confluence Abdominal aortic aneurysm screening what is the need?

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1 issue three august 10 confluence concepts and opinions in invasive cardiology Abdominal aortic aneurysm screening what is the need? EDITOR-IN-CHIEF Christian W Hamm (germany) EDITORIAL BOARD ROSSELLA FATTORI (ITALY) ANTHONY GERSHLICK (UK) HENNING KELBÆK (DENMARK) IRENE LANG (AUSTRIA) CHAIM LOTAN (ISRAEL) VINCENT RIAMBAU (SPAIN) ALEC VAHANIAN (FRANCE) ARNOUD VAN T HOF (THE NETHERLANDS) THOMAS WALTHER (GERMANY) Franz Weidinger (austria) Acute aortic syndromes: the need for aortic centres The management of AMI today: interview with Petr Widimsky Supported by an unrestricted educational grant from Medtronic, Inc

2 Dear colleagues, EDITOR-IN-CHIEF Christian W Hamm Welcome to the third issue of Confluence: concepts and opinions in invasive cardiology. We hope that you enjoy reading it. We begin the third issue by looking at the management of abdominal aortic aneurysm (AAA). The evidence base for AAA screening is largely in favour of screening in men over the age of 65 years. However, there is limited supporting data on the clinical effectiveness for screening in elderly women. Professor Janet Powell discusses the latest concepts on AAA screening, current strategies in place and areas for future research. Also in this issue, Dr Rosella Fattori and colleagues share their experiences from Bologna, Italy with a treatment pathway for patients with suspected acute aortic syndromes (AAS). In this interesting account, they present some convincing results with endovascular repair in AAS patients using a dedicated, multidisciplinary aortic team approach. Finally, we talk to Professor Petr Widimsky about the overall management of acute myocardial infarction and his efforts, as part of the Stent for Life initiative, to improve the level of care across Europe. As always, it is our aim to ensure that Confluence remains a valuable resource for its readers. Your opinion is very important to us and we would encourage you to get in contact by ing us at confluence@axon-com.com. Please let us know what you think of this issue and tell us what you would like to see in future issues. Contents Review article Abdominal aortic aneurysm screening what is the need? 2 J T Powell Review article Acute aortic syndromes: the need for aortic centres 7 R Fattori, V Russo, L Lovato, R Di Bartolomeo Interview Christian W Hamm 1 Management of AMI today: interview with Petr Widimsky 11

3 review article Abdominal aortic aneurysm screening what is the need? Four population-based trials of screening for abdominal aortic aneurysm (AAA) have been conducted and summarised in a Cochrane review and a systematic review. These reviews are broadly in favour of screening being offered for men aged 65 years and more, since screening clearly reduces aneurysm-related mortality. There is weak evidence from one trial to suggest that screening also may have late benefits (7 10 years) on all-cause mortality. However, there is no good evidence to support screening in older women. The success of regional or national screening programmes depends on the prevalence of aneurysms, the uptake of screening, local operative mortality rates for aneurysm repair and other factors. For this reason, it is reasonable to conduct a pilot phase of screening before offering screening more widely. There is no robust evidence about optimal rescreening surveillance for those in whom small aneurysms are detected. J T Powell Introduction Janet t powell The population of Europe and the Western world is ageing a contributing factor underlying the continuing increase in prevalence for AAA. Abdominal aortic aneurysm, the most common form of aortic aneurysm, has a prevalence in men over 60 years of age of approximately 5% (the prevalence in women of the same age is much less at only 1 2%); however, some variation in prevalence across Europe has been reported (Figure 1). Although the prevalence of AAA has been increasing for the past two decades, it is uncertain if this high prevalence will be sustained. Smoking the principal risk factor for AAA has been in decline for some years, particularly in men. This may be mirrored with a future reduction in AAA prevalence. Amongst women, however, declines in smoking rates have been more modest, which in combination with an ageing population may result in a continued increase in AAA rates. Population prevalence is fig. 1 Sweden 15% Norway 8% Some reported percentage population prevalences for abdominal aortic aneurysm in older men across Europe Denmark 4% Netherlands 4% Belgium 4% Northern Ireland 6% Czech Republic 4% Ireland 4% Vascular Surgery Research Group, Imperial College, London England 5% Turkey 4% Italy (Genoa 9%) Greece 4% Israel 3% 2

4 a critical factor for the success and costeffectiveness of any screening programme. Effective screening uptake rates and disease intervention are also important to the success of screening programmes. Abdominal aortic aneurysms are extremely dangerous. This is because they are usually asymptomatic until rupture a catastrophic event in more than 80% of cases. Small aneurysms have a very low risk of rupture, but this risk escalates as the aneurysm enlarges which is the natural progression of an AAA. Open surgical or endovascular repair of the aneurysm prevents the risk of future rupture in nearly all cases, but repair itself carries a significant 30-day mortality rate. This initial risk seems to be three times higher for conventional surgical repair compared with open surgical repair, but beyond 1 2 years post-repair mortality rates are similar. These discrepancies have been addressed in a number of randomised clinical trials, which support management of AAA by vascular surgeons and population screening for AAA in order to improve patient outcomes. Aneurysm screening is performed using ultrasonography Ultrasonography is highly specific and sensitive for the detection of AAA, which is commonly defined as a maximum infra-renal aortic diameter of 3 cm. This diameter may be measured in both anterior-posterior and transverse orientations, although reproducibility is better for the anteriorposterior approach, with measurement variability of ± 2 mm being attainable by a well-trained operator. It also is possible to train any healthcare worker to undertake aortic ultrasonography and specialist ultrasonographers or radiologists are only essential for maintaining quality control. Not surprisingly, all the population-based randomised trials of AAA screening have been based on measurement of anterior-posterior diameters by ultrasonography. These trials have been conducted in the UK, Australia and Denmark, with participant follow-up extending to 10 years, and although there are differences between the trials, they have been summarised in both a Cochrane review and a review for the US Preventive Services Task Force. 1,2 The evidence in favour of screening in men The four randomised trials of population screening are the Chichester trial in the UK, 3 the Viborg trial in Denmark, 4 the Western Australia trial 5 and the MASS trial in the UK. 6 In each trial, participants were randomised to receive either; an offer of aneurysm screening or no offer of screening. In each trial, screening was shown to reduce aneurysm-related mortality for men. In the Cochrane Review the odds ratio in favour of screening for men was 0.60 [95% CI ]. 1 The systematic review reported a similar benefit for screening in men, odds ratio 0.53 [95% CI ]. 1 The Chichester, Viborg and Western Australia trials have not reported any benefit of screening on all-cause mortality, 3-5 although a small late benefit has been reported from the MASS trial. 7 The individual characteristics of the trials, including the percentage uptake of screening (68 80%) are summarised in Table 1. This table also serves to illustrate some of the differences between the trials. Of note, there is one broad similarity between the trials, not listed in Table 1, in that all trials were conducted in relatively advanced socioeconomic areas where a semi-rural hinterland is dotted with medium or small size towns. None of the screening trials were conducted, except in a small part, in very deprived large city districts. Update on the screening trials After a seven-year follow-up, the MASS trial reported an all-cause mortality benefit in favour of screening at the limits of statistical significance. Very recently the MASS trial published 10-year results. 7 These showed that aneurysm-related deaths were halved in the group invited for screening at a cost of 100 3

5 Trial Chichester Viborg Western MASS characteristics UK 3 Denmark 4 Australia 5 UK 6 N 15,775 12,639 41,000 67,800 Gender men & women Men men Men Age (years) *** Samping dates Date published % accepting screening Aneurysm prevalence 4.0% (7.6% in men) 4.0% 7.2% 4.9% Place of screening Hospital Hospital Community Community Intervention policy at 6.0 cm At 5.0 cm none At 5.5 cm Mean follow-up (months) AAA mortality, odds ratio men only Screened vs. not (95% CI) * ( ) ( ) ( ) ( ) All-cause mortality, odds ratio men only Screened vs. not (95% CI) ** ( ) ( ) ( ) ( ) Hospital deaths Other outcomes reported No aneurysm- N/A Quality of life Costs related mortality Quality of life Costs benefits in women Total mortality Workload Number of operations and indications for operations Number of ruptured aneurysms Extended follow-up available Yes No No yes Table 1 Summary of the population based randomised screening trials KEY * Reported odds ratio taken from Cochrane review. 1 Pooled odds ratio over all four trials strongly in favour of screening, odds ratio 0.57 ( ), together with a halving of the incidence of aneurysm rupture in screened populations. 2 ** Reported odds ratio taken from Cochrane review. 1 Pooled odds ratio trend in favour of screening, odds ratio 0.98 ( ). 2 *** Because of the method of recording age in the electoral roll some men were older than the target age range by the time they were invited for screening and, as a result, 725 (5.9%) of those who attended were aged years. As percentage of those alive when invitation for screening was sent, randomisation predated this invitation by several months in a large sector of subjects. The MASS trial recently published 10-year follow-up, demonstrating the cost-effectiveness of screening and a significant all-cause mortality benefit but a rising incidence of AAA rupture in the screened group. per person screened. Overall there were 552 elective aneurysm repairs in the screened group (with an operative mortality of 4%) versus 226 in the control group (with an operative mortality of 6%). However, after 8 years there was a noticeable increase in ruptures in the screened group. Although studies have reported that a single screen at age 65 years is sufficient, this may require re-evaluation, given the current and continuing trend for longevity. 8 The evidence for screening in women The population prevalence of AAA is three times higher in men than women. Therefore, not surprisingly, there is limited evidence to support aneurysm screening in older women. The only screening trial conducted in women was in Chichester, UK and is reported as part of the Chichester trial 3 in Table 1. Can screening cause harm? There are three potential dangers that may be caused by screening. Firstly, there is the anxiety and subsequent impact on quality of life associated with being told that you have a serious, potentially fatal, condition. Both the MASS and Viborg trials reported that subjects diagnosed with an aneurysm on screening experienced anxiety and a decreased quality of life for a short period afterwards. 4-6 Such effects were most marked in those with poor quality of life at baseline but the effects resolved within a few months of screening. Secondly, and perhaps more importantly, there is the mortality risk associated with intervention. If screening is to be conducted safely, the vascular surgical referral centres for patients must have an audited low mortality for both open and endovascular aneurysm repair (EVAR) 9 for elective open repair, the 4

6 fig. 2 Management of small abdominal aortic aneurysms operative mortality must be less than 5% and for EVAR less than 2%. Recent work clearly shows that most patients have a preference for aneurysm repair by EVAR rather than by open repair, although some patients still prefer open repair since it avoids the need 10, 11 for long-term post-operative surveillance. Thirdly, screening may cause an unacceptable burden on local vascular surgical services. The MASS trial has shown that the rate of elective repairs doubled with the advent of screening, although the burden of out-of-hours ruptures is reduced. Current status of aneurysm screening Given the results of these trials, a decision has been made in the UK to roll out a national aneurysm screening programme during The programme will be community-based and target men in the year they reach 65 years. Time will tell if the ambitious national screening programme in the UK will be successful. In the US a more cautious approach has been adopted, with recommendations to screen male smokers in the year age range. Implementation of these recommendations, however, appears to be poor. The potential benefits of screening are under debate in the Netherlands and other European countries. In addition, a pilot study of 10,000 men is to be undertaken in Italy. Local aneurysm screening programmes exist in Sweden and some other countries. In Sweden it has been argued that screening might be cost-effective for women too. What has changed since the screening trials were conducted? The recruitment phase for the screening trials mentioned above occurred more than 10 years ago. Since then the prevalence of smoking has declined, national legislation to ban smoking in public places has come into force across much of Europe and there has been a rise in the use of statins for cardiovascular risk prevention. Weak evidence suggests statins reduce both aneurysm growth and rupture rates. 12, 13 Does this mean that the prevalence of AAA will decline and that AAA will become less dangerous? Preliminary evidence from two London-based screening districts suggests that the prevalence of AAA in 65-year old men is now closer to 1% than to 5% and that in inner city areas the acceptance of screening is much lower than the 80% of the MASS trial. 6 Therefore, the cost effectiveness of screening in such communities may be compromised. What has not changed since these screening trials were conducted? The threshold for surgery in men remains at 5.5 cm, as originally set by the UK Small Aneurysm and Aneurysm Detection and Management trials. 13 These trials compared surveillance with early open surgical repair of the AAA and showed surveillance was safe and cost less. Specifically, in men the aneurysm rupture rates were very low (<1% per annum), but higher in women. We now know that the operative mortality from open repair is three times higher than for EVAR. New trials, 14, 15 have compared surveillance of small aneurysms with early EVAR; however, there is still no survival or cost benefit associated with early intervention to exclude small AAAs. 3 cm Community surveillance (annual) and comorbidity management 4 cm Community surveillance (6 monthly) and comorbidity management 5 cm Community surveillance (3 monthly) and comorbidity management 5.2 cm FEMALES only, grey area, refer to vascular surgeon and consider repair 5.5 cm ALL LARGE ANEURYSMS, rapid referral to vascular surgeon, assess fitness and aneurysm morphology ANEURYSM REPAIR 5

7 An algorithm for the current management of small aneurysms is shown in Figure 2. Missing evidence Currently there are no robust data to support any particular frequency of small aneurysm surveillance according to aneurysm diameter, although a modeling exercise has suggested the frequencies shown in Figure The National Institute of Health Research in the UK has commissioned analysis to establish the cost-effective rescreening intervals. This project will use data from the four screening trials as well as other large cohort studies from Spain, Sweden and the UK. There is no evidence as to whether screening in the community is more effective than screening in hospital, although community screening is likely to be cheaper. We have yet to find a robust therapy to reduce small aneurysm growth rates, although it is possibly too late to establish the benefit of statins in a randomised trial. It has been suggested that use of angiotensinconverting enzyme (ACE) inhibitors may diminish the risk of aneurysm rupture, 17 which raises the potential for all patients with small aneurysms to be prescribed these drugs for control of hypertension. The optimal cardiovascular risk prevention strategy for patients with small aneurysms remains to be established and implemented, although many consider AAA to be a coronary heart disease equivalent. Similarly, the potential benefits of rescreening men after 75 years or screening women at age 70 years has yet to be evaluated. It should be considered that the age-dependent increase in AAA prevalence may be offset by the rising mortality from elective repair, particularly by EVAR, in women and the elderly. 18 Summary Although both a Cochrane review and a systematic review suggest a benefit for population aneurysm screening for older men, the effectiveness of screening for AAA has not been definitively established. If the prevalence in older men falls below 3% and the uptake of screening falls below 70%, population screening may no longer be cost-effective and a change from population screening to targeting those at highest risk (smokers) may be appropriate. It is also possible that indirectly, screening may do harm rather than benefit if local operative mortality rates for aneurysm repair are high. Much will be learned from the UK National Aneurysm Screening programme and regular publically available updates from this programme will be essential. In other countries and geographical areas it would be prudent to initiate pilot studies of aneurysm screening before the decision is taken to implement population screening. Address for correspondence Janet T Powell MD, PhD, FRC Path Vascular Surgery Research Group, Imperial College, Charing Cross Campus, St Dunstan s Road, London W6 8RP j.powell@imperial.ac.uk DISCLOSURES: The opinions and factual claims herein are solely those of the authors and do not neccesarily reflect those of the publisher, editor-in-chief, editorial board and supporting company. JP has no competing interests to declare. REFERENCES 1 Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database of Systematic Reviews 2007 issue 2, Art No:CD Fleming C et al. Screening for abdominal aortic aneurysm: a best-evidence systematic review for the US Preventive Services Task Force. Ann Intern Med. 2005;142: Scott RA et al. Influence of screening on the incidence of ruptured abdominal aortic aneurysm: 5-year results of a randomised controlled study. Br J Surg 1995;82: Lindholt JS et al. Screening for abdominal aortic aneurysms: single centre randomised controlled trial. BMJ 2005;330: Norman PE et al. Population based randomised controlled trial on impact of screening on mortality from abdominal aortic aneurysm. BMJ 2004:329: Multicentre Aneurysm Screening Study Group. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. The Lancet 2002;360: Thompson SG et al. Multicentre Aneurysm Screening Study Group. Screening men for abdominal aortic aneurysm: 10-year mortality and cost-effectiveness results from the Multicentre Aneurysm Screening Study. BMJ 2009:338: Crow P et al. A single normal ultrasonographic scan at 65 years rules out significant aneurysm disease in men for life. Br J Surg. 2001;88: Greenhalgh RM, Powell JT. Screening for abdominal aortic aneurysm can save lives but only if operative mortality is low. BMJ 2007;335: Winterborn RJ et al. Preferences for endovascular (EVAR) or open surgical repair among patients with abdominal aortic aneurysms under surveillance. J Vasc Surg. 2009;49: Reise JA et al. Patient Preference for Surgical Method of Abdominal Aortic Aneurysm Repair: Postal Survey. Eur J Vasc Endovasc Surg. 2010;39: Guessous I et al. The efficacy of pharmacotherapy for decreasing the expansion rate of abdominal aortic aneurysms: a systematic review and meta-analysis. PLOS ONE 2008;3(3):e Powell, J.T., Brown, L.C., Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. Ann Surg 1999:230; Cao P. Comparison of surveillance vs Aortic Endografting for Small Aneurysm Repair (CAESAR) trial: study design and progress. Eur J Vasc Endovasc Surg. 2005;30: Ouriel K. The PIVOTAL study: a randomized comparison of endovascular repair versus surveillance in patients with smaller abdominal aortic aneurysms. J Vasc Surg 2009;49: Brady AR et al. Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance. Circulation 2004;110: Hackam DG et al. Angiotensin-converting enzyme inhibitors and aortic rupture: a population-based case-control study. The Lancet 2006;368: Abedi NN, Davenport DL, Xenos E, Sorial E, Minion DJ, Endean ED. Gender and 30-day outcome in patients undergoing endovascular aneurysm repair (EVAR): An analysis using the ACS NSQIP dataset. J Vasc Surg 2009;50:

8 review article Acute aortic syndromes: the need for aortic centres Rossella Fattori Vincenzo Russo Luigi Lovato Cardiovascular Radiology University of Bologna, Italy Roberto Di Bartolomeo Cardiac Surgery Department, University of Bologna, Italy Endovascular repair of the thoracic aorta is fast becoming the standard of care for most cases of aortic disease. It offers potential benefits regardless of disease stage and clinical condition and, for older patients with a high mortality risk, it represents a good alternative to open surgery. Thoracic endovascular aneurysm repair (TEVAR) may also offer benefit in chronic cases by helping to delay disease progression. However, the best results have been shown in acute cases (such as traumatic aortic injury and acute type B dissection), which are historically associated with the highest risk for cardiovascular disease mortality. 1-4 In 1996, a multicentre, prospective, observational study the International Registry of Acute Aortic Dissection (IRAD) was initiated to assess the clinical features of aortic dissection in the current era. Today, the IRAD includes 24 centres in twelve countries spanning three continents and has enrolled more than 1,500 patients. Findings from the IRAD show that endovascular repair was associated with a lower risk of mortality and morbidity compared with open surgical repair in patients with acute type B dissection. 5 In addition to results from the IRAD, several case series and a meta-analyses have shown positive results for the use of TEVAR in the early treatment of type B dissection and other aortic emergencies. 1-7 The need for aortic centres To help ensure clinical success and positive patient outcomes, it is important to identify promptly any haemodynamic complications in acute type B dissection (eg, visceral malperfusion or signs of impending rupture) and to provide timely endovascular treatment. One of the major barriers to the widespread use of endovascular treatment in acute complicated type B dissection is the relatively low incidence (1 2 cases/100,000 people/year), coupled with variable morphological features which demand a thorough knowledge of imaging and 3-D reconstruction software to identify patients suitable for stent-graft repair. Therefore, many small centres are constrained by their limited clinical and technical expertise in managing this complex and high risk disease. Results from a meta-analysis of endovascular treatment for type B dissection suggest surgical mortality is associated with physician s endovascular experience; the reported mortality in high volume centres (>20 patients) was 3.1% compared with 8.5 % in low-volume centres (<20 patients). 7 The Bologna experience Today, the Department of Cardiac Surgery at the S. Orsola Hospital, Bologna, Italy is a recognised centre for aortic surgery and has extensive clinical expertise in vascular diseases within different disciplines including cardiology, surgery, anaesthesiology and radiology. The centre s first experience with thoracic endovascular repair occurred in 1997 with a patient with chronic post-traumatic aneurysm, followed by the centre s first cases of aortic dissection in Since then, there has been a steady increase in similar examples over the years which have allowed physicians in the centre to build their experience and knowledge with this innovative technique. Initially, the centre at S. Orsola Hospital did not have a dedicated aortic team; however, as 7

9 the number of patients increased so too did a need for a specialised heart team. In 2004, we devised a clinical programme for the diagnosis and management of patients with acute aortic syndromes (AAS) the Aortic Syndrome Pathway. Central to the pathway was a multidisciplinary approach with a specialised heart team comprising cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and cardiovascular radiologists. Particularly important to the heart team are the cardiovascular radiologists who have detailed knowledge and extensive experience of the diagnosis and endovascular treatment of aortic disease. Crucially, they are on call 24-hours to act as consultants during endovascular repair of descending aortic disease. A critical technological advance for endovascular repair has been the development of several stent-graft configurations with the potential to treat any kind of aortic size and morphology. When the Aortic Syndrome Pathway was first devised it was only used for patients admitted to S. Orsola Hospital. However, since then it has been extended to encompass Bologna, its surroundings, and five other nearby cities (Imola, Ravenna, Forli-Cesena, Ferrara, Rimini) with a combined population of over 2,000,000 people (Figure 1). Under the auspices of the Pathway, patients with suspected AAS are first admitted to the intensive care unit of the cardiology or cardiac surgery department. After initial medical intervention to stabilise haemodynamic parameters, imaging documentation is examined by the on-call cardiovascular radiologist. Following this, the multidisciplinary heart team evaluate the clinical condition of the patient and determine the optimal course of treatment: surgery (for type A dissection or intramural haematoma), endovascular repair (for complicated type B dissection, traumatic aortic injury, penetrating aortic ulcer or other descending aortic injuries) or medical therapy (for stable patients, unsuitable anatomy or excessive risk for surgery/tevar). If endovascular repair is indicated, then the operating theatre can be opened within a few hours. fig. 1 Piacenza Parma Reggio Emilia Modena Ferrara Clinical pathways for acute aortic syndromes in Bologna Bologna and surrounding areas: 2,363,625 inhabitants Bologna Ravenna Forli-Cesena Rimini Ferrara 355,231 Bologna 936,531 Ravenna 379,468 Forli-Cesena 388,019 Rimini 303,270 8

10 Results of endovascular repair in acute aortic syndromes Among 321 patients admitted for endovascular repair at the S. Orsola Hospital between , 83 presented with AAS. These included 62 males and 21 females, with a mean age of 56 years (range years). Thirty-five had type B aortic dissection, 27 were affected by traumatic injury, seven had ruptured aneurysm, 10 penetrating ulcers and there were four cases of dehiscence of the surgical suture. Endovascular repair was successful in 81 out of the 83 cases (97.6%; two cases were unsuccessful due to inadequate vascular access). Four patients died (4.6%) of multi-organ failure despite successful endovascular repair. Delayed diagnosis and referral was a likely cause in at least three of the four cases. In-hospital major complications were limited, with two cases of postoperative renal insufficiency and two patients with stroke. Among these was a 22-year old patient with traumatic injury in whom the left subclavian artery was occluded without previous revascularisation. Interestingly, among 12 cases treated for acute type B dissection complicated by malperfusion, the simple closure of the entry site with stent graft was sufficient to improve visceral perfusion without adjunctive treatment, such as fenestration or vascular stent (Figure 2). There were no deaths associated with the procedures in these patients, and clinical and serological recovery of renal and/or mesenteric function was good. Imaging and clinical follow-up was performed in all patients at 1, 3, 6 and 12 months post treatment, and once a year thereafter. Multidetector computed tomography (CT) was used in the majority of patients, while in young patients or in case of renal insufficiency magnetic resonance imaging was preferred. During follow-up (range months [mean 34, SD ± 11 months]), only one case of aortic-related mortality was reported: the patient presented with a new distal dissection complicated by malperfusion syndrome, and died during hospital transfer. Reinterventions fig. 2 Acute complicated type B dissection complicated by malperfusion. A) Multidetector computed tomography (MDCT) axial before treatment. Periaortic haemorrhagic haematoma is visible (arrows). B) Volume rendering image before treatment. C) MDCT axial after treatment. Total false lumen thrombosis, shrinkage of thoracic and abdominal false lumen. D) Volume rendering image after treatment. A C B D 9

11 fig. 3 Acute complicated type B dissection: A) Main entry site at the left subclavian artery. B) Multiple re-entry sites (arrows). C) Emergency endovascular aneurysm repair: stent-graft coverage after cartoid to subclavian bypass occlusion of the left subclavian artery with Amplatzer vascular plug A B C were performed successfully in eight patients including stent-graft extension in six patients and left-subclavian artery embolisation in two patients (Figure 3). There are two major challenges associated with improving the efficacy of TEVAR in patients. Firstly, there is a lack of awareness that the use of stent grafts can allow the treatment of descending aortic disease at any age and clinical condition, and that time is crucial in most cases of AAS. Secondly, there are a limited number of radiologists with the required experience of aortic disease features. In addition, they do not have the specific expertise and understanding of effective TEVAR-related techniques, such as the need for thin [1 2 mm] slices on CT acquisition, longitudinal and coronal reconstruction 10

12 Address for correspondence Rossella Fattori Cardiovascular Radiology Istituto di Cardiologia, Pad 21 Policlinico S Orsola Via Massarenti 9, Bologna Italy rossella.fattori@unibo.it images with precise measurements of proximal/distal neck, access sites. These barriers can delay diagnosis and, in some cases, may result in wasted patient transfer if the aortic anatomy does not allow for stent-graft repair. Advancements in imaging systems and software will help increase knowledge of aortic disease among physicians and will assist in the identification of anatomical details associated with AAS. Moreover, a high speed, dedicated network and PACS (Picture Archiving Communication Systems) will enable faster transmission of images from candidate patients to the referral aortic centre, allowing early evaluation by the expert heart team. Ultimately, these developments will result in cost savings for the healthcare system and, importantly, improved patient outcomes for those affected by AAS. Conclusion Our experience in Bologna indicates good results can be achieved through establishment of a dedicated aortic team. A multidisciplinary approach is essential, as is the engagement of an experienced, dedicated cardiovascular radiologist. A large patient population coverage is also essential to maintain clinical and technical expertise. DISCLOSURES: The opinions and factual claims herein are solely those of the authors and do not neccesarily reflect those of the publisher, editor-in-chief, editorial board and supporting company. RF, VR, LL and RDB have no conflicts of interest to declare. REFERENCES 1. Dake MD et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. NEJM. 1999; 340: Nienaber CA et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. NEJM. 1999; 340: Szeto WY et al. Results of a new surgical paradigm: endovascular repair for acute complicated type B aortic dissection. Ann Thorac Surg Jul;86(1): Kische S et al. Endovascular treatment of acute and chronic aortic dissection: midterm results from the Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg. 2009;138(1): Fattori R et al. Complicated acute type B dissection: is surgery still the best option?: a report from the International Registry of Acute Aortic Dissection. JACC Cardiovasc Interv. 2008;1(4): Tsai TT et al. Long-Term Survival in Patients Presenting With Type B Acute Aortic Dissection. Insights from the International Registry of Acute Aortic Dissection. Circulation 2006;114: Eggebrecht H, et al. Endovascular stent-graft placement in aortic dissection: a meta-analysis. Eur Heart J 2006; 27(4): Let us know what you think of this issue us at confluence@axon-com.com Your feedback is important to us! 11

13 interview The management of AMI today: interview with Petr Widimsky P Widimsky What do you consider have been the most important achievements in the management of acute myocardial infarction (AMI) have been over the last 20 years? There have been three key achievements in the past 20 years. Firstly, the development of primary percutaneous coronary intervention (PCI) techniques has redefined how we treat AMI. Secondly, advances in drug therapy mean that we now have a full armoury of antithrombotic drugs available to us without which primary PCI would not be possible. Finally, better organisation of care has resulted in improved access to angioplasty centres for those in need of acute PCI, which is crucial for patient outcomes. How well do you think current guidelines translate into real-life clinical practice across Europe? There is quite a difference across Europe. For example, the latest European Society of Cardiology (ESC) guidelines recommend primary PCI as the preferred treatment for ST elevation acute myocardial infarction (STEMI) patients, provided it is available within minutes of first seeking medical attention. However, results from a recent study (Widimsky et al. Eur Heart J. 2010; 31: ) show large differences in access to primary PCI between countries. These inequalities are also evident within countries, regions and sometimes even within a hospital. In our research, we found that the best organisation of care for reperfusion therapy in patients with AMI is in the Central, North and, to a lesser extent, Western parts of Europe. Specifically, countries like Switzerland, Germany, Czech Republic, Austria, The Netherlands, Sweden, Norway, Denmark and Poland all have effective strategies in place. When you look at countries like France and the UK, the situation is less optimal and further South the situation becomes progressively worse. Countries such as Spain, Southern Italy, Greece, Turkey, Bulgaria, and Serbia have less organised primary PCI networks. What do you think the reasons for this are? I think the guidelines for both STEMI and non ST segment myocardial infarction (NSTEMI) are complete and well balanced. Where there is a failure to adopt the guidelines, the cause is nearly always suboptimal organisation of care. In perhaps only 10% of cases the issue is limited resources. Generally speaking, limited resources for the provision of primary PCI are not a big problem in Europe (with the exception of Romania). Most countries have sufficient numbers of cath labs and interventional cardiologists based on the population size meaning that sufficient access is possible. The development of primary percutaneous coronary intervention (PCI) techniques has redefined how we treat AMI How important do you think a multidisciplinary approach is for the long-term management of AMI? It is very important; many patients who have a myocardial infarction (MI) have multiple co-morbid conditions, such as diabetes or renal failure. The effective control University Hospital Vinohrady, Prague, Czech Republic 12

14 of co-morbidities is important as it has an impact on the risk of cardiac death. Therefore, a multidisciplinary approach is required to ensure correct management of any other conditions as well as the MI. Furthermore, all cardiac patients undergoing non-cardiac surgery and those administered with modern antithrombotic drugs will require very close cooperation between the cardiologist, surgeon and anaesthesiologist to optimise treatment. What can be done to improve the long-term management of AMI and, ultimately, patient outcomes? What is the ideal situation? This is a difficult question to answer due to the variability in access across Europe. In the short-term, improved organisation of care could help in many countries. Currently only 55% of cath labs in Europe offer non stop acute PCI services 24-hours, seven-days a week. This is unfortunate because, on the whole, the resources are available but they just need to be organised better. I am involved in the 'Stent for Life' Initiative, an official project of the ESC Working Group on Acute Cardiac Care and the European Association of Percutaneous Cardiovascular Interventions. The programme aims to encourage the wider use of reperfusion therapy with PCI and, ultimately, improve the level of care in those countries where the current treatment is sub-optimal. In the initial six target countries (Turkey, Greece, Bulgaria, Serbia, France and Spain), the standard of care can be improved easily because the infrastructure is already in place with sufficient numbers of cardiologists and cath labs. As part of the programme we are working with the local cardiologists to form 'Stent for Life' groups in each country and help identify the best strategies to improve the situation. What has been very clear from our discussions with these groups is that the needs/issues are unique to each country/area/hospital and what the 'Stent for Life' initiative can do is create a strategic framework in which those issues can be identified and resolved. The 'Stent for Life' programme aims to encourage the wider use of reperfusion therapy with PCI and, ultimately, improve the level of care Where resources or trained staff are limited other strategies may be required. One programme in the US has taken a different approach where they do not transport patients to the PCI centre but, instead, they transport an experienced cardiologist to a local cath lab in a local hospital with the patient as needed. This model would not work in every country across Europe. In the Czech Republic for instance it would not work and, in fact, it would not be necessary, because for a population of 10 million people we have 22 cath labs which can be considered to be the optimal density of cath labs (approx 0.5 million people per cath lab). This keeps the cath lab busy and builds experience with the management of MI, but does not over burden the lab. What do you think of manual thrombus aspiration? It is extremely useful in selected patients and with some patients it is not possible to perform effective PCI without it. The Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction (TAPAS) study (Svilaas et al., N Engl J Med. 2008; 358(6):557-67) has shown that the use of manual thrombus aspiration can be beneficial for most STEMI patients and results in improved clinical outcomes. What is not yet clear is whether it should be performed in STEMI patients routinely during every primary angioplasty. Results from TAPAS are extremely useful but only represent experience from a 13

15 single centre and I think a larger multicentre international randomised controlled trial would help answer this question. Currently only 55% of cath labs in Europe offer non-stop acute PCI services 24-hours, seven-days a week For patients with a very large thrombus burden, do you believe that thrombus aspiration is enough? I don t believe that thrombus aspiration alone is enough but it must be the first step. Are there times when you think thrombolysis is still indicated? For me thrombolysis is only required in very sparsely populated regions such as Northern Scandinavia, some of the Greek islands, Alaska or Antarctica. However, it really depends on how accessible the nearest cath lab is. Guidelines recommend that treatment should be administered a maximum of minutes following the first report of symptoms but it is very important to differentiate according to how this time is measured. For instance, with thrombolysis the time of first injection is considered the start of treatment, while with angioplasty it is the time of balloon inflation. However, with thrombolysis, while the injection of antithrombotic drugs is immediate, the time for these drugs to take effect can be as long as 50 minutes. With angioplasty the effect is immediate as soon as the balloon is inflated. Based on this I think a more fair comparison would be the time from onset of symptoms to injection of thrombolysis drugs and time of onset of symptoms to insertion of sheath at the beginning of an angioplasty procedure. With the right organisation and co-operation between cardiologists and other healthcare providers, countries can set up an effective primary angioplasty network How else will 'Stent for Life' activities help improve the overall management of AMI? A recent article published by the 'Stent for Life' group (Knot et al. EuroIntervention. 2009;5(3):299, ) describes some best practice examples from The Netherlands, Sweden, Denmark, Austria and the Czech Republic. These show how, with the right organisation and co-operation between cardiologists and other healthcare providers, countries can set up an effective primary angioplasty network. Based on the experiences in these countries, three realistic goals were identified: (1) primary PCI should be used for >70% of all STEMI patients; (2) primary PCI rates should reach >600 per million inhabitants per year; and (3) existing PCI centres should treat all their STEMI patients by primary PCI, i.e. should offer a 24/7 service. Address for correspondence Petr Widimsky Cardiocenter, University Hospital Vinohrady, robárova 50, Prague 10, Czech Republic widim@fnkv.cz DISCLOSURES: The opinions and factual claims herein are solely those of the author and do not neccesarily reflect those of the publisher, editor-in-chief, editorial board and supporting company. PW has no relevant disclosure to declare. Let us know what you think of this issue us at confluence@axon-com.com Your feedback is important to us! 14

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