Endovascular management of aortoiliac occlusive disease

Outcomes of balloon angioplasty and stent placement for iliac artery lesions classified as TASC II A, B: a single-center study

Background

Iliac artery stenosis or occlusion is a critical condition that can severely impact a patient's quality of life. The effectiveness of balloon angioplasty and intraluminal stenting for the treatment of iliac artery lesions classified as TASC II A and B was evaluated in this single-center prospective study.

Methods

Conducted between October 2016 and September 2020 at Cho Ray Hospital's Vascular Surgery Department, this prospective study involved PAD patients categorized by TASC II A and B classifications who underwent endovascular intervention. Intervention outcomes were assessed peri-procedure and during short-term and mid-term follow-ups.

Results

Of the total of 133 patients, 34.6% underwent balloon angioplasty, while 65.4% received stenting. The immediate technical success rate was 97.7%, while the clinical success rate was 62.4%. Complications were minimal, with major limb amputation reported in 1.5% of the cases. There was a significant improvement in Rutherford classification and ABI at short-term follow-up, with a patency rate of 90.2%. The mid-term post-intervention follow-up yielded similar results with an 86.1% patency rate. The mortality rates associated with arterial occlusion were 2.3% during short-term follow-up and 1.7% during mid-term follow-up.

Conclusion

Balloon angioplasty and stent placement are effective and safe interventions for TASC II A and B iliac artery occlusions with favorable short and mid-term outcomes. Further, multi-center studies with larger sample sizes are recommended for more comprehensive conclusions, including long-term follow-up assessment.

Endovascular Aorto-Iliac Reconstruction vs. Aortobifemoral Bypass as First Choice for a Durable Revascularization for Aorto-Iliac Occlusive Disease

INTRODUCTION

Aortoiliac occlusive disease (AIOD) is defined as atherosclerotic obstruction of the distal abdominal aorta and iliac arteries. Multiple options exist for management of AIOD including endovascular aortoiliac reconstruction and aortobifemoral bypass. As new technologies are developed, the best approach to manage this condition is evolving.

METHODS

We performed a literature review to assess the current state of endovascular aortoiliac reconstruction and aortobifemoral bypass as options for revascularization of aortoiliac occlusive disease.

CONCLUSION

Endovascular aortoiliac reconstruction and aortobifemoral bypass are both feasible and clinically effective options for management of aortoiliac occlusive disease. No randomized controlled trial has been performed to show one option to be more effective than the other. Recent literature demonstrates comparable long-term patency, limb salvage and survival among endovascular approaches to the treatment of AIOD with quicker recovery, lower costs and improved quality of life when compared to open aortobifemoral bypass (ABF) surgery. Selection of procedure should be tailored to the individual patient in order to develop an effective long-term successful strategy for management of aortoiliac occlusive disease. Further study is warranted to define durability of these endovascular approaches as well as patient specific characteristics that influence outcomes.

New paradigms in minimally-invasive vascular surgery

INTRODUCTION

Vascular surgery has been greatly evolved during the last decades and novel minimally invasive techniques have been introduced. Aim of this review is to briefly present all these advances and compare them with traditional repairs.

AREAS COVERED

The authors have extensively searched literature through the Pubmed and Embase databases. All articles published up to December 2021 referring to minimally invasive techniques used for treatment of peripheral artery disease, carotid disease, aortic aneurysms and venous disease were evaluated. Minimally invasive techniques under investigation included endovascular and hybrid techniques, robot-assisted and laparoscopic approaches.

EXPERT OPINION

Several minimally invasive techniques such as endovascular and hybrid approaches have been extensively used during the last two decades to treat vascular surgery patients offering them lower mortality and morbidity risks. Novel robot assisted techniques have shown promising results in preclinical studies although further clinical evaluation is needed.

Comparison of epidural analgesia with ultrasound-guided bilateral erector spinae plane block in aorto-femoral arterial bypass surgery

Objective:

Thoracic Epidural Analgesia (TEA) was compared with ultrasound-guided bilateral erector spinae plane (ESP) block in aorto-femoral arterial bypass surgery for analgesic efficacy, hemodynamic effects, and pulmonary rehabilitation.

Design:

Prospective randomized.

Setting:

Tertiary care centre.

Participants:

Adult patients, who were scheduled for elective aorto-femoral arterial bypass surgery.

Interventions:

It was a prospective pilot study enrolling 20 adult patients who were randomized to group A (ESP block = 10) and group B (TEA = 10). Monitoring of heart rate (HR) and mean arterial pressure (MAP) and pain assessment at rest and deep breathing using visual analog scale (VAS) were done till 48-h post-extubation. Rescue analgesic requirement, Incentive spirometry, oxygenation, duration of ventilation and stay in Intensive Care Unit (ICU) were reported as outcome measures. Statistical analysis was performed using unpaired Student T-test or Mann-Whitney U test. A value of P < 0.05 was considered significant.

Results:

HR was lower in group B than group A at 1 and 2 h post- surgery and at 0.5, 16, 20, and 32 h post-extubation (P < 0.05). MAP were lower in group B than A at 60, 90, 120, 150, 180, 210, 240, 270 minutes and at 0 hour post-surgery and at 4 hours, every 4 hours till 32 hours post-extubation (P < 0.05). Intraoperative midazolam and fentanyl consumption, ventilatory hours, VAS at rest, incentive spirometry, oxygenation, and ICU stay were comparable between the two groups. VAS during deep breathing was more in group A than B at 0.5, 4 hours and every 4 hours till 44 hours post-extubation. The time to receive the first rescue analgesia was shorter in group A than B (P < 0.05).

Conclusion:

Both ESP block and TEA provided comparable analgesia at rest. Further studies with larger sample size are required to evaluate whether ESP block could be an alternative to TEA in aorto-femoral arterial bypass surgery.

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.

[Predictive factors of amputation after iliac angioplasty in patients with severe artery disease]

INTRODUCTION

Despite the success of angioplasty of the iliac artery, this technique remains associated with significant amputation rates. The purpose of this study was to identify predictive factors for lower limb amputation after iliac angioplasty in patients with critical ischemia.

METHODS

We reported a retrospective study including patients who successfully underwent angioplasty of the iliac artery between 2014 and 2018. The primary endpoint was limb salvage at 1 month. The variables were studied in univariate and multivariate analysis.

RESULTS

Our study included 86 patients. The median age was 57±10 and the sex ratio was 4.7. Cardiovascular risk factors were represented by smoking in 14 cases (16.3%), diabetes in 25 cases (29.1%), arterial hypertension in 2 cases (2.3%) and dyslipidemia in 2 cases (2.3%). Seventy patients (81.3%) were classified as stage 4 according to the Leriche and Fontaine classification and 16 patients (18.7%) were classified as stage 3. The lesions were stenosing in 48 cases (55.8%) and occlusive in 38 cases (44.2%). These lesions were classified according to the TASC classification "Trans-Atlantic-Society-Consensus" in TASC A-B in 61 cases (70.9%) and TASC C-D in 35 cases (29.1%). Distal arteritis was found in 8 cases (9.3%). Balloon angioplasty was performed in 36 cases (41.8%) and angioplasty stenting in 50 cases (58.2%). At 1 month, the amputation rate was 9.3%. Univariate analysis showed that diabetes and smoking were the most important factors associated with amputation (respectively P=0.007, OR=9.31, 95% CI=[1.73-50.07] and P=0.022; OR=6.8; 95% CI=[1.46 to 31.61]). Multivariate analysis showed that diabetes and distal arteritis were the predictive factors for amputation (respectively P=0.034, OR=21.06, 95% CI=[1.25 to 354.46] and P=0.008, OR=11,61, 95% CI=[1.88 to 71.69]).

CONCLUSION

Diabetes and distal arteritis are the predictive factors for lower limb amputation after iliac angioplasty.

Monitored Anesthesia Care Is Associated With a Decrease in Morbidity After Endovascular Angioplasty in Aortoiliac Disease

OBJECTIVES

Few studies have evaluated the association between anesthesia type and outcomes after endovascular angioplasty/stents for aortoiliac occlusive disease. The aim of the present study was to evaluate the association between primary anesthesia type and postprocedural complications for endovascular angioplasty of aortoiliac occlusion.

DESIGN

Retrospective cohort study.

SETTING

Multi-institutional.

PARTICIPANTS

The study comprised 3,110 patients undergoing endovascular angioplasty of aortoiliac occlusive disease, with 1,974 and 1,136 patients who underwent monitored anesthesia care (MAC) and general anesthesia (GA), respectively. The American College of Surgeons National Surgical Quality Improvement Program database for the years 2012 to 2016 was used for the present study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The final analysis included 3,110 patients, 63% of whom received MAC and 37% of whom received GA. The mean age was 64 years among the GA group, of whom 57.2% were male. The mean age among that MAC group was 65 years, 55.8% of whom were male. After adjusting for demographic factors and preoperative comorbidities, there was a statistically significant lower odds of postoperative complications (ie, pulmonary complications, infection, intraoperative/postoperative transfusion, reoperation, and amputation) and shorter length of stay in the MAC group compared with the GA group (p < 0.05).

CONCLUSIONS

Although larger observational studies and randomized controlled trials are needed to further evaluate the potential effect of MAC versus GA, MAC anesthesia should be considered for patients undergoing endovascular angioplasty for aortoiliac occlusion.

A Comparison of Aortoiliac Disease between Eastern and Western Countries

A variety of diseases are known to develop in the aortoiliac segment; these include abdominal aortic aneurysm (AAA) and aortoiliac occlusive disease. This review summarizes several differences of aortoiliac diseases between eastern and western populations. The prevalence of AAA was higher in western countries (4.57% to 19%) than in eastern countries (0.89% to 4.9%). Greater aortic bifurcation angles were observed in the eastern population, while longer common iliac arteries and aneurysm necks were found in the western population with AAA. However, the angle of the aneurysm was found to be more acute in patients from western countries. Several differences were found between patients from western countries and those from eastern countries regarding the diseases that occur in the aortoiliac segment and their anatomical characteristics. Therefore, different approaches to the treatment of aortoiliac diseases in these two groups should be considered.

External Iliac Occlusion Does Not Preclude Endovascular Management of Aortoiliac Disease-Technique and Evolution of Therapy

BACKGROUND

Controversy remains over how to best manage chronic total occlusions of the aortoiliac (AI) system. Uncovered stents are the traditional choice but offer less durability in theory with the risk of stent ingrowth. External iliac artery (EIA) occlusions are challenging due to access difficulty.

METHODS

We performed a retrospective study of patients who had undergone endovascular AI intervention between December, 2014 and March, 2017 for Trans-Atlantic Inter-Society Consensus D lesions. The primary study end point was overall survival. Secondary end points included primary assisted or secondary patency and procedural complications.

RESULTS

Twenty-one patients were identified in the 22-month period that underwent recanalization of at least 1 iliac segment, using Atrium iCAST in the aorta and common iliac segments and/or Viabahn stents in the external iliac arteries. Overall AI patency was 100% (mean 6.8 months). Six AI bifurcation advancements were performed (primary patency 100%, mean 8 months). Eight patients with EIA occlusion underwent total percutaneous revascularization (primary patency 88%, secondary patency 100% mean 6 months). Five outflow procedures were performed concurrent to the AI recanalization. Two patients (15.4%) died of cardiovascular events. No access site complications were observed in the cohort.

CONCLUSIONS

AI occlusive disease remains a surgical challenge. Although uncovered stents are a common therapy for revascularization of this vascular bed, our experience with balloon-expanding and self-expanding covered stents suggests they may be used to good effect with minimal complications in the intermediate term.

Endovascular management of TransAtlantic Inter-Society Consensus D iliac artery occlusion secondary to radiation arteritis

Management of limb ischemia caused by radiation injury can be challenging. Atypical conduits or tunnels have been used for bypass through or around the injured area. Application of endovascular therapy for revascularization has not been widely published. Standard and alternative access sites with or without hybrid arterial adjuncts can be used successfully in cases in which surgical bypass is prohibitive. We describe a case of limb salvage in a patient treated with high-dose radiation for recurrent endocervical adenocarcinoma using a hybrid open surgical and endovascular approach.

Lower extremity pain and numbness

CLINICAL INTRODUCTION

A 45-year-old man with no past medical history presents with bilateral lower extremity pain and perineal numbness after walking 10-15 min. The pain starts in his bilateral buttocks and radiates down into his thigh and into his toes. He has no back pain, fever, difficulty urinating or stooling, incontinence or trauma. Social history is positive for smoking. Physical examination was only remarkable for non-dopplerable lower extremity pulses, and he was unable to ambulate down the ED hallway without becoming symptomatic. Ultrasound of his abdominal aorta (figure 1) was performed.emermed;35/7/419/F1F1F1Figure 1Transverse view of distal abdominal aorta, just proximal to the bifurcation. (A) The aorta without Doppler. (B) The same image with Doppler mode activated.

QUESTION

What is the most likely diagnosis based on the image?A. Lumbar stenosisB. Abdominal aortic aneurysmC. Aortic thrombusD. Aortic dissection.

Abdominal Aortic Emergencies

This article discusses abdominal aortic emergencies. There is a common thread of risk factors and causes of these diseases, including age, male gender, hypertension, dyslipidemia, and connective tissue disorders. The most common presenting symptom of these disorders is pain, usually in the chest, flank, abdomen, or back. Computed tomography scan is the gold standard for diagnosis of pathologic conditions of the aorta in the hemodynamically stable patient. Treatment consists of a combination of blood pressure and heart rate control and, in many cases, emergent surgical intervention.

Endovascular Treatment for Steno-Occlusive Iliac Artery Disease: Safety and Long-Term Outcome

We evaluated safety and long-term outcome of endovascular therapy for steno-occlusive iliac artery disease. All endovascular procedures of iliac artery lesions performed at our institution between 2001 and 2014 (n = 676) were retrospectively analyzed. The overall technical success rate was 99% and yielded 100% for stenoses (n = 596) and 95% for chronic total occlusions (n = 80). Lesion complexity defined by the Trans-Atlantic Inter-Society Consensus (TASC) II classification had no impact on success rates (TASC A + B vs C + D; 99.5% vs 98.6%, P = .359). During a median follow-up of 11 months, the overall rate of restenosis was 9.4%. After 1 and 3 years, the primary patency rates were 94% and 86% and the secondary patency rate was 100%, respectively. The TASC II classification had no impact on long-term patency rates (TASC A + B vs C + D; 86% vs 81%). In a multivariable analysis, stent diameter remained the only significant predictor for restenosis (hazard ratio: 0.58; 95% confidence interval: 0.41%-0.81%; P = .002). In this single-center retrospective study, endovascular therapy for steno-occlusive iliac artery disease was associated with high technical and clinical success rates as well as an excellent long-term patency rate irrespective of lesion complexity.

Current Status and Outcomes of Iliac Artery Endovascular Intervention

Aortoiliac occlusive disease (AIOD) is widely prevalent and leads to significant limitations in patient quality of life. All patients with aortoiliac occlusive disease should be managed with approved medical therapies in addition to a supervised exercise program. Persistence of significant symptoms despite noninvasive therapy should prompt further management with endovascular revascularization. Although patients with the most complex cases of AIOD anatomy may ultimately require surgery, advances in endovascular techniques have made it possible to treat most of these patients with AIOD using an endovascular-first approach.

Patency of the Internal Iliac Artery after Placement of Common and External Iliac Artery Stents

BACKGROUND

Treatment of severe aortoiliac occlusive disease (AIOD) frequently requires long-segment stenting of the common and external iliac arteries (CIA and EIA, respectively). This study aims to analyze the patency of the internal iliac artery (IIA) after placement of a CIA and EIA stents across the orifice.

METHODS

A retrospective analysis of all patients who underwent de novo ipsilateral stent placement in the CIA and EIA between 2006 and 2013 was performed. Kaplan-Meier analysis was used to analyze patency of the IIA, and Cox proportional hazard models were used to identify characteristics associated with occlusion.

RESULTS

We identified 77 patients and 93 limbs where ipsilateral CIA and EIA stents were placed. Preintervention angiographic review found 52 cases of a patent ipsilateral IIA where stents were placed across the origin of the IIA in 31 cases and staggered across the orifice in 20 limbs. Kaplan-Meier analysis demonstrated a 37% patency in limbs where the stent covered the IIA orifice compared to 78% patency in uncovered arteries (P = 0.04). New-onset buttock claudication developed in 4 patients, 2 with patent IIAs and 2 with occluded. New-onset impotence also developed in 3 patients with occluded IIA and 5 patients with patent IIAs.

CONCLUSIONS

Placement of stents across the origin of the IIA may not result in immediate occlusion, but long-term patency of covered IIAs is decreased compared to uncovered IIAs. This study is limited by a small sample size, but when treating AIOD, coverage of the internal iliac origin should be avoided to maintain patency of the pelvic circulation.

[Reconstruction of the aortic bifurcation: endovascular aortic repair (EVAR) and alternatives]

CLINICAL ISSUE

Diseases of the aortic bifurcation, whether stenotic or dilating, are mostly a manifestation of arteriosclerosis. If only stenosis is present aortic bifurcation disease is equivalent to a certain form of peripheral arterial occlusive disease (PAOD) characterized by the specific anatomical location. Aneurysmal disease and PAOD of the aortic bifurcation may occur together and men older than 60 years are particularly affected. The main symptom of aortic bifurcation PAOD is bilateral claudication whereas aneurysmal disease of the aortic bifurcation is frequently asymptomatic.

STANDARD TREATMENT

Therapy of stenotic and aneurysmal disease of the aortic bifurcation depends on the degree of the disease. Simple lesions, such as isolated stenoses of the aortic bifurcation or unilateral occlusions of the common iliac artery extending to the aortic bifurcation have been treated endoluminally for many years. Current standard treatment of complex aortic bifurcation disease is open surgery with implantation of an aortobifemoral bypass graft. However, recent developments in less invasive endoluminal methods have shifted the indications more towards endoluminal therapy. This development is mirrored by the international TransAtlantic Inter-Society Consensus (TASC) II recommendations from 2007 and even more clearly by the current national S3 guidelines on PAOD (http://www.degir.de/site/leitlinien). It is stated that in complex aortic bifurcation disease, such as bilateral occlusions of the common iliac arteries (TASC C lesions) or diffuse aortobiiliac stenoses and occlusions (TASC D lesions), endoluminal therapy may be considered as an alternative to open surgery. Therapy of aneurysmal disease of the aortic bifurcation depends on the pathoanatomical conditions. Prerequisite for endoluminal therapy is a sufficient landing zone for the prostheses. If this prerequisite is fulfilled endoluminal therapy is very likely comparable to open surgery with regard to technical and clinical success. Long-term results are still lacking.

DIAGNOSTIC WORK-UP

For the decision on the type of therapy and the sizing of the prostheses, thin-slice (≤ 3 mm slice thickness) computed tomography angiography (CTA) of the abdominal aorta and the iliac arteries including multiplanar reconstruction in the sagittal and coronal plane are sufficient. The inguinal arteries have to be included in the CTA volume.

PERFORMANCE

Compared to open surgery, endoluminal therapy of stenotic and aneurysmal disease of the aortic bifurcation has the advantage of reduced invasiveness. Hence patient recovery and hospital stay may be shorter.

ACHIEVEMENTS

Therapy of stenotic and aneurysmal disease of the aortic bifurcation is changing. Standard treatment of complex aortic bifurcation disease, which is open surgery is extended by the possibilities of endoluminal methods. Due to improvements in current endoluminal systems and development of new techniques, the importance of endoluminal therapy will further increase.

PRACTICAL RECOMMENDATIONS

Good quality of the preinterventional CTA is important for planning the intervention. In order for a radiologist to offer endoluminal therapy, besides knowledge of interventional skills a close cooperation with clinical colleagues, in particular vascular surgeons is mandatory.

Assessment of effectiveness of endovascular treatment of common and external iliac artery stenosis/occlusion using self-expanding Jaguar SM stents

The goal of this work was to assess the effectiveness of endovascular treatment of common and external iliac artery stenosis/occlusion classified according to TASC using a self-expanding stent Jaguar SM. The study group included 95 patients (61 men and 34 women) who underwent treatment for stenosis or occlusion of lower limb arteries at the Department of Radiology of the University Hospital in Bialystok and the Diagnostic Radiology Department of the Central Clinical Hospital of the Ministry of Interior (MSWiA) in Warsaw between 2005 and 2007. All arterial lesions were of atherosclerotic etiology. The shortest stenotic fragment was 10 mm long and the longest occluded arterial fragment did not exceed 90 mm. Morphological classification of iliac artery lesions in treated patients was performed according to TASC II classification and included 10 patients with type A, 39 cases of type B, 36 with type C and 10 patients with type D lesions. Endovascular procedure failed to restore flow in five patients with TASC type D lesions, who were later referred for surgery. One patient suffered a complication – vessel perforation during predilatation, and had a stentgraft implanted. In 95% of patients stents were expanded using a balloon after implantation. Good results were achieved in practically all patients who underwent stent implantation. Patients were subjected to follow-up clinical and imaging evaluation during next 1–24 months. Success rate of the performed procedures as well as in a 30-day observation period was 100% in case of stenosis and 80% in case of vessel occlusion. A follow-up after 12 and 24 months showed patency of treated vessels in 84% and 76% of patients, respectively.