Total occlusion of iliac arteries: results of balloon angioplasty

Percutaneous Endoluminal Treatment of Iliac Occlusions: Long-Term Follow-up in 105 Patients

Purpose:

To evaluate the long-term results of percutaneous recanalization techniques in occluded iliac arteries.

Methods:

Percutaneous recanalization was attempted in 105 patients (97 men; mean age 56 years, range 34 to 80) with iliac occlusions using thrombolysis (n = 15), excimer laser (n = 4), mechanical thrombectomy (n = 16), balloon angioplasty alone (n = 23), and angioplasty plus stenting (n = 69). The majority of lesions (n = 72) were in the common iliac artery (CIA); 33 were in the external iliac artery (EIA).

Results:

The primary recanalization rate was 88% (92/105) independent of location (EIA: 90%, CIA: 86%) and lesion length, but dependent on age of thrombus (< 3 months: 100%, > 3 months: 79%, p < 0.02). Complications included 5 (4.8%) cases of distal embolism treated by thromboaspiration or Fogarty balloon embolectomy. Seven (6.7%) early thromboses were treated surgically. Primary and secondary patency rates were calculated at 6 years for all 105 cases and for the 92 recanalized lesions using life-table analysis. Overall, primary patency was 52% (CIA: 58%, EIA: 34%) and secondary 66% (CIA: 74%, EIA: 40%). Lesions < 6 cm had a primary patency of 70%, while those > 6 cm had a 31% rate (p < 0.01). Secondary patencies were 86% and 42%, respectively (p < 0.01). Among recanalized lesions, the primary patency was 61% (CIA: 69%, EIA: 38%) and secondary 77% (CIA: 88%, EIA: 45%; p < 0.05). Lesions < 6 cm had a primary patency rate of 72%, while longer lesions had a primary rate of 44% (p < 0.04); secondary patencies were 89% and 59%, respectively (NS). Primary patency without stent was 57% and with stent 65% (NS); secondary patency without stent was 71% and with stent 82% (NS).

Conclusions:

Percutaneous recanalization of iliac occlusions represents a true alternative to vascular surgery and a first-line treatment option. Stents have a tendency to improve long-term results and are recommended for routine use in chronic iliac occlusions.

Local delivery of paclitaxel in the treatment of peripheral arterial disease

BACKGROUND

Despite advancements from balloon angioplasty to drug-eluting stents, primary patency rates after endovascular revascularization of peripheral artery disease have remained inferior compared to surgery. Endovascular revascularization has been limited by restenosis and mechanical stent failure. Thus, there is increased research into other nonstent-based local drug delivery modalities, which can provide an active drug to inhibit restenosis focally and avoid the risk of systemic adverse effects.

METHODS

This review will summarize the unique properties of paclitaxel and studies on paclitaxel local delivery for the treatment of peripheral artery disease. A MEDLINE search for relevant peer-reviewed scientific literature published in English was conducted. Search terms included but were not limited to paclitaxel pharmacodynamics, paclitaxel local drug delivery, and drug eluting balloons, with a focus on the use of paclitaxel in the context of coronary and peripheral vascular disease.

RESULTS

The primary search produced 182 results of which 51 papers were relevant. Of the 51 relevant papers, 27 were original research papers and 24 were either review papers, commentary or opinion papers.

CONCLUSIONS

Paclitaxel has several chemical properties, which make it ideal for local drug delivery including its hydrophobicity, ability to concentrate into the arterial intima layer and prolonged effect on cells even after brief exposure periods. Local delivery of paclitaxel via injection catheters, balloon catheters and coated balloons has shown encouraging results in terms of efficacy and safety in small-scale animal and clinical studies. Additional preclinical and clinical studies are needed to determine the long-term efficacy and safety of these treatments in humans.

Strategies for successful percutaneous revascularization of chronic total occlusion of the femoropopliteal arteries when the antegrade passage of a guide wire fails

Objective

To evaluate the efficacy of various strategies for revascularization of chronic total occlusion of femoropopliteal arteries when the guide wire does not pass in an anterograde direction.

Materials and Methods

Twenty-four patients with totally occluded femoropopliteal arteries (mean occlusion length 13.75 cm; range, 6-22 cm) were treated by using a retrograde approach and two novel catheters. After successful recanalization or reentry, balloon angioplasty followed by stent placement was performed to complete the revascularization.

Results

In 16 cases in which to cross the occlusion via intraluminal or subintimal route was failed, we used Frontrunner catheters in five cases and Outback catheters in 11 cases. In eight cases in which to reenter after subintimal passage of the guide wire was failed, we used Outback catheters. Successful recanalization was achieved intraluminally or subintimally in all cases. One perforation occurred during subintimal passage of the guide wire that was controlled by recanalization of another subintimal tract. There were no cases of distal thromboembolism or other complications.

Conclusion

A retrograde approach and using the Frontrunner and Outback catheters are safe and effective for successful revascularization of chronic total occlusion of femoropopliteal arteries. In particular, they are useful when the initial antegrade attempts at recanalization have failed.

Impact of Aggressive Endovascular Recanalization Techniques on Success Rate in Chronic Total Arterial Occlusions (CTOs)

Purpose: To report experience with aggressive recanalization approaches in chronic total arterial occlusion (CTO). Methods: Chronic total arterial occlusion recanalization was attempted on 112 limbs in 99 consecutive patients between January 1999 and December 2006. Results: There were 63 iliac arteries, 45 femoropopliteal arteries, and 4 occluded stents. Mean occlusion length was 8.7 ± 4.7 cm. Conventional recanalization was attempted first and was successful in 71 limbs (70%). Probing with the guidewire’s stiff end was attempted in 33 of the 41 procedures where conventional techniques failed and was successful in 18 (54%), improving the overall procedural success rate to 80%. For the remaining 15 limbs, home-made directional sharp needle recanalization was attempted in 11 and was successful in 9 (82%), further improving the overall recanalization success to 88%. Procedural complications were self-limited or managed nonoperatively. Conclusions: Aggressive recanalization techniques in CTO following failure of traditional means are safe and can substantially improve procedural success rates.

Intravascular ultrasound-guided true lumen reentry device for recanalization of unilateral chronic total occlusion of iliac arteries: technique and follow-up

BACKGROUND

Endovascular revascularization of chronic total occlusion (CTO) of the iliac arteries is rapidly becoming first-line treatment, with surgical aortofemoral bypass procedures reserved for failure of endovascular treatment. Percutaneous subintimal recanalization is the most common endovascular revascularization technique for CTO of the iliac arteries. The primary reason for failure of the subintimal recanalization technique is failure to reenter the true lumen. This report describes the benefits of using true lumen reentry devices to improve the success and safety of conventional subintimal recanalization for revascularization of CTO of the iliac arteries.

METHODS

This is a retrospective review of 11 patients with CTO of the iliac arteries in whom true lumen reentry was not successful using conventional subintimal recanalization. An intravascular ultrasound (IVUS)-guided true lumen reentry device was used in all patients to assist true lumen reentry. Clinical records, procedural records, angiographic imaging, and follow-up data were analyzed. Indications for intervention, length and location of the lesion treated, access site(s), location of true lumen reentry, stent use, procedural times, technical success, and complications were analyzed in all patients.

RESULTS

The technical success of true lumen reentry at the desired point was 100%. Total procedure time from the start of reentry device manipulation to achieve reentry was <10 min (routinely <5 min). Mean patient follow-up was 10.5 months. At follow-up, all patients had palpable femoral pulses. The ankle-brachial index normalized (>0.9) in six patients and improved significantly in the remaining five patients. Rest pain resolved and claudication improved in all patients. Out of seven patients who had foot ulcers, the ulcers healed completely in five and demonstrated improved healing in two, with the clinical manifestation of osteomyelitis resolved in two. No procedure-related complications were noted. The amputation-free survival was 100%.

CONCLUSION

True lumen reentry devices greatly improve the technical success and safety of percutaneous recanalization procedures in CTO of the iliac arteries. There are significant reductions in procedure time and complication rates associated with the use of these devices.

Quality improvement guidelines for endovascular treatment of iliac artery occlusive disease

Endovascular therapy is the treatment of choice for type A and the preferred treatment for type B lesions. In selective patients, this type of treatment can be applied in type C and even type D lesions. Ipsilateral femoral, contralateral femoral, and brachial approach and both the intraluminal and subintimal space can be used for successful recanalization. The application of stents has improved the immediate hemodynamic and probably long-term clinical results of iliac percutaneous transluminal angioplasty. However, the superiority of primary or direct stenting over selective stenting has not been proven yet. The choice of stent type depends on lesion morphology and location but otherwise there is insufficient evidence to support the use of a particular stent design. There is insufficient evidence to justify routine use of covered stents. All patients should receive antiaggregant therapy following endovascular recanalization of iliac arteries. There is no consensus regarding prophylaxis with antibiotics in iliac recanalization procedures.

Reduction of Stenosis Due to Intimal Hyperplasia After Stent Supported Angioplasty of Peripheral Arteries by Local Administration of Paclitaxel in Swine

PURPOSE

To assess if local intra-arterial administration of paclitaxel using drug-coated balloons or an admixture of paclitaxel to contrast medium inhibits stenosis after percutanous transluminal angioplasty (PTA) of peripheral arteries in a porcine overstretch model.

METHODS

Neointimal proliferation and stenosis were induced by overstretch and stenting of 40 peripheral arteries in 20 pigs. Paclitaxel was administered locally during PTA using coated balloons (n = 20) or dissolved in contrast medium (n = 10). Conventional balloons and contrast medium were used in a control group (n = 10). Reangiography with quantitative analysis was performed after 5 weeks.

RESULTS

On reangiography diameter stenosis and late lumen loss were significantly reduced by both methods of local drug delivery compared with control group; minimal luminal diameter was significantly larger in the treatment groups.

CONCLUSIONS

Local short-term administration of paclitaxel during PTA of peripheral arteries using balloons or contrast medium as drug carriers reduced stenosis due to intimal hyperplasia.

Real-time magnetic resonance imaging-guided endovascular recanalization of chronic total arterial occlusion in a swine model

BACKGROUND

Endovascular recanalization (guidewire traversal) of peripheral artery chronic total occlusion (CTO) can be challenging. X-ray angiography resolves CTO poorly. Virtually "blind" device advancement during x-ray-guided interventions can lead to procedure failure, perforation, and hemorrhage. Alternatively, MRI may delineate the artery within the occluded segment to enhance procedural safety and success. We hypothesized that real-time MRI (rtMRI)-guided CTO recanalization can be accomplished in an animal model.

METHODS AND RESULTS

Carotid artery CTO was created by balloon injury in 19 lipid-overfed swine. After 6 to 8 weeks, 2 underwent direct necropsy analysis for histology, 3 underwent primary x-ray-guided CTO recanalization attempts, and the remaining 14 underwent rtMRI-guided recanalization attempts in a 1.5-T interventional MRI system. Real-time MRI intervention used custom CTO catheters and guidewires that incorporated MRI receiver antennae to enhance device visibility. The mean length of the occluded segments was 13.3+/-1.6 cm. The rtMRI-guided CTO recanalization was successful in 11 of 14 swine and in only 1 of 3 swine with the use of x-ray alone. After unsuccessful rtMRI (n=3), x-ray-guided attempts were also unsuccessful.

CONCLUSIONS

Recanalization of long CTO is entirely feasible with the use of rtMRI guidance. Low-profile clinical-grade devices will be required to translate this experience to humans.

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.

Technical Report and Preliminary Clinical Data of a Novel Catheter for Luminal Re-Entry After Subintimal Dissection

RATIONALE AND OBJECTIVES

The objective of this study was to evaluate the safety and the effectiveness of the Outback catheter for intraluminal re-entry after subintimal dissection in the crossing of chronic arterial occlusions.

METHODS

This study was a proof-of-concept feasibility. Ten patients with totally occluded arteries in the iliac artery to the distal femoral artery (mean occlusion length, 13.1 cm; range, 5-25 cm) were treated with the novel catheter. After successful re-entry, PTA or PTA plus stenting was performed.

RESULTS

No perforations, dissections, lacerations, or device complications occurred. The procedural re-entry success rate with the Outback catheter was 50% (5/10 patients).

CONCLUSIONS

Although the Outback catheter is safe, the percentage of intraluminal reaccess should be ameliorated through engineering improvements because there is some evidence to suggest that subintimal recanalization could produce improved long-term results.

Randomized clinical trial of the antiplatelet effects of aspirin-clopidogrel combination versus aspirin alone after lower limb angioplasty

BACKGROUND

There is a high risk of reocclusion after successful lower limb angioplasty. Platelets play a central role in this process. The aim of this study was to investigate the antiplatelet effect of a combination of aspirin and clopidogrel compared with aspirin alone in patients with claudication undergoing endovascular revascularization.

METHODS

This was a double-blind randomized placebo-controlled trial. Some 132 patients were randomized to clopidogrel and aspirin or placebo and aspirin, with a loading dose 12 h before endovascular intervention. Flow cytometric measurements of platelet fibrinogen binding and P-selectin expression were taken as measures of platelet function at baseline, 12 h after the loading dose, and 1 h, 24 h and 30 days after intervention.

RESULTS

Within 12 h of the loading dose, platelet activation in the clopidogrel group had decreased (P-selectin by 27.3 per cent, P = 0.017; fibrinogen binding by 34.7 per cent, P = 0.024; stimulated fibrinogen binding by 49.2 per cent, P < 0.001). No change was observed in the placebo group. Platelet function in the clopidogrel group was significantly suppressed compared with baseline at 1 h, 24 h and 30 days after endovascular intervention (stimulated fibrinogen binding by 53.9, 51.7 and 57.2 per cent respectively; all P < 0.001).

CONCLUSION

A combination of clopidogrel and aspirin inhibited platelet function more than aspirin alone in patients with claudication before and after angioplasty.

Lower extremity arterial occlusive disease: Role of percutaneous revascularization

Percutaneous endovascular interventions for peripheral arterial disease are indicated in carefully selected patients with favorable anatomy and associated clinical symptoms. Although endovascular therapy appears to be hemodynamically equivalent to other modalities in isolated iliac disease, this does not appear to be the case for infrainguinal disease, particularly when the disease is diffuse and extensive. Such disease in these beds can often be treated surgically, although there is an increasing role for percutaneous therapies, particularly in patients at higher surgical risk. Catheter-based therapy should be considered an integral part of comprehensive medical therapy in patients with lower extremity peripheral arterial disease. Embarking on an endovascular approach to therapy should involve a frank physician-patient discussion of the risks, benefits, and durability of the proposed procedure tailored to anatomic locale and patient-specific factors.

Subintimal Angioplasty as a Primary Modality in the Management of Critical Limb Ischemia:Comparison to Bypass Grafting for Aortoiliac and Femoropopliteal Occlusive Disease

PURPOSE

To compare the 30-day morbidity, mortality, length of hospital stay, and patency rates in patients with critically ischemic limbs treated with subintimal angioplasty (SA) versus standard bypass surgery.

METHOD

Between October 2001 and August 2003, 137 patients (74 women; mean age 70 years, range 43-92) with critical limb ischemia underwent subintimal angioplasty (n=88) or bypass surgery (n=49) for superficial femoral artery (SFA) or aortoiliac lesions. All patients had lesions classified as C or D according to the TransAtlantic Inter-Society Consensus. Data was retrieved from hospital inpatient inquiry and VascuBase. Parallel group comparison was used in performing a prospective observational study.

RESULTS

Primary technical success was 100% for both SA and bypass grafting. Thirty-day survival was 100% in the SFA-SA and aortoiliac bypass groups and 96% and 93%, respectively, in the SFA bypass and aortoiliac SA groups. Limb salvage was 97% and 82% in the SFA-SA and SFA bypass groups, respectively; at the aortoiliac levels, the rates were 100% and 86% for SA versus bypass. Subintimal angioplasty significantly reduced hospital stay (p<0.001). Primary patency was not statistically different in the SA versus bypass groups; however, secondary patency was higher in the SFA bypass group.

CONCLUSIONS

Frequent clinical follow-up and a duplex surveillance program are necessary to maintain patency in this cohort. Subintimal angioplasty is increasingly replacing bypass surgery in the management of critical limb ischemia without compromising primary patency, limb salvage, patient survival, or subsequent vascular intervention.

Novel Intravascular Ultrasound-Guided Method to Create Transintimal Arterial Communications: Initial Experience in Peripheral Occlusive Disease and Aortic Dissection

PURPOSE

To report our experience using a commercially available catheter-based system equipped with an intravascular ultrasound (IVUS) transducer to achieve controlled true lumen re-entry in patients undergoing subintimal angioplasty for chronic total occlusions (CTO) or aortic dissections.

METHODS

During an 8-month period, 10 patients (6 men; mean age 73.4 years) with lower extremity (LE) ischemia from CTOs (n=7) or true lumen collapse from aortic dissections (n=3) were treated. Subintimal access and controlled re-entry of the CTOs were performed with a commercially available 6.2-F dual-lumen catheter, which contained an integrated 64-element phased-array IVUS transducer and a deployable 24-G needle through which a guidewire was passed once the target lumen was reached. The occluded segments were balloon dilated; self-expanding nitinol stents were deployed. In the aortic dissections, fenestrations were performed using the same device, with the IVUS unit acting as the guide. The fenestrations were balloon dilated and stented to support the true lumen.

RESULTS

Time to effective re-entry ranged from 6 to 10 minutes (mean 7) in the CTOs; antegrade flow was restored in all 7 CTOs, and the patients were free of ischemic symptoms at up to 8-month follow-up. In the aortic dissection cases, the fenestrations equalized pressures between the lumens and restored flow into the compromised vessels. There were no complications related to the use of this device in any of the 10 patients.

CONCLUSIONS

Our preliminary results demonstrate the feasibility of using this catheter-based system for subintimal recanalization with controlled re-entry in CTOs and for aortic flap fenestrations in aortic dissections. This approach can improve the technical success rate, reduce the time of the procedure, and minimize potential complications.

Percutaneous bypass: subintimal recanalization of peripheral occlusive disease with IVUS guided luminal re-entry

Angioplasty of chronic total occlusions (CTOs) has lower technical success rates with longer procedure times and poorer outcomes. Subintimal recanalization remains limited by the lack of controlled re-entry into the true lumen of the target vessel. We report our experience using a commercially available catheter-based system equipped with an intravascular ultrasound scanner to achieve controlled true lumen re-entry in patients with peripheral CTOs. In a 4-month period, 6 patients with lower extremity (LE) ischemia from CTOs were treated. Occluded segments were crossed subintimally, and controlled re-entry was secured using the CrossPoint TransAccess catheter. This 6.2 F dual-lumen catheter contains an integrated 64-element phased array intravascular ultrasound scanner enabling targeting of structures. Intravascular ultrasound-guided luminal re-entry was achieved by advancing a 24-gauge needle to a desired length and delivering a 0.014" guide wire into the target lumen. The occluded segments were balloon dilated and stented using self-expanding nitinol stents. Effective luminal re-entry and re-establishment of antegrade flow occurred in all 6 patients. Time to recanalization ranged from 5 to 10 minutes. All patients were free of ischemic symptoms at 1 to 5 month follow-up. There were no procedure-related complications. Our preliminary results demonstrate the feasibility of using this catheter system for subintimal recanalization with controlled re-entry in CTOs. This approach can improve the technical success rate, reduce the time of the procedure, and minimize potential complications.

Subintimal Versus Intraluminal Recanalization of Chronic Iliac Occlusions

PURPOSE

To present our experience with subintimal recanalization of chronic iliac occlusions and retrospectively compare the results of this technique with those of standard intraluminal recanalization.

METHODS

A retrospective review was conducted of 98 patients (91 men; mean age 61+/-10 years, range 37-77) with unilateral chronic iliac occlusions who underwent standard intraluminal recanalization or subintimal recanalization if intraluminal wire passage failed. The technical success, complications, and patency rates were statistically compared between groups.

RESULTS

In 59 (60%) of 98 patients, the occlusions were successfully crossed with ipsilateral intraluminal recanalization, while failure of intraluminal recanalization in the remaining 39 led to attempted subintimal recanalization (ipsilateral in 17 and antegrade-retrograde in 22). Overall, ipsilateral intraluminal recanalization was technically successful in 56 (57%) of 98 patients; subintimal recanalization was successful in 35 (90%) of 39 patients. Technical success was only 29% in 17 patients who underwent subintimal recanalization via an ipsilateral retrograde approach. During a follow of 27+/-16 months, primary and assisted primary patencies were not significantly different between the patients treated with intraluminal versus subintimal recanalization (p=0.81 and 0.64, respectively).

CONCLUSIONS

Subintimal recanalization is a safe and effective supplement to standard intraluminal recanalization techniques in the endovascular treatment of chronic iliac occlusions. Because of the poor outcome associated with the ipsilateral route, subintimal recanalization of these lesions should preferably be performed via a combined antegrade-retrograde approach.

Long-term results of stenting for chronic iliac artery occlusion

PURPOSE

To evaluate the long-term results of stent placement for chronic occlusions of the iliac arteries.

METHODS

Between October 1992 and December 1997, 73 patients (40 men; median age 64 years, range 42-89) with 76 occluded iliac arteries (33 common, 34 external, and 9 both vessels) were treated with percutaneous recanalization and stenting using a variety of self-expanding and balloon-expandable devices. Median occlusion length was 7 cm (range 1-14). Follow-up consisted of clinical assessment, ankle-brachial index measurement, and arteriography or duplex ultrasound when indicated.

RESULTS

Anatomical success was achieved in 74 (97%) limbs. Seven (10%) patients experienced major complications: 2 distal embolizations, 2 arterial ruptures, 1 myocardial infarction, 1 groin hematoma requiring surgery, and 1 contrast-induced nephropathy. There was no 30-day mortality. Over a median follow-up of 27 months (range 1-75), there was 1 early occlusion (< or = 30 days) and 16 late recurrent lesions (11 occlusions and 5 stenoses) at a median 6.2 months (range 1.4-30). The recurrent lesions were treated with endovascular techniques in 8 limbs and surgery in 7 limbs (5 after failed endovascular procedures); 1 patient died before retreatment, and 1 patient refrained from further intervention. Primary and secondary patencies were 79% and 87% at 1 year and 69% and 81% at 3 years, respectively.

CONCLUSIONS

Stenting of chronic iliac occlusions is a safe and durable alternative to surgical treatment.

Intravascular ultrasound scanning improves long-term patency of iliac lesions treated with balloon angioplasty and primary stenting

PURPOSE

Underdeployment of an intravascular stent has been identified as a cause of restenosis or occlusion of a treated arterial lesion. Intravascular ultrasound (IVUS) has been shown to initially improve the anatomic and clinical stenting. The purpose of this study was to determine whether the use of IVUS increased long-term patency of this intervention.

METHODS

Between March 1992 and October 1995, 71 limbs (52 patients) with symptomatic aortoiliac occlusive disease underwent balloon angioplasty with primary stenting. IVUS and arteriography were used in 49 limbs (36 patients) to evaluate stent deployment. Arteriography alone was used in 22 limbs (16 patients) to evaluate stent deployment. Patients were captured prospectively in a vascular registry and retrospectively reviewed.

RESULTS

Mean age of patients treated with IVUS was 61.1 plus minus 9.0 years (range, 38-85) versus 70.0 plus minus 10.1 years (range, 57-87) in patients treated without IVUS (P <.01). There was no difference between the groups with respect to preoperative comorbidities, ankle-brachial indices, or number of stents per limb. Mean follow-up for IVUS patients was 62.1 plus minus 7.3 months (range, 15-81) and 57.9 plus minus 8.7 months (range, 8-80) for patients treated without IVUS (P = not significant). In 40% (20/49) of limbs, IVUS demonstrated inadequate stent deployment at the time of the original procedure. Kaplan-Meier 3- and 6-year primary patency estimates were 100% and 100% in the IVUS group and 82% and 69%, respectively, in limbs treated without IVUS (P <.001). There have been no secondary procedures performed in limbs treated with IVUS and a 23% (5/22) secondary intervention rate in the non-IVUS group (P <.05). Overall Kaplan-Meier survival estimates at 3 and 6 years for all patients were 84% and 67%, respectively.

CONCLUSION

Balloon angioplasty and primary stenting of symptomatic aortoiliac occlusive lesions is a durable treatment option. Long-term follow-up of treated patients shows outcomes that are comparable with direct surgical intervention. IVUS significantly improved the long-term patency of iliac arterial lesions treated with balloon angioplasty and stenting by defining the appropriate angioplasty diameter endpoint and adequacy of stent deployment.

Stent-supported recanalization of chronic iliac artery occlusions

PURPOSE

Iliac artery occlusions that are more than a few centimeters in length are normally treated with surgical bypass grafting. The aim of this study was to evaluate the results of primary stent implantation after Excimer laser-assisted recanalization of iliac artery occlusions.

SUBJECTS AND METHODS

We studied 212 consecutive patients with chronic unilateral iliac artery occlusions (mean [+/- SD] length 8.9 +/- 3.9 cm) who were treated with Excimer laser-assisted recanalization and stent implantation. Based on the criteria of the Society of Cardiovascular and Interventional Radiology, lesions were graded as class III occlusions (<5 cm) in 46 patients and as class IV (> or =5 cm) in 166 patients. A total of 527 stents (Palmaz stent, 346; Wallstent, 94; Strecker stent, 38; covered stents, 49) were implanted.

RESULTS

Technical success was achieved in 190 (90%) patients. There was a clinical improvement of three grades in 112 (53%) patients and of two grades in 67 (32%) patients. The rate of major complications was 1.4%, which included arterial rupture (1) and embolic events (2). Primary patency rates were 84% at 1 year, 81% at 2 years, 78% at 3 years, and 76% at 4 years. Secondary patency rates were 88% at 1 year, 88% at 2 years, 86% at 3 years, and 85% at 4 years.

CONCLUSION

Stent-supported angioplasty is an effective treatment for iliac artery occlusions, with less morbidity and mortality than is associated with surgery. However, reported long-term patency rates after bypass surgery are greater than those we observed with interventional treatment. The value of primary stenting as compared with angioplasty alone should be evaluated in a randomized trial.

Peripheral arterial obstruction: prospective study of treatment with a transluminally placed self-expanding stent-graft. International Trial Study Group

PURPOSE

To evaluate the safety and efficacy of an endoluminal prosthesis for treatment of peripheral arterial occlusive disease (PAOD).

MATERIALS AND METHODS

A self-expanding endoprosthesis with an expanded polytetrafluoroethylene tube inside a nitinol support structure was implanted in 127 patients with symptomatic PAOD in the iliac (61 limbs) and femoral arteries (80 limbs). Clinical category status, ankle-brachial index, and color duplex flow imaging results were recorded before treatment, at discharge, and at 1, 3, 6, and 12 months after treatment. Aspirin was administered throughout the study, and heparin was administered during and for 2 days after the procedure.

RESULTS

Endoprosthesis deployment was technically successful in all patients. Complications occurred in 24 of 141 procedures and included three major complications. Early thrombosis (within 30 days) occurred in one iliac and three femoral arteries. Late restenosis or reocclusion was observed in five iliac and 14 femoral arteries within the 1st year. Primary patency rates in iliac arteries were 98% +/- 3% (standard error) and 91% +/- 4%, respectively, at 6 and 12 months after treatment. Primary patency rates in femoral arteries were 90% +/- 3% and 79% +/- 5%, respectively, at 6 and 12 months. Secondary patency rates were 95% and 93% for iliac and femoral arteries, respectively, at 12 months after treatment.

CONCLUSION

The device used in this study can be implanted without additional risks to the patient and provided encouraging patency rates up to 1 year.

Long-term results after recanalisation of chronic iliac artery occlusions by combined catheter therapy without stent placement

OBJECTIVES

to evaluate the long-term outcome after recanalisation of chronic iliac artery occlusions by combined catheter therapy without stent placement.

DESIGN

retrospective study.

MATERIAL AND METHODS

between 1979 and 1995 75 consecutive patients were treated (53 men, 22 women; mean age 63.1+/-13.7 years; mean length of the occluded segment 6.9+/-3.5 cm). The indication for treatment was incapacitating claudication (n=55) or chronic critical ischaemia (n=20). At follow-up clinical data, pulse volume and pressure measurements were recorded and duplex-sonography and/or angiography performed, if clinically indicated.

RESULTS

mean follow-up was 7. 2+/-4.1 years. The primary clinical success rate was 64% at 12 months, 57% at 4 years and remained stable for up to ten years. The secondary clinical success rate after 12 months was 83% and remained stable at 81% for up to 10 years. Peripheral embolisation as complication of the intervention occurred in 18 patients (24%) and was treated by percutaneous thromboembolectomy in 15 patients during the same procedure. In the remaining three patients no intervention was necessary. One patient had to undergo surgery for a groin haematoma.

CONCLUSIONS

recanalisation of segmental chronic iliac artery occlusions by catheter therapy without stent placement has favourable long-term results comparable to primary stent placement. Randomised controlled studies are required to determine the appropriate role of catheter therapy alone and primary or selective stenting for iliac artery occlusions.

Aortoiliac stenting, determinants of clinical outcome

OBJECTIVES

To determine predictors of clinical outcome in stenting aortoiliac disease.

DESIGN

Prospective/retrospective study.

MATERIALS AND METHODS

One hundred and forty patients (163 limbs) underwent iliac artery stenting in the period 1994-1997. Ninety-eight occlusions and 65 stenoses were treated, either with primary stenting (n = 129) or after failed angioplasty (n = 34). Median follow-up 18 months (1-66). Factors analysed for their effect on outcome were: gender, age, Fontaine stage, ABI, lesion type/length/site, primary or secondary stenting, stent type, BP, smoking, diabetes, aspirin, cholesterol, residual gradient, overhanging and run-off.

RESULTS

The immediate success was 95%. The primary successful clinical outcome was 90% at 12 months and 84% at 36 months; the primary-assisted successful clinical outcome was 95% at 12 months and 91% at 36 months and the secondary successful clinical outcome was 92% at 12 months and 87% at 36 months. Adverse factors affecting outcome were: residual pressure gradient (> 10 mmHg) and no treatment with aspirin (p < 0.05). Major complications occurred in 18% of patients with a re-intervention in 8%. The 30-day mortality was 5.5%.

CONCLUSIONS

Stenting for aortoiliac occlusive disease has good short and long term clinical success, with low morbidity and mortality. Factors that might improve results further are ensuring that patients are taking aspirin and any residual pressure gradient is abolished.

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.

Impact of intravascular ultrasonography in the endovascular management of aortoiliac occlusive disease

Intravascular ultrasonography (IVUS) is one of several new imaging technologies that have been applied in the treatment of arterial occlusive disease. Endovascular procedures are increasing annually, and arteriography, which is thought to be the "gold standard" for assessing adequacy of endovascular therapy, appears to have flaws. IVUS, a new imaging technique that expands the understanding of atherosclerotic lesions, images a vessel in a cross-sectional plane and provides information about the morphology of the lesion and the vessel wall. IVUS clearly visualizes the spatial relationship between a deployed stent and the vessel wall; this information is not usually obtainable with arteriography. We conducted 2 studies at our institution to evaluate the use of IVUS in the endovascular treatment of atherosclerotic aortoiliac occlusive disease. The first study showed that actual vessel size and lumen diameter were underestimated 62% of the time by arteriography and that 40% of stents (P < .01) placed in the iliac arterial system were underdeployed, which might be related to treatment failure. The second study showed that the use of IVUS had a positive effect on the long-term patency of angioplastied and stented iliac lesions--all of these reconstructions have remained patent to date. IVUS appears to be the best means of assessing morphology of the arterial occlusive lesions and the results of endovascular intervention. IVUS provides valuable information related to diagnosis and treatment that can alter the conduct of endovascular procedures.

A balloon protection sheath to prevent peripheral embolization during aortoiliac endovascular procedures

Peripheral embolization is a known complication occurring during aortoiliac recanalization. In particular, acute, fresh thrombotic occlusions, with a history shorter than 6 months, have a high risk for peripheral embolization. We describe a balloon occlusion sheath used to manage embolic material while preventing peripheral embolization.

Percutaneous endoluminal treatment of iliac occlusions: long-term follow-up in 105 patients

PURPOSE

To evaluate the long-term results of percutaneous recanalization techniques in occluded iliac arteries.

METHODS

Percutaneous recanalization was attempted in 105 patients (97 men; mean age 56 years, range 34 to 80) with iliac occlusions using thrombolysis (n = 15), excimer laser (n = 4), mechanical thrombectomy (n = 16), balloon angioplasty alone (n = 23), and angioplasty plus stenting (n = 69). The majority of lesions (n = 72) were in the common iliac artery (CIA); 33 were in the external iliac artery (EIA).

RESULTS

The primary recanalization rate was 88% (92/105) independent of location (EIA: 90%, CIA: 86%) and lesion length, but dependent on age of thrombus (< 3 months: 100%, > 3 months: 79%, p < 0.02). Complications included 5 (4.8%) cases of distal embolism treated by thromboaspiration or Fogarty balloon embolectomy. Seven (6.7%) early thromboses were treated surgically. Primary and secondary patency rates were calculated at 6 years for all 105 cases and for the 92 recanalized lesions using life-table analysis. Overall, primary patency was 52% (CIA: 58%, EIA: 34%) and secondary 66% (CIA: 74%, EIA: 40%). Lesions < 6 cm had a primary patency of 70%, while those > 6 cm had a 31% rate (p < 0.01). Secondary patencies were 86% and 42%, respectively (p < 0.01). Among recanalized lesions, the primary patency was 61% (CIA: 69%, EIA: 38%) and secondary 77% (CIA: 88%, EIA: 45%; p < 0.05). Lesions < 6 cm had a primary patency rate of 72%, while longer lesions had a primary rate of 44% (p < 0.04); secondary patencies were 89% and 59%, respectively (NS). Primary patency without stent was 57% and with stent 65% (NS); secondary patency without stent was 71% and with stent 82% (NS).

CONCLUSIONS

Percutaneous recanalization of iliac occlusions represents a true alternative to vascular surgery and a first-line treatment option. Stents have a tendency to improve long-term results and are recommended for routine use in chronic iliac occlusions.

Use of intravascular ultrasound improves long-term clinical outcome in the endovascular management of atherosclerotic aortoiliac occlusive disease

PURPOSE

This study was undertaken to determine whether the use of intravascular ultrasound (IVUS) during balloon angioplasty and stenting of atherosclerotic aortoiliac occlusive lesions improved long-term clinical outcome. IVUS has been previously shown to be more accurate than arteriography in evaluating the deployment of stents in both peripheral and coronary arteries. Incomplete stent deployment has been anecdotally identified as a cause of restenosis or occlusion of a treated lesion. To our knowledge, there have been no previous studies that demonstrate whether the use of IVUS will affect the long-term patency rate of stented arterial lesions.

METHODS

Between March 1992 and October 1995, 52 patients with symptomatic aortoiliac occlusive disease underwent balloon angioplasty and stenting of their lesions. We retrospectively reviewed these cases to determine whether the use of IVUS influenced the long-term patency rate of these interventions. Follow-up ranged from 1 to 4 years with a mean of 28 months.

RESULTS

Fifty-two patients had confirmation of adequate stent deployment by arteriography. IVUS was used in conjunction with arteriography in 36 patients to evaluate stent deployment. Patients in the IVUS-assisted group were slightly younger than those patients who were evaluated solely by arteriography (p < 0.01). No statistical differences were noted between the two groups with respect to coronary artery disease, diabetes mellitus, obstructive pulmonary disease, hypertension, or obesity. Length of hospital stay, number of stents used, and preoperative ankle brachial indexes were comparable in both groups. In the arteriography plus IVUS group, 40% of patients had underdeployed stents by IVUS evaluation, though they appeared adequately expanded by arteriography. No restenoses or occlusions were seen in the arteriography plus IVUS group. Restenosis or occlusion of the stented lesion occurred in 25% of patients evaluated by arteriography alone (p < 0.01). These failures were treated by either thrombolysis or catheter thrombectomy and were then evaluated with IVUS. All were found to have underdeployed stents. Subsequent treatment consisted of adequate redeployment of existing stents using IVUS criteria. These salvaged reconstructions have continued to remain patent.

CONCLUSIONS

The use of IVUS may be the best means for assessing adequacy of arterial stent deployment. Our study suggests that the use of IVUS improves the long-term clinical outcome of balloon angioplasty and stented aortoiliac occlusive lesions.

The treatment of aortoiliac occlusions by endovascular stenting with or without adjuvant femorofemoral crossover grafting

We present four consecutive patients in whom we have used a combination of vascular and endovascular techniques in order to revascularise ischaemic legs caused by extensive aortoiliac occlusions. We believe that the techniques presented offer a viable alternative to more conventional surgical approaches in such cases.

Treatment of chronic iliac artery occlusions with guide wire recanalization and primary stent placement

PURPOSE

To evaluate the results of primary stent placement without initial thrombolysis in the treatment of iliac occlusions.

MATERIALS AND METHODS

During a 3-year period, 61 iliac artery occlusions were treated in 59 patients. The mean length of the occluded segment was 10 cm (range, 4-25 cm). The occluded arteries were treated with primary placement of self-expandable metallic stents.

RESULTS

Successful recanalization with primary stent placement was possible in 56 of 61 occlusions (92% technical success rate). Mean Doppler ankle/brachial index increased from 0.51 to 0.90 immediately after treatment and was 0.91 on the last follow-up (P < .05). Primary patency rate at 24 months was 73%, and secondary patency rate was 88%. Procedural complications included distal embolization (n = 4) and an episode of massive intra-abdominal bleeding. Three patients developed a hematoma at the puncture site that did not require additional therapy. Late complications included stent occlusion (n = 9) and significant stenosis related to intimal hyperplasia (n = 1). Mean follow-up period was 29 months (range, 7-55 months).

CONCLUSION

Primary stent placement is an effective therapeutic option for iliac artery occlusions.

Use of intravascular ultrasound in the endovascular management of atherosclerotic aortoiliac occlusive disease

BACKGROUND

Intravascular ultrasound (IVUS) has been described as interesting technology in search of a clinical application by some and by others as a valuable diagnostic tool for many endovascular interventions. Its clinical usefulness has yet to be fully defined. When used during endovascular interventions, it can provide structural and diagnostic information, assess effectiveness of the therapy, and identify treatment-related complications.

METHODS

Thirty-two consecutive patients with atherosclerotic aortoiliac occlusive disease who presented with 40 separate arterial lesions were evaluated with IVUS before and after balloon angioplasty and intraluminal stent placement. Information obtained from IVUS was compared with similar data obtained from simultaneous angiographic images. Both techniques were evaluated with respect to assessment of vessel size, lesion location, adequacy of therapy, and identification of complications.

RESULTS

Real time IVUS imaging compared with angiographic imaging showed that in 62% of the patients, vessel diameter was underassessed using angiographic criteria alone. More importantly, 40% (16 of the 40 lesions) had underdeployed stents by IVUS evaluation that appeared adequately expanded by angiographic criteria. Further stent expansion with a larger balloon was necessary to achieve accurate stent to vessel wall apposition. This was found to be significant by an exact binomial 95% confidence interval. Incomplete stent deployment has been identified as a possible cause for restenosis and vessel occlusion. Information obtained from IVUS imaging substantially altered the endovascular therapy in approximately 40% of our patients and provided valuable vessel sizing and lesion composition information in 62% of the patients.

CONCLUSION

Intravascular ultrasound can provide important diagnostic information that can alter the conduct of selected endovascular procedures. It is especially useful when the procedure requires deployment of arterial stents.