Outcomes of covered versus bare-metal balloon-expandable stents for aortoiliac occlusive disease

Editor's Choice - Covered Stents Versus Bare Metal Stents in the Treatment of Aorto-iliac Disease: A Systematic Review and Individual Participant Data Meta-analysis

OBJECTIVE

To assess the comparative safety and efficacy of covered stents (CS) and bare metal stents (BMS) in the endovascular treatment of aorto-iliac disease in patients with peripheral arterial disease.

DATA SOURCES

A systematic review was conducted adhering to the PRISMA 2020 and PRISMA for Individual Participant Data 2015 guidelines.

REVIEW METHODS

A search of PubMed, Scopus, and Web of Science for articles published by December 2023 was performed. The primary endpoint was primary patency. Certainty of evidence was assessed via the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework.

RESULTS

Eleven studies, comprising 1 896 patients and 2 092 lesions, were included. Of these, nine studies reported on patients' clinical status, with 35.5% classified as Rutherford 4 - 6. Overall primary patency for CS and BMS at 48 months was 91.2% (95% confidence interval [CI] 84.1 - 99.0%) (GRADE, moderate) and 83.5% (95% CI 70.9 - 98.3%) (GRADE, low). The one stage individual participant data meta-analyses indicated a significant risk reduction for primary patency loss favouring CS (hazard ratio [HR] 0.58, 95% CI 0.35 - 0.95) (GRADE, very low). The 48 month primary patency for CS and BMS when treating TransAtlantic Inter-Society Consensus (TASC) C and D lesions was 92.4% (95% CI 84.7 - 100%) (GRADE, moderate) and 80.8% (95% CI 64.5 - 100%) (GRADE, low), with CS displaying a decreased risk of patency loss (HR 0.39, 95% CI 0.27 - 0.57) (GRADE, moderate). While statistically non-significant differences were identified between CS and BMS regarding technical success, 30 day mortality rate, intra-operative and immediate post-operative procedure related complications, and major amputation, CS displayed a decreased re-intervention risk (risk ratio 0.59, 95% CI 0.40 - 0.87) (GRADE, low).

CONCLUSION

This review has illustrated the improved patency of CS compared with BMS in the treatment of TASC C and D lesions. Caution is advised in interpreting overall primary patency outcomes given the substantial inclusion of TASC C and D lesions in the analysis. Ultimately, both stent types have demonstrated comparable safety profiles.

Covered endovascular reconstruction of the aortic bifurcation: A systematic review aggregated data and individual participant data meta-analysis

BACKGROUND

We investigated the early and midterm efficacy and safety of covered endovascular reconstruction of the aortic bifurcation (CERAB) in the treatment of aortoiliac disease (AID).

METHODS

A systematic search on PubMed, Scopus, and Web of Science for articles published by August 2023 was performed. The primary end points were primary patency and secondary patency.

RESULTS

Eleven retrospective case series, involving 579 patients, were incorporated in the review with 88.9% of the included lesions being categorized as Trans-Atlantic Inter-Society Consensus (TASC) C or D. The pooled primary patency estimates at 12, 24 and 36 months were 94.4% (95% confidence interval [CI], 89.4-99.7), 84.4% (95% CI, 72.3-98.5) and 83.8% (95% CI, 71.4-98.3) respectively. The mean primary patency time, representing the period during which individuals remained event-free, was 51.9 months (95% CI, 43.6-55.4). The pooled 36 months primary patency for studies with a predominantly claudicant patient population (>75% of patients) was 89.4% (95% CI, 78.5-100.0), compared with 71.5% (95% CI, 45.6-100.0) for studies with a mixed population (50% of patients). The pooled 36 months primary patency for studies with a predominantly TASC D patient population (>82% of patients) was 70.4% (95% CI, 46.4-100.0) compared with 91.0% (95% CI, 79.1-100.0) for studies with a more homogenous cohort. The pooled secondary patency estimates at 12, 24, and 36 months were 98.6% (95% CI, 96.2-100.0), 97% (95% CI, 93.1-100.0), and 97% (95% CI, 93.1-100.0), respectively. The pooled technical success, 30-day mortality and 30-day systemic complications estimates were 95.9% (95% CI, 93.7- 97.4), 1.9% (95% CI, 1.0-3.5), and 6.4% (95% CI, 4.4-9.1), respectively. The pooled intraoperative and postoperative 30-day CERAB-related complications estimates were 7.3% (95% CI, 2.0-23.0) and 4.2% (95% CI, 0.7-21.0), respectively. The pooled major amputation and target lesion reinterventions by the end of follow-up were 1.9% (95% CI, 1.0-3.4) and 13.9% (95% CI, 9.9-19.2), respectively. The pooled access site complication estimate was 11.7% (95% CI, 5.9-21.7).

CONCLUSIONS

Although this review has showcased the safety and feasibility of the CERAB technique in treating AID, it has also highlighted the necessity for a close and prolonged follow-up period extending beyond 1 year. Moreover, the favorable secondary patency estimates predominantly attained via endovascular reinterventions emphasize a potentially advantageous characteristic of the CERAB technique, particularly valuable when addressing late-stage AID disease or anatomically complex lesions.

Combination of BeGraft and Solaris Stent Grafts for the Covered Endovascular Reconstruction of Aortic Bifurcation-BS-CERAB Technique

Background: This study examines the impact of the use of the combination of BeGraft and Solaris stent grafts on the outcomes during the covered endovascular reconstruction of aortic bifurcation (BS-CERAB) technique and extension to the iliac arteries. Methods: Consecutive patients with aortoiliac occlusive disease who underwent endovascular treatment using BS-CERAB between January 2020 and December 2023 were included. Patient demographics, symptoms, lesion characteristics, and procedural and follow-up details were collected and analyzed. Perioperative complications and reinterventions were also identified. Results: A total of 42 patients met the inclusion criteria (32 men, 76.2%, median age 72 years, range 59-85). Indications for treatment were intermittent claudication (42.9%) and critical limb ischemia (57.1%). Procedure success was achieved in all cases. The median patient follow-up time was 14 months (1-36). One patient died at a 10-month follow-up due to lung cancer. The mean pre-operative ABI increased from 0.37 ± 0.19 before intervention to 0.71 ± 1.23 post-operatively at 12 months (p = 0.037). The estimated primary patency rates at 3, 6, and 12 months were 90.5%, 85.7%, and 81.0% and primary assisted patency rates were 90.5%, 90.5%, and 85.7%, respectively. Secondary patency was 95.2% at 3 and 6 months and 90.5% at a 12-month follow-up. Active cancer (p = 0.023, OR 2.12 95%CI 1.14-3.25) was a risk factor for restenosis. Conclusions: This mid-term experience shows that the CERAB technique using the combination of BeGraft and Solaris stents grafts, for the endovascular treatment of severe aortoiliac atherosclerotic disease, may allow an effective reconstruction of the aortic bifurcation and iliac arteries related to high-patency and lower-reintervention rates.

Efficacy and Safety of Covered Stents Versus Bare-Metal Stents for Aortoiliac Occlusive Disease: A Systematic Review and Meta-Analysis

PURPOSE

This study aimed to assess the efficacy and safety outcome of covered stents (CSs), as compared with bare-metal stents (BMSs), for the treatment of patients with aortoiliac occlusive disease (AIOD).

MATERIALS AND METHODS

A systematic literature search was conducted in PubMed, Embase, and Cochrane Library up to August 2023 to identify all studies comparing efficacy and safety outcomes of CSs versus BMSs for treating AIOD. Our outcome was primary patency, secondary patency, technical success, ankle-brachial index (ABI) variation, target lesion revascularization (TLR), limb salvage, complications, and long-term survival. Dichotomous outcomes were pooled as relative risks (RR) or hazard ratio with the 95% confidence interval (CI). Continuous outcomes were pooled as weighted mean differences and 95% CI. Model selection was based on the heterogeneity of the included studies.

RESULTS

There were 10 studies (2 randomized controlled trials, 8 retrospective cohort studies), comprising 1676 sample size. Compared with BMSs, CSs use was associated with better primary patency of patients with a Trans-Atlantic Inter-Society Consensus II (TASC) D lesion (RR, 1.15, 95% CI, 1.04 to 1.27, p=0.007), TLR (RR, 0.39, 95% CI, 0.27 to 0.56, p<0.001), technical success (RR, 1.01, 95% CI, 1.00 to 1.02, p=0.010), and long-term survival (RR, 1.06, 95% CI, 1.01 to 1.11, p=0.020). There is no difference between CSs and BMSs regarding primary patency of all patients, secondary patency, variation in ABI, limb salvage, and complications.

CONCLUSIONS

Compared with BMSs, CSs used in AIOD was associated with more favorable primary patency in patients with TASC D lesions, TLR, technical success rates, and patient long-term survival. These results provide evidence of the advantages of using CSs for AIOD treatment. Future studies focusing on long-term variations in ABI, primary patency of different degrees of calcification, vascular segments, and TASC classification are warranted.

CLINICAL IMPACT

Although several studies evaluated the clinical efficacy of CS in the context of AIOD treatment, the significance and consistency of these findings were not determined to date. We found that CS was used in AIOD associated with better technical success rate, long-term patient survival, lower target lesion revascularization, and higher primary patency of patients with a Trans-Atlantic Inter-Society Consensus II D lesion when compared with BMSs. Our study provides evidence supporting the superiority of CSs over BMSs in the treatment of AIOD, and furnishing clinicians with guidance for treatment decisions.

Outcomes of covered vs bare metal stents for the treatment of aortoiliac occlusive disease

OBJECTIVE

We retrospectively compared the clinical outcomes of self-expanding covered stents (CSs) and bare metal stents (BMSs) in the treatment of aortoiliac occlusive disease (AIOD) at a single center between 2016 and 2022.

METHODS

All patients with AIOD receiving endovascular therapy at a single center from January 2016 to October 2022 were continuously analyzed, including patients with lesions of all classes according to the Trans-Atlantic Inter-Society Consensus II (TASC-II). Relevant clinical and baseline data were collected, and propensity score matching was performed to compare CSs and BMSs in terms of baseline characteristics, surgical factors, 30-day outcomes, 5-year primary patency, and limb salvage. The follow-up results were analyzed by Kaplan-Meier curves. Cox proportional hazard models were used to identify predictors of primary patency.

RESULTS

A total of 209 patients with AIOD were enrolled in the study, including 135 patients (64.6%) in the CS group and 74 patients (35.4%) in the BMS group. Surgical success rates (100% vs 100%; P = 1.00), early (<30-day) mortality rates (0% vs 0%; P = 1.00), cumulative surgical complication rate (12.0% vs 8.0%; P = .891), 5-year primary patency rate (83.4% vs 86.9%; P = .330), secondary patency rate (96% vs 100%; P = .570), and limb salvage rate (100% vs 100%; P = 1.00) did not exhibit significant differences between the two groups. Patients in the CS group had a lower preoperative ankle-brachial index (0.48 ± 0.26 vs 0.52 ± 0.19; P = .032), more cases of complex AIOD (especially TASC D) (47.4% vs 9.5%; P < .001), more chronic total occlusive lesions (77.0% vs 31.1%; P < .001), and more severe calcification (20.7% vs 14.9%; P < .036). After propensity score matching, 50 patients (25 with CS and 25 with BMS) were selected. The results showed that only severe calcification (32.0% vs 8.0%; P = .034) and ankle-brachial index increase (0.45 ± 0.15 vs 0.41 ± 0.22; P = .038) were significantly different between the groups. In terms of surgical factors, patients in the CS group had more use of bilateral femoral or combined brachial artery percutaneous access (60.0% vs 12.0%; P < .001), more number of stents used (2.3 ± 1.2 vs 1.3 ± 0.7; P < .001), longer mean stent length (9.3 ± 3.3 vs 5.8 ± 2.6 cm; P < .001), and more catheter-directed thrombolysis treatment (32.0% vs 4.0%; P = .009). Multivariate Cox survival analysis showed that severe calcification (hazard ratio, 1.32; 95% confidence interval, 1.04-1.85; P = .048) was the only independent predictor of the primary patency rate.

CONCLUSIONS

All patients with AIOD who underwent endovascular therapy were included and achieved good outcomes with both CSs and BMSs. The influence of confounding factors in the two groups was minimized by propensity score matching, and the 5-year patency rates were generally similar in the unmatched and matched cohorts. Postoperative hemodynamic improvement was more obvious in patients in the CS group. For more complex lesions, CS is recommended to be preferred. Especially for severe calcification lesions, which is the only independent predictor of primary patency, CS showed obvious advantages. Further studies with more samples are needed to investigate the role of stent types in AIOD treatment.

Covered Stents vs Bare Metal Stents for Aortoiliac Arterial Diseases: A Systematic Review and Meta-Analysis

PURPOSE

Covered stents and bare metal stents (BMS) have been regarded as viable treatment options for aortoiliac arterial diseases. We performed this systematic review and meta-analysis to compare the efficacy of covered stents with BMS for aortoiliac arterial diseases.

MATERIALS AND METHODS

The Cochrane Library, Embase, and Medline databases were searched by 2 authors (C.Z. and Z.W.) to retrieve all studies comparing the outcomes of covered stents vs BMS for aortoiliac arterial diseases. The Cochrane tool and the Newcastle-Ottawa scale were used to assess the risk of bias in randomized controlled trials and observational studies, respectively. The outcomes at the same stage reported in at least 2 studies were pooled together. The fixed effects model combined the data when I2<50%, otherwise the random effects model was applied. The results for dichotomous variables were presented as odds ratio (OR) or risk difference and 95% confidence interval (CI); continuous variables were reported as mean difference and 95% CI.

RESULTS

Herein, 10 studies with a total of 1695 limbs were included. The covered stents significantly increased the freedom from target lesion revascularization (OR 2.85, 95% CI: 1.28-6.33, p=0.010) compared to the BMS during a 24-month follow-up. However, no statistically significant difference was found in the technical success, primary patency, secondary patency, major adverse events (MAEs), ankle-brachial index (ABI) improvement, limb salvage, and survival between the two groups.

CONCLUSION

Compared to BMS, covered stents appear to have similar technical success, primary patency, secondary patency, MAEs, ABI improvement, limb salvage, and survival but may have advantages in reducing target lesion revascularization. More well-designed, prospective studies are warranted to determine such findings.

CLINICAL IMPACT

Covered stents may increase freedom from target lesion revascularization (TLR) compared to bare metal stents (BMS) in the treatment of aortoiliac arterial diseases. However, technical success, primary patency, secondary patency, major adverse events (MAEs), ABI improvement, limb salvage, and survival were similar. The aforementioned results are still not sufficient to draw a solid conclusion about the selection of stents for aortoiliac arterial diseases. More well-designed, prospective studies are warranted to determine such findings.

Results of endovascular treatments of Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation

Objectives

The current study aims to report midterm results of patients treated with endovascular intervention, kissing stent, or covered endovascular reconstruction of the aortic bifurcation, for Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation.

Methods

Eighteen patients who have intermittent claudication or chronic limb threatening ischemia with Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation enrolled to the study between January 2018 and January 2021. Kissing stents, Advanta V12 (Atrium, Getinge Group), were used in 13 patients, and the covered endovascular reconstruction of the aortic bifurcation technique was used in 4 patients to reconstruct the aortic bifurcation. The patients were followed for a median of 49 months (min. 2, max.58 months). Patency rates, mortality, morbidities, and reinterventions were recorded.

Results

The mean age of the patients was 60.4 ± 10 years. Technical success was achieved in 94.4% of the patients, but one patient had to convert to open surgery. Primary patency rate of the remaining patients was 85.6% at 58 months. Target lesion revascularization rate was 11.7%. One patient had successful reintervention for in stent restenosis, and secondary patency rate was 93.3% at 58 months. Limb salvage rate was 84.6% during the follow-up. Two patients had myocardial infarction (11.1%) and one mortality (5.6%) occurred because of cerebrovascular event in the follow-up.

Conclusions

Endovascular techniques can be used safely for reconstruction of the aortic bifurcation in Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease in selected patients who have high risk for open surgery. Covered endovascular reconstruction of the aortic bifurcation is the only technique that showed patency rates approaching open surgery in treatment of aortoiliac occlusive disease involving the aortic bifurcation to date. Although promising patency results were achieved with kissing-covered stents, long-term patency rates were still lower than those achieved with open surgery. Further randomized controlled studies comparing the long-term results of these techniques are needed.

Efficacy of closed cell self expandable metallic stent for peripheral arterial disease in the porcine iliac artery

This study aimed to investigate the efficacy of a closed-cell self-expandable metallic stent (SEMS) with or without expanded-polytetrafluoroethylene (e-PTFE)-covering membrane in a porcine iliac artery model. Twelve Yorkshire domestic pigs were divided into a bare closed-cell SEMS (B-SEMS) group (n = 6) and covered closed-cell SEMS (C-SEMS) group (n = 6). Both closed-cell SEMSs were placed in the right or left iliac artery. Thrombogenicity score in the C-SEMS group was significantly higher than that in the B-SEMS group (p = 0.004) after 4 weeks. Angiographic findings of mean luminal diameters at 4 weeks follow-up did not differ significantly between B-SEMS and C-SEMS groups. Neointimal hyperplasia thickness as well as degree of inflammatory cell infiltration and collagen deposition in the C-SEMS group was significantly greater than that in the B-SEMS group (p < 0.001). Closed-cell SEMSs successfully maintained patency for 4 weeks without stent-related complications in the porcine iliac artery. Although mild thrombus with neointimal hyperplasia was observed in the C-SEMS group, subsequent occlusion, and in-stent stenosis did not occur in any of the pigs until the end of the study. Closed-cell SEMS with or without the e-PTFE covering membrane is effective and safe for the porcine iliac artery.

Midterm Outcomes of Kissing Covered Self-Expanding Stents for Reconstruction of Complex Aortoiliac Occlusive Disease

BACKGROUND

We sought to investigate the midterm results of kissing self-expanding covered stents (SECSs) for the reconstruction of aortic bifurcation in complex aortoiliac occlusive disease.

METHODS

Data of consecutive patients who had undergone endovascular treatment for aortoiliac occlusive disease were screened. Only patients with TransAtlantic Inter-Society Consensus (TASC) class C and D lesions treated by bilateral iliac kissing stents (KSs) were included. Midterm primary patency, risk factors, and limb salvage rates were analyzed. Follow-up results were analyzed using the Kaplan-Meier curves. Cox proportional hazards models were used to identify the predictors of primary patency.

RESULTS

A total of 48 patients (95.8% men; mean age, 65.3 ± 10.2 years) were treated with kissing SECSs. Of them, 17 patients had TASC-II class C lesions and 31 had class D lesions. There were 38 total occlusive lesions, with a mean occlusive lesion length of 108.2 ± 57.3 mm. The overall mean lesion length was 140.3 ± 60.5 mm, and the mean length of implanted stents in the aortoiliac arteries was 141.9 ± 59.9 mm. The mean diameter of the deployed SECSs was 7.8 ± 0.5 mm. The mean follow-up time was 36.5 ± 15.8 months, and the follow-up rate was 95.8%. At 36 months, the overall primary patency, assisted primary patency, secondary patency, and limb salvage rates were 92.2%, 95.7%, 97.8%, and 100%, respectively. Univariate Cox regression analysis revealed that stent diameter ≤7 mm (hazard ratio [HR]: 9.53; 95% confidence interval [CI] 1.56-57.94, P = 0.014) and severe calcification (HR: 12.66; 95% CI 2.04-78.45, P = 0.006) were significantly associated with restenosis. Multivariate analysis showed severe calcification to be the only significant determinant of restenosis (HR: 12.66; 95% CI 2.04-78.45, P = 0.006).

CONCLUSIONS

Kissing SECSs provide good midterm results for the treatment of aortoiliac occlusive disease. A stent diameter >7 mm is a potent protective factor against restenosis. Because severe calcification appears to be the only significant determinant of restenosis, patients with severe calcification require close follow-up.

Iliac occlusion due to covered stent deformation following abdominal massages

Extrinsic compression is a potential cause of stent failure. We have described the case of a 65-year-old paraplegic patient with acute right leg ischemia. His medical history was relevant for aortobifemoral bypass, followed by kissing covered stent reconstruction of a proximal anastomotic false aneurysm. The computed tomography scan showed collapse of the right iliac covered stent with ipsilateral iliofemoral graft thrombosis and partial collapse of the left iliac covered stent. He underwent emergent right iliac limb open thrombectomy and redo covered stent relining. The cause of compression was found to be daily deep abdominal massages for intestinal evacuation. The endovascular device should be tailored to the patient's particularities.

Comparison of BARD®LIFESTREAM™ covered balloon-expandable stent versus GORE® VIABAHN™ covered self-expandable stent in treatment of aortoiliac obstructive disease: study protocol for a prospective randomized controlled trial (NEONATAL trial)

BACKGROUND

Covered stent has become one of the mainstream therapies for aortoiliac obstructive disease (AIOD), with a higher patency rate than bare metal stent. Covered balloon-expandable (CBE) stent can be placed more accurately with higher a radial support force, while covered self-expanding (CSE) stent has greater elasticity and higher trackability. However, there is no level I evidence regarding the comparison safety and efficacy between the CSE stent and CBE stent in AIOD to date. Therefore, this study aims to compare the efficacy and safety of CBE stent (BARD®LIFESTREAM™) and CSE stent (GORE® VIABAHN™) in AIOD.

METHODS

This trial is a prospective, single-center, parallel, noninferiority, randomized controlled trial. A total of 106 patients will be enrolled and these patients will be randomized to either the CBE stent group or the CSE stent group. The primary end point of the study is the occurrence of target lesion revascularization (TLR) at 12 months after the intervention.

DISCUSSION

To our knowledge, the ballooN sElf cOver steNt AorToiliAc occuLusive (NEONATAL) trial is the first RCT to compare CBE and CSE stent in AIOD patients. The main aim is to compare the TLR of the target lesion between CBE stent and CSE stent at 12 months post-procedure. The results of clinical trials may contribute to establishing a strategic guideline for choosing the optimal type of covered stent in the treatment of AIOD patients.

TRIAL REGISTRATION

Chinese Clinical Trials Registry ChiCTR2100046734. Registered on 27 May 2021.

A Computational Framework Examining the Mechanical Behaviour of Bare and Polymer-Covered Self-Expanding Laser-Cut Stents

PURPOSE

Polymer covered stents have demonstrated promising clinical outcomes with improved patency rates compared to traditional bare-metal stents. However, little is known on the mechanical implication of stent covering. This study aims to provide insight into the role of a polymeric cover on the biomechanical performance of self-expanding laser-cut stents through a combined experimental-computational approach.

METHODS

Experimental bench top tests were conducted on bare and covered versions of a commercial stent to evaluate the radial, axial and bending response. In parallel, a computational framework with a novel covering strategy was developed that accurately predicts stent mechanical performance. Different stent geometries and polymer materials were also considered to further improve understanding on covered stent mechanics.

RESULTS

Results show that stent covering causes increased initial axial stiffness and up to 60% greater radial resistive force at small crimp diameters as the cover folds and self-contacts. The incorporation of a cover allows stent designs without interconnecting struts, thereby providing improved flexibility without compromising radial force. It was also shown that use of a stiffer PET polymeric covering material caused significant alterations to the radial and axial response, with the initial axial stiffness increasing six-fold and the maximum radial resistive force increasing four-fold compared to a PTFE-PU covered stent.

CONCLUSION

This study demonstrates that stent covering has a substantial effect on the overall stent mechanical performance and highlights the importance of considering the mechanical properties of the combined cover and stent.

Clinical outcomes of endovascular procedure using VIABAHN® VBX covered stent in complex aortoiliac artery disease: Result from AVOCADO study

OBJECTIVE

To investigate the safety and efficacy of a balloon-expandable covered stent in the treatment of complex aortoiliac artery disease.

BACKGROUND

Peripheral intervention in complex aortoiliac disease still remains a challenge.

METHODS

We retrospectively analyzed symptomatic patients with aortoiliac disease who were treated with GORE® VIABAHN® VBX covered stent (W.L. Gore & Associates, Flagstaff, AZ). The primary study outcome was a 1-year primary patency without the necessity of any subsequent clinically-driven target revascularization (CD-TLR) based intervention. The proportion of technical success, defined in terms of the absence of residual stenosis, stent edge dissection, and procedure-related severe complications, was also reported.

RESULTS

VBX covered stent was used in 231 patients. Key patient characteristics include mean age of 73.4 ± 9 years, 77% male, 45% diabetes, and 18% suffering from end-stage renal dysfunction on dialysis. TASC II CD lesions were observed in 51% patients, which included 81% calcified lesions. Combined therapy with standard self-expandable stent was performed in 40% patients. The technical success rate was 92.6%. During median follow-up after 13.1 months, the primary patency rate was estimated to be 93.4% (95% confidence interval, 90.0%-96.8%) at 12 months, whereas the rate of freedom from TLR was 95.3% (92.5%-98.2%). As per the univariate analysis, the TASC II classification, number of diseased regions, and chronic total occlusion were significantly associated with risk of restenosis.

CONCLUSIONS

The results of the year-long AVOCADO study demonstrated that usage of the novel VBX covered stent has a patency-based advantage with reduced chances for subsequent revascularization procedures.

Transbrachial and transfemoral approaches combined with visceral protection for the treatment of juxtarenal aortoiliac occlusive disease: Technical issues and clinical outcomes

PURPOSE

To evaluate the safety and efficacy of transbrachial and transfemoral approaches combined with visceral protection for the endovascular treatment of juxtarenal aortoiliac occlusive disease (AIOD) over an average 19-month follow-up period.

METHODS

In this retrospective analysis, all patients with juxtarenal AIOD at a single institution were reviewed from June 2015 to January 2020. Patient characteristics, angiographic results, and follow-up outcomes were retrospectively recorded. The indications for treatment were critical limb threatening ischemia in 12 patients and bilateral claudication in five patients. Percutaneous access via the left brachial artery was first obtained to recanalize the infrarenal occluded lesions. After that, femoral accesses were achieved. A 4-Fr catheter, a 4 mm balloon, or a 6-Fr 90-cm-long sheath was used to complete visceral artery protection.

RESULTS

A total of 17 juxtarenal AIOD patients (14 males; mean age, 63.4 ± 8.1 years) underwent endovascular treatment. The technical success rate was 100%. Complete reconstruction was achieved in 15 (88.2%) patients. The infrarenal aorta was reconstructed with kissing covered stent grafts (n = 7), kissing bare-metal stents (n = 2), covered stent grafts (n = 2), bare-metal stents (n = 1), or the off-label use of iliac limb stent grafts (n = 5). Renal embolization was found in 3 (17.6%) patients during intraoperative angiography. There was 1 (5.9%) case of distal runoff embolization after CDT and 1 (5.9%) case of left iliac artery rupture. One (5.9%) death occurred due to acute myocardial infarction 20 days after the operation. The average follow-up period was 19.3 ± 16.7 months (range, 1-54 months) in the remaining 16 cases. The renal artery patency rate was 100%. The estimated cumulative primary patency rates were 92.3% at 12 months and 59.3% at 36 months according to the Kaplan-Meier method.

CONCLUSIONS

Transbrachial and transfemoral approaches combined with visceral protection offer a safe and effective alternative to open revascularization for the endovascular treatment of juxtarenal AIOD.

Two-year single centre results with covered endovascular reconstruction of aortic bifurcation (CERAB) in the treatment of extensive aorto-iliac occlusive disease

OBJECTIVE

To report the results of a single-centre in the treatment of extensive aorto-iliac occlusive disease (AIOD) by the covered endovascular reconstruction of aortic bifurcation (CERAB) technique.

METHODS

A retrospective analysis was conducted on data obtained from the review of medical charts of all consecutive patients treated with CERAB technique for AIOD between January 2016 and December 2019 in San Giovanni-Addolorata Hospital (Rome, Italy). Clinical examination, duplex ultrasound with ankle-brachial index measurement and contrast-enhanced computed tomography angiography were performed preoperatively. A clinical and ultrasound follow-up was carried out at one month and then half yearly after the intervention to evaluate patients' clinical status, limb salvage, target lesion revascularization rate, primary and secondary patency rate.

RESULTS

During the study period, 24 patients (14 men, 58.3%; 10 women, 41.7%; median age 59 years, range 37-79 years) underwent CERAB for AIOD (TASC II C 29.2%, TASC II D 70.8%). Indications for treatment were: intermittent claudication in 18 patients (75%) and critical limb ischemia in 6 (25%). Technical success was achieved in all cases. Perioperative minor complications occurred in three cases (12.5%). One patient reported an intraoperative iliac rupture requiring adjunctive covered stenting. Median hospital length of stay was two days (range 1-9). No patient died perioperatively nor at the last follow-up. At a median follow-up of 18 months (range 6-48 months), mean ankle-brachial index increased significantly (from 0.62 ± 0.15 before the procedure to 0.84 ± 0.18) (P < 0.001) and target lesion revascularization rate was 12.5%. At two years, the limb salvage rate was 100%, and primary and secondary patency rates were 87.5% and 100%, respectively.

CONCLUSION

CERAB technique demonstrated to be effective at the mid-term follow-up with low rate of complications and short length of stay. Long-term results and more robust data are needed to affirm this technique as the first-line treatment for extensive AIOD. However, it could become the preferred option especially in fragile patients and during contemporary COVID-19 pandemic due to the current limitations in vascular and critical care bed capacity.

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.

Endovascular interventions for claudication do not meet minimum standards for the Society for Vascular Surgery efficacy guidelines

OBJECTIVE

Because the treatment of intermittent claudication (IC) is elective, good short- and long-term outcomes are imperative. The objective of the present study was to examine the outcomes of endovascular management of IC reported in the Vascular Quality Initiative and compare them with the Society for Vascular Surgery guidelines for IC treatment to determine whether real-world results are within the guidelines.

METHODS

Patients undergoing peripheral vascular intervention for IC from 2004 to 2017 with complete data and >9 month follow-up were included. The primary outcome measures were IC recurrence and repeat procedures performed ≤2 years after the initial treatment.

RESULTS

A total of 16,152 patients met the inclusion criteria, with a mean age of 66 years. Of the 16,152 patients, 61% were men, 45% were current smokers, and 28% had been discharged without antiplatelet or statin medication. Adjusted analyses revealed that treatment of more than two arteries was associated with a shorter time to IC recurrence (hazard ratio [HR], 1.19; 95% confidence interval [CI], 1.09-1.31) and a shorter time to repeat procedures (HR, 1.25; 95% CI, 1.09-1.45). The use of atherectomy was also associated with a shorter time to IC recurrence (HR, 1.29; 95% CI, 1.08-1.33) and a shorter time to repeat procedures (HR, 1.31; 95% CI, 1.13-1.52). Discharge with antiplatelet and statin medications was associated with a longer time to IC recurrence (HR, 0.84; 95% CI, 0.78-0.91) and a longer time to repeat procedures (HR, 0.77; 95% CI, 0.69-0.87). Life-table analysis at 2 years revealed that only 32% of patients were free from IC recurrence, although 76% had not undergone repeat procedures. Stratified by anatomic treatment level, 37% of isolated aortoiliac interventions, 22% of aortoiliac and femoropopliteal interventions, 30% of isolated femoropopliteal interventions, and 20% of femoropopliteal and tibial interventions had remained free from IC recurrence at 2 years.

CONCLUSIONS

Most patients treated with an endovascular approach to IC did not meet the Society for Vascular Surgery guidelines for long-term freedom from recurrent symptoms of >50% at 2 years. Many lacked preprocedure optimization of medical management. The use of atherectomy and treatment of more than two arteries were associated with poor outcomes after peripheral vascular intervention for IC, because only 32% of these patients were free from recurrent symptoms at 2 years. Even when risk factor modification is optimized before the procedure, vascular specialists should be aware of the association between atherectomy and multivessel interventions with poorer long-term outcomes and counsel patients appropriately before intervention.

Treatment of iliac atherosclerotic lesions using the balloon-expandable dynamic bare metal stent: One-year outcomes of the BIODYNAMIC single-center retrospective analysis

OBJECTIVES

Endovascular therapy using balloon expandable stents has become the treatment standard for most iliac atherosclerotic lesions. We aimed to assess the safety and performance of the Dynamic stainless-steel balloon-expanding stent system in this location.

METHODS

BIODYNAMIC is a retrospective single center study including consecutive patients with iliac lesions treated with the Dynamic stent system. Not included were implantations inside an endograft. The primary endpoint was freedom from major adverse limb events (MALE) at 12 months, defined as index limb amputation or target lesion revascularization (TLR). Secondary endpoints were procedure success, ankle brachial index (ABI) and Rutherford class change, mortality and freedom from TLR after 12 months.

RESULTS

Within two years, 182 patients with 234 lesions in the common iliac artery were enrolled. Rutherford class 5 and 6 were present in 11.5% of patients, average stent diameter was 8.0 ± 0.5 mm and stented length 40.0 ± 15.3 mm. The primary endpoint was reached in 96.2% (225/234) of the cases, with six TLR (2.6%) and three target limb amputations (1.3%). Procedure success was obtained in all but three patients (98.4%). In paired analysis, ABI improved by 0.25 ± 0.21 from baseline to 0.90 ± 0.16 post-procedure and Rutherford class improved by -1.75 ± 1.53. There were four non-device-related deaths (2.2%). Freedom from TLR was 97%, 95.3%, 94% and 92.7% at 24, 36, 48 and 60 months, respectively.

CONCLUSION

The Dynamic balloon-expandable stent system proved to be safe and effective in a population with common iliac artery lesions.

Bare Stents for Iliac Chronic Total Occlusions ("TELIS"): A Prospective Cohort Study with a Midterm Follow-up

BACKGROUND

This study aims to assess primary bare stenting for iliac chronic total occlusions (CTOs) with midterm follow-up.

METHODS

From April 2013 to May 2016, all patients presenting with symptomatic iliac CTO were treated endovascularly and included in a prospective single-center cohort. Common iliac CTOs were treated with balloon-expandable bare-metal stents. External iliac lesions were treated with bare self-expandable nitinol stents. Primary end point was primary sustained clinical improvement. A total of 49 iliac CTOs were treated in 46 patients.

RESULTS

A total of 22 lesions were located at the level of the common iliac artery (45%), 20 at the external iliac artery (41%), and 7 extending to both (14%). Mean stenting length was 114.4 ± 49.8 mm. Technical success was 98%. Primary sustained clinical improvement was achieved for 93.4 ± 3.7% of patients at 12 months and 87.7 ± 5.2% at 24 months. Three in-stent thrombosis were observed with no restenosis in the remaining patients at 24 months. Freedom from target lesion revascularization was 93.3% ± 3.7% at 24 months. Three stent fractures were noted, none were symptomatic. Mean quality of life (EQ5D-3L) was significantly improved at 24 months (71.2 ± 20.3 vs. 52.4 ± 22.6, P = 0.001).

CONCLUSIONS

Our results showed that primary bare-metal stenting for iliac CTO is safe and efficient at 24 months and could be considered as a first-line strategy.

Comparative Long-term Outcomes of Patients with Aortoiliac Occlusive Disease Limited to Common Iliac Arteries Who Underwent Endarterectomy versus Bypass Grafting

BACKGROUND

The objective of this study was to compared outcomes of patients with aortoiliac occlusive disease (AIOD), limited to the common iliac artery, who underwent either aortoiliac thromboendarterectomy (AIE) or aortobiiliac bypass grafting (ABIB).

METHODS

A single-center, retrospective analysis of consecutive patients with AIOD who underwent either AIE or ABIB between 2010 and 2019 from a prospective database. Patients with disease extending to the external iliac or common femoral arteries were excluded. Data collected included demographics, cardiovascular risk factors, indication for surgery, preoperative and postoperative ankle brachial indexes (ABIs), estimated blood loss, major adverse events (MAEs), and long-term patency. The study end point was clinical success, defined as improvement in ABIs with resolution of symptoms. MAEs included return to the operating room for any reason, postoperative myocardial infarction, stroke, pneumonia, or venous thromboembolism.

RESULTS

Thirty-three patients, who met inclusion criteria, underwent repair for AIOD (AIE: 13; ABIB: 20) at our institution during this time. In both groups, there were more women than men (AIE: 11, ABIB: 10) with a mean age of 55 ± 7 years and 58 ± 6 years in the AIE and ABIB group, respectively. Indication for surgery included disabling claudication in 19 patients, ischemic rest pain in 13 patients, and tissue loss in one patient. No difference in cardiovascular risk factors or AIOD severity was noted between groups. Patients in the AIE group had slightly higher body mass index (30 ± 5 vs. 26 ± 6, P = 0.06). Two patients in each group required concomitant renal/mesenteric artery endarterectomy. One patient in the AIE group required bilateral femoral artery exposure and external iliac thrombectomy. MAEs (4 vs. 0) were higher in the ABIB group including, pneumonia in one patient, myocardial infarction in another, return to the operating room for evacuation of hematoma in the third and bypass graft thrombectomy with lower extremity angiography in the fourth patient. There were no differences in the intensive care unit or hospital length of stay between groups. Patients in both groups achieved return of normal ABI and complete resolution of their symptoms. At mean follow-up time of 43.4 ± 25.2 and 52.9 ± 35.4 months in the AIE and ABIB group, respectively, there was no symptomatic recurrence or need for reintervention while two patients in the ABIB group died of non-aortic-related issues.

CONCLUSIONS

Both procedures were safe, effective, and conferred high long-term primary patency with no need for reintervention in patients with AIOD limited to the common iliac arteries.

A systematic review of covered balloon-expandable stents for treating aortoiliac occlusive disease

OBJECTIVE

To evaluate and compare studies reporting the outcomes of the use of covered balloon-expandable (CBE) stents for the treatment of aortoiliac occlusive disease.

METHODS

A systematic literature search was conducted to identify studies that investigated the use of CBE stents for the treatment of aortoiliac occlusive disease and were published between 2000 and 2019. Baseline demographic data, procedural variables, and long-term outcomes were extracted from publications for analysis.

RESULTS

A total of 15 published articles about 14 studies were included in the review. Of these, eight studies were prospective clinical trials and six studies were retrospective real-world studies. The articles included data regarding five different CBE stents, namely, the iCast/Advanta V12, Viabahn VBX, BeGraft, LifeStream, and JOSTENT. Lesion severity was higher in real-world studies, with more TransAtlantic Inter-Society Consensus Classification class D lesions and a higher percentage of occlusions. All studies showed high rates of technical success and patency over the course of 12 months. Long-term data were only available for the iCast/Advanta V12 device, which had a primary patency rate of 74.7% at 5 years.

CONCLUSIONS

CBE stents are a viable treatment option for patients with complex aortoiliac lesions because of their high rates of technical success and favorable patency across all devices at 12 months. However, long-term data are only available for a single device, the iCast/Advanta V12. The results of using this device were favorable over the course of 5 years.

Midterm Results of Endovascular Treatment for Complete Iliac Axis Occlusions Using Covered Stents

BACKGROUND

Endovascular treatment of complex aortoiliac disease is seeing a growing popularity despite the Trans-Atlantic Inter-Society Consensus (TASC) II recommendations for open surgery in this cases. However, the available evidence does not focus particularly on patients with complete unilateral iliac axis obstruction (CIAO) (TASC II D4 group). This study reports mid-term results of endovascular therapy with covered stents for CIAO.

METHODS

This is single-center retrospective review of patients with CIAO endovascular treatment from January 2015 to December 2017 (3 years). Two types of covered stents were used, alone or combined: the Viabahn self-expandable stent (W. L. Gore, Flagstaff, AZ) and the Advanta V12 balloon-expandable stent (Atrium-Maquet, Hudson, NH). Thirty-day outcomes, long-term patency (assessed with Kaplan-Meier estimates), in-hospital stay, and limb salvage were analyzed.

RESULTS

Thirty-nine patients with CIAO were treated in the period (87.2% male, mean age 64.3 ± 9 years). A majority presented with critical limb ischemia (56.4%, n = 22). Recanalization could be accomplished from an ipsilateral or contralateral femoral access in 82.1% of patients (1 case needed the use of a re-entry device), and from a left brachial access in 17.9%. Technical success was 100%. About 66.7% of cases received an aortic kissing stent technique. Common femoral artery/profundoplasty with prosthetic or bovine patch was associated with 74.3% of cases. Thirty-day mortality was 2.6% (1/39). Primary, assisted, and secondary patency rates at 24 months were all 96.8%. Mean in-hospital stay was 5 days; no limb loss was registered during follow-up.

CONCLUSIONS

Endovascular treatment of complete iliac axis occlusions can offer comparable midterm patency rates to open surgery aortoiliac femoral bypass, when an adequate combination of balloon and self-expandable covered stents is used and an appropriate outflow through the common femoral artery is warranted.

Outcomes From the Multicenter Italian Registry on Primary Endovascular Treatment of Aortoiliac Occlusive Disease

Purpose: To report the results of endovascular treatment of iliac and complex aortoiliac occlusive disease (AIOD) in a multicenter Italian registry. Materials and Methods: A retrospective, multicenter, observational cohort study analyzed 713 patients (mean age 68±10 years; 539 men) with isolated iliac and complex aortoiliac lesions treated with primary stenting between January 2015 and December 2017. Indications for treatment were claudication in 406 (57%) patients and critical limb ischemia in 307 (43%). According to the TransAtlantic Inter-Society Consensus II (TASC) classification, the lesions were categorized as type A (104, 15%), type B (171, 24%), type C (170, 24%), and type D (268, 37%). Early (<30 days) endpoints included mortality, thrombosis, and major complications. Late major outcomes were primary and secondary patency and freedom from reintervention as estimated by Kaplan-Meier analysis; estimates are given with the 95% confidence intervals (CIs). Associations between baseline variables and primary patency were sought with multivariate analysis; the results are presented as the hazard ratio (HR) and 95% CI. Results: Technical success was achieved in 708 (99%) lesions; in-hospital mortality was 0.6% (n=4). The median follow-up was 11 months (range 0-42). The estimated primary patency rate was 96% (95% CI 94% to 97%) at 1 year and 94% (95% CI 91% to 96%) at 2 years. The estimated secondary patency was 99% (95% CI 97% to 99%) at 1 year and 98% (95% CI 95% to 99%) at 2 years. The estimated freedom from reintervention was 98% (95% CI 96% to 99%) at 1 year and 97% (95% CI 94% to 98.5%) at 2 years. Cox regression analysis demonstrated that the application of a covered stent was associated with an increased need for reintervention (HR 1.4, 95% CI 1.10 to 1.74, p=0.005). Chronic obstructive pulmonary disease was associated with decreased primary patency (HR 3.7, 95% CI 1.25 to 10.8, p=0.018). Conclusion: Endovascular intervention with primary stent placement for aortoiliac occlusive disease achieved satisfactory 2-year patency regardless of the complexity of the lesion. Almost all TASC lesions should be considered for primary endovascular intervention if suitable.

Utilization of Vasculoprotective Therapy for Peripheral Artery Disease: A Systematic Review and Meta-analysis

INTRODUCTION

Practice guidelines recommend that patients with peripheral artery disease receive antiplatelets, statins, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). We sought to quantify the rates of prescribing these therapies in patients with peripheral artery disease in the literature.

METHODS

We performed a systematic review and meta-analysis of treatment prescribing rates in observational studies containing peripheral artery disease patients published on or after the year 2000. We also assessed whether prescribing rates are increasing over time.

RESULTS

A total of 86 studies were available for analysis. The aggregate sample size across all studies was 332,555. The pooled estimates for utilization of antiplatelets, statins, and ACE inhibitors or ARBs were 75% (95% confidence interval [CI], 71%-79%), 56% (95% CI, 52%-60%), and 53% (95% CI, 49%-58%), respectively. Statin use was directly related to publication year (+2.0% per year, P < .001), but this was not the case for antiplatelets (P = .68) or ACE inhibitors or ARBs (P = .066).

CONCLUSIONS

Although some improvement in statin prescribing has occurred in recent years, major practice gaps exist in the treatment of peripheral artery disease. Effective measures to close these gaps should be implemented.

Long-term Results of Endovascular Treatment of TASC C and D Aortoiliac Occlusive Disease with Expanded Polytetrafluoroethylene Stent Graft

BACKGROUND

The aim of this study is to retrospectively analyze the early and long-term outcomes of endovascular treatment of Trans-Atlantic Inter-Society Consensus II class C and D (TASC II) aortoiliac occlusive disease with an expanded polytetrafluoroethylene-covered stent graft.

METHODS

Between January 2006 and November 2017, 61 patients (53 males, 8 females), with symptomatic aortoiliac stenotic and/or occlusive disease, were treated with VIABAHN (W.L. Gore and Associates, Flagstaff, Ariz) at 2 University medical centers. The morphology of the lesions was evaluated and classified by contrast-enhanced computed tomography angiography. Demographic data, operation details, and postoperative outcomes were collected. Follow-up data were analyzed by a life-table analysis (Kaplan-Meier test).

RESULTS

Mean age of the patients was 64.89 ± 10.77 years (range 44-89). Thirty-seven patients (60.7%) presented with severe claudication (Rutherford 3), whereas 21 (34.4%) were in Rutherford class 4 and the remaining 3 patients (4.9%) suffered from necrotic lesions (Rutherford 5/6). Fifty-six patients were smokers (91.8%), 38 (62.3%) had hypertension, 23 (37.7%) had coronary artery disease, 30 (40.2%) had dyslipidemia, 18 (29.5%) had chronic obstructive pulmonary disease, 6 (9.5%) had renal insufficiency (serum creatinine>2.0 mg/dL) and 24 (39.3%) had diabetes. Technical success was achieved in 59/61 patients (96.7%) with 16 patients (26.2%) requiring combined percutaneous brachial access to obtain iliac recanalization. Perioperative mortality was 1.6%, whereas postoperative major complications occurred in 2 patients (3.6%). The mean number of VIABAHN placed was 1.77/patient. Mean follow-up was 31.5 months (range 1-108) and primary patency at 36 months was 94.9%. Two major amputations of the lower limbs occurred during the follow-up.

CONCLUSIONS

Open surgery with the aortobifemoral bypass has been the gold standard treatment for complex aortoiliac occlusive disease although complications and mortality still remain significant issues. Our results suggest that endovascular therapy of TASC C and D iliac lesions using the VIABAHN stent graft is feasible, effective, and has good, long-term patency.

Endovascular and Hybrid Revascularization for Complicated Aorto-Iliac Occlusive Disease: Short-Term Results in Single Institute Experience

Background

Treatment for extensive aortoiliac occlusive disease (AIOD) includes endovascular interventions, hybrid procedures and surgical reconstruction. This study evaluated the short-term outcomes of endovascular and hybrid procedures in patients with Trans-Atlantic Inter-Society Consensus II (TASC-II) D AIOD lesions.

Materials and Methods

From January 2013 to June 2015, 41 patients with TASC-II D AIOD lesions who underwent revascularization at our institute were retrospectively included. Nineteen underwent endovascular procedures and 22 underwent hybrid procedures with a postoperative surveillance program for at least 1 year. Patient demographics and short-term outcomes were analyzed.

Results

The procedural success rate in all patients was 100%. The accumulative postoperative complication rate was 20.2%, and the major complication was acute kidney injury (14.6%). The time of freedom from target lesion revascularization was 18.9 months. The primary patency rates in the endovascular group were 89.5% and 84.2% at 1 and 2 years, respectively, compared to 95.5% at 1 and 2 years in the hybrid group; however, the difference was not significant (p = 0.234). The secondary patency rates were 94.7% and 93% at 1 and 2 years, respectively, in the endovascular group, and 95.5% and 94% at 1 and 2 years, respectively, in the hybrid group; however, the differences was not significant (p = 0.916).

Conclusions

Our study revealed that endovascular and hybrid procedures are favorable treatment choices for patients with TASC-II D AIOD lesions. In patients with multilevel steno-occlusive lesions, hybrid procedures improved distal runoff flow and reduced the complexity of endovascular procedures.

Comparison of Covered Versus Uncovered Stents for Benign Superior Vena Cava (SVC) Obstruction

PURPOSE

To identify whether long-term symptom relief and stent patency vary with the use of covered versus uncovered stents for the treatment of benign SVC obstruction.

METHODS AND MATERIALS

We retrospectively identified all patients with benign SVC syndrome treated to stent placement between January 2003 and December 2015 (n = 59). Only cases with both clinical and imaging follow-up were included (n = 47). In 33 (70%) of the patients, the obstruction was due to a central line or pacemaker wires, and in 14 (30%), the cause was fibrosing mediastinitis. Covered stents were placed in 17 (36%) of the patients, and 30 (64%) patients had an uncovered stent. Clinical and treatment outcomes, complications, and the percent stenosis of each stent were evaluated.

RESULTS

Technical success was achieved in all cases at first attempt. Average clinical and imaging follow-up in years was 2.7 (range 0.1-11.1) (covered) and 1.7 (range 0.2-10.5) (uncovered), respectively. There was a significant difference (p = 0.044) in the number of patients who reported a return of symptoms between the covered (5/17 or 29.4%) and uncovered (18/30 or 60%) groups. There was also a significant difference (p = < 0.001) in the mean percent stenosis after stent placement between the covered [17.9% (range 0-100) ± 26.2] and uncovered [48.3% (range 6.8-100) ± 33.5] groups. No significant difference (p = 0.227) was found in the time (days) between the date of the procedure and the date of clinical follow-up where a return of symptoms was reported [covered: 426.6 (range 28-1554) ± 633.9 and uncovered 778.1 (range 23-3851) ± 1066.8]. One patient in the uncovered group had non-endovascular surgical intervention (innominate to right atrial bypass), while none in the covered group required surgical intervention. One major complication (SIR grade C) occurred that consisted of a pericardial hemorrhagic effusion after angioplasty that required covered stent placement. There were no procedure-related deaths.

CONCLUSION

Both covered and uncovered stents can be used for treating benign SVC syndrome. Covered stents, however, may be a more effective option at providing symptom relief and maintaining stent patency if validated by further studies.

Percutaneous Therapies for Peripheral Artery Disease

Percutaneous therapies for peripheral artery disease continue to evolve with new techniques and devices. Although guidelines-recommended therapies have impacted cardiovascular morbidity and mortality, endovascular interventions have been shown to reduce limb pain, improve quality of life, and prolong walking distance for those with claudication and to reduce amputation rates among those with critical limb ischemia. Novel devices such as drug-eluting stents and drug-coated balloons have improved patency for moderate-length lesions, whereas others allow treatment of heavily calcified and tortuous segments. New adjunctive devices to cross lesions and reduce or modify associated plaque have also been developed, although level 1 data regarding their efficacy are sparse. There has also been a better mechanistic understanding of lower extremity endovascular treatment using tools such as intravascular ultrasound. This information has highlighted the need for better stent size selection for the femoropopliteal arterial segments and larger balloon diameters for the tibial arteries. Moreover, a wound perfusion approach with direct in-line flow, the so-called angiosome approach, and reconstruction of the pedal loop have been advocated for improved wound healing. Technical advances such as the tibiopedal access and reentry methods have allowed crossing of lesions that were considered no option for the endovascular approach in the past. Collectively, there has been increased awareness, interest, and commitment by various specialty societies and organizations to advance the treatment of peripheral artery disease and critical limb ischemia. This is also evident by the recent coalition of 7 professional societies and organizations that represented >150 000 allied health professionals and millions of patients with peripheral artery disease at the 2015 Centers for Medicaid and Medicare Services Medicare Evidence Development and Coverage Analysis Committee meeting. The percutaneous therapies for peripheral artery disease continue to evolve with longer follow-up with randomized data and larger prospective registries. In the future, it is hopeful that we will treat the lower extremity arteries according to segments, taking into account plaque morphology, luminal versus subintimal crossing, location, and stenotic versus occlusive disease. Until then, we must identify the most cost-effective, efficacious, and safe treatment for each patient. The goal of this article is to aid the practicing vascular specialist consider the optimal choices for the management of patients with vascular disease.

Results From the VISIBILITY Iliac Study: Primary and Cohort Outcomes at 9 Months

Purpose: To evaluate the safety and effectiveness of primary stenting of the common (CIA) or external iliac artery (EIA) using the Visi-Pro Balloon-Expandable Peripheral Stent System for treatment of stenotic, restenotic, or occluded lesions. Methods: Between 2011 and 2012, 75 patients (mean age 64.2±8.9 years; 46 men) with Rutherford category 2–4 ischemia and atherosclerotic lesions ≤10 cm in length underwent iliac artery stenting at 17 centers in the United States and Europe. The primary outcome of the study was the major adverse event (MAE) rate at 9 months postprocedure [composite of periprocedural death, in-hospital myocardial infarction, clinically driven target lesion revascularization (CD-TLR), and amputation of the treated limb]. Secondary outcomes included 30-day MAE rate, 9-month primary patency, changes in ankle-brachial index (ABI) and the Walking Impairment Questionnaire at 30 days and 9 months postprocedure, device success, and clinically driven target vessel revascularization (CD-TVR) at 30 days and 9 months. Outcomes in specific patient cohorts (ie, gender, stent location, calcification severity, and lesion grade) were analyzed. Results: Eighty-one stents were implanted in 61 CIA and 15 EIA lesions (41 with moderate/severe calcification). The mean lesion treated length was 29.3±13.9 mm. All devices were successfully deployed. MAE occurred in 3 (4.0%) of 75 subjects at 9 months. Primary patency and freedom from CD-TVR at 9 months were both 95.8%. ABI improved from 0.67±0.14 at baseline to 0.94±0.14 and 0.96±0.16 at 30 days and 9-month follow-up, respectively (p<0.001 for both). There were no differences with respect to any of the analyzed patient characteristics, including gender. Conclusion: Nine-month results of the VISIBILITY Iliac stent study (ClinicalTrials.gov identifier NCT01402700) demonstrated safety and effectiveness for the treatment of atherosclerotic CIA and EIA lesions with the Visi-Pro stent across all treated cohorts.

Open and Endovascular Treatment of Trans-Atlantic Inter-Society Consensus II D Aortoiliac Occlusive Lesions: What Determines the Rate of Restenosis?

Background:

Open surgery is the preferred approach for the treatment of type D lesions according to the Trans-Atlantic Inter-Society Consensus (TASC) II guideline, but endovascular solutions also appear to be a valid option in selected patients. The study aimed to identify the risk factors of restenosis after open and endovascular reconstruction of symptomatic TASC II D aortoiliac occlusive lesions (AIOLs).

Methods:

Fifty-six patients (82 limbs) who underwent open repair and endovascular treatment (ET) for symptomatic TASC ΙΙ D AIOLs between March 2005 and December 2012 were retrospectively reviewed. Baseline characteristics, preoperative and postoperative imaging, and operation procedure reports were reviewed and analyzed. Restenosis after revascularization was assessed by duplex ultrasound or computed tomography angiogram. Kaplan-Meier survival analysis, Log-rank test, and multivariate Cox regression were used to evaluate the relevance between risk factors and patency.

Results:

The mean duration of follow-up was 42.8 ± 23.5 months (ranging from 3 to 90 months). Primary patency rates at 1-, 3-, 5-, and 7-year were 93.6%, 89.3%, 87.0%, and 70.3%, respectively. Restenosis after revascularization occurred in 11 limbs. Kaplan-Meier survival analysis and the Log-rank test revealed that diabetes, Rutherford classification ≥5^th and concurrent femoropopliteal TASC II type C/D lesions were significantly related to the duration of primary patency. According to the result of Cox regression, diabetes and femoropopliteal TASC ΙΙ type C/D lesions were identified as the risk factors for restenosis after revascularization.

Conclusion:

This study demonstrated that diabetes and femoropopliteal TASC ΙΙ type C/D lesions are risk factors associated with restenosis after open and ET of TASC II D AIOLs.

First-in-Human Experience With the Gore Balloon-Expandable Covered Endoprosthesis in Iliac Artery Occlusive Disease

Purpose: To report the first-in-human iliac artery experience of a new balloon-expandable covered endoprosthesis. Methods: A prospective, single-center pilot study recruited 30 symptomatic patients (mean age 64 years; 18 men) to evaluate the safety and early efficacy of the new Gore balloon-expandable covered endoprosthesis for the treatment of de novo or restenotic common and/or external iliac artery lesions. According to protocol, up to 2 discrete lesions could be treated with a maximum total treated length ≤110 mm. Follow-up included clinical evaluation with duplex ultrasound at 1, 6, and 12 months. Data are presented through 12-month follow-up. The primary safety endpoint was a composite of device- or procedure-related death, myocardial infarction, or amputation in the treated leg within 30 days of the index procedure. Multiple performance outcomes were also evaluated. Results: The primary 30-day safety endpoint was 0%. Per-subject estimates of primary patency, freedom from target lesion revascularization, and freedom from target vessel revascularization were 100% at 1 and 6 months and 96.6% at 12 months. Estimates of assisted primary and secondary patency were both 100% at 12 months. Freedom from major adverse events at 12 months was 100%. Most patients experienced improvements in Rutherford category, ankle-brachial index, and functional status that were sustained to 12 months. Conclusion: This positive first-in-human experience with the Gore balloon-expandable covered endoprosthesis suggests this device will have an important role in the management of aortoiliac occlusive disease.

Covered vs Uncovered Stents for Aortoiliac and Femoropopliteal Arterial Disease

Purpose: To evaluate outcomes of covered vs bare metal stents for the treatment of lower limb peripheral artery disease. Methods: A search of electronic databases was performed to identify all studies comparing outcomes of covered vs bare metal stents for treatment of aortoiliac and femoropopliteal arterial disease. The Cochrane tool and the Newcastle-Ottawa scale were used to assess the risk of bias in randomized controlled trials (RCTs) and observational studies, respectively. Fixed or random effects models were applied to analyze pooled outcome data. The results for dichotomous outcome variables are presented as the odds ratio (OR) and 95% confidence interval (CI); intergroup comparisons of continuous clinical variables are reported as the mean difference (MD) and 95% CI. Results: Two RCTs and 4 retrospective cohort studies, enrolling 744 patients (mean age 67 years; 477 men) and 918 diseased arteries, were identified. For aortoiliac disease, treatment with a covered stent showed no significant improvement in primary patency (OR 2.10, 95% CI 0.48 to 9.11, p=0.32), but it was associated with higher ankle-brachial index (ABI) (MD 0.08, 95% CI 0.07 to 0.09, p<0.001) and a lower reintervention rate (OR 0.19, 95% CI 0.09 to 0.42, p<0.001). For femoropopliteal disease, use of covered stents was associated with increased primary patency (OR 1.84, 95% CI 1.11 to 3.06, p=0.02), higher ABI (MD 0.08, 95% CI 0.00 to 0.16, p=0.04), and a lower reintervention rate (OR 0.51, 95% CI 0.30 to 0.87, p=0.01). No significant differences in technical success, complications, limb salvage, or survival were identified between the groups in either segment. Conclusion: Theoretically, the use of covered stents may increase the patency rate due to decreased restenosis after stent placement. This analysis found that the primary patency was improved with the use of a covered stent in femoropopliteal lesions but not in aortoiliac disease. Improved outcomes were seen with covered stents compared with bare metal stents as indicated by a lower need for reintervention and an improved ABI. It remains to be investigated whether such beneficial effects can be translated into improved clinical outcomes, such as limb salvage and amputation-free survival. Long-term results of the comparative efficacy of covered stents over bare metal stents are not currently available.

Endovascular revascularization for aortoiliac atherosclerotic disease

Atherosclerotic iliac artery disease is increasingly being treated with endovascular techniques. A number of new stent technologies can be utilized with high long-term patency, including self-expanding stents, balloon-expandable stents, and covered stents, but comparative data on these stent types and in more complex lesions are lacking. This article provides a review of currently available iliac stent technologies, as well as complex procedural aspects of iliac artery interventions, including approaches to the treatment of iliac bifurcation disease, long segment occlusions, choice of stent type, and treatment of iliac artery in-stent restenosis.

An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries: A Supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II): The TASC Steering Comittee(.)

The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.