BSET discusses the future of endovascular therapies

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Vascular News attended the inaugural meeting of the British Society of Endovascular Therapy (BSET), Meriden, UK, held on the June 8, 2007. The Society is not designed to compete with existing UK organisations for vascular surgery or interventional radiology, but rather to provide a platform where endovascular specialists can exchange ideas and discuss practice.

Mr John Brennan’s, Royal Liverpool Hospital, UK, introduced BIBA Medical’s research director, Jonathan Sheldrake, London, UK, who presented a discussion demonstrating the development of endovascular procedures across Europe. He demonstrated through data from the European Vascular and Endovascular Monitor (EVEM) how endovascular procedures are gradually increasing at the expense of open procedures. However, he also pointed out that recent clinical trial results in the carotid (EVA-3S and SPACE) and abdominal aortic aneurysms (AAA) indications (DREAM), in particular, were slowing down growth in these areas. Longer-term clinical trials were needed before it could be sure whether endovascular procedures would continue the high growth rates shown over recent years, he said.

Sheldrake was followed by a series of presentations. The first presenter was Ms T Tang, Cambridge University Hospitals NHS Foundation Trust, who addressed the BASIL (Bypass versus Angioplasty in Severe Ischaemia of the Leg Bypass versus Angioplasty in Severe Ischaemia of the Leg) trial. She showed that there were few randomised controlled trials looking specifically at infrainguinal disease and in her opinion, BASIL was the only robust large-scale study to date. Tang felt it was difficult to analyse outcomes of earlier studies following significant advances in endovascular techniques although the data suggested the preferential use of angioplasty for the treatment of lower limb occlusive arterial disease reduces morbidity.

Mr Rob Morgan, St Georges Vascular Institute, London, discussed bilateral internal artery embolisation before endovascular aneurysm repair (EVAR) and asked if it was safe. He felt that it was safe and in support of this, stated that the long-term claudication rate was 9%. Morgan felt that proximal occlusion was preferable to distal occlusion and that simultaneous procedures may be better than sequential ones.

Ms Claire Brown, Leicester, UK, looked at the EVAR 1 trial and if it had changed practice. She showed that since the publication of EVAR 1 data in 2005, the number of AAA endovascular procedures had gone up significantly at her centre. Nevertheless, she concluded that despite the proven benefits of EVAR, the publication of the EVAR 1 trial data had not resulted in significant changes in her practice. She stated that there was still a significant proportion of patients undergoing open repair who are suitable for open repair, and are suitable for EVAR. This may be due to doubts over stent durability causing bias towards open repair in younger patients.

The session concluded with Dr D Beckett, Sheffield Vascular Institute, UK. He discussed the possibility of a hybrid endograft for one-step treatment of thoracic aortic pathology. The preliminary study he had been working on showed promising results. It suggested that intraoperative antegrade stenting of the descending aorta combined with aortic arch repair is an easy and safe method to employ, and does not significantly increase circulatory arrest time.

Next, in a award-giving ceremony, the BSET prize was awarded to Professor Chee Soong and his group, Royal Belfast Hospital, Ireland. Dr R Makar, Royal Belfast Hospital, Ireland, briefly presented the work that Soong and his team had performed. They had completed a prospective study comparing the effects of EVAR vs. open repair (OR) on post-operative abdominal pressure, systemic inflammatory response (SIRS) and pulmonary function.

Their methodology was that all patients with ruptured AAA (rAAA) with endo-suitable anatomy underwent EVR while the remaining patients had OR. Intra-abdominal pressure (IAP) was measured at two hours, six hours and 24 hours post-operatively, then daily for five days. SIRS and lung injury score were recorded daily for five days. Data analysis was performed using non-parametric tests with significance taken at the 5% level. Results are expressed as median (inter-quartile range).

Summarising the results, Makar reported that 30 patients were recruited (October 2004 to January 2007). Fourteen patients had EVAR and sixteen had OR. Two patients died in each group. The open group had a significantly higher lung injury score at day one and day three (p=0.03 & p = 0.02) respectively. There was a significant correlation between the IAP at day four and the SIRS at day five (r=0.37 & p=0.049).

Makar concluded that the data the Belfast group had collected suggested that EVAR of ruptured AAA can reduce the host systemic inflammatory response and pulmonary dysfunction because it minimises the increase to IAP when compared to OR.

Vascular surgery – past to present

Sir Peter Bell then discussed the past and future of vascular surgery in the UK. He referred to a publication he had authored in 1981 to demonstrate the dominance of vascular surgery at that time. He explained that aorto-iliac surgery had now been replaced by endovascular techniques. Angiography, in his opinion, had revolutionised vascular surgery and allowed surgeons to see the pathology prior to surgery. Bell then discussed the Russian origins of the stent graft and the role Juan Parodi had played in popularising it.

Bell then discussed EVAR and stated that although it costs more, it does have the benefit of 3% better aneurysm related survival. He felt that, in general, younger patients under 65 were better suited to open repair but that older patients were usually more suited to EVAR. He did, however, caution that very unfit patients should not be treated at all.

Concluding, Bell contended that open procedures were getting less common and endovascular procedures were attaining better and better results. According to Bell, patients were also demanding less invasive therapy. Nevertheless, more evidence of efficacy was needed. He also warned that cardiologists were increasingly interested in treating peripheral vascular disease and that obtaining adequate training in open surgical techniques was likely to be increasingly difficult in the future. Finally, Bell explained that he felt that vascular surgery must become a speciality worldwide and in the UK. Vascular surgeons, in his opinion, no longer had time to spend training in general surgery.

In the quick fire sessions which took place in the afternoon, Mr Umar Sadat, Addenbrooke’s Hospital, Cambridge, UK, examined endovascular vs. open repair of acute abdominal aortic aneurysms. He told the audience that there had been much debate about the benefit of EVAR in rAAA. The meta analysis indicates clear benefits to the selected group of patients undergoing this minimally invasive procedure. The analysis showed a significant reduction in the high mortality, prolonged intensive care requirement and total hospital stay, which are historically associated with open repair. Due to the hetrogenity of data conclusion, Sadat, nevertheless urged that his conclusions be treated with caution.

The Vascular Department of St James Hospital, Dublin, Ireland, discussed type 2 Endoleaks after EVAR. They concluded that type 2 endoleaks were benign and that few if any needed treating. They had looked at this issue for seven years and their study concluded that in the absence of sac expansion, conservative management of Type 2 endoleaks is safe beyond 12 months and at least up to three years.

Mr Michael Wall, University of Birmingham, UK, then looked at endovascular stenting for iliac artery disease. He stated that iliac angioplasty is technically successful in the majority of patients providing good short- to medium-term results. The rate of early restenosis being sufficiently significant to warrant enrollment into a duplex ultrasound surveillance programme, in his opinion.

Dr Peter Gaines, Sheffield Hospital, UK, concluded the discussions with a look at training in endovascular intervention. He explained that centres with higher operation volumes usually had lower mortality rates than centres with less patient throughput and showed them a proposed vascular specialist training programme which he believed was the way forward.

The BSET meeting was very useful and there was a high quality both in terms of the speakers and also in the quality of abstracts presented.