Early experience with stenting for iliac occlusive disease

Endovascular Treatment of Iliac Occlusive Disease: Review and Update

Use of endovascular interventions for arterial occlusive lesions continues to increase. With the evolution of the technology supporting these therapeutic measures, the results of these interventions continue to improve. In general, a comparison of techniques for revascularization of iliac occlusive diseases shows similar initial technical success rates for open versus percutaneous transluminal angioplasty. Angioplasty is often associated with lower periprocedural morbidity and mortality rates. Conversely, surgery frequently provides greater long-term patency, although late failure of percutaneous therapies may occur but still can be treated successfully with reintervention. The perpetual buildup of experience with angioplasty and stenting will eventually characterize its role in the management of occlusive disease. This review outlines the current consensus and applicability of endovascular management of iliac occlusive diseases.

Iliac Artery Stent Placement: Clinical Experience and Short-term Follow-up Regarding a Self-expanding Nitinol Stent

PURPOSE

To evaluate the effectiveness, safety, and short-term patency rates of a self-expandable nitinol stent (JostentSelfX; Abbott Laboratories, Chicago, IL) for treatment of iliac artery stenoses.

MATERIALS AND METHODS

In a prospective study, 34 chronic iliac artery stenoses were primarily treated in 27 patients (mean age, 61.7 years +/- 9.4) by placement of a JostentSelfX. Handling and visibility of the stent was scored on a 4-point scale. Before stent placement, within 3 days after stent placement and at 6 months follow-up, the clinical history, clinical stage according to the Rutherford classification, and the ankle-brachial index (ABI) were assessed. Intra-arterial digital subtraction angiography including measurement of the mean pressure gradient was performed at the time of stent placement and at 6 months follow-up or in case of recurrence of symptoms. The Wilcoxon signed rank test and Kaplan-Meier method were applied for statistical analysis.

RESULTS

The immediate technical success rate was 94%. The clinical success rate immediately after the procedure was 96% and 85% at 6 months follow-up. Stent placement significantly decreased the severity of stenoses as well as the mean pressure gradients and significantly increased the ABI. Handling of the stent was judged good. No misplacement occurred. Foreshortening during deployment was negligible and no stent migration was seen. However, visibility of the stent during fluoroscopy was ranked as moderate to bad. Follow-up at 6 months revealed the cumulative angiographic primary patency rate (<50% restenosis and <10 mm Hg mean pressure gradient) to be 0.96.

CONCLUSION

The evaluated self-expandable nitinol stent is an effective tool in treating iliac artery stenoses. Apart from poor visibility, handling was good. The angiographic patency rate is comparable with data reported in other stent trials.

Late complication of aortoiliac stent placement- atheroembolization of the lower extremities

BACKGROUND

Atheroembolization following aortoiliac stent placement is uncommon. The purpose of this study was to examine the management and risk factors of lower extremity atheroembolization following aortoiliac stent placement for occlusive disease.

MATERIALS AND METHODS

From March 1993 to February 2001, the hospital records of all patients who developed thromboembolic events following aortoiliac stent placement were reviewed. Risk factor analysis was performed by comparing with the control group, which consisted of 493 patients treated with aortoiliac stents during the study period who did not develop atheroembolic complications. Patients with cardiac etiologies or aortic aneurysms as the source of embolization as well as those who developed acute embolization following stent deployment (<30 days) were excluded.

RESULTS

Atheroembolization occurred in eight patients (12 iliac artery stents and 1 aortic stent) at intervals ranging from 9 to 43 months (mean 22 months) following aortoiliac stent placement. Arteriography in all patients implicated the stented artery as the source of atheroembolism. Five corrective operations (two aorto-bifemoral bypasses, one ileofemoral bypass, and two aortoiliac endarterectomies) along with two concomitant femoropopliteal thrombectomies were performed successfully in five patients. The remaining three patients were treated with either thrombolysis and/or additional stent placement, which resulted in either iliac occlusion or recurrent embolic symptoms (P < 0.05). All 3 patients subsequently underwent bypass procedures (one ileofemoral and two femorofemoral bypasses). There was no perioperative mortality. During a mean follow-up of 16 months (range 3 to 45 months), two patients required minor amputations, whereas one required major leg amputation. No further episodes of atheroembolism occurred in the involved limbs following surgical bypass procedures. Risk factor analysis failed to identify potential variables that correlated with atheroembolism following aortoiliac stent placement.

CONCLUSION

Patients with atheromatous embolization following aortoiliac stent placement should be evaluated aggressively. The treatment of choice is surgical correction or bypass with exclusion of the offending embolic source. Although intra-arterial stent placement in the atheroembolic stented iliac artery is feasible, it may provide a less durable result.

Long-term results of stenting for chronic iliac artery occlusion

PURPOSE

To evaluate the long-term results of stent placement for chronic occlusions of the iliac arteries.

METHODS

Between October 1992 and December 1997, 73 patients (40 men; median age 64 years, range 42-89) with 76 occluded iliac arteries (33 common, 34 external, and 9 both vessels) were treated with percutaneous recanalization and stenting using a variety of self-expanding and balloon-expandable devices. Median occlusion length was 7 cm (range 1-14). Follow-up consisted of clinical assessment, ankle-brachial index measurement, and arteriography or duplex ultrasound when indicated.

RESULTS

Anatomical success was achieved in 74 (97%) limbs. Seven (10%) patients experienced major complications: 2 distal embolizations, 2 arterial ruptures, 1 myocardial infarction, 1 groin hematoma requiring surgery, and 1 contrast-induced nephropathy. There was no 30-day mortality. Over a median follow-up of 27 months (range 1-75), there was 1 early occlusion (< or = 30 days) and 16 late recurrent lesions (11 occlusions and 5 stenoses) at a median 6.2 months (range 1.4-30). The recurrent lesions were treated with endovascular techniques in 8 limbs and surgery in 7 limbs (5 after failed endovascular procedures); 1 patient died before retreatment, and 1 patient refrained from further intervention. Primary and secondary patencies were 79% and 87% at 1 year and 69% and 81% at 3 years, respectively.

CONCLUSIONS

Stenting of chronic iliac occlusions is a safe and durable alternative to surgical treatment.

Stenting for localised arterial stenoses in the aorto-iliac segment

OBJECTIVE

to determine complications and patency following angioplasty (PTA) and stenting of aorto-iliac stenoses.

SETTING

District General Hospital in U.K.

DESIGN

prospective observational study.

PATIENTS AND METHODS

between December 1994 and June 2000, 50 patients (38 men), median age 64 (41-89) years underwent aorto-iliac stenting. A total of 61 stents were placed. Indications were intermittent claudication in 38 and rest pain, ulceration or gangrene in 12. Sites stented were aorta 11, common iliac artery 32, external iliac artery 14, common and external iliac arteries two. Bilateral iliac procedures were carried out in nine. Two stents were used to correct residual stenoses after aortic stenting. Some 11 recurrent stenoses were treated. The other reasons for stenting were residual stenoses greater than 30% after PTA, tight calcified stenoses or when a stenosed iliac artery was being used as a donor prior to crossover or femoropopliteal bypass.

RESULTS

two immediate technical failures occurred due to malposition. Residual stenoses were corrected by PTA. Two further patients sustained minor complications. None of the aortic stents occluded through two required secondary procedures. Primary-assisted patency was thus 100% at three years. Primary patency following iliac stenting for claudication and critical ischaemia were 97% and 86% at three years respectively.

CONCLUSION

PTA and stenting of aorto-iliac stenoses can be safely achieved with durable results.

Integrated minimally invasive approaches for the treatment of atherosclerotic vascular diseases: Hybrid procedures

Patients may develop simultaneous symptoms of atherosclerotic vascular disease from different arterial beds. A concurrent minimally invasive approach to the management of these clinical situations may be an advantage over conventional surgical procedures. This study describes two separate case series of patients undergoing coronary/peripheral (n = 38) and peripheral/peripheral procedures (n = 10). Technical and clinical success was achieved in all patients. There were two periprocedural complications (retroperitoneal bleed and septicemia) in the coronary/peripheral series and no complications in the peripheral/peripheral series. We also present five case reports to illustrate the utility of hybrid procedures in various clinical settings. This study suggests that the use of simultaneous or sequential minimally invasive procedures appears to be a safe and feasible strategy for the treatment of patients with symptoms from more than one vascular bed. Cathet Cardiovasc Intervent 2001;52:154-161.

The Use of Vascular Stents in the Treatment of Iliac Artery Occlusion

To evaluate our experience of selective iliac artery stenting for total occlusions, a prospective observational study of 25 patients with an occluded iliac artery was designed to run from January 1996-May 1997. Exclusion criteria were an occlusion extended to the femoral artery, claudication Grade III or IV, according to the standards for reports dealing with lower extremity ischemia, and vascular (bypass) surgery in the past. Complete recanalization and selective stent placement was possible in all patients. No complications occurred. In one patient re-stenosis happened inside the stent after a year. Percutaneous reintervention was performed with success. The mean ankle-brachial pressure increased from 0.46 before the procedure to 0.95 after the procedure. After two years of follow-up, the mean ankle-brachial pressure is 0.93. The clinical stage improved by at least one grade to Grade 0 (Rutherford classification). The overall probability of patency for occluded iliac arteries in this study was 95% after two years. Recanalization, followed by percutaneous transluminal angioplasty (PTA) in the treatment of iliac artery occlusions, is our first choice of intervention, considering the absence of complication and satisfactory patency rates in patients with claudication Grade I or II.

Iliac occlusions: stenting or crossover grafting? An examination of patency and cost

OBJECTIVES

Percutaneous transluminal angioplasty with stenting is perceived to be a less invasive and cheaper option for the treatment of iliac artery occlusion than surgical reconstruction. We have carried out a prospective observational study of all patients undergoing an iliac stent or femorofemoral crossover graft for iliac artery occlusion to assess the cost effectiveness of the two approaches in a district general hospital.

METHODS

Fifty-one patients underwent primary angioplasty with stenting and 87 patients crossover grafting. Patients were all assessed 2 months after their procedure and then at intervals over the following years.

RESULTS

In 13 cases, it was impossible to place the stent successfully. In a further 10 patients, major complications occurred which were mainly thromboembolic. Fifteen patients underwent crossover grafting after failure to insert a stent, or after stent occlusion. No major complications occurred following crossover grafting. The median length of stay following successful stenting was 1 day; the following crossover grafting was 4 days. The mean stay was higher in each group (2.5 and 5.8 days) and is a more accurate parameter for estimation of cost, which for iliac stenting is estimated at pound1912 versus pound3072 for crossover grafting. The mean additional cost of those patients sustaining complications after stenting was pound2481. On an <<<<intention to treat>>>> basis, patency following stent insertion at 6 months was 52%; patency after bypass was 100% (p <0.0001). If any complication occurs after stenting, the cost advantage of the procedure is lost. In those patients without complication, the initial cost benefit of iliac stenting is lost within 6 months, as patients require further intervention, usually as a crossover graft, when the stent occludes. Crossover grafting is a durable low-risk procedure.

CONCLUSIONS

We suggest that stenting of occluded iliac arteries should be reserved for those patients with limited life expectancy. Patients who are younger and fitter should be offered femorofemoral crossover grafting as a primary procedure until research enables identification of those patients who are most likely to maintain long-term patency after stenting.

Blunt injury to the common iliac artery

OBJECTIVES AND DESIGN

iliac artery lesion after blunt trauma is uncommon, with only 12 previously reported cases. We report nine patients treated in two French teaching hospitals over a six-year period. Mechanism, symptomatology, treatment and outcome were analysed.

MATERIAL AND METHOD

All patients were male with a mean (range) age of 29 (16-43) years. Median delay to operative repair was 15 days. Through an extraperitoneal approach PTFE grafts were used in five cases and autogenous graft in four.

RESULTS

Morbidity was 22%. Reoperation was necessary in two cases at a mean follow-up of 48 months, at which time all patients were asymptomatic with normal pulses.

CONCLUSION

Clinicians should be alert to the possibility of this injury. An arteriography for Doppler ultrasound should be performed. Treatment is mainly surgical and produces excellent long-term results.