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Superior Femoral Artery Occlusion||89|Male
Superior Femoral Artery Occlusion||89|Male
2016accessaneurysmangiogramarteryballooncalcificationcapturecathetercoronarycreatefemoralflourofluoroglidewirelumenmagnifiedmicromicropunctureobliqueocclusionPatentperonealpoplitealposteriorpushSIRsnarestenosisstentsubintimaltibialultrasoundwirewires
Update On The Advantages, Limitations And Midterm Results With The Terumo Aortic 3 Branch Arch Device: What Lesions Can It Treat
Update On The Advantages, Limitations And Midterm Results With The Terumo Aortic 3 Branch Arch Device: What Lesions Can It Treat
4 branch CMD TAAA deviceacuteAscending Graft Replacementcardiac arrestRelayBranchRepair segment with CMD Cuffruptured type A dissection w/ tamponadestent graft systemTerumo Aortictherapeutic
Vacuum Assisted Thrombectomy With The Penumbra Indigo System For Visceral And Lower Limb Artery Occlusions
Vacuum Assisted Thrombectomy With The Penumbra Indigo System For Visceral And Lower Limb Artery Occlusions
Aorto-Renal BypassAspiration SystemGore Viabahn VBX (Gore Medical)PenumbraPenumbra’s Indigotherapeutic
Which Stent Would I Use In: Malignancy, Across Inguinal Ligament, IVC, Into Profunda Femoris Vein
Which Stent Would I Use In: Malignancy, Across Inguinal Ligament, IVC, Into Profunda Femoris Vein
Bardo Venovo / Medtronic ABRE / Optimed SInus oblique / Veniti ViciCook Zilver VenaMedtronicstent
Terumo Aortic Relay Thoracic Endograft For TEVAR In Complex Aortic Pathology With Angles >90°: Advantages And Results
Terumo Aortic Relay Thoracic Endograft For TEVAR In Complex Aortic Pathology With Angles >90°: Advantages And Results
Gore Tag (Gore Medical) / Valiant (Medtronic) / Zenith Alpha (Cook Medical)RelayPlusstent graft systemTerumo Aortictherapeutic
Value Of Parallel Grafts To Treat Chronic TBADs With Extensive TAAAs: Technical Tips And Results
Value Of Parallel Grafts To Treat Chronic TBADs With Extensive TAAAs: Technical Tips And Results
GORE MedicalGORE VIABAHNL EIA-IIA bypassleft carotid subclavian bypassstent graft systemTBAD with TAAAtherapeutic
Going Rogue: Off The Grid Venous Malformation Sclerotherapeutic Techniques
Going Rogue: Off The Grid Venous Malformation Sclerotherapeutic Techniques
coil embolizationPersisting Venous MalformationsclerotherapyTherapeutic / Diagnostic
Octopus Technique To Treat Urgent Or Ruptured TAAAs With OTS Components: What Is It, Technical Tips And Results
Octopus Technique To Treat Urgent Or Ruptured TAAAs With OTS Components: What Is It, Technical Tips And Results
6.8 cm TAAAGORE MedicalGore Viabahn VBXOctopus Endovascular Techniquestent graft systemtherapeuticviabahn
Transcript

88-year old male, non-healing ulcers,

and most of our treatment indications are patients with critical limb ischemia for non-healing wounds, some rest pain. We rarely ever treat claudication. They're either gangrene, or ulcers, or pre-amputation, planned amputation,

to make sure that the amputation heals. This patient initially got the angiogram, planned the treatment, but had a CVA. Discharged, came back awhile later. According to the son, the wound was getting

worse, and then decided to bring his father to the hospital for the wounds. And then he's feeling better in general, but the wound, foot pain is getting worse, etc., he's not doing well in that regard. He's about to lose his leg.

So these are some history, I'm gonna skip these. We'll go to the case. This is his left lower extremity that we treated. I'm not gonna go into that one.

He has complete occlusion of the SFA, and we did our access on the flouro to make sure we don't go through this stent graft here. We always check with our accesses, you don't wanna get a high access. I just saw a complication from a high access

earlier today that turned into a big mess, and eventually the patient died. It's simple as this, you should always check. Our practice is we put our micropuncture and put our wire in. Always get a fluoro image,

making sure that we're in the mid cam of it, it takes just a few seconds. If you're too high, too low it may become issue. >> You use ultrasound much for access? >> No, we use flouro. We use ultrasound sometimes on difficult

patients. We use flouro, but we check with fluoro before we proceed with the sheath. So if this access was too high, what I usually do is I just leave the wire in there as a target.

In this patient, you have the calcification still, and just use the micropuncture needle to stick exactly where I need to be. So after getting access, this is our angiogram. [BLANK_AUDIO] So it's heavily calcified, deep femoral disease, SFA is occlusive,

multiple calcifications. Going further down, not much flow or collaterals. [BLANK_AUDIO] This is just PlayView, and in addition to everything else patient does have a popliteal aneurysm which is thrombosed,

that becomes important. Has anyone done a chronic occlusion treatment through a popliteal artery aneurysm? Okay, so I thought this was interesting. So sometimes you think something is interesting, and ten people

have done it already. So this is below the knee area. We do have, [UNKNOWN] Going well for him. They're not the most healthiest, but he has an AT, peroneal and a PT.

They are kind of diseased, especially AT is severely diseased, but it goes all the way down to the foot. So we do assessment of the whole leg from aorta to the foot, before we start because all those things that you're gonna do, things may go wrong, etc. You wanna know

where your starting point was, and then to make sure you made things worse or better. So this is at the level of the foot. Kind of decent actually, better than most of our patients at this level. So we went ahead and got a magnified image to see where we're going,

so going to the SFA. Our usual technique is use a glidewire and a Berenstein catheter. Angiographic Berenstein catheter, we just try to go through. If it doesn't work then you try to use more advanced tools, or

dedicated tools like a Quick-Cross or a Zig Zag, some sort of Crossing catheter. Sometimes 014 or 018 wires, either V-18, V-14 or PT Graphix, otherwise there's a lot of them out there. All companies provide these to you, so whatever you like should work.

>> Gonna stop you for a second there. What do you guys normally for your fem-pop disease occlusions, let's say? What is your first go-to wire? Do you start O35, or do you?

>> O35, the LLT. >> Same, same. Yeah. >> I like to use the 014. I guess I'm the anomaly. >> Okay.

So just further down, as you get in there, you can see how irregular it is. There are areas of very high grade stenosis, maybe occlusions, etc., but it looks patent at least upto a level, and then you have the total occlusion with the collaterals around it that's

typical. And this is just kind of a video showing how you may get stuck at one level with the wire, just a glidewire actually. It's usually kind of my go-to wire in these scenarios. So sometimes just the wire angle doesn't work, so you have to get the

catheter in there. I use this a lot, both catheter with the wire. The combination gives you a little additional kind of ability to do stuff, and by approaching the catheter over there, you pass one of them. And this was just one of the probably ten we did until we reached

from the femoral to the popliteal, it took about an hour to get to that level. Just to demonstrate the things that you may come across. And eventually we went subintimal,

sometimes it's gonna go subintimal. There is no reason to fight it, you just have to go where it goes because the lumen may not be just crossable. So we fell into this popliteal artery aneurysm, so it's really

not gonna go anywhere from here. We ballooned everything to create a track because it's hard to push from the subintima without dilating the areas. I always balloon it with two or three balloons. So if you're gonna get another device down the road, you don't have pushability problems.

And after doing this, we were kind of floating in there, it's not going anywhere, and we ballooned it a little larger just to create a channel. And there was no way we were gonna be able to go distally from the upper and lower approach. So we got access from the lower extremity,

this is the AT after the pedal access. You can see that it's actually, this is diseased quite a bit. It doesn't look it. if you don't look at a magnified view, sometimes you don't recognize these subtle lesions.

I'd recommend everyone to get magnified images of tibial arteries. You may recanalize the whole tibial artery if you just do a completely de-mag image look at it. It's flowing fine, but there may be a few stenosis in there, tiny little ones, 90% etc. For wound healing, it's gonna become an issue.

You wanna leave no significant stenosis, and getting nice big images will allow you to assess that better. And so we went from below, again same thing. This is a hydro or a selective guidewire. You can see, this

is an issue you're gonna come across. This is I think a PT Graphix wire. So it's like a stenosis in a relatively larger lumen area. The wire doesn't follow, it gets ballooned up. It's not happening.

I changed my wire. I'm very liberal, and I don't think you should persist on something that doesn't work. I've worked with a lot of people, everyone has different approach.

I've seen somebody for example, they would try it with the same wire for about an hour until they give up. If something is not working, just move on. There's a lot of things out there. Don't waste stuff obviously,

you need to be cost-effective. But another added fluoro over here without reaching anywhere is a bigger waste than using another wire. I'm actually sorry, I think wanted to show that, how the other wire worked. So this is the heavy-tipped wire, it just went through with no problem. So on the straight areas,

I use heavy-tipped wires, there's a lot of them out there. But if you're gonna take a turn, this wire will not take a turn. What I do is I come to that angle of the anterior tibial and follow with my Crossing catheter. At that point I go back to GlideTech wire

because this wire is just gonna try to go straight. It's too heavy to reach it. And this is our angiogram at that level, showing the trifurcation kind of diseased, but patent in that area and so we tried to come from below, it's in a different plane.

You can't see how the wires opened it up, so we're subintimal. And we attempted a lot to get connected with the origin of the kind of, I don't know if you can appreciate it, but calcification is here. This is where it's connected, this area with the oblique field. Definite oblique band we had.

It just was coming out, it wasn't going in the right direction. So, attempted a little bit more. We spent quite a bit here with different wires, different catheters. It's just not reaching to the higher level, and you can push as aggressively as you want.

You're in an occlusive space, you're not gonna do harm. Sometimes it will just pop, and I will go through, it's gonna give in. Sometimes it won't happen, but the worst thing is it's not going to happen. So trying different wires, and pushing as much as you can is not

a big deal. So as you can see this is very odd, from the area. So we were set from the AT access, we're just subintimal, and at this point I think we're even outside the artery potentially. Because

subintimal, you're almost adjacent outside, but adjacent to the calcification. In this one, we were way out of the calcification. So what do you do? We have one access, we came back. I'm not gonna kind of go into those parts.

I tried to re-enter that popliteal artery with different, very different catheters, it just goes through the same track. It's just - >> Going sideways or from both sides? >> Well, but we're not able to reach the aneurysm, that's the problem. Our wire is from the AT access that I had, it's just coming out of the

vessel, and we tried different wires. I ballooned that track to create a little different path for myself. I sometimes inflate the balloon, use a rigid wire to push into a

different plane, if your current plane is not working. So that will allow you to maybe find a better path for yourself. Whatever view that it didn't happen from the AT because from the beginning of the distal end of the popliteal artery, we were always coming into the subintimal tract. And again, ballooned those areas, etc., It

didn't work, it didn't work. Then we decided to get an access from the PT. This is our PT access. This is very calcified, so you use fluoro. Most of the time we use ultrasound, but I quite often I also use flouro for this, and you can see that your wire is going through

no problem, and this is further up. So from the posterior tibial access, the reason that I did that is I thought the popliteal artery was more in line with the posterior tibial artery origin, and we were right. You can actually see, now it's actually

in the lumen of the artery over here. [BLANK_AUDIO] And this is our angiogram right there. You can see that the posterior tibial artery is as far as in the lumen of the popliteal, and the other wire is

in this plane, and so that allowed us actually to move a little bit more forward. At this point actually I left, I had to do a radiangle/g next door. Another colleague of mine came in, and he kind of progressed a little bit further. Turba came in and he got into that area. He actually advanced the wire further near the aneurysm by

pushing, pushing. Now we're in the right place, we're following the aneurysm. It's still a problem that with the three dimensionals, those wires could be like way away from each other, but we did oblique fields from the kind of fluoro. At this

location, they were within a centimeter of each other. It opened up a little bit, but it didn't open up enough that it was too far away. [BLANK_AUDIO] So, the next step is, let's move on.

So the next step is to get, sorry. So this is what we have from above injection, and the wire is over there, and what do you do at this stage? Any suggestions?

>> To snare. You snare it. >> Snare from where? >> From top. Get the snare down into the aneurysm, and get the wire from below and just snare it. >> But this is not in the aneurysm.

This is in the subintimal space of the popliteal aneurysm. >> But you can use a different tube, and one different from above and one different from below. >>Mm-mh. >> Make the two balloons one - >> Create a space in between in that area? >> Create the balloons, [INAUDIBLE] >> I don't know if everyone can hear that.

Sorry, it's really loud. That's actually a very good technique that he just mentioned, we use that. It's basically a kissing balloon. If you take two balloons that are in different planes, and usually you just need to overlap a very small part, but that will create a rent in the intimal and allow the wires to communicate.

In my experience, it works about 70 to 80% of the time. It's definitely worth trying cause it's easy. >> Yeah, exactly. Put one balloon here and the other balloon here, try to kind of match those. It may or may not happen. In my experience, I would say 50/50.

And since it's not working all the time, we actually stopped doing that any more. What we do is we just kind of put a snare in there, but how are you gonna get the other wire into the snare? That's the problem. Snare is the easy answer,

you have to snare it otherwise this is not gonna work. But you have to connect the wires, and you have to be able to capture it. >> So you can get an Outback? >> Exactly.

So that's what we do. So we bring an Outback from above, and then we bring the snare from below. Position that over there, and this is our micro snare. Since you're coming from below, you cannot use 75, 1 cm snares,

we have 4mm and 2mm micro snares. Those are the ones that we generally use for this, and open up the snare. And then once you puncture with the Outback, you just gently, kind of gently pull it down to see if you're actually over the needle.

If you're over the needle, then you push the wire out and then take the needle, retract the needle back and capture the wire and move forward. This was kind of testing. You normally want a lot more wire here, longer distance. Because pushing and pulling through Outback, which is a long metal

cannula tracted catheter, is not easy, there is a lot of friction. There's many cases that I lost access, not be able to pull-push at the same time. So you want to make sure that while you're pulling it, it's not pulling, it's actually pushing action. The snare is just gently bringing down

in a kind of coordinated fashion. Okay, we're almost there. Okay, and then this is just the snare going all the way down. Once we got it kind of through and through, we just stented the whole thing with wire band in this case.

Obviously nothing else probably would have worked. Balloons. This is our angiogram, and this is pre and post. In this area, it didn't look great. Time is up, so I'm gonna go really fast.

And this is like, we came from above in this area to treat that. This is subintimal of our initial, so we took that one out. We were actually able to get back into the AT from above, from the true lumen.

We snared that one to make sure we're in the right lumen, and we pulled that out, and what we did is this area was a problem. So we brought a coronary stent here while protecting the tibial peroneal trunk with a balloon from below, and placed the coronary stent and

got this result in the end. Any questions? >> Yeah. >> Go ahead. >> I'm sorry to disagree, whilst it's a fantastic technical result. >> Mm-hm, >> You started off with a very, very heavy calcification and you started out with large popliteal aneurysm. You've been at it for three hours, for four hours, with two access into micro vessels. >> Correct. >> Has he been clinically tested for these devices? >> He was evaluated for a bypass.

If you read the initial story, he's 88. He had a stroke, he was discharged, he received TPA, he doesn't have a vein. I think if you did a prosthetic bypass on this patient, the chances are he would have died. If he made it, yeah.

- Thanks, Stefan and Frank for having me back again this year. These are my disclosures as it pertains to the renal topics here. We all know that renal dysfunction severely impacts survival, whether we're doing open or endovascular aortic repair,

as you see by these publications over the past decade, patients with no dysfunction have a significant advantage in the long term, compared to those patients who suffer acute kidney injury, or go on to be on new hemodialysis. When you look at the literature,

traditionally, through open repair, we see that the post-operative rate of acute kidney injury ranges anywhere from 20 to almost 40 percent, and it doesn't seem to vary whether it's a suprarenal or infrarenal type

of clamp or repair. Chronic renal replacement therapy in this population ranges somewhere between 0 and 3 percent. That really forms a baseline when we want to compare this to the newer techniques such as chimney and fenestrated or branched EVAR.

Now, if you look at the results of the ZFEN versus Zenith AAA trials, and this is published by Gustavo, the acute kidney injury rate is approximately at 25%, acute kidney injury rate being defined as patients, excuse me, greater than 25% change in GFR,

but in one month acute kidney injury rate is 5% for FEVAR and about 9% for EVAR in this study. There's no difference in these rates at two years or five years between the Zenith AAA and the ZFEN devices. What about the progression of patients

with Stage 4 or Stage 5? At two years, it's about the same, 2% versus 3% for EVAR, and at five years, 7 and 8% respectively. Overall, progression to renal failure occurs in about 1.5% of patients in this cohort.

Well, how does that compare to chimney cases, if you look at the Pythagoras and PERICLES studies, there are a limited number of patients, you see in Pythagoras, 128 patients, 92% of them had either one or two chimneys, meaning generally addressing renal arteries in this case,

patency of those grafts was about 96% and there is no real discussion in that manuscript of the degree of acute kidney injury. And in PERICLES registry, however, they report a 17.5% incidence of acute kidney injury post-op,

and a 1.5% incidence of temporary or permanent dialysis. What about if you compare them? This is a publication in 2017, if you look at both of these studies, very similar, 17.8% for acute kidney injury in FEVAR, and about 19% for a chimney.

You have to realize, though, there are more complete repairs in the FEVAR group, and there are more symptomatic patients in the ChEVAR group, so these aren't completely comparable, but you get some idea that they're probably in the general range of one another.

So the real questions, I think, that come up, is, which arteries can you sacrifice? Are renal embolizations impacting patients' overall function? And what is the mid-term impact of branch and fenestrate on volume of your kidneys

and patients' eGFR. We've studie we looked at the incidence and clinical significance of renal infarcts, whether we actually embolized these pre-procedure,

or whether we accidentally covered or intentionally covered an accessory renal artery, what was the outcome of those patients? We see over time, the average renal volume loss, calculated by a CT scan and VAT volume, is about 2.5% if you embolize it

and if you just cover an accessory renal, about 6.4%. But overall, about 4%, didn't change significantly, overall the GFR changed over the lifespan of the first two years of the patient of 0.1, so it wasn't a significant clinical impact on the patient's overall renal function.

Now what about looking at it specifically of what happens when you do branch and fenestrate cases with respect to eGFR and volume of those? We presented this at this past year's SABS, and it is in submission. If you look at the changes of eGFR,

you notice that in the first six months, the patient declines, but not significantly, and then you see in the graph there, it tends to come back up by a year, year and a half. Very similar to what Roy Greenberg published in his initial studies,

but what we did in this study was actually compare it to the age match publications, and you see that eGFR over time was similar to what happens in age-related changes, but we also noticed that 16% of the patients, 9 of 56, had improvement of their eGFR

to greater than 60. Now whether this is just related to the inaccuracy of the eGFR and its variance, or whether we actually improved some renal stenosis, is difficult to tell in this small study. In conclusion, open, fenestrated,

and chimney EVAR procedures are associated with acute kidney injury in approximately 20% of patients. Causes of deterioration are likely multifactorial and may be different for each technique used. Renal infarcts from covering accessory renal arteries

and embolization occur in about a quarter of the patients, and is a small contributor to renal decline over time. Renal decline made after FEVAR is similar to associated with age. Thank you.

- Thank you, Mr. Chairman. Good morning ladies and gentleman. I have nothing to disclose. Reportedly, up to 50 percent of TEVARs need a left subclavian artery coverage. It raises a question should revascularization cover the subclavian artery or not?

It will remain the question throughout the brachiograph available to all of us. SVS guidelines recommend routine revascularization in patients who need elective TEVAR with the left subclavian artery coverage. However, this recommendation

was published almost ten years ago based on the data probably even published earlier. So, we did nationwide in patient database analysis, including 7,773 TEVARs and 17% of them had a left subclavian artery revascularization.

As you can see from this slide, the SVS guideline did affect decision making since it was published in 2009, the left subclavian artery revascularization numbers have been significantly increased, however, it's still less than 20%.

As we mentioned, 50% of patient need coverage, but only less than 20% of patient had a revascularization. In the patient group with left subclavian artery revascularization, then we can see the perioperative mortality and morbidities are higher in the patient

who do not need a revascularization. We subgroup of these patient into Pre- and Post-TEVAR revascularization, as you can see. In a Post-TEVAR left subclavian revascularization group, perioperative mortality and major complications are higher than the patient who had a revascularization before TEVAR.

In terms of open versus endovascular revascularization, endovascular group has fewer mortality rate and major complications. It's safer, but open bypass is more effective, and durable in restoring original profusion. In summary, TEVAR with required left subclavian artery

revascularization is associated with higher rates of perioperative mortality and morbidities. Routine revascularization may not be necessary, however, the risks of left subclavian artery coverage must be carefully evaluated before surgery.

Those risk factors are CABG using LIMA. Left arm AV fistula, AV graft for hemodialysis. Dominant left vertebral artery. Occluded right vertebral artery. Significant bilateral carotid stenosis.

Greater than 20% of thoracic aorta is going to be or has been covered. And a history of open or endovascular aneurysm repair. And internal iliac artery occlusion or it's going to be embolized during the procedure. If a patient with those risk factors,

and then we recommend to have a left subclavian artery revascularization, and it should be performed before TEVAR with lower complications. Thank you very much.

- The only disclosure is the device I'm about to talk to you about this morning, is investigation in the United States. What we can say about Arch Branch Technology is it is not novel or particularly new. Hundreds of these procedures have been performed worldwide, most of the experiences have been dominated by a cook device

and the Terumo-Aortic formerly known as Bolton Medical devices. There is mattering of other experience through Medtronic and Gore devices. As of July of 2018 over 340 device implants have been performed,

and this series has been dominated by the dual branch device but actually three branch constructions have been performed in 25 cases. For the Terumo-Aortic Arch Branch device the experience is slightly less but still significant over 160 device implants have been performed as of November of this year.

A small number of single branch and large majority of 150 cases of the double branch repairs and only two cases of the three branch repairs both of them, I will discuss today and I performed. The Aortic 3-branch Arch Devices is based on the relay MBS platform with two antegrade branches and

a third retrograde branch which is not illustrated here, pointing downwards towards descending thoracic Aorta. The first case is a 59 year old intensivist who presented to me in 2009 with uncomplicated type B aortic dissection. This was being medically managed until 2014 when he sustained a second dissection at this time.

An acute ruptured type A dissection and sustaining emergent repair with an ascending graft. Serial imaging shortly thereafter demonstrated a very rapid growth of the Distal arch to 5.7 cm. This is side by side comparison of the pre type A dissection and the post type A repair dissection.

What you can see is the enlargement of the distal arch and especially the complex septal anatomy that has transformed as initial type B dissection after the type A repair. So, under FDA Compassion Use provision, as well as other other regulatory conditions

that had to be met. A Terumo or formerly Bolton, Aortic 3-branch Arch Branch device was constructed and in December 2014 this was performed. As you can see in this illustration, the two antegrade branches and a third branch

pointing this way for the for the left subclavian artery. And this is the images, the pre-deployment, post-deployment, and the three branches being inserted. At the one month follow up you can see the three arch branches widely patent and complete thrombosis of the

proximal dissection. Approximately a year later he presented with some symptoms of mild claudication and significant left and right arm gradient. What we noted on the CT Angiogram was there was a kink in the participially

supported segment of the mid portion of this 3-branch graft. There was also progressive enlargement of the distal thoracoabdominal segment. Our plan was to perform the, to repair the proximal segment with a custom made cuff as well as repair the thoracoabdominal segment

with this cook CMD thoracoabdominal device. As a 4 year follow up he's working full time. He's arm pressures are symmetric. Serum creatinine is normal. Complete false lumen thrombosis. All arch branches patent.

The second case I'll go over really quickly. 68 year old man, again with acute type A dissection. 6.1 cm aortic arch. Initial plan was a left carotid-subclavian bypass with a TEVAR using a chimney technique. We changed that plan to employ a 3-branch branch repair.

Can you advance this? And you can see this photo. In this particular case because the pre-operative left carotid-subclavian bypass and the extension of the dissection in to the innominate artery we elected to...

utilize the two antegrade branches for the bi-lateral carotid branches and actually utilize the downgoing branch through the- for the right subclavian artery for later access to the thoracoabdominal aorta. On post op day one once again he presented with

an affective co arctation secondary to a kink within the previous surgical graft, sustaining a secondary intervention and a placement of a balloon expandable stent. Current status. On Unfortunately the result is not as fortunate

as the first case. In 15 months he presented with recurrent fevers, multi-focal CVAs from septic emboli. Essentially bacteria endocarditis and he was deemed inoperable and he died. So in conclusion.

Repair of complex arch pathologies is feasible with the 3-branch Relay arch branch device. Experience obviously is very limited. Proper patient selection important. And the third antegrade branch is useful for later thoracoabdominal access.

Thank you.

- Jim, thanks so much, and thanks to Doctor Veith for the opportunity to get involved. Here's my disclosure. So, certainly you don't want to be an expert on limb thromboses, however, it happens. And so, when you see these patients, no longer are we looking at fem-fem,

or even lytics, catheter-directed lytics. So how do we get from screen left to screen right in a single session therapy? Well, as we know, when these patients present, there's several different management options. You can do open thrombectomy with or without

a fem-fem, pharmacomechanical thrombectomy. There's catheter delytic and ultrasound accelerated thrombolytics, and then now, today, we have vacuum-assisted thrombectomy, as we've heard throughout this session, or continuous aspiration thrombectomy,

however you want to mention it. Regardless, when you end up with lytics, this is exactly what you're dealin' with. You're playing with fire, and if we do it long enough, you're going to see this complication. So we've really adopted a clot extraction

instead of a clot dissolution policy at our institution. I think Jim just showed you this technique that is afforded to us by the Indigo thrombectomy system, as you can see here in a Vivo model, this catheter actually does work extremely well.

It'll remove this soft thrombus, as you can see here. My first experience with this was actually for an occluded popliteal stent, as you can see here. We had a occlusion of the standard nitinol stent. This aspiration power was incredibly surprising to me. As you can see, it collapsed the standard nitinol stent.

So at that point, several years ago, we realized how good this device was, and how we want to minimize lytics for our folks. So we started in 2014 and recently this year at the Midwest Vascular forum in Saint Louis, we presented our data.

At that time, we had 73 patients over the years with acute limb ischemia. And here you can see the breakdown. For this presentation I'm going to focus on this cohort here, which is seven. But as you can see, like my panelists here,

we use it for occlusions, for not only occlusions but emboli as well, and also we had one case of an upper extremity embolism that we were able to successfully treat with this device. At that time, again, looking at all 73 patients,

you can see here that it's a very efficacious device. There were a couple folks who needed transfusion and perhaps the blood loss was a little higher than 300. However, as you can see here, the folks who had a blood loss, all five had open adjunctive interventions as well, and the ones who needed transfusion

all had catheter directed lytics as adjunctive therapy. As far as our efficacy endpoints, what we looked at was antegrade flow. As you can see here, oftentimes with your vacuum system thrombectomy, you're able to get antegrade flow. However, intermittently there's also other

adjunctive therapies that we had to use frequently as well. Going back to what, you know, my topic for today, how do you go from screen left to screen right, where here you can see one of our patients who came in. We did a retrograde ipsilateral stick,

crossed the lesion with the wire, then we delivered our eight french Indigo catheter and were able to get, in a single session, as you can see here, antegrade flow. So here's another, all this in one single session therapy. Here's another patient of ours.

As you can see to the left, one of our Gore Excluder limbs had occluded, and again, with single session therapy we were able to provide patency to that occluded right limb. Another case here, you can see one of our other Medtronic grafts.

And what you'll see here as you're looking to the right, here we are with our eight french Indigo catheter, is the separator, which is like a pipe cleaner. And we were able to clear out this clot and provide patency to this

all in a single session therapy. And again, here you can see from left to right how we were able to thrombectomize that limb. So over the years, the last three years, we do about 80 to 90 EVARs a year. During that time period, we have seven patients

come in with limb occlusions. And as you can see here, four of them were chronic, three claudicants and one res-pain, and three of them were acute limb Rutherford one, two A or two B. As you can see here, 42% of the time for these

occluded limbs, we were able to do it with no lytics, not even a pulse spray, nothing, not one drop of lytics. As you can see here, some of them we did have to do it in a single session. What we do is use a McNamara catheter.

We would squirt out, you know, anywhere from, as you can see, 14 to 18 milligrams of lytics, go get a cup of coffee, go make rounds, come back 20 minutes later, then utilize your device. And again, you can see, in a single session therapy we were able to afford patency.

And then finally, you can see here the blood loss was minimal. So this is a safe device. So in conclusion, I think that single session therapy is safe. It can facilitate achieving antegrade flow

in the management of stent graft limb occlusions. And single session therapy is the future of not only stent graft limb occlusions but all acute limb ischemia. Thanks so much.

- Thank you for introduction. Thanks to Frank Veith for the kind invitation to present here our really primarily single-center experience on this new technique. This is my disclosure. So what you really want

in the thromboembolic acute events is a quick flow restoration, avoid lytic therapies, and reduce the risk of bleeding. And this can be achieved by surgery. However, causal directed local thrombolysis

is much less invasive and also give us a panoramic view and topographic view that is very useful in these cases. But it takes time and is statistically implied

and increases risk of bleeding. So theoretically percutaneous thrombectomy can accomplish all these tasks including a shorter hospital stay. So among the percutaneous thrombectomy devices the Indigo System is based on a really simple

aspiration mechanism and it has shown high success in ischemic stroke. This is one of my first cases with the Indigo System using a 5 MAX needle intervention

adapted to this condition. And it's very easy to understand how is fast and effective this approach to treat intraprocedural distal embolization avoiding potential dramatic clinical consequences, especially in cases like this,

the only one foot vessel. This is also confirmed by this technical note published in 2015 from an Italian group. More recently, other papers came up. This, for example, tell us that

there has been 85% below-the-knee primary endpoint achievement and 54% in above-the-knee lesions. The TIMI score after VAT significantly higher for BTK lesions and for ATK lesions

a necessity of a concomitant endovascular therapy. And James Benenati has already told us the results of the PRISM trials. Looking into our case data very quickly and very superficially we can summarize that we had 78% full revascularization.

In 42% of cases, we did not perform any lytic therapy or very short lytic therapy within three hours. And in 36% a long lytic therapy was necessary, however within 24 hours. We had also 22% failure

with three surgery necessary and one amputation. I must say that among this group of patients, twenty patients, there were also patients like this with extended thrombosis from the groin to the ankle

and through an antegrade approach, that I strongly recommend whenever possible, we were able to lower the aspiration of the clots also in the vessel, in the tibial vessels, leaving only this region, thrombosis

needed for additional three hour infusion of TPA achieving at the end a beautiful result and the patient was discharged a day after. However not every case had similar brilliant result. This patient went to surgery and he went eventually to amputation.

Why this? And why VAT perform better in BTK than in ATK? Just hypotheses. For ATK we can have unknown underlying chronic pathology. And the mismatch between the vessel and the catheter can be a problem.

In BTK, the thrombus is usually soft and short because it is an acute iatrogenic event. Most importantly is the thrombotic load. If it is light, no short, no lytic or short lytic therapy is necessary. Say if heavy, a longer lytic therapy and a failure,

regardless of the location of the thrombosis, must be expected. So moving to the other topic, venous occlusive thrombosis. This is a paper from a German group. The most exciting, a high success rate

without any adjunctive therapy and nine vessels half of them prosthetic branch. The only caution is about the excessive blood loss as a main potential complication to be checked during and after the procedure. This is a case at my cath lab.

An acute aortic renal thrombosis after a open repair. We were able to find the proximate thrombosis in this flush occlusion to aspirate close to fix the distal stenosis

and the distal stenosis here and to obtain two-thirds of the kidney parenchyma on both sides. And this is another patient presenting with acute mesenteric ischemia from vein thrombosis.

This device can be used also transsympatically. We were able to aspirate thrombi but after initial improvement, the patient condition worsened overnight. And the CT scan showed us a re-thrombosis of the vein. Probably we need to learn more

in the management of these patients especially under the pharmacology point of view. And this is a rapid overview on our out-of-lower-limb case series. We had good results in reimplanted renal artery, renal artery, and the pulmonary artery as well.

But poor results in brachial artery, fistula, and superior mesenteric vein. So in conclusion, this technology is an option for quick thromboembolic treatment. It's very effective for BTK intraprocedural embolic events.

The main advantage is a speeding up the blood flow and reestablishing without prolonged thrombolysis or reducing the dosage of the thrombolysis. Completely cleaning up extensive thromobosed vessels is impossible without local lytic therapies. This must be said very clearly.

Indigo technology is promising and effective for treatment of acute renovisceral artery occlusion and sub massive pulmonary embolism. Thank you for your attention. I apologize for not being able to stay for the discussion

because I have a flight in a few hours. Thank you very much.

- I have no disclosures. So I'm going to show you some pictures. Which of the following patients has median arcuate ligament syndrome? A, B, C, D, or E? Obviously the answer is none of these people.

They have compression of their celiac axis, none of them had any symptoms. And these are found, incidentally, on a substantial fraction of CT scans. So just for terminology, you could call it celiac compression

if it's an anatomic finding. You really should reserve median arcuate ligament syndrome for patients who have a symptom complex, which ideally would be post-prandial pain with some weight loss. But that's only I think a fraction of these patients.

Because most of them have sort of non-specific symptoms. So I'm going to say five things. One, compression of the celiac artery is irrelevant in most patients. It's been found in up to 1/3 of autopsies, MRIs, diagnostic angiography, CT.

This is probably about par, somewhere in that 5% or 10% of CT scans that are in asymptomatic patients will have some compression of the celiac axis. The symptoms associated with median arcuate ligament syndrome are non-specific,

and are really not going to tell you whether patients have the disease or not. So for instance, if you look here's like 400 CT scans, 19 of these patients had celiac compression. But the symptom complex in patients

who had abdominal pain for other reasons looked exactly the same as it did for people who had celiac compression. So symptoms isn't going to pull this apart. So you wind up with this kind of weird melange of neurogenic, vascular,

and you got to add a little psychogenic component. Because if any of you have taken care of these people, know that there's a supertentorial override that's pretty dramatic, I think, in some fraction of these people. So if you're not dizzy yet, the third thing I would say,

symptom relief is not predicted by the severity of post-operative celiac stenosis. And that's a little distressing for us as vascular surgeons, because we think this must be a vascular disease, it's a stenotic vessel. But it really hasn't turned out that way, I don't think.

There's several papers, Patel has one just in JVS this month. Had about a 66% success rate, and the success did not correlate with post-op celiac stenosis. And here's a bigger one,

again in Annals of Vascular Surgery a couple years ago. And they looked at pre- and post-op inspiratory and expiratory duplex ultrasound. And basically most patients got better, they had an 85% success rate. But they had patients,

six of seven who had persistent stenosis, and five of 39 who didn't have any symptoms despite improved celiac flow. So just look at this picture. So this is a bunch of patients before operation and after operation,

it's their celiac velocity. And you can see on average, their velocity went down after you release the celiac, the median arcuate ligament. But now here's six, seven patients here who really were worse

if you looked at celiac velocity post-op, and yet all these people had clinical improvement. So this is just one of these head scratchers in my mind. And it suggests that this is not fundamentally a vascular problem in most patients. It goes without saying that stents are not effective

in the presence of an intact median arcuate ligament. Balloon expandable stents tend to crush, self-expanding stents are prone to fracture. This was actually published, and I don't know if anybody in the audience will take credit for this.

This was just published in October in Vascular Disease Management. It was an ISET online magazine. And this was published as a success after a stent was put in. And you can see the crushed stent

because the patient was asymptomatic down the road. I'm not discouraging people from doing this, I'm just saying I think it's probably not a great anatomic solution. The fifth thing I'd say is that comorbid psychiatric diagnoses are relatively common

in patients with suspected median arcuate ligament syndrome. Chris Skelly over in Chicago, they've done an amazing job of doing a very elaborate psych testing on everybody. And I'll just say that a substantial fraction of these patients have some problems.

So how do you select patients? Well if you had a really classic history, and this is what Linda Riley found 30 years ago in San Francisco. If they had classic post-prandial pain with real weight loss and a little bit older patient group,

those people were the easiest and most likely to have a circulatory problem and get better. There are some provocative tests you can do. And we did a test a few years ago where we put a catheter in the SMA and shoot a vasodilator down,

like papaverine and nitroglycerin. And I've had patients who spontaneously just said, "That's the symptoms I've been having." And a light bulb went off in our head and we thought, well maybe this is actually a way you're stealing from the gastroduodenal collaterals.

And this is inducing gastric ischemia. I think it's still not a bad test to use. An alternative is gastric exercise tonometry, which is just incredibly elaborate. You got to sit on a bicycle, put an NG tube down to measure mucosal pH,

get an A-line in your wrist to check systemic pH, and then ride on a bike for 30 minutes. There's not many people that will actually do this. But it does detect mucosal ischemia. So for the group who has true circulatory deficiency, then this is sort of a way to pick those people up.

If you think it's fundamentally neurogenic, a celiac plexus block may be a good option. Try it and see if they react, if maybe it helps. And the other is to consider a neurologic, I mean psychologic testing. There's one of Tony Sadawa's partners

over at the VA in Washington, has put together a predictive model that uses the velocity in the celiac artery and the patient's age as a kind of predictive factor. And I'll let you look it up in JVS. Oddly enough,

it sort of argues again that this is not a circulatory problem, in that the severity of stenosis is sort of inversely correlated with the likelihood of success. So basically what I do is try to take a history,

look at the CTA, do inspiratory and expiratory duplex scans looking for high velocities. Consider angiography with a vasodilator down the SMA. If you're going to do something, refer it to a laparoscopist. And not all laparoscopists are equal.

That is, when you re-op these people after laparoscopic release, you often times find a lot of residual ligament. And then check post-operative duplex scans, and if they still have persistent symptoms and a high-grade stenosis,

then I would do something endovascular. Thank you.

- Thanks very much, and thanks Frank for the invitation to join us once again at this excellent meeting. These are my disclosures. Now, it's well documented and all of you are fully aware that the periprocedural risk of stroke and death following transfemoral CAS

has been shown to be twice that of when compared with CEA in the important non-industry supported trials of EVA3s, ICSS, and CREST. The increase in the rate of events with CAS however,

is front loaded and occurs, certainly within the first 30 days, and more often than not within the first day or two, after that the subsequent event rates and durability parallel that of CEA. And this is nicely shown in the four-year data from EVA 3S, where we can see that the big jump in event rates

between CAS and CEA occurs upfront, after which, these two curves become entirely parallel. The 10-year data from CREST has been published, and the same phenomenon occurs here, and that is that the higher event rate with stenting compared with carotid endarterectomy occurs right here,

after which the two curves become entirely parallel. So, one has to ask what are the potential causes for periprocedural events with transfemoral CAS and it's already been discussed, a diseased aortic arch, a Type 3 aortic arch making catheterization of the right carotid artery more challenging,

and finally the need to traverse the lesion in order to place a distal embolic protection device. Obviously the embolic protection device doesn't work until it's in place, and when you pass it over the lesion the possibility of knocking free embolic debris is quite high.

I don't expect anybody to read this from the back of the room, but in 2004 there were two seminal papers that were published looking at the possibility of a direct approach to carotid artery stenting, thus avoiding the aortic arch and using flow reversal

by clamping the common carotid artery and diverting blood flow in a reverse direction back to the venous system and were showed excellent results. Along comes industry to provide us with the hardware with which to do this,

these are the components from Silk Road, and basically a small cutdown over the common carotid artery, the placement of the sheath clamping the carotid artery with reversal of flow, thus carrying any embolic material before the placement of a stent is neuroprotective.

One other thing that wasn't mentioned this morning and one of the advantages of flow reversal and the possibility of encouraging all of the release of the embolic material initially is to carry out predilatation of the lesion before placing the stent and not postdilate.

The first-in-man data on the use of this technique was published in Germany and in the proof study, in the proof study there were 44 patients undergoing TCAR, no deaths, no strokes, silent brain infarction rate of 16%, which was entirely comparable to that of carotid endarterectomy.

Along comes the ROADSTER trial at ROADSTER 141 pivotal patients deemed to be high risk by either anatomic or medical criteria, carried out in 20 US sites, there was no major strokes, there were two minor strokes, two deaths, no permanent cranial nerve injuries. And if we compare the TCAR data with CREST data,

here's the transfemoral CAS data out of CREST, 4.1%, 2.3% with carotid endarterectomy, 1.4% with TCAR. And here are the ROADSTER 2 data, if we look at stroke and death in asymptomatic patients in ROADSTER 1, 1.3% dropping to .9%,

stroke and death, ROADSTER 1 in symptomatic patients 2.2% dropping to an astonishing 0.8%. So, from my personal perspective I can offer patients either TCAR or CEA based upon selection criteria with a high degree of comfort that

both of these are going to result in excellent results. How about CREST-2, as you know this is two studies in one, comparing CAS with intensive medical therapy alone and CEA with intensive medical therapy versus intensive medical therapy alone. The future of invasive intervention

to treat asymptomatic carotid stenosis will really depend upon the results of this trial. What are the possible outcomes? Intensive medical management may be equal to or better than either, carotid endarterectomy and CAS may be better than intensive medical management,

or CEA but not CAS may be better than intensive medical management alone, those are the possible possibilities To date, half of the patients have been enrolled, so stay tuned, and thanks very much for your attention.

- Thank you for the opportunity to present this arch device. This is a two module arch device. The main model comes from the innominated to the descending thoracic aorta and has a large fenestration for the ascending model that is fixed with hooks and three centimeters overlapping with the main one.

The beginning fenestration for the left carotid artery was projected but was abandoned for technical issue. The delivery system is precurved, preshaped and this allows an easy positioning of the graft that runs on a through-and-through wire from the

brachial to the femoral axis and you see here how the graft, the main model is deployed with the blood that supported the supraortic vessels. The ascending model is deployed after under rapid pacing.

And this is the compilation angiogram. This is a case from our experience is 6.6 centimeters arch and descending aneurysm. This is the planning we had with the Gore Tag. at the bottom of the implantation and these are the measures.

The plan was a two-stage procedure. First the hemiarch the branching, and then the endovascular procedure. Here the main measure for the graph, the BCT origin, 21 millimeters, the BCT bifurcation, 20 millimeters,

length, 30 millimeters, and the distal landing zone was 35 millimeters. And these are the measures that we choose, because this is supposed to be an off-the-shelf device. Then the measure for the ascending, distal ascending, 35 millimeters,

proximal ascending, 36, length of the outer curve of 9 centimeters, on the inner curve of 5 centimeters, and the ascending model is precurved and we choose a length between the two I cited before. This is the implantation of the graft you see,

the graft in the BCT. Here, the angiography to visualize the bifurcation of the BCT, and the release of the first part of the graft in the BCT. Then the angiography to check the position. And the release of the graft by pushing the graft

to well open the fenestration for the ascending and the ascending model that is released under cardiac pacing. After the orientation of the beat marker. And finally, a kissing angioplasty and this is the completion and geography.

Generally we perform a percutaneous access at auxiliary level and we close it with a progolide checking the closure with sheet that comes from the groin to verify the good occlusion of the auxiliary artery. And this is the completion, the CT post-operative.

Okay. Seven arch aneurysm patients. These are the co-morbidities. We had only one minor stroke in the only patient we treated with the fenestration for the left carotid and symptomology regressed completely.

In the global study, we had 46 implantations, 37 single branch device in the BCT, 18 in the first in men, 19 compassionate. These are the co-morbidities and indications for treatment. All the procedures were successful.

All the patients survived the procedure. 10 patients had a periscope performed to perfuse the left auxiliary artery after a carotid to subclavian bypass instead of a hemiarch, the branching. The mean follow up for 25 patients is now 12 months.

Good technical success and patency. We had two cases of aneurysmal growth and nine re-interventions, mainly for type II and the leak for the LSA and from gutters. The capilomiar shows a survival of 88% at three years.

There were three non-disabling stroke and one major stroke during follow up, and three patients died for unrelated reasons. The re-intervention were mainly due to endo leak, so the first experience was quite good in our experience and thanks a lot.

- Thank you very much, thank you Cees, that was really interesting, it's um, it's a topic close to my heart and I think that there's a great deal of work about pneumatic compression that we can learn from. These are my disclosures. Your stent choice, well,

we talk an awful lot about stents, but it is really only one part of the entire spectrum of factors that get it right. And when you get it right, you have an open vein and we believe that the open vein works, although the open vein hypothesis

seems somewhat compromised, considering where it came from in terms of open arteries. But your stent choice is just one of the factors that goes into it, and your inflow, and your outflow generally we can improve upon. Your muscle pump we'd like to improve

by using pneumatic compression boots, and then obviously getting your anti-coagulation right, as Dr. Weinberg explained, is really really key afterward. So, stent choice is one of the aspects, but it's certainly not the only aspect. You're familiar, and probably sick of these diagrams

showing the differences between radial force, crush resistance, and the trade-offs between stent flex, strengths, rather, and when I use strength it's a fairly generic term, and flexibility. And obviously in Europe, we have access to a wide variety of stents.

The Cook Zilver Vena first came out in 2010. Bard Venovo was, I think, 2016. The ABRE was just last December, but it's commercially available. The Optimed Sinus-Venous has been around for quite some time, I'm going to say 2011 if I'm correct.

And the Sinus Obliquus, then it was a little bit later, maybe 2014, 2015, and for those of you who haven't seen this before, this has got a, a closed-cell design at the top which is quite rigid, if I may, and then a very flexible sinus,

or rather open-cell design at the inferior portion, the top portion is angled to address the IVC confluence. And then the Veniti Vici, which is, (coughs) excuse me, was extensively studied in the VIRTUS trial, and this is a more closed-cell, but there's still a considerable flexibility.

So, like everything else in life, you know, you can go for the old broad who's got loads of money, or you can go for the young hot chick, and you know, she's broke. And you know, life is like that, and stents are like that too.

You know, what you get in one you lose in the other. And like a lot of the other things, you have to get everything right to make the stent work. That analogy certainly does not apply to women. But the closed-cells generally have higher force but they're slightly more rigid.

The open-cells are, perhaps, slightly weaker, but there's infinite varieties of imaginations and changes that can be made to those two very generic statements. For instance, in the newer stents, if you cut off a larger, laser cut a Nitinol tube,

you will intrinsically get thicker struts, and therefore slightly larger sheath size, but ultimately slightly more strength at the expense of slightly less flexibility. I think for me, the thing that I've learned the most about the newest venous stents,

or using the newer venous dedicated stents, is that you must do very aggressive balloon dilatation pre and post, that's absolutely essential. Regardless of what stent you use. And I'm horrified to see some of the Twitter handles of people using pre-dilatation

with an eight millimeter balloon, then putting in a 20 millimeter Wallstent and then ballooning it again to 14. Absolutely no logic to any of that. So I think you should balloon to the nominal diameter of the stent.

And it is interesting that you get a much higher force when you get that stent to the nominal diameter. The actual physical properties of the stent change when it hits that diameter. So not getting to the diameter of the stent is a huge mistake.

Now, do fractures really matter? We've been looking extensively at this in a variety of the different trials, and it's hard to know. Certainly, luminal reduction does. Fractures, not so sure about. Fractures sound like they're easy to diagnose.

They're actually very difficult. And compression at the inguinal ligament, is it real? It seems to be real. It seems to be more real than I certainly believed, in a certain proportion of patients. Typically skinnier ones, in my experience,

again, skinny females. Flexibility is obviously a big, big issue, and when you think of where your knee goes in relation to your shoulder if you're doing your yoga class, or anything else for that matter, tying your shoelaces,

there's a lot of bend required. And if you think of where we are now in aortic stent grafting compared to where we were when I last had hair, everything has changed. All of the devices have changed.

We went from Ancure, which had 64 steps, through AneuRx, and now, you know, things have moved on way past 2010 as well. So, in terms of my choices, in the USA you've got two choices, you got Wallstent and Z stent.

And if you got a rupture, use a Gore or something like that. In Europe, it's a much more, nuanced and challenging to try and figure out which ones you do. And these are just my choices. Is there any evidence to back them up?

None whatsoever. Have I had problems with most of the stents? Yes. Most of those problems were probably self-induced. I've certainly learned that pre-dilatation and post-dilatation are the essentials.

And flexibility is a lot more important than I would've thought if you had asked me five years ago. Thank you very much.

- My disclosures are not relevant. Joe showed this slide, this is the original SVS guidelines, which really, as he mentioned, is a lesion-based evaluation of what the trauma looks like. And, for the purposes of this discussion, we'll be focusing on grade three injuries. Which really means there's blood outside the aortic wall.

There is loss of integrity of all layers and there's a pseudoaneurysm. We've all transitioned to delayed TEVAR for grade one and two. But, what do we do with these grade three injuries? Where's the boundary between medical therapy

that puts the patient at risk of interval rupture and early repair? Which may, as I'll show, put them at risk of other problems. This is a pretty widely adopted prac the idea of treating traumatic pseudoaneurysms,

at least initially, with some medical therapy. This is a review of 18 studies, almost 1,000 patients. It showed really one in five were managed non-operatively. There is a very low rate of aorta-related mortality which will be a recurring theme on all the data I show you. And, there's a really low rate

of required late interventions. As true for many of our trauma-related literature, there's a really poor long-term follow-up rate. The AAST studies have shown us that delayed repair really can improve outcomes. There's a significant selection bias in

these are non-randomized trials for, I think, exclusively. But the reality is, if a patient can wait until stabilization of their other injuries, they do better if you can wait on repairing the aorta, both mortality and the paraplegia rates are lower.

But, it's not just completely a selection bias. There are maybe some other benefit here. And, one of the things that plays into play is: What are their other injuries like? What is their traumatic brain injury look like? And, we use this as a defining point at Grady

about figuring out whether someone really should be figured for early repair or not. If you look at this series of 300 patients with traumatic aortic injury, 248 had a concomitant brain injury, and those are obviously of a variety of different grades,

from a little blip on the CT scan to a potentially devastating neurologic insult. But, it's not uncommon to have to manage both injuries at the same time. That is the rule rather than the exception. They can be pretty significant

and, again, there's significant selection bias in this series out of Maryland. But, there's about a one third, one third, one third early repair, delayed repair or non-operative strategy. If you look at the non-op patients and the delayed patients, you can see

that we get to that very, very low mortality rate. The early repair patients, as you can imagine, are often associated with a fatal outcome. Now, that fatal outcome is not always a it is usually related to something else

and highlights the selection bias of series like this one, that show us that if you're sick when you come in with an aortic tear, you're going to continue to be sick regardless of whether we fix your tear or not. But, there is some other benefit, potentially. The traumatic brain injury is one piece that I've mentioned,

but it's not uncommon, I think we've all experienced situations like this where the trauma physician and the orthopedic physician and everyone who is taking care of these patients is really focused on a grade three aortic injury. And, it oftentimes allows for neglect

or missing of other injuries that may be more life-threatening. How do we avoid delay? There's a few areas where we can think about intervening. The first thing is getting a good radiographic grade, as Joe alluded to, and there's a variety

of different scoring systems. This ultimately amounts to a simplification of the Harborview scoring system which is the one that I personally have gravitated to over the last two years. Which demonstrates that for the old grade one and two

there is probably no benefit of repeat imaging, there is probably no benefit of intervention, and pseudoaneurysms should be fixed when they are stable and severe ongoing-rupture patients should be fixed right away. That assessment of stability is an important part of this.

Part of Dr. Crawford's interest, in particular, was evaluating the size of the pseudoaneurysm and the size of the hematoma. And so, all of these are things that we've seen before but they all probably behave a little bit differently. So, how do we look and see:

Are there specific types of injury that are more prone to rupture with non-operative therapy? And one of the things that's been assessed is the diameter ratio. I think Joe showed this data a second ago. Another is the size of the periaortic hematoma.

In this large series, if you had two of these three factors: a lactate greater than four, a mediastinal hematoma greater than 10 millimeters or a lesion to normal aortic ratio of greater than 1.4. That was 90% accurate in terms of theoretically predicting early rupture.

Which, if you just look at clinical judgment alone, goes down to 65%. Keeping in mind that clinical rupture, true rupture is very often a fatal event. There is a lot of value in moving that number from 65 to 90. If we can get good modeling that tells us

who is at particularly high risk of rupture in this selected group, there is a lot of potential benefit. Just as importantly, as I've mentioned earlier, if you have a higher aortic grade of injury, you are more likely to die but it does not predict aorta-related mortality.

Much of that is the selection bias that people with higher grades of aortic injury are fixed sooner and therefore are not candidates to die from aorta-related mortality. Let's skip through this. And then again, (audience member coughing)

the idea that we need additional information and we need better imaging, better physiologic data that predicts the need for early repair is the take-home message. The answer, as you can imagine, is more information. Part of what the Aortic Trauma Foundation is doing

is going to be evaluating: Are patients really going to do better with non-operative therapy if they have very specific criteria that allows them to be selected out? Are there high-risk criteria that we can figure out besides just eyeballing the CT scan and saying:

This is someone who's not going to do well if we sit on them. Thank you very much.

- Thank you to the committee and Dr. Veith for inviting me to speak today. Here are my disclosures. Over the past several years there's been a large increase in the wave of opioid overdose deaths in both heroin and prescribed narcotics in the US. Infected pseudoaneurysms are a terrible problem

resulting from this that vascular surgeons are seeing more increasingly. With this increase in IVDA use, we want to evaluate the trends in the increase and treatment of groin pseudoaneurysms and we used the National Inpatient Sample.

This looked over ten years from 2004 to 2014. Patients with a primary diagnosis of aneurysm or pseudoaneurysm, as well as different ICD-9 codes which were related to drug abuse. Looking at these data from 2004 to 2014, there was a large increase in the diagnoses

of pseudoaneurysms in IV drug abusers. Looking at the demographics of these patients, around 75% of these were white males with the average age of 45. This data, the location was mostly the West, hospital type was usually at an urban teaching hospital. Only 15% of these patients had private insurance.

Most of them were Medicaid, self-pay or no charge. As far as operative approach, and again, this is from a large database using codes, the resection of vessel with replacement had the highest increase, but there was an increase in all the operative approaches, including vascular shunt or bypass or aneurysm repair.

Which leads us to the question of what's the optimal therapy for IV drug abuse mycotic pseudoaneurysms? There's several surgical options, including ligation debridement with non-selective revascularization, ligation debridement of the aneurysm with selective revascularization, just ligation and excision and the

possibility of stents has been brought to attention recently. This study from Iran looked at 41 patients who were IV drug abusers with infected pseudoaneurysms. Of these patients, 32 patients were primarily ligated and nine patients were ligated with revascularization.

Of those patients, the ligation and excision, there were nine of 32 patients had complications and there was one amputation in this study. With a ligation and early revascularization, six out of nine patients had complications and there were three early graph failures.

These patients were only followed up to nine months. Of note, in this population, studies are often poor as the follow-up, as you can imagine, at these institutions is not very good. This study from Dr. Padberg and Hobson's group from the early 90's looked at performing

selective revascularization and using external iliac clamping to assess distal flow with a hand-held doppler, although further studies have looked at use of pulse oximetry as well. If there was a dopplerable signal, they felt there was no need to reconstruct at the time of surgery.

Using these methods, six patients had just a ligation with no mortality, no re-operations. Twelve of the 18 patients had a revascularization as well, and there were three amputations, no mortality. There are other extra-anatomic ways to reconstruct. Dr. Caligaro will describe the lateral tunneling

in a further talk in this session. An obturator bypass is another good option. Axel popliteal bypasses have also been described by Dr. Veith and his group several years ago. A new method that I've used instead of external iliac artery clamping is getting

proximal control from the contralateral groin. I usually get a CTA on these patients and use a 8 to 12 millimeter ballon, which often saves a retroperitoneal incision. As far a stenting, there's some, few studies looking at the use of stent in this patient population.

This study from China, 29 patients with pseudoaneurysms in SFA were treated with a covered stent. There was only short-term follow-up, but there was no amputation, no pain in these patients. And five patients continued to inject at the site. Here's another small case series describing

a retrograde stenting after a cutdown on the SFA into the common femoral artery, and they had two patients in the series with no complications over two years. Conclusion, IV drug abuse is on the rise and we're seeing more of the pseudoaneurysms that we'll need to treat. The data is difficult, but ligation may be the

best outcomes if there is a dopplerable signal. And for an absolute emergency, stenting may be used, however, on these young, non-compliant patients it is unlikely to be a good long-term option. Thank you.

- Thank you and good morning. I have no relevant financial disclosures. At Mayo, we have long been proponents of in-situ replacement of infected, both open and endografts with good results, both in terms of mortality and limb salvage. Our approach to graft infection involves

draining abscesses prior to the operation. Completely removing the infected graft and debriding the periaortic tissues, and replacement in-situ with a new graft sewn to help the aorta. Covering the graft 360 degrees

with omentum and long term suppressive antibiotic therapy. Rifampin-soaked conduits work well for low grade infections and aortaonteric fistula, but for patients with large abscesses we prefer cryopreserved allografts. Naturally para and suprarenal aortic graft infections

add another measure of challenge in the form of need for preservation of renal and visceral blood flow and sometimes presence of large abscesses around the grafts create further challenges to in-situ repair requiring creative

positioning and tunneling of the grafts. Dr.Milina mentioned the Swedish registry and yes, there are encouraging early results of EVAR for infected aortas, but mind you, these were all primary mycotic aortic aneurysms

and not infected grafts which are a different level of infection as he pointed out as well. So, we still prefer in this situation as well, in-situ reconstruction for most patients, but periaortic abscess may dictate the need for remote reconstruction,

and treatment needs to be customized to each patient's different anatomy. And it's important to have a multidisciplinary team. Our treatment strategy includes a single stage procedure with sequential visceral and aorto-iliac reconstruction. We like to have several plans for reconstruction ready

as CT often underestimates the amount of periaortic inflammation. And we like to perform separate bypasses for the renal or visceral arteries prior to the aortic reconstruction to reduce the physiologic stress.

This is one example of antegrade debranching of the viscerals and renals, and a synthetic graft replacement. And here, one for an infected endograph with cryopreserved aorta. This is a gentleman who presented

with an infected infrarenal opening aortic graft and a suprarenal mycotic aneurysm. Osteomyelitis extensively in the spine. He was status post lumber decompression and suffered a post operative myocardial infection as well. PCR demonstrated Q fever and he

had a large paraspinal abscess that had been drained preoperatively. He underwent a decompressing axillofemoral graft temporarily to offload the heart. And then an intra-abdominal exposure of the supraceliac aorta,

And debranching of the viscerals and the right renal artery. Tunneling these grafts to the foramen of Winslow, to the right side of the abdomen. And then tunneling similarly, an aortic replacement graft

in the right paracolic gutter and down into the pelvis, followed finally by a left medial visceral rotation and dealing with the left-sided paraspinal abscess debridement of the periaortic tissues as well as the vertebral bodies. And this is the final result with a post operative CT.

Another patient with an infected endograft and a aortoenteric fistula, who underwent a similar reconstruction tunneled on to the left side of the abdomen in the paracolic gutter, and appropriate pre-debranching of the visceral and renal arteries

to reduce that physiologic stress. In this patient we used saphenous vein grafts to perform the renal artery bypasses in a similar fashion. Sometimes you do have to go to the thoracic aorta to do the debranching to the viscerals and renals,

to stay away from the infected tissue. And lastly, this is a patient with an infected Carrel patch aneurism after the thorocoabdominal repair previously debranched in this fashion, preserving part of the patch and then wrapping the whole graft with omentum.

So, thus far we have experience with 16 such patients with paravisceral graft infection. Just over half were dealt with in a trans-abdominal manner, about two-thirds with in-situ reconstruction using Dacron and majority underwent Omentoplasty. About half of them underwent only renal,

and the other half renal and visceral reconstruction concomitantly. Majority with rifampin-soaked polyester. 30 day mortality was zero, however these are very sick patients, and three patients did succumb within the next 90 days, from multisystem organ failure

and just overall debility. Major renal and respiratory complications were of the order of about 15% but there was no further mortality over a median clinical follow-up of six years. And no graft thrombosis or reinfections.

So, although challenging single stage infected aortic graft excision with visceral and aortic reconstruction can be safely performed. Sequentially to decrease the physiologic stress. The new grafts can be successfully routed away from areas of major sepsis.

Early mortality and morbidity are significant but complete graft excision results in low risk of reinfection in survivors. I thank Dr.Veith for the kind invitation.

- Thank you very much, Gustavo, you read the abstract so now my task is to convince you that this very counter-intuitive technique actually works, you are familiar with Petticoat, cover stent to close a proximal entry tear and then uncover stents, bear stents, downstream. This what it would look like when we open up

the bare stent, you know dissect the aorta. So here's a case example, acute type B with malperfusion, the true lumen is sickle shaped, virtually occluded. So we use Petticoat, and we end up with a nice reopening of the true lumen, it is tagged here in green, however if you look more closely you see that here

wrapping around the true lumen there is a perfused false lumen. This is not an exception, not a complication, this is what happens in most cases, because there are always reentries in the celiac portion of the aorta.

So the Stablise concept was introduced by Australian group of Nixon, Peter Mossop in 2012, after you do the Petticoat, you are going to voluntarily balloon inside both the stent graft and the bare stents in order to disrupt, to fracture the lamel, obtain a single-channeled aorta.

This is what it looks like at TEE, after deployment of the stent graft, you see the stent graft does not open up completely, there is still some false lumen here, but after the ballooning, it is completely open. So the results were immediately very, very good, however technique did not gain a lot of consensus,

mainly because people were afraid of rupturing the aorta, they dissect the aorta. So here's a Stabilise case, once again, acute setting, malperfusion, we do a carotid subclavian bypass because we are going to cover the subclavian artery, we deploy

the cover stent graft, then with one stent overlap, we deploy two bare stent devices all the way down to the iliacs and then we start ballooning from the second stent down, so you see Coda balloon is used here, but only inside the cover stent with fabric.

And then more distally we are using a valvuloplastic balloon, which is noncompliant, and decides to be not larger than the aorta. So, I need probably to go here, this is the final result, you can see from the cross-sections that the dissection is completely gone and

the aorta is practically healed. So you might need also to address reentries at the iliac levels, attention if you have vessels that only come from the false lumen, we want to protect them during the ballooning, so we have a sheath inside this target vessel, and we are

going to use a stent afterwards to avoid fragments of the intima to get into the ostium of the artery. And this is a one-year control, so as you can see there is a complete remodeling of the aorta, the aorta is no longer dissected, it's a single channel vessel, here we can see stents in two vessels that came

from the false lumen, so very satisfactory. Once again, please remember, we use compliant latex balloons only inside the the cover stent graft, and in the bare stents we use non-compliant balloons. We have published our first cases, you can find more details in the journal paper, so in conclusion,

dear colleagues, Stabilise does work, however we do need to collect high-quality data and the international registry is the way to do this, we have the Stabilise registry which is approved by our ethical committee, we have this group of initial friends that are participating,

however this registry is physician initiated, it's on a voluntary base, it is not supported by industry, so we need all the possible help in order to get patients as quickly as possible, please join, just contact us at this email, we'd be more than happy to include everybody who is

doing this technique according to this protocol, in order to have hard data as soon as possible, thank you very much for your attention.

- I have nothing to disclose but what I will tell you is that the only way for me to learn the mechanics of treating low-flow malformations has been to learn from Wayne, follow what he's doing, and basically what I've done is I've filmed every single step he's taking,

dissect that, and then present you the way that he's doing it. The best way to do that is not listen to Wayne, but to film him, and just to check that afterwards. And he goes regularly to Cairo, this is the place of Dr. Rodovan sitting here

in front of us, and with Dr. Alaa Roshdy. I've learned a lot there from Wayne. This is Wayne's techniques, so normally if you look at puncture, the low flow malformations here then you get return or you aspirate so this is what happens, they inject contrast then they find volume

and inject whatever agent you prefer to inject. It happens to be alcohol but that is not essential. More often than not, there is no return. What to do then? There is a technique that Wayne has developed. Stab-Inject-Withdraw, just under high modification inject,

identify that you're not outside the vessel, get the vessel, start to fill slowly, and identify that and inject the alcohol. Of course you can do that under exposure just to see the effect of the alcohol thrombosing, et cetera.

Another example of no return is to subcutaneously certainly show that there is a low pressure system, and again, Stab-Inject-Withdrawal, and there is a cyst. Is it extravasation or is the malformation aspirate? And if it collapses, that's the malformation.

And then continue to fill in with contrast, define how big the malformation is, and then accordingly inject the amount of abrasive agent that you're using. Lymphatic malformation is very difficult to treat because the vessel's so small, would say microscopic,

and again, Stab-Inject-Withdraw, identify that it's not extravasating but it is the vessel, and start slowly, slowly to fill and any time in doubt that should there, just do a run, identify, and that is the vessel, or the network of the vessels and

start to fill that with the agent you're using. But there are certain zones that just don't inject anything, and these are the arteries. How often do arteries occur? When you puncture them. I just directly looked at all these 155 patients I've seen Wayne treat there a matter of,

I would say, 100 patients in three days. 30 patients per day, that's about six percent. And you see the artery by pulsating flow depending on the pressure that you apply. And we see again the artery pulsating and we have no doubt about that.

However, it could be difficult to see. Depending on how much you push in the contrast and you see these being ornery so there's a No-Go-Zone, no injection of any agent and again, a tiny bit of lottery there in the foot could be disastrous.

You inject any agent, any, you will have ended up with necrosis of course if you don't inject inhibitors, but not yet. The humorous may not end up with necrosis when all the mysticism with puncture will be gone. So we have extravasation, when you say extravasation

like starting injecting, still good, looking good, but you see how the extravasation even blows up and at the end it bursts, again under pressure they should apply, so pressure is really important to control and then you stop and don't inject any more.

Extravasation, you see how its' leaking in the back there, but you correct the position of the needle, identify all the vessels, the tiny little vessels, just have to be used to identify the pattern and then you start to inject the agent again.

Control is very essential. Here is the emphatic malformation labia and though there is this tiny little bity extravasation you continue because there is you know, run-off, it is filling the system and you can safely inject the alcohol.

Intraarticular could be malformation there and this is definitely safe pla however, if it is in the free space in the the joint, that's again, it's No-Go-Zone. How you see that is just be used to

the pattern recognition and you find that this is free. It's around the condyle there so there is no injection. Compression is again good to note to control by compression where the agents go. This is a normal vein, certainly at risk of getting with alcohol, whatever agent

you're using deep in the system, avoid that by compression. Compression can be applied manually and then that gives you a chance to fill the malformation itself and not strike connection too deep in the system. Intraosseous venous malformation,

low-flow malformations can occur anywhere, here in the spine and the axis is transpedicular patient prone because it's soft. The malformation has softened up the bone. You can just use a 21-gauge needle and identify the malformation and follow

by the agent you're using. Peculiar type of venous malformation called capillary venous malformation. Basically it's a low-flow malformation without any shunt here in the sciatic notch of the patient and geography shows that there is no shunt

there is just big veins and intense pacification. And identify the veins by indirect puncture again, see the pattern of that and inject alcohol and following geography we can see that there has decreased the density but it is a lot more left to be done.

In conclusion, direct puncture is the technique in this low-flow malformation but Stab-Inject-Withdraw is the really helpful technique for successful treatment of microvascular, microcystic lesion. No-Go-Zones for certain when you see arteries

and anytime in doubt you just have to do a run to identify if they're arteries or not. Intraarticular free space and extravasation and normal veins, similarly, No-Go-Zone. Capillary venous, intraosseous malformations can be treated successfully. Thank you.

(audience applause) - [Facilitator] Thank you, Crossey. Excellent talk, very practical and pragmatic. Any comments or questions? Dr. Yakes. - [Dr. Yakes] We have been to many meetings and people have talked about doing

other ultrasound guides, accessing the malformations. You'll never see those arteries by ultrasound. - [Facilitator] That's absolutely correct. I concur. I concur and I think some of the disasters we've seen where suddenly something falls off

have been in these situations because they don't understand or in expansile foam-based therapies, I've seen that. I've seen plenty of these, so it's always present, potentially.

- When stenting are not enough, venoplasty stenting is undoubtedly the treatment of choice in relieving iliocaval obstruction and we have no doubt on what we can technically today obtain with this technique. But open surgery still has a place. The place for the iliocaval segment is today limited

only to oncological patients, their trauma. The disease, given by PTS, is not justifying an open surgery on those segments. But in some cases, at least less than ten percent in our federal center like we are, endovascular technique alone may be not sufficient

to provide durable patency of the iliocaval stenting. An open surgical approach, limited to the common femoral vein, can be required in addition to iliocaval stenting. And I would like to underline that open surgery should not be confused with open access

in event of catheterization failure. It's completely different. At the end, what we apply is endophlebectomy, which is the surgical removal of intraluminal fibrotic tissues. And contrapulizes of the extraluminal damage.

After endophlebectomy, the caliber of the vein is restored by means of bovine pericardium patch. In order to go back to the normal anatomy. Which are the indications for this type of operation? The main indication is to improve the inflow. When the deep femoral system confluence

is inadequate or the axial system is not preserved we have to try to improve the inflow at that level. And it is an essential moment to get a stable patency in the iliocaval segment. The second indication is to provide sufficient room for adequate stent expansion.

If there is lots of rubber and hard tissues that occupies the commofemoral vein, maybe in the long term, the stent can be sufficiently, adequately expanded. And if we remove this tissue we can get a better stent deployment.

The third indication is to reconstruct the vein conduit when it has been lost. This may happen after trauma, after drug injection, and after heterogenic problem. When the vein wall is too damaged, to be treated only by stenting or

only by endophlebectomy, a new conduit can be maybe the better option. What we apply today is a tubulization of bovine pericardium in order to obtain a correct way. And this is probably what we have to underline much more than everything else,

it is a type of hybrid procedure. The operation of endophlebectomy on new oxcilization are rarely performed alone today. We should go down with the stent if required to cover the endophlebectomy area and to treat iliac obstruction in the same moment.

As we listen before, the endophlebectomy limits is to open up the deep femoral conference and the stent usually stop over there. And it is essential because at the present, if we do not apply this, we can say, a kind of protection way to treat

the endophlebectomy segment, its difficult to maintain a long term patency. In this type of operation at the present, we do not apply anymore AV fistula which was limited in our historical work. I would say that today, open surgery

and hybrid procedures are essential in post traumatic treatment strategy. Outcomes in complex cases can be strongly improved. And I would like to underline that it is complex cases. This is not a surgery that is applied in every case of iliocaval stenting.

Its, there has to be attentively, selected because this type of surgery is undoubtedly very delicate, but we can get very good results and despite what we can think, get a good patency over time. It can really today be something

that we can obtain quite attentively. Thank you so much.

- Thank you Rod and Frank, and thanks Doctor Veeth for the opportunity to share with you our results. I have no disclosures. As we all know, and we've learned in this session, the stakes are high with TEVAR. If you don't have the appropriate device, you can certainly end up in a catastrophe

with a graph collapse. The formerly Bolton, now Terumo, the RelayPlus system is very unique in that it has a dual sheath, for good ability to navigate through the aortic arch. The outer sheath provides for stability,

however, the inner sheath allows for an atraumatic advancement across the arch. There's multiple performance zones that enhance this graph, but really the "S" shape longitudinal spine is very good in that it allows for longitudinal support.

However, it's not super stiff, and it's very flexible. This device has been well studied throughout the world as you can see here, through the various studies in the US, Europe, and global. It's been rigorously studied,

and the results are excellent. The RelayPlus Type I endoleak rate, as you can see here, is zero. And, in one of the studies, as you can see here, relative to the other devices, not only is it efficacious, but it's safe as well,

as you can see here, as a low stroke rate with this device. And that's probably due to the flexible inner sheath. Here again is a highlight in the Relay Phase II trial, showing that, at 27 sites it was very effective, with zero endoleak, minimal stent migration, and zero reported graph collapses.

Here again you can see this, relative to the other devices, it's a very efficacious device, with no aneurism ruptures, no endoleaks, no migration, and no fractures. What I want to take the next couple minutes to highlight, is not only how well this graph works,

but how well it works in tight angles, greater than 90 degrees. Here you can see, compliments and courtesy of Neal Cayne, from NYU, this patient had a prior debranching, with a ascending bypass, as you can see here.

And with this extreme angulation, you can see that proximally the graph performs quite well. Here's another case from Venke at Arizona Heart, showing how well with this inner sheath, this device can cross through, not only a tortuous aorta, but prior graphs as well.

As you can see, screen right, you can see the final angiogram with a successful result. Again, another case from our colleagues in University of Florida, highlighting how this graph can perform proximally with severe angulation

greater than 90 degrees. And finally, one other case here, highlighting somebody who had a prior repair. As you can see there's a pseudoaneurysm, again, a tight proximal, really mid aortic angle, and the graph worked quite well as you can see here.

What I also want to kind of remind everybody, is what about the distal aorta? Sometimes referred to as the thoracic aorta, or the ox bow, as you can see here from the ox bow pin. Oftentimes, distally, the aorta is extremely tortuous like this.

Here's one of our patients, Diana, that we treated about a year and a half ago. As you can see here, not only you're going to see the graph performs quite well proximally, but also distally, as well. Here Diana had a hell of an angle, over 112 degrees,

which one would think could lead to a graph collapse. Again, highlighting this ox bow kind of feature, we went ahead and placed our RelayPlus graph, and you can see here, it not only performs awesome proximally, but distally as well. And again, that's related to that

"S" shaped spine that this device has. So again, A, it's got excellent proximal and distal seal, but not only that, patency as well, and as I mentioned, she's over a year and a half out. And quite an excellent result with this graph. So in summary, the Terumo Aortic Relay stent graph is safe,

effective, it doesn't collapse, and it performs well, especially in proximal and distal severe angulations. Thank you so much.

- Thanks (mumbles) I have no disclosures. So when were talking about treating thoracoabdominal aortic aneurysms in patients with chronic aortic dissections, these are some of the most difficult patients to treat. I thought it would be interesting

to just show you a case that we did. This is a patient, you can see the CT scrolling through, Type B dissection starts pretty much at the left subclavian, aneurysmal. It's extensive dissection that involves the thoracic aorta, abdominal aorta,

basically goes down to the iliac arteries. You can see the celiac, SMA, renals at least partially coming off the true and continues all the way down. It's just an M2S reconstruction. You can see again the extent of this disease and what makes this so difficult in that it extends

from the entire aorta, up proximally and distally. So what we do for this patient, we did a left carotid subclavian bypass, a left external to internal iliac artery bypass. We use a bunch of thoracic stent grafts and extended that distally.

You can see we tapered down more distally. We used an EVAR device to come from below. And then a bunch of parallel grafts to perfuse our renals and SMA. I think a couple take-home messages from this is that clearly you want to preserve the branches

up in the arch. The internal iliac arteries are, I think, very critical for perfusing the spinal cord, especially when you are going to cover this much. And when you are dealing with these dissections, you have to realize that the true lumens

can become quite small and sometimes you have to accommodate for that by using smaller thoracic endografts. So this is just what it looks like in completion. You can see how much metal we have in here. It's a full metal jacket of the aorta, oops.

We, uh, it's not advancing. Oops, is it 'cause I'm pressing in it or? All right, here we go. And then two years post-op, two years post-op, you can see what this looks like. The false lumen is completely thrombosed and excluded.

You can see the parallel grafts are all open. The aneurysm sac is regressing and this patient was successfully treated. So what are some of the tips and tricks of doing these types of procedures. Well we like to come in from the axillary artery.

We don't perform any conduits. We just stick the axillary artery separately in an offset manner and place purse-string sutures. You have to be weary of manipulating around the aortic arch, especially if its a more difficult arch, as well as any thoracic aortic tortuosity.

Cannulating of vessels, SMA is usually pretty easy, as you heard earlier. The renals and celiac can be more difficult, depending upon the angles, how they come off, and the projection. You want to make sure you maintain a stiff wire,

when you do get into these vessels. Using a Coda balloon can be helpful, as sometimes when you're coming from above, the wires and catheters will want to reflux into that infrarenal aorta. And the Coda balloon can help bounce that up.

What we do in situations where the Coda doesn't work is we will come in from below and a place a small balloon in the distal renal artery to pin the catheters, wires and then be able to get the stents in subsequently. In terms of the celiac artery,

if you're going to stent it, you want to make sure, your wire is in the common hepatic artery, so you don't exclude that by accident. I find that it is just simpler to cover, if the collaterals are intact. If there is a patent GDA on CT scan,

we will almost always cover it. You can see here that robust collateral pathway through the GDA. One thing to be aware of is that you are going to, if you're not going to revascularize the celiac artery you may need to embolize it.

If its, if the endograft is not going to oppose the origin of the celiac artery in the aorta because its aneurysmal in that segment. In terms of the snorkel extent, you want to make sure, you get enough distal purchase. This is a patient intra-procedurally.

We didn't get far enough and it pulled out and you can see we're perfusing the sac. It's critical that the snorkel or parallel grafts extend above the most proximal extent of your aortic endograft or going to go down. And so we take a lot of care looking at high resolution

pictures to make sure that our snorkel and parallel grafts are above the aortic endograft. This is just a patient just about a year or two out. You can see that the SMA stent is pulling out into the sac. She developed a endoleak from the SMA,

so we had to come in and re-extend it more distally. Just some other things I mentioned a little earlier, you want to consider true lumen space preserve the internals, and then need to sandwich technique to shorten the parallel grafts. Looking at a little bit of literature,

you can see this is the PERCLES Registry. There is a number of type four thoracos that are performed here with good results. This is a paper looking at parallel grafting and 31 thoracoabdominal repairs. And you can see freedom from endoleaks,

chimney graft patency, as well as survival is excellent. This was one looking purely at thoracoabdominal aneurysm repairs. There are 32 altogether and the success rates and results were good as well. And this was one looking at ruptures,

where they found that there was a mean 20% sac shrinkage rate and all endografts remained patent. So conclusion I think that these are quite difficult to do, but with good techniques, they can be done successfully. Thank you.

- Thank you. Thank you again for the invitation, and also my talk concerns the use of new Terumo Aortic stent graft for the arch. And it's the experience of three different countries in Europe. There's no disclosure for this topic.

Just to remind what we have seen, that there is some complication after surgery, with mortality and the stroke rate relatively high. So we try to find some solution. We have seen that we have different options, it could be debranching, but also

we know that there are some complications with this technique, with the type A aortic dissection by retrograde way. And also there's a way popular now, frozen elephant trunk. And you can see on the slide the principle.

But all the patients are not fit for this type of surgery. So different techniques have been developed for endovascular options. And we have seen before the principle of Terumo arch branch endograft.

One of the main advantages is a large window to put the branches in the different carotid and brachiocephalic trunk. And one of the benefit is small, so off-the-shelf technique, with one size for the branch and different size

for the different carotids. This is a more recent experience, it's concerning 15 patients. And you can see the right column that it is. All the patients was considered unfit for conventional surgery.

If we look about more into these for indication, we can see four cases was for zone one, seven cases for zone two, and also four cases for zone three. You can see that the diameter of the ascending aorta, the min is 38,

and for the innominate artery was 15, and then for left carotid was eight. This is one example of what we can obtain with this type of handling of the arch with a complete exclusion of the lesion, and we exclude the left sonography by plyf.

This is another, more complex lesion. It's actually a dissection and the placement of a stent graft in this area. So what are the outcomes of patients? We don't have mortality, one case of hospital mortality.

We don't have any, sorry, we have one stroke, and we can see the different deaths during the follow-up. If we look about the endoleaks, we have one case of type three endoleak started by endovascular technique,

and we have late endoleaks with type one endoleaks. In this situation, it could be very difficult to treat the patient. This is the example of what we can observe at six months with no endoleak and with complete exclusion of the lesion.

But we have seen at one year with some proximal type one endoleak. In this situation, it could be very difficult to exclude this lesion. We cannot propose this for this patient for conventional surgery, so we tried

to find some option. First of all, we tried to fix the other prosthesis to the aortic wall by adjusted technique with a screw, and we can see the fixation of the graft. And later, we go through the,

an arrangement inside the sac, and we put a lot of colors inside so we can see the final results with complete exclusion. So to conclude, I think that this technique is very useful and we can have good success with this option, and there's a very low

rate of disabling stroke and endoleaks. But, of course, we need more information, more data. Thank you very much for your attention.

- Thank you, Mr. Chairman. Ladies and gentleman. I'd also like to thank Dr. Veith for the kind invitation. This presentation really ties to the presentation of Erik Verhoven, I believe. These are my disclosures. So we basically have, obviously, two problems. We treat a dynamic disease by fairly static means.

One of the problems, a local problem, is aortic neck degeneration which is the problem basically of progression of disease. We know in general if you stent them, if you operate them, if you don't treat them they will just dilate and it's a question of time

whether you have a problem or not. So, they will inevitably, if patients live long enough, cause a change of geometry of the aorta and the branch vessels and that cause obviously, that can cause stent fractures and other problems.

That's just one of many papers Erik also has shown a migrated graft. With his fenestrated grafts showing that the problem is also prevalent in M stents and Z stents, and obviously also in

as in the Fenestrated Anaconda. So I'll talk briefly about our experience. In Vienna where we have treated so far 179 patients with either double, triple, or quadruple fenestrated grafts. Majority nowadays are quadruple in our series

where we have also treated patients with extensions of thoracic stent grafts or extensions further down to the iliac arteries. In these patients we've had relevant neck degenerations in five cases. Where either the branches had issues

or the graft had migrated relevantly. And these basically represent three different faces of the problem. So one is neck degeneration with migration and loss of seal. Certainly the biggest problem that can cause ruptures. That's one of the cases in 2015

what is certainly important is to have a look at the super celiac area of the aorta and you see it's degenerated, it's dilated. So we have a nice ring of aorta at the visceral segment but above it wasn't. And it was a

you see the saddle of the stent graft and one and a half years later the saddle (cough) has flattened out. We've had a stent fracture of the left renal stent.

We screwed it with anchors and fixed the stent graft. We believe that's going to be the solution. We were wrong. Yet anothe leak and a further migration of the case.

So we had to put in a thoracic endograft and bring in a 4 fen and a mono-iliac crossover solution. The other problem would be neck degeneration or progression of disease without migration or loss of seal. As in this case where we have implanted a 4 fen case and you can see here that there is

a diseased proportion of the thoracic aorta. Could look like a penetrating ulcer. And again we had to put in a thoracic stent graft and a 4 fen solution with a mono-iliac ending and a crossover. What's more important, I believe,

is the progression of general, generalized aortic disease. So there is no real migration, as in this case in 2013. You can see a nice saddle and very straight iliac limbs. 2018 you can see that the saddle is actually flattened out. Renal arteries look upwards, so you would actually believe in

a migration of the stent graft. Also if you look at the iliac limbs you can see that they have actually compressed somewhat. But if you look closely at the difference between the ring and the SMA, so that's lateral view, you can see that there is no difference.

The stent graft actually has not migrated. What happened is that the patient developed a thoracic aneurysm of 7.5cm and the whole aorta is not only increased in diameter but also in length. So the whole thing has moved its confirmation without basically a migration of the

not yet. So, Mr Chairman, Ladies a lessons we have learned is- and I could also repeat wh

seal in the healthiest proportion of the aorta. So if you see a nice visceral ring and above that you see a diseased proportion of the aorta, as in this case, where you have already a degenerated thoracic aorta.

You should really treat this as well and not go for a 2 or 3 fen case. And also the progressio the general progression of disease is an issue. So even if you have no migrations

you may end up with real problems and target vessel occlusions or stent graft fractures. Thank you very much

- Thank you very much for the presentation. Here are my disclosures. So, unlike the predecessor, Zenith Alpha has nitinol stents and a modular design, which means that the proximal component has this rather gentle-looking bear stents and downward-looking barbs.

And the distal part has upward-looking barbs. And it is a lower-profile device. We reported our first 42 patients in 2014. And now for this meeting we updated our experience to 167 patients operated in the last five years.

So this includes 89 patients with thoracic aneurysms. 24 patients in was the first step of complex operations for thoracoabdominals. We have 24 cases in the arch, 19 dissections, and 11 cases were redos. And this stent graft can be used as a single stent graft,

in this case most of the instances the proximal component is used or it can be used with both components as you can see. So, during the years we moved from surgical access to percutaneous access and now most of the cases are being done percutaneously

and if this is not the case, it's probably because we need some additional surgical procedures, such as an endarterectomy or in cases of aorto-iliac occlusive disease, which was present in 16% of our patients, we are going to need the angioplasty,

this was performed in 7.7% of cases. And by this means all the stent grafts were managed to be released in the intended position. As far as tortuosity concerned, can be mild, moderate, or severe in 6.6% of cases and also in this severe cases,

with the use of a brachio-femoral wire, we managed to cross the iliac tortuosity in all the cases. Quite a challenging situation was when we have an aortic tortuosity, which is also associated with a previous TEVAR. And also in this instances,

with the help of a brachio-femoral wire, all stent grafts were deployed in intended position. We have also deployed this device both in chronic and acute subacute cases. So this can be the topic for some discussion later on. And in the environment of a hybrid treatment,

with surgical branching of the supoaortic tranch, which is offered to selected patients, we have used this device in the arch in a number of cases, with good results. So as far as the overall 30-day results concerned, we had 97.7% of technical success,

with 1.2% of mortality, and endoleaks was low. And so were reinterventions, stroke rate was 1.2%, and the spinal cord injury was 2.4%. By the way we always flash the graft with CO2 before deployment, so this could be helpful. Similar results are found in the literature,

there are three larger series by Illig, Torsello, and Starnes. And they all reported very good technical success and low mortality. So in conclusion, chairmen and colleagues, Zenith Alpha has extended indications

for narrow access vessels, provide safe passage through calcified and tortuous vessels, minimize deployment and release force, high conformability, it does retain the precision and control of previous generation devices,

however we need a longer term follow up to see this advantages are maintained over time. Thank you very much.

- Good morning, I want to thank Professor Vitta for the privilege of presenting on behalf of my chief, Professor Francesco Speziale, the result from the EXTREME Trial on the use of the Ovation stent graft. We know that available guidelines recommend to perform EVAR in patient presenting at least a suitable

aortic neck length of >10mm, but in our experience death can be a debatable indication because it may be too restrictive, because we believe that some challenging necks could be effectively managed by EVAR. This is why when we published our experience 2014,

on the use of, on EVAR, on the use of different commercially available device on-label and off-label indication, we found no significant difference in immediate results between patient treated in and out IFU, and those satisfactory outcomes were maintained

during two years of follow-up. So, we pose ourself this question, if conventional endografts guarantee satisfactory results, could new devices further expand EVAR indication? And we reported our experience, single-center experience, that suggests that EVAR by Ovation stent-graph can be

performed with satisfactory immediate and mid-term outcomes in patient presenting severe challenging anatomies. So, moving from those promising experiences, we started a new multi-center registry, aiming to demonstrate the feasibility of EVAR by Ovation implantation in challenging anatomies.

So, the EXTREME trial was born, the expanding indication for treatment with standard EVAR in patient with challenging anatomies. And this is, as I said, a multi-center prospective evaluation experience. The objective of the registry was to report the 30-day and

12 month technical and clinical success with EVAR, using the Ovation Stend-Graft in patient out of IFU for treatment by common endograft. This is a prospective, consecutively-enrolling, non-randomized, multi-center post market registry, and we plan to enroll at least 60 patients.

We evaluated as clinical endpoints, the freedom from aneurysm-related mortality, aneurysm enlargement and aneurysm rupture. And the technical endpoint evaluate were the access-related vascular complications, technical success, and freedom from Type I and III endoleaks, migration,

conversion to open repair, and re-interventions. Between March 17 and March 18, better than expected, we enrolled 122 patients across 16 center in Italy and Spain. Demographics of our patient were the common demographic for aneurysm patients.

And I want to report some anatomical features in this group. Please note, the infrarenal diameter mean was 21, and the mean diameter at 13mm was 24, with a mean aortic neck length of 7.75mm. And all grafts were released accorded to Ovation IFU. 74 patients out of 122

presented an iliac access vessel of <7mm in diameter. The technical success reported was 98% with two type I endoleak at the end of the procedure, and 15 Type II endoleaks. The Type I endoleak were treated in the same procedure

by colis embolization, successfully, and at one month, we are no new Type Ia endoleaks, nine persistent Type II endoleaks, and two limb occlusion, requiring no correction. I want to thank my chief for the opportunity of presenting and, of course, all collaborators of this registry,

and I want to thank you for your attention, and invite you, on behalf of my chief, to join us in Rome next May. Thank you.

- Okay, thank you very much. I appreciate the invitation from Dr Veith to discuss this technique and really, this is a how to do it technique. These are my disclosures. So we know that if you're doing a type B dissections that are chronic and you're going to use a fenestrated

device often times you have vessels that are on the false lumen that are not easily accessible. You can see in this picture up above, here's you're flap, this is the right renal artery across the fenestration and you can't really see the actual original fenestration.

There can also be some misalignment between the natural fenestration and where you want to put your fenestration. So this technique allows us to create a neo-fenestration at your site of choice. So here's our stent graft planning in this particular patient.

Here's the dissection flap, here's our graft in the true lumen with the SMA and celiac and the right renal. We've placed the fenestration for the left renal right opposite the left renal artery. And this is a schematic representation of

our in press article. Basically once you've accessed the bottom of the graft you can use a steerable directional sheath and put it right at the level of your fenestration. Use the power wire from Baylis, and what you do is put it right up against the graft.

It's like a cautery, you step on the pedal, it gives a one second burst and that goes across the flap. You can then widen it and then connect your stent graft. This is an example of one of our early cases. Here you can see injection in the true lumen with the right renal, you can't see the left renal,

that's bowel gas and another one of the true lumen branches. You can see with the fusion imaging we've now been able to put the graft, the right renal and the graft expanded. Here you can see an injection and we've got our catheter right up against the left renal fenestration. And here you can next see, the power wire,

the tip of the power wire is just at the edge of the catheter. And if you step on the pedal you can see that the power wire goes across into the false lumen right near here, you can inject your false lumen, you can see your renal

and after that you can see that we've now accessed the artery. We balloon it and then stent it. So these are the tools that are required. You need the power wire generator, you need the power wire itself,

you need a pad on the patient just like a cautery pad, and an Oskar or other steerable sheath is very effective in helping you. A short pulse in one second is usually enough to cross the lumen. Here's a second example.

A patient again with a false lumen, the right renal artery is the one this particular time. You can see the dissection flap is here. We planned the fenestration right opposite the renal artery.

And you can see here similar technique with the catheter. The power wire is already actually been deployed across the channel and then put in place. So this is a relatively simple technique that you can use to access false lumen branches. It allows planning the fenestration on your pre-op plan

close to the target vessel, and it assists you when the natural fenestration is not visible, or misaligned. And it uses an existing technique that we've used for left subclavian in situ fenestration and for some aortic dissection acute cases where you need to fenestrate the false lumen.

Thank you.

- Thank you Mr. Chairman. Good morning ladies and gentlemen, and thank you for Frank, for inviting me to be here. I have no disclosure. For the diagnoses of the infected aneurysm we rely on the positive culture specimen, blood test. We didn't rely on the negative culture

with the eccentric aneurysm sign of infection of preoperative treatment of antibiotics. For the principle of operative treatment of the infected aneurysm, initially antibiotics and surgical treatment to excise the infected artery and surrounding tissue.

Arterial reconstruction in-situ or extra-anatomical and followed by appropriate postoperative antibiotics. Diagnosis of the infected, okay, oh, back again. Endografts for the treatment of the infected aneurysms started at 1992,

two years after EVAR. It's a less invasive method and alternative to open surgery and a better choice for the critically ill patient. The earlier report, very successful because of using of the broad spectrum antibiotic

and most of the surgery, they have negative result for the culture. Some of them used the antibiotic coat graft and adjunct procedures such as drainage or debridement. Followed by prolonged postoperative antibiotic therapy. We have a role for the EVAR

in the treatment of the infected aneurysm in the well controlled patient with the active infection by broad-spectrum antibiotic and with the patient without fever and stable hemodynamic. In acute presentation with fever

and active bleeding or aneurysm rupture. We have experience with both, EVAR and also open surgery at the same time on the three year period. For all of the five cases that elective open repair we have no mortality in 30 days

with a significant operative complication in 40% and surgical complication 21%. All patients survived. But for the patient with the EVAR all survived but we have a problem with the infected stent graft in two

and we need a CT guideline drainage and end it by explanation in two. In emergency EVAR we have one infected stent graft that need CT guideline and the patient don't want to have an operation by experimentation and after that, she died.

All of the bicasted operative treatment we have 60% for the mortality rate. We then certify with the endovascular stenting for infected graft because of the precedent of graft in the infected area.

It doesn't resolve the infection. Okay. Okay. And in conclusion, good immediate results for the infected graft with the EVAR. Good immediate result, no poor mortality there.

But a problem with the persistent infection. For the infected stent graft, after how do we treat. Okay. For the conventional open repair of the infected, in about two percent, EVAR for less than one percent,

and EVAR for the infected graft, one third. Mechanism of the graft infections is contamination and re-intervention. Here's now four cases with the infected stent graft. Four for the infected aneurysm and one for the patient disease that have a

explanation and eto-entric fistula. A primary goal of the treatment is the removal of the infected graft. When is non-excision of the infected graft acceptable for the treatment? We have to consider this.

For the patient with the major criteria we should go over what stent graft explantation. It maybe have a role in the minor criteria. Conservative management have a high mortality rate, nearly 100%. It depends on bacterial virulence,

onset of the graft infection, and localization. To consider that we should treat them conservatively or not. In conclusion, conservative treatment should be used in the moribund patient, high risk to operation and minimal graft contamination. Thank you for attending.

- Yeah, thank you very much. Unfortunately Dierk Scheinert couldn't come, so thankfully he's allowed me here to take this presentation over so thanks a lot for this. So these are the latest 5-year results of the INCRAFT device from Cordis Devices currently under FDA review not yet approved

in the US, but in Europe. These are the conflict of interests, this is (mumbles). So this device is a three-piece modular system, low porosity polyester. You can bilaterally in-situ length adjust it up to 3cm. And the main feature I think with this device

is it's a low-profile device, 13 Fr inside 14 Fr outside except the biggest body which has an outer diameter of 16 Fr. The innovation study that was 60 patients, you can see here some objectives. So the question was whether you could deploy it

accurately where you wanted to have it without any type I, III, and IV endoleaks and of course there were also some other primary and secondary endpoints and again follow-up had to be done up to five years. This is a busy slide just showing you,

please look to the right side, to show you that there were quite some violations of the recommendations in which kinds of anatomies to implant this craft. Here for example neck lengths less than 10mm, here were some patients implanted.

Also angulations over 60 degrees, three patients, there were some thrombus in the neck, and here you can see aortic bifurcation smaller than 18mm, there were quite some patients and especially the iliac sealing length was shorter than 10mm in nearly 50% of the patients

and also the diameter of the external iliac arteries were nearly 50% lower than 7mm. Here the freedom from endoleaks type I was one at 30 days which has been resolved and another one developed after 30 days which also has been involved. No type III.

Stent graft patency after 30 days also 100% and otherwise also no other adverse events with this device at thirty days. So to answer the question with this device to the first question of (mumbles) will lighter fabrics and stent material decrease EVAR durability?

Will there be more endoleaks I, III, or IV? You can see here the long-term data so no Ia endoleak developed over four and five years, there was one Ib endoleak which developed at four years which also was apparent at five years. No type III endoleak.

One graft patency failure with a (mumbles) occlusion here at four years which also was here at five years. No migration, one fraction of the (mumbles) proximal third graft, otherwise it was very safe. You can see here once again the Kaplan-Meier curve for type I endoleaks through five years here

with type Ib here later on, and this is the patency Kaplan-Meier curve also showing here the good patency at five years, and this is freedom from second large vent. Here I don't have any data whether this is type II endoleak or not so this still has to be reported and clarified.

So to conclude the INCRAFT performed well on long-term while overcoming more difficult access morphologies. The endograft can be utilized in patients with demanding access and vessel morphology, and there are more studies ongoing.

There is one in the US and Japan where we wait for long-term data, 190 patients and also from Europe's 180 patients also there we still wait for long-term data. Thank you.

- Thank you Dr. Melissano for the kind interaction. TEVAR is the first option, or first line therapy for many pathologies of the thoracic aorta. But, it is not free from complications and two possible complications of the arch are the droop effect and the bird-beak. I was very interested as Gore came up with the new

Active Control System of the graft. The main features of this graft, of this deployment system are that the deployment is staged and controlled in putting in the graft at the intermediate diameter and then to the full diameter. The second important feature is that we can

optionally modify the angulation of the graft once the graft is in place. Was very, very interesting. This short video shows how it works. You see the graft at the intermediate diameter, we can modify the angulation also during this stage

but it's not really used, and then the expansion of the graft at the full diameter and the modification of the angulation, if we wished. This was one of the first cases done at our institution. A patient with an aneurysm after Type B dissection. You see the graft in place and you see the graft after

partial deployment and full deployment. Perhaps you can appreciate, also, a gap between the graft and the lesser curvature of the arch, which could be corrected with the angulation. As you can see here, at the completion angiography we have an ideal positioning of the graft inside the arch.

Our experience consisted only on 43 cases done during the last months. Mostly thoracic aneurysm, torn abdominal aneurysm, and patients with Type B aortic dissection. The results were impressive. No mortality, technical success, 100%,

but we had four cases with problems at the access probably due to the large bore delivery system as you can see here. No conversion, so far and no neurological injury in this patient group. We have some patients who came up for the six months follow-up and you see here we detected one Type 1b endoleak,

corrected immediately with a new graft. Type II endoleak which should be observed. This was our experience, but Gore has organized all the registry, the Surpass Registry, which is a prospective, single-arm, post market registry including 125 patients and all these patients

have been already included in these 20 centers in seven different countries in Europe. This was the pathology included, very thorough and generous, and also the landing zone was very different, including zone two down to zone five. The mean device used per patient were 1.3.

In conclusion, ladies and gentlemen, the Active Control System of the well known CTAG is a really unique system to achieve an ideal positioning of the graft. We don't need to reduce the blood pressure aggressively during the deployment because of the intermediate diameter

reached and the graft angulation can be adjusted in the arch. But, it's not reversible. Thank you very much for your attention.

3

- This is from some work in collaboration with my good friend, Mike Dake. And, a couple of years of experience at Stanford now. First described by Kazy? years ago. This technical note of using multiple main-body endographs in a sandwich formation.

Up at the top but, then yielding multiple branches to get out to the visceral vessels and leaving one branch for a bifurcated graft. We've sort of modified it a little bit and generally either use multiple

grafts in order to create a branch the celiac and SMA. Left the celiac sometimes for a chimney, but the strategy really has been in one of the limbs to share both renals and the limb that goes down to the legs. We noticed early on that this really was not for

non-operative candidates, only for urgent cases and we recognize that the visceral branches were the most important to be in their own limb. I'll just walk you through a case. 6.8 centimeter stent for foraco above

the prior opened repair. The plan drawn out here with multiple main bodies and a second main body inside in order to create the multiple branches. The first piece goes in. It's balloon molded at the level of pulmonary

vein with enough length so that the ipsalateral limb is right next to the celiac. And we then, from above get into that limb and down into the celiac vessel and extend with either a limb or a viabahn. Next, we deploy a second main body inside

of the gate, thus creating now another two limbs to work through. And then through that, extend in its own branch a limb to the SMA. This was an eight by 79 vbx. Then we've got a third limb to go through.

We put a cuff that measures about 14. This is the math so that the double renal snorkle plus the main body fills up this hole. Now, double sheath access from above, looking for both renals. Sheaths out into both renals with viabahns

inside of that. Deployment of the bottom device and then a final angiogram with a little bit of a gutter that we often see when we have any kind of parallel graft configuration. Here's the post-op CT scan wherein

that limb is the two shared renals with the leg. This is the one year post-op with no endo leaks, successful exclusion of this. Here's another example of one of an eight and a half centimeter stent three thorico similar strategy, already with an occluded

celiac. Makes it a little bit easier. One limb goes down to the superior mesenteric artery and then the other limb then is shared again bilateral renals in the lower main body. Notice in this configuration you can get all the way up to the top then by putting a thoracic component

inside of the bifurcated subabdominal component. There's the final CT scan for that. We've spent some time looking at the different combinations of how these things will fill up to minimize the gutters through some more work. In collaboration with some friends in Kampala.

So we've treated 21 patients over the last couple of years. 73 years of age, 48 percent female usual comorbid factors. Oh, I thought I had more data there to show you. O.K. I thought this was a four minute talk.

Look at that. I'm on time. Octopus endovascular strategy is a feasible off the shelf solution for high risk patients that can't undergo open repair. You know obviously, sort of in this forum and coming to this meeting we see what's

available outside of the U.S. and I certainly am awaiting clinical trial devices that will have purpose specific teacher bi-graphs. The end hospital morbidity has still been high, at four percent. The one year survival of 71 percent in this select

group of 21 patients is acceptable. Paraplegia is still an issue even when we stage them and in this strategy you can stage them by just doing the top part plus the viscerals first and leaving the renals for another day. And branch patency thus far has been

in the short term similar to the purpose specific graft as well as with the parallel graft data. Thank you.

- Thank you Mr. Chairman. Thank you, Dr. Veith for you kind invitation. Okay, there we go. Excuse me. DEVASS stands for Dutch EVAS study Group. We all know that women have a twofold, increased risk frequency of rupture.

The average aortic size at rupture is five millimeters smaller. They have a higher rate of undiagnosed cardiovascular diseases. They have smaller ileofemo

more concomitant iliac aneurysms They have a more challenging aortic neck. Smaller proportion is eligible for EVAR and, therefore less likely to meet EVAR IFU. They have a longer length of hospital stay after EVAR, a higher re-admission rate, more major complications,

a higher mortality rate. So, women and AAA is a challenging combination. The rationale behind EVAS is known to you all, I think. The DEVASS cohort is from three high volume centers in The Netherlands. It's a retrospective cohort of 355 patients,

included from April, 2013 to December 2015. So I have two years of result data. If you look at the baseline characteristics, 45 females were in this cohort, with the age of 76 and with some known comorbidities. They were within the instructions for use of 2013, at 28.9%

and even less in the IFU of 2016. These are some more anatomical characteristics with the AAA outer diameter 5.6 centimeters. This is the procedure, most of the patients were under general anesthesia, with the cutdown and the procedure time

was about 100 minute. Straight forward procedure 33 cases out of these 45. Let's have a quick look at the clinical outcomes. The re-intervention's done in the first 12 month. One patient had to conversion to open repair at month 11 due to type 1A Endoleak, and the others were not directly

related to the procedure itself. Although, there was thrombus in approximate stand. In the second month we saw, in the second year we saw some more type 1A migrations and a Stenosis that needed relining, and two out of these patients were within IFU.

If you look at the total cohort of type 1A Endoleak, one patient was not operated on and the other were, either open conversion or relining, and one patient was within IFU. A quick look at the death characteristics. Only one patient was within IFU,

and died after open procedure. So the re-interventions, once again, the first year four patients, in the second year five patients. Conversion to open repair, in total three patients. Endovascular re-intervention was performed

in the first year in two patients and in the second year there were three relinings performed. Endoleak 1A, in total six as stated before. No type two Endoleak reported, and in the first year five patients died, which one was aneurisym related, as in the second year, two patients died,

which one was aneurysm related. If we compare this data with the EVAS Global data, of two years not the three year data, this is the freedom from all persistent Endoleak, close to 98% which is good. Freedom from type 1A Endoleak is within IFU, 97% in the global and outside IFU 85%,

and remind these patients 71% were outside IFU. Freedom from secondary interventions, we had to re-intervene in nine patients and its comparable with outside IFU. Freedom from mortality at two years, a bit higher, aneurism related mortality is 95% which is higher, and also the all cost mortality is higher in women.

So to conclude, this is the first cohort that focuses on women after EVAS. The majority of the patients was outside IFU, and as in EVAR women do not that very good in result, appear to be very much like an EVAR. Thank you.

- Mister Chairman, ladies and gentlemen. Good morning. I am excited to present some of the data on the new device here. These are my disclosure. There are opportunities to improve current TEVAR devices. One of that is to have a smaller device,

is a rapid deployment that is precise, and wider possibilities to have multiple size matrix to adapt to single patient anatomy. The Valiant device actually tried to meet all these unmet needs, and nowadays the Navion has been designed on the platform

of the Valiant Captivia device with a completely different solution. First of all, it's four French smaller than the Valiant Captivia, and now it's 18 French in outer diameter for the smallest sizes available.

The device has been redesigned with a shorter tip and longer length of the shaft to approach more proximal diseases, and the delivery system deploys the graft in one step that is very easy to accomplish and precise.

The fabric has been changed with nowadays the Navion having the multi-filament weave of the Endurant that already demonstrates conformability, flexibility, and long-term durability of the material. It's coming with a wide matrix of options available. In terms of length, up to 225 mm.

Diameters as small as 20 mm, and tapered device to treat particular anatomical needs. But probably the most important innovation is the possibility to have two proximal configuration options: the FreeFlo and the CoveredSeal.

Both tied to the tip of the device with the tip-capture mechanism that ensures proximal deployment of the graft that is very accurate. This graft is being under trial in a global trial

that included 100 patients all over the world. The first 87 patients have been submitted for primary endpoint analysis. 40% of the patients were females. High risk patients showed here by the ASA class III and IV. Most of the patients presented

with a fusiform or saccular aneurysm, and the baseline anatomy is quite typical for these kinds of patients, but most of the patients have the very tortuous indices, both at the level of the access artery tortuosity and the thoracic aorta tortuosity.

Three-fourths of the patients had been treated with a FreeFlo proximal end of the graft, while one-fourth with the CoveredSeal. Complete coverage of the left subclavian occurred in one-fifth of the patients. Almost all had been revascularized.

Procedure was quite short, less than one and half hour, percutaneous access in the majority of cases. There were no access or deployment failures in this series. And coming to the key clinical endpoints, there were two mortality reported out of 87 patients.

One was due to the retrograde type A dissection at day one, and one was not device related almost at the end of the first month. Secondary procedures were again two. One was in the case of retrograde type A dissection, and the second one in a patient

that had an arch rupture due to septicemia. Type 1a endoleak was reported in only one case, and it was felt to be no adverse event associated so was kept under surveillance without any intervention. Major Adverse Events occurred in 28% of the cases. Notably four patients had a stroke

that was mild and not disabling, regressing in two weeks. Only one case of spinal cord ischaemia that resolved by drainage and therapy in 20 days. In summary, we can say that the design enhancement of Valiant Navion improved upon current generation TEVAR.

Acute performance is quite encouraging: no access or deployment failure, low procedural and fluoro times, low rate of endoleaks, Major Adverse Events in the range expected for this procedure.

Nowadays the graft is USA FDA approved as well as in Europe CE mark. And of course we have to wait the five years results.

- Now I want to talk about, as Chrissy mentioned AVM Classification System and it's treatment implication to achieve cure. How do I put forward? Okay, no disclosures. So there are already AVM Classification Systems. One is the well-known Houdart classification

for CNS lesions, and the other one is quite similar to the description to the Houdart lesion, the Cho Do classification of peripheral AVM's. But what do we expect from a good classification system? We expect that it gives us also a guide how to treat with a high rate of cure,

also for complex lesions. So the Yakes Classification System was introduced in 2014, and it's basically a further refinement of the previous classification systems, but it adds other features. As for example, a new description of

a new entity, Type IV AVM's with a new angioarchitecture, it defines the nidus, and especially a value is that it shows you the treatment strategy that should be applied according to angioarchitecture to treat the lesion. It's based on the use of ethanol and coils,

and it's also based on the long experience of his describer, Wayne Yakes. So the Yakes Classification System is also applicable to the very complex lesions, and we start with the Type I AVM, which is the most simple, direct

arterial to venous connection without nidus. So Type I is the simplest lesion and it's very common in the lung or in the kidney. Here we have a Type I AVM come from the aortic bifurcation draining into the paralumbar venous plexus,

and to get access, selective cauterization of the AVM is needed to define the transition point from the arterial side to the venous side, and to treat. So what is the approach to treat this? It's basically a mechanical approach, occluding

the lesion and the transition point, using mechanical devices, which can be coils or also other devices. For example, plugs or balloons. In small lesions, it can also be occluded using ethanol, but to mainly in larger lesions,

mechanical devices are needed for cure. Type II is the common and typical AVM which describes nidus, which comes from

multiple in-flow arteries and is drained by multiple veins. So this structure, as you can see here, can be, very, very dense, with multiple tangled fistulaes. And the way to break this AVM down is mainly that you get more selective views, so you want to get selective views

on the separate compartments to treat. So what are the treatment options? As you can see here, this is a very selective view of one compartment, and this can be treated using ethanol, which can be applied

by a superselective transcatheter arterial approach, where you try to get as far as possible to the nidus. Or if tangled vessels are not allowing transcatheter access, direct puncture of the feeding arteries immediately proximal to the nidus can be done to apply ethanol. What is the difference between Type IIa and IIb?

IIb has the same in-flow pattern as Type a, but it has a different out-flow pattern, with a large vein aneurysm. It's crucial to distinguish that the nidus precedes this venous aneurysm. So here you can see a nice example for Type IIb AVM.

This is a preview of the pelvis, we can here now see, in a lateral view, that the nidus fills the vein aneurysm and precedes this venous aneurysm. So how can this lesion be accessed? Of course, direct puncture is a safe way

to detect the lesion from the venous side. So blocking the outflow with coils, and possibly also ethanol after the flow is reduced to reflux into the fistulaes. It's a safe approach from the venous side for these large vein aneurysm lesions,

but also superselective transcatheter arterial approach to the nidus is able to achieve cure by placing ethanol into the nidus, but has to be directly in front of the nidus to spare nutrient arteries.

Type IIIa has also multiple in-flow arteries, but the nidus is inside the vein aneurysm wall. So the nidus doesn't precede the lesion, but it's in the vein wall. So where should this AVM be treated?

And you can see a very nice example here. This is a Type IIIa with a single out-flow vein, of the aneurysm vein, and this is a direct puncture of the vein, and you can see quite well that this vein aneurysm has just one single out-flow. So by blocking this out-flow vein,

the nidus is blocked too. Also ethanol can be applied after the flow was reduced again to reflux into the fistulas inside the vein aneurysm wall. And here you can see that by packing a dense packing with coils, the lesion is cured.

So direct puncture again from the venous side in this venous aneurysm venous predominant lesion. Type IIIb, the difference here is again, the out-flow pattern. So we have multiple in-flow arteries, the fistulaes are again in the vein aneurysm.

Which makes it even more difficult to treat this lesion, is that it has multiple out-flow veins and the nidus can also precede into these or move into these out-flow veins. So the dense packing of the aneurysm might have to be extended into the out-flow veins.

So what you can see here is an example. Again you need a more selective view, but you can already see the vein aneurysm, which can be targeted by direct puncture. And again here, the system applies. Placing coils and dense packing of the vein aneurysm,

and possibly also of the out-flow veins, can cure the lesion. This is the angiogram showing cure of this complex AVM IIIb. Type IV is a very new entity which was not described

in any other classification system as of yet. So what is so special about this Type IV AVM is it has multiple arteries and arterioles that form innumerable AV fistulaes, but these fistulaes infiltrate the tissue. And I'm going to specify this entity in a separate talk,

so I'm not going too much into details here. But treatment strategy of course, is also direct puncture here, and in case possible to achieve transarterial access very close to the nidus transarterial approach is also possible. But there are specific considerations, for example

50/50 mixture of alcohol, I'm going to specify this in a later talk. And here you can see some examples of this micro-fistulae in Type IV AVM infiltrative type. This is a new entity described. So the conclusion is that the Yakes Classification System

is based on the angioarchitecture of AVM's and on hemodynamic features. So it offers you a clear definition here the nidus is located, and where to deliver alcohol in a safe way to cure even complex AVM's.

Thank you very much.

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