Aortoiliac occlusive disease local operator's long-term success - - PowerPoint PPT Presentation

4/18/2015 1

Aortoiliac occlusive disease

Bala Ramanan, MBBS 1st year vascular surgery fellow

Per the TASC II Document:

• Surgery is the treatment of choice for

type D lesions

• Surgery is the preferred treatment for

good-risk patients with type C lesions. The patient's co-morbidities, fully informed patient preference and the local operator's long-term success rates must be considered when making treatment recommendations for type C lesions

• Since the introduction of TASC

guidelines for the treatment of aortoiliac

• cclusive disease, there has been

tremendous advancement in endovascular techniques

Role of endovascular therapy in TASC II C & D inflow disease

Data available since the TASC II guidelines were published

• Review articles and several studies have shown the feasibility of endovascular

therapy for TASC II C and D lesions.

• Primary patency rate is lower for endovascular therapy compared to surgery (60-

86%) at 5 years.

• Secondary patency rate is 80-98% for endovascular therapy at 5 years.

Case Presentation

• 63 year old female.
• Life style limiting left calf claudication for one year.
• CT angiogram at outside hospital demonstrated left diffuse common and external

iliac disease.

• Unsuccessful anterograde and retrograde attempts at an outside hospital 2 weeks

prior to presentation at UCSF.

• PMH: HTN, dyslipidemia, CAD s/p MI 2006 and subsequent PCI-stable from cardiac

standpoint for surgery.

• Medications: Tylenol with codeine, alprazolam, aspirin, carvedilol, metformin,

multivitamin, simvastatin .

• SH: 99 pack-year smoking history, stopped 2 months prior to presentation, non-

drinker.

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Physical Examination

• Abdomen- soft, non tender. Aorta not palpable.
• Left groin incision was not completely healed. No sign of infection.
• Pulse exam: R side lower extremity pulses were normal.
• Left lower extremity pulses were not palpable.
• Left foot was cool with intact capillary refill, some digit mottling and

dependent rubor. No cyanosis or ulcerations.

• Non invasive studies: ABI : Right-139 (0.87)/ Left-60 (0.56).
• Toe Pressures : 89 (0.56)/ 43 (0.32).

Imaging: CT angiogram

Aortic bifurcation with severe calcification Small common iliac arteries with severe calcification on the left side

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Bilateral CFA calcification worse on the left Patent profunda femoris arteries bilaterally

Angiogram Outside Hospital

L CFA shows severe calcification and stenosis

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What would you do?

• A. Aortobifemoral bypass with femoral

artery endarterectomy. B. Left iliac stent with L Common femoral endarterectomy. C. Bilateral “kissing” common iliac stents with L common femoral endarterectomy.

• D. Right iliac stent with right to left femoro-

femoral bypass and left CFA endarterectomy. E. As per CLEVER trial, supervised exercise, risk factor management and guideline- directed medical optimization.

A

• r

t

• b

i f e m

• r

a l b y p a s s w i . . L e f t i l i a c s t e n t w i t h L C . . . B i l a t e r a l “ k i s s i n g ” c

• m

m

• .

. . R i g h t i l i a c s t e n t w i t h r i g h . . . A s p e r C L E V E R t r i a l , s u p e . . .

14% 17% 17% 14% 38%

Case Management

• Bilateral common iliac balloon expandable covered stents

in a kissing technique, left external iliac artery self- expanding covered stent with left common femoral endarterectomy.

PREINTERVENTION ANGIOGRAM POST DEPLOYMENT OF BALLOON EXPANDABLE KISSING STENTS

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POSTINTERVENTION ANGIOGRAM

TO WHAT LEVEL SHOULD THE AORTIC BIFURCATION BE RAISED?

• A. 1-2 cm above the native aortic

bifurcation.

• B. 2-3 cm above the native aortic

bifurcation.

• C. aortic bifurcation should never

be raised.

1

• 2

c m a b

• v

e t h e n a t i v e . . . 2

• 3

c m a b

• v

e t h e n a t i v e . . . a

• r

t i c b i f u r c a t i

• n

s h

• u

l d . . .

79% 0% 21% ISSUES AROUND RAISING THE AORTIC BIFURCATION

• Greiner and colleagues showed that if

the proximal end of the kissing stents

• verlapped by more than half of the

angiographic width within the aorta their 2 year primary and assisted primary patency rate was significantly less than if the stents crossed by less than 50%.

• Compression phenomenon can occur

with kissing stent technique- one of the kissing stents compresses the other one and diminishes the lumen until unilateral occlusion follows. Diagnosed

• n CT scan.
• Ability to cross from one femoral artery

to another may be eliminated.

WOULD YOU USE COVERED OR BARE METAL STENT IN THE COMMON ILIAC ARTERY?

• A. Covered stent.
• B. Bare metal stent.

C

• v

e r e d s t e n t . B a r e m e t a l s t e n t .

46% 54%

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• COBEST RCT.
• N= 168 iliac arteries in 125 patients with severe aortoiliac occlusive disease.
• RESULTS:
• Covered stent was associated with less binary restenosis.
• Covered stent was associated with higher freedom from occlusion than bare metal stent (but

did not reach statistical significance).

• TASC C and D lesions treated with covered stents had less binary restenosis than those

treated with bare metal stents.