Awareness, Investigation, Management, and Prevention

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Keynote lecture

Renal revascularization: a lost art? When is it imperative and which technique?
José Fernandes e Fernandes (Portugal)

Secondary renal arterial hypertension is mostly due to atherosclerosis (80%), which is often found in men >50 years. Most of the atherosclerotic lesions occur in the ostia or the proximal segment of the renal artery, where 20% have renal atrophy. A minority of renal arterial hypertension is caused Takayasu’s disease, spontaneous dissections, aneurysms, and fibromuscular dysplasia (10%). Fibromuscular dysplasia is found in women, where the lesions are centered in the distal two-thirds of the artery, where 90% of the lesions are caused by medial fibromuscular dysplasia. The renal artery, and induces arterial hypertension and ischemic nephropathy due to a reduction in blood flow and atheroembolization.

Several questions and controversies remain concerning the pathophysiology and the indications for intervention for secondary renal arterial hypertension. In fact, should it be considered a “benign disease?” Are there any hemodynamic or biological markers that can act as prognostic factors? What is the role of ischemic nephropathy, considering the evidence of areas of renal infarction areas detected by MRI and the progressive renal dysfunction? What is the real morbidity and mortality of revascularization? Additionally, there has been a reduction in patient referrals due to insufficient knowledge regarding the cause of renal artery stenosis, inadequate methods to assess its hemodynamic effects, lack of routine imaging to identify renal infarcts and determine the plaque structure, new advances in medical treatment, and, perhaps, most importantly, the negative outcomes of the two most recent randomized trials (ie, the ASTRAL and CORAL trials). The negative results of these trials could be due to several weaknesses in the trial design, such as the high number of patients included who did not have a severe stenosis (>70%) and the high rates of complications associated with renal artery stenting. Patient selection needs to be improved for future trials and in the clinical setting, eg, for patients with severe bilateral disease; a single or transplanted kidney; a hemodynamic assessment of the lesions (consider focal increased velocities and low resistive index); a rapid decline in the renal function (without proteinuria); accelerated, malignant, and resistant hypertension (>4 drugs); or flush pulmonary edema.

For endovascular techniques for renal revascularization, Fernandes e Fernandes argued that low profile systems and stents reduce the risk of complications (dissection, distal embolization), reduce the combined morbidity and mortality rates to <3%, increase long-term efficacy on blood pressure control, and preserves or improves renal function. Low-profile systems and stents should be the first-line treatment for atherosclerotic renal artery stenosis. Open revascularization has restricted, but clear, indications, and it should be kept as an alternative for the treatment of specific renal artery issues (mainly, aortic occlusion or abdominal aortic aneurysm with surgical indication and symptomatic renal artery stenosis).

What do we need for a better perspective in the vascular field?

Data on the worldwide epidemiology of peripheral arterial disease
Gerry Fowkes (UK)

Peripheral arterial disease is a worldwide problem, but data on its prevalence are not available in many countries. Ankle brachial index data are the most appropriate tool for the global comparison of peripheral arterial disease. The estimated prevalence of peripheral arterial disease in Europe is 17% to 20%. More data is required for age, sex disparities, and risk factors in low and middle-income countries. The burden of peripheral arterial disease is projected to increase (aging of the population, trends in cardiovascular risk factors, and survival from acute myocardial infarction and stroke); therefore, data are needed regarding treatment planning and prevention services.

Peripheral arterial disease prevalence and characteristics: data from the ERV study
Katalin Farkas (Hungary)

The objectives of the EVR study were to evaluate the prevalence of clinical and preclinical peripheral arterial disease in hypertensive patients and make a risk assessment comparison using the traditional risk factors from the SCORE model (Systematic COronary Risk Evaluation) and ankle brachial index in a hypertensive population during a 5-year prospective phase. The prevalence of low ankle brachial index increases in hypertensive patients and the presence of peripheral arterial disease doubles the 5-year cumulative mortality in the same patients. An ankle brachial index <0.9 was a stronger predictor of death than was the presence of diabetes. In the different risk groups of the SCORE model, the presence of an ankle brachial index <0.9 doubled the mortality during the observational period. In hypertensive patients with an ankle brachial index <0.9, the mortality risk increases with a systolic blood pressure <120 mm Hg in both sexes and with a diastolic blood pressure <70 mm Hg in men, regardless of a previous acute myocardial infarction or stroke.

SVS iPG: easy access to evidence-based guidelines to aid appropriate care of the vascular patients
Peter Gloviczki (USA)

Peter Gloviczki presented the interactive practical guidelines (iPG), a free application created by the Society for Vascular Surgery. Currently, the application contains 11 guidelines that cover most vascular fields (eg, diabetic foot, peripheral arterial disease, venous leg ulcers, threatened lower limb, acute deep vein thrombosis, carotid disease, varicose veins and chronic venous disease, thoracic aortic trauma, subclavian artery and thoracic endovascular aortic repair, abdominal aortic aneurysm, and hemodialysis access); other topics are under development.

Ultrasound-guided vascular procedures

Guidance for endovascular procedures: current place and ultrasound perspectives
Antoine Diard (France)

There are three important steps to consider before conducting endovascular procedures. First, before puncture, information about the patient’s clinical condition, choice of the puncture site, and the appropriate material is needed. Second, during the procedure, it is necessary to have adequate guide wire progression, repair, and positioning in the lesion to be treated, and be able to adapt the strategy. Third, after the procedure, efficacy control measures need to be taken, and the ability to treat occasional complications is needed. Ultrasound guidance results in fewer complications, uses no irradiation, and is cheaper. The echo-guidance contributes to medical information by visualizing the anatomic repair (less legal medical implications). Avoiding radiation exposure and the risk of leukemia, lung cancer, thyroid cancer, gonadal cancer, etc, especially in endovascular procedures, for the entire surgical team (surgeon, nurses) justifies moving from radiation to echography in endovascular procedures when possible. In conclusion, the benefits are significant for the patients who avoid contrast for renal protection and for the surgeons and surgical team who avoid radiation exposure; therefore, it is recommended to use ultrasound guidance as much as possible during endovascular procedures.

Ultrasound guidance for endovenous treatments
Olivier Pichot (France)

Duplex ultrasound, which is complementary to clinical examinations, helps analyze and precisely describe superficial venous insufficiency (ie, the anatomic extent of reflux or obstruction). It is essential for defining the management strategy (medical or interventional treatment), type of ablation, and technical modalities because it provides information on the reflux origin, extension, and drainage. In endovenous procedures, ultrasound guidance has a grade 1C recommendation for vein access, grade 2C for catheterization, grade 1B for catheter positioning, and grade 1B for tumescent anesthesia. In conclusion, duplex scanning is mandatory before endovenous therapy to select patients, techniques, and decide upon the strategy; during endovenous therapy to guide the procedure safely and effectively; and after endogenous therapy to evaluate the results.

Ultrasound guidance angioplasty for vascular access during hemodialysis
Fabrice Abbadie (France)

The first communication about using ultrasound guidance during angioplasty for vascular access in hemodialysis was in 2007. Abbadie discussed a current study on 78 ultrasound-guided angioplasties in 50 patients between January 2015 and January 2016. Patients were excluded when there was a recanalization of occluded segments, salvage angioplasty (volume flow

Peripheral arterial angioplasties: place of ultrasound guidance
Enrico Ascher (USA)

The main advantages of ultrasound-guided vascular interventions include no radiation exposure, no nephrotoxic contrast, multiplanar magnification, and arterial wall visualization. Other advantages include the selection and placement of the balloon and stent, treatment of complications, and technical adequacy (anatomical and hemodynamic). During 2005 to 2015, Ascher performed 1533 cases of ultrasoundguided balloon angioplasty using the following access points: arteriovenous (n=741 cases), femoral-popliteal (n=514), infrapopliteal (n=86), infrainguinal bypass (n=66), carotid artery (n=62), popliteal aneurysm (n=38), and others (n=26). The popliteal arterial volume flow measured by ultrasound is a good predictor of patency. Technical success was observed in 95% of cases (stenoses 99.6% and occlusions 87%). Ascher recommends using ultrasound-guided angioplasty for peripheral arterial disease.

Ultrasound guidance angioplasties: a medical and surgical collaborative model
Carmine Sessa (France)

Sessa emphasized the importance of a hybrid treatment of ultrasound-guided angioplasty with collaboration between vascular surgeons and angiologists. The presence of an angiologist who has vascular ultrasound knowledge provides better surgical results for the patients. The standardization of ultrasound guidance procedures will benefit new generations of vascular surgeons.

Is endovascular management the first option in the treatment of popliteal aneurysms? Why not?
José Fernandes e Fernandes (Portugal)

Open repair remains the reference treatment for a majority of surgical centers, but the use of an endovascular approach has been increasingly reported with favorable outcomes. The availability of the great saphenous vein appears to be the determinant in the decision for open repair (3-year patency, 88% for veins vs 57% for prosthetic grafts). Treatment is indicated for aneurysms over 2 cm in the presence of an intravascular thrombus and/or symptoms. Open surgery is still the first choice for patients with acute ischemia, distal embolization, and concomitant occlusion of crural vessels and the presence of an adequate vein conduit.