Abdominal aortic aneurysm screening of years old men: A single centre feasibility study

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1 Freie Mitteilungen / Communications libres FM1.1 Abdominal aortic aneurysm screening of years old men: A single centre feasibility study C. Urena, M. Sarti, F. Del Grande, R. Canevascini, J. C. Van den Berg, R. Rosso, L. Giovannacci (Lugano) Objective: Several randomized trials have shown the effectiveness of screening programs in reducing AAA mortality at a moderate cost. The present pilot study is focused on the technical feasibility and acceptability of a screening program in a defined group of the population in our region. Methods: To all years old men outpatients visiting our hospital clinics during the study period was given the opportunity to perform a free ultrasound exam for the measurement of the infrarenal abdominal aorta. The result was communicated to the patient's general pratictioner, who was invited to provide follow-up control or to organize the surgical treatment for patients screened positive. Results: Between 17 January and 27 December 2013, 1390 eligible patients were identified. 744 (64%) ultrasound scans were performed while 646 (46%) did not participate (27,3% logistic problems,7% disinterest, 12,1% unavailability, 0,1% death). 7 (1%) of the performed exams were not diagnostic. Of the remaining 737 aortic measurements (53,5%), 31 (4%) were positive: one patient (0,1%) underwent successful surgical repair without complications for an aortic aneurysm of 5,7 cm, while 30 patients were directed to follow up programs. The costs of screening per patient was Fr Conclusion: AAA screening can be performed with benefit to the patient and very reasonable organizational and financial effort. Patients'low interest and low participation to the study requires a detailed analysis of the reasons for their refusal. Methods to improve the acceptability should be developed, before considering an extension to the entire cantonal population FM1.2 Chimney EVAR for pararenal AAAs has a less deleterious effect on renal function than open repair Z. Rancic, M. Voutat, D. Mayer, G. D. Puippe, T. Pfammatter, D. Becker, P. Ghibu, F. Veith, M. Lachat (Zürich) Objective: In patients with pararenal aortic aneurysm (PRAA) the incidence of renal function deterioration during treatment is high, and is identified as a primary risk factor for perioperative morbidity. Our objective was to determine the impact on renal function of three different treatment options for PRAA: 1.complete open repair (OR), 2.hybrid repair using VORTEC technique to bypass the renal arteries with subsequent aortic endografting and 3.complete endovascular repair using parallel grafts to revascularize the renal arteries (Chimney-EVAR). Methods: This is a single center experience with retrospective analysis of prospectively collected data from all 79 patients treated for PRAA from January 1, 2002 to February 28, 2012, included 16 patients treated by OR, 26 by hybrid repair using VORTEC technique, and 37 by Chimney-EVAR technique. The renal function was assessed trough serum creatinine levels, estimated GFR and reduced kidney perfusion or incidence of kidney infarction as shown on CT scans. Results: The baseline serum creatinine concentrations did not differ significantly between the groups. However there was a significant difference between the groups after treatment (P =.001,). Serum creatinine concentration is significant higher for OR (139 +/- 38 µmol/l) and for Hybrid procedures (139 +/- 37 µmol/l) compared to Chimney-EVAR (104 +/- 40 µmol/l). Estimated GRF is 6 DOI: / /a000480

2 significantly lower for OR and for Hybrid procedures compared to Chimney-EVAR, but this difference was transient and there was no difference in e-gfr after discharge, 1 month and 12 month of follow-up. A total of 8 patients (10.1%) required postoperative dialysis, including permanent dialysis for two (2.5%). Requirement for dialysis did not significantly differ among the three treatment options. CT scans performed at discharge, at 1 and 12 months showed no significant differences in term of reduced kidney perfusion or incidence of kidney infarction. During hospital stay a total of 12 patients (15%) died with a slightly greater number of deaths for OR and hybrid procedures (P =.008). Conclusion: The less severe deterioration of renal function after Chimney-EVAR treatment for PRAA lends additional support to the use of this method as an established treatment option for complex PRAAs when fenestrated and branched EVAR is not feasible or available. Long-term comparative studies of the latter 2 methods with Chimney-EVAR are needed. FM1.3 Patterns of rupture of abdominal aneurysms after endovascular aortic repair (EVAR) S. Hofer, G. Heller, U. Derungs, P. Knüsel, M. Furrer (Chur) Objective: Risk of rupture after endovascular aortic repair is low but a major concern. Surveillance after EVAR should be focused to detect sac growth or stentgraft migration and/or to rule out type I or III endoleak. The purpose of this study was to analyse the incidence and the rupture mechanism with regard to the currently employed follow-up schedule after EVAR. Methods: Between June 2008 and January 2015 data from patients after EVAR were collected prospectively in our surveillance program and were retrospectively analysed. The results of contrast enhanced computed tomographic imaging or duplex ultrasound during the follow-up period were compared. Results: We treated 118 patients with abdominal and iliac aneurysm endovascularly. All patients were included in a surveillance program 3, 9, 15 months after EVAR and at yearly intervals thereafter. Either a CT scan or duplex ultrasound was performed depending on an postoperatively endoleak type II. In our patient cohort we observed 2 cases of ruptured aneurysm and 2 symptomatic aneurysms after EVAR. We detected one type III endoleak with a symptomatic aneurysm after 8 months and three type I endoleaks due to graft migration, one with an symptomatic aneurysm after 64 months and two with established retroperitoneal ruptures after 32 and 43 months, respectively. The last surveillance in these two patients was performed by duplex ultrasound because of an apparently uneventful follow-up with aneurysm sac shrinking. The graft migration was not discerned. These four patients underwent emergency surgery, one by open and three by endovascular repair. The 30-day mortality was zero. Conclusion: The rupture risk in our cohort was 0,8% per 100 person-years and thus slightly higher than in previous reports. However, the mortality rate was 0% and therefore lower than in the literature. Follow-up by duplex ultrasound alone could not reveal graft migration in two patients. As a consequence, we redesigned our surveillance program for patients after EVAR. In patients at risk, i.e.: with short aortic or iliac sealing zones, thrombotic or angulated neck, off-label-use of stentgraft systems and existing endoleak we advocate yearly CT scans. 7

3 FM1.4 Exzellentes Langzeit-Outcome bei Implantation von Rinder-Xenoperikard Prothesen zur Behandlung infra- und juxtarenaler Aortenaneurysmen D. Mayer, Z. Rancic, M. Da Col, M. Lachat (Zürich) Objective: Erfassung des Langzeit-Outcomes nach chirurgischer Behandlung von abdominalen Aortenaneurysmen mittelsrinder- Xenoperikard Prothesen beim multimorbiden Patienten. Methods: Retrospektive Datenanalyse aller (n=24) infra- und juxtarenal implantierten Xenoperikard Prothesen im Zeitraum von 2003 bis 2006 am Universitätsspital Zürich im Rahmen einer Masterarbeit. Patientengut: mittleres Alter 66 Jahre (min 52, max 82), 22 (92%) männlichen und 2 (8%) weiblichen Geschlechts. Eingriffsart: 9 (38%) notfallmässig bei Aneurysmaruptur, 15 elektiv. Lokalisation der Aneurysmen: 15 (63%) infrarenal, 9 (37%) juxtarenal. Endpunkte waren Mortalität, Verschlussrate und generelle Morbidität. Results: Die Gesamt-Mortalität bei einem mittleren Follow-up von 10 Jahren (min 8 Jahre, max 11 Jahre) betrug 29%. Die 30-Tages-Mortaliät betrug 12.5% (n=3), die Langzeit-Mortalität, nach Exklusion der innerhalb von 30 Tagen verstorbenen Patienten, ist 16.7% (n=4, alle non-aneurysm related ). Die 30-Tages-Verschlussrate lag bei 0%. Langfristig waren 2 (8%) Verschlüsse zu verzeichnen, die erfolgreich revaskularisiert werden konnten. Die sekundäre Langzeit-Offenheitsrate beträgt dementsprechend 100%. Wir fanden folgende 30-Tages-Morbidität: Graftinfekt (n=2), Graftruptur (n=1), paralytischer Ileus (n=2) und pulmonale Dekompensation (n=1). Langzeitmorbidität bezüglich Xenoperikard Prothese war keine nicht zu verzeichnen. Conclusion: Die Rinder-Xenoperikardprothese erwies sich sowohl elektiv als notfallmässig als eine gute Therapieoption bei der Behandlung von infra- und juxtarenalen Bauchaortenaneurysmen in einem komplexen und multimorbiden Patientengut. Das Langzeit-Outcome ist exzellent sowohl bezüglich Überleben als auch Beschwerdefreiheit. Es wurde keine Langzeitdegeneration der Xenoprothesen festgestellt. FM1.5 Early outcome after use of EndoAnchors during endovascular aortic repair two center experiences V. Makaloski 1, S. Déglise 2, J.-M. Corpataux 2, F. Saucy 2, D.D. Do 1, J. Schmidli 1 ( 1 Bern, 2 Lausanne) Objective: Challenging anatomies of aortic aneurysm neck are the most common reason for type Ia endoleak (EL) or graft migration during or after thoracic and abdominal endovascular aortic repair ((T)EVAR). The use of active transmural aortic wall fixation with EndoAnchors (Aptus Endosystems, Sunnyvale, Calif) allows better fixation and alignment of the endograft to the aortic wall, with the potential to reduce early and late aortic neck complications. The aim was to report our experience with EndoAnchors in ((T)EVAR) Methods: Retrospective analysis of data retrieved from two centers between January 2013 and May All patients where EndoAnchors were used for primary procedures with challenging neck anatomies (neck length <10mm or neck angulation >60 ) or for secondary procedures (due to type Ia EL and/or graft migration) were analysed. End points were technical deployment, procedural success (no type Ia EL at the end), postoperative morbidity and any aneurysm-related reinterventions during follow-up. All patients were followed either with ultrasound or with computed tomography after 1, 6 and 12 months and yearly thereafter Results: Eight patients (five males, mean age 80 years, range 75-85) were identified. Seven underwent EVAR and one TEVAR. In four cases (one TEVAR) EndoAnchors were used for primary and in four 8

4 for secondary procedures (three for type Ia EL and one for type Ia EL + migration). In two secondary procedures an additional aortic cuff was needed. A mean of 8 anchors (range 5-9) was applied. Technical deployment was uneventful and no anchor was lost. Procedural success was achieved in four cases and in four low flow type Ia EL was detected. At one month two of them resolved spontaneously and two were still present without aneurysm sac growth are still treated conservative. No endograft migration was registered during the mean follow-up of 8.5 months (range 1-27), with three patients completing 24 months. No aneurysm-related reintervention was needed during followup. No periaortic hematoma or any EndoAnchors dislocation was seen Conclusion: The use of EndoAnchors is safe and provides excellent fixation of the endograft to the aortic neck wall. Abdominal aortic aneurysms with challenging aortic necks can be treated with EndoAnchors as an adjunct to prevent proximal extension or the use of fenestrated endografts. Additionally EndoAnchors can be used in secondary type Ia EL after (T)EVAR FM1.6 Langzeitresultate nach Endovaskulärer Behandlung von Bauchaortenaneurysmen mittels Endoprothesen der ersten Generation S. Nordbeck 1, M. Lachat 1, T. Pfammatter 1, G. D. Puippe 1, M. Glenck 1, P. Ghibu 1, D. Becker 1, F. Veith 1,2, D. Mayer 1, Z. Rancic 1 ( 1 Zürich, 2 New York) Objective: Die endovaskuläre Behandlung eines abdominalen Aortenaneurysma (EVAR) ist heute weit verbreitet. Die Betrachtung von Langzeitresultaten mittels Prothesen der ersten Generation zeigte, dass bei vielen Patienten Komplikationen im Verlauf auftraten. Auf Grund dessen mussten auch teilweise sekundäre Interventionen zur Korrektur vorgenommen werden. Anschliessend soll analysiert werden, ob dabei ebenfalls Komplikationen im längeren Verlauf zu beobachten sind und wenn ja um welche es sich dabei handelt. Methods: Seit dem Jahr 1997 wurde Bauchaortenaneurysma im Universitätsspital Zürich mittels Prothesen der ersten Generation endovaskulär behandelt. In dieser retrospektiven Studie mit prospektiv gesammelten Daten wurden die ersten 100 konsekutiven Patienten am Universitätsspital Zürich eingeschlossen, deren abdominales Aortenaneurysma endovaskulär mittels Prothesen der ersten Generation behandelt wurde. Des Weiteren mussten die Patienten eine Verlaufskontrolldauer von mehr als 2 Jahren aufweisen. Results: Die mediane Follow up Zeit der 100 Patienten betrug 72 Monate (24 Monate 183 Monate). Bei 82% der Patienten (n = 82) traten eine oder mehrere Komplikationen während der gesamten Verlaufskontrolle auf. Die häufigste Komplikation war das Endoleak (55,7%). 69,5% der Patienten mit Komplikationen mussten sich einer sekundären Intervention unterziehen. Die mediane Dauer bis zur sekundären Intervention betrug 35,5 Monate nach der Prothesenimplantation. Conclusion: Die Analyse der Verlaufskontrollen von 100 Patienten zeigte, dass es bei der Verwendung der ersten Generation der Prothesen für eine endovaskuläre Behandlung von Aortenaneursymen zu zahlreichen Komplikationen, unabhängig vom implantierten Prothesentyp, im Verlauf kommt. Diese zogen teils auch weitere notwendige Eingriffe zur Korrektur nach sich. Aufgrund dieser Erkenntnis zeigt dies, dass eine Notwendigkeit einer engmaschigen Überwachung dieser Patienten besteht. Daher wird empfohlen, dass Patienten, deren Bauchaortenaneurysma mit Prothesen der ersten Generation behandelt wurden, eine lebenslange Verlaufskontrolle durchführen lassen. Mit Hilfe dieser Kontrollen lassen sich Komplikationen rechtzeitig erkennen und wenn nötig entstandene Schäden mittels Intervention beheben. Diese Kontrollen können mittels bildgebender Verfahren (wie zum Beispiel Computer- oder Magnetresonanztomographie) erfolgen und erwiesen sich als sehr zuverlässig. 9

5 FM2.1 Short and long-term outcomes of the Viabahn stent in the treatment of popliteal aneurysms E. Allain, T. Holzer, L. Briner, S. Deglise, J.-M. Corpataux, F. Saucy (Lausanne) Objective: The treatment of asymptomatic popliteal aneurysm is still controversial. Since a few years, endovascular treatment with covered stent has selected indications with acceptable patency rates (Ref). Nevertheless, surgical approach is still the gold standard with a reverse saphenous bypass. The aim of this study is to assess primary and secondary patency rates at different times of follow-up while using expandable polytetrafluoroethylene-covered stent and to report potential adverse event of this technique. Methods: This retrospective monocenter cohort study included 36 patients, male (n= 33, 91.7%), female (n= 3, 8.3%), and 38 limbs, right (n= 21, 55.3%), left (n= 17, 44.7%.). From October 2009 to April 2014, we included all consecutive patients who did undergo an endovascular repair of a popliteal aneurysm with a Viabahn (Gore, Flagstaff, USA) stent-graft. All data were retrospectively analyzed from a prospective database (Secutrial, Interactive Systems, Germany). Primary outcomes are primary and secondary patencies. Patency rates were assessed at 6, 12 and 24 months. Patency of the stent is assessed by duplex scan. Results: We included 27 (71.1%) asymptomatic and 11 (28.9%) symptomatic politeal aneurysms. Primary patency rate at 6, 12 and 24 months is 78.8%, 78.8% and 71.0% respectively. Secondary patency rate at 6, 12 and 24 months is 94.3%, 90.6% and 83.0% respectively. The mean follow-up is 505 days [range ; ]. 9 occlusions occured during the follow-up with a 82% of events before 12 months. Freedom of postoperative complications is 89.5%. Median length of stay is 6 days [range; 2-95]. Runoff score showed that 3 crural vessels were patent in 63.9%, two in 30.6% and 1 in 5.6% of the cases. Conclusion: The endovascular repair of popliteal aneurysm is a valid therapeutical option with acceptable patency rates when runoff score shows more than one crural vessel patent. FM2.2 Radioprotective light-weight caps in the interventional setting: a randomized controlled trial (PROTECT-trial) H. Uthoff 1,2, R. Quesada 3, B. T. Katzen 3, A. S. Kreusch 4, D. Staub 2 ( 1 Luzern, 2 Basel, 3 Miami, 4 Winterthur) Objective: To test the radioprotection efficacy and comfort of newer bilayer barium sulfate bismuth oxide composite (XPF) caps in an interventional setting. Methods: Operators were randomly assigned to wear standard fabric (n=59), 0.3mm (n=74) or 0.5mm (n=64) lead-equivalent XPF caps during fluoroscopy guided interventions. Radiation doses were measured by using dosimeters placed outside and underneath the caps. Wearing comfort was assessed at the end of each procedure on a visual analog scale (0 100, with 100 indicating optimal comfort). Results: Procedure data did not differ between the XPF and standard groups. Mean standard, XPF- 0.3mm and XPF-0.5mm cap weights were 12.5g (95%-CI 12.5 to 12.6g), 118.4g (95%-CI to 120.3g) and 123.7g (95%-CI to 124.6g)(p<0.001), respectively. Comfort ratings for the XPF caps (median VAS 90, IQR90 90) were not significantly lower compared to the comfort ratings for the standard caps (VAS 90, IQR90 100; p=0.272). The mean radiation protection was 12.0% 95%-CI 4.9 to 19.1% (standard caps, n=35), 91.5% 95%-CI 87.4 to 95.6% (XPF 0.3mm caps, n=45) and 97.1% 95%-CI 92.5 to 100% (XPF 0.5mm caps (n=44)(p for all group comparisons). 10

6 Conclusion: Lightweight XPF caps show comparable comfort to standard fabric caps, but provide substantial radiation protection during fluoroscopy-guided cardiac interventions. FM2.3 Dialysis access angioplasty/stenting under sonographic guidance : safety, feasibility and efficacy of the first 40 procedures in a single center D. Périard, L. Morel, M.-A. Rey Meyer, D. Hayoz (Fribourg) Objective: Management of dialysis access stenosis is usually performed by percutaneous transluminal angioplasty (PTA) or stenting, in cathlab under fluoroscopy. As Duplex scan provides complete information on fistula volume flow, vessel diameters and focal stenosis, we investigated whether fistula PTA/stenting is feasible under sonography guidance without fluoroscopy. Methods: From September 2011 to May 2015, 46 fistula required endovascular correction of a stenosis. For 6 of them, a central stenosis was suspected and the interventions was performed in the regular cathlab. The 40 remaining interventions (22 patients) were performed in the angiology outpatient clinic under sonographic guidance. Duplex scan (flow measurement, PSV of the stenosis) was performed at beginning and end of the procedure. After chlorhexidine disinfection and sterile draping, intervention was performed with short dedicated angioplasty material/device, under sonographic control (with sterile cover). Results: 40 procedure were performed without any major adverse event. All patients could leave the clinic after procedure. Two patients with long stenosis required surgical enlargement plasty within 30 days after the procedure, for technical failure. The 38 remaining interventions had technical success (mean 410 ml/min increase in volume flow and 3.1 m/s reduction of PSV of the most severe stenosis). Patient were treated by plain balloon (9 interventions), drug-eluting balloon (24 interventions) and stenting (7 interventions). Conclusion: Sonographic guidance is safe, feasible and efficient for PTA/stenting of stenosis that are not located in the central veins. The technic is accurate, simple, and cheaper as the standard and does not expose the operator s hands to radiations. FM2.4 Self-Expanding Nitinol Stent for the Treatment of Atherosclerotic Lesions in the Popliteal Artery : a single-center experience S. Déglise, M. Benezit, T. Holzer, C. Dubuis, F. Saucy, J.-M. Corpataux (Lausanne) Objective: Since endovascular therapy became the first-line treatment in many situations in peripheral arterial disease, technology consistently increased. However, the endovascular management of popliteal atherosclerotic lesions remains challenging. The goal is to ensure recanalization by avoiding stenting. Indeed, the popliteal artery is submitted to extreme mechanical forces leading to an increased risk of stent fracture, neotinima development and lumen obliteration. The aim of this study is to report our experience using self-expanding stent (SES) for the treatment of atherosclerotic popliteal lesions. Methods: Retrospective analysis of data retrieved from our Department From January 2011 to November 2014 was done from a prospective database (Secutrial). All patients where a self-expanding stent was used to treat popliteal artery occlusive disease were included. Primary endpoints were immediate technical success rate and patency rates at mid-term follow-up. Secondary outcome was the post-operative complications rate. 11

7 Results: This retrospective monocenter cohort study included 51 limbs in 50 patients with a mean age of 77 years (range 43-96). Indications were critical ischemia in 46 limbs (90%) and claudication in 5. There were 22 stenoses and 29 occlusions. Technical success was 98%. One stent was implanted in most cases (88%) except in 6 patients where 2 stents were required for a total of 57 SES. The majority was Pulsar18 (32) and Innova (13). Mean diameter was 5.2 mm (range 4-7mm) and mean length was 81 mm (range mm). Four post-operative complications occurred. There were 3 cases of stent occlusion (6%) leading to a bypass and 1 groin hematoma requiring surgery. The mean follow-up was 286 days (range d). Among 11 re-interventions performed, there were 3 bypasses for total occlusions, 3 angioplasties for in-stent restenosis or occlusion and 4 amputations. Five patients (10%) died during follow-up. Estimates of primary, primary assisted and secondary patency rates at 6, 12 and 18 months were 88.2%,80.7%,74.9% and 88.2%,84.2%,84.2% and 91.3%,87.1%,87.1% respectively. Conclusion: This study suggests that stenting of popliteal atherosclerotic lesions is safe and offers good sustained results in term of patency at mid-term considering this old population with reduced life expectancy. However, furthers patients and longer follow-up are required. FM2.5 Treatment of infrainguinal bypass occlusion with AngioJet rheolytic thrombectomy K. Dessi, L. Briner, T. Holzer, F. Saucy, J.-M. Corpataux, S. Déglise (Lausanne) Objective: Despite routine surveillance, occlusion of infra-inguinal bypass still occurs. The classic solutions as intra-arterial thrombolysis and open surgery carry risks. The role of AngioJet rheolytic thrombectomy in venous thrombosis and pulmonary embolism have been assessed and reported but its impact in case of acute limb ischemia due to bypass occlusion is unknown. The aim of this study is to report our early experience using rheolytic thrombectomy with the AngioJet catheter for the treatment of lower limb bypass occlusion. Methods: Retrospective analysis of data retrieved from our Department From May 2013 to May 2015 was done from a prospective database. All patients where AngioJet thrombectomy was used to treat infrainguinal bypass graft thrombosis were included. Primary endpoints were immediate technical success rate of revascularisation and patency rates at short-term follow-up. Secondary outcome was the post-operative complications rate. Results: This retrospective monocenter cohort study included 13 limbs in 13 patients with a mean age of 73 years (range 47-92). There were 5 femoro-popliteal and 8 femoro-tibial (62%). All of them were venous grafts except for 3. Ten patients (77%) presented with an acute ischemia of which 31% had associated sensitivity/motor disorders. In 4 patients, previous attempt of thrombolysis failed. A percutaneous approach was performed in 85% (11/13) of patients. 11 procedures (85%) required additional balloon angioplasty with 8 stent implantation. Immediate technical success was 100%. Complication at 30 days included 1 major amputation and 1 occlusion requiring a new bypass. The mean follow-up was 9 months (1-14 months). During this period, 3 susequent occlusions occured but without any amputation. Primary and primary assisted patency rates at 1, 3 and 6 months were 83%, 67% and 33% and 83%, 83% and 67% respectively. Mortality rate at 1 year was 8%. Conclusion: This study suggests that AngioJet rheolytic thrombectomy is a safe and useful percutaneous procedure in old patients avoiding open surgery. Recurrent stenosis is a frequent complication requiring close surveillance and additional treatment. However, limitations of this study are a small population and a short follow-up and additional data are needed to consider AngioJet thrombectomy as a first-line therapy. 12

8 FM2.6 Physical exercise prior to lower limb stenosis prevents walking capacity impairment in a mouse model of intermittent claudication M. Pellegrin, M. Mayer, K. Bouzourène, J.-F. Aubert, L. Mazzolai (Lausanne) Objective: Physical exercise (PE) therapy is indicated to improve walking capacity in patients with intermittent claudication (IC) due to atherosclerotic stenosis of lower extremity arteries. The effect of PE prior to arterial stenosis on walking capacity is unknown. Aim of the present study was therefore to explore the protective effects of PE prior to peripheral arterial stenosis in a mouse model of IC. Methods: Atherosclerotic C57BL/6 ApoE-/- mice were allowed free access to a voluntary wheel running (WR; daily average running distance: 4.2 ± 1.6 km) or remained sedentary (SED) for 5 weeks before unilateral iliac artery ligation. Thereafter, the two groups were kept sedentary for 5 weeks. Maximal running distance and time until exhaustion were determined on a rodent treadmill. Hindlimb perfusion was assessed using laser Doppler imaging. Real-time RT-PCR was used to determine macrophage phenotypes (pro-inflammatory M1 versus anti-inflammatory M2 macrophages) in hindlimb quadriceps muscle. Flow cytometry was employed to analyse blood circulating monocyte subsets (Ly6Chigh inflammatory monocytes versus Ly6Clow resident monocytes ). Results: Maximal walking distance and time were significantly improved by 23% and 13%, respectively, in WR mice compared to SED mice at 5 weeks post-arterial ligation. Compared to SED mice, ischemic hindlimb perfusion in WR mice was significantly increased at week 3 (+40%), week 4 (+50%) and week 5 (+28%) post-arterial ligation. In WR mice, mrna expression of M2 marker CD206 in ischemic muscle significantly increased (1.7-fold versus non-ischemic muscle at week 5 post-arterial ligation) whereas no significant change was observed in SED mice. M1 marker CD11c mrna expression did not significantly differ between ischemic and non-ischemic muscle both in WR and SED mice. WR significantly increased the resident monocyte Ly6Clow subset in the circulation (+45% versus SED mice at 5 weeks post-arterial ligation). Conclusion: PE prior to peripheral arterial stenosis ameliorates impaired walking capacity subsequent to arterial stenosis. Underlying mechanisms include an enhancement of the ischemic hindlimb perfusion and a polarization of circulating monocytes and muscular macrophages toward an antiinflammatory phenotype. Our findings support the role of PE in primary prevention of IC. FM3.1 Einfluss kardiovaskulärer Risikofaktoren auf das Stadium der peripheren arteriellen Verschlusskrankheit T. Wyss, L. Adam, A. Haynes, N. Kucher, G. Silbernagel, D.D. Do, J. Schmidli, I. Baumgartner (Bern) Objective: Die Entwicklung der peripheren arteriellen Verschlusskrankheit wird durch das Vorhandensein von kardiovaskulären Risikofaktoren beeinflusst. Es ist jedoch unklar, ob bestimmte Risikofaktoren zu unterschiedlichen klinischen Stadien der peripheren arteriellen Verschlusskrankheit führen. Ziel dieser retrospektiven Kohortenstudie war es, die Assoziation von kardiovaskulären Risikofaktoren mit dem Auftreten einer kritischen Extremitätenischämie zu untersuchen. Methods: Die Studienkohorte stammt aus einem konsekutiven Register von Patienten, welche an einem Zentrumsspital zwischen Januar 2000 und April 2014 eine endovaskuläre Therapie erhalten haben. Patienten mit einer Primärintervention bei chronischer peripherer arterieller Verschlusskrankheit der unteren Extremitäten wurden eingeschlossen. Uni- und multivariate logistische Regressionsmodelle wurden angewandt, um die Assoziation von Alter, Geschlecht, 13

9 Diabetes mellitus, arterieller Hypertonie, Dyslipidämie, Nikotinabusus und Niereninsuffizienz mit Claudicatio intermittiens versus kritischer Ischämie zu prüfen. Results: Es wurden 3406 Patienten in die Studie eingeschlossen (Durchschnittsalter 71.7 ± 11.8 Jahre, 2075 [61%] Männer). Es bestand eine signifikante Assoziation von Alter (odds ratio [OR] 1.67, 95% confidence interval [CI] , p <0.001), männlichem Geschlecht (OR 1.23, 95%-CI , p = 0.016), Diabetes mellitus (OR 1.99, 95%-CI , p <0.001) und Niereninsuffizienz (OR 1.62, 95%-CI , p <0.001) mit kritischer Extremitätenischämie. Nikotinabusus war mit Claudicatio intermittens assoziiert (OR 0.78, 95%-CI , p = 0.010). Arterielle Hypertonie und Dyslipidämie zeigten keine signifikante Assoziation mit Claudicatio intermittens oder kritischer Extremitätenischämie. Conclusion: Bei Patienten mit peripherer arterieller Verschlusskrankheit, welche sich erstmalig einer Katheterintervention unterziehen, sind Alter, männliches Geschlecht, Diabetes melllitus und Niereninsuffizienz die stärksten Prediktoren für das Vorhandensein einer kritischen Extremitätenischämie. FM3.2 Predictive role for atherosclerotic cardiovascular disease of peripheral artery disease in menopausal women A. Alatri, M. Depairon, R. Darioli, N. Aebischer, J. Schwitter, L. Mazzolai (Lausanne) Objective: Peripheral arterial disease (PAD) is a leading atherosclerotic vascular morbidity together with myocardial infarction and stroke. Patients with PAD have a 3-6 fold increased risk rate of cardiovascular morbidity and mortality. Data about women and PAD are limited. We evaluated the impact of atherosclerotic cardiovascular risk factors (CVRF) on PAD in menopausal women as well as the relative predictive role of PAD for cardiovascular disease compared to other CVRF. Methods: Single centre cohort study evaluating consecutive menopausal women. PAD was screened by ankle-brachial index (ABI) measurement. For each subject a medical history questionnaire considering CVRF, body mass index, chronic renal failure, familial history of myocardial infarction, personal history of coronary artery disease (CAD) and cerebrovascular disease (CeVD) was collected. Results: Overall, 381 women, mean age 69.7 ±11 years, were included in the study and 153 (40.2%) of them had PAD. Prevalence of CAD and CeVD was 10.8% and 5.8%, respectively. All prevalence increases with age. Fifty-one (30.3%) patients with PAD had CAD and CeVD and 80.5% of patients with CAD and 81.8% of patients with CeVD had a concomitant PAD. Diabetes, hypertension, dyslipidemia, smoking, chronic renal failure as well as personal history of CAD and CeVD were significantly more frequent in PAD group (p<0.001). Multiple logistic regression analyses showed that smoking, hypertension, previous CAD or CeVD are the stronger independent PAD predictors with an odds ratio (OR) of In patients with a history of CAD, OR for PAD, smoking and hypertension was 3.29, 3.00, and 4.99, respectively. In patients with CeVD history, PAD resulted to have an OR of Conclusion: We found a bidirectional relationship between PAD and cardiovascular disease in menopausal women. The risk of PAD increases 3-4 times in patients with history of CAD or CeVD. PAD, smoking, and arterial hypertension were independent risk factors for CAD and PAD was the only independent predictor for CeVD. 14

10 FM3.3 Early cannulation arteriovenous grafts should be used to reduce central venous catheter T. Holzer, A. Schmit, S. Déglise, J.-M. Corpataux, F. Saucy (Lausanne) Objective: When native hemoaccess is not indicated, arteriovenous grafts (AVG) is frequently required with a mandatory delay before the first puncture of two to three weeks to limit bleeding risk. Meanwhile, when dialysis is urgent, a central venous catheter (CVC) is used with subsequent risks of infection and central venous stenosis. Therefore early cannulation grafts are used to allow immediate AVG puncture after confection. The aim of this study is to assess if early cannulation grafts reduces the prevalence and duration of CVC. Methods: This is a retrospective monocentric study in a tertiary hospital. All consecutive patients with an early cannulation AVG confection between 2009 and 2014 were included. AVG revisions were excluded. Primary outcomes are prevalence of CVC and post-operative duration of CVC. Secondary outcomes are time to first puncture, complications and patency. Patency rates were described with Kaplan-Meier curves. Results: We included 73 patients with an early cannulation AVG confection. Median age (±SD) was 67 years (±13). 84% were already dialysed at the time of intervention with a mean dialysis duration of 1821 days [ ]. All early cannulation grafts were Flixene (Atrium, Maquet). CVC prevalence before operation was 49%. 22/36 (61%) pre-operative CVC were removed at 7 days post-operatively, 32/36 (88%) at 14 days and 33/36 (92%) at 21 days. The mean post-operative CVC duration was 7 days [0-31]. Post-operative cumulative complication rate was 26%. Primary patency was 65.5%, 45.6% and 34% at 6, 12 and 24 months respectively. Primary assisted patency was 72.5%, 60.5% and 53.9% at 6, 12 and 24 months respectively. Secondary patency was 89%, 79.2% and 72.2% at 6, 12 and 24 month respectively. In the 34 patients without pre-operative CVC who needed urgent dialysis only two (5.8%) required a post-operative CVC. Therefore early cannulation grafts permitted to avoid 32 CVC. If we consider that all 36 patients with a pre-operative CVC would have kept it postoperatively during 21 days until AVG maturation, early cannulation grafts permitted to avoid 14 days of CVC use per patient. Conclusion: Early cannulation AVG is a recommended option when an urgent haemodialysis access is required because it decreases the use of CVC and has an acceptable patency and complications rate. FM3.4 Percutane Valvuloplastie: Die minimal-invasive Wiederherstellung der Funktion von Venenklappen mittels quervernetztem Hyaluronsäure-Gel J. C. Ragg (Zürich) Objective: Die heutigen Therapiekonzepte für insuffiziente Stammvenen sind in erster Linie destruktiv, mit Ausrichtung auf endovenöse Okklusionen. Die chirurgische Option einer venenerhaltenden Korrektur (extraluminale Valvuloplastie, EVP) wird trotz guter evidenzbasierter Daten wenig beachtet, zeigt aber die Wirksamkeit des Prinzips. Bereits die ersten Versuche einer Venenformung mittels perivenöser Depots von Hyaluronsäurepräparaten (2012/2013) waren hämodynamisch erfolgreich. In 2015 erfolgten erste Anwendungen von feinkörnigen Präparaten, die hier vorgestellt werden. Methods: In einer Pilotstudie wurden 12 Patienten (8 f, 4 m; J.) mit insuffizienten, aber morphologisch erhaltenen und mobilen proximalen Klappen der VSM (7,0 11,6 mm Ø, MW: 8,5) ausgewählt für den Versuch einer percutanen Valvuloplastie (PVP). Es wurde ein feinkörniges 15

11 quervernetztes NASHA Gel verwendet, welches mittels einer Sicherheitskanüle mit 0,65 mm Lumenweite unter Ultraschallsicht am stehenden Patienten (Kippliege) perivenös injiziert wurde bis zum Sistieren des Refluxes. Klinische Untersuchungen und Ultraschall erfolgten nach 2, 12 und 26 Wochen. Results: Ein orthograder Fluss konnte in allen Fällen (12/12) hergestellt werden, wobei Volumina von 4 9 ml (MW: 6,2 ml) erforderlich waren. Der Zeitbedarf lag bei min. (MW: 20,3) einschliesslich der vorausgehenden Klappenanalyse. 3/12 Patienten (25%) benötigten 2 Sitzungen bis zum hämodynamischen Primärerfolg. Bis zum Kontrollzeitpunkt nach 26 Wochen erhielten 2/12 Patienten ergänzende Injektionen von 2 bzw. 3 ml. Dies einbezogen zeigten alle Fälle einen orthograden Fluss. Es waren keinerlei verfahrensbezogenen Komplikationen zu verzeichnen. Conclusion: Die PVP mittels ultraschallgestützter Injektion von Hyaluronsäure-Gel ist effektiv und sicher. Venenerhaltende Flusskorrekturen sind somit auch ohne Operation möglich. Die große Einfachheit der minimal-invasiven Behandlung ist bei den derzeit verfügbaren Präparaten allerdings mit dem Nachteil gelegentlicher Ergänzungsinjektionen verbunden. FM3.5 Human Vein Intimal Hyperplasia development after Arterial Implantation is mediated by Connexin43 S. Déglise 1, A. Longchamp 2,1, F. Allagnat 1, F. Alonso 1, S. Berceli 2, C. Ozaki 2, J.-A. Haefliger 1, J.-M. Corpataux 1 ( 1 Lausanne, 2 Boston) Objective: Half of venous bypass grafts fail in the year following arterial implantation due to excessive smooth muscle cells (SMCs) proliferation and intimal hyperplasia (IH). Cell to- cell communication mediated by Connexins (Cx) regulates proliferation in various cell types. We thus investigated the specific contribution of Cx43 to SMCs proliferation and vein graft IH. Methods: We used a rabbit carotid artery interposition grafts model, a human ex-vivo vein grafts perfusion system and human primary SMCs. Pharmacological Cx43 blockade was achieved with the specific 43gap26 inhibitory peptide. In human SMCs, Cx43 was knockdown or overexpressed using specific sirnas, or adenoviruses Results: In all the models, arterial implantation up-regulated Cx43 and increased myointimal proliferation. In-vitro, Cx43 knockdown or overexpression inhibited or stimulated respectively SMCs proliferation. Finally, in human veins, the inhibitory peptide 43gap26 prevented myointimal proliferation and IH formation. Conclusion: Arterial engraftment triggers Cx43 upregulation that regulates SMCs proliferation and vein graft remodeling. FM3.6 Prosthetic vascular graft infections: cultures from NPWT foams are of no value in decision making D. Mayer, A. U. Scherrer, G. Bloemberg, R. Zbinden, C. Fuchs, Z. Rancic, B. Hasse (Zürich) Objective: In recent years prosthetic vascular graft infections are increasingly operated in a graftpreserving manner together with the use of negative pressure wound therapy (NWPT). The use of NPWT in vascular graft infection shortens the time to complete wound healing, has a high success rate, and the complication rate is low. During NWPT either polyurethane- or polyvinylalcoholcontaining sponges are exchanged on a regular basis. The aim of this study was to compare bacteria retrieved from the NWPT-sponges with the bacteria detected by conventional methods in order to 16

12 examine if microorganisms from NPWTW sponges help to determine the bacterial burden of vascular wounds. Methods: Diagnostic accuracy of NPWT sponges was assessed. The standard of reference was a microbiological culture, obtained after open biopsy or graft explantation. We calculated sensitivity, specificity, positive predictive (PPV) and negative predictive values (NPV). Results: 109 negative pressure wound therapy treatment cycles were performed among 104 patients with prosthetic vascular graft infections. Median duration of negative pressure wound therapy therapy was 36 days (Interquartile range [IQR] 19-62) with a median pressure of 75 (IQR ) mm Hg. The NWPT system was changed 10 times (SD 9.4) in each patient yielding 506 microbiological samples. In 55 patients deep wound cultures could be compared to cultures from the negative pressure wound therapy foams. Sensitivity, specificity, PPV and NPV for bacteria retrieved from negative pressure wound therapy foams compared to deep wound cultures as gold standard were 67%, 56%, 65%, and 58%, respectively (Table 1). Conclusion: Hence, antimicrobial therapy should primarily focus on deep wound cultures, whereas bacteria obtained from NWPT foams seem to be less important. FM4.1 The choice of patch material for angioplasty following femoral endarterectomy may be fatal M. Berner, T. Lattmann, P. Stalder, P. Wigger (Winterthur) Objective: Patch angioplasty following femoral endarterectomy is the preferred surgical technique to treat atherosclerotic lesions in the common femoral artery. A variety of different patch materials can be used. Due to the risk of deep wound infections in the groin with consecutive infection of the patch material we pursued an autologous distal great saphenous vein (GSV) patch policy, whenever possible. Because of three vein patch ruptures, we reviewed our cases and the literature. Methods: Between May 2012 and May femoral endarterectomies with patch angioplasty were performed in our institution (mean age 73±7 (58-93) years, 70% male). In 77% of the cases an autologous distal GSV patch was used for angioplasty. In three cases (2.6%) a patch rupture occurred all of them a distal GSV patch was used. In 1 case the patient was found dead in her bed in the early morning 1 hour after walking along the corridor of the ward. In 1 case emergency revision surgery could not prevent the fatal result in the 17

13 third case the vein patch was successfully replaced by a biological patch. All ruptures occurred within the first three postoperative days. Results: Literature about the ideal patch material for femoral endarterectomy is scarce. The majority of data is obtained from carotid patch angioplasty, where autologous vein patches, biological and synthetic patches (PTFE, Dacron and Polyurethane) are used with equal outcome regarding patency and infection rate. The potentially fatal complication of vein patch rupture is described between 0.5 und 4 %. The diameter of the vein appears to be related to the risk of rupture, since rupture did not occur in patches made from veins with a diameter of >3.5 mm. The vein diameter seems to be a surrogate marker for the quality of the vein wall. As the reported rate of deep wound infection is around 1.5%; we think, that small diameter GSV patch with a rupture rate up to 4% should not be used. In order to avoid synthetic patches, which have to be removed if deep wound infection occurs, bovine pericardium is a newer alternative, which seems to be more resistant to infections since it is also successfully used to replace infected aortic grafts. Conclusion: When choosing the patch material for patch angioplasty following femoral endarterectomy, vein patches made from small veins should be used with caution as they bare a risk of rupture. FM4.2 Safety of CEA in patients after intravenous thrombolysis in patients with symptomatic carotid stenosis D. Becker, P. Ghibu, D. Mayer, M. Lachat, Z. Rancic (Zürich) Objective: Early CEA is the preferred treatment in patients with symptomatic carotid stenosis to prevent a new stroke. In some cases CEA follows successful intravenous thrombolysis. Intuitively CEA within short time after thrombolysis might be associated with increased risk of intracerebral bleeding. But that was not confirmed in studies with limited number of patients. Our study compares the outcome of patients undergoing CEA after thrombolysis (CEA - thrombolysis) and those without thrombolysis (CEA- only) for symptomatic carotid artery stenosis. Methods: The study includes all symptomatic patients operated for carotid artery stenosis, who underwent CEA with or without preoperative i.v. thrombolysis between 2010 and 2014 at university hospital. The primary outcome was 30-day stroke or death. The secondary outcome was 30-day morbidity. Results: During the period from 2010 and 2014, in total 78 patients were treated by CEA for symptomatic carotid artery stenosis ( 57 male/21 female ). 78 patients underwent only CEA and 7 patients received a preoperative i.v.-lysis. The mean age of patients was 74. The mean time between i.v. lysis and operation was 9 days (min 4 days-max 3 weeks). The 30-day stroke, death and morbidity rate in the group of patients with lysis and CEA was 0%. The 30-day stroke and death rate in patients with CEA only was 1,4 % ( 1 patient with intracerebral mass bleeding in case of malignant hypertension ). Conclusion: CEA after thrombolysis appears to be safe with stroke, death and morbidity rates similar to CEA without thrombolysis. The strict control of systolic blood pressure according to NIRS after CEA and internal carotid artery declamping (near infrared spectroscopy) is the main preventive measure to prevent postoperative hyperperfusion syndrome and consequent intracranial hemorrhage. Many open questions will be defined within randomized controlled studies: time between thrombolysis and CEA, intra-arterial or intravenous administration of thrombolytic agents. 18

14 FM4.3 Five years single-center experience of consecutive open repair and endovascular treatment of popliteal artery aneurysm S. Déglise, F. VanOuwenaller, L. Briner, C. Dubuis, F. Saucy, J.-M. Corpataux (Lausanne) Objective: Popliteal artery aneurysms (PAA) represent 70% of all peripheral aneurysm and are associated to potentially dramatic complications in case of thrombosis and distal embolisation. Preventive treatment is often recommended and 2 different approaches exist. Open surgery remains the gold standard but endovascular treatment has shown good results in selected cases. The aim of this study is to analyze the single-center results of PAA management. Methods: Retrospective analysis of data retrieved from our Department From January 2017 to December 2012 was done from a prospective database (Secutrial). All consecutive patients treated for a PAA in our Department were included. Both techniques were compared in term of initial presentation and complications as well as patency rates. Results: This retrospective monocenter cohort study included 106 PAAS with 83 in the open surgical group (OS) and 23 in the endovascular (EN). Both populations are similar in term of comorbidities but in the OS group, more patients were symptomatic (69%) and especially with acute ischemia (25%). Moreover, in the EN group, there were significantly more patients with 2 or 3 patent tibial vessels at time of diagnosis (91% vs 62%). Operative time and length of hospital stay were significantly shorter in the EN group. There were no differences in term of post-operative complications with thrombosis occurring in 4% of cases in both groups. The 4 amputations occured only in the OS group and all of them followed acute ischemia. Estimates of primary and secondary patency rates at 6, 12 and 24 months were 86%, 79%, 72% and 92%, 89%, 86% respectively in the OS group and 79.5%, 79.5%, 72.5% and 90%, 85%, 85% respectively in the EN group (p=ns). Conclusion: Both techniques show similar results in term of patency rates and complications rates. Advantages of endovascular therapy are shorter operative time of hospital stay. However, preoperative selection of treatment exists based principally on the presence of symptoms and the quality of the run-off. FM4.4 Long-term results after retrograde stenting of the proximal supra-aortic vessels via surgical cutdown of the common carotid artery V. Makaloski, T. Wyss, D.D. Do, J. Schmidli (Bern) Objective: The aim of this study was to evaluate the long-term results after hybrid treatment of severe stenosis/occlusion of the proximal supra-aortic vessels with retrograde stenting via surgical cut-down of the common carotid artery (CCA), with or without synchronous carotid endarterectomy (CEA) of the ipsilateral internal carotid artery for tandem stenosis. Methods: Consecutive case series of patients having retrograde stenting of the proximal supra-aortic stenosis/occlusion via surgical cut-down of the CCA, with or without synchronous CEA between April 1999 and March All patients had preoperative duplex ultrasonography, verified with MR- and/or CT-angiography of the supraaortic vessels and head. Stent patency, freedom from reintervention, late neurologic events and the overall survival were analysed. Outpatient follow-up was performed with colour duplex and MRI, if necessary, after 3, 6 and 12 months as well as yearly thereafter. Results: A total of 32 patients (16 men) with mean age of 67±9 years was analysed. Additional ipsilateral CEA was performed in 13 (39%) cases. No additional neurological complication was 19

15 recorded perioperatively. Median hospital stay was 9±9.1 days. Mean follow-up was 68 months (range 1-192). Nine patients (28%) died in total. After 5, 10 and 15 years the overall survival rate was 85%, 52% and 52%, respectively. During follow-up 3 moderate ( 50%), 2 high-grade (>80%) stenosis and 2 stent occlusion were diagnosed. Both high-grade stenoses were successfully restented resulting with 94% of overall primary assisted patency during follow-up. Both stent occlusion correlated with new neurological symptoms, one of them operated with ascending aortic-carotid bypass and the other treated conservative. All reintervention were performed within first year postoperative. In total 5 new neurologic events occurred during follow-up, 3 ipsi- (9%) and 2 contralateral (6%). Freedom from reintervention was 91%. Conclusion: The retrograde hybrid approach to proximal supra-aortic vessel disease is a safe procedure with very promising long-term results. Majority of relevant in-stent stenosis/occlusion occurred within the first year, which suggests that these patients should be monitored rigorous early postoperative. FM4.5 Percutaneous, subclavian artery access with Perclose -AT preclosing for large-sized access G. D. Puippe, M. Lachat, M. Glenck, R. Pfiffner, T. Pfammatter (Zürich) Objective: Commonly, the axillary artery is surgically exposed in visceral chimney endograft procedures. A percutaneous approach offers potential advantages. Purpose of this study was to retrospectively analyze ultrasound-guided percutaneous subclavian artery access with Perclose-AT preclosing (PC) for patients requiring large-sized access for chimney and periscope endografting. Methods: In eighteen patients (mean age 73.9±9.2years; 17 men) a total of 19 ultrasound-guided retrograde punctures of left subclavian artery (LSA) with single PC for chimney and periscope grafts were performed. Technical success of US-guided puncture, primary success of PC, puncture and PC related complication rate, percutaneous bailout procedures as well as an evaluation of the access site at computed tomography angiography (CTA) with focus on vessel integrity and perivascular soft tissue changes was evaluated. Results: Ultrasound-guided puncture of LSA was successful in all patients (100%). One patient (1/18) had two sequential punctures as he required two sheaths for the intervention. Single PC for each access was performed in all patients. Average sheath size used was 9.4±1.7French. Single PC allowed for successful closure of access site in 73.7%(14/19). Two accesses required additional postclosing with one (1/19) and two Perclose-AT (1/19), respectively. Pre- and postclosing attempts failed in three access sites (15.8%).Stent-grafting by transfemoral (2/19, 10.5%) or transbrachial (1/19, 5.3%) route was successfully performed as a bailout procedure. CTA was performed 3.1±1.7days following the intervention. No focal dissection, stenosis or pseudoaneuryms were detected. All stent-grafts were patent. Two subcutaneous (10.6%) and one pectoralis minor muscle hematoma (5.3%) could be detected. Conclusion: Percutaneous ultrasound-guided retrograde access to subclavian artery is save and feasible with high technical success rate enabling the use of large-sized vascular sheaths without the need for surgical exposure of axillary artery. Preclosing with Perclose-AT allows for successful hemostasis in up to 75% of access sites. Failures of PC can be managed fully endovascularly, either by postclosing maneuver or stent-grafting of access sites. 20

16 Poster P1 Folienkompressionsverband: Eine neue Modalität zur alltags- und sporttauglichen Versorgung nach endovenöser Varizentherapie J. C. Ragg (Zürich) Objective: Textile Kompressionsmittel (Strümpfe, Verbände) sind im Komfort und in der Compliance begrenzt, und in der Regel wird die Anwendung zumindest über Nacht unterbrochen. Wie kann man die Venenkompression verbessern, ohne die Patienten zu belasten? Ein neuartiger Folienkompressionsverband wurde nach Schaumverödungen auf Anwendbarkeit, Verträglichkeit, Wirkung und Komfort untersucht. Methods: Der Folienkompressionsverband (FKV, Prototyp, Venartis Inc./3M) besteht aus einem selbstklebenden, dampfdurchlässigen und streifenförmigen Polymerfilm von < 20 Dicke. Für die Anwendung wurden 62 konsekutive Patienten mit 90 erkrankten Beinen mit oberflächlichen Varizen von 5-12 mm Ø (MW: 7,3 mm) ausgewählt, die tägliche Sportaktivitäten von > 30 Minuten angaben. Tägliches Duschen war erlaubt. Die Beine wurden in 3 Gruppen randomisiert: A) FKV 14 d + medizinischer Kompressionstrumpf KKl. 2 (MKS) 28 d, B) nur MKS (28 d), C) nur FKV (14 d). Klinische und sonographische Kontrollen erfolgten nach 2, 4 und 6-8 Wochen. Results: Die Anwendung des FKV gelang in allen Fällen, im Mittel in 3,5 min. (2,1 5,5). In 57/60 Fällen (95%) wurde die vorgesehene Tragezeit erfüllt, während sie in 3 Fällen wegen Hautreizungen am Oberrand (n=2) bzw. vorzeitiger Ablösung (n=1) nach 8 10 Tagen beendet wurde. Nach 14 betrug die Reduktion der Venendurchmesser 29-54% (MW: 43,5%) für FKV + MKS (A), 16-44% (MW: 29,4%) für MKS (B) und 24 50% (MW: 37,3%) für FKV (C). Symptomatische Verödungsreaktionen wurden unter FKV (14 d) in 5/60 Fällen (8,3%, A+C) beobachtet, während sie unter alleinigem MKS (B) in 19/30 Fällen (63,3%) auftraten. Der Tragekomfort wurde auf einer Skala von 1 (sehr schlecht) bis 10 (hervorragend, nichts verspürt) subjektiv bewertet mit 6.6 (A), 4.3 (B) und 9.2 (C). Conclusion: Der Folienverband stellt eine effektive und sichere Kompressionsmodalität dar, die in der Regel zumindest über 2 Wochen trotz Sport und Duschen kontinuierlich getragen werden kann. Die Wirkung auf schaumbehandelte oberflächliche Varizen ist günstiger als die eines MKS KKl. 2. Sowohl die Kombination mit MKS als auch die alleinige Anwendung sind künftige klinische Optionen. P2 A new biphasic drug delivery system to prevent the vascular graft failure F. Strano 1, I. Mylonaki 2, F. Alonso 1, C. Dubuis 1, F. Delie 2, O. Jordan 2, J.-A. Haefliger 1, J.-M. Corpataux 1, S. Déglise 1, F. Saucy 1 ( 1 Lausanne, 2 Genève) Objective: Open surgical revascularization using venous graft is the first line option in many clinical situation. However the venous wall needs to adapt to the new arterial environment and it can lead to intimal hyperplasia (I.H.) development, responsible to almost 50% of graft failure the year following the operation. On the contrary of endovascular treatment, the open surgical approach has no drug delivery system to inhibit (I.H.) The aim of our study is to develop a biphasic drug delivery system using atorvastatin(atv) to inhibit (I.H.) development in open vascular surgery. 21

17 Methods: An emulsion evaporation method was used to prepare the microsphere. Free or atorvastatinloaded microparticles (M.) and/or free atorvastatin were incorporated in a cross-linked hyaluronic acid (G.)(Hydrogel Fortelis Extra, Anteis). We thus obtained four different combinations (G.M. as control, GatvM., G.Matv, GatvMatv) applied on an in vivo intimal hyperplasia model represented by carotid artery ligation in C57Bl6 strain mice, euthanasied 28 days after the intervention. Atorvastatin concentration release from these formulations and drug power diffusion through the human vein wall was tested using a Franz Cell. Results: The different combination of formulation had three different kinetics of atorvastatin release; GatvM.-3 days,g.matv-45 days and GatvMatv-45 days and burst at 3 days. The cross-linked hydrogel ensures the permanence of the formulation in vivo over 28 days and the loaded ATV-microparticles, a sustained drug release over the same period.we observed a non significant inhibition of intimal hyperplasia when atorvastatin is loaded or in gel or in microparticles (GatvM;GMatv), however the combination made of both atorvastatin-loaded gel and microparticles (GatvMatv) significantly inhibited intimal hyperplasia after four weeks demonstrating to be the most effective formulation. The Franz Cell set-up showed a peak drug diffusion within 60 hours through the human vein and its histological analysis the tissue viability. Conclusion: The efficiency of this formulation, powered by its biphasic feature, with an initial burst and a sustained release could prevent intimal hyperplasia development and find its application during the surgical procedures. P3 Early bicentric experience with the Nellix Endovascular Aneurysm Sealing system for abdominal aortic aneurysm repair S. Déglise 1, G. Gemayel 2, F. Saucy 1, D. Mugnai 2, L. Briner 1, N. Murith 2, J.-M. Corpataux 1 ( 1 Lausanne, 2 Genève) Objective: Despite increase in experience and technological improvement in EVAR devices, the longterm durability remains problematic with 20% of re-interventions, especially due to endoleak (EL). The Nellix device (Endologix, Irvine, Calif) is an innovative concept of endovascular aneurysm sealing (EVAS) based on the deployment of polymer-filled EndoBags surrounding the endograft and filling the aneurysmal sac. The aim of this study was to report our early experience in 2 Departments. Methods: Retrospective analysis of data from 2 centers between May 2014 and 2015 was done. All patients with the Nellix system were analyzed. Endpoints were technical success, postoperative morbidity, rate of endoleak and any aneurysm-related re-interventions during follow-up. All patients were controlled with computed tomography (CT) after 1, 6 and 12 months as well as yearly thereafter. Results: Nineteen patients (mean age 77 years, range 62-88) were identified. Two of them were operated in emergency for increasing diameter associated to pain in one patient and for a ruptured thoraco-abdominal aneurysm (rtaaa) in the other. The 18 male and 1 female patients had aneurysms 56.8mm (range 48-81) in diameter with an average infrarenal aortic neck length of 24.0 mm (range, 8-51) and diameter of 25.4mm (range, 19-40). Operative time was 98 minutes (range, ) with a procedural success achieved in all cases but one (99%): one patient had a type II EL. The mean length of the stents was 149 mm (range, ) and the mean volume of polymer used was 62 ml (range, ). The patient admitted for rtaaa died intra-operatively. In the post-operative period, 2 complications occurred, 1 deep vein thrombosis and 1 wound dehiscence requiring a surgical revision. At the CT scan at 1 month, no type I/III EL were observed. During the median follow-up of 10 months (range, 1-13), no stent occlusions occurred and there was 1 persistent type II EL. The mean decrease of the sac diameter was 1mm (0-4). No aneurysm-related reintervention was needed during this period. One patient died due to pulmonary complications at 2 months. 22

18 Conclusion: The EVAS concept using the Nellix system appears to be safe and provides excellent results during this early learning phase. High rate of aneurysm sealing was achieved with rare complications. It could be a valid alternative to standard EVAR but larger trials and registries are needed to draw definitive conclusions. P4 Endovenöse Therapie von nicht sondierbaren Insuffizienzen der V. saphena parva mit 1-Jahres- Follow-up J. C. Ragg (Zürich) Objective: Die Crosse der V. saphena parva (VSP) ist aufgrund ihrer komplexen Anatomie häufiger als die V. saphena magna von De-novo- oder rezidivierten Insuffizienzen betroffen, die sich mit Führungsdrähten, Kathetern und Sonden nicht passieren lassen. Andererseits sind chirurgische Eingriffe in diesen Fällen ebenfalls erschwert. Welche interventionellen Optionen gibt es, und wie sind die Ergebnisse? Methods: Es wurden 25 sukzessive Patienten (14 w, 11 m; J.) mit nicht sondierbarer Crosseninsuffizienz der VSP dokumentiert. Es fanden sich: A) C-förmig elongiertes Crossensegment, von der VSP o gewinkelt abgehend (n = 8), B) Crossenrezidiv nach OP mit Stumpf (n = 7), C) Reflux der Crosse über ein 1,2 3 cm langes proximales Segment mit Fortleitung in die V. femoropoplitea (n = 4), D) subakute Phlebitis mit offener VSP-Mündung (n = 4) sowie E) Crossenrezidiv nach Radiowelle mit Stumpf (n = 2). Die Therapie erfolgte durch selektive Schaumverödung mit Mikrokathetern (SSM) oder Laserokklusion ball-tip (LBT) über Mikrokatheter mit minimaler Tumeszenzanästhesie (2 10 ml). Kontrollen erfolgten nach 1 2 Wochen, nach 8 Wochen sowie nach einem Jahr. Results: Alle Behandlungen waren nach einer (18/25, 72%) oder zwei Sitzungen (7/25, 28%) erfolgreich. Crossenstümpfe und Abgangssegmente konnten in 17/25 Fällen (68%) mittels LBT erreicht werden und in 8/25 Fällen (32%) mittels SSM. Alle übrigen insuffizienten VSP-Abschnitte wurden mit SSM erreicht. Nach einem Jahr wurden in zwei Fällen (2/25, 8%, SSM) partielle Rekanalisationen beobachtet und erfolgreich mittels Schaumverödung nachbehandelt. Conclusion: Auch nicht sondierbare VSP-Insuffizienzen lassen sich mit hoher Erfolgsrate auf endovenösem Weg und ohne Narkose behandeln. Falls ein segmentaler Lasereinsatz möglich ist, ist dieser wegen der etwas besseren Nachhaltigkeit zu bevorzugen. P5 Common iliac artery pseudo aneurysm after blunt abdominal trauma F. Solimene, P. Nussbaumer, A. Browa, S. Bäuml (Lachen) Objective: Isolated vascular injuries due to blunt abdominal trauma are very rare but potentially life threatening lesions. Early diagnosis and treatment are crucial for the successful management of these patients. We present a case of a seat belt related rupture of the left common iliac artery after a blunt abdominal blunt trauma. Methods: The 53-year old male patient was referred to our Emergency Room by the emergency rescue service after a road traffic accident. Because of the high velocity trauma we performed a trauma computed tomography (CT) scan despite the fact that there were no obvious injuries and FAST ultrasound was normal. This approach is correspondent to our ER guidelines. 23

19 Results: CT scan showed an isolated contained rupture of the left common iliac artery. The pseudo aneurysm was treated postprimarely with a combined endovascular / open approach. First the rupture was sealed with a stent graft from the common to the external iliac artery. Then the internal iliac artery was revascularised through a lumbotomy. The patient was discharged after 5 days, 2 months follow-up was uneventful. Conclusion: According to the ATLS trauma schedule, all patients who have experienced a high energy trauma should undergo routine screening using a trauma CT scan with contrast agents to detect potential life-threatening injuries. In this case adherence to protocol prevented a diagnostic delay and sequelae. The combined endovascular and open approach allowed for an appropriate repair and rapid recovery. P6 Fokale Kompression von Stammvenen, Varizen und Besenreisern nach Verödungsbehandlung mit individuellen Siliconpads aus der Kartusche J. C. Ragg (Zürich) Objective: Es ist bekannt, dass eine exzentrische Kompression Heilungsvorgänge nach invasiven Venentherapien günstig beeinflussen kann. Allerdings lassen die meist aus Gazerollen oder Schaumstoffstücken improvisierten Kompressionselemente keine längere Tragezeit zu, die Hygiene leidet, die Erneuerung ist mühsam und nicht selten treten Reibungsbelastungen und Hautirritationen auf. In dieser Untersuchung wurden drei neue Varianten des Venartis silicone gel pads (SGP, Prototypen) evaluiert. Methods: Das SGP - System verwendet Silikongel au seiner 2K-Kartusche, welches auf eine selbstklebende hauchdünne Folienunterlage aufgebracht und mit einer weiteren Folie bedeckt wird, so dass eine mit der Haut verbundene aber dennoch ablösbare Einheit entsteht. Es wurden folgende Silikone im Zusammenhang mit Mikroschaumverödungen bei je 20 Patienten über 2 8 Wochen evaluiert: A) SGP 22 (Shore-A 22) für Stammvenen von mm Durchmesser und einem Abstand von < 10 mm vom Hautniveau, B) SGP 14 (Shore-A 14) für die Anwendung in Gelenknähe, insbesondere der Kniekehle, und C) SGP 24 fh (Shore-A 24, fast hardening) für Besenreiser von 0,5 1 mm Durchmesser. Die äußere Kompression wurde mittels medizinischer Kompressionsstrümpfe KKl. 2 (MKS) oder Kompressionsfolie (KF) erzeugt. Zum Vergleich dienten kontralaterale oder gleichartige benachbarte Venenpathologien, die ohne SGP versorgt wurden. Results: Die mit SGP 22 versehenen Stammvenen zeigten nach 14 Tagen eine um 33 62% (MW 48,1%) vermehrte Volumenrückbildung im Vergleich zu MKS oder KF. Symptomatische Verödungsreaktionen wurden um 78% reduziert. Das popliteale SGP14 erreichte um 21 52% (MW 36,2) verbesserte Durchmesserreduktionen. Bei Besenreisern zeigte der Fotovergleich nach 8 Wochen einen Therapieerfolg in 82.1% in SGP-bedeckten Stellen gegenüber 31.3% in Regionen ohne SGP. Geringe Hautirritationen, die die Tragezeit nicht limitierten, wurden nach 2 Wochen in 8/60 Fällen (13.3%) gesehen. Andere Nebenwirkungen, insbesondere allergische Reaktionen, traten nicht auf. Conclusion: Die untersuchten Varianten des SGP sind sichere, effektive und komfortable Modalitäten zur Unterstützung der Venenrückbildung nach Verödungstherapien, insbesondere bei oberflächlichen Verläufen der Stammvenen, der empfindlichen Kniekehlenregion und sogar großen Besenreisern. 24

20 P7 Heparin-induced Thromboytopenia (HIT) in a Patient with Systemic Lupus Erythematodes (SLE) and Antiphospholipid Antibody Syndrome (APLAS) D. Luchsinger, J. D. Studt, M. Lachat, T. Pfammatter, B. Amann-Vesti (Zürich) Results: A 52 year old patient underwent hip replacement for coxarthrosis. Several years ago, he had been diagnosed with SLE and secondary APLAS with recurrent venous thromboembolism. Few days after hip replacement, additional cholecystectomy was performed due to acute cholecystitis. During this time, he was treated with unfractionated heparin. Few days afterwards, he was referred for angiologic consultation because of an occlusion of the left brachial artery and ischemia of the left forearm and hand. Platelet count was decreased (74 G/l upon admission to our hospital, nadir 59 G/l). Thrombectomy was performed; after reocclusion the next day intraarterial thrombolysis was performed followed by another thrombectomy and continuous extracorporal membrane oxygenation. Recurrent arterial occlusion led to further thrombectomy and stent placement. Meanwhile, additional laboratory investigation revealed high-titer lupus anticoagulant, anti-cardiolipin and anti-beta2 glycoprotein antibodies; criteria for diagnosing probable catastrophic APLAS were met. Also, hightiter antibodies to platelet factor 4/heparin complex were detected, and were platelet-activating by additional functional assay (HIPA) leading to the additional diagnosis of HIT. Complementary computed tomography revealed pulmonary embolism and splenic infarction. In order to cover both possible etiologies, treatment included anticoagulation with a direct thrombin inhibitor (bivalirudin), high dose corticosteroids, plasma exchange, and administration of intravenous immunoglobulin. However, despite substantial increase of the platelet count and decrease of activation markers of coagulation (d-dimers) perfusion could not be restored satisfactorily, eventually requiring amputation of the affected limb. Conclusion: This complex case describes a severe prothrombotic condition which probably was primarily caused by HIT but also promoted by high-risk APLAS. Together with the preceding surgery, the latter might have led to increased platelet activation facilitating subsequent HIT development in a highly inflammatory environment. Despite aggressive and multimodal treatment satisfactory limb reperfusion could not be achieved. The case also illustrates the importance of rapid and comprehensive diagnostics followed by specific therapeutic measures. P8 Femoral-axillary by-pass for upper limb ischemia C. A. Stanescu, B. Marty, M. Menth, B. Egger (Fribourg) Objective: Endovascular treatment has become the first choice for symptomatic stenosis of the supraaortic arteries. In case of failure, open revascularization becomes necessary. In distal subclavian artery occlusion a femoral-axillary by-pass is the appropriate procedure. Methods: An 83 year old female patient presented with sub-acute right upper limb ischemia following an acute occlusion of the distal subclavian artery in the thoracic outlet. She had a history of a left hemilaringectomy, cervical radiotherapy for a laryngeal carcinoma and a right mastectomy with radiotherapy for a breast carcinoma. First, a thrombectomy by a brachial artery cutdown was performed followed by immediate reocclusion. Two further attempts of angioplasty failed. Considering the difficult local conditions after radio-therapy, a carotid-axillary by-pass could not be performed and a right femoral axillary graft by-pass was decided. 25

21 This type of revascularization had been reported for the first time in Since, 4 cases had been published with encouraging results. Results: The patient presented complete relief of symptoms and the CT angiograms showed graft patency at 18 months after surgery. Conclusion: Arm ischemia due to distal subclavian artery occlusion, after failed endovascular attempt, is successfully treated by a femoral-axillary by-pass. P9 CO2-Angiographie bei EVAR die Lösung für niereninsuffiziente Patienten? C. J. Geppert 1,2, V. Makaloski 1, M. Widmer 1, D.D. Do 1, J. Schmidli 1 ( 1 Bern, 2 Biel) Objective: Die Verwendung von iodhaltigem Kontrastmittel (KM) für die Angiographie während endovaskulären Eingriffen an der Aorta (EVAR) bleibt der Goldstandard. Aufgrund der nephrotoxischen Wirkung kann dieses jedoch bei Patienten mit schwerer Niereninsuffizienz (NI) der Grund sein, das endovaskuläre Verfahren nicht in Betracht zu ziehen. Die Alternative, die Aorta während EVAR mittels CO2-Angiographie darzustellen, ist bisher noch unbekannt. Wir berichten hier über unsere erste Erfahrung mit CO2-Angiographie während EVAR. Methods: Wir berichten über alle Patienten, die im Mai 2015 eine CO2-Angiographie während EVAR aufgrund ihrer Niereninsuffizienz hatten. Die CO2-Angiographie erfolgte mit einer CO2- Kompressionspumpe, welche eine manuelle Injektion des Gases ermöglicht. Bei Bedarf wurde zusätzlich KM (Iobitridol, Xenetix ) verwendet. Alle Operationen wurden im Hybrid-Saal durchgeführt. Die postoperativen Kontrollen wurde nach 1 und 6 Monaten mittels contrast-enhanced ultrasound scan (CEUS) realisiert. Results: Drei männliche Patienten (63-71jährig) mit einer Niereninsuffizienz Grad III bis IV nach CKD (Clearance 19-60ml/min) und infrarenalen Aortenaneurysmen (50-90mm Durchmesser) wurden rekrutiert. In allen Operationen konnten wir eine klare Darstellung der Nierenarterien- und der A. iliaca interna-abgänge erreichen. In einem Fall wurde kein KM benötigt. In den zwei anderen Fällen wurden insgesamt 15ml bzw. 72ml KM appliziert. Beim letzteren musste wegen einer kurzstreckigen Dissektion der A. iliaca externa ein Stent mit zusätzlicher Applikation von KM verwendet werden. In einem Fall war am Ende der Operation ein Typ II Endoleak vorhanden. Kein Typ I oder III Endoleak wurde diagnostiziert. Diese Ergebnisse konnten postoperativ mittels CEUS bestätigt werden. In den drei Fällen kam es weder zu Nebenwirkungen noch zu Verschlechterung der Niereninsuffizienz. Conclusion: Die Applikation von C02 während EVAR ist einfach und sicher und bietet eine valable Alternative zur herkömmlichen Applikation von KM, insbesondere bei Patienten mit schwerer Niereninsuffizienz. P10 Lower Limb Revascularization and Pulse Wave Velocity of elastic and muscular arteries in Peripheral Arterial Disease N. Ulmer 1, V. Jacomella 1, I. B. Wilkinson 2, B. Amann-Vesti 1, M. Husmann 1 ( 1 Zürich, 2 Cambridge) Objective: Peripheral arterial disease (PAD) may interfere with the assessment of pulse wave velocity PWV) due to atherosclerotic lesions along the arterial tree. To evaluate the effect of percutaneous transluminal angioplasty (PTA) of the lower limb on pulse wave velocity in patients with PAD. 26

22 Methods: Pulse wave velocity (PWV) was measured prior and after lower limb angioplasty in patients with PAD. Aortic PWV was assessed with the Mobil-O-Graph (ABPM by IEM; Stolberg, Germany) derived from the brachial artery (apwv) using a brachial cuff-based method. In addition, PWV was assessed with an oscillometric technique (Vicorder system SMT Medical, Würzburg, Germany) for the carotid-femoral (cfpwv) and femoro-tibial (ftpwv) segments in both limbs. Periinterventional changes were analysed by the Wilcoxon signed rank test. Results: Overall 58 patients were treated with angioplasty for Rutherford stage 2-5 with bilateral treatment in four patients. Treated limbs (n=62) were compared with control limbs (n=54). In the PTA-limbs, the ftpwv and the ankle-brachial arterial pressure index improved both from 7.6±2.5m/s to 9.2±2.3m/s (p<0.0001) and from 0.67±0.32 to 0.86±0.28 (p<0.0001), respectively. In the untreated limbs, ftpwv remained unchanged (9.1±2.7 m/sec and 9.2±2.6 m/sec, p=0.334). No significant changes were observed for the cfpwv for both the control-limb (8.6±2.5 m/s and 8.4±2.2m/s at follow-up, p=0.744) and the PTA limb (8.2±2.2 m/s and 8.3±2 m/s at follow-up, p=0.116). Likewise, apwv remained unchanged with 11.6± 2.7m/s and 11.5± 2.6m/s (p=0.410). Conclusion: Lower limb angioplasty in peripheral arterial disease leads to an increase in pulse wave velocity in the treated segments. This indicates that peripheral arterial obstructions lower PWV in the muscular-arterial segments. In contrast, lower limb angioplasty does not affect aortic and cfpwv. P11 Optimierte Verteilung von Mikroschaum durch ultraschallkontrollierte Muskelaktivierung J. C. Ragg (Zürich) Objective: Während Verödungsbehandlungen mit Mikroschaum bewegt sich der Patient üblicherweise nicht. Da eine adäquate Mikroschaumverteilung einen Spasmus der Zielvene zur Folge hat und somit einen sehr hohen Widerstand im venösen Netzwerk, könnte es möglich sein, Schaumüberschüsse sofort durch vermehrte Kollateralperfusion gezielt auszuspülen? Wir evaluierten die sogenannte ultraschallkontrollierte Muskelaktivierung (UMA). Methods: Zwischen 3/2013 und 3/2015 wurden 2780 Beine in 1640 Patienten mit Insuffizienz der VSM oder VSP einschliesslich Perforansdefekten und varikösen Seitenästen nach dem UMA- Protokoll mit Mikroschaum (Basis: Aethoxysklerol 1 3%, Vol ml) behandelt: Mit Einsetzen des Spasmus in der ersten Lokalisation wurden 1.) die Patienten zu Zehenbewegungen (Flexion - Extension) aufgefordert und 2.) mögliche Abfluss- und Akkumulationsstellen sonographisch gescannt, 3. eventuelle Depots durch intensivierten Venenfluss mittels 4.) Fußbewegungen (Flexion Extension), wenn unzureichend 5.) manuelle Muskelkompression oder, wenn unzureichend, 6.) durch intermittierende Kompression mit dem Schallkopf eliminiert. Die Zehen- oder Fußbewegungen wurden kontinuierlich bis 2 Minuten nach Ende der Behandlung (incl. Strumpfanlage) ausgeführt und allenfalls für Sekunden weiterer Punktionen oder Injektionen unterbrochen. Klinische und sonographische Kontrollen erfolgten nach 2 und 8 Wochen. Results: An Komplikationen wurde verzeichnet: Thrombosen der tiefen Beinvenen n=3 (0,11%), davon 1 asymptomatisch; Muskelvenenthrombosen n=11 (0,40%); Sehstörungen n=2 (< 20 min, 0,07%); Bronchiospasmen/Husten: n = 4 (< 20 min., 0,14%). Unerwünschte Mitbehandlungen gesunder Venensegmente, soweit aus Mapping ersichtlich: n = 33 (1,2%). Antikoagulantien (NMH oder DOAK, 1 5 d) wurden nur gegeben, wenn dystope Schaumdepots nicht binnen 15 Sekunden aufgelöst werden konnten (n = 17; 0,6%). Der Zeittakt der Behandlungen wurde nach Einführung des UMA-Protokolls nicht verändert. Conclusion: Die sonographische Detektion von dystopen Schaumdepots und insbesondere deren Eliminierung durch aktivierten Venenfluss ist eine sehr einfache Maßnahme zur Verringerung von 27

23 schaumtypischen Nebenwirkungen. Das UMA-Protokoll trägt somit neben anderen Faktoren wie Schaumdosis und Injektionsmodus - signifikant zur Sicherheit und Präzision vom Schaumverödungen bei. P12 Faster healing of full thickness wounds with fish skin acellular dermal graft vs porcine smallintestinal submucosa B. T. Baldursson, H. Kjartansson, F. Konradsdottir, S. H. Lund, G. F. Sigurjonsson (Reykjavik) Objective: We have earlier reported the results of a study that showed that fish skin acellular dermal graft (ADG) is non-inferior to extracellular matrix (ECM) derived from porcine small-intestinal submucosa (SIS). We now report that the wounds treated with the fish skin ADG healed significantly faster than wounds treated with the porcine SIS ECM. Methods: 81 patients with 162 full thickness wounds made with a 4mm punch biopsy instrument were randomized to receive treatment with either a fish skin ADG or a porcine SIS ECM. Labeling each wound as individual, using a mixed effects logistic regression model there was significantly faster healing over all time points with the fish skin ADG. Results: Full-thickness wounds treated with the fish ADG healed significantly faster than wounds treated with porcine SIS ECM Conclusion: The results might be interesting for those treating diabetic foot ulcers because after aggressive debridement the chronic ulcer will have assumed many of the characteristics of acute full thickness wounds. Case series reported at this meeting showing good clinical outcome with the use of the fish skin ADM on diabetic foot ulcers are important and have led to ongoing randomized controlled trials on those ulcers. 28

24 Vasa 2015; 44: Suppl

25 P13 Management of traumatic dissections of the cervical arteries B. Brinken, S. Hofer, R. Marugg, C. Sommer, M. Furrer (Chur) Objective: Traumatic dissections (TD) of extra-cranial cervical arteries due to high energy trauma are rare injuries and can usually be managed conservatively. We present a case with total occlusion of the right internal carotid artery (ICA) with subsequential cortical ischemia. In addition we reviewed patients with TD of vertebral arteries (VA) or ICA presenting in our institution. Methods: From 2010 to 2014 we retrospectively identified 9 patients with TD of VA or ICA. We analysed symptoms and therapy and the immediate and longterm outcome of these patients. Results: The mean age and gender of these patients were 38.7 (23-79) years, 4 female, 5 male. All TD were identified by CT scan. Four patients suffered from TD of the VA, five of the ICA. Two of the four TD of the VA were asymptomatic, one had a cerebellar infarction and the other suffered from a minor stroke due to hemispheric ischemia. All of them were treated conservatively. Four patients out of the five ICA TD were asymptomatic and received antiplatelet therapy. Additional injuries were severe thorax trauma, brain injuries and cervical spine fractures. During follow-up three patients showed remodelling of the dissected arteries and no neurological symptoms occurred. One patient after a supposed minor trauma with TD of ICA presented with a tonic clonic convulsive seizure and a left sided hemiplegia. In the CT angiography a total occlusion of the right ICA was detected, as well as a variety of Willis circle with a missing right anterior communicating cerebral artery. The patient underwent emergency open surgical thrombectomy and transluminal dilatation of the true lumen. The postoperative MRI showed a small cortical ischemic lesion, but a complete remission of neurological symptoms could be achieved immediately after the operation. Conclusion: The management of traumatic dissections of the cervical arteries is mainly conservative and in accordance with the literature - the prognosis seems to be favourable. Our case with initially disabling neurological symptoms shows however that exceptionally a surgical approach has to be considered in selected cases. P14 A retrospective study of outcomes after treatment of symptomatic femoro-popliteal artery disease with drug eluting balloon F. Strano, T. Holzer, L. Briner, S. Déglise, C. Kazandjan, M. Benezit, J.-M. Corpataux, F. Saucy (Lausanne) Objective: The drug eluting balloon(deb) technology is a new controversial treatment of peripheral artery disease (PAD) with interesting results in terms of early and midterm patency rates. The aim of our study is to show the results of our experience in the treatment of femoro-popliteal artery disease using the Drug Eluting Balloon. Methods: In this monocenter retrospective study of a prospective maintained database, we included all consecutive patients with femoro-popliteal artery disease treated by angioplasty using a DEB from March 2013 to December 2014.The primary endpoint is primary patency, defined as freedom of clinically-driven target lesion revascularization at 6 and 12 months. The second endpoints are postoperative complication and length of stay (LOS). Results: We included 39 patients undergone to DEB dilatation. The mean age was 73.76(+/-10.7) years with a majority of male patient (54%). The indication of revascularization was claudication (25/39; 64%) and critical ischemia (16/39; 41%). The lesions were stenosis ( 29/41, 70.7%) or 30

26 occlusion (12/41, 29.3%). Primary patency was 95% and 67.2% at 6 and 12 months respectively. A significant postoperative improving of ABI (P<0.0001) and plethysmography (P=0.002) was also observed. The LOS was 6.5 days [ range, 1-26] and we have not observed major adverse events postoperatively. Technical success was 95.1%. Conclusion: Angioplasty with DEB is a valid option in the treatment of stenotic and occlusive femoro-popliteal artery disease rate with acceptable patency rates. This new strategy may decrease the percentage of stents in the femoro-popliteal arteries limiting the stent fracture and in stent restenosis. P15 First experience in Switzerland of the HeRO graft for arterio-venous access for hemodialysis L. Briner, T. Holzer, F. Saucy, J.-M. Corpataux, S. Déglise (Lausanne) Objective: Central venous occlusive disease represents one of the major complication and remains a therapeutical challenge in patients requiring hemodlialysis. Recently, the Hemodialysis Reliable Outflow (HeRO) graft has provided a new solution to maintain access on the upper limb. We report here the first 3 implantations in Switzerland. Methods: The HeRO graft is composed of a silicone-coated stent that is inserted through a venous denudation and puncture until the entrance of the right atrium. It is then connected through a titanium connector to an eptfe graft that is sutured to the brachial artery. Results: The first patient was a male of 54 years old with occlusion of the right subclavian and internal jugular veins and left subclavian vein and multiple vascular access failure. HeRO graft implantation was performed in the left internal jugular vein. Re-operation at day one was necessary for displacement of the venous outflow component. At 8 months, the graft was patent without any reintervention with a blood flow of 1500 ml/min. The second case was a female, 51 years old, with multiples AVF on both arms and total central vein occlusion except the left jugular vein, where the HeRO graft was implanted. At 3 months, the graft was patent with blood flow of 950 ml/min. The third case was a 56 years old man with multiples AVF at the left and right upper limb, all occluded. He has a severe stenosis of the right subclavian vein. Immediate postoperative, he presents an important steal syndrome and the HeRo Graft has to be explanted on the same day. Conclusion: HeRo-Graft is a solution to avoid catheters for patients who needs a dialysis access but have stenosis or occlusion of bilateral central veins and are not good candidates for femoro-femoral AVG. Preliminary results in the literature reported good primary patency rates. However, it has been then questioned by subsequent recent published studies, as many re-interventions are required to achieve acceptable patency rates. In terms of patency and infection, the HeRO seems equal to tight grafts but superior to central catheters. Therefore, additional studies are awaited to determine the exact role and place of the HeRO graft among vascular access possibilities. 31

27 P16 A rare case of mycotic Abdominal Aortic Aneurysm (maaa) due to Coxiella Burnetii A. Ferrario di Tor Vajana, S. Engelberger, R. Rosso, L. Giovannacci (Lugano) Objective: maaa is rare with an incidence of 1% of all abdominal aneurysms. Staphylococcus, Spirochaetes and Salmonella are typical agents. Coxiella burnetii, the etiologic agent of Q fever, is a very uncommon cause of aortitis. We present the case of a patient treated for AAA, with a postoperative diagnosis of Coxiella burnetii infection. Methods: A 52 y old man was submitted to MRI for low back pain. Incidentally, a 7.7cm aortic aneurysm was diagnosed. The patient reported severe long term weakness, no fever. Clinical history revealed successfully treated syphilis. An aneurysm repair with bifurcated silver impregnated Dacron graft was performed. At surgery the aortic wall appeared inflamed, so samples of the aorta were sent for pathological examination. Histology described a marked chronic aortitis with necrosis and granulomatosis, no evidence of bacteria, particularly no Spirochaetes. Postoperatively the patient developed fever and the inflammatory parameters increased. A PET/CT scan showed intense periprosthetic tracer uptake. PCR serology was performed and Cloxiella burnetii infection was diagnosed. Long term antibiotic therapy with Doxicycline and Plaquenyl was started. He was discharged in good conditions at day 9. At 1 year follow up the patient was asymptomatic, in good general condition, with normal PCR and a fair compliance to the therapy. Results: C. burnetii causes Q fever. Due to its affinity for cardiovascular tissue, endocarditis is the main manifestation (65% of all cases). It is diagnosed almost exclusively in patients with valvulopathy, with prosthesis or in immunocompromised patients. Mycotic aortic aneurysm in the absence of vascular graft is extremely rare and just a few cases are described in literature. Concerning treatment, surgery must be associated with antibiotic therapy for at least 3 years. A safer option could be secondary replacement of the synthetic graft with femoral vein or homograft. In our case the patient refused a second operation. Conclusion: C. burnetii is a rare cause of maaa, thus it can be easily unrecognized. Serological test is crucial in all cases where maaa is suspected in order to make the correct diagnosis and set the appropriate specific therapy. 32

28 P17 Rivaroxaban for thrombosis prophylaxis in endovenous laser ablation with and without miniphlebectomy: a multicenter experience H. Uthoff 1,2, D. Holtz 3, L. Spinedi 2, P. Broz 4, D. Staub 2 ( 1 Luzern, 2 Basel, 3 Rapperswil, 4 Limmattal) Objective: To report our three-center experience on the safety (observed bleeding events) and efficacy (observed endovenous heat-induced thrombosis = EHIT levels) of rivaroxaban 10mg for EHIT prophylaxis in endovenous laser ablation with and without mini-phlebectomy. Methods: Multi-center, retrospective observational single-arm study. The medical records of all patients with endovenous thermal vein ablation of the great, accessory and/or small saphenous vein performed at three medical centers (University Hospital Basel, Hospital Limmattal and Vascular Center Rapperswil) between 2012 and 2014 and EHIT prophylaxis with rivaroxaban will be included in this analysis (estimated n= ). Demographic data, preoperative risk factors, vein characteristics, procedural data including concomitant phlebectomies and outcome data including ultrasound findings and complications will be assessed. The observed absolute and relative number of venous thrombus extending into the deep venous system (EHIT level 2-4) up to 42 days post EVLA (efficacy endpoint)and the incidence of major and minor bleeding beginning after the first dose of the study drug and up to 42 days after the last dose of the study drug (follow-up period) (safety endpoint)will be reported. Results: The study protocol has been approved by the local ethics commitees and data aquisition has been completed. Data analysis is pending and results will be presented at the meeting. Conclusion: There is no generally accepted standard for post-pocedural care after EVLA to promote the vessel occlusion process and decrease the incidence of EHIT. EHIT prophylaxis using rivaroxaban therefore may offer several advantages it can be easily administered orally, and may provide superior venous thromboembolism prophylaxis without increasing bleeding complications. The present study will be the first one to report on the use of rivaroxaban in the setting of thermal vein ablation. 33

29 P18 Successful sclerotherapy of postoperative lymphocele after lymphnodectomy A. Stellio, R. Clemens, B. Amann-Vesti, T. O. Meier (Zürich) Objective: Sclerotherapy is a common treatment of macrocystic lymphatic malformation whereas its use in postoperative lymphocele is infrequent. We investigated the efficacy of OK432 based sclerotherapy during the treatment of lymphoceles after lymphadenectomy in two patients with melanoma. Methods: Two patients (Patient 1: female, 75yrs; patient 2: male, 66yrs) with melanoma underwent axillary inguinal lymphadenectomy due to metastasis. The lymphoceles developed postoperatively were resistant to repeated percutaneous aspirations and pressure dressing. Daily aspiration yielded repeatedly 200 to 300 ml of lymphatic fluid. Therefore we repeatedly performed ultrasound guided sclerotherapy with application of 500mg Doxycycline (Vibravenös Pfizer AG, Zürich) or 0.2mg OK-432 (Picibanil, Chungai Pharmaceutical Ca., Tokyo, Japan). After 90 minutes exposure time the sclerosant was completely aspirated. Follow-ups including sonography, were performed every 7 to 10 days. Results: Sclerotherapy with Doxycyclin showed no effect after 3 sessions in patient 1 and 5 sessions in patient 2. Treatment with 5 sessions of OK432 resulted in complete occlusion in patient 1 without recurrence. In patient 2, 11 injections of OK432 reduced dramatically the size of the lymphocele to a volume of only 25 ml. Fibrotic transformation of the lymphoceles was found in both cases. No inflammatory reaction as common side effect of the treatment occurred in either patient. Conclusion: To our knowledge this is the first report of a OK432-sclerotherapy of lymphoceles after axillar and inguinal lymphadenectomy. OK432 is an efficient alternative sclerosant for the treatment of postoperative lymphoceles. P19 Acute reversible cortical ischaemia after renal transplantation M.-L. Valentin, K. Hübel, K. Kotteck, O. de Rougement, R. Clemens, B. Amann-Vesti, C. Thalhammer (Zürich) Objective: Acute cortical ischaemia is a rare and possibly compromising complication of renal transplants, which requires urgent diagnosis. All patients are routinely evaluated by colour-coded duplex ultrasound (CCDU) after kidney transplantation at our institution. We report the case of acute cortical ischaemia of a kidney graft, which completely resolved within a week. Results: A 62 year old female patient with hypertensive nephropathy and glomerulosclerosis received a 55-year old DCD (donation after circulatory death) kidney graft. The perioperatively course was uneventful. First evaluation by CCDU six hours postoperative showed a normal perfusion with a resistive index (RI) between 0.74 and 0.80 and a short acceleration time of the Doppler-curve. Because of delayed graft function a further CCDU was performed at the second postoperative day two. Central perfusion was present, but the perfusion of the cortical region was absent. Doppler-curve showed a pendular flow of the feeding arteries (figure 1). Contrast enhanced ultrasound (CEUS, 2.0 ml intravenous SonoVue) confirmed the finding of cortical ischaemia (figure 2). Pendular flow typically is observed in renal vein thrombosis, but renal vein was patent. Renal biopsy excluded acute rejection, showing few signs of tubular necrosis and small cholesterol emboli. Kidney function slowly recovered during the hospital stay. Eight days later CCDU showed a Doppler-curve with normal perfusion of the 34

30 Vasa 2015; 44: Suppl. 89 entire kidney with RI s of 0.80 to Renal function 8 weeks post transplantation is excellent with a glomerular filtration rate > 50 ml/min. Conclusion: Differential diagnoses are acute cortical necrosis, cholesterol embolism, severe peripheral vasospasm or a haematoma. Acute cortical necrosis is a fatal pathology and is not reversible. Cholesterol embolism may occur during fixing the arterial anastomosis and should have been observed in the first postoperative CCDU. No vasoactive drugs had been given. A haematoma seems to be the most likely diagnosis. This case emphasises the importance of postoperative CCDU and CEUS after renal transplantation. 35

31 P20 Ruptured abdominal aortic aneurysm in a patient with double inferior vena cava D. Celio, S. Engelberger, L. Giovannacci, R. Rosso (Lugano) Objective: Open repair in ruptured abdominal aortic aneurysm is associated with high postoperative morbidity and mortality reflecting the complexity of the disease. Vascular anatomic variation does add further challenges to the intricacy of the procedure. Methods: We present the case of a 66-years old male patient who was transferred with the established diagnosis of a ruptured abdominal aortic aneurysm. The CT scan showed a large retroperitoneal hematoma with active bleeding from a large aneurysm sac (85 mm in maximal diameter). Open surgical repair was performed. Because of the extended retroperitoneal hematoma the operator chose to proceed with subdiaphragmatic clamping first. Opening of the retroperitoneum showed a double inferior vena cava not anticipated preoperatively. The infrarenal clamp was positioned after careful mobilisation of the left vena cava. A straight tube graft repair was successfully performed. The postoperative course was complicated by ischemic colitis which was treated conservatively. On day 9 the patient underwent repeat laparotomy for abdominal exploration because of focal abdominal wall dehiscence. The further course was uneventful. Results: The vena cava results from a complex genesis of the three paired embryological venous systems¹. A large spectrum of anatomic variations has been described. Double inferior vena cava is present in 1-3% of all adult individuals.² As a rare variation it is not often encountered in cases of ruptured abdominal aortic aneurysms. Retroperitoneal hematoma does complicate anatomic orientation and thus may have been a risk factor for iatrogenic damage to the left sided vena cava in our case. Conclusion: Vascular anomalies of the inferior vena cava are rare and if not recognised may have fatal consequences during open repair of ruptured aortic aneurysm. The preoperative CT-scan, if performed, should be actively scanned for vascular anatomic details and variations. 36

32 P21 Fish skin acellular dermal graft facilitates cellular ingrowth H. Kjartansson, S. Magnusson, B. T. Baldursson, G. F. Sigurjonsson (Reykjavik) Objective: Acellular dermal grafts (ADGs), in this case fish skin xenografts, have successfully been used to treat chronic wounds. The wound healing properties of the ADGs, also known as acellular dermal matrices, have been attributed to the ability of the grafts to act as support for cell migration and regeneration of tissue. Chronic wounds are indeed characterized by a lack of cell migration to the wound bed. Our investigation focused on an ADG from fish skin, in particular its ability to serve as support for fibroblast ingrowth. Methods: The structure of the fish skin ADG was examined with scanning electron microscopy (SEM) to assess its suitability to support cell ingrowth. Further experiments focused on the interaction of cells with the fish derived ADG. NIH 3T3 fibroblasts were seeded onto a definite area of ADG pieces anchored in 96 well plates. Fish skin ADG was viewed with confocal microscopy after fluorescent labeling with actin and nuclear markers. Slices of fish skin ADG embedded into paraffin mold and stained with hematoxylin and eosin (H&E) were examined with light microscopy. Negative control was fish skin ADG that didn't receive cells. Results: SEM images suggested that the structure of the fish skin ADG supports cell ingrowth. Following experiments using light- and confocal-microscopy revealed that NIH 3T3 fibroblasts can migrate into and grow within the fish skin ADG as well as on its surface. Conclusion: The ability of fish skin ADG to support cell ingrowth indicates its suitability for the treatment of chronic wounds and tissue repair. 37

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35 P22 Healing profile and fish antibodies of 59 patients treated with fish skin acellular dermal fraft: A retrospective clinical study M. Flanagan 1, B. T. Baldursson 2, F. Konradsdottir 2, G. F. Sigurjonsson 2 ( 1 United Kingdom, 2 Reykjavik) Objective: The ominous outlook of an explosive increase in the number of non-healing wounds, driven by increasing age, obesity and diabetes, has increased acceptance for novel therapy options of chronic wounds. Amongst these is a fish skin acellular dermal graft (ADG), the latest of a group of wound treatment materials that utilize animal tissues that have been cleaned of cellular material, leaving the intact extracellular matrix of the fish skin. Investigation objectives included, studying the; safety, efficacy and possible side effects of fish skin graft on chronic non-healing wounds in a retrospective clinical study. Methods: 59 adult patients with 68 wounds were treated with fish skin ADG for a period of four weeks. Of the 68 wounds treated, 17 (25%) healed completely after 4 weeks and 43 wounds improved. Only 8 wounds were not responsive to treatment. No participant developed immediate wheal, flare, itching or other adverse effect on the skin or body after contact with fish skin ADG. Results: In search for induction of fish allergy, all 28 participants that agreed to be tested were negative for the antibodies that cause fish allergy (RAST for s-ige to Gadus morhua (Atlantic Cod)). Venous or mixed venous/arterial wounds accounted for 38% of treated wounds and in that group 92% of wounds improved or healed. 83% of the wounds that healed were of surgical or traumatic origin, 71% of arterial ulcers, 83% of diabetic foot ulcers and 83% of the ulcers caused by pressure improved or healed. Conclusion: Acellular fish skin graft is safe to use as a treatment material for wounds. Fish skin ADG, does not induce allergic reactions or sensitivities and appears to be effective on a range of different types of chronic wounds. No adverse events were noted. 40

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37 P23 A retrospective study of outcomes after ruptured abdominal aortic aneurysm repair in a tertiary center T. Holzer, S. Déglise, J.-M. Corpataux, F. Saucy (Lausanne) Objective: Ruptured abdominal aortic aneurysm (raaa) is an emergency that affects principally old and fragile patients. Untreated it is almost always fatal1. If treated, its mortality is around 48%. For patients over 75 years old the mortality can be as high as 60-67%.The decision to intervene or not must be taken rapidly. Often the pain and shock render difficult a discussion with the patient and it is finally the surgeon that has to take the decisions. With this study we want to identify easily accessible predictive factors of death to guide us toward the decision process. Methods: From a prospective maintained database, we included all consecutive patients with raaa treated in our service during the last 14 years. The design is a retrospective cohort study. Primary outcome is in hospital mortality rate. The secondary outcomes are postoperative complication rates, length of stay and institutionalization rate. Results: We identified 41 patients. The mean age (+/-SD) was 74.6 (+/- 10.5) with a majority of male patients (85.6%). The preoperative risk factors were cardiopathy (36.6%), chronic obstructive pulmonary disease (24.4%), tobacco (43.9%), chronic kidney disease (19.5%), diabetes (17.1%), cerebro-vascular disease (9.7%), peripheral arterial disease (7.3%). Risk factors at admission were unconsciousness (14.6%), cardiac arrest (7.3%). Overall in hospital mortality was 32%. Mortality was respectively 10 % for patients between years old, 8.3 % between years old, 27 % between years old and 100% between years old. Acute compartment syndrome occurred in 20% of the patients, 17% of the patients necessitated transit dialysis, 8% necessitated definitive dialysis, 20% had acute limb ischemia but only one patients was amputated, 12% had intestinal ischemia leading to 3 patients with a definitive stomia, 7.3 patients had post-operative myocardial ischemia and 44% pneumonia. All 27 survivors except one returned home. Conclusion: Age seems to be a key predictive factor for mortality. Others risk factors need to be identified. When the patient survives he can in most of the cases return to the life he had before the rupture. 42

38 P24 Cystische Adventitadegeneration der A.femoralis communis als ungewöhnliche Ursache für Beinschmerzen K. Necke, S. Hofer, M. Furrer, G. Heller (Chur) Objective: Cystische Adventitiadegeneration als Ursche einer Claudicatio intermittens wurde bereits beschrieben. In fast allen Fällen handelt es sich dabei um eine Pathologie auf Kniegelenkshöhe im Bereich der A.poplitea und das Geschlechtsverhältnis beträgt männlich : weiblich 5 : 1. Cystische Adventitiadegeneration im Bereich der A. femoralis communis bei einer Frau sind eine Rarität auf die wir in dieser Fallbeschreibung hinweisen wollen. Methods: Eine 50 jährige Patientin wird mit einer halbjährlichen Anamnese von rechtsseitigen Beinschmerzen zugewiesen. Aufgrund von Schmerzen beim Treppaufgehen sowie nach 200 Metern geradeaus bei weitgehend fehlenden Risikofaktoren für eine PAVK wurde die Patientin neurologisch abgeklärt. Erst später fand eine Gefässabklärung statt. Die Duplex und Angio CT Untersuchung zeigte eine Erweiterung der Femoralarterie mit Teilthrombosierung und Einengung des Lumens (A.femoralis rechts 18 mm mit Teilthrombosierung gegenüber links von 9 mm Durchmesser). Wir gehen von einer aneurysmatischen Erweiterung aus. Die Patientin verneint Gefässzugänge in der Leiste, Unfälle, Auslandaufenthalte oder sonstige grösseren Vorerkrankungen. Die Untersuchungen ergaben in Ruhe keinen relevanten Unterschied des ABI von rechts zu links. Results: In der Annahme eines teilthrombosierten A.femoralis Aneursmas weisen wir die Patientin einer operativen Sanierung zu. Intraoperativ zeigt sich wohl die erwartete Erweiterung der Femoralarterie, jedoch besteht die Wand aus einer csystischen Veränderung. Diese ist etwa 7 cm lang und verläuft spiralförmig auf die Rückseite der A.profunda femoris hin. Die übliche Therapie mit Resektion der cystischen Formation und Patchplastik ist so nicht anwendbar und wir entschliessen uns für ein PTFE Interponat von der terminalen A.iliaca externa auf die A.profunda femoris mit Implantation der A. femoralis superficialis in den Graft. Die Patientin hat den Eingriff gut toleriert und wird beschwerdefrei entlassen. Die Histologie zeigt in der Adventitia eine teilweise inkomplett septierte cystische Läsion mit chronischen makrophagenreichen Entzündungskomponenten. Conclusion: Eine Cystische Adventitiadegeneration kann in seltenen Fällen auch an Nichtpoplitealgefässen sowie bei Frauen auftreten. Die Symptome können bedingt durch die kompressive Komponente eine Claudicatio intermittens hervorrufen und aspektmässig wie ein teilthrombosiertes Aneurysma imponieren. P25 An uncommon retroperitoneal tumour in an elderly patient A. Ferrario di Tor Vajana, S. Engelberger, R. Rosso, L. Giovannacci (Lugano) Objective: Vascular leiomyosarcomas are very rare malignant tumours, with less than 300 cases reported. Prognosis is often very poor. We present a patient with incidental diagnosis of a leiomyosarcoma of the vena cava, that underwent surgical resection. Methods: An 84 year old woman with intermittent claudication underwent a duplex ultrasound that incidentally revealed a large retroperitoneal tumour. A CT-scan confirmed the tumour, adherent to duodenum, pancreas and vena cava. There were no metastasis to lymph nodes,the liver or the lung. The CT guided biopsy showed a sarcoma. In absence of sings for metastasis, primary surgical resection was indicated. During surgery the sarcoma was identified to originate from the infrarenal vena cava. The tumour could be easily isolated from duodenum and pancreas. Clamping of 43

39 the vena cava proximal to the renal vein was necessary because of the close proximity to the left renal vein but no hemodynamic changes were observed. The mass was completely removed with a segment of the inferior vena cava which was reconstructed using a PTFE prosthesis. The pathologic study confirmed a leiomyosarcoma of the vena cava with free resection margins. The patient was discharged in good conditions at day seven. Oral anticoagulant therapy was given for 3 months and the patient is under long-life antiplatelet therapy. At follow up three months after surgery, the patient was in good general condition. Considering the patient s age, adjuvant therapy is not indicated. For follow up radiological controls every 6 months are scheduled Results: the leiomyosarcoma (LMS) is a rare retroperitoneal tumour arising from smooth muscle of vein s wall. The signs and symptoms are nonspecific and their onset is often very late. Diagnosis is therefore often tardive: 50% of the patients present already with liver or lung metastases at diagnosis. Complete surgical resection is the only option for long-term survival. Thanks to technical progresses in vascular surgery, even advanced disease can be treated nowadays through extended resection combined with vascular reconstruction. Conclusion: vascular tumours can be successfully treated, with modern techniques and appropriate medical devices, although they represent a challenge for surgeons, especially in elderly patients. Due to their rarity and to the variability of clinical manifestations, they need to be treated in specialized centre by a multidisciplinary team. 44

40 P26 Acute Aortic Dissection type B with concomitant abdominal aortic aneurysm or status post EVAR T. Holzer, F. Saucy, M. Benezit, J.-M. Corpataux, S. Déglise (Lausanne) Objective: Acute aortic dissection (AAD) can be associated with an abdominal aortic aneurysm (AAA) in up to 16% of the cases. Five to six percent had their AAA already repaired by open surgery at the time of the AAD. Nowadays an increasing number of patients present with AAD and a status post EVAR. Our goal is to understand what are the risks and what is the best treatment for those patients. Methods: We present four cases of acute aortic dissection type B with concomitant AAA or status post EVAR. A summary of the evidences found in the literature is then proposed. Results: AAD with AAA or previously repaired AAA present a higher risk of complications than AAD alone. Conclusion: We recommend to consider those dissections as complicated and to treat them aggressively. The abdominal aortic aneurysm should be repaired with endovascular techniques or open surgery as soon as possible. 45

41 P27 Fish skin acellular dermal graft for difficult to heal wounds C. L. Winters 1, H. Kjartansson 2, J. L. Patterson 1 ( 1 Indiana, 2 Reykjavik) Objective: There are many different kinds of wound matrix products available for healing ulcers; however, many fail to heal those harder to heal chronic wounds. A new acellular dermal graft composed of fish skin contains omega-3 fatty acids that reduce inflammation to a level that allows wounds to progress from the chronic inflammatory stage and complete the healing process. Methods: Four cases are illustrated that use this new acellular dermal graft in patients with chronic ulcers. Case 1 is a 67-year-old female with type 2 IDDM and peripheral neuropathy who had a Wagner grade I ulcer of the right first toe. At each office visits the ulcer was debrided, the graft placed in the ulcer base, medical trade honey put onto the graft then a non-adhere and steri-strips were applied.case2 is a 45-year-old man with type 2 IDDM with wound dehiscence from a transmetatarsal amputation. He had a history of peripheral neuropathy, end stage renal disease and was on dialysis. Case 3 is a 65 year-old female with type 2 IDDM sho had wound dehiscence from a left partial second ray amputation. Case 4 is a 51-year-old female with a dorsal foot ulcer with a history of vasculitis, venous stasis, and chronic bilateral lower leg edema. Results: Case 1: The wound healed in less than 2 months with 6 graft applications. Case 2: In months with 10 graft applications the wound was healed. Case 3: The wound was healed in 5 weeks with 5 graft applications. Case 4: In 6 weeks with 5 graft applications, the wound was healed. Conclusion: This new acellular dermal graft with omega-3 fatty acids contains the properties needed to heal these recalcitrant wounds and may be more effective than similar products in decreasing healing time. 46

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