon To The Practice Of Other Specialties And To An Institution: How Can Vascular Surgeons Be Adequately Compensated By Institutions For Their Unique And Vital Contributions
Value Of A Vascular Surgeon To The Practice Of Other Specialties And To An Institution: How Can Vascular Surgeons Be Adequately Compensated By Institutions For Their Unique And Vital Contributions
aneurysmcardiaccenterscoworkersenablingendovascularfavorablehealthcarehospitalimpactmarginmedicareorthopedicpatientspayorprofessionalrevenuervusspecialtiesspinestentsurgeonsurgeonssurgeryvascularVeith
Technical Tips For Facilitating Deep Vein Grafts For Aortoiliac Arterial And Graft Infections: The NAIS Procedure
Technical Tips For Facilitating Deep Vein Grafts For Aortoiliac Arterial And Graft Infections: The NAIS Procedure
abdominalaneurysmaortaconfigurationconfluentdeepdiameterfemoralgraftgroinincisionincorporatedinfectionmycoticOpen repairrenalscanvein
How To Treat By EVAR Complex Aorto-Iliac AAAs In Patients With Renal Transplants, Horseshoe Or Pelvic Kidneys: Technical Tips
How To Treat By EVAR Complex Aorto-Iliac AAAs In Patients With Renal Transplants, Horseshoe Or Pelvic Kidneys: Technical Tips
accessoryaneurysmalaneurysmsantegradeaorticapproacharteriesarteryatypicalbifurcationbypasscontralateraldistalembolizationendoendograftingendovascularevarfairlyfemoralfenestratedflowfollowuphybridhypogastriciliacincisionmaintainmaneuversmultipleocclusiveOpen Hybridoptionspatientspelvicreconstructionreconstructionsreinterventionsrenalrenal arteryrenalsrepairsurvival
The Guidewire Fixator: A New Tool To Facilitate Treatment Of Complex AAAs And F/EVAR: How Does It Work
The Guidewire Fixator: A New Tool To Facilitate Treatment Of Complex AAAs And F/EVAR: How Does It Work
anchoraorticarteryavoidbraidedcomplexComplex aortic repair - stent graftingdevicedistallyembolizationEndovabendovascularfenestratedfenestrationfilterfrenchgraftguidewireGuidewire fixatornitinolpositionpreloadedrecruitingrenalsheathsituationstablestentsubclaviantargettherapeutictoolVeithvisceral
Vascular Malformations Should be Managed With Ablation and Without Open Surgery
Vascular Malformations Should be Managed With Ablation and Without Open Surgery
ablationargumentbehaviorcytokinecytokinesDirect PunctureendovascularlesionLVMmalformationmicrovascularmilligramreconstructivesurgerySurgical Treatments x 20therapeuticTracheostomyvascular
The Retrograde Vein Approach To AVMs – The Lublin Method
The Retrograde Vein Approach To AVMs – The Lublin Method
accessaneurysmaneurysmalangiogramapproacharteriesavmsBothcatheterizationchallengingcoilcoilscompletelydensedirectDirect PunctureembolicendovascularethanolflowfulfillhemodynamiciiiaiiibiliacLiquid embolic agentmalformationsnidusoccludeoccludedocclusionovarianpackingpelvicpercutaneouspouchpunctureretrogradetypeType III a AVMveinvenousyakes
The Retrograde Vein Approach To AVMs – The Lublin Method
The Retrograde Vein Approach To AVMs – The Lublin Method
accessaneurysmaneurysmalangiogramapproacharteriesavmsBothcatheterizationchallengingcoilcoilscompletelydensedirectDirect PunctureembolicendovascularethanolflowfulfillhemodynamiciiiaiiibiliacLiquid embolic agentmalformationsnidusoccludeoccludedocclusionovarianpackingpelvicpercutaneouspouchpunctureretrogradetypeType III a AVMveinvenousyakes
Update On Indications For Invasive Treatment Of Carotid Disease (Symptomatic And Asymptomatic) By CEA Or CAS Before Major Surgery Or Coronary Bypass
Update On Indications For Invasive Treatment Of Carotid Disease (Symptomatic And Asymptomatic) By CEA Or CAS Before Major Surgery Or Coronary Bypass
asymptomaticbilateralcabgcarotidCASCEAconsidereddeathendarterectomyimaginginterventionisolatedliteratureobservationalpatientsperioperativepriorrandomizedrateratesrecommendedrevascularizationriskstagedstenosesstenosisstentingstrokestrokesstudysurgerysynchronousundergoundergoingunderlyingunilateral
Pelvic Reflux: Is Coil Embolization The Answer
Pelvic Reflux: Is Coil Embolization The Answer
allergicanalogcoilsdatadiameterembolizationhighlightincompetencemeissnermisdiagnosedovarianpatientspelvicrefluxsymptomatologysymptomstreatingvaricoseveinveinsvenous
New Developments In The Management Of Thoracic Outlet Syndromes (TOSs): Neurogenic, Venous And Arterial
New Developments In The Management Of Thoracic Outlet Syndromes (TOSs): Neurogenic, Venous And Arterial
inconsistentnetherlandsneurogenicoutcomesoutletpatientsreportingseveritystandardizesurgerytalktextbookthoracic
Value Of CO2 DSA For Abdominal And Pelvic Trauma: Why And How To Use CO2 Angiography With Massive Bleeding And When To Supplement It With Iodinated Contrast
Value Of CO2 DSA For Abdominal And Pelvic Trauma: Why And How To Use CO2 Angiography With Massive Bleeding And When To Supplement It With Iodinated Contrast
abdominalangiographyanterioraortaaorticarteriogrambasicallybleedingcarboncatheterceliaccoilcontrastdiaphragmdioxideembolizationholeimaginginjectinjectioninjectionsiodinatedliverlowmultiplepatientpelvicrenalruptureselectivesolublesplenictraumavascularizationveinvesselvesselsvolumes
Propensity Matched Comparison Of F/B/EVAR And Open Repair For TAAAs Shows That Endovascular Treatment Is Best
Propensity Matched Comparison Of F/B/EVAR And Open Repair For TAAAs Shows That Endovascular Treatment Is Best
aneurysmcomparativecomparingcorddifferenceendoendovascularFBEVARincludingischemiamajormayomortalitypatientspelvicperformedpropensitypublishedreinterventionrepairreperfusionreportingspinalstatisticallystephansurgerytermsthoracoabdominalversus
How & What Should the Venous Duplex Examination Include?
How & What Should the Venous Duplex Examination Include?
abdomenassessmentcommonlycompressiondiagnosticdiameterdiametersdistalduplexevaluatehilariliaciliac veinovarianpatientpatientspelvicpositivesrefluxrenalreproduciblerequiressourcestandardstandingsupinesymptomsultrasoundveinveinsvelocityvenous
Why Open Surgery Is Still The Best Treatment For Juxta- And Pararenal AAAs In Good Risk Patients: Technical Tips
Why Open Surgery Is Still The Best Treatment For Juxta- And Pararenal AAAs In Good Risk Patients: Technical Tips
aaasadrenalanastomosisaneurysmaneurysmalaneurysmsanteriorlyaortaaorticarteryceliacclampclampingdemonstrateddissectiondivisionendovascularevarfavorablefenestratedgonadalgraftjournalleftleft renalmanipulationmedialOpen repairorificeperformedperfuseperfusedperfusionposteriorproximalproximallyrenalrenal arteryrenal veinrepairstumpsurgerysuturetechnicaltipstreatmenturetervascularveinvisceral
Building Your Pelvic Congestion Practice: Educating The Community And Using Large Volume Coils For Efficient Embolizations
Building Your Pelvic Congestion Practice: Educating The Community And Using Large Volume Coils For Efficient Embolizations
anchoringanswerschroniccoilcoilscongestionconventionaldetachablediagnosisdifferentialdiseaseeducateembolizationembolizingendovascularhealthcareinternetovarianpackingpainpatientspelvicPenumbrapotentialprovidersrenalsofttreatmentveinsvenousversusvesselvolume
"Acquired" AVMs: More Common Than We Think
acquiredarterialarteriogramarteriovenousavmscoilcollateralsconnectionsDeep vein trombosisduralDVTentityepisodeevarextensiveextremityfemoralFistulahistoryiliacinflammatorylesionlesionsocclusionpelvicpriorstentingstimulationswellingthrombosistreatedtreatmentuterineveinvenouswayne
Reasons New Nomenclature Is Needed For Pelvic Venous Disorders
Reasons New Nomenclature Is Needed For Pelvic Venous Disorders
chronicclinicalcommoncommon iliaccompensatedcongestiondecompressiondisordersdrainageextremityflankhilariliaciliac veinincludesinternalinternal iliacleftleft renallowermesentericobstructionoutflowovarianpainPathophysiologypelvicprimaryrecognizerenalrenal veinspectrumsymptomssyndrometransmittedtreatmentunderlyingvaricesveinvenous
Value Of A Vascular Surgeon To The Practice Of Other Specialties And To An Institution: How Can Vascular Surgeons Be Adequately Compensated By Institutions For Their Unique And Vital Contributions
Value Of A Vascular Surgeon To The Practice Of Other Specialties And To An Institution: How Can Vascular Surgeons Be Adequately Compensated By Institutions For Their Unique And Vital Contributions
aneurysmcardiaccenterscoworkersenablingendovascularfavorablehealthcarehospitalimpactmarginmedicareorthopedicpatientspayorprofessionalrevenuervusspecialtiesspinestentsurgeonsurgeonssurgeryvascularVeith
New Developments In The Treatment Of The Nutcracker Syndromes - Arterial (Duodenal Compression) And Venous (Renal Vein Compression)
New Developments In The Treatment Of The Nutcracker Syndromes - Arterial (Duodenal Compression) And Venous (Renal Vein Compression)
abdominalarterycavacharacterizedclinicalcompressioncongestiondecreasesdiagnosisdopplerduodenalduodenumendovascularExternal Reinforecment of LT Renal Veinextrinsichematuriainterventionischemiaivusleftleft renalmanagementmesentericmrispelvicprevalenceptferelievesrenalrenal veinrepositioningretroperitonealscanssensitivitySMA TranspositionstentStent graftstentingsuperiorsurgicalsymptomssyndrometherapeutictranspositionveinvenavenographyvenous
How To Remedy The Projected Shortage Of Vascular Surgeons In The US By Increasing The Number Of 0+5 Training Programs: Would An Independent Board Help
How To Remedy The Projected Shortage Of Vascular Surgeons In The US By Increasing The Number Of 0+5 Training Programs: Would An Independent Board Help
acgmeapplicationsdemandfellowshipgraduategraduatesincreaseincreasedintegratedmedicalpositionpositionspredictedprocessedprogramprogramsremainedresidencyresidentsspecialtysupplysurgeonssurgerytrainingvascularvascular surgeonsVeith
Vascular Malformations Should be Managed With Ablation and Without Open Surgery
Vascular Malformations Should be Managed With Ablation and Without Open Surgery
ablationargumentbehaviorcytokinecytokinesendovascularlesionmalformationmicrovascularmilligramreconstructivesurgerytherapeuticvascular
Femoral Vein Transposition
Femoral Vein Transposition
accessarterialbostoncomplicationsconfluencedistalensureexhaustedfemoralFemoral vein transposition for AV HD accessgraftsincisionincisionsischemicmaturationmedianpatencypatientpatientspoplitealprimaryrenalseriesstealsuperficialtherapeuticthightranspositiontypicallyveinwound
Transcript

an unusual thing we see it rarely but it in the setting of prior myomectomy so prior myomectomy is interesting it causes all kinds of information in the

pelvis which tends to cause parasitization of normal branches it can cause recruitment of ovarian artery so for example one of the previous positions for ovarian supply is prior pelvic surgery including

myomectomy prior tubal surgery large fundal fibroid big uterus those are things that would make ovarian supply more likely so this is a patient who had

- [Thomas] Thank you, so you've heard about why stenting is not the right solution. I'm going to try to argue the other point. A little review about nutcracker, we all have just heard, I'm not going to spend too much time. There are in fact numerous types of this

and I agree with Dr. Shortell you have to recognize and appreciate which you're dealing with. I'll also want to agree with Dr. Almeda that unless a patient has hematuria I generally don't entertain this as the correct diagnosis

and really would not even intervene at all. Some sort of representative pictures here of nutcracker syndrome, the open surgical treatment has been around for some time. It certainly is the gold standard, I would submit to you that like open aortic surgery

was the gold standard in 1990, I do believe that this is not, that stenting is here to stay and with new techniques and new technology it is going to essentially replace open surgery in the future.

These are the different options, you can see some nice pictures from the AO Clinic here with left renal vein transposition, this is the one that we tend to do most at our institution. And the review as Dr. Hartung mentioned,

there are a number of patients now treated with open surgery and you can see that there is in fact a complication rate which can be significant. Chylous leaks, retroperitoneal hematomas, et cetera, not to mention some of the failures of treatment.

And see here that this is a paper also referenced by Dr. Hartung earlier, Dr. Arbens. Experience and you can see of the 36 patients treated with open surgery, decent results but in fact there is a bailout and the bailout wouldn't you know is stenting

One in three patients required stenting in patients who underwent open surgery so need for secondary interventions is not insignificant with open surgery. A little bit of endovascular treatment. This is, as I said, in my opinion,

going to the future of this disease. If it's, it has the right stent developed or design. In general, these are self-expanding stents. We need high radial strength, conformability (coughs), accuracy. In general, some tips and tricks

we'll get to in a minute. There have been a number of cases reported already and you can see that the largest experience really is from China and the Far East, and these 126 patients actually do quite well. There are of course complications as with any procedures,

stent migration being the most problematic. Factors affecting stent migration may include distance between the ostium and the first large branch of the lef increase in the left renal vein intraluminal pressure

may affect stabilization and of course pulsatility of the underlying aorta can also affect the stent's positioning. Do they last? Well, this is again one of those,

Chinese papers here, the Journal of Urology, 61 patients with five years follow-up, and see these patients in fact did quite well and their symptoms resolved. Certainly by six months all of them had resolved symptoms.

The elephant in the room of course is stent migration. What do we do about this? Well we certainly, this is in my opinion a very, very serious complication so then we have to be very respectful of. Some classic examples here as Dr. Hartung said,

they can go into the renal vein or the IVC but more troubling, they can migrate all up to the heart. This is again, another one of those large series showing some of the, lessons learned for them.

These are stent migration occurring in five patients or 6.7%, and you can see one was malpositioned, one was undersized, and these are patients that they then tried to analyze what predictors of stent migration, they tried to compare anteroposterior diameters of left renal vein,

peak velocities, didn't find any real statistical significance here. Hard to predict. What we have learned from Dr. Hartung is that longer self expanding stents are preferred. We generally want to engage the first order branch

left renal vein and protrusion to the IVC is not such a bad thing. We've published some of our experience with left renal vein stenting and we also find this stent positioning especially trying not to, trying to straddle the lesions is quite important

to prevent toothpasting of the stent and to assure accuracy. Again, try and engage that first order branch (coughs) also helps (cough). Retroaortic vein or circumaortic vein we've heard a little bit about just now (coughs).

Of course we do want to recognize that we've had a patient, we treated the anterior left renal vein and did resolve symptoms. So in conclusion, oversizing by 20% specifically to the left renal vein distally in the renal hilum is quite important.

Duplex can help with this. IVUS may be more accurate. Self-expanding stents, especially longer stents I think are important to use. Engaging distally as we mentioned is an important tip. Avoiding deployment of stents asymmetrically,

important to straddle the lesion to avoid toothpasting the stent. We're in the early vascular, early days of endovascular treatment. Surgical treatment continues to be the benchmark for now. But up to 15% have perioperative complication rate

and one in three requires intervention, usually with stenting. Stenting appears safe, effective, durable, and as we improve technology I think that stents will replace open surgery in the future as standard of care. Thank you.

- [Bijan] Thank you very much, Chair. It's an honor to be here again. These are my disclosures. So, the most important hurdle considered by some is 30-day mortality when it comes to aortic repair. And we have got better at achieving lower 30-day mortalities, because the techniques

that we use have improved, we're better at perioperative care, and this, despite the fact that we are operating on older patients on the whole. But I think we have to think about whether this is really an important outcome

as far as the patient is concerned. Let's look at these two series. The one on the left is from the '80s, from the Mayo Clinic. The one on the right is a recent systematic review from the Saint George's Group looking at long-term outcomes after endovascular aortic repair.

If you look at many, the open series on the left from the Mayo Clinic, over a thousand patients with a 68% five-year survival, and a 23% mortality from patients who sustained an MI. Larger series in the systematic review, and you can see that the survival rate

has not changed very much. So we looked at our series, just under 1,800 cases from 2008. We've picked out the ones that were done for aneurysmal disease, these are all endovascular repairs, and we had 148

juxtarenal aneurysms and 737 infrarenal endovascular repairs. You can see that half of the patients in both groups have cardiac disease. There's more chronic kidney disease and peripheral vascular disease in the juxtarenal group.

When you look at the short-term mortality, the 30 day mortality in the juxtarenal group is 3%, and it goes up to 4% at 90 days, and you can see the mortalities in the infrarenal group that doubles at 90 days. Chronic kidney disease was a predictor

of early mortality in this cohort, age a weaker predictor, and also a weak predictor for 90 day mortality. And if you take this cohort to the longer term, you can see at five years we have again, a survival rate of around sixty-something percent.

It sounds familiar, doesn't it, so not much change. And here cancer, so a pre-operative history of cancer is a relatively strong predictor of long-term mortality. And we're looking more into which cancers are particularly predictive. So then we wanted to know, in this cohort

what's the burden of post-operative coronary artery disease complications, so this is the nationwide Myocardial Ischemia National Audit Project that actually, based on the patients NHS number, going forward records all the patients post-operatively that have presented with a stemi or

non-stemi myocardial infarction. So we linked our database with this national audit. And when you look at this, you can see on the top here the percentage of patients in each cohort that had a pre-operative history of, a acute coronary syndrome, so stemi and non-stemi.

In hospital, the instance of cardiac complications was 4 and 5%, but when you look at the myocardial infarctions, the instance is low, and actually post-operatively, there's also relatively low instance of myocardial infarction, but those that do sustain that

have all had pre-operative cardiac history, and they don't do so well as far as mortality is concerned. And if you put the pre-operative characteristics of these patients into the VQI risk-scoring system, that specifically for EVAR that was published recently in the Journal of Vascular Surgery,

you can see the average risk score is 2%. So what about a larger series, so this is the EVAR 1 trial, looking at the long-term mortalities, you can see the biggest killer of these patients is Atherosclerotic disease, so stroke, and myocardial infarction.

About a quarter of these deaths are from myocardial infarction, both at six months to four years, and four to eight years. So, the other question in the title was, what can we do about it? But that's a whole different subject on its own,

but it's encouraging, that we're starting to think about optimizing these patients pre-operatively, to enroll into exercise programs before they have their elective repair. And also, there's plans afoot to carry out trials to look at what happens if we look more closely,

look after these patients better after we operate on them. So, not to carry out surveillance only, but to try and modify their risk factors going forward. And I look forward to the outcome of this trial, that I think is underway

by the St. George's Group in London. So, particularly want to thank Alex, Jayna and Jun, and the rest of the guys on St. Thomas' team. Thank you.

- [Speaker] Thanks very much. So three clinical scenarios: a 35 year old women with pelvic fullness, pain a a patient with lower extremity swelling that we need to evaluate the deep

and can I remove this IVC filer? Starting with the first one. So this is a classic pelvic congestion syndrome. Picture, you see this reflexing gonadal veins. As you go to the next catheter venography,

it's confirmed on the diagnosis, with direct venography. But what I would like to focus a little bit more on, is a rare etiology for PCS, the nutcracker syndrome, in which the left renal vein is compressed, resulting in venous hypertension, hematuria/flank pain and this reflux.

So this is a classic nutcracker case. You can see where the arrow points out the SMA and aorta pinching off the mid-left renal vein. And here are some more pictures. And then this last one shows some collaterals, through which the left kidney is being decompressed.

The retroaortic left renal vein, with the posterior nutcracker can be a variant of this and it's shown here, where the left renal vein is passing posterior to the aorta into the IVC. So what MRV tells me in the setting of Pelvic congestion syndrome is the direction of flow,

the size of the ovarian vein, characteristics of the ovarian vein in terms of tortuosity, duplications, that might inform the intervention, unilateral versus bilateral disease, it can be helpful in that distinction, degree of peri-uterine venous plexus engorgement,

the presence or significance of a nutcracker lesion, always important to look up by that area, and then the question of a May-Thurner that may be contributing. Moving onto the next clinical history. A patient with lower extremity swelling in which the

deep pelvic veins and IVC need to be evaluated. So what is happening in this man's pelvis, well this was his MR, done with LAVA blood pool imaging, you can see this is a May-Thurner variant in which the external iliac artery is compressing the external iliac vein, and the vertebral bodies behind it.

What does blood pool imaging offer? Basically it's a Gadolinium containing agent that binds to albumin. It keeps the contrast agent intravascular and reduces extravascular distribution. Allows for high resolution steady state imaging

where venous contamination is what you want. And can be used in tandem with MR angiography. This is another picture that I like very much. It shows very clearly a classic May-Thurner lesion right where that arrow is, on two separate images. And then this is a reformation which shows that iliac artery

making that indentation where we would expect it to be. What MRV tells me in the setting of deep venous disease the presence of an iliocaval obstruction, the degree of that obstruction, and then the presence of a luminal irregularity such as a venous web which can be seen in this calf vein right there.

So this is a patient I saw in whom she had extensive chronic thrombus from the left common iliac vein to the calf veins. This is what she looked like before. After a considerable amount of work this is what she looked like after she came back to my clinic.

I actually entered her into research studies. She was doing quite well but I wanted to see if I could see her stents with MR. And this is one imaging modality called FIESTA. And here it looks as if the stent is perhaps not open but then on the time of flight,

as you pass through the abdomen and pelvis, you can see that they clearly are. So there are some modalities that can see through nitinol stents particularly. Stainless steel is a little more difficult is what we found in our experience.

Can you remove this IVC filter? So imaging IVC filters, the challenge is this: you have this number of filters and they can do all sorts of things in the abdomen. So IVC filter questions: What is the status of this filter? Is there tilt?

Penetration? Thrombus? Or fracture? And then what is the status of the cava in patients who have a symptomatic caval stenosis, and what is that degree of that stenosis? And what is the status of the iliacs?

So this is a particular case which I think we've all seen, where the filters penetrating through the cava, it's tilted, it's going to be quite a difficult scenario for the patient and for the retriever. And this is another case in which, even without contrast, you can see the difference between the suprarenal

and infrarenal IVC, as well as collaterals, which certainly can inform your interventions. So in conclusion, for gonadal vein pathologies, time resolved contrast MR venography confirms the diagnosis, helps with treatment planning, looks for compressive lesions.

Deep venous pathologies, blood pool contrast-enhanced MR can influence whether an intervention is necessary. IVC filters I believe are truly best evaluated by CT Thank you.

- Thank you and thanks Dr. Veath and the organizing committee for allowing me to present something that I'm very passionate about. No disclosures. The Portland VA is the main tertiary care center for the Pacific Northwest and does 80% of the complex surgery for the Pacific Northwest for the veterans.

We do such things as liver transplant there, about 300 hearts a year and overall, I have 16 surgical divisions. Everyone would agree that critical incidents or never-events or sentinel events still remain a threat to patient safety and I want to share with you today the system that the VA

has in place and one that we've put in place in our own institution to really minimize avoidable disasters. In the VA system, these are the definitions of a sentinel event or a critical incident. Wrong patient, side/site, implant or surgery.

Retained item. Death in the operating room. Death by hemorrhage within 24 hours. Or an OR fire or burn. These are things we've put in place in our own institution over the last several years to avoid disasters.

One is putting in the ... Following the World Health Organization for OR checklists. We have a high-risk patient protocol now in place. We have a robust medical even reporting system and just culture in the operating room and we have key signage which I'll share with you as well.

So, with regards to a checklist, many of you have seen this already but we actually do this. We do a pre-op briefing in the operating room with the surgeon, anesthesiologist, scrub tech, and circulator before the patients brought in.

We have a time out and fire safety check before the incision is made and then we have a pre-op debriefing after the final counts are done. In regards to a high-risk patient protocol, if a patient has a great event equal to 5% mortality with a potential operation due to the morbidities

as calculated by the VASQIP or NSQIP calculator these things must be done prior to the operation. A high-risk note must be completed. There needs to be a peer to peer review of the case. There must be a palliative care consultation. There needs to be good documentation as to why

the operation's going to be done or why not and then if the surgery is going to be done, there needs to be a plan in place with the ICU and potentially two attendings to make sure the surgery gets done well. And then at any time, stakeholders can stop the line

to have further discussion to assure that this is the right decision to take this patient to the operating room if they are truly high-risk. We have a very robust medical event reporting system and just culture in our operating room and this took a lot of work to get in place

but anybody in the operating room can put in a medical event report in the intranet and then this gets followed up by coming back to myself as well as the chief nursing director and then all these are reviewed in the surgical work group for which I chair. Here's an example.

This was done in 2017. You can see at the bottom. Instrument count was not performed prior to the incision for an A-V fistula. This was not communicated to the primary circulator. Sponge needle counts were performed in the usual manner.

Dr. Blank is aware and a preventative retention x-ray was taken in the OR. This comes back to the chief nurse. She states that that nurse was re-educated and that the proper protocol was followed and then in the work group, our OR manager basically states that a new

instrument count process is put in place. So, there is a complete accountability in a full circle to the staff that are putting in these medical event reports which are not punitive in any way. You can see that after we worked hard at this, the number of medical event reports coming in really went up

and it could be something as simple as not having the suture available. A medical event report could be put in and this will always get followed up on. This is something we did two years ago. It's like on the work site, injuries in the last year

or last day, or last week but this is week since last OR incident or never event and here when I took this picture it had been eight weeks since we had an OR burn. That burn was a 3ml inadvertent burn on another part of the body from the bovie when somebody stepped

on the foot pedal by accident. Very small, but it was reported all the way to central office. Here they are pictures when they leave the OR and this is all throughout the operating room including entry into the operating room for the core.

And you can see here our five year trend, on the left is the number of operations and on the right the number of critical incidents and this year we only have had one critical incident. Last year we only had one. So, I think the things we put in place really have

made a difference. If we have one of these, there are lots of things we can do afterwards and we actually do. We have larger groups stakeholder debriefings, peer review process, root cause analysis, something new called a unit-based ethics conversation

which I'd be happy to talk about in any questions and then we have very close conversations with our network and central office when these things occur. So, lessons learned all stakeholders should participate in implementation of these changes.

Leadership needs to really lead by example. You want to lead by example, reward reporting, problem solving and emotional intelligence and really piloting allows for buy-in prior to broad implementation. Thank you.

- So I have no disclosures related to this topic regarding open surgery. In terms of extent one, two, three thoracoabdominal aneurysms, Dr. Crawford's Benchmark Series really highlighted the risks of mortality in spinal cord ischemia related to this. And in terms of development techniques to improve,

these outcomes, most of them have centered on the spinal cord because the impact to spinal cord ischemia on perioperative mortality and longterm patient morbidity is so significant. Therefore, over the years we've developed things like CSF drainage, which has been studied in randomized

controlled trials, and have showed significant reduction in spinal cord ischemia rates. Early techniques also centered on improving spinal cord blood supply, such as a intercostal re-implantation techniques. However things like the collateral network concept

developed by Dr. Griepp suggest a routine sacrifice of these vessels, can be performed without major neurologic injury. Furthermore this elegant studies from Dr. Jacobs groups looking at MRAs after patient's thoracoabdominal aneurysms suggest that these collaterals actually originate caudal to the distal clamp

suggesting importance of pelvic perfusion. And therefore really sort of highlighting the importance of distal perfusion techniques during the operation. This has been shown by Dr. Safi's group. Again looking at adjunct's spinal cord drainage Motivo potentials and distal perfusion

with spinal cord ischemia rates are down to 2.4%. This has also been shown in Dr. Safi's hands to reduce organ disfunction, namely liver and kidney disfunction. As such, looking at this in the Medicare population in our own work looking at about 4,000 patients. Those that had extracorporeal circulation

utilized during their thoracobdominal repairs had a lower perioperative mortality and complications. And also improved survival. Based on these Dr. Cambria's experience at the Mass General Hospital, we sort of adopted a lot of these techniques.

And for the routine extent one through three, thoracoabdominal aneurysms we performed atrial femoral bypass, Motivo potential monitoring, inter-operative spinal drainage, and permissive hypothermia

resulting operative mortality rates of 4%, and paraplegia rates of 2.3%. However, in terms of the extent four thoracoabdominal aneurysms are approached just a little bit different. We don't use any of the aforementioned adjuncts. Namely in sort of a favor of a simplified technique,

whereas the thoracoabdominal incision is performed. We partially divide the diaphragm. Cold renal perfusion is used to protect the kidneys. A beveled proximal suture line facilitates a rapid revascularization of the visceral segment, and a routine left renal sidearm

to help reconstruct the left renal artery. This is resulted in excellent results. This is a paper I published in 2011, looking at about 178 patients with operative mortality rates of about 2.8%. Spinal cord ischemia rates of about 2.2%.

More recently, our resident Christopher Latz and partner Darrin Clouse have actually updated this data looking at about 226 patients. With again pretty good mortality and spinal cord ischemia rates. I do agree with Dr. Farber, that hospital volume

actually really is important. Overall mortality in the real world is 22% for thoracoabdominals. And this is outdated data, back in 2003, however high volume hospitals clearly perform better than low volume hospitals.

We've also looked at this in the Medicare population, looking at about 763 hospitals with 3,500 patients. High volume was defined at any hospital performing more than eight per year. With high volume hospitals having improved mortality. Furthermore Gib Upchurch recent work

suggested down-staging patients. Also improves the outcomes. And in this comparison of extent two thoracoabdominal aortic aneurysms where 25 were performed in stage fashion with a proximal TVAR followed by a lower thoracoabdominal, versus 88 standard.

There was lower major adverse events. Lower EBL, lower operative time, lower length of stay. Resulting in an operative mortality of about 4%. This is what a stage looks like with the TVAR on the left side, right side of the screen and the open reconstruction here.

Some terms of technical pearls to improve outcomes which is the focus of my talk, patient selection is very important. Anatomy and physiologic risk, spinal cord drainage, neuromonitoring, distal perfusion techniques, permissive hypothermia.

High volume centers, and down-staging to mitigate risks. So on to the debate. So Open versus Endo thoracoabdominal aneurysm prepare. This is a single, there center study looking at propensity match patients showing comparable results. Suggesting that both actually are good.

I think high volume centers that know how to do these operations are really the key in terms of improving outcome. And in the real world for using the French multi center experience, operative mortality and spinal cord ischemia rates

for branch and fenestrated graphs isn't as good as the IDE centers, which are obviously expert and have certain patient selections. Thank you.

- [Prof. Laurent] Thank you very much for giving me the privilege to present here this series. So that I don't have any disclosures. The definition of the aneurysm is there, you can see that there's three segments in which the aneurysm can be developed and these three segments are differs for their protological approach.

The aneurysms limits are best depicted by the dimensional imagery as you can see here. The aneurysms are really different according to their etiology the most frequent are

Atherosclerotic aneurysms, accounting for about 50% of the aneurysms and then you can have Dysplastic aneurysms accounting for about 20% which are very different in their morphology as you can see there. There's a neuro, you can see that this kind of aneurysm

is very difficult to be treated by endovascular procedures. Dysplastic aneurysms can be huge aneurysms. The Posttraumatic aneurysms account for about 20% or so, just like Spontaneous dissecting aneurysms are quite rare, it's about 2% only.

It's a very rare situation, only occurring in young patients finally. Unfrequent causes includes Mycotic aneurysms, Takayasu Disease or Becet's Disease, or other congenital origin or connective tissue disorders. The clinical presentation of the aneurysms

they are almost symptomatic only in about 80% either because of central symptoms or isolated local symptoms. The surgical approach differs according to the segment in which the aneurysm is developed. Of course the segments one and two are easily assessed

and the segment three needs a two team approach with neuroradiologist, which will do the access and going into the bone and the base of the skull finally. The open method you can approach the carotid artery you can be able to make an arterial reconstruction

in more than 80% of the patients either with graft-resection or with reconstructive aneurysmorrhaphy. The ligation occurs in less than 10% and should be mandatory associated with anticoagulation therapy. This is a new story called cervico petrous. From the beginning we were able to care for

and you can see that there were almost 20% of aneurysms occurring in this segment three, and the rest in segment one and two. These accounted for about 60 aneurysms. In the 61 operations, we made as you can see in the table

most of the time, bypasses with the great saphenous vein the superficial femoral artery or E-P-T-F and finally only nine resection-sutures. The mean clamping time for this patient was 46 minutes, and there were only seven ligation. Mortality rates, 3.2% including one patient who had

very large reconstruction of Takayasu Disease creating a thoracic arch on approach. The mortality and stroke rate is 8% or so. The late results are quite excellent, mostly seen here, you can see the Acturial survival was good because they were young patients.

The Peripheral and local sequelae was rare and the patency rates were excellent. The freedom from ipsilateral neurologic symptoms was excellent also. So what would you expect from endovascular therapy, which has been described with occlusive balloons,

coils, flow diverting stents and stent-grafts or bare metal stents, probably there can be room for this but there are several issues. First, the level of the aneurysm and the length of stented segment is to be considered. The Distal internal carotid artery is fragile

and a small diameter there can be usually intrasaccular thrombus in such aneurysms, kinks and tortuosities. And finally, I think that for low aneurysms in the carotid artery it's not necessary to have stent. In the aneurysms coming from the bifurcation it's

not necessary to have stents and probably the main reason to have a stent is for I located an aneurysm just like here but you can see that in this publication there was a risk to notice at the base of the stent so it can be an issue. And probably the hybrid surgery will go with

further progress in this kind of surgery because you can imagine having a stent at the base of the skull like this, and the stent can come here and overcome all the difficulties for kinking and tortuosities like this by an approach, a surgical approach of the carotid artery.

And if you go further you can imagine that we can have a hybrid surgery with approximate disease and this starts stenting off the aneurysm and the carotid artery. So in conclusion, this is a rare disease. Revascularization is performed in more than 80%

it provides excellent results. Surgical issues directly related to location and the role of endovascular and hybrid procedures, especially for segment two and three, should be established by further studies. Thank you very much.

- [Patrick] So, these are my disclosures. This is done under an IDE. You know, when we start talking about all the outcomes, let's first talk about how it works. And how it works, we set a criteria of design that we wanted something that was durable. Something that handled virtually any anatomy.

Something that provided favorable flow characteristics and we can talk about the patency rates. Provided unimpeded flow so we could stop it at any point and walk away. That which created stageability and we wanted it to be off-the-shelf.

So, that's a pretty big dream. That's a pretty big wants list. Well, you know, currently most designs are trying to basically mimic the aorta and as we know, this is a diseased aorta that becomes

quite angulated and deformed and is tough to mimic that because this type of configuration would really be tough to match normal anatomy. So we've approached by three concepts, proximal deployment,

where we actually deploy a graft proximal to the visceral vessels, divide that flow into five parts. One for the formimino area and then one for each of the visceral vessels. Then we do endo-bypasses.

We try to follow the same rules that we learn in open surgery. We want gradually sweeping bypass that have good flow dynamics and we did this one vessel at a time. So we do an eight front sheath

from the arm single sheath and we pick up the celiac, the SAM, the right renal, the left renal, and because of that, you can see that this is stageable. I can stop at any point.

I'm still going to have good flow to those visceral vessels in the legs. Once we have that visceral segment excluded, now we do delayed distal seal and it's just the standard evi after that point. Pretty simple.

So, we've come up with this. This is our manifold system. But as you can see, this can have a pretty torturous, awful anatomy even if there's been previously placed grafts. And we've actually now evolved from the manifold system,

which covers much bigger aneurisms to a shorter system for the type fours and perirenals and periviscerals, covering less aorta and hopefully less risk of paraplegia. So how does it work? That's the question.

Well, we've done some pretty extensive flow dynamics and if you start looking at flow dynamics in osculating sheer index, how well is that blood moving? Is it moving in an organized way? We want that to have organized flow

by the time it reaches the end of those branch vessels so that the endothelium has good oxygenation and less chance of inter-hypoplasia stenosis. So, at this point with this visceral manifold, we've done 42 patients. About a 50/50 split between male and female

and you see a pretty wide range of ages from 58 to 89 years old and a good number of these people have had previous surgeries. 34 of these were non-emergent, five of these were dissections

with type-B dissection of aneurism and three of these were ruptures. Pretty sick people. ASA scores, more than half of them were greater than four. Surgical times, as we saw earlier and these can be complex cases

that can take quite a bit of time. Implant time, much reduced with the use of direction sheaths Fluoro time has gone down dramatically from the early times. Use of contrast, nine CCs. We've evolved and we use a lot just CO2. CO2 works very well, lays it out nicely.

So, of the 157 potential grafts, we've been able to successfully implant to 154. Two patients had a super renal fixation that we were not able to reverse early on. Mortality rates in hospital. Two in hospital mortality,

one from a retrograde dissection, and the other one from an MI. That was the gentleman who ruptured. Two renal failures acutely. No CVAs and I think that speaks to that single eight front sheath from the arm.

Two paraplegias. Length of hospital stay, about 10 days. What's really cool is that more than half of these people are discharged straight to home. One year follow up, not a big change. There's still those two people that died

from interoperatively, not interoperatively, from the retrograde dissection and that MI. One all cause mortality, 14 of 42. Device related deaths, none. Renal failures, we did see people progress on to more acute renal failure.

That these are people that were already on the verge. And then one additional paraplegia. No type one endoleaks or type threes that were seen after the first two patients. Keep an eye on this one year all cause mortality, 14/42, because when we move to,

later you'll see this, of the 85 potential grafts for patency at one year, 83 of those remained patent with a 98% patency rate. So now the two year data. Still the two patients that aneurismal deaths and the MI in the retrograde dissection in that first 30 days.

Only one additional all cause mortality death. So the grafts are performing well, people are dying from their comorbidities. And then you see renal failure, paraplegia, and endoleaks really have not changed. Patency rates, still in that 93 to 97% range.

Thank you.

- [Karl Illig] Thanks Rob and Mark and thanks to Frank and the team for inviting me again. What they forgot to say is this is clearly the most exciting session of the whole VEITH meeting so you guys are lucky that you're here, you go got your seats early and we'll go from there.

So there's no conflict of interest to be had in TOS. My caveat is for the next four and a half minutes, I'm just really going to be talking about Neurogenic thoracic outlet system. So I was asked to talk about what's new and it's a little bit of a conundrum.

There's actually plenty new. I'm going to briefly review the reporting standards document that was published last year to sort of try to bring order to chaos. Also talk about a few selected publications over the last year or two.

Some international outreach efforts and there's another edition of the textbook coming out so love to chat with anybody who wants to be an author. So thoracic outlet syndrome and again, mostly neurogenic, suffers from inconsistent terminology, no agreement on diagnostic criteria and inconsistent

outcomes reporting. And as a result, we're not even sure what we're talking about. We're talking about the same thing. Very poor data. Sort of a negative feedback loop that we've got

no data, no good results, nobody likes it, it's very subjective, et cetera, et cetera. So a few years ago, it really spurred by the meeting that Rob held in St. Louis around 2009, 2010 or so, we came up with the society for vascular surgery reporting standards document.

Really three objectives. One is to standardize terminology. Number two is to standardize the diagnosis. And we don't pretend to have a cosmic knowledge of what it actually is. Depends on what the meaning of the word is is.

But we want everyone to be talking about the same thing and therefore standardize reporting requirements. At the bottom there, there's two references. One is the executive summary and one is the full document. Number one to diagnose TOS, neurogenic TOS, you need three of the following four criteria.

Pain, tenderness at the scalene triangle, tends to radiate around. It hurts when you press. There's a problem at the scalene triangle. Number two is distal neurological symptomatology. The nerves are being squeezed.

Tends to be worse with arms overhead, tends to be worse with dangling, et cetera et cetera. Number three is absence of other things that could cause these symptoms. And number four is positive response to a properly preformed scalene test injection.

Some people inject everybody, some people just use this as a tiebreaker in confusing situations. We ask people to ignore pulse obliteration. It's time that really went away. Many, many normal people obliterate and many people with neurogenic TOS do not.

It is not sensitive or specific enough. The physician ranks their severity as low, medium or high and the patient ranks the severity as low, medium or high. We ask for a QuickDASH and CBSQ on everybody.

Report outcomes primarily at three to twelve months but use life table analysis afterward and talk about it recurrence rate. How about some recent publications? There's a few interesting things out there. Bottros, a group from Washington University

described a stress block for those athletes who are only symptomatic during their athletic endeavors. I've contributed some patients to that and to my knowledge, our two groups together, we've never had anyone who has not recovered, who's had a positive block.

Dr. Peek from the Netherlands did a beautiful meta analysis and came up with numbers exactly what we quote from our experience. 90% of patients properly treated with surgery improve, and QuickDASH drops 28 points which is pretty nice. Rob Thompson next to me looked at his experience

with major league pitchers, found that about 80% return to full function and that's a pretty good number to tell your athletes. And Wooster from our group, we published a nice cocktail of pain medicine in addition to dropping the pain score, we reduced the our length of stay but a day and a half

which was kind of a nice thing. Now there's a talk I believe immediately following mine on robotic or thoracoscopic rib resection which I'm interested to hear. Couple of papers out, one from Lafosse in France. Again got a 90% improvement with the thoracoscopic

rib resection. I'm sorry, with just brachial plexus lysis, endoscopic lysis and professor George from England had 10 patients with thoracoscopic first rib resection. 9 of the 10 improved. So again, 90% success rate which I think

is a good number for the modern era. International outreach. I've heard TOS described as an American invention just to make money but I think more and more people now, especially in Europe and various places are getting interested.

I had conversation with two very interested people a couple of days ago which was a lot of fun. England's interested, France is interested, Netherlands has a great center. People from China are interested. And there's sort of a grassroots thing

sort of led by a non physician, kind of philanthropist millionaire called TOSCOE which is aiming to increase this in Europe. Finally, the textbook Thoracic Outlet Surgery came out in 2013. Interestingly we missed many topics

and many things have changed since then. So we're getting a lot of new chapters. So I would say, many of the editors are in this room and please talk to us. We're looking for interested people who are not only interested

but also can write specific things. So thank you very much, that's what new in TOS in five minutes.

- [Presenter] Thanks doctors, well I can shorten my title a little bit [Laughter] These are my disclosures. So before I get into the value of the vascular surgeon in the healthcare system I thought it's interesting to sort of look at

what vascular surgery may look like through an administrator's eyes, you know and in general in vascular surgery we have relatively poor payor mix, frequently more than 70% of our patients are Medicare beneficiaries, and the ones that are younger

than 65 cause of their lower socio-economic class are frequently on Medicaid. And also we do a lot of high-cost procedures, a good example of that is endovascular aneurysm repair. And you know, we looked at that a few years ago, and we compared the DRG reimbursements

to what it cost, and if you notice, you know, two-thirds of the DRG payment is consumed by the cost of the stent graft. Which really doesn't leave much left for other supplies and for salaries, and so in general we are running

about a $5000 negative margin per case. Despite this, there are three things where vascular surgeons do add value to the healthcare system. I think you can actually look at the P&L for vascular surgery and it's going to be positive. The vascular surgery is an enabling service,

every hospital wants a vascular surgeon because they want to be able to support their cardiologists, their spine surgeons, their oncologists, and urologists. And lastly I'll talk a few minutes about the benefit of a high vascular

case index on hospital revenue. So we looked at our own vascular surgery P&L over a six year period, and we were looking at physician-generated revenue as well as hospital-generated revenue through DRG and HBAS payments. The top line result is shown here,

and on the left in yellow are RVUs, its professional revenue indexed to inflation. And you can see that it's not a big surprise that physician revenue dropped around 21% over the six-year period. And the red is the hospital revenue.

But what's really interesting, what kind of demonstrates the value of vascular surgery, is if you look at the professional revenue per RVU, it's around $100. But then if you look at revenue that you bring in based on the hospital reimbursement,

based on your work, and index it to RVUs, it's around $500 per RVU. And you know in our own instance, at Dartmouth-Hitchcock, if you look at, take the technical and professional revenue, and you look at operating margin per case, you can see cardiac surgery which in most cases

is going to be, you know, doing pretty well $7500 a case, but you can see vascular surgery is relatively high up on the list there with a margin of around $2500 per procedure. Hospital medicine you might think is kind of an outlier, but at Dartmouth the orthopedic patients

are placed on the hospital medicine service. So when you look at vascular surgery as an enabling service line, Tonita and coworkers looked at 300 off-service patients over a four-year period, and you know in half the cases the

surgeons are doing spine exposure, in 14% they are doing vascular control prior to hemorrhage, and interestingly, in another 14% it was vascular control after hemorrhage. And then 19% of the patients required a vascular reconstruction,

and this generated around 1400 RVUs per year. And then lastly, just to say a couple words about Case Mix Index, this may be the most important and have the biggest impact on hospital reimbursement. Case Mix Index reflects the diversity and complexity of the patients a hospital cares for.

And the CMI affects hospital-wide Medicare reimbursement, so at our institution, each increase in the CMI of 0.01, which sounds like a small number, results in a $3 million increase in annual revenue. So here's a list of Case Mix Indexes from 2010 from various academic medical centers in the United States.

And you can see at Dartmouth-Hitchcock, so our hospital is around 2.13, the section of vascular surgeries' CMIs increased during this time from 2.4 up to 2.8. And so obviously we're going to have a positive impact on the hospital's CMI.

And then the question is, well where might we fit in sort of with the specialties that are typically associated with the heart and vascular center. And you can see the CMI for cardiac surgery, and this is pretty typical throughout,

from institution to institution, is around five and a half, and vascular surgery is at 2.8, and cardiology is around 1.87. And the hospital CMI is 2.13. So we're, we are contributing to increasing the CMI, which is going to have a significant

impact on hospital revenue. So in conclusion, vascular surgery technical revenue really drives the majority of hospital vascular reimbursement. And the vascular surgery presence allows for safe conduct of many additional highly reimbursed procedures.

Favorable vascular surgery CMI improves hospital-wide reimbursement from CMS, and while RVUs can measure productivity, they are not a good measure of value of the vascular surgeon. Thank you, I'd like to thank Dr. Veith for

the privilege of inviting me to this outstanding meeting. Thanks.

- [James] Sort of continuing the theme of the vascular house of horrors here. But this is a video that I had made. No disclosures. I'm going to illustrate a case and talk about some of the technical tips. This is a 51 year old man who presented

with left groin infection and malaise and had previously been treated with an aortobifemoral graft and had a groin exploration a few months before coming to us. This is a typical CAT scan that you'll see with fluid around all the graft limbs

and a mycotic aneurysm in both groins. This patient we did a tagged white blood cell scan mostly to see the extent of the infection. The key operative steps are listed here, and I'm going to go through these over the next several minutes.

First, if you're going to consider the femoral vein you're have to always know that the femoral vein is intact. And so the duplex checks and make sure the diameter is adequate. In terms of the exposure, you start with a curved linear incision that starts

into the anterior superior iliac spine and then move the sartorius medially. In doing so, you're going to have full access to the entire course of the femoral vein from it's confluence with the profunda femoral vein all the way down to the adductor hiatus.

You do not have to take the sartorius down you just keep moving it medially. This is a relief from one of Jim Valentine's papers, a nice paper on the subject. Here you can see a course of the femoral vein on both sides. Importantly, you want to make sure

you harvest the femoral vein all the way up to where it becomes confluent with the deep femoral vein. Leaving a stump there is a recipe for pulmonary embolism in your patient. So you're going to transect right to that level. After you take the vein out,

and perhaps when your fellows open the abdomen, you can be doing this which is transfixing all of the confluent femoral vein branches and make sure that none of those little ties pop off, which is an immediate re-exploration in almost every case. It also helps to make sure that those don't pop off

when you're tunneling from the abdomen to the groin. There's the abdominal incision. We prefer the transabdominal incision for these. It just puts you in a better situation. You'd have to reposition otherwise if you're going from the left flank.

And see the graft is not incorporated as one would expect. And obviously mobilizing this area is oftentimes very difficult. In this case the graft was infected. There was not an aortoenteric fistula, but certainly we would resect the duodenum,

that's been our playbook for that. We also divide the left renal vein. Just gives you a little better exposure to the suprarenal aorta. And potentially an area that hasn't been dissected on a prior occasion.

You could see sharp dissection in the area the renal artery and the juxtarenal aorta in this location. Once we have everything all identified we'll come down and do the dirtiest part of the operation which is usually the fistula, or the graft continuous fistula.

Here's a mycotic aneurism. In this case, there were multiple pieces of graft. It felt like we were on a fishing trip just pulling fish after fish out of this groin. But eventually, once we have all these different graft pieces cut out of the groin

we'll get down to the scene of the action, which is all the way down. We're going to try and maintain those femoral branches, certainly the deep femoral if at all possible. This is back up to the aorta now. We're going to trim all this aorta off of the,

all the graft off of the aorta itself. The aorta you can see is pretty thickened, and this is always a question as to the suitability of a femoral vein graft with the diameter of the aorta. And most of these femoral veins

are going to be anywhere from eight to 12 diameter. Most of your aortas on occlusive disease, of course, are going to be around 16 to 20. The size matches nice. You do have to mobilize the aorta carefully off of the spine.

And then, as was instructed by Pat Clyde, another reason you put up your 12 o'clock and your six o'clock stitches, first, to help stretch the graft into position and then essentially just run the suture around from 12 to six and from 12 to six on the other side.

The vein will sort of incorporate into this, and it's a nice, obviously, thick aorta, and we're going to get a little bit of the vein to sit in place. You can see here I've not created the configuration of the one femoral vein

to the other femoral vein. This is just a straight shot, and I'm going to pull this down eventually to the groin And we'll put the other femoral vein as a Y graft off of the other. Of course the grafts are not incorporated.

They're all infected. They'll slide easily out of the tunnels. And once the tunnels are liberally irrigated then we'll put the femoral vein through the same tunnel, which can be a difficult proposition if they are incorporated where extent of the infection

is just in the abdominal portion of the presentation. Here's just the pass from one to another. This will be sewn down to the femoral artery. And then we'll put the other piece sort of back up near the top. This is just using a punch to make a nice oval venotomy,

and then we'll take the other femoral vein limb and attach it to there to give us a nice Y configuration. That, of course, we pull down to the right groin which is where that mycotic aneurysm was, and then we'll sew this into place after we get everything out of position.

There's your deep femoral artery. Here's a couple of configurations. If you're short on vein you can sometimes do configuration A, which works nicely, and of course, the patient we left the groins open, but everything else was closed.

We did pretty well with this operation. Seven and a half hours for a surgical team, but they can go longer. Thank you very much.

- Good morning, thank you, Dr. Veith, for the invitation. My disclosures. So, renal artery anomalies, fairly rare. Renal ectopia and fusion, leading to horseshoe kidneys or pelvic kidneys, are fairly rare, in less than one percent of the population. Renal transplants, that is patients with existing

renal transplants who develop aneurysms, clearly these are patients who are 10 to 20 or more years beyond their initial transplantation, or maybe an increasing number of patients that are developing aneurysms and are treated. All of these involve a renal artery origin that is

near the aortic bifurcation or into the iliac arteries, making potential repair options limited. So this is a personal, clinical series, over an eight year span, when I was at the University of South Florida & Tampa, that's 18 patients, nine renal transplants, six congenital

pelvic kidneys, three horseshoe kidneys, with varied aorto-iliac aneurysmal pathologies, it leaves half of these patients have iliac artery pathologies on top of their aortic aneurysms, or in place of the making repair options fairly difficult. Over half of the patients had renal insufficiency

and renal protective maneuvers were used in all patients in this trial with those measures listed on the slide. All of these were elective cases, all were technically successful, with a fair amount of followup afterward. The reconstruction priorities or goals of the operation are to maintain blood flow to that atypical kidney,

except in circumstances where there were multiple renal arteries, and then a small accessory renal artery would be covered with a potential endovascular solution, and to exclude the aneurysms with adequate fixation lengths. So, in this experience, we were able, I was able to treat eight of the 18 patients with a fairly straightforward

endovascular solution, aorto-biiliac or aorto-aortic endografts. There were four patients all requiring open reconstructions without any obvious endovascular or hybrid options, but I'd like to focus on these hybrid options, several of these, an endohybrid approach using aorto-iliac

endografts, cross femoral bypass in some form of iliac embolization with an attempt to try to maintain flow to hypogastric arteries and maintain antegrade flow into that pelvic atypical renal artery, and a open hybrid approach where a renal artery can be transposed, and endografting a solution can be utilized.

The overall outcomes, fairly poor survival of these patients with a 50% survival at approximately two years, but there were no aortic related mortalities, all the renal artery reconstructions were patented last followup by Duplex or CT imaging. No aneurysms ruptures or aortic reinterventions or open

conversions were needed. So, focus specifically in a treatment algorithm, here in this complex group of patients, I think if the atypical renal artery comes off distal aorta, you have several treatment options. Most of these are going to be open, but if it is a small

accessory with multiple renal arteries, such as in certain cases of horseshoe kidneys, you may be able to get away with an endovascular approach with coverage of those small accessory arteries, an open hybrid approach which we utilized in a single case in the series with open transposition through a limited

incision from the distal aorta down to the distal iliac, and then actually a fenestrated endovascular repair of his complex aneurysm. Finally, an open approach, where direct aorto-ilio-femoral reconstruction with a bypass and reimplantation of that renal artery was done,

but in the patients with atypical renals off the iliac segment, I think you utilizing these endohybrid options can come up with some creative solutions, and utilize, if there is some common iliac occlusive disease or aneurysmal disease, you can maintain antegrade flow into these renal arteries from the pelvis

and utilize cross femoral bypass and contralateral occlusions. So, good options with AUIs, with an endohybrid approach in these difficult patients. Thank you.

- [Krister] Good morning. I thank Frank Veith for the opportunity to present a new tool to facilitate treatment of complex aortic aneurysms. My disclosure. So in endovascular work, don't lose your guidewire position during your endovascular mission.

That's... It's what we want to avoid and normally we don't succeed to avoid that in every situation. But here is a way to do it. You have a braided tool,

a nitinol braid with a shape of a cylinder with two cones and it's delivered over an 0.035 guidewire and through a seven French sheath into a target artery. And when you pull on the guidewire

you get an interaction distally with a stopper on the guidewire to give shortening of the device and the radial force towards the vessel wall to hold the guidewire. Comes in three sizes

and it's oversized slightly, one millimeter in relation to the target artery. So this tool is indicated for complex aortic repair but it can also be used in any situation where you would want a stable guidewire position. So here is an example.

We have here single fenestrated Cook graft for the left subclavian and instead of the typical normal use of a through and through wire, we use this anchor guidewire, which we position in the left subclavian artery

and we then feed the guidewire through the preloaded catheter in the delivery device through the fenestration arm table, prior to introducing the stent graft. As can be seen here, we position the device in the left subclavian by use of a seven French sheath.

And then we can introduce a stent graft over the leading guidewire and the guidewire that we have anchored. And when we are positioned and deploy, we put some traction on the guidewire, and that helps us to get perfect alignment

of the fenestration with target artery. And in this situation we do not need an anchor anymore so we can back with the seven French sheath and retrieve the anchor from the left subclavian. And when we've done that, we can position the braided stent graft

or we can do it the other way around if we want to have the anchor still there when we position the graft, completed procedure. So problem here could be that we have a guidewire interference with a top cap that can be avoided by top cap configuration

that holds the top cap towards the rod of the delivery device. And we can have happen a wire wrap which is easily sorted out by going backwards snaking to the descending and the forwards again so that we sort it out.

We've also tested it in chimneys and snorkels and in this situation we did it in the SMA and also in renal artery. It works well except for the thing that in the renal artery we may get into a situation where the renal artery's too short

to harbor both the 28 millimeters device and the sealing zone of the braiding graft and the tip of the braiding graft, as we can see here. So in the situation I think we need to modify the device in order to handle the chimneys.

So we haven't had any safety problem and we have technical success with those few cases. And we are recruiting further. So we have a new endovascular tool, a guidewire fixator terminator to old loss of the guidewire

in difficult situations in complex work in the aorta. Feasibility trial is ongoing. We have recruited a few patients and we are still recruiting up to 20 patients in this registry. And for the future we want combine this

with a filter to use it to have a stable guidewire position together with a filter to avoid distal embolization in visceral and in peripheral interventions. Thank you for listening.

- [Presenter] Ablation is not surgery. Surgery as we define it is cutting and excising tissue and ablation doesn't do that. So, it's actually different than surgery. And the lesion can actually not be completely visualized. So even though it's open,

you're not able to visualize the lesion completely with surgery. So you're handicapped with that. So, as Dr. Hepworth said, our argument that ablation is preferable over surgery is certainly true that there undesirable effects.

Our second argument is that there's unusual behavior with the vascular malformation following surgery. We know that there's cytokines released and it's certainly been published in the Journal of Pathology. I can cite the reference, if you want, in 1990,

that the release of cytokine causes the endovascular cells to actually upload the messenger RNA with release of some of the hormones related to inflammation and vascular increase. There's also an effect of integrity when we think that the nitis is incised, that there may be

some actual spread of these types of tissues that send to proliferate. So there's a change in the microvascular architecture. Our third argument is that ablation is safe. We have seen many presentations that ethanol toxicity,

that the risk of that is actually very low and the dose is kept at one milligram per kilogram and that contrast can be delivered at the same time to outline the lesion and where the treatment is. So we think that ablation is safe, even with the very adhesives

and some of the side effects of it. Our last argument is that by treating ablation, if there is to be any surgery, it's going to be from a functional or aesthetic side and we think that ablation helps with that.

And so our fourth argument is that reconstructive options are preserved. So, our team on the pro side believe that that we've proven the vascular malformation should be managed with ablation

and without open surgical intervention. And so we feel that our opponents at this point, Dr. Kim is coming and he's got a little bit of work to do in order to strengthen their side. Thank you, I conclude the presentation of the pro side.

- [Presenter] It's a great pleasure for me to share our experience with retrograde vein approach with you. So as you can see, vascular malformations presents one of the most challenging entities to diagnose and treat. And the basic thing is that we have

to understand AVM angioarchitecture. And we have to determine the specific endovascular treatment strategies. And the Yakes Classification is very helpful and useful, too, to determine endovascular approaches and embolic agents.

So it was firstly described in early '90s by Yakes and then by Jackson. This retrograde vein approach, I mean, it's an access to the AVM from the venous site. Either it's a direct puncture of the vein, just close to the nidus

or either retrograde catheterization. It's mostly used in type IIb and type IIIa and b in the Yakes Classification. IN type IIIb AVM are more challenging because due to the more complex vein outflow morphology. So what about the technique?

As you can see here, we can have them both accesses as a direct percutaneous access with 18 G needle, or we can also use retrograde venous access with a four or five French catheter. We use fluoroscopy and ultrasound guidance to get as close as possible to the nidus.

Nidus which is in the wall of the vein, in the wall of enlarge aneurysmal vein. Then we have to full feel with the coils, usually, mostly we use fibred coils, 0.035 coils. If the vein is really large to get good structure, we use a J-movable core wire.

We have two different techniques. In the beginning we can see saline flush to put the coil into the enlarged vein. Or after that, when it's really compacted and there a lot of coils in the vein, we can just a regular pusher

to put as many coils as possible. We really want to have a really dense packing in the aneurysmal vein to have a total occlusion and then we want to stop the blood flow through the nidus. Or like Professor Yakes saying nidum because

it's so beautiful it has to be a lady. Not every AVM can be treated with only with coils. Sometimes we also have to add a little bit of ethanol in the end of the procedure just fulfill all the arteries in the nidus,

just to occlude it and completely kill it. As you can see in this pictures we got 20 years old female with non-cyclic abdominal pain. She has a type III a AVM with multiple in flow arteries and really big one single out flow vein.

This AVM is supplied by the arteries from the right and left internal iliac artery and it's draining into the left iliac and ovarian vein. As you can see in the picture, she was treated before with a different liquid embolic agents like Onyx or glue.

Also, there was some coils implanted, placed, but they were placed in the arterial side of the AVM so just the feeding arteries were closed, but as you can see it was ineffective. So we decide to do a direct puncture of that venous pouch

and then fill it with coils. And after that just give a little bit of ethanol in the end. So as you can see here it's the final angiogram right after embolization. Please take a look on the iliac arteries. The hemodynamic flow is completely different.

We can even see the string of pearls. And there's the angiogram one year after embolization, which is really successful. Nothing left, and the patient is completely cured. That's the similar case. The young male with pelvic ACM type III a.

And the same approach was done, the direct puncture, and we filled pouch with the coils. After that give a little bit of ethanol to completely occlude it and with a good, good result. Those both cases were done in one session.

So it's a great thing. Unfortunately not all AVMs are so straighforward. Sometimes we have to deal in the steps and we have to use a direct punch or retrograde catheterization in different places and fill those veins

in couple of places, but step by step we can approach the good final outcome. So the conclusion, that the Retrograde Vein Approach for AVMs treatment is relatively safe and effective method. IIIa and IIIb can be permanently occluded by dense coil packing of the vein aneurysm

with or without ethanol injection embolization. This can be done via direct puncture of the vein aneurysm or just by the retrograde vein catheterization. Thank you.

- [Presenter] It's a great pleasure for me to share our experience with retrograde vein approach with you. So as you can see, vascular malformations presents one of the most challenging entities to diagnose and treat. And the basic thing is that we have

to understand AVM angioarchitecture. And we have to determine the specific endovascular treatment strategies. And the Yakes Classification is very helpful and useful, too, to determine endovascular approaches and embolic agents.

So it was firstly described in early '90s by Yakes and then by Jackson. This retrograde vein approach, I mean, it's an access to the AVM from the venous site. Either it's a direct puncture of the vein, just close to the nidus

or either retrograde catheterization. It's mostly used in type IIb and type IIIa and b in the Yakes Classification. IN type IIIb AVM are more challenging because due to the more complex vein outflow morphology. So what about the technique?

As you can see here, we can have them both accesses as a direct percutaneous access with 18 G needle, or we can also use retrograde venous access with a four or five French catheter. We use fluoroscopy and ultrasound guidance to get as close as possible to the nidus.

Nidus which is in the wall of the vein, in the wall of enlarge aneurysmal vein. Then we have to full feel with the coils, usually, mostly we use fibred coils, 0.035 coils. If the vein is really large to get good structure, we use a J-movable core wire.

We have two different techniques. In the beginning we can see saline flush to put the coil into the enlarged vein. Or after that, when it's really compacted and there a lot of coils in the vein, we can just a regular pusher

to put as many coils as possible. We really want to have a really dense packing in the aneurysmal vein to have a total occlusion and then we want to stop the blood flow through the nidus. Or like Professor Yakes saying nidum because

it's so beautiful it has to be a lady. Not every AVM can be treated with only with coils. Sometimes we also have to add a little bit of ethanol in the end of the procedure just fulfill all the arteries in the nidus,

just to occlude it and completely kill it. As you can see in this pictures we got 20 years old female with non-cyclic abdominal pain. She has a type III a AVM with multiple in flow arteries and really big one single out flow vein.

This AVM is supplied by the arteries from the right and left internal iliac artery and it's draining into the left iliac and ovarian vein. As you can see in the picture, she was treated before with a different liquid embolic agents like Onyx or glue.

Also, there was some coils implanted, placed, but they were placed in the arterial side of the AVM so just the feeding arteries were closed, but as you can see it was ineffective. So we decide to do a direct puncture of that venous pouch

and then fill it with coils. And after that just give a little bit of ethanol in the end. So as you can see here it's the final angiogram right after embolization. Please take a look on the iliac arteries. The hemodynamic flow is completely different.

We can even see the string of pearls. And there's the angiogram one year after embolization, which is really successful. Nothing left, and the patient is completely cured. That's the similar case. The young male with pelvic ACM type III a.

And the same approach was done, the direct puncture, and we filled pouch with the coils. After that give a little bit of ethanol to completely occlude it and with a good, good result. Those both cases were done in one session.

So it's a great thing. Unfortunately not all AVMs are so straighforward. Sometimes we have to deal in the steps and we have to use a direct punch or retrograde catheterization in different places and fill those veins

in couple of places, but step by step we can approach the good final outcome. So the conclusion, that the Retrograde Vein Approach for AVMs treatment is relatively safe and effective method. IIIa and IIIb can be permanently occluded by dense coil packing of the vein aneurysm

with or without ethanol injection embolization. This can be done via direct puncture of the vein aneurysm or just by the retrograde vein catheterization. Thank you.

- Thank you very much Frank and thanks for the invitation. My first thing is to deal with the patient who's awaiting CABG who's had a previous stroke or TIA. This is the only study of it's kind showing that if you proceed with isolated CABG, the risk of stroke is extremely high and if you look at the meta-analysis that we've done of whether you do endarterectomy or

stenting in symptomatic patients, this is all the literature there is. And what you can clearly see is that the death and stroke rates in patients undergoing CAS followed by CABG are much higher than after carotid and endarterectomy. And that lead us to recommend that a stage of

synchronous carotid intervention should be considered in CABG patients with a history of stroke or TIA and who have a 50 to 99% stenosis. But advise that for now, if you're going to do that such an intervention, surgery should probably be considered instead of stenting.

But 96% of all interventions of the CABG and carotid variety are in asymptomatic patients, so what about them? Well, this is all the literature there is on stroke risk in patients undergoing isolated CABG with a unilateral asymptomatic stenosis of 70 to 99 or 80 to 99 and you can see there is an awful lot of zeroes

in that table and if you go at patients with bilateral significant disease, the death and stroke rate is much higher but again there is not too many strokes here. And if you look critically at the literature and ask yourself okay we've had so many strokes, how many of them can be attributable to underlying

carotid disease by looking at the CT scans or the distribution of lesions, you'll see that between 85 and 95% of all strokes cannot be attributed to an underlying significant carotid stenosis. And if you look at all the death and stroke rates and this is a multiple meta-analysis that our

group have done over the last 15 years, these are the death and stroke rates depending on how you treat the patients, and 80% of these are asymptomatic and 80% have got unilateral stenosis and the death and stroke rates are far in excess of the risk of stroke if you just perform an

isolated CABG in patients with unilateral asymptomatic disease. There have been two randomized trials. This is one, the Iluminati trial that Jean-Baptiste was involved in, 30-day death and stroke rates not significantly different.

There is quite an astonishing trial from Germany, which was again unilaterally asymptomatic stenosis with a near 20% death and stroke rate with synchronous carotid CABG and a 10% definite stroke rate with medical therapy, ah isolated CABG, sorry. So the ESVS have advised that a staged synchronous

carotid intervention is not recommended in CABG patients with an asymptomatic unilateral, 70 to 99% stenosis for preventing stroke after CABG. A staged synchronous intervention may be considered in patients with bilateral disease, the evidence is not brilliant but it's such a rare thing that it's

probably not worth arguing about. Now what about patients who are undergoing non-cardiac surgery? This is quite an interesting group, because if say, a gastrectomy, a hip replacement or whatever, if they've had a previous history of stroke or TIA

they should undergo carotid imaging and if they've got a significant stenosis they should undergo prior carotid revascularization prior to undergoing their gastrectomy et cetera. But what about the asymptomatic patient? This is quite interesting.

First of all, let's just look at a very large study by Jorgensen, 4 nearly 500,000 elective non-cardiac operations and 7,000 had suffered a prior stroke or TIA, and the most important thing was, the stroke risk was directly related to the time from the onset of the TIA to doing the operation.

So if you did it within three months of the stroke or TIA there was a 12% peri-operative stroke rate, but if you managed to get out to six months, the stroke rate was only 0.1% so the lesson learned there is that if it's possible to delay surgery in patients who've had a prior stroke or TIA

or a recent one, you should delay it for six months. Only two studies have looked at whether asymptomatic carotid stenosis increased the stroke risk in patients undergoing non-cardiac operations. Ballotta did a randomized trial, and Sonny, which is a very large observational study,

looked at the impact of asymptomatic carotid stenosis on outcome and found that there was no evidence that a pre-existing carotid stenosis increased the risk of stroke in patients undergoing major non-cardiac surgery. Similarly, in a huge study on TAVI patients,

no evidence that carotid disease was a risk factor for perioperative stroke. So in our recommendations we advised routine carotid imaging in asymptomatic patients undergoing major non-cardiac surgery is not recommended and prophylactics and arterial stenting is not

recommended in patients with asymptomatic carotid stenoses undergoing non-cardiac/vascular procedures. And if you'd like to look at all the literature and data that we came to in using to our conclusions, the guidelines are free to access on the internet.

Thank you very much.

- Thank you very much again. Thank you very much for the kind invitation. The answer to the question is, yes or no. Well, basically when we're talking about pelvic reflux, we're talking really, about, possibly thinking about two separate entities. One symptoms relate to the pelvis

and issues with lower limb varicose veins. Really some time ago, we highlighted in a review, various symptoms that may be associated with the pelvic congestion syndrome. This is often, either misdiagnosed or undiagnosed. The patients we see have had multiple investigations

prior to treatment. I'm not really going to dwell on the anatomy but, just really highlight to you it is incompetence in either the renal pelvic and ovarian veins. What about the patterns of reflux we've heard from both Mark and Nicos what the pattern are

but, basically if you look a little more closely you can see that not only the left ovarian vein is probably effected in a round-about 60%. But, there is incompetence in many of the other veins. What does this actually have implication for with respect to treatment.

Implications are that you probably, if you only treat an isolated vein. There is a suggestion, that the long term outcomes are not actually as good. Now this is some work from Mark Whiteley's group because, we've heard about the diagnosis

but, there is some discussion as to whether just looking at ovarian vein diameter is efficient and certainly the Whiteley group suggests that actually diameter is relatively irrelevant in deciding as to whether there is incompetence in the actual vein itself.

That diameter should not be used as a single indicator. You may all well be aware, that there are reporting standards for the treatment of pelvic venous insufficiency and this has been high-lighted in this paper. What of the resuts, of pelvic embolization and coiling? The main standard is used, is a visual analog scale

when you're looking at pelvic symptoms to decide what the outcome may be. This is a very nice example of an article that was... A review that was done in Niel Khilnani's group and you can see if you look at the pre

and post procedural visual analog scales there is some significant improvement. You can see that this is out at one year in the whole. Now, this is a further table from the paper. Showing you their either, there's a mixture

of glue, coils, scleroses and foam. The comments are that, there are significant relief and some papers suggest its after 100% and others up to 80%. If you look at this very nice review that Mark Meissner did with Kathy Gibson,

you will see that actually no improvement in worse. There's quite a range there for those patients 53% of patients in one study, had no improvement or the symptoms were potentially worse. We know that those patients who have coil embolization will have reoccurrence of symptomatology

and incompetence up to about a quarter of the patients. What about varicose veins? The answer is there is undoubtedly evidence to suggest that there is physiological/anatomical incompetence in some of the pelvic veins in patients

who have recurrent varicose veins. Whether this is actually a direct cause or an association, I think it's something we need to have some further consideration of. As you know, there are many people who now would advicate actually treating

the pelvic veins prior to treating the leg veins. You can maybe discuss that in the question time. If we then look at a comparative trial. Comparing coils and plugs, you can see over all there really isn't no particular difference. If we then look again to highlight this,

which comes again from the Whiteley group. You can see that 20% of patients will have some primary incompetence but, it'll go up to around 30% if they are re-current. There is no randomized control data looking at this. What are the problems with coils?

Actually, a bit like (mumbling) you can find them anywhere. You can find them in the chest and also you can find that there are patients now who are allergic to nickel and the very bottom corner is a patient who's coils I took out by open laparotomy because they were allergic to nickel.

So, ladies and gentlemen I would suggest to you certainly, for continuing with pelvic embolization when doubtedly it needs some more RCT data and some much better registry data to look where we're going. Thank you very much.

- [Karl Illig] Thanks Rob and Mark and thanks to Frank and the team for inviting me again. What they forgot to say is this is clearly the most exciting session of the whole VEITH meeting so you guys are lucky that you're here, you go got your seats early and we'll go from there.

So there's no conflict of interest to be had in TOS. My caveat is for the next four and a half minutes, I'm just really going to be talking about Neurogenic thoracic outlet system. So I was asked to talk about what's new and it's a little bit of a conundrum.

There's actually plenty new. I'm going to briefly review the reporting standards document that was published last year to sort of try to bring order to chaos. Also talk about a few selected publications over the last year or two.

Some international outreach efforts and there's another edition of the textbook coming out so love to chat with anybody who wants to be an author. So thoracic outlet syndrome and again, mostly neurogenic, suffers from inconsistent terminology, no agreement on diagnostic criteria and inconsistent

outcomes reporting. And as a result, we're not even sure what we're talking about. We're talking about the same thing. Very poor data. Sort of a negative feedback loop that we've got

no data, no good results, nobody likes it, it's very subjective, et cetera, et cetera. So a few years ago, it really spurred by the meeting that Rob held in St. Louis around 2009, 2010 or so, we came up with the society for vascular surgery reporting standards document.

Really three objectives. One is to standardize terminology. Number two is to standardize the diagnosis. And we don't pretend to have a cosmic knowledge of what it actually is. Depends on what the meaning of the word is is.

But we want everyone to be talking about the same thing and therefore standardize reporting requirements. At the bottom there, there's two references. One is the executive summary and one is the full document. Number one to diagnose TOS, neurogenic TOS, you need three of the following four criteria.

Pain, tenderness at the scalene triangle, tends to radiate around. It hurts when you press. There's a problem at the scalene triangle. Number two is distal neurological symptomatology. The nerves are being squeezed.

Tends to be worse with arms overhead, tends to be worse with dangling, et cetera et cetera. Number three is absence of other things that could cause these symptoms. And number four is positive response to a properly preformed scalene test injection.

Some people inject everybody, some people just use this as a tiebreaker in confusing situations. We ask people to ignore pulse obliteration. It's time that really went away. Many, many normal people obliterate and many people with neurogenic TOS do not.

It is not sensitive or specific enough. The physician ranks their severity as low, medium or high and the patient ranks the severity as low, medium or high. We ask for a QuickDASH and CBSQ on everybody.

Report outcomes primarily at three to twelve months but use life table analysis afterward and talk about it recurrence rate. How about some recent publications? There's a few interesting things out there. Bottros, a group from Washington University

described a stress block for those athletes who are only symptomatic during their athletic endeavors. I've contributed some patients to that and to my knowledge, our two groups together, we've never had anyone who has not recovered, who's had a positive block.

Dr. Peek from the Netherlands did a beautiful meta analysis and came up with numbers exactly what we quote from our experience. 90% of patients properly treated with surgery improve, and QuickDASH drops 28 points which is pretty nice. Rob Thompson next to me looked at his experience

with major league pitchers, found that about 80% return to full function and that's a pretty good number to tell your athletes. And Wooster from our group, we published a nice cocktail of pain medicine in addition to dropping the pain score, we reduced the our length of stay but a day and a half

which was kind of a nice thing. Now there's a talk I believe immediately following mine on robotic or thoracoscopic rib resection which I'm interested to hear. Couple of papers out, one from Lafosse in France. Again got a 90% improvement with the thoracoscopic

rib resection. I'm sorry, with just brachial plexus lysis, endoscopic lysis and professor George from England had 10 patients with thoracoscopic first rib resection. 9 of the 10 improved. So again, 90% success rate which I think

is a good number for the modern era. International outreach. I've heard TOS described as an American invention just to make money but I think more and more people now, especially in Europe and various places are getting interested.

I had conversation with two very interested people a couple of days ago which was a lot of fun. England's interested, France is interested, Netherlands has a great center. People from China are interested. And there's sort of a grassroots thing

sort of led by a non physician, kind of philanthropist millionaire called TOSCOE which is aiming to increase this in Europe. Finally, the textbook Thoracic Outlet Surgery came out in 2013. Interestingly we missed many topics

and many things have changed since then. So we're getting a lot of new chapters. So I would say, many of the editors are in this room and please talk to us. We're looking for interested people who are not only interested

but also can write specific things. So thank you very much, that's what new in TOS in five minutes.

- Thank you very much for the opportunity to speak carbon dioxide angiography, which is one of my favorite topics and today I will like to talk to you about the value of CO2 angiography for abdominal and pelvic trauma and why and how to use carbon dioxide angiography with massive bleeding and when to supplement CO2 with iodinated contrast.

Disclosures, none. The value of CO2 angiography, what are the advantages perhaps? Carbon dioxide is non-allergic and non-nephrotoxic contrast agent, meaning CO2 is the only proven safe contrast in patients with a contrast allergy and the renal failure.

Carbon dioxide is very highly soluble (20 to 30 times more soluble than oxygen). It's very low viscosity, which is a very unique physical property that you can take advantage of it in doing angiography and CO2 is 1/400 iodinated contrast in viscosity.

Because of low viscosity, now we can use smaller catheter, like a micro-catheter, coaxially to the angiogram using end hole catheter. You do not need five hole catheter such as Pigtail. Also, because of low viscosity, you can detect bleeding much more efficiently.

It demonstrates to the aneurysm and arteriovenous fistula. The other interesting part of the CO2 when you inject in the vessel the CO2 basically refluxes back so you can see the more central vessel. In other words, when you inject contrast, you see only forward vessel, whereas when you inject CO2,

you do a pass with not only peripheral vessels and also see more central vessels. So basically you see the vessels around the lesions and you can use unlimited volumes of CO2 if you separate two to three minutes because CO2 is exhaled by the respirations

so basically you can inject large volumes particularly when you have long prolonged procedures, and most importantly, CO2 is very inexpensive. Where there are basically two methods that will deliver CO2. One is the plastic bag system which you basically fill up with a CO2 tank three times and then empty three times

and keep the fourth time and then you connect to the delivery system and basically closest inject for DSA. The other devices, the CO2mmander with the angio assist, which I saw in the booth outside. That's FDA approved for CO2 injections and is very convenient to use.

It's called CO2mmander. So, most of the CO2 angios can be done with end hole catheter. So basically you eliminate the need for pigtail. You can use any of these cobra catheters, shepherd hook and the Simmons.

If you look at this image in the Levitor study with vascular model, when you inject end hole catheter when the CO2 exits from the tip of catheter, it forms very homogenous bolus, displaces the blood because you're imaging the blood vessel by displacing blood with contrast is mixed with blood, therefore as CO2

travels distally it maintains the CO2 density whereas contrast dilutes and lose the densities. So we recommend end hole catheter. So that means you can do an arteriogram with end hole catheter and then do a select arteriogram. You don't need to replace the pigtail

for selective injection following your aortographies. Here's the basic techniques: Now when you do CO2 angiogram, trauma patient, abdominal/pelvic traumas, start with CO2 aortography. You'll be surprised, you'll see many of those bleeding on aortogram, and also you can repeat, if necessary,

with CO2 at the multiple different levels like, celiac, renal, or aortic bifurcation but be sure to inject below diaphragm. Do not go above diaphragm, for example, thoracic aorta coronary, and brachial, and the subclavian if you inject CO2, you'll have some serious problems.

So stay below the diaphragm as an arterial contrast. Selective injection iodinated contrast for a road map. We like to do super selective arteriogram for embolization et cetera. Then use a contrast to get anomalies. Super selective injection with iodinated contrast

before embolization if there's no bleeding then repeat with CO2 because of low viscocity and also explosion of the gas you will often see the bleeding. That makes it more comfortable before embolization. Here is a splenic trauma patient.

CO2 is injected into the aorta at the level of the celiac access. Now you see the extra vascularization from the low polar spleen, then you catheterize celiac access of the veins. You microcatheter in the distal splenic arteries

and inject the contrast. Oops, there's no bleeding. Make you very uncomfortable for embolizations. We always like to see the actual vascularization before place particle or coils. At that time you can inject CO2 and you can see

actual vascularization and make you more comfortable before embolization. You can inject CO2, the selective injection like in here in a patient with the splenic trauma. The celiac injection of CO2 shows the growth, laceration splenic with extra vascularization with the gas.

There's multiple small, little collection. We call this Starry Night by Van Gogh. That means malpighian marginal sinus with stagnation with the CO2 gives multiple globular appearance of the stars called Starry Night.

You can see the early filling of the portal vein because of disruption of the intrasplenic microvascular structures. Now you see the splenic vein. Normally, you shouldn't see splenic vein while following CO2 injections.

This is a case of the liver traumas. Because the liver is a little more anterior the celiac that is coming off of the anterior aspect of the aorta, therefore, CO2 likes to go there because of buoyancy so we take advantage of buoyancy. Now you see the rupture here in this liver

with following the aortic injections then you inject contrast in the celiac axis to get road map so you can travel through this torus anatomy for embolizations for the road map for with contrast. This patient with elaston loss

with ruptured venal arteries, massive bleeding from many renal rupture with retro peritoneal bleeding with CO2 and aortic injection and then you inject contrast into renal artery and coil embolization but I think the stent is very dangerous in a patient with elaston loss.

We want to really separate the renal artery. Then you're basically at the mercy of the bleeding. So we like a very soft coil but basically coil the entire renal arteries. That was done. - Thank you very much.

- Time is over already? - Yeah. - Oh, OK. Let's finish up. Arteriogram and we inject CO2 contrast twice. Here's the final conclusions.

CO2 is a valuable imaging modality for abdominal and pelvic trauma. Start with CO2 aortography, if indicated. Repeat injections at multiple levels below diaphragm and selective injection road map with contrast. The last advice fo

t air contamination during the CO2 angiograms. Thank you.

- Thank you, Mr. Chairman, thank you, Frank, for inviting me again in New York. Well, this is my disclosure. Thoracoabdominal repair is today performed with respectable results mainly in high-volume centers. Endo repair is attracting more and more patients, most of them are generally denied open surgery.

Data supporting endo repair also in low-average risk patients are lacking. As lacking are comparative studies, especially in major cohort of population. If we need to compare one option of treatment versus the other one, we need a standard.

One standard for open surgery can be, this is very important meta-analysis, recently published on JBS in 2018, including 9,963 patients. Well, the pool mortality in open thoracoabdominal surgery was 11%, and the pool of spinal cord ischemia,

including all kind of ischemia, 8.2%. There was no difference, in terms, at the multivariate analysis, in terms of the end points, regarding mortality. But it was statistically significant association between mortality and volume of cases performed

in each center. Experience is a very important issue in treating this disease, as demonstrated by these two papers. One is a very, very diffused, very famous paper, from Stephan Haulon,

comparing the first experience in endo, fenestrated, then branch, then the graft, versus the second experience, with statistically significant decrease of mortality in spinal cord ischemia, due to very aggressive approach of a giant procedure

like CSF drainage and early closure of lower limb to have early reperfusion of pelvic area and limbs. Similarly, more recent paper is reporting similar results of increasing, better outcome, according to aggressive approach, with blood pressure and blood transfusion.

Similar results are recently published by the group of Mayo Clinic, reporting striking difference in terms of reducing mortality in the second half of this experience, from 7.5% to 1.2%. And, regarding the long-term results, important the data coming from Cleveland Clinic,

with acceptable results of aneurysm rate mortality, and no difference between type 2 and type 3 of reinterventions. There are some concern about the cost effectiveness, as reported by the French study, reporting no difference in time of the end point,

but a striking difference in term of cost, regarding mainly the cost of the endograft. Contradicted by this paper, published by the group, reporting 879 patient with thoracoabdominal, reporting similar cost, or even worse cost,

in open surgery, due to collateral expenses. What about comparative study? We had only two matchable comparative study, with propensity score analysis. One is recently published by the group of Rome, in Catholic University, and Stephan Haulon,

showing no difference in terms of main end point, only difference in reversible acute kidney ischemia, and early reintervention. We recently published our experience, with 341 patients operated in Milano by San Raffaele in the same team in Perugia and Rome,

comparing 341 patients, 84 thoracoabdominal endo repair versus 257. There was a striking difference in terms of risk factors, so we selected according to propensity score, to comparable subgroup. 65 patients in each group,

with standard methodology of intervention, in endo, as well as in open. There was no difference in terms of endo. There was difference in terms of aggregated end points, including respiratory complication, ICU stays and hospital stays,

no difference in term of spinal cord ischemia and mortality. Survival and reintervention were the same in both group after three and a half years. So, in conclusion, endovascular repair of a thoracoabdominal aneurysm continue to evolve. Learning curve and adjunct procedure

are major factors for improving results. Nowadays, major mortality and major morbidity are comparable. The operation require centralization. A limitation of this study is that we have still small studies with matched control population.

Consequently, endovascular repair and open surgery should not be offered at random, but the choice should be individualized. Thank you for your attention.

- [Mark H. Meissner] Good morning. I'd like to thank Noel and Jose for inviting me, and thank you for the introduction of B.K. and Bill. I have no disclosures relevant to this presentation. I think as we've heard this morning, and everyone is aware, Ultrasound has really changed the way we manage Venous Disease,

and really has become an essential component in it's management. And the standard ultrasound exam, I'm sure everyone is familiar with, includes a supine assessment of obstruction, assessment of axial reflux, which should be performed

in the standing position. Can be preformed with a distal compression as the provocative maneuver, and either you can obtain satisfactory results with either distal cuff compression or manual compression. Reflux, at least in our lab,

being defined as retrograde flow, greater than .5 seconds and mostly for the insurance company's measurement of Venous diameters. Assessment of the reflux should be in the Deep veins, the Superficial veins, that we've heard a little bit about, Non-saphenous veins as well as Perforators.

And the critical point is that all reflux, has to be chased to its origin, and a 5 minute talk, have to choose what to focus on, and what I'm going to talk about is the how, Particularly the importance of the standing position. And the what, particularly who requires more,

than a basic duplex examination. Fedor Lurie, a few years ago looked at the reproducibility and repeatability of duplex ultrasound with a number of variables including the time of day, the position, the technologist, and not surprisingly found that the shortest reflux times,

were obtained in the standing position, and this was also the most reproducible way of detecting reflux and the most standardized way of measuring the time, and the most reproducible results were done in the standing position in the morning. And this is quite important,

because I think there's a perception that the main problem with the supine position is false negatives, which is absolutely not true. The problem is, you don't know what you're getting, it's false positives as well as false negatives. And I think that's a real problem with protocols

that say were going to check first in the supine position, and then if we don't find reflux, we'll stand them up. You generate false positives as well as false negatives and although this isn't a large study, I think this best demonstrates, that we've done this same thing in our lab,

which is not quite as clear as Nikos did. With this study in 10 patients in which the false negatives, probably due to an absence of dependent vasodilation occurred in 7%, but more importantly, false positives were seen in 12%. So this concept of initially examining the patient supine

and standing them up only if you don't find reflux, is just blatantly false. For what to asses, were going to talk who requires more, than a standard duplex examination. We know Neil has told us earlier, that about 10% of patients will have a Non-saphenous origin of the reflux.

58% of this is from non-saphenous perforators most commonly in the posteriolateral thigh. And 42% will have a pelvic source reflux. So who requires more than a standard ultrasound examination? I would submit that most of these, are the pelvic source varices,

particularly for atypically distributed varices in the vulva, the perineum, or the posterior thigh, as well as those patients, when the signs and symptoms particularly pain and swelling don't match up with the ultrasound examination, or for atypical symptoms such as Venous claudication,

and recurrent ulceration, and these patients do require a more thorough examination of their abdomen and pelvis, which I think is an important part of our armamentarium as venous specialists. We use a low frequency curved array transducer, we do the standard Lay and Reverse Trendelenberg position.

although particularly for renal vein compression if we don't find it, we'll sometimes stand the patient up and repeat it with the patient standing. Specifically evaluate the ovarian veins, both their diameter defining pathologic in our lab greater than 6 millimeters as well as evidence of

reflux within the ovarian vein. Look at internal iliac vein reflux, we measure diameters although we haven't found diameters of the internal iliac vein to be particularly helpful, and evaluate particularly for the presence of pelvic varices.

And I think this should be the minimum competence of everyone who takes care of venous disease, is at least to be evaluated for para uniroid crossing veins which even someone who's not a skilled technologist such as myself, can easily see, at the the bedside in a patient with a full bladder.

Also evaluate for venous obstruction particularly in the iliac veins, not looking just at common femoral waveforms but also looking at velocity ratios across a stenosis as well as planometric measurements of venous diameters particularly at the crossing of the common iliac vein

on the left between the L5 vertebral body and the right common iliac artery. And we also thoroughly evaluate the left renal vein for evidence of compression over the aorta. I think it's a misnomer, this nutcracker phenomenon. I don't think the superior mesenteric artery

has anything to do with it in most patients. Its more commonly just stretching over the aorta. We use both the peak systolic velocity ratio of greater than five, or a diameter ratio, of greater than five as well. We don't use the 'and' criteria,

it can be either one we use to go under further imaging, and then look for hilar collaterals and hilar varices. So in conclusion, I think all ultrasound examinations for chronic venous disease, should be preformed in the upright position. Advanced ultrasound particularly with evaluation

of the abdomen and pelvis are needed, either for pelvic source varices, or when the signs and symptoms don't fit the duplex examination that's standardly preformed. And have a low threshold to proceed with thorough evaluation of the abdomen and pelvis.

Thanks very much.

- The title is Why Open Surgery is Still the Best Treatment for Juxta- and Pararenal AAAs in Good Risk Patients: Technical Tips. This slide demonstrates the trends of AAA repair in our university, my institution. After the introduction of EVAR in 2007 in Japan, more than half of AAA was treated with endovascular repair.

However, open repair also remains the mainstay. After the introduction of EVAR, comparing the percentage of open repair with renal artery clamping between pre and post EVAR, there was a significant increase. Recently EVAR with fenestrated graft and snorkel technique

has been performed for the treatment of JAAA in high risk patients with favorable outcome. However, open surgery is typically used as first-time treatment in low-risk patients. We demonstrated the outcome with results in Journal of Vascular Surgery in 2018.

Among 451 open surgery, 111 underwent repair of JRAA aortic aneurysms. In hospital death was less than 1%. This study suggests that open repair of juxtrarenal and pararenal aortic aneurysms can be done safely. We will show the technical tips for juxta-

and pararenal AAAs. Operative approach, manipulation of the left renal vein, method of anastomosis and method of reconstruction of the renal artery. The position of proximal clamps were decided based on the anatomy of the aneurysmal neck,

which was two approach. One was transperitoneal approach. Proximal clamp site, it's placed in inter-renal was suprarenal, which is proximal upwards. Like this 3DCT, if the orifice of the renal artery and the SMA are at the same level,

we choose supra-celiac clamping. In those cases, we user a transabdominal approach with left-sided medial visceral rotation. As you can see the descending colon and pancreas, spleen and stomach are rotated anteriorly and medially, leaving the left kidney, adrenal gland, ureter

and gonadal vein in situ. Using this approach, we can control the orifice of the celiac artery and the SMA and both renal arteries and therefore we can directly clamp all of these arteries. After exposure, the proximal anastomosis was made without PCPS.

After finishing the proximal anastomosis, the clamp was then moved down to the graft to perfuse the renal arteries. The next, manipulation of left renal vein. This is a dissection of renal vein and dissection of the branches

such as the adrenal vein or gonadal vein frees the left renal vein and makes it easier to expose the proximal aorta and to perform proximal anastomosis. The next is on the left side with the division and stump closure.

Divide the renal vein proximally to the adrenal vein and gonadal vein and they close the stump by 4-0 prolene running sutures. On the left side it's a very rare case, but sometimes re-anastomosis in the vein. We demonstrated renal artery clamping and left renal vein

division during abdominal aortic aneurysm repair. That's not in itself compromised for long time renal function. In reaction to that, we demonstrate that in publication in Journal of Vascular Surgery, the division had no significant impact

on CRD for up to two years during follow-up. Then this is initially pressed on posterior and ends on anastomosis was performed by placing a 3-0 Prolene suture in the posterior wall and continued anteriorly in a running fashion. Regarding the renal artery perfusion,

perfusion it with cold ringer solution undertaken. The bypass graft for the renal artery was anastomosed to the main body or limb of the main graft in advance, then the main body was anastomosed to the aorta. During the aorta clamping, the renal artery was perfused with chilled solution.

Finally we demonstrated the technical tips for juxta- and pararenal AAAs. Thank you for your attention.

- [Joseph] Thanks, good morning everybody. I have no disclosures. So, you know, the differential diagnosis of chronic pelvic pain is vast and is very difficult to make sometimes. Pelvic congestion is only one of a myriad of potential I didn't mention syndrome there.

There is only one of a myriad of potential conditions that can cause chronic pelvic pain. Routine tests will often not identify any source of pain in up to 30% of patients. And pelvic congestion accounts for, can account for up to 30% of these cases.

So because of this when you are trying to build your practice to treat these patients, you really need to make significant efforts to raise awareness and educate not only the healthcare providers but the community. What I found to be most helpful, is number one,

just to start out with outreach talk and grand rounds to the healthcare providers, you know, who are the target audience? The target audience are the people that take care of all these conditions, so primarily it's OB/GYN, primary care doctors, psychiatrists, neurologists,

gastroenterologists, orthopedists and hematology/oncologists. I have also found it very helpful to actually go directly to the community. A lot of these women have seen various physicians and healthcare providers and have really gotten unsatisfactory

answers for their symptoms and have, you know, entered into this sort of, this desperation phase of 'what can we do to help them'. And so, talking to them directly going to community centers, social clubs, church groups, et cetera, has been helpful. I think internet presence is key,

not only for this condition but also for all venous diseases. My feeling is that patients with venous disease are more likely to be searching for answers on the internet then patients with arterial disease because again a lot of these diagnosis are difficult to make.

A lot of the health care providers that they see, don't pay a lot of importance to venous disease and they really don't get the satisfactory answers from their doctors. And so having a robust website with patient testimonials, educational blogs and even social media,

I found Facebook posts, boosts to be quite helpful. A lot of these patients, again come, I think self referred rather than referred from a specific physician. Treatment, we are going to have a whole session on how to treat these things since so I won't go into that.

But, primarily we are talking about embolization again of the ovarian and pelvic veins, or treatment of potential ongoing causes. Again, the anatomy, we are talking about the left ovarian draining to the left renal and the right ovarian to the IVC

and then the pelvic veins usually into the internal iliac vein. And this is just an example of one of our cases embolizing the left ovarian vein when we do embolizations. This is a study at a JVS, Vascular Lymphatic last year that looked at the efficacy of endovascular treatment

for pelvic congestion. It's a meta analysis of 20 studies and basically the take home message was the technical success is high, but patients actually did well after five years, 87% experienced relief of their symptoms. So, there is benefit to endovascular treatment of this,

this disease process. When I do these procedures I like to use large volume coils because they reduce the number of coils that you need to use, it shortens the procedure time, decreases radiation exposure and I think leads to

less failure in recanalization rates. You can see on the bottom left there, there is a large volume coil, it is densely packed you know, 27% packing is very high. Anything over 25% is what we want versus a detachable regular detachable conventional detachable coil

with only 12% packing. I usually use the Penumbra line of coils because they have a versatile stable of devices that we can use. They have long lengths up to 60 cm even though it's an 025 system. They have a similar size to 035 coils.

It's an easy detachment process and again they have a versatile stable of products with the Ruby soft coils, the POD anchoring coils and then the POD packing coil. Here is an example of a hypogastric aneurysm you can see. Here it took about 20 conventional O18 detachable coils to pack this but only one anchoring coil

and three of the Penumbra Ruby coils. There's another renal artery case. Again, one coil has significant surface area coverage versus three conventional 018 coils. Again, these coils are also very soft which allows again very dense packing of the vessel and it also allows

it to take the side branches of the vessel so you get the added benefit of embolizing the side branches of the main vessel as well. And then again, the POD packing coil. This is a little video here. It's a long soft coil with a wave shape that allows

you to rapidly tightly pack the vessel, conforms to the vessel diameter. It almost looks like you're injecting a liquid embolic agent like Onyx. So, very very useful. So, in summary the differential diagnosis

of pelvic pain is vast but pelvic congestion can present in up to 30% of cases. We really need to educate and raise awareness through outreach talks and internet presence. And large volume coils are beneficial

when performing embolization of of the ovarian and pelvic veins Thank you.

- This talk is a brief one about what I think is an entity that we need to be aware of because we see some. They're not AVMs obviously, they're acquired, but it nevertheless represents an entity which we've seen. We know the transvenous treatment of AVMs is a major advance in safety and efficacy.

And we know that the venous approach is indeed very, very favorable. This talk relates to some lesions, which we are successful in treating as a venous approach, but ultimately proved to be,

as I will show you in considerable experience now, I think that venous thrombosis and venous inflammatory disease result in acquired arteriovenous connections, we call them AVMs, but they're not. This patient, for example,

presented with extensive lower extremity swelling after an episode of DVT. And you can see the shunting there in the left lower extremity. Here we go in a later arterial phase. This lesion we found,

as others, is best treated. By the way, that was his original episode of DVT with occlusion. Was treated with stenting and restoration of flow and the elimination of the AVM.

So, compression of the lesion in the venous wall, which is actually interesting because in the type perivenous predominant lesions, those are actually lesions in the vein wall. So these in a form, or in a way, assimilate the AVMs that occur in the venous wall.

Another man, a 53-year-old gentleman with leg swelling after an episode of DVT, we can see the extensive filling via these collaterals, and these are inflammatory collaterals in the vein wall. This is another man with a prior episode of DVT. See his extensive anterior pelvic collaterals,

and he was treated with stenting and success. A recent case, that Dr. Resnick and I had, I was called with a gentleman said he had an AVM. And we can see that the arteriogram sent to me showed arterial venous shunting.

Well, what was interesting here was that the history had not been obtained of a prior total knee replacement. And he gave a very clear an unequivocal history of a DVT of sudden onset. And you can see the collaterals there

in the adjacent femoral popliteal vein. And there it is filling. So treatment here was venous stenting of the lesion and of the underlying stenosis. We tried an episode of angioplasty,

but ultimately successful. Swelling went down and so what you have is really a post-inflammatory DVT. Our other vast experience, I would say, are the so-called uterine AVMs. These are referred to as AVMs,

but these are clearly understood to be acquired, related to placental persistence and the connections between artery and veins in the uterus, which occurs, a part of normal pregnancy. These are best treated either with arterial embolization, which has been less successful,

but in some cases, with venous injection in venous thrombosis with coils or alcohol. There's a subset I believe of some of our pelvic AVMs, that have histories of DVT. I believe they're silent. I think the consistency of this lesion

that I'm showing you here, that if we all know, can be treated by coil embolization indicates to me that at least some, especially in patients in advanced stage are related to DVT. This is a 56-year-old, who had a known history of prostate cancer

and post-operative DVT and a very classic looking AVM, which we then treated with coil embolization. And we're able to cure, but no question in my mind at least based on the history and on the age, that this was post-phlebitic.

And I think some of these, and I think Wayne would agree with me, some of these are probably silent internal iliac venous thromboses, which we know can occur, which we know can produce pulmonary embolism.

And that's the curative final arteriogram. Other lesions such as this, I believe are related, at least some, although we don't have an antecedent history to the development of DVT, and again of course,

treated by the venous approach with cure. And then finally, some of the more problematic ones, another 56-year-old man with a history of prior iliofemoral DVT. Suddenly was fine, had been treated with heparin and anticoagulation.

And suddenly appeared with rapid onset of right lower extremity swelling and pain. So you see here that on an arteriogram of the right femoral, as well as, the super selective catheterization of some of these collaterals.

We can see the lesion itself. I think it's a nice demonstration of lesion. Under any other circumstance, this is an AVM. It is an AVM, but we know it to be acquired because he had no such swelling. This was treated in the only way I knew how to treat

with stenting of the vein. We placed a stent. That's a ballon expanded in the angiogram on your right is after with ballon inflation. And you can see the effect that the stenting pressure, and therefore subsequently occlusion of the compression,

and occlusion of the collaterals, and connections in the vein wall. He subsequently became asymptomatic. We had unfortunately had to stent extensively in the common femoral vein but he had an excellent result.

So I think pelvic AVMs are very similar in location and appearance. We've had 13 cases. Some with a positive history of DVT. I believe many are acquired post-DVT, and the treatment is the same venous coiling and or stent.

Wayne has seen some that are remarkable. Remember Wayne we saw at your place? A guy was in massive heart failure and clearly a DVT-related. So these are some of the cases we've seen

and I think it's noteworthy to keep in mind, that we still don't know everything there is to know about AVMs. Some AVMs are acquired, for example, pelvic post-DVT, and of course all uterine AVMs. Thanks very much.

(audience applause) - [Narrator] That's a very interesting hypothesis with a pelvic AVMs which are consistently looking similar. - [Robert] In the same place right? - [Narrator] All of them are appearing at an older age. - [Robert] Yep.

Yep. - This would be a very, very good explanation for that. I've never thought about that. - Yeah I think-- - I think this is very interesting. - [Robert] And remember, exactly.

And I remember that internal iliac DVT is always a silent process, and that you have this consistency, that I find very striking. - [Woman] So what do you think the mechanism is? The hypervascularity looked like it was primarily

arterial fluffy vessels. - [Robert] No, no, no it's in the vein wall. If you look closely, the arteriovenous connections and the hypervascularity, it's in the vein wall. The lesion is the vein wall,

it's the inflammatory vein. You remember Tony, that the thing that I always think of is how we used to do plain old ballon angioplasty in the SFA. And afterwards we'd get this

florid venous filling sometimes, not every case. And that's the very tight anatomic connection between those two. That's what I think is happening. Wayne? - [Wayne] This amount is almost always been here.

We just haven't recognized it. What has been recognized is dural fistula-- - Yep. - That we know and that's been documented. Chuck Kerber, wrote the first paper in '73 about the microvascular circulation

in the dural surface of the dural fistula, and it's related to venous thrombosis and mastoiditis and trauma. And then as the healing process occurs, you have neovascular stimulation and fistulization in that dural reflection,

which is a vein wall. And the same process happens here with a DVT with the healing, the recanalization, inflammation, neovascular stimulation, and the development of fistulas. increased vascular flow into the lumen

of the thrombosed area. So it's a neovascular stimulation phenomenon, that results in the vein wall developing fistula very identical to what happens in the head with dural fistula had nothing described of in the periphery.

- [Narrator] Okay, very interesting hypothesis.

- [Mark] Thank you, Lowell. Thank you, Jose and Lowell, for the invitation this morning. I have no disclosures relevant to this presentation. If you look at where we are currently, we're in this alphabet soup of syndromes. We have this pelvic congestion syndrome. We have this nutcracker syndrome

and this May-Thurner syndrome, which I think has led to a lot of problems in this whole area of abdominal and pelvic venous disease. It leads to inaccurate diagnosis. It leads to poor treatment outcomes. And I think we're going to see that later in the debates,

how for aortal mesenteric compression of the left renal vein, everybody has a different way to treat it. And maybe the differences arise from, there's differences in the pathophysiology between these. And all of these procedures may be appropriate,

but we're not selecting the patients correctly. And denied reimbursement, and I think all of these are problems. And I think if you look back originally, everybody's seen this slide before, but I think it shows the problem with where we are.

This pelvic congestion syndrome was originally described in 1949 independently by Lo and Taylor. And if you look at Lo's description, Taylor's is somewhat better, starts out okay with appropriate symptoms, pelvic dragging, backache, on and on and on.

And then it attributes it to strong corsets, which are appropriate in molding the figure in a well-approved fashion, which I would submit to you, this has very little to do with the modern medical treatment of this. And I think it's analogous to,

would anybody take it seriously if we talked about leg congestion syndrome for lower extremity varices? It makes no sense at all. And I think this pelvic congestion syndrome term is nonsense and needs to be abandoned in favor of a more global approach

to pelvic venous disorders. Most importantly, I think it's important to recognize that we ought to get rid of this term pelvic congestion syndrome and talk about pelvic venous disorders, which is actually a spectrum

of four different clinical problems. It does include chronic pelvic pain due to venous causes, but it also includes atypical varices as well as typical saphenous varices in the lower extremity. It includes renal symptoms, particularly, such as flank pain and hematuria.

And it includes leg symptoms, what we classically associate with May-Thurner syndrome, pain, swelling, venous claudication. These are all part of the spectrum that arise from two patterns of reflux, either in the ovarian vein or the internal iliac vein,

and two patterns of obstruction, either in the left renal vein or in the iliac vein. And it's important to recognize that either of these can lead to reflux in the internal iliac vein in the case of common iliac obstruction and in the ovarian vein

in the case of renal vein compression. We have to start with the female pelvic circulation, which is actually a vastly interconnected system of the left renal vein, the left ovarian vein, which communicates with the pelvic venous plexus and branches of the internal iliac vein,

and lastly, with the saphenofemoral junction. And it's important to recognize that these four venous systems are connected by three venous reservoirs. And the symptoms arise from the venous reservoirs. That's the renal hilar plexus.

Here are shown hilar varicosities from distension of that plexus. The pelvic venous plexus, which is drained both by the ovarian veins and the internal iliac veins. And then the lower extremity, because pelvic venous disorders

do lead to lower extremity symptoms. And all of the symptoms are presumably related to reservoir distension. And all of these occur in two patterns. You can either have an uncompensated pattern where there's no outflow from the distal reservoirs

in the case of flank pain and renal vein compression, or compensated where you have collateral outflow such as pelvic symptoms from renal vein compression. I would submit to you that the treatment of those is probably different depending on whether it's compensated or uncompensated.

So this is the diagram of it. If we look at uncompensated obstruction, we could have uncompensated obstruction either of the left renal vein or of the left common iliac vein. If we have uncompensated obstruction of the left renal vein,

pressure is transmitted to the renal reservoir. These patients have flank pain and hematuria. In the case of the common iliac vein, if it's uncompensated, pressure is transmitted to the leg, and we get leg symptoms. We can also have compensated obstruction,

which is drainage via collaterals. In the case of the left renal vein, we get decompression, usually via the left ovarian vein with pelvic symptoms. And similarly, for the common iliac vein, we get decompression via the internal iliac vein and get pelvic symptoms as well.

For uncompensated reflux, either in the ovarian vein or in the internal iliac vein, we have no drainage from the pelvic reservoir, and we get pelvic symptoms. In contrast, if we have compensated reflux, we have decompression through the pelvic floor

and get lower extremity symptoms. And I think this is critical in understanding how we develop treatment algorithms for this. So we need to get rid of all of these syndromes. And I would challenge everybody to not mention a syndrome the rest of the day

and see how far we can go without talking about a syndrome. I think, in contrast, for now, we need to refer to the primary underlying pathophysiology. Left renal vein obstruction, I would submit to you, left renal vein obstruction has nothing to do with the superior mesenteric artery

in a lot of these patients. It's stretching over the aorta. We need to talk about primary or secondary iliac vein obstruction, primary ovarian vein reflux, and primary internal iliac vein reflux.

And we need a new classification system that should harmonize with CEAP. And Mel Rosenblatt and I have talked a lot about this. This isn't anything that's written in stone. This is my idea of a pelvic CEAP, where C0 would be no clinical manifestations,

C1, lower extremity pain of pelvic venous origin, either venous claudication or posterior thigh pain, C2, pelvic origin lower extremity varices, C3, lower extremity edema, C4, non-cyclic chronic pelvic pain, the classic pelvic congestion syndrome, I just said it,

and C5 would be chronic left flank pain and renal vein symptoms. In a similar fashion, we do etiology, anatomy, and pathophysiology. So in conclusions, pelvic venous disorders are complex, but the anatomy and physiology are well-defined.

And we need to stop talking about syndromes and really classify them based on the underlying pathophysiology and symptoms. Thanks very much.

- [Presenter] Thanks doctors, well I can shorten my title a little bit [Laughter] These are my disclosures. So before I get into the value of the vascular surgeon in the healthcare system I thought it's interesting to sort of look at

what vascular surgery may look like through an administrator's eyes, you know and in general in vascular surgery we have relatively poor payor mix, frequently more than 70% of our patients are Medicare beneficiaries, and the ones that are younger

than 65 cause of their lower socio-economic class are frequently on Medicaid. And also we do a lot of high-cost procedures, a good example of that is endovascular aneurysm repair. And you know, we looked at that a few years ago, and we compared the DRG reimbursements

to what it cost, and if you notice, you know, two-thirds of the DRG payment is consumed by the cost of the stent graft. Which really doesn't leave much left for other supplies and for salaries, and so in general we are running

about a $5000 negative margin per case. Despite this, there are three things where vascular surgeons do add value to the healthcare system. I think you can actually look at the P&L for vascular surgery and it's going to be positive. The vascular surgery is an enabling service,

every hospital wants a vascular surgeon because they want to be able to support their cardiologists, their spine surgeons, their oncologists, and urologists. And lastly I'll talk a few minutes about the benefit of a high vascular

case index on hospital revenue. So we looked at our own vascular surgery P&L over a six year period, and we were looking at physician-generated revenue as well as hospital-generated revenue through DRG and HBAS payments. The top line result is shown here,

and on the left in yellow are RVUs, its professional revenue indexed to inflation. And you can see that it's not a big surprise that physician revenue dropped around 21% over the six-year period. And the red is the hospital revenue.

But what's really interesting, what kind of demonstrates the value of vascular surgery, is if you look at the professional revenue per RVU, it's around $100. But then if you look at revenue that you bring in based on the hospital reimbursement,

based on your work, and index it to RVUs, it's around $500 per RVU. And you know in our own instance, at Dartmouth-Hitchcock, if you look at, take the technical and professional revenue, and you look at operating margin per case, you can see cardiac surgery which in most cases

is going to be, you know, doing pretty well $7500 a case, but you can see vascular surgery is relatively high up on the list there with a margin of around $2500 per procedure. Hospital medicine you might think is kind of an outlier, but at Dartmouth the orthopedic patients

are placed on the hospital medicine service. So when you look at vascular surgery as an enabling service line, Tonita and coworkers looked at 300 off-service patients over a four-year period, and you know in half the cases the

surgeons are doing spine exposure, in 14% they are doing vascular control prior to hemorrhage, and interestingly, in another 14% it was vascular control after hemorrhage. And then 19% of the patients required a vascular reconstruction,

and this generated around 1400 RVUs per year. And then lastly, just to say a couple words about Case Mix Index, this may be the most important and have the biggest impact on hospital reimbursement. Case Mix Index reflects the diversity and complexity of the patients a hospital cares for.

And the CMI affects hospital-wide Medicare reimbursement, so at our institution, each increase in the CMI of 0.01, which sounds like a small number, results in a $3 million increase in annual revenue. So here's a list of Case Mix Indexes from 2010 from various academic medical centers in the United States.

And you can see at Dartmouth-Hitchcock, so our hospital is around 2.13, the section of vascular surgeries' CMIs increased during this time from 2.4 up to 2.8. And so obviously we're going to have a positive impact on the hospital's CMI.

And then the question is, well where might we fit in sort of with the specialties that are typically associated with the heart and vascular center. And you can see the CMI for cardiac surgery, and this is pretty typical throughout,

from institution to institution, is around five and a half, and vascular surgery is at 2.8, and cardiology is around 1.87. And the hospital CMI is 2.13. So we're, we are contributing to increasing the CMI, which is going to have a significant

impact on hospital revenue. So in conclusion, vascular surgery technical revenue really drives the majority of hospital vascular reimbursement. And the vascular surgery presence allows for safe conduct of many additional highly reimbursed procedures.

Favorable vascular surgery CMI improves hospital-wide reimbursement from CMS, and while RVUs can measure productivity, they are not a good measure of value of the vascular surgeon. Thank you, I'd like to thank Dr. Veith for

the privilege of inviting me to this outstanding meeting. Thanks.

- Mr. Chairman, ladies and gentlemen, I'd like to thank the organizing committee for the invitation once again to be here. I have no disclosures. The nutcracker is defined as a rigid lever hinged and pivoted about a fulcrum. And it has different meanings

to different people, of course. Nutcracker syndrome is characterized by impeded outflow from the left renal vein into the inferior vena cava due to extrinsic compression of the superior mesenteric artery onto the abdominal aorta. Superior mesenteric artery syndrome though

is somewhat different, and it's a rare cause of abdominal pain, nausea and vomiting, and is characterized by compression of the duodenum by the superior mesenteric artery as it crosses the aorta. The clinical diagnosis of nutcracker syndrome has a high index of suspicion,

it's essentially a diagnosis of exclusion. And it's characterized by left renal vein hypertension and venous pelvic engorgement, pelvic vein engorgement. The symptoms that are characterized include abdominal and flank pain, hematuria and pelvic congestion syndromes.

The prevalence is essenti a lot of people with mild and moderate symptoms are really not treated for nutcracker syndrome. The peak prevalence is in the second or third decade but it can occur at any age.

It's a very rare condition. A recent review published looked for studies including two or more patients over a 35 year period, and only came up with about 18 studies which were suitable for assessment, and they included only 284 patients.

Investigations for nutcracker syndrome includes Doppler ultrasound, CT venography, MR venography, contrast stenography and IVUS. Renal ultrasound scans have a high sensitivity and specificity, and a PSVR ratio of greater than four to five

is usually diagnostic of nutcracker syndrome. IVUS however is much more sensitive and specific for renal nutcracker syndrome. It represents a more accurate representation of vessel compression and diameter assessments. And IVUS is also important for what is the new development

in renal nutcracker syndrome management which is assessment of renal vein size for stenting. Venography also enables management of the venous pressure gradient. Usually it's less than one millimeter of mercury in healthy patients,

but when it's greater than three millimeters of mercury it's usually enough to diagnose nutcracker syndrome. CT scans and MRIs demonstrate compression of the veins and also duodenal compression, and it also delineates other soft tissue anatomy which may mimic the syndrome.

And it has a high sensitivity and specificity. Now the management options, there's not a huge amount of new management apart from the endovascular approach, and I'll talk about that in a bit. But the non-operative measures, surgical measures, and the endovascular approaches.

The open surgical approaches include the old-fashioned left renal vein transpositions, and the superior mesenteric artery transpositions. The other procedures are not done very much nowadays. So conservative therapy is to be recommended, and by and large it consists of

nutritional support for these patients. It works by increasing the retroperitoneal fat layer, which then increases the aortomesenteric angle and relieves symptoms in up to 30% of patients. And it's to be recommended, especially in this day and age of aggressive dieting.

Superior mesenteric artery transposition relieves compression of the left renal vein by repositioning the superior mesenteric artery as we see here. And venous transposition also decreases the compression of the left renal vein. This is the only picture I could find of

external reinforcement of the left renal vein using a ring supported PTFE graft on the outside of the vein, which decreases the pressure. Endovascular intervention is probably the newest thing that is available to us, but this is very attractive because it avoids renal ischemia and laparotomy.

We do not have a specific stint designed for the renal vein, though, and vein sizing is difficult. IVUS is almost essential for doing this procedure, though. And there are cases of stent migration to the heart, and this is reported to be up to 6.6% in some series. And as you can see here in this patient,

after the stent has been deployed, the pelvic venous congestion has decreased almost immediately. SMA syndrome, on the other hand, includes compression of the duodenum as it crosses the abdominal aorta.

And there are so many reasons for this that's it's very difficult, usually, to ascribe this to one of the nutcracker syndromes. But a surgical bypass procedure is quite effective in solving this problem. So in summary Mr. Chairman, ladies and gentlemen,

although endovascular intervention is in its infancy here, it's probably the newest management feature. And when clinical features and anatomical features coexist, then it's virtually diagnostic, open surgical repair offers effective therapy, and results of venous stenting is encouraging, but durability is yet unproven.

Thank you very much.

- Thanks very much and thanks to Dr. Veith and the organizers for the opportunity to be back. I've noted disclosures that are relevant to this talk. So with an aging population, and a longer average life expectancy, the demand for vascular surgeons is predicted to dramatically increase in the next 15 years.

By 2030, there will be an estimated shortage of about 400 vascular surgeons in the United States. And in 2003, it was predicted that 160 vascular surgeons would need to enter practice every year in order to avoid the anticipated 2030 shortage. In March of 2005, the ACGME approved

the vascular surgery primary certificate, and the first integrated vascular surgery residencies were approved shortly thereafter. In 2015, there were 48 programs and 56 positions which were offered for matriculation in July of 2016. That date is relevant for the work I'll show you here.

We first looked at this back in 2009, trying to better understand the applicant pool, and showed that there was a ten-fold increase demand for zero and five residency positions compared to vascular fellowships. And that the zero, five applicants to position ratio

of 8 to 1 in 2009. Despite initial concerns regarding this shortened training structure, studies have demonstrated equivalent case volumes and job opportunities for integrated vascular residents and vascular fellows.

We wanted to update that experience and look at that out to 2015. Primary aim we are looking at, as integrated vascular surgery residency graduates have begun to enter the workforce, we wanted to evaluate the current supply and demand

for zero and five training programs. The current supply and demand for the five and two training programs. And the quality and attributes of zero and five residency applicants. The Association of AAMC was petitioned

for data on applicants to integrated vascular surgery residents from 2008 to 2015, as well as vascular surgery fellowships from 2007 to 2016. Publicly available match data from 2008 through 2015 were queried through the National Residency Matching Program.

And specifically we wanted to look at the number of programs, the number of positions, the total number of applicants, the applications per program, the applications per position, sex of the applicants, and the U.S. versus international medical graduate ratios.

De-identified USMLE step one and step two scores among applicants who have matched in their preferred specialty through the NRMP were evaluated and it's important to note that all applications received through the ERAS system are processed for residency matriculation the following year.

In other words, ERAS of 2008 is processed for matriculation in 2009. When looking at the integrated program we saw that the number of integrated vascular residency programs has increased from four to 48

with an increase from four to 56 positions during the study period. Looking at supply and demand. The demand for integrated vascular residency has increased four-fold from 112 applicants in 2008 to 434 in 2015.

And during this time frame, the number of positions had increased from four to 56. The total number of U.S. medical school graduate applicants has significantly increased from 40 in 2008 to 230 in 2015. The increase in the average number of applicants per program is driven predominantly by U.S. medical school graduates.

With the number of international medical graduates per program decreasing from 57 in 2008 to 37 in 2015. Interestingly, the percentage of women applicants has steadily increased from 16% to 27%. And currently women constitute 41% of all the integrated vascular residents.

Overall, the number of applicants per integrated residency position has continued to increase from 5.9 in 2008 to 7.8 in 2015. Looking at the vascular surgery traditional fellowship programs, you can see that the change has been relatively flat,

with a significant number of unfilled positions in each year of the match. The supply and demand for the vascular surgery fellowship has remained stable with ratios of applicants to positions ranging from 0.9 to 1.2. So, in conclusion, overall,

the supply for integrated vascular surgery residency positions continues to be outnumbered by the number of applicants. With increasing applicant to position ratios, 7.8 in 2015. while the total number of vascular surgery fellowship positions has remained stable

at about one to one. So as the societal need for vascular surgeons continues to expand, it's imperative that we continue to increase the number of integrated vascular surgery residencies. And with the opportunity to introduce new clinicians

into the workforce after five years of training, vascular surgery will be in a position to decrease the projected future deficit. With regards to the independent board, I'll skip the history because Maria alluded to that, but I think we all know that Frank Veith would say,

yes, we definitely should. And I would agree with that. Ultimately, we need to inspire med students and residents to do vascular surgery and we need to expand the number of training positions. Growing our identity and our brand

will only help with this mission. Thanks very much for your time and attention.

- [Presenter] Ablation is not surgery. Surgery as we define it is cutting and excising tissue and ablation doesn't do that. So, it's actually different than surgery. And the lesion can actually not be completely visualized. So even though it's open,

you're not able to visualize the lesion completely with surgery. So you're handicapped with that. So, as Dr. Hepworth said, our argument that ablation is preferable over surgery is certainly true that there undesirable effects.

Our second argument is that there's unusual behavior with the vascular malformation following surgery. We know that there's cytokines released and it's certainly been published in the Journal of Pathology. I can cite the reference, if you want, in 1990,

that the release of cytokine causes the endovascular cells to actually upload the messenger RNA with release of some of the hormones related to inflammation and vascular increase. There's also an effect of integrity when we think that the nitis is incised, that there may be

some actual spread of these types of tissues that send to proliferate. So there's a change in the microvascular architecture. Our third argument is that ablation is safe. We have seen many presentations that ethanol toxicity,

that the risk of that is actually very low and the dose is kept at one milligram per kilogram and that contrast can be delivered at the same time to outline the lesion and where the treatment is. So we think that ablation is safe, even with the very adhesives

and some of the side effects of it. Our last argument is that by treating ablation, if there is to be any surgery, it's going to be from a functional or aesthetic side and we think that ablation helps with that.

And so our fourth argument is that reconstructive options are preserved. So, our team on the pro side believe that that we've proven the vascular malformation should be managed with ablation

and without open surgical intervention. And so we feel that our opponents at this point, Dr. Kim is coming and he's got a little bit of work to do in order to strengthen their side. Thank you, I conclude the presentation of the pro side.

- [Lecturer] Well, the prevalence of end-stage renal disease i surgeons often encounter, these day, patients with end-stage renal disease who either have developed recalcitrant central venous obstruction, or exhausted options for upper extr

and at that point, the next step is the leg, and you sawthe picture Dr. Peden just showed, and it typically makes many of us nervous. The truth is, a recent meta-analysis of 660 upper thigh prosthetic grafts showed that

the mean primary patency of these grafts are awful, 48% nfection rates, leading to graft removal, is very high at 18%. In 2000, two authors described the femoral vein transposition separately,

under separate publications, but the femoral vein transposition was really popularized by Wayne Gradman at Cedars-Sinai who published on it in 2001 and 2005. Wayne, through the course of his experience, realized that femoral vein transposition procedures

led to a significant degree of steal because of the size of the femoral vein, and started banding them intraoperatively, as per the picture that I'm and he found that in his latter series of patients,

adopting this technique required no reparation for ischemia, there were no access infections, and a very high secondary patency rate. The largest series of femoral vein transpositions comes to us from France and Morocco, two centers there, over a 25-year period, 72 procedures,

18% major complication rates, including six cases that actually had to be ligated, but an amazing 82% maturation rate, and an amazing 45% primary patency rate at nine years' follow-up. Despite this, the femoral vein transposition is not

common it's because people are worried about wound complications, whether because they're worried about ischemic steal, whether because they're worried about leg edema, was not clear to me, but we decided to dive into this

procedure in 2006, learn how to do it, and start performing it. So, we considered all patients at Boston Medical Center who exhausted their arm options for this procedure. The workup was non-invasive studies that looked at the femoral vein duplex,

and a non-invasive arterial of the legs to ensure adequate profusion. We excluded the frail and morib we excluded patients who had femoral vein chronic thrombosis,

or those with moderate-to-severe arterial ischemia. I'll show you a little movie of how we do it. The leg is circumferentially prepped and draped. We make a medial incision it's a pretty large incision and it's a big operation.

The patient is typically asleep. We dissect-out the proximal femoral vein up to its confluence with the deep femoral vein, take great care, you can see the confluence right there, to tie all the branches.

There are multiple branches that are present in this vein. You end up dissecting it up to the sartorius, and then below the sartorius, and then distal to the sartorius. We then go through the adductor canal completely, and dissect the vein out to the mid-popliteal vein,

basically as far away as possible. You can see the vein here dissected out from the confluence, up to the popliteal there, vein. The vein is divided, we dilate it, we clip it distally so it maintains it's dilatation,

and we mark it, and then we fashion two incisions about 4 centimeters laterally, and ensure that we have at least 10 centimeters of vein to be available for cannulation. Incisions are made, the vein is tunneled superficially,

and then again there's a plan as to where it goes into the superficial femoral artery. The next thing we do is we place a straight clamp across the vein, narrowing it by about 50%, and band it using 6-0 Prolene sutures. After we do that ...

This is after we do that, we perform the anastomosis to the superficial femoral artery, and this is what it looks like. We ensure that there's no kinks at the tunnel,

and then close. As you can see, it's a big operation. So, we looked at our series at Boston Medical Center, of femoral vein transpositions performed between 2006 and 2017.

We had 17 patients, the mean age was 55, 29% were female, and 71% were African-American, the mean BMI was 29. As you can see, the usual comorbidities you'd expect to see in this patient population. Average pre-op ABI was 1.17,

and average pre-op femoral vein minimal diameter was 6.4 centimeters. Everybody underwent general anesthesia. The median operative time was 249 minutes, estimated blood loss was 217 cc, and most patients were banded.

These are our 30-day complications. So, the majority of complications were cardiac, and there were 29% wound complications. In terms of return to the operating room within 30 days, one patient had to go back for a thigh abscess, one for revision and thrombectomy, one for hematoma,

and one for unrelated open colectomy. We only had one case of distal arterial ischemia that required a femoral popliteal bypass. The mortality was 5.9% at 90 days, and resource utilization within 30 days: two admissions and three Emergency Room visits.

So, of the patients that we followed for more than six months post-procedure, 80% matured their fistula. Median patency was 537 days, and our primary patency was 74%, secondary patency was 94% at one year. So, in summary, the femoral vein transposition

can be successfully used in patients with limited dialysis options. Self-limited wound complications are common. Ischemic steal is rare if you band it. Maturation rates are extraordinarily high, and almost twice as high as you'd expect to see in the arm,

and the patency rates are high. So, I believe that femoral vein transposition is a durable access that has a concrete role in the armamentarium of the access surgeon. Thank you.

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