CX NEWS

The development of new stents specifically designed for deep venous reconstruction, new techniques for lysis and imaging are playing a key role in the treatment of deep vein thrombosis; an area that, according to Stephen Black (Guy’s and St Thomas NHS Foundation Trust, London, UK), member of the CX Programme Organising Board, has been largely neglected for years. In this interview, Black, who will be chairing a session dedicated to the deep venous system at the Venous Controversies session of CX 2015, speaks about the advances in the field.    

What is the major controversy in deep venous treatment?

The main controversy is still the role of the new venous stents and whether these will really change treatment and outcome for patients with chronic obstructive disease causing post thrombotic syndrome.

What methods are showing optimal results in deep venous reconstruction?

Currently the new techniques for lysis and the development of more robust stents have renewed interest in this area. There is certainly great potential with these new developments; however, we still need to be cautious using them given the real absence of descent data to support how, when and why we treat these patients.

Now more stents have been developed specially for the venous anatomy; what impact have these devices had in the treatment of venous disease?

The new stents for venous treatment have raised awareness and led to a renewed focus on what was a largely neglected area for a number of years. Patients with symptoms after deep vein thrombosis are desperate for treatment and have received the answer of nothing to be done for too long. As a group of clinicians we need to embrace this momentum to see if we can make a difference to this group of patients.

What is the role of imaging in deep venous interventions?

The role of imaging is to try and outline anatomy in the best possible manner. In particular, we need to identify what inflow the patient will have into the area that needs stenting and also whether there is a problem more proximally. It helps to identify if there is an obstructive lesion (i.e. May Thurners/Cockets lesion) and whether the patient may require a purely stent procedure or possibly open surgery or a combination of both.

What imaging methods are showing best results?

Intravascular ultrasound (IVUS) and magnetic resonance imaging (MRI) currently have the greatest potential for diagnosis in deep venous treatment. MRI helps to reduce the radiation dose in what are usually a young group of patients. MRI has also the potential to age clot, which is really exciting (delegates will have the opportunity to learn about this MRI capability at the Venous Controversies of the CX Main Programme). IVUS may also help reduce radiation exposure but also provides significantly more real time detail when treating these patients.

Currently we are limited by the imaging modalities all providing us with static images. We need to develop techniques that help identify what the flow is like in the system and measure pressure.

The CX Venous Controversies Day will take place at the Charing Cross Symposium on Friday 1 May – Main Auditorium, Olympia Grand, London, UK.

Delegates will have the opportunity to get hands-on training on the latest techniques for deep venous thrombosis treatment at the CX Venous Workshop on Wednesday 29 April and Thursday 30 April – Gallery Upper Level, Olympia Grand, London, UK 

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The controversy around the treatment of infrarenal abdominal aortic aneurysm necks of less than 15mm will spark the discussion in the Abdominal Aortic Controversies Day of this year’s CX Main Programme. Delegates will also hear the latest evidence on the best way to manage a ruptured aneurysm and will have the opportunity to discuss whether too many patients with ruptured abdominal aortic aneurysms are being denied intervention. In addition, the controversy regarding radiation damage to the operator and the patient will be addressed and a series of clinical approaches for elective aneurysm repair will be discussed.  

“The management of the aortic neck of less than 15mm is certainly very controversial,” says Roger Greenhalgh (Imperial College, London, UK), chairman of the CX Programme Organising Board. Therefore, he comments, “We will try to address every possible way of treatment.”

Commenting on endovascular aneurysm repair (EVAR) for short necks, Andrew Holden (Auckland City Hospital, Auckland, New Zealand), member of the CX Programme Organising Board, says: “We are aware that using EVAR to treat infrarenal aneurysms with hostile necks has been historically associated with higher aneurysm-related morbidity and mortality. Can new EVAR technologies and techniques change this paradigm?”

Delegates will have the opportunity to hear about the latest evidence regarding EVAR, open surgery and new technologies that are addressing the treatment of infrarenal abdominal aortic neck at the CX Abdominal Aortic Controversies Day (Wednesday 29 April). (Read an interview on the subject with Frans Moll, co-chairman of the CX Programme Organising Board).

Management of ruptured abdominal aortic aneurysms

The latest evidence on the best way to manage a ruptured aneurysm will be presented including the one-year results of the IMPROVE trial and the IPD 3 trial. In the same session, the controversy as to whether many patients with ruptured abdominal aortic aneurysms are denied intervention will be discussed.

Greenhalgh comments: “Perhaps doctors are becoming more concerned about operating for fear of having poor mortality figures. We need to find evidence whether indeed patients are denied intervention.”

Janet Powell (Imperial College, London, UK), member of the CX Programme Organising Board, considers that a few patients are offered repair of ruptured aortic aneurysm because perhaps “not all centres have an endovascular team and facilities available at all times; additionally, there are financial stringencies on healthcare systems and many of these patients may need intervention out of hours.”

Holden adds that many questions on this subject remain unanswered: “Do we have sufficient data to support an ‘EVAR first’ approach for ruptured abdominal aortic aneurysm repair patients? If not, who should be offered EVAR? Does the lower early morbidity associated with EVAR mean more ruptured aneurysms should be treated?”

These and other questions will stir a debate on the subject to be led by Matt Thompson (St George’s Vascular Institute, London, UK) and Peter Lamont (North Briston, NHS Trust, Bristol, UK).

Radiation exposure concerns

Additionally, in the CX Abdominal Aortic Controversies Day, strategies for radiation exposure reduction to the operator and to the patient will be discussed in a mini-symposium. Members of the CX Programme Organising Board consider this subject a top priority in the field. Greenhalgh comments: “The risk of radiation damage to the operator and to the patient is now known to be serious and many physicians have damaged themselves trying to treat their patients.” Powell adds: “Many of the early pioneers of EVAR/TEVAR are now dying of cancer. The importance of reducing radiation burden and safety is one of the key contemporary issues that need to be addressed.”

Subsequently, delegates will learn about a series of clinical approaches for elective aneurysm repair including the latest evidence on a new iliac branch endoprosthesis and treatment strategies for octo- and nonagenarians.

Moreover, the long-term follow-up of EVAR after 20 years of introduction will be also addressed. Holden comments: “The optimum follow-up protocol after EVAR is also likely to be controversial. This is an important discussion as post-procedural surveillance is a major cost contributor to EVAR.”  

The CX Abdominal Aortic Day will close with a mini-symposium on the management of type I endoleaks.

 
The CX Abdominal Aortic Controversies Day will take place at the Charing Cross Symposium on Wednesday 29 April – Main Auditorium, Olympia Grand, London, UK

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Frans Moll (University Medical Center Utrecht, Utrecht, The Netherlands), co-chairman of the CX Programme Organising Board, gives his views as to why the management of short necks is a hot topic in the field and discusses the current strategies of treatment. He will moderate the session “Procedures for infrarenal abdominal aortic neck” of the CX Abdominal Aortic Controversies Day.   

Why is the management of aortic necks of less than 15mm controversial?
There is still an axiom that durability for proximal fixation of the aortic neck with endovascular aneurysm repair (EVAR) depends on sealing and fixation, so you do not only need fixation but you also need a certain amount of sealing zone. The critical sealing zone corresponds to one ring of the stent graft. This is usually between 1.2 and 1.5cm in length.

What are the factors that must be considered when treating short infrarenal aortic necks with endovascular approaches?
If you think that the patient will really benefit from endovascular procedures as opposed to open procedures you need to accept shorter necks (>1.5cm in length). The conditions in which it can be accepted are either suprarenal fixation or T-branched.  

What endovascular approaches are currently addressing the management of this type of necks?
In shorter stenting we could use sealing prototypes; for example, there is a device that inflates the sealing zone and another one where the polymer is used to fill the aneurysm sac. You could also use a stent graft that is specifically designed for shorter necks (1.5cm up to 1cm). There is also a system that uses endoluminal staples designed to secure the neck.

At the “Procedures for infrarenal abdominal aortic neck” session, physicians will debate whether EVAR is not sensible for abdominal aortic aneurysms with a neck length shorter than 10mm; are you for or against the motion and why?
I think that necks shorter than 10mm can be treated safely with EVAR but you need to consider the latest generation stent grafts. Not every stent graft is able to provide a good result between 8mm and 10mm length.  

 
The CX Abdominal Aortic Controversies Day will take place at the Charing Cross Symposium on Wednesday 29 April – Main Auditorium, Olympia Grand, London, UK

 
Click here to see the CX Main Programme Sessions

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Type B dissection of the aorta will be the main topic of controversy at this year’s Charing Cross Symposium. Predictions of clinical success after thoracic endovascular aortic repair (TEVAR), factors that predict success after TEVAR for chronic type B dissection, the latest evidence for embolisation of false lumen and spinal cord protection are some of the topics that will be discussed in the CX Thoracic Aortic Controversies Day (Thursday 30 April).    

Last year, the majority of delegates who attended a debate titled “For uncomplicated type B dissections, early intervention is indicated” voted against the motion. This year, the debate in this area will assess whether the long-term results following intervention for sub-acute uncomplicated type B dissection warrant intervention.

The Thoracic Aortic Day will also include discussions on the incidence of stroke during aortic arch interventions, treatment options for ascending and arch of the aorta including TEVAR, branched stent grafts for complex arch lesions, open surgery and the use of robotic systems.  

Furthermore, amongst the descending thoracic aortic, thoracoabdominal and juxtarenal aortic controversies, the question of threshold diameter for intervention in the thoracic aorta will be raised. Roger Greenhalgh (Imperial College, London, UK), chairman of the CX Programme Organising Board, says: “Evidence for the precise diameter to intervene is extremely sparse and this will be brought out in the session”.

Interview with Andrew Holden, member of the CX Programme Organising Board

Andrew Holden (Auckland City Hospital, Auckland, New Zealand), member of the CX Programme Organising Board and chairman of the session “Controversies in chronic type B dissection of the aorta” speaks on the subject.  

Why is the management of chronic type B dissections controversial?

Currently, this is one of the most important sessions at CX and hopefully some consensus will emerge. There is no doubt that treatment of acute complicated type B aortic dissection is widely accepted. What is less clear is whether uncomplicated type B dissection should undergo endovascular treatment and if so when (acute, sub-acute or chronic). In chronic type B dissection, the biggest challenge is to successfully exclude the aneurysmal component (preventing retrograde false lumen perfusion) and maintain branch artery patency.

What are the factors that must be considered when treating chronic type B dissections?

The common thread when treating chronic type B dissection is to exclude the primary (or inflow) intimal tear. It is then unclear how much aorta needs to be covered and how retrograde perfusion of the false lumen can be avoided. In the dissected and aneurysmal abdominal aorta, the challenge is to exclude the false lumen but maintain branch artery patency.

What challenges in TEVAR have to be overcome in order to avoid complications?

Feared complications in TEVAR include retrograde dissection and spinal ischaemia. A number of strategies have been developed and will be discussed at the CX Thoracic Aortic Controversies Day.

The CX Thoracic Aortic Controversies Day will take place at the Charing Cross Symposium on Thursday 30 April – Main Auditorium, Olympia Grand, London, UK

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With the aim to study key controversies from its Main Programme in technical detail, the Charing Cross Symposium is launching the CX Edited Live Cases, a session that will focus on aortic and carotid procedures. Delegates will have the opportunity to explore the application of different techniques in complex situations, which perhaps could not have been broadcast in a live case because of patient’s safety. Roger Greenhalgh (Imperial College, London, UK), chairman of the CX Programme Organising Board, explains the details of this new session.  

Why are the CX Edited Live Cases focusing on the aortic and carotid fields?
The CX Programme Organising Board decided that live cases will be broadcast only in situations where the patient’s life is not at risk and where the surgeon is doing something which is not life-threatening, hence the existence of the CX Live Peripheral Arterial Cases. In peripheral procedures the risk is not as high as in aortic or carotid interventions so we thought it was legitimate to have live cases only for lower limb procedures.  

The CX Edited Live Cases are being offered in situations in which the patient’s life or condition could in some way be made worse through having the operator concentrate on filming rather than focusing on the patient. In aortic procedures the slightest slip could be very disastrous for the patient. In this kind of intervention the surgeon requires complete concentration on the patient. Another example is in carotid procedures where there is a risk of embolisation to the brain.

What makes the CX Edited Live Cases different from edited live cases presented at other conferences?
The difference in our Edited Live Cases is that we are relating this session systematically to our Main Programme (Aortic and Carotid) and at all points we will be stressing the evidence that the procedure works. For example, a short presentation in the Main Programme could include a specific device for abdominal aortic aneurysm treatment. In the CX Edited Live Cases that same product can be exposed to show in more detail what is special about it, compared to other aortic devices, and how and why it can be used in that specific case. The topics in the Main Programme normally give the evidence on how to fix a certain condition, but there will always be discussions about why it is thought it works and for the audience to cross question any person. The CX Edited Live Cases will bring an additional space to expand on these discussions and show the technical details.

What kind of procedures should delegates expect to see in the CX Edited Live Cases session?
Delegates should expect to see cases addressing endovascular aneurysm repair (EVAR), thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm sealing (EVAS). The cases will include thoracic complex procedures and abdominal procedures of different types. A carotid mesh procedure, which is aimed to reduce embolisation to the brain to prevent stroke, will also be presented. In addition, we are going to have an Edited Live Case about how to control infection, which you could not do in a live case. We will have approximately 10 Edited Live Cases.

Could you explain what the format of the session will be?
Similar to the Main Programme sessions, the panel of the CX Edited Live Cases will include a chairman, the operator in the Edited Live Case, the phycisian who will be explaining it to the audience and two invited discussants. The speaker will present the case including patient characteristics, reason for the procedure, the necessary investigation undertaken (eg. X-rays), the choice of devices available, the strategies of treatment proposed and all of the pitfalls and concerns raised before the procedure.

After this presentation, a 10-minute edited video will be presented. In order to allow room for discussion about a specific technique the video could be stopped—this is an added benefit you could not have in a live case presentation. This approach will help to improve the educational basis of this session. After that, the aim will be to engage the audience in discussion.

Delegates will also have the opportunity to see these cases post Charing Cross 2015 from a video library that will be created from this initiative.

The CX Edited Live Cases (Aortic and Carotid) will take place at the Charing Cross Symposium on Tuesday 28 April – Grey Learning Centre, Olympia Grand, London, UK

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Strategies for treatment of the superficial femoral artery with the concepts of “Leaving nothing behind” or “Leaving something in” will take centre stage in the Peripheral Arterial Controversies session of this year’s CX Main Programme. In addition, delegates will hear about early clinical outcomes with a new flexible endoluminal stent for iliac artery disease. The treatment of popliteal aneurysms by endovascular means will also be subject of discussion, as well as the best treatment options for below-the-knee lesions.    

Roger Greenhalgh, chairman of the CX Programme Organising Board, says that the session aiming at “unpacking” the superficial femoral artery will be one of the highlights of the CX Peripheral Arterial Day in the Main Programme (Tuesday 28 April). “We will try to inform the audience about what to do in the superficial femoral artery and when, depending on the type and length of lesion and based on the available evidence.” He adds, “The speakers will consider more severe arterial disease which in their view requires a stent. If something is to be ‘left behind’ this needs to be justified”.

Commenting on the “Leaving nothing behind” concept, Cliff Shearman (University of Southampton, Southampton, UK), member of the CX Organising Board, says: “This is a great idea but the technology (drug-coated balloons, atherectomy) is expensive and we have to see the evidence on how much benefit it does give and for how long.”

Moreover, attendees will learn the results, at five years, of the superficial femoral artery treatment with open surgery.     

Delegates will also have the opportunity to discuss in more detail the superficial femoral artery controversies on Thursday 30 April in two roundtables to be held at the CX ilegx Collaboration Day course.

Furthermore, in the CX Peripheral Arterial Day, iliac reconstruction will be addressed with early clinical outcomes of a new flexible endoluminal stent graft. Additionally, the treatment of popliteal aneurysms by endovascular means will be subject of discussion. Commenting on his view on the topic, Shearman says: “Although this is commonly advocated we need to see the long-term results. Also we need to ask ourselves, ‘How many popliteal aneurysms are really suitable for endovascular treatment’?” Physicians will have the chance to discuss their views during this debate at the end of the session.

Below-the-knee treatment options and their effectiveness will also be discussed. Michael Edmonds, member of the CX Organising Board, says: “Addressing below-the-knee intervention strategies is of great importance considering the dramatic rise in the incidence of diabetes mellitus.” Greenhalgh adds: “The below-the-knee arteries are smaller and have difficult technical challenges—the durability of the procedures is seldom stated longer than for two years.”

When treating patients with peripheral arterial disease Greenhalgh says, “advising the patient on self-management including smoking cessation, exercise and healthy living is fundamental”. The second principle, he adds, is to intervene only when it is necessary and avoid making the patient worse. And finally, it is necessary to intervene with a technique as minimal as possible and that can produce durable results. “In the end, it is the patient’s quality of life that matters and if the arterial disease is overcome the symptoms should improve,” he notes.

The CX Peripheral Arterial Day will take place at the Charing Cross Symposium on Tuesday 28 April – Main Auditorium, Olympia Grand, London, UK

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