Patency of Direct Revascularisation of the Hypogastric Arteries in Patients with Aortoiliac Occlusive Disease

Exercise transcutaneous oximetry significantly modifies the diagnostic hypotheses and impacts scheduled investigations or treatments of patients with exertional limb pain

INTRODUCTION

In lower extremity peripheral artery disease (PAD), transcutaneous oximetry at exercise (Ex-TcpO2) has been largely validated in research practice, but evidence of routine practice in various vascular laboratories is missing. We hypothesized that Ex-TcPO2 would change the diagnosis hypotheses, investigations and treatments for patients referred for exertional limb pain.

MATERIAL & METHODS

A multicenter prospective trial was conducted in nine different referral centers. Investigators performed Ex-TcpO2 and recorded investigations and treatments already scheduled for the patient. We encoded referral physician's diagnostic hypothesis. Before Ex-TcpO2, vascular physicians were asked to give their diagnosis hypotheses. A minimal decrease from rest of oxygen pressure (DROP)<minus 15mmHg defined the presence of exercise-induced ischemia on the area of interest. After Ex-TcPO2, we recorded post-test diagnostic hypothesis and investigations and treatments to be cancelled or performed. We compared the diagnosis hypotheses, scheduled investigations and treatments, before and after the Ex-TcpO2.

RESULTS

We included 603 patients (485 males: 80.4%), aged 64.7±9.8years. The post-test diagnosis hypothesis differed in 266 patients (44.1%; p<0.0001) and in 96 patients (15.9%) from the pre-test hypothesis of referring and vascular physician, respectively. This led to the recommendation to cancel 27 scheduled investigations or treatments of a total cost of ~130,000 euros.

DISCUSSION

Ex-TcPO2 in patients with exertional limb pain is applicable in various vascular institutions, and significantly modifies the diagnostic hypotheses and impacts scheduled investigations or treatments of patients with exertional limb pain.

Patency of the Internal Iliac Artery after Placement of Common and External Iliac Artery Stents

BACKGROUND

Treatment of severe aortoiliac occlusive disease (AIOD) frequently requires long-segment stenting of the common and external iliac arteries (CIA and EIA, respectively). This study aims to analyze the patency of the internal iliac artery (IIA) after placement of a CIA and EIA stents across the orifice.

METHODS

A retrospective analysis of all patients who underwent de novo ipsilateral stent placement in the CIA and EIA between 2006 and 2013 was performed. Kaplan-Meier analysis was used to analyze patency of the IIA, and Cox proportional hazard models were used to identify characteristics associated with occlusion.

RESULTS

We identified 77 patients and 93 limbs where ipsilateral CIA and EIA stents were placed. Preintervention angiographic review found 52 cases of a patent ipsilateral IIA where stents were placed across the origin of the IIA in 31 cases and staggered across the orifice in 20 limbs. Kaplan-Meier analysis demonstrated a 37% patency in limbs where the stent covered the IIA orifice compared to 78% patency in uncovered arteries (P = 0.04). New-onset buttock claudication developed in 4 patients, 2 with patent IIAs and 2 with occluded. New-onset impotence also developed in 3 patients with occluded IIA and 5 patients with patent IIAs.

CONCLUSIONS

Placement of stents across the origin of the IIA may not result in immediate occlusion, but long-term patency of covered IIAs is decreased compared to uncovered IIAs. This study is limited by a small sample size, but when treating AIOD, coverage of the internal iliac origin should be avoided to maintain patency of the pelvic circulation.

Internal Iliac Artery Stenosis: Diagnosis and How to Manage it in 2015

Lower extremity arterial disease (LEAD) is a highly prevalent disease affecting 202 million people worldwide. Internal iliac artery stenosis (IIAS) is one of the localization of LEAD. This diagnosis is often neglected when a patient has a proximal walking pain since most physicians evoke a pseudoclaudication. Surprisingly, IIAS management is reported neither in the Trans-Atlantic Inter-Society Consensus II nor in the report of the American College Foundation/American Heart Association guidelines. The aims of this review are to present the current knowledge about the disease, how should it be managed in 2015 and what are the future research trends.

[Occlusion of the aorta and iliac arteries]

Occlusion of the aorta and the iliac arteries leads to an insufficient perfusion of the legs and the genital and gluteal region. The occurring symptoms may be variable, mainly depending on the collateralization network of the internal iliac artery (IIA) circulation. Various differential diagnoses need to be excluded. Invasive therapy is almost always inevitable if an aortoiliac stenosis is established. With good patency rates and low mortality rates the indications for reconstructive procedures are liberally interpreted; therefore, invasive therapy can be performed in the early stages of claudication in certain situations. Due to lower invasiveness and therefore lower risk of complications while showing comparable long-term patency rates, endovascular treatment is the preferred first line therapy for the majority of occlusions. Because aortoiliac occlusion processes also affect patients who are actively involved in a professional career, the indications for invasive therapy can be attained even in Fontaine stage IIa.

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.