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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