Abstracts DGG

An Experimental Approach to Combine Robot-Assistance and Duplex-Navigation for Peripheral Endovascular Interventions

(Abstract ID: 218)

M. Kaschwich¹, F. von Haxthausen², T. Aust², S. Ipsen², V. García-Vázquez², F. Matysiak¹, F. Ernst², M. Kleemann¹

¹Universitätsklinik Schleswig-Holstein (UKSH), Campus Lübeck

²Universität zu Lübeck

Background:

Peripheral endovascular interventions are now standard therapy in vascular medicine. However, an unsolved problem continues to be the need of using hazardous X-rays and kidney toxic contrast agents in these procedures. Navigation by ultrasound could be an alternative in this context. Nevertheless, the hitherto uncomfortable manual transducer guidance makes these interventions a challenging task, as it is difficult to keep the transducer always in the intervention focus and to reproduce settings exactly.

Objectives:

Aim of the research project is the development of a robot assistance system (RAS) for the implementation of ultrasound-supported peripheral endovascular interventions.

Materials and methods:

In cooperation with the Institute of Robotics and Cognitive Systems at the University of Lübeck, the development of an intelligent transducer control system for duplex sonographic navigation of peripheral endovascular interventions took place. For the project, the KUKA LBR iiwa 7 R800 robot system was used.

Results:

We developed a robot assistance system (RAS) which guides the transducer in peripheral endovascular interventions and always presents the intervention focus to the surgeon.

Conclusion:

With the help of RAS it has become possible to perform duplex-controlled peripheral endovascular interventions comfortably as an alternative to conventional X-ray assisted interventions. In addition to the avoidance of X-rays, this has the further effect of real-time information of hemodynamic parameters.

New, innovative model for vascular surgery

(Abstract ID: 612)

S. Härteis¹, T. Aung²

¹Univ. Regensburg

²Universitätsklinikum Regensburg

Background:

The handling of vascular anatomy is only weakly pronounced during the studies of medicine as well as during the clinician's daily routine. So far, there is no model close to clinic for a vascular surgical training. To get a better understanding of the vascular anatomy, the chorioallantoic membrane (CAM) represents a new and innovative tool.

Materials and methods:

Fertilized eggs were incubated for four days in a ProCon egg incubator at 37.8°C and 63% humidity. A window was cut into the eggshell to make the CAM accessible and was sealed with tape again for further incubation of the eggs. On day 10 to 14, the vessels of the chicken embryo are developed in a good stage to use it as model for vascular surgery.

Results:

We describe the CAM as a model system to improve the fine motor skills, the precision and the safety in handling surgical instruments. Furthermore, the fine structures of the vessels can be displayed using the CAM. Another option for the application of the CAM model is the training of advanced physicians in the plastic microsurgery / visceral surgery as well as in the minimal invasive surgery using the Da-Vinci operation robot. In addition, the handling of vascular preparation/-dissection/-anastomosis should be practiced using the CAM model.

Conclusion:

In conclusion, the CAM that is easy accessible and responses to injury represents a new and innovative tool with a variety of applications for students, resident physicians and experienced physicians including (1) the training of the vascular anatomy, (2) improvement of fine motor skills/precision/safety, (3) the training for microsurgery, and (4) minimal invasive surgery.

Indocyanine green fluorescence angiography can help to detect sigmoid malperfusion in aortic aneurysm repair

(Abstract ID: 1025)

K. Nowak¹, P. Victorov¹, A. Amphlett¹, I. Karampinis¹, M. Keese¹

¹RoMed Klinikum Rosenheim

Background:

Malperfusion of the sigmoid and descending colon is a significant risk in open aortic aneurysm repair contributing to morbidity and mortality. Intraoperative laserfluorescence with indocyanine green (ICG) is an established method in colorectal surgery to evaluate bowel perfusion before and after anastomosis placement. We hypothesized that the ICG perfusion might be useful in bowel evaluation after aortic aneurysm repair of the sigmoid and descending colon.

Materials and methods:

A series of 5 patients (4 male, 67+/-11yrs of age) with infrarenal aneurysms were evaluated for the intraoperative use of ICG fluorescence. 3 of the aneurysms were ruptured.

Results:

3 of 5 patients showed a homogenous perfusion of the descending and sigmoid colon after aortic repair. 2 of 5 patients showed sigmoid malperfusion on table after aortic reconstruction in ICG fluorescence (video). In both cases the surgeon did not suspect malperfusion of the sigmoid by vision alone. In both cases a reinsertion of the inferior mesenteric artery into the aortic prosthesis has been performed (picture). After revascularization ICG fluorescence showed a homogenous perfusion of the sigmoid colon (video). Both revascularized patients had an uneventful postoperative course.

Conclusion:

ICG perfusion assessment of the sigmoid colon after infrarenal aortic repair can give valuable information to the surgeons. Malperfusion of the sigmoid colon in fluorescence assessment might result in revascularization or early postoperative endoscopic assessment.

Real word data of contemporary Popliteal artery Aneurysm Treatment – Peri- and postoperative results of 794 cases from the multicenter POPART registry

(Abstract ID: 739)

M.-E. Leinweber¹, G. Jung¹, D. Gray¹, W. Derwich¹, T. Dietrich¹, R. T. Grundmann¹, T. Schmitz-Rixen¹

¹Universitätsklinikum Frankfurt am Main

Background:

The Popliteal Artery Aneurysm (PAA) is a rare vascular disease with a prevalence of 0,1–1%. Evaluating the comparability of endovascular repair (ER) to open repair (OR) has become an issue of growing concern in current PAA therapy. The POPART-registry was initiated in 2014 to provide real-world data on contemporary PAA treatment and has since developed to one of the largest patient collectives to this entity worldwide. Perioperative outcome and midterm results of Follow-up (FU) data of OR and ER are presented.

Materials and methods:

POPART is a multicenter, multinational registry on comparative peri- and postoperative outcomes of ER and OR PAA repair. The data collection is based on the online survey-tool Surveymonkey. All patients older than 18 years who underwent PAA treatment can be considered for inclusion; patients have to sign an informed consent before study participation. High data quality is ensured by continuous monitoring and plausibility check. Presently, 41 vascular institutions are participating in POPART.

Results:

From 06/2014 to 08/2019, a total of 794 cases were collected in the POPART-registry. N=662 patients were treated with OR, n=106 underwent ER, n=23 stayed under surveillance, and two patients underwent lysis without surgical treatment. N=4 ER patients had to be converted to OR. ER patients were significantly older (ø=71,2 years) than patients treated with OR (ø=67,3 years; p<0.005). Despite a higher incidence of obesity and smoking history in the OR group (p<0.05), no other significant differences in comorbidities were observed. There was a high coincidence of a contralateral PAA in both groups (OR=52% (n=344) and ER=57,5% (n=61) p>0.05). 32% of OR and 40,6% of ER also had an abdominal aortic aneurysm (p>0.05).

Whereas OR and ER patients had similar findings in PAA length and diameter (p>0.05), they differed in their clinical presentation: While 50,3% (n=333) OR patients were symptomatic, only 29,2% (n=31) symptomatic patients underwent ER (p<0.05). N=149 OR patients (22,5%) and n=11 ER patients (10,3%) had to be operated in an emergency setting because of acute/critical limb ischemia or rupture. Impaired wound healing (OR: 7,1% (n=47); ER: 2,8% (n=3) p> 0.05) and major bleeding (OR: 3,9% (n=26); ER: 2,8% (n=3), p> 0.05) were the most observed postoperative complications. Emergency patients showed a significantly worse outcome in both groups than patients in an elective setting. ER patients had a shorter in-hospital stay than OR patients (7,97 days vs 12,8 days, p<0.005). FU was available for 360 OR patients (54,4%) and 47 ER patients (44,3%). Primary Patency rates after 12 and 24 months (m) were significantly better for OR (12m: 84,7% vs. 44,7%, p<0.005; 24m: 80,3% vs. 36,2%, p<0.005). In the OR collective, patients treated with a vein graft showed significantly better patency rates after 12m and 24m than patients with prosthetic graft (12m: 89,1% vs. 73,4%; 24m: 85,2% vs. 67,0%, p<0.005).

Conclusion:

These midterm results provide valuable insights into the current treatment of PAA patients in German-speaking countries. Despite good perioperative results and significant shorter in-hospital stay for ER in elective setting, the primary patency rates in ER patients after 12 and 24 months are inferior compared to the results of OR. Due to incomplete FU data, particularly for ER, a selection bias could not be excluded.

ER might be considered in well-selected patients, but our data suggest poor outcome in emergency setting. OR remains gold standard.

Visible collateral vessel development in patients with peripheral artery disease

(Abstract ID: 879)

F. Dahi¹, D. Gray¹, T. Schmitz-Rixen¹

¹Uniklinik Frankfurt am Main

Background:

Peripheral artery disease (PAD) is a common manifestation of atherosclerosis. Collateral vessel development is a main goal in PAD patients with stage IIb as conservative treatment to get better walking performance. In this study we analyzed the associations of the number and size collateral vessels with the ankle-brachial index (ABI) and walking distance in patients with isolated superficial femoral artery (SFA) occlusion. We hypothesized that PAD patients with Fontaine stage II would have more collateral vessels compared to Fontaine stages III-IV.

Materials and methods:

All intra-arterial angiographies performed in our institution between January 2014 and December 2016 were retrospectively screened for patients with PAD stage II-IV with isolated occlusion of the SFA with at least 5 cm. Fontaine Classification was used for PAD stage definition. Number and size of collateral vessels in the angiography were analyzed. We then compared patients in stage II with III/IV. Patients with more than 8 collateral vessels or 4-7 collateral vessel with a diameter of more than 50% of the SFA diameter were defined as having "good" collateral vessels. Clinical data included age, gender, comorbidities, walking distance and ABI were also assessed. Independent t-test was used to compare continuous variables.

Results:

From overall 101 viewed angiographies a total of 80 patients with PAD and isolated SFA occlusion were included in the analysis. Fifty-two patients (15 female, 37 male; mean age, 68 years; range, 29–96 years) had PAD stage IIb and twenty-eight (15 female, 13 male; mean age, 74 years; range, 53–89 years) stage III/IV. Patients with good collateralization in stage II were n=46 (88%) vs. n=28 (100%) in stage III/IV. Patients in stage II had significant higher number of collateral vessels, but these vessels had a small diameter (p=0,032) compared to patients in stage III and IV. Surprisingly, there was no significant difference in ABI value and walking distance in the group with patients with stage II compared to the patients with stage III/IV (ABI Index 0.42 vs. 0.44 (p>0.05), walking distance 60.9 m vs 52.6m (p>0.05)). This could be a result of to the small sample size.

Conclusion:

PAD patients with stage II showed a higher number of collateral vessels but the ABI value and walking distance were not significant higher compared to patients with stage III/IV.

Comorbidity Patterns among Patients with Peripheral Arterial Occlusive Disease in Germany – a Trend Analysis of Health Insurance Claims Data

(Abstract ID: 145)

C.-A. Behrendt¹, T. Schwaneberg¹

¹Universitätsklinikum Hamburg-Eppendorf

Background:

Patients suffering from peripheral arterial occlusive disease (PAOD) are a central target population for multidisciplinary vascular medicine. This study aims to illuminate the trends in treatment patterns and comorbidities utilizing up to date longitudinal patient-related data from Germany.

Materials and methods:

This study is a retrospective health insurance claims data analysis of patients insured by the second largest health insurance provider in Germany, BARMER. All hospitalisations of patients with PAOD between 2008 and 2016 were included. The comorbidities were categorized with Elixhauser groups by using WHO ICD-10 codes and summarized as the linear van Walraven score (vWS). A trend analysis of the comorbidities was performed after standardisation by age and sex.

Results:

A total of 156,217 patients underwent 202,961 hospitalisations (49.4% for critical limb-threatening ischaemia in 2016) with PAOD during the study period. While the estimated annual incidence of PAOD among the BARMER cohort slightly decreased (-4.4%), we observed an increase for the prevalence of PAOD ( 23.1%), number of hospitalisations ( 25.1%), peripheral vascular interventions (PVI, 61.1%), and disease-related reimbursement costs ( 31%) from 2008 to 2016. Meanwhile, a decreasing number of major amputations (-15.1%) appeared. The proportion of patients aged 71-80 years increased about 10% among PAOD patients and the mean vWS also increased by 2 points during the study period. Considerable increases were found in the rates of hypertension, renal failure, and hypothyroidism, whereas the rates of diabetes and congestive heart failure decreased over time.

Conclusion:

Increasing numbers of PVI performed to these ageing and sicker patients cause rising costs but correlate with decreasing major amputation rates.

Significant association between the neurological status on admission and the in-hospital risk of stroke or death following carotid endarterectomy and carotid artery stenting

(Abstract ID: 615)

P. Tsantilas¹, C. Knappich¹, S. Schmid¹, M. Kallmayer¹, T. Breitkreuz², A. Zimmermann¹, A. Kuehnl¹, H.-H. Eckstein¹

¹Klinikum Rechts der Isar, München

²aQUA - Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen, Göttingen

Background:

Purpose of this observational study was to describe and to analyze the association between the last neurologic event and the risk of any inhospital stroke or death in patients treated with carotid endarterectomy (CEA) or carotid artery stenting (CAS) under routine conditions in Germany.

Materials and methods:

Secondary data analysis based on the German statutory quality assurance database for carotid procedures between 2009-2014. The primary outcome was any periprocedural stroke or all-cause death until discharge. Descriptive results were calculated using statistical standard methods. To analyze the association between neurological status on admission and the outcome, a multilevel multivariable regression analyses adjusting for known confounders and clustering of patients within hospitals was performed.

Results:

From a total of 182,033 patients documented between 2009 and 2014, 144,347 patients treated with CEA and 14,794 patients treated with CAS were included in the analysis. In total, there were 108,379 men (68%) and the mean age of cohort was 70.5±9.1 years.

The primary outcome of any in-hospital stroke or death in patients treated by CEA was 2.0%. The raw risk of any in-hospital stroke or death was 1.4% in asymptomatic patients and 3.0% in symptomatic patients treated with CEA. Within the group of symptomatic patients, risk of any in-hospital stroke or death after CEA increased from 1.2% (amaurosis fugax, AFX), 2.3% (TIA), 2.8% (minor stroke), 4.4% (major stroke), 4.8% (crescendo TIA, cTIA) to 9.0% (stroke in evolution, SIE).

The primary outcome of any in-hospital stroke or death in patients treated by CAS was 3.6% (n=538/14794). The raw risk of any in-hospital stroke or death was 1.7% in asymptomatic patients and 6.1% in symptomatic patients treated by CAS. Within the group of symptomatic patients, risk for any in-hospital stroke or death increased from 1.0% (AFX), 4.1% (TIA), 4.1% (minor stroke), 5.4% (major stroke), 5.2% (cTIA) to 11.7% (SIE).

Regression analysis revealed that the severity of initial neurologic symptoms was associated with an increasing risk for any in-hospital stroke or death in both patients treated for CEA and CAS.

Conclusion:

Perioperative risk for any stroke or death did not significantly differ between asymptomatic patients and patients with AFX but between asymptomatic patients and patients with TIA, stroke, crescendo TIA or SIE.

Short-term outcomes of a consecutive series of 708 patients with acute limb ischaemia – data from a large single-center cohort

(Abstract ID: 646)

K. Stoklasa¹, S. Dallmann-Sieber¹, T. Stadlbauer¹, H.-H. Eckstein¹

¹Klinikum rechts der Isar, München

Background:

Acute ischemia of the lower limb (ALI) is a frequent emergency in vascular medicine with a high periprocedural mortality and amputation rate. The aim of this study is to assess the clinical presentation, outcomes potential risk variables in a large single-center patient cohort.

Materials and methods:

Retrospective analysis of 708 patients (55% male, median age 72 years) with the hospital main diagnosis of an ALI (I74.0, I74. I74.5), treated between January 2004 and December 2016. The electronic patient files were used to record clinical and procedural variables. Endpoints of this study are 30-day mortality, 30-day major amputations and other serious complications. Statistics were performed by univariate and multivariate analysis (chi-square, t-test, wald-test).

Results:

According to the TASC classification, 22%, 38%, 35% and 5% were TASC grade I, IIa, IIb and III ischemia. An occlusion of the femoral artery (31.6) and the occlusion of a bypass (20.1%) were the most common closure localizations, followed by an occlusion of the iliac artery (19.4%) and an occlusion below the knee (5.1). An occlusion of the aorta was detected in 6%.Most of the patients were classified as ASA stage 3 and 4 (82%), followed by ASA stage 2 with 17.9%. The overall collective yielded the typical cardiovascular disease and risk factors like coronary artery disease (39.5%), hypertension (68.6%), peripheral artery disease (38.1%), smoking (41.7%) and atrial fibrillation (33%). Furthermore, 42% received preoperative therapy with statins. Acute limb ischemia was caused by arterial thrombosis (58%), cardiac embolism (37%) embolizing or thrombosed popliteal artery aneurysm (5%). The treatment modalities included open surgical thrombectomy/embolectomyor other surgical procedures (43%), hybrid procedures (23%). primary bypass surgery (18%) and endovascular treatment alone (14%). A primary amputation was necessary in 2% of all cases. The 30-day-mortality was 8% and the 30-day major amputation rate 9%. Bleeding complications occured in 4% and reocclusions in 15% of the patients. Major adverse cardiac events were were documented in 14%, respiratory failure in 11% and renal failure in 9% respectively.A multivariate analysis revealed that patients with an advanced TASC ischaemia and patients with ASA status 2 to 4 have a significantly higher 30-day-mortality (OR 3.2, 95% CI 1.6-6.7), whereas a preoperative statin therapy appears to be protective (OR 0.3, 95% CI 0.1-0.6). Almost in line with the results of 30 day mortality, the amputation was significantly higher for patients with advanced ischaemia.

The reocclusion rate and occurence of internistic complications also showed almost similar results compared to the results of mortality and amptation rate. Additionally, patients suffering from coronary artery disease are significantly more prone to the risk of severe general complications.

Conclusion:

These results demonstrate a combined death and amputation rate of almost 17%. Patients with advanced ischaemia, multimorbidity (increased ASA classification) are at an even higher mortality and amputation risk within 30 days.

Open repair of a segment IV aortic rupture using extracorporeal membrane oxygenation

(Abstract ID: 129)

J. P. Frese¹, M. Schomaker¹, I. Hinterseher¹, S. Omran¹, A. Greiner¹

¹Charité Universitätsmedizin Berlin

Background:

The ongoing development of endovascular equipment is changing the standards in the treatment of type IV thoracoabdominal aneurysm (TAA) and segment IV penetrating aortic ulcer (PAU). A growing percentage of TAA can be excluded by fenestrated or branched endovascular grafts. In some cases, endovascular treatment is not feasible due to a difficult anatomy or an emergency situation. These cases represent a special challenge for open surgery, too. We present a HD video of an emergency thoracoabdominal aortic repair using extracorporeal membrane oxygenation (ECMO) to maintain renal, visceral, and lower extremity perfusion.

Materials and methods:

A 59 yo male patient was admitted to our emergency department in hypovolemic shock due to a penetrating aortic ulcer (PAU) in the reno-visceral segment of the aorta. As the adjacent abdominal and thoracic aorta were too narrow in diameter, an endovascular treatment by a T-branch or chimney technique was not feasible. Via left femoral access, a veno-arterial ECMO for distal perfusion was established. After left thoracoabdominal incision, the reno-visceral segment of the aorta was exposed, the visceral branches were cannulated separately, and the aorta was repaired by a Dacron graft.

Results:

The postoperative course was uneventful. Renal and bowel function remained normal. The patient was discharged home on the 11th postoperative day.

Conclusion:

In the endovascular era, open thoracoabdominal aortic repair remains to be a valuable option for selected patients. In emergency cases, open surgery sometimes represents the last resort. In the future, we assume that in open surgery, we’ll see the more complex cases and that we’ll gain more experience in redo aortic surgery after previous endovascular repair.

Impact of weekend treatment on short-term and long-term survival after urgent repair of ruptured aortic aneurysms in Germany

(Abstract ID: 151)

C.-A. Behrendt¹, H. Rieß¹

¹Universitätsklinikum Hamburg-Eppendorf

Background:

There is some evidence that weekend admission to the hospital is associated with worse outcomes compared with weekday admission. However, only a few studies have focused on weekend vs weekday surgery outcomes. This study aimed to determine whether there is a weekend effect on outcomes in the treatment of ruptured aortic aneurysms in Germany.

Materials and methods:

Health insurance claims of Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate short-term and long-term mortality after weekend vs weekday treatment of ruptured aortic aneurysm. Patients undergoing endovascular repair (ER) or open surgical repair (OSR) between January 2008 and December 2016 were included in the study. Both propensity score matching and regression methods were used to adjust for confounding.

Results:

There were 1477 patients in the cohort, of whom 517 (35.0%) underwent ER and 960 (65.0%) OSR. Overall, 995 (67.4%) patients underwent an operation on weekdays (Monday to Thursday), and 482 (32.6%) patients underwent an operation on a weekend (Friday to Sunday). In multivariable models, patients who underwent an operation on a weekend were at higher risk of in-hospital death after OSR (49.2% vs 38.0%; odds ratio [OR], 1.61; P = .001), and there was a trend toward higher in-hospital mortality after ER (29.5% vs 21.2%; OR, 1.55; P = .056). The ER of thoracic or thoracoabdominal aortic ruptures was associated with significantly higher in-hospital mortality compared with ER of abdominal aortic aneurysm (OR, 1.69; P = .026).

Conclusion:

Weekend repairs of ruptured aortic aneurysms are associated with worse in-hospital survival compared with weekday surgery. ER of thoracic or thoracoabdominal aortic ruptures is associated with worse in-hospital survival compared with ER of ruptured abdominal aortic ruptures. This might be an international phenomenon requiring joint learning and action in times of centralization of aortic procedures.

Quality Indicators in Peripheral Arterial Occlusive Disease Treatment: A Systematic Review

(Abstract ID: 146)

A. Larena-Avellaneda¹, H. Rieß¹, E. S. Debus¹, C.-A. Behrendt¹

¹Universitätsklinikum Hamburg-Eppendorf

Background:

This systematic review aimed to identify evidence based quality indicators for invasive revascularisation of symptomatic peripheral arterial occlusive disease (PAOD).

Materials and methods:

A systematic search of clinical practice guidelines, consensus statements, systematic reviews, and meta-analyses reporting quality indicators in patients undergoing invasive open and percutaneous revascularisations for symptomatic PAOD (PROSPERO registration number: CRD42019116317) was performed. Furthermore, a grey literature search was conducted involving databases of professional vascular medical organisations. The identified publications were screened independently by two reviewers for possible inclusion and full texts of potentially relevant records were independently evaluated for eligibility. Disagreement was resolved by discussion involving a third reviewer.

Results:

From 685 articles initially identified, one systematic review and one consensus statement focusing on quality indicators were selected for inclusion in the review. From these sources, a total of three process quality indicators matched the search criteria: one on pharmacological intervention, another on smoking cessation, and a third on surveillance of lower extremity vein bypass grafts. The grey literature search revealed an additional 31 structure, process, and outcome quality indicators.

Conclusion:

This study revealed a lack of published evidence based quality indicators concerning invasive treatment for PAOD in the literature. An additional 31 indicators from the databases of professional societies and organisations have not been incorporated in prior guidelines. Interestingly, no indicator related to patient reported outcomes could be identified from either high quality sources or grey literature. Further research and harmonisation of different quality indicators is needed to enhance their evidence and subsequently improve patient centred decision making on invasive treatment.

Multidisciplinary team decision is rare and decreasing in percutaneous vascular interventions despite positive impact on in-hospital outcomes

(Abstract ID: 150)

A. Larena-Avellaneda¹, H. Rieß¹, E. S. Debus², C.-A. Behrendt¹

¹Universitätsklinikum Hamburg-Eppendorf

²Universitätsklinikum, Hamburg

Background:

Worldwide prevalence of peripheral artery disease (PAD) is increasing and peripheral vascular intervention (PVI) has become the primary invasive treatment. There is evidence that multidisciplinary team decision-making (MTD) has an impact on in-hospital outcomes. This study aims to depict practice patterns and time changes regarding MTD of different medical specialties.

Materials and methods:

This is a retrospective cross-sectional study design. 20,748 invasive, percutaneous PVI of PAD conducted in the metropolitan area of Hamburg (Germany) were consecutively collected between January 2004 and December 2014.

Results:

MTD prior to PVI was associated with lower odds of early unsuccessful termination of the procedures (Odds Ratio 0.662, p < 0.001). The proportion of MTD decreased over the study period (30.9 % until 2009 vs. 16.6 % from 2010, p < 0.001) while rates of critical limb-threatening ischemia (34.5 % vs. 42.1 %), patients´ age (70 vs. 72 years), PVI below-the-knee (BTK) (13.2 % vs. 22.4 %), and rates of severe TASC C/D lesions BTK (43.2 % vs. 54.2 %) increased (all p < 0.001). Utilization of MTD was different between medical specialties with lowest frequency in procedures performed by internists when compared to other medical specialties (7.1 % vs. 25.7 %, p < 0.001).

Conclusion:

MTD prior to PVI is associated with technical success of the procedure. Nonetheless, rates of MTD prior to PVI are decreasing during the study period. Future studies should address the impact of multidisciplinary vascular teams on long-term outcomes.

Fenestrated versus debranching TEVAR for endovascular treatment of aortic arch and descending aortic lesions

(Abstract ID: 964)

N. Konstantinou¹, T. Kölbel², E. S. Debus³, F. Rohlffs², N. Tsilimparis¹

¹Klinikum der Universität München, Ludwig-Maximilian Universität

²Universitäres Herzzentrum Hamburg

³Universitäres Herz- und Gefäßzentrum, Hamburg

Background:

Thanks to the advancements in endovascular surgery, increasingly more aortic arch pathologies are tackled either totally endovascularly or through hybrid procedures. Cervical debranching followed by thoracic endovascular aortic repair (TEVAR) to create a better proximal landing zone is a well-established technique in Ishimaru zone 2, but total endovascular repair with a fenestrated endograft has not been adequately studied yet. This is the first direct comparison of the two techniques.

Materials and methods:

This was a single-center, retrospective, comparative study between patients that underwent debranching-TEVAR (dTEVAR) or fenestrated TEVAR (fTEVAR) for thoracic aortic lesions with a proximal landing zone in Ishimaru Zones 1 and 2. The stent-grafts in the fTEVAR group were based on the ZFEN platform (COOK Medical, Bloomington, IN) and had a single fenestration for the left subclavian artery and a scallop for the left carotid artery. Patients in the dTEVAR group underwent a hybrid repair with a thoracic stent-graft (COOK Medical) and cervical debranching on the left side to preserve flow in the left subclavian artery. Emergency cases were excluded. Endpoints of the study were technical success, 30-day outcomes of the two techniques as well as re-interventions on follow-up.

Results:

From 2012 to 2018, 19 patients (58% male) underwent elective fTEVAR (Group A) and 17 patients (82% male) underwent elective dTEVAR (Group B). Mean age ± SD in Group A was 65.8 ± 2 years and in Group B 68 ± 3 years. The two groups were comparable regarding comorbidities, except for peripheral arterial disease (PAD): 26% (5/19) of patients in Group A were suffering from PAD and none in Group B (p=0.049). Dissection or post-dissection aneurysm was the indication for treatment in 5/19 patients in the fTEVAR group and in 12/17 patients in the dTEVAR group (26.3% vs. 70.6%; p=0.018); the rest were for degenerative aortic aneurysms. Left carotid-subclavian bypass was performed in 15/17 (88%) patients in Group B and transposition of the left subclavian artery on the ipsilateral carotid artery in 2/17 (12%) patients; timing of the debranching operation was before TEVAR in 14/17 (82.4%) patients, synchronous with TEVAR in 2/17 (11.8%) cases and after the TEVAR procedure in 1 patient (5.9%). Technical success was achieved in all cases but one dTEVAR with a small Type Ia endoleak in the final angiogram that was however not deemed relevant for an immediate re-intervention; total operation time (combined OR-time for the hybrid procedures) was significantly lower in the fTEVAR group (total mean OR-time in Group A 191 ± 120 minutes vs. total mean OR-time in Group B 300 ± 93 minutes; p=0.005). There were no deaths or major strokes in the early postoperative period (30 days). 6/17 (35%) patients in Group B suffered a complication related to the debranching operation. Mean follow-up was 14.6 ± 2 months for Group A and 17 ± 2 months for Group B. No aneurysm-related deaths occurred during follow-up. Two patients in Group A and five patients in Group B received a secondary re-intervention related to the thoracic stent-graft during the follow-up period (p=ns) to complete or optimize the repair. Primary patency of the LSA or the carotid-subclavian bypass was 100% in both groups.

Conclusion:

Both techniques showed excellent patency rates for the target vessel and a high rate of clinical success. However, operation times were significantly lower in the fenestrated-TEVAR group and the complications of the debranching procedures were avoided.

Ten Years of Urgent Care of Ruptured Abdominal Aortic Aneurysms in a High-Volume-Center

(Abstract ID: 147)

C.-A. Behrendt¹, E. S. Debus²

¹Universitätsklinikum Hamburg-Eppendorf

²Universitäres Herz- und Gefäßzentrum, Hamburg

Background:

The urgent treatment of ruptured abdominal aortic aneurysms (rAAA) remains a challenging condition with devastating morbidity and mortality. Available studies are often limited due to a significant selection bias. This study aims to illuminate real-world evidence using comprehensive data from electronic health records, registries, postmortem findings, and administrative data on all consecutively treated patients presenting with rAAA at a tertiary care center.

Materials and methods:

This is a retrospective cross-sectional cohort study covering consecutively treated patients with rAAA between 2009 and 2018. All non-invasive treatments, fatalities, and invasive repairs were included. Information on patient´s characteristics, prehospital and inpatient care were gathered. Short-term outcomes and long-term survival were analyzed for relevant subgroups.

Results:

In total, 139 patients with rAAA (median age 75 years and 20.9% females, 79.9% infrarenal) were treated increasingly frequent by endovascular aortic repair (EVAR) when compared to open-surgical aortic repair (OSR) during the study period (16.7% in 2009 to 33.3% in 2018, p<0.05). The rate of patients who had been turned down for rAAA repair was 10.8%, and the overall in-hospital mortality was 43.2%. Perioperative morbidity and mortality were similar for EVAR and OSR, although patients treated by OSR presented with a lower mean Glasgow Coma Scale during the prehospital (12.7 vs. 14.3) and inpatient care (12.7 vs. 14.4) (both p<0.001), higher rates of intubation (12.8% vs. 10.9%, p<0.001), lower systolic blood pressure (115mmHg vs. 127mmHg, p=0.042), and had more often a cardiac arrest before the operation (14.1% vs. 2.3%, p<0.001). Higher patient´s age (Odds Ratio, OR 1.09; Hazard Ratio, HR 1.06), history of stroke or transient ischemic attack (OR 5.30; HR 2.64), higher serum creatinine (OR 1.81; HR 1.31), and occurrence of colonic ischemia (OR 11.31; HR 2.82) were significantly associated with higher odds of dying in hospital and in the longer term, respectively.

Conclusion:

We observed comparable outcomes following OSR and EVAR although hemodynamically instable patients were more likely to be treated by OSR. This study also confirmed the impact of colonic ischemia as a devastating complication following rAAA repair emphasizing the need of further reflection by the vascular community.

Predictors of bleeding or anemia requiring transfusion in complex endovascular aortic repair and its impact on outcomes in health insurance claims

(Abstract ID: 148)

C.-A. Behrendt¹, T. Kölbel¹

¹Universitätsklinikum Hamburg-Eppendorf

Background:

This study aimed to determine predictors and outcomes associated with bleeding or anemia requiring transfusion (BAT) after fenestrated or branched endovascular aneurysm repair (FB-EVAR).

Materials and methods:

Health insurance claims data of Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate BAT in elective FB-EVAR performed between 2008 and 2017. International Classification of Diseases and German Operations and Procedure Key codes were used.

Results:

A total of 959 patients (24.8% with BAT) matching the inclusion criteria were identified during the study period. Compared with patients without BAT, patients with BAT were older (74.4 vs 73.0 years; P = .015) and suffered more frequently from congestive heart failure (18.5% vs 9.4%), cardiac arrhythmias (26.9% vs 14.7%), and hereditary or acquired coagulopathy (31.9% vs 6.2%; all P < .001). Coagulopathy (odds ratio [OR], 3.65; 95% confidence interval [CI], 2.29-5.84), female sex (OR, 2.67; 95% CI, 1.78-4.00), and multiple comorbidities (OR, 1.10; 95% CI, 1.07-1.14) were independent predictors of BAT (all P < .001). BAT was associated with higher in-hospital (11.3% vs 2.6%), 30-day (12.2% vs 3.1%), and 90-day (18.5% vs 4.4%) mortality (all P < .001). Furthermore, myocardial infarction (23.9% vs 2.8%) and paraplegia (9.7% vs 0.7%) were more frequent in the BAT group (all P < .001). In multivariable analyses, BAT was associated with worse short-term (OR, 3.19; 95% CI, 1.63–6.33; P = .001) and long-term survival (hazard ratio, 1.62; 95% CI, 1.24-2.11; P < .001).

Conclusion:

Patients with hereditary or acquired coagulopathy, patients with multiple comorbidities, and women are at higher risk for development of BAT after FB-EVAR. The occurrence of this event was strongly associated with higher major complication rates and worse short-term and long-term survival. This emphasizes a need to further illuminate the value of patient blood management in FB-EVAR.

Material-associated influences of patch material on the development of intimal hyperplasia after Internal Carotid Artery Endarterectomy (CEA)

(Abstract ID: 538)

L. Poser¹, U. Barth¹, F. Meyer¹, Z. Halloul¹, M. Görtler¹

¹Universitätsklinikum Magdeburg

Background:

The risk of stroke can be significantly reduced by means of thrombendarteriectomy with patch plasty of a high-grade asymptomatic stenosis of the internal carotid artery (CEA) with a correspondingly low complication rate of less than 3 %. The postoperative recurrence of a stenosis due to the so-called intimal hyperplasia may be related to the patch material used. The aim of this study is the assessment of the influence of two patch materials in comparison (Dacron/PTFE) used in vascular occlusion onto postoperative recurrent stenosis due to intimal hyperplasia.

Materials and methods:

All perioperative patient-, local finding- and early postoperative outcome-associated data were documented in a study-specific computer-based registry including postoperative Duplex ultrasonographic control findings (using graduation of intimal hyperplasia in %), which were obtained from all consecutive patients treated with Dacron and PTFE patches for vascularsurgical CEA using regional anesthesia during a 12-year-time period and over a follow-up period of two years as maximum (=inclusion criteria vs. exclusion criteria such as other patch material [vein, pericardium], other surgical techniques [eversion, direct suture, interponate] and other causes of the operation than arteriosclerotic stenosis [aneurysm] and recurrence operations) for the purpose of quality assurance and description of daily vascularsurgical practice (study design, systematic clinical single-center prospective observational study with retrospective data analysis).

Results:

Over the investigation period from 07/01/1994 to 06/19/2012, 567 CEA patients treated with Dacron-Patch were compared with 317 subjects treated with PTFE-Patch. Interestingly, a 10 % intimal hyperplasia was found in 8.3 % of cases, a 50 % intimal hyperplasia in 2.6 % of cases and a 70 % intimal hyperplasia in 1.5 % of cases, respectively. The latter two (just not significant) occurred more frequently in patients treated with Dacron (p=0.051). The significantly more frequent bleeding with Dacron patch treatment (revealed by univariate analysis) could be explained by perioperative factors that have changed over a long period of time in addition to the patch type, the consideration of which in the multivariate analysis did not lead to any difference in bleeding rates between the two patch types. The factors tested for their impact onto the risk or development of a re-stenosis were gender, age, concomitant diseases such as diabetes mellitus and hyperlipidemia, smoking as well as the expertise of the first surgeon. Interestingly, there was a correlation between gender and age with recurrent stenosis: Men showed a higher postoperative re-stenosis rate and the higher the patient’s age at the time of CEA the higher the re-stenosis risk. With regard to the postoperative dynamics of re-stenosis development, it starts (already) after 6 weeks, reaches a steady state after 1.5 years and, ultimately, leads only in a small percentage to high-grade recurrent stenoses.

Conclusion:

The results show similarities with those reported in the literature. There is a correlation between the incidence of intimal hyperplasia and following re-stenosis and patient’s gender as well as age. PTFE showed a trend of a lower recurrent stenosis rate than Dacron but with no significant difference prompting to use rather PTFE (if there is a choice). However, further studies appear to be required to elucidate re-stenosis rate after the today’s favored patch plasty using xenogenic material obtained from bovine pericardium.

The inside out system (Surfacer) – single center use demonstrates safe and effective performance and significant reduction in radiation in total central venous occlusion

(Abstract ID: 578)

T. Steinke¹

¹schoen klinik düsseldorf

Background:

Central venous stenosis and occlusion is an increasing burden especially in ESRD Patients. We report the results of the prospective, singlecenter, observational registry for the treatment of patients with limited or diminishing upper body venous access or pathology impeding standard access methods.

Materials and methods:

The purpose of this registry is to assess the clinical outcomes of the Surfacer-Inside-Out-Access-Catheter-System used in clinical routine according to the approved commercial indications. The Surfacer System is a novel device designed to facilitate reliable upper body central venous access suitable for patients with upper body venous occlusions or other conditions that preclude central venous access by conventional methods. 16 patients were enrolled between Oct.-2016 and Sept.-2019. Patients are presented with a variety of occlusion types, including bilateral internal jugular (BIJ) and subclavian (SC) occlusion, brachiocephalic (BC) occlusion, superior vena cava (SVC) occlusion above the azygos and patients with total occlusion of the SVC.

Results:

In all patients enrolled in the registry, central venous catheters were placed according to labeled indications with a 100%success in achieving patency and access. Absence of adverse events in data reported for all treated patients. All primary safety and performance endpoints were met. Mean fluro-time was 3,26min ( max. 6,54min, min. 1,33min.) and the launch of the surfacer inside out system reduced the radiation exposure with an average of 5,163 Gy/cm^2 (minimal 1,7, maximum 29,2, median 3,05 Gy/cm^2). This shows a remarkable reduction in intraoperative radiation dose and fluro-time in comparison to standard recanalisation procedures in central venous occlusion.

Conclusion:

Positive results were demonstrated supporting the safety and clinical utility of the Surfacer-Inside-Out-Access-Catheter-System including a reduction in intraoperative radiation dose and fluro-time.

Reduction in radiation using intraoperative ultrasound and the 4 French instead of 6 Fr. EndoAVF catheter system in creating endovascular AV-fistulas

(Abstract ID: 584)

T. Steinke¹

¹schoen klinik düsseldorf, Tönisvorst

Background:

Endovascular AV-fistula creation is an increasing field of innovation and technical development. We report the results of a single center prospective observational study for the creation of endovascular AV-Fistulas in endstage renal disease (ESRD) patients with the new 4Fr. EndoAVF-System.

Materials and methods:

The purpose of this observational study is to assess the clinical outcomes of the 4Fr. EndoAVF-System used in clinical daily practice according to the approved commercial indications in Europe especially focusing on intraoperative radiation dose. The 4Fr. WavelinQ-System is a novel device designed to facilitate arterial and venous access from the wrist to create an endovascular AV-Fistula between the proximal ulnar or radial artery and the concomitant vein for hemodialysis access.10 patients were enrolled between Sept.2017 and Sept.2018 and compared to a previous series of 16patients being treated with the 6Fr.-System before.

Results:

In all patients, catheters were placed according to indications with a 100%success in achieving radial arterial and venous access. There was one conversion due to an active bleeding at the intended creation site. Although some of the steps can be done by ultrasound guidance, angiographic imaging during the procedure is still required. With the 6Fr.-System we had an average radiation dose of 2,15Gy/cm^2 (minimal 0,82, maximal 4,89, median 1,77Gy/cm^2). The launch of the 4Fr.-System more than halved the radiation exposure with an average of 0,91Gy/cm^2 (minimal 0,41, maximal 1,74, median 0,78Gy/cm^2), showing a remarkable reduction in intraoperative radiation dose.

Conclusion:

Positive results demonstrated safety and clinical utility of the 4Fr. EndoAVF-System as a primarily option gaining radial access for creating endovascular AV-fistulas for ESRD-patients and proving a significant reduction in radiation dose.

Toll-like receptor 2/6 stimulation by the lipopeptide MALP-2 promotes collateral growth

(Abstract ID: 660)

K. Troidl¹, K. Grote², C. Schubert¹, A.-K. Vlacil², T. Schmitz-Rixen¹

¹Universitätsklinikum Frankfurt am Main

²Universitätsklinikum Marburg

Background:

Beyond their crucial role for pathogen recognition and initiation of the immune defense, Toll-like receptors (TLRs) are known to be involved in various vascular processes in health and disease. We here investigated the potential of the lipopeptide and TLR2/6 ligand macrophage activating protein of 2-kDA (MALP-2) to promote blood flow recovery after experimental ligation of the femoral artery by collateral growth in mice.

Materials and methods:

Hypercholesterolemic apolipoprotein E (Apoe)-deficient mice were subjected to experimental microsurgical ligation of the left femoral artery.

Results:

MALP-2 significantly improved blood flow recovery in the hind limb at early time points (3 and 7 days) as assessed by repeated laser speckle imaging. MALP-2 application increased the growth of pre-existing collateral arteries in the upper hind limb (M. adductor) along with intimal endothelial cell proliferation in the collateral wall and pericollateral macrophage accumulation. In addition, MALP-2 injection increased capillary density in the downstream supply area of the lower hind limb (M. gastrocnemius). MALP-2 enhanced endothelial nitric oxide synthase (eNOS) phosphorylation and nitric oxide (NO) release from isolated endothelial cells and improved experimental vasorelaxation of mesenteric arteries ex vivo. In vitro, MALP-2 led to up-regulated expression of major endothelial adhesion molecules as well as their leukocyte integrin receptors and consequently enhanced endothelial adhesion of leukocytes

Conclusion:

Using the experimental approach of femoral artery ligation, we achieved promising results with the TLR2/6 ligand MALP-2 to promote peripheral blood flow recovery by collateral artery growth.

Anterior spinal artery syndrome – comparison of different animal models

(Abstract ID: 661)

F. Simon¹, H. Schelzig¹

¹Heinrich-Heine-Universität, Düsseldorf

Background:

The anterior spinal artery syndrome might result in paraplegia of the lower limbs of the patient. To study this problem animal models are warranted that can immitate clinical situation. As different animal models offer different advantages, but also disadvantages, several models are needed.

Materials and methods:

Our research group gained research experience in several different animal models. Three animal models of different sizes (pig, rabbit, mouse) were used. The aim in all this models was to establish an experimental setup to study the anterior spinal artery syndrome.

Results:

Large animal models are as close to the clinical situation as a model can be. Organs, blood supply and common physiology are relatively close to human beings. Because of the animal size human clinical equipment of daily clinical use can be utilized. Disadvantages are high costs, high personal and work effort, limitation of follow-up period and availability of markers to study special histological issues.

Middel sized animal models in rabbits offer a simple but effectful advantage, as spinal cord blood supply is strictly segmental. This offers the possibility to provoke paraplegia by clamping the infrarenal aorta only. This reduces operating time and work effort as no thoracical procedure is needed. Costs are lower than in a large animal model and is therefore better affordable. Because of the small operating trauma it is possible to investigate animals for several days. The disadvantages are caused by a relative high genetical range and little marker offer to examine special questions in the laboratory.

Small animal models offer the easiest way to keep animals at low costs for longer time with a high reproduction rate. The offer of antibodys and markers for laboratory examinations of tissue samples etc. are the biggest in the market. On the other hand clinical situation is as far away as it can be so that results must be interpret very carfully and often require further studies in larger animal models.

Conclusion:

As animal models always only can be understood as an attempt to reflect clinical situation of patients several models are needed to investigate it. Each animal model has its own advantages and disadvantages that must be considered carefully before initializing a study.

Long term recurrence free survival after endovenous and open varicose vein surgery

(Abstract ID: 581)

B. Cucuruz¹, M. Koller², K. Tripal³, K. Pfister², R. Kopp⁴, T. Schmitz-Rixen¹, T. Noppeney³

¹Universitätsklinikum Frankfurt am Main

²Universitätsklinikum Regensburg

³Krankenhaus Martha Maria, Nürnberg

⁴Universitätsspital Zürich

Background:

Minimal invasive techniques in the treatment of varicose veins are broadening. In this study we present our experience with radio frequency ablation (RFA) treatment or open surgery of varicose veins with now more than 10 years of follow up.

Materials and methods:

Between 01/2007 and 12/2008 RFA was used in 60 patients with varicose veins, 352 patients were treated open with ligation of the sapheno-femoral/-popliteal junction and stripping. For RFA ClosureFast® catheter from Covidien® was used. Compression stockings were used for 6 weeks after interventions. Patients received clinical exam one day after intervention, clinical exam and duplex sonography after 1 day, 1 week, 6 months and annually during follow up. Follow up ranged 1 moth - 12 years, mean follow up was 6.9 years. The study was reported to the local ethics committee and registered before data analysis (Z-2019-1316-10).

Results:

Technical success after RFA was 100%, recanalization occurred in 7/60 (12%). 9/60 (15%) patients developed recurrent varicose veins after RFA, 42/352 (12%) after stripping. Recurrence free survival was mean 8.67 years after RFA and mean 6.5 years after stripping (p=0.027).

Conclusion:

After more than 10 years of follow up, recurrence rate is similar after RFA and stripping. Recurrence free survival seem to be longer after RFA than after stripping.

The Use of Indocyanine green (ICG) imaging technique in the groin lymphocele microsurgical resection

(Abstract ID: 703)

T. Aung¹

¹Universitätsklinikum Regensburg

Background:

The postoperative occurrence of lymph fistulas and lymphoceles in the groin is a complication that should be taken seriously. These fistulas or lymphocele cause an increase in morbidity and can support local and ascending infections. Furthermore a conservative treatment is not always successful. We recently described the Microsurgical resection of peripheral lymphoceles.

In the following study we investigated the efficacy of a pre-operativ and intraoperativ diagnostic and therapeutic protocol to manage inguinal lymphoceles using lndocyaningreen (ICG) and microsurgical procedures. All the patients completely recovered without the need of any compression garment, after the surgery.