This year’s Multidisciplinary European Endovascular Therapy (MEET) conference in Cannes, France, assessed the current status of endovascular therapies and asked what lessons have been learnt and what improvements can be made.
Dr Jon Matsumura, began the meeting by saying that endovascular techniques have been well documented and that in anatomically suitable fit patients with large abdominal aortic aneurysms (AAAs), endovascular aneurysm repair (EVAR) is an alternative treatment as it is faster, has fewer complications and a lower peri-operative mortality and aneurysm related mortality. However, he added that there is no difference in overall survival and EVAR is more expensive and requires more interventions.
Matsumura then explained that stent grafts need to be durable with many issues not apparent until later, and he urged delegates to investigate the root causes of stent graft failure and that it should be performed early and critically. He also said that education needs to focus on real problems and solutions, and delegates should be aware of device-specific failure modes and appropriately adjust surveillance and reintervention strategies, he also urged professional societies to unify.
Christopher Zarins, US, in presenting the lessons that had been learnt from the US multi-centre AneuRx clinical trial, said patient selection and technique of implantation had improved results. Moreover, he added that knowledge of migration, ruptures and endoleaks has improved and stressed the importance of proximal and distal fixation.
Matsumura then assessed the lessons that had been learnt from thoracic endovascular aneurysm repair (TEVAR) and the impact those lessons will have on stent design. He said that TEVAR is currently in evolution, but stressed that clinical results are improving, however definitive trials are needed when the therapy matures.
Current data has demonstrated that TEVAR does have persistent advantages (such as for traumatic injury), although for uncomplicated chronic aortic dissection medical treatment is better than immediate TEVAR (although 11% still have TEVAR in the first year). He added that many questions remain and the technology is still under development, in particular neuroprotection strategies need further investigation.
Dr Luigi Inglese, S San Danato, Milan, Italy, discussed the midterm results from the Endofit thoracic endograft (LeMaitre Vascular). He revealed that in this consecutive series of 41 patients treated for all types of aortic disease with endovascular therapy, the Endofit has proven to be safe and effective with an excellent performance in the mean term follow-up (2.5 years). He reported no incidences of stent fractures or migration of the device.
Next, Dr Sam Ramee examined the techniques and outcomes of aorto-iliac recanalisation. He began by stating that the TransAtlantic Inter-Society Consensus (TASC) document was a fundamentally flawed document, as a multidisciplinary panel will recommend a document that is not scientific, politically correct, self-serving and protects their own financial interests – therefore, TASC is not is the best interests of the patients, physician or medicine.
In looking at a number of papers (Holm J, et al: Euro J Vasc Surg 1991;5:517-522), Ramee said that percutaneous transluminal angioplasty (PTA) yields numerically (but not statistically) and superior results at one year with significantly shorter hospital stay. He added that if either PTA or surgery is appropriate, then PTA should be attempted first.
In the subsequent debate, Dr Dimitris Kiskinis, Greece, argued that surgery was the only solution to treat chronic iliac stent occlusions. He began by stating that iliac stenting presented problems of crossing the lesion (technical success), as well as acute stent thrombosis, internal iliac occlusion and importantly, a lower patency for critical leg ischaemia or diabetes.
He cited a paper from Leville CD, (J Vasc Surg. 2006 Jan;43(1):32-9) in which 89 patients were treated for symptomatic iliac occlusions (TASC B, C and D) by endovascular means. Recanalisation and PTA/stenting was successful in 84 (91%) of 92 procedures. However, TACS C and D patients often required multiple acess sites (50%) and femoral artery endarterectomy/patch angiography for diffuse disease (24%).
Kiskinis concluded that the presence of poor run off, external iliac artery disease and female gender are independent predictors of poor outcome after iliac stenting and therefore these risk factors should determine the need for surgical reconstruction.
Francis van Elst, Belgium, said that there are many alternative therapies to treat chronic occlusions such as thrombolysis, atherectomy, mechanical aspiration (followed by PTA/stent), cutting balloons and possibly drug-eluting stents. He highlighted that two papers that demonstrated the effectiveness of endovascular therapies (Vorwerk et al Radiology 1995;197:479-84 and Kropman et al Eur J Vasc Endovasc Surg 2006;32:634-38) compared to surgery.
Although he acknowledged that more studies comparing surgery to endovascular therapies are needed, van Elst argued that endovascular therapies for iliac in-stent occlusions seems to be a safe procedure with good technical and clinical success rates, with low peri-procedural complication and morbidity rates.