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Mikaelsson Catheter | Advanced UFE
Mikaelsson Catheter | Advanced UFE
2016arteriesarterychapterdistallyembolicsembolisationembolizationembolizeembospheresembozeneendpointentirefibroidsmesentericmicrocatheternitroglycerineoccludeovarianovarysbvSIRuterus
Pelvic Reflux: Is Coil Embolization The Answer
Pelvic Reflux: Is Coil Embolization The Answer
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Why Open Endarterectomy Is The Best Treatment For Common Femoral Artery Lesions: It Is Still The Gold Standard In Most Cases Despite What You May Read And Hear
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With Large Iliac Arteries, When Are Flared Limbs Acceptable And When Are IBDs Needed For Good Results
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Single Branch Carotid Ch/TEVAR With Cervical Bypasses: A Simple Solution For Some Complex Aortic Arch Lesions: Technical Tips And Results
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Why CREST 2 And ACST 2 May Have Little Definitive Value Although They May Provide Useful Information
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New ESVS Guidelines For Treatment Of Occlusive Disease Of The Celiac Trunk And SMA: What Do They Tell Us About The Best Current Treatment
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Surveillance Protocol And Reinterventions After F/B/EVAR
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Long-Term Histologic Evaluation Of Resected AVMs In Head And Neck Post-Onyx Embolization
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New Developments In The Prevention And Treatment Of SCI With Open And Endo TAAA Repairs
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Minimal Invasive Segmental Artery Coil Embolization (MISACE) For Prevention Of Spinal Cord Ischemia During EVAR Of Thoracoabdominal Aortic Pathologies: Initial Clinical Results
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New Developments In Access Site Closure For Small Sheaths; For Large Sheaths
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Transcript

catheter we use it just happens to be AngioDynamic's version you know I don't there are several companies that make this I just happen to have this on the shelf which is why I took the picture of it

and again that's the picture what it looks like and our target for the microcatheter is probably going to be going to get over here I probably usually get the microcatheter back down to about here now if I only

got two here I suppose that would be fine i would really be reluctant to embolize if I was at this level where I'd have to be extremely careful getting around this curve and getting down into here somewhere is probably where you really

want to be I think and we're going to use particulate embolics you're going to may have to force the material not force it but injected positively it is Bob made the point yesterday he like's to get a free-flow embolisation which I agree with

unfortunately don't always get a free flow embolization the ovarian artery you think the uterine arteries are subject to spasm the ovarian arteries are unbelievable you don't want to go through that sort of you know curved

segment down and try to get passed the ovary you know I once saw Dave he's a good friend I you know yeah I always go down passed the ovary that way I don't have to worry about the ovary I said how the heck do you do that

He said I don't have any problem doing it so I was visiting him when he started telling me all this he went in to do a case and he spent like two and a half hours trying to get down that overian.. you know and he came out and said maybe you're right it's like anyway

some people use a nitroglycerine I tend not to use nitroglycerine mostly because it requires someone to go and find it and get it all mixed up not so but using nitroglycerine is okay but you're going to use particle embolics and I don't

think i ever my entire life have used more than one container on a side and usually it's half a container of embospheres or embozene and whatever it is you're using use PVA you can even use the gel-foam slurry although i kinda like the idea of

particles because you can get them to float in a free-flowing embolization you can get them to go down and they will go to the fibroids and what you want to do is kind of go until you don't see the uterus anymore and once you don't see

the uterus anymore you don't need anymore as long as you have a stable endpoint and you know oftentimes you'll still see some branches going to do the ovary but you just want to prune off those branches down distally you do not need

to occlude the entire ovarian artery ok so inferior mesenteric supply kind of

- 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.

- Thank you. Historically, common femoral endarterectomy is a safe procedure. In this quick publication that we did several years ago, showed a 1.5% 30 day mortality rate. Morbidity included 6.3% superficial surgical site infection.

Other major morbidity was pretty low. High-risk patients we identified as those that were functionally dependent, dyspnea, obesity, steroid use, and diabetes. A study from Massachusetts General Hospital their experience showed 100% technical success.

Length of stay was three days. Primary patency of five years at 91% and assisted primary patency at five years 100%. Very little perioperative morbidity and mortality. As you know, open treatment has been the standard of care

over time the goal standard for a common femoral disease, traditionally it's been thought of as a no stent zone. However, there are increased interventions of the common femoral and deep femoral arteries. This is a picture that shows inflection point there.

Why people are concerned about placing stents there. Here's a picture of atherectomy. Irritational atherectomy, the common femoral artery. Here's another image example of a rotational atherectomy, of the common femoral artery.

And here's an image of a stent there, going across the stent there. This is a case I had of potential option for stenting the common femoral artery large (mumbles) of the hematoma from the cardiologist. It was easily fixed

with a 2.5 length BioBond. Which I thought would have very little deformability. (mumbles) was so short in the area there. This is another example of a complete blow out of the common femoral artery. Something that was much better

treated with a stent that I thought over here. What's the data on the stenting of the endovascular of the common femoral arteries interventions? So, there mostly small single centers. What is the retrospective view of 40 cases?

That shows a restenosis rate of 19.5% at 12 months. Revascularization 14.1 % at 12 months. Another one by Dr. Mehta shows restenosis was observed in 20% of the patients and 10% underwent open revision. A case from Dr. Calligaro using cover stents

shows very good primary patency. We sought to use Vascular Quality Initiative to look at endovascular intervention of the common femoral artery. As you can see here, we've identified a thousand patients that have common femoral interventions, with or without,

deep femoral artery interventions. Indications were mostly for claudication. Interventions include three-quarters having angioplasty, 35% having a stent, and 20% almost having atherectomy. Overall technical success was high, a 91%.

Thirty day mortality was exactly the same as in this clip data for open repair 1.6%. Complications were mostly access site hematoma with a low amount distal embolization had previously reported. Single center was up to 4%.

Overall, our freedom for patency or loss or death was 83% at one year. Predicted mostly by tissue loss and case urgency. Re-intervention free survival was 85% at one year, which does notably include stent as independent risk factor for this.

Amputation free survival was 93% at one year, which factors here, but also stent was predictive of amputation. Overall, we concluded that patency is lower than historical common femoral interventions. Mortality was pretty much exactly the same

that has been reported previously. And long term analysis is needed to access durability. There's also a study from France looking at randomizing stenting versus open repair of the common femoral artery. And who needs to get through it quickly?

More or less it showed no difference in outcomes. No different in AVIs. Higher morbidity in the open group most (mumbles) superficial surgical wound infections and (mumbles). The one thing that has hit in the text of the article

a group of mostly (mumbles) was one patient had a major amputation despite having a patent common femoral artery stent. There's no real follow up this, no details of this, I would just caution of both this and VQI paper showing increased risk amputation with stenting.

Thank you.

- Thank you again to Dr. Veith for the kind invitation. This is my disclosures. Open thoracic conversion is an increasing problem. Jose Jucadel speak two years ago in my congress in Milano showing the number of obstruction increase. The my experience in Milano in 25 years, we did global number of 2400 operation for

arch, descending thoracic artery, and thoracoabdominal and particularly more than 1000 open thoracoabdominal. And you have on this number, a total of 206 reintervention after TEVAR in particular for our center 84 patients and 9.8% after treatment.

There are different type of reintervention Endo Relining, Open conversion, and hybrid approach. Today we speak about open conversion. Why open conversion? Open conversion because sometimes the patients are young or fit, for an unstable condition and emergency,

infection of fistula, no proximal neck, and some anatomical barrier like MFM and PETTICOAT. And this is the first case, it's a patient with a dissection with multitreatment a young patient you see acute type B dissection treated in emergency for impending rupture

with three Gore TAG and from left subclavian artery to the super mesenteric artery covering the celiac trunk. Five month later you see "home-made" occluder for false lumen perfusion, but one month later, still perfusion you see a large perfusion of the false lumen with the sac expansion and pain.

So you decide to open the patient with the thoracofemoral approach with a thoracoabdominal operation, you see the proximal clamping opening on the aorta and you see the removing of the prosthesis and partial graft excision near to the neck

of the aneurysm for preparing the anastamosis The anastamosis with a triple-layer technique with a strip of felt and false lumen thrombus removal you see the normal distal and the occlusal false lumen device removal. You start with re-implantation of the single vessel

with complete left renal artery re-implantation of the true vessel. And you see the final result. This is another case, conversion of the patient after PETTICOAT. This is a patient with Marfan syndrome

in 2015 TVAR and PETTICOAT for acute type B dissection and enlargement in the next two years of thoracic and abdominal aorta. So decide for open conversion. You can see here through thoracofemoral operotomy the petticoat on the serosa of the aorta

and you see the stent complete removal after acute declamping and you see visceral renal perfusion and endartherectomy of the petticoat. Perfusion through the PETTICOAT and you see a large endartherectomy of the old PETTICOAT

and this intima-media of the aorta. And here the final result. Our definitive result, we performed a total of 81 open conversions with a mortality of 13%. Major morbidity with respiratory, renal, and parapalegia 7%. And the result is strictly dependent

from the kind of conversion. You see an indication to conversion, in endoleak, you have 6% mortality at one month, for endograft migration and failure 12% mortality, for retrograde dissection 33% mortality, for infection and fistula 30% mortality.

So in conclusion, Mr. Chairman, ladies and gentlemen, I think that close follow up after TEVAR is more and more necessary. Open conversion is always a technical challenge, acceptable in high volume centers, and increased mortality, my experience is due mainly

to retrograde dissection and infection. Thanks for attention.

- Okay, so I first continue. So after this data, which really, in our experience, really changed our treatment, we really don't want to treat, actually thoracoabdominals without coiling anymore. Now how to do it and, in fact, we also went through quite a learning curve. In the beginning, of course, was not easy for us

to reach segment arteries and big aneurysms all the tine. We learned form coiling in infrarenal aneurysms, I think, quite a lot and extended then to a higher segment of the aorta. So all together, it was not a short learning curve. So first of all, again, how do we do it?

We do it in local anesthesia, percutaneous, actually, always trans-femoral, although, sometimes the segmented arteries have a steep, at least in the beginning, a steep course downwards. We actually never come from brachial. We don't do a spinal drainage during coiling

and we monitor the patients 48 hours after that. We keep them in the hospital to see whether they develop any neurological complications, which they have, so far, never done. We don't do it on an intensive care and we also do not do spinal drainage then

during the stent graft implantation, which eventually, later then is done in general anesthesia. So this is the basic of the treatment, this is a little bit adopted from neuro radiology. Though, we are just taking bigger devices, so standard is so to say takes some six French

guiding catheter, usually I take an ema curve like this here. And into that very nicely fits a catheter, which is usually a source catheter, not this one, the source catheter is straight here. And through that source catheter, which is five French

catheter, we take a micro catheter through and that is here, this so called tower of power, which has been described, as I said, for neuro radiology procedures. So this is, however, sometimes the problem, you can of course choose several different curves here,

some are smaller, some are bigger. Bigger may not be so easy to handle and direct to your origin of the segmental artery, but in big aneurysms, of course, that can be a problem here to reach the arteries. So what we do with sticking a diagnostic catheter

into the guiding catheter is, that if you pull back here, now, your five French diagnostic catheter, you can really make out of this, move the twistable, toggleable catheter and that enables you in many cases to eventually then, really, in a stable way reach the ostium.

In those cases, where this is not possible, we use this steering deflecting steerable guiding catheters or sheaths, which is, of course, expensive and is really only necessary in very few selective cases, but this is clearly also helpful here. Side wind to one is loaded and then you can reach,

also, in very big arteries, aortas, the segmental ostium quite conveniently. So, of course, we don't do it in all cases, not in urgent repair, because after coiling or after every session of coiling, we want to have some time to let the spinal network develop.

So we can't do it in urgent cases. Renal insufficiency is a problem, although, with CT reading sometimes it's not so difficult to find the segmental artery origins, also, with very little contrast. Severe iliac kinking, aortic elongation

can be a problem indeed, we have some tricks for this and adipositas permagna, well, can be difficult, of course, difficult to see sometimes these arteries and that also requires then quite high radiation doses. This is what we do in very kinked iliac arteries and this is extremely helpful to have this some kind

of reinforced or extended power of tower. So in the beginning, we took a 12 French sheath in, we let the stiff wite in and we punctured, once again, up here of the sheath and brought parallel up then our usually power of tower and with this, you have a very, very stable condition

to reach the segmental arteries. Reason, that we changed to 12 French to nine French sheath, I don't think this is a problem in our days, having closure devices available for these kind of cases. So what shall we take for coiling, usually, we take this, let's call it regular coils

with these feathers, like, things here on top to induce thrombosis. Sometimes, in bigger segmental arteries, you can also do use a vascular plugs. This requires relatively stable access to the arteries. Clearly, no fluids, which are risky

and can embolize distally, we fear and may induce here even a spinal ischemia. So we have never used any fluids in these kind of cases. We are also still in the learning curve, for example, sometimes the arteries after coiling to open up again. Here is a case several weeks after coiling,

you can see here, that the blood here just passes these coils here, this is another case, where you can see, that actually the blood flow seems to be not diminished due to this coiling. So segmental arteries, we learned, are really completely different to others, you never see atherosclerosis here,

sometimes in the origin, probably some plug from the aorta, but they can develop very quickly to bigger arteries and that's why we probably see sometimes here a flow going down. So again, also, we have still a lot of things to work. Is it necessary to occlude them completely?

Is maybe reduction of flow sufficient? Sometimes maybe spinal ischemia is also due to embolization through segmental arteries and then this should actually be sufficient to avoid any embolization into the spinal cord. So after embolization, well, during embolization, also,

we also have to ask ourselves how densely do we have to pack these, cuz you can see, that there is several open areas between the coils. That should be actually usually enough to induce thrombosis. This is, we think, clearly, not enough and this is from the first publication,

not from our institute, I think this is definitely not enough, so indeed, you have to have some stable position of your catheter to pack these coils in and try to occlude the arteries as good as you can. So again, some questions to the coils, which should be used, the standard coils, maybe, which still have always

some holes in between. There are others, for example, the volume coils, which are used in neuro radiology. Which with one coil you can complete occlude the artery. Or there are some micro plugs, which actually go through micro catheters, those here are really

more sufficient and effective in closing the artery, but clearly they are also much more expensive, than regular coils. Where to coil, I think, it's very important not to coil too far distal, because then you're counter productive, you maybe avoid production or development

of this spinal network, you should really try to coil here at that proximal part here to let those networks here distally develop. This is, I think, very important and nevertheless, it can also occur, that you're actually coiling here at that proximal part or some collaterals develop

also proximal to these coils. So the more ostium your coil, I think, are better here. You can see, that we coiled here, but some coils collaterals developed here, feeding, now, here another segmental artery, which is secluded and the proximal part, but at the end we were not completely successful here

in occluding this segmental artery. So shall we also close every artery, shall we only close small arteries, sometimes we see, especially, in big aneurysms, that your ostium here is twisted and become stenotic, will become very difficult to get in. Same artery six weeks later, you can see here,

that it has developed already some collaterals, so do we need to coil this also? These are also still open questions. And then some thoughts about where to start. In the past, it was thought, that it was one big Adamkiewicz artery, great marginal artery,

but that is currently obsolete. We know, that there are several here. So shall we look for the biggest anterior radiculomedullary artery and shall we start with coiling here or shall we start somewhere else? Usually this ARMA, this big ARMA comes off

between TH 11, L one, L two, usually on the left side, here on the right side, so we found here, with our first shot here, this big ARMA going here into this spinal artery. So should we not close this now or should we exactly close this first, these are still open questions. First we go to this here, to have this closed

and let others develop here, some collaterals here. Here is another case, where a stent graft was already in this, not a covered stent, but an open cell stent and here we saw, that here are already some collaterals opened up. You can see here due to an injection to the right side,

this collateral worked upwards and then to the left side, finally here feeding the anterior spinal artery. So also in these cases, it demonstrates to you, that you should coil here, maybe, first, before you go to the other arteries. This is another example here, where to start,

how many and the first session, usually, we do four arteries. In the beginning, this is just our protocol, where we start now. We start usually in that area, we think the main radiculomedullary artery has its offspring

and from that we go more distal and into the proximal counterpart. So to summarize segmental artery coiling and these thoracoabdominal aneurysms can be challenging, it's a new field with may open questions. About our first experience with this is, for us,

really very promising and it's also safe. Thank you very much. (applauding) - [Man] Thank you for this great presentation. I have few questions to you, how long do you need for such an intervention?

And how can you be sure before you start with implantation, I suppose, that you will do this not in one session, but you will do this with a timeframe. That was a long year waiting and before you start to implant the prothesis, it is the question for you too, how you control, that all artery occlude?

- [Presenter] Yeah, many questions, so first of all, how long does it take to coil. So of course, in the beginning it took us some time. It always-- - [Man] Some hours. - [Presenter] Not some hours,

but you have published this also in your publication. - So the data, that we started with like two hours, maybe, it was two hours, but now we got under one hour. - [Presenter] Under one hour per session, let's say for segmental arteries.

It always depends, also, on the anatomy. In the beginning, we were waiting quite a lot between these coilings, because of course, that was all new for us, so we took the time, usually, these are cases, where you ordered a CMD, so you had a timeframe of two months or longer

to wait for the graft anyway. So this time we took for segmental artery coiling, we took several weeks in between segmental artery coiling, bu knowing from the animal models, that during one week, that spinal network should develop, actually, now, down to one week in between coiling sessions.

- [Man] Okay and how you control before you implant? - [Presenter] We don't. - [Man] You don't, you're hoping only? - [Presenter] Well, we have seen some segmental arteries open again, so we did, clearly, did not investigate this systematically, how many did open.

Again, because there are many questions. Maybe it's really enough to just have some coils and to prevent any embolization during the stent graft implantation towards spinal ischemia. We don't know all this, it seems to be a little bit problematic to really check it, we could check it by CT,

you could check it by angiography, but since you're using a lot of contrast during the stent graft implantation anyway there was a step, which we actually did not, now, do systematically. - [Man] And how many coils do you need to close all these arteries?

- [Presenter] For one segmental artery, you need something like four, five, six coils. So this, usually, coils, they recently got very cheap. - [Man] A very cheap intervention. - [Presenter] It is, it is, in fact, not too expensive. If you would use these volume coils, plugs,

that would be a completely other story on micro plugs, but these very standard coils is not expensive, indeed. - [Man] The last question, it is in regard of the application of this technique. Did you have any spinal lesions after stent implantation? - [Woman] So in this series, we have not had any issues

and we are currently looking at the matter, the non invasive imaging to exactly establish when is the point, the best point to implant the stent graft do we really need to wait as long or if we can implant it sooner. So we have some clues, that the preconditioning,

it's developing in one week and we are ready to go for the stent graft. It's very important, that you perioperatively, you adopt the classical perioperative on your strategies. That means we stop the blood pressure, lowering medication so we have a minatorial pressure of 85 to 90 millimeter

of mercury, we have a good oxygen saturation, that means you have a hemoglobin level around 10 gram per deciliter. And also on the ISU, the patient have the same tract. And we basically, we looked, that during the first month, the blood pressure of the patient, it's not too low.

- [Man] Do you have the impression this relationship between the type of aneurysm or the length of aneurysm, they're anatomical and the need of such an intervention? - [Woman] Well, basically, you've seen the data, the published data shows, that the inner thoracoabdominal krau-for type two after, endovascular period

you have up to 19% spinal cord ex-pand-ment of open repair, it's 22%. My opinions is, that the mechanism of spinal cord ischemia after about this procedure, it's different, but basically you need to treat both type of patient for the endovascular pair with both.

We think, that we should treat type two for sure and type three also and maybe type four, and we think type four too, because the proximal landing zone in those type of repair, it's not, it's not the same. So type four, basically, you treat it endo, you get your landing zone, as for treating type three,

and type three, it's getting in type two. - [Man] And did you observe any neurological side effect during the embolization? - [Woman] Recently, we had a patient, where we inject contrast and she had some numbness in her legs, but after two minutes or less than one minute,

she had nothing and we continue with the procedure and she recovered. But her blood pressure were, as I remember, it was not high, it was at systolic of 120 millimeter, that's why we stopped that coiling for that patient. And we had her blood pressure medication stopped

and recoiled them, her, after, I think, seven days. And we had no clinical evidence of spinal cord ischemia. - [Man] Thank you again for all this information, so that we implanted stents for years without this technique.

- [Presenter] Sorry? - [Man] Was that a criminal act? - [Presenter] No, I can only, from our experience, we did have quite some spinal cord ischemias after extensive stent grafting in long thoracoabdominal aneurysms.

It's always very terrible experience to have this. Since we do coiling, we didn't have any problem anymore. It's not a lot of patients, which I think, all together, we have maybe 80 now, but due to this experience, I don't want to do stent grafting without coiling anymore. - [Man] Okay, this is a very important message,

because this is a real religious message.

- 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.

- So Beyond Vascular procedures, I guess we've conquered all the vascular procedures, now we're going to conquer the world, so let me take a little bit of time to say that these are my conflicts, while doing that, I think it's important that we encourage people to access the hybrid rooms,

It's much more important that the tar-verse done in the Hybrid Room, rather than moving on to the CAT labs, so we have some idea basically of what's going on. That certainly compresses the Hybrid Room availability, but you can't argue for more resources

if the Hybrid Room is running half-empty for example, the only way you get it is by opening this up and so things like laser lead extractions or tar-verse are predominantly still done basically in our hybrid rooms, and we try to make access for them. I don't need to go through this,

you've now think that Doctor Shirttail made a convincing argument for 3D imaging and 3D acquisition. I think the fundamental next revolution in surgery, Every subspecialty is the availability of 3D imaging in the operating room.

We have lead the way in that in vascular surgery, but you think how this could revolutionize urology, general surgery, neurosurgery, and so I think it's very important that we battle for imaging control. Don't give your administration the idea that

you're going to settle for a C-arm, that's the beginning of the end if you do that, this okay to augment use C-arms to augment your practice, but if you're a finishing fellow, you make sure you go to a place that's going to give you access to full hybrid room,

otherwise, you are the subservient imagers compared to radiologists and cardiologists. We need that access to this high quality room. And the new buzzword you're going to hear about is Multi Modality Imaging Suites, this combination of imaging suites that are

being put together, top left deserves with MR, we think MR is the cardiovascular imaging modality of the future, there's a whole group at NIH working at MR Guided Interventions which we're interested in, and the bottom right is the CT-scan in a hybrid op

in a hybrid room, this is actually from MD Anderson. And I think this is actually the Trauma Room of the future, makes no sense to me to take a patient from an emergency room to a CT scanner to an and-jure suite to an operator it's the most dangerous thing we do

with a trauma patient and I think this is actually a position statement from the Trauma Society we're involved in, talk about how important it is to co-localize this imaging, and I think the trauma room of the future is going to be an and-jure suite

down with a CT scanner built into it, and you need to be flexible. Now, the Empire Strikes Back in terms of cloud-based fusion in that Siemans actually just released a portable C-arm that does cone-beam CT. C-arm's basically a rapidly improving,

and I think a lot of these things are going to be available to you at reduced cost. So let me move on and basically just show a couple of examples. What you learn are techniques, then what you do is look for applications to apply this, and so we've been doing

translumbar embolization using fusion and imaging guidance, and this is a case of one of my partners, he'd done an ascending repair, and the patient came back three weeks later and said he had sudden-onset chest pain and the CT-scan showed that there was a

sutured line dehiscence which is a little alarming. I tried to embolize that endovascular, could not get to that tiny little orifice, and so we decided to watch it, it got worse, and bigger, over the course of a week, so clearly we had to go ahead and basically and fix this,

and we opted to use this, using a new guidance system and going directly parasternal. You can do fusion of blood vessels or bones, you can do it off anything you can see on flu-roid, here we actually fused off the sternal wires and this allows you to see if there's

respiratory motion, you can measure in the workstation the depth really to the target was almost four and a half centimeters straight back from the second sternal wire and that allowed us really using this image guidance system when you set up what's called the bullseye view,

you look straight down the barrel of a needle, and then the laser turns on and the undersurface of the hybrid room shows you where to stick the needle. This is something that we'd refined from doing localization of lung nodules

and I'll show you that next. And so this is the system using the C-star, we use the breast, and the localization needle, and we can actually basically advance that straight into that cavity, and you can see once you get in it,

we confirmed it by injecting into it, you can see the pseudo-aneurism, you can see the immediate stain of hematoma and then we simply embolize that directly. This is probably safer than going endovascular because that little neck protects about

the embolization from actually taking place, and you can see what the complete snan-ja-gram actually looked like, we had a pig tail in the aura so we could co-linearly check what was going on and we used docto-gramming make sure we don't have embolization.

This patient now basically about three months follow-up and this is a nice way to completely dissolve by avoiding really doing this. Let me give you another example, this actually one came from our transplant surgeon he wanted to put in a vas,

he said this patient is really sick, so well, by definition they're usually pretty sick, they say we need to make a small incision and target this and so what we did was we scanned the vas, that's the hardware device you're looking at here. These have to be

oriented with the inlet nozzle looking directly into the orifice of the mitro wall, and so we scanned the heart with, what you see is what you get with these devices, they're not deformed, we take a cell phone and implant it in your chest,

still going to look like a cell phone. And so what we did, image fusion was then used with two completely different data sets, it mimicking the procedure, and we lined this up basically with a mitro valve, we then used that same imaging guidance system

I was showing you, made a little incision really doing onto the apex of the heart, and to the eur-aph for the return cannula, and this is basically what it looked like, and you can actually check the efficacy of this by scanning the patient post operatively

and see whether or not you executed on this basically the same way, and so this was all basically developed basing off Lung Nodule Localization Techniques with that we've kind of fairly extensively published, use with men can base one of our thoracic surgeons

so I'd encourage you to look at other opportunities by which you can help other specialties, 'cause I think this 3D imaging is going to transform what our capabilities actually are. Thank you very much indeed for your attention.

- Mr Chairman, dear colleagues. I've nothing to disclose. We know that aneurysm or dilation of the common iliac artery is present in almost 20% of cases submitted to endovascular repair and we have a variety of endovascular solution available. The first one is the internal iliac artery

embolization and coverage which is very technically easy but it's a suboptimal choice due to the higher risk of thrombosis and internal iliac problems. So the flared limbs landing in the common iliac artery is technically easy,

however, the results in the literature are conflicting. Iliac branch devices is a more demanding procedure but has to abide to a specific anatomical conditions and is warranted by good results in the literature such as this work from the group in Perugia who showed a technical success of almost 100%

as you can see, and also good results in other registries. So there are unresolved question about this problem which is the best choice in this matter, flared limbs or iliac branch devices. In order to solve this problem, we have looked at our data,

published them in Journal Vascular Interventional Neurology and this is our retrospective observational study involving treatment with either flared limbs or IBD and these are the flared limbs devices we used in this study. Anaconda, Medtronic, Cook and Gore.

And these are the IFU of the two IBD which were used in this study which were Gore-IBE and Cook-ZBS. So we looked at the 602 EVAR with 105 flared limbs which were also fit for IBD. And on the other side, we looked at EVAR-IBD

implanted in the same period excluding those implanted outside the IFU. So we ended up with 57 cases of IBD inside the IFU. These are the characteristics of the two groups of patients. The main important finding was the year age which was a little younger in the IBD group

and the common iliac artery diameter which was greater, again in the IBD group. So this is the distribution of the four types of flared limbs devices and IBD in the two groups. And as you can see, the procedural time and volume of contrast medium was significantly

higher in the IBD group. Complications did not differ significantly however, overall there were four iliac complication and all occurred in the flared limbs group. When we went to late complications, putting together all the iliac complication, they were significantly

greater in the flared limbs group compared with the IBD with zero percent complication rate. Late complications were always addressed by endovascular relining or relining and urokinase in case of infusion, in case of thrombosis. And as you can see here, the late outcome

did not differ significantly in the two groups. However, when we put together all the iliac complication, the iliac complication free survival was significantly worse in the flared limbs group. So in conclusion, flared limbs and IBD have similar perioperative outcomes.

IBD is more technically demanding, needs more contrast medium and time obviously. The complications in flared limbs are all resolvable by endovascular means and IBD has a better outcome in the long term period. So the take-home message of my presentation

is that we prefer IBD in young patients with high life expectancy and in the presence of anatomical risk factors of flared limbs late complications. Thank you for your attention.

- BEVAR through the false lumen, it's rarely indicated. These are my disclosures. And usually, we proceed through the true lumen using BEVAR for post dissection aneurysm like in this case. From our experience, Regensburg and Nuremberg, at the moment the biggest surveys of 71 patient with post dissection aneurysm published

this year in European journal of Vascular and Endovascular Surgery. Sometimes it's necessary to go through the membrane from the true to the false lumen because of the urging of the arteries. And it was necessary in 14 out of 261

target vessels in this material. It makes about 5%. But sometimes, we have a very different cause of the chronic dissection. Like in this patient, where the true lumen shows a very big opening for the false lumen

and ends at the level of the renal arteries. And both legs are only perfused by the false lumen. So, what to do, and it was already some years ago, we decided to make a bypass from ascending to both femoral arteries and pseudoextenders use TEVAR for the aneurysm of the descending aorta.

Now, a case presentation, a 55 years old male patient with hypertension and nicotine consumption. He has had acute aortic dissection, 2014 with a true lumen collapse and dissection of superior mesenteric artery. He has had malperfusion of his intestine and right limb.

At that time, he was treated just by femoral-femoral bypass from left to the right and right hemicolectomy due to ischemic complication. Between 2014 to 2017, this dissection still started at the level of left subclavian artery. The aneurysm was progressive to 63 mm.

He has had the complete thrombosis of the thulomen at the level of the right renal artery with atrophic right kidney. He has had celiac trunk, left renal, and inferior mesenteric artery from the false lumen and dissected superior mesenteric artery.

The first procedure was in October, 2017 with the branching and the Amplatzer to the left subclavian artery to prevent retrograde flow. Branch device and uni-iliac tube because of occluded right iliac artery. After the first operation, we have seen

thrombosis of the thoracic aorta and patent segmental arteries at the level of celiac trunk. The second operation was deployment of covered stentgrafts balloon-expandable covered stentgrafts to the superior mesenteric, left renal and inferior mesenteric artery, why?

If you remember, the patient has had mesenteric dissection and only the right hemicolectomy. So we try to preserve all the collaterals to the intestine. And the third procedure, after balloon occlusion of the celiac trunk and branch, drainage, MEPS, and intrasaccular pressure measurement

was a completion of the celiac trunk with two stent grafts. Preoperative CT, a staged procedure with open aorta at the level of renal and mesenteric arteries, and then completion postoperative with all arteries perfused. Now, what we learned after this.

We may have different methodology. This patient is stable, the reconstruction is well-functioning after 12 months of follow-up, but we should always remember to tailor the procedure to the morphology, it is one of the ways. Thank you very much.

- Thanks Dr. Weaver. Thank you Dr. Reed for the invitation, once again, to this great meeting. These are my disclosures. So, open surgical repair of descending aortic arch disease still carries some significant morbidity and mortality.

And obviously TEVAR as we have mentioned in many of the presentations has become the treatment of choice for appropriate thoracic lesions, but still has some significant limitations of seal in the aortic arch and more techniques are being developed to address that.

Right now, we also need to cover the left subclavian artery and encroach or cover the left common carotid artery for optimal seal, if that's the area that we're trying to address. So zone 2, which is the one that's,

it is most commonly used as seal for the aortic arch requires accurate device deployment to maximize the seal and really avoid ultimately, coverage of the left common carotid artery and have to address it as an emergency. Seal, in many of these cases is not maximized

due to the concern of occlusion of the left common carotid artery and many of the devices are deployed without obtaining maximum seal in that particular area. Failure of accurate deployment often leads to a type IA endoleak or inadvertent coverage

of the left common carotid artery which can become a significant problem. The most common hybrid procedures in this group of patients include the use of TEVAR, a carotid-subclavian reconstruction and left common carotid artery stenting,

which is hopefully mostly planned, but many of the times, especially when you're starting, it may be completely unplanned. The left common carotid chimney has been increasingly used to obtain a better seal

in this particular group of patients with challenging arches, but there's still significant concerns, including patients having super-vascular complications, stroke, Type A retrograde dissections and a persistent Type IA endoleak

which can be very challenging to be able to correct. There's limited data to discuss this specific topic, but some of the recent publications included a series of 11 to 13 years of treatment with a variety of chimneys.

And these publications suggest that the left common carotid chimneys are the most commonly used chimneys in the aortic arch, being used 76% to 89% of the time in these series. We can also look at these and the technical success

is very good. Mortality's very low. The stroke rate is quite variable depending on the series and chimney patency's very good. But we still have a relatively high persistent

Type IA endoleak on these procedures. So what can we do to try to improve the results that we have? And some of these techniques are clearly applicable for elective or emergency procedures. In the elective setting,

an open left carotid access and subclavian access can be obtained via a supraclavicular approach. And then a subclavian transposition or a carotid-subclavian bypass can be performed in preparation for the endovascular repair. Following that reconstruction,

retrograde access to left common carotid artery can be very helpful with a 7 French sheath and this can be used for diagnostic and therapeutic purposes at the same time. The 7 French sheath can easily accommodate most of the available covered and uncovered

balloon expandable stents if the situation arises that it's necessary. Alignment of the TEVAR is critical with maximum seal and accurate placement of the TEVAR at this location is paramount to be able to have a good result.

At that point, the left common carotid artery chimney can be deployed under control of the left common carotid artery. To avoid any embolization, the carotid can be flushed, primary repaired, and the subclavian can be addressed

if there is concern of a persistent retrograde leak with embolization with a plug or other devices. The order can be changed for the procedure to be able to be done emergently as it is in this 46 year old policeman with hypertension and a ruptured thoracic aneurism.

The patient had the left common carotid access first, the device deployed appropriately, and the carotid-subclavian bypass performed in a more elective fashion after the rupture had been addressed. So, in conclusion, carotid chimney's and TEVAR

combination is a frequently used to obtain additional seal on the aortic arch, with pretty good results. Early retrograde left common carotid access allows safe TEVAR deployment with maximum seal,

and the procedure can be safely performed with low morbidity and mortality if we select the patients appropriately. Thank you very much.

- Thank you. I have no conflict of interest. Now the first burning question in carotid artery disease management. I agree with the previous speaker somewhat. Is that is who if anyone with asystematic Carotid Stenosis is likely to benefit from a carotid procedure

in addition to current optimal medical intervention? Where I have to ask this question because of significant advances in medical revascularization over the last three to four decades. Particularly since ACAS was published.

Now at most about 4% of persons with asystametic cartonied stenosis will have a stroke caused by the lesion as explained on Tuesday. We just know that its overall harmful and wasteful to do a procedure on all of them.

But stoke risk stratification cannot identify those who now benefit from carotid endocardectomy and stenting is overall more harmful than endocardectomy. There are many proposed markers of high stroke risk in asymptomatic carotenosis patients given just medical treatment.

Including those some of the European society vascular surgeons. But we already know that each of these markers used in isolation they lack sufficient specificity to identify those most likely to benefit from a procedure. In other words they are to common.

And also the event rates with these individual markers are too low. Particularly considering that all of these studies of these markers were done with suboptimal medical treatment. The second burning question.

Is will prevailing carotid trails find a current procedural indication in stroke prevention? Well the answer with respect to ACST-2 is no. Because its just a trail of stinted verse endocaretomy There is no medical treatment only arm. So its not testing the efficacy of these procedures.

It will help to measure harm of one procedure versus another. But this is of little value without a procedurual indication in the first place. The answer of CREST-2 is not too. Because unfortunately there randomizing

average risk patients like those in ACAS. And we already know that to do a procedure on all of these people is going to be futile and harmful. There's no stroke risk stratification before recruitment. An although they are doing some sub group analysis with markers.

Are these powered sufficiently? I haven't seen that is the case so far. If you look at the CREST-2 sample size. There is approximately 85% power to detect differences in peri-procedural stroke or death or later ipsilateral stroke with endocardectomy versus stent

or stenting versus medical treatment. If the average annual event rate in the medical intervention arm is greater than 2.1 or less than .2 compared to .9 in those procedural arms. Now we know from CREST-1 that they did achieve and average annual event rate of .9 with endocardectomy

but not with stenting. The risk there was about twice as high at 1.6. And its highly likely that they will get an annual event rate in the medical intervetion arm within that range. So that means that the overall role

CREST is most likely to show that stenting causes harm and endocardrectomy knows significant difference with the respect to medical intervention on its own. In other words no procedural indication because if stenting is more harmful we won't do it. And if endocardectomy adds no benefit we won't do it.

The same response for ESCT-2 because like CREST-2 its randomizing average surgical risk patients. No stroke risk stratification before recruitment. Not pre-powered for high stroke risk markers that we have been talking about. ACTRIS has the best chance of finding a procedural role

in asystematic carotid stenosis because they are doing stroke restratification before recruitment. Using embolize detection, errands of impaired to cerebral vascular reserve, errands of intraplaque hemorrhage on MRI

and errands of rapid and severe stenosis progression. But the outcome of this will depend on how the data is analyzed. For example these markers be tested separtly or combined. We already know that markers individually lack specificity. And at the moment the trail does appear to underpowered

with the total of only 700 total patients expected. Mean while TCAR is being accessed only in registries plus or minus input in CREST-2. So it appears we have absent or underpowered comparisons with current medical intervention.

So a clinical indication is unlikely to be established with the current research that is planned. Actually procedural trails are premature when it comes to asystametic cartonid stenosis. What we should be doing is first defining current optimal medical treatment.

Measuring its impact. Risk stratifying people. Using procedural trials only if we find a sub group with an ipsilateral stroke rate that is high enough despite current optimal medical treatment. So if anyone would like to help on this path.

Please speak to me afterwards.

- Thank you so much. I have no disclosures. These guidelines were published a year ago and they are open access. You can download the PDF and you can also download the app and the app was launched two months ago

and four of the ESVS guidelines are in that app. As you see, we had three American co-authors of this document, so we have very high expertise that we managed to gather.

Now the ESVS Mesenteric Guidelines have all conditions in one document because it's not always obvious if it's acute, chronic, acute-on-chron if it's arteri

if there's an underlying aneurysm or a dissection. And we thought it a benefit for the clinician to have all in one single document. It's 51 pages, 64 recommendations, more than 300 references and we use the

ESC grading system. As you will understand, it's impossible to describe this document in four minutes but I will give you some highlights regarding one of the chapters, the Acute arterial mesenteric ischaemia chapter.

We have four recommendations on how to diagnose this condition. We found that D-dimer is highly sensitive so that a normal D-dimer value excludes the condition but it's also unfortunately unspecific. There's a common misconception that lactate is

useful in this situation. Lactate becomes elevated very late when the patient is dying. It's not a good test for diagnosing acute mesenteric ischaemia earlier. And this is a strong recommendation against that.

We also ask everyone uses the CTA angiography these days and that is of course the mainstay of diagnoses as you can see on this image. Regarding treatment, we found that in patients with acute mesenteric arterial ischaemia open or endovascular revascularisation

should preferably be done before bowel surgery. This is of course an important strategic recommendation when we work together with general surgeons. We also concluded that completion imaging is important. And this is maybe one of the reasons why endovascular repair tends to do better than

open repair in these patients. There was no other better way of judging the bowel viability than clinical judgment a no-brainer is that these patients need antibiotics and it's also a strong recommendation to do second look laparotomoy.

We found that endovascular treatment is first therapy if you suspect thrombotic occlusion. They had better survival than the open repair, where as in the embolic situation, we found no difference in outcome.

So you can do both open or endo for embolus, like in this 85 year old man from Uppsala where we did a thrombus, or the embolus aspiration. Regarding follow up, we found that it was beneficial to do imaging follow-up after stenting, and also secondary prevention is important.

So in conclusion, ladies and gentlemen, the ESVS Guidelines can be downloaded freely. There are lots of recommendations regarding diagnosis, treatment, and follow-up. And they are most useful when the diagnosis is difficult and when indication for treatment is less obvious.

Please read the other chapters, too and please come to Hamburg next year for the ESVS meeting. Thank You

- 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.

- Thank you for the invitation to discuss suprarenal bare stent fixation. Here are my disclosure. Aneurismal over graft extension is a part of the natural evolution and the natural history of this degenerative disease, and it could be extended to the celiac aorta

and the common iliac, as well. Regarding the extension to the celiac aorta, we have to consider the infrarenal aorta status, when we want to correct that, and mainly the lengths in between renal artery and the bifurcation of the previously implanted graft,

but also the quality of the access route from below. Most importantly is juxtarenal status, with or without bare stent, and we have nine cases of each. The way to correct this kind of failure is the use of chimney,

when fenistrated graft are not usable. And, the secondary chimney celiac extension, we have 18 cases, when there is a long aortic segment longer than 50 mm, we use a combination of a non-bare stent cuff, associated with balloon-expandable covered parallel stents.

And, when there is a short aortic segment, less than 50 mm, or a difficult access, we use an EVAS device, associated, the same way, with balloon-expandable parallel stents. When the juxtarenal aorta is free of bare stent, it's quite easy to place a wire and stents,

and there is no major contrast in between the different components of the chimney, whatever it is, a cuff extension or the use of an EVAS. It's quite different to when there is, when we have to perform a renal stenting over a bare stent, and you can see that we have to develop tricks

to stabilize a wire into the renal stent by aortic balloon, or by a renal balloon, or renal filter, but this kind of tricks are not working very well. And, we had, in some cases, the need for using push-up procedures, which means that we are exerting forces

onto the delivery system and there's a parallel stent, and that lead to compression in between the different components of this chimney. And, in addition, when there is a bare stent previously implanted, there are forces and there is room

for gutter and that's the way to get type 1 Endoleak. And, it's more difficult when the bare stent is creating a stenosis on the ostium of the renal artery, and we had here to place a stent, a bare stent, for angioplasties and to go to a push-up procedures, before implanting the endoaortic graft

and you can see that there is a lot of contrast, onto this renal stent. When there is a bare stent, there is a slight, the operating time is longer, and one type A Endoleak

more in the bare-stent population of patient but we have one occlusion stent on the non-bare stent group. Endoleak could be treated by embolization into the gutter. But, as we want to avoid this kind of difficult procedures, we use a classification,

based on the evolution profile of the aneurysm. When the neck are safe, we use EVAS to prevent type 2 Endoleak. When the neck is cylindrical, but slightly disease, we use a bifurcated graft, with infrarenal fixation. When the neck is short or when there is no neck,

we use four fenestrated graft, or tri-chimney procedures, and when there is a celiac aneurysm, we use thoracoabdominal reconstruction, using a thoracic segment, in addition with four-fenestrated graft, or a thoracic branch device.

Then, to conclude, the bare stent doesn't prevent the evolution of the aneurysmal disease, that means that we have to reconsider the use of endoaortic graft, with bare stent suprarenal fixation, just to anticipate what could happen during the evolution and the ability to perform

a secondary device extension. And thank you for your attention.

- That's a long title, thank you. We shortened the title, and just said, The Iliac Artery's Complicating Complex Juxtarenal and Thoracal Abdominal Repair. I have no disclosures. So, Iliac artery preservation is important whenever we start doing complex aortic aneurysm repair.

We don't understand completely what the incidence is with these extensive aneurysms. We know with AAAs, anywhere in the 10 to 40% have some sort of iliac artery involvement. It certainly can complicate the management as we get to these more complicated repairs.

Iliac artery preservation may be important for prevention of spinal cord ischemia, and those people in whom we can maintain both hypogastric arteries, it occurs at a less significant rate, with less severe symptoms and higher rates of recovery.

The aim of our study was to evaluate the incidence, management, and outcomes of iliac artery aneurysms associated with complex aortic aneurysms treated with fenestrated and branched endografts. Part of a PS-IDE study over a 15 year period of time,

this is dated from the Cleveland Clinic for the treatment of juxtarenal aneurysms and thoracal abdominal aortic aneurysms. For the purpose of this study, we defined an iliac artery aneurysm is 21 mm or greater as determined by diameter

by our core lab. We chose 21 mm because this was outside of the IFU for the iliac wounds that we had currently available to us at that time. We did multivariable analysis on the number of different outcomes. And we looked at the incidence

of iliac artery aneurysms by repair type. In all the aneurysms we treated, we see about a third of the patients had some level of iliac artery aneurysm involvement. In those patients that had less extensive thoracal abdominals, the type three

and type four abdominals, it occurred in about a third of the cases. A little bit less than the type two and the type one thoracal abdominals. We look at the demographics between those that had iliac artery aneurysm

involvement and those that did not have iliac artery involvement. It was more common in males to have iliac artery involvement than any other group. There are more females that didn't have iliac artery aneurysms. The rest

of the demographics were the same between the two groups. We look at the anatomic characteristics of the iliac artery aneurysms, about 60% of them were unilateral, about 40% of them were bilateral.

The mean iliac artery aneurysm size was 28 mm and that was the same on both sides. And we look at thought the percent that were actually very large, or considered large enough to potentially in and of themselves the repairs

greater than three centimeters. About 28% of them were greater than three centimeters on each side. If we look at our iliac artery aneurysm treatment type, this is 509 iliac artery aneurysms that

were treated out of all these patients. About 46% of them, we were able to obtain a seal distal to the iliac artery aneurysm. So it really only involved the proximal portion, the proximal half of the iliac artery.

20% of them, we placed a hypogastric branched endograft, and about 20% of them, we placed a hypogastric coverage plus embolization of that internal iliac artery. About 13% of them were left untreated at the time for a variety of different operative reasons.

Why is there a difference between the hypogastric coverage and embolization? It was availability of devices and surgeon choice at the time. At one point, we had a opportunity to be able to treat both fairly easily

on both sides and at one point we did not. Larger iliac artery aneurysms were treated with hypogastric coverage or hypogastric branched endografts, and there was a significant difference between the two. Most of the mean

size of those that were actually treated with either hypogastric branch or embolization for greater than three centimeters. If we look at peri-operative outcomes in those without iliac artery aneurysms versus those with iliac artery aneurysms.

We see that the fluoroscopy estimated blood loss is larger for those with iliac artery aneurysms, fluoroscopy time was longer and procedure duration was a bit longer as well. Obviously, a bit more complicated procedure,

more steps that's going to take a little bit longer to perform them. It did not effect the length of stay for these patients or the length of stay in the intensive care unit following the procedures. We look

at all-cause mortality at five years, no difference in whether they had an iliac artery aneurysm or not. It didn't matter whether it was unilateral or bilateral. If we look at aneurysm-related mortality, it's the same whether

they had the iliac artery aneurysm or not. Same for unilateral versus bilateral as well. Where we start to see some differences are the freedom from reintervention. This did vary between, among the three groups. In those patients without an iliac

artery aneurysm, they had the lower reintervention rate than those with the unilateral iliac artery aneurysm, and even lower rates from freedom from reintervention in those that had bilateral iliac artery aneurysms. Spinal cord ischemia, one of the

reasons we try to preserve both the hypogastric arteries. Look at our total spinal cord ischemia incidents. It didn't vary between the two groups, but if we look specifically, the type two thoracal abdominal aortic aneurysms in those patients that had bilateral

iliac arte higher rate of spinal cord ischemia compared to those that did not have any iliac artery aneurysms or those that had an internal iliac, a single iliac artery aneurysm.

So, iliac artery aneurysms affect about a third of the patients with complex aortic disease. They do not, their presence does not affect all-cause mortality or aneurysm related mortality. They are associated with a higher reintervention rate.

In extensive aneurysms, may be higher association with higher spinal cord ischemia rates. We need additional efforts are needed to improve outcomes and understanding appropriate application of different treatment options for patients with

complex aortic disease. Thank you.

- Thank you Mr. Chairman. Ladies and gentleman, first of all, I would like to thank Dr. Veith for the honor of the podium. Fenestrated and branched stent graft are becoming a widespread use in the treatment of thoracoabdominal

and pararenal aortic aneurysms. Nevertheless, the risk of reinterventions during the follow-up of these procedures is not negligible. The Mayo Clinic group has recently proposed this classification for endoleaks

after FEVAR and BEVAR, that takes into account all the potential sources of aneurysm sac reperfusion after stent graft implant. If we look at the published data, the reported reintervention rate ranges between three and 25% of cases.

So this is still an open issue. We started our experience with fenestrated and branched stent grafts in January 2016, with 29 patients treated so far, for thoracoabdominal and pararenal/juxtarenal aortic aneurysms. We report an elective mortality rate of 7.7%.

That is significantly higher in urgent settings. We had two cases of transient paraparesis and both of them recovered, and two cases of complete paraplegia after urgent procedures, and both of them died. This is the surveillance protocol we applied

to the 25 patients that survived the first operation. As you can see here, we used to do a CT scan prior to discharge, and then again at three and 12 months after the intervention, and yearly thereafter, and according to our experience

there is no room for ultrasound examination in the follow-up of these procedures. We report five reinterventions according for 20% of cases. All of them were due to endoleaks and were fixed with bridging stent relining,

or embolization in case of type II, with no complications, no mortality. I'm going to show you a couple of cases from our series. A 66 years old man, a very complex surgical history. In 2005 he underwent open repair of descending thoracic aneurysm.

In 2009, a surgical debranching of visceral vessels followed by TEVAR for a type III thoracoabdominal aortic aneurysms. In 2016, the implant of a tube fenestrated stent-graft to fix a distal type I endoleak. And two years later the patient was readmitted

for a type II endoleak with aneurysm growth of more than one centimeter. This is the preoperative CT scan, and you see now the type II endoleak that comes from a left gastric artery that independently arises from the aneurysm sac.

This is the endoleak route that starts from a branch of the hepatic artery with retrograde flow into the left gastric artery, and then into the aneurysm sac. We approached this case from below through the fenestration for the SMA and the celiac trunk,

and here on the left side you see the superselective catheterization of the branch of the hepatic artery, and on the right side the microcatheter that has reached the nidus of the endoleak. We then embolized with onyx the endoleak

and the feeding vessel, and this is the nice final result in two different angiographic projections. Another case, a 76 years old man. In 2008, open repair for a AAA and right common iliac aneurysm.

Eight years later, the implant of a T-branch stent graft for a recurrent type IV thoracoabdominal aneurysm. And one year later, the patient was admitted again for a type IIIc endoleak, plus aneurysm of the left common iliac artery. This is the CT scan of this patient.

You will see here the endoleak at the level of the left renal branch here, and the aneurysm of the left common iliac just below the stent graft. We first treated the iliac aneurysm implanting an iliac branched device on the left side,

so preserving the left hypogastric artery. And in the same operation, from a bowl, we catheterized the left renal branch and fixed the endoleak that you see on the left side, with a total stent relining, with a nice final result on the right side.

And this is the CT scan follow-up one year after the reintervention. No endoleak at the level of the left renal branch, and nice exclusion of the left common iliac aneurysm. In conclusion, ladies and gentlemen, the risk of type I endoleak after FEVAR and BEVAR

is very low when the repair is planning with an adequate proximal sealing zone as we heard before from Professor Verhoeven. Much of reinterventions are due to type II and III endoleaks that can be treated by embolization or stent reinforcement. Last, but not least, the strict follow-up program

with CT scan is of paramount importance after these procedures. I thank you very much for your attention.

[Mollie Meek] We are going to talk about our histology of head and neck AVMs after Onyx embolization. Like I said previously, we were in love with Onyx at the end of the 2000's. So we used lots and lots of Onyx, and then the patients generally went for resection.

Sometimes immediately, and sometimes years after the embolization. We are not as in love with Onyx anymore, and our hospital was certainly not in love with us using Onyx the way we were using it in the past, because it was super expensive,

and they weren't getting reimbursed for the multiple vials we were using. I had no disclosures. If I have time, I'll talk to you about radiation dose. The most important part is the pathological response. This is a slide of a typical AVM.

You see the thick walled arterial portion of the vascular channels and the thinner walled venous portion. This is just a higher magnification. I am not a pathologist. So when we did our scoring of our specimens,

we scored some acute and inflammatory changes, some chronic inflammatory changes, and then the amount of recanalization that we saw. What we found is that recanalization was extremely common. We saw it in 13 of our 18 specimens,

and the specimens that had minimal inflammatory changes had minimal recanalization. That's the take home message. This is a specimen with Onyx in cast material in the vessels. Trying not to blind our moderators like I did earlier.

This is a really pretty picture of the vessel wall, the Onyx material, and a brand new vessel in the middle of this old vessel. This is what just sort of a scout image of what their faces looked like.

One of, a sample. This is like a longitudinal slice of a vessel. So this is vessel wall on one side, vessel wall on the other side, Onyx material, and then new vessel formation

and interstitial tissue stuff in the middle of that old, big vessel. These are just some pictures. Another example of Onyx with vessels inside the Onyx. We saw a fair amount of giant cell formation, which you can kind of see these clusters

of multi nucleated things, are the giant cells. They come in and clean up the Onyx material. These are just more Onyx specimens. Here's a nice picture of giant cell. We also counted vessel wall necrosis in our tabulations.

And you can see this Onyx material is in the endothelial cells, and it kills the endothelial cells. So we did see some vessel wall necrosis. So the short story is there's no definitive time for the recanalization,

but we think it takes about a year for you to really see nicely formed vessels in the Onyx. And in our experience in the head and neck, it was common. It may be different in other locations, because obviously your head and neck

has different lymphatic ratios and inflammatory things, and there's all kinds of differences between the head and neck, and say your arm or your leg. The second part of this is your radiation dose,

which has been touched on a little bit. The plug and push technique, part of why I don't like it, and why I don't like using Onyx, is it's just slow. You have to wait, and wait.

And it takes a lot of x-ray penetration, because your computer is going to try to up your dose because you've got the black Onyx in the x-ray beam, if that makes any sense. Your machine's going to try to help you, and it amps up your dose

really quickly if you're not careful. And for our head and neck patients, obviously we're doing AP and lateral views. This is our equipment. We put dots, radiation dosimeters on peoples' heads

and one in their oropharynx before our treatments, and we did calculations of a sequence of patients. You can see the ages of the patients in the group, and the number of the patients. This was just for a short time period we did this.

This is the important part, that the AVMs have a much higher skin entrance dose than the venous malfs. Part of that is we don't put on in venous mals. Sometimes I will put glue in a venous mal if a surgeon wants to resect it

because they like the way it comes out when you do that. But otherwise I generally just use alcohol in venous mals. And then these were on X AVMs at this point in time when we collected this data. Some alcohol.

This is a reminder about the dosimetry. And this was the number of sessions, embolization sessions versus the skin entrance dose. And just some more pictures of yeah. So Onyx is not permanent in my histologic experience.

Watch out for wound healing issues and recanalization, and watch out for skin burns. That's it. Thanks.

- Thank you very much for the introduction and for the invitation to be here. This is my disclosures. If you look at the literature, recent review about spinal cord ischemia in Endo repairs and select only the thoraco-abdominal repairs, you see the spinal cord ischemia

is still an important problem with 13% transient and 5% permanent spinal cord ischemia. The same figures for open repair. Also this year published in experience centers, a lot of patients, 5% permanent paraplegia. There are a lot of strategies used.

Some of them are both used for open and endo repair. Most of them in this slide you know, and probably can add now hyperbaric therapy, and glucose management. Some of them are more for open alone.

Hypothermia disorder, perfusion and reattachment of intercostals. And early leg reperfusion is more specific for endovascular repair. But all of them are involved in preservation of original inflow and stimulation

of alternative inflow in the collateral network around the spinal cord. During this talk I will mainly focus on the stage repair, because this is probably the newest kid on the block. Can be done and it's proven to be useful

in open and endo repair. Is done because of previous aortic repair in a historical staging. You can plan multiple operations, both in open and endo. And probably the segmental artery coil embolization,

that we'll hear later, is also a form of staging. For the endo, the open branch staging, leaving one branch open, connecting it later, is also a way of staging. However, using staging, it takes longer to exclude the aneurysm,

and probably the patient is at risk for a longer time. If you look at our endo results, for thoraco-abdominal aneurysms, there is a lot of historical staging. Some TEVAR staging that we mainly use

open branch staging in a selective way, just when we occlude the last branch to connect with the balloon test motor evoked potentials, if they go down, do an angio, if there is a major endoleak. And if this is all okay, we connect it,

and in 20% of the patients, we will stage the procedure. Looking at our results, at spinal cord ischemia, total 6%, and these are seven patients, and only two of them have complete persistent paraplegia,

which is 1.9% If you look at the literature, there is a clear correlation between the extent of the thoraco-abdominal aneurysm and the presence of spinal cord ischemia, both in endo and open.

And that is something we cannot see anymore in our data. The spinal cord ischemia is equally distributed among all stages. And this is probably because we tend to stage more selectively

based on the motor evoked potentials in type two and type three, almost 30% of the cases, and just 15% in type one and four, with the same spinal cord ischemia results. So in conclusion, spinal cord ischemia is still a serious problem both in open and endo repair.

If you look at the literature in endovascular repair, the spinal cord ischemia rate seems to decrease in the last years. Staging is an effective way to reduce spinal cord ischemia, both in open and endo. And if you use selective staging

with motor evoked potentials during branch test occlusion, this is, at least in our practice, associated with a low spinal cord ischemia rate. We tend to stage more in more extensive Crawford types, this means we don't need to stage in 80% of the cases.

Thank you.

- Thank you very much, Dr. Veith, and thank you to you and the organizing committee for inviting me to participate again this year in, really, the premiere vascular meeting. This morning, I'd like to talk about the contemporary management of carotid artery aneurysms. These are my disclosures.

Extracranial carotid artery aneurysms and pseudoaneurysms may result from a variety of causes, including trauma, fibromuscular dysplasia, atherosclerosis. They're associated with dissection, connective tissue disorders, mycotic aneurysms associated with infection.

We see patch aneurysms from prior carotid endarterectomy, as well as aneurysms associated with radiation, and those that occur spontaneously. Sequelae of these aneurysms are often distal embolization, potential for thrombosis, some patients experience compressive symptoms, and rupture may occur as well.

Treatment has traditionally been through open surgical repair, but there have been advances in endovascular treatments, including covered stents, woven stents, such as the pipeline stent in size-appropriate cases, bare stents with or without adjunctive coil embolization.

Open surgical repair has been time tested and it's proven to be very effective, but there are potential morbidities associated with challenges or surgical exposure, particularly in patients with prior surgery or radiation and those with anatomically-challenging lesions.

A very definitive review of this has been conducted by the surgeons at the Mayo Clinic, including Drs. Money, Bower, and Fowl, and they have described the treatment of 141 aneurysms in 132 patients. In the evolution of treatment with endovascular techniques, covered stents have been employed.

These eliminate aneurysm and pseudoaneurysm perfusion completely and immediately after deployment, but there have been reports of delayed thrombosis of these covered stents when they've been deployed in the cervical distribution. This is a patient of ours who has a large patch aneurysm, nearly four centimeters in size.

If you look on the CAT scan you'll see there's very limited, essentially no overlying soft tissues as a result of the previous radical neck dissection. In this case, we'd elected to use a covered stent to achieve exclusion of this patch aneurysm, and then used a bare metal stent distally to augment the treatment itself.

Our therapies progressed to the use of bare metal stents with associated coil embolization so-called stent, assisted coil embolization. As you can see, there are two sequential, very large, pseudoaneurysms of the internal carotid artery. Here's the carotid bifurcation.

Here, I hope you can see between these green arrows, is the stent that's been deployed. We use closed cell stents typically for these applications, and we can use a microcatheter cannulate that pseudoaneurysm and deploy large neuro-embolic coils to promote flow of cessation.

When we follow up with these patients, here's this patient's one-month post-operative duplex ultrasound, there's no flow in the pseudoaneurysm, and excellent flow in the internal carotid artery without stenosis. We've then progressed to the use of overlapping closed cell stents, and in doing so,

hoped to sort of simulate the pipeline woven stent configuration but have greater applicability in terms of diameter of the internal carotid. Here, you can see this internal carotid artery spontaneous pseudoaneurysm. We then go ahead and bring our initial stent into position

across the origin of the pseudoaneurysm. Here's after initial stent deployment on this static image. Here, after our second stent deployment, you can see very limited static flow within the pseudoaneurysm itself, and that's evidenced by, after the flowed out of the internal carotid artery,

there's still residual contrast within the pseudoanerusym. Here are the individual characteristics of the patients that we've treated using endovascular techniques. To summarize those data, the mean duration of follow up for these patients is 331 days.

But we have followed one patient out to eight years. The study's limited by the relatively small number of patients and the limited duration of follow up in these patients. But our technical success has been 100%, in terms of being able to deploy the endovascular

techniques, and maintain patency. We've had no patients who've experienced neurologic sequelae, including no strokes or TIAs. There've been no cases in which the aneurysm has expanded, in most cases, the aneurysm itself regresses and there's been no flow within those aneurysms or pseudoaneurysms.

Finally, we have been able to maintain 100% patency in these patients, as monitored using our standard follow up protocol with duplex ultrasound being performed every three months for the first year, and annually thereafter. In conclusion, extracranial carotid artery aneurysms and pseudoaneurysms may be treated effectively

using standard open techniques. However, surgical exposure and perioperative morbidity may present challenges for open repair. Endovascular approaches to aneurysm and pseudoaneurysm treatment have evolved progressively. The preliminary results of our analysis with mid-term

follow up suggest that these techniques are effective and durable, with limited procedural morbidity. Thank you very much.

- Well, thank you Andrej, I will present you the minimal invasive segmental artery coil embolization for prevention of spinal cord ischemia during EVAR of thoracoabdominal aortic pathologies, our initial clinical results. As all, I have nothing to disclose related to this presented topic.

As all we know ischemic spinal cord injury has a high incidence up to 20% after open or endovascular repair of thoracoabdominal aortic aneurysm and this is despite conventional perioperative neuroprotective strategies such as blood pressure management or continuous CSF drainage and also despite staged aortic repair such as

staged endovascular repair or temporary aneurysm sac perfusion. That's why our opinion is that, we have to have a pragmatic approach for prevention of spinal cord ischemia. First, our opinion is that you've to revascularize as many inflow arteries as possible such as

subclavian or hypogastric artery. You've to optimize your hemodynamic management perioperatively and last but not the least, we think that you've to improve your strategies that induce development of collateral arteries, that means, you have to ischemic precondition the spinal cord.

The ischemic preconditioning of the spinal cord is based on the collateral network concept of the spinal cord perfusion and that means that the hypothesis of spinal blood supply depending mainly on the critical arterial input of the Adamkiewicz artery is obsolete. As you can see here, of some of our intraoperative images

that blood supply of the spinal cord is guaranteed by two nal and intraspinal compartment And from this compartment, there are very small arteries, you can see here on this image. The anterior radiculomedullary artery, that gives further

supply to the main spinal cord artery, the anterior spinal artery. So, based on this concept, we developed ischemic preconditioning and that means that we occlude the main stem of several segmental arteries in order to preserve the capability of

paraspinous collateral network to build new arteries and we do that by minimal invasive staged occlusion of the segmental artery and basically this is an entirely endovascular first stage of a staged approach for thoracoabdominal aortic repair to reduce the ischemic injury of the spinal cord.

The procedure performed local anesthesia with a percutaneous trans-femoral access with a small bore sheath, the patient is awake, there has no cerebrospinal fluid drainage and we perform the clinical monitoring of the patient for at least 48 hours after the procedure. I won't go in details about the procedure, Andrej will let

you guide you through, I will show you our data. You can see, here between September 2014 and December 2017 we've treated 57 patients with MISACE in our institution. You can see here the characteristic of the patient. 75% were male with mean age of 69.6 years of age all over they were hypertension, and most of them, 39, had a

extensive Crawford type II and type III aortic aneurysm. The mean aortic diameter was 62.7. Some of them, they had previous repair of the aorta and 94% were atherosclerotic in all age. So, how do we perform the procedure? So, we look, we've, we look at our CT scan of the patient

and we know from the pre-planning where the aorta will be covered. And in this area, we look at the segmental arteries and we count the segmental arteries, we don't only count, also mark the segmental arteries that will be covered by the stent grafts.

And, you can see here in median we had nine open segmental arteries of this area ranging from 2 up to 26. Then we start the coiling procedure and you can see here that 38.6% of patient had only one coiling session, 42.1% had 2 session of Minimally invasive coil embolization and 19.3% of the patient had more than two stage coil.

And you can see here that, between those two coiling sessions, we had mean interval of 60 days. And you can see here that we have performed maximum five sessions per patient and during those sessions we've coiled maximum six segmental arteries and per patient we've coiled up to 19 segmental arteries

and median was number of 5. You can see here distribution of the segmental arteries after MISACE at the level of the planned aortic coverage. With blue, sorry with dark, it's the, they're segmental arteries were already occluded, with grey it's segmental arteries that we've already coiled

and with red is segmental arteries that we've not coiled. Again this is the first initial clinical experience and at the end of the entire coiling procedure, we've occluded median 77.7% of the entire segmental arteries of that level. You can see here the characteristic of the

coiling of session. You can see here that basically between the first and second sessions, they're not too many differences, the third session is quiet quicker and we've no spinal cord ischemia after this coiling sessions and we've some minor complication like quarter of our patient developed

backpain which resolved with NSAIDs, we had lost two coils, we were able to recover and we were unable to occlude one segmental artery in three patients. After seven days but no sooner than that, in order to let the collaterals of spinal cord to develop, we performed the complete aneurysm exclusion of these patients.

You can see here, 55 of our patient were completely excluded in the mean time of 83 days. To mention that, two patients died waiting for the CMD graft due to the cardiac problems not related to the aneurysm pathology. You can see here the characteristic of the TEVAR procedure.

You can see here we performed, all type of stent grafts from tube stent-graft to fenestration branch combined stent graft. In one patient, we've the subclavian coverage on the left side and in 80% of the patients the hypogastric are true or patent.

To mention that, the length of the covered aorta in our cohort was 270 mm. After the complete repair of the thoracoabdominal aortic aneurysm, at 30 days, you can see our result, we've no spinal cord ischemia in this patient, one patient died due to related aneurysm problem.

And by looking at this data, we conclude that the first experience suggest that the minimal invasive segmental artery coil embolization is feasible, safe and in our opinion, effective but can be challenging and it's a new field with a many open questions. And we think that the ultimate proof of this technology

of this procedure requires randomized trial which is currently underway, this PAPA-ARTiS trial, paraplegia prevention in aortic aneurysm repair by thoracoabdominal staging with MISACE. Thank you for your attention.

- Thank you, chairman. Good afternoon, ladies and gentlemen. I've not this conflict of interest on this topic. So, discussion about double-layer stent has been mainly focused about the incidence of new lesions, chemical lesions after the stenting, and because there are still some issue

about the plaque prolapse, this has still has been reduced in a comparison to conventional stent that's still present. We started our study two years ago to evaluate on two different set of population of a patient who underwent stent, stenting,

to see if there is any different between the result of two stents, Cguard from Inspire, and Roadsaver from Terumo in term of ischemic lesion and if there is a relationship between the activity of the plaque evaluated with the MRI

and new ischemic lesion after the procedure. So, the population was aware of similar what we found, and that there's no difference between the two stent we have had, and new ischemic lesions is, there's a 38%, for a total amount of 34 lesions,

and ipsilateral in 82% of cases. The most part of the lesion appeared at the 24 hours, for the 88.2% of cases, while only the 12% of cases, we have a control at our lesion. According to the DWI, we have seen that

the DWI of the plaque is positive, or there is an activity of the plaque. There's a higher risk of embolization with a high likelihood or a risk of 6.25%. But, in the end, what we learned in the beginning, what there have known,

there's no difference in the treatment of the carotid stenosis with this device, and the plaque activity, when positive at the DWI MR, is a predictive for a higher risk of new ischemic lesions at 24 hours. But, what we are still missing in terms of information,

where something about the patency of the stents at mid-term follow-up, and the destiny of external carotid artery at mid-term follow-up. Alright, we have to say we have an occlusion transitory, occlusion of the semi-carotid artery

immediately after the deployment of the Terumo stent. The ECA recovery completely. But in, what we want to check, what could happen, following the patient in the next year. So, we perform a duplicate ultrasound, at six, at 12, and 24 months after the procedure,

in order to re-evaluate the in-stent restenosis and then, if there was a new external carotid artery stenosis or occlusion. We have made this evaluation according to the criteria of grading of carotid in-stent restenosis proposed on Stroke by professors attache group.

And what we found that we are an incidence of in-stent restenosis of 10%, of five on 50 patient, one at six month and four at one year. And we are 4% of external carotid artery new stenosis. All in two patient, only in the Roadsaver group.

We are three in-stent restenosis for Roadsaver, two in-stent restenosis for Cguard, and external new stenosis only in the Roadsaver group. And this is a case of Roadsaver stent in-stent restenosis of 60% at one year. Two year follow-up,

so we compare what's happening for Cguard and Roadsaver. We see that no relation have been found with the plaque activity or the device. If we check our result, even if this is a small series, we both reported in the literature for the conventional stent,

we've seen that in our personal series, with the 10% of in-stent restenosis, that it's consistent with what's reported for conventional CAS. And the same we found when we compared our result with the result reported for CAS with conventional stent.

So in our personal series, we had not external carotid artery occlusion. We have 4% instance, and for stenosis while with conventional CAS, occlusion of external carotid artery appear in 3.8% of cases.

So, what can we add to our experience now in the incidence, if, I'm sorry, if confirmed by larger count of patient and longer study? We can say that the incidence of in-stent restenosis for this new double-layer stent and the stenosis on the external carotid artery,

if not the different for all, with what reported for conventional stent. Thank you.

- [William] I would like to thank Dr. Veith for the opportunity to speak here this afternoon. The title of my talk is How to Neutralize and Unmask Hostile Medical Expert Witnesses and Their Testimony. The best way to address an expert who provides false testimony

is to unmask them during a deposition or trial and make certain that they can never testify again as an expert. An expert can be unmasked in several ways. One is review certification, two, reviewing their training,

three, speak with the expert's colleagues, four, review caseloads, and five, review old depositions. Ask for board certification. There was recently a case where the expert stated that he simply had not gotten around to recertifying.

He actually had not recertified in over 10 years. When the jury found this out, he no longer was a credible expert. In a second case, an expert stated he was board-certified in vascular surgery. He was not certified.

The jury returned a no cause verdict in 10 minutes. As far as reviewing training, there was an expert who said he was trained in vascular surgery, yet never finished his training. A second example was an expert who said

he had training in vascular surgery, but that training consisted of a three-month rotation on vascular surgery. In speaking with an expert's colleagues, it was found out that an expert had alleged that he had privileges to operate

at a well-known university hospital. However, he in fact had lost those privileges. The expert was charged with perjury. He had to turn in his Missouri license, he was fined $100,000, and he turned himself in to the Boone County Jail

and was freed on $50,000 bond. A second example was a heart surgeon in Miami who stated that he performed a couple hundred coronary artery bypass grafts between 1995 and 2002. In fact, he had performed none. He ended up losing his license,

and when he refused to surrender his license, he was placed in jail. It's important to remember that depositions and trial testimony, in general, are public record, and not privileged materials. Depositions of experts should be reviewed

for medical inconsistencies. We have gray testimony, in which people say things such as, it is negligent to injure the hypoglossal nerve during a carotid endarterectomy. There is clearly false testimony. This would be things such as,

it is malpractice for a patient to develop a bowel obstruction following an open abdominal aortic aneurysm repair. Second example would be if a patient has a post-operative bleed from an anastomosis, malpractice must have occurred.

Otherwise, this complication does not occur. Two other examples, the most common reason for a graft to occlude is the individual dies. And finally, my favorite, the success rate of a popliteal to posterior tibial artery bypass in a diabetic in preventing an amputation, as terms of the expert,

"in my hands would be virtually 100%" It's important to remember that a plaintiff attorney must show all four of these components, the most important being the breach of the standard of care, and they need an expert to do that. If you eliminate the experts, you eliminate the lawsuit.

So what can we do? We can send a letter to the Ethics and Professional Conduct Committee of appropriate societies. We can send a letter to the American College of Surgeons, and we can name names with specific testimony. Recently, an expert and false testimony was unmasked

on a slide at a national meeting. The expert, who was showing up regularly as a plaintiff's expert, suddenly was no longer providing false testimony. An expert should be willing to stand by their testimony and not be afraid to see it on a slide

at a national meeting. In conclusion, we need to thoroughly research the testimony of experts. If false testimony is found, it should aggressively be pursued and any and all remedies,

including expulsion from professional societies and reporting the physician to the state medical board. As far as I'm concerned, this is really the only conclusion for experts who lie. Thank you.

- Thank you, good morning everybody. Thank you for the kind invitation, Professor Veith, it's an honor for me to be here again this year in New York. I will concentrate my talk about the technical issues and the experience in the data we have already published about the MISACE in more than 50 patients.

So I have no disclosure regarded to this topic. As you already heard, the MISACE means the occlusion of the main stem of several segmental arteries to preserve the capability of the collateral network to build new arteries. And as a result, we developed

the ischemic preconditioning of the spinal cord. Why is this so useful? Because it's an entirely endovascular first stage of a staged approach to treat thoracoabdominal aortic aneurysm in order to reduce the ischemic spinal cord injury.

How do you perform the MISACE? Basically, we perform the procedure in local anesthesia, through a percutaneous trans-femoral access using a small-bore sheath. The patient is awake, that means has no cerebrospinal fluid damage

so we can monitor the patient's neurological for at least 48 hours after the procedure. So, after the puncture of the common femoral artery, using a technique of "tower of power" in order to cannulate the segmental arteries. As you can see here, we started with a guiding catheter,

then we place a diagnosis catheter and inside, a microcatheter that is placed inside the segmental artery. Then we started occlusion of the ostial segment of the segmental artery. We use coils or vascular plugs.

We don't recommend the use of fluids due to the possible distal embolization and the consequences. Since we have started this procedure, we have gained a lot of experience and we have started to ask,

what is a sufficient coilembolization? As you can see here, this artery, we can see densely packed coils inside, but you can see still blood flowing after the coil. So, was it always occluding, or is it spontaneous revascularization?

That, we do not know yet. The question, is it flow reduction enough to have a ischemic precondition of the spinal cord? Another example here, you can see a densely packed coil in the segmental artery at the thoracic level. There are some other published data

with some coils in the segm the question is, which technique should we use, the first one, the second one? Another question, is which kind of coil to use? For the moment, we can only use the standard coils

in our center, but I think if we have 3-D or volume coils or if you have microvascular plugs that are very compatible with the microcatheter, we have a superior packing density, we can achieve a better occlusion of the segmental artery, and we have less procedure time and radiation time,

but we have to think of the cost. We recommend to start embolization of the segmental artery, of course, at the origin of it, and not too far inside. Here, you can see a patient where we have coiled a segmental artery very shortly after the ostium,

but you can see here also the development of the collaterals just shortly before the coils, leading to the perfusion of segmental artery that was above it. As you can see, we still have a lot of open question. Is it every patent segmental artery

a necessary to coil? Should we coil only the large ones? I show you an example here, you can see this segmental artery with a high-grade stenotic twisted ostium due to aortic enlargement.

I can show you this segmental artery, six weeks after coiling of a segmental artery lower, and you can see that the ostium, it's no more stenotic and you can see also the connection between the segmental artery below to the initial segmental artery.

Another question that we have, at which level should we start the MISACE? Here, can see a patient with a post-dissection aneurysm after pedicle technique, so these are all uncovered dissection stent, and you can see very nicely the anterior spinal artery

feeded by the anterior radiculomedullary artery from the segmental artery. So, in this patient, in fact, we start the coiling exactly at the seat of this level, we start to coil the segmental artery that feeds the anterior spinal artery.

So, normally we find this artery of the Th 9 L1, and you can see here we go upwards and downwards. We have some challenges with aneurysm sac enlargement, in this case, we use this technique to open the angle of the catheter, we can use also deflectable steerable sheath

in order to reach the segmental artery. And you can see here our results, again, I just will go fast through those, we have treated 57 patients, most of them were Type II, Type III aortic aneurysms. We have found in median nine patent segmental artery

at the level of the aorta to be treated, between 2 and 26, and we have coiled in multiple sessions with a mean interval of 60 days between the sessions. No sooner than seven days we perform the complete exclusion of the aneurysm

in order to let the collateral to develop, and you can see our result: at 30 days we had no spinal cord ischemia. So I can conclude that our first experience suggest that MISACE is feasible, safe, and effective, but segmental artery coiling in thoracoabdominal aneurysm

can be challenging, it's a new field with many open questions, and I looking forward for the results with PAPA_ARTiS study. Thank you a lot.

- I'd like to thank Dr. Veith for this kind invitation and the committee as well. So these are my disclosures, there's none. So for a quick background regarding closure devices. Vascular closure devices have been around

for almost 20 years, various types. Manual compression in most studies have always been shown to be superior to vascular closure devices mainly because there's been no ideal device that's been innovated to be able

to handle all sorts of anatomies, which include calcified vessels, soft plaque, etc. So in this particular talk we wanted to look at to two particular devices. One is the Vascade vascular closure device

made by Cardiva and the other is the CELT arterial closure device made by Vasorum in Ireland. Both these devices are somewhat similar in that they both use a disc. The Vascade has a nitinol disc

as you can see here that's used out here to adhere to the interior common femoral artery wall. And then once tension is applied, a series of steps is involved to deploy the collagen plug

directly on to the artery which then allows it to expand over a period of time. The CELT is similar in that it also uses a stainless steel disc as you can see here. Requires tension up against the interior wall of the common femoral artery.

Nice and tight and then you screw on the top end of the device on to the interior wall of the artery creating a nice little cylinder that compresses both walls of artery. As far as comparability is concerned between the two devices you can see

here that they're both extravascular, one's nitinol, one's stainless steel. One uses a collagen material, the other uses an external clip in a spindle-type fashion. Both require about, anywhere between three to seven minutes of pressure

to essentially stop the tract ooze. But the key differences between the two devices, is the amount of time it takes for patients to ambulate. So the ambulation time is two hours roughly for Vascade, whereas for a CELT device

it's anywhere from being immediate off the table at the cath lab room to about 20 minutes. The data for Vascade was essentially showing the RESPECT trial which I'll summarize here, With 420 patients that was a randomized trial

to other manual compression or the device itself. The mean points of this is that the hemostasis time was about three minutes versus 21 minutes for manual compression. And time to ambulation was about 3.2 hours versus 5.7 hours.

No major complications were encountered. There were 1.1% of minor complications in the Vascade versus 7% in the manual compression arm. This was actually the first trial that showed that a actual closure devices

had better results than manual compression. The main limitations in the trial didn't involved complex femoral anatomy and renal insufficiency patients which were excluded. The CELT ACD trial involved 207 patients that were randomized to CELT or to manual

compression at five centers. Time to hemostasis was anywhere between zero minutes on average versus eight minutes in the manual compression arm. There was one complication assessed at 30 days and that was a distal embolization that occurred

early on after the deployment with a successfully retrieved percutaneously with a snare. So complication rate in this particular trial was 0.7% versus 0% for manual compression. So what are some pros and cons with the Vascade device?

Well you can see the list of pros there. The thing to keep in mind is that it is extravascular, it is absorbable, it's safe, low pain tolerance with this and the restick is definitely possible. As far as the cons are involved.

The conventional bedrest time is anywhere between two to three hours. It is a passive closure device and it can create some scarring when surgical exploration is necessary on surgical dissections.

The key thing also is you can not visualize the plug after deployment. The pros and cons of the CELT ACD device. You can see is the key is the instant definitive closure that's achieved with this particular device, especially in

calcified arteries as well. Very easy to visualize under fluoroscopy and ultrasound. It can be used in both antegrade and retrograde approaches. The key cons are that it's a permanent implant.

So it's like a star closed devised, little piece of stainless steel that sits behind. There's a small learning curve with the device. And of course there's a little bit of discomfort associated with the cinching under the (mumbles) tissue.

So we looked at our own experience with both devices at the Christie Clinic. We looked at Vascade with approximately 300 consecutive patients and we assessed their time to hemostasis, their time to ambulation,

and their time to discharge, as well as the device success and minor and major complications. And the key things to go over here is that the time to hemostasis was about 4.7 minutes for Vascade, at 2.1 hours for ambulation, and roughly an average

of 2.4 hours for discharge. The device success was 99.3% with a minor complication rate of .02% which we have four hematomas and two device failures requiring manual compression. The CELT ACD device we also similarly did

a non-randomized perspective single center trial assessing the same factors and assessing the patients at seven days. We had 400 consecutive patients enrolled. And you can see we did 232 retrograde. We did a little bit something different

with this one, we did we 168 antegrade but we also did direct punctures to the SFA both at the proximal and the mid-segments of the SFA. And the time to hemostasis in this particular situation was 3.8 minutes,

ambulation was 18.3 minutes, and discharge was at 38.4 minutes. We did have two minor complications. One of which was a mal-deployment of the device requiring manual compression. And the second one was a major complication

which was an embolization of the device immediately after deployment which was done successfully snared through an eighth front sheath. So in conclusion both devices are safe and effective and used for both

antegrade and retrograde access. They're definitely comparable when it comes, from the standpoint of both devices (mumbles) manual compression and they're definitely really cost effective in that they definitely do increase the

throughput in the cath lab allowing us to be able to move patients through our cath lab in a relatively quick fashion. Thank you for your attention.

- I'm giving this talk for Thomas who has better things to do as he's about to become father of his first boy so that's the reason I'm standing here and I have no disclosures related to this topic and the purpose of this talk is really to tell you about the simple technique

that is the manual thromboaspiration that we use a lot in Nuremberg for acute limb ischemia besides this you can see thrombolysis and the more sophisticated mechanical thrombectomies. So this is the equipment you need

for this thromboaspiration. An eight French sheath with a removable valve and depending on the location of the aspiration we use either an eight French or a six French aspiration catheter with an end-hole and with a 50cc syringe you can do the job.

Technically we try to not pass or cross the thrombus to avoid distal embolization and for the rest it's very smooth and simple technique where you withdraw your catheter under continuous aspiration and then you can remove the clot and if the clot is fairly thick

you can remove the valve to get larger thrombus out. The advantage of this technique is you can repeat the sequence as many times as you want and obviously with your control angiogram you can do an additional PTA or stenting if needed. You can see that we use it quite a lot here

in more than 400 patients both for viable acute limb ischemia and threatened limb ischemia and the outcomes are fairly good with a higher than 90% technical success and you can see the data with regard to additional PTA

and stenting and sometimes open surgery. The one complication if you achieve it completely by endovascular and percutaneous means is the access site hematoma in 5.2% only 2% of those required a surgical revision. A quick two cases that you can see here

with the obvious acute limb ischemia and after a few passages with the catheter and the thromboaspiration you can see the restoration of the flow into the three coronal vessels so here with the popliteal and the fibular artery and this is another case fairly similar

but you can see here that we needed additional PTA and stenting to achieve a correct outflow in this patient. Besides this cheap and easy technique there are of course more sophisticated industrialized techniques like the mechanical thrombectomy devices that we all know.

I'm showing you very quickly the INDIGO Penumbra and these are all working with an aspiration pump or the Angiojet which works with a venturi effect and a fragmentation of the thrombus by flushing it. They'll all work and there is one very good study

on the Angiojet here and you can see that additional use thrombolysis to achieve and good job so to conclude really we like the manual thromboaspiration as a first resort in many of our acute limb ischemia patient because, as I said, it's cheap and it's very available

and we actually leave the more sophisticated treatment techniques as a second choice and obviously all these techniques are complimentary. You can use thrombolysis interoperatively PTA stenting as shown. Thank you very much for you attention.

- So, my talk now, is about treating with multiple agents and I think there is a lot of consensus here. We have multiple agents out there, you normally use liquid agents, and you combine it with some mechanical thing for flow modulation.

So you can use coils or plugs, but you never use something like particles. That's not really, in any way, worth while. And, I knew what my role is here. My role is I'm always here as a counter-part to all these alcohol things, and we will discuss it later.

We have, and I just want to make one point here. You have to use this thing, this Onyx, or Squid, or PHIL- or whatever it is. You have to actively inject it, and you have to know the technique, and you have to do it like pressure cooker or plug and push technique, otherwise it won't work.

Otherwise, you will make things worse. So, just show me some failed cases where you used the plug and push techniques. Don't show me cases where you did it wrongly. Of course, that doesn't prove anything. Um, and I think, well you know all of this about

the plug and push technique, here, and I want to go too much into the details. I just want to show you two examples here, and this ght-sided, it's a dominantly venous thing,

it's something that we really like to treat because we'll cure it. There is definitely, regardless with which technique you do, you occlude the vein- you will cure the patient. But, the patient was totally Asymptomatic at the time. So I decided, we wait, he's asymptomatic.

Even if it's something we can do, you mustn't do everything. And, that's interesting because this was 2007, and this is how it looked like in April this year. So, 11 year later, you can see a huge... oh we'll have to go back because it's interesting. You see it, the same patient, after 11 years,

and this is something that is speaking for your hypothesis. That, is an acquired thing, because he's quite old. He's like 40ish/50ish this patient. And he is for us, for an AVM patient, it's brutally old. I mean, I'm really thinking about 'should I treat him?'. (Audience laughs)

Yeah, you know, and this is after 11 years, the sort of venous flow-related aneurysm, it really dilated, and it not only dilated, the venous outflow dilated as well. And, this is how it looked like, here at the perineum pod. You can see, he developed some draining veins

under pressure here at the perineum. So, this is something you have to treat now. I think we all agree, and, my topic here is to do it in the mixture, you can see of course, this is a predominantly venous AVM. Here is the one venous outflow, and the other venous outflow

is up there, it's fed by multiple feeders from the right iliac and of course, at this stage, even from the left internal iliac artery. This is one venous drainage, and this is the other venous drainage. First of all, you occlude the venous drainage.

Because, I don't want to fill this giant aneurysm with coils. You could've done it, and it would be obviously successful. So this is an occlusion of the distal part, with coils, and the proximal venous outflow occluded with an Amplatzer Vascular plug, and this is retrograde

transvenously injection of the venous pouch. So, there was almost no outflow, but there was a little bit left. So, you have to go for it, because otherwise, it will be recanalized. So then, I injected from the transarterial,

so, this is why I have to call about mixed agents. So, we put in an AVP, we put in plugs. And this is some, in this case, squid, in into the venous pouch, and that's at the end.

That's the result in one session. First, block the venous outflow, and then push enough material in that it clots, and its done. So, you don't need to use any ethanol in these cases. You could just do it, just with coils,

but you'd need hundreds. I prefer to do it with some coils, or a plug into the venous outflow. Then I'd push some Onyx into the venous cast, it thrombosis, and it's done, and it's very safe. This is another mixed method,

this is really a failed Onyx case. And, I call this a failed Onyx case, because its really properly done. It's not just some arteries filled with Onyx, but you see some residual like capillary shunts there. And, if you have this small vessel type, or type 4 AVM,

you can never cure it with Onyx alone. Or, I'm not even doing it. This is an ethanol case, you can just kill it, and with this 50/50 mixture, this is very helpful. And, what I do in these, formally type three b, with (mumbles).

I treat them with the safest way I know, with a polymerizing agent, and at the end, if it's necessary, you have these (undistinguishable), you add some ethanol injections, I call that finishing, and then it's done as well. So, at the end, and this is the most important slide here.

We do have different agents, and sometimes we have to mix them. And, ethanol is not everything. A type one, direct connection, whatever classification system you use, a type one, a direct connection,

you can use any mechanical things, and you will cure it. A dominant venous outflow thing, you have to occlude the venous side, and you have to occlude it as close to the arteriovenous connections, or whatever you call it, as you can, and you will be successful.

And, from my point of view, I never use ethanol in these cases, because I think it's dangerous. But anyway, you have to occlude the veins, and in the type three ones, you have to use ethanol in some cases, I call that finishing, before I've done something safer.

And, maybe, we have something more like the MEK1 Inhibitors, that's really something I hope that will be helpful for all of us. And, of course, if you use the wrong technique, and if you use Onyx like glue, you will make things worse. Thanks for your attention.

(Audience claps) - [Audience member One] I just wanted to make one comment, when you talk about ethanol, using it as finishing, I would sort of, think that more as the start of the case. In that, you're doing all of these other things, which I do too, to shut down flow.

What you are doing is occupying space within the venous side of things, what you are doing it basically maximizing the concentration of ethanol to where at's the definitive part of the therapy, and that everything you're doing

up to that point... Like, I mean, granted some of them you're curing without it. But, I mean, when you're giving that ethanol then, I've had a number of cases where you're sort of filling that type two- B Nitus or type three situation, what you then are actually enveloping that with the ethanol,

it's actually going to where it's exactly meant to go, and that's the critical manoeuvre. - (Lecturer) That would be true, if the only cases where it was successful were with a mixture. - [Audience Member] Mhm. - But this is for just for maybe 30% of the patients.

- Well, I guess what I'm trying to say is if, that up to that point on those cases though, it seems that the ethanol is the thing that's probably finishing the job. I mean, help me out here Wayne. (Laughter)

- [Wayne] We will have that discussion later. We will have that discussion later. - [Audience Member two] (mumbling) Can't we stick to a specification lets say (mumbles), not because I like it so much, but type two b, three a, three b, if we throw in some other specifications then

we can (mumbles). - [Audience Member One] But then, I just have to say, please publish it. Because you can't look up everywhere, there is no publication, so if you publish it I could use it.

- Thank you for asking me to speak. Thank you Dr Veith. I have no disclosures. I'm going to start with a quick case again of a 70 year old female presented with right lower extremity rest pain and non-healing wound at the right first toe

and left lower extremity claudication. She had non-palpable femoral and distal pulses, her ABIs were calcified but she had decreased wave forms. Prior anterior gram showed the following extensive aortoiliac occlusive disease due to the small size we went ahead and did a CT scan and confirmed.

She had a very small aorta measuring 14 millimeters in outer diameter and circumferential calcium of her aorta as well as proximal common iliac arteries. Due to this we treated her with a right common femoral artery cutdown and an antegrade approach to her SFA occlusion with a stent.

We then converted the sheath to a retrograde approach, place a percutaneous left common femoral artery access and then placed an Endologix AFX device with a 23 millimeter main body at the aortic bifurcation. We then ballooned both the aorta and iliac arteries and then placed bilateral balloon expandable

kissing iliac stents to stent the outflow. Here is our pre, intra, and post operative films. She did well. Her rest pain resolved, her first toe amputation healed, we followed her for about 10 months. She also has an AV access and had a left arterial steel

on a left upper extremity so last week I was able to undergo repeat arteriogram and this is at 10 months out. We can see that he stent remains open with good flow and no evidence of in stent stenosis. There's very little literature about using endografts for occlusive disease.

Van Haren looked at 10 patients with TASC-D lesions that were felt to be high risk for aorta bifem using the Endologix AFX device. And noted 100% technical success rate. Eight patients did require additional stent placements. There was 100% resolution of the symptoms

with improved ABIs bilaterally. At 40 months follow up there's a primary patency rate of 80% and secondary of 100% with one acute limb occlusion. Zander et all, using the Excluder prothesis, looked at 14 high risk patients for aorta bifem with TASC-C and D lesions of the aorta.

Similarly they noted 100% technical success. Nine patients required additional stenting, all patients had resolution of their symptoms and improvement of their ABIs. At 62 months follow up they noted a primary patency rate of 85% and secondary of 100

with two acute limb occlusions. The indications for this procedure in general are symptomatic patient with a TASC C or D lesion that's felt to either be a high operative risk for aorta bifem or have a significantly calcified aorta where clamping would be difficult as we saw in our patient.

These patients are usually being considered for axillary bifemoral bypass. Some technical tips. Access can be done percutaneously through a cutdown. I do recommend a cutdown if there's femoral disease so you can preform a femoral endarterectomy and

profundaplasty at the same time. Brachial access is also an alternative option. Due to the small size and disease vessels, graft placement may be difficult and may require predilation with either the endograft sheath dilator or high-pressure balloon.

In calcified vessels you may need to place covered stents in order to pass the graft to avoid rupture. Due to the poor radial force of endografts, the graft must be ballooned after placement with either an aortic occlusion balloon but usually high-pressure balloons are needed.

It usually also needs to be reinforced the outflow with either self-expanding or balloon expandable stents to prevent limb occlusion. Some precautions. If the vessels are calcified and tortuous again there may be difficult graft delivery.

In patients with occluded vessels standard techniques for crossing can be used, however will require pre-dilation before endograft positioning. If you have a sub intimal cannulation this does put the vessel at risk for rupture during

balloon dilation. Small aortic diameters may occlude limbs particularly using modular devices. And most importantly, the outflow must be optimized using stents distally if needed in the iliac arteries, but even more importantly, assuring that you've

treated the femoral artery and outflow to the profunda. Despite these good results, endograft use for occlusive disease is off label use and therefor not reimbursed. In comparison to open stents, endograft use is expensive and may not be cost effective. There's no current studies looking

into the cost/benefit ratio. Thank you.

- [Doctor] Thank you Tom and thanks Dr Veith for the invitation to be here again. These are my disclosures, so hypogastric embolization is not benign, patients can develop buttock claudication, higher after bilateral sacrifice, it can be persistent in up to half of patients. Sexual dysfunction can also occur, and we know that

there can be catastrophic complications but fortunately they're relatively rare. So now these are avoidable, we no longer have to coil and cover in many patients and we can preserve internal iliac's with iliac branch devices like you just heard. We had previously published the results of looking from

the pivotal trial, looking at the Gore IBE device with the six month primary end point showing zero aneurysm-related morality, high rates of technical success, 95% patency of the internal iliac limb, no type one or type three endoleaks and 98% freedom from reintervention. Importantly on the side of the iliac branch device, there

was prevention of new-onset of buttock claudication in all patients, and importantly also on the contralateral side in patients with bilateral aneurysms that were sacrificed, the incidents in a prospect of trial of the development of buttock claudication was 28%, confirming the data from those prior series.

And this is in line with the results of EVAR using iliac branch device published by many others showing low rates of mortality, high rates of technical success and also good patency of the devices. In press now we have results with follow-up out through two years, in the Gore IBE trial, we also compared

those findings to outcomes in a real world experience from the great registry, so 98 patients from the pivotal and continued access arm's of the IBE trial and also 92 patients who underwent treatment with the Gore IBE device in the great registry giving us 190 patients with 207 IBE devices implanted.

Follow-up was up to three years, it was an longer mean follow-up in the IDE study with the IBE device. Looking at outcomes between the clinical trial and the real world experience, they were very similar. There was no aneurysm-related mortality, there was no recorded new-onset ipsilateral buttock claudication,

this is all from the IDE trial since we didn't have that information in the great registry, and looking at the incidence of reinterventions, it was similar both in the IDE clinical trial experience and also in the great registry as well. Looking at patency of the internal iliac limb, it was

93.6%, both at 12 months and 24 months in the prospective US IBE pivotall trial and importantly all the internal iliac limb occlusions occurred very early in the experience likely due to technical or anatomic factors. When we look at the incidence of type two endoleaks, we had previously noted there was a very high incidence of

type two endoleaks, 60% at one month, this did tail off a bit over time but it was still 35% at two years. A total of five patients in the pivotal IBE trial had a reintervention for type two endoleak through two years, and despite that high incidence of type two endoleak, overall the incidence of aortic aneurysm sac expansion

of more than five millimeters has been rare and low at two and nine percent at 12 and 24 months, and there's been no expansions of the treated common iliac artery aneurysm sac's at either 12 or 24 months. Freedom from reintervention has been quite good, 90.4% through two years in the trial and most of these

re-interventions were type two endoleaks. We now have some additional data out through three years in about two thirds of the patients we have imaging data available now through three years in the pivotal IBE trial, there have been no additional events, device related events reported since the two year data and through three years

we have no recorded type one or type three endoleaks, no aneurysm ruptures, no incidences of migration, very high rates of patency of the external and internal iliac arteries, good freedom from re-intervention and good freedom from common iliac artery aneurysm sac enlargement. And I think, in line with these findings, the guidelines

now from the SVS are to recommend preservation of the internal iliac arteries when ever present and that's a grade 1A recommendation, thank you.

- Thank you. Thank you for the opportunity to present this technique and here are the results. Residual Type B Aortic Dissection in patients previously treated by TEVAR by frozen elephant trunk. It makes a new kind of patients need appropriate treatment.

There might be contraindication to further endovascular repair and these are associate visceral arterial dissection or occlusion, collapsed true lumen if it is relative, connective disorder, young age, excessive tortuosity and multiple renal arteries.

The reverse cactus principle is to implant two additional prosthesis to a main prosthesis very proximal and it is a four branch prosthesis like a cactus reversed and the principle is CSF drainage and potential. Left thoracophreno-laparotomy

and retroperitoneal abdominal aortic approach, left artio-femoral pump, double clamp of the proximal aorta within the endograft and make the proximal anastomosis with the graft while all the rest perfuses on below. Prepare the CT, superior mesenteric

and left renal at its origin outside the aorta and the ligature and section of the celiac trunk at its origin and anastomosis with one side-branch of the graft and then do the same with the other branches progressively while all the rest of the aneurysm is perfused

from below. Open the aorta, connect the intercostals and the right renal artery and make the distal anastomosis. So this is the double clamping of the proximal aorta and you can predict the presence of the endograft and so you have a proximal stamp.

A very firm proximal stamp when you can make the proximal anastomosis and you clamp the proximal anastomosis like blocked and so you have no ischemia and neither visceral nor spinal cord ischemia. You cut the celiac.

In this case the celiac was dissected, you identify the lumen by clamping alternately from one to the other side and you see there is the true lumen so you identify the true lumen and you suture it to this then you clamp the celiac trunk.

You do the same with the mesenteric artery and with the renal artery and then you open the sac and you perfuse the intercostals with an additional pump if necessary and after you are connected you are ready to do the distal anastomosis

and this is the final results. You see that it fits very well the anatomy into intercostal you see intercostal, intercostal and here are some examples. You see how the harmonic and the intercostals, posterior.

And so the early results were only a few patients deserved this operation but technical success was obtained in all cases. Two to six additional branches for each reconstruction. No 30 day mortality, reintervention or acute renal failure.

Spinal cord ischemia was reported unfortunately in one patient and it's a long operation but the intra-operative blood loss is contained for this kind of operation and the mean ICU stay was for 4.2 day. This is the curve of creatinine

which is a really very stable and all patients recovered within the six post recovery day. At one year reintervention was null. No patients developed late-onset renal failure. All visceral branches were present. We lost two intercostals without consequences.

In conclusion, residual type A aortic dissection is a challenging disease. The reverse cactus operation is no need for rush, it fits all anatomies, fixes associated visceral arterial disease, contains blood loss, great hemodynamic and metabolic stability

and satisfactory one year results. Thank you for your attention.

- Thank you very much Mr. Chairman. Thank you very much Dr. Veith and Jackie and her team. Aortic thrombus is not the same as endograft thrombus. So I will talk about them separately. And these aortic conditions are rarely causing embolic events, while aortic mural thrombus may cause macro-embolization

and shaggy aorta often cause micro-embolization. And this is the topic of this talk. So aortic mural thrombus develops in the absence of pre-existing aortic disease and can be nonpedunculated versus sessile. It is uncommon with an incidence of 0.45%

in this great autopsy registry, however, leading in 17% of cases to embolization. Therefore, it must be considered in the differential diagnosis of embolic events. In 50% of the patients with aortic mural thrombus, there is a coagulation disorder present.

So imaging of the complete aorta and a hyper-coagulability workup should be done in every patient with aortic mural thrombus. Thrombus in female patients and in younger patients have a higher risk of embolization just as mobile thrombus and thrombus at noncalcified insertion sites.

In symptomatic thrombus in the aorta, you have to treat the emboli first and subsequently the aorta. And this is the largest series comparing anticoagulation along with open aortic surgery, favoring aortic surgery, because of a lower recurrence and lower embolization

rates than anticoagulation alone. However, in a more recent paper TEVAR demonstrated a 93% of thrombus regression, resolution or exclusion, while there was persistent thrombus in 31% of open surgery and medical treatments patients leading for patients to crossover to TEVAR.

So TEVAR or EVAR performs best. And this may lead to suggesting that primary interventional treatments could be considered even for asymptomatic mural thrombus. However, anticoagulation should be reserved for high-risk patients or difficult thrombus locations.

This is a CT scan we have all seen in our practice, in the follow-up of an infrarenal EVAR. Because mural thrombus in endograft is common and mostly develops in the first year post EVAR. - [Man] I don't know, maybe. - It is not associated with age, smoking, malignancy,

anticoagulation or antiplatelet therapy, but may be with coagulation disorders. However, endograft thrombus is associated with a short and wide infrarenal neck and with preoperative thrombus loads. Moreover from a graft perspective,

polyester-coated devices are associated with a higher incidence of endograft from thrombus in analogy with open surgery. This may also be the cause because of hemodynamic properties of these polyester-coated devices, which are usually longer body length,

with smaller limb diameters. This is also the reason why the AUIs are associated with endograft thrombus and a barrel-like configuration of a main body and finally a bell-bottom configuration. So risk factors are aneurysm-related, graft related, and possibly coagulation disorders.

Is mural thrombus associated with thrombo-embolic complications in an endograft? The answer is no, according to these five papers and a recent systematic review. So endograft thrombus rarely leads to thromboembolic complications.

However, thrombus lining in the main body may be less harmful than in the iliac limb. If asymptomatic, consider follow-up. - [Man] With heparin because. - However if limb kinking stenosis or outflow limitations are present, then treatment is advised to prevent occlusion.

And if there is claudication symptomatically then anticoagulation or endograft relining may be considered. This patient presented with an ischemic limb, an ischemic left limb, two years after his EVAR. And you will appreciate on the CT a whole lot

of thrombus in the left stent graft. He was, this thrombus was lodged into the popliteal artery and he was therefore treated with thrombectomy. And in the second stage with relining of the left limb. So if symptomatic and thromboembolic events,

then endograft relining is advised. And if relining, then consider to reline with a less thrombogenic device at BTFE (mumbles). Thank you very much for your attention.

- Thank you Giancarlo. This is my disclosure. This is our experience on the first hybrid foot vein arterialization in no-option patients with critical limb ischemia. 36 patients, we selected a patient according to an acceptable heart function,

acceptable life expectancy. On the foot, we wanted to have critical limb ischemia with tissue lesion, wifi ischemia grade 3, absence of infection. On the Angio, the baseline Angio, we decided to treat patient with disease

of the foot arteries considered not revascularization by means of angioplasty or distal bypass. We have our population consisting 35 patient, predominantly diabetic, 68 years old mean age, and 36 limbs. The bypass was done a the in the majority

of the cases with a prox anastomosis on the P3 segment of the popliteal artery. It was in 72% of the cases great saphenous vein, and the distal anastomosis was done in half of the cases according to the mutirangura technique on the posterior tibial vein, and half

of the cases according to the lengua technique on the medial marginal vein. After the bypass, we made the one, the first post bypass procedure with endovascular valve destruction through high pressure POBA.

The second procedure later with focalization of blood flow to the wound and embolization of proximal foot vein collaterals stealing blood and eventually maintenance procedure in case of stenosis occlusions of the arterialized circuit detected by duplex scan.

After the arterialization, we applied flow-guided and tension-free foot surgery, waiting for swelling, waiting for arterialized network expansion, respecting the arterialized circuit, especially the forefoot cross using a tension free surgery to avoid focal ischemia.

This is an example of a young patient with type two diabetes and toes gangrene. On the left side you can see a baseline bare x-ray demonstrating the classification of everything. On the right side you can see that big vessel artery in some way opened, but in the distality

we have a very low blood flow and the classification of all these vessels occludes completely. The foot, this is the baseline edge of the foot, you can see how there is nothing really going distally. This is after the arterialization. We made the arterialization of the great saphenous vein.

This is a medial marginal vein and obviously we found two main problems. So the first one is the distilling of blood by this big proximal circuit at the ankle level and the second one occlusion by valve of the distal medial marginal vein.

So we have treated both this, this is the final result with data blood flow going to the forefoot, and this is the patient about four months later. Now, why does arterialization of the foot vein function? I want to propose you two hypothesis.

The first, a mechanical hypothesis. Arterial and hydrostatic pressure force vein valves leading to progressive valve incompetence, distal veins recruitment, and finally, direct tissue nutrition by reverse blood flow. 1906 Alexis Carrel made some experiments on dogs with an arteriovenous fistula at the femoral level.

In this he wrote that the valves prevent, at first, the reversion of circulation in the veins, but finally after three hour it passes through the capillaries, and the arteries are filled with dark blood. So he demonstrated that practically complete reversal

of the circulation is established at about three hours after the operation. This is an example of a patient with an arterialization, with an injector contrast dye here, and the injector after an ankle tourniquet higher pressure expands the vein network.

The second hypothesis is a biological hypothesis, vein wall shear stress promotes a global remodeling and or neoangiogenesis of the vascular system of the foot, creating a new distribution system. This images published by Lengua who died this year on March, and he was the first one understand

that a temporal venous arterialization of the diabetic foot can be sufficient for healing. This is an example of a patient with a desert foot at the beginning, the arterialized circuit well functioning and some months later after the occlusion of the arterialized circuit, you can see

how the vascularity is totally different than the beginning. Our results were of a 69% of limb salvage at 10.8 months follow-up. The good result was correlated with the patency of the bypass, the primary, secondary patency were both correlated with this.

The early failure of the bypass always led to major amputation. Hybrid funding valuation adjustment can be proposed in no-option CLI patients as the last attempt to avoid major amputation. The low patency rate of the arterialized circuit

was a key factor in reducing success rate and I can explain it with our learning curve and the crude method used to break distal vein valves leading to spasm, early thrombosis and restenosis. Thank you very much for your attention.

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