Endovascular treatment of occlusive lesions in the distal aorta: mid-term results in a series of 31 consecutive patients

Aortic Stenting in Symptomatic Infrarenal Aortic Stenosis and Subtotal Aortic Occlusion

Objective:

The aim of this study was to evaluate the long-term results of aortic stent placement in patients with infrarenal aortic occlusive disease.

Methods:

Between April 1996 and May 2014, 34 patients with symptomatic infrarenal atherosclerotic aortic stenosis or subtotal aortic occlusion underwent percutaneous angioplasty with primary aortic stent implantation. There were 21 patients with Fontaine stage of the peripheral arterial disease (PAD) II, 5 patients with stage III, and 8 patients with stage IV. One patient withdrew informed consent and was excluded from further analysis.

Results:

Patients (n = 34, mean age: 62 ± 12 years) were followed for a mean period of 81 months. There were 2 procedure-related access-related complications. Six patients died during follow-up from non-procedure-related causes. Eight patients had late recurrence of symptoms during follow-up. Only in 2 cases, symptomatic recurrences were due to aortic in-stent stenosis (77 and 132 months after the primary stent implantation). Additionally, these 2 patients required therapy for PAD progression distal to the aorta. Five patients required further surgical or endovascular reconstruction for PAD progression distal to the aorta. In another case, clinical treatment failure was due to the progression of atherosclerotic lesion in the perirenal, nonstented part of the abdominal aorta. The mean estimated primary patency rate was 185.6 months (95% confidence interval: 161.3-209.8).

Conclusion:

Endovascular stent implantation is a safe and long-term effective strategy for the treatment of infrarenal aortic occlusive disease. In our study, the recurrence of symptoms was observed mainly due to atherosclerosis progression by multilevel disease with associated infrainguinal occlusive lesions but not to aortic in-stent restenosis. The prognostic advantage for this relatively young cohort of patients can be the possibility to repeat a percutaneous procedure with less technical difficulties when compared to surgical revision.

Endovascular Treatment of Iliac Occlusive Disease: Review and Update

Use of endovascular interventions for arterial occlusive lesions continues to increase. With the evolution of the technology supporting these therapeutic measures, the results of these interventions continue to improve. In general, a comparison of techniques for revascularization of iliac occlusive diseases shows similar initial technical success rates for open versus percutaneous transluminal angioplasty. Angioplasty is often associated with lower periprocedural morbidity and mortality rates. Conversely, surgery frequently provides greater long-term patency, although late failure of percutaneous therapies may occur but still can be treated successfully with reintervention. The perpetual buildup of experience with angioplasty and stenting will eventually characterize its role in the management of occlusive disease. This review outlines the current consensus and applicability of endovascular management of iliac occlusive diseases.

Long-term outcomes of endovascular therapy for aortoiliac bifurcation lesions in the real-AI registry

PURPOSE

To report long-term outcomes of endovascular therapy (EVT) for aortoiliac bifurcation lesions.

METHODS

Patients enrolled in the multicenter REtrospective AnaLysis of Aorto-Iliac stenting (REAL-AI) registry in Japan were pooled. Of 2096 patients who underwent EVT for de novo aortoiliac disease between January 2005 and December 2009, 190 patients (148 men; mean age 70±9 years) had aortoiliac bifurcation lesions that were treated with stents, whose configuration (single, V, or kissing) and type (balloon-expandable or self-expanding) were subjected to regression analysis to determine any impact on primary patency along with other demographic, clinical, and lesion characteristics, including Trans-Atlantic Inter-Society Consensus II C/D classification. The primary endpoints were restenosis and target lesion revascularization (TLR). Secondary endpoints were all-cause death, major cardiovascular events, and major cardiovascular + limb events.

RESULTS

The overall complication rate was 6.3%, and 1- and 5-year primary patency rates were 87% and 73%, respectively. Over a mean follow-up of 31±15 months, there were 36 (19.0%) restenoses, 22 (11.6%) TLRs, and 4 (2.1%) reocclusions; stent fracture (2, 1.1%) and major amputation (2, 1.1%) were rare. Only female gender [adjusted hazard ratio (AHR) 4.26, 95% CI 1.89 to 9.71, p<0.001] and residual diameter stenosis (AHR 1.04, 96% CI 1.01 to 1.06, p=0.01) were independent predictors of primary patency.

CONCLUSION

Stenting for aortoiliac bifurcation lesions was found to be safe and effective. Neither stent configuration nor type appeared to affect vessel patency in true bifurcation lesions.

Transbrachial and femoral artery approach endovascular therapy for flush infrarenal aortic occlusion

OBJECTIVE

The purpose of this study is to report the efficacy of transbrachial and femoral artery approach endovascular therapy with catheter-directed thrombolysis (CDT) and adjunctive therapy for flush infrarenal aortic occlusion (FIAO).

MATERIALS AND METHODS

From March 2012 to December 2013, 11 consecutive patients (9 males; mean age 68 years; range 54-80 years) were submitted to endovascular therapy for FIAO. All patients were treated with CDT initially and then adjunctive endovascular treatments were performed to correct the underlying lesions.

RESULTS

Complete reconstruction of occluded aortoiliac arteries was successfully achieved in 81.8% (9/11) of patients. Left brachial and bilateral femoral arterial accesses were obtained in nine patients, and brachial and unilateral femoral in two patients. The residual lesions after CDT were corrected in nine patients and concomitant endovascular recanalization of superficial femoral artery was performed in two patients. Self-expandable stents were implanted in the all aortoiliac lesions with pre- and post-dilation. No renal or distal runoff embolization was seen during intraoperative angiography. Seven (7/9) patients with rest pain or tissue loss showed significant improvements in symptoms and two (2/9) patients with intermittent claudication gained an improved walking distance. The ABI rose significantly between pre- and post-procedure (0.84 ± 0.18 vs. 0.44 ± 0.13 on the right leg, p < .01; 0.89 ± 0.23 vs. 0.48 ± 0.16 on the left, p < .01).

CONCLUSIONS

Transbrachial and femoral artery approach endovascular therapy for FIAO offers an alternative to surgical reconstruction with immediate outcomes.

Successful endovascular management of an aortic rupture following stent placement for severe atherosclerotic stenosis: A case report

Aortic rupture during endovascular procedures is a devastating complication that mandates expedient intervention. The present report describes a case in which endovascular treatment was used to successfully manage an aortic rupture following placement of a covered stent graft for severe infrarenal aortic stenosis. Successful management of this case was the result of the procedure being performed in an operating room under appropriate anesthesia and close hemodynamic monitoring. Bilateral common femoral arterial access and use of covered aortic stent grafts also contributed to a favourable outcome.

T-stenting with small protrusion technique (TAP-stenting) for stenosed aortoiliac bifurcations with small abdominal aortas: an alternative to the classic kissing stents technique

PURPOSE

To report the feasibility and midterm results of aortic bifurcation reconstruction in patients with small abdominal aortas using commercially available stents applied in a modified T-stenting technique adapted from coronary angioplasty.

METHODS

Twenty-three patients (16 men; mean age 52.4 years) with lower limb ischemia (Fontaine stage IIb or III) and distal abdominal aortas <14 mm in diameter were treated for 39 common iliac artery and 16 aortic stenotic lesions involving the aortic bifurcation. A large, self-expanding stent was implanted from the lower aorta to one iliac branch, followed by deployment of a balloon-expandable stent in the contralateral iliac artery such that its proximal edge protruded a few millimeters through the struts of the self-expanding stent into the aorta [TAP (T And Protrude)-stenting technique]. Follow-up clinical, Doppler ultrasound, and computed tomography examinations were scheduled for each patient.

RESULTS

Angiographic success was obtained in all 23 patients, who received 23 self-expanding aortomonoiliac stents (mean diameter 13.5 mm) and 22 balloon-expandable stents (mean diameter 8.14 mm) in the contralateral iliac branch. No complications were reported. At a mean 16.3-month follow-up (range 2-60), clinical and ankle-brachial index (0.6±0.2 at baseline versus 1.04±0.1, p<0.01) improvement was observed in all patients. All stents were patent (patency rate 100%). Two late technical failures of the contralateral stent were observed (incomplete dilation requiring angioplasty and incomplete protrusion without any hemodynamic impact).

CONCLUSION

The TAP-stenting technique adapted to the aortoiliac bifurcation appears to be feasible, with satisfactory early and midterm patency rates in patients with small abdominal aortas. Larger series with longer follow-up times are necessary.

Outcomes of covered kissing stent placement compared with bare metal stent placement in the treatment of atherosclerotic occlusive disease at the aortic bifurcation

PURPOSE

To review the outcomes with the use of balloon-expandable covered iliac kissing stents as compared with bare metal stents in the treatment of atherosclerotic disease at the aortic bifurcation.

MATERIALS AND METHODS

A review of consecutive patients from a single institution with atherosclerotic occlusive disease at the aortic bifurcation treated with balloon-expandable kissing stents was performed between January 1, 2002, and September 1, 2007. Fifty-four patients were identified and divided into two groups: those with bare metal stents and those with covered stents. Technical and clinical success (Fontaine classification), complications, and patency at follow-up were documented.

RESULTS

Twenty-six patients (17 men, nine women; mean age, 61 years; age range, 39-79 years) received covered stents and 28 patients (15 men, 13 women; mean age, 61 years; age range, 38-82 years) received bare metal stents. Technical success was achieved in 100% of patients in both groups. Major complications occurred in three of the 26 (11%) with covered stents (P = .66) and two of the 28 patients (7%) with bare metal stents. The median follow-up was 21 months (20 months for covered stents vs 25 months for bare metal stents; range, 1-62 months). Twenty-two of the 26 patients (85%) with covered stents had sustained improvement in clinical symptoms during the follow-up period compared with 15 of the 28 patients (54%) with bare metal stents (P = .02). Primary patency rates at 1 and 2 years were 92% and 92%, respectively, for covered stents and 78% and 62% for bare metal stents (P = .023).

CONCLUSIONS

The use of covered balloon-expandable kissing stents for atherosclerotic aortic bifurcation occlusive disease provides superior patency at 2 years as compared with bare metal balloon-expandable stents.

Endovascular management of chronic infrarenal aortic occlusion

PURPOSE

To review our experience with the endovascular treatment of chronic infrarenal aortic occlusion with regard to technical success and midterm patency, as well as perioperative mortality and morbidity.

METHODS

A retrospective review was performed of patients who presented from January 1, 2000, to December 31, 2005, with a diagnosis of chronic infrarenal aortic occlusion (TASC D) treated with endovascular techniques. In this time period, 31 patients (22 women; mean age 63 years) underwent attempted recanalization of the occluded aorta and iliac arteries. Claudication was the most common presenting symptom (14, 45%). Patients were treated solely with angioplasty and stenting or thrombolysis followed by angioplasty/stenting based on surgeon preference.

RESULTS

Technical success was 93%. The 2 failures were individual cases of wire-induced iliac artery perforation and failed access; both patients were treated with bypass grafting. Nine (29%) patients had thrombolysis prior to angioplasty. There were no perioperative deaths. Postoperative ankle-brachial indexes increased significantly from preoperative values (p<0.0001). There were 3 technical complications: 1 (3%) iatrogenic iliac artery injury and 2 (6%) perioperative limb thromboses requiring intervention. Other complications included 6 (19%) access site events and 5 (16%) episodes of acute renal dysfunction, 2 requiring permanent dialysis. Over a mean follow-up of 12 months, there was no limb loss. At 1 and 3 years, the primary/secondary patency rates were 85%/100% and 66%/90%, respectively.

CONCLUSION

Endovascular therapy for chronic infrarenal aortic occlusion has a high technical success rate, with good midterm primary and secondary patency rates. However, renal dysfunction can occur; the etiology is likely multifactorial from contrast volumes, embolization, and/or renal arterial disease.

Standards for the Endovascular Management of Aortic Occlusive Disease

Occlusive disease of the infrarenal aorta and aorto-iliac arteries can be safely treated by minimally invasive therapy and is now widely available. The aim of this article is to produce standards for the management of these patients using current endovascular techniques.

Endovascular treatment of isolated atherosclerotic lesions of the infrarenal aorta is technically feasible with acceptable long-term results

OBJECTIVES

To investigate the results of endovascular treatment of symptomatic, atherosclerotic lesions of the infrarenal aorta.

PATIENTS AND METHOD

This is a retrospective study including 30 procedures performed on 25 patients in the period from 1990 through 2003. There were 16 women (64%) and 9 men, with a mean age of 55 years (range 35-81 years). The indication was disabling intermittent claudication in all cases. Preoperative assessment was done with ankle-arm pressure measurement and angiography. The mean length of the lesions was 2.5cm (range 1-6cm). One lesion was a short occlusion and nine were >90% stenoses. The remaining 20 lesions were significant (>70%) stenoses. The procedure was done with PTA alone in 13 cases, and with additional stenting in 17.

RESULTS

The procedures were technically successful in 28 cases and clinically successful in all 30. In two cases, a >50% residual stenosis was not dilated further because of stretch pain. The mean observation time was 40 months (range 0-135 months). The primary 2 and 5 year patency rates calculated on basis of intention to treat were 90 and 77%. The primary assisted patency rate was 90% at 2 years and 83% at 5 years. Eight patients developed significant restenosis, of which five were treated with a new endovascular procedure. Two failures were treated conservatively and one with surgical thrombendarterectomy.

CONCLUSION

Endovascular treatment of isolated atherosclerotic lesions of the infrarenal aorta is feasible in patients with suitable anatomy. Clinical success rates are high and long-term patency is good. Complications are few and minor. The majority of failures are amenable to new endovascular treatment.

Endovascular Therapies for Noncoronary Atherosclerosis in the Elderly: Aortoiliac and Femorotibial Lesions

Many interventional cardiologists are becoming interested in the interventional treatment of noncoronary atherosclerotic disease. The elderly may be especially benefited by the application of many new techniques for the treatment of lower limb atherosclerosis, such as protection and thromboaspiration devices, new atherectomy devices, and cryoplasty. In this review the authors offer geriatric cardiologists an overview and an update of the most recent advances in techniques and results in the field of interventional treatment of aortoiliac and femorotibial artery atherosclerosis in the elderly.

Hybrid treatment for juxtarenal aortic occlusion: Successful revascularization using iliofemoral semiclosed endarterectomy and kissing-stents technique

A 53-year-old man with a significant respiratory history waiting for lung transplantation presented with severe bilateral buttock and thigh claudication. Angiography revealed severe stenosis of the left renal artery and total occlusion of the infrarenal abdominal aorta and iliac vessels. Via a bilateral surgical femoral exposure, we performed semiclosed endarterectomy of the iliofemoral vessels and percutaneous transluminal angioplasty stenting of the infrarenal aorta with two Palmaz stents and percutaneous transluminal angioplasty "kissing stents" of the iliac arteries with three Luminexx stents bilaterally. Completion angiography showed successful complete recanalization of the aortoiliofemoral axis. Palpable distal pulses were restored. A combined surgical and endovascular approach should be considered a viable alternative to laparotomy in selected patients with total juxtarenal aortic occlusion.

Endovascular Treatment of Isolated Atherosclerotic Stenosis of the Infrarenal Abdominal Aorta: Long-term Outcome

The purpose of this multicenter study was to assess the long-term outcome of endovascular treatment of isolated atherosclerotic stenosis of the infrarenal abdominal aorta on the basis of clinical and ultrasound examination. Clinical, ultrasound, and angiographic findings from 36 women and 50 men (mean age, 53.2 years) treated for atherosclerotic stenosis of the infrarenal abdominal aorta were reviewed. Patients had claudication in 74 cases and rest pain in 4. Seven patients presented trophic manifestations and one had blue toe syndrome. Mean preoperative systolic index was 0.71. Mean diameter reduction was 77%. Circumferential calcification was partial in 36 cases (41%) and complete in 30 cases (35%). Percutaneous transluminal angioplasty was performed using the single-balloon technique in 60 cases and double-balloon technique in 26 cases. A stent was placed in 76 cases (88%) by necessity in 34% of cases (22 residual stenoses, 4 dissections). Completion angiographic findings were considered good in 82 cases (95%). The remaining four patients had residual stenosis with a diameter reduction >30%. One patient died during the immediate postoperative period from septicemia unrelated to treatment (early mortality, 1.2%). Aortic angioplasty was complicated by stent detachment from the angioplasty balloon in two patients, retroperitoneal hematoma in one, peripheral embolism in two, puncture-site hematoma in three, myocardial infarction in one, and thrombophlebitis of deep femoral artery in one patient (early morbidity, 9.3%). All patients underwent follow-up with clinical and hemodynamic evaluation (mean follow-up, 31 months). Actuarial survival at 3 years was 91%. Primary actuarial patency was 94% at 1 year, 89% at 3 years, and 77% at 5 years. Aortic restenosis occurred in seven patients and was treated by angioplasty in two, aortobifemoral bypass in four, and surveillance in one. Mean systolic index was 0.89. Statistical analysis of patency demonstrated no factor predictive of long-term complication. From the long-term follow-up findings in this study, we conclude that aortic angioplasty is a reliable minimally invasive technique for treatment of isolated atherosclerotic stenosis of the infrarenal abdominal aorta.