Kissing stents in the aortic bifurcation--a valid reconstruction for aorto-iliac occlusive disease

Comparative outcomes of aortobifemoral bypass with or without previous endovascular kissing stenting of the aortoiliac bifurcation

OBJECTIVE

The aim of this multicenter national study was to compare the outcomes of primary open surgery by aorto-bifemoral bypass (ABFB) with those performed after a failed endovascular treatment (EVT) by kissing stent technique for complex aortoiliac occlusive disease (AIOD) lesions (TransAtlantic Inter-Society Consensus [TASC] II C and D).

METHODS

All consecutive ABFB cases carried out at 12 vascular surgery centers between 2016 and 2021 were retrospectively collected and analyzed. Data included patients' baseline demographics and clinical characteristics, procedural details, perioperative outcomes, and follow-up results (survival, patency, amputation). The study cohort was divided into two groups based on indications for ABFB: primary treatment vs secondary treatment after EVT failure.

RESULTS

Overall, 329 patients underwent ABFB during the study period (71% males; mean age, 64 years), of which 285 were primary treatment and 44 were after prior EVT. At baseline, no significant differences were found between study groups in demographics and clinical characteristics. TASC C and D lesions were similarly represented in the study groups (TASC C: 22% vs 78%; TASC D: 16% vs 84%). No major differences were found between study groups in terms of procedural details, early mortality, and perioperative complications. At 5 years, primary patency rates were significantly higher for primary ABFB (88%; 95% confidence interval [CI], 93.2%-84%) as compared with ABFB after prior EVT (69%; 95% CI 84.9%-55%; log rank P value < .001); however, the 5-year rates of secondary patency (100% vs 95%; 95% CI, 100%-86%) and limb salvage (97%; 95% CI, 99%-96 vs 97%; 95% CI, 100%-94%) were similar between study groups.

CONCLUSIONS

Surgical treatment of TASC C/D AIOD with ABFB seems to be equally safe and effective when performed after prior EVT, although primary ABFB seemed to have higher primary patency rates. Despite the need for more frequent reinterventions, secondary patency and limb salvage rates were similar. However, future large prospective trials are required to confirm these findings.

Comparison of Clinical Outcomes of Endovascular Therapy and Hybrid Surgery in the Treatment of Trans-Atlantic Inter-Society Consensus II D Aortoiliac Occlusive Disease

Purpose

To study and compare the clinical outcomes of endovascular therapy with those of hybrid surgery in the treatment of Trans-Atlantic Inter-Society Consensus II (TASC II) D aortoiliac occlusive disease (AIOD).

Patients and Methods

Patients with TASC II D-type AIOD who underwent their first surgical treatment at our hospital between March 2018 and March 2021 were enrolled and followed up to evaluate the improvement in symptoms, complications, and primary patency. The Kaplan-Meier method was used to compare the differences in primary patency between the treatment groups.

Results

In total, 132 of 139 enrolled patients (94.96%) achieved technical success following treatment. The perioperative mortality rate was 1.44% (2/139), and postoperative complications occurred in two patients. Among the patients who successfully underwent surgery, 120 underwent endovascular treatment (110 patients with stenting and 10 patients with thrombolysis before stenting), 10 underwent hybrid surgery, and 2 underwent open surgery. The follow-up data were compared between the endovascular and hybrid groups. At the end of the follow-up period, the patency rates in the hybrid and endovascular groups were 100% and 89.17% (107/120), respectively. The endovascular group achieved primary patency rates of 94.12%, 92.44%, and 89.08% at 6, 12, and 24 months postoperatively, respectively, whereas the primary patency rate remained at 100% in the hybrid group, with no significant variation between the endovascular and hybrid groups (P = 0.289). The endovascular group was further divided into a stent subgroup (110 patients) and a thrombolysis/stent subgroup (10 patients), and no prominent variation was noted in the primary patency between the two subgroups (P = 0.276).

Conclusion

Although open surgery is the gold standard treatment for TASC II D-type AIOD, endovascular and hybrid treatments are feasible and effective. Both methods showed good technical success and early to midterm primary patency rates.

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.

Fate of Asymptomatic Limb after Kissing Stents in Aortoiliac Occlusive Disease

Purpose

Kissing stent angioplasty is an established endovascular treatment strategy for stenosis at the aortic bifurcation but not without its detractors. This study aimed to analyze the outcomes of kissing stents with regard to stent occlusion and complications in which an asymptomatic limb was treated.

Methods

Materials and A total of 106 patients undergoing aortic bifurcation intervention from January 2015 to November 2020 were retrospectively reviewed. Only patients with at least one common iliac artery (CIA) ostium and undergoing bilateral CIA intervention were included in the study.Results: Patients were followed up for a median period of 26 months (interquartile range, 21-51 months). The TransAtlantic InterSociety Consensus (TASC)-II classification of lesions was as follows: A, 49%; B, 41%; C, 6%; and D, 5%. The treatment indication was limited to one side in 53% of patients. Technical and procedural success rates were 99% and 90%, respectively. Ischemic events in an asymptomatic limb occurred in 6% of cases, 3% due to late stent thrombosis >30 days, and 3% due to progression of downstream infrainguinal disease. Primary and secondary patency rates at 1, 3, and 5 years were 98%, 87%, and 85%, and 99%, 94%, and 94%, respectively. Periprocedural mortality developed in two patients with no amputation.

Conclusion

Kissing stent deployment is a safe and effective strategy for the treatment of aortoiliac bifurcation disease. Unfavorable outcomes due to stenting in the asymptomatic iliac artery are very rare. Long-term surveillance is necessary due to the risk of late thrombosis or downstream disease progression.

Midterm results of kissing stent reconstruction of the aortoiliac bifurcation

Purpose

One subset of peripheral arterial disease is aortoiliac occlusive diseases (AIOD). AIOD is the term for all arterial lesions between the infrarenal distal aorta and common femoral artery. Implantation of kissing stents (KS) with covered stents (CS), bare-metal stents (BMS) is one of the endovascular treatment (ET) modalities for AIOD involving aortic bifurcation. In this study, we report the outcomes of the KS technique in infrarenal AIOD.

Methods

Between January 2014 and September 2017, 31 patients who underwent ET were treated with KS technique either with balloon-expandable BMS or balloon-expandable CS. Technical details, clinical success, complications, and patency at follow-up were documented.

Results

The majority of patients were male (77.4%), and the median age was 62 years (range, 45-78 years). All patients were classified according to the TASC II criteria. Eight patients (25.8%) were classified as TASC B. Fifteen patients (48.4%) were classified as TASC C, and 8 patients (25.8%) were classified as TASC D. These 23 patients were classified as complex AIOD group. BMS was used in 17 patients (54.8%), and CS was used in 14 patients (45.2%). Technical and clinical success was achieved in 100% of treated cases. The median follow-up was 24 months (range, 24-34 months). Primary patency rates at 12, 18, and 24 months after ET were 100%, 96.8%, and 90.3%, respectively.

Conclusion

We found that the KS technique has satisfying 24-month results, even in complex AIOD lesions, with high technical success and acceptable midterm patency. Key Words: Aorta, Arterial occlusive diseases, Endovascular procedures, Iliac artery, Stents.

Covered Stents for Endovascular Treatment of Aortoiliac Occlusive Disease: A Systematic Review and Meta-Analysis

PURPOSE

The treatment of aortoiliac occlusive disease (AIOD) has largely shifted to endovascular techniques, with primary stenting constituting the preferred treatment approach. The goal of the current study was to summarize available literature and to determine whether covered stents are superior to bare metal stents for the treatment of AIOD, in terms of both periprocedural and long-term outcomes.

METHODS

A meta-analysis of 47 studies was conducted with the use of random effects modeling. The incidence of adverse events during follow up among the individual included studies was synthesized.

RESULTS

Most of the lesions were located at the common iliac arteries and were chronic total occlusions. The procedure was technically successful in almost all cases in both groups, with a low rate of periprocedural complications observed in both groups. The reported primary patency rates for the non-covered and covered stent group during an average follow up of 24.3 months among the individual studies, were 84% and 92% respectively, while surgical or endovascular re-intervention was required in 10% of non-covered stent cases and in 6% of covered stent cases. Eight studies comparing covered vs non-covered stents in terms of patency demonstrated superiority of covered stents (OR: 2.47; 95% CI: 1.01-6.01; p = 0.047 Combining TASC C/D lesions together 12 studies reported 92% (95%CI:89%-95%) primary patency in the covered stent group, while 7 studies reported 75% (95%CI: 60%-88%) primary patency for cases treated with non-covered stents.

CONCLUSION

This study demonstrated that covered stents are safe and effective when utilized for the treatment of AIOD. Covered stents were associated with a statistically significant higher odds of primary patency in both the overall cohort and in more complex TASC C/D lesions. However, additional high-quality comparative analyses between covered vs bare metal stents and between several types of covered stents are needed to determine the most optimal treatment modality for AIOD.

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.

Outcomes Analysis of Surgical Conversion for Kissing-Stent Occlusion

BACKGROUND

We aimed to describe the operative outcomes following open aortoiliac/femoral graft reconstruction for bilateral kissing-stent (KS) occlusion.

METHODS

This is a bicentric, retrospective, observational cohort study. Between September 2007 and December 2019, 205 patients were treated with KS for aortoiliac reconstruction. Only those who had bilateral KS occlusion with subsequent aortoiliac/femoral graft replacement were included in this analysis. Primary outcomes were early (<30 days) and late survival, postoperative (<30 days) complications, and patency rates.

RESULTS

Nine patients (male, n = 7) were analyzed. The patient's mean age was 60 ± 5 years (range 55-62). Median delay from initial KS procedure was 36 months (interquartile range [IQR] 19-252). On admission, all patients presented with a worse Rutherford class compared to their initial pre-KS clinical presentation. Aortobifemoral bypass was performed in 5 patients, and aortobi-iliac reconstruction in 4 patients. There were no perioperative deaths and only 1 new case of erectile dysfunction occurred. At a median follow-up time of 24 months (IQR 12-54), primary patency rate was 88.9%.

CONCLUSIONS

Open aortic reconstruction after KS occlusion was feasible and effective. Endovascular repair for aortoiliac obstructive disease may be pursued as first-line treatment even in complex lesions.

Propensity-Matched Comparison of Endovascular versus Open Reconstruction for TASC-II C/D AortoIliac Occlusive Disease. A Ten-Year Single-Center Experience with Self-Expanding Covered Stents

BACKGROUND

To compare endovascular therapy (EVT) using kissing self-expanding covered stents, with open repair (OR) with aortobifemoral bypass (ABF), for reconstruction of the aortic bifurcation in Trans-Atlantic Inter-Society Consensus II (TASC-II) C/D aortoiliac occlusive disease (AIOD).

METHODS

A single-center retrospective analysis of patients treated by EVT or ABF for TASC-II C/D AIOD (2009-2018) was carried out. The perioperative risk was quantified by the Society for Vascular Surgery (SVS) and American Society of Anesthesiologists (ASA) scores. Outcomes of interest were early (30 days) mortality and complication rates, length of hospitalization, and midterm patency that were compared between EVT and OR after propensity score matching. Follow-up results were analyzed with Kaplan-Meier curves. Cox proportional hazards were used to identify predictors of patency.

RESULTS

Sixty-three EVT and 55 OR patients were treated; the EVT group had higher perioperative risk (ASA score, P = 0.012. SVS score, P = 0.012) and less advanced disease (TASC D lesions, 52.3% vs. 72.7%; P = 0.036. Iliac occlusion, 46.8% vs. 87.2%; P = 0.024). After propensity score matching, 148 limbs were selected (74 EVT and 74 OR), resulting in well-balanced groups regarding risk (ASA score, P = 0.514. SVS score, P = 0.373) and anatomical complexity (TASC D lesions, 60.4% vs. 63.0%; P = 0.516. Iliac occlusion, 47.3% vs. 59.5%; P = 0.187). Mortality was 0%. The EVT group showed significantly shorter hospital (4.5 ± 7.6 days vs. 9.9 ± 6.8 days; P < 0.001) and intensive care unit stay (0 ± 0.1 days vs. 1.7 ± 1.5 days; P = 0.046) and less surgical complications (4% vs. 14.8%; P = 0.046). Five-year primary patency was similar between EVT and OR (84.1% vs. 88.3%; P = 0.454); multivariate analysis showed that Rutherford category was the only predictor of primary patency (HR 4.1, P = 0.023).

CONCLUSIONS

The endovascular kissing self-expanding covered stent technique for TASC-II C/D AIOD presented a primary patency equal to ABF at 5 years, with the advantage of less surgical complications and shorter hospitalization. Therefore, it may be considered as a valid option for complex atherosclerotic lesions involving the aortic bifurcation.

The Viabahn balloon expandable stent for endovascular reconstruction of the infrarenal aorta and its bifurcation in cases of severe obstructive disease

INTRODUCTION

The covered endovascular reconstruction of the aortic bifurcation (CERAB) represents a promising technique for the treatment obstructive lesions involving the aortic bifurcation. The aim of this report is to describe the use of a new generation balloon-expandable stent-graft (Viabahn VBX, W.L. Gore&Associates, AZ, USA), in the CERAB configuration for the treatment of aorto-iliac obstructive lesions involving the infrarenal aorta and bifurcation.Technical note: This technique was adopted in two patients with severe aorto-iliac obstructive lesions. After bilateral iliac recanalization, an 11 mm diameter VBX stent was deployed in the infrarenal aorta; a post-dilatation up to 16 mm with a non-compliant balloon was performed to adapt the proximal edge of the stent to the aortic diameter. Two 8 mm diameter VBX stents were then deployed at the aortic bifurcation in a kissing conformation, overlapping with the previously positioned aortic stent for 15 mm. A post-ballooning with two kissing 12 × 20 mm compliant balloons (Powerflex Pro PTA, Cordis, CA, USA) was performed to adapt the parallel stents to the aortic cuff. A post-operative angio-CT demonstrated optimal conformability of the aortic cuff to the aortic wall, and apposition of the kissing stents to the aortic cuff.

CONCLUSIONS

This preliminary experience shows that the VBX stent may allow an effective reconstruction of the aortic bifurcation; the conformability and flaring capability may allow to overcome the diameter mismatch between the aorta and the iliac arteries.

Meta-analysis of direct surgical versus endovascular revascularization for aortoiliac occlusive disease

OBJECTIVE

There is a paucity of good-quality evidence comparing direct surgical (DS) with endovascular/hybrid (EVH) revascularization for aortoiliac occlusive disease (AIOD). We aimed to perform a meta-analysis of studies comparing DS and EVH revascularization for AIOD.

METHODS

PubMed, Ovid MEDLINE, Cochrane, and Embase databases were searched for studies comparing DS and EVH revascularization for AIOD from 2000 to 2018. Risk of bias assessment was performed using the Methodological Index for Non-Randomized Studies. Demographics, clinical presentation, and comorbidities of the two groups were compared. Kaplan-Meier curves from selected studies were digitized with WebPlotDigitizer. Meta-analysis was conducted using Review Manager, and outcome measures were compared. Subgroup analysis was performed for primary patency in the EVH group.

RESULTS

Eleven observational studies were identified comparing a sample of 4030 patients. The median Methodological Index for Non-Randomized Studies score was 19 of 24. A total of 1679 and 2351 patients underwent DS and EVH techniques, respectively. No significant difference was found between means for sex, claudication, rest pain, tissue loss, preoperative ankle-brachial pressure index, and TransAtlantic Inter-Society Consensus C and D lesions in the two groups averaged across studies. However, the DS group had significantly younger patients (average age, 61.83 vs 66.77; P = .0011). The risk factors of the two groups, such as smoking, diabetes, ischemic heart disease, hypertension, hyperlipidemia, renal failure, and chronic lung disease, were comparable. Average hospital stay was significantly higher for the DS group (7.76 days vs 3.12 days; P = .025). Change in ankle-brachial pressure index, 30-day mortality, and 30-day graft/stent thrombosis were not significantly different for the groups. Overall, primary patency for a median follow-up of 50 months favored the DS group (hazard ratio [HR], 0.51; confidence interval [CI], 0.36-0.73; P = .0002). There was moderate heterogeneity among studies (I² = 46%). The HR for the subgroup for which endovascular procedures were combined with common femoral endarterectomy was 0.43 compared with 0.88 for endovascular revascularization alone. Limb salvage was similar in both groups (HR, 1.10; CI, 0.74-1.64; P = .63), but overall survival after the procedure favored the DS group (HR, 0.75; CI, 0.60-0.94; P = .01; I² = 0%).

CONCLUSIONS

Moderate-quality studies showed that DS revascularization had significantly better primary patency than EVH revascularization for AIOD, although DS patients were younger and may have differed on other confounding variables. Both techniques had similar limb salvage rates, and the primary patency was better for endovascular revascularization combined with common femoral endarterectomy than for endovascular revascularization alone.

Meta-analysis of Individual Patient Data After Kissing Stent Treatment for Aortoiliac Occlusive Disease

PURPOSE

To evaluate short- and long-term technical and clinical outcomes after kissing stent treatment of aortoiliac occlusive disease (AIOD) based on an individual participant data (IPD) meta-analysis.

MATERIALS AND METHODS

A search of the Scopus database identified 156 articles on KS treatment of AIOD; of these 22 met the inclusion criteria. Authors of 19 articles with contact information were approached to join an IPD consortium. Eight author groups responded and 5 provided anonymized data for merging into an IPD database. The number of included procedures was equal before and after 2005. The primary study outcome was the cumulative patency at 24 months. Secondary outcomes were patency at up to 60 months, complications, and changes in Rutherford category and ankle-brachial index. The predictive value of stent protrusion length, pre-/postdilation, stent type, and patient demographics on primary patency were examined with Cox proportional hazard modeling; outcomes are reported as the hazard ratio (HR). The Kaplan-Meier method was employed to estimate patency rates.

RESULTS

In total, 605 (40.9%) of 1480 patients presented in the literature were included in the IPD analysis. The indication for intervention was intermittent claudication in 84.2% and critical limb ischemia in 15.8%. Lesions were classified as TransAtlantic Inter-Society Consensus (TASC) A or B in 52.8% and TASC C and D in 47.2%. The overall primary patency estimate was 81% at 24 months. Primary patency significantly increased after 2005 (p=0.005). Cox regression analysis revealed only age as a significant predictor of sustained primary patency (HR 0.60, p<0.005). Any previous endovascular intervention (HR 2.52, p=0.02) was the main predictor for loss of secondary patency; history of cardiovascular disease (HR 0.27, p=0.04) was the main predictor of sustained secondary patency.

CONCLUSION

The kissing stent technique has a good safety profile and acceptable patency rates up to 2 years, even in TASC C and D lesions, supporting an endovascular-first approach for AIOD.

Stent Protrusion >20 mm Into the Aorta: A New Predictor for Restenosis After Kissing Stent Reconstruction of the Aortoiliac Bifurcation

Purpose: To determine the long-term patency of aortoiliac kissing stents and to identify predisposing factors for the development of in-stent restenosis (ISR). Methods: A retrospective analysis was conducted of 105 patients (median age 60.9 years; 64 women) with symptomatic aortoiliac occlusive disease who had kissing stents implanted between 2001 and 2015. The indication for kissing stents was severe claudication in 91 (86.7%) patients and critical limb ischemia in 14 (13.3%). Lesions were TASC A in 52 (49.5%), B in 29 (27.6%), C in 4 (3.8%), and D in 20 (19%) patients. Twenty-five (23.8%) patients had heavily calcified lesions. In all, 210 stents were deployed [180 (85.7%) self-expanding and 30 (14.3%) balloon-expandable]. Follow-up included clinical evaluation, ankle-brachial index measurement, and duplex ultrasonography. Results: The median follow-up was 45 months. The primary patency rates were 93%, 86%, and 77% at 12, 24, and 60 months, respectively. Significant ISR developed in 23 (21.9%) patients (12 unilateral and 11 bilateral). Univariate Cox regression analysis revealed older age [hazard ratio (HR) 0.5, 95% confidence interval (CI) 0.31 to 0.81, p=0.004] and larger aortic diameter (HR 0.42, 95% CI 0.25 to 0.7, p<0.001) to be variables favoring long-term patency, while a longer aortic stent segment (HR 1.56, 95% CI 1.16 to 2.09, p=0.003) and a larger discrepancy between the summed stent diameters and the aortic diameter (HR 1.64, 95% CI 1.01 to 2.65, p=0.043) were associated with ISR development. Multivariate analysis showed a longer aortic stent segment to be the only significant determinant of ISR (HR 1.44, 95% CI 1.02 to 2.01, p=0.035). Conclusion: The kissing stent technique can be performed with good long-term patency. Patients whose iliac stents protrude too far into the aorta need closer follow-up.

Endovascular Reconstruction for Chronic Infrarenal Aortoiliac Occlusive Disease

According to the 2007 TransAtlantic Inter-Society Consensus (TASC II) guidelines, surgery is the preferred treatment for extensive (TASC II type C and D) aortoiliac occlusive disease (AIOD). Recent studies, however, have shown that endovascular management can be an effective first-line treatment option for TASC II type C and D categories. While endovascular therapy is now commonly performed in patients with TASC II type D lesions, very few studies have investigated the feasibility and effectiveness of extending endovascular therapy to the most severe subcategory of TASC II D lesions, chronic infrarenal aortoiliac occlusion (CIAO). Herein, we present our technique for endovascular treatment of CIAO which relies on bidirectional subintimal aortoiliac dissection, wire snare for true lumen reentry, and combined balloon-expandable and self-expanding covered stent reconstruction of the aortic bifurcation and bilateral iliac arteries. This technique safely extends the reach of endovascular therapy to the most severe subcategory of TASC II D AIOD, CIAO. It is a viable minimally invasive alternative to aortobifemoral bypass surgery. Long-term follow-up of larger cohorts is needed to verify clinical efficacy and durability of therapy.

Successful Endovascular Treatment of Aortoiliac Bifurcation Stenosis Using an Empirically Based T and Protrude-Stenting with Self- and Balloon-Expandable Stents

A 73-year-old woman with arteriosclerosis obliterans (ASO) was underwent a crossover stenting for an aortoiliac bifurcation from the right common iliac artery (CIA) with a self-expandable bare-metal stent (SE-BMS); however, a new stenosis later occurred just behind the bifurcation of the left CIA. An ex vivo experiment demonstrated that culotte-stenting by additional implantation of a balloon-expandable bare-metal stent (BE-BMS) through stent struts of the SE-BMS would be empirically infeasible. Although we had initially planned a T-stenting for the additional implantation of a BE-BMS in the left CIA, we finally deployed the stent in the CIA with the proximal end protruding into the previously-implanted SE-BMS through the stent struts to avoid incomplete coverage of the stenosis by reference to the ex vivo experiments. The patient has had no recurrence for 36 months.

Endovascular Management of Flush Common Iliac Artery Occlusive Disease: Challenges and Solutions

The aim of this study was to assess the difficulties met with possible recommendations in management of flush common iliac artery occlusive disease (FCIAOD). This a prospective study assessing FCIAOD along the period of 24 months. We defined FCIAOD as more than 90% occlusion of diameter of common iliac artery (CIA) with less than 2 mm patent iliac stump from its origin from the abdominal aorta. Our study included 51 cases. Technical success was achieved in 47 patients (92%); 82.5% of cases were done via two accesses (65% of cases were done using bilateral femoral). Primary stenting was done in all cases. Sixty-eight percent of cases were treated by unilateral stents (81.3% of them were done using self-expandable) and 32% of cases were treated by kissing stents (50% using self-expandable). Prestent dilatation was selectively used in 77% of cases. Follow-up (12 months) revealed primary patency of 82.5% and secondary patency was 98% with no amputation done. Mortality rate was 4%. Endovascular treatment provides a successful option for the management of FCIAOD with a technical success rate of 92%, the option of selective use of prestent dilatation. FCIAOD does not preclude the use of unilateral stent in CIA, which can be completed to kissing stents if needed.

Treatment of Aortoiliac Occlusive Disease with the Endologix AFX Unibody Endograft

OBJECTIVE/BACKGROUND

Aorto-bifemoral bypass remains the gold standard for treatment of aortoiliac occlusive disease (AIOD) in patients with advanced (TASC D) lesions, but has significant associated morbidity and mortality. Treatment with a unibody stent-graft positioned at the aortic bifurcation is a potential endovascular option for the treatment of AIOD. The current study examines the safety, efficacy, and early patency rates of the Endologix AFX unibody stent-graft for treatment of AIOD.

METHODS

A multicenter retrospective review was conducted of patients treated exclusively for AIOD with the AFX device. Primary, assisted primary, and secondary patency rates were noted. Clinical improvement was assessed using Rutherford classification and ankle brachial index. Mean duration of follow-up was 22.2 ± 11.2 months. Ninety-one patients (56 males [62%]) were studied.

RESULTS

Sixty-seven patients (74%) presented with lifestyle-limiting intermittent claudication and the remaining 24 (26%) had critical limb ischemia. Technical success was 100%. Complications included groin infection (n = 4 [4%]), groin hematoma (n = 4 [4%]), common iliac rupture (n = 4 [4%]), iliac dissection (n = 4 [4%]), and thromboembolic event (n = 3 [3%]; one femoral, one internal iliac artery, and one internal iliac with bilateral popliteal/tibial thromboemboli). Thirty-day mortality was 1% (1/91) resulting from a case of extensive pelvic thromboembolism. At 1 year, 73% of patients experienced improvement in Rutherford stage of -3 or greater compared with baseline. Nine patients (10%) required 16 secondary interventions. At all time points, primary patency rates were > 90%, assisted patency rates were > 98%, and secondary patency rates were 100%.

CONCLUSION

This is the largest study to examine the use of the Endologix AFX unibody stent-graft for the treatment of AIOD. Use of the AFX stent-graft appears to be a safe and effective endovascular treatment for complex AIOD.

Endovascular Management of Aorta-Iliac Stenosis and Occlusive Disease by Kissing-Stent Technique

Kissing-stenting treatment has been used to treat patients with peripheral artery disease (PAD). However, the long term efficacy of the stenting therapy is not well defined in Chinese PAD patients. To investigate the question, sixty-three PAD patients (37 males and 26 females), aged 66 ± 7.3 years, were analysed in the study. They were featured as claudication (n = 45, 71.4%), rest pain (n = 18, 28.6%), or gangrene (n = 8, 12.7%). In total, 161 stents were applied in aorta-iliac lesions with 2.6 stents for each patient, including 55 self-expanding stents, 98 balloon expandable stents, and 8 covered stents. The success rate of implanting Kissing-stents was 100%. Catheter-directed thrombolysis (CDT) with urokinase was performed in 8 cases (12.7%). The severity of peripheral ischemia was significantly improved, as evidenced by 3.3-fold increase of ankle-brachial pressure index (ABI) after the surgery (P = 0.008). One, three, five, and seven years after surgery, the primary patency rate was 87.3%, 77.4%, 71.1%, and 65.0%, whereas the secondary patency rate was 95.2%, 92.5%, 89.5%, and 85.0%, respectively. No in-hospital mortality was recorded. In conclusion, Kissing-stenting technique for aorta-iliac lesions is safe and effective with lower complications. It is beneficial for aorta-iliac occlusions that are longer than 60 mm.

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.

The Results of Self-Expandable Kissing Stents in Aortic Bifurcation

Purpose:

Kissing stent reconstruction is a widely used technique for the management of aortoiliac occlusive disease involving the aortic bifurcation or proximal common iliac arteries. The purpose of this study was to evaluate the results of self-expandable kissing stents in the aortic bifurcation.

Materials and Methods:

We reviewed medical records of the patients treated with a kissing stent retrospectively from January 2007 to December 2012. The primary and secondary patencies were determined with Kaplan-Meier analysis, and Cox regression was used to determine the factors associated with patency.

Results:

A total of 21 patients were included, and all were male (median age 53±15 years, range 48–78 years). Major symptoms were claudication (n=16, 61.9%), rest pain (n=5, 23.8%) and gangrene (n=5, 23.8%). Tans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II classification was A 2 (9.5%), B 5 (23.8%), C 7 (33.3%) and D 8 (38%). The mean follow-up was 40.7 months. Major complication occurred in only one case which consisted of distal limb ischemia by emboli. Six patients developed symptomatic restenosis or occlusion. There was no major amputation, but minor amputation occurred in 3 patients. There were 2 mortalities not associated with the procedure (lung cancer and intracranial hemorrhage). Primary patency was 89.6% at 1 year, 74.7% at 3 years and 64.0% at 5 years. Secondary patency was 94.1% at 1 year, 88.2% at 3 years and 68.6% at 5 years. No risk factors for restenosis or occlusion were identified.

Conclusion:

Self-expandable kissing stents can be used successfully with comparable patency for endovascular treatment of symptomatic atherosclerotic occlusive lesions in the aortic bifurcation area.

Early and midterm results of kissing stent technique in the management of aortoiliac obstructive disease

BACKGROUND

To retrospectively analyze the early and the midterm results of endovascular management of aortoiliac obstructive disease with the kissing stent technique.

METHODS

From January 2005 to September 2012, 229 consecutive endovascular interventions for aortoiliac obstructive disease were performed; data from all the interventions were prospectively collected in a dedicated database. In 41 patients, the kissing stent technique at the level of aortic bifurcation was performed (group 1), whereas in the remaining 188 it was not (group 2). Perioperative results were compared with chi-squared test. Follow-up results were analyzed with Kaplan-Meier curves and compared with log-rank test.

RESULTS

Trans-Atlantic Inter-Society Consensus II C and D lesions were present in 66% of patients in group 1 and in 28.5% in group 2 (P < 0.001), whereas iliac occlusion rather than stenosis was detected in 78% of patients in group 1 and in 50% in group 2 (P = 0.001). The mean number of placed stents was 2.5 in group 1 and 1.4 in group 2 (P < 0.001). Technical success was 100% in group 1 and 98% in group 2 (P = 0.3). The rate of perioperative complications was 7.3% in group 1 and 4.2% in group 2 (P = 0.4). At 30 days, neither deaths nor major cardiovascular complications occurred. There was no thrombosis or significant restenosis at the early postoperative follow-up visit. Mean duration of follow-up was 22 months. Primary patency rates at 4 years were 70.5% (standard error [SE], 0.09) in group 1 and 75.5% (SE, 0.06) in group 2 (P = 0.7). At the same interval, assisted primary and secondary patency and survival rates were also similar; reintervention rates were 15.5% in group 1 (SE, 0.1) and 19.5% in group 2 (SE, 0.06; P = 0.6).

CONCLUSIONS

The kissing stent technique provided satisfactory results in patients with obstructive aortoiliac diseases, without an increase in immediate and midterm complications, representing an effective solution in complex anatomies.

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.

Endovascular stents: a review of their use in peripheral arterial disease

Technological advances in the past decade have shifted revascularization strategies from traditional open surgical approaches toward lower-morbidity percutaneous endovascular treatments for patients with lower extremity peripheral arterial disease (PAD). The continuing advances in stent design, more than any other advances, have fueled the growth of catheter-based procedures by improving the safety, durability, and predictability of percutaneous revascularization. Although the 2007 TransAtlantic Inter-Society Consensus (TASC) guidelines recommend endovascular therapy for type A and B aortoiliac and femoropopliteal lesions, recent developments in stent technology and increased experience of interventionists have suggested that a strategy of endovascular therapy first is appropriate in experienced hands for TASC type D lesions. The role of endovascular interventions is also expanding in the treatment of limb-threatening ischemia.

Endovascular reconstruction of iliac artery bifurcation atherosclerotic disease with the kissing technique

A 71-year-old male patient with severe left buttock and lower-extremity claudication due to iliac artery bifurcation stenoses was referred to our institution for endovascular treatment. A 'kissing' technique was used in order to dilate the proximal parts of both internal and external iliac arteries and avoid compromization of the internal iliac artery during proximal external iliac artery stenting. A balloon expandable stent was inserted via a left ipsilateral retrograde access to the narrowed origin of the left external iliacartery and a balloon catheter via a right contralateral access inside the origin of the left internal iliac artery. Simultaneous balloons inflation restored full patency of both vessels. Twelve months later the patient is doing well, free of buttock or lower-extremity claudication symptoms. For iliac artery bifurcation atherosclerotic disease, endovascular repair with the 'kissing' technique can achieve a complete bifurcation reconstruction offering significant clinical benefit in selected patients.

Long-term results of stenting of the aortic bifurcation

BACKGROUND

To evaluate the long-term results in a multicentric continuous series of narrowing lesions of the aortic bifurcation treated with a kissing stent.

METHODS

From January, 1st 1999 to the December, 31st 2001, all of the patients (n = 80) presenting with stenosis of the aortic bifurcation (n = 15) and/or the 2 common iliac arteries (n = 65), treated with a kissing stent, in 8 teaching hospitals were collected retrospectively. The risk factors were smoking (91%), dyslipidemia (60%), arterial hypertension (42%) and diabetes (27%). In 84% of cases, the indication for treatment was claudication. The lesions were stenotic < 70% (n = 76) and/or thrombotic (n = 18). The associated lesions were external iliac stenoses (n = 21), common femoral stenoses (n = 19), femoro-popliteal stenoses (n = 42), arteriopathy in the leg (n = 35). Follow-up was clinical examination and Doppler US scan.

RESULTS

The success rate of the technique was 89%. There were 4 cases (5.3%) of residual stenosis and 4 cases (5.3%) of dissection. The length of the lesions treated in the aorta and the iliac arteries was respectively 17.1 ± 7 and 17.3 ± 9 mm. The stents were all placed as kissing stents, and had a mean diameter and a mean length of 13.75 mm and 56 mm in the aorta and 9 mm and 48 mm in the iliac arteries, respectively. At 5 years, 19 patients had required repeat angioplasty in the treated area, and 13 had undergone open surgery. Primary and assisted primary patency at 5 years were 64.5% and 81.8%, respectively.

CONCLUSION

Long-term follow-up of endovascular treatment with kissing stents for stenosis of the aortic bifurcation shows that this technique gives good results, though it does not justify doing away with classical revascularisation surgery, in a population with major cardiovascular risk factors.

Acute lower limb ischaemia due to delayed upstream migration of an iliac stent

We report a case of acute limb ischaemia due to unusual upstream stent migration into the aorta 2 years after successful kissing stenting. Angiography showed a misplacement of both common iliac stent into the aorta, upstream migration with a fracture on the left external iliac stent into the iliac common artery, occlusion of the left iliac and femoral artery, dilatation of aortic bifurcation and stent separation on the right side. The patient underwent a successful axillo-bifemoral bypass graft. Vessel wall remodelling due to overestimation of stent size, aortic turbulence and rebound effect may explain this complication.

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.

"Staged" kissing stent placement under computed tomographic angiography guidance for a bilateral aortoiliac occlusion

A 64-year-old female with chronic hemodialysis complained of a worsening of bilateral intermittent claudication. Computed tomographic angiography (CTA) demonstrated severe calcified bilateral aortoiliac occlusions. The kissing stent placement was therefore attempted: A 10 × 60 mm SMART stent was placed into the right aortoiliac lesion at the 1st session, and a 10 × 60 mm SMART stent was placed into the left aortoiliac lesion parallel with the previous SMART stent at the 2nd session, thus completing the "staged" kissing stent placement. CTA indicated the penetrating point in the calcified plaque clearly, and this case suggested the usefulness of CTA guided percutaneous peripheral intervention.

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.