Theodosios Bisdas

Dr.
I studied medicine at the Aristotle University of Thessaloniki, Greece. I spent my residency in Cardiovascular Surgery at Hannover Medical School (Professor Haverich) and the University Clinic of Muenster (Professor Torsello). I completed my research fellowship in Vascular Surgery at the Dept. of Surgery, Mount Sinai School of Medicine (Professor Marin). In October 2014, I submitted my habilitation about the prevention and treatment of vascular graft infections at the University of Muenster and became Associate Professor of Vascular Surgery. In 2015, I received the Vascular Career Advancement Award from VIVA/LINC symposia. I served the European Society of Vascular Surgery as representative of all German vascular trainees and I was the Secretary-General of the Annual Meeting of the German Society of Vascular Surgery in September 2015. Today, I work as consultant for the aortic and peripheral endovascular programme at Franziskus Hospital Muenster. I am an active researcher and my topics of interest are the peripheral arterial disease and the complex aortic interventions. Finally, I am a certifed Endovascular Specialist and Phlebologist. Conflicts of interest: Consultancy for Medtronic, Boston Scientific, COOK Medical, Penumbra Advisory Board: Boston Scientific, BARD
  • Function: Senior Consultant
  • Speciality: Vascular Surgery
  • Country: DE
  • Working place: Athens Medical Center, Athens, GR

Activities

Live case

The GORE cTAG conformable thoracic stent-graft with ACTIVE CONTROL system for the endovascular repair of a challenging thoracic aortic aneurysm

This is a case of 63 yrs old female with a very challenging TAA (7.8 cm, massive elongation of the aorta, short proximal neck and type III aortic arch), who was treated endovascularly with the new cTAG endograft. The proximal landing zone was extended through a left carotid subclavian bypass up to the LCCA and the device showed an excellent conformability to this challenging anatomy. In this video, all the important steps of TEVAR as well as of cTAG implantation are illustrated.

April 5, 2020 4 Comments
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Recorded video case

Transaxillary TEVAR with an in situ fenestrated Endurant tube endograft for a ruptured thoracoabdominal aortic aneurysm

This patient was admitted at Athens Medical Center with a contained rupture of the thoracoabdominal aorta. The CT scan revealed complete occlusion of the infrarenal aorta with collateralisation of the profunda arteries at both sites through the SMA and the Riolan anastomosis. In his previous history, the patient was treated with an aortobifemoral bypass for Leriche syndrome (2008) with graft infection (2010) and replacement of the aorta with femoral veins (2010). We planned a transaxillary TEVAR (diameter of proximal left axillary artery: 6.5cm) and triple puncture of the right axillary artery.

March 17, 2020 1 Comment
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Technical note

Endovascular treatment of acute and chronic deep vein thrombosis and pulmonary embolism

Dr. Bisdas (Athens Medical Center) presents during the 12th Athens Crossroad Congress a short overview of current endovascular techniques for acute and chronic deep vein thrombosis.

March 3, 2020 No Comments
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Comment on Jan 19, 2020

Mohamed Elfarok replied to your comment on presentation Spontaneous Rupture of SFA.

»Thank you for a great comment 1- the diameter of this patient SFA was 8 mm, i thought 10 mm will do ok , did not want to use any bigger diameter because this is a friable artery 2- there is no need to evacuate the haematoma unless it becomes infected or cause complication, it has resolved after 2 months«
Comment on Jan 17, 2020

Amr Abdelghaffar commented on presentation Spontaneous Rupture of SFA.

»Thank you so much dear Prof. Alfarouk , I have 2 questions : 1) Wallstent covered stent is 10 / 10 , Do you think it's perfect for SFA as regard sizing 2) Did you needed to evacuate hematoma and make open surgery ? Thanks«
Comment on Jan 17, 2020

Amr Abdelghaffar commented on presentation Spontaneous Rupture of SFA.

»Thank you so much dear Prof. Alfarouk , I have 2 questions : 1) Wallstent covered stent is 10 * 10 , Do you think it's perfect for SFA as regard sizing 2) Did you needed to evacuate hematoma and make open surgery ? Thanks«
Comment on Dec 20, 2019

Basma Algettawi commented on presentation Spontaneous Rupture of SFA.

»Great job Prof. Thank you so much for this sharing. I am really apperciate that and waiting for the next.«
Comment on Dec 19, 2019

Mohamed Elfarok replied to your comment on presentation Spontaneous Rupture of SFA.

»Dearest Prof Sharkawey , thank you very much for your comment, actually this patient is a grandfather of a cardiologist and he had duplex scan arterial left leg before this event and there was no aneurysm found just diffuse atherosclerosis, so it is really spontaneous rupture of SFA which is very rare event only 5 cases reported in literature whorld wide , as we get older our arteries rupture due to wall weakness without aneurysmal formation, and also if you notice this is SFA zone two middle zone which is very rare to develop aneurysm it is usually in zone 1, and thank you again for your comment«
Comment on Dec 19, 2019

Mohamed sharkawy commented on presentation Spontaneous Rupture of SFA.

»Dear Professor Omar, very nice case. May I suggest that the diagnosis is ruptured SFA aneurysm from the start. and the concomitant DVT was created by the pressure of the adjacent aneurysm ! You did the best cover to the leaking area, but I would take care more to the Proximal end (feeding) cover than the distal one. Thank you, I appreciate much your really great way to spread knowledge, learn and benefit everybody including myself.«
Comment on Dec 19, 2019

Mohamed Elfarok commented on presentation Spontaneous Rupture of SFA.

»Dearest Prof Bisdas , 1- the use of the two needles with to mark the proximal and distal part of the ruptured segment in the SFA, so I need to cover the distance between these two needles and 2 cm proximal and distal landing zones 2- I totally agree it can be rupture of mycotic aneurysm of this patient although it can also be spontaneous rupture of SFA without previous aneurysmal dialatation , there was no eivdece of previous aneurysm in the patient SFA . very very rare case thank you very much my dearest Prof Bisdas«
Comment on Dec 19, 2019

Mohamed Elfarok replied to your comment on presentation Spontaneous Rupture of SFA.

»Dearest Prof Bisdas , 1- the use of the two needles with to mark the proximal and distal part of the ruptured segment in the SFA, so I need to cover the distance between these two needles and 2 cm proximal and distal landing zones 2- I totally agree it can be rupture of mycotic aneurysm of this patient although it can also be spontaneous rupture of SFA without previous aneurysmal dialatation , there was no eivdece of previous aneurysm in the patient SFA . very very rare case thank you very much my dearest Prof Bisdas«
Comment on Dec 17, 2019

Theodosios Bisdas commented on presentation Spontaneous Rupture of SFA.

»Mohammed amazing case. Why did you use the two needles? I did not understand it very well. Second what about the pathology behind this aneurysm? Could it be mycotic?«
Comment on Oct 22, 2019

Mohamed Elfarok commented on presentation Endovascular treatment of CFA disease.

»that is a great presentaiton , i wish it has a voice narration will be great to hear your comment on each slide , excellent effot , keep the good work«
Recorded video case

Retrograde femoropopliteal recanalization through the dorsal pedal artery

This case demonstrates the recanalization of the femoropopliteal artery in a patient with CLTI. The reason for the solely retrograde approach was a Y-graft for AAA having the anastomoses at both common femoral arteries, the above-knee amputation of the contralateral limb and the extent of the disease. Primary stent implantation was performed by using the Pulsar-18 (Biotronik) bare-metal stent, which has a 4Fr profile and a proven efficacy according to the 4EVER trial.

July 14, 2019 No Comments
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Comment on Jul 10, 2019

Theodosios Bisdas replied to your comment on presentation Step by step isolated aortomesenteric bypass for chronic visceral ischemia.

»Dear Ricardo, thank you for your comments. Q1: Yes, in patients that they are not so obese, it is simple. You have to be gentle to the oesophagus and by vertically dividing the median arcuate ligament and the interdigitating fibers of the left and right crura over the anterior aortic surface. Keep in mind, the aorta is always deeper than you think. You do not need to clamp the total aorta. You can partially clamp with a Satinsky. Q2: If the wall is of good quality, about 10-15 minutes. Q3: Absolutely! I would prefer the retrograde bypass only in really obese patients or in an unfriendly enviroment (redo) at the level of the supraceliac aorta,«
Comment on Jul 10, 2019

Ricardo Pereira commented on presentation Step by step isolated aortomesenteric bypass for chronic visceral ischemia.

»Hello Theodosios, congratulations for the great exposure of a unusual case. I have couple of questions : 1. Is it easy to isolate enough aortic segment to perform an proximal anastomosis? Enough space to sit the clamps? Have you considered using a partial clamp? 2. How much aortic clamping time? 3. Do you think the disadvantages of a retrograde bypass surpasses the risk/benefit from an anterograde bypass? Thank you.«
Comment on Jul 08, 2019

Gioele Simonte replied to your comment on presentation Complex multi stage thoracoabdominal aneurysm correction. Branched endograft with forced femoral access and flap perforation.

»Thanks for asking. to fenestrate the septum we used the stiff back end of a standard Terumo wire, into a bended steerable sheat in order to ensure a perpendicular incidence angle. We did not feel necessary to use IVUS since with fusion image guidance we could easily identify the right projection and the right point to perform the fenestration«
Comment on Apr 18, 2019

Gioele Simonte replied to your comment on presentation Complex multi stage thoracoabdominal aneurysm correction. Branched endograft with forced femoral access and flap perforation.

»thanks for the comment, actually the steerable sheats used were two different Oscor . We had to use two devices since once deployed the SMA bridging stent the radius curve of the sheat we used (7 fr) turned out to be too sharp for the advancement of the CT bridging stent as we were not able to push it over the sheat curve. we had than to pick up a 10 fr with a wider curve easily resolving the problem. no experience with the Fustar in my facility«
Comment on Jan 22, 2019

Gladiol Zenunaj commented on presentation VRTD 2: Association between PTX-coated devices and overall mortality.

»Greetings, thanks for sharing your research. The authors are reporting that mortality paclitaxel- related is dependent on the dose loaded on the device. Do the authors think that mortality paclitaxel-related after 1 year could depend whether on the paclitaxel load transferred to vessel wall or the load lost in the bloodstream during the delivering of the device. If this could be related to the load of paclitaxel lost during the delivering it shuld urge the developement of better drug bonding to the device.«
Comment on Jan 14, 2019

Gladiol Zenunaj replied to your comment on presentation VRTD 2: Association between PTX-coated devices and overall mortality.

»Very interesting paper. However, if their findings are confirmed in other studies, I think it might have any impact on the PTX-devices use rather than reducing the number of endovascular procedures. Nowadays, the increasing age, number of comorbidities of patients we have to deal with, make an open approach unthinkable.«
Comment on Jan 14, 2019

Konstantinos Katsanos commented on presentation VRTD 2: Association between PTX-coated devices and overall mortality.

»RCTs were included only in the meta-analysis. The paclitaxel arms and the control arms had similar-comparable baseline demographics without any significant differences (please refer to Appendix of the paper in JAHA). Not all studies had the same periods of follow-up time. Hence, the different number of studies for each time point. Our raw data is available 'open access' in the paper for any body to double-check. Independent reviews are of course more than welcome.«
Comment on Jan 13, 2019

Giovanni Torsello commented on presentation VRTD 2: Association between PTX-coated devices and overall mortality.

»I am not a statistician. But the statement "the two group are identical" is wrong. The groups may be comparable. Randomization was for sure not done for life expectancy, but for lesion characteristics. We need the opinion of a statistician. The study was not accepted for publication in "high ranked" Journals. Why? Additionally, the comparison of many studies at the beginning and of a few studies at 2 and 5 years looks "strange" in my opinion. The studies were externally controlled by Independent committees. What is the reason why they did not find safety issues? It is a pity that these points were not addressed during the round table.«
Awareness

VRTD 2: Association between PTX-coated devices and overall mortality

This is an exclusive interview with the first three authors (Dr. Katsanos, Dr. Spiliopoulos, Dr. Kitrou) of the paper entitled ‘Risk of Death Following Application of Paclitaxel-Coated Balloons and Stents in the Femoropopliteal Artery of the Leg: A Systematic Review and Meta-Analysis of Randomized Controlled Trials’ (J Am Heart Assoc. 2018 Dec 18;7(24):e011245). The authors answered relevant questions about the impact of their findings and the future of PTX-eluting devices.

January 11, 2019 6 Comments
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Recorded video case

Step by step isolated aortomesenteric bypass for chronic visceral ischemia

This video summarizes in 3 minutes all important steps to perform an isolated antegrade aortomesenteric bypass. The patient had a chronic occlusion of the superior mesenteric artery and underwent a primary stenting of a high-grade stenosis of the celiac trunk (CT). The endovascular recanalization of the SMA at that time was not feasible. The CT-stent occluded 8 months postimplantation with a complete thrombosis of the hepatic artery as well. The splenic artery arose from the aorta directly.

November 8, 2018 2 Comments
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Comment on Oct 05, 2018

Theodosios Bisdas commented on presentation Removing stent grafts and implications for putting them in.

»Thank you Dr. Park for this nice presentation. The message is clear and I found the paradigm about pacemakers and the results of the EVAR-1 trial very pertinent and successful. However, as you mention in your presentation, the majority of the stent-grafts that you have already explanted are more or less stent-grafts of the previous generations. Do you not believe that the next generation of endografts (similarly to the next generation of pacemakers) have a much higher safety profile? Finally, I would like to invite you to upload any presentations or videos regarding technical tips for the surgical explantation of endografts after failed EVAR. That would be a great help for the daily practice of several vascular surgeons. Unfortunately, we are missing such kind of presentations in most congresses.«
Comment on Oct 05, 2018

Raphael Coscas replied to your comment on presentation Clampless Anastomosis on the Supraceliac Aorta for Aorto-mesenteric Bypass.

»Thank you for your comment, This is not our standard technique since it leave a stent across the anastomosis and some uncertainties remain about the durability. However, we performed our first case 3 years ago (on the infrarenal aorta) and the patient is still doing well with a patent stent and bypass.«
Comment on Oct 02, 2018

Theodosios Bisdas commented on presentation Clampless Anastomosis on the Supraceliac Aorta for Aorto-mesenteric Bypass.

»Great contribution Raphael. Did I understand your technique right? Are you puncturing the graft twice or only at the distal part? How are you puncturing the aortic wall in order to introduce your wire? My second question: can you provide us the diameters of the graft and the BeGraft? Do you perform any predilatation of the aorta at the level of the anastomosis?«
Review of the literature

Paraplegia after endovascular TAAA-repair:

Why does the endovascular TAAA repair increase the risk of spinal cord ischemia (SCI)? Which are the challenges? How can you prevent SCI during complex endovascular TAAA repair? Do we have enough evidence for the prohylactic use of cerebrospinal fluid drainage in the endovascular treatment of complex TAAAs?

September 18, 2018 No Comments
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Comment on Aug 13, 2018

Theodosios Bisdas replied to your comment on presentation Paving and cracking technique for severely calcified SFA lesions.

»Dear Fernando, Regarding your questions: 1. Exactly, we performed an endo-bypass with Viabahn and we reinforced the stent-graft at the level of the severe calcification. 2. I have also the same opinion, but this was challenged by other specialists. We have no data regarding this issue in the bypass studies because the quality of the vessel wall was not always analyzed. 3. Totally agree. 4. When you decide to perform an endobypass I do not think that you need such a dedicated device for vessel prep and cause extra costs, because you are going to use a non-compliant balloon for the paving and cracking technique. If you decide to leave nothing or a BMS behind, I would suggest cutting balloon or Shockwave balloon.«
Comment on Aug 02, 2018

Fernando Gallardo commented on presentation Paving and cracking technique for severely calcified SFA lesions.

»Thanks for sharing this complex case Theo. Just two comments, 1. How many stents did you finally use in this case? Once you have crossed the lesion why not perform a endobypass with 25 cm Viabahn? or did you use this ballon expandable stent to reinforce the Viabahn?? 2. Even with such calcifications, I don't agree that PTFE fempop bypass has superior patency to endobypass with Viabahn. 3. I know you are most experienced than me, but I recommend you US guided puncture always, specially in this calcified arteries, all closure devices can fail if you puncture in a calcium plaque and the only way to avoid it is with US guidance. 4. Do you see role of SERRATO/CHOCOLATE/SCORED OR CUTTING BALLON for vessel preparation here?? Best regards, Fernando«
Comment on Jul 29, 2018

Konstantinos Stavroulakis commented on presentation Paving and cracking technique for severely calcified SFA lesions.

»Thank you Theo for this interesting case. 2 Questions as always: 1. If you have to deal with such a heavy calcification why not preparing the vessel with endovascular lithotripsy and proceed to either DCB angioplasty or Interwoven stent deployment? 2. Do you think that this patient would benefit from a primary above the knee bypass given 1) the severe calcification and the length of the CTO, which will surely challenge the outcomes of endovascular therapy, and 2) the superior outcomes of primary surgery than secondary grafting after endo failure in CLI patients?«
Comment on Jul 19, 2018

Theodosios Bisdas replied to your comment on presentation Principles of EVAR planning and sizing – Chapter 2: Sizing & Oversizing.

»Dear Dr. Rashaideh, thank you for the kind words. There is no specific way to measure the real deployment neck diameter in the case of angulation. Thus, the angulated necks are challenging and the poor outcomes of the literature in such necks can be correlated, in my opinion, to wrong oversizing. In the majority of the cases, the markers will stay at the level of the deployment on the side of the attachment of Lunderquist on the aortic wall. If the endograft is undersized, the proximal markers on the other side will be placed underneath of this level and if the endograft is oversized will stay at that level. It makes also no difference if the wire is from the right side or the left side because this is not something that you can influence. It has to do with the angulation of the neck (right- or left-sided). In any case, I will suggest going for at least 30% oversizing in angulated necks. If the 30% oversizing indicates an endograft with a diameter between the pre-specified diameters (28, 32, 36) of the available endografts (e.g. 33 mm), select then the endograft with the bigger diameter (36 mm).«
Comment on Jul 17, 2018

mohammed rashaideh commented on presentation Principles of EVAR planning and sizing – Chapter 2: Sizing & Oversizing.

»very nice teaching presentation . is there a specific way to measure the real deployment neck diameter in case of angulation .. i mean how to predict where and how the graft will deploy depending on the stiff wire . and will it make a difference if the wire is from the right or left side? thanks a lot am very impressed on how you present the data in very interesting way.«
Recorded video case

Paving and cracking technique for severely calcified SFA lesions

This is a recorded case about the treatment of a severely calcified chronic total occlusion (CTO) of the SFA in a patient with critical limb ischemia. In this video, you will see all the important steps of such an intervention: 1. puncture 2. cross-over sheath advancement 3. crossing of the lesion 4. vessel preparation 5. paving and cracking and 6. final treatment.

July 17, 2018 3 Comments
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Technical note

Principles of EVAR planning and sizing – Chapter 2: Sizing & Oversizing

This is the second chapter of the EVAR tutorial about planning and sizing of the endovascular AAA repair. Following topics are included:
– How to measure exactly the right diameter of our proximal landing zone?
– How to oversize in angulated necks?
– Which ancillary products should be available in challenging cases?
– How to select the length and diameter of the iliac limbs?
– Specific scenarios

July 4, 2018 5 Comments
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Comment on Jul 02, 2018

Martin Schroeder commented on presentation Hybrid atherectomy for the infrainguinal arteries: why, when and how?.

»Dear Theo Thank you for this excellent presentation. What possibilities do you have if you receive a recanalization subintimally, can you also use the hybrid atherectomy system or is it absolutely necessary to have a true lumen for the atherectomy? If yes - is there a good tip for this? Thanks in advance. Martin«
Comment on Jun 29, 2018

Xiaolei Sun commented on presentation Venous arterialisation for no option CLI: Limflow procedure.

»What a case presented. Thank Dr. Michael Lichtenberg. As for the pain and edema after the venous arterialisation, in my opinion, it is due to the pathological cause of ischemia reperfusion injury with a mount of temporary release of inflammatory factors. The better with the revascularization, the worse with the edema. Thus, some anti-inflammatory drug might be a good option, such as glucocorticoid once or twice.«
Comment on Jun 29, 2018

Michael Lichtenberg commented on presentation Venous arterialisation for no option CLI: Limflow procedure.

»Two important questions. Because of the massive venous filling after the procedure a significant edema in these patients is usually seen which causes pain. Leg elevation and bed rest for 2-3 days together with pain medication is recommended during this initial phase. Anticoagulation (Vit. K antagonist) plus at least one antplatelet medication (preferable Clopidogrel) is standard after the procedure.«
Comment on Jun 28, 2018

Theodosios Bisdas commented on presentation Venous arterialisation for no option CLI: Limflow procedure.

»Michael thank you for this excellent video. I have two questions about the postoperative course: 1. These patients develop severe pain after the revascularization, probably due to the hyperemia. Have you seen also the same problem in your patients? Do you have any specific recommendation? 2. What is the postoperative anticoagulation in those patients?«
Comment on Jun 23, 2018

Theodosios Bisdas commented on presentation Aspiration thrombectomy for venous stent occlusion at the iliac vein.

»Thank you Martin! The lady was under LMWH due to ovarian cancer. However, I do not believe that the reason for the occlusion was the anticoagulation. The possible reasons are (1) that the first stent did not cover adequately the compressed vein or (2) there was a progression of the tumour despite the radiation or (3) it was a paraneoplastic thrombosis. In any case, we are still using LMWH in patients with cancer-associated DVT. There is some evidence of dabigatran for such patients, but I think that we need more evidence especially after stenting of the iliac veins. What is your algorithm? Finally, regarding IVUS, I cannot agree more with your comment. Fortunately, we have also IVUS now in our clinic. But the absence of clear evidence regarding the importance of IVUS does not allow reimbursement and several clinics cannot afford this type of examination. In my opinion and due to the increasing number of vein interventions, the societies of vascular surgery, interventional radiology and cardiology should focus on this issue.«
Recorded video case

Aspiration thrombectomy for venous stent occlusion at the iliac vein

This a case of aspiration thrombectomy of an occluded venous stent after treatment of an iliac vein compression due to ovarian cancer. We used the Indigo thrombectomy catheter (Penumbra) to remove the clot and a Veniti stent (Boston Scientific) to optimize the final result. In this video, you will learn important steps of the procedure, tips and tricks for the use of the Indigo system as well as important features of both devices.

June 22, 2018 2 Comments
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Comment on Jun 18, 2018

Theodosios Bisdas replied to your comment on presentation Hybrid atherectomy for the infrainguinal arteries: why, when and how?.

»Thank you Kostas! Regarding your questions: 1. It depends on the vessel that you treat; for SFA I would use the recommended Nitrix wire (Medtronic) or the hi-torque Iron Man (Abbott) and for the below-the-knee arteries more stiff wires like the Hi-Torque Extra S'port (Abbott) and Astato XS 20 (Asahi) 2. I do not use a DPD and I would not recommend it, because you may have problems between the proximal tip of the device and the wire of the filter. 3/4. At the moment I use atherectomy for tibial disease only in case of in-stent stenosis and severe recoil after PTA. If I perform atherectomy, then I would combine it with DCB. Do you have a different algorithm?«
Comment on Jun 15, 2018

Michael Lichtenberg replied to your comment on presentation Revascularization of chronic iliiac vein obstruction.

»Great question Theo. I recommend to use IVUS always also after venous stent implantation to proof Aspect Ratio = 1. If AR is > 1 another post dilatation must be done to achieve good flow and long term patency (for more details see uploaded paper on lumen quality). Michael«
Comment on Jun 15, 2018

Theodosios Bisdas commented on presentation Revascularization of chronic iliiac vein obstruction.

»Dear Michael! Thank you for the nice case! What are you doing, if the IVUS shows a recoil of the stent? Repeat-PTA, Stent-in-Stent or your give time to the stent to work on the lesion? Finally, can you provide us your algorithm about anticoagulation?«
Comment on Jun 15, 2018

Theodosios Bisdas replied to your comment on presentation Total endovascular treatment of the aortic arch after type A dissection with chimney and sandwich technique.

»Hi Michel! Thank you for your question. Regarding your first question. I did not use for example the Endurant limb because of the length (82mm) and the difference of the materials compared to the cTAG (Dacron vs PTFE). I think the gutter could be an issue. The IIA-branch of the IBD device is tapered (16 to 12mm) and shorter (70mm). Regarding your second question, the downwards orientated branch for the LSA allows access for a branched endograft and principally for a transbrachial approach.«
Comment on Jun 15, 2018

Theodosios Bisdas replied to your comment on presentation Total endovascular treatment of the aortic arch after type A dissection with chimney and sandwich technique.

»Thank you, Martin! Well, we are far away from a well-established protocol for CSI protection. Especially, in that case, you have to be very quick after deploying the thoracic endograft over the aortic arch. There are some new filters for the brachiocephalic trunk and the LCCA but these are applicable only in TEVAR cases. When you have to get access for the supraaortic vessels you have no option to protect the brain. My measures are: 1. Remove very carefully the air from the devices 2. Check multiple times your angiographic catheters to avoid air embolisation 3. Avoid a lot of manipulations with your thoracic endograft 4. Introduce the large-bore sheaths (12F), when you really need them and not from the beginning of the procedure 5. Check the quality of your arch at the angio-CT before planning your procedure.«
Comment on Jun 15, 2018

MARTIN MARESCH commented on presentation Total endovascular treatment of the aortic arch after type A dissection with chimney and sandwich technique.

»Amazing case Theo! Great tutorial from many points of view. Great discussion. Meticulous planning is the key to success in these cases! That's why they didn't use C-S bypass, Michael even so it would make sense, but this would have closed the door for further interventions distally if needed. Theo, can you comment on your CSI protective measures in complex TEVAR cases and what's the incidence of stroke and how to minimize it? Thanks«
Comment on Jun 15, 2018

MARTIN MARESCH commented on presentation Revascularization of chronic iliiac vein obstruction.

»Nice case Michael. Can you make some comments regarding your access strategy? I would access PV or combine JV access for precise distal positioning of the stent. One more question is overlapping contralateral side since it's givving me bad dreams; you do have significant number of the cases- what is the incidence of the contralateral thrombosis as the consequence of compromised flow in your cohort? Have you considered other tactic (Oblique stent, Gianturco Z stent)?«
Comment on Jun 11, 2018

Özgün Sensebat replied to your comment on presentation Total endovascular treatment of the aortic arch after type A dissection with chimney and sandwich technique.

»Thank you for your answer Theo! My question was not precise, sorry. It is obvious, that you've done a great case with this chimney/periscope exclusion and not with a CMD. I am sure the planning was complex. My question is your general opinion about CM-branched-devices for the arch if indicated. You answered my question why it was not possible in this particular case. Maybe it is possible in the future to see a CMD-case for the arch at Vascupedia. Your opinion about the indication and characteristics would be valuable for the vascular public. Again, great job!«
Comment on Jun 11, 2018

Theodosios Bisdas replied to your comment on presentation Total endovascular treatment of the aortic arch after type A dissection with chimney and sandwich technique.

»Thank you Arne for your questions. 1. We decided against a 3 chimney for 2 reasons: (a) to avoid a bigger gutter and (b) to have the option for an antegrade (transbrachial) access to the descending aorta (e.g. further endovascular repair with fenestrated or branched endograft) 2. See my comment to Dr. Sensebat 3. The patient will receive dual antiplatelet treatment for 3 months and afterwards only ASA. However, I cannot support this with any kind of evidence. The advantage is that we have large bridging stent-grafts (12 mm for the brachiocephalic trunk and 10mm for LCCA and LSA).«
Comment on Jun 11, 2018

Theodosios Bisdas replied to your comment on presentation Total endovascular treatment of the aortic arch after type A dissection with chimney and sandwich technique.

»Thank you Özgün for your question. This was not a custom-made device, but an off-the-shelf treatment with chimney and sandwich technique. A custom-made device was not indicated in that case due to the short length of the replaced ascending aorta. There are strict inclusion and exclusion criteria for those cases. We decided to go forward with an endovascular approach due to the comorbidity of the patient and the redo operation.«
Recorded video case

Total endovascular treatment of the aortic arch after type A dissection with chimney and sandwich technique

This is a very advanced case of a total endovascular repair of a post-type A dissection aneurysm of the aortic arch with chimney endografts for the brachiocephalic trunk and the LCCA and a periscope in Sandwich technique for the LSA. See the procedure in chapters for the different steps under: https://vascupedia.com/video/total-endovascular-treatment-of-the-aortic-arch-after-type-a-dissection-with-chimney-and-sandwich-technique/

June 11, 2018 10 Comments
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Comment on Jun 07, 2018

Efstratios Georgakarakos replied to your comment on presentation A case of bilateral symptomatic aneurysms of common femoral arteries: surgical management.

»Hi Theo and thanks for your attention. I usually suggest a FU examination at 1-, 6- and 12months postoperatively. If a femoral aneurysm is asymptomatic most authors suggest intervention at a diameter greater than 2.5-3.0cm. Depending on the size of the inflow and outflow vessel to be clamped, i prefer Dacron for large diameters or PTFE if the vessel sizes are smaller. I certainly perform a CTA scan to rule out comcomitant aneurysms in remote locations, since femoral aneurysms -although rare, accounting for 3-4% of all peripheral aneurysms- are bilateral in 1/3 of cases while associated with aortic- or popliteal aneurysms in 66%. Therefore, a CTA is mandatory.«
Recorded video case

Principles of EVAR planning and sizing – Chapter 1: Drawing & Measurements

This short tutorial is the first chapter of an online workshop about the principles of EVAR planning. Herein, you will find all important steps for a successful preparation of your EVAR procedure. What about drawing? What should I draw? What are the anatomic issues need to be addressed and considered? and much more information.

June 6, 2018 6 Comments
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Comment on Jun 05, 2018

Fernando Gallardo commented on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Thanks for sharing your tricks. For this maniouver I have used as Pr Efstratios comments a Relliant Ballon partially inflated to straight the neck is much us possible, but also using the contralateral limb sistems works, and probably a long big sheat or anything that could make righter the neck could works... Anyway for more 70 angulation we should be careful, my option now for this neck is more Aorfix or even Gore with Aptus, more comfortable grafts. The battle stentgrafts VS hostile anatomy will be always won by the anatomy at mid-long term!! Also consider that Endurant suprarrenal stent is totally straight, difference with COOK suprarrenal stent, and in cases with severe angulations I have seen total apposition of the suprarrenal stent one half side and the half of the suprarrenal stent free in the aorta without wall contact... Best regards Fernando«
Comment on Jun 05, 2018

Efstratios Georgakarakos commented on presentation Treatment of a challenging case of acute limb ischemia.

»Theo, thanks for your interest and your prompt reply! Certainly this was an embolism after all, since the angiographic picture left no doubt about that. I just raised a concern about the initial approach of this case, leaving a place for thrombosis in the differential diagnosis based on the peculiar -according to my opinion- picture of 3-sites embolization. Certainly, the pros and cos of each approach encourage the scientific dialog and enrich the phycisian's armamentarium!«
Comment on Jun 05, 2018

Theodosios Bisdas replied to your comment on presentation Treatment of a challenging case of acute limb ischemia.

»Hi Stratos! Thank you for your comment. Your approach is also safe and easy, but we do not have any evidence about cost effectiveness. Let me please disagree with your concept. The angiography after the aspiration thrombectomy showed no atherosclerotic lesions at the level of the CFA or even popliteal artery. Thus, I still believe that this was an embolism. The total amount of contrast agent used was 60ml. If we had an atherosclerotic lesion in the CFA, your approach would be the treatment of choice. In our case, we prevented any wound complication, we reduced the hospital stay, we did not use lysis and of course also no ICU. The total operation time was 49 minutes. I am looking forward to your comment on this.«
Comment on Jun 03, 2018

Efstratios Georgakarakos commented on presentation Treatment of a challenging case of acute limb ischemia.

»Nice try! Did the patient experienced reperfusion syndrome postoperatively with need for fasciotomies? It seems a bit ackward to me the multiplicity of occlusive lesions on the basis of an emboli phenomenon eg. 3 remote sites infespopliteal, CFA as well as iliac axis thrombus from a single atrial thrombus? I would personally put into play the scenario of a atheromatous steno-occlusive lesion either in the popliteal or CFA site. In such case, an open CFA preparation with proximal and distal embolectomy effort would immediately remove thrombus and would decrease the amount of subsequent contrast agent needed to check for remnant stenotic disease proximally or centrally i.e., in order to differentiate the thrombotic vs. embologenic phenomenon and proceed immediately with primary stenting. This would also be faster. Admittedly, remnant thrombus in the popliteal segment would necessitate local injection of theombolytic agent with potential need for further thrombectomies distally; but then, again, such approach would be time and cost effective, let alone the fact that it would enable-if needed- CFA endarterectomy and hybrid approach.«
Comment on Jun 03, 2018

Theodosios Bisdas replied to your comment on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Exactly Stratos! You could not describe it by a better way. The risk of angulated necks is the poor apposition of the proximal stents on the wall. This is a good solution. Your suggestion is also good and works fine. I have tried it in the past. The only advantage of my tip is that you win some time because you do not need to remove the sheath of the contralateral extension. After implanting the ETLW you do not remove it but you further open the main body. Then, you connect the top cap and you advance the sheath of contralateral extension at the height of the top cap. In any case, both work fine.«
Comment on Jun 03, 2018

Efstratios Georgakarakos commented on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Nice information and demonstration. If i get it right, the philoshophy of the “pushing-up”maneuver of the mainbody after the top-cap release (and before the contralateral limb release) is to shrink the fabric between the 1st and 2nd covered stent, thereby reducing the distance between these covered stents and aproximating them in order to achieve the optimal position of these within the infrarenal neck length; therefore, you should start pushing-up the whole device just after the deployment of the 1st stent-top cap release and before the deployment of the 2nd covered stent, so that the latter could actually be positioned as close as it gets to the 1st one, leaving perhaps extra place for the third stent etc., isn’t it? Regarding the 2nd excellent tip of yours i.e., engagement of cap with suprarenal stent, an alternative maneuver would be to inflate a Relay molding balloon mildly leaving a pathway through which the top cap could withdraw safely without the aforementioned problem.«
Comment on Jun 03, 2018

Theodosios Bisdas commented on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Thank you, Philippe, for your comment. Of course, you need experience with this maneuver. The trick here is to 'cram' the prosthesis into the angulated neck. I have not seen an upward migration yet, but there is sure a risk for this. Thus, you have to do smooth movements and to use some landmarks of the vertebral bodies for your renal arteries. An important issue is also the oversizing in those cases: we recommend at least 30%.«
Comment on Jun 03, 2018

commented on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Hi Theo, very nice case! By what means you judge the pushing-up manoueuvre of the main body once the struts are opened? I'm sure in your hands this reflects experience, but is it not a quite risky step for some less experienced operators? I like a lot the move with the contralateral limb, never thought about this! Very smart indeed!!! Best, P«
Comment on Jun 03, 2018

commented on presentation Percutaneous thrombectomy of bridging stent-grafts after chEVAR.

»Hi Theo, sorry I answered initially to the post of Arne on LinkedIn.. Very interesting to know that relining an Advanta is rather not so Good. The video is very helpful to learn how to do it!!! Thank you very much! Points taken! Best from Baden, Phil«
Recorded video case

Two technical tips for severely angulated infrarenal necks during EVAR

This is a short video with two technical tips for the treatment of severely angulated necks with standard EVAR (Endurant, Medtronic) if an open surgical repair is not indicated. The first tip starts with the release of the top cap before the opening of the contralateral gate and the second tip is a solution to pull safely back the top cap if you have a conflict with the suprarenal stent. However, do not forget that this is an outside the IFU implantation of the device.

June 2, 2018 7 Comments
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Comment on Jun 02, 2018

Theodosios Bisdas replied to your comment on presentation Percutaneous thrombectomy of bridging stent-grafts after chEVAR.

»Hi Philippe! You mean probably Theo! :-) We have seen several occlusions with the bridging stent-grafts after both chimney and branched endografting and the majority of them were observed at the renal arteries. The incidence is lower with fenestrated endografts. The oversizing was 1 mm as usually. We think that the problem was the relining with the bare-metal stent. In the video (7:31), after the Indigo thrombectomy, someone has the feeling that the distal end of the bare metal stent has almost perforated the native vessel wall. We have studied this issue in a previous paper (Panuccio et al. Eur J Vasc Endovasc Surg. 2015 Jul;50(1):60-70) and we found that relining of the Advanta with a self-expanded bare-metal stent was a risk factor for occlusion in the renal arteries after brEVAR.«
Comment on Jun 02, 2018

Theodosios Bisdas commented on presentation Treatment of a severely calcified lesion with Supera and balloon-expandable stents.

»Thank you Stratos for the comment. The total duration was about 1 hour. Of course, the most challenging part was the recanalization. Regarding your second question, the nose cone is moved through the advancement of the thumb slide. By advancing the thumb slide the outer sheath retracts proximally and the stent is deployed. Actually, the full advancement of the thumb slide is prespecified by the manufacturer and allows the deployment of a short section of the stent. I prefer short thumb slide advancement at the beginning of the stent implantation and full thumb slide advancement afterward.«
Comment on Jun 02, 2018

Konstantinos Stavroulakis replied to your comment on presentation Stent Graft deployment for AV Graft salvage.

»Thank you Theo for your comment! 1) Given the lack of head to head comparisons/trials only an individualized approach can be recommended. Despite the lack of data we usually try to avoid a stent deployment and we favor DCB angioplasty. The launch of DCBs up to 12mm might be useful in the treatment of central vein stenosis. On the other hand, fibrotic lesions might require a stent. A strategy that could be valuable is the use of vein dedicated stents, as the one used for the pelvic veins. Of note this strategy is not in the IFUs of these devices and we have no data at all. 2) The problem of the most vessel prep modalities is that they are all designed for the peripheral vasculature (lower extremities). Thus, they are sufficient in the treatment of vessels with a max. diameter of 7-8 mm. In this context, their use in central veins is up to now not really reasonable. However, they might provide a benefit in the treatment of AV-Fistula stenosis of the upper extremities. Again, this is only hypothetical as no study evaluated the efficacy of DAART for AV-Fistula/graft salvage.«
Review of the literature

Iliac-side branch devices: What does the data teach us?

This is an overview of the literature about the revascularization of the hypogastric artery (HA) in patients with aortoiliac aortic aneurysms. Should we preserve the HA? If yes, how? If not, which is the best method to avoid complications? Which are the current IBD devices?

May 30, 2018 No Comments
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Recorded video case

Treatment of a severely calcified lesion with Supera and balloon-expandable stents

This case shows step by step the treatment of a severely calcified lesion in the SFA. The video includes the recanalization of the lesion with use of different support catheters and wires, solutions for the subintimal course of the wire, intraoperative AV fistula, vessel preparation and the use of a balloon-expandable stent with a Supera stent for lumen gain.

May 27, 2018 2 Comments
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Technical note

Zenith t-branch for the treatment of TAAAs: planning and algorithm

This presentation is a snapshot of the main characteristics of the t-branch endograft for the treatment of thoracoabdominal aortic aneurysms (TAAA). Moreover, we present our institution’s algorithm regarding the steps of the procedure and the OP setting in order to achieve the best outcome for the patient and to prevent spinal cord ischemia.

May 27, 2018 1 Comment
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Clinical investigation

Endovascular therapy vs bypass surgery: interim analysis of the CRITISCH registry

This presentation provides an overview of the interim analysis of the CRITISCH registry comparing the endovascular therapy and the bypass surgery as first-line treatments in CLI patients. Original publication: Bisdas et al. JACC Cardiovasc Interv. 2016 Dec 26;9(24):2557-2565.

May 27, 2018 No Comments
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Comment on May 26, 2018

Theodosios Bisdas commented on presentation Stent Graft deployment for AV Graft salvage.

»Excellent case Kostas! Thank you for this. I have two questions for you: 1. Which is your treatment strategy for central vein stenosis: DCB, BMS or stent-graft. If you use BMS, which one do you recommend? 2. What is the role of DAART for such ISR in AV-fistula?«
Recorded video case

Percutaneous thrombectomy of bridging stent-grafts after chEVAR

This case demonstrates the percutaneous transluminal thrombectomy of a bridging stent-graft after chEVAR. The clot removal was performed with the Indigo thrombectomy catheter (Penumbra) through a transaxillary approach. In this video, you will find important technical aspects as well as all relevant characteristics of the device.

May 24, 2018 6 Comments
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Recorded video case

Endovascular treatment of CFA with DAART

In this case, the patient is a poor candidate for an open surgical endarterectomy of the common femoral artery (CFA) due to a post radiation hostile groin. The lesion was treated by performing a directional atherectomy with antirestenotic therapy. Check all the steps of the procedure and important technical tips for this challenging lesion.

May 23, 2018 No Comments
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Case report

Multiple occlusions of a bare-metal stent in the popliteal artery

Herein, we present the follow-up examination and reinterventions after treatment of the popliteal artery with a bare-metal stent. It is interesting, the decision making and the durability of the different procedures until the final treatment with a vein surgical bypass. A very interesting case, which could raise a discussion about the current first-line treatment strategies in patients with popliteal lesions as well as in-stent stenosis.

May 8, 2018 No Comments
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Case report

Lower limb and visceral malperfusion in acute type B aortic dissection

In this case report, we present the endovascular treatment of a malperfusion syndrome of the left limb as a consequence of an acute type B dissection. Additionally, to the technical details regarding the procedure, we also demonstrate our strategy regarding the assessment of the CT-angiography for the planning of the procedure.

May 8, 2018 1 Comment
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Review of the literature

My technical choice in the treatment of severely calcified lesions of the SFA

Overview of current techniques and evidence regarding the treatment of severely calcified lesions in the SFA. In this presentation, an algorithm for those challenging lesion is presented.

May 8, 2018 No Comments
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Case report

Treatment of a challenging case of acute limb ischemia

Treatment of a challenging case of acute limb ischemia (external iliac, common femoral and popliteal artery) with the Indigo thrombectomy system – Step by step procedure and description of decision making for this case

May 8, 2018 3 Comments
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Poll 01/12/2018 – 31/12/2018

Chronic deep vein thrombosis and postthrombotic syndrome

Case presentation:

41 years old female patient presenting with swelling of both limbs, diffuse aching, heaviness and tiring of both extremities since 5 years from a previous deep vein thrombosis on both limbs. At the time of presentation, the patient showed severe dermatoliposclerosis on the right extremity and ulceration at the level of the left internal malleolus. The patient had no other risk factors except Factor V Leiden mutation.

Poll 01/08/2018 – 31/08/2018

Asymptomatic carotid artery disease

Patient’s characteristics

 

Gender: Female

Age: 72 years old

Comorbidity: Arterial hypertension, hypercholesterinemia, previous smoker

Symptoms: None

Previous operations: None

Vascular Imaging of the left internal carotid artery: Duplex ultrasound with peak systolic velocity (PSV)> 230 cm/sec

Poll 01/10/2018 – 31/10/2018

Critical limb-threatening ischemia – CLI Global Society

Patient’s characteristics

 

Gender: Male

Age: 79 years old

Comorbidity: Arterial hypertension, hypercholesterinemia, chronic kidney disease (GFR: 53 ml/min/1,73m²), NYHA II, Coronary artery disease, previous CABG

Symptoms:  Toe ulceration of the left limb

Previous operations: None

ABI: incompressible, Toe pressure: 32 mmHg

Vascular Imaging – Duplex ultrasound: Isolated tibial vessel disease

Poll 01/11/2018 – 30/11/2018

Ilio-femoral deep vein thrombosis

45 years old female patient presenting with painful swelling of the right limb during the last 24 hours. Wells score on admission was 4 points. The duplex ultrasound scanning revealed a femoropopliteal and iliac deep vein thrombosis. No other risk factors were present. No previous operations. No thrombophilia documented.

Poll 02/02/2019 – 28/02/2019

The acute limb ischemia

Patient’s characteristics

Gender: Female

Age: 65 years old

Comorbidity: Arterial hypertension, Dyslipidemia

Symptoms:  Acute onset of claudication (<2 weeks), Rutherford class 3 of the left limb

Previous operations: None

ABI: 0.5

DUS: Occlusion of the left popliteal artery

Poll 01/03/2019 – 31/03/2019

The chronic mesenteric ischemia

Patient’s characteristics

 

Gender: Female

Age: 69 years old

Comorbidity: Arterial hypertension, Dyslipidemia, coronary heart disease (DES deployment 2 years ago)

Symptoms:  Postprandial pain

Previous abdominal operations: None

DUS: Occlusion of the superior mesenteric artery

Poll 01/04/2019 – 30/04/2019

The AV access salvage procedure

Gender: Male

Age: 75 years old

Comorbidity: End-Stage Renal Disease, Diabetes, Arterial hypertension, Dyslipidemia, on hemodialysis in the last 5 years

Symptoms:  Acute occlusion of a surgically created left-sided brachial cephalic AV fistula

Poll 04/10/2019 – 31/10/2019

Choice of antiplatelet therapy around complex revascularisation

A 79-year-old diabetic male patient with no history of coronary disease is referred to you to undergo angioplasty for tissue loss on the tips of the hallux and second toe. He is taking Aspirin 75mg. From preoperative imaging he needs a 20cm SFA occlusion stopping before the adductor hiatus recanalizing as well as multilevel tibial disease which appears to be a combination of short occlusions and stenoses. The dorsal pedal is seen in the foot and is in continuity with the arch. The PT artery appears occluded through it’s whole length.

Poll 13/04/2018 – 30/06/2018

Topic: Asymptomatic juxta- and pararenal aortic aneurysms

Patient’s characteristics

Gender: Female
Age: 75 years old
Comorbidity: Arterial hypertension, hypercholesterinemia, previous aortocoronary bypass grafting, previous myocardial infarction, previous smoker, peripheral arterial disease, atrial fibrillation
Symptoms: None
Previous operations: None

 

Aneurysm characteristics:

Max. aneurysm diameter: 54 mm

Length of proximal infrarenal neck: 0 mm

Distance between SMA and LRA: 20 mm

Diameter of renal arteries: RRA: 5,3 mm, LRA: 6 mm

Suprarenal angulation: 60°

Diameter of distal neck: 30 mm

Minimum diameter of common iliac arteries: R: 11 mm, L:9 mm

Maximum diameter of common iliac arteries: R: 11 mm, L: 14 mm

Minimum diameter of external iliac arteries: R: 7 mm, L: 6,2 mm