EVC 2006: Expanding endovascular indications

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At this year’s meeting of the European Vascular Course (EVC), in Amsterdam, The Netherlands, demonstrated the ever increasing role of endovascular treatments and highlighted the ever more challenging and complex cases to which they are being applied. Organised by Professors Michael Jacobs (Maastricht, The Netherlands) and Alain Branchereau, Paris France, the topics under discussion assessed how endovascular therapies are challenging surgical procedures and examined the evidence available. Speaking to Vascular News, Branchereau commented, “At this year’s meeting we tried to challenge both the concept of the surgery as the ‘gold standard’, but also asked ‘what evidence is there for endovascular treatment’?”

The subjects under discussion included several presentation assessing whether the endovascular or the surgical approach is most beneficial for abdominal aortic aneurysms (AAA), ruptured AAA, carotid artery stenosis and alternatives to lower limb amputations in elderly patients.

One fascinating session looked at expanding indications for aortic endografting and how to deal with the visceral arteries. Dr Frank Veith, New York, USA, said that occlusion of the hypogastric arteries (HAs) during endovascular repair of aortoiliac aneurysms (AIAs) results in a significant incidence of buttock claudication, and has been suggested as a causative factor in the development of postprocedural colonic ischaemia, in addition to factors such as systemic hypotension, embolisation of atheromatous debris, and interruption of inferior mesenteric artery inflow. He said that in patients with obesity, extreme tortuosity and marked calcification, internal iliac artery aneurysms were unavoidable, adding that the complexity of the anatomy can dictate possible treatments/outcomes. He said that significant buttock claudication can occur in approximately 14% of patients, so even though it is safe, hypogastric artery interruption should only be performed when no other good, easy option exists. Next, Dr Thomas Umscheid, Munster, Germany, discussed the use of the hypogastic side branch. He said that the best outcomes are often the result of preliminary coil embolisation, an endograft extension to the external iliac artery outcome or branched endografts. He said the limitations of utilising a side branch include: the angle of aortic bifurcation; angle of the internal iliac; kinking of access vessels; short common iliacs; and handling.

Stephan Haulon, Lille, France, discussed whether juxtarenal aneurysms can be safely treated with fenestrated endografts. In a retrospective review that included 231 stented renal arteries, there were 22 renal events, with four patents needing permanent dialysis and one death. From the data presented, he commented that fenestrated endografting is a viable option for compromised infra-renal necks with an earlt post-operative mortality rate, however, the procedure requires careful planning and sizing and longer follow-up in required.

Next, Buth highlighted some of the limitations of fenestrated endgrafting claiming that a short infrarenal is the primary anatomic reason for excluding a patient from EVAR is a risk factor for type I proximal endoleak and is associated with an increased risk of rupture and conversion to open repair. He added that there needs to be a better delineation of indications for use of fenestrated grafts and the role of hybrid procedures should be analysed further. On the other hand, surgery requires clamping and is associated with increased mortality and risk of complications.

There was also an update from several clinical trials including: the New ERA (Endograft treatment in Ruptured Abdominal Aortic Aneurysms) study, presented by co-principal investigator Dr Jaap Buth (Catharina Hospital, Eindhoven, The Netherlands); the EVAS-3S (Endarterectomy Versus Angioplasty in patients with Symptomatic Severe carotid Stenosis), presented by Professor Branchereau; and the CAESAR (Comparison of surveillance vs. Aortic Endografting for Small Aneurym Repair) trial, presented by Dr Piergiorgio Cao (Perugia, Italy), the trial’s Principal Investigator. There were also numerous satellite symposia sponsored by Medtronic, Gore, Pfizer, Intervascular, Vascutek and Cordis, and a workshop hosted by Cook.

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