The 26th Charing Cross International Symposium - Vascular and Endovascular Challenges

New anticoagulants
(09.45 - 09.55, Sunday 4 April)
Samuel Money (New Orleans, USA)
Venous thromboembolism (VTE) afflicts 2 million a year in the US alone, according to Money. Strong clinical demand exists for inexpensive, safe, and efficacious anticoagulants

Low molecular weight heparin (LMWH) incited the treatment of VTE as an outpatient. Pentasaccharides are pure, synthetic drugs which indirectly, selectively inhibit factor Xa. Pentasaccharides are as effective as LMWH in VTE prophylaxis after major orthopaedic surgery. Direct factor Xa antagonists, the most selective of the anticoagulants, are in clinical trials. Ximelagatran, an oral direct thrombin inhibitor, effectively prophylaxes and treats VTE. Money says an 'ideal anticoagulant' has few side effects, a wide therapeutic window, and can be given orally

Combination thrombolysis
(10.15 - 10.25, Sunday 4 April)
Kim Hodgson (Springfield, USA)
Combination thrombolysis for peripheral arterial and venous thrombosis has the potential to restore flow more quickly and with reduced risk of systemic bleeding complications than the prolonged thrombolytic infusions of the past. Furthermore, these same characteristics may permit the endoluminal treatment of patients with relative contraindications to standard lytic infusions, including those at risk for serious systemic bleeding and those with critical limb ischaemia for whom a more prompt restoration of flow is required. Unfortunately, all reports to date have been uncontrolled, non-randomised, and non-standardised with regard to device and lytic agent used, vessels treated, and, as well, as to lytic dosages and device protocols followed. Considering the innumerable variables involved, an absolute scientific answer as to the best combination therapy protocol for various vascular thromboses may never be determined. As such, it may very well be that the best we can expect for the foreseeable future is to have both mechanical devices and pharmacologic agents in our endovascular toolboxes to be used at physician discretion, customised to clinical circumstances and guided by individual experience.

Gene therapy for critical limb ischaemia
(09.10 - 09.20, Monday 5 April)
Janet Powell (Coventry, UK)
There are many experimental studies with tantalising results to indicate the promise of gene therapy in the management of limb ischaemia. In man quality studies have been limited to the proof of safety and efficacy for angiogenesis, ulcer healing or vein graft survival. Angiogenesis trials appear to be limited by the poor standardisation of outcome measures, particularly radiographic measures. Although commercial companies appear to have Phase III trials in progress for angiogenesis, the long- term efficacy of this approach is questionable. To deliver improvement to ischaemic limbs, it will be necessary to improve blood flow. This must be measured. The magnitude of the improvement required suggests that focus should shift to arteriogenesis. Currently, the highest chance of successful gene therapy would appear to be for vein grafts and ulcer healing.

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AAA repair - total laparoscopic
(11.00 - 11.10, Monday 5 April)
Marc Coggia (Boulogne-Billancourt, France)
According to Coggia, further evaluation is justified to ensure the real benefits of the laparoscopic technique compared with open surgery. However, if initial results are confirmed, laparoscopic AAA repair will probably be driven by patients who are hesitant about undergoing a major vascular operation and who are more likely to undergo the same operation if performed with a mini-invasive technique

AAA repair - partial laparoscopic
(11.10 - 11.20, Monday 5 April)
David Nott (London, UK)
The laparoscopic-assisted technique for abdominal aortic aneurysm repair is certainly a technically feasible procedure. Nott feels that the laparoscopic skills required are no more than that necessary to perform a laparoscopic cholecystectomy. The new generation HALS ports may make the operation less challenging to those who have limited laparoscopic skills. He does not feel that it was necessary to use devices to keep the whole of the small bowel away from the operating field, a fan retractor seemed to suffice in the majority of cases. There is no doubt that the benefit to the patient comes from the mini-laparotomy incision, with respect to less time on the intensive care unit and earlier hospital discharge. This must be related to less pain associated with a smaller wound. The next step obviously from this is totally laparoscopic abdominal aortic aneurysm repair and at present there are a number of investigators performing this procedure. The technique for exposure of the aorta is now almost perfected, the major concern is bleeding and control of vessels that are calcified. This technique requires a different level of laparoscopy, being able to suture expeditiously being one. However with the introduction of one shot stapling devices in the future this may simplify this procedure. The field of laparoscopic vascular surgery is becoming very exciting and the prediction by Sir Peter Bell that vascular surgery could be 60 percent endovascular, 25 per cent laparoscopic and 15 per cent open in the next 10 years makes the future look bright.

Combined endovascular & laparoscopic
(11.20 - 11.30, Monday 5 April)
Ralf Kolvenbach (Düsseldorf, Germany)
Kolvenbach says that we now have the techniques and the instrumentation to use laparoscopic techniques routinely in aortic aneurysm surgery. The hybrid approach can offer to the patient the best of two worlds improving the outcome of endografing. This minimal invasive technique is one of the most effective ways to eliminate type II endoleaks and to prevent graft migration just like in open surgery. Intraoperatively the surgeon can in one session directly occlude the lumbar arteries and after thrombus removal wrap the endogaft like in a Creech procedure. The mid term results show that an outcome similar to open surgery can be obtained.

Computed tomography angiography and MRA imaging for EVAR
(12.00 - 12.10, Monday 5 April)
Jan Blankensteijn (Nijmegen, The Netherlands)
In his talk, Blankensteijn is expected to indicate that in the pre-operative imaging for EVAR, CTA is the imaging modality of choice. All necessary assets of the patient selection, sizing and planning can be done on these images providing a standardized, accurate image post-processing protocol is used. Accurate measurements and planning on a graphical workstation will decrease the risk of misplacement and inadequate seal.

According to Blankensteijn, post-operatively, a dedicated CTA protocol will be able to detect most problems, provided it is combined with an adequate image post-processing protocol. Though there is only limited evidence for the value of MRI and MRA techniques after EVAR, this modality seems to be much more sensitive to endoleak detection then CTA is. Furthermore, the combination of the high soft tissue contrast in the T2-weighted images, the comparison of the T1-weighted scans before and after contract enhancement and the possibility of performing dynamic CE MRA might very well make MRI the imaging modality of choice after EVAR in the future.

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