The 2014 China meeting of the International Society for Vascular Surgery

Keynote addresses

The first scientific session consisted of keynote addresses and was a concurrent session of all the four meetings. The opening address was given by Christos Liapis, ISVS President, who addressed the best modern approach to carotid disease. Carotid disease is increasing in China, and the discussion of optimal stroke prevention was timely. Key discussion points included the need to identify the population of patients at high risk for stroke to allow for targeted intervention, discussion of the need to improve methods to identify the vulnerable plaque, the need to include biomarkers in future randomized trials, as well as the ever-increasing need to improve technology specifically targeting carotid interventions.

Next Professor Wang Zhong-Gao discussed his experience with treating inferior vena caval occlusion due to hepato-caval syndrome, typically known as Budd-Chiari syndrome. Some of the shunts that Professor Wang introduced included the mesocaval shunt, portacaval shunt, and other more unusual shunts such as the cavo-atrial, meso-atrial, meso-jugular, and capito medusa-jugular shunts. These shunts routinely achieved >20 year patency rates and frequently were performed in children and young adults. These spectacular cases essentially eliminated ascites due to Budd-Chiari syndrome in many parts of China and changed this incurable disease to curable.

The last keynote address was given by Professor Wang Shen-Ming, President of the First Affiliated Hospital of Sun Yat-sen University and Chairman of the Chinese Society of Vascular Surgery. Professor Wang discussed the development and current status of Vascular Surgery in China; although the history of Vascular Surgery in China is long, only recently has it expanded. Aortic dissection is a disease of primary focus, with over 3500 cases treated yearly. Experience with 5294 cases of chronic type B dissection showed a younger and male-predominant population compared to Western series, and endovascular treatment is the overwhelming therapeutic option chosen. Vascular surgeons treat 54% of cases, with cardiovascular surgeons treating 17% and cardiologists treating 11% of cases. Fenestrated and branched devices are becoming common, and chimneys have been used since they were introduced to China in 2010. Recent mortality is 3.2%, and complications are 8% based on a review of 67 published reports. Of note, there are no randomized trials reported in the Chinese literature, and follow-up imaging is not standardized. To achieve a better understanding of aortic remodeling and improved results, improved and standardized follow-up should be achieved. Endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) was also discussed, being first introduced to China in 1998 by Professor Wang Zhong-Gao. Chimneys for short necks, fenestrated devices for juxtarenal aneurysms, four-branched stents, multiple bare stents, and laparoscopic approaches are all becoming commonplace in China. Long-term AAA-related mortality is approximately 0.6%, and reintervention rates approach 3%, lower than many Western series. Use of EVAR for ruptured aneurysms is performed by Chinese vascular surgeons, but neither widely published in a systematic fashion nor well-known outside China.

Plenary sessions

Four plenary sessions were given during the meeting by faculty representing China (10), the United States (7), Greece (1), Hong Kong (1), Italy (1), Brazil (1), and Ireland (1). The first plenary session concentrated on peripheral arterial disease (PAD). The first two presentations were themed as a debate, with Alik Farber presenting the position that critical limb ischemia (CLI) is best treated with endovascular therapy, and Matt Menard arguing that CLI is best treated with surgical bypass. Dr Farber presented the benefits of minimally invasive therapy and recent results showing that endovascular therapy is now demonstrating similar patency as open procedures and in some cases even exceeds the traditional open patency rates. Dr Menard questioned the durability of endovascular therapy, especially since patients with CLI typically have disease patterns that favor surgical therapy. Since Drs. Farber and Mendard are the co-principal investigators of the recently approved and funded BEST-CLI trial, the call for a randomized trial can actually be answered. Audience questions included whether Chinese sites could participate in the trial, although this is not yet set up. Dr Wang Jin-Song discussed the treatment of popliteal artery aneurysms and lamented the lack of standard indications for endovascular therapy given the low incidence of this condition. Dr BB Lee discussed the contemporary management of arterialvenous malformations, emphasizing that accurate diagnosis, including embryological characterization, is critical to treat these life- and limb-threatening lesions.

The second plenary session focused on aortic dissection, a particularly important clinical entity in China. Dr Santi Trimarchi discussed the current management of acute and chronic dissection, stressing the importance of the acute, subacute, and chronic presentations, as well as the development of complications, on the management of dissection. In particular, the current controversy in determining a group of patients that would obtain maximal benefit from thoracic endovascular aneurysm repair (TEVAR) was discussed. The importance of documenting long-term aortic remodeling after treatment with newer branched and fenestrated devices was stressed, as well as the importance of open surgery for younger patients with connective tissue disorders. Professor Shu Chang discussed his experience with the management of patients with complicated aortic dissection, presenting 958 cases over 12 years that were treated with 1.3% mortality and 3% complications. Complications of dissection were generally hemothorax, distal malperfusion, and retrograde dissection, all of which can be treated with TEVAR. Other lessons learned included the ability to sacrifice the celiac artery, the adjunctive use of bare stents, and the importance of medical management, such as cerebrospinal fluid (CSF) drainage, stress steroids, and blood pressure control, during emergent cases. Dr Jing Zai-Ping discussed his experience extending the use of TEVAR to the arch and ascending aorta with TEVAR. Some of the important tips presented included straightening tortuous anatomy with wires, adding distal bare stents to prevent recurrence of dissection, and using new devices that include fenestrations, scallops, and branches. Plans to treat the aortic valve are a natural extension of these procedures. Dr Xin Shi-Jie concluded the session discussing his single-center experience treating dissection with 114 TEVAR performed in four years. Discussion included the ability to cover the left subclavian artery without need for revascularization in the majority of cases as well as the importance of TEVAR in uncomplicated acute dissection to prevent late (>five years) mortality that is associated with medical therapy.

The third plenary session continued the aortic theme. Professor Tulio Navarro discussed his recent experience with treatment of zone 0 aortic disease, expanding the proximal seal zone during TEVAR. Treatment of zone 0 was the evolution of experience moving from zone 2 to zone 1, using customized devices, chimneys, and hybrid procedures to treat more difficult anatomy. The lesson is that zone 0 is reachable, and future experience with branched and/or fenestrated devices may avoid the need for chimneys in this area. Dr Mark Eskandari discussed a unique series of late TEVAR failures, including failures due to endoleak, stent fracture, retrograde dissection, collapse, and infection. Dr Eskandari stressed that the occurrence of late endoleaks is important to detect; type I endoleaks occur secondary to size mismatch, late degeneration especially in short seal zones, and migration especially in angulated anatomy with short seal zones. Types II and III endoleaks also develop late and must be detected. Although delayed failures are unusual, most were able to be managed with endovascular techniques, except for failures due to infection or retrograde dissection that were generally managed with open techniques. Dr Guo Wie next compared the use of fenestrated and chimney techniques in the treatment of juxtarenal AAA based on his experience with 50 cases. He concluded that fenestrated EVAR is the ideal technique to use currently, with diminished endoleaks postoperatively, although it is associated with increased technical demands and costs; as such, chimney techniques are a good alternative technique in selected patients, being easier technically, but associated with even higher costs and postoperative endoleaks. Dr Stephen Cheng discussed his experience with fenestrated and branched devices to treat juxtarenal aneurysms, describing the evolution of devices over time and issues associated with these different generations. Major issues include renal preservation given the tendency for renal arteries to dissect, small access vessel size including small aortic bifurcations, and the presence of dissection with a small true lumen, all of which complicate the procedure further; the development of devices that are pre-loaded as well as liberal use of the brachial approach make the procedure much easier to perform. Current results of 5% mortality, 5% paraplegia, and 5% stroke are excellent. Finally Dr Fu Wei-Guo discussed the risk factors for paraplegia after TEVAR, which still occurs in 2–6% of cases. In his experience with 2100 TEVAR since 2000, risk factors include coverage of branches such as intercostals, spinal, iliac, pelvic, and subclavian vessels, >20 cm length of coverage, coexisting AAA or previous AAA repair, and intraoperative hypotension. The importance of knowing the anatomy, keeping the systolic blood pressure generally between 120 mmHg and 140 mmHg, the use of CSF drainage, and hypothermic protection, was discussed.

The final plenary session finished the theme of aortic disease and focused on PAD. Dr Wayne Zhang discussed the management of traumatic aortic injury, speaking from his experience with 41 patients over eight years. Some of the important points included treatment of all injuries greater than Grade II, or those that progress during observation; treatment of aortic injuries urgently, but allowing delay to treat other life-threatening associated injuries, reserving emergent treatment for aortic rupture. Technical issues include the proper sizing of the thoracic stent graft in a small aorta, the use of intravascular ultrasound to determine treatment areas as well as assessment of lower grade injuries, the ability to cover the subclavian artery, as well as the lack of needing routine CSF drainage. Dr Gu Yong-Quan discussed his experience with four randomized trials using mononuclear cells (MNC) to treat ischemic disease since 2003. These trials showed the importance of using a high cell number (>10⁸ cells) to achieve ulcer healing, the ability to use intra-muscular injections that have similar results as intra-arterial delivery, the ability to use peripherally-derived MNC that achieve the same results as bone marrow-derived cells, and the use of G-CSF to mobilize peripheral MNC, improving CD34 cell mobilization and improving ulcer healing. Stem cell therapy is now being focused on use in Buerger’s disease, which may be an ideal disease to treat with this therapy. Dr Alan Dardik discussed the significance of metabolic syndrome for the vascular patient. The importance of metabolic syndrome in China, in addition to Western countries, was emphasized, with recent data showing over 100 million Chinese people at risk for developing metabolic syndrome. Recent data shows, in addition to increased risk of stroke and myocardial infarction, diminished survival in patients with metabolic syndrome and end stage renal disease, a population of patients commonly treated by vascular surgeons. Patients with metabolic syndrome are at high risk of diminished secondary patency after arteriovenous fistula (AVF) creation, type II endoleak after EVAR, and restenosis after carotid endarterectomy (CEF). However, exercise and healthy diet may be ways to prevent these complications as they are associated with diminished incidence of metabolic syndrome. Finally Dr Sherif Sultan discussed the optimal medical management of the vascular patient, given the approximate 75% mortality due to cardiovascular disease in vascular patients. Some of the factors that should be considered include smoking cessation, assessment of pre-operative diastolic dysfunction and NT-proBNP as markers of peri-operative cardiac events, use of duplex to limit dye exposure and potential renal injury, treatment of hyper-homocysteinemia and elevated HbA1C, and use of endovascular procedures to obtain the metabolic benefits of minimally invasive therapy.

Career development session

A unique session in the meeting was the academic plenary session, focusing on career development of the surgeon. This session targeted the Chinese vascular surgeon with specific advice relevant to aspiring and junior surgeons. The lead speaker was Dr Ken Ouriel who discussed how to publish one’s work, including the point of view from the journal publisher; Dr Ouriel is currently the Editor in Chief of the journal Vascular. Dr Ouriel emphasized that original articles are frequently easier to publish compared to review articles and case reports. He also discussed the composition of papers that are interesting and published, including attention to appearance and style; following reviewers’ comments are critical. Dr Wayne Zhang discussed improving publications in English-language journals. This insightful talk discussed the importance of paper construction and was instructional even for native English speakers. Dr Wu Xiang-Wei presented strategy to get papers published. A critical point is to determine whether one will publish research as several lower quality papers or to consolidate work to present fewer high-quality papers; both strategies have importance for career development. Given the overall high rejection rate of papers from journals, generally over 90%, it is important to work on novel ideas that advance the field or challenge established paradigms. Dr Sherif Sultan presented his perspective on achieving success in Vascular Surgery, focusing on the importance of practice and hard work, rather than talent. Dr Sultan stresses the importance of publishing and collaboration, especially for translational research, over a multiple decade-long time frame. The last speaker of this session was Dr Alik Farber who used his experience with the recently funded BEST-CLI trial to describe some of the issues with getting a clinical trial started. He presented the importance of asking a question with clinical equipoise, having the passion and ambition to answer the question, having strong support from the professional community, organization, having preliminary data, and perseverance over the five-year process that the entire process takes from idea to funding. The consensus was that these sessions were extremely important not only to early career surgeons but also to the entire community, as the lessons are timeless throughout one’s career.

Abstract presentations

Thirty-one abstracts were accepted for presentation among the submitted abstracts, and these were presented in three separate sessions interspersed among the plenary sessions. Abstracts were presented from China (21), Ireland (3), Saudi Arabia (2), Poland (1), United Kingdom (1), Egypt (1), Israel (1), and Uzbekistan (1). The presentations were scored by the ISVS faculty and the top presentations (Table 1) were awarded prizes (Figure 1). All abstracts were presented orally as podium presentations, and the reception to these presentations was enthusiastic. Attendees commented on the excellent response to the presentations, with positive factors that included varied abstract themes and presentation styles, oral presentations to all the attendees rather than small groups, and the ability to have senior vascular surgeons comment on and discuss the presentations. Collaborations were formed that will hopefully stimulate future work. OPEN IN VIEWER

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Table 1.

ISVS 2014 China abstract competition winners.

Name	Country	Abstract title
Mohamed Elsharawi	Saudi Arabia	Reperfusion of delayed acute occlusive limb ischemia; is it worthwhile?
Wafaa Nour Elddin Elhadi	United Kingdom	Outcome of surgical revascularization of the lower limb
Jiang Jun-Hao	China	Loss of bifurcation patency after cross-over stenting of ostial lesions in superficial femoral artery
Li Zi-Lun	China	Initial and middle-term outcome of treatment for isolated dissection of superior mesenteric artery
Daniel Silverberg	Israel	Increased pressure gradients within an aortic arch endograft are associated with rapid development of in-stent stenosis in a porcine model
Edel Kavangh	Ireland	Endothelialisation processes and kinetics of stents
Wang Mian	China	Hybrid treatment of aortic arch disease with ascending aorta to carotid artery revascularization and subsequent endovascular repair
Li Dong-Lin	China	Management strategy for spontaneous isolated dissection of the superior mesenteric artery based on morphological classification
Abdel Motaal Waleed	Egypt	Klippel-Trenaunay syndrome (KTS)
Niamh Hynes	Ireland	Illness severity scoring systems and risk prediction in vascular intensive care admissions

Conclusions

The 2014 meeting of the ISVS was a great success. Partnership of this meeting with host Chinese Vascular Surgery societies was of mutual benefit, bringing vascular surgeons of international reputation to the local area for academic and intellectual exchange and formation of collaborations; integration of the meetings allows easier logistics to facilitate meeting organization and optimization of time for both faculty and attendees. This integrated model may serve as an optimal model for future meetings.