Debates and challenges in peripheral interventions

This session will consider three areas: surgical versus endovascular treatment of peripheral emboli and thrombosis, the management of renal artery thrombosis and the indications for closed and open treatment of abdominal aortic aneurysm (AAA).

Generalisations are particularly difficult in the treatment of peripheral thrombotic or embolic events, not least because randomised studies to guide these decisions are lacking. Endovascular treatment is probably more appropriate for localised emboli, whilst larger emboli and acute thrombosis are most likely better managed by surgical interventions.

Perhaps a progressive approach of initial thrombolysis, use of mechanical systems followed by open surgery if indicated may serve as a "working algorithm", which Professor Biamino will advocate, though the final approach will always vary from patient to patient.

The debate over the treatment of renal artery stenosis promises to be particularly lively. The ASTRA trial, a relatively large randomised trial (> 800 patients), suggests no advantage for stenting over medical treatment, there having been no demonstrable improvement in diastolic BP, cardiovascular events or creatinine levels. However, were the baseline characteristics fully representative of the treatable population? Mean stenosis was only 75% and quantitative data on the lesion, though problematic to acquire, would have been preferable. Similarly, mean BP was 150/76; not hypertensive. Dr Zeller, in contrast, will provide new data arguing a definite role for stent treatment.

Thanks to better technology and better systems of delivery, the transcutaneous treatment of AAA enjoys expanding indications and is the treatment of choice for easier anatomy and elderly patients. Controversy arises, however, when the anatomy becomes more complicated and this problem is also not yet well informed by appropriate studies. This broad debate, chaired by Professor Biamino, will be supplemented by live case transmissions from Eindhoven and promises to be anything but a peripheral discussion!