The 24th Charing Cross International Symposium will be remembered for years to come for many reasons, including eloquent oratory by the faculty, skilful presentations of the evidence to support positions, the humour, and the Great Debates on the highly controversial subjects of carotid stenting and aortic endografting. There were some tense moments when some of the faculty launched verbal assaults on opponents during debates. Jim May’s attack on the opposition, Ted Diethrich, Piergiorgio Cao, and Krassi Ivancev, over the main EVAR indication being patients unfit for endovascular repair in the Great AAA Debate will be remembered for a long time by those who attended the session, about 800 people. Is Diethrich really looking for a stage career as May suggested? Maybe May has a point, but Diethrich is considered by many to be one of the best presenters on the international scene. Is Piergiorgio Cao operating on undersized aortic aneurysms, and some that are not even aneurysms, as Jim May suggested? Well Cao assured the audience this is not the case.
The Great Debate on carotid stenting versus endarterectomy was the last session of the symposium and it kept the audience at the meeting right up to the very end. Roger Greenhalgh, Peter Bell and Patrice Bergeron teamed up against Tom Fogarty, Peter Gaines and Plinio Rossi to defend endarterectomy not becoming the gold standard in carotid vascular disease. This was another classic debate with Roger Greenhalgh getting the better of Tom Fogarty, but not without Tom scoring a few points against Roger.
Truly an international masterclass
The 24th Charing Cross International Symposium was truly a masterclass for interventional specialists, including angiologists, cardiologists, radiologists, vascular surgeons and cardiovascular surgeons. Its theme departed from traditional surgery more than ever before, and although the majority of attendees were vascular surgeons, important numbers of radiologists and cardiologists were present. The Global Endovascular Forum, being introduced for the first time next year, should attract even greater numbers of radiologists and cardiologists, establishing Charing Cross as Europe’s leading international platform for discussing peripheral vascular and endovascular controversies, and new device technologies.
Upper Limb Controversies and Challenges
The opening session started with a debate on first rib excision. David Bergqvist spoke for the motion that first rib excision is seldom required and Jörg-Dieter Gruss, who has significant experience with the procedure, was against the motion. Bergqvist asserted that randomised trials are needed to evaluate the effect of first rib excision in neurogenic thoracic outlet syndrome. Meanwhile, Gruss said that thoracic outlet syndrome is commonly diagnosed only following the occurrence of an arterial or venous complication. He stated that it has not yet been possible to present definitive data on the incidence of thoracic outlet syndrome since the disease is largely unknown, with many patients being misdiagnosed and wrongly treated as a result.
Jim Reekers, in the second debate, on the side of interventional radiology, proposed that subclavian artery stenosis should be managed by PTA and (eventually) with stents and Peter Polterauer, chief of vascular surgery at Vienna’s University Hospital, opposed the motion. Reekers proposed that PTA alone should be tried first and stenting carried out if the result is sub optimal, but he said that there was no evidence for stents in subclavian or innominate artery lesions, and that randomised trials are required. He concluded that given the evidence that the result from PTA is no different from surgery in terms of patients being free of symptoms, some 70%, that PTA should be used before surgery is considered. Peter Polterauer thought that there should be a randomised study to show how the two approaches compare.
The upper limb session closed with a larger debate on EVAR: whether it will take over emergency AAA rupture repair. It had Jaap Buth and Brian Hopkinson proposing the motion and Wilhelm Sandmann and Dieter Raithel opposing the motion. Jaap Buth, speaking first, said that conventional surgery mortality is too high in rupture cases. He said that it is not possible to catch the ruptures before they occur in many cases because screening the population is too expensive, and therefore ruptures will persist in the current healthcare system. Jaap Buth presented evidence that supported the application of EVAR in emergency cases, but made it clear that very important organisational changes are required for hospitals taking on emergency EVAR. Clearly the idea of abandoning open surgery for emergency procedures is some way off. Dr Buth said that only 90% of patients in his series in Eindhoven, between May 2001 and February 2002, could be done by EVAR and only 70% were done by EVAR.
Wilhelm Sandmann added that the evidence was not yet there to support the use of EVAR although some publications, not well defined, are fascinating (he quoted the Montefiore Hospital in New York). Meanwhile, Takao Ohki has been presenting data at European meetings that show very low mortality. Wilhelm Sandmann did nevertheless accept that he could be convinced that EVAR is a viable treatment option if the high mortality rates of conventional repair in the general surgical community were to persist. He added the caveat that few centres are currently properly equipped for routine emergency AAA repair and that EVAR is at best a clinical experiment in selected patients with stable haemodynamic conditions.
Dieter Raithel, normally a strong advocate of EVAR was against EVAR for emergency repair. He argued that the current emergency devices were compromises and that EVAR presented a major logistical problem. He pointed out that one big drawback to the devices is that “one size fits most”, evidently not all, and precious time may be spent finding that out.
Aortic and Lower Limb Arterial Controversies and Challenges
For a start, Amman Bolia went head to head with Rodney White over whether superficial femoral subintimal angioplasty beats luminal PTA. In some respects both men where preaching from the same book, in that angioplasty is better than surgery. Rodney White got closest to the mark by making the important distinction between the value of PTA and SAP as a therapy.
The second discussion focused on whether aorto iliac reconstruction should avoid femorofemoral crossover. The current ESVS president, André Nevelsteen, was proposing the motion and the former ESVS president William Paaske was opposing the motion. Nevelsteen, against doing the femorofemoral procedure except as a rescue procedure, gave an account of the evidence for aorto iliac reconstruction. “It is a rescue way so let’s keep it that way,” he said. Nevelsteen claimed that unilateral direct prosthetic reconstruction is justified in selected cases and produces superior results over femorofemoral crossover. Paaske on the other hand thinks femorofemoral crossover is a simple procedure and “should be a selected procedure rather than a compromise”. He said, “Clinical experience shows that it can be performed in even high risk patients with low mortality and morbidity, and acceptable patency rates.” The audience were divided on what option was best, and Jean-Pierre Becquemin, who chaired the debate, called the vote a draw.
Later, two Americans debated whether balloon angioplasty is the first-line treatment for acute limb ischaemia. Tom Fogarty was the proposer and Ken Ouriel was the opposer. Fogarty made it clear that he thought, “Acute limb ischaemia with loss of function requires urgent and definitive treatment, which is best accomplished by surgical balloon catheter treatment.” He said that other resorts such as surgical thrombectomy and (mechanical) thrombolysis techniques were better than thrombolytic treatment, which is too uncertain. He added that when the condition is not life threatening, clearly definitive action is necessary to avoid amputations or subsequent surgical treatment. He gave details of several new catheter-based approaches that break up and aspirate thrombus. Ken Ouriel thought that the evidence suggests there is a higher than expected amputation and death rate in the primary open surgery group. He said that the technical improvements in surgical procedures and perioperative care the rates remain high. The debate was a close call, but it was decided that Fogarty had carried the motion.
The next debate concentrated on whether there is a place for primary amputation for critical ischaemia. In this debate two Dutchmen were in conflict: Hero van Urk proposing the motion and Jan Blankensteijn opposing it. Hero van Urk was clear that for him primary amputation was the only and unavoidable choice of treatment, if there is no run off below the popliteal artery when no bypass surgery is feasible. Jan Blankensteijn flatly disagreed saying “Many surgeons take the easy way out and amputate when salvage becomes difficult.” He added, “When there is no artery there is no issue, amputation must be carried out. However, if the limb is potentially salvageable it should be attempted.” He said that it often means a lot to the patient to have a limb for a little bit longer, even if it is going to be lost in the end. Blankensteijn convincingly won the debate.
Another debate saw former CIRSE President Dierk Vorwerk clash with the UK’s vascular surgeon Andrew Bradbury. The issue being debated was whether mild intermittent claudication is benefited by angioplasty. Vorwerk proposed the motion and Bradbury opposed. Dierk Vorwerk stated: “There is a long-standing consensus that a vascular surgical approach to peripheral vascular disease requires major clinical symptoms such as severe claudication or rest pain.” Clearly the surgeons do not accept to treat until clearly necessary because their approach is very invasive. Endovascular treatment is much less invasive and has been proved to cause a low morbidity and even lower mortality, with a satisfactory outcome. Vorwerk then eloquently argued that protocols need to be rethought, no longer waiting until the severe conditions, risking limb ischaemia, that result from claudication. He made the point that treatments do not meet the individual situation of a patient. Andrew Bradbury thought that lifestyle changes and drugs to reduce cholesterol and antiplatelet therapy help reduce cardiovascular morbidity. He was concerned by the volume of infrainguinal PBAs that have been performed across the world without any evidence for its durable efficacy. He added that it is extremely unfortunate that the number of procedures appears to be increasing. Part of his presentation explained why PBA does not work. This included discussion about the pathophysiology of intermittent claudication and the failure of the technique itself. He said improvement from PBA was too short lived to be of value and that the high cost of devices has been instrumental in the development of this practice, and that patients were assisting because they perceived high-tech as better than low-tech. He concluded randomised controlled trials currently in progress will help define the role for PBA in intermittent claudication, if there is one. He encouraged all European vascular surgeons and radiologists to enter their patients into these trials so that progress can be made, because PBA has been around for the last 40 years and using it for intermittent claudication disease remains a contentious issue.
Erich Minar and Takoa Ohki were then in conflict over whether vascular brachytherapy is preferable to drug-eluting stents to reduce restenosis. The main argument made by Takao Ohki was that brachytherapy is an overkill procedure with a lot of fall out. He thought that ‘the cruse missile approach’, to get precise treatment to the required area, is more appropriate. Pharmacoated stents remain an unproven technology in peripheral applications despite the successful outcome in their prevention of restenosis in coronary disease.
Venous Controversies and Challenges
The start of the venous session saw Ralf Kolvenbach battle it out with Charles McCollum over whether phlebectomy is the treatment of choice for varicose veins. Ralf Kolvenbach has considerable experience in using phlebectomy in treatments and is a pioneer in this area. He understands the drawbacks and is happy with the initial results. He said the microsurgical techniques that he uses can be performed safely with significantly better intermediate results, making them better than other surgical options. He accepts, however, that there is a high recurrence rate. Charles McCollum concluded that phlebectomy alone is inadequate in the treatment of varicose veins, stating that there would be recurrence of the condition.
Then Jean-Georges Kretz squared up to Bruce Campbell over whether below knee duplex venous thrombus merits treatment. Both speakers gave a breakdown of the various conditions and how they should be treated. Kretz quoted various papers including those by Kakkar in 1969, Browse in 1974, Mottos in 1996 and most recently the report of Labropoulos in 1999, which involved a series of 5,250 patients. In fact, he made 24 references compared to Bruce Campbell’s 16. The benefit from treating by surgery was weighed up by Campbell. He said in minor cases of calf vein thromboses, which are common, “the thromboses usually resolve spontaneously”. He talked about anticoagulated patients and said “anticoagulants have not been shown to reduce the risk”. He added, “There is an argument for serial duplex scanning of isolated calf vein thrombosis, but not for the routine use of anticoagulants.”
Thoracic Aortic Controversies and Challenges
The thoracic aortic session started with Peter Taylor, standing in for Christop Nienaber, facing Hans Myhre over whether thoracic aneurysms and type B dissections should be treated by stent graft. Christop Nienaber’s presentation was very thorough, hardly surprising since he has been pioneering this area for many years and has considerable experience with use of stent grafts and alternative drug therapy, plus close contacts with surgeons who undertook surgical procedures. His paper, delivered by Taylor, did not discuss open surgery as an alternative, but rather concentrated on the real alternative often offered, that of drug therapy. He described stent-grafts as being conceptually promising but acknowledged the drawbacks. He thought that non-surgical reconstruction of the aorta should be subjected to a randomised evaluation. Hans Myhre claimed open surgery remains the gold standard as it has been for some decades. He added that serious complications with endovascular repair have been reported and that it must therefore be regarded for the time being as experimental.
The second debate saw Jon Moss engage George Hamilton over whether renal artery lesions should always be treated by angioplasty and stent. Moss talked extensively about PTA and stenting, saying that there is a learning curve with renal stenting and about 100 cases are required to pass this phase. Hamilton thought it was “worth having a crack at treating these patients by surgery because haemodialysis mortality is so high” and preserving the artery would reduce that. He said that the Birmingham meta-analysis had demonstrated that the “ethical window had been lost to them” and that he hoped to convince the audience that “there is a case for surgery”. Moss won the debate for PTA and PTA plus stenting although he was really proposing stenting, not PTA alone.
The Great Carotid Debate
The Great Carotid debate was well worth waiting for, delivering what it promised, a great finale to the meeting, with the Greenhalgh camp (Roger Greenhalgh, Peter Bell and Patrice Bergeron) beating Tom Fogarty’s camp (himself, Peter Gaines and Plinio Rossi). Whether or not carotid stenting ever becomes the gold standard – the debate was won by the surgeons, even with an interventional radiologist as chairman. However, it was always going to be a tall order for the stenting side in front of an audience predominately populated with vascular surgeons. Tom Fogarty showed that there is an evolution in the results of carotid stenting and that in more experienced hands results are improving. Roger Greenhalgh demonstrated why endarterectomy is still the main technology used. He said there is no certainty at all that stenting results will ever approach best surgery. Published 30-day stroke and mortality results are superior following carotid endarterectomy.
Peter Gaines, who followed Greenhalgh, said that the only completed randomised trial indicates that endovascular treatment of carotid stenosis is as efficacious as surgery, and that the results of endovascular therapy are improving, and moreover, that carotid stenting would become the gold standard. Plinio Rossi called for randomised controlled trials. He probably hit the right note when he said that we should consider endovascular therapies as an alternative, not as a gold standard.
The educational supplement CD that accompanies this issue of Vascular News contains the satellite symposia from this year’s Charing Cross International Symposium (the CD should autorun, but if you have trouble click on the scan.hta file). However, if you are intrigued by the debates mentioned in this article, which took place during the symposium’s main programme, then don’t despair. Video and audio coverage of the full symposium is available on CD from BIBA Medical (cost £145 or 235 Euros).
For further information, please
contact Eleanor Thorneycroft on:
tel: + 44 (0)20 7381 1333 or
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paul@bibamedical.com 
