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Smith AH, Beach JM, Dash S, Rowse J, Parodi FE, Kirksey L, Caputo FJ, Lyden SP, Smolock CJ. Comparison of Aortobifemoral Bypass to Aortoiliac Stenting with Bifurcation Reconstruction for TASC II D Aortoiliac Occlusive Disease. Ann Vasc Surg 2021; 82:120-130. [PMID: 34788703 DOI: 10.1016/j.avsg.2021.10.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Long-segment stenting of the infrarenal aorta and bilateral iliac arteries, with or without femoral endarterectomy for diffuse disease, has been adopted for treatment of severe aortoiliac occlusive disease (AIOD). The objective of this study was to compare outcomes of this reconstruction, termed aortoiliac stenting with bifurcation reconstruction (AISBR), to aortobifemoral bypass (ABF) in patients with comparable TASC II D lesions. METHODS This is a single-center, retrospective review of patients treated with ABF or AISBR for comparable TASC II D lesions between 2010 and 2018. ABF patients were included only if they were deemed anatomic candidates also for AISBR after review of preoperative imaging. Patients treated for acute limb ischemia and bypass graft infection were excluded. Statistics included Fisher exact test, Kaplan-Meier analysis, and Cox proportional hazards regression. RESULTS There were 24 ABF and 75 AISBR included in the study. The primary indication for treatment was claudication in 55 (55.6%) patients, rest pain in 28 (28.3%), and tissue loss in 16 (16.2%). Patients undergoing AISBR were more likely to be female. Femoral endarterectomies were performed in 37/75 (49.3%) AISBR and 14/24 (58.3%) ABF (p=0.44). AISBR were performed percutaneously in 34/75 (45.1%). No AISBR required conversion to ABF. Intraoperative blood loss, procedure time and hospital length of stay (LOS) were significantly less for AISBR compared to ABF. Surgical site infections (SSI) were less common in patients undergoing AISBR (AISBR: 6/75 (8.0%) vs. ABF: 9/24 (37.5%), (p<0.01). One AISBR and two ABF developed late SSI >30 days postoperatively. The reductions in blood loss, LOS and SSI remained significant after excluding percutaneous AISBR from the analysis. Five-year primary patency was 50.8% (95% CI: 33.3, 68.4%) for AISBR and 88.1% (72.7, 100.0%) for ABF (p=0.04). Five-year survival was 76.5% (95% CI: 63.6, 89.5) for AISBR and 100% (95% CI: 100.0, 100.0) for ABF (p = 0.07). Five-year primary assisted patency, secondary patency, freedom from reintervention and major adverse limb events did not differ significantly between groups. CONCLUSIONS AISBR is a viable option for management of TASC II D AIOD, with lower morbidity and acceptable durability when compared to traditional ABF.
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Affiliation(s)
- Andrew H Smith
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Jocelyn M Beach
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756
| | - Siddhartha Dash
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Jarrad Rowse
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Frederico E Parodi
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC 27599
| | - Lee Kirksey
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Francis J Caputo
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Sean P Lyden
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Christopher J Smolock
- Aortic Center and Heart Vascular and Thoracic Institute, Department of Vascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195.
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Serefli D, Saydam O, Engin AY, Atay M. Midterm results of kissing stent reconstruction of the aortoiliac bifurcation. Ann Surg Treat Res 2021; 101:247-255. [PMID: 34692597 PMCID: PMC8506018 DOI: 10.4174/astr.2021.101.4.247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/19/2021] [Accepted: 08/27/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose One subset of peripheral arterial disease is aortoiliac occlusive diseases (AIOD). AIOD is the term for all arterial lesions between the infrarenal distal aorta and common femoral artery. Implantation of kissing stents (KS) with covered stents (CS), bare-metal stents (BMS) is one of the endovascular treatment (ET) modalities for AIOD involving aortic bifurcation. In this study, we report the outcomes of the KS technique in infrarenal AIOD. Methods Between January 2014 and September 2017, 31 patients who underwent ET were treated with KS technique either with balloon-expandable BMS or balloon-expandable CS. Technical details, clinical success, complications, and patency at follow-up were documented. Results The majority of patients were male (77.4%), and the median age was 62 years (range, 45-78 years). All patients were classified according to the TASC II criteria. Eight patients (25.8%) were classified as TASC B. Fifteen patients (48.4%) were classified as TASC C, and 8 patients (25.8%) were classified as TASC D. These 23 patients were classified as complex AIOD group. BMS was used in 17 patients (54.8%), and CS was used in 14 patients (45.2%). Technical and clinical success was achieved in 100% of treated cases. The median follow-up was 24 months (range, 24-34 months). Primary patency rates at 12, 18, and 24 months after ET were 100%, 96.8%, and 90.3%, respectively. Conclusion We found that the KS technique has satisfying 24-month results, even in complex AIOD lesions, with high technical success and acceptable midterm patency. Key Words: Aorta, Arterial occlusive diseases, Endovascular procedures, Iliac artery, Stents.
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Affiliation(s)
- Deniz Serefli
- Department of Cardiovascular Surgery, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Onur Saydam
- Department of Cardiovascular Surgery, Tepecik Training and Research Hospital, Izmir, Turkey
| | - A Yaprak Engin
- Department of Cardiovascular Surgery, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Mehmet Atay
- Department of Cardiovascular Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Borghese O, Ferrer C, Coscarella C, Spataro C, Diotallevi N, Giudice R. Two-year single centre results with covered endovascular reconstruction of aortic bifurcation (CERAB) in the treatment of extensive aorto-iliac occlusive disease. Vascular 2021; 30:500-508. [PMID: 34056974 DOI: 10.1177/17085381211018336] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Ottavia Borghese
- Departement of Surgery "Paride Stefanini", Sapienza University, Rome, Italy.,University Sapienza, Rome, Italy
| | - Ciro Ferrer
- Vascular and Endovascular Surgery Unit, Addolorata Hospital, Rome, Italy
| | - Carlo Coscarella
- Vascular and Endovascular Surgery Unit, Addolorata Hospital, Rome, Italy
| | - Claudio Spataro
- Vascular and Endovascular Surgery Unit, Addolorata Hospital, Rome, Italy
| | - Nicolò Diotallevi
- Vascular and Endovascular Surgery Unit, Addolorata Hospital, Rome, Italy
| | - Rocco Giudice
- Vascular and Endovascular Surgery Unit, Addolorata Hospital, Rome, Italy
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Blood Flow Quantification in Peripheral Arterial Disease: Emerging Diagnostic Techniques in Vascular Surgery. Surg Technol Int 2021. [PMID: 33970476 DOI: 10.52198/21.sti.38.cv1410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The assessment of local blood flow patterns in patients with peripheral arterial disease is clinically relevant, since these patterns are related to atherosclerotic disease progression and loss of patency in stents placed in peripheral arteries, through mechanisms such as recirculating flow and low wall shear stress (WSS). However, imaging of vascular flow in these patients is technically challenging due to the often complex flow patterns that occur near atherosclerotic lesions. While several flow quantification techniques have been developed that could improve the outcomes of vascular interventions, accurate 2D or 3D blood flow quantification is not yet used in clinical practice. This article provides an overview of several important topics that concern the quantification of blood flow in patients with peripheral arterial disease. The hemodynamic mechanisms involved in the development of atherosclerosis and the current clinical practice in the diagnosis of this disease are discussed, showing the unmet need for improved and validated flow quantification techniques in daily clinical practice. This discussion is followed by a showcase of state-of-the-art blood flow quantification techniques and how these could be used before, during and after treatment of stenotic lesions to improve clinical outcomes. These techniques include novel ultrasound-based methods, Phase-Contrast Magnetic Resonance Imaging (PC-MRI) and Computational Fluid Dynamics (CFD). The last section discusses future perspectives, with advanced (hybrid) imaging techniques and artificial intelligence, including the implementation of these techniques in clinical practice.
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Engelhard S, van de Velde L, Jebbink E, Jain K, Westenberg J, Zeebregts C, Versluis M, Reijnen M. Blood Flow Quantification in Peripheral Arterial Disease: Emerging Diagnostic Techniques in Vascular Surgery. Surg Technol Int 2021. [DOI: https:/doi.org/10.52198/21.sti.38.cv1410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
The assessment of local blood flow patterns in patients with peripheral arterial disease is clinically relevant, since these patterns are related to atherosclerotic disease progression and loss of patency in stents placed in peripheral arteries, through mechanisms such as recirculating flow and low wall shear stress (WSS). However, imaging of vascular flow in these patients is technically challenging due to the often complex flow patterns that occur near atherosclerotic lesions. While several flow quantification techniques have been developed that could improve the outcomes of vascular interventions, accurate 2D or 3D blood flow quantification is not yet used in clinical practice. This article provides an overview of several important topics that concern the quantification of blood flow in patients with peripheral arterial disease. The hemodynamic mechanisms involved in the development of atherosclerosis and the current clinical practice in the diagnosis of this disease are discussed, showing the unmet need for improved and validated flow quantification techniques in daily clinical practice. This discussion is followed by a showcase of state-of-the-art blood flow quantification techniques and how these could be used before, during and after treatment of stenotic lesions to improve clinical outcomes. These techniques include novel ultrasound-based methods, Phase-Contrast Magnetic Resonance Imaging (PC-MRI) and Computational Fluid Dynamics (CFD). The last section discusses future perspectives, with advanced (hybrid) imaging techniques and artificial intelligence, including the implementation of these techniques in clinical practice.
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Affiliation(s)
- Stefan Engelhard
- Department of Vascular Surgery, Rijnstate, Arnhem, The Netherlands
| | | | - Erik Jebbink
- Department of Vascular Surgery, Rijnstate, Arnhem, The Netherlands
| | - Kartik Jain
- Department of Thermal and Fluid Engineering, University of Twente, Enschede, The Netherlands
| | - Jos Westenberg
- Department of Radiology, Cardiovascular Imaging Group, Leiden University Medical Center, Leiden, The Netherlands
| | - Clark Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Michel Versluis
- Physics of Fluids Group, Technical Medical (TechMed) Centre, University of Twente, Enschede, The Netherlands
| | - Michel Reijnen
- Department of Vascular Surgery, Rijnstate, Arnhem, The Netherlands
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Abstract
Objective The covered endovascular reconstruction of the aortic bifurcation (CERAB) technique was introduced in 2009 in order to provide an anatomically and physiologically optimal endovascular reconstruction of the aortic bifurcation. Method In the current review, all available evidence on this technique was summarized. Results In vitro studies have shown a more favorable geometry of CERAB compared to kissing stents, leading to better local flow conditions. The results of CERAB are at least as good as those achieved with kissing stents in a more complex group of treated patients. The mid-term patency rates approach those of surgical reconstruction. Initial data show that the technique can also be used in combination with chimney grafts in order to preserve side branches. Conclusion CERAB has proven to be the most optimal endovascular treatment option for aorto-iliac occlusive disease with regard to geometry and flow and is related to promising clinical outcomes. Prospective and comparative trials are necessary to elucidate the most optimal treatment algorithm for patients with aorto-iliac occlusive disease.
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Affiliation(s)
- Michel MPJ Reijnen
- Department of Surgery, Rijnstate, Arnhem and the Multi-Modality Medical Imaging Group, University of Twente, Enschede, The Netherlands
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Groot Jebbink E, Mathai V, Boersen JT, Sun C, Slump CH, Goverde PC, Versluis M, Reijnen MM. Hemodynamic comparison of stent configurations used for aortoiliac occlusive disease. J Vasc Surg 2017; 66:251-260.e1. [DOI: 10.1016/j.jvs.2016.07.128] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/27/2016] [Indexed: 10/20/2022]
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Groot Jebbink E, Ter Mors TG, Slump CH, Geelkerken RH, Holewijn S, Reijnen MM. In vivo geometry of the kissing stent and covered endovascular reconstruction of the aortic bifurcation configurations in aortoiliac occlusive disease. Vascular 2017; 25:635-641. [PMID: 28530484 PMCID: PMC5714162 DOI: 10.1177/1708538117708912] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Objectives Various configurations of kissing stent (KS) configurations exist and patency rates vary. In response the covered endovascular reconstruction of the aortic bifurcation configuration was designed to minimize mismatch and improve outcome. The aim of the current study is to compare geometrical mismatch of kissing stent with the covered endovascular reconstruction of the aortic bifurcation configuration in vivo. Methods Post-operative computed tomographic data and patient demographics from 11 covered endovascular reconstruction of the aortic bifurcation and 11 matched kissing stent patients were included. A free hand region of interest and ellipse fitting method were applied to determine mismatch areas and volumes. Conformation of the stents to the vessel wall was expressed using the D-ratio. Results Patients were mostly treated for Rutherford category 2 and 3 (64%) with a lesion classification of TASC C and D in 82%. Radial mismatch area and volume for the covered endovascular reconstruction of the aortic bifurcation group was significantly lower compared to the kissing stent configuration (P < 0.05). The D-ratio did not significantly differ between groups. Measurements were performed with good intra-class correlation. There were no significant differences in the post-procedural aortoiliac anatomy. Conclusions The present study shows that radial mismatch exists in vivo and that large differences in mismatch exist, in favour of the covered endovascular reconstruction of the aortic bifurcation configuration. Future research should determine if the decreased radial mismatch results in improved local flow profiles and subsequent clinical outcome.
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Affiliation(s)
- Erik Groot Jebbink
- 1 Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands.,2 MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Thijs G Ter Mors
- 1 Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands.,2 MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Cornelis H Slump
- 2 MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Robert H Geelkerken
- 2 MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands.,3 Department of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - Suzanne Holewijn
- 1 Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
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Editor's Choice – First Results of the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) Technique for Aortoiliac Occlusive Disease. Eur J Vasc Endovasc Surg 2015; 50:638-47. [DOI: 10.1016/j.ejvs.2015.06.112] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 06/30/2015] [Indexed: 11/22/2022]
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Endovascular Treatment of Occlusive Lesions in the Aortic Bifurcation with Kissing Polytetrafluoroethylene-Covered Stents. J Vasc Interv Radiol 2015; 26:1277-84. [DOI: 10.1016/j.jvir.2015.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 11/18/2022] Open
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Suh Y, Ko YG, Shin DH, Kim JS, Kim BK, Choi D, Hong MK, Jang Y. Outcomes of the single-stent versus kissing-stents technique in asymmetric complex aortoiliac bifurcation lesions. J Vasc Surg 2015; 62:68-74. [DOI: 10.1016/j.jvs.2015.02.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 02/13/2015] [Indexed: 10/23/2022]
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de Donato G, Bosiers M, Setacci F, Deloose K, Galzerano G, Verbist J, Peeters P, Setacci C. 24-Month Data from the BRAVISSIMO: A Large-Scale Prospective Registry on Iliac Stenting for TASC A & B and TASC C & D Lesions. Ann Vasc Surg 2015; 29:738-50. [DOI: 10.1016/j.avsg.2014.12.027] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 12/29/2014] [Accepted: 12/30/2014] [Indexed: 10/23/2022]
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Geometrical consequences of kissing stents and the Covered Endovascular Reconstruction of the Aortic Bifurcation configuration in an in vitro model for endovascular reconstruction of aortic bifurcation. J Vasc Surg 2014; 61:1306-11. [PMID: 24486037 DOI: 10.1016/j.jvs.2013.12.026] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/06/2013] [Accepted: 12/09/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Kissing stents (KS) are commonly used to treat aortoiliac occlusive disease, but patency results are often lower than those of isolated stents. The Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) technique was recently introduced to reconstruct the aortic bifurcation in a more anatomical and physiological fashion. The aim of this study is to compare the geometrical consequences of various stent configurations in vitro. METHODS Anatomic vessel phantoms of the aortoiliac bifurcation were created to accommodate stent configurations. Self-expandable nitinol KS, balloon-expandable covered KS, and two versions of the CERAB configuration were deployed, one with the iliac legs positioned inside the tapered part of the aortic cuff (1) and one with the legs deployed above this level (2). Computed tomography data were obtained to assess the geometry. The conformation ratio (D-ratio) was calculated by use of the ratio of the major and minor axes. The proximal mismatch area, mean mismatch area, and total mismatch volume were calculated. RESULTS The highest D-ratios were observed in the nitinol KS and the CERAB configuration, implying an ideal "double-D" shape. The proximal and mean mismatch areas were four- to sixfold lower in the CERAB (1) configuration when compared with nitinol KS and CERAB (2), respectively, whereas the covered KS had the highest mismatch area. Nitinol and covered KS had the largest mismatch volume, whereas the mismatch volume was the lowest in the CERAB (1) configuration. CONCLUSIONS Although nitinol self-expandable stents have a high stent conformation, the lowest radial mismatch was found in the CERAB (1) configuration, supporting the hypothesis that the CERAB configuration is the most anatomical and physiological reconstruction of the aortic bifurcation. Within the CERAB configuration, the two limbs are ideally positioned inside the tapering portion of the cuff, minimizing mismatch.
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Abello N, Kretz B, Picquet J, Magnan PE, Hassen-Khodja R, Chevalier J, Rosset E, Feugier P, Fleury M, Steinmetz E. Long-term results of stenting of the aortic bifurcation. Ann Vasc Surg 2012; 26:521-6. [PMID: 22410142 DOI: 10.1016/j.avsg.2011.05.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 05/03/2011] [Accepted: 05/15/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND To evaluate the long-term results in a multicentric continuous series of narrowing lesions of the aortic bifurcation treated with a kissing stent. METHODS From January, 1st 1999 to the December, 31st 2001, all of the patients (n = 80) presenting with stenosis of the aortic bifurcation (n = 15) and/or the 2 common iliac arteries (n = 65), treated with a kissing stent, in 8 teaching hospitals were collected retrospectively. The risk factors were smoking (91%), dyslipidemia (60%), arterial hypertension (42%) and diabetes (27%). In 84% of cases, the indication for treatment was claudication. The lesions were stenotic < 70% (n = 76) and/or thrombotic (n = 18). The associated lesions were external iliac stenoses (n = 21), common femoral stenoses (n = 19), femoro-popliteal stenoses (n = 42), arteriopathy in the leg (n = 35). Follow-up was clinical examination and Doppler US scan. RESULTS The success rate of the technique was 89%. There were 4 cases (5.3%) of residual stenosis and 4 cases (5.3%) of dissection. The length of the lesions treated in the aorta and the iliac arteries was respectively 17.1 ± 7 and 17.3 ± 9 mm. The stents were all placed as kissing stents, and had a mean diameter and a mean length of 13.75 mm and 56 mm in the aorta and 9 mm and 48 mm in the iliac arteries, respectively. At 5 years, 19 patients had required repeat angioplasty in the treated area, and 13 had undergone open surgery. Primary and assisted primary patency at 5 years were 64.5% and 81.8%, respectively. CONCLUSION Long-term follow-up of endovascular treatment with kissing stents for stenosis of the aortic bifurcation shows that this technique gives good results, though it does not justify doing away with classical revascularisation surgery, in a population with major cardiovascular risk factors.
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Affiliation(s)
- Nicolas Abello
- Service de Chirurgie Cardiovasculaire, CHU Le Bocage, et Université de Bourgogne, Dijon, France
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Sabri SS, Choudhri A, Orgera G, Arslan B, Turba UC, Harthun NL, Hagspiel KD, Matsumoto AH, Angle JF. Outcomes of covered kissing stent placement compared with bare metal stent placement in the treatment of atherosclerotic occlusive disease at the aortic bifurcation. J Vasc Interv Radiol 2010; 21:995-1003. [PMID: 20538478 DOI: 10.1016/j.jvir.2010.02.032] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Revised: 01/25/2010] [Accepted: 02/08/2010] [Indexed: 10/19/2022] Open
Abstract
PURPOSE To review the outcomes with the use of balloon-expandable covered iliac kissing stents as compared with bare metal stents in the treatment of atherosclerotic disease at the aortic bifurcation. MATERIALS AND METHODS A review of consecutive patients from a single institution with atherosclerotic occlusive disease at the aortic bifurcation treated with balloon-expandable kissing stents was performed between January 1, 2002, and September 1, 2007. Fifty-four patients were identified and divided into two groups: those with bare metal stents and those with covered stents. Technical and clinical success (Fontaine classification), complications, and patency at follow-up were documented. RESULTS Twenty-six patients (17 men, nine women; mean age, 61 years; age range, 39-79 years) received covered stents and 28 patients (15 men, 13 women; mean age, 61 years; age range, 38-82 years) received bare metal stents. Technical success was achieved in 100% of patients in both groups. Major complications occurred in three of the 26 (11%) with covered stents (P = .66) and two of the 28 patients (7%) with bare metal stents. The median follow-up was 21 months (20 months for covered stents vs 25 months for bare metal stents; range, 1-62 months). Twenty-two of the 26 patients (85%) with covered stents had sustained improvement in clinical symptoms during the follow-up period compared with 15 of the 28 patients (54%) with bare metal stents (P = .02). Primary patency rates at 1 and 2 years were 92% and 92%, respectively, for covered stents and 78% and 62% for bare metal stents (P = .023). CONCLUSIONS The use of covered balloon-expandable kissing stents for atherosclerotic aortic bifurcation occlusive disease provides superior patency at 2 years as compared with bare metal balloon-expandable stents.
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Affiliation(s)
- Saher S Sabri
- Division of Angiography, Interventional Radiology, and Special Procedures, Department of Radiology/Box 800170, University of Virginia Health System, Jefferson Park Ave, Charlottesville, VA 22908, USA
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van't Riet M, Spronk S, Jonkman J, Den Hoed T. Endovascular treatment of atherosclerosis at the aortoiliac bifurcation with kissing stents or distal aortic stents: a temporary solution or durable improvement? JOURNAL OF VASCULAR NURSING 2008; 26:82-5. [PMID: 18707997 DOI: 10.1016/j.jvn.2008.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Revised: 06/01/2008] [Accepted: 06/09/2008] [Indexed: 10/21/2022]
Abstract
To evaluate medium-term technical and clinical success after endovascular treatment of stenosis or occlusion at the aortoiliac bifurcation with a distal aortic stent or kissing stents. Between 1995 and 2004, 25 patients were included in the study. Nine patients were treated with an aortic stent, and 16 patients were treated with kissing stents. Clinical and radiologic findings were retrospectively reviewed, and statistical analysis was performed. In all cases, the procedure was technically successful. Hemodynamic success was observed in 22 patients (88%), and clinical success was observed in 23 patients (92%). After a median follow-up of 21 months, 8 patients developed a restenosis (n = 6) or occlusion (n = 2). Two patients with restenosis were treated successfully with aortic bifurcation grafts, and 4 patients underwent endovascular reintervention. No risk factors for restenosis were identified. Primary patency was 87% after 1 year and 65% after 2 years. Secondary patency was 90% after 1 year and 72% after 2 years. At the last outpatient control, 22 patients (88%) were free of symptoms. Endovascular treatment of symptomatic aortoiliac atherosclerosis at the aortoiliac bifurcation by means of a distal aortic stent or kissing stents can be used successfully with durable improvement in the majority of patients. We recommend it as the initial treatment modality.
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Long-Term Outcome following Stent Reconstruction of the Aortic Bifurcation and the Role of Geometric Determinants. Ann Vasc Surg 2008; 22:346-57. [DOI: 10.1016/j.avsg.2007.12.013] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2007] [Revised: 10/10/2007] [Accepted: 12/04/2007] [Indexed: 11/23/2022]
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Yilmaz S, Sindel T, Golbasi I, Turkay C, Mete A, Lüleci E. Aortoiliac Kissing Stents:Long-term Results and Analysis of Risk Factors Affecting Patency. J Endovasc Ther 2006; 13:291-301. [PMID: 16784315 DOI: 10.1583/05-1708.1] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To present the early and long-term results of aortoiliac kissing stents implantation and evaluate the risk factors affecting patency. METHODS The data were retrospectively reviewed on 68 patients (64 men; mean age 55+/-11, range 32-77) who underwent kissing stents implantation during a 12-year period. The majority of patients (64, 94%) had claudication; 4 patients had rest pain. All were smokers. There were bilateral or unilateral stenoses in 42 (62%) patients, and unilateral occlusion and contralateral stenosis in 26 (38%). Lesions were treated with simultaneous implantation of self-expanding (n=52) or balloon-expandable (n=16) stents. After the procedure, patency was determined with Doppler ultrasonography or angiography at 1, 3, 6, and 12 months and annually thereafter. Primary, assisted primary, and secondary patency rates were calculated with Kaplan-Meier analysis on an intention-to-treat basis, and risk factors affecting the patency rates were determined with the Cox regression analysis. RESULTS All procedures were technically and clinically successful. Complications occurred in 12%, but none required surgery. The follow-up period was 35+/-31 months. Primary, assisted primary, and secondary patency rates, respectively, were 76%, 90%, and 94% at 1 year; 63%, 86%, and 92% at 3 years; and 63%, 64%, and 81% at 5 years. In multivariate analysis, age <50 years and presence of iliac occlusion were identified as risk factors for reduced primary and assisted primary patency; a crossed configuration of kissing stents was identified as a risk factor for reduced primary patency. CONCLUSION Implantation of kissing stents is a safe and effective alternative in the treatment of aortoiliac obstructions. However, overall primary and assisted primary patency rates are inferior to those reported for surgery. Long-term patency comparable to surgery may be obtained in patients >50 years and in those without an iliac occlusion, particularly if a favorable stent configuration is achieved.
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Affiliation(s)
- Saim Yilmaz
- Department of Radiology, Akdeniz University School of Medicine, Arapsuyu, Antalya, Turkey.
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Nagata SI, Kazekawa K, Matsubara S, Sugata S. Percutaneous reconstruction of the innominate bifurcation using the retrograde ‘kissing stents’ technique. Neuroradiology 2006; 48:537-40. [PMID: 16642322 DOI: 10.1007/s00234-006-0090-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2005] [Accepted: 02/01/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Obstructions of the supraaortic vessels are an important cause of morbidity associated with a variety of symptoms. Percutaneous transluminal angioplasty has evolved as an effective and safe treatment modality for occlusive lesions of the supraaortic vessels. However, the endovascular management of an innominate bifurcation has not previously been reported. METHODS A 53-year-old female with a history of systematic hypertension, diabetes mellitus and hypercholesterolemia presented with left hemiparesis and dysarthria. Angiography of the innominate artery showed a stenosis of the innominate bifurcation. RESULTS The lesion was successfully treated using the retrograde kissing stent technique via a brachial approach and an exposed direct carotid approach. CONCLUSION The retrograde kissing stent technique for the treatment of a stenosis of the innominate bifurcation was found to be a safe and effective alternative to conventional surgery.
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Affiliation(s)
- Shun-ichi Nagata
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 377-1 Zokumyoin, Chikushino, Fukuoka, 818-8502, Japan
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Hughes M, Forauer AR, Lindh M, Cwikiel W. Conformation of Adjacent Self-expanding Stents: A Cross-Sectional In Vitro Study. Cardiovasc Intervent Radiol 2006; 29:255-9. [PMID: 16391952 DOI: 10.1007/s00270-005-0033-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We examined the proximal conformation of three commonly used self-expanding stents when the stents were deployed adjacent to one another in a tubular model, simulating a "kissing" stent technique. The stent pairs were evaluated by computed tomogrphy to determine the cross-sectional area excluded by the stents within the model. The mean areas associated with each stent pair were compared and significance evaluated by a t-test. A statistically significant difference was found when the area excluded by adjacent Wallstents was compared with both the Luminexx and SMART stents (p < 0.001 and p < 0.002, respectively). The difference in the area excluded and differences in conformation might play a role in the lower patencies that have been observed in "kissing" stent series.
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Affiliation(s)
- Marion Hughes
- Section of Vascular & Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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Greiner A, Mühlthaler H, Neuhauser B, Waldenberger P, Dessl A, Schocke MFH, Jaschke W, Fraedrich G. Does Stent Overlap Influence the Patency Rate of Aortoiliac Kissing Stents? J Endovasc Ther 2005; 12:696-703. [PMID: 16363899 DOI: 10.1583/06-1633.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine if the position of kissing stents in the distal aorta has any influence on the patency rate. METHODS A retrospective review was conducted of 41 patients (22 men; median age 60.8 years, range 44-86) electively treated for atherosclerotic aortoiliac occlusive disease with angioplasty and kissing stents between January 1997 and January 2005. Two patient groups were defined by reviewing postinterventional anteroposterior radiograms: (1) patients in whom the proximal end of the kissing stents overlapped more than half of their angiographic width within the aorta ("crossing" group) and (2) patients in whom the proximal ends of the stents overlapped half of their width or less ("non-crossing" group). RESULTS At 2 years, the primary and assisted primary patency rates by life-table analysis were 60.8% and 69.4%, respectively, for the 35 patients included in the life-table analysis. There was no significant difference between the 16-patient "crossing" group and the 19-patient "non-crossing" group in terms of the baseline demographic, morphological, and procedural variables. The primary and assisted primary patency rates at 2 years for the "non-crossing" group were significantly higher (94.1% and 100%, respectively) compared to 33.2% and 45.3%, respectively, for the "crossing" group (p=0.01). CONCLUSIONS Failure of kissing stents in the aortic bifurcation may be significantly increased by the overlap of the free proximal stent ends in the distal aorta.
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Affiliation(s)
- Andreas Greiner
- Department of Vascular Surgery, Medical University Innsbruck, Austria.
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Maynar M, Zander T, Qian Z, Rostagno R, Llorens R, Zerolo I, Kirsch D, Sorrells L, Castañeda WR. Bifurcated Endoprosthesis for Treatment of Aortoiliac Occlusive Lesions. J Endovasc Ther 2005; 12:22-7. [PMID: 15683268 DOI: 10.1583/04-1370r.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To report our initial experience with a bifurcated endoprosthesis in the management of aortoiliac occlusive disease. METHODS From May 2001 to February 2004, 112 patients were referred to our institution for the management of aortoiliac disease. Among these, 5 (6%) patients (3 men; mean age 57.8 years) with severe ischemia owing to TASC C or D iliac occlusions were selected for endovascular treatment with a bifurcated stent-graft. An Excluder stent-graft was placed after preliminary recanalization (thrombolysis and/or balloon dilation) the day before. The patients were followed clinically and ultrasonographically every 3 months during the first year and semiannually thereafter. RESULTS Technical success was achieved in all patients. Endovascular aortoiliac bifurcation reconstruction restored iliac artery flow immediately in all cases. There were no procedure-related complications. The mean ankle-brachial index (ABI) was significantly improved, from 0.66+/-0.04 before the procedure to 0.94+/-0.06 immediately after the procedure (p<0.01). The aortoiliac reconstructions remained patent during the mean 17-month follow-up (range 3-36), and the ABIs were stable. There was no mortality or amputation required in this series. CONCLUSIONS Endovascular placement of a bifurcated stent-graft appears to be technically feasible, effective, and safe in the management of aortoiliac occlusive disease.
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Affiliation(s)
- Manuel Maynar
- Hospiten Rambla, Las Palmas de Gran Canaria University, Santa Cruz de Tenerife, Spain
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Greiner A, Dessl A, Klein-Weigel P, Neuhauser B, Perkmann R, Waldenberger P, Jaschke W, Fraedrich G. Kissing stents for treatment of complex aortoiliac disease. Eur J Vasc Endovasc Surg 2003; 26:161-5. [PMID: 12917831 DOI: 10.1053/ejvs.2002.1882] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to determine medium term technical and clinical success of kissing stents for aortoiliac occlusive disease. DESIGN retrospective study. SUBJECTS twenty-five patients presenting with intermittent claudication (IC) or critical limb ischaemia (CLI) due to aortoiliac disease (41 complex stenoses, 8 occlusions). METHODS balloon- or self-expanding kissing stents, with or without predilatation depending upon the nature of the disease, were inserted via bilateral retrograde femoral artery punctures. Clinical examination, ABPI, exercise testing and duplex ultrasound were performed at 1, 3, 6, and 12 months, and then annually. RESULTS technical success was achieved in 86% segments. All patients with CLI improved and 6 of 7 ulcerated limbs showed complete healing. During follow-up, 7 patients died and two patients required major amputation at 7 and 8 months. The primary assisted patency rate was 94, 91 and 65% at 6, 12, and 24 months, respectively. CONCLUSIONS despite acceptable short-term technical and clinical success, as the medium term patency rates are clearly inferior to those of bypass surgery, the kissing stent technique should be reserved for high risk patients with a limited life expectancy.
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Affiliation(s)
- A Greiner
- Department of Vascular Surgery, University Hospital, Leopold Franzens University, Anichstrasse 35, A-6020 Innsbruck, Austria
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Leung DA, Spinosa DJ, Hagspiel KD, Angle JF, Matsumoto AH. Selection of stents for treating iliac arterial occlusive disease. J Vasc Interv Radiol 2003; 14:137-52. [PMID: 12582183 DOI: 10.1097/01.rvi.0000058316.82956.56] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Intravascular stents play an increasingly important role in the treatment of iliac artery occlusive disease and their use has expanded the indications for percutaneous endoluminal therapies. The past several years have seen a sharp increase in the number of commercially available covered and uncovered stents. Knowledge of their design and mechanical properties is crucial for selecting the appropriate stent for a particular type of lesion. In this article, the indications for and results of iliac artery stent placement are reviewed and the various characteristics of the currently available stents that may influence operator choice for use in specific lesions are discussed.
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Affiliation(s)
- Daniel A Leung
- Division of Angiography/Interventional Radiology and Special Procedures, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
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