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CX 2016 DIGEST

Challenges UpdateVascular & Endovascular

CHALLENGESCONTROVERSIES CONSENSUS

PeripheralArterial

Challenges

AorticChallenges

AcuteStroke

Challenges

VenousChallenges

CX Digest 2016

The CX 2016 Digest contains a summary of the key topics discussed at the 38th Charing Cross Symposium, held from 26–29 April 2016 at Olympia Grand in London, UK.

This year – halfway through its cycle of Controversies, Challenges and Consensus – CX explored the numerous Challenges in the vascular and endovascular space, covering peripheral arterial, aortic and venous topics. The inclusion of acute stroke, which is an extension of the carotid programme held in previous years, and a new vascular access course were key components at this year’s symposium.

Throughout this document, members of the CX Programme Organising Board provide insights into the take-home messages of the Main Programme and Parallel Sessions in which they participated as a chairperson or moderator.

As always, audience participation and interaction were important features of CX; therefore, 49 questions were asked during the four days of the symposium for voting. The results, followed by comments from Roger Greenhalgh, CX Programme Organising Board chairman, have been included on the following pages.

Additionally, the CX 2016 Digest brings key statistics highlighting the general attendance at this year’s event as well as a breakdown of specialties and countries.

The organisers of the Charing Cross Symposium would like to thank the Faculty members, delegates and industry for their continued support, and look forward to seeing you in London on 25–28 April 2017 for the 39th Charing Cross Symposium.

Chairman

Roger Greenhalgh

Emeritus Professor of Surgery and Head of Vascular Surgery Research Group at Imperial College London, London, UK

Co-chairmen

Frans Moll

Professor and Head of the Department of Vascular Surgery at University Medical Center Utrecht, Utrecht, Netherlands

Matt Thompson

Professor of Vascular Surgery at St George’s University of London and Consultant Vascular Surgeon at St George’s Vascular Institute, London, UK

Aortic

Andrew Holden

Associate Professor of Radiology at Auckland University School of Medicine and Director of Interventional Services at Auckland City Hospital, Auckland, New Zealand

Janet Powell

Professor of Vascular Biology and Medicine, Imperial College London, London, UK

Dittmar Böckler

Professor of Vascular Surgery at University of Heidelberg and Head of Department of Vascular Surgery and Endovascular Surgery at University Hospital Heidelberg, Heidelberg, Germany

Giovanni Torsello

Professor, Head of Department of Vascular Surgery at Franziskus Hospital and Director of the Clinic for Vascular and Endovascular Surgery at the University of Münster, Münster, Germany

Acute Stroke Challenges

Ross Naylor

Honorary Professor of Vascular Surgery at University of Leicester and Consultant Vascular Surgeon at Leicester Royal Infirmary, Leicester, UK

Martin Brown

Professor of Stroke Medicine, Stroke Research Centre, UCL Institute of Neurology and Consultant Neurologist, The National Hospital for Neurology & Neurosurgery, Queen Square, London, UK

Peripheral Arterial

Cliff Shearman

Professor of Vascular Surgery at University of Southampton and Vascular Surgeon in the Department of Vascular Surgery, University Hospital Southampton Foundation Trust, Southampton, UK

Michael Edmonds

Professor of Diabetic Foot Medicine and Consultant Diabetologist at King’s College Hospital, London, UK

Thomas Zeller

Professor of Angiology at Albert-Ludwigs University of Freiburg and Head of Department of Angiology at Universitäts – Herzzentrum Freiburg, Bad Krozingen, Germany

Iris Baumgartner

Professor and Head of Clinical and Interventional Angiology and Director of Vascular Research at University Hospital Bern, Bern, Switzerland

Andrew Bradbury

Sampson Gamgee Professor of Vascular Surgery in the College of Medical and Dental Sciences at the University of Birmingham, UK, and Consultant Vascular and Endovascular Surgeon at the Heart of England NHS Foundation Trust in Birmingham, UK. (He also advises in the Venous area of CX)

Venous

Ian Franklin

Consultant Vascular Surgeon at London Vascular Clinic, London, UK

Alun Davies

Professor of Vascular Surgery at Imperial College London and Consultant General Surgeon at Charing Cross Hospital, London, UK

Mark Whiteley

Visiting Professor at University of Surrey and Consultant Vascular Surgeon at The Whiteley Clinic, Guildford, UK

Stephen Black

Consultant Vascular Surgeon at Guy’s and St Thomas’ Hospital, London, UK

International AdvisorsEric Verhoeven

Gunnar Tepe

Jan Brunkwall

Krassi Ivancev

Patrick Peeters

Nick Cheshire

Eric Chemla

CX Abstract BoardIan Loftus, Co-chairman

Richard Gibbs, Co-chairman

Paul Hayes

Robert Hinchliffe

Colin Bicknell

Daryll Baker

Rachel Bell

Marcus Brooks

Meryl Davis

Simon Ashley

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2016 CX Digest

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The CX Symposium has a great impact on vascular surgery practice.

The Acute Stroke Challenges session was excellent; please have a whole day next year!

The CX Vascular Access workshop was amazing this year.

What participants say about CX 2016

The symposium has prompted many questions and answers to the interventional procedures we undertake and the path that our department is taking. I enjoyed the deep venous

session. It was well organised, well attended and well debated. This highlights the growing importance of this aspect of vascular surgery.

CME feedback

51% of the CME respondent delegates rated the Charing Cross programme as ‘excellent’ and 45% rated it as ‘good’

50% of CME respondent delegates rated the Charing Cross Symposium as ‘excellent’ (an increase of 4% from 2015) and 46% rated it as ‘good’

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Germany

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5% Other clinicians

7% Vascular scientists and nurses

9% Other cardiovascular specialists

11% Interventionalists

68% Vascular & Endovascular surgeons

4% Asia

5% Middle East

8% Eastern Europe

10% North America

69% Western Europe

1% Australasia

3% South America

4% Fair

45% Good

51% Excellent

0% Poor

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Belgium

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5% Other clinicians





4% Asia

5% Middle East

8% Eastern Europe

10% North America

69% Western Europe

1% Australasia

3% South America

4% Fair

45% Good

51% Excellent

0% Poor

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50% Excellent

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CX Digest 2016

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In 2016, CX included four days of Peripheral Arterial Challenges with sessions in the Main Programme, the CX Peripheral Live and Edited Cases, the CX ilegx Collaboration Day and Peripheral Arterial

Abstract Presentations.

In the Main Programme, discussions centred on the optimal management of superficial femoral artery lesions, below-the-knee lesions, and popliteal aneurysms. There were also talks on the benefits of exercise therapy for intermittent claudication.

Regarding the superficial femoral artery, treatment strategies, depending on lesion type and length, were analysed and there was special emphasis on the status and expectations with different modalities: drug-coated balloons, drug-eluting stents, new stents (swirling flow and biomimetic stents) and stent grafts. During the “Current status and expectations of drug-coated balloons”, new data were presented for complex patients and complex lesions. Both Peter Schneider (Honolulu, USA) and Gunnar Tepe (Rosenheim, Germany) reviewed results for Medtronic’s IN.PACT Admiral drug-coated balloon—Schneider looked at two-year outcome data for the device in female patients and in diabetic patients while Tepe gave the talk “IN.PACT Global drug-coated balloon for chronic total occlusion” Schneider stated that, among both female and diabetic patients, the IN.PACT Admiral balloon was associated with a higher rate of primary patency at two years than was balloon angioplasty. Clinically-driven target-lesion revascularisation was also lower with the drug-coated balloon in both groups. According to Tepe, the outcomes of the IN.PACT Global study were “excellent and remarkably consistent” with that of the overall IN.PACT Global cohort “despite the complexity of these challenging and complex long chronic total occlusion lesions”.

Thomas Zeller (Bad Krozingen, Germany) reviewed 12-month interim data from the ILLUMENATE global study (which evaluated Spectranetic’s Stellarex device), stating: “Overall, these interim results compare well with the highest drug-coated patency reported in

comparable studies with similar patient populations, but with a lower level of drug concentration.”

Also as part of the superficial femoral artery section, Peter Gaines (Sheffield, UK) told delegates why he believed inducing swirling flow with a biomimetic stent (BioMimics 3D, Veryan) improves outcomes, noting that a study had indicated that “primary patency significantly improved with a helical stent rather than a straight stent.” Furthermore, Michael Dake (Stanford, USA) explained why five-year data for the Zilver PTX stent (Cook Medical) show the “long-term benefit” of drug-eluting stents over bare metal stents.

Focusing on the management of long superficial femoral artery lesions, Michael Jaff (Boston, USA) observed that the use of a drug-coated balloon represented an “important advance” in endovascular treatment of peripheral arterial disease but noted that the utility of these devices in lesions longer than 15cm was limited. Donald L Jacobs (St Louis, USA) then spoke about the use of single long stents versus multiple stents for long lesions.

In the below-the-knee section of the day, there was a mini symposium dedicated to wound healing. William Jeffcoate (Nottingham, UK), for example, spoke about the need to measure wound healing.

Giovanni TorselloUniversity of Münster, Münster, GermanyI have been attending CX from the very beginning, and I have seen the fantastic development of this meeting. I rank CX as one of the best meetings worldwide. Here, we have the opportunity to debate and discuss. The voting allows us to

engage with the opinions of the audience, and to gain an insight into how we should all be working.

The most important message of the Peripheral Arterial session is that lesions of the superficial femoral artery are not the same in all patients. We discussed how to deal with short lesions, long lesions and calcified lesions; additionally we learnt strategies to treat de novo lesions or in-stent restenosis, concluding that we need a tailored strategy to treat each patient on an individual basis.

We also looked at new data regarding the optimal treatment for different lesion lengths. We have a lot of data for the different kinds of lesions, but not enough to compare different treatment strategies head-to-head for the same lesion. I was surprised by the audience’s answer to one of the peripheral arterial questions—60% of the audience said we still need surgery for complex lesions. Of course, over the next few years we will see if we have any alternatives at least as effective as surgery. This year I was impressed with the long-term results for drug-eluting stents. For other strategies, however, we have only one- or two-year results, so we will have to wait.

At this year’s CX, we also saw the development of some new technologies. These are very exciting times for the treatment of these patients and lesions.

2016 CX Digest

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Supervised exercise, smoking cessation and best medical treatment should precede intervention:

89% Yes

11% No

The evidence for exercise therapy in selected patients with intermittent claudication is strong but the majority of patients in my practice are either unwilling or unable to undertake supervised exercise programmes:

70% Agree

30% Disagree

Pretreatment of superficial femoral artery lesions before drug-coated balloon has CX audience support:

87% Yes

13% No

Greater and greater CX audience acceptance.

What is the role for drug-coated balloons?As an alternative to stents

64% For in-stent restenosis

28% As a last resort

6% No role

2%

Drug-coated balloon (DCB) is finding its place at CX and the story unfolds annually.

Are drug-coated balloons equally effective in all lesion subsets?

20% Yes

80% No

No! The CX audience recognises that it matters in which situation DCB is used. The jigsaw puzzle comes together over the years.

Does stent design impact vessel patency after stenting of the femoropopliteal artery?

87% Yes

13% No

A huge win for stent design at CX 2016.

Has the introduction of drug-coated balloon technology reduced your utilisation of drug-eluting stents?Yes

41%No, I never used drug-eluting stents

30%No, I still use drug-eluting stents in more complex lesions

29%

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Cliff ShearmanUniversity of Southampton, Southampton, UKThe first session of the Peripheral Arterial Challenges largely concentrated on non-intervention treatments for the management of intermittent claudication, for which the evidence is strong. However, my impression was that the audience views about exercise before

intervention have softened compared with previous years, largely based on the poor patient acceptance of exercise programmes. There needs to be a lot of work done to develop new approaches to motivating patients to engage with these programmes, possibly encouraged by electronic remote monitoring devices.

Stent design remains an issue and stents designed to produce more physiological flow patterns (swirling flow) are intriguing. The debate about endovascular treatment of the superficial femoral artery continues. One of the more contentious areas is debulking prior to drug-coated balloons. My impression is that this simply means it takes a little longer for the disease to recur. It was interesting to compare these outcomes with the surgical series reported from Finland. The role of surgery seems to have been largely overlooked.

Our ability to assess lower limb blood supply is quite crude and I thought some of the most exciting sessions were on new assessment technologies, particularly Jim Reekers’ perfusion angiography.

2014 2012As an alternative to stents 72% 27%For in-stent restenosis 21% 33%As a last resort 3% 19%No role 4% 21%

2015 2014 2013Yes 77% 43% 32%No 23% 57% 68%

2015 2014Yes 97% 71%No 3% 29%

CX Digest 2016

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12%Vessel preparation followed by drug-coated balloon

15%Drug-eluting stents

2%Sequential stenting

2%Stent graft (Viabahn)

8%Full lesion bare metal stent implantation with a long stent

1% Bypass surgery

60%

So even with a progressive, predominantly endovascular specialist CX audience, the place of bypass surgery is a huge contender in 2016!

In-stent restenosis after drug-eluting stent placement is more benign than after bare metal stent placement:

82% Yes

18% No

Oh yes! The CX audience accepted that!

My preference for the treatment of in-stent restenosis is:Drug-coated balloon

76%Drug-eluting stent

8%Viabahn endoprosthesis

9%Atherectomy or photoablation

4%Mechanical thrombectomy

3%

The CX audience gave a clear answer.

In patients with a popliteal aneurysm and impaired distal run-off (two or less patent crural arteries) endovascular treatment is contraindicated:

58% Agree

42% Disagree

One can speculate why 58% favoured an open approach. The increased chance of improving run-off by catheter embolectomy with or without local thrombolysis comes to mind.

What is the best revascularisation strategy in below-the-knee arterial disease?Bypass surgery with use of a vein

49%Endovascular therapy following the angiosome concept

17%Endovascular therapy to open as many vessels

33%None of the above

1%

Again bypass surgery is not dead at CX!

Andrew HoldenAuckland University School of Medicine, Auckland, New ZealandAt the Peripheral Arterial sessions, we received a lot of new information about drug-coated balloons; the importance of predilatation and the latest randomised controlled data. It

was also interesting seeing subgroup analyses, covering topics such as how drug-coated balloons work in chronic total occlusions. We also got the latest data on drug-eluting stents and their durability and saw some interesting new stent designs, some covered stents and how to deal with restenosis.

We covered the still considerable debate about which technologies should be used to treat which types and lengths of lesion in the superficial femoral artery. The big question is whether a drug-coated balloon approach is a strategy enough on its own for longer lesions. I think the jury is still out on exactly which group of patients we should be offering a permanent scaffold, a stent or a debulking strategy.

We also saw some really interesting new imaging techniques to try to identify critical limb ischaemia patients we should be treating, and discussed new ideas about how to optimise wound healing.

2016 CX Digest

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61%Thrombolysis

19%Clot aspiration with or without thrombolysis

20%

And again an open approach!

All patients with diabetic foot ulcers and impalpable foot pulses need revascularisation to ensure wound healing:

57% Agree

43% Disagree

This sounds a logical CX audience view.

The most reliable assessment of whether diabetic foot ulcer will heal is:Transcutaneous oxygen measurement >25mmHg

17%The presence of pedal pulses on palpation

21%Toe pressure >45mmHg

50%Wound colour (pink)

12%

The CX audience has a clear favourite.

The commonest factor preventing healing in a diabetic foot ulcer is:Chronic infection

13%Poor wound environment (lack of debridement)

39%Inadequate blood supply

22%Impaired healing secondary to hyperglycaemia

26%

A CX audience winner again!

CX Peripheral Live and Edited cases

The CX Peripheral Live and Edited cases session was chaired by Michael Jaff (Boston, USA), and

moderated by Giovanni Torsello (Münster, Germany) and Thomas Zeller (Bad Krozingen, Germany). The live cases were performed by Arne Schwindt and Theodosios Bisdas (from St Franziskus Hospital in Münster, Germany) and the edited cases were from across Europe and were presented by members of the CX Faculty.

The aim of the session was to review why a specific technique is chosen for a particular clinical situation. For example, in the first live case, an AngioSculpt scoring balloon catheter followed by a Stellarex drug-coated balloon (both Spectranetics) was used to treat a 67-year-old male patient with critical limb ischaemia (Rutherford class 4) of his left leg and rest pain at the right stump after below-the-knee major amputation.

The other five live cases featured the use of the Rotarex device (Straub Medical) in an 83-year-old female patient with critical limb ischaemia (Rutherford class 4); the Zilver PTX (Cook Medical) drug-eluting stent for an occlusion in the superficial femoral artery; the Supera stent (Abbott Vascular) for a calcified artery without pretreatment; the Eluvia drug-eluting stent (Boston Scientific) used in a long occlusion of the superficial femoral

artery; and finally, the combined use of the HawkOne atherectomy device and the IN.PACT drug-coated balloon (both Medtronic) was demonstrated in a 69-year-old male with intermittent claudication (Rutterford class 3).

For the edited cases, the presenters gave an overview of the case details, showed a video of the procedure and explained why each device was selected for the respective case. The devices highlighted were the IN.PACT drug-coated balloon for long lesions; the Jetstream atherectomy system and Ranger drug-coated balloon (both Boston Scientific) in restenosis of a bare metal stent; the use of the Tigris dual component stent (Gore); the use of the Smart Flex stent (Cordis); and finally, the Viabahn stent graft (Gore) for the treatment of a popliteal aneurysm.

Giovanni TorselloUniversity of Münster, Münster, GermanyThe live cases are a very important component of the Charing Cross Symposium. During the main sessions, physicians have the opportunity to discuss data to have an insight from different studies. With the live-case approach physicians have the opportunity to see how treatment strategies work in practice, and to discuss best perioperative strategies with the Faculty. Most importantly, we can also discuss this with the audience. This is the best part of the session.

The treatment of in-stent restenosis was highlighted at the CX Peripheral Live and Edited Cases. We had the opportunity to see different ways to treat these lesions—for example, removing the fresh part of the thrombus, removing the plaque, and then using the drug-coated balloons for the treatment of this specific and very demanding lesion.

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At the CX ilegx Collaboration Day, the difficulties and challenges of managing diabetic vascular disease were reviewed.

Experts discussed the optimum imaging approaches, the benefits of exercise therapy, and novel methods of enhancing wound healing. The management of ischaemic foot, including the role of stenting, was also explored during the day.

Jim Reekers (Amsterdam, Netherlands), in the first talk of the day, addressed the question “What is the optimum method of vessel imaging in people with diabetes?” by reviewing the “pros” and “cons” of the available options—duplex-Doppler ultrasound, computed tomography (CT) angiography, magnetic resonance (MR) angiography, and digital subtraction angiography. For example, he said that the “pros” of CT angiography are that it is non-invasive, could be rapidly performed, and has better spatial resolution than MR angiography, but the “cons” are that it involves “high-doses of radiation, has artifacts in heavily calcified arteries, and has limited usefulness in many patients with diabetes.” Reekers also looked at the value of using anatomical imaging to direct revascularisation in diabetic foot, noting that it was “at least unclear” how useful such an approach was.

In his talk, Robert Hinchliffe (London, UK) looked at whether there were any specific tests for identifying which patients with diabetic foot needed to undergo revascularisation. Moving on to treatment approaches, Nicola Troisi (Florence, Italy) reported that, last year, his centre started a supervised exercise programme for diabetic foot patients. He commented: “Overall, in the patients who completed the 16-week programme, there was a significant increase of transcutaneous oxygen (46.3mmHg pre vs. 58.8mmHg post; p=0.02), maximum walking distance (188.8m pre vs. 444.7m post; p=0.001), and walking impairment questionnaire (0.57 pre vs. 0.78 post; p<0.001).”

Andrew Boulton (Manchester, UK) also reviewed therapies for treating diabetic foot—looking at

adjunctive techniques for healing ulcers. He claimed the view that “a wound would not heal because of diabetes” was not true. “A diabetic foot wound will heal if three factors are attended to: first, there needs to be an adequate arterial inflow; second, infection should be aggressively managed; and third—and most frequently neglected—all pressure should be kept off the wound and its margins,” Boulton explained. Furthermore, he added that some patients with a diabetic foot ulcer, as a result of chronic sensorimotor diabetic peripheral neuropathy, have lost “the gift of pain”. Therefore, to the confusion of healthcare

professionals, these patients are able to walk on a large plantar neuropathic ulcer. He noted: “Enforced offloading—using either a total

contact cast or a removable cast walker rendered irremovable—has been

shown in randomised controlled trials to be effective in speeding up wound healing.”

As well as diabetic vascular disease, other topics discussed

during the CX ilegx Collaboration Day included “The King’s

College Hospital open access vascular diabetic foot care pathway”,

“Revascularisation of the ischaemic foot”, and when to use a stent to manage peripheral arterial lesions.

Michael EdmondsKing’s College Hospital, London, UK Ilegx, an initiative launched in 2008, is a collaboration of healthcare professionals who recognise that too many legs are amputated and many of these amputations are completely unnecessary. In keeping with the ilegx initiative, in 2016, the CX ilegx Collaboration Day provided delegates with an overview of the latest treatment strategies

for the ischaemic foot, particularly the ischaemic diabetic foot as diabetic patients suffer a high rate of amputation. There are three main reasons for the high rate of amputation in diabetic patients: infection, which can spread rapidly leading to overwhelming tissue destruction, severe peripheral arterial disease and the badly deforming Charcot foot. At this year’s ilegx, crucial significant advances in diabetic foot care to improve the outlook of these diabetic patients were highlighted.

For example, physicians presented the modern successful approach for treating diabetic foot at King’s College Hospital in London, UK. At the institution, a multidisciplinary team including diabetologists, podiatrists, nurses, orthotists, surgeons and radiologists work closely to successfully manage infection, ischaemia and the Charcot foot. Its focus is in an outpatient diabetic foot clinic but also extends to the inpatient location of wards, operating theatres and angiography suites. In this model, instant emergency access service is provided so that patients with new ulcers, pain or discolouration can be seen on the same day and can benefit from intensive and coordinated services for the aggressive treatment of infection, ischaemia and the Charcot foot.

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Venous Challenges

For the first time, the Venous Challenges Main Programme was held on the first day of the symposium. The discussions focused on the areas of deep venous and superficial venous disease,

with a special emphasis on the latest evidence of when and in which patients techniques and technologies should be used. A new session on lymphoedema was also highlighted. These main lectures were followed by the CX Venous Workshop, which ran for two days, and a CX Venous Abstract Presentations session.

The morning sessions of the Main Programme were dedicated to deep venous treatment. Highlights included data on the first investigational device exemption studies conducted for the dedicated venous stents as well as a number of new developments in clot lysis and mechanical thrombectomy. Lowell Kabnick (New York, USA) who presented feasibility data from the ongoing VIRTUS study on iliofemoral venous outflow obstruction treatment with the Vici venous stent (Veniti) said: “In terms of the feasibility trial, dedicated venous stents are necessary and the early results are very promising. Twelve-month primary patency rates in this feasibility cohort are >90%.” Gerard O’Sullivan (Galway, Ireland) reviewed interim results from a European study (VIVO-EU) of the Zilver Vena venous stent (Cook Medical), he reported that stent placement resulted in a greater than 100% luminal diameter improvement. In his presentation, Paul Gagne (Darien, USA) discussed a study (VIDIO) that compared IVUS with multiplanar venography to diagnose and direct treatment of iliofemoral vein obstruction. Based on the results of the study, he stated: “I believe that IVUS should be considered the gold standard for diagnosing and directing treatment in the iliac and common femoral veins and the basis for trial research imaging.”

Studies on pelvic vein reflux were thereafter presented with talks on male pattern pelvic reflux by Previn Diwakar (London, UK), pelvic vein embolisation for treatment of haemorrhoids by David Beckett (Guildford, UK) and a colorectal surgeon’s perspective on the pathogenesis of haemorrhoids by Peter Dawson (Imperial College, London, UK).

In the afternoon, delegates learnt about the latest advances in lymphoedema treatment followed by a comprehensive session on superficial venous treatment with updates on endovenous ablation,

sclerotherapy, laser therapy and embolisation techniques. Course director Ian Franklin highlighted Lowell Kabnick’s talk on a novel device, which allows a small metal clip to be applied to a vein to close it under ultrasound guidance through a pin-hole. “Although still under development, this technique may have a number of applications, in particular it might lead to increased interest in the CHIVA method to treat varicose veins,” Franklin said. “Many practitioners have been put off in the past learning the nuances of CHIVA as the procedure required skin incisions. The new ultrasound-guided clip would allow CHIVA to be performed without incising the skin and Dr Kabnick explained how the method may become more attractive to formerly sceptical surgeons.”

Raghu Kolluri (Columbus, USA) presented two-year data of the VeClose randomised controlled trial for acrylocyanate glue treatment of veins with the VenaSeal closure system (Medtronic). The method, which does not require any heating of the tissue or tumescent anaesthesia, seems to be at least as effective as the gold standard endothermal methods. Positive results in quality of life with cyanoacrylate adhesive embolisation were presented by Kathleen Gibson (Bellevue, USA).

Franklin commented that there is a plethora of treatment choices available now for truncal reflux. He said: “Most studies are confined to efficacy of use in the main truncal veins but neglect the complexities of accessory and anomalous veins. Steve Elias (Englewood, USA) provided an overview of methods available and considered what factors should be taken into account when selecting a treatment modality for different anatomical patterns of reflux.” Moreover, Thomas Weiler (Pforzheim, Germany) described the use of the bipolar Olympus radiofrequency method to treat truncal reflux and explained why he finds it to be an excellent treatment. Which method do you prefer to check for pelvic vein reflux in female patients with varicose veins?I do not check at all

7%Duplex ultrasound extracorporeal

15%Duplex ultrasound transvaginal

39% Venogram

10% MRI/MRV

22%CT

7%

A clear favourite here with the CX audience.

CX Digest 2016

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Venous

Do you think that haemorrhoids will be treated by phlebologists within the next decade?

49% Yes

51% No

So a substantial number of this CX audience visualise a “turf” change here.

What is your standard diagnostic test for lymphoedema?Nothing

20%Lymphangiogram

13%Ultrasound

15% Lymphoscintigraphy

50% Other

2%

A clear CX audience favourite is declared!

If CHIVA (haemodynamic or “saphenous bearing” surgery) could be made minimally invasive, would you prefer this to endovenous ablation treatment?Yes

21%No

59%Don’t really understand the difference

20%

“No” wins!

Do you treat the anterior accessory saphenous vein with endovenous techniques regularly (i.e. in at least 20% of your veins patients)?

51% Yes

49% No

The CX audience is not sure about that!

Do you think the future of endovenous surgery is tumescence or tumescence-less?Tumescence

26%Tumescence-less

74%

A huge win for the avoidance of tumescent anaesthesia and it was so popular so recently at CX!

Ian FranklinLondon Vascular Clinic, London, UK One of the great things that happened at this year’s Venous

sessions was the scheduling of the Venous Main Programme on the first day. This meant that all of the concepts and the evidence for and against the various venous interventions could be discussed in general terms which led to a very natural progression to the CX Venous Workshop, where delegates could explore the specific techniques we use to treat these conditions, and discuss them in detail with the

Faculty.

The best thing about the Venous Main Programme was how it was structured. Now, delegates will have a sense that when they are assessing somebody with lower limb symptoms they should not categorise too quickly if the patient is a lymphatic patient or a varicose vein patient or a deep vein patient. We are all starting to understand that there is a lot of overlap between these symptoms, and that the symptoms are often quite complex and multifactorial, and that to come at it with a very simplistic view does not help. You have to understand the overall symptomatology so that you can then pick the right treatment modality.

Stephen BlackGuy’s and St Thomas’ NHS Foundation Trust, London, UK This year’s Venous

programme highlighted how the interest in all aspects of venous disease has grown over the last several years. It is no longer simply about superficial venous reflux and the packed auditorium on the first day of the symposium reflected this.

The morning session focused on the treatment of acute deep vein thrombosis (DVT). There is a real awareness now that there are more options than just anticoagulation and stockings. Marzia Lugli gave her usual high standard

presentation on how patients progress to post thrombotic syndrome and this was followed by excellent summaries of how to assess and treat patients presenting with DVT.

The late morning session highlighted how the focus is now shifting from “can we stent” to “how do we do it better” and “how do we focus on improving outcomes for the patients”. A particular highlight of the programme for me was the lymphoedema session. Often the “ugly sibling” of vascular surgery, the talks were high quality and extremely interesting. Eva Sevick and Rajesh Hydrabadi gave really excellent talks on some genuinely fascinating advances in the treatment and assessment of lymphoedema.

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CX Venous Workshop

The CX Venous Workshop ran on days two and three of the symposium. On the first day, the main focus was on

superficial venous issues, giving delegates the opportunity to discover new techniques, with a hands-on approach, and speak to experts across the different fields of phlebological practice. The second day reviewed innovation in deep venous technologies, including deep vein stenting, venous ultrasound and valve technologies.

Course director Ian Franklin commented that delegates, on either day of the course, could “walk up to a member of the training faculty who is an expert in that field” and “interact over different techniques and share their experiences.”

For the first time, on the first day, the workshop featured a lymphoedema section, highlighting groundbreaking imaging solutions, genetic research, and novel treatment techniques. Oliver Lyons (London, UK), who showcased his genetic research into the aetiology of lymphoedema, highlighted the importance of this new part of the workshop. “It has been a fantastic forum for people to get together. We are already talking about potential ways we can join these technologies together to develop new treatments for patients,” he said.

Also, Eva Sevick (Houston, USA) took delegates through a new imaging system developed from Gulf War military night-vision technology. Using infrared heat signatures and trace amounts of dye to look through several centimetres of human tissue, a camera can capture images of the lymphatic system every 15 milliseconds. This has allowed physicians to create videos of lymph function for the first time. “We have imaged about 350 patients, and found that the lymphatic system is really important in vascular diseases… if the lymphatics are not working, fixing the venous problem is not going to help,” Sevick said.

Manos Protonotarios, who showcased the

AngioJet Zelante deep vein thrombosis thrombectomy catheter from Boston Scientific on the second day of the Workshop, praised the opportunity to communicate with individual physicians about innovative new uses for existing products. “This is the first time some of them have been introduced to the technology in general. Even the physicians who are already using our product today for arterial work have not started using it for venous…this is why we are here; to educate physicians on the use of the device in deep vein thrombosis.”

Bard offered a training station for their Venovo venous stent. “The CX Venous Workshop offers us the opportunity to show the benefits of our product—to give physicians a chance to get hands-on; to feel it and experience the product for themselves,” said Alicia Barns who was representing Bard.

One of the highlights of the second day was the opportunity to try out a new virtual reality training suite for deep venous surgery, comprising a smartphone and an Occulus headset (both Samsung). Course director Stephen Black described the immersive training environment as “awesome”. He added that Jean-Francois Uhl (Paris, France), who developed the training software, was “doing some amazing work in this area.” Uhl commented that the system might eventually be developed for intraoperative use. He praised the opportunity offered by the workshop to showcase novel technologies, “A lot of people are interested in this technology. There is a lot of very nice venous research here,” he said.

Noting the consistently high levels of attendance throughout the second day, Black said: “It has been great to see the interest growing. These techniques work. They are becoming much more mainstream and much more acceptable. We know that we can get good results for patients.”

Ian FranklinLondon Vascular Clinic, London, UKIn 2016, for the first time the CX Venous Workshop followed the Venous Main Programme. Quite often in lectures you can run out of time to ask questions, even though we allow quite a lot of generous discussion time at the CX Symposium. By running the Workshop later, it effectively prolonged the discussion, with Main Programme speakers demonstrating on the CX Venous Worksop training stations. That has been a huge and very beneficial change, for which we received a lot of positive feedback.

As well as learning, for example, when to treat and when not to treat during the Main Programme, delegates were able to visit the CX Venous Workshop and look at all the different devices—the deep vein thrombosis devices and superficial vein devices—and have an individual demonstration with each of them. Delegates could also explore revolutionary lymphoedema imaging techniques and treatment options hands-on. The Venous Main Programme and the Venous Workshop integrated and complemented each other very well this year at the CX Symposium.

Venous

Stephen BlackGuy’s and St Thomas’ NHS Foundation Trust, London, UKThe great advance this year was to move the Venous Main Programme to the day before the CX Venous Workshop. The workshop had a real buzz and was full for the two days. It gives a unique opportunity for direct engagement with experts and an excellent learning opportunity. Ian Franklin has done a truly fantastic job in building the CX Venous Workshop up over the years and is to be congratulated.

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Abdominal Aortic Challenges

At CX 2016, Aortic Challenges were discussed over all four days. Abstract presentations took place on the first and last days of the meeting, with the Main Programme and Live Edited Cases

sessions held on the second and third days. The Programme covered the wide range of aortic challenges facing professionals, and provided a platform for thought-leaders and delegates to exchange ideas.

In the Abdominal Aortic Challenges Main Programme, the teams of researchers and principal investigators who collected and analysed the data for the Individual Patient Data meta-analysis and EVAR 1 trial presented their data.

The meta-analysis analysed data from the EVAR 1, DREAM, OVER and ACE randomised controlled trials that compared elective endovascular and open repair of abdominal aortic aneurysm, and revealed that overall, there was no difference with regard to survival benefit (total or aneurysm-related) between endovascular aneurysm repair (EVAR) and open repair over the first five years of follow-up.

The new data from the EVAR 1 trial, presented by Roger Greenhalgh (Imperial College, London, UK) and colleagues, were a first-time presentation of the eight to 15-year period. The results showed that once again, there was a high reintervention rate in the group of patients receiving EVAR and that these reinterventions occurred throughout the follow-up period. The investigators reported that aneurysm-related mortality occurred throughout the follow-up period.

Greenhalgh concluded on behalf of his colleagues that even with the data based on experience with these early devices, there was much to learn about the cluster awareness with regard to secondary sac rupture.

Among other highlights of the Abdominal Aortic Challenges Main Programme, delegates heard about challenges in abdominal aortic aneurysm population screening programmes. They also heard different views about the threshold for elective intervention for abdominal aortic and iliac aneurysm, a session which closed with a split audience voting 50/50 for/against the motion in the Great Debate: The threshold for intervention for abdominal aortic aneurysm should be settled by randomised controlled trials.

Lifestyle risk factor modification and medication can alter abdominal aortic aneurysm growth:

89% Yes

11% No

Medication can prevent and inhibit abdominal aortic aneurysm growth:

49% Yes

51% No

Uncertain prevails! Time for more trials?

There is sufficient evidence to treat women at a diameter threshold below 5cm:

40% Yes

60% No

Oh no there is not!

Andrew HoldenAuckland University School of Medicine, Auckland, New ZealandThe key highlight from the Abdominal Aortic Aneurysm Challenges for me was the long-term follow-up of the famous randomised controlled EVAR trials. This threw us some new information, including some things that were a little counterintuitive. For example, we learnt that younger patients do better with EVAR than older patients. We would have expected to offer open repair to younger patients, but, as a group, they actually do better with EVAR. There has also been a big question about the very long-term durability of EVAR, which makes us pause again to think about exactly which patients we should be treating.

This year we were exposed to some new technologies that are continuing to evolve, and the big questions are: are they associated with better outcomes, and, can we start treating more aggressive anatomies? I think that this last question is still unanswered, but we definitely made significant progress at CX.

There was also an interesting discussion about screening, and one interesting point is that as the incidence of aneurysms goes down, what is the true validity of screening? I think that is getting more and more questionable. Related to this is the interesting topic of how we should approach female patients. We know that women are under-represented in terms of aneurysms, but we have to get better at identifying those at risk.

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There is sufficient evidence to introduce population-based abdominal aortic aneurysm screening programmes:

71% Yes

29% No

Correct!

There should be international consensus on how to measure abdominal and iliac aneurysms:

91% Yes

9% No

CX audience says “absolutely right!”

There should be international consensus on absolute thresholds for treatment of abdominal and iliac aneurysms:

79% Yes

21% No

Of course there should be!

The diameter threshold for treating internal artery aneurysms is:3-4 cm

44%4-5 cm

42%5-6 cm

5%6-7 cm

2%>7 cm

1%Don’t know

6%

...is somewhere between 3cm and 5cm says 96% of the CX audience!

The threshold for intervention for abdominal aortic aneurysm should be settled by randomised controlled trials:

50% For

50% Against

The CX audience listened to the doubters.

All the risk scores are useless for elective abdominal aortic aneurysm:

35% For

65% Against

So they are not all useless!

More patients with ruptured abdominal aortic aneurysm should be offered endovascular intervention than currently occurs:

85% Agree

15% Disagree

“Oh yes they should” says the CX audience.

A management protocol for ruptured abdominal aortic aneurysm improves outcomes:

96% Yes

4% No

Say 96%!

EVAR for ruptured abdominal aortic aneurysm in local anaesthesia is beneficial:

78% Yes

22% No

Overwhelmingly accepted by the CX audience.

The unstable patient should be treated by EVAR:

59% Yes

41% No

Dittmar BöcklerUniversity Hospital Heidelberg, Heidelberg, GermanyNew data on the long-term (15-year follow-up) clinical benefits of EVAR presented for the first time at CX have put the minimally invasive technique in a less than favourable light. However, these findings are not expected to dent the

market for these devices as continued improvements in newer-generation EVAR systems appear successful in countering the technology’s known shortcomings.

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Thoracic Aortic Challenges

One of the most talked-about sessions of the week in the Aortic Main Programme was a mini-symposium focusing on the radiation damage that has occurred to pioneering operators

in the field. It also focused on currently available methods to reduce radiation exposure during endovascular procedures.

Since its introduction in the late 80s, endovascular therapy has become increasingly widespread and important. At the session, Roger Greenhalgh (Imperial College, London, UK) read out a list of names of pioneers in the endovascular world, who had personally been affected by working with ionising radiation. The effects included cataracts, calcified plaque in arteries, brain tumours and even death. It is important to note that when the endovascular revolution began, the dangers of working with radiation were not the first concern in physicians’ minds. This meant that they were often putting themselves at risk in the process, and this is why, Greenhalgh emphasised, we owe these pioneers a huge debt of gratitude.

Another popular session was the Great Debate, which discussed false lumen embolisation for chronic type B dissection. A small majority of the CX audience (53%) voted against the motion “In chronic type B dissection, there is no place for false lumen embolisation—true lumen TEVAR is preferred”. The voting signalled victory for Fabrizio Fanelli (Rome, Italy) and Tilo Kölbel (Hamburg, Germany) who cleverly unpicked the motion to show that if false lumen embolisation was used even in select cases, it would go against the motion. Peter Mossop (Melbourne, Australia) and Stéphan Haulon (Lille, France) argued for the motion, and made the case that false lumen embolisation had no place in chronic type B dissection. The EVAR 1 data also shed light on the fact that diseased aortas continue to dilate over time and that even a well-placed good device can leak later on. Panellists noted that patients should be followed-up better so that aneurysms do not get to the point of rupture. Experts commented that if the disease process could be controlled, the devices would perform better.

Debate: Growth rate of small thoracic abdominal aortic aneurysm (TAAA) is known and relevant:

30% For

70% Against

It is not known!

Branched stent grafting is the future treatment standard for aortic arch pathologies:

78% Yes

22% No

A huge endorsement from the CX audience.

Matt ThompsonSt George’s University Hospitals and St George’s Vascular Institute, London, UKAs always, CX offered such a plethora of educational opportunities. There were debates, presentations of new evidence, key messages voiced by opinion leaders, as well as

case-base discussions. Recorded and live cases were also presented and discussion inside and outside of the sessions was encouraged. For me, it is the debates and the quality of the education that make CX what it is.

The key messages from the Thoracic Aortic Challenges Main Programme included the understanding of how to prevent spinal cord ischaemia after thoracic endografting. We heard some very clear presentations about how having a protocol to try and reduce spinal cord ischaemia is absolutely essential. Such protocols would include guidance on the management of blood pressure, during the perioperative period, placement of spinal drain and revascularisation of collateral circulation. We learnt that it is as important to have clear postoperative protocols. We also heard that over the last few years, centres that have instituted such protocols have dramatically reduced their spinal cord ischaemia rates.

The data presented have evolved over a number of years and, in general, it looks to me as if over the past three to five years we have seen a remarkable improvement in spinal cord ischaemia after the treatment of the most complex aneurysms, as we learn how to stage these procedures and how to put these perioperative protocols into practice.

The thoracic day featured a very lively debate about false lumen embolisation. It was quite clear that embolisation techniques have some promise but, overall, the audience and the panel seemed to be unsure about how robust the evidence is. I think that we will continue to see this situation evolve year-by-year as people present and publish their results.

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Spinal cord ischaemia is a major influencing factor for outcome and survival:

79% Agree

21% Disagree

It really is.

There is now sufficient evidence to offer endovascular repair in the sub-acute phase of all cases of asymptomatic acute aortic dissection:

49% Agree

51% Disagree

Neck and neck!

In chronic type B dissection, there is no place for false lumen embolisation – true lumen TEVAR is preferred:

47% For

53% Against

Very close but a majority see at least a place for this, but with a background of ongoing uncertainty.

Parallel grafts have the same durability in treating juxta-renal abdominal aortic aneurysms as fenestrated grafts:

44% Yes

56% No

More than two parallel grafts relates to poorer outcome:

65% For

35% Against

Agreed.

CX Aortic Edited Cases

The CX Aortic Edited Cases session provided the unique opportunity for the audience to interact with experts and ask questions about the cases being presented. Each case was

introduced by discussing patient details and indications, a case plan with device selection, sizing, adjunctive strategies and anticipated videos. This information was followed by a video of the procedure with several pauses to facilitate discussion between the panellists and audience.

The thoracic aortic cases looked at the use of thoracic branch endoprostheses for the arch (TAG, Gore), expanding the proximal neck in patients with challenging thoracic anatomy (Relay, Bolton Medical), and the treatment of thoracic aneurysms with a modular system (Zenith Alpha, Cook Medical).

The abdominal aortic cases comprised the rest of the session, the presentations covering the accuracy of placement and reduced contrast when deploying INCRAFT (Cordis); treating a wider range of patients using Zenith Alpha; chimney EVAR for type Ia endoleak using Endurant II (Medtronic) and V12 (Maquet Getinge); preoperative intent of use of EndoAnchor (Medtronic) for neck length <10mm; techniques for EVAS/Nellix use (Endologix); control of infected EVAR using INTERGARD SYNERGY (Maquet Getinge); and the Onyx liquid embolic system embolisation for type II endoleaks (Medtronic).

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New Acute Stroke Challenges

The new Acute Stroke Challenges session, an extension of the long-standing Carotid session, focused on patient selection for interventional procedures, carotid stenting and endarterectomy,

intracranial clot retrieval and cerebral embolisation reduction and arch protection devices.

On the final day of Charing Cross 2016, the half-day Acute Stroke Challenges programme was introduced following the realisation that a number of strokes are caused by interventions in the aorta and manipulations in the arch. The purpose of this new programme therefore, was to encourage a multidisciplinary approach, such that unwanted emboli to the brain can by managed by clot retrieval, and the optimisation of referral so that stroke patients reach the best hands as fast as possible.

A particular highlight of the new Acute Stroke Challenges session was the section on intra-cranial clot retrieval. This section encouraged a true multidisciplinary discussion, with a number of stroke experts—in both neurointervention and vascular surgery—from around the world providing their input in the form of talks and commentary. Of note was the debate: “Only neuroradiologists should undertake intra-arterial thrombectomy”, which incited a lot of discussion from the panel and the audience, with the final consensus clear from all sides that mechanical thrombectomy operators do not necessarily have to be neuroradiologists, but they must have the proper knowledge, experience and training as outlined in the respective guidelines.

Ross Naylor remained as course director and was joined by Martin Brown in 2016.

Do you think a worthwhile case has been made to support screening for aymptomatic carotid stenosis?

43% Yes

57% No

A majority say no!

Will carotid artery stenting one day become the preferred treatment for all carotid stenosis patients?

22% Yes

78% No

Not at CX 2016!

For carotid endarterectomy, many of the more subtle complications are not recognised in the randomised controlled trials:

62% Yes

38% No

Agreed!

I am comfortable performing carotid endarterectomy in a patient on dual antiplatelet therapy:

78% Yes

22% No

Yes.

Do we need to select patients for intra-arterial stroke treatment?

93% Yes

7% No

Yes, for sure.

Only neuroradiologists should undertake intra-arterial thrombectomy:

31% Agree

69% Disagree

No. It seems to depend on who is properly trained and experienced.

Cerebral protection systems are an effective way of preventing perioperative stroke during arch catheter directed interventions:

81% Yes

19% No

Effective but probably underused.

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Ross NaylorUniversity of Leicester and Leicester Royal Infirmary, Leicester, UKFriday 29 April 2016 saw the new Acute Stroke Challenges session at CX. Instead of focusing primarily on outcomes after carotid interventions, the symposium addressed a wide

range of topical and innovative issues relating to all aspects of modern stroke management and prevention.

The first session opened with a paper by Martin Björck (Uppsala, Sweden) on the merits of screening for carotid disease (the audience voted 57% vs. 43% against him), before focusing on innovative imaging strategies for identifying the high-risk carotid plaque (Clark Zeebregts, Groningen, Netherlands) and for triaging acute stroke patients (Tudor Jovin, Pittsburgh, USA; Arnd Doerfler, Erlangen, Germany). Martin Brown (London, UK) provided an update on modern medical therapy, while Charles McCollum (Manchester, UK) gave an overview on the role of microembolisation in the pathophysiology of dementia. Jaap Kappelle (Utrecht, Netherlands) concluded with an overview of the VIST randomised trial (medical therapy versus stenting of symptomatic vertebral artery stenoses), which was unfortunately abandoned before completing recruitment. There was, however, no evidence that stenting improved outcomes in the patients that were analysed.

In the carotid interventions section, the main theme focused on the logistics and results associated with performing carotid artery stenting (CAS) or carotid endarterectomy (CEA) in the first few days after onset of symptoms (Trevor Cleveland, Sheffield, UK; Daniel Behme, Göttingen, Germany; Ian Loftus, London, UK), while Hans-Henning Eckstein (Munich, Germany) reported on the performance of CEA for progressing stroke. The audience voted 78% vs. 22% that CAS would never replace CEA in all carotid interventions. The audience

also voted 78% vs. 22% in “being happy” to perform CEA in patients on dual antiplatelet therapy after I showed that dual therapy reduced recurrent events prior to CEA, without increasing bleeding complications. Domenico Valenti (London, UK) concluded this section with a description of a hybrid bypass technique following failed CEA.

The third session opened with six papers related to the compelling evidence supporting a role for clot extraction and thrombolysis in the first few hours after stroke onset (Alexander Khalessi, San Diego, USA; Jaap Kappelle, Utrecht, Netherlands; Laurent Spelle, Paris, France; Annika Kowoll, Bochum, Germany and Kyriakos Lobotesis, Imperial College, London, UK), as well as data on how clot composition influences catheter-based treatment strategies (Tommy Andersson, Kortrijk, Belgium). The key issue, however, was how this kind of service can be delivered 24/7 to all patients and in a debate between Jos van den Berg (Lugano, Switzerland) and Andrew Clifton (London, UK), the audience favoured Van den Berg (69% vs. 31%) in that emergency mechano-thrombolysis should not only be performed by neurointerventionists.

The fourth session focused on neuroprotection during interventions involving the aortic arch. Arno Nierich (Zwolle, Netherlands) discussed how modified transoesophageal echocardiography could identify higher-risk patients for intra-operative embolisation, while Dittmar Böckler (Heidelberg, Germany) presented data on how a modified endovascular left subclavian artery implantation technique reduced cerebral embolisation. The session concluded with two papers by Alexandra Lansky (New Haven, USA) and Richard Gibbs (Imperial College, London, UK) on the role of temporarily placed embolic protection systems, which were deployed immediately prior to stent delivery into the aortic arch. The audience was clearly impressed with these devices, voting 81% to 19% that they were effective in preventing procedure-related stroke.

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CX Abstract and Poster Presentations

Over four days, nine abstract sessions covered vascular and endovascular domains including: thoracic aortic, abdominal aortic, peripheral arterial, imaging, acute

stroke, vascular access and venous with more than 200 abstracts and posters presented by senior and trainee clinicians from 31 countries.

Katariina Noronen (Helsinki, Finland) won the best Senior Clinician Abstract Prize and Dominic Howard (Oxford, UK) won in the trainee category.

The senior clinician and trainee clinician winners have been awarded £1,000 each and a diploma for best presentation on the basis of originality, potential clinical benefit, delivery of presentation and handling of a question and answer session. A great benefit for both CX Abstract Prize winners and Certificate of Merit winners is that they all get the opportunity to submit topics to become invited Faculty for next year’s Charing Cross Symposium.

2015 winners

Last year’s senior clinician abstract winner Murray Shames (Tampa, USA) and trainee clinician abstract winner Alan Karthikesalingam (London, UK) had the opportunity to present at CX 2016 in the Main Programme as invited Faculty members. Shames discussed how configuration affects parallel graft results during the Juxtarenal Challenges session. Karthikesalingam spoke against the motion in the Abdominal Aortic Great Debate “The threshold for intervention for abdominal aortic aneursysm should be settled by randomised controlled trials”.

Likewise, Certificate of Merit holders Previn Diwakar (London, UK) and Ruth Benson (Stoke-on-Trent, UK) presented in the Main Programme. At the Venous Challenges session, Diwakar discussed male pattern pelvic reflux. At the Thoracic Aortic Challenges session, Benson revised the neurological consequences of endovascular aortic aneurysm surgery in EVAR and TEVAR.

Ian Loftus and Richard Gibbs are co-chairmen of the CX Abstract Board. Other members include: Paul Hayes, Robert Hinchliffe, Colin Bicknell, Daryl Baker, Rachel Bell, Marcus Brooks, Meryl Davis and Simon Ashley.

CX Abstract Sessions – Certificates of MeritSenior CliniciansPhilipp Geisbuesch, Heidelberg, Germany – “Accuracy of fusion imaging to guide endovascular aortic repair”

Thomas Zeller, Bad Krozingen, Germany – “Early results for a novel drug-coated balloon catheter for the treatment of femoropopliteal lesions”

Yiu Che Chan, Hong Kong – “Up to one-year results on the use of endovenous cyanoacrylate for great saphenous vein incompetence”

Johan Christof Ragg, Berlin, Germany – “Percutaneous valvuloplasty – a new way to vein restoration”

Christopher Lattimer, Imperial College, London, UK – “Haemodynamic impact of stenting on symptomatic iliac venous lesions”

Trainee CliniciansHector de Beaufort, San Donato Milanese, Italy – “Aortic stiffness increases after thoracic endovascular aortic repair in an ex-vivo porcine model”

Daniel Urriza Rodriguez, Southampton, UK – “Impact of reconfiguration on emergency abdominal aortic aneurysms management and outcomes across a vascular network”

David Saunders, Leeds, UK – “Assessment of the utility of a vascular early warning system in the assessment of peripheral arterial disease in patients with diabetes and incompressible vessels”

Pasha Normahani, Imperial College, London, UK – “Wearable sensor technology efficacy in peripheral vascular disease (wSTEP): a randomised clinical trial”

Tesse Leunissen, Utrecht, Netherlands – “Validation of transcranial Doppler-automated embolic detection software in patients undergoing carotid endarterectomy”

Muholan Kanapathy, London, UK – “Connexin expression in venous disease progression: a biomarker for venous ulceration”

CX Abstract Prize winners

Senior Clinician Abstract Prize Katariina Noronen (Helsinki, Finland)

In the study “Delay designates disaster in the treatment of diabetic foot ulcers”, Noronen and colleagues found that diagnostics of diabetic foot with suspected ischaemia need to be organised rapidly to ensure revascularisation without delay. According to their findings, revascularisation should be performed “within two weeks of the first evaluation”.

Trainee Clinician Abstract Prize Dominic Howard (Oxford, UK)

In the paper, “A population-based study of incidence, risk factors, outcome and prognosis of ischaemic peripheral arterial events: implications for prevention” Howard and colleagues highlight that the clinical burden of peripheral arterial events is high in Oxfordshire, UK, and they note that “although the vast majority of patients with incident events have known vascular disease in other

territories and multiple risk factors, premorbid control is poor.”

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CX Vascular Access Course

In 2016, the Charing Cross Symposium launched the new CX Vascular Access Course; a three-day insight into the main challenges facing haemodialysis vascular access and the methods employed to overcome them. The course ran for three days and was made up

of a vascular access masterclass, a practical skills course with 21 skills stations—including ultrasound assessment, duplex surveillance and various arteriovenous fistula techniques—and an abstract presentation day, immersing delegates in the most important issues and innovation in haemodialysis vascular access medicine.

This year, the CX Vascular Access Course took a new direction with a masterclass session on the controversial topic of steal in vascular access held on the first day of the course. This brought together world experts and pioneers in the field to cover the whole area in a complete session. In doing so, the topic was covered in depth and evidence reviewed to a level not previously attempted at a conference. The format was a great success with a consensus statement being generated. The masterclass format will be planned again for next year’s CX Vascular Access Course.

This was followed by an update on innovations and devices allowing delegates an up-to-date review of the available and future technologies in the field. To finish off the day, interactive case discussions of speakers’ own cases were presented in a multidisciplinary format with lots of opinions being generated.

The second day was a walkabout workshop (CX Vascular Access Skills Course) with one-to-one hands-on experience in all things access. Delegates were able to train with experts in ultrasound assessment, surgical techniques and new devices and were also able to chat through issues with the international Faculty in a more relaxed environment.

The third day was back in the delightful Pillar Hall where the scientific session had speakers from around the world presenting some cutting edge-data from varied research areas at the CX Vascular Access Abstract Presentations session.

The format of the course allowed delegates to experience vascular access education, hear about innovation and discuss controversies. Everyone went away knowing more than when they arrived and as such this year’s CX Vascular Access Course was a great success.

Nicholas InstonQueen Elizabeth Hospital, Birmingham, UK

Domenico ValentiKing’s College London, London, UK

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CX Innovation Showcase

The CX Innovation Showcase, described by chair Stephen Greenhalgh as “action packed”, featured presentations on next-generation devices for thoracic aneurysms, abdominal aneurysms, and peripheral arterial disease.

During a session dedicated to new approaches to managing thoracic aortic pathologies, Mårten Falkenberg (Gothenberg, Sweden) discussed the off-label use of the Amplatzer vascular plug (St Jude Medical) to seal small chronic dissection entries in the aortic arch. Pierre Galvagni Silveira (Florianópolis, Brazil) presented the results of a study that evaluated the use of a thoracoabdominal branched endoprosthesis (Tambe, Gore) for the management of Crawford type III & IV and Safi type V thoracoabdominal aneurysms and abdominal aneurysms that are involved in the renal arteries.

Speaking at the abdominal aortic session, Benjamin Starnes (Seattle, USA) described the first-in-man use of patient-specific, 3D-printed aortic templates with a novel fenestration-alignment software (AortaFit, Aortica Corporation) to optimise the modification of endografts for fenestrated endovascular aneurysm repair (FEVAR) procedures. Starnes commented that, at present, the software had only been used to create templates for physician-modified endografts “but ultimately, it is intended for use in the direct manufacture of patient-specific endografts”. Blandine Maurel (London, UK) presented data for novel software that could be used to optimise treatment for aortic aneurysms.

In the peripheral session, Jean-Paul de Vries (Nieuwegein, Netherlands) reported outcomes for the use of endovascular aneurysm sealing (EVAS; Nellix, Endologix) for the management of common iliac artery aneurysms.

At the “Dragons’ Den” session in which physician-inventors competed to win a £1,000 prize for the most innovative device, Mark Vrancken Peeters (Nijmegen, Netherlands) won the 2016 competition for his Switch suturing device, which can be held in one hand. Vrancken said that the device enables surgeons to be more precise and faster.

According to chair Stephen Greenhalgh, the CX Innovation Showcase provided a “glimpse into the future” regarding emerging technologies that address current unmet therapeutic needs.

CX Imaging Day

The CX Imaging Day offered delegates a comprehensive programme of state-of-the-art imaging technology, incorporating both scientific presentations and product demonstrations. Kicking off the day was a session on peripheral arterial imaging, followed by talks on venous imaging, aortic imaging, and an abstract presentation session.

An afternoon of practical demonstrations from Siemens, Phillips Volcano, Hansen, Ziehm, and GE Healthcare allowed delegates to get hands-on experience with state-of-the-art imaging technology.

Eric Verhoeven (Nuremberg, Germany), who demonstrated Siemens’ automated workflow imaging solution for EVAR procedures, commended the year-on-year improvement in the CX Imaging Day, saying, “It is very enjoyable. My overall impression is a very good one.” Stéphan Haulon (Lille, France), presenting GE Healthcare’s imaging technology, commented, “This set-up allows us to share that with the CX participants which is very interesting because it is not just about showing slides.” Stefanie Antonis-Klerks, who demonstrated the Philips Volcano system, said, “For us it is very important to have our system here, to demonstrate it and show what it can do.” Alan Lumsden (Houston, USA), presenting on behalf of Hansen, asserted, “We are proceduralists; we want to do things with our hands.” Complementing his experiences at CX, he said, “What has been important about this meeting over the years has been its emphasis on imaging. In the past, imaging was done in a radiology department. Now you look around here and see hybrid rooms and fixed imaging systems. There is a huge need for education in the surgical community about imaging capabilities.”

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From left to right: Dragons Bob Mitchell (Endologix), Daveen Chopra (Medtronic) and Chas Taylor (medical device entrepreneur),

with the winner of Dragons’ Den 2016 Mark Vrancken Peeters, course director Stephen Greenhalgh and dragon Jason Field (Gore)

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CX Meets Latin America

This year’s symposium featured the highly popular “CX Meets Latin America” session, now in its fourth year. This session highlights the vascular and endovascular techniques currently being used in Latin America, giving delegates the chance to discover how such procedures are performed in different populations.

Speakers from across Latin America presented talks on topics including thoracic outlet syndrome and challenging aortic arches. Alberto Muñoz (Bogotá, Colombia) discussed the importance of recognising differences in treatments and diagnosis across the world, noting, for example, that “in Bogotá, we diagnose much less neurogenic thoracic outlet syndrome, than the 95% reported in the world literature.” Marco Laurenço (Curitiba, Brazil) went on to describe the adapted thoracic endovascular aortic repair techniques used in his practice for challenging aortic arches.

As well as covering novel local techniques, the CX Meets Latin America session discussed issues surrounding peripheral arterial disease. Talks from Argentina and Brazil covered the use of prostanoids in critical limb ischaemia, endoluminal popliteal bypass, and finally a presentation arguing that long femoropopliteal occlusive disease can be best treated by a covered stent.

CX Paediatric Vascular IssuesThis year’s CX Paediatric Vascular Issues session tackled some of the specific implications for vascular surgery on paediatric patients, giving attendees the chance to learn about such diverse areas as paediatric imaging challenges and ischaemic limb in neonates.

The session was dominated by a discussion of the challenges presented by the different vascular pathologies of children and adults. Speakers and audience members raised the need for not only training in paediatric surgery for vascular surgeons, but for greater integration between the disciplines of plastic, paediatric and vascular surgery. Course director Malcolm Simms (Birmingham, UK), said, “There is certainly an important role for collaboration, because none of us have the full range of skills and experience…we need to pool our resources.”

The CX Paediatric Vascular Issues session also discussed acute ischaemia, chronic ischaemia, arterial pathologies and venous pathologies and malformations in children.

CX Vascular Malformations

This years’ Vascular Malformations course provided education focusing on diagnostic imaging, venous malformations, Klippel-Trenauney syndrome, arteriovenous malformations, and the treatment of congenital vascular malformations in children.

A highlight of the course was a lesson in how to handle localised intravascular coagulopathy in venous malformations, from course director Iris Baumgartner (Bern, Switzerland). Taking attendees through a detailed management algorithm for the diagnosis and treatment of coagulation disorders in venous malformation, she highlighted the importance of understanding this area.

European Vascular Surgeons in Training

The European Vascular Surgeons in Training (EVST) featured the research of selected vascular surgeons and interventionalists in training who presented their work at the session “Stars of the Future” held at CX. EVST awarded three trainees for their outstanding effort as well as contributions to the field of vascular and endovascular surgery. The winners at this year’s event were: Niels Vos (Alkmaar, Netherlands) for his paper “Outcome of surgical treatment for thoracic outlet syndrome: systematic review and meta-analysis”; Andreia Coelho (Espinho, Portugal) who presented on “Acute mesenteric ischaemia – still high mortality disease?” and Sarah Lesche (Schönebeck, Germany) for her research on “Migration of coils to the pulmonary artery after coiling of supposed left ovarian vein for pelvic congestion syndrome”.

On behalf of the EVST council, course director Hubert Stepak (Poznan, Poland) said: “We would like to thank the trainees and seniors who took time to present their work at the ‘Stars of the future’ session. EVST is committed to remaining a dynamic society that inspires future vascular and endovascular surgeons, we look forward to creating more opportunities for you in the years ahead.”

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CX Digest 2016

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CX through the lens

2016 CX Digest

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CX through the lens

CX Digest 2016

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In 2016, Charing Cross had 4,311 participants at Olympia Grand in London, UK.Charing Cross represents a truly multidisciplinary approach to the management of vascular disease.While vascular and endovascular surgeons remain the largest group attending the Symposium, there is significant representation from interventionalists and other cardiovascular specialists, both among the Faculty and the audience.

2016 Statistics

20 40 60 80 100







Prices 2015

Prices 2016

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Fair

Excellent/Good

1000

2000

3000

4000

5000

CX

2016

CX

2015

CX

2014

CX

2013

CX

2012

CX

2011

CX

2010

CX

2009

CX

2008

CX

2007

CX

2006

CX

2005

CX

2004

CX

2003

CX

2002

CX

2001

0 200 400 600 800 1000

Other

India

Hungary

Thailand

Canada

Russia

Finland

Argentina

Singapore

Saudi Arabia

Czech Republic

Israel

Denmark

Greece

Norway

Japan

Austria

Australia

China

Portugal

Egypt

Sweden

Brazil

Poland

Ireland

Turkey

Belgium

Switzerland

Spain

Netherlands

France

Italy

United States

Germany

United Kingdom

5% Other clinicians





4% Asia

5% Middle East

8% Eastern Europe

10% North America

69% Western Europe

1% Australasia

3% South America

4% Fair

45% Good

51% Excellent

0% Poor

3% Fair

46% Good

50% Excellent

1% Poor

20 40 60 80 100







Prices 2015

Prices 2016

Poor

Fair

Excellent/Good

1000

2000

3000

4000

5000

CX

2016

CX

2015

CX

2014

CX

2013

CX

2012

CX

2011

CX

2010

CX

2009

CX

2008

CX

2007

CX

2006

CX

2005

CX

2004

CX

2003

CX

2002

CX

2001

0 200 400 600 800 1000

Other

India

Hungary

Thailand

Canada

Russia

Finland

Argentina

Singapore

Saudi Arabia

Czech Republic

Israel

Denmark

Greece

Norway

Japan

Austria

Australia

China

Portugal

Egypt

Sweden

Brazil

Poland

Ireland

Turkey

Belgium

Switzerland

Spain

Netherlands

France

Italy

United States

Germany

United Kingdom

5% Other clinicians





4% Asia

5% Middle East

8% Eastern Europe

10% North America

69% Western Europe

1% Australasia

3% South America

4% Fair

45% Good

51% Excellent

0% Poor

3% Fair

46% Good

50% Excellent

1% Poor

2016 CX Digest

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Charing Cross benefited from participation from nearly 80 countries. While Western Europe contributed the largest number of vascular specialists, the trend towards strong attendance from the rest of the world continued.

20 40 60 80 100







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Excellent/Good

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2015

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CX

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CX

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2002

CX

2001

0 200 400 600 800 1000

Other

India

Hungary

Thailand

Canada

Russia

Finland

Argentina

Singapore

Saudi Arabia

Czech Republic

Israel

Denmark

Greece

Norway

Japan

Austria

Australia

China

Portugal

Egypt

Sweden

Brazil

Poland

Ireland

Turkey

Belgium

Switzerland

Spain

Netherlands

France

Italy

United States

Germany

United Kingdom

5% Other clinicians





4% Asia

5% Middle East

8% Eastern Europe

10% North America

69% Western Europe

1% Australasia

3% South America

4% Fair

45% Good

51% Excellent

0% Poor

3% Fair

46% Good

50% Excellent

1% Poor

20 40 60 80 100







Prices 2015

Prices 2016

Poor

Fair

Excellent/Good

1000

2000

3000

4000

5000

CX

2016

CX

2015

CX

2014

CX

2013

CX

2012

CX

2011

CX

2010

CX

2009

CX

2008

CX

2007

CX

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CX

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CX

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CX

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CX

2002

CX

2001

0 200 400 600 800 1000

Other

India

Hungary

Thailand

Canada

Russia

Finland

Argentina

Singapore

Saudi Arabia

Czech Republic

Israel

Denmark

Greece

Norway

Japan

Austria

Australia

China

Portugal

Egypt

Sweden

Brazil

Poland

Ireland

Turkey

Belgium

Switzerland

Spain

Netherlands

France

Italy

United States

Germany

United Kingdom

5% Other clinicians





4% Asia

5% Middle East

8% Eastern Europe

10% North America

69% Western Europe

1% Australasia

3% South America

4% Fair

45% Good

51% Excellent

0% Poor

3% Fair

46% Good

50% Excellent

1% Poor

CX Digest 2016

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The Charing Cross Symposium would like to thank all the Pavilion Sponsors and Major Sponsors.

Pavilion Sponsors Major Sponsors

2016 CX Digest

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CX 2016 Faculty

Anders Albäck, Helsinki, FinlandTommy Andersson, Kortrijk, BelgiumGary Ansel, Columbus, United StatesMichele Antonello, Padua, ItalyFrank Arko, Charlotte, United StatesCarsten Arnoldussen, Maastricht, NetherlandsSimon Ashley, Plymouth, UKAli Azizzadeh, Houston, United StatesDomenico Baccellieri, Milan, ItalyDaryll Baker, London, UKRon Balm, Amsterdam, NetherlandsGareth Bate, Solihull, UKIris Baumgartner, Bern, SwitzerlandJonathan Beard, Sheffield, UKDavid Beckett, Guildford, UKJean-Pierre Becquemin, Créteil, FranceDaniel Behme, Göttingen, GermanyRachel Bell, London, UKRuth Benson, Stoke-on-Trent, UKXavier Berard, Bordeaux, FranceSerge Bernasconi, Brussels, BelgiumGiancarlo Biamino, Mercogliano, ItalyColin Bicknell, Imperial College, London, UKTheodosios Bisdas, Münster, GermanyMartin Björck, Uppsala, SwedenStephen Black, London, UKJan Blankensteijn, Amsterdam, NetherlandsErwin Blessing, Heidelberg, GermanyDittmar Böckler, Heidelberg, GermanyAndrew Boulton, Manchester, UKPierre Bourquelot, Paris, FranceMatthew Bown, Leicester, UKKursat Bozkurt, Istanbul, TurkeyAndrew Bradbury, Birmingham, UKKaren Breen, London, UKMarianne Brodmann, Graz, AustriaJoe Brookes, London, UKMarcus Brooks, Westbury-on-Trim, UKMartin Brown, London, UKBao Bui, Sherbrooke, CanadaMiroslav Bulvas, Prague, Czech RepublicNick Burfitt, Imperial College, London, UKFrancis Calder, London, UKPiergiorgio Cao, Rome, ItalyDan Carradice, Hull, UKEddie Chaloner, London, UKHarvey Chant, Truro, UKSylvain Chastanet, Nice, FranceEric Chemla, London, UKIan Chetter, Hull, UKRoberto Chiesa, Milan, ItalyShakila Chowdhury, London, UKTrevor Cleveland, Sheffield, UKAndrew Clifton, London, UKJoannis Constantinides, London, UKFrank Criado, Baltimore, United StatesLizzie Curry, Stoke-on-Trent, UKMartin Czerny, Freiburg, GermanyMichael Dake, Stanford, United StatesKaty Darvall, Taunton, UKSaroj Das, Imperial College, London, UKIngemar Davidson, Dallas, United StatesAlun Davies, Imperial College, London, UKHuw Davies, Birmingham, UKMeryl Davis, London, UKPeter Dawson, Imperial College, London, UKRick de Graaf, Maastricht, NetherlandsJean-Paul de Vries, Nieuwegein, NetherlandsColin Deane, London, UK

Sebastian Debus, Hamburg, GermanyFatima Defigueiredo, London, UKKoen Deloose, Dendermonde, BelgiumBrahman Dharmarajah, Imperial College, London, UKLuca di Marzo, Rome, ItalyPrevin Diwakar, London, UKArnd Doerfler, Erlangen, GermanyKonstantinos Donas, Münster, GermanyEric Ducasse, Bordeaux, FranceStephan Duda, Berlin, GermanyMatthew Eagleton, Cleveland, United StatesJonothan Earnshaw, Gloucester, UKHans-Henning Eckstein, Munich, GermanyMichael Edmonds, London, UKAlan Edwards, Ruthin, UKKarim El Sakka, Brighton, UKSteve Elias, Englewood, United StatesMary Ellis, Imperial College, London, UKDavid Epstein, York, UKIgnacio Escotto Sanchez, Mexico City, MexicoMarten Falkenberg, Gothenburg, SwedenFabrizio Fanelli, Rome, ItalyAlik Farber, Boston, United StatesJorge Fernandez Noya, Santiago de Com-postela, SpainColin Forman, London, UKClaude Franceschi, Paris, FranceIan Franklin, Imperial College, London, UKBen Freedman, London, UKGregory Fulton, Wilton, IrelandMartin Funovics, Vienna, AustriaLuiz Furuya, São Paulo, BrazilDennis Gable, Dallas, United StatesPaul Gagne, Darien, United StatesPeter Gaines, Sheffield, UKPierre Galvagni Silveira, Florianópolis, BrazilRaghvinder Gambhir, London, UKRoberto Gandini, Rome, ItalyMargaret Gardner, Ashtead, UKGuillermo Javier Garelli, Cordoba, ArgentinaMauro Gargiulo, Bologna, ItalyPaul Gibbs, Portsmouth, UKRichard Gibbs, Imperial College, London, UKKathleen Gibson, Bellevue, United StatesJames Gilbert, Oxford, UKPanos Gkoutzios, London, UKManj Gohel, Cambridge, UKYann Goueffic, Nantes, FrancePeter Goverde, Antwerp, BelgiumJuan Granada, Orangeburg, United StatesWilliam Gray, Wynnewood, United StatesRoger Greenhalgh, Imperial College, London, UKStephen Greenhalgh, London, UKDavid Greenstein, London, UKFranco Grego, Padua, ItalyAina Greig, London, UKRichard Grieve, London, UKGerd Groezinger, Tübingen, GermanyJulian Hague, London, UKMo Hamady, Imperial College, London, UKGeorge Hamilton, London, UKHosny Hamza, Gillingham, UKStéphan Haulon, Lille, FrancePaul Hayes, Cambridge, UKThomas Heller, Rostock, GermanyRobert Hinchliffe, London, UKJonny Hisdal, Oslo, NorwayAndrew Holden, Auckland, New Zealand

Judith Holdstock, Guildford, UKPeter Holt, London, UKDean Huang, London, UKRajesh Hydrabadi, Ahmedabad, IndiaNicholas Inston, Birmingham, UKFatih Islamoglu, Izmir, TurkeyDonald Jacobs, St Louis, United StatesMichael Jacobs, Maastricht, NetherlandsMichael Jaff, Boston, United StatesUsman Jaffer, Imperial College, London, UKWilliam Jeffcoate, Nottingham, UKWilliam Jordan, Atlanta, United StatesTudor Jovin, Pittsburgh, United StatesLowell Kabnick, New York, United StatesEvi Kalodiki, Imperial College, London, UKJaap Kappelle, Utrecht, NetherlandsAlan Karthikesalingam, London, UKNarayan Karunanithy, Imperial College, London, UKKonstantinos Katsanos, London, UKBarry Katzen, Miami, United StatesVenu Kavarthapu, London, UKRichard Kellersmann, Wurzburg, GermanyPatrick Kelly, Sioux Falls, United StatesAlexander Khalessi, San Diego, United StatesDavid King, London, UKDavid Kingsmore, Glasgow, UKCuneyt Koksoy, Ankara, TurkeyTilo Kölbel, Hamburg, GermanyRaghu Kolluri, Columbus, United StatesRalf Kolvenbach, Düsseldorf, GermanyAnnika Kowoll, Bochum, GermanyDainis Krievins, Riga, LatviaRombout Kruse, Zwolle, NetherlandsConstantinos Kyriakides, London, UKTristan Lane, Imperial College, London, UKAlexandra Lansky, New Haven, United StatesThomas Larzon, Orebro, SwedenChristopher Lattimer, Imperial College, London, UKFrank Lederle, Minneapolis, United StatesMichael Lichtenberg, Arnsberg, GermanyPatrick Lintott, High Wycombe, UKKyriakos Lobotesis, Imperial College, London, UKDavid Lockie, Brighton, UKIan Loftus, London, UKLars Lönn, Copenhagen, DenmarkAnthony Lopez, London, UKMarco Lourenco, Curitiba, BrazilLeonardo Lucas, Rio de Janeiro, BrazilMarzia Lugli, Modena, ItalyAlan B Lumsden, Houston, United StatesOliver Lyons, London, UKAnil Madhavan, Gillingham, UKMichel Makaroun, Pittsburgh, United StatesGeert Maleux, Leuven, BelgiumKevin Mani, Uppsala, SwedenTara Mastracci, London, UKBlandine Maurel, London, UKKieran McBride, Kirkcaldy, UKCharles McCollum, Manchester, UKAndrew McIrvine, London, UKDavid McLain, Llantarnam, UKClare McLaren, London, UKRichard McWilliams, Liverpool, UKGuilherme Meirelles, Córdoba, ArgentinaGaspar Mestres, Barcelona, SpainMatthew Metcalfe, Stevenage, UKAntonio Micari, Palermo, Italy

Nicola Milburn, London, UKHiren Mistry, London, UKKasuo Miyake, São Paulo, BrazilFrans Moll, Utrecht, NetherlandsHayley Moore, Imperial College, London, UKJose Pablo Morales, Silver Spring, United StatesRobert Morgan, London, UKPeter Mortimer, London, UKNilo Mosquera, Ourense, SpainPeter Mossop, Melbourne, AustraliaAlberto Muñoz, Bogotá, ColombiaPiotr Musialek, Krakow, PolandSriram Narayanan, SingaporeTulio Navarro, Belo Horizonte, BrazilRoss Naylor, Leicester, UKArno Nierich, Zwolle, NetherlandsIsaac Nyamekye, Worcester, UKGerard O’Sullivan, Galway, IrelandJuling Ong, London, UKKlaus Overbeck, Sunderland, UKLuis Mariano Palena, Abano Terme, ItalyHonorio Palma, São Paulo, BrazilGustavo Paludetto, Brasilia, BrazilVikas Pandey, Imperial College, London, UKRaj Patel, Imperial College, London, UKKristine Paule, London, UKPaul Pittaluga, Nice, FranceJanet Powell, Imperial College, London, UKGiovanni Pratesi, Rome, ItalyBarrie Price, Guildford, UKThomas Proebstle, Mainz, GermanyRaffaele Pulli, Florence, ItalyEnrique Puras Mallagray, Madrid, SpainNadeem Qazi, Imperial College, London, UKAnnette Quinn, London, UKSamina Qureshi, Imperial College, London, UKJohann Christof Ragg, Berlin, GermanyKazem Rahimi, Oxford, UKDheeraj Rajan, Toronto, CanadaVentakesh Ramaiah, Phoenix, United StatesHema Rao, Imperial College, London, UKHisham Rashid, London, UKAlvaro Razuk, São Paulo, BrazilUlf Redlich, Magdeburg, GermanyJim Reekers, Amsterdam, NetherlandsMichel Reijnen, Arnhem, NetherlandsSophie Renton, Harrow, UKTimothy Resch, Malmö, SwedenRobert Rhee, New York, United StatesVincent Riambau, Barcelona, SpainCelia Riga, Imperial College, London, UKPeter Riley, Birmingham, UKAlex Rodway, Redhill, UKDerek Roebuck, London, UKFiona Rohlffs, Hamburg, GermanyHervé Rousseau, Toulouse, FrancePrakash Saha, London, UKBertrand Saint-Lebes, Toulouse, FranceAndreas Saleh, Munich, GermanyWilhelm Sandmann, Duisburg, GermanyDaniele Savio, Turin, ItalyHarry R Schanzer, New York, United StatesDierk Scheinert, Leipzig, GermanyCarl Henrik Schelp, Bergen, NorwayAndrej Schmidt, Leipzig, GermanyThomas Schmitz-Rixen, Frankfurt, GermanyPeter Schneider, Honolulu, United StatesArne Schwindt, Münster, GermanyJohn Scurr, London, UK

Ferdinand Serracino-Inglott, Manchester, UKEva Sevick, Houston, United StatesJoseph Shalhoub, Imperial College, London, UKMurray Shames, Tampa, United StatesCliff Shearman, Southampton, UKAmanda Shepherd, Imperial College, London, UKDavid Sidloff, Leicester, UKMalcolm Simms, Birmingham, UKRavi Singh Ranger, Cirencester, UKJonathan Sobocinski, Lille, FranceKate Sommerville, London, UKLaurent Spelle, Paris, FranceGerry Stansby, Newcastle-upon-Tyne, UKBenjamin Starnes, Seattle, United StatesKate Steiner, Stevenage, UKMichael Sweeting, Cambridge, UKAttila Szabo, Budapest, HungaryNigel Tai, London, UKUlf Teichgraeber, Jena, GermanyGunnar Tepe, Rosenheim, GermanyFabien Thaveau, Strasbourg, FranceRobert Thomas, Imperial College, London, UKJohn Thompson, Exeter, UKMatt Thompson, London, UKGiovanni Torsello, Münster, GermanyMatteo Tozzi, Varese, ItalySanti Trimarchi, San Donato Milanese, ItalyStephen Tristram, Basingstoke, UKNicola Troisi, Florence, ItalyRami Tzafriri, Lexington, United StatesJean-Francois Uhl, Paris, FrancePinar Ulug, Imperial College, London, UKDomenico Valenti, London, UKJeff van Baal, Almelo, NetherlandsJos van den Berg, Lugano, SwitzerlandLeo van den Ham, Arnhem, NetherlandsRamon Varcoe, Sydney, AustraliaMaarit Venermo, Helsinki, FinlandHence Verhagen, Rotterdam, NetherlandsEric Verhoeven, Nuremberg, GermanyRenu Virmani, Gaithersburg, United StatesTom Wallace, Hull, UKJeffrey Y Wang, Rockville, United StatesAnders Wanhainen, Uppsala, SwedenThomas Weiler, Pforzheim, GermanyRodney White, Torrance, United StatesMark Whiteley, Guildford, UKMatthias Widmer, Bern, SwitzerlandAndrew Wigham, Maidenhead, UKJason Wilkins, London, UKAngela Williams, London, UKKatherine Williams, Imperial College, London, UKWalter Wohlgemuth, Regensburg, GermanyDennis Wolf, London, UKKenneth Woodburn, Truro, UKThomas Wyss, Bern, SwitzerlandPatricio Zaefferer, Buenos Aires, ArgentinaJürgen Zanow, Jena, GermanyClark Zeebregts, Groningen, NetherlandsThomas Zeller, Bad Krozingen, Germany

Industry speakersDaveen Chopra, Santa Rosa, United StatesJason Field, Flagstaff, United StatesBob Mitchell, Hertogenbosch, NetherlandsRichard Rapoza, Santa Clara, United StatesChas Taylor, Horsham, UK

Consensus UpdateVascular & Endovascular

25–28 APRIL 2017OLYMPIA GRAND • LONDON • UNITED KINGDOM

See you next year for moreEDUCATION • INNOVATION • EVIDENCE

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