Percutaneous placement of stents in chronic iliac and aortic 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.

Great saphenous vein sparing surgery by angioscopic valvuloplasty combined with axial transposition of a competent tributary vein--5-year follow-up

OBJECTIVE

To evaluate the efficacy and haemodynamic effects of great saphenous vein (GSV) sparing surgery--valvuloplasty combined with axial transposition of a competent tributary vein (A-VACT).

MATERIALS AND METHODS

Eighty-five limbs in 74 patients with isolated GSV incompetence were selected for GSV sparing surgery. After angiographic valvuloplasty, the competent tributary vein was exposed and cut 1.5 cm distal to its insertion point on the GSV. The transected vein was anastomosed end-to-side to the GSV, which was ligated between the tributary insertion site and the anastomosis. Venous valve competence were screened by serial postoperative duplex examination, and venous haemodynamic changes were analyzed using venous filling index (VFI) measured by air plethysmograph pre- and postoperatively. The follow-up period was 5-years.

RESULTS

Sixty-seven patients were included in whom 76 limbs were treated. There was a statistically significant reduction in the vein diameter at the SFJ after 5-years (0.83 S.D. 0.29 cm to 0.46 S.D. 0.12 cm, p=0.0002, Wilcoxon). Similarly, significant reduction was found in the GSV at the 5-year follow-up point (0.63 S.D. 0.19 cm to 0.39 S.D. 0.11 cm, p<0.0001, Wilcoxon). On the other hand, there was significant increase in the diameter of the competent tributary vein postoperatively (0.22 S.D. 0.13 cm to 0.31 S.D. 0.12 cm, p<0.0001, Wilcoxon). Duplex scanning demonstrated reflux at the SFJ in 12 limbs (16%). Similarly, in the GSV, venous reflux was found in 13 limbs (17%). Reflux in the transposed tributary vein was found in 20 limbs (26%). But only 7 limbs (9%) had minor varicose veins' recurrence. VFI remained normal during the follow-up examination. The preoperative VFI confirmed the presence of venous reflux, but there were significant improvement in the VFI values at all postoperative examinations.

CONCLUSIONS

A-VACT procedure improves venous function, resolves varicose veins at 5-years follow-up as well as preserving the GSV for future grafting.

Traitement endovasculaire par « kissing stent » des lésions oblitérantes du carrefour aorto-iliaque

PURPOSE

To evaluate short and medium-term results of endovascular repair of the aortoiliac bifurcation for occlusive disease by the kissing stent technique.

METHOD

Twenty patients were included in this retrospective study between May 1999 and November 2002 (13 men, mean age 58 years, range 42-86). Fifteen were treated for bilateral common iliac artery stenosis (75%), four for unilateral common iliac artery occlusion with or without controlateral stenosis (20%), and one for bilateral common iliac artery occlusion (5%). Each patient had a clinical examination and dupplex-scan prior to discharge, at three months, twelve months then yearly.

RESULTS

All procedures were successful. Forty balloon expandable stents were deployed in the kissing position (mean length and diameter, 45 mm and 9 mm). Nine other stents were also deployed either in the abdominal aorta (one patient) either in the lower portion of the common iliac artery. Intra-operative complications were represented by one hematoma of the groin region treated surgically, one emboli of the femoral bifurcation treated by Forgarty balloon embolectomy, three dissections of the common iliac arteries treated by stenting, and one internal iliac artery occlusion not treated. Mean follow-up was 21 months (range 3-36). Three significant restenoses (>50%) were diagnosed during this period and one patient had an additional transluminal procedure. No intra-stent occlusion was found. Primary and secondary cumulative patencies at 12 and 36 months were respectively 94.7%, 84,4% and 100%, 89%.

CONCLUSION

We confirm the feasibility, and the reliability of endovascular aorto-iliac kissing stent reconstruction in occlusive disease for selected patients.

Traitement endovasculaire percutané des lésions oblitérantes du carrefour aorto-iliaque : résultats chez 28 patients

OBJECTIVE

We conducted a retrospective analysis of short- and mid-term results of endoluminal treatment of obstruction lesions involving the terminal aorta and the initial portions of the iliac arteries in 28 patients.

PATIENTS AND METHODS

Twenty-eight patients (9 women, 19 men, mean age 57.5 Years) presented 52 obstructive atheromatous lesions of the aorto-iliac bifurcation. The lesions were divided into three topographic groups (9 unilateral lesions, 19 bilateral ostial lesions, 5 widespread lesions of the terminal aorta) and identified as simple (44%) or complex (56%, more than 2 cm in length and/or calcified and/or eccentric).

RESULTS

Technical success was achieved in 93% of the cases with only one hematoma of the puncture site. Primary and secondary patencies were 78.9% and 93% after a mean follow-up of 50 Months (range 4-85). Clinical outcome remained good at this term for all cases of technical success but complete resolution of the symptoms was more frequent when a stent was used (84%) than for simple balloon dilatation (49%).

CONCLUSION

Percutaneous treatment of obstructive lesions of the aorto-iliac bifurcation may be proposed when possible as a first-line treatment.

Percutaneous reconstruction of the aortoiliac bifurcation with the "kissing stents" technique: long-term follow-up in 106 patients

PURPOSE

To evaluate the long-term results using the kissing stents technique for treatment of occlusive disease involving the aortoiliac bifurcation.

METHODS

One hundred six patients (97 men; mean age 52.5 +/- 10.2 years, range 33-78) were treated with the kissing stents technique for bilateral aortoiliac stenosis (55, 51.9%), unilateral occlusion of the common iliac artery (CIA) with contralateral stenosis (47, 44.3%), and bilateral CIA occlusion (4, 3.8%). Clinical examination and duplex scans were performed prior to discharge and at 1, 6, and 12 months, followed by yearly examinations thereafter.

RESULTS

Bilateral stent implantation was successful in all patients. No major procedure-related complications were observed. Self-expanding stents were deployed in 62 (58.5%) patients and balloon-expandable devices in 44 (41.5%). Fifteen (7.1%) hematomas were observed at the 212 access sites. Mean follow-up was 30.1 +/- 11.1 months (range 12-137). Duplex imaging diagnosed significant (>50%) restenosis in 15 (14.8%) of 101 patients and reocclusion in 4 (4%); 17 (89.5%) of these patients had recurrent symptoms and all were retreated (endovascular procedure in 18 and an aortobifemoral bypass in 1). Primary and secondary cumulative patency rates at 36 months were 79.4% and 97.7%, respectively. Balloon-expandable stents had a nonsignificantly higher patency rate compared to self-expanding stents.

CONCLUSIONS

Based on our experience, aortoiliac endovascular reconstruction with the kissing stents technique is a safe and effective procedure, representing an alternative to conventional surgery in selected patients.

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.