International Angiology

VOLUME 33. AUGUST 2014. Suppl. 1 to issue No. 4 International Angiology ABSTRACT BOOK XXVI WORLD CONGRESS OF THE INTERNATIONAL UNION OF ANGIOLOGY Sydney, Australia August 10-14, 2014

INTERNATIONAL ANGIOLOGY Official Journal of International Union of Angiology, Union Internationale de Phlébologie, Central European Vascular Forum FOUNDER AND EDITOR-IN-CHIEF EMERITUS EDITOR-IN-CHIEF P. BALAS, Athens, Greece A. NICOLAIDES, Nicosia, Cyprus CO-EDITORS A. SCUDERI, Sao Paolo, Brazil (UIP) G. GEROULAKOS, London, UK (Ang. Forum, RSM) J. FAREED, Chicago, USA (IUA) V. STVRTINOVA, Bratislava, Slovakia (CEVF) SPECIALIST COMMITTEE S. A.N. ALAM, Dhaka, Bangladesh F. A. ALLAERT, Dijon, France B. AMANN-VESTI, Zurich, Switzerland P. L. ANTIGNANI, Rome, Italy R. M. BAUERSACHS, Munich, Germany C. CAMPISI, Genoa, Italy A. CARLIZZA, Rome, Italy P. CARPENTIER, Grenoble, France J. CAPRINI, Chicago, USA M. CAZAUBON, Paris, France S. CHENG, Hong Kong, China D. CLEMENT, Ghent, Belgium A. CORNU-THENARD, Paris, France P. DIMAKAKOS, Athens, Greece E. CORRADO, Palermo, Italy L. DAVIDOVIC, Belgrade, Serbia C. DELIS, Athens, Greece C. DELTAS, Nicosia, Cyprus E. DIMAKAKOS, Athens, Greece M. DOBLAS, Toledo, Spain R. DONNELLY, Nottingham, UK D. DUPREZ, Minneapolis, USA B. EKLOF, Råå, Sweden S. ESSAM, Cairo, Egypt J. FLETCHER, Sydney, Australia S. GEORGOPOULOS, Athens, Greece B. GORENEK, Eskisehir, Turkey A. GIANNOUKAS, Larissa, Greece M. GRIFFIN, London, UK J. D. GRUSS, Kassel, Germany H. HAYOZ, Lausanne, Switzerland U. HOFFMANN, Munich, Germany M. HORROCKS, Bath, UK M. K. JEZOVNIK, Ljubljana, Slovenia S. KAKKOS, Patras, Greece P. KALMAN, Chicago, USA E. KALODIKI, London, UK A. KATSAMOURIS, Heraklion, Greece R. KISTNER, Honolulu, USA N. LABROPOULOS, New York, USA B. B LEE, Washington DC, USA C. LIAPIS, Athens, Greece F. H.A. MAFFEI, Sao Paolo, Brazil A. MARKEL, Haifa, Israel S. R. MARQUES, Recife, Brazil R. MARTIN, Bristol, UK P. J. MATLEY, Claremont, South Africa R. MATTASSI, Milan, Italy L. MENDES PEDRO, Lisbon, Portugal F. MIRANDA Jr, Sao Paolo, Brazil J. L. NASCIMENTO Silva, Rio, Brazil L. NORGREN, Örebo, Sweden A. PANAYIOTOU, Nicosia, Cyprus H. PARTSCH, Vienna, Austria Z. PECSVARADY, Budapest, Hungary M. PERRIN, Lyon, France O. PICHOT, Grenoble, France A. PIERIDES, Nicosia, Cyprus A. D. POLYDOROU, Athens, Greece P. POREDOS, Ljubljana, Slovenia E. RABE, Bonn, Germany D. RADAK, Belgrade, Serbia G. H. R. RAO, Minneapolis, USA V. RIAMBAU, Barcelona, Spain X. SCHMID-SCHOEBEIN, San Diego, USA A. SCUDERI, Sorocaba, Brazil F. SPINELLI, Messina, Italy M. SPRYNGER, Liège, Belgium I. STAELENS, Brussels, Belgium J. WALENGA, Chicago, USA H. VANDAMME, Leuven, Belgium Gu YONG-QUAN, Beijing, China N. S. ANGELIDES, Nicosia, Cyprus L. BANFIÇ, Zagreb, Croatia J. BELCH, Dundee, UK H. BOCCALON, Toulouse, France T. BOWER, Rochester, USA M. BRODMANN, Graz, Austria M. CAIROLS, Barcelona, Spain M. CASTRO SILVA, Belo, Horizonte, Brazil M. CATALANO, Milan, Italy E. DIAMANTOPOULOS, Athens, Greece D. DZSINICH, Budapest, Hungary J. FERNANDES E FERNANDES, Lisbon, Portugal REGIONAL EDITORS H. GIBBS, Brisbane, Australia P. GLOVICZKI, Rochester, USA D. HOPPENSTEADT, Chicago, USA S. HOSHINO, Tokyo, Japan E. HUSSEIN, Cairo, Egypt A. JAWIEN, Bydgoszcz, Poland F. KHAN, Glasgow, UK J. J. MICHIELS, Rotterdam, Netherlands M. MIRALLES, Barcelona, Spain S. NOVO, Palermo, Italy J. PANNETON, Rochester, USA J. PERREIRA ALBINO, Lisbon, Portugal E. PILGER, Graz, Austria E. PURAS, Madrid, Spain H. RIEGER, Engelskirchen, Germany K. ROZTOCIL, Praque, Czech Republic T. SASAJIMA, Muroran, Japan H. SHIGEMATSU, Tokyo, Japan R. SIMKIN, Buenos Aires, Argentina V. TRIPONIS, Vilnius, Lithuania J. ULLOA, Bogota, Colombia O. N. ULUTIN, Istanbul, Turkey A. van RIJ, Dunedin, New Zealand M. VELLER, Parktown, South Africa Z. G. WANG, Beijing, China E. ASCER, New York, USA M. AMOR, Nancy, France E. BASTOUNIS, Athens, Greece P. BELL, Leicester, UK G. BIASI, Milan, Italy L. CASTELLANI, Tours, France K. CHERRY, Jr., Rochester, USA M. CHOCHOLA, Praque, Czech Republic F. CRIADO, Baltimore, USA E. B. DIETHRICH, Phoenix, Arizona J. A. DORMANDY, London, UK E. ERACLEOUS, Nicosia, Cyprus I. ERIKSON, Uppsala, Sweden J. R. ESCUDERO, Barcelona, Spain P. FIORANI, Rome, Italy EDITORIAL COMMITTEE A. FROIO, Milan, Italy L. J. GREENFIELD, Ann Arbor, USA J. J. GUEX, Nice, France J. HALLET, Maine, USA M. HENRY, Nancy, France L. HOLLIER, New Orleans, USA P. KALMAN, Chicago, USA M. R. LASSEN, Aalbord, Denmark M. MALOUF, Sydney, Australia P. G. MATTHEWS, Melbourne, Australia M. A. McGRATH, Darlinghurst, Australia D. MIKHAILIDIS, London, UK N. NAKAJIMA, Chiba, Japan W. PAASKE, Aarhus, Denmark S. RAJU, Jackson, USA M. M. SAMAMA, Paris, France J. SCURR, London, UK S. J. SIMONIAN, Annandale, USA C. SPARTERA, L Aquila, Italy F. SPEZIALE, Rome, Italy A. TAKESHITA, Fukuoka, Japan O. THULESIUS, Linkoping, Sweden P. VALE, Sydney, Australia J. L. VILLAVICCENCIO, Bethesda, USA M. YOKOHAMA, Kobe, Japan J. ZHANG, Beijing, China C. K. ZARINS, Stanford, USA R. E. ZIERLER, Seattle, USA EDITORS EMERITUS C. ALLEGRA, Rome, Italy P. MAURER, Munich, Germany ADMINISTRATIVE EDITOR D. BOND, London, UK MANAGING EDITOR A. OLIARO, Turin, Italy

Abstract Book XXVI World Congress of the International Union of Angiology August 10-14, 2014 SYDNEY, AUSTRALIA Congress President JOHN FLETCHER EDIZIONI MINERVA MEDICA TORINO 2014

INTERNATIONAL ANGIOLOGY Official Journal of the International Union of Angiology Volume 33 No. 4 (August 2014) C O N T E N T S FREE PAPER SESSION 1 1 Evaluating the intracranial perforating branches by micro angiographic system using a rotating cerium anode C. Tanaka, Y. Ikeya, T. Shizuma, N. Fukuyama, H. Mori 1 An endovascular-first paradigm shift results in superior limb salvage rates S. Thomas, N. Katib, R. Varcoe 2 Covered stents in treating peripheral aneurysms in patients with behcet s disease Z. Sun, H. Wang, Y. Shen, W. Jiang 2 Covered stent for carotid aneurysm in patients with bovine aortic arch A. Bashar, G. Hossain, E. Hakim, N. Mandal, M. Hossain, N. Dey, S. Alam 3 Has carotid artery stenting found its place? a 10-year regional centre perspective. N. Biggs, S. Rangarajan, D. McClure 3 Contemporary epidemiological study of abdominal aortic aneurysm (aaa) in men and women of different ages. a case-control study M. Chabok, M. Farahmandfar, M. Aslam, N. Garbani, A. Manganaro, J. Coltart, A. Nicolaides 3 Vascular complications in intravenous drug abusers. vascular surgeons up against a social scourge in a developing country A. Bashar, G. Hossain, E. Hakim, M. Hossain, N. Mandal, S. Alam 4 Hemolytic anemia in thromboangiitis obliterans; a report of 29 cases B. Fazeli, H. Ravari, M. Akbarin 4 Investigation of disease severity in patients with scleroderma using the lakk-m device F. Adams, J. Millar, S. Sokolovski, J. Belch, E. Rafailov, F. Khan 5 Chronic kidney disease and cardiovascular comorbidities M. Chabok, M. Farahmandfar, M. Aslam 5 The contemporary management and cost-analysis of symptomatic aorto-iliac occlusive disease (AIOD) M. Ahmad, T. Nieto, T. Wilmink, A. Ganeshan, D. Adam, M. Claridge 6 Corrosion resistance and surface evaluation of five selfexpanding nitinol stents used in clinical practice J. Morrison, M. Pelletier, A. Rives, W. Walsh, J. Yang, R. Varcoe FREE PAPER SESSION 2 7 A novel mouse model that reflects human atherosclerotic plaque instability is a unique tool for drug testing and mechanistic discoveries K. Peter, Y. Chen 7 Correlation between carotid plaque burden, carotid intima media thickness (cimt) with heart disease risk factors M. Farahmandfar, M. Chabok, M. Aslam 8 Serum phosphatidylcholine plasmalogen concentrations are strongly predictive of myocardial infarction risk in patients with peripheral artery disease J. Moxon, G. Wong, R. Jones, D. Liu, J. Weir, B. Kingwell, P. Meikle, J. Golledge 8 The association of calf skeletal muscle characteristics with major adverse events in peripheral artery disease D. Morris, J. Moxon, M. Cunningham, J. Golledge Vol. 33 - Suppl. 1 to No. 4 V

9 Early onset aggressive atherosclerotic peripheral arterioocclusive disease. search for the pathogenic factor A. Bashar, E. Hakim, G. Hossain, M. Hossain, N. Mandal, N. Dey, M. Arif, A. Mamun, S. Alam 9 The association of lower extremity performance with cardiovascular and all-cause mortality in patients with peripheral artery disease D. Morris, A. Rodriguez, J. Moxon, M. Cunningham, R. Jones, J. Golledge 10 The 78 kda glucose response protein (grp78) is recruited to the surface of endothelium by interacting with thrombomodulin and it demonstrates antithrombotic activity H. Nandurkar, A. Sharma, X. Zhang, C. Selan, A. Samudra, E. Salvaris, B. Michell, B. Kemp, P. Cowan 10 The ankle cubital d-dimer ratio (acdr) is independent of age and confirms increased pro-thrombotic activity at the site of varicose veins C. Lattimer, E. Kalodiki, G. Geroulakos, J. Fareed, D. Hoppensteadt, D. Syed FREE PAPER SESSION 3 13 Incidence and risk factors of asymptomatic central vein or proximal vein stenosis in acute arteriovenous graft and fistula thrombosis in dialysis patients K. Lawanwong, W. Tirapanich, S. Jirasiritham, S. Leela- Udomlipi, P. Pootrakool, P. Lertsithichai, S. Horsirimanont 13 Carbon dioxide as the primary contrast media in endovascular therapy for preventing renal complications T. Sahu 14 Comparision of vacuum-assisted closure and moist wound dressing in the treatment of diabetic foot ulcers H. Ravari, M. Saeed Modaghegh, G. Kazemzade, H. Ghoddusi Johari, A. Mohammadzadeh, A. Sangaki, M. Vahedian Shahrodi 14 Full field laser perfusion imager (FLPI) and post occlusive reactive hyperaemia (PORH) for the assessment of skin microvascular endothelial function? F. Adams, J. Belch, F. Khan 15 Investigating the effect of changing air pressure on microvenous function J. Marx, A. Granot, I. Carlisle, O. Hirth 15 French cross-cultural translation and adaptation of the ausviquol. australian disease-specific quality of life questionnaire (QoL) for peripheral arterial disease (PAD) S. Zerrouk, J. Renaudin, C. Rotonda, E. Chou, P. Julia FREE PAPER SESSION 4 17 Comparison of trauma patients with or without runoff in angiographic findings H. Ravari, M. Pezeshki Rad, A. Bahadori, O. Ajami 17 Adjunctive techniques to facilitate endovascular repair of aortic dissection of the arch and its branches. hybrid repairs and chimneys S. Chang, F. Kun 18 Laser-doppler flowmetry. a practical, predictive tool of free flap behaviour in breast reconstruction surgery? J. Butterworth, M. Aslam, A. Fitton 18 A new method of preoperative marking for reconstructive surgery using a sural-medial perforating flap. a duplex ultrasound study S. Zerrouk, E. Simon, M. Brix, S. Malikov 19 Cd39 is antithrombotic and protects from ischaemia reperfusion injury by adenosine generation. H. Nandurkar, S. Crikis, B. Lu, L. Murray-Segal, C. Selan, S. Robson, P. Cowan, K. Dwyer 19 Dermo epidermal autologous implant device (iddea) produced by tissue engineering R. Vellettaz, M. Lavigne, D. Dominici, L. Correa 20 Use of eco-guided laser approach in the treatment of venous leg ulcers. N. R. Ramírez, N. Lecuona Huet 20 Pushing the limits and optimizing the outcomes of closure fast radio frequency (r-f) ablation and complimentary procedure for gsv-ssv incompetence N. Ibrahim, G. Bicanic, K. Huang, A. Zea, J. Diaz 20 Simultaneous duplex using two probes as a novel method for assessing superficial venous insufficiency C. Lattimer, E. Mendoza VI

21 10 years experiences with endovenous laser ablation of varicose veins S. Julinek, I. Maly, D. Klein 21 Incidence of deep venous reflux in primary varicose veins P. Pootracool, S. Jirasiritham, S. Leela-Udomlipi, W. Tirapanich, S. Horsirimanon 22 Early experience with fenestrated and chimney endografts for short neck aortic aneurysms repair in Ramathibodi Hospital. A. Suesawatee, P. Pootracool, S. Horsirimanont, W. Tirapanich, S. Leela-Udomlipi, S. Jirasiritham FREE PAPER SESSION 5 23 Estimation of diagnostic informativity of multispiral computed tomography angiography in patients with peripheral arterial disease by findings of the intraoperative revision. N. Abushov, S. Manafov, N. Hasayeva, E. Zakirjayev 23 Carotid artery stenting via the right brachial access for left carotid stenosis in the bovine arch G. Lianrui, G. Yongquan, T. Zhu, L. Xuefeng, G. Jianming, Z. Jian, W. Zhonggao 24 Interaction of cardio-renal and bone marrow-renal mechanisms and the micro-circulation (capillary) theory of hypertension. J. Myers 24 Retrospective analysis of 200 cases of superficial femoral artery disease D. Dekiwadia, H. Dekiwadia, S. Saji 25 Will the angiosome concept be supported by measurements of microperfusion after tibial angioplasty or bypass surgery? W. Lang 25 Silverhawk plaque excision vs. angioplasty for symptomatic infrapopliteal arterial occlusive disease. J. Guo, Y. Gu, L. Guo, S. Cui, Z. Tong, X. Wu, X. Gao 25 Prevention of groin wound infection after vascular surgery in patients with peripheral arterial disease T. Beck, M. Engelhardt, C. Mueller, C. Willy 26 Nitinol multiple stents in TASC D superficial femoral artery lesions. analysis with ankle brachial index and duplex scan L. Castro, A. Freitas, D. Freitas 26 Inhibiting the superficial femoral artery sympathetic nervous to treat thromboangiitis obliterans T. Jingdong, G. Shujie, Z. Ci, L. Ke, Q. Shuixian 27 Cardiovascular disease prevention in patients with peripheral arterial disease - results of a 5-year observational study A. Blinc, M. Kozak, M. Sabovic, M. Bozic Mijovski, M. Stegnar, P. Poredos, A. Kravos, B. Barbic Zagar, M. Pohar Perme, J. Stare 27 Low flow vascular malformations J. Soracco 27 Open vascular injuries repaired with primary prosthetic graft interposition. Padre Hurtado Hospital s initial 3 year experience. G. Cassorla, C. Hevia, C. Vallejos, J. Torres, H. Rojas FREE PAPER SESSION 6 29 A suggestive activity score for thromboangiitis obliterans B. Fazeli, H. Ravari 29 Ultrasonic wound irrigation experience with chronic wounds over a 24 month period. C. Frank 30 More than one in two instances of venous thromboembolism treated in French hospitals could have occurred during the hospital stay F. Allaert, E. Benzenine, C. Quantin 30 Catheter directed thrombolysis in deep vein thrombosis, technique and results over last decade. D. Dekiwadia 30 Adenosine generation protects in a murine model of antiphospholipid antibody-induced miscarriages H. Nandurkar, A. Samudra, X. Zhang, C. Selan, K. Dwyer, P. Cowan Vol. 33 - Suppl. 1 to No. 4 VII

31 Endovascular treatment of juxtarenal aortic dissections with iliac occlusions using bare metal stents, without proximal stent graft. A. Chatterjee 31 Inferior vena cava filter retrieval, experience of a South American center V. Bianchi, P. Vargas, F. Allamand, G. Cassorla, B. Horwitz 32 Gold Coast Vasculab chronic wound clinic model. C. Frank 32 Social media and the phlebologist s practice. 3 strategies for connecting with patients S. Peek 32 Vnus closure fast radiofrequency ablation. clinical experience of the treatment in patients with lower limb varicose disease. N. Abushov, E. Zakirjayev, M. Karimov, F. Abbasov, Z. Aliyev, G. Abushova 33 The absorption characteristics of the venous wall for the various laser wavelength A. Tsyplyashchuk, Y. Stoyko, K. Mazayshvili, A. Krasnovsky, T. Khlevtova, S. Akimov, M. Yashkin 33 Three parts of the mechanism endovenous laser ablation A. Tsyplyashchuk, K. Mazayshvili, Y. Stoyko, T. Khlevtova, S. Akimov, M. Yashkin OTHER ABSTRACTS 35 Efficacy of rivaroxaban for prevention of venous thromboembolism after knee arthroscopy. a randomized double-blind trial (erika study) G. Camporese, E. Bernardi, F. Noventa, M. Bosco, C. Bortoluzzi, C. Mazzola, G. Zanon, D. Imberti, S. Vitali, C. Lodigiani on behalf of ERIKA. Study Group 35 Fifteen-year follow up of late type i/iii endoleaks after evar. how safe is non-interventional treatment J. May 36 Treatment of the venous thoracic outlet syndrome (pagetschroetter) E. Molina 36 Arterial complications of cervical ribs. Surgical outcome S. A. Nurul Alam, 37 Popliteal vein compression D. Huber 37 Venous thromboembolism in asia an unrecognised and under-treated problem? P. Angchaisuksiri 37 Coronary microcirculation in diabetic and hypertensive patients S. Novo, V. Sucato, A. Quagliana, S. Evola, E. Bronte, G. Inga, G. Pace, G. Tona, R. Trovato, G. Novo 39 Polarisation of the monocyte classical subset to an m1 phenotype in atherosclerosis H. Medbury, H. Williams, G. Cassorla, N. Pertsoulis, N. Marmash, V. Patel, K. Hitos, J. Fletcher 39 Blood vessel regenerative medicine in China Y. Gu, J. Zhang, Z. Wang 40 Intimal hyperplasia development and characterization in a nitinol u-clip versus sutured arteriovenous anastomosis R. Varcoe 40 Catheter directed thrombolysis for deep vein thrombosis. preliminary results from Chile V. Bianchi, P. Vargas, G. Cassorla, B. Horwitz, F. Allamand 40 Closurefast endovenous radiofrequency ablation (ERFA) for GSV-SSV incompetence: efficacy and failure patterns. a 3-year follow-up N. Ibrahim, K. Huang, A. Zea, J. Diaz, G. Bicanic 41 Dyslipidemia in peripheral artery disease with respect to presence/absence of smoking and diabetes mellitus. J. Pitha, D. Karetova, B. Seifert, J. Vojtiskova, K. Roztocil 41 Endovenous heat-induced thrombosis (EHIT) after EVLT of GSV with 1470nm laser and bared tip fibers R. Vellettaz 42 Pelvic congestion syndrome C. Jara, A. Kornberg, J. Pratt 42 Diagnostic guidelines of vascular anomalies. vascular malformations and hemangiomas P. Antignani 43 Outcomes following elective non-fenestrated aaa repair. 13 years experience M. Neale, M. McCaffrey, J. Edwards, C. Thoo VIII

43 Pedal bypass with deep venous arterialisation for the limb salvage in critical limb ischemia with unreconstructable distal artery P. Mutirangura, C. Ruangsetakit, C. Wongwanit, N. Sermsathanasawadi, K. Chinsakchai 44 Combining drug-eluting stents and stent-grafts for the treatment of femoro-popliteal occlusive disease. early outcomes R. Huilgol, D. Hagley 44 Genetics in primary lymphoedema S. Michelini, A. Bruson, M. Cardone, F. Sirocco, A. Fiorentino, S. Cecchin, F. Cappellino, M. Bertelli 44 Anatomy and Micro-anatomy of the lymphatic system N.B. Piller 45 Postoperative control of type ii endoleaks in patients submitted to evar for aaa B. Gossetti 45 The role of duplex ultrasound in the management of peripheral artery disease R. Pulli 46 Metabolic syndrome and cardiovascular risk S. Novo, V. Evola, M. Sinacori, A. Peritore, R. Trovato, F. Guarneri, E. Corrado, I. Muratori, G. Novo 47 Private community screening for vascular disease in Australia S. Kitchener, R. Denniss 47 Contemporary diagnostic evaluation - update N.B. Piller 48 Clinical applications of novel angiographic scoring system M. Jackson, C. Krampl 48 Is aspirin still the drug of choice for management of peripheral arterial disease? P. Poredoš 49 Anticoagulant drugs for the management of peripheral arterial disease (pad) M. Jezovnik 49 Objective proof for oedema reduction N.B. Piller 50 Four-layer compression is an effective treatment for lower limb venous ulceration A. Giannoukas, N. Rousas, M. Papadopouloy, A. Drakoy, R. Stankova-Salta, C. Nakos, V. Salepstis, K. Spanos, A. Athanasoulas, 50 Factors associated with short-term endoleak development after EVAR with the use of new generation endografts A. Giannoukas, V. Saleptsis, K. Spanos, K. Antonopoulos, C. Karkos, C. Ioannou, D. Tsetis, I. Kakissis, K. Papazoglou, C. Liapis, 51 Experience with endovascular repair of complex abdominal aortic aneurysm Y. Gu, L. Guo, L. Qi, H. Yu, X. Li, B Chen, Z. Tong, X. Wu, J. Guo, Z. Wang 51 Prospective randomized trial of endovenous laser ablation of great saphenous veins with 1470 nm diode laser and 2ring fibers comparing compression therapy 0 days, 7 days and 28 days after therapy. U. Maurins, J. Rits, A. Kadiss, S. Prave, E. Rabe, F. Pannier 52 Prevalence of venous thromboembolism treated in French and USA hospitals F. Allaert, E. Benzenine, C. Quantin 52 New trends for pathophysiology and diagnosis in critical limb ischemia P. Antignani 52 New trends in medical treatment in critical limb ischemia. current state and future directions P. Poredoš 53 Preliminary results from a screening programme of lower limb arterial occlusive disease in elderly males in central greece A. Giannoukas, N. Rousas, G. Makrygiannis, V. Saleptsis, K. Spanos, C. Argyriou, S. Koutsias, 53 Thrombophilia panel results in patients after the first venous thromboembolic event in view of recommended selection criteria for thrombophilia testing J. Hirmerova, J. Seidlerova, I. Subrt, J. Slechtova Vol. 33 - Suppl. 1 to No. 4 IX

54 New approach in the treatment of heparin-induced thrombocytopenia B. Chong, Z. Ahmedi, J. New, X. Jiang 54 Combining drug-eluting stents and stent-grafts for the treatment of femoro-popliteal occlusive disease: early outcomes R. Huilgol, D. Hagley 54 Management of acute and chronic pain R. Halliwell ELECTRONIC POSTERS 57 Low concentration detergent sclerosants stimulate white blood cells apoptosis in vitro O. CooleyAndrade, W. XianGoh, D. Connor, K. Parsi 57 Ex-vivo and in vitro analysis of coagulum formation after administration of detergent sclerosants D Connor, O. CooleyAndrade, J. Weisel, K. Parsi 57 The effect of temperature on sclerosant foam stability and structure X. Tan, G.C. Valenzuela, K. Wong, D. Connor, M. Behnia, K. Parsi 58 The effect of dilution with water or saline on the critical micelle concentration of detergent sclerosants K. Wong, T. Chen, D. Connor, M. Behnia, K. Parsi, 58 High incidence of haemostatic defects in pigmented purpuric dermatoses D. Vekic, D. Connor, K. Parsi 59 Sclerosant foam structure is strongly influenced by the liquid air fraction E. Cameron, T. Chen, D. Connor, M. Behnia, K. Parsi 59 Sonographic anatomy of t he sural nerve in relationship to endovenous thermal ablation of incompetent small saphenous vein N. Ibrahim, K. Huang, A. Zea, J. Diaz 59 Classification and algorithmic selective management of ssv incompetence (reflux) in radiofrequency endovenous ablation (evrfa) setting N. Ibrahim, A. Zea, K. Huang, J. Diaz 60 Hydrodisplacement to safeguard sural nerve and to optimise closurefast endovenous thermal ablation (EVTA) of small saphenous vein (SSV) incompetence. N. Ibrahim, A. Zea, K. Huang, J. Diaz 60 Intra-arterial injections of sclerosants: management with steroids P. Hannaford, K. Parsi 61 Therapeutic strategy of intravenous leiomyomatosis with intracaval and intracardiac extension in 18 cases L. Guo 61 Treatment of chronic venous insufficiency with superficial, perforator, and deep vein surgery. Y. Hoshino 61 Ultrasound guided foam sclerotherapy (UGFS) to treat varicose veins at the WA Vascular Centre J Teasdale 62 Telemedicine screening for vascular disease of lower limbs M. Petrlik, T. Bohrn 62 Limiting indications for varicose vein surgery to maximise service provision in an era of restricted funding; an audit of compliance at the GCHHS M. Bavahuna, M. Jackson, W. Butcher 63 Treatment of scrotal and pelvic varicocele: our experience. R. Moia, A. LaRosa, J Clerissi, C. MassaSaluzzo, E Moia, V. Saracino, E. Castronovo, R. Nuzzo, M. Dondi 63 Recurrent varicose veins post CHIVA R. Moia, A. LaRosa, J Clerissi, C. MassaSaluzzo, E Moia, R. Nuzzo, V. Saracino, M. Dondi, E. Castronovo 63 Endovenous laser ablation in symptomatic patients with varicose veins: saphenous vein diameter and reflux detection correlates well with clinical symptoms. M Vítovec, V. Horvath, M. Slais, J. Honek, T. Honek 64 Clinical outcome of patients with truncal saphenous incompetence: comparison of endovenous laser ablation and conservative treatment. M Vítovec, J. Honek, M. Slais, V. Horvath, T. Honek X

64 Heredity of chronic venous disorders: an epidemiological study on 21319 patients challenging the predominantly maternal character of CVD heredity F. Allaert, V. Crebassa, J. Guex 65 Development and validation of the psychometric properties of a self-reported questionnaire assessing adherence to the wearing of elastic compression stockings F. Allaert, D. Rastel, A. Graissaguel, B. Lun, G. Chauferind 65 Causes of recurrent varicose veins D. Musil, J. Herman, M. Tichy, P. Bachleda 66 Axial splitting of medial cutaneous nerve of forearm facilitates the 2nd stage superficialization of basilic or brachial vein in patients with brachial basilic or brachial brachial arterio-venous fistula. S. Przywara, T. Zubilewicz, M. Ilzecki, P. Terlecki 66 Risk factors for failure of native arteriovenous fistulas (kafka study) M. Harazim, I Hofírek, O. Sochor 66 Isolated acute abdominal aortic dissection with huge pseudoaneurysm successfully treated with combination of bare metal stent and unibody bifurcated stent graft B Yang 67 AAA morphology and management: what features effect treatment and outcome by evar T Daly, J Mah, N Young, K Hitos, J Fletcher 67 Differential diagnosis of aortic dilatation in pictures M Kaletova, D Musil, P Marcian, J Ostransky, M Cerna, M Taborsky 68 Endovascular interventional treatment of superior mesenteric arteries stenosis L. Tan, S. Sheng-Han, Z. Wang-De, Z. Yang, Y. Biao, Y. Bao- Zhong 68 Pseudo aneurysms: endovascular treatment R. Moia, A. LaRosa, J Clerissi, C. MassaSaluzzo, E Moia, M. Dondi, R. Nuzzo, V. Saracino, E. Castronovo 68 Endovascular treatment of peripheral aneurysms R. Moia, A. LaRosa, J Clerissi, C. MassaSaluzzo, E Moia, R. Nuzzo, V. Saracino, E. Castronovo, M. Dondi 69 Aneurysms of visceral arteries: endovascular treatment R. Moia, A. LaRosa, J Clerissi, C. MassaSaluzzo, E Moia, M. Dondi, R. Nuzzo, E. Castronovo, V. Saracino 69 Prevention and treatment of conversion complications in totally laparoscopic aortic bypass surgery for aortoiliac occlusive disease G. Lianrui, G. Yongquan, Q. Lixing 70 Management strategy of isolated spontaneous dissection of the superior mesenteric artery H Satokawa, H Yokoyama, T Igari 70 Open surgical repair for inflammatory abdominal aortic aneurysms K Igari, T Kudo, M Nakamura, S Katsui, M Nishizawa, H Uchiyama, S Koizumi, T Toyofuku, Y Inoue 70 Replantation of amputated arms M Salah 71 Angiographic findings of patients with extremity injuries: is vascular proximity it a valid indication for angiography? H. Ravari, A. Bahadori, M. PezeshkiRad, O. Ajami 71 Iatrogenic injury to the superior vena cava and brachiocephalic vein J. Herman, D. Musil, P. Bachleda, M. Cerna, V. Prasil, P. Santavy 72 Endovascular treatment of arterio-venus malformations R. Moia, A. LaRosa, J Clerissi, C. MassaSaluzzo, E Moa, E. Castronovo, V. Saracino, M. Dondi, R. Nuzzo 72 SEVERE LYMPHEDEMA OF THE LOWER LIMBS. TRANSDISCIPLINARY TREATMENT J. Soracco, J L. Ciucci, J. Krapp, O. Regalado, L. Marcovecchio, S. Gerez, M. Amore, G. Bengoa, F. Díaz Bessone, L. Rodríguez 72 Variation of blood vessels in the cranial-cervical region. rare forensic pathological findings due to variation of the blood vessels S Furukawa, S Morita, H Okunaga, L Wingenfeld, K Nishi 73 Efficacy and safety of 12 to 24 versus 25 to 36 months of dual antiplatelet therapy after implantation of overlapping drug-eluting stents D Kim, J Kim, B Hwang, K Yoo, S Her, K Moon Vol. 33 - Suppl. 1 to No. 4 XI

73 Clinical efficacy of endovascular therapy in critical limb ischemia of the upper limb T. Sahu 73 Porphyromonas gingivalis and platelets aggregation in patients with peripheral artery disease. M. Jibiki, Y. Inoue 74 Bone marrow derived stem cell therapy to stimulate angiogenesis in patients with critical limb ischaemia A. Morrow, M. Krishnaswamy, J. Griffin, D. McClure 74 Pre-reconstruction of cervical-to-petrous internal carotid artery: improved technique for treatment of vascular lesions involving internal carotid artery at the skull base F. Li, Y. Zheng 75 Load transfer from the foot to the walls of the total contact cast in patients with a diabetic foot wound. L. Begg, P. McLaughlin, M. Vicaretti, J. Fletcher, J. Burns 75 Efficacy of short-term catheter-directed thrombolysis used with rt-pa combined with endovascular interventional therapy in patients with lower limb ischemia Z. Yang, Z. Wangde, L. Tan, Y. Biao, S. Shenghan. 76 The influence of ozonated autohemotherapy on lipid peroxidation system in patients with thromboangiitis obliterans and critical limb ischemia. N. Abushov, E. Zakirjayev, R. Guliyev, M. Ahmadov, G. Tagizade, E. Aliyev, L. Mammadova 76 Establishment of the Brunei diabetic foot registry N. HajiZaine, K. Hitos, J. Fletcher, M. Vicaretti, L. Begg, J. Burns 76 Endovascular treatment of iliac arteries R. Moia, A. LaRosa, J Clerissi, C. MassaSaluzzo, E Moia, E. Casronovo, V. Saracino, R. Nuzzo, M. Dondi 77 Endovascular treatment in patients with below the knee vessels desease R. Moia, A. LaRosa, J Clerissi, C. MassaSaluzzo, E Moia, E. Castronovo, V. Saracino, M. Dondi, R. Nuzzo 77 Endovascular rivascularization of the lower limb through profunda femoral artery R. Moia, A. LaRosa, J Clerissi, C. MassaSaluzzo, E Moia, R. Nuzzo, M. Dondi, E. Castronovo, V. Saracino 78 Efficacy and safety of hybrid therapy for complex peripheral arterial disease S. Ito, M. Hashimoto, N. Katayama, T. AMemiya, H. Suesada, H. Tsuchida 78 Microcirculation in patients with clinical signs of critical lower limb ischemia S. Rosfors, L. Kanni, T. Nystrom 78 Dying digits, no place to run no place to hide D Dekiwadia 79 N-3 polyunsaturated fatty acids, 24-h ambulatory blood pressure, and heart rate in incident hypertension J. HagstrupChristensen, C. Strandhave, M. Svensson, E. BergSchmidt 79 The Impact of Plain X-ray Calcium Score in Revascularized Critical Limb Ischemia Patient B. Wasin, H. Suthas, P. Piyanut, T. Wiwat, L. Surasak-Udomlipi, J. Sopon 80 Long-term Patency and Fracture Rates of Stents Placed in the Popliteal Arteries in Chinese Patients With Chronic Critical Limb Ischemia or Lifestyle-limiting Claudication C. Shijun, G. Lianrui, L. Xuefeng, W. Xin, T. Zhu, Z. Jian, G. Yongquan 80 Tibial angioplasty for limb salvage in patients with endstage renal disease (esrd) W. Lang, A. Meyer 81 Effect of low-level laser therapy on blood flow and oxygenhemoglobin saturation of the foot skin in healthy subjects W. Lang, F. Heu, B. Namer, C. Forster 81 Endovascular mechanical rotational thrombectomy in cases of occluded native arteries, bypass grafts and stents T. Zahariev, V. Govedarski, S. Genadiev, I. Petrov., B. Denchev, G. Nachev 81 Fibulin-1 levels in patients with coronary artery disease H. Karpuz, D. Filiz, B. Ikitimur 82 Reduced thickness of the choroid in patients with asymptomatic internal carotid artery stenosis. pilot study. S. Przywara, A. Zubilewicz, P. Bielinski, M. Ilzecki, P. Terlecki, J. Mackiewicz, T. Zubilewicz XII

82 Application of micronized diosmin in patients with chronic peripheral artery disease of the lower limbs T. Zahariev, S. Dimitrov, V. Popov, B. Denchev, G. Nachev 83 Nitinol multiple stents in TASC D superficial femoral artery lesions: analysis with ankle brachial index and duplex scan L. Castro, A. Freitas, D. Freitas, C. Virgini, P. Areas 83 Above knee femoropopliteal TASC C and D revascularization angioplasty with single or multiple stents versus bypass surgery L. Castro, A. Freitas, C. Virgini, D. Freitas, P. Areas 83 Prevalence of venous thromboembolism in hospitalized patients with haematological malignancies receiving chemotherapy A. Wiszniewski, P. Szopinski, K. Warzocha 84 An uncommon case of deep venous thrombosis and pulmonary thromboembolism in a juvenile with compound heterozygous congenital protein S deficiency I. Kosugi, S. Matano, F. Taniguchi, E. Morishita 84 Role of pharmaco-mechanical thrombolysis in acute deep vein thrombosis. V. Chadachan, N. Pandit, M. Singh, J. Tay 85 VTE events in patients with advanced metastatic bladder cancer treated with cisplatin and gemcitabine P. Patrik, K. Dostálová, V. Štvrtinová, G. Annaáková 85 Pulmonary tuberculosis associated venous thromboembolism: how to diagnose and treat V. Chadachan, N. Pandit, J. Tay 86 Compliance of arthroplasty surgeon protocols with Australian guidelines for preventing VTE JM Naylor, Badge H, Harris IA, Fletcher J, Xuan W,Armstrong E,, Lin C. 86 Venous Thromboembolism Prophylaxis in Surgery J Butterworth 87 Evaluation of postthrombotic syndrome in patients treated by catheter directed thrombolysis for deep vein thrombosis (3 years follow up) D Karetova, D Rucka, J Lubanda, L Skalicka, S Heller, M Chochola, P Prochazka, P Varejka, A Linhart 87 Midterm outcome of endovascular treatment for acute lower extremity deep venous thrombosis X Li, Q Meng, K Jiang, H Sang, J Rong, X Yu, A Qian 88 Cost-effectiveness of pharmacological prophylaxis in preventing venous thromboembolism and associated long term complications in colorectal surgery K. Hitos, B. Sanderson, C. Stratton, J. Fletcher 88 Epidemiology of venous thromboembolism after major trauma: the efficacy, cost-effectiveness and associated bleeding complications with pharmacological prophylaxis K. Hitos, J. Hsu, C. Stratton, J. Fletcher 89 Exercise training suppresses strenuous exercise-induced procoagulant factors and thrombin generation Y. Chen, J. Wang 89 Stop the clot L Everest-Rolfe, U Buehner 90 Surgical thrombectomy and simultaneous stenting for deep venous thrombosis caused by May-Thurner syndrome M. Nishizawa, T. Kudo, K. Igari, M. Nakamura, S. Katsui, H. Uchiyama, S. Koizumi, T. Toyofuku, Y. Inoue 90 Air travellers: a pharmacist s study shows a higher risk of DVT than usually described and the benefit of wearing elastic compression F. Allaert, J. Mongold 91 How do we safely anticoagulate a patient with pulmonary embolism who is having recurrent haemoptysis in an outpatient setting? A. Sule, S. Gohar, J. Tay 91 Left iliac vein thrombosis in a young patient: need to evaluate for May Thurner syndrome? T. Quah, A. Sule, J. Tay 92 Progression of thrombus in portal vein, superior mesenteric vein and splenic vein even on anticoagulation in a patient with ascending colonic malignancy with liver metastasis portal vein thrombosis vs portal vein tumour thrombosis A. Sule, A. Borja, J. Tay 92 Treatment of pulmonary embolism with hemoptysis in a middle aged lady on low molecular weight heparin in outpatient setting and role of peak anti- xa monitoring C. Yee, A. Sule, S. Gohar Vol. 33 - Suppl. 1 to No. 4 XIII

93 Popliteal vein aneurysm: a rare cause of pulmonary embolism R Flekser, W Mohabbat 93 Vascular imaging and renovascular disease L Aluigi 94 T1, and t2 weighted se carotid plaque imaging and contrastenhanced mr angiography comparison with intravascular ultrasonography (qualitative and quantitative assessment) - pilot study W Iwanowski 94 Diagnosis of acute thrombosis using non-invasive molecular ultrasound imaging and novel platelet-targeted microbubbles. X Wang, C Hagemeyer, J Hohmann, I Ahrens, K Peter 95 Evaluation of intracranial haemodynamic by TCCS in patient with significant asymptomatic internal carotid stenosis case report J. Zizka 95 Evaluation of intracranial circulation in selection of patients with asymptomatic carotid stenosis to carotid endarterectomy role of transcranial ultrasound J Zizka XIV

FREE PAPER SESSION 1 Evaluating the intracranial perforating branches by micro angiographic system using a rotating cerium anode C. Tanaka, Y. Ikeya, T. Shizuma, N. Fukuyama, H. Mori Kanagawa, Japan chitty@is.icc.u-tokai.ac.jp Purpose. The clinical availability of X-ray radiographic system using a rotating cerium anode which we developed is discussed. We evaluated the resolution for the perforating branches from the middle cerebral artery which may cause cause lacunar infarction. Methods and Materials. The new micro angiographic system was developed with a cerium anode which has characteristic X-ray around 34.6Kev. It is close to K-edge of contrast materials (Iodine and Barium), therefore, the system can detect tiny amount of the materials. Additionally, the high X-ray photon flux generated by 5MHU generator allows to maintain enough photon number at the surface of a flat panel detector even after passing through the body. Three animal experiments were performed. First, barium was injected from the left ventricle during the heart beating to spread intracranial vessels in 32 rats. Second, barium was injected from the ascending aorta during the heart beating in 3 dogs. Then the brains of rats and dogs were removed and irradiated. Third, in living 2 dogs, iodine was injected into the ascending aorta under radiation by the new angiographic system to visualize the movement of materials in the perforating branches. Results. The new angiographic system showed the circle of Willis and the perforating branches in the rats. In the brains of dogs, it showed those arteries more clearly. The minimum diameter of vessels which were visualized was approximately 50μm. In the living dogs, it visualized the realtime movement of materials inside of the perforating branches which are difficult to be evaluated by the conventional methods. Conclusion. The system visualized the perforating branches, and the resolution was preserved even in the living body. It can be used in clinical settings, and will help in evaluating the intracranial small vessels, decreasing invasive examinations, and elucidating the functions or pathologies which are unknown. An endovascular-first paradigm shift results in superior limb salvage rates S. Thomas, N. Katib, R. Varcoe University of New South Wales, Sydney, Australia shannondthomas@gmail.com Adopting an Endovascular-first strategy (endofirst) to treat critical limb ischaemia (CLI) is contentious, with evolving technique and technological improvements vexing the applicability of literature reported results. In this study, we analysed long term limb salvage outcomes produced by an overall shift in strategy 4 years ago from an open first to a contemporary and aggressive endo first strategy. With a change in strategy occurring in July 2008, we collected longitudinal admission and interventional data for all patients presenting with CLI to our institution between January 2004 and June 2012. Patients were allocated to a therapeutic group (Non-revascularisation, Endo-first, Open First) based on the initial revascularisation procedure. The primary outcome measure was defined as freedom from amputation, with secondary outcomes of minor amputation rate, Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 1

length of hospital stay, admissions/patient and Intensive care Utilisation time. 307 patients with 357 critically ischaemic limbs were recorded, with 86 Patients (96 Limbs), 68 patients (74 limbs) and 153 patients (187 Limbs) allocated to the Non-revascularsation, Open first and Endo first groups respectively. There were fewer limbs with Ulcers/gangrene in Open-first group (55.4%) compared to the Non-revascularisation (91.7%) and Endo-first (79.7%) group (p<0.001). There were less major amputations in the Endofirst group (n=8, 4.3%) compared to the Openfirst (n=17, 23%) and Non-revascularisation group (n=23, 24%: p<0.001). Kaplan-Meier estimates demonstrated persistent freedom from amputation in the endo-first group compared to the other two groups out to 8 years (p<.05). Whilst there was a trend towards more admissions/patient and minor amputation/debridements in the endo-first group compared to the other two groups, there was a decreased length of stay and ICU utilisation time in the endo-first group. An endo first approach is associated with a trend towards a higher minor amputation rate and readmission rate, however major amputation is significantly reduced, with a persistent benefit out to 8 years. Covered stents in treating peripheral aneurysms in patients with behcet s disease Z. Sun, H. Wang, Y. Shen, W. Jiang Heilongjiang, China szfvascular@126.com Behcet s disease (BD) is a chronic multisystemic disorder of unknown etiology that is prevalent in the Middle East, the Mediterranean, and East Asia. Vascular involvement is not uncommon in BD. Peripheral aneurysms (PAs) in BD are not rare. Complications of PA such as thrombosis, embolism and rupture might threaten organs, limbs and even the patient s life. In the past two decades, endovascular repair has emerged as a safe and efficient treatment method and a possible surrogate of open surgery for aneurysms caused by BD. Aneurysms caused by BD are subject to high recurrence and complication rates which usually require reintervention. Up to date, systemic comparison between endovascular and open surgical methods is lacking. Since July 2007, 11 peripheral aneurysm cases (male 9, mean age 45.2y) were treated in our unit, and 3 patients were suffering from BD and managed with covered stents. There was 100% overall technical success, 100% primary patency and 0% of overall peri-op mortality for both BD and non- BD patients. Perioperative complications included 2 cases (18%) of gastrointestinal bleeding, 1 case (9%) of distal thrombosis. A mean follow-up of 24.5 months revealed one death (9 %) due to heart failure 4 years after aneurysm repair; patency rate was 90% (10/11) with one restenosis in a BD patient and need reintervention. Compared with non-bd patients, BD patients tend to relapse in aneurysm or thrombosis in stents. Relevant literature has shown comparable outcomes of endovascular treatment for vasculo-behcet s disease in contrast to open surgical repairs. In conclusion, aneurysms developed in Behcet s disease, though subject to clinical treatment difficulties, could be effectively and safely managed through endovascular techniques such as covered stents. In the future, however, large series data are needed to determine the long-term patency and reintervention rate Covered stent for carotid aneurysm in patients with bovine aortic arch A. Bashar, G. Hossain, E. Hakim, N. Mandal, M. Hossain, N. Dey, S. Alam National Institute of Cardiovascular Diseases & Hospital, Bangladesh ahmbashar@yahoo.com Introduction. Carotid aneurysm constitutes less than 1% of all carotid pathologies and less than 4% of all peripheral aneurysms. Treatment options include open surgical repair and endovascular exclusion. Surgical repair- an extensive procedure entails significant morbidity and mortality risks. Endovascular exclusion is emerging as an effective alternative treatment. We undertook this study to analyze our initial experiences with the endovascular exclusion of carotid aneurysm with covered stent. Methods. Over a period of 2 years, five male patients aged between 28-65 years presented with pulsatile neck swelling. Duplex ultrasound established the diagnosis of aneurysm of left common carotid artery (LCCA) in 3 cases, left internal carotid artery (LICA) in 1 and right common carotid artery (RCCA) in 1. Arch aortogram revealed bovine type aortic arch in 2 patients- both having aneurysms in the left carotid system. In one of these patients, the LCCA took origin from the Brachio- Cephalic Trunk (BCT) and in another LCCA and BCT had a common origin from the arch. Wire manipulation from the BCT into the left carotid system was significantly difficult in cases with bovine arch. Long sheath supported hydrophilic terumo guide wire was helpful. Covered stents used to exclude the aneurysms were of self-expanding type in 2 patients and balloon expandable type in 3. No cerebral protection device (CPD) was used. Results. Successful aneurysm exclusion was 2 INTERNATIONAL ANGIOLOGY August 2014

Vascular complications in intravenous drug abusers. vascular surgeons up against a social scourge in a developing country A. Bashar, G. Hossain 1, E. Hakim 1, M. Hossain 1, N. Mandal 1, S. Alam 1 1National Institute of Cardiovascular Diseases & Hospital, Dhaka, Bangladesh ahmbashar@yahoo.com Objectives. Intravenous drug abuse (IVDA) is a global health care problem that has tremendous socio-economic implications. Vascular complicaachieved in all five cases. In 2 patients receiving self-expanding device, small proximal type I endoleak was seen which persisted even after additional balloon angioplasty. No neurological deficit was noted. Conclusion. Endovascular intervention with covered stents is a safe, effective and minimally invasive option to treat carotid aneurysms even when performed without CPD. Aneurysm in the left carotid system in patients with bovine arch may present significant technical difficulty. Balloonexpandable devices were likely to have more precise placement. Has carotid artery stenting found its place? a 10-year regional centre perspective. N. Biggs, S. Rangarajan, D. McClure Geelong, Victoria, Australia ngbi.biggs@gmail.com Introduction. The post Carotid Revascularization Endarterectomy versus Stenting Trial era has seen a dramatic decline in the practice of carotid artery stenting (CAS). A retrospective review of prospectively collected CAS outcomes over a 10-year period by a single operator was undertaken to determine if this change in practice is justified, and to identify the place of carotid stenting in current practice. Methods. One hundred and fifty nine carotid stent procedures were undertaken on 137 patients from 2002 to 2012. Cases were selected for CAS only if they fulfilled the inclusion criteria for the SAPPHIRE trial. Post-procedural outcomes were compared against those of a contemporaneous cohort of patients undergoing endarterectomy (CEA) by the same operator, and against published metaanalyses. The measure of CAS durability was need for reintervention, based on the presence of ultrasound detected restenosis > 70%. Results. No significant difference was identified in 30-day complication rates between patients undergoing CAS and those having CEA. Compared to published meta-analyses of CAS, our practice was accompanied by a significantly lower rate of periprocedural stroke (1.26% vs. 6%, p=0.014), while carrying equivalent 30-day death and myocardial infarction. Four stented arteries had reintervention, due to asymptomatic in-stent stenosis of >70%. Further intervention was declined in a fifth case. This represents a restenosis rate of 3.1% over a mean follow up of 40.2 ± 27.6 months. Discussion. Carotid artery stenting can provide a safe and durable treatment option for selected patients with carotid artery disease, in the hands of appropriately trained proceduralists who meet accepted standards of practice. Contemporary epidemiological study of abdominal aortic aneurysm (aaa) in men and women of different ages. a case-control study M. Chabok, M. Farahmandfar 1, M. Aslam 2, N. Garbani 3, A. Manganaro 3, J. Coltart, A. Nicolaides 2 1Imperial College London, Life Line Screening 2Imperial College London 3Life Line Screening London, UK mohsenchabok@hotmail.com Introduction. Most recent population screening studies for AAA focused on men 65 y/o and provided little information on women and/or younger patients. Whilst AAA in women is less frequent than in men, women are reported to have a poorer outcome compared with men. Specific risk factors are associated with the development of AAA, and subgroups of women can be identified that are at a substantially increased risk of aneurysmal disease. We aim to identify factors that are independently associated with AAA. Methods. Demographics and risk factors were collected from 2069 patients with AAA, including women and <65 years old subjects, detected by ultrasound screening. For statistical analysis, 2069 age and gender matched cases were randomly selected from the same database. Logistic regression was used to look at factors associated with having AAA including age, gender, diabetes, cardiovascular disease (CVD), hypertension, hyperlipidaemia, exercise, smoking, BMI, family history of CVD and AAA. Results. There were 444 women (21.4%) and 1625 (78.6%) with AAA in this cohort. The mean age for both cases and controls was 71.4 (±7.5) years with identical sex distribution. For women, there was no evidence of an association between smoking, hypertension, family history of AAA and atrial fibrillation. For men, significant carotid artery disease, history of MI, diabetes, hyperlipidaemia, smoking, family history of AAA and stroke were determined to be independent risk factors for AAA. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 3

tions following IVDA are not uncommon and may have serious consequences. At the National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh, there has been a steady rise in the number of cases with vascular complications of IVDA in recent years. The aim of the study was to analyze our experiences with various types of vascular complications following IVDA. Materials and Methods. Between January 2011 and December 2013, a total of 135 patients presented with various complications of IVDA. One hundred and seven patients presented with bleeding from ruptured pseudoaneurysm or impending pseudoaneurysm rupture and the remaining 28 with Deep Venous Thrombosis (n=13), superficial thrombophlebitis (n=12) and acute limb Ischemia due to thromboembolism (n=3). For the management of pseudoaneurysm, resuscitation was done when necessary followed by excision of pseudoaneurysm either with simple ligation of the artery (Group A, n=77) or with restoration of arterial continuity (Group B, n=30), decision being guided mainly by the severity of infection. Outcome in the two groups were compared against the following parameters; acute limb ischemia, chronic limb ischemia, wound infection and lymphorrhoea. Results. There was no in-hospital mortality in this series. Both ligation and restoration of arterial continuity following aneurysmectomy were effective in treating the bleeding aneurysm. However, restoration of arterial continuity was more effective in preventing acute and chronic limb ischemia than simple ligation. (P=0.04 and 0.02, respectively). Most patients required long-term general and plastic surgical care. Conclusions. In Bangladesh, the incidence of IVDA with vascular complications is increasing at an alarming rate. Management of these patients requires dedicated centers with vascular surgical expertise and appropriate logistic support. Restoration of arterial continuity should be targeted whenever feasible to prevent acute and chronic limb ischemia in these patients. Hemolytic anemia in thromboangiitis obliterans; a report of 29 cases B. Fazeli, H. Ravari, M. Akbarin Khorasan, Iran bahar.fazeli@gmail.com Introduction. The aetiology and pathophysiology of Thromboangiitis Obliterans (TAO) remains puzzling. Plasma samples from many TAO patients show evidence of anaemia and macroscopic haemolysis, which may indicate haemolytic anaemia. Potential causes causes were investigated. Methods. An Indirect Coombs test, and tests for lactate dehydrogenize (LDH), D-aspartate aminotransferase (AST), D-alanine aminotransferase (ALT), and complements system proteins C3 and C4 were evaluated in 29 plasma samples, which had been banked between 2010 and 2012 from patients diagnosed with TAO. Results. The indirect Coombs test was positive in 23 out of 29 samples (79.2%). The mean documented haemoglobin of the patients was 12.28±0.6 g/dl. The LDH level was high in all samples, with a mean of 2552±315 u/l. High levels of AST (mean: 67±7 u/l), normal levels of ALT (26±3 u/l), high levels of C3 (2.08±0.7g/l) and normal levels of C4 (0.38±0.11g/l) were also observed. Conclusion. These results indicate that many TAO patients have haemolytic anaemia. However, in light of the clinical manifestation of TAO and the relatively high levels of C3 and C4 in the samples studied, haemolytic anaemia in TAO is likely to be due to the presence of infectious pathogens rather than autoimmune mechanisms. Investigation of disease severity in patients with scleroderma using the lakk-m device F. Adams, J. Millar 1, S. Sokolovski 2, J. Belch 1, E. Rafailov 3, F. Khan 1 1Vascular & Inflammatory Diseases Research Unit, Ninewells Hospital & Medical School, Dundee, Scotland 2Photonics & Nanoscience Group, Division of Physics, University of Dundee, Dundee, Scotland 3Aston Institute of Photonic Technologies, Aston Triangle, Birmingham, England f.z.adams@dundee.ac.uk Scleroderma is a chronic autoimmune disorder characterised by collagen deposition in the skin. The skin may be used as a marker of disease activity and progression; however currently there are no objective tests available. The multifunctional laser-based non-invasive diagnostics system (LAKK-M) has been developed as part of the MEDILASE project (Multifunctional Medical Diagnostic LASEr) to simultaneously monitor several tissue parameters (microcirculation & oxygen levels; fluorescence of endogenous tissue biomarkers: collagen, flavins etc.) and may provide a useful method to detect varying degrees of scleroderma. The aim of this study was to use the LAKK-M to investigate the extent of disease severity in patients with scleroderma using skin autofluorescence and to compare these results with healthy subjects free of cardiovascular disease (CVD). The LAKK-M was used to measure skin fluorescent biomarkers related to vascular function and 4 INTERNATIONAL ANGIOLOGY August 2014

CVD risk (including collagen and elastin & markers of oxidative stress) in 18 patients with varying degrees of scleroderma and 7 healthy subjects. There were significant differences in skin autofluorescence measurements between patients with scleroderma and healthy subjects for collagen, elastin, NADH, and pyridoxine. The biomarkers were significantly higher in patients compared to healthy subjects (Results in arbitrary fluorescence units (AU) ±SD: Collagen 170.5±62.3 VS. 98.8±37.1 p=0.005; Elastin 370.2±147.1 VS. 216.3±94.7 p=0.009; NADH 467.25±172.0 VS. 304.7±138.3 p=0.018; Pyridoxine 242.3±98.3 VS. 169.3±74.6; p=0.005). There were no significant differences between the groups for any of the other biomarkers measured; flavins, lipofuscin and carotin (p>0.05). The LAKK-M is a promising tool for the clinical assessment of disease severity in patients with scleroderma. The device was able to detect increased levels of collagen, elastin, NADH and pyridoxine in patients with scleroderma. In the future, application of the LAKK-M in larger studies would be useful to further assess its ability to monitor disease activity and progression in this patient group. Chronic kidney disease and cardiovascular comorbidities M. Chabok, M. Farahmandfar 1, M. Aslam 2 1Imperial College London, Life Line Screening 2Imperial College London, UK mohsenchabok@hotmail.com More than 1.8 million people in England have diagnosed chronic kidney disease (CKD) and there are thought to be around a million people who have undiagnosed CKD. The risk of cardiovascular events rises substantially as GFR falls. CKD can substantially reduce quality of life, and leads to premature death, due to cardiovascular events for thousands of people each year. Clinically significant CKD (Stages 3-5) is relatively common and the incidence is rising. Method. Between May 2012 to Jan 2013, demographics and risk factors were collected from nearly 14000 apparently healthy Irish and British individuals who were self-selected for cardiovascular check-ups. Cockroft-Gault and abbreviated MDRD methods was used to calculate creatinine clearance and egfr. Carotid, peripheral arterial disease and abdominal aortic aneurysm studies were performed for all participants. Major cardiovascular risk factors and current medications were also recorded via questionnaires. Results. 2995 individuals entered the study. The mean age of the population was 63.3 (±9.98) and the mean age of patients with CKD was 68.3 (±10.06) years. 43.3% (1183) of attendees were male. 8.9% of participants had egfr less than 60 (Stage 3+ CKD) (266/2984): 10.4% (161/1547) in women and 7.1% (84/1183) in men. The average BMI was 28.5 kg/m2. Diabetes mellitus was present in 6.7% (196), hypertension in 34.9% (939), and hyperlipidaemia in 36.2% (970). The point prevalence of cardiovascular risk factors and cardiovascular disease was significantly higher in the Stage 3+ group than the remainder of the population. Conclusion. CKD is associated with higher prevalence of cardiovascular disease risk factors. Understanding the contemporary prevalence of cardiovascular risk factors associated with CKD may help inform the development of new strategies for early detection and disease management, which could prevent premature deaths in men and women The contemporary management and cost-analysis of symptomatic aorto-iliac occlusive disease (AIOD) M. Ahmad, T. Nieto 1, T. Wilmink 1, A. Ganeshan 1, D. Adam 1, M. Claridge 1 1Heart of England NHS Foundation Trust, UK tabbyahmad@doctors.org.uk We have performed a single-centre, six-year retrospective analysis to determine the outcomes of intervention for symptomatic AIOD. Average treatment costs per patient were calculated. In the study-period, 284 patients [203 men; median age 65years (range 40-91)] with intermittent claudication (n=227) and critical limb ischaemia (n=115) underwent 344 procedures: 169 balloon angioplasty (PTA), 45 bare-stent, 22 stent-graft, 71 anatomical bypass and 37 extra-anatomical bypass procedures were performed. Median (range) follow-up was: 21 (0-60), 18 (0-74), 22 (0-82), 28 (0-75), and 29 (0-73) months, respectively. We found no significant difference in mortality (chi2=2.4725, P=0.48), numbers of amputations (chi2=0.035, P=0.998), or re-interventions (chi2=3.29, P=0.35) according to TASC lesion. We found no significant difference in mortality (chi2=5.75, P=0.22) and number of amputations (chi2=5.06, P=0.28) according to procedure. PTA and E-AB were associated with significantly more re-interventions (chi2=9.28, P=0.05). A cox model of re-intervention free survival adjusted for age, sex, TASC lesion and procedure (relative to TASC A and PTA) showed TASC C and D lesions had significantly higher re-intervention rates (P=0.053, P=0.044 respectively) whilst anatomical bypass procedures had significantly lower re-intervention rates (P=0.007). Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 5

Average costs per patient were calculated to include in-patient stay, cost of stents, out-patient follow-up and imaging. For PTA, bare-stent, stentgraft, anatomical bypass and extra-anatomical bypass the costs were: 3576, 4950, 5652, 7581 and 10898 respectively. We conclude that extra-anatomical bypass is associated with higher re-intervention rates and is expensive compared with endovascular treatment. In patients unsuitable for anatomical bypass, endovascular treatment with stent-grafting should be considered first. Corrosion resistance and surface evaluation of five self-expanding nitinol stents used in clinical practice J. Morrison, M. Pelletier 1, A. Rives 1, W. Walsh 1, J. Yang 2, R. Varcoe 1 1Surgical and Orthopaedic Research Laboratories, Prince of Wales Clinical School, 2Lowy Cancer Research Centre, Faculty of Medicine, University of New South Wales Sydney, Australia j.morrison@unswalumni.com The purpose of this study was to investigate the surface quality and corrosion resistance properties of 5 commercially available nitinol stents used to treat peripheral artery disease. Samples of 5 different designs of nitinol peripheral stents [LifeStent (n=4), Philon (n=6), Epic (n=6), S.M.A.R.T. Control (n=7), and Complete SE (n=7)] were examined using stereomicroscopy and environmental scanning electron microscopy. Corrosion resistance testing was performed in accordance with ASTM International s standard test method (F2129-08). Thirteen (43%) of 30 stents corroded during this experiment. Stent fracture was observed in 12 (92%) of these corroded stents. Mean breakdown potentials ranged from 517 to 835 mv (vs. Ag/ AgCl) for the Philon, Complete SE, S.M.A.R.T. Control, Epic, and LifeStent models from lowest to highest. A statistically significant difference in breakdown potential was observed between the LifeStent vs. Philon stents (835 vs. 517 mv, p=0.01) and Epic vs. Philon stents (833 vs. 517 mv, p=0.03). Stents with lower breakdown potentials and relative breakdown potentials were associated with a higher fracture frequency (Spearman correlation coefficient -0.44, p=0.015 and -0.869, p<0.01, respectively). Lateral stent surfaces were always less polished in comparison to the smoother luminal and abluminal surfaces. Occasional surface defects were seen in similar frequency between devices, including scratches running oblique to the strut axis, longer surface cracks running parallel, irregular surface deposits and inclusion bodies. Corrosion foci were observed to occur in an unpredictable location throughout stents. This in vitro study demonstrated that corrosion may independently cause nitinol stent fracture, that there is a significant association between lower mean breakdown/relative breakdown potentials and stent fracture, and that there is significant variability in the corrosion resistance of commercially available stents. 6 INTERNATIONAL ANGIOLOGY August 2014

FREE PAPER SESSION 2 A novel mouse model that reflects human atherosclerotic plaque instability is a unique tool for drug testing and mechanistic discoveries K. Peter, Y. Chen Baker Heart Research Institute, Melbourne, Australia karlheinz.peter@bakeridi.edu.au Introduction. The high morbidity/mortality of atherosclerosis is typically precipitated by plaque rupture. However, research on underlying mechanisms and therapeutic approaches is hampered by the lack of animal models that reproduce plaque instability observed in humans. Methods. Haemodynamic conditions that drive the development of unstable atherosclerotic plaques are low shear and high tensile stress. Based on computational fluid dynamics modelling, we developed an ApoE-/- mouse model that mimics these conditions via a surgically applied tandem stenosis. Results. At 7 weeks postoperatively, we observed intraplaque hemorrhage in ~50% of mice, as well as disruption of fibrous caps, intra-luminal thrombosis, neovascularization and further characteristics typically seen in human unstable atherosclerotic plaques. Administration of atorvastatin was associated with plaque stabilisation. Microarray profiling of mrna and microrna and in particular its combined analysis demonstrated major differences in the hierarchical clustering of genes and micrornas between non-atherosclerotic arteries, stable and unstable plaques and allows the identification of distinct genes/micrornas, potentially representing novel therapeutic targets. The feasibility of the described animal model as a discovery tool was established in a pilot approach, identifying ADAMTS4 and mir-322 as potential pathogenic factors of plaque instability in mice and the involvement in plaque instability was validated in human atherosclerotic plaques. Conclusion. The newly described mouse model reflects human atherosclerotic plaque instability/ rupture and represents a unique discovery tool that allows the identification of distinctly expressed genes and micrornas that are linked to plaque instability. It also holds promise towards the testing of therapeutic strategies aimed at preventing plaque rupture. Correlation between carotid plaque burden, carotid intima media thickness (cimt) with heart disease risk factors M. Farahmandfar 1, M. Chabok, M. Aslam 2 1Imperial College London, Life Line Screening, 2Imperial College London, UK mohsenchabok@hotmail.com Introduction. The clinical utility of risk factors to predict cardiovascular events is limited. Detection of subclinical atherosclerosis by noninvasive methods such as cimt, carotid plaque burden, and ABPI may improve risk prediction above that of established risk scoring models, namely, Framingham Risk Score (FRS). This study aims to investigate correlation between carotid artery plaque burden, and cardiovascular disease risk factors. Method. There were 120 asymptomatic participants recruited. Carotid Plaque Burden was studied and defined as the total number of plaques from B-Mode ultrasound imaging as well as Total Plaque Volume (TPV). In case of bilateral or multiple unilateral plaques, the sum of all number of plaques/tpv was considered as Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 7

the carotid plaque burden. The sample size was divided into 3 sub-groups, based on the number of plaques detected in the internal and common carotid arteries; group 1 (no plaques detected), group 2 (number of plaques less that 3), and group 3 (with more than 3 plaques detected). Results. Early results of the study were assessed and showed the mean age for group 1 to 3 was 63.6, 68.3, 72.3 y/o respectively and mean BMI was 25.5, 26.9, 26.2. The percentage of never smokers in was 24.2%, 23.5%, 50% in groups 1-3, while the percentages for statin therapy were at 21.2%, 33.8%, and 47.6% respectively. TPV in group 2 and 3 was.327 cm3, and 1.679 cm3. The mean CIMT for group 2 and 3 was calculated by.101 cm, and.103 cm. Conclusion. TPV was significantly higher in groups 2 and 3 indicating that TPV is a better predictor for heart disease, and may improve FRS significantly. This could increase the predictive value of CAD risk assessment to prevent apparently healthy but at risk population from developing significant CAD. Cox regression demonstrated significant associations between serum concentrations of the phosphatidylcholine plasmalogen PC(P-40:6) and total phosphatidylcholine plasmalogen (tpc(p)) with MI incidence (Benjamini-Hochberg q-values 3.39x10-2 and 2.85 x10-2 respectively). The association of serum tpc(p) with MI incidence was not solely driven by PC(P-40:6). Kaplan Meir analysis revealed that 2-year MI incidence was 7.4% and 1.9% for patients with serum tpc(p) concentrations below and above median respectively (log-rank p=0.003). Stepwise cox regression identified serum tpc(p) concentration <median as the strongest predictor of MI in the patients studied, compared to other potential risk factors (hazards ratio: 6.8 (95%CI 1.7-29.8), p=0.010). Findings of this study suggest that serum tpc(p) concentrations are negatively associated with future MI in PAD patients. Treatments to increase tpc(p) concentration may be beneficial in PAD patient management. A major limitation of this study was low MI incidence. Evaluation of a larger cohort is required to confirm the negative association of serum tpc(p) with MI risk. Serum phosphatidylcholine plasmalogen concentrations are strongly predictive of myocardial infarction risk in patients with peripheral artery disease J. Moxon, G. Wong 1, R. Jones 2, D. Liu 2, J. Weir 3, B. Kingwell 3, P. Meikle 3, J. Golledge 2 1Baker IDI Heart and Diabetes Resarch Institute 2James Cook University 3Baker IDI Heart and Diabetes Research Institute joseph.moxon@jcu.edu.au Peripheral artery disease (extra-coronary stenosis or aneurysm, PAD) affects ~25% of adults aged >40 years. Patient management focusses on the reduction of cardiovascular risk factors, although the risk of myocardial infarction (MI) is ~6-fold higher in PAD patients than an agematched healthy population. Effective markers and therapies to manage MI risk in PAD patients are required. 265 patients with PAD (lower limb athero-thrombosis 144; abdominal aortic aneurysm (AAA) 121) were followed for a median of 22.5 (inter-quartile range 9.4-43.0) months; 18 patients suffered an MI. 332 serum lipid species and 25 lipid classes were measured for all patients via tandem mass spectrometry. The association of lipid species and classes with MI incidence was assessed via Cox regression adjusting for age, gender, smoking, diabetes, hypertension, CHD, AAA and dyslipidemia. MI incidence was compared between patients with serum concentrations of MI-associated lipids above and below median. The association of calf skeletal muscle characteristics with major adverse events in peripheral artery disease D. Morris, J. Moxon 1, M. Cunningham 2, J. Golledge 1 1Queensland Research Centre for Peripheral Vascular Disease, James Cook University, Queensland, Australia 2Psychology Department, University of Stirling, Stirling, United Kingdom dylan.morris@my.jcu.edu.au Patients with lower extremity peripheral artery disease (PAD) have a three-fold increased risk of mortality and major cardiovascular events (myocardial infarction and stroke) compared to individuals without PAD. Lower extremity skeletal muscle is the end organ affected by PAD, and undergoes degenerative changes in response to chronic ischaemia, reduced physical activity and comorbidities. This study assessed whether lower extremity calf muscle density, volume and adiposity were associated with increased risk of major adverse events in patients with PAD. 102 PAD patients were recruited prospectively between 2006 and 2011. All patients underwent computed tomographic angiography (CTA) of their lower extremities on a Phillips 64-detector row scanner. Lower extremity calf skeletal muscle volume, skeletal muscle mean attenuation (density) and adiposity were measured using post-processing quantitative CTA analysis. Patients were monitored prospectively for major adverse events (MAE), including myocardial inf- 8 INTERNATIONAL ANGIOLOGY August 2014

arction, stroke and death. Kaplan-Meier and Cox proportional analysis were used to examine the association of lower extremity calf muscle characteristics with MAEs. There were 32 MAEs during a median follow-up of 3.2 years (interquartile range: 2.0-4.5 years). The incidence of MAEs at four years were 13.7%, 35.2% and 37.3% for patients in the highest, middle and lowest tertiles of calf muscle density respectively (p=0.044). Lower calf muscle density was associated with higher MAEs (lowest density tertile hazard ratio = 3.09, 95% confidence interval 1.16-8.05, p=0.024) after adjusting for age, sex, BMI, smoking history, hypertension, diabetes and ischaemic heart disease. Calf muscle volume and adiposity were not associated with adverse events. In conclusion, lower calf muscle density is independently and significantly associated with MAEs in PAD patients. Mechanisms underlying this association are unclear and need to be elucidated in further studies. Early onset aggressive atherosclerotic peripheral arterio-occlusive disease. search for the pathogenic factor A. Bashar, E. Hakim 1, G. Hossain 1, M. Hossain 1, N. Mandal 1, N. Dey 1, M. Arif 1, A. Mamun 1, S. Alam 1 1National Institute of Cardiovascular Diseases & Hospital, Dhaka, Bangladesh ahmbashar@yahoo.com Objectives. Atherosclerosis Obliterans (AO) is generally considered a disease of the elderly. AO in patients less than 50 years of age has a prevalence of less than 1% in general population. Peripheral Arterial Occlusive Disease (PAOD) in patients younger than 40 years of age with a history of smoking is more likely to be ThromboAngitis Obliterans (TAO) or Buerger s disease. Although sporadic reports of early atherosclerotic PAOD exist in the literature, little effort is seen to understand the etiopathological clue of this entity. The present study is an attempt to understand the etiology and histopathological characteristics of early atherosclerotic PAOD. Materials and Methods. Early atherosclerotic PAOD was defined as AO involving the abdominal aorta and lower limb arteries in patients younger than 35 years of age. Between January 2011 and December 2013, a total of 255 patients were surgically treated for atherosclerotic PAOD. Of them, 27 patients fitted in the demographic inclusion criteria for this study. Preoperative work-up included complete hemogram with markers of inflammation, markers of thrombophilia, lipid profile and serum homocystine level. Duplex vascular ultrasound including carotid intima-media thickness (IMT) and peripheral angiogram were also performed. Tissue was harvested from the affected arterial segment for histopathological analysis. Results. All of the 27 patients had single or multisegment focal rather than generalized atherosclerotic arterial occlusion or stenosis. Atheromatous plaques were more common at the point of vessel bifurcation. Plaques were immature and friable in most cases making endarterectomy technically difficult. CRP was positive in 85%, HDL low in 76% and LDL high in 43% of these patients. One or more markers of thrombophilic state were present in 19%. Histopathology revealed a thrombotic core in the atheromatous plaque in 33%, intimal fragmentation in 65%, increased collagen content in 70% and chronic inflammatory infiltrate in 85%. Increased carotid IMT was seen in 35% and raised serum homocystine level in 54% of the patients. Conclusions. Early onset aggressive atherosclerotic PAOD is an etiopathologically distinct disease entity. In Bangladesh, it seems to be more prevalent than in other parts of the world. Racial and environmental factors may be implicated in the causation and progression of this disease. The association of lower extremity performance with cardiovascular and all-cause mortality in patients with peripheral artery disease D. Morris, A. Rodriguez 1, J. Moxon 1, M. Cunningham 2, R. Jones 3, J. Golledge 1 1Queensland Research Centre for Peripheral Vascular Disease, James Cook University 2Psychology Department, University of Stirling, Stirling, United Kingdom 3Faculty of Medicine, Health and Molecular Sciences, James Cook University, Townsville Australia dylan.morris@my.jcu.edu.au Peripheral artery disease (PAD) is associated with impaired mobility and a high rate of mortality. The aim of this systematic review was to investigate whether reduced lower extremity performance and leg strength are associated with an increased incidence of cardiovascular and allcause mortality in people with PAD. A systematic search of the MEDLINE, EMBASE, SCOPUS, Web of Science and Cochrane Library databases was conducted. Cohort studies assessing the association between an objective or subjective measure of lower extremity performance with cardiovascular and/or all-cause mortality in PAD patients were included. A meta-analysis was conducted combining data from commonly assessed performance tests. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 9

128 studies were screened and ten were selected for inclusion. A variety of lower extremity performance tests were reported, including lower limb strength, treadmill walking performance, 6 minute walk, walking velocity, walking impairment questionnaire (WIQ) and calf muscle characteristics. A meta-analysis combining treadmill performance and 6 minute walk distance revealed that shorter maximum walking distance was associated with increased 5 year cardiovascular mortality (RR=2.64 95%CI 1.76-3.96, p<0.00001, n=1577) and all-cause mortality (RR=2.23 95%CI 1.85-2.69, p<0.00001, n=1710). 4 meter walking velocity, WIQ stair climbing score, calf muscle density and lower limb strength assessed by hip extension, knee flexion and plantar flexion were also associated with increased mortality. In conclusion, poorer walking endurance and slower walking velocity are strong prognostic markers for mortality in PAD and may provide a useful tool for identifying patients at higher risk of death. also inhibits FXa generation (Xa spectrozyme assay) while showing no effect on thrombin time. We have demonstrated for the first time that recombinant GRP78 (8 10 μg/ml) can inhibit platelet aggregation up to 80% (compared to buffer) in response to collagen (1 U/mL), TRAP (1 lm) and ADP (10 lm). Pre administration of GRP78 prolonged mouse tail bleeding time (buffer (3.1 ± 0.7), 1 μg/g (4.5 ± 0.9), 2 μg/g (8.9 ± 0.8) and 5 μg/g (11.2 ± 1.3)) respectively, P < 0.003, n = 6). GRP78 confers significant protection in a platelet dependent model of acute venous thrombosis, induced by collagen (1.2 μg/g) into the jugular vein of anaesthetised mice and monitored for morbidity (percent survival within 30 min post collagen challenge; buffer (15.4 ± 10.4) 4 μ/g (66.7 ± 16.7), 8 μg/g (85.7 ± 14.3), P < 0.003, n = 11). Thus, we have identified a novel mechanism where TM regulates coagulation (via LLD) through interaction with GRP78, concentrating its anticoagulant, antithrombotic and antiplatelet properties on the endothelium. The 78 kda glucose response protein (grp78) is recruited to the surface of endothelium by interacting with thrombomodulin and it demonstrates antithrombotic activity H. Nandurkar, A. Sharma 1, X. Zhang 2, C. Selan 1, A. Samudra 1, E. Salvaris 1, B. Michell 3, B. Kemp 3, P. Cowan 1 1St. Vincent s Hospital and University of Melbourne 23rd Hospital, Wuhan, China 3St. Vincent s Institue Melbourne, Australia hhnandurkar@gmail.com Thrombomodulin (TM) is a multi-domain glycoprotein expressed primarily on vascular endothelial cells. The anti inflammatory activities of the lectin like domain (LLD) of TM are independent of activated protein C. Using LLD as a bait, we have identified a specific interaction with the 78 kda glucose regulated protein (GRP78; MS/MS, Mowse score = 637). Further validation of LLD was shown to immunoprecipitate GRP78 from normal human plasma. TM was shown to colocalize with GRP78 on cell surface. GRP78, an ER chaperone, is found on the surface of endothelial and several tumour cells. It has been reported to inhibit tissue factor (TF) induced coagulation and platelet adhesion in patients treated with rosuvastatin. We generated recombinant GRP78, analysed its effect on haemostasis in vitro and in vivo. We show GRP78 prolongs TF dependent clotting (P < 0.0025) and not TF independent clotting. GRP78 The ankle cubital d-dimer ratio (acdr) is independent of age and confirms increased pro-thrombotic activity at the site of varicose veins C. Lattimer, E. Kalodiki 1, G. Geroulakos 1, J. Fareed 2, D. Hoppensteadt 2, D. Syed 2 1Josef Pflug Vascular Laboratory, Imperial College, London, UK 2Thrombosis & Hemostasis Research Laboratory, Loyola University, Maywood, USA c.lattimer09@imperial.ac.uk The aim of the study was to detect whether blood samples taken from the site of varicose veins may be more sensitive in detecting pro-thrombotic biomarkers than arm samples. Twenty-four patients, 17 male, age 45(25-91) awaiting varicose vein laser treatment were compared to 24 matched controls, 17 male, age 42(24-89). The CEAP classification of the patients was: C2=6, C3=4, C4a=1, C4b=6, C5=5, C6=2, with a median venous clinical severity score of 6(4-10) and a diameter of a refluxing saphenous vein of 8.2(6-12)mm. Five ml of venous blood was withdrawn from the cubital fossa, with a concurrent sample from the ankle. The samples were centrifuged at 3,500 rpm for 10 minutes and frozen at -20 C for batch analysis. D-dimer levels were measured using a commercially available ELISA method (Asserachrom DDi). The median (inter-quartile range) D-dimer (ng/ ml) was significantly greater in the ankle than the cubital blood of the same patient at 319(164-631) versus 281(167-562), p=0.003, Wilcoxon. This 10 INTERNATIONAL ANGIOLOGY August 2014

did not occur in the controls at 269(80-564) versus 262(106-526), p=0.361, Wilcoxon. Furthermore, the ACDR was significantly greater in the patients, p=0.018. Increasing age correlated significantly with increasing D-dimer levels, irrespective of whether the samples were withdrawn from the arm (r=0.536, p<0.0005) or the leg (r=0.649, p<0.0005), Spearman. However, there was no correlation with ACDR and age, r=0.252, p=0.085. The ACDR is unaffected by age or measuring as- say. It was sensitive enough to detect a significant increase in pro-thrombotic activity in the legs of patients with chronic venous insufficiency. Since D-dimer is a screening test for the detection of deep vein thrombosis (DVT) with 94% sensitivity and 50% specificity, a regional sample providing the ACDR might improve the specificity of D-dimer in DVT detection. Future studies in patients with suspected DVT are required to support this hypothesis. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 11

FREE PAPER SESSION 3 Incidence and risk factors of asymptomatic central vein or proximal vein stenosis in acute arteriovenous graft and fistula thrombosis in dialysis patients K. Lawanwong, W. Tirapanich 1, S. Jirasiritham 1, S. Leela-Udomlipi 1, P. Pootrakool 1, P. Lertsithichai 1, S. Horsirimanont 1 1Vascular and Transplantation unit, Ramathibodi hospital, Mahidol University, Bangkok, Thailand kwan_sunny@yahoo.com Background. Incidence and risk factor of proximal vein or central vein stenosis in Thailand has not been documented. Objective. To evaluate incidence and risk factors of asymptomatic central vein or proximal vein stenosis in acute vascular access thrombosis in dialysis patients in Ramathibodi Hospital. Methodology. Prospective cohort study between April 2013 to December 2013. Intraoperative venogram were performed in all patients who underwent AV graft or fistula revision to detected proximal vein or central vein stenosis. In this group additional treatment is balloon angioplasty. Demographics data, timing of access and dialysis, previous central catheter and rethrombosis rate after revision were analyzed. Results. From 62 Pts., 1 Pt. was excluded due to contrast allergy, 18 patients have central or proximal vein stenosis (30%); 11 (61%) patients have proximal vein stenosis and 7 (39%) patients have central vein stenosis. Those patients were treated by balloon angioplasty; for those patients treated technical success rate 83% (15/18). Follow up period for a median time was of 2.3 months (range 0.38 month to 11 months), rethrombosis rate 37.7% (23/61). Independent risk factors for rethrombosis consist of presence of central vein or proximal vein stenosis (hazard ratio 3.74), DM (hazard ratio 3.07) Conclusion. The incidence of asymptomatic central vein or proximal vein stenosis in acute arteriovenous graft and fistula is high. In this study, there is no significant risk factor for development of central vein or proximal vein stenosis. After revision, early rethrombosis is associated with DM and central vein or proximal vein stenosis. Carbon dioxide as the primary contrast media in endovascular therapy for preventing renal complications T. Sahu Karnataka, India tapish@doctor.com Purpose. Contrast-induced nephropathy /CIN)is a significant source of iatrogenic morbidity and mortality with the ever-increasing use of iodinated contrast media /ICM)during Endovascular Therapy /EVT)and is known to be related to ICM volume used. We sometimes experience CIN regardless of renal function and ICM volume;thus, it is advisable to reduce the ICM volume as low as possible for all EVTs. The carbon dioxide / CO2)is used as the alternative contrast medium and contributes to the reduction of ICM volume. Therefore, we evaluated the effects on renal function and reduction of ICM volume by using CO2 contrast in treating complex lesions. Material and Methods. From January 2013 to January 2014, EVT was performed in 50 consecutive patients with iliofemoral artery disease at our centre. We divided them into two groups of 25 patients each, group A /CO2 group)comprised of patients undergoing EVT with CO2 as the primary contrast agent with only small amount of ICM. Group B /ICM group) comprised of patients Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 13

undergoing EVT with only ICM as the contrast media. CO2 was injected by using Angioset device (Optimed Corp., GmbH). Lesions were classified according to TASC II document and the effects on renal function and ICM volume between the two groups were recorded. Results. The overall technical success rate was 100% in both groups without any major complications. CO2 contrast group had significantly less worsening of estimated glomerular filtration rates (egfr)pre and post procedure (ΔeGFR. ml/ min/1.73m2: -1.523±11.48 vs. -0.29±6.23, P= 0.035). In addition, we could significantly reduce the ICM volume by using CO2, especially for the treatment of TASC C&D lesions (ICM group: 99.55ml±50.69 vs CO2 group: 45.25ml±30.39, P=0.043). Conclusions. In conclusion, this study shows that ICM in EVT can be significantly reduced by using CO2 regardless of renal function, which will have result in minimal change in egfr, especially to treat complex lesions. We suggest that CO2 contrast can be used as the primary contrast agent in all EVTs. Comparision of vacuum-assisted closure and moist wound dressing in the treatment of diabetic foot ulcers H. Ravari, M. Saeed Modaghegh, G. Kazemzade, H. Ghoddusi Johari, A. Mohammadzadeh, A. Sangaki, M. Vahedian Shahrodi Vascular and Endovascular Surgery Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran hassanravari@yahoo.com Background. Vacuum-assisted closure (VAC) is a new method in wound care which speeds wound healing by causing vacuum, improving tissue perfusion and suctioning the exudates. This study aims to evaluate its efficacy in the treatment of diabetic foot ulcers. Materials and Methods. Thirteen patients with diabetic foot ulcers were enrolled in the moist dressing group, and 10 patients in the VAC group. The site, size and depth of the wound were inspected and recorded before and every three days during the study period. Patient satisfaction and formation of granulation tissue were also assessed. Results. Improvement of the wound in the form of reducing the diameter and depth and increasing proliferation of granulation tissue was significant in most of the patients of the VAC group after two weeks. Satisfaction of patients in the VAC group was evaluated as excellent as no amputation was done in this group. Wagner score was reduced in both the study groups, although this decrement was not significant in the moist dressing group. Conclusion. VAC appears to be as safe as and more efficacious than moist dressing for the treatment of diabetic foot ulcers. Full field laser perfusion imager (FLPI) and post occlusive reactive hyperaemia (PORH) for the assessment of skin microvascular endothelial function? F. Adams, J. Belch 1, F. Khan 1 1Vascular & Inflammatory Diseases Research Unit, Ninewells Hospital & Medical School, Dundee, Scotland f.z.adams@dundee.ac.uk The Full Field Laser Perfusion Imager (FLPI) is a new, non-invasive device which can measure dynamic changes in blood flow over large areas of the skin microcirculation, with excellent dayto-day reproducibility. Endothelial dysfunction is the earliest detectable functional indicator of cardiovascular disease (CVD), contributing to the development of atherosclerosis. Assessment of endothelial function provides a powerful method to identify patients at risk of developing CVD before the appearance of clinical symptoms. FLPI in combination with PORH has the potential to become an important tool for the assessment of skin microvascular function and dysfunction. The aims of this study were to assess FLPI in combination with post occlusive reactive hyperaemia (PORH) (following 5 minutes of arterial occlusion) as a method of measuring microvascular endothelial function and to compare this test with peripheral arterial tonometry (PAT) using the EndoPAT device, the only FDA validated assessment. FLPI was used to measure changes in forearm skin blood flow following PORH in two groups of healthy volunteers (G1 n=15: 18-30 years; G2 n=15: 40-70 years) and compared with EndoPAT. No significant differences were noted between G1 and G2 for the PORH response measured by FLPI (G1 228.9±74.1% vs. G2 230.2±86.6%) however a significant negative correlation was found between PORH response and age in G2 (r=-0.599; p<0.05). Significant differences were observed between G1 and G2 by EndoPAT (G1 2.68±0.6units vs. G2 2.28±0.6units, p<0.05). In addition, the PORH test did detect significant differences between males and females (M 202.1±63.5% vs. F 256.9±85.8%, p<0.05) undetected by EndoPAT. PORH coupled with FLPI has the potential to become a useful biomarker of skin microvascular endothelial function. FLPI was able to detect changes in endothelial function between males 14 INTERNATIONAL ANGIOLOGY August 2014

French cross-cultural translation and adaptation of the ausviquol. australian disease-specific quality of life questionnaire (QoL) for peripheral arterial disease (PAD) S. Zerrouk, J. Renaudin 1, C. Rotonda 2, E. Chou 3, P. Julia 1 1HEGP-Cardiovascular surgery dept-university Paris, France 2CHU Nancy, Clinical Epidemiology and Evaluation Department, INSERM CIC-EC CIE6, France 3English Department, Lorraine-Metz University, France saminouar@hotmail.com Peripheral arterial disease (PAD) is a common pathology, with a prevalence of 12 to 14 % in the adult population. The handicap caused by intermittent claudication, which is significantly linked to this pathology, degrades patients quality of life (QoL). The AUSVIQUOL Australian Vascular Quality of Life Index is a specific self-questionnaire developed to evaluate the QoL of subjects affected by peripheral vascular disease. Objective. To obtain a transcultural translation and adaptation of the AUSVIQUOL in French. Methodology. We used a method validated by international publications. The questionnaire was translated into French separately by one clinician and two translators, back-translated by expert translators and harmonized by a multi-disciplinary team. The harmonized versions were evaluated through a cognitive debriefing process by discussing any discrepancies. This resulted in a preliminary version that maintained the intent of the original questions. The pre-final version was tested in a sample of 21 patients with vascular claudication. Results. The 10 questions with 3 dimensions were conserved at the end of the translation. 3 terms in question 7 concerning the neurological symptoms were considered difficult to understand and were modified in the final French version. The time it took to fill out the questionnaire was an average of 3,08 minutes. The field-test inand females and within an older healthy population. Further work is needed to evaluate this method in patients with varying levels of disease. Investigating the effect of changing air pressure on microvenous function J. Marx, A. Granot 1, I. Carlisle 2, O. Hirth 1 1Australasian College of Phlebology 2Royal Australian College of Surgeons Melbourne, Victoria, Australia drjmarx@bigpond.net.au Aim. To measure the effect of changing Air Pressure on Microvenous function. Method. Measurements of Microvenous function were made using photoplethysmography (PPG) on both commercial airline passengers, and on visitors to high altitude resorts. Results. Airliner passengers experience four distinct phases of Microvenous function: 1. Ascent-Induced Vessel Expansion: From sea level (760 mmhg) a Tissue depressurization of 200 mmhg in 20 minutes caused the PPGs to demonstrate a rapidly deteriorating Microvenous function. 2. Cruising Phase: This is the period of peripheral Fluid shift causing flyer s ankle oedema. With a Hypobaric Cabin environment of only 560 mmhg, PPGs showed that all individuals had been plunged into a state of total Microvenous failure (VRT < 10 sec). Partial Pressure Adaptation occurs during this period of slow vessel constriction. 3. Descent-Induced Vessel Constriction: A Tissue Repressurization of 200 mmhg in 20 minutes, caused the PPGs to demonstrate a rapidly improving Microvenous function. 4. Jet Lag Phase: With a Normobaric sea-level environment of 760 mmhg, PPGs showed superior Microvenous pumping power, occurring along with the reversal of the Fluid shift. In contrast visitors to high altitude resorts experience only two phases: - 1. Ascent-Induced Vessel Expansion: Driving up the mountain is essentially the same process as experienced above by airline passengers during ascent. 2. Prolonged stay up at high altitude: PPGs showed that when initially arriving up at the alpine resort, individuals were in a state of total Microvenous failure. However after a prolonged stay of 3 to 4 days, a slow constriction of the vessels eventually resulted in Complete Pressure Adaptation, a new state of Pressure Equilibrium, and hence normal Microvenous function. Discussion. Ascent-Induced Tissue Depressurization must now be considered as a seriously demanding physical challenge. The original concepts of Torricelli and Pascal on the subject of Air Pressure must be factored into future high altitude research. For far too long high altitude exercise physiology has been dominated by just hypoxia and low haematocrit. The Total Barometric Pressure has been largely ignored. Credited with inventing the Barometer, Torricelli also had a very advanced insight into our human environment, and the Power of Air Pressure. In 1643 Torricelli wrote: We live submerged at the bottom of an ocean of elementary air. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 15

terview participants had answered all the questions and found them to be relevant and comprehensible. Conclusion. The AUSVIQUOL is rapid and easy to complete in both its original version and the French version. In addition, we believe that the questionnaire can benefit from its use as an assessment of French patients with PAD as well as in clinical research and in medical practice. We hope that this first transcultural translation and adaptation will lead to a study that further validates the French-AUSVIQUOL. 16 INTERNATIONAL ANGIOLOGY August 2014

FREE PAPER SESSION 4 Comparison of trauma patients with or without runoff in angiographic findings H. Ravari, M. Pezeshki Rad 1, A. Bahadori 1, O. Ajami 1 1Vascular and Endovascular surgery research center, Emamreza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Iran hassanravari@yahoo.com Introduction. Arterial trauma is one of serious traumatic injury and its prognosis was related to prompt diagnosis and treatment. Also investing about angiographic findings of arterial injury and their influence on treatment strategy and prognosis is necessary. Patients & Method. Mechanism of trauma, type of injury and angiographic findings were recorded in questionnaire for each patient when they referred to angiography department and after completion of treatment and discharge, treatment type was added. Results. In this study, 148 traumatic patients including 15 female with the mean age of 32(11-82 years) were evaluated. Abnormal angiographic findings were seen in 99(66.9%) patient including: cutoff with distal runoff (n=60, 60.6% of abnormalities), cut off without distal runoff (n=21, 21.2%) and spasm (n=14, 14.1%) and other findings (n=4, 4%). 51 cases were treated with open surgery and in 13 patients finally amputation of traumatic limb was done. Amputation rate was higher in traumatized patients with cutoff without runoff (33.33%) than cutoff with runoff (6.78%). Conclusion. causes and types of traumatic arterial injury in our results were different with studies in other countries. Compared with final result from angiography (normal and abnormal) and arterial name, Angiographic findings are less important in prognosis and selection of patient management. Patients with spasm in angiography had better prognosis than other abnormal patients and almost always did not need vascular surgery. The presence or absence of distal run off in primary angiography has predictive value in final amputation rate. Adjunctive techniques to facilitate endovascular repair of aortic dissection of the arch and its branches. hybrid repairs and chimneys S. Chang, F. Kun Department of Vascular Surgery, Second Xiangya Hospital, Central South University, Changsha 410011, China. changshu01@yahoo.com Objective. To report our early experiences of endovascular stent-graft repair combined with adjunctive techniques in treating acute aortic arch dissections. Procedure and Method: From Jul 2002 to Feb 2013, 926 patients of type B aortic dissection were treated with endovascular stent-graft repair. All patients medical records and imaging materials were collected and analyzed retrospectively. 255 patients had insufficient ideal proximal landing zone for endovascular aortic repair alone whose tear site located <1.5cm distal to LSA (143 men, 51.3±11.4 year, range 20~86). 65 single chimney stents were inserted into LSA or LCCA, 3 double chimney stents of LCCA and innominate arteries, 23 extra-anatomic bypass performed prior to or followed intervention, 1 entire aortic arch bypass procedure without CBP performed before TEVAR, 14 PDA excluders were deployed to prevent retrograde flow from LSA after intervention, 1 branched stent-graft and fenestration stent-graft were deployed, retrospectively. Results. Technical success rate was 99.3%, 30- Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 17

day mortality was 1.9%(5/255) due to myocardial infarction, cerebral infarction, respiration failure, the overall endoleak rate was 5.8% (secondary TEVAR was performed for all typei patients, 13 stopped, 2 continued). The mean duration of follow-up was 25.4 months (1~ 118 months). 3 patients suffered from LSA steal syndrome (surgery for 1, 2 recovered spontaneously). Expanded true lumen and reduced of the false lumen happened in 215 patients, with 212 cases revealed thrombosis filling in false lumen. Conclusions. Several supplemental techniques with endovascular aortic repair for aortic arch dissection are available, chimney and supra-aortic bypass should be selected due to different anatomic configurations, Chimney technique is a safe and less invasive method according mid-term results. Laser-doppler flowmetry. a practical, predictive tool of free flap behaviour in breast reconstruction surgery? J. Butterworth, M. Aslam 1, A. Fitton 2 1Imperial College London, UK 2Derriford Hospital, Plymouth jamesfomsf@googlemail.com Flap failure is the most clinically devastating consequence of reconstructive breast surgery with an incidence of 0.6% in Deep Inferior Epigastric Perforator (DIEP) flaps. Early detection of vascular compromise is crucial to enable surgical revision and at present no consensus best monitoring method exists. In this prospective study we assess efficacy of Laser-Doppler Flowmetry (LDF) in prediction of flap behaviour in DIEP and Transverse Rectus Abdominis Myocutaneous (TRAM) flaps for breast reconstruction and the effect of sympathomimetic medication on flap perfusion. 5 women (average age 47.6 years, age range 22-59) received free flaps including two TRAM flaps, one left DIEP and two bilateral DIEP flaps. 3 out of 5 free flaps (60%) received metaraminol, a potent sympathomimetic, for intraoperative hypotension and 2 (66%) of these had complications including ischaemic necrosis of zone 3 of one TRAM flap and haematoma formation in one bilateral DIEP flap. The two patients receiving no metaraminol had consistently high LDF values making a good recovery without complications. LDF identified vascular compromise in both patients with complications before it was detected clinically: in one right TRAM flap low LDF values of 9.8 Units (U) in peripheral zone 3 were detected day 3 postoperatively whereas clinical vascular compromise was only detected on day 5. In one bilateral DIEP flap low LDF values of 8.2 U were detected in the right breast day 1 postoperatively compared to clinical detection on day 2. Following surgical intervention both compromised flaps survived and LDF values returned to high levels (17.1 U and 44.2 U respectively). LDF is a useful predictive tool in monitoring microcirculation in free flap breast reconstruction allowing prompt surgical intervention. Caution is advised in use of sympathomimetics in free flaps pending larger observational studies to further assess their impact on flap behaviour and long term outcome. A new method of preoperative marking for reconstructive surgery using a sural-medial perforating flap. a duplex ultrasound study S. Zerrouk, E. Simon 1, M. Brix 1, S. Malikov 2 1CHU Nancy-Plastic and maxillofacial surgery Dept 2CHU Nancy-Vascular Surgery Dept saminouar@hotmail.com Our knowledge of cutaneous vascularization has considerably developed in the past three decades, thanks to advances in plastic and vascular surgery. In an anatomical study of dissection, we put forward a description of perforating pedicles on the medial side of the leg. Other anatomical studies concerning the size and density of perforating vessels confirm the variability of the vascular plexus. In addition, it would be pertinent to develop techniques for surgical procedure planning that integrate this dimension of anatomical variability. Objective. to introduce a preoperative ultrasoundguided marking method for perforating vessels that is likely to be used in a transfer of the suralmedial fasciocutaneous perforating flap. Method. It consisted of an ultrasound analysis of sural-medial perforating vessels on 38 subjects with an average age of 55.89 (minimum 34-maximum 74 years old). Results. The 42 perforating veins (PV) detected were consistently accompanied by an arterial structure. The preoperative marking consisted of identifying a dominant sural-medial PV through an ultrasound mode B, followed by marking with an indelible felt pen. Then, the satellite perforating artery (PA), consistently present, was detected by a color and pulsed Doppler and marked. Lastly, the neighboring perforating were marqued in the same manner so as to circumscribe the marked anatomical cutaneous area Conclusion. According to the angiosome concept, a single perforating vessel can vascularize the area in a radial manner until the next perforator, depending on its size and its location. The increasing ease in tracking the subcutaneous arterialvenous network and especially inter-perforating anastomosis (IPA), is thanks to the advent of high frequency Ultrasound -Doppler probes which we 18 INTERNATIONAL ANGIOLOGY August 2014

predict will better evaluate the viability of the perforating flap. We believe that the vascular physician is in a position to bring a precise and useful preoperative marking to reconstructive surgery by this method. mote adenosine generation and signalling may have beneficial effects in IRI with implications for therapeutic application in clinical renal transplantation. Cd39 is antithrombotic and protects from ischaemia reperfusion injury by adenosine generation. H. Nandurkar, S. Crikis 1, B. Lu 1, L. Murray-Segal 1, C. Selan 1, S. Robson 2, P. Cowan 1, K. Dwyer 1 1Immunology Research Centre and St. Vincent s Hospital, Melbourne, Australia 2Beth Israel Deaconess Medical Centre Boston hhnandurkar@gmail.com Extracellular nucleotides play an important role in thrombosis and inflammation, triggering a range of effects such as platelet activation and recruitment, endothelial cell activation, and vasoconstriction. CD39, the major vascular nucleoside triphosphate diphosphohydrolase (NTPDase), converts ATP and ADP to AMP, which in turn is hydrolysed by endothelial enzyme CD73 to adenosine. We have demonstrated that CD39 transgenic mice are antithrombotic and generate increased amount of adenosine. Moreover, CD39 over expression protects donor hearts from thrombosis in a mouse cardiac transplant model of vascular rejection. We tested whether CD39 expression improves organ survival in the context of ischaemia reperfusion injury (IRI). Renal model of warm IRI was established by performing unilateral nephrectomy and cessation of blood supply to the remaining kidney for 20 min by the placement of an aneurysm clip. The overexpression of CD39 conferred protection with reduced histological injury, less apoptosis and preserved serum creatinine and urea levels. Adoptive transfer experiments showed that expression of CD39 on either the vasculature or circulating cells mitigated IRI. Benefit was abrogated by pretreatment with an adenosine A2A receptor antagonist. Furthermore, CD39 transgenic kidneys transplanted into syngeneic recipients after prolonged cold storage performed significantly better and exhibited less histological injury than wildtype control grafts. We then designed a novel therapeutic rsolcd39- PSGL containing recombinant CD39 fused to a peptide derived from the adhesion molecule P- selectin glycoprotein-1 with the aim of delivering CD39 activity specifically to activated platelets and endothelium that expresses P-selectin, the cognate receptor for PSGL-1. Initial studies reveal protection from renal IRI at doses that do not cause systemic anticoagulation. Thus, targeted strategies to enhance the antithrombotic activity of the endothelium and pro- Dermo epidermal autologous implant device (iddea) produced by tissue engineering R. Vellettaz, M. Lavigne, D. Dominici, L. Correa Buenos Aires, Argentina drrubenvellettaz@hotmail.com In chronic wounds, the cellular and molecular mechanisms of healing are altered, therefore is necessary to develop new therapeutic options to improve results. Objectives. Primary, to generate a IDDEA, to demonstrate its effectiveness in acute surgical skin lesions in an animal model. Secondary: to identify macroscopy, microscopy, integration, vascularisation, assessment of the quality of the repair tissue, determination of specific molecules in skin, potency, oncologic mutations, GMP. Method. Acute surgical lesion of deep skin, biopsy pigskin and human, development of autologous and heterologous DDE, implant in pig, skin biopsy at 14 and 21 days post-implant, hematoxylin/eosin and Masson trichrome PAS stains, immunohistochemistry, GMP microbiological analysis and control cell bank for culture, discarded pollutants, purity analysis method LAL pyrogen control, determination of oncogenes. Results. DDE appearance of normal skin without attachments; histological organization - complete epidermis with rudimentary keratinisation; adequate integration and vascularisation; dermis - vimentin+; epithelium- involucrin and panqueratinas+; antibodies pankeratin positive - AE1, AE3+; extracellular matrix - Masson trichrome+; basement membrane - PAS+; cells in growth phase with high viability; PPP - optimal skeleton for cell cultures; co-cultivation of cells: increased rate of extracellular factors; TGF beta, Ki67, EGF, interleuquina1 alpha, absence of immune rejection CD1A - ; wound repair after 14 days, the controls do not heal after 21 day; quality repair tissue better the longer post-implant; absence of mutations in codons 12, 13 of N-ras; GMP sterility testing and negative purity Conclusions. We present a reproducible method to develop IDDEA structural and ultra-structural features are compatible with skin graft, effective in the treatment of surgical wounds induced in pigs. Implementing the DDE heterologous (human) in pig: no evidence of rejection generated. We started a pilot study in humans to test the usefulness of IDDEA in venous ulcers resistant to treatment Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 19

Use of eco-guided laser approach in the treatment of venous leg ulcers. N. R. Ramírez, N. Lecuona Huet 1 1Hospital Angeles Mexico, Mexico City, Mexico neftali_rodriguez@yahoo.com Venous hypertension from failure of proper venous valve function in the veins of the lower extremities causes changes over time in the microcirculation of the skin of the distal extremity. These changes set the stage for the development of a chronic nonhealing ulceration. Elimination of the venous hypertension should be the goal therapy using endovenous surgical techniques like the laser to close incompetent perforator or other superficial veins that are frequently found in or near the ulcer bed. Our goal with this approach is shorten ulcer healing time and reduce recurrence rates. From January 2010 to March 2014 we treated at 42 patients with CEAP 6 we divide the patients in two groups in the first group just treated the truncal reflux in the great, small saphenous and perforators veins after give to the ulcer the estándar care with local treatment and compression therapy. The second group was treated with the ablation of the truncal reflux and the ablation of the perforator and the small veins in close proximity or under the ulceration with percutáneos laser approach eco-guided. We used a 1470 nm of long wave laser and bare laser fiber tip, after give to the ulcer same management that the first group. Ulcers healed in 87% of limbs treated 45% were healed in 30 days 42% in 55 days. In conclusión no good study has yet been published using the laser and ultrasound-guided with a percutaneous approach in the treatment of venous ulcers. The use of this technique stimulates more quickly the repid venous ulcer healing and decreases the recurrence. Pushing the limits and optimizing the outcomes of closure fast radio frequency (r-f) ablation and complimentary procedure for gsvssv incompetence N. Ibrahim, G. Bicanic 1, K. Huang 1, A. Zea 1, J. Diaz 1 1Advanced Laser Vein Clinic and Sydney Centre for Venous Disease Sydney, New South Wales, Australia dri@zip.com.au To assess the feasibility, safety, efficacy and patient tolerance to treat symptomatic bilateral multiple saphenous trunk incompetence with ra- diofrequency ablation and complimentary procedures concurrently under local anaesthesia in a single ambulatory setting. Part of ongoing prospective study between April 2008 and December 2013. 143 consecutive symptomatic patients with bilateral venous incompetence. From this group, 3 patients opted out to Conventional stripping under GA. 140 patients underwent ablation, pinhole phlebectomy and sclerotherapy under general anesthesia or in an ambulatory setting under local anesthesia. Patients. 140; Total limbs: 284; Total truncal ablations: 331; F/U at 1-2 weeks, 4-6 weeks to exclude DVT, assess completion of closure and need for secondary procedures, 3 months to reassess completion of truncal closure. Completed treatment in 1 session: 98.6%; Deferred second leg treatment: 1.4%; DVT: 0%; Patients with 3 trunks: 32 (22 F, 10 M); Patients with 4 trunks: 8 (5 F, 3 M); Patients with 3 and 4 trunks: 40 (27 F, 13 M); Truncal closure: 100% at one and three months. Procedure time: 90 minutes Patients requiring: secondary phlebectomy: 1%; secondary sclerotherapy: 26% of females, 11% of males); tertiary sclerotherapy: 5.6% of females. Complications. Vaso-vagal episodes: 3; Thermal skin damage: 1; Slipped micro guide wire requiring retrieval: 1; Partial disintegration of R-F element (no ill effect): 1; Neurological: 1 patient. Delayed foot drop 1 hour after conclusion of procedure lasting 6 hours. RF ablation and complementary procedures are feasible, safe, well tolerated by patient, functionally effective, time efficient and appropriate to carry out concurrently for bilateral lower limb venous insufficiency with dual and multiple trunk disease. Simultaneous duplex using two probes as a novel method for assessing superficial venous insufficiency C. Lattimer 1, E. Mendoza 2 1Imperial College London, UK 2Venenpraxis Speckenstr. 10, 31515 Wunstorf, Germany c.lattimer09@imperial.ac.uk Previous duplex studies on patients with superficial venous insufficiency have demonstrated that reflux occurs at many sites with different durations. Furthermore, venous filling from reflux should stop from the ground up. The aim was to test Trendelenburg s hypothesis of recirculation by measuring reflux duration simultaneously, above and below the knee. The 17 patients characteristics were: 17 legs /12 20 INTERNATIONAL ANGIOLOGY August 2014

female, 9 left), median age 51(28-71) years, weight 76.8(63.5-189)Kg, height 169(153-180)cm, clinical CEAP (C2:6, C3:4, C4a:5, C4b:2), median VCSS 5(1-12) and shunt classification (I:3, III:7, IV:2, V:5). Reflux duration was recorded at point A (10 cm below the groin crease) and point B (a refluxive tributary/saphenous vein below the knee) from 2 monitors simultaneously using one video camera following an elevation-dependency manoeuvre. This was performed 3 times in each leg and the duplex probes were swapped to negate any differences in machine sensitivity. The median vein diameters at points A and B were 6.1(2.8-9.3)mm and 5.5(2.5-8.1)mm, respectively, with a median inter-probe distance of 41(23-59) cm. There was no significant difference in reflux duration between point A with 27(9-150)s and point B with 27(10-149)s, p=0.943, Wilcoxon. The correlation was excellent: r=0.986, p<0.0005, Spearman. Interestingly, reflux fluctuations appeared simultaneous at points A and B during patient talking. When both transducers were repositioned at knee level, antegrade popliteal vein flow commenced immediately after saphenous reflux stopped. This study introduces a novel way of assessing venous haemodynamics using two duplex probes at the same time. Simultaneous reflux cessation above and below the knee was demonstrated which is in agreement with the hypothesis of a private circulation. The results support conservative treatment strategies which target the recirculation circuit. Further studies using this technique are required to assess flow within superficial, deep and perforating veins after different provocation tests. 10 years experiences with endovenous laser ablation of varicose veins S. Julinek 1, I. Maly 2, D. Klein 1 1The Department of One-Day Surgery, Palas Athena, Prague, Czech Republic 2The Out-patient Department of General and Vascular Surgery, Prague, Czech Republic, simon.julinek@seznam.cz Introduction. The authors of the retrospective study present 10 years outcomes with endovenous laser ablation of the varicose veins. Material and method. Endolaser surgery of varices has been performed since 2004, firstly with the instrument of 980nm wavelength; and exclusively with 1470 nm wavelength laser beam since 2008. All procedures were performed only in One day surgery mode. At the beginning we used general anaesthesia and later we preferred combination tumescent anaesthesia and analgaesia. The big tributary veins we often performed phlebectomy or the endovenous laser during the procedure on the main vein. In our patients the procedure is always performed under the protection of LMWH, in accordance with other authors. Results. 694 patients, who passed the total of 846 ELVeS procedures in the period from 2004 till 2013, were assessed in this study. 96 of the procedures were bilateral; the great saphenous vein was treated in 85.9 % cases, and the small saphenous vein in 14.0 % patients. The reflow in the great saphenous vein occurred in 5.88%, and in the small saphenous vein in 8.82 %. Conclusion. The successful endo-laser ablation of insufficient main veins of lower limbs and all their affected branches is a very significant progress. However, it must be performed radically and with the attempt to treat the disease the most complexly even during the primary treatment. Incidence of deep venous reflux in primary varicose veins P. Pootracool, S. Jirasiritham 1, S. Leela-Udomlipi 1, W. Tirapanich 1, S. Horsirimanon 1 1Vascular and Transplantation Division, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand rappeg@gmail.com Objective. To determine the incidence of femoral venous (FV) reflux and popliteal venous reflux (PV) in greater saphenous vein (GSV) and short saphenous vein (SSV). Methods. The patients were evaluated from January 2011 to December 2012. In total 149 limbs, Duplex ultrasound was identified greater saphenous vein (GSV) and, short saphenous vein (SSV) incompetence, sapheno femoral junction (SFJ), sapheno popliteal junction (SPJ), and deep venous incompetence. The correlationship between superficial venous system and deep venous system were analysed by chi-quare test. Result. A total 121 patients, 149 limbs were evaluated, median age 57.06 years (range 22-81), 28.93 % was male, 71.08 % was female, (male. female ratio 1:2.45), 8.3 % had popliteal vein and femoral vein incompetence, 59.5 % had GSV and SFJ incompetence, 44.6 % had primary varicose vein both legs. In the patients with SFJ incompetence had femoral vein incompetence 70.4 % (p < 0.01), GSV incompetence had popliteal vein incompetence 87 % (p < 0.01) We also noted that if presence of reflux in SSV, the SPJ reflux was 76.9 % (p < 0.01) Conclusion. The incidence of deep venous reflux Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 21

in primary varicose veins were relatively high. If the primary varicose vein involving the main trunk of GSV, SSV, SFJ or SPJ should evaluated the reflux of deep venous system (FV or PV). Early experience with fenestrated and chimney endografts for short neck aortic aneurysms repair in Ramathibodi Hospital. A. Suesawatee, P. Pootracool, S. Horsirimanont, W. Tirapanich, S. Leela-Udomlipi, S. Jirasiritham Vascular Surgery and Transplantation Division, Department of Surgery, Ramathibodi Hospital, Faculty of Medicine, Mahidol University, Bangkok, Thailand arkomsur@gmail.com Objective. To present our early experience for the use of fenestrated and chimney endograft techniques in the endovascular management for short neck of descending thoracic aortic aneurysm (DTAA) and abdominal aortic aneurysm (AAA) in Ramathibodi hospital. Methods. Retrospective reviewed fenestrated and chimney endograft techniques for short neck DTAA and AAA performed from January 2012 to January 2014. The aneurysms included; DTAA neck < 2 cm to the left subclavian artery and AAA neck < 1.5 cm to the lowest renal artery. The advanced endovascular techniques included; chimney technique for thoracic endovascular an- eurysm repair (chtevar), chimney technique for endovascular abdominal aneurysm repair (chevar), and fenestrated-endovascular aneurysm repair (FEVAR). Results. In total 19 patients (16 men and 3 women), median age 77 years. DTAA 3 cases and juxtarenal AAA 16 cases, median aneurysm diameter 60 mm and mean neck length 2.16 mm. The procedure included; chtevar 3 cases, chevar 11 cases, and FEVAR 5 cases. Technical success for exclude aneurysm from circulation 89.4%. Technical success for target vessels preservation 97.6%. No procedure conversion to open repair. Endoleak type Ia were found in 2 cases (1 case spontaneous thrombosis at 1 month after operation). Perioperative complications within 30 days included; NSTEMI 1 case, ARF 4 cases, pseudoaneurysm at right brachial artery 1 case. Median hospital stay 8 days and median ICU stay 2 days. In mean follow-up period (7.07 months) found that aneurysm sac completely thrombosis 94.7%. Death 1 case was completely thrombosed in and develop new type 1a endoleak 1 case, all target vessels were patent. Conclusions. Advanced endovascular aneurysm repair in short neck or inadequate proximal landing zone in high-risk patients by using technique of fenestrated endograft, chimney technique can reduced perioperative morbidity, mortality and favorable outcome. 22 INTERNATIONAL ANGIOLOGY August 2014

FREE PAPER SESSION 5 Estimation of diagnostic informativity of multispiral computed tomography angiography in patients with peripheral arterial disease by findings of the intraoperative revision. N. Abushov, S. Manafov 1, N. Hasayeva 1, E. Zakirjayev 1 1Scientific Centre of Surgery named after M.A. Topchubashov, Baku, Azerbaijan abushov1950@mail.ru Purpose. Multispiral computed tomography angiography (MSCTA) method opens new possibilities in diagnosis and surgical tactics at patients with peripheral arterial disease (PAD). The aim: estimation of diagnostic informativity of MSCTA in patients with lower limbs PAD using findings of the intraoperative revision and verification of diagnosis as a reference method. Methods. MSCTA of lower limbs was applied in 150 patients with PAD using 64-slice spiral CT and intravenous bolus injection of nonionic iodinated contrast agent (Ultravist 350: 100-120 ml, rate of 2-2.5 ml/sec) with automatic injector in the cubital vein. Subsequent image processing (including the creation of 2D, 3D, 4D with their visualization and analysis, 3D shaded surface displays (SSD), which represent the 3D surface reconstruction of vascular structures), maximum intensity projection (MIP) and multiplanar reconstruction (MPR) images were made on a graphic station. For estimation of informativity of diagnostic methods in patients with PAD comparative analysis was conducted between MSCTA and contrast angiography (160 patients). The intraoperative revision and verification of diagnosis was used in 60 of cases. Results. Analysis showed, that there were significant deficiencies of roentgen contrast angiography: impossibility of multifactorial evalua- tion of vascular wall condition (atherosclerotic plaques located at rear wall), decrease of informativity in oblique direction of the vessel, multiple deviation of vessels, severe atherosclerotic deformation, movement artifacts which lead to reduced quality of iliac arteries visualization, overlapping of the proximal segment of profunda femoris artery in the frontal plane. Diagnostic value of MSCTA in severe stenosis and occlusion was 98%, which verificated by intraoperative revision. Conclusion. The obtained findings suggest a high informative value of MSCT, hence making it possible to recommend it for use as an alternative means of the alternative method to the routinely used roentgen-contrast angiography in patients with lower limb PAD for choose an adequate surgical treatment tactics Carotid artery stenting via the right brachial access for left carotid stenosis in the bovine arch G. Lianrui, G. Yongquan, T. Zhu, L. Xuefeng, G. Jianming, Z. Jian, W. Zhonggao Department of Vascular surgery, Xuanwu Hospital, Capital Medical University, Institute of Vascular Surgery of Capital Medical University, Beijing, China lianruiguo@sina.com A 63 year-old female patient suffered from stroke and subsequent frequent transient ischemic attack /TIA) was treated with CAS in October, 2013 in our department. Preoperative CTA and Duplex revealed a tight stenosis of the left carotid artery in the bovine arch, but the high location of carotid lesion was not suitable for carotid endarterectomy. Using the right brachial artery as access, we performed CAS with a 6Fr long sheath advancing into the the left Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 23

Retrospective analysis of 200 cases of superficial femoral artery disease D. Dekiwadia, H. Dekiwadia, S. Saji Dekiwadia Institute of Vascular Sciences, Rajkot, India dekiwadia@rediffmail.com Aim. Approach to SFA disease, isolated and with multiple ilio or tibio-peroneal trunk occlusions. Method. Retrospective analysis of 200 cases from June 2008 to Feb. 2014 involving Superficial Femoral Artery (SFA) disease. Of 200 cases with chronic lower limb ischemia (CLI) the age range was from 30 years to 90 years, with 184 males and 16 females, duration of symptoms was from 1 month to 8 years. Diagnosed with CT angiogram or conventional angiogram. The analysis: out of all cases basically five types of procedures were done. 1) Endovascular procedure 152 cases 2) Combines surgery with endovascular procedure 38 cases 3) Thrombolysis 16 cases. 4) Thrombectomy 16 cases. 5) Primary SFA bypass surgery 58 cases. Technique. For endovascular procedures antegrade, crossover trans-brachial and retrograde trans-popliteal approaches were used. The surgical cases underwent venous or PTFE graft bypasses. 40 cases needed minor amputations and 4 cases required major amputations. Results. In all cases revascularization could be done successfully. Improved vascularity is seen in pulse palpability, limb warmth, with improved ABI. The level of amputation could be converted from a major to a minor one in 40 cases. All claudicants had a response assessed by the shift of ABI which increased by 30% to 40% and the complete relief or improved claudication distance on conventional walk test. Conclusion. SFA is the longest artery of the body and suffers maximum damage from any vasculopathy. Effective treatment to provide distal circulation is the goal. All forms of availcommon carotid artery. A Spider Embolic protection device was positioned within the left internal carotid artery distal to the stenosis, then the lesion was routinely dilated, and followed by satisfactory deployment of a self-expending Protege stent. CAS succeeded without any complications. The patient recovered well and TIA totally disappeared. Duplex showed a patent left carotid artery stent at one month follow-up. CAS via the right brachial artery for left carotid stenosis in the bovine arch appears feasible and safe. Interaction of cardio-renal and bone marrow-renal mechanisms and the micro-circulation (capillary) theory of hypertension. J. Myers Wellspring s Universal Environment, Canberra, Australia rebdoc1@bigpond.net.au Aim. To focus on the role of capillaries and migratory cells in ECF volume regulation and large vessel responsiveness. Methods and Results. In studies in normotensive subjects, aged 3-72y, (Myers, Morgan 1983) it was found that haematocrit rose (n=43) in the presence of weight gain and diastolic blood pressure (DBP) rose on increasing sodium intake (from 1 to 3 mmol/kg/24h), for two weeks, or heamatocrit fell or did not change (n=74). Plasma sodium concentration did not change in those in whom DBP rose but increased in those in whom DBP did not change. Creatinine clearance was indirectly related to DBP change, Discussion. Myers (1987) proposed the Microcirculation (capillary) theory of hypertension is based on these findings of transvascular fluid shift and perhaps intra-vascular fluid shift occurred. Rise in plasma sodium observed in sodium resistant (SR) subjects did not occur in sodium sensitive (SS) subjects. Migratory cells or adsorption onto extracellular matrix proteins could have accounted for this. The hypertension dynamic results from altered fluid distribution which would reduce venous capacitance and increase in right atrial filling pressure (RAFP). Pre-venular arteriolar capillary units, PVCAU s) act as a negative feedback to ΔRAFP, to control capillary flow, systemically to reduce the altered fluid distribution (and pulmonary), and in the kidney, by increasing efferent arteriolar tone and thus glomerular filtration fraction (GFF). RAFP effector mechanisms provides the cardio-renal neurohumoral-modulated link for ECF control. Renal-bone marrow interaction is provided by Erythropoietin which decreases when GFR falls, as this would maximise plasma flow for filtration. Migratory cells may also be involved in buffering sodium and in maintaining arteriolar responsiveness as well as osmotic control. Conclusion. RAFP-pre-venular arteriolar feedback, systemic and renal, regulates ECF. Circulating cells and migratory cells as well as matrix proteins in ECF control and vascular sensitivity to vasoactive substances may also be involved. 24 INTERNATIONAL ANGIOLOGY August 2014

able modalities should be attempted to achieve this. This was successfully done in 198 cases out of 200. Will the angiosome concept be supported by measurements of microperfusion after tibial angioplasty or bypass surgery? W. Lang Department of Vascular Surgery, University Hospital Erlangen, Germany werner.lang@uk-erlangen.de There is an ongoing discussion about any superior effects of a direct revascularization of specific angiosomes at the foot. An angiosomeguided revascularization, e.g. by angioplasty might be more effective than a more general one, however, there are a lot of different collaterals in the ischemic or diabetic foot. In this study lightguide spectrophotometry is used to assess microvascular function before and after invasive treatment. There were 11 endovascular and 18 vascular procedures of the lower extremity. All examinations were done at the elevated limb by the micro-lightguide spectrophotometer O2C (Oxygen to See; LEA Medizintechnik, Giessen, Germany) with skin probes at the typical angiosomes. Relative blood flow (LDF) and oxygen saturation (SO2) measurements were performed before and after the procedure. Units of measurement were percent for SO2 and arbitrary units (AU) for blood flow and velocity. Groups were devided into optimal targets (OT) and non-optimal targets (NOT) depended on the relation of the angiosome to a direct or indirect revascularization of the area. There was a significant postprocedural increase of SO2 (pre/post: 28.02% vs. 39.46%; CI -14.569;- 8.302; SD ± 22.585; P.001) as well as for relative blood flow (14.93 AU vs. 30.47 AU; CI -19.932;- 11.148; SD ± 31.656; P.001). The positive effects of revascularization were seen in both groups, however, there was no significant difference. For the OT-group: SO2 pre/post 20.36% vs. 33.04% and relative blood flow 8.56 AU vs. 23.56 AU for the NOT-group: SO2 29.04% vs. 39.96% and relative blood flow 15.41 AU vs. 33.22 AU. No significant differences were also seen in the non-treated extremity. Perfusion measurements by a micro-lightguide spectrophotometer before and after revascularization demonstrate a significant overall improvement of the microcirculation of the treated foot. However, they fail to demonstrate a significant benefit for only those angiosomes which gain a direct exclusive revascularization. Silverhawk plaque excision vs. angioplasty for symptomatic infrapopliteal arterial occlusive disease. J. Guo, Y. Gu, L. Guo, S. Cui, Z. Tong, X. Wu, X. Gao Beijing, China guojianming1020@icloud.com Purposes. To evaluate periprocedural and shortterm outcomes of endovascular treatment of symptomatic infrapopliteal arterial occlusive disease (IPAD) using Silverhawk plaque excision and angioplasty. Methods. Retrospective analysis of consecutive patients undergoing endovascular treatment for IPAD between 2011 and 2013 in a teaching hospital. Patients information included demographic data, perioperative complications, limb salvage and freedom form reintervention. Results. nine vessels were treated by plaque excision and foury-five vessels were treated by angioplasty. Totally technical success was 92% (plaque excision group 100% versus angioplasty group 86%, p=ns). The arterial-relative complication rate was 9% (plaque excision group 11% versus angioplasty group 6%, p=ns). One perforation occurred in the plaque excision group and Two dissection and One acute thromboembolic events occurred in the angioplasty group. Limb salvage and freedom from reintervention at six months were similar between the groups (plaque excision group 100% and 89% respectively; angioplasty group 95% and 89% respectively). Conclusions. Both plaque excision and angioplasty were safe and acceptable method to treat symptomatic IPAD. Prevention of groin wound infection after vascular surgery in patients with peripheral arterial disease T. Beck 1, M. Engelhardt 1, C. Mueller 1, C. Willy 2, 1Department of Vascular Surgery, Military Hospital Ulm, Germany 2Department of Orthopedic Surgery, Military Hospital Berlin t.n.beck@web.de Introduction. Groin wound infections after vascular surgery for peripheral arterial disease (PAD) pose a major problem as they have a high incidence of 10% to 30%. The Prevena Incision Management System (KCI Medical, San Antonio, Texas, USA) is a negative pressure device designed for the management of incisions at risk of such postoperative complications. Aim of this randomized controlled study was to investigate if Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 25

the Prevena system could reduce the incidence of groin wound infection after vascular surgery in patients with PAD. Methods. Data on 60 consecutive patients with PAD, scheduled for vascular surgery with a longitudinal femoral cutdown, were collected prospectively. All patients were randomized either to the VAC group or the Non-VAC group. In the VAC group the Prevena system was applied intraoperatively and removed after 5 days. The Non- VAC group received an absorbent dressing. Groin wounds were evaluated after 5, 14, 28, and 42 days, and infections were graded according the Szilagyi classification. Results. There were no significant differences between both groups considering risk factors and co-morbidities. Five patients were lost to follow up. Indications for surgery were Fontaine stage IV (13; 24%), stage III (9; 16%), and stage II (33; 60%). After 5 days, in the VAC group (n=26) none of the incisions had an infection. In the Non-VAC group (n=29) five (17%) had Szilagyi grade I infections (P=.036). After 42 days, in the VAC group 2 (8%) wounds had infections, classified as Szilagyi I (1; 4%) and II (1; 4%), and in the Non-VAC group five (17%) incisions had infections, classified as Szilagyi I (3; 10%), and II (2; 7%) (P=.173). Stratified for risk factors (diabetes, obesity, age) there was no significant difference in overall incidence of groin wound infection in either group. Conclusions. These first results of a randomized controlled trial indicate that the Prevena System reduces the incidence of groin wound infection after vascular surgery in patients with PAD. Nitinol multiple stents in TASC D superficial femoral artery lesions. analysis with ankle brachial index and duplex scan L. Castro, A. Freitas, D. Freitas Rio de Janeiro, Brazil decastrodoc@hotmail.com Objective. It s the purpose of this study to analyse the above-knee femoro-popliteal arterial revascularization through peripheral transluminal angioplasty with multiple stents for patients with femoral popliteal atherosclerotic disease and critical limb ischaemia. Methods. Retrospectively analysis of 25 patients selected by the revascularization technique used- Angioplasty with multiple stents. Medical record, angiographic and non-invasive studies involving Ankle-Brachial Index, Rutherford s Clinical Classification for chronic arterial disease and Hyperplasia analysis by Duplex scan were reviewed in detail. Primary endpoints were amputation free survival and death. Results. The overall amputation free survival rates in this group of patients did not differ between the 6 and 12 month analysis. The final endpoint analysis among the entire cohort did not differ significantly (P-value = 0,05). Before and After procedure analysis of the Ankle-Brachial Index was associated with a statistical significant heighten (P-value <0,01). Patency analysis during 3, 6, and 12 month follow-up period did not differ statistically (P-value >0.05). Hyperplasia analysis during 3, 6, and 12 month follow-up period was not associated with statistical difference (P-value > 0.05). Conclusions. In the intermediate term, treatment of above knee femoro-popliteal artery disease by primary angioplasty with multiple stents yielded results equal to those currently reported in the world literature. The Ankle Brachial Index was associated with positive improvement of clinical status in the group analysed. Inhibiting the superficial femoral artery sympathetic nervous to treat thromboangiitis obliterans T. Jingdong, G. Shujie, Z. Ci, L. Ke, Q. Shuixian Department of Vascular Surgery, The First people s Hospital, Shanghai drtangjingdong@126.com Objective. To assess the inhibiting the superficial femoral artery sympathetic nervous to treat the Buerger diseases. Methods. The records of 10 cases of Buerger. All of the cases treatment was the inhibiting the superficial femol artery sympathetic nervous by Radiofrequency ablation. Results. 10 cases lower extremity arterial lumen balloon and radiofrequency ablation were successful. Three patients showed significant improvement of clinical symptoms, Fontaine stage IIb, III, III stage, ABI increased from preoperative to postoperative 1.0~0.8 from 0.3~0.2, CTA Show original occlusive vascular patency. After surgery (12 months) follow-up period, three patients had no clinical symptoms of relapse. Conclusions. It was safe that all of the cases treatment was the inhibiting the superficial femoral artery sympathetic nervous by Radiofrequency ablation. The checking results of the cases were ABI, CTA and DSA. It was not only preventing the human body from the complication of Lumbar sympathectomy, and also recovering Buerger s arteries. However, it was a few cases and follow up time, we should have a lot work to do. 26 INTERNATIONAL ANGIOLOGY August 2014

Cardiovascular disease prevention in patients with peripheral arterial disease - results of a 5-year observational study A. Blinc, M. Kozak 1, M. Sabovic 1, M. Bozic Mijovski 1, M. Stegnar 1, P. Poredos 1, A. Kravos 2, B. Barbic Zagar 3, M. Pohar Perme 4, J. Stare 4 1Department of Vascular Diseases, University of Ljubljana Medical Centre, Slovenia 2Department of Family Medicine, University of Maribor Faculty of Medicine, Slovenia 3Krka, d. d., Novo mesto, Slovenia 4Institute of Biostatistics and Medical Informatics, University of Ljubljana Faculty of Medicine, Slovenia ales.blinc@kclj.si Patients with peripheral arterial disease (PAD) are more endangered by myocardial infarction and stroke than by limb gangrene. Do patients with PAD benefit from treatment by the European guidelines on cardiovascular disease prevention? We tested whether PAD remains an adverse prognostic indicator in spite treatment by the recommended antiplatelet, antihypertensive and lipolytic medication and healthy lifestyle advice. 743 patients with PAD, defined by reduced ankle brachial pressure index, and 713 control subjects, aged 65 (SD 9) years at inclusion, were subjected treatment by the European guidelines on cardiovascular disease prevention and evaluated yearly for occurrence of death, non-fatal acute coronary syndrome, stroke or critical limb ischemia (major events) and revascularization procedures (minor events). Classical risk factors were significantly more prevalent in the PAD group and protective cardiovascular medication was prescribed more frequently to patients with PAD than to control subjects. In the PAD group, the 5-year Kaplan- Meier survival estimate was 84.7% (CI 82.1 87.3%) vs. 93.3% (CI 91.5 95.2%) in the control group, p<0.001. In the PAD group the proportion of cardio-vascular causes of death did not differ significantly from non-cardio-vascular causes (6.9 vs. 8.4%), while in the control group cardiovascular causes of death were the minor proportion (2.4 vs. 4.3 %, p < 0.01). The groups differed in 5-year major event-free survival: 76.7% (CI 73.7 79.8%) in PAD vs. 89.9% (CI 87.7 92.2%) in controls, p<0.001, as well as in event-free survival: 56.2% (CI 52.7 59.9%) in PAD vs.82.4% (CI 79.9-85.3%) in controls, p<0.001. In conclusion, patients with PAD had a higher risk of all-cause death, major and minor nonfatal cardiovascular events compared to control subjects. However, cardiovascular events were no longer the leading cause of death in patients with PAD and treatment according to guidelines resulted in encouragingly low absolute mortality and morbidity. (ClinicalTrials.gov number NCT00761969.) Low flow vascular malformations J. Soracco Phlebolymphology, Military Hospital, Buenos Aires, Argentina. jesoracco@gmail.com It is the objective of this presentation to propose another application for the laser in endoluminal contact mode, as a therapeutic alternative for the treatment of the slow flow vascular malformations (VM). Laser devices operating at wavelengths of 810, 980 and 1470 nm were used, with optical fibers having radial or frontal emission tip and a diameter of 400 and 600 μ. The lesion was accessed percutaneously or transdermal. In ambulatory surgery unit, under sedation or local anesthesia, ultrasound mapping is performed, in which the best place to access is located. This is performed under visual control on the monitor, introducing the 18 or 16g needle into the cavity and inserting the optical fiber through it which advances to the interior of the malformation. Laser energy is delivered in contact mode and continuosly, withdrawing the optical fiber and monitoring under visual display the photodermocoagulation effect achieved. Each laser wavelength is absorbed by the tissues by a specific cromophore, in our case we used those that are absorbed by hemoglobin and water, which act as light targets. The results were excellent in the superficial lesions with transdermal in one session, the pain, tumor and cosmetic disorders were reduced. In the endoluminally treated it varied, depending on the size and location of the disease. Due to the high recurrence rate, it was necessary to re-treat some cases after one year; being the second sessions simpler because of the smaller size of the lesions. This technique is valid as an alternative therapeutic as a sole treatment or combined with pre or post surgery and sclerotherapy. Open vascular injuries repaired with primary prosthetic graft interposition. Padre Hurtado Hospital s initial 3 year experience. G. Cassorla 1, C. Hevia 1, C. Vallejos 2, J. Torres 2, H. Rojas 1 1Universidad del Desarrollo / Hospital Padre Hurtado / Clínica Alemana de Santiago 2Universidad del Desarrollo / Hospital Padre Hurtado gcassorlamd@gmail.com Padre Hurtado Hospital serves the poorest, most marginalised and violent suburbs of Santiago, Chile. A significant number of emergency room Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 27

consult and emergent surgeries are due to gunshot wound (GSW) and stab wounds (SW). Because of this, our hospital reports high incidence of vascular trauma which is managed in the majority of cases by general surgeons. In this setting, we report a series of patients that were managed with primary prosthetic graft interposition, as reported in recent publications regarding wartime vascular trauma, which presents the advantages of shorter operative time and the preservation of venous capital. We report a series of 18 patients (17 men and 1 woman) with an average age of 31 years old. Fifteen of these where GSW and 3 corresponded to SW. The location of the vascular trauma was 14 lower extremities, 1 abdominal, 2 cervical and 1 upper extremity injury. Of these patients, 9 had also venous trauma and 3 had simultaneous bone fractures. All patients where managed with primary prosthetic graft interposition; one was first managed with a temporary vascular shunt due to extreme haemodynamic instability. Technical success in our reported series was 100%. Primary patency during the fist year was 81 %, primary assisted patency was 94% and secondary patency was 100% for the same period of time. The longest follow up was nearly 3 years with a mean of 113 days. The mortality in our series was 11% (3 deaths, 2 in the same admission and the other due to another cranial GSW later), all with patent grafts and death cause which was not related directly to the vascular injury. During the study 2 patients developed soft tissue infection not related to the prosthetic graft. Our series had 100% limb salvage. Vascular trauma requires opportune intervention to secure irrigation and reduce the rate of complication. We present the results obtained by primary prosthetic graft interposition in vascular trauma. 28 INTERNATIONAL ANGIOLOGY August 2014

FREE PAPER SESSION 6 A suggestive activity score for thromboangiitis obliterans B. Fazeli, H. Ravari Mashhad University of Medical Sciences, Khorasan, Iran bahar.fazeli@gmail.com Introduction. The aim of this study was to find a disease-specific activity score for Thromboangiitis Obliterans (TAO). Methods. About 173 admission records from 125 patients with TAO over the period 2005-2011 were evaluated. Clinical signs recorded in these documents were categorized as cutaneous, vascular or neural. The outcome of the patients was also categorized as saved-limb or limb-loss. The risk of limb loss associated with each sign or symptom was then assessed. This risk assessment value was multiplied by 100 to reach to the percentage of the risk and this value was then considered the risk score. Complete blood count (CBC) data from the patients in limb-loss and saved-limb groups were compared; risk scores associated with CBC results were then calculated. The receiver operating characteristic (ROC) curve was used for demonstrating cut-offs for each score. The reliability of the questionnaire was evaluated using split-half reliability test. The predictive validity of the questionnaire was tested using Pearson correlation between the total score of the patients with and without limb loss. Results. The predictive validity (p=0.4) and reliability (SBel=0.68) of the questionnaire were confirmed. The maximum possible clinical and CBC scores were 221 and 180, respectively, giving a maximum total score of 401. The cut-offs for clinical, laboratory and total score was 115, 75, 213, respectively. Conclusion. Further cohort studies for evaluating the TAO activity score in patients with limb loss are suggested, along with ways to evaluate the efficacy of different treatments based on these score. Ultrasonic wound irrigation experience with chronic wounds over a 24 month period. C. Frank Gold Coast Health District, Queensland, Australia cherylafrank@gmail.com Ultrasonic Wound Irrigation (UWI) experience with chronic wounds over a 24 month period. Chronic wounds are defined as wounds, which have failed to proceed through an orderly and timely reparative process to produce anatomic and functional integrity over a period of 3 months. The appearance of chronic wounds despite different eitiologies of a raised, hyperproliferative base, excoriation of the periwound, yellow fibrinous film, pain and oedema. This inflammatory response may also predispose these lesions to malignant changes. The Gold Coast Vasculab Chronic Wound Clinic utilizes an organized conceptual approach to wound healing utilising international consensus guidelines and following the principles of the internationally recognized TIME acronym. The Clinic managed 140 patients on a weekly basis over a two year period. This population consisted of 92 male patients with an average age of 69 years, and 48 female patients with an average age of 74 years. The average number of treatments per patient were 7 per male and 6 per female. This paper will report the complex nature of the 140 patients with a chronic wound/wounds managed in the clinic. It will discuss the eitiology, duration of wound, population demographics (smoking, diabetes, PVD, CVI, orthopaedic issues, immunosuppression, vasculitis) It will also disclose healing outcomes, number of visits, surgical interventions and outcome variance. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 29

More than one in two instances of venous thromboembolism treated in French hospitals could have occurred during the hospital stay F. Allaert, E. Benzenine, C. Quantin Department of Medical Information, CHU Dijon, France allaert@cenbiotech.com Objective. To describe the prevalence of venous thromboembolism (VTE), pulmonary embolism (PE) and deep vein thrombosis (DVT) without PE among all hospitalized patients and the percentages of those occurring during the hospital stays. Methods. Statistics are issued from the national PMSI MCO databases which are encoded using the CIM10. The codes used for VTE are I801 to I809 for DVT and codes I260, I269 for PE. Any stay with the ICD-10 codes selected regardless of the Principal Diagnosis of Medical Unit Summaries and whatever its position (Principal, Related or Associated Diagnosis) was considered as a hospital-occurred thrombosis unless it was the Principal Diagnosis of the first Medical Unit Summary of the stay. To eliminate outpatient consultations or in day care, stays of < 48 hours were excluded. The term of hospitaloccurred is preferred to hospital-acquired VTE suggesting a nosocomial origin which can be the case or not. Results. The results bear on the 18683603 hospital stays in 2010-2011. Out of 100 hospital stays involving VTE, for 40.3% VTE was the cause of hospitalization whereas 59.7% can be considered to have occurred during hospital-stay. These distributions are of 25.6% and 74.4% for DVT respectively 53.8% and 46.2% for PE. The age of patients varies little with whether VTE, DVT, and PE were hospital-occurred or not and are similar in men and women. The percentage of mortalities of these VTE is high and reaches 6.58% and the mortality from VTE, DVT, and PE is multiplied by a factor of 3 to 4 (p<.0001) when hospital-occurred. Conclusion. The high proportion of hospital-occurred VTE is an alarming situation that should question the quality of prevention and/or its effectiveness. VTE prevention policies must be strengthened in hospitals for the sake of patients and healthcare savings alike. Catheter directed thrombolysis in deep vein thrombosis, technique and results over last decade. D. Dekiwadia Dekiwadia Institute of Vascular Sciences, Rajkot, India dekiwadia@rediffmail.com Deep Vein Thrombosis (DVT) is recognized clinically by painful edema of the leg, tender calf, thigh and iliac fossa and tense superficial veins. Vascular ultrasonography clinches the diagnosis. Untreated DVT may result in pulmonary embolism (PE), pulmonary hypertension or post thrombotic syndrome. Immobility, surgery, tumor, pregnancy certain medicines, protein abnormality and air travel are the assessed risk factors. Commonly practiced treatment is heparin therapy. Surgery is uncommon. In Catheter Directed Thrombolysis a tissue plasminogen activator (Urokinase, r-tpa or streptokinase) is directly delivered into the thrombus and most effective clot lyses is achieved. A retrospective analysis of 243 CASES OF DVT, treated with urokinase was done. This included 150 males and 93 females between the age of 18 years to 80 years with duration of symptoms from 1 week to 4 months. USG guided puncture of popliteal or posterior tibial vein (PTV) was done with surgical exposure of PTV in selected cases to place the sheath. Multihole catheter was fixed in the thrombus and thrombolysis done with urokinase with 250000 units/hr. Check fluoroscopy was done at 12 hourly intervals and catheter repositioned. Adjuvant heparin was given. Procedure was terminated at complete resolution or a maximum of 1 million unit infusion. Post procedure oral anticoagulant was given with INR set at 2.5. Results. Complete resolution 206 cases, partial resolution 33 cases, rethrombosis 2 cases, no result 2 cases. Follow up at 8 years: Post Thrombotic Syndrome five, Secondary Varicose Veins 2. Conclusion. TPA delivered intrathrombus gives optimum results in DVT, preserves valves and prevents post thrombotic syndrome. Adenosine generation protects in a murine model of antiphospholipid antibody-induced miscarriages H. Nandurkar, A. Samudra 1, X. Zhang 2, C. Selan 1, K. Dwyer 1, P. Cowan 1 1St. Vincent s Hospital and University of Melbourne, Melbourne, Australia 23rd Hospital, Wuhan, China hhnandurkar@gmail.com Autoantibodies (apl-ab) generated in Antiphospholipid Syndrome (APS) cause arterial and venous thrombosis, and miscarriages. Antiphospholipid antibodies stimulate cytokine release leading to tissue factor (TF) expression, inflammation and complement activation, all of which have been implicated in the pathogenesis of APSrelated foetal loss. ATP and ADP are extracellular purines and important signaling molecules that activate inflammation and thrombosis, respectively. ATP and ADP are hydrolysed by the cell sur- 30 INTERNATIONAL ANGIOLOGY August 2014

face enzyme CD39 (NTPDase) to AMP and AMP in turn is subsequently hydrolysed to adenosine by the action of another enzyme, CD73. In contrast to the effect of ATP and ADP, adenosine signals via A2 receptors to inhibit inflammation and suppress TF expression on endothelial cells and monocytes. We have established an apl-ab-induced model of miscarriages by administration of apl-ab (purified from patients with APS) to pregnant mice. We applied this model to mice with modifications of several of the purinergic pathway enzymes: A) CD39-Transgenic (CD39-TG on a BALB/c strain) mice with increased hydrolysis of ATP and ADP to AMP and adenosine: demonstrate reduction in apl-ab-induced miscarriages. B) CD39-null (CD39-/-, on a C57Bl/6 strain, which is more resistant to miscarriages than BALB/c) mice with decreased hydrolysis of ATP and ADP: demonstrate higher frequency of miscarriages. C) CD73-/- (C57BL/6 strain) mice cannot hydrolyse AMP further to adenosine: demonstrate higher frequency of miscarriages. We further demonstrated that TF mrna expression is more (>2-fold, p<0.05) in cohorts with increased miscarriages. Also, complement activation and TNF expression is reduced in the placentae of CD39-TG mice that have fewer miscarriages. Conclusions. Hydrolysis of ATP and ADP and adenosine generation is protective in APS miscarriages. Endovascular treatment of juxtarenal aortic dissections with iliac occlusions using bare metal stents, without proximal stent graft. A. Chatterjee Department of Vascular Surgery, Fortis Hospital, Kolkata, West Bengal, India dvsur13@outlook.com Aim. Spontaneous juxtarenal aortic dissection is an extremely rare event. And associated ischemic legs are even rarer. Open surgery results are not encouraging with high incidence of renal complications and immediate or delayed failure of revascularisation of ischemic legs. Endovascular repair with covered stent grafts are also fraught with renal complications. Hence, we reviewed our limited experience to assess the outcomes of endovascular repair of juxtarenal aortic dissections with iliac occlusions causing ischemic legs using bare metal stents without proximal stent grafts. Methods. Between 2008 and 2013, we managed 11 (4 male and 7 female) patients with spontaneous juxtarenal aortic dissections extending into iliac arteries causing significantly ischemic legs due to iliac occlusions and extreme low flow states, treated in our institute. All underwent endovascular repairs using bare metal aortic stents with overlapping bi iliac kissing stents to cover the entire length of the dissection flaps. No proximal covered stent grafts were used. Mean duration of follow up was 3 years 8 months +/- 1 year complete for all survivors. Results. Total 11 patients were identified (4 male and 7 female). Minimum age 37 years, maximum age 63 yrs, mean age 50 years. All patients underwent endovascular repair of aortic dissection and revascularisation of iliac arteries using bare metal aortic stents with overlapping bi-iliac kissing bare metal stents to cover entire length of dissection flaps, without any proximal stent graft. 8 of them had their symptoms relieved within 4 hours of endovascular repair of aortic dissection with revascularisation. 2 patients were kept intubated overnight but had no complaints after extubation. 1 patient suffered a sudden drop in haemoglobin within 6 hours of the procedure by 4 gm/dl, but with no other symptoms. Immediate CT angiography revealed patent stents with no bleeding whatsoever. Patient was stabilised with blood transfusions. She had an uneventful recovery thereafter. Mean ITU stay was 48 hrs and mean hospital stay was 3 days. All patients are leading a normal life to date with normal mobilisation. No abdominal or low back pains and claudication cited to date. Conclusion. Endovascular treatment of juxtarenal aortic dissections using bare metal aortic stents without proximal covered stent graft covering entire length of dissection flap, may be a viable alternative avoiding chances of renal ischemia. These are early results. Further long term follow up is necessary. However, considering the rarity of this condition, it is probably worth considering Inferior vena cava filter retrieval, experience of a South American center V. Bianchi, P. Vargas 1, F. Allamand 2, G. Cassorla 2, B. Horwitz 1 1Department of Radiology, Clinica Alemana de Santiago 2Unit of Vascular Surgery, Clinica Alemana de Santiago, Universidad del Desarrollo Santiago, Chile vbianchi@alemana.cl Inferior Vena Cava filters (IVCF) have had an explosive increment in their use since the 1990s. Although the only widely accepted uses are patients with contraindication to a therapeutic anticoagulation and a proximal DVT, prophylactic indications such as in trauma patients have also arisen. Unfortunately, the long-term use of IVC Filters does carry a slight risk of complications. Nevertheless, only 25% of the IVC Filters are ever Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 31

removed. Here we present our experience on recovering IVC filters and discuss indications and techniques. All clinical data was reviewed since our first patient to have an IVCF removed in our center in 2006 to January 2014. Demographic data, indication for the IVCF use, type of filter, time elapsed with filter and other relevant indicators were registered. Cases in which information was incomplete or debatable were discussed by both Vascular Surgery and Interventional Radiology teams. From 2006 to 2014, 58 IVCF were removed at our institution. 32 male (55.1%), 26 female (44.8%), with and median age of 37 years. Most of them were also installed in our institution. The median procedure duration time was 42 minutes and the median time elapsed with the IVC Filter was 218 days (ranging from less than one day to 1023 days). The original indications for the filter to be installed were 4 (6.89%) DVT with a high risk for bleeding, 13 (22.41%) proximal DVT, 19 (32.75%) DVT with formal contraindication to anticoagulation, and 23 (39.65%) trauma patients. IVCF installation will continue to increase. Although rates of complications for a longstanding IVCF remain low, as long as institutions don t make an effort on recovering filters, more patients will face long-term problems. Reports on IVCF recovery are still scarce and larger investigations are needed to define indications for retrieval. Gold Coast Vasculab chronic wound clinic model. C. Frank Gold Coast Vasculab, Queensland, Australia cherylafrank@gmail.com The management of the chronic wound has often been an overlooked source of medical expenses affecting both the hospital and community health budgets. The cost of wound care management is a burden not only to health facilities but also to some of the least able in the community, as costs are often met by the patients themselves. Studies conducted in several sites have shown a point prevalence of leg ulcers to be 1 2% in developed countries, however a point prevalence study conducted in Perth indicated that wounds in the over 80 year population increased to 9%. Despite improvements in the science of tissue repair and modern moist wound pharmaceuticals, patients still languish for months and years with non-healing wounds due to inferior wound management. The impact of chronic wounds is more evident in communities such as the Gold Coast with a large retiree population. This paper will discuss the 1. Gold Coast Vasculab Chronic Wound Clinic model that promotes a private/public sector collaboration promoting optimal wound assessment, prompt investigation and diagnosis of chronic wounds, effective wound bed preparation utilizing ultrasonic debridement, interdisciplinary communication and experience based management protocols. 2. The costs incurred to both the patient and the clinic in the transition between inflammatory wounds to proliferating wounds discharged back to the care of the referring G.P. Social media and the phlebologist s practice. 3 strategies for connecting with patients S. Peek Incredible Marketing, California, USA sam@incrediblemarketing.com Today, healthcare professionals know they need a strong social media presence to generate trust as reputable sources of information and medical care to an ever-growing, digitally savvy patient base. However, with nearly one-quarter of a million active users on Twitter and 1 billion active users on Facebook in 2013, connecting with patients requires specialized skills of engagement to walk the fine line between social media success and falling prey to common pitfalls. The purpose of this presentation is to demonstrate how phlebologists can effectively connect with patients, build a specialized community, and promote their medical expertise and reputation using the two most popular social media platforms, Facebook and Twitter, using a content mix that includes articles, surveys, video, blogs, images and patient reviews. A case study will be presented that documents the impact of social media on the phlebologist s practice and shows how using social media has become a necessary component for healthcare professionals to build and maintain a trusted reputation. Vnus closure fast radiofrequency ablation. clinical experience of the treatment in patients with lower limb varicose disease. N. Abushov, E. Zakirjayev 1, M. Karimov 2, F. Abbasov 1, Z. Aliyev 1, G. Abushova 1 1Scientific MA Topchubashov Centre of Surgery 2Azerbaijan Medical University Baku, Azerbaijan Purpose. Endovenous radiofrequency thermal ablation (ERFA) of the great saphenous vein (GSV) is a new method, which has been described as a less invasive and cost-saving alternative to 32 INTERNATIONAL ANGIOLOGY August 2014

Three parts of the mechanism endovenous laser ablation A. Tsyplyashchuk, K. Mazayshvili, Y. Stoyko 1, T. Khlevtova 1, S. Akimov 1, M. Yashkin 1 1Pirogov National Medical and Surgical Center vascul@yandex.ru The aim of our research was to specify the mechanisms of action of laser radiation in the process of endovenous laser ablation (EVLA). For our in vitro experiments we used glass capillary tubes with the inner diameter 1 mm and the length 20 mm. In experiments ex vivo of endovenous laser ablation, segments GSV after phlebectomy were placed in shrink tube, shrinkage occurred at 120 C. As a result of the experiment 3 phases of endovenous ablation have been revealed. The first phase involves burning of blood and carbonizastripping for the treatment of refluxing GSV. The aim: estimation of ERFA results using the VNUS Closure FAST procedure in patients with lower limb varicose disease (LLVD). Methods. We have treated 52 limbs (29 patients, 10(34.5%) males and 19(65.5%) females, aged 22-72 years) with LLVD (C3-C6), diameters of GSV-5 to 15 mm. C3 were noted in 7(13.5%), C4-29(55.7%), C5-9(17.3%), C6-7(13.5%). 23(79.3%) patients had primary and 6(20.7%)-secondary varicose caused previous post-thrombotic syndrome. Concomitant diabetes mellitus-14%, arterial hypertension-16%. In one case, ERFA was used simultaneously at patient with ascending thrombophlebitis in the saphenofemoral junction (SFJ), after resection of proximal part of the GSV, thrombectomy from SFJ and femoral vein, ligation of GSV on the opposing limb. Tumescent anesthesia was used in 100%, in 93%-with the combined using of spinal anesthesia. The venous status was evaluated by objective examination and duplex angioscanning. In all cases, ERFA of the GSV, intra- and postoperative foam sclerotherapy was used under control of Doppler ultrasound. Results. Occlusion rate at 6 months (52 extremities) was achieved in 100% with no recanalization, neuritis, skin burns, infection, inguinal neovascularization and deep vein thrombosis. 2(6.9%) patients had paresthesia, 4(13.8%)-skin pigmentation, 3(10.3%)-transient superficial thrombophlebitis in a treated segment of superficial inflow of the GSV. All patients returned to the habitual activity on the 1-2 day of operation. Conclusion. Our experience reveals that, there are significant advantages in ERFA of the GSV using the VNUS Closure FAST procedure in patients with lower limb varicose disease. In effect, the ERFA procedure offers reduced postoperative pain, shorter sick leaves, faster return to normal activities compared with vein stripping, and it appears to be cost-saving for society. The absorption characteristics of the venous wall for the various laser wavelength A. Tsyplyashchuk, Y. Stoyko 1, K. Mazayshvili 1, A. Krasnovsky 2, T. Khlevtova 1, S. Akimov 1, M. Yashkin 1Pirogov National Medical and Surgical Center 2Russian Academy of Science ANBach Institute of Biochemistry vascul@yandex.ru The aim of the research is to identify absorption characteristics of biological fluids (whole blood and blood serum) and the venous wall in order to reveal the main acceptor of laser radiation. This data can help to optimize EVLA. 29 samples were used in the research: 26 experi- mental samples and 3 control samples (a vein segment acquired during coronary artery bypass surgery). Absorption spectra were measured with Hitachi U-3 400 spectrophotometer. Measurements were performed in the spectral range of 450 to 2 000 nm. We have carried out a comparative analysis of optical density of vein wall tissues for wavelengths of 1 030 and 1 470 nm, which are most frequently used in Russian clinical practice. Higher indices of optical density range from1450 nm to 1455 nm. The radiation absorption spectrum of the venous wall completely depends on the presence of blood. As a result of the experiment, the broad absorption band of the venous wall was registered at 650-950 nm, the main absorption bands of water at 1 450 and 1 900 nm. Absorption maxima of blood range from 1 450 1 455 nm to 1 937 nm. In general, they correspond to the optical density curve of water with a slight increase in degree of absorption within the range of 1 030 1 370 nm. No statistically significant differences between absorption spectra for different clinical categories of chronic vein diseases of lower limbs have been found, (1) based on the fact that the venous wall has acceptors of laser radiation both of one micron and one and a half micron range, (2) the main acceptor of laser radiation at the range of 1300 nm is water; blood serum, whole blood and the venous wall contain water, explaining the similarity of absorption spectra of these substances, (3) the presence of venous wall proteins as non-specific chromophores can explain a broad absorption band in the pre-micron range of wavelengths, (4) the optical density of venous wall tissues for laser radiation of 1 030 nm is 0.602 and for laser radiation of 1 470 nm - 0.872. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 33

tion of fibre tip with the first impulses. This period lasts from split seconds in the conditions of high value of energy fluent rate up to 5-6 seconds in the conditions of its minimal values. The burning of blood (not vaporization) appears with the formation of gas (not the steam) under the influence of laser radiation and heating to the extreme temperatures of fibre. The vein lumen is filled with gas after complete burning. The main physical factor in the process of EVLA is the direct influence of laser radiation on vein wall. If there is no traction of fiber or it is too slow, the overheated fiber tip starts influencing directly the vein. This mechanism is universal, and it doesn t depend on the wave length of the laser. The influence of laser radiation on the vein complex is not realized through steam bubbles, EVLA consists of 3 phases, the main factor in EVLA is direct laser radiation influence. 34 INTERNATIONAL ANGIOLOGY August 2014

OTHER ABSTRACTS Efficacy of rivaroxaban for prevention of venous thromboembolism after knee arthroscopy. a randomized double-blind trial (erika study) G. Camporese, E. Bernardi 1, F. Noventa 2, M. Bosco 3, C. Bortoluzzi 4, C. Mazzola 5, G. Zanon 6, D. Imberti 7, S. Vitali 8, C. Lodigiani on behalf of ERIKA. Study Group 9 1Hospital of Conegliano 2Unversity Hospital of Padua 3Catholic University of Rome 4Hospital of Venice 5University Hospital Galliera of Genova 6University Hospital of Pavia 7Hospital of Piacenza 8University Hospital of Perugia 9Humanitas Hospital of Rozzano Giuseppe.Camporese@sanita.padova.it Background. Without thromboprophylaxis, knee arthroscopy (KA) carries a definite risk of venous thromboembolism (VTE). Nonetheless, the last ACCP guidelines do not recommend routine prophylaxis in these patients. While the efficacy of the new oral factor Xa inhibitor rivaroxaban for VTE prevention in major orthopaedic surgery is well established, no randomized clinical trials employing rivaroxaban for VTE prevention in KA are available. Aim of the study. To assess the efficacy and safety of rivaroxaban for VTE prevention after KA. Design of the study and Methods. Multicentre, randomized, double-blind superiority trial. Patients undergoing KA were randomized to rivaroxaban (10 mg od, orally) or matching placebo, for 7 days. A clinical visit plus bilateral whole-leg color-coded Doppler ultrasonography was obtained for all patients at day 7(+1), or earlier should the patients develop symptoms/signs suggestive of VTE. Patients were followed-up clinically for 3 months. Study Outcomes. Primary efficacy outcome: combined incidence of asymptomatic proximal deep-vein thrombosis, symptomatic VTE and allcause mortality. Primary safety outcome: incidence of major bleeding. Results. Two-hundred forty-one patients were randomized (123 to rivaroxaban, and 118 to placebo). The 3-month cumulative incidence of the primary efficacy outcome was 0.84% in the rivaroxaban group, versus 6.14% in the placebo group (crude OR 0.13; 95% CI 0.02 to 1.08 [p=0.033]). No major bleeding events were observed. Minor, peri-surgical site bleeding occurred in 3.38% of the rivaroxaban group, versus 5.26% of the placebo group (crude OR 0.64; 95% CI 0.18 to 2.34 [p=0.53]). Conclusions. Oral rivaroxaban 10 mg od, for 7 days, is effective and safe for VTE prevention in patients undergoing KA. (ClinicalTrials.gov Identifier: NCT01629381) Fifteen-year follow up of late type i/iii endoleaks after evar. how safe is non-interventional treatment J. May University of Sydney, Sydney, Australia james.may@sydney.edu.au It has been suggested that patients with late Type 1/ Type III endoleaks following EVAR may be at greater risk of rupture than those with early occurrence of these endoleaks. This hypothesis is based on the possibility that a shrunken AAA sac which has not been exposed to arterial pressure for some years, may have weakened. The alternative view is that a shrunken AAA sac has the same Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 35

potential for rupture as an untreated AAA of the same diameter. To test which of the above hypotheses is correct, by retrospectively analysing a group of patients who had their late Type 1 / Type III endoleaks after EVAR managed conservatively by surveillance of sac size. Four patients mean age 82 years (range 77-89 years) developed late Type 1 / Type III endoleaks at a mean of 9.3 years (range 6.3-10.5 years) following EVAR. All had comorbidities placing them at high risk for open repair of AAA at the time of their original presentation. Three had undergone reduction in diameter of AAA sac after EVAR from a mean of 45.8mm to a mean of 35.7mm at the time of endoleak diagnosis. The diameter of the AAA sac in the remaining patient increased from 50mm after EVAR to 64mm at endoleak diagnosis. All were treated by surveillance using contrast CT and duplex US. The three patients undergoing reduction AAA sac in diameter after EVAR remain alive and free from rupture at a mean of 4 years (range 1.75-7 years) following diagnosis of their late Type 1 endoleaks. During this time interval their AAA sac size remained stable: mean diameter at time diagnosis of endoleak (35.7mm) compared with mean diameter at current follow up (37.0.mm). The single patient whose AAA sac increased in diameter (14mm over 10 years, post EVAR to diagnosis of endoleak) continued to increase (12mm over 2 years) and underwent secondary endograft intervention at this time He remains alive and free from rupture 2 years after secondary intervention. This limited experience suggests that shrunken AAA sacs neither rupture rapidly nor expand rapidly when re-exposed to arterial pressure after a long interval. No ruptures or deaths occurred in three such patients during the 4 year mean period of surveillance. Expansion of AAA sac after Type 1 / Type III endoleak diagnosis, however, requires intervention. Further experience is required to confirm the safety of treating an arterialised AAA sac by using the same guidelines that are currently recommended for untreated AAA Treatment of the venous thoracic outlet syndrome (paget-schroetter) E. Molina Minneapolis, Minnesota, USA molin001@umn.edu Subclavian Vein thrombosis known also as Paget- Schroetter syndrome is a surgical disease. No conservative treatment with anticoagulants alone or even with thrombolytics and balloon angioplasties are effective. Surgical decompression of the thoracic inlet is mandatory in all cases along with direct repair of the subclavian vein to reestablish its normal caliber. The syndrome affects mostly young people involved in physical work or sports. It has a sudden occurrence and if not treated properly, ideally within 2 weeks, leads to rapid occlusion of the distal veins in the arms that evolve into fibrosis and total obliteration of those veins. The process is irreversible unless prompt intervention is undertaken. Permanent disability of the arm is the result. The protocol of treatment developed at the University of Minnesota entails venography, thrombolytic therapy, followed by immediate surgery with or without subsequent implant of the endovascular stent. This protocol has been implemented for 29 years in over 230 patients suffering from acute or chronic obstruction resulting in a vein patency rate of 100% and permanent cure in a long term follow up. The complete care and operative technique will be shown step by step in this presentation. Arterial complications of cervical ribs. Surgical outcome S. A. Nurul Alam, Associate Prof.and Head of the Department, Vascular Surgery. National Institute of Cardiovascular diseases (NICVD) Dhaka, Bangladesh. s_nurulalam@yahoo.com Aims. Arterial complications of cervical ribs are uncommon but they can be serious and include limb threatening ischaemia. In the present study, we analyzed our experience at the National Institute of Cardiovascular Diseases (NICVD) with the surgical management of vascular TOS. Methods. One hundred and forty seven patients of TOS and arterial complications were treated in between 1994-2013, at NICVD, Dhaka, Bangladesh. Out of those. 89 were female and 58 male. They were either present with digital gangrene, advanced neurological symptoms associated with a cervical rib or a pulsatile supraclavicular mass. Out of 147 patients, 138 were surgically treated. Out of those, 76 underwent aneurysmectomy of subclavian artery followed by reconstruction (end to end anastomosis in 46 and interposing autogenous saphenous venous grafting in 30 cases). Rest 62 patients were taken care by Fogarty embolectomy (50 cases) and open thrombectomy followed by direct repair or vein patch angioplasty (12 cases). In all patients culprit cervical ribs were removed. In addition scalenectomy and excision of fibrious bands were done in 25 and 6 patients respectively. All operations were done through supraclavicular approach. Results. In 128 patients (92.75%) surgery was suc- 36 INTERNATIONAL ANGIOLOGY August 2014

cessful in relieving ischaemic symptoms of TOS. Recurrent thrombosis of distal arterial tree was found in 10 patients requiring repeat embolectomy. Coldness of hand in 6 and numbness in 22 patients were the most common symptoms in followup period ranging from 1-3 years. Conclusion. Though relatively uncommon, vascular TOS is a potentially limb threatening condition. Early detection of the anatomical abnormality with its surgical correction is required to avoid major complications. Popliteal vein compression D. Huber Wollongong, Australia davidhuber@me.com Popliteal vein compression (PVC) is a relatively new concept. Entrapment has been recognized for quite a long time, and its relationship to DVT has been well documented. Popliteal vein compression is more common and is caused by raised pressure in the popliteal compartment with the vein in its normal anatomical position. The frequency in the normal population is not known although it is likely to be higher than 20%. In the operating theatre, with the heel raised, the incidence is around 64%. This has serious consequences for the likelihood of developing a perioperative DVT, and some authors suspect that it also has implications for long haul flights. The pathophysiology will be discussed and studies will be presented discussing the relationship between PVC and the likelihood of developing a perioperative DVT as well as the effect of PVC on the function of calf compressors. Venous thromboembolism in asia an unrecognised and under-treated problem? P. Angchaisuksiri Division of Hematology at Ramathibodi Hospital, Mahidol University, Bangkok, Thailand pantep.ang@mahidol.ac.th Venous thromboembolism (VTE) has been perceived for a long time to be less common in Asian populations, particularly in the Far East, than in Western populations. Generally, thromboprophylaxis is not implemented as frequently as it should be in high-risk patients. However, recent prospective studies undertaken in Asian countries have demonstrated higher rates of VTE after major surgery and in medical wards, approaching those observed in Western populations. Risk factors for VTE are not different in Asian patients from those of Western patients with the exception of throm- bophilic mutations. Deficiencies of the natural anticoagulants (protein S, protein C, and antithrombin) are the predominant thrombophilias in Asia whereas factor V Leiden and prothrombin G20210A gene mutation are not found or rarely reported. Further large well-designed clinical studies are needed to evaluate the magnitude of the risk of VTE and the appropriate use of thromboprophylaxis in different clinical situations. Coronary microcirculation in diabetic and hypertensive patients S. Novo, V. Sucato, A. Quagliana, S. Evola, E. Bronte, G. Inga, G. Pace, G. Tona, R. Trovato, G. Novo Department of Internal Medicine and Specialties, University of Palermo, Italy salvatore.novo@unipa.it From 20 to 30 percent of patients undergoing coronary angiography to evaluate chest pain have normal coronary angiograms. The term stable microvascular angina (SMVA) or cardiac syndrome X (CSX) describes a framework in which episodes of angina are exclusively or predominantly related to exertion. During diagnostic investigation, physician demonstrate findings compatible with myocardial ischemia, normal coronary arteries on angiography, absence of any other specific cardiac disease (i.e., variant angina, cardiomyopathy, and valvular disease. Today, SMVA appears to be a heterogeneous group of disorders related to several mechanisms still largely speculative, operating alone or in combination, in the different cases. The precise site in which the microvascular abnormality can be highlighted is debatable, though some investigators have indicated the resistive arterioles as responsible, while other investigators have argued the dysfunction to be pre-arteriolar and caused by reduced production of endothelium-derived relaxing factor. Maseri et al. suggested that microvascular dysfunction could be limited to pre-arterioles (small coronary artery < 500 microns that are resistance vessels not visible during angiography). So, an inappropriate constriction or impaired pre-arteriolar dilation, in response to arteriolar metabolic dilation, could determine an ischemia in a small myocardial area. However, the specific role of cardiovascular (CV) risk factors (RF) in coronary microangiopathy is unclear. Several studies investigated the association between CV/RF and coronary microvascular dysfunction, but their results are discordant. Some studies show that CSX patients have substantially lower frequency of all conventional CV/RF than patients with obstructive CAD. Other studied instead show that they have similar risk profile and, therefore, that CV/RF (including serum CRP levels), alone or in combination, cannot reliably pre- Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 37

dict neither endothelium-dependent nor endothelium-independent SMVA. Hypertension is one of the most widespread CV/ RF underlying the establishment of an atherosclerotic deterioration of arterial walls; furthermore, high BP levels determine a higher risk of having a major CV event, by destabilizing atherosclerotic plaques and boosting platelets tendency to aggregate. As far as the role of hypertension on the pathophysiological mechanisms underlying the onset of a microvascular angina is concerned the possibility for different factors of concurring in the establishment of the dysfunction is nowadays considered the most suitable by a long way. Indeed, some studies have described, over the last years, structural alterations of small coronary arteries, namely smooth muscle hypertrophy, while several other study groups did not get to the same conclusions. They focused on a pattern of differently combined functional abnormalities, such as an altered endothelial functionality, determining an imbalance in the production of vasomotor mediators in favour of vasoconstrictors like endothelin, and a reduced response of microvessels to endothelium-independent vasodilators (e.g. adenosine). In a recent our work we studied 120 patients who had essential hypertension, 57 of them showed at echocardiography LVH, in comparison with 63 normotensive people who had BP levels under optimal control (< 140/90 mmhg for three consecutive supine measurements) without any medical therapy. Hypertensive patients had normal coronary arteriograms and they had angina. We wanted to investigate whether or not a microvascular dysfunction could underlie the onset of such symptoms, by calculating Timi Frame Count (TFC) and Myocardial Blush Grade (MBG) according to Gibson and Yusuf; therefore we compared them to the results of myocardial scintigraphy. The comparison between TFC and MBG values, used as indices of microvascular functionality, between hypertensive and normotensive patients showed remarkable and significant differences. These are related to the effects of hypertension on the establishment of a microvascular resistance dysregulation and on the reduced management coronary flow reserve according to myocardial needs. This observation could give an explanation for exertional angina in hypertensive patients, though the absence of coronary stenosis. Also in this population Total TFC and Total MBS have an inverse proportionality. TMBS showed a reduction of its value which show a slow flow and a slow removal of the contrast from the microvascular territory. This reveals altered microvascular functionality. So, we focused on the correlation between scintigraphy defect and angiography data in the arteries of ischemia relieved by nuclear imaging. The analysis showed that healthy vessels had a lower TFC than diseased vessels and therefore a better microcirculation with a high statistical significance (p=0.0001); moreover the study of microcirculation by coronary angiography and myocardial scintigraphy shows a good correlation between two methods. Metabolic disorder affecting the handling of energy substrates by the heart muscle has been suggested as another hypothesis. In particular the role of nitric oxide is very important in the development of diabetes-related vascular disease and several studies suggest that nitric oxide metabolism and vascular responsiveness to nitric oxide are altered in diabetes mellitus type 2. Coronary microvascular dysfunction is an important pathophysiologic feature of diabetes. Insulin resistance, glycemic control, and lipid disorders are related to vascular angiopathy in diabetics. So, hyperglycaemia reduces NO production by the enos (endothelial nitric oxide synthase), and increases its degradation through the production of oxygen free radicals. These free radicals are produced by the cells of the vessels, they originate from sources of oxidative enzymatic stress (protein kinase C and NADPH oxidase) and sources of oxidative non-enzymatic stress (such as AGEs, Advanced Glycation End-products). A recent work has shown a new potential mechanism to explain the impaired endothelium-dependent vasodilator function. The ADMA (Asymmetric Dimethyl-Arginine) is an endogenous competitive inhibitor of NO synthase. It increases in circulation in direct proportion with insulin resistance in non-diabetic while it increases in direct proportion with blood glucose control in diabetics. The accumulation of ADMA can derive from the inhibition of its catabolism, which is caused by the reduction of dimethyl-arginine synthase. The ADMA acts at several levels because it increases the production of oxygen free radicals. It induces the proliferation of smooth muscle cells. It promotes monocyte adhesion and platelet aggregation. It causes endothelial vasoconstriction. It has also a role in LDL oxidation thus favouring the atherosclerotic processes. In a recent our work we studied 310 patients with SMVA and we divided them into two populations: diabetic-non hypertensive (164 patients) and non-diabetic-hypertensive (146 patients). We calculated, on autobiographic images for each patient, TIMI Frame Count (TFC), Myocardial Blush Grade (MBG) and Total Myocardial Blush Score (TMBS) using the protocol described by Gibson and Yusuf. Based on Yusuf s experience we used a new index: TTFC, as the sum of the three coronary TFC. We demonstrated a worse coronary microcirculation in diabetic-non hypertensive patients with lower values of TFC, MBG and TMBS (p=0.02), compared with nondiabetic hypertensive. The new index TTFC is 38 INTERNATIONAL ANGIOLOGY August 2014

usually higher in diabetic-non hypertensive than non-diabetic hypertensive patients. Patients with positive scintigraphy had a worse TMBS than patients with a negative one, with a high statistical significance (p=0.003). The analysis of diabetic non-hypertensive and non-diabetic-hypertensive patients with cardiac syndrome X has led to assess that the diabetic population has a greater involvement of microcirculation. In addition, the new index, TTFC, proved to be a good marker, in agreement with the results of other indexes. CD163 ratio, donors were ~5 times more likely to be patients. Conclusion. While the intermediate monocyte subset is more inflammatory in all donors, the classical monocyte subset adopts a skewed M1 marker profile with atherosclerosis or increased atherosclerotic risk. This may impact on atherosclerosis progression as it would mean that most monocytes (not just the minor intermediate subset) are circulating inflammatory in the atherosclerotic patient. Polarisation of the monocyte classical subset to an m1 phenotype in atherosclerosis H. Medbury, H. Williams 1, G. Cassorla 1, N. Pertsoulis 1, N. Marmash 2, V. Patel 1, K. Hitos 1, J. Fletcher 1 1Surgery, University of Sydney, Westmead Hospital 2Research Network, Westmead Hospital, Sydney, Australia heather.medbury@sydney.edu.au Background. While monocytes play a key role in atherosclerotic plaque initiation and progression the contribution of the different monocyte subsets (classical, intermediate and non classical) is not clear. Though there is an increase in intermediate monocyte cell count in patients compared to controls, it is not known how this promotes atherosclerosis. Aim. To compare monocyte subset inflammatory (M1) profile in atherosclerosis. Methods. Blood samples were collected from controls and atherosclerotic patients. Donor lipid profiles were measured and flow cytometry used to examine the inflammatory profile (expression of M1(CD86) compared to M2(CD163) surface markers) of the major (classical) and minor (intermediate) monocyte populations. Results/discussion. In control donors, the intermediate subset was more inflammatory as seen by a higher CD86/CD163 ratio (P<0.05). However, for classical, but not intermediate, monocytes there was an inverse correlation between CD86/CD163 expression and donor s HDL ratio (P<0.05), and decreased TNFα production relative to donor ApoA1 (P<0.05). In patients, intermediate monocytes were similarly found to have a higher CD86/CD163 ratio than classical monocytes (P<0.05). However, the intermediate CD86/ CD163 ratio was the same for patients and controls, while CD86/CD163 in the classic subset was higher in the patient group (P<0.05). Conversely, CD163 expression by classical monocytes was higher in controls than patients (P<0.05). Assessing odds ratios, for each unit increase in CD163 expression, donors were 40 times less likely to be patients and for each unit increase in the CD86/ Blood vessel regenerative medicine in China Y. Gu, J. Zhang, Z. Wang Beijing, China guojianming@aliyun.com There are many treatment options such as arterial bypass surgery and balloon angioplasty available for treatment of lower limb ischemia. However, it is difficult to treat patients with poor arterial outflow or with poor general conditions. Neovascularization may be a good approach (Therapeutic angiogenesis for patients with limb ischemia by autologous transplantation of bone-marrow cells: a pilot study and a randomised controlled trial, The Lancet. 2002;10(360):427-435). We successfully started the first clinical trial in China in early 2003 after obtaining approval from the hospital ethics committee. Improved clinical parameters were observed in the transplanted patients, even diabetics, including elevated transcutaneous oxygen pressure, decreased need for major amputation, reduced pain, improved ankle-brachial index, and richer collaterals on angiography. Now we have done more than 500 lower limb ischemic patients with good results. There are three elements for traditional Tissue Engineering: 1. seeding cells, 2. bioabsorbable materials and scaffold, 3. In vitro construction. We did a lot of work to choose materials. Finally, we decided to use decellular tubular scaffold with EPCs implanted on decellular tubular scaffold and use three-dimensional cell culture system depending on Pulsatile Flow. Then followed swine decellular vessel animal experiments. Angiography found the tissue-engineered blood vessels still patent one year after bypass. According to the rules of the SFDA, we put forward the clinical trial application for our hospital. We successfully started the first clinical trial in China in early 2003 after obtaining approval from the hospital ethics committee. We did three such patients, with very good results. Summary. Regenerative Medicine including Stem Cell and Tissue Engineering in China has developed very quickly from 2000. Our work could help poor arterial outflow patients and patients in poor general condition. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 39

Intimal hyperplasia development and characterization in a nitinol uclip versus sutured arteriovenous anastomosis R. Varcoe University of New South Wales, Sydney, Australia r.varcoe@unsw.edu.au Objective. This study sought to compare the local tissue response and subsequent volume of intimal hyperplasia (IH) that develops throughout the maturation of an arteriovenous fistula which was created using continuous/interrupted polypropylene with that of a novel, metal-alloy, anastomotic device. Methods. Forty-six fistulae were created in 23 sheep using the nitinol U-clip (n=23) or continuous (n=20)/ interrupted (n=3) polypropylene suture. Animals were sacrificed at 4(n=3), 14(n=3), 28(n=10), 42(n=3) and 180(n=4) days. Histological sections were evaluated for quantitative histology and immunohistochemistry. Results. Compared with continuous polypropylene, 4 day U-clip specimens demonstrated 5% lower values of intima-media area per unit length (IMA/L), 273% fewer proliferating cells (PC) and 204% less tissue necrosis (TN). Similarly at longer time points the U-clip was favoured (by 37% IMA/L, 182% PC, 139% TN at 14d; by 32.6% IMA/L, 319% PC, 32% TN at 28d; by 9% IMA/L, 37% PC, 26% TN at 42d; by 14% IMA/L, 150% PC, 328% TN at 180d) (MANOVA, F=8.8-24.1, all P.005); observed power >82%). Luminal circumference was indistinguishable between these two groups at all time points. U-Clip compared to interrupted polypropylene at 4 weeks demonstrated a 4% reduction in IMA/L (P=0.59), 74% in PPC (P <.01) and 42% in TN (P <.01), whereas luminal circumference was 19% greater in the U-clip group (P <.01). Conclusions. These results provide clear evidence of reduced local tissue necrosis, proliferating cell numbers and intimal hyperplasia favoring arteriovenous fistulae created using the U-clip anastomotic device over conventional polypropylene suture techniques Catheter directed thrombolysis for deep vein thrombosis. preliminary results from Chile V. Bianchi, P. Vargas 1, G. Cassorla 2, B. Horwitz 1, F. Allamand 3 1Departamento de Radiologia, Clinica Alemana, Universidad del Desarrollo 2Unidad de Cirugia Vascular, Clinica Alemana, Universidad del Desarrollo 3Fellow Cirugia General, Clinica Alemana, Universidad del Desarrollo Santiago, Chile vbianchi@alemana.cl Deep Vein Thrombosis is a common condition whose accepted standardized treatment is anticoag- ulation; unfortunately it is well recognized that the risk of post thrombotic syndrome is maintained due to valve dysfunction or residual stenosis / occlusions especially when it affects proximal veins. Percutaneous options have been proposed in the last 10 years and are being actively studied as an alternative approach. We identified all our cases from the haemodynamic unit, searching for procedures that had a diagnosis of DVT and/or thrombolysis since the start of our program in 2007. All clinical, demographic and technical details were registered. All cases were done with participation of interventional radiologist as well as vascular surgeons. Procedures were done in two steps, maintaining patients between treatments in the ICU From July 2007 to February 2014, 17 DVT cases with a mean age of 32 were treated by catheter directed thrombolysis, 10 (59%) of those were females. In 15 (88%) a mechanical adjunct was needed to lyse thrombi. Further 10 (59%) cases needed stenting to correct underlying residual stenosis. Upon completion 16 (94%) cases were free from significant residual thrombosis. The average time to complete the therapy was 19 hours. 2 (12%) cases needed more than 2 sessions of thrombolysis. 15 (88%) of patients had no complications. Of the complications, one was an iliac re-thrombosis that was resolved with further thrombolysis two weeks later; one was a respiratory depression that resolved in 12 hours. Percutaneous thrombolysis could be offered with good results and low rate of complications. This option has the potential to become a reliable alternative to anticoagulation alone in selected patients. Long-term outcomes are essential to validate the technique, and trials are needed to address the issue of long-term permeability and protection from post thrombotic syndrome. Closurefast endovenous radiofrequency ablation (ERFA) for GSV-SSV incompetence: efficacy and failure patterns. a 3-year follow-up N. Ibrahim 1, K. Huang 1, A. Zea 1, J. Diaz 1, G. Bicanic 1 1Advanced Laser Vein Clinic and Sydney Centre for Venous Disease Assessment of randomly recruited patients 3 years after ERFA to establish efficacy and failure contributing factors. 190 patients treated for venous incompetence were invited to participate for assessment as part of an ongoing prospective study follow up and who completed 3 years post treatment. The first 80 responders were reviewed. 49 females. 31 males. Number of limbs: 138. Number of incompetent trunks: 159. GSV: 135. SSV: 24. Patients underwent clinical assessment and duplex venous incompetence study. 40 INTERNATIONAL ANGIOLOGY August 2014

All 80 patients had earlier 9 and 12 months f/u. 3 patients (2 F, 1 M) had unclosure (2GSV and 1 SSV) treated with secondary sclerotherapy. No recurrence in this group. 3 years visible disease progression: 21.7%. 3 years truncal recanalisation: 13 patients. 8 F; 5 M. 10 GSV (2 segmental GSV and 2 recanalised GSV and yet competent. 3 SSV. Further analysis showed that patients with recurrent truncal recanalisation all had BMI > 34. BMI range: 34 42. The group undergoing follow-up is heterogenous and there could be self-selection bias. 3 years recanalisation rate is higher than is reported in the literature. BMI appears to be a contributing factor. Further investigation is required. It might be necessary to have a special minimally invasive treatment protocol for patients with high BMI undergoing ERFA. Dyslipidemia in peripheral artery disease with respect to presence/ absence of smoking and diabetes mellitus. J. Pitha, D. Karetova 1, B. Seifert 2, J. Vojtiskova 2, K. Roztocil 3 11st Faculty of Medicine, Charles University, Prague, Czech Republic 2MOET group 3IKEM japi@ikem.cz The main risk factors for peripheral artery disease (PAD) are smoking and diabetes mellitus. Potential association of dyslipidemia and hypertension with PAD is more complex. We analyzed differences in lipid parameters and blood pressure between nonsmoking non-diabetic patients and smoking diabetic patients. In the unselected population of 853 men and women with lower grade of PAD (Fontaine classification 1-2a), diagnosed and treated by primary care physicians we analyzed differences in traditional cardiovascular risk factors including calculated non-hdl cholesterol (=total cholesterol HDL cholesterol) between non-smoking non-diabetic patients and their smoking diabetic counterparts. For statistical analysis we used unpaired t-test. In non-smoking non-diabetic women (n=240, mean age 67.0 ± 9.5 years), waist circumference, diastolic blood pressure and triglycerides, were significantly lower than in smoking diabetic women (n=87, mean age 64.8 ± 7.9 years). In contrast, HDL cholesterol and surprisingly non-hdl cholesterol in non-smoking non-diabetic women were higher. No differences were observed for age, duration of PAD, systolic blood pressure and LDL cholesterol. In non-smoking non-diabetic men (n=258, mean age 64.2 ± 10.7 years), waist circumference, systolic blood pressure and triglycerides, were significantly higher than in smoking diabetic men (n=268, mean age 64.3 ± 8.4 years). HDL cholesterol in non-smoking non-diabetic men was higher. No differences were observed for age, duration of PAD, diastolic blood pressure, LDL cholesterol, and non-hdl cholesterol. In non-smoking non-diabetic women non-hdl cholesterol embracing remnant particles and LDL cholesterol could be associated with PAD. This association was not found in non-smoking, non-diabetic men. Supported by Ministry of Health, Czech Republic - conceptual development of research organization (Institute for Clinical and Experimental Medicine IKEM, IN 00023001) Endovenous heat-induced thrombosis (EHIT) after EVLT of GSV with 1470nm laser and bared tip fibers R. Vellettaz Buenos Aires, Argentina drrubenvellettaz@hotmail.com Introduction. EHIT is a pathognomonic complication of thermal ablation. Objective. to evaluate incidence, progression and risk factors of EHIT. Type of study: non-randomized, retrospective; period15/08/08-15/8/13. Surgical technique: percutaneous, in ambulatory unit with local anesthesia and sedation. Materials:1470 nm diode laser, bare tip fibers Population:1063 GSV patients Method. We measured the diameter of GSV at the SFJ, the reflux time, the distance from the tip of the fiber to the terminal valve and residual stump. Diagnosis and progression of EHIT: 3rd, 7th and 30th day We do not indicate simultaneous complementary treatment, we analysed demographic data: sex, age and clinic severity; we indicated DVT prophylaxis according to risk factors and compression therapy after EVLA Results. Incidence 3rd day1.22% - Type 1(1050 MMII) 98.78%, Type 2 (12MMII) 1.12%, Type3 (1MMII) 0.09%, Type 4 not detected. Incidence 7th day 1.51% - Type 1 (1047 MMII) 98.49%, 3 patients developed EHIT Type 2; Type 2 (15MMII) 1.41%, Type 3 (1 MMII) 0.09%, Type 4 not detected. EHIT progression: 15patients with EHIT2 resolved spontaneously at one month, 3patients with EHIT1 progressed to EHIT2; DVT and PE were not detected. Comparison G1no EHIT versus G2 EHIT: average age G1 53.7/G2 62.4 (statistically significant); male G132/G2 56.25% (statistically significant); clinical diagnosis highest percentage was CEAP C3 Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 41

(not statistically significant); degree of reflux severe G1 89/G2 87% (not statistically significant); diameter of GSV G2 116/G1 92mm (statistically significant); mean distance of fiber tip 2 cm /1.8-2.3cm, not statistically significant); residual GSV stump 2.3cm (1.4-3.3cm,, not statistically significant). Conclusion. Incidence of EHIT is low, early DUS determines increase the rate of diagnosis and progression of EHIT. Risk factors associated with increased rate include age, sex, vein size Clinical severity, degree of reflux, position of the catheter tip and length of stump were not a risk factor. We do not perform simultaneous complementary treatments and perform DVT prophylaxis in all patients according to risk of thrombosis, therefore these cannot be considered as bias. EHIT resolves in 1 month in most patients; EHIT is due to technical problems rather than a thrombotic tendency of the patient. Pelvic congestion syndrome C. Jara 1, A. Kornberg, J. Pratt 2 1Italian Hospital of the South 2Tornú Hospital, Buenos Aires Buenos Aires, Argentina carlosjara@argentina.com Introduction. The syndrome of pelvic congestion (PCS) and the varicose vulvar veins appear in the 8% of the pregnant women an in the 0.8% of the women with multiparity. It is characterized by the enlargement and tortuosity of the veins the uterus and ovarian plexus and produces a feeling of heaviness, oedema and pain in the lowers limb and pelvis due to the venous cronic stasis. Aim. The objective and protocol of work according to our experience since year 2006 to 2013 determining a frequency of symptoms originated by hormonal level, thrombofilic factor, genetic, compression syndrome and a new treatment in compression post sclerotherapy in varicose vulvar veins with a Panty Girdle Compression Mideni Method. 252 patients age: 33 to 52 years old, underwent: semiology pelvic congestion test, pain (dyspareunia) study, transvaginal doppler duplex ultrasound, doppler ultrasound of lower limbs, hormonal level dosage of: FSH, TSH, stradiol, thrombophilic factors, homocysteinemia, phlebography and MRAngiography Result. of 252 patients in 32(13%) we found pelvic congestion syndrome, 11 of them (35%) had varicose vulvar veins and PCS; 10 patients (32%) only varicose vulvar veins, and 11(35%) patients with massive gonadal reflux Discussion. More than 80% of studied women suffer from dyspareunia and pelvic pain; the transvaginal duplex ultrasound shows us the refluxes existing. Both the selective embolization ( sandwich technique ) with coils in hypogastria veins and tuboovarian veins are treated with Polidocanol at 1%. In varicose vulvar veins, the sclerotherapy treatment with Foam of Tetradecylsulphate of sodium 1% and therapeutic compression with Panty Girdle Compression device. Conclusion. The Pelvic Congestion Syndrome, as well as the varicose vulvar veins are undergo by 8% of all pregnant woman and 0, 8% of the whole population of multiparity women. These are caused by congenital, mechanical, hormonal, hemostasis and procoagulant factors The most important symptom is dyspareunia and it is diagnosed by the transvaginal duplex ultrasound. Embolization with coils and sclerotherapy with polidocanol and tetradecylsulphate of sodium are the ideal treatments in varicose vulvar veins with compression post procedure with Panty Girdle Compression Mideni device with relapse of less than 2% to 1% in the long term follow up. Diagnostic guidelines of vascular anomalies. vascular malformations and hemangiomas P. Antignani Rome, Italy mc0587@mclink.it Vascular malformations and hemangiomas altogether as vascular anomalies remain one of the enigmas in modern medicine. Given the paucity of knowledge in this field, employing an appropriate diagnostic approach to vascular anomalies is a major challenge for most physicians. Furthermore, achieving a precise diagnosis of a vascular anomaly is a complex task requiring in-depth knowledge of embryology, pathophysiology and appropriate acknowledgement of the clinical, hemodynamic and morphologic features. As a joint initiative, the International Union of Angiology (IUA) and the Italian Society for Vascular Investigation (ISVI) established an expert Panel under the auspices of the International Union of Phlebology (IUP) to formulate guidelines for physicians and vascular technicians/sonographers on the evaluation of vascular anomalies. The diagnostic approach to vascular anomalies should include the distinction between vascular tumors (i.e. hemangiomas) and congential vascular malformations (CVMs). This step is based more on history and clinical examination rather than on instrumental evaluation. In children Duplex ultrasound and histology can be helpful to separate hypervasularized tumors from CVMs. Appropriate record of objective measures as size or flow volume is required in order to evaluate the progress of the pathology and/or to assess the results of adopted therapeutic interventions. The 42 INTERNATIONAL ANGIOLOGY August 2014

anatomic, pathological and hemodynamic characteristics, the secondary effects on the surrounding tissues and the systemic manifestations should be defined. Basic diagnostic tools are Duplex sonography followed by MRI or CT scanning. Diagnostic investigations are best undertaken at centers where subsequent therapeutic interventions will be performed. Outcomes following elective nonfenestrated aaa repair. 13 years experience M. Neale, M. McCaffrey, J. Edwards, C. Thoo Royal North Shore Hospital, Sydney, Australia neales@bigpond.net.au Endovascular grafting for abdominal aortic aneurysm disease (EVAR) has developed since initial patient implants in the early 1990s and is now widely regarded as the treatment of choice for aortic aneurysm repair. Questions however still remain about the long term durability of EVAR (and of the patients undergoing EVAR). In this study a review of 230 patients (85% males) who underwent elective non-fenestrated EVAR during a 13 year period from 2000 to 2013 was performed to assess survival and outcome information. A prospectively collected database from a single surgical practice was used to identify patients with further data collected via retrospective medical record review and phone interviews with GPs. Age ranged from 59 to 90 years, and mean aneurysm size was 5.8cm (range 4 10cm). There was zero operative/30 day mortality in the group with 2 immediate (Day 0 and Day 1) open conversions (0.9%). Mean follow up was 36 months (median 24 months, range 0 132 months). Follow up data (minimum 6 month review) was obtained in 222 patients (96%). There were 71 deaths in this group (32%) with a median time to death of 3.7 years. Death occurred within 2 years of EVAR in 18 patients (25% of deaths). No aneurysm related death was able to be identified, though cause of death was unable to be confirmed in 12 patients (17% of deaths). None of these were felt to be aneurysm related on discussion with their GPs as patients had known co-morbidities (eg malignancy) which were likely to be the cause of death though could not be confirmed from available records. Of the remaining 151 patients who were confirmed to still be alive, 41 (27%) were no longer receiving active follow up for various reasons whilst 110 (73%) continue with regular followup. Median survival in those patients still alive is 54 months (range 1-145 months). There were 3 post EVAR aortic ruptures (1.3%). One patient had a known type I endoleak being planned for re-intervention with rupture at 3 months post implant, 1 patient had declined to attend follow-up with rupture 3 years post implant and 1 patient with rup- ture at 2 ½ years post implant having had followup within 6 months of the rupture without any problems identified. All patients survived emergency open repair (2 converted to standard graft, one with the endovascular graft sutured in-situ as the repair) and all remain alive 3-6 years following rupture. Secondary intervention was required in 31 patients (14%, including the above ruptures) with 26 patients undergoing 28 secondary interventions related to the initial endovascular graft and 5 patients undergoing intervention for the development of iliac aneurysmal disease. In summary, EVAR can be performed with minimal mortality, with good long term survival. There is still a significant re-intervention rate following EVAR, however aneurysm related death is uncommon following EVAR (no confirmed deaths in this series). Pedal bypass with deep venous arterialisation for the limb salvage in critical limb ischemia with unreconstructable distal artery P. Mutirangura, C. Ruangsetakit, C. Wongwanit, N. Sermsathanasawadi, K. Chinsakchai Vascular Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Bangkok 10700, Thailand. In critical limb ischemia with tissue loss, major amputation is inevitable when the distal artery run off is extremely poor and unsuitable for any modalities of arterial reconstruction such as arterial bypass surgery and endovascular treatment. We proposed the special bypass technique entitled Pedal Bypass With Deep Venous Arterialisation for the successful limb salvage in this critical situation in 2002. The principle of this technique is the use of deep vein at the ankle, mainly posterior tibial vein as a vascular channel carrying oxygenated blood from proximal artery into the ischemic foot. The complete destruction of valve competency in the distal vein is the cornerstone of this technique. Circulation from proximal artery will be freely passed through the deep venous valve into the ischemic foot and adequate for the healing of ischemic ulcer. This bypass also required a long vascular conduit joining between the large proximal artery at any site and the small distal vein at the ankle. The composite graft, the combination between prosthetic graft and natural vein graft is the most suitable vascular conduit of this procedure. The whole long saphenous vein has to be preserved as the major venous flow of the foot as well as the other deep venous system in order to reduce the possibility of postoperative limb swelling. Subsequently, the natural vein segment of composite graft has to be harvested from the contralateral greater saphenous vein or arm vein. The physical findings of the Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 43

successful procedure are the continuous thrill palpable over the distal anastomosis, the mild swelling of the foot and calf and the rapid healing of ischemic ulcer. The adequate circulation in the foot can be confirmed by duplex ultrasonography and transcutaneous oxygen pressure measurement. The whole successful procedure can be visualization by computed tomographic angiography or magnetic resonance angiography. Since the year 2002, we have performed this technique in 50 patients with 78.8% successful outcome. The midterm outcome of 2 year graft patency and 2 year amputation free survival were 57% and 81% respectively. In conclusion, we would like to propose that pedal bypass with deep venous arterialisation may enhance the limb salvage in critical limb ischemia with poor distal outflow artery. Combining drug-eluting stents and stent-grafts for the treatment of femoro-popliteal occlusive disease. early outcomes R. Huilgol, D. Hagley Department of Vascular Surgery, St Vincent s Hospital Sydney, Sydney, Australia rhuilgol@hotmail.com Aim. To investigate the outcomes of combining drug-eluting stents with stent-grafts (DES+SG) versus stent-grafts (SG) alone in the treatment of femoro-popliteal occlusive disease. Methods. All patients undergoing stent-graft treatment between 2010-13 were identified. Patency outcomes were compared between two cohorts of patients. Primary patency was defined as freedom from binary restenosis. Results. There were 37 SG procedures and 23 DES+SG procedures. The most common indication was claudication. There was no mortality, major morbidity or major amputation in either cohort. 12 month primary patency was 83% SG versus 88% DES+SG (p = NS). There were more reinterventions in the SG group. Conclusion. DES+SG procedures are safe. Early results show a non-significant trend towards improved patency in the DES+SG group. Genetics in primary lymphoedema S. Michelini, A. Bruson 1, M. Cardone 2, F. Sirocco 1, A. Fiorentino 2, S. Cecchin 1, F. Cappellino 2, M. Bertelli 1 1Magi s Lab Rovereto Italy 2San Giovanni Battista Hospital ACISMOM Rome Rome, Italy s.michelini@acismom.it In later stage of lymphangiogenesis, in some cases can develop primary lymphoedema. Clinical appearance of illness is variable in different moments of life, with the evidence of an oedema affecting the limbs or external genitalia which tends to progress, involving, in some case, all the limb. In familial forms, it is usually inherited as an autosomal dominant disease linked to heterozygous mutations in genes involved in lymphangiogenesis (above all VEGFR3 and FOXC2 genes). Due to its rarity, exhaustive genotype-phenotype correlation studies are lacking and lymphoscintigraphy studies have never been performed on subjects with inherited mutations but without clinical presentation. Tha AA. previously reported clinical and genetic analysis of 52 Italian probands screened for VEGFR3 and FOXC2 mutations [Michelini S.et al., 2012]. Here, they focus on the nine familial cases with positive molecular diagnosis (6 with mutations in VEGFR3; 3 in FOXC2). These patients and their relatives also underwent lymphoscintigraphy. In one of the nine families was identified a clinically normal subject carrying a FOXC2 heterozygous mutation. The same variant was detected in his daughter, who has an overt phenotype. Lymphoscintigraphy in family proved to be very similar. Results of the FOXC2 patient without clinical manifestations indicated bilateral delay in lymphatic drainage through inguinal nodes. When major parameters (age of onset, clinically involved limbs and evolution) were considered, a genotype-phenotype correlation was observed in patients carrying the same mutations from this and previous case studies. In conclusion, lymphoscintigraphy of clinically normal patient with FOXC2 mutation indicate that subjects without manifestations but carrying mutations may have silent failure of lymphatic capacity of traasport. This experience suggests that in late forms, subclinical disease is already present at birth and only manifests after physical trauma. Primary lymphoedema should therefore be regarded as having variable clinical expression and not, as currently considered, incomplete penetrance. Anatomy and Micro-anatomy of the lymphatic system N.B. Piller Lymphoedema Research Unit, Department of Surgery, School of Medicine, Flinders University, Adelaide, South Australia neil.piller@flinders.edu.au Understanding the Anatomy the lymphatic system as well as relationships between formational, pathological, surgical, radio-therapeutical or ac- 44 INTERNATIONAL ANGIOLOGY August 2014

cidental (that is misguided sclerotherapy, ligation, stripping etc) changes and functional outcomes in terms of being able to act as a drainage system for metabolic wastes, high molecular weight products, a signalling pathway, as well as a path for cytokine, lymphokine and adipogenic factor homeostasis and removal is critical if the lymphatic system functionality is to be maximised when there is a failing venous system, whether that be linked to overload or damage to it. At a basic level there are subfascial and epifascial and some-times intrafascial lymphatic collector pathways. These, their locations and numbers are enormously variable between individuals and we are often not drawn to these issues until they fail. Increasingly, also we are becoming aware that at least for some lymphoedemas (Breast Cancer Related) that one of the reasons for unexpected lymphatic failure and chronic oedema (lymphoedema) is related to lymphatic malformation or lymphatic pump insufficiencies. The genes are being identified and genetic screening may play an important role in the near future in identifying potential lymphatic weakness/its tendency to fail when we load it. But they tell us nothing of the pathways or location. From functional point of view, the location of the lymphatic collectors (and the lymphatic capillaries) will determine outcomes, but when we don t know or aren t aware of them, outcomes are hard to predict. Our knowledge does however contribute two important points. We know that many lymph collectors are located in the adventitial/ peri adventitial region of the medium/large veins, so ligation, sclero-therapy, stripping etc, may damage them. We also know that the proximity issue means phlebitis, DVT etc will impact strongly on the lymphatic system and that most likely the failure of the lymphatics starts in the weakest area and spreads from it (possibly proximally and distally similar to venous failure). Further we know that any fibrotic induration (surgical/radiotherapeutical scarring or due to the progression of Lymphoedema) will further compromise lymphatic function. The solutions in part are better understanding the locations and functioning of the lymphatic microvasculature. In the past this has been the domain of lympho scintigrams but now techniques using Indocyanine green are providing much needed non invasive information (at least for the superficial lymphatics). But alone this is inadequate we have means to detect local lymphatic failure signs (Bio-impedance spectroscopy, Tissue Dielectric Constants), induration/fibrosis of the tissues (Tonometry, Indurometry, US) but often do not use them and if we do, rarely in combination to give a solution to our problems. Maybe its time for change. Postoperative control of type ii endoleaks in patients submitted to evar for aaa B. Gossetti University of Rome La Sapienza, Rome, Italy bruno.gossetti@uniroma1.it The term endoleak (EL) refers to persistent blood flow into the aneurysmal sac after endovascular aneurysm repair (EVAR). In the Eurostar registry the prevalence during follow-up was 19.8% for EL (7.8% were type II leaks and 12% were type I or III or multiple leaks). In some experiences 40% of patients had EL discovered within the 6-month follow-up interval, whereas the majority (60%) had new type II leaks discovered at least 6 months after their initial procedure. The presence of EL correlates with high risk for aneurysmal rupture and/or conversion after EVAR: type I and type III leaks are associated with a significantly greater risk of rupture than type II EL. Despite this, aortic aneurysm rupture due to type II leak has been reported in 16.8% and therefore we should assume that type II EL are not entirely benign. It is not clear whether and how the timing of appearance of type II leaks affects subsequent evolutions towards spontaneous closure (about 30% of cases) or complication. Therefore type II EL should be carefully monitored over the long term with a plan for aggressive correction in the event of aneurysmal sac expansion. Helical computed tomography (CT) is recognized as the test of choice, but color-coded Duplex ultrasonography (US) and contrast enhanced US (CEUS) seems to be a good alternative to CT scan up to date. Type II leaks are usually characterized by a low velocity of blood flow: a to/from Doppler scan waveform pattern was associated with spontaneous Type II leak seal, and a monophasic or biphasic waveform was associated with EL persistence. Clearly, the treatment needs to be thoughtfully planned and carefully executed under CT guidance and arteriographic evaluation is necessary to delineate the anatomy of the leak ad to perform its treatment. The role of duplex ultrasound in the management of peripheral artery disease R. Pulli Tuscany, Italy raffaele.pulli@unifi.it Peripheral artery disease (PAD) is a well recognized disease threatening either the limb or the survival of the affected patients, since it represents an independent factor of a vascular death. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 45

In this perspective a systemic and multidisciplinary approach is crucial in the assessment and management of PAD, searching for other possible atherosclerotic localizations. In case of medical failure or in presence of a quick progression of the disease, it is important to grade and classify the severity of PAD in the single patient in order to offer the best therapeutic option. The current worldwide trend in the treatment of PAD is towards an increase in endovascular procedures either in the aorto-iliac area or in the infrainguinal district. In PAD management the role of diagnostic tools has been changing in the recent years and Duplex ultrasound (DUS) has gained more importance in its diagnostic assessment and nowadays it is considered the new gold standard for screening and diagnosis of PAD. The simple CW Doppler and the measurement of ankle brachial index (ABI) allow physicians to confirm the clinical diagnosis and to graduate the severity of the disease. Whenever PAD is diagnosed, Duplex scanner is able to localize the site and the extension of the atherosclerotic lesions with a good sensibility and specificity in comparison with the other diagnostic methods. On the basis of DUS alone many authors chose the best therapeutic option, deciding for the endovascular approach in case of short and segmental lesions, still reserving a traditional open surgery in case of long and complex occlusion. Adopting this strategy, the diagnostic angiography is almost completely avoided and the patient is directly addressed to an endovascular procedure. Only in case of uncertain or unreliable DUS, CT scan or angio-mr can be performed to complete the assessment of PAD. Metabolic syndrome and cardiovascular risk S. Novo, V. Evola, M. Sinacori, A. Peritore, R. Trovato, F. Guarneri, E. Corrado, I. Muratori, G. Novo Department of Internal Medicine and Specialties, University of Palermo, Division of Cardiology, University Hospital P Giaccone, Palermo, Italy salvatore.novo@unipa.it The metabolic syndrome (MetS) is a cluster of interrelated risk factors for cardiovascular disease (CVD) and type 2 diabetes mellitus (DM2), such as dysglycemia, raised blood pressure, elevated triglyceride (TG) levels, low high-density lipoprotein (HDL) cholesterol levels and central obesity. Despite the association and clustering of these factors have been known for decades, in recent years there has been considerable disagreement over the terminology and diagnostic criteria. The most relevant definition of MetS is that of 2004 revised National Cholesterol Education Program (rncep), based on the presence of 3 or more of the following 5 CV risk factors: 1) central obesity (waist circumference: men 102cm and women 88 cm); 2) elevated TG ( 150 mg/dl or on treatment); 3) reduced levels of HDL cholesterol (men < 40 mg/dl; women < 50 mg/dl); 4) systemic hypertension ( 130/ 85 mmhg or on treatment); and 5) elevated fasting glucose ( 100 mg/dl or on treatment), published as statement by Alberti KG et al. in Circulation of October 2009. However, irrespectively of the various definition used, it has been demonstrated clearly that the syndrome is common and that it has a rising prevalence worldwide, which relates largely to increasing obesity and sedentary lifestyles. Each of the associated conditions in MetS has an independent effect, but clustering together they become synergistic, making the risk of developing CVD and DM2 greater. Although the true pathophysiological mechanism by which MetS increases cardiovascular risk is still not completely clear, central obesity and insulin resistance seems to play an essential role, even in the determination of the other metabolic disorders, systemic low-grade inflammation, pro-thrombotic status and increased oxidative stress, and this could explain the more rapid progression towards endothelial dysfunction, atherosclerosis and cardiovascular events, demonstrated by the patients with MetS. MetS is therefore considered a strong clinical predictor of cardiovascular disease, especially in the long term. In our precedent experience, we studied a population of 529 asymptomatic patients (mean age 62 ± 12.8 years), performing at baseline the ultrasound examination of Carotid intima-media thickness. After a 20 years follow-up, we found that patients suffering from MetS showed reduced survival and a higher prevalence of all cerebro and cardiovascular events (144 vs. 98, p < 0.0001), and of all non-fatal CV events (120 vs. 79, p < 0.0001). We demonstrated also that patients with MetS had higher mean values of carotid intima-media thickness compared to individuals without MetS, and the presence of the syndrome determined an increased risk of cardiovascular events in both patients with preclinical atherosclerosis and in patients without atherosclerotic lesions. Concluding, although it is still uncertain whether the cardiovascular risk associated with MetS is over and above the risk associated with its individual components, considering that many of the risk factors associated with MetS, such as high TG, low HDL, impaired fasting glucose, visceral obesity, hyperuricaemia and oxidative stress are not considered by the actual score systems for cardiovascular risk estimation, and thinking also that, in the MetS, each factor is never an isolated component but interacts synergistically with the other metabolic disorders in increasing the progression towards endothelial dysfunction and vascular inju- 46 INTERNATIONAL ANGIOLOGY August 2014

ry, we consider reasonable to put the patients with MetS in a category of high cardiovascular risk, especially when preclinical atherosclerosis of carotid artery is associated, irrespectively of the given risk estimation with the cards of the risk. Private community screening for vascular disease in Australia S. Kitchener, R. Denniss Griffith University, Queensland, Australia kitcheners@bigpond.com We report here on preliminary findings from the first year (to April 2013) of a private screening program conducted in Sydney and Melbourne by Screen for Life. During this period 18589 people over the age of 49 years responded to notices of these services in their local area, presented for screening and completed valid records of their occasion of service. Their average age was 63.6 years with 60% females and only 277 declared smokers. They received abdominal aorta (AA) and internal carotid arteries (ICA) ultrasonography screening conducted by accredited ultrasonographers and reviewed by a Cardiologist. Prevalence of significant (flow > 270cm/s with visible plaque) carotid vessel disease in our series was 1.7%. The prevalence of aortic dilatation >3cm was 2% with 0.05% overall found to have dilatation >5cm. Carotid ultrasound screening of asymptomatic people is not recommended in Australia for stroke prevention based on a high yield of false positives from screening and limited benefit of surgery. Primary prevention of cardiovascular disease is a major health strategy in the Australian public and private health care sector. Secondary prevention of cardiovascular disease in general practice and referred medical practice is strongly promoted in Australia and depends on early identification of disease. However, identification of asymptomatic disease is not as readily available to Australians as tertiary prevention and management of established disease. Indeed Australian recommendations are against carotid ultrasound screening due to perceived prevalence of disease as <1%. Australian guidelines for screening for AAA follow US guidelines, screening men aged between 65-75 years of age if they are smokers1. The NNS (50) in our sample, supports current recommendations in Australia of ultrasound screening for AAA, though without the restriction of age and smoking status. Our conclusions are that a significant proportion of the population have vascular disease identifiable by community ultrasound screening. With the availability of medical and surgical management, the place of screening asymptomatic people should be re-evaluated and perhaps expanded. Contemporary diagnostic evaluation - update N.B. Piller Lymphoedema Research Unit, Department of Surgery, School of Medicine, Flinders University, Adelaide, South Australia neil.piller@flinders.edu.au Often we have made assumptions about the reasons for the swelling and often have attributed it to some prior surgery or radio-therapeutical intervention or to a poorly formed lymphatic system or lymphatic pump pressure fault. The more holistic reasons underlying it are sometimes ignored, that is the effect of medications (Ca antagonists, Beta blockers, antipsychotics etc), the impact of kidney, liver or heart failure (hypertension or elevated venous pressure) or local events like DVT, phlebitis, stripping etc. Contemporary diagnosis must be more comprehensive and recognise and pick out these other potential confounders as they are an important part or an accurate and differential diagnosis. Lymphoedema (and other oedemas) are most commonly determined by some history taking, circumferential measurement (and sometimes volume determination based on that) or on plethysmography. Lymphoedema (unlike oedema) is more than just fluid accumulation. As it progresses (through an inability of the lymphatic system to clear cytokines, lymphokines and adipogenic factors and a range of other high molecular weight substances and associated fluids), it develops from fluid rich, through a fatty phase to a fibrous stage, with varying amounts of each generally epifasically and varying often for each lymphatic territory. Fluids can be detected by Bio-impedance Spectroscopy (BIS) and Tissue Di-electric Constants (TDC). Their accumulation is the first sign of lymphatic failure. The fluids detected by BIS are generally limited to whole limbs or segments but some studies have been able to show differentiation of fluids in the 4 breast quadrants. Tissue fluids detected by TDC can be at depths from 1 mm down to a few cms. But what has happened/what is happening to the lymphatic system to cause the fluid accumulation? This can best be answered by either lymphoscintigrams (useful for deep and superficial functioning and failure, performed under standard activity), the use of Indo-cyanine Green (useful for superficial system lymphatic location and function), and perhaps Gadoteridol in combination with CT or MRI. What about the fatty and fibrous stages? The middle stage is a little harder to detect specifically an requires MRI or US, although in a clinic examination for the pea de orange and lumpy appearance of the skin can give a useful but non objective measure. Fibre build up and location is a little easi- Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 47

er. Many will still use the Stemmer sign but only on the base of the toes and not other lymphatic territories and also don t make an attempt to objectify it. Tonometry has been used to objectively assess tissue hardness (resistance of the tissues to compression) since the 70s. More recently other techniques based on the same principle such as Indurometry refined in Flinders Biomedical Engineering are proving an easier and more reliable way. So we can measure Fluids and Fibre in the tissues relatively easily and objectively but for many it s not done. Often when we do make measures of fluids in the limbs and make assumptions of their change over time we are wrong since we do not consider limb components and the reasons why a limb may change in size (it s not always due to fluids). We don t think holistically enough, and don t help the lymphatic system in reducing its load (dealing with hypertension, oedema causing medications etc). So we send out patient down a wrong treatment path, or think the lymphoedema is worse when it s better, or worse, improved when it s not! Clinical applications of novel angiographic scoring system M. Jackson, C. Krampl 1 1Griffith University Gold Coast, Queensland, Australia m.jackson@coastvascular.com.au We aim to demonstrate the clinical utility and validity of a novel infra-inguinal angiographic scoring system. Objective assessment of anatomical data pertaining to severely ischaemic limbs is important to allow stratification of groups and fair comparison of techniques within research. Additionally, we will discuss relevant clinical applications. This novel scoring system (A) was adapted from the established Bollinger method (B) with purposeful weighting of scores towards the below knee segment. It allows for comparing serial observations and may also have a predictive role with regard to clinical outcomes. We retrospectively assessed a total of 218 limbs with A as well as two other well established scoring methods; the Bollinger Scoring System (B) and TASC II infra-inguinal classification (T). This was conducted in a blinded manner independently by a consultant surgeon and registrar. Demographics, risk factors and outcomes were also recorded. A was on average 12.7% quicker to complete than B. It was also more reproducible with a +5.2% to -6.2% intra-observer variability (95% CI) whilst B scores showed a difference of +15.8% to -13.9% (95% CI). A and B results correlated well with each other but neither correlated well with T. Scores also correlated with Rutherford classification (p=0.001) and when compared to the number of risk factors (p=0.015) (Kruskal-Wallis test). A correlated well with patient survival on Mann-Whitney plots (p=0.0001). A threshold score of <60% in the below the knee segment for A correlated with amputation rates and amputation free survival on Kaplan-Meier analysis (p=0.02 & p=0.0003 respectively). This simplified angioscoring method which is weighted towards the below knee arteries was found to be reproducible, correlated better with clinical indicators (established comorbidities) and clinical outcomes (limb salvage and overall survival). Is aspirin still the drug of choice for management of peripheral arterial disease? P. Poredoš University Clinical Centre Department of Vascular Disease Ljubljana, Slovenia pavel.poredos@kclj.si Antiplatelet drugs represent one of the basic options for management of patients with different atherosclerotic diseases. Aspirin is the oldest and most often prescribed antiplatelet drug. The efficacy of aspirin depends on the clinical characteristics of the treated population and probably also on the type or location of the atherosclerotic disease. It seems that it is most effective in coronary patients with clinically unstable disease, less effective in prevention of cerebrovascular incidents and its efficacy is uncertain in peripheral artery disease (PAD) patients. One of the first meta-analyses (Antithrombotic Trialists Collaboration ATC) indicated that antiplatelet drugs also significantly reduce cardiovascular events in patients with PAD. However, only one third of the PAD patients included were treated with aspirin, while the rest received other anti-platelet drugs. The latest ATC meta-analysis of a randomized control trial of aspirin therapy involving patients with diabetes and PAD demonstrated no benefit of aspirin in reducing cardiovascular events. Also in patients with preclinical PAD (pathological ABI) aspirin did not result in a significant reduction of vascular events. The new anti-platelet drugs prasugrel, ticagrelor and picotamide seem to be more effective than aspirin in PAD patients, particularly in diabetic patients with PAD. In conclusion, antiplatelet drugs are effective in prevention of cardiovascular events in different atherosclerotic diseases, including PAD. However, recent studies indicated that in PAD patients aspirin is less effective than in coronary artery disease. New anti-platelet drugs showed marginal superiority over aspirin without definite advantages. 48 INTERNATIONAL ANGIOLOGY August 2014

Aspirin thus remains the first line of antiplatelet drug for secondary prevention of cardiovascular events in PAD patients and clopidogrel as its effective alternative. Furthermore, new studies on PAD patients are necessary to better define the role of anti-platelet agents in these patients and one of the promising ways of access to antiplatelet treatment would be personalized anti-platelet therapy. Anticoagulant drugs for the management of peripheral arterial disease (pad) M. Jezovnik University Clinical Centre Department of Vascular Disease Ljubljana, Slovenia matejakaja@gmail.com Antithrombotic drugs (antiplatelet drugs and anticoagulants) represent one of the basic options for prevention of progression and thromboembolic complications in patients with peripheral arterial disease (PAD). Aspirin and other antiplatelet agents were extensively evaluated and it was shown that some antiplatelet drugs significantly reduce cardiovascular events and probably also prevent progression of local disease in PAD patients. However, a few randomised controlled trials have studied long-term effects of anticoagulants and compared the effects of antiplatelet agents with oral anticoagulants in PAD. In general, the effectiveness of oral anticoagulants in reducing vascular morbidity and mortality is still uncertain. PAD patients are at high risk for atherothrombotic events and are more prone to bleeding complications in comparison to other vascular disease patients. Oral anticoagulant therapy alone or in combination with aspirin was in PAD patients not shown to be more effective than aspirin alone in prevention of cardiovascular events. Furthermore, the reduction of ischaemic events by oral anticoagulants was associated with a significantly increased risk of bleeding. Oral anticoagulants have been shown to be superior to aspirin only for prevention of infrainguinal bypass occlusion of venous grafts if the bypass is at high risk for occlusion. There are some positive experiences in the efficacy of use of anticoagulant drugs in the prevention of reoclusion after successful local thrombolytic treatment of the occlusion of peripheral arteries, particularly in patients with the reduced outflow. Moderate intensity of warfarin treatment would be acceptable in the presence of coexisting indications for anticoagulation such as atrial fibrillation or recent venous thromboembolism. Novel anticoagulants so far were not approved for secondary prevention of atherosclerosis. Direct thrombin inhibitors and anti-fxa-inhibitors, are targeting at the crucial phase of thrombin generation with the potential to prevent thrombosis and progression of atherosclerosis alike. It is expected that combination of novel anticoagulant drugs with antiplatelet agents could reduce ischaemic events but would probably be associated with an increased risk for major bleeding. The combination of only one antiplatelet agent with one new oral anticoagulant, of which rivaroxaban at a dosage of 2.5 mg twice daily seems to be the candidate for patients with PAD. In conclusion, oral anticoagulants have a limited role in patients with symptomatic PAD. Objective proof for oedema reduction N.B. Piller Lymphoedema Research Unit, Department of Surgery, School of Medicine, Flinders University, Adelaide, South Australia neil.piller@flinders.edu.au Lymphoedema progresses through three stages, firstly fluid rich, then fatty and finally one of significant skin and tissue changes most related to fibrous tissue formation. These changes are epifascial in the limbs. We must realise that each lymphatic territory may progress at a different rate. Our concern is in this case, oedema and its change since that is the sign of current lymphatic failure. Fluid accumulation usually in the epifacial compartment is the most common sign of lymphatic failure whether that failure is related to the superficial or deep lymphatic system. In the limbs, at least, sub-fascial fluid accumulation is minimal, due to the non elastic nature of the deep fascia and hard to detect due to its depth. I acknowledge that there are high level accurate often hospital based means of detecting oedema, MRI, US etc, but here we are concerned with the more common clinic based ones. Commonly, circumference measurements and derived volumes or plethysmography or perometry are used to indicate differences between one limb or section of it and another with respect to oedema/ lymphoedema. Even at a static point this is frought with possible inaccuracies unless limb dominance is taken into account. Even worse, over time since a limb consists of three major variable components, fluids, fats and muscle, a limb which gets bigger is not necessarily worse in terms of oedema and one which is smaller is not necessarily better. We need then to specifically detect fluids, sometimes in the whole limb, sometimes in a segment and sometimes at a given point within a lymphatic territory. Commonly we use the pitting test for this, but its often mis-used (not applied long enough) and rarely done in any area except for the dorsum of foot and maybe medial and lateral ankle. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 49

The two major contemporary modalities for dealing with this relate to Bio-Impedance Spectroscopy(BIS), the broad terms of which relate to measurement of the resistance of the various tissues to various frequencies of current flow, but with a specific interest in the low frequency resistance which is a measurement of fluids and Tissue Di-electric Constants (TDC) in which electromagnetic fields are passed through the tissues. The TDC is proportional to the amount of fluid in the tissue at a depth dependant on the head size of the unit. Other strategies include measuring transepidermal water loss. While this can indicate the skin s barrier function it s an indication also of fluids superficially. Combined with this is often a temperature probe, which can provide information about possible superficial dilation, infection etc is useful. Both have their benefits and together with circumference and volume measurements can provide an accurate picture of current lymphatic functional status in the limb or area. Both have limitations but represent what I believe are current best practice standards for fluid measurement. Their benefit really comes from the ability to detect early signs of lymphatic failure. In this respect, BIS has been shown to be able to detect this up to 8 months before a patient realises or it can be measured by volume determination. Four-layer compression is an effective treatment for lower limb venous ulceration A. Giannoukas 1, N. Rousas, M. Papadopouloy, A. Drakoy 1, R. Stankova-Salta 2, C. Nakos 3, V. Salepstis 1, K. Spanos 1, A. Athanasoulas 1, 1Department of Vascular Surgery, University of Thessaly, Larissa, Greece 2Department of Physiotherapy, University of Thessaly, Larissa, Greece 3Department of Psychiatry, University of Thessaly, Larissa, Greece rousasnik@gmail.com Aim. Compression bandaging is considered as an effective treatment of venous ulcers. However, this mode of treatment has not been adopted widely in clinical practice in Greece, being used occasionally and with no reported data. Therefore, our aim was to assess our initial experience with the use of the only commercially available four- layer bandaging system in our country as standard care for patients with venous ulcers. Methods. Over the last 2 years we treated in our service 25 patients with a lower limb venous ulcer. Duration of ulcer s presence ranged from 6 months to 2.5 years and all patients had received previously treatment with various forms of foam pad- ding. Ulcers length ranged from 2 to 20mm, width ranged from 1 to 12mm and depth from 1 to 10mm to in depth. Our multidisciplinary care included non adhesive foam padding, four-layer bandaging that was renewed 3 times during the first week and thereafter once a week, and dietary and exercise advice. Pain intensity and patient satisfaction were assessed by a Visual Analogue Scale. Results. All but one ulcer healed with our multidisciplinary care within a 2-month period. The remaining one healed after 4 months. All patients were satisfied with the result and reported that pain receded from the first session. Conclusions. Implementation of a multidisciplinary approach including four- layer compression bandaging achieved healing of venous ulcer in all cases and it appears as to be an effective treatment option in daily practice. Factors associated with short-term endoleak development after EVAR with the use of new generation endografts A. Giannoukas, V. Saleptsis 1, K. Spanos 1, K. Antonopoulos 2, C. Karkos 3, C. Ioannou 4, D. Tsetis 5, I. Kakissis 2, K. Papazoglou 3, C. Liapis 6, 1University Hospital of Larisa, Greece 2University Hospital Attikon of Athens, Athens, Greece 35th General Surgical Department of Hippokration Hospital of Thessaloniki, Thessaloniki, Greece 4Vascular Surgery Unit of University Hospital of Heraklion Crete, Heraklion, Greece 5Radiology Department of University Hospital of Heraklion Crete, Heraklion, Greece 6University Hospital Attikon of Athens, Athens, Greece. agiannoukas@hotmail.com Objectives. To assess factors associated with shortterm development of endoleak after endovascular repair (EVAR) using new generation endografts. Methods. Retrospective analysis of prospectively collected data from 400 EVARs with Endurant, Zenith LP, Excluder C3, Anaconda and Ovation. Patients demographic data, risk factors, type of operation (elective vs. urgent), proximal fixation type, graft configuration (bifurcated vs. uni-iliac), type of intervention (elective vs. emergency) and AAA neck diameter, length, angle, calcification and thrombus and sac diameter were analysed in respect to endoleak and sac expansion during the first post-operative year. As per protocol CT scanning was performed on 1st month and 1st year. Multivariate and logistic regression analysis was undertaken. Results. In 32 cases the neck angle was >60, in 9 the proximal length neck was <10mm and in 49 was >10mm but <15mm. Type 1a endoleak was present in 13 cases (6 suprarenal fixation) on the 1st month and in two additional cases on 1st year. In logistic regression analysis, only sac diameter > 50 INTERNATIONAL ANGIOLOGY August 2014

55mm (p=0.031), neck diameter >30 mm (p=0.032) and infra-renal fixation were associated with type 1a endoleak. Type 2 endoleak detected in 75 cases on 1st month were present also on 1st year. Six additional cases were identified at 1st year. No association was found with type 2 endoleak. Sac expansion on 1st year was detected in 293 cases and it was associated with only the presence of type 2 and 1 endoleak (p=0.019). No rupture occurred. Conclusions. New generation endografts perform satisfactorily in short-term even in aneurysms with severely angulated and short necks. Type 1a endoleak is associated only with sac and neck diameter and infra-renal fixation. Type 2 endoleak is not related to any endograft or AAA geometric characteristics and it requires close surveillance as it is associated with sac expansion. Experience with endovascular repair of complex abdominal aortic aneurysm Y. Gu, L. Guo, L. Qi, H. Yu, X. Li, B Chen, Z. Tong, X. Wu, J. Guo, Z. Wang Beijing, China guojianming@aliyun.com Purposes. To explore the results of endovascular repair of complex infrarenal abdominal aortic aneurysm. Methods. Data of endovascular treatment of 65 cases with complex infrarenal abdominal aortic aneurysm were retrospectively analyzed. Complexity of abdominal aortic aneurysm included: short neck (15 cases, 23.1%), severe angulated neck (28 cases, 43.1%), bilateral involvement of common iliac arteries (5 cases, 7.7%), difficulty in sending the delivery system because of stenosis or occlusion in arterial access (5 cases, 7.7%) and other complicated types of aneurysm (2 cases, 3%). All the cases underwent EVAR. The short neck was overcome by relatively proximal deployment of the stent with reference to the distal renal artery; the severe angulation of the aneurysm neck was relatively straightened to guarantee safe stent deployment; unilateral internal iliac artery was kept patent with either stenting or bypass grafting in case of iliac aneurysm. Results. Procedure success rate was 100%. 23 cases /35.4%) suffered from immediate endoleak, including type I in 6 cases /26.1%), type II in 14 cases /60.9%), type III in 3 cases /13.0%). No procedurerelated death occurred. Follow-up 60 cases /92.3%), mean follow-up period was 3.5 years. 5(8.3%) cases died of diseases other than aneurysm. One case had stent migration in 6 months after operation and underwent further endovascular treatment because of endoleak. Up to 22 months follow-up revealed no stent migration or new endoleak for this patient. All other endoleaks recovered in other cases. Lower limb ischemia was found in 3 cases. One suffered from graft migration and ischemia was alleviated by femofemoral bypass; the other 2 cases suffered from stentt folding, and treated with bare stent implantation. Conclusions. As the improvement of endovascular technology and equipments, many complex abdominal aortic aneurysm can also be treated with good results. Prospective randomized trial of endovenous laser ablation of great saphenous veins with 1470 nm diode laser and 2ring fibers comparing compression therapy 0 days, 7 days and 28 days after therapy. U. Maurins, J. Rits 1, A. Kadiss 1, S. Prave 1, E. Rabe 2, F. Pannier 3 1Dr Maurins Vein Clinic, Riga, Latvia 2Department of Dermatology, University of Bonn 3Department of Dermatology, University of Cologne uldis.maurins@venucentrs.lv Objectives. To assess outcome one month after endovenous laser ablation (EVLA) of incompetent great saphenous veins (GSV) with 1470 nm diode laser (Ceralas E, biolitec) and a new 2Ring fibers (biolitec) comparing compression therapy 0 days, 7 days and 28 days after therapy. Methods. 94 patients with primary incompetence of GSV underwent EVLA with 1470 nm laser and 2Ring fibers. Randomisation was conducted immediately after EVLA in three groups: First, with compression stockings (23-32 mmhg), worn during the day for 1 week; Second, with compression stockings (23-32 mmhg), worn during the day for 4 weeks and third - without compression. The mean (s.d.) LEED were 63(15) J/cm, 65(20) J/cm and 64(16) J/cm respectively. Follow-up investigations after 1, 7 and 28 days included complications, occlusion rate, vein diameter, VCSS, QoL and pain on a scale between 0 and 10. Results. After a mean follow-up period of 28 days, occlusion rate was 100% in all three groups. Diameter of GSV 3 cm below saphenofemoral junction dropped 43% (0.7 to 0.4 cm), 39% (0.8 to 0.5 cm) and 39% (0.8 to 0.5 cm) respectively. The mean /s.d.) post-intervention pain scores (scale 0-10) were 0.4(0.7), 0.7(1.0) and 0.8(0.8) respectively. In al groups VCSS improved from 6 to 3 after 28 days. The average (range) time to return to normal activity was 0.5(0-3), 0.3(0-1) and 0.3(0-2) days respectively. The average (range) time to resume work was 1.3(0-10), 0.9(0-8) and 0.8(0-7) days respectively. Conclusion(s). EVLA of GSV with 1470 nm diode laser and 2Ring fiber is a minimally invasive, safe and efficient treatment option with a high success Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 51

rate. Use of compressions stockings after EVLA with 1470 nm laser and 2Ring fiber has no additional benefit to the following outcome measures: efficacy, pain, vein diameter, time of work and normal activity, symptoms, complications and VCSS. Prevalence of venous thromboembolism treated in French and USA hospitals F. Allaert, E. Benzenine 1, C. Quantin 1 1Department of medical information, CHU Dijon, France allaert@cenbiotech.com Objective. Describe the national prevalence of deep vein thrombosis (DVT) and pulmonary embolism (PE), among patients hospitalized in private and public French hospitals and to compare it to those described in US Hospitals. Methods. The statistics are from the national PMSI MCO databases inspired by the US Medicare system. They are complied each calendar year from the RSA (anonymous discharge summary) files forwarded and validated by health establishments with admissions in medicine, surgery, obstetrics and odontology (MCO). The anonymous summaries are encoded using the 10th edition of the international classification of diseases. The codes used for characterizing VTE are I801 to I809 for DVT and codes I260, I269 for PE. The analyses identify all VTE, DVT without PE (DVT) and PE with or without previous/associated diagnosis of DVT. The study data cover the period 2005 to 2011. The French data are compared to those issued in the Morbidity, Mortality Weekly Report of the Centre for Disease Control and Prevention. Results. Data from the national database reveal that over the period 2005 to 2011 the incidence of hospital stays came to 860 343 (1.09%) for VTE, with 428 261 (0.543%) for DVT without PE and 432 082 (0.548%) for PE. All told, the mean number of VTE hospitalized per year over the period was 122 906, including 61 180 for DVT and 61 726 for PE. Out of the French national population older than 18 years old in 2010 (49.7 million inhabitants), those 122 906 admissions for VTE correspond to an incidence of 247 hospitalisations for 100 000 vs. 239 in the USA for the VTE, of 124 vs. 118 for the DVT without PE and of 123 vs. 121 for the PE which is very similar. These instances of VTE occurred in France for 43.4% in men vs. 45.8% in the USA and 56.6% vs. 54.2% in women. Conclusion. French VTE incidence is high and similar to those described in the USA. These results point out an alarming situation that should make us question the quality of prevention implemented and/or its effectiveness. VTE prevention policies must be strengthened in hospitals for the sake of patients and healthcare savings alike. New trends for pathophysiology and diagnosis in critical limb ischemia P. Antignani Rome, Italy mc0587@mclink.it Factors that influence blood flow in critical leg ischemia (CLI) to affected tissues include the location, degree, and length of the stenosis or occlusion, blood viscosity, blood flow velocity, perfusion pressure, and extent of angiogenesis and arteriogenesis. These hemodynamic factors are diseased in patients with CLI, leading to a decrease in ankle blood pressure. While the macrovascular changes associated with PAD are often the initial events of CLI, the response to chronic ischemia also results in microvascular dysfunction. There is an alteration in structure and function of endothelial cells and the activation of white blood cells and inflammation. Ischemia with endothelial trauma results in increased free radical production, inappropriate platelet activation, and leukocyte adhesion. Muscle ischemia is associated with an increase in oxidative stress, that occurs when the cell or tissue fails to detoxify the free radicals produced during metabolic activity. Free radicals damage proteins, lipids and nucleic acids. The production of oxygen-free radicals may be a unifying mechanism of vascular and skeletal muscle injury in CLI. Repeated episodes of ischemia and reperfusion during recovery may promote oxidative injury to endothelial cells, muscle mitochondria, muscle fibers, and distal motor axons. Mitochondria are the major source of free radicals within the cell and somatic mutations in mitochondrial DNA are an important marker of oxidant injury. Several studies have revealed increased mitochondrial content in muscle of patients with CLI. That might improve oxygen extraction under ischemic conditions or could reflect a compensatory mechanism for any intrinsic abnormality in mitochondrial oxidative capacity. Conditions of metabolic stress leads to accumulation of corresponding acylcarnitine in the tissues and plasma, emphasizing the importance of altered skeletal muscle metabolism in the pathophysiology of PAD. New trends in medical treatment in critical limb ischemia. current state and future directions P. Poredoš University Clinical Centre Department of Vascular Disease Ljubljana, Slovenia pavel.poredos@kclj.si Atherosclerotic critical limb ischemia (CLI) is manifested by ischemic rest pain, non-healing 52 INTERNATIONAL ANGIOLOGY August 2014

ulcers or gangrene. Patients diagnosed with CLI are at very high risk of major amputation and cardiovascular morbidity and mortality and experience poor physical function and quality of life. The goals of treatment for CLI are relieving ischemic pain, healing ulcers, preventing limb loss, improving patient function and quality of life, and prolonging survival. Prompt surgical or endovascular revascularization is recommended as the first choice of treatment for limb salvage in CLI. However, only a part of these patients are candidates for revascularization procedures. In non-reconstructable patients with stable rest pain and tissue loss, evidence suggests that prostanoids, dedicated wound care programs, and several mechanical devices, such as spinal cord stimulation, intermittent pneumatic compression, and hyperbaric oxygen therapy, can alleviate ischemic symptoms and improve limb salvage. Current medical armamentarium used in treating ischemic wounds also includes ultrasound and negative pressure wound therapy. Therapeutic neovascularization, including gene- and cellbased approaches, is a novel promising tool in the management of CLI under ongoing investigation. All patients with CLI should receive cardiovascular risk reduction therapies, focused on optimizing antiplatelet therapy and intensive risk factor management, to reduce cardiovascular event rates. Preliminary results from a screening programme of lower limb arterial occlusive disease in elderly males in central greece A. Giannoukas 1, N. Rousas, G. Makrygiannis 1, V. Saleptsis 1, K. Spanos 1, C. Argyriou 1, S. Koutsias 1, 1Department of Vascular Surgery, University of Thessaly, Larissa, Greece agiannoukas@hotmail.com Aim. To estimate the prevalence of peripheral arterial disease (PAD) in males over 60 years and to highlight the level of risk factor management in the primary care setting of a population in the region of Thessaly, Central Greece. Methods. From 6/2008 to 10/2013 600 males with a mean age 72 years (70-92 years) have been screened. The ankle-brachial index (ABI) and their clinical data including risk factors and medication were recorded. The presence of PAD was confirmed when the ABI was less than 0.9. Asymptomatic PAD was defined by the presence of a pathologic ABI but without history of limb revascularization or previous consultation by a vascular physician. Results. The overall prevalence of PAD was 8% (48/600). Among 48 subjects with PAD according to our criteria, 83.3% (40/48) were under medical therapy for hypertension, 58.3% (28/48) for dyslipidemia, 27% (13/48) for diabetes mellitus and 52% (25/48) for coronary artery disease, while 56% (26/48) had ever smoked. The subset of subjects with known diagnosis of PAD, were those having the worst ABI ranging from 0.6 to 0.4. Only 16.6% (7/48) of the subjects with confirmed PAD were aware of their problem. Similar was the level of awareness regarding the subjects problem among their primary care physicians. Conclusions. Our preliminary results show a high prevalence of PAD among males over 60 years in our region. Also it appears that PAD diagnosis is often overlooked from primary care physicians and thus the coexistent risk factors are not appropriately prevented. These findings justify the need of establishing strategies to raise physicians and public awareness. Thrombophilia panel results in patients after the first venous thromboembolic event in view of recommended selection criteria for thrombophilia testing J. Hirmerova 1, J. Seidlerova 1, I. Subrt 2, J. Slechtova 3 12nd Department of Internal Medicine, University Hospital, Charles University, Pilsen, Czech Republic 2Institute of Medical Genetics, University Hospital, Charles University, Pilsen, Czech Republic 3Insitute of Clinical Biochemistry and Haematology, University Hospital, Charles University, Pilsen, Czech Republic hirmerova@fnplzen.cz Background. The last IUA Guidelines recommend thrombophilia testing after the first event of venous thromboembolism (VTE) only in selected cases. Patients older than 40 years with a provoked event and all above 60 should not be tested. However, rigid compliance with these selection criteria may theoretically cause missing a significant disorder. Aim. To compare thrombophilia workup results in patients after the first VTE (without active malignancy), meeting or not meeting the proposed selection criteria. Methods. 544 individuals underwent thrombophilia testing (molecular genetic and coagulation assays, ELISA for antiphospholipid antibodies). Events associated with injury, surgery, immobility, inflammatory disease, oestrogen use or pregnancy were considered provoked. Homozygous factor V Leiden or prothrombin gene mutation, protein C, S or antithrombin deficiencies, antiphospholipid syndrome or combination of 2 thrombophilias were evaluated as strong thrombophilia. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 53

Results. In the patients above 40 (n=416), the prevalence of thrombophilia was 25.4% in provoked events and 28 % in unprovoked events (P=0.55) and the prevalence of strong thrombophilia 7.3% and 8.8%, respectively (P=0.59). In the patients above 60 (n=243) and under 60 (n=301), thrombophilia was found in 27.6% and 29.2%, respectively (P=0.67) while the prevalence of strong thrombophilia was 9.1% and 4.7%, respectively (P=0.041). Factors associated significantly with positive thrombophilia finding were positive family history of VTE (including superficial vein thrombosis) OR 1.80; 95% CI 1.71-2.77 and proximal location of deep vein thrombosis (DVT) OR 1.94; 95% CI 1.25-3.02. Conclusion. In the group of 544 patients with a first VTE event, thrombophilia (including strong thrombophilia) in subjects above 40 years of age was found almost equally in provoked and unprovoked cases. Prevalence of thrombophilia was similar in the patients under and above 60 while strong thrombophilia was even more frequent in those above 60. In the whole group, thrombophilia was significantly associated with positive family history and proximal DVT location. New approach in the treatment of heparin-induced thrombocytopenia B. Chong, Z. Ahmedi, J. New, X. Jiang University of New South Wales, Sydney, Australia Heparin-Induced Thrombocytopenia (HIT) is a life threatening immune platelet disorder that affects 1-5% of patients receiving heparin therapy. HIT is mediated by an autoantibody that recognizes and binds Platelet Factor 4 (PF4) /heparin complex. The immune complex thus formed, then binds to FcRIIa receptors on platelets and causes platelet activation, and consequently initiates and continues to fuel thrombosis. Current treatment of HIT is based on (1) withdrawal of the offending drug, heparin and (2) inhibition of thrombosis with anticoagulant. There is as yet no treatment that specifically stops or extinguishes platelet activation, which drives the thrombosis in HIT. In this study we have developed a humanized antibody fragment (scfv) that binds to FcRIIa, blocks the binding of pathogenic immune complexes to platelets, stops platelet activation and consequently suppresses the thrombotic processes. The scfv was formed by joining together with a flexible linker, the variable domain of the heavy chain (VH) and the light chain (VL) of an anti- FcRIIa monoclonal antibody. The scfv was expressed in bacteria, purified from the bacteria lysates, and analysed. It was found that the scfv inhibits HIT antibody-induced platelet aggregation, 14C-serotonin release and thrombus formation under high-shear flow condition. Combining drug-eluting stents and stent-grafts for the treatment of femoro-popliteal occlusive disease: early outcomes R. Huilgol, D. Hagley Department of Vascular Surgery, St Vincent s Hospital, Sydney, Australia Aim. To investigate the outcomes of combining drug-eluting stents with stent-grafts (DES+SG) versus stent-grafts (SG) alone in the treatment of femoro-popliteal occlusive disease. Methods. All patients undergoing stent-graft treatment between 2010-13 were identified. Patency outcomes were compared between two cohorts of patients. Primary patency was defined as freedom from binary restenosis. Results. There were 37 SG procedures and 23 DES+SG procedures. The most common indication was claudication. There was no mortality, major morbidity or major amputation in either cohort. 12 month primary patency was 83% SG versus 88% DES+SG (p = NS). There were more reinterventions in the SG group. Conclusion. DES+SG procedures are safe. Early results show a non-significant trend towards improved patency in the DES+SG group. Management of acute and chronic pain R. Halliwell University of Sydney and Westmead Hospital, Sydney, Australia Management of pain in the patient with an ischaemic wound can be challenging. In these patients the wound may be slow to heal and have multiple mechanisms of pain. In the worst scenario the wound may be non-healing and need a chronic or palliative approach to pain management. A mechanisms-based approach to pain should consider somatic, neuropathic and sympathetic causes of pain. Severe ischaemic pain responds poorly to further increase of opioids, and different classes of analgesics will need to be added to the patient s pain management. This can include anti-neuropathic analgesics such as the gabapentinoids or NMDA antagonists like ketamine. Methadone may be beneficial due to its combined opioid and NMDA antagonist effects. In the usual clinical scenario the wound will respond to revascularisation and will be expected 54 INTERNATIONAL ANGIOLOGY August 2014

to heal. During wound dressings the predominant pain mechanism will be somatic pain. Depending on the extent of pain from the dressing change a decision will need to be made whether the pain can be managed using analgesic agents alone or if general anaesthesia is required. A key consideration is patient safety in this decision making step. Convenience for the treating clinician should not outweigh patient safety. Analgesic options include inhalational agents such as nitrous oxide or methoxyflurane. Prolonged or frequent administration of these agents can lead to toxicity. Intravenous agents include the opioids, benzodiazepines and ketamine. Dressing changes done on the ward must have an end-limit of the patient remaining conscious while having adequate monitoring and training of the supervising clinicians. Chronic or non-responsive pain in the patient with an ischaemic limb can be challenging. When the wound is persistent, and non-healing, then decisions must be made about whether to consider the patient s wound management from a palliative care perspective. This may mean that it is justifiable to use drug doses and combinations of analgesics that wound normally not be accepted. Long-term neuraxial analgesia (epidural or intrathecal) may be a suitable option in endof-life care for the patient with a non-treatable ischaemic wound. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 55

ELECTRONIC POSTERS Low concentration detergent sclerosants stimulate white blood cells apoptosis in vitro O. CooleyAndrade 1,2, W. XianGoh 2, D. Connor 1,2, K. Parsi 1,2 1Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent s Centre for Applied Medical Research, St. Vincent s Hospital, Sydney, Australia 2The University of New South Wales, Sydney, Australia The aim of this study was to investigate the mechanism of cellular death in human leukocytes following exposure to low concentrations of Sodium Tetradecyl Sulphate (STS) and Polidocanol (POL). Confocal microscopy and flow cytometry were used to discriminate between cellular activation, apoptosis and oncosis. Human leukocytes were isolated and labelled with different antibodies for activation (lactadherin), apoptosis (lactadherin, Caspsase 8 and Bax) and oncosis (poromin). Leukocytes stimulated with low concentration detergent sclerosants showed a viability of 40% after exposure to low concentrations of STS and POL (0.3% and 0.6% respectively). The exposure of phosphatidylserine using lactadherin increased in a time and dose dependent manner. Both Caspase 8 and Bax expression were increased following STS stimulation, Bax expression only was significantly increased on following POL stimulation. Both STS and POL increased the expression of porimin. Both STS and POL trigger apoptosis and oncosis in leukocytes. STS activates both the extrinsic and the intrinsic pathways of apoptosis. The activation of apoptotic pathways seems to be a Ca2+dependent process Ex-vivo and in vitro analysis of coagulum formation after administration of detergent sclerosants D Connor, O. CooleyAndrade 1, J. Weisel 2, K. Parsi 1 1St Vincent s Centre for Applied Medical Research, St. Vincent s Hospital, University of New South Wales, Sydney, Australia 2Perelman School of Medicine, University of Pennsylvania, USA The aim of this study was to determine the microscopic characteristics and structural composition of ex-vivo coagulum/trapped blood postsclerotherapy. Coagulum/trapped blood was identified and extracted with a 20ml syringe during sclerotherapy. Samples were stained for fibrinogen and analyzed with fluorescence microscopy or dehydrated and coated in gold palladium and analyzed by scanning electron microscopy. On fluorescence microscopy fibrin strands in trapped blood appeared to be thinner than the strands found in spontaneous thrombus samples. Trapped blood displayed a disorganized meshlike pattern. On scanning electron microscopy, a disorganized pattern was evident. There was a small number of clusters of platelets and multiple polyhedrocytes generated during the platelet contraction stage of the clot. There were also multiple debris and structures resembling casts of cells. In conclusion, coagulable/trapped blood seen after sclerotherapy shares similarities with spontaneous thrombus formed in superficial veins. Trapped blood contains a vast number of polyhedrocytes confined into the fibrin strands. They also present a reduced number of clusters of platelets. However, the distribution of the fibrin strands is different showing a disorganized, mesh-like pattern and the strands seem to be thinner. There were also an increased number of cast structures that have not been described previously The effect of temperature on sclerosant foam stability and structure X. Tan 1,2, G.C. Valenzuela 1,2, K. Wong 1,2, D. Connor 1,3, M. Behnia 2, K. Parsi 1,3 1Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent s Centre for Applied Medical Research, Sydney, Australia 2School of Aerospace, Mechanical & Mechatronic Engineering, University of Sydney, Sydney, Australia 3Faculty of Medicine, University of New South Wales, Sydney, Australia Sclerosant foams are aqueous and break down under the influence of gravity, pressure, and temperature. The aim of this study was to investigate the effects of temperature on foam stability and microstructure. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 57

Sodium tetradecyl sulphate (STS) and polidocanol (POL) liquid and foam (1 þ 4, liquid-plus-air fraction) were investigated in a range of concentrations (0.5%, 1.5%, 3.0%) and temperatures (10-40ºC). Surface tension was measured by the Du Nuoy ring method. Liquid drainage from foam was measured and documented by serial photography. Both pre- and post-cooling variations were investigated. Sclerosant foam microstructure was analysed by light microscopy, with bubble counts and diameter assessed using MATLAB. Surface tension decreased at higher temperatures. Surface tension of POL was higher than STS at concentrations tested. POL foam halftime increased significantly at higher concentrations while the half-time of STS foam was not affected by concentration. Heating the sclerosant foam above the ambient temperature reduced its half-time while cooling below the ambient temperature prolonged the half-time. Both pre- and post-cooling of the foams resulted in significant prolongation of half-times when compared to no cooling. Maximum stability of the two sclerosant foams tested was achieved at 10ºC. Conclusion. Foam drainage was prolonged at colder temperatures, and surface tension increased at colder temperatures. POL foam was more viscous and stable at colder temperatures than STS at high concentrations The effect of dilution with water or saline on the critical micelle concentration of detergent sclerosants K. Wong 1,2, T. Chen 1,2, D. Connor 2,3, M. Behnia 1, K. Parsi 1,2, 3 1School of Aerospace, Mechanical & Mechatronic Engineering, University of Sydney, Sydney, Australia 2Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent s Centre for Applied Medical Research, Sydney, Australia 3University of NSW, Sydney, Australia Low concentration commercial detergent sclerosants are available in a pre-diluted format, diluted using sterile water, however sclerosants may also be diluted in-house, often using normal saline. The objective of this study was to determine whether the dilution of sclerosant in water or saline affects the critical micelle concentration of the sclerosant. The detergent sclerosants sodium tetradecyl sulphate (STS) or polidocanol (POL) were diluted using either water or normal saline (0.9%w/v). The surface tension of the sclerosant liquid was determined using the Du Nuoy ring method. Using this data, the critical micelle concentration (CMC) was determined. The CMC of STS was higher than POL (0.2% vs 0.002%, respectively). The dilution of STS with saline significantly decreased the CMC of STS, when compared to STS diluted with water (0.075% vs 0.2%, respectively). The dilution of POL with saline had no effect when compared to POL diluted with water (both 0.002%). The dilution of sclerosants in-house with saline as opposed to a commercially available dilution in sterile water may have significant effects on the activity of the sclerosant for STS, but not for POL. High incidence of haemostatic defects in pigmented purpuric dermatoses D. Vekic 1,2, D. Connor 12, K. Parsi 1,2 1Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St. Vincent s Centre for Applied Medical Research, Sydney, Australia 2The University of New South Wales, Sydney, Australia Pigmented purpuric dermatoses (PPD), also known as Capillaritis, are a group of rare, chronic disorders. Although clinical presentation varies amongst PPD subtypes in its distribution, the dermatoses are characterised by a symmetrical purpuric cayenne pepper rash confined to the lower extremities. Histopathology of PPD shows extravasation of erythrocytes in the superficial dermis, marked hemosiderin deposition, and perivascular lymphocytosis composed primarily of CD4+ cells. The aetiology of PPD remains unknown. Medications, supplements, food additives, external contact agents, infections, exercise, gravitational forces, capillary fragility, venous insufficiency and other disease associations appear to contribute to PPD progression. More recently, immune-cell modulation of vascular haemostasis has been proposed as a key factor in PPD. We hypothesise that PPD was associated with a combination of venous disease and platelet dysfunction We present a review of 68 patients with biopsy proven PPD who were seen over a 10 year period. Patient reviews included clinical and histological assessment, Doppler ultrasound for vein competence and blood testing for haemostatic function. Coagulation abnormalities where analysed by testing for factor deficiencies and von Willebrand factor (vwf). Platelet function abnormalities were assessed by testing with platelet function analyser 100; and platelet aggregation studies by light transmission aggregometry (LTA) and impedance aggregometry (Multiplate). All patients who were identified to have reversible contributors to disease progression (such a medication, supplement use or food items) dis- 58 INTERNATIONAL ANGIOLOGY August 2014

continued their use and were reassessed a month later. Venous incompetence was found in an overwhelming 84% majority of patients. Over half of the patients in this study were found to have an underlying haemostatic abnormality, with platelet dysfunction being more common than coagulation abnormalities. After cessation of reversible factors, most patients had improvement or complete resolution of their PPD. Our results show a previously unreported high percentage of PPD patients with haemostatic abnormalities. We propose that platelet dysfunction and coagulation abnormalities have a correlation with PPD aetiology. Further studies are needed to evaluate this association Sclerosant foam structure is strongly influenced by the liquid air fraction E. Cameron 1,2, T. Chen 1,2, D. Connor 2,3, M. Behnia 1, K. Parsi 1,2,3 1School of Aerospace, Mechanical & Mechatronic Engineering, University of Sydney, Sydney, Australia 2Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent s Centre for Applied Medical Research, Sydney, Australia 3University of NSW, Sydney, Australia The aim of this study was to determine the effects of sclerosant foam composition on foam structure, coarsening and liquid drainage. Sodium tetradecyl sulphate (STS) and polidocanol (POL) foams were investigated at a range of concentrations (0.5%-3%) and liquid air fractions (LAF, 1+2-1+8). Foam was prepared neat using a 3-way stopcock and injected into a 3mm PVC vein model filled with either saline or blood. Liquid drainage and bubble count and size were documented by serial photography. Liquid drainage was faster in the vertical position than the horizontal one. In all variations, very small bubbles (diameter <30 mm) were generated initially that coarsened to form microfoams (<250 mm). By 3 minutes mini-foams (>250 mm) and by 7.5 minutes macro-foams (>500 mm) were formed. Following injection, the upper regions of foam coarsened faster as liquid drained to the bottom of the vessel. Wet preparations produced significantly smaller bubbles. Low concentration POL foam produced significantly higher bubble counts and coarsened slower than STS. In conclusion, foam structure is influenced by the LAF. Despite the initial formation of microbubbles in the syringe, mini- and macro-bubbles are formed in target vessels with time post injection. Sonographic anatomy of t he sural nerve in relationship to endovenous thermal ablation of incompetent small saphenous vein N. Ibrahim 1, K. Huang 1, A. Zea 1, J. Diaz 1 1Advanced Laser Vein Clinic and Sydney Centre for Venous Disease, Sydney, Australia Neurological events are well documented in association with both surgical stripping or disconnection and thermal ablation of SSV incompetence. The sural serve (SN) is most vulnerable, however, popliteal and tibial nerve are also vulnerable in the popliteal fossa. Prospective study of the sonographic anatomy of 50 Australian Patients of varying ethnic origin to determine the course of the SN and its relationship to the SSV and to apply the knowledge into an ongoing prospective study to determine outcome of endovenous radiofrequency ablation (EVRFA) in relation to SN safety. Sonographic mapping of the SN is performed on 50 Australian patients of varying ethnic origins tracing the nerve from the level of the lateral malleolus (LM) to measure the distance from the SSV at 3 reference points in lower calf. The uppermost at midcalf point at which the nerve becomes subfascial proximally. The other 3 points are located at 5, 10 and 15 cm above LM proximally, the nerve is traced to the popliteal fossa. SN was visualised in 100% of patients below the mid calf level in the epifascial plane. The nerve is adjacent to the SSV at 5 cm above the LM with no separation in 100% of the patients. Mean SSV SN separation: 7 mm at mid calf and 4mm at 10 cm above LM. EVRFA of incompetent SSV can be made safer by careful selection of entry point of the catheter, adequate tumescent infiltration and hydrodisplacement of the SN, which is easy to visualise in the epifascial plane, careful positioning of the tip of the catheter at 3 cm from the saphenopopliteal junction as well as adequate measured perivenous infiltration around the tip of the catheter. Classification and algorithmic selective management of ssv incompetence (reflux) in radiofrequency endovenous ablation (evrfa) setting N. Ibrahim 1, A. Zea 1, K. Huang 1, J. Diaz 1 1Advanced Laser Vein Clinic and Sydney Centre for Venous Disease, Sydney, Australia Endovenous ablation (EVA) for incompetence of small saphenous vein (SSV) is shown to be both effective and safer than conventional open surgery. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 59

Combined SSV and GSV reflux management (including the need to treat secondary SSV reflux in this setting) is still controversial in regard to which venous trunk to do first. This paper discusses a suggested classification and algorithmic management strategy with emphasis on secondary SSV incompetence. The SSV reflux can be classified into Solitary (or Primary) and Combined (GSV and SSV incompetence). For Primary SSV Reflux, the proximal segment ablation is appropriate. The distal segment is suited for ultrasound guided sclerotherapy (UGS) to avoid injury to the SN. SSV incompetence in Combined Reflux setting can be classified as Primary (or Dominant) and Secondary (or non Dominant fed by incompetent intersaphenous tributaries and reversible on compression of the intersaphenous tributaries). Primary Incompetence management is the same as for Solitary Incompetence. The management for Secondary SSV reflux in the combined setting consists of UGS +/- pinhole phlebectomy to the incompetent intersaphenous tributaries. If reflux is not reversed, secondary sclerotherapy could be carried out to both proximal and distal segments. Of 79 patients with SSV incompetence, 16 were found to be of the secondary category: 7 proximal and 9 distal. Incompetence was reversed in all 7 patients with proximal incompetence, with interruption/ugs of the intersaphenous incompetence. Of the 9 distal, only 5 reversed after interruption of the intersaphenous incompetence. The 4 non reversals were treated with secondary sclerotherapy. Selective Algorithmic Management of SSV is shown to meet logic in 100% of proximal SSV incompetence and only 56% of patients with distal incompetence Hydrodisplacement to safeguard sural nerve and to optimise closurefast endovenous thermal ablation (EVTA) of small saphenous vein (SSV) incompetence. N. Ibrahim 1, A. Zea 1, K. Huang 1, J. Diaz 1 1Advanced Laser Vein Clinic and Sydney Centre for Venous Disease, Sydney, Australia Neurological Events are well documented in association with both Surgical Stripping or disconnection and thermal ablation of SSV incompetence. The Sural Nerve (SN) is most vulnerable, however, popliteal and tibial nerve are also vulnerable in the popliteal fossa. Safeguarding the SN using tumescent anaesthesia hydrodisplacement in ClosureFast EVTA. 79 patients with isolated SSV incompetence or combined SSV and GSV incompetence underwent EVTA in an ongoing prospective study. The Radiofrequency catheter entry point is midcalf or lower to optimise the length of ablatable segment, and advanced proximally with the tip carefully placed at the point where the SSV dives into the popliteal fossa. Tumescent anaesthesia infiltration is introduced to hydrodisplace the SN laterally in the epifascial plane and to ensure adequate infiltration on the deep aspect of the SSV. A lateral hydrodisplacement of SN of greater than 1 cm is feasible in 88 % of patients to optimise the length of ablatable SSV segment. 12 % of patients may not be suited due to other anatomical variations. 79 patients underwent successful SSV EVTA with complete closure. 2 neurological events. 1 patient had a temporary foot drop (< 6 hours) due to over infiltration of tumescent around the tip of the catheter. 1 patient developed SN sensory deficit current at 6 weeks. EVTA of incompetent SSV can be made safer by careful selection of entry point of the catheter, adequate tumescent infiltration and hydrodisplacement of SN, which is easy to visualise in the epifascial plane, careful positioning of the tip of the catheter at 3 cm from the saphenopopliteal junction as well as adequate measured perivenous infiltration around the tip of the catheter. Intra-arterial injections of sclerosants: management with steroids P. Hannaford 1, K. Parsi 1 1St Vincent s Hospital, Sydney, Australia Intra-arterial injection of sclerosants is a significant but rare complication of sclerotherapy that may result in significant tissue necrosis and in rare cases lead to digit or limb amputation. There are currently no evidence-based guidelines to describe the optimal management of this adverse event. We describe three cases of intra-arterial injections of detergent sclerosants where polidocanol (supplied as AETHOXYSKLEROL 3%; Chemische Fabrik Kreussler, Wiesbaden, Germany) was used in 2 instances and sodium tetradecyl (supplied as FIBRO-VEIN 3%, Australian Medical and Scientific, Chatswood, NSW, Australia) in 1 case. Foam was used in two of these cases and liquid in one. All three patients complained of an immediate acute pain and presented with a sharply demarcated stellate purpura. All patients were managed with a combination of oral steroids (prednisone 0.5 mg/kg), anticoagulants (enoxaparine 1.5 mg/ kg daily SCI) and non-steroidal anti-inflammatory drugs. One case resulted in skin ulceration where prednisone was started 5 days after the event and prematurely stopped after 4 weeks. The other two patients were commenced on prednisone imme- 60 INTERNATIONAL ANGIOLOGY August 2014

diately and were treated with a reducing regime over the following 12 weeks. These two patients had no skin ulceration or significant long-term sequelae. Evidently, the inflammation that follows an intra-arterial injection may play a significant role in skin ulceration and the immediate management of this adverse event should incorporate antiinflammatory measures such as oral steroids if not contra-indicated. Therapeutic strategy of intravenous leiomyomatosis with intracaval and intracardiac extension in 18 cases L. Guo 1 1Peking Union Medical School Hospital, Beijing, China Objective. To summarize the diagnosis and management of intravenous leiomyomatosis, and to compare effect of the one-stage surgery and twostage surgery. Methods. Clinicopathological data of 18 patients hospitalized in Peking Union Medical College Hospital who were diagnosed as intravenous leiomyomatosis with intracaval and intracardiac extension during Jan. 2002 to Sep. 2013 were collected, and some indexes of the one-stage surgery group and two-stage surgery group were compared, including blood loss, blood transfusion, operation time, period of stay in ICU, hospital stay, and hospitalization expense. Results. All the patients were diagnosed as intravenous leiomyomatosis pathologically after operation. Of the 18 patients, 6 ( 33.3%) patients underwent one-stage surgery and 12 ( 66.7%) patients underwent two-stage surgery. There were no significant differences on blood loss, blood transfusion, operation time, period of stay in ICU, hospital stay, and hospitalization expense (P>0.05. No significance had been found in incidence rate of complication between one-stage surgery group and two-stage surgery group (P=1.000). Tumours of 2 patients who underwent two-stage surgery had developed before the second surgery, increasing the difficulty and risk of the second surgery. Three cases of one-stage group were followed up for 48-63 months (the median time was 62.0 months), 10 cases in two- stage group were followed up for 1-43 month (the median time was 19.5 months). During the followed-up period, occurrence happened in 1 case of two-staged group, but without death in all cases. Conclusions. Both one-stage surgery and staged surgery are effective and safe. Taking physical and psychological endurance of patients into consideration, one-stage surgery is highly recommended if the patient is in good status and can tolerate the strike brought by the surgery. Treatment of chronic venous insufficiency with superficial, perforator, and deep vein surgery. Y. Hoshino 1 1Saiseikai Fukuoka General Hospital The purpose of this study was to analyse the outcomes associated with superficial vein surgery, perforator surgery, and deep vein surgery in the management of patients with chronic venous insufficiency (CVI). From September 2009 to February 2014, 64 patients with venous ulcers were examined in the following groups. Group1: has superficial venous insufficiency (SVI), no incompetent perforator vein (IPV) observed; Group2: IPV observed (with or without SVI): Group3: has deep venous incompetence and persistent ulcers even after performing superficial vein surgery and/or perforator surgery. The superficial, deep vein, and the IPV (>3 mm, toand-fro flow) were examined by duplex ultrasound. We performed stripping or endovenous laser ablation as superficial vein surgery, and subfascial endoscopic perforator surgery (SEPS) to eliminate IPV. We performed the Neovalve reconstruction as a deep vein surgery. Sixteen patients in Group1 were treated with a superficial procedure alone. Clinical improvement was seen in 15 cases (94%), average follow-up was 27.9 months with 6% of healed ulcers recurring. Forty six patients in Group 2 were treated with SEPS concomitant with or without a saphenous ablation. Of the 48 limbs treated with SEPS, 96% of the IPVs were ablated, and 91% of the limbs remained clinically improved with 8% ulcer recurrence rate with a mean follow-up of 29.6 months. Four patients in Group 3 underwent the Neovalve reconstruction, and demonstrated a 100% ulcer healing rate with no recurrent symptoms with a mean follow-up of 3 months. Even if the persistence of deep reflux is a cause of CVI, the SVI and the IPVs should be corrected first, since these procedures are effective for most patients. The persistent ulcers which do not respond to superficial venous surgery and perforator surgery are an indication to correct the deep reflux. Ultrasound guided foam sclerotherapy (UGFS) to treat varicose veins at the WA Vascular Centre J Teasdale Perth, Australia 1. Healing of Varicose Ulcers Diagnosis: Duplex ultrasound The incompetent segments of superficial (saphenous) veins, incompetent perforating veins and deep veins are mapped out in size and position, Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 61

using duplex ultrasound. Perforating veins are demarcated in size and position (from height above medial malleolus) especially those in close association with any varicose ulcers. The superficial varicosities associated with the latter are injected with Polidocanol foam generally using ultrasound to guide the injection of sclerosant and a standard post sclerotherapy protocol followed. Healing rates for venous ulcers was not 100%, but most ulcers healed following sclerotherapy. 2. Treatment of patients with a thrombophilia No patients are excluded from sclerotherapy at the W.A. Vascular Centre due to the presence of a thrombophilia. If not already anti-coagulated patients are administered a regime of a course of immediate pre then post injections of S/C Clexane as well as the standard post sclerotherapy advice. Results. No DVT have been diagnosed in patients with known thrombophilia and no observed impairment of successful results of duplex guided sclerotherapy. Patients normally taking warfarin are advised to continue to take their warfarin. Telemedicine screening for vascular disease of lower limbs M. Petrlik, T. Bohrn Prague, Czech Republic Our presentation shows the screening system for detection of ischemia and venous insufficiency of the lower limbs, based on telemedicine application. Its operation is very simple, but detection of pathological cases is nearly 100%. The system use fully automatic air plethysmograph own production. For patient comfort and rapidly implemented are investigating a sitting position, as if testing the performance of venous reflux and venous muscle pump. The curve passes through a rather demanding mathematical analysis. This eliminates errors in the examination and provides a range of parameters. For their connections determine the degree of probability of ischemia or venous insufficiency of the lower limbs and divide examined persons into three basic groups: Normal suspect - clearly pathological. The curve is automatically sent in encrypted form to a central storage. Suspect a pathological curve are automatically forwarded experienced angiologist, who recommend next actions. Currently were examined over 1,000 people, most suspicious and pathological cases examined triplex ultrasound. Indicated cases investigated by angiography followed by interventions. Devices on the principle of telemedicine work reliably only in Czech Republic but also in Brazil, Portugal and Switzerland. We believe that our system can significantly contribute to the detection of early stages of peripheral vessel disease and prevent many complications, including the most serious, such as amputation and venous ulcers. Limiting indications for varicose vein surgery to maximise service provision in an era of restricted funding; an audit of compliance at the GCHHS M. Bavahuna 1, M. Jackson 1, W. Butcher 2 1Gold Coast University Hospital 2Gold Coast Hospital & Health Service In 2011 Queensland Health implemented the Scope of Publically Funded Services Policy to improve effectiveness of health services through re-allocation of resources to priority areas. The treatment of uncomplicated varicose veins no longer attracted funding under the Activity Based Funding (ABF) model. The exceptions are varicose vein patients with significant dysfunction or disability, or venous ulcers. As the exact scope of the change was never formally defined, local policy was formulated at the Gold Coast Hospital (GCH). From January 2013 surgery was only offered for active or recent history of eczema, lipodermatosclerosis, thrombophlebitis, bleeding or ulceration. An audit of practice at the GCH was conducted from 2011-2013 to compare changes to service delivery and outcomes based on the new policy. As sclerotheraphy provision (for high risk surgical patients) is now performed in the outpatient setting it was excluded from this study. Data was obtained from the Australasian Vascular Audit (AVA) database. 158 procedures were performed in 2011, 72 in 2012 and 59 in 2013. Between 75%- 90% of cases wee conventional varicose vein surgery, compared to Radiofrequency Ablations (5-21%). In 2013, 51% of cases were bilateral compared to 33% (2012) and 44% (2011). 95-100% of all patients had day surgery with no overnight admission. In 2013, 3% of procedures were for recurrent varicose veins compared to 7% (2012) and 13 % (2011) highlighting the growth of Outpatient Sclerotheraphy in managing this patient group. ASA scores have increased across the years (6% ASA 3&4 in 2011, 12.5% in 2012 and 18.6% in 2013) highlighting more complex patients being selected for. Other metrics included waiting times, CEAP Scores & indications, recurrence, complications and costs. Careful patient selection and increased provi- 62 INTERNATIONAL ANGIOLOGY August 2014

sion of outpatient management has allowed us to continue varicose vein management provision in complex patients requiring treatment in an era of funding shortfall. Treatment of scrotal and pelvic varicocele: our experience. R. Moia 1, A. LaRosa 1, J Clerissi, C. MassaSaluzzo, E Moia, V. Saracino 1, E. Castronovo 1, R. Nuzzo 1, M. Dondi 1 1Università degli Studi di Pavia, Italy The purpose of our study was to retrospectively evaluate our clinical experience in the treatment of scrotal and pelvic varicocele using foam (atossisclerol 2% + Oxygen) in association with Fibered Coils (3%) or Platinum Coils 0035, 0018 in 92% of cases; glucosata 33% in association with Fibered Coils (3%) or Platinum Coils 0035, 0018 in 5% of cases. The study considered 78 patients (36 females and 42 males), treated in our vascular unit from January 2009 to December 2013 using right basilic or cephalic vein approach 4F in 90% of cases. Female symptom was characterized by chronic pelvic pain unilateral or bilateral, associated at times with abdominal heaviness, due to venous dilatation and congestion. The symptoms are accentuated with the menstrual flow, the upright position, fatigue and sexual intercourse. Male varicocele is characterized by swelling, testicular shrinking, infertility, and sometimes pain. Furthermore decrease of count and motility of sperm and increase of the number of deformed sperm, determines a framework of male infertility. The results obtained showed a success rate of 98% of the techniques used and a low rate of recurrence. This method is therefore preferable to conventional surgery for less invasiveness, for the reduced hospitalization time and for the possibility to embolize the almost totality of the vessels responsible for the pathology although small. This fact remains a major cause of relapse in traditional surgery, due to the ability of the surgeon to recognize and isolate every collateral vein and to detection during the surgical intervention the possible anatomical variations Recurrent varicose veins post CHI- VA R. Moia 1, A. LaRosa 1, J Clerissi, C. MassaSaluzzo, E Moia, R. Nuzzo 1, V. Saracino 1, M. Dondi 1, E. Castronovo 1 1Università degli Studi di Pavia, Italy The varicose veins treatment ranks among longterm complications the emergence of varicose recidivism. We propose a comparison between the traditional surgical procedure and CHIVA tech- nique conceived and proposed in 1986 by Franceschi as a global strategy for outpatient treatment of venous insufficiency. From March 2001 to December 2013 we treated 263 patients with varicose veins of the lower limbs already undergone in the past to surgery for the same condition with CHIVA method. All patients underwent clinical examination to assess the type of symptoms means of CDI (Prosound Aloka SSD -3500 Plus) in order to objectify the seat of venous reflux. The protocol Duplex Scan was obtained by examining upright, from groin to ankle the superficial venous system (hosts saphenous - femoral - popliteal saphenous vein great saphenous vein, lesser saphenous vein, piercing and any varicosities extrasafeniche) and deep venous (common femoral, superficial femoral, popliteal vein) by Valsalva maneuver and with manual compression of the muscular cavities. These patients were then subjected to the intervention of varicectomy multiple lower limb. Recurrences after- CHIVA due to failure to break all the veno- venous shunt, the improper splitting of the hydrostatic column, failure to observe the re-entry perforating or not binding under these occurred in 79,7% cases received prior to CHIVA. Considering the different techniques, the CHIVA procedure is more laborious, requires mapping procedures that are, of course, operator dependent, and it becomes difficult to have unique approaches in methodology and comparable results. Concerning the CHIVA method its important to report events of angiogenesis and side effects that frustrate the surgical procedure. Endovenous laser ablation in symptomatic patients with varicose veins: saphenous vein diameter and reflux detection correlates well with clinical symptoms. M Vítovec 1, V. Horvath 2, M. Slais 2, J. Honek 2, T. Honek 2 1Medivican Praha, Czech Republic 2Avicena Chirurgie Praha Background. Venous insufficiency is a common medical condition difficult to objectively describe. Indication for surgery is based mostly on clinical symptoms. The aim of study. To determine if great and small saphenous vein (GSV, SSV) diameter and sonographic signs of reflux correlate with clinical symptoms of chronic venous insufficiency and may be used for indication to endovenous laser ablation (EVLA). Methods. A total of 1177 pts. were examined for varicose veins between Jan 2012 and Jan 2013. The diameter of the GSV and SSV was measured by B mode imaging, reflux was identified by Doppler Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 63

measurements. Patients were indicated to surgery based on clinical signs and symptoms associated with varicose veins. Sonographic data were compared in the group of operated and non-operated patients respectively. Results. In 752 patients indicated for EVLA diameters of truncal veins were significantly larger than in the 425 non-indicated patients (for GSV 11.8 ± 1.9 mm vs. 5.9 ± 2.6 mm, p<0.01; for SSV 7.2 ± 1.6 mm vs. 3.2 ± 2.6 mm; p<0.01). Pathological reflux was present in all operated pts. compared to 56 (13%) non-operated pts. (p<0.01). There were no major complications of EVLA. Conclusion. Duplex ultrasound measurements of saphenous vein diameter and detection of pathological reflux correlated well with clinical symptoms of venous insufficiency. We suggest that both parameters in the presence of clinical signs and symptoms are useful in the decision to perform EVLA. Supported by the Foundation for Biomedical Research, Prague, Czech Republic CZ28427718. Clinical outcome of patients with truncal saphenous incompetence: comparison of endovenous laser ablation and conservative treatment. M Vítovec 1, J. Honek 2, M. Slais 2, V. Horvath 2, T. Honek 2 1Medivican Praha, Czech Republic 2Avicena Chirurgie Praha Introduction. Endovenous laser ablation (EVLA) is an efficient method to treat incompetent saphenous veins with high occlusion rates, even in elderly patients and patients with severe co-morbidities. However, not all patients choose this treatment, mostly for economic reasons. The aim of study. Compare clinical and sonographic outcome of operated and non-operated patients based on clinical-etiology-anatomypathophysiology (CEAP) classification. Methods. A total of 745 patients (age 44+/-12 yrs, 70% females) were enrolled in this non-randomized study between Jan 2012 and Jun 2013. All patients were indicated to EVLA fbased on the presence of varicose veins and sonograpicaly proved venous reflux. 340 patients were operated (37+/-10 yrs, 79% females), 405 (51+/-15 yrs, 54% females) were not operated (280 for economic reasons, 125 for other reasons). During the follow-up period (mean 340 days, range 185-740 days) duplex ultrasonography and clinical assesment was performed every 6 months. The primary endpoint was the clinical classification according to CEAP criteria. Results. No severe complications related to EVLA occurred in the 340 operated patients. Post-oper- ative ecchymosis (76%) and mild pain (52%) were common, pain requiring analgetic drug administration occurred only in 6 (2%) patients. Occlusion was confirmed snographically in all intervened veins, reflux was present in all non-operated patients at the end of follow-up. Out of operated patients: occurrence of varicose veins (C2) decreased by 100% (85% to C1 and 15% to C0), edema (C3) decreased by 60%, pigmentations (C4) by 0%, no patients were classified C5 or C6 prior to intervention. In the non-operated group: C2 remained 100%, C3 increased by 20%, C4 by 15%, ulcers (C5 and C6) newly developed in 3 patients (100% increase), 76 % patients failed to comply strictly with compression therapy. Conclusion. EVLA was associated with improved clinical outcome based on CEAP classification compared to conservative treatment. Occlusion of intervened vein was successful in all patients, no major adverse events were associated with EVLA. Majority of non-operated patients failed to comply strictly with compression therapy. Supported by the Foundation for Biomedical Research, Prague, Czech Republic CZ28427718. Heredity of chronic venous disorders: an epidemiological study on 21319 patients challenging the predominantly maternal character of CVD heredity F. Allaert 1, V. Crebassa 2, J. Guex 3 1Medical evaluation Chair Dijon 2Vascular medicine Montpellier 3Vascular medicine Nice Objective: evaluate the heredity factor of the chronic venous disorders (CVD) after adjustment on sex and age and calculate the odd ratio linked to mother or/and father past history of venous diseases Methods. epidemiological study conducted in daily medical practice of medical practitioners. Each general practitionners described during 2 consecutive days the venous status of all patients consulting them whatever the reason of the consultation and recorded their familial past-history of venous disorders. Odd ratio and their 95% Confidence interval were calculated after adjustment on sex and age in a logistic regression model. Results. Among 21319 patients, 60.4% have a familial history of CVD: unilateral paternal 7.5% unilateral maternal 40.9%, bilateral: 12.0%. The prevalence of CVD is 58,8% in the global population, 38.2% in the absence of parental history, 67.0% for unilateral paternal history, 71.3% for unilateral maternal history and 79.2% for bilateral familial history (p <0.0001). After adjustment on age and sex, results show significant (p<0.0001) 64 INTERNATIONAL ANGIOLOGY August 2014

OR of 3.2 [2.8;3.6] for unilateral paternal history of 3.4 [3.2;3.7] for maternal history and of 5.6 [5.0;6.2] for a history in both parents. In the context of a history in both parents, the odds ratio increased to 5.6 for women and 8.4 for men. If there was a hereditary risk, the frequency and severity of the illness were greater, regardless of the age group studied (P<0.0001). Conclusion. This study confirms the heredity factor of the venous disease but its results, especially those conducted separately in women and men, could call into question the maternal predominant character of the CVD heredity. Development and validation of the psychometric properties of a selfreported questionnaire assessing adherence to the wearing of elastic compression stockings F. Allaert 1, D. Rastel 2, A. Graissaguel 3, B. Lun 3, G. Chauferind 4 1Medical Evaluation Chair ESC and Cenbiotech, Dijon, France 2Vascular Medicine Grenoble, France 3Sigvaris 4Orméa Conseil Objective. To identify the discriminant questions of a short self-questionnaire measuring patients adherence to the wearing of elastic compression stockings and to validate the questionnaire s mandatory psychometric properties: acceptability, test-retest reliability, internal consistency and external validity. Methods. The gold standard for the development of an evaluation questionnaire involves, in succession, conducting an exhaustive review of the existing peer-reviewed literature, identifying the questionnaire items through patient interviews, reducing and selecting the questions by the use of statistical methods such as PCA using Varimed rotation and the Rasch model, and measuring the comprehensibility and acceptability of the first version of the final questionnaire. Once these steps have been completed, test and retest reliability has then to be conducted through a group of patients answering the questionnaire repeatedly over a short time interval. Then, the questionnaire has to be filled out by a large sample of patients in order to evaluate its internal consistency using Cronbach s alpha test and its external validity by comparison to other adherence indicators and, better still, by direct objective measurement of compliance as part of a clinical trial. This study also provides the opportunity to score the questionnaire so as to define the adherence threshold using ROC analysis. Results. Patient interviews revealed that besides direct compliance questions, other questions about adherence to wearing elastic compression and patient satisfaction need to be added. Therefore the initial idea of a simple compliance questionnaire has changed into an adherence questionnaire including a section on compliance. An objective device has been developed to measure and record electronically how long patients wear their elastic stockings in order to test the external validity of the adherence questionnaire. The first version of the compression adherence questionnaire will be presented. Conclusion. A validated compression adherence self-questionnaire will soon be available to fill a large gap in current clinical trials on elastic compression efficacy Causes of recurrent varicose veins D. Musil 1, J. Herman 2, M. Tichy 3, P. Bachleda 2 1Department of Internal Medicine I Cardiology, Palacky University, Cardiovascular Centre, Olomouc, Czech Republic 2Department of Surgery II Vascular and Transplantation Surgery, Palacky University, Cardiovascular Centre, Olomouc, Czech Republic 3Department of Clinical and Molecular Pathology, Palacky University, Olomouc, Czech Republic Aim. The purpose of this study was to explore the causes of recurrent lower limb varicose veins after surgical intervention and estimate the role of the neovascularisation. Methods. A retrospective survey of 217 legs after second surgery due to recurrent varicose veins. All patients underwent colour-doppler ultrasonography, histological and histochemical (nestin) analysis of resected veins. Results. Reflux as the cause of recurrent varicose veins was defined in 93 % of the limbs. In the rest of 7 % of the lower limbs the cause of recurrence has not been identify. The most common site of reflux was the saphenofemoral junction (73.7 %), followed by the reflux in the saphenopopliteal junction (18 %). Reflux in the perforating veins was almost invariably secondary to the reflux in saphenofemoral and saphenopopliteal junction. Only in 1.5% of the legs the perforating vein was the primary site of reflux. Histological and histochemical analysis was performed for the samples of eleven veins in which neovascularisation was suspected based on preoperative duplex ultrasonography evaluation. Neovascularisation was confirmed in no of these veins and no of them was the cause of recurrence. Conclusion. The major cause of recurrent lower limb varicose veins is a reflux left unresolved during the primary surgery, particularly in the area of the saphenofemoral junction. A less common cause is progression of the disease and the occurrence of a new reflux. Neovascularisation is of no importance for the recurrence of varicose veins. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 65

Axial splitting of medial cutaneous nerve of forearm facilitates the 2nd stage superficialization of basilic or brachial vein in patients with brachial basilic or brachial brachial arterio-venous fistula. S. Przywara 1, T. Zubilewicz 1, M. Ilzecki 1, P. Terlecki 1 1Department of Vascular Surgery and Angiology, Medical University of Lublin, Poland We describe a novel surgical technique to facilitate the second stage superficialization of basilic (BV) or brachial vein (BrV), in patients with brachial basilic (BB) or brachial brachial (BBr) arterio-venous (A-V) fistula, by axial splitting of medial cutaneous nerve of forearm (MCNF). Filaments of MCNF typically traverse the front aspect of BV and thus BrV which is located deeper. The 2nd stage superficialization of BV or BrV, not to cause an injury of cutaneous branches of MCNF, requires transection of the vein, its transposition over the branches and re-anastomosis of the vein. We have developed our own method of axial splitting of MCNF proximally, what enables superficialization of BV or BrV without necessity of reanastomosis of the vein. Myeline sheath of the MCNF is gently incised longitudinally, towards the armpit, what enables separation of nerve fibers. Cutaneous branches are split and retracted lateraly and medially. Then BV or BrV is elevated between separated nerves and superficialized. 28 patients (20 with the 1st stage BB and 8 with BBr A-V fistula underwent this simplified superficialization of BV or BrV). In each case superficialization was performed without transection and reanastomosis of the vein. On discharge and 1 month after surgery, patients completed simple neurological questionnaire and were neurologically examined. Only one patient reported a local, patch hypoesthesia. Our novel technique does not require re-anastomosis of superficialized vein and thus shortens the surgery and does not cause significant neurological deficits Risk factors for failure of native arteriovenous fistulas (kafka study) M. Harazim 1, I Hofírek 2, O. Sochor 1 1Department of Cardiovascular Diseases, St. Anne s Hospital, ICRC, Brno, Czech Republic 2Department of Cardiovascular Diseases, St. Anne s Hospital, Brno A well-functioning vascular access is mandatory for successful maintenance renal replacement therapy. Arteriovenous fistula (AVF) is consid- ered as first choice for the patients with end-stage renal disease patient undergoing haemodialysis therapy. The recent reported rate of early fistula failure varies from 30% to 90%. Our aim was to examine which risk factors for AVF failure (early or late) could be identified in our patients. Data of patients who underwent creation of an AVF at the St. Anne s Faculty Hospital Brno from 2004 to 2012 were reviewed. Early failure was defined as a nonfunctioning fistula (thrombosis or absence of fistula maturation) in 3 months. Preoperative variables studied were age, sex, diabetes mellitus, coronary artery disease, peripheral artery disease, previous stroke, antiplatelet therapy, anticoagulation therapy, use of statins and ACEI/ARB in therapy, smoking, body mass index, and identification of performing surgeon. A total amount of 135 native AVF were created in 91 patients, 83 (61,5%) in the forearm and 52 (38,5%) in the upper arm. In a multiple logistic regression analysis, significant predictive factors of failure were surgeon-related factors; no other risk factors were significantly associated with an increased frequency of AVF complications Isolated acute abdominal aortic dissection with huge pseudoaneurysm successfully treated with combination of bare metal stent and unibody bifurcated stent graft B Yang Beijing, China Isolated acute dissection of abdominal aorta (IAAAD) is rare, accounting for 0.4%-5% of all aortic dissections. Its symptoms, though evident clinically, are nonspecific and treatment options remains controversial. We successfully treated an unusual case of isolated abdominal aortic dissection with a huge pseudoaneurysm and a dilated and incompletely thrombosed false lumen which extended retrograde from aortic bifurcation to superior mesenteric artery (SMA). Case report. A 57-year-old man with hypertension was admitted for 10-day history of acuteonset persistent abdominal pain,. which was aggravated after meal. He couldn t eat afterwards. Ultrasonography indicated dissection of the abdominal aorta. On admission, he complained of severe pain in the left lower quadrant (LLQ) of abdomen radiating to his left waist and lower limb followed by loss of motor function of left lower limb. A large pulsating mass was palpable on LLQ of his abdomen. He was hemodynamically stable but was in distress from the severe pain that was unresponsive to aggressive blood pressure control and pain control. CT angiography (CTA) 66 INTERNATIONAL ANGIOLOGY August 2014

revealed a ruptured IAAA, with a huge pseudoaneurysm (maximum diameter, 10.5cm), and dilated and incompletely thrombosed false lumen which extended retrograde from aortic bifurcation to SMA. One visible entry tear of intima was just above aortic bifurcation. No further re-entry tears were noted. The thoracic and iliac arteries, were normal. Because of severe refractive pain and concern for impending rupture, emergent repair by either open abdominal surgery or EVER is advisable. we chose EVAR as primary treatment for this particular case, due to its less invasiveness and patient s poor condition and history of coronary heart disease. Obviously, due to anatomical features revealed on CTA and fragility of dissected intima in acute stage, supra-sma aorta should be the ideal anchoring area and fenestrated SG seemed to be the optimal treatment for this special case. As fenestrated SG was not available in emergency case, we attempted to use infrarenal aorta as anchoring zone (as for infrarenal AAA) with aim to simplify the treatment procedure and ensure visceral arterial flow. Considering the high pressure persistently imposed on the fragile intima by the bare anchoring stent and hooks or barbs at the proximal end of SG would inevitably cause immediate or late intimal disruption, we, therefore, first implanted a bare mental stent (OptiMed, 20 60 mm) below the renal arteries to create an anchoring zone to limit the expansion force of the bare anchoring stent or barbs on the SG; and subsequently, deployed a home-made unibody bifurcated SG (Microport, AB201212-0804030-200010) inside the bare mental stent with adequate overlapping. The bilateral limbs were placed to the common iliac arteries. No endoleak was shown on completion angiography. The postoperative course was uneventful with complete resolution of abdominal pain and neurological deficit. CTA at 5th month documented intact stent-graft, with no endoleak and migration, and complete thrombosis of false lumen and pseudoaneurysmal sac. We recommend the bare metal stent be the same size as normal aorta or slightly larger, because an oversized stent placed at the fragile area may also create iatrogenic intimal tear. We deliberately chose unibody (rather than the commonly used) bifurcated SG in this setting, due to its advantage of directly covering the entry site with graft main body without distal migration (because it rode on the aortic bifurcation rather than suspended in the aorta). In addition, the false lumen without branch vessels and reentries was likely to thrombose quickly, which could strengthen the dissecting membrane at the anchoring zone. However long-term surveillance is still required for this case despite its good immediate results. AAA morphology and management: what features effect treatment and outcome by evar T Daly, J Mah, N Young, K Hitos, J Fletcher University of Sydney, Westmead Hospital, Sydney, Australia The use of Endoluminal AAA repair dominates the management of abdominal aortic aneurysm. The range of the morphology considered for intervention is increasing and in some ways could be outside the IFUs for individual grafts. Aim to accurately assess the morphology of AAA presented during a fixed period and consider the morphological aspects that determine the type of repair, the method and grafts used during this period. Method: Using a specific criteria a prospective assessment reviewing source data scans were assessed over a 9 month period. The patients were referred for CT angiographic assessment for aortic aneurysmal disease considered appropriate for repair. The imaging softwares used were CDN- PACS, GE-PACS, Voxar 3D and Vitrea platforms. Results. 42 patients were assessed during this period (M=34, F = 8). The average sac size was 52mm. The most important areas for consideration of an endovascular graft were the average neck length (20.6mm (17.9-23.3 CI 95%)), the average neck angle (33.1degrees (28.6-37.6 CI 95%)), haematoma around the proximal fixation zone (46% had less than 50%, and 5% had almost circumferential haematoma formation), tortuosity of the access vessels (14.2% had classed as severe on the left and 4.8% on the right) and extensive calcification (19% on the right, 16.7% on the left). Conclusion. This information is used to follow up each patient and assess which morphological features of an individual AAA contributes to decision making and outcome in our institution. Differential diagnosis of aortic dilatation in pictures M Kaletova, D Musil, P Marcian, J Ostransky, M Cerna, M Taborsky Department Cardiology, Department of Cardiac Surgery, University Hospital and Palacky University, Olomouc, Czech Republic X-Ray picture of thoracic aortic dilatation can be caused by different diseases. For cause differentiation of aortic dilatation use CT angiography, MR angiography, transoesophageal echocardiography, Positron emission tomography combined with CT. Authors present 4 Picture Case Reports with different source of aortic dilatation: Thoracic aortic dissection by Marfan syndrome patient, Thoracic aortic aneurysm with family history, Aortal Giant cell arteriitis, Aortal Arch Pseudoaneurysm. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 67

Endovascular interventional treatment of superior mesenteric arteries stenosis L. Tan, S. Sheng-Han, Z. Wang-De, Z. Yang, Y. Biao, Y. Bao-Zhong Department of Vascular Surgery, Beijing Chaoyang Hosptial, Capital Medical University, Beijing,China Objectives. To research the diagnoses and treatments of ischemic enteropathy resulted from superior mesenteric arteries (SMA) stenosis and evaluate the safety and effectiveness of endovascular interventional technique for SMA stenosis. Methods. 7 cases with SMA stenoses were treated with percutaneous transluminal balloon angioplasty (PTA) and stent placement. During the 6-58 months follow-up, we observed the effectvieness and prognosis of endovascular interventional technique for SMA stenosis. Results. Among the 7 cases, 6 cases have been diagnosed by Computerized tomographic angiograms (CTA), PTA and stent placement were technically successful in all cases. 6 cases were implanted one stent respectively and another was implanted two stents. After procedure, symptoms relief occurred in 6 cases in one week and their body weight increased to the ideal level during 3-6 months. The postoperative who regain his health fastest disappears abdominal pain within one day after procedure, and relieve intestinal obstruction within two days. The remaining one obtained conspicuous alleviation of abdominal pain, but she still had the intermittent abdominal discomfort and her body weight didn t increased markedly. Two patients died from other disease, but not have recurrent symptoms during the period of follow-up. During the follow-up, restenosis didn t occur in all the cases which assessed by duplex sonography. Conclusions. Computerized tomographic angiograms (CTA) and other imaging diagnosis are important methods for the diagnosis of SMA stenosis. Stent-assisted angioplasty of mensenteric arterial occlusive diseases is a safe and effective therapy. Moreover the progress of treat technology should reduce the quantity of incidence of complications. Pseudo aneurysms: endovascular treatment R. Moia 1, A. LaRosa 1, J Clerissi, C. MassaSaluzzo, E Moia, M. Dondi 1, R. Nuzzo 1, V. Saracino 1, E. Castronovo 1 1Università degli Studi di Pavia, Italy The endovascular approach is now entered in the routine diagnostic and treatment of vascular diseases. The minimally invasive procedure may represent, in selected cases, the technique of first choice, or an excellent alternative to invasive surgery. The prospect of an optimal cost-benefit ratio, especially for those patients with many comorbidities of considerable clinical impact, makes the endovascular treatment of largely used in practice diagnostic therapeutics. However, this approach is not without risks, the most frequent is represented by the formation of pseudo aneurysm (0.5%). This is a retrospective analysis conducted on Patients from January 2009 to December 2013 debating the cost benefit ratio and the therapeutical indications between three procedures commonly used in the treatment of pseudo aneurysm: embolization through fibrin, embolization through metal spirals and vessel repair closure performed by stent graft and fibrin injection. In the first case the procedure is performed injecting fibrin in angiographic access achieving the vessel closure with the help of a Doppler ultrasound examination. The second one consists in an angiographic procedure where the lesion, originating pseudo aneurysm, is reached with a guided-wire releasing metal coils from the inside of the vessel. The last one (usually used for wider lacerations) we examine is the employment of a stent-graft positioned where the lesion is located to repair the vessel wall and, at a later stage, a fibrin injection. This double approach promotes a better result and avoids fibrin diffusion risk. Endovascular treatment of peripheral aneurysms R. Moia 1, A. LaRosa 1, J Clerissi, C. MassaSaluzzo, E Moia, R. Nuzzo 1, V. Saracino 1, E. Castronovo 1, M. Dondi 1 1Università degli Studi di Pavia, Italy Aneurysms of peripheral arterial lesions are quite rare, can remain asymptomatic or present a variety of complications that put at risk the integrity of the involved limb. Popliteal district is the the most affected (70-80%), followed by the femoral: common femoral artery (26%), superficial femoral artery (3.5%), deep femoral artery (0.5%). From a clinical point of view the first manifestation of symptoms is represented by thrombosis and more rarely by breaking. Therefore is important an early diagnosis in order to proceed to an appropriate preventive treatment. The traditional surgical technique is aneurysmectomy with or without the interposition of a prosthesis. In the case of popliteal district we proceed to packaging of a femoropopliteal bypass after the exclusion of the aneurysm sac with proximal and distal ligatio. More frequent is the use of endovascular technique with endoprostheses. Our series includes 27 peripheral aneurysms treated with endovas- 68 INTERNATIONAL ANGIOLOGY August 2014

cular technique from January 2001 to December 2013: 21 men (77.7%) and 6 women (22.3 %) range 45-71 years old. The localization of aneurysmal lesions was: 12 in popliteal level, 10 in iliac level, 5 in femoral level. 24 patients (85 %) were treated by placement of stent-grafts, 3 (11 %) with simple stents. There has not been any periprocedural complication. The mortality rate was affected in one case (3.7%) at 7 months after treatment cause of earlier comorbidities and for reasons not related to the angiographic procedure. The reconstruction of endovascular aneurysm of peripheral arteries demonstrates minimal invasiveness, a low mortality rate and eliminates the need for blood transfusion. Therefore it s an effective and safe method, with a high success rate in short and medium term. Aneurysms of visceral arteries: endovascular treatment R. Moia 1, A. LaRosa 1, J Clerissi, C. MassaSaluzzo, E Moia, M. Dondi 1, R. Nuzzo 1, E. Castronovo 1, V. Saracino 1 1Università degli Studi di Pavia, Italy Aneurysms of the visceral arteries (VAAs) represent a rare but important, life-threatening, vascular disease with high mortality rate (20-70%) depending on localization of aneurysm, dimensions and other comorbidities. The incidence in post-mortem reports varies from 0.098 to 10.4%[1], about 0.01-2% in vivo [2]. The most frequent site of VAAs are: splenic artery (60%), hepatic arteries (20%), celiac trunk (5,5%), superior mesenteric (4-5%), gastric and gastroepiploic arteries (4%), intestinal arteries (3%), pancreaticoduodenal arteries (2%), gastroduodenal artery (1,5%) inferior mesenteric artery (<1%) renal arteries (0.01-0.09%). Multiple localizations are also frequent clinically. VAAs can be classified into true or pseudoaneurysm or in saccular and fusiform. Etiology is multifactorial: fibrodysplasia, atherosclerosis, infection after infective endocarditis, vasculitis (PAN), trauma, iatrogenic procedures, pancreatitis, portal hypertension. Most of the time visceral artery aneurysms are asymptomatic and diagnosis occurs occasionally through TC or angiography undertaken for some other reason. When they re symptomatic they occur with abdominal pain, mass effect, intestinal bleeding, anemia, haematuria, emobilia, jaundice, hypertension. In the 20% of cases this disease is manifested with rupture. The approach to this disease is multimodal: open surgery, laparoscopic, mini-invasive approach with Da Vinci technique and endovascular treatment. The aim is assess the feasibility and effectiveness of endovascular treatment using different techniques depending on the sites and the morphology of pa- tients treated. This study was conducted between 2009 and 2013. 18 patients are analyzed. 12 aneurysms are treated with aneurismal sac embolization using coil with or without glue, thrombin, onyx, gelfoam, while 6 aneurysms are treated with stent graft. In all cases was obtained complete aneurysm exclusion. During follow up did not observe any reperfusion or treatment-related complication with secondary success rate of 100%. Endovascular treatment of VAAs is an efficacy treatment with low mortality and comorbidity peri and post operative Prevention and treatment of conversion complications in totally laparoscopic aortic bypass surgery for aortoiliac occlusive disease G. Lianrui, G. Yongquan, Q. Lixing Vascular surgery department of Xuan Wu Hospital, Institute of Vascular Surgery, Capital Medical University, Beijing, China. Objective. To evaluate the safety and feasibility on totally laparoscopic aortobifemoral bypass surgery for aortoiliac occlusive disease (AIOD). Methods. From November 2008 to November 2012, 7 patients were enrolled consecutively for severe AIOD with a totally laparoscopic aortobifemoral bypass at our hospital. Demographic data, operative data, postoperative recovery data, morbidity and mortality were analysed. Results. The 7 consecutive patients were all male at a mean age of 60.6 (52-70), with the lesions of 2 cases in TASC C and 5 cases in TASC D. Rutherford class: 5 cases in class 3, 1 case in class 4, 1 case in class 5. Comorbidity included diabetes in 4 cases, coronary heart disease in 2, hypertension in 2, cerebral vascular disease in 2, hypercholesterolemia in 6. Six patients had smoking history of more than 30 years and 3 of them suffered COPD. Mean operating time was 561 (420-840) minutes. Mean blood loss was 929 (400-1500) ml. Mean aortic anastomosis time was 81 (40-150) minutes. Conversion was undergone in the first two patients. Postoperative complications developed in the same 2 patients, the first patient recovered smoothly except a transient hydronephrosis which restored well a month later. The No. 2 patient experienced a colonic fistula which restored after colostomy, and pneumonia on the basis of COPD, which resulted in respiratory failure and death on the 46th day after laparoscopic surgery. Two patients who suffered juxtarenal aortoiliac occlusion undergone Fogarty catheter thromboembolectomy during laparoscopic surgery, one had a severe aortic residual stenosis proximal to anastomosis site, and restored patent after endovascular stenting on 12th Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 69

day postoperatively, the other had a small partial asymptomatic left renal infarction which found by enhanced CT. The unconverted 5 patients recovered smoothly and completely and discharged on postoperative 5-14th day. All grafts were patent by Duplex examination with a mean followup time of 12.9 (2-61) months. Conclusion. Total laparoscopic aortobifemoral bypass surgery is a safe and feasible procedure for the treatment of AIOD. Conversion in time is a safe way to overcome the learning curve. Management strategy of isolated spontaneous dissection of the superior mesenteric artery H Satokawa, H Yokoyama, T Igari Department of Cardiovascular Surgery, Fukushima Medical University, School of Medicine, Japan Objectives. Isolated spontaneous dissection of the superior mesenteric artery (SMA) is very rare among of the visceral artery dissection and its treatment is not established. In this paper we present our experiences and consider the treatment of isolated SMA dissection. Methods. A retrospective review of our cases from 2005 was performed. Clinical symptoms, radiologic findings and results were evaluated. There were 14 cases of visceral artery dissection, in which all cases were with SMA dissection. There were 12 males and 2 females with a mean age of 57 years (range 41 78 years). Results. We categorized SMA dissection into the 6 types according to the Sakamoto s and Zerbib s classification. One patient with type VI underwent emergent endovascular surgery with stent. One patient with type VI received thrombectomy and intimectomy with open surgery. One patient with type II underwent aneurysmectomy due to enlarged dissected SMA 3months later from onset. The other 9 patients were managed conservatively. At follow-up, the diameter of SMA did not enlarged and the length of the dissection significantly decreased to 20.7±15.7mm from 38.0±15.1mm at onset (p<0.01). After treatment, imaging indicated the following changes in classification: type I, one patient; type II, 4 patients; type IV, 4 patients; complete remodelling, one patient, all without any event during the follow-up period of 5 82 months. Conclusion. Most patients with isolated visceral artery dissection occurred in superior mesenteric artery and can be treated conservatively; however, endovascular or surgical procedures including laparotomy are indicated when there is suspicion of severe mesenteric ischemia. Because the dissection configuration will change, long term follow-up is necessary Open surgical repair for inflammatory abdominal aortic aneurysms K Igari, T Kudo, M Nakamura, S Katsui, M Nishizawa, H Uchiyama, S Koizumi, T Toyofuku, Y Inoue Division of Vascular and Endovascular Surgery, Department of Surgery, Tokyo Medical and Dental University, Tokyo, Japan This study was performed to describe our experience with inflammatory abdominal aortic and iliac artery aneurysms, and to evaluate the results of open surgical repair (OSR) during a long-term follow-up period. We retrospectively reviewed the charts of patients who underwent OSR for inflammatory abdominal aortic and iliac artery aneurysms at Tokyo Medical and Dental University Hospital between January 2000 and June 2013. The diagnosis of inflammatory aneurysms were made based on the clinical signs such as abdominal/lower back pain, anorexia/weight loss and inflammatory symptoms, the findings of computed tomography, and intraoperative findings such as a thick, shiny white aneurysmal wall. Nine male and two female patients (Median 67 years) were treated. The majority of patients experienced symptoms of pain (eight of 11), but two patients were asymptomatic. The median abdominal aortic aneurysm diameter was 55 mm (range, 45 65 mm), and the median iliac artery aneurysm diameter was 25 mm (range, 20 30 mm). Five of the eleven patients developed hydronephrosis, and ureteral stents were placed preoperatively. There were no intraoperative and postoperative complications. During the follow-up period, there were no signs of the progression of perianeurysmal inflammation after the repair; however, two patients developed aneurysmal changes of native iliac artery in the distal anastomosis site, and re-interventions were needed. There were no aneurysm-related deaths. Recently, endovascular repair for inflammatory aneurysms has been reported as alternative treatment. Even though the endovascular repair has minimal invasiveness, OSR can be safely performed, and effectively exclude the aneurysms and regress the perianeurysmal inflammation in our results. The endovascular repair might be an effective treatment for inflammatory aneurysms, but there may be less resolution of the inflammatory process, so OSR may be preferred in the patients who are deemed to be at low risk for undergoing open surgery. Replantation of amputated arms M Salah Saudi German Hospitals group, Saudi Arabia Major replantation of the upper limb, or macroreimplantation is a tremendous challenge for 70 INTERNATIONAL ANGIOLOGY August 2014

both the patient and the surgeon. Although the technical aspect of microsurgery associated with this procedure are often less challenging than replantation of more distal segments because of the size of the neurovascular structure, there are many other difficulties. As multiple studies have documented, the degree of injury of both the stump and the amputated segment dictates the success and the surgical outcome. The more traumatized segments tend to produce less predictable surgical outcomes. A recent study documented that the serum potassium concentration in the amputated part was the best objective predictor of surgical outcome. The surgical procedure can be long and of significant medical morbidity for the patient. Postoperatively, the patient must be actively involved in a rigorous rehabilitation program. Assessment of upper extremity replantation is very difficult because it is not feasible to design a randomized clinical trial. Results are assessed by case series. In general, the survival of replantation is dependent on the patient age, being worst in the extremes of age. Sharp injuries have better survival rates than crushed injuries. Replantation should not be done for hopeless cases, as this will consume all the resources and give false hopes to the patient and family. If we decided to go for replantation, removing a small segment of the bone will make life easier in every anastomosis, arterial, venous, nerves and muscles; what is called Proximal level replantation. I m presenting some of the successful cases, and some of the other cases. Although there are many challenges in this procedure, yet I consider the most challenging point is the decision at the very beginning whether to do it or not. Angiographic findings of patients with extremity injuries: is vascular proximity it a valid indication for angiography? H. Ravari 1, A. Bahadori 1, M. PezeshkiRad 1, O. Ajami 1 1Vascular and Endovascular surgery research center, Emamreza Hospital, Faculty of medicine, Mashhad University of Medical Sciences, Iran Background. Certain clinical findings in extremity trauma increasing suspicion to arterial injury. Some of them like severe ischemia and active hemorrhage have very high diagnostic value and often lead to surgical intervention without need to diagnostic procedure. If peripheral pulse examination was impaired, angiography is usually indicated. In contrast, there are some controversies about prognostic value of some other indications for angiography like proximity of injury to artery with normal pulse examina- tion. Patients and methods. All patients with extremity trauma who presented to the Imam Reza Hospital, Mashhad/Iran, with angiography indication between September 2011 and March 2013 were evaluated in a cross sectional study. The aim was to study the etiology, signs and symptoms, angiography indications and angiography results in our population. Results. During the study period, 148 patients (15 female) with a mean age of 31 years (11-82 years) were evaluated. The most common cause of injury was motor vehicle accident (127 patients 85%). Angiography causes including: abnormal distal pulse examination (124, 83.8%), complex fracture or dislocation (7, 4.7%), near arterial trauma (4, 2.7%), fixed hematoma (3, 2%), nerve damage (1, 0.7%). Patient referral for angiography was indeterminate in 9 patients. 49 (33.1%) patients had normal angiography. Conclusion. The most important factor in prediction of result of angiography was distal arterial pulses examination. But these data confirm the low incidence of vascular injury in asymptomatic patients with proximity. So the use of angiography when proximity is the sole indication in an asymptomatic patient with a normal vascular examination must be questioned. Iatrogenic injury to the superior vena cava and brachiocephalic vein J. Herman 1, D. Musil 2, P. Bachleda 1, M. Cerna 3, V. Prasil 4, P. Santavy 5 1Department of Surgery II Vascular and Transplantation Surgery, Palacky University, Cardiovascular Centre, Olomouc, Czech Republic 2Department of Internal Medicine I Cardiology, Palacky University, Cardiovascular Centre, Olomouc, Czech Republic 3Department of Radiology, Palacky University, Cardiovascular Centre, Olomouc, Czech Republic 4Palacky University, Cardiovascular Centre, Olomouc, Czech Republic 5Dept. of Cardiosurgery, Palacky University, Cardiovascular Centre, Olomouc, Czech Republic Aim. The aim of this work was to present two cases with serious complications of central venous cannulation and to propose optimal treatment. Case Report. We report two serious complications related to cannulation and angioplasty of the central venous system. In patient 1 superior vena cava rupture occurred in an attempt to dilate a stenosis; in patient 2 perforation of the brachiocephalic vein occurred during the placement of a dialysis catheter. These rare complications are mostly fatal. Our two female patients Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 71

were treated surgically and both survived despite major blood loss and hemopericardium. Conclusions. Although iatrogenic injuries to the central venous system are rare, they must be constantly kept in mind since, because their outcome is fatal when undetected and treated late,. Of crucial importance is early detection of venous system perforation, its temporary tamponade, and immediate treatment, preferably surgical. Endovascular treatment of arterio-venus malformations R. Moia 1, A. LaRosa 1, J Clerissi, C. MassaSaluzzo, E Moa, E. Castronovo 1, V. Saracino 1, M. Dondi 1, R. Nuzzo 1 1Università degli Studi di Pavia, Italy Arteriovenous malformation are a rare vascular pathology must be differentiated from acquired arterio-venous fistulae. Histologically AVMs present dysplastic elements in the vessel walls. They can be classified in syndromes (1 patient with Klippel-Trenaunay syndrome) or sporadically, in predominantly venous, predominantly arterial or mixed and in high or low flow. They may be clinically obvious from birth and they occur usually with pulsating mass accompanied by a breath, increase in skin temperature and Branham s sign. Usually they are multiple. The most frequent sites for congenital arterio-venous fistulae is the brain, but in this article we analyze peripheral arterio-venous fistulae particularly in the lower and upper limbs. AVM complications are: rupture, the shunt left to right that may precipitate cardiac failure, limb ischemia due to steal syndrome, necrosis. No standardized best practices exist for their treatment, but there are multiple choices of treatment options depending on the AVM s characteristics (size, location, flow rate number of feeding vessels) and patient s age. Between January 2001 and December 2013 52 patients were subjected to embolization of fistula/ae. The patients are preliminarily studied by angio-rm or angio-tc to exclude AVMs in other sites specially in brain, also by angiography to individuate the nidus of malformation. The procedure of embolization was performed using by direct puncture when the malformation aren t visible by angiography or by retrograde venous. The material used to procedure are coil, ethanol, athoxysclerol plus O2, athoxysclerol pure, Onyx and glue in solution with Lipiodol. From the analysis of angiographic finding and from this study embolotherapy results an efficacy of therapy to reduce mass of malformation because it s impossible to obliterate all nidi of AVMs and to prevent disease-related complications. There was no treatment-related complication. SEVERE LYMPHEDEMA OF THE LOWER LIMBS. TRANSDISCIPLINARY TREATMENT J. Soracco, J L. Ciucci, J. Krapp, O. Regalado, L. Marcovecchio, S. Gerez, M. Amore, G. Bengoa, F. Díaz Bessone, L. Rodríguez Phlebolymphology. Military Hospital. Buenos Aires. R.Argentina Introduction. It is the objective to present the experience in the treatment of severe lymphedema of the lower limbs, the therapeutic methodology and its results with an transdisciplinary approach, considering the patient a whole, addressing his illness fully. Methods. between January 2012 and 2014 were treated six grave lymphedema of the lower limbs, five primary and one secondary. Primary, one bilateral, three unilateral the fifth s associated with lymphedema of penis and scrotum; two affected left limbs. The secondary was a neoplasm of vulva and bilateral inguinal dissection. The range of age was 46.5 years (22-68). Four male. All previously with irregular medical treatment and in one case resection surgery. In five, background of local infection (erysipelas and lymphangitis). The common characteristic is longstanding edema with bulky extremities. Therapeutic handle aspects that interact in this disease, psychological, social, clinical, patient s infection, dermatological, therapeutic pain and lymphedema treatment with lymphatic drainage, sequential pressure pump and multilayer bandage, to arrive finally at the surgical stage consisted performing resection techniques in 100% of cases. Results. improved quality of life achieving social reintegration in all patients. In two (33%) occurred dehiscence and partial necrosis of the scar. Rehabilitation and retooking walking in the six. All continue medical treatment. Conclusions. Transdisciplinary treatment for severe lymphedema of the lower limbs and the immediate results are presented, achieving psycho-social and physical improvement in 100% of treated patients. Variation of blood vessels in the cranial-cervical region. rare forensic pathological findings due to variation of the blood vessels S Furukawa, S Morita, H Okunaga, L Wingenfeld, K Nishi Japan The blood vessels in the head and neck have several main roots for supplying blood to the brain and returning of blood to the heart. It was well known that each artery and vein in the head and neck has its variation. The variation of the vessels sometimes gives rise to un-expectable findings, which are not 72 INTERNATIONAL ANGIOLOGY August 2014

described in the textbook. In this study we like to show the morphological variations observed at routine autopsy cases and some forensic pathological findings caused by those variations. Efficacy and safety of 12 to 24 versus 25 to 36 months of dual antiplatelet therapy after implantation of overlapping drug-eluting stents D Kim, J Kim, B Hwang, K Yoo, S Her, K Moon South Korea The optimal duration of dual antiplatelet therapy (DAPT) for patients receiving overlapping drugeluting stents (DES) remains uncertain. The objective of this study was to the efficacy and safety of the 12 to 24 months DAPT compared to 25 to 36 months DAPT for patients with overlapping DES. 1,313 patients of the 17,241 registry patients were enrolled based on the following inclusion criteria: (1) patient receiving two overlapping DES (2) follow up period of more than 3 years. The primary end point was a composite end point of major adverse cardiac or cerebrovascular events (death from any causes, non-fatal myocardial infarction (MI) or stroke). 277 patients received 12 to 24 months and 1,036 patients received 25 to 36 months DAPT. The primary end point occurred in 93 patients. The cumulative risk of the primary end point at 3 years was 7.6% with 12 to 24 months DAPT, as compared with 6.9% with 25 to 36 months DAPT (adjusted hazard ratio,1.08; 95% confidence interval, 0.34-2.44; P=0.69). The individual risks of death from any cause, non-fatal MI, stroke, very late stent thrombosis, repeat target vessel revascularization, and major bleeding did not differ significantly between the two groups. After propensity-score matching, there was no significant difference in the occurrences of the primary end point between 12 to 24 months versus 25 to 36 months DAPT. Current evidence suggests that 12 to 24 months DAPT in patients, who have received overlapping DES, is as effective and safe as 25 to 36 months DAPT in reducing the composite of all death, nonfatal MI and stroke focused on the long-term durability of endovascular therapy (EVT) for subclavian artery stenosis or occlusions. This study attempts to document longterm durability of EVT during a 5-year period at a single-center. Methods. From July 2008 to June 2013,20 patients (12 men;8 women, mean age: 52 years) underwent EVT for symptomatic (>75%) stenosis or occlusion of the subclavian artery (left: right:11:9). Of the total 144 patients who presented with upper limb ischemia, only the above mentioned 20 patients had an identifiable underlying lesion, rest of which were treated by only embolectomy or required intra operative angiogram. All patients presented with critical limb ischemia, duplex scans and arteriograms confirmed significant stenosis or occlusion.5 patients required thrombectomy so were approached through open brachial approach while 15 were percutaneous (9 brachial, 6 transfemoral). PTA alone was done in 6 patients while 14 were stented. Results. Technical success was 100%, however 3 patients (15%) had minor wound related problems (hematoma, SSI) all without permanent sequelae while other 3 patients with percutaneous brachial approach had thrombosis of the brachial artery, which required no intervention as the patients were asymptomatic. Follow-up with duplex scanning ranged from 3 months to 5 years (mean 34 months). Primary clinical patency at 5 years was 89%,with a median recurrent obstruction free period of 23 months. There was no major amputation and those who were treated by PTA alone had radiologically evident restenosis in 2 patients (33%) while in patients who were stented, the stenosis was evident in 2(14%) patients however, none had symptoms. Conclusions: EVT of the proximal subclavian artery is not only an effective initial treatment, but is also successful over short-term and long-term. We could not prove positive or negative influence of additional placement of stents; however, the number of recurrent stenoses might be too small in this retrospective study to draw firm conclusions. Adverse events of any kind are certainly no greater than with invasive surgical procedures thus making the procedure far less morbid. Therefore PTA must be seriously considered in patients with localized obstruction of the proximal subclavian artery Clinical efficacy of endovascular therapy in critical limb ischemia of the upper limb T. Sahu 1 1JIVAS, Karnataka, India Purpose. Symptomatic occlusive disease of the upper extremities is much less common than in the lower extremities, accounting for limb ischemia in approximately 5% of the patients. Few authors have Porphyromonas gingivalis and platelets aggregation in patients with peripheral artery disease. M. Jibiki 1, Y. Inoue 2 1Department of Vascular Surgery, International University of Health and Welfare, Shioya Hospital, Japan 2Department of Vascular Surgery, Tokyo Medical and Dental University Introduction. It is reported that peripheral artery disease (PAD) is associated with periodon- Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 73

tal bacterial infection. And in previous study, we have showed Porphyromonas gingivalis (Pg) induced platelet aggregation in patients with PAD more strongly and that the patients with more severe PAD showed stronger whole-blood platelet aggregation by Pg. IgG titers against Pg have been measured in both groups, and its relation with platelet aggregation was statistically evaluated. In this study, we examined that whether Pg induces platelets aggregation using an antibody and a factor Xa inhibitor attenuated Pg-induced platelets aggregation in patients with PAD. Materials and Methods. Venous blood (4.5ml) was collected from 40 patients and the 500μL of 3.8% sodium citrate was added to that. And the 500μL of the sample was diluted with 500μL PBS and that 1000μL was used. Pg was incubated anaerobically and was provided. Electrical impedance was measured as the platelets aggregation using Whole Blood Impedance Aggregometer. Platelets aggregation was measured when the blood sample was monitored before Pg was added and, was measured when anti-cd32 antibody (Ab) was added in the sample and, was measured when Pg was added after Ab was added in the sample. Moreover, platelets aggregation was measured when Pg was added after Fondaparinux sodium and PBS were added in the sample. Results: The change of electrical impedance levels was 7.9 ohm in Pg and 5.5 ohm in Ab (1.0μg/50μL) but there were no changes in Ab (0.1μg/50μL). In addition, Fondaparinux sodium attenuated Pginduced platelets aggregation. Conclusion: We demonstrated that Ab and Pg stimulate the CD32 receptor on platelets and that the activation depended on Ab density. And that a large dose of Ab prevented Pg-induced aggregation. Pg bacteremia which brushing or polishing temporally causes might deteriorate ischemic symptoms in patient with PAD and periodontal bacterial disease. Bone marrow derived stem cell therapy to stimulate angiogenesis in patients with critical limb ischaemia A. Morrow 1, M. Krishnaswamy 2, J. Griffin 2, D. McClure 2 1Deakin University/Barwon Health, Victoria, Australia 2Barwon Health Critical limb ischaemia (CLI) is the result of end stage peripheral arterial disease. Many individuals suffering from CLI are, for one reason or another, not considered suitable candidates for traditional revascularisation procedures and often ultimately require amputation. Recent international studies have demonstrated promising results in these individuals with the use of intramuscularly injected autologous Bone Marrow De- rived Stem Cells (BDSCs). This study aims to observe the effectiveness of BDSC therapy in patients with CLI. To date, three patients have undergone BMDSC therapy, each of whom has attended two followup assessments. No subject has reported any adverse effects. Objective measures, ABI and toe pressures, have demonstrated a minimal trend towards improvement (except in one patient for whom a toe pressure could not be recorded), but small numbers limit formal statistical analysis. All patients have reported improvements in rest pain and claudication distance and have improved QoL scores. While this study represents preliminary observations, procedural safety as recorded by others has been confirmed. Immediate and short-term results from the small number of patients in this study offer some promise of leading to improved quality of life; free of lower limb amputation. Outcome trends from further follow up is eagerly anticipated. Pre-reconstruction of cervical-topetrous internal carotid artery: improved technique for treatment of vascular lesions involving internal carotid artery at the skull base F. Li 1, Y. Zheng 1 1 Department of Vascular Surgery, Peking Union Medical Hospital, Beijing, China Objective. To introduce an improved technique for operation for vascular lesion involving the lateral skull base. Summary Background Data. Surgical treatments for vascular lesions involving the internal carotid artery (ICA) close to the skull base are effective, but still challenging. Anatomical difficulties, blood loss, potential intraoperative cranial nerve injury and the need for cerebral protection all make the procedure a tough task. Patients and Methods. From January 2010 to December 2013, 9 patients were operated for high ICA vascular lesions: 8 for extended paragangliomas and 1 for large symptomatic ICA aneurysm. All lesions were removed after reconstructing the ICA with autologous grafts. The fractionatedclamping method was used to perform the proximal anastomosis, leading to a reduced clamping time, which enabled the cerebral protection. Results. All operations were technically successful with no operative mortality or strokes. The mean blood loss was 921±210 ml. The median operating time was 400 minutes (range 350-600). The mean total clamping time for common carotid artery (CCA) and ICA reconstruction was 74 INTERNATIONAL ANGIOLOGY August 2014

18±5 minutes. During the follow-up periods ranging from 5 to 48 months, 4 patients (44.4%) suffered persistent cranial nerve paresis, mainly due to the involvements of the specific nerve, otherwise the other 5 patients had minimal long-term sequelae. Conclusion. Reconstruction of the ICA in advance with the fractionated-clamping method for the treatment of vascular lesions close to the skull base could be applied with shorter clamping time, less blood loss and slight cranial nerve injuries This study confirms that the TCC continues to be recommended for the treatment of plantar ulceration due to the mechanism of reducing plantar pressures. If a TCC is not utilised, it is recommended that the mode of offloading contain the principles of the TCC and that it extends proximal to the malleolus. With direct measurement, is has been established that a substantial amount of plantar load is transferred to the cast walls of the TCC. Load transfer from the foot to the walls of the total contact cast in patients with a diabetic foot wound. L. Begg 1,2, P. McLaughlin 3,4, M. Vicaretti 1,2, J. Fletcher 1,2, J. Burns 1,5 1Foot Wound Clinic, Department of Surgery, Westmead Hospital, NSW, Sydney, Australia 2University of Sydney, Department of Surgery, Westmead Hospital, NSW, Sydney, Australia 3School of Biomedical and Health Sciences, Faculty of Health, Engineering and Science, Victoria University, Melbourne, Australia 4Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Australia 5The University of Sydney and The Children s Hospital Westmead, Sydney, Australia Load transfer from the plantar surface of the foot to the walls of the Total Contact Cast (TCC) has been assessed indirectly in the vicinity of 30%. More recently, load transfer has been measured directly and it was found that the two highest areas of load transfer from the plantar surface of the foot were to the posterior lateral malleolus and extensor retinaculum. The aim of this study was to directly measure the load between the cast wall and the lower leg while simultaneously, measuring plantar load. 17 patients with forefoot plantar wounds participated. A Pedar capacitance sensor insole was placed on to the plantar area of the TCC and canvas cast shoe. Two Pliance sensors (90 cm2) were also placed along the lower leg at the two areas of highest force locations. Following testing, the TCC was then cut down to create a shoe-cast (SC). Force transference to the pliance sensors was 4.1 to 12.4% of the SC totalling 16.5%. Peak pressure (PP) transference to the pliance sensors, was 10.5 to 25.8% of the SC totalling 36.3%. Compared to the SC, mean pressure was lower at whole foot, midfoot and forefoot in TCC. PP was reduced at midfoot and forefoot in TCC. Contact area was reduced for whole foot, midfoot and forefoot in TCC. Pressure Time Integral was higher at the rear foot in the TCC. Efficacy of short-term catheterdirected thrombolysis used with rt-pa combined with endovascular interventional therapy in patients with lower limb ischemia Z. Yang, Z. Wangde, L. Tan, Y. Biao, S. Shenghan. Department of Vascular Surgery, Beijing Chaoyang Hosptial, Capital Medical University, Beijing, China Objectives. To evaluate the performance effect of short-term catheter-directed thrombolysis with different dosage of rt-pa allied with endovascular interventional therapy for patients with acute lower limb ischemia. Methods. To separate 84 consecutive patients suffered from acute lower limb ischemia into two groups at random, then adopt catheter-directed thrombolysis for each group of patients injected 20mg (Group A) or 10mg (Group B) rt-pa into the occlusive lesion correspondingly, and subsequently perform endovascular intervention on significant underlying lesions on the base of angiography results. Adopt statistical methods to assess treatment effectiveness, rates of complication and amputation rates within 30 days, 6 months or 12 months. The statistic analysis was performed under SPSS16.0 format, and adopts t test and χ2 test. Results. There was no statistical difference on patient characteristics and lesions between both groups (P>0.05). Procedural success rates as well clinical success rates were all 100%. Not incur any diversity on thrombolysis effectiveness between both groups injected different dosage of rt- PA (P>0.05). Not found major differences on ratios of PTA or implant stent between both groups (P>0.05). During the follow-up period of 30-day, 6-, 12- months, there were no statistical differences on the amputation-free survival rates and complication rates between both groups. Conclusions. Whereas short-term catheter-directed thrombolysis combined with endovascular interventional therapy won good operation effectiveness on patients with acute lower limb ischemia, moreover the dosage of rt-pa did not impact on thrombolysis, it is worthy to be applied in the clinical practice. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 75

The influence of ozonated autohemotherapy on lipid peroxidation system in patients with thromboangiitis obliterans and critical limb ischemia. N. Abushov 1, E. Zakirjayev 1, R. Guliyev 1, M. Ahmadov 1, G. Tagizade 1, E. Aliyev 1, L. Mammadova 1 1Scientific Centre of Surgery named after M.A. Topchubashov, Baku, Azerbaijan Purpose. It is known, that oxidative stress significantly affects the course and prognosis of disease in patients with thromboangiitis obliterans (TAO) and critical limb ischemia (CLI). In this study, we estimated the influence of ozonated autohemotherapy on lipid peroxidation (LPO) levels in patients with TAO and CLI. Methods. There was presented the experience of treatment and the analysis of changes in the LPO system at 65 patients with TAO and CLI, which were divided into 2 groups depending on the used therapy. Patients of control group (n=35) received a basic course of medical treatment, which includes rheology, vasoactive drugs, anticoagulants and antiplatelet. At main group patients (n=30), along with a protocol of basic therapy perioperative major ozonized autohemotransfusion was employed. Comparison groups were comparable in terms of nosological form of the disease, sex, age, nature of comorbidity. Indicators of LPO were determined prior to the passage of the programs and after a three-week course of treatment. The activity of blood lipid peroxidation was evaluated on the content of malondialdehyde (MDA) (nmol/mg lipid) in erythrocytes. Results. According to our data after a threeweek course of treatment, in the basic group of «ozonated autohemotherapy» had a significantly tendency to decrease LPO products MDA (18,6 ± 4,8; 13,2 ± 4,2 nmol/mg. p < 0.05). In the control group significant changes in the level of MDA were not found (19,4 ± 3,8; 16,4±4,2 nmol/mg.) Conclusion. We consider that employing of ozonated autohemotherapy improves the lipid peroxidation system and antioxidant status in patients with TAO and CLI, which promotes to optimization of complex surgical treatment results. Establishment of the Brunei diabetic foot registry N. HajiZaine 1, K. Hitos 2, J. Fletcher 2, M. Vicaretti 2, L. Begg 3, J. Burns 1 1Arthritis and Musculoskeletal Research Group, The University of Sydney, NSW, Australia 2Westmead Research Centre for the Evaluation of Surgical Outcomes, Westmead Hospital, NSW, Australia 3Foot Wound Clinic, Department of Surgery, Westmead Hospital, NSW, Australia The national diabetes prevalence estimates for Brunei Darussalam in 2010 was 10.7%. This estimate is expected to increase to 13.4% by 2030 as one of the highest in the Western Pacific region. Unpublished estimates of 2009-10 Podiatry service reports suggest 60%-70% of patients with diabetes assessed in the Podiatry Unit at the main referral hospital in Brunei Darussalam had chronic and recurrent foot ulcers. There are no published reports on the prevalence and characteristics of diabetic foot ulcers in Brunei Darussalam. Our primary aims are to determine the prevalence and characteristics of diabetic foot ulcers and to determine which factors are associated with the development and healing of these foot ulcers in a tertiary outpatient hospital setting. One of the secondary aims is to determine causal pathways of foot ulcers. Our objective is to develop a Brunei Diabetic Foot Registry to achieve these aims. The Diabetic Foot Registry will comprise of two clinician-completed sections which will include patient details, clinical and wound assessments. Patients details will include demographics, medical history, medications, and history of amputations or ulcerations. The assessments will include measures such as PPG (photoplethysmography) and wound diagnostics. A pilot study for a period of 6-12 months will be conducted to validate the Registry. The Podiatrists at the Podiatry Unit in the main referral hospital in Brunei Darussalam will be participating in this pilot study. The increasing prevalence of patients with diabetes and associated complications is becoming a national concern in Brunei Darussalam. There is clear paucity of data on the prevalence and characteristics of diabetic foot ulcers and there is a need to develop a Diabetic Foot Registry. This will also facilitate improvements in research and development in the area of diabetic foot management as one of the strategic objectives of the Ministry of Health in Brunei Darussalam. Endovascular treatment of iliac arteries R. Moia 1, A. LaRosa 1, J Clerissi, C. MassaSaluzzo, E Moia, E. Casronovo 1, V. Saracino 1, R. Nuzzo 1, M. Dondi 1 1Università degli Studi di Pavia, Italy The purpose of our study is to demonstrate the intravascular treatment value (PTA and PTA+STENTING) performed in patients with severe occlusions in iliac district. This is a retrospective study from January 2009 to December 2013 considering 319 patients treated with PTA and PTA + stenting techniques. Patients underwent clinical exam and arterial US echography of aortobi-iliac district and lower limbs to evaluate the presence of partial or complete occlusions and 76 INTERNATIONAL ANGIOLOGY August 2014

position of the lesions. Intermittent claudication is the most frequent symptom, found in 144 patients (45%); pain at rest was present in 99 patients (31%) and 76 patients (24%) presented ulcerative trophic lesions of lower limbs. The intravascular lesions were localized in 153 cases (48%) at common iliac artery, in 126 cases (39,6%) at external iliac artery, and in 40 cases (12,4%) in both the arteries.. Stents have been used only when arterial dissection or residual stenosis was higher than 30%. The procedural success has been established by the restoration of blood flow without residual stenosis. We use the US ecography to check up the results. Follow-up provides check-up 3, 6 and 12 months after the procedure. The restenosis, clinically or instrumentally evaluated, represents the failure of the procedure. The techniques of PTA and PTA+stenting represent a valid alternative to surgery, especially in patients with advanced age and comorbidity and repeatability of this procedure allows to treat again cases showing restenosis at US echography control. Endovascular treatment in patients with below the knee vessels desease R. Moia 1, A. LaRosa 1, J Clerissi, C. MassaSaluzzo, E Moia, E. Castronovo 1, V. Saracino 1, M. Dondi 1, R. Nuzzo 1 1Università degli Studi di Pavia, Italy In order to evaluate the efficacy of percutaneous transluminal angioplasty (PTA) in a selected population of 976 patients with below-the-knee (BTK) disease and to analyze the efficacy of treatment in the prevention of major amputations. Patients undergone clinical examination of lower limbs with ecocolordoppler. The endovascular procedure is performed in cases with hemodynamically significant lesions conditioning intermittent claudication stage II B sec. Leriche-Fontaine, rest pain or trophic ulcerative lesions. Anticoagulant therapy was interrupted 5 days before the angiographic procedure and has been replaced by low molecular weight heparin. It must administer to all patients hydration with saline and sodium bicarbonate. The arterial access is executed after local anesthesia with ipsilateral and contralateral injection in inguinal district. A 5 or 6 Fr introducer is located to make preliminary angiographic test by injection of iodinated contrast (dilution 50%). The procedural success is established when the direct flow without residual stenosis is restored. The follow-up consisted in checkups every three months. We considered a fail procedure in presence of clinical arterial restenosis, based on the recurrence of pain or lesions or non-healing trophic ulcerative lesions. In this case we must execute another angiographic procedure and if necessary a new PTA or PTA+stenting. In our experience, hemodynamic procedures performed with PTA and stenting technique in region below knee is a safe and effective option to reduce the risk of major amputation also thanks to utilization of new dedicated stents for popliteal artery (Supera Abbot, Smart Flex Cordis, Tigris). In fact the success of the procedure ensure to the patients with critical ischemia an excellent clinical and instrumental option to revascularized the limbs or in a few cases to restrict the amputation area. Endovascular rivascularization of the lower limb through profunda femoral artery R. Moia 1, A. LaRosa 1, J Clerissi, C. MassaSaluzzo, E Moia, R. Nuzzo 1, M. Dondi 1, E. Castronovo 1, V. Saracino 1 1Università degli Studi di Pavia, Italy Heavy calcified and long occlusion of SFA in diabetic, IV stage LF patients with cutaneous ulcerations and other main arteries treatable steno-obstructions, could be considered a relative contraindication for an endovascular reconstruction. Our purpose is to suggest the possibility of achieving limb salvage performing an endovascular intervention of diseased arteries, and sometimes using the sfa just to achieve BTK vessels. From January 2009 to December 2013 we treated 15 patients, diabetic mellitus type II, Stage IV LF. Heavy calcified long occlusion of SFA and both popliteal and BTK steno-obstructions. Mean percutaneous oximetry was 9 mmhg. 6 patients underwent femoral approach; 4 patients needed double approach: both antegrade common femoral and popliteal approach 4F; 3 patients underwent brachial approach 4F; a pedal approach was used for 2 patient. During angiography we found 5 medium to severe stenosis of PFA treated successfully with PTA alone and 2 with self-expandable naked stents; 11 patients had SFA occlusion caused by severe calcifications: sfa was recanalized in 8 cases just to push through materials (balloons, ect) to achieve and treat both popliteal and BTK vessels; 7 patients had severe stenosis of re-entry collaterals PFA into femoro-popliteal tract: 5 of them were treated with PTA alone and 1 with stent; 2 popliteal stenosis were treated with PTA and 1 with stent. After SFA predilation, naked self-expandable stents were implanted: heavy calcifications detained correct stents expansion even if they were aggressively postdilated. Stents were not able to support the walls and failed in creating a new good lumen. Three days after procedures mean oximetry was 45mmHg. Ulcer healing was obtained in all patients after 40 days. Stage IV LF patients with Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 77

heavy calcified SFA total occlusion, PTA of PFA and re-entry collaterals, together with PTA of BTK vessels is a sufficient procedure to obtain ulcerations remission. Efficacy and safety of hybrid therapy for complex peripheral arterial disease S. Ito 1, M. Hashimoto 1, N. Katayama 1, T. AMemiya 1, H. Suesada 1, H. Tsuchida 2 1Nishitokyo Chuo General Hospital, Japan 2Mito Hospital Purpose. Recently peripheral arterial disease (PAD) is observed to be complicated lesion such as multiple stenosis, occlusion and severe calcification. It is difficult to make a strategy decision. We report hybrid therapy for four cases of PAD. Cases. Case 1: A 71-year-old male. He noticed intermittent claudication (IC). His ankle-brachial index (ABI) was 0.54(left) and 1.16(right). Angiogram revealed severe stenosis of superficial femoral artery (SFA), total occlusion of popliteal artery and severe stenosis with calcification of common femoral artery. Case2: A 71-year-old male who had post peripheral artery bypass surgery (right superficial femoral artery to anterior tibial artery by saphenous vein). His right ABI was 0.43. Angiogram revealed severe stenosis of common iliac artery (CIA) to external iliac artery (EIA) and severe stenosis with calcification of common femoral artery. Case3: A 68-year-old female. An ABI was 0.41(right). Angiogram revealed total occlusion of right CIA and SFA. Case4: An 81-year-old male. An ABI was 0.52 (left) and 0.90(right). Angiogram revealed total occlusion of right SFA and severe stenosis of right popliteal artery. Strategy and treatment. Under general anesthesia, one stage hybrid therapy was selected and performed by cardiologist and surgeon in all cases. Percutaneous intervention was performed for SFA (stent implantation) and popliteal artery (balloon angioplasty) in case1, and from CIA to EIA (stent implantation) in case2 by cardiologist. After that thromboendarterectomy (TEA) for stenosis of common femoral was performed in case1 and 2 by surgeon. Case 3 and 4 were performed percutaneous intervention for stenosis of CIA (stent implantation) and popliteal artery (balloon angioplasty) by cardiologist. After that femoro-popliteal artery bypass was performed for total occlusion of SFA by surgeons. In all cases, hybrid therapy was successfully performed and ABI was recovered. Conclusion. Hybrid therapy was effective and safe strategy for PAD with multiple complications. Microcirculation in patients with clinical signs of critical lower limb ischemia S. Rosfors 1, L. Kanni 1, T. Nystrom 2 1Clinical Physiology, Sodersjukhuset, Karolinska Institutet, Sweden 2Internal Medicine, Sodersjukhuset, Karolinska Institutet, Sweden Background. The combination of measurements of toe pressure (TP) and transcutaneous oxygen pressure (TcPO2) makes it possible to determine the role of macro- (TP) and microvascular (TcPO2) disease in the evaluation of critical limb ischemia. Moreover, this approach can be useful to classify ulcers in diabetic and non-diabetic patients. Aims. To describe macro- and microvascular disease and types of ulcers in a consecutive series of patients referred to vascular laboratory with suspected critical ischemia. To evaluate whether patients with diabetes have more pronounced microvascular disease compared with patients without diabetes. Material and Methods. The study includes 498 patients; 211 females and 287 males with a mean age of 76 years. TP was measured with laser Doppler-technique and TcPO2 was measured at the dorsum of the foot, in cases with low values also after oxygen inhalation. In each case TP and TcPO2 was graded as normal, reduced or critically reduced. Results. There were 300 diabetic och 198 nondiabetic patients. Eighty-five per cent of the patients had ulcers, both in the diabetic and in the non-diabetic group. In both groups 90% of the ulcers were found to have an ischemic component, and in 19% of diabetics and 20% of non-diabetics dominantly microvascular disease. TP could not be achieved in 6% of the diabetics or in 3% of non-diabetics, due to amputation or extensive ulcers. Totally, in 17% of the patients the degree of ischemia was underestimated if only TP was used. Conclusions. Transcutaneous oxygen pressure measurement is a valuable tool in the evaluation of patients with suspected critically limb ischemia. In comparison with TP, TcPO2 gives additional information regarding the microcirculation, useful for determining ulcer etiology. Advanced microvascular disease was equally common in diabetic and in non-diabetic patients. Dying digits, no place to run no place to hide D Dekiwadia Gujarat, India Aim. to analyse effectiveness of Prostaglandin E1 in cases of sever ischemia of digits. 78 INTERNATIONAL ANGIOLOGY August 2014

Method. From June 2009 through February 2014, 94 cases studied retrospectively in whom regardless of the proximal arterial lesion the fingers/toes were deeply cyanosed, or ulcerated. The cases were grouped in 4 different subsets. (1) total occlusion of the femoral or popliteal artery with only collateral flow. (2) diabetics with high ABI, and isolated ischemic digits with normal proximal arterial pulse and pressure. (3) proximal occlusive lesions treated by endovascular or surgery with persistent digital ischemia distal to palpable arteries. (4) Acute thrombo-embolic event with post operative inadequate digital reperfusion. Ischemia was diagnosed clinically and by photoplethesmography (PPG) record. Prostaglandin E1 was infused in these patients. Serum potassium levels were corrected, cases with known myocardial ischemia were excluded. Infusion with an infusion pump 100mcgs/day over a period of five hours for five days. Daily clinical evaluation and PPG repeated after five days. Results. Ppositive response assessed by reduced pain and tenderness, increased warmth and pain free movements of digits. Improvement in PPG was evaluated. Conclusion. PGE1 is effective adjuvant in all 4 subsets where direct vascular or endovascular procedure does not show circulatory benefit in the digits. PGE1 is similarly effective in primary Raynaud s phenomenon N-3 polyunsaturated fatty acids, 24-h ambulatory blood pressure, and heart rate in incident hypertension J. HagstrupChristensen 1, C. Strandhave 1, M. Svensson 2, E. BergSchmidt 3 1Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark 2Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark 3Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark Hypertension is common in Western populations. n-3 polyunsaturated fatty acids (PUFA) have antihypertensive effects as well as they may modulate cardiac autonomic function by reducing heart rate (HR). HR is a risk marker for vascular disease in patients with hypertension. Previous studies have mainly examined patients with established hypertension already treated with antihypertensive medication. The aim of the present study was to examine whether n-3 PUFA levels in patients with incident hypertension were related to blood pressure (BP) and HR. Patients with incident hypertension (n=129, mean age 49 years (20-73), 68 women) and without antihypertensive treatment were included. Ambulatory BP measurements (24-h) were performed and HR was obtained from these measurements. Also, the content of n-3 PUFA in plasma phospholipids was analyzed. The patients were divided in quartiles according to the n-3 PUFA content. This division revealed a striking difference in age with a mean age of 45 years (+10) in the first quartile and 56 years (+11) in the upper quartile. Twenty-four hour systolic BP (SBP) was 148 mmhg (+11) in the first quartile compared to 144 mmhg (+12) in the fourth quartile (p=0.1). The diastolic BPs (DBP) were 91 mmhg (+ 8) and 88 mmhg (+9), respectively (p=0.1). A significantly lower HR was observed in the fourth quartile compared to the first quartile (71 bpm (+ 7) versus 78 bpm (+10), p<0.01). In incident untreated hypertensive patients 24h SBP and DBP tended to be lower in patients with a high content of plasma n-3 PUFA, and furthermore, these patients had a significantly lower 24-h HR indicating a lower cardiovascular risk. These findings were obtained despite the fact that patients with the highest content of n-3 PUFA in plasma were significantly older than patients in the lowest n-3 PUFA quartile. The Impact of Plain X-ray Calcium Score in Revascularized Critical Limb Ischemia Patient B. Wasin, H. Suthas, P. Piyanut, T. Wiwat, L. Surasak- Udomlipi, J. Sopon Ramathibodi Hospital, Bangkok, Thailand Background. In PAD patient, calcific atherosclerosis and calcific medial vasculopathy are the most common calcification of the vessels. In long term hemodialysis patient with high calcium score due to the medial arterial calcification, the risk of major amputation and mortality rate are increased. The present study aimed to evaluate the impact of plain film calcium score on the early outcome of revascularization in critical limb ischemic patients (CLI). Method: This is a prospective non- randomized controlled study of the CLI patients who underwent revascularization at Ramathibodi hospital during June 2013 to February 2014. The VC data were evaluated by plain film pelvis and hand and scored (Total score 0-8). The other associated factors including of DM, HT, CKD, bypass surgery, angioplasty, serum calcium, phosphate, vitamin D, PTH.The early postoperative clinical outcome (30 days) were studied including wound infection, cardiac complication, pulmonary complication, LOS and mortality rate. The Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 79

severity of the VC was compared to these clinical outcomes. Result: In this study, 38 patients were enrolled. The revascularization were 19 (50%) and 19 (50%) bypass and angioplasty surgery. The median calcium score (IQR) was 4±3. There was no relationship between the severity of calcium score and mortality rate (p=0.939) but in the patient with plain film calcium score > 2 have significant increase of the early post operative AKI and CHF when compare to the patient who have plain film calcium score 2 (p = 0.045 in CHF and p = 0.023 in AKI) Conclusion. The plain film calcium score more than 2 are not associated with early post operative mortality but associated with early post operative AKI and CHF Long-term Patency and Fracture Rates of Stents Placed in the Popliteal Arteries in Chinese Patients With Chronic Critical Limb Ischemia or Lifestyle-limiting Claudication C. Shijun, G. Lianrui, L. Xuefeng, W. Xin, T. Zhu, Z. Jian, G. Yongquan Vascular Surgery Department of Xuan Wu Hospital, Institute of Vascular Surgery, Capital Medical University, Beijing, China Objective. We wanted to evaluate efficacy, safety, and long-term patency and fracture rates of self-expanding nitinol stent after failed percutaneous transluminal angioplasty (PTA) of popliteal artery in patients with chronic critical limb ischemia (CLI) or lifestyle-limiting claudication in Chinese patients. Materials and Methods. We retrospectively analysed 64 patients (68 limbs) who underwent endovascular treatment for steno-occlusive lesions in the popliteal artery from January 2008 to July 2012. In a single-center study, self-expanding nitinol stents were implanted in 68 popliteal arteries for the treatment of stenosis greater than 75% or occlusions in the P1 (n =10), both P1 and P2 segment (n =28), both P2 and P3 segment (n = 18), P1 to P3 segment (n=8), or P3(n=4). Follow-up patency was assessed by clinical examination, anklebrachial index, and color ultrasound or digital subtraction angiography, and stent fracture was assessed by plain X-rays at 6 and 12 months and annually thereafter. Results. Stent implantation was successful in 63 patients (98.5%). The complication rate was 7.8% (4 access-site hematoma, an early stent thrombosis). Mean follow-up was 22.1 months (range 8.3 35.9). 1-year, 2-year and 3-year primary patency rate (PPR): 76%, 60% and 43%. 1-year, 2-year and 3-year secondary patency rate (PPR):87%, 82% and 73%. Respectively, 1-year,2-year and 3-year PPRs for subgroups: trans-articular surface (P2-3, P1-3) versus no trans-articular surface (P1, P1-2, P3): 76%, 70%, 45% vs 80%, 54%, 42%, p= 0.78; 1-year,2- year and 3-year SPRs for subgroups: trans-articular surface (P2-3, P1-3) versus no trans-articular surface (P1, P1-2, P3): 87%, 75%, 75% vs 88%, 88%, 72%, p= 0.65. Stent fractures were seen in 11 limbs (11 of 68, 16.2%) and the fractures were identified in P1 and P2 segment. Three patients were performed above-knee amputation because of stent occlusion and gangrene of limb (3 of 68, 4.4%). Conclusion. Stent implantation is a safe and effective treatment of popliteal artery occlusion. Stent were used for the treatment of blocked blood flow caused by residual stenoses and dissection after percutaneous transluminal angioplasty (PTA) of popliteal artery with acceptable longterm patency. We can improve the popliteal arterial stent patency rate by interventional technique, such as transcatheter arterial thrombolysis, balloon angioplasty, silverhawk atherectomy, rescue stent, and so on. We maybe try to avoid stent placement up to the popliteal arterial P1 and P2 segment owing to stent fracture. Trans-articular surface (P2-3, P1-3) stent were not worsen the stent patency than no trans-articular surface (P1, P1-2, P3) stent. It may be necessary to develop a stent design and structure for the patients with popliteal artery steno-occlusive disease that can resist the bending force in the knee joint. Tibial angioplasty for limb salvage in patients with end-stage renal disease (esrd) W. Lang 1, A. Meyer 1 1University Hospital Erlangen, Germany Prospective follow up of 19 ERSD patients on hemodialysis (mean age 72 years) with CLI (Rutherford 5 and 6) and consecutive infrapopliteal angioplasty over a 3-year period 2010-2012. Mean follow-up was 8 months (range: 0-27 months). Statistical endpoints were defined for patient survival, freedom from major amputation and wound healing. A total of 29 vessels in 19 ischemic legs was treated. Additional in-flow PTA was performed in 8 patients. Technical success was achieved in 89.5% of patients, no major complications were observed. 30 days mortality rate amounted 10.5% with no procedure related deaths. Wound healing occurred in 6/19 and 8/19 legs at 6 and 12 months. Postprocedural overall survival was 12/19 and 7/19 patients at 6 and 12 months. Only one major amputation (1/19) was required. Subsequent revascularisation procedures were necessary in 2 patients (one redo-angioplasty, one 80 INTERNATIONAL ANGIOLOGY August 2014

pedal bypass graft). No statistical significant differences in terms of survival or wound healing rate were observed between patients with and without in-flow PTA. Simultaneous minor amputation for infection control was carried out in 12/19 Patients. Below the knee angioplasty should be offered as firstline treatment in ERSD patients with CLI. As described in other studies, wound healing rates are low; however, limb salvage is often possible even case of gangrene or infected ulcers. Surgical revascularisation is associated with high mortality rates and comparable results. Primary amputation is spared for immobile patients. Effect of low-level laser therapy on blood flow and oxygen-hemoglobin saturation of the foot skin in healthy subjects W. Lang 1, F. Heu 1, B. Namer 2, C. Forster 2 1University Hospital Erlangen, Germany 2Institute of Physiology I, FAU Erlangen-Nuremberg, Germany This study on healthy test subjects intends to show whether one-off Low-Level Laser Therapy (LLLT) has an instant effect on the perfusion or the oxygenation of the skin tissue. These possible instant effects may have an influence on the accelerated wound healing which is often observed after application of LLLT, in addition to the usual postulated effects of LLLT which occur with a time delay normally. The study was carried out double-blind and placebo-controlled in two batches of testing. The test subjects received one-off LLLT on a defined area of the arch of the foot. Simultaneously a placebo treatment was carried out on the corresponding contralateral area. In the first batch of tests, the blood flow was measured immediately before and after treatment using thermography and LDI. In the second batch of tests, the blood flow and the oxygen saturation were determined immediately before and after the treatment using an O2C device. No evidence that the LLLT has a significant instant effect on the circulation or the oxygen saturation could be found. No immediate effect of an LLLT on the perfusion or oxygenation situation is to be expected with physiologically normal starting conditions. An additional investigation should be carried out in which either the radiation dose is varied or the starting conditions are pathological (e.g. chronic wounds) in order to rule out immediate effects on circulation or oxygen saturation as the cause of the improved wound healing which is often observed. Endovascular mechanical rotational thrombectomy in cases of occluded native arteries, bypass grafts and stents T. Zahariev 1, V. Govedarski 1, S. Genadiev 1, I. Petrov. 1, B. Denchev 2, G. Nachev 1 1 St. Ekaterina University Hospital Sofia, Bulgaria 2 Virgin Mary Multiprofile Hospital for Active Treatment Burgas, Bulgaria Introduction. Endovascular therapy has gained acceptance as a valuable alternative to the surgical treatment of occluded lower extremity native arteries, bypass grafts and stents. Because of the high initial restenosis rates various methods have been developed to increase patency drug eluting balloons and stents, as well as different athero- and thrombectomy devices. Aim of study.to evaluate the results of mechanical rotational thrombectomy in the treatment of subacute and chronic occlusions of lower extremity native arteries, bypass grafts and stents with regard to its safety and efficacy. Materials and methods. A prospective study of 92 patients started January 2011 divided in 3 groups (native arteries, bypass grafts, stents). All patients presented with occlusions of different mean lengths which were treated with mechanical rotational thrombectomy, PTA and/or stent placement. We did follow-up for 24 months (clinical, ABI, DUS) and calculated primary, primary assisted and secondary patency, as well as the rate of limb salvage. Results. Acceptable primary, primary assisted and secondary patency at 24 months in the group of treated native artery occlusions (55%,72%,79%), unsolved problem with high rethrombosis rates of treated bypasses (60%) and in-stent occlusions (42%). High rate of limb salvage in all groups (above 90%). Low number of minor and major complications. Conclusion. Endovascular mechanical rotational thrombectomy is our first choice of treatment for a large variety of pathologies, as repetition is possible at any time. It s simple, fast, safe and effective, having low number of complications with low clinical significance. Fibulin-1 levels in patients with coronary artery disease H. Karpuz 1, D. Filiz 1, B. Ikitimur 1 1Istanbul University Cerrahpasa School of Medicine Department of Cardiology, Fatih/Istanbul, Turkey Objectives. Fibulin-1 is an extracellular matrix protein which plays an important role in fibrinogen-platelet interaction and is known to be involved in the formation of fibrin clots. The aim of this study was to compare serum fibulin-1 levels Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 81

of acute coronary syndrome (ACS) patients with chronic stable ischemic heart disease (IHD) patients and healthy controls. Material-Method. Serum fibulin-1, high sensitive CRP (hs-crp) and troponin T levels were measured at admission in 40 ACS patients (age: 59 ± 12 years, 70% males) and were compared to those of 20 stable IHD patients (age: 64 ± 10 years, 55% males) and 20 age matched healthy controls. TIMI and GRACE scores were calculated for ACS patients and extent of coronary artery disease (CAD) was evaluated with the Gensini score. Results. There was no statistically significant difference between ACS, chronic IHD and control patients in terms of serum fibulin-1 levels (35.5 ± 43.4 μg/dl vs. 48.2 ± 49.8 μg/dl vs. 51.0 ± 46.3 μg/dl, p=0.39). Moreover, fibulin-1 levels were not found to be correlated with troponin T, hs-crp, TIMI and GRACE risk scores, as well as the Gensini score. Conclusions. Although the role of fibulin-1 in the thrombogenetic process has been established by previous studies, we were unable to demonstrate the clinical significance of serum fibulin-1 levels in CAD patients. Further studies are needed to clarify whether our findings are also relevant for fibulin-1 at tissue level, as in the case of atherosclerotic plaques. Reduced thickness of the choroid in patients with asymptomatic internal carotid artery stenosis. pilot study. S. Przywara 1, A. Zubilewicz 2, P. Bielinski 2, M. Ilzecki 1, P. Terlecki 1, J. Mackiewicz 2, T. Zubilewicz 1 1Department of Vascular Surgery and Angiology, Medical University of Lublin, Poland 2Department of Ophthalmology, Medical University of Lublin, Poland The aim of this pilot study was to measure the pre- and post-operative thickness of the choroid in patients undergoing carotid endarterectomy due to asymptomatic internal carotid artery stenosis. Review of available literature shows that this is the first study reporting potential diagnostic value of optical coherence tomography of the choroid in patients with carotid artery disease. 6 patients with asymptomatic, unilateral internal carotid artery stenosis were qualified for carotid endarterectomy according to the Society for Vascular Surgery Guidelines for management of extracranial carotid disease. Macular and paramacular thickness of the choroid in both eyes was measured by means of deep range imaging optical coherence tomography before and after surgery. All patients showed reduced thickness of the choroid in the eye ipsilateral to stenosed carotid artery as compared to contralateral eye. Carotid endarterectomy caused an increase in the thickness of the choroid in all patients. Reduced thickness of the choroid in one eye observed in patients during routine, optical coherence tomography ophthalmological examinations, should aware the ophthalmologist for the need of preventive ultrasound of carotid arteries in this specific group of patients. Our hypothesis is to be confirmed on larger population of patients with carotid artery disease. Application of micronized diosmin in patients with chronic peripheral artery disease of the lower limbs T. Zahariev 1, S. Dimitrov 1, V. Popov 2, B. Denchev 3, G. Nachev 1 1University Hospital St. Ekaterina Sofia, Bulgaria 2Multiprofile Hospital for Active Treatment Blagoevgrad 3Multiprofile Hospital for Active Treatment Virgin Mary Burgas Introduction. Diosmin as a naturally occurring flavonoid glycoside is a potent inhibitor of prostaglandin E2 and thromboxane A2, which inhibits leukocyte aggregation, migration and adhesion, and provides protection against the microcirculatory damage. Good function of microcirculation is a qualifying factor in treatment outcomes, not only in patients with chronic venous disease, but also has a decisive impact on the effect of treatment in patients with chronic arterial pathology. Increased peripheral resistance in patients with chronic arterial lesions determines unsatisfactory results both from surgical and drug therapy. Aim. of this study was to investigate the effect of micronized diosmin as adjuvant therapy in patients with chronic peripheral artery disease of the lower limbs (PAD). Material and methods. A prospective study for over 12 months was performed on the use of micronized diosmin as adjuvant therapy in patients with chronic PAD of the lower limbs. The study was conducted at three clinical centers in Bulgaria including 1727 patients with chronic PAD and a control group. Subjective indicators like pain severity, heaviness, stepping edema and muscle cramps were assessed in both groups by the patients. Postoperatively, patients were followed up on the first and third month after the discharge from the hospital. Results. Reduction of complaints in all subjective symptoms was found in the study group. Decrease of the moderate symptoms and almost complete disappearance of the strongest symptoms were registered in the first month and trend to decline till the third. A reduction in frequency of all subjective complaints was reported, too. Significant 82 INTERNATIONAL ANGIOLOGY August 2014

increasing of the mean values of ankle brachial index was reported in the first and third month. Conclusion. Our study on micronized diosmin as adjuvant therapy in patients with chronic PAD demonstrates the positive effect of the drug on these patients. Nitinol multiple stents in TASC D superficial femoral artery lesions: analysis with ankle brachial index and duplex scan L. Castro 1, A. Freitas 2, D. Freitas 2, C. Virgini 3, P. Areas 2 1SBACV, 2 HCE, 3 UERJ Rio de Janeiro, Brazil Objective. It s the purpose of this study to analyse above-knee femoropopliteal arterial revascularization through peripheral transluminal angioplasty with multiple stents for patients with femoral popliteal atherosclerotic disease and critical limb ischaemia. Methods. Retrospectively analysis of 25 patients selected by the revascularization technique used- Angioplasty with multiple stents. Medical record, angiographic and noinvasive studies involving Ankle-Braquial Index, Rutherford s Clinical Clasification for chronic arterial disease and Hyperplasia analysis by Duplex scan were reviewed in detail. Primary endpoints were amputation free survival and death. Results. The overall amputation free survival rates in this group of patients did not differ between the 6 and 12 month analysis. The final endpoint analysis among the entire cohort did not differ significantly (P-value = 0,05). Before and After procedure analysis of the Ankle-Braquial Index was associated with a statistical significant heighten (P-value <0,01). Patency analysis during 3, 6, and 12 month follow-up period did not differ statistically (P-value >0.05). Hyperplasia analysis during 3, 6, and 12 month follow-up period was not associated with statistical difference (P-value > 0.05). Conclusions. In the intermediate term, treatment of above knee femoropopliteal artery disease by primary angioplasty with multiple stents yielded results equal to those currently reported in the world literature. The Ankle Brachial Index was associated with positive improvement of clinical status in the group analysed. Above knee femoropopliteal TASC C and D revascularization angioplasty with single or multiple stents versus bypass surgery L. Castro 1, A. Freitas 2, C. Virgini 3, D. Freitas 2, P. Areas 2 1SBACV, 2 HCE, 3 HUPE Rio de Janeiro, Brazil Objective. It s the purpose of this analysis to compare the above knee femoropopliteal arterial revascularization with peripheral angioplasty using single or multiple stents or surgery for patients with femoral atherosclerotic lesions TASC C and D and critical limb ischaemia. Methods. Retrospectively analysis of 75 patients gathered into three different groups selected by the revascularization technique employed: Surgery or peripheral angioplasty with single or multiple stents. Medical records, angiographic and non invasive studies involving ankle brachial index, Rutherford s clinical classification for chronic arterial disease and hyperplasia analysis by Duplex scan were reviewed in detail. Primary endpoints were amputation free survival and death. Results. The overall amputation free survival rates in the first 6 months were higher in the surgical and single stent group than the multiple stent group (P-value < 0,05). The overall amputation free survival rates in the multiple stent group did not differ between the 6 and 12 month analysis. The final endpoint analysis among the entire cohort did not differ significantly (P-value = 0,05). Before and after procedure analysis of the ankle braquial index was associated with a statistical significant improvement in all three groups (Pvalue < 0,01). Patency analysis for each group and among the groups during 3, 6, and 12 month follow-up period did not differ statistically (P-value > 0,05). Hyperplasia analysis for each group was not associated with statistical difference (P-value > 0,05). The Hyperplasia analysis among all three groups was associated with higher levels in the multiple stent group (P-value < 0,01). Conclusions. Hemodynamic improvement was observed in all three groups. The significance level of clinical status improvement was not observed in the multiple stent group as was in the surgical and single stent groups. The actual tendency of using peripheral angioplasty with multiple stents for the treatment of patients with TASC C and D femoral atherosclerotic disease and critical limb ischaemia is not justified yet. Prevalence of venous thromboembolism in hospitalized patients with haematological malignancies receiving chemotherapy A. Wiszniewski 1, P. Szopinski 1, K. Warzocha 2 1Institute of Haematology and Blood Transfusion, Department of Vascular Surgery, Poland 2Institute of Haematology and Blood Transfusion, Department of Haematology, Poland Patients with haematological neoplasms (acute myeloid leukaemia, AML; acute lymphoblastic Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 83

leukaemia, ALL; chronic lymphocytic leukaemia, CLL; myeloma plasmocyticum, MP; Hodgkin lymphoma, HL; and non-hodgkin lymphoma, NHL) carry increased risk of venous thromboembolism (VTE). The mechanisms that link these malignancies to activated coagulation have not been fully identified. The aim of this study was retrospective analysis of the frequency of VTE in patients with haematological malignancies treated with chemotherapy. Material and methods. Within the period Jan 2005 Dec 2013, the following patients were admitted to the hospital and subjected to chemotherapy: 327 patients with AML, 144 with ALL, 491 with CLL, 503 with MP, 138 with HL, and 589 NHL. The clinical diagnosis of symptomatic VTE was confirmed by the objective imaging procedures, including lower and upper limb venous color Doppler, CT angiography of lungs, ventilation-perfusion lung scan. All patients with confirmed VTE were treated with low molecular weight heparin (LMWH) at individual doses related to the platelet counts. Additionally in 8 patients were used catheter-directed thrombolysis (CDT) and in 5 patients with pulmonary embolism (PE) and recurrent deep vein thrombosis (DVT) were cava filters implantation. Results. VTE was diagnosed in 143/2192 (6,5%) patients during the first or subsequent hospitalizations, including 18/327 (5,5%) with AML, 22/144 (15,3%) ALL, 31/491 (6,3%) CLL, 36/503 (7,15%) MP, 13/138 (9,4%) HL, and 23/589 (3,9%) with NHL. In half of these group VTE occurred in association with central venous catheters. During antithrombotic treatment, neither VTE recurrences, haemorrhagic complications nor heparin-induced thrombocytopenia occurred. Any patients had no complications after treatment of CDT and cava filters implantation. Conclusion. VTE is quite common complication in hospitalized patients with haematological malignancies receiving chemotherapy. Intensive effort at thromboprophylaxis in these patients is warranted. CDT and/or cava filter implantation may be efficiency treatment VTE in some patients. An uncommon case of deep venous thrombosis and pulmonary thromboembolism in a juvenile with compound heterozygous congenital protein S deficiency I. Kosugi 1, S. Matano 2, F. Taniguchi 3, E. Morishita 3 1Department of Cardiovascular Surgery/Tonami General Hospital, Japan 2Department of Hematology/Tonami General Hospital 3Clinical Laboratory Medicine/Kanazawa University Object. Protein S deficiency is an autosomal dominant disease with a morbidity of 1.12% in Japan. We experienced an uncommon case of deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE) in a juvenile with phleboliths on the right external iliac vein associated with protein S deficiency. Case. A 14-year-old girl consulted our hospital because her whole right leg had been swollen and stiff with rest pain for 4 days. She did not have any relevant past history or injury. Her mother had had three miscarriages and her younger brother had epilepsy, while her father and elder brother were healthy. Blood examination showed an extremely high D-dimer level, 83.90μg/ml (normal range: 0.0-0.4), and quite low protein S activity, 12% (normal range: 60-150%). Enhanced CT of the whole body revealed DVT from the right calf to right common iliac vein with phleboliths in the right external iliac vein and PTE of bilateral lungs. She received thrombolytic and antithrombotic treatment immediately and the symptoms were improved. We investigated protein S activity and genetic diagnosis in her family. The father s protein S activity was 34% and the mother s was 50%, with each having a protein S deficiency caused by a different gene mutation. The patient was found to have both gene mutations originating from her parents, namely compound heterozygous congenital protein S deficiency. Conclusion. This is an uncommonly rare and only the fifth such case excluding the protein S-Tokushima in Japan. We should continue the treatment and observe her and her family meticulously for life to prevent further DVT and PTE Role of pharmaco-mechanical thrombolysis in acute deep vein thrombosis. V. Chadachan 1, N. Pandit 1, M. Singh 1, J. Tay 1 1Tan Tock Seng Hospital, Singapore Deep vein thrombosis (DVT) is a common disorder which is associated with significant morbidity and mortality. Standard recommendation for treatment of these patients is oral anticoagulation therapy which may reduce thrombus propagation, pulmonary embolism (PE), and the risk of recurrent venous thrombosis. However anticoagulation therapy does not lyse the clot nor can restore the vein valve function and therefore does not prevent post-thrombotic syndrome. Natural history studies of acute DVT have demonstrated that when spontaneous lysis of thrombus occurs, valve function is better preserved whereas persistent thrombus leads to poor vein valve function and therefore post-thrombotic syndrome. Earlier observations involving systemic thrombolysis re- 84 INTERNATIONAL ANGIOLOGY August 2014

vealed reduced post-thrombotic morbidity, but were associated with high the failure rates and high bleeding complications. We report a middle-aged lady who presented with unprovoked extensive ilio-femoral deep vein thrombosis. She was treated with catheterdirected administration of a fibrinolytic agent directly into the venous thrombus with concomitant use of catheter-based device to macerate the thrombus and speed thrombus removal. Subsequent follow-up of the patient revealed long-term patency of the vein, with no clinical evidence of post-thrombotic syndrome. Pharmacomechanical thrombectomy, which involves catheter-directed administration of a fibrinolytic agent coupled with catheter-based mechanical thrombectomy, results in faster and complete removal of clot using significantly lower doses of thrombolytic agent. This facilitates reduction of overall infusion time and dosage of thrombolytic agent and shorter stay in-patient DVT treatment, thus reducing the rate of bleeding complications. The early clot clearance results in reduced rate of long-term post-thrombotic complications. In this presentation, we will review the evolution of thrombolytic therapy for patients with acute DVT and address the integration of pharmacomechanical techniques VTE events in patients with advanced metastatic bladder cancer treated with cisplatin and gemcitabine P. Patrik 1, K. Dostálová 2, V. Štvrtinová 3, G. Annaáková 4 12nd Oncology Department, Medical School, Comenius University and National Cancer Institute, Bratislava, Slovakia 2Faculty of Public Health, Slovak Medical University, Bratislava, Slovakia 32nd Medical Department, Medical School, Comenius University, Bratislava, Slovakia 4Pharmacobiochemical Laboratory, 3rd Medical Department, Medical School, Comenius University, Bratislava, Slovakia Background. Venous thromboembolism (VTE) in oncology is considered to be a serious complication with overall incidence up to 20%. However, VTE incidence in patients with advanced or metastatic bladder cancer treated with cisplatin and gemcitabine is not known. The objective of this study was to find out the overall incidence of VTE events in patients with bladder cancer treated with cisplatin and gemcitabine during their hospitalization stay at the 2nd Oncology Department in National Cancer Institute (Slovakia). Methods. From May 2010 to January 2014, 91 pa- tients (23 women, 25.28%) with advanced or metastatic urothelial bladder cancers treated with chemotherapy gemcitabine 1000 mg/m2 i.v. days 1 and 8, and cisplatin 70 mg/m2 i.v. day 1 were prospectively evaluated. The median of age was 65 years (range 38 84). Results. In this study 18 (19.78%) VTE events including 12 (66.67%) deep vein thrombosis (DVT) and 6 (33.33%) pulmonary embolisms (PE) were observed. VTE events were diagnosed by Doppler ultrasound (in case of DVT) and CT angiography (in case of PE). All patients were treated by lowmolecular weight heparins (LMWHs), the average lenght of treatment was 4.6 ± 2.3 months. No death related to VTE event was noticed. The overall VTE incidence in this study was comparable with that of Numico et al. (2005). Conclusion. The overall incidence of VTE events in this study was comparable to data published in patients with different advanced or metastatic lung cancers, but the same used treatment. This study is supported by VEGA 1/0614/12. Literature. 1. Numico G, Garrone O, Dongiovanni V, et al. Prospective evaluation of major vascular events in patients with nonsmall cell lung carcinoma treated with cisplatin and gemcitabine. Cancer 2005; 103:994-999. Pulmonary tuberculosis associated venous thromboembolism: how to diagnose and treat V. Chadachan 1, N. Pandit 1, J. Tay 1 1Tan Tock Seng Hospital, Singapore Tuberculosis (TB) is one of the most prevalent infectious diseases worldwide, especially in South East Asia. Although venous thromboembolism (VTE) is a rare complication of this disease, it may be a potentially life-threatening event. Review of literature does not reveal any guidelines on the diagnosis and management of VTE associated with pulmonary tuberculosis. Case series presentation. We report here two cases of severe pulmonary tuberculosis associated with venous thromboembolism (VTE). In the first case we report a young male with no apparent risk factors who had extensive unprovoked venous thrombosis extending into inferior venecava as an unusual presenting feature of pulmonary tuberculosis. In the second case, we report an elderly male, who presented with severe pulmonary tuberculosis, and was found to have concomitant pulmonary embolism. Conclusion. Pulmonary tuberculosis-induced vascular inflammation is more common than thought about to be associated with a hypercoagulable state. Therefore, a physician should have a high index of suspicion for the diagnosis of VTE in patients with pulmonary tuberculosis so that Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 85

prompt treatment can be instituted in order to prevent fatal outcomes. On the other hand, a physician should also consider tuberculosis as one of the possible risk factors for the development of VTE. We will highlight in this presentation what are the situations wherein we should suspect pulmonary tuberculosis as a possible risk factor for venous thromboembolism and when should we suspect venous thromboembolism, especially pulmonary embolism, in patients with pulmonary tuberculosis. The treatment is also challenging in view of drug interactions of Warfarin with the anti tubercular treatment. We will conclude with our recommendations on how to treat patients with venous thromboembolism associated with pulmonary tuberculosis Compliance of arthroplasty surgeon protocols with Australian guidelines for preventing VTE JM Naylor, 1,2,3 Badge H, 1,2,3 Harris IA, 1,2,3 Fletcher J, 4,5 Xuan W, 3 Armstrong E, 1,2,3, Lin C. 5,6 1Whitlam Orthopaedic Research Centre, Liverpool Hospital 2University of NSW 3Ingham Institute of Applied Medical Research 4Westmead Hospital 5University of Sydney 6The George Institute. Background and Aims. There is evidence linking compliance with evidence-based standards and better outcomes after total knee or total hip arthroplasty (TKA, THA). The extent arthroplasty services in Australia comply with guidelines intended to prevent venous thromboembolism (VTE) is unknown. This study aimed to establish the level of compliance of arthroplasty VTE prevention protocols with Australian guidelines. Method. A part-random, part-convenience sample of high-volume arthroplasty service providers was surveyed regarding VTE prevention protocols. Site coordinators detailed surgeon-specific chemo- and mechano-prophylaxes via written and telephone survey. Protocols were assessed against NHMRC Guidelines and manufacturer recommendations for drug dosages. Results. 136 THA and 147 TKA protocols from 11 public and 7 private hospitals across five states were included. THA protocols: 15% of protocols complied fully with the guidelines; that is, 15% prescribed a recommended drug in the right daily dose (Enoxaparin 40 mg, Dalteparin 5000 IU, Rivaroxaban 10 mg, Dabigatran 220 mg, or Fondaparinux 2.5 mg), for the recommended duration (28-35 days post-surgery), AND prescribed the use of intermittent compression devices (ICD) and/or graded compression stockings (GCS) until discharge from acute-care, AND prescribed GCS post-discharge. TKA protocols: 3% of protocols complied fully with the guidelines; that is, 3% prescribed a recommended drug at the right dose (as above) for the recommended duration (10-14 days post-surgery), AND prescribed the use of ICDs until acute-care discharge. Non-recommended practices included the use of aspirin as a sole chemoprophylactic agent (39%, THA; 36% TKA), the use of GCS after TKA (80%), and cessation of chemoprophylaxis after the acute-care episode (7% THA; 9% TKA). Conclusions. Protocols for preventing VTE following arthroplasty in Australia vary widely. Low compliance with Australian guidelines is apparent with multiple factors contributing. Studies are needed to determine if compliance with guidelines specific to the Australian context is associated with better patient outcomes. Venous Thromboembolism Prophylaxis in Surgery J Butterworth Imperial College, London, UK. 25,000 people die each year from venous thromboembolism (VTE) in the UK. Deep vein thrombosis (DVT) occurs in over 20% of surgical patients and over 40% of those who are undergoing major orthopaedic surgery. The importance of mechanical thromboprophylaxis in addition to chemical thromboprophylaxis is clearly outlined by published research and National Institute of Clinical Evidence (NICE) guidelines. NICE advises that all patients should be assessed on admission to identify those who are at increased risk of VTE. All patients at high risk should have appropriate mechanical and pharmacological thromboprophylaxis administered. We conducted a retrospective audit of 70 patients notes across 4 surgical wards at Derriford Hospital between 10th February 2014 and 11th February 2014. Drug charts were analyzed for completion of VTE risk assessment and appropriate administration of mechanical and pharmacological VTE prophylaxis. Following electronic and poster educational interventions for Junior Doctors and nurses on importance of thromboprophylaxis in surgical patients we completed the loop with a re- audit of 52 surgical patients notes from 3 surgical wards. First cohort: 15 patients (21%) had no VTE form completed, 100% had chemical prophylaxis administered appropriately, 12 patients (17%) had no mechanical prophylaxis and no valid contraindications and 17 patients (24%) had no mechanical prophylaxis prescribed though they were receiving mechanical prophylaxis. Second cohort: 16 patients (31%) had no VTE form com- 86 INTERNATIONAL ANGIOLOGY August 2014

pleted, again 52 patients (100%) had appropriately administered chemical prophylaxis, 9 patients (17%) had no mechanical prophylaxis with no valid contraindications and 21 (40%) had mechanical prophylaxis administered but not prescribed. As a trust we are successfully administering chemical VTE prophylaxis to surgical patients. However, following departmental discussions further more effective interventions are required to improve our completion of VTE risk assessments and appropriate prescription and administration of mechanical thromboprophylaxis. Evaluation of postthrombotic syndrome in patients treated by catheter directed thrombolysis for deep vein thrombosis (3 years follow up) D Karetova, D Rucka, J Lubanda, L Skalicka, S Heller, M Chochola, P Prochazka, P Varejka, A Linhart Prague, Czech Republic Post-thrombotic syndrome (PTS) is a common and troublesome complication of deep vein thrombosis (DVT). With conservative medical treatment, PTS is reported in up to 50% of cases with proximal DVT after 3-5 years. Catheter directed thrombolysis (CDT) has been proposed as an efficient treatment for selected patients with ileofemoral thrombosis. The aim of the study was to evaluate effectiveness of CDT in terms of mid-term vein patency and rate of clinically evident PTS. Patients with ileofemoral thrombosis treated with CDT and available long-term follow-up at our institution were included in the study. The CDT procedure consisted of local thrombolysis, combined with stent insertion and percutaneous mechanical thrombectomy in appropriate cases. Patients were followed over a 3-year period with regular visits at 3, 6, 12, 24 and 36 months. Each visit consisted of clinical examination oriented at signs of PTS and duplex ultrasonography focused on patency of intervened veins. Out of 342 patients treated with CDT, 204 pts with available follow-up were included (age 30 ± 15 yrs, 76% female, 77% with left-sided and 6% with bilateral ileofemoral thrombosis). Most frequent risk factor for DVT was hereditary thrombophilia (70% pts, majority with heterozygous factor V mutation). May-Thurner syndrome in left-sided location occurred in 96% of pts. Initial vein recanalization with CDT was successful in 89% patients. DVT recurred in 13%, in majority of the cases in the first 3 months, risk of recurrence after 3 months was low (0,5-1% per year). Post-thrombotic syndrome occured in 17% of pts with patent pelvic veins and in 75% of patients with occluded iliac veins. CDT in properly selected patients (younger individuals with acute proximal thromboses, and relatively few comorbidities) can reduce clot burden and DVT recurrence and consequently prevents the formation of PTS. Midterm outcome of endovascular treatment for acute lower extremity deep venous thrombosis X Li, Q Meng, K Jiang, H Sang, J Rong, X Yu, A Qian 2nd Affiliated Hospital of the Soochow, Jiangsu, China After the treatment of Catheter-directed thrombolysis (CDT) for acute lower extremity deep venous thrombosis (DVT), whether iliac vein stent placement is still controversial. We have reported that patients with stenting of iliac vein obstruction after operation follow-up visits for a period of 11-43months had an increase in the patency of the deep vein. This study shows the midterm outcomes of the patients after stenting of iliac vein obstruction. Patients received catheter directed thrombolysis under the protection of (inferior vena cava filters, IVCF). After CDT treatment, the patients divided into two groups. One is using balloon angioplasty / stenting approach. Another group maintains the anticoagulant and thrombolytic therapy without other operation. After discharge, all patients were followed-up in tabular form collected by our members. It contains clinical symptoms improvement (including observation of lower extremity edema and skin pigmentation conditions, CEAP classification, (venous clinical severity score, VCSS) and (chronic venous insufficiency questionnaire, CIVIQ) rated conditions). Use ultrasonography or angiography of the deep venous to assess limb deep vein blood flow patency. Assess DVT patients the recovery after iliac vein stent placement. 220 patients were collected from dec. 2008 to dec. 2012. 66 patients were successfully followed-up. 27 patients in the group of using balloon angioplasty / stenting approach. 39 patients are in the other group. The average age is 50.85 ± 1.95 years. Mean duration is 5.96 ± 0.56 days. The average follow-up time is 22.15 ± 0.95 months. In the group of using balloon angioplasty / stenting approach, the limb deep vein blood flow patency 74.07% (20/27) and the other group is 43.59% (17/39). According to the classification of CEAP, the stenting group was 3.19 ± 0.08, and the control group was 3.15 ± 0.06, respectively after operation was 1.26 ± 0.36 and 2.63 ± 0.33 (P=0.002). Preoperative VCSS the stent group was 8.04 ± 0.20, and the control group was 8.07 ± 0.18, re- Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 87

spectively after operation was 1.07 ± 0.31 and 1.96 ± 0.32 (P=0.05). Postoperative CIVIQ score stent group was 93.11 ± 1.28, and the control group was 88.56 ± 1.40 (P=0.009). After treatment of anticoagulation and thrombolysis, two cases occurred around the puncture site hematoma, one case retroperitoneal hematoma, bleeding, local pressure dressing after treatment cured. Patients with pulmonary embolism symptoms were not found in CDT treatment process. 3 cases of thrombosis in the filter occurred during follow-up, 5 cases of recurrent thrombosis. The patients all recovered well after thrombolysis treatment once again. This midterm study concluded that the interventional surgical treatment after catheter-directed thrombolysis can increase the iliac vein patency and improve clinical symptoms occurred after the lower limbs. It also has a better effect to avoid postoperative thrombotic syndrome. Deep venous thrombosis (DVT) has the high incidence gradually attracted people s attention, especially the two mainly complications included pulmonary embolism (PE) and post-thrombotic syndrome (PTS). And the treatment mainly including systemic anticoagulant and thrombolytic therapy. But there is a relatively high incidence of thrombosis after insufficient syndrome and bleeding complications. With the development of interventional technique, catheter-directed thrombolysis (CDT) of lower extremity DVT which started in the early 1990s has become a frequently recommended strategy. It offers a significant advantage over systemic thrombolytic therapy by delivering higher local concentrations of the thrombolytic agent with lower systemic doses. The technique has shown good clinical efficacy and safety and has been promoted to improve thrombus removal, prolong venous patency, prevent venous insufficiency, and reduce the incidence and severity of PTS, also reduce the recurrence of DVT. Cost-effectiveness of pharmacological prophylaxis in preventing venous thromboembolism and associated long term complications in colorectal surgery K. Hitos 1, B. Sanderson 1, C. Stratton 2, J. Fletcher 1 1Department of Surgery, University of Sydney, Westmead Hospital, Australia 2Sanofi-Aventis, Sydney, Australia Patients undergoing colorectal surgery are at high risk of developing venous thromboembolism (VTE) with associated long term complications imposing a potential economic burden. The aim of this study was to assess the VTE incidence, cost effectiveness of low molecular weight heparin (LMWH) in relation to unfractionated heparin (UH) and long term complications in these patients. 417 patients underwent colorectal surgery between 2005-2009. Demographics, diagnosis, hospital length of stay (LOS), prophylactic details and post-operative bleeding were assessed. An economic model based on incidence of VTE and major bleeding from local treatment algorithms and randomised clinical trials was developed. Treatment costs for deep vein thrombosis (DVT), pulmonary embolism (PE), heparin induced thrombocytopenia (HIT) and post thrombotic syndrome (PTS) were derived from Australian Refined Diagnosis-Related Groups and published sources. Costs are expressed in Australian Dollars (AUD). Median age was 67 years (58.3-76) and hospital LOS was 10 days (7-14). Stage three or more cancer was present in 72.7% of patients. UH was used in 52.7% of patients, LMWH in 35.3% and 10.7% received UH followed by LMWH. Major bleeding occurred in 4% of patients. VTE incidence was 0% in-hospital, 1.4% at three months and 2.4% at one year. A predicted improvement in adherence to evidence based LMWH prophylaxis resulted in a decreased annual cost from 105,085 AUD for use of UH and LMWH to 88,828 AUD for use of LMWH in 90% of patients. The estimated overall annual savings for major bleeding was 6,173 AUD and 13,140 AUD for HIT. The model estimated 18.5% fewer bed days. Most VTE events occurred at three months after discharge with continued events up to one year. This highlights the importance of VTE prophylaxis beyond hospitalisation. An increase in use of LMWH predicted savings for major bleeding, HIT and a reduction in number of bed days. Epidemiology of venous thromboembolism after major trauma: the efficacy, cost-effectiveness and associated bleeding complications with pharmacological prophylaxis K. Hitos 1, J. Hsu 1, C. Stratton 2, J. Fletcher 1 1Department of Surgery, University of Sydney, Westmead Hospital, Australia 2Sanofi-Aventis, Sydney, Australia Trauma patients are at high risk of developing venous thromboembolism (VTE) due to the pathogenesis and multi-fold risk factors. This study investigates the incidence of VTE, the efficacy and cost-effectiveness of prophylaxis and associated bleeding complications. Over six months, 1182 patients were admitted to the Westmead Hospital Level 1 trauma centre. 88 INTERNATIONAL ANGIOLOGY August 2014

Demographics, injury type, hospital length of stay (LOS), injury severity score (ISS) >12, prophylactic modalities, VTE incidence and bleeding complications were assessed. An economic model based on VTE rates and major bleeding from local treatment algorithms and randomised trials was developed. Treatment costs in relation to VTE, heparin induced thrombocytopenia (HIT), and post thrombotic syndrome (PTS) were derived from Australian Refined Diagnosis-Related Groups and published resources. Costs are expressed in Australian Dollars (AUD). Major trauma represented 21.6% of the cohort. Mean age was 46 years (16-91) and hospital LOS was 17.2 days (1-133). Low molecular weight heparin (LMWH) was used in 3.8% of patients, unfractionated heparin (UH) in 88.5% and no pharmacological prophylaxis in 7.7%. Major bleeding rates were 10.7% with no prophylaxis and 34.8% with use of UH. In-hospital VTE incidence was 7.8% (7.0% for DVT and 0.8% for PE) and 9.0% (7.4% for DVT and 1.6% for PE) at three months. Mortality was 7.8%. Predicted improved adherence to evidence based prophylaxis using LMWH resulted in a decrease in annual cost for all patients from 342,699 to 264,790 AUD. Savings for DVT treatment was 21,415 AUD, 3,123 AUD for PE, 39,392 AUD for major bleeds, 11,013 AUD for HIT and 8,149 AUD for PTS. Bed days decreased by 24.8%. The importance of increasing optimal prophylaxis was reflected in the increased out of hospital PE incidence. The economic model on the benefits of using LMWH compared to UH improved outcomes, reduced health care costs and overall economic burden Exercise training suppresses strenuous exercise-induced procoagulant factors and thrombin generation Y. Chen 1, J. Wang 1 1Chang Gung University, Taiwan Aerobic exercise may modulate the risk of vascular thrombotic events. This study investigated how interval and continuous exercise training influenced coagulant factors and thrombin generation (TG) in plasma with/without interaction of platelets and neutrophils. Twelve healthy sedentary males were randomly divided into moderate continuous exercise training (MCT; 60% VO2max, n=6) group and aerobic interval exercise training (AIT; 3-minute intervals at 80% and 40% of VO2max, n=6) group for 30 minutes per day, 5 days per week for 6 weeks. The coagulant factors and dynamic TG parameters were measures by automated coagulation analyzer and calibrated automatic thrombinography, respectively. Acute strenuous exercise reduced prothrombin time (PT) and activate partial thromboplastin time (APTT); it also increased the levels of factor V (FV), factor VIII (FVIII), and fibrinogen, which responses were accompanied by increased TG rate and total thrombin in plasma. Before training, neutrophil prolonged the PT and APTT, and meanwhile decreased TG rate and levels of FV and FVIII at rest. Nevertheless, after neutrophils interacting with platelets for 4 hours would improve dynamic TG at rest. However, both MCT and AIT for 6 weeks slight prolonged PT by decreased TG rate and the levels of FV and fibrinogen whether at rest or following the strenuous exercise. This training effect was only in platelets or neutrophils plasma, not in neutrophil-platelet interaction plasma. We conclude that both MCT and AIT suppress the PT and APTT reaction after strenuous exercise by down-regulated pro-coagulant factors: FV and fibrinogen, which may decrease the risk of inflammatory thrombosis evoked by strenuous exercise. Neutrophil prolong the PT and APTT at rest may due to the consumption of fibrinogen, FVIII and FV. Nevertheless, neutrophil-platelet interaction may reduce the effects of exercise training on coagulant factors and TG. Stop the clot L Everest-Rolfe, U Buehner Lakes DHB, Bay of Plenty, New Zealand Venous Thromboembolism (VTE) prevention in hospitalized patients is internationally recognised as a major opportunity to improve patient safety. At Lakes DHB we have implemented a successful VTE prevention programme that protects patients quality of life, saved actual lives and significantly reduced healthcare costs. By preventing chronic disease which impacts long term on heath care resources and acute length of stays plus interventions we have estimated to have made a 90,000 dollar cost saving over a 12 month period. In July 2011 the Stop the Clot campaign was launched at Lakes DHB. The idea was to raise awareness for Venous Thromboembolism (VTE) prevention across the hospital. Baseline audits showed poor compliance with VTE prevention guidelines, especially with medical and orthopaedic patients. The aim was to achieve a 100% compliance rate for routine assessment within the first 24hrs of hospital admission for persons over 18 years and pregnant teenagers and 100% appropriate, evidence-based prescribing of thromboprophylaxis. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 89

In June 2012 a VTE Prevention Nurse was appointed 0.2FTE to continue to collect bi-monthly data from the different departments on compliance rates and to educate medical and nursing staff on hospital guidelines and effective and appropriate prescribing of thromboprophylaxis. VTE Prevention Guidelines were updated for medical, surgical, orthopaedic and obstetric patients. To ensure the appropriate VTE prophylaxis was provided for individual patients, risk assessment tools were developed to guide therapy for each department. Compliance rates have improved dramatically in all departments to date and we were able to reduce the hospital-associated VTE event rate by 50% within one year from a mean of 12.5 events, which included 3 deaths from PE to only 6 nonfatal VTE events. Surgical thrombectomy and simultaneous stenting for deep venous thrombosis caused by May-Thurner syndrome M. Nishizawa 1, T. Kudo 1, K. Igari 1, M. Nakamura 1, S. Katsui 1, H. Uchiyama 1, S. Koizumi 1, T. Toyofuku 1, Y. Inoue 1 1Tokyo Medical and Dental Univ. Division of Vascular and Endovascular Surgery, Department of Surgery, Tokyo, Japan Purpose. May-Thurner syndrome is characterized by left common iliac obstruction secondary to compression of the left iliac vein by the right common iliac artery against the fifth-lumbar vertebra. This anatomic variant results in an increased incidence of deep venous thrombosis (DVT). We herein present our experience with thrombectomy and simultaneous stenting for DVT due to May-Thurner syndrome, and evaluate the outcomes. Materials and Methods. From January 2009 to December 2013, a total of ten patients (seven females, two males; median age, 75 years) underwent surgical venous thrombectomy with stenting. All patients were admitted for acute (<14 days) DVT involving the iliofemoral segment, and were diagnosed with May-Thurner syndrome. One patient had a hypercoagulable disorder and three had malignant disorders. Patients were followed-up, and the stent patency was assessed by means of duplex sonography performed at 1, 3, 6 and 12 months, and then yearly thereafter. Results. In all patients, the procedure successfully achieved re-canalization of the iliofemoral veins at the end of the operation. Perioperatively, there was no mortality and there were no case of clinically detected pulmonary embolism. Rethrombosis occurred within seven days of the op- eration in two patients. The mean follow-up time was 24.2 months (range, 1-57 months). Conclusion. Venous thrombectomy with simultaneous stenting is a safe, efficient, and durable technique to treat iliofemoral DVT due to May- Thurner syndrome. This technique also restores venous patency and provides relief of acute symptoms. Air travellers: a pharmacist s study shows a higher risk of DVT than usually described and the benefit of wearing elastic compression F. Allaert 1, J. Mongold 2 1Medical Evaluation Chair and Angiology ESC Dijon, France 2Gibaud, France Objectives. to describe the clinical profiles of people buying or not elastic compression (EC) when proposed by their pharmacists to prevent the risk of deep venous thrombosis (DVT) linked to their next air flight and the incidence of DVT occurring during their holidays or when they returned. Methods. national observational study conducted by a representative sample of pharmacists. They described all patients seeking advices before holiday s departures whatever their concern (sunburn, tourista prevention...), informed them about the risk of DVT when flying, proposed them to buy EC (15-20 mmhg) and asked them to fill up and return a self questionnaire describing health problems occurring during holidays or 15 days after. Results. 2096 persons were included among whom 47.9% accepted to buy EC. Multifactorial logistic analysis shows that EC buyers presented more DVT risk factors than non buyers: venous insufficiency OR 2.0 (p<0.0001), personal pasthistory of DVT OR 1.6 (p<0.05), familial pasthistory of DVT OR 1.5 (p<0.01), flight duration > 4 hours OR 1.5 (p<0.001), women/men OR 1.2 (p<0.05) and they were more aware of the risk OR 2.3 (P<0.0001). The incidence of DVT was much higher than generally described ranging from 1.2 to 1.9 in the global population (1.0 to 1.7 with EC and 1.5 to 2.2 without EC) and logistic analysis showed the predictive value of personal DVT history OR 3.8 (p<0.05), flight duration > 4 h OR 3.7 (p<0.05) and puffy feet when landing O R 10.0 (p<0.01). Conclusion. Today people buying EC are at higher risk and more aware of the risk of DVT than non buyer and wearing their EC decreases their risk of DVT to the same level or even lower than those at lower risk but not wearing them. Reports 90 INTERNATIONAL ANGIOLOGY August 2014

of DVT are much higher than generally described and may challenge previous evaluations of that risk. How do we safely anticoagulate a patient with pulmonary embolism who is having recurrent haemoptysis in an outpatient setting? A. Sule 1, S. Gohar 1, J. Tay 1 1Tan Tock Seng Hospital, Singapore Introduction. It can be challenging to manage patients with PE with haemoptysis. The severity of bleeding and patient s anticoagulation status needs to be taken into account. We also need to rule out other causes of haemoptysis other than PE. There are little literature data on ideal management of PE with hemoptysis. We take such opportunity to present a case of young Indian gentleman with known non-ischaemic cardiomyopathy with apical thrombus admitted with haemoptysis and pulmonary embolism. Case description. A 45 years old Indian man with past medical history of hypertension, nonischaemic heart disease with apical left ventricular thrombus was admitted with mild to moderate haemoptysis on and off since 6 weeks. CT pulmonary angiogram had shown pulmonary embolism associated with thrombus in right and left internal jugular veins. He was on warfarin. Investigations showed that there was no other source of hemoptysis. Patient was haemodynamically stable. He was started on low-molecular weight heparin (LMWH) enoxaparin 1 mg/kg BD dose with regular monitoring of peak anti- Xa levels. The LMWH dose was continuously adjusted to keep anti Xa level between therapeutic range of 0.5-1 U/ml and more towards the lower limit. The haemoptysis resolved and patient improved well. He was discharged home on SC enoxaparin. Once there was no hemoptysis for a month, as he needed long term anticoagulation, he was switched back to warfarin with no recurrence of hemoptysis. Discussion. Treatment of pulmonary embolism or any venous thrombo-embolism associated bleeding such as haemoptysis in our patient needs to be managed cautiously with IV heparin or LMWH in an outpatient setting. If on IV heparin in wards, aptt should be measured and dose titrated as per hemopotysis. But in outpatient setting where it is difficult to dose with IV heparin, subcutaneous (SC) low-molecular weight heparin (LMWH) is an alternative. On SC LMWH enoxaparin 1mg/kg twice a day, peak anti-xa range should range from 0.5-1 U/ml. However, if the regime of enoxaparin 1.5 mg/kg once a day dose is followed instead of BD dosing, then the peak anti-xa range should range from 1-2 U/ml. In a patient with recurrent haemoptysis, we would recommend to target this at the lower end of the range when managing patients in an outpatient setting. Conclusion. Management of pulmonary embolism with haemoptysis, especially in an outpatient setting, can be challenging. LMWH is preferred to warfarin. Peak anti-xa monitoring on LMWH could be useful especially in a specialised centres, provided that the haemoptysis is mild and regular follow-up with monitoring is done and available Left iliac vein thrombosis in a young patient: need to evaluate for May Thurner syndrome? T. Quah 1, A. Sule 1, J. Tay 1 1General Medicine Department, Tan Tock Seng Hospital, Singapore Objective. To present a case of iliac vein thrombosis turned out to be May Thurner Syndrome. Case Report. A 28 years old male was diagnosed with a proximal Deep Vein Thrombosis of his left common femoral and external iliac veins. He had no known predisposing factors for Venous Thromboembolism. He was initiated on anticoagulation with Low Molecular Weight Heparin followed by Warfarin to maintain a therapeutic INR in the range 2-3. After completing the minimum recommendation of anticoagulation for 3 months, he opted for further evaluation of the VTE. Investigations. The initial ultrasound Doppler showed left femoral vein. Further Computed Tomography of abdomen and pelvis after completion of treatment showed extension of thrombosis of the common femoral and external iliac veins, suggestive of May Thurner Syndrome. There were varicosities in the lower anterior abdominal wall and thigh is noted. Pelvic venogram suggests chronic thrombus up to the left external external iliac vein. A repeated Computed Tomography of abdomen and pelvis a week after insertion of left femoro-caval bypass graft showed the left femoral graft lumen has heterogeneous enhancement with a few areas of low density within its lumen suspicious for a graft thrombosis. Progress. In view of the anatomical abnormality predisposing to thrombosis, he was advised for long-term anticoagulation and was referred for surgical evaluation. Since persistent thrombosis with collateral formation indicating chronicity of the thrombus, stenting on the iliac vein is not possible. Therefore, Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 91

he successfully underwent a left femoro-caval bypass graft and was further advised to continue Warfarin for at least 6 more months. However, a week after surgery, a repeat Doppler scan showed a graft thrombosis, despite adequate anticoagulation. After discussion with the patient, he is not keen for further surgical intervention and opted for continuation of warfarin. Conclusions: We suspect the possibility of having May Thurner Syndrome in the case of iliac vein thrombosis. Progression of thrombus in portal vein, superior mesenteric vein and splenic vein even on anticoagulation in a patient with ascending colonic malignancy with liver metastasis portal vein thrombosis vs portal vein tumour thrombosis A. Sule 1, A. Borja 1, J. Tay 1 1Tan Tock Seng Hospital, Singapore Introduction. Portal vein thrombosis (PVT) in a setting of liver metastasis is not easy to treat. It is at times difficult to say whether the thrombus is PVT or a portal vein tumour thrombus (PVTT). CT scan abdomen with contrast can differentiate depending on the vascularity of the thrombus as seen in PVTT. We describe an elderly gentleman, treated as PVT which was very resistant to treatment. He had liver metastasis and final diagnosis in him was a PVTT with colonic malignancy with metastasis to the liver. Case report. 77 years old gentleman, diagnosed as ascending colon carcinoma, underwent right hemicolectomy in 1991. He had a recurrence in 2009. He was treated with chemotherapy (6 cycles) and was followed up in medical oncology. In August 2009, he underwent CT abdomen which showed evidence of superior mesenteric vein thrombosis with no liver metastasis. He was started on anticoagulation, initially given enoxaparin and then warfarin. He was maintained on warfarin (as he was not keen on injections) with PTINR maintained between 2-3. On anticoagulation, he was admitted with severe abdominal pain in February 2012 and diagnosed as mesenteric ischaemia. CT scan abdomen and pelvis showed progression of mesenteric lymphadenopathy, tumour thrombus involving the superior mesenteric vein, branches of the superior mesenteric vein, lower segment of the main portal vein and in the splenic vein. It was also noted that there was a heterogenous hypodense lesion in segment 2/3 of the liver, suspicious of hepatic metastasis. His tumour marker carcinoembryonic antigen (CEA) was 24 ug/l (Jul 2011) --> 34 ug/l (Feb 2012). He was continued on anticoagulation. Progress. On long term anticoagulation, he still had abdominal symptoms related to mesenteric ischemia. CT scan abdomen in January 2014 showed, increase in size of hepatic metastasis, extensive thrombus involving the superior mesenteric vein (SMV), branches of the superior mesenteric vein, lower segment of the main portal vein and in the spleenic vein with collaterals. Mesentery congested due to extensive SMV thrombus. Discussion. Portal vein thrombosis in a setting of hepatic metastasis is very difficult to treat. This is due to the fact that PVT may actually be PVTT. PVTT doesn t respond well to anticoagulation as treatment of primary tumour and metastasis is difficult. Conclusion. Anticoagulation is the mainstay in the treatment of PVTT, these patients don t respond well to anticoagulation and the thrombosis progresses in spite of long term anticoagulation. Treatment of pulmonary embolism with hemoptysis in a middle aged lady on low molecular weight heparin in outpatient setting and role of peak anti- xa monitoring C. Yee 1, A. Sule 1, S. Gohar 1 1Tan Tock Seng Hospital, Singapore Introduction. Treatment of pulmonary embolism with hemoptysis is challenging. We describe a middle aged lady who was admitted in wards, underwent extensive investigations and finally managed on low-molecular weight heparin with close monitoring of peak anti-xa levels. Case report. We describe a 63 years old lady, with background history of hypertension and old stroke with good functional recovery, diagnosed as pulmonary embolism in early November 2013, presented to us with recurrent haemoptysis on warfarin, needed admission. During her treatment of pulmonary embolism, she underwent extensive investigations including bronchoscopy. There was no evidence of any infection, vascular anomalies or malignancy. She was discharged from the wards, and was switched to once a day dose of 1.5 mg/kg of enoxaparin with close monitoring of peak anti-xa levels between 1-1.5 IU/ml. Her peak anti-xa level was done in clinic on 2-occasions was 1.36 IU/ml and 1.4 IU/ml. She did not have further hemoptysis and did not need further hospitalisation during her treatment of pulmonary embolism over 3 months. Discussion. Hemoptysis with pulmonary embolism is not an uncommon problem in our 92 INTERNATIONAL ANGIOLOGY August 2014

Vascular Centre and is difficult to treat. Patient needs to be hospitalised and started on intravenous heparin with close monitoring of PTT in the wards, until there is complete resolution of hemoptysis. Treating such patients in an outpatient setting is challenging and needs close monitoring as hemoptysis can be life threatening. Treatment with enoxaparin or low-molecular weight heparin with close monitoring of peak anti-xa levels would be a useful strategy. Targeting the peak anti-xa closer to 1-1.5 IU/ml in a once a day dosing of 1.5mg/kg and 0.5-0.75 IU/ml in twice a day dosing would be a useful strategy for anticoagulation in an outpatient setting. Conclusion. Besides renal impairment, obesity and pregnancy, use of peak anti-xa levels in a setting of pulmonary embolism with hemoptysis would be useful to treat patients in an outpatient setting with close monitoring. Popliteal vein aneurysm: a rare cause of pulmonary embolism R Flekser, W Mohabbat Sydney, Australia Venous aneurysms are rare but popliteal vein aneurysms (PVA) are exceedingly rare. While the overall incidence is unknown, the male/ female ratio is equal and they are usually found in quinquagenarians. Most PVAs are asymptomatic and detected on routine investigation for varicose veins. However, they are a potential source of thromoemboli and can therefore be associated with fatal or near fatal pulmonary embolus. Here we report a case of a pulmonary embolus (PE) in a patient who was found to have a large popliteal vein aneurysm. Vascular imaging and renovascular disease L Aluigi Department of Internal Medicine, Maggiore Hospital, Bologna, Italy Anatomical and pathological changes that reduce the lumen of the arteries of the kidney, leading to renal ischemia, identify the so called nephrovascular disease. The deriving main clinical pictures may be nephrovascular hypertension and ischemic nephropathy: the first one coming from atherosclerotic lesions or angiodysplasia of the arteries of the kidney, the second one resulting from hormonal and anatomical functional alterations secondary to kidney chronic hypoperfusion due to stenosis of one or both renal arteries. Ultrasound diagnosis of renal arteries has become the baseline survey in clinical suspicion of nephrovascular hypertension or ischemic nephropathy; today, except in rare cases related to somatic features of the subject or to conditions that hinder the methodology, such as marked intestinal meteorism or the presence of scarring, the technological improvement of ultrasound equipment allows to perform a precise diagnosis, reliable, reproducible and relatively cheap. Eco-color-Doppler (CCDU) allows to get at the same time anatomical and structural information together with hemodynamic ones through the application of the typical functions to study the flow (Pulsed Doppler, Color, Power, B-flow) and through derivate diagnostic indices obtainable from main renal artery or from the parenchymal arteries of the kidney: the former are represented by peak systolic velocity (PSV), the relationship between renal-aortic PSV (aorto-renal ratio), and the relationship between the PSV just at the stenosis and PSV distal to the stenosis (PSV ratio); the latter are represented by the acceleration time (AT), resistive index (RI) derived from the relationship between PSV and diastolic peak velocity, pulsatility index (PI) derived from the relationship between PSV and average diastolic velocity. In normal subjects, the peak systolic velocity (PSV) is about 100 ± 20 cm/sec and speed levels are similar in both renal arteries. Aortorenal ratio, which would be more correct to call reno-aortic ratio (RAR), is normally < 3.5. When a less than 60% stenosis occurs, PSV results < 180 cm/sec and a RAR < 3.5, while a higher 60% stenosis is characterized by a PSV > 180 cm/sec and a 3.5 > RAR. (This relationship is valid in absence of ectasia or aneurysm of the aorta). The study of suspected renal artery stenosis has high sensitivity and specificity when some of these parameters are applied. Normal values of resistance index (RI) are between 0.55 and 0.75-0.77. In the case of intra-parenchymal or so called post-renal disease, echo-color-doppler reveals an increase of RI, equal to or greater than 0.80, detectable at the level of the renal artery outlet that maintains or increases in its intermediate segment, at the renal hilum and intraparenchymally. A significant decrease of RI (less than 0.55) can appear in case of tight stenosis or renal artery occlusion at the origin, with characteristic downstream flow signal ( dumped ). The advantage of parenchymal indexes is to be evaluated also in difficult technical conditions, particularly when renal arteries at the origin and along their course are not well displayed or for the evaluation after renal transplantation: in this case the resistive index (RI) for example may result very high when allograft dysfunction occurs. The study of renal arteries with US is low cost and noninvasive, moreover iodinated contrast media are not required. Contrast agents for ultrasound in selected Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 93

cases may add differentiating diagnostic elements. Very important for the reliability of the methodology, the learning curve for operators who must be particularly experienced and suitably trained. T1, and t2 weighted se carotid plaque imaging and contrastenhanced mr angiography comparison with intravascular ultrasonography (qualitative and quantitative assessment) - pilot study W Iwanowski Regional Specialist Hospital, Wroclaw, Poland The study aim is to assess in vivo quantitative and qualitative plaque features on 1.5 T carotid MR imaging and CE MRA in comparison with standard IVUS. Material and method. 21 pts (age 73 +/-9 yr, 11 females) with symptomatic carotid stenosis 50% - 90 % initially detected in duplex Doppler ultrasound were enrolled to study. Patients underwent carotid MRI and carotid angiography one to two weeks before conventional angiography (DSA) with IVUS study and PCI. Patients were imaged with a whole-body MR imaging scanner (Aera, Siemens) with use 4-channel phased-array surface head and neck coil. MR pre-contrast images were obtained with 3-D TOF images, inversion recovery precontrast T1WI, double inversion T2WI and proton density fatsaturation (mean in plane resolution 0.7 x 0.7x2 mm). Carotid Aniography, were obtained with bolus tracking methode and study inversion recovery CE-T1WI 5 minutes after intravenous infusion of 0.2mmol gadoteridolum/kg. MRI images were transferred and analysed on commercially available software (Syngovia, Siemens). IVUS imaging was performed using Volcano Therapeutics EagleEye Gold catheter. Spearman rank correlation (rho) and p-value for 95% CI were calculated for measured parameters. Results. There were no statistical difference (p<0.05) and significant correlation rho = 0.54 between pre contrast MRI (T1WI, T2WI imaging) and IVUS calculations of maximal plaque area, referenece area, area. Low correlation rho 0.55 and pvalue > 0.11 were found in measurements of CE-angiography stenosis, minimal lumen area minimal lumen diameter compared with IVUS. Overall high signal intensity (PD imaging) and high contrast enhancement correlated with fibroatheroma, fibrocalcific and Fibroatheroma plaques (p<0.01). Conclusions. T1WI and T2WI are useful to quantitative assessment of carotid plaque CE-an- giography weakly correlated with IVUS stenosis measurements T1WI contrast study and PD imaging could be useful in detection complicated and advanced plaques. This publication is part of project Wrovasc Integrated Cardiovascular Centre, co-financed by the European Regional Development Fund, within Innovative Economy Operational Program, 2007-2013 realized in Provincial Specialized Hospital, Research and Development Center in Wroclaw Diagnosis of acute thrombosis using non-invasive molecular ultrasound imaging and novel platelettargeted microbubbles. X Wang, C Hagemeyer, J Hohmann, I Ahrens, K Peter Melbourne, Victoria, Australia Molecular imaging is a rapidly emerging enabling technology allowing non-invasive detection of vascular pathologies. However, imaging technologies offering a high resolution are currently not inherently real-time applications. We hypothesised that microbubbles targeted to activated platelets offer high-resolution, real-time molecular imaging of evolving and dissolving arterial thrombi. Lipid-shell based gas-filled microbubbles (MB) were conjugated to either a single-chain antibody (scfv) specific for activated GPIIb/IIIa (Ligand-induced binding site (LIBS)-MB), or a non-specific scfv (control-mb). Successful conjugation was assessed in flow cytometry and immunofluorescence double staining. LIBS-MBs but not control MBs strongly adhered to both immobilized activated platelets and microthrombi under flow. Thrombi, induced in carotid arteries of C57Bl6-mice in vivo by ferric chloride injury, were assessed with ultrasound before and 20 minutes after microbubble injection. Greyscale units converted to decibels demonstrated a significant increase after LIBS-MB but not after control-mb injection (9.55 ± 1.7 versus 1.46 ± 1.3 db; n>/=8, p<0.01). For monitoring of thrombolysis with LIBS-MBs, urokinase plasminogen activator (UPA) was injected and monitored every 5 minutes over a period of up to 1 hour. A reduction in thrombus size and/or thrombus dislodgement could be directly observed (n=3, p<0.001 vs.vehicle control). Similar results were obtained when comparing the thrombus area reduction to thrombus area grayscale intensity unit reduction. Both, cross section ultrasound imaging as well as longitudinal section imaging demonstrated similar outcomes (n=4). We demonstrate that GPIIb/IIIa-targeted microbubbles specifically bind to activated platelets in vitro and allow real-time molecular imaging of 94 INTERNATIONAL ANGIOLOGY August 2014

acute arterial thrombosis as well as monitoring of pharmacological thrombolysis in vivo. This non-invasive and cost effective imaging modality provides a unique opportunity to detect arterial (micro) thrombi with high resolution at an early stage allowing for early diagnosis and therapy and it allows to identify failure or success of thrombolytic therapy. Evaluation of intracranial haemodynamic by TCCS in patient with significant asymptomatic internal carotid stenosis case report J. Zizka 1 1Institute of Clinical and Experimental Medicine; Dept of Internal Medicine, Thomayer Hospital. Prague Man 72y with hypertension, PAD, ex-smoker, post ischemic stroke with right side hemiparesis. DUS of neck arteries revealed occlusion of left ICA and 60% proximal stenosis of right ICA.TCCS was performed with following findings: middle cerebral artery (MCA) lv mean (cm/s): left 50, right 68. Normal findings on both posterior cerebral arteries. Reversal blood flow in anterior cerebral artery (ACA) and ophthalmic artery (OA) on the side of occluded ICA. Conclusion: sufficient flows in both MCA with good collaterals to the occluded ICA from contralateral ICA via reversal flow of ACA and OA. Testing of cerebrovascular reserve (CVR) was performed by providing breath holding index (BHI):BHI left MCA was 0.30, on right MCA it was 0.45. Conclusion: impaired CVR on both MCA meaning altered haemodynamic on the side of occluded ICA as well as on the contralateral side due to steal phenomenon from stenotic ICA to the occluded one. Based on these findings patient was indicated to CEA of right ICA. Operation and postoperative period without complication. Control CVR testing two months post-operation proved improvement of cerebral haemodynamic with normal symetric blood flow in both MCA at rest as well as normal CVR following breath holding test. The patient is currently doing well neurogicaly asymptomatic. Conclusion: management of patients with asymptomatic internal carotid stenosis remains controversial and the risk stratification of this population is highly needed. One of the options is to test the intracranial haemodynamic by TCCS at rest and CVR. There is evidence that impaired CVR is an independent risk factor for stroke and hence this test can be useful for selecting patients who likely would benefit from revascularization. We present case of patient with complex lesions of extracranial parts of ICA which led to alteration of intracranial haemodynamic-impaired CVR. Based on this, patient was indicated to successful ECA. In our clinic we systematically test intracranial haemodynamics in patients with asymptomatic significant CAS where CEA is considered. Evaluation of intracranial circulation in selection of patients with asymptomatic carotid stenosis to carotid endarterectomy role of transcranial ultrasound J Zizka Prague, Czech Repiublic Of all ischemic strokes 15-20% result from carotid occlusive disease. Of these 75% occur without previous transient ischemic attack (TIA). The prevalence of asymptomatic carotid artery stenosis (CAS) in general population is 2-8%.Annual risk of ipsilateral stroke on optimal medical treatment is currently 1-2% meaning that routine carotid artery endarterectomy (CEA) is not justified. However there are patient subgroups with substantial higher risk whom CEA is still indicated in. Hence risk stratification is needed. One of the options is to test intracranial haemodynamic by Transcranial Color-coded Sonography (TCCS) at rest and cerebrovascular reserve (CVR) which can be studied by the changes of blood flow in response to vasodilatory stimuli. There is evidence that impaired CVR is an independent risk factor for stroke. Recently published metaanalysis of prospective studies comparing risk of cerebral ischemic events in patients with significant asymptomatic CAS revealed that impaired CVR was associated with significantly increased risk of ipsilateral stroke (OR 6,14; p=0,02) and ipsilateral stroke/tia (OR 4,76; p=0,001). There is also evidence from results of prospective studies showing significant improvement of CVR following CEA in patients with impaired CVR preoperatively. Other contribution of transcranial US to the risk stratification of patients with asymptomatic CAS is possibility to test risk of cerebral microembolisation. Microembolic signals (MES) can be detected by transcranial dopplerometry (TCD) and are independent risk factor for stroke. Results of recently published large prospective study showed that MES positive patient are at substantial higher risk of ipsilateral stroke and TIA (primary endpoint, HR 2,54;p=0,015) in comparision to MES negative. Annual risk of ipsilateral stroke/tia is 3% in MES negative and 7% in MES positive patients respectively. Conclusion: management of patients with asymptomatic CAS is controversial. Risk stratification is needed. TCCS/TCD can test both-risk of atheroembolic and haemodynamic ischemic cerebral events. In our clinic we have recently introduced both technics and we test patients with asymptomatic significant CAS where CEA is considered. Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 95

96 INTERNATIONAL ANGIOLOGY August 2014

Official Journal of the International Union of Angiology INTERNATIONAL ANGIOLOGY Index VOLUME 33 - Suppl. 1 to No. 4 - August 2014 Authors Index A Abbasov F., 32 Abushov N., 23, 32, 76 Abushova G., 32 Adam D., 5 Adams F., 4, 14 Ahmad M., 5 Ahmadov M., 76 Ahmedi Z., 54 Ahrens I., 94 Ajami O., 17, 71 Akbarin M., 4 Akimov S., 33, 33 Alam S., 2, 3, 9 Aliyev E., 76 Aliyev Z., 32 Allaert F., 30, 52, 64, 65, 90 Allamand F., 31, 40 Aluigi L., 93 AMemiya T., 78 Amore M., 72 Angchaisuksiri P., 37 Annaáková G., 85 Antignani P., 42, 52 Antonopoulos K., 50 Areas P., 83 Argyriou C., 53 Arif M., 9 Armstrong, E., 86 Aslam M., 3, 5, 7, 18 Athanasoulas, A., 50 B Bachleda P., 65, 71 Badge H., 86 Bahadori A., 17, 71 Bao-Zhong Y., 68 Barbic Zagar B., 27 Bashar A., 2, 3, 9 Bavahuna M., 62 Beck T., 25 Begg L., 75, 76 Behnia M., 57, 58, 59 Belch J., 4, 14 Bengoa G., 72 Benzenine E., 30, 52 BergSchmidt E., 79 Bernardi E., 35 Bertelli M., 44 Bianchi V., 31, 40 Biao Y., 68, 75 Bicanic G., 20, 40 Bielinski P., 82 Biggs N., 3 Blinc A., 27 Bohrn T., 62 Borja A., 92 Bortoluzzi C., 35 Bosco M., 35 Bozic Mijovski M., 27 Brix M., 18 Bronte E., 37 Bruson A., 44 Buehner U., 89 Burns J., 75, 76 Butcher W., 62 Butterworth J., 18, 86 C Cameron E., 59 Camporese G., 35 Cappellino F., 44 Cardone M., 44 Carlisle I., 15 Casronovo E., 76 Cassorla G., 27, 31, 39, 40 Castro L., 26, 83, 83 Castronovo E., 63, 68, 69, 72, 77 Castronovo E., 68 Cecchin S., 44 Cerna M., 67, 71 Chabok M., 3, 5, 7 Chadachan V., 84, 85 Chang S., 17 Chatterjee A., 31 Chauferind G., 65 Chen B., 51 Chen T., 58, 59 Chen Y., 7, 89 Chinsakchai K., 43 Chochola M., 87 Chong B., 54 Chou E., 15 Ci Z., 26 Ciucci J.L., 72 Claridge M., 5 Clerissi J., 63, 68, 69, 72, 76, 77 Coltart J., 3 Connor D., 57, 58, 59 Connor2 D., 58 CooleyAndrade O., 57 Corrado E., 46 Correa L., 19 Cowan P., 10, 19, 30 Crebassa V., 64 Crikis S., 19 Cui S., 25 Cunningham M., 8, 9 D Daly T., 67 Dekiwadia D., 24, 30, 78 Dekiwadia H., 24 Denchev B., 81, 82 Denniss R., 47 Dey N., 2, 9 Diaz J., 20, 40, 59, 60 Díaz Bessone F., 72 Dimitrov S., 82 Dominici D., 19 Dondi M., 63, 68, 69, 72, 77 Dondi M., 63, 68, 76 Dostálová K., 85 Drakoy A., 50 Dwyer K., 19, 30 E Edwards J., 43 Engelhardt M., 25 Everest-Rolfe L., 89 Evola S., 37 Evola V., 46 F Farahmandfar M., 3, 5, 7 Fareed J., 10 Fazeli B., 4, 29 Filiz D., 81 Fiorentino A., 44 Fitton A., 18 Flekser R., 93 Fletcher J., 39, 67, 75, 76, 86, 88 Forster C., 81 Frank C., 29, 32 Freitas A., 26, 83 Freitas D., 26, 83 Fukuyama N., 1 Furukawa S., 72 G Ganeshan A., 5 Gao X., 25 Garbani N., 3 Genadiev S., 81 Gerez S., 72 Geroulakos G., 10 Ghoddusi Johari H., 14 Giannoukas A., 50, 53 Gohar S., 91, 92 Golledge J., 8, 9 Gossetti B., 45 Govedarski V., 81 Graissaguel A., 65 Granot A., 15 Griffin J., 74 Gu Y., 25, 39, 51 Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 97

Guarneri F., 46 Guex J., 64 Guliyev R., 76 Guo J., 25, 51 Guo L., 25, 51, 61 H Hagemeyer C., 94 Hagley D., 44, 54 HagstrupChristensen J., 79 HajiZaine N., 76 Hakim E., 2, 3, 9 Halliwell R., 54 Hannaford P., 60 Harazim M., 66 Harris I.A., 86 Hasayeva N., 23 Hashimoto M., 78 Heller S., 87 Her S., 73 Herman J., 65, 71 Heu F., 81 Hevia C., 27 Hirmerova J., 53 Hirth O., 15 Hitos K., 39, 67, 76, 88 Hofírek I., 66 Hohmann J., 94 Honek J., 63, 64 Honek T., 63, 64 Hoppensteadt D., 10 Horsirimanon S., 21 Horsirimanont S., 13, 22 Horvath V., 63, 64 Horwitz B., 31, 40 Hoshino Y., 61 Hossain G., 2, 3, 9 Hossain M., 2, 3, 9 Hsu J., 88 Huang K., 20, 40, 59, 60 Huber D., 37 Huilgol R., 44, 54 Hwang B., 73 I Ibrahim N., 20, 40, 59, 60 Igari K., 70, 90 Igari T., 70 Ikeya Y., 1 Ikitimur B., 81 Ilzecki M., 66, 82 Imberti D., 35 Inga G., 37 Inoue Y., 70, 73, 90 Ioannou C., 50 Ito S., 78 Iwanowski W., 94 J Jackson M., 48, 62 Jara C., 42 Jezovnik M., 49 Jian Z., 23, 80 Jiang K., 87 Jiang W., 2 Jiang X., 54 Jianming G., 23 Jibiki M., 73 Jingdong T., 26 Jirasiritham S., 13, 21, 22 Jones R., 8, 9 Julia P., 15 Julinek S., 21 K Kadiss A., 51 Kakissis I., 50 Kaletova M., 67 Kalodiki E., 10 Kanni L., 78 Karetova D., 41, 87 Karimov M., 32 Karkos C., 50 Karpuz H., 81 Katayama N., 78 Katib N., 1 Katsui S., 70, 90 Kazemzade G., 14 Ke L., 26 Kemp B., 10 Khan F., 14 Khan F., 4 Khlevtova T., 33 Kim D., 73 Kim J., 73 Kingwell B., 8 Kitchener S., 47 Klein D., 21 Koizumi S., 70, 90 Kornberg A., 42 Kosugi I., 84 Koutsias, S., 53 Kozak M., 27 Krampl C., 48 Krapp J., 72 Krasnovsky A., 33 Kravos A., 27 Krishnaswamy M., 74 Kudo T., 70, 90 Kun F., 17 L Lang W., 25, 80, 81 LaRosa A., 63, 68, 69, 72, 76, 77 Lattimer C., 10, 20 Lavigne M., 19 Lawanwong K., 13 Lecuona Huet N., 20 Leela-Udomlipi S., 13, 21, 22 Lertsithichai P., 13 Li F., 74 Li X., 51, 87 Lianrui G., 23, 69, 80 Liapis, C., 50 Lin C., 86 Linhart A., 87 Liu D., 8 Lixing Q., 69 Lodigiani C., 35 Lu B., 19 Lubanda J., 87 Lun B., 65 M Mackiewicz J., 82 Mah J., 67 Makrygiannis G., 53 Malikov S., 18 Maly I., 21 Mammadova L., 76 Mamun A., 9 Manafov S., 23 Mandal N., 2, 3, 9 Manganaro A., 3 Marcian P., 67 Marcovecchio L., 72 Marmash N., 39 Marx J., 15 MassaSaluzzo C., 63, 68, 69, 72, 76, 77 Matano S., 84 Maurins U., 51 May J., 35 Mazayshvili K., 33 Mazzola C., 35 McCaffrey M., 43 McClure D., 3, 74 McLaughlin P., 75 Medbury H., 39 Meikle P., 8 Mendoza E., 20 Meng Q., 87 Meyer A., 80 Michelini S., 44 Michell B., 10 Millar J., 4 Moa E., 72 Mohabbat W., 93 Mohammadzadeh A., 14 Moia E., 63, 68, 69, 76, 77 Moia R., 63, 68, 69, 72, 76, 77 Molina E., 36 Mongold J., 90 Moon K., 73 Mori H., 1 Morishita E., 84 Morita S., 72 Morris D., 8, 9 Morrison J., 6 Morrow A., 74 Moxon J., 8, 9 Mueller C., 25 Muratori I., 46 Murray-Segal L., 19 Musil D., 65, 67, 71 Mutirangura P., 43 Myers J., 24 N Nachev G., 81, 82 Nakamura M., 70, 90 Nakos C., 50 Namer B., 81 Nandurkar H., 10, 19, 30 Naylor J.M., 86 Neale M., 43 New J., 54 Nicolaides A., 3 Nieto T., 5 Nishi K., 72 Nishizawa M., 70, 90 Noventa F., 35 Novo G., 37, 46 Novo S., 37, 46 Nurul Alam, S. A., 36 Nuzzo R., 63, 68, 69, 76, 77 Nuzzo R., 72, 77 Nystrom T., 78 O Okunaga H., 72 Ostransky J., 67 P Pace G., 37 Pandit N., 84, 85 Pannier F., 51 Papadopouloy M., 50 Papazoglou K., 50 Parsi K., 57, 58, 59, 60 Patel V., 39 98 INTERNATIONAL ANGIOLOGY August 2014

Patrik P., 85 Peek S., 32 Pelletier M., 6 Peritore A., 46 Pertsoulis N., 39 Peter K., 7, 94 Petrlik M., 62 Petrov. I., 81 Pezeshki Rad M., 17 PezeshkiRad M., 71 Piller N.B., 44, 47, 49 Pitha J., 41 Piyanut P., 79 Pohar Perme M., 27 Pootracool P., 21, 22 Pootrakool P., 13 Popov V., 82 Poredos P., 27 Poredoš P., 48, 52 Prasil V., 71 Pratt J., 42 Prave S., 51 Prochazka P., 87 Przywara S., 66, 82 Pulli R., 45 Q Qi L., 51 Qian A., 87 Quagliana A., 37 Quah T., 91 Quantin C., 30, 52 R Rabe E., 51 Rafailov E., 4 Ramírez N. R., 20 Rangarajan S., 3 Rastel D., 65 Ravari H., 4, 14, 17, 29, 71 Regalado O., 72 Renaudin J., 15 Rits J., 51 Rives A., 6 Robson S., 19 Rodriguez A., 9 Rodríguez L., 72 Rojas H., 27 Rong J., 87 Rosfors S., 78 Rotonda C., 15 Rousas N., 50, 53 Roztocil K., 41 Ruangsetakit C., 43 Rucka D., 87 S Sabovic M., 27 Saeed Modaghegh M., 14 Sahu T., 13, 73 Saji S., 24 Salah M., 70 Salepstis V., 50 Saleptsis V., 50, 53 Salvaris E., 10 Samudra A., 10, 30 Sanderson B., 88 Sang H., 87 Sangaki A., 14 Santavy P., 71 Saracino V., 63, 68, 72, 76, 77 Saracino V., 69, 77 Satokawa H., 70 Seidlerova J., 53 Seifert B., 41 Selan C., 10, 19, 30 Sermsathanasawadi N., 43 Sharma A., 10 Shen Y., 2 Sheng-Han S., 68 Shenghan. S., 75 Shijun C., 80 Shizuma T., 1 Shuixian Q., 26 Shujie G., 26 Simon E., 18 Sinacori M., 46 Singh M., 84 Sirocco F., 44 Skalicka L., 87 Slais M., 63, 64 Slechtova J., 53 Sochor O., 66 Sokolovski S., 4 Sopon J., 79 Soracco J., 27, 72 Spanos K., 50, 53 Stankova-Salta R., 50 Stare J., 27 Stegnar M., 27 Stoyko Y., 33 Strandhave C., 79 Stratton C., 88 Štvrtinová V., 85 Subrt I., 53 Sucato V., 37 Suesada H., 78 Suesawatee A., 22 Sule A., 91, 92 Sun Z., 2 Surasak-Udomlipi L., 79 Suthas H., 79 Svensson M., 79 Syed D., 10 Szopinski P., 83 T Taborsky M., 67 Tagizade G., 76 Tan L., 68, 75 Tan X., 57 Tanaka C., 1 Taniguchi F., 84 Tay J., 84, 85, 91, 92 Teasdale J., 61 Terlecki P., 66, 82 Thomas S., 1 Thoo C., 43 Tichy M., 65 Tirapanich W., 13, 21, 22 Tona G., 37 Tong Z., 25, 51 Torres J., 27 Toyofuku T., 70, 90 Trovato R., 37, 46 Tsetis D., 50 Tsuchida H., 78 Tsyplyashchuk A., 33 U Uchiyama H., 70, 90 V Vahedian Shahrodi M., 14 Valenzuela G.C., 57 Vallejos C., 27 Varcoe R., 1, 6, 40 Varejka P., 87 Vargas P., 31, 40 Vekic D., 58 Vellettaz R., 19, 41 Vicaretti M., 75, 76 Virgini C., 83 Vitali S., 35 Vítovec M., 63, 64 Vojtiskova J., 41 W Walsh W., 6 Wang H., 2 Wang J., 89 Wang X., 94 Wang Z., 39, 51 Wang-De Z., 68 Wangde Z., 75 Warzocha K., 83 Wasin B., 79 Weir J., 8 Weisel J., 57 Williams H., 39 Willy, C., 25 Wilmink T., 5 Wingenfeld L., 72 Wiszniewski A., 83 Wiwat T., 79 Wong G., 8 Wong K., 57, 58 Wongwanit C., 43 Wu X., 25, 51 X XianGoh W., 57 Xin W., 80 Xuan W., 86 Xuefeng L., 23, 80 Yang B., 66 Yang J., 6 Yang Z., 68, 75 Yashkin M., 33 Y Yee C., 92 Yokoyama H., 70 Yongquan G., 23, 69, 80 Yoo K., 73 Young N., 67 Yu H., 51 Yu X., 87 Z Zahariev T., 81, 82 Zakirjayev E., 23, 32, 76 Zanon G., 35 Zea A., 20, 40, 59, 60 Zerrouk S., 15, 18 Zhang J., 39 Zhang X., 10, 30 Zheng Y., 74 Zhonggao W., 23 Zhu T., 23, 80 Zizka J., 95 Zubilewicz A., 82 Zubilewicz T., 66, 82 Vol. 33 - Suppl. 1 to No. 4 INTERNATIONAL ANGIOLOGY 99