Percutaneous endovascular treatment for stenoses and occlusions of infrarenal aorta and aortoiliac bifurcation: midterm results

Balloon-expandable stent graft for coral reef aorta

Coral reef aorta (CRA) is a rare aortic occlusive disease with calcified intraluminal lesions. We report the case of a patient with CRA who underwent endovascular treatment (EVT). A 78-year-old woman presented with intermittent claudication. A computed tomography scan showed a preocclusive calcified lesion in the infrarenal aorta. EVT with a balloon-expandable stent graft was successfully performed, and her intermittent claudication improved. Compared with the conventional surgical treatments for CRA, EVT with a balloon-expandable stent graft is less invasive. This procedure is an effective option for the treatment of CRA.

Aortic Stenting in Symptomatic Infrarenal Aortic Stenosis and Subtotal Aortic Occlusion

Objective:

The aim of this study was to evaluate the long-term results of aortic stent placement in patients with infrarenal aortic occlusive disease.

Methods:

Between April 1996 and May 2014, 34 patients with symptomatic infrarenal atherosclerotic aortic stenosis or subtotal aortic occlusion underwent percutaneous angioplasty with primary aortic stent implantation. There were 21 patients with Fontaine stage of the peripheral arterial disease (PAD) II, 5 patients with stage III, and 8 patients with stage IV. One patient withdrew informed consent and was excluded from further analysis.

Results:

Patients (n = 34, mean age: 62 ± 12 years) were followed for a mean period of 81 months. There were 2 procedure-related access-related complications. Six patients died during follow-up from non-procedure-related causes. Eight patients had late recurrence of symptoms during follow-up. Only in 2 cases, symptomatic recurrences were due to aortic in-stent stenosis (77 and 132 months after the primary stent implantation). Additionally, these 2 patients required therapy for PAD progression distal to the aorta. Five patients required further surgical or endovascular reconstruction for PAD progression distal to the aorta. In another case, clinical treatment failure was due to the progression of atherosclerotic lesion in the perirenal, nonstented part of the abdominal aorta. The mean estimated primary patency rate was 185.6 months (95% confidence interval: 161.3-209.8).

Conclusion:

Endovascular stent implantation is a safe and long-term effective strategy for the treatment of infrarenal aortic occlusive disease. In our study, the recurrence of symptoms was observed mainly due to atherosclerosis progression by multilevel disease with associated infrainguinal occlusive lesions but not to aortic in-stent restenosis. The prognostic advantage for this relatively young cohort of patients can be the possibility to repeat a percutaneous procedure with less technical difficulties when compared to surgical revision.

Predictors of Failure of Endovascular Therapy for Peripheral Arterial Disease

The objective of this study was to assess the usefulness of a comparison of clinical failure and restenosis rates of endovascular procedures at 1 year in patients with peripheral arterial disease. The resulting comparison is presented as “clinical failure/restenosis coordinate.” The authors screened 171 papers describing the outcome of lower extremity angioplasty or stent placement. In 20 of them, authors reported detailed outcomes of interest, including baseline demographic measurements, location of arterial occlusive lesions, a measure of restenosis (measured by ankle-brachial indices, ultrasonography, or angiography), and clinical outcomes (mortality, repeat percutaneous transluminal angioplasty, or amputation). An overview of these 20 angioplasty papers was performed. Besides the usual meta-analyses of each end point separately, data were also plotted as coordinates of clinical failure versus restenosis. The clinical failure-to-restenosis coordinate was calculated and reported for percutaneous transluminal angioplasty of the aortoiliac and femoropopliteal distributions. Clinically reported outcomes in the literature were used to calculate the clinical failure/restenosis coordinate. This value was significantly different for various locations of the angioplasty and various baseline angiographic characteristics. A numeric coordinate pair of clinical failure and restenosis is identifiable in patients undergoing endovascular treatment of peripheral arterial disease. The varying coordinates may be important in elucidating the incidence and mechanisms of clinical failure after endovascular treatment. The coordinate reported in this article is hypothesis-generating about mechanisms of endovascular treatment failure. This coordinate is important in determining the role of restenosis in the clinical failure of endovascular therapy of peripheral arterial disease.

T-stenting with small protrusion technique (TAP-stenting) for stenosed aortoiliac bifurcations with small abdominal aortas: an alternative to the classic kissing stents technique

PURPOSE

To report the feasibility and midterm results of aortic bifurcation reconstruction in patients with small abdominal aortas using commercially available stents applied in a modified T-stenting technique adapted from coronary angioplasty.

METHODS

Twenty-three patients (16 men; mean age 52.4 years) with lower limb ischemia (Fontaine stage IIb or III) and distal abdominal aortas <14 mm in diameter were treated for 39 common iliac artery and 16 aortic stenotic lesions involving the aortic bifurcation. A large, self-expanding stent was implanted from the lower aorta to one iliac branch, followed by deployment of a balloon-expandable stent in the contralateral iliac artery such that its proximal edge protruded a few millimeters through the struts of the self-expanding stent into the aorta [TAP (T And Protrude)-stenting technique]. Follow-up clinical, Doppler ultrasound, and computed tomography examinations were scheduled for each patient.

RESULTS

Angiographic success was obtained in all 23 patients, who received 23 self-expanding aortomonoiliac stents (mean diameter 13.5 mm) and 22 balloon-expandable stents (mean diameter 8.14 mm) in the contralateral iliac branch. No complications were reported. At a mean 16.3-month follow-up (range 2-60), clinical and ankle-brachial index (0.6±0.2 at baseline versus 1.04±0.1, p<0.01) improvement was observed in all patients. All stents were patent (patency rate 100%). Two late technical failures of the contralateral stent were observed (incomplete dilation requiring angioplasty and incomplete protrusion without any hemodynamic impact).

CONCLUSION

The TAP-stenting technique adapted to the aortoiliac bifurcation appears to be feasible, with satisfactory early and midterm patency rates in patients with small abdominal aortas. Larger series with longer follow-up times are necessary.

"Staged" kissing stent placement under computed tomographic angiography guidance for a bilateral aortoiliac occlusion

A 64-year-old female with chronic hemodialysis complained of a worsening of bilateral intermittent claudication. Computed tomographic angiography (CTA) demonstrated severe calcified bilateral aortoiliac occlusions. The kissing stent placement was therefore attempted: A 10 × 60 mm SMART stent was placed into the right aortoiliac lesion at the 1st session, and a 10 × 60 mm SMART stent was placed into the left aortoiliac lesion parallel with the previous SMART stent at the 2nd session, thus completing the "staged" kissing stent placement. CTA indicated the penetrating point in the calcified plaque clearly, and this case suggested the usefulness of CTA guided percutaneous peripheral intervention.

Endovascular treatment of peripheral vascular disease

Peripheral arterial disease (PAD) affects about 27 million people in North America and Europe, accounting for up to 413,000 hospitalizations per year with 88,000 hospitalizations involving the lower extremities and 28,000 involving embolectomy or thrombectomy of lower limb arteries. Many patients are asymptomatic and, among symptomatic patients, atypical symptoms are more common than classic claudication. Peripheral arterial disease also correlates strongly with risk of major cardiovascular events, and patients with PAD have a high prevalence of coexistent coronary and cerebrovascular disease. Because the prevalence of PAD increases progressively with age, PAD is a growing clinical problem due to the increasingly aged population in the United States and other developed countries. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, endovascular practice, percutaneous transluminal angioplasty with or without stenting, is used far more frequently for all types of lower extremity occlusive lesions, reflecting the continuing advances in imaging techniques, angioplasty equipment, and endovascular expertise. The role of endovascular intervention in the treatment of limb-threatening ischemia is also expanding, and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes percutaneous transluminal angioplasty/stenting an attractive alternative to surgery and, as most endovascular interventions are performed on an outpatient basis, hospital costs are cut considerably. In this monograph we discuss current endovascular intervention for treatment of occlusive PAD, aneurysmal arterial disease, and venous occlusive disease.

Kissing stents in the aortic bifurcation--a valid reconstruction for aorto-iliac occlusive disease

OBJECTIVE

To evaluate outcome and patency predicting factors of kissingstent treatment for aorto iliac occlusive disease (AIOD).

METHODS

Patients treated with kissingstents for AOID between 1995 and 2004 at a tertiary referral center were identified through local databases. Chart review and preoperative images were used for TASC and Fontaine classification. Follow-up consisted of clinical exams, ABI and/or duplex. Patency rates were estimated by Kaplan-Meier analysis, and Cox multivariate regression was used to determine factors associated with patency.

RESULTS

173 consecutive patients (46% male, mean 64 years) were identified. TASC distribution was: A 15%, B 34%, C 10%, D 41%. Mean follow-up was 36 months (range: 1-144). 30-day mortality was 1% (2 patients), and 1-year survival was 91% (157 patients). 2 patients underwent late, open conversion and 13 patients suffered minor puncture site complications. Primary, assisted primary and secondary patency was: 97%, 99% and 100%, and 83%, 90% and 95% at twelve and 36 months respectively. There was no significant difference in patency between the TASC groups. Patency was significantly worse for patients in Fontaine class III.

CONCLUSIONS

Aortoiliac kissing stents is a valid alternative to open repair for TASC A-D lesions. The procedure has low mortality and morbidity and good patency at 3 years.

Standards for the Endovascular Management of Aortic Occlusive Disease

Occlusive disease of the infrarenal aorta and aorto-iliac arteries can be safely treated by minimally invasive therapy and is now widely available. The aim of this article is to produce standards for the management of these patients using current endovascular techniques.

Long-term results after placement of aortic bifurcation self-expanding stents: 10 year mortality, stent restenosis, and distal disease progression

PURPOSE

To retrospectively evaluate the 10 year follow-up results in patients who had "kissing" self-expanding stent aortic bifurcation reconstruction.

METHODS

Forty-three patients were treated with "kissing" self-expanding stents for aortoiliac occlusive disease. Early follow-up with clinical and ankle brachial pressure indices (ABPI) was performed at 3, 6, 12, and 24 months and with intra-arterial digital subtraction angiography at 12-24 months; clinical and angiographic follow-up was performed for symptom recurrence up to 10 years after treatment. Retrospective record review was performed to assess mortality, clinical patency, angiographic patency, and secondary assisted patency of both stents and downstream peripheral vessels at 5 and 10 years follow-up.

RESULTS

The 2 year primary angiographic and secondary assisted stent patencies were 89% and 93%, respectively. At 10 years follow-up in 40 patients the mortality was 38% (due to myocardial infarction, stroke, chronic renal failure, malignancy, and liver failure). At 5 and 10 years follow-up the primary clinical stent patency was 82% and 68%, and the secondary assisted stent patency 93% and 86%, respectively. At 5 and 10 years, the distal vessel patency was 86% and 72%, and the secondary assisted distal vessel patency treated by surgical or endovascular techniques was 94% and 88%, respectively. At 10 years there was no limb loss.

CONCLUSION

The long-term (10 year) results of aortic bifurcation arterial self-expanding stent placement in patients with arterial occlusive disease show a 10 year primary stent patency rate of 68% but a secondary assisted patency rate of 86%. In addition there is a high overall mortality due to other cardiovascular causes and the rate of distal disease progression and loss of patency is similar to the loss of stent patency rate.

Endovascular Therapies for Noncoronary Atherosclerosis in the Elderly: Aortoiliac and Femorotibial Lesions

Many interventional cardiologists are becoming interested in the interventional treatment of noncoronary atherosclerotic disease. The elderly may be especially benefited by the application of many new techniques for the treatment of lower limb atherosclerosis, such as protection and thromboaspiration devices, new atherectomy devices, and cryoplasty. In this review the authors offer geriatric cardiologists an overview and an update of the most recent advances in techniques and results in the field of interventional treatment of aortoiliac and femorotibial artery atherosclerosis in the elderly.

Primary Endovascular Stent Placement for Focal Infrarenal Aortic Stenosis: Long-term Results

PURPOSE

The objectives of this retrospective study were to determine the technical success, safety, and long-term results of primary stent implantation in infrarenal aortic stenosis.

MATERIALS AND METHODS

A total of eight atherosclerotic stenoses and one occlusion of the infrarenal aorta (ie, midaortic syndrome) were treated with endoluminal stent placement after balloon angioplasty. Aortoiliac lesions were excluded. Technical success and patency were assessed.

RESULTS

Primary technical success in percutaneous transluminal angioplasty and subsequent stent placement was achieved in all patients. No complications occurred, and no morbidity was encountered. Primary clinical patency rates were 100% on all follow-up examinations. Long-term results with a mean follow-up of 110 months (range, 99-117 months) were recorded in seven patients; one patient had died and one was lost to follow-up.

CONCLUSIONS

In view of the excellent initial results and promising long-term follow-up data in a small series, stent placement after predilation in properly selected patients with isolated infrarenal aortic stenosis appears to be a promising, durable treatment. It should be considered as a primary method of treatment.

Long-term Results After Primary Stenting of Distal Aortic Stenosis

PURPOSE

To review the long-term results of primary stent placement in the distal aorta above the bifurcation.

METHODS

Fourteen patients (8 men; mean age 62 years, range 46-82) underwent primary stent implantation performed by an interdisciplinary radiosurgical team. In 10 patients, a long-term follow-up examination consisting of patient history, clinical examination, and duplex sonography was performed. The ankle-brachial index (ABI) for the posterior tibial artery was calculated on the basis of Doppler pressure measurements.

RESULTS

The clinical success rate at the first follow-up examination (mean 2.9 months, range 2.1-4.4) was 100% (n = 14). The mean baseline ABI of 0.64 +/- 0.12 had risen to 1.02 +/- 0.10 (p < 0.0001). At midterm follow-up (mean 22.8 months, range 14-42) in 12 patients, the ABI was 0.96 +/- 0.12 (p < 0.0001 versus baseline). At a mean 86 months (range 51-119) after stent treatment, the ABI in 10 patients was 0.90 +/- 0.20 (p < 0.0001 versus baseline). Over the long term, the clinical success rate was 70%. Deterioration was due to the progression of atherosclerosis distal to the aorta; duplex sonography showed no aortic restenosis or occlusion.

CONCLUSION

In view of the excellent long-term results in our small series, primary stent placement in focal abdominal aortic stenosis in properly selected patients is a durable treatment. In addition, the mortality and morbidity risks are markedly reduced compared with open surgery.

Endovascular Management of Isolated Infrarenal Aortic Occlusive Disease is Safe and Effective in Selected Patients

OBJECTIVE

To examine the safety and efficacy of endovascular management of isolated infrarenal aortic occlusive disease within our centre.

DESIGN AND METHODS

Retrospective analysis of all patients who underwent endovascular treatment of occlusive disease that is confined to the infrarenal aorta between September 1993 and November 2004.

RESULTS

Primary aortic stenting was carried out in 16 women and five men using self-expanding (12 patients) and balloon expanding stents to treat both occlusions (six) and stenoses (15). Indications included intermittent claudication (13), critical limb ischaemia (six), and distal embolisation (three). Significant postoperative complications within 30 days were noted in three, including one death. Fifteen patients completed 1-year follow-up with primary patency in 14 and secondary patency in the remaining patient. Clinical improvement was documented in all patients.

CONCLUSION

Primary stenting for occlusive disease isolated in the infrarenal aorta is relatively safe in selected patients with encouraging early follow-up results.

Evaluation and medical treatment of peripheral arterial disease

PURPOSE OF REVIEW

This review reports various advances in the evaluation and medical management of patients with peripheral arterial disease (PAD) in the last 1 to 2 years.

RECENT FINDINGS

Several community surveys have clearly highlighted the fact that despite being a very highly prevalent disease, physicians underdiagnose and undertreat PAD. This led to the Executive Committee of the Prevention of Atherothrombotic Disease Network to issue a "call to action," citing critical issues in PAD detection and management.

SUMMARY

PAD affects more than 27 million people in North America and Europe, and the prevalence of this disease continues to increase as the population ages. This disease has significant adverse effects on the quality of life and survival, with mortality as high as 30% in 5 years and 50% in 10 years. Although surgical, endovascular, and medical therapies for atherosclerosis in general, and PAD specifically, continue to be developed, there appears to be considerable room for improvement in physician adoption of proven effective therapies, such as cholesterol-lowering therapies and blood pressure management. Additionally, new therapies, such as gene transfer and cell therapy, are under development for this population.