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 

Click here to see the CX Main Programme Sessions

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Click here to see the CX Venous Workshop

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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

Click here to see the CX Main Programme Sessions

Click here to see the CX Parallel Sessions

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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

Click here to see the CX Parallel Sessions

Click here to register