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C0449: Thrombophilia Markers in Patients with Ischemic Stroke
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POSTERS / Thrombosis Research 133S3 (2014) S35–S123
time (cerebrovascular disease and peripheral arteritis disease) and the conjunction of long time drugs consumption of cannabis, alcohol and tobacco. C0410 HEMOSTATIC DERANGEMENTS IN PATIENTS UNDERGOING OPEN AND ENDOVASCULAR REPAIR OF ABDOMINAL AORTIC ANEURYSMS A. Raptis1 , C. Antonopoulos1 , J. Kakisis1 , A. Blann2 , G. Kavalieratos1 , G. Mantas1 , S. Mylonas1 , F. Markatis1 , C. Papasideris1 , C. Liapis1 . 1 Athens University Medical School, “Attikon” University Hospital, Athens, Greece; 2 City Hospital, Birmingham, UK Background: Abdominal Aortic Aneurysm (AAA) is associated with chronic mural inflammation and hemostatic derangements presenting as increased thrombin generation, thrombin activity and fibrin turnover. However, it is unclear if these hemostatic derangements are altered after AAA repair. The aim of our study was to investigate the effect of open surgical repair (OSR) and endovascular aortic repair (EVAR) upon coagulation and fibrinolysis. Methods: A systematic review and meta-analysis on the impact of AAA repair upon 14 different biomarkers of coagulation and fibrinolysis was performed. Standardized Mean Difference (SMD) and 95% Confidence Intervals (CIs) were calculated for the assessed biomarkers after 1 day and 1–5 months of operation, compared to baseline. Subgroup analyses on OSR and EVAR were also performed. Results: A total of 11 studies were deemed eligible. A statistically significant hypercoagulation was evidenced on the 1st postoperative day (SMD = 0.98, 95% CI 0.39 to 1.57). Subgroup analyses evidenced that this effect was only replicated after EVAR (SMD = 1.15, 95% CI 0.37 to 1.93), whereas no hypercoagulation was evidenced after OSR (SMD = 0.68, 95% CI −0.30 to 1.66). Similarly, fibrinolysis was significantly increased on the 1st postoperative day (SMD = 1.44, 95% CI 0.99 to 1.89). Subgroup analysis evidenced that this effect was replicated on both EVAR (SMD = 1.52, 95% CI 0.95 to 2.08) and OSR (SMD = 1.21, 95% CI 0.66 to 1.76). Coagulation and fibrinolysis were not significantly altered after 1–5 months of AAA repair, compared to baseline (SMD = −0.13, 95% CI −0.33 to 0.08 and SMD = −0.22, 95% CI −0.71 to 0.27, respectively). This was also replicated in the subgroup analyses of both OSR and EVAR. Conclusions: This study indicated that both OSR and EVAR may exaggerate the hemostatic derangements on the 1st postoperative day. However, coagulation and fibrinolysis were normalized 1–5 months after both OSR and EVAR. Future research should examine whether these findings suggest a potentially increased cardiovascular risk in the acute postoperative period after AAA repair. C0431 HIGH INCIDENCE OF THROMBOTIC CEREBRAL LESIONS IN ADULT PATIENTS WITH BETA-THALASSEMIA MAJOR I. Pazgal1 , E. Inbar1 , M. Cohen1 , O. Shpilberg1 , P. Raanani1 , E. Rachmilewitz2 , P. Stark1 . 1 Beilinson Hospital, Rabin medical Center, Petah Tikva & Sackler School of Medicine, Tel Aviv University, Israel; 2 Wolfson Hospital. Clinical Center 1. Holon, Israel Background: The prolonged survival of b-thalassemia major (TM) patients due to improved treatment, results in complications that have not been recognized before, including thromboembolic complications, such as cerebral thrombotic events. Asymptomatic silent cerebral infarctions (SCI), at incidence of 27–60%, have been demonstrated by MRI in patients with b-thalassemia intermedia (TI) (Musallam et al. Thromb Res 130: 695, 2012), but less data is available for TM. In this study, we determined the incidence of SCI in transfusion-dependent TM patients.
Methods: The study included 18 patients with transfusiondependent TM, 10 males and 8 females, 21–42 years old. Sixteen patients were Spx. After obtaining an informed consent, brain MRI was performed prior to receiving blood transfusion, using 3T Ingenia (Philips) system in SET1 TSET2 diffusion SWI (5 mm slice) and 3DFLAIR (1.1 mm slice). Results: Average platelet count in Spx patients was 565k/ml (range 330–784) and in 2 unspx – 242k/ml (164, 320). Average ferritin level was 1707 ng/ml (range 295–7431). Twelve patients had focal bright lesions in the cerebral white matter. Ten spx patients had a mean of 16 lesions (range 1–73), while 2 unspx had 1 and 53 lesions. Most of the lesions were in frontal lobes and bilateral, maximal diameter up to 7 mm. All lesions were negative in diffusion with no susceptibility artifacts. The MRI findings did not correlate with the laboratory parameters, except for ferritin which was higher (1918 ng/ml) in patients with SCI lesions vs. those without lesions (1215 ng/ml). Moreover, 5 of the 9 patients with ferritin 1000 ng/ml had a mean of 21.1 lesions. Conclusions: The results demonstrate a 66% incidence of asymptomatic SCI in TM patients which were similar in size and location to those observed in TI. These findings suggest that the increased number of activated platelets in Spx patients with TI as well as in patients with TM, rather than the high number of pathological circulating RBC, is a factor in the etiology of SCI. In addition, iron overload, documented by high ferritin levels, may also play a role in the etiology of hypercoagulability in thalassemia. Based on the results, we recommend that, in addition to iron chelation, low dose aspirin should be given routinely to transfused TM patients. C0439 FIBRINOLYTIC HEMORRHAGES IN SURGICAL PRACTICE I. Ovtcho Topalov1 , K. Guirov1 , M. Topalova1 , E. Aleksiev1 . 1 Surgical Clinic, Medical Institute – MI Clinic of Vascular Surgery and Angiology – MMA, Bulgaria Background: Study of fibrinolytic process (FP) proved that, except the liver, almost every tissue has the ability to activate the plasminogen. Plasminogen activator accumulates in the endothelial cells of the vessels’ walls, but the release mechanism of angiokinase (plasminogen activator) is not fully uncovered. Methods: The authors had studied the appearance and development of the fibrinolytic process in the surgical practice for more than 40 years. Their personal experience consisted of diagnosis and treatment of 28 patients (Table 1). Results: Analysis of FP showed high lethality – 46.43%, despite the modern treatment. Conclusions: The authors developed method of local antifibrinolytic therapy in cardiac and vascular surgery, apart from the general one. The method was applied successfully in both experiments, and clinical practice. C0449 THROMBOPHILIA MARKERS IN PATIENTS WITH ISCHEMIC STROKE H. Kallel1 , R. Ellouze1 , M. Ben Said1 , S. Guermazi1 . 1 Hˆ opital Charles Nicolle de Tunis. Hematology, Tunis, Tunisia Background: Cerebral stroke is frequently associated with risk factors including diabetes, hypertension, hyperlipidemia, smoking or valvular heart disease. Inherited thrombophilia are more frequently associated with venous than arterial thrombosis. On the other hand, antiphospholipids syndrome is considerate as a risk factor of arterial thrombosis. This study aimed to analyze the association between thrombophilia markers (acquired and congenital) and cerebral stroke. Methods: This is a retrospective study including 37 patients with a history of cerebral stroke. Deficiencies in protein S (PS),
POSTERS / Thrombosis Research 133S3 (2014) S35–S123
protein C (PC), antithrombin (AT), activated protein C resistance (APCR) and antiphospholipid antibodies (APL) was evaluated in all patients. Protein S, protein C, antithrombin, activated protein C resistance and lupus anticoagulant (LA) were tested on STA Compact automate with Stago reagents. IgG and IgM anti beta2 Glycoprotein I (anti-B2GP1) and anticardiolipin have been measured by ELISA using commercial kits. Results: The mean age of the population studied was 45 years (range 23–62 years). Sex ratio: 0.85 (17M/20F). 2 patients (23 and 28 years old) had PC deficiency associated with a positive antiB2GP1 (IgM class); APCR was detected in 3 patients (40, 47 and 47 years old). We found 1 patient with an isolated LA, and 19 with anti-B2GP1 antibodies. ACL were negative in all patients. Among 19 patients with anti-B2GP1, an isolated positivity was found in 13 patients (1 IgG, 9 IgM, 3 IgA). 6 patients had associations of 2 isotypes (2 IgM+IgG, 3 IgG+IgA, 1 IgM+IgA). Conclusions: The relationship between cerebral stroke and congenital thrombophilia is not demonstrated in the majority of studies. However antiphospholipid syndrome is the most incriminated. According ISTH recommendations, antiphospholipid antibodies research include: LA, ACL (IgG, IgM) and anti-B2GP1 (IgG, IgM). IgA class are not recommentated. We found no association between LA and anti-B2GP1. In our study none of the patients had ACL positive, and 19 had anti-B2GPI. IgA and IgM are the most frequent isotypes (respectively 7 and 13). IgA anti-B2GPI could play a role in arterial thrombosis. C0461 OUTCOMES OF ENDOVASCULAR TREATMENT FOR TASC-II D FEMOROPOPLITEAL OCCLUSIVE LESIONS 1 ´ Torres1 , G. Edo1 , F. Julian A. ´ Gomez ´ , M. Ram´ırez1 , E. Ort´ız1 . 1 Hospital Dr. Peset, Av/Gaspar Aguilar Valencia, Spain
Background: TransAtlantic Society Consensus (TASC)-II recommends open surgical revascularization as the treatment of choice for type D femoropopliteal lesions. These patients often presents with critical limb ischemia, but many times they are high-risk for by-pass and endovascular treatment is a less invasive option. The aim of the study is to assess the efficacy and safety of endovascular treatment on these femoropopliteal lesions. Methods: Patients underwent endovascular treatment for femoropopliteal occlusive disease between June 2005 and Dec 2013 were reviewed and those with TASC D lesions were selected. We reviewed retrospectively from a prospectively maintained database. Data included demographics, anatomic features, pre- and postprocedure ankle-brachial indices (ABI), duplex ultrasound, medical therapy and periprocedural complications. Primary patency, assisted-patency and secondary patency were assessed by Kaplan–Meier estimation. Angiograms were reviewed to determine the type of lesion and the number of runoff vessels. Results: Thirty-two patients underwent endovascular treatment of 35 TASC D de novo femoropopliteal occlusions. Mean age was 76±9 and 56% were men. Mean lesion length was 23±5 cm. Indication included claudication in 8% and critical limb ischemia in 92% (70% with tissue loss). 17 limbs underwent treatment by stent (49%), 13 by stentgraft (37%) and 5 by balloon angioplasty (14%). Mean follow-up was 31±28 months. Preoperative ABI were unobtainable for 13 patients, and the remaining had a mean ABI of 0.38±0.1. Periprocedural complications: one hematoma that needed transfusion, one thrombosis of distal vessel and one embolization. Postoperative mean ABI was 0.92±0.1. One patient was lost to follow up. Restenosis was detected in eleven patients (31%) and occlusion in five (14%). All the limbs with restenosis and one with occlusion underwent endovascular reintervention, and two limbs with occlusion underwent by-pass. Five patients required major amputation and four patients died during follow-up. Primary patency, assisted-primary patency and secondary patency rates at
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12 and 24 months were 72%, 83%, 83% and 60%, 79% and 79% respectively. Conclusions: Endovascular treatment for TASC II D lesions is safe and offers satisfying outcomes. This patient subset would benefit from a minimally invasive approach. Follow-up is advisable due to a high rate of restenosis. Further follow-up is necessary to know the long-term efficacy of these procedures. C0496 ENDOVASCULAR TREATMENT OF A CHALLENGING FEMOROPOPLITEAL OCCLUSION THROUGH A RETROGRADE APPROACH ´ Torres Blanco1 , F. Gomez G. Edo Fleta1 , A. ´ Palones ´ 1 , M. Ram´ırez Montoya1 , E. Ort´ız Monzon ´ 1 . 1 Hospital doctor Peset, gaspar aguilar Valencia, Spain Background: For type D femoropopliteal occlusions Trans-Atlantic Society Consensus (TASC-II) recommends by-pass as the treatment of choice. Advances in endovascular techniques make possible to treat these lesions in high-risk patients with low morbidity. We report a successful treatment of a long and very calcified femoropopliteal artery through a popliteal retrograde approach. Methods: A 88-year-old man presented with rest pain and a tissue loss lesion of the second finger and heel of the right feet. Comorbidities were hypertension, diabetes, dyslipidemia, smoking, atrial fibrillation and a cronic renal failure. He underwent two previous endovascular attempts of revascularization in other hospital. He presented femoropopliteal occlusion semiology with ankle-brachial index (ABI) of 0.4. Arterial access was performed via the common femoral artery through a contralateral approach. Angiogram showed heavily calcified total femoropopliteal occlusion from the superficial femoral artery take off to the first portion of popliteal artery and a single-vessel runoff, the anterior tibial artery. As the antegrade passage of the occlusion was unsuccessful, a retrograde popliteal approach was performed with a 20G neddle. A 0.018 guidewire and a 0.018 support catheter were selected to cross the occlusion. The wire did not pass completely the lesion and recanalization was achieved by means of the double-balloon technique. Balloon angioplasty and stenting was performed from antegrade in all the occluded segment, using an stentgraft of 6×250 mm for the distal segment and overlapping self-expanding stent for the proximal segment of 6×60 mm. Completion angiogram showed femoropopliteal patency without residual stenosis. Patient was administered aspirin and heparin during one month. After, patient received dual antiplatelet therapy with aspirin and clopidogrel. Results: After the procedure the patient recovered popliteal and pedis pulse, with an ABI of 0.95 and wound healing in a few weeks. Six months later, patency with no restenosis was confirmed by duplex ultrasound. Conclusions: Recanalization through retrograde approach can be a technical resource for complex femoropopliteal lesions after failed antegrade approach. C0509 PATIENT WITH CONGENITAL AFIBRINOGENEMIA AND PERIPHERAL ARTERIAL THROMBOSIS. THERAPEUTIC ANTITHROMBOTIC MANAGEMENT BASED ON MONITORING A. Moscardo´ 1 , A. Cid2 , S. Haya2 , A. Latorre1 , M. Teresa Santos3 , V. Villa3 , S. Bonanad2 , J. Valles ´ 3 . 1 IIS La Fe, University Hospital La Fe, Valencia, Spain; 2 Thrombosis and Haemostasis Unit, University Hospital La Fe, Valencia, Spain; 3 Research Center, University Hospital La Fe, Valencia, Spain Background: Congenital afibrinogenemia is a rare severe bleeding disorder. Paradoxically, rarely is associated with arterial or venous thrombotic problems. In these cases the complexity of the therapeutic management must be underlined.
POSTERS / Thrombosis Research 133S3 (2014) S35–S123
time (cerebrovascular disease and peripheral arteritis disease) and the conjunction of long time drugs consumption of cannabis, alcohol and tobacco. C0410 HEMOSTATIC DERANGEMENTS IN PATIENTS UNDERGOING OPEN AND ENDOVASCULAR REPAIR OF ABDOMINAL AORTIC ANEURYSMS A. Raptis1 , C. Antonopoulos1 , J. Kakisis1 , A. Blann2 , G. Kavalieratos1 , G. Mantas1 , S. Mylonas1 , F. Markatis1 , C. Papasideris1 , C. Liapis1 . 1 Athens University Medical School, “Attikon” University Hospital, Athens, Greece; 2 City Hospital, Birmingham, UK Background: Abdominal Aortic Aneurysm (AAA) is associated with chronic mural inflammation and hemostatic derangements presenting as increased thrombin generation, thrombin activity and fibrin turnover. However, it is unclear if these hemostatic derangements are altered after AAA repair. The aim of our study was to investigate the effect of open surgical repair (OSR) and endovascular aortic repair (EVAR) upon coagulation and fibrinolysis. Methods: A systematic review and meta-analysis on the impact of AAA repair upon 14 different biomarkers of coagulation and fibrinolysis was performed. Standardized Mean Difference (SMD) and 95% Confidence Intervals (CIs) were calculated for the assessed biomarkers after 1 day and 1–5 months of operation, compared to baseline. Subgroup analyses on OSR and EVAR were also performed. Results: A total of 11 studies were deemed eligible. A statistically significant hypercoagulation was evidenced on the 1st postoperative day (SMD = 0.98, 95% CI 0.39 to 1.57). Subgroup analyses evidenced that this effect was only replicated after EVAR (SMD = 1.15, 95% CI 0.37 to 1.93), whereas no hypercoagulation was evidenced after OSR (SMD = 0.68, 95% CI −0.30 to 1.66). Similarly, fibrinolysis was significantly increased on the 1st postoperative day (SMD = 1.44, 95% CI 0.99 to 1.89). Subgroup analysis evidenced that this effect was replicated on both EVAR (SMD = 1.52, 95% CI 0.95 to 2.08) and OSR (SMD = 1.21, 95% CI 0.66 to 1.76). Coagulation and fibrinolysis were not significantly altered after 1–5 months of AAA repair, compared to baseline (SMD = −0.13, 95% CI −0.33 to 0.08 and SMD = −0.22, 95% CI −0.71 to 0.27, respectively). This was also replicated in the subgroup analyses of both OSR and EVAR. Conclusions: This study indicated that both OSR and EVAR may exaggerate the hemostatic derangements on the 1st postoperative day. However, coagulation and fibrinolysis were normalized 1–5 months after both OSR and EVAR. Future research should examine whether these findings suggest a potentially increased cardiovascular risk in the acute postoperative period after AAA repair. C0431 HIGH INCIDENCE OF THROMBOTIC CEREBRAL LESIONS IN ADULT PATIENTS WITH BETA-THALASSEMIA MAJOR I. Pazgal1 , E. Inbar1 , M. Cohen1 , O. Shpilberg1 , P. Raanani1 , E. Rachmilewitz2 , P. Stark1 . 1 Beilinson Hospital, Rabin medical Center, Petah Tikva & Sackler School of Medicine, Tel Aviv University, Israel; 2 Wolfson Hospital. Clinical Center 1. Holon, Israel Background: The prolonged survival of b-thalassemia major (TM) patients due to improved treatment, results in complications that have not been recognized before, including thromboembolic complications, such as cerebral thrombotic events. Asymptomatic silent cerebral infarctions (SCI), at incidence of 27–60%, have been demonstrated by MRI in patients with b-thalassemia intermedia (TI) (Musallam et al. Thromb Res 130: 695, 2012), but less data is available for TM. In this study, we determined the incidence of SCI in transfusion-dependent TM patients.
Methods: The study included 18 patients with transfusiondependent TM, 10 males and 8 females, 21–42 years old. Sixteen patients were Spx. After obtaining an informed consent, brain MRI was performed prior to receiving blood transfusion, using 3T Ingenia (Philips) system in SET1 TSET2 diffusion SWI (5 mm slice) and 3DFLAIR (1.1 mm slice). Results: Average platelet count in Spx patients was 565k/ml (range 330–784) and in 2 unspx – 242k/ml (164, 320). Average ferritin level was 1707 ng/ml (range 295–7431). Twelve patients had focal bright lesions in the cerebral white matter. Ten spx patients had a mean of 16 lesions (range 1–73), while 2 unspx had 1 and 53 lesions. Most of the lesions were in frontal lobes and bilateral, maximal diameter up to 7 mm. All lesions were negative in diffusion with no susceptibility artifacts. The MRI findings did not correlate with the laboratory parameters, except for ferritin which was higher (1918 ng/ml) in patients with SCI lesions vs. those without lesions (1215 ng/ml). Moreover, 5 of the 9 patients with ferritin 1000 ng/ml had a mean of 21.1 lesions. Conclusions: The results demonstrate a 66% incidence of asymptomatic SCI in TM patients which were similar in size and location to those observed in TI. These findings suggest that the increased number of activated platelets in Spx patients with TI as well as in patients with TM, rather than the high number of pathological circulating RBC, is a factor in the etiology of SCI. In addition, iron overload, documented by high ferritin levels, may also play a role in the etiology of hypercoagulability in thalassemia. Based on the results, we recommend that, in addition to iron chelation, low dose aspirin should be given routinely to transfused TM patients. C0439 FIBRINOLYTIC HEMORRHAGES IN SURGICAL PRACTICE I. Ovtcho Topalov1 , K. Guirov1 , M. Topalova1 , E. Aleksiev1 . 1 Surgical Clinic, Medical Institute – MI Clinic of Vascular Surgery and Angiology – MMA, Bulgaria Background: Study of fibrinolytic process (FP) proved that, except the liver, almost every tissue has the ability to activate the plasminogen. Plasminogen activator accumulates in the endothelial cells of the vessels’ walls, but the release mechanism of angiokinase (plasminogen activator) is not fully uncovered. Methods: The authors had studied the appearance and development of the fibrinolytic process in the surgical practice for more than 40 years. Their personal experience consisted of diagnosis and treatment of 28 patients (Table 1). Results: Analysis of FP showed high lethality – 46.43%, despite the modern treatment. Conclusions: The authors developed method of local antifibrinolytic therapy in cardiac and vascular surgery, apart from the general one. The method was applied successfully in both experiments, and clinical practice. C0449 THROMBOPHILIA MARKERS IN PATIENTS WITH ISCHEMIC STROKE H. Kallel1 , R. Ellouze1 , M. Ben Said1 , S. Guermazi1 . 1 Hˆ opital Charles Nicolle de Tunis. Hematology, Tunis, Tunisia Background: Cerebral stroke is frequently associated with risk factors including diabetes, hypertension, hyperlipidemia, smoking or valvular heart disease. Inherited thrombophilia are more frequently associated with venous than arterial thrombosis. On the other hand, antiphospholipids syndrome is considerate as a risk factor of arterial thrombosis. This study aimed to analyze the association between thrombophilia markers (acquired and congenital) and cerebral stroke. Methods: This is a retrospective study including 37 patients with a history of cerebral stroke. Deficiencies in protein S (PS),
POSTERS / Thrombosis Research 133S3 (2014) S35–S123
protein C (PC), antithrombin (AT), activated protein C resistance (APCR) and antiphospholipid antibodies (APL) was evaluated in all patients. Protein S, protein C, antithrombin, activated protein C resistance and lupus anticoagulant (LA) were tested on STA Compact automate with Stago reagents. IgG and IgM anti beta2 Glycoprotein I (anti-B2GP1) and anticardiolipin have been measured by ELISA using commercial kits. Results: The mean age of the population studied was 45 years (range 23–62 years). Sex ratio: 0.85 (17M/20F). 2 patients (23 and 28 years old) had PC deficiency associated with a positive antiB2GP1 (IgM class); APCR was detected in 3 patients (40, 47 and 47 years old). We found 1 patient with an isolated LA, and 19 with anti-B2GP1 antibodies. ACL were negative in all patients. Among 19 patients with anti-B2GP1, an isolated positivity was found in 13 patients (1 IgG, 9 IgM, 3 IgA). 6 patients had associations of 2 isotypes (2 IgM+IgG, 3 IgG+IgA, 1 IgM+IgA). Conclusions: The relationship between cerebral stroke and congenital thrombophilia is not demonstrated in the majority of studies. However antiphospholipid syndrome is the most incriminated. According ISTH recommendations, antiphospholipid antibodies research include: LA, ACL (IgG, IgM) and anti-B2GP1 (IgG, IgM). IgA class are not recommentated. We found no association between LA and anti-B2GP1. In our study none of the patients had ACL positive, and 19 had anti-B2GPI. IgA and IgM are the most frequent isotypes (respectively 7 and 13). IgA anti-B2GPI could play a role in arterial thrombosis. C0461 OUTCOMES OF ENDOVASCULAR TREATMENT FOR TASC-II D FEMOROPOPLITEAL OCCLUSIVE LESIONS 1 ´ Torres1 , G. Edo1 , F. Julian A. ´ Gomez ´ , M. Ram´ırez1 , E. Ort´ız1 . 1 Hospital Dr. Peset, Av/Gaspar Aguilar Valencia, Spain
Background: TransAtlantic Society Consensus (TASC)-II recommends open surgical revascularization as the treatment of choice for type D femoropopliteal lesions. These patients often presents with critical limb ischemia, but many times they are high-risk for by-pass and endovascular treatment is a less invasive option. The aim of the study is to assess the efficacy and safety of endovascular treatment on these femoropopliteal lesions. Methods: Patients underwent endovascular treatment for femoropopliteal occlusive disease between June 2005 and Dec 2013 were reviewed and those with TASC D lesions were selected. We reviewed retrospectively from a prospectively maintained database. Data included demographics, anatomic features, pre- and postprocedure ankle-brachial indices (ABI), duplex ultrasound, medical therapy and periprocedural complications. Primary patency, assisted-patency and secondary patency were assessed by Kaplan–Meier estimation. Angiograms were reviewed to determine the type of lesion and the number of runoff vessels. Results: Thirty-two patients underwent endovascular treatment of 35 TASC D de novo femoropopliteal occlusions. Mean age was 76±9 and 56% were men. Mean lesion length was 23±5 cm. Indication included claudication in 8% and critical limb ischemia in 92% (70% with tissue loss). 17 limbs underwent treatment by stent (49%), 13 by stentgraft (37%) and 5 by balloon angioplasty (14%). Mean follow-up was 31±28 months. Preoperative ABI were unobtainable for 13 patients, and the remaining had a mean ABI of 0.38±0.1. Periprocedural complications: one hematoma that needed transfusion, one thrombosis of distal vessel and one embolization. Postoperative mean ABI was 0.92±0.1. One patient was lost to follow up. Restenosis was detected in eleven patients (31%) and occlusion in five (14%). All the limbs with restenosis and one with occlusion underwent endovascular reintervention, and two limbs with occlusion underwent by-pass. Five patients required major amputation and four patients died during follow-up. Primary patency, assisted-primary patency and secondary patency rates at
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12 and 24 months were 72%, 83%, 83% and 60%, 79% and 79% respectively. Conclusions: Endovascular treatment for TASC II D lesions is safe and offers satisfying outcomes. This patient subset would benefit from a minimally invasive approach. Follow-up is advisable due to a high rate of restenosis. Further follow-up is necessary to know the long-term efficacy of these procedures. C0496 ENDOVASCULAR TREATMENT OF A CHALLENGING FEMOROPOPLITEAL OCCLUSION THROUGH A RETROGRADE APPROACH ´ Torres Blanco1 , F. Gomez G. Edo Fleta1 , A. ´ Palones ´ 1 , M. Ram´ırez Montoya1 , E. Ort´ız Monzon ´ 1 . 1 Hospital doctor Peset, gaspar aguilar Valencia, Spain Background: For type D femoropopliteal occlusions Trans-Atlantic Society Consensus (TASC-II) recommends by-pass as the treatment of choice. Advances in endovascular techniques make possible to treat these lesions in high-risk patients with low morbidity. We report a successful treatment of a long and very calcified femoropopliteal artery through a popliteal retrograde approach. Methods: A 88-year-old man presented with rest pain and a tissue loss lesion of the second finger and heel of the right feet. Comorbidities were hypertension, diabetes, dyslipidemia, smoking, atrial fibrillation and a cronic renal failure. He underwent two previous endovascular attempts of revascularization in other hospital. He presented femoropopliteal occlusion semiology with ankle-brachial index (ABI) of 0.4. Arterial access was performed via the common femoral artery through a contralateral approach. Angiogram showed heavily calcified total femoropopliteal occlusion from the superficial femoral artery take off to the first portion of popliteal artery and a single-vessel runoff, the anterior tibial artery. As the antegrade passage of the occlusion was unsuccessful, a retrograde popliteal approach was performed with a 20G neddle. A 0.018 guidewire and a 0.018 support catheter were selected to cross the occlusion. The wire did not pass completely the lesion and recanalization was achieved by means of the double-balloon technique. Balloon angioplasty and stenting was performed from antegrade in all the occluded segment, using an stentgraft of 6×250 mm for the distal segment and overlapping self-expanding stent for the proximal segment of 6×60 mm. Completion angiogram showed femoropopliteal patency without residual stenosis. Patient was administered aspirin and heparin during one month. After, patient received dual antiplatelet therapy with aspirin and clopidogrel. Results: After the procedure the patient recovered popliteal and pedis pulse, with an ABI of 0.95 and wound healing in a few weeks. Six months later, patency with no restenosis was confirmed by duplex ultrasound. Conclusions: Recanalization through retrograde approach can be a technical resource for complex femoropopliteal lesions after failed antegrade approach. C0509 PATIENT WITH CONGENITAL AFIBRINOGENEMIA AND PERIPHERAL ARTERIAL THROMBOSIS. THERAPEUTIC ANTITHROMBOTIC MANAGEMENT BASED ON MONITORING A. Moscardo´ 1 , A. Cid2 , S. Haya2 , A. Latorre1 , M. Teresa Santos3 , V. Villa3 , S. Bonanad2 , J. Valles ´ 3 . 1 IIS La Fe, University Hospital La Fe, Valencia, Spain; 2 Thrombosis and Haemostasis Unit, University Hospital La Fe, Valencia, Spain; 3 Research Center, University Hospital La Fe, Valencia, Spain Background: Congenital afibrinogenemia is a rare severe bleeding disorder. Paradoxically, rarely is associated with arterial or venous thrombotic problems. In these cases the complexity of the therapeutic management must be underlined.