Endovascular treatment of steno-occlusions of the infrarenal abdominal aorta

Endovascular treatment of aorto-iliac occlusive disease with TASC II C and D lesions: 10 year's experience of clinical technique

OBJECTIVES

The purpose of this study was to evaluate the therapeutic efficacy and safety of endovascular treatment aorto-iliac occlusive disease (AIOD) with TransAtlantic Inter-Society Consensus II (TASC II) C and D lesions. In addition, 10 years of experience with interventional procedures and treatment options in our center were also worthy of further discussion.

METHODS

Between January 2011 and December 2020, a total of 26 consecutive AIOD patients with TASC-II C and D lesions treated endovascular approach were enrolled in this study. Patients' demographic and clinical data were collected, and the safety and efficacy of endovascular therapy were evaluated. In addition, operation procedures were also described.

RESULTS

The mean age of patients was 62.2 ± 7 years (49-57 years), and the mean body mass index of patients was 24.2 ± 2.6 kg/m². Fifteen patients (57.7%) were Rutherford 4, 5 each (19.2%) were Rutherford 3 and 5, and 1 (3.8%) was Rutherford 2. No other serious complications occurred except death in 3 patients. Most of the patients (73.1%) had a history of smoking, and hypertension and hyperlipidemia were common comorbidities. Endovascular therapy was successfully performed in 25 patients, and the technical success rate was 96.2%. The patient's ankle-brachial index improved significantly postoperatively compared with preoperatively (preoperative 0.33 ± 0.14 vs 1.0 ± 0.09, P < 0.001). The primary patency rates were 100%, 95.7%, and 91.3% at 1, 3, and 5 years, while the secondary patency rates were 100%. No treatment-related deaths or serious complications occurred.

CONCLUSIONS

Endovascular treatment of AIOD patients with TASC-II C and D lesions might be safe and have a high rate of middle-term and long-term primary patency.

Management of Extensive Aorto-Iliac Disease: A Systematic Review and Meta-Analysis of 9319 Patients

PURPOSE

Despite advances in endovascular management of aorto-iliac occlusive disease (AIOD) including covered endovascular reconstruction of aortic bifurcation (CERAB) techniques, guidelines for management of symptomatic Trans-Atlantic Inter-Society Consensus (TASC II) type C/D lesions favour open surgical revascularisation. This meta-analysis investigates outcomes in patients with TASC II C/D lesions treated with open bypass procedures (OS), standard endovascular treatments (SEV) or CERAB.

METHODS

Multiple databases (MEDLINE, EMBASE and the Cochrane database) were searched to identify studies reporting endovascular and open treatment of extensive AIOD. Studies were independently assessed. Outcomes reported included 30-day morbidity/mortality and patency rates.

RESULTS

A total of 9319 patients undergoing intervention for extensive AIOD were identified from 66 studies. Median patient age was 64 years (n = 3204) for SEV, 58 years (n = 240) for CERAB and 59 years for OS (n = 5875). Pooled meta-analysis for 30-day morbidity in patients undergoing SEV, CERAB and OS was 9, 10 and 15%, respectively. Thirty-day mortality rate was 0.79, 0 and 3% in the SEV, CERAB and OS groups, respectively. In these groups, one-year primary and secondary patency was 90, 88, 96 and 96, 97, and 97% whilst three-year primary and secondary patency was 78, 82, 93 and 93, 97, 97% respectively. Five-year primary and secondary patency was 71 and 89% for SEV and 88 and 95% for OS, respectively. CERAB data were only available to 3 years.

CONCLUSIONS

This meta-analysis shows that thirty-day morbidity and mortality favours endovascular techniques. Primary patency remains better with OS in both early and midterms;; however, secondary patency is comparable in all groups. These findings suggest that SEV/CERAB may be considered as an alternative to OS in higher-risk patients.

Endovascular Reconstruction of Aortoiliac Occlusive Disease with an Aberrant Pelvic Kidney

Aortoiliac occlusive disease coincident with a congenital ectopic pelvic kidney is a rare occurrence. Traditionally, the treatment has been open aortobifemoral repair with reimplantation of the renal artery. We present a patient with Trans-Atlantic Inter-Society Consensus (TASC) D bilateral aortoiliac occlusive disease, an ectopic pelvic kidney, and prohibitive medical comorbidities. We describe a totally endovascular repair using a chronic total occlusion crossing device, a luminal re-entry device, and balloon-mounted covered stents to revascularize the lower extremities and the ectopic pelvic kidney. We discuss various aspects of this endovascular approach as the incidence of patients with TASC D lesions and prohibitive comorbidities continue to rise.

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 revascularization to right coronary artery by percutaneous coronary intervention after endovascular therapy for leriche syndrome

A 69-year-old man with effort angina was admitted to our institution. Echocardiography showed poor left ventricular systolic function with akinesis of the anterior wall and severe hypokinesis of the inferior wall. We performed coronary angiography, which revealed two diseased vessels including chronic total occlusion in the left anterior descending artery and severe stenosis in the right coronary artery (RCA). In addition, aortography revealed aortoiliac occlusive disease known as Leriche syndrome. As the patient's symptom was stable, we first planned to perform endovascular therapy (EVT) for Leriche syndrome to make a route for intra-aortic balloon pumping. We prepared a bi-directional approach from bi-femoral arteries and a left brachial artery. The guidewire was passed through the occlusive area using the retrograde approach. The self-expanding stents were deployed by a kissing technique. At one week after EVT, a 6Fr sheath was inserted from the right radial artery and an intra-aortic balloon pump was successfully inserted through the right femoral artery for percutaneous coronary intervention (PCI) to the RCA. Two drug-eluting stents were successfully deployed to RCA after using an atherectomy device (rotablator). We reported the case as a successfully performed PCI to the RCA after EVT for Leriche syndrome.

New treatment of iliac artery disease: focus on the Absolute Pro® Vascular Self-Expanding Stent System

Management of iliac artery disease has evolved over the years, from a surgical-only approach to a primarily endovascular-only approach as the first line treatment option. This has been continuously improved upon with the advent of new devices and applied technologies. Most recently in particular, the literature has shown good, reliable outcomes with the use of self-expandable stents in iliac artery atherosclerotic lesions. Nevertheless, no device is without its limitations, and the Absolute Pro® Vascular Self-Expanding Stent System was designed with the intent of overcoming some of the shortcomings of other available stents while maintaining acceptable postprocedural outcomes. Based on preliminary industry-acquired data, it has achieved these goals and appears to be an emergent competitor for the treatment of both focal and complex iliac artery lesions.

A case achieved successful revascularization to severe ischemic coronary artery disease after endovascular recanalization with infrarenal aortic occlusion

An 80-year-old woman was admitted to our emergency department with ongoing dyspnea for 2 weeks. The patient was immediately intubated endotracheally because of the hypoxia with flush pulmonary edema. Electrocardiogram showed ST depression and echocardiogram showed hypokinesis of anterior left ventricular wall with poor systolic function. Also her cardiac enzymes were elevated, emergency coronary angiogram was performed from radial artery because both femoral arteries were not fully palpable. Coronary angiogram showed three vessels disease including chronic total occlusion of right coronary artery and left main bifurcation lesion. Also blood flow of left anterior descending coronary artery was delayed. Acute coronary syndrome was the cause of acute heart failure and revascularization was needed but aortography revealed total occlusion of infrarenal aorta. Patient was relatively hemodynamically stable; we planned treating total occlusion of infrarenal aorta with endovascular therapy to maintain a rout for cardiopulmonary support system. With bi-directional approach from both femoral artery and left brachial artery, occlusion site with heavy calcification was finally passed through by guide wire from retrograde approach. After pull-through technique, self-expanding nitinol stent was implanted after pre dilation with small balloon. Considering her EURO score, supposed perioperative mortality was high, percutaneous coronary intervention was performed. A 7 fr sheath was inserted from right femoral artery and intra-aortic balloon pump was inserted from left femoral artery. Sirolimus-eluting stent was implanted to left circumflex artery and also from ostium of left main to mid left anterior descending coronary artery after using an atherectomy device. After successful revascularization, patient became hemodynamically stable and weaning off the respirator was successful. Reporting case achieved successful revascularization to severe coronary artery disease after endovascular recanalization with infrarenal aortic occlusion.

A vascular cause of painful lumbar transverse syndrome

BACKGROUND

Despite typical signs of Leriche syndrome, this patient was misdiagnosed with disk prolapse. Vascular insufficiency, such as aortic occlusion, may underlie a motor-sensory deficit in the lower extremities.

METHOD

Case report.

FINDINGS

A 67-year-old woman was admitted for cramping pain in the lumbar spine, hips, and legs; diffuse weakness and sensory disturbances of both legs for weeks; and a cold feeling and livid colorization of the legs. Her complaints were attributed to a disk prolapse L5/S1, for which she underwent immediate laminectomy. Postoperatively, symptoms and signs were aggravated, abdominal pain developed, and C-reactive protein and creatinine were elevated. On the fourth postoperative day, femoral pulses were no longer palpable, anuria developed, and computed tomographry angiography showed occlusion of the abdominal aorta distal to the superior mesenteric artery and absent kidney perfusion. The patient died one day later. Postmortem review showed a visible intra-aortic mass on the previous lumbar magnetic resonance image.

CONCLUSIONS

The differential diagnosis of painful lumbar transverse syndrome should include vascular disease. Misinterpretation of a Leriche syndrome as a disk prolapse has not been reported.

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.