Percutaneous transluminal recanalization of common iliac artery occlusions

Controlled blunt microdissection for percutaneous recanalization of lower limb arterial chronic total occlusions: A single center experience

BACKGROUND

Percutaneous techniques for the revascularization of symptomatic lower limb arterial chronic total occlusions (CTOs) remain suboptimal due to difficulty in safely and reliably crossing these heavily calcified lesions using standard guidewire and balloon technology.

OBJECTIVES

The objective of this prospective study was to evaluate the technical success and safety of controlled blunt microdissection (CMD) for the treatment of resistant peripheral CTOs.

METHODS

This series enrolled 36 patients (26 men; mean age 67 +/- 12 years), with 44 symptomatic CTOs (2 terminal aortic, 24 iliac, 16 femoral, and 2 popliteal), which had previously failed conventional percutaneous revascularization. CMD was carried out using a specialized prototype catheter. Actuation of the hinged jaws of this CMD catheter created a channel within the occluded arterial segment for guidewire passage, and subsequent angioplasty and stenting using standard procedures. The problem of subintimal CMD catheter passage, creating an eccentric channel, was addressed using a second novel device, the true-lumen reentry (LRE) catheter, which allowed reentry into the downstream lumen.

RESULTS

Procedural success, evaluated angiographically, was achieved in 40 (91%) of the 44 CTOs. Fourteen (35%) of these 40 successful recanalizations required guidewire redirection, using the LRE catheter for lesion traversal. There were no complications related to CMD per se; although one patient experienced acute in-stent thrombosis, managed successfully with intra-arterial thrombolysis.

CONCLUSIONS

We therefore conclude that CMD can be used safely and successfully to facilitate recanalization of resistant CTOs in the pelvic and lower limb arteries.

Primary stent placement for recanalization of iliac artery occlusions: using a self-expanding spiral stent

PURPOSE

To report the clinical results for recanalizations of an occluded iliac artery by a self-expanding spiral stent.

METHODS

We attempted to recanalize 36 iliac artery occlusions in 34 patients [33 men, 1 woman, aged 51-75 years (average 61.6 years)]. The average lesion length was 6.92 cm (range 1-14 cm). The patients' chief complaints were intermittent claudication and resting pain. Fontaine classification was assigned before and after the procedure. Technical and clinical success were also analyzed.

RESULTS

Forty-five stents were successfully deployed in 34 patients. All 36 lesions (13 in the external iliac artery, 12 in the common iliac artery, and 11 in both) were patently recanalized on angiography. The follow-up period ranged from 6 months to 36 months (mean 11.9 months). Fourteen stents (39%) with incomplete expansion were dilated with a balloon catheter. Good technical (100%) and clinical (94%) results were obtained. The only complication was one hematoma at the puncture site. Reocclusions were noted in two lesions (5%) at 1 week and 15 months, respectively.

CONCLUSION

A self-expanding spiral stent is a safe and effective device for recanalization of an iliac artery occlusion as the primary stent without any previous intervention.

Aortic bifurcation reconstruction: use of the Memotherm self-expanding nitinol stent for stenoses and occlusions

PURPOSE

To assess the technical success, initial clinical outcome, and intermediate follow-up of the Memotherm nitinol self-expanding stent in aortic bifurcation reconstruction.

METHODS

Thirty-three patients (13 male, 20 female), mean age 64 years, were treated, who had symptoms classified by the Surgical Vascular Society/International Society of Cardiovascular Surgery (SVS/ICVS) classification as grade 2 in 11 (33%), grade 3 in 19 (58%) and grade 4 in 3 (9%) patients. Lesions were classified according to severity and type. Indications for placement of a Memotherm nitinol self-expanding stent were failed angioplasty in 14 (42%), chronic occlusions in 12 (37%), and complex stenoses in seven (21%) patients.

RESULTS

Sixty-seven stents were technically successfully placed in 66 aorto-iliac segments in 33 patients, with one major complication. Initial clinical outcome was improvement in 25 (81%), no change in four (13%), and a worsening in two (6%) patients by Rutherford criteria. Mean early ankle/brachial pressure index (ABI) gain was 0. 27 for occlusions and 0.05 for stenoses. Clinical follow-up was obtained in all patients, with retrospective angiographic follow-up in 28 (85%) at a mean of 16 months (range 12-26 months). The decrease in ABI and the decrease in angiographic luminal diameter at follow-up was determined as the "late loss." The mean ABI late losses were -0.06, 0.00, and 0.09, and the mean angiographic late losses were 6.7%, 10% and 14% for occlusions, stenoses, and normal segments respectively. Primary clinical patency was 96%, primary angiographic patency was 89%, and secondary angiographic patency was 93%.

CONCLUSION

The high technical success of stent placement, the low complication rates for aortic bifurcation reconstruction using the Memotherm self-expanding stent, and high clinical and angiographic patency maintained at intermediate follow-up support their use in aortic bifurcation reconstruction.

Chronic iliac artery occlusion: treatment with the Strecker stent after PTA

The purpose of this retrospective study was to evaluate the use of percutaneous transluminal angioplasty (PTA) and subsequent. Strecker stent implantation for the treatment of chronic iliac artery occlusions. A total of 39 patients were subjected to this procedure. The occluded vessels were catheterized, dilated and subjected to stenting in all patients: the length of occlusion varied from 4.5 to 10.5 cm (mean 5.9), lesions were located in common iliac arteries (25), external iliac arteries (10) and in combinations of both (4). Twenty-five patients presented stage II according to Fontaine classification, nine patients stage III and five patients stage IV. The stent was mounted on balloon catheter and introduced through a 9 French sheet (for 8-10 mm stent diameter). After this procedure, 37 out of 39 patients showed a statistically significant increase in the Doppler sonographic ankle-arm index (AAI) (P = 0.001) and improvement of clinical symptoms, while in two patients a complete occlusion resulted due to long dissection not covered by the stent in one case and to stent misplacement in the other case. After stenting, 27 patients improved to stage I, ten patients to stage IIa and two patients showed no changes. Two complications were observed: one groin hematoma and one distal embolization. At a 6-month follow-up, a 89.7% of patency was observed. This study shows that Strecker stent can be successfully employed in addition to PTA to treat occlusions of the iliac arteries.

[Treatment of iliac artery stenosis and obliteration by transluminal angioplasty]

PURPOSE

Percutaneous transluminal angioplasty (PTA) has an established and valuable role in the treatment of iliac stenoses and occlusions. The use of stents may improve the results of PTA. The aim of this study is to report our surgical experience of iliac angioplasty over the past 5 years.

PATIENTS AND METHODS

From January 1993 to October 1997, 201 iliac PTA were performed in 175 patients, at the level of the common iliac artery (n = 111) and external iliac artery (n = 90). In 26 cases, two iliac lesions were treated simultaneously. There were 188 stenoses and 13 chronic occlusions. During PTA, 55 stents were used, because of unsatisfactory results (dissection, residual stenosis) or in case of total occlusion, in the common iliac artery in 35 cases and in the external iliac artery in 20 cases. In 15 cases (8.6%), a femoro-popliteal bypass was associated to the iliac PTA, because of multilevel occlusive disease.

RESULTS

There were no early deaths. There were seven initial failures. The initial success rate was 96%. The clinical follow-up has been achieved in 163 patients, (range: 3 to 48 months, mean: 28 months). The primary patency rates were 84%, 79% and 63% respectively at 1, 2, and 4 years. The secondary patency rates were 87%, 85% and 73% respectively at 1, 2, and 4 years.

Stent-graft repair of aorto-iliac occlusive disease coexisting with common femoral artery disease

PURPOSE

Significant disease or occlusion of the common femoral artery may preclude percutaneous therapy for aorto-iliac occlusive disease. In addition, aorto-iliac angioplasty may not reverse the ischemic symptoms when common femoral artery disease exists. The authors describe the feasibility of endoluminal stent-grafts to treat multilevel aortoiliofemoral occlusive disease.

MATERIALS AND METHODS

The authors placed 18 stent-grafts for aorto-iliac occlusive disease in 17 patients with limb-threatening ischemia and significant common femoral artery disease. These procedures were performed as a joint effort between vascular surgery and interventional radiology staff in the operating room. The common femoral artery was occluded in 10 or severely diseased in eight, necessitating endoluminal bypass to the superficial femoral or popliteal artery (n = 7) or to the deep femoral artery (n = 7), or necessitating patch angioplasty of the common femoral artery (n = 4). Stent-grafts were fabricated from 6-mm polytetrafluoroethylene and 29-mm Palmaz stents.

RESULTS

All 18 grafts were placed successfully. Follow-up ranged from 3 to 38 months (mean, 21 months). Seven patients died of myocardial infarction; two grafts occluded and one required angioplasty during follow-up, resulting in a primary patency rate of 81% at 2 years.

CONCLUSION

Endoluminal stent-graft placement is a useful method of treatment for advanced atherosclerotic aorto-iliac disease, particularly in the presence of common femoral artery disease. This approach avoids an extra-anatomic bypass or a major transabdominal aortic bypass procedure. Longer follow-up with a larger series is needed to ensure the safety and late graft patency comparable to the traditional aortofemoral and iliofemoral bypass grafts.

Percutaneous revascularization of complex iliac artery stenoses and occlusions with use of Wallstents: three-year experience

PURPOSE

To assess the outcome of percutaneous placement of Wallstents for treatment of hemodynamically significant diffuse stenoses (> 3 cm in length), chronic occlusions, failed angioplasty procedures, and flow-limiting dissection in the iliac arteries.

MATERIALS AND METHODS

Lesions in 94 iliac limbs were treated in 66 patients. Indications for stent placement included claudication in 49 limbs and limb-threatening ischemia in 45. Forty-two limbs were treated for diffuse disease, 39 for chronic occlusion, nine for failed angioplasty, and four for flow-limiting dissection.

RESULTS

Technical success was achieved in 86 of 94 limbs (91%), with major complications in 9% of patients. One death occurred within 30 days (not procedure-related). Ankle-brachial indexes improved from 0.51 +/- 0.24 to 0.76 +/- 0.22 (P < .001). Eighty-five percent demonstrated improvement under Rutherford criteria. Follow-up was obtained up to 38 months (mean, 14 months +/- 8). Cumulative primary patency rates were 78% at 1 year and 53% at 2 and 3 years (standard error 10%). Secondary patency rates were 86% at 1 year and 82% up to 32 months (standard error > 10% after 32 months). No significant decrease in mean ankle-brachial index was observed during follow up. No difference in primary patency was observed based on lesion type, symptom severity, lesion location, or runoff status. The limb salvage rate for patients with limb-threatening ischemia was 98% at a mean follow-up of 14 months +/- 7.

CONCLUSIONS

Technical success and complication rates for percutaneous iliac artery revascularization with use of Wallstents are favorable, symptoms improved in the majority of patients, and excellent secondary patency can be achieved. With use of Wallstents, most patients with iliac artery insufficiency as a result of long-segment disease or chronic occlusions can be treated percutaneously.

Total occlusion of iliac arteries: results of balloon angioplasty

Fifty-six occluded iliac arteries (mean length 6.1 cm; range 1-17 cm) in 50 patients were treated by percutaneous transluminal angioplasty (PTA) or laser-assisted PTA (bilateral lesions in 6 patients). Twenty-seven patients (54%) were at high risk for surgery. Patients were followed for a maximum period of 72 months (mean 23.12 months; median 20 months). The initial success rate was 78.57% for arteries and 82% for patients. Laser-assisted PTA was attempted in 11 occluded arteries (19.64%) and was successful in 4 arteries (7.14%). Conventional PTA was successful in 71.4% of arteries including all 7 arteries for which laser-assisted PTA failed (76% of patients). PTA was unsuccessful in 12 arteries (21.43%). Urokinase was used before PTA in 1 artery. The effect of PTA was evident clinically by relief of rest pain (66.66%), healing of ulcer (57%), increased claudication distance or no claudication (79%) in limbs, and objectively, by improvement in ankle/arm index (AAI) (an increase of 0.16 to 0.91) and increased exercise tolerance. Continuous improvement in AAI was observed after PTA on follow-up in 9 limbs. One patient died during follow-up. On follow-up, 3 arteries were occluded, 6 showed evidence of stenosis, and 1 showed fusiform dilatation at the PTA site. The long-term results using the life-table method determined a 76% primary patency rate and 81% secondary patency rate for 72 months. The overall patency including failures was 63%. Age of the patients (p = 0.0169) and hypertension (p = 0.0015) significantly affected the long-term patency of the artery but not the initial success. The major complications were arterial rupture in a repeat procedure in 1 artery, axillary artery thrombosis in 1, and distal thromboembolic occlusion during PTA in 4. The long-term patency rates suggest that PTA of totally occluded iliac arteries is a safe and effective procedure and provides a long-term benefit.

Stent placement in iliac arterial lesions: three years of clinical experience with the Wallstent

Within a 3-year period, 125 patients with 63 iliac occlusions and 62 complex iliac stenoses underwent stent placement using self-expandable vascular endoprostheses. Early technical success rate was 98%, with a total complication rate of 4%. Major complications were seen in 1.6%. Early reobstruction occurred in 4 patients with previous occlusions. Late reobstruction due to a clinically relevant restenosis or reocclusion occurred in 10 patients and required 12 repeat interventional procedures. Cumulative patency, excluding early technical failure, was 100% at 6 months and 89.4% at 24 months. Stenting of iliac arteries using self-expandable endoprostheses is a safe and effective treatment of complex iliac lesions.

Surgical and percutaneous management of contralateral thrombus dislodgement following stent placement and dilatation of iliac artery occlusions: technical note

Primary stenting of common iliac artery occlusions was complicated by dislodgement of occluding material to the contralateral common iliac artery in 2 of 59 patients following successful stent placement. In both patients, the complication occurred after balloon dilatation of the inserted self-expanding stent. In the first patient the embolus dislodged to the tibioperoneal trunk and required surgical embolectomy. In the second patient, percutaneous insertion of a self-expanding stent into the contralateral common iliac artery prevented distal embolization.

Peripheral vascular disease. Treatment with balloon angioplasty

Peripheral vascular disease imposes daily inconveniences and limitations on many patients. The primary care physician and vascular specialist can work together to alleviate the restrictions of this disorder by prompt recognition, investigation, and therapy. It is no longer necessary to wait until patients are extremely debilitated before offering intervention. Initial success rates of percutaneous transluminal (balloon) angioplasty are very high and increasing, and restenosis rates are acceptable and decreasing. The procedure is economical and has a short convalescent period and low patient risk. Physicians should be aware that underuse of medical technology may be as costly as overuse. In upcoming years, further advances will allow even more patients with peripheral vascular disease to be treated with lesser expense; lower risk; and greater salvage of lives, limbs, and life-styles.