Bifurcated endograft in aortoiliac type C and D lesions: long-term results

Using bifurcated endoprosthesis after iliac artery recanalization for concomitant abdominal aortic aneurysm and chronic total occlusions of access routes

OBJECTIVE

Concurrent abdominal aortic aneurysm (AAA) and unilateral iliac occlusion is a challenge in the implantation of bifurcated stent grafts (BFGs). The endovascular approach is less invasive than open surgery; the aortouni-iliac (AUI) graft with crossover femorofemoral bypass (CFFB) has many problems associated with extra-anatomic reconstruction. We attempted endovascular aneurysm repair (EVAR) using BFGs in such cases and evaluated the outcomes.

METHODS

This was a retrospective study. Between October 2012 and December 2017, there were 649 patients who underwent surgery for AAA, of whom 32 patients underwent open reconstruction and 617 patients underwent endovascular aneurysm repair; 15 patients with unilateral occluded iliac arteries and AAA were included. The analysis included patients with unilateral iliac chronic total occlusion (CTO). The intraoperative, postoperative, and follow-up variables were reviewed.

RESULTS

The occluded lesions were the common iliac artery in 5 patients, the common iliac artery-external iliac artery (EIA) in 2 patients, the EIA in 7 patients, and the EIA-common femoral artery in 1 patient. The mean occlusive length was 89.7 ± 43.6 mm, and the mean AAA size was 54.6 ± 5.6 mm. Technical success was achieved in 13 patients (87%). All patients underwent recanalization through the true lumen and stent placement. The only procedure-related complication was distal embolism, which was treated with intraoperative thrombectomy. Recanalization of CTO lesions was not possible in two patients (13%), who underwent AUI graft placement with CFFB. The 30-day mortality and morbidity rates were 0%. The mean follow-up periods were 12 and 32 months for patients who underwent BFG placement and AUI graft placement with CFFB, respectively. During follow-up, the primary patency rate of successfully recanalized arteries was 100%. Aneurysm size decreased in four patients who underwent BFG placement; no change was seen in the other 11 patients. Freedom from aneurysm-related events was 100%; no patient needed secondary interventions. All patients with claudication pain preoperatively reported improvement in their symptoms during follow-up. In addition, the ankle-brachial index improved significantly from 0.51 ± 0.25 preoperatively to 0.88 ± 0.20 postoperatively (P < .001) in patients who underwent BFG placement.

CONCLUSIONS

Recanalization of unilateral iliac CTO lesions and placement of BFG in cases with concomitant aneurysmal disease and unilateral iliac occlusive disease demonstrated a significant primary patency rate with improvements in claudication and ankle-brachial index.

ACR Appropriateness Criteria® Iliac Artery Occlusive Disease

Iliac artery occlusive disease can present as a sudden-onset acute thrombotic or thromboembolic event or as a chronic progressive atherosclerotic process that presents as claudication progressing to rest pain. Depending on the clinical presentation, the diagnosis is usually confirmed through Doppler vascular ultrasound, CT angiography, or MR angiography; the choice of imaging is usually based on modality availability and the presence of patient comorbidities such as chronic kidney disease. The Trans-Atlantic Inter-Society Consensus II classification system is commonly used to describe the extent of the peripheral vascular disease. Depending on the pathophysiology, clinical presentation, and radiologic extent of the disease process, therapeutic options for acute thrombotic cases can include supportive care, anticoagulation, thrombolytic therapy, surgical or catheter-directed mechanical thrombectomy, and surgical bypass. Therapeutic options for atherosclerotic disease include supportive measures such as behavior modification, a supervised exercise program, adjunctive treatment with anticoagulation and antiplatelet medications, angioplasty, stent placement, stent-graft placement, surgical or catheter-directed endarterectomy or plaque excision, and surgical bypass. This document describes the appropriateness of imaging in this patient population, treatment procedures for specific clinical scenarios, and the likely prognosis for these patients. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Endovascular treatment of TransAtlantic Inter-Society Consensus D aortoiliac occlusive disease using unibody bifurcated endografts

OBJECTIVE

Aortobifemoral bypass has been the gold standard treatment for extensive aortoiliac occlusive disease. Endovascular therapy and stenting of aortic and iliac occlusive lesions has proven to be efficacious, especially when dealing with short segment lesions. Endovascular treatment of TransAtlantic Inter-Society Consensus II (TASC) D aortoiliac occlusive lesions remains a challenge, but a valuable treatment option in poor surgical candidates. We present our operative technique and midterm results in treating TASC D aortoiliac occlusive disease using unibody bifurcated endografts.

METHODS

We performed a retrospective review of patients with TASC D aortoiliac occlusive disease who underwent transfemoral endovascular revascularization with the Endologix Powerlink unibody bifurcated endograft (Endologix, Irvine, Calif). Demographic data, operative details, and outcomes were collected. Paired t-tests were performed to compare preoperative and postoperative ankle brachial indexes.

RESULTS

Between March 2009 and July 2011, 10 high-risk patients (8 male and 2 female) for a traditional aortobifemoral bypass were treated using this endovascular technique. The mean age was 59 ± 6 years (range, 50-69 years). All patients presented with rest pain, and four with tissue loss. Technical success was 100%, with two patients requiring brachial access and eight patients requiring additional stent placement. Postoperatively, all patients reported clinical improvement with resolution of ischemic symptoms. Mean improvement ankle brachial index was 0.50 ± 0.08 (P = .028) and 0.50 ± 0.01 (P = .034) in the left and right legs, respectively. Mean follow-up time was 40 ± 24 months (range, 4-81 months). The primary and secondary patency rates were 80% and 100%, respectively. Complications requiring early reintervention occurred in two patients and included one expanding hematoma from the percutaneous access site and one acute iliac artery thrombosis. Additionally, one patient underwent repeat angioplasty/stenting for threatened endograft limbs at 4 months. One patient expired during follow-up from an unrelated cardiac cause 19 weeks postoperatively.

CONCLUSIONS

This series demonstrates that endovascular repair using a unibody bifurcated endograft for TASC D aortoiliac occlusive disease is feasible, effective, and has excellent midterm patency. It should be considered an effective treatment option when the disease process involves the aorta, in particular if the patient is surgically unfit for a traditional aortobifemoral bypass. The unibody configuration preserves the anatomic aortic bifurcation, which is particularly important in patients with peripheral occlusive disease who are deemed to undergo subsequent endovascular interventions.

Results of Open Surgical Repair of Chronic Juxtarenal Aortic Occlusion

PURPOSE

The aim of study was to review the results of open surgical repair (OSR) of chronic juxtarenal aortic occlusion (JRAO).

MATERIALS AND METHODS

We retrospectively reviewed the results of OSR performed in 47 patients (male, 92%; mean age, 59.9±9.3 years [range, 44-79]) with chronic JRAO during the past 21 years. In order to reduce intraoperative renal ischemic time (RIT), we excised a portion of the occluded segment of the infrarenal aorta without proximal aortic clamping. We then performed suprarenal aortic clamping with both renal arteries clamped, removed the proximal aortic thrombus cap, confirmed both renal artery orifices, and moved the suprarenal aortic clamp to the infrarenal aorta to allow renal perfusion and standard aortoiliac reconstruction. We investigated early (<30 days) postoperative surgical morbidity (particularly renal function), operative mortality, and longterm patient survival. We conducted risk factor analysis for postoperative renal insufficiency.

RESULTS

The mean intraoperative RIT was 10.7±5.5 minutes (range, 3-25), including 6 patients who underwent concomitant pararenal aortic thromboendarterectomy. Postoperatively, five (11%) patients had transient renal insufficiency, one had pneumonia, and one patient had an acute myocardial infarction. However, there was no operative mortality or newly developed dialysis-dependent renal failure. Postoperative follow up was available in 36 (77%) patients for a mean period of 6.3 years (range, 1 month-17 years). Kaplan Meier calculations of patient survival at 5 and 10 years after surgery were 91.2% and 83.6%, respectively.

CONCLUSION

We have experienced short RIT, acceptable early postoperative results and long-term survival after OSR of chronic JRAO.

Midterm outcomes of stent placement for long-segment iliac artery chronic total occlusions: a retrospective evaluation in a single institution

PURPOSE

To assess the clinical and patency results of stent placement for long-segment iliac artery chronic total occlusions (CTOs).

MATERIALS AND METHODS

A retrospective analysis of 217 patients (141 men and 76 women; mean age, 76.6 y; 256 limbs) with long-segment (>5 cm) iliac artery CTOs treated with stent placement was conducted in a single institution from January 2005 to July 2011. Demographics, clinical presentation, classification, comorbidity, ankle-brachial index (ABI) before and after treatment, technical success, patency, and complications were recorded at follow-up. The approach was initial access from the left brachial artery or the contralateral femoral artery.

RESULTS

According to the TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) classification, 27 patients were type B, 143 were type C, and 47 were type D. Clinical presentation was recorded according to the Rutherford-Becker classification: 35 patients presented with stage 3; 108, with stage 4; 53, with stage 5; and 21, with stage 6. Technical success was 96.5% (247 of 256). Periprocedural in-stent thrombosis occurred in nine patients and was treated successfully with catheter-directed thrombolysis. ABI increased from 0.36±0.16 (range, 0-0.57) before the procedure to 0.79±0.24 (range, 0.56-1.12) after the procedure. The mean duration of follow-up was 25.4 months (range, 1-72 months). The primary, primary assisted, and secondary patency of the iliac artery was 95.1%, 98.4%, and 99.2% at 1 year and 91.9%, 95.6%, and 97.5% at 2 years, respectively. Major complications were encountered in 17 (6.6%) patients, and minor complications occurred in 12 (4.7%) patients.

CONCLUSIONS

These data suggest that stent placement is an effective, safe, and feasible method for treating long-segment iliac artery CTOs.

Endovascular repair of abdominal aortic aneurysm using bifurcated stent-graft in a patient with complete occlusion from the common to the external iliac artery

Extensive iliofemoral occlusive disease can limit the use of endovascular aortic aneurysm repair (EVAR), and the treatment strategy varies depending on severity of the lesion. In cases of mild iliac artery (IA) stenosis, predilation using a balloon catheter before EVAR is relatively common, and for severe IA stenosis, the technique of internal endoconduits has been reported with good results. In contrast, EVAR using an aortouni-iliac stent graft with femorofemoral crossover bypass has traditionally been used for abdominal aortic aneurysm with IA occlusion. However, EVAR using a bifurcated stent graft has some clear advantages over aortouni-iliac stent grafts. In this report, we describe and discuss technical aspects and feasibility of chronically occluded iliac artery recanalization before EVAR to facilitate the use of bifurcated stent grafts in a patient with concomitant complete common to external IA occlusion.

Current state of diagnosis and management of critical limb ischemia

Critical limb ischemia represents the most severe form of peripheral arterial disease and carries with it severe morbidity and mortality risks. Because of comorbidity risks, early diagnosis and aggressive medical management make up an important part of the treatment paradigm for these individuals. However, in addition to managing these comorbid conditions, the physician caring for these individuals must be able to provide revascularization options that will improve arterial flow to the threatened extremity and assure healing of complicated wounds. Both open surgical and endovascular therapies have proven beneficial in restoring flow to severely ischemic limbs in these patients. Additionally, combinations of the above therapeutic methods have offered more available options for these patients. This article reviews care of patients with critical limb ischemia with critical assessment of options for medical and revascularization options.