June 2023 / Issue 98
www.vascularnews.com
25 Transcarotid artery revascularisation Latest updates
Hanaa Dakour-Aridi
Featured in this issue:
9 Antithrombotic guidelines
16 Profile
Key takeaways
Rachel Bell
69% of the CX 2023 audience agreed: bioresorbable wins
S Keisin Wang
14 Bioresorbable stents
The CX audience has its say
CAROTID
Efforts to move towards routine patch closure or eversion endarterectomy among all carotid surgeons “warranted”
First results of BASIL-2 randomised controlled trial revealed at CX 2023 A question from Manj Gohel (Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK) on what the Charing Cross (CX) audience should take back to their multidisciplinary team meetings from the firsttime presentation of the BASIL-2 trial led chief investigator Andrew Bradbury (University of Birmingham, Birmingham, UK) to deliver the stark message: a patient who needs a belowthe-knee revascularisation with or without a femoropopliteal revascularisation is likely to do better if they are treated with a best endovascular-first strategy rather than a vein bypass-first approach.
I
n the BASIL-2 (Bypass versus angioplasty for severe ischaemia of the leg) trial of 345 patients with chronic limbthreatening ischaemia (CLTI), a best endovascular treatmentfirst revascularisation strategy was associated with better amputation-free survival than a vein bypass-first strategy in those who required an infrapopliteal repair—with or without a more proximal infrainguinal procedure. This result was largely driven by fewer deaths in the best endovascular treatment group. Bradbury presented this key finding at the 2023 CX International Symposium (25–27 April, London, UK). The results were simultaneously published in The Lancet. “It all seems to be pointing towards attempting an endovascular procedure first and then if that does not work, doing something else—which could be more endovascular,” Bradbury said in response to Gohel. Alternatively, he added, this could be the point at which the vascular specialist switches over to a bypass approach. BASIL-2, however, “lends quite a lot of weight” to an endovascular-first revascularisation strategy, “with all the caveats that we have to consider”. Bradbury, delivering the data for the first time during day one
of CX 2023, revealed that 63% of patients randomised to a vein bypass-first strategy of treatment underwent a major amputation or died during follow-up, compared to just 53% of those allotted to a best endovascular-first approach—BASIL-2’s primary outcome measure (adjusted hazard ratio 1.35, 95% confidence interval [CI] 1.02–1.08, p=0.037). “Essentially this means that, in this cohort, a vein bypass revascularisation strategy resulted in a 35% increased risk of amputation or death during the follow-up compared with a best endovascular-first revascularisation strategy,” Bradbury said. Median survival for the whole cohort was 3.8 years—3.3 years for the vein bypass group and 4.4 for the endovascular arm, he said. “The significant difference we have observed in favour of best endovascular therapy with amputation-free survival is very largely driven by the fact that there were more deaths in the vein bypass group—53% of vein bypass patients and 45% of best endovascular therapy patients,” Bradbury continued. “There is no significant difference of 30-day mortality but you can see that the median survival of the two groups is quite different.” CLTI is the “severest manifestation” of peripheral arterial disease (PAD) and presents as ischaemic pain at rest or tissue loss, or both, the authors detail in The Lancet. Against this backdrop, Bradbury and colleagues were comparing
It is very, very crucial that whatever you do first, it does not have to be the last word—” Roger Greenhalgh
A NATIONWIDE COHORT study of over 9,000 patients shows that the “controversial” practice of arteriotomy closure for carotid endarterectomy (CEA) is associated with an increased risk of ipsilateral stroke and “should be avoided”. Instead, authors Magnus Jonsson (Karolinska University Hospital, Stockholm, Sweden) and colleagues argue, endarterectomy should be performed with either routine patch closure or using the eversion technique. Despite these findings, the authors underline the fact that primary closure “remains common practice” among some surgeons. The study—recently published as an Editor’s Choice paper in the European Journal of Vascular and Endovascular Surgery (EJVES)— also shows that the long-term durability of different patch materials is equivalent, and that bovine pericardium and eversion have a lower risk of late infections. Jonsson et al note in their introduction that current European guidelines recommend both eversion CEA and conventional CEA with routine patch closure, rather than routine primary closure. However, they add, “many surgeons prefer selective patching and there remains much controversy about the relative benefits of the different surgical techniques and patches for CEA”. The aim of the present study was to evaluate the short- and longterm outcomes after CEA based on surgical technique and patch material. The investigators detail that there are several available patch types on the market at present. “Dacron, vein and polytetrafluoroethylene (PTFE) Continued on page 3
Continued on page 2