annals of vascular diseases - jstage.jst.go.jp

ANNALS OF VASCULAR DISEASEShttp://www.avd.umin.jp/

Asian Venous ForumAsian Society for Vascular Surgery

Asian Society for Vascular SurgeryAsian Venous ForumPublished by the Editorial Committee of Annals of Vascular Diseasesc/o Medical Tribune Inc., 2-1-30 Kudan Minami, Chiyoda-ku 102-0074 ABSTRACT BOOK

18th Congress of Asian Society for Vascular Surgeryand the 12th Asian Venous Forum

In Conjunction with the 4th Kuala Lumpur Vascular Access Conference

October 25th - 28th, 2017 Shangri-La Hotel Kuala Lumpur

Mentoring the Modern Vascular Surgeon

LIST Speaker’s Abstract 1 - 8Oral Presentation 9 - 14Poster Presentation 14 - 42

ABSTRACT Speaker’s Abstract 43 - 82Oral Presentation 83 - 107Poster Presentation 108 - 225

Table of Content

1

Speaker’s AbstractAortic 1

Operating below and AAA threshold of 5.5cm saves lives - An analysis of international practiceMatt Thompson

Characteristics of the arch of aorta in asian patients with arch pathologyYiu Che ChanDivision of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, Queen Mary Hospital, Hong Kong

Aortic 2

Nexus endograftKong Teng Tan

Debranching with TEVAR for aortic arch pathologyJulian Wong

Aortic 3

Association between aortic remodeling and stent graft-induced new entry in extensive residual type a dissecting aortic aneurysm after hybrid arch repairChun Che ShihDivision of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Institute of Clinical Medicine, School of Medicine, National Yang Ming University Taipei, Taiwan

Experience of zenith stent graft used in stanford type a dissectionZhe ZhangDepartment of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China

Hybird ThoraflexTM graft for the technique of frozen elephant trunkRandolph HL WongDivision of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR

Aortic 4

In situ venous laser fenestration of Stanford type A aortic dissection during thoracic endovascular aortic repairXinwu Lu1,2

1Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, P. R. China2Vascular Center of Shanghai JiaoTong University, Shanghai, P. R. China

Endovascular treatment of type B aortic dissection with multiple self-expanding stents: Case reportChenglei Zhang

Does dissection bare stent improve aortic remodeling in dissection cases?Chun Che ShihDivision of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Institute of Clinical Medicine, School of Medicine, National Yang Ming University Taipei, Taiwan

Aortic 5

Radiologic malperfusion in acute type B dissection: Can we justify prophylactic repair in cases of asymptomatic severe compression of the true lumen?Frank J Criado

Study on the causes of death in acute type B aortic dissectionQingbo Fang

2

Type 2 dissection in pregnancy. Is there a role for urgent TEVAR?Michael G WyattNorthern Vascular Centre, Freeman Hospital, Newcastle Upon Tyne, United Kingdom

Carotid 1

Asymptomatic carotid surgery is not indicated prior to cardiac surgeryAH Davies

Risk factor for development of an early postoperative stroke after carotid endarterectomyYoung-Wook Kim, DI Kim, YJ Park, SH Heo, BH Chung, DH Lee, OY Bang, KM KimVascular Surgery, Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Feasibility and safety of simultaneous CEA and CAS for Bilateral Carotid StenosisZhi Dong Ye

Open vs endovascular solution for carotid stenosis: Current evidence and typical lesion selection criteriaI-Ming ChenDivision of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taiwan

CVD 1

Haemodynamic assessment in CVDChris Lattimer

Pathophysiology of chronic venous diseaseEvi KalodikiJosef Pflug Vascular Laboratory, Ealing Hospital, Imperial College, West London Vascular and Interventional Center & Thrombosis & Haemostasis Laboratory, Loyola University, Chicago IL, USA

Progress in medical therapyJean-Francois Uhl

CVD 2

Obesity and CVIRamakrishna PinjalaChief Vascular Surgeon, Nizam’s Institute of Medical Sciences, Hyderabad, India

Superficial vein intervention prevents venous progressionAH Davies

CVD 3

Setting up a day care vein practice as a Vascular SurgeonLaurencia Villalba

The haemodynamic results at 5 years of laser vs foam randomised controlled trialEvi KalodikiJosef Pflug Vascular Laboratory, Ealing Hospital, Imperial College, West London Vascular and Interventional Center & Thrombosis & Haemostasis Laboratory, Loyola University, Chicago IL, USA

CVD 5

Reflux versus obstruction in the post-thrombotic syndrome: Which is worse?Chris Lattimer

Speaker’s Abstract

3

Sulodexide in preventing recurrent venous tromboembolism (r-VTE)Evi KalodikiJosef Pflug Vascular Laboratory, Ealing Hospital, Imperial College, West London Vascular and Interventional Center & Thrombosis & Haemostasis Laboratory, Loyola University, Chicago IL, USA

Percutaneous catheter directed foam sclerotherapy of ovarian varicoceleXin DuPLA General Hospital, Beijing, China

PAD 1

Aorto-biliac/bifemoral bypass - Is it still relevantNaresh GovindarajanthranConsultant Vascular Surgeon, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia

PAD 4

Iatrogenic occlusion of femoral artery in children with endovascular procedureLei Li

Management of acute limb ischema in the himalayasSandeep Raj PandeyConsultant Vascular & Endovascular Surgeon, Norvic Int’l Hospital/Annapurna Hospital, Ktm, Nepal

Access 1

Safety issues in renal accessMatthias K WidmerDepartment of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland

Access 2

New ESVS guidelines on renal accessMatthias K WidmerDepartment of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland

Should dialysis access be a new subspecialty?Ingemar DavidsonDallas, TX

Simulation in vascular access trainingMatthias K WidmerDepartment of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland

Access 3

Failure to mature - New insightsIngemar Davidson

Haemodialysis vascular access - Reverse flow technique re-exploredKevin MoissinacPenang, Malaysia

Secondary native fistula techniques - Should 1 or 2 stage BBT be preferredKittipan Rerkasem

Access 4

Brachio-basilic transposition - Techniques to achieve improved patencyBenjamin Leong


4

Can steal syndrome be prevented at initial fistula constructionKittipan Rerkasem

Haemodialysis vascular access - Multiple channel flow, does it affect patencyKevin MoissinacPenang, Malaysia

Aortic 10

Consideration of possible mechanism influencing type II endoleak following EVARYoshihiko Kurimoto1, Ryushi Maruyama1, Shuhei Miura1, Kosuke Ujihira1, Yutaka Iba1, Eiichiro Hatta1, Akira Yamada1, Hideyuki Harada2, Katsuhiko Nakanishi1

1Teine Keijinkai Hospital, Sapporo, Japan2Kushiro Koujinkai Memorial Hospital, Kushiro, Japan

When EVAR and endovascular reintervention fail: What are the open options and are they safe?Michael G WyattNorthern Vascular Centre, Freeman Hospital, Newcastle Upon Tyne, United Kingdom

Aortic 6

Management of left subclavian artery during TEVARZhi Dong Ye

In situ fenestration in TEVAR using laser Assisted and puncture methodsJun Bai, LeFeng Qu

Aortic 7

Open repair of type IV thoraco-abdominal aneurysm: A 20 year experienceRTA Chalmers, PJ Burns, O Falah, CR Moores, AJ Thomson, AF NimmoScottish National Service For Thoraco-Abdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

From open to total endovascular: Tevar for thoracoabdominal aortic aneurysm treatmentChun Che ShihDivision of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Institute of Clinical Medicine, School of Medicine, National Yang Ming University Taipei, Taiwan

Aortic 8

Accessory renal arteries can be covered with impunity during EVAR, with few exceptionsFrank J Criado

EVAS vs fenestrated EVARTze Tec Chong

Aortic 9

Treatment of Juxta-Renal Aneurysm with CHEVASMatt Thompson

Carotid 2

Carotid body tumour’s: Stretching the boundaries of excisionEdwin StephenChristian Medical College, Vellore, India

Application of a novel intermittent pneumatic compression device assists long-term dilation of radiocephalic fistulasTej M Singh


5

Ultrasonic quality control in vascular surgeryBeat H Walpoth1, Damiano Mugnai1, Shahrul A Saat2, Jeswant Dillon2, Nicolas Murith1, Christoph Huber1

1Department of Cardiovascular Surgery, University Hospital of Geneva, Switzerland2Department of Cardiothoracic Surgery, National Heart Institute, Kuala Lumpur, Malaysia

CVD 6

Role of compression as the primary therapyChris Lattimer

Sclerotherapy or surgery of perforators causing venous ulcerAH Davies

CVD 7

Iliac vein compression syndrome in a nonvascular related symptomatic patient populationFuxian Zhang, Long Cheng, Hui ZhaoDepartment of Vascular Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, PR China

Evaluation of iliac vein before superficial vein interventionAH Davies

CVD 8

Management of lymphatic malformationRamakrishna PinjalaNizam’s Institute of Medical Sciences, Hyderabad, India

Innovations in lymphedema managementEdwin StephenChristian Medical College, Vellore, India

DVT 1

Are western VTE prophylaxis guidelines applicable to the asian population?Limi LeeDepartment of Surgery, University Putra Malaysia, Serdang, Malaysia

Bleeding risk of anticoagulants in the prevention of venous thromboembolism among asiansNgoh Chin Liew, Limi LeeDepartment of Surgery, University Putra Malaysia, Serdang, Malaysia

How to deal with thromboembolism of vena cava filterDan Ming Wu

DVT 2

Efficacy of compressive stockings in VTE preventionChris Lattimer

How and why to develop an acute VTE service as a vascular surgeonLaurencia Villalba

Surgical Thrombectomy for Acute Ilio-femoral DVT revisitedTomohiro Ogawa

PAD 5

Multipoint puncturing technique to treat complex lower extremity arterial occlusive diseasesYong Liu


6

PAD 6

The importance of establishing the plantar pedal loop in CLIM Manzi

PAD 7

Global vascular guidelines for chronic limbthreatening ischemiaPhilippe Kolh, Robert FitridgeLiege, Belgium and the University of Adelaide, Australia

Assessment of risk of failure following infrainguinal vein graft BypassReza Mofidi

PAD 8

Critical limb ischemia in the Japanese populationTetsuro MiyataVascular Center, Sanno Hospital and Sanno Medical Center

Managing critical limb ischaemia in BangladashAbul Hasan Muhammad BasharNational Institute of Cardiovascular Diseases & Hospital (NICVD), Dhaka, Bangladesh

Trauma

Duplex guided thrombin injection versus compression treatment of femoral pseudoaneurysm - KSUMC experienceMussaad S Al SalmanDivision of Vascular Surgery, Dept of Surgery KSU Riyadh

Management of brachial artery injuryKhang Nan Chuang

Access 5

Fore Arm Graft OptionsAhmad Rafizi Hariz

Open Techniques in Graft SalvageBeng Kiat Lim

Access 6

HeRO graft in central vein occlusionEdward Choke

How to fix pd catheter mechanical complicationsIngemar DavidsonDallas, TX

Access 8

Has cannulation techniques improved patencyEdward Choke

Flow device in helping fistula maturationTej M Singh


7

Aortic 12

Overcoming difficult vascular access in EVAR & TEVARTarun GroverDivision of Vascular & Endovascular Surgery, Medanta Medicity Hospital, Gurugram, National Capital Region, New Delhi

The influence of sarcopenia and common iliac artery calcification on outcomes following endovascular abdominal aortic aneurysm repairRobert Fitridge, Benjamin Thurston, Guilherme Pena, Stuart Howell, Prue CowledDiscipline of Surgery, The University of Adelaide, Vascular and Endovascular Service, Royal Adelaide Hospital. Data Management and Analysis Centre, School of Population Health, The University of Adelaide

Aortic 13

Endovascular management of isolated mycotic aneurysms of common iliac artery: Report of three casesBenjamin Leong

Factors influence to durable treatment in EVAR for infected AAAKhamin Chinsakchai, Chumpol Wongwanit, Kiattisak Hongku, Suteekhanit Hahtapornsawan, Nattawut Puangpunngam, Nuttawut Sermsathanasawadi, Chanean Ruansetakit, Pramook MutiranguraDivision of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Aortic 14

Training procedures in TEVAR of TBAD: Program accreditation and practitioner certificationXiao Tang

Single center experience with the anaconda on endovascular treatmentPao-Yen Lin, Lih-Sheng Wen, Di-Yong Chen

Aortic 15

Type B thoracic intramural haematoma - When to intervene?Benjamin Leong

Long-term outcomes of endovascular aortic aneurysm repair versus open surgical repair of an abdominal aortic aneurysm: A single center studyTae-Won KwonDepartment of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Songpa-Gu, Seoul, Republic of Korea

Imaging

The risk of cancer associated with EVAR - A comparison with open surgeryMatt Thompson

Duplex ultrasound can be a reliable screening tool for iliac obstruction following a dedicated criterionLaurencia Villalba

Innovation / Radiation

Shaping the future of clinical research in MalaysiaKhairul Faizi

Application of a novel intermittent pneumatic compression device assists long-term dilation of radiocephalic fistulasTej M Singh


8

Updates in vascular tissue engineering: In-Vivo vascular tissue engineering depends on implantation site and speciesBeat H Walpoth1, Shahrul A Saat2, Tornike Sologashvili1, Damiano Mugnai1, Sarra de Valance3, Jean-Christophe Tille4, Jeswant Dillon2, Yakub Azhari2, Michael Moeller3

1Service of Cardiovascular Surgery, University Hospital of Geneva, Switzerland2Cardiothoracic Surgery Department, National Heart Institute, Kuala Lumpur, Malaysia3Department of Pharmaceutics, EPGL, University Hospital of Geneva, Switzerland4Department of Clinical Pathology, University Hospital of Geneva, Switzerland

PAD 9

Meta-analysis of antiplatelet agents in intermittent claudicationPeng Foo Wong

Vascular Anomaly

Klippel - Trenaunay Syndrome - Vellore experienceEdwin Stephen

Endovascular management on vascular malformationPatrianef DarwisVascular and Endovascular Division, Department of Surgery, Ciptomangunkusumo National Hospital/Faculty of Medicine University of Indonesia

Vasculitis

Buerger’s disease - The vellore approachEdwin StephenChristian Medical College, Vellore, India

Midaortic syndrome due to takayasu arteritis in adult patients: An optimal management strategyYoung-Wook KimDivision of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Updates in takayasu’s arteritisTetsuro Miyata1, Yoshiko Watanabe2, Kazuo Tanemoto3

1Vascular Center, Sanno Hospital and Sanno Medical Center2First Department of Physiology, Kawasaki Medical School3Department of Cardiovascular Surgery, Kawasaki Medical School

Visceral

Spontaneous superior mesenteric artery dissection: What is its natural course?Young-Wook KimDivision of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Management options of visceral artery aneurysmsMasanori Hayashi1, Hideaki Obara1, Kentaro Matsubara1, Keita Hayashi1, Yuki Kamiya1, Masanori Inoue2, Seishi Nakatsuka2, Masahiro Jinzaki2, Yuko Kitagawa1

1Department of Surgery, Keio University School of Medicine, Tokyo, Japan2Department of Radiology, Keio University School of Medicine, Tokyo, Japan

Wound Care

Holistic approach in management of diabetic foot woundsAziz NatherNational University Hospital, National University Health System Singapore, Singapore

The use of negative pressure wound therapy in diabetic foot woundsIsmazizi Zaharuddin


9

Renal Access for Haemodialysis

01-01 Paper No: 045 The results of venogram after hemodialysis catheter removal Yoon-Sung Joo Vascular surgery, Good Gang-An hospital, Busan, South Korea

01-02 Paper No: 447 Ultrasound derived parameters as predictors of future intervention in radio-cephalic

arteriovenous fistulas Lucy Guazzo1, Mark Jackson1,2, David Baker1

1Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, QLD, Australia 2Griffith University, Gold Coast, Gold Coast, QLD, Australia

01-03 Paper No: 110 Does systemic heparin reduces thrombosis rate of radiocephalic fistula: A double-blinded

randomized study Karthigesu Aimanan1, Lenny Suryani1, Putera Mas Pian3, Mohamad Azim Mohd Idris1, Chew Loon Guan2,

Hanafiah Harunarashid1

1Department of Surgery, National University of Malaysia, Selangor, Malaysia 2Department of Surgery, Hospital Serdang, Selangor, Malaysia 3Department of Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

01-04 Paper No: 391 Management options for radial cephalic arteriovenous fistula stenosis Putera MP, Naresh G, Hafizan T, Hanif H, Zainal AA Department Vascular Surgery, Hospital Kuala Lumpur, Malaysia

Others

02-01 Paper No: 252 Light and mirrors: The role of optical coherence tomography in peripheral vascular

intervention S Peden1, S D Thomas1,2,3, R L Varcoe1,2,3

1Department of Surgery, Prince of Wales Hospital, Sydney, Australia 2University of New South Wales, Sydney, Australia 3The Vascular Institute, Prince of Wales, Sydney, Australia

02-02 Paper No: 264 Surgical treatment of thoracic outlet syndrome Byeoung-Hoon Chung, Dong-Heon Lee, Shin-Young Woo, Seon-Hee Heo, Yang-Jin Park, Dong-Ik Kim, Young-Wook

Kim Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

02-03 Paper No: 317 Management of vascular malformations in a developing country: Evolving experience with

evolution of technology Abul Hasan Muhammad Bashar, GM Mokbul Hossain, Md Enamul Hakim, Md Fidah Hossain, NC Mandal Department of Vascular Surgery, National Institute of Cardiovascular Diseases & Hospital (NICVD), Sher-E-Bangla

Nagar, Dhaka

02-04 Paper No: 347 Resection of renal cell carcinoma complicated with inferior vena cava tumor thrombus Atsushi Yamashita, Tetsuro Uchida, Azumi Hamasaki, Yoshinori Kuroda, Masahiro Mizumoto, Jun Hayashi, Shuto

Hirooka, Ai Takahashi, Centavo Akabane, Seigo Gomi, Mitsuaki Sadahiro Department of Cardiovascular Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan

Oral Presentation

10

02-05 Paper No: 097 The usefulness of stent insertion of central venous stenosis of incomplete balloon dilation in

hemodialysis patients HJ Shim1, DE Goo2, YJ Kim2

1Department of Radiology, Chung-Ang University Hospital, Seoul, Korea 2Soonchunhyang University Hospital, Seoul, Korea

Vascular Trauma

03-01 Paper No: 066 Delayed carotid stenting for traumatic intracerebral infarction due to carotid artery dissection Jihoon Kim, Minjeng Cho, Hojong Park Department of Surgery, Ulsan University Hospital, Ulsan, Korea

03-02 Paper No: 230 Endovascular salvage for iatrogenic arterial injury from image guide procedures Lam Jeffrey Chun Yin, Tsang Yi Po, Pang Skyi Yin Chun, Tang Chung Ngai Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong

03-03 Paper No: 320 Blunt thoracic aortic injury: New paradigms and prognostic factors Seiichi Yamaguchi, Hisanori Fujita, Tomoyoshi Kanda, Shigeyasu Takeuchi Department of Cardiovascular Surgery, Chiba Emergency Medical Center, Chiba, CHIBA, Japan

Aortic Aneurysms and Aortic Dissection

04-01 Paper No: 038 Current evidence on management of aortic stentgraft infection: A systematic review and

metaanalysis Hai-Lei Li1, Yiu-Che Chan2, Stephen W Cheng2

1Division of Vascular Surgery, Department of Surgery, University of Hong Kong Shenzhen hospital, Shenzhen, Guangdong, China 2Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong

04-02 Paper No: 077 Early sac shrinkage as a predictor of low risk of complications after endovascular aneurysm

repair in Japanese patients Naoki Fujimura1,7, Kentaro Matsubara1, Mitsuyoshi Takahara2, Hirohisa Harada3, Atsunori Asami4, Shintaro

Shibutani5, Susumu Watada6, Hideaki Obara1, Yuko Kitagawa1

1Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan 2Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan 3Department of Surgery, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba, Japan 4Department of Surgery, Saitama City Hospital, Saitama, Saitama, Japan 5Department of Vascular Surgery, Saisekai Yokohamashi Tobu Hospital, Kawasaki, Kanagawa, Japan 6Department of Surgery, Kawasaki Municipal Hospital, Kawasaki, Kanagawa, Japan 7Division of Vascular Surgery, Saiseikai Central Hospital, Minato, Tokyo, Japan

04-03 Paper No: 181 Surgical outcomes of total arch replacement with frozen elephant trunk using Japanese newly

commercially device (J-Graft Frozenix®) for type A acute aortic dissection Takayuki Kadohama, Hiroshi Yamamoto, Genbu Yamaura, Yoshifumi Chida, Fuminobu Tanaka, Daichi Takagi,

Kentaro Kiryu, Yoshinori Itagaki Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan

Oral Presentation

11

Oral Presentation04-04 Paper No: 185 Clinical outcomes of ruptured abdominal aortic aneurysm (AAA) in single institution Sang Seob Yun, Cheng Quan, Young Hwa Kim, Gyeong Jae Koh, Jin Go, Mi Hyeong Kim, Kang Woong Jun, Jeong

Kye Hwang, Sang Dong Kim, Jang Yong Kim, Sun Cheol Park, Ji Il Kim, Yong Sung Won, In Sung Moon Department of Surgery, Catholic University of Korea, Seoul, Korea

04-05 Paper No: 186 Management of endoleak after Endovascular Aneurysm Repair(EVAR) in single institution In Sung Moon, Cheng Quan, Young Hwa Kim, Gyeong Jae Koh, Jin Go, Mi Hyeong Kim, Kang Woong Jun, Jeong

Kye Hwang, Sang Dong Kim, Jang Yong Kim, Sun Cheol Park, Ji Il Kim, Yong Sung Won, Sang Seob Yun Department of Surgery, Catholic University of Korea, Seoul, Korea

04-06 Paper No: 334 Graft infection after endovascular aortic repair Takashi Hashimoto, Noriyuki Kato, Takafumi Ouchi, Ken Nakajima, Takatoshi Higashigawa, Shuji Chino Department of Radiology, Mie University Hospital, Tsu, Mie, Japan

Venous Thromboembolism

05-01 Paper No: 142 Long-term outcomes of stent placement for may thunner syndrome Shinho Hong1, Keun-Myoung Park1, Yong Sun Jeon2, Soon Gu Cho2, Kee Chun Hong1

1Department of Surgery, College of Medicine, Inha University, Incehon, Korea 2Department of Radiology, College of Medicine, Inha University, Incehon, Korea

05-02 Paper No: 479 Validation of the caprini risk assessment model for venous thromboembolism in chinese

hospitalized patients in a general hospital Xiaoyun Luo, Fuxian Zhang Department of Vascular Surgery, Capital medical University, Beijing, China

05-03 Paper No: 021 Mid-and-long term results of subfascial endoscopic perforator surgery in Japan Hitoshi Kusagawa1, Naoki Haruta2, Ryo Shinhara3, Yuji Hoshino4, Atsushi Tabuchi5, Hiromitsu Sugawara6

1Matsusaka Ohta Clinic, Matsusaka, Mie, Japan 2Takanobashi Central Hospital, Hiroshima, Japan 3Mitsubishi Mihara Hospital, Mihara, Japan 4Fukuoka Sanno Hospital, Fukuoka, Japan 5Kawasaki Medical School, Kurashiki, Japan 6Sendai Hospital of East Japan Railway Company, Sendai, Japan

05-04 Paper No: 091 Venous ultrasonography findings and clinical correlations in 104 Thai patients with chronic

venous insufficiency of the legs Burapa Kanchanabat Department of Surgery, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand

05-05 Paper No: 263 Stump of the great saphenous vein after Radiofrequency Ablation Takahiro Imai Department of Vascular Surgery, Nishinokyo Hospital, Nara, Japan

05-06 Paper No: 248 Ultrasound guided foam sclerotherapy for management of varicose veins - A prospective

observational study on efficacy and recurrence Jason Toniolo1, Diana Munteanu1, Noel Ramdwar1, Nathaniel Chiang1, Huming Hao1, Jason Chuen1,2

1Department of Vascular Surgery, The Austin Hospital, Melbourne, Victoria, Australia 2Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia

12

Oral PresentationTravel Fellow Award

06-01 Paper No: 396 Comparison of vascular remodeling between the bioresorbable Poly-L-lactic acid scaffold

and the metallic stent in porcine iliac artery Keita Hayashi1, Hideaki Obara1, Kentaro Matsubara1, Yuki Kamiya1, Masanori Hayashi1, Yasuhito Sekimoto2,

Yuko Kitagawa1

1Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo 2Department of Surgery, Tokyo Medical Center, Meguro, Tokyo

06-02 Paper No: 329 Role of plasma levels of d-dimer and fibrin degradation products as predictors of endoleaks

following endovascular abdominal aortic aneurysm repair Masahiro Mizumoto, Tetsuro Uchida, Seigo Gomi, Azumi Hamasaki, Yoshinori Kuroda, Atsushi Yamashita, Jun

Hayashi, Shuto Hirooka, Ai Takahashi, Kentaro Akabane, Mitsuaki Sadahiro Division of Cardiovascular Surgery, Department of Surgery II, Yamagata University Faculty of Medicine, Yamagata,

Japan

06-03 Paper No: 298 Early experiences with physician modified stent grafts for endovascular treatment of hostile

abdominal aortic aneurysms Hyung Sub Park1, Kyunglim Koo1, Daehwan Kim1, In Mok Jung2, Taeseung Lee1

1Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea 2Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea

06-04 Paper No: 303 Very elderly patients with ruptured abdominal aortic aneurysm are not good candidates for

open repair Takuro Shirasu, Takatoshi Furuya, Yukihiro Nomura, Nobutaka Tanaka Department of Surgery, Asahi General Hospital, Chiba, Japan

06-05 Paper No: 068 Radiation exposure during infrarenal endovascular aortic aneurysm repair Aadil Ahmed, Ayman Badawy, Arindam Chaudhury Vascular Surgical Department, Bedford Hospital NHS Trust, Bedford, United Kingdom

06-06 Paper No: 051 Comparison between freeze dried arterial allograft and fresh frozen arterial allograft as an

alternatif conduit on vascular bypass operation: Experimental study on new zealand rabbit Joalsen I1, Legowo J2, Prasmono A3

1Division of Thoracic,Cardiac and Vascular Surgery - Abdul Wahab Sjahranie General Hospital, Samarinda, Kalimantan Timur Indonesia 2Veterinary Pathologist of Veterinary Medicine of Airlangga University, Surabaya-East Java, Indonesia 3Department Thoracic,Cardiac and Vascular Surgery Dr.Soetomo Hospital- Airlangga University, Surabaya, East Java, Indonesia

06-07 Paper No: 265 Comparison of prosthetic femoro-popliteal bypass versus endovascular stenting for treatment

of TASC II type C/D Lesions in superficial femoral artery disease: Single center Sang Bong Lee1, Dong Hyun Kim1, Sang Su Lee1, Soon Cheon Lee2, Yung Baom Park3, Min Sang Song4

1Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea 2Gwangyang Sarang Hospital, Gwangyang, Korea 3Cheongmac Vascular and Vein Clinic, Busan, Korea 4Dongrae Bongseng Hospital, Busan, Korea

13

Oral Presentation06-08 Paper No: 216 Validating the use of contrast induced nephropathy prediction models in endovascular aortic

aneursym repairs Zhiwen Joseph Lo, Qiantai Hong, Evelyn Cheng, Sadhana Chandrasekar, Glenn Wei Leong Tan Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore

06-09 Paper No: 115 Surgical management of mangled extremity - Primary amputation vs limb salvage: A

systematic review of the current scoring system Eu Jhin Loh, David Hardman Department of Vascular Surgery, The Canberra Hospital, Garran, ACT, Australia

06-10 Paper No: 318 Treatment of varicose veins: Comparison between conventional surgery and endovenous laser

ablation in a developing country Abul Hasan Muhammad Bashar, GM Mokbul Hossain, Naresh Chandra Mandal, Md Mynul Islam, Saffait Jamil Department of vascular Surgery, National Institute of Cardiovascular Diseases & Hospital (NICVD), Sher-E-Bangla

Nagar, Dhaka

06-11 Paper No: 162 Lower extremity arterial injury pattern and revascularization outcomes at Hospital Kuala

Lumpur Malaysia: A 5-year retrospective review Fatin MN, Feona SJ, Zainal AA Vascular Surgery Unit, Department of Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

06-12 Paper No: 412 Comparative outcomes of vascular access in patients older than 70 years with end stage renal

disease Deokbi Hwang, Sujin Park, Hyung-Kee Kim, Seung Huh Division of Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea


07-01 Paper No: 218 Long-term survival and secondary procedures after open or endovascular repair of abdominal

aortic aneurysms: Results from the DREAM-trial Kak K Yeung, Theodorus G Van Schaik, Hence JM Verhagen, Jorg L de Bruin, Marc RHM Van Sambeek, Ron

Balm, Clark J Zeebregts, Joost A Van Herwaarden, Jan D Blankensteijn Department of Vascular Surgery, VU Medical Center, Amsterdam, Noord-Holland, Netherlands

07-02 Paper No: 373 Computational fluid dynamics investigation of pulsatile flow patterns in the development of a

type V thoracoabdominal aortic pseudoaneurysm Ong Chi Wei1, Leo Hwa Liang1, Arthur Mark Richards2,3, Andrew MTL Choong4,5

1Department of Biomedical Engineering, National University of Singapore 2Cardiovascular Research Institute, National University of Singapore 3Department of Cardiology, National University Heart Centre, Singapore 4Division of Vascular Surgery, National University Heart Centre, Singapore 5Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore

Peripheral Arterial Disease

08-01 Paper No: 086 The angiosome concept evaluated by intraoperative fluorescence angiography after tibial

bypass surgery Werner Lang, Alexander Meyer, Susanne Regus, Ulrich Rother Department of Vascular Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg,

Erlangen

14

Oral Presentation08-02 Paper No: 116 The association of heart valve calcification (aortic and mitral valve calcification) with clinical

outcomes in patients undergoing endovascular revascularization for peripheral arterial disease

Yoong Seok Park1, Ji Young Park2, Seung Kyu Han3, Byoung Geol Choi4, Seung-Woon Rha5, Se Yeon Choi4, Jae Kyeong Byun4, Hu Li4, Jun Hyuk Kang5, Eun Jin Park5, Sung Hun Park5, Jah Yeon Choi5, Sunki Lee5, Jin Oh Na5, Cheol Ung Choi5, Hong Euy Lim5, Jin Won Kim5, Eung Ju Kim5, Chang Gyu Park5, Hong Seog Seo5, Dong Joo Oh5

1Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea 2Division of Cardiology, Eulji Hospital, Eulji University, Seoul, Korea 3Department of Plastic Surgery, Korea University Guro Hospital, Seoul, Korea 4Department of Medicine, Korea University Graduate School, Seoul, Korea 5Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea

08-03 Paper No: 404 Factors associated with long term patency of lower extremity arterial bypass for patients with

chronic atherosclerotic arterial occlusive disease Seon-Hee Heo, B-H Chung, D-H Lee, S-Y Woo, Y-J Park, D-I Kim, Young-Wook Kim Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

08-04 Paper No: 417 Does aortomesenteric angle affect occurrence of spontaneous isolated superior mesenteric

artery dissection? Hyangkyoung Kim, Hanbyul Lee, Park Byung Wook Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea

08-05 Paper No: 399 Near-infrared monitor is useful as a blood flow evaluation method at the time of

revascularization Taku Kokubo1, Yumi Sasajima2,Tadahiro Sasajima1

1Department of Vascular Disease, Vascular Surgery, Edogawa, Tokyo, Japan 2Hokkaido University of Education, Asahikawa College, Asahikawa, Hokkaido, Japan

08-06 Paper No: 454 Angiosome-targeted isolated tibial angioplasty for healing of ischemic foot ulcer: A

retrospective study Mohamed Farag, Khaled El Alfy, Hosam Roshdy, Hesham Sharaf Vascular Surgery Department, Mansoura University Hospital, Mansoura, Egypt

Acute Limb Ischaemia

P01-01 Paper No: 058 Penumbra Indigo„¢ aspiration thrombectomy versus catheter directed thrombolysis for

treatment of acute limb ischaemia: A retrospective review of a single unit’s experience Fleming Scott, Kwok Chi Ho Ricky, Chan Kenneth Kwok-Cheong, Tibballs Jonathan, Samuelson Shaun, Ferguson

John, Nadkarni Sanjay, Hockley Joseph, Jansen Shirley Department of Vascular Surgery, Peking Union Medecal College Hospital, Beijing, China

P01-02 Paper No: 308 In acute limb ischaemia, late presentation is the major impedance: National institute of

cardiovascular diseases, dhaka perspective M M Islam, S Jamil Department of Vascular Surgery, NICVD, Dhaka, Bangladesh

Poster Presentation

15

Poster PresentationP01-03 Paper No: 340 Endovascular treatment for rheumatoid arthritis induced acute aortic thrombosis Saritphat Orrapin1, Tunyarat Wattanasatesiri2, Thoetphum Benyakorn1, Kanoklada Srikuea1, Boonying

Siribumrungwong1

1Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand 2Division of Interventional Radiology, Department of Radiology, Faculty of Medicine, Thammasat University, Pathumthani, Thailand

P01-04 Paper No: 422 Hybrid procedures in acute on chronic limb ischemia Vinay K S, Murali Krishna N, P S Seetharam Bhat Vascular Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research Centre, Bangalore


P02-01 Paper No: 013 Bovine pericardium patch plasty as a surgical option for infected abdominal aortic aneurysm Xiaoning Tong, Hideyuki Harada Cardiovascular Surgery, Kushiro Kojinkai Memorial Hospital, Kushiro, Hokkaido, Japan

P02-02 Paper No: 039 Early and midterm results of endovascular aneurysm repair for solitary common iliac artery

aneurysm Yasuyuki Kanno, Takayuki Hori, Yusuke Takei, Yuta Kanazawa, Hironaga Ogawa, Toshiyuki Kuwata, Koji Ogata,

Ikuko Shibasaki, Hirotsugu Fukuda Department of Cardiac and Vascular Surgery, Heart Center, Dokkyo Medical University Hospital

P02-03 Paper No: 057 Application of color-coded quantitative digital subtraction angiography in predicting the

outcomes of immediate type I and type III endoleaks Min Zhou1, Zijie Su1, Zhenyu Shi1, Weiguo Fu1, Xiangdong Meng1, Yonggang Wang1, Baolei Guo1, Kaiyi Huang2

1Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, Fudan University, Shanghai, China 2Siemens Healthcare, Shanghai, China

P02-04 Paper No: 069 A comparison of radiation exposure during endovascular aortic aneurysm repair with or

without endostapling Aadil Ahmed, Ayman Badawy, Arindam Chaudhuri Department of Vascular Surgery, Bedford Hospital NHS Trust, Bedford, United Kingdom

P02-05 Paper No: 072 Midterm results of total arch replacement with frozen elephant trunk in acute type A aortic

dissection Yusuke Takei, Takayuki Hori, Toshiyuki Kuwata, Hironaga Ogawa, Masahiro Seki, Yuriko Kiriya, Yasuyuki Kanno,

Koji Ogata, Ikuko Shibasaki and Hirotsugu Fukuda Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Tochigi, Japan

P02-06 Paper No: 075 The impact of maximal diameter and hematoma thickness in conservative management of

type-A acute aortic intramural hematoma Akihito Kagoshima, Hirono Satokawa, Shinya Takase, Hitoshi Yokoyama Department of Cardiovascular Surgery, Fukushima Medical University, Japan

P02-07 Paper No: 089 Clinical outcomes of crossing-limb technique in Endovascular Aneurysm Repair (EVAR) Ki Hyuk Park, Jae Hoon Lee, Sang Ho Lee Department of Surgery, College of Medicine, Daegu Catholic University, Daegu, Korea

16

Poster PresentationP02-08 Paper No: 098 Thoraflex hybrid graft for treatment of arch pathologies: A single center early experience Randolph HL Wong, Jacky YK Ho, Simon CY Chow, Peter SY Yu, Micky WT Kwok, Malcolm J Underwood Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong

Kong SAR

P02-09 Paper No: 099 Relationship between aortic aneurysm shrinkage after endovascular repair and aortic wall

enhancement on contrast enhanced CT scan. A new aneurysm shrinkage predictor Eisaku Ito1, Naoki Toya1, Soichiro Fukushima1, Yuri Murakami1, Tadashi Akiba2, Takao Ohki3

1Department of Surgery, Division of Vascular Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan 2Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan 3Department of Surgery, Division of Vascular Surgery, The Jikei University School of Medicine, Tokyo, Japan

P02-10 Paper No: 101 Screening of thoracic aortic aneurysm in chinese hypertensive patients using pocket-size

mobile echocardiographic device: An interim result Peter SY Yu1, Fan Yang1, Evelynn YH Lui1, Simon CY Chow1, Jacky YK Ho1, Malcolm J Underwood1, Simon CH Yu3,

Alex PW Lee2, Randolph HL Wong1

1Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong 2Division of Cardiology, Department of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong 3Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong

P02-11 Paper No: 102 Our clinical outcomes of the PETTICOAT technique for aortic dissection Masatoshi Komooka, Shinichi Higashiue, Satoshi Kuroyanagi, Onichi Furuya, Saburo Kojima, Naohiro

Wakabayashi Department of Cardiovascular Surgery, Kishiwada Tokusyukai Hospital, Kishiwada City, Osaka, Japan

P02-12 Paper No: 103 The midterm results of TEVAR for chronic aortic dissection with aneurysmal dilatation.

What the affect is the distal-entry closure? Kiyoshi Chiba1, Hiroshi Nishimaki1, Yukihisa Ogawa2, Satoshi Kinebuchi1, Syouta Kita1, Hirotoshi Suzuki1, Yuka

Sakurai1, Daijun Ro1, Hirokuni Ono1, Makoto Ono1, Masahide Chikada1, Takeshi Miyaili1

1Department of Cardiovascular Surgery, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan 2Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan

P02-13 Paper No: 104 Early-and mid-term outcome of TEVAR for rupture of acute type B aortic dissection Daichi Takagi, Kadohama Takayuki, Itagaki Yoshinori, Kiriu Kentaro, Tanaka Fuminobu, Chida Yoshifumi,

Yamaura Genbu, Yamamoto Hiroshi Cardiacsurgery, Akitauniversity, Akita, Japan

P02-14 Paper No: 105 Total endovascular repair in arch aneurysm patients with bovine aortic arch using the Najuta

fenestrated stent graft Naoki Toya1, Soichiro Fukushima1, Eisaku Ito1, Yuri Murakami1, Tadashi Akiba2, Takao Ohki3

1Department of Surgery, Division of Vascular Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan 2Department of Surgery,The Jikei University Kashiwa Hospital, Chiba, Japan 3Department of Surgery, Division of Vascular Surgery, The Jikei University School of Medicine, Tokyo, Japan

17

Poster PresentationP02-15 Paper No: 111 EVARable abdominal aortic aneurysm that turned up with open surgical repair: Causes and

result. A retrospective study in tertiary vascular centre Aizat Sabri I1, Lenny SS2, Azim I2, H Harunarashid2

1Department of Surgery, Universiti Science of Malaysia 2Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

P02-16 Paper No: 117 Early experiences with physician modified stent grafts for endovascular treatment of hostile

abdominal aortic aneurysms Hyung Sub Park1, Kyunglim Koo1, Daehwan Kim1, In Mok Jung2, Taeseung Lee1


P02-17 Paper No: 118 Aneurysm sac enlargement 18 years after EVAR due to late type3b endoleak; A case report Yuri Murakami1, Naoki Toya1, Soichiro Fukushima1, Eisaku Ito1, Tadashi Akiba2, Takao Ohki3

1The Jikei University Kashiwa Hospital Department of Surgery, Division of Vascular Surgery 2The Jikei University Kashiwa Hospital Department of Surgery 3The Jikei University School of Medicine Department of Surgery, Division of Vascular Surgery

P02-18 Paper No: 127 Debranching thoracic endovascular aneurysm repair for a case of thoracoabdominal aortic

pseudoaneurysm accompanied by advanced calcification Kazushige Inoue1, Takanori Tokuda1, Takashi Murakami2, Akimasa Morisaki2

1Department of cardiovasucular Surgery, Hirakata kohsai Hospital, Hirakata Osaka, Japan 2Department of cardiovasucular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan

P02-19 Paper No: 132 Stanford Type B aortic dissection due to a primary entry tear in the abdominal aortic aneurysm Kimimasa Sakata, Kanetsugu Nagao, Katsunori Takeuchi, Akio Yamashita, Naoki Yoshimura Department of Thoracic and Cardiovascular Surgery, Toyama University, Toyama, Japan

P02-20 Paper No: 140 A novel technique for in-situ fenestration TEVAR for arch aneurysm using radio-frequency

ablation catheter Masami Shingaki1, Yoshihiko Kurimoto2, Kiyofumi Morishita1, Toshio Baba1, Tsuyoshi Shibata1, Kohei Narayama1

1Department of Cardiovascular Surgery, Hakodate Municipal Hospital, Hokkaido Pref., Japan 2Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Hokkaido Pref., Japan

P02-21 Paper No: 147 Clinical experience of endoleaks that were newly diagnosed over 1 year after EVAR Keun-Myoung Park1, Yong Sun Jeon2, Soon Gu Cho2, Kee Chun Hong1

1Department of Surgery, Inha University, Incehon, Korea 2Radiology College of Medicine, Inha University, Incehon, Korea

P02-22 Paper No: 150 Open conversion for Type II endoleak after endovascular aneurysm repair - Lumbar artery

ligation by laparotomy approach K Ozaki, S Yamamoto, T Hirokami, Y Hirai, J Shimamura, S Sakurai, S Oshima, S Sasaguri Kawasaki Saiwai Hospital, Kanagawa, Japan

18

Poster PresentationP02-23 Paper No: 155 Outcomes of open conversion after failed endovascular aortic aneurysm repair according to

the indication of explantation Choi KH, Kwon TW, Cho YP, Han YJ, Jeong MJ Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

P02-24 Paper No: 156 Long term outcomes of endovascular aortic aneurysm repair and open surgical repair of

abdominal aortic aneurysm in terms of cancer incidence and cost effectiveness Choi KH, Kwon TW, Cho YP, Han YJ, Jeong MJ Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

P02-25 Paper No: 164 Endovascular repair of a spontaneous ilio-iliac fistula with unilateral leg swelling Takuya Miyazaki, Tadashi Isomura, Yasuhisa Fukada, Yoshiki Endo, Minoru Yoshida, Takahiko Masuda, Masahiro

Endo Department of Cardiovascular Surgery, Tokyo Heart Center, Shinagawa, Tokyo, Japan

P02-26 Paper No: 178 Risk factors of type II endoleak in EVAR: 8-year single institutive study Chung Won Lee, Jinseok Choi, Up Huh, Sung Woon Chung Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Medical Research

Institute, Pusan National University Hospital, Republic of Korea

P02-27 Paper No: 183 Treatment options for isolated iliac artery aneurysm according to patient’s clinical

characteristics Seung Nam Kim, Cheng Quan, Young Hwa Kim, Gyeong Jae Koh, Jin Go, Mi Hyeong Kim, Kang Woong Jun, Jeong

Kye Hwang, Sang Dong Kim, Jang Yong Kim, Sun Cheol Park, Ji Il Kim, Yong Sung Won, Sang Seob Yun, In Sung Moon

Department of Surgery, Catholic University of Korea, Seoul, Korea

P02-28 Paper No: 190 Outcomes of open repair of mycotic thoracic and abdominal aortic aneurysms Hyo-Hyun Kim, Do Jung Kim, Hyun-chel Joo Department of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine,

Seoul, Korea

P02-29 Paper No: 198 Endovascular aneurysm repair with bifurcated endograft in narrow aortic bifurcation Shinsuke Kotani, Takumi Ishikawa, Tadahiro Murakami, Hirokazu Minamimura Department of Cardiovascular Surgery, Bellland General Hospital, Osaka, Japan

P02-30 Paper No: 204 Mid-term outcomes of flared iliac limb used for combined common iliac artery aneurysm

during endovascular aneurysm repair Dong-Heon Lee, Byeoung-Hoon Chung, Yang-Jin Park, Seon-Hee Heo, Dong-Ik Kim, YW Kim Vascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea

P02-31 Paper No: 208 Bolton relay thoracic stent graft offers precise placement during aortic arch TEVAR and good

initial results Hiroshi Banno, Yohei Kawai, Naohiro Akita, Takayuki Fujii, Takuya Tsuruoka, Masashi Sakakibara, Noriko

Takahashi, Masayuki Sugimoto, Kiyoaki Niimi, Akio Kodama, Kimihiro Komori Department of Vascular Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan

19

Poster PresentationP02-32 Paper No: 209 Incidence and risk factor for iliac limb stent graft occlusion after endovascular aneurysm

repair K Kritayakirana1, P Kranokpiraksa2, N Chenpen2, N Narueponjirakul1, A Uthaipaisanwong1

1Department of Surgery, King Chulalongkorn Memorial Hospital, Bangkok, Thailand 2Department of Radiology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand

P02-33 Paper No: 228 Postoperative renal function after left renal vein (LRV) division during juxtarenal abdominal

aortic aneurysm repair Shinichi Nata, Shinichi Hiromatsu, Shinichi Imai, Ryo Kanamoto, Yusuke Shinitani, Hiroyuki Otsuka, Tohru

Takaseya, Satrou Tobinaga, Seiji Onitsuka, Hiroyuki Tanaka Department of Surgery, Kurume University School of Meidcine, Japan

P02-34 Paper No: 234 Hybrid procedure in high landing zone abdominal aorta aneurysm with multiple aneurysm Maheranny M, Suhartono, Jayadi A Vascular and Endovascular Surgery Division, Departement of Surgery, Faculty of Medicine Universitas Indonesia/Cipto

Mangunkusumo National Hospital Jakarta, Indonesia

P02-35 Paper No: 244 Mid-term outcome following embolization of the internal iliac artery before endovascular

abdominal aortic aneurysm repair Riha Shimizu1, Takayuki Hori2, Yasushi Matsushita1, Hirotsugu Fukuda2

1Department of Cardiac and Vascular Surgery, Dokkyo Medical University Nikko Medical Center, Nikko, Tochigi, Japan 2Department of Cardiac and Vascular Surgery, Dokkyo Medical University Hospital, Mibu, Tochigi, Japan

P02-36 Paper No: 245 Initial results of TEVAR for uncomplicated type B dissection using custom-made thoracic

fenestrated stent graft Soichiro Fukushima1, Naoki Toya1, Eisaku Ito1, Yuri Murakami1, Tadashi Akiba2, Takao Ohki3

1Department of Surgery, Division of Vascular surgery, The Jikei University Kashiwa Hospital, Chiba, Japan 2Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan 3Department of Surgery, Division of Vascular Surgery, The Jikei University School of Medicine, Tokyo, Japan

P02-37 Paper No: 255 Endovascular treatment combined with open surgery for malperfusion in acute type A aortic

dissection Tassei Nakagawa1, Soichiro Hase1, Motoshige Yamasaki1, Nobukazu Moriya1, Susumu Oshima2, Kensuke Ozaki2,

Shigeru Sakurai2, Junichi Shimamura2, Yuki Hirai2, Tomohiro Hirokami2, Syuichi Tochigi2, Makoto Okiyama2, Koichi Akutsu2, Shin Yamamoto2, Shiro Sasaguri2

1Endovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kanagawa, Japan 2Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kanagawa, Japan

P02-38 Paper No: 258 Different level Sandwich technique treatment for Type V endoleak after EVAR by SEAL graft

in abdominal aortic aneurysm patient Dong Hyun Kim1, Sang Bong Lee1, Soon Cheon Lee2, Yung Baom Park3, Min Sang Song4, Sang Su Lee1

1Department of Surgery , Pusan National University School of Medicine, Yangsan, Korea 2Gwangyang Sarang Hospital, Gwangyang, Korea 3Cheongmac Vascular and Vein clinic, Busan, Korea 4Dongrae Bongseng Hospital, Busan, Korea

P02-39 Paper No: 261 Risk factor analysis for persistent Type 1a endoleak after standard EVAR Seon-Hee Heo, Dong-Heon Lee, Byeoung-Hoon Chung, Shin-Young Woo, Yang-Jin Park, Dong-Ik Kim, Young-Wook

Kim Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

20

Poster PresentationP02-40 Paper No: 267 Endovacular exclusion of abdominal aortic aneurysm in patients with concomitant abdominal

malignancy Soo Jin Na Choi, Hong Sung Chung, Hokyun Lee, Sang Young Chung Department of Surgery, Chonnam National University, Gwangju, Korea

P02-41 Paper No: 272 Composite endografts for chronic aortic dissecting aneurysm””EVAR for TEVAR Ming Qi, Yan Wang, Nai-Wen Tsao Center of Vascular Surgery, Department of Surgery, Wuhan Asia Heart Hospital, Wuhan, China

P02-42 Paper No: 273 Is age over 85 years a limiting factor to undergo an EVAR in patients with infrarenal AAA? Wah Wah Lin, Robert Tewksbury, Jens Carsten Ritter Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia

P02-43 Paper No: 283 Open surgery repair of an aortic stent migration after unsuccessful endovascular abdominal

aorta aneurysm repair Inga Ä akoviÄ‡ Bacalja1, Lidija Erdelez2, Predrag PaviÄ‡2, Slaven SuknaiÄ‡2

1Department of Surgery, General Hospital Bjelovar, Bjelovar, Croatia 2Department of Vascular Surgery, Clinical Hospital Merkur, Zagreb, Croatia

P02-44 Paper No: 294 A multicenter experience with abdominal aortic endograft infection in Japan Kentaro Matsubara1, Hideaki Obara1, Norio Uchida2, Atsunori Asami3, Taku Fujii3, Hirohisa Harada4, Koji Osumi5,

Shintaro Shibutani6, Tsunehiro Shintani7, Susumu Watada8, Shigeshi Ono9, Tatsuya Shimogawara9, Naoki Fujimura10, Yasuhito Sekimoto11, Yuko Kitagawa1

1Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan 2Department of Surgery, Mito Red Cross Hospital, Mito, Ibaraki, Japan 3Department of Surgery, Saitama City Hospital, Saitama, Saitama, Japan 4Department of Surgery, Saiseikai Central Hospital, Minato, Tokyo, Japan 5Department of Surgery, Hiratsuka City Hospital, Hiratsuka, Kanagawa, Japan 6Department of Vascular Surgery, Saiseikai Yokohamashi Tobu Hospital, Kawasaki, Kanagawa, Japan 7Department of Vascular Surgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan 8Department of Surgery, Kawasaki Municipal Hospital, Kawasaki, Kanagawa, Japan 9Department of Surgery, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba, Japan 10Division of Vascular Surgery, Saiseikai Central Hospital, Minato, Tokyo, Japan 11Department of Surgery, Tokyo Medical Center, Meguro, Tokyo, Japan

P02-45 Paper No: 295 Mini Aortic Repair Takashi Murakami, Hiromichi Fujii, Yosuke Takahashi, Akira Morisaki, Shinsuke Nishimura, Daisuke Yasumizu,

Yoshito Sakon, Kokoro Yamane, Tohihiko Shibata Department of Cardiovascular Surgery, Osaka City University, Osaka, Japan

P02-46 Paper No: 299 Early experiences of the sandwich technique to preserve pelvic circulation during endovascular

aneurysm repair Kyunglim Koo1, Hyung Sub Park1, Daehwan Kim1, In Mok Jung2, Taeseung Lee1


21

Poster PresentationP02-47 Paper No: 301 Clinical audit: Outcome of open vs. endovascular treatment of mycotic aortic aneurysms in

two vascular centres in Malaysia Izzuddin A1, Vinoshini DK2, Siti Fareeda3, Lenny SS1, Tan Yee Ling1, Syed Alwi3, Azim I1, Chew Loon Guan4, H

Harunarashid1

1Universiti Kebangsaan Malaysia (UKM) Medical Centre, Malaysia 2International Medical University (IMU), Malaysia 3Hospital Sultanah Aminah Johor Bahru (HSAJB), Malaysia 4Hospital Serdang, Malaysia

P02-48 Paper No: 323 Initial outcomes of emergency thoracic endovascular aortic repair in our hospital Hirotoki Ohkubo, Toshiaki Mishima, Tadashi Kitamura, Rihito Horikoshi, Haruna Araki, Takamichi Inoue, Kenjiro

Sakaki, Miyuki Shibata, Yuuki Tanaka, Kensuke Kobayashi, Mitsuhiro Hirata, Shinzou Torii, Kagami Miyaji Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan

P02-49 Paper No: 327 Hybrid endovascular repair for multiple visceral artery aneurysms and thoracoabdominal

aortic aneurysm; A case report Takuya Matsushiro, Hirotoki Ohkubo, Mitsuhiro Hirata, Toshiaki Mishima, Shinzo Torii, Tadashi Kitamura,

Kensuke Kobayashi, Kagami Miyaji Department of Cardiovascular Surgery, Kitasato University, Sagamihara, Kanagawa, Japan

P02-50 Paper No: 331 Accurate assessment of cross-sectional area reduction of the aortic ostium by synchrotron

radiation Zhonghua Sun, Curtise, KC Ng Department of Vascular Surgery, NICVD, Dhaka, Bangladesh

P02-51 Paper No: 337 Analysis of biomarkers regarding inflammation and coagulation/fibrinogenolysis system in

cases with endovascular aneurysm repair for abdominal aortic aneurysm Rie Kageyama1, Hirofumi Midorikawa1, Kyohei Ueno1, Gaku Takinami1, Megumi Kanno1, Hirotsugu Fukuda2

1Department of Cardiovascular Surgery, Southern TOHOKU General Hospital 2Department of Cardiac and Vascular Surgery, Heart Center, Dokkyo Medical University Hospital

P02-52 Paper No: 338 Testicular infarction: A rare complication post EVAR Seenarain V, Quick M, Weerasuriya A, Chuen G Vascular department, Fiona Stanley Hospital, WA, Australia

P02-53 Paper No: 344 Atypical debranched TEVAR for shaggy aorta report of three cases Takayuki Uchida Department of Cardiovascular Surgery, Iizuka Hospital, Iizuka, Fukuoka, Japan

P02-54 Paper No: 349 Percutaneous closure of a large saphenous vein graft aneurysm with a vascular plug Kazuyuki Ishibashi1, Jyunichi Shimotakahara2, Hideaki Kurata2, Joji Tomioka2, Koji Yonemori2

1Department of Cardiovascular Surgery, Yonemori Hospital, Kagoshima, Japan 2Department of Emergency, Yonemori Hospital, Kagoshima, Japan

P02-55 Paper No: 350 Endovascular therapy for DeBakey’s type 3B dissecting aortic aneurysm Shunichiro Fujioka1, Shigeru Hosaka1, Yusuke Irisawa1, Hirotoki Okubo2, Tetuya Horai1

1Department of Cardiovascular Surgery, National Center of Global Health and Medicine, Tokyo, Japan 2Department of Vascular Surgery, Kitazato University School of Medecine, Kanagawa, Japan

22

Poster PresentationP02-56 Paper No: 351 Outcome of open stent-graft for thoracic aortic aneurysm repair: Comparison of handmade

and commercial-made open stent graft Jun Hayashi, Tetsuro Uchida, Azumi Hamasaki, Yoshinori Kuroda, Masahiro Mizumoto, Atsushi Yamashita, Shuto

Hirooka, Ai Takahashi, Kentaro Akabane, Seigo Gomi, Mitsuaki Sadahiro Department of Sugery II, Yamagata University, Yamagata, Japan

P02-57 Paper No: 369 Early Outcomes of AAA EVAR with the low profile Ovation Stent-Graft System Matt Trinder, Kishore Sieunarine

P02-58 Paper No: 371 Endovascular repair as an alternative paradigm for retrograde type A aortic dissection Tomoyoshi Kanda, Seiichi Yamaguchi, Hisanori Fujita, Shigeyasu Takeuchi Department of Vascular Surgery, NICVD, Dhaka, Bangladesh

P02-59 Paper No: 382 Management of Salmonella-infected aortic aneurysm with Anaconda endovascular stent graft - Case report Pao-Yen Lin, Di-Yung Chen, Jih-Shen Wen Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan

P02-60 Paper No: 400 The PETTICOAT technique for malperfusion which occurred after the operation of Debakey

type I aortic dissection; Report of a case Onichi Furuya, Shinichi higashiue, Satochi Kuroyanagi, Masatoshi Komooka, Saburo Kojima, Naohiro

Wakabayashi Department of Cardiovascular Surgery, Kishiwada Tokusyukai Hospital, Kishiswada, Osaka, Japan

P02-61 Paper No: 410 En-block resection followed by in situ replacement and duodenum repair for secondary aorto-

duodenal fistula Nobuoki Tabayashi1, Tomoaki Hirose1, Takehisa Abe1, Yoshihiro Hayata1, Keigo Yamashita1, Rei Tonomura1,

Yoshio Kaniwa1, Hiroshi Nishikawa1, Shinichi Iwakoshi2, Shigeo Ichihashi2, Kimihiko Kichikawa2, Shigeki Taniguchi1

1Department of Thoracic and Cardiovascular Surgery, Nara Medical University, Kashihara, Nara, Japan 2Department of Radiology, Nara Medical University, Kashihara, Nara, Japan

P02-62 Paper No: 415 3D virtual intravascular endoscopy in the visualisation of aortic aneurysm and aortic dissection Sultan Aldosari, Zhonghua Sun Department of Medical Radiation Sciences, Curtin University, Perth, Western Australia, Australia

P02-63 Paper No: 445 Reoperation for a giant aortic arch aneurysm using cervical cannulation of the common

carotid artery for cerebral perfusion after the ascending aortic replacement: Report of a case Shigenobu Senaha, Tozuka Yuichi, Mitsuyoshi Shimoji, Mitsuru Akasaki

P02-64 Paper No: 446 Three cases of emergent debranching TEVAR for acute type B aortic dissection with rupture Shunsuke Ohori Cardiovascular Surgery, Hokkaido Ohno Hospital, Sappooro, Hokkaido, Japan

23

Poster PresentationP02-65 Paper No: 448 EVAR survival in octogenarians - Is 85 the new 80? Wah Wah Lin1, Robert Tewksbury1, Patrick Tosenovsky2, Joe Hockley3, Jens Carsten Ritter1

1Fiona Stanley Hospital, Perth, Western Australia 2Royal Perth Hospital, Perth, Western Australia 3Sir Charles Gairdner Hospital, Perth, Western Australia

P02-66 Paper No: 452 To present a case report and review of literature: Fibromuscular dysplasia and Takayasus

Aortoarteritis can be a major diagnostic dilemma and we present a known case of FMD presenting with Aortic aneurysm, an unusual presentation in FMD

Krunal Gohil, Bhavin Ram, Robbie George Department of Vascular Surgery, Narayana Hrudayalaya Health City, Karnataka, India

P02-67 Paper No: 469 Aortoduodenal syndrome from infected abdominal aortic aneurysm treated with endovascular approach Thoetphum Benyakorn1, Saritphat Orrapin1, Kanoklada Srikuea1, Tunyarat Wattanasatesiri2, Boonying

Siribumrungwong1

1Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand 2Division of Interventional Radiology, Department of Radiology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand

P02-68 Paper No: 471 Management of aortoduodenal fistula: Report of three cases Tohru Ishimine, Hiroshi Yasumoto, Toshiho Tengan, Mitsuhide Mototake Department of Cardiovascular Surgery, Okinawa Prefectural Chubu Hospital, Okinawa, Japan

P02-69 Paper No: 474 Using of endovascular aneurysm sealing system for ruptured and symptomatic abdominal

aortic aneurysm in Thailand Thoetphum Benyakorn, Saritphat Orrapin, Kanoklada Srikuea, Boonying Siribumrungwong Division of Vascular and Endovascular, Department of Surgery, Faculty of Medicine, Thammasat University, Pathum

Thani, Thailand

P02-71 Paper No: 153 A novel technique of “Chimney Nellix” for the management of type 1a endoleak following

EVAR Joseph SZ1, Kwok CHR1, Abdelhamid M1, Hockley JA1, Garbowski MW1, Ferguson J2, Samuelsson S2, Jansen SJ1,3,4,5

1Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia 2Department of Interventional Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia 3Faculty of Health Sciences, Curtin University, Perth, Western Australia 4Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia 5Heart Research Institute, Harry Perkins Institute of Medical Research, Perth WA

Arteritis

P03-01 Paper No: 036 Demand for surgical treatment in Japanese patients with Takayasu arteritis Yoshiko Watanabe1, Kazuo Tanemoto2

1Department of Physiology, Kawasaki Medical School, Kurashiki, Okayama, Japan 2Department of Cardiovascular Suugery, Kawasaki Medical School, Kurashiki, Okayama, Japan

24

Poster PresentationP03-02 Paper No: 385 Case report: Endovascular approach for takayasu’s arteritis with midaortic syndrome Rosnelifaizur Ramely1, Mohd Ammar Ahmad2, Hanif Hussein2, Zainal Ariffin Azizi2

1Department of Surgery, School of Medical Sciences,Universiti Sains Malaysia, Kelantan, Malaysia 2Department of Surgery Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

P03-03 Paper No: 395 Management options of visceral artery aneurysms Masanori Hayashi1, Hideaki Obara1, Kentaro Matsubara1, Keita Hayashi1, Yuki Kamiya1, Masanori Inoue2, Seishi

Nakatsuka2, Masahiro Jinzaki2, Yuko Kitagawa1

1Department of Surgery, Keio University School of Medicine, Tokyo, Japan 2Department of Radiology, Keio University School of Medicine, Tokyo, Japan

P03-04 Paper No: 462 Improving pulmonary perfusion in a child with Takayasu’s arteritis Bhavin Ram, Krunal Gohil, Robbie George Department of Vascular Science, Narayana Hrudayalaya Health City, Bangalore, Karnataka, India

Carotid Artery Diseases

P04-01 Paper No: 042 Carotid surgery and cranial nerve injuries: Its common! Singh TM Chief Vascular Surgery, El Camino Hospital, Silicon Valley California, USA

P04-02 Paper No: 083 Operations on the internal carotid artery in patients with atrial fibrillation whis using

dabigatran etexilate Alexandr Korotkikh1,2, Dmitry Nekrasov1

1Regional Clinical Hospital 2, Tyumen, Tyumen Region, Russian Federation 2Far Eastern State Medical University, Khabarovsk, Khabarovsk Region, Russian Federation

P04-03 Paper No: 114 Surgical management of carotid body tumours: A 25-year experience Eu Jhin Loh, Stephen Bradshaw AM Department of Vascular Surgery, The Canberra Hospital, Garran, ACT, Australia

P04-04 Paper No: 206 Comparison result of treatment outcome between patch angioplasty and primary closure

during carotid endarterectomy using propensity score matching analysis Byeoung-Hoon Chung, Dong-Heon Lee, Seon-Hee Heo, Yang-Jin Park, Young-Wook Kim, Shin-Young Woo, Dong-Ik Kim Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

P04-05 Paper No: 402 Intraoperative microembolic signals during carotid endarterectomy Jeensoo Bae, Woo-Sung Yun, Shin-Seok Yang, Bo-Yang Seo Division of Transplantation and Vascular Surgery, Department of Surgery, Yeungnam University Medical Center,

Yeungnam University College of Medicine, Daegu, Korea

P04-06 Paper No: 328 Aneurysm-like entity inside a giant carotid body tumor reaching lateral skull base Hui Zhang1,2, Yuehong Zheng1

1Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China 2Tsinghua University School of Medicine, Beijing, China

25

Poster PresentationDiabetic Foot

P05-01 Paper No: 279 Cost effectiveness of wound treatment with fish skin: Results of a prognostic study Gunnar Johannsson1, Christopher Winters DPM2, Skuli Magnusson BSc1, Baldur T Baldursson1,3, Hilmar

Kjartansson1,3, G Fertram Sigurjonsson M Eng1

1Kerecis, Skolavordustig, Iceland 2American Health Network, Indianapolis, Indiana 3Landspitali The National University Hospital of Iceland, Iceland

P05-02 Paper No: 280 Omega3 rich fish skin to prevent re-infection and amputation in exposed bone lower extremity

wounds with history of MRSA and chronic osteomyelitis Christopher Winters DPM1, Gunnar Johannsson2

1American Health Network, Indianapolis, Indiana 2Kerecis, Reykjavik Iceland, Iceland

P05-03 Paper No: 325 Relations procalcitonin and other factors with lower extremity amputation in infected diabetic

foot in the emergency room RSCM in January 2013 - June 2016 Sari Febriana1, Patrianef Darwis2

1Surgery Training Program Department of Surgery, Universitas Indonesia, Jakarta Pusat, DKI Jakarta, Indonesia 2Universitas Indonesia, Jakarta Pusat, DKI Jakarta, Indonesia

Others

P06-01 Paper No: 014 A third-time open heart surgery for a marfan`s syndrome with prosthetic valve dysfunction

after mitral valve plasty and bentall procedure Xiaoning Tong, Hideyuki Harada Cardiovascular Surgery, Kushiro Kojinkai Memorial Hospital, Kushiro, Hokkaido, Japan

P06-02 Paper No: 017 Comprehensive neurosurgical management for deep-seated brain avms Hiroyuki Nakase, Shuichi Yamada, Ichiro Nakagawa, Fumihiko Nishimura, Matsuda Ryosuke, Yasushi Motoyama,

Park Young-Su Department of Neurosurgery, Nara Medical University, Kashihara Nara, Japan

P06-03 Paper No: 029 AVM in scalp: Diagnostic dilemma - A case report Shantonu Kumar Ghosh1, Alpana Majumder2

1Department of Vascular Surgery, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh 2National Center for Control of Rheumatic Fever & Heart Diseases, Dhaka, Bangladesh

P06-04 Paper No: 046 Spontaneous (True) aneurysm of the superficial temporal artery: A case report of 72 years old

male I Joalsen1, G Sianturi2, M Niasari3

1Division of Thoracic, Cardiac and Vascular Surgery, Abdul Wahab Sjahranie General Hospital - Mulawarman University, Samarinda, East-Borneo, Indonesia 2Division of NeuroSurgery, Abdul Wahab Sjahranie General Hospital- Mulawarman University, Samarinda, East-Borneo, Indonesia 3Department of Pathologic Anatomy, Abdul Wahab Sjahranie General Hospital- Mulawarman University, Samarinda, East- Borneo, Indonesia

P06-05 Paper No: 060 Quantative analysis of digitaized books in the field of vascular surgery: Culturomics Joong Hwan Oh, Kwan-Wook Kim, Chang-Won Kim, Soon-Chang Hong, Chun Sung Byun Department of Thoracic and Cardiovascular Surgery, Wonju Severance Christian Hospital, Yonsei University, Wonju city,

Kangwondo, Republic of Korea

26

Poster PresentationP06-06 Paper No: 081 Effectiveness of multi-disciplinary perioperative geriatric consultation for Vascular in-patient

population Jasmine Ge1, Zhiwen Joseph Lo2, Jennifer Yuan Li2, Sherilyn Liew1, Ruth Yap1, Sriram Narayanan2, Sadhana

Chandrasekar2, Glenn Wei Leong Tan2, Esmiller Froilan2, Natesan Selvaganapathi2

1Yong Loo Lin School of Medicine, National University of Singapore, Singapore 2Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore

P06-07 Paper No: 122 The clinical significance of morphological changes on CT scan of isolated superior mesenteric

artery dissection treated with conservative treatment Hye Young Ahn1, Byung Sun Cho2

1College of Nursing, Eulji University, Daejeon, South, Korea 2Department of Surgery, Eulji Medical Center, Daejeon, South Korea

P06-08 Paper No: 139 The effect of catheter diameter on left innominate vein stenosis in breast cancer patients after

totally implantable venous access port implantation Tae-Seok Seo1, Myung Gyu Song1, Yun Hwan Kim2, Sung Bum Cho2, Hwan Hoon Chung3, Seung Hwa Lee3

1Department of Radiology, Korea University Guro, Hospital, Korea University College of Medicine 2Department of Radiology, Korea University Anam, Hospital, Korea University College of Medicine 3Department of Radiology, Korea University Ansan, Hospital, Korea University College of Medicine

P06-09 Paper No: 175 Case report: Remembering the basics iatrogenic injury to Superficial Femoral Artery (SFA)

mistaken as Great Saphenous Vein (GSV) Mohammad Fahad Tariq Berlas1, Farhina Salahuddin2

Department of Vascular Surgery, Shaheed Mohtarma Benazir Bhutto Trauma Centre Civil Hospital, Karachi, Pakistan, Pakistan

P06-10 Paper No: 177 Case report: Adventitial cystic disease of the femoral vein Park SS, Jang LC Department of Surgery, Chungbuk National University Hospital, Cheongju, Chungcheongbuk-do, South Korea

P06-11 Paper No: 179 Managing infected pseudo aneurysms in IV drug abusers - A challenging problem for the

vascular surgeon of the developing world Farhina Salahuddin, Muhammad Fahad Tariq Berlas, Zulfiqar Ali, Najamuddin Rajpar, Waryam Panhwar, Khalil-ur-Rehman Department of Vascular Surgery, Shaheed Mohtarma Benazir Bhutto Trauma Centre Civil Hospital, Saddar Town,

Karachi, Pakistan

P06-12 Paper No: 215 Abdominal aortic replacement in intimal sarcoma of an abdominal aortic stenosis: A case

report Katsunori Takeuchi, Akio Yamashita, Kanetsugu Nagao, Kimimasa Sakata, Naoki Yoshimura Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of Toyama, Toyama,

Japan

P06-13 Paper No: 226 Development of the gene therapy with CRE decoy ODN to prevent vascular intimal hyperplasia Daiki Uchida

27

Poster PresentationP06-14 Paper No: 237 Splenic artery aneurysm arising from a hepatosplenomesenteric trunk Wah Wah Lin, Jens Carsten Ritter, Brendan Stanley Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia

P06-15 Paper No: 247 The effect of protease inhibitor on atherosclerosis biomarker in HIV infected patients Kittipan Rerkasem1,2, Khuanchai Supparatpinyo3,4, Romanee Chaiwarith4, Kanokwan Watcharasaksilp4, Nattapol

Kosachunhanun3, Thaweewat Supintham3, Patcharaphan Sugandhavesa3, Thananchai Kampee5, Sakaewan Ounjaijean3, Kanokwan Kulprachakarn1

1NCD Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 2NCD Centre of Excellence, RIHES, Chiang Mai University, Chiang Mai, Thailand 3Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand 4Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand 5Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

P06-16 Paper No: 257 Successful management of tumors invading the superior vena cava using a endovascular stent

graft Yoon-Sung Joo Soon cheon Lee1, Dong Hyun Kim2, Min Sang Song3, Yung Baom Park4, Sang Su Lee2, Sang Bong

Lee2

1Gwangyang Sarang Hospital, Gwangyang, Korea 2Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea 3Dongrae Bongseng Hospital, Busan, Korea 4Cheongmac Vascular and Vein clinic, Busan, Korea

P06-17 Paper No: 259 A retrospective review of underlying causes and treatment results of aorto-enteric fistula or

aortoenteric erosion Dong-Heon Lee1, Shin-Young Woo1, Seon-Hee Heo1, Yang-Jin Park1, Dong-Ik Kim1, Ki-Ik Sung2, Young-Wook Kim1

1Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea 2Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

P06-18 Paper No: 292 A systematic review of transcatheter aortic valve implantation via carotid artery access Ian Wee Jun Yan1,2, Thomas Stonier1,3, Michael Harrison1,4, Andrew MTL Choong1,5,6

1SingVaSC, Singapore Vascular Surgical Collaborative 2Faculty of Medicine, University of New South Wales, Sydney, Australia 3Princess Alexendra Hospital, Harlow, United Kingdom 4Department of General Surgery, Sir Charles Gairdner Hospital, Australia 5Division of Vascular Surgery, National University Heart Centre, Singapore 6Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

P06-19 Paper No: 293 The kidney wrapping nitric oxide releasing nanofiber diminishes apoptosis and inflammation

after renal ischemia-referfusion injury in rat Hyung Joon Ahn, Hyun Min Ko, Jung Min Lim, Hye Jin Kim Department of Surgery, Kyung Hee University, Seoul, Republic of Korea

P06-20 Paper No: 360 Two elderly patients with atypical coarctation treated with axillo-bilateral femoral artery

bypass Shuto Hirooka, Tetsuro Uchida, Azumi Hamasaki, Seigo Gomi, Yoshinori Kuroda, Masahiro Mizumoto, Atsushi

Yamashita, Jun Hayashi, Takahashi, Kentaro Akabane, Mitsuaki Sadahiro Division of Cardiovascular Surgery, Department of Surgery II, Yamagata University Faculty of Medicine, Yamagata,

Japan

28

Poster PresentationP06-21 Paper No: 387 Giant hepatic artery aneurysm: The evil within Rosnelifaizur Ramely1, Lenny Suryani Safri2, Azim Idris2, Hanafiah Harunarashid2

1Department of Surgery, School of Medical Science, Universiti Sains Malaysia, Kelantan, Malaysia 2Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Malaysia

P06-22 Paper No: 398 Infected femoral pseudoaneurysms in Intravenous Drug Abusers (IVDAs): A 10 year, single-

institution experience L Chen, D Lim, D Ho, YK Tan, S Kum Vascular Service, Department of Surgery, Changi General Hospital, Singapore

P06-23 Paper No: 408 Visceral artery aneurysms seen in Abdominal CT Lee Chan Jang, Sung Su Park Department of Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea

P06-24 Paper No: 424 Endovascular aneurysm repair increases augmentation index and reflection magnitude Shinya Negoto, Tohru Takaseya, Hiroyuki Otsuka, Seiji Onitsuka, Shinichi Nata, Ryo Kanamoto, Shinichi Imai,

Shinichi Hiromatsu, Hiroyuki Tanaka Department of Surgery, Kurume University, Kurume, Fukuoka, Japan

P06-25 Paper No: 470 Modern day ileo caval surgery: A perspective Prasenjit Sutradhar, Ankur Aggarwal, Bhavin Ram, Rajesh S, Robbie K George Department of Vascular Surgery, Narayana Health, Bengaluru, Karnataka, India

P06-26 Paper No: 473 A contemporary experience of thoracic outlet surgery Prasenjit Sutradhar, Ankur Aggarwal, Bhavin Ram, Rajesh S, Robbie K George Department of Vascular Surgery, Narayana Health, Bengaluru, Karnataka, India

P06-27 Paper No: 477 Is it possible to treat Gerbode type VSD+ sever TR by invasive percutaneus procedure? A

case with succesful repairment of congenital Gerbode type VSD by amplatzer muscular VSD occluder and improvement of severe TR

Zeynep Ã‡olakoÄŸlu Gevher1, Nuh YÄ±lmaz2, Sabri Seyis3, Helen Bournaun4

1Department of Cardiology, Kanuni Sultan Suleyman Educational and Research Hospital, Istanbul, Turkey 2Department of Pediatric Cardiology Istinye University Liv Hospital, Istanbul, Turkey 3Department of Pediatric Cardiology Istinye University Liv Hospital, Istanbul, Turkey 4Department of Pediatric Cardiology, Kanuni Sultan Suleyman Educational and research Hospital, Istanbul, Turkey

P06-28 Paper No: 182 Vascular access for breast cancer chemotherapy according to patient’s clinical characteristics Sun Cheol Park, Cheng Quan, Young Hwa Kim, Gyeong Jae Koh, Jin Go, Mi Hyeong Kim, Kang Woong Jun, Jeong

Kye Hwang, Sang Dong Kim, Jang Yong Kim, Ji Il Kim, Yong Sung Won, Sang Seob Yun, In Sung Moon Department of Surgery, Catholic University of Korea, Seoul, Korea

P06-29 Paper No: 361 The prevention of aorto-duodenal erosion: A case of aorto-duodenal erosion with penetration

due to compression and graft infection Takashi Mori, Takuro Shirasu, Yusuke Suka, Takatoshi Furuya, Yukihiro Nomura, Nobutaka Tanaka Department of Surgery, Asahi General Hospital , Asahi, Chiba Prefecture, Japan

29

Poster PresentationP06-30 Paper No: 341 The bomb squad - A northeast Malaysian experience managing pseudoaneurysms Sophia Heng Si Ling1,2, Arman Zaharil Mat Saad1, Wan Azman Wan Sulaiman1

1Plastic and Reconstructive Surgery, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia 2Universiti Malaysia Sabah, Sabah , Malaysia

P06-31 Paper No: 380 “Carbon Savior” - The final weapon against carotid artery invasion in a case of advanced

recurrent laryngeal carcinoma Sophia Heng Si Ling1,2, Arman Zaharil Mat Saad1, Wan Azman Wan Sulaiman1

1Plastic and Reconstructive Surgery, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia 2Universiti Malaysia Sabah, Sabah , Malaysia


P07-01 Paper No: 031 A series of 210 peripheral arterial disease below knee amputations and predictors for

subsequent above knee amputations Jing Ting Wu1, Maggie Wong1, Zhiwen Joseph Lo2, Wei-En Wong1, Sriram Narayanan2, Glenn Wei Leong Tan2,

Sadhana Chandrasekar2

1Yong Loo Lin School of Medicine, National University of Singapore, Singapore 2Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital (Singapore), Singapore

P07-02 Paper No: 043 Nineteen surgically treated cases of popliteal artery aneurysms Hironobu Fujimura1, Takashi Shintani1, Takuma Iida1, Takashi Shibuya2, Yoshiki Sawa2

1Department of Cardiovascular Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan 2Department of Cardiovascular Surgery, Osaka University, Suita, Osaka, Japan

P07-03 Paper No: 063 Improvement of activity of daily living by open bypass leads to superior long-term outcomes

in patients with critical limb ischemia Shinsuke Mii 1Department of Orthopaedic Surgery, Faculty of Medicine and Health Sciences Universiti Putra Malaysia 2Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia 3Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre

P07-04 Paper No: 100 Atherosclerotic axillary artery aneurysm presenting as distal digital emboli Omer Tetik, Funda Yildirim, Dilsat Amanvermez Senaslan, Abdulkerim Damar, Baris Bayram Department of Cardiovascular Surgery, Manisa Celal Bayar University Uncubozkoy, Manisa, Turkey

P07-05 Paper No: 108 Clinical outcome after distal bypass surgery for critical limb ischaemia: Single centre

experience Johan Abdul Kahar1, Rosnelifaizur Ramely2, Lenny SS3, Mohamad Azim Md Idris3, Hanafiah Harunrashid3

1Department of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia 2Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia 3Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre

P07-06 Paper No: 120 Vein graft quality, decided at bypass surgery, is reflected pathological changes, and may

influence on the primary graft patency Yukihiro Saito, Manabu Issiki, Shinsuke Kikuchi, Daiki Uchida, Nobuyoshi Azuma, Tadahiro Sasajima, Satoshi

Hirata Division of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan

30

Poster PresentationP07-07 Paper No: 135 Distal open revascularization in chronic kidney disease; Is it worth your while? Nalaka Gunawansa National Institute of Nephrology and Transplant Colombo, Sri Lanka

P07-08 Paper No: 152 Foreign body micro-emboli following endovascular intervention: A case study Joseph SZ1, Kwok CH1, Harvey N2, Garbowski M1, Jansen S1,3,4,5


P07-09 Paper No: 167 Can postoperative ST-segment change and blood pressure variability predict short term

mortality in patients following major vascular surgery Aekkaphod Liwatthanakun1, Arintaya Phrommintikul2,3, Orapin Pongtam3, Kanokwan Kulprachakarn3, Kittipan

Rerkasem1,3,4

1Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 2Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 3NCD Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 4NCD Center of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand

P07-10 Paper No: 189 Effectiveness of Transcutaneous oxygen pressure measurement (TcPO2) for critical limbs

ischemia (CLI) Jang yong Kim, Cheng Quan, Young Hwa Kim, Gyeong Jae Koh, Jin Go, Mi Hyeong Kim, Kang Woong Jun, Jeong

Kye Hwang, Sang Dong Kim, Sun Cheol Park, Ji Il Kim, Yong Sung Won, Sang Seob Yun, In Sung Moon Department of Surgery, Catholic University of Korea, Seoul, Korea

P07-11 Paper No: 205 Clinical experience of Arterial Cystic Adventitial Disease Byeoung-Hoon Chung, Dong-Heon Lee, Seon-Hee Heo, Chi-Woo Lee, Yang-Jin Park, Young-Wook Kim, Dong-Ik Kim Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

P07-12 Paper No: 254 The atherosclerosis risk factor control in diabetic patients with peripheral arterial disease: 18

months follow up Kittipan Rerkasem1,2, Ampica Mangklabruks1, Natapong Kosachunhanun1, Arintaya Phrommintikul1, Kiran

Sony3, Nimit Inpankaew4, Saritphat Orrapin1, Orapin Pongtam1, Paweena Thongkham1, Prakaydao Abkom2

1NCD Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 2NCD Centre of Excellence, RIHES, Chiang Mai University, Chiang Mai, Thailand 3Department of Internal Medicine, Chiangrai Prachanukroh Hospital, Chang Wat Chiang Rai, Thailand 4Department of Internal Medicine, Lamphun Hospital, Chang Wat Lamphun, Thailand

P07-13 Paper No: 270 Alteration of ankle - Brachial index after kidney tranplantation Sang Young Chung, Soo Jun Na Choi, Ho kyun Lee, Hyo Shin Kim, Dae Jung Kim, Hong Sung Jung Department of Surgery, Chonnam National University Medical School , Gwangju, Korea

P07-14 Paper No: 309 The outcome of an endovascular-first approach to limb salvage in a multi-ethnic asian

population Vikram Vijayan, Alok Tiwari, Chen Min Qi, Harvinder Raj Singh Sidhu Division of Vascular Surgery, Department of General Surgery, Ng Teng Fong General Hospital, Singapore

31

Poster PresentationP07-15 Paper No: 326 Determinants of one-year wound healing in patients undergoing distal bypass for ischemic

tissue loss Kiyoshi Tanaka1, Daisuke Matsuda1, Jin Okazaki1, Shinsuke Mii2

1Depatment of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu-City Japan 2Depatment of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu-City Japan

P07-16 Paper No: 333 The middle term results of common femoral artery thromboendarterectomy for PAD patients Naoki Hayashida, Souichi Asano, Hideomi Hasegawas, Takahiro Itoh, Shintaroh Koizumi, Hiroki Ikeuchi,

Shinichiro Abe, Masashi Kabasawa, Kouzou Mastuo, Hirokazu Murayama Department of Cardiocvascular Surgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan

P07-17 Paper No: 339 Surgical treatment for femoral artery aneurysm - Single center experience Hiroyuki Morishita, Tatsuo Kaneko, Masahiko Ezure, Yutaka Hasegawa, Yasuyuki Yamada, Shuichi Okada,

Shuichi Okonogi, Yuta Kanazawa Division of Cardiovascular Surgery, Gunma Prefectural Cardiovascular Center, Gunma, Japan

P07-18 Paper No: 345 Endovascular management for ruptured hepatic artery (7), GDA (2), and SMA (1)

Pseudoaneurysm Dae Hyun Hwang, Changhyun Park, Jeong Wook Seo, Gam Hur Ilsan Paek Hospital, Inje University, Seoul, Republic of Korea

P07-19 Paper No: 375 Thrombotic occlusion of superficial femoral artery aneurysm combined multiple

atherosclerotic aneurysms Ji-Hoon Jang, Min-Gu Kim, Seung-Jae Byun, Byung Jun So Department of Surgery, Wonkwang Uni. School of Medicine & Hospital, Jeonbuk, Korea

P07-20 Paper No: 392 Intermediate-term outcomes after endovascular treatment of atherosclerotic femoropopliteal

occlusive lesions Young-Nam Roh, Ui Jun Park, Hyoung Tae Kim Division of Transplantation and Vascular Surgery, Department of Surgery, Keimyung University Dongsan Medical

Center, Daegu, Republic of Korea

P07-21 Paper No: 394 Outcomes after angioplasty of isolated, below-the-knee arteries in severe limb ischemia Young-Nam Roh, Ui Jun Park, Hyoung Tae Kim Division of Transplantation and Vascular Surgery, Department of surgery, Keimyung University Dongsan Medical Center,

Daegu, Republic of Korea

P07-22 Paper No: 436 Supra-celiac aorta-to-bilateral external iliac artery bypass and superior mesenteric artery

bypass for severe calcified aortic occlusion with severe claudication and abdominal angina: A case report

Kazunori Hashimoto, Harunobu Matsumoto, Takao Nonaka, Daijiro Hori, Naoyuki Kimura, Koichi Yuri, Atsushi Yamaguchi

Department of Cardiovascular Surgery, Jichi Medical University Saitama Medical Center, Saitama, Japan

P07-23 Paper No: 443 An evaluation of hemodynamic and perfusion parameters and the response to revascularization

among patients with critical lower limb ischemia Prasenjit Sutradhar, Robbie K George Department of Vascular Surgery, Narayana health, Bengaluru, Karnataka, India

32

Poster PresentationP07-24 Paper No: 444 Early Experience of Rotational Atherothrombectomy Catheter in treating instent re-stenosis

or occluded stent Skyi Yin Chun Pang, CN Tang Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR

P07-25 Paper No: 468 MACE in diabetic patients with peripheral arterial disease: 18 months follow up in Chiang

Mai Thailand Kittipan Rerkasem1,2, Ampica Mangklabruks1, Natapong Kosachunhanun1, Arintaya Phrommintikul1, Kiran

Sony3, Nimit Inpankaew4, Saritphat Orrapin1, Orapin Pongtam1, Paweena Thongkham1

1NCD Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 2NCD Centre of Excellence, RIHES, Chiang Mai University, Chiang Mai, Thailand 3Department of Internal Medicine, Chiangrai Prachanukroh Hospital, Chang Wat Chiang Rai, Thailand 4Department of Internal Medicine, Lamphun Hospital, Chang Wat Lamphun, Thailand

P07-26 Paper No: 170 Cardiovascular safety of sulfonylureas in peripheral artery disease patients with diabetes in

Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand Nutthanun Tungsrirut1, Kanokwan Kulprachakarn1, Natapong Kosachunhanu2, Arintaya Phrommintikul2, Orapin

Pongtam1, Suwinai Saengyo1, Antika Wongthanee3, Kittipan Rerkasem1,3

1NCD Center and Department of Surgery, Faculty of Medicine, Chiang Mai University, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand 2Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 3NCD Center of Excellence, Research Institute of Health Science, Chiang Mai University, Chiang Mai, Thailand

P07-27 Paper No: 191 Qualitative assessment of carbon dioxide as a contrast agent for infra-inguinal arterial

diagnostic and therapeutic procedures in critical limb ischemia: A modality to prevent contrastinduced nephropathy in patients with chronic kidney disease

Sumanthraj Kolalu, Dharmesh D, Sravan CPS, Piyush J, Vaibhav L, Vishnu M, Vivekanand, Suresh K R Jain Institute of Vascular Sciences (JIVAS), Bangalore, India

P07-28 Paper No: 236 Technical consideration for endovascular recanalization of aortoiliac occlusive lesions: Single-

center experiences Haeng Jin Ohe1, Mi Hyeong Kim2, Kang Woong Jun2, Jeong Kye Hwang2, Jang Yong Kim2, Sun Cheol Park2, Ji Il

Kim2, Yong Sung Won2, Sang Seob Yun2, In Sung Moon2

1Inje University, Seoul Paik Hospital, Vascular and Transplantation Surgery 2The Catholic University of Korea College of Medicine, Vascular and Transplantation Surgery

Peripheral Arteries

P08-01 Paper No: 220 Changes of microperfusion of the foot after tibial angioplasty in critical limb ischemia Werner Lang, Alexander Meyer, Susanne Regus, Ulrich Rother Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany


P09-01 Paper No: 041 Fist Assist Device helps AV fistulas enlarge Tej Singh Fist Assist Devices, LLC

33

Poster PresentationP09-02 Paper No: 059 Comparative patency of one-stage and twostage brachiobasilic arteriovenous fistulae: A

systematic review and meta-analysis Ian Wee Jun Yan1,2, Ismail Heyder Mohamed1,3, Amit Patel1,4,5, Andrew MTL Choong1,6,7

1SingVasC, Singapore Vascular Collaborative, Singapore 2Faculty of Medicine, University of New South Wales, Sydney, Australia 3General Surgery & Renal Transplant, London Deanery, Royal London Hospital 4Stem Cell Transplantation & Haemato-oncology, Institute of Translational Medicine, University of Liverpool, United Kingdom 5Stem Cell Transplantation & Haemato-oncology, Royal Liverpool University Hospital, Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Uinted Kingdom 6Division of Vascular Surgery, National University Heart Centre, Singapore 7Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore

P09-03 Paper No: 090 Arterio-venous fistula flow dynamic and results of flow reduction revision in limb edema

patients from central venous occlusion Burapa Kanchanabat Department of Surgery, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand

P09-04 Paper No: 093 The incidence and management of central vein rupture occurring during PTA for hemodialysis

access patients DE Goo1, YJ Kim1, SB Yang1, D Song2, SC Yoon2

1Department of Radiology, University of Soonchunhyang, Seoul, Ref of Korea 2Department of Vascular Surgery, University of Soonchunhyang, Seoul, Ref of Korea

P09-05 Paper No: 106 A retrospective study of factors contributing to maturation rate of Brachio-cephalic Fistula

(BCF) Lenny SS, Amirullah, Kothai, Noratul, Murni, Heknes, Zuhaily, Mohamad Azim Md Idris, Hanafiah Harunrashid Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

P09-06 Paper No: 107 Results of surgical intervention following thrombosed arteriovenous grafts from a single

tertiary vascular centre Fattah AH, Lenny Suryani, Azim I, H Harunarashid Vascular Unit, Department of Surgery, UKM Medical Centre, Kuala Lumpur, Malaysia

P09-07 Paper No: 109 Effect on handgrip exercise on the distal forearm cephalic vein diametre in patients with

chronic renal disease Aminnur Hafiz Maliki1, Lenny Suryani Safri2, Mohamad Azim Mohd Idris2, Hanafiah Harunarashid1

1Department Of Surgery, Hospital Umum Sarawak, Kuching, Sarawak, Malaysia 2Vascular Unit, Department of Surgery, National University of Malaysia, Bangi, Selangor, Malaysia

P09-08 Paper No: 112 Predictors of functional and radiological patency following fistuloplasty in arteriovenous

fistulas Kishen Raj1, Ismazizi Zaharuddin1, Mohamad Azim Mohd Idris2, Zainal Ariffin1, Hanafiah Harunarashid2

1Department of Surgery Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2Department of Surgery, National University of Malaysia, Bangi, Selangor, Malaysia

34

P09-09 PaperNo:113 Theeffectofresidualclotandstenosispostrecanalisationof thromboseddialysisaccesson

patencyduration Eu Jhin Loh1, Robert Allen2, John Cockburn2

1Department of Vascular Surgery, The Canberra Hospital, Garran, Australia 2Department of Radiology, The Canberra Hospital, Garran, Australia

P09-10 PaperNo:121 Basilic vein transposition as an alternative technique of AV fistula: Experiences from

midindonesianregion Joalsen I Division of Cardiothoracic and Vascular Surgery, Mulawarman University - Abdul Wahab Sjahranie General Hospital,

Samarinda, East Borneo, Indonesia

P09-11 PaperNo:123 Preoperativeveinmappingforarteriovenousfistulacreation:Anationalkidneyandtransplant

instituteexperience Jonathan L Lumicday II, Ricardo DT Qiuntos II, Leo Carlo V Baloloy Department of Organ Transplantation and Vascular Surgery, National Kidney and Transplant Institute, Diliman,

Philippines

P09-12 PaperNo:128 Axillaryartery todistal femoralveingraft fistulaasalternativeoption for femoralartery

obstructionorstenosisinpatientsreceivingdialysis Hyun Hee Kim, Dan Song, Sang Chul Yun Department of Surgery, College of Medicine, Soonchunhyang University, Seoul, Republic of Korea

P09-13 PaperNo:129 Femoralveintranspositionforarteriovenoushemodialysisaccess Hyun hee Kim, Dan Song Department of Surgery, College of Medicine, Soonchunhyang University, Seoul, Republic of Korea

P09-14 PaperNo:130 Longtermoutcomesofarteriovenousgraftsforhemodialysisinlowerextremities Hyun Hee Kim, Sangchul Yun, Dan Song Department of Surgery, College of Medicine, Soonchunhyang University, Seoul, Republic of Korea

P09-15 PaperNo:133 Autologous basilic vein fistula versus prosthetic grafts; A prospective comparison for vascularaccess Nalaka Gunawansa National Institute of Nephrology and Transplant, Colombo, Sri Lanka

P09-16 PaperNo:154 DirectRevascularizationandIntervalLigation(DRIL)formanagementpreservingvascular

accessforhemodyalisisandextremityinstealsyndrome:Firstexperience Sudarma I W1, Sintoro H2, Revianto O3

1Department Cardio Thoracic and Vascular, Airlangga University, Surabaya, Indonesia 2Dr Soetomo General Hospital, Surabaya, Indonesia

P09-17 PaperNo:159 Arteriovenousfistulasurgery:OurexperienceinDistrictHospital,Taiping,Malaysia Chiar Churn Inn, See Boon Keong, Leow Yeen Chin, Alden Ong, Umasangar Ramasam Department of Surgery, Taiping Hospital, Perak, Malaysia

Poster Presentation

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P09-18 PaperNo:160 Factorsaffectingpatencyrateofarteriovenous fistula:Ourchallenge inDistrictHospital,

Taiping,Malaysia Chiar Churn Inn, Leow Yeen Chin, See Boon Keong, Goh Yen Nee, Umasangar Ramasamy Department of Surgery, Taiping Hospital, Perak, Malaysia

P09-19 PaperNo:168 Prevalenceandriskfactorsofperipheralarterialdiseaseinpatientswithhemodialysisaccess Kittipan Rerkasem1,2, Supapong Arworn1, Saranat Orrapin1, Tempong Reanpang1, Kanokwan Kulprachakarn1,

Orapin Pongtam1, Paweena Thongkham2, Suwinai Saengyo2

1NCD Centre and Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 2NCD Centre of Excellence, RIHES, Chiang Mai University, Chiang Mai, Thailand

P09-20 PaperNo:194 An analysis of the outcomes of 75 Brachiobasilic upper arm transposition arteriovenous

fistuladonein2016 Angamuthu Rajoo, HZ Haroon Anga AVF Centre Sdn Bhd, Johor Bahru

P09-21 PaperNo:246 Thecomparisonofbaselinecharacteristicsinendstagerenaldiseasepatientsbetweenpatients

withandwithoutcentrallinecannulation Kittipan Rerkasem1,2, Derek Bunnachak3, Panjapone Kobpungton6, Surachet Vongsanim3, Puntapong

Taruangsri5, Wuttikorn Siriplubpla7, Ratree Uoykaew8, Termpong Reanpang4, Chanawit Sitthisombat6, Antika Wongthanee3, Paweena Thongkham1, Phatcharin Pasa2

1NCD Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 2NCD Centre of Excellence, RIHES, Chiang Mai University, Chiang Mai, Thailand 3Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand 4Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 5Nakornping Hospital, Chiang Mai, Thailand 6Chiangrai Prachanukroh Hospital, Chiangrai, Thailand 7Phrae Hospital, Phrae, Thailand 8Uttaradit Hospital, Uttaradit, Thailand

P09-22 PaperNo:251 Goodforearmveinsbutpoorarteries-looparteriovenousfistula,anoptioninveinpreservation Angamuthu Rajoo, HZ Haroon Anga AVF Centre Sdn Bhd, Johor Bahru

P09-23 PaperNo:253 Percutaneoustransluminalangioplastyformalfunctionofautologousarteriovenousfistula:

Singlecenterexperience Jun Seong Kwon, Jeong Kye Hwang, Sun Cheol Park, Ji Il Kim, Sang Seob Yun, In Sung Moon, Sang Dong Kim Division of Vascular & Transplant Surgery, Department of Surgery, College of Medicine, The Catholic University of

Korea, Seoul, Korea

P09-24 PaperNo:296 Bypass graft to the internal jugular vein for central venous stenosis or occlusion of a functioninghemodialysis Tomohiro Nakamura, Katsuaki Meshii, Norihisa Hosokawa, Kouichi Okada, Morihiro Kondo Department of Vascular Surgery and Internal Medicine, Division of Nephrology, Rakuwakai Otowa Memorial Hospital,

Kyoto, Japan

P09-25 PaperNo:300 AnauditofvascularaccessforhaemodialysisattheNationalUniversityHospitalofMalaysia Gerald Tan JS1, Lenny S2, Azim I2, H Harunarashid2

1Newcastle University, Johor, Malaysia 2Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Poster Presentation

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P09-26 PaperNo:311 Brachiobasilic upper arm transposition arteriovenous fistula - How i do it under local

anaesthesiawithorwithoutnerveblock Angamuthu Rajoo A, HZ Haroon B ANGA AVF Centre Johor Bahru Malaysia, Johor Bahru, Johor, Malaysia

P09-27 PaperNo:324 Aanalysisoftheoutcomesoffirsttimearteriovenousfistulascreatedin2015 HZ Haroon

P09-28 PaperNo:346 Latearterialaneurysmformationwithvenousvaricosityfollowingligationofarteriovenous

fistulainkidneytransplantedpatient Ui Jun Park, Young Nam Roh, Hyoung Tae Kim Department of Surgery, Dongsan Medical Center, Keimyung Univ., Daegu, Korea

P09-30 PaperNo:372 Nativeradiocephalicfistulas:Pre-operativeresistiveindexasapredictorofsuccessfulfistula

creation Hazim K, Naresh G Department of Vascular and General Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

P09-31 PaperNo:374 Outcomesofendovascularinterventionforsalvageoffailing/failedhemodialysisaccess Ji-Hoon Jang, Min-Gu Kim, Seung-Jae Byun, Byung Jun So Department of Surgery, Wonkwang Uni. School of Medicine & Hospital, Jeonbuk, Korea

P09-32 PaperNo:383 AtypicalpresentationofCentralVenousOcclusion(CVO)disease Aizat Sabri I1, Rosnelifaizur R1, Azim I2, H Harunarashid2

1Department of Surgery, School of Medical Science, Universiti Sains Malaysia, Kelantan, Malaysia 2Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

P09-33 PaperNo:384 Saphenofemoralarteriovenousfistulaashemodialysisaccess:PPUKMearlyexperience Aizat Sabri I1, Rosnelifaizur R1, Azim I2, H Harunarashid2

1Department of Surgery, School of Medical Science, Universiti Sains Malaysia, Kelantan, Malaysia 2Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

P09-34 PaperNo:405 Apilotstudyintopercutaneousangioplastyinvenousoutflowstenosisovera4yearperiod Ee Tan1, Yii M2

1Department of General Surgery, Monash Health, Melbourne, Australia 2Department of Vascular Surgery, Monash Health, Melbourne, Australia

P09-35 PaperNo:429 Efficacyofcreationofarteriovenousfistulabytranspositiontechniqueforthepatientswith

poorupperarmcondition Masaru Kimura, Daisuke Akagi, Masaya Sano, Kazuhiro Miyahara, Jun Nitta, Akihiko Seo, Yoshihisa Makino,

Masamitsu Suhara, Atsushi Akai, Toshio Takayama, Kota Yamamoto, Katsuyuki Hoshina, Toshiaki Watanabe Division of Vascular Surgery, The University of Tokyo, Bunkyoku, Tokyo, Japan

Poster Presentation

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P09-36 PaperNo:434 ModifiedMILLERprocedureusingultrasonographyonpatientwithvenoushypertension: Acasereport Kevin Ardito Prabowo1, Niko Azhari Hidayat2

1Medical Student, Airlangga University, Surabaya, Jawa Timur, Indonesia 2Thorax, Cardio & Vascular Surgeon, Universitas Airlangga Hospital, Surabaya, Jawa Timur, Indonesia

P09-37 PaperNo:451 ToevaluatetheearlypostoperativepredictorsusingDuplexUltrasoundscanformaturation

ofArterio-venousfistula(AVF) Krunal Gohil, Bhavin Ram, Rajesh S, Robbie George Narayana Institute of Vascular Sciences, Narayana Health, Karnataka, India

P09-38 PaperNo:472 Transposedfemoralveinarteriovenousfistula:ChiangMaiexperience Kittipan Rerkasem1,2, Saranat Orrapin1

1Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 2NCD Centre of Excellence, RIHES, Chiang Mai University, Chiang Mai, Thailand

P09-39 PaperNo:342 Developingascoringsystemofpredictivesuccessfularteriovenousfistulaaccessinhemodialysis

patients:Singlecenterexperience Ayudika M1, Puruhito2

1Department of Surgery Division of Cardiothoracic and Vascular Surgery School of Medicine Sumatera Utara University - Sumatera Utara University Hospital Medan, Indonesia 2Department of Surgery Division of Cardiothoracic and Vascular Surgery School of Medicine Airlangga University - Dr. Soetomo General Hospital Surabaya, Indonesia

VaricoseVein&ChronicVenousDiseases

P10-01 PaperNo:008 PreservationoftherenalfunctioninsurgicalresectionforLeiomyosarcomaoftheInferior

VenaCavainvolvingrenalveins Yuehong Zheng, Duan Liu Department of Vascular surgery, Peking Union Medecal College Hospital, Shuaifuyuan Wangfujing Dongcheng District,

Beijing,China

P10-02 PaperNo:020 Holistic management of venous ulcers especially with endovenous laser treatment using

980nmlaserinanethnicallydiversesociety Murli Naraindas Lakhwani1, Toong Chow Lee2, Mei Lee Beh3

1Department of Surgery, Penang Adventist Hospital, Penang, Malaysia 2Gleaneagles CRC, Gleaneagles Medical Centre, Penang, Malaysia

P10-03 PaperNo:050 The impacton residualvenous refluxandvaricoseveinson thedevelopmentof reccurent

vericoseveinafter5yearsfollowupforprimaryvaricosevein Tomohiro Ogawa, Shunichi Hoshino Cardiovascular Surgery, Fukushima Daiichi Hospital, Fukushima, Japan

P10-04 PaperNo:065 Analysisoffactorsthatassociatedwiththe‘phlebitislikeabnormalreaction’afterVenaSeal

TMsystem Insoo Park Charm Vein Center, Seoho-medical Building, Bongcheon-ro, Gwanak-gu, South Korea

Poster Presentation

38

P10-05 PaperNo:076 6monthsshorttermresultsofVenaSealTMsystemforthetreatmentofincompetent37SSVs Insoo Park Charm Vein Center, Seoho-medical Building, Bongcheon-ro, Gwanak-gu, South Korea

P10-06 PaperNo:095 Earlyexperienceofendovenouslaserablation(EVLA)forsuperficialveinincompetence Tatsuya Kaneshiro, Toshimi Yonaha, Hideyoshi Henzan Department of Vascular surgery, Nakagami General Hospital, Okinawa, Japan

P10-07 PaperNo:141 EVLAwithradialfiberforbranchvaricosevein Yongbeom Bak1, Jinwon Jeon1, Jilan Zhang1, Byeongwan Kang2, Hyeongdong Do2

1Cheongmac Vascular and Vein Clinic, Bukgu, Busan, South Korea 2Cheongmac Vascular and Vein Clinic, Namgu, Ulsan, South Korea

P10-08 PaperNo:171 FoodconsumptiononpatientwithvaricoseveinsatMaharajNakornChiangMaihospitalin

Thailand Kanokwan Kulprachakarn1, Orapin Pongtum1, Paweena Thongkham1, Suwinai Saengyo1, Apinya Suwannasaen1,

Kittipan Rerkasem1,2,3

1NCD Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 2Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 3NCD Center of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand

P10-09 PaperNo:197 Mid-termresultsofendovenouslaserablationforthetreatmentofvaricoseveins Atsushi Tabuchi1, Yasuhiro Yunoki1, Yoshiko Watanabe2, Kazuo Tanemoto1

1Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan 2Department of First Physiology, Kawasaki Medical School, Kurashiki, Okayama, Japan

P10-10 PaperNo:213 TreatmentofacutevenousthromboembolismwithdirectoralanticoagulantsorvitaminK

antagonists Yuka Sakurai, Hiroyuki Abe, Satoshi Kinebuchi, Shota Kita, Hirotoshi Suzuki, Daijyun Ro, Tokuichirou Nagata,

Kiyoshi Chiba, Hirokuni Ono, Makoto Oono, Chikada Masahide, Hiroshi Nishimaki, Takeshi Miyairi St Marianna University School of Medicine, Kasasaki, Kanagawa, Japan

P10-11 PaperNo:222 Earlyoutcomeofendovenousradiofrequencyversuslaserablationfortreatmentofvaricose

vein:Singlecenterexperiencefrommidindonesiaregion Ivan Joalsen1, A Prasetyo U2

1Division of Cardiothoracic and Vascular Surgery, Mulawarman University - Abdul Wahab Sjahranie General Hospital, Samarinda, East Borneo, Indonesia 2Division of Cardiothoracic and Vascular Surgery, Mulawarman University - Abdul Wahab Sjahranie General Hospital, Samarinda, East Borneo, Indonesia

P10-12 PaperNo:233 Thefirsthumanuseofpolidocanolendovenousmicrofoam(Varithena)forsaphenofemoral

trunklowerlimbvaricoseveinsinAsia Mingli Li Cardiovascular division of Surgery, China Medical University Hospital, Taichung, Taiwan

Poster Presentation

39

P10-13 PaperNo:243 InitialexperienceofsaphenousveinsparingsurgeryforchronicvenousinsufficiencyinKorea Dong Jae Jeon1, Sangchul Yun1, Miok Hwang2

1Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, South Korea 2Thrombosis clinic, Soonchunhyang University Seoul Hospital, Seoul, South Korea

P10-14 PaperNo:249 VaricoseveinamongnursesinMaharajNakornChiangMaiHospital,ChiangMai,Thailand Prakaydao Abkom1, Orapin Pongtam2, Paweena Thongkham2, Kittipan Rerkasem1,2

1NCD Center of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand 2NCD Center Faculty of Medicine, Chiang Mai University, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand

P10-15 PaperNo:277 Comparisonbetweendeep,superficialandcombinedvenoussysteminsufficiency:A6-year

singlecenterexperience Cristina Marie Lajom, Josefino Sanchez, Dana Rubiano Department of Surgery, University of Santo Tomas Hospital, Manila, Philippines

P10-16 PaperNo:319 Doctors’chooseonmanagementofvaricoseveins:ResultsofChina Mingyi Zhang, Tao Qiu, Xiangtao Li, Gangzhu Liang, Huan Zhang, Luyuan Niu, Hui Zhao, Fuxian Zhang Department of Vascular Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, People’s Republic of

China

P10-17 PaperNo:336 Relationshipbetweentherightheartfunctionandvenousbloodflowvelocityandvaricose

veinsinthelowerlimbs Yasuhiro Ozeki1, Kazuo Tsuyuki1, Shinich Watanabe2, Yuki Ishida1, Kunio Ebine1, Susumu Tamura1, Toshifumi

Murase1, Kaoru Sugi1, Kenta Kumagai1, Itaru Yokouchi1, Kenji Yamazaki1

1Odawara Cardiovascular Hospital, Odawara, Japan 2Development of Clinical Engineering, Kanagawa Institute of Technology, Atsugi, Japan

P10-18 PaperNo:343 Advantageofwoundcontrolofcryotherapyinvaricositytreatment In Mok Jung, Jungkee Chung Department of Surgery Boramae Hospital, Seoul National University College of Medicine, Shindaebang-dong Dongjakgu,

Seoul Korea

P10-19 PaperNo:265 Excessivecostofovarianveinembolization:Opportunitytorationalizetechniqueandreduce

cost Mina Giurgis, Kishore Sieunarine

P10-20 PaperNo:386 Femoralendovenectomywithiliacstentingforchroniciliofemoralvenousocclusion Won Pyo Cho, Sungsin Cho, Min-Ji Cho, Sanghyun Ahn, Sang-il Min, Jongwon Ha, Seung-Kee Min Department of Surgery, Seoul National University Hospital, Seoul, Korea

P10-21 PaperNo:418 Riskfactorofphlebitisaftercyanoacrylateclosure Jin Hyun Joh, Ho-Chul Park Department of Surgery, Kyung Hee University, Seoul, South Korea

Poster Presentation

40

P10-22 PaperNo:442 AnoddpulsatingveinstreatedwithEndovenousLaserAblation(EVLA) Caesario Tri Prasetyo1, Niko Azhari Hidayat2

1Medical Student, Airlangga University, Surabaya, Indonesia 2Cardiothoracic and Vascular Surgeon, Universitas Airlangga Hospital, Surabaya, Indonesia

P10-23 PaperNo:463 Endovenousablationofvaricosevein:AnexperienceinBangladesh SMG Saklayen1, GM Mokbul Hossain2

1Department of Vascular Surgery, Ibrhim Cardiac Hospital and Research Institute, Shahbag Avenue, Dhaka,, Bangladesh 2Department of Vascular Surgery, National Institute of Cardiovascular Diseases, Shere e bangla Nagar, Dhaka, Bangladesh

VascularTrauma

P11-01 PaperNo:049 Falseaneurysminlowerextremity:Aserialcasefromeastkalimantan Joalsen Division of Thoracic, Cardiac and Vascular Surgery, Abdul Wahab Sjahranie General Hospital - Mulawarman University,

Samarinda, East Borneo, Indonesia

P11-02 PaperNo:064 LimitationofradiologicevaluationforZoneIIcervicalpenetratinginjury:Hiddenarterial

injury Jihoon Kim, Hojong Park, Minjeng Cho Department of Surgery, Ulsan university hospital, Ulsan, Korea

P11-03 PaperNo:161 Steal syndrome from a traumatic arteriovenous fistula leading to severe lower extremity

gangrene-Acasereport John Michael F Lopez, Josefino I Sanchez, Teodoro B Bautista Jr Department of Surgery, University of Santo Tomas Hospital, Sampaloc, Manila, Philippines

P11-04 PaperNo:180 Successfulendovascularrepairofocclusivetraumaticaorticinjury:Kissing-stent Jinseok Choi, Chung Won Lee, Up Huh, Sung Woon Chung Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Medical Research

Institute, Pusan National University Hospital, Seo-Gu, Busan, Republic of Korea

P11-05 PaperNo:262 Emergenttaeinaproneposition;Rightinternaliliacarteryinjuryduringsupinesurgery Hirokuni Ono1, Satoshi Kinebutchi1, Syouta Kita1, Hirotoshi Suzuki1, Yukaã€€Sakurai1, Tokuichirou Nagata1,

Daijun Ro1, Yukihisa Ogawa2, Kiyoshi Chiba1, Makoto Ono1, Masahide Chikada1, Hiroshi Nishimaki1, Takeshi Miyairi1

1Department of Cardiovascular Surgery, St. Marianna University School of Medicine, Kanagawa Prefecture, Japan 2Department of Radiology, St. Marianna University School of Medicine, Kanagawa Prefecture, Japan

P11-06 PaperNo:305 Acaseofbluntabdominalaorticinjuryduetolumbararteryavulsion Yamada Takayuki1, Kotani Shinsuke2, Ishikawa Takumi2, Murakami Tadanori2, Minamimura Hirokazu2

1Department of Cardiology, Bellland General Hospital, Sakaishi, Osaka-fu, Japan 2Department of Cardiovascular Surgery, Bellland General Hospital, Sakai-shi, Osaka-fu, Japan

Poster Presentation

41

P11-07 PaperNo:403 Endovascular repair of fistularized pseudoaneurysm of the left common iliac artery to

commoniliacveinafterlumbarspinesurgery:Casereport Jeensoo Bae, Woo-Sung Yun, Shin-Seok Yang, Bo-Yang Seo Division of Transplantation and Vascular Surgery, Department of Surgery, Yeungnam University Medical Center,

Yeungnam University College of Medicine, Daegu, Korea

P11-08 PaperNo:413 Endovascularmanagementofaniatrogenicsubclavianarterypseudoaneurysm:Acasereport Yoo Young Sun Department of Surgery, College of Medicine, Chosun University, Gwangju, Korea

P11-09 PaperNo:419 Successfulrevascularizationforacutemesentericarterialocclusionrelatedtotraumatictype

Baorticdissectionwithmakingasurgicalfenestration Tadao Kubota1, Koichiro Kubo2, Yoshihiro Morimoto2

1Department of General Surgery, Tokyo Bay Medical Center, Urayasu, Chiba, Japan 2Department of Surgery, Chibanishi General Hospital, Matsudo, Chiba, Japan

VenousThromboembolism

P12-01 PaperNo:028 Advantages&challengeswithTSOACs(targetspecificoralanticoagulants) Sandeep Raj Pandey Department of Vascular Surgery, Annapurna Hospital, Kathamndu, Nepal

P12-02 PaperNo:037 Safetyandefficacyofperformingshort-termendovasculartreatmentforacutelowerextremity

deepveinthrombosisusinglow-doseurokinaseinasinglesessionwithasinglevenousaccessapproach

Sang Yong Chung, Soo Jin Na Choi Department of Surgery, Chonnam National University Hospital, Gwangju, Korea

P12-03 PaperNo:040 LowerextremitiesdeepvenousthrombosiseventinvascularsurgicalpatientsinChiangMai

UniversityHospital Wiwat Yimkosol, Saranat Orrapin, Supapong Arwon, Termpong Reanpang, Kitipan Rerkasem Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

P12-04 PaperNo:052 Pharmacomechanical Thrombectomy (PMT) withAngiojet Solent Omni Compared with

Catheter DirectedAspiration Thrombectomy (CDAT) for Treatment ofAcute Deep VeinThrombosis(DVT)

Young Hwa Kim, Kyung Jai Ko, Jin Ko, Sang Seob Yun, Sun Cheol Park, Ji Il Kim, In Sung Moon, Jang Yong Kim Division of Vascular and Transplant Surgery, Department of Surgery, The Catholic University of Korea College of

Medicine

P12-05 PaperNo:131 Deepveinthrombosisinpatientswithpulmonaryembolism:Prevalence,clinicalsignificance

andoutcome Joonyoung Choi1, Jun Sung Lee1, Se Young Kim1, Tae Hoon Kim1, Ho Kyeong Hwang2, Yu Jin Kwon1, Kyung Bok Lee1

1Department of Surgery, Seoul Medical Center, Seoul, Korea 2Department of Radiology, Seoul Medical Center, Seoul, Korea

Poster Presentation

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P12-06 PaperNo:169 Incidenceofperioperativevenousthromboembolisminpatientswithahistoryofdeepvein

thrombosis.Howeffectivearedirectoralanticoagulantsinreducingrecurrence? Satoko Funata, Yutaka Hosoi, Masao Nunokawa, Makoto Haga, Toru Ikezoe, Yoshifumi Nishino, Hiroshi Kubota Department of Cardiovascular Surgery, Kyorin University, Tokyo, Japan

P12-07 PaperNo:184 Development&clinicalapplicationofautomaticalarmingsystemforpatientwithhighriskof

DVTusingElectronicMedicalRecord(EMR)forDVTprophylaxis Si Jin Jo, Cheng Quan, Young Hwa Kim, Gyeong Jae Koh, Jin Go, Mi Hyeong Kim, Kang Woong Jun, Jeong Kye

Hwang, Sang Dong Kim, Jang Yong Kim, Sun Cheol Park, Ji Il Kim, Yong Sung Won, Sang Seob Yun, In Sung Moon Department of Surgery, Catholic University of Korea, Seoul, Korea

P12-08 PaperNo:225 Clinical outcomeof edoxaban for venous thromboembolism in the real-worldof Japanese

singlecenter Shinichi Imai, Hiroyuki Otsuka, Shinichi Hiromatsu, Ryo Kanamoto, Yusuke Shintani, Shinichi Nata, Tohru

Takaseya, Satoru Tobinaga, Seiji Onitsuka, Hiroyuki Tanaka

P12-09 PaperNo:229 TheclinicaloutcomeofDOACsinthetreatmentofvenousthromboembolismwithcancer Ryo Kanamoto, Shinichi Hiromatsu, Shinichi Imai, Shinichi Nata, Yusuke Shinitani, Hiroyuki Otsuka, Tohru

Takaseya, Satoru Tobinaga, Seiji Onitsuka, HIroyuki Tanaka

P12-10 PaperNo:271 Inferior vena cava filter insertion through the popliteal vein: Enabling the percutaneous

endovenousinterventionofdeepveinthrombosiswithasinglevenousapproachinasinglesession

Hong Sung Jung, Dae Jung Kim, Hyo Shin Kim, Ho Kyun Lee, Soo Jin Na Choi, Sang Young Chung Department of Surgery, Chonnam National University Medical School, Gwangju, Korea

P12-11 PaperNo:358 Short-term catheter-directed thrombolysis with low-dose urokinase and mechanical

thrombectomyfortreatmentofsymptomaticlowerextremitydeepvenousthrombosis Soo Jin Na Choi, Hong Sung Chung, Dae Jung Kim, Hyo Shin Kim, Ho Kyun Lee, Sang Young Chung Department of Surgery , Chonnam National University Hospital, Gwangju, Korea

P12-12 PaperNo:388 Ararecomplicationofacuteappendicitis:Superiormesentericveinthrombosis Dongjae Jeon, Sangchul Yun Department of Surgery, Soonchunhyang University, Seoul, South Korea

Poster Presentation

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Aortic 1

Operating below and AAA threshold of 5.5cm saves lives - An analysis of international practice

Matt Thompson

IntroductionConsiderable international variation exists in thresholds for abdominal aortic aneurysm repair. This study examined differences between England and the USA in the frequency of aneurysm repair and mean aneurysm diameter at the time of the procedure, as well as discrepancies in rates of aneurysm rupture and aneurysm-related mortality.

MethodsThe frequency of intact abdominal aortic aneurysm repair, in-hospital mortality, and aneurysm rupture were extracted from English Hospital Episode Statistics and the USA Nationwide Inpatient Sample for 2005-2012. Aneurysm diameter at repair was extracted from the English National Vascular Registry (for 2014), and the USA National Surgical Quality Improvement Program (for 2013). Aneurysm-related mortality was determined from the USA Centers for Disease Control and the English Office of National Statistics for 2005-2012. Comparisons between England and the USA were performed after age and gender standardization or conditional regression.

ResultsFrom 2005-2012, 29,300 English and 278,921 USA patients underwent intact abdominal aortic aneurysm repair. Intact aneurysm repair was less common in England (OR 0.49; 95% CI 0.48-0.49; p<0.001) and aneurysm-related mortality more common in England (OR 3.60; 95% CI 3.55-3.64; p<0.001). Aneurysm rupture occurred more frequently in England (OR 2.23; 95% CI 2.19-2.27; p<0.001). The mean aneurysm diameter at the time of repair was larger in England (6.37 cm vs 5.83 cm, p<0.001).

ConclusionWe found a lower rate of abdominal aortic aneurysm repair at a larger mean diameter in England, and lower rates of aneurysm rupture and aneurysm-related mortality in the USA.

Characteristics of the arch of aorta in asian patients with arch pathology

Yiu Che ChanDivision of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, Queen Mary Hospital, Hong Kong

Durable successful hybrid or pure endovascular repair of ascending or aortic arch pathology requires sufficient proximal ‘landing zone’, while preserving aortic valvular competence, coronary and supra-aortic perfusion. We retrospective review prospectively collected computerized database on 3 groups of Asian patients: 1. degenerative arch aortic aneurysms 2. Type B thoracic aortic dissection with aneurysmal dilatation, 3. control group of infrarenal aortic aneurysms without thoracic aortic pathology. Their computed tomography (CT) images were reconstructed using the Aquarius workstation (TeraRecon, San Mateo, Calif, USA) and measurements of ascending aortic diameter and proximal landing zone was measured at the root of the aorta, mid- ascending aorta, distal ascending aorta just proximal to the inominate artery, just proximally to the left carotid artery, and just proximally to the left subclavian artery. Presence and absence of thrombus and calcification scores were also measured. There were 30, 30, 15 patients in groups 1, 2, 3 respectively. We found that patients with degenerative arch aneurysms had statistically significant unhealthy ascending aorta in terms of diameter, calcification, and thrombus load, compared to group 2 and 3. There was no significant different in ascending aortic dimensions across all levels between dissection and control group. This study showed that ascending aortae and proximal landing zones are often enlarged and unhealthy in Asian patients with thoracic aortic aneurysm, and such unhealthy zone 0 and 1 landing zones may predispose to post-operative complications, or even deny such patients from consideration of endovascular therapy. These results have important impact on endovascular planning, and perhaps consideration should be given to intervene on smaller arch aneurysm when the ascending aortic is healthier.

Aortic 2

Nexus endograft

Kong Teng Tan

AbstractTo present our experience on NEXUS arch endograft in Toronto General Hospital. 5 consecutive patients with arch aneurysmal disease (1 chronic type B dissection, 1

44


post type A repair and 3 degenerative aneurysms) with mean size of 6.8cm. Age 65-82 yr old. 3 males, 2 females. All patients underwent carotid carotid and carotid subclavian bypass.

ResultsNo death or neurological events or renal failure. One patient required revision of carotid-carotid bypass. One patient developed ascending dissection requiring open repair. No proximal endoleaks.

Debranching with TEVAR for aortic arch pathology

Julian Wong

Aorta Arch pathology continues to post a challenge. We would like to share our tevar experience the last 12 years in NUH from 2005 to 2016. Although the last few years there are endovascular devices custom made for arch pathology, however it takes a long time (minimum 3 months) to even get hold of one.

We continue to use de branch approach as a first line rather endovascular approach as there are lots of patients who may not be able to wait for customized devices. We will share with you our complications as well as success in tackling the aortic arch and hope to continue raise issues and learning points amongst our Asia vascular surgeons.

Aortic 3

Association between aortic remodeling and stent graft-induced new entry in extensive residual type a dissecting aortic aneurysm after hybrid arch repair

Chun Che ShihDivision of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Institute of Clinical Medicine, School of Medicine, National Yang Ming University Taipei, Taiwan

BackgroundThis sequential aortic morphologic remodeling and influencing factors between distal stent graft-induced new entry (SINE) in chronic residual type A dissecting aortic aneurysm after extensive hybrid arch repair.

MethodsWe retrospectively analyzed operative and follow-up data of 30 consecutive patients with chronic residual

type A aortic dissection aneurysm treated by hybrid type III arch repair (ascending aortic and arch replacement combined with elephant trunk technique before stent-graft deployment) between November 2006 and October 2011.

ResultsIn 3 years, follow-up of 24 patients with successful 1-stage hybrid arch repair and stent grafting. The ratio of true lumen area increased at pulmonary artery level, but minimal change was seen in the thoracic segment distal to stent graft and abdominal aorta. Late distal SINE occurred in 14 patients (SINE group). Cross-sectional area showed significant differences in distal end of pre-stenting graft oversizing ratio (SINE group 4.32 vs. non-SINE group 2.23, P=0.021(*)). The thoracic segment thrombosis rate was 90% in SINE and 57% in non-SINE (P = 0.089) groups.

ConclusionsIn homogenous population of chronic residual type A dissection, noticeable false lumen thrombosis with true lumen progressive dilatation was only found at the proximal descending aortic segment extending to the middle of stent grafts in both groups. A smaller size selection of the distal stent graft by area measurement would be accompanied with poor aortic remodeling but might be beneficial for SINE prevention. On the other hand, a larger size selection of the distal stent graft area might be favorable for aortic remodeling but could potentially induce SINE.

Experience of zenith stent graft used in stanford type a dissection

Zhe ZhangDepartment of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China

ObjectiveTo review the experience of endovascular treatment for Stanford type A aortic dissection using Zenith stent graft.

MethodsFrom January 2012 to January 2017, 21 patients with Stanford type A aortic dissection underwent endovascular treatment or hybrid procedure using Zenith stent graft. The clinical data of these patients were retrospectively analyzed. All patients were diagnosed by enhanced Computer Tomography. Fourteen cases with entry tear at ascending aorta underwent stent graft placement in ascending aorta with/without arch branch bypass. 7 cases with entry tear at aortic branch

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underwent stent graft placement and debranching or chimney technique.

ResultsProcedures were successfully performed in all patients. Twenty-four stent grafts were implanted, of which the diameter was from 36mm to 42mm and the length was from 60mm to 200mm. After operation, acute cerebral infarction occurred in two cases; acute myocardial infarction occurred in one case; respiratory failure occurred in two cases; and wound infection occurred in three cases. One case died on postoperative day 1 due to hemorrhage from aortic rupture. The remaining cases were safely discharged. During 6 to 48-month follow-up, all patients accepted CT review and 19 cases were found decreased false lumen. Six cases developed type I endoleak, but only one of them accepted second intervention by stent grafting plus debranching. The other 5 cases were continuously followed- up without a second operation. Two patients died during follow-up because of heart failure and respiratory failure.

ConclusionFor some high-risk patients who cannot tolerate traditional surgery, endovascular stent grafting with/without hybrid procedure by virtue of their minimal invasiveness can be used as an alternative approach to seal the primary entry tear and save their lives.

KeywordsAortic dissection; Endovascular treatment; Stent graft

Hybird ThoraflexTM graft for the technique of frozen elephant trunk

Randolph HL WongDivision of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR

ObjectiveAortic arch pathologies remain to be one of the most challenging conditions despite recent endovascular and surgical advances. We reviewed the total aortic arch replacement and frozen elephant trunk (FET) with ThoraflexTM hybrid stent graft system as a single stage repair of complex arch pathologies in our institution.

MethodsBetween August 2014 and Aug 2017, patients with complex thoracic aortic pathologies underwent FET implant with the Vascutek ThoraflexTM system were recruited. Patients’ perioperative parameters, clinical and radiological outcomes were reviewed.

ResultsTwenty-six patients with aortic arch pathologies, including acute dissections and chronic dissecting aneurysms, were treated with ThoraflexTM hybrid stent graft FET system. Overall mortality rate was 7.4% (n=2) and no 30-days mortality in the elective subgroup. Stroke occurred in 1 patient (3.7%). No recorded permanent spinal cord injury. Mean operative, moderate hypothermic circulatory arrest and antegrade cerebral perfusion time were 436±130min, 90±28min and 145±36 min respectively. In the follow up CT, 81% patients showed false lumen thrombosis and none with evidence of endoleak to distal stent graft.

ConclusionThis series represent one of the largest hybrid-FET experiences of the ThoraflexTM system in Asia. We demonstrated the use of ThoraflexTM system as a safe, single stage and effective way to treat complex aortic pathologies, in both emergency and elective settings. Further study is warranted to evaluate its impact on survival and disease progression in descending thoracic aorta.

Aortic 4

In situ venous laser fenestration of Stanford type A aortic dissection during thoracic endovascular aortic repair

Xinwu Lu1,2

1Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, P. R. China2Vascular Center of Shanghai JiaoTong University, Shanghai, P. R. China

ObjectiveThis study aimed to evaluate the feasibility, effectiveness, and safety of in situ venous laser fenestration of Stanford type A aortic dissection during thoracic endovascular aortic repair (TEVAR).

MethodsThirty patients (22 males and 8 females; mean age 42 years) with acute or subacute Stanford type A aortic dissection treated with in situ venous laser fenestration during TEVAR under cerebral circulation protection with an extracorporeal bypass were reviewed retrospectively. Routine postoperative outcomes were recorded and assessed. Computerized tomography angiography (CTA) was performed during the follow-up at 3, 6, and 12 months.

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ResultsProcedural success was achieved in 28 patients (93.33%). The average procedure time was 162±36 min. One patient died of pericardial tamponade during operation, and one died of severe pneumonia after the operation. No perioperative paraplegia, stent fracture or displacement, limbs or abdominal organ ischemia, or other severe complications occurred. Except one minor stroke, no more fenestration-related complications occurred 30 days and 12 months after operation. Active blood flow in ascending aorta and aortic arch dissection disappeared after TEVAR, and intramural hematoma shrank. CTA imaging demonstrated 100% primary patency for the left subclavian artery and carotid arteries with favorable aortic remodeling after TEVAR during the follow-up. One patient had a type Ia endoleak and another a type II endoleak.

ConclusionsIn situ venous laser fenestration of Stanford type A aortic dissection was found to be feasible, safe, and effective, and may be beneficial as a less invasive approach. However, the results are preliminary and long-term follow-up is required.

KeywordsAortic arch; in situ laser fenestration; Stanford type A aortic dissection; thoracic endovascular aortic repair; venous laser

Endovascular treatment of type B aortic dissection with multiple self-expanding stents: Case report

Chenglei Zhang

Special type B aortic dissection that the primary entry tear located in distal descending aorta can not be simply treated by covered stents placement because the Adamkiewics artery (AKA) originates from these segments in most circumstance. In particular, covered stents placement in these segements is not applicable because of high risk for postoperative ischemic spinal cord injuries such as paraparesis or paraplegia. Moreover, open surgery demands not only well-trained performers but also patients in good condition. In this report,we present a compromise but less invasive approach to repair such a complicated lesion.

Case reportThe patient was a 74-year-old man with sudden onset of severe chest pain radiating to the back, moreover, dizziness, oliguria and facial swelling were also observed. His medical history was notable for

hypertension, dyslipidemia and chronic obstructive pulmonary disease. After a series of physical and laboratory examinations, a set of significant datas were found: the bilateral upper limbs systolic blood pressure (SBP) were 170-180mmHg while the bilateral lower limbs 92-99mmHg, the left ankle brachial index (ABI) was 0.51 while the right 0.55. Furthermore, the serum creatinine increased to a high level of 550umol/L.

The malperfusion syndrome caused by aortic dissection was highly suspected and an aortic angiography via the left radial artery was performed immediately. It finally revealed the reason for renal impairment and upper-lower blood pressure separation. The angiography showed that a 1.0cm “primary” entry tear was located in the distal descending aorta, which was feeding the false lumen (Fig 2). The aorta ture lumen below the level of the superior mesenteric artery origin was being compressed severely and therefore enhancing poorly (Fig 3), which results in ischemia of his bilateral renals and lower limbs.

Given the patient’s high risk for open surgery (ASA 4), we decided to adopt a less invasive approach. However, the problems were, covered stents placement in these segements was not applicable because of high risk for ischemic spinal cord injuries, meanwhile, multilayer stents were not available in our department. After reassessment of our work team and approval of our hospital, multiple self-expanding stents were employed ultimately.

Does dissection bare stent improve aortic remodeling in dissection cases?


Combined proximal stent-grafting with distal bare stenting (petticoat procedure) appears to be a feasible approach for the management of Type B aortic dissection. This approach clearly improved true lumen perfusion and diameter, but it failed to completely suppress false lumen patency. In our previous publication, we had proposed that the remodeling effect might be beneficial to improve the stent conformity and further reduce the distal SINE occurrence. If the false lumen complete regression of entire aorta obliteration, there was 0 % of distal SINE occurrence. But for total thrombosis and patent only group, the same detection rate of around 28% to 30 % occurrence rate were

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noted.1 The potential benefit of Petticoat concept for endovascular treatment of Type B aortic dissection had first pointed out by Dr Neilissano in 20122 that progressive remodeling of the TL was recorded over time in both thoracic and abdominal segments with shrinkage of the FL but mainly in the thoracic segment. For acute Type A aortic dissection, Dr. Hsu had also demonstrated that a significant increase the diameter of true lumen and more case of total thrombosis or regression of FL, but only to the level of renal artery in Petticoat group.3 Both of them still required large cohort study to convince us with stronger evidences of these potential benefits? (n=25 and 18 respectively)

In this presentation, we will demonstrate the equivocal effects of Petticoat procedure on distal SINE prevention after TEVAR. Four of recurrent distal SINE patients had received extension of distal dissection bare stent with positive and uneventful result. Unfortunately, distal SINE was detected at the junction between the dissection graft and bare stent (n=2) and distal end of dissection bare (n=1). The incidence and mechanism required further longitudinal observation.

References1 Chen IM, Chen PL, Huang CY, Weng SH, Chen WY, Shih

CC. Factors Affecting Optimal Aortic Remodeling After Thoracic Endovascular Aortic Repair of Type B (IIIb) Aortic Dissection. Cardiovasc Intervent Radiol 2017;40:671-81.

2 Melissano G, Bertoglio L, Rinaldi E, Civilini E, Tshomba Y, Kahlberg A et al. Volume changes in aortic true and false lumen after the “PETTICOAT” procedure for type B aortic dissection. J Vasc Surg 2012;55:641-51.

3 Hsu HL, Chen YY, Huang CY, Huang JH, Chen JS. The Provisional Extension To Induce Complete Attachment (PETTICOAT) technique to promote distal aortic remodelling in repair of acute DeBakey type I aortic dissection: preliminary results. Eur J Cardiothorac Surg 2016;50:146-52.

Aortic 5

Radiologic malperfusion in acute type B dissection: Can we justify prophylactic repair in cases of asymptomatic severe compression of the true lumen?

Frank J Criado

It is not unusual to find severe compression if not near-collapse of the true in the thoracic aorta when evaluating cases of acute/subacute type B aortic dissection with CT imaging (CTA). And often, such finding may not be associated with symptoms of malperfusion. It has been labelled radiologic malperfusion and it is presently

a controversial or unresolved matter vis-à-vis the question of whether intervention is necessary and can be justified in the absence of clinical manifestations of malperfusion.

I have found that world-class experts disagree on how to handle this situation, and the available data or published reports are not very helpful or definitive in this regard. During the presentation, I intend to review the available information and attempt to define the problem more accurately to see if progress can be made as to the best course of action on a given patient.

Study on the causes of death in acute type B aortic dissection

Qingbo Fang

We find some uncomplicated acute B aortic dissection died on the period which waiting for the TEVAR on clinical, and some complicated acute B aortic dissection died after TEVAR, but the cause of the death is uncertain or unknown. So we retrospective analysis the deaths in the last five years and try to find the reason. There are eleven cases contain seven cases dead before TEVAR and four cases dead after TEVAR, simply analysis the cause of death and review the recent literature.

Type 2 dissection in pregnancy. Is there a role for urgent TEVAR?

Michael G WyattNorthern Vascular Centre, Freeman Hospital, Newcastle Upon Tyne, United Kingdom

Aortic dissection (AoD) during pregnancy is a rare condition and can be potentially lethal. If often occurs in patients with connective tissue disorders, such as Marfan Syndrome, and management can be challenging. This paper describes the processes involved in the treatment of acute dissection in patients with Marfan Syndrome and pregnancy. It highlights the importance of multidisciplinary collaboration in the decision making processes and the dilemmas involved in the management of both the mother and her foetus. The relative duties and decision making of the surgeons and the obstetricians to both the foetus and the mother are often diametric. The arguments regarding conservative management, early TEVAR, termination and pre-term elective caesarian are challenging. The paper is illustrated by a recent case managed successfully by the author and the relevant professionals.

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Carotid 1

Asymptomatic carotid surgery is not indicated prior to cardiac surgery

AH Davies

The enthusiasm for asymptomatic surgery has waxed and waned. With the improvement in best medical therapy the risk of embolic problems secondary to carotid artery needs to be considered. There is probably no indication to evaluate the carotid arteries prior to cardiac intervention. The cost of this screening will be evaluated. The stroke risk from carotid intervention will be discussed with respect to:- a) Carotid intervention prior to coronary intervention b) Carotid intervention simultaneously c) Carotid intervention post cardiac surgery.

The evidence will show that routine asymptomatic carotid intervention is not indicated prior to cardiac surgery.

Risk factor for development of an early postoperative stroke after carotid endarterectomy

Young-Wook Kim, DI Kim, YJ Park, SH Heo, BH Chung, DH Lee, OY Bang, KM KimVascular Surgery, Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

PurposeTo determine risk factors for the development of an early postoperative stroke (EPOS) after carotid endarterectomy (CEA).

MethodA retrospective review and analysis was conducted using database of patients who underwent CEA in a single institution during the past 22 years. CEAs were performed in standard fashion under the general anesthesia using carotid shunt. EPOS was defined as stroke of any cause which developed within 30 days after CEA. To determine risk factors for the development of EPOS, univariate and multivariable analyses were conducted using demographic, clinical, anatomic and procedural variables.

Results1,065 CEAs were performed for 977 patients (male, 87.1%; mean age, 68.1±7.7 years; symptomatic, 34.6%). After endarterectomy, primary closure was performed in 48% while patch closure was used in 52%. In 48(4.5%) patients, CEAs underwent with coronary artery bypass

grafting (CABG) and 6% of CEAs underwent for patients with contralateral internal carotid occlusion. Within 30 days after CEAs, EPOS developed in 18 (1.7%) patients which included 13 (72%) ischemic and 5 (28%) hemorrhagic; 15 (83%) in ipsilateral and 3 (17%) in non-ipsilateral territory. Among 15 ipsilateral EPOSs, 11 were ischemic strokes (3 major and 8 minor strokes) while 4 were hemorrhagic type. On a multivariate analysis, we found that symptomatic carotid stenosis (OR, 2.806; 95% CI, 1.033-7.626; p=0.043 compared to asymptomatic patients) and synchronous CEA and CABG (OR, 6.454; 95% CI, 1.505-27.628; p=0.012, compared to CEA only group) were independent risk factors for the development of EPOS after CEA.

ConclusionEPOS developed in less than 2% after CEA either ischemic or hemorrhagic type. Symptomatic carotid stenosis and synchronous CEA and CABG were independent risk factors for the development of EPOS after CEA.

Feasibility and safety of simultaneous CEA and CAS for Bilateral Carotid Stenosis

Zhi Dong Ye

Bilateral Carotid Stenosis commonly seen clinically and the optimal strategy for treating is contraversal. Staged procedure is main treatment for BCS with the following order( Symptomatic site- Severe stenotic site- dominant blood supply site), but stroke and delay of life-saving treatment(CABG) may occur during interval. In highly selected patient, from anatomic view and risk factor, 8 BCS cases were finished simultaneous CEA for unilateral and CAS for contralateral site, and good surgical results was achieved.

Table 1. Univariable analysis of risk factors for early (< 30 days) postoperative stroke (EPOS) after CEAs

Univariate analysis Variable

Total n=1065

EPOS (-) 1047 (%)

EPOS (+) 18 (%)

P

Age, years, median(IQR) 69 (63-73) 69 (63-73) 70.5(65-77) 0.153a Age > 80years 69 (6.5%) 69 (6.6%) 0 1.000b Female (%) 137 (12.9%) 135 (12.9%) 2 (11.1%) 1.000b Hypertension 833 (78.2%) 818(78.1%) 15(83.3%) 0.777b Diabetes mellitus 449 (42.2%) 442(42.2%) 7(38.9%) 0.777c Coronary artery disease 434 (40.8%) 425(40.6%) 9(50%) 0.421c Past history of PCI or CABG 328 (30.8%) 320(30.6%) 8(44.4%) 0.206c Hyperlipidemia 749 (70.3%) 738(70.5%) 11(61.1%) 0.388c Ex-or current smoking 561 (52.7%) 554(52.9%) 7(38.9%) 0.237c Atrial fibrillation 62 (5.8%) 59(5.6%) 3(16.7) 0.082b CRF 36 (3.4%) 35 (3.3%) 1(5.6) 0.464b Contralateral ICA occlusion 64 (6%) 62 (5.9%) 2(11.1) 0.296b Previous neck irradiation 8(0.8%) 8 (0.8%) 0 1.000b Symptomatic (< 6months) 369 (34.6%) 359(34.3) 10(55.6) 0.060c

TIA 148 145 3 Amaurosis fugax 25 25 0 Minor stroke 196 189 7

Primary closure 514 (48.3%) 508(48.5) 6(33.3) 0.201c Synchronous CEA & CABG 48 (4.5%) 44(4.2) 4(22.2) 0.007b

Multiple logistic regression analysis Variable Reference OR (95% CI) P

Atrial fibrillation (A Fib) No A Fib 2.992 (0.812-11.031) 0.100 Symptomatic (<6mo) Asymptomatic 2.806 (1.033-7.626) 0.043 Primary closure Patch closure 0.718 (0.259-1.994) 0.525 Synchronous CEA & CABG CEA alone 6.454(1.505-27.682) 0.012

EPOS, early(<30d) postoperative stroke; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; ICA, internal carotid artery; TIA, transient ischemic attack; aMann-Whitney test; bFisher’s exact test; cChi-square test

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Open vs endovascular solution for carotid stenosis: Current evidence and typical lesion selection criteria

I-Ming ChenDivision of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taiwan

Carotid intervention including carotid endarterectomy and carotid stenting are the treatment of choice treating carotid stenosis. Current evidence showed that the major stroke rate and overall mortality rate are similar in both groups even in asymptomatic patients. How to choose an appropriate method to treat patients with carotid stenosis is a crucial issue. Vascular surgeons are the only expert personnel to do both modalities to treat carotid stenosis. Here, we introduced our experience of approaching carotid intervention.

CVD 1

Haemodynamic assessment in CVD

Chris Lattimer

Chronic venous insufficiency (CVI) occurs when veins have difficulty in performing their function, which is drainage. It is a haemodynamic term. In contrast to most drainage mechanisms in engineering this is upwards and against the force of gravity. Venous drainage insufficiency or CVI can be divided into 5 separate components which can occur in varying amounts in a single patient. They are reflux, obstruction, loss of tone, calf muscle pump impairment and physiological. Measurement of each component is possible using air-plethysmography (APG) complemented with duplex ultrasound. This has the potential of labelling each patient with a haemodynamic profile which informs the investigator how much of each component is present in its contribution to the drainage impairment.

The important APG parameters are the venous filling index (VFI) for reflux, the venous drainage index (VDI) for obstruction, the outflow fraction (OF) for venous tone, the ejection fraction for calf muscle pump function and the venous filling time (VFT) for a physiological measurement. Ultrasound measurements related to CVI include the re-circulation index (RCI), the postural diameter change (PDC) and the venous arterial flow index (VAFI). The common observation of saphenous pulsation is associated with advanced CVI and may indicate impairment of the microcirculation.

Haemodynamic measurements are objective and related to the patho-physiology of the patient. Venous

symptoms are subjective and often absent in an advanced stage of clinical severity. The opposite is true also. Furthermore, leg pain is multi disciplinary, CVI is multi-factorial and there may be a lag time between the haemodynamic insult and the clinical symptoms and signs of the patient. For these reasons, haemodynamic assessments will never correlate well with symptoms or clinical severity. The practice of benchmarking haemodynamics against clinical assessments should be discontinued. Haemodynamic measurements should occupy a prominent place in diagnosis, quantification and outcome assessment.

Pathophysiology of chronic venous disease

Evi KalodikiJosef Pflug Vascular Laboratory, Ealing Hospital, Imperial College, West London Vascular and Interventional Center & Thrombosis & Haemostasis Laboratory, Loyola University, Chicago IL, USA

Venous hypertension affects the macrocirculation causing altered shear stress, venous wall stretch, dilatation, valve damage, blood stasis and oedema. This is manifested by reflux, obstruction, alteration of venous tone and physiological oedema.

On the microcirculation it causes glycocalix (GAGs) alteration, altered shear stress, extracellular matrix remodelling, venous wall hypoxia, peri-capillary fibrin cuff formation and endothelial activation. The above, through recruitment of leukocytes, monocytes and macrophages lead to inflammation. This inflammation causes endothelial dysfunctions, chronic venous disease (CVD), lipodermatosclerosis and pigmentation that can lead to venous ulcers.

Glycocalyx is a thin-filament of GAGs and should be considered as the transducer between the haemodynamic macrocirculatory system and endothelial function. It counteracts the injuries to endothelial function induced by haemodynamic stress. The endothelium regulates the microcirculation depending upon the synthesis of autocrine and paracrine molecules like: tissue plasminogen activator, prostacyclin, nitric oxide, thrombomodulin, tissue factor and proteins C and S. Circulating leukocytes and platelets are also involved in the expression and release of several molecules, including inflammatory cytokines, integrins, leukotrienes and platelet activating factor. The endothelium acts against increased shear stress caused by macrocirculatory haemodynamic injuries such as: ischemia, venous hypertension and stasis or hypoxia, promoting the release of protective factors with relevant

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antithrombotic and fibrinolytic activities. However, the endothelium may exhaust its reactive capacity and activate inflammatory mediators such as cytokines.

Venous hypertension is an ideal chronic disease to study because the stimulus can be switched off and on and local blood samples can be drawn from the site of the pathology. Recently a relationship has been demonstrated between the damaging effects of gravity during prolonged standing manifested as an increase in MMPs as well as an increase of the markers of cell destruction. Interestingly these markers were reduced when lying down and with the effects of compression.

Progress in medical therapy

Jean-Francois Uhl

1-Progress in medical therapy.Medical therapy of primitive chronic venous disorders includes: Venoactive drugs, compression and the fight against risk factors. Veno-active drugs act at the microcirculatory level particularly on the endotheliumleucocyte interaction which avoids the inflammatory reaction of the tissues. Compression reduces the trans mural pressure of the veins due to venous hypertension and so acts on the main macrocirculatory cause of CVD.

2-Superficial venous reflux: are the path of venous reflux predictable ?The knowledge of venous anatomy is essential for phlebological practice In particular the venous superficial mapping. (VHM) this includes the assessment of anatomy and hemodynamics (reflux). This talk will summarize the main paths of superficial reflux related to anatomy. They are perfectly predicable for the different locations of reflux great saphenous, smaill saphenous and non saphenous territories.

CVD 2

Obesity and CVI

Ramakrishna PinjalaChief Vascular Surgeon, Nizam’s Institute of Medical Sciences, Hyderabad, India

Chronic Venous disease and obesity are commonly associated in the adult population. The population with this association is on rise. Obesity is a risk factor for all types of symptomatic and asymptomatic venous disease. The obese people present more challenges not

only during the diagnosis but also during Endovenous, surgical and medical therapies. The outcomes of therapies in obese people are also inferior to those in non-obese people. In our hospital obesity was found to be common in patients with venous disease. The diameter of femoral vein was significantly greater in obese than in nonobese. Venous peak and minimum velocities differed between nonobese and obese individuals. Calculation of venous amplitude and shear stress showed significantly higher values in nonobese. There is a significant inverse correlation between waist-to-hip ratios and waist circumference and venous peak velocity, mean velocity, velocities amplitude and shear stress.

Obesity leads to a 2 to 3-fold higher risk of venous thrombosis in both sexes. The risk associated with severe obesity is higher. India is behind US and China in this global hazard list of top 10 countries with highest number of obese people. The US topped the list with 13 per cent of the obese people worldwide in 2013, while China and India together accounted for 15% of the world’s obese population. Obesity is a vexing problem in the developed economies. As a disease, obesity is complex and its solutions too are difficult. The epidemic of obesity needs to be tackled at several levels: the individual level, the community level, and the government level. It needs to be addressed at the socioeconomic level as well as in the biological and the behavioral arenas. Technology, political will and legislative action are some of the other innovative solutions that can usher in sweeping changes to tackle the obesity epidemic.

Superficial vein intervention prevents venous progression

AH Davies

Does intervention prevent venous progression? It is well documented that venous disease is progressive influenced by age, gender, parity and obesity. A number of epidemiological studies have identified a progression of about 2/3% per annum. Progression can be measured in terms of symptom progression or worsening physiological function.

The evidence of the role of compression and ablative procedure on disease progression will be presented. The need for further studies will be evaluated.

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CVD 3

Setting up a day care vein practice as a Vascular Surgeon

Laurencia Villalba

Setting up a day care vein practice involves many important decisions about workspace environment, staffing training, equipment, optimization of reimbursement, and marketing. In addition to favorable clinical results and increased patient demand, procedures performed on an outpatient basis can be expected to significantly increase revenues. With proper strategy and organization, an outpatient vein practice can round out the existing vascular practice and be a profitable adjunct to an already established vascular surgery practice.

The haemodynamic results at 5 years of laser vs foam randomised controlled trial


BackgroundIn venous treatment, haemodynamic outcomes are conventionally reported using duplex ultrasound. Occlusion of the treated saphenous vein is defined as succes. This is supplemented by clinical evaluation regarding residual or recurrent varicosities. Additional treatments, may change the final haemodynamic outcome between the groups. The aim was to report the 5 year results of a randomised controlled trial.

MethodsPatients were randomised into endovenous laser ablation (EVLA-n=50) with concurrent phlebectomies vs ultrasound-guided foam sclerotherapy (UGFS-n=50) into the great saphenous vein (GSV). Inclusion criteria were refluxing GSV without significant deep venous, pelvic or small saphenous vein reflux. Additional treatment with UGFS was the patient’s decision. Assessment included the venous clinical severity score (VCSS) and the venous filling index of air-plethysmography (APG).

ResultsThe median [inter-quartile range] follow-up was 68 [64-72] months. Follow-up was complete in 44/50 in each group. If GSV occlusion above knee is defined as success, then the results are 93.2% for EVLA and 63.6% for UGFS (p=.001), even though this may be associated

with concurrent saphenous reflux and by dismissing competency of an open trunk. The anatomical sites of reflux considered as failure appeared similar between the 2 groups. In the EVLA group 20 legs had additional foam compared to 56 in the UGFS group. If treatment of the tributaries with one extra foam session was included in the 44 patients in the UGFS group the “extra” foam figures would be reduced considerably. The VCSS was statistically higher with foam: EVLA 2 [0-3], UGFS 3 [2-5], p=.001. The VFI was significantly greater in the UGFS group and in those patients with reflux somewhere in the leg, irrespective of group. ConclusionsResidual reflux after varicose vein ablation is common and under-reported. In the majority of patients it may be asymptomatic and therefore ignored. Haemodynamic investigations complimenting ultrasound, like APG, may evaluate better the treated leg.

CVD 5

Reflux versus obstruction in the post-thrombotic syndrome: Which is worse?

Chris Lattimer

The venous leg symptoms and signs which persist or develop 6 months after a deep venous thrombosis (DVT) is termed the post-thrombotic syndrome (PTS). This can occur in a leg without pre-existing chronic venous insufficiency (CVI) or one in good health. The haemodynamic pattern with a DVT begins usually with obstruction. As the weeks or months ensue, this may change to a mixed pattern with concurrent reflux and obstruction. In the later stages, reflux predominates. Obstructing thrombus may disappear early with assisted or natural fibrinolysis. Alternatively, by 3 months, it may have organised into fibrosis and scarring. Both these processes may damage valve function and result in reflux. The pathology is compounded usually by loss of venous tone from a non-obstructive white opaque film-like scarring of the venous wall.

The Villalta scale of symptoms and signs is recommended for diagnosis and quantification of PTS. However, it has many weaknesses including that ulceration, venous claudication and collaterals are excluded from the score. Furthermore, some features may be from pre-existing CVI and others from conditions unrelated to the original DVT. The term DVT is also imprecise. It provides no information on the origin, location, extent or the direction of any propagation.

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Given these limitations, an objective haemodynamic assessment may be a way forward in solving the question. For example, air-plethysmography (APG) may be able to quantify the relative contributions of reflux, obstruction and loss of tone. These can be performed using a variety of gravitational and occlusive challenge tests, with or without saphenous occlusion. Directly how-much-of each is measured, the clinician will be informed as to which is worse. Treatment can then be focussed on the main pathology rather than the blanket, one-size-fits-all mantra, of “always treat the obstruction first”.

Sulodexide in preventing recurrent venous tromboembolism (r-VTE)


BackgroundFollowing VTE anticoagulants are administered in order to prevent propagation of the thrombus, decrease the duration and severity of the acute symptoms and reduce the risk of pulmonary embolism (PE) and r-VTE. The risk of r-VTE in patients with a first episode of unprovoked DVT is high following discontinuation of anticoagulants. Continuation of anticoagulants reduces the risk of r-VTE but is associated with increased bleeding. Sulodexide is a glycosaminoglycan with antithrombotic and profibrinolytic actions and a low bleeding risk when administered orally. It inhibits thrombin generation, has pro-fibrinolytic effects and restores endothelial homeostasis. The aim of the SURVET study (Andreozzi et al. Circulation 2015;132:1891-7), was to study the benefit of sulodexide in the prevention of r-VTE.

MethodsThis multicenter, double-blind study, recruited 615 patients with a first episode of unprovoked VTE who had completed 3-12 months of oral anticoagulants. They were randomly assigned to oral sulodexide, 500 lipasemic units bid or placebo for 2 years and elastic stockings. The primary efficacy outcome was r-VTE. The primary safety outcome was major or clinically relevant bleeding.

ResultsA r-VTE was found in 15/307 sulodexide and in 30/308 placebo patients (hazard ratio, 0.49; 95% confidence interval [CI], 0.27-0.92; P=0.02). In the analysis patients lost to follow-up were assigned as failure. The risk ratio

among treated versus control was 0.54 (95% CI, 0.35-0.85; P=0.009). There were no major bleeding episodes;2 patients in each treatment group had a clinically relevant bleeding episode. The adverse events were similar in the 2 groups.

ConclusionFollowing discontinuation of anticoagulants, administration of sulodexide reduced the risk of r-VTE in patients with unprovoked VTE, without apparent increase of bleeding risk.

Percutaneous catheter directed foam sclerotherapy of ovarian varicocele

Xin DuPLA General Hospital, Beijing, China

ObjectiveStudy the longterm outcomes of the microfoam scelrotherapy for ovarian varicocele.

MethodsA selective series of 30 females (mean age 37.1 years) who were diagnosed as ovarian varicocele were treated with microfoam sclerotherapy from 2008 to 2015. Patients were treated with 1% polidocanol foam through a catheter, which was inserted percutaneously over a guidewire into the trunk of vena ovarica. All successfully treated patients were examined by colour duplex after 3 months.

Results30 patients with an insufficiency reflux of the vena ovarica were treated with the catheter-directed foam sclerotherapy. Primary technical success was achieved in all the patients. Mean doses 5.45ml (2-15ml). Mean follow-up time was 37.1 months. Symptoms recurrence rate is 23.3%, reintervention rate is 10%.

ConclusionThe use of percutaneously catheter directed foam sclerotherapy over a guidewire is feasible and has resulted in high primary occlusion rates during long-term followup.

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PAD 1

Aorto-biliac/bifemoral bypass - Is it still relevant

Naresh GovindarajanthranConsultant Vascular Surgeon, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia

Severe Aortoiliac Occlusive Disease often results in debilitating claudication and critical limb ischaemia. These patients with severe stenosis may end with an acute aortic occlusion which carries a high morbidity and mortality if not treated. Aortic bifemoral bypass has been traditionally the treatment of choice for these patents. The 5 year primary patency of aorto-bifemoral bypass approaches 90% in most studies.

Endovascular treatment of aorto-iliac disease has emerged as the preferred treatment with reduced morbidity and moratlity, Moreover most these patients have multiple co-morbidities making the less invasive endovascular treatment an attractive modality.

With the advancement of technology, the relevance of the classical aorto-bifemoral bypass has come into question. The primary patency of aorto bifemoral bypass compare favourably compared to endovascular procedures (93 vs 74%). However, the secondary patency of both procedures were no different at 96%. The higher patency and the reduced need for reintervention proves to be an important factor in regions where accessibility to healthcare is an issue. In addition to that, in hospitals where the cost of procedures outweighs the cost of hospital stay, aortobifemoral bypass may be the treatment of choice. We will report the results of aorto-biiliac/bifemoral bypass procedures done from 2014 until 2017.

KeywordsAortoiliac Occlusive Disease, Aorto-bifemoral bypass, Aorto-biiliac bypass

PAD 4

Iatrogenic occlusion of femoral artery in children with endovascular procedure

Lei Li

ObjectivesEndovascular procedure in children has been widely accepted since 1962. Femoral artery occlusion (FAO) is one of the most common complications (0.8-11.4%)

in this situation. Some risk factors has been reported, which include age, weight, cyanosis, size of needle and sheath, puncture times, number of procedural catheter changes and total procedure time. The objective of this study was to review the prevalence of FAO, identify risk factors and the standard FAO treatment in children under 12 years old after catheterization in our center.

MethodsThere are 1974 pediatric endovascular procedures retrospective analyzed from 1st hospital of Tsinghua university from 8/1/2009 to 9/30/2016. Sex, age, weight, height, procedure type, cyanosis, hemoglobin, puncture site, sheath size, operation time, sheath exchange, diagnosis, complications, treatment protocols (In the earlier time, we used catheter direct thrombolysis (CDT) with UK via contralateral access to relieve the occlusion entirely, which was named as CDT protocol. Then we modified it as Fasudil i.v. initially, and if there were no SaO2 wave detected at ipsilateral toe in 6 hours, a conservative CDT followed, which was named as FaST protocol.) for occlusion and results were record and analyzed.

ResultsOver a 6-year period, out of the 1974 cases, 15 (15/1974, 0.8%)children developed FAO following endovascular procedures. Besides the risk factors already published, we find that the cardiac electrophysiological procedure (p<0.01) is an additional risk factor. All occlusive femoral arteries got successful recanalization eventually. 4 (4/15, 26.7%) received CDT protocol and 11 (11/15, 73.3%) received FaST protocol. 2 children of the 11 (2/11, 18.2%) failed to recanalization with Fasudil in 6 hours and then successfully by CDT. There were two groin bleeding in CDT protocol and ceased with groin compression.

ConclusionsFaST protocol may be a feasible protocol for iatrogenic FAO in children with endovascular procedure.

Management of acute limb ischema in the himalayas

Sandeep Raj PandeyConsultant Vascular & Endovascular Surgeon, Norvic Int’l Hospital/Annapurna Hospital, Ktm, Nepal

IntroductionAcute Limb Ischemia: Acute (<2 wk), severe hypoperfusion of the limb characterized by these features: pain, pallor, pulselessness, poikilothermia (cold), paresthesias, and paralysis.

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Causes of Acute Limb Ischemia in the HimalayasResults from a sudden obstruction in the arterial flow to the extremity due to an embolism or thrombosis; due to a decline in the incidence of rheumatic heart disease, advances in cardiac surgery, and the widespread use of anticoagulation for arterial arrhythmias, generalized atherosclerosis.;aggressive use of bypass grafts; Polycthemia vera with high altitude changes;Excessive cigarettes/fire smoke to stay warm;Some times frost bite progressing to ALI.

Clinical presentations of ALIPatients with ALI should be emergently evaluated by a clinician with sufficient experience to assess limb viability and implement appropriate therapy.Sometimes CT-angio or conventional angio can be helpful if avaialble at center.But its always inappropriate at our centers on emergency basis.So I mostly rely on clinical & doppler findings.

Medical Therapy for ALIIn patients with ALI, systemic anticoagulation with heparin should be administered unless contraindicated. Revascularization for ALI: In patients with ALI, the revascularization strategy should be determined by local resources and patient factors; Catheter-based thrombolysis is effective for patients with ALI and a salvageable limb; In patients with ALI due to embolism and with a salvageable limb, surgical thromboembolectomy can be effective; Embolectomy is preferred choice in the himalayas-done - 3rd day to 3rd week as per limbs viability;In patients with ALI with a salvageable limb, percutaneous mechanical thrombectomy can be useful as adjunctive therapy to thrombolysis; The usefulness of ultrasound-accelerated catheter-based thrombolysis for patients with ALI with a salvageable limb is unknown; Patients with ALI should be monitored and treated (e.g., fasciotomy) for compartment syndrome after revascularization;Amputation is much more common in the himalayas due to delayed referral & lack of proper communcation & transportation.

ConclusionAdministration of thrombolytics dramatically reduces the rate of amputation in patients with severe frostbite & acute limb aschemia.Most common treatment fr acute limb ischemia in himalayas are thromboembolectomy & amputation.

Access 1

Safety issues in renal access

Matthias K WidmerDepartment of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland

Patients suffering from ESRD with comorbidities generally have a high risk to suffer adverse events. Dialysis access and maintenance are also prone to complications. Preventive strategies are key to avoid harm and to improve the outcome in the treatment of this growing population. Interprofessional collaboration, participation of the patients and and individualized planning of vascular access creation can help avoiding complications. While performing vascular access and treating patients with chronic kidney failure physicians have to permanently improve their technical skills and address human factors. Being aware of safety issues is the first step to increase safety.

LiteratureMatthias K.Widmer/Jan Malik: Safety in Diaylsis Access, Huber, 2015

Access 2

New ESVS guidelines on renal access


General Surgeons, Nephrologists and Vascular Surgeons perform vascular access; with radiologists also involved in the maintenance. To show the evidence in vascular access (VA) and to improve the performance of Vascular Surgeons the European Society of Vascular Surgery endorsed by the Vascular Access Society support a writing committee to summarize the content of the literature und to define more than 80 recommendations of which 6 have evidence level A. Epidemiology, clinical decision making, diagnostic methods, creation of VA, maintenance and surveillance of VA, clinical outcomes and tertiary VA are topics in these practical guidelines. Numerous pictures illustrate technical details. The authors think that the guidelines are ready for publication by the end of 2017.

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Should dialysis access be a new subspecialty?

Ingemar DavidsonDallas, TX

Take home points1. Yes, dialysis access already is a specialty with formalities lacking. We must not forget to include peritoneal dialysis.

2. The strong argument for a dialysis access subspecialty relates to its complexity in decision-making and patient variability with more than 300 treatment options; in any given case there are 25 possible dialysis access surgical anatomical sites and as many patient variables.

3. Barriers remain to the realization of formation of a dialysis access specialty including obstacles is the structure and organizations of current societies. For example the ISPD (International Society for Peritoneal Dialysis) operates in isolation with an independent journal separate from hemodialysis that is mainly represented by the J Vasc Access.

4. Peritoneal dialysis and hemodialysis must not be competitive, but rather complementary treatments; keeping the big picture in mind, over a patient’s lifetime several renal replacement options are used including renal transplantation.

5. For a global dialysis access specialty to be effective, much cooperation and trust is required to bring about synergy and unprecedented progress. International key opinion leaders need to direct such efforts. Resources are likely available if convincing arguments for improved patient outcomes are presented.

6. There will be internal barriers from current medical vascular societies.

7. The greatest benefit of a dialysis access sub-specialty is the creation of focused training and treatment algorithms benefitting an international audience.

Simulation in vascular access training


Rapidly growing technical developments and working time constraints call for changes in trainee formation. In reality, trainees spend fewer hours in the hospital

and face more difficulties in acquiring the required qualifications in order to work independently as specialists. Simulation-based training is a potential solution. It offers the possibility to learn basic technical skills, to repeatedly perform key steps in procedures, and to simulate challenging scenarios in team training. Patients are not at risk and learning curves can be shortened. Advanced learners get opportunities to train rare complications. Senior faculty member’s presence is key to assess and debrief effective simulation training. In the field of vascular access surgery, simulation models are available for open as well as endovascular procedures. Workshops with prepared cadavers allow a realistic scenario. After a structured simulation training work place assessments in the clinics with immediate feedback is a practical tool to further improve the operative performance of trainees in different levels of their education.

LiteratureWidmer L.W., Schmidli J., Widmer M.K. Wyss T.R.: Simulation in vascular access surgery training. J Vasc Access. 2015;16 Suppl 9:S121-5

Access 3

Failure to mature - New insights

Ingemar Davidson

Take home points1. A dialysis access is defined as not matured if it cannot be effectively used for dialysis. This includes peritoneal dialysis (PD) catheters and catheters for hemodialysis.

2. Failure to mature (FTM) for native vein AVFs was reported above 60% in a multi-center double blind, randomized study including 877 patients. (Dialysis Access Consortium Study Group. JAMA. 2008; 299(18):2164-2171).

3. Complex issues are at play, including selection criteria for mode of dialysis i.e. HD vs. PD, the vascular mapping vessel anatomical criteria, surgical skills, nephrology training and referral pattern and patient co-morbidity.

4. The probability of FTM is strongly related to the center of access creation and the vascular surgeon’s skills and decision-making process. (J Vasc Surg 2007;45:962-7)

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5. The unrestricted and careless use of veins for blood draws and IV infusion lines play a major role in making veins unusable for vascular access.

6. Local, often unpopular leadership decisions, are needed to redirect the current practice of vein destruction or abuse by healthcare workers, preventing the creation of native vein AVFs as the desirable vascular access when indicated.

Haemodialysis vascular access - Reverse flow technique re-explored

Kevin MoissinacPenang, Malaysia

In haemodialysis vascular access, the reverse flow technique entails inducing flow distal from a proximal (e.g. cubital fossa) fistula into the forearm veins.

Although the wrist radiocephalic fistula has been a popular option when feasible, it has been associated with substantial failure rates. More proximal cubital fossa fistula do not usually supply flow to the forearm veins and do not allow their use for haemodialysis puncture.

In order to allow flow from a cubital fossa fistula to the forearm veins, the valves in the forearm veins can be made incompetent so that flow in these veins could be used for haemodialysis vascular access.

The vein valves can be made incompetent by passing a probe distally to break the valves in the forearm veins though the cubital fossa venotomy prior to undertaking a side to side anastamosis. The procedure is be guided by palpation, supplemented by exposure of the vein if necessary. To avoid venous hypertension in the hand, only 2 or 3 valves are made incompetent with the distal valves being preserved.

Other ways of making the valves incompetent which have been used include valvulotomy using valvulotomes.

Reversed flow into the forearm vein is helpful in haemodialysis vascular access as it (i) may provide additional vein “real estate“ for haemodialysis puncture, and (ii) allows reverse flow into and use of veins not usually used for puncture. Other uses of reverse flow in haemodialysis vascular access which have been described, include, the vascularisation of isolated vein segments for haemodialysis, and for the proximalisation of arterial inflow in the treatment of access associated steal.

The proposed possible adverse of reverse flow, recirculation and inadequate haemdialysis have not been encountered clinically.

Secondary native fistula techniques - Should 1 or 2 stage BBT be preferred

Kittipan Rerkasem

In 1979, a new type of fistula was described the brachial basilic (BB) fistula. The BB fistula can either be created by one of two methods e a single stage or a two stage procedure. The single stage operation is carried out as an inpatient under general anaesthetic or a brachial plexus block. The two stage procedure involves two operations, which consist of one minor operation to connect AVF and another one is for superficialisation of the AVF. Each method has different benefits and disadvantages. A single stage procedure provides a quicker way of vascular access and perhaps a shorter total stay in hospital. The two stage procedure subjects the patient to two operations, longer period in hospital and as it involves two hospital visits is more costly. If after the first stage, the vein has not adequately matured, the patient may have a chance to repair in a bigger operation, or a revision of the fistula can be performed during the second stage of creation. One stage formation potentially uses less resources and less operating room time when compared to a two stage procedure. However In two staged operation, after the first operation, the vein is big and tortuosity, so the length is the fistula tend to be longer than those following the single stage. Another benefit that the single stage method has when compared with the two stage, is the avoidance of injury to the medial anti-brachial cutaneous nerve and the medial cutaneous nerve of the forearm. These nerves supply sensation to area in the arm and sit lateral and superficial to the basilic vein and encircle it. In a single stage, as the vein is disconnected and dissected free, there is no need to significantly dissect adjacent tissue and consequently the lower chance of nerve injury.

Access 4

Brachio-basilic transposition - Techniques to achieve improved patency

Benjamin Leong

Native fistula creation for haemodialysis in patients who have exhausted all their superficial veins presents a challenge to vascular practice. Options are confined to either brachio-basilic transposition (BVT) or arteriovenous graft (AVG).

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The basilic vein is situated deep at the medial aspect of the arm and is relatively free from cannulation and trauma. It also has decent diameter and a straight course making it a good option for AVF construction. However, the basilic vein is often deeply located within the deep fascia with close proximity to the brachial artery and medial cutaneous nerve of the forearm. As such, cannulation of this vein without transposition or superficialization is often dangerous. BVT can be created as single or 2-stage procedure but evidence suggested that 2-stage approach has better outcome. Pre-operative ultrasound assessment to locate and identify suitable basilic vein and, as well as, assessment of the arterial system further improve the outcome of BVT.

When compared to AVG, BVT has the advantage of being a native fistula and, in general, has longer patency than AVG. Complications, which include infection and arterial steal, occurred two and a half times more frequently in AVG than in BVT. In a series from Kuala Lumpur Hospital, BVT has primary patency of 67.7% in 40 months. The only advantage of AVG is that it has much shorter creation to needling time and, hence, decreases the number of dialysis catheter-related complications for patients who are already on dialysis.

In conclusion, BVT is a credible option for challenging patients with absence of superficial veins for native fistula creation with good patency and low operative complication rate. Besides, pre-operative ultrasound assessment improves patient selection and outcome of BVT.

Can steal syndrome be prevented at initial fistula construction

Kittipan Rerkasem

Avoiding dialysis access-associated ischemic steal syndrome (DASS) in patients with upper extremity peripheral vascular occlusive disease while creating a functional hemodialysis vascular access could be challenging. The conditions that are high risk of DASS include absent radial pulse, absent ulnar pulse, diabetics and brachial palpable pulses associated with small calcified vessels by ultrasound examination. Several techniques were described in order to prevent DASS in primary arteriovenous fistula creation in literatures. Firstly upper arm autogenous fistulae are formed using the ‘extension technique’. In this technique, the fistula is formed by anastomosing the median vein to the radial or ulnar artery just below the brachial bifurcation, thus preserving part of the blood supply to the hand, to

prevent steal syndrome. Secondly surgeons construct an autogenous access with primary proximalization of the arterial inflow to prevent DASS. For example. The arteriovenous fistula was either a reversed flow basilic vein transposition supplemented by valvulotomy with axillary artery inflow. Experts in this techniques found creating a basilic vein transposition for vascular access utilizing axillary artery inflow is a good option because it offers a high patency rate and the prevention of DASS. Lastly in case of lower extremity autogenous fistulae creation, a distal revascularization and interval ligation (DRIL) procedure concurrently performed at initial arteriovenous formation. Authors suggest that DRIL may represent an effective surgical strategy that can prophylactically be used to minimize the incidence of ischemic complications in carefully selected, high-risk patients.

Haemodialysis vascular access - Multiple channel flow, does it affect patency

Kevin MoissinacPenang, Malaysia

In haemodialysis vascular access, multiple channel flow entails flow supplied to 2 or more vein channels, usually from a fistula constructed using the side to side anastomosis.

This strategy is used to (i) potentially compensate for technical imperfections which may result in fistula failure, should there be only flow into one vein channel, (ii) increase the amount of vein which may be used for haemodiaysis puncture (vein real estate) and (ii) provide flow to veins which are not usually used for haemodialysis vein puncture.

Adverse effects of flow to multiple vein channels which have been proposed include (i) delayed maturation and failure to mature , (ii) impaired functional patency, (iii) recirculation and inadequate dialysis.Converesly, it has been proposed that one artery can support flow to 2 or 3 veins without adverse effects.

A study to evaluate the effects of flow to multiple vein channels comparing (i)the proportion of fistulae adequately maturing for haemodialysis, (ii) mean maturation period, (iii) mean functional patency, between fistulae supplying (a) one, (b) two, and (c) three vein channels , showed that fistulae which supplied 3 vein channels,showed a higher propotionof fistulae which attained maturation for haemodialysis, and had a longer duration of mean functional patency, when

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compared to fistulae which supplied flow to 2 and 1 vein channels. There were no differences found in mean maturation peiod between fistulae supplying 3, 2, or 1vein channels.

The effects of recirculation and inadequate dialysis, have not been clinically encountered.

Although perhaps subject to, the limitations of selection bias, and modest sample size, the study indicates that flow to multiple vein channels does not impede fistula patency.

Flow to multiple vein channels probably does not impede patency. Further evaluation may enlighten.

Aortic 10

Consideration of possible mechanism influencing type II endoleak following EVAR

Yoshihiko Kurimoto1, Ryushi Maruyama1, Shuhei Miura1, Kosuke Ujihira1, Yutaka Iba1, Eiichiro Hatta1, Akira Yamada1, Hideyuki Harada2, Katsuhiko Nakanishi1

1Teine Keijinkai Hospital, Sapporo, Japan2Kushiro Koujinkai Memorial Hospital, Kushiro, Japan

BackgroundType II endoleak (T2E) is the leading reason of secondary interventions following EVAR. An analysis of a stent graft (SG) with a low incident rate of T2E should be useful.

MethodIncident rates of T2E were evaluated for the patients who underwent EVAR using AFX including Powerlink (AFX group) or Excluder (Excluder group) from 2008 to 2014. T2E was diagnosed by contrasted CT at 1 week after EVAR. Intra-AAA sac pressures (AAA pressure) were measured during EVAR before and after SG placement for the patients treated by AFX including Powerlink or Excluder from 2013 to 2017. The relationship of AAA pressure and T2E was evaluated for these SGs of zero graft-material porosity.

ResultsThe incident rates of T2E were 28.1% and 46.0% in the AFX group (n=32) and the Excluder group (n=37), respectively (p=0.128). AAA pressure was measured in 13 patients in the AFX group and 21 in the Excluder group. AAA pressures were decreased after EVAR 22.3±15.5 and 42.1±16.5 mmHg as systolic pressure in the AFX group and the Excluder group (p=0.005), and 14.2±13.6

and 18.1±9.4 mmHg as mean pressure in the AFX group and the Excluder group (p=0.208), respectively.

ConclusionConsidering the relatively low incident rate of T2E of AFX, small systolic blood-pressure gradient between the intra-AAA sac and the systemic artery just after SG placement might reduce T2E.

When EVAR and endovascular reintervention fail: What are the open options and are they safe?

Michael G WyattNorthern Vascular Centre, Freeman Hospital, Newcastle Upon Tyne, United Kingdom

Since December 1995, we have implanted over 1000 EVAR (endovascular aneurysm repair) devices, mainly for abdominal AAA (abdominal aortic aneurysm). Each patient has been followed up using standardized protocols and 19% have required re-interventions for failing stent grafts. Although most of these “failures” can be treated using endovascular techniques, a significant proportion requires surgery. This article describes the cohort of patients for whom open surgery was required to treat the “failing EVAR”. It outlines the results of open intervention and gives the author’s personal experience of the techniques required to manage this difficult patient group.

Aortic 6

Management of left subclavian artery during TEVAR

Zhi Dong Ye

TEVAR is rapidly new treatment for Aortic aneurysm and dissection, up to 40-50% TEVAR will plan to cover LSA. There is three main way to deal with LSA: LSA routinely perform revascularization, LSA perform revascularizaton in certain condition and LSA routinely cover without revascularization unless symptom occur after TEVAR. For elected TEVAR need cover LSA, we suggest routine preoperative LSA revascularization.

In situ fenestration in TEVAR using laser Assisted and puncture methods

Jun Bai, LeFeng Qu

ObjectiveTo evaluate the efficacy, safety and complication of in situ fenestration in TEVAR using laser assisted and puncture methods.

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MethodsTwenty-seven patients with thoracic aortic lesions were retrospectively analyzed from December 2015 to June 2017. All of these patients underwent TEVAR with in situ fenestration using laser assisted or puncture. To compare the safety efficacy and complication of these two methods, and to summarize the key points and advantages and disadvantages of different technical methods in situ fenestration.

ResultsA total of 27 cases were treated with in situ fenestration in TEVAR, 28 branches success and 1 branche failed. There were 11 cases include 12 branches with laser assisted (left subclavian artery 11, left common carotid artery 1), 1 branche failed and turn to chimney, success rate of 92%, the average time is 5.5min, a sheath burned in 1 case, postoperative branch arterial thrombosis in 1 case. 16 cases using puncture, 17 branches of vessels (left subclavian artery 16, left common carotid artery 1) success, the success rate of 100%, the average time is 3.5min, puncture point hematoma in 1 case.

ConclusionIn situ fenestration provides an effective method in TEVAR for the treatment of complex aortic diseases. Both laser assisted and puncture methods are safe and effective means, both of which have advantages and disadvantages.

Aortic 7

Open repair of type IV thoraco-abdominal aneurysm: A 20 year experience

RTA Chalmers, PJ Burns, O Falah, CR Moores, AJ Thomson, AF NimmoScottish National Service For Thoraco-Abdominal Aneurysms, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

The Edinburgh Vascular Service is the home of the Scottish National Service for the treatment of thoracic and thoraco-abdominal pathologies. This incorporates all forms of aortic repair: open, endovascular and hybrid.The most frequently performed open operation is the Type IV TAAA repair.

Pre-operative assessment includes dobutamine stress echocardiography, cardiopulmonary exercise testing, CT coronary angiography and multidisciplinary group discussion of treatment options.

The study group consisted of 232 patients who underwent open Type IV repair. There were 180 men

(77%) and the median age was 73 years (22-88). Mean operation time was 6 hours (3-8) and mean visceral ischaemia time 47 minutes (28-62). A bifurcated graft was used in 72 cases (31%). Ten patients (4%) were reintubated post-operatively.

In-hospital mortality was 14/232 (6%). Temporary renal replacement therapy was needed in 11 patients (5%) and permanent dialysis in one. Two patients (1%) developed permanent paraplegia and mean length of stay was 15 days (3-97).

Forty percent of patients with mild renal impairment (eGFR 31-60) and 80% of patients with severe renal impairment (eGFR15-30) experienced improved renal function over time.

Eight year survival after surgery was 68%. Two year survival of non-operated patients was 50%.

In a dedicated, specialist centre, open Type IV TAAA repair has excellent immediate and late outcomes. Rigorous multidisciplinary pre-operative assessment is a key factor. The operation appears to be associated with improved renal function in a significant proportion of patients. Open Type IV TAAA repair should be considered the gold standard for comparing alternative interventions.

From open to total endovascular: Tevar for thoracoabdominal aortic aneurysm treatment


BackgroundTo evaluate the availability and efficacy of off-the-shelf multibranched endograft (t-branch) in the treatment of thoracoabdominal aortic aneurysms (TAAA) in Taiwan.

MethodsFrom June 2015 to May 2017, 12 patients (12 men, median age 75 years old) diagnosed having TAAA underwent total endovascular treatment to t-branch graft in our institution consecutively. All of them were high risk patients, with degenerative aneurysms. The median size was 65 mm. Six had previous open or endovascular aortic management. Patient characters, underlying diseases, mortality, post-operative complications were accessed retrospectively.

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ResultsFor 45 target vessels, 43 were successfully assured and remained patent during follow up. Ten patients were extubated within one day, and the median intensive care unit (ICU) stay was 3 days (1-43 days). The major post-operative complication was acute renal insufficiency (5 patients). Stroke happened to two patients. There was one in-hospital mortality and one temporary paraplegia. Acute myocardial infarction (AMI) happened to one patient as well. The median follow-up was 14 months (1-24months). One non-aneurysm related death happened at 10 months. There was no re-intervention required the aneurysms, and the following aneurysm size were stable within follow-up.

ConclusionsTreat TAAA by off-the shelf t-branch graft is an effective alternative for high risk patients. The overall cumulative complication is still an issue but the survival rate is acceptable. Further studies are required to confirm its efficacy and long-term outcomes.

KeywordsThoracoabdominal aortic aneurysm, t-branch, endograft

Aortic 8

Accessory renal arteries can be covered with impunity during EVAR, with few exceptions

Frank J Criado

Accessory renal arteries, whether polar or not, are relatively common and we often encounter them in the process of evaluating AAA and planning EVAR. Available information from published reports in the literature point to the fact that in most cases the accessory renal artery can be covered/excluded with near-impunity - not causing any significant side-effect or problem with renal function or anything else, with the exception of asymptomatic kidney infarcts.

But the above-stated is not universal as there are some patients with ARAs where the exclusion of such a vessel during EVAR can and occasionally does lead to severe consequences. We will examine such scenarios and try to define situations where the ARA cannot or should not be covered.

EVAS vs fenestrated EVAR

Tze Tec Chong

Endovascular Aneurysm Sealing (EVAS) is a newer concept based on polymer technology for fixation to provide a solution in the endovascular treatment of abdominal aortic aneurysms. This technology has recently been refined to certain neck anatomy. Asian patients have slightly different anatomy and often have juxta or para renal aneurysms. In such cases, endovascular options of fenestrated, chimney devices are used. Now with Nellix, there is an added option of chimney EVAS which represents an off the shelf, unique solution to the gutter leak phenomenon seen in chimney EVAR. Data for this technique and fenestrated EVAR are compared.

Aortic 9

Treatment of Juxta-Renal Aneurysm with CHEVAS

Matt Thompson

IntroductionEndovascular aneurysm sealing (EVAS) has been described for the treatment of abdominal aortic aneurysms (AAA). Utilization of EVAS in combination with parallel branch grafts (ch-EVAS) for the treatment of para and juxt-renal AAA is an interesting concept due to the potential of polymer technology to mitigate gutter endoleaks observed with conventional chimney techniques (ch-EVAR). We report the results of the ASCEND Registry of cases involving endovascular aneurysm sealing (EVAS) in combination with chimney grafts (chEVAS) for the treatment of para- and juxtarenal aortic aneurysms (AAA).

MethodsA retrospective, multicenter registry established in 8 vascular centers between 2013 and 2016 recorded the treatment results and follow-up of chEVAS procedures for nonruptured AAAs; data were analyzed using standardized outcome measures. In the observation period, 154 patients (mean age 72.3±7.7 years; 124 men) underwent elective treatment for de novo juxtarenal and pararenal aneurysms and formed the study group.

ResultsSixty-two (40.3%) of the cohort were treated using a single parallel graft, 54 (35.1%) with double chimneys, 27 (17.5%) with triple chimneys, and 11 (7.1%) with 4 chimneys. The 30-day mortality was 2.8%, and there were

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4 perioperative strokes (1 fatal). At 1 year, the freedom from all-cause mortality was 89.8% and the freedom from aneurysm-related mortality was 94.3%. There were 3 endoleaks within 90 days of the procedure, one type Ia and 2 type Ib. The freedom from type Ia endoleaks was 95.7% at 1 year. There were no types II or III endoleaks in this series; the freedom from all endoleaks was 94.2% at 1 year. Freedom from reintervention at 1 year was 89.2%. Target vessel patency rates at 1 year were 97.7%, 99.3%, 100%, and 100% for the left renal, right renal, superior mesenteric artery, and celiac axis stents, respectively. Subsequent core lab analysis of imaging studies supported the absence of migration and adverse events in patients that had a 15mm achieved seal zone in a parallel walled aortic neck <32mm diameter.

ConclusionThe ASCEND Registry supports a proof of concept of the use of polymer technology and EVAS with parallel grafts in managing patients with complex aortic disease. The future role of chEVAS will be defined by studies that assess mid- to long-term durability.

Carotid 2

Carotid body tumour’s: Stretching the boundaries of excision

Edwin StephenChristian Medical College, Vellore, India

Our institution is a tertiary care center and hence often encounters challenging cases of carotid body tumors. We have arguably the highest numbers in the country and have published several papers on the subject.

Over a decade we have performed 108 carotid body tumor excisions, majority of which belong to Shamblin grade II/III. We hardly use pre-operative embolization.

Mandibular translocation, reconstruction of the ICA, treating familial and bilateral tumors, performing re-do cases has increased over the past couple of years. Neurological complications are at par with world literature.

The talk will share our experience of treating Shamblin II/III cases that are upto and beyond the base of skull by, stretching the boundaries of excision.

Application of a novel intermittent pneumatic compression device assists long-term dilation of radiocephalic fistulas

Tej M Singh

AimsArteriovenous fistulas (AVF) are the preferred type of vascular access for hemodialysis patients. AVF have the lowest complication rate and highest long-term survival rate compared to other types of vascular access. Among AVF, radiocephalic fistulas (RCF) are considered first choice due to their advantageous location at the wrist, allowing for lower flow rates and lower rates of complications. However, this low flow rate makes RCF maturation difficult, and it has historically been inferior to that of brachiocephalic fistulas (BCF). Previous research indicates that increased distention pressure and intermittent wall shear stress as a result of intermittent compression of upper arm veins may aid in forearm vein dilation. The aim of the present study is to determine if the use of a novel intermittent compression device assists long-term clinical dilation of RCF.

MethodsThis was an IRB approved study conducted at the MS Ramaiah Medical College in Bangalore, India. After AVF creation, a novel, intermittent pneumatic compression device enabling 60 mm Hg of cyclic compression was worn 15 cm proximal to AVF intermittently for 6 hours daily for 3 months. Patients in the treatment group (n=41) wore the device. Of these patients, twenty-four (n=24) had BCF, while seventeen (n=17) had RCF. Controls (n=12) used a sham device. Vein size was measured and recorded at baseline and after 3 months by duplex measurement. Clinical results (percentage increase) were recorded and tested for significance.

ResultsAfter three months, the mean percentage increase in vein diameter in the RCF treatment group was significantly larger than those in the BCF treatment group at proximal distances of 5 cm, 10 cm, and 15 cm from the anastomosis (p=0.000, p=0.000, p=0.017, respectively). Patients in the RCF treatment group also had significantly larger mean percentage increases in vein diameter as compared to controls at proximal locations of 5 cm and 10 cm (p=0.008, p=0.006, respectively). All fistulas treated with FA are still functional with no reported thrombosis, extravasations or other adverse effects.

ConclusionsApplication of this novel intermittent pneumatic compression device is safe and may be more effective at assisting long-term RCF maturation (3 months) as compared to BCF. RCF are associated with lower risks of infection, distal ischemia, and steal syndrome. Thus, efficiently maturing RCF is extremely important because this may decrease costs associated with vascular access, reduce complications, and preserve upper arm veins for future use in vascular access.

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Ultrasonic quality control in vascular surgery

Beat H Walpoth1, Damiano Mugnai1, Shahrul A Saat2, Jeswant Dillon2, Nicolas Murith1, Christoph Huber1

1Department of Cardiovascular Surgery, University Hospital of Geneva, Switzerland2Department of Cardiothoracic Surgery, National Heart Institute, Kuala Lumpur, Malaysia

BackgroundTransit-time flow measurement (TTFM) was introduced more than 20 years ago in clinical practice for cardiac revascularisation procedures and has then been extended to vascular surgery (carotid, peripheral, access surgery). However, there are still critical situations such as low flow and high pulsatility when an additional alternative method for visualising the anastomoses and/or the graft would be very welcome. The new MiraQ combines the physiologic aspect of flow measurement with the morphologic aspect of ultrasound.

MethodA.Carotid Surgery: In a prospective study of 40 patients we used TTFM before and after carotid artery thrombendarterectomy (TEA) and followed the patients up to one year with several colour Doppler exams. B.Peripheral Surgery: TTFM is used routinely in our clinic to measure the flow before and after peripheral revascularisation procedures. If the measured flow is inadequate and the pulsatility index high the surgeons perform ultrasonic imaging and colour flow Doppler to verify the graft and anastomoses. C.Access Surgery: TTFM should be used regularly to verify the flow values after creation of an AV fistula as well as in AV shunts (predictor of maturation and patency).

ResultsA.Carotid Surgery: TTFM doubled after TEA (p<0.05). In two cases an intimal flap was diagnosed which could be repaired during the same procedure. All patients survived long-term and the post-operative Doppler examination showed a constant Vmax. Burnett showed that using MiraQ enabled the reduction of perioperative stroke rate. B.Peripheral Surgery: In our experience the TTFM increased significantly in both endarterectomies and bypass grafts. In rare cases morphologic verification by the imaging modality was required due to limited flow and high pulsatility index. In most cases intra-operative revision could ameliorate the operation result. Ilberg showed that TTFM >100mL/min had a better long-term patency in infrainguinal bypass. C.Access Surgery: TTFM has shown a significant correlation with the maturation of AV fistulas (Saucy) as well as patency rates of autologous or prosthetic AV shunts (Lundel).

ConclusionsTransit-time flow combined with the possibility of ultrasound imaging and a pulse-waved Doppler is optimal to ascertain the early intra- and post-operative results of revascularisation procedure. By using these two modalities clinical long-term outcome may be improved.

CVD 6

Role of compression as the primary therapy

Chris Lattimer

Chronic venous insufficiency (CVI) is a chronic disease which results when the drainage function of the venous system becomes impaired. The 5 causes of CVI are reflux, obstruction, loss of tone, poor muscle pumping and physiological. The chronic nature results from the battle between the relentless downward force of gravity versus the gradually failing upward drainage mechanisms of the leg. Venous leg volume increases with time and venous tone diminishes. Pumping muscles, including the heart, become weaker. Given enough time every ambulant leg will develop the disorder. Genetic and hormonal factors often hasten the process.

The deterioration processes can be interrupted with interventional procedures like endovenous ablation for reflux or stenting for obstruction. Nevertheless, compression will remain the primary therapy and universal treatment option for CVI because it is a life-long, day-to-day defence against gravity.

In any surgical practice a procedure could be interpreted as the primary therapy. However, the benefits are short lived in the lifetime of the patient, often lasting 10 years or less before the venous disorder reoccurs. Revision surgery or foam sclerotherapy is then required to maintain the primary effect, again with variable long term results. Occasionally, an intervention may even hasten the disease process.

Firm evidence from long term studies that compression delays the progression of venous disease is lacking. Such a trial would be costly and may not be possible. There would be major difficulties in measurable endpoints, long term supervision, occupational activities, general health status and compression compliance. Nevertheless, current evidence supports the role of compression in healing venous leg ulcers, reducing skin changes, lessening clinical severity, alleviating venous symptoms, improving quality of life and in preventing leg oedema.

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There is also haemodynamic evidence to support the benefits of compression. The case that compression delays progression may already be made.

Sclerotherapy or surgery of perforators causing venous ulcer

AH Davies

Treatment of perforators in the presence of venous ulceration is controversial in the presence of truncal veins that need interventional treatment. Both sclerotherapy and surgery can cause skin damage. In all ready damaged skin, the effect of another “ischaemic” insult can result in further tissue damage and hence ulceration. The incidence and potential mechanisms of this iatrogenic injury will be explored.

CVD 7

Iliac vein compression syndrome in a non-vascular related symptomatic patient population

Fuxian Zhang, Long Cheng, Hui ZhaoDepartment of Vascular Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, PR China

BackgroundIt is the purpose of this prospective study to determine the incidence of iliac vein compression syndrome (IVCS) in an asymptomatic population.

MethodsFrom October 2011 to November 2012, A totally 500 patients who were informed consented with non-vascular related symptoms was enrolled in our study. A CT scanner was used in all cases. The degree of venous compression was calculated as the diameter of the common iliac vein at the site of maximal compression divided by the mean diameter of the uncompressed proximal and caudal left common iliac vein (LCIV). Meanwhile, we compared the compression degree of the common iliac vein in tumor and non-tumor patients, and detecting the function of coagulation.

Results37.8% of patients had a compression degree greater than 25% while 9.8% greater than 50%. There was a significant difference between men and women in the compression degree of the LCIV (P<0.01). In addition, the LCIV compression degree of the youth women group has a statistically significant difference (P<0.001) when compared with middle-aged women group. We found a significant difference in comparison of coagulation

function in tumor and non-tumor group, while no difference was found in the compression degree of common iliac vein. The incidence of IVCS in the follow-up period was 0.71%.

ConclusionsIliac vein compression and IVCS were the different stages of the disease. The incidence of IVCS was low, but left iliac vein compression is a frequent anatomic variant in asymptomatic individuals, especially in young women who have a greater compression degree of LCIV. This prompts us that, we may not need to actively deal with the common iliac vein compression until patients showed symptoms even if the patients with a higher iliac vein compression degree. Cancer patients exists abnormal coagulation function generally, tumor and coagulation disorders are the high risk factors of the occurrence of IVCS.

KeywordsIliac vein compression; non-vascular related; malignancy; coagulation function; Thrombosis

Evaluation of iliac vein before superficial vein intervention

AH Davies

In my view, all patients should have a comprehensive history and duplex evaluation prior to superficial intervention. The reason for this will be elucidated. The question does a rise as whether treat the SVI and if poor outcome then go on to evaluate the iliac veins.

Duplex examination is possible in the majority of individuals. Those with an elevated BMI do pose a challenge. The role of cross-sectional imaging will be discussed.

CVD 8

Management of lymphatic malformation

Ramakrishna PinjalaNizam’s Institute of Medical Sciences, Hyderabad, India

Commonly errors in vascular formation during embryonic life lead to congenital vascular malformations. These lesions generally enlarge without involution unlike hemangiomas. During the past 2 decades they have been classified as high flow, slow flow, and combined slow/fast flows. Similarly, the lymphatic malformations (truncal and extra truncal) are also reclassified as microcystic lesions (open cell and closed cell), macrocystic lesions

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and combined forms. the term cystic hygroma has now been replaced by the term macrocystic LM. Macrocystic LMs can be associated with several congenital disorders, including Down syndrome and other trisomy disorders, Turner syndrome, hydrops fetalis, Noonan syndrome and several others. Contrast enhanced MRI and ultrasound examination are diagnostic tools and they differentiate lymphatic malformations from other types of vascular malformations. Indications for treatment depend on symptoms, location and size of the lesion. Cosmetic disfigurement and complications are the frequent indications for interventions. Sclerotherapy (Ethanol, bleomycin, doxycycline, polidocanol, sodium tetradecyl sulfate and OK32) and surgery are usually treatments suggested. Surgery is known to be associated with recurrence of lesions after few years. When the lesions are small and excisable in the extremities (superficial) we consider surgery as a first choice, in others sclerotherapy (foam and ultrasound guided) with or without surgery in multiple sessions is the preferred mode of therapy. Surgery is avoided for large lesions, localized near vital structures such as the optic nerve, facial nerve. A decision to treat patients with asymptomatic macrocystic LMs should be undertaken by a multidisciplinary team, after careful consideration in preference to observation alone. Multidisciplinary clinical setting, including a vascular surgeon, plastic surgeon, pediatric surgeon, diagnostic radiologist, interventional radiologist, dermatologist, ophthalmologist and orthopedic surgeon will give optimum results in different types of lymphatic malformations.

Innovations in lymphedema management


Lymphedema as we all know has no definitive cure. Measures revolve around early detection, reducing edema, infection, manual decongestive therapy and compression.

In the Indian sub-continent this problem is associated with a social stigma and the absence of center’s where patients can get the above mentioned advice.

In 2006 our department started the training of physiotherapists, psychologist’s, dietician’s and developed handouts, which has been shared with the rest of the country. This lead to the formation of a MDT, which included our plastic and bariatric surgeons.

The talk will share our institutional experience of a decade and more recent developments in the use

of silicone tubing to help reduce the edema in these patient’s, besides, our findings in a study on veno-lymphedema.

DVT 1

Are western VTE prophylaxis guidelines applicable to the asian population?

Limi LeeDepartment of Surgery, University Putra Malaysia, Serdang, Malaysia

Background and aimIncidence of venous thromboembolism (VTE) in Asia is lower than in Western. There is yet an appropriate risk assessment model that is validated in this population with lower VTE incidence. While the acquired risk factors are similar to Asian population, there may be difference in the ethnic or familial risk factors. With a difference in the incidence of VTE between Asia and the West, are ACCP VTE prophylaxis guidelines applicable to Asians? To determine whether ACCP guidelines were suitable for Asians, a retrospective VTE risk assessment study using ACCP based Caprini model was conducted

MethodsThe electronic records of 9904 patients aged 18 years and above admitted to surgical, gynaecological and orthopaedic wards of a General hospital between 1 January 2013 and 31 December 2015 were reviewed. Non- Asian patients such as Caucasians, Middle Easterners and Africans were excluded. VTE risk of each the patient was assessed with Caprini risk assessment model (RAM). Medical records were reviewed for VTE risk factors and evidence of symptomatic VTE during hospital admission and within 90 days after discharge. Descriptive analysis of individual risk factors, overall VTE incidence and incidence of VTE in each risk category was performed. Association between each risk factors and incidence of VTE was analysed using Chi-square or Fisher’s exact test.

ResultsThe overall symptomatic VTE incidence was 0.5%. Incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) were 0.3% and 0.2% respectively. In each risk levels of Caprini RAM, the incidence were 0% in very low, 0.2% in low, 0.4% in moderate and 2.3% in high categories. The significant risk factors using Caprini RAM associated with VTE were obesity with BMI>25 (p=0.028), varicose veins (p=0.013), serious lung disease including pneumonia (p=0.008), history of prior major surgery (p=0.032), swollen legs (p<0.001), age 61-74

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years (p=0.029), patient confined to bed >72 hours (p=0.013), malignancy (p=0.001), history of DVT/PE (p<0.001) and positive lupus anticoagulant (p=0.011).

ConclusionThe overall VTE incidence among Asian patients was much lower than the incidence reported in a similar retrospective hospital discharge study in Michigan as reported by Bahl et al. Caprini RAM overestimated VTE risk and using this model may lead to unnecessary VTE prophylaxis in Asia. Thus, there is a need to propose a new VTE risk assessment model based on Asian VTE guidelines.

Bleeding risk of anticoagulants in the prevention of venous thromboembolism among asians

Ngoh Chin Liew, Limi LeeDepartment of Surgery, University Putra Malaysia, Serdang, Malaysia

Background and aimDespite the rising incidence of venous thromboembolism (VTE) in Asia, there is a reluctance to subscribe to routine chemoprophylaxis in high risk hospitalized patients. This is probably due to fear of bleeding risk in a population that is believed to have a lower incidence of VTE. There is also a belief that Asians are genetically different from Caucasians, in which the incidence of Factor V Leiden is lower and there is increased fibrinolysis in Asians. A systematic review on prophylactic use of anticoagulants for VTE among hospitalized medically ill and perioperative Asian patients, aims to determine bleeding risk of anticoagulants and to compare it with Caucasian studies.

MethodsAll articles on bleeding risk of anticoagulants in VTE prevention among medically ill and perioperative patients in Asia, searched through MEDLINE and Cochrane Database of Systematic Reviews from January 1996 to December 2015, were included and reviewed.

ResultsThere were insufficient Asian cohort studies and randomized controlled trials on VTE chemoprophylaxis. Most data were extracted from international multicentre trials involving Asians. The MEDENOX trial showed no increase in bleeding risk with the prophylactic use of enoxaparin 40 mg and 20 mg among medical patients. Based on available evidence from large phase III trials in medical and orthopaedic patients, most of which included Asian patients (up to 20% of the safety population), significant bleeding rates in the order of

<5% were reported following prophylaxis with either low molecular weight heparin or novel anticoagulants. In patients undergoing total knee replacement, major bleeding was reported in 1.3% of patients receiving enoxaparin and 1.5% of patients on dabigatran. Other multicentre randomized controlled trials of enoxaparin, rivaroxaban, dabigatran, apixaban and edoxaban which included Asians have not reported increased adverse bleeding events involving this sub-group of patients when compared to the Caucasians. Phase III trials comparing edoxaban 30 mg with enoxaparin 20mg daily in VTE prophylaxis after total hip and knee arthroplasties in Japan and total hip arthroplasty in Taiwan showed that rates of major and clinically relevant non major bleeding episodes ranged from 0.7 to 2.0% following total hip arthroplasty and 7.4 to 13.9% after total knee replacement. Renal impairment and low body weight were found to be risk factors for bleeding.

ConclusionThere is contradictory evidence that Asians are at higher risk of bleeding after VTE chemoprophylaxis. The suggestion that lower body weight has increased bleeding risk and that lower dose of anticoagulant is equally efficacious warrants further investigations.

How to deal with thromboembolism of vena cava filter

Dan Ming Wu

ObjectiveTo investigate the effectiveness of catheter directed thrombolysis (CDT) with/without a new retrievable filter placement to treat acute thromboembolism in retrievable vena cava filters.

MethodsFrom January 2007 to December 2016, retrievable vena cava filters (Aegisy, Lifetech, OptEase, Cordis)were implanted in 189 patients because of venous thromboembolism (VTE). 16 patients (8.5%)had acute thromboembolisms within filters. CDT combined with/without a new retrievable filter placement was used to retrieve the original filter.

ResultsFilter was successfully retrieved in 13 patients. The other 3 patients were unable to retrieve because of the residual blood clots after CDT, and they were treated with Long-term anticoagulation. Of the 13 patients who retrieved successfully, blood clots in 9 patients were completely dissolved within the time window,and the filters were

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successfully retrieved. 4 patients were treated with a new retrievable filter pacement at the proximal end of the previous filter because of the incomplete dissolving of the thrombus in the time window.The previous filter was retrieved under the protection of the new filter. Continuous CDT was carried out until the thrombus is completely dissolved and the new filter was retrieved. All patients had no perioperative new VTE and no important organ bleeding.

ConclusionCDT combined with/without new retrievable filter placement is effective and safe in treatment of acute thromboembolism in retrievable filters.

DVT 2

Efficacy of compressive stockings in VTE prevention

Chris Lattimer

Evidence on the efficacy of compression stockings is strengthened usually when a mechanism of action can be reconciled with a measured outcome. In thromboprophylaxis a plausible mechanism of action is that they exert circumferential pressure distally to proximally, thereby encouraging the venous return. This is only possible when the massaging effect of a stocking is activated by the muscular activity of the limb. Furthermore, they have been shown to decrease the venous diameter in the lying position thereby increasing venous blood flow velocity. For these reasons they are indicated during bed rest. Thromboprophylaxis stockings (TPS) have a compression strength between 15 and 18mmHg. They should be distinguished from the higher strength (≥18mmHg) medical compression stockings (MCS) which provide additional protection against the gravitational force when sitting.

Currently, the evidence recommends the use of TPS in patients undergoing major surgery and situations where anticoagulants are contraindicated. In stroke patients, the evidence for TPS is less clear with an incidence of skin complications. If TPS is considered, a thigh length should be used. In long distance travel and in patients with a high risk of DVT, the current evidence supports the use of MCS.

Stockings and other mechanical methods, like intermittent pneumatic compression and neuromuscular stimulation, are often combined with pharmacological prophylaxis. However, in surgical patients there is a

risk of bleeding using a pharmacological approach. This makes the mechanical methods relatively safer.

Three Cochrane reviews and 3 CLOT trials have investigated the efficacy of TPS in VTE prevention: (i) Sachdeva A, CD001484 (surgical patients), (ii) Sajid MS, CD007162 (stroke patients), (iii) CLOTS I, II & III trials (stroke patients), (iv) Clarke M, CD004002 (MCS in airline passengers).

How and why to develop an acute VTE service as a vascular surgeon

Laurencia Villalba

Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the world and remains the most common preventable cause of in-hospital death. Forty percent or more of cases of iliofemoral venous thrombosis have associated PE. Vena cava thrombosis or tumours may present with PE.

Saving a patient with an acute PE through catheter-directed lysis and debulking represents an opportunity to save lives using techniques that lie within the skill set of the contemporarily trained vascular surgeon. As rewarding as a successful management of a ruptured aneurysm is, most of those patients are elderly with multiple comorbidities, while PE patients tend to be younger with a productive life ahead. In our case, it was our established involvement in major venous interventions that followed a natural progression to PE intervention.

Management of PE may be challenging, patients with acute PE are underserved because specialized care is frequently unavailable or PE programs nonexistent. In communities and hospitals where vascular surgeons represent the lead interventionalists, involvement in this field might even be considered a responsibility. Failure to be involved in the PE movement deprives patients of the experience of vascular surgeons and potentially threatens the venous intervention practice of nonparticipating surgeons.

Surgical Thrombectomy for Acute Ilio-femoral DVT revisited

Tomohiro Ogawa

The goal for the treatment of deep venous thrombosis (DVT) is to prevent life threatening pulmonary embolism, the acute painful swelling and the postthrombotic syndrome. Although anticoagulant

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therapy is not enough to prevent the postthrombotic syndrome, many current guidelines for the management of DVT recommend anticoagulation alone. However, early thrombus removal is recommended for patients with acute iliofemoral DVT by the American Venous Forum and the Society for Vascular Surgery guidelines in 2012 as well as in the 4th edition Handbook of venous and lymphatic disorders in 2017. A strategy of early thrombus removal was suggested in selected patients meeting the following criteria:• firstepisodeofacuteiliofemoralDVT;• symptoms<14days;• alowriskofbleeding;• ambulatory with good functional capacity and an acceptable life expectancy.

Percutaneous catheter-based techniques (pharmacologic or pharmacomechanical) are recommened as first-line therapy for early thrombus removal. Open surgical thrombectomy is recommened in selected patients who are candidates for anticoagulation but in whom thrombolytic therapy is contraindicated. The Swedish RCT comparing surgical thrombectomy combined with a temporary arteriovenous fistula and anticoagulation versus anticoagulation alone in patients with acute iliofemoral DVT showed in the 10 year follow-up significant higher patency of the iliac outflow in the thrombectomized group (77 vs 47%).

In this presentation tips and tricks for successful surgical thrombectomy will be presented.

PAD 5

Multipoint puncturing technique to treat complex lower extremity arterial occlusive diseases

Yong Liu

Abstract ObjectiveTo discuss the methods advantages and indications of multipoint puncturing in the therapy for complex lower extremity arterial occlusive diseases.

MethodsDuring the period from April 2011 to April 2017 a total of 76 patients with complex lower extremity arterial occlusive diseases were accepted endovascular treatment by using multipoint puncture technique. The puncture methods and the advantages of multipoint puncture technique were analuzed.

ResultsAll of the aterial vessles in lower or upper extremities are choosed as target puncture vessles, antegrade and retrogradepuncturewereperformed;Thesuccessrateofendovascular treatment was 95.3%.

Conclusionmultipoint puncture technique improve endovascular treatment success rate for lower extremity arterial occlusive diseases. Mastering a skillful puncture technique, perfect preoperative planing and proper interventional equipments are helpful to ensure a successful treatment.

KeywordMultipoint puncturing technique; arterial occlusive diseases; endovascular treatment

PAD 6

The importance of establishing the plantar pedal loop in CLI

M Manzi

The distibution of the arterial lesions in Diabetic patients with CLI in our published experience, demontrates as more than 80% of the patients presents 2-3 BTK vessels diseased , in particular we had more occlusions than stenosis and the average lenght was >22 cm.

This kind of involvement represents a sort of transmission failure from the thigh-knee to the foot.

We could demonstrate as well that more than 52% of the same patients have 2-3 foot vessels and arch involved.This disease pattern can be defined as a distribution failure and alone is able to cause CLI.

Achieving foot vessels revascularization and, in particular, arch reopening has been demonstrated more important than a direct (angiosome concept) revascularization without an outflow and distal distribution.

We report some clinical samples.

PAD 7

Global vascular guidelines for chronic limb-threatening ischemia

Philippe Kolh, Robert FitridgeLiege, Belgium and the University of Adelaide, Australia

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The Global Vascular Guidelines for Chronic Limb-Threatening Ischemia (CLTI) have been developed by a unique international collaboration of the Society for Vascular Surgery (SVS), the European Society for Vascular Surgery (ESVS) and the World Federation of Vascular Societies (WFVS).

This project was conceived by these vascular societies, due to the increasing prevalence of CLTI throughout the world and the diverse spectrum of clinicians involved in the care of these patients.

The lack of consensus definitions and disease staging as well as the marked variability in resources available internationally to manage patients with CLTI supports the development of an international guideline.

Fifty-eight authors from 24 countries and 6 continents contributed to the guideline. Authors from Vascular Surgery, Interventional Radiology and Cardiology, Vascular Medicine, Podiatry and Epidemiology have contributed to the process.

Systematic reviews were commissioned and the GRADE system was adopted for providing recommendations and evidence strength.

A structured assessment PLAN is proposed, taking into account Patient risk, Limb threat severity (using WIfI staging) and Anatomical pattern of disease.

A summary will be presented at the ASVS meeting and the draft guidelines will be sent to the contributing societies for review and feedback prior to publication.

Assessment of risk of failure following infrainguinal vein graft Bypass

Reza Mofidi

Autologous veins are the conduit of choice when performing an infra-inguinal arterial bypass procedure. These grafts are at threatened by a multifactorial process which is associated with factors relating to the procedure as well as adaptive processes which occur after the formation of the bypass graft. Duplex ultrasound assessment of haemodynamic findings within the graft is an accurate method of identifying a threatened graft. Although US based surveillance using Duplex ultrasound have not been found to reduce graft failure, US examinations findings together with clinical factors can be used to individualise vein graft surveillance and identify grafts which are at highest risk. This review

examines the steps involved in a successful vein graft surveillance program, how to optimise the cost utility of vein graft surveillance by identifying the grafts which are at highest risk of failure and how there has been a paradigm shift away from surgical revision and towards endovascular revision of failing infrainguinal grafts.

PAD 8

Critical limb ischemia in the Japanese population

Tetsuro MiyataVascular Center, Sanno Hospital and Sanno Medical Center

Since 2013, the Japanese Society for Vascular Surgery (JSVS) has started the project of nationwide registration and a tracking database for patients with critical limb ischemia (CLI) who are treated by vascular surgeons. The purpose of this project is to clarify the current status of the medical practice for patients with CLI to contribute to the improvement of the quality of medical care. This database, called JAPAN Critical Limb Ischemia Database (JCLIMB), is created on the National Clinical Database (NCD); a nationwide registration databaseof whole surgical procedures in Japan, and collects data of patients’ background, therapeutic measures, early results, and long term prognosis as long as five years after the initial treatment. The limbs managed conservatively are also registered in JCLIMB, together with those treated by surgery and/or EVT.

In 2013, 1207 CLI limbs (male 874 limbs: 72%) were registered by 87 facilities. In 2014, 1347 CLI limbs (male 936 limbs: 69%) were registered by 95 facilities. ASO has accounted for 98% of the pathogenesis of these limbs followed by Buerger and vasculitis mainly due to collagen disease. Among these patients, 65% were diabetic, 43% had past history of coronary arterial disease, 25% cerebrovascular disease, 15% heart failure, and 45% underwent hemodialysis for renal failure. 21% of the limbs with CLI also had CLI in the contralateral limbs. 43% of CLI limbs had occlusive lesion below the knee. Infection of the wound increased according to the increase of Rutherford stage, and 25% of Rutherford stage 5 and 67% of stage 6 had local infection.

Clinical studies utilizing these data will also be performed under specific conditions. By analyzing several factors on JCLIMB, we would like to establish JAPAN score for CLI to predict the outcome of the treatment in the near future.

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Managing critical limb ischaemia in Bangladash

Abul Hasan Muhammad BasharNational Institute of Cardiovascular Diseases & Hospital (NICVD), Dhaka, Bangladesh

Critical limb ischemia (CLI) refers to a severe form of peripheral arterial disease (PAD) that clinically manifests itself by rest pain with or without tissue loss due to non-healing ulcer or gangrene. These patients belong to Fontaine stages III, IV and Rutherford Grade II-IV (category 4, 5 and 6) clinical classes for PAD.

In Bangladesh, the rate of PAD patients presenting with CLI is alarmingly high. Though definitive statistics are lacking, personal and institutional data suggest the rate to be more than 75%. This means that PAD patients in this country rarely present to vascular surgeons in the stage of claudication and are treated by general physicians or specialists like orthopedic surgeons and neurologists until intractable rest pain or tissue loss appears.

Approach to CLI patients in Bangladesh is not much different from that in the developed world. After taking a careful history, diagnostic work-up starts with a Duplex scan which is followed by catheter or CT angiogram. Though limb salvage is always the ultimate goal, it often needs to be revised to minimizing the extent of amputation. Endovascular revascularization in the form of Percutaneous Transluminal Angioplasty (PTA) with or without stenting is always considered the first option whenever technically feasible. Surgical revascularization like arterial bypasses or endarterectomies are also routinely performed. For multi-segment lesion a combination of endovascular and surgical revascularization is employed in stages. Below-knee interventions and distal bypasses are the recent additions to revascularization procedures. Lack of hybrid operation theater is one limitation that influences strategic decisions in multi-segment disease.

As for medical management, conventional flow enhancing medications supplemented by Prostaglandin infusion is used for patients in whom there is no revascularization option. Wound care including scalpel debridement is always integrated in the whole treatment strategy.

Despite best efforts, some kind of amputation becomes inevitable in most patients. Digital, mid-tarsal and below-knee amputations are common but sometimes above-knee amputations are necessary.

Trauma

Duplex guided thrombin injection versus compression treatment of femoral pseudoaneurysm - KSUMC experience

Mussaad S Al SalmanDivision of Vascular Surgery, Dept of Surgery KSU Riyadh

ObjectivesFemoral Artery Pseudo-aneurysms have traditionally been treated surgically and also by Duplex Guided compression which is time consuming, painful & sometimes unsuccessful procedure. Duplex Guided Thrombin ln.iection treatment has been advocated as a superior alternative. ln this we compare our experience with both techniques in terms of success rate and complications.

Methodsultra sound Guided compression Repair of Post cath Femoral Pseudo-aneurysm a Prospective, non.randomized study done from Feb 1999 to march 2002 is compared with Duplex Guide Thrombin lnjection Repair of Post cath Femoral Pseudo-aneurysm a Prospective, non-randomized study started from June 2oo3 to December 2015. Both the groups have similar Demographics and Aneurysm sizes.

ResultsUltrasound guided compression repairthe femoral pseudo-aneurysm cause in 62% was related to Cardiac Cath related procedures and others were due to femoral access for Arteriog rcphy 27% and Renal dialysis related procedures in 11%. The compression repair was successful in 81% and failed were treated surgically. Hypertension, Anticoagulation and Aneurysm size were the predictors of failure. compression required multiple sessions (1-3) average of 3o minutes and procedure was uncomfortable & painful, needed analgesia.

Duplex guided thrombin injection repair, the femoral pseudo-aneurysm cause in 68% Cardiac Cath refated procedures and others were due to femoral access for Arteriogra phY 2Lo/o and Renal dialysis related procedures in 11%. Thrombin injection successfully treated all the pseudo-aneurysm with success rate of 100%. Hypertension, Double antiplatelet, Anticoagulation and Aneurysm size does not hinder the successful repair of pseudo-aneurysm. Thrombosis occurred within seconds of the thrombin injection required an average of 500 to 1500 units and procedure was comfortable and analgesia was not required.

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Neither group had comPlications

ConclusionsDuplex guided thrombin iniection is safe, fast, painless, effective treatment even in patients with hypertension and patient on double antiplatelet and anticoagulant medications, that completely obliterated femoral pseudo-aneurysm. There is shift in practice from duplex guided compression to Thrombin injection in the management of femoral pseudo-aneurySm in our Vascular Division.

Management of brachial artery injury

Khang Nan Chuang

Brachial artery injury represents a relatively small percentage of injury compare to lower limb arterial injury. Nevertheless, it is a vulnerable structure that can be easily injured. Two major contributing causes are trauma and iatrogenic.

We analyzed data from three major hospitals in the country from 2012 to 2016 and found that of the 8 cases were from penetrating injury (stab, industrial cut), 9 cases of blunt trauma from road traffic accident and 6 were from iatrogenic injuries such as cannulation and metal instrumentation. 26% of them had associated nerve injuries.

All patients underwent open surgical repair. 17 of the patients underwent primary repair of arterial injury either by direct anastomosis or patch repair. The rest had reverse vein graft interposition repair. All repairs were successful with restoration of arterial blood flow. No limb or life loss reported.

Most brachial artery injury involves other associated injuries such as nerves, muscle and bones. As such treatment usually involves open surgical exploration and repair. Multi disciplinary team approach is important in preserving and restoring the functions of the damaged upper limb, both intra-operatively as well as post operatively. The role of endovascular intervention is minimal unless it is iatrogenic direct arterial injury where the puncture is small. Most of the brachial artery injuries have good outcome as long as they are repaired within a short period of time after injury.

Access 5

Fore Arm Graft Options

Ahmad Rafizi Hariz

End-stage renal failure (ESRF) is a massive public health problem with significant morbidity, mortality, and cost. For a vascular surgeon, a mature autogenous access represents the most likely optimal access choice with minimal associated complications. However, maintaining effective hemodialysis access still remains a lifelong challenge.

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice has recommended autogenous arteriovenous (AV) access as “preferred” and stated that the prosthetic AV access was “acceptable.” The patency rates for prosthetic accesses should be more than 2 years with a thrombosis rate of less than 0.5 episodes/patient-year and an infection rate of less than 10% over the lifetime of the access. Forearm prosthetic access was not usually an option (i.e., no suitable outflow veins at the antecubital fossa) after other autogenous options in the forearm and upper arm had been exhausted.

In University Kebangsaan Malaysia Medical Centre (UKMMC), we started using deep veins (brachial vein/vena comitantes) as outflow veins for a fore arm loop graft. It is usually performed as a two stage surgery whereby the first stage is to create a mature brachio-brachial vein fistula. Once the outflow vein is sufficiently matured, we proceed with the second stage of loop graft insertion with inflow from brachial artery and outflow into the brachial vein.

We have performed a total of 63 brachio-brachial vein fore arm loop graft in 58 patients from April 2008 until August 2015. The mean age of these patients was 59.1 +/- 13.3. The primary patency for 6 months, 1 year and 2 years were 42.9%, 23.8% and 11.1% respectively. The secondary patency for 1 year and 2 years were 60.3% and 46.0%. In terms of complication rates, graft thrombosis was 44.4%, graft infection which required removal 25.4%, steal syndrome 0.02% and pseudoaneurysm 0.03%.

As a conclusion, brachio-brachial vein fore arm loop graft is a viable option for difficult access haemodialysis patients with acceptable primary and secondary patency. However, one must be aware of its high complication rates which put a constraint on both time and resources.

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Open Techniques in Graft Salvage

Beng Kiat Lim

Salvaging a failing or failed graft allows for the continue use of the graft, avoids interruption of the dialysis treatment and thus without the need of temporary central catheter placement and the risks associated with it. The most common cause of failed graft is graft thrombosis followed by graft infection. Other causes of graft failure or lost of graft are central vein stenosis, wear and tear of the graft and severe steal syndrome.

The causes of graft thrombosis are suboptimal vessels and poor surgical techniques (early thrombosis), anastomotic stenosis especially at the vein-graft junction, graft pathology (stenosis, aneurysm, infection), systemic factors (hypercoagulability state, hypotension), dialysis-related factors (puncture techniques, excessive compression) and central vein stenosis or occlusion.

The principles of treatment of graft thrombosis are to ensure an adequate inflow, establish outflow venous tract and preserve an adequate conduit length for cannulation. The treatment modalities of graft thrombosis include surgery, endovascular approach (thrombolysis, angioplasty, stenting) or combined approach (mechanical thrombectomy and angioplasty/stenting). The surgical treatment (open technique) of graft thrombosis includes graft thrombectomy, repair of the Vein-Graft junction (patchplasty, PTFE interposition graft), repair of the Graft-Arterial junction, segmental excision and bypass graft and balloon dilatation. The surgical approach may involve single or a combination of these procedures.

The treatment outcome depends on the duration and extent of the thrombus, site of stenosis and the graft configuration. An accurate clinical assessment, timely intervention and appropriate management of clotted graft will reduce morbidity and mortality of patients on haemodialysis.

Access 6

HeRO graft in central vein occlusion

Edward Choke

A general overview of HeRO graft will be presented including indications and IFU. The procedure for the insertion of HeRO graft will be presented. Tips and tricks on successful and smooth implantation will be discussed including potential pitfalls and how to overcome difficulties, and avoid complications.

How to fix pd catheter mechanical complications

Ingemar DavidsonDallas, TX

Take home points1. The majority of peritoneal catheter failures are

mechanical in nature.

2. The most common surgical technical skill related complications involve the catheter exit site and the angle of entrance into the abdomen. These are preventable by using proper surgical techniques. (Peritoneal Dialysis. Surgical Technique and Medical Management. Eds. Davidson, Saxena, Gallieni). Publ. 2012 by DIVADI LLC, Dallas, TX. ISBN: 978-0-9845463- 2-9).

3. The most important factor is the proper selection of patients for the most appropriate dialysis access at all times.

4. Mechanical peritoneal catheter complications needing revision are best managed using the laparoscopic approach. (Open versus Laparoscopic Peritoneal Dialysis Catheter Placement. J Vas Access, 2013, DOI:10.5301/jva.5000174).

5. Outcome success of peritoneal dialysis is determined by the dedicated expert team of nurses, nephrologists and surgeons.

6. Using these approaches the success rate with peritoneal dialysis or catheter survival exceeds 90% at three years. (Risk Factors Associated with Peritoneal Dialysis Catheter Survival: a 9-year single-center study in 315 patients. J Vasc Access 2010; 11(4) 316-322).

Access 8

Has cannulation techniques improved patency

Edward Choke

An update of the overview of different cannulation techniques will be presented.

Flow device in helping fistula maturation

Tej M Singh

BackgroundVascular access success requires many factors including patient vein and artery quality along with surgical skill and training. After completion of any vascular access, no

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objective data is available to predict potential of success in access maturation. Intraoperative volume flow measurements immediately post surgery and long term followup with vascular access registries like the Vascular Quality Initiative (VQI) are important process steps to insure high qulaity vascular access results and part of a quality imporvement program.

Material and MethodsWe reviewed our three year data on vascular access procedures for our vascular center. We recorded immediate post anastomosis flow measurements on completion of all fistulas and also added all patients for long term followup in the VQI registry. All intraoperative measurements were recorded and VQI data entered for monitoring per registry fields for followup and analysis of access success.

ResultsTen (n=10) patients were monitored with our new quality moniotoring program. Our primary fistula placement rate was over 91%. Intraoperative flow measurements over 300 ml/min for upper arm fistula and 150 ml/min were recorded in all patients at time of surgery. Patients achieving these measurements had successful fistula maturation within 6 weeks (95%) and minimal interventions (1 or less) for maturation assistance. Flow measurements assisted in banding steps, drill procedure revisions, technical troubleshooting, and anastomotic revisions. Long term registry data provided important long term vascular access success reporting to the dialysis center and referring nephrologists.

ConclusionDeveloping an intraoperative flow measurement program and vascular access registry for all vascular accces procedures insure immediate and long term vascular access quality improvement and will assist in vascular access successful maturation.

Aortic 12

Overcoming difficult vascular access in EVAR & TEVAR

Tarun GroverDivision of Vascular & Endovascular Surgery, Medanta Medicity Hospital, Gurugram, National Capital Region, New Delhi

PurposeTo describe a technique that facilitates the safe introduction of aortic stent-grafts through diseased iliac arteries.

IntroductionAnatomic constraints for endovascular aortic aneurysm repair are being reduced with evolving technology. However, vascular access continues to limit the feasibility of EVAR & TEVAR in some patients. Unsuitable iliofemoral arterial anatomy predisposes to access site complications and represents a relative contraindication to EVAR & TEVAR. Moreover in thoracic endovascular cases because of the large outer diameter of the necessarydevices. Advancement of an endograft via femoral access can be extremely challenging in the face of aortoiliac occlusive disease and impossible in patients with pathologic or iatrogenic interruption of the abdominal aorta. In such cases, alternative method for stent graft delivery are required.

TechniqueThe technique involves relining and dilating (“paving and cracking”) stenosed iliac arteries with covered stents prior to the introduction of the main aortic stent-graft. It has been successfully used to introduce aortic stent-grafts in patients where other transfemoral endovascular measures have failed.

ConclusionThis technique increases the applicability of transfemoral EVAR and prevents serious complications as a result of access-related damage to the iliac arteries. This techniquecan be very effective for performing Chimney procedure for Juxta-Renal Aortic aneurysm with B/L Chronic total occlusion of Subclavian arteries.

The influence of sarcopenia and common iliac artery calcification on outcomes following endovascular abdominal aortic aneurysm repair

Robert Fitridge, Benjamin Thurston, Guilherme Pena, Stuart Howell, Prue CowledDiscipline of Surgery, The University of Adelaide, Vascular and Endovascular Service, Royal Adelaide Hospital. Data Management and Analysis Centre, School of Population Health, The University of Adelaide

IntroductionTotal psoas area at the level of the L3 vertebra has been identified as a surrogate marker for sarcopenia. Increased calcification of the common iliac arteries is another possible risk factor for adverse outcomes following EVAR.

We aimed to evaluate whether pre-operative common iliac artery calcification and low total psoas area could identify patients with increased risk of early mortality, longer length of stay or significant complications following EVAR.

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MethodsWe had access to 191 pre-operative CTAs of patients who underwent EVAR, together with follow-up data for 3 years. For each scan we extracted the axial slice at the most caudal level of the L3 vertebra and also generated a reconstruction of each common iliac artery using the OSIRIX imaging software. Three observers independently calculated the combined cross-sectional area of the left and right psoas on the axial slice. Psoas area was normalised for patient height with sarcopenia defined as total psoas area of <500mm2/m2. The observers also assessed both common iliac arteries for extent of calcification. For those methods found to be reproducible between observers, we assessed the effect of sarcopenia and common iliac calcification on patient survival, length of stay and rate of complications using Cox proportional hazards and relative risk models.

Results Sarcopenic patients had poorer overall survival (HR: 2.37;p=0.011)andanincreasedhospitallengthofstay(4.0 v 3.0 days; p=0.008)when compared to the non-sarcopenic patients.

When counting the number of calcification-containing quadrants on cross-sectional slices and averaging over the entire artery, calcification scores correlated well with an increased risk of all-cause mortality at 3 yrs (RR=5.51 95%CI=1.89-16.11), early complications <30 days (RR=3.05, 95%CI=1.21-7.71) and all complications in the follow up period (RR=3.33 95%CI=1.37-8.07).

ConclusionThe presence of sarcopenia and common iliac artery calcification significantly increased the risk of 3-year mortality. Sarcopenia was also associated with longer length of stay and high iliac artery calcification correlated with an increased risk of complications.

Aortic 13

Endovascular management of isolated mycotic aneurysms of common iliac artery: Report of three cases

Benjamin Leong

IntroductionMycotic aneurysms are localized dilatations of the artery secondary to infection with destruction of the arterial wall. They are not common and are more likely to affect patients with underlying immuno-compromising conditions such as diabetes mellitus and Human

Immunodeficiency Virus (HIV) infection. Isolated common iliac artery mycotic aneurysm is rare and poses a challenging condition to manage. Here, we report our experience in managing such condition in three patients successfully with endovascular intervention. To the best our knowledge, this report represents the largest series of reported isolated common iliac artery mycotic aneurysms.

Case ReportsAll three patients are male with mean age of 52.7 (31- 77) years old. They presented with pyrexia for 2 to 8 weeks, associated with myalgia and arthralgia with raised inflammatory markers. One patient had undiagnosed HIV infection. Two patients had associated left iliac fossa pain. CT scan revealed isolated left common iliac artery pseudoaneurysm with sizes from 3.5 to 5.5 cm. One of them had associated fistula with the left common iliac vein. They were treated empirically with intravenous (IV) Ceftazidime 2g tds. Blood culture was positive only in one patient, which grew Burkholderia Pseudomallei, diagnostic of Melioidosis. Endovascular stenting was performed after 14 to 20 days of antibiotic treatment to decrease the risk of stent infection. The procedures were performed under local anesthesia in two patients and general anesthesia in the other via total percutaneous approach with suture-mediated closure device, Perclose ProGlide (Abbott). Two patients were stented with Endurant iliac limb grafts (Medtronic) and one with Atrium Advanta V12 (Maquet). One patient had the origin of the internal iliac artery covered due to inadequate distal landing zone. Total intra-procedural exclusion of the aneurysm was achieved in one patient. There was persistent flow in into common iliac vein in the patient with fistula and Type 2 endoleak from the internal iliac artery in another. All patients completed 30 days of IV Ceftazidime and were discharged home with long-term oral antibiotics (Ciprofloxacin and Doxycycline). The surveillance protocol was CT scan at 1 month, 3 months and 6 months post-procedure and annually thereafter. Follow up CT scans revealed total exclusion of the aneurysms with absence of fistula and endoleak in all patients by 3 months. Mean period of follow up to date is 18 (6-27) months. All patients are symptoms-free with normalized inflammatory markers and no evidence of endoleak in surveillance CT scan.

ConclusionsIsolated mycotic aneurysm of the common iliac artery is rare. Endovascular treatment offers a non-invasive and safe option. Total exclusion of the aneurysm may

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be achieved at a delayed stage. Long-term antimicrobial treatment is needed to prevent stent infection, however, duration is controversial. Life-long surveillance is mandatory.

Factors influence to durable treatment in EVAR for infected AAA

Khamin Chinsakchai, Chumpol Wongwanit, Kiattisak Hongku, Suteekhanit Hahtapornsawan, Nattawut Puangpunngam, Nuttawut Sermsathanasawadi, Chanean Ruansetakit, Pramook MutiranguraDivision of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

BackgroundInfected abdominal aortic aneurysm (AAA) is not uncommon in Asian population. Open repair has been the gold standard treatment for several decades. Endovascular aneurysm repair (EVAR) has been increasingly performed since the last decade, especially in unfit patients.

ObjectiveTo present the incidence and factors related to the durable outcome in the infected AAA treated with EVAR in 8-year clinical experience.

MethodsPatients with infected AAA treated with EVAR from January 2010 to October 2017 were retrospectively reviewed. Analyzed durable outcome was defined by discontinued antibiotic without any re-intervention following EVAR for infected AAA. Discontinued antibiotic free survival and survival between discontinued antibiotic group (group 1) and persistent infection group (group 2) were calculated by Kaplan-Meier analysis. Factors related to durable outcome were calculated by Binary logistic regression. Differences between groups were determined using analysis of variance with P<0.05 considered significant.

ResultsSeventy patients (56 males/14 females) with a median age of 72 years (range, 18-94 years) were treated during the study period. Twenty-four (34.2%) patients could discontinue antibiotic (group 1) and forty-six patients (65.8%) still had persistent infection (group 1). Estimate median time for discontinued antibiotics was 24.6±1.8 months. Neither recurrent of infection nor re-intervention was developed in group 1. Thirty-day mortality was 0% and 8.7% in group 1 and 2, respectively.

In-hospital mortality was 0% and 15.2% in group 1 and 2, respectively. At 5-year follow-up, the rate of overall survival was 95.8% in group 1 and 15.2% in group 2 (P<0.001). Isolated aortic aneurysm morphology was the factor related durable outcome compared with aorto-iliac and isolated iliac aneurysm morphology (Oddsratio=3.265;95%confidenceinterval(CI)=1.03-10.33;P=0.039) ConclusionsEVAR might be feasible treatment for infected AAA. The incidence of durable outcome in this study was 34.2% with estimate median time for discontinued antibiotics at 24.6 months. The discontinued antibiotic group has a tendency of better outcomes in term of peri-operative, in-hospital mortality rate and 5-year survival rate compared with persistent infection group. Isolated aortic aneurysm morphology was the factor related durable outcome compared with the other aneurysm morphology.

Aortic 14

Training procedures in TEVAR of TBAD: Program accreditation and practitioner certification

Xiao Tang

The overall goal of the integrated vascular residency program is the consummate preparation of physicians as vascular and endovascular specialists, an important area of concern is the adequacy training of thoracic endovascular aortic repair (TEVAR) of type B aortic dissection (TBAD). Different from the open aortic surgery, TEVAR uses minimally invasive catheter-based technology and radiological imaging to diagnose and treat TBAD. The practitioner needs an extensive knowledge of the vascular anatomy, physiology and pathology. A sufficient volume of clinical and interventional experience is required so that these treatments can be undertaken safely and effectively. The material herein outlines the requirements for individual subspecialty training programs in TEVAR. This document also clarifies the pathway to certification through an advanced practice track mechanism for those current practitioners who trained for advanced training standards for complicated aortic dissection. We seek to standardize TEVAR training to ensure the highest quality delivery of this subspecialty within China.

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Single center experience with the anaconda on endovascular treatment

Pao-Yen Lin, Lih-Sheng Wen, Di-Yong Chen

From October 2016 to June 2017, ten AAA (5.0 cm to 6.9 cm in diameter) male patients in National Cheng Kung University Hospital (NCKUH), Tainan, Taiwan had undergone EVAR with Anaconda stent graft. Common characters of these AAAs were saddle aneurysms, that is, these aneurysms usually located at the terminal aorta and aortic bifurcation. Moreover, three of them were associated with unilateral common iliac aneurysms whose diameters were 3.2cm, 4.5cm and 6.2cm respectively. Severely angulated neck (>60 degree) was noted in one case. All stent grafts were successfully installed during these ten EVAR procedures. No type Ia or Ib endoleak was found intra-operatively except one case with highly suspicion of type III endoleak. Such a type III endoleak was thereafter resolved by adding cuff stent to enforce the flawed limb extension stent. Type II endoleak occurred in one case and that was thought to result from back flow of pre-existed ileo-mesentary fistula. Because the flow jet was small, no further management was performed for occluding the fistula. At the later CTA follow-up, the ileo-mesentary fistula closed spontaneously and thus, type II endoleak disappeared. As for aneurysm shrinkage, all iliac aneurysms would diminish their diameters to almost normal about 3 months after stent implantation. However, only two AAAs shrank to normal size during 6-month follow-up. Other AAAs decreased one third of their maximal diameters at the end of 3-month follow-up. In conclusion, our experience disclosed Anaconda stent system could be easily conducted and precisely installed within a limited space like saddle aneurysm. Short-term follow-up demonstrated significant efficacy occurred in aneurysm shrinkage which would develop within 3 to 6 months.

Aortic 15

Type B thoracic intramural haematoma - When to intervene?

Benjamin Leong

Intramural hematoma (IMH) is an important entity and is part of the three components of acute aortic syndrome with mortality rate of up to 25%. It is characterised as excentric hematoma within aortic wall with thickening more than 7mm with no obvious detectable intimal tear. As for pathophysiology, it is believed to be caused by rupture of aortic vasa vasorum, either spontaneously,

induced by a penetrating aortic ulcer (PAU) or trauma. Classification is the same as acute aortic dissection, Stanford Type A and B. When compared to aortic dissection, IMH patients tend to be older and more likely to involve the distal aorta (60% Type B vs 35% Type A). They also tend to have more severe initial pain but are less likely to have visceral and distal malperfusion or aortic valve insufficiency.

Current indications for intervention include Type A involvement, aortic diameter >50mm, IMH thickness >11mm, persistent pain, worsening imaging, aneurysm formation, rupture and IMH associated with PAU. Endoluminal stent-graft intervention is very promising as a less invasive treatment option. Aim is to cover full extent of involved aorta with no or minimal oversizing with avoidance of post-ballooning of endograft. Patients with no intervention, blood pressure control and close follow-up are required.

Long-term outcomes of endovascular aortic aneurysm repair versus open surgical repair of an abdominal aortic aneurysm: A single center study

Tae-Won Kwon Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Songpa-Gu, Seoul, Republic of Korea

ObjectiveTo compare the treatment outcomes and cost effectiveness of endovascular aortic aneurysm repair (EVAR) and open surgical repair (OSR) in patients with an abdominal aortic aneurysm (AAA) at a single center.

MethodsPatients treated for an AAA at a single center between January 2007 and December 2012 were retrospectively identified and classified based on the treatment that they received (EVAR or OSR). Patient demographics, rates of cancer incidence, and in hospital costs were recorded. Long-term survival was calculated using the Kaplan–Meier method.

ResultsDuring the study period, 401 patients with AAA were treated at Asan Medical Center. Among these cases, 226 were treated with EVAR (56%) and 175 received OSR (44%). The mean age of the EVAR group was greater than that of the OSR group (71.25±7.026 vs 61.26±8.175, P<0.001). The need for intraoperative transfusion and total length of in hospital stay were significantly lower in the EVAR group (P<0.001). The OSR group

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showed significantly reduced rates of overall mortality (P=0.003), overall re-intervention (P=0.001) and long-term survival (63.98±1.86 vs 99.54±3.17, P<0.001). The OSR group was charged significantly less than the EVAR group ($12,879.21 USD vs $18,057.78 USD, P<0.001).

ConclusionOur study supports the notion that OSR is superior to EVAR for long-term survival. Additionally, OSR is more cost effective, supporting its use for the treatment of AAA.

A plea for more frequent consideration of open repair and no repair for select patients with complex-anatomy aortic aneurysms

Frank Criado

Truly “inoperable patients” pose a serious challenge when presenting with a significant or large aortic aneurysm. Their life expectancy is severely limited, regardless whether the aneurysm is treated or not, leading to appropriate questioning of the wisdom of recommending and undertaking elective repair for many such individuals.

The other end of that spectrum relates to low-risk or good-health patients presenting with large aneurysms and complex anatomy that precludes standard open surgical treatment or standard endovascular repair.

The two above-described important clinical scenarios will be dissected out, providing those in attendance a current review and the most reasonable guideline for treatment.

Imaging

The risk of cancer associated with EVAR - A comparison with open surgery

Matt Thompson

IntroductionEndovascular abdominal aortic aneurysm repair (EVAR) might be associated with a higher late incidence of cancer compared to open aortic aneurysm (AAA) repair, due to increased abdominal radiation from the procedure or stent surveillance with computerised tomography. This hypothesis was tested in a population-based cohort study.

MethodsThe nationwide English Hospital Episode Statistics database was used to identify all patients aged over 50 years who received an AAA repair in 2005-2013. EVAR and open AAA repair groups were compared for the incidence of postoperative cancer using inverse probability weights and G-computation formula to adjust for selection bias and confounding.

Results14150 patients underwent EVAR and 24645 patients underwent open AAA repair, with a median follow-up of 2.54 years. EVAR was associated with a significant increase in the incidence of postoperative abdominal cancer (HR=1.18, 95% CI 1.06-1.31) and all cancers (HR=1.12, 95% CI 1.04-1.20). However, there was no significant difference between the groups in the incidence of lung cancer (HR=1.04, 95% CI 0.92-1.18) or obesity-related non-abdominal cancer (HR=1.12, 95% CI 0.69-1.83). Within the EVAR group, the use of computerised tomography surveillance was not associated with any increased risk of abdominal or all cancers.

ConclusionsThis study suggests an increased association with abdominal cancer following EVAR compared to open AAA repair. The differential cancer risk should be further explored.

Duplex ultrasound can be a reliable screening tool for iliac obstruction following a dedicated criterion

Laurencia Villalba

Iliac vein lesions (IVLs) or May-Thurner syndrome (MTS) is increasingly recognised as an important contributor in the development of Chronic Venous Insufficiency (CVI) and Deep Venous Thrombosis (DVT). Historically, a transabdominal duplex ultrasound has largely been ignored as part of the assessment of a lower limb with chronic venous insufficiency, numerous studies have suggested that duplex is not useful in the diagnosis of iliac vein lesions and that CTV or MRV should be considered as first line non-invasive imaging when a high suspicion is raised. We postulate that, in the hands of experienced operators, and using a comprehensive criterion, transabdominal duplex ultrasound can be reliable and cost effective as a first line study in diagnosing iliac vein lesions

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Innovation / Radiation

Shaping the future of clinical research in Malaysia

Khairul Faizi

CRM is a non-profit company wholly owned by the Ministry of Health which was established in June 2012 to position Malaysia as a preferred global destination for Industry Sponsored Research (ISR). CRM plays an important role to improve the local ecosystem to support growth in ISR, facilitate the needs and requirements of industry players, grow the pool of capable investigators, support staff and trial sites, and improve their capabilities and capacities to conduct ISR. Malaysia has seen a steady increase in the number of ISR with 143 trials in 2010 to 201 in 2015. In 2015, there was a 200% growth in the number of CROs and five times more sponsors who utilized CRM’s services compared to 2014. The number of principal investigators from January until September 2016 doubled the numbers recorded in 2015. CRM also grew its pool of Study Coordinators from 22 in 2012 to 93 as of September 2016 to support the growing needs of the clinical research ecosystem which has seen a growth of 53% in the number of sites conducting ISR in 2015 compared to 2013. The gross national income (GNI) created by clinical trials in 2015 totaled over Malaysian Ringgit (RM) 125 million, an addition of RM 76 million from 2011. The overall strategies initiated by CRM has resulted in it achieving 94% of its key performance index 1 (KPI 1) determined by the number of ISRs conducted in Malaysia during the year 2015 (201 ISRs conducted vs. goal of 214), translating to a 13% increase compared to 2014. This in turn significantly increased the number of clinical trials performed in Ministry of Health facilities (KPI 2; 128/120) during the same year resulting in a 107% achievement of its KPI 2. This presentation will address the strategies and initiatives developed by CRM in improving the clinical research ecosystem in Malaysia as well as its future collaborations with the government and the industry.

Application of a novel intermittent pneumatic compression device assists long-term dilation of radiocephalic fistulas

Tej M Singh

AimsArteriovenous fistulas (AVF) are the preferred type of vascular access for hemodialysis patients. AVF have the lowest complication rate and highest long-term survival rate compared to other types of vascular access. Among AVF, radiocephalic fistulas (RCF) are considered

first choice due to their advantageous location at the wrist, allowing for lower flow rates and lower rates of complications. However, this low flow rate makes RCF maturation difficult, and it has historically been inferior to that of brachiocephalic fistulas (BCF). Previous research indicates that increased distention pressure and intermittent wall shear stress as a result of intermittent compression of upper arm veins may aid in forearm vein dilation. The aim of the present study is to determine if the use of a novel intermittent compression device assists long-term clinical dilation of RCF.

MethodsThis was an IRB approved study conducted at the MS Ramaiah Medical College in Bangalore, India. After AVF creation, a novel, intermittent pneumatic compression device enabling 60mm Hg of cyclic compression was worn 15cm proximal to AVF intermittently for 6 hours daily for 3 months. Patients in the treatment group (n=41) wore the device. Of these patients, twenty-four (n=24) had BCF, while seventeen (n=17) had RCF. Controls (n=12) used a sham device. Vein size was measured and recorded at baseline and after 3 months by duplex measurement. Clinical results (percentage increase) were recorded and tested for significance.

ResultsAfter three months, the mean percentage increase in vein diameter in the RCF treatment group was significantly larger than those in the BCF treatment group at proximal distances of 5cm, 10cm, and 15cm from the anastomosis (p=0.000, p=0.000, p=0.017, respectively). Patients in the RCF treatment group also had significantly larger mean percentage increases in vein diameter as compared to controls at proximal locations of 5cm and 10cm (p=0.008, p=0.006, respectively). All fistulas treated with FA are still functional with no reported thrombosis, extravasations or other adverse effects.

ConclusionsApplication of this novel intermittent pneumatic compression device is safe and may be more effective at assisting long-term RCF maturation (3 months) as compared to BCF. RCF are associated with lower risks of infection, distal ischemia, and steal syndrome. Thus, efficiently maturing RCF is extremely important because this may decrease costs associated with vascular access, reduce complications, and preserve upper arm veins for future use in vascular access.

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Updates in vascular tissue engineering: In-Vivo vascular tissue engineering depends on implantation site and species

Beat H Walpoth1, Shahrul A Saat2, Tornike Sologashvili1, Damiano Mugnai1, Sarra de Valance3, Jean-Christophe Tille4, Jeswant Dillon2, Yakub Azhari2, Michael Moeller3 1Service of Cardiovascular Surgery, University Hospital of Geneva, Switzerland2Cardiothoracic Surgery Department, National Heart Institute, Kuala Lumpur, Malaysia3Department of Pharmaceutics, EPGL, University Hospital of Geneva, Switzerland4Department of Clinical Pathology, University Hospital of Geneva, Switzerland

BackgroundPoly (ε-caprolactone)(PCL) was previously used as interposition abdominal aortic graft showing better results than ePTFE with good patency, endothelialisation, cellular infiltration, vascularisation, extracellular matrix (ECM) formation and mechanical properties. We investigated whether implanting the grafts in the carotid position of rats and pigs would reveal similar good results as in the rat abdominal position.

MethodPCL (1mm ID) grafts were implanted in the common carotid artery in 15 anesthetized rats (A). Follow-up at 3, 6, 12 weeks. Similarly end-to-end pig carotid replacement was done with 4mm ID PCL grafts in 11 Swiss Landrace pigs followed for 1-month (B). At each time point, in-vivo compliance, angiography and ex-vivo histological examination with morphometry were performed. Results of A & B were compared to rat abdominal replacement (C).

ResultsPatency rates were 60% (A), 78% (B) compared to 100% (C). Graft compliance was reduced by 69% (A), 40% (B) and 62% (C). Complete endothelialization was achieved at 3 weeks in the rat (A & C) and near confluence (86%) in the pig at 1 month (B). Intimal thickness was low for A&C and not relevant for B. Early cellular infiltration (3-4 weeks) was 82% (A), 90% (C) and 44% (B).

ConclusionsThe degradable PCL grafts showed fast endothelialization, good cellular infiltration, reduced compliance and low IH in the pig and rat carotid artery replacement models. However, compared to the abdominal position there was a higher occlusion rate in both species due probably to the small graft diameter and the different flow pattern. Therefore tissue-engineered vascular-grafts have to be tested at several time-points, implantation sites using

various species before considering a clinical use as a coronary bypass graft.

PAD 9

Meta-analysis of antiplatelet agents in intermittent claudication

Peng Foo Wong

BackgroundPeripheral arterial disease is a marker of systemic atherosclerosis. Patients with intermittent claudication (IC) are at increased risk of cardiovascular events (myocardial infarction (MI) and stroke) and of both cardiovascular and all-cause mortality.

ObjectivesTo determine the effectiveness of antiplatelet agents in reducing mortality (all cause and cardiovascular) and cardiovascular events in patients with intermittent claudication.

Main results12 studies (randomised controlled trials comparing oral antiplatelet agents versus placebo, or versus other antiplatelet agents in patients with stable IC) with a combined total of 12168 patients were included. Antiplatelet agents reduced all-cause (RR 0.76, 95% CI 0.60 to 0.98) and cardiovascular mortality (RR 0.54, 95% CI 0.32 to 0.93) compared with placebo. A reduction in total cardiovascular events was not statistically significant (RR 0.80, 95% CI 0.63 to 1.01). Data from two trials showed a significantly lower risk of all-cause mortality (RR 0.73, 95% CI 0.58 to 0.93) and cardiovascular events (RR 0.81, 95% CI 0.67 to 0.98) with other antiplatelet agents when compared with aspirin. Antiplatelet therapy was associated with a higher risk of adverse events, including gastrointestinal symptoms (dyspepsia) (RR 2.11, 95% CI 1.23 to 3.61) and adverse events (RR 2.05, 95% CI 1.53 to 2.75) compared with placebo; data on major bleeding (RR 1.73, 95% CI 0.51, 5.83) and on adverse events in trials of aspirin versus alternative antiplatelet were limited.

Conclusions:Antiplatelet agents have a beneficial effect in reducing all-cause mortality and fatal cardiovascular events in patients with IC. Treatment with antiplatelet agents is associated with an increase in adverse effects, including GI symptoms. Evidence on the effectiveness of aspirin versus either placebo or an alternative antiplatelet agent is lacking. Evidence for thienopyridine antiplatelet

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agents was particularly compelling and there is an urgent need for multicentre trials to compare the effects of aspirin against thienopyridines.

Vascular Anomaly

Klippel - Trenaunay Syndrome - Vellore experience

Edwin Stephen

Klippel - Trenaunay Syndrome [KTS], the most popular name based syndrome, is a congenital vascular malformation [CVM] that continues to baffle clinicians. The understanding of this syndrome, amongst other vascular malformations, has seen a surge over the past six years in our institution. We ,in turn have imparted this knowledge in various forums in our country.

Over the past decade we have seen 127 patients with KTS and managed them with combinations of conservative management, sclerotherapy, and surgical intervention. Our youngest patient to undergo lateral marginal vein excision is seven years old.

The talk will cover our experience, lessons learnt ,tips and tricks in managing this interesting CVM.

Endovascular management on vascular malformation

Patrianef DarwisVascular and Endovascular Division, Department of Surgery, Ciptomangunkusumo National Hospital/Faculty of Medicine University of Indonesia

Clinical features of vascular malformation are unpredictable, high recurrence rate, complicated, destructive potency, potentially limb threatening/life threatening. Patient’s complaints could be : mass (100%), pain (80%), edema (68%), ulcer (18%) dan bleeding (6%). Other signs and symptoms are hyperhidrosis, hyperthermia, thrill or bruit, CHF (large shunt), joint disturbance, ischemia, gangrene. According to location e.g. Viscera: hematuria, hematemesis, hemoptysis, melena, stroke etc. Imaging examination that could be used are US Dopper, CTA, MRA, Angiography.

Absolute indication of vascular malformation are: bleeding, heart failure, ischemic complication by high-flow AV shunting. The main therapy is surgery, but there was high recurrence rate. Current management are multiple embolization, hybrid techniques (pre/post operative embolization). Embolic agents that couls be used are gelatin sponge, polyvinyl alcohol (PVA) particles,

liquid (absolute alcohol), coils, tissue adhesives, ethanol, microfibrillar collagen, autologous blood clot. Some of our case management experiences will be presented.

KeywordEndovascular, Vascular Malformation

Vasculitis

Buerger’s disease - The vellore approach


Thromboangitis obliterans [ TAO.Buerger’s disease] has a higher incidence in Asian countries. This perhaps is because of the increased consumption of poorly refined tobacco in its various forms.

Practicing vascular surgeons do not have much in their armamentarium to offer besides symptomatic care.

We have used combinations of Sympathectomy [CT guided / Laproscopic], Prostaglandin E1 infusion, Stem cell therapy, Sub-intimal angioplasty, crural artery bypass and more recently deep vein arterialization in order to help prevent amputation or reduce the level of amputation.

The talk will share outcomes of a few studies that we have conducted in our patients with TAO and a recommend protocol to manage this cohort.

Midaortic syndrome due to takayasu arteritis in adult patients: An optimal management strategy

Young-Wook KimDivision of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Midaortic syndrome (MAS) is defined as a segmental or diffuse narrowing of abdominal and/or distal descending thoracic aorta with variable involvement of renal and visceral arteries. Though MAS is more common in children or adolescent, it can be encountered in adult patients with Takayasu’s arteritis (TA). Pharmacologic therapy is the first line treatment for most patients with TA while an interventional treatment is usually reserved for patients with severe medically-intractable hypertension or progressive renal functional impairment. For treatment of MAS due to TA, we would like to recommend followings:

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• Before treating MAS patients due to TA, it is recommended to consider patient age, risk of disease progression, durability of the treatment efficacy and treatment-related complication together.

• It is recommended not to perform endovascular or open surgical treatment (OST) in an acute inflammatory stage of TA.

• Thoughefficacyofendovasculartreatment(ET)may not last long, it can be a useful provisional treatment option before definitive surgery (eg, renal artery intervention before aortic surgery) for patients with very high surgical risk or in pediatric patients.

• Werecommendballoonangioplastyonlyratherthan stent insertion in renal or visceral artery lesion.

• Itisdifficulttogettruebloodpressure(BP)insomeof TA patients with arch branch involvement. Monitoring of true BP is important in the perioperative period.

• For aortic reconstruction, either anatomic or extra- anatomic (eg, ascending thoracic aorta-to-abdominal aortic bypass) bypass can be performed according to the location of aortic lesion.

• Aortic wall in acute inflammation should not be included in the aortic anastomosis to avoid late development of anastomotic aneurysm or restenosis. FDG18-PET CT can be a useful tool to locate acute inflammatory lesions in the aortic wall.

• PostoperativesurveillanceofBP,biologicmarkersand patency of reconstructed vessels are recommended and pharmacologic therapy (eg, corticosteroid or antimetabolite) may be needed postoperatively.

Updates in takayasu’s arteritis

Tetsuro Miyata1, Yoshiko Watanabe2, Kazuo Tanemoto3

1Vascular Center, Sanno Hospital and Sanno Medical Center2First Department of Physiology, Kawasaki Medical School3Department of Cardiovascular Surgery, Kawasaki Medical School

Information from nationwide registration forms submitted by patients with Takayasu’s arteritis (TA) between April 2001 and March 2011 were analyzed as part of a research program by the Japanese Ministry of Health, Labor and Welfare to clarify the clinical features of newly diagnosed Japanese patients with TA. Especially we aimed to determine their onset age-

specific and sex-specific features to provide information for the early diagnosis of TA and to clarify the effects of time interval from onset to registration on their clinical status.

1372 newly registered patients with TA (female 83.8%) were analyzed among the 7779 patients who submitted their forms. The age at onset (median 35 years) was significantly higher in male (median 43.5 years) than in female (median, 34 years; P<0.001). Local symptoms and findings in the cervicobrachial area were most commonly observed, with more complaints in the head or neck than in the upper limbs. The involvement of the aortic arch and its branches was the most common vascular lesion. However, patients with a later age at onset and male patients had additional lesions in extensive areas of the aorta, regardless of the interval from onset to registration. Localized abdominal lesions were more frequent in male patients with age at onset >40 years than in other age sex groups. Disease statuses were severe in patients who registered at ≥1 year after onset.

Among the newly registered Japanese TA patients, the proportions of male patients and patients with elderly onset increased. Their clinical and angiographic features differed according to onset age and sex.

Visceral

Spontaneous superior mesenteric artery dissection: What is its natural course?

Young-Wook KimDivision of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is increasingly reported in these days than before. It seems attributed to more frequent use of advanced imaging technology.

To determine the natural course of SISMAD, we retrospectively reviewed database of SISMAD patients who were prospectively collected in a single institution from 2001 through 2016. Diagnosis and angiographic type of SISMAD were determined with contrast-enhanced CT images, and clinical symptoms were interrogated using a fixed form questionnaire. All patients were treated conservatively, except for 5 patients who unselectively underwent primary interventional treatment in the earlier period of this study. For the follow-up examinations, clinical examinations and CT

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angiography were performed every 6 to 12 months to find symptom recurrence or morphologic changes at the arterial dissection.

During the past 15 years, 116 patients with SISMAD (male, 92%; mean age, 54.7±10.8 years; symptomatic at initial presentation, 76%) were encountered. During the mean follow-up of 53±39 months, clinical and CT follow-up examinations were available in 100% and 88%, respectively. Of 83 (71.6%) symptomatic patients, 96% achieved pain resolution with conservative treatment; 4% showed prolonged abdominal pain including one (1.2%) patient who developed bowel gangrene. After pain resolution with conservative treatment, 20% of patients developed recurrent abdominal symptom during the follow-up period. Among the patients with recurrent abdominal symptom, 2 (12%) patients required surgery due to bowel stricture. On follow-up CT angiography (n=102), we found no change in 34%, partial or complete remodeling in 63%, mild aneurysmal change in 2%, and progression of dissection in 1%. Antithrombotic therapy offered no beneficial effects on either clinical or morphologic outcomes. Majority of patients showed clinical improvement and no changes or improved morphology during the follow-up period. For patients with SISMAD, we recommend conservative management as the first-line treatment regardless of pain severity or angiographic finding unless there is an obvious evidence of bowel gangrene.

Management options of visceral artery aneurysms

Masanori Hayashi1, Hideaki Obara1, Kentaro Matsubara1, Keita Hayashi1, Yuki Kamiya1, Masanori Inoue2, Seishi Nakatsuka2, Masahiro Jinzaki2, Yuko Kitagawa1

1Department of Surgery, Keio University School of Medicine, Tokyo, Japan2Department of Radiology, Keio University School of Medicine, Tokyo, Japan

PurposeVisceral artery aneurysms (VAAs) represent a rare and life-threatening disease when ruptured with an incidence of 0.1 to 1.0%. The aim of this study was to review our experience with VAA treatment at a single institution.

Methods and ResultsBetween January 1995 and March 2017, 59 VAAs were treated in 55 patients (37 males, 18 females) with mean age of 62 years old (range, 21-90). Postoperative visceral artery pseudoaneurysms were excluded from this study. The VAAs location sites were: splenic artery

(n=27), pancreaticoduodenal artery (n=9), superior mesenteric artery (n=7), celiac trunk (n=4), hepatic artery (n=3), gastroduodenal artery (n=3), common celiomesenteric trunk (n=2), gastric artery (n=2), and gastroepiploic artery (n=2). Of the 59 patients, 6 patients were recipients of living liver transplantation, 4 patients presented with ruptured aneurysm, and 14 patients had multiple aneurysms. Thirty five patients had endovascular procedures, 18 patients underwent open surgery, and 2 patients underwent hybrid therapy.In the endovascular group, most VAAs were treated by coil embolization. While in the open surgery group VAAs were treated by splenectomy (n=5), aneurysmectomy (n=2), aneurysmorrhaphy (n=1), and aneurysmectomy with arterial reconstruction (n=10), in the hybrid therapy group, one patient underwent bypass surgery with embolization, and one patient underwent release of the median arcuate ligament under laparotomy and embolization. The results were satisfactory enough with no severe perioperative complication or death. No aneurysm reperfusion or enlargement was observed during follow-up period.

ConclusionsOur study suggests that an aggressive treatment of VAA is safe and effective because of the low morbidity and mortality rates. Regardless of the type of intervention, it is important to assess and maintain end organ perfusion via adequate collateral circulation or direct revascularization.

Wound Care

Holistic approach in management of diabetic foot wounds

Aziz NatherNational University Hospital, National University Health System Singapore, Singapore

NUH adopts a 2-Prong Strategy to manage diabetic foot wounds :Strategy 1: Prevention of Diabetic Foot Wounds. This is the best way to manage it. To prevent development of diabetic foot complications requires • CareofDiabetesitself• CareoftheFoot• Adviceonuseandchoiceoffootwear

In addition all DM patients must undergo annual foot screening to detect “Foot At Risk” for only intervention by orthopaedic surgeon or vascular surgeon.

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Strategy 2: Management of Diabetic Foot Wounds by Inter-disciplinary diabetic foot team involving endocrinologist, orthopaedic surgeon, vascular surgeon, podiatrist, dietitian, infectious disease physician.

It is important to understand the pathogenesis of diabetic foot wounds - the Diabetic Foot Triad of Neuropathy, Vasculopathy and Immunopathy. It is also important to understand the Basic Science of Wound Healing and to adopt a Classification for Wounds - Wagner’s Classification is recommended.

Management requires a Holistic Approach including endocrine control, nutritional support, antibiotics, choose the right dressings and choosing the right surgical option when necessary. If needed surgery must be performed appropriately and decisively.

Careful evaluation of the diabetic wound must be performed including assessment for vasculopathy, neuropathy and immunopathy. Basic investigations must be performed including markers of infection, markers of healing, plain radiography. Other investigations which may be needed include MRI Bone scan, Arterial Doppler.

Choice of antibiotics and dressings are also important when conservative treatment fails, surgery is required. Surgical options include debridement, ray amputation, other distal amputations - Trans-metatarsal, Pirogoff. Distal amputation are preferred to achieve limb salvage. One distal pulse must be palpable.

Where distal amputation is no longer possible, major amputation must be performed decisively. Avoid “Creeping Amputation”. Major amputation include Below Knee, Through Knee or Above Knee Amputation.

The use of negative pressure wound therapy in diabetic foot wounds

Ismazizi Zaharuddin

Diabetic foot ulcers affect millions of people in the world wide and impose tremendous medical, psychosocial and financial loss or burden. Negative pressure wound therapy (NPWT) is generally well tolerated and appears to stimulate a robust granulation tissue response compared with other wound healing modalities. This device may be a cost-effective adjunctive wound healing therapy. This talk review will focus on the clinical outcome of diabetic foot wound treated with NPWT and Hospital Kuala Lumpur Surgical Wound Care Team experiences.

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01-01Paper No: 045The results of venogram after hemodialysis catheter removal

Yoon-Sung JooVascular surgery, Good Gang-An hospital, Busan, South Korea

BackgroundThe exact incidence of central venous stenosis in the dialysis populations is unknown. Several factors have an impact on the development of central venous stenosis, including longer catheter indwelling times, multiple catheterizations and longer functioning ipsilateral AV access for ipsilateral catheter placement. But generally, the hemodialysis jugular catheters have been removed easily without confirming central vein stenosis. So in our vascular center, central venograms have been done in all patients who have removed hemodialysis catheter.

MethodsFrom January 2013 to February 2017, 228 catheters have been removed safely. The central venograms could not be done in 15 patients because of incooperations. There were 10 uncuffed hemodialysis catheters and 218 tunneled cuffed catheters. All patients were grouped by catheter indwelling time(Group I: <4 weeks, Group II: 4~8 weeks, Group III: 8~12 weeks, Group IV: 12~20 weeks, Group V: 20-28 weeks, Group VI: >28 weeks).

ResultsThere are 38.6% (88 cases) central vein stenosis in all patients. There are 25% central vein stenosis patients in Group I, 31.34% (Group II), 32% (Group III), 45.94% (group IV), 33.33% (group V) and 75% (group VI).

ConclusionsCentral venous catheterization for hemodialysis is related to central vein stenosis development. But the symptoms related to stenosis develops very slowly. So central venogram following catheter removal is important for diagnosis of central vein stenosis.

01-02Paper No: 447Ultrasound derived parameters as predictors of future intervention in radio-cephalic arteriovenous fistulas

Lucy Guazzo1, Mark Jackson1,2, David Baker1

1Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, QLD, Australia2Griffith University, Gold Coast, Gold Coast, QLD, Australia

IntroductionAutologous radio-cephalic arteriovenous fistulas (RCAVFs) are considered superior vascular renal access due to well regulated flow, improved venous drainage and decreased steal. Better understanding of ultrasound-derived parameters indicative of poorly functioning or failing RCAVFs allows for appropriate surveillance and expedient intervention. The waveform of the radial artery distal to the arteriovenous anastomosis has never previously been investigated for its diagnostic role in fistula function and outcomes. This study investigates distal radial artery waveform, along with other ultrasound-derived characteristics, as predictors of future intervention in RCAVFs.

Methodology222 duplex ultrasounds of RCAVFs performed between 2010 and 2017 were retrospectively reviewed. Fistulas were characterized as clinically functional or dysfunctional. Ultrasound derived estimates of ‘bulk-flow” through brachial and radial arteries, absolute minimum luminal diameter and distal radial waveform were recorded. The distal radial waveform was classified as occluded, partial steal, retrograde or antegrade flow. Review of medical records determined if the fistula required future intervention.

ResultsCox regression analysis determined an antegrade waveform in the distal radial artery was a significant predictor of need for future intervention (p=0.001). Its significance was found to be independent of fistula ‘bulk flow”. Receiver-operator curves found a brachial flow of 476.5ml/min or greater (sensitivity 94%, specificity 73%) and radial flow of 436ml/min or greater (sensitivity 75%, specificity 82%) to differentiate between clinically functional and dysfunctional fistulas. The area under the curve was 83.4%. Flow below these cut offs in either the brachial or radial artery was also found to be a strong prognosticator of need for further intervention (p<0.001). Minimum luminal diameter was found to be a less significant predictor of outcome (p=0.098).

ConclusionAntegrade flow in the distal radial artery, along with radial and brachial ‘bulk flow”, are powerful predictors of RCAVF outcomes. We propose that an antegrade waveform signifies a haemodynamically significant stenosis distally, leading to preferential flow through the hand and poor fistula function. When performing surveillance USS of RCAVFs arterial flow and waveform should be assessed first, progressing to evaluation for treatable lesions if these initial parameters are below

84

Oral Presentation

threshold. Assessment of distal radial waveform for predictive purposes is unique to RCAVFs and doesn’t apply to other fistula types.

01-03Paper No: 110Does systemic heparin reduces thrombosis rate of radiocephalic fistula: A double-blinded randomized study

Karthigesu Aimanan1, Lenny Suryani1, Putera Mas Pian3, Mohamad Azim Mohd Idris1, Chew Loon Guan2, Hanafiah Harunarashid1

1Department of Surgery, National University of Malaysia, Selangor, Malaysia2Department of Surgery, Hospital Serdang, Selangor, Malaysia3Department of Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

IntroductionThrombosis is an important cause of arteriovenous fistula failure. This study was conducted to show the effect of intraoperative systemic heparin on thrombosis rate and associated morbidities over duration of four weeks. Secondary objectives were to determine maturation rate associated with intraoperative systemic heparin at six weeks.

MethodsThis is a single centre double blinded randomized study with a calculated sample size of 45 participants per arm. Patients were randomized to group A (heparin) 80U/kg and group B (saline) from the clinic. The drug will be administered intraoperatively before clamping the artery. Patients will be followed up at 1st week for infection, hematoma and early thrombosis assessment. Follow up at 4th week will be for assessment of late thrombus. Maturation of fistula will be assessed at 6th week.

ResultsNinety patients were recruited for the study with 45 peoples each arm. A total of 88 patients were managed to complete the study with 44 patients per arm. The population demographic assessment showed they were no different in term of age, gender, and comorbidities. Surgical factors such as duration of surgery and experience of surgeons also did not differ in both the group. Intraoperative heparin administration group showed significance reduced early and late thrombosis rate with better maturation rate compare to the placebo group. There was no statistically significant difference in term of hematoma and infection between the groups.

ConclusionThis study reveals the beneficial outcome of intraoperative administration of heparin in the radio-cephalic group with no adverse effect. Better maturation has been demonstrated in heparin group at six weeks follow-up. These beneficial outcomes should be taken into consideration in future to change the practice of arteriovenous fistula creation.

01-04Paper No: 391Management options for radial cephalic arteriovenous fistula stenosis

Putera MP, Naresh G, Hafizan T, Hanif H, Zainal AADepartment Vascular Surgery, Hospital Kuala Lumpur, Malaysia

BackgroundRadial-cephalic fistula (RCF) are considered the gold standard of native fistula creation. However due to variety of factors it is prone to stenosis formation. These stenosis generally occur around the juxta-anastamosis, venous limb or arterial limb at the para-anastomosis region. The purpose of this study is to access the clinical success of the 2 methods of tackling this problem. It will look at the clinical success and primary patency at 6 months of both surgical intervention (proximalization of RCF) and percutaneous transluminal angioplasty (PTA). This study will also look into reintervention rates after failure of initial management.

MethodologyThis retrospective study included 59 patients treated for RCF stenosis between Jan 1 2016 till Jan 31 2017 in a single centre. Patients mean age was 59 years old. Patients were divided into 2 groups. Those who had proximalization of RCF (n=24) or PTA (n=35). Proximalization meant creation of a new anastomosis and exclusion of stenosis. Patients enrolled had a minimum follow up of 6 months.

ResultsClinical success rates were 87.5% for those in the surgery group and 74% (p=0.2) in the PTA group. Primary potency at 6 months for the surgery group was 83.33% and 62.9% (p=0.08) in the PTA group. Reintervention rates for PTA group was 37.1% with 17.1% undergoing re angioplasty and 20% undergoing surgery. The surgery group had reintervention rates of 16.67%. All the reintervention for this group underwent surgical revision.

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ConclusionThis study demonstrates that there was no significant difference in clinical success between the 2 groups. However the treatment recommended for RCF stenosis should be surgery (proximalization) rather than PTA as both clinical success and primary patency were higher. Reintervention rates were also higher with PTA.

Others

02-01Paper No: 252Light and mirrors: The role of optical coherence tomography in peripheral vascular intervention

S Peden1, S D Thomas1,2,3, R L Varcoe1,2,3

1Department of Surgery, Prince of Wales Hospital, Sydney, Australia2University of New South Wales, Sydney, Australia3The Vascular Institute, Prince of Wales, Sydney, Australia

PurposeOptical Coherence Tomography (OCT) is an established form of medical imaging which utilises broad bandwidth light and image reflection to produce high resolution, cross sectional images of biological tissue. Angiographic imaging of peripheral vascular disease is 2-dimensional and limited in the ability to define plaque morphology and micro-structure of atherosclerotic disease. The use of OCT is well established in coronary and retinal disease but there is limited experience to dictate its use in peripheral and carotid artery occlusive disease. Ours was an observational pilot study designed to give insights into the strengths and weaknesses of the modality used within those applications.

MethodologyOCT images in suitable patients undergoing endovascular intervention within the carotid (n=7) or peripheral (n=4) arterial circulation were generated using the Dragonfly OPTIS St Jude Medical system. The three-dimensional high resolution images were analysed using the OPTIS Integrated Computer System. The OCT images included internal carotid (n=7), common carotid (n=7), superficial femoral (n=2), popliteal (n=2) and tibial disease (n=2).

ResultsEight patients and eleven OCT images of pre and post intervention were generated over a twelve-month period. Stent apposition, plaque morphology and atherosclerotic characteristics were examined through the high resolution images created by OCT. The image

results gave several insights into the disease process and the intervention including adequate stent sizing and wall apposition, plaque morphology and finer anatomical detail of atherosclerotic lesions.

ConclusionOCT may have a role in peripheral vascular intervention through accurate high-resolution cross-sectional imaging. Expanding the use of OCT guidance to percutaneous carotid and lower extremity revascularisation has the potential to give additional information that may improve endovascular intervention. Further research is required to determine if OCT could improve patency of endovascular interventions through accurate imaging and therefore assist with guiding treatment options.

02-02Paper No: 264Surgical treatment of thoracic outlet syndrome

Byeoung-Hoon Chung, Dong-Heon Lee, Shin-Young Woo, Seon-Hee Heo, Yang-Jin Park, Dong-Ik Kim, Young-Wook KimVascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

PurposeTo report our experience of surgical treatment of TOS patients in a single institution.

MethodsWe retrospectively reviewed a database of TOS patients who underwent surgical treatment in a single institution from July 2004 to May 2017. TOS was stratified into 3 types; neurogenic, venous and arterial types. We reviewed the underlying pathology, treatment procedure and treatment results.

ResultsDuring the past 12 years, we have experienced 23 TOS, 18 patients including 5 neurogenic, 5 venous and 13 arterial TOS. Patient characteristics were summarized in Table 1. For the decompression of thoracic outlet, anterior and middle scalenectomy were performed for all patients through the supraclavicular with or without infra-clavicular approaches. And adjuvant procedures were demonstrated in Table 2. As postoperative complications, thoracic duct leakage (n=1), wound hematoma (n=1) and one pneumothorax developed. After surgical decompression, symptom was relieved in 80%, 100% and 100% in neurogenic, venous and arterial TOS, respectively (Table 2).

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Oral Presentation

02-03Paper No: 317Management of vascular malformations in a developing country: Evolving experience with evolution of technology

Abul Hasan Muhammad Bashar, GM Mokbul Hossain, Md Enamul Hakim, Md Fidah Hossain, NC MandalDepartment of Vascular Surgery, National Institute of Cardiovascular Diseases & Hospital (NICVD), Sher-E-Bangla Nagar, Dhaka

BackgroundVascular malformation (VM) is a fairly common clinical problem. Complex classification exists for these lesions. It has varying types and presentations and curative treatment is often not feasible. The objective of this study was to analyze our experiences with VM with evolution of technology.

MethodsBetween July 2014 and June 2017, a total of 1050 patients with VM were received at the vascular outpatient department. The patients ranged in age from 1 month to 50 years with a male female ratio of 1:1.2. Diagnostic work-up started with Duplex ultrasound scan. Contrast MRI was done for lesions with a venous predominance. Lesions with an arterial predominance underwent catheter angiogram with a view to identify and occlude feeders. 120 patients (11.5%), all under the age of 10 years having a diagnosis of vascular tumor were enrolled in to a quarterly follow-up with or without medication. 785 patients with venous predominant VM (74.7%) underwent sclerotherapy in stages with or without surgical resection. 145 patients with arterial predominant VM (13.8%) were treated with transcatheter emolotherapy followed by surgical excision in selected patients. Patients were followed up at quarterly intervals and evaluated for tumor size, recurrence and sensory motor deficits. ResultsComplete or partial involution of vascular tumor was observed in 57% of the patients. Sclerotherapy alone proved curative in 45% patients with venous predominant VM. Sclerotherapy and embolotherapy supplemented by surgery resulted in cure for 78% of the patients. Catheter based treatment was successful in occluding feeders in 93% cases. Recurrence was high in arterial predominant VM (25%). Lifestyle limiting sensory or motor deficits was low (10%) and mostly observed in limb lesions. ConclusionsIncidence of VM and tumors appears high in Bangladeshi population. Though curative treatment is difficult in a large number of patients, the use of newer technology can be beneficial for most of the patients when used judiciously according to lesion type.

02-04Paper No: 347Resection of renal cell carcinoma complicated with inferior vena cava tumor thrombus

Atsushi Yamashita, Tetsuro Uchida, Azumi Hamasaki, Yoshinori Kuroda, Masahiro Mizumoto, Jun Hayashi, Shuto Hirooka, Ai Takahashi, Centavo Akabane, Seigo Gomi, Mitsuaki SadahiroDepartment of Cardiovascular Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan

ConclusionWe think TOS may be under-detected in Korean society due to surgeon’s negligence of this disease and variable clinical symptom in patients with neurogenic TOS. If TOS patients are correctly diagnosed and treated, we have experienced acceptable surgical results.

Table 1. Patient characteristics in TOS patients

Characteristic N-TOS V-TOS A-TOS

Number 5 5 13

Median age (years,

range)

43 (32-71) 43 (32-68) 35 (21-68)

Sex, male 2 (40%) 3 (60%) 11 (84.6%)

Chief complaint Motor weakness

Paresthesia

Arm swelling Pain 4; Finger tip

gangrene 2

Raynaud's phenomenon

10

Symptom duration

(median, range, mo)

13mo (2-180) 0.4 mo(0.1-36) 12mo (3-48)

Hand muscle

hypotrophy

4 (80%) NA 0

SCA aneurysm NA NA 2 (15.4%)

Distal artery embolism NA NA 4 (30.8%)

Acute DVT NA 3 (60%) NA

Table 2. Treatment of TOS and its results

Treatment N-TOS V-TOS A-TOS

Number 5 5 13

Scalenectomy all all all

Cervical bone removal 2 (40%) 0 7 (53.8%)

Adjunctive procedure

Venous thrombolysis NA 3 (60%) NA

Arterial

reconstruction

NA NA 4 (30.8%)

Distal artery bypass NA NA 2 (15.4%)

Symptom relief 4 (80%) 5 (100%) 13 (100%)

Table 1. Patient characteristics in TOS patients

Characteristic N-TOS V-TOS A-TOS

Number 5 5 13

Median age (years,

range)

43 (32-71) 43 (32-68) 35 (21-68)

Sex, male 2 (40%) 3 (60%) 11 (84.6%)

Chief complaint Motor weakness

Paresthesia

Arm swelling Pain 4; Finger tip

gangrene 2

Raynaud's phenomenon

10

Symptom duration

(median, range, mo)

13mo (2-180) 0.4 mo(0.1-36) 12mo (3-48)

Hand muscle

hypotrophy

4 (80%) NA 0

SCA aneurysm NA NA 2 (15.4%)

Distal artery embolism NA NA 4 (30.8%)

Acute DVT NA 3 (60%) NA

Table 2. Treatment of TOS and its results

Treatment N-TOS V-TOS A-TOS

Number 5 5 13

Scalenectomy all all all

Cervical bone removal 2 (40%) 0 7 (53.8%)

Adjunctive procedure

Venous thrombolysis NA 3 (60%) NA

Arterial

reconstruction

NA NA 4 (30.8%)

Distal artery bypass NA NA 2 (15.4%)

Symptom relief 4 (80%) 5 (100%) 13 (100%)

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BackgroundThe successful excision of a renal cell carcinoma invading the inferior vena cava (IVC) remains a technical challenge and requires a careful preoperative surgical management planning. We report our experience in the patients with renal cell carcinoma causing IVC tumor thrombus.

MethodsBetween January 2004 and December 2016, 9 patients with renal cell carcinoma causing IVC tumor thrombus underwent surgical treatment. The mean patient age was 59.6 years and the male to female ratio was 7:2. The extension of the tumor was suprarenal in all cases, being infrahepatic in 4 patients, intrahepatic in 3 patients, and suprahepatic with right atrial extension in 2 patients. All tumors were resected via IVC isolation and, when necessary, extended hepatic mobilization and Pringle maneuver. We used cardiopulmonary bypass (CPB) in all cases. Reconstruction of IVC was performed with graft replacement in 3 cases, patch closure in 5 cases, and primary closure in 1 case.

ResultsThe operative mortality rate was 11.1% (1 patient died on the 10th postoperative day due to pulmonary embolism). The remaining 8 patients could be successfully discharged from the hospital. Three of them were lost during follow-up because of tumor progression. In previous 2 cases who underwent intermittent clamping of healthy renal vein, renal dysfunction was noted. However, after we have implemented a sustained renal vein drainage using a cardiopulmonary bypass, the postoperative renal function passed satisfactory.

ConclusionsComplete surgical excision of renal cell carcinoma with IVC tumor progression was achieved successfully. Selective renal vein drainage was considered to be useful for intraoperative renal protection.

02-05Paper No: 097The usefulness of stent insertion of central venous stenosis of incomplete balloon dilation in hemodialysis patients

HJ Shim1, DE Goo2, YJ Kim2

1Department of Radiology, Chung-Ang University Hospital, Seoul, Korea2Soonchunhyang University Hospital, Seoul, Korea

ObjectiveTo analysis the effectiveness of percutaneous stent insertion of central venous obstructions/stenoses of

incomplete balloon dilation in patients undergoing hemodialysis.

Materials and methodsWe performed 1,016 central venous interventional procedures in 891 patients during recent 10 years period. 425 subclavian (occlusion:97, stenosis:328) and 591 innominate (occlusion:156, stenosis:435) venous stricture were included in this study. Preferentially balloon dilation was performed and stent was inserted at stricture site if venous lumen was incomplete dilated with balloon.

Technical success, procedure related complications and long-term patency were calculated. Also, we studied the statistic difference between the location of stricture, occlusion or stenosis, the existence of DM and the history of central catheter.

ResultsStents were implanted in 294 patients in 1,016 procedures. All but one of the procedures was technically successful (99.7%). The one patient with an unsuccessful procedure was due to incomplete stent expansion. Overall, major complications occurred in 2 stent migration. The 6- and 12-month primary patency rate were 43.8% and 17.7%, respectively, and mean patency rate was 7.9 months. Repeat intervention, including balloon angioplasty and additional stent placement, were required in 172 patients (average; 2.54). There was no statistic difference except the history of central catheter (p=0.0128).

ConclusionPercutaneous central venous stent insertion of incomplete balloon dilation in hemodialysis patients is safe and effective to maintain the hemodialysis function. But, repeated interventions are usually required to prolong stent patency.

Vascular Trauma

03-01Paper No: 066Delayed carotid stenting for traumatic intracerebral infarction due to carotid artery dissection

Jihoon Kim, Minjeng Cho, Hojong ParkDepartment of Surgery, Ulsan University Hospital, Ulsan, Korea

A 55-year-old woman presented to the emergency department subsequent to a high-velocity single vehicle

88

Oral Presentation

road traffic accident with a fracture of right forearm and humerus, right femur, tibia, fibular and right ribs. There was no history of loss of consciousness. Her Glasgow Coma Scale on presentation was 13 and quickly improved to 15. Her vital sign was stable except relatively high heart rate. An initial CT brain was normal. After 2 hours later, she developed rapidly progressive weakness to all four limbs and loosing breath. Emergent intubation was performed to keep air way. An emergent CT brain and Diffusion MRI brain revealed extensive areas of cerebral infarction. Based on the preceding history of trauma, an urgent cerebral and carotid CT angiography was carried out which showed right internal carotid thrombosis and dissection.

She was drowsy, however responding to verbal stimuli. Brain CT scan was repeated after 2 days and it showed no progression of infarction. We decided to insert stent for recanalization of internal carotid artery because location of lesion was relatively high level of internal carotid artery to approach surgically.

7mm-30mm nitinol self-expandable stents were deployed in the true arterial lumen. Insufficient vessel lumen dilation by stent was achieved additional angioplasty was carried out with an 7mm-30mm balloon. Directly after the procedures, control angiography was performed to assess the procedures’ efficacy. Flow was improved. No adverse events during angioplasty were observed. After 1 week, ventilator support was stopped. After 3 weeks, GCS was 15. Her dysarthria had improved significantly; and the power on his left side improved to be 3/5. She is on an antiplatelet agent.

In our opinion, Implantation of self-expandable stents in treatment of selected ICAD patients is safe. This method may also enable us to restore immediately and usually permanently proper arterial blood flow in the ICA and in consequence can expect to significant clinical improvement.

03-02Paper No: 230Endovascular salvage for iatrogenic arterial injury from image guide procedures

Lam Jeffrey Chun Yin, Tsang Yi Po, Pang Skyi Yin Chun, Tang Chung NgaiDepartment of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong

BackgroundIatrogenic arterial injury has become an important cause of arterial trauma. The increasing number of

percutaneous procedure could be one of the postulated reasons. Image guide procedure, most common by ultrasound, aims to increase the success rate but complications might still arise especially in difficult situations. MethodWe report two cases of iatrogenic arterial injury in our institution to illustrate the importance of endovascular salvage. ResultThe 1st case is an iatrogenic arterial injury during double lumen catheter insertion for a 34 year-old intravenous drug abuser. Arterial injury was noticed while the insertion of the Fr10 dilator but the physician had withdrawn the dilator before notify vascular surgeon. CT scan was performed promptly reveal contrast extravasation the junction of right subclavian artery and internal mammary artery. Patient was transferred directly to the intervention suite after CT scan. Coil embolization of right internal mammary artery and a covered stent placement at subclavian artery was performed via right brachial approach. Completion angiogram showed good radiological result and patient was stabilized subsequently. Our 2nd case is an iatrogenic aortic injury during ultrasound guided pleural tapping in a 94 year-old lady with lung cancer. Arterial blood spurting was observed while insertion of a Fr 6 dilator. A double pigtail plastic stent in then introduced and spigot before notify vascular surgeon. CT scan revealed the injury at the distal descending thoracic aorta. Patient was then transferred to intervention suit with the endovascular procedure performed under local anaesthesia. A 32x70mm Endurant II tube stent-graft was introduced and deployed at the site of injury whereas the pigtail stent was removed simultaneously. No leaking detected on completion angiography and patient was stabilized afterwards. ConclusionIatrogenic arterial injury sporadically occurs even extra-precaution is made. Timely management with endovascular salvage might save the patients from this major complication with lower morbidity.

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03-03Paper No: 320Blunt thoracic aortic injury: New paradigms and prognostic factors

Seiichi Yamaguchi, Hisanori Fujita, Tomoyoshi Kanda, Shigeyasu TakeuchiDepartment of Cardiovascular Surgery, Chiba Emergency Medical Center, Chiba, CHIBA, Japan

BackgroundBlunt thoracic aortic injury (BTAI) is known to be the second leading cause of death in blunt trauma, following head injury. The majority of BTAI occur at the isthmus of the descending thoracic aorta, in which BTAI has potential endovascular options for repair. We report on the experience of endovascular treatment for recent BTAI in our hospital with some literature review.

MethodThirty-two cases were diagnosed as BTAI with CT scan during the 38 months from January 2014 to February 2017. Among them 13 cases of out-of-hospital cardiopulmonary arrest (OHCA) died without ROSC, and there were 19 cases of non-OHCA. As a parameter of general condition at hospitalization in 19 non-OHCA cases, systolic blood pressure (sBP, mmHg), heart rate (HR, bpm), shock index (SI, HR/sBP), hemoglobin (g/dl), D-dimer (µg/ml), fibrinogen (mg/dl) were selected. They were divided into three groups; 8 cases who died in several hours before completion of aortic repair (group D), 5 cases in whom TEVAR were completed (group T) and 6 conservative therapy cases (group C). All aortic repair surgery were TEVAR.

ResultsIn 19 cases of non-OHCA BTAI, 16 were males (84.2%), and the average age was 58 years (16 - 89 years). All cases were transported to our hospital in the acute phase after injury. The leading cause of injuries was a traffic accident (3/19, 84.2%) and the second was a fall (3/19, 15.8%). The aortic injury site was the aortic isthmus in 18 cases (94.7%) and the ascending aorta in 3 cases (15.8%). All patients in group T and group C were discharged uneventfully. The t-test was used to compare outcomes between groups. There was no significant difference between group D and T in the comparison of the parameters. In group D or T, sBP was significantly lower (D, T, C; 82±48, 101±18, 127±13; P”¹0.05) and D-dimer value was higher (129±79, 89±42, 27±26; P”¹0.05) in comparison with group C. These two parameters were considered to be potential prognostic factors for BTAI.

ConclusionsIt is considered that expeditious TEVAR will greatly benefit BTAI patients with multiple injuries. On consideration of image findings, we should prepare for TEVAR as the pri¬mary treatment in BTAI patients with hypotension or elevated D-dimer value on admission.


04-01Paper No: 038Current evidence on management of aortic stent-graft infection: A systematic review and meta-analysis

Hai-Lei Li1, Yiu-Che Chan2, Stephen W Cheng2

1Division of Vascular Surgery, Department of Surgery, University of Hong Kong Shenzhen hospital, Shenzhen, Guangdong, China2Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong

ObjectiveAortic stent-graft infection is rare, but remains one of the most challenging and threatening complications. This systematic review aimed to identify the clinical features, treatment and outcomes of endograft infection after abdominal endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR).

MethodsA systematic literature review of all published literature from January 1991 to September 2016 on stent-graft infection was performed under the instruction of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Aorta, aneurysm, endovascular, stent-graft, endograft and infection were the keywords used in our comprehensive search in PubMed and MEDLINE databases. Data analysis was performed using SPSS V 22.0.

ResultsA total of 185 potential relevant articles were identified but only 11 studies with 402 patients met the inclusion criteria. Majority of the patients were male (308/402, 77%), with a mean age ranging from 65 to 73 years old. Most of the endografts were implanted for EVAR (351/402, 87%), while the other 51 (13%) endografts were infected following TEVAR. Among the 402 patients, 39 (9.7%) patients presented with aortic rupture. Ninety-two out of 380 (24.2%) patients with available data had aortoenteric fistula. Sixty-nine patients (17%) died in hospital or within 30 days after

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operation. One hundred and fourteen patients (28%) died during follow-up. The most commonly used stent grafts were Zenith (Cook Inc, Bloomington, IN) (22%) and Excluder (W.L. Gore, Flagstaff, AZ) (20%). Out of the 402 patients in this series, 108 patients (27%) had negative culture, and multiple microorganisms were identified in 103 patients (26%). The most frequently isolated microorganisms were Staphylcoccus species (30.1%), Streptococcus (14.8%), and Fungus (9.2%). Forty-two patients (42/401, 10%) received conservative treatment, whereas 359 (90%) patients underwent surgical treatment, including stent graft removal with in situ reconstruction or extra-anatomical bypass, and secondary endovascular procedure. Patients in the surgical group had a higher survival rate compared with conservative group (58% vs 33%, P=0.002). The survival rate was higher in the patients with infected EVAR than TEVAR (58% vs 27%, P=0.000). Patient with aortoenteric fistula had a worse prognosis (survival rate 72% vs 33%, P=0.002).

ConclusionCurrent evidence suggests that surgical treatment is a better option compared with conservative management in selected patients with aortic endograft infection. The outcome was worse in patients with infected TEVAR and aortoenteric fistula.

04-02Paper No: 077Early sac shrinkage as a predictor of low risk of complications after endovascular aneurysm repair in Japanese patients

Naoki Fujimura1,7, Kentaro Matsubara1, Mitsuyoshi Takahara2, Hirohisa Harada3, Atsunori Asami4, Shintaro Shibutani5, Susumu Watada6, Hideaki Obara1, Yuko Kitagawa1

1Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan2Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan3Department of Surgery, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba, Japan4Department of Surgery, Saitama City Hospital, Saitama, Saitama, Japan5Department of Vascular Surgery, Saisekai Yokohamashi Tobu Hospital, Kawasaki, Kanagawa, Japan6Department of Surgery, Kawasaki Municipal Hospital, Kawasaki, Kanagawa, Japan7Division of Vascular Surgery, Saiseikai Central Hospital, Minato, Tokyo, Japan

ObjectiveThe applicability of early sac shrinkage as a predictor of a low risk of late complications after endovascular

aneurysm repair in Asian populations has not been validated. This study aimed to analyze early sac shrinkage and its relationship with late complications in Asian people, using a Japanese multicenter database. We also assessed the impact of endoleaks.

MethodsA retrospective analysis of 697 patients who had undergone endovascular aneurysm repair of abdominal aortic aneurysms from 2008 to 2014 and were followed-up for at least 1 year was conducted. Late complications were defined as any aneurysm-related events occurring more than 1 year after endovascular aneurysm repair, including >5-mm aneurysm sac enlargements and any reinterventions performed.

ResultsEarly sac shrinkage, defined as a >5-mm diameter decrease within 1 year of endovascular aneurysm repair, occurred in 335 patients (48.1%); type 1 and isolated type 2 endoleaks were observed in 4.0% and 29.4%, respectively. During the mean follow-up period of 45.5 months, 93 late complications (13.3%) occurred. Kaplan-Meier curve and log-rank analyses showed that early sac shrinkage was a significant predictor for a lower risk of late complications (P<.001). Multivariate Cox regression analysis revealed that early sac shrinkage was independently associated with a lower risk of late complications (adjusted hazard ratio 0.421; P=.002). Conversely, type 1 and isolated type 2 endoleaks were positively associated with late complication (adjusted hazard ratio 5.702 and 4.487, respectively; both P<.001). Subsequent multivariate logistic regression analysis demonstrated that type 1 and isolated type 2 endoleaks were negatively associated with early sac shrinkage (adjusted odds ratio 0.112 and 0.271, respectively; both P<.001).

ConclusionsEarly sac shrinkage was associated with a low risk of late complications in Asian people, and may be a good surrogate marker of durable success after endovascular aneurysm repair. Type 1 and isolated type 2 endoleaks were negatively associated with early sac shrinkage and positively with late complications. Given the high incidence of isolated type 2 endoleaks, we recommend isolated type 2 endoleaks to be recognized as a serious condition after endovascular aneurysm repair in Asian people.

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04-03Paper No: 181Surgical outcomes of total arch replacement with frozen elephant trunk using Japanese newly commercially device (J-Graft Frozenix®) for type A acute aortic dissection

Takayuki Kadohama, Hiroshi Yamamoto, Genbu Yamaura, Yoshifumi Chida, Fuminobu Tanaka, Daichi Takagi, Kentaro Kiryu, Yoshinori ItagakiDepartment of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan

BackgroundThe first report of total arch replacement with frozen elephant trunk technique (TAR-FET) for type A acute aortic dissection (TAAD) was published by Kato et al in 2002 from Japan. Since 2014, newly commercially device, J-Graft Frozenix®, has been available in Japan and TAR-FET has increased in number of cases. We present our technique and postoperative results in patients receiving TAR-FET with J-Graft Frozenix®.

MethodsBetween October 2014 and March 2017, 70 patients (37 women, 33 men; mean age, 67 +/- 13 years; range, 30-88 years) with TAAD underwent TAR-FET (J-graft Frozenix®) under hypothermic cardiopulmonary bypass (rectal temp: 25°C) and selective cerebral perfusion. The graft size was decided according to the preoperative CT findings or intraoperative sizing using a ball-shaped sizer (90-100% diameter of the descending thoracic aorta). We confirmed the position of the FET with real-time TEE guidance. The distal end of the FET graft was positioned up to above the aortic valve level to avoid spinal cord injury.

ResultsThirty-day mortality was 4.3% (3/70 patients), and in-hospital mortality was 8.6% (6/70 patients). Cerebral infarction occurred in 5 patients, visceral ischemia occurred in 3 patients and stent-graft migration occurred in one patient. No spinal cord injury was observed. During a mean follow-up of 17 +/- 9 months, 4 patients (5.7%) required additional thoracic endovascular aortic repair (in-hospital 3, late period 1) for aneurysmal dilatation or true lumen collapse of the residual descending aorta. One patient died due to deep sternal infection at 15 months after the initial operation.

ConclusionsTAR-FET using J-Graft Frozenix® seems to be less invasive than conventional total arch replacement, as evidenced by our results demonstrating a relatively lower mortality rate in 70 patients with TAAD. This technique

has some advantages for additional aortic procedures to the residual false lumen and its progressive aortic dilatation during the long-term period although further investigation is required.

04-04Paper No: 185Clinical outcomes of ruptured abdominal aortic aneurysm (AAA) in single institution

Sang Seob Yun, Cheng Quan, Young Hwa Kim, Gyeong Jae Koh, Jin Go, Mi Hyeong Kim, Kang Woong Jun, Jeong Kye Hwang, Sang Dong Kim, Jang Yong Kim, Sun Cheol Park, Ji Il Kim, Yong Sung Won, In Sung MoonDepartment of Surgery, Catholic University of Korea, Seoul, Korea

BackgroundThe treatment of ruptured abdominal aortic aneurysm is still challenging even in endovascular era. Authors report clinical outcomes of ruptured AAA repair in single institution.

MethodsThis is a retrospective study of patients who admitted with ruptured AAA in Seoul St. Mary’s hospital from 2012 to 2017. Patients’ clinical characteristics were evaluated with EMR and PACS including pre/post-operative outcomes including survival rate, morbidity or acute compartment syndrome rate.

ResultsTwenty four patients were enrolled. 2 patients arrived as death on arrival. 22 patients underwent emergent treatments (11 for open surgical repair, 11 for EVAR including 2 hybrid treatment). Sex ratio was M:F = 17:7 and mean age was 72.5 years old [range; 31-88]. In preoperative period, mean blood pressure was 104/62 mmHg [range; asystole - 150/110 mmHg] and cardiopulmonary resuscitation was done in 9 patients. The mean time form ER to OR was 93 minutes. The reason for OSR was surgeon’s preference (3), lack of devices (0), and poor anatomy for EVAR (8). The reason for EVAR was optimal anatomy for EVAR (3), poor general condition (3) and reasonable anatomy for EVAR (5). Intraoperative period, aortic occlusion balloon was used in 13 patients. There were devices employed by tube grafts in 5 patients for OSR and bifurcated devices in 7 patients for EVAR. Embolization or surgical ligation was done in 4 patients. There were 2 intraoperative deaths in 23 patients who underwent any type of operation. A patient was done Hartmann’s operation due to abdominal compartment syndrome which was found 2 patients during study period. During in hospital treatment, there were 7 patients who

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done with hemodialysis, 4 patients who treated about pneumonia, respectively. In hospital 30-days mortality after emergent treatments were 36.4% (=8/22), in OSR was 54.5% (=6/11). EVAR = 18.2% (=2/11).

Conclusion30-days mortality rate after treatment in ruptured AAA is 36.4% and still relatively high. Endovascular treatment for ruptured AAA can be considered alternative treatment if indicated.

04-05Paper No: 186Management of endoleak after Endovascular Aneurysm Repair(EVAR) in single institution

In Sung Moon, Cheng Quan, Young Hwa Kim, Gyeong Jae Koh, Jin Go, Mi Hyeong Kim, Kang Woong Jun, Jeong Kye Hwang, Sang Dong Kim, Jang Yong Kim, Sun Cheol Park, Ji Il Kim, Yong Sung Won, Sang Seob YunDepartment of Surgery, Catholic University of Korea, Seoul, Korea

BackgroundEndovascular Aneurysm Repair(EVAR) is well accepted treatment modality for abdominal aortoiliac artery aneurysm(AAA). Endoleak is one of frequent complication, which needs medical attention depending on type of endoleak. Authors tried to evaluate management of endoleak in single institution.

MethodsThis is a retrospective study from prospectively registered data base for the patients, who underwent EVAR from 2012 to 2016 in Seoul ST. Mary’s hospital in vascular and transplant surgery. Patient’s clinical characteristics were evaluated with EMR and PACS.

ResultsOne hundred and thirteen patients were treated for AAA. EVAR or Hybrid treatment were done in 90 patients. Endoleak was detected during procedure in 12.2%(11/90)(Type Ia(3), Type II(4), Type III(4)). New endoleak was detected in 3.3%(3/90)(Type Ia(1), Type Ib(1), Type V(1)). Additional chimney stentgraft for renal artery and proximal aortic extension was done for persistent type Ia endoleak though two type Ia endoleaks disappeared spontaneously. Type Ib endoleak was managed by embolization of internal iliac artery and iliac limb extension deployment. 4 patients with type II endoleak were followed up without sac size change though sac size increased by 1cm in one patient. One patient suffered from limb occlusion and acute limb ischemia after type V endoleak. There were 2 type III

endoleaks in EVARs with sandwich techniques, in which one type III endoleak disappeared whereas the other is under observation. Survival of group with endoleak in any period was not significantly different from group without endoleak when treated properly.

ConclusionUnfavorable aneurysm morphologic characteristics and endograft implantation not in compliance with IFU guidelines did not adversely affect patient occurrence of endoleak and change of sac size after EVAR in this group of patients. This implies that unfavorable anatomy, even that which would necessitate implantation of the EVAR device outside of the IFU guidelines, should not necessarily contraindicate EVAR. It may be more important that an EVAR can be performed with technical success than the specifics of the anatomy or the limitations of the device IFU.

04-06Paper No: 334Graft infection after endovascular aortic repair

Takashi Hashimoto, Noriyuki Kato, Takafumi Ouchi, Ken Nakajima, Takatoshi Higashigawa, Shuji ChinoDepartment of Radiology, Mie University Hospital, Tsu, Mie, Japan

BackgroundGraft infection after endovascular aortic repair (EVAR) is rare, but one of the serious adverse events.

MethodsSince 1997 through 2016, 1302 patients underwent EVAR in our hospitals. Their medical records were retrospectively surveyed.

ResultsStent-graft infection was clinically diagnosed in twelve patients. There were 10 men and 2 women. The mean age was 68 ± 12 years. The mean interval between EVAR and the diagnosis of stent-graft infection was 23 ± 26 months. The original pathologies were thoracic aortic aneurysm in 3 patients, aortic dissection in 2, and abdominal aortic aneurysm in 7. A custom-made device was used in 2 patients, Talent in 2, TAG in 2, Najuta in 1, Zenith in 2, Excluder in 1, Powerlink in 1, and Endurant in 1. Bacterial culture was positive in 7 of 12 patients. It identified Staphyrococcus aureus, MRSA, Bacteroides fragilis, Escherichia coli, Pseudomonas aeruginosa, Clostridium perfringens, and Roseomonas species in the respective patients. One patient died of aneurysmal rupture just after the diagnosis of infection. Four patients underwent open surgery. Two of them

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died of bleeding immediately after the surgery, and one died of sepsis 5 months later. Only one patient (25%), who underwent graft replacement and omentum packing after extracting stent-graft, survived. Five patients underwent conservative treatment with the use of antibiotics. Four of them died of sepsis. Only one patient (20%) survived and are being followed-up with permanent oral administration of antibiotics. Two patients underwent a less invasive intervention than open surgery. Both of them underwent percutaneous drainage of the infected aneurysmal sac, and one of them underwent additional TEVAR before the drainage. Both patients are alive during follow-up term of more than one year.

ConclusionsStent-graft infection was a grave adverse event, which is resistant to surgical or medical treatment alone. Drainage of the infected aneurysmal sac may be a promising concomitant measures to improve the prognosis.


05-01Paper No: 142Long-term outcomes of stent placement for may thunner syndrome

Shinho Hong1, Keun-Myoung Park1, Yong Sun Jeon2, Soon Gu Cho2, Kee Chun Hong1

1Department of Surgery, College of Medicine, Inha University, Incehon, Korea2Department of Radiology, College of Medicine, Inha University, Incehon, Korea

PurposeWe assess the clinical results of stent placement after treatment of deep vein thrombosis (DVT) in patients who previously underwent venous stenting for May-Thurner syndrome (MTS).

MethodsWe reviewed the data of 128patients with DVT caused by MTS who were treated with stent placement from January 2005 to May 2016. We evaluated to patency of iliac vein stent, venous clinical Severe score (VCSS) after contralateral occlusion during follow up.

ResultsAmong 128 iliac vein stentings, male patients were 26 and mean age is 54.3 (Range : 19-85). During follow-up (mean 46 months, Range 1-133), 5 year patency rate of iliac vein stent is about 80%. There were 21 ipsilateral stent occlusions and 10 contralateral occlusions. There

were 12 post-thrombotic syndromes over VCSS 5. Factors of ipsilateral and contralateral occlusion of iliac vein after stent are coagulopathy (CI: 1.254-5.535, p<0.001) and stent deployment into IVC (CI: 1.325-7.324, P<0.001).

ConclusionsIliac vein stenting in MTS shows good long-term result. But, accurate deployment of iliac vein stent during procedure and regular follow-up in patients with coagulopathy are necessary.

05-02Paper No: 479Validation of the caprini risk assessment model for venous thromboembolism in chinese hospitalized patients in a general hospital

Xiaoyun Luo, Fuxian ZhangDepartment of Vascular Surgery, Capital medical University, Beijing, China

BackgroundThis study was conducted in the largest Chinese series of hospitalized patients to assess the validity of Caprini risk assessment model in prediction of venous thromboembolism in a general hospital.

MethodsMedical record review was performed in Beijing Shijitan Hosital for all eligible hospitalized patients who underwent screening for venous thromboembolism. The Caprini score in patients with or without venous thromboemboilism and incidence of venous thromboembolism in patients with different Caprini risk levels was compared.

ResultsA total of 6966 patients were identified. Three hundred and ninety six patients developed venous thromboembolism. The median Caprini score of patients with venous thromboemboilism was 5(2-7) higher than 3(2-5) of patients without venous thromboembolism (Z=-13.68, P60 years old), there was significantly different incidences of deep venous thrombosis between patients with score greater and less than 6. The incidence of venous thromboembolism was no different between medicine and surgery department in the same low (χ2=3.58, P=0.058), moderate (χ2=2.89, P=0.09), high (χ2=0.46, P=0.49), highest (χ2=1.61, P=0.20) risk level.

ConclusionsCaprini risk assessment model can effectively predict the incidence of venous thromboembolism in Chinese

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hospitalized patients in a general hospital with high risk (Caprini score>2) of VTE. But more accurate stratification in patients with highest risk level should be defined

05-03Paper No: 021Mid-and-long term results of subfascial endoscopic perforator surgery in Japan

Hitoshi Kusagawa1, Naoki Haruta2, Ryo Shinhara3, Yuji Hoshino4, Atsushi Tabuchi5, Hiromitsu Sugawara6

1Matsusaka Ohta Clinic, Matsusaka, Mie, Japan2Takanobashi Central Hospital, Hiroshima, Japan3Mitsubishi Mihara Hospital, Mihara, Japan4Fukuoka Sanno Hospital, Fukuoka, Japan5Kawasaki Medical School, Kurashiki, Japan6Sendai Hospital of East Japan Railway Company, Sendai, Japan

ObjectiveTo clarify the clinical results of subfascial endoscopic perforator surgery (SEPS) supported by Japanese national insurance after April 2014, which has been performed in the 21st century in Japan primarily with a new method using screw-type ports.

MethodsThis study included 1287 limbs of 1091 patients who underwent SEPS in 14 facilities. In these cases, clinical status in the CEAP classification, simultaneous saphenous vein surgery, and merger of the deep venous lesions were checked. In each limb, the venous clinical severity score (VCSS) was calculated before and 6 to 12 months after surgery. The ulcer healing rate and ulcer recurrence rate were calculated cumulatively. The clinical status of each limb was divided into 351 C6s, 72 C5s, 358 C4bs, 201 C4as, 40 C3s, and 265 C2s. Simultaneous saphenous vein treatment was performed in 1079 limbs (83.8%), and 118 limbs (9.2%) had deep venous lesions.

ResultsPreoperative VCSS was significantly decreased from 10.0±6.6 to 3.1±3.4 (P<.0001) postoperatively, it was similarly decreased from 17.4±5.3 to 5.5±4.1 (P<.0001) in C6 limbs and from 11.8±6.4 to 4.7±4.4 (P<.0001) in limbs without simultaneous saphenous vein ablation. The primary ulcer healing rate was 96.2% (332/345 C6 limbs), and the ulcer recurrence rate was 12.0% (49/393 C5, C6 limbs) at the average follow-up period of 46.0 months after the ulcer healed. Recurrent ulcers were followed up in 38 limbs, and secondary ulcer healing was obtained in 20 limbs (52.6%). In the remaining recurrent 18 limbs and 6 limbs whose ulcers did not show primary healing, problems included

residual venous lesions containing deep venous lesions and/or incompetent perforating veins, muscle weakness, autoimmune coagulopathy with arteriolar disease, trauma, and giant ulcers.

ConclusionThese results indicate that SEPS is an important new alternative within the Japanese medical system for treating incompetent perforating veins in patients with severe skin lesion.

05-04Paper No: 091Venous ultrasonography findings and clinical correlations in 104 Thai patients with chronic venous insufficiency of the legs

Burapa KanchanabatDepartment of Surgery, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand

IntroductionThe pattern of venous reflux in Thai patients with chronic venous insufficiency (CVI) was studied in correlation with clinical manifestations.

MethodsUltrasonography findings and clinical data were prospectively collected and retrospectively reviewed.

ResultsCVI was found in 104 legs of 79 patients (mean age 59.8 ± 12.5 years; C4: 24.1%, C5: 8.9%; C6: 67.1%). Among 104 legs, 6.7% had history of deep vein thrombosis (DVT). The prevalence of superficial vein reflux (SVR), deep vein reflux (DVR), and combined SVR and DVR in 90 legs without previous venous surgery was 82.2%, 63.3% and 57.8%, respectively. In legs with SVR, the prevalence of great saphenous vein reflux (GSVR), small saphenous vein reflux (SSVR), and combined GSVR and SSVR was 91.9%, 33.8% and 25.7 respectively. 77.0% of SVR involved the calf segment. For medial ulceration, 79.6% had GSVR and 35.2% had SSVR. For lateral ulceration, 46.7% had SSVR and 33.3% had isolated GSVR. The pulsatile venous signal was found in 3.3% of legs. In 17 legs with ulceration after previous surgical treatment, calf vein reflux (residual calf great saphenous vein or small saphenous vein) was found in 12 (70.6%) legs.

ConclusionCalf vein reflux plays an important role in CVI, including in patients with recurrent ulceration after previous superficial venous surgery. Although GSVR was present

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in most patients with CVI in legs, SSVR may present in one-third of patients, especially those with lateral ulceration. The high prevalence of DVR in the absence of DVT and the presence of pulsatile venous signal in some patients highlight the incomplete understanding of CVI aetiology.

05-05Paper No: 263Stump of the great saphenous vein after Radiofrequency Ablation

Takahiro ImaiDepartment of Vascular Surgery, Nishinokyo Hospital, Nara, Japan

BackgroundWe evaluated for occlusion rate of a great saphenous vein(GSV) and its stump by ultrasound scan after varicose veins treatment with Radiofrequency Ablation(RFA).

PurposeWhen the surgery is performed the catheter tip is usually advanced to 15mm from the sapheno-femoral junction (SFJ). However, there are cases when the blood flow is found in the tributaries near SFJ by ultrasound scan after surgery although GSV itself become occluded. The dissection of the tributaries near SFJ has some variations, but normally, there are five divergence. It can be presumed that we can reduce the recurrence rate if the 4 tributaries are occluded except the superficial epigastric vein which flows into the center. The purpose of this research is to reduce recurrence risk after surgery based on this evaluation results.

MethodsThe subject of this study is 300 treated cases (65.5 years / 90 males and 210 females) using Endovenous Closure from May to November 2015. In all cases, the catheter tip was positioned 15mm from the SFJ. On the next day of surgery ultrasound scan was performed for evaluation.

ResultsAfter RFA, the distance from SFJ to the occlusion was 13.8 mm on the average. The occlusion rate of main trunk of GSV was 100%. As for tributaries, the cases which the blood flow was found were regarded as positive. The cases which became occluded and which was not able to identify itself were regarded as negative. The average number of tributaries was 0.62 which the blood flow was found. The breakdown is as follows: 0:139cases/1:137cases /2:24cases /3:0cases /4:0cases.

DiscussionIt is considered that occlusion rate of tributaries is affected by the catheter tip position, shape of GSV around starting point for ablation and the positional relationships among tributaries. Therefore, the preoperative confirmation (evaluation) by ultrasound scan for SFJ is considered very important.

ConclusionHere we report evaluation results for occlusion rate of main trunk and tributaries of GSV using ultrasound scan after varicose veins treatment with RFA. In this research we explored relationship between the occlusion rate and recurrence of varicose veins.

05-06Paper No: 248Ultrasound guided foam sclerotherapy for management of varicose veins - A prospective observational study on efficacy and recurrence

Jason Toniolo1, Diana Munteanu1, Noel Ramdwar1, Nathaniel Chiang1, Huming Hao1, Jason Chuen1,2

1Department of Vascular Surgery, The Austin Hospital, Melbourne, Victoria, Australia2Department of Surgery, The University Of Melbourne, Melbourne, Victoria, Australia

BackgroundUltrasound guided foam sclerotherapy (UGFS) is a recognized treatment option for varicose veins (VV). Compared to surgery, there is a relative paucity of outcome reports. UGFS remains to be low-cost and minimally-invasive, even in repeat interventions. MethodsA prospective study of UGFS patients between 2010 and 2017 was completed at a tertiary public hospital. Treatment of the greater saphenous vein (GSV) or short saphenous vein (SSV) were included. Extent of VV were reported using the CEAP classification assessing clinical class, etiology, anatomical distribution and pathology. Pre-operative, intra-operative, 6-week and 1-year post-operative ultrasound reports were analyzed. Primary outcome was sonographic evidence of success stratified by thrombosed treated veins, and partial or complete recanalization or recurrence of reflux at one year. Secondary outcome were procedural complications.

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Results242 patients completed 397 treatments. 28% of the patients were male with a mean age of 58 years. Of the 397 interventions, 324 (82%) targeted GSV, 109 (28%) had CEAP of at least 4, and 83 (21%) was for recurrent VV. An average of 3mls (range 1-8) of 3% Aethoxyslerol was applied per procedure. At six weeks, complete success, partial success and treatment failure rates for GSV were 56%, 32% and 12% respectively. Of the 146 patients with complete success at six-weeks, partial and complete recanalization at one-year were 21% and 30%, respectively. For the SSV system, complete success, partial success and treatment failure at 6-weeks were 52%, 34% and 13%, respectively. Similarly, partial and complete recurrence at one-year were 32% and 44%, respectively. Complete obliteration of the recurrent veins at 6 weeks occurred in 37 treatments and 8 at 1 year. Seven received further sclerotherapy during the study period. 16 (4%) new onset DVTs and 4 (1%) venous malformations were detected on follow-up images. Injection-site related complications developed in 71 (18%) treatments with dermal staining and 17 (4%) injection-related ulcers. ConclusionMore than 50% achieved complete obliteration at 6 weeks. Significant sonographic recurrence developed at one-year. Their impact on clinical recurrence is not fully known. Further studies may interrogate correlations between recanalization and pre-operative vein size.

Travel Fellow Award

06-01Paper No: 396Comparison of vascular remodeling between the bioresorbable Poly-L-lactic acid scaffold and the metallic stent in porcine iliac artery

Keita Hayashi1, Hideaki Obara1, Kentaro Matsubara1, Yuki Kamiya1, Masanori Hayashi1, Yasuhito Sekimoto2, Yuko Kitagawa1

1Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo2Department of Surgery, Tokyo Medical Center, Meguro, Tokyo

BackgroundClinical outcome of endovascular therapy for peripheral arterial disease (PAD) were dramatically improved by Bare metal stents (BMSs) and Drug-eluting stents (DESs). However, stent fracture and in-stent restenosis remain major clinical limitations. Bioresorbable scaffolds (BRSs) have the potential to overcome several

problems associated with BMSs and DESs. Bioresorbable poly-L-lactic acid (PLLA) scaffold implantation for the treatment of PAD has already been reported in animal models and clinical trials; however, no studies comparing BRSs and BMSs with regard to vascular morphological changes, identified using intravascular ultrasound (IVUS) analysis, have been reported. The aim of this study is to assess the technical feasibility and biocompatibility of BRSs comparing with BMSs in porcine iliac arteries.

MethodsBRSs and BMSs were implanted bilaterally in iliac arteries of 3 miniature pigs. Digital subtraction angiography (DSA) and intravenous ultrasound (IVUS) were performed before and immediately after the stent placement and 6-week, 12-week, 24-week follow-up. In IVUS analysis, the percent area stenosis at minimum lumen area (%AS at MLA) and the percent volume obstruction (%VO) were calculated in each follow-up period. All stents were harvested at 24-week follow-up.

ResultsAll BRS and BMS placement succeeded safety. Only one BMS was occluded at 12-week follow-up, but other BMSs and BRSs were patent at 24-week follow-up. The maximum stenosis of BRS group showed at 6-week follow-up by DSA and the stenosis was gradually improved at 12-week and 24-week follow-up. Conversely, the stenosis of BMS group was worsened with time. In IVUS analysis, %AS at MLA did not significantly differ between BRS group and BMS group at 6-week follow-up. However, there was significantly difference between BRS group and BMS group at 12-week (35.6% vs. 85.3%, P=0.05) and 24-week (24.1% vs. 88.6%, P=0.004) follow-up.

ConclusionsVascular remodeling of BRSs in normal porcine iliac artery was good outcome compared with BMSs. In the future, further studies of atherosclerotic models are needed.

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06-02Paper No: 329Role of plasma levels of d-dimer and fibrin degradation products as predictors of endoleaks following endovascular abdominal aortic aneurysm repair

Masahiro Mizumoto, Tetsuro Uchida, Seigo Gomi, Azumi Hamasaki, Yoshinori Kuroda, Atsushi Yamashita, Jun Hayashi, Shuto Hirooka, Ai Takahashi, Kentaro Akabane, Mitsuaki SadahiroDivision of Cardiovascular Surgery, Department of Surgery II, Yamagata University Faculty of Medicine, Yamagata, Japan

ObjectiveAlthough an endoleak is the commonest complication following endovascular abdominal aortic aneurysm repair (EVAR), an effective noninvasive method for detection of endoleaks is not available. We investigated the role of plasma levels of d-dimer and fibrin degradation products (FDP) as predictors of endoleaks following EVAR.

MethodsBetween June 2011 and January 2014, 65 consecutive patients underwent EVAR at our hospital. We evaluated 55 patients, excluding 10 patients, viz., those with pre-existing aortic dissection, arterial or venous thrombosis, conversion to open surgery, and difficulties with outpatient visits. Enhanced computed tomography (CT) examination was performed over 12 months following EVAR. Persistent endoleaks and maximum aneurysmal diameter were evaluated at each follow-up. Based on CT findings 12 months after EVAR, patients were divided into groups as: endoleak 26 patients vs. non-endoleaks 29 patients, unchanged aneurysm 34 patients vs. aneurysmal shrinkage 21 patients. No patient showed aneurysmal enlargement. Plasma levels of d-dimer, and FDP were measured, and also platelet counts, prothrombin time (PT), and activated partial thromboplastin time (APTT).

ResultsNo operative death or major complications were reported. All patients demonstrated type II endoleaks, and none needed re-intervention. In the endoleak group, plasma levels of d-dimer and FDP were significantly higher than those in the non-endoleak group at each follow-up. Although postoperative platelet counts were significantly lower in the endoleak group, PT and APTT did not significantly differ between the groups. In the aneurysm unchanged group, postoperative d-dimer and FDPs were higher compared to the shrinkage group, but postoperative platelet counts were lower, and PT and APTT did not differ significantly.

ConclusionPlasma levels of d-dimer and FDP could be useful predictors of endoleaks after EVAR.

06-03Paper No: 298Early experiences with physician modified stent grafts for endovascular treatment of hostile abdominal aortic aneurysms

Hyung Sub Park1, Kyunglim Koo1, Daehwan Kim1, In Mok Jung2, Taeseung Lee1

1Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea2Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea

BackgroundPhysician modified stent grafts (PMSG) can be an alternative option for treatment of hostile abdominal aortic aneurysms (AAA) that are anatomically contraindicated for standard endovascular aneurysm repair (EVAR). In this study we analyzed our early experiences with use of PMSGs for treatment of complex AAAs with focus on the technical aspects related to PMSG creation and deployment.

MethodsFrom Jan 2016 to May 2017, a total of 8 EVARs were performed using PMSGs at a single institution. The indications for use of PMSGs were preservation of renal flow in 6 cases and preservation of pelvic circulation in 2 cases. Fenestrations and/or scallops were created on stent grafts by use of ophthalmic electrocautery and ringed golden markers from snares reinforced with polypropelene sutures. Branches were created in a similar way to commercially available iliac branched devices by using a PTFE graft anastomosed to the stent graft in a beveled fashion and placement of a radiopaque marker on the PTFE graft. Self-expanding covered stents were used to bridge the fenestrations and branches. Preoperative planning was performed using 3 dimensional reconstruction software programs.

ResultsThe mean age was 72.3 years and all patients were male. The mean number of fenestrations/scallops was 1.5. Four cases were performed for ruptured (or impending rupture) AAA and 2 cases were performed for mycotic aneurysms. There was 1 case of PMSG for treatment of type Ia endoleak, and the 2 cases of IBD were for treatment of iliac aneurysms. Technical success rate was 87.5% (7 out of 8 cases) with one failure occurring in a patient with ruptured AAA in which failed cannulation

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of one renal fenestration led to a type III endoleak, eventually requiring open repair. Otherwise there were no endoleaks requiring treatment and no early mortalities during the relatively short follow-up period.

ConclusionsPMSGs can be a good alternative for treatment of complex AAAs not amenable for standard EVAR in situations where commercial devices are not available or in emergent situations where the long manufacturing process cannot be awaited. Technical success rate was high, although the long-term durability of PMSGs is still to be determined.

06-04Paper No: 303Very elderly patients with ruptured abdominal aortic aneurysm are not good candidates for open repair

Takuro Shirasu, Takatoshi Furuya, Yukihiro Nomura, Nobutaka TanakaDepartment of Surgery, Asahi General Hospital, Chiba, Japan

BackgroundThere is discussion on the optimal treatment for ruptured abdominal aortic aneurysm (rAAA). This retrospective study was conducted to determine risk factors of hospital death following open surgery for rAAA, with special focus on very elderly (VE) patients (>=85years old).

MethodsA total of 124 consecutive patients who underwent open surgery for rAAA (excluding ruptured iliac artery aneurysms and Fitzgerald type 1) between 1993 and 2017 at Asahi General Hospital in Japan were included in the analysis. [Analysis 1] Preoperative background, operative procedures and outcomes were analyzed in relation to hospital death. [Analysis 2] Outcomes of VE patients were compared to the control group.

ResultsMean age was 75 ± 9 years old with 17 VE patients and 106 (85%) male. Preoperatively, 102 patients (82%) were in shock status, 55 patients (44%) lost consciousness, 21 patients (17%) were hemodynamically deteriorated. Mean aortic diameter was 77 ± 15 mm, and Fitzgerald classification were as follows; class 2, 8 patients (7%); class 3, 91 patients (76%); class 4, 21 patients (18%). Time to aortic clamp was 19 ± 18 minutes, operation time 171 ± 62 minutes with estimated blood loss of 2021 ± 1767 grams and intraoperative urine output was 400 ± 390 mL. Thirty two patients (26%) died in hospital. [Analysis 1]

Compared with survivors, deceased group patients were significantly older, hemodynamically deteriorated, lost more blood, and need more transfusion. Multivariate analysis revealed higher age, more transfusion and less urine output were significant risk factors of hospital death. [Analysis 1] Although VE patients group did not differ in preoperative status and operation factors including above-mentioned risk factors compared with the control group, mortality was significantly high in the VE group (59% vs. 21%, p=0.0008).

ConclusionsVery elder age was an independent risk factor for hospital death after open surgery for rAAA, with 60% mortality. There remains doubt in the tolerability of open repair for rAAA among VE patients.

06-05Paper No: 068Radiation exposure during infrarenal endovascular aortic aneurysm repair

Aadil Ahmed, Ayman Badawy, Arindam ChaudhuryVascular Surgical Department, Bedford Hospital NHS Trust, Bedford, United Kingdom

BackgroundEndovascular Aneurysm Repair (EVAR) of abdominal aortic aneurysms exposes patients and healthcare professions to the deterministic and stochastic effects of ionization radiation. The study aim was to determine our standard of radiation exposure in infrarenal EVARs and compare it against other published data and national guidelines.

MethodsA retrospective analysis of a prospectively collected database of patients undergoing EVARs was obtained. Radiation dose, fluoroscopy time, aneurysm size and patient characteristics were collected. Results are expressed as mean with 95% confidence interval.

ResultsThis study included 147 elective patients undergoing aorto bi-iliac EVAR with a mean age of 76 years from June 2013 until December 2016. The mean dose area product (DAP) was 5.91 (5.07-6.75) mGy.m2, cumulative air kerma (CAK) 248 (211-284) mGy & fluoroscopy time 32.5 (28.5-36.5) minutes. A greater BMI and a longer fluoroscopy time caused a significantly greater DAP to be administered to the patient. The device type, sex, AAA size, smoking status did not significantly effect the DAP administered to the patient.

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ConclusionRadiation exposure during endovascular aneurysm repairs is a significant hazard to both the patient and the theatre staff. Our study shows that a greater BMI & total fluoroscopy time can cause greater radiation exposure to patient. Anatomical & technical difficulties are also related to increased radiation exposure. Radiation exposure at our centre is below threshold levels suggested by Stecker et al before radiation induced skin injuries can manifest. Additionally, radiation exposure is comparable to other centres but can be reduced further by reducing our fluoroscopy time and adhering to the principles of ALARA (As low as reasonably achievable).

06-06Paper No: 051Comparison between freeze dried arterial allograft and fresh frozen arterial allograft as an alternatif conduit on vascular bypass operation: Experimental study on new zealand rabbit

Joalsen I1, Legowo J2, Prasmono A3

1Division of Thoracic,Cardiac and Vascular Surgery - Abdul Wahab Sjahranie General Hospital, Samarinda, Kalimantan Timur Indonesia2Veterinary Pathologist of Veterinary Medicine of Airlangga University, Surabaya-East Java, Indonesia3Department Thoracic,Cardiac and Vascular Surgery Dr.Soetomo Hospital- Airlangga University, Surabaya, East Java, Indonesia

BackgroundVascular Graft is an important material for vascular reconstruction procedure, caused by either trauma or vascular disease. Freeze-Dried Arterial Allograft can be used as one of alternatif conduit in some condition which autograft is not available or limited. Freeze-Dried Arterial Allograft offers many advantages compared to Fresh Frozen Arterial Allograft, eventhough there are still some controversies in its patency. Recently, there are not many research related to the implantation of Freeze Dried Arterial Allograft as an alternative conduit.

ObjectiveTo compare the risk of thrombus formation, neo-intimal hyperplasia, and local immune response between the implantation of Freeze-dried arterial allograft and Fresh Frozen arterial allograft on New Zealand (NZW) Rabbit’s carotid artery bypass procedure.

MethodsThis experimental study used New Zealand (NZW) Rabbits. Sixteen rabbits were divided randomly into 2 groups. Both groups underwent right carotid bypass

procedure. In first group, we implanted freeze-dried arterial allograft as a conduit, and we implanted fresh frozen one as conduit in the second group. Four weeks after implantation, we evaluated histopathologically the risk of thrombus formation, neo-intimal hyperplasia, and local immune response. The results were analyzed by using chi square test, T test statistic and Mann Whitney test.

ResultsThe histopathological results showed that there is no significant differences in the risk of thrombus formation (p=0.131) and neo-intimal hyperplasia (p=0.07) between freeze-dried arterial allograft and fresh frozen one. Ratio of neo-intimal hyperplasia in freeze-dried arterial allograft is 2.8-6.2 and fresh frozen one is 2.5-4.1. The local immune response in freeze-dried arterial allograft is lower than fresh-frozen one.

ConclusionThe implantation of freeze-dried arterial allograft as an alternative conduit on NZW rabbit’s carotid artery bypass operation showed that there is no significant differences in the risk of thrombus formation and neo-intimal hyperplasia, compared to fresh frozen one, altough freeze-dried arterial allograft had local immune response lower than fresh frozen.

KeywordArterial allograft, Freeze-dried, vascular reconstruction

06-07Paper No: 265Comparison of prosthetic femoro-popliteal bypass versus endovascular stenting for treatment of TASC II type C/D Lesions in superficial femoral artery disease: Single center

Sang Bong Lee1, Dong Hyun Kim1, Sang Su Lee1, Soon Cheon Lee2, Yung Baom Park3, Min Sang Song4

1Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea2Gwangyang Sarang Hospital, Gwangyang, Korea3Cheongmac Vascular and Vein Clinic, Busan, Korea4Dongrae Bongseng Hospital, Busan, Korea

IntroductionFemoral-popliteal surgical bypass and endovascular stenting are both accepted treatment for TASC II C/D superficial femoral artery (SFA) disease because of intensive development of endovascular technology. We evaluated mid-term outcome in terms of clinical data and patency between surgical bypass using prosthetic graft and endovascular stenting.

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Material and methodsWe evaluated 154 patients with TASC II Type C/D lesions in SFA disease who received surgically prosthetic femoro-popliteal bypass or endovascular stenting from January 2012 to December 2015. We compared primary, primary assisted, and secondary patency between two groups in TASC II C/D lesions. Descriptive analyses and categorical variables were performed using Two-tailed t-test and two-tailed Fisher exact test.

ResultsWe identified 83 surgical bypass (mean age 71.7±8.95 years; males, 81.9%) and 71 stenting (mean age, 70.4±10.00 years; males, 76.1%). The mean stenting length was 11.6 cm, and material for bypass was PTFE graft. The primary patency at 12, 24, and 36 months were bypass group 85%, 80.6%, and 75.2% vs stenting group 67.3%, 55.6%, and 37.5% (P).

ConclusionsThis is the study comparing prosthetic femoro-popliteal bypass and stenting in TASC II Type C/D lesions. Even though prosthetic femoro-popliteal bypass showed superior result for revascularization of TASC II Type C/D lesions, results of stenting showed feasible outcomes after re-intervention according to primary assisted patency and secondary patency. We suggest bypass is considered last method after failing SFA stenting.

06-08Paper No: 216Validating the use of contrast induced nephropathy prediction models in endovascular aortic aneursym repairs

Zhiwen Joseph Lo, Qiantai Hong, Evelyn Cheng, Sadhana Chandrasekar, Glenn Wei Leong TanVascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore

BackgroundExisting risk prediction models for contrast induced nephropathy (CIN) are based on studies for percutaneous coronary intervention, with none validated for use in vascular endovascular procedures.

AimsTo validate existing CIN prediction models in patients who underwent endovascular aortic repair (EVAR).

MethodsRetrospective review of patients who underwent EVAR between January 2008 and December 2015 at Tan Tock Seng Hospital, Singapore. Incidence of acute kidney

injuries (AKI) at 24-hours, 48-hours, 72-hours and at follow-up were evaluated. Validation of 8 existing CIN prediction models was performed with C-statistics.

ResultsThere were 216 EVARs performed within the study period. Mean age was 73 years and 162 (75%) were performed in an elective setting. Percentage of pre-operative chronic kidney disease (CKD) stages 1 to 5 were 16%, 42%, 31%, 6% and 5% respectively. Mean intra-procedure contrast volume used was 280ml. Incidence of AKI at 24-hours, 48-hours, 72-hours and at follow-up were 8%, 12%, 11% and 6% respectively. 3% of patients became dialysis dependent. Validation of 8 existing CIN predication models reveal area under curve (AUC) between 0.613 to 0.745, with z stastistic significance ranging from 0.026 to <0.001.

ConclusionAll 8 CIN prediction models were validated for use in patients undergoing EVAR and are useful in identifying patients at risk for CIN.

06-09Paper No: 115Surgical management of mangled extremity - Primary amputation vs limb salvage: A systematic review of the current scoring system

Eu Jhin Loh, David HardmanDepartment of Vascular Surgery, The Canberra Hospital, Garran, ACT, Australia

BackgroundIn recent times, a lot of new reconstructive techniques were developed for the treatment of mangled lower extremity. However failed attempt to limb salvage is related to high risk of mortality for the patient. Several scoring systems were developed to establish guidelines for the decision to amputate or salvage the limb. However, there was no consensus about the reliability of these scores in the literature.

MethodsWe focused our attention on the most used score system out there in clinical practice. The search terms used included mangled lower extremity, Mangled Extremity Severity Score (MESS), Predictive Salvage Index (PSI), Limb Salvage Index (LSI) and Nerve Injury, Ischaemia, Soft-Tissue Injury, Skeletal Injury, Shock and Age of Patient (NISSSA) scores. A systematic review of 5 electronic databases (Cochrane, PubMed, Ovid, Scopus, Google Scholar) was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-

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Analyses guidelines. We included studies published in English in the last 30 years, minimum cases in study of 15 and minimum follow up period of one year.

ResultsA total of 289 articles were identified but only 17 studies met our search criteria. The most used score system in the literature is the MESS. Few results were shown using the other severity scores. MESS seems to be the most accurate in predicting successful limb salvage compared to the other scoring systems. The literature was very poor of articles related to mangled lower extremity in children.

ConclusionThe mangled lower extremity treatment is a challenge for the surgeon. Many scores were developed to help the surgeon, however they cannot be used as the sole criterion by which amputation decision are made and, in case of successful limb salvage, they are not predictive of the functional recovery. Moreover, undue enthusiasm for new surgical techniques can lead to increased morbidity and mortality in case of secondary amputation.

06-10Paper No: 318Treatment of varicose veins: Comparison between conventional surgery and endovenous laser ablation in a developing country

Abul Hasan Muhammad Bashar, GM Mokbul Hossain, Naresh Chandra Mandal, Md Mynul Islam, Saffait JamilDepartment of Vascular Surgery, National Institute of Cardiovascular Diseases & Hospital (NICVD), Sher-E-Bangla Nagar, Dhaka

BackgroundVaricose vein is a common vascular problem in Bangladesh. Presentations range from C2-C6 according to CEAP classes with most patients presenting in advanced stages. Treatment of primary varicose veins has been traditionally by open surgical means. Endovenous Laser Ablation (EVLA) has been a new addition to the treatment option in the recent years. The present study was undertaken to analyze and compare the early outcome of the two treatment modalities.

MethodsBetween October 2013 and October 2015, a total of 215 limbs of 205 patients with primary varicose veins were treated by conventional surgical means. Technique included flush ligation at the Sapheno-femoral and/or Sapheno-Popliteal junction with stripping of the long

Saphenous vein, phlebectomy and/or sclerotherapy. One or more perforators were present in 55% of the patients which were subfascially ligated by Linton’s technique. Over the same period of time, a total of 297 limbs of 220 patients underwent EVLA for primary varicose veins along the long Saphenous vein using an energy delivery of 980 nm wavelength. Tumescence local anesthesia was used along the course of the long Saphenous vein. Foam sclerotherapy was used for varices but no specific technique was applied to address perforators.

Outcome was compared between the two groups against the following variables; Duration of procedure, Postoperative pain, thigh induration, skin changes, wound infection, hospital stay, procedural cost and recurrence within one year. ResultsHospital stay, duration and success of the two procedures were comparable. Lifestyle limiting pain persisting more than 7 days was seen in 11% of open surgery and 10% of EVLA patients. Major thigh hematoma/induration/bruising persisting more than 2 week was present in 5% of open surgery patients and 3% of EVLA (P= 0.2). Procedure cost was significantly higher with EVLA compared with open surgery (P). ConclusionsEVLA is a useful new addition to the existing treatment modality for primary varicose veins in Bangladesh. Immediate postoperative and early outcome of EVLA are comparable with open surgery. Procedure cost was generally higher with EVLA which is expected to come down with more widespread use of the technique. Major perforators not addressed during the index procedure may be a cause for concern in the long term after EVLA.

06-11Paper No: 162Lower extremity arterial injury pattern and revascularization outcomes at Hospital Kuala Lumpur Malaysia: A 5-year retrospective review

Fatin MN, Feona SJ, Zainal AAVascular Surgery Unit, Department of Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

BackgroundThis study aim to evaluate the short-term outcome of traumatic arterial injury of lower extremities, the variety of cofounding factors that influence limb salvage and follow up of patients that were ascertain at Hospital Kuala Lumpur in the year 2012-2017.

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Methods50 cases of vascular trauma involving lower extremity arterial injury requiring vascular surgery were retrospectively analysed from 2012-2017 at Hospital Kuala Lumpur, Malaysia. Extensive patient demographics, fracture associations, soft tissue injury, clinical detections of vascular injury, surgical interventions and postoperative follow up were systemically gathered.

ResultsMale patients suffered from traumatic lower limb arterial injury with 44 patients (88%), with mean age of 30.68. Mean ischaemic time is 14.95 hours. Road traffic accidents are the main cause of vascular injuries that were ascertained in HKL with 84%, followed by iatrogenic injuries (6%), industrial injuries (6%) and falls (4%). Associated injury involved femur fracture with 23 patients (46%), tibia and fibula fracture 17 patients (34%), and knee dislocation 17 patients (34%). 50 % of patients were detected by positive clinical findings, positive Doppler signal and positive imaging, whether it be CTA or Duplex scan. Most common vessels to be injured involve thrombosis of popliteal artery with 30 patients (60%) followed by transection of artery 14 patients (28%) and contusion of artery 4 patients (8%).

Types of revascularization surgery performed involved RSVG (74%), primary repair (16%), patch repair (2%), and primary amputation (8%). The outcome of 46 patients whom underwent revascularization surgery, 4 patients developed chronic kidney injury, meanwhile 3 patients have positive bacterial colonisation and another 3 patients undergoes delayed amputation. ConclusionsPatients who suffer vascular trauma should be transferred to vascular surgery centre as soon as possible. Decisive management of vascular trauma will maximize patient survival and limb salvage. Priorities must be established in the management of associated injuries, and delay must be avoided to prevent ischemic changes.

06-12Paper No: 412Comparative outcomes of vascular access in patients older than 70 years with end stage renal disease

Deokbi Hwang, Sujin Park, Hyung-Kee Kim, Seung HuhDivision of Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea

BackgroundIn view of the controversy about utility of Arteriovenous fistulas(AVFs) in older patients requiring hemodialysis(HD), we reviewed our vascular access(VA) experience in patients >70 years of age(EP) compared with non-elderly patients(NP).

MethodsWe analyzed consecutive patients with access operation between 2013-2016. All patients had ultrasound vessel mapping. Primary failure(PF) and primary patency(PP) data between EP and NP group before and after adjustment with propensity score matching(PSM) about patients’ characteristics and composition of VA. PF was defined as VA occlusion or maturation failure without occlusion, not amendable for 2 sessions of successful cannulation for HD regardless of salvage procedures and PP as the time with uninterrupted patency and without intervention.

ResultsAmong 562 patients, a total of 594 consecutive VA was created and 179 accesses in each group were allocated after PSM. In whole cohort, EP group consisted of 193(32.5%) accesses and AVFs were performed in 130(67.4%) of EP group and 293(73.1%) of NP group. Overall(14.8 vs. 6.5%, p=0.001) and AVF(16.4 vs. 5.7%, p=0.001) PF rates were higher in EP group compared with NP group. Overall PP at 6 and 12 months differed by group: 73.2% and 61.2% for EP group, 83.5% and 70.9% for NP group(p=0.023). Regarding AVFs, overall PP at 6 and 12 months also differed by group: 73.1% and 57.1% for EP group, 86.7% and 77.7% for NP group(p=0.009). There were no difference in PF and PP for AVGs between two groups. In terms of the location of AVFs, the PF(FA: 25% vs. UA: 7%, P=0.007) of FA-AVF was higher compared with UA-AVF and PP showed the similar results(UA: 86%, 71% at 6, 12 months and FA: 63%, 47%, P=0.007) in EP group. The results of PF(p=0.036) and PP(p=0.071) after PSM were similar to those of whole cohort.

ConclusionsThe outcomes in elderly patients receiving AVFs were inferior to those of non-elderly patients and the results of UA-AVF were superior to FA-AVF. The results of AVG were comparable to non-elderly patients’ and not inferior to AVF within elderly patients. Thus, in elderly patients without exceptional FA vasculature, AVGs following UA-AVFs could be considered by priority.

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07-01Paper No: 218Long-term survival and secondary procedures after open or endovascular repair of abdominal aortic aneurysms: Results from the DREAM-trial

Kak K Yeung, Theodorus G Van Schaik, Hence JM Verhagen, Jorg L de Bruin, Marc RHM Van Sambeek, Ron Balm, Clark J Zeebregts, Joost A Van Herwaarden, Jan D BlankensteijnDepartment of Vascular Surgery, VU Medical Center, Amsterdam, Noord-Holland, Netherlands

BackgroundRandomized trials have shown an initial survival benefit of endovascular over conventional open abdominal aortic aneurysm repair, but no long-term difference up to 6 years after repair. We performed a longer follow-up over twelve years to evaluate the cumulative impact on survival and reintervention rates after endovascular and open repair.

MethodsWe updated the results of the DREAM-trial, a multicentre, randomized controlled trial comparing open with endovascular aneurysm repair, up to 15 years of follow-up (mean 12). Survival and reinterventions were analyzed on an intention-to-treat-basis. Causes of death and secondary interventions were compared by use of an events-per-person-year analysis.

Results178 patients were randomized to open and 173 to endovascular repair. Twelve years after randomization, the cumulative overall survival rates were 42.2% for open and 38.5% for endovascular repair, for a difference of 3.7-percentage points (95% confidence interval [CI], -6.7 to 14.1; P=.48). The cumulative rates of freedom from reintervention were 78.9% for open repair and 62.2% for endovascular repair, for a difference of 16.7 percentage points; (95% confidence interval [CI], 5.8 to 27.6; P=.01). No differences were observed in causes of death. Cardiovascular and malignant disease account for the majority of deaths after prolonged follow-up.

ConclusionsOver twelve years of follow-up, there was no survival difference between patients who underwent open or endovascular abdominal aortic aneurysm repair, despite a continuously increasing number of reinterventions in the endovascular repair group. Endograft durability and the need for continued endograft surveillance remain key issues.

07-02Paper No: 373Computational fluid dynamics investigation of pulsatile flow patterns in the development of a type V thoracoabdominal aortic pseudoaneurysm

Ong Chi Wei1, Leo Hwa Liang1, Arthur Mark Richards2,3, Andrew MTL Choong4,5

1Department of Biomedical Engineering, National University of Singapore2Cardiovascular Research Institute, National University of Singapore3Department of Cardiology, National University Heart Centre, Singapore4Division of Vascular Surgery, National University Heart Centre, Singapore5Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore

BackgroundThoracoabdominal aortic aneurysms (TAAAs) arise as a result of dilation of the descending thoracic and abdominal aorta segment involving the visceral and renal arteries. It is believed that biomechanical factors such as recirculation and wall shear stress (WSS) play a role in the development of TAAAs. In this study, we investigated pre-aneurysmal aorta and post aneurysmal aorta and compare the differences regarding haemodynamics pattern to shed light on the formation of TAAA. MethodA patient-specific TAAA geometry was segmented and reconstructed into a 3D model using Materialise Mimics, segmentation software. We removed the TAAA from the aorta using reverse engineering to create a pre-aneurysmal aorta. Once both geometries were generated, we performed computational fluid dynamics studies in ANSYS FLUENT. The fluid model was assumed to be non-Newtonian fluid. The inlet boundary condition was formulated with a pulsatile flow waveform, with the superior branches were formulated with 5% of flow volume while the infrarenal arteries were formulated with 10% of thoracic flow volume. A pressure outlet waveform was prescribed at the common iliac artery outlets. ANSYS ICEM was used to mesh both geometries with tetrahedral elements. We ran the simulation for three cycles, only the last cycle results were presented in this paper.

ResultsOur results suggest that the disturbed flow regions at the TAAA may be related to the unique flow patterns in this pre-aneurysmal aorta. Relatively high time-averaged WSS at the region between the descending and infrarenal aortic segments infer the possible location of the future TAAA. This may indicate that the

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haemodynamics patterns observed can help to predict future aneurysmal formation.

ConclusionsIn this study, we have investigated the haemodynamic parameters of a pre-aneurysmal and post aneurysmal aorta of a patient who suffered from a type V thoracoabdominal pseudoaneursym. This computational study may assist in medical planning by providing clinicians more information on the biomechanical factors (such as velocity pattern and WSS) which are difficult to measure in vivo, and may in turn assist in predicting the development of aortic aneurysmal disease.


08-01Paper No: 086The angiosome concept evaluated by intraoperative fluorescence angiography after tibial bypass surgery

Werner Lang, Alexander Meyer, Susanne Regus, Ulrich RotherDepartment of Vascular Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg, Erlangen

BackgroundThe angiosome concept as a model for decision-making in revascularization of patients with critical limb ischemia (CLI) has fallen victim to a lively discussion in recent years. In this context, we focused on an evaluation of this concept on the level of microcirculation after tibial bypass surgery by using intraoperative fluorescence angiography.

MethodsProspective analysis of 40 patients presenting with CLI stage Rutherford IV to VI before and after tibial bypass surgery was performed. Macrocirculation was measured by the ankle-brachial index (ABI). In order to assess the skin microcirculation intraoperative fluorescence angiography was used (SPY Elite„¢, NOVADAQ, Canada). The alteration of microcirculation was compared in direct and indirect revascularized angiosomes by calculation of the fluorescence parameters Ingress (IN) and Ingress rate (InR). Clinical Follow-up investigations were performed and the wound healing rate was compared between the different revascularization methods.

ResultsTechnical success was achieved in all patients. An improvement of the macrocirculation could be

demonstrated postoperatively by a significant higher ABI (p).

ConclusionIntraoperative fluorescence angiography proved to be feasible for measuring therapy related changes of microcirculation postoperatively. However, the microcirculatory improvement was recognized over the whole foot after tibial bypass operation. Therefore, the concept of angiosome-directed revascularization could not be proven relevant with respect to the level of skin microcirculation.

08-02Paper No: 116The association of heart valve calcification (aortic and mitral valve calcification) with clinical outcomes in patients undergoing endovascular revascularization for peripheral arterial disease

Yoong Seok Park1, Ji Young Park2, Seung Kyu Han3, Byoung Geol Choi4, Seung-Woon Rha5, Se Yeon Choi4, Jae Kyeong Byun4, Hu Li4, Jun Hyuk Kang5, Eun Jin Park5, Sung Hun Park5, Jah Yeon Choi5, Sunki Lee5, Jin Oh Na5, Cheol Ung Choi5, Hong Euy Lim5, Jin Won Kim5, Eung Ju Kim5, Chang Gyu Park5, Hong Seog Seo5, Dong Joo Oh5

1Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea2Division of Cardiology, Eulji Hospital, Eulji University, Seoul, Korea3Department of Plastic Surgery, Korea University Guro Hospital, Seoul, Korea4Department of Medicine, Korea University Graduate School, Seoul, Korea5Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea

BackgroundThe aim of this study is to reveal the association between HVC and outcome in patients undergoing endovascular revascularization for PAD.

MethodA total 504 patients who had undergone PTA from September 2004 to December 2014 397 patients had heart valve calcification and 107 patients did not. The primary end points was amputation event.

ResultsHVC patients had a higher percentage of wound as initial diagnosis for PTA, hypertension, diabetes mellitus, atrial fibrillation, chronic renal insufficiency and lower rates of resting pain. PTA below the knee was more commonly performed in the HVC group. HVC group had higher rates of binary restenosis, total occlusion and lower rates of primary patency and primary assisted patency

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in the limb. HVC and non-HVC group had no significant differences in the rates of repeat PTA, amputation at 1 year.

ConclusionHVC effected binary restenosis in patients of PAD after revascularization but didn’t effect amputation and survival in patients of PAD.

08-03Paper No: 404Factors associated with long term patency of lower extremity arterial bypass for patients with chronic atherosclerotic arterial occlusive disease

Seon-Hee Heo, B-H Chung, D-H Lee, S-Y Woo, Y-J Park, D-I Kim, Young-Wook KimVascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

ObjectivesTo evaluate long-term patency and the factors associated with graft occlusion after lower extremity bypass (LEAB) for patients with atherosclerotic chronic arterial occlusive disease.

MethodsWe performed a retrospective analysis using the database of patients who underwent LEAB due to atherosclerotic, chronic arterial occlusive disease at a single institution during the past 13 years. To assess the graft patency, periodic examinations of duplex ultrasonography were routinely performed following LEABs. Graft patency was calculated using Kaplan-meier method and risk factors of graft occlusion were determined using cox proportional hazard model using demographic, clinical and anatomical features, coexisting morbidity or atherosclerotic risk factors, preoperative blood test results, postoperative anti-platelet or statin use and procedural details of the LEAB.

ResultsAmong 800 LEABs performed during the study period, 653 LEABs (CLI, 42%; vein graft, 61%; redo bypass, 4%; below the knee bypass, 50%; secondary procedure for failing graft, 7.5%) for 531patients (mean age, 68.5 years; range, 42-90 years; male, 88%; diabetes mellitus, 48%; CRF, 7%) were included for analysis. During the follow-up period (median 85.6, IQR, 39.5-103.5; mean±SD, 77.1±42.7 months, range 1-158), graft patency rate was 63.6%, 58.6% and 52.5% at 5 years, 7 years and 10 years after LEAB. On a Cox proportional hazard regression model, below the knee bypass (hazard ratio [HR], 2.3; confidence interval [CI], 1.5-3.5; Pversus above the knee

bypass), prosthetic graft (OR, 3.2; CI, 2.2-4.8; P<0.001 versus vein graft), no secondary procedure for the failing graft (OR, 2.9; CI, 1.2-6.7; P=0.013) and not taking statin (OR, 1.8; CI, 1.2-2.6, P=0.003).

ConclusionLong-term patency after LEABs was achieved in patients with above the knee bypass, vein graft, secondary procedure for failing graft and taking the statin medication.

08-04Paper No: 417Does aortomesenteric angle affect occurrence of spontaneous isolated superior mesenteric artery dissection?

Hyangkyoung Kim, Hanbyul Lee, Park Byung WookDepartment of Surgery, Chung-Ang University College of Medicine, Seoul, Korea

BackgroundReports about spontaneous isolated superior mesenteric artery (SMA) dissection (SISMAD) is increasing recently, and it is known to be prevalent in Asian continent. However, the etiology is unclear. The purpose of this study was to determine the relationship between anatomic difference of the degree of aortomesenteric angle (AMA) and the occurrence of SISMAD.

MethodsCase-control study was performed by comparing 45 SISMAD patients (PG), including symptomatic group and asymptomatic group, with the control group who underwent periodic health examination. We have selected equal number of Korean control group (KG) and foreign control group (FG) among 5,182 patients regarding the risk factors, such as gender, age, BMI, drinking, smoking, hypertension, diabetes and cancer using propensity score-matching method, and compared the AMA of each group.

ResultsThe matched cohorts’ characteristics were well-balanced. After matching, we analyzed the data from 135 subjects including 125 men and 10 women. The average age of the subjects was 50.61 ± 7.17 years (range, 33-71 years), and the average of AMA with normal SMA anatomy was 56.83 ± 19.50áµ’ (range, 10.2-91.9áµ’) in FG, and 62.37 ± 19.08áµ’ (range, 25.4-110.8áµ’) in KG (p=0.177). The average of AMA in PG was 74.94 ± 17.45áµ’ (range, 45.9-110.9áµ’). The group who were diagnosed with SISMAD showed blunter angle compared to FG and KG (p).

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Oral Presentation

ConclusionsWhen compared with people with normal SMA, larger degree of AMA was confirmed in SISMAD patients. However, there was no significant difference of AMA between races.

08-05Paper No: 399Near-infrared monitor is useful as a blood flow evaluation method at the time of revascularization

Taku Kokubo1, Yumi Sasajima2,Tadahiro Sasajima1

1Department of Vascular Disease, Vascular Surgery, Edogawa, Tokyo, Japan2Hokkaido University of Education, Asahikawa College, Asahikawa, Hokkaido, Japan

PurposeAlthough there are several noninvasive examination methods for evaluating the condition of blood flow on feet, near-infrared (NIR) monitors are known as a method that can be easily and continuously monitored over tome. In this study, the feet mixed blood tissue oxygen saturation (rSO2) before the revascularization of the lower extremity with chronic limb ischemia (CLI) was measured and the validity of the measured value was verified. In addition, the values of rSO2 on feet were presented during the bypass surgery continuously and the effectiveness as a blood flow evaluation method at the time of revascularization was also examined.

MethodsWe measured the rSO2 of the foot before surgery for cases in which ABI was less than 0.3 in CLI or 1.4 or more due to hyper-calcification of arteries. Furthermore, during bypass surgery, a sensor was attached to the plantar part of the foot, and the change in rSO2 in bypass surgery was recorded. To measure the value of healthy volunteers, we measured eight limbs without CLI. INVOSTM5100 C (Covidien) was used as the NIR monitor. [Results] The rSO2 value of health foot was 76.2% (74-80%). In 27 cases with CLI, the average of rSO2 value was 43% (15-74%). In addition, the average of the rSO2 value before bypass was 43.3% (15-80%) and the average of the rSO2 value after bypass was 70.6% (51-80%). The increase of rSO2 value after bypass surgery was observed in all cases.

ConclusionsThe rSO2 value reflects the degree of ischemia of foot, and there is a possibility that it can be used as a noninvasive examination method for evaluating the CLI conditions. This monitor was short in measurement

time and simple. In addition, it is a useful inspection method that can monitor continuously over time and can promptly evaluate the degree of improvement in foot blood flow. as an intraoperative monitor. However, it was considered that a sufficient analysis on rSo2 value such as measurement site and factors to be measured was necessary.

08-06Paper No: 454Angiosome-targeted isolated tibial angioplasty for healing of ischemic foot ulcer: A retrospective study

Mohamed Farag, Khaled El Alfy, Hosam Roshdy, Hesham SharafVascular Surgery Department, Mansoura University Hospital, Mansoura, Egypt

PurposeOn the basis of the angiosome concept in critical limb ischemia patients who presented with isolated tibial lesions and foot ulcers, we evaluated and compared clinical outcomes, ulcer healing, and amputation-free survival between patients with successful angiosome-targeted tibial angioplasty alone [direct revascularization (DR)], patients with indirect revascularization (IR) in whom the dilated vessels successfully were the non angiosome target, and those who underwent combined revascularization (CR) (both DR and IR were achieved).

Patients and MethodsWe retrospectively analyzed a total of 66 critical limb ischemia patients who presented with ischemic foot ulcer with isolated tibial vessel lesions at Mansura University Hospital during the period from January 2014 to January 2016. DR of the ischemic angiosome was performed in 37.8% (n=25), IR in 33.3% (n=22), and CR in 28.7% (n=19) of patients. All patients were evaluated for the status of wound healing and limb salvage at 1, 3, 6, 9, and 12 months. The study endpoints were major amputation or death, limb salvage, and ulcer epithelialization at 12 months.

ResultsThe mean follow-up was 11.08±3.2, ranging from 3 to 13 months. On Kaplan-Meier analysis, 65% of patients were diabetic. Ulcer healing rate at 12-month follow-up based on angiosome hypothesis among groups CR, DR, and IR was 94.7, 66.7, and 57.17%, respectively, with a significant P value (0.013) between CR and DR and a significant P value.

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ConclusionIf technically feasible, dilation of angiosome target artery plus any other significant tibial artery lesions should be considered. We should orient procedures toward multiple angiosome reopening with better ulcer healing rate and limb salvage. However, with limitations and challenges of angiosome-based strategies, especially in diabetic patients with depletion of choke vessels, we believe that IR should not be denied with acceptable result over the time.

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Poster Presentation

Acute Limb Ischaemia

P01-01Paper No: 058Penumbra Indigo„¢ aspiration thrombectomy versus catheter directed thrombolysis for treatment of acute limb ischaemia: A retrospective review of a single unit’s experience

Fleming Scott, Kwok Chi Ho Ricky, Chan Kenneth Kwok-Cheong, Tibballs Jonathan, Samuelson Shaun, Ferguson John, Nadkarni Sanjay, Hockley Joseph, Jansen ShirleyDepartment of Vascular Surgery, Peking Union Medecal College Hospital, Beijing, China

BackgroundAcute limb ischaemia is an emergent diagnosis requiring timely treatment for limb salvage. Open surgery and endovascular options each have potential significant complications. Percutaneous aspiration thrombectomy (PAT) uses endovascular suction to remove thrombus, restoring flow and avoiding thrombolysis with its potential complications. We review our unit’s experience with Penumbra Indigo„¢ PAT system for acute lower limb ischaemia, comparing outcomes and costs against catheter-directed thrombolysis (CDT). MethodsBetween January 2015 and January 2017, all patients presenting with acute lower limb ischaemia were treated with either Indigo„¢ PAT or primary CDT. Where treatment with Indigo„¢ PAT was unsuccessful or incomplete, adjunctive CDT was used. Endpoints included technical success, lower limb salvage, and 30-day complication rate. An estimate of average treatment costs for each group was calculated. Results11 patients were treated with Indigo„¢ PAT and 23 patients were treated with primary CDT. Technical and clinical success was achieved with Indigo„¢ PAT alone in 6 patients (55%), with the remaining 5 attaining restoration of flow and limb salvage after adjunctive CDT. One 30-day complication was recorded (groin haematoma in a patient who underwent adjunctive CDT). Technical and clinical success with primary CDT was 21 patients (91%); the other two patients had manual aspiration of residual thrombus with syringe and catheter. There were 6 clinically significant 30-day complications in this group, including 5 groin/retroperitoneal bleeds/haematomata, and 1 death from intracranial haemorrhage. No significant differences in procedural costs were found.

ConclusionAll PAT patients had flow restoration and limb salvage with less complications than CDT and less requirement for higher level care, further reducing cost. Our study supports a clinical and economic advantage in utilising Indigo„¢ PAT first in patients with acute lower limb ischaemia undergoing endovascular treatment. We believe it is able to reduce utilisation of CDT, and potentially allows faster restoration of flow and reduction of reperfusion-related complications.

P01-02Paper No: 308In acute limb ischaemia, late presentation is the major impedance: National institute of cardiovascular diseases, dhaka perspective

M M Islam, S JamilDepartment of Vascular Surgery, NICVD, Dhaka, Bangladesh

BackgroundOutcome of acute limb ischaemia depends on the timely intervention. In an ischaemic organ or tissue, following revascularization, a cascade of pathophysiological events often occurs known as Reperfusion Injury. Delayed repurfusion of an acute occlusive limb ischaemia causes local and systemic serious consequences and is the major cause of morbidity and mortality in these patients. Late presentation of acute limb ischaemia was defined as occlusion occurring 72 or more hours after initial menifestation of patient complaint related to the affected ischaemic extremity.

Materials & MethodA Retrospective study evaluated time of reporting and management in a consecutive series of 62 patients with ALI between July 2013 to July 2016 in National Institute of Cardiovascular Diseases, Dhaka. ALI was defined as symptoms within 2 weeks of presentation. Time of presentation, Grades of ischaemia, co-morbidities, morbidities and mortality were recorded.

ResultsDuring the study period, 62 patients were included, 35 male (56.45%) and 27 female (43.55%). Average age was 63 years ( 30 years-87 years). 4 patients (6.45%) reported within 6 hours of symptom, 10 patients (16.13%) within 24 hours, 20 patients (32.26%) within 72 hours and 28 patients (45.16%) after 72 hours. On admission, 30 patients had grade-III ischaemia, 22 had grade-IIb & 10 had grade-IIa. 10 patients (16.12%) died and 30 patients (45.16%) had amputation. The risk factors of amputation were grade of ischaemia, extremity (Lower limb 45% vs. Upper limb), age and co-morbidity.

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ConclusionLate presentation of acute occlusive ischaemia carries high morbidity and mortality. Lack of awareness and negligence of symptoms delay the reporting time to hospital.

P01-03Paper No: 340Endovascular treatment for rheumatoid arthritis induced acute aortic thrombosis

Saritphat Orrapin1, Tunyarat Wattanasatesiri2, Thoetphum Benyakorn1, Kanoklada Srikuea1, Boonying Siribumrungwong1

1Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand2Division of Interventional Radiology, Department of Radiology, Faculty of Medicine, Thammasat University, Pathumthani, Thailand

BackgroundRheumatoid arthritis (RA) is an inflammatory polyarthritis with extraarticular manifestation, including vascular involvement or rheumatoid vasculitis (RV)). Longstanding RA cause RV which occurs in 10% of RA population. Uncontrolled RA also promotes premature atherosclerotic disease. Aortitis with acute ischemia have been described, but is rare. Revascularization by open surgery is significant risk of perianastomotic leakage or thrombosis induced graft failure. Successful endovascular therapy in acute aortic occlusion with RA has not been reported. Methods46-year-old male with longstanding RA and a history of cerebrovascular accident underwent left below knee (BK) amputation due to acute osteomyelitis. Seven days after amputation, the patient presented sudden left leg and gluteal pain with non-fixed mottling and some area of necrotic tissue. After systemic heparinization, a multidetector computed tomography (MDCT) revealed a total occlusion of distal aorta to common iliac arteries with atherosclerosis of distal aorta and wall enhancement with intraluminal thrombus, few collateral vessels was seen. An echocardiography revealed severe concentric ventricular hypertrophy with hypokinesia. Considering underlying RV with immunosuppressive state and cardiac comorbidity, the less invasive endovascular treatment was performed by pulse-spray thrombolysis (PST) and self-expandable kissing stents graft placement to cover the thrombus attachment site under percutaneous technique.

ResultsCompletion angiography showed good conformation of the stent grafts involving the distal aorta and bilateral common iliac artery without residual stenosis, clot or distal embolization. Histologic examination confirmed the red clot from aorta to be an organized thrombus. The level of immunosuppressive drugs adjusted for controlling active disease of RA. Gluteal and limb ischemia were sequential debridement and negative pressure wound therapy until complete wound healing. A 2-month postoperative MDCT revealed well patency of stent grafts with infrarenal atherosclerotic lesion concealment, completely. Long-term low dose aspirin with immunosuppressive drugs were prescribed. ConclusionsAcute aortic thrombosis and RV are fatal condition. Endovascular treatment can achieve the good peri-operative and short-term outcome for RV patient. However, the risk of stent graft thrombosis is still high. Proper adjunctive treatment with immunosuppressive agents are vital for maintaining patency of revascularization conduit and recurrent disease prevention.

P01-04Paper No: 422Hybrid procedures in acute on chronic limb ischemia

Vinay K S, Murali Krishna N, P S Seetharam BhatVascular Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research Centre, Bangalore

BackgroundTo evaluate the need for hybrid procedure in acute on chronic ischemia.

MethodsAll patient who underwent interventions for acute limb ischemia from Study period, march 2016 to march 2017 were included. Study was prospective type and was done at SJICR. 38 patients were included in the study. Hydrid procedures included thromboembolectomy and endovascular procedures. Follow up was done on at 1 week, 1 months, 2 months, 6 months and yearly interval.

ResultsOut of 38 patients included in the study, 33 patient who underwent lower limb thromboembolectomy and 8 patient underwent hybrid procedures. Post procedure technical and clinical success noted with respect to decreased limb pain, increased limb warmth, improved

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Poster Presentation

toe and ankle movements and improved Doppler ankle signals.

ConclusionHybrid procedures is the treatment of choice in acute on chronic limb ischemia. there Is need to subclassify acute limb ischemia.


P02-01Paper No: 013Bovine pericardium patch plasty as a surgical option for infected abdominal aortic aneurysm

Xiaoning Tong, Hideyuki HaradaCardiovascular Surgery, Kushiro Kojinkai Memorial Hospital, Kushiro, Hokkaido, Japan

BackgroundAlthough surgeries for infected abdominal aortic aneurysm (IAAA) have various options, such as graft replacement and patch plasty, no optimal method was reported. Several advantages of patch plasty of IAAA are less invasive/time-consuming, hence potentially beneficial in clinical outcome. The aim of this study is to elucidate mid-term surgical outcomes of IAAA, incorporating patch plasty with bovine pericardium.

MethodsSix patients underwent surgery (bovine pericardium patch plasty in 5 and graft replacement in1) for IAAA from June 2011 to July 2015. Median age was 75 (IQR: 68-78) years old. All 6 patients were performed through midline abdominal approach. Severe adhesion around the aneurysm was observed. Mural thrombosis was removed after aneurysm was incised, and then irrigated with saline solution. Bovine pericardial patches were used to close the defects with double 3-0 prolene continuous sutures (figure). However, the arterial wall in 1 patient was too fragile to repair, resection of aneurysm and replacement with artificial graft soaked in rifampicin was required. One patient had an aneurysm ruptured into colon preoperatively and a colostomy was performed simultaneously. Retroperitoneal spaces were implanted with greater omentum in all patients.

ResultsThe blood cultures of all patients were negative. The intraoperative abscess cultures demonstrated positive in 2 patients (Klebsiella pneumoniae in 1and Î±-streptococcus in 1) and negative in 4 patients, respectively. There was no surgical/hospital death. With

median follow-up period of 38.5 (33.5-43.5) months, recurrent aneurysm formation due to infection was not observed. No IAAA-related death was seen.

ConclusionsSurgical outcome for IAAA was satisfactory. Bovine pericardial patch plasty could be one of the surgical options, especially in patients with severe adhesion to the aneurysm. The long-term follow-up is warranted to further validate the advantage/disadvantage. The blood cultures of all patients were negative. The intraoperative abscess cultures demonstrated positive in 2 patients (Klebsiella pneumoniae in 1and Î±-streptococcus in 1) and negative in 4 patients, respectively. There was no surgical/hospital death. With median follow-up period of 38.5 (33.5-43.5) months, recurrent aneurysm formation due to infection was not observed. No IAAA-related death was seen.

P02-02Paper No: 039Early and midterm results of endovascular aneurysm repair for solitary common iliac artery aneurysm

Yasuyuki Kanno, Takayuki Hori, Yusuke Takei, Yuta Kanazawa, Hironaga Ogawa, Toshiyuki Kuwata, Koji Ogata, Ikuko Shibasaki, Hirotsugu FukudaDepartment of Cardiac and Vascular Surgery, Heart Center, Dokkyo Medical University Hospital

BackgroundWe reviewed the early and midterm results of endovascular aneurysm repair in patients with solitary common iliac artery aneurysm (CIAA), without using iliac branched device which has not been approved in Japan.

Method and PatientsOne or both legs were landed to external iliac artery (EIA). In terms of management of internal iliac artery (IIA), coil embolization of ipsilateral IIA in cases of unilateral CIAA or IIA translocation to ipsilateral EIA, simultaneously with coil embolization of contralateral IIA in cases of bilateral CIAA. We performed these procedures in 32 pts with CIAA from August 2008 to April 2017.

ResultsMean age was 77.9 years old. (61-89), 26 pts were male and six patients were female. 22 pts had unilateral CIAA, 10 pts had bilateral CIAA. 4 pts had ruptured CIAA. Used endo-grafts were EXCLUDER in 23 pts, ZENITH in 5, ENDURANT in 3, and AFX in 1. We performed coil

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embolization of unilateral IIA in 22 pts, bilateral IIA coiling in 1, and contralateral IIA translocation in 7.

As major complication, access rout injury (right femoral artery) occurred in 1 pt. Hospital death occurred in 2 pts, whose etiology was necrotizing enterocolitis due to thromboembolism. Mean durations of hospitalization were 9.75 days (4-36 days). Mean follow up periods were 916.5 days (9-2226 days). Endo-leak (EL) were found in 4 pts; type Ia in 1, type II in 3. Open graft replacement was done successfully after EVAR in 2 pts due to each type Ia and type II EL. Gluteal muscle claudication occurred in 2 pts. There were no leg occlusions and no deaths associated with aortic event.

ConclusionOur early and midterm results of endovascular aneurysm repair for solitary CIAA were reasonably good. Case accumulation and detailed anatomical analysis will be needed in future.

P02-03Paper No: 057Application of color-coded quantitative digital subtraction angiography in predicting the outcomes of immediate type I and type III endoleaks

Min Zhou1, Zijie Su1, Zhenyu Shi1, Weiguo Fu1, Xiangdong Meng1, Yonggang Wang1, Baolei Guo1, Kaiyi Huang2

1Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, Fudan University, Shanghai, China2Siemens Healthcare, Shanghai, China

ObjectiveImmediate type I and type III endoleaks after endovascular aneurysm repair (EVAR) could be persistent or temporary. We aimed to use color-coded quantitative digital subtraction angiography (CQDSA) to quantitatively evaluate immediate type I and type III endoleaks after EVAR and to find a practical way to predict their outcomes. MethodsBetween January 2012 and December 2014, 35 patients (31 men, 4 women) with slight immediate type I and type III endoleaks after EVAR were recruited in the prospective observational nested case-control study. After at least 6 months of follow-up, these patients were divided into two groups based on endoleak-related adverse events. Their final intra-procedure DSA images were collected and converted into a single polychromatic image for CQDSA measurements. The parameter time to peak (TTP) of the selected regions of interest in the

endoleak area and a reference area at the same latitude within the stent graft were derived from the time-intensity curve. A receiver operating characteristic curve was generated to test the ability of TTP to predict endoleak-related adverse events and to identify the optimal cutoff value. ResultsFinally, two groups were identified: 12 patients with endoleak-related adverse events and 23 patients without endoleak-related adverse events. Median follow-up time for all patients was 24.0 months. Age, gender, and comorbidity were similar in these two groups. TTP was significantly lower in patients with endoleak-related adverse events (P=0.002). The risk of endoleak-related adverse events was significantly higher in patients with mixed-type endoleak than in those with simple-type endoleak (P=0.003). According to the receiver operating characteristic curves, TTP<5 seconds reached the maximal sum of sensitivity and specificity (sensitivity, 91.67%; specificity, 69.57%). Logistic regression analysis confirmed that TTP<5 seconds (P=0.016) and mixed-type endoleak (P=0.044) were associated with higher risk of endoleak-related adverse events. ConclusionsCQDSA could help predict the outcomes of immediate type I or type III endoleaks after EVAR. TTP<5 seconds and mixed-type endoleak were two potential predictors of endoleak-related adverse events. This approach may offer an objective assessment of such immediate endoleaks and reference for immediate re-intervention or conservative therapy.

P02-04Paper No: 069A comparison of radiation exposure during endovascular aortic aneurysm repair with or without endostapling

Aadil Ahmed, Ayman Badawy, Arindam ChaudhuriDepartment of Vascular Surgery, Bedford Hospital NHS Trust, Bedford, United Kingdom

BackgroundComplications of Endovascular Aneurysm Repair (EVAR) include endoleaks, proximal neck dilatation & stent migration, which have a greater likelihood with larger neck angulations. To mitigate against these complications endostapling of the stent-graft to the aortic wall is being implemented. With this extra stage in EVARs, this study aims to establish whether use of endostapling increases patient radiation exposure.

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Poster Presentation

MethodsA retrospective analysis of a prospectively collected database of patients undergoing EVAR & EVAR with endostapling was obtained. Radiation dose, fluoroscopy time, aneurysm size and patient characteristics were collected. Endostapling was performed using the Aptus Endostapling system (Aptus Endosystems Inc, Sunnyvale, Calif). Results are expressed as mean with 95% confidence interval. Statistical significance was set at P.

ResultsThis study included 30 patients undergoing elective aorto bi-iliac EVAR with endostapling and 147 patients undergoing elective aorto bi-iliac EVAR without endostapling. Patient characteristics between the two groups were comparable. Within the endostapled group the mean dose area product (DAP) was 5.54 (4.18-6.91) mGy.m2, cumulative air kerma (CAK) 289 (230-348) mGy & fluoroscopy time 35.9 (29.6-42.2) minutes. Within the non-endostapled group the mean DAP was 5.91 (5.07-6.75) mGy.m2, CAK 248 (211-284) mGy & fluoroscopy time 32.5 (28.5-36.5) minutes. There was no statistically significant difference in DAP , CAK or fluoroscopy time between patients undergoing EVAR with or without endostapling.

ConclusionRadiation exposure during endovascular aneurysm repairs is a significant hazard to both the patient and the theatre staff. Our study shows that the additional step of endostapling the aortic stent-graft to prevent future reinterventions for endoleaks, stent migration or rupture does not significantly increase radiation exposure to the patient.

P02-05Paper No: 072Midterm results of total arch replacement with frozen elephant trunk in acute type A aortic dissection

Yusuke Takei, Takayuki Hori, Toshiyuki Kuwata, Hironaga Ogawa, Masahiro Seki, Yuriko Kiriya, Yasuyuki Kanno, Koji Ogata, Ikuko Shibasaki and Hirotsugu FukudaDepartment of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Tochigi, Japan

BackgroundAscending aorta or hemiarch replacement is the most common procedure in type A aortic dissection. However limited aortic resections may lead to late distal aortic complication including aneurysmal degeneration and rupture. The frozen elephant trunk (FET) procedure

exclude intimal tears and improve true lumen (TL) perfusion. That promotes thrombosis, shrinkage and obliteration of the false lumen (FL). The aim of this study is that to analyse the clinical outcomes of total arch replacement with FET and to evaluate the aortic remodeling in midterm period.

MethodsBetween Dec. 2014 and Apr. 2017, 19 patients (mean age 56.6±12.0) were operated with FET using J Graft OPEN STENT (Japan Lifeline Co., Ltd., Tokyo, Japan) for type A aortic dissection. Antegrade selective cerebral perfusion was initiated. All open stent graft prostheses were inserted into the totally incised aorta just before the origin of the left common carotid artery under circulatory arrest. The all length of the stent grafts was 9cm and the size of those was determined as 90% oversized of total aortic diameter at distal thoracic descending aorta. Postoperative variables and follow up data including aortic remodeling analysis are presented.

Results30-day mortality was 10.5%(2/19); 2 patients died due to cerebral hypoxia and multiple organ failure. Two (10.5%) patients had a stroke and one (5.3%) had a spinal cord injury. One patient had additional endovascular treatment for distal aortic rupture. A median follow up period of 14.1 months. Post-operative CT scans revealed FL thrombosis in 94.7 % of the patients at the level of stent graft. In 13 cases (68.4%) over 6 months’ follow-up (midterm period), positive or stable aortic remodeling down to the stent end was achieved 69.2% (9/13). However, negative aortic remodeling was observed in 30.8% (4/13); two patients had a stent graft new injury (SINE). There was not Aorta-related late death, but one patient of pseudoaneurysm had re-intervention in midterm period. ConclusionsThese early and midterm outcomes were satisfied. But negative aortic remodeling cases remain at risk for re-intervention and can be identified in the careful follow-up examinations.

P02-06Paper No: 075The impact of maximal diameter and hematoma thickness in conservative management of type-A acute aortic intramural hematoma

Akihito Kagoshima, Hirono Satokawa, Shinya Takase, Hitoshi YokoyamaDepartment of Cardiovascular Surgery, Fukushima Medical University, Japan

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BackgroundThe effectiveness of initial conservative management of type-A acute aortic intramural hematoma (IMH) has been reported particularly from Eastern, and the prognosis is favorable in most while some cases requiring surgery. Consideration of optimal time to surgery, the computed tomography (CT) findings are important because the maximal diameter and thickness may be related to dilatation or progression to dissection.Objectives: This study aimed to compare the CT findings of IMH between the cases requiring surgery and conservative management to clarify the impact of maximal diameter, thickness and other findings.

Materials and MethodsA total of eighteen patients with acute type-A IMH were admitted to Fukushima Medical University between June 2010 and December 2015. All patients received initial conservative management. Of these, 8 patients (44%) underwent surgery during hospital stay (mean, 22 days; range, 2-46 days) due to progression to dissection or dilatation. While 10 patients discharged without operation, 4 patients required surgery due to dilatation with and without ulcer-like projection (ULP) after discharge in mid-term (mean, 204 days; range, 84-526 days) and other 6 were treated medically. We retrospectively analyzed the CT findings and outcome between early surgery (ES), late surgery (LS) and conservative management (CM) group.

ResultsAll patients survived at April 2017 (follow up range, 1.4-4.6 years). There were no significant differences between groups with patient characteristics. Six patients were performed open surgery and 2 were endovascular surgery in ES group (3 of 8 were progression to dissection in 7 days). In LS group, 2 patients were performed open surgery and 2 were endovascular surgery. No significant differences between ES, LS and CM group in maximal diameter (43±5.8mm, 45.7±3.3mm and 44.8±3.7mm respectively; P=0.648), and hematoma thickness (8.7±1.8mm, 9.3±2.8mm and 11.8±5.7mm respectively; P=0.351), but enlargement with new ULP within 14 days were seen in ES group. In CM group, the hematoma vanished within 14 days.

ConclusionsConsideration of management of IMH, it is important not only measurement of the maximal diameter and thickness in initial phase, but following the other CT findings sequentially.

P02-07Paper No: 089Clinical outcomes of crossing-limb technique in Endovascular Aneurysm Repair(EVAR)

Ki Hyuk Park, Jae Hoon Lee, Sang Ho LeeDepartment of Surgery, College of Medicine, Daegu Catholic University, Daegu, Korea

PurposeThis study assessed the difference of clinical outcome between using ballerina technique and conventional technique in endovascular aneurysm repair (EVAR).

MethodsFrom July 2010 to February 2015, 108 patients with abdominal aortic aneurysm underwent EVAR in our institution. Among them, 79 patients with bifurcated limb device were included this study. We compared the operation time, the difference of iliac angle after limb deployment and the frequency of type Ib endoleak and limb migration between using ballerina technique and conventional technique. For statistical analysis, two sample t-test and chi-square test were used.

ResultsThere were no significant differences of patient demographics and clinical characteristics between two groups. The operation time and the change of iliac angle after limb deployment were not different between two groups (P=0.584, P=0.109). Mean follow-up period was 25.34 ± 23.02 months. A significant increase of type Ib endoleak in ballerina group was found comparing with conventional group (12.5% vs. 1.82%, P<0.046). There were 3 cases of type Ib endoleak in ballerina group. Among them, 2 cases of immediate type Ib endoleak after stent graft deployment were solved by reballooning. In 1 case of type Ib endoleak after 6months, additional limb stent graft was performed to seal the distal limb. There was no limb migration in ballerina group.

ConclusionBallerina technique was involved in the high frequency of type Ib endoleak but we successfully had overcome the endoleak with additional adjuvant treatment. The proper application of ballerina technique may be useful when limb selection is difficult.

P02-08Paper No: 098Thoraflex hybrid graft for treatment of arch pathologies: A single center early experience

Randolph HL Wong, Jacky YK Ho, Simon CY Chow, Peter SY Yu, Micky WT Kwok, Malcolm J Underwood

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Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR

ObjectiveAortic arch pathologies remain to be one of the most challenging conditions despite recent endovascular and surgical advances. We reviewed the total aortic arch replacement and frozen elephant trunk (FET) with ThoraflexTM hybrid stent graft system as a single stage repair of complex arch pathologies in our institution.

MethodsBetween August 2014 and March 2017, patients with complex thoracic aortic pathologies underwent FET implant with the Vascutek ThoraflexTM system were recruited. Patients’ perioperative parameters, clinical and radiological outcomes were reviewed.

ResultsTwenty-six patients with aortic arch pathologies, including acute dissections and chronic dissecting aneurysms, were treated with ThoraflexTM hybrid stent graft FET system. Overall mortality rate was 7.7% (n=2) and no 30-days mortality in the elective subgroup. Stroke occurred in 1 patient (3.8%). No recorded permanent spinal cord injury. Mean operative, moderate hypothermic circulatory arrest and antegrade cerebral perfusion time were 436±130min, 90±28min and 145±36 min respectively. In the follow up CT, 81% patients showed false lumen thrombosis and none with evidence of endoleak to distal stent graft.

ConclusionThis series represent one of the largest hybrid-FET experiences of the ThoraflexTM system in Asia. We demonstrated the use of ThoraflexTM system as a safe, single stage and effective way to treat complex aortic pathologies, in both emergency and elective settings. Further study is warranted to evaluate its impact on survival and disease progression in descending thoracic aorta.

P02-09Paper No: 099Relationship between aortic aneurysm shrinkage after endovascular repair and aortic wall enhancement on contrast enhanced CT scan. A new aneurysm shrinkage predictor

Eisaku Ito1, Naoki Toya1, Soichiro Fukushima1, Yuri Murakami1, Tadashi Akiba2, Takao Ohki3

1Department of Surgery, Division of Vascular Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan

2Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan3Department of Surgery, Division of Vascular Surgery, The Jikei University School of Medicine, Tokyo, Japan

BackgroundEndoleaks after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) results in aneurysm expansion. However, prediction of aneurysm shrinkage remains difficult. Aneurysm wall enhancement (AWE) in a cerebral aneurysm is a known predictor for expansion/rupture. However, it is unknown whether AWE is associated with aneurysm growth after EVAR. We retrospectively assessed the relationship between AWE and AAA growth.

MethodsFrom August 2011 to July 2016, data on 176 EVAR for AAA were retrospectively collected. AWE was defined as an increase of more than 20 HUs in mean CT values when images in delayed enhanced scans were compared with those in unenhanced scans. The primary endpoint was aneurysm expansion and shrinkage (>5mm).

ResultsThere were 127 men (80.9%) and median age was 75 years (45-93) old. The median follow-up period after EVAR was 23.6 months (6-59). There were 62 cases with aneurysm shrinkage after EVAR, 63 cases with stable aneurysm size, and 32 cases with aneurysm expansion. In AWE negative group, there were 29 cases (28.2%) with aneurysm shrinkage and 26 cases (25.2%) with expansion. On the other hand, in AWE positive group, there were 33 cases (53.2%) with aneurysm shrinkage and 6 cases (18.8%) with expansion. (Chi-square test: p<0.001). ConclusionsAWE may be a new aneurysm growth predictor after EVAR.

P02-10Paper No: 101Screening of thoracic aortic aneurysm in chinese hypertensive patients using pocket-size mobile echocardiographic device: An interim result

Peter SY Yu1, Fan Yang1, Evelynn YH Lui1, Simon CY Chow1, Jacky YK Ho1, Malcolm J Underwood1, Simon CH Yu3, Alex PW Lee2, Randolph HL Wong1

1Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong2Division of Cardiology, Department of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong

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3Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong

BackgroundThe prevalence of thoracic aortic aneurysm (TAA) among Chinese hypertensive patients in Hong Kong is unknown. A safe and cost-effective screening tool remains to be developed.

MethodsConsecutive patients of Chinese Ethnicity attending Hypertension clinic at Prince of Wales Hospital were recruited. A Pocket-size mobile echocardiographic (PME) device - VScanTM [GE Healthcare, Milwaukee, WI], was used for screening of TAAs. Echocardiographic examinations were performed to measure the size of different parts of thoracic aorta through various views. TAA was defined as an area of aorta with maximum diameter >=4.5cm or >50% greater than the adjacent aortic diameter.

ResultsFrom June 2016 to May 2017, a total of 834 hypertensive patients with mean age 60.5±11.6 years old were recruited. The prevalence rate of TAA was 9.2% (N=77), and it was most prevalent in patients aged from 60 to 70 years old (33.8% of TAA cohort, 3.1% of all screened cohort). Distal ascending aorta (52.8%) was the most commonly diseased part, followed by aortic sinus (24.7%) and arch (19.5%). Risk factors for TAA included male [71.4% vs. 52.7%, p=0.002], age >=70 [31.7% vs. 20.1%, p=0.023] and history of coronary heart disease [29.9% vs. 18.9%, p=0.022]. Good blood pressure control (defined as systolic pressure).

ConclusionsTAA is significantly prevalent among Chinese hypertensive population in Hong Kong. Optimal blood pressure control should be the treatment goal in hypertensive patients to prevent the development of TAA. The use of a PME device can be a cost-effective method in screening for TAA, which could potentially identify at-risk patients before complications arise.

P02-11Paper No: 102Our clinical outcomes of the PETTICOAT technique for aortic dissection

Masatoshi Komooka, Shinichi Higashiue, Satoshi Kuroyanagi, Onichi Furuya, Saburo Kojima, Naohiro WakabayashiDepartment of Cardiovascular Surgery, Kishiwada Tokusyukai Hospital, Kishiwada City, Osaka, Japan

Background/IntroductionThe PETTICOAT (Provisional Extension To Induce Complete Attachment) is an endovascular technique to treat acute and subacute type B aortic dissection (TBAD). In recent days this technique has been applied to the treatment for the patent false lumen after operation of type A aortic dissection (TAAD).

ObjectiveThis study objective was to evaluate the feasibility, safety, and early clinical outcome of a new endovascular device specially designed for aortic dissection that has been available since October 2015 in Japan.

Materials and MethodsFrom October 2015 to May 2017, the Zenith Dissection Endovascular System (Zenith TXD) was used in 12 nonconsecutive patients with TAAD (9 men, mean age 59.1 years; 5 post-Total Arch Replacement cases, 7 post-Hemiarch replacement cases), and in 10 nonconsecutive patients with TBAD (10 men, mean age 63.2 years; 3 complicated cases; 2 bowel ischemia, 1 lower limb ischemia). Indications were compression and collapse of the true lumen and abdominal side branches and/or symptomatic malperfusion. Patients were studied for computed tomography imaging, operative complications, and technical aspect of the procedure.

ResultsDelivery was successful in all cases. The median interval between the primary surgery for TAAD or clinical presentation of TBAD and the endovascular procedure was 31 days (range 2-68 days), 39 days (range 7-200 days) respectively. In 2 patients of TAAD and 6 patients of TBAD, the left subclavian artery revascularization by debranching was performed before device deployment to obtain adequate proximal landing zone. Mean operation time was 91±23 minutes and 133±52 minutes, mean hospital stay was 22±18 days and 21±7 days, for patients in TAAD and TBAD. No 30-day complication including spinal cord ischemia were found and preoperative symptomatic malperfusion was abolished. Postoperative and follow-up imaging showed that false lumen was thrombosed in large part of thoracic to aorta and the compressed true lumen enlarged without any obstruction of the abdominal side branches.

ConclusionsThe perioperative and early follow-up results showed that the PETTICOAT technique with Zenith TXD can be safely used without affecting the patency of the abdominal side branches covered by the bare stent.

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P02-12Paper No: 103The midterm results of TEVAR for chronic aortic dissection with aneurysmal dilatation. What the affect is the distal-entry closure?

Kiyoshi Chiba1, Hiroshi Nishimaki1, Yukihisa Ogawa2, Satoshi Kinebuchi1, Syouta Kita1, Hirotoshi Suzuki1, Yuka Sakurai1, Daijun Ro1, Hirokuni Ono1, Makoto Ono1, Masahide Chikada1, Takeshi Miyaili1

1Department of Cardiovascular Surgery, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan2Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan

BackgroundRecent studies have shown that false lumen thrombosis (FLT) and aortic remodeling are associated with better long-term outcomes.

In this study, we considered the midterm results of the TEVAR with dsital flow control (distal-entry-closure) for chronic type B aortic dissection (CTBAD), for the purpose of making a total false lumen thrombosis.

PatientsIn 16 patients who underwent TEVAR for chronic aortic dissection with aneurysmal dilatation until December 2010 to December 2016 (including the 8 cases after Type A aortic dissection). The mean age, 59.6±10.7 years (40-78 years), 13 male patients. The average observation period is 30.3±23.8 months. The period from the dissection onset to TEVAR is a 59.1±61.7 months. As aortic surgery history, root to ascending 1 case, ascending replacement 3 cases, arch replacement 4 cases, descending replaced 2 examples, and abdominal aorta replacement 2 cases.

MethodsAnalysis of operative outcome, survival and freedom from additional aortic surgery rate. Patients were divided into 2 groups according to TEVAR strategy (A group: Isolated TEVAR in 6 patients/B group: TEVAR with distal-entry-close in 10 patients).

In two groups, we evaluated the false lumen area and thrombosis of the false lumen on the descending aorta at the level of trachea , aortic valve, celiac artery and abdominal aorta before and after TEVAR. The details of distal entry closure: Candy-plug method (n=7), stenting or coiling for abdominal branch (n=8), EVAR (n=5).

ResultsTechnical success is 94.1%, and neurological complications is 0%. Kaplan-Meier survival curves in

3-year was 92.9%. Freedom aortic additional surgery rate was 74.8%. The cross section of false lumen was reduced in both groups at the chest area (carina from descending aorta at the aortic valve level), but the A groups is expanding under the diaphragm; on the other hands, the B groups were reduced the false lumen at the same level significantly (Group A, P=0.56/Group B, P=0.04),

ConclusionWe showed the midterm results of TEVAR with distal entry closure for the chronic aortic dissection. Reduction of the false lumen under the diaphragm was obtained by distal entry closure.

P02-13Paper No: 104Early-and mid-term outcome of TEVAR for rupture of acute type B aortic dissection

Daichi Takagi, Kadohama Takayuki, Itagaki Yoshinori, Kiriu Kentaro, Tanaka Fuminobu, Chida Yoshifumi, Yamaura Genbu, Yamamoto HiroshiCardiacsurgery, Akitauniversity, Akita, Japan

ObjectiveThoracic endovascular aortic repair (TEVAR) for rupture of type B acute aortic dissection (BAAD) has been reported to be an effective therapeutic strategy. We evaluated the early-and mid-term results of TEVAR for rupture of BAAD in our hospital as a single center study.METHOD:From October 2014 through May 2017, 7 patients (1 woman, 6 men) with cBAD (mean age, 74 years; range, 65-79 years) were treated with TEVAR using Relay Plus® to cover tears as many as possible. Five patients presented with shock vital status, and 2 patients manifested malperfusion or severe stenosis of the true lumen. The follow-up rate was 100% during a postprocedulal period of 14.6 months (range, 0.6-22.8 months).

ResultsTechnical success was achieved in all patients. An adjunctive procedure was required at the time of TEVAR in one patient(axillo-axillo bypass). No patient died in hospital. Three patients (43%) had postprocedulal complications (cerebral infarction in 2; temporary paraparesis in 1), and one patient (6.7%) underwent re-interventions in hospital (Abdominal aortic replacement for re-rupture in 1) After discharge, there was no mortality but one patient required re-intervention for aortic enlargement caused by stent graft-induced new entry at the distal site of endograft. Postprocedual CT angiography showed complete thrombo-occlusion of

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the false lumen with restoration of the true-lumen dimension in almost patients.

ConclusionsTEVAR is a technically feasible and effective therapeutic strategy for rupture of BAAD. Further long-term evaluation, however, is required for assessing the effectiveness of TEVAR in cBAD patients.

P02-14Paper No: 105Total endovascular repair in arch aneurysm patients with bovine aortic arch using the Najuta fenestrated stent graft

Naoki Toya1, Soichiro Fukushima1, Eisaku Ito1, Yuri Murakami1, Tadashi Akiba2, Takao Ohki3

1Department of Surgery, Division of Vascular Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan2Department of Surgery,The Jikei University Kashiwa Hospital, Chiba, Japan3Department of Surgery, Division of Vascular Surgery, The Jikei University School of Medicine, Tokyo, Japan

BackgroundBovine arch in which the brachiocephalic artery shares a common origin with the left common carotid artery is the most common variant of the aortic arch. We report a new management approach using the Najuta fenestrated stent graft for the treatment of aortic arch aneurysm with bovine arch.

MethodsThe Najuta stent graft is a customized fenestrated device comprising of self-expandable stainless steel Z-stent and an ePTFE graft. The Najuta was approved for use in Japan in January 2013. Between April 2015 and February 2016, 23 fenestrated TEVAR using the Najuta stent graft were performed in our facility, including 8 cases in which zone 0 landing for arch aneurysm with bovine arch was performed.

ResultsTechnical success was 100% with no 30-day mortality, stroke, or paraplegia. The left subclavian artery was covered in 4 (50%) patients. In 6 (75%) patients we used the CTAG or the TX2 stent graft in distal site of aneurysm to enhance sealing. There was no endoleak in all patients.

ConclusionsThe Najuta fenestrated stent graft performs well for the treatment of arch aneurysm with bovine arch.Please paste your abstract here.

P02-15Paper No: 111EVARable abdominal aortic aneurysm that turned up with open surgical repair: Causes and result. A retrospective study in tertiary vascular centre

Aizat Sabri I1, Lenny SS2, Azim I2, H Harunarashid2

1Department of Surgery, Universiti Science of Malaysia2Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

IntroductionThis study is to identify the incidence of EVARable cases of Abdominal Aortic Aneurysm (AAA) that end up with open surgical repair and to determine the causes.

MethodologyWe conducted a retrospective database review to identify all open AAA surgical repair performed in elective case between 2014 and 2016. All open surgical repair cases were analyzed whether the cases are EVARable or not. The causes of converting to open repair are identified. An EVARable AAA is decided upon multidisciplinary meeting between the vascular team and the Interventional Radiologist team.

ResultsIn all, 31 open surgery AAA repair and 6 EVAR took place during the study period. Six patients (19%) from open AAA repair was initially planned for EVAR but ended with open repair. Their mean age was 66 (range 64-79) years and all were men. The mean age for open repair and EVAR was 68 (range 54-82) years and 65 (range 56-74) years respectively. For the mean aneurysmal size of EVARable group was 6.5cm and for open repair and EVAR group was 6.4cm each. The reasons of being end up with open repair were patient’s decision (n=2), bacteremia (n=1), refusal for annual CTA surveillance (n=1), delayed financial subsidy (n=1) and due to worsening kidney function (n=1). Median length of stay in hospital was 5 (range 4-6). There was noted only 2 post-operative complication in this group, ileus and reduce perfusion of unilateral lower limb. There were no instances of early or in-hospital mortality following conversion.

CONCLUSIONDespite the modern endovascular technology in treating AAA disease, the open technique is still an available safe option of treatment and acting as bail out management for AAA disease.

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P02-16Paper No: 117The initial result of EVAR combined with renal stents or stent grafts

Kiyohito Yamamoto, Seisaku Tokunago, Naomichi NishikimiDepartment of Vascular Surgery, The Japanese Red Cross Nagoya Daiichi Hospital, Nakamura-ku, Japan

BackgroundTo extend proximal landing zone for the treatment of short neck abdominal aortic aneurysm (AAA), EVAR was performed with the combination of deployment of the renal stents or stent grafts.

MethodsNine cases of EVAR with renal stents or stent grafts performed during past 2 years in our institution were retrospectively reviewed.

ResultsThere were 5 cases with EVAR with renal stents for short neck AAA, 3 cases with EVAR with renal stent grafts for juxta-renal AAA (Chimney/snorkel EVAR), and 1 case with renal stent deployment with EVAR for rescue of covered renal artery by the main body. There were no cases with renal dysfunction after the procedures. During follow up from 6 months up to 2 years, there were 1 cases with gutter leak in chimney EVAR and 3 cases with type II endoleak. The shrinkage of AAA sac was observed in 4 cases, and there were no cases with sac enlargement. All renal stents or stent grafts were patent.

ConclusionsThe initial results of EVAR combined with renal stents or stent grafts were satisfactory. To confirm the long-term results, careful follow-up is mandatory.

P02-17Paper No: 118Aneurysm sac enlargement 18 years after EVAR due to late type3b endoleak; A case report

Yuri Murakami1, Naoki Toya1, Soichiro Fukushima1, Eisaku Ito1, Tadashi Akiba2, Takao Ohki3

1The Jikei University Kashiwa Hospital Department of Surgery, Division of Vascular Surgery2The Jikei University Kashiwa Hospital Department of Surgery3The Jikei University School of Medicine Department of Surgery, Division of Vascular Surgery

BackgroundWe report a case of late type 3b endoleak from in the main body of a Zenith endograft 18 years after deployment and treatment with an AFX endograft relining.

Case reportA 84-year-old man was referred to our hospital with an incidental finding of aneurysm sac enlargement after endovascular aneurysm repair (EVAR) which was performed at another hospital in 1998 using the Zenith endograft. Previous CT showed significant sac shrinkage after EVAR. However he presented delayed aortic aneurysm enlargement due to assumed endoleak. A duplex ultrasound showed endeleak from the main body of the stent graft and from the distal edge of the right leg. Therefore a type 3b and type 1b endoleak was suspected. We performed a late reintervention with an AFX endograft relining due to persistent type 3b endoleak. In addition we placed an Endurant contralateral leg to right common iliac artery for a treatment of type1b endoleak.Completion aortogram showed no obvious endoleak. And a postoperative ultrasound revealed no endoleak.

ConclusionWe report a case of aneurysm sac re-enlargement once disappeared 18 years after EVAR. A PTFE endograft relining may be considered an effective procedure for type 3b endoleak.

P02-18Paper No: 127Debranching thoracic endovascular aneurysm repair for a case of thoracoabdominal aortic pseudoaneurysm accompanied by advanced calcification

Kazushige Inoue1, Takanori Tokuda1, Takashi Murakami2, Akimasa Morisaki2

1Department of cardiovasucular Surgery, Hirakata kohsai Hospital, Hirakata Osaka, Japan2Department of cardiovasucular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan

A 78-year-old male with a previous history of chronic dialysis and three times laparotomies (appendectomy, right hemicolectomy and hepatectomy) was given a detailed examination for abdominal pain and fever. Computed tomography (CT) revealed a pseudoaneurysm of the aorta just proximal to the celiac artery. Thoracic and abdominal aorta was circumferentially heavily calcified throughout the entire length. The patient was given a left external iliac artery - superior mesenteric artery bypass using a 6-mm expanded polytetrafluoroethylene graft under median laparotomy. The celiac artery and the renal arteries were not reconstructed due to obstruction and dialysis, respectively. Thoracic endovascular aneurysm repair (TEVAR) was also performed using a 31mm x 20cm GORE CTAG and 24mm x 8cm Zenith TX2 from the descending thoracic aorta to the abdominal aorta distal

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to the renal artery branches via the right femoral artery. Intraoperative contrast imaging showed no end leak, but contrast CT performed 7th postoperative day revealed contrast agent inside the pseudoaneurysm. TEVAR was therefore performed again on the 14th postoperative day as an additional treatment. Intraoperative contrast imaging revealed a type 1a endleak from the proximal side of the stentgraft, which was consequently covered with a 32mm x 20cm VALIANT stent graft. Further intraoperative contrast imaging showed that the endleak had disappeared and postoperative CT also showed almost no leakage of contrast agent into the pseudoaneurysm. We encountered a patient with a highly calcified aorta in whom TEVAR was possible by using the appropriate stent and providing a sufficient running zone.

P02-19Paper No: 132Stanford Type B aortic dissection due to a primary entry tear in the abdominal aortic aneurysm

Kimimasa Sakata, Kanetsugu Nagao, Katsunori Takeuchi, Akio Yamashita, Naoki YoshimuraDepartment of Thoracic and Cardiovascular Surgery, Toyama University, Toyama, Japan

The number of reports on patients with aortic aneurysms complicated by aortic dissection has increased recently. However, there are still few case reports of patients with primary tear in the aortic aneurysm resulting in aortic dissection retrogradely, and its treatment strategy is controversial. In our patient, the primary entry in the aortic aneurysm was sealed by placing a stent graft during the acute phase. She followed a benign course. We report this patient with some literature review.

An 80-year-old woman had an abdominal aortic aneurysm that was pointed out and was treated conservatively by a primary care physician for approximately six years. On the day of onset, she visited the physician with complaints of sudden low back pain. As a result of close inspection, she was diagnosed with Stanford Type B aortic dissection and was transferred to our hospital by ambulance. On contrast-enhanced CT, abdominal aortic aneurysm with a maximal minor axis of 57mm was located below the renal artery, and aortic dissection was detected from the thoracic descending aorta to the terminal aorta. No apparent entry tear was found outside the aneurysm. Thus, abdominal aortic aneurysm was regarded as the primary entry. All the abdominal branches originated from the true lumen. For

the purpose of providing treatment for sealing the entry tear in aortic dissection and for the abdominal aortic aneurysm, abdominal aortic stent graft was implanted. By placing a stent graft from a site just below the branches of the renal artery to bilateral common iliac arteries, the false lumen was completely thrombosed. The patient was discharged without any apparent adverse event.

P02-20Paper No: 140A novel technique for in-situ fenestration TEVAR for arch aneurysm using radio-frequency ablation catheter

Masami Shingaki1, Yoshihiko Kurimoto2, Kiyofumi Morishita1, Toshio Baba1, Tsuyoshi Shibata1, Kohei Narayama1

1Department of Cardiovascular Surgery, Hakodate Municipal Hospital, Hokkaido Pref., Japan2Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Hokkaido Pref., Japan

BackgroundThere are some reports of in-situ fenestration TEVAR for arch aneurysm using a long needle to make a fenestration so far, and now we developed a novel and easy technique to make an in-situ fenestration using radio-frequency ablation catheter.

Methods and ResultsWe used this technique for 3 cases of arch aneurysm and 1 case of Kommerell diverticulum. After deploying stentgraft on aortic arch, we inserted and advanced 6 Fr inner sheath with ablation catheter through 0.035 inch hydrophilic wire from left axillary artery to the stentgraft. Applying a light pressure on ablation catheter to make sure the contact of catheter and the outer wall of stentgraft, we generated electricity and ablated the fabric of stentgraft without any pressure. Exchanging the hydrophilic wire to a stiff wire which was advanced deeply enough into aorta, the fenestration was expanded using PTA balloon and placed a bare metal stent to keep the shape of fenestration. In Kommerell diverticulum case, we delivered and deployed EVAR leg stentgraft to exclude aneurysm. All cases gained good clinical results without any endoleaks and complications.

ConclusionThe novel and easy technique for in-situ fenestration TEVAR using radio-frequency ablation catheter was safe and feasible.

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P02-21Paper No: 147Clinical experience of endoleaks that were newly diagnosed over 1 year after EVAR

Keun-Myoung Park1, Yong Sun Jeon2, Soon Gu Cho2, Kee Chun Hong1

1Department of Surgery, Inha University, Incehon, Korea2Radiology College of Medicine, Inha University, Incehon, Korea

ObjectiveEndovascular aneurysm repair (EVAR) is treatment of choice for abdominal aortic aneurysm (AAA). Endoleak is common complication that is necessary to follow up for long time. But, there were rare study about endoleaks that were newly diagnosed over 1 year after EVAR. Our study is to determine the incidence and outcomes of endoleaks that were newly diagnosed over 1 year after EVAR.

MethodsWe retrospectively analyzed the data of 120 patients who underwent EVAR for AAA at our institution from December 2010 to June 2015. We included the patients who had follow-up over 1 year. We defined delayed endoleaks as newly diagnosed over 1 year after EVAR and defined persistent endoleak as that lasted over 1 year after EVAR. We compared patients characteristics, procedural detail and postoperative follow up among delayed endoleaks group, persistent group and none group.

ResultsA total of 60 patients (51 men (85%), mean age; 71.9) were enrolled in this study. The mean age was 71.9 years (range, 34-89 years). The mean follow-up duration was 39.6 months (range, 12-101 months). There were endoleaks in twenty-five patients (41.7%) including 18 early endoleaks (30%) and 7 delayed endoleaks (11.7%). The delayed endoleak group consisted of 6 types II and 1 type Ia endoleaks.

The mean time of detection was 37.6 months (range, 15-60 months) after EVAR. In AAA with hostile neck, there were more delayed endoleaks comparing other groups (84% vs 33% p).

There were no difference in aneurysm rupture and re-intervention between delayed group and persistent group (0/7 vs. 2/18 (11.1%), 0.38; 2/7 (28.6%) vs. 6/18 (33.3%),0.82).

ConclusionAbout 12% of follow up, new endoleaks were diagnosed over 1 year after EVAR. This endoleaks were associated with hostile aneurysmal neck. Long-term imaging follow-ups are needed to clarify further complications such as aneurysm rupture and re-intervention.

P02-22Paper No: 150Open conversion for Type II endoleak after endovascular aneurysm repair - Lumbar artery ligation by laparotomy approach

K Ozaki, S Yamamoto, T Hirokami, Y Hirai, J Shimamura,S Sakurai, S Oshima, S SasaguriKawasaki Saiwai Hospital, Kanagawa, Japan

BackgroundEndoleaks are critical complications of endovascular abdominal aortic aneurysm repair (EVAR). Type II endoleak is the most common type, reported to occur after EVAR in 10 to 30% of cases. In our center, endovascular approaches are indicated for type II endoleak at first. For refractory cases, lumbar artery ligation by laparotomy is indicated. MethodBetween 2016. April and 2017. May, 12 patients underwent lumbar artery ligation for type II endoleak after EVAR. Mean age is 76.7±7.1 years old. 70% are male. Angiography, enhanced computed tomography (CT) and magnetic resonance imaging (MRI) are perfomed as preoperative examination. MRI is useful in a thrombus evaluation inside of aneurysm. We approach the aortic aneurysm by median laparotomy, and make a proximal clamp site to control type I endoleak. Aneurysm is decompressed by puncture and aspiration, before opening. We open the aneurysm, remove thrombus and ligate lumbar arteries backflows inside the aneurysm. After checking hemostasis, the aortic wall was closed with reefing. On the fourth and tenth day after surgery, we perform CT and confirm that there is not aneurysm expansion.

ResultsMean operative time is 147.7±38.0 minutes. Mean length of stay in hospital is 15.5±8.6 days. There is no operative death. Intraoperative findings showed that 8 cases (75%) are type II endoleak, 2 cases (12.5%) are type II with IIIb endoleak, and type IIIb endoleak is confirmed in 2 cases (12.5%).

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ConclusionOpen conversion for type II endoleak with median laparotomy approach can be performed with acceptable early outcomes. Concomitant type IIIb endoleak should be carefully diagnosed and treated.

P02-23Paper No: 155Outcomes of open conversion after failed endovascular aortic aneurysm repair according to the indication of explantation

Choi KH, Kwon TW, Cho YP, Han YJ, Jeong MJDepartment of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

ObjectiveTo evaluate the open surgical repair of failed endovascular aneurysm repair (EVAR) and compare the outcomes of open conversion according to the indication of explantation of inserted stent graft.

MethodsBetween 2008 and 2016, a retrospective analysis of open conversion in single center due to failed EVAR was performed. Preoperative information, intraoperative factors, and postoperative outcomes were evaluated.

ResultsFor 8 years, 16 patients underwent open conversion of EVAR. The average age was 71; most of the patients were male. The mean duration of implantation of stent graft was 41 months (range 0~119 months). 8 cases were performed in our clinic, and the other 8 cases were from other centers. There were 2 rupture cases and 2 emergency cases. 8 patients needed open conversion because of the graft infection, and 8 patients had to explant the graft due to uncontrolled endoleak. 7 of 8 Endoleak patients had secondary intervention, including embolization and stent graft insertion previously. 1 patient who was operated due to graft infection was expired on postoperative 12th day with proximal anastomosis site bleeding. There was another mortality case in endoleak patient who developed sepsis due to ischemic colitis followed by open conversion in the 4th of postoperative days. Supra renal clamping was conducted in both mortality cases during operation. Postoperative major complication and the length of hospital stay were significantly high in infection group. However, there was no significant difference in mortality between two groups.

ConclusionsExplantation of stent graft has been increased as the case of EVAR increases. Indication of open conversion does not affect the survival after surgery. Active open conversion is a challenging but can be feasible treatment option if failed EVAR hardly corrected via radiologic intervention. Also, we recommend to avoid supra renal clamping during operation.

P02-24Paper No: 156Long term outcomes of endovascular aortic aneurysm repair and open surgical repair of abdominal aortic aneurysm in terms of cancer incidence and cost effectiveness

Choi KH, Kwon TW, Cho YP, Han YJ, Jeong MJDepartment of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

ObjectiveTo compare the treatment outcomes of endovascular aortic aneurysm repair (EVAR) and Open surgical repair (OSR) in patients of abdominal aortic aneurysm (AAA) in single center including cost effectiveness.

MethodsPatients treated for an AAA in a single center between January 2007 and December 2012 were retrospectively identified and separated into two groups based on the treatment they received, EVAR and OSR. Their demographics, cancer incidence, and in hospital cost were recorded. Long term survival was also calculated with Kaplan-Meier method.

Results491 patients were treated with AAA during the period. Of 491 patients, 239 were treated with EVAR (49%) and 252 received open surgical repair (51%). There was no significantly difference in postoperative cancer incidence between EVAR and OSR group (5.0% vs 6.0%, p value: 0.651). OSR group showed significant advancement in Long term survival (62.40 ± 1.78 vs 87.93 ± 3.01, P value: 0.005). OSR group charged significantly less than EVAR group (16,521.55 USD vs 15,510.71 USD).

ConclusionOur study convinced the recent tendency that the OSR show advancement in terms of long term survival against EVAR. In addition, there is no significant difference in cancer incidence between two groups and OSR has advantage in cost effectiveness that it is appropriate to treat with OSR in AAA.

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Poster Presentation

P02-25Paper No: 164Endovascular repair of a spontaneous ilio-iliac fistula with unilateral leg swelling

Takuya Miyazaki, Tadashi Isomura, Yasuhisa Fukada, Yoshiki Endo, Minoru Yoshida, Takahiko Masuda and Masahiro EndoDepartment of Cardiovascular Surgery, Tokyo Heart Center, Shinagawa, Tokyo, Japan

IntroductionSpontaneous rupture of a common iliac artery aneurysm into the common iliac vein is a rare occurrence with iliac vein occlusion by an arterial iliac aneurysm. Clinical presentation commonly includes dyspnea, high-output congestive heart failure and the presence of a massive pulmonary embolism. Fortunately, there was no embolism of venous thrombosis from lower limbs because of occlusion of the iliac vein.

Case reportWe report the case of a 76 years old man presented with breathlessness, acute cardiac failure, and unilateral lower limb swelling as a complication of a spontaneous ilio-iliac arteriovenous fistula (AVF), secondary to aneurysmal rupture. The patient presented with acute onset of exertional dyspnea and unilateral leg swelling. A physical examination indicated a right lower abdominal thrill and murmur, jugular venous distention, cardiomegaly, and diminished motor in the right leg by severe swelling. The patient was found to have right lower leg edema and was wrongly assumed to have deep venous thrombus (DVT) as the underlying cause of pulmonary embolus. However, the patient did not have a massive pulmonary embolism due to occluding of the right iliac vein. Multidetector-row computed tomography (MDCT) revealed a 7-cm long common iliac arterial aneurysm at aortic bifurcation. Furthermore, the MDCT confirmed the presence of an AVF between the right common iliac artery aneurysm and occluded right common vein by an arterial aneurysm. The early appearance of contrast was remarkable in the right iliac vein alone, indicating the presence of the AVF. We subjected the patient to endovascular treatment of the AVF complicated with severe cardiac failure. An intraoperative arteriography reveals a false aneurysm and the AVF to the right iliac vein. The aneurysm was successfully excluded using stent grafts (Medtronic ENDURANT) in the right iliac artery, sealing the fistula. Control arteriography confirmed a slight flow from the fistula. There were no postoperative complications, and his congestive heart failure symptom and swelling right leg disappeared. Endovascular repair of these pathologies is a feasible therapeutic treatment. Five months later, the follow-up CTA scan demonstrated

no fistula and diminishing the size of the iliac arterial aneurysm from 7-cm to 5-cm.

P02-26Paper No: 178Risk factors of type II endoleak in EVAR: 8-year single institutive study

Chung Won Lee, Jinseok Choi, Up Huh, Sung Woon ChungDepartment of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Republic of Korea

BackgroundWe reviewed our 8-year experience type II endoleak (T2EL) in endovascular aortic repair (EVAR), and reported the risk factors of T2EL occurrence and affecting factors of secondary intervention in T2EL group.

MethodsWe retrospectively reviewed the electronic records of all patients undergoing EVAR for infra-renal type abdominal aortic aneurysm in single institution from August 2007 to November 2015. Demographics and clinical data were collected for each patient and preoperative contrast computed tomography scans were reviewed to determine aneurysm morphology.

ResultsThere were 62 patients who underwent EVAR during this period, and the follow-up duration is 35.82 ± 31.89 months. There were statistically significant differences in female (P=.040), the number of lumbar arteries in preoperative computed tomography (P=.010), and smoking (P=.031) between patients with T2EL and without T2EL. There were statistically significant differences in the maximum AAA diameter (P=.034), and the size of IMA (P=.043) between patients with secondary intervention and without secondary intervention in T2EL. In the group of T2EL, the affecting factors of secondary intervention were the maximum AAA diameter (P=.033), the number of lumbar arteries in preoperative computed tomography (P=.009), and smoking (P=.043). There was one instance of the late mortality after EVAR, however there was no mortality associated T2EL.

ConclusionsIt requires a more judicious approach to perform EVAR about the risk of T2EL in cases of female, the number of lumbar arteries which enter into AAA sac in preoperative computed tomography >6, and smoking history. It is

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necessary to have regard to the probability of secondary intervention in T2EL about the patients who have the maximum AAA diameter >7cm, and the size of IMA >3cm.

P02-27Paper No: 183Treatment options for isolated iliac artery aneurysm according to patient’s clinical characteristics

Seung Nam Kim, Cheng Quan, Young Hwa Kim, Gyeong Jae Koh, Jin Go, Mi Hyeong Kim, Kang Woong Jun, Jeong Kye Hwang, Sang Dong Kim, Jang Yong Kim, Sun Cheol Park, Ji Il Kim, Yong Sung Won, Sang Seob Yun, In Sung MoonDepartment of Surgery, Catholic University of Korea, Seoul, Korea

BackgroundIsolated iliac artery aneurysms (IIAA) are relatively uncommon and represent 2-7% of all intra-abdominal aneurysms. Endovascular treatment of aneurysm (EVAR) is already popular in treatment of IIAA. This paper reviews our experience in treatment of IIAAs.

MethodsThis is retrospective study of patients, who were treated for IIAA in St. Mary Hospital and Seoul National University Bundang Hospital from 2005 to April 2016. We reviewed clinical characteristics and treatment’s results and evaluated technical success and overall mortality.

ResultsForty eight patients (41 men and 7 women; mean age, 73.7 years) were treated. Common iliac artery was most frequently involved (77.1%, 37 patients). Sixteen (33.3%) of those patients also had an internal IAA. Nine patients had an isolated internal IAA. There were 5 ruptured aneurysms, treated with endovascular(1) or hybrid methods(4). The mean diameter of ruptured cases was 70mm, bigger than those of elective cases (40mm). There were 9 open surgical treatment, 31 EVAR and 1 hybrid treatment in 41 elective cases. EVAR included 14 bifurcated stent-graft placemen, 13 straight Stent-graft, 2 coil embolization only and 2 failed cases. Two patients with a mycotic aneurysm of the right common iliac artery underwent hybrid treatments. A technical success of treatment was 93.8% without in hospital mortality.

ConclusionsThis study documents the various options in emergency and elective treatment of iliac aneurysms and

endovascular treatment is becoming the first-choice treatment.

KeywordsAneurysm, Iliac artery, Iliac aneurysm, Endovascular procedure

P02-28Paper No: 190Outcomes of open repair of mycotic thoracic and abdominal aortic aneurysms

Hyo-Hyun Kim, Do Jung Kim, Hyun-chel JooDepartment of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea

BackgroundMycotic thoracic and abdominal aortic aneurysms are rare and life-threatening. Unfortunately, no established guidelines exist for the treatment of patients with mycotic aortic aneurysms. The purpose of this study was to evaluate the mid-term outcomes of open repair of mycotic thoracic and thoracoabdominal aneurysms and suggest therapeutic strategy.

Patients and MethodsFrom 2006 to 2016, 19 patients underwent open repair for their aortic aneurysm. Extensive debridement of all infected tissue and aortic reconstruction with csoft tissue overage was performed. We recorded clinical findings, anatomic location of the aneurysm, bacteriology results, antibiotic therapy, morbidity, and mortality. Mean follow-up time was 43.2±11.7 months.

ResultsMedian age was 62±7.2 years (range, 16-78 years), 13 patients (68%) were men, and mean aneurysm size was 44.5±4.9mm. Mean time from onset of illness to surgery was 14.5±2.4 days. Aortic continuity was restored in situ with a Dacron prosthesis (79%), homograft (16%), or Gore-tex (5%) and extra anatomical bypass was performed in one patient. Soft tissue coverage of the prosthesis was performed in 8 patients (42%). Early mortality rate was 10.5% and the 5-year survival rate was 74.9 ±11.5%.

ConclusionThe early and mid-term outcomes of open mycotic thoracic and abdominal aortic aneurysms are favorable. Aggressive intraoperative debridement with in-situ prosthetic reconstruction and soft-tissue coverage yielded a high rate of success in these very high-risk patients.

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Poster Presentation

P02-29Paper No: 198Endovascular aneurysm repair with bifurcated endograft in narrow aortic bifurcation

Shinsuke Kotani, Takumi Ishikawa, Tadahiro Murakami, Hirokazu MinamimuraDepartment of Cardiovascular Surgery, Bellland General Hospital, Osaka, Japan

BackgroundIn endovascular aneurysm repair (EVAR), narrow aortic bifurcation has been shown to be a risk factor for endograft limb occlusion. Although aortouiiliac EVAR has been well established as a safe strategy in these patients, it requires femorofemoral bypass grafting and may result in complications such as graft occlusion and wound complications. However, few study reports the safety and effectiveness of bifurcated endograft in narrow aortic bifurcation. The purpose of this study is to evaluate the early outcomes of EVAR in patient with narrow aortic bifurcation using bifurcated endograft to avoid aortouniiliac EVAR.

MethodsThe clinical data of 87 patients who underwent EVAR between July 2014 and April 2017 at our institution was retrospectively reviewed. Patients with the narrow aortic bifurcation which diameter was less than 18mm were included. Early outcomes were evaluated in terms of technical success, endoleaks, graft patency and ankle brachial pressure index.

ResultsThere were 12 patients (mean age, 79 years) with a narrow aortic bifurcation.

ConclusionsEVAR using bifurcated endograft can be safely performed in narrow distal aorta, even when the diameter is 8mm. Unibody endograft may be effective in case of extremely narrow aorta. We should carefully consider the diameter of proximal aorta as well as distal aorta to avoid graft occlusion.

P02-30Paper No: 204Mid-term outcomes of flared iliac limb used for combined common iliac artery aneurysm during endovascular aneurysm repair

Dong-Heon Lee, Byeoung-Hoon Chung, Yang-Jin Park, Seon-Hee Heo, Dong-Ik Kim, YW KimVascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea

PurposeTo determine the outcomes of flared iliac limb used for combined common iliac artery aneurysm (CIAA) during endovascular aneurysm repair (EVAR).

MethodsThis single center study retrospectively compared outcomes of flared iliac limb (diameter >24mm) (Group 1, 75 limbs in 65 patients) and hypogastric artery embolization with iliac limb extension (Group 2, 101 limbs in 92 patients).

ResultsWe treated 176 CIAAs in 141 (33.5%) patients among 421 EVARs. The median maximum diameter of AAA was 53.2mm (51.3-58) in Group 1 vs. 53.2mm (50.9-62) in Group 2 (P=0.334). Median follow-up was 14.3 months (1.4-33) in Group 1 vs. 24.4 months (6.8-59.7, P=0.008) in Group 2. 30-day re-intervention (8.0% vs. 1.0%, P=0.043) and type 1b or 3 endoleaks (9.3% vs. 1.0%, P=0.011) were significantly higher in Group 1 compared to Group 2. However, iliac limb stenosis or occlusion (1.3% vs. 0%, P=0.426) was not significantly different between the groups. There was no 30-day mortality. During the follow-up, overall limb stenosis or occlusion was not different between two groups, however, re-intervention rate was significantly higher in Group 1 compared to Group 2. There were two aortic aneurysm-related deaths in group 2 caused by late aneurysm rupture from stent graft migration, but there was no significant difference in reintervention-free survival during the follow-up.

ConclusionsThere was significant difference in limb-related complication or re-intervention between flared limb and limb extension during EVAR in mid-term follow-up. Close longer-term follow-up and careful surveillance would be recommended in the patients using flared limb.

P02-31Paper No: 208Bolton relay thoracic stent graft offers precise placement during aortic arch TEVAR and good initial results

Hiroshi Banno, Yohei Kawai, Naohiro Akita, Takayuki Fujii, Takuya Tsuruoka, Masashi Sakakibara, Noriko Takahashi, Masayuki Sugimoto, Kiyoaki Niimi, Akio Kodama, Kimihiro KomoriDepartment of Vascular Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan

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ObjectiveBolton Relay thoracic stent graft has been designed for aortic arch pathology with some specific features. The purpose of this study is to compare the deployment accuracy of this device in aortic arch TEVAR with other devices and report its initial results.

MethodsConsecutive 55 patients (40 men, median 72.5±9.0 y.o.) who underwent TEVAR with proximal fixation in zones 1, 2, or 3 (Ishimaru Classification) from March 2009 to February 2017 were enrolled in this study (3 patients during the same period were excluded due to the absence of available post-operative CT scan and 13 patients were due to intentional placement not just distal to the left subclavian artery). Post-operative (within 1 month after surgery) CT scans were retrospectively reviewed using Aquarius iNtuition software (Terarecon, San Mateo, Calif). Major adverse events (MAEs) included stroke, paraplegia/paraparesis, myocardial infarction, respiratory failure, renal failure, and aneurysm-related mortality.

ResultsAortic arch pathology included 42 aneurysms, 9 aortic dissections, 3 pseudoaneurysms, and 1 patent ductus arteriosus. Bolton Relay stent grafts were implanted in 17 patients, including 2 emergent cases, and others, included 23 TAG, 10 Zenith TX2 and 5 Valiant in 38 patients, including 14 emergent cases. Bolton Relay was used in cases required more proximal fixation. Distance from predetermined launch site was shorter in Bolton Relay group (1.8±2.7mm), compared with that in other devices (3.6±3.2mm) (p).

ConclusionsBolton Relay thoracic stent graft offers precise placement during aortic arch TEVAR and good initial results.

P02-32Paper No: 209Incidence and risk factor for iliac limb stent graft occlusion after endovascular aneurysm repair

K Kritayakirana1, P Kranokpiraksa2, N Chenpen2,N Narueponjirakul1, A Uthaipaisanwong1

1Department of Surgery, King Chulalongkorn Memorial Hospital, Bangkok, Thailand2Department of Radiology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand

BackgroundNowadays, endovascular aneurysm repair (EVAR) is an effective approach in treating abdominal aortic

aneurysm. Apart from Endoleak, iliac limb stent graft occlusion is one of the most well-known stent-related complication which requires reintervention. The incidence from previous study was 2-6 %. This study was intended to determine the incidence and risk factors of Iliac limb stent graft occlusion.

MethodEighty two patients who underwent conventional EVAR during January 2012 to December 2016 from King Chulalongkorn Memorial Hospital were analyzed and iliac limb stent graft occlusion within 30 days were collected. Demographic data, anatomical feature of AAA, technique of EVAR and risk factor for iliac limb stent graft occlusion were analyzed compared between two groups (with or without iliac occlusion).

ResultIncidence of Iliac limb stent graft occlusion within 30-day after EVAR was 6 cases (7.3%). Five cases presented with acute limb ischemia. One case follow up CTA at 1 week after EVAR showed significant decrease flow in iliac limb stent graft without ischemic symptom. The occurrence of iliac occlusion had been reported from immediate postoperative period until 2 weeks after EVAR. Five iliac limb stent graft occlusion occurred in 22 cases with distal landing zone in external iliac artery and 1 iliac limb stent graft occlusion occurred in 60 cases with distal landing zone in common iliac artery. Distal landing zone in external iliac artery was a significant risk factor comparing to landing in the common iliac artery (P=0.001). Other risk factors such as chronic renal failure, small aortic neck or distal diameter, and Endoleak were analyzed but were not statistically significant. For treatment, one case was treated with balloon angioplasty. Four cases underwent femoro-femoral crossover bypass. Another, case of Aorto uni-iliac EVAR with femerofemoral bypass, was treated by axillofemoral bypass. The outcome of treatment was good. None of the cases required secondary procedure.

ConclusionRisk factor for iliac stent graft occlusion was distal landing zone in External iliac artery. High incidence occurred within two weeks after EVAR. Surgical or endovascular management were effective therapeutic procedures.

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Poster Presentation

P02-33Paper No: 228Postoperative renal function after left renal vein (LRV) division during juxtarenal abdominal aortic aneurysm repair

Shinichi Nata, Shinichi Hiromatsu, Shinichi Imai, Ryo Kanamoto, Yusuke Shinitani, Hiroyuki Otsuka, Tohru Takaseya, Satrou Tobinaga, Seiji Onitsuka, Hiroyuki TanakaDepartment of Surgery, Kurume University School of Meidcine,Japan

ObjectivesIn elective AAA repair requiring suprarenal aortic cross-clamping, division of LRV can facilitate the exposure of the pararenal aortic region. This study assessed the effect on postoperative renal function of LRV division.

MethodsBetween January 1, 2001, and December 31, 2016, we underwent AAA repair for 656 at Kurume University Hospital. We evaluated post operative renal function for 30 pts (4.6%) who need suprarenal aortic clamping with/without LRV division (21 pts: LRV preservation group (P) (mean age. 74.5±6.9 years, 20 men and, 1 woman) and 9 pts: LRV division group (D) (mean age, 70.7±8.4 years, 8 men and, 1 woman). We compared early and mid-term postoperative renal function in both groups retrospectively. In both group simple suprarenal cross-clamping was applied without the additional renal protection.

ResultsMean aneurysms size was 59.8±14.8 min in group P and 55.6±9.8 mm in group D (NS). Preoperative serum creatinie, glomerular filtration (GFR) and more than 3 grades of GFR stage were 1.14±0.32 mg/dl (P) vs. 1.03±0.25mg/dl (D), 52.4±17.4 ml/min/1.73m3(P) vs. 56.6±16.1ml/min/1.73m3 (D) and 14 cases (66.7%) (P) Vs. 7cases (77.8%) (D), respectively. Mean operative time, the mean aortic cross clamping time and mean renal ischemia time were 323±71min (P) vs. 336±79min (D), 65.4± 17.7 min (P) vs. 72.0± 18.8min (D) and 30.7±10.9 min (P) and 37.5± 13.9 min (D) respectively. There was no significant difference in the preoperative renal function and intraoperative details between the two groups. No pts required postoperative continuous hemodiafiltration (CHDF) and temporary dialysis and also new postoperative permanent dialysis. There was no hospital mortality. In mid-term outcome (mean observation period, 2.5 years), one patient in each group required permanent dialysis. Progression of CKD stage was 5 pts. (23.8%) in group P and 3pts (33.3%) in group D, respectively (NS).

ConclusionsLRV division of elective AAA repair requiring suprarenal aortic cross-clamping did not deteriorate post operative renal function in early and midterm period compared to LRV preservation group. Therefore, LRV division is useful and safe optional tool to get good exposure of pararenal aortic region for AAA repair with supraaortic clamping.

P02-34Paper No: 234Hybrid procedure in high landing zone abdominal aorta aneurysm with multiple aneurysm

Maheranny M, Suhartono, Jayadi AVascular and Endovascular Surgery Division, Departement of Surgery, Faculty of Medicine Universitas Indonesia/Cipto Mangunkusumo National Hospital Jakarta, Indonesia

BackgroundThe proximal aortic neck is one of the limiting factors for endovascular aneurysm repair (EVAR) and represents a crucial factor for success or failure of the procedure. A hybrid procedure was chosen: bypass from renal arteries to external iliac arteries and superior mesenteric artery to celiac artery after that we did EVAR. We did bypass procedure for vascularization gastrointestinal and renal. Aneurysm in right subclavia artery we did endovascular repair.

Case ReportFemale 58 years old, with complain a lump in the left abdomen raised since 5 months before came hospital. The lump is painless, getting bigger. Patients had ultrasound examination with result aortic aneurysm with thickening of the arterial wall, we diagnosed with Abdominal Aorta Aneurysm.

From Physical examination there was palpable pulsatile mass, at the upper left abdomen about 8x12cm. From CTA there was proximal landing zone below celiac artery as high as vertebral spine L1, the distance between the aneurysm and celiac artery 13,5mm with neck diameter 22,8 - 22,9mm, the largest diameter 51,3 - 59,2mm, from celiac artery to bifurcatio aorta 144,1 mm, diameter of bifurcatio 14,5mm, no calsification of RCIA and LCIA with severe tortuosity, diameter of RCIA 11,8 - 11,9mm and LCIA 11,3 - 11,6mm. Aneurysm in the right subclavia artery there was with the largest diameter 51,2 - 52,9mm with neck diameter 8,4 - 9,3mm.

We started procedure with bypass from renal arteries to external iliac arteries and superior mesenteric artery

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to celiac artery after that we did EVAR. For Aneurysm in the right subclavia artery we did endovascular repair with cover stent. After 4 months we evaluated with CT angiography with contras with result decreased blood flow to the renal artery. We did bypass from left femoral artery to right femoral artery ResultThe patient tolerated the procedure well and was discharged home on day 7. Subsquent postoperative CTA will be heald after 3 month as a first evaluation.

KeywordAbdominal Aorta Aneurysm

P02-35Paper No: 244Mid-term outcome following embolization of the internal iliac artery before endovascular abdominal aortic aneurysm repair

Riha Shimizu1, Takayuki Hori2, Yasushi Matsushita1, Hirotsugu Fukuda2

1Department of Cardiac and Vascular Surgery, Dokkyo Medical University Nikko Medical Center, Nikko, Tochigi, Japan2Department of Cardiac and Vascular Surgery, Dokkyo Medical University Hospital, Mibu, Tochigi, Japan

PurposeEndovascular abdominal aortic aneurysm repair (EVAR) is performed outside of instructions for use (IFU). In Japan, there is no iliac branch device. Therefore, internal iliac artery (IIA) embolization require due to extension of external iliac artery (EIA). We report our mid-term outcomes after EVAR with EIA landing by coil embolization to IIA.

MethodA total of 191 patients underwent EVAR for AAA from 2010 to 2016. 64 patients who underwent elective EVAR with EIA landing. The outcomes were assessed retrospectively by reviewing medical records and follow-up imaging.

ResultThe mean follow-up for all patients was 36.3±20.1 months. 4 patients were treated bilateral IIA coil embolization, and 9 patients were underwent unilateral IIA coil embolization with EIA-IIA bypass. IIA embolization was technically successful in 100% of cases. By Kaplan-Meier analysis, over all survival at 1 year and 5 years was 93.2% and 69.6%. There was no aortic death. Buttock claudication was reported in 17% of cases, 2 (3%) were ongoing 1 year over. 2 patients

were with distal IIA embolization. There was no difference in bilateral IIA coil embolization and unilateral IIA coil embolization with EIA-IIA bypass. No bowel ischemia occurred in this series. Reintervention free survival at 1 year and 5 years was 98.2% and 70.6%. 9 (14%) reinterventions were performed. 1 patient had stentgraft occlusion due to EIA heavy angulation. Therefore, we use Excluder leg to reduce graft kinking. After that there was no stentgraft occulusion.

ConclusionCoil embolization to IIA before EVAR is safe. This suggests that IFU can be extended to require EIA landing.

P02-36Paper No: 245Initial results of TEVAR for uncomplicated type B dissection using custom-made thoracic fenestrated stent graft

Soichiro Fukushima1, Naoki Toya1, Eisaku Ito1, Yuri Murakami1, Tadashi Akiba2, Takao Ohki3

1Department of Surgery, Division of Vascular surgery, The Jikei University Kashiwa Hospital, Chiba, Japan2Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan3Department of Surgery, Division of Vascular Surgery, The Jikei University School of Medicine, Tokyo, Japan

BackgroundMost type B aortic dissection (TBAD) have their primary tear at the distal side of the left subclavian artery, but some patients show retrograde progression towards the aortic arch. We have treated TBAD including the aortic arch by thoracic endovascular aneurysm repair (TEVAR) with aortic arch reconstruction using custom-made fenestrated stent graft. We report our initial results of TEVAR for TBAD.

MethodsOur strategy is to treat TBAD by TEVAR with over 2cm proximal landing zone at healthy aorta, and we use custom-made fenestrated stent graft for uncomplicated case if it is anatomically suitable.

Between 2011-2017, we treated 48 cases of uncomplicated TBAD by TEVAR, in which 23 cases were treated with aortic arch reconstructions. Of these cases, we used custom-made fenestrated stent graft in 12 cases (F group), and debranching TEVAR in 11 cases (D group). We retrospectively compared the 2 groups. Primary endpoints were technical success, mortality, morbidity (retrograde type A dissection (RTAD), stroke, type 1a endoleak).

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Poster Presentation

ResultsIn the F group, we used the Najuta® custom-made fenestrated stent graft, and in the D group, we used other non-fenestrated stent graft. According to the zone classification, zone 0,1,2 TEVAR were 6,5,1 cases in the F group, and 1,5,4 cases in the D group, respectively. Technical success rate was 91.7% in the F group, and 90.5% in the D group. The mortality rate was 0%, and there was no RTAD in both groups. In the F group, there was 1 case of type 1a endoleak, and in the D group, there was 1 case of stroke and another case of type 1a endoleak. There was no statistical difference between 2 groups in mortality, or morbidity. But, the mean operation time was shorter in the F group (151min) than in the D group (255min) (p<0.01), and also the postoperative hospital stay was shorter in the F group (7days) than in the D group (22days) (p=0.04<0.05).

ConclusionsInitial result of aortic arch reconstruction duringTEVAR for TBAD was acceptable. Custom-made fenestrated stent graft may be a useful option for aortic arch reconstruction during TEVAR for TBAD.

P02-37Paper No: 255Endovascular treatment combined with open surgery for malperfusion in acute type A aortic dissection

Tassei Nakagawa1, Soichiro Hase1, Motoshige Yamasaki1, Nobukazu Moriya1, Susumu Oshima2, Kensuke Ozaki2, Shigeru Sakurai2, Junichi Shimamura2, Yuki Hirai2, Tomohiro Hirokami2, Syuichi Tochigi2, Makoto Okiyama2, Koichi Akutsu2, Shin Yamamoto2, Shiro Sasaguri2

1Endovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kanagawa, Japan2Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kanagawa, Japan

BackgroundTo present the early outcomes of endovascular treatment combined with open repair for malperfusion in acute type A aortic dissection (ATAD).

MethodsA total of 191 patients underwent open surgery for ATAD between January 2016 and May 2017 in Kawasaki aortic center. These patients were retrospectively reviewed regarding malperfusion syndromes except coronary circulation and central nervous system, in which endovascular approach was treatment of choice combined with open repair.

ResultsMalperfusion syndromes indicative for endovascular treatment were diagnosed in 18 (9.4%) patients and were involved in mesenteric circulation in 8 patients, limb ischemia in 13 patients, and renal circulation in 3 patients. 17 out of 18 patients with malperfusion syndromes underwent hemi-arch replacement in hypothermic circulatory arrest and one patient underwent total arch replacement. Among them, 8 (44.4%) patients underwent thoracic endovascular aortic repair (TEVAR) concomitant with superior mesenteric artery (SMA) stenting in one patient and concomitant with iliac percutaneous transluminal angioplasty (PTA) with stenting in 2 patients. SMA stenting was performed in 8 patients, iliac PTA in 8 patients, brachial PTA in one patient, and renal PTA in one patient. 15 (83.3%) patients underwent endovascular treatments in acute phase and each one case of TEVAR, iliac PTA, and renal PTA performed in the subacute phase.

In-hospital mortality was 22.2% (4 out of 18 patients). One patient died of gastrointestinal necrosis, one died of multi-organ failure secondary to DIC, and two patients died probably of descending aortic re-dissecting rupture following TEVAR and hemi-arch replacement which was shown by autopsy imaging.

ConclusionsTEVAR and PTA with stenting may be feasible treatment of choice for malperfusion in acute type A aortic dissection combined with open repair. Besides ischemia, descending aortic re-dissection might be critical after TEVAR with central open repair.

P02-38Paper No: 258Different level Sandwich technique treatment for Type V endoleak after EVAR by SEAL graft in abdominal aortic aneurysm patient

Dong Hyun Kim1, Sang Bong Lee1, Soon cheon Lee2, Yung Baom Park3, Min Sang Song4, Sang Su Lee1

1Department of Surgery , Pusan National University School of Medicine, Yangsan, Korea2Gwangyang Sarang Hospital, Gwangyang, Korea3Cheongmac Vascular and Vein clinic, Busan, Korea4Dongrae Bongseng Hospital, Busan, Korea

Since 2007, the availability of the Seal (S & G Biotech Inc, Seong-nam, Gyeonggi-do, Korea) stent graft for endovascular aneurysm repair (EVAR). IT hras been used for EVAR in Korea and a few other Asian countries. These devices have two main body types (bifurcated and tubular), with the bifurcated type consisting of an

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unsupported main body graft and an inner bare metal stent, which facilitates a smaller diameter for the preloaded 15-Fr introducer sheath.

PurposeTo describe the successful Different level Sandwich technique treatment for Type V endoleak after EVAR by SEAL graft in abdominal aortic aneurysm patient.

Case reportA men aged 75 years presented with type V endoleak for 6 years and enlarged 5.3cm to 6.7cm after initial EAVR by seal stent graft. Endurant Extender cuff (28mm x 3.3cm) endoprosthesis were deployed in the stent-grafts, and the both limbs (16mm diameter, respectively) were located different level sandwich technique to seal the defect and eliminate the endoleak. The perioperative periods were uneventful. At up to 6-month follow-up, no endoleaks were detected, aneurysm diameters were unchanged, and the endografts were patent.

ConclusionDifferent level Sandwich technique may prove useful for the treatment of Type V endoleak after EVAR in abdominal aortic aneurysm.

P02-39Paper No: 261Risk factor analysis for persistent Type 1a endoleak after standard EVAR

Seon-Hee Heo, Dong-Heon Lee, Byeoung-Hoon Chung, Shin-Young Woo, Yang-Jin Park, Dong-Ik Kim, Young-Wook KimVascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

PurposeTo determine risk factors for persistent Type 1a endoleak (T1aEL) after standard EVARs for patients with infrarenal abdominal aortic aneurysm(AAA).

MethodA retrospective review was conducted with a database of patients who underwent standard EVAR outside of instructions for use (IFU) regarding proximal neck anatomy at a single institute. For surveillance after EVAR, duplex ultrasonography (DUS) or CT scan was performed before hospital discharge and every 3-6 months after EVAR. We investigated occurrence of T1aEL, secondary intervention including open conversion, AAA rupture, and AAA-related death. To determine risk factors for T1aEL, univariate and multivariate analyses were conducted with ÃŸ-angle

>60°-75°, short neck >3mm at the proximal neck), large diameter (>28-32mm; according to device-specific IFU), aortic wall thrombus or calcification >50% of arotic circumference (various anatomic factors).

ResultsAmong 424 patients who underwent standard EVARs, 101 (23.8%) patients (male, 85%; mean age, 72 years, no ruptured AAA) underwent EVAR out of device-specific IFU regarding proximal neck anatomy. On the completion angiograms during the EVARs for those patients, 32 (32%) T1aEL were noted. To treat T1aEL, repeated balloon molding was performed for all patients and adjuvant endovascular procedures were performed in 32 (100%) patients which included use of proximal extension cuff (n=9), Palmaz stent (n=4) or coil embolization (n=1). By the intraoperative adjunctive procedures, 14 (47%) T1aEL was abolished. During the follow-up period (median 32.5 months), 9 (22%) T1aEL were spontaneously abolished while 7 (7%) T1aEL persisted. For patients with persistent T1aEL, 2 open conversions and 3 secondary endovascular interventions were performed. To determine risk factors for persistent T1aEL after standard EVARs, univariate and multivariate analysis were conducted. Among the anatomical variables, infra-renal aortic angle >60° was an independent risk factors for persistent T1aEL after standard EVARs. During the follow-up period, there was no aneurysm rupture or AAA-related mortality among those patients with persistent T1aEL.

ConclusionAfter standard EVARs for patients with hostile proximal neck, T1aEL was frequently detected. However, infra-renal aortic angle >60° was an only risk factor for persistent T1aEL.

P02-40Paper No: 267Endovacular exclusion of abdominal aortic aneurysm in patients with concomitant abdominal malignancy

Soo Jin Na Choi, Hong Sung Chung, Hokyun Lee, Sang Young ChungDepartment of Surgery, Chonnam National University, Gwangju, Korea

PurposeTo assess the outcomes of endovascular aortic aneurysm repair (EVAR) for the treatment of abdominal aortic aneurysm in patients undergoing curative surgical treatment for concomitant abdominal malignancy.

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Poster Presentation

Material and MethodsMaterials were 23 patients with both abdominal neoplasia and AAA were treated by surgical method and EVAR. The neoplasm consisted with gastric, colorectal, pancreas, prostate and gall bladder. The follow up period was 3-57 months (mean 25.8 months). All medical record and imaging analysis were reviewed with CTA and/or color Doppler US, retrospectively.

ResultsSuccessful endoluminal repair was accomplished in all twelve patients. The mean interval after EVAR to surgery was 58.6 days. Small amount of type 2 endoleaks were detected in four patients (17%). Adult respiratory distress syndrome after Whipple’s operation on postoperative 20th day was developed in one patient, which led to hopeless discharge. There were no procedure-related mortalities or morbidity and graft-related infection.

ConclusionExclusion of AAA in patients with accompanying malignancy show with a relatively low procedure morbidity and mortality. So endoluminal AAA repair in patients with synchronous neoplasia may allow greater flexibility in the management of offending malignancy.

P02-41Paper No: 272Composite endografts for chronic aortic dissecting aneurysm””EVAR for TEVAR

Ming Qi, Yan Wang, Nai-Wen TsaoCenter of Vascular Surgery, Department of Surgery, Wuhan Asia Heart Hospital, Wuhan, China

BackgroundThe treatment of aortic dissection was one of the main issue in the developing category of endovascular aortic intervention; both of devices and methods. Chronic aortic dissecting aneurysms (CADA) with symptoms and specific size were indicated to interfere for prevention of rupture and resolution of discomfort. We introduce a novel method that combined bifurcated mainbody, double lumen endografts and candy-plug device to repair a CADA.

Case ReportA fifty-five years old male was a victim of DeBakey Type I aortic dissection, who underwent Bentall procedure and total aortic arch repair with intra-operative frozen elephant trunk (FET) stent 10 years ago. Follow-up contrast computed tomography (CT) scan revealed the FET stent overridden a distal end induced intimal

entry and the false lumen of residual DeBakey Type III aortic dissection was dilated to form a CADA, by the way, left lower limb and some visceral arteries were perfused by false lumen. Patient hesitated to receive another open surgery for informed high risks. Upper back pain also developed in recent 3 months. Both anatomy and symptom were indicated to interfere. We performed thoracic endovascular aortic repair (TEVAR) with composite endografts combined with bifurcated mainbody stent-graft that was designed for endovascular aortic repair (EVAR), parallel limb endografts and a stent-graft rebuilt candy-plug device. We named this composite endografts as an EVAR-TEVAR stent-graft. Postoperative CT scan showed the complete exclusion of thoracic CADA and no endoleak was detected. The perfusion of visceral and lower limb arteries were reserved.

ConclusionThe combination of composite EVAR-TEVAR stent-graft plus candy-plug device could treat CADA and preserve those false lumen perfused visceral and lower limb arteries, especially when prior FET stent had provided an appropriate landing zone.

P02-42Paper No: 273Is age over 85 years a limiting factor to undergo an EVAR in patients with infrarenal AAA?

Wah Wah Lin, Robert Tewksbury, Jens Carsten RitterDepartment of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia

BackgroundWe analyzed midterm survival of endovascular abdominal aortic aneurysm repair (EVAR) in patients 85 years and older as compared to early octagenerians.

MethodsData for 96 patients who underwent elective EVAR between 01/01/2010 and 31/12/2015 were retrospectively reviewed. 37patients (38.54%) were 85 years or older (study group [SG]; mean age, 91 years; range, 85-97 years), and 59 patients (61.46%) were 80 - 84 years old (control group [CG]; mean age, 82 years). Statistical analysis was undertaken using the Chi-Square test.

ResultsData will be presented.

ConclusionElective EVAR in patients 85 years and older is safe and effective over midterm follow up. Although EVAR has

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been shown to be appropriate in selected octagenerians, patients 85 years and older have shown to have a comparable survival rate compared to patients 80-84 years. Advanced chronologic age is not associated with diminished procedural outcome, clinical success, or peri-operative survival, compared with younger age. Therefore, age over 85 years should not preclude patients from undergoing EVAR.

P02-43Paper No: 283Open surgery repair of an aortic stent migration after unsuccessful endovascular abdominal aorta aneurysm repair

Inga Ä akoviÄ‡ Bacalja1, Lidija Erdelez2, Predrag PaviÄ‡2, Slaven SuknaiÄ‡2

1Department of Surgery, General Hospital Bjelovar, Bjelovar, Croatia2Department of Vascular Surgery, Clinical Hospital Merkur, Zagreb, Croatia

BackgroundEndovascular aneurysm repair (EVAR) has revolutionized abdominal aorta aneurysm repair and provided a safe and efficacious treatment in both elective and acute settings. However, in case of EVAR complications, open surgical repair is often treatment of choice. We present an EVAR complication, a stent migration and an aortic obliteration by the stent. Rates of aortic stent migration range from 3,6-16,6% with a tendency to increase over time.1

Methods and ResultsA 56-year old woman was admitted to our ward with a previously diagnose of Leriche syndrome. She was initially presented with a short pain-free walking distance 20-50m and the absence of femoral pulsation. Multislice computed tomography angiography (MSCTA) revealed a significant stenosis (70%) of infrarenal aorta and patent iliac arteries. A percutaneous transluminal angioplasty (PTA) was performed and a self-expandable tube stent was placed 28mm below renal arteries’ ostia. A statin and 100mg of acetylsalicylic acid were administered. 7,5 months later the patient returned to our hospital with absent femoral pulsation and ischemic changes of her right foot. MSCTA showed a collapsed stent moved caudally occluding infrarenal aorta. During open surgery, the stent was removed and an aortobiiliac bypass was created together with thrombectomy of the right femoral, popliteal and crural arteries. She was followed up for 4 years biannually.

ConclusionsWhile endovascular procedures offer significantly lower short term complications, it is estimated that there is a significantly higher rate of long term complications comparing to open surgery.2,3 Risk factors, such as aneurysm morphology, continued aneurysm degeneration have been estimated to have an impact on possible stent migration.1 These should be taken into consideration when choosing type of stent and a technique of installation. In the case described, a bifurcation system would have possibly been more appropriate or additional fixation techniques (endostapling).4

P02-44Paper No: 294A multicenter experience with abdominal aortic endograft infection in Japan

Kentaro Matsubara1, Hideaki Obara1, Norio Uchida2, Atsunori Asami3, Taku Fujii3, Hirohisa Harada4, Koji Osumi5, Shintaro Shibutani6, Tsunehiro Shintani7, Susumu Watada8, Shigeshi Ono9, Tatsuya Shimogawara9, Naoki Fujimura10, Yasuhito Sekimoto11, Yuko Kitagawa1

1Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan2Department of Surgery, Mito Red Cross Hospital, Mito, Ibaraki, Japan3Department of Surgery, Saitama City Hospital, Saitama, Saitama, Japan4Department of Surgery, Saiseikai Central Hospital, Minato, Tokyo, Japan5Department of Surgery, Hiratsuka City Hospital, Hiratsuka, Kanagawa, Japan6Department of Vascular Surgery, Saiseikai Yokohamashi Tobu Hospital, Kawasaki, Kanagawa, Japan7Department of Vascular Surgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan8Department of Surgery, Kawasaki Municipal Hospital, Kawasaki, Kanagawa, Japan9Department of Surgery, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba, Japan10Division of Vascular Surgery, Saiseikai Central Hospital, Minato, Tokyo, Japan11Department of Surgery, Tokyo Medical Center, Meguro, Tokyo, Japan

BackgroundEndovascular aneurysm repair (EVAR) is widely used with stable results, and its infectious complication is considered to be rare with poor prognosis. However, there is still no definite treatment strategy. We report a Japanese multicenter experience with infected EVAR and their outcomes.

MethodsIn 110 months from July 2007 to August 2016 at our department and related facilities, 1407 EVARs for

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Poster Presentation

abdominal aortic aneurysms or iliac artery aneurysms were performed, and patients diagnosed with infected endografts were reviewed.

ResultsSeven patients (0.5%) with an infected endograft were identified. The implanted device was 4 of Excluder and 3 of Zenith. Median time between EVAR procedure and diagnosis of endograft infection was 7 months (2.8 - 31 months). Clinical findings at presentation included fever (n=5), abdominal/ back pain (n=3), and rupture (n=1). Preoperative blood cultures were gram-positive (n=2) and gram-negative (n=1). Medical treatment with antibiotics was performed in 6 patients except for a ruptured patient. Ultimately, 5 of 7 patients underwent endograft explantation after a median of 17 days (0-40 days). In situ aortic replacement was performed in all 5 patients using autogenous femoral vein in 3 and prosthetic graft in 2. Early mortality was only in a ruptured patient who died the day after the surgery, and median hospital length of stay was 38 days in survived 4 patients. Two patients who had been managed only medically died 6 months by comorbidity and 22 months by graft-related.

ConclusionsAortic endograft infection after EVAR should be treated by excision and in situ or extra-anatomic replacement in principle. When the patient’s general condition is stable, replacement using autogenous femoral vein graft might be recommended.

P02-45Paper No: 295Mini Aortic Repair

Takashi Murakami, Hiromichi Fujii, Yosuke Takahashi, Akira Morisaki, Shinsuke Nishimura, Daisuke Yasumizu, Yoshito Sakon, Kokoro Yamane, Tohihiko ShibataDepartment of Cardiovascular Surgery, Osaka City University, Osaka, Japan

BackgroundOpen aortic repair via partial ministernotomy has been reported in some small cohorts with promising results. We describe our preliminary experiences of mini-aortic repair for thoracic aortic aneurysm via partial upper sternotomy in 7 patients.

MethodsThis retrospective study includes 7 patients who underwent mini-aortic repair for TAA between May 2016 and April 2017. The patients’ age were from 68

to 79 years old, and 5 patients were male. Hemiarch replacement with aortic valve procedure was performed in 4 patients and total arch replacement (TAR) with the use of frozen elephant trunk in 3 patients. Upper partial sternotomy with reversed T shape, or more recently L shape, to the 4th intercostal space were made. Central aortic cannulation, femoral venous cannulation, and pulmonary artery venting were our standard. For TAR, antegrade selective cerebral perfusion (ACP) was employed, whereas for hemiarch replacement, retrograde cerebral perfusion (RCP) was used. Body temperature during circulatory arrest was 25 „ƒ in all cases.

ResultsThe surgical procedure was successfully completed in all patients without conversion to full sternotomy. There was no perioperative death or 30-day mortality.

The mean cardiopulmonary bypass time in hemiarch replacement and TAR were 191±46.1 minutes and 228±10.7 minutes, respectively. Circulatory arrest time was 32±9.3 minutes and 49.7±5.9 minutes, respectively. Even with moderate hypothermia, circulatory arrest with retrograde cerebral perfusion for 27 to 41 min was well tolerated. No postoperative permanent neurological complication occurred. Three patients experienced pericardiocentesis. Three patients were operated by surgical fellows. ConclusionsOur preliminary experience suggests that mini-aortic repair for TAA was feasible and reproducible, despite a limited operative field, without compromising surgical outcomes.

P02-46Paper No: 299Early experiences of the sandwich technique to preserve pelvic circulation during endovascular aneurysm repair

Kyunglim Koo1, Hyung Sub Park1, Daehwan Kim1, In Mok Jung2, Taeseung Lee1

1Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea2Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea

Background Background: Preservation of pelvic flow during endovascular repair (EVAR) of complex aortic or aortoiliac aneurysms is important to prevent complications ranging from buttock claudication to

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bowel ischemia or pelvic necrosis. In this study we report our early experiences of using the sandwich technique (ST) for preservation of pelvic flow during EVAR.

MethodsEight patients underwent elective EVAR using the ST between March 2013 and February 2017. The anatomic indications for the ST were complex aortoiliac aneurysms with no distal landing zones in the common iliac artery (CIA) and/or coexistence of large internal iliac aneurysms (IIA) in 5 cases, abdominal aortic aneurysms (AAA) with non-diseased but short bilateral CIAs in 2 cases and AAA with an occluded unilateral CIA in 1 case. The ST was performed through bilateral femoral and brachial approaches. Patient clinical and radiologic data were collected and analyzed.

ResultsEight patients (7 male; mean age 73.4 years) were followed over a mean period of 277 days (range 9-1106 days). The technical success rate was 100%. Adjunctive procedures included IIA embolization, physician modified iliac branch device placement, and crossover femoro-femoral bypass. The primary patency rate of the iliac stent-grafts was 88% (14/16): 1 internal iliac and 1 external iliac stent-graft occlusion was found during the early postoperative period. The external iliac graft occlusion was reintervened by thrombolysis and additional stent insertion while the internal iliac graft occlusion was simply observed. There was also 1 gutter endoleak which disappeared spontaneously within 4 days, and there were 2 type II endoleaks: one treated by coil embolization after 13 months, and the other observed without treatment. There were no cases of sac growth or aneurysm-related deaths, and no cases of buttock claudication or impotence during the follow-up period.

ConclusionsThe ST is a safe and feasible technique to preserve pelvic circulation during endovascular treatment of complex aortoiliac aneurysms. The need to expand the indications for complex EVARs with adjunctive procedures such as the ST is highlighted especially in situations where branched/fenestrated device availability is limited.

P02-47Paper No: 301Clinical audit: Outcome of open vs. endovascular treatment of mycotic aortic aneurysms in two vascular centres in Malaysia

Izzuddin A1, Vinoshini DK2, Siti Fareeda3, Lenny SS1, Tan Yee Ling1, Syed Alwi3, Azim I1, Chew Loon Guan4, H Harunarashid1

1Universiti Kebangsaan Malaysia (UKM) Medical Centre, Malaysia2International Medical University (IMU), Malaysia3Hospital Sultanah Aminah Johor Bahru (HSAJB), Malaysia4Hospital Serdang, Malaysia

IntroductionThis clinical audit is to compare the survival rate of patients whom was treated via open vs endovascular repair and to determine the complications of open vs endovascular repair, the length of hospital stay, common organisms, choices of antibiotics, duration of sterilization prior to repair, emergency vs elective repair and the choice of graft being used during the repair. MethodologyThis is a restrospective audit of cases in Universiti Kebangsan Malaysia Medical Centre (UKMMC), Hospital Serdang and Hospital Sultanah Aminah Johor Bahru (HSAJB) done between year of 2009 until 2016. Data was obtained using the hospital information system, post-operative reports and laboratory report database. A retrospective analysis was done on patients diagnosed with mycotic aortic aneurysm evidenced by infective symptoms, infective markers, Computed Tomography (CT) findings and a positive culture. Data collection includes dimension of the aneurysms on CT, septic parameters and operative intervention. ResultsWe identified 17 patients who received treatment for mycotic aneurysm of abdominal aorta, 10 were from UKMMC, 4 from HSAJB and 3 from Hospital Serdang respectively. 13 of them were male patients while 4 were female patients; from the ages from 54-84 with a mean age of (66.1±9.758) years. The mean length of hospital stay prior to operative intervention was (25.2±17.139) days. All patients had both a positive history of infection and had a CT scan done. 16 patients had an infrarenal aneurysm while one had a juxtarenal aneurysm. Total White Cell Count was elevated in all patients with a mean Total White Blood Cell Count of (21.50±10.074) x10^9/L. ESR was taken for only 7 patients and was found to be elevated with a mean ESR of (86.14±33.578)mm/Hr. The mean C- reactive protein (CRP) obtained from our audit is (15.79±5.662).

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Poster Presentation

Out of 17 patients, 14 were sterilized with antibiotics prior to operative intervention. 15 out of 17 patients underwent open repair of the mycotic aneurysm while two underwent EVAR. As for survival after operation, 12 were still alive for open repair while only one was alive for EVAR approach.

Our clinical audit has found that PTFE was used for all open repair except for one were repaired using Dacron. ConclusionThe main modality used to treat mycotic aneurysms is still open repair despite the accessibility of EVAR. Open repair in comparison to an endovascular approach leads to a longer hospital stay and a longer operative time. Outcome of survival in open repair does seem better in comparison with EVAR.

P02-48Paper No: 323Initial outcomes of emergency thoracic endovascular aortic repair in our hospital

Hirotoki Ohkubo, Toshiaki Mishima, Tadashi Kitamura, Rihito Horikoshi, Haruna Araki, Takamichi Inoue, Kenjiro Sakaki, Miyuki Shibata, Yuuki Tanaka, Kensuke Kobayashi, Mitsuhiro Hirata, Shinzou Torii, Kagami MiyajiDepartment of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan

BackgroundOpen surgical repair is the operative procedure of choice for the emergency treatment of aneurysms of the thoracic aorta in our hospital. However, we perform emergency thoracic endovascular aortic repair (TEVAR) in patients who cannot tolerate surgery or who cannot undergo open surgical repair.

Subjects and MethodsAmong the 15 patients who underwent emergency TEVAR from January 2016 through March 2017, we excluded 1 patient who concurrently underwent arch replacement and studied the other 14 patients. The mean age of the subjects was 71±21 years, and 7 of the patients were men. The diagnosis was rupture of a thoracic aortic aneurysm in 8 patients, rupture of the distal arch of a Stanford type B acute aneurysm of the thoracic aorta in 1 patient, rupture of a vascular anastomosis after replacement of the thoracoabdominal aortic aneurysm in 1 patient, traumatic injury of the thoracic aorta in 2 patients, iatrogenic injury in 1 patient, and rupture of an Visceral artery aneurysm in 1 patient. Nine patients had preoperative shock, and 6 patients had disturbed consciousness.

Contrast-enhanced computed tomography was performed in all patients to decide the size of the stent graft. A Conformable Gore TAG stent graft was used in all patients, with deployment distal to Zone 1.

ResultsTwo patients underwent 2-debranching TEVAR to preserve the landing zone on the peripheral side. Visceral debranching TEVAR was performed in 2 patients to preserve the landing zone on the peripheral side. The operation time was 239±168 minutes. Five patients (35.7%) died within 30 days after surgery. The cause of death was hemorrhagic shock in 2 patients, exacerbation of chronic obstructive pulmonary disease (COPD) in 1 patient, rupture of an abdominal aortic aneurysm in 1 patient, and rupture of a thoracoabdominal aortic aneurysm in 1 patient.

ConclusionsTreatment outcomes were very difficult to evaluate for sampling bias. However, the mortality rate 30 days after surgery was satisfactory. We conclude that emergency TEVAR may lead to improved treatment outcomes in patients with rupture or injury of the thoracic aorta.

P02-49Paper No: 327Hybrid endovascular repair for multiple visceral artery aneurysms and thoracoabdominal aortic aneurysm; A case report

Takuya Matsushiro, Hirotoki Ohkubo, Mitsuhiro Hirata, Toshiaki Mishima, Shinzo Torii, Tadashi Kitamura, Kensuke Kobayashi, Kagami MiyajiDepartment of Cardiovascular Surgery, Kitasato University, Sagamihara, Kanagawa, Japan

Case reportA 51-year-old male was admitted to our hospital because of right back pain.

The patient was followed up with hypertension and rheumatoid arthritis.

In 2014 he underwent emergency operation for ruptured thoracoabdominal aortic aneurysm. In 2015, he underwent emergency EVAR for pseudoaneurysm at the distal anastomosis. In 2016, he underwent surgical repair for left common femoral artery aneurysm due to previous puncture. Subsequently he developed right common iliac artery pseudoaneurysm at the distal landing of the previous EVAR, and underwent stent grafting.

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This time he presented to the emergency department with right back pain.

CT showed Crawford type V thoracoabdominal aortic aneurysm, celiac artery aneurysm, SMA aneurysm, rupture of huge right renal artery aneurysm and extensive infarcts in the right kidney. Therefore we chose Hybrid endovascular repair. The proximal end of an Intergard knitted graft was anastomosed to the EIA. Then the distal branches were anastomosed to SMA, common hepatic artery and splenic artery. The right renal artery had aneurysmal dilatation throughout the length and therefore it was impossible to reconstruct it. After debranching, a Gore Dryseal sheath was inserted to the 8-mm branch of the graft and a Gore CTAG was placed from the level of 6th thoracic vertebra down to the previous Excluder. In this case, the most serious problem was rupture of the right renal artery, and there were celiac artery and SMA aneurysms as well. In addition, the patient had newly developed Crawford type V thoracoabdominal aortic aneurysm which also needed to be treated in a redo situation. However, the open surgical repair remains a significant challenge with considerable perioperative morbidity and mortality in this case. Taking all these into account, hybrid operation was considered to be the only solution in this case. Hybrid endovascular repair was effective to treat multiple visceral artery aneurysm and concomitant thoracoabdominal aortic aneurysm.

P02-50Paper No: 331Accurate assessment of cross-sectional area reduction of the aortic ostium by synchrotron radiation

Zhonghua Sun, Curtise, KC NgDepartment of Vascular Surgery, NICVD, Dhaka, Bangladesh

BackgroundComputed tomography (CT) imaging is the preferred imaging modality for follow-up of endovascular stent graft repair of abdominal aortic aneurysm. However, its spatial resolution is limited hindering accurate assessment of cross-sectional area reduction of the aortic ostium by stent wires. Here we report our experience of assessment of cross-sectional area reduction of the aortic ostium by synchrotron radiation based on a phantom study.

MethodsThis study was performed on a human aorta phantom with a Zenith AAA stent graft placed in the aorta to simulate treatment of abdominal aortic aneurysm.

Synchrotron radiation scans were performed on imaging and medical beamline at the Australian Synchrotron facility, with use of beam energy between 40 and 100 keV, with spatial resolution of 19.88 µm per pixel. Cross-sectional area reduction of the aortic ostium by suprarenal stent wires was calculated based on these exposure factors and was compared with that from computed tomography (CT) angiographic images which were performed on a 64-slice CT with slice thickness of 1.0, 1.5 and 2.0 mm.

ResultsImages acquired with synchrotron radiation showed less than 10% of the cross-sectional area occupied by stent wires when a single wire crossed the renal ostium, and less than 20% for two wires crossing the aortic ostium. The corresponding areas were between 24% and 25%, 40% and 48% for single and two wires crossing these aortic ostia, respectively when measured on CT images. The stent wire was accurately assessed on synchrotron radiation with diameter between 0.38 ± 0.01 mm and 0.53 ± 0.03 mm which is close to the actual size of 0.47 ± 0.01 mm. The wire diameter was overestimated on CT images ranging from 1.15 ± 0.01 mm to 1.57 ± 0.02 mm.

ConclusionWe demonstrate the superiority of synchrotron radiation over CT for more accurate assessment of aortic stent wires and cross-sectional area reduction of the aortic ostium.

P02-51Paper No: 337Analysis of biomarkers regarding inflammation and coagulation/fibrinogenolysis system in cases with endovascular aneurysm repair for abdominal aortic aneurysm

Rie Kageyama1, Hirofumi Midorikawa1, Kyohei Ueno1, Gaku Takinami1, Megumi Kanno1, Hirotsugu Fukuda2

1Department of Cardiovascular Surgery, Southern TOHOKU General Hospital2Department of Cardiac and Vascular Surgery, Heart Center, Dokkyo Medical University Hospital

Endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) has widely spread, and good long-term results has also reported. However, there are a few reports about abnormality of biomarkers regarding inflammation and coagulation/fibrinogenolysis system due to remained aneurysm sac. We evaluated these biomarkers in our cases before and after EVAR. We analysed white blood cell (WBC), C-reactive protein (CRP), Platelet (Plt), fibrinogen (Fib) and fibrinogen

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Poster Presentation

degradation products (FDP) as biomarkers of inflammation and coagulation/firinogenolysis system at before surgery, postoperative day 1, 3, 5, and 7 in 64 patients (mean age 75 years old) treated by EVAR using Excluder endograft. Endoleak was evaluated by contrast CT scan at postoperative day 7. Technical success were achieved in all cases, and there were no hospital deaths. 14 of 64 pts (21.9%) had endoleak by contrast CTscan, which were all type II endoleak. WBC, CRP, Fib, and FDP were significantly higher after EVAR than before. On the other hand, Plt was significantly lower. WBC and Plt recovered to preoperative levels at 7 postoperative day. Compared between cases with endoleak and without endoleak, only FDP was higher in cases with endoleak than without endoleak, but not statistically significant. In cases with endoleak, FDP tended to be higher compared to in cases without endoleak. FDP may be a useful biomarker to detect type …¡ endoleak after EVAR. Further evaluations at longer follow up will be needed.

P02-52Paper No: 338Testicular infarction: A rare complication post EVAR

Seenarain V, Quick M, Weerasuriya A, Chuen GVascular department, Fiona Stanley Hospital, WA, Australia

Endovascular aneurysm repair (EVAR) was pioneered in the early 1990s and has advantages of a less invasive procedure compared to open aneurysm repair. Although EVAR procedures have shown improved 30-day mortality and morbidity rates, there are still complications with EVAR’s. These can result in early morbidity and even mortality, thus stressing the need for prompt detection and management. One such complication is limb graft occlusion. Unfavourable anatomy usually restricts or increases the risk of device related complications.

We present a rare case of an acute right testicular infarction requiring orchidectomy day 2 following EVAR insertion. The case involved a 64 year old male who had an asymptomatic 71mm saccular infra-renal abdominal aortic aneurysm (AAA) with favourable neck anatomy, however distal aortic narrowing inferior to the aneurysm was present and not initially appreciated intra-op. He underwent inferior mesenteric artery coiling and standard placement of the EVAR (GORE Excluder, Arizona, USA). Post operatively in recovery he was noted to have an acute ischaemic right limb with no palpable pulses. Urgent angiogram confirmed right iliac limb graft occlusion which required bilateral iliac stents (Atrium V12, Rastatt, Germany) and extension of the right iliac limb with an uncovered stent (Complete

SE, Medtronic, Minneapolis, USA) into the external iliac artery. Right iliac limb occlusion was suspected to have been caused by EVAR limb compromise within a narrowed distal aortic segment and possible thrombus dislodgement post initial EVAR deployment and balloon moulding. Post stenting angiogram confirmed right iliac and common femoral artery patency. However this gentleman developed worsening right testicular pain 36 hours post-operatively, with an ultrasound confirming occluded testicular blood flow. An orchidectomy was performed and histology showed global testicular infarction with no obvious embolic event.

This case highlights a rare EVAR complication with less than five cases having previously been published.

P02-53Paper No: 344Atypical debranched TEVAR for shaggy aorta report of three cases

Takayuki UchidaDepartment of Cardiovascular Surgery, Iizuka Hospital, Iizuka, Fukuoka, Japan

Recently, due to development of devices, branched or fenestrated stent device is going to become main stream for complex lesion cases. But in some special cases, debranched TEVAR still has advantage.

We report three cases of such atypical debranced TEVAR.

First; Total debranch of arch vessels+TEVAR (via ascending Aorta) for Extremely shaggy descending Aorta

Second and third; debranch of visceral arteries +TEVAR (balloon occulusion of debranch graft during srtent delivery) for Extremely shaggy TAAA.

Fortunately peri and postoperative courses of all three cases were good and patients discharged on foot.

In these cases, for avoiding lethal embolic events, branched TEVAR procedure was thought to have more advantage than totally endovascular procedure (branched or fenestrated TEVAR). Off course some tips exist in each case.

Totally endovascular procedure is least invasive of course. But, in some cases which have anatomical difficulties (especially for shaggy Aorta), conventional open surgery should be selected first. But for high risk patient with anatomical difficulties, partially endovascular (debranced TEVAR) may be one useful option.

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P02-54Paper No: 349Percutaneous closure of a large saphenous vein graft aneurysm with a vascular plug

Kazuyuki Ishibashi1, Jyunichi Shimotakahara2, Hideaki Kurata2, Joji Tomioka2, Koji Yonemori2

1Department of Cardiovascular Surgery, Yonemori Hospital, Kagoshima, Japan2Department of Emergency, Yonemori Hospital, Kagoshima, Japan

Saphenous vein graft (SVG) aneurysm is one of the late unusual complications of coronary artery bypass grafting (CABG). We report a case of a very large saphenous vein graft aneurysm successfully treated with a vascular plug.

A 94-year-old man was referred to our hospital for an expanding aortic aneurysm. The patient had undergone CABG 24 years prior, with three saphenous vein grafts to the left anterior descending (LAD), left circumflex arteries (LCX) and right coronary artery (RCA). A chest X-ray revealed a right mediastinal mass becoming large over the years. A computed tomography (CT) scan of the chest demonstrated 8.8 cm Ã- 6.5 cm aneurysm arising from an ascending aortic wall. It was filled with low-density thrombus with evidence of active bleeding into the lumen. Coronary angiography revealed an aneurysm arising from the proximal segment of the SVG to RCA. The distal graft anastomosis of SVG was occluded to RCA and LCX. Another SVG to LAD was widely patent. Given the risks of redo cardiac surgery, advanced age and absence of angina he was planned for closing of the aneurysm with a vascular plug.

From a radial approach, guidewire was inserted into the SVG aneurysm, and over that, 6-Fr. Guide catheter was used to engage the neck of the SVG. 5-French catheter was advanced into its cavity. The wires were removed curved Stiff guidewire was then inserted to provide maximal distal support. Finally, a 7-mm Amplatzer Vasular Plug 4 was successfully delivered. A contrast CT was performed seven days later which confirmed a thrombus development in the cavity. The patient was discharged home.

However interventions utilising vascular plug insertion are limited to cases where graft occlusion, we report a case of the treatment of a large SVG aneurysm successfully treated with use of vascular plug.Please paste your abstract here.

P02-55Paper No: 350Endovascular therapy for DeBakey’s type 3B dissecting aortic aneurysm

Shunichiro Fujioka1, Shigeru Hosaka1, Yusuke Irisawa1, Hirotoki Okubo2, Tetuya Horai1

1Department of Cardiovascular Surgery, National Center of Global Health and Medicine, Tokyo, Japan2Department of Vascular Surgery, Kitazato University School of Medecine, Kanagawa, Japan

Though thoracic endovascular aortic repair (TEVAR) for atherosclerotic descending aortic aneurysms is recognized a supreme surgical therapy, TEVAR for DeBakey’s type 3B dissecting aortic aneurysms (DAA 3B) is controversial. Segmental resection and graft replacement is employed as a conventional surgical repair. We started to operate for a descending aortic dissection with TEVAR from 2 years ago.

Surgical ProcedureThe proximal landing site is taken at healthy aorta without dissection. When a stent-graft is placed at zone 1 or zone 2, extra-anatomical bypass to left common carotid artery and left axial artery to debranch arch vessels and coil-embolization of left subclavian artery are employed as necessary. More long-size devices are selected to adjust to the true lumen with large discrepant diameters between proximal landing site and distal one.

ResultsNine patients are treated and TEVAR were succeeded in all patients. One patient was treated from zone 1 and 6 patients were done from zone 3. The postoperative CT scanning revealed that pseudo lumen of all patients were thrombo-occuluded and were shrinking. No visceral ischemic complications occurred early and late postoperatively.

ConclusionIt is emphasized that TEVAR is an excellent surgical strategy for DAA 3B. A long follow-up is important to observe the enlargement of pseudo lumen at thoracoabdominal aortic region.

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P02-56Paper No: 351Outcome of open stent-graft for thoracic aortic aneurysm repair: Comparison of handmade and commercial-made open stent graft

Jun Hayashi, Tetsuro Uchida, Azumi Hamasaki, Yoshinori Kuroda, Masahiro Mizumoto, Atsushi Yamashita, Shuto Hirooka, Ai Takahashi, Kentaro Akabane, Seigo Gomi, Mitsuaki SadahiroDepartment of Sugery II, Yamagata University, Yamagata, Japan

ObjectiveTotal arch replacement accompanied with open stent-graft became a standard therapeutic option for thoracic aortic aneurysm. Recently, the J graft open stent-graft (JOSG), which is a Japanese commercial-made open stent-graft, has become available and used widely in Japan. This research aimed to analyze the technical and clinical success of total arch replacement with open stent-graft and compare handmade and commercial-made devices.

Materials and MethodsThirty-five patients who underwent total arch replacement with an open stent-graft between September 2009 and January 2016 were evaluated. The operative outcomes were compared between handmade (group H, n=15) and J graft open stent-graft groups (group J, n=20).

ResultsMost patients were men (28 patients, 80%), and the mean age was 72 years. Although an open stent-graft procedure was achieved in all the cases, intraoperative technical troubles occurred in 2 cases with a JOSG. Case 1 was obstruction of a systemic blood perfusion due to graft kinkingã€€occurred in a patient. It was resolved by shortening of the graft and re-anastomosis. In the other case, an obstruction of systemic blood perfusion also occurred. In this case, an intimal flap at descending aorta was stuck to the distal end of the open stent-graft. Release the stuck by shortening the graft improved the pathology immediately. The overall operative and hospital mortality rates were 14% (n=5, group H; n=3, group J; n=2). Paraplegia occurred in 2 cases. Postoperative aortic events occurred in 2 cases in each group. In group H, the distal end of the open stent-graft induced a new tear at the descending aorta in 1 patient, and an open stent-graft could not exclude the aneurysm completely in another patient. Both patients underwent a thoracic endovascular repair with good results. In group J, 2 acute aortic dissection cases

required an additional endovascular repair for a stenotic true lumen of the descending aorta.

ConclusionThe handmade and commercial-made open stent-graft procedures enabled good technical and clinical results without significant complications. Whereas the commercial-made device may have more advantages than the handmade device, attention should be given to some technical pitfalls that result from conformation of the commercial-made stent-graft.

P02-57Paper No: 369Early Outcomes of AAA EVAR with the low profile Ovation Stent-Graft System

Matt Trinder, Kishore Sieunarine

PurposeThe early safety and effectiveness of the low profile Ovation Stent-Graft System in the treatment of abdominal aortic aneurysm.

MethodsTwenty patients with AAA (18 males and 2 female; mean age 76.1 years) were electively treated with Ovation device between August 2016 and June 2017. Procedural, postop and followup data at one and six months with Clinical and Imaging assessment was collected and analysed.

ResultsTechnical success was 100% with easy passage of the device. Clinical Success 95% mean screening time was 26.4minutes, mean LOS was 2.5 days. The average follow-up was 5.9 months (range 1-10 months). There was no conversion to open surgery or aneurysm enlargement, rupture, fracture or migration during the study period. There was one type Ia endoleak awaiting treatment with a covered stent and four type II endoleak from the IMA and lumbar arteries. One patient was found to have a 50% aortic stenosis at the graft sealing rings. Technically challenging cannulation of the contralateral limb occurred in 6 with brachial access in one and fine 0.018 wire. Hospital and 30 day mortality was 0%.One common femoral artery occluded and treated conservatively. No other complications were observed.

ConclusionOur experience provides early evidence that it is a safe and effective device with high technical success. Technical challenges with cannulation is a problem.

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P02-58Paper No: 371Endovascular repair as an alternative paradigm for retrograde type A aortic dissection

Tomoyoshi Kanda, Seiichi Yamaguchi, Hisanori Fujita, Shigeyasu TakeuchiDepartment of Vascular Surgery, NICVD, Dhaka, Bangladesh

BackgroundStanford type A aortic dissection (TAAD) is one of life-threatening diseases despite recent advance of treatment. While most TAADs have a tear in aortic root or ascending aorta with antegrade progression of false lumen, retrograde type A aortic dissection (RTAD) arises from a tear in descending aorta with retrograde propagation into ascending aorta. There is controversy about optimal treatment for this pathology.

MethodsSince 2014, we experienced 3 cases of treating RTAD with thoracic endovascular aortic repair (TEVAR). We report them with literature review.

ResultsCase 1: A 67-year-old man admitted for loss of consciousness. Computed tomography (CT) showed RTAD with a thrombosed false lumen having a tear in the mid-descending aorta and pericardial effusion. Emergency surgery was not to be performed because of prolonged severe unconsciousness. TEVAR, however, was performed 18 days after onset to close an enlarged ulcer-like projection (ULP)/initial tear because he gradually recovered consciousness. Postoperative course was uneventful, and 5-month follow-up CT showed the disappearance of the false lumen in the thoracic aorta. Case 2: A 71-year-old woman presented with back pain. CT on admission showed TAAD with a patent entry tear in the proximal descending aorta and a partially thrombosed false lumen. Emergency TEVAR was performed into the descending aorta distal to subclavian artery. CT on POD 3 showed narrowing of thrombosed false lumen. However, CT on POD 9 indicated proximal re-dissection with a large tear at the proximal end of the endograft. Emergency ascending and total arch replacement was performed successfully. Case 3: A 62-year-old man with chest pain had RTAD with a tear in the distal descending thoracic aorta. The thrombosed false lumen of the ascending aorta was about 3 mm in diameter, and conservative medical management was attempted initially. CT performed 16 days after onset showed thickened false lumen in ascending aorta up to 10mm and enlarged ULP. TEVER was performed to close ULP in 22 days, after onset. The false lumen of

the thoracic aorta completely disappeared at 3-month follow-up.

ConclusionTEVAR for RTAD can be performed safely and should be a reliable alternative for selected patients.

P02-59Paper No: 382Management of Salmonella-infected aortic aneurysm with Anaconda endovascular stent graft - Case report

Pao-Yen Lin, Di-Yung Chen, Jih-Shen WenDivision of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan

BackgroundSalmonella-infected aortic aneurysm is a vexing condition which is vulnerable to rupture and results in poor prognosis of survival. Timely surgical intervention and prolonged antibiotic treatment have been recognized as the golden principle for preventing rupture and inhibiting recurrence. However, open surgical repair with extensive debridement of infected tissues increases not only the difficulty of arterial reconstruction but also the peri-operative morbidity and mortality. Moreover, in situ graft replacement at or near the infected area may develop late device-related infection, particularly among those aged or immune-suppressive patients. To reduce the peri-operative risk as well as avoid contamination by the infected tissues, endovascular aortic graft stenting could be an alternative therapeutic modality. We, herein, report a successful experience by managing Salmonella-infected aortic and left common iliac arterial aneurysms with Anaconda stent graft. Brief historyA 76 year-old male was admitted to infectious ward because of persisting fever for 2 weeks. Salmonella enteritidis group B infection was proved by blood culture and parenteral antibiotic (Rocephin 100 mg, q12h) was given. One week later, fever subsided whereas low back pain with left sciatica was complained of. CTA revealed three irregular outpouching lesions at the terminal aorta and left common iliac artery. Besides, large amount hyperdense fluid was found around left common iliac artery. Ruptured infected aneurysm with contained hematoma was therefore diagnosed. Urgent EVAR was conducted while blood culture showed no growth of bacteria. Parenteral Rocephin continued for 4 weeks after surgery and then was substituted by oral form antibiotic (Ciproxin). This patient recovered very well without fever and sciatica at discharge. First post-

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Poster Presentation

operative CTA was followed one month after discharge and complete resolution of infected aneurysm and hematoma was noted. No recurrence of in situ or new aneurysm was found during the one-year follow-up.

ConclusionEVAR seems to be an effective alternative for treating Salmonella-infected aortic aneurysms. However, bacteremia should be definitely eliminated before endovascular graft implantation.

P02-60Paper No: 400The PETTICOAT technique for malperfusion which occurred after the operation of Debakey type I aortic dissection; Report of a case

Onichi Furuya, Shinichi higashiue, Satochi Kuroyanagi, Masatoshi Komooka, Saburo Kojima, Naohiro WakabayashiDepartment of Cardiovascular Surgery, Kishiwada Tokusyukai Hospital, Kishiswada, Osaka, Japan

Background/IntroductionThere are some reports that the PETTICOAT (Provisional Extension To Induce Complete Attachment) technique is an effective endovascular procedure to treat complicated DeBakey type III aortic dissection. In recent days this technique has been applied to the treatment for the patent false lumen after operation of DeBakey type I aortic dissection.

MethodAn 86-year-old woman was transported to our hospital for the diagnosis of DeBakey type I aortic dissection which caused cardiac tamponade with shock vitals. We performed an emergent hemiarch replacement with the resection of large entry tear in ascending aorta. At postoperative day 2, she suddenly had symptoms of lower limb faintness with loss of sensation and anuria. Emergent enhanced computed tomography showed that the descending aorta was dissected from distal aortic arch to terminal aorta with patent false lumen compressing true lumen nearly occluded below the left renal artery level of the aorta of which new entry tear was located at 2.5 cm distal to the left subclavian artery. We performed emergent TEVAR with PETTICOAT technique using Zenith Dissection Endovascular System (Zenith TXD) which was available from October 2015 in Japan.

ResultFrom the left common femoral artery, with the guidance wire, stent grafts (Zenith TX2) were deployed at the proximal landing zone 3 to close new entry tear and 2

distal bare metal stents were deployed from the thoracic endograft down to terminal aorta. Operation time was 91 min. The symptoms recovered promptly after the procedure with PETTICOAT technique. The follow-up CT showed that the compressed true lumen was dramatically enlarged and almost all descending aorta was completely remodeled without any obstruction of the abdominal side branches. She was discharged without any complication after 60 postoperative days.

ConclusionThe PETTICOAT technique with Zenith TXD was an effective additional procedure for malperfusion which occurred after hemiarch replacement for DeBakey type I aortic dissection.

P02-61Paper No: 410En-block resection followed by in situ replacement and duodenum repair for secondary aorto-duodenal fistula

Nobuoki Tabayashi1, Tomoaki Hirose1, Takehisa Abe1, Yoshihiro Hayata1, Keigo Yamashita1, Rei Tonomura1, Yoshio Kaniwa1, Hiroshi Nishikawa1, Shinichi Iwakoshi2, Shigeo Ichihashi2, Kimihiko Kichikawa2, Shigeki Taniguchi1

1Department of Thoracic and Cardiovascular Surgery, Nara Medical University, Kashihara, Nara, Japan2Department of Radiology, Nara Medical University, Kashihara, Nara, Japan

Backgroubd and objectiveSecondary aorto-duodenal fistula (ADF) is uncommon, but lethal complication after open and endovascular aortic repair, with significant morbidity and mortality. The optimal surgical management for ADF remains unclear. To prevent aortic and gastrointestinal complications, we performed en-block resection of ADF followed by in situ replacement with prosthetic or pericardial roll graft covered with omental flap and duodenum repair. We evaluate our strategy for secondary ADF.

Patients and methodsFrom September 2009 to Jun 2017, 4 patients were operated on for secondary aorto-duodenal fistula. All were men with a mean age of 65 years. Our surgical strategy for ADF consists en-block resection followed by in situ replacement with prosthetic or pericardial roll grafts covered with omental flap and duodenum repair (direct suture or duodenojejunum bypass). In 2 cases of hemorrhagic shock, endovascular hemostatic procedures with Excluder aortic extensions were performed prior to definitive surgical repair.

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ResultsThere was no 30-day mortality. Follow-up periods ranged from 1 to 108 (mean 33) months. During this follow-up periods, there were no gastrointestinal troubles and no recurrent ADF in all patients. Also, no late mortality was observed.

ConclusionIt seems effective for secondary ADF that en-block resection followed by in situ replacement with prosthetic or pericardial roll grafts covered with omental flap and duodenum repair.

P02-62Paper No: 4153D virtual intravascular endoscopy in the visualisation of aortic aneurysm and aortic dissection

Sultan Aldosari, Zhonghua SunDepartment of Medical Radiation Sciences, Curtin University, Perth, Western Australia, Australia

BackgroundVirtual intravascular endoscopy (VIE) is a 3D visualisation tool which offers intravascular views of the arterial wall as well as pathological changes by utilising volumetric dataset. Computed tomography (CT) VIE shows promise by providing unique intravascular details of aortic disease when compared to the conventional 2D and 3D extraluminal views. This presentation provides an overview of CT VIE applications in the diagnosis of aortic disease including aortic aneurysm and aortic dissection. VIE visualisation of endovascular stent graft repair of these two conditions is also demonstrated.

MethodsThis retrospective study included 50 patients with 30 of them diagnosed with abdominal aortic aneurysm (AAA) who were treated with aortic stent grafting, and another 20 patients with type B aortic dissection. CT angiography was performed on either 64- or 320-slice CT with slice thickness of 0.7-1.0 mm to acquire high-resolution images. VIE was generated in all patients to demonstrate intravascular views of normal aortic anatomy, aortic aneurysm, aortic dissection in terms of true lumen, false lumen, intimal flap and aortic branches. Intraluminal stent grafts were also demonstrated.

ResultsVIE offers different views of the aortic aneurysm as well as its relationship to the aortic ostia. VIE also enables detection of ostial calcification in the aortic branches, which assists clinical assessment of degree of artery

stenosis and morphological changes following placement of endovascular stent grafts. VIE offers excellent views of looking inside the aorta and its branches to assist assessment of 3D relationship between the dissection and arteries. Despite narrowed true lumen in most of the cases, VIE is still able to produce intraluminal views of true and false lumens, in addition to identification of intimal flap or entry site. In contrast to the conventional visualisations which offer external views of the stent grafts, VIE is a unique visualization tool providing intraluminal views of stent-grafts relative to aortic branches.

ConclusionVIE has been shown to be superior to conventional CT images in the visualisation and assessment of endovascular stent grafts with respect to the aortic aneurysm and aortic dissection, therefore, playing an important role in the follow-up of stent graft repair of these aortic diseases.

P02-63Paper No: 445Reoperation for a giant aortic arch aneurysm using cervical cannulation of the common carotid artery for cerebral perfusion after the ascending aortic replacement: Report of a case

Shigenobu Senaha, Tozuka Yuichi, Mitsuyoshi Shimoji, Mitsuru Akasaki

Redo surgery for a giant thoracic aneurysm touching the sternum needs to be performed with special precautions. The patient was a 65-year-old man who had undergone ascending aortic replacement due to acute Stanford type A dissection 5 years previously. He visited an outpatient clinic after an interval of 4 years, and was diagnosed with an aortic arch aneurysm which was touching the sternum. Preoperative examinations suggested a high risk of rupture if redosternotomy was performed. Therefore, we performed resternotomy under cardiopulmonary bypass. In addition, the left carotid artery was secured for cerebral perfusion through the neck incision, which enabled core cooling in case of uncontrollable hemorrhage. He successfully underwent aortic arch replacement, and he was discharged without any neurological complications.

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Poster Presentation

P02-64Paper No: 446Three cases of emergent debranching TEVAR for acute type B aortic dissection with rupture

Shunsuke OhoriCardiovascular Surgery, Hokkaido Ohno Hospital, Sappooro, Hokkaido, Japan

BackgroundTEVAR has replaced open surgery for acute complicated type B dissection due to promising short and midterm result. We present three cases of acute type B aortic dissection with rupture treated with debranching TEVAR

MethodsAll patient underwent emergency CT scan upon their arrival and it revealed an acute Stanford type B aortic dissection with hematoma of the aortic arch. We performed emergent TEVAR immediately. all patients had coverage of the left subclavian artery. Two patient underwent axillo-axillary bypass, another one patient underwent left carotid-left axillary bypass.

ResultThere was no operative death. Technical success was achieved in 100%. One patient had paraplegia. At last follow up CT scan, all patient had complete remodeling of the aortic wall.

ConclusionTEVAR for acute type B aortic dissection with rupture could be performed with relatively low morbidity and mortality. The main objective of TEVAR for acute type B aortic dissection with rupture is control of bleeding, which can be achieved by closing the primary entry site and the secondary tear site in the descending thoracic aorta if possible.

P02-65Paper No: 448EVAR survival in octogenarians - Is 85 the new 80?

Wah Wah Lin1, Robert Tewksbury1, Patrick Tosenovsky2, Joe Hockley3, Jens Carsten Ritter1

1Fiona Stanley Hospital, Perth, Western Australia2Royal Perth Hospital, Perth, Western Australia3Sir Charles Gairdner Hospital, Perth, Western Australia

BackgroundAs the population is aging, more procedures are performed in the elderly. Multiple studies have shown good outcomes for endovascular abdominal aortic

aneurysm repair (EVAR) in patients >80 years. In Australia, the average life expectancy for women was 85 years in 2015. This study aims to investigate EVAR survival in the patient group that specifically exceeds this age.

MethodRetrospective review of abdominal aortic aneurysm (AAA) audit data from three Western Australian tertiary hospitals over a five year period from 2010-2015. All patients who had elective standard infra-renal abdominal EVAR were included in the study. Patients who had fenestrated or branched devices, ruptured, thoracic or iliac aneurysms were excluded.

Results265 patients were included. Mean age was 76 years with a range from 55-97. 47 patients were women and 118 were men. 37 patients were >85 years (group X), 59 patients were between 80-84 years (group Y), and 169 patients were <80 years (group Z). Total number of death in all 3 study groups was 53 (20%) over the study period; from date of operation to 31st January 2017. 10 patients (27%) died in group X, 18 patients (31%) died in group Y, and 25 patients (15%) died in group Z. Patients under 80 years have a significantly higher survival probability (P=0.0015) post EVAR in the comparison of study group X,Y and Z. However, there was no survival difference in comparison of patients >85 years (group X) and patients between 80-84 years (group Y) post EVAR (P=0.5687). Data comparison was shown in Kaplan-Meier curve.

ConclusionThe study showed no stastistical difference in survival rate in patients >85 years who underwent elective standard EVAR in contrast to patients between 80-84 years after the same procedure. Despite studying a state-wide experience, the numbers for patients aged over 85 years old are low, hence larger numbers are required to confirm the trend.

P02-66Paper No: 452To present a case report and review of literature: Fibromuscular dysplasia and Takayasus Aorto-arteritis can be a major diagnostic dilemma and we present a known case of FMD presenting with Aortic aneurysm, an unusual presentation in FMD

Krunal Gohil, Bhavin Ram, Robbie GeorgeDepartment of Vascular Surgery, Narayana Hrudayalaya Health City, Karnataka, India

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BackgroundTo present a case report and review of literature: Fibromuscular dysplasia and Takayasus Aorto-arteritis can be a major diagnostic dilemma and we present a known case of FMD presenting with Aortic aneurysm, an unusual presentation in FMD.

MethodsA 39-year-old female presented for treatment of incidentally detected infrarenal saccular aortic aneurysm having interesting past history. She underwent right nephrectomy at age of 20 years for non functioning kidney with secondary hypertension presumed to be due to renal artery stenosis. Histopathology of the specimen was suggestive of intimal fibroplasia of renal artery. After few years, during pregnancy left upper limb pulses were found to be absent. CT angiogram in 2007 showing diffusely stenosed left Subclavian origin with post vertebral short segment occlusion, a small diverticulum in the distal aorta with diffuse long segment narrowing- features consistent with aortoarteritis. She had been followed up after that with repeated imaging and inflammatory markers with a suspicion of Takayasus arteritis. She had never been on immunosuppression.

As the couple were planning for a second pregnancy she presented for assessment and evaluation of the aortic aneurysm. On CT the aorta was found to be narrowed with a saccular aneurysm of 37x14mm. Inflammatory marker and PET scan was done did not show any active inflammation.

ResultsShe underwent stent grafting of the aneurysm with a 13.5mm Fluency plus stent graft (Bard V5 033) with successful exclusion of the aneurysm.

ConclusionFMD and Takayasus often affect a similar population i.e young women though they tend to have a slightly different anatomical distribution. FMD mainly involves the distal renal, extracranial cerebrovascular, coronary and mesenteric arteries. Takayasus aortoarteritis is an inflammatory disease involving medium to large size vessels with aortic involvement and ostial involvement being more common. A diagnosis of Takayasus will often commit the patient to long term immunosuppression with all its attendant complications.

Presentation with saccular aneurysm with other radiological feature mimicking aortoarteritis with a past

histological diagnosis of FMD is a unique dilemma with challenges in establishing the appropriate treatment strategy.

P02-67Paper No: 469Aortoduodenal syndrome from infected abdominal aortic aneurysm treated with endovascular approach

Thoetphum Benyakorn1, Saritphat Orrapin1, Kanoklada Srikuea1, Tunyarat Wattanasatesiri2, Boonying Siribumrungwong1

1Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand2Division of Interventional Radiology, Department of Radiology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand

IntroductionAortoduodenal syndrome is a rare case entity. The duodenal obstruction is caused by abdominal aortic aneurysm compression, first described by Osler in 1905 and only 40 cases had been reported worldwide. Choices of treatment for aorotoduodenal syndrome are open repair and duodenum resection. To the best of our knowledge, this is the first case of aortoduodenal syndrome caused by infected abdominal aortic aneurysm and successful treatment with endovascular approach. Case reportA 56 year-old- man presented with history of abdominal pain, nausea vomiting of food content and dark brown blood clot for 2 days; and had history of pneumonia and septicemia two months prior. Due to external compression, the esophagogastroscope couldn’t passed to the third part duodenum; and CT scan reported large submucosal hematoma (11.2x9.0x5.7 cm) which compress the entire third part duodenum extending from saccular abdominal aortic aneurysm. Blood culture reported positive for Salmonella enteriridis. Our decision to operate endovascular method as the result of poor nutritional status, large hematoma compress at the aortic neck and anatomy suitability. On the early post-operative day, abdominal pain was relieved. He could step up feeding on day 18, post-operatively. one months after the operation, CT scan indicated decrease in size of hematoma and no residual hematoma without any type of endoleak 6 months later. At one year follow up, he doing well and CT scan showed no any type of endoleak was detected.

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Poster Presentation

ConclusionThe endovascular treatment can be performed as a single treatment in selected patient and duodenal hematoma was totally resolved on follow up periods.

P02-68Paper No: 471Management of aortoduodenal fistula: Report of three cases

Tohru Ishimine, Hiroshi Yasumoto, Toshiho Tengan, Mitsuhide MototakeDepartment of Cardiovascular Surgery, Okinawa Prefectural Chubu Hospital, Okinawa, Japan

BackgroundAn aortoduodenal fistula (ADF) is a rare cause of upper gastrointestinal bleeding but life threatening condition. In this study, we present three patients who underwent surgical procedure for ADF.

Case presentationCase 1; A 78-year-old man who underwent aortic reconstructive surgery for abdominal aortic aneurysm (AAA) 10 years previously was reffered to our emergency room with sudden onset of epigastric pain, massive hematemesis. CT showed adhesion between duodenum and recurrent infrarenal AAA at the proximal side of anastomosis of the prosthetic graft. The patient collapsed in the emergency room and we immediately performed in situ aortic reconstruction, primary closure of the duodenum for ADF, and right hemicolectomy for bowel necrosis. The patient developed multiple organ failure and died 6 hours after surgery.

Case 2; A 68-year-old man with a history of aortic reconstructive surgery for AAA 2 months previously presented with massive hematochezia and shock. CT described adhesion between duodenum and pseudoaneurysm at the proximal anastomosis of the prosthetic graft. In situ aortic reconstruction, and primary closure of the duodenum were performed emergently. Left hemicolectomy for bowel necrosis, and omental coverage of prosthetic graft were added 3 days after the initial operation. The patient was discharged on postoperative day 62.

Case 3; A 82-year-old man with untreated AAA presented with hematemesis. CT revealed adhesion between duodenum and AAA. In situ aortic reconstruction with omental coverage and resection of duodenum were performed emergently. The patient was discharged on postoperative day 86.

ConclusionImmediate control of bleeding and management of contamination are necessary to improve surgical outcome of ADF. ADF should be suspected in case of gastrointestinal bleeding with a history of AAA or previous aortic surgery.

P02-69Paper No: 474Using of endovascular aneurysm sealing system for ruptured and symptomatic abdominal aortic aneurysm in Thailand

Thoetphum Benyakorn, Saritphat Orrapin, Kanoklada Srikuea, Boonying SiribumrungwongDivision of Vascular and Endovascular, Department of Surgery, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand

IntroductionAcute Abdominal Aortic Aneurysm (aAAA) is a ruptured and symptomatic AAA and a fatal disease causing high mortality rate compared to asymptomatic AAA. Besides a traditional open repair treatment, Endovascular method has been endorsed by many literatures as a prefered treatment for aAAA because of its efficacies in reducing short-term morbidity and mortality. Comparing to Endovascular treatment, Endovascular Aneurysm Sealing System (EVAS) yields a better result for AAA in term of post-operative recovery and decrease in mortality. To the best of our knowledge, this is the first report of acute AAA with EVAS in Asia

MethodsFrom December 2016 to June 2017, fifteen aAAA patients were included in this study. For this study, the primary endpoint is a 30 days mortality; and the secondary endpoint are endoleak, 30 days morbidity, and re-intervention rates.

ResultsAll patients were between 56 and 85 years old and thirteen were male. Seven were diagnosed with Ruptured AAA (rAAA) and the rest with Symptomatic AAA (sAAA). Eleven cases with fusiform aneurysm while the rest were saccular aneurysm. All cases were conducted as emergency operation of which twelve cases were percutaneous approach.The mean of maximum AAA diameter was 70.4 mm; and the average operative time and blood loss were 2.15 hours and 460 ml consecutively. Six patients died within 30-days post operative. Aneurysm-related complications caused four deaths, three with peri-operative cardiac arrest and one with post-operative myocardial infarction. While two

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of six cases were caused by septicemia and pneumonia. We found no endoleak and 30-days morbidity. Two cases were detected with re-intervention, one with common iliac artery dissection and the other with stent misplacement.

ConclusionEVAS is feasible treatment for an acute AAA with only 26.6% 30 days mortality rate without endoleak and acceptable secondary endpoint.

P02-71Paper No: 153A novel technique of “Chimney Nellix” for the management of type 1a endoleak following EVAR

Joseph SZ1, Kwok CHR1, Abdelhamid M1, Hockley JA1, Garbowski MW1, Ferguson J2, Samuelsson S2, Jansen SJ1,3,4,5

1Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia2Department of Interventional Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia3Faculty of Health Sciences, Curtin University, Perth, Western Australia4Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia5Heart Research Institute, Harry Perkins Institute of Medical Research, Perth WA

BackgroundThe presence of type 1a endoleak after endovascular aortic aneurysm repair (EVAR) results in ongoing enlargement of the aneurysmal sac with risk of aneurysm-related death. Treatment options for type 1a endoleak are complicated by the existing EVAR device, difficult visceral vessel access in the setting of a previous endovascular device or diseased vessels, and non-favourable aneurysm morphology. Whilst options such as coiling, endoanchors, and fenestrated stent grafting have been explored, the use of Nellix endovascular sealing (EVAS) in conjunction with ‘chimney” stents (ChEVAS) is relatively novel. MethodsWe present a retrospective series of the first 3 cases at our institution in which ChEVAS was used to repair persisting type 1a endoleaks post EVAR. ResultsCase 1 involved a three-vessel ChEVAS for treatment of type 1a endoleak following previous two-vessel fenestrated EVAR with superior mesenteric artery (SMA) scallop. Repair options were complicated by tortuous and diseased access vessels, downward facing renal

stents and a large SMA infundibulum. Case 2 involved a two vessel ChEVAS. This repair was complicated by difficult access to renal arteries which were jailed between struts of the original EVAR graft. Case 3 was a three-vessel ChEVAS in a patient with a type 1a endoleak which failed to resolve following endoanchors. In all 3 cases technical success was achieved with good flow in all target vessels and resolution of type 1a endoleaks on final angiography. One peri-operative mortality was due to myocardial infarction, and one pseudoaneurysm and retroperitoneal bleed from access complications resolved with conservative management. ConclusionsType 1a endoleaks were successfully treated in all 3 cases despite one non-device related mortality. The benefit of polymer filled endobags generating a seal around ‘chimney”stents allows maintained perfusion of visceral vessels and reduces endoleaks from ‘guttering”. Major benefits include smaller access sheaths and no delay while custom-made components are manufactured. Finally, there is no commitment to using the most expensive component (stent graft) until successful cannulation of visceral vessels is achieved, a major advantage when compared to fenestrated endografting. Early experiences with ChEVAS for repair of type 1a endoleak are promising and warrant further investigation with larger series.

Arteritis

P03-01Paper No: 036Demand for surgical treatment in Japanese patients with Takayasu arteritis

Yoshiko Watanabe1, Kazuo Tanemoto2

1Department of Physiology, Kawasaki Medical School, Kurashiki, Okayama, Japan2Department of Cardiovascular Suugery, Kawasaki Medical School, Kurashiki, Okayama, Japan

BackgroundThe demand for surgical treatment in patients with Takayasu arteritis (TAK) is currently unknown in Japan.

MethodsWe analyzed information regarding the histories of surgical treatment including endovascular therapies from nationwide registration forms submitted by TAK patients between April 2001 and March 2011, as part of a research program by the Japanese Ministry of Health, Labour and Welfare. After counting all surgical procedures including general surgeries, we quantified

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and categorized the procedures related to cardiovascular insufficiencies.

ResultsAmong the 7705 patients (790 male patients and 6915 female patients) who submitted their registration forms, 1793 patients (23%: 35% of the male patients and 22% of the female patients) had past histories of surgical treatment once or more. The total number of all procedures was 2362, and 468 patients had surgeries 2 times or more. Two patients had surgery 5 times, which was the highest number of times of surgeries per patient. Among the 1793 patients, 6% had aortic valve surgeries, 3% had aortic aneurysm repairs, 3% had procedures for occlusive disease of the aorta and/or lower extremities, 4% had procedures for diseases caused by aortic arch branch lesions, 4% had procedures for the coronary arteries, and 3% had procedures for renal artery diseases. Some patients had several or repetitive surgeries in the same disease category: 2.5% of the patients with aortic valve surgery, 2% of the patients with aortic aneurysm repair, 6% of the patients with surgery for occlusive diseases of the aorta and/or lower extremities, 12% of the patients with procedures related to aortic arch branch lesions, 17% of the patients with surgery for the coronary arteries, and 13% of the patients with surgery for renal artery diseases.

ConclusionsIn Japan, one-fourth of TAK patients had undergone surgical treatments. As for cardiovascular surgeries, the most common procedure was aortic valve surgery including aortic root repair. Multiple surgeries were more frequently required for arterial occlusive diseases than for aortic valve disease and aortic aneurysm.

P03-02Paper No: 385Case report: Endovascular approach for takayasu’s arteritis with midaortic syndrome

Rosnelifaizur Ramely1, Mohd Ammar Ahmad2, Hanif Hussein2, Zainal Ariffin Azizi2

1Department of Surgery, School of Medical Sciences,Universiti Sains Malaysia, Kelantan, Malaysia2Department of Surgery Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

IntroductionMidaortic syndrome (MAS) is a rare vascular disorder characterized by segmental narrowing of abdominal or distal thoracic aorta. This presentation represents about 0.5-2% of all aortic coarctation cases. It is commonly acquired due to Takayasu’s arteritis but it may be

congenital, due to developmental anomaly in fusion and maturation of embryonic dorsal aortas. Abstract We reported a case of mid aortic syndrome in Takayasu’s arteritis. Our patient is a 23 years old gentleman with history of claudication pain for 1 year, 3 weeks history of non healing wound over left 5th toe, and bilateral lower limb resting pain for the past 3 days prior to presentation. The pulses were not palpable from femoral down to dorsalis pedis and posterior tibial arteries bilaterally. The blood investigation were suggestive of Takayasu’s arteritis and he was started on prednisolone. Imaging study revealed circumferential thickening of infrarenal aortic wall at the level of L1 until L2/L3 with smallest luminal diameter of 4 mm. There was no stenosis distal to the affected level. We decided to proceed with endovascular aortic stenting instead of aortic bypass graft after thorough discussion with patient and his parents. The procedure was successful and patient regained his lower extremities perfusion. He was started on double antiplatelet therapy. The outcome was satisfactory and patient had significant relief of the claudication pain after a month assessment and remain symptoms free after 2 years follow up.

ConclusionManagement of MAS is complex, hence it requires a multi-disciplinary approach. The data of long term outcome of aortic stenting in MAS is lacking and no recent report regarding natural history of MAS thus it is rather difficult to make inferences regarding the improvement in survivalPlease paste your abstract here.

P03-03Paper No: 395Management options of visceral artery aneurysms

Masanori Hayashi1, Hideaki Obara1, Kentaro Matsubara1, Keita Hayashi1, Yuki Kamiya1, Masanori Inoue2, Seishi Nakatsuka2, Masahiro Jinzaki2, Yuko Kitagawa1

1Department of Surgery, Keio University School of Medicine, Tokyo, Japan 2Department of Radiology, Keio University School of Medicine, Tokyo, Japan

PurposeVisceral artery aneurysms (VAAs) represent a rare disease with an incidence of 0.1 to 1.0% and life-threatening when ruptured. The aim of this study was to review our experience with VAA treatment at a single institution.

Methods and Results

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Between January 1995 and March 2017, 59 VAAs were treated in 55 patients (37 males, 18 females) with mean age of 62 years old (range, 21-90). Postoperative pseudoaneurysms were excluded from this study. The VAAs locations were: splenic artery (n=27), pancreaticoduodenal artery (n=9), superior mesenteric artery (n=7), celiac trunk (n=4), hepatic artery (n=3), gastroduodenal artery (n=3), common celiomesenteric trunk (n=2), gastric artery (n=2), and gastroepiploic artery (n=2). Of the 59 patients, 6 patients were recipients of living liver transplantation, 4 patients presented with ruptured aneurysm, and 14 patients had multiple aneurysms. Thirty five patients had endovascular procedures, 18 patients underwent open surgery, and 2 patients underwent hybrid therapy. In the endovascular group, most VAAs were treated by coil embolization. While in the open surgery group VAAs were treated by splenectomy (n=5), aneurysmectomy (n=2), aneurysmorrhaphy (n=1), and aneurysmectomy with arterial reconstruction (n=10), in the hybrid therapy group one patient underwent bypass surgery with embolization, and one patient underwent release of the median arcuate ligament followed by embolization of the aneurysm. The results were satisfactory enough with no severe perioperative complication or death. No aneurysm reperfusion or enlargement was observed during follow-up period.

ConclusionsOur study suggests that an aggressive treatment of VAA is safe and effective because of the low morbidity and mortality rates. Regardless of the type of intervention, it is important to assess and maintain end organ perfusion via adequate collateral circulation or direct revascularization.

P03-04Paper No: 462Improving pulmonary perfusion in a child with Takayasu’s arteritis

Bhavin Ram, Krunal Gohil, Robbie GeorgeDepartment of Vascular Science, Narayana Hrudayalaya Health City, Bangalore, Karnataka, India

BackgroundImproving pulmonary perfusion in a child with Takayasu’s arteritis.

MethodsA 14 year boy, a known case of Takayasu’s arteritis on medical management from 8 months, presented with difficulty in breathing on walking few steps and

sometimes at rest with occasional fever for 1 month. On evaluation, he was found to have severe pulmonary artery hypertension on 2-D echo. His V-Q scanning was showing a non-visualized left lung with large perfusion defects in the right lung parenchyma. Initially he was treated with IV antibiotics suspecting right lower lobe pneumonia. Spiral CT pulmonary angiogram was done showing total occlusion of left main pulmonary trunk with short segment concentric thickening of right lower lobar artery with aneurysmal dilation just beyond its bifurcation.

In view of worsening and disabling pulmonary compromise despite optimum medical therapy, we offered right pulmonary branch angioplasty and stenting with explained risk of procedure.

Under local anesthesia procedure was performed with standard technique. The PA pressure was found to be normal at the time of the procedure. A 6x30mm balloon expandable stent was deployed across the main right inferior pulmonary artery and apical branch angioplasty was done with 5x20mm balloon with a good radiological result.

ResultsThere was significant and rapid improvement in the clinical condition and the boy was relieved of oxygen dependency. At 18 months follow up he is participating in school sports, continues to remain on regular medical treatment.

ConclusionAlthough primary aim for choosing angioplasty in this case was initially to improve pulmonary reserve and to protect the heart due to suspected high PAH. Angioplasty and stenting of the diseased pulmonary artery and its branches was performed to reduce ventilation perfusion mismatch and improve oxygenation. The patient showed a dramatic response to the intervention. This suggests improvement of pulmonary perfusion has direct respiratory benefits in addition to the cardiorespiratory improvement as a consequence of reduction of PAH. This can be a helpful adjunct to the management of the primary autoimmune pathology.

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Poster Presentation

Carotid Artery Diseases

P04-01Paper No: 042Carotid surgery and cranial nerve injuries: Its common!

Singh TMChief Vascular Surgery, El Camino Hospital, Silicon Valley California, USA

BackgroundCarotid artery surgery is a very common procedure with low stroke and death complications. Cranial nerve injury (CNI) has been reported. More patients complain of CNI. Materials and MethodsUsing our Vascular Quality Initiative registry at the hospital, we reviewed our incidence of CNI over the past 3 years. We reviewed our reports and Center Opportunity for Performance Improvement report. We also reviewed the types of CNI from CN 10,7, and 12. We reviewed each case for CNI type and procedure details. Data was recorded and analyzed. ResultsIn our series, our incidence of CNI was close to 15% with CN 7 the most common. We had no incidence of CN 12 and 2 cases of CN 10 injury. All patients improved within 6 months after injury. We evaluated CB 7 cases and felt it was retractor placement. We have changed our practice on deep weitlaner retractor placement. We now have an incidence of 0% over last 10 cases. ConclusionAll surgeons should review CNI incidence in their carotid surgery practice. We report an incidence of 15% in our practice and this was related to deep retractor placement. We have made a procedure change. VQI registry data can help you identify CNI in your practice. Clinical compromise is minimal.

P04-02Paper No: 083Operations on the internal carotid artery in patients with atrial fibrillation whis using dabigatran etexilate

Alexandr Korotkikh1,2, Dmitry Nekrasov1

1Regional Clinical Hospital 2, Tyumen, Tyumen Region, Russian Federation2Far Eastern State Medical University, Khabarovsk, Khabarovsk Region, Russian Federation

ObjectiveTo evaluate the effectiveness of dabigatran etexilate in patients with atrial fibrillation who underwent operative treatment at the ICA.

Materials and methodsFrom Sept 1, 2015 to Dec 27, 2016, in the Department of Vascular Surgery and Cardiology was performed 694 operations on the ICA. Of these 94 (13,5%), surgery patients with atrial fibrillation. The average age of patients in the main group 68,5±8,5 years, the control group - 65,0±10,2 years. The comparison groups significantly differed in the following characteristics: postinfarction cardiosclerosis in the anamnesis of the main group 25,5%, control - 15,0% (P-value - 0,015); NYHA functional class I, main group 16,0%, control - 31,0 % (P-value 0,002); NYHA functional class III, 18.1%, control 4.8% (P-value 0.00028); diabetes mellitus main group 28.7%, controls 18,2% (P-value 0,024). All patients with atrial fibrillation for 5-7 days before surgery, warfarin was canceled and dabigatran etexilate was administered at a dose of 150mg 2 times a day. When optimal numbers of INRs were reached, surgery was performed. Operational criteria and the results were evaluated in the endpoint - ‘stroke + lethality’.

Results and discussionTotal completed 84 CEA and CAS 10. The average time of operations of the main group 44,5±17,1 min, control group - 40,7±9,5 min, P-value 0,05. In patients with atrial fibrillation surgery performed significantly longer, but the time of the main stage - clamping ICA, were not significantly different. Consequently, an increase in the time of surgery is associated with a longer hemostasis at the stage of allotment of the ICA and/or after removal of the clamps off the arteries. In the early postoperative period, extensive hematomas in the postoperative areas and sites of arterial puncture were not noted. Indicator ‘stroke + lethality’ in observation group was 0%.

ConclusionsCEA and CAS in patients with atrial fibrillation receiving dabigatran etexilate are effective and safe. When performing CEA, additional time is required for more thorough hemostasis.

P04-03Paper No: 114Surgical management of carotid body tumours: A 25-year experience

Eu Jhin Loh, Stephen Bradshaw AMDepartment of Vascular Surgery, The Canberra Hospital, Garran, ACT, Australia

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BackgroundParagangliomas of the neck are rare, with most common form being the carotid body tumour (CBT). Although CBTs are rare tumours, diagnosed with incidence of about 1:30 000 in the general population, they account for >50% of head and neck paragangliomas. Surgical excision remains the only curative treatment. The objective of our study was to assess the short and long-term outcome for patients treated with surgical resection of carotid body tumour in our institution and analyse the Shamblin’s classification in predicting post-surgical morbidity.

MethodsWe retrospectively analysed all consecutive patients who underwent surgical CBT resection at the Canberra Hospital between January 1992 and December 2016. Clinical, operative, pathological and outcomes were recorded and analysed.

ResultsA total of thirty-four consecutive patients (thirteen males; mean age of 48 years) with 34 CBT operations were recorded during the period. A non-tender neck mass was the presenting complain in 88%. Ten CBTs (29.4%) were Shamblin class I, fourteen (41.2%) were class II and ten (29.4%) were class III. Four operations required vascular resection and reconstruction. All 34 cases achieved complete resection. Complications included three major strokes, 4 cases temporary nerve palsies and were more likely to occur in tumours of larger volume. All patients have been followed-up postoperatively for a mean of 11 years. The Shamblin classification was a significant predictor of operative time, blood loss and difficulty of resection, but could not predict postoperative complication.

ConclusionThis cohort showed that the Shamblin classification was significant in predicting technical difficulties but could not predict occurrence of complications. Early resection of carotid body tumours should be undertaken to minimise the risk of neural injury, which increases with tumour size. Mandatory lifelong follow-up is essential in these cases.

P04-04Paper No: 206Comparison result of treatment outcome between patch angioplasty and primary closure during carotid endarterectomy using propensity score matching analysis

Byeoung-Hoon Chung, Dong-Heon Lee, Seon-Hee Heo, Yang-Jin Park, Young-Wook Kim, Shin-Young Woo, Dong-Ik KimDivision of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

PurposePrimary closure (PC) and Patch angioplasty (PA) during carotid endarterectomy (CEA) have been compared in previous studies and disfavoring the use of PC after CEA because its possibility of association with higher perioperative neurologic complication and restenosis rate. The aim of this study was to evaluate the outcomes of PC versus PA using propensity score matching (PSM) and multiple logistic regression analysis.

MethodsBetween November 1994 and October 2016, patients underwent primary CEA procedures at our institution and retrospectively analyzed. One vascular surgeon prefers routine PC and the other prefers routine PA closure using bovine pericardial patch. Endpoints were ipsilateral stroke, any clinical stroke, cranial nerve palsy, hematoma, bleeding which required re-operation within 30 postoperative days. Restenosis rate, overall survival, stenosis-free survival, and stroke-free survival during follow up periods were also investigated.

ResultsDuring study period, 435 PC cases and 476 PA cases were included in this study. After PSM, baseline characteristics (age, gender, hypertension, diabetes, dyslipidemia, smoking, atrial fibrillation, previous percutaneous coronary intervention or coronary artery bypass grafting, contralateral carotid occlusion, degree of carotid stenosis, and symptomatic status within 6 month) were balanced. Finally, 377 pairs of matched cases were analyzed. Statistical analysis showed that there were no statistical differences between two groups in ipsilateral stroke (p=0.45), any clinical stroke (p=0.75), cranial nerve palsy (p=1), hematoma (p=0.18), bleeding which required re-operation (p=0.12) within 30 postoperative days and restenosis rate during follow up (p=0.16). Additionally there were no differences between two groups during follow-up in overall survival, stroke-free survival, and restenosis-free survival with p value of 0.136, 0.07, and 0.06, respectively.

ConclusionIn our study, PC during CEA is not inferior to PA closure in perioperative and long-term outcome.

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Poster Presentation

P04-05Paper No: 402Intraoperative microembolic signals during carotid endarterectomy

Jeensoo Bae, Woo-Sung Yun, Shin-Seok Yang, Bo-Yang SeoDivision of Transplantation and Vascular Surgery, Department of Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea

BackgroundTranscranial Doppler (TCD) can detect microembolic signals (MES) that are one of the pathogenic mechanisms of ischemic stroke. MES are not uncommon findings during carotid endarterectomy (CEA). The aim of this study is to evaluate the relationship between MES and perioperative ischemic stroke or new brain lesions on MRI.

MethodsAmong the 205 patients who underwent CEA, 160 who were monitored intraoperatively for MES using TCD were enrolled. Postoperative MRI was performed between postoperative day 1 and 7 in 131 patients. Medical records were retrospectively reviewed.

ResultsPerioperative ischemic stroke rate was 3% (4/16) and the postoperative MRI revealed NBLs in 19% (25/131). MES during CEA were detected in 105 patients (66%). In binary logistic regression analysis, MES>10 was not an independent predictor of perioperative ischemic stroke (P=.060, OR: 2.514, CI: .963-6.567) or NBL (P=.909, OR: 1.147, CI: .111-11.871).

ConclusionMES are frequently found during CEA. However, they are not associated with perioperative stroke or NBL on MRI.

P04-06Paper No: 328Aneurysm-like entity inside a giant carotid body tumor reaching lateral skull base

Hui Zhang1,2, Yuehong Zheng1

1Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China2Tsinghua University School of Medicine, Beijing, China

BackgroundA patient with lump on right neck complained of feeling dizzy. She was reported with a giant carotid body

tumor (CBT) reaching lateral skull base. Computed tomographic angiography (CTA) revealed a mass of 8.6cm*5.6cm*8.8cm and an entity appeared as non-enhancing soft tissue opacity with heterogeneous density was observed inside the mass. The low-density entity was considered as liquefaction necrosis pre-operatively.

MethodsThe patient was diagnosed with right carotid body tumor. Surgical excision was conducted by vascular surgeons and otolaryngologists. Mastoid and styloid were partially removed under the microscope to expose internal carotid artery (ICA) at superior border of the tumor body. Cranial nerve VII (facial nerve) was recognized and well protected. Pre-reconstruction technique was used for anastomosis to reduce brain damage. Resultsthe low-density area in CTA was observed pulsing during removal. The entity was occasionally cut and instead of necrosis expected, fresh blood squirted out. Vascular shunt was immediately used to reduce blood loss. The tumor was fully resected with no cerebral or cranial nerve damage. Histologic analysis revealed a carotid body paraganglioma. No recurrence or any complications were noted at 3-month or 12-month follow-up.

ConclusionsFirst, we found that the low-density entity on CTA was not liquefactive necrosis of tumor as expected, but an aneurysm-like cyst with fresh blood and pulsing like artery. This phenomenon was barely reported in previous publications. It may indicate that the blood flow inside the tumor body distributed unevenly. Further study is needed to explore the mechanism of CBT and possible connection between CBT and aneurysms. To achieve a better pre-operative evaluation of tumors, imaging techniques in addition to CT may be applicable.

Second, for resection of a giant CBT reaching lateral skull base, exposure of ICA and protection of nerves and brain are as crucial. We presented two satisfactory approaches. One is removing mastoid and styloid to expose distal ICA. The other is using of ‘pre-reconstruction” technique, which means the ICA was reconstructed in advance of excising the tumors, to farthest maintain intraoperative cerebral flow by reducing clamping time.

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Diabetic Foot

P05-01Paper No: 279Cost effectiveness of wound treatment with fish skin: Results of a prognostic study

Gunnar Johannsson1, Christopher Winters DPM2,

Skuli Magnusson BSc1, Baldur T Baldursson1,3, Hilmar Kjartansson1,3, G Fertram Sigurjonsson M Eng1

1Kerecis, Skolavordustig, Iceland2American Health Network, Indianapolis, Indiana3Landspitali The National University Hospital of Iceland, Iceland

BackgroundDiabetic foot ulcers (DFUs) put a huge burden on both private and public payers. Any means to reduce hospitalization by speeding up healing of foot ulcers will contribute most to cost saving.1 In many cases advanced tissue strategies are used to help close DFUs.

AimThe objective of this study was to assess the potential cost savings of treating diabetic foot ulcers with acellular fish skin* using prognostics model.

MethodsThe cost-effectiveness study was based on a prognostic model generated by data from 27,630 patients and predictes the likelihood of a wound not healing after 20 weeks; based on the parameters:(1) The size of the ulcer larger than 2cm2

(2) The previous duration of wound more than 2 months(3) The Wagner grade greater than, or equal to 3

Data from 27 diabetic wounds treated with acellular fish skin* was then inserted this prognostic model,2 and compared with the actual outcome of the treatment.

[Costs were modeled on the Stockl et al article; from which the cost are modeled the total ulcer-related costs averaged $13,179 per ulcer episode, ranging from $1,892 (Wagner level 1) to $27,721 (Wagner level 4/5) on average.3]

ResultsThe 27 patients received 5.6 applications of fish skin* on average and they took average of 8.7 weeks to close (median:7.5 weeks) and 89% were closed at week 20. This closure rate was then compared to the Margolis prognostic DFU model which predicted that 42% of the wounds would close after 20 weeks. Therefore, the fish skin treated patients healed 112% percent more often than predicted at 20 weeks. This resulted in a 62.5% cost

reduction for those patients that healed. The cost per week for the total remaining non-healed wounds at 20 weeks was 28,576 USD for the fish skin* group compared to 93,575 USD for the modeled standard of care group.

ConclusionThe results show that treatment with acellular fish skin* is a cost-effective option for diabetic foot ulcers with important implications for diabetic wound care and the health care system.

Trademarked Items*Kerecis Omega3 by Kerecis

P05-02Paper No: 280Omega3 rich fish skin to prevent re-infection and amputation in exposed bone lower extremity wounds with history of MRSA and chronic osteomyelitis

Christopher Winters DPM1, Gunnar Johannsson2

1American Health Network, Indianapolis, Indiana2Kerecis, Reykjavik Iceland, Iceland

BackgroundChronic osteomyelitis is the most common cause of amputations in diabetic foot ulcers. A novel approach to reduce the risk of re-infections was tried combining a treatment with a topical antibiotics in a sponge for the infection and a fish skin graftA rich in Omega3 to speed up the healing process.

Human skin and fish skin are similar due to evolutionary homology.1 Fish skin graftsA are, however, naturally more rich in Omega-3 polyunsaturated fatty acids (PUFAs). A double blind randomized controlled clinical trial has shown that acellular fish skin graftsA promote significantly faster healing compared to a mammalian derived product.2

AimEvaluation of the efficacy of using a fish skin graftA in combination with antibiotic impregnated bioabsorbable chitosan spongeB to heal wounds with history of chronic infection.

Cases1: 65 y.o. diabetic male with transmetatarsal amputation wound and osteomyelitis. Unresponsive to topical collagen dressingC. Treated with fish skin graftA and chitosan spongeB & impregnated with vancomycin and tobramycin. Healed in 20 weeks after with 6 applications of fish skin graftA and no incidence of reinfection.

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Poster Presentation

2: 68 y.o. non-diabetic male. Initial presentation with infected ulcer on his left heel and exposed bone with calcaneal osteomyelitis and maggots. Partial calcanectomy in O.R. Treated with fish skin graftA and chitosan spongeB with vancomycin. Healed in 12 weeks with 2 reapplications (3 total) of fish skin graftA, no instances of reinfection.

3: 70 y.o. male initial presentation with exposed bone and wagner 3 ulcer medial and lateral side of 3rd toe left foot. History of MRSA. Debrided bone in OR, chitosan spongeB with vancomycin and applied fish skin graftA. The infection cleared completely after one debridement in the OR. Healed in 20 weeks after 1 further fish skin graftA application, later had a BKA due to an unrelated issue.

ConclusionFish skin graftsA can be used in combination with topical antibiotics to combat infection. Tissue regeneration and barrier from re-infections was observed and warrants further research in a larger trial.

Trademarked ItemsA Kerecis„¢ Omega3 Wound by Kerecis B Sentrex BioSponge by Bionova MedicalC Primatrix by Integra

P05-03Paper No: 325Relations procalcitonin and other factors with lower extremity amputation in infected diabetic foot in the emergency room RSCM in January 2013 - June 2016

Sari Febriana1, Patrianef Darwis2

1Surgery Training Program Department of Surgery, Universitas Indonesia, Jakarta Pusat, DKI Jakarta, Indonesia2Universitas Indonesia, Jakarta Pusat, DKI Jakarta, Indonesia

BackgroundDiabetic foot infection remains a serious problem for the patient and often lead to lower limb amputation. Determination of aggressive action is needed to prevent the worsening of the patient’s condition. Procalcitonin as a sensitive marker of infection is expected to help to diagnose early so that management implemented more precise. This study aims to determine the relationship of procalcitonin on the risk of lower limb amputation. MethodComparative analytic study with cross-sectional design conducted at the Vascular and Endovascular Divison Department of Surgery Faculty of Medicine

Universitas Indonesia-Cipto Mangunkusumo Hospital from January 2013 to June 2016 in all patients with diabetic foot infection who come to the ER RSCM without pneumonia, malaria, severe trauma, burns, autoimmune, and medullary thyroid carcinoma. Subject are grouped into amputation and not amputation, then do analysis to find correlation values of procalcitonin on the occurence of the lower limb amputation. Data are extracted from medical records (secondary data) and performed statistical tests with significance p<0,05. ResultThe study included 110 subjects. The result is every 0.86 procalcitonin levels will have 2.36 times the risk for amputation (95 % CI 1.227 to 4.568). Another factor that has the greatest strength of the relationship of the amputation is the ankle brachial index 15,000/µL (p=0,004), and erythrocyte sedimentation rate >100mm/h (p=0,005).

ConclusionProcalcitonin independently have a significant relationship with the occurrence of lower limb amputation. Another significant independent factor to amputation in this research that the ABI (ankle brachial index) and osteomyelitis.

Others

P06-01Paper No: 014A third-time open heart surgery for a marfan`s syndrome with prosthetic valve dysfunction after mitral valve plasty and bentall procedure

Xiaoning Tong, Hideyuki HaradaCardiovascular Surgery, Kushiro Kojinkai Memorial Hospital, Kushiro, Hokkaido, Japan

IntroductionA Marfan`s syndrome patient underwent mitral valve plasty and Bentall procedure when she was 16 years old and 24 years old, respectively. The patient desired to bear children when she recieved Bentall procedure, so a biological valve was used in that operation .And this time we do the third-time open heart surgery for her because of prosthetic valve dysfunction. Now we would like to report this case for the good surgical outcome.

MethodsThe patient was a 36 year-old female. She came to the outpatient department for distress of breath. After 6 days of medication, pulmonary congestion and distress of breath got better tremendously, while the patient

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was able to walk as usual. However, distress of breath got worse suddenly on the 10th day, so we performed tracheal intubationoperate, after which we did a emergency operation for the patient. Intraoperatively, the biological valve was found severely calcificated, and the commissure of both edges of left coronary leaflet were teared. So we replaced for a 21mm mechanical valve.

ResultsPostoperatively, pulmonary congestion and distress of breath were disappeared. The function of mechanical valve was good in cardiac ultrasound both right after operation and 6 months later of following.

ConclusionsFor young patients who have the desire to bear children, the using of biological valve in valve replacement is inevitable because wafarin is forbidden for pregnant people .However, due to the dysfunction of biological valve in relatively short time, the second-time valve replacement is also unavoidable. In this case, we get good surgical outcome of a third-time open heart operation for the patient above.

P06-02Paper No: 017Comprehensive neurosurgical management for deep-seated brain avms

Hiroyuki Nakase, Shuichi Yamada, Ichiro Nakagawa, Fumihiko Nishimura, Matsuda Ryosuke, Yasushi Motoyama, Park Young-SuDepartment of Neurosurgery, Nara Medical University, Kashihara Nara, Japan

ObjectivesDeep-seated brain arteriovenous malformations (AVMs), located in the basal ganglia, thalamus, insula, and posterior fossa, are uncommon and have higher risk of rupture and higher potential for morbidity and mortality. We present our experience with multimodality treatment and the outcome of deep-seated AVMs.

MethodsSince 2000, we treated 27 deep-seated AVMs in our institute. The series consist of 16 males and 11 females; their ages ranged from 7 to 74 years old. Twenty one cases (77%) presented with hemorrhage. Locations include cerebellar hemisphere in 7, dorsal cerebellar hemisphere in 6, thalamus in 6, cerebellar pontine angle in 4, and periventricle, basal ganglia, corpus callosum and vermis in 1 case each.

ResultsSixteen patients were operated directly, 2 cases with severe hemorrhage treated only by ventricular drainage, and 9 deep highly eloquent cases were treated by radiosurgery. Two-staged operation were performed in 8 ruptured AVMs with hematomas. Preoperative embolization was performed in 7 cases. The direct surgical results in 16 cases was mRS-0 in 4, mRS-1 in 3, mRS-2:4, mRS-3 in 3 mRS-4 in 1, and mRS-5 in 1. Radiosurgery group (9 cases) could be followed from 9 to 77 months (mean 44.2 months). Decrease of size in 6 and disappear in 3 cases. No hemorrhage and complications were seen during the follow-up periods.

ConclusionsDeep seated AVMs are complex neurovascular lesions that pose an increased risk for hemorrhagic presentation as well as increased morbidity and mortality. Multidisciplinary teams will probably become increasingly important for optimal management to these complex lesions.

P06-03Paper No: 029AVM in scalp: Diagnostic dilemma - A case report

Shantonu Kumar Ghosh1, Alpana Majumder2

1Department of Vascular Surgery, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh2National Center for Control of Rheumatic Fever & Heart Diseases, Dhaka, Bangladesh

BackgroundDiagnosis of a pulsatile mass in scalp includes history, clinical examination and imaging. In almost all cases there is a history of trauma until and unless it is present since birth. If imaging reports are not conclusive it becomes a challenge to decide the plan of treatment.

MethodsOur case was a woman of 24 year, presented with a pulsatile mass in scalp which was noticed only three months earlier. She experienced sleep disturbance due to discomfort in head for pulsatile mass. She had no history of trauma to head, unconsciousness or visual disturbance. On local examination, a soft, globular, non-tender mass measuring about 3.0 X 2.5 cm was palpable over the right side of scalp in the region of parieto-occipital suture. The mass was compressible, free from underlying structure, could not be separated from overlying skin. Surface was smooth, margin ill defined, local temperature not raised. It was pulsatile, not expansile, rather transmitted. Duplex scan of the mass revealed arterial predominant AVM, but CT Angiogram

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Poster Presentation

reported venous malformation arising from right external jugular vein and getting venous drainage from right retro mandibular vein and facial vein. As there was diagnostic dilemma, decision was taken in favor of open surgery.

ResultsUnder general anesthesia excision of AVM and ligation of feeding vessels were done. It was found originating from branches of right superficial temporal artery.

ConclusionsConfusion frequently may arise while diagnosing a pulsatile scalp lesion. Clinical judgment should be most reliable to a surgeon for taking decision.

KeywordsPulsatile Mass; Arterio-venous Malformation (AVM)

P06-04Paper No: 046Spontaneous (True) aneurysm of the superficial temporal artery: A case report of 72 years old male

I Joalsen1, G Sianturi2, M Niasari3

1Division of Thoracic, Cardiac and Vascular Surgery, Abdul Wahab Sjahranie General Hospital - Mulawarman University, Samarinda, East-Borneo, Indonesia2Division of NeuroSurgery, Abdul Wahab Sjahranie General Hospital- Mulawarman University, Samarinda, East-Borneo, Indonesia3Department of Pathologic Anatomy, Abdul Wahab Sjahranie General Hospital- Mulawarman University, Samarinda, East- Borneo, Indonesia

IntroductionSpontaneous Aneurysms of the superficial temporal artery (STA) are rare. Although STA aneurysms have a relatively benign course, when compared with aneurysms of larger caliber arteries, they may occasionally lead to severe hemorrhage and be associated with a multitude of bothersome symptoms.

Objectiveto report a case of 72-year old male presented with spontaneous STA aneurysm in our center.

MethodA 72 years old male presented with a lump on his right temporal side without any previous history of trauma and there was history of long standing hypertension. The lump had first been noticed 2 years before and it had been gradually increasing in size especially within last 6 months. On physical examination there was a pulsatile

mass around 2 cm in diameter just above right ear. There was no thrill and bruit. CT angiography showed findings compatible with a STA aneurysm. The patient underwent proximal and distal ligation of the superficial temporal artery and excision of the aneurysm. Histopathological examination confirmed a true aneurysm of STA. The post operative period was uneventful

ConclusionSpontaneous STA aneurysm was best managed by surgical procedure. It was consist ligation and excision. It is simple, safe, and avoids recurrence.

KeywordsSuperficial Temporal Artery, True aneurysm

P06-05Paper No: 060Quantative analysis of digitaized books in the field of vascular surgery: Culturomics

Joong Hwan Oh, Kwan-Wook Kim, Chang-Won Kim, Soon-Chang Hong, Chun Sung ByunDepartment of Thoracic and Cardiovascular Surgery, Wonju Severance Christian Hospital, Yonsei University, Wonju city, Kangwondo, Republic of Korea

BackgroundIn 2004, the Google team started to digitalize books using optical character recognition system. Now we can approach big datas consisting of 500 billion words from more than 5 million books over five centuries. But the past 60 years have witnessed the most spectacular period of development of vascular surgery. Culturomics is a new form of computational lexicology that studies human cultural trends through quantitative analysis of digitalized texts. ObjectivesThe purpose of our study was to analyse the words used in the field of vascular surgery from the past to the present and to predict the future trends in the detailed fields. Materials and MethodsWe selected the incidents or words (anesthesia, angiography, anticoagulation, heparin, blood transfusion, antibiotics, arterial substitues, suture material, extracorporeal circulation, defibrillator, embolectomy, sympathectomy, endovascular stent, dissection, aneurysm, saphenous bypass) contributed to the development of vascular surgery. After entering a word or phrase, Google Books Ngram Viewer tool displays a graph charting how frequently term has

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appeared in books. And the tool shows traces or changing of the usage of a word or phrase during the five centries. We focused on the past 60 years. Results 1) At the beginning of the 20th century, blood transfusion was done safely after establishment of blood type and blood bank. Our selected incidents or words for the past 60 years contributed to the development of vascular surgery. 2) Extracoporeal circulation in 1953 contributed to the development of the cardiovascular surgery. 3) Interventional endovascular stent procedure is increasing compared to the classic vascular surgery. Conclusions Culturomics by analyzing big datas in the historical details of vascular surgery, each field can be predicted for the future details. Developments in industrial and technical fields outside medicine have also played important roles for the development of vascular surgery.

P06-06Paper No: 081Effectiveness of multi-disciplinary perioperative geriatric consultation for Vascular in-patient population

Jasmine Ge1, Zhiwen Joseph Lo2, Jennifer Yuan Li2, Sherilyn Liew1, Ruth Yap1, Sriram Narayanan2, Sadhana Chandrasekar2, Glenn Wei Leong Tan2, Esmiller Froilan2, Natesan Selvaganapathi2

1Yong Loo Lin School of Medicine, National University of Singapore, Singapore2Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore

BackgroundGeriatric surgical patients are at increased risk of peri-operative morbidity and mortality, especially so for Vascular in-patient population, who often has multiple co-morbidities. AimsTo evaluate the outcomes before and after the implementation of a geriatric perioperative consultation service - Geriatric Surgical Service (GSS) for elderly (age > 60 years-old) Vascular acute admissions. MethodsMatched case-cohort study of 211 Vascular acute admissions at a tertiary teaching hospital. Prospective data from 75 patients who were co-managed with GSS between August 2015 and May 2016 were matched

with 135 patients between 2014 and 2015 in a 1:2 ratio, according to age, gender, diagnosis and operative procedure. ResultsBaseline characteristics between the two study groups were similar, with mean age at 76 years-old. There was no significant difference in their co-morbidities and Charlson Index with age score (6.59 within GSS group vs 6.54 within control group). 76% of the study population were admitted for complications of lower limb peripheral vascular disease, with 30% undergoing revascularisation, 21% undergoing major amputations and 39% undergoing minor amputations. In terms of outcome, there was no significant difference in major complication rates of acute myocardial infarction (6.7% vs 5.9%), congestive cardiac failure (6.7% vs 7.4%) and 30-days readmission rate (34.7% vs 33.8%). There was a slight increase in post-operative delirium (13.3% vs 10.3%, p=0.315) which is likely due to better detection within the GSS group. There was also a trend of decreased post-operative pneumonia (10.7% vs 14.0%, p=0.325), urinary tract infection (8.0% vs 11.8%, p=0.286) and 30-day mortality (1.7% vs 4.4%, p=0.232) within the GSS group. Significantly, there was a shorted length of stay within the GSS group as compared to the control group (15days vs 20 days, p=0.003). ConclusionWithin our study population, elderly Vascular patients who were acutely admitted had significantly shorter length of stay through a multi-disciplinary and collaborative model of care between the Vascular surgical team and GSS. There was also a trend of decreased nosocomial infections and 30-day mortality.

P06-07Paper No: 122The clinical significance of morphological changes on CT scan of isolated superior mesenteric artery dissection treated with conservative treatment

Hye Young Ahn1, Byung Sun Cho2

1College of Nursing, Eulji University, Daejeon, South, Korea2Department of Surgery, Eulji Medical Center, Daejeon, South Korea

BackgroundIsolated superior mesenteric artery dissection (ISMAD) is not a rare disease. However, its natural course and optimal treatment strategy has not yet been established.

MethodsThis study included 21 consecutive patients with ISMAD

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Poster Presentation

who were treated between April 2010 and September 2016 according to our published treatment guidelines. We categorized ISMAD into 4 types based on CT scan. We investigated it’s natural history and treatment results according to the types.

ResultsIn the present study, 19 patients had acute onset abdominal pain and 2 patients were asymptomatic. Mean follow-up duration was 10.3 months. The Number of initial type II, IIa, III, IV was 2, 2, 10, 7, respectively. There were transformations between types on follow-up CT scan. Nineteen patients were treated with conservative treatment initially except 2 asymptomatic patients. One patient categorized as type IV underwent coil embolization due to persistence of abdominal pain and aneurysmal change on follow-up CT scan. Conservative treatment failure rate was 4.8%.

ConclusionsIf bowel necrosis or arterial rupture was not present, conservative treatment of ISMAD was a safe and effective treatment. Aneurysmal type IV patients on computed tomography scan should be carefully followed up, and if there is a recurrence of pain or aneurysmal progression, an endovascular procedure could be safely performed.

P06-08Paper No: 139The effect of catheter diameter on left innominate vein stenosis in breast cancer patients after totally implantable venous access port implantation

Tae-Seok Seo1, Myung Gyu Song1, Yun Hwan Kim2, Sung Bum Cho2, Hwan Hoon Chung3, Seung Hwa Lee3

1Department of Radiology, Korea University Guro, Hospital, Korea University College of Medicine2Department of Radiology, Korea University Anam, Hospital, Korea University College of Medicine3Department of Radiology, Korea University Ansan, Hospital, Korea University College of Medicine

BackgroundThe purpose of this study was to evaluate effect of catheter diameter on left innominate vein stenosis in breast cancer patients after implantation of totally implantable venous access ports (TIVAPs).

Materials and MethodsTIVAPs were placed in 241 women with right breast cancer via the internal jugular vein (IJV) from January 2010 to December 2014 (mean age, 51.5 years, range, 19 - 83 years) by left-side approach. There were 67 TIVAPs with 6.5F-catheter and 142 TIVAPs with 8F-catheter,

respectively. Medical records were retrospectively reviewed. The presence of significant left innominate vein stenosis, tip location of the catheter, and retrosternal space were evaluated on chest CT images. Statistical analysis was performed.

ResultsLeft innominate vein stenosis developed 1 (1.5%) and 13 (9.2%) patients after implantation with 6.5F and 8F, respectively. Differences in the cumulative incidence of left innominate vein stenosis were statistically significant between 6.5F- and 8F-catheter groups (log rank test p-value: 0.002). In Cox regression analysis, the hazard ratio for left innominate vein stenosis was 20.766 (p=0.005) in the TIVAP with 8F-catheter. The distance between the sternum and the left innominate vein was found to be significantly related to the development of left innominate vein stenosis, the hazard ratio was 0.781 (p=0.003).

ConclusionThe incidence of left innominate vein stenosis in breast cancer patients was higher after implantation of TIVAPs with 8F-catheter. When left-side approach of TIVAP in a patient with right breast cancer was performed, TIVAP with 6.5F-catheter was more helpful for preventing of left innominate vein stenosis.

P06-09Paper No: 175Case report: Remembering the basics iatrogenic injury to Superficial Femoral Artery (SFA) mistaken as Great Saphenous Vein (GSV)

Mohammad Fahad Tariq Berlas1, Farhina Salahuddin2

Department of Vascular Surgery, Shaheed Mohtarma Benazir Bhutto Trauma Centre Civil Hospital, Karachi, Pakistan, Pakistan

IntroductionIatrogenic arterial injury during varicose vein surgery is a rare but potentially limb threatening complication. We are presenting a case, referred to our center of iatrogenic injury to SFA during GSV stripping. Case Presentation28 year gentleman underwent Trendelenburg operation for varicose veins treatment involving his right leg. The surgeon misidentified the SFA as GSV, divided the artery and passed the stripper down the artery, failure of the stripper to appear distally alerted the surgeon who then identified the injury to the artery and repaired the artery with interrupted prolene. Fortunately, the limb remained viable with a segment of contused SFA on

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angiogram. Patient was managed with anticoagulants and did not require immediate vascular reconstruction. ConclusionFemoral artery injuries during GSV stripping are unusual occurrences. However this case made us realize that may be remembering the simple basics such as knowledge of anatomy and variations, adherence to principles of dissection and meticulous technique can prevent such a mishap from occurring. KeywordsTrendelenburg Operation, Varicose Vein, Misidentified, Anticoagulants

P06-10Paper No: 177Case report: Adventitial cystic disease of the femoral vein

Park SS, Jang LCDepartment of Surgery, Chungbuk National University Hospital, Cheongju, Chungcheongbuk-do, South Korea

BackgroundAdventitial cystic disease (ACD) of the venous system is an extremely rare condition. Very few cases of ACD in the venous system have been reported in the worldwide medical literature. ACD of the femoral vein is particularly difficult to diagnose due to the similarity in symptoms to those of deep vein thrombosis(DVT). We report the case of a patient who was referred to us after a diagnosis of a right DVT.

MethodA 60-year-old man with edema two weeks history of in his right thigh was referred to us. He has been healthy except for swelling in his leg. He has no history of other traumas in his leg, or any interventions, operations. No other abnormality without right leg swelling was found on physical examination. An ultrasonography indicated a cystic mass containing hypoechoic materials attached to the right common femoral vein. The computed tomography (CT) showed a 3 cm sized unenhanced mass compressing the right common femoral vein with enlarged lymph nodes.

ResultThe surgery was performed. The extensive cystic involvement of the vein was completely resected and reconstructed with a 10mm ringed polytetrafluoroethylene(PTFE) graft. Histologic examination of the femoral vein revealed that the adventitia had a cystic cavity consisting of fibrous tissue

filled with colloidal mucinous material. The leg swelling resolved postoperatively, and anticoagulation therapy with warfarin was continued for 3 months. He has not complained of any kind of discomfort, pain, or swelling in his left leg from now.

ConclusionACD is a rare condition, but it should be suspected in patients with the symptoms of DVT, and especially when a young man without risk factor of DVT. Surgical treatments ACD of femoral vein include transluminal fenestration, transadventitial evacuation, and segmental resection. In our patient, the femoral vein was patent, so the ACD wall was segmentally resected. We had a successful outcome.

P06-11Paper No: 179Managing infected pseudo aneurysms in IV drug abusers - A challenging problem for the vascular surgeon of the developing world

Farhina Salahuddin, Muhammad Fahad Tariq Berlas, Zulfiqar Ali, Najamuddin Rajpar, Waryam Panhwar, Khalil-ur-RehmanDepartment of Vascular Surgery, Shaheed Mohtarma Benazir Bhutto Trauma Centre Civil Hospital, Saddar Town, Karachi, Pakistan

BackgroundWith the ever so increasing use of illicit drugs certain areas in the developing world have now an endemic state of IV drug abuse. The vascular surgeon is faced to deal with the potentially fatal complication of infected pseudo aneurysm in these patients. We are presenting our case series of 23 patients with infected pseudo aneurysm managed in a short period of one year. MethodRetrospective analysis of 23 IV drug abuser patients with infected pseudo aneurysm managed from June 2016 to May 2017.The variables observed are demographic data, clinical presentation, management and outcome. ResultsTwenty three patients, intravenous drug abusers with infected pseudoaneurysms were included in the study. All were male with, mean age of 32 years. Among these patients 70% were seropositive for HCV. 18 patients (78.2%) had femoral artery involvement and the remaining 5 patients (22.8%) had brachial artery pseudoaneurysms. At presentation 52% were already ruptured.

158

Poster Presentation

Ligation of the artery and excision of pseudoaneurysm along with debridement was done in all cases.. 20% case also had an arteriovenous fistulous communication found per operatively for which ligation of the artery, disconnection of the fistulous communication and ligation of involved veins was done with no attempt of vascular reconstruction. Three (13%) patients required primary amputation at the time of initial surgery due to non-viable limb at presentation all at above knee level.

Postoperatively 16(69.5%) patients had an uneventful recovery, one (4.3%) patient developed dry gangrene of little toe requiring digit amputation. Three (13%) patients had neurological symptoms .There was no case related mortality. ConclusionLigation and excision of pseudoaneurysm with debridement is a safe and effective procedure in iv drug abuser patients with infected pseudoaneurysm and done timely can be life saving. KeywordsPseudoaneurysm, IV drug abuser, Excision, Ligation, Arteriovenous fistulous communication

P06-12Paper No: 215Abdominal aortic replacement in intimal sarcoma of an abdominal aortic stenosis: A case report

Katsunori Takeuchi, Akio Yamashita, Kanetsugu Nagao, Kimimasa Sakata, Naoki YoshimuraDepartment of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, University of Toyama, Toyama, Japan

BackgroundAortic intimal sarcoma (AIS) is an exceedingly rare tumor. The tumor occurs primarily in the pulmonary artery and intima of the aorta, and frequently metastasizes to the bone and visceral organs. The symptom is nonspecific and often bogged down with a diagnosis. The tumor sometimes causes distal embolism. Many AIS cases result in death within 1 year from discovery.

CaseA 59-year-old male patient had anemia, which was detected in a routine physical examination . When he visited an internist because of anemia and lumbago, multiple metastatic bone tumors were detected on positron emission tomography/computed tomography. An increased uptake of 18F-fluorodeoxyglucose was found at the location corresponding to the abdominal

aorta, lumbar spine, and ilium bone. The infrarenal abdominal aorta had stenosis, and angiosarcoma was suspected as a cause. The patient required rapid diagnosis because he was at risk of embolic and ischemic events. Therefore, we decided to perform an abdominal aortic replacement. The tumor was thought to be fragile and mobile, so we took care not to touch the abdominal aorta as much as possible. The infrarenal abdominal aorta was resected and replaced with a bifurcated graft (main size, 16 mm; leg size, 8 mm). The macroscopic findings from the resected abdominal aorta showed that the tumor had originated from the aortic intima and had grown into the aortic inner lumen, and no clot was found. On histological examination, epithelioid angiosarcoma was diagnosed as broad intimal sarcoma. The pain was controlled, and he was discharged from our hospital on the 18th day post-surgery. ConclusionAIS has nonspecific clinical manifestations and often present with lumen obstruction, such as ischemic symptoms or symptoms with tumor emboli. In addition, the metastasis of the primary aortic lesion reaches 80% and is common in the bone, lungs, liver, and skin. Unfortunately, the prognosis of patients with aortic sarcoma is poor. Intimal lesions with intramural extension may be mistaken for bland luminal thrombi on computed tomographic angiography. AIS should be considered in the differential diagnosis in any patient that presents with thickening of the aortic wall, shaggy aorta, or acute peripheral or visceral embolic phenomena.

P06-13Paper No: 226Development of the gene therapy with CRE decoy ODN to prevent vascular intimal hyperplasia

Daiki Uchida

ObjectiveIntimal hyperplasia (IH) is the main cause of vein graft stenosis or failure after bypass surgery. However, in the previous study derived from an animal model, no therapeutic targets for the treatment of IH have been identified. Our recent research using human vein graft samples have been reported that the inhibition of Cyclic adenosine monophosphate response-element (CRE) binding protein (CREB) activation is a key role for suppressing IH. We focused on decoy oligodeoxynucleotide (ODN) transfection as gene therapy strategy of IH. The goal of the present study is to identify whether the CRE decoy ODN had the therapeutic efficacy for suppressing IH.

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Methods and ResultsWe designed and synthesized phosphorothioated CRE decoy ODN and checked binding capacity to CRE sequence of CREB cis-element. Transfer of the CRE decoy ODN to vascular smooth muscle cells (VSMCs) strongly repressed CRE activity and decreased proliferation and migration in vitro. Now we check the therapeutic efficacy of the decoy therapy on mouse model.

ConclusionsThe present result suggested that CRE decoy ODN provide an effective therapeutic approach to suppressing IH.

P06-14Paper No: 237Splenic artery aneurysm arising from a hepatosplenomesenteric trunk

Wah Wah Lin, Jens Carsten Ritter, Brendan StanleyDepartment of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia

BackgroundWe report a case of a 3.5 cm splenic artery aneurysm (SAA) located in a challenging position in a patient with a common hepatosplenomesenteric trunk. A 53 years old woman was under investigations for unspecified abdominal pain and diarrhoea. A computed tomographic angiogram (CTA) identified a vascular variation of her visceral vessels with a common hepatosplenomesenteric trunk. The aneurysm was located at the proximal splenic artery 1 cm distal to the SMA origin. Visceral aneurysms of this size warrant treatment.

MethodDespite the challenging location of the aneurysm in immediate proximity to the origins of splenic and hepatic arteries, it was possible to manage it by endovascular means; a combination of a vascular plug to the splenic artery distal to the aneurysm, coil embolization of the aneurysm and stenting of the superior mesenteric artery (SMA).

ResultAt one month postoperative follow up the patient is well. A repeat CTA showed the SMA and hepatic arteries to be patent. The proximal splenic artery remains occluded as desired with reformation distal to the thrombosed aneurysm sac.

ConclusionIn the review of the literature, only one SAA arising from the hepatosplenomesenteric trunk was identified, which

was managed with open surgical procedure. Our case demonstrates for the first time successful endovascular management of this rare anatomical variant in combination with aneurysmal disease.

P06-15Paper No: 247The effect of protease inhibitor on atherosclerosis biomarker in HIV infected patients

Kittipan Rerkasem1,2, Khuanchai Supparatpinyo3,4, Romanee Chaiwarith4, Kanokwan Watcharasaksilp4, Nattapol Kosachunhanun3, Thaweewat Supintham3, Patcharaphan Sugandhavesa3, Thananchai Kampee5, Sakaewan Ounjaijean3, Kanokwan Kulprachakarn1

1NCD Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand2NCD Centre of Excellence, RIHES, Chiang Mai University, Chiang Mai, Thailand3Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand4Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand5Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

BackgroundRecent studies demonstrates HIV infected patients suffer from atherosclerosis in cardiovascular disease more and more. Based on literatures HIV infection treatment with antiretroviral drug, namely a protease inhibitor (PI), seems to increase cardiovascular events. Therefore we wonder whether the mechanism of PI lead to vascular atherosclerosis due to any inflammatory biomarkers, which has been confirmed as a fundamental process of atherosclerosis. MethodsPatients with HIV infection were recruited between January and July 2016 from Outpatient Department of Maharaj Nakorn Chiang Mai hospital. The study was conducted in two groups; group A (30 patients) was HIV-infected patients with receiving PI drug (PI group) and group B (30 patients) was HIV-infected patients with none receiving PI drug (none PI group). Both of groups were compared with vascular atherosclerosis biomarkers such as high-sensitivity C-reactive protein (Hs-CRP), interleukin-6 (IL-6), intercellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1) and osteoprotegerin (OPG), respectively. This study was supported by Chiang Mai University. ResultsThe Hs-CRP level was significantly increased in none PI group than PI group (14.94 ± 19.37 mg/mL and 5.42 ± 9.14 mg/mL, P=0.041). In the other hand, the VCAM-

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Poster Presentation

1 and OPG levels in PI group were significantly higher than none PI group (1,135.29 ± 224.34 ng/mL vs 985.15 ± 214.61 ng/mL, P=0.005 and 153.66 ± 57.08 pg/mL vs 126.40 ± 35.78 pg/mL, P=0.036, respectively). ConclusionsOur results revealed that PI in HIV infected patients may be cause of atherosclerosis through inflammation. Mare studies are needed to confirm this findings.

P06-16Paper No: 257Successful management of tumors invading the superior vena cava using a endovascular stent graft

Yoon-Sung Joo Soon cheon Lee1, Dong Hyun Kim2, Min Sang Song3, Yung Baom Park4, Sang Su Lee2, Sang Bong Lee2

1Gwangyang Sarang Hospital, Gwangyang, Korea2Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea3Dongrae Bongseng Hospital, Busan, Korea4Cheongmac Vascular and Vein clinic, Busan, Korea

Malignant invasion is the most frequent indication for SVC resection and reconstruction.

Surgical procedure such as partial resection of SVC, SVC replacement and palliative bypass need to block the blood flow of patient’s vessels that may produce intracranial bleeding, brain edema, damage and reduction of cardiac output. Furthermore, a number of potential postoperative complications may be associated with resection and reconstruction of the SVC such as stenosis, thrombosis and infection.

PurposeTo report successful management superior vena cava resection by inserting endovascular stent graft in a 65-years-old woman who had malignant lung cancer invading superior vena cava.

CaseA 65-years-old woman presented with lung cancer with right upper and lower paratracheal lymphadenopathy with direct SVC invasion. The patient was scheduled for right upper lobectomy and was referred to the vascular surgeon for insertion of the endovascular stent graft in the superior vena cava. First, 24*54mm extender stent graft was inserted in the superior vena cava through the right internal jugular vein by vascular surgeon, and right upper lobectomy, paratracheal lymph node dissection and superior vena cava resection were performed by a thoracic surgeon.

ConclusionBy performing endovascular stent graft insertion, the patient was able to undergo surgery without blocking the blood flow and it was possible to prevent complications that might occur as a result of blocking the blood flow of the patient.

P06-17Paper No: 259A retrospective review of underlying causes and treatment results of aorto-enteric fistula or aorto-enteric erosion

Dong-Heon Lee1, Shin-Young Woo1, Seon-Hee Heo1, Yang-Jin Park1, Dong-Ik Kim1, Ki-Ik Sung2, Young-Wook Kim1

1Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea2Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

PurposesTo determine underlying causes and treatment results of aorto-enteric fistula(AEF) and aorto-enteric erosion(AEE). MethodsWe retrospective reviewed database of patients with AEF and AEE and investigated demographic and clinical features, underlying causes of AEF/AEE, prior aortic surgery or disease, treatment procedure and its results.

ResultsFrom September 2000 to December 2016, 21 patients (age, median 60 years; range, 30-76 years, male 81%) with AEF or AEE were found from the database searching. Thirteen (62%) patients were secondary to prior aortic surgery and 16 (76%) AEFs/AEEs were associated with abdominal aortic aneurysm. Time interval between aortic surgery and occurrence of AEF/AEE was so variable from a few months to 20 years. Most common clinical symptom was abdominal /chest pain in AEF patients and fever was most common symptom in AEE patients. The clinical features, underlying causes and treatment results of those patients were demonstrated in the table (Table). There was no difference in mortality between primary and secondary AEFs. In hospital mortality rate was higher in AEF than in AEE (23.5% vs 0%) and multi-organ failure was most common cause of death.

ConclusionAEF more often attributed to prior aortic surgery either endovascular or open repair than primary aortic pathology. AEF/AEE can occur at long time after aortic surgery. Even after successful bleeding control and

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arterial reconstruction, mortality rate was still high commonly due to multi-organ failure in patients with AEF.

P06-18Paper No: 292A systematic review of transcatheter aortic valve implantation via carotid artery access

Ian Wee Jun Yan1,2, Thomas Stonier1,3, Michael Harrison1,4, Andrew MTL Choong1,5,6

1SingVaSC, Singapore Vascular Surgical Collaborative2Faculty of Medicine, University of New South Wales, Sydney, Australia3Princess Alexendra Hospital, Harlow, United Kingdom4Department of General Surgery, Sir Charles Gairdner Hospital, Australia5Division of Vascular Surgery, National University Heart Centre, Singapore6Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

PurposeThe carotid artery is a novel access route for transcatheter aortic valve implantation (TAVI), especially useful in patients unsuitable for traditional access routes including transfemoral, subclavian, transapical, and aortic. This systematic review summarises the evidence for its efficacy and safety.

MethodologyA systematic review was conducted as per the Preferred Reporting Instructions for Systematic Reviews and

Meta-analysis (PRISMA) guidelines utilizing five electronic databases.

ResultsThere were 21 studies identified, including 7 prospective cohort studies, 2 retrospective cohort studies, 3 case series, and 8 case reports. Data on 392 patients (mean age 79.4 years) was extracted including pre-operative work-up, technical procedure details, and outcomes.

There were 7 perioperative deaths, 18 further deaths within 30 days, 15 incidences of transient ischemic attack, 1 incidence of myocardial infarction, 4 incidences of stroke, no incidence of carotid access site complications. 2 patients died of infection, 1 patient required new dialysis, 1 patient had a self-resolved intraoperative dissection, 4 patients had prosthetic embolization, 7 had second implantation, 4 had cardiac tamponade due to left ventricular wire perforation. Follow-up to 1 year showed 19 further deaths, but overall symptomatic and echocardiographic improvement in line with those seen in transfemoral TAVI.

ConclusionThe available data on transcarotid TAVI show comparable technical feasibility with other traditional access routes, representing a viable alternative. A low number of patients, heterogeneous clinical endpoints and relatively short follow-up periods limit formal meta-analysis and firmer conclusions.

P06-19Paper No: 293The kidney wrapping nitric oxide releasing nanofiber diminishes apoptosis and inflammation after renal ischemia-referfusion injury in rat

Hyung Joon Ahn, Hyun Min Ko, Jung Min Lim, Hye Jin KimDepartment of Surgery, Kyung Hee University, Seoul, Republic of Korea

BackgroundRenal ischemia-reperfusion injury (IRI) is very important in various clinical setting including aortic surygery. Nitric oxide (NO) was well known to be a protector of IRI in many organs. However there was no appropriate delivery system into target organ. The aim of this study was to investigate the effect of the nitric oxide releasing nanofiber on renal IRI in a rat models.

MethodsMale Sprague-Dawley rats were divided into three groups: (1) sham group (n=5); (2) control group, renal

Abstract ID : 259 Type : Either Category : 11 Others Presenter : Dr DONG-HEON LEE Title : A retrospective review of underlying causes and treatment results of aorto-

enteric fistula or aorto-enteric erosion Authors: Dong-Heon Lee1, Shin-Young Woo1, Seon-Hee Heo1, Yang-Jin Park1, Dong-Ik Kim1, Ki-Ik Sung2, Young-Wook Kim1* 1Vascular Surgery, 2Thoracic surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

Purposes: To determine underlying causes and treatment results of aorto-enteric fistula(AEF) and aorto-enteric erosion(AEE).

Methods: We retrospective reviewed database of patients with AEF and AEE and investigated demographic and clinical features, underlying causes of AEF/AEE, prior aortic surgery or disease, treatment procedure and its results.

Results: From September 2000 to December 2016, 21 patients (age, median 60 years; range, 30-76 years, male 81%) with AEF or AEE were found from the database searching. Thirteen (62%) patients were secondary to prior aortic surgery and 16 (76%) AEFs/AEEs were associated with abdominal aortic aneurysm. Time interval between aortic surgery and occurrence of AEF/AEE was so variable from a few months to 20 years. Most common clinical symptom was abdominal /chest pain in AEF patients and fever was most common symptom in AEE patients. The clinical features, underlying causes and treatment results of those patients were demonstrated in the table (Table). There was no difference in mortality between primary and secondary AEFs. In hospital mortality rate was higher in AEF than in AEE (23.5% vs 0%) and multi-organ failure was most common cause of death.

Conclusion: AEF more often attributed to prior aortic surgery either endovascular or open repair than primary aortic pathology. AEF/AEE can occur at long time after aortic surgery. Even after successful bleeding control and arterial reconstruction, mortality rate was still high commonly due to multi-organ failure in patients with AEF.

Table. Underlying causes, clinical features and treatment of AEF/AEE

Feature AEF (n=17) AEE (n=4) Median age (years, range) 60 (30-76) 60 (42-71) Gender (male) 13 (76.5%) 4 (100%) Primary Secondary

8 (47.1%) 9 (52.9%)

NA 4 (100%)

Underlying disease Aortic aneurysm Behcet's disease Marfan's syndrome RT for cancer

13 (76.5%) 1 (5.9%) 1 (5.9%) 2 (11.8%)

3 (75.0%) 1 (25.0%) - -

Prior aortic surgery Open aortic surgery EVAR

9 (52.9%) 6 3

4 (100%) 3 1

Elapsed time after aortic surgery Median, mo (range)

27.6mo (3.3-169.4)

39.5mo (4.1-256.9)

Clinical feature (No. can be overlapped) Fever

Abdominal or chest pain GI bleeding Hypotension (SBP < 80mmHg)

8 (47.1%) 12 (70.6%) 15 (88.2%) 5 (29.4%)

3 (75.0%) 1 (25.0%) 1 (25.0%) -

Site of GI fistula Esophagus Gastric

Duodenum Jejunum

Ileum Descending colon

5 (29.4%) 1 (5.9%) 8 (47.1%) 2 (11.8%) - 1 (5.9%)

- - 3 (75.0%) - 1 (25.0%) -

Treatment Secondary AEF/AEE

Graft removal & in situ aortic reconstruction Graft removal & extra-anatomical bypass Graft preservation & bowel resection

6 (35.3%) 3 (17.6%) -

3 (75.0%) - 1 (25.0%)

Primary AEF Open aneurysm repair and enteral closure Aortic patch angioplasty Extra-anatomical bypass & bowel resection

5 (29.4%) 2 (11.8%) 1 (5.9%)

NA NA NA

AEF, aorto-enteric fistula; AEE, aorto-enteric erosion; NA, not applicable

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Poster Presentation

IRI without any treatment (n=4); (3) NO group, the renal IRI with wrapping the liver using NO rapid releasing-polymer nanofiber matrix (n=6). For renal IRI procedure, Rt nephrectomy was done one week before renal IRI. NO releasing sheet was applied by wrapping left kidney one hour before clamp of renal artery. Renal ischemia was sustained during 55 minutes, followed by reperfusion. NO sheet was removed 24 hours. And 48 hours after surgery, the rats were sacrificed.

ResultsFor identifying the effect of NO, we analyzed the creatinine. There were significant differences between groups. (p=0.002) Mean of sham, control and NO group at 48 hours after operation were 0.48(±0.08), 4.67(±0.33) and 2.60(±1.0) respectively. And Bax/bcl-2 mean ratio were 0.44(±0.57), 1.91(±1.23) and 0.42(±0.31) respectively. The level of Bax/bcl-2 in NO group was significantly lower than in control group.

ConclusionsNO nanofiber has the protective effect against rat renal IRI. This finding might be correlated with Bax/bcl-2 ratio. Furthermore, this NO delivery system might be considered as valuable method to decrease the renal IRI in vascular surgery.

P06-20Paper No: 360Two elderly patients with atypical coarctation treated with axillo-bilateral femoral artery bypass

Shuto Hirooka, Tetsuro Uchida, Azumi Hamasaki, Seigo Gomi, Yoshinori Kuroda, Masahiro Mizumoto, Atsushi Yamashita, Jun Hayashi, Takahashi, Kentaro Akabane, Mitsuaki SadahiroDivision of Cardiovascular Surgery, Department of Surgery II, Yamagata University Faculty of Medicine, Yamagata, Japan

BackgroundAtypical coarctation can cause hypertensive heart failure and renal dysfunction. Procedures used to treat coarctation include open surgery, angioplasty, endovascular treatment, and extra-anatomical bypass, with the primary goal being to relieve stenosis. We report two successful surgical cases of atypical coarctation.

PatientsTwo elderly women presented with bilateral claudication. Both were 74 years old. Case 1 was hospitalized with hypertensive heart failure. Both cases had renal

dysfunction (creatinine in Case 1: 1.53, Case 2: 1.82), and a decreased ankle-brachial index (ABI) (Case 1: right 0.56, left 0.76; Case 2: right 0.65, left 0.63). Computed tomography revealed severe descending aortic stenosis with calcification. The diameter at the narrowest segment was 6 mm in Case 1 and 4 mm in Case 2. Endovascular treatment was considered difficult. In addition, obstruction of the right internal carotid artery was observed in Case 2. Both cases underwent axillo-bilateral femoral artery bypass, and both recovered well. Postoperative renal function was improved (creatinine in Case 1: 1.21, Case 2: 1.30) and the bilateral ABI increased (Case 1: right 0.76, left 0.77; Case 2: right 0.85, left 0.83). Case 2 has been well-controlled on a lower antihypertensive dose.

ConclusionExtra-anatomical axillo-bifemoral bypass for atypical coarctation improved renal function and claudication in both patients. Graft replacement of a stenotic segment via thoracotomy is optimal, but is too invasive in high-risk cases. Axillo-femoral artery bypass is a less-invasive alternative, with rapid clinical improvement and a lower surgical mortality rate. This extra-anatomical bypass procedure appears to be a suitable option for elderly patients with atypical coarctation of the aorta accompanied by persistent severe hypertension and prolonged renal dysfunction.

P06-21Paper No: 387Giant hepatic artery aneurysm: The evil within

Rosnelifaizur Ramely1, Lenny Suryani Safri2, Azim Idris2, Hanafiah Harunarashid2

1Department of Surgery, School of Medical Science, Universiti Sains Malaysia, Kelantan, Malaysia2Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Malaysia

IntroductionHepatic artery aneurysm (HAA) is a rare presentation, with reported incidence ranging from 0.01 to 0.2% in the general population. It is the second most common form of visceral aneurysm, comprising approximately 20% of splanchnic aneurysms. Majority of cases are asymptomatic prior to rupture. Thus ruptured hepatic artery aneurysms carries a high mortality rate. Therefore, aggressive management of HAA is recommended upon diagnosis. We presented a case of HAA pseudoaneurysm successfully managed with surgery.

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Case reportThis is a case of a 56-year-old lady presented with a history of intermittent upper abdominal pain for the past one month. The pain is a dull aching pain radiating to the back and she had significant lost of weight during this period. Physical examination revealed a tender, pulsatile mass at the epigastrium. Computed tomographic angiogram revealed a large saccular aneurysm of the common hepatic artery measuring 6.2x7.0x12.0cm with intramural thrombus within. The aneurysm sac encases both the common hepatic and splenic artery, displacing the gastroduodenal artery posterolaterally. An emergency laparotomy was performed and intraoperative findings noted the huge aneurysm measuring 16cm have ruptured posteriorly, forming a pseudoaneurysm. It was released from the duodenum and omentum and excised. The gastroduodenal artery adhered to the sac was ligated. The right long saphenous vein was harvested for an interposition graft between the proximal and distal common hepatic artery. Postoperatively, the patient developed a superficial infection at the surgical site which required surgical debridement. The drain fluid biochemistry revealed raised amylase level of 70000 mmol/L, which prompted the diagnosis of pancreatic fistula. Endoscopic retrograde cholangiopancreatography was done and her pancreatic duct was stented. Histology confirmed an aneurysmal sac with no features of vasculitis or thickening of the vasa vasorum. The patient recovered and was discharged on the day 19 post-operation.

ConclusionHepatic Artery Aneurysym is a rare entity with high rates or morbidity and mortality. All symptomatic patients should be considered for treatment. Options for treatment include open or laparoscopic surgery, endovascular procedures or combination therapies.Please paste your abstract here.

P06-22Paper No: 398Infected femoral pseudoaneurysms in Intravenous Drug Abusers (IVDAs): A 10 year, single-institution experience

L Chen, D Lim, D Ho, YK Tan, S KumVascular Service, Department of Surgery, Changi General Hospital, Singapore

IntroductionInfected femoral pseudoaneurysms are a common vascular complication in intravenous drug users (IVDAs) with potential sequelae of sepsis, hemohrrage, digital embolization, limb loss and death. However, there is no published randomized trial or guidelines for the management of infected femoral pseudoaneurysms. ObjectiveThe objective of this paper to evaluate a single institution’s experience with infected femoral pseudoaneurysms in IVDAs. A retrospective review was performed over a 10 year period from January 2006 to December 2016. Results A total of 27 infected femoral pseudoaneurysms among 26 patients were identified during the study period. The majority were male (92%) and of Malay ethnicity (54%). The median age was 51 years (range 31 to 62 years). The commonly abused drugs were Buprenorphine (‘Subutex”; 58%) and Midazolam (‘Dormicum”; 54%). Groin pain and swelling (100%), fever (67%) and the presence of a pulsatile mass (52%) were the most common presenting symptoms. Diagnosis was confirmed via either US duplex or computed tomography (CT) angiography in all the cases. Of these 27 cases, 25 cases underwent arterial ligation with debridement, 1 underwent excision of the infected pseudoaneurysm with Sartorius flap closure and 1 refused surgery and discharged against medical advice. Of these 25 cases, 3 required concurrent surgical revascularization; 2 required an external iliac to popliteal artery bypass and 1 required thrombectomy of the superficial femoral artery. Post-operative complications included wound infection (43%), bleeding (11%), necrotising fasciitis eventually resulting in limb loss (4%), and post-op ischemic limb (4%). There were no associated mortalities. ConclusionThe infected pseudoaneurysm in an IVDA poses a unique challenge to the vascular surgeon. Our series has shown that simple ligation and debridement (without revascularization) is a safe and effective treatment for such patients.

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Poster Presentation

P06-24Paper No: 424Endovascular aneurysm repair increases augmentation index and reflection magnitude

Shinya Negoto, Tohru Takaseya, Hiroyuki Otsuka, Seiji Onitsuka, Shinichi Nata, Ryo Kanamoto, Shinichi Imai, Shinichi Hiromatsu, Hiroyuki TanakaDepartment of Surgery, Kurume University, Kurume, Fukuoka, Japan

IntroductionEndovascular aneurysm repair (EVAR) is considered as the predominant treatment for abdominal aortic aneurysms (AAA). Cardiovascular mortality remains the main cause of death among AAA patients treated with EVAR. Aortic stiffness has been proposed as a risk factor of cardiovascular events. However, the effects of EVAR on aortic stiffness remain to be clarified. Therefore, we hypothesized that EVAR could increase aortic stiffness by assessment of analyzed central aortic pressure pulse waves.

MethodsWe studied the effect of EVAR in 24 consecutive abdominal aortic aneurysm (AAA) patients (mean age = 76.2 years, M/F = 22/2). We performed trans-catheter measurement of aortic systolic blood pressure (aSBP) and aortic diastolic blood pressure (aDBP) at aortic root, and wave analysis based on an oscillometric method using a common cuff (ARCSolver) in AAA patients at both pre and post EVAR in general anesthesia during surgery. ARCSolver measured the systolic and diastolic pressure at brachial artery and determined pressure waves at the central aortic level (aSBP and aDBP). The augmentation pressure (AP) and the augmentation index (AIx) and reflection magnitude (RM) were analyzed from determined central aortic pressure waves.

ResultsTrans-catheter aSBP was significantly increased from 94.9 to 105.5 mmHg (p).

ConclusionsOur results show that EVAR increase aortic stiffness. The indication of EVAR is expanding to younger age, but we have to evaluate long-term results because increasing aortic stiffness might be a risk factor of cardiovascular events treated AAA patients.

P06-23Paper No: 408Visceral artery aneurysms seen in Abdominal CT

Lee Chan Jang, Sung Su ParkDepartment of Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea

BackgroundThe incidence of VAAS(visceral artery aneurysms) was estimated from the incidence of splenic artery aneurysm. The incidence of splenic artery aneurysms based on autopsy studies was 0.01-10.4% and divided into two different ranges (0.01% ~ 0.23% vs 8%~10.4%) according to a size of an aneurysm, dissection method or scrutiny. VAAs have been found more frequently by common use of abdominal CT. We would like to know the incidence, characteristics of VAAs found in abdominal CT.

MethodsI reviewed radiologic reports of abdominal CT for 12 years between Jan-01-2005 and Dec-31-2016 in Chungbuk National University Hospital. If I found a word like ‘aneurysm’ in radiologic reports of 59383 patients, I reviewed the CT images to find VAAs. False VAAs by trauma or operation were excluded from calculation of the incidence.

ResultsWe found 117 VAAs in 108 patients and the incidence was 0.18%. A mean patient’s age was 70.3 years (range, 30-96 years). A ratio of male versus female was 1:1.6. VAAs in the splenic artery is the most common(43.6%) , followed by the renal arteries(38.4%), celiac trunk (7.7%), hepatic arteries (4.3%), gastroduodenal arteries(2.6%), superior mesenteric artery (1.7%) , pancreaticoduodenal artery(1.1%) and middle colic artery(1.1%).

Multiple VAAs were found in 7 patients(6.5%). Ruptured VAAs were found in 3 patients(2.7%). Seven patients underwent surgical treatment (3 bypass, 1 nephrectomy, 2 splenectomy, 1 excision) for VAAs . Seven patients received an endovascular treatment(6 coil embolization, 1 stent). Although 2 patients were a candidate for treatment, they did not receive treatment.

ConclusionsThe incidence of VAAs was 0.18%. VAAs unintentionally found were usually stable in follow-up. Characteristics of VAAs were quite similar to other reports.

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P06-25Paper No: 470Modern day ileo caval surgery: A perspective

Prasenjit Sutradhar, Ankur Aggarwal, Bhavin Ram, Rajesh S, Robbie K GeorgeDepartment of Vascular Surgery, Narayana Health, Bengaluru, Karnataka, India

BackgroundA look at the role of vascular surgeon in open IVC surgery in the era of endovascular venous interventions.

MethodsA retrospective study of all open IVC interventions over a period of 6 years at a single centre multispecialty hospital.

ResultsA total of 21 cases were seen over the period of 6 years. 3 patients underwent femoro caval bypass. 1 case of infected right cavo femoral graft explantation was seen. 2 patients presented with primary IVC leimyosarcoma, for which IVC resection with reconstruction with PTFE graft was done. 3 cases of retroperitoneal tumour with IVC involvement were found in whom partial resection of wall of IVC with reconstruction using PTFE patch was done. In 12 cases of renal cell carcinoma with extension of tumour thrombus in the IVC, exploration of IVC with removal of thrombus and primary closure was done. In majority of the cases a multidisciplinary approach with the urology team was taken.

ConclusionsThe role of open IVC surgery has changed with the advent of endovascular options for venoocclusive disease. The role of a vascular surgeon in open IVC interventions is more often seen in resection and reconstruction of IVC in retroperitoneal and renal neoplasms involving the IVC.

P06-26Paper No: 473A contemporary experience of thoracic outlet surgery

Prasenjit Sutradhar, Ankur Aggarwal, Bhavin Ram, Rajesh S, Robbie K GeorgeDepartment of Vascular Surgery, Narayana Health, Bengaluru, Karnataka, India

IntroductionThoracic outlet syndrome (TOS) is a disease which involves compression of the neurovascular bundle as

it exits the thoracic girdle and is becoming a common diagnosis in vascular surgery clinics around the world. This study assessed contemporary management of thoracic outlet syndrome at a high volume referral centre.

MethodsA retrospective study of all operated cases of thoracic outlet syndrome over a period of 5 years at a single centre multispecialty hospital. Descriptive statistics were used to look at type of presentation, surgical intervention and post operative complications.

Results Total number of patients recruited were 31. Out of them, 17 (~ 55%) were males and 14(~45%) were females. 15 (48%) were arterial alone, 8(26%) were neurogenic and 3 (10%) were venous. 4 patients (13%) had both arterial and neurogenic components and 1 patient (3%) had both venous and neurogenic components. First rib and cervical rib both were resected in 4 (13%) patients. 6 patients (19%) had only 1st rib who underwent resection. In 21 patients (67.7 %), only cervical rib was resected. 9 (19%) out of 31 patients also underwent SCA intervention. Endovascular intervention was done in 3 patients (9.6%). Neuropraxia was present in 4 patients (13%) post operatively all of whom had recovered in follow up (6 weeks). Chylothorax was present in 3 patients (9.6%) out of which, 2 recovered with ICD placement and 1 needed VATS and decortication. Hematoma requiring drainage was seen in 2 patients (6.4%)

ConclusionThis relatively large single-institution series demonstrates the current experience of thoracic outlet syndrome. Current surgical protocols can achieve excellent outcomes for this rare and often complicated condition.

P06-27Paper No: 477Is it possible to treat Gerbode type VSD+ sever TR by invasive percutaneus procedure? A case with succesful repairment of congenital Gerbode type VSD by amplatzer muscular VSD occluder and improvement of severe TR

Zeynep Ã‡olakoÄŸlu Gevher1, Nuh YÄ±lmaz2, Sabri Seyis3, Helen Bournaun4

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Poster Presentation

1Department of Cardiology, Kanuni Sultan Suleyman Educational and Research Hospital, Istanbul, Turkey2Department of Pediatric Cardiology Istinye University Liv Hospital, Istanbul, Turkey3Department of Pediatric Cardiology Istinye University Liv Hospital, Istanbul, Turkey4Department of Pediatric Cardiology, Kanuni Sultan Suleyman Educational and research Hospital, Istanbul, Turkey

IntroductionGerbode type VSD is a rare condition that causes acquired left ventricule to right atrial shunt. The mechanism of the shunt is eÅŸtherdirectly coonection or the production of TR caused by VSD jet flow which makes deformation on tricuspit valve. Management of Gerbode VSD is generally via surgical methods. We report a 23 year old patient with tricuspid valve deformation and severe tricuspid regurgitation (TR). At initial evaluation this case could be easily misdiagnosed with inoperable criterias of pulmonary hypertension caused by L to R shunt defect or could be made a decision of VSD closure via surgical technique . Ä°n this case we opted transcathater closure that resulted successfully on both VSD shunt and TR repairment.

CaseA 23 yo male patient with progression of exercise dyspnea in last 6 months and murmur in cardiac oscultation was referred to our cardiology clinic.In echocardiography, severe TR whith the maximum gradient of tricuspid jet flow was assessed 100 mmHG and periembranous VSD was shown.The patient was referred to our invasive cath lab with pre-diagnosed pulmonary hypertension caused by VSD shunt or Gerbode type VSD .The patient had catheterization to assess true pulmonary artery pressure and if suitable for transcatheter closure .During left ventricular injection of opaque medium,both aorta and right atrium was filled at the same time, so we decided that this was a Gerbode type VSD.PA pressure (mmHg) was measured as systolic: 32,diastolic:10, mean:21. Concurrent angiography and Transthoracic echocardiography via right femoral artery access we reached pulmonary artery(PA) passing across perimembranous VSD whith had a muscular component also. In PA the guidewire was catched by snare and a loop was created by simultaneous femoral vein access.By right femoral vein access VSD was occluded with a 8 mm Amplatz muscular VSD device. After procedure there was no residual shunt and TR was relieved.Post procedure 3 months, device was at the right position and there was no residual shunt.

ConclusionSuitable Gerbode type VSD could be occluded by transcatheter methods, and total TR improvement can be acchieved.

P06-28Paper No: 182Vascular access for breast cancer chemotherapy according to patient’s clinical characteristics

Sun Cheol Park, Cheng Quan, Young Hwa Kim, Gyeong Jae Koh, Jin Go, Mi Hyeong Kim, Kang Woong Jun, Jeong Kye Hwang, Sang Dong Kim, Jang Yong Kim, Ji Il Kim, Yong Sung Won, Sang Seob Yun, In Sung MoonDepartment of Surgery, Catholic University of Korea, Seoul, Korea

BackgroundPeripheral intravenous chemotherapy can cause thrombophlebitis for affected arm. Central vascular access for chemotherapy can avoid thrombophlebitis and Various methods are available in clinical practice. Authors tried to evaluate effectiveness of chemoport and Peripheral Inserted Central Catheterization(PICC) for breast cancer chemotherapy.

MethodsThis is a retrospective study from prospectively registered data base for the breast cancers patients, who underwent PICC or chemoport insertion from April 2015 to December 2015 in Seoul ST. Mary’s hospital in vascular and transplant surgery. Modalities for vascular access were decided depending on duration of chemotherapy and patient’ clinical characteristics. PICC was inserted in the opposite basilic vein from breast cancer site. Chemoport was inserted in opposite jugular vein from breast cancer site. Patient’s clinical characteristics were evaluated with EMR and PACS.

ResultsOne hundred ninety two patients were enrolled for this study (84 patients for PICC and 108 patients for chemoport). PICC was inserted for breast cancer chemotherapy less than 4months and chemoport more than 4months. There was no mortality related to vascular access for breast cancer chemotherapy. Vascular access was removed earlier than end of scheduled chemotherapy in 7.3% (14/192) (9.5% in PICC (8/84), 5.5% in chemoport (6/108)). The reasons for early removal of vascular access were catheter insertion site (7) and incidental removal (1) in PICC group, infection (2) and painful erythema and chemical irritation along catheter (4) in chemoport group. Other complications included malfunctions (4), pain (2), central vein

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thrombosis (1),thrombophlebitis (6) and non removal of chemoport after end of chemotherapy (3).

ConclusionPICC and chemoport for breast cancer chemotherapy can be used in 92.7% until end of chemotherapy without serious complications. They are effective method with reasonable complications.

P06-29Paper No: 361The prevention of aorto-duodenal erosion: A case of aorto-duodenal erosion with penetration due to compression and graft infection

Takashi Mori, Takuro Shirasu, Yusuke Suka, Takatoshi Furuya, Yukihiro Nomura, Nobutaka TanakaDepartment of Surgery, Asahi General Hospital , Asahi, Chiba Prefecture, Japan

The standard treatment of aorto-iliac occulusive disease (AIOD) is open surgery. Aorto-duodenal erosion (ADE) is a rare complication which occurs after surgery for AIOD. We present a case of secondary ADE, causing penetration of the duodenum and infection of the graft.

A 68-year-old man was admitted to our hospital with fever of unknown origin. He had an operation of aorto-bilateral external iliac artery bypass grafting for AIOD 2 years before. He had recurrent episodes of fever and chill for a year. His blood culture was positive for Lactobacillus rhamnosus. There was no cause of fever on CT scan. FDG-PET showed abnormal uptake in the right limb of the vascular graft. An upper gastrointestinal endoscopy showed erosion in the inferior part of the duodenum. The diagnosis of ADE and graft infection was made and operation was performed.

During the operation, we detected a 2cm defect in the inferior part of the duodenum. The right limb of the graft was adjacent to the defect. We suspected that the compression of the duodenum by the graft caused the penetration, thus infecting the graft. There was no abscess around the infected graft. We partially resected the infected right limb, reconstructed the aorta with rifampin-soaked graft and wrapped the graft with omentum to avoid direct contact with the bowel. Repair of the duodenum was primarily closed with two layer anastomosis with a jejunal serosal patch. We also made a feeding jejunostomy. Postoperative course was uneventful and he was discharged on 49 days after operation. There is no recurrent infection after three months.

ADE is rare, but is has high rates of morbidity and mortality. Secondary ADE occurs more frequently than primary ADE. It is said that ADE is more likely to occur after operation for AIOD than abdominal aortic aneurysm because there is no native tissue to wrap the graft. An optimal surgical management for ADE is important, but controversial. Prevention remains the most effective treatment. The key to prevent ADE is to avoid direct contact of the graft with the duodenum.

P06-30Paper No: 341The bomb squad - A northeast Malaysian experience managing pseudoaneurysms

Sophia Heng Si Ling1,2, Arman Zaharil Mat Saad1, Wan Azman Wan Sulaiman1

1Plastic and Reconstructive Surgery, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia2Universiti Malaysia Sabah, Sabah , Malaysia

BackgroundPseudoaneurysms of any etiology or arising in any location can quickly develop into a life-threatening condition if not managed appropriately. Whether traumatic, mycotic, or spontaneous, these time-bombs require swift yet delicate skill to thwart a potential catastrophe. We present a series of pseudoaneurysms with different etiologies and their surgical management in Kelantan, the northeast state of Malaysia. Through this case series, we hope to share our experience in managing a variety of pseudoaneurysms in our clinical setting.

MethodsAll the records of patients with pseudoaneurysms managed surgically from January 2015 - June 2017 in Hospital Universiti Sains Malaysia, Kelantan were retrospectively reviewed and their outcomes analyzed.

ResultsAll patients were discharged well at 5-10 days after surgery. No complications, such as re-bleeding, hematoma, ischaemia, or neurological damage were observed.

ConclusionDifferent etiologies and intra-operative findings impact the ultimate surgical technique in managing pseudoaneurysms. Technical expertise and precise intra-operative decision-making involved in diffusing these time-bombs are imperative for a successful outcome.

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Poster Presentation

P06-31Paper No: 380“Carbon Savior” - The final weapon against carotid artery invasion in a case of advanced recurrent laryngeal carcinoma

Sophia Heng Si Ling1,2, Arman Zaharil Mat Saad1, Wan Azman Wan Sulaiman1

1Plastic and Reconstructive Surgery, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia2Universiti Malaysia Sabah, Sabah , Malaysia

BackgroundAdvanced laryngeal carcinoma with carotid artery invasion carries a poor patient survival rate. Especially in a previously irradiated patient, the options are limited with no consensus on optimal management and are mostly palliative. Carotid artery resection with or without anastomosis, surgical peel, interposition bypass graft are aggressive surgical approaches in managing carotid artery involvement. Whether in previously untreated or recurrent disease, there is still a debate on whether the risks of aggressive surgical approaches are justified in advanced cases. We seek to share our positive experience of one stage carotid artery reconstruction with a PTFE(polytetrafluorourethylene) graft and soft tissue coverage with a pedicled pectoralis major flap in an unfortunate man with a second bout of laryngeal carcinoma recurrence involving his right carotid artery.

MethodsThe recurrent right neck mass was resected together with the overlying skin, vagus nerve and right common artery with an involvement of 7cm in length. Carotid artery reconstruction done with size 5mm diameter and 7cm length of PTFE graft. During anastomosis, a temporary modified shunt was created with size 14F drain tube. Soft tissue coverage of the neck defect was achieved with a pedicled right pectoralis major musculocutaneous flap.

ResultsThere was no perioperative neurological complication in this patient. Post-operative assessment at 8 months shows good carotid arterial flow, no carotid artery blowout or stroke. He initially had a small surgical site infection at the lateral edge of the pedicled pectoralis major flap which subsequently healed well without complications. He is independent, able to perform daily activities without assistance. He has a good quality of life post-surgery. Thus far there are no signs of further recurrence and he is being closely monitored for any signs of recurrence.

ConclusionCarotid artery reconstruction is feasible and can provide a second or third chance at survival in patients with advanced laryngeal carcinoma with carotid artery involvement. We should not be so quick to condemn them to lead the remainder of their lives in suffering and strive to provide the best possible care we can in this era of technological advances.


P07-01Paper No: 031A series of 210 peripheral arterial disease below knee amputations and predictors for subsequent above knee amputations

Jing Ting Wu1, Maggie Wong1, Zhiwen Joseph Lo2, Wei-En Wong1, Sriram Narayanan2, Glenn Wei Leong Tan2, Sadhana Chandrasekar2

1Yong Loo Lin School of Medicine, National University of Singapore, Singapore2Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital (Singapore), Singapore

BackgroundTo review patient characteristics and outcomes after peripheral arterial disease (PAD)-related below knee amputations (BKA) and identify risk factors predicting for subsequent above knee amputations (AKA).

Method A retrospective study of 210 below knee amputations between May 2008 and December 2015.

ResultsWithin our study population, the mean age was 66 years-old with 64% male and majority with cardiovascular co-morbidities (98% Type 2 Diabetes Mellitus, 90% hypertension, 90% hyperlipidemia, 62% ischaemic heart disease). 33% had end-stage renal failure (ESRF), 89% were ASA 3 (75%) or 4 (14%), 49% had previous ipsilateral lower limb minor amputations whilst 20% had previous contralateral lower limb major amputations. 98% had toe pressures of

ConclusionsWithin our study population, majority suffered from diabetic foot disease and 27% had extensive tissue loss which was not suitable for limb salvage. The failure rate of BKA with subsequent need of AKA was 9%. Overall 1-year survival was 75% whilst 5-year survival was 58%. Patients with underlying end-stage renal failure and preoperative non-ambulatory status may benefit from direct AKA if major amputation is required.

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P07-02Paper No: 043Nineteen surgically treated cases of popliteal artery aneurysms

Hironobu Fujimura1, Takashi Shintani1, Takuma Iida1, Takashi Shibuya2, Yoshiki Sawa2

1Department of Cardiovascular Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan2Department of Cardiovascular Surgery, Osaka University, Suita, Osaka, Japan

BackgroundEven in recent years, most popliteal aneurysms are diagnosed after various symptoms and operative procedures are still unfixed. Especially for acutely thrombosed cases, the prognosis is poor. We experienced 19 surgical cases of popliteal aneurysm and summarize these cases.

MethodBasically, our operative method was arterial reconstruction by bypass with aneurysmectomy to avoid continued aneurysm expansion. If necessary, distal embolectomy was added. Graft conduit was selected by the lesion of distal anastomosis, ePTFE graft until mid popliteal artery and autologous vein under below knee popliteal artery.

ResultWe experienced 19 popleteal aneurysms from 13 patients. Eleven men and two women, ranged from 63-83 years old (average 72.8) were enrolled. Nine of 13 had acute or chronic ischemia, 2 had ruptured aneurysms, and 2 were asymptomatic. All popliteal aneurysms were diagnosed by contrast enhanced computed tomography, which indicated surgical approach. A posterior approach was used in 8 cases and a medial approach was used in 8 cases. Both approach was used in the rest one case. ePTFE graft was used in 15 cases. All cases had uneventful postoperative courses with good arterial perfusion. For the primary patency, two cases were occluded, but for secondary patency, all graft was patent (1-123month, median follow-up 37.5 months).

ConclusionsOur strategy for popliteal aneurysm repair showed excellent results.

P07-03Paper No: 063 Improvement of activity of daily living by open bypass leads to superior long-term outcomes in patients with critical limb ischemia

Shinsuke Mii1Department of Orthopaedic Surgery, Faculty of Medicine and Health Sciences Universiti Putra Malaysia2Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia3Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre

BackgroundImprovement of activity of daily living (ADL) is one of goals of treatment for critical limb ischemia (CLI). The aim of this study is to investigate whether or not change of ADL by open bypass affects the long-term outcomes and to clarify which factors have significant association to improvement of ADL at discharge.

Methods‘271patients undergoing infrainguinal bypass for CLI from January 2015 to March 2017 were reviewed. To evaluate ADL, Barthel Index (BI) was measured at admission and at discharge and BI was classified into 4 levels; Level 4 (100-91, full independency or slight dependency), 3 (90-61, moderate dependency), 2 (60-21, severe dependency), and 1 (20-0, total dependency). Patients were divided into 3 groups based on change of the level of BI: A group (BI level at discharge - at admission >0 or BI at discharge =100), B group (BI level at discharge - at admission =0) and C group (BI level at discharge - at admission

ResultsBI level at admission/discharge was 4, 3, 2, and 1 in 68/81, 83/82, 101/68, and 19/27 patients, respectively. Thirteen patients (1, 2, 10, and 0 patients in level 4, 3, 2, and 1, respectively), who died before discharge, were excluded from the data for analysis. A, B, and C group included 119, 87, and 52 patients, respectively. A group was significantly superior to B or C group in both long-term outcomes. Significant factors affecting amelioration of ADL were

ConclusionsImprovement of BI by open surgery led to improvement of long-term outcomes. Patients under 80 years of age without hemodialysis or stroke can be good candidates for open surgery.

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Poster Presentation

P07-04Paper No: 100Atherosclerotic axillary artery aneurysm presenting as distal digital emboli

Omer Tetik, Funda Yildirim, Dilsat Amanvermez Senaslan, Abdulkerim Damar, Baris BayramDepartment of Cardiovascular Surgery, Manisa Celal Bayar University Uncubozkoy, Manisa, Turkey

BackgroundThe upper extremity peripheric artery aneurysms are not seen commonly and when diagnosed is mostly secondary to trauma. The atherosclerotic axillary artery aneurysm is seldomly experienced in surgical clinics. These aneurysms are source of distal emboli and have rupture risk and upper extremity ischemia.

MethodsThis case report presents a 81 years old female patient with left axillary artery aneurysm. The patient was formerly operated for left upper extremity acute arterial occlusion at another medical center. The source of embolus was diagnosed as axillary artery aneurysm and referred to us for further treatment.The computerized tomography angiography was reported as 90 mm length and 40 mm width fusiform aneurysm. The aneurysmal sac was covered circumferentially with thrombus. This was the source of distal emboli. The conventional surgery was planned.

ResultsUnder general with infraclavicular incision the pectoralis major muscle was separated and the proximal axillary artery was snared. The distal axillary artery was reached by upper extremity medial incision just after the aneurysmal mass. The proximal left brachial artery was snared. The two incisions were united over the aneurysmal sac and the deltopectoral fascia was openned. The meticulous dissection was performed for aneurysmal mass separation. The axillary vein, the branches of the brachial plexus were separated carefully and encircled by nylon tapes. After systemic heparinization the artery was clamped proximally and distally. The aneurysmal mass was removed. we preferred the saphenous vein bypass. The proximal anastomosis was performed by end to side fasion. The distal anastomosis was performed by end to end fasion. The radial and ulnar pulses were palpated postoperatively. The incision was closed appropriately. The specimen was sent for the pathologic examination.

ConclusionsEndovascular therapy is another therapeutic option. But for this case, mismatch of the proximal and distal

diameter of the artery that is involved in the aneurysmal segment, the type of aneurysm saccular or fusÄ±form and the motion of the extremity limits endovascular intervention. This was a rare case of axillary artery aneurysm treated with open surgery to prevent further ischemic complication.

P07-05Paper No: 108Clinical outcome after distal bypass surgery for critical limb ischaemia: Single centre experience

Johan Abdul Kahar1, Rosnelifaizur Ramely2, Lenny SS3, Mohamad Azim Md Idris3, Hanafiah Harunrashid3

1Department of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia 2Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia3Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre

IntroductionVascular bypass surgery has been known to markedly reduce symptoms of critical limb ischemia (CLI). It can be performed as primary procedure or secondary procedure following failure of endovascular therapy. This study is to audit outcome of lower limb arterial bypass surgeries performed on our patients from January 2014 to September 2016.

MethodsWe retrospectively reviewed the medical records of all patients who underwent lower limb arterial bypass surgeries performed by vascular surgeons in Universiti Kebangsaan Malaysia Medical Centre from January 2014 to September 2016. These patients were at least 6-12 months post-operative currently. Patients who defaulted follow-up and not contactable were excluded. Their clinical data were analysed with regards to patients’ demographics, risk factors, types of graft, patency and final outcome of the patients.

Results:A total of 13 patients were selected out of 21 patients, with mean age of 65.9 years (range: 48-88) and a male to female predominance (8 to 5). According to the Fontaine classification, the grade was evaluated as III in 3 limbs and IV in 10 limbs. Arterial bypass surgery was the primary choice of treatment for 3 (23.1%) patients, while the other 10 (76.9%) was planned for bypass after failing angioplasty. Types of graft used for bypass consisted of either native: 7 (53.8%) or synthetic: 6 (46.2%). Early post-operative outcome shows 3 (23.1%) of them had thrombosis of the synthetic graft in which 2 of them managed to be salvaged with successful emergency

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thrombectomy and the other one ended up with major amputation. The remaining 10 patients (76.9%) had patent graft and the patency persisted until their last follow-up with us. Final outcome of the 13 patients were as follows; 8 (61.5%) had fully healed ulcer/wounds, 3 (23.1%) had resolved rest pain, 1 (7.7%) had thrombosed graft leading to a major amputation and 1 (7.7%) passed away (cause of death was cardiac in origin).

Discussion/conclusion:In our review, the 1-year limb salvage and survival rates were 92.3 %. Among the 3 patients with thrombosed synthetic graft, the apparent common risk factors were diabetics with chronic kidney disease. Otherwise there were no significant correlation with other risk factors or type of graft used. Since the sample size was small, it is difficult to make inferences regarding the clinical outcome of distal bypass surgery. We have also identified that many of our patients were non-compliant to follow-up, thus it is important to educate our patient to be compliant.

P07-06Paper No: 120 Vein graft quality, decided at bypass surgery, is reflected pathological changes, and may influence on the primary graft patency

Yukihiro Saito, Manabu Issiki, Shinsuke Kikuchi, Daiki Uchida, Nobuyoshi Azuma, Tadahiro Sasajima, Satoshi HirataDivision of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan

BackgroundThe purpose of this study is to investigate the relation between the vein graft (VG) quality decided by surgeon at bypass surgery and pathological findings of pre-grafting vein, and to reveal the factors to influence the VG quality.

MethodsIn this retrospective study, 68 patients (68 VGs), excluded varicose VG or spliced VG, were enrolled, who were operated at Asahikawa medical university hospital from 2002 Jan to 2011 Dec. VG was classified into good(G), fair(F), and poor(P) VG by surgeon at operation, according to the diagnostic criteria. The sampled pieces of pre-grafting vein were stained by Hematoxylin-Eosin, Masson-Trichrome, and Elastica van Gieson method, respectively. Ratio of intima thickness (RIT), density of muscle and fiber within intima (DMFI), density of muscle within media (DMM), and density of fibrous tissue

within adventitia (DFA) were calculated pathologically using Image J.

Results 33 VGs were classified as G-VG, 27 VGs as F-VG, and 8 VGs as P-VG. At 2 years after bypass surgery, 59 VGs went well, and 9 VGs were failed. 2-year primary graft patency of G-VG group was significantly higher than that of F+P-VG group (93% vs. 73%, p=0.035). As the results of pathological findings with pre-grafting vein samples collected at the bypass surgery, DMFI of patent group were lower than that of obstruction group (35% vs. 45%, p=0.032), and DMM of patent group were higher than that of obstruction group (48% vs. 26%, p=0.002). Furthermore, 2-year primary graft patency of high-DMM group (37 VGs) was significantly superior, compared with that of F+P-VG group (31 VGs) (96% vs. 67%, p=0.002). There was no significant difference between the any groups in RIT and DFA. Low albumin and high HbA1 were related with VG quality, when patient character was analyzed by multivariate analysis (p=0.018, p=0.006, respectively).

ConclusionsIn this study, VG quality decided by surgeon at bypass surgery is related with pathological changes of pre-grafting vein, especially DMM. These pathological changes, caused by nutritional disturbance or diabetes mellitus, may influence on the primary graft patency.

P07-07Paper No: 135Distal open revascularization in chronic kidney disease; Is it worth your while?

Nalaka GunawansaNational Institute of Nephrology and Transplant Colombo, Sri Lanka

ObjectivesManagement of Critical Limb Ischaemia (CLI) in patients with Chronic Kidney Disease (CKD) is truly challenging and has limited data on outcomes. The aging population and the epidemic of diabetes have resulted in the higher incidence of co-existing CKD and CLI. The affected patients are generally in poor overall health, have heavily calcified distal outflows, have limitations regarding contrast imaging and interventional techniques and fair poorly after revascularization. MethodsA prospective case control study was done evaluating the outcome of distal surgical revascularization for

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Poster Presentation

CLI (ulcer, gangrene, rest pain), comparing patients with established CKD (eGFR 90; Group 2). Those with previous failed endovascular interventions in the same limb were excluded. Mean ages were 54 years (Group-1) and 58 years (Group-2). All had arterial duplex imaging performed by the operating surgeon while those in Group-2 had additional CT angiography. Study period was January 2010 to January 2015; the 1-year patient survival, graft patency and limb salvage rates were compared. All patients had autogenous reversed saphenous vein grafts. The type of anaesthesia, surgical technique, use of perioperative antibiotics and post-operative antiplatelet medication were all standardized. Post-operative follow up was by clinical assessment and graft duplex imaging. Results67 consecutive surgical revascularizations were performed in 65 patients (Group-1, 37; Group-2, 28) at the National Institute of Nephrology, Colombo, Sri Lanka. There was one peri-operative death in Group-1, on day-02 after surgery, due to a confirmed myocardial infarction. The respective rates of patient survival were (86% v 89%; p>0.05), graft patency (84% v 87%; p=>0.05) and limb salvage (81% v 87%; p ConclusionCLI in the presence of CKD should not deter the attempts at open revascularization where the expected life expectancy is beyond 2 years. Despite a statistically significant difference in limb salvage rates compared to the control group, the overall results were impressive and encouraging.

P07-08Paper No: 152Foreign body micro-emboli following endovascular intervention: A case study

Joseph SZ1, Kwok CH1, Harvey N2, Garbowski M1, Jansen S1,3,4,5

1Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia2Department of Pathology, Sir Charles Gairdner Hospital, Perth, Western Australia3Faculty of Health Sciences, Curtin University, Perth, Western Australia4Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia5Heart Research Institute, Harry Perkins Institute of Medical Research, Perth WA

BackgroundEndovascular devices are coated with hydrophilic polymer to reduce friction between sheaths and

arterial intima, improving manoeuvrability in tortuous vasculature. However, often underappreciated, is the risk of hydrophilic polymer coating causing iatrogenic foreign body embolization to distal vasculature. A few small case series have presented findings of this in the pulmonary, cerebral and cutaneous vessels following various endovascular procedures causing pulmonary infarction, stroke, gangrene or death. In this context, this phenomenon may be under reported in patients following endovascular intervention.

MethodsWe present a case in which an incisional tissue biopsy was taken from a non-healing ulcer in a patient who had recently undergone endovascular stenting and histological examination demonstrated foreign body embolization.

ResultsAn 88-year-old male presented following an ipsilateral endovascular procedure following 6 months of left sided bi-malleolar ulcers. Two years prior, he had undergone superficial femoral artery and tibioperoneal trunk/peroneal stenting, and saphenofemoral junction (SFJ) ligation with great saphenous vein stripping for mixed arteriovenous ulcers.

Recent angiography revealed patency of this existing stents but occlusion of the mid to distal posterior tibial artery which was recannalised and stented. Venous insufficiency scans excluded recurrent SFJ incompetence. Following this procedure, the patient presented with worsening of his ulcer which was larger and with an inflamed violaceous border, and significant pain. Given these atypical ulcer features, an incisional biopsy was taken. Histopathology showed multiple intraluminal fragments of basophilic material similar in appearance to recently reported hydrophilic polymer microemboli thought to originate from endovascular sheaths, catheters and wires. The patient was admitted to hospital for antibiotics and iloprost which improved the ulcer markedly.

ConclusionThe finding of foreign body polymer causing small vessel occlusion in a deteriorating ulcer post endovascular stenting, although incidental, may reflect the under-recognised occurrence of iatrogenic foreign body emboli. We are performing further investigation to characterise the source of this foreign material which may have implications for management of patients with ulceration or cutaneous involvement post endovascular procedures. It may also have further implications in

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providing a possible explanation for the increased amputation rate seen in a tibial drug coated angioplasty trial which was prematurely ceased.

P07-09Paper No: 167Can postoperative ST-segment change and blood pressure variability predict short term mortality in patients following major vascular surgery

Aekkaphod Liwatthanakun1, Arintaya Phrommintikul2,3, Orapin Pongtam3, Kanokwan Kulprachakarn3, Kittipan Rerkasem1,3,4

1Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand2Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand3NCD Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand4NCD Center of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand

BackgroundThe objective of the study was to evaluate the association between the ST-segment abnormality, blood pressure variability, and short term mortality in patients who had undergone major vascular surgery. MethodsA prospective cohort study of 71 patients underwent major vascular surgery between June 2011 and May 2013 at Maharaj Nakorn Chiang Mai Hospital. Blood pressure was recorded for the first week after surgery, as well as electrocardiograms at baseline for the first 4 postoperative days. The association between abnormality of ST-segment, blood pressure variability (BPV), and short-term mortality were analysed. Results9 (13%) patients had ST-segment change and 18 (25%) patients had blood pressure variability the first week of postoperation. The median follow-up was 11 months. 13 (18%) patients died during follow up. Postoperative ST-change was associated with a significant increased risk of short-term mortality (hazard ratio (HR) 24.74%, 95% confidence interval (95% CI) 6.23-98.27). BPV was also associated with short-term mortality (HR 4.65, 95%CI 1.31-16.49). Also the risk of stroke in patients with BPV was 20.6 times higher than those without BPV. ConclusionST-change and blood pressure variability after major vascular surgery were associated with a significantly increased risk of short-term mortality.

P07-10Paper No: 189Effectiveness of Transcutaneous oxygen pressure measurement (TcPO2) for critical limbs ischemia (CLI)

Jang yong Kim, Cheng Quan, Young Hwa Kim, Gyeong Jae Koh, Jin Go, Mi Hyeong Kim, Kang Woong Jun, Jeong Kye Hwang, Sang Dong Kim, Sun Cheol Park, Ji Il Kim, Yong Sung Won, Sang Seob Yun, In Sung MoonDepartment of Surgery, Catholic University of Korea, Seoul, Korea

BackgroundWound healing in CLI is challenging and few studies reflect possibility of wound healing or potential need of revascularization. TcPO2 can reflect microcirculation and is known to give information about possibility of wound healing. We tried to evaluate effectiveness TcPO2 in CLI and compare it with other modalities.

MethodsThis is a retrospective study of patients with CLI in Seoul St. Mary’s hospital from 2016 to 2017 from prospectively registered. Patients with CLI treated according to TcPO2. CLI with TcPO2 above 40 was underwent surgical approach such as amputation, skin graft and debridement. CLI with TcPO2 less 40 underwent to restore peripheral vascularization. Patients’ clinical characteristics were evaluated with EMR and PACS including patient’s wound, ABI, TBI, duplex scan, contrast enhanced CT, amputation success rate, results of revascularization.

ResultsTwenty two (22) critical limb ischemic patients with untreated ulcer were enrolled. Sex ratio was M:F = 16:6. The mean age was 65.6 years old. Comorbidities with CLI were HTN (13), DM (14) and ERSD with Hemodialysis (8). In this study, we divided two groups that the one was the difference in TcPO2 score before-and-after vascular management and the other was the success rate of healing process in CLI patients after surgical management of intractable ulcer. In the difference of TcPO2 score before-and-after vascular management, mean gap of score in before-and-after vascular treatment was +10.39, clinically results healed ulcer without amputation (6), healed ulcer with amputation (3), need for taking follow-up measures (1). In this group, vascular managements were divided into 7 percutaneous transluminal angioplasty including drug-eluting balloon, 1 hybrid operation and 2 open surgical managements. The other group, primary success rate in surgical management was 83.3% (10/12 patients). The primary surgical managements for CLI consisted of

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Poster Presentation

orthopedic amputations (7), skin grafts for intractable ulcer (2) and debridement for necrotic tissues (1).

ConclusionTcPO2 was able to predict results of primary amputation and need for revascularization according to its data. It can predict amputation level for amputation and wound healing potential after revascularization.

P07-11Paper No: 205Clinical experience of Arterial Cystic Adventitial Disease

Byeoung-Hoon Chung, Dong-Heon Lee, Seon-Hee Heo, Chi-Woo Lee, Yang-Jin Park, Young-Wook Kim, Dong-Ik KimDivision of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

PurposesArterial cystic adventitial disease (CAD) is a rare cause of intermittent claudication and nonatherosclerotic condition without cardiovascular risk factors. The etiology and treatment of CAD have remained controversial. The purpose of this study was to analyze the results of surgical treatment in arterial CAD.

MethodsWe retrospectively reviewed 22 patients with arterial CAD who have undergone surgical treatment in our hospital from March 2006 to May 2017. All of the patients were diagnosed with using both computed tomography and duplex sonography. 4 patients were performed by adding magnetic resonance imaging.

ResultsThere were 19 (86.4%) patients in men and median age was 51.2 years old. The popliteal artery was the most commonly involved artery (90.9%) and left side was more commonly involved rather than right side (63.6% vs 36.4%). There were 21 (95.5%) symptomatic cases with claudication (18 cases, 81.8%), swelling (1 case, 4.5%) or calf clamping pain (2 case, 9.1%). Only one patient had not any symptoms related with CAD. 14 (63.6%) patients were treated with cystic resection only, 7 (31.8%) patients were underwent bypass with saphenous vein reconstruction, only 1 (4.5%) patient was underwent bypass with synthetic graft reconstruction. Recurrence was observed in 2 (9.1%) patients who underwent cystic resection only.

ConclusionThis study was conducted with small group of patients, so further comparative study with large group patients might be required.

P07-12Paper No: 254The atherosclerosis risk factor control in diabetic patients with peripheral arterial disease: 18 months follow up

Kittipan Rerkasem1,2, Ampica Mangklabruks1, Natapong Kosachunhanun1, Arintaya Phrommintikul1, Kiran Sony3, Nimit Inpankaew4, Saritphat Orrapin1, Orapin Pongtam1, Paweena Thongkham1, Prakaydao Abkom2

1NCD Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand2NCD Centre of Excellence, RIHES, Chiang Mai University, Chiang Mai, Thailand3Department of Internal Medicine, Chiangrai Prachanukroh Hospital, Chang Wat Chiang Rai, Thailand4Department of Internal Medicine, Lamphun Hospital, Chang Wat Lamphun, Thailand

BackgroundPeripheral arterial disease (PAD) in diabetic patients is associated with high morbidity and mortality. The mortality rate in such patients is 56.5% in 3 years follow up period in Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. This study was conducted in 18 months follow-up. It focused on the control of risk factor for atherosclerosis, which causes PAD. Method500 diabetic patients with being diagnosed as PAD between June 2014 to July 2016, were followed up at 6, 12 and 18 months follow up period. Assessing the 5 risk factor control for atherosclerosis namely diabetic, smoking, systolic blood pressure, diastolic blood pressure and dyslipidemia by a Cox regression model was done by using the criteria of American Heart Association (AHA) and the Royal College of Physicians of Thailand (RCPT). Good control defined when one can meet in the target level at least 3 out of 5 factors of AHA/RCPT criteria. This study was supported by the Health Systems Research Institute. ResultDuring a mean follow-up of 18 months period, all risk factors was controlled less than 50% in all risk factors except smoking cessation. For example 23.48% of patients was controlled adequately in LDL, while 91.83% of patients was former smokers or no history of smoking in the past. 63.44% of patients were met with good control criteria. Participant at 18 months visit

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had increase statistically significant adequate control of diastolic blood pressure compared with first visit (Day 0) from 58.92% to 73.10%, whereas other factors were not change significantly. Interestingly the percentage of patients met good control increase statistically significantly form 56.11% in first visit to 63.44% in 18 months visit. ConclusionAlthough control of atherosclerotic risk factor in 18 months was still not good, it seems better from the beginning of study. There was still a large gap of improvement in this aspect.

P07-13Paper No: 270Alteration of ankle - Brachial index after kidney tranplantation

Sang Young Chung, Soo Jun Na Choi, Ho kyun Lee, Hyo Shin Kim, Dae Jung Kim, Hong Sung JungDepartment of Surgery, Chonnam National University Medical School , Gwangju, Korea

BackgroundA occlusion of iliac artery can mimic renovascular hypertension and is an important cause of renal dysfunction in renal transplant recipients. This study was evaluated hemodynamic alteration to measure of Ankle Brachial Index after kidney transplantation by end to side anastomosis of the external iliac artery to the renal artery.

MethodsIn fifty two patients, they was performed kidney transplantation between March 1, 2010 and November 30, 2012 at Chonnam National University Hospital. We measured ABI at pre-operation and post operation. We analyzed anatomical features of recipients’external iliac aretery (diameter, calcification, tortuosity, stenosis and occlusion) and renal artery (diameter, calcification, stenosis) of transplanted kidney. All procedure were end to side anastomosis of the external iliac artery to the renal artery. This study was performed prospectively.

ResultsFifty patients was performed kidney transplantation by end to side anastomosis of the external iliac artery to the renal artery. A mean of preoperative ABI was 1.16±0.11 and a mean of postoperative 1week ABI was 1.14±0.90 and a mean of postoperative 6months ABI was 1.16±0.11 at right posterior tibial artery. There was not alternation of ABI (P=0.331, P=0.888) in

comparison with preoperative ABI and postoperative ABI at posterior tibial artery.

ConclusionsThese results suggest that a blood flow of low extremity was unhindered due to kidney transplantation by end to side anastomosis of the external iliac artery to the renal artery in the short term period. But there is a more long-term study will be needed.

KeywordsOcclusion of iliac artery, Ankle Brachial Index, end to side anastomosis

P07-14Paper No: 309The outcome of an endovascular-first approach to limb salvage in a multi-ethnic asian population

Vikram Vijayan, Alok Tiwari, Chen Min Qi, Harvinder Raj Singh SidhuDivision of Vascular Surgery, Department of General Surgery, Ng Teng Fong General Hospital, Singapore

BackgroundAn endovascular-first approach is being increasingly utilised worldwide for lower limb salvage. There is currently very little in the published literature regarding this approach and of the burden of disease in a multi-ethnic group of patients from Asian countries.

MethodAll patients presenting to a single institution as an emergency with critical limb ischaemia and tissue-loss (Rutherford grade 5 to 6) undergoing angioplasty under the Division of Vascular Surgery were identified from the hospital database. Patient demographics and the anatomical distribution of disease were retrospectively analysed from computerised hospital records and imaging databases. Primary outcome was the number of lower limb arteries successfully revascularised as well as the 30 day amputation-free survival.

Results107 limbs (100 patients, 65% male) underwent an angiogram with a view to angioplasty from January 2016 to December 2016. The mean age of the males was 64.5 years and the female was 67.6 years. The ethnic distribution of this patient population was 55% Chinese, 28% Malay and 17% Indian. 73% of patients were diabetic. 61(57%) limbs had right-sided disease. The mean number of arteries affected was 3.8. The majority of patients had infra-popliteal disease with the Anterior Tibial (82.2%), Posterior Tibial (81.3%) and

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Poster Presentation

Peroneal (68.2%) arteries affected. Iliac artery disease was only seen in 6.5% of limbs. The mean number of arteries revascularised at the primary operation was 2.9. One patient underwent a bypass due to a failed attempt at revascularization and one patient had a hybrid procedure. The follow up ranged from 7 to 485 days. The estimated 30 day amputation-free survival was 86%.

ConclusionsMulti-ethnic Asian patients, presenting with critical limb ischaemia and tissue-loss, have significant multilevel peripheral arterial disease which can be safely and successfully managed with an endovascular-first approach. There exists an enormous burden of disease in these patients, requiring multiple vessel recanalizations to affect limb salvage. Despite this, there remains a significant risk of limb-loss and mortality in such patients, primarily due to late presentation.

P07-15Paper No: 326Determinants of one-year wound healing in patients undergoing distal bypass for ischemic tissue loss

Kiyoshi Tanaka1, Daisuke Matsuda1, Jin Okazaki1, Shinsuke Mii2

1Depatment of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu-City Japan2Depatment of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu-City Japan

BackgroundWound healing is one of goals in treatments for critical limb ischemia (CLI). The aim of this study was to identify which factors affected wound healing after distal bypass.

MethodsWe reviewed 122 limbs in 109 patients who underwent distal bypass for ischemic tissue loss from January 2011 to December 2016. Wound healing was set as a primary endpoint and graft patency, major amputation, and overall survival were set as secondary endpoints. One-year outcomes were calculated by Kaplan Meier method and a Cox proportional hazard regression analysis was performed to determine significant factors of wound healing.

ResultsThe femoral and popliteal artery was selected as an inflow artery in 56 and 66 limbs, respectively. Distal anastomosis was placed at tibial trunk in 3, anterior tibial artery or dorsal pedis artery in 60, posterior tibial artery or plantar artery in 55, and peroneal artery in

4. Six patients died within 30 days after surgery. One-year wound healing rate was 79% and mean time of wound healing was 118 days after surgery. One-year primary and secondary graft patency, amputation free, and overall survival rate was 54% and 77%, 86%, and 77%, respectively. A multivariate analysis demonstrated secondary graft patency, clopidogrel use and left ventricular ejection fraction (EF) >60 as a significant factor of wound healing.

ConclusionsContinuation of patency revascularized artery, clopidogrel use and EF >60% identified as a determinant of one-year wound healing. Careful surveillance and appropriate revision without delay were important to reach goals for CLI treatment.

P07-16Paper No: 333The middle term results of common femoral artery thromboendarterectomy for PAD patients

Naoki Hayashida, Souichi Asano, Hideomi Hasegawas, Takahiro Itoh, Shintaroh Koizumi, Hiroki Ikeuchi, Shinichiro Abe, Masashi Kabasawa, Kouzou Mastuo, Hirokazu MurayamaDepartment of Cardiocvascular Surgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan

ObjectivesThe thromboendarterectomy (TEA) of common femoral artery (CFA) has been increased because CFA is one of access routes for percutaneous transluminal angioplasty (PTA). So we evaluated the results of CFA-TEA.

SubjectsTwelve patients with peripheral artery disease (PAD) were treated with CFA-TEA in our hospital between 2007 and 2016. The male to female ratio was 9:3. The mean age was 72 years old (59-82). The TEA was performed for 13 limbs. In Fontaine classification. five limbs showed class 2, four limbs in class 3 and four limbs in class 4. The combined procedure is PTA in 6 cases, FP bypass in 4cases, FT bypass in 2cases, FF bypass in 2 cases, and Ax-bF bypass in one case. In three cases, only TEA was performed. In the repair after TEA, direct closure was performed in 4 cases, saphenous patch in 3, artificial prosthetic patch in 3 and graft anastomosis in 3. The mean follow-up time was 54.3 months.

MethodsAn ankle brachial index (ABI) or s skin perfusion pressure (SPP) was measured before and after surgery. Primary patency rate was calculated with Kaplan-Meier method.

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Results: The operative mortality is 0 and the symptoms of all patients were improved. The mean values of ABI was increased from 0.22 to 0.77. The mean values of SPP was increased from 12.8mmHg to 31.5mmHg. Two patients had occlusion of CFA treated with TEA. In one case, right external iliac artery with stent, CFA with TEA and FT bypass graft were all totally occluded at the postoperative 1st month. The redo-surgery was performed in this case. In the other case, the stenosis of the treated CFA was found at the postoperative 77th month. Then, PTA of CFA was performed in this case. The primary patency rate was 92.3 % at the postoperative 5th year.

ConclusionsThe middle term results of CFA-TEA for PAD patients were acceptable.

P07-17Paper No: 339Surgical treatment for femoral artery aneurysm - Single center experience

Hiroyuki Morishita, Tatsuo Kaneko, Masahiko Ezure, Yutaka Hasegawa, Yasuyuki Yamada, Shuichi Okada, Shuichi Okonogi, Yuta KanazawaDivision of Cardiovascular Surgery, Gunma Prefectural Cardiovascular Center, Gunma, Japan

BackgroundIt is known that femoral artery aneurysm coexists with other arterial aneurysms and been bilaterally. There are some case reports in the world, however, case series are rare in the past.

MethodBetween 2002 and 2016, 14 cases 18 legs had been repaired femoral artery aneurysms surgically in our institute. Retrospective investigation with medical records was performed.

ResultsOnly one patient was female, mean age was 72 years old. 6 femoral artery aneurysms exists in left, 4 in right, 4 were bilaterally. Initial symptoms were distention of inguinal region in 5 cases, acute lower extremity thromboembolism in 1 case, others were detected incidentally by computed tomography for other diseases. Pre-operative aneurysmal diameter was 48±23mm. In the group that had distention of inguinal region, mean diameter was 68.6mm. Common femoral artery aneurysms were in 10 legs, 5 were artificial graft replacement with deep femoral artery reconstruction,

5 were straight graft replacement. Deep femoral artery aneurysms were treated by artificial graft replacement in 5, 3 aneurysms were treated by ligation of aneurysmal orifice. PTFE graft were used almost all cases. Operative death was only one case which had been presenting acute limb ischemia, complications were surgical site infection, acute kidney injury and seroma.

ConclusionsThe results of elective surgery for femoral artery aneurysm was effective and satisfactorily. Aortic and arterial aneurysms occur multiply, so we must be carefully scrutinized for long-term aneurysm formation.

P07-18Paper No: 345Endovascular management for ruptured hepatic artery (7), GDA (2), and SMA (1) Pseudoaneurysm

Dae Hyun Hwang, Changhyun Park, Jeong Wook Seo, Gam HurIlsan Paek Hospital, Inje University, Seoul, Republic of Korea

IntroductionPseudoaneurysms are a serious complication of acute, chronic surgical injury and pancreatitis to the hepatic artery, GDA and SMA . Transcatheter embolization has been considered as the treatment of choice.The purpose of this study is to assess the efficacy of embolization by coil and glue. Materials and Methods10 cases in eight patients (seven men and one woman; mean age, 52; range, 28-76) were treated with transcatheter arterial nine patients by coil embolization and one patient by glue between January 2007 and September 2016.

They were analyzed with regard to the clinical presentation, radiological finding, procedure, and outcome. All patients presented with epigastric pain and gastrointestinal bleeding. ResultThe aneurysms ranged from 0.4 to 4.4cm in size. The aneurysms were located in the common hepatic artery (n=7), GDA (n=2), and one SMA (n=1). Embolization was performed with fibered micor coiles in 9 aneurysms (n=9). One SMA aneurysm emabolized by glue.

There are all stoped bleeding after embolization but two pateint bleeding post embolization after 1 week and 2 weeks.

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Poster Presentation

After one week and two weeks bleeding pateint embolization by coils. ConclusionTranscatheter arterial embolization for ruptured pseudoaneurysm is effective by coil and glue. Trans arterial embolization technique is very safe and effective treatment for pseudoaneusym ruptured cases.

P07-19Paper No: 375Thrombotic occlusion of superficial femoral artery aneurysm combined multiple atherosclerotic aneurysms

Ji-Hoon Jang, Min-Gu Kim, Seung-Jae Byun, Byung Jun SoDepartment of Surgery, Wonkwang Uni. School of Medicine & Hospital, Jeonbuk, Korea

IntroductionTrue atherosclerotic aneurysms of superficial femoral artery(SFA) are rare and often associated with other peripheral or aortic aneurysms.The relative uncommonness of SFA aneurysms has been described as a result of the protection provided by surrounding muscles and the lack of bending stress. These aneurysms could remain unperceived until they reach a considerable diameter or until they become symptomatic. The first most common symptom of SFA aneurysm is rupture. We reported a case of true giant aneurysm of superficial femoral artery in patients with multiple atherosclerotic aneurysms including both internal iliac aneurysm, both deep femoral artery aneurysms.

Case reportAn 85-year-old man was admitted due to ischemic pain on left lower leg. This pain developed about 8 hours ago. Physical examination revealed a large, hard, pulsatile mass in his left inner thigh. There were severe ischemic changes in his legs. A non-contrasted CT-scan showed a 50 mm sized aneurysm of SFA. The CT-scan also showed the both internal iliac aneurysms and both deep femoral artery aneurysms with great diameter range from 19mm to 40mm. So, we decided to operate immediately. Under local anesthesia, we started thrombolytic therapy for the thrombotic occlusive lesion of left lower leg, and 5 hours later we did stent graft deployment for exclusion of aneurysm of left SFA. But, the left leg should go above-the-knee amputation at HD #5. We did second operation of aneurysmectomy and bypass surgery for the aneurysm of left deep femoral artery at HD #8. The patient was discharged from the hospital at 20th postoperative day. The histological examination showed

a degenerative aneurysm. The twelve months follow up show a perfect patency of right DFA.

ConclusionThrombotic occlusive arteriosclerotic aneurysm of the SFA is very uncommon. Early diagnosis and surgical reconstruction is recommended for patients with aneurysm of the SFA that are 2.5cm or greater in maximum diameter and for complicated aneurysms of any size. It’s also recommended to screen those patients for other aneurysms locations.

P07-20Paper No: 392Intermediate-term outcomes after endovascular treatment of atherosclerotic femoropopliteal occlusive lesions

Young-Nam Roh, Ui Jun Park, Hyoung Tae KimDivision of Transplantation and Vascular Surgery, Department of Surgery, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea

BackgroundEndovascular treatment is considered first-line therapy for most femoropopliteal occlusive disease. This study evaluated the Intermediate-term outcomes of endovascular treatment on atherosclerotic femoropopliteal occlusive lesions.

Materials and methodsFrom among the 675 endovascular procedures on lower extremity arteries in our database, we retrospectively selected a consecutive series of 286 procedures on femoropopliteal lesions with or without other target arteries on 262 limbs in 215 patients from 2010 to 2017. The Target Lesion Revascularization (TLR) free rate, limb salvage and patients’ survival were investigated.

ResultsMean age was 71.0 ± 10.4 years, and mean follow-up duration was 21.8 ± 18.2 (range, 0.1 - 82.9) months. During follow-up, repeated procedures were needed in 30 limbs (11.5%). 72 patients (33.5%) had died because of medical conditions unrelated to angioplasty. The TLR free rate at 1 year, 3 years, and 5 years were 91.3%, 84.4%, and 68.9%, respectively. Amputation-free survival at 1 year, 3 years, and 5 years were 81.4%, 55.0%, and 41.0%, respectively.

ConclusionsEndovascular treatment on atherosclerotic femoropopliteal lesions showed acceptable TLR free

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rate in intermediate-term. However, the amputation free survival rate was relatively low mainly due to poor survival.

P07-21Paper No: 394Outcomes after angioplasty of isolated, below-the-knee arteries in severe limb ischemia

Young-Nam Roh, Ui Jun Park, Hyoung Tae KimDivision of Transplantation and Vascular Surgery, Department of surgery, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea

BackgroundFew published studies have specifically investigated outcomes in ischemic limbs associated with isolated small BTK (Below-The-Knee) vessel disease. This study aimed to evaluate the results of successful endovascular treatment for limb salvage in such patients.

Materials and methodsFrom among the 675 endovascular procedures on lower extremity arteries in our database, we retrospectively selected a consecutive series of 44 procedures on isolated BTK lesions on 41 limbs in 39 patients from 2010 to 2017. The Target Lesion Revascularization (TLR) free rate, limb salvage and patients’ survival were investigated.

ResultsMean age was 63.8 ± 14.0 years, and mean follow-up duration was 18.1 ± 16.5 (range, 0.1 - 80.2) months. During follow-up, repeated procedures were needed in 6 limbs (14.6%) for recurrent ischemia. 13 patients (33.3%) had died because of medical conditions unrelated to angioplasty. The TLR free rate at 1 year, 3 years, and 5 years were 85.7%, 79.1%, and 79.1%, respectively. Amputation-free survival at 1 year, 3 years, and 5 years were 73.0%, 41.2%, and 41.2%, respectively.

ConclusionsIn our selected patient population with ischemic limbs and isolated BTK lesions, a successful endovascular procedure led to an acceptable TLR free rate and relatively low amputation free survival.

P07-22Paper No: 436Supra-celiac aorta-to-bilateral external iliac artery bypass and superior mesenteric artery bypass for severe calcified aortic occlusion with severe claudication and abdominal angina: A case report

Kazunori Hashimoto, Harunobu Matsumoto, Takao Nonaka, Daijiro Hori, Naoyuki Kimura, Koichi Yuri, Atsushi YamaguchiDepartment of Cardiovascular Surgery, Jichi Medical University Saitama Medical Center, Saitama, Japan

We report a case of successful surgical treatment of severe claudication and visceral ischemia due to severe calcified aortic occlusion. A 44-year-old man with end-stage renal failure who was receiving chronic hemodialysis for 18 years was admitted to our hospital. He complained of claudication in 100 meters and abdominal pain after eating and during hemodialysis. His claudication worsened during the outpatient course, and ankle-brachial pressure index (ABI) was not measurable.

Computed tomography and angiography revealed aortic occlusion at the superior mesenteric artery level to the terminal aorta and iliac bifurcation with severe calcification. Axillofemoral bypass had poor patency, and he needed treatment for abdominal angina. As thoraco-abdominal replacement of the aorta with cardiopulmonary bypass was much invasive, we planned to perform supra-celiac abdominal aorta-to-iliac artery bypass and superior mesenteric artery bypass.

The supra-celiac artery was approached through a median abdominal incision with an additional left anterolateral chest incision through the seventh left intercostal without thoracotomy and a cut to the right crus of the diaphragm. For the supra-celiac abdominal aorta-to-bilateral external iliac artery bypass, a 14 x 8mm bifurcated Dacron graft was used. For the superior mesenteric artery bypass, a 6-mm dacron graft was used.Although he required mechanical ventilation for 6 days and fever of unknown origin continued for 3 weeks after the operation, his severe claudication and abdominal angina improved, and postoperative ABI increased to 1.3. He was transferred to another hospital at the 55th postoperative day. Eighteen months have passed since the operation, and he has not experienced any further claudication and abdominal angina.

We conclude that for this patient, although the postoperative course was prolonged, supra-celiac aorta-to-bilateral external iliac artery bypass and superior

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mesenteric artery bypass were appropriate, particularly considering his young age and the promising long-term results.

P07-23Paper No: 443An evaluation of hemodynamic and perfusion parameters and the response to revascularization among patients with critical lower limb ischemia

Prasenjit Sutradhar, Robbie K GeorgeDepartment of Vascular Surgery, Narayana health, Bengaluru, Karnataka, India

BackgroundA prospective cohort study to assess the ability ABI/TBI/TcPO2 to predict successful wound healing of lower limb critical limb ischemia by open/endovascular revascularization technique in patients presenting with Rutherford Class V/VI critical ischemia. MethodsIn all adult patients presenting with Rutherford class V/VI disease, ABI/TBI/TcPO2 pre intervention and post intervention (post operative day 2 and day 5) were recorded. Patients were followed up to look for wound healing or amputation/limb loss. Results47 patients with 49 affected limbs were recruited over a period of 1 year. Wound healing was achieved in 43 out of 49 limbs (87.8%). 1 patient expired during the course of the study. Analysis of variance (ANOVA) was used to find the significance of study parameters between three or more groups of patients. Student t test (two tailed, independent) was used to find the significance of study parameters on continuous scale between two groups (Inter group analysis) on metric parameters.

A comparison of the pre and post operative assessment markers showed a rise in ABI, TBI, TcPO2 post revascularization in the group with successful wound healing that continued from POD 2 to POD5. TcPO2 was found to be the most significant predictor of wound healing (p=2 of less than 30mmHg achieved healing and all wounds that healed were associated with a TcPO2 of more than 30mm hg by post revascularization day 2 itself. ConclusionsOur study demonstrates an improvement in all 3 parameters i.e. ABI, TBI and TcPO2 following successful surgical or endovascular revascularization. We have

found TBI to be the least sensitive and a TcPO2 of more than 30 mmHg the most accurate.

We feel these parameters, especially TcPO2>30mmHg, are valid early indicators of wound healing in a clinical context and can help identify wounds that may fail to heal and would need adjunctive procedures.

P07-24Paper No: 444Early Experience of Rotational Atherothrombectomy Catheter in treating in-stent re-stenosis or occluded stent

Skyi Yin Chun Pang, CN TangDepartment of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR

IntroductionAfter the adoption in government reimbursement program on femoro-popliteal stent in Hong Kong, re-intervention in patients with femoro-popliteal stent become inevitable. Here we report our early experience in the use of rotational atherothrombectomy catheter (Rotarex®S) in re-intervention of patients with severe diffuse in-stent restenosis or occluded stent.

Method A retrospective case series from May 2015 to April 2017 for patient using Rotational Atherothrombectomy Catheter (Rotarex®S) for severe diffuse in-stent restenosis or occluded stent. The peri-operative details and follow-up data are retrieved from electronic patient record for analysis.

ResultFrom May 2015 to April 2017, we have 11 patients received 15 interventions using rotational atherothrombectomy catheter for severe diffuse in-stent re-stenosis or occluded stent. 80% of cases presented with Rutherford 4-6. The mean stent length is 14.7±8.5cm. Technical success achieved in thirteen cases (86.7%). Near half of the cases (46.7%) required bidirectional approach for intervention. Concomitant interventions have been performed in two-third of cases. 46.2% cases received additional drug eluting balloon after atherothrombectomy. Additional stent at the distal end to enhance outflow in used 30.8% cases. The mean follow up in our series is 12 months. Clinical symptoms improvement is observed in successful cases. Severe diffuse re-stenosis or occlusion is observed in 3 patients during subsequent follow-up requiring re-intervention.

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Conclusion Rotational atherothrombectomy catheter is a useful endovascular adjunct for treating severe in-stent restenosis or occluded stent achieving high successful rate in recanalization. The additional tools such as drug eluting balloon or further stenting at distal outflow may provide better patency rate.

P07-25Paper No: 468MACE in diabetic patients with peripheral arterial disease: 18 months follow up in Chiang Mai Thailand

Kittipan Rerkasem1,2, Ampica Mangklabruks1, Natapong Kosachunhanun1, Arintaya Phrommintikul1, Kiran Sony3, Nimit Inpankaew4, Saritphat Orrapin1, Orapin Pongtam1, Paweena Thongkham1

1NCD Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand2NCD Centre of Excellence, RIHES, Chiang Mai University, Chiang Mai, Thailand3Department of Internal Medicine, Chiangrai Prachanukroh Hospital, Chang Wat Chiang Rai, Thailand4Department of Internal Medicine, Lamphun Hospital, Chang Wat Lamphun, Thailand

BackgroundPeripheral arterial disease (PAD) in diabetic patients has been known as a high risk subset for cardiovascular morbidity and mortality in diabetic patients. Therefore the predictive factors were needed to identify in order to reduce poor outcomes. However this data was very little in Asia. MethodThis study run between June 2014 to July 2016 in diabetic patients with PAD. Patients were followed up at 6, 12 and 18 months follow up period for the major adverse cardiovascular events (MACE). MACE consisted of death, non fatal myocardial infarction and non fatal stroke. The Cox regression was used to identify the independent risk factors. Data was shown in hazard ration (HR) and confidence interval (CI). This study was supported by the Health Systems Research Institute. ResultThere were 500 diabetic patients with being diagnosed as PAD. 63 MACE was found during 18 moth follow up. The independent predictive factors were history of chronic heart failure (HR=3.13, 95%CI 1.02-9.62), previous history of aortic surgery (HR=56.51, 95%CI 5.29-604.13), history of previous peripheral arterial bypass (HR=3.04, 95%CI1.08-8.60), body mass index19-23 (HR=2.50, 95%CI 1.03-6.06), on warfarin

(HR=3.50, 95%CI 1.28-9.60), on antihyperlipidemia (HR=0.44, 95%CI 0.22-0.89) and on biguanide (HR=0.38, 95%CI 0.14-0.98).

ConclusionIn our study with 18 month follow up, physician should reduce or modify the predictive factors for MACE namely chronic heart failure, previous history of aortic surgery, history of previous peripheral arterial bypass, body mass index 19-23 and on warfarin. In contrast, patients should have more protective factors namely on antihyperlipidemia and on biguanide. Longer study are needed to confirm the findings.

P07-26Paper No: 170Cardiovascular safety of sulfonylureas in peripheral artery disease patients with diabetes in Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand

Nutthanun Tungsrirut1, Kanokwan Kulprachakarn1, Natapong Kosachunhanu2, Arintaya Phrommintikul2, Orapin Pongtam1, Suwinai Saengyo1, Antika Wongthanee3, Kittipan Rerkasem1,3

1NCD Center and Department of Surgery, Faculty of Medicine, Chiang Mai University, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand 2Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand3NCD Center of Excellence, Research Institute of Health Science, Chiang Mai University, Chiang Mai, Thailand

BackgroundThe purpose of this study was to evaluate the safety of sulfonylurea use in peripheral artery disease patients (PAD) with diabetes in term of all-cause and cardiovascular mortality and cardiovascular events. MethodsA prospective cohort study was conducted. A total of 368 PAD patients with diabetes were enrolled with an 18 month follow-up period. The patients were classified as lifestyle modification group, sulfonylureas group, and non-sulfonylureas group. Primary end point was major adverse cardiovascular event (MACE), which composed of non-fatal myocardial infarction, non-fatal stroke, worsening PAD, and death. Results368 PAD patients with diabetes were analyzed using Cox-regression model, most with sulfonylurea agents (130 patients, age 67.03±9.88 years old), including glipizide (Hazard Ratio (HR)=0.212, 95% Confidence Interval (95%CI) = 0.087-0.516, P=0.001), gliclazide (HR=0.310,

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Poster Presentation

95%CI=0.109-0.888, P=0.029), and glibenclamide (HR=0.342, 95%CI=0.131-0.896, P=0.029) were associated with lower risks of composite severe outcome as compared to lifestyle modification (81 patients, age 68.92±10.14 years old). No composite severe outcome observed in glimepiride. The Non-sulfonylureas (157 patients, age 65.66±10.44 years old) also showed the same result (HR=0.539, 95%CI=0.328-0.887, P=0.015). Symptomatic peripheral arterial disease, including intermittent claudication (HR=1.661, 95%CI=1.035-2.665, P=0.036) and chronic ulcer (HR=2.708, 95%CI=1.725-4.250, P=0.000) associated with higher risks of composite severe outcome. ConclusionSulfonylureas were involved with lower risks of composite severe cardiovascular outcome as compared with lifestyle modification.

P07-27Paper No: 191Qualitative assessment of carbon dioxide as a contrast agent for infra-inguinal arterial diagnostic and therapeutic procedures in critical limb ischemia: A modality to prevent contrast-induced nephropathy in patients with chronic kidney disease

Sumanthraj Kolalu, Dharmesh D, Sravan CPS, Piyush J, Vaibhav L, Vishnu M, Vivekanand, Suresh K RJain Institute of Vascular Sciences (JIVAS), Bangalore, India

BackgroundIodinated contrast volume reduction is effective strategy to prevent contrast-induced nephropathy (CIN). Patients with peripheral vascular disease (PVD) often have chronic kidney disease (CKD) which may enhance the risk of CIN in endovascular therapy (EVT). This study is to assess whether CO2 Angiogram (CO2A) can replace conventional iodine contrast guided EVT in CKD patients.

MethodsA prospective single center study in patients with an estimated glomerular filtration rate(eGFR)2. Patients were recruited between April 2015 and December 2016. CO2 angiography-guided EVT was performed for critical limb ischemia (CLI). The CO2A of each patient were graded as good, fair or poor by two independent observers. CO2A were supplemented by minimal iodinated contrast media if opacification was not acceptable. The primary endpoint was a qualitative assessment of CO2A for infra-inguinal arterial EVT and freedom from adverse renal events.

ResultsThis study included 47 patients (47 limbs) with CLI (Rutherford Class 5/6). The mean baseline eGFR was 35.06±10.42ml/min/1.73m2 with mean age 70±9 years (CKD class-3/4/5). CO2 angiography-guided angioplasty were performed in 14 superficial femoral arteries, 9 in popliteal arteries, 26 anterior tibial arteries, 12 posterior tibial arteries, 11 Peroneal, 6 tibio-peroneal trunk. The technical success rate was 81% (38/47). Average CO2 consumption was 489±133ml, average dose of iodinated contrast media was 10±8ml. Incidence of CIN was 6.38% (3/47), all patients eventually recovered, no patients required dialysis. CO2A related leg pain occurred in 32% (15/47). Quality evaluation of CO2A by two observers showed that good CO2A were obtain in 37 cases with inter-rater reliability (IRR) of 80% (kappa-0.79) in Femoropopliteal segment. The good CO2A in only 6 (13%) cases in infrapopliteal segments but poor CO2A in 30 cases with IRR of 64% (kappa-0.69). Perioperative mortality was 4.3% (not related to CO2A complication or CIN). ConclusionsPoor CO2A in infrapopliteal vessels are due pain and movement of limb while injecting CO2 gas. Infrapopliteal segment opacification with CO2A is still an issue and need to sort out with modern angiography equipment, regional anesthesia to reduce pain and injection of CO2 as close possible to lesions. CO2 angiography guided endovascular therapy can be alternate for femoropopliteal lesions in CKD patients.

P07-28Paper No: 236Technical consideration for endovascular recanalization of aortoiliac occlusive lesions: Single-center experiences

Haeng Jin Ohe1, Mi Hyeong Kim2, Kang Woong Jun2, Jeong Kye Hwang2, Jang Yong Kim2, Sun Cheol Park2, Ji Il Kim2, Yong Sung Won2, Sang Seob Yun2, In Sung Moon2

1Inje University, Seoul Paik Hospital, Vascular and Transplantation Surgery2The Catholic University of Korea College of Medicine, Vascular and Transplantation Surgery

PurposeEndovascular treatment of aortoiliac occlusive disease is challenging and still on the debate. Authors reviewed our experience of endovascular management for aortoiliac occlusive disease(AIOD), focusing on technical considerations.

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MethodRetrospective study was done from prospectively registered data for the patient with aortoiliac occlusive disease (AIOD) treated by endovascular means in vascular and transplantation surgery in Seoul St. Mary’s hospital from May 2012 to Feb 2017. Patient’s clinical characteristics, procedure in details and post operative record were summarized.

ResultFourteen patients was enrolled. The mean age was 59 years (range, 43-75 years). The indication of the treatment was 5 acute attack on chronic AIODS, 4 chronic limb threatening Ischemia and 5 chronic short distance claudication. There was 2 extensive AIOD: 1 common femoral artery, 1 superficial femoral artery. Two methods of access was used to recanalize each iliac lesion: 25 ipsilateral groin access with retrograde recanalization, 3 brachial access with antegrade recanalization after failed femoral access. Thrombectomy was done in 8 cases: 7 open thrombectomy and 1 AngioJet thrombectomy. Stents was used in all cases including 2 Viabahn covered stent. The 30-day post procedural mortality and morbidity rate was 0%.

ConclusionDifferent modalities used for the aortoiliac endovascular treatment offer all the benefits for treatment on a case-by-case basis. In our experiences of failed retrograde recanalization via femoral access, early change of brachial arterial access with antegrade recanalization is taken into consideration to avoid technical failure.

Peripheral Arteries

P08-01Paper No: 220Changes of microperfusion of the foot after tibial angioplasty in critical limb ischemia

Werner Lang, Alexander Meyer, Susanne Regus, Ulrich RotherDepartment of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany

ObjectivesIn recent years a controversial discussion about the clinical relevance of the angiosome concept during tibial angioplasty has developed. Therefore, we conducted a prospective study to evaluate the angiosome concept on the level of microcirculation during tibial vascular interventions.

Methods30 patients with isolated tibial angioplasty were examined prospectively. Macrocirculation was evaluated by measurement of the ankle-brachial index. For the assessment of microcirculation a combined method of Laser-Doppler flowmetry and tissue spectrometry (O2C®, LEA Medizintechnik GmbH, Giessen, Germany) was applied. Microcirculatory parameters were measured continuously during the procedures. Measuring points were located over different angiosomes of the index foot, while a control probe was placed on the contralateral leg.

ResultsCumulated microcirculation parameters (sO2, Flow) as well as the ankle brachial index (ABI) showed a significant improvement postinterventionally (ABI: P<.001, sO2 P<.001, Flow P<.001). Assessment of the separate angiosomes of the index leg, and the comparison of the direct (DR) and indirect (IR) revascularized angiosomes showed no significant difference concerning the micro-perfusion postinterventionally (DR - IR: sO2 P .399, Flow P .909) as well as during angioplasty. Even a further subdivision of the collective in diabetics and renal-insufficient patients could not demonstrate a superiority of the direct revascularization at the level of microcirculation in these patients (Comparison DR - IR: diabetes sO2 P .445, Flow P .758, renal insufficiency sO2 P .246, Flow P .691).

ConclusionThere is a significant overall improvement in tissue perfusion of the foot immediately after tibial angioplasty. The effect shown in this study however was found to be global and was not restricted to certain borders, such as defined by angiosomes.


P09-01Paper No: 041Fist Assist Device helps AV fistulas enlarge

Tej SinghFist Assist Devices, LLC

BackgroundDelays in AV fistula (AVF) maturation cause dialysis delays and increased costs. Early use of non-invasive devices may help assist clinical AVF maturation and dilation. Wrist fistula seem to have poor maturation. Materials and MethodsOne week after AVF creation, a novel, intermittent pneumatic compression device [Fist Assist (FA)] was

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applied 15 cm proximal to the AVF in order to apply cyclic compression 50 mm Hg for six hours daily for 30 days. Thirty (n=40) AVF patients were enrolled in an IRB approved study to test vein maturation at baseline and with the FA. Controls (n=20) used a sham device. Vein size was measured and recorded at baseline and after 30 days by duplex measurement. Clinical results (percentage increase) were recorded and tested for significance. Wrist fistulas were compared to upper arm fistulas.

ResultsNo patients experienced thrombosis or adverse effects. After one month, the mean percentage increase in vein diameter in the FA treatment group was significantly larger (p=0.05) than controls in the first 5 mm segment of the fistula. Positive results were also noted in regards to forearm fistula maturation compared to upper arm with wrist fistulas dilating in all portions (p<.05). ConclusionEarly application of an intermittent pneumatic compression device may assist in AVF maturation and success. Novel, non-invasive devices like Fist Assist may have clinical utility to create functional fistulae development and decrease costs as they may assist in maturation. Excellent results were seen with wrist fistulas.

P09-02Paper No: 059Comparative patency of one-stage and two-stage brachiobasilic arteriovenous fistulae: A systematic review and meta-analysis

Ian Wee Jun Yan1,2, Ismail Heyder Mohamed1,3, Amit Patel1,4,5, Andrew MTL Choong1,6,7

1SingVasC, Singapore Vascular Collaborative, Singapore2Faculty of Medicine, University of New South Wales, Sydney, Australia3General Surgery & Renal Transplant, London Deanery, Royal London Hospital4Stem Cell Transplantation & Haemato-oncology, Institute of Translational Medicine, University of Liverpool, United Kingdom5Stem Cell Transplantation & Haemato-oncology, Royal Liverpool University Hospital, Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Uinted Kingdom6Division of Vascular Surgery, National University Heart Centre, Singapore7Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore

BackgroundLong term patency of arteriovenous fistulae is critical for haemodialysis vascular access. We compared the

efficacy of a one-stage versus two-stage approach to brachiobasilic arteriovenous fistulae (BB AVF) creation by primarily investigating primary and secondary patency rates.

MethodsThis review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Searches were performed on five electronic databases. Risk of bias and quality assessment scores were both performed.

ResultsThe systematic search revealed a total of 242 publications for possible inclusions. On the basis of title and abstract review, 3 randomized controlled trials, and 8 case-cohort series fitted our inclusion criteria. Only 7 studies were reviewed after Quality Assessment Scores.

The overall patency was higher for two-stage, trending towards statistical significance (RR=1.17,95%CI 0.94-1.46). Both one-year (RR=1.43, 95%CI 0.70-2.93 and two-year secondary patency rates (RR=1.31, 95%CI 0.75-2.31) were higher in two-stage. Overall, complication rates were higher in one-stage procedures (RR=1.15, 95%CI 0.89-1.49). Haematoma (RR=1.28,95%CI 0.65-2.52), and thrombosis rates (RR=2.11, 95%CI 0.94-4.74) were higher in one-stage, while pseudoaneurysm rates were higher in two-stage (RR=0.49,95%CI 0.17-1.38). Complication rates of steal syndrome (RR=0.88,95%CI 0.35-2.22), infection (RR=1.20,95%CI 0.53-2.71), venous hypertension (RR=1.07,95%CI 0.23-4.98), and stenosis (RR=0.98,95%CI 0.49-1.95), were not statistically significant. There was no statistical significance in subgroups comparing vein size and study designs.

ConclusionWe have been able to compare one-stage versus two-stage BBAVF procedures where larger RCTs do not exist. Overall patency was higher in two-stage, approaching statistical significance. Overall, complication rates were higher in one-stage, approaching statistical significance. The lack of statistical significance is likely due to poor sample size and heterogeneity. There needs to be larger RCTs with proper design and methodology for a firm conclusion.

P09-03Paper No: 090Arterio-venous fistula flow dynamic and results of flow reduction revision in limb edema patients from central venous occlusion

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Burapa KanchanabatDepartment of Surgery, Vajira Hospital, Navamindradhiraj university, Bangkok, Thailand

BackgroundTo investigate the flow dynamics and results of arterio-venous fistula (AVF) flow reduction surgery using distal inflow in patients with arm or neck edema due to central venous occlusion.

MethodsFlow dynamic of 19 successive patients presented with neck or arm edema from central venous occlusion between February 2011 and May 2014 were reviewed.

AVF flow rate was measured by duplex Doppler ultrasound. Flow reduction surgery was performed in high flow AVF patients by switching inflow distally to radial or ulna artery with interpositioning autogenous veins or 5 mm prosthetic graft.

ResultsFifteen patients (79%) had autogenous AVF with brachial arteries inflow. Thirteen (68%) central venous lesion patients had complete obstruction. The mean flow rate of brachial (n=15) and radial artery based AVF (n=4), was 2191ml/min and 1455ml/min. For the brachial artery based AVF, 40% had AVF flow rate above 2500ml/min. The size of the brachial arteries was significantly larger in the AVF with flow rate>1200 ml/min (mean 6.7mm vs. 4.7mm, p=.009). The flow reduction revision was performed in 7 patients (8 operations) which resulted in significant reduction of AVF flow (mean, 2880ml/min to 860ml/min, p.

ConclusionsAVF flow rate tends to be high regardless of the complete obstructive lesion in the majority of circumstances. Surgical revision using distal inflow is a viable option in high flow AVF patients.

P09-04Paper No: 093The incidence and management of central vein rupture occurring during PTA for hemodialysis access patients

DE Goo1, YJ Kim1, SB Yang1, D Song2, SC Yoon2

1Department of Radiology, University of Soonchunhyang, Seoul, Ref of Korea2Department of Vascular Surgery, University of Soonchunhyang, Seoul, Ref of Korea

PurposeTo evaluate the incidence and management of central vein rupture occurring during PTA for central vein stenosis/occlusion in hemodialysis patients. Materials and MethodsBetween 1998 and 2015, 3103 PTA were performed for central vein stenosis (2437)/occlusion (666) in hemodialysis patients (1445 males and 1658 females; 1368 subclavian veins and 1735 innominate veins) using various techniques. PTA or stenting were performed regardless of vein rupture if a guide wire was passed through the stenosis/occlusion lesion. The incidence of central vein rupture according to the location, sex, right and left, thrombosis, stenosis or occlusion were analyzed using Chi-Square test. Percutaneous managements of central vein rupture were also evaluated. ResultsCentral vein rupture was documented by fistulography in 12 cases (0.39%). They were all central vein occlusion patients and no stenosis (p=0.000). Central vein rupture involved the innominate vein in 9, and subclavian vein in 3 cases. There were no statistically significance in location (p=0.409), sex (p=0.811), right and left (p=0.081), thrombosis (p=0.331). Causes of central vein rupture were as follow; a guide wire induced rupture in 9, sharp recanalization with Colapinto needle in 2, and during balloon dilation in one case. Central vein rupture were managed by stenting (n=5), low pressure ballooning in the rupture site (n=2), balloon occlusion in the proximal vein of rupture site and observation (n=5). There were no surgical procedure for the management of central vein rupture. Finally, 7 patients had successfully angioplasty for central vein stenosis/occlusion and 5 patients failed. ConclusionCentral vein rupture occurs very rare during PTA, and the majority can be easily managed by percutaneous techniques. If a guide wire can be passed through the occlusive lesion, PTA could be possible even if central vein rupture occurs.

P09-05Paper No: 106A retrospective study of factors contributing to maturation rate of Brachio-cephalic Fistula (BCF)

Lenny SS, Amirullah, Kothai, Noratul, Murni, Heknes, Zuhaily, Mohamad Azim Md Idris, Hanafiah HarunrashidDepartment of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

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IntroductionBrachio-cephalic fistula(BCF)is a popular arteriovenous fistula. This study is to identify the prevalence of BCF maturation and to determine predictors that affect the BCF maturation rate.

MethodologyWe conducted a retrospective study of database review to identify all brachio-cephalic fistula creation performed in UKMSC from 2014 to 2016. Defaulted patient are excluded. We include all the patient who undergone for vein scan and meet all the standard criteria for BCF creation, arterial size minimum 2.5mm, good blood flow and good vein which is fully compressed and no thrombus. We will identify the comorbid factor and the correlation with the maturation of BCF.

ResultA total of 215 patients range from age 30-80 were included. Majority of them had risk factors which is underlying comorbidity such as Diabetes Mellitus, hypertension, ischaemic heart disease (IHD) and end stage renal failure. From all 215 BCFs included in the study, 94 were female and 121 were male. Overall maturation rate in our study was 91.2% which is 196/215. In our study, we found that demographic factor such as age; gender and race did not influence the maturation rate. The group with the vein diameter of less than 2.5 mm maturation rate was 85.3%. The group with vein diameter of more than 2.5mm was 94.3%. The P value was 0.028 which is significant. The patient with IHD maturation rate was 79.3% comparing to the group without IHD was 93%. The P value was 0.016 which is significant. Other predictors like DM, HTN & ESRF has no effect on BCF maturation rate.

ConclusionThis study shows that maturation rate of brachiocephalic fistula in the centre is 91.2%. Vein diameter of less than 2.5mm and ischaemic heart disease are negative predictors of the BCF maturation.

P09-06Paper No: 107Results of surgical intervention following thrombosed arteriovenous grafts from a single tertiary vascular centre

Fattah AH, Lenny Suryani, Azim I, H HarunarashidVascular Unit, Department of Surgery, UKM Medical Centre, Kuala Lumpur, Malaysia

IntroductionArteriovenous graft (AVG) thrombosis is a major challenge. Its development can be related to stenotic lesions affecting the feeding arteries, within the graft or in the draining veins. Several management strategies have been recommended. This study is to evaluate the primary patency of thrombosed AVGs after surgical intervention after 1 year.

MethodsThis is a retrospective audit. All patients who underwent surgical intervention to thrombosed AVGs performed at our centre from March 2013 to June 2016 were reviewed. The list of patients and their clinical data were retrieved from the surgical logbook and patients’ notes. Patients were then assessed in the clinic; examining the patency of their AVGs for at least a year after the surgical intervention. Finally, the findings were analysed with regards to types of surgical intervention taken and primary patency.

Results34 patients with thrombosed AVGs were examined. 28 (82.4%) underwent surgical intervention: 23 (82.1%) underwent AVG-salvage intervention and 5 (17.9%) underwent non AVG-salvage intervention (ligation of AVG; 4 and explantation of AVG; 1). The AVG-salvage intervention included thrombectomy; 6 (21.4%), thrombectomy with jump graft; 12 (42.9%), thrombectomy with interposition graft; 4 (14.3%) and thrombectomy with venous patch; 1 (3.6%). Slightly half of these patients; 13 (56.5%), required re-intervention within one year. Primary patency was 69.6% within one year and 30.4% for more than one year.

ConclusionOnce thrombosed AVG has occurred, treatment options include percutaneous or surgical thrombectomy, in conjunction with angioplasty of any identified stenotic lesions or to bypass or putting a interposition graft at the stenotic lesion.

P09-07Paper No: 109Effect on handgrip exercise on the distal forearm cephalic vein diametre in patients with chronic renal disease

Aminnur Hafiz Maliki1, Lenny Suryani Safri2, Mohamad Azim Mohd Idris2, Hanafiah Harunarashid1

1Department Of Surgery, Hospital Umum Sarawak, Kuching, Sarawak, Malaysia2Vascular Unit, Department of Surgery, National University of Malaysia, Bangi, Selangor, Malaysia

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BackgroundThis study is to investigate the effect of local physical training, namely handgrip exercise, on the distal forearm cephalic vein diameter in patients with chronic renal disease.

MethodTotal number of 34 chronic renal disease patients (stage 3 and 4) were recruited into two arms, intervention and control group. Handgrip exercise was performed for eight weeks in the intervention group. The following parameters were measured at the beginning of the study, at four and eight weeks later for both groups: handgrip strength measurement, distal forearm cephalic vein diameter of non-dominant hand (with and without tourniquet).

ResultsThe diameter of distal forearm cephalic vein of non-dominant hand in the intervention group increased significantly (p<0.05) after handgrip exercise compared to the control group when measured in both the absence (mean change 0.39±0.06 mm versus 0.01±0.02mm) and the presence of tourniquet (mean change 0.47±0.07mm versus 0.01±0.01mm) at the end of eight weeks of study period.

ConclusionsThese findings indicate that a simple non-invasive handgrip exercise can cause a significant increase in the diameter of distal forearm cephalic vein that commonly used in the creation of native arterio-venous fistula.

P09-08Paper No: 112Predictors of functional and radiological patency following fistuloplasty in arteriovenous fistulas

Kishen Raj1, Ismazizi Zaharuddin1, Mohamad Azim Mohd Idris2, Zainal Ariffin1, Hanafiah Harunarashid2

1Department of Surgery Hospital Kuala Lumpur, Kuala Lumpur, Malaysia2Department of Surgery, National University of Malaysia, Bangi, Selangor, Malaysia

BackgroundThis study was conducted to look at the predictors of functional and radiological patency following fistuloplasty in arteriovenous fistulas (AVF) and to identify radiological and functional patency rates after fistuloplasty for dysfunctional arteriovenous fistula.

MethodsThis is a prospective cohort study. 303 Patients with dysfunctional native arteriovenous fitula (with no history of fistuloplasty) underwent fistuloplasty from January 2013 till May 2015. Patient records were traced based on surgical log entry. Data obtained were patient demographics, AVF creation history, type of AVF, intervention, duration of patency, duration of ESRF and diabetes (if present), and experience of surgeon performing the procedure. Clinical success i.e. functional patency in our study is described as the ability of the fistula to undergo satisfactory hemodialysis and not requiring further referral for intervention. Assisted primary patency is defined as patency during the interval between first intervention and fistula thrombosis or repeated intervention. Radiological or technical success is described as residual stenosis assessed by means of angiography, and were grouped to 30% recoil (failure). The Phillips Veradius Unity Mobile C-arm with Flat Detector was used in all our procedure with high pressure dilation catheter, either the Mustang 4-6mm by Boston Scientific or Paseo 9mm by Biotronik, in our fistuloplasties. Patients were then reviewed in clinic and duration of assisted primary patency was measured.

ResultsA total of 311 patients were analysed in this study, in which 164 had brachiocephalic fistula (BCF) and 147 had radiocephalic fistulas (RCF). 179 was male and the remainder were females. The clinical success of functional patency rate was 77% (240 of 311 interventions), where as the radiological i.e. technical success rate was 75%. Brachiocephalic fistula (BCF) had assisted primary patency rates at 3, 6, and 9 months, of 88.8% +- 2.6%, 79.4% +- 3.4 and 69.8% +- 3.9. For RCF, it was 89.2% +- 2.8, 70.9% +- 4.3 and 60.5% +- 4.7. There was no significant difference in assisted primary patency rates at all-time between brachiocephalic and radiocephalic fistulas (p=0.587, log-rank test). Radiological success predictors according to results of univariate analysis shows that patient’s race and type of fistula were the only predictors with significant p value. The same was observed for clinical success. The following factors such as patients’ age, gender, diabetes mellitus, end stage renal failure (ESRF), hypertension, type of fistula and side of fistula have no significant factor.

ConclusionThe functional patency rate for both brachiocephalic and radiocephalic fistula following a fistuloplasty are about the same. Radiological success predictors are the patient’s race and type of fistula.

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Poster Presentation

P09-09Paper No: 113The effect of residual clot and stenosis post-recanalisation of thrombosed dialysis access on patency duration

Eu Jhin Loh1, Robert Allen2, John Cockburn2

1Department of Vascular Surgery, The Canberra Hospital, Garran, Australia2Department of Radiology, The Canberra Hospital, Garran, Australia

BackgroundWe have previously demonstrated high patency rates following recanalization of blocked fistulas and grafts using a novel ‘fast urokinase’ technique. It was hypothesized that this was due to superior clot clearance. This study aimed to evaluate the extent of clot clearance achieved with the above technique and investigate if the presence of residual clot and stenosis following recanalization of thrombosed dialysis access have bearing on patency. Methods and MaterialsWe conducted a retrospective study of all declotting interventions to upper limb fistulas and grafts using the ‘fast urokinase’ technique undertaken at the interventional suite in the Canberra Hospital Department of Medical Imaging between the period of Jan 2010 to Nov 2016. This yielded 91 haemodialysis patients with 94 thrombosed upper limb dialysis access. The medical record for each intervention was reviewed for presence of residual clot/stenosis identified in completion angiography. The interval period between consecutive interventions were then calculated and divided into 2 groups: with and without residual clot/stenosis. Statistical analysis was conducted via simple unpaired t-test. ResultsA total of 405 interventions were analysed. In 71 (17.1%) interventions, there was residual clot/stenosis identified on completion angiography. The mean duration of patency following these interventions was 195.25 days. The mean duration of patency following interventions where there was no residual clot/stenosis was 241.63 days. There was no statistically significant difference between the 2 groups (p=0.2620). When further divided into native fistula versus graft, there was no difference between the 2 groups (p=0.69 and p=0.14 respectively). There was no effect of specific interventional radiologist on patency duration. The complication rate was 0.04%, with 16 minor and 1 major complication.

ConclusionThe decision against further treatment of residual clot/stenosis is often due to several factors including non-significant limitation on flow rate, prolonged procedure, patient intolerance, and lesions resistant to treatment. Our results suggest that there are other factors which may influence the patency of dialysis access such as flow rates achieved following recanalization, time between recanalization and haemodialysis, and anticoagulation status.

P09-10Paper No: 121Basilic vein transposition as an alternative technique of AV fistula: Experiences from mid-indonesian region

Joalsen IDivision of Cardiothoracic and Vascular Surgery, Mulawarman University - Abdul Wahab Sjahranie General Hospital, Samarinda, East Borneo, Indonesia

BackgroundThe basilic vein is well protected from vein puncture through its deep position in the subfascial plane. Basilic Vein Transposition (BVT) is a suitable option for access in those unfortunate patients when the cephalic vein is inadequate for fistula creation.

ObjectiveTo report a short-term outcome of 15 patients who undergone the BVT procedure from january 2015 to May 2017 in our vascular center.

MethodsDuring a 2.5-year perIod, BVT procedures in upper arm or forearm region were performed in 15 patients with failed previous RCF or BCF; or who had small caliber and thrombosed cephalic vein. This study analyzed a volume flow rate; diameter and complication after six weeks postoperatively as an early outcome.

ResultFifteen patients who underwent BVT in our center mostly was female (80%). The mean age of 15 pts was 47.4±11.84 y.o.Thirteen pts (86.67%) done with one staged and two pts (13.33) with two staged. Sixty percent of 15 pts were done in upper arm area (brachio-basilic anastomosis) and 40 % in forearm area (Radio-basilic anastomosis). Mostly BVT procedure were done by multiple incision technique (66.67%). After 6 weeks, this study showed that the average matured vein diameter was 5.57 mm; and the average volume flow rate was 556.77 ml/min. Only 4 pts suffered from the

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complication such as arm swelling (1 pts), hematoma (1 pts) and failed to mature due to thrombosis (2 pts).

ConclusionOur experiences showed that basilic vein transposition is one of an alternative technique that should be considered in ESRD patients with inadequate cephalic vein. This technique offered a good result after 6 weeks post-operatively.

KeywordBasilic Vein Transposition, Vascular access, Hemodialysis

P09-11Paper No: 123Preoperative vein mapping for arteriovenous fistula creation: A national kidney and transplant institute experience

Jonathan L Lumicday II, Ricardo DT Qiuntos II, Leo Carlo V BaloloyDepartment of Organ Transplantation and Vascular Surgery, National Kidney and Transplant Institute, Diliman, Philippines

ObjectiveTo assess outcome of preoperative vein mapping with the maturity of AVF in NKTI.

MethodsA prospective cross-sectional study was done on patients who underwent vein mapping prior to arteriovenous fistula creation at iVASC-NKTI between September 19 and October 19, 2016. Vein mapping findings were then correlated with patient’s demographic profile and arteriovenous fistula clearance ultrasound.

ResultsA total of 71 patients underwent vein mapping with a total of 48 (67.6%) patients were able to complete the study, 13 (18.3%) patients were lost to follow-up and 10 (14.1%) had no adequately sized cephalic vein on vein mapping ultrasound. of the 48 patients who underwent fistula creation, 90% had adequately sized fistula and was cleared for hemodialysis use. The preoperative vein diameter and the cephalic vein outflow tract diameter were factors correlated with fistula maturity.

ConclusionPreoperative vein mapping for arteriovenous fistula access creation was a useful tool for patients who will undergo the procedure.

KeywordsVein mapping, Arteriovenous fistula, Hemodialysis

P09-12Paper No: 128Axillary artery to distal femoral vein graft fistula as alternative option for femoral artery obstruction or stenosis in patients receiving dialysis

Hyun Hee Kim, Dan Song, Sang Chul YunDepartment of Surgery, College of Medicine, Soonchunhyang University, Seoul, Republic of Korea

ObjectiveThe population of end-stage renal failure patients dependent on hemodialysis continues to expand with an increasing number of patients having failed access on both upper extremities. Femoro-femoral fistula can be an option, but some patients have unsuitable femoral artery due to repeated cannulation or atherosclerotic change of vessels. So, we performed 3 cases of bypass between axillary artery to distal femoral vein as an alternative option in this situation. MethodsAxillo-femoral bypass via subcutaneous 6~7-mm polytetrafluoroethylene bridge graft was performed to 3 patients undergoing hemodialysis with stenosis or obstruction of femoral artery, who already failed with both upper extremity access. Cannulation on the new access was made 1~2 months after the operation, under the preference of surgeon. Long-term patency was evaluated by telephone questionnaire. ResultsNo intraoperative or immediate post-operative occlusion of fistula was observed. There was no operation-related death. 2 postoperative complications were developed in 2 patients, including seroma and steal syndrome. Postoperative steal syndrome on ipsilateral foot was observed in one patient, and orthostatic hypotension subsequently followed. ConclusionBypass between axillary artery to distal femoral vein can be an alternative option in patients with both femoral artery obstruction. Further studies should be followed to validate the patency and feasibility of axillo-femoral bypass. KeywordsFemoral artery occlusion, Central vein occlusion, Hemodialysis

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Poster Presentation

ConclusionFemoral vein transposition AVF for hemodialysis access in lower extremities is a valuable than AV graft because of lower complications and higher patency. So, transposition of Femoral vein can be an option in patients with no accessible vessels in upper extremities.

P09-14Paper No: 130Long term outcomes of arteriovenous grafts for hemodialysis in lower extremities

Hyun Hee Kim, Sangchul Yun, Dan SongDepartment of Surgery, College of Medicine, Soonchunhyang University, Seoul, Republic of Korea

PurposeThe lower extremity began to get received attention as vascular access site in that patient who have exhausted upperarm vessel. Experience with arteriovenous graft in lower extremities has been disappointed because of high infection rates and severe limb ischemia. We report our experience with hemodialysis access in the lower extremity.

MethodDuring the period January 2003 to December 2011, a retrospective review of sixty arteriovenous graft of lower extremities was performed. Age, sex, etiology of endstage renal disease and complications were tabulated. Primary and secondary patency rates were determined.

ResultsThe average age was 56 years, 38 patients were female. Renal failure was associated with hypertension in 40 (67%) patients, diabetes in 28 (47%) patients and cardiovascular disease in 9 (15%) patients. Follow-up period was 8 ~ 108 months. 54 patients had both central vein stenoses. 7 (12%) cases were primary failure. There was no operation related death. Primary and secondary patency rate were 66%, 90% at 1 year, 40%, 90% at 2 years, 27%, 87% at 3 years and 18%, 87% at 5 years, respectively. There were 99 postoperative complications that were developed in sixtyseven patients, including thrombosis , proximal vein stenosis, infection, bleeding with hematoma, perigraft seroma, steal syndrome and pseudoaneurysm.

ConclusionsThe lower extremity arteriovenous graft seems to be a viable option with patients who is unable to use any of their upper extremity veins.

P09-13Paper No: 129Femoral vein transposition for arteriovenous hemodialysis access

Hyun hee Kim, Dan SongDepartment of Surgery, College of Medicine, Soonchunhyang University, Seoul, Republic of Korea

IntroductionWhen all access options in the both upper extremities have been exhausted and obstructed due to both ventral vein stenosis or obstruction, we should consider a arteriovenous fistula(AVF) at lower extremities. Construction of prosthetic arteriovenous access (AV graft) for hemodialysis in the lower extremities result in a high incidence of graft failure and infection. In this aspect, autologous access in lower extremities is valuable than AV graft. So, we report our experience of transposition of the femoral vein (tFV).

Patients and MethodFrom January 2012 to January 2014, 10 patients who underwent tFV in Soonchunhyang University Hospital were enrolled in this study. All patients had exhausted both upperarm extremities veins and had central vein obstruction. All complications were recorded and statistical analysis of patency was performed using life-table method. Patients’ records were retrospectively analyzed. The patients underwent a through history taking and physical examination which included inspection of the extremities for edema, asymmetry of blood flow and pulse, investigation of proximal vein patency with fistulogram and Doppler ultrasonogram.

ResultThe mean age was 65.6 years, with 6 males and 4 females. Renal failure was associated with both Diabetes and hypertension in 4 patients and Hypertension only in 5 patients, and neither diabetes nor hypertension in 1 patient. Prosthetic graft was used in 4 patients due to shortness of femoral vein. There was no immediate failure and postoperative infection. 8 patients experienced minor complications (lymphocele, 6; hematoma, 3; delayed wound healing, 1). 2 patients experienced mild complications(immediate outflow stenosis, 1; obstruction due to thrombosis, 1), and all treated with percutaneous balloon angioplasty. 1 patient experienced major complication (acute distal ischemia), and treated by reducing AVF size(change anastomosis site more proximally). The primary failure was occurred in 2 patients. The secondary patency rate at 6, 12, 18 month was 100, 100, 100, respectively.

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Keywordshemodialysis, lower extremity arteriovenous graft

P09-15Paper No: 133Autologous basilic vein fistula versus prosthetic grafts; A prospective comparison for vascular access

Nalaka GunawansaNational Institute of Nephrology and Transplant, Colombo, Sri Lanka

IntroductionIncreased ‘life years’ on haemodialysis often requires patients to seek secondary and tertiary vascular access routes during their lifetime. Despite the ‘fistula first’ initiative, there has been an increasing trend towards Arterio Venous Grafts (AVG) when the superficial fistula options have been exhausted. The basilica vein fistula option tends to get overlooked in this situation.

ObjectiveTo study the performance of Transposed Brachio Basilic Arterio Venous Fistula (TBB-AVF) as a second line access where superficial autologous venous access in both upper limbs have been exhausted.

Study Design A single centre (The National Institute of Nephrology and Transplant, Sri Lanka) prospective non-randomized study (January 2014 to March 2016) comparing TBB-AVF and AVG, in terms of performance and associated morbidity.

All had pre-operative duplex venous mapping. Those without suitable cephalic vein on either arm were included. Those who preferred a tunneled central catheter, those requiring urgent dialysis with a catheter and those considered unfit for anaesthesia were excluded. TBB-AVF was performed where the basilic vein was >2mm. AVG was used when it was 4mm diameter, others had a staged procedure. All had post-operative aspirin 75 daily unless contra-indicated.

The primary and functional patencies were monitored by duplex (1,4,8,12 & 24 weeks). Flow rates were measured using ultrasound dilution.

ResultsThere were 459 patients enrolled; 382 (83%) TBB-AVF, 77(17%) AVG. Mean follow-up was 11 months.

The all-cause mortality rate was 5/382 (1.3%) in TBB-AVF and 4/77 (5.2%) in AVG; p=0.04. Surgical Site Infection (SSI) was seen in 24 (6.4%) TBB-AVFs and 10 (13.7%) AVGs; p=0.049.

Primary patency for TBB-AVF and AVG were 80.8% and 76.7% respectively (p=0.4). Overall functional patency was 81.9% and 78.1% (p=0.5). There was no significant difference between re-intervention rates. There was no statistically significant difference between other peri-operative morbidities such as pain, haematoma or distal ischaemia.

ConclusionTBB-AVF provides comparative medium-term results to AVG in this subset of patients. In addition, it is cheaper and is associated with a significantly lower all-cause mortality and SSI risk compared to AVG.

P09-16Paper No: 154Direct Revascularization and Interval Ligation (DRIL) for management preserving vascular access for hemodyalisis and extremity in steal syndrome: First experience

Sudarma I W1, Sintoro H2, Revianto O3

1Department Cardio Thoracic and Vascular, Airlangga University, Surabaya, Indonesia2Dr Soetomo General Hospital, Surabaya, Indonesia

BackgroundThe global increase of chronic renal failure has resulted in a growing number of patients on haemodialysis using arteriovenous fistulas (AVFs). By virtue of their very function, AVFs at times shunt blood away from regions distally, resulting in an ischaemic steal syndrome. Distal revascularisation with interval ligation (DRIL) has been described as a procedure to treat symptomatic ischaemic steal. We present our experience in the management of this complication.

Methods32 years old patient suffered from chronic renal failure and history of pain during routine hemodyalisis through her arteriovenous fistula attended to our hospital. We perform DRIL procedure as a treatment of her ischemic steal syndrome and also maintaining the acces of hemodyalisis.

ResultsVascular access was maintained along with the elimination of ischaemic symptoms using an ipsilateral reversed basilic vein graft. Interval ligation of the distal

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Poster Presentation

brachial artery was performed at the same time. Patient showed immediate and sustained clinical improvement of symptoms with a demonstrable increase in digital pulse oximetry.

ConclusionsDRIL is a beneficial treatment option that has proven successful at alleviating ischemic steal symptoms and preserving vascular access. This avoids placement of central lines, its associated risks, and the need to create an alternative sited fistula.

P09-17Paper No: 159Arteriovenous fistula surgery: Our experience in District Hospital, Taiping, Malaysia

Chiar Churn Inn, See Boon Keong, Leow Yeen Chin, Alden Ong, Umasangar RamasamDepartment of Surgery, Taiping Hospital, Perak, Malaysia

BackgroundArteriovenous fistula (AVF) has become one of the commonest routes for dialysis in patient diagnosed with end stage renal disease (ESRD). Compare to vascular catheter dialysis, patients is less likely to developed catheter related sepsis and better cosmetic reason.

ObjectivesTo evaluate demographic data, patency rate and AVF related complication in Taiping Hospital.

MethodsThis is a retrospective analysis done by reviewing AVF clinic record from June 2015 to December 2016. Data was processed by SPSS version 22.

ResultsA total of 270 males and 156 females underwent AVF in Taiping Hospital. The ratio is 1.7:1. 92.9% (n=330) suffered from hypertension while 76.3% (n=271) are diabetic. Others include ischemic heart disease 12.6% (n=45), cardiovascular disease 3.1% (n=11) and connective tissue disease 0.8% (n=3). Only 121 out of 355 completed 1 year surveillance. Our AVF patency rates at third, sixth, ninth month were reported as 65.7%, 46.3%, 46.2%, 43.9%, and 38.8% at one year. AVF which failed at creation was 34.7%. 64% (n=228) of them underwent AVF for first time, 29% (n=103) were second attempt, 9.2% (n=33) were third attempt while only 1 was fourth attempt. AVF created in our center were mostly brachiocephalic fistula 53.5% (n=190), radiocephalic fistula 32.9% (n=117), brachiobasilic fistula 13% (n=44) and ulnocephalic fistula 0.6% (n=2).

Only 39.4% (n=140) were from Taiping region. Other districts referral were Manjung 25.6% (n=91), Kerian 16.3% (n=58), Kuala Kangsar 6.2% (n=22), Selama 3.9% (n=14), Perak Tengah 3.7% (n=13), Kinta and Hulu Perak at 1.4% (n=5) each respectively, Hilir Perak (n=1). Complication rate was relatively low at 20% (n=72), which were thrombosis 34% (n=33), hematoma formation and steal syndrome each at 8.3%(n=8), aneurysm 7.2% (n=7), surgical site infection 5.2% (n=5), seroma 4.2% (n=4), stenosis and central venous obstruction each at 3.1% (n=3) and 1% (n=1) noted to have nerve injury.

ConclusionThough Taiping Hospital is not a vascular centre, we demonstrated a satisfactory patency rate with relatively low complications. This data helps auditing and improves our service in northern state of Malaysia in future. This will reduce the waiting time of AVF construction and congestion of referral to tertiary vascular centre.

P09-18Paper No: 160Factors affecting patency rate of arteriovenous fistula: Our challenge in District Hospital, Taiping, Malaysia

Chiar Churn Inn, Leow Yeen Chin, See Boon Keong, Goh Yen Nee, Umasangar RamasamyDepartment of Surgery, Taiping Hospital, Perak, Malaysia

BackgroundAs renal transplantation is still not widely available in Malaysia, temporary haemodialysis via arteriovenous fistula (AVF) still remains as an important temporary alternative treating end stage renal disease (ESRD) due to its cost effectiveness, ease of surgery and low complication rates.

ObjectivesTo evaluate the effects of age, antiplatelet or anticoagulant use, site selection, stages of ESRD upon referral towards the one year patency rate of AVF.

MethodsRetrospective data collection by reviewing 355 patients’ vascular clinic records was done from 1st June 2015 to 31st December 2016. Data was analyzed by SPSS version 22. Patient who defaulted follow up were excluded.

ResultsMean age is 57.07 with youngest aged 14 and eldest is 88 year-old. Mode group is 51-60 year-old (33%, n=119). However, there is no significant association

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between age and AVF patency rate (p=0.135). 44.5% of them are on anti-platelet or anticoagulant. However, this study shows no statistical significance of these medications use on the AVF outcome. 60.5% (n=125) has no previous central venous catheter cannulation as temporary dialysis measure. It is found that absence of central venous dialysis catheter did not improve outcome of AVF. However, if catheter was placed before, contralateral or ipsilateral site selection is significantly affecting the AVF outcome (p=0.029) as patency rate of AVF constructed contralateral to dialysis catheter is 72% while ipsilateral is only 28%. Analysis of the site selection effect towards AVF patency rate is found to be significant (p=0.01) as distal sites (radio-cephalic and ulno-cephalic fistula) achieve higher 35.3% failure rate while failure rate of brachiocephalic fistula (BCF) is only 17.1%. However, BCF is still preferred over brachiobasilic (BBF) as BBF failure rate is higher (26.7%). Majority (94%) was referred in end stage while only 6% was referred in stage 4 disease. Nevertheless, there is no significant association of ESRD stage and AVF outcome (p=0.054).

ConclusionAge, anticoagulant and antiplatelet use do not affect AVF outcomes significantly. If central venous dialysis catheter is present, ipsilateral site of AVF construction should be avoided. Proximal construction (BCF) should be chosen instead of distal (RCF) to achieve optimal outcome.

P09-19Paper No: 168Prevalence and risk factors of peripheral arterial disease in patients with hemodialysis access

Kittipan Rerkasem1,2, Supapong Arworn1, Saranat Orrapin1, Tempong Reanpang1, Kanokwan Kulprachakarn1, Orapin Pongtam1, Paweena Thongkham2, Suwinai Saengyo2

1NCD Centre and Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand2NCD Centre of Excellence, RIHES, Chiang Mai University, Chiang Mai, Thailand

BackgroundThe risk of peripheral arterial disease (PAD) is higher in patients with chronic kidney disease (CKD) compared with those without in Western countries. However, there is shortage in such data among Asian population. Therefore the prevalence and risk factors were identified in this study. MethodsWe studied risk and risk factors for incident PAD among 63 participants in the CKD patients with hemodialysis. Study. Patients with CKD aged 50-78 years were

recruited between 2014 and 2015. Incident PAD was defined as a new onset ankle-brachial index (ABI) of <0.9 or confirmed clinical PAD. This study was supported by Health System Research Institute, Thailand.

ResultsThere were 33 males and 30 females. 16 patients were diagnosed as PAD patients. In a multivariate-adjusted model, older age, female sex, current smoking, diabetes, blood pressure, the history of hypercholesterolaemia and underlying disease, female [odds ratio (OR) 7.8 and 95% confidence interval (CI) 1.30-47.18] P=0.025, age older than 60 years [OR5.8, 95% CI 1.19-24.36] P=0.029 and any previous history of cardiovascular intervention [OR 20.80, 95% CI 2.99-139.30] P=0.002 were the associated risk factors with PAD.

ConclusionsAmong patients with CKD, females, elder patients and any history of any previous history of cardiovascular intervention were associated with an increased risk of PAD, independent of traditional risk factors. Hemodialysis patients have high chance to have PAD, so foot should be carefully looked after to avoid amputation. Also foot should be inspected as much as AV access in patients’ arms.

P09-20Paper No: 194An analysis of the outcomes of 75 Brachiobasilic upper arm transposition arteriovenous fistula done in 2016

Angamuthu Rajoo, HZ HaroonAnga AVF Centre Sdn Bhd, Johor Bahru

ObjectivesTo determine the primary patency, complications, and factors affecting patency of Brachiobasilic upper arm transposition arteriovenous fistulas (BBAVF). MethodsPatients who underwent BBAVF between January to December 2016 were identified from the centre’s operation list. Data was collected from case records and by telephone interviews. Statistical analysis was performed using SPSS version 15.0. ResultA total of 75 BBAVF were created on 74 patients. Mean age was 60 years (SD 12.05), 75% diabetic, 95% hypertensive, 50% male, 9% peripheral vascular disease and 17% ischaemic heart disease.

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Poster Presentation

The mean number of previous arteriovenous fistulas (AVF) was 2.1±1.23. In 14% of patients, BBAVF was done in one stage since the basilic veins were arteriolised from previous forearm AVFs. The mean interval between 1st stage and 2nd stage was 41±14.66 days. Mean augmented vein sizes at first and second stages were 3.4±0.94 mm and 6.2±1.41 mm respectively. Complications included 2 haematomas, 1 wound infection, 1 steal grade 2, 3 juxta-anastomotic stenosis, 3 mid-vein stenosis, 4 proximal vein stenosis, 2 valve thickening and 2 primary failures. Secondary procedures done before vein cannulation were 4 interposition vein grafts, 3 vein patch grafts, 1 interposition PTFE graft, 2 valve excisions and 1 venoplasty. In the 2 cases of primary failure BBAVF were done in the contralateral arms. In 6 patients the BBAVF were not used and 7 patients were not contactable. 10 patients deceased before use of BBAVF. The primary (unassisted) patency rates at 3, 6 and 12 months is 86%, 81% and 77% respectively. Age, sex, DM, HPT, PVD, IHD, vein size at first and second stage, vein and arterial pathology, number of previous AVF and time between first and second stages did not have significant effect on AVF maturation and patency. ConclusionsBBAVF is another option in native AVF creation in patients who have exhausted all superficial veins in the forearm and upper arms.

P09-21Paper No: 246The comparison of baseline characteristics in end stage renal disease patients between patients with and without central line cannulation

Kittipan Rerkasem1,2, Derek Bunnachak3, Panjapone Kobpungton6, Surachet Vongsanim3, Puntapong Taruangsri5, Wuttikorn Siriplubpla7, Ratree Uoykaew8, Termpong Reanpang4, Chanawit Sitthisombat6, Antika Wongthanee3, Paweena Thongkham1, Phatcharin Pasa2

1NCD Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand2NCD Centre of Excellence, RIHES, Chiang Mai University, Chiang Mai, Thailand3Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand4Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand5Nakornping Hospital, Chiang Mai, Thailand6Chiangrai Prachanukroh Hospital, Chiangrai, Thailand7Phrae Hospital, Phrae, Thailand8Uttaradit Hospital, Uttaradit, Thailand

BackgroundKidney Disease Outcomes Quality Initiative (KDOQI) suggest that arteriovenous fistula (AVF) should be done before any central lime cannulation like stage 4 CKD in order to have the best outcome. However patients in Asia usually seek the advice for AVF creation quite late, so perhaps this might not be as good as expected. While we are running study to compare the outcome between patients with (group A) and without (Group B) the history of central line cannulation (CVC) before. We reported here the baseline characteristic between 2 groups. MethodsThis study was conducted in patients with chronic kidney disease at Maharaj Nakorn Chiang Mai Hospital, Chiang Mai province and Chiangrai Prachanukroh Hospital, Chiangrai province on December 2016-May 2017. Both groups were interviewed on basic information, cardiovascular risk factors, history and physical Examination, laboratory, drugs, quality of life (short form (SF) 36) have been examined. Then we compared two groups in these characteristics. This study was supported by the Health Systems Research Institute. ResultsThere were 182 patients in this study (group A=116 patients, group B=66 patients). BMI in group B (24.23±5.90) higher than those in group A (21.60±3.90 (P=0.0018), Serum Creatinine (mg/dl) in group A=7.70±4.27 higher than group B=5.63±1.54 (P=0.0088). In SF questionnaire, on the whole, there were no major difference in the baseline between two groups in terms of quality of life. However the social aspect in group B was significantly better than group A (P<0.001). Also group B had positive attitude to their own health than group A (P=0.001) ConclusionsSerum creatinine of group A is higher than group B. This reflect that patients in group A has lower kidney dysfunction than those in group B. In quality of life aspect, although there were not major difference between group, social aspect and attitude to health group B seems to be better than group A. Our ongoing study will provide more information on the best timing of AVF creation for Asian population in near future.

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P09-22Paper No: 251Good forearm veins but poor arteries-loop arteriovenous fistula, an option in vein preservation

Angamuthu Rajoo, HZ HaroonAnga AVF Centre Sdn Bhd, Johor Bahru

ObjectivesTo analyse the outcomes of loop arteriovenous fistulas (LAVFs) done between January 2015 to September 2016.

MethodsPatients undergoing LAVFs procedures were identified from the operation list. Information was extracted from patient case records. Data on the status of the fistulas were obtained from patient case records and by phone interview as of 30-4-17. Data was analysed using SPSS version 15.0.

Results21 LAVFs were done during the study period and 19 patients were contactable. 16 cases were cephalic vein looped to brachial artery while another 2 were to proximal radial artery. In 3 cases of forearm ulnar basilic arteriovenous fistulas, the basilic veins were looped to the brachial arteries. The median age was 57 (IQR:50.0,65.5) years, 95 % diabetic, 95% hypertensive, 38% peripheral vascular disease, 33% ischaemic heart disease.

14 patients used the LAVF for dialysis and the primary (unassisted) survival rates (%) at 3, 6 and 12 months are 81, 67 and 50 respectively. 5 patients deceased and never used the LAVF. In 3 patients, the LAVF thrombosed at cannulation sites after being used for 2, 3 and 5 months respectively while in another patient the LAVF thrombosed during intraoperative hypotension. One patient had juxta-anastomotic stenosis and vein graft was done. 2 patients had superficialisation of deep veins.

There was no post-operative complications.

ConclusionsLAVF is an option in patients with good forearm vein but with poor radial artery inflow. This conserves the upper arm veins for future use.

P09-23Paper No: 253Percutaneous transluminal angioplasty for malfunction of autologous arteriovenous fistula: single center experience

Jun Seong Kwon, Jeong Kye Hwang, Sun Cheol Park, Ji Il Kim, Sang Seob Yun, In Sung Moon, Sang Dong KimDivision of Vascular & Transplant Surgery, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea

PurposeThe percutaneous transluminal angioplasty (PTA) for malfunction of autologous arteriovenous fistula (AVF) for hemodialysis (HD) is emerging as a salvage management. But, details of PTA for AVF malfunction have not been fully evaluated. So, we studied about clinical aspects of PTA for AVF malfunction.

MethodsBetween January 2013 and December 2016, total 549 PTAs in 312 patients were performed for vascular access (VA) malfunctions. VAs included 211 AVFs and 127 AVGs. 211 AVFs consisted of 121 brachiocephalic (BC) and 90 radiocephalic (RC) AVFs. 279 PTAs in 211 AVF patients were performed. Among 279 PTAs, we evaluated clinical characteristics, locations of lesion, etiologies of malfunction, AVF flows, AVF flow ratios, numbers of BAs, intervals of BAs, treatment modalities and balloon-assisted maturation (BAM) rate.

ResultsThere was no difference in clinical characteristics, locations of lesion, etiologies of malfunction, AVF flow ratios, numbers of BAs, intervals of BA, and BAM rate between BC and RC AVF groups. Locations of lesion were anastomosis site, puncture site, and central vein in two AVF groups proportionally. AVF flows in BC group were higher than those in RC group. Stent insertions for central vein lesions were more performed in BC group.

ConclusionsThe PTA for malfunction of AVF is an applicable and effective modality as a salvage management for non-functioning AVFs. So, we need to do a regular surveillance for a possibility of malfunction of AVF and extend to perform PTA.

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P09-24Paper No: 296Bypass graft to the internal jugular vein for central venous stenosis or occlusion of a functioning hemodialysis

Tomohiro Nakamura, Katsuaki Meshii, Norihisa Hosokawa, Kouichi Okada, Morihiro KondoDepartment of Vascular Surgery and Internal Medicine, Division of Nephrology, Rakuwakai Otowa Memorial Hospital, Kyoto, Japan

Introduction and ObjectivesWhile the lifespan of hemodialysis patients is prolonged, none the less their vessels are aging. Stenosis/obstruction in the subclavian vein or innominate vein is often problematic in dialysis patients. So we created the bypass graft to the internal jugular vein while maintaining the functional AVF/AVG to treat upper extremity swelling and venous hypertension.

Material and MethodsFrom April 2014 to May 2017, a total of 709 AVG were performed on patients suffering from chronic renal failure, among which included 14 patients, 16 operations (11 males, 3 females, average age 68.9 +/- 12.2 years) for bypass graft to the internal jugular vein with central stenosis or occlusion of functioning hemodialysis.

Surgical TechniqueThe surgery was performed under general anesthesia. First, the internal jugular vein was mobilized at the inside of the sternocleidomastoid muscle. The tunnel was placed below the sternocleidomastoid muscle, and then the prosthetic graft was anastomosed to the sidewall of the internal jugular vein. Second, the other end of the prosthetic graft was anastomosed with the proximal axillary vein or the proximal brachial basilic vein, which functioned well at the site.

ResultsThe operative time was 145.9 +/- 40.0 minutes. The mean follow up time was 18 months. There were no early postoperative deaths, no early postoperative graft obstructions or infections. We had six cases of late death, two of which were due to sepsis, 2 by sudden death, 1 by worsening cardiac function, and 1 by pneumonia. Primary patency rate at 6 months and 12 months were 90% and 56%, respectively. Seven patients underwent PTA targeting the anastomosis site between the internal jugular vein and prosthetic graft.

ConclusionThe success rate for the bypass to the internal jugular vein is unfortunately unsatisfactory. However, this

procedure might currently be the only way to preserve the functioning access in the forearms. Importantly, the number of dialysis patients with a pacemaker implantation or postoperative breast cancer is increasing so that establishing a way to treat venous hypertension is important.

P09-25Paper No: 300An audit of vascular access for haemodialysis at the National University Hospital of Malaysia

Gerald Tan JS1, Lenny S2, Azim I2, H Harunarashid2

1Newcastle University, Johor, Malaysia2Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

BackgroundVascular access creation is a crucial aspect of therapy for patients requiring haemodialysis. An arterio-venous fistula (AVF) offers the best form due to lower rates of infection and clot formation. Poor selection of vascular access and AVF failures are leading to increased use of catheters as alternatives. Pre-operative vessel ultrasonography and appropriate vessel selection are predicted to improve the outcome of AVFs.

MethodsA retrospective audit of all patients (n=408) admitted during the year 2016 for vascular access creation for haemodialysis at the National University Hospital of Malaysia was carried out. This was based on local guidelines adapted from the UK Renal Association with AVF as the preferred first choice of vascular access, AVF location should be as distal as possible and the minimum vessel diameter for access should be 2.0mm. A standardised proforma was used to collect data from patient files and e-records.

ResultsData was analysed to identify the proportion of vascular access types and locations & the average vessel sizes used for access creation. A total of 408 patients were analysed and reviewed (Male=209, female=199, mean age 60.3 years). 69% of all patients had AVFs, thus having fulfilled the primary recommendation of vascular access types. Only 27% of patients are shown to have the first preference of AVF access location, which shows poor selection. Approximately half of the patients had brachio-cephalic fistulas (52%) as they are mostly due to unavailability of suitable vessels for vascular access at the radio-cephalic region. 8 of 408 patients had vessels

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smaller than the recommendation, demonstrating excellent adherence in practice.

ConclusionBased on the audit, we highly recommend the implementation of arranging early patient referrals to the vascular service within the hospital for planning of suitable vascular access options. The practice of pre-operative ultrasonography is also strongly suggested for access creation to select the optimum location and size of vessels, thus reducing its failure rates and complications.

P09-26Paper No: 311Brachiobasilic upper arm transposition arteriovenous fistula - How i do it under local anaesthesia with or without nerve block

Angamuthu Rajoo A, HZ Haroon BANGA AVF Centre Johor Bahru Malaysia, Johor Bahru, Johor, Malaysia

IntroductionBrachiobasilic upper arm transposition arteriovenous fistula (BBAVF) is a complex haemodialysis access surgery and is normally done under general or regional anaesthesia. MethodPatients with poor pain threshold as determined by observation of patient behaviour during brachiobasilic arteriovenous surgery are excluded. Patient case records of BBAVF done in 2016 were analysed for details of anaesthesia. Operative DetailsThe arteriolised basilic vein (BV) and branches is mapped and marked with ultrasound. The 3 skip incision sites are infiltrated with 10ml. of 0.25% of bupivacaine.

Through the distal incision, the BV is mobilised and brachial artery is dissected. A small infiltration cannula is passed along the side of the BV up to the axilla. 10ml of 0.15% bupivacaine (LA) is infiltrated as the cannula is slowly withdrawn. Next, the cannula is passed through the subcutaneous tissue along the length of dissection and LA is infiltrated similarly. In patients who are sensitive to pain, the cutaneous nerves are exposed at the proximal incision and are blocked with a cocktail of 2.5ml of 2% lignocaine and 2.5ml of 0.5% ropivacaine.

The BV is mobilised up to the middle incision. An artery forceps is placed as a marker at proximal end of dissection. Mobilisation of BV is completed via the

middle and proximal skip incisions. Additional LA is infiltrated as and when it is required. The BV is marked for proper orientation, divided at or near anastomosis and is exteriorised. Hydro-dissection is done to check for leakage and to dilate the vein. The transposition subcutaneous tunnel is infiltrated with 10 ml of LA with a cannula. The BV is tunnelled subcutaneously and re-anastomosed. Haemostasis is checked and two long Yates drain inserted, wounds sutured. ResultsBetween January to December 2016, 75 cases of BBAVF were done. 54 were done under local anaesthesia (LA),15 LA with nerve block and 6 under regional anaesthesia. The mean amount of 0.5% bupivacaine used was 17.97 (range 12 to 29) mls. ConclusionBBAVF under local anaesthesia with or without nerve block is an option in select patients where anaesthetic services may not be readily available.

P09-27Paper No: 324A analysis of the outcomes of first time arteriovenous fistulas created in 2015

HZ Haroon

ObjectivesTo determine the primary patency of arteriovenous fistulas (AVFs) and factors affecting patency. MethodsPatients who underwent AVF creation for the first time in January 2015 to December 2015 were identified from the centre’s operation list. Data was collected from case records and by means of telephone interview. Statistical analysis was performed using SPSS version 15.0. ResultsA total of 1219 cases of AVF creation was done in the period January to December 2015 of which 663 AVFs were either 1st time Radiocephalic fistulas (RCF) (n=579) or Brachiocephalic fistulas (BCF) (n=84). Median age was 56 years (SD 13.24), 51% were males, 74% diabetic and 93% hypertensive.

The primary (unassisted) patency rates (%) for RCF and BCF at 1 and 2 years were 76 and 51, and 71 and 62, respectively. Patients with diabetes had a 1.58 times higher risk of having AVF failure when compared to non-diabetics. For all patients who have undergone

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AVF creation for the first time, patency rates were not influenced by gender, ethnicity, hypertension or peripheral vessel disease. Artery and vein sizes were also insignificant in determining patency rates.

ConclusionFor both RCFs and BCFs, patency rates are adversely affected by the presence of diabetes. A study to correlate timing of diagnosis of diabetes to patency rates is suggested.

P09-28Paper No: 346Late arterial aneurysm formation with venous varicosity following ligation of arteriovenous fistula in kidney transplanted patient

Ui Jun Park, Young Nam Roh, Hyoung Tae KimDepartment of Surgery, Dongsan Medical Center, Keimyung Univ., Daegu, Korea

Late occurrence of arterial aneurysm following the ligation of a hemodialysis arteriovenous fistula (AVF) is rare. Here, we report the case of 50-year-old male patient. He had created radiocephalic (RC) AVF of left arm for hemodialysis in 2000; he had received the living related donor kidney transplantation from his father in the same year; his RC AVF had been ligated in 2009; his arm has been being bigger gradually after ligation and he visited hospital due to acute pain and erythema around left elbow in 2017. Because allograft renal function has deteriorating, Duplex ultrasonography has been performed. It revealed two huge aneurysms at distal brachial artery about 3.0cm in diameter and at proximal radial artery about 2.8cm in diameter respectively. Superfical veins of left upper arm showed varicosity and had multifocal thrombi in them. Microfistula between artery and vein was highlighted by contrast enhanced ultrasound and the direction of the microbulbbles of the contrast agent was from artery toward the superficial veins. Aneurysm was resected and arteries were reconstructed with great saphenous vein. There were no perioperative complications and discharged on 3 days after surgery. There have been no complications on arm and bypassed conduit until 5 months after surgery.

P09-29Paper No: 352How to choose the treatment modality (endovascular therapy or surgical revision) for dysfunctional AVF

Jae Young Park, Chan Hyun YooBusan Vascular Center, Busan, South Korea

BackgroundIn these days, failing AVFs are mostly corrected by endovascular methods. But, surgical revision should be the last stand for failing AVFs. We suggest how to select treatment modality for dysfunctional AVFs.

MethodsFor five years, annually, we have experienced more than 1000 cases of AVF-related surgery and more than 3000 cases of endovascular therapy. By our experience, we suggest the optimal treatment modality for failing AVFs.

ResultsThe optimal management modality is as below. First, for new AVF within a single year after creation, endovascular management is better than surgical revision. This contains angioplasty for maturation enhancement. Second, in any dysfunctional AVF which needs more than 3 times of endovascular therapy for a single year, surgical revision should be considered above all. Third, dysfunctional AVFs which have good arterial inflow, endovascular methods can work better. Positive vein remodeling is predicted when arterial inflow is good.

ConclusionsAVF surgeons should have a certain criteria for dysfunctional AVFs management. We should not be a blind admirer for endovascular management; the results of data will be presented.

P09-30Paper No: 372Native radiocephalic fistulas: Pre-operative resistive index as a predictor of successful fistula creation

Hazim K, Naresh GDepartment of Vascular and General Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

BackgroundThe radiocephalic arteriovenous fistula (RCF) is considered one of the best options for establishing initial haemodialysis access, but its primary failure rate is considerably high due to failed maturation and stenotic complications. Preoperative anatomic and hemodynamic assessment of the radial artery via ultrasound has been proven to increase the success rates of arteriovenous fistulae. The aim of this prospective study is to look at the ultrasonographic features of the radial artery and its relation to maturation of native RCF.

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MethodsA prospective study of 70 consecutive patients undergoing RCF creation in the Vascular Seurgery Unit, Hospital Kuala Lumpur were recruited and pre-operative ultrasonographic features of the forearm vessels were assessed and recorded. Patients were then grouped into two groups, i.e Resistive Index at Reactive Hyperemia (RI at RH) <0.7 (Group 1) and those with RI at RH >0.7 (Group 2). The clinical success of the created RCFs are then reviewed 6 weeks post operatively and statistical analysis using binomial logistic regression was performed.

ResultsThe RCF creation clinical success rate in the overall study population was 77.1%. There were 42 patients in Group 1 and 28 patients in Group 2. The clinical success rate was higher in Group 1 versus Group 2 (92.9% versus 53.6%). There was a statistically significant association between RI at RH and clinical success, Ï‡2=14.705, p=<0.001) and cigarette smoking (p<0.05) with failure of RCF creation.

ConclusionThe use of pre-operative RI at RH may successfully predict successful RCF creation. This may improve the current rate of successful RCF creation and aid operating surgeons in deciding the best hemodialysis access option for the patient.

P09-31Paper No: 374Outcomes of endovascular intervention for salvage of failing/failed hemodialysis access

Ji-Hoon Jang, Min-Gu Kim, Seung-Jae Byun, Byung Jun SoDepartment of Surgery, Wonkwang Uni. School of Medicine & Hospital, Jeonbuk, Korea

PurposeTo evaluate the outcomes of the endovascular treatment for failing and/or failed arteriovenous access with various interventional technique.

MethodsPatients on hemodialysis who received endovascular intervention for access problems from a single institution between 2006 and 2017 were retrospectively analyzed. Patients’ comorbidities, graft or fistular configuration, lesion characteristics, and procedural characteristics intervention performed were analyzed with respect to technical success, primary patency, primary assisted patency, and secondary patency.

Results143 endovascular intervention procedures were performed on 73 patients, 52 AVFs and 21 AVGs. Patients consisted of 60% men and 40% woman with a mean age of 64±17 years. The lesions intervented on were located at: inflow artery in 8 cases; juxta anastomotic vein in 23 cases; mid-vein in 19 cases; and out-flow stenosis in 28 cases. 40 among the total 143 procedures were transluminal angioplasty alone with plain and/or cutting balloon, and the rest of them were treated by combined procedures such as open thrombectomy in 38 cases, cutting balloon in 29 cases, stent in 6 cases, Adherent clot catheter in 5 cases, and Arrow Trerotola in 5 cases. The frequency of intervention performed to each patient ranged from once to 7 times: once for 46 patients; twice for 13 patients; 3 times for 13 patients; and 7 times for 1 patient. Technical success rate was achieved in 89.7%. Primary patency, primary assisted patency, secondary patency at one-year were respectively 56.4%, 24.4%, and 91.1%; and those at three-year 46.4%, 90.3%, and 61.1%.

ConclusionAggressive endovascular rescue procedures with various method are effective in restoring patency, and should be considered as a way to maintain arteriovenous access function for longer patency.

P09-32Paper No: 383Atypical presentation of Central Venous Occlusion (CVO) disease

Aizat Sabri I1, Rosnelifaizur R1, Azim I2, H Harunarashid2

1Department of Surgery, School of Medical Science, Universiti Sains Malaysia, Kelantan, Malaysia2Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Introduction Chylothorax is an accumulation of lymph (containing a great amount of lymphocytes, triglycerides, and chylomicrons) in the pleura due to the blockage of thoracic duct drainage. The etiology may be from either traumatic or non-traumatic causes (sarcoidosis, neoplasm, chest irradiation, SVO etc), however there also have been reported as idiopathic forms. Direct trauma and malignancy are the most common causes of the chylothorax in adult with reported incidence of 50% and 30% respectively. However, the central vein thrombosis as a cause of chylothorax is uncommon and only a few cases has been reported in literature. It was mainly related with central venous catheterization. We reported

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Poster Presentation

a case of end stage renal failure (ESRF) patient with a previous history of central venous cannulation before and presented with persistent unilateral chylothorax.

Abstract A 58 years old gentleman, a case of ESRF presented with recurrent shortness of breath, chesty cough and intermittent fever. He had a history of Right Internal jugular cannulation of venous access in 2012. Clinically, there were dullness on percussion up to midzone of right lung and reduce air entry on auscultation. Chest radiograph showed opacity of the right lung. Pleural drainage was inserted and the fluid was milky in nature. It was confirmed as chylothorax with presence of cholesterol in a pleural fluid analysis. Computed tomography of the thorax showed complete occlusion of the superior vena cava with an established collateral circulation. Lymphangiogram revealed lipiodol seen as opacified lymph node and lymphatic vessels until the level of T3 on the right and T5 on the left. There was no obvious lipiodol opacification seen at the region of the right thorax. Effusion was improved after the instillation of fibrinolytic agent and the chest radiograph showed improvement. ConclusionIn conclusion, the presence of unilateral chylothorax with the previous history of central venous cannulation before should raise a high clinical index of suspicion among the clinicians to alert more about the presence of SVO and it should be considered in the differential diagnosis of non-traumatic chylous pleural effusion.

P09-33Paper No: 384Saphenofemoral arteriovenous fistula as hemodialysis access: PPUKM early experience

Aizat Sabri I1, Rosnelifaizur R1, Azim I2, H Harunarashid2

1Department of Surgery, School of Medical Science, Universiti Sains Malaysia, Kelantan, Malaysia2Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

IntroductionThe biggest and difficult challenge in hemodialysis access is to maintain it over the time in the expanding number of patients with end-stage renal failure. There is little consensus discussed about the option available for small subset of patients repeated failures or unsuitable veins in published guidelines. So far, there have been few reports of saphenofemoral AV fistula (SFAVF) over the

last 10-20 years because of previous suggestion of poor patencies and needling difficulties. Here, we describe our early clinical experience with SFAVF. The function and patency rate of accesses appeared to be similar like other mature arteriovenous fistula in the short-term, although further longitudinal studies are required.

AbstractWe report 2 cases of saphenofemoral arteriovenous fistula in our centre.

Our first patient was 20 years old lady who known case of ESRF and had failed of right brachiobasilic arteriovenous fistula with complication of right central venous occlusion. With a good size of thigh vein and artery, the venogram of lower limb extremity shown normal variant of vein with no thrombosis, she subsequently subjected for right loop graft of saphenofemoral arteriovenous fistula. Operation uneventful. 3 weeks later the graft was infected and she subsequently planned for graft explantation together with native saphenofemoral AVF creation. Post-operative good thrill palpable and the fistula mature adequately. The patient has dialysed through the access for the past 27 months without any problems.

Our second patient was 36 years old gentleman who known case of gout, hypertension and ESRF in the past 11 years. He has been dialysed using right and left brachiocephalic and brachiobasilic fistula previously. Then he dialysed using right central permanent catheter. The CT venogram shown good patency and size of bilateral iliac and femoral vein. From the duplex scan shown long saphenous vein was in good patency and size. Hence he was subjected for SFAVF creation. Post operatively only seroma collection after 1 month of surgery and he has been used the graft for 2 years before he passed away because of severe pneumonia.

ConclusionSFAVF can be considered as a viable alternative assess for patients which left no more options for vascular access in upper limbs. With good technical skills, wide exposure and experience allowing efficient dialysis with good outcome, low morbidity and good patency in long term.

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P09-34Paper No: 405A pilot study into percutaneous angioplasty in venous outflow stenosis over a 4 year period

Ee Tan1, Yii M2

1Department of General Surgery, Monash Health, Melbourne, Australia2Department of Vascular Surgery, Monash Health, Melbourne, Australia

BackgroundThis pilot study aims to investigate the 48-month assisted patency of fistulas post-percutaneous angioplasty for treatment of venous outflow stenosis.

MethodsThis is a retrospective cohort study that includes adult patients within the Renal Unit in a tertiary undergoing percutaneous angioplasty. Basic demographics including age, gender and aetiology of renal failure were recorded. Follow-up period was 48 months with death of patients included in the study.

ResultsThere are 63 patients included in the study. There were 18 forearm (radio-cephalic) fistulas and 46 upper arm (brachio-cephalic, brachio-basilic and loop graft) fistulas. Assisted patency for fistulas at the 12-month were 73% but declined to 28% at the 48-month mark. Without further percutaneous angioplasty, most fistulas often develop another stenosis requiring treatment within the 12-month period. Only 12% of all fistulas maintained patency throughout the 48-month period. A third of the population died during this studied period.

ConclusionMaintaining the patency of arteriovenous fistulas in haemodialysis patients is a significant challenge to clinicians. There is a modest benefit in treating venous outflow stenosis using percutaneous angioplasty in the 12-month period.

P09-35Paper No: 429Efficacy of creation of arteriovenous fistula by transposition technique for the patients with poor upper arm condition

Masaru Kimura, Daisuke Akagi, Masaya Sano, Kazuhiro Miyahara, Jun Nitta, Akihiko Seo, Yoshihisa Makino, Masamitsu Suhara, Atsushi Akai, Toshio Takayama, Kota Yamamoto, Katsuyuki Hoshina, Toshiaki WatanabeDivision of Vascular Surgery, The University of Tokyo, Bunkyo-ku, Tokyo, Japan

BackgroundWe sometimes found it difficult to create the arteriovenous fistula (AVF) in the upper arm with poor condition, such as abolished superficial veins, small brachial arteries, and history of the vessel occlusion. To avoid using prosthetic graft which have possible risk of infection and occlusion in the short term, we sometimes create AVF via transposition technique (tAVF).

Methods and ResultsWe performed the tAVF by one-stage transposition when we use the basilic vein, and by two-stage when we use the brachial vein. For one-stage, we transposed the vein through a subcutaneous tunnel and created AVF. For the two-stage, we create the AVF with brachial artery and vein first, followed by transposition of the developed vessel 1 or 2 months later.

This research is a retrospective review by medical records at the University of Tokyo Hospital from April 2011 to December 2016. Among the AVF creations of all the 176 cases, there were 7 tAVF cases. The comorbidities of these 7 cases included post cardiac transplantation with immunosuppressant agents, rheumatoid arthritis, malignancy, aplastic anemia, liver cirrhosis and prior AVG infection. There were 3 cases of one-stage transposition (2 males and 1 female, average 60 years) and 4 cases of two-stage (all females, average 59 years). The average of observation periods was 9 months (range; 3-26 months). One patient of one-stage showed the occlusion of the AVF 3 months after the surgery. Although two cases required re-intervention, all the other tAVFs were patent so far. There were no cases of infection.

ConclusionThe outcome of tAVF procedures should be acceptable, considering the patients’ backgrounds with high risks and the poor upper arm conditions.

P09-36Paper No: 434Modified MILLER procedure using ultrasonography on patient with venous hypertension: A case report

Kevin Ardito Prabowo1, Niko Azhari Hidayat2

1Medical Student, Airlangga University, Surabaya, Jawa Timur, Indonesia2Thorax, Cardio & Vascular Surgeon, Universitas Airlangga Hospital, Surabaya, Jawa Timur, Indonesia

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BackgroundArteriovenous fistula creation is a vital step in treatment process for patients with end-stage renal disease. A number of complications may occur after its creation, with venous hypertension being one of them. MILLER procedure, originally devised for correction of DASS (dialysis-associated steal syndrome) and high flow, can be used to treat such condition. It has been proved to be an effective and durable option for treating dialysis access-related steal syndrome and high-flow associated symptoms. However, the original MILLER procedure requires angiography to visualize the AV fistula body, to help in access gaining and the selection of the banding site. Angiography requires modern, high-priced imaging products such as C-arm fluoroscopy machine, which is not conventional for developing countries such as Indonesia. Therefore, a slight modification is needed to allow MILLER procedure operable in more health facilities in Indonesia.

MethodA 46-year-old male patient with peripheral venous hypertension due to AV fistula were treated in our hospital. Modified MILLER procedure using Color Doppler USG as a guiding device was performed to control the venous flow rate and preventing any further complications. Technical success was achieved when a band was created and the patient underwent at least one successful hemodialysis.

ResultA satisfactory result was achieved. Target venous flow rate reduction by more than 50%, from initially 3800 ml/min to 1600 ml/min, was attained. There were not any complications occurred. Successful hemodialysis treatments were done in the following weeks.

DiscussionWriter is proposing the usage of ultrasonography in exchange of angiography. Color Doppler USG is a noninvasive method widely used for the diagnosis of vascular diseases because of its acceptable accuracy in detection of vascular lesions. It is relatively less aggressive and less expensive as a bedside method compared to angiography, in which contrast has to be injected. Moreover, angiography fluoroscopy machines emit radiation which might harm the patient and health workers in long-term use.

ConclusionColor Doppler USG may be considered as an effective and safe alternative for vascular guiding in MILLER

procedure, particularly in countries or areas with limited facility.

P09-37Paper No: 451To evaluate the early post operative predictors using Duplex Ultrasound scan for maturation of Arterio-venous fistula (AVF)

Krunal Gohil, Bhavin Ram, Rajesh S, Robbie GeorgeNarayana Institute of Vascular Sciences, Narayana Health, Karnataka, India

BackgroundTo evaluate the early post operative predictors using Duplex Ultrasound scan for maturation of Arterio-venous fistula(AVF).

MethodsA prospective cohort study was conducted for a year. During the period 152 native fistulas were created, 33 fistulas failed either on table or in immediate post-operative period before the first visit while 25 patients defaulted on follow up. Data for the remaining 94 patients was analyzed. 47 underwent RC (Radio cephalic) AVF, 44 were BC(Brachiocephalic) AVF and 3 were Brachio-basilic AVF (BVT Stage 1). All clinically working fistulas were evaluated for vein diameter, flow volume in vein and brachial artery, flow rates in brachial artery and spiral laminar flow with duplex scan at 2-5 days post operatively and 6 weeks follow up. This data was analyzed keeping maturation of AVF as outcome. Maturity was defined as achievement of at least 3 successful dialysis sessions.

For analysis Shapiro wilk test was used for normality, Students t-test, Mann Whitney test, Chi square and fisher exact test were used as appropriate. P.

ResultsAmongst 94 AVF, 17 RC AVF failed to mature and none of the working BC /BVT AVF at 2-5 days follow up failed to mature. We found that an RC AVF with diameter of >4.7mm, flow volume of >480ml/min in vein, >568ml/min in brachial artery and flow rate of >180cm/sec in brachial artery at 2-5 days follow up was associated with a 90% chance of successful maturation and cannulation. Conversely an RC AVF with vein diameter of.

ConclusionThe early duplex scan in RC AVFs may assist in selection of patients who may benefit from early interventions to augment the fistula or look for an alternative access rather than the usual 6-8 week wait. A clinically

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functional BC/BVT stage 1 at 2-5 days can be expected to mature without intervention.

P09-38Paper No: 472Transposed femoral vein arteriovenous fistula: Chiang Mai experience

Kittipan Rerkasem1,2, Saranat Orrapin1

1Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand2NCD Centre of Excellence, RIHES, Chiang Mai University, Chiang Mai, Thailand

BackgroundNKF-KDOQI guideline suggests native fistulae rather than synthetic graft but there is little consensus about the most appropriate access options in patients with repeated access failure and unsuitable vein. Femoral vein transposition (tFV) was offered for our patients with such problem. MethodtFV was carried out in 16 patients in our center. Inclusion criteria was patients with bilateral central vein occlusion and/or lack of suitable arm vein. Before offering all patients met these conditions: good pedal pulse (ankle brachial pressure index >0.9) No history of DVT or severe chronic venous disease (C2-C6) in the leg and no iliac vein stenosis. In patients with history of femoral cannulation, venogram was performed to confirm patency of central vein. Operation was done under spinal block. The superficial FV was dissected from adductor canal up to confluence of common femoral vein. Then it was divided and connected to superficial femoral artery. This study was supported by the Health Systems Research Institute. ResultThere were 16 patients. In perioperative period, there was no death, no heart failure, no compartment syndrome and no steal syndrome. Also there were no DVT- no chronic venous insufficiency (C4-6). During follow up period (3 months to 5 years) there was 3 patients need intervention. One case AVF stenosis close to the anastomosis, which repaired by using synthetic graft. AVF stenosis was found in another case close to common femoral vein due to muscle entrapment and the patch angioplasty was performed. One case with massive edema due to iliac vein stenosis. This case needed AVF ligation. S

ConclusiontFV is an excellent vessel to use in HD. The diameter is 6-8mm for an adult, and the wall is thick. Low risk of infection, reasonable long term patency. It should be reserved for good risk patients who have exhausted other autogenous option.

P09-39Paper No: 342Developing a scoring system of predictive successful arteriovenous fistula access in hemodialysis patients: Single center experience

Ayudika M1, Puruhito2

1Department of Surgery Division of Cardiothoracic and Vascular Surgery School of Medicine Sumatera Utara University - Sumatera Utara University Hospital Medan, Indonesia2Department of Surgery Division of Cardiothoracic and Vascular Surgery School of Medicine Airlangga University - Dr. Soetomo General Hospital Surabaya, Indonesia

BackgroundHemodialysis needs a vascular access. Fistulas are the preferred permanent hemodialysis vascular access but the failure rates are still high. This study aimed to (1) identify preoperative clinical characteristics that are predictive of successful AV fistula access and (2) use these predictive factors to develop and validate a scoring system to stratify the success rate for AV Fistula.

MethodsThis is a prospective analysis of gathered data using consecutive sampling technique. From a derivation set of 254 patients who had a first fistula created, 178 patients undergone radiocephalic AV fistula and 76 undergone brachiocephalic AV fistula. Scoring system was created using multivariate stepwise logistic regression. Than the study was validated by applicating the scoring system to the radiocephalic AV fistula data.

ResultsThere were 2 demographic data was made, but only radiochephalic AV fistula that can proceed to make the scoring system. There were 11 predictors that we collect but only 4 have statistical value (P < 0.1) to continue to make a score and the final result we succeed to develop a scoring system and tried to applicated it to the data. The total score are 5 with the description: 0 - 1 low risk, 2 - 3 moderate risk, and 4 - 5 high risk.

ConclusionsThis pilot study was success to make a score called PAVAS score, but still need further study to prove the sensibility

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and specificity and also need a larger population to complete the scoring system.

Keyword: Scoring System, AV Fistula

Varicose Vein & Chronic Venous Diseases

P10-01Paper No: 008Preservation of the renal function in surgical resection for Leiomyosarcoma of the Inferior Vena Cava involving renal veins

Yuehong Zheng, Duan LiuDepartment of Vascular surgery, Peking Union Medecal College Hospital, Shuaifuyuan Wangfujing Dongcheng District, Beijing,China

BackgroundPrimary leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare entity for which en bloc resection offers the only chance of cure. Right nephrectomy was usually performed because reconstruction of the right renal vein represents surgical challenge. The purpose of this study was to show our experience in preserving the renal function in the radical resection of LMS involving the renal veins at a single institution over a 4-year-period.

Patients and MethodsFrom May 2009 to July 2015, six patients (4 females, 2 males, median age 48.5 years) with LMS of the IVC were reviewed. Data of patient details, preoperative preparation, surgical procedures, postoperative recovery and follow-up results were obtained and retrospectively reviewed.

ResultsFive of the six patients were identified as a tumor localized in IVC and the other was only diagnosed as ‘retroperitoneal mass” before operation. The renal vein confluence was involved in each case through CT examination and operative check. Everyone underwent radical en bloc excision of the tumor without further postoperative radiotherapy. Nephrectomy was performed only in the one patient who was diagnosed as ‘retroperitoneal mass” before operation. At a median follow up of 30.5 months, local recurrence, distant metastases, and survival rate were 0, 0, and 100%, respectively.

ConclusionBy recognizing the collateral run-off from kidney preoperatively, prolonged and super selective renal arteriography is an efficient way to assess whether

ligation of the right renal vein without reconstruction is feasible. And the reserved renocaval conjunction is a convenient and effective portion for reconstruction of the renal vein and IVC simultaneously.

P10-02Paper No: 020Holistic management of venous ulcers especially with endovenous laser treatment using 980nm laser in an ethnically diverse society

Murli Naraindas Lakhwani1, Toong Chow Lee2, Mei Lee Beh3

1Department of Surgery, Penang Adventist Hospital, Penang, Malaysia2Gleaneagles CRC, Gleaneagles Medical Centre, Penang Malaysia

Chronic venous ulcers usually occurs as an occupational hazard occur due to venous insufficiency with venous hypertension and is more common in older age. 145 lower limbs with venous ulcers involving reflux of the great saphenous (132 cases) and/or small saphenous veins (57cases) underwent endolaser vein treatment (EVT) with 980 nm diode laser for single (123 cases) or both legs (11 cases) intervention. Supplementary procedures required multiple avulsions and or sclerotherapy. Holistic advice of graduated compression stockings, weight reduction, and life-style changes enforced. The Chinese (84 cases) were the most affected group followed by the Indians (51 cases) and Malays (7 cases). The average age with venous ulcers was 53.6 years with a peak age incidence in the 50-89 years skewed to females. The mean BMI was 26.8. The Chinese, Indian and Malay BMIs were 25.1, 28.1 and 31.3 respectively. Of the occupations involved by race, the Chinese were mostly salespersons, Indians blue collar workers and Malays, food-related workers. Medial malleolar (73.8%) and lateral malleolar (15.2%) ulcers were commonest. Most ulcers 34.5% were less than 1cm while 29.0% measured 1-2cm. Gram negative organisms 63.4% and gram positive organisms 36.6% were the isolated from the ulcers. Results of EVT in healing ulcers with no recurrence more than 2 years were successful in 89.7.0% (130/145). Complications included numbness foot 7.5% and deep venous thrombosis 1.4%. 10.3% (15 cases) had recurrence of venous ulcers within 2 years following treatment either at new (5 cases) or same old sites (10 cases). In terms of satisfaction 32.3% expressed as very satisfied while 63.4% were satisfied and 4.3% were unsatisfied. In conclusion, endolaser vein treatment is a useful modality in managing occupation-related venous ulcers non-invasively.

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P10-03Paper No: 050The impact on residual venous reflux and varicose veins on the development of reccurent vericose vein after 5 years follow up for primary varicose vein

Tomohiro Ogawa, Shunichi HoshinoCardiovascular Surgery, Fukushima Daiichi Hospital, Fukushima, Japan

BackgroundThe rate of recurrent varicose vein is high in the long term follow up after both surgical stripping and endovenous ablation of saphenous vein for primary varicose vein. The venous reflux sites of recurrent varicose vein is identified, however, fundamental reasons of recurrent varicose vein are still unclear. This study was conducted to identify the impact of residual venous reflux and varicose veins at post-operative early periods for recurrent varicose veins after saphenous ablation with phlebectomy of varicose veins.

Material and methods484 (595 legs) consecutive patients (C2:230, C3:137, C4a:82, C4b:27, C6:8) underwent saphenous ablation (High ligation + stripping: 343 legs or Endovenous ablation: 252 legs, all endovenous ablations were performed using 980 nm diode bare fiber laser) with phebectomies for primary varicose veins from 2009-2010 were included in this study. Ablation was performed of 538 great saphenous veins and 57 small saphenous veins.

The patients underwent clinical assessment and duplex ultrasound scanning for venous reflux before surgery and 1month and 5 years after surgery. 31% cases had complete follow-up up to 5 years after surgery, while 69 % of the cases lost to follow-up after 1 month operation were interviewed for varicose veins by phone at 5 years post operation.

Results378 of 595 legs had venous reflux or residual varicose veins at postoperative 1 month (Residual varicose vein without detection of venous reflux: 39 legs, Saphenous venous reflux alone: 273, Saphenous + deep venous reflux: 20, Deep venous reflux alone 46). 27.5 % of legs with venous reflux and residual varicose veins at post-operative 1 month were diagnosed recurrent varicose vein until post-operative 5 years. However, 5.5 % of legs without venous reflux and residual varicose veins at post-operative 1 month were diagnosed recurrent varicose vein.

ConclusionsPersistent and residual venous reflux and varicose veins after saphenous ablation become a big risk of recurrent varicose vein.

P10-04Paper No: 065Analysis of factors that associated with the ‘phlebitis like abnormal reaction’ after VenaSeal TM system

Insoo ParkCharm Vein Center, Seoho-medical Building, Bongcheon-ro, Gwanak-gu, South Korea

VenaSeal TM system, Cyanoacrylate closure, for the treatment of incompetent saphenous veins is a effective technique. However, ‘phlebitis like abnormal reaction’ were reported in about 10% of treated patients and the mechanisms are not identified yet. We analyzed that the groups with female, GSV, low BSA and bilateral treatment showed significant higher rate of ‘phlebitis like abnormal reaction’.

P10-05Paper No: 0766 months short term results of VenaSeal TM system for the treatment of incompetent 37 SSVs

Insoo ParkCharm Vein Center, Seoho-medical Building, Bongcheon-ro, Gwanak-gu, South Korea

We report the 6 months short term results of VenaSeal TM system, Cyanoacrylate closure, for the treatment of incompetent small saphenous veins(SSVs). 32 patientss with 37 incompetent SSVs were treated. Closure rate were 100%, 97.3% and 97.3% at 1 month, 3 months and 6 months. No major complications were occured. Cyanoacrylate closure, VenaSeal TM system, is a effective treatment for the incompetent SSVs.

P10-06Paper No: 095Early experience of endovenous laser ablation (EVLA) for superficial vein incompetence

Tatsuya Kaneshiro, Toshimi Yonaha, Hideyoshi HenzanDepartment of Vascular surgery, Nakagami General Hospital, Okinawa, Japan

BackgroundSuperficial vein incompetence in the lower extremity is one of most commonly encountered diseases. Recently, minimally invasive surgery, including endovascular

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thermal ablation with laser or a radiofrequency energy source, and sclerotherapy have replaced traditional open surgery. We report the early results of endovenous laser ablation (EVLA) for superficial vein incompetence at a single hospital.

MethodsA total of 166 consecutive patients (203 legs) were treated between September 2013 and January 2017 (3.5 years). All patients received 980-nm laser ablation (ElVeSR) with a bare-tip fiber. The mean patient age was 63.5±12.1 years. There were 57 men and 109 women, with 203 affected legs including 177 great saphenous veins, 20 small saphenous veins, and 6 accessory saphenous veins. We investigated the CEAP (clinical, etiological, anatomical, and pathological) classification, length of ablation, number of incisions of varicectomy, transition of vein diameter, recurrence, and complications.

ResultsThe mean follow-up duration was 4.7 ± 2.5 months (range: 1 day to 12 months). The clinical classifications were as follows: C2, 94 legs (46.3%); C3, 24 legs (11.8%); C4a, 59 legs (29.0%); C4b, 15 legs (7.3%); C5, 3 legs (1.4%); and C6: 8 legs (3.9%). The preoperative mean vein diameter was 6.5 ± 1.5mm. The mean diameter of treated veins was 4.9 ± 1.1 mm after 1 month and 2.0 ± 0.5mm after 6 months. The mean length of treated veins was 29.5 ± 11.0 cm. The occlusion rate was 100%, and no recurrence was observed. Varicectomy was performed in 85.2% of cases at the same setting, and the mean number of incisions was 4.2 ± 2.9 (range 0-15). Complications included endovenous heat-induced thrombus (EHIT) class 1 (23.1%), EHIT class 2 (9.8%), EHIT class 3 (0.4%), bruising (24.6%), and thrombophlebitis (19.7%). Only one patient with EHIT class 3 required anti-coagulation therapy. No deep vein thrombosis and pulmonary embolism were observed.

ConclusionWe report the early results of EVLA at a single hospital. Although there were some complications including EHIT, bruising, and thrombophlebitis, no recurrence was observed.

P10-07Paper No: 141EVLA with radial fiber for branch varicose vein

Yongbeom Bak1, Jinwon Jeon1, Jilan Zhang1, Byeongwan Kang2, Hyeongdong Do2

1Cheongmac Vascular and Vein Clinic, Bukgu, Busan, South Korea2Cheongmac Vascular and Vein Clinic, Namgu, Ulsan, South Korea

BackgroundAfter first endovenous laser ablation (EVLA) for varicose vein, the technology of equipment (generators, fibers etc) has been improved.

So EVLA can be standard treatment modality for varicose vein.

But unfortunately EVLA is usually used in the straight truncal vein.

Tortuous varicosities are treated with phlebectomy or sclerotherapy.

The main causes of this restriction are anatomy and physical characteristics of laser and fiber.

But more efficient laser wavelength and different type fibers have been developed.

And they can reduce the emitted laser power and make low complication rate.

We did EVLA with radial fiber at tortuous branch varicose vein and share the results.

MethodFor 1 year, from December 2015 to November 2016, we did 1,470nm laser EVLA with radial fiber in 181 patients who had 338 tortuous branch varicose vein.(clinical stage>C2).

Follow up period was from 6 to 12 months.

Recurrent and secondary varicose vein were excluded.

ResultsMain truncal veins were treated at the same time.

The laser power for branch varicose vein was 6W and linear endovenous energy density (LEED) was 13.4J (6J~24J).

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The operating time per branch varicose vein was 8.7 minutes (3~25).

As early complications, there were 5 cases of painful phlebitis which had preoperative diameter over 8mm and intraoperative LEED over 18J. 1 case of paresthesia occurred (BMI 18.7kg/m2) and it lasted more than 12 months.

At 1 month most of patients had cord formation but usually disappeared within 6 months without extra treatment.

14 recanalization were found. 11 EVLA and 3 sclerotherapy were done for them.

ConclusionTortuous branch varicose vein can be treated with EVLA using radial fiber with low major complications.

P10-08Paper No: 171Food consumption on patient with varicose veins at Maharaj Nakorn Chiang Mai hospital in Thailand

Kanokwan Kulprachakarn1, Orapin Pongtum1, Paweena Thongkham1, Suwinai Saengyo1, Apinya Suwannasaen1, Kittipan Rerkasem1,2,3

1NCD Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand2Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand3NCD Center of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand

BackgroundAlthough the risk factors determine varicose vein like female hormone intake was well established, but the nutritional association has never been investigated properly. The aim of this study was to investigate the impact of various food intake on varicose veins patients at Maharaj Nakorn Chiang Mai hospital in Thailand.

MethodsA cross-sectional study was conducted between December 2012 and November 2014. Patients at out-patient department (OPD) 101 at Maharaj Nakorn Chiang Mai hospital, Chiang Mai, Thailand, aged > 18 years were invited to be concerned in this study. Patients were questioned about their demographic data, frequency of meat consumption and physical measurement for the varicose veins according to CEAP classification (C:Clinical, E:Etiological, A:Anatomical and P:Pathophysiological, respectively).

ResultsA total of 558 eligible outpatients were recruited for the study. The most of patients were females (78.9%) and aged >50 years (47.1%). The average of body weight, height and body mass index (BMI) were 58.8±11.5kg., 158.1±7.2cm. and 23.5±4.0, respectively. 17 patients out of 558 were diagnosed with high severity of varicose veins (C3 to C6=3.14%). We also found that the percentage of C3 to C6 was more than C0-C2 in those patients who were over 50 years old (94.1%, P=0.001), high body weight and BMI (73.8±13.9 kg. and 28.8±4.4, P=0.000). About meat consumption, only chicken intake demonstrated the different association with varicose veins. Interestingly, patients with regularly consume chicken had the lower risk of varicose veins than those patients who sometimes or never consumed chicken (51.2%, 40.1% and 8.7%, P=0.022).

ConclusionPeople who consumed chicken regularly may have a lower chance of advance chronic venous diseases.

P10-09Paper No: 197Mid-term results of endovenous laser ablation for the treatment of varicose veins

Atsushi Tabuchi1, Yasuhiro Yunoki1, Yoshiko Watanabe2, Kazuo Tanemoto1

1Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan2Department of First Physiology, Kawasaki Medical School, Kurashiki, Okayama, Japan

Background and ObjectivesWe evaluated the mid-term surgical outcomes, improvements in subjective and objective symptoms of varicose veins, and changes in venous function after endovenous laser ablation (EVLA) using a 980-nm diode laser.

MethodsBetween October 2011 and December 2016, 964 limbs (706 patients) were treated for incompetent saphenous veins at our institution. We studied the operative complications, venous clinical severity score (VCSS), and surgical outcomes of the treated limbs. We assessed saphenous vein occlusion, endovenous heat-induced thrombus (EHIT), and deep vein thrombosis (DVT) using duplex ultrasonography and measured venous filling index (VFI) using air plethysmography, preoperatively and 1, 6, 12, 24 and 36 months postoperatively.

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ResultsThirty-six months after surgery, the technical success rate (cumulative occlusion rate) was 99.1%. Although EHIT occurred in 5.8% of limbs, class 3 EHIT occurred in only 1.3% and all cases were recovered 6 months postoperatively. Severe complications such as DVT and skin burns were not observed. The mean preoperative VCSS was 5.3 ± 2.2, and this value improved to 1.9 ± 1.1 at 1 month, 0.6 ± 1.0 at 12 months, and 0.7 ± 1.0 at 36 months postoperatively. The mean preoperative VFI was 6.3 ±4.4 mL/s, and this value improved to 2.2 ± 1.5 mL/s at 1 month, 2.4 ± 1.7 mL/s at 12 months, and 2.6 ± 1.9 mL/s at 36 months postoperatively. At 36 months after EVLA, the mean VCSS and VFI values were significantly lower than the preoperative values.

ConclusionsEVLA did not cause severe complications, and good surgical outcomes were obtained. VCSS and venous function were significantly improved at 36 months postoperatively. EVLA is a safe and effective treatment for incompetent saphenous veins.

P10-10Paper No: 213Treatment of acute venous thromboembolism with direct oral anticoagulants or vitamin K antagonists

Yuka Sakurai, Hiroyuki Abe, Satoshi Kinebuchi, Shota Kita, Hirotoshi Suzuki, Daijyun Ro, Tokuichirou Nagata, Kiyoshi Chiba, Hirokuni Ono, Makoto Oono, Chikada Masahide, Hiroshi Nishimaki, Takeshi MiyairiSt Marianna University School of Medicine, Kasasaki, Kanagawa, Japan

BackgroundIn the past, unfractionated heparin and warfarin requiring dose adjustments were used as anticoagulants for treatment of venous thromboembolism (VTE) in Japan. Direct oral anticoagulants (DOAC), including direct anti-Xa and thrombin inhibitors, have recently been introduced and may have advantages over vitamin K antagonists such as warfarin.

Patients and methodsWe report our experience in the treatment of acute VTE with direct oral anticoagulants (DOACs) and vitamin K antagonists in the last 7 years. They are also the patient to whom foreignness is going regularly at present. We used edoxaban, apixaban, and rivaroxaban as DOACs and adjusted the internal doses in accordance with the patients’ weights and kidney functions. The condition of

the patients with vitamin K antagonists were controlled, with target international normalized ratios (INRs) ranging from 1.5 to 2.0.

ResultsOf the 21 patients, 11 had deep-vein thrombosis (DVT) and 10 had DVT and pulmonary embolism (PE). Six patients had DOACs, and 15 had vitamin K antagonists. The period of service was set to 3 months in accordance with a guideline. One patient had bleeding as an adverse event caused by the vitamin K antagonist, and another had rascality and vomiting caused by edoxaban.

ConclusionThe DOACs and vitamin K antagonists had similar efficacies in the treatment of acute symptomatic deep-vein thrombosis and PE. Treatment with DOACs was associated with a significant reduction in major bleeding, intracranial bleeding, and fatal and clinically relevant nonmajor bleeding rates. The suitability of these drugs in fragile patients has not been established. Therefore, further studies are required to increase the usefulness of DOACs in the treatment of VTE.

P10-11Paper No: 222Early outcome of endovenous radiofrequency versus laser ablation for treatment of varicose vein: Single center experience from mid indonesia region

Ivan Joalsen1, A Prasetyo U2

1Division of Cardiothoracic and Vascular Surgery, Mulawarman University - Abdul Wahab Sjahranie General Hospital, Samarinda, East Borneo, Indonesia2Division of Cardiothoracic and Vascular Surgery, Mulawarman University - Abdul Wahab Sjahranie General Hospital, Samarinda, East Borneo, Indonesia

BackgroundEndovenous laser therapy (EVLT) and radiofrequency ablation (RFA) are minimally invasive percutaneous endovenous techniques for ablation of the incompetent great saphenous vein (GSV). East kalimantan was the first area in Mid Indonesia Region that use these alternatives methods for treatment of varicose vein.

PurposeTo compare the early outcome between endovenous radiofrequency and laser ablation of varicose vein patient in Abdul Wahab Sjahranie General Hospital, Samarinda, East Kalimantan.

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MethodsDuring period of April 2015 up to March 2017, Endovenous Ablation was performed on 43 limbs in 36 patients. Of 43 limbs, there were 14 limbs (0.33%) in C2; 21 limbs (0.49%) in C3; 5 limbs (0.12%) in C4; 3 limbs (0.06%) in C6. RF ablation with the closure system was performed on 23 limbs and the rest of 20 patients were treated by using a 1410 nm laser ablation. We analyze the outcome after 1 month post-operatively such as: recanalisation/occlusion rate; the improvement of Revised of Venous Clinical Severity Score (VCSS); the improvement of the pain; and the complication between these two procedures.

ResultOcclusion of the GSV at 1 months was 100% in both groups. There were also no deep vein thrombus and endothermal heat induced thrombosis (EHIT) in both groups. There were a significant improvement of revised VCSS between two groups (p=0.047) after 1 month post operatively: RFA (Mean Revised VCSS pre-operatively was 8.61; post-operatively was 2.30); EVLA (Mean Revised VCSS pre-operatively was 6.30; post operatively was 1.50). There was no significant difference in pain scoring assesment between two groups (p:0.47) The overall complication rate were 11.6% (8.6% in EVRFA and 15 % in EVLA) and included hematoma in 1 pts, erythema in 1 pts (2 pts in RFA group); hematoma in 3 pts (3 pts in EVLA group).

ConclusionThere was no significant difference result between Endovenous Radiofrequency or Laser ablation for treatment of varicose vein. Both methods offered a good result and less complication in our population. Long term follow up are required to confirm the durability of these procedures.

KeywordsVaricose vein, endovenous treatment

P10-12Paper No: 233The first human use of polidocanol endovenous microfoam (Varithena) for saphenofemoral trunk lower limb varicose veins in Asia

Mingli LiCardiovascular division of Surgery, China Medical University Hospital, Taichung, Taiwan

BackgroundUltrasound-guided foam sclerotherapy (UGFS) is an effective and recommended alternative treatment for

trunk varicose vein if patients deferred endovenous laser or radiofrequency therapy. A new commercially available polidocanol endovenous microfoam, VarithenaR (BTG international ltd., UK ) has been imported into Taiwan for compassion use of certain patients this May. Herein, we reported our primitive experience of this new product.

MethodTotal 6 patients with symptomatic or complicated lower limb trunk varicose vein applied for compassion use of this new product this May. The preoperative CEAP, AVVQ, VCSS, sonography and appearance pictures were recorded. All patients were treated on supine position with ultrasound-guided puncture of greater saphenous vein distal to diseased segment with two to three intravenous catheters (18Gx1.88IN, BD, Sandy, Utah, USA) and scalp needles (23G, JMS, Singapore). The leg was raised to a 45 degree angle. The trunk varices and big branch varices were treated from proximal to distal. The form was constrained to the treated vein by manual compression at groin and vein segment distal to injection site for 3-5 minutes till no foam flowing in the treated segment by ultrasound. Total 15ml Varithena foam was injected via these preset catheters. The transthoracic echocardiography was monitored throughout whole procedures to detect the bubble volumes in heart chambers. The treated veins were compressed with cotton tubular bandage-covered bubble wrap rolls, cohesive bandages and Class II compression hosiery for 48 hours followed by 2 weeks of Class II compression hosiery in daytime.

ResultsThe patients were followed up regularly on postoperative day 3 and 10 for additional sclerotherapy for tributaries as necessary. The ecchymosis, pain scores and duplex ultrasound were recorded. The primitive follow-up showed promising results with accurate closure of saphenofemoral junction under duplex ultrasound. The VCSS and AVVQ life quality scores and duplex ultrasound sapheno-femoral junction closure rate will be surveyed on postoperative 90 days and 180 days.

P10-13Paper No: 243Initial experience of saphenous vein sparing surgery for chronic venous insufficiency in Korea

Dong Jae Jeon1, Sangchul Yun1, Miok Hwang2

1Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, South Korea2Thrombosis clinic, Soonchunhyang University Seoul Hospital, Seoul, South Korea

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ObjectiveThis study evaluated initial experience of conservative hemodynamic treatment for venous insufficiency in Korean population.

MethodFrom February 22 to October 31, 2016, 95 lower limbs in 64 patients were treated with CHIVA procedures. Patients had clinical follow up visit, including Doppler ultrasound examination 1 week, 1month, 3months and 6 months after operation. One month after operation, 18 patients (28.1%) was lost to follow up, total 67 lower limbs in 46 patients (71.8%) were followed up and included to assess the clinical effectiveness and the safety of CHIVA procedure.

ResultsAmong 67 lower limbs in 46 patients, shunt type was distributed as type I 4 (5.9%), type I+II 18 (26.9%), type II 13 (19.4%), type III 32 (47.8%), type IV 1 (1.5%), and type V 5 (7.5 %), type VI 3 (4.5%). 38 CHIVA I and 26 CHIVA II (1st stage) procedure was performed. The procedure included 1 pelvic point ligation, 17 SFJ ligation, and 11 SPJ ligation. There was a statistically significant reduction in the mean vein diameter at the SFJ postoperatively (7.8 ± 2.4 mm to 6.0 ± 1.8, p=0.000). Similarly, significant mean diameter reduction was found in the GSV at middle thigh level (5.5 ± 1.3 mm to 4.3 ± 1.2 mm, p=0.000). The mean diameter of the SSV was also significantly reduced (5.4 ± 1.3 mm to 3.2 ± 1.6 mm, p= 0.000). Venous clinical severity score (VCSS) was improved significantly after operation (5.3 ± 3.1 to 1.8 ± 1.6, p=0.000). Venous refill time was also improved with significance (8.4 ± 5.2 sec to 14.6 ± 8.6 sec, p=0.004). Postoperative complications was 1 recurrent reflux from saphenous ligation, 1 itching sensation, 10 focal thrombosis at GSV, 1 long segment thrombosis at GSV, 1 ecchymosis, 1 wound infection and 1 numbness.

ConclusionCHIVA procedure was seems to be feasible and acceptable for varicose vein treatment.

P10-14Paper No: 249Varicose vein among nurses in Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand

Prakaydao Abkom1, Orapin Pongtam2, Paweena Thongkham2, Kittipan Rerkasem1,2

1NCD Center of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand2NCD Center Faculty of Medicine, Chiang Mai University, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand

BackgroundVaricose vein is very common in nurse. Interestingly operating room (OR) nurses are expected to have high prevalence of varicose vein because of long standing hours in OR. We wonder whether the prevalence of varicose vein in OR nurse was higher than non OR nurses.

MethodsIn this cross-sectional study was performed between June 2013 and May of 2013. The study population were non OR nurses and OR nurses at Maharaj Nakorn Chiang Mai. Data was collected by questionnaire. The first section of questionnaires were about personal characteristics, risk factors and history of chronic venous disease. The second section of questionnaires were about quality of life by using ChronIc Venous Insufficiency Questionnaire-14 (CIVIQ-14). The physical examination was performed by the investigators for the varicose vein based on the clinical finding using CEAP standards (C: Clinical, E: Etiological, A: Anatomical, P: Pathophysiological). Descriptive statistics of continuous variables were presented using mean±standard. Categorized variables were presented using n percent. Differences between two groups were analyzed with Chi-square or T-test/Mann Whitney U test. This study was supported by Chiang Mai University.

ResultsA total of 222 nurses participated were females (94.1%), aged between 41 and 50 years (37.60%), non OR nurse (55.4%) and OR nurses (44.6%). Regarding to severity of varicose vein (CEAP) in nurses, the most frequent stage was C1 (66.5%), C0 (20.8%) and C2 (12.7%). The prevalence of C0, C1. C2 was significantly different between two groups (P=0.000). The prevalence of C1 in non OR nurses and OR nurse was 72.1 and 59.6% respectively, whereas the prevalence of varicose vein (C2) in non OR nurse and OR nurse was 16.4 and 8.1% respectively. However, the quality of life was not significantly different (85.66 ± 12.04; P=0.962) between two groups.

ConclusionsThe results suggested that prevalence of varicose veins (C2) in non OR nurse seems higher than than OR nurse but the quality of life was not difference between two groups.

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P10-15Paper No: 277Comparison between deep, superficial and combined venous system insufficiency: A 6 -year single center experience

Cristina Marie Lajom, Josefino Sanchez, Dana RubianoDepartment of Surgery, University of Santo Tomas Hospital, Manila, Philippines

Chronic venous insufficiency (CVI) is a common problem worldwide with a vast clinical spectrum. Since early times, CVI have caused stasis ulcers that significantly impact the quality of life (QOL). Several methods have been described for preventing or treating these ulcers and aims to eliminate pathological refluxes, avoiding long-term complications of CVI, and improving disease-related QOL. The objective of this study is to describe the outcome of patients who underwent surgical treatment of chronic venous insufficiency with superficial, deep and combined venous insufficiency.

This is a retrospective study where a review of medical records for 6 years was done from January 2011 to December 2016 at the University of Santo Tomas Hospital under a single surgeon. A total of 75 patients were included with a mean age of 60 years old. All patients underwent venous duplex scan and operation done were EVLT (66.60%), Vein Stripping (29.3%), stab phlebectomy (32%), and wound debridement (4.3%). All patients were found to have superficial venous insufficiency (SVI) with concomitant deep venous insufficiency (DVI) in 53.3%, and perforator venous insufficiency (PVI) in 1.3% and with 2.60% a combination of all. Ninteen patients had ulcers (C6) and majority of which had combined SVI and DVI. Two patients had residual varicosities who underwent foam sclerotherapy. Complications post operation were edema and pain which were resolved with the use of Daflon. It is shown in this study that DVI can occur concurrently or may develop in time in patients with primary venous insufficiency. Early diagnosis and surgical treatment of CVI is still the mainstay in the correction of primary venous insufficiency may suggest better outcome and QOL.

P10-16Paper No: 319Doctors’ choose on management of varicose veins: Results of China

Mingyi Zhang, Tao Qiu, Xiangtao Li, Gangzhu Liang, Huan Zhang, Luyuan Niu, Hui Zhao, Fuxian ZhangDepartment of Vascular Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, People’s Republic of China

ObjectivesWe aimed to investigate the current status of treatment of varicose veins, and to evaluate how patient related factors and duplex ultrasound findings influence management decisions of Chinese vascular physicians.

MethodsA face-to-face survey was conducted among 726 vascular physicians who were attending the four largest vascular surgery conferences in China during August 2016 to May 2017. The survey comprised 3 parts and 28 points. The first 2 parts collected data on physician’s characteristics and their clinical departments. In the third part, we first provided a basic case vignette representing a 52-year-old healthy female patient with great saphenous vein (GSV) reflux above the knee (C2SEpAsPr). Afterwards, this basic case was modified step by step, changing complications and duplex findings. Participants chose their preferred procedures for these cases from a list of proposed answers. Distributions of management strategies between the basic case and modified vignettes were compared by the Bhapkar test.

P10-17Paper No: 336Relationship between the right heart function and venous blood flow velocity and varicose veins in the lower limbs

Yasuhiro Ozeki1, Kazuo Tsuyuki1, Shinich Watanabe2, Yuki Ishida1, Kunio Ebine1, Susumu Tamura1, Toshifumi Murase1, Kaoru Sugi1, Kenta Kumagai1, Itaru Yokouchi1, Kenji Yamazaki1

1Odawara Cardiovascular Hospital, Odawara, Japan2Development of Clinical Engineering, Kanagawa Institute of Technology, Atsugi, Japan

BackgroundThe prevalence of varicose veins in hemodialysis patients is significantly lower than that in healthy subjects, and this is considered to be due to a faster blood flow velocity in the lower limb veins than that in healthy subjects. Promotion of the right heart function is considered the cause of a fast blood flow velocity in the lower limb veins, and we previously demonstrated that right heart function measurements were significantly higher in dialysis patients than in healthy individuals. In this study, the direct relationship between the right heart function and lower limb venous blood flow velocity was investigated.

MethodsFifteen subjects with a 50% or higher left ventricular ejection fraction, tricuspid valve insufficiency milder

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than grade I, and sinus rhythm (4 healthy persons and 11 dialysis patients) were involved. The right heart function and maximum blood flow velocity in the common femoral vein were measured. For the right heart function measurement method, the right ventricular fractional area change (FAC) on echocardiography was used. The maximum blood flow velocity in the common femoral vein was measured while standing employing the pulse Doppler method using an ultrasonic diagnostic device. Pearson’s correlation coefficient between the right heart function and maximum blood flow velocity in the common femoral vein was determined.

ResultsThe mean±standard deviation of FAC was 39.4±13.1%, and that of the maximum blood flow velocity in the common femoral vein was 14.0±4.2 cm/s. A correlation was noted between the 2 parameters (r=0.52, p).

ConclusionsIt was clarified that the lower limb venous blood flow velocity is determined by the right heart function. The right heart function is promoted in hemodialysis patients, and this may be due to continuous loading of venous return on the arteriovenous fistula. It was concluded that the lower limb venous blood flow velocity increases in hemodialysis patients due to promotion of the right heart function, decreasing the prevalence of varicose veins compared with that in healthy persons.

P10-18Paper No: 343Advantage of wound control of cryotherapy in varicosity treatment

In Mok Jung, Jungkee ChungDepartment of Surgery Boramae Hospital, Seoul National University College of Medicine, Shindaebang-dong Dongjak-gu, Seoul Korea

Objectives/Purpose StatementCryotherapy (CT) is recognized as supplementary to conventional stripping procedure in varicosity treatment. In removing saphenous trunk inguinal incision 1.5cm and knee level incision 0.5cm are needed. To remove tributary varicosity we use same wounds without additional puncture as cryoavulsion (CA) mostly. We evaluated patients’ satisfaction with this procedure in aesthetic aspect. MethodDuring 2 years(from Jan. 2014 to Dec. 2015) 70 varicose patients with clinical class 2-4/CEAP had been treated

by CT and CA was also performed with same wounds. Patients demographics, wound number, complications and satisfaction score in AVVSS(preop/postop 2mos) were evaluated. Results1) In 70 patients male to female ratio was 34:36, mean age was 46+/-18.5 and in CEAP class@2:41 C3:15 C4:4 patients in each and all patients were As 2, 3 and or 4.2) Numbers of wound were 1.5+/-0.38 (except groin incision).3) Complications such as hematoma were 60 cases (85.4%) which were subsided within 6 wks and mild neuralgis occurred in 18 cases (25.7%) which were controlled by analgesics.4) AVVSS scores were changed from 8.6+/-3.2 to 1.9+/-1.1 within 2 months. Conclusions1) Cryoavulsion of tributary varicosity maybe combined with cryostripping without additional puncture wounds efficiently.2) Hematoma incidence was relatively high because of accompanying subcutaneous fat removal in early postoperative period and was lasting 3 weeks.3) Two month later cryotherapy resulted minimal puncture scars on patients’ aesthetic aspects.

P10-19Paper No: 365Excessive cost of ovarian vein embolization: Opportunity to rationalize technique and reduce cost

Mina Giurgis, Kishore Sieunarine

IntroductionRecurrent varicose veins and pelvic congestion syndrome can be due to incompetent ovarian veins. Treatment is mainly by embolization usually coils. This is a simple procedure with little variation and can be used as a procedure to assess for endovascular cost variation.The variety of embolic material used can vary widely in type and price with no evidence that the outcomes are different with each device. We performed a retrospective study on ovarian vein embolisation in one institution to analyse the material used and the cost.

MethodsA retrospective study of all cases over a two year period performed in one hospital. The operation details especially the number and type of coils used per case was

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BackgroundCyanoacrylate closure (CAC) for varicose veins using VenaSeal Closure System (Medtronic, Plymouth, MN) has recently been introduced for treatment of the incompetent saphenous vein. The previous clinical studies have demonstrated the safety and effectiveness of this system, utilizing a proprietary cyanoacrylate adhesive for the treatment of refluxing saphenous veins. Although there were no severe procedure- or device-related adverse events, the post-treatment phlebitis might be the troublesome complication. The purpose of our study is to evaluate the risk factor of the phlebitis after CAC.

MethodsA retrospective review was performed from prospectively collected data of CAC patients. The CAC was performed in patients with symptomatic great saphenous vein (GSV), small saphenous vein (SSV), and/or accessory saphenous vein (ASV) a single session. After discharge, the patient returned to clinic at one week and again at three months. We collected the possible risk factors for the development of phlebitis including the amount of injected adhesive, access site, treated segment, compression stocking application, and other clinical factors. For the statistical analyses, data were analyzed using the IBM SPSS Statistics ver. 22.0 (IBM Co., Armonk, NY, USA). P-value.

ResultsDuring the study period, 190 saphenous veins were embolized in 100 patients. Sixty-four (64%) patients were female. The mean age was 55.5±12.8 years (19-84). The complete occlusion was achieved in all patients. The endovenous glue-induced thrombosis (EGIT) occurred in 9 (9%) patients. After CAC, the mean VAS was 2.59 and 0.32 on postoperative 0 and 7 days, respectively (P

ConclusionCAC is an effective and safe modality to treat the saphenous vein insufficiency. The phlebitis occurred when the adhesive was injected at the below-the-knee GSV segment. The mechanical irritation due to knee joint movement might be the possible mechanism for the development of phlebitis.

P10-22Paper No: 442An odd pulsating veins treated with Endovenous Laser Ablation (EVLA)

Caesario Tri Prasetyo1, Niko Azhari Hidayat2

recorded and analysed.The cost for each coil used in the cases were obtained from the company.

ResultsThere were 20 cases and three different coils were used. The coils were detachable 0.018 and were 10-20 times more expensive than 0.035 coils. All cases were successfully embolised. The number of coils were total 177, average 9 (range from 3 to 31). The total cost was 199,200 dollars with a median cost of 4875(range 2250-39000 dollars) Simulating the cost of 0.035coils

ConclusionThe cost of this procedure is excessive and provides an ideal opportunity to assess the number and type of coils to assist in reducing the cost of this procedure by choosing cheaper effective options. This can be used as a template for other costly endovascular procedures.

P10-20Paper No: 386Femoral endovenectomy with iliac stenting for chronic iliofemoral venous occlusion

Won Pyo Cho, Sungsin Cho, Min-Ji Cho, Sanghyun Ahn, Sang-il Min, Jongwon Ha, Seung-Kee MinDepartment of Surgery, Seoul National University Hospital, Seoul, Korea

A 62-year-old man with progressive swelling on his left thigh and leg was referred to the division of vascular surgery. He had no trauma history nor any accidents. Anticoagulation therapy did not improve chronic deep vein thrombosis from his left external iliac vein to posterior tibial vein. He underwent femoral endovenectomy, thrombectomy and stent insertion in left iliac vein. The patient had additional balloon angioplasty for stenosis in left common femoral vein. He had an uneventful postoperative recovery without complication. Leg swelling has been improving and follow-up continues under anticoagulation. We report a case of femoral endovenectomy with iliac stenting, which may be an efficacious treatment for chronic DVT.

P10-21Paper No: 418Risk factor of phlebitis after cyanoacrylate closure

Jin Hyun Joh, Ho-Chul ParkDepartment of Surgery, Kyung Hee University, Seoul, South Korea

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Poster Presentation

1Medical Student, Airlangga University, Surabaya, Indonesia2Cardiothoracic and Vascular Surgeon, Universitas Airlangga Hospital, Surabaya, Indonesia

BackgroundVascular system contain arterial and venous system and connected with capillaries system. The venous problems are caused by internally or externally of the system and not commonly discussed. A rare cause of the problem is from cardiac and associated with the abnormalities of cardiac valves, especially tricuspid valve regurgitated alone or due to mitral valve abnormalities. They will give high backward pressure of blood flow from cardiac to the vein and eventually becomes pulsatile. Besides, The vein will enlarge and twist called varices and give many clinical symptoms. The treatment of pulsating veins are done commonly by surgery and then conservative. However, Endovenous Laser Ablation is proposed to minimize the complication and risks during the operation and also shorten the duration of staying at the hospital.

MethodA 70-year-old-male patient with chronic pain ulcer in right leg due to varicose vein was treated in our hospital. The patient also had hypertension and abnormal cardiac valves (mitral and tricuspid regurgitated), then he undergone the Doppler USG to evaluate the varicose vein and we got the veins was pulsatile. Then he was performed Endovenous Laser Ablation (EVLA) with local anesthesia to treat right leg pulsating vein and wound care for the ulcer.

ResultThe pulsating veins disappeared after laser ablation and there was no complication. The patient went home a few days later.

ConclusionPulsating veins due to abnormalities of cardiac valve can be treated effectively by using Endovenous Laser Ablation rather than surgery because of its satisfactory result and has no complication.

P10-23Paper No: 463Endovenous ablation of varicose vein: An experience in Bangladesh

SMG Saklayen1, GM Mokbul Hossain2

1Department of Vascular Surgery, Ibrhim Cardiac Hospital and Research Institute, Shahbag Avenue, Dhaka,, Bangladesh2Department of Vascular Surgery, National Institute of Cardiovascular Diseases, Shere e bangla Nagar, Dhaka, Bangladesh

Endovenous laser therapy (EVLT), mechano-chemical ablation and radiofrequency ablation (RFA) are new, minimally invasive percutaneous endovenous techniques for ablation of the incompetent great saphenous vein (GSV). As these are the newer techniques done in Bangladesh we reviewed early outcome of both procedures by saphenous closure rates and complications of both the procedures. MethodsEndovenous GSV ablation was performed on 300 limbs in 220 patients. RFA was the procedure of choice in 9 limbs, mechano-chemical ablation in 10 limps and EVLT in rest of the 281 limbs. According to the CEAP classification, 180 limbs were C2-C4, and 95 were C5-C6. Concomitant procedures included multiple phlebectomy in 30 cases, small saphenous vein ablation in 10 cases, Flush ligation of saphenofemoral junction in 20 cases. Varicosity was treated with sclerosing agent, sodium tetrdecyle sulfate (STS). Routine follow up was done at 7th day and Duplex scan follow up at 1 month. No specific complications recorded except 7 cases of abscess formation at the site of introduction of sclerosing agents, Echymosis in several cases. ResultsOcclusion of the GSV was confirmed in 99.9% with EVLT and 96% with RFA and mechano-chemical ablation. Two cases were treated with Rivaroxavan for 48 hours and 8 cases were admitted in hospital, 7 for abscess drainage and one for suspected DVT. ConclusionGSV occlusion was achieved in >98% of cases after both EVLT, mechano-chemical ablation and RFA at 1 month. DVT prophylaxis should be started in case suspected cases of thrombus propagation. Long-term follow-up and comparison with standard GSV stripping are required to confirm the durability of these endovenous procedures.

Vascular Trauma

P11-01Paper No: 049False aneurysm in lower extremity: A serial case from east kalimantan

JoalsenDivision of Thoracic, Cardiac and Vascular Surgery, Abdul Wahab Sjahranie General Hospital - Mulawarman University, Samarinda, East Borneo, Indonesia

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BackgroundFalse aneurysm of the artery consist in a dilation of an artery with actual disruption of one or more layers of its walls, rather than with expansion of all wall layers. These formations in lower extremity are infrequent. There is no literary data that shows the incident of false aneurysm in lower extremity. They are commonly caused by traumatic or iatrogenic lesions.

ObjectiveTo report four cases of false aneurysm in lower extremity which has undergone surgical procedure, in Abdul Wahab Sjahranie General Hospital, Samarinda- East Borneo since 2014 until 2017.

MethodsFirst case was 34 y.o male presented with false aneurysm of deep femoral artery; second and third cases both were 40 y.o males presented with false aneurysm of posterior tibial artery; fourth cases was 66 y.o male presented with false aneurysm of popliteal artery. Four patients were presented by a pulsating mass, leg swelling and pain. Two patients had an history of traffic accident before admission. One patient had a history of traditional massage; and one patient had an history of surgical procedure. Pre-operatively, three patients underwent MSCT angiography and one patient underwent MRI. All the diagnostic data concluded that in all four cases, there were false aneurysm. All patients underwent open surgical repair by closing the defect primarily.

ResultAll patient’s postoperative course were uneventful and there were no complication such as ischemic sign. Legs swelling were reduced after 3 months follow up.

ConclusionIn our centre, all cases of false aneurysm in lower extremity mostly caused by trauma. MSCT angiografi were sufficient to diagnosed this anomaly. All cases were managed by open surgery and resulted a good outcome.

P11-02Paper No: 064Limitation of radiologic evaluation for Zone II cervical penetrating injury: Hidden arterial injury

Jihoon Kim, Hojong Park, Minjeng ChoDepartment of Surgery, Ulsan university hospital, Ulsan, Korea

An 56-year-old woman sustained multiple stab wounds to her thorax, neck, and limbs. On admission to the hospital, she was conscious. Glasgow Coma Scale was 13

with dyspnea, aphasia,and right hemiparesis. His blood pressure was l00/65 mm Hg, and hemoglobin level was 10.5 g dL

No significant arterial injuries were identified by CT arteriography in the absence of suggestive physical findings. On exploration, an intact vagus nerve and internal jugular vein were found, but the common carotid artery was not immediately apparent. Careful dissection confirmed a near completely transected common carotid artery. A End to end anastomosis was performed without shunt and post-operatively the patient recovered completely and had no neurological deficit.Thorough neck exploration with dissection of the carotid sheath in patients with physical diagnostic criteria for surgery eliminates the need for angiography in most cases and avoids the consequences of a possible false-negative. Dynamic CT scan contributes minimally to the sensitivity of physical examination in the diagnosis of surgically significant penetrating zone II neck injury. We recommend Zone II cervical penetrating injury need to exploration fully for not missing important vessel injury

P11-03Paper No: 161Steal syndrome from a traumatic arteriovenous fistula leading to severe lower extremity gangrene - A case report

John Michael F Lopez, Josefino I Sanchez, Teodoro B Bautista JrDepartment of Surgery, University of Santo Tomas Hospital, Sampaloc, Manila, Philippines

BackgroundTraumatic arteriovenous fistulae of the extremities usually arise as rare complications of penetrating injuries. Of all traumatic arteriovenous fistulae, only very few will progress to develop steal syndrome, and much less would eventually lead to severe gangrene of the involved extremity.

Case PresentationWe present a case of a 28 year-old male who had an accidental self-inflicted gunshot wound to the left thigh 1 month prior. No vascular evaluation and only wound care and suturing was done at the time of the accident. 2 weeks later, edema and signs of ischemia were noted on the left leg. Despite repeated debridement and antimicrobial therapy, there was progressive gangrene of the left leg which led to the suspicion of a possible vascular injury. CT angiogram of the lower extremities done showed an arteriovenous fistula on the left,

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Poster Presentation

between the distal superficial femoral artery and femoral vein with no distal runoff. He was then referred to our institution and underwent above the knee amputation of the said extremity.

ConclusionComplete vascular examination and more aggressive vascular evaluation should be done in penetrating extremity trauma. Missing the presence of such injuries could lead to devastating complications and consequences, which could be avoided by early recognition.

P11-04Paper No: 180Successful endovascular repair of occlusive traumatic aortic injury: Kissing-stent

Jinseok Choi, Chung Won Lee, Up Huh, Sung Woon ChungDepartment of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Seo-Gu, Busan, Republic of Korea

BackgroundThe kissing stent has been mainly performed in aortoiliac occlusive disease. We report our experience using the kissing stent technique in blunt traumatic aortic injury.

MethodsA 47-year-old man presented to the emergency department (ED) after a high-speed motor vehicle accident involving impact on driver’s side. He was hemodynamically stable (initial blood pressure 180/100 mmHg, pulse 85 bpm, SpO2 100%) and alert (GCS 15) at the time to the ED. Multiple injuries were found on CT scan including thrombotic occlusion in terminal aorta, duodenal perforation, colon injury, and right distal tibia fracture. We figured that traumatic aortic injury was the thrombotic occlusion in bifurcation of terminal aorta. The thrombectomy with Forgaty catheter (Edwards lifesciences, Irvine, CA, USA) was performed from terminal aorta to both CIAs through both CIAs. However, the pulsation of both femoral arteries was not still detected. We mistook traumatic aortic injury for thrombotic occlusion. Y-graft interposition had no regard because graft infection could be caused by duodenal perforation, and meso-colon rupture. The endovascular repair with kissing-stent was performed after the exploratory laparotomy. After stent deployment, concomitant post-dilatation was performed using the kissing balloon technique.

ResultsThe recanalization of terminal aorta and both CIA was confirmed by complete angiograms and the pulsation of both femoral arteries was achieved. In immediate postoperative periods, Urine output was decreased and rhabdomyolysis was diagnosed with acute renal injury because of the compartment syndrome of left thigh. Continuous renal replacement therapy was promptly performed and acute renal injury was fully recovered before discharge. As of 12 months after the procedure, he remains alive and the patency of kissing stents was intact.

ConclusionsWe think that the kissing stent could be help to treatment of blunt traumatic aortic injury in terminal aorta.

P11-05Paper No: 262Emergent tae in a prone position; Right internal iliac artery injury during supine surgery

Hirokuni Ono1, Satoshi Kinebutchi1, Syouta Kita1, Hirotoshi Suzuki1, Yukaã€€Sakurai1, Tokuichirou Nagata1, Daijun Ro1, Yukihisa Ogawa2, Kiyoshi Chiba1, Makoto Ono1, Masahide Chikada1, Hiroshi Nishimaki1, Takeshi Miyairi1

1Department of Cardiovascular Surgery, St. Marianna University School of Medicine, Kanagawa Prefecture, Japan2Department of Radiology, St. Marianna University School of Medicine, Kanagawa Prefecture, Japan

IntroductionAlthough iatrogenic vascular injury during lumber disc surgery is a rare complication, it is sometimes a life-threatening condition when it occurred.

We report a patient whom critical vascular injury occurred during intervertebral disc surgery at the level of L4/5.

CaseThe patient is a 72-year-old female. The patient was admitted to our hospital because of lumbago. The patient was diagnosed with spinal canal stenosis and spinal scoliosis. The medical history was an angina pectoris.

Operation of orthopedic was in a prone position, laminectomy and discectomy with posterior approach.

During surgery, there was sudden and continuing bleeding from between the intervertebral discs after removing the intervertebral disc, and the blood pressure simultaneously decreased. Patient developed hypotensive shock.

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We performed emergency angiography, the patient was continuing supine position, we punctured from the popliteal artery.

As a result, we diagnosed with a pseudoaneurysm of the right internal iliac artery and abdominal compartment syndrome. We performed the coil embolization for the pseudoaneurysm of the right internal iliac artery.

DiscussionThe incidence of vascular injury during lumbar intervertebral disc surgery is reported as 0.039-0.14%.

At the L3-4 disc level, the aorta and inferior vena cava are at risk and an aorto-caval fistula is most likely to result. Disc surgery at the L4-5 level is most commonly performed,resulting in the highest number of injuries. The anatomical combination is variable but unually involves the right or left common iliac arteries or vein. At L5-S1, the injury is uncommon and may involve avariety of vessels,including the internal iliac vessel.

ConclusionIt is an important to understand the possibility of vascular complications during operation of the lumber disc.Transpopliteal approach in a prone position may be useful when transfemoral approach proves difficult such as this condition.

P11-06Paper No: 305A case of blunt abdominal aortic injury due to lumbar artery avulsion

Yamada Takayuki1, Kotani Shinsuke2, Ishikawa Takumi2, Murakami Tadanori2, Minamimura Hirokazu2

1Department of Cardiology, Bellland General Hospital, Sakai- shi, Osaka-fu, Japan2Department of Cardiovascular Surgery, Bellland General Hospital, Sakai-shi, Osaka-fu, Japan

BackgroundBlunt aortic injury is generally associated with high-energy trauma such as traffic collisions or falls and commonly occurs at thoracic aorta. Blunt abdominal aortic injury (BAAI) is rare and has been shown to be 5% of blunt aortic injury. We present a case of a 35-year-old man with the BAAI due to the lumbar artery avulsion.

Method The patient was admitted to our hospital after getting caught between an excavator and a water pipe, with chief complaint of abdominal pain. His vital signs were stable and his blood tests didn’t show any evidence of

anemia. A bruise was observed on his abdomen. There was no other surface wound. Enhanced computed tomography revealed retroperitoneal hematoma without extravasation of contrast at the level of the infrarenal abdominal aorta. There was no injury of the abdominal visceral organs except abdominal aorta on the CT scan. We urgently decided to perform open surgery for the treatment of BAAI. We didn’t choose endovascular surgery because long-term prognosis of stent graft was currently unclear and it was difficult to specify the location of bleeding point. At laparotomy, we found a small amount of bloody ascites and mesenteric hemorrhage, which was later repaired. There was no evidence of visceral organs injury. We found the retroperitoneal hemorrhage and the bleeding out of the origin of the lumbar artery. The lumbar artery was ligated resulting in hemostasis. We performed replacement of the infrarenal aorta with an interposition graft in order to expose intima of the aorta. Since there was no damage in the abdominal aortic intima, we diagnosed that the abdominal aortic rupture was caused by the lumbar artery avulsion.

ResultThe postoperative course was uneventful. He discharged in a stable condition on postoperative day 9. He was doing well 6 months after the surgery. Follow-up CT at 6 months after the surgery revealed that there was no hematoma around the abdominal aorta. Now, He is working again using a excavator.

ConclusionAlthough BAAI is often fatal, we successfully treated the case of BAAI by urgent open surgery with no perioperative complications.

P11-07Paper No: 403Endovascular repair of fistularized pseudoaneurysm of the left common iliac artery to common iliac vein after lumbar spine surgery: Case report

Jeensoo Bae, Woo-Sung Yun, Shin-Seok Yang, Bo-Yang SeoDivision of Transplantation and Vascular Surgery, Department of Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea

BackgroundAorto-iliac arterial injury is a rare complication during intervertebral-disc surgery. However, it makes a potential for life-threatening. We experienced a pseudoaneurysm which was fistularized between iliac artery and vein.

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Poster Presentation

CaseA 73-year-old female presented with the left leg swelling and short-distance claudication. Two months ago, she underwent discectomy because the right foot drop developed due to L4-L5 herniated lumbar disc. After surgery, the left leg swelling developed. On duplex scan, deep vein thrombosis (DVT) was not identified, but spectral Doppler waveform of the left common femoral vein showed pulsatile waveform rather than phasic. The left ankle-brachial index (ABI) was 0.71. CT angiography revealed the 31x20cm sized fistularized pseudoaneurysm of the left common iliac artery (CIA) to the left common iliac vein (CIV). It was successfully treated with placement of a stent graft.

P11-08Paper No: 413Endovascular management of an iatrogenic subclavian artery pseudoaneurysm: A case report

Yoo Young SunDepartment of Surgery, College of Medicine, Chosun University, Gwangju, Korea

BackgroundIatrogenic subclavian artery pseudoaneurysm is an uncommon complication secondary to inadvertent puncture of the subclavian artery in central line placement. We present the case of a large subclavian artery pseudoaneurysm treated by stent-graft placement.

CaseA 39-year-old man had a kidney transplant from a deceased donor. Three days after transplantation, urine output decreased gradually, and serum creatinine did not decrease to normal range. To facilitate renal replacement therapy, an attempt has made to insert a central venous dialysis catheter into the left subclavian vein. After overwire dilation of the tract, it was recognized that the catheter had been inadvertently placed in the left subclavian artery. The catheter was removed immediately, and the local pressure was applied to puncture site. The patient complained of the left side neck pain with swelling five days after the puncture. Initial ultrasound duplex scan confirmed the presence of large pseudoaneurysm in the left supraclavicular fossa. A contrast-enhanced computed tomography (CT) scan demonstrated a 1.8 x 2.0cm sized pseudoaneurysm in the upper left side of the neck region originating from the left subclavian artery. Due to the patient’s poor medical condition and continuous hemodialysis, the pseudoaneurysm was planned to observe for a while. However, the patient’s discomfort

got worse gradually and the size of palpable mass on left neck more increased. Two weeks after the initial CT scan, CT was checked again, and it demonstrated 3.5 x 3.8cm sized pseudoaneurysm. Finally, a stent-graft placement was chosen. Through left brachial approach by open exposure, 10 x 60mm stent-graft was placed on the proximal subclavian artery. Follow-up CT scan at one month later confirmed a patent stent-graft without a sign of stent-graft deformation or fracture and a patent vertebral artery.

ConclusionStent-graft repair of iatrogenic subclavian artery pseudoaneurysm is a feasible option, yielding satisfactory results.

P11-09Paper No: 419Successful revascularization for acute mesenteric arterial occlusion related to traumatic type B aortic dissection with making a surgical fenestration

Tadao Kubota1, Koichiro Kubo2, Yoshihiro Morimoto2

1Department of General Surgery, Tokyo Bay Medical Center, Urayasu, Chiba, Japan2Department of Surgery, Chibanishi General Hospital, Matsudo, Chiba, Japan

IntroductionAbdominal visceral ischemia is rare complication of blunt trauma. Revascularization of visceral artery is one of challenging problems for general surgeons. In the case of mesenteric ischemia, anastomosis of superior mesenteric artery (SMA) and infra-renal aorta or iliac artery is generally recommended.

Case Report78 year-old female had been transferred to our emergency department with blunt thoracoabdominal trauma caused by motor vehicle accident. She was shock on arrival and complained of severe abdominal pain. After primary survey and initial fluid resuscitation, she had been recovered from shock and followed secondary survey. On physical examination, her abdomen was board like and diffuse rebound tenderness was observed. Enhanced thoracoabdominal CT scan revealed mesenteric injury and type B aortic dissection with coexistence of occlusion of the SMA. So, she underwent emergent laparotomy. When the peritoneum was opened, there was a rupture of the ileum and moderate amount of bloody ascitis. Almost all small intestines were ischemic because of SMA occlusion. At first, a segment of damaged bowel was resected. Next, non-

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palpable SMA was isolated just below the pancreas, and transverse incision was made it. Arterial flow was supplied through false lumen and distal was completely occluded. Then we made a fenestration with anastomosis between proximal adventitia and distal whole wall of SMA. Abdominal wall was temporally closed by vacuum assisted closure technic. 24 hours after initial surgery, we checked the viability of intestines and anastomosis of the ileum was done at 2nd look operation.

ConclusionIn case of trauma surgery, quick and easy are essential. Although bypass graft is standard technic for SMA occlusion, auto graft bypass needs long time and artificial graft has disadvantage of infection. We feel that it is good alternative method to make a surgical fenestration for revascularization of visceral ischemia related to aortic dissection.


P12-01Paper No: 028Advantages & challenges with TSOACs (target-specific oral anticoagulants)

Sandeep Raj PandeyDepartment of Vascular Surgery, Annapurna Hospital, Kathamndu, Nepal

BackgroundAdvantages: Fixed-dose oral dosing;Fewer drug-drug and dietary interactions; No need for routine coagulation monitoring; At present, all three are approved for use in preventing stroke in atrial fibrillation; Rivaroxaban is also approved for treatment and prevention of VTE.TSOACs challeneges: TSOACs have no clinically proven antidotes yet””there is no way to reverse anticoagulation for any TSOACs; Patients who orally ingest a TSOAC are actively anticoagulated within several hours; Because the half-life of TSOACs is shorter than VKA, most of the anticoagulant effect will typically wear off within 1-2 days;As TSOACs are cleared by the kidney, they are not recommended in patients with severe renal insufficiency.

Materials & methodsWe selected 50 patients on oral-anticoagulants from jan 2017-March 2017. 40 were on warfarin & 10 on TSOACs.

ResultsPatients on warfarin had INR monitoring issues due to many patients from out of kathamndu valley & 5 of them came with hematuria & 1 with menorrhagia having INR 9. Warfarin effect was reversed with vitakin

K. Patients on TSOACs had no any bleeding or hematuria but there was challenge if the dose is appropriate or not as there was no appropriate monitoring & if bleeding no antidote.

ConclusionTSOACs have become viable alternatives to conventional oral anticoagulants and have advantages of fixed-dose oral dosing, relatively rapid onset and offset, and fewer drug-drug interactions compared with VKA. Common errors related to TSOAC use include prescribing to inappropriate patients, recommending an inappropriate dose or administration, and inappropriate monitoring.

P12-02Paper No: 037Safety and efficacy of performing short-term endovascular treatment for acute lower extremity deep vein thrombosis using low-dose urokinase in a single session with a single venous access approach

Sang Yong Chung, Soo Jin Na ChoiDepartment of Surgery, Chonnam National University Hospital, Gwangju, Korea

PurposeTo evaluate the safety and efficacy of performing short-term endovascular treatment for acute lower extremity DVT using low-dose urokinase in a single session with a single venous access approach. To evaluate the efficiency of placing IVC filter through the same popliteal vein access site used for endovascular treatment Materials and MethodsFrom October 2003 to June 2015. 98 patients with symptomatic acute DVTs were analyzed. Symptom durations of all patients were under 14 days. Durations and urokinase infusions were not over 8 hours. All patients were performed with short-term endovascular treatment for acute lower extremity DVT using low-dose urokinase in a single session with a single popliteal venous approach. IVC thrombus &/or a large amount of a thrombus without underlying vascular stenosis on CT Venography were performed 33 double-basket shaped retrievable IVC filters. Deployed in the infra-renal IVC under fluoroscopic guidance were used. ResultsFemale patients were 62 patients. Mean age was 62.6 years. Locations of thrombosis were left in 88 patients. DVTs with May-Thurner syndrome was 68 patiens. Iliofemoral affected in 53 patients. Iliopopliteal affected in 25 patients and IVC inloved in 22. Mean urokinase

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Poster Presentation

infusion time was 181 ± 76 minutes. Mean total urokinase in single dose was 5.16 ± 2.76 x 104 IU and mean total continuous infusion dose was 33.49 ± 13.08 x 104 IU. Immediated success rates were 100 percents. Primary patency rate at 6 months and 12 months were 82% and 79%. Total prophylactic IVC filter placements were 33/98. Follow-up CTV data obtained within 2wks of procedure 26/33. Significant filter tilt was found in 3 cases out of 26 patients. So, significant filter tilt rates (> 15°) was 11.5%. ConclusionShort-term endovascular treatment using low-dose urokinase in a single session with a single venous access approach is a safe and effective method for treating symptomatic acute lower extremity DVT.Transpopliteal IVC filter insertion is an efficient therapy that results in low rates of significant filter tilt and enables a singe-session procedure using a single venous access site for filter insertion and endovascular procedures for DVT.

P12-03Paper No: 040Lower extremities deep venous thrombosis event in vascular surgical patients in Chiang Mai University Hospital

Wiwat Yimkosol, Saranat Orrapin, Supapong Arwon, Termpong Reanpang, Kitipan RerkasemDepartment of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

ObjectiveThe incidence of deep venous thrombosis (DVT) in vascular surgical patients has not been well documented, and the need for prophylaxis remains controversial. the purpose of this study was designed to measure the incidence of lower extremities deep vein thrombosis after vascular procedure.

Patients and MethodsAll consenting, consecutive patients who came to Chiang Mai University Hospital for vascular procedure from January to October 2016, were studied. clinical, laboratory and operative data were recorded. Bilateral lower extremities venous duplex scan was performed preoperatively and within 1 week and 2-6 weeks, postoperatively. DVT prophylaxis was not used, with anticoagulation reserved for specific indication.

Result87 patients were enrolled. Abdominal aortic aneurysm repair were performed on 22 patients, Lower extremities arterial revascularization were performed on 11

patients, and Varicose vein procedure were performed on 23 patients. A post operative DVT was not detected in all vascular surgical patients.

ConclusionPostoperative deep vein thrombosis in vascular surgical patients was not founded in this study.

P12-04Paper No: 052Pharmacomechanical Thrombectomy (PMT) with Angiojet Solent Omni Compared with Catheter Directed Aspiration Thrombectomy (CDAT) for Treatment of Acute Deep Vein Thrombosis (DVT)

Young Hwa Kim, Kyung Jai Ko, Jin Ko, Sang Seob Yun, Sun Cheol Park, Ji Il Kim, In Sung Moon, Jang Yong KimDivision of Vascular and Transplant Surgery, Department of Surgery, The Catholic University of Korea College of Medicine

BackgroundConventional anticoagulation for acute DVT can cause post thrombotic syndrome (PTS). Therefore, early thrombus removal strategies for acute DVT are widely appreciated across different societies. PMT is recently-established therapy to manage acute DVT, when experts and resources are available. In Korea, CDAT is popular options for acute DVT because PMT devices are limited by reimbursement issues. We compared the results of PMT with Angiojet with CDAT and evaluated risk factors affecting patients’ outcome.

Materials and MethodThis is a retrospective study from prospectively registered database of the patients, who underwent interventional procedures due to acute DVT in Seoul St. Mary’s Hospital from 2013 to 2015. PMT with AngioJet and Solent Omni catheter was compared to CDAT for acute DVT. Patients’ demographics, procedural information, their results and complications were retrieved from EMR and PACS and analyzed with SPSS 10.1.

ResultsFifty eight patients were enrolled. 22 patients were treated by PMT, and 36 by CDAT. There was no procedure or inhospital mortality in both groups. There were 3 additional thrombolysis in PMT group and 6 in CDAT group. There was no difference of technical success rate between PMT and CDAT regardless of thrombolysis (P=0.4183, P=9.205). The limitation of PMT with Angiojet was short operating time of AngioJet (less than 5mins) with residual thrombus while large thrombus embolization in CDAT.

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ConclusionPMT with AngioJet and CDAT are an safe and effective strategy for early thrombus removal of patients with acute DVT with different pitfalls. This study is limited by small number and retrospective study. Primary technical success rate of PMT with AngioJet and Omni catheter is 81% and Sencondary success rate is 91%. Rheolytic treatment of DVT is safe and effective and can potentially reduce the need for concomitant CDAT and intensive care unit.

P12-05Paper No: 131Deep vein thrombosis in patients with pulmonary embolism: Prevalence, clinical significance and outcome

Joonyoung Choi1, Jun Sung Lee1, Se Young Kim1, Tae Hoon Kim1, Ho Kyeong Hwang2, Yu Jin Kwon1, Kyung Bok Lee1

1Department of Surgery, Seoul Medical Center, Seoul, Korea2Department of Radiology, Seoul Medical Center, Seoul, Korea

PurposeDeep venous thrombosis (DVT) and pulmonary embolism (PE) are considered as similar disease entities representing different clinical manifestations.

The objectives of this study were1) to determine the prevalence and outcome of DVT in patients with PE; 2) to identify additional risk factors for PE-related unfavorable outcome and 30-day all-cause mortality; and 3) to establish the clinical importance of screening for concomitant DVT.

Materials and MethodsFrom January 2013 to December 2015, a total of 141 patients with confirmed PE were evaluated. The prevalence and outcome of DVT in patients with PE was determined. Furthermore, the potential risk factors for PE-related unfavorable outcome and 30-day all-cause mortality were also analyzed.

ResultsThe prevalence of concomitant DVT was 45.4%. PE-related unfavorable outcome was observed in 21.9% of all concomitant DVT, with all-cause mortality of 21.9%. There was no significant relationship between the presence of concomitant DVT and the development of PE-related unfavorable outcome or all-cause mortality. Our results indicated that heart rate >100/min and peripheral oxygen saturation outcome. Regarding all-cause mortality, active malignancy and hypotension or shock were significant risk factors.

ConclusionOur findings demonstrate that approximately half of patients with PE possess DVT. However, this study failed to establish any clinical significance of concomitant DVT for PE-related unfavorable outcome and all-cause mortality. Tachycardia and hypoxemia were identified as significant predictors for PE-related unfavorable outcome along with active malignancy and hypotension or shock as significant risk factors of all-cause mortality.

P12-06Paper No: 169Incidence of perioperative venous thromboembolism in patients with a history of deep vein thrombosis. How effective are direct oral anticoagulants in reducing recurrence?

Satoko Funata, Yutaka Hosoi, Masao Nunokawa, Makoto Haga, Toru Ikezoe, Yoshifumi Nishino, Hiroshi KubotaDepartment of Cardiovascular Surgery, Kyorin University, Tokyo, Japan

BackgroundPatients who undergo surgery are at risk for venous thromboembolism (VTE), which is higher in those with prior history of deep vein thrombosis (DVT). Increased concern for the risk associated with DVT has led to the rapid growth of the number of DVT cases detected by preoperative duplex scanning in the current clinical practice. The purpose of this study was to determine the incidence of perioperative VTE recurrence in patients with a history of lower extremity DVT and to investigate the efficacy of direct oral anticoagulants (DOACs) in reducing thrombus recurrence.

MethodsBetween January 2014 and December 2015, 165 patients (53 men and 112 women; mean age 71 years), who were diagnosed as having DVT by duplex scanning before surgery and also had a follow-up images within 6 weeks after surgery, were included in this study. The location of thrombi, type of surgery, prophylactic measures including placement of an inferior vena caval (IVC) filter, and incidence and patterns of recurrence were evaluated. The recurrence was defined as having thrombus extension, new-site thrombus formation, or pulmonary embolism (PE) detected by follow-up duplex scanning or computed tomography, regardless of presence or absence of symptoms.

ResultsOf 165 patients, 144 cases (87%) had isolated calf DVT. Seventy-nine cases (48%) underwent surgery for malignant disease, and 36 (22%) for orthopaedic

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Poster Presentation

diseases. Fifteen patients (9%) received an IVC filter before surgery. Majority of patients (85%) received anticoagulation for prevention of VTE, while 24 had only compression therapy. Overall, 46 patients (28%) developed VTE recurrence, including 3 symptomatic PE cases in the perioperative period. Patients treated with compression alone had higher frequency of recurrence than those receiving anticoagulation (16/24 vs 30/141, p<0.0001).

ConclusionOur data revealed that a substantial number of patients with a previous history of DVT developed perioperative VTE. DOACs showed a significant low rate of recurrence compared with standard therapy with warfarin after initial heparin.

P12-07Paper No: 184Development & clinical application of automatic alarming system for patient with high risk of DVT using Electronic Medical Record (EMR) for DVT prophylaxis

Si Jin Jo, Cheng Quan, Young Hwa Kim, Gyeong Jae Koh, Jin Go, Mi Hyeong Kim, Kang Woong Jun, Jeong Kye Hwang, Sang Dong Kim, Jang Yong Kim, Sun Cheol Park, Ji Il Kim, Yong Sung Won, Sang Seob Yun, In Sung MoonDepartment of Surgery, Catholic University of Korea, Seoul, Korea

BackgroundDeep vein thrombosis (DVT) is one of major causes of in hospital death causing lethal pulmonary embolism (PE) or chronic post-thrombotic syndromes(PTS). DVT prophylaxis is known to be effective but has been underused because of the lack of awareness of DVT and the absence of DVT prophylaxis protocol. Aim of the study is to evaluate development of Automatic alarming system for patient with high risk of DVT using EMR and clinical application.

MethodsAutomatic alarming system for patient with high risk of DVT developed for automatically monitoring all hospitalized patient in tertiary referral hospital, Seoul St. Mary’s Hospital since first consensus meeting in Jan 2015. Routine DVT risk assessment is done based on Caprini risk scoring model with risk categorization(low, moderate, high and very high) according patient’s history on admission. Alarming system automatically notifies patient’s risk to patient’s department whose DVT risk is very high. Once notified, attending physician can choose DVT prophylaxis by themselves or under

vascular surgeon’s support. DVT prophylaxis regimen is decided based on DVT risk categorization, hemorrhage risk, creatinine clearance. Prophylactic regimen included medication (LMWH, NOAC, etc.) and mechanical method (Compression stocking, intermittent pneumatic compression, etc.). Primary end points were DVT prophylaxis compliance and the proportion of patient consulted to the department of VS. Secondary end point was the rate of DVT events.

Results6141 and 6507 patients were evaluated from March, 2016 to August, 2016 each. The DVT alarming rate for very high risk for DVT was 36%, 33% and whose DVT prophylaxis activation rate was 78%, 81%, the rate of choosing VS consult was 6%, 9% each of the period. Incidence of The DVT alarm rate by specialty was highest on general surgery (GS) followed by orthopedic surgery (OS), neurosurgery (NS), and urology (URO). These department performance of DVT prophylaxis was 80~96%. Consultation to VS from OS, NS was 10~50% of the DVT alert, the other departments choose to decide prophylactic regimen by themselves.

ConclusionAutomatic alarming system for patient with high risk of DVT can find patients with very high risk for DVT and can offer the patient DVT prophylaxis according to patient’s comorbidities. Long term outcome of this system nee.

P12-08Paper No: 225Clinical outcome of edoxaban for venous thromboembolism in the real-world of Japanese single center

Shinichi Imai, Hiroyuki Otsuka, Shinichi Hiromatsu, Ryo Kanamoto, Yusuke Shintani, Shinichi Nata, Tohru Takaseya, Satoru Tobinaga, Seiji Onitsuka, Hiroyuki Tanaka

IntroductionEdoxaban have been approved first in Japan as DOAC for the treatment of VTE in 2014. However there were few real-world data in the use of DOACs for patients with VTE in Japan. In this study, we reviewed edoxaban real-world safety and efficacy for patients with VTE in our institution.

Patients and methodsWe retrospectively reviewed 72 patients (30 men and 42 women, mean age 64.3±15.8 years) to whom edoxaban was administrated for treatment of VTE at Kurume Univ Hospital from January 2015 to December

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2016. We compared our own data at our institution to a subanalysis of East Asian population in the Hokusai-VTE trial.

ResultsPatient demographic and baseline clinical characteristics were different between our data at Kurume Univ Hosp (K) and East Asia in the Hokusai-VTE trial (H). Proportion of woman (58.3% (K) versus 51.3%(H)), proportion of a body weight of less 60kg (68.1%(K) versus 33.9%(H)), proportion of patients with 30mg once daily (66.1% (K) versus 41.4%(H)) were significantly higher at our institute than in East Asia from the Hokusai-VTE trial. Symptomatic recurrent VTE occurred in 2 of 72 (2.8%, 95%CI:0. 3~9.6) in our institution versus 16 of 563 (2.8%, 95%CI: 1.6~4.6) in edoxaban treatment group of East Asia population. The recurrence of VTE in our institute was similar to that in edoxaban treatment group of East Asia population. Regarding to the principal safety outcome of clinically relevant bleeding, there were no significant differences between our series and Hokusai-VTE trial in the East Asia (95%CI 5.9~22.4% vs. 7.6~12.7%). There were no mortality related to edoxaban during the on- treatment period in our series and it was the similar to that of edoxaban of East Asian population in the Hokusai-VTE trial.

ConclusionThe safety and efficacy of DOACs were similar between our Japanese pts. and East Asian population subanalysed in the Hokusai-VTE trial although our Japanese pts. were more female, smaller (less BW) and treated with less dosage of DOAC. There remains a need for selection of the appropriate patient, drug and dose and careful follow up.

P12-09Paper No: 229The clinical outcome of DOACs in the treatment of venous thromboembolism with cancer

Ryo Kanamoto, Shinichi Hiromatsu, Shinichi Imai, Shinichi Nata, Yusuke Shinitani, Hiroyuki Otsuka, Tohru Takaseya, Satoru Tobinaga, Seiji Onitsuka, HIroyuki Tanaka

IntroductionVenous thromboembolism (VTE) is a major complication of malignant diseases and is the second rank of the cause of death of the cancer patients. Managing anticoagulation in these patients is not simple because the cancer patients have higher risk of recurrence of VTE and serious bleeding compared to patients without a malignancy.The aim of this study was to compare the efficacy and safety of DOAC between cancer-associated

VTE (cancer group) and non-cancer-associated VTE (non-cancer group).

PatientsThis study was observed in 94 patients ( cancer group:45 cases vs. non-cancer group: 49 cases) who were treated with DOAC (Rivaroxaban ,Edoxaban and Apixaban) at Kurume University Hospital from June 2015 to December 2016.

ResultsTwenty-three patients (51.1%) in cancer group were VTE due to compression of common iliac vein and/or IVC by big mass of gynecologic cancer. Demographic and baseline clinical characteristics were similar between cancer group and non-cancer group. The mean age in cancer group (67.1±14.2 years) was significantly older than that in non-cancer group (61.9±17.6 years). There was no significantly difference in occurrence of symptomatic recurrent VTE between two groups {3 of 45 (6.7%) in cancer group versus 1 of 49 (2.0%) in non-cancer group}. Regarding to the principal safety outcome of clinically relevant bleeding, there were also no significant differences between two groups (13.3% in cancer group vs. 10.2% in non cancer group). In cancer group, 6 cases (13.3%) died because of progression of the disease. There was no mortality related to VTE in both groups.

ConclusionsThe safety and efficacy of DOACs in cancer group were similar to those in non-cancer group. VTE with cancer can be safely treated witout the additional bleeding risk by the same protocol to usual VTE pts. Further analytical studies with larger samples are required to evaluate the safety and efficacy of this treatment in patients with cancer.

P12-10Paper No: 271Inferior vena cava filter insertion through the popliteal vein: Enabling the percutaneous endovenous intervention of deep vein thrombosis with a single venous approach in a single session

Hong Sung Jung, Dae Jung Kim, Hyo Shin Kim, Ho Kyun Lee, Soo Jin Na Choi, Sang Young ChungDepartment of Surgery, Chonnam National University Medical School, Gwangju, Korea

PurposeTo evaluate the efficiency of placing an inferior vena cava (IVC) filter through the same popliteal vein access site used for peripheral endovascular intervention (PEVI)

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Poster Presentation

in patients with extensive lower extremity deep vein thrombosis.

Materials and methodsThis retrospective study included 21 patients undergoing IVC filter insertion through the popliteal vein over a 3-year period. Patient medical records were reviewed for the location of the deep vein thrombosis, result of filter removal, and total number of endovascular procedures needed for filter insertion and recanalization of the lower extremity venous system. Follow-up lower extremity computed tomography (CT) venography was also reviewed in each patient to assess the degree of filter tilt in the IVC.

ResultsAll patients had extensive lower extremity deep vein thrombosis involving the iliac vein and/or femoral vein. Seventeen patients showed deep vein thrombosis of the calf veins. In all patients, IVC filter insertion and the recanalization procedure were performed during a single procedure through a single popliteal vein access site. In the 17 patients undergoing follow-up CT, the mean tilt angle of the filter was 7.14±4.48° in the coronal plane and 8.77±5.49° in the sagittal plane. Filter retrieval was successful in 16/17 patients (94.1%) in whom filter retrieval was attempted.

ConclusionTranspopliteal IVC filter insertion is an efficient therapy that results in low rates of significant filter tilt and enables a single session procedure using a single venous access site for filter insertion and PEVI.

P12-11Paper No: 358Short-term catheter-directed thrombolysis with low-dose urokinase and mechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis

Soo Jin Na Choi, Hong Sung Chung, Dae Jung Kim, Hyo Shin Kim, Ho Kyun Lee, Sang Young ChungDepartment of Surgery , Chonnam National University Hospital, Gwangju, Korea

PurposeTo evaluate the immediate and late venous patency in patients treated by short-term catheter-directed thrombolysis with low-dose urokinase (UK) for symptomatic lower extremity deep venous thrombosis (DVT).

Materials & methodsEighty-nine consecutive patients (46 women and 43 men; age range, 16-86 years; mean 58.1 years) with DVT who treated by catheter-directed thrombolysis with low-dose UK (applied either as a single intravenous bolus or as a continuous infusion less 480 minutes) were included in this retrospective study. Immediate venous patency was evaluated in terms of technical success (>50% restoration of venous flow at completion of the procedure) and clinical success (significant reduction of clinical symptoms before hospital discharge). Late venous patency was evaluated in terms of anatomic success (>50% venous patency at treated segments) and clinical success. Anatomic success was evaluated in 68 patients who underwent follow-up computed tomography angiography (CTA).

ResultsThirty-seven (41.6 %) patients were given a single bolus injection of UK (range, 4-14 x 104 IU, mean dose, 4.89 ± 2.51 x 104 IU) and 52 (58.4 %) patients had a continuous infusion of UK (range, 12-80, mean dose, 33.73 ± 16.42 x 104 IU) for a mean of 168 minutes (range, 30-420 minutes). Before or after catheter-directed thrombolysis, aspiration thrombectomy with or without mechanical thrombectomy was performed in 69 patients (77.5%). Subsequent angioplasty and/or stent placement was performed in 85 patients (95.5%) for underlying stenosis or residual thrombosis. Immediate technical success was achieved in 87 (97.8 %) patients and immediate clinical success in 80 of 89 (90%) patients. There was no major systemic bleeding complication. Primary patency after a median imaging follow-up interval of 10 months was 57 of 68 (83.8%) patients. Fifty-six of 89 (62.9%) patients were asymptomatic after a median clinical follow-up of 18 months, eleven (12.4%) patients were moderately improved, seven (7.9%) patients were unchanged, and 15 (16.9%) patients had no clinical follow-up.

ConclusionShort-term catheter-directed thrombolysis with low-dose UK infusion and mechanical thrombectomy can be effectively and safely used for lower extremity DVT.

P12-12Paper No: 388A rare complication of acute appendicitis: Superior mesenteric vein thrombosis

Dongjae Jeon, Sangchul YunDepartment of Surgery, Soonchunhyang University, Seoul, South Korea

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BackgroundSuperior mesenteric vein thrombosis is relatively rare and symtoms of which is nonspecific, so early diagnosis could be difficult. We describe two cases of acute appendicitis complicated by SMV thrombosis, in which the thrombosis was identified early with computerised tomography scan and patients have been managed conservatively with antibiotics and anticoagulation.

Case 1A 56-year-old male came to our institute after diagnosed as acute appendicitis with SMV thrombosis and receiving laparoscopic appendectomy.

Case 2A 47-year-old male visit our outpatient clinic after diagnosed as SMV thrombosis. He received laparoscopic appendectomy at local clinic and abdominal pain persisted, so CT scan was done 16 days after the surgery.

Summary & ConclusionSuperior mesenteric venous thrombophlebitis is a rare but potentially fatal complication of acute intra-abdominal suppuration such as appendicitis. Greater use of diagnostic radiological imaging may lead to increased recognition. A high index of suspicion is required to allow prompt recognition and treatment.

annals of vascular diseases - jstage.jst.go.jp

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