www.cacvs.org

ChairmanJean-Pierre Becquemin

French Scientific CommitteeYves S. Alimi Jean-Luc GrardEric AllairePierre BourquelotPascal DesgrangesHicham KobeiterJean Marzelle

International Scientific CommitteePiergiorgio CaoNicholas CheshireHans-Henning EcksteinChristos D. Liapis Martin MalinaArmando Mansilha

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Table of contents Chairman Pr Jean-Pierre Becquemin MD, Professor of Vascular Surgery Crteil, France

Scientific Committee Pr Yves S. Alimi MD, PhD, Professor of Vascular Surgery, Marseille, France Dr Jean-Luc Grard MD, Paris, France Pr Eric Allaire MD, PhD, Professor of Vascular Surgery, Crteil, France Dr Pierre Bourquelot MD, Paris, France Pr Pascal Desgranges MD, PhD, Professor of Vascular Surgery, Crteil, France Pr Hicham Kobeiter MD, PhD, Professor of Vascular Radiology, Crteil, France Dr Jean Marzelle MD, Crteil, France

International Scientific Committee Pr Piergiorgio Cao MD, PhD, Professor of Vascular Surgery, Perugia, Italy Pr Nicholas Cheshire Professor of Vascular Surgery, London, United Kingdom Pr Hans-Henning Eckstein MD, PhD, Vascular surgeon, Munich, Germany Christos D. Liapis Professor of Vascular Surgery, Chaidari, Greece Dr Martin Malina MD, PhD, Vascular surgeon, Malmo, Sweden Pr Armando Mansilha Professor of Vascular Surgery, Porto, Portugal

CONTROVERSIES & UPDATES IN VASCULAR SURGERY

THURSDAY JANUARY 23Thoracic aorta: open, endo or hybrid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Aortic dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Thoraco abdominal segment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

FRIDAY JANUARY 24 Parallel sessionTunneled catheters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Operative techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

State of the art & future trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Main sessionImaging and navigation tools: where are we? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Carotid latest news . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

AAA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Abdominal aorta and iliac arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Visceral arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

SATURDAY JANUARY 25SFA: latest news from the endo technology and techniques . . . . . . . . . . . . . . . . . . . 62

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Legs arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

CONTROVERSIES & UPDATES IN VENOUS DISEASE

SATURDAY JANUARY 25SESSION I: DEEP VEIN AND PERFORATOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

SESSION II: WHAT HAS CHANGED IN THE PAST 10 YEARS? . . . . . . . . . . . . . . . . . . . . 89

SESSION III: VASCULAR MALFORMATIONS . CLASSIFICATION AND TREATMENT . . . . 94

SESSION IV: LIVE ULTRASOUND AND VIDEO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

SESSION V: SCLEROTHERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

SESSION VI: THERMAL TECHNIQUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

E-POSTERS

AORTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

CASE REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

PAOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

VASCULAR ACCESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

VEINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

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Faculty autors

MAIN PROGRAMYves S . ALIMI, Marseille, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Jean-Marc ALSAC, Paris, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Ali AMIN, West Reading, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Patrick BAGAN, Argenteuil, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Iris BAUMGARTNER, Bern, Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . 59Colin BICKNELL, London, United Kingdom . . . . . . . . . . . . . . . . . . . . . 15Jan BLANKENSTEIJN, Amsterdam, The Netherlands . . . . . . . . . . . . . . . 49Lo BONATI, Basel, Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Giuseppe BONFORTE, Como, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Marc BOSIERS, Dendermonde, Belgium . . . . . . . . . . . . . . . . . . . . . . . 45, 69Benot BOURA, Paris, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Pierre BOURQUELOT, Paris, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Armand BOURRIEZ, Rouen, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83Jan BRUNKWALL, Cologne, Germany . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Bernard CANAUD, Bad Homburg, Germany . . . . . . . . . . . . . . . . . . . . . . 17Ludovic CANAUD, London, United Kingdom . . . . . . . . . . . . . . . . . . . . . . 5Piergiorgio CAO, Roma, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Xavier CHAUFOUR, Toulouse, France . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Roberto CHIESA, Milan, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Rachel CLOUGH, London, United Kingdom . . . . . . . . . . . . . . . . . . . . . . 35Jack L . CRONENWETT, Lebanon, USA . . . . . . . . . . . . . . . . . . . . . . . 41, 67Daniel DANZER, Sion, Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Alan DARDIK, New Haven, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Jean-Paul DEVRIES, Nieuwegein, The Netherlands . . . . . . . . . . . . . . . . 54Koen R . DELOOSE, Dendermonde, Belgium . . . . . . . . . . . . . . . . . . . . . . 70Pascal DESGRANGES, Crteil, France . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Nicoletta FOSSATI, London, United Kingdom . . . . . . . . . . . . . . . . . . . . 30Christopher GIBBONS, Oxfordshire, United Kingdom . . . . . . . . . . . . . 20Monika GLOVICZKI, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Yann GOUFFIC, Nantes, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Roger M . GREENHALGH, London, United Kingdom . . . . . . . . . . . . . . 74Stphan HAULON, Lille, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Ulf HEDIN, Stockholm, Sweden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Hassan HOSSEINI, Crteil, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Stavros KAKKOS, Patras, Greece . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Hicham KOBEITER, Crteil, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Tilo KLBEL, Hamburg, Germany . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Kimihiro KOMORI, Nagoya, Japan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Eric LADENHEIM, Fresno, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Miltos LAZARIDES, Athens, Greece . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Christos D . LIAPIS, Chaidari, Greece . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Herv MAISONNEUVE, Paris, France . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Armando MANSILHA, Porto, Portugal . . . . . . . . . . . . . . . . . . . . . . . . . . 79Giustino MARCUCCI, Rome, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Tara MASTRACCI, Cleveland, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Richard MCWILLIAMS, Liverpool, United Kingdom . . . . . . . . . . . . . . . 13Luis MENDES-PEDRO, Lisbon, Portugal . . . . . . . . . . . . . . . . . . . . . . . . . 57Firas MUSSA, New York, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Vo NGUYEN, Olympia, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Gustavo ODERICH, Rochester, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Josette PENGLOAN, Nantes, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Nicola PIROZZI, Rome, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Janet POWELL, London, United Kingdom . . . . . . . . . . . . . . . . . . . . . . . . 55Alain RAYNAUD, Meudon, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Olgierd ROWINSKI, Galway, Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Franois SAUCY, Lausanne, Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . 80Peter SCHNEIDER, Honolulu, USA . . . . . . . . . . . . . . . . . . . . . . . . 36, 63, 76Richard SHOENFELD, Newark, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Maxime SIB, Bordeaux, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Eric STEINMETZ, Dijon, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Matthew THOMPSON, London, United Kingdom . . . . . . . . . . . . . . 8, 50Isabelle VAN HERZEELE, Gent, Belgium . . . . . . . . . . . . . . . . . . . . . . . . 72Marc VAN SAMBEEK, Eindhoven, The Netherlands . . . . . . . . . . . . . . . 48Frank J . VEITH, Riverdale, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Pierfrancesco VEROUX, Catania, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . 25Thomas ZELLER, Bad Krozingen, Germany . . . . . . . . . . . . . . . . . . . . . . . 68

VENOUS PROGRAMFranois-Andr ALLAERT, Dijon, France . . . . . . . . . . . . . . . . . . . . . . . 107Annouk BISDORFF BRESSON, Paris, France . . . . . . . . . . . . . . . . . . . . . 94Mohamed BOUAYED, Oran, Algeria . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Anthony COMEROTA, Toledo, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87Alun Huw DAVIES, London, United Kingdom . . . . . . . . . . . . . . . 105-115Alessandro FRULLINI, Figline Valdarno-Florence, Italy . . . . . . . . . . . . 104Jean-Luc GRARD, Crteil, France . . . . . . . . . . . . . . . . . . . . . . . . . . 98, 100Peter GLOVICZKI, Rochester, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114Manj GOHEL, London, United Kingdom . . . . . . . . . . . . . . . . . . . . . . . . . 113Jean-Jrme GUEX, Nice, France . . . . . . . . . . . . . . . . . . . . . . . . . . . 86, 103Claudine HAMEL DESNOS, Caen, France . . . . . . . . . . . . . . . 99, 101, 103Lowell S . KABNICK, New York, USA . . . . . . . . . . . . . . . . . . . . . . . . 92, 112Philippe LEMASLE, Le Chesnay, France . . . . . . . . . . . . . . . . . . . . . . . . . . 89Oscar MALETI, Modena, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84Martin MALINA, Malm, Sweden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96Armando MANSILHA, Porto, Portugal . . . . . . . . . . . . . . . . . . . . . . . . . 111Olle NELZEN, Uppsala, Sweden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Laure PERRISSIN-CHEVALIER, Arcueil, France . . . . . . . . . . . . . . . . . 102Olivier PICHOT, Grenoble, France . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Eberhard RABE, Bonn, Germany . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93Albert-Adrien RAMELET, Lausanne, Switzerland . . . . . . . . . . . . . . . . . 91Lars RASMUSSEN, Copenhagen, Denmark . . . . . . . . . . . . . . . . . . . . . . 109Gilles SOULEZ, Montreal, Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Giorgio SPREAFICO, Padova, Italy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110Renate VAN DEN BOS, Rotterdam, The Netherlands . . . . . . . . . . . . . 108

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Thoracic aorta: open, endo or hybrid Can we stratify the operative risk of TEVAR? Matt Thompson SGVI, London, United Kingdom

INTRODUCTIONThoracic endovascular aneurysm repair (TEVAR) is associated with less short-term mortality and morbidity than traditional open surgery. Despite this, serious adverse events occur in 10-15% of patients and the rate of all cause death at follow-up is high. The objective of this study was to develop a patient-specific risk stratification system to aid in pre-operative planning.

METHODSThe MOTHER database consists of five prospective clinical trials and a single institutional series. Logistic regression and Coxs proportional hazard modelling were used to construct models using pre-operative variables to predict peri-operative and mid-term adverse events. ROC curve analysis and the Hosmer-Le-meshow test were used to determine discrimination and goodness of fit of the models.

RESULTSOf 670 patients that underwent TEVAR for thoracic aneurysm, 5% died, 5% had a stroke and 3% developed spinal-cord injury (SCI) post-operatively. Independent predictors of 30-day death were age, non-elective surgery and the need for >2 devices (c-statistic=0.71). Stroke was predicted by female gender, previous stroke, coverage of the left subclavian artery and the need for >2 devices (c-statistic=0.77). SCI was predic-ted by female gender, smoking, previous stroke, non-elective surgery and the need for >2 devices (c-statis-tic=0.72). Aortic re-intervention was predicted by aneurysm length, maximum diameter and iliac tortuosity and a high-risk cohort could be identified. Patients could be successfully divided into tertiles of risk using the mid-term all-cause death model.

CONCLUSIONThese models predict important outcomes following TEVAR relatively accurately. External validation of this risk stratification system is required before it can be introduced into clinical practice.

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Thoracic aorta: open, endo or hybrid Objective assessment of current stent grafts: which graft for which lesion Ludovic Canaud, Pascal Branchereau, Charles Marty-An, Pierre Alric Arnaud de Villeneuve Hospital, Montpellier, France

AIMThe first decade of thoracic endovascular aortic repair (TEVAR) has demonstrated good short- and midterm outcomes. These results support endovascular repair as the procedure of choice for patients presenting with thoracic aortic diseases. Currently, 4 thoracic stent-grafts have achieved the CE labelling: Valiant (Medtronic Vascular, Santa Rosa, CA, USA), Zenith TX2 thoracic stent-graft with ProForm (Cook Medical, Bloomington, IN, USA), TAG (W.L. Gore & Associates, Flagstaff, AZ, USA) and the Relay Stent-graft (Bolton Medical, Sunrise,FL, USA). These stent-grafts have different features in term of stent-graft design (PTFE versus Dacron, stent framework) and delivery system. Knowledge of stent-graft conformability, radial force and accuracy of the delivery system is crucial to prevent devastating complications such as stent-graft col-lapse, type I endoleak, retrograde ascending aortic dissection and inadvertent coverage of the supra-aortic trunks.

METHODS- Experimental study: This study has been performed using a benchtop pulsatile flow model and human ca-

daveric aortas too assess the conformability of the latest generation of thoracic stent-grafts as a function of oversizing and increasing aortic arch angulation.

- Clinical study: A comprehensive review of the literature combined with a review of our single center ex-perience has been performed to identify device related complications.

RESULTS- Experimental study: The requirement for close conformability has influenced the design of next-genera-

tion devices. Manufacturers have modified devices and/or their deployment system to specifically address this problem. When compared to the results of our previous experimental test, these alterations have resulted in a marked improvement in the performance of commercially available stent-graft systems.

- Clinical study: Regarding RTAD, inappropriate stent-graft oversizing, particularly in patients with aortic wall fragility, should be avoided. Iteration of stent-graft design will be important in reducing the incidence of RTAD, but the present study suggests that the presence of a bare proximal stent does not lead to an increased rate of RTAD. Considering the thoracic stent-graft collapse, accurate assessment of aortic arch anatomic features, as well as the choice and sizing of the device, may prevent this complication. Preven-tion of the risk of inadvertent coverage of the supra-aortic trunks is based on the choice of a stent-graft with a controlled delivery system.

CONCLUSIONImprovement in the performance of commercially available stent-graft systems combined with a proper knowledge of the different features of these stent-grafts will allow to prevent most of device relate.

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Thoracic aorta: open, endo or hybrid Ascending aorta: is the endovascular approach realistic? How I do it. Tilo Klbel University Heart Center Hamburg, Hamburg, Germany

The current standard treatment for pathologies of the ascending aorta is open surgery. For patients with lesions such as dissection, aneurysm or rupture open surgery is the mainstay of treatment but includes substantial morbidity and mortality rates. Operative mortality from acute aortic type A dissection has de-creased in recent years ranging from 7% to 17% owing to major advancements in ascending aortic surge-ry, but is still substantial especially in patients with older age, severe comorbidities and previous cardiac surgery. Thoracic endovascular aortic repair (TEVAR) has developed as a therapeutic alternative for open repair of the descending thoracic aorta during the last decade. However, technical and anatomical challen-ges persist for endovascular repair of the proximal segments of the aorta, rendering TEVAR an exceptional indication. Current problems of endovascular treatment from a downstream access-site include the ina-bility to advance, control and deploy the endo-graft due to iliac and aortic pathology. Severe tortuosity of the iliac and aortic access vessels, the necessity to place a stiff guide-wire into the left ventricle and the shortness of currently available stent-graft introducing systems are further. To overcome theses limitations, alternative retrograde access-techniques have developed including subclavian access, conduits to iliac arteries, infrarenal and thoracic aorta. Antegrade access and transcardial stent-graft deployment might be an alternative access in patients unfit or with high risk for open surgery or retrograde access. MacDonald et al. have first described this access technique in an elective setting using a mini-thoracotomy as utilized for transapical aortic valve implantation. Other groups have adopted this technique and reported their experience. Potential advantages of transapical access include: avoidance of downstream access-problems, short distance with excellent trackability, pushability, rotational control, nearly unlimited profile, instant decompression of the pericardial tamponade, and availability, as transapical access is a standard technique for TAVI in many cardiovascular centers.

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Thoracic aorta: open, endo or hybrid Hybrid techniques for the arch: are they effective and durable? Ciro Ferrer, Federica De Crescenzo, Carlo Coscarella, Gabriele Pogany, Piergiorgio Cao Vascular Surgery Unit - San Camillo Forlanini Hospital, Rome, Italy

INTRODUCTIONWhat is the best approach for aortic arch disease is currently debated. Most of the data available in litera-ture is mainly based on limited series and heterogeneous populations. The aim of this study is to evaluate long term results of hybrid and endovascular procedures for aortic arch.

METHODSFrom 2005 to 2013, 104 consecutive patients underwent partial or total debranching associated with the positioning of one or more thoracic endografts. Rates of perioperative mortality and neurological compli-cations, and mortality, endoleak, supra-aortic vessel patency, and arch diameter changes at 5 years were analyzed.

RESULTSThe mean age of the patients was 69.8 years and 14 were females. Nineteen patients required total de-branching for extension of the disease to zone 0. At 30 days, death, stroke, and spinal cord ischemia occurred in six, four, and three patients, respectively. Extension to ascending aorta (zone 0 landing) was the only multivariate independent predictor for perioperative mortality (odds ratio, 9.6; 95% confidence interval, 1.54-59.90; P =.015), but not for stroke. Four retrograde dissections, two fatal, occurred during the perioperative period. At 1, 3, and 5 years, Kaplan-Meier survival rates were 89.0%, 82.8%, and 70.9%, and freedom from persistent endoleak rates were 96.1%, 92.5%, and 88.3%, respectively. Over 5-year fol-low-up, 34 aneurysms shrank >5 mm, and four grew. Five reinterventions were required. Two supra-aortic vessel occlusions and no late aorta-related mortalities were recorded.

CONCLUSIONSDespite the perioperative mortality risk, the late outcome of endovascular arch repair presents a low rate of aorta-related deaths and reinterventions and acceptable midterm survival. Furthermore, more than one-third of the aneurysms diameters decrease over 5 years as a measure of the long-term efficacy of treat-ment. Retrograde type A dissection remains a major concern in the perioperative period and careful arch approach is required.1

References1. De Rango P, Cao P, Ferrer C, Simonte G, Coscarella C, Cieri E, Pogany G, Verzini F. Aortic arch debranching and thoracic en-

dovascular repair. J Vasc Surg 2013.

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Aortic dissection Controversy: Timing of TEVAR for uncomplicated acute type B dissection

Early intervention is the best choice Jan Brunkwall, University Clinics, Cologne, Germany

Acute Type B Dissection is a potentially lethal disease. Even though the mortality has decreased from 90% in the sixties, with modern antihypertensive medication and intensive care surveillance, the mortality is at the level of 6-10% the first 30 days according to several retrospective publications including the IRAD data.There are not sufficient reports on how patients with a primarily uncomplicated type B dissection are doing during the first 30 days. How many of these will develop a complication or even mortality is not fully reported. Most of the patients with a complicated dissection seem to enter the hospital with such a complication but some of the uncomplicated ones turn in to a complication like malperfusion, rupture, type A dissection, and even mortality. When treating these uncomplicated patients in the acute phase (

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Aortic dissection Malperfusion and acute dissection type B: what is the best strategy Tara M. Mastracci The Cleveland Clinic Foundation, Cleveland, USA

The global understanding of aortic dissection has progressed significantly this year with the publication of long-term outcomes from the INSTEAD XL trial1, and in uncomplicated dissection, the field is beco-ming much more comfortable with the use of thoracic stents to promote aortic remodeling and change the natural history of the disease. However, complicated dissection, especially those which present with malperfusion, remain a challenging clinical problem which can be lethal very early in the presentation of the disease. In the IRAD database, visceral ischemia is the cause of death in 15.4% of patients (95% CI 8 22). Malperfusion can be dynamic or static, and can have a variety of etiologies including intimal dis-section and complete occlusion of branch vessels, intimal tear of the dissection flap causing interrupted flow, or dissection flap collapse during systole.2 This makes the treatment of malperfusion a challenge, and the endovascular surgeon must have a good understanding of the disease, as well as the likely clinical scenario based on individual patient characteristics.

The endovascular approach to malperfusion has included a variety of techniques, but most will agree mo-dern solutions are a combination of thoracic stenting, branch vessel stenting, and fenestration. The thirty day mortality in centres which have reported this ranges from 0 to 25%, and represents a heterogeneous group of patients and approaches, making it challenging to gain insight into the best approach based on the reported literature alone. Where a good proximal landing zone exists, our centre favours placement of a thoracic stent as the first line approach to malperfusion. This addressed the issue of altered flow dynamics in the true lumen, which is very commonly the cause of malperfusion in our experience. As we gain more insight into this disease, we have thought that changing the flow dynamics between true lumen and false lumen, and not radial force alone is the reason why proximal thoracic stenting is successful. When primary thoracic stent does not resolve all malperfusion, and the large intimal tears above the celiac artery have been adequately covered, we adopt an approach of selective recanalization and stenting of branch ves-sels. Our experience with this, published this year, describes 61 patients with malperfusion over a 11 year span.3 Malperfusion in these patients occurred in at least one territory (including spinal cord 7/61 (12%), mesenteric 37/61 (61%), renal 45/61 (73%), and lower extremity 38/61 (62%).), but 43/61 patients had >1 bed effected, and 54/61 patients included mesenteric or renal involvement. Most patients were treated

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Figure

Angiogram of dissection with malperfusion.

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Aortic dissection Acute type B dissection: is closure of the proximal tear sufficient? Jean-Marc Alsac Hpital Europen Georges Pompidou, Paris, France

Because of its less invasive and reproducible character, thoracic endovascular aortic repair became the treatment of choice for aortic dissections interesting the descending thoracic aorta. The placement of a covered stentgraft on the proximal tear of the dissection redirects blood flow in the true lumen, and treats most complications that may occur during the acute phase. However, the existence of other distal entry tears often leads reperfusion downstream of the stentgraft, which maintains a circulating flow in the false lumen of the dissection.

In case of visceral malperfusion during the acute phase of the dissection, a higher pressure in the false lumen of the dissected aorta may lead to a dynamic compression of the true lumen where most col-lateral for visceral arteries arise.1 To promote the true lumen expansion and perfusion versus the false lumen pressure, the Zenith Dissection Endovascular System (Cook medical, Bloomington, Ind.) proposes a composite device with non-covered metal stents that extend into the thoracoabdominal aorta, below the proximal thoracic aortic stentgraft.2,3 In our experience of a systematic treatment for dynamic malperfusion complicating acute dissections, the Zenith Dissection Endovascular System achieved safely and effectively satisfactory clinical results in the short term. But the long term impact of this composite treatment on aortic remodeling remains to be determined.

Regarding midterm evolution of aortic dissections, a persisting circulating flow in the false lumen of the dissection often promotes aneurysmal degeneration of the thoracoabdominal aorta. To avoid distal perfu-sion of the false lumen, we propose to adjunct a retrograde endovascular fenestration of aortic dissection flap to obtain a seal at the distal portion of the aortic stentgraft: the DEFINITE technique (Distal Endovas-cular Fenestration INsIde Thoracic Exclusion). This combined endovascular treatment could limit the fre-quent aneurysmal evolution of aortic dissection, and its fatal complications.

References1. Ryan C, Vargas L, Mastracci T, Srivastava S, Eagleton M, Kelso R, et al. Progress in management of malperfusion syndrome from

type B dissections. J Vasc Surg. 2013 May;57(5):1283-90.2. Nienaber CA, Kische S, Zeller T, Rehders TC, Schneider H, Lorenzen B, et al. Provisional extension to induce complete attach-

ment after stent-graft placement in type B aortic dissection: the PETTICOAT concept. J Endovasc Ther. 2006 Dec;13(6):738-46.3. Lombardi JV, Cambria RP, Nienaber CA, Chiesa R, Teebken O, Lee A, et al.; STABLE investigators. Prospective multicenter clinical

trial (STABLE) on the endovascular treatment of complicated type B aortic dissection using a composite device design. J Vasc Surg. 2012 Mar;55(3):629-640.e2.

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Aortic dissection Acute type B dissection. Closure of the infra diaphragmatic tear: how and when? Olgierd Rowinski Varsaw, Poland

Thoracic endografting (TEVAR) is now considered the mainstay of treatment modalities in type B aortic dissections. This approach restores wide flow in the true lumen, closes the primary entry tear and helps induce thrombosis of the false channel. Combined with BMT, more than 90% of patients will benefit from this treatment modality.In the remaining patients, while TEVAR proves beneficial in aortic remodelling in the thoracic region adjacent to the endograft, further concern remains regarding the supra and infrarenal aorta as TEVAR usually fails to induce thrombosis of the abdominal aortic false lumen because of persisting reentry points at this level.We present various secondary endovascular methods that we have employed with a varying degree of success in order to promote false lumen thrombosis, prevent aortic dilatation and avoid rupture.The intention to treat was mainly based on the following indications: dilatation of the false lumen above 5 mm/year with persistent turbulent flow into the false dissection lumen on follow-up, the presence of com-promised vessel patency with increasing static malperfusion and recurrent pain responding poorly to medi-cal treatment, an AAA coexisting with a type B disscetion or a ruptured false lumen of the infrarenal aorta.The following different techniques were used alone or in conjunction: 1) occlusion of a reentry point at the level of the detached renal artery ostium using a covered peripheral stent, 2) occlusion of a major entry tear using an occlusion device 3) occlusion of distal reentry points (intimal defects) in the abdominal aorta using a straight or bifurcated endograft.Using these various endovascular techniques we were able to limit false lumen expansion and promote thrombosis in the majority of treated patients. Such an approach may prevent impeding rupture in patients not eligible for open aortic repair.

Thoraco abdominal segment Open surgical technique for type IV TAAA: the latest improvements Xavier Chaufour CHU Rangueil, Toulouse, France

Thoracoabdominal aneurysm type IV (TAA IV) represents only a minority of aortic aneurysms, but as it is an entirely abdominally located aneurysm, vascular surgeons are likely to see such aneurysms in their practice. Computed tomographic angiography of the aorta has become the gold standard for preoperative imaging. This modality is extremely useful in preoperative planning to aid in selection of appropriate open repair stratgies. The patient is positioned in right lateral dcubitus for a thoraco-retroperitoneal retrorenal approach in the nine or tenth intercostal space without resection of rib. A short anterior diaphragm inci-sion is associated with full dissection of the left crus ligament. The use of a self-retaining retractor allows short incision with stable operative field. The clamp-and-sew technique was used for all operations, Opera-tive reconstruction consisted of one beveled proximal anastomosis incorporating the descending thoracic aorta, celiac, superior mesenteric artery, and right renal arteries origins and a side-arm graft to the left renal artery. Uncomplicated repair has a minimal risk of neurological injury and a low risk of renal failure requiring dialysis in patients without preoperative renal dysfunction or renal artery stenosis. Under these conditions intraoperative renal protection is not needed. If the patient has preoperative renal failure, then each kidney is perfused with 300 mL of cold (+4 C) Ringers lactate solution after opening the aneurysm. The infusion is undertaken for 4 - 5 min at 150 mm-Hg. Maintaining a high cardiac output and mean arte-rial pressure > 70 mm-Hg during and after surgery are two major elements to ensure satisfactory diuresis A simplified operative approach for type IV TAAA repair is associated with favorable perioperative results. Literature and own datas refute the need for surgical adjuncts commonly applied in more extensive TAAA and indicate that the hybrid operation is an illogical posture. Long-term survival equates that observed after routine AAA repair.

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Thoraco abdominal segment Paraplegia following F and B EVAR: incidence, severity and ways to prevent it Richard McWilliams1, Fatameh Jafarzadeh2, Mike Desmond2

1. Royal Liverpool University Hospital, Liverpool, United Kingdom 2. Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

Spinal cord ischaemia (SCI) is one of the major complications after fenestrated and branched EVAR. The GLOBALSTAR database of FEVAR in the UK records 5 cases of SCI in 318 registered patients. All were in grafts with four fenestrations which is consistent with the known increased risk of SCI with greater aortic coverage. For this reason the risk of paraplegia is much higher with thoracoabdominal branched grafts.

Strategies to reduce the risk of SCI include preservation of the left subclavian and hypogastric arteries, minimising the length of aortic coverage, staging complex endovascular procedures, adjusting CSF and mean arterial pressures to maintain the spinal cord perfusion pressure and using dedicated paraplegia prevention branches in endografts.

Neuromonitoring using evoked potentials has an established role in open repair of thoracoabdominal aor-tic aneurysms. Changes in the recorded traces are used to guide modifications to surgery and spinal cord perfusion pressure.

Our endovascular service has a strong collaboration with the Liverpool Heart and Chest Hospital and we have started using motor evoked potential (MEP) monitoring during TEVAR and BEVAR. Monitoring is only valuable if there is a potential response strategy if the motor evoked potentials deteriorate. Unfortunately we do not have endografts which are resheathable so if the MEPs deteriorate during a procedure then the response strategy is aimed at increasing spinal cord perfusion through changes in CSF/mean arterial pressure and, if this fails, by trying to increase spinal cord perfusion directly by inducing an endoleak. MEP monitoring may also be used during a procedure to test occlude the last branch and decide if this should be left open as per a paraplegia prevention branch. Ischaemia from large groin sheaths and from arm access can complicate the interpretation of changes to MEPs.

This presentation will discuss how we have established and use neuromonitoring in our TEVAR and com-plex aneurysm programme.

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Thoraco abdominal segment. Controversy: Off the shelf grafts. Are they needed and up to the job?

Off the shelf grafts: are they needed and up to the job? For the motion Stephan Haulon CHRU Lille, Lille, France

Fenestrated and branched endografts have evolved as an effective treatment option for patients with jux-tarenal, pararenal and thoracoabdominal aneurysms. However, these technologies have required that they be specifically manufactured to fit an individual patients anatomy. More recently, off-the-shelf technologies have emerged as an additional option. These devices simplify case planning and preparation as visceral anatomy can be simply compared with device anatomical requirements. In addition, they are available for treatment of acute or symptomatic patients. When used within their indicated anatomical requirements, short-term results for some off-the-shelf fenestrated and branch grafts are comparable to their custom-ma-nufactured counterparts.

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Thoraco abdominal segment. Controversy: Off the shelf grafts. Are they needed and up to the job?

Off the shelf grafts: are they needed and up to the job? Against the motion. Colin Bicknell Imperial College London, London, United Kingdom

Despite an increasing role the major criticism of fenestrated/branched stent grafts is the delay and cost of bespoke production. Therefore a promise of off-the-shelf graft technology is very attractive.

Few vascular specialists would challenge the premise that this technology will play a major role in the future. It is very hard to argue against the need for off-the-shelf grafts but we should be mindful that with advances in technology, this may not be the only mechanism with which to treat urgent/emergency complex aneurysms. The technique of in-situ fenestration 1 or rapid in-house bespoke manufacturing would certainly challenge the need for off-the-shelf grafts with advances in imaging and robotics 2.

Even if one admits that an off-the-shelf solution is the only viable prospect of treating this group of pa-tients there are many unanswered questions. The main question is regarding tolerance of different anato-mical configurations. With bespoke manufacturing fenestrations/branches can be matched exactly to the required height and clockface orientation. However if the fenestration/branch is misaligned there may be significant difficulties. Double diameter reducing ties and certainly intelligent catheter technologies will smooth the cannulation of vessels and introduction of branch stents, but the long-term durability of mi-saligned branches is yet to be understood due to aortic remodeling and the potential for fracture, kinking and dislocation.

With dome shaped fenestrations, wide coeliac artery scallops and branch technology the number of pa-tients that may be treated with a few graft configurations is thought to be acceptable in morphological studies 3,4. There should be some caution however, as urgent and emergency cases are well accepted to be significantly larger and have more complex anatomical configurations 5.

The number of patients that may be treated and success of off-the-shelf grafts is yet to be proven. They are not up to the job at this present time.

References1. Robot-assisted antegrade in-situ fenestrated stent grafting. Riga CV, Bicknell CD, Wallace D, Hamady M, Cheshire N. Cardio-

vasc Intervent Radiol. 2009 May;32(3):522-4. 2. The role of robotic endovascular catheters in fenestrated stent grafting. Riga CV, Cheshire NJ, Hamady MS, Bicknell CD. J Vasc

Surg. 2010 Apr;51(4):810-93. Toward an off-the-shelf fenestrated endograft for management of short-necked abdominal aortic aneurysms: an analysis

of current graft morphological diversity. Nordon IM, Hinchliffe RJ, Manning B, Ivancev K, Holt PJ, Loftus IM, Thompson MM. J Endovasc Ther. 2010 Feb;17(1):78-85.

4. Off-the-shelf fenestrated endografts: a realistic option for more than 70% of patients with juxtarenal aneurysms. Sobocinski J, dUtra G, OBrien N, Midulla M, Maurel B, Guillou M, Azzaoui R, Roeder B, Resch TA, Haulon S. J Endovasc Ther. 2012 Apr;19(2):165-72.

5. Comparison of morphologic features of intact and ruptured aneurysms of infrarenal abdominal aorta. Hinchliffe RJ, Alric P, Rose D, Owen V, Davidson IR, Armon MP, Hopkinson BR. J Vasc Surg. 2003 Jul;38(1):88-92.

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Tunneled catheters Prevention and treatment of sepsis Josette Pengloan Nantes, France

Tunneled catheters (TC) are essential devices for patients on hemodialysis. However TC use is associated with a high morbidity and mortality rate related to inflammatory status and/or acute infection. Conse-quences are both reduction of patient survival and CVC lifespan. TC related bacteraemia (TCRB) rate has to be below 1 p 1000 TC days. Development of intraluminal bacterial biofilm is responsible of bacteraemia and/or distant abscesses; it is mainly initiated by the introduction of pathogens from skin flora during the maneuvers of TC connection and disconnection. The fundamental preventive measures are based on the strict application of hygiene rules during these procedures. Additional preventive measures are to be considered: locking solutions, early diagnosis and treatment of TC colonisation (based on monthly cultures of the content of each lumen before a dialysis session). Treatment is initiated if cultures of CVC content are positive and immediately in case of systemic signs. It is based on the association of systemic antibiotic treatment, antibiotic lock-solution and fibrinolytic treat-ment of TC and continued at least 2 weeks after cultures turn negative. Cefazoline and Vancomycine reserved to MRSA carriers are the preferred first-line antibiotics. With this protocol a rate of TCRB of 0, 3 p 1000 TC days can be achieved. A TC surveillance program has to be implemented with analyze of the results every each 3-6 months. In case of TCRB rate increase adherence to protocol and training of staff has to be evaluated and protocol revised if necessary. Many questions remain debatable: what design and material for TC? What is the best prophylactic lock-so-lution? How to eradicate Staphylococcus aureus which remains one of the most dangerous pathogen for haemodialyzed patients and cannot be predicted through monthly cultures of TC content?

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Tunneled catheters When should an infected catheter be changed? Bernard Canaud, Hlne Leray-Moragus, Leila Chenine Montpellier University I - UFR Medicine & FMC Medical Board, Montpellier, France

Tunneled central venous catheters (TCVC) are frequently used in hemodialysis (HD) patients to overcome either temporary or permanent vascular access problems. Despite international guideline recommenda-tions, the prevalence of TCVC use remains high averaging 20% worldwide, with large intercountry varia-tions (< 5% in Japan to > 40% in Belgium) reflecting differences in patient medical profiles and clinical practices. Infection remains a major burden for HD patients representing the second cause of hospitaliza-tion and mortality. Due to the immunodepression status of chronic kidney disease patients and multiple and repeated invasive acts (access needling, exploration, catheters), HD patients are predisposed to severe infection by direct blood bacterial seeding. In this context, TCVC represents an additive risk factor for infection (foreign material, permanent open access to blood, and repeated manipulations for HD connec-tion) for whom incidence of blood stream infection (bacteremia) has been estimated 7 to 8 times higher as compared to native arterio-venous fistula. Several clinical measures have proved to be efficient in preventing and reducing TCVC related infections. These measures representing the basic of best clinical practices should be implemented in any dialysis units since they represent the best barrier against bacterial TCVC seeding. Strict hygienic handling and reinforced universal precautions of aseptic manipulation are the basic of TCVC use. These measures should be applied along TCVC lifecycle with the same precaution, from insertion to removal time, including catheter manipulations during HD sessions. Catheter locking solutions (CLS) based on dual activities (antithrombotic and antiseptic) offer a new and complementary option to minimize the risk of TCVC intraluminal bacterial contamination and colonization. CLS have been proved to be particularly efficient in reducing TCVC blood stream infection. CLS use represents an additio-nal measure for preventing TCVC related infection is now strongly recommended by international recent guidelines. However, CLS must not be considered as an alternative, and cannot be substituted, to universal hygienic and aseptic precautions TCVC infection prevalence varies between 0.1 to 6.0 episodes per 1000 days according to literature data. Catheter-related infection covers several forms, from limited skin exit infection to tunnel or track infection (tunnelitis), including isolated bacteremia and septicemia. In all cases, TCVC-related infection must be considered as potential serious clinical condition bearing the risk of bac-terial systemic dissemination with endocarditis (or osteomyelitis or lung or brain abscess) due to the high prevalence of Staphylococci species, and more rarely septic shock when Gram negative bacteria are invol-ved. Facing TCVC-related infection situations, the main concerns for referent Physician are thrice: First, to evaluate gravity and potential risk of dissemination (form of infection, type of bacteria, comorbidities, early response to treatment); Second; to identify if the catheter is colonized and/or bacterial biofilm has taken place in the inner lumen of the catheter; Third, to explore alternative vascular access possibilities in case of TCVC removal. Infective endocarditis (IE) is a major risk and the most serious complication of HD patients in this setting with very poor outcomes as compared to general population. Therefore all immediate thera-peutic actions including early TCVC removal must be considered to prevent this devastating complication. IE incidence is estimated 50 to 180 fold higher than the general population. The use of a TCVC is strongly associated with IE prevalence in HD patients exceeding 50 to 60% in some series. Curiously the tricuspid valve is rarely affected while the mitral valve is involved in more than 50% of cases, the aortic valve in more than 30% and involvement of both valves is relatively frequent. Staphylococcus Aureus and Staph. Species are the main cause of TCVC-related bacteremia among HD patients (2/3rd of cases). Enterococcus and streptococcus are less frequent (1/3rd of cases). Gram-negative species and Pseudomonas are very rarely found TCVC-related infection diagnostic is usually easy relying on clinical signs and symptoms, blood (peripheral and catheter) and/or catheter cultures and microbiological identification of pathogen. More dif-ficult in practice is assessing prognosis and endoluminal contamination of catheter. Echocardiography and various imaging technics have been proposed to document disseminated septicemia and distant bacterial tissue seeding such endocarditis or abscess (lung, brain or bone). In all cases, TCVC-related infection must be considered as serious and critical condition in which immediate therapeutic action is needed and close

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patient follow-up is required. Medical treatment consists in systemic antibiotic, targeting initially Staph. Aureus secondary adapted to bacteria species, combined with local antibiotic (skin, catheter lock solution) and/or dual catheter locking solution (fibrinolytic plus antibiotic). Clinical re-assessment is performed on a short period of time according to severity and treatment response. Catheter removal should be considered anytime as an option in case of extreme severity or poor response to initial treatment. Immediate, TCVC withdrawal should be considered when facing extended tunnelitis and/or sepsis and/or unusual bacteria and/or high risk patient. Delayed, TCVC removal must be considered after 24 to 48 hours of optimal medi-cal treatment and persistence of infection symptoms. Another approach is sometimes proposed consisting in replacing TCVC over guide wire keeping the same subcutaneous track. This approach increases the risk of propagating bacteria, creating septicemia and should be abandoned. Now, if venous access is the only vascular access option possible then removal of infected catheter, followed by temporary use of acute ca-theter and then later on insertion of a second TCVC is highly recommended. Prolonged systemic antibiotic treatment (4 weeks) and antiseptic or antibiotic catheter locking must be considered to consolidate treat-ment efficacy in severe cases. In addition, it is important to mention that HD patients that had developed TCVC-related infection may present secondary and/or late distant complications (endocarditis, abscess) and therefore prolonged follow-up based on microbiological blood catheter culture, inflammatory biomar-kers (CRP, fibrinogen) and hematological pictures (Leukocytes and Platelets count) must be maintained over 3 consecutive months. To conclude, infection of permanent TCVC constitutes a constant and potential serious hazard for HD patients that should be prevented by strict compliance to hygienic rules. Risks versus benefits of keeping in place TCVC must be considered carefully case by case. Optimal medical treatment including systemic antibiotic therapy and antibiotic catheter locking solution are the first line of treatment. Catheter removal must be considered in case of severe sepsis and when facing poor or incomplete control of infection for preventing occurrence of more severe complication such as endocarditis.

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Tunneled catheters Difficult catheter insertions Richard Shoenfeld The Access Center at West Orange, West Orange, New Jersey, USA

Central vein stenosis or occlusion is reported in up to 42% of patients with chronic or prior indwelling dia-lysis catheters1. Permacaths induce fibrin sheath formation, stenosis and ultimately, occlusion. In addition to consuming precious venous capital and ultimately compromising future ipsilateral or contralateral cen-tral venous access, central vein obstruction may result in SVC syndrome or disabling arm swelling. In the absence of infection and when feasible, recanalization/angioplasty remains the first line of treatment. Sten-ting is reserved for lesions unresponsive to angioplasty, for maintaining patency of recanalized conduits to the right atrium and/or for treatment of hemorrhage/tamponnade secondary to attempted recanalization.

Central vein patency is perquisite for optimum chronic dialysis catheter tip position. The pathway we choose to reach a large central vein or the right atrium has little impact on catheter function. When jugular and subclavian access are no longer an option and recanalization is unobtainable, alternative cannulation may be safely performed via external jugular or other suitable collateral veins in or near the neck or by transfemoral or translumbar routes.

Funaki et al. 2 described a novel technique for radiologic placement of tunneled dialysis catheters in oc-cluded neck, chest or small thyrocervical collateral veins in central vein occlusion, allowing for recycling of previously abandoned access sites.

More recently, new innovative techniques have proved to be safe and effective in recanalizing occluded central veins where conventional endovascular techniques have failed. Gimaraes et al. 3 reported using a Power Wire radiofrequency guide wire together with an intravascular loop snare and body flossing technique with angioplasty and stenting to safely restore patency to previously uncrossable central vein obstructions.

In patients with true end-stage access needs, cannulation sites of last resort include the transhepatic4 and transrenal5 routes. Both of these approaches are at increased risk of procedural complications and catheter failure due to organ motion.

References1. Schillinger, F., D. Schillinger, R. Montagnac and T. Milcent (1991). Post Catheterisation Vein Stenosis in Haemodialysis: Com-

parative Angiographic Study of 50 Subdavian and 50 Internal Jugular Accesses. Nephrology Dialysis Transplantation 6(10): 722-724.

2. Funaki, B., G. X. Zaleski, J. A. Leef, J. N. Lorenz, T. Van Ha and J. D. Rosenblum (2001). Radiologic placement of tunneled he-modialysis catheters in occluded neck, chest, or small thyrocervical collateral veins in central venous occlusion. Radiology 218(2): 471-476.

3. Guimaraes, M., C. Schonholz, C. Hannegan, M. B. Anderson, J. Shi and B. Selby (2012). Radiofrequency Wire for the Recanali-zation of Central Vein Occlusions that Have Failed Conventional Endovascular Techniques. Journal of vascular and interven-tional radiology : JVIR 23(8): 1016-1021.

4. Smith, T. P., J. M. Ryan and D. N. Reddan (2004). Transhepatic Catheter Access for Hemodialysis1. radiology 232(1): 246-251.5. Murthy, R., M. Arbabzadeh, G. Lund, H. Richard, A. Levitin and B. Stainken (2002). Percutaneous Transrenal Hemodialysis

Catheter Insertion. Journal of vascular and interventional radiology : JVIR 13(10): 1043-1046.

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Operative techniques Snuffbox fistula Chris Gibbons Morriston Hospital, Swansea, United Kingdom

The snuffbox AV fistula was first described over 30years ago but is less commonly used by access surgeons than the radiocephalic AV fistula at the wrist. However, it is the most distal AV fistula possible, thus giving the longest length of forearm cephalic vein for needling and is the ideal access for maximum venous pre-servation. In a series of 210 snuffbox AV fistulae in 201 patients, the patency was similar to that reported for wrist AV fistulas (82% at 6weeks, 65% at 12months and 45% at 5years). In this study patency was not affected by age or diabetes but was significantly worse in women than in men. After thrombosis, an ipsila-teral wrist fistula was still possible in 45% of cases. In a personal series of the snuffbox AV fistula was the primary access in 52% of 1408 cases which was a major factor in the high prevalence of distal AV fistulas in our haemodialysis population (67% of all access and 76% of all permanent access). In a recent study from our unit, the application of a scoring system (DISTAL) using six factors has been found potentially to increase patency by 23% at the expense of 12% fewer snuffbox AV fistulas.

ReferencesWolowczyk L, Williams AJ, Donovan KL, Gibbons CP. (2000) The Snuffbox Arteriovenous Fistula for Vascular Access. Eur J Vasc Endovasc Surg; 19: 70-76.Twine CP, Haidermota M, Woolgar JD, Gibbons CP, Davies CG. A scoring system (DISTAL) for predicting failure of snuffbox arte-riovenous fistulas. Eur J Vasc Endovasc Surg 2012; 44: 88-91.

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Operative techniques Middle forearm fistula Giuseppe Bonforte AO Ospedale SantAnna Como, Como, Italy

The distal radial-cephalic fistula (dRCF) proposed by Cimino-Brescia is recommended as the first and best hemodialysis access because requires an easy placement procedure. When is not feasible, guidelines sug-gest artero-venous fistula (AVF) placement in the upperarm. This second option, compared with a dRCF, enables an higher flow AVF, with a shorter maturation time and an earlier development of more easily available veins for hemodialysis. However, the surgical intervention required for the brachial artery inflow AVF placement has a greater risk of distal steal syndrome, arm ischemia and high output heart failure than the distal approach. In the last 30 years, the hemodialysis population has become older and sicker, comorbid factors have increased and the life expectancy in hemodialysis population has been increased, so nowadays it is even more important to create a working vascular access with as few complications as possible. Several studies have shown that the classic dRCF in this populations (older, sicker, high comorbid factors) has an increased rate of early failure (early thrombosis or failed maturation) and a limited primary unassisted patency due to the frequent need of surgical revisions or angiographic procedures, or both, with increased costs and reduced patient quality of life. On this basis, it is questionable if dRCF should be still considered as the first best choice for vascular access. The middle-forearm fistula (MAF), consisting of an anastomosis between proximal radial artery and the nearest suitable vein located in the antecubital fossa (median, perforating, or cephalic vein), is suggested as an alternative option. According to our results re-garding primary assisted/unassisted patency rates and complications of middle-arm fistula, MAF demons-trated a good unassisted primary patency, suggesting that this kind of AVF could be a valuable alternative surgical approach when dRCF is not feasible in ESRD patients.

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Operative techniques What is the less worst arteriovenous bypass at the upper limb? Miltos Lazarides Democritus University, Alexandroupolis, Greece

European and USA guidelines encourage the increased use of autogenous AV fistulae as more durable access procedure ones matured. However approximately half of all AV fistulae performed fail.1 Although prosthetic AV grafts (AVG) are definitely not superior to AV fistulae, they present the only choice in selected patients in whom an autogenous fistula simply cannot be constructed. The presence of certain factors as advanced patient age, short life expectancy and suboptimal vascular anatomy may favour a prosthetic rather than an autogenous access, the latter being not better to an AVG in every clinical setting. Upper limb AVG may be straight forearm, looped forearm and upper-arm grafts. While straight forearm grafts have lower patencies, looped forearm and upper-arm grafts present similar 2-year secondary patency rates 51-70% in two systematic reviews.2,3 However revisions in the elbow area to maintain patency of looped forearm grafts may jeopardize future use of the arm veins, while basilic transposition was found preferable in a meta-analysis to looped forearm grafts.4 In contrast upper limb grafts present similar patency rates with basilic vein transposition and can still be created after its failure, representing a good last upper limb option. An additional indication of prosthetic grafts is the use of short PTFE segments in revisions of auto-genous accesses, without further consumption of the venous capital by harvesting veins or compromising more proximal access sites,5 this practice is justified and encouraging patencies have been reported, espe-cially when avoiding to cannulate the prosthetic segment.

References1. Dember LM et al. JAMA 2008; 299:2164-21712. Huber TS et al. J Vasc Surg 2003;38:1005-10113. Cull DL. Semin Vasc Surg 2011;24:89-954. Lazarides M et al. Eur J Vasc Endovasc Surg 2008; 36: 597-6015. Georgiadis GS et al. J Vasc Surg 2005;41:76-81

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Operative techniques A new sterile elastic exsanguination tourniquet Eric Ladenheim LDAC Vascular Centers, Fresno California, USA

Because of the rising prevalence of obesity among dialysis patients techniques to superficialize the veins are frequently needed to enable cannulation of fistulas that would otherwise be too deep. However in the upper arm there is not enough space for the pneumatic tourniquet between the axilla and the surgi-cal incision (s). Instead of doing these operations without a tourniquet we have utilized an ultra-narrow non-pneumatic elastic exsanguination tourniquet for preventative hemostasis during lipectomy, liposuc-tion, superficial transposition and translocation of the vessels.

We utilized the HemaClear surgical exsanguination tourniquet (OHK Medical Devices, Haifa Israel) This is a sterile elastic device which rolls over the limb starting from the fingers by pulling two handles. The Elastic exsanguination tourniquet is commercially available and packaged sterile. The elastic silicone ring provide sufficient pressure (220 +/- 30 mm Hg) to block arterial flow into the limb. It is available in several sizes to match the arm circumference.

We routinely stage our upper arm AV fistulas by creating the fistula first and then performing a superficia-lization procedure once fistula function is assured. However, the very high blood flow in the limb during a secondary procedure can make the secondary procedure rather bloody without a tourniquet. By utilizing an ultra-narrow tournequet on the upper arm the secondary procedure can be done almost bloodlessly.

Using the tournequet and having a dry surgical field has significantly reduced blood loss during AVF lipo-suction. It has also allowed for easier exposure through smaller incsions during transpositions promoting increased patient acceptance of the procedures.

Upper Arm Lipectomy with Hemaclear Tournequet Elas-tic Exsanguination Tournequet Stays out of the way

ReferencesBourquelot PD. Preventive haemostasis with an infla-table tourniquet for microsurgical distal arteriovenous fistulas for haemodialysis. Microsurgery 1993; 14: 462-3.Jordan SC and Pescovitz MD. Presensitization: the pro-blem and its management. Clin J Am Soc Nephrol 1: 421432, 2006.Ladenheim E, Our Technique for Performing Upper Arm Lipectomy of Arteriovenous Fistula Under Tourni-quet Control Using the Hemaclear Surgical Exsangui-nation Tourniquet, Presented at VAS 8th International Congress, April 25-27, 2013 Prague, Czech Republic. Abstract published in Journal of Vascular Access, v. 14, No. 1 Jan-March 2013Ladenheim E, Krauthammer J, Agrawal S, et al. A sterile Elastic Exsanguination Tourniquet is Effective in Preven-ting Blood Loss during Hemodialysis Access Surgery, Seminars in Dialysis, 2012 pp 689-692 (November-De-cember)

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Operative techniques Tagliatelle technique: a revolution in vascular access of the lower limbs? Benoit Boura, Faris Alomran, Alexandros Mallios, Romain de Blic,

Alessandro Costanzo, Myriam Combes Institut Mutualiste Montsouris, Paris, France

When all options of upper extremity vascular access are exhausted, vascular surgeons are required to consider a new lower extremity access 1. In the lower limb, publications show a high rate of infectious and thrombotic complications when prosthetic conduits are used 2. The use of a superficial femoral vein is known to be a complex procedure with risk of steal syndrome and recurent oedema 3, 4, 5. The greater saphenous vein (GSV) has proved previously to be a poor conduit due to its resistance to dilatation 6, 7. In such cases, we propose an alternative technique 8, using the GSV, harvested in the thigh and just below the knee, then longitudinally opened, freed from all valves, folded in 2, creating one anterior and one posterior vein panel, both sutured edge to edge as already described in other locations 9, 10, 11. The final result is a conduit which doubles the initial diameter suitable for haemodialysis. This new conduit is subcutaneously tunnelled and then anastomosed end to side to the superficial femoral artery in the mid-thigh. This has all the advantages of a native fistula without the morbidity associated with the superficial femoral vein graft. Also, we believe that this technique can be used in other anatomies, such as the upper limb in selected patients, not candidates for prosthetic graft.

References1. NFK-KDOQI: Clinical Practice For Vascular Access: update 2006. Am J Kidney Dis 2006, 48:248-272.2. Antoniou GA, Lazarides MK, Georgiadis GS, Sfyroeras GS, Nikolopoulos ES, GIannoukas AD. Lower-extremity arteriovenous

access for haemodialysis: a systematic review. Eur J Endovasc Surg 2009;38:365-72.3. Bourquelot P, Rawa M, Van Laere O, Franco G. Long-term results of femoral vein transposition for erogenous arteriovenous

hemodialysis access. J Vasc Surg 2012;56-2:440-5.4. Gradman WS, Cohen W, Haji-Aghaii M. Arteriovenous fistula construction in the thigh with transposed superficial femoral vein:

our initial experience. J vasc Surg 2001;33:968-75.5. Gradman WS, Laub J, Cohen W. Femoral vein transposition for arteriovenous hemodialysis access: improved patients selection

and intra-operative measures reduce postoperative ischemia. J Vasc Surg 2005; 41:279-84.6. Pierre-Paul D, Williams S, Lee T, Gahtan V. Saphenous vein loop to femoral artery arteriovenous fistula: a practical alternative.

Ann Vasc Surg 2004;18:223-7.7. Correa JA, de Abreu LC, Pires AC, Breda JR, Yamazaki YR, Fioretti AC, Valenti VE, Vanderlei LC, Macedo H Jr, Colombari E, Mian-

da F Jr: Saphenofemoral arteriovenous fistula as hemodialysis access. BMC Surg 2010, 10:28.8. Alomran F, Boura B, Mallios A, de Blic R, Costanzo A, Combes M. Tagliatelle technique for arteriovenous fistula creation using

a greater saphenous vein semi-panel graft. J Vasc Surg 2013 May 1.doi:pii:S0741-5214 (13) 01277-9.10.1016/jvs 2013.06.082 (Epub ahead of print).

9. Mallios A, Boura B, Alomran F, Combes M. A new technique for reconstruction of the Aortic Bifurcation with Saphenous Vein Panel Graft.J Vasc Surg. 2013 May 1. doi:pii: S0741-5214(13)00556-9. 10.1016/j.jvs.2013.02.245. [Epub ahead of print].

10. Mallios A, Boura B, Yankovic W, Costanzo A, Combes M. Replacement of infected prosthetic femoral graft with longitudinally Vein Patches. Eur J Vasc Endovasc Surg Extra 2012;23:e40-e41.

11. van Zitteren M, van der Steenhoven TJ, Burger DHC, van Berge Henegouwen DP, Heyligers JMM, Vriens PWHE. Spiral vein re-construction of the infected abdominal aorta using the greater saphenous vein: preliminary results of the Tilburg experience. Eur J Vasc Endovasc Surg 2011;41:637-646.

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Operative techniques. Controversy: Small veins at forearm AVF creation Peroperative balloon angioplasty Pierfrancesco Veroux, Giaquinta A., Tallarita T., Sinagra N., Virgilio C.,

Zerbo D., Gloviczki P., Veroux M. University of Catania, Catania, Italy

PRIMARY BALLOON ANGIOPLASTY OF SMALL (2 MM) CEPHALIC VEINS IMPROVES PRIMARY PATENCY OF ARTERIOVENOUS FISTULAE AND DECREASES REINTERVENTION RATES.Source: Vascular Surgery and Organ Transplant Unit, Department of Surgery, Transplantation and Advanced Technologies, Uni-versity Hospital of Catania, Catania, Italy. veroux@unict.it

PURPOSEThe purpose of this study was to evaluate the effect of primary balloon angioplasty (PBA) of cephalic veins with diameter2 mm on patency and maturation time of autogenous radiocephalic arteriovenous fistulae (AVF) for hemodialysis.

METHODSForty patients, all candidates for distal AVF, with a cephalic vein2 mm, were randomized to two different surgical procedures: (1) PBA of a long segment of the cephalic vein from the wrist up to the elbow (n=19); and (2) hydrostatic dilatation (HD) of a short venous segment (5 cm) at the level of the anastomosis (n=21). PBA was performed using a standard balloon 4150 mm. Primary end points were primary patency and reintervention rates. Secondary end points were maturation time and the rate of working AVF. Follow-up included physical and duplex ultrasound (DUS) examinations at 1,4, and 8 weeks, and every 3 months thereafter.

RESULTSRisk factors were homogeneously distributed between the two groups. Mean vein diameter was 1.80.2 mm for the PBA group and 1.70.2 mm for HD. Immediate success rate was 100% for PBA and 67% for HD groups (P=.04). Causes of failure in the HD group included early vein thrombosis in seven patients (33%). Mean fistula maturation time was 32 days in the PBA group and 55 days in the HD group (P=.04). During the mean follow-up of 7 months, three patients un-derwent drug-eluting balloon angioplasty for failure of AVF to mature due to stenosis (1 in the PBA group and 2 in the HD group). Six-month reintervention rate was significantly lower in the PBA group (5%) compared with the HD group (43%) (P=.02). At 6 months, primary patency rates were 95% in the PBA group and 57% in the HD group (P=.01). Working AVF rate was 100% in the PBA vs 90% in the HD group.

CONCLUSIONSPBA of very small cephalic veins during the creation of a distal AVF for hemodialysis is a safe and feasible procedure. This technique assures excellent primary patency, maturation time, and dramatically decreases reintervention rate.

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References1. National Kidney Foundation. Guidelines and com-

mentaries. Available at: http://www.kidney.org/professionals/KDOQI/guidelines.cfm. Accessed December 9, 2011.

2. Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK. Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int 2001;60:1443-51.

3. Young E. Vascular access. Current practice and practical aspects of management, ASN renal week 2000. Toronto: American Society of Nephro-logy; 2000, p. 377-85.

4. Murphy GJ, White SA, Nicholson ML. Vascular ac-cess for haemodialy- sis. Br J Surg 2000;87:1300-15.5. Ascher E, Gade P, Hingorani A, Mazzariol F, Gun-

duz Y, Fodera M, et al. Changes in the practice of angioaccess surgery: impact of dialysis outcome and quality initiative recommendations. J Vasc Surg 2000; 31(1 Pt 1):84-92.

6. Kherlakian GM, Roedersheimer LR, Arbaugh JJ, Newmark KJ, King LR. Comparison of autogenous fistula versus expanded polytetrafluo- roethylene graft fistula for angioaccess in hemodialysis. Am J Surg 1986;152:238-43.

7. Oliver MJ, Rothwell DM, Fung K, Hux JE, Lok CE. Late creation of vascular access for hemodialysis and increased risk of sepsis. J Am Soc Nephrol 2004;15:1936-42.

8. Allon M, Robbin ML. Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions. Kidney Int 2002;62:1109-24.

9. Huijbregts HJ, Bots ML, Wittens CH, Schrama YC, Moll FL, Blank- estijn PJ, et al. Hemodialysis arteriovenous fistula patency revisited: results of a prospective, multicenter initiative. Clin J Am Soc Nephrol 2008;3:714-9.

10. Grogan J, Castilla M, Lozanski L, Griffin A, Loth F, Bassiouny H. Frequency of critical stenosis in primary arteriovenous fistulae before hemodialysis access: should duplex ultrasound surveillance be the stan- dard of care? J Vasc Surg 2005;41:1000-6.

11. Sidawy AN, Gray R, Besarab A, Henry M, Ascher E, Silva M Jr, et al. Recommended standards for reports dealing with arterio-venous hemo- dialysis accesses. J Vasc Surg 2002;35:603-10.

12. Arteriovenous Fistula First Breakthrough Coalition. Available at: http://www.fistulafirst.org. Accessed December 9, 2011.13. Allon M, Lockhart ME, Lilly RZ, Gallichio MH, Young CJ, Barker J, et al. Effect of preoperative sonographic mapping on vascular

access outcomes in hemodialysis patients. Kidney Int 2001;60: 2013-20.14. Dixon BS, Novak L, Fangman J. Hemodialysis vascular access survival: Upper arm native arteriovenous fistula. Am J Kidney

Dis 2002;39:92- 101.15. Oliver MJ, McCann RL, Indridason OS, Butterly DW, Schwab SJ. Comparison of transposed brachiobasilic fistulas to upper arm

grafts and brachiocephalic fistulas. Kidney Int 2001;60:1532-9.16. Rocco MV, Bleyer AJ, Burkart JM. Utilization of inpatient and outpa- tient resources for the management of hemodialysis

access complica- tions. Am J Kidney Dis 1996;28:250-6.17. De Marco Garcia LP, Davila-Santini LR, Feng Q, Calderin J, Krishna- sastry KV, Panetta TF. Primary balloon angioplasty plus bal-

loon angio- plasty maturation to upgrade small-caliber veins (3 mm) for arterio- venous fistulas. J Vasc Surg 2010;52:139-44.

18. Lipari G, Tessitore N, Poli A, Bedogna V, Impedovo A, Lupo A, et al. Outcomes of surgical revision of stenosed and thrombosed forearm arteriovenous fistulae for haemodialysis. Nephrol Dial Transplant 2007; 22:2605-12.

19. Tessitore N, Mansueto G, Bedogna V, Lipari G, Poli A, Gammaro L, et al. A prospective controlled trial on effect of percu-taneous transluminal angioplasty on functioning arteriovenous fistulae survival. J Am Soc Nephrol 2003;14:1623-7.

20. TessitoreN,LipariG,PoliA,BedognaV,BaggioE,LoschiavoC,etal. Can blood flow surveillance and pre-emptive repair of subcli-nical ste- nosis prolong the useful life of arteriovenous fistulae? A randomized controlled study. Nephrol Dial Transplant 2004;19:2325-33.

21. Karakayali F, Basaran O, Ekici Y, Budakoglu I, Aytekin C, Boyvat F, et al. Effect of secondary interventions on patency of vas-cular access sites for hemodialysis. Eur J Vasc Endovasc Surg 2006;32:701-9.

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Operative techniques. Controversy: Small veins at forearm AVF creation Postoperative Balloon Angioplasty Alain Raynaud Clinique Alleray Labrouste, Paris, France

Creation of a radiocephalic fistula requires a cephalic vein able to enlarge, to mature and to be punctured 3 times a week. The minimal diameter, measured by ultrasonography, required for the cephalic vein de-pends on the surgeon and varies from 2 to 3 millimetres. Some proposed to dilate such small vein during the access creation. Every surgeon knows that a tiny trauma of the vein during access creation may lead to the occurrence of a stenosis and even that the trauma due to the turbulences at the anastomosis is the responsible for the occurrence of the post anastomotic stenosis. Dilatations cause a major trauma to the venous wall with high risks of rupture and of occurrence of venous stenoses. Knowing that a small but nor-mal vein well fed by an artery will maturate normally but will require few more days or weeks, the per ope-rative dilatation appears deleterious Moreover the measurement of venous diameter by ultrasonography is often underestimated, despite a well tighten tourniquet. When a phlebography is performed the injection of nitroglycerine upstream to the tourniquet sometime provides a supplementary venous dilatation. In such case, the preoperative dilatation will be not only deleterious but also useless. Actually, maturation failures of fistulas are due to an overlooked arterial or venous lesion or to a de novo lesion such as a post anasto-motic stenosis; then, to dilate or to surgically redo the anastomosis (for the juxta anastomotic stenosis) will allow the maturation of the fistula. Such angioplasties are performed in better conditions with less risks of acute thrombosis because of the higher flow and with less risks of complication such as rupture the veins being partly matured so less brittle.

CONCLUSIONThe dilatation of a small cephalic vein during an access creation is often useless and/or deleterious there-fore it should not be performed

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Operative techniques. Lecture Vascular steal and ischemia after vascular access Pierre Bourquelot Clinique Jouvenet, Paris, France

Distal ischemia following access creation may be related to steal of blood flow from the arterial system by the arteriovenous access (AVA), in association with artery disease. Most publications refer to steal syn-drome but the term hemodialysis access-induced distal ischemia (HAIDI) would be more appropriate as the physiopathology of ischemia is not restricted to steal.

After fistula creation, the flow that is increased in the proximal artery, above the anastomosis, is totally or partially diverted into the low-pressure venous system, instead of flowing down into the main artery or into collaterals to supply the distal extremity. The flow in the distal artery below the anastomosis will simul-taneously decrease and may even become retrograde to the fistula, being supplied by collateral arteries. This retrograde flow is observed physiologically in >90% of forearm AVAs and very frequently in upper arm angioaccesses. Finally, when associated with arterial lesions preventing normal compensation by collateral flow, both antegrade and retrograde flow diversion into the fistula (steal) can result in insufficient blood supply to peripheral tissues and lead to clinical manifestations of distal ischemia (110% of patients).

HAIDI is a serious complication of hemodialysis access related to the steal of arterial flow associated with artery disease, and is increasing as the numbers of patients who are ageing increase. Prevention of distal ischemia is difficult. Because there is less risk of ischemia an AVA must be created as distally as possible, even in elderly patients. Furthermore patients with occlusive disease of distal arteries must defi-nitely be excluded from performing an autologous lower limb AVA. When present, proximal artery stenosis is best treated percutaneously. For upper arm accesses DRIL (distal revascularization-interval ligation) is the gold-standard technique for increasing flow and pressure in the distal arteries, and DRAL (distal radial artery ligation) is the most frequently used procedure for forearm AVAs. When associated with a high-flow AVA, ischemia may be treated effectively with surgical flow reduction techniques, as transposition of the radial artery or PTFE-distalization of the arterial anastomosis for upper arm access, and PRAL (proximal radial artery ligation) for forearm access, while the favorable results of two recently reported series using banding await confirmation. Although it results in access loss, fistula ligation may be necessary in some patients with distal ischemia. Finally, we proposed an algorithm for the surgical treatment of HAIDI.

ReferencesBourquelot P. Hemodialysis access-induced distal ischemia (HAIDI): surgical management. In: Asif A, Agarwal AK et al., eds. Interventional Nephrology, New York, Mc Graw Hill Medical; 2012: p 601-614. Scheltinga MR, van Hoek F, Bruijninckx CM. Time of onset in haemodialysis access-induced distal ischaemia (HAIDI) is related to the access type. Nephrol Dial Transplant 2009;10:3198e204.

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State of the art & future trends A surgeons perspective Ulf Hedin Dep Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden

In the current tsunami of endovascular advances, questioning the future role for the traditional access surgeon is perhaps justified. Nevertheless, access surgery, despite these technical advancements, appears to remain a corner stone of modern access care. In fact, it is fair to state that the role of the surgeon on this scene should become even more in the centre of the stage. In predicting this development, the future surgical perspective includes a central role in access care organisation, a critical position in decision-ma-king, responsibilities in registry aspects of follow-up and outcome, technical aspects on diagnostic tools and treatment modalities.

Starting with organisational matters, accepted state of the art is that the surgeon should be engaged in the creation of a access team that cross professionally in a smooth and effective manner deals with everything from planning, to follow-up, problem solving, and quality control of access patients. Technical aspects include the development of a multi-skilled access surgeon with the capacity to deal with bedside duplex assessment of preoperative evaluation as well as access problems. In addition, and probably of most significant magnitude, the skills should be complemented with endovascular competence with a mi-nimum requirement to achieve intraoperative problem solution capacity to utilize the technical advantage of endovascular adjunct procedures.

Given the opportunity, there is no doubt in my mind that the multitude of approaches and considerations that are necessary to take in order to create a well-functioning access service will stand out as a feasible and attractive goal for the access surgeon of the future. Conventional access surgery is not going to die, its just being reborn into multifunctionality.

ReferencesBiological grafts for hemodialysis access: historical lessons, state-of-the-art and future directions. Dukkipati R, Peck M, Dhamija R, Hentschel DM, Reynolds T, Tammewar G, McAllister T. Semin Dial. 2013 Mar-Apr;26(2):233-9. Back to the future: how biology and technology could change the role of PTFE grafts in vascular access management. Roy-Chaud-hury P, El-Khatib M, Campos-Naciff B, Wadehra D, Ramani K, Leesar M, Mistry M, Wang Y, Chan JS, Lee T, Munda R. Semin Dial. 2012 Sep-Oct;25(5):495-504. Hemodialysis access monitoring and surveillance, how and why? Haddad NJ, Winoto J, Shidham G, Agarwal AK. Front Biosci (Elite Ed). 2012 Jun 1;4:2396-401. Considerations in the optimal preparation of patients for dialysis. Saggi SJ, Allon M, Bernardini J, Kalantar-Zadeh K, Shaffer R, Mehrotra R; Dialysis Advisory Group of the American Society of Nephrology. Nat Rev Nephrol. 2012 Apr 10;8(7):381-9. Pharmacotherapy to improve outcomes in vascular access surgery: a review of current treatment strategies. Jackson AJ, Coats P, Kingsmore DB. Nephrol Dial Transplant. 2012 May;27(5):2005-16.Vascular access for dialysis in the United States: progress, hurdles, controversies, and the future. Wish JB. Semin Dial. 2010 Nov-Dec;23(6):614-8. Novel insights into the pathobiology of the vascular access - do they translate into improved care? Diskin CJ. Blood Purif. 2010;29(2):216-29.Whats next after fistula first: is an arteriovenous graft or central venous catheter preferable when an arteriovenous fistula is not possible? James MT, Manns BJ, Hemmelgarn BR, Ravani P; Alberta Kidney Disease Network. Semin Dial. 2009 Sep-Oct;22(5):539-44.Tunneled dialysis catheters: recent trends and future directions. Chan MR, Yevzlin AS. Adv Chronic Kidney Dis. 2009 Sep;16(5):386-95.Advances and new frontiers in the pathophysiology of venous neointimal hyperplasia and dialysis access stenosis. Lee T, Roy-Chaudhury P. Adv Chronic Kidney Dis. 2009 Sep;16(5):329-38. Hemodialysis vascular access monitoring: current concepts. Allon M, Robbin ML. Hemodial Int. 2009 Apr;13(2):153-62. Vascular access: the past, present and future. Sands JJ. Blood Purif. 2009;27(1):22-7.

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